Inducing labour

Why the committee made the recommendations

Based on their knowledge and experience the committee made recommendations on the advice that should be provided to all women in early pregnancy about mode of birth, the process of inducing labour, and the impact this may have on their place of birth, mode of birth and on their experience of birth. The committee also made recommendations about how these discussions may need to be revisited in later pregnancy, or if women decline induction.

There was evidence that caesarean birth, perinatal mortality and neonatal intensive care unit admission are reduced by earlier induction of labour (at 41+0 weeks) compared to later induction (at 42+0 weeks or after). However, there was not enough evidence, so the committee made a recommendation for research to identify the optimal timing of induction more precisely.

The committee were aware that data from the 2020 MBRRACE-UK report on perinatal mortality had shown that babies born to certain groups of women may be at higher risk of stillbirth and chose to highlight this in the guideline. As there was no evidence, the committee made a recommendation for research to identify the optimal timing of induction in groups of women who may be at higher risk of stillbirth.

How the recommendations might affect practice

The recommendations decrease the gestational age at which induction of labour is discussed to prevent prolonged pregnancy, and may increase the number of women who undergo induction. The recommendations on monitoring may also increase the number of women who decline induction and then choose to have additional monitoring. Both these factors may increase resource use in the NHS.

Return to recommendations 1.1.3 and 1.1.6

Return to recommendations 1.2.3 to 1.2.5, 1.2.8 and 1.2.9

Why the committee made the recommendations

The committee were aware of the recommendations in the NICE guideline on neonatal infection that advised immediate induction of labour or caesarean birth after preterm prelabour rupture of the membranes between 34+0 weeks and 37+0 weeks in women with a positive group B streptococcus test, and so added this recommendation to this section of the guideline.

Based on their knowledge and experience of the risks of group B streptococcal infection to the baby after rupture of the membranes, the committee agreed that with prelabour rupture of the membranes after 37+0 weeks in women with a positive group B streptococcus test, immediate induction of labour or caesarean birth would also be recommended.

In women who did not have a positive group B streptococcus test, but who had prelabour rupture of the membranes after 37+0 weeks, the committee were aware that expectant management for 24 hours was an option as the risk of infection to the baby was low. However, after that period, induction should be advised as the committee were aware that prolonged pregnancy at term after rupture of the membranes can increase risks to the baby, and they therefore advised that birth options should be discussed with women who choose not to have induction of labour after 24 hours.

How the recommendations might affect practice

The recommendations will reinforce current practice.

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Why the committee made the recommendations

There was some evidence of both benefits and harms for induction of labour and for expectant management in women without diabetes with suspected fetal macrosomia, but there was uncertainty around this evidence, particularly relating to the risk of perineal tears. As there was not enough evidence to recommend one method over another, the committee recommended that women should be provided with information about different modes of birth so they can make an informed decision, and that recruitment into relevant clinical trials should be supported.

How the recommendations might affect practice

Currently, there is variation in clinical practice and so the recommendations may mean an increase in consultation time to counsel women appropriately in some areas. This is not expected to lead to a substantial resource impact at national level.

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Why the committee made the recommendations

In the absence of evidence, the committee made recommendations based on their knowledge and experience and also made a recommendation for research on intrauterine fetal death after previous caesarean birth. The committee agreed that the different options for birth should be discussed with women after intrauterine fetal death if they have had a previous caesarean birth, and their choice should be respected. They also agreed that women with IUFD should be cared for on a one-to-one basis and monitored.

The committee explained that, after intrauterine fetal death, women with a scarred uterus are at increased risk of uterine rupture. This should be taken into account when considering options for birth and if induction is carried out, uterine contractions should be carefully monitored.

The committee discussed that mifepristone 600 mg daily for 2 days is approved for the induction of labour following intrauterine fetal death when prostaglandin or oxytocin cannot be used, but that no evidence for its safety or efficacy in women with a previous caesarean birth had been identified and so they were unable to recommend it. The committee discussed that in women with intrauterine fetal death and no previous caesarean birth a lower dose of mifepristone was used to sensitise the myometrium to prostaglandin-induced contractions, followed by a prostaglandin (dinoprostone or misoprostol). However, the committee were aware that both dinoprostone and misoprostol are contraindicated after previous caesarean birth and so made a recommendation to state this.

The committee recognised that mechanical methods of induction may be safe to use in women with a previous caesarean birth, and so they advised that these could be considered. This also brought the recommendations for induction after a previous caesarean birth for women with live babies or after intrauterine fetal death, in line with each other.

How the recommendations might affect practice

Currently, there is variation in the management of women after an intrauterine fetal death who have had previous caesarean birth, so the recommendations may mean an increase in consultation time to counsel women appropriately in some areas, and an increase in monitoring to reduce the risk of uterine rupture. This is not expected to lead to a substantial resource impact at national level.

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Why the committee made the recommendations

The committee agreed that, in their experience, women value being informed about the reason why certain treatments are offered, and that it should be made clear to women that the possible methods for induction of labour will depend primarily on the readiness of their cervix, which is assessed with a vaginal examination and recorded as the Bishop score.

There was good evidence that vaginal dinoprostone was effective at promoting vaginal birth within 24 hours for women with a Bishop score of 6 or less, without significantly increasing the risk of adverse outcomes for the woman or her baby. When the different preparations of vaginal dinoprostone were compared, there was little evidence to demonstrate that one preparation was superior to another. Therefore, the committee agreed that it was appropriate to offer a choice of preparation, depending on availability and the woman's preference. There was some evidence that dinoprostone preparations could lead to hyperstimulation with fetal heart rate changes.

Misoprostol was as effective as dinoprostone at promoting vaginal birth within 24 hours. There was evidence showing a risk of hyperstimulation with misoprostol, although this was predominantly with higher doses and vaginal preparations, and the committee took into consideration previous MHRA warnings relating to the misoprostol vaginal insert about this risk. The committee noted that, for the low dose oral preparations of misoprostol, the risk of hyperstimulation appeared to be the same or lower than with the dinoprostone vaginal preparations. Therefore, the committee agreed that misoprostol could be an alternative to dinoprostone for induction of labour, particularly for women who would prefer an oral preparation.

There was evidence that there was no increased risk of hyperstimulation when using mechanical methods for induction of labour (including osmotic cervical dilators and balloon catheters). Balloon catheters were also effective at promoting vaginal birth within 24 hours and did not appear to markedly increase the risk of other adverse outcomes. There was no evidence for the effectiveness of osmotic cervical dilators at promoting vaginal birth within 24 hours, but they too did not appear to markedly increase the risk of other adverse outcomes. Therefore, the committee agreed that these mechanical methods could be considered for induction of labour for women, particularly when there is a concern about hyperstimulation.

There was very little evidence for women with a Bishop score of more than 6. However, the committee noted that amniotomy and intravenous oxytocin was the most effective method to promote vaginal birth within 24 hours across the whole population. This was in keeping with their clinical experience, so they agreed that this should be the first choice for induction of labour for women in this group.

How the recommendations might affect practice

Most hospitals use the recommended methods for induction of labour already, so these recommendations will not result in a significant change of practice. The advice specific to women with a Bishop score of more than 6 should provide more individualised care and standardise practice for this subgroup of women.

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