Red Flags
- Uterine hyperstimulation with non-reassuring CTG during prostaglandin or oxytocin — stop agent, remove pessary if present, lateral position, IV fluids; tocolysis (terbutaline) if persistent; deliver if not resolving[1]
- Suspected uterine rupture during induction with prior caesarean — emergency theatre; high index of suspicion with VBAC[1]
- Cord prolapse on artificial membrane rupture — emergency caesarean; manual elevation of presenting part; knee-chest position[1]
- Failed induction (cervix unfavourable after maximum prostaglandin and 12–24 h of oxytocin in active labour) — caesarean section per local protocol[1]
First-line treatment
Interventions
- Membrane sweep at 39–41 weeks[1]Offer at term to women undergoing or considering induction; reduces need for formal induction; consent required as part of clinic visit
- Cervical ripening for unfavourable cervix (Bishop ≤6)[1]Mechanical (Foley balloon, double-balloon catheter) or pharmacological (vaginal PGE2 pessary or gel; oral or vaginal misoprostol per local protocol). Mechanical preferred in VBAC and some cardiac/asthmatic women
- Active labour induction[1]Artificial rupture of membranes followed by oxytocin titration once Bishop favourable; continuous CTG; titrate oxytocin to 3–4 contractions in 10 minutes; manage hyperstimulation per protocol
- Alternative — outpatient cervical ripening[1]Selected low-risk women with mechanical ripening (Foley) or low-dose vaginal PGE2 in pathways with safe community follow-up
- Mechanical cervical ripening (Foley or double-balloon)[1]Insert under aseptic technique; inflate to 30–60 mL; remove at 12 h or spontaneous expulsion; safe in VBAC and many cardiac and asthmatic women; very low hyperstimulation risk
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Vaginal dinoprostone (PGE2) pessary or gel[1] | Synthetic prostaglandin E2 | Pessary 10 mg controlled-release × 24 h; gel 1–2 mg, repeat at 6 h if no response | — | Primary cervical ripening; remove for hyperstimulation, established labour, ROM, or 30 min before oxytocin start; avoid with prior caesarean (uterine rupture risk) |
| Misoprostol (vaginal or oral)[1] | Synthetic prostaglandin E1 | Vaginal: 25 µg every 4 h × max 5 doses. Oral: 50 µg every 4 h. Sublingual 25 µg every 2 h (per local protocol) | — | Cervical ripening and labour induction; lower cost than PGE2; contraindicated with prior caesarean section (rupture risk); follow weight-based titration |
| Oxytocin (IV infusion)[1] | Synthetic oxytocin | Start 1–4 mU/min IV infusion; double every 30 min to maximum 32 mU/min titrated to 3–4 contractions in 10 min | — | After cervical ripening or with favourable cervix; continuous CTG; manage hyperstimulation by reducing rate; do not co-administer with prostaglandin within 30 min |
Vaginal dinoprostone (PGE2) pessary or gel[1]
Synthetic prostaglandin E2
- Adult
- Pessary 10 mg controlled-release × 24 h; gel 1–2 mg, repeat at 6 h if no response
- Paediatric
- —
Primary cervical ripening; remove for hyperstimulation, established labour, ROM, or 30 min before oxytocin start; avoid with prior caesarean (uterine rupture risk)
Misoprostol (vaginal or oral)[1]
Synthetic prostaglandin E1
- Adult
- Vaginal: 25 µg every 4 h × max 5 doses. Oral: 50 µg every 4 h. Sublingual 25 µg every 2 h (per local protocol)
- Paediatric
- —
Cervical ripening and labour induction; lower cost than PGE2; contraindicated with prior caesarean section (rupture risk); follow weight-based titration
Oxytocin (IV infusion)[1]
Synthetic oxytocin
- Adult
- Start 1–4 mU/min IV infusion; double every 30 min to maximum 32 mU/min titrated to 3–4 contractions in 10 min
- Paediatric
- —
After cervical ripening or with favourable cervix; continuous CTG; manage hyperstimulation by reducing rate; do not co-administer with prostaglandin within 30 min
Safety-net
- Induction can take 24–48 hours from start of cervical ripening to delivery — anticipate longer first labour and bring support, food, drinks per local policy[1]
- Persistent abdominal pain between contractions, frank bleeding, or change in fetal movements — tell the midwifery team immediately[1]
- If induction fails or fetal distress occurs, caesarean is the safest course — counselling about this possibility is part of pre-induction consent[1]
Referral criteria
- Indications for induction at unfavourable term (post-dates 41+, hypertension, diabetes, FGR, IUFD, PROM)Obstetric labour ward booking[1]
- Prior caesarean section requesting trial of labourSenior obstetric review and counselling; mechanical ripening preferred[1]
- Failed induction or non-reassuring CTG during inductionTheatre and obstetric escalation[1]
- Cervical ripening or induction in cardiac, severe asthma, or severe anaemia patientsJoint obstetric and medical anaesthetic team[1]
Clinical summary
Indications, methods, and monitoring for elective and indicated induction of labour at term and post-dates in singleton pregnancies.