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All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jun 2019. | This topic last updated: Jun 26, 2019.
INTRODUCTION
● (See "Cervical ripening and induction of labor in women with a prior cesarean
delivery".)
PREVALENCE
Between 1990 and 2012, the overall frequency of labor induction more than
doubled in the United States, rising from 9.5 in 1990 to a high of 23.8 percent in
2010, before declining to 23.3 percent in 2012 [1].
The only interventions to effect delivery before onset of spontaneous labor are
induction of labor and cesarean delivery. Induction is generally preferred when
there are no contraindications to labor and vaginal birth, given the increased
maternal risks associated with cesarean delivery. (See 'Contraindications' below
and "Cesarean delivery: Postoperative issues".)
● Fetal demise (see "Late fetal death and stillbirth: Maternal care")
Some maternal disease states and fetal anomalies also warrant labor induction.
These are discussed in UpToDate topics that review management of specific
maternal and fetal disorders.
CONTRAINDICATIONS
● Prior classical or other high-risk cesarean incision (see "Choosing the route of
delivery after cesarean birth", section on 'Prior transfundal uterine incision')
● Prior uterine rupture (see "Choosing the route of delivery after cesarean birth",
section on 'Prior uterine rupture')
● Prior transmural uterine incision entering the uterine cavity (see "Pregnancy in
women with uterine leiomyomas (fibroids)", section on 'Management of
patients with prior myomectomy')
● Active genital herpes infection (see "Genital herpes simplex virus infection
and pregnancy", section on 'Route of delivery')
● Category III fetal heart rate tracing (see "Management of intrapartum category
I, II, and III fetal heart rate tracings", section on 'Category III pattern')
ELECTIVE INDUCTION
Based on the results of this trial, the American College of Obstetricians and
Gynecologists concluded that offering elective induction of labor to low-risk
nulliparous women at 39 weeks of gestation is a reasonable option that should be
a shared decision of a woman and her obstetric provider, with consideration of
available resources [21]. The Society for Maternal-Fetal Medicine also concluded
that it is reasonable to offer elective induction to low-risk nulliparous women who
are ≥39+0 weeks of gestation and recommended that providers who choose this
approach ensure that women meet the eligibility criteria of the ARRIVE trial [22].
PREINDUCTION ASSESSMENT
● Evaluating the fetal heart rate pattern to assess whether there are clear
indications that the fetus is unlikely to tolerate initiation of labor
● Reviewing the patient's pregnancy and medical history for risk factors for
potential problems that may develop during labor and delivery
Patient preparation, laboratory studies, and labor management are generally the
same as in women in spontaneous labor (see "Management of normal labor and
delivery"). In addition, the indications for and alternatives to induction, planned
drugs and procedures including side effects and complications, and the possibility
of cesarean delivery or induction over several days should be discussed.
Despite its limitations, the Bishop score appears to be the best available tool for
assessing cervical status. Systematic reviews have concluded that the Bishop
score is as, or more, predictive of successful induction than fetal fibronectin [34]
or sonographic measurement of cervical length [35]. Cervical dilation is
considered to be the most important element of the Bishop score [34].
● Multiparous women
In preterm gestations, a study of labor induction using data from the National
Institute of Child Health and Human Development Consortium on Safe Labor
found that multiparity was the best predictor of vaginal delivery (multiparity versus
nulliparity: odds ratio [OR] 6.8, 95% CI 6.4-7.2, n = 6555 women) [44]. Higher
gestational age also was associated with vaginal delivery: Women <34 weeks of
gestation were less likely to deliver vaginally than those ≥34 weeks of gestation;
nevertheless, 57 percent of pregnancies induced at 24 to 28 weeks, 54 percent of
those induced at 28 to 31 weeks, and 67 percent of those induced at 31 to 34
weeks had a successful vaginal live birth.
The time of day when induction is started does not appear to be a factor in
success [45]. Early administration of neuraxial analgesia also does not appear to
be a factor in success [46]. (See "Adverse effects of neuraxial analgesia and
anesthesia for obstetrics", section on 'Effects on the progress and outcome of
labor'.)
PROCEDURE
In both low and high dose protocols, the dose is typically increased until labor
progress is normal or uterine activity reaches 200 to 250 Montevideo units (ie, the
peak strength of contractions in mmHg measured by an internal monitor
multiplied by their frequency per 10 minutes). Although there is no evidence-based
optimal upper limit for the oxytocin dose, most protocols will limit the oxytocin
infusion during labor with a live fetus in the third trimester to no more than 40
milliunits/minute.
There is no maximum cumulative dose limit for oxytocin that is known to improve
outcomes.
Side effects
While this meta-analysis found the practice was not associated with an increase in
neonatal infection, Group B Streptococcus (GBS) colonization status was not
specifically addressed. Subsequently, an observational study compared maternal
and neonatal outcomes following membrane stripping among GBS-positive (n =
135), GBS-negative (n = 361), and GBS-unknown (n = 46) women and found no
significant difference in adverse maternal or neonatal outcomes among groups
[87]. Most GBS-positive women received intrapartum GBS antibiotic prophylaxis.
Although these results are reassuring, the study did not have adequate power to
detect modest differences in less frequent outcomes and is subject to the
limitations of an observational design. We believe GBS colonization is not a
contraindication to membrane sweeping as there is no direct evidence of harm.
(See "Neonatal group B streptococcal disease: Prevention", section on 'Antepartum
procedures'.)
COMPLICATIONS
Tachysystole
● Induction of labor at term does not appear to be a risk factor for spontaneous
preterm birth in the subsequent pregnancy [127,128].
OUTCOME
A workshop convened by the United States National Institute of Child Health and
Human Development, Society for Maternal-Fetal Medicine, and American College
of Obstetricians and Gynecologists attempted to provide evidenced-based criteria
for reducing the number of cesarean deliveries performed for failed induction in
the latent phase of labor. The group proposed defining failed induction as: failure
to generate regular (eg, every 3 minutes) contractions and cervical change after at
least 24 hours of oxytocin administration, with artificial membrane rupture as soon
as feasible and safe [137]. The time devoted to cervical ripening is not included
when calculating the length of induction or diagnosing failed induction [138].
● For parous women, the 12 hour criteria essentially eliminated failed labor
induction as an indication for cesarean birth [136].
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also locate
patient education articles on a variety of subjects by searching on "patient info"
and the keyword(s) of interest.)
● Basics topic (see "Patient education: Labor and delivery (childbirth) (The
Basics)")
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge Deborah A Wing, MD,
MBA, who contributed to an earlier version of this topic review.
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