Grand Rounds

CMECNE

A New Predictive Model for Successful Induction of Labor

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:

Ashley Comfort, MD, FACOG is the Director of Medical Content, ObG Project.

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Ashley Comfort, MD, has a financial interest in Pfizer and has no other conflicts of interest to disclose.

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 07/15/2022, 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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