Download PDF
Am J Perinatol
DOI: 10.1055/a-2729-1329
Original Article

Implementation of an Outpatient Cervical Ripening Initiative: Outcomes and Patient and Provider Perspectives

Authors

  • Katherine H. Zhu   ‡

    1   Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, Illinois, United States

  • Sonia Gilani

    2   Department of Obstetrics & Gynecology, Endeavor Health, Evanston, Illinois, United States
    3   Department of Obstetrics & Gynecology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, United States

  • Sunitha C. Suresh

    1   Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, Illinois, United States
    2   Department of Obstetrics & Gynecology, Endeavor Health, Evanston, Illinois, United States

  • Marci Adams

    2   Department of Obstetrics & Gynecology, Endeavor Health, Evanston, Illinois, United States

  • Emmet Hirsch

    1   Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, Illinois, United States
    2   Department of Obstetrics & Gynecology, Endeavor Health, Evanston, Illinois, United States
Further Information
Also available at
   Permissions and Reprints

Abstract

Objective

This study aimed to examine implementation and patient/provider acceptance of an outpatient mechanical cervical ripening program for labor induction with the goal of reducing length of stay in labor and delivery (L&D) unit.

Study Design

Initially, outpatient cervical ripening was “available,” and later (due to low utilization) “mandatory” for eligible patients who were induced Monday through Friday, with weekend induction available for those declining outpatient ripening. Single-balloon catheters were used, with supplemental vaginal misoprostol for inpatients. Utilization was compared for two 3-month periods (pre- and post-mandatory phases). Patient and provider surveys queried perceived benefits, risks, barriers, pain, likelihood to recommend, and satisfaction. Outcomes (length of stay in L&D, delivery mode, chorioamnionitis, hemorrhage, and NICU admission) were compared between the inpatient and outpatient groups.

Results

Outpatient ripening among eligible patients increased from 13.5 to 55.1% after becoming mandatory (p < 0.01), with 71.4% of patients undergoing either outpatient ripening or induction over the weekend. Staff satisfaction was high, with 91.7% “somewhat” to “very likely” to recommend outpatient ripening. Perceived benefits included decreased time in L&D. Barriers included office workflow and provider comfort with placement. Patient satisfaction and pain scores did not differ by balloon placement location. Among patients eligible for outpatient ripening (n = 224), there was no difference in length of stay in L&D (22.1 hours outpatient versus 24.2 inpatient, p = 0.19). However, among all patients undergoing mechanical ripening (n = 397, a measure of the initiative's impact on L&D congestion), outpatient ripening length of stay was shorter by 4 hours (22.1 versus 26.1 hours, p = 0.01). Delivery outcomes were similar between groups.

Conclusion

Outpatient cervical ripening utilization was minimal until it became mandatory. Providers were overall satisfied. Balloon placement location did not affect patient satisfaction. Among patients undergoing mechanical ripening, those receiving an outpatient balloon had a 4-hour decreased L&D length of stay. There were no differences in delivery outcomes.

Key Points

  • We studied adoption of outpatient cervical ripening.

  • A mandatory program was required for adoption.

  • Staff were satisfied with the program.

  • Ripening location did not affect patient satisfaction.

  • L&D time decreased without affecting outcomes.

Keywords

induction of labor - cervical ripening - cervical balloon - implementation science

Note

This study was previously presented at the Central Association of Obstetrics & Gynecology 90th Annual Meeting, Nashville, Tennessee, United States, October 25–28, 2023. Received Young Investigator's Award.


‡ Katherine H. Zhu, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, Missouri, United States


Supplementary Material



Publication History

Received: 25 July 2025

Accepted: 21 October 2025

Accepted Manuscript online:
24 October 2025

Article published online:
06 November 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA