Implementation of an Outpatient Cervical Ripening Program: Outcomes and Provider and Patient Perspectives
Authors: Zhu Katherine , Gilani Sonia , Suresh Sunitha , Adams Marci , Hirsch Emmet 
Published: July 2024

Purpose: The purpose of this study is to evaluate the implementation, outcomes, and patient/provider acceptance of an outpatient cervical ripening program for induction of labor (IOL) at a teaching hospital.

Methods: In an effort to reduce patient risk resulting from congestion in the Labor and Delivery (L&D) unit of a level III maternity hospital with 3400 annual births, our department promoted the use of outpatient cervical balloon ripening. Over the course of 5 months, educational materials were distributed, Grand Rounds were held, an appeal to use outpatient cervical ripening was issued, and providers received written personal requests to consider outpatient balloons for each of their upcoming eligible scheduled inductions. Despite these efforts, uptake was minimal, as determined by a manual review over a 1-month period. Beginning in September 2022, new workflows were mandated: all patients needing cervical ripening and not meeting a defined list of exclusions were required to have outpatient balloons placed 6-18 hours prior to IOL in L&D, or to be scheduled for IOL over the weekend. Routine practice for inpatient balloons included planned removal after 6 hours and use of a ripening agent (vaginal misoprostol 25 ug every 3 hours for 1-2 doses or intravenous oxytocin). The institution’s Data Warehouse was queried to obtain clinical outcomes for all IOL requiring cervical ripening occurring over a 3-month period beginning one month after implementation of the new workflow (October-December 2022). A survey was distributed to all L&D providers 1 month prior to and 5 months following initiation of the mandatory outpatient cervical ripening program. Providers were asked their perception on benefits, risks, barriers, and likeliness to recommend outpatient cervical ripening. Patients who delivered following IOL over the same 3-month period were contacted via telephone and/or email and consented to complete a survey regarding their delivery experience. Outcomes were compared using chi square and t-test

Results: Outpatient cervical balloon utilization increased to 27.7% of eligible patients during the 3-month auditing period after implementation of mandatory outpatient cervical ripening from 7.2% at baseline. Among 141 subjects with inpatient and 54 with outpatient cervical balloons, there were no significant differences between groups in the rates of cesarean delivery (24.8% vs 18.5%, p=0.35), operative vaginal delivery (6.4% vs 11.1%, p=0.27), chorioamnionitis (12.1% vs 16.7%, p=0.40), postpartum hemorrhage (17.0% vs 13.0%, p=0.49), or NICU admission (12.1% vs 9.3%, p=0.58). Length of stay in L&D was significantly less in the outpatient group (1606 minutes vs 1366, p=0.02).

Fifty-three providers responded to the pre-implementation survey. Perceived benefits to outpatient ripening included less time in the hospital (94.3% of respondents), and patient comfort (37.7%). There were 34 respondents to the post-implementation survey. Decreased time in the hospital (94.3% pre vs 91.2% post, p=0.16) remained a perceived benefit, however patient comfort did not (37.7% pre vs 17.6% post, p=0.046). Concern over incorrect placement diminished significantly on post survey (50.9% pre vs 29.4% post, p=0.049). Respondents additionally reported concerns regarding delays in L&D causing balloons to remain in situ for longer than scheduled and subsequent effect on patient anxiety. Barriers to outpatient ripening before and after implementation included office workflow (58.5% pre vs 52.9% post, p=0.65), and provider comfort with the procedure (32.1% pre vs 41.2% post, p=0.39). Over time, respondents were increasingly “somewhat” to “very likely” to recommend outpatient ripening to their patients (64.2% pre vs 91.7% post, p=0.004). On post survey, most respondents were “somewhat” to “very satisfied” with the current program (64.7%), and “somewhat” to “very likely” to recommend to their colleagues (82.4%).

A total of 188 patients who underwent balloon cervical ripening were contacted, and 63 (33.5%) responded. Forty-five (71.4%) patients surveyed had a spontaneous vaginal delivery, 4 (6.35%) required operative vaginal delivery, and 14 (22.2%) underwent cesarean delivery. The majority (61.9%) were nulliparous. Seventeen (27%) patients had an outpatient balloon. Mean pain scores were not statistically significant between outpatient and inpatient groups (6.13 vs 5.28, p=0.25). There was no difference in patient self-perceived preparedness for balloon placement (41.2% outpatient vs 41.3% inpatient, p=0.99). There were no differences in delivery-related anxiety between groups (47.1% outpatient vs 60.9% inpatient, p=0.32) or in likelihood to recommend the experience (41.2% outpatient somewhat to very likely to recommend versus 32.6% inpatient, p=0.53).

Conclusion: Adoption of outpatient cervical ripening required a mandatory program, as persuasion and education were insufficient to induce a change in practice. No differences were seen in delivery outcomes between inpatient and outpatient balloon ripening, though this analysis is not powered to assess outcomes. A 4-hour decreased length of stay on L&D was observed in those who had an outpatient balloon. Providers are overall satisfied with outpatient cervical ripening. Patient satisfaction remains mixed regardless of cervical balloon placement location.