Guidelines

Indications for Inducing Labour

• >41 weeks gestation (due to ↑ risk of stillbirth and Caesarean birth)

 

• P-PROM at 34-37 weeks – see this article for more details
  • If 34-37 weeks → offer induction of labour now OR expectant management until 37 weeks
  • If <34 weeks → do not offer induction unless there are additional indications
• Prelabour rupture of membrane at term
  • Offer induction of labour now OR induction after 24 hours (if labour not naturally started)

 

• GBS +ve status if
  • P-PROM at 34-37 weeks → induction now OR Caesarean birth
  • Prelabour rupture of membrane at term → induction now OR Caesarean birth
• Maternal request
• Intrauterine fetal death

 

Assessment and Monitoring

Assessment Before Induction

• Assess fetal head position and engagement:
  • Abdominal palpation
  • If uncertain (e.g. breech suspected) → ultrasound

 

• Vaginal examination to calculate the Bishop score (see details below)

 

• Perform cardiotocography to confirm:
  • Normal fetal heart rate pattern, and
  • Absence of significant uterine contractions (to rule out labour or hyperstimulation)

 

Monitoring During Induction

Once contraction begins after induction → cardiotocography monitoring

• If normal and low risk → switch to intermittent auscultation
• If abnormal fetal heart rate / uterine hyperstimulation → continuous cardiotocography + stop further induction doses and remove if possible

Methods of Labour Induction

Membrane sweep

Timing: offer the woman an option of membrane sweeping after 39 weeks

Membrane sweep counselling:

• Procedure performed during vaginal examination:  a finger is inserted into the cervix to perform a circular sweeping motion, attempting to separate the  amniotic sac membrane from the uterine wall
• Underlying mechanism: this stimulates the release of prostaglandins which helps to soften and open the cervix
• Possible side effects: discomfort, light bleeding / cramping, but generally safe

 

Bishop Score Guided Decision Algorithm

If labour induction is intended, the Bishop score is used to decide which method to use:

Score	Cervix dilation (cm)	Cervix position	Cervical effacement (%)	Cervical consistency	Fetal station
0	0	Posterior	0-30	Firm	-3
1	1-2	Midposition	40-50	Moderately firm	-2
2	3-4	Anterior	60-70	Soft	-1,0
3	≥5		≥80		+1,+2

Bishop score interpretation:

• ≥8: indicates a favourable / ripe cervix (i.e. cervix is ready to dilate)
• 6: cut-off to determine the choice of induction method

 

Bishop Score ≤6 → Cervical Ripening Methods

Offer pharmacological induction methods:

• Topical dinoprostone (PGE2) as vaginal tablet / gel / vaginal delivery system, or
• Oral misoprostol (low dose 25 mcg)

Consider mechanical methods (e.g. balloon catheter, osmotic cervical dilator) if any of the following:

• High risk of uterine hyperstimulation and/or uterine rupture
  • e.g. previous Caesarean birth, multiple pregnancy, complex uterine scars, history of uterine rupture
• Patient preference

 

Bishop Score >6 → Labour Stimulating Methods

Offer induction with:

• Amniotomy, and
• IV oxytocin infusion

  

Uterine Hyperstimulation

Uterine hyperstimulation is defined by:

• Tachysystole: >5 contractions per 10 min for at least 20 min, and
• Hypersystole / hypertonicity: contraction lasting ≥2 min

Management:

• Stop giving further induction medication
• Remove vaginally administered products if possible
• Perform continuous cardiotography
• Consider tocolysis

 

Outpatient Labour Induction

For those who wish to return home, with no contraindications, consider:

• Vaginal dinoprostone or
• Mechanical methods

Ask the women to contact their maternity team if ANY of the following:

• Contraction begins
• No contractions in an agreed timeframe
• Membrane ruptures
• Bleeding develops
• Any other concerns (e.g. reduced fetal movement, excessive pain or contractions, side effects)

Simplified Flow Chart

Labour Induction Method Decision Algorithm

References

Original Guideline