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Department of Health

Maternity and Neonatal Clinical Guideline

Induction of labour

Queensland Clinical Guideline: Induction of labour

Document title:

Induction of labour

Publication date:

September 2011

Document number:

MN11.22-V4-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

April 2015

Replaces document:

MN11.22-V3-R16

Author:

Queensland Clinical Guidelines

Audience:

Health professionals in Queensland public and private maternity services

Review date:

September 2016

Endorsed by:

Queensland Clinical Guidelines Steering Committee


Statewide Maternity and Neonatal Clinical Network
Queensland Health Patient Safety and Quality Executive Committee

Contact:

Email: Guidelines@health.qld.gov.au
URL: www.health.qld.gov.au/qcg

Disclaimer
This guideline is intended as a guide and provided for information purposes only. The information has
been prepared using a multidisciplinary approach with reference to the best information and evidence
available at the time of preparation. No assurance is given that the information is entirely complete,
current, or accurate in every respect.
The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice.
Variation from the guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are
responsible for:

Providing care within the context of locally available resources, expertise, and scope of practice
Supporting consumer rights and informed decision making in partnership with healthcare practitioners
including the right to decline intervention or ongoing management
Advising consumers of their choices in an environment that is culturally appropriate and which
enables comfortable and confidential discussion. This includes the use of interpreter services where
necessary
Ensuring informed consent is obtained prior to delivering care
Meeting all legislative requirements and professional standards
Applying standard precautions, and additional precautions as necessary, when delivering care
Documenting all care in accordance with mandatory and local requirements

Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability
(including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred
for any reason associated with the use of this guideline, including the materials within or referred to
throughout this document being in any way inaccurate, out of context, incomplete or unavailable.
State of Queensland (Queensland Health) 2015

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to
copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines,
Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit
http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en
For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email Guidelines@health.qld.gov.au, phone
(07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48,
Brisbane Qld 4001, email ip_officer@health.qld.gov.au, phone (07) 3234 1479.

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Page 2 of 26

Queensland Clinical Guideline: Induction of labour

Flowchart: Induction of labour: summary of recommendations

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
Fetal growth restriction
IUFD
Maternal request
Other maternal conditions

Indications
Offer at 39 - 40 weeks
Membrane
Sweep

Contraindications
Low lying placenta
Elective caesarean section
is planned

Indications
Favourable cervix
ARM
Cautions
Avoid with high head

Monitor FHR appropriate to


clinical circumstances
Advise may cause
discomfort, bleeding and
irregular contractions

Monitor FHR immediately


post procedure
Document liquor colour/
consistency
Mobilise

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

Indications
Unfavourable cervix
Transcervical
Catheter

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

Cautions
Antepartum bleeding
Rupture of membranes
Cervicitis

Prostaglandin

Oxytocin

Monitor FHR appropriate to


clinical circumstances
If not spontaneously expelled
within 12 hours then obstetric
review

Contraindications
Hypersensitivity to
Prostaglandin
Grandmultiparity gel
High parity (>3) pessary
Previous uterine surgery
High presenting part
Malpresentation

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

Indications
Favourable cervix
o If cervix unfavourable
consider Dinoprostone
(PGE2)

Indications
Unfavourable cervix

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

Contraindication
Low lying placenta

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
Observations as per QCG
Normal birth guideline and
prior to IV Oxytocin rate
increase
Maintain fluid balance
Assess progress of labour

Queensland Clinical Guideline (QCG): Induction of labour. Guideline No. MN11.22-V4-R16

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Queensland Clinical Guideline: Induction of labour

Abbreviations
ARM
CS
CTG
FGR
FHR
GBS
GDM
IOL
IUFD
NICU
PGE2
PPROM
PROM
PV
RCT
TGA
VBAC
VE

Artificial rupture of membranes; amniotomy


Caesarean section
Cardiotocography
Fetal growth restriction
Fetal heart rate
Group B streptococcus
Gestational Diabetes Mellitus
Induction of labour
Intrauterine fetal death
Neonatal intensive care unit
Dinoprostone, Prostaglandin E2
Preterm prelabour rupture of membranes
Prelabour rupture of membranes
Per vaginam
Randomised controlled trial
Therapeutic Goods Administration
Vaginal birth after caesarean
Vaginal examination

Definition of Terms
1

Amniotomy

Artificial rupture of membranes to initiate or speed up labour.

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
1
interventions.

Dinoprostone

Prostaglandin gel or pessary.

Expedited IOL PROM


Expectant Management

Favourable cervix
Fetal growth restriction
(FGR)
Induction of labour
Mechanical method
Uterine hypercontractility

Obstetrician

Prolonged pregnancy

Induction of labour (IOL) commencing between 2 and 12 hours after


1
prelabour rupture of membranes (PROM).
Non-intervention at any particular point in the pregnancy, allowing
progress to a future gestational age. Intervention occurs only when
2
clinically indicated.
The cervix is said to be favourable when its characteristics suggest
there is a high chance of spontaneous onset of labour, or of
1
responding to interventions made to induce labour.
Also known as intrauterine growth restriction (IUGR). Fetal growth
restriction (FGR) indicates the presence of a pathophysiological
3
process occurring in utero that inhibits fetal growth.
The process of artificial initiation of labour before its spontaneous
4
onset.
1

Non-pharmacological method of inducing labour.

More than 5 contractions in 10 minutes for two consecutive 10 minute


1
intervals or a contraction lasting more than 2 minutes.
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.
+0
1
A pregnancy past 42 weeks gestation.

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Queensland Clinical Guideline: Induction of labour

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................................................................................................... 9
2.5
Obstetric cholestasis ............................................................................................................ 10
2.6
Diabetes ............................................................................................................................... 10
2.7
Hypertensive disorders of pregnancy .................................................................................. 11
2.8
Twin pregnancy ................................................................................................................... 11
2.9
Suspected fetal macrosomia (> 4000 grams) ...................................................................... 11
2.10 Fetal growth restriction ........................................................................................................ 12
2.11 Intrauterine fetal death ......................................................................................................... 12
2.12 Maternal request .................................................................................................................. 12
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
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 .................................................................................................... 9
Table 6. Obstetric cholestasis ............................................................................................................. 10
Table 7. Gestational diabetes/diabetes mellitus .................................................................................. 10
Table 8. Hypertensive disorders of pregnancy .................................................................................... 11
Table 9. Twin pregnancy ..................................................................................................................... 11
Table 10. Suspected fetal macrosomia ............................................................................................... 11
Table 11. Fetal growth restriction ........................................................................................................ 12
Table 12. Intrauterine fetal death ......................................................................................................... 12
Table 13. Maternal request .................................................................................................................. 12
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
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Queensland Clinical Guideline: Induction of labour

Introduction

Induction of labour (IOL) is a relatively common procedure. In 2009 the IOL rate in Queensland was
5
22.4%. 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.
6

In Queensland, only 27.1% of women who had an IOL reported having made an informed decision :
1,4
Provide women with information on the :
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
7
Consider the use of decision aids to assist the woman make informed choices

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.
8

At 41 weeks or later gestation, it has been shown for those women who :
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
9
monitoring consisting of twice weekly:
10
Cardiotocography (CTG)
Ultrasound assessment of amniotic fluid volume using:
10,11
o Estimation of maximum amniotic pool depth
, or
12,13
o Amniotic fluid index
12
Umbilical arterial Doppler ultrasound

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Queensland Clinical Guideline: Induction of labour

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
1
available

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

Risk/Benefit

Recommendations

Is not a method of IOL


Is used to reduce the need for formal IOL by encouraging spontaneous
labour
From 38-40 weeks onwards, significantly reduced pregnancies beyond 41
14
weeks
Repeated membrane sweeping has been found to decrease the proportion
15
of postterm pregnancies
16
15
Reduced need for formal IOL , particularly in multiparous women
17
Limited data on risk in Group B streptococcus (GBS) carriers
14
No evidence of increased risk of maternal or neonatal infection
14,15
Associated with discomfort
, vaginal bleeding and irregular
14
contractions
15
Most women would choose membrane sweeping again
Optimal frequency unknown. Practice varies from weekly to several times a
1,14
week
Consider offering membrane sweep at 39-40 weeks, especially to low risk
18
multiparous women
Advise of the benefits of repeated membrane sweeping
If the cervix is closed and membrane sweeping is not possible, cervical
1
massage in vaginal fornices may achieve similar effect

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Queensland Clinical Guideline: Induction of labour

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

Recommendations

2.2

19

The risk of fetal death increases significantly with gestational age :


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
13
for at least one week is associated with :
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%)
19
Most women prefer IOL at 41 weeks over serial antenatal monitoring
For women with uncomplicated pregnancies, recommend IOL between 41
1,20
and 42 weeks
1,20,21
Waiting after 42 weeks is not recommended
Exact timing depends on the womens preferences and local
circumstances

Preterm prelabour rupture of membranes

Table 3. Preterm prelabour rupture of membranes

Preterm prelabour rupture of membranes


+0

Risk/Benefit

Recommendations

+6

Gestation between 34 36
IOL versus expectant management:
22,23
o Reduces chorioamnionitis
22
o Reduces maternal length of stay
o Insufficiently sized studies to determine difference in:
22,23
Neonatal sepsis
23
Respiratory distress
23
Newborn intensive care resource use
Decreased neonatal intensive care unit (NICU) length of stay and
hyperbilirubinaemia is demonstrated if delivery occurs after, rather than
24
before, 34 weeks
Gestation less than 34 weeks
25
Birth before 34 weeks is associated with increased neonatal mortality ,
25
24
adverse neonatal outcomes including respiratory distress syndrome ,
24
24
intraventricular haemorrhage , necrotising enterocolitis and other long
25
term complications
25
Mortality and morbidity increase with decreasing gestational age
+0
+6
Gestation between 34 36
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
1
indications

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Queensland Clinical Guideline: Induction of labour

2.3

Term prelabour rupture of membranes

Table 4. Term prelabour rupture of membranes

Term prelabour rupture of membranes (PROM)

Risk/Benefit

Recommendations

2.4

26

Spontaneous labour commences


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
27
need for epidural analgesia
A policy of expedited IOL compared to expectant management
28
decreases :
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
29
sepsis
Women with planned management are more likely to view their care more
29
positively than expectantly managed women
When associated with GBS:
o Compared to expectant management and IOL with Dinoprostone,
IOL with Oxytocin is associated with lower rate of neonatal infection
30
2.5% versus greater than 8%
31
Refer to Guideline: Early onset Group B streptococcal disease
To confirm PROM, offer sterile speculum vaginal examination (VE)
Discuss expectant management (provided a digital VE has not been
performed) and expedited management
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
30
Oxytocin

Previous caesarean section

Table 5. Previous caesarean section

Previous caesarean section


Risk/Benefit

Recommendations

32

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


Taking into account individual circumstances, discuss IOL, CS and
1
expectant management
1,33
Inform women of the increased risk of CS and uterine rupture in IOL
34
Discuss decisions about care with the responsible obstetrician
32
Refer to guideline: Vaginal birth after caesarean section (VBAC)

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Queensland Clinical Guideline: Induction of labour

2.5

Obstetric cholestasis

Table 6. Obstetric cholestasis

Obstetric cholestasis

Risk/Benefit

Recommendations

2.6

35

There is no quality evidence to recommend best management


36
Is associated with increased risk of :
o Intrauterine fetal death (IUFD) 2%
o Preterm birth 44%
o Meconium staining of liquor 25-45%
36
90% of fetal deaths occur after 37 weeks
A correlation has been shown between serum bile acid levels and fetal
36,37
:
complication rates
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
38,39
levels. It is uncertain if this translates to reduced perinatal risk
40
o Poor fetal outcome is associated with :
Deteriorating biochemical tests
Unresponsiveness to Ursodeoxycholic acid
CTG and Doppler surveillance have no role in the prediction of perinatal
37
risk
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
41
literature
Decision to deliver should be made on an individual basis
Based on weak evidence, IOL may be recommended at 37 weeks
36
Consider IOL at 35-37 weeks for severe cases with jaundice ,
36
progressive elevations in serum bile acids and liver enzymes, and
36
suspected fetal compromise

Diabetes

Table 7. Gestational diabetes/diabetes mellitus

Gestational diabetes (GDM)/diabetes mellitus

Risk/Benefit

Recommendations

27% of non-malformed stillbirths in women with pre-existing diabetes


42
occur after 37 completed weeks
th
In women with GDM on insulin, comparing IOL in the 38 week with
,
43
expectant management showed :
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
44
Diet controlled, mild GDM is associated with good pregnancy outcome
o No data on risk of perinatal mortality after 40 weeks
Until quality evidence becomes available, offer delivery at 38 weeks to
43
women with diabetes requiring insulin
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

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Queensland Clinical Guideline: Induction of labour

2.7

Hypertensive disorders of pregnancy

Table 8. Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy

Risk/Benefit

Recommendations

2.8

1,14,45

The only cure for pre eclampsia is birth


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
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
4,46
obstetric indications
47
Refer to Guideline: Hypertensive disorders of pregnancy

Twin pregnancy

Table 9. Twin pregnancy

Twin pregnancy

Risk/Benefit

Recommendations

2.9

48

Optimal timing for uncomplicated twin pregnancy is uncertain


Retrospective studies demonstrate:
49
o Perinatal mortality rate is lowest for birth at 37 weeks gestation
50
o An increase in stillbirth, particularly from 38 weeks
o An underpowered randomised controlled trial (RCT) comparing
expectant management with IOL at 37 weeks showed no statistical
51
difference in CS, CS for fetal distress or perinatal death
In uncomplicated twin pregnancy there is insufficient data to support the
48
practice of planned birth from 37 weeks
The main determinant of risk in a multiple pregnancy is chorionicity and
this may influence decisions regarding the timing of delivery in individual
cases
+0
Taking into account individual circumstances, plan birth soon after 38
50
weeks
Refer for specialist consultation when risk factors, such as twin-to-twin
transfusion syndrome, indicate the need

Suspected fetal macrosomia (> 4000 grams)

Table 10. Suspected fetal macrosomia

Suspected fetal macrosomia

Risk/Benefit

Recommendations

52

Accuracy of estimating fetal weight varies :


o From 15-79% using ultrasound
o From 40-52% using clinical judgement
Comparing IOL and expectant management there are no significant
53
differences in :
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
In the absence of other indications, IOL should not be recommended
1,21,53
simply on suspicion that a baby is macrosomic
However, it is important to discuss and consider maternal concerns

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Queensland Clinical Guideline: Induction of labour

2.10 Fetal growth restriction


Table 11. Fetal growth restriction

Fetal growth restriction

Risk/Benefit

Recommendations

There are no clear guidelines supported by strong evidence on timing of


54
delivery when fetal growth restriction (FGR) has been diagnosed
Use of umbilical artery and ductus venosus Doppler has been shown to
54
assist in improving perinatal outcome
Preterm FGR
The GRIT study comparing expectant versus immediate birth (IOL and
CS) between 24-36 weeks showed:
55
o Expectant group
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%)
56
o At two years :
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
57
versus immediate birth at term, showed no significant difference in :
o Obstetric interventions, for example CS
o Neonatal morbidity
In term and preterm pregnancies with FGR there is little evidence to guide
1
timing of birth
Timing of birth will depend on gestational age, severity of FGR and results
of tests of fetal well being
58
Recommend expedited birth for a woman with FGR diagnosed at term
55
Severity affects the decision of the most appropriate mode of birth

2.11 Intrauterine fetal death


Table 12. Intrauterine fetal death

Intrauterine fetal death


Risk/Benefit

Recommendations

There is no evidence addressing immediate versus delayed IOL


Many women go into spontaneous labour within 2-3 weeks of IUFD
59
Risk of coagulopathy is usually only of concern after 4 weeks
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
1
No evidence of infection

2.12 Maternal request


Table 13. Maternal request

Maternal request
Risk/Benefit
Recommendations

There are no studies that address this group specifically


In uncomplicated pregnancies consider the risk of neonatal respiratory
13
distress syndrome and related adverse effects
Consider IOL based on exceptional circumstances of the woman and her
family

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Queensland Clinical Guideline: Induction of labour

2.13 Other maternal conditions


Table 14. Other maternal conditions

Anticoagulant therapy and maternal cardiac condition

Risk/Benefit

Recommendations

For a woman on anticoagulant therapy, IOL is timed around the


60
medication protocol
For maternal cardiac conditions, the objective of care is to minimise the
additional load on the cardiovascular system, ideally through spontaneous
60
onset of labour
A multidisciplinary team, consisting of an obstetrician, cardiologist or
physician as appropriate, anaesthetist, and midwife is essential
60
Involve an intensivist and neonatologist as required
Develop a plan for peripartum management of anticoagulant therapy
61
(prophylactic or therapeutic)
If receiving anticoagulant therapy, wean and cease prior to IOL
For a woman with a maternal cardiac condition, plan for an IOL when
60
required :
o Anticoagulant therapy protocol
o Availability of medical staff
o Deteriorating maternal cardiac function
Refer to Guideline: Venous thromboembolism (VTE) prophylaxis in
61
pregnancy and the puerperium

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Queensland Clinical Guideline: Induction of labour

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
12
period
Abdominal palpation to confirm presentation and engagement
4
Assessment of membrane status (ruptured or intact)
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
1
monitoring
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
62
then the scores are summed. Table 15 provides an example of a modified Bishop score .
4
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
Table 15. Modified Bishop score

Cervical feature

Score
0

Dilation (cm)

<1

1-2

3-4

>4

Length of cervix (cm)

>3

<1

Station (relative to ischial spines)

-3

-2

-1 / 0

+1 / +2

Firm

Medium

Soft

Posterior

Mid

Anterior

Consistency
Position

Methods of induction of labour

Methods used for IOL include:


Medical methods
o Dinoprostone preparations (Prostaglandin E2, PGE2, PG gel, Prostin E2, Cervidil)
o Oxytocin infusion
Surgical methods
o Artificial rupture of membranes (ARM)
Mechanical methods
o Transcervical catheter (Foley or Atad)

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Queensland Clinical Guideline: Induction of labour

4.1

Dinoprostone

Dinoprostone (vaginal Prostaglandin E2) promotes cervical ripening and stimulates uterine
contractions. [refer to Table 16 and Table 17]. Dinoprostone preparations include:
Vaginal gel (Prostaglandin E2, PGE2, PG gel, Prostin E2, , gel) 1mg and 2 mg
Controlled release vaginal pessary (Cervidil)
Table 16. Dinoprostone considerations

Consideration

Dinoprostone

Indications

Contraindications

Cautions

Risk/Benefit

Monitoring

Assessment of
progress

Unfavourable cervix
63,64
Known hypersensitivity to Dinoprostone or other constituents
64,65
Ruptured membranes pessary contraindicated
65
Multiple pregnancies
High parity
63
o Gel parity greater than 4 and
64
o Pessary parity greater than 3
63,64,65
Previous CS or any uterine surgery
63
Malpresentation / high presenting part
Unexplained vaginal discharge and / or uterine bleeding during current
63,64,65
pregnancy
65
Use caution in women with asthma due to potential bronchoconstriction
65
Ruptured membranes use gel with caution
63,64,65
Oxytocin administration
65
Epilepsy
65
Cardiovascular disease
65
Raised intraocular pressure, glaucoma
65

Nausea, vomiting and diarrhoea may occur soon after insertion


Increased risk of hyperstimulation with or without FHR abnormality in
66
approximately 4% of women
66
Incidence of CS is not increased
The risk of hyperstimulation is higher with the pessary than with the gel
67
(4.5% versus 2.4%)
68
Risk of hyperstimulation is higher if Oxytocin is also used
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,
1
the gel may be more appropriate for a woman with a favourable cervix
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
1
CTG for 30 minutes:
o If applicable, remove pessary
o Intermittent FHR auscultation may be used as in normal
1
spontaneous labour unless concerns are identified
If contractions do not commence, reassess the modified Bishop score:
65
o Dinoprostone gel 6 hours after insertion
65
o Dinoprostone pessary 12 hours after insertion

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Queensland Clinical Guideline: Induction of labour

4.1.1

Dinoprostone dose and administration

Table 17. Dinoprostone administration

Aspect

Dose

Dinoprostone administration
Dinoprostone gel
Initial dose:
69
o Nulliparous 2 mg PV
o Multiparous 1 mg PV
Repeat dose, after 6 hours:
o Nulliparous 2 mg
o Multiparous 1-2 mg
Dinoprostone pessary
66
10 mg PV (released at a rate of approximately 4 mg in 12 hours)
Dinoprostone gel
65
Maximum 3 mg over 6 hours

Maximum dose
Dinoprostone pessary
64
4 mg (12 hours after insertion)
Dinoprostone gel
Use water soluble lubricants (not obstetric cream)
Remove from refrigeration and stand at room temperature for at least 30
63
minutes prior to use
63
Insert into the posterior fornix of the vagina
63
Not for intracervical administration
63
Advise recumbent and left lateral position for 30 minutes after insertion
to facilitate absorption

Administration

Side effects

Indications for
removal

Dinoprostone pessary
64
Remove from freezer or fridge immediately prior to use
Can be stored in the fridge for up to one month after removal from the
64
freezer
64
Warming is not required
Open the foil only after decision has been made to use it
Use water soluble lubricants (not obstetric cream)
65
64
Insert into the posterior fornix of the vagina in transverse position
64
Ensure sufficient tape outside vagina to allow removal
64
Remain recumbent for 30 minutes
Advise women to avoid inadvertent removal of pessary and to report if
pessary falls out
Uterine hypercontractility [For management: refer Section 5]
64
Dinoprostone pessary
Onset of regular uterine contractions
Membranes rupture (spontaneous or ARM)
Fetal distress
Uterine hypercontractility
Insufficient cervical ripening after 12 hours
o There is minimal evidence on the administration of Dinoprostone
gel if there is no cervical change 12 hours after pessary insertion.
Base decision on the womans individual circumstances. Timing of
gel administration at the obstetricians discretion

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Queensland Clinical Guideline: Induction of labour

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
Indications

Clinical practice point

Cautions

Risk/Benefit

Monitoring

Assessment of
progress

IOL using ARM and intravenous Oxytocin infusion is the preferred method
70
once the cervix is favourable
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
64
of its removal
If not already ruptured, perform ARM prior to initiation of Oxytocin infusion
Oxytocin is contraindicated in women with previous uterine scar or high
68
parity (greater than 4). Discuss with an obstetrician prior to
commencement
Compared to IOL with vaginal Prostaglandin:
o Is associated with more failures to achieve vaginal birth within 24
71
hours
71
o Shows no significant difference in caesarean birth rates
71
o Increased the need for epidural
1
o Mobility is restricted
o Refer to Table 16 for Dinoprostone considerations
Is associated with lower infection rates in both mother and baby when
71
membranes are ruptured at the time of IOL
Oxytocin induced contractions may be perceived as more painful
4
Provide one-to-one midwifery care
Use continuous electronic FHR monitoring once Oxytocin infusion
72,68
commenced
Titrate dose to achieve 3-4 strong regular contractions in 10 minutes
Maternal and fetal observations:
73
o Refer to guideline: Normal birth
o Assess maternal observations and FHR prior to any increase in the
infusion rate
Maintain fluid balance as water intoxication may result from prolonged
68
infusion (rare with the use of isotonic solutions)
Assess pain relief requirements
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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Queensland Clinical Guideline: Induction of labour

4.2.1

Oxytocin administration

Table 19. Oxytocin administration

Consideration

Oxytocin administration

Administration

Maximum dose
Side effects

Cease infusion if:

4,68

Use a volumetric pump to ensure an accurate rate of infusion


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
4
o Titration should occur at 30 minute or greater intervals
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
4
Use the minimum dose required to establish and maintain active labour
Record the dose in milliunits per minute
Mark changes to dose clearly and contemporaneously on the CTG and / or
intrapartum record
Review by an obstetrician should occur before exceeding a dose of 20
milliunits per minute
68
Cardiovascular disturbances (e.g. bradycardia, tachycardia)
68
Headache (can be associated with fluid overload)
68
Gastrointestinal disorders (e.g. nausea, vomiting)
68
Uterine activity becomes hypertonic
68
Resting uterine tone increases
68
Fetal compromise occurs (any concerning FHR abnormality)
Consult with an obstetrician before recommencing infusion

4.2.2 Oxytocin regimens


4
The ideal dosing regime of Oxytocin is unknown. Suggested regimens are outlined in Table 20.
Table 20. Oxytocin regimen

Time after
starting
(minutes)
0
30
60
90
120
150
180
210
240
270

Oxytocin dose
Volume infused (mL/hour)
(milliunits per
10 IU in
20 IU in
30 IU in
minute)
500 mL
1000 mL
500 mL
1
3
3
1
2
6
6
2
4
12
12
4
8
24
24
8
12
36
36
12
16
48
48
16
20
60
60
20
Obstetrician review prior to exceeding 20 milliunits per minute
24
72
72
24
28
84
84
28
32
96
96
32

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Queensland Clinical Guideline: Induction of labour

4.3

Artificial rupture of membranes

Table 21. Artificial rupture of membranes considerations

Artificial rupture of membranes (ARM)


Indications
Cautions

Risk/Benefit

Monitoring

74

Favourable cervix Bishop score 7 or more


May be used alone especially in a multiparous woman (may initiate
74
contractions) or in combination with Oxytocin infusion
Caution should be exercised where the head is high due to the risk of
1
cord prolapse [refer to Section 5]
74
Risk of pain, discomfort, bleeding
75
May shorten length of labour by speeding up contractions
Nulliparous women with ARM and immediate Oxytocin compared to
76
delayed Oxytocin (commenced 4 hours post ARM) showed :
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
Before ARM:
77
o Explain the procedure to the woman
78
o Abdominal palpation to determine descent
o Assess for possible cord presentation
78
o Consult obstetrician if the head is not engaged 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
72
Monitor FHR immediately following procedure 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
70
7 or more

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Queensland Clinical Guideline: Induction of labour

4.4

Transcervical catheters

Transcervical catheters (e.g. Foley, Atad) are used to ripen the cervix through:
Direct dilatation of the canal or
79
Indirectly by increasing prostaglandin and/or oxytocin secretion
Table 22. Transcervical catheter considerations

Consideration
Indications

Cautions

Comment

Risk/Benefit

Monitoring

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
Contraindication:
79
o Low lying placenta
Cautions:
4
o Antepartum bleeding
4
o Rupture of membranes
4
o Cervicitis
79
Low cost and no specific storage or temperature requirements
No evidence of an increased risk of chorioamnionitis or endometritis
79
although data is limited
May be associated with slight vaginal bleeding
In women with a very unfavourable cervix, use seems to reduce failed
79
IOL when compared to IOL with Oxytocin alone
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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Queensland Clinical Guideline: Induction of labour

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 Practice Point

Failed IOL

Uterine
hypercontractility

Cord prolapse

Uterine rupture

The criteria for failed IOL are not generally agreed


1
Recommended care options include :
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
80
Attempt removal of any remaining Dinoprostone gel
80
Remove Dinoprostone pessary if still in situ
1
Stop Oxytocin infusion 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
1
If persists use tocolytics :
70
o Terbutaline 250 micrograms subcutaneously
72
o Salbutamol 100 micrograms by slow intravenous (IV) injection
72
o *Sublingual Glyceryl Trinitrate (GTN) spray 400 micrograms
1
If clinically indicated perform emergency CS
1
Is a potential risk at the time of membrane rupture especially with ARM
1
Is an obstetric emergency
1
Precautions should include :
o Assessment of engagement of the presenting part
o Caution during ARM if the babys head is high
1
Uterine rupture is an uncommon event with IOL
Uterine rupture is a life-threatening event for mother and baby
1
If suspected, prepare for an emergency CS, 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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Queensland Clinical Guideline: Induction of labour

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Acknowledgements
Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and
other stakeholders who participated throughout the guideline development process particularly:

Working Party Clinical 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 Jennifer 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 Jessie 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
Queensland Clinical Guidelines Team
Associate Professor Rebecca Kimble, Program Director
Ms Jacinta Lee, Manager
Ms Jackie Doolan, Clinical Midwifery Consultant
Ms Lyndel Gray, Clinical Nurse Consultant
Mr Keppel Schafer, Program Officer
Steering Committee

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

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