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CMECNE

A New Predictive Model for Successful Induction of Labor

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. State the reasoning behind the development of another calculator to predict induction success
2. Appropriately apply the induction calculator into practice when counseling patients about the risks and benefits of induction with an unfavorable cervical exam at term

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from March 12 2018 through March 11 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

BACKGROUND AND PURPOSE: 

  • Previous studies to predict induction success are focused on nulliparous women and are weighted towards a favorable cervical exam   
  • Levine et al. (AJOG, 2018) sought to derive and validate an induction prediction model for women with an unfavorable cervix in both nulliparous and multiparous women 

METHODS:

  • Based on a planned secondary analysis of a large randomized trial
  • Foley or Misoprostol for the Management of Induction (FOR MOMI)
    • Study compared time to delivery among 4 induction methods
      • Misoprostol alone | cervical Foley alone | misoprostol & cervical Foley concurrently | cervical Foley & oxytocin concurrently
  • Both nulliparous and multiparous women at full-term (≥37 weeks) with a singleton gestation and intact membranes were included
  • Unfavorable cervix: Bishop score ≤6 and dilation ≤2 cm
  • Multivariable logistic regression was used to construct the prediction model
  • The prediction model was further refined by using an observational cohort of women from the same institution who underwent an induction during the trial period
  • An external validation was performed utilizing a publicly available database (Consortium for Safe Labor)

RESULTS: 

  • The cesarean delivery rates in the derivation and external validation groups were: 27.7% (n = 136/491) and 26.4% (n = 2235/8466) 
  • There were no differences in cesarean rate between the derivation group and external validation group (P = .53) 
  • In multivariable modeling, nulliparity, gestation age ≥40 weeks, BMI at delivery, modified Bishop score, and height were significantly and independently associated with cesarean delivery  
  • A nomogram and calculator were created and found to have an area under the curve (ROC) in the external validation cohort of 0.73 (95% confidence interval, 0.72-0.74) 

CONCLUSION: 

  • A nomogram and user-friendly Web-based calculator that incorporates 5 variables known at the start of induction has been developed and validated 
  • Calculators should not be used in isolation and clinical context should be included in clinical decision making  
  • The calculator should not be used to  
    • Forego medically indicated induction  
    • Lower the threshold for elective primary cesarean delivery 
    • Lower the threshold for cesarean delivery in labor in the absence of other clinical information 
  • The web-based calculator has been developed based on this data and can be found in the ‘Learn More – Primary Sources’  

Learn More – Primary Sources: 

A validated calculator to estimate risk of cesarean after an induction of labor with an unfavorable cervix.

Penn Medicine: Labor Induction Calculator

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Related ObG Topics:

The ARRIVE Trial and Professional Guidance: Elective 39 Week Induction to Reduce the Risk of Cesarean Section
Practical info on evidence based medicine for your women's healthcare practice
Labor induction and an unripe cervix: does it result in more C-sections?
Cochrane Review 2017: Outpatient Cervical Ripening and Labor Induction

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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