4 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline (see section 5).

4.1 Prolonged pregnancy

Research question

Pregnancies that continue after term run a higher risk of fetal compromise and stillbirth; can ways be found to identify pregnancies within that population that are at particular risk of these complications?

Why is this important?

Although the risks of fetal compromise and stillbirth rise steeply after 42 weeks, this rise is from a low baseline. Consequently, only a comparatively small proportion of that population is at particular risk. Because there is no way to precisely identify those pregnancies, delivery currently has to be recommended to all such women. If there were better methods of predicting complications in an individual pregnancy, induction of labour could be more precisely directed towards those at particular risk.

4.2 Preterm prelabour rupture of membranes

Research question

What are the relative risks and benefits of delivery versus expectant management in women whose membranes have ruptured spontaneously between 34 and 37 weeks?

Why is this important?

Intrauterine sepsis is more likely to develop in pregnancies that continue after the membranes have ruptured, putting both the woman and the baby at risk. In some such pregnancies, labour begins spontaneously at a variable interval after the membranes have ruptured, avoiding the need for induction. The value of antibiotic therapy and the administration of corticosteroids to the woman is unclear in this situation. A randomised study of active versus expectant management, taking account of time since membrane rupture, gestational age and maternal therapy, would be valuable.

4.3 Setting for induction of labour

Research question

Is it safe, effective and cost effective to carry out induction of labour in an outpatient setting? What are the advantages and disadvantages of such an approach, taking into account women's views?

Why is this important?

In line with the way healthcare has developed in many areas of acute care, there is an increasing desire to reduce the time women spend in hospital. Several units are already exploring outpatient induction of labour policies and there is a need to study this approach in order to determine relative risks and benefits, as well as acceptability to women.

4.4 Membrane sweeping

Research question

What are the effectiveness and acceptability of, and maternal satisfaction with, the following:

  • multiple versus once-only membrane sweeping, at varying gestational ages, depending on parity

  • membrane sweeping versus cervical massage?

Why is this important?

Membrane sweeping is considered to be a relatively simple intervention that may positively influence the transition from maintenance of pregnancy to the onset of labour, reducing the need for formal induction of labour. However, there are disadvantages, such as possible vaginal bleeding and discomfort. Research into when and how frequently membrane sweeping should be carried out to maximise its effectiveness and acceptability would be of value.

4.5 Vaginal PGE2

Research question

What are the effectiveness, safety and maternal acceptability of:

  • different regimens of vaginal PGE2, stratified by: clinical indications; cervical and membrane status; parity; and previous caesarean section

  • different management policies for failed induction of labour with vaginal PGE2 (additional PGE2, oxytocin, elective caesarean or delay of induction, if appropriate).

Why is this important?

Despite extensive studies carried out over the past 30 years to determine the most effective ways of inducing labour with vaginal PGE2, uncertainties remain about how best to apply these agents in terms of their dosage and timing. It would be particularly useful to understand more clearly why vaginal PGE2 fails to induce labour in some women.

  • National Institute for Health and Care Excellence (NICE)