Press release

NICE 2001/021 Issued 12 June 2001

National Guideline on Induction of Labour

The National Institute for Clinical Excellence (NICE) has today issued a clinical guideline on the Induction of Labour (IOL) to the NHS in England & Wales. Induction of labour is a common procedure; about 1 in 5 women have their labour induced.

The summary guideline published by NICE is derived from a full guideline developed by a multidisciplinary group and published by the Royal College of Obstetricians and Gynaecologists (RCOG). The guideline provides a series of recommendations based on the evidence, ranging from indications for Induction of Labour, the methods that can be used, through to the care that should be provided during induction.

Andrea Sutcliffe (Director and Executive Lead)said, "today's guideline will help the NHS provide the same high quality care to pregnant women and their unborn babies, no matter where they are in England and Wales.

We are grateful to the team of health professionals and patients who worked together to turn the evidence into meaningful guidance for the NHS and pregnant women.

In summary we have recommended that

  • women who are healthy and have had a trouble free pregnancy should be offered Induction of labour if their pregnancy extends beyond 41 weeks, this reduces perinatal mortality (death of the baby before, during or just after delivery), without increasing the number of caesarean sections performed, and
  • women whose waters break before their labour starts should be offered a choice of immediate induction of labour or expectant management (watchful waiting), however because of the risks of infection, expectant management should not exceed 4 days".

Ends

Notes for Editors:

Induction of Labour Guidelines

Background

1. Induction of labour is indicated when it is agreed that the foetus or mother will benefit from a higher probability of a healthy outcome than if birth is delayed. The process of induction of labour should only be considered when vaginal delivery is felt to be the appropriate route of delivery.

2. Population studies indicate that the risk of stillbirth increases from:

- 1 per 3000 ongoing pregnancies at 37 weeks to
- 3 per 3000 ongoing pregnancies at 42 weeks to
- 6 per 3000 ongoing pregnancies at 43 weeks.

A policy of offering routine induction of labour after 41 weeks reduces perinatal mortality without increasing the caesarean section rate.

3. Data from a cohort study revealed that at:

- 40 weeks only 58% of women had delivered.
- 41 weeks this increased to 74% of women having delivered and
- 42 weeks 82% of women had delivered

A policy of induction of labour prior to 41 weeks would generate an increase in workload without reducing perinatal mortality.

4. UK population studies show a four or five fold increase in perinatal mortality rate (including an increased rate of late fetal death) in pregnancies in women with diabetes in pregnancy compared to the general population

5. Pre-labour rupture of the membranes (breaking of waters) occurs in 6-19% of term pregnancies. Most women (86%) go into spontaneous labour within 24hrs of rupturing their membranes. The rate of spontaneous labour after this is about 5% per day. As the time between the rupture of the membranes and the onset of labour increases, so do the risks of maternal and fetal infection. Induction of labour reduces these risks.

6. The NICE guideline has been provided to NHS clinicians in England and Wales and a version for pregnant women and their families is also available, both documents can be requested from the NHS response line on 0870 155 455 or downloaded from the NICE web site (www.nice.org.uk).

Summary of guideline recommendations.

7. The guidance identifies when induction of labour should be offered to pregnant women. It provides specific advice for diabetic women and those whose waters have broken before labour has started. It makes recommendations on the methods of induction of labour, the appropriate drug dosages and the topics for further research. In summary:

  • For women who are healthy and have had a trouble free pregnancy induction of labour should only be offered if their pregnancy extends beyond 41 weeks
  • Women who have pregnancies complicated by diabetes should be offered induction of labour prior to their estimated date for delivery.
  • •Women with pre-labour rupture of the membranes at term (>37 weeks) (i.e. their waters break before labour starts) should be offered a choice of immediate induction of labour or expectant management (because of the risks of infection expectant management should not exceed 96 hours following membrane rupture).

8. Labour can be started through a variety of methods, which can be used individually or in combination. These include:

  • a technique called membrane sweeping, where the doctor or midwife separates the membrane containing the amniotic fluid from the cervix using their finger.
  • The use of drugs
    - prostaglandins (inserted into the vagina) that encourage the cervix to ripen and contractions to start,
    - oxytocin, delivered through a drip, which encourages the uterus to contract.

9. Misoprostol is a drug that has been investigated for the induction of labour. It is not licensed in the UK for obstetric use and the safety aspects have not been fully evaluated. The full guideline has a section on this product and recommends that its use must be restricted to clinical trials. The NICE Guideline recommends that the risks and benefits of vaginal/oral misoprostol for the induction of labour should be evaluated using commercially produced tablets of appropriate dose and randomised controlled trials.

10. Local health communities will need to review their existing service provision against the NICE guideline. Relevant local clinical guidelines and protocols should be reviewed in light of the guidance and revised accordingly.

11. Copies of the NICE guideline on Induction of labour can also be obtained by contacting the NHS Response Line on 0870 155 455 and quoting reference 24010. Information for pregnant women, their partners and their families is also available in English (ref. 24011) and English and Welsh (ref. 24012).

12. The multidisciplinary guideline development group who prepared the full guideline published by the RCOG included :

- Professor A A Calder (Chairman)
- Mrs B Beech Lawrence (Association for Improvements in the Maternity Services)
- Mr R Cookson (Health Economist from the University of East Anglia)
- Dr P Crowley (Royal College of Obstetricians and Gynaecologists)
- Dr P Danielian (British Maternal Fetal Medicine Society)
- Dr A Farebrother (Faculty of Public Health Medicine)
- Mr A Foulkes (Royal College of General Practitioners)
- Mr P Harris (Help for Health Trust)
- Dr M Kilby (British Association of Perinatal Medicine)
- Dr G Lewis (Department of Health observer)
- Professor J Neilson (Royal College of Obstetricians and Gynaecologists)
- Miss J Rogers (Royal College of Midwives)
- Ms J M Thomas MRCOG (Director, Clinical Effectiveness Support Unit, Royal College of Obstetricians and Gynaecologists)
- Mr A Kelly MRCOG (Research Fellow, Clinical Effectiveness Support Unit, Royal College of Obstetricians and Gynaecologists)
- Ms J Kavanagh (Research Fellow, Clinical Effectiveness Support Unit, Royal College of Obstetricians and Gynaecologists)

General Information

13. Clinical Guidelines are produced to help health professionals and patients make the right decisions about health care in specific clinical circumstances. Research has shown that if properly developed, communicated and implemented, guidelines can improve patient care. Clinical guidelines sit alongside, and do not replace, the knowledge and skills of experienced health professionals.

14. Copies of the NICE summary, the full guideline and the 'patient' text, will be available on the NICE web site (www.nice.org.uk) from midday on Tuesday 12th June 2001.

15. The guideline published today is part of the Institute's Inherited Clinical Guidelines work programme. Inherited guidelines were commissioned by the Department of Health before the Institute was formed in April 1999 and have been developed following the brief that was agreed at the time of commissioning. The developers have worked with the Institute to ensure, in the time available, that the guidelines have been subject to validation and to consultation with stakeholders. However it has not been possible to subject them to the full guideline development process that the Institute has now adopted.

16. The NICE Guidance represents the view of the Institute, which was arrived at after careful consideration of the available evidence. Health professionals are expected to take it fully into account when exercising their clinical judgment. This Guidance does not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual woman, in consultation with her and, where appropriate and necessary, her guardian or carer.

17. The National Institute for Clinical Excellence (NICE) is a part of the NHS. Part of its work is the development of clinical guidelines. The Institute produces guidance for both the NHS and patients on best practice in the treatment of specific clinical areas and is developed with groups that represent patients/carers and healthcare professionals.

18. See full details of the Institute's guidelines development process and principles.

Other Media contacts

  • Rachael Collins, PR Manager, Royal College of Obstetricians and Gynaecologists Tel: 020 7772 6357 or out-of-hours 07803 276283.