159 The contribution of regional protocols on practice variation in induction of labor The overall scores showed the highest scores for the guidelines on late term pregnancy (5.33) and reduced fetal movements (4.57). All reviewing authors recognized both guidelines as appropriate for use in clinical practice, according to the question in the AGREE II instrument. In contrast, the guidelines on elective induction of labor and shoulder dystocia had low overall scores (resp. 3.67 and 2.33) and were not recognized by the reviewing authors as appropriate for use in clinical practice. 3.2 General impression regional protocols The purpose of all regional protocols was to describe maternal and perinatal care in the MCN, including primary midwife-led care and secondary obstetrician-led care. Not every MCN had a regional protocol for all four selected topics. None of the MCNs had a protocol for elective induction of labor, and for the topics late term pregnancy and macrosomia two or three protocols were identified in one MCN. In total, 18 regional protocols were identified in the six participating MCNs describing the recommended care for (prevention of) shoulder dystocia, large-for-gestational-age or macrosomia (n=6), reduced fetal movements (n=5), and late term pregnancy (≥41 weeks) (n=7) (Table 3). Table 3. Amount of regional protocols per subject (n=18) Subject MCN 1 MCN 2 MCN 3 MCN 4 MCN 5 MCN 6 Shoulder dystocia 1 1 0 1 0 3 Reduced fetal movements 0 1 1 1 1 1 Elective induction of labor 0 0 0 0 0 0 Late term pregnancy (≥41weeks) 1 2 1 2 0 1 A large variation was seen in document types. Documents varied from short and staccato protocols of one page describing what to do, to extensive protocols of ten pages describing not only recommended care, but also providing background, flowcharts, and recommendations for counseling. The documents were named differently, such as protocol, guideline, or care pathway. Three of the six MCNs consequently described authors, version number, and revision date in the document, while the other three MCNs did not. Some regional protocols described the full range of perinatal care in the specific situation, including a description of what should be done in the event of a referral from midwife-led care to obstetrician-led care for all professionals involved. Others focused separately on recommended midwife-led primary care or obstetrician-led secondary care. 7
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