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European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Historical review

A hundred years of induction of labour methods

Hafiz Abdel Nabi 1, Nasreen B. Aflaifel 2,3, Andrew D. Weeks 3,*
Department of Women’s and Children’s Health, University of Liverpool, Liverpool Women’s Hospital, Liverpool, UK

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Induction of labour is the process of artificially initiating labour in order to end a pregnancy.
Received 11 December 2013 We sought to explore changes in practice as documented in ‘Ten Teachers’, an undergraduate textbook
Received in revised form 11 March 2014 that was first published in 1917 and is now in its 19th edition.
Accepted 31 March 2014
Study design: The description of labour induction methods from each edition were described and
tabulated.
Keywords: Results: Historically, the dangers of induction meant that it was only conducted in the event of life-
Labour
threatening maternal disease. However, with improved methods, the threshold for intervention has
Induction of labour, Prostaglandins,
Oxytocin
reduced and it is now one of the most common interventions in pregnancy. Induction methods have
changed over the last century from vaginal caesarean section, castor oil and De Ribes’ bag at the start of
the century to prostaglandins and oxytocin today.
Conclusions: Techniques for labour induction have changed markedly over the last century.
ß 2014 Elsevier Ireland Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Contributorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Condensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

Introduction The undergraduate textbook Obstetrics by ten teachers has

been a favourite with students for many generations. First
The methods of labour induction have witnessed a great deal published in 1917 as Midwifery by Ten Teachers [1], the book
of change over the past century. The evolution of these methods was renamed [2] and is now in its 19th edition. Each edition is
has improved the outcomes of labour induction and made it written by 10 leading obstetricians from the British Isles with the
significantly safer than it was a hundred years ago. authors chosen by the senior editor. With a complete absence of
references in the text, the series provides an excellent example of
eminence based medicine and gives an insight into changes in
* Corresponding author. Tel.: +151 7959578; fax: +151 7959599. labour ward practice over the past century.
E-mail address: aweeks@liverpool.ac.uk (A.D. Weeks).
1
Present address: Royal College of Surgeons in Ireland, Medical University of
Bahrain, Al Sayh, Bahrain. Materials and methods
2
Present address: Department of Obstetrics and Gynaecology, University of
Omar Al Mukhtar, Al Bida, Libya.
3
Present address: Sanyu Research Unit, University Department of Women’s and We reviewed the methods for labour induction between 1917
Children’s Health, University of Liverpool, Liverpool, UK. and 2011 as described in successive editions.

http://dx.doi.org/10.1016/j.ejogrb.2014.03.045
0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: Abdel Nabi H, et al. A hundred years of induction of labour methods. Eur J Obstet Gynecol (2014),
http://dx.doi.org/10.1016/j.ejogrb.2014.03.045
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Results
From 1917 till 1931 induction of labour was achieved purely
through surgical methods. These included the use of uterine
Bougies, De Ribes’s bag, forced rapid dilatation of the cervix, and
vaginal caesarean section (see definitions below). In 1925 stomach
tubes were introduced as alternative to bougies. The decision on
which method to use was largely based on whether labour was
being induced in the interest of the mother or the foetus.
Artificial rupture of membranes was not taught in detail by the
teachers until 1931 due to a belief that loss of amniotic fluid
endangered the fetus. However, by 1942 amniotomy became the
method of choice, superseding the old methods of inserting foreign
bodies (bougies and bags) into the cervix, which had been almost
entirely abandoned by 1948. Initially only high rupture was taught
(1931–1938), but low rupture was introduced in 1942. Until 1955,
high rupture was preferred over low rupture as it was thought that
preserving the membranes helped in cervical dilatation. Following
the edition 1955, amniotomy was always described as compli-
mentary to other methods, and used in conjunction with them
rather than as a primary induction method. Membrane sweeping is
not described as an induction method until the 2011 edition
(except for its mention in early editions as a preliminary step prior
to the insertion of bougies).
Medical methods for induction were first taught in 1931 with
the use of oral castor oil. However, this only lasted until 1948 due
to the side effects of violent diarrhoea, resulting in ‘‘patient
exhaustion’’. It was initially given with quinine at hourly intervals,
followed by a hypodermic injection of 2 units of oxytocin if labour
did not start within 9 h. From 1942–1948, castor oil, quinine and
oxytocin were described as all being given together for medical
induction.
In 1961, after the discontinuation of castor oil, Oxytocin became
the most common drug described for induction. Although oxytocin
has been described since 1931 (initially given as ‘pituitary extract’),
the method of administration has changed considerably with
intramuscular injection (1931–1955) being replaced with gravity
infusions (1961–1985) and then by infusion pumps (1990–2011).
1917 1922 1925 1931 1935
Medical
Cas t o r Oi l + Qu i n i n e
Pituitary
extract
Surgical
B o u g i es
Oes o p h ag eal /St o m ac h Tu b e
De Ri b es ’ s b ag
Amniotomy
Forced dilatation of the cervix
(Manual/Instrumental)
Vag i n al Caes ar ean Sec t i o n
Please cite this article in press as: Abdel Nabi H, et al. A hundred years of induction of labour methods. Eur J Obstet Gynecol (2014),
http://dx.doi.org/10.1016/j.ejogrb.2014.03.045
Buccal oxytocin ‘‘linguettes’’, with one or more tablets placed at
once, were described in the 1966–1972 editions, but never
mentioned again by the teachers. Although oxytocin was first
described as being used alone (1961–1985), it became more
commonly used as an adjunct, combined either with prostaglan-
dins (1990–1995) or with amniotomy following cervical ripening
(2000–2011).
Prostaglandins became commercially available in 1980, and
were described as mimicking natural labour. They were also said to
increase the rate of induction success from 80-85% to 95% of
induction at first attempt with fewer foetal and maternal
complications. In 1980 Prostaglandin E2 and F2a were both
described for the induction of labour and cervical ripening before
amniotomy, administered via intravenous infusion as well as by
pessary. In subsequent editions, the prostaglandin regimens
become more complex with different doses according to parity
and formulation. The F2a formulation was discontinued after the
1990 edition.
In the event of a stillbirth (or therapeutic abortion), the lack of
concern about fetal side effects allows the use of a wider range of
drugs. For example, induction using oestrogen was described in
1942–1948, given as large doses of the teratogenic Stilboestrol or
hexoestrol. Intra-amniotic injections of hypertonic saline solution
(20%) were described in 1972–1978, and hypertonic urea solution
(40%) in 1980–1985 (only if prostaglandin induction failed). After
1990, the widening prostaglandin regimens included special
options for the termination of pregnancy with vaginal PGE1
tablets (Gemeprost) in 1990–1995 and 15 methyl-analogues in
1995. In 2011, a new drug combination of the anti-progesterone
Mifepristone and oral PGE1 (misoprostol) was described for the
first time.
Comments
The ‘Ten Teachers’ collection provides an intriguing insight into
the history of medical care in pregnancy through the last 100 years.
Although only a snapshot of the teaching from a single textbook, it
has provided us with the opinions of some of the most respected
1938 1942 1948 1955 1961 1966 1972 1980 1985 1990 1995 2000 2006 2011
Oxytocin (IM) Oxytocin (IV Drip) Oxytocin (IV Infusion Pump)
Buccal
Oxytocin
Prostaglandin E2 (Gel/Tablet/Pessary)
F2α F2α
Gemeprost Misoprostol
Stilboestrol
Hypertonic intra-
amniotic inj.
Membrane
sweeping
Fig. 1. Methods used in labour induction.
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Fig. 2. Illustration of the use of Bougies for labour induction (with permission from
Berkeley et al. [5].
obstetricians of their day. Whilst not a comprehensive or complete
historical review, it is likely to be an accurate representation of
medical student teaching at that time, especially in the first half of
the century when ‘Ten Teachers’ was one of very few textbooks
available.
It is striking that the methods taught for labour induction early in
the century were often very dangerous, and this might have
contributed to a high mortality rate figure during that era. The
increased mortality would occur both as a result of an understand-
able reluctance to induce women with dangerous complications like
severe pre-eclampsia, as well as the procedures themselves which
included ‘vaginal caesarean sections’ and manual or instrumental
‘forced cervical dilatation’. As medical options became available, as
well as safe caesarean sections, the use of these aggressive surgical
methods was rapidly dropped from the teaching (Fig. 1).
Over the course of seven decades, the teachings on oxytocin
administration have changed quite significantly making it safer for
the patient and foetus. Although from 1938 to 1955, oxytocin was
administered by intramuscular injection; in 1961 it was changed
to a gravity intravenous drip. This allowed continuous adminis-
tration and facilitated titration of the oxytocin dose according to
response and eliminating the problem of erratic absorption. Since
1990, electronic intravenous infusion pumps have been used
instead of the gravity infusion, allowing a more accurate regulation
of oxytocin flow rate.
Fig. 3. De Ribes’ Bag (with permission from Science Museum Group).
Please cite this article in press as: Abdel Nabi H, et al. A hundred years of induction of labour methods. Eur J Obstet Gynecol (2014),
http://dx.doi.org/10.1016/j.ejogrb.2014.03.045
3
Fig. 4. Illustration of a metal screw-dilator for forced cervical dilation (with
permission from Berkeley et al. [5].
It is interesting that some of the recently-introduced induction
methods are simply modifications of old technologies that have
been used in the past but went out of fashion. Membrane
sweeping, for example, first described as an initial step in
introducing bougies, is now used separately as an induction
method. It also has similarities to the forced manual cervical
dilatation method. Another example is the recent emergence of the
transcervical Foley catheter for cervical ripening [3,4]. Although
not yet described by the Ten Teachers, the mechanism of action is
similar to that of cervical bougies and De Ribes’s bag, methods
recommended from 1917 to 1938. Both examples demonstrate the
resumption of principles derived from former aggressive methods
but in a much gentler and safer form.
In this era of evidence-based medicine, it is noticeable how far
the textbooks have lagged behind evidence-based practice. For
example the benefits of membrane sweeping have been clear
since the mid 1990s [6] but did not enter the Ten Teachers’ text
until 2011. The same is true for Foley catheter inductions which
are now commonplace in European practice, but have yet to be
described in this textbook. These recent examples demonstrate
the limitations of using these texts to describe ‘current practice’.
They also demonstrate the problems of ‘eminence-based’ medi-
cine where authorities’ opinions may not always reflect the
most up-to-date or evidence-based practice. Nevertheless, it is
likely that they will reflect some of the most widely-used
practices of the day. The emergence of on-line publications and
resources (e.g. Cochrane and UpToDate) will make the problem of
time lag and eminence-based medicine less important as students
worldwide gain easy access to rapidly updated evidence-based
medicine.
Bougie A cylinder of celluloid or gum-elastic which is
inserted through the cervix into the uterus under
anaesthetic (Fig. 2). The authors describe
preceding the insertion with a membrane sweep
and inserting 2 to 3 bougies into the uterus.
Vaginal packing was used to prevent expulsion
Castor oil A potent laxative, derived from the castor plant
bean, used to stimulate labour since ancient
Egyptian times
Stomach tube A long flexible tube for introduction into the
stomach, used as an alternative to a bougie
De Ribes’ Bag Champetier-de-Ribes designed this reusable,
rubber-covered, silk inflatable bag in 1887 (Figs. 3
and 4). It was inserted through the cervix using
special forceps and filled with water to a
maximum of 500 ml. it was typically expelled
spontaneously after 5 h. The process could be
accelerated by traction on the tubing using a 2 lb.
weight hung over the end of the bed
Vaginal caesarean Under anaesthetic, the anterior vaginal wall and
section the anterior portion of the cervix are incised in the
midline and the bladder pushed up. The
membranes are ruptured and the baby is delivered
through the resulting space. It was noted to be a
much more difficult operation than the caesarean
section and only to be carried out after the 7th
month
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Stilboestrol Diethylstilbestrol is a synthetic nonsteroidal Funding

oestrogen that was first synthesized in 1938. Its
use in the first trimester is known to cause foetal
urogenital tract abnormalities This research received no specific grant from any funding
Quinine A potent anti-malarial drug. Its use in pregnancy is agency in the public, commercial, or not-for-profit sectors.
common to treat malaria; it has now been shown
not to induce labour
Forced dilatation of This could be done manually under anaesthetic
the cervix where the finger and thumb were used to stretch Condensation
the cervix until the whole hand could be inserted
and a breech extraction conducted. Alternatively, a A review of 19 editions of the ‘Ten Teachers’ undergraduate
metal screw-dilator was used (Fig. 4). Both
textbook shows that techniques for labour induction have changed
methods carried high risk of laceration and
infection markedly over the last century.

Conflict of interest
AW has on-going relationships with multiple interested parties
on misoprostol use including FIGO, WHO and Gynuity Health
Projects. He also runs an independent, non-profit making website
called www.misoprostol.org which seeks to disseminate guide-
lines on the optimal doses for misoprostol use. It does not receive
any funding or sponsorship. Other Authors declare that there is no
conflict of interest.
Contributorship
AW had the original idea for the paper, NA chose the subject,
organised and edited the paper. HA researched and collated the
results, formulated the graphs and wrote the first draft of the paper
with help from NA. All authors approved the manuscript before
submission.
Acknowledgements
None.
References
[1] Berkeley C, Andrews HR, Fairbairn SJ. Midwifery by ten teachers. 1st ed. London,
UK: Edward Arnold; 1917.
[2] Clayton S, Fraser D, Lewis T. Obstetrics by ten teachers. 11th ed. London, UK:
Edward Arnold Ltd.; 1966.
[3] WHO. WHO recommendations for induction of labour. Geneva, Switzerland:
WHO; 2011.
[4] Jozwiak M, Rengerink KO, Benthem M, et al. Foley catheter versus vaginal
prostaglandin E2 gel for induction of labour at term (PROBAAT trial): an open-
label, randomised controlled trial. Lancet 2011;378(9809):2095–103.
[5] Berkeley C, Andrews H, Fairbairn SJ. Midwifery by ten teachers. 2nd ed. London,
UK: Edward Arnold; 1922.
[6] Boulvain M, Stan CM, Irion O. Membrane sweeping for induction of labour.
Cochrane Database of Syst Rev )2005;(1). http://dx.doi.org/10.1002/
14651858.CD000451.pub2 (Art. No.: CD000451).

Please cite this article in press as: Abdel Nabi H, et al. A hundred years of induction of labour methods. Eur J Obstet Gynecol (2014),
http://dx.doi.org/10.1016/j.ejogrb.2014.03.045