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Induction of labour

Queensland Maternity and Neonatal Clinical Guideline: Induction of labour


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Document title: Induction of labour
Publication date: September 2011
Document number: MN11.22-V3-R16
Document
supplement:
The document supplement is integral to and should be read in conjunction
with this guideline
Amendments Full version history is supplied in the document supplement
Amendment date J anuary 2014
Replaces document: MN11.22-V2-R16
Author: Queensland Maternity and Neonatal Clinical Guidelines Program
Audi ence: Health professionals in Queensland public and private maternity services
Review date: September 2016
Endorsed by:
Queensland Maternity and Neonatal Clinical Guidelines Program
Statewide Maternity and Neonatal Clinical Network
Queensland Health Patient Safety and Quality Executive Committee
Contact:
Email: MN-Guidelines@health.qld.gov.au
URL: http://www.health.qld.gov.au/qcg

Discl aimer

These guidelines have been prepared to promote and facilitate standardisation and consistency of
practice, using a multidisciplinary approach.

Information in this guideline is current at time of publication.

Queensland Health does not accept liability to any person for loss or damage incurred as a result of
reliance upon the material contained in this guideline.

Clinical material offered in this guideline does not replace or remove clinical judgement or the
professional care and duty necessary for each specific patient case.

Clinical care carried out in accordance with this guideline should be provided within the context of
locally available resources and expertise.

This Guideline does not address all elements of standard practice and assumes that individual
clinicians are responsible to:
Discuss care with consumers in an environment that is culturally appropriate and which
enables respectful confidential discussion. This includes the use of interpreter services
where necessary
Advise consumers of their choice and ensure informed consent is obtained
Provide care within scope of practice, meet all legislative requirements and maintain
standards of professional conduct
Apply standard precautions and additional precautions as necessary, when delivering care
Document all care in accordance with mandatory and local requirements




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licence, visit http://creativecommons.org/licenses/by-nc-nd/2.5/au/
State of Queensland (Queensland Health) 2010
In essence you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authors
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email ip_officer@health.qld.gov.au , phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal Clinical
Guidelines Program, RBWH Post Office, Herston Qld 4029, email MN-Guidelines@health.qld.gov.au phone (07) 3131 6777.
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour
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Flowchart: Summary of recommendations for Induction of labour

Indications
Maternal and fetal benefit
Consider individual
circumstances
Potential circumstance
Prolonged pregnancy
PPROM / PROM
Previous caesarean section
Obstetric cholestasis
Diabetes
Hypertensive disorder
Twin pregnancy
Suspected fetal macrosomia
FGR
IUFD
Maternal request
Other maternal conditions
Contraindications
As for vaginal birth
Communication & information for
women
Maternal and fetal benefit & risk
Indications
Methods of IOL
Pain relief
Possibility of failure
Time for decision-making
Document above
Pre-induction assessment
Review history
Confirm gestation
Baseline observations
(temperature, pulse, BP)
Abdominal palpation
(presentation, engagement)
CTG
Assess membrane status (intact
or ruptured)
Vaginal examination
Cervix
Favourable:
o Bishop score >6
Unfavourable:
o Bishop score 6
Declined induction
Offer increased antenatal
monitoring x 2/week:
o CTG
o Ultrasound scan:
Amniotic fluid index
Umbilical arterial Doppler
Postponed induction
Consider individual
circumstances
Perform maternal and fetal
assessment
Document assessment and plan
of care in the health record
Advise the woman to return if
concerned
Continuous CTG minimum
30 minutes
Recumbent left lateral for 30
minutes post insertion
Temperature, BP, pulse,
monitor uterine activity and
PV loss hourly for 4 hours
VE reassess:
o Gel - after 6 hours
o Controlled release - after
12 hours
Prosta-
glandin
Queensland Maternity and Neonatal Clinical Guideline: MN11.22-V3-R16: Induction of labour
Indications
Favourable cervix
o If cervix unfavourable
consider Dinoprostone
(PGE
2
)
Cautions
Not within 6 hours of
Dinoprostone gel
Not within 30 minutes of
removal of Dinoprostone
pessary(Cervidil)
Previous uterine surgery
High parity (>4)
One to one midwifery care
ARM prior to Oxytocin
Continuous CTG
Assess uterine contractions
for 10 minutes every 30
minutes
Temperature - 2 hourly
BP, Pulse, PV loss - hourly
Maintain fluid balance
Assess progress of labour
according to local guideline
Oxytocin
Indications
Unfavourable cervix
Contraindications
Hypersensitivity to
Prostaglandin
Grandmultiparity gel
High parity (>3) pessary
Previous uterine surgery
High presenting part
Malpresentation
Indications
Unfavourable cervix
Contraindication
Low lying placenta
Cautions
Antepartum bleeding
Rupture of membranes
Cervicitis
Monitor FHR appropriate to
clinical circumstances
If not spontaneously expelled
within 12 hours then obstetric
review
Trans-
cervical
Catheter
Indications
Favourable cervix
Cautions
Avoid with high head
Monitor FHR immediately
post procedure
Document liquor colour/
consistency
Mobilise
ARM
Indications
Offer at 39 - 40 weeks
Contraindications
Low lying placenta
Elective caesarean section
is planned
Monitor FHR appropriate to
clinical circumstances
Advise may cause
discomfort, bleeding and
irregular contractions
Membrane
Sweep




Queensland Maternity and Neonatal Clinical Guideline: Induction of labour
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Abbreviations
ARM Artificial rupture of membranes; amniotomy
CS Caesarean section
CTG Cardiotocography
FGR Fetal growth restriction
FHR Fetal heart rate
GBS Group B streptococcus
GDM Gestational Diabetes Mellitus
IOL Induction of labour
IUFD Intrauterine fetal death
NICU Neonatal intensive care unit
PGE
2
Dinoprostone, Prostaglandin E
2

PPROM Preterm prelabour rupture of membranes
PROM Prelabour rupture of membranes
PV Per vaginam
RCT Randomised controlled trial
VBAC Vaginal birth after caesarean
VE Vaginal examination

Definition of Terms
Amniotomy Artificial rupture of membranes to initiate or speed up labour.
1

Cervical ripening
A prelude to the onset of labour whereby the cervix becomes soft and
compliant. This allows its shape to change from being long and
closed, to being thinned out (effaced) and starting to open (dilate). It
either occurs naturally or as a result of physical or pharmacological
interventions.
1

Dinoprostone Prostaglandin gel or pessary.
Expedited IOL PROM
Induction of labour (IOL) commencing between 2 and 12 hours after
prelabour rupture of membranes (PROM).
1

Expectant Management
Non-intervention at any particular point in the pregnancy, allowing
progress to a future gestational age. Intervention occurs only when
clinically indicated.
2

Favourable cervix
The cervix is said to be favourable when its characteristics suggest
there is a high chance of spontaneous onset of labour, or of
responding to interventions made to induce labour.
1

Fetal growth restriction
(FGR)
Also known as intrauterine growth restriction (IUGR). Fetal growth
restriction (FGR) indicates the presence of a pathophysiological
process occurring in utero that inhibits fetal growth.
3

Induction of labour
The process of artificial initiation of labour before its spontaneous
onset.
4

Mechanical method Non-pharmacological method of inducing labour.
1

Uterine hypercontractility
More than 5 contractions in 10 minutes for two consecutive 10 minute
intervals or a contraction lasting more than 2 minutes.
1

Obstetrician
Local facilities may differentiate the roles and responsibilities
assigned in this document to an Obstetrician according to their
specific practitioner group requirements; for example to General
Practitioner Obstetricians, Specialist Obstetricians, Consultants,
Senior Registrars, Obstetric Fellows or other members of the team as
required.
Prolonged pregnancy A pregnancy past 42
+0
weeks gestation.
1

Queensland Maternity and Neonatal Clinical Guideline: Induction of labour
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Table of Contents
1 Introduction ................................................................................................................................................... 6
1.1 Communication and information .......................................................................................................... 6
1.2 Indications ........................................................................................................................................... 6
1.3 Contraindications ................................................................................................................................. 6
1.4 Care if induction of labour declined ..................................................................................................... 6
1.5 Care if induction of labour postponed .................................................................................................. 7
1.6 Clinical standards ................................................................................................................................ 7
1.7 Membrane sweeping ........................................................................................................................... 7
2 Specific circumstances ................................................................................................................................. 8
2.1 Prolonged Pregnancy .......................................................................................................................... 8
2.2 Preterm prelabour rupture of membranes ........................................................................................... 8
2.3 Term prelabour rupture of membranes ................................................................................................ 9
2.4 Previous caesarean section ...............................................................................................................10
2.5 Obstetric cholestasis ..........................................................................................................................10
2.6 Diabetes .............................................................................................................................................11
2.7 Hypertensive disorders of pregnancy .................................................................................................11
2.8 Twin pregnancy ..................................................................................................................................11
2.9 Suspected fetal macrosomia (>4000grams) .......................................................................................12
2.10 Fetal growth restriction .......................................................................................................................12
2.11 Intrauterine fetal death........................................................................................................................13
2.12 Maternal request ................................................................................................................................13
2.13 Other maternal conditions ..................................................................................................................13
3 Pre induction of labour assessment .............................................................................................................14
3.1 Cervical assessment ..........................................................................................................................14
4 Methods of induction of labour .....................................................................................................................14
4.1 Dinoprostone ......................................................................................................................................15
4.1.1 Dinoprostone dose and administration ...........................................................................................16
4.2 Oxytocin infusion ................................................................................................................................17
4.2.1 Oxytocin administration ..................................................................................................................18
4.2.2 Oxytocin regimens .........................................................................................................................18
4.3 Artificial rupture of membranes ...........................................................................................................19
4.4 Transcervical catheters ......................................................................................................................20
5 Risks associated with induction of labour.....................................................................................................21
References ..........................................................................................................................................................22
Acknowledgements ..............................................................................................................................................26

List of Tables
Table 1. Membrane sweeping considerations ........................................................................................................ 7
Table 2. Prolonged pregnancy ............................................................................................................................... 8
Table 3. Preterm prelabour rupture of membranes ................................................................................................ 8
Table 4. Term prelabour rupture of membranes .................................................................................................... 9
Table 5. Previous caesarean section ................................................................................................................... 10
Table 6. Obstetric cholestasis .............................................................................................................................. 10
Table 7. Gestational diabetes/diabetes mellitus ................................................................................................... 11
Table 8. Hypertensive disorders of pregnancy ..................................................................................................... 11
Table 9. Twin pregnancy ...................................................................................................................................... 11
Table 10. Suspected fetal macrosomia ................................................................................................................ 12
Table 11. Fetal growth restriction ......................................................................................................................... 12
Table 12. Intrauterine fetal death ......................................................................................................................... 13
Table 13. Maternal request .................................................................................................................................. 13
Table 15. Modified Bishop score .......................................................................................................................... 14
Table 16. Dinoprostone considerations ................................................................................................................ 15
Table 17. Dinoprostone administration ................................................................................................................ 16
Table 18. Oxytocin considerations ....................................................................................................................... 17
Table 19. Oxytocin administration ........................................................................................................................ 18
Table 20. Oxytocin regimen ................................................................................................................................. 18
Table 21. Artificial rupture of membranes considerations .................................................................................... 19
Table 22. Transcervical catheter considerations .................................................................................................. 20
Table 23. Risk factors associated with IOL .......................................................................................................... 21
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour
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1 Introduction
Induction of labour (IOL) is a relatively common procedure. In 2009 the IOL rate in Queensland was
22.4%.
5
The aim of IOL is to achieve vaginal birth before the spontaneous onset of labour.

The purpose of this guideline is to guide the IOL process. Specific circumstances and methods of IOL
are included in this guideline.
1.1 Communication and information
Discuss the risks and benefits of IOL as they pertain to each individual woman to enable the woman
to make an informed decision in consultation with her health care provider.

In Queensland, only 27.1% of women who had an IOL reported having made an informed decision
6
:
Provide women with information on the
1,4
:
o Indications for IOL
o Potential risks and benefits of IOL
o Proposed method(s) of IOL
o Options for pain relief
o Options if IOL is unsuccessful
o Options if IOL is declined
Provide women with time for questions and decision making
Clear and contemporaneous documentation is required in the womans healthcare record
Consider the use of decision aids to assist the woman make informed choices
7

1.2 Indications
IOL is indicated when the maternal and/or fetal risks of ongoing pregnancy outweigh the risks of IOL
and birth. Specific circumstances are considered in section 2.2.
1.3 Contraindications
Contraindications to IOL are consistent with vaginal birth contraindications. Specific circumstances
where IOL is to be performed with caution are described in section 2.2.
1.4 Care if induction of labour declined
Women who decline IOL should have their decision respected. Usually, these are women who have
been offered IOL for prolonged pregnancy.

At 41 weeks or later gestation, it has been shown for those women who
8
:
Waited for labour to start 38% would choose to wait next time
Were induced 73% would choose an IOL next time

No form of increased antenatal monitoring has been shown to reduce perinatal mortality associated
with postterm pregnancy. However, it is recommended from 42 weeks, to offer increased antenatal
monitoring
9
consisting of twice weekly:
Cardiotocography (CTG)
10

Ultrasound assessment of amniotic fluid volume using:
o Estimation of maximum amniotic pool depth
10,11
, or
o Amniotic fluid index
12,13

Umbilical arterial Doppler ultrasound
12

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1.5 Care if induction of labour postponed
Take into account the womans individual clinical circumstances and preferences, the indication for
IOL and the local service capabilities and priorities when determining if a booked IOL can be
postponed (e.g. due to resourcing issues or as a result of maternal request). When a booked
induction of labour is postponed:
Perform an assessment of maternal and fetal wellbeing
Involving the woman, develop a plan for continued care including, arrangements for
ongoing monitoring (if required) and return for IOL
Document the assessment and plan in the health record
Advise the woman to contact the facility if she has concerns about her wellbeing or that of
her baby
1.6 Clinical standards
When offering IOL:
Consider the service capabilities of the facility
Ensure availability of health care professionals appropriate to the circumstances
Continuous electronic fetal heart monitoring and uterine contraction monitoring should be
available
1

1.7 Membrane sweeping
Membrane sweeping refers to the digital separation of the fetal membranes from the lower uterine
segment during vaginal examination. This movement helps to separate the cervix from the
membranes and helps to stimulate the release of prostaglandins. Table 1 outlines considerations for
membrane sweeping.
Table 1. Membrane sweeping considerations
Membrane sweeping
Indication
Is not a method of IOL
Is used to reduce the need for formal IOL by encouraging spontaneous
labour
Risk/Benefit
From 38-40 weeks onwards, significantly reduced pregnancies beyond 41
weeks
14

Repeated membrane sweeping has been found to decrease the proportion
of postterm pregnancies
15

Reduced need for formal IOL
16
, particularly in multiparous women
15

Limited data on risk in Group B streptococcus (GBS) carriers
17

No evidence of increased risk of maternal or neonatal infection
14

Associated with discomfort
14,15
, vaginal bleeding and irregular
contractions
14

Most women would choose membrane sweeping again
15

Optimal frequency unknown. Practice varies from weekly to several times a
week
1,14

Recommendations
Consider offering membrane sweep at 39-40 weeks, especially to low risk
multiparous women
18

Advise of the benefits of repeated membrane sweeping
If the cervix is closed and membrane sweeping is not possible, cervical
massage in vaginal fornices may achieve similar effect
1


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2 Specific circumstances
Considerations for specific IOL indications are outlined in the following sections.
2.1 Prolonged Pregnancy
Table 2. Prolonged pregnancy
Prolonged pregnancy
Risk/Benefit
The risk of fetal death increases significantly with gestational age
19
:
o At 38 weeks gestation 0.25%
o At 42 weeks gestation 1.55%
IOL at 41 weeks or beyond compared with awaiting spontaneous labour
for at least one week is associated with
13
:
o Fewer perinatal deaths 1/3285 (0.03%) versus 11/3238 (0.34%)
o No significant difference in the risk of caesarean section for women
induced at 41 and 42 weeks
o Lower risk of meconium aspiration syndrome at 42 weeks (3.0%
versus 4.7%), and significantly lower risk at 41 weeks (0.9% versus
3.3%)
Most women prefer IOL at 41 weeks over serial antenatal monitoring
19

Recommendations
For women with uncomplicated pregnancies, recommend IOL between 41
and 42 weeks
1,20

Waiting after 42 weeks is not recommended
1,20,21

Exact timing depends on the womens preferences and local
circumstances

2.2 Preterm prelabour rupture of membranes
Table 3. Preterm prelabour rupture of membranes
Preterm prelabour rupture of membranes
Risk/Benefit
Gestation between 34
+0
36
+6

IOL versus expectant management:
o Reduces chorioamnionitis
22,23

o Reduces maternal length of stay
22

o Insufficiently sized studies to determine difference in:
Neonatal sepsis
22,23

Respiratory distress
23

Newborn intensive care resource use
23

Decreased neonatal intensive care unit (NICU) length of stay and
hyperbilirubinaemia is demonstrated if delivery occurs after, rather than
before, 34 weeks
24

Gestation less than 34 weeks
Birth before 34 weeks is associated with increased neonatal mortality
25
,
adverse neonatal outcomes
25
including respiratory distress syndrome
24
,
intraventricular haemorrhage
24
, necrotising enterocolitis
24
and other long
term complications
25

Mortality and morbidity increase with decreasing gestational age
25

Recommendations
Gestation between 34
+0
36
+6

Decision should be based on discussion with the woman and her partner
and on the local availability of Special Care Nursery/ NICU facilities
Gestation less than 34 weeks
IOL is not recommended unless there are additional obstetric or fetal
indications
1

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2.3 Term prelabour rupture of membranes
Table 4. Term prelabour rupture of membranes
Term prelabour rupture of membranes (PROM)
Risk/Benefit
Spontaneous labour commences
26

o Within 24 hours in 70% of women
o Within 48 hours in 85% of women
o This may decrease the need for continuous fetal heart rate (FHR)
monitoring
IOL is perceived as being more painful. These women may have a greater
need for epidural analgesia
27

A policy of expedited IOL compared to expectant management
decreases
28
:
o Admissions to the NICU from 17% to 12.6%
o Chorioamnionitis from 9.9% to 6.8%
o Postpartum endometritis from 8.3% to 2.3%
o No differences in caesarean section (CS) rate
Waiting greater than 96 hours is associated with higher risk of neonatal
sepsis
29

Women with planned management are more likely to view their care more
positively than expectantly managed women
29

When associated with GBS:
o Compared to expectant management and IOL with Dinoprostone,
IOL with Oxytocin is associated with lower rate of neonatal infection
2.5% versus greater than 8%
30

Recommendations
To confirm PROM, offer sterile speculum vaginal examination (VE)
Discuss expectant management (provided a digital VE has not been
performed) and expedited management
Recommend expedited IOL
If the woman wishes to await spontaneous labour:
o Digital VE should not be performed
If a digital VE has been performed, the use of prophylactic
antibiotics while awaiting the onset of spontaneous labour is
recommended
o Waiting greater than 96 hours is not recommended
In the woman known to be GBS positive advise expedited IOL with
Oxytocin
30

Refer to Guideline: Early onset Group B streptococcal disease
31


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2.4 Previous caesarean section
Table 5. Previous caesarean section
Previous caesarean secti on
Risk/Benefit
Dinoprostone (Prostin, Prostaglandin E
2
) gel and pessary are widely used
in the UK, with good effect
1

Data on risk of uterine rupture are mainly based on retrospective studies
32

The risk of uterine rupture with
33
:
o Spontaneous labour is 4/1000
o Augmentation with Oxytocin is 9/1000
o Induction with Oxytocin is 11/1000
o Induction with Prostaglandin with/without Oxytocin is 14/1000
o Induction with mechanical methods with/without Oxytocin 9/1000
In a large study, neither induction nor augmentation of labour was
associated with uterine rupture, compared to women who labour
spontaneously. However risk of uterine rupture increased when both
Oxytocin and Prostaglandin were used for labour induction
34

Recommendations
Taking into account individual circumstances, discuss IOL, CS and
expectant management
1

Inform women of the increased risk of CS and uterine rupture

in IOL
1,35

Discuss decisions about care with the responsible obstetrician
36

Refer to guideline: Vaginal birth after caesarean section (VBAC)
37

2.5 Obstetric cholestasis
Table 6. Obstetric cholestasis
Obstetric chol estasis
Risk/Benefit
There is no quality evidence to recommend best management
38

Is associated with increased risk of
39
:
o Intrauterine fetal death (IUFD) 2%
o Preterm birth 44%
o Meconium staining of liquor 25-45%
90% of fetal deaths occur after 37 weeks
39

A correlation has been shown between serum bile acid levels and fetal
complication rates
39,40
:
o Bile acids of less than 40 micromol/L were associated with no
increase in fetal risk
o Ursodeoxycholic acid has been shown to reduce serum bile acid
levels. It is uncertain if this translates to reduced perinatal risk
41,42

o Poor fetal outcome is associated with
43
:
Deteriorating biochemical tests
Unresponsiveness to Ursodeoxycholic acid
CTG and Doppler surveillance have no role in the prediction of perinatal
risk
40

IOL at 37 weeks or at time of diagnosis, before or after 37 weeks, had a
decreased risk of IUFD:
o 0/218 (0%) compared to 14/888 (1.6%) for historical controls in the
literature
44

Recommendations
Decision to deliver should be made on an individual basis
Based on weak evidence, IOL may be recommended at 37 weeks
Consider IOL at 35-37 weeks for severe cases with jaundice
39
,
progressive elevations in serum bile acids
39
and liver enzymes, and
suspected fetal compromise
39


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2.6 Diabetes
Table 7. Gestational diabetes/diabetes mellitus
Gestational diabetes (GDM)/diabetes mell itus
Risk/Benefit
27% of non-malformed stillbirths in women with pre-existing diabetes
occur after 37 completed weeks
45

In women with GDM on insulin, comparing IOL in the 38
th
week with
expectant management
,
showed
46
:
o Reduced macrosomia in the IOL group, 10% versus 23%
o No difference in caesarean section rates
o A non-significant increase in shoulder dystocia in the expectant
group
Diet controlled, mild GDM is associated with good pregnancy outcome
47

o No data on risk of perinatal mortality after 40 weeks
Recommendations
Until quality evidence becomes available, offer delivery at 38 weeks to
women with diabetes requiring insulin
46

Advise women with well-controlled, diet controlled GDM, and no fetal
macrosomia or other complications, to await spontaneous labour unless
there are other indications for IOL
2.7 Hypertensive disorders of pregnancy
Table 8. Hypertensive disorders of pregnancy
Hypertensive disorders of pregnancy
Risk/Benefit
The only cure for pre eclampsia is birth
1,14,48

In non-severe hypertension, compared to IOL, expectant management
showed increased poor maternal outcome, using a composite measure:
o 44% compared to 31% in IOL group
o No differences in composite neonatal outcome
Recommendations
Consider individual circumstances when determining timing of birth
Consider delivery where hypertension initially diagnosed after 37 weeks
Consider vaginal birth unless a caesarean section is required for other
obstetric indications
4,49

Refer to Guideline: Hypertensive disorders of pregnancy
50

2.8 Twin pregnancy
Table 9. Twin pregnancy
Twin pregnancy
Risk/Benefit
Optimal timing for uncomplicated twin pregnancy is uncertain
51

Retrospective studies demonstrate:
o Perinatal mortality rate is lowest for birth at 37 weeks gestation
52

o An increase in stillbirth, particularly from 38 weeks
53

o An underpowered randomised controlled trial (RCT) comparing
expectant management with IOL at 37 weeks showed no statistical
difference in CS, CS for fetal distress or perinatal death
54

In uncomplicated twin pregnancy there is insufficient data to support the
practice of planned birth from 37 weeks
51

The main determinant of risk in a multiple pregnancy is chorionicity and
this may influence decisions regarding the timing of delivery in individual
cases
Recommendations
Taking into account individual circumstances, plan birth soon after 38
+0

weeks
53

Refer for specialist consultation when risk factors, such as twin-to-twin
transfusion syndrome, indicate the need

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2.9 Suspected fetal macrosomia (>4000grams)
Table 10. Suspected fetal macrosomia
Suspected fetal macrosomia
Risk/Benefit
Accuracy of estimating fetal weight varies
55
:
o From 15-79% using ultrasound
o From 40-52% using clinical judgement
Comparing IOL and expectant management there are no significant
differences in
56
:
o CS rate
o Instrumental birth
o Perinatal morbidity although 6/189 cases of brachial plexus injury
or fractured clavicle were found in the expectant group and 0/183 in
the IOL group, the difference was not statistically different
Recommendations
In the absence of other indications, IOL should not be recommended
simply on suspicion that a baby is macrosomic
1,21,56

However, it is important to discuss and consider maternal concerns
2.10 Fetal growth restriction
Table 11. Fetal growth restriction
Fetal growth restriction
Risk/Benefit
There are no clear guidelines supported by strong evidence on timing of
delivery when fetal growth restriction (FGR) has been diagnosed
57

Use of umbilical artery and ductus venosus Doppler has been shown to
assist in improving perinatal outcome
57

Preterm FGR
The GRIT study comparing expectant versus immediate birth (IOL and
CS) between 24-36 weeks showed:
o Expectant group
58

Prolonged pregnancy by 4 days
Decreased CS rate (79% versus 91%)
Increased stillbirth rate (3.1% versus 0.7%)
Decreased post birth death rate, prior to discharge (6.2%
versus 9.1%)
o At two years
59
:
Similar rates of mortality
More severe disability noted in immediate birth group if less
than 31 weeks at birth
Term FGR
Small pilot RCT, with a total of only 33 cases, comparing expectant
versus immediate birth at term, showed no significant difference in
60
:
o Obstetric interventions, for example CS
o Neonatal morbidity
Recommendations
In term and preterm pregnancies with FGR there is little evidence to guide
timing of birth
1

Timing of birth will depend on gestational age, severity of FGR and results
of tests of fetal well being
Recommend expedited birth for a woman with FGR diagnosed at term
61

Severity affects the decision of the most appropriate mode of birth
58



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2.11 Intrauterine fetal death
Table 12. Intrauterine fetal death
Intrauterine fetal death
Risk/Benefit
There is no evidence addressing immediate versus delayed IOL
1

Many women go into spontaneous labour within 2-3 weeks of IUFD
Risk of coagulopathy is usually only of concern after 4 weeks
62

Recommendations
Support the woman's preferences regarding timing of IOL:
o Delaying IOL for a few days should be supported, if desired,
provided:
Membranes are intact
No evidence of infection
1

2.12 Maternal request
Table 13. Maternal request
Maternal request
Risk/Benefit
There are no studies that address this group specifically
1

In uncomplicated pregnancies consider the risk of neonatal respiratory
distress syndrome and related adverse effects
13

Recommendations
Consider IOL based on exceptional circumstances of the woman and her
family
2.13 Other maternal conditions
Table 14. Other maternal conditions
Anticoagulant therapy and maternal cardiac condition
Risk/Benefit
For a woman on anticoagulant therapy, IOL is timed around the
medication protocol
63

For maternal cardiac conditions, the objective of care is to minimise the
additional load on the cardiovascular system, ideally through spontaneous
onset of labour
63

Recommendations
A multidisciplinary team, consisting of an obstetrician, cardiologist or
physician as appropriate, anaesthetist, and midwife is essential
Involve an intensivist and neonatologist as required
63

Develop a plan for peripartum management of anticoagulant therapy
(prophylactic or therapeutic)
64

If receiving anticoagulant therapy, wean and cease prior to IOL
For a woman with a maternal cardiac condition, plan for an IOL when
required
63
:
o Anticoagulant therapy protocol
o Availability of medical staff
o Deteriorating maternal cardiac function
Refer to Guideline: Venous thromboembolism (VTE) prophylaxis in
pregnancy and the puerperium
64

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3 Pre induction of labour assessment
Prior to IOL an assessment of the woman should include:
Review of maternal history
Confirmation of gestation
o Reliable menstrual dates supported by early ultrasound examination
o Ultrasound scan may be more reliable even in women who are sure of last menstrual
period
12

Abdominal palpation to confirm presentation and engagement
Assessment of membrane status (ruptured or intact)
4

Vaginal examination to assess the cervix
o Refer to Section 3.1
Assessment of fetal wellbeing
o A normal fetal heart rate pattern should be confirmed using electronic fetal
monitoring
1

o Consult an obstetrician if cardiotocograph (CTG) is abnormal
Assessment of contraindications
Consideration of urgency of IOL

3.1 Cervical assessment
The Bishop score is commonly used to assess the cervix. Each feature of the cervix is scored and
then the scores are summed. Table 15 provides an example of a modified Bishop score
65
.
The state of the cervix is one of the important predictors of successful IOL
4

The cervix is unfavourable if the score is 6 or less
4

Table 15. Modified Bishop score
Cervical feature
Score
0 1 2 3
Dilation (cm) <1 1-2 3-4 >4
Length of cervix (cm) >3 2 1 <1
Station (rel ative to ischial spines) -3 -2 -1 / 0 +1 / +2
Consistency Firm Medium Soft
Position Posterior Mid Anterior

4 Methods of induction of labour
Methods used for IOL include:
Medical methods
o Dinoprostone preparations (Prostaglandin E
2
, PGE
2
, PG gel, Prostin E
2
, Cervidil)
o Oxytocin infusion
Surgical methods
o Artificial rupture of membranes (ARM)
Mechanical methods
o Transcervical catheter (Foley or Atad)
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4.1 Dinoprostone
Dinoprostone (vaginal Prostaglandin E
2
) promotes cervical ripening and stimulates uterine
contractions. [refer to Table 16 and Table 17]. Dinoprostone preparations include:
Vaginal gel (Prostaglandin E
2
, PGE
2
, PG gel, Prostin E
2,
, gel) 1mg and 2 mg
Controlled release vaginal pessary (Cervidil)
Table 16. Dinoprostone considerations
Consideration Dinoprostone
Indications Unfavourable cervix
Contraindications
Known hypersensitivity to Dinoprostone or other constituents
66,67

Ruptured membranes pessary contraindicated
67,68

Multiple pregnancies
68

High parity
o Gel - parity greater than 4
66
and
o Pessary - parity greater than 3
67

Previous CS or any uterine surgery
66,67,68

Malpresentation / high presenting part
66

Unexplained vaginal discharge and / or uterine bleeding during current
pregnancy
66,67,68

Cautions
Use caution in women with asthma due to potential bronchoconstriction
68

Ruptured membranes use gel with caution
68

Oxytocin administration
66,67,68

Epilepsy
68

Cardiovascular disease
68

Raised intraocular pressure, glaucoma
68

Risk/Benefit
Nausea, vomiting and diarrhoea may occur soon after insertion
68

Increased risk of hyperstimulation with or without FHR abnormality in
approximately 4% of women
69

Incidence of CS is not increased
69

The risk of hyperstimulation is higher with the pessary than with the gel
(4.5% versus 2.4%)
70

Risk of hyperstimulation is higher if Oxytocin is also used
71

Compared to IOL with Oxytocin refer to Table 18
For a woman with an unfavourable cervix, the pessary may be more
appropriate as it will avoid repeated application of the gel. Conversely,
the gel may be more appropriate for a woman with a favourable cervix
1

Monitoring
Prior to insertion, encourage voiding
Perform CTG to confirm fetal well being
Remain recumbent (to retain gel) left lateral (to prevent supine
hypotension) for 30 minutes after insertion
Perform CTG after insertion (minimum 30 minutes)
Temperature, BP, pulse, per vaginam (PV) loss, uterine activity - hourly
for 4 hours
Advise the woman to inform staff as soon as contractions commence
When contractions commence, confirm fetal wellbeing with continuous
CTG
1
for 30 minutes:
o If applicable, remove pessary
o Intermittent FHR auscultation may be used as in normal
spontaneous labour unless concerns are identified
1

Assessment of
progress
If contractions do not commence, reassess the modified Bishop score:
o Dinoprostone gel 6 hours after insertion
68

o Dinoprostone pessary 12 hours after insertion
68

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4.1.1 Dinoprostone dose and administration
Table 17. Dinoprostone administration
Aspect Dinoprostone admini stration
Dose
Dinoprostone gel
Initial dose:
o Nulliparous 2 mg PV
72

o Multiparous 1 mg PV
Repeat dose, after 6 hours:
o Nulliparous 2 mg
o Multiparous 1-2 mg

Dinoprostone pessary
10 mg PV (released at a rate of approximately 4 mg in 12 hours)
69

Maximum dose
Dinoprostone gel
Maximum 3 mg over 6 hours
68


Dinoprostone pessary
4 mg (12 hours after insertion)
67

There is no information on the use of Dinoprostone if no cervical change
after pessary insertion
67

To avoid hyperstimulation, the gel should not be inserted within 6 hours
of pessary removal
Admini stration
Dinoprostone gel
Use water soluble lubricants (not obstetric cream)
Remove from refrigeration and stand at room temperature for at least 30
minutes prior to use
66

Insert into the posterior fornix of the vagina
66

Not for intracervical administration
66

Advise recumbent and left lateral position for 30 minutes after insertion
66

to facilitate absorption

Dinoprostone pessary
Remove from freezer or fridge immediately prior to use
67

Can be stored in the fridge for up to one month after removal from the
freezer
67

Warming is not required
67

Open the foil only after decision has been made to use it
Use water soluble lubricants (not obstetric cream)
Insert into the posterior fornix of the vagina
68
in transverse position
67

Ensure sufficient tape outside vagina to allow removal
67

Remain recumbent for 30 minutes
67

Advise women to avoid inadvertent removal of pessary and to report if
pessary falls out
Side effects Uterine hypercontractility [For management: refer Section 5]
Indications for
Removal
Dinoprostone pessary
67

Onset of regular uterine contractions
Membranes rupture (spontaneous or ARM)
Fetal distress
Uterine hypercontractility
Insufficient cervical ripening after 12 hours
o At the obstetricians discretion, Dinoprostone gel 2 mg may be
inserted 30 minutes after removal of the Dinoprostone pessary

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4.2 Oxytocin infusion
Oxytocin stimulates the smooth muscle of the uterus producing rhythmic contractions. Syntocinon is
synthetic Oxytocin [refer to Table 18].
Table 18. Oxytocin considerations
Consideration Clinical practice point
Indications
IOL using ARM and intravenous Oxytocin infusion is the preferred method
once the cervix is favourable
73

Cautions
Should not be started within 6 hours of administration of vaginal
Prostaglandin gel administration
Should not be used with Dinoprostone pessary insitu or within 30 minutes
of its removal
67

If not already ruptured, perform ARM prior to initiation of Oxytocin infusion
Oxytocin should be used with caution in women with previous uterine scar
or high parity (greater than 4).
71
Discuss with an obstetrician prior to
commencement
Risk/Benefit
Compared to IOL with vaginal Prostaglandin:
o Is associated with more failures to achieve vaginal birth within 24
hours
74

o Shows no significant difference in caesarean birth rates
74

o Increased the need for epidural
74

o Mobility is restricted
1

o Refer to Table 16 for Dinoprostone considerations
Is associated with lower infection rates in both mother and baby when
membranes are ruptured at the time of IOL
74

Oxytocin induced contractions may be perceived as more painful
Monitoring
Provide one-to-one midwifery care
4

Use continuous electronic FHR monitoring once Oxytocin infusion
commenced
75,71

Titrate dose to achieve 3-4 strong regular contractions in 10 minutes
Assess maternal observations and FHR prior to any increase in the
infusion rate
Maternal observations (more frequently if clinically indicated)
o Temperature 2 hourly
o BP hourly
o Pulse hourly
o Vaginal loss hourly
Maintain fluid balance as water intoxication may result from prolonged
infusion
71
(rare with the use of isotonic solutions)
Assess pain relief requirements
Assessment of
progress
Commence the partogram or intrapartum record with the start of the
infusion
When labour established, consider the use of alert and action lines to
monitor progress

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4.2.1 Oxytocin admini stration
Table 19. Oxytocin administration
Consideration Oxytocin admini stration
Admini stration
Use a volumetric pump to ensure an accurate rate of infusion
4,71

o Consider the need for sideline/secondary IV access as per local
protocols
A standard dilution of Oxytocin should always be used
Individual protocols should specify maximum doses
The dose should be titrated against uterine contractions
o Titration should occur at 30 minute or greater intervals
4

o Aim for 3-4 contractions in a 10 minute period with duration of 40-60
seconds and resting period not less than 60 seconds
Use the minimum dose required to establish and maintain active labour
4

Record the dose in milliunits per minute
Mark changes to dose clearly and contemporaneously on the CTG and / or
intrapartum record
Maximum dose
Review by an obstetrician should occur before exceeding a dose of 20
milliunits per minute
Side effects
Cardiovascular disturbances (e.g. bradycardia, tachycardia)
71

Headache
71

Gastrointestinal disorders (e.g. nausea, vomiting)
71

Cease infusion if:
Uterine activity becomes hypertonic
71

Resting uterine tone increases
71

Fetal compromise occurs (any concerning FHR abnormality)
71

Consult with an obstetrician before recommencing infusion

4.2.2 Oxytocin regimens
The ideal dosing regime of Oxytocin is unknown.
4
Suggested regimens are outlined in Table 20.
Table 20. Oxytocin regimen
Time after
starting
(minutes)
Oxytocin dose
(milliunits per
minute)
Volume infused (mL/hour)
10 IU in
500 mL
20 IU in
1000 mL
30 IU in
500 mL
0 1 3 3 1
30 2 6 6 2
60 4 12 12 4
90 8 24 24 8
120 12 36 36 12
150 16 48 48 16
180 20 60 60 20
Obstetrician review prior to exceeding 20 milliunits per minute
210 24 72 72 24
240 28 84 84 28
270 32 96 96 32

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4.3 Arti ficial rupture of membranes
Table 21. Artificial rupture of membranes considerations
Artificial rupture of membranes (ARM)
Indications
Favourable cervix Bishop score 7 or more
76

May be used alone especially in a multiparous woman (may initiate
contractions) or in combination with Oxytocin infusion
76

Cautions
Caution should be exercised where the head is high due to the risk of
cord prolapse
1
[refer to Section 5]
Risk/Benefit
Risk of pain, discomfort, bleeding
76

May shorten length of labour by speeding up contractions
77

Nulliparous women with ARM and immediate Oxytocin compared to
delayed Oxytocin (commenced 4 hours post ARM) showed
78
:
o Increased rate of established labour 4 hours after ARM
o Shorter ARM to birth interval
o Increased rate of vaginal birth within 12 hours
o Increased satisfaction with the induction process and the duration
of labour
Monitoring
Before ARM:
o Explain the procedure to the woman
79

o Abdominal palpation to determine descent
80

o Assess for possible cord presentation
o Consult obstetrician if the head is not engaged
80
or with possible
cord presentation
Immediately after ARM, examine to ensure there is no cord prolapse
Refer to Table 23 for risk factors associated with IOL including cord
prolapse
Monitor FHR immediately following procedure
75
preferably by continuous
electronic monitoring. Confirm normal CTG before discontinuing
Document liquor colour and consistency
Encourage mobilisation to promote onset of uterine contractions
Following ARM, consider Oxytocin in:
o Multiparous women: if no contractions after 2 hours
o Nulliparous women: immediately following ARM as few women will
commence contractions spontaneously unless the cervical score is
7 or more
73


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4.4 Transcervical catheters
Transcervical catheters (e.g. Foley, Atad) are used to ripen the cervix through:
Direct dilatation of the canal or
Indirectly by increasing prostaglandin and/or oxytocin secretion
81

Table 22. Transcervical catheter considerations
Consideration Comment
Indications
May be particularly useful where the cervix is unfavourable
May be used where Dinoprostone has had no effect on cervical ripening
May be considered in women with previous CS
Cautions
Contraindication:
o Low lying placenta
81

Cautions:
o Antepartum bleeding
4

o Rupture of membranes
4

o Cervicitis
4

Risk/Benefit
Low cost and no specific storage or temperature requirements
81

No evidence of an increased risk of chorioamnionitis or endometritis
although data is limited
81

May be associated with slight vaginal bleeding
In women with a very unfavourable cervix, use seems to reduce failed
IOL when compared to IOL with Oxytocin alone
81

Monitoring
Monitor FHR as appropriate to individual clinical circumstances
If after 12 hours, the catheter has not spontaneously fallen out, obstetric
review is indicated
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5 Risks associated with induction of labour
IOL may increase the risk of the following conditions outlined in Table 23.
Table 23. Risk factors associated with IOL
Risk Good Practi ce Point
Failed IOL
The criteria for failed IOL are not generally agreed
1

Recommended care options include
1
:
o Review the individual clinical circumstances
o Assess fetal wellbeing using CTG
o Discuss options for care with the woman
o If appropriate consider discharging home for 24 hours followed by
second attempt at IOL
o Caesarean section
Uterine
hypercontractility
Attempt removal of any remaining Dinoprostone gel
82

Remove Dinoprostone pessary if still in situ
82

Stop Oxytocin infusion
1
while reassessing labour and fetal state
Position woman left lateral
Assess BP and FHR
Commence intravenous hydration if not contraindicated by maternal
condition
Pelvic exam to assess cervical dilation
If persists use tocolytics
1
:
o Terbutaline 250 micrograms subcutaneously
73

o Salbutamol 100 micrograms by slow intravenous (IV) injection
75

o *Sublingual Glyceryl Trinitrate (GTN) spray 400 micrograms
75

If clinically indicated perform emergency CS
1

Cord prolapse
Is a potential risk at the time of membrane rupture especially with ARM
1

Is an obstetric emergency
1

Precautions should include
1
:
o Assessment of engagement of the presenting part
o Caution during ARM if the babys head is high
Uterine rupture
Uterine rupture is an uncommon event with IOL
1

Uterine rupture is a life-threatening event for mother and baby
If suspected, prepare for an emergency CS,
1
uterine repair or
hysterectomy
*Not currently listed on the Queensland Health List of Approved Medications (LAM)
Not TGA approved for this purpose
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Acknowledgements
The Queensland Maternity and Neonatal Clinical Guidelines Program gratefully acknowledge the
contribution of Queensland clinicians and other stakeholders who participated throughout the
guideline development process particularly:

Working Party Cl inical Lead
Associate Professor Kassam Mahomed, Senior Staff Specialist, Obstetrics and Gynaecology,
Ipswich Hospital and University of Queensland

Working Party Members
Dr Michael Beckman, Director Obstetrics and Gynaecology, Mater Health Services, Brisbane
Dr Lindsay Cochrane, Staff Specialist, Caboolture Hospital
Ms J ennifer Fry, A/Midwife Educator, Womens Health, Darling Downs West Moreton District Health
Service
Professor Michael Humphrey, Clinical Adviser, Office of Rural and Remote Health
Associate Professor Rebecca Kimble, Clinical Director, Obstetric Services, Royal Brisbane and
Womens Hospital
Ms Sarah Kirby, Midwifery Unit Manager, Royal Brisbane and Womens Hospital
Associate Professor Alka Kothari, Obstetrician, Redcliffe Hospital
Dr David Moore, Obstetric Registrar, Ipswich Hospital
Ms Gloria OConnor, Clinical Midwife, Redcliffe Hospital
Ms J essie Offer, Consumer, Home Midwifery Association
Ms Pamela Sepulveda, Clinical Midwifery Consultant, Logan Hospital
Ms Rachel Thompson, Health Psychology Academic, Queensland Centre for Mothers and Babies
Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Womens Hospital
Ms Robin Turnbull, Network Coordinator, South Queensland and Maternity and Neonatal Clinical
Network

Program Team
Associate Professor Rebecca Kimble, Program Director, Queensland Maternity and Neonatal Clinical
Guidelines Program
Ms J acinta Lee, A/Manager, Queensland Maternity and Neonatal Clinical Guidelines Program
Ms J ackie Doolan, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program
Ms Lyndel Gray, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program
Mr Keppel Schafer, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines
Program
Steering Committee, Queensland Maternity and Neonatal Clinical Guidelines Program


Funding
This clinical guideline was supported by funding from Centre of Healthcare Improvement,
Queensland Health