Do practice guidelines guide practice? A prospective audit of induction oflabor - three years experience

Background. To examine the effect of implementation of guidelines for induc tion of labor on the process of care and outcome measures. Method. Guidelines for induction of labor were implemented in January 1996 following an audit report identifying inconsistency in clinical practice. A prospective audit was carried out following the implementation of a new st rategy directed towards pre-induction cervical ripening in nulliparae with unfavorable cervices and the use of low dosages of vaginal prostaglandin E- 2 for induction of labor. Level of compliance and outcome measures were com pared before and after implementation of guidelines. Results. In the period of January 1995 to November 1997, 1,230 women were i nduced with a singleton viable pregnancy in a cephalic presentation with a gestational age greater than or equal to 37 weeks with no history of ruptur e of membranes or cesarean section. Completed forms were available for 1,14 7 women (370, 421 and 356 in 1995, 1996 and 1997, respectively). Among null iparous women, there was a reduction in the number of women who were admitt ed with cervical score of less than or equal to4 (24%, 40%, and 54% in 1997 , 1996, and 1995, respectively; p=0.0001), an increase in the number of wom en who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995 , respectively; p=0.0001) and a shorter induction-delivery interval. No cha nge in outcome measures was noted among multiparous women despite reduced d ose of prostaglandin E2 used for induction of labor. A marginal reduction o f both Cesarean section and failed induction rates were noted in both nulli parae and multiparae. Level of compliance improved with successive rounds o f audit. Conclusion. Explicit guidelines do improve clinical practice, when introduc ed and monitored in the context of rigorous evaluations. However, the size of improvement could vary.