"We Just Did It": Eliminating Elective Inductions Before 39 Weeks

Purpose for the program:

The lenses of patient safety, evidence-based practice and quality improvement have focused on inpatient OB care.  We were struggling to comply with several recommended practice changes in the fall of 2008, when one of these converging forces, the elimination of elective inductions before 39 weeks of gestation, became a priority for our ninety-bed inpatient perinatal unit.  Increasing delivery rates amplified the number of inductions and cesarean sections and more, larger babies required admission to our NICU.  

Proposed change:

Members of our leadership team heard Miller and Clark’s presentation of their Oxytocin Protocol at the 2008 AWHONN Convention.  This protocol adheres to ACOG guidelines on gestational dating for elective inductions.  They described reduced numbers of inductions, cesareans and NICU admissions resulting from inductions.  Additional emphasis from the March of Dimes 39 Weeks Campaign encouraged us to develop a plan to eliminate elective inductions before 39 weeks completed gestation.

 Implementation, outcomes and evaluation:

Using an evidence-based practice model, a multi-professional team reviewed available literature to determine options for best practice.  Our medical director became our physician champion and drove the change after the ISMP placed oxytocin on the High Alert medication list.  The new protocol, including consents and checklists, was presented and approved by the OB Department in October 2008.

Stakeholder education included nurses, physicians, pharmacy and medical records, but key to our success was an informational session provided to the physician’s office managers.  We explained the rationale for this change, previewed the required documentation, and provided ordering information and individual packets with a checklist for forms required when admitting an elective induction.  After publicizing our “Go Live” date of April 1, 2009, the Nurse Educator and CNS made frequent rounds, published clarifications when questions arose and referred recalcitrant physicians to our Chief of OB and Medical Director: it was essential to minimize conflict over the new requirements when it arose between physicians and the surgery schedulers or labor nurses.

The outcome data validates our efforts.  By delaying induction until 39 weeks, more women went into labor spontaneously, a decrease of 17%; fewer women undergoing induction required a cesarean delivery, down 21%; and admissions of larger babies to the NICU decreased.  A year later, elective inductions are not performed before 39 weeks.

 Implications for nursing practice:

Our program will be of interest to hospitals seeking improved quality and safety when implementing the new Joint Commission Core Measure to eliminate elective deliveries before 39 weeks.

Keywords: Elective Induction, Pre-oxytocin Checklist, 39 Week Pregnancy