Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Information and decision making

This section should be read in conjunction with the NICE guidelines on antenatal care, caesarean birth and intrapartum care for healthy women and babies.

1.1.1 Discuss preferences about mode of birth with women early on in their pregnancy. Take into account their individual circumstances, and discuss that options for birth can include:

1.1.2 Confirm a woman's preferences for birth at antenatal visits towards the end of pregnancy, as these may have changed since earlier discussions. [2008, amended 2021]

1.1.3 Explain to women that induction of labour is a medical intervention that will affect their birth options and their experience of the birth process. This could include that:

  • vaginal examinations to assess the cervix are needed before and during induction, to determine the best method of induction and to monitor progress

  • their choice of place of birth will be limited, as they may be recommended interventions (for example, oxytocin infusion, continuous fetal heart rate monitoring and epidurals) that are not available for home birth or in midwife-led birth units

  • there may be limitations on the use of a birthing pool

  • there may be a need for an assisted vaginal birth (using forceps or ventouse), with the associated increased risk of obstetric anal sphincter injury (for example, third- or fourth-degree perineal tears)

  • pharmacological methods of induction can cause hyperstimulation – this is when the uterus contracts too frequently or contractions last too long, which can lead to changes in fetal heart rate and result in fetal compromise

  • an induced labour may be more painful than a spontaneous labour

  • their hospital stay may be longer than with a spontaneous labour. [2021]

1.1.4 Discuss with women being offered induction of labour:

  • the reasons for induction being offered

  • when, where and how induction could be carried out

  • the arrangements for support and pain relief (see also recommendations on pain relief)

  • the alternative options if the woman chooses not to have induction of labour, or decides at a later stage that she no longer wishes to proceed with the induction process

  • the risks and benefits of induction of labour in specific circumstances, and the proposed induction methods

  • that induction may not be successful, and how this would affect the woman's options (see the recommendations on unsuccessful induction). [2008, amended 2021]

1.1.5 When offering induction of labour:

  • give women time to discuss this information with others (for example, their partners, birthing companion or family) if they wish to do so before making a decision

  • encourage women to look at other information (for example, by providing written information leaflets or encouraging them to look at information on the NHS website)

  • ensure women have the opportunity to ask questions, and time to think about their options

  • recognise that women can decide to proceed with, delay, decline or stop an induction. Respect the woman's decision, even if healthcare professionals disagree with it, and do not allow personal views to influence the care they are given. Record the woman's decision in her notes. [2008, amended 2021]

1.1.6 Provide information on induction of labour in line with the NICE guideline on patient experience in adult NHS services. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on induction of labour for pregnancy lasting longer than 41 weeks.

Full details of the evidence and the committee's discussion are in evidence review C: induction of labour for prevention of prolonged pregnancy.

1.2 Induction of labour in specific circumstances

Pregnancy lasting longer than 41 weeks

1.2.1 Give women with uncomplicated pregnancies every opportunity to go into spontaneous labour. [2008]

1.2.2 Explain to women that labour usually starts naturally before 42+0 weeks, based on the gestational age estimated by their dating scan (see table 1). [2008, amended 2021]

Table 1. Gestational age at which labour started, as a proportion of labours which started spontaneously

Gestational age (weeks)

Proportion of spontaneous labours that started at this gestational age

Cumulative proportion of spontaneous labours that started by this gestational age

31 weeks and under

2.4%

2.4%

32+0 to 36+6 weeks

5.3%

7.7%

37+0 to 37+6 weeks

5.1%

12.8%

38+0 to 38+6 weeks

12.1%

24.9%

39+0 to 39+6 weeks

25.4%

50.3%

40+0 to 40+6 weeks

32.5%

82.8%

41+0 to 41+6 weeks

16.2%

99.0%

42+0 weeks and over

0.9%

100%

Data from NHS Hospital Episode Statistics/Maternity Services Data set 2019-20.

1.2.3 Using the information in appendix A, explain to women that some risks associated with a pregnancy continuing beyond 41+0 weeks may increase over time and these include:

  • increased likelihood of caesarean birth

  • increased likelihood of the baby needing admission to a neonatal intensive care unit

  • increased likelihood of stillbirth and neonatal death. [2021]

1.2.4 Discuss with women that induction of labour from 41+0 weeks may reduce these risks, but that they will also need to consider the impact of induction on their birth experience (see recommendations on information and decision making) when making their decision. [2021]

1.2.5 Be aware that, according to the 2020 MBRRACE-UK report on perinatal mortality, women from some minority ethnic backgrounds or who live in deprived areas have an increased risk of stillbirth and may benefit from closer monitoring and additional support. The report showed that across all births (not just those induced):

  • compared with white babies (34/10,000), the stillbirth rate is

    • more than twice as high in black babies (74/10,000)

    • around 50% higher in Asian babies (53/10,000)

  • the stillbirth rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many stillbirths for women living in the most deprived areas (47/10,000) compared with the least deprived areas (26/10,000). [2021]

1.2.6 If a woman chooses not to have induction of labour, discuss the woman's options from this point on with her (for example, expectant management or caesarean birth) and record the woman's decision in her notes. [2008, amended 2021]

1.2.7 Discuss with women who choose not to have their labour induced if they wish to have additional fetal monitoring from 42 weeks. Advise women that:

  • monitoring only gives a snapshot of the current situation, and cannot predict reliably any changes after monitoring ends, but provides information on how their baby is at the moment and so may help them make a decision on options for birth

  • adverse effects on the baby (including stillbirth), and when these events might happen, cannot be predicted reliably or prevented even with monitoring

  • fetal monitoring might consist of twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth. [2008, amended 2021]

1.2.8 Offer women who choose to await the spontaneous onset of labour the opportunity to discuss their decision again at all subsequent reviews, if they wish to do so. [2021]

1.2.9 Advise women to contact their midwife or maternity unit if they change their mind before their next appointment, or as soon as possible if they have concerns about their baby (for example reduced or altered fetal movements). [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on induction of labour for pregnancy lasting longer than 41 weeks.

Full details of the evidence and the committee's discussion are in evidence review C: induction of labour for prevention of prolonged pregnancy.

Preterm prelabour rupture of membranes

1.2.10 If a woman has preterm prelabour rupture of membranes, do not carry out induction of labour before 34+0 weeks unless there are additional obstetric indications (for example, infection or fetal compromise). Offer expectant management until 37+0 weeks. [2008, amended 2021]

1.2.11 If a woman has preterm prelabour rupture of membranes after 34+0 weeks, but before 37+0 weeks, discuss the options of expectant management until 37+0 weeks or induction of labour with her. When making a shared decision, take into consideration the following factors:

  • risks to the woman (for example, sepsis, possible need for caesarean birth)

  • risks to the baby (for example, sepsis, problems relating to preterm birth)

  • local availability of neonatal intensive care facilities

  • the woman's individual circumstances and her preferences [2008, amended 2021]

1.2.12 If a woman has preterm prelabour rupture of membranes after 34+0 weeks (but before 37+0 weeks), and has had a positive group B streptococcus test at any time in their current pregnancy, offer immediate induction of labour or caesarean birth. See the NICE guidelines on neonatal infection and preterm labour and birth. [2021]

Prelabour rupture of membrane at term

1.2.13 Offer women with prelabour rupture of membranes at term (at or after 37+0 weeks) a choice of:

  • expectant management for up to 24 hours, or

  • induction of labour as soon as possible.

    Discuss the benefits and risks of these options with the woman, and take into account her individual circumstances and preferences. [2008, amended 2021]

1.2.14 For women who choose expectant management after prelabour rupture of the membranes at term (at or after 37+0 weeks), offer induction of labour if labour has not started naturally after approximately 24 hours. See the NICE guideline on intrapartum care. [2008, amended 2021]

1.2.15 Respect the woman's decision if she chooses to wait for spontaneous onset of labour for over 24 hours after prelabour rupture of membranes at term. Discuss the woman's options for birth from this point onwards with her. [2021]

1.2.16 If a woman has prelabour rupture of membranes at term (at or after 37+0 weeks) and has had a positive group B streptococcus test at any time in their current pregnancy, offer immediate induction of labour or caesarean birth. See the NICE guideline on neonatal infection for advice on intrapartum antibiotics. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on induction of labour for prelabour rupture of membranes.

Previous caesarean birth

1.2.17 Advise women who have had a previous caesarean birth that:

  • induction of labour could lead to an increased risk of emergency caesarean birth

  • induction of labour could lead to an increased risk of uterine rupture

  • the methods used for induction of labour will be guided by the need to reduce these risks (for example, by using mechanical methods). See the recommendations on methods for induction of labour

  • some methods used for induction of labour may not be suitable (for example, both dinoprostone and misoprostol are contraindicated in women with a uterine scar). [2008, amended 2021]

1.2.18 If birth needs to be expedited, offer women who have had a previous caesarean birth a choice of:

  • induction of labour, or

  • planned caesarean birth.

    Take into account the woman's circumstances and preferences and record the discussions and plan in the woman's notes. [2008, amended 2021]

1.2.19 Advise women that they can choose not to have induction of labour or caesarean birth, even when it may benefit their or their baby's health [2008, amended 2021]

Maternal request

1.2.20 Consider requests for induction of labour only after discussing the benefits and risks with the woman, taking into account the woman's circumstances and preferences. [2008, amended 2021]

Breech position

1.2.21 Induction of labour is not generally recommended if a woman's baby is in the breech position. [2008, amended 2021]

1.2.22 Consider induction of labour for babies in the breech position if:

  • birth needs to be expedited, and

  • external cephalic version is unsuccessful, declined or contraindicated, and

  • the woman chooses not to have a planned caesarean birth.

    Discuss the benefits and risks associated with induction of labour with the woman. [2008, amended 2021]

Fetal growth restriction

1.2.23 Do not induce labour if there is fetal growth restriction with confirmed fetal compromise. Offer caesarean birth instead. [2008, amended 2021]

Suspected fetal macrosomia

1.2.24 Using the information in appendix B, discuss with women without diabetes and with suspected fetal macrosomia that:

  • the options for birth are expectant management, induction of labour or caesarean birth (see the NICE guideline on caesarean birth)

  • there is uncertainty about the benefits and risks of induction of labour compared to expectant management, but:

    • with induction of labour the risk of shoulder dystocia reduced compared with expectant management

    • with induction of labour the risk of third- or fourth-degree perineal tears is increased compared with expectant management

    • there is evidence that the risk of perinatal death, brachial plexus injuries in the baby, or the need for emergency caesarean birth is the same between the 2 options

  • they will also need to consider the impact of induction on their birth experience and on their baby (see recommendation 1.1.3).

    Discuss the options for birth with the woman, taking into account her individual circumstances and her preferences, and respect her decision. Support recruitment into clinical trials, if available. [2021]

1.2.25 For guidance on suspected fetal macrosomia in women with pre-existing or gestational diabetes see the NICE guideline on diabetes in pregnancy. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on induction of labour for suspected fetal macrosomia.

Full details of the evidence and the committee's discussion are in evidence review A: induction of labour for suspected fetal macrosomia.

History of precipitate labour

1.2.26 Do not routinely offer induction of labour to women with a history of precipitate labour to avoid a birth unattended by healthcare professionals. [2008]

Intrauterine fetal death – all women

1.2.27 In the event of an intrauterine fetal death, offer support to help women and their partners and family cope with the emotional and physical consequences of the death. Offer them information about specialist support. [2008]

1.2.28 In the event of an intrauterine fetal death, if the woman appears to be physically well, her membranes are intact and there is no evidence of infection or bleeding, discuss the options for birth (expectant management, induction of labour or caesarean birth) and respect the woman's decision. [2008, amended 2021]

1.2.29 In the event of an intrauterine fetal death, if there is evidence of ruptured membranes, infection or bleeding, offer immediate induction of labour or caesarean birth. [2008, amended 2021]

1.2.30 If a woman with an intrauterine fetal death chooses an induced labour, follow the recommendations on monitoring of uterine contractions (preferably using manual assessment) and provide one-to-one midwifery care of the woman during labour and birth. [2021]

Intrauterine fetal death – women with a non-scarred uterus

1.2.31 If a woman with an intrauterine fetal death chooses an induced labour, offer:

  • oral mifepristone 200 mg followed by vaginal dinoprostone or oral or vaginal misoprostol. Base the choice and dosage of drug used on clinical circumstances and national protocols, or

  • a mechanical method of induction. [2008, amended 2021]

    In November 2021, some uses of mifepristone, dinoprostone and misoprostol were off label. See NICE's information on prescribing medicines.

Intrauterine fetal death – women who have had a previous caesarean birth

1.2.32 Advise women who have intrauterine fetal death, and who have had a previous lower segment caesarean birth, that:

  • induction of labour could lead to an increased risk of uterine rupture

  • the methods used for induction of labour will be guided by the need to reduce these risks (for example, by using mechanical methods). See the recommendations on methods for induction of labour.

  • some methods used for induction of labour may not be suitable (for example, both dinoprostone and misoprostol are contraindicated in women with a uterine scar). [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on induction of labour for intrauterine fetal death after previous caesarean birth.

Full details of the evidence and the committee's discussion are in evidence review D: induction of labour for intrauterine fetal death after previous caesarean birth.

1.3 Methods for induction of labour

Membrane sweeping

1.3.1 Explain to women:

  • what a membrane sweep is

  • that membrane sweeping might make it more likely that labour will start without the need for additional pharmacological or mechanical methods of induction

  • that pain, discomfort and vaginal bleeding are possible from the procedure. [2008, amended 2021]

1.3.2 At antenatal visits after 39+0 weeks, discuss with women if they would like a vaginal examination for membrane sweeping, and if so obtain verbal consent from them before carrying out the membrane sweep. [2008, amended 2021]

1.3.3 Discuss with women whether they would like to have additional membrane sweeping if labour does not start spontaneously following the first sweep. [2008, amended 2021]

Pharmacological and mechanical methods for inducing labour

1.3.4 Explain to women that a vaginal examination to assess the readiness of the cervix (recorded as the Bishop score) will help to decide which method of induction they will be offered first, and obtain consent to carry this out. [2021]

1.3.5 Discuss with women the risks and benefits of different methods to induce labour. Include that:

  • both dinoprostone and misoprostol can cause hyperstimulation (see information on hyperstimulation rates in appendix C)

  • when using pharmacological methods of induction, uterine activity and fetal condition must be monitored regularly

  • if hyperstimulation does occur, the induction treatment will be stopped by giving no further medication, or by removal of vaginally administered products when possible

  • there are differences in the ease with which different vaginal products can be removed (for example, dinoprostone controlled-release vaginal delivery systems can be more easily removed than gel or vaginal tablets)

  • hyperstimulation can be treated with tocolysis, but hyperstimulation caused by misoprostol may be more difficult to reverse

  • mechanical methods are less likely to cause hyperstimulation than pharmacological methods. [2021]

1.3.6 Follow the manufacturers' guidance on the use of dinoprostone and misoprostol preparations for the induction of labour, including when to remove dinoprostone controlled-release vaginal delivery systems. [2021]

1.3.7 For women with a Bishop score of 6 or less, offer induction of labour with dinoprostone as vaginal tablet, vaginal gel or controlled-release vaginal delivery system or with low dose (25 microgram) oral misoprostol tablets. [2021]

1.3.8 For women with a Bishop score of 6 or less, consider a mechanical method to induce labour (for example, a balloon catheter or osmotic cervical dilator) if:

1.3.9 For women with a Bishop score of more than 6, offer induction of labour with amniotomy and an intravenous oxytocin infusion. [2021]

1.3.10 Advise women that they can have an amniotomy and can choose whether or not to have an oxytocin infusion, or can delay starting this, but that this may mean labour takes longer and there may be an increased risk of neonatal infection. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on methods for induction of labour.

Full details of the evidence and the committee's discussion are in evidence review B: methods for induction of labour.

1.5 Assessment before induction, monitoring and pain relief

Assessment before induction

1.5.1 Ensure the position of the baby and the woman's condition are suitable for induction by:

  • abdominally assessing the level and stability of the fetal head in the lower part of the uterus at or near the pelvic brim

  • carrying out an ultrasound scan if there are any concerns about the position of the baby (for example, if it might be in the breech position)

  • assessing and recording the Bishop score

  • confirming a normal fetal heart rate pattern using antenatal cardiotocography interpretation

  • confirming the absence of significant uterine contractions (not Braxton-Hicks) using cardiotocography. [2008, amended 2021]

1.5.2 Ensure facilities are available for cardiotocography wherever induction of labour is started. [2008, amended 2021]

Monitoring

Note that the summaries of product characteristics for different preparations of dinoprostone contain different monitoring requirements. Always use the NICE guidance on dinoprostone in conjunction with the relevant summary of product characteristics.

1.5.3 When uterine contractions begin after administering dinoprostone or misoprostol, assess fetal wellbeing and uterine contractions with intrapartum cardiotocography interpretation and:

  • if the cardiotocogram is confirmed as normal, review the individual circumstances and, if considered low risk, use intermittent auscultation unless there are clear indications for further cardiotocography

  • if the fetal heart rate is abnormal or there are excessive uterine contractions:

    • continue or restart continuous cardiotocography

    • do not administer any more doses, and

    • remove any vaginal pessaries or delivery systems if possible.

      Follow the advice on monitoring during labour in the NICE guideline on intrapartum care. [2008, amended 2021]

1.5.4 Offer to reassess the wellbeing of the woman and baby and the Bishop score at appropriate intervals to monitor progress, depending on the method of induction being used, and the clinical condition of the woman. [2008, amended 2021]

1.5.5 Once active labour is established, carry out maternal and fetal monitoring as described in the NICE guideline on intrapartum care. [2008]

Pain relief

1.5.6 Explain to women that induced labour may be more painful than spontaneous labour. [2008]

1.5.7 Discuss the available pain relief options in different settings with women. [2008]

1.5.8 During induction of labour, provide women with the pain relief appropriate for them and their pain as described in the NICE guideline on intrapartum care. This can include simple analgesia, labour in water and epidural analgesia. [2008, amended 2021]

1.6 Outpatient induction

Note that the summaries of product characteristics for different preparations of dinoprostone contain different monitoring requirements. Always use the NICE guidance on dinoprostone in conjunction with the relevant summary of product characteristics.

1.6.1 Consider outpatient induction of labour with vaginal dinoprostone preparations or mechanical methods in women who wish to return home, and who have no co-existing medical conditions or obstetric complications. Discuss with the woman the benefits and risks of returning home, and respect her decision. [2008, amended 2021]

1.6.2 Carry out a full clinical assessment of the woman and baby (see recommendations 1.5.1 and 1.5.2) and ensure safety and support procedures are in place. [2008, amended 2021]

1.6.3 For induction being undertaken on an outpatient basis, agree a review plan with the woman before she returns home. [2008, amended 2021]

1.6.4 Ask women to contact their midwife, maternity unit or obstetrician:

  • when contractions begin, or

  • if there are no contractions (in an agreed timeframe, depending on the method used), or

  • if her membranes rupture, or

  • if she develops bleeding, or

  • if she has any other concerns, such as reduced or altered fetal movements, excessive pain or uterine contractions, side-effects or loss of the pessary. [2008, amended 2021]

1.7 Prevention and management of complications

Uterine hyperstimulation

1.7.1 If uterine hyperstimulation occurs during induction of labour:

  • carry out a fetal assessment

  • do not administer any more doses of medicines to induce labour and remove any vaginal pessaries or delivery systems if possible

  • consider tocolysis. [2008, amended 2021]

Unsuccessful induction

1.7.2 If induction is unsuccessful, discuss this with the woman and provide support. Fully reassess the woman's condition and the pregnancy in general, and assess fetal wellbeing using antenatal cardiotocography interpretation. [2008, amended 2021]

1.7.3 If induction is unsuccessful, discuss and agree a plan for further management with the woman, including whether she would like further attempts at induction, taking into account the clinical circumstances and her preferences. [2008, amended 2021]

1.7.4 If induction is unsuccessful, the subsequent management options include:

  • offering a rest period if clinically appropriate and then re-assessing the woman

  • expectant management

  • further attempts to induce labour

  • caesarean birth. See the NICE guideline on caesarean birth. [2008, amended 2021]

Cord prolapse

1.7.5 Take the following precautions to avoid the adverse effects of cord prolapse, which may occur if labour is induced:

  • before induction, abdominally assess the level and stability of the fetal head in the lower part of the uterus at or near the pelvic brim (see the recommendations on assessment before induction)

  • during the preliminary vaginal examination, obstetricians and midwives should palpate for umbilical cord presentation and avoid dislodging the baby's head

  • carry out continuous cardiotocography during induction after the membranes have ruptured, if the presenting part is not stable and not well-applied to the cervix. In this situation, discuss the risks and benefits of induction of labour with the woman, and if necessary consider caesarean birth. If the presenting part stabilises and the cardiotocogram is normal, use intermittent auscultation unless there are clear indications for further cardiotocography. [2008, amended 2021]

Placenta praevia, low-lying placenta or a previous history of antepartum haemorrhage

1.7.6 Check that there is no evidence of a low-lying placenta on previous scans before membrane sweeping and before induction of labour. [2008, amended 2021]

Uterine rupture

1.7.7 If uterine rupture is suspected during induced labour, carry out an immediate category 1 caesarean birth. See the NICE guideline on caesarean birth. [2008, amended 2021]

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

Bishop score

The Bishop score is a numerical value obtained by doing a vaginal examination, and is based on the dilation, effacement (or length), position and consistency of the cervix and the station of the head with respect to the ischial spines of the pelvis. A score of 8 or more generally indicates that the cervix is ready to dilate, (previously the terms 'ripe' or 'favourable' were widely used) and when there is a high chance of spontaneous labour, or response to interventions made to induce labour. For the purposes of this guideline, a Bishop score of less than or equal to 6, or a score greater than 6, was used to help determine choice of pharmacological or mechanical methods to induce labour.

Dinoprostone

Dinoprostone is the international non-proprietary name for prostaglandin E2. Previous versions of this guideline referred to prostaglandin E2, or PGE2, but in order to ensure uniformity with the naming conventions in the BNF, this version refers to this medication as dinoprostone.

Expectant management

A management approach, also called 'watch and wait', when no medical or surgical treatment is given. The aim is to allow labour to begin naturally.

Hyperstimulation

This is overactivity of the uterus as a result of induction of labour. It is variously defined as uterine tachysystole (more than 5 contractions per 10 minutes for at least 20 minutes) and uterine hypersystole/hypertonicity (a contraction lasting at least 2 minutes). These may or may not be associated with changes in the fetal heart rate pattern (persistent decelerations, tachycardia or increased/decreased short term variability).

Membrane sweeping

Membrane sweeping involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua of the uterus. If the cervix will not admit a finger, massaging around the cervix in the vaginal fornices may achieve a similar effect.

MBRRACE-UK

Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) is a series of audits carried out with the aim of identifying causes of maternal and perinatal death and morbidity and making recommendations to inform maternity care and so reduce these poor outcomes.

Osmotic cervical dilator

A medical device used to dilate the uterine cervix by swelling as it absorbs fluid from surrounding tissue.

Precipitate labour

A labour that is very quick and short, and the baby is born less than 3 hours after the start of uterine contractions.

Suspected fetal macrosomia

A baby that is believed to be large for its gestational age, defined for the purposes of this guideline as an estimated fetal weight above the 95th percentile, at or after 36 weeks of pregnancy.

Unsuccessful induction

Unsuccessful induction is defined as labour not starting after one cycle of treatment.

  • National Institute for Health and Care Excellence (NICE)