Standardization of labor induction management: A mixed-methods evaluation of the clinician perspective

Standardizing labor induction (IOL) practices may reduce cesarean delivery rates and improve obstetric disparities. Such labor induction protocols focus on active management with recommendations for frequent cervical exams, early amniotomy, and intervention when no cervical change is made (e.g., oxytocin or intrauterine pressure catheter). Here, we aimed to characterize the clinician perspective on the feasibility and acceptability of each of these components of a standardized labor induction protocol to improve implementation of standardized labor induction practices.

This sequential mixed-methods study first surveyed clinicians after implementation of a standardized labor induction protocol at two sites in 2021. We used the four-question validated Acceptability of Intervention Measure (AIM; total 4-20) as well as a single acceptability item (1-5) for each of eight specific protocol components. Total AIM scores were grouped into tertiles. Clinicians in the top ("High" Acceptability) and bottom ("Low" Acceptability) tertiles were purposively sampled to participate in a semi-structured interview. Topics included (1) acceptability of protocol components, (2) barriers/facilitators to adherence, and (3) strategies for overcoming barriers. Interviews were coded using an integrated approach with high inter-rater reliability (k = 0.83).

A total of 104 clinicians (57 physicians, 43 RNs, 4 CNMs) completed the survey. Median total AIM score was 15/20 [IQR 12-19]. Protocol components with the highest scores on the individual acceptability item focused on not continuing "futile" cervical ripening, as well as interventions for active labor dystocia. Components with low acceptability included frequent cervical exams and early amniotomy. A total of 24 clinicians were interviewed (12 "High" and 12 "Low" Acceptability). Clinicians described barriers to implementation of less acceptable components of the protocol, including staff/time constraints, best-practice disagreements, and concerns around patient satisfaction. Clinicians recommended more education around the protocol's safety/efficacy and communication about anticipated labor induction steps to overcome these barriers.

This work describes the clinician perspective on specific labor induction interventions and provides concrete recommendations to overcome implementation barriers of a standardized labor induction protocol.