NICE clinical guidelines
Issued: July 2008
CG70

Induction of labour

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg70

1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 Information and decision-making

This section should be read in conjunction with 'Antenatal care: routine care for the healthy pregnant woman' (NICE clinical guideline 62) and 'Intrapartum care: care of healthy women and their babies during childbirth' (NICE clinical guideline 55).

1.1.1.1 Women should be informed that most women will go into labour spontaneously by 42 weeks. At the 38 week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 42 weeks, and their options. The information should cover:

  • membrane sweeping:

  • that membrane sweeping makes spontaneous labour more likely, and so reduces the need for formal induction of labour to prevent prolonged pregnancy

  • what a membrane sweep is

  • that discomfort and vaginal bleeding are possible from the procedure

  • induction of labour between 41+0 and 42+0 weeks

  • expectant management.

1.1.1.2 Healthcare professionals should explain the following points to women being offered induction of labour:

  • the reasons for induction being offered

  • when, where and how induction could be carried out

  • the arrangements for support and pain relief (recognising that women are likely to find induced labour more painful than spontaneous labour) (see also 1.6.2.1 and 1.6.2.2)

  • the alternative options if the woman chooses not to have induction of labour

  • the risks and benefits of induction of labour in specific circumstances and the proposed induction methods

  • that induction may not be successful and what the woman's options would be.

1.1.1.3 Healthcare professionals offering induction of labour should:

  • allow the woman time to discuss the information with her partner before coming to a decision

  • encourage the woman to look at a variety of sources of information

  • invite the woman to ask questions, and encourage her to think about her options

  • support the woman in whatever decision she makes.

1.2 Induction of labour in specific circumstances

1.2.1 Prevention of prolonged pregnancy

1.2.1.1 Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour.

1.2.1.2 Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy. The exact timing should take into account the woman's preferences and local circumstances.

1.2.1.3 If a woman chooses not to have induction of labour, her decision should be respected. Healthcare professionals should discuss the woman's care with her from then on.

1.2.1.4 From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twiceweekly cardiotocography and ultrasound estimation of maximum amniotic pool depth[2].

1.2.2 Preterm prelabour rupture of membranes

1.2.2.1 If a woman has preterm prelabour rupture of membranes, induction of labour should not be carried out before 34 weeks unless there are additional obstetric indications (for example, infection or fetal compromise).

1.2.2.2 If a woman has preterm prelabour rupture of membranes after 34 weeks, the maternity team should discuss the following factors with her before a decision is made about whether to induce labour, using vaginal PGE2[3]:

  • risks to the woman (for example, sepsis, possible need for caesarean section)

  • risks to the baby (for example, sepsis, problems relating to preterm birth)

  • local availability of neonatal intensive care facilities.

1.2.3 Prelabour rupture of membranes at term

1.2.3.1 Women with prelabour rupture of membranes at term (at or over 37 weeks) should be offered a choice of induction of labour with vaginal PGE2[3] or expectant management.

1.2.3.2 Induction of labour is appropriate approximately 24 hours after prelabour rupture of the membranes at term.[4]

1.2.4 Previous caesarean section

1.2.4.1 If delivery is indicated, women who have had a previous caesarean section may be offered induction of labour with vaginal PGE2[3], caesarean section or expectant management on an individual basis, taking into account the woman's circumstances and wishes. Women should be informed of the following risks with induction of labour:

  • increased risk of need for emergency caesarean section during induced labour

  • increased risk of uterine rupture.

1.2.5 Maternal request

1.2.5.1 Induction of labour should not routinely be offered on maternal request alone. However, under exceptional circumstances (for example, if the woman's partner is soon to be posted abroad with the armed forces), induction may be considered at or after 40 weeks.

1.2.6 Breech presentation

1.2.6.1 Induction of labour is not generally recommended if a woman's baby is in the breech presentation. If external cephalic version is unsuccessful, declined or contraindicated, and the woman chooses not to have an elective caesarean section, induction of labour should be offered, if delivery is indicated, after discussing the associated risks with the woman.

1.2.7 Fetal growth restriction

1.2.7.1 If there is severe fetal growth restriction with confirmed fetal compromise, induction of labour is not recommended.

1.2.8 History of precipitate labour

1.2.8.1 Induction of labour to avoid a birth unattended by healthcare professionals should not be routinely offered to women with a history of precipitate labour.

1.2.9 Intrauterine fetal death

1.2.9.1 In the event of an intrauterine fetal death, healthcare professionals should offer support to help women and their partners and/or family cope with the emotional and physical consequences of the death. This should include offering information about specialist support.

1.2.9.2 In the event of an intrauterine fetal death, if the woman appears to be physically well, her membranes are intact and there is no evidence of infection or bleeding, she should be offered a choice of immediate induction of labour or expectant management.

1.2.9.3 In the event of an intrauterine fetal death, if there is evidence of ruptured membranes, infection or bleeding, immediate induction of labour is the preferred management option.

1.2.9.4 If a woman who has had an intrauterine fetal death chooses to proceed with induction of labour, oral mifepristone, followed by vaginal PGE2 or vaginal misoprostol[5], should be offered. The choice and dose of vaginal prostaglandin should take into account the clinical circumstances, availability of preparations and local protocol.

1.2.9.5 For women who have intrauterine fetal death and who have had a previous caesarean section, the risk of uterine rupture is increased. The dose of vaginal prostaglandin[3] should be reduced accordingly, particularly in the third trimester.

1.2.10 Suspected fetal macrosomia

1.2.10.1 In the absence of any other indications, induction of labour should not be carried out simply because a healthcare professional suspects a baby is large for gestational age (macrosomic).

1.3 Recommended methods for induction of labour

Membrane sweeping involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua. If the cervix will not admit a finger, massaging around the cervix in the vaginal fornices may achieve a similar effect. For the purpose of this guideline, membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction.

The Bishop score is a group of measurements made by doing a vaginal examination, and is based on the station, dilation, effacement (or length), position and consistency of the cervix. A score of eight or more generally indicates that the cervix is ripe, or 'favourable' – when there is a high chance of spontaneous labour, or response to interventions made to induce labour.

1.3.1 Membrane sweeping

1.3.1.1 Prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping[6].

1.3.1.2 At the 40 and 41 week antenatal visits, nulliparous women should be offered a vaginal examination for membrane sweeping.

1.3.1.3 At the 41 week antenatal visit, parous women should be offered a vaginal examination for membrane sweeping.

1.3.1.4 When a vaginal examination is carried out to assess the cervix, the opportunity should be taken to offer the woman a membrane sweep.

1.3.1.5 Additional membrane sweeping may be offered if labour does not start spontaneously.

1.3.2 Pharmacological methods

1.3.2.1 Vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it (in particular the risk of uterine hyperstimulation). It should be administered as a gel, tablet or controlled-release pessary. Costs may vary over time, and trusts/units should take this into consideration when prescribing PGE2. For doses, refer to the SPCs. The recommended regimens are:

  • one cycle of vaginal PGE2 tablets or gel: one dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses)

  • one cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours.

1.3.2.2 When offering PGE2 for induction of labour, healthcare professionals should inform women about the associated risks of uterine hyperstimulation.

1.3.2.3 Misoprostol[5] should only be offered as a method of induction of labour to women who have intrauterine fetal death (see section 1.2.9) or in the context of a clinical trial.

1.3.2.4 Mifepristone should only be offered as a method of induction of labour to women who have intrauterine fetal death (see section 1.2.9).

1.4 Methods that are not recommended for induction of labour

1.4.1 Pharmacological methods

1.4.1.1 The following should not be used for induction of labour:

  • oral PGE2

  • intravenous PGE2

  • extra-amniotic PGE2

  • intracervical PGE2

  • intravenous oxytocin alone

  • hyaluronidase

  • corticosteroids

  • oestrogen

  • vaginal nitric oxide donors.

1.4.2 Non-pharmacological methods

1.4.2.1 Healthcare professionals should inform women that the available evidence does not support the following methods for induction of labour:

  • herbal supplements

  • acupuncture

  • homeopathy

  • castor oil

  • hot baths

  • enemas

  • sexual intercourse.

1.4.3 Surgical methods

1.4.3.1 Amniotomy, alone or with oxytocin, should not be used as a primary method of induction of labour unless there are specific clinical reasons for not using vaginal PGE2, in particular the risk of uterine hyperstimulation.

1.4.4 Mechanical methods

1.4.4.1 Mechanical procedures (balloon catheters and laminaria tents) should not be used routinely for induction of labour.

1.5 Setting and timing

1.5.1.1 In the outpatient setting, induction of labour should only be carried out if safety and support procedures are in place.

1.5.1.2 The practice of induction of labour in an outpatient setting should be audited continuously.

1.5.1.3 In the inpatient setting, induction of labour using vaginal PGE2 should be carried out in the morning because of higher maternal satisfaction.

1.6 Monitoring and pain relief

1.6.1 Monitoring

1.6.1.1 Wherever induction of labour is carried out, facilities should be available for continuous electronic fetal heart rate and uterine contraction monitoring.

1.6.1.2 Before induction of labour is carried out, Bishop score should be assessed and recorded, and a normal fetal heart rate pattern should be confirmed using electronic fetal monitoring.

1.6.1.3 After administration of vaginal PGE2, when contractions begin, fetal wellbeing should be assessed with continuous electronic fetal monitoring. Once the cardiotocogram is confirmed as normal, intermittent auscultation should be used unless there are clear indications for continuous electronic fetal monitoring as described in 'Intrapartum care' (NICE clinical guideline 55).

1.6.1.4 If the fetal heart rate is abnormal after administration of vaginal PGE2, recommendations on management of fetal compromise in 'Intrapartum care' (NICE clinical guideline 55) should be followed.

1.6.1.5 Bishop score should be reassessed 6 hours after vaginal PGE2 tablet or gel insertion, or 24 hours after vaginal PGE2 controlled-release pessary insertion, to monitor progress (see 1.3.2.1).

1.6.1.6 If a woman returns home after insertion of vaginal PGE2 or tablet or gel, she should be asked to contact her obstetrician/midwife:

  • when contractions begin, or

  • if she has had no contractions after 6 hours.

1.6.1.7 Once active labour is established, maternal and fetal monitoring should be carried out as described in 'Intrapartum care' (NICE clinical guideline 55).

1.6.2 Pain relief

1.6.2.1 Women being offered induction of labour should be informed that induced labour is likely to be more painful than spontaneous labour.

1.6.2.2 Women should be informed of the availability of pain relief options in different settings (see 1.1.1.2 and 1.5.1.1).

1.6.2.3 During induction of labour, healthcare professionals should provide women with the pain relief appropriate for them and their pain (as described in 'Intrapartum care' [NICE clinical guideline 55]). This can range from simple analgesics to epidural analgesia.

1.6.2.4 Birth attendants (carers and healthcare professionals) should offer women support and analgesia as required, and should encourage women to use their own coping strategies for pain relief.

1.6.2.5 The opportunity to labour in water is recommended for pain relief[7].

1.7 Prevention and management of complications

1.7.1 Uterine hyperstimulation

1.7.1.1 Tocolysis should be considered if uterine hyperstimulation occurs during induction of labour.

1.7.2 Failed induction

Failed induction is defined as labour not starting after one cycle of treatment as described in 1.3.2.1.

1.7.2.1 If induction fails, healthcare professionals should discuss this with the woman and provide support. The woman's condition and the pregnancy in general should be fully reassessed, and fetal wellbeing should be assessed using electronic fetal monitoring.

1.7.2.2 If induction fails, decisions about further management should be made in accordance with the woman's wishes, and should take into account the clinical circumstances.

1.7.2.3 If induction fails, the subsequent management options include:

  • a further attempt to induce labour (the timing should depend on the clinical situation and the woman's wishes)

  • caesarean section (refer to 'Caesarean section' [NICE clinical guideline 13]).

1.7.2.4 For women who choose caesarean section after a failed induction, recommendations in 'Caesarean section' (NICE clinical guideline 13) should be followed.

1.7.3 Cord prolapse

1.7.3.1 To reduce the likelihood of cord prolapse, which may occur at the time of amniotomy, the following precautions should be taken:

  • Before induction, engagement of the presenting part should be assessed.

  • Obstetricians and midwives should palpate for umbilical cord presentation during the preliminary vaginal examination and avoid dislodging the baby's head.

  • Amniotomy should be avoided if the baby's head is high.

1.7.3.2 Healthcare professionals should always check that there are no signs of a low-lying placental site before membrane sweeping and before induction of labour.

1.7.4 Uterine rupture

1.7.4.1 If uterine rupture is suspected during induced labour, the baby should be delivered by emergency caesarean section (refer to 'Caesarean section' [NICE clinical guideline 13]).



[2] Recommendation 1.2.1.4 is from 'Antenatal care: routine care for the healthy pregnant woman' (NICE clinical guideline 62).

[3] Vaginal PGE2 has been used in UK practice for many years in women with ruptured membranes. However, the SPCs (July 2008) advise that in this situation, vaginal PGE2 is either not recommended or should be used with caution, depending on the preparation (gel, tablet or pessary). Healthcare professionals should refer to the individual SPCs before prescribing vaginal PGE2 for women with ruptured membranes, and informed consent should be obtained and documented.

[4] Recommendation 1.2.3.2 is from 'Intrapartum care: care of healthy women and their babies during childbirth' (NICE clinical guideline 55).

[5] At the time of publication (July 2008), misoprostol was not licensed for use for labour induction in fetal death in utero in the UK. Informed consent should therefore be obtained and documented.

[6] Recommendation 1.3.1.1 is from 'Antenatal care: routine care for the healthy pregnant woman' (NICE clinical guideline 62).

[7] Recommendation 1.6.2.5 is from 'Intrapartum care: care of healthy women and their babies during childbirth' (NICE clinical guideline 55).