Induction of Labour: Maternity and Neonatal Clinical Guideline

Queensland Health
Maternity and Neonatal Clinical Guideline
Induction of labour
Queensland Clinical Guideline: Induction of labour
Document title: Induction of labour

Publication date: March 2017
Document number: MN17.22-V6-R22
Document supplement: The document supplement is integral to and should be read in conjunction
with this guideline
Amendments: Full version history is supplied in the document supplement
Amendment date: June 2017
Replaces document: MN17.22-V5-R22
Author: Queensland Clinical Guidelines
Audience: Health professionals in Queensland public and private maternity and
neonatal services
Review date: March 2022
Endorsed by: Queensland Clinical Guidelines Steering Committee
Statewide Maternity and Neonatal Clinical Network (Queensland)
Contact: Email: [email protected]
URL: www.health.qld.gov.au/qcg
Disclaimer
This guideline is intended as a guide and provided for information purposes only. The information has been
prepared using a multidisciplinary approach with reference to the best information and evidence available
at the time of preparation. No assurance is given that the information is entirely complete, current, or
accurate in every respect.
The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice.
Variation from the guideline, taking into account individual circumstances, may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are
responsible for:
• Providing care within the context of locally available resources, expertise, and scope of
practice
• Supporting consumer rights and informed decision making in partnership with healthcare
practitioners, including the right to decline intervention or ongoing management
• Advising consumers of their choices in an environment that is culturally appropriate and
which enables comfortable and confidential discussion. This includes the use of interpreter
services where necessary
• Ensuring informed consent is obtained prior to delivering care
• Meeting all legislative requirements and professional standards
• Applying standard precautions, and additional precautions as necessary, when delivering
care
• Documenting all care in accordance with mandatory and local requirements
Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability
(including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for
any reason associated with the use of this guideline, including the materials within or referred to throughout
this document being in any way inaccurate, out of context, incomplete or unavailable.
© State of Queensland (Queensland Health) 2017
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Refer to online version, destroy printed copies after use Page 2 of 30

Flow Chart: Method of induction of labour
Induction of labour Method
Indication Pre IOL assessment

• Maternal and/or fetal benefit • Review history
• Confirm gestation
Contraindications • Baseline observations
• As for vaginal birth • Abdominal palpation (presentation,
Communication with woman attitude, position, lie, engagement)
• Indication • CTG: consult obstetrician if abnormal
• Maternal &/or fetal benefit & risk • Vaginal examination:
o Assess MBS
• Individual circumstances
o Membrane status (intact or ruptured)
• Proposed IOL methods
• Options for pain management
• Options if:
o IOL unsuccessful
o IOL declined
o Expectant management Yes
Membranes
preferred ruptured?
• Time for decision-making
• Obtain informed consent
• Document above
No
Membrane sweep
• Discuss antenatally
• Offer prior to IOL Yes
MBS ≥ 7
(favourable)
If IOL declined or postponed
• Consider individual circumstances,
woman’s preferences, local
service capabilities and priorities No
• Perform maternal and fetal
assessment
• Arrange ongoing monitoring No
• From 42+0 weeks offer twice Previous CS?
weekly:
o CTG
o USS for fetal wellbeing
Yes
• Provide verbal and written
information on fetal movement
• Advise to contact health care
provider if concerned Balloon
ARM
• Document assessment and plan of catheter
care in the health record
either
Dinoprostone Oxytocin
Modified Bishop Score (MBS)

0 1 2 3
Cervical dilatation (cm) <1 1–2 3–4 >4
Cervical length (cm) >3 2 1 <1
Refer to relevant flow chart
Station (ischial spines) –3 –2 – 1/0 + 1 /+ 2
Cervical consistency Firm Medium Soft -
Cervical position Posterior Mid Anterior -
Queensland Clinical Guidelines: F17.22-1-V5-R22
ARM Artificial rupture of membranes; cm centimetres, CS Caesarean section; CTG Cardiotocography; IOL Induction of
labour; MBS Modified Bishop Score; USS Ultrasound scan; < less than; > greater than; ≥ greater than or equal to

Flow Chart: Balloon catheter

Induction of labour
Balloon catheter
See flowchart: Method of induction
Indications Insertion procedure

• MBS ≤ 6 • Pre catheter insertion:
• Previous CS o Ensure pre IOL assessment complete
• Following dinoprostone if no/minimal o Encourage to empty bladder
effect on cervical ripening and ARM • Performed by medical or midwifery staff:
not technically possible o Contact a more experienced clinician if two
• Reduced risk of uterine unsuccessful attempts
hyperstimulation is desirable • Inflate balloon catheters with sterile water or
Contraindications 0.9% sodium chloride:
• Ruptured membranes o Double balloon: 80 mL each balloon
• Undiagnosed bleeding o Single balloon: 30–80 mL
• Simultaneous use of prostaglandins • Document inflation volume
• Low lying placenta
• Polyhydramnios Post procedure observation and care
• Abnormal FHR auscultation or CTG • Pulse, BP, FHR, uterine activity, engagement of
Relative contraindications fetal head and vaginal loss
• Antepartum bleeding o Immediately, and repeat at 30 minutes
• Lower tract genital infection o Medical review if malpresentation or fetal head
• Fetal head not engaged (4/5 or 5/5 palpable after insertion
5/5 above pelvic brim o CTG not required (unless other indications)
• If observations normal, no contractions and not
otherwise indicated, ongoing care as for latent first
stage of labour
Moderate or severe discomfort? • Assess for/ask about discomfort
as required
Yes any of
Labour
commenced?
SROM?
Catheter out?
No Yes Observations abnormal?
Labour
commenced?
Reduce balloon volume
• Remove 10 mL from each
balloon No
• Reassess and repeat to a
minimum of 50 mL of residual 12 hours after insertion:
volume in each balloon (Do not leave catheter in situ
• Document volume removed longer than 18 hours)
• Reassess in birth suite
• Recommend ARM
No Moderate
or severe
discomfort?
ARM No
Yes successful?
If not in labour, offer analgesia

and sedation Yes
Continue IOL Obstetric review

Ongoing
Labour care Recommend Consider:
No Yes (Birth Suite)
pain/
Ongoing care as immediate • Dinoprostone, or
discomfort?
indicated commencement of • Reinsert catheter
oxytocin after 24 hours
ARM Artificial rupture of membranes; BP Blood pressure; CS Caesarean section; CTG Cardiotocography; FHR Fetal
heart rate; IOL Induction of labour; MBS Modified Bishop Score; SROM Spontaneous rupture of membranes; ≤ less
than or equal to,

Flow Chart: Prostaglandin E2 (dinoprostone)

Induction of labour
Prostaglandin E2 (dinoprostone)
Indications Pre dinoprostone insertion

• Unfavourable cervix (MBS ≤ 6) • Complete pre IOL assessment
• Following balloon catheter if no/ • Encourage to empty bladder
minimal effect on cervical ripening
and ARM not technically possible
Contraindications
• Known hypersensitivity
• Ruptured membranes
• Multiparity ≥ 5 Dinoprostone GEL
Dinoprostone PESSARY
• Previous CS or uterine surgery • Nulliparous: 2 mg PV
• 10 mg PV
• Malpresentation/high presenting • Multiparous: 1 mg PV
• Position transversely in
part • Insert high into posterior
posterior fornix
• Undiagnosed PV bleeding fornix
• Wait at least 12 hours after
• Abnormal CTG/fetal compromise • Wait at least 6 hours after
insertion then reassess
insertion then reassess
Cautions MBS
MBS
• Multiple pregnancy
• Asthma, chronic obstructive
pulmonary disease: may cause
bronchospasm
• Epilepsy
• Cardiovascular disease Recommend ARM
• Raised intraocular pressure, irrespective of MBS
glaucoma
• Avoid concurrent oxytocin use
Post dose care ARM Yes

successful?
• TPR, BP, FHR, uterine activity, or SROM?
PV loss hourly for 4 hours
• CTG for minimum of 30 minutes
• If observations normal, no No
contractions and not otherwise
indicated, ongoing care as for
latent first stage of labour
If GEL used:
• Continuous CTG when in active
• May repeat to maximum of 3 If PESSARY used:
labour or when contractions are
doses at least 6 hours apart • Give one dose of
≥ 3 in 10 minutes
o Nulliparous 2 mg dinoprostone GEL
• After insertion advise woman to:
o Multiparous 1–2 mg • Wait at least 6 hours then
o Remain recumbent for 30
• Wait at least 6 hours then reassess MBS
minutes
reassess MBS
o Inform staff as soon as
contractions commence
PESSARY removal indications

• Onset of regular, painful uterine
contractions, occurring every
3 minutes regardless of cervical No ARM Yes
change successful?
or SROM?
• Fetal distress
• Uterine hyperstimulation or
hypertonic uterine contractions Recommend oxytocin
• Maternal systemic adverse effects Consider balloon • 6 hours after GEL
(e.g. nausea, vomiting, catheter • 30 minutes after removal
hypotension, tachycardia) of PESSARY (minimum)
ARM Artificial rupture of membranes; BP Blood pressure; CS Caesarean section; CTG Cardiotocography; FHR Fetal
heart rate; IOL Induction of labour; MBS Modified Bishop Score; PV Per vaginam; SROM spontaneous rupture of
membranes; TPR: Temperature, pulse and respirations; ≥ greater than or equal to; ≤ less than or equal to

Flow Chart: Artificial rupture of membranes

Induction of labour Artificial rupture of membranes (ARM)
Pre ARM
Indications • Complete pre IOL assessment
• After cervical ripening method • Encourage to empty bladder
• Favourable cervix (MBS ≥ 7) • Abdominal palpation to determine:
• Before oxytocin infusion o Descent
commenced o Position
o Presentation
Relative contraindications
• Poor application of the VE to identify:
presenting part/unstable lie • Stage of labour
• Fetal head not engaged • MBS
• Presentation
• Position and descent
• Membranes
Post ARM care
• Immediately after procedure Assess for clinical concerns:
document: • Polyhydramnios
o Abdominal palpation • Head not engaged
o VE findings • Malpresentation
o FHR • Possible cord presentation
o Uterine activity • Unstable lie
o Vaginal loss (liquor amount,
colour consistency)
• If oxytocin commenced,
monitor as for oxytocin
• If oxytocin not commenced and Clinical Yes
observations normal and no concerns
contractions, then ongoing identified?
monitoring as for latent first
stage
• If FHR or liquor abnormalities No
discuss/refer/consult
• Encourage mobilisation to
promote onset of uterine
ARM
contractions
• Continue to ARM from assessment VE
• Confirm passage of fluid and check for
presence of blood and meconium
• Ensure good application of presenting
part before completing VE
• FHR immediately following procedure
No FHR or liquor
abnormalities?
Yes
CTG
Recommend immediate
Discuss, refer or consult Consult obstetrician
commencement of oxytocin
as indicated
ARM Artificial rupture of membranes; CTG: Cardiotocograph, FHR Fetal heart rate; IOL Induction of labour; MBS
Modified Bishop Score; VE Vaginal examination

Flow Chart: Oxytocin
Induction of labour
Oxytocin
Pre oxytocin commencement:

Indications • Complete pre IOL assessment
• IOL with ruptured membranes • Verify CTG normal
• If membranes intact, perform ARM
Cautions
• Do not commence oxytocin within:
Oxytocin administration:
o 6 hours of dinoprostone gel
• Via sideline/secondary IV access
o 30 minutes of removal of
• Volumetric pump required
dinoprostone pessary
• Record dose in milliunit/minute
• Discuss with obstetrician if:
o Previous uterine surgery (e.g. CS)
o Multiple pregnancy
o More than 4 previous births
o Cardiovascular disease
Observation and care
• Provide one-to-one midwifery care
Potential side effects • Commence intrapartum record
• Uterine hyperstimulation • Commence continuous CTG at the onset of
• Nausea and vomiting first contractions
• Water intoxication or hyponatremia • Maternal and fetal observations as per first
with prolonged infusion (rare with stage of active labour
isotonic infusion) • Maintain fluid balance chart
• Primary postpartum haemorrhage
• If planned VBAC: uterine dehiscence Dose management
and rupture • Use minimum dose required to establish
• Rarely (< 0.1%) arrhythmias, ECG and maintain active labour
changes, anaphylaxis, tetanic • Maternal and FHR prior to any increase
contractions, transient hypotension, • Aim for contractions:
reflex tachycardia o 3–4 in a 10 minute period
o Duration of 40–60 seconds
o Resting period not less than 60 seconds
• Titrate against uterine contractions
• Increase at 30 minute or longer intervals
• Obstetric review required:
Infusion: oxytocin o Prior to exceeding 20 milliunit/minute
(30 International units in 500 mL) o At 32 milliunit/minute if labour has not
1 milliunit/minute = 1 mL/hour commenced
Time after starting Dose o If infusion ceased
(minutes) (milliunit/minute) o Prior to recommencing
0 1 • Document changes to dose clearly and
contemporaneously on the intrapartum
30 2 record and/or CTG
60 4
90 8 If recommencing infusion
• Consult with an obstetrician
120 12
• If ceased for less than 30 minutes,
150 16 recommence at half the previous rate
180 20 • If ceased for greater than 30 minutes,
Prior to exceeding 20 milliunit/minute recommence at initial starting dose
obstetrician review required
210 24
240 28
270 32
ARM Artificial rupture of membranes; CS Caesarean section; CTG Cardiotocography; ECG Electrocardiograph; FHR
Fetal heart rate; IOL Induction of labour; IV Intravenous; VBAC Vaginal birth after caesarean section; < less than; ≥
greater than or equal to

Abbreviations
ARM Artificial rupture of membranes
BP Blood pressure
CI Confidence interval
CS Caesarean section
CTG Cardiotocography
EFW Estimated fetal weight
FGR Fetal growth restriction
FHR Fetal heart rate
IOL Induction of labour
MBS Modified Bishop Score
NICU Neonatal intensive care unit
NNT Number needed to treat
PGE2 Prostaglandin E2
PPH Primary postpartum haemorrhage
PV Per vaginam
RCT Randomised controlled trial
RR Risk ratio
SROM Spontaneous rupture of membranes
TPR Temperature, pulse, respiration
USS Ultrasound scan
VBAC Vaginal birth after caesarean
VE Vaginal examination
VTE Venous thromboembolism
x is number of completed weeks of pregnancy
+y
x +y is the number of days past the number of completed weeks of pregnancy
+3
(e.g. 40 is 40 completed weeks of pregnancy plus 3 days)
Definition of terms
1
Amniotomy Artificial rupture of membranes to initiate or speed up labour.
A flexible tube with an inflatable balloon at one end. This can be introduced
Balloon catheter through the cervix and the balloon inflated, holding the catheter in place. Also
known as transcervical catheter
A prelude to the onset of labour whereby the cervix becomes soft and
compliant. This allows its shape to change from being long and closed, to being
Cervical ripening
thinned out (effaced) and starting to open (dilate). It either occurs naturally or as
1
a result of physical or pharmacological interventions.
Allowing labour to develop and progress under supervision without intervention,
Expectant management 1
unless clinically indicated.
The cervix is said to be favourable when its characteristics suggest there is a
Favourable cervix high chance of spontaneous onset of labour, or of responding to interventions
1
made to induce labour.
Also known as intrauterine growth restriction (IUGR). Fetal growth restriction
Fetal growth restriction (FGR) indicates the presence of a pathophysiological process occurring in utero
2
that inhibits fetal growth.
Grand multipara A woman who has given birth to five or more babies.
1
Induction of labour The process of artificially initiating labour.
1
Mechanical method Non-pharmacological method of inducing labour.
Local facilities may differentiate the roles and responsibilities assigned in this
document to an “Obstetrician” according to their specific practitioner group
Obstetrician requirements; for example to General Practitioner Obstetricians, Specialist
Obstetricians, Consultants, Visiting Medical Officers, Senior Registrars,
Obstetric Fellows or other members of the team as required.
+0 1
Prolonged pregnancy A pregnancy past 42 weeks gestation.
Transcervical catheter Refer to the definition for balloon catheter.
3
Uterine hyperstimulation Either uterine tachysystole or uterine hypertonus with FHR abnormalities.
Contractions lasting more than two minutes in duration or contractions occurring
Uterine hypertonus 3
within 60 seconds of each other, without fetal heart rate abnormalities.
3
Uterine tachysystole More than 5 contractions in 10 minutes without FHR abnormalities.

Table of Contents
1 Introduction ................................................................................................................................... 10
1.1 Communication and information .......................................................................................... 10
1.2 IOL declined or postponed................................................................................................... 11
1.3 Clinical standards ................................................................................................................ 11
2 Specific indications and circumstances ........................................................................................ 12
2.1 Prolonged pregnancy prevention ......................................................................................... 12
2.2 Concern for fetal wellbeing .................................................................................................. 12
2.3 Twin pregnancy ................................................................................................................... 13
2.4 Fetal macrosomia ................................................................................................................ 13
2.5 Advanced maternal age ....................................................................................................... 13
2.6 Obstetric cholestasis (intrahepatic cholestasis of pregnancy) ............................................. 14
2.7 Maternal ethnicity ................................................................................................................. 14
2.8 Maternal request .................................................................................................................. 14
3 Pre IOL assessment ..................................................................................................................... 15
3.1 Cervical assessment............................................................................................................ 15
3.2 Membrane sweeping ........................................................................................................... 16
4 Methods of IOL ............................................................................................................................. 17
4.1 Balloon (transcervical) catheter ........................................................................................... 18
4.1.1 Balloon (transcervical) catheter insertion ........................................................................ 19
4.1.2 Balloon (transcervical) catheter post insertion care......................................................... 20
4.2 Dinoprostone ....................................................................................................................... 21
4.2.1 Dinoprostone administration ............................................................................................ 22
4.3 Artificial rupture of membranes ............................................................................................ 23
4.4 Oxytocin ............................................................................................................................... 24
4.4.1 Oxytocin regimen administration ..................................................................................... 25
5 Risks and benefits associated with IOL ....................................................................................... 26
References .......................................................................................................................................... 27
Acknowledgements.............................................................................................................................. 30
List of Tables
Table 1. Communication and information-........................................................................................... 10
Table 2. IOL declined or postponed .................................................................................................... 11
Table 3. Clinical standards .................................................................................................................. 11
Table 4. Prolonged pregnancy ............................................................................................................ 12
Table 5. Fetal growth restriction .......................................................................................................... 12
Table 6. Twin pregnancy ..................................................................................................................... 13
Table 7. Suspected fetal macrosomia ................................................................................................. 13
Table 8. Advanced maternal age ......................................................................................................... 13
Table 9. Obstetric cholestasis ............................................................................................................. 14
Table 10. Maternal ethnicity ................................................................................................................ 14
Table 11. Maternal request .................................................................................................................. 14
Table 12. Modified Bishop score ......................................................................................................... 15
Table 13. Membrane sweeping ........................................................................................................... 16
Table 14. Methods of IOL .................................................................................................................... 17
Table 15. Balloon catheter considerations .......................................................................................... 18
Table 16. Balloon catheter insertion procedure ................................................................................... 19
Table 17. Post balloon catheter insertion ............................................................................................ 20
Table 18. Dinoprostone considerations and dose ............................................................................... 21
Table 19. Dinoprostone administration ................................................................................................ 22
Table 20. Artificial rupture of membranes............................................................................................ 23
Table 21. Oxytocin ............................................................................................................................... 24
Table 22. Oxytocin administration ....................................................................................................... 25
Table 23. Oxytocin regimen ................................................................................................................. 25
Table 24. Risks and benefits associated with IOL ............................................................................... 26

1 Introduction
Induction of labour (IOL) is the initiation of contractions in a pregnant woman who is not in labour.
IOL is indicated when the maternal and/or fetal risks of ongoing pregnancy outweigh the risks of IOL
and birth. Contraindications to IOL are consistent with those for vaginal birth. A woman’s individual
circumstances and preferences will influence the timing and method of IOL. In 2014 the IOL rate in
4
Queensland was 24.9% of all births.
The purpose of this guideline is to guide the IOL process in women at or near term. Refer to
associated Queensland Clinical Guidelines for specific circumstances outside the scope of this
guideline including:
• Early pregnancy loss
5
• Therapeutic termination of pregnancy

6
• Perinatal care at the threshold of viability

7
• Stillbirth care
8
1.1 Communication and information

Discuss the risks and benefits of IOL as they pertain to each individual woman. Take into account
individual needs and preferences, to enable the woman to make an informed decision in consultation
9
with her health care provider.
Table 1. Communication and information-
Aspect Good practice points

• Provide time for questions and decision making
• In 2014–2015 in Queensland, for women who had an IOL:
10
Maternal o 27% reported having made an informed decision
experience o 91% felt the reasons for the IOL were explained in a way they could
11
understand
o 21% felt they had no choice about whether their labour would be
11
induced
• Indication for IOL
• Method of IOL
• Potential risks and benefits
IOL discussion
o Refer to Section 5 Risks and benefits associated with IOL
points
• Options for pain relief
• Options if unsuccessful
• Options if declined
• Consider the use of decision aids to assist the woman make informed
12
Written/online choices
information o Refer to Queensland Clinical Guideline parent information: Induction of
13
labour
• Clear and contemporaneous documentation is required in the healthcare
record including:
o The indication for IOL
o The content and outcome of discussions [refer to discussion points
Documentation
above]
o Informed consent/choice
o Care provided (e.g. Bishop score, observations)
o Clinician signature and designation

1.2 IOL declined or postponed

Table 2. IOL declined or postponed

• If IOL is declined, respect the woman’s decision
• Where pregnancy gestation was greater than 41 weeks gestation, women
14
who :
Communication o Waited for labour to start–38% would choose to wait next time
o Were induced–73% would choose IOL next time
• No form of increased antenatal monitoring has been shown to reduce
15
perinatal mortality associated with prolonged pregnancy
• If IOL is declined or postponed (e.g. due to resourcing issues or as a
result of maternal request), take into account the:
o Individual clinical circumstances and preferences
o Indication for IOL
o Local service capabilities and priorities
• Perform an assessment of maternal and fetal wellbeing
• Develop a plan with the woman for continued care including:
o Arrangements for ongoing monitoring
o Return for IOL
• From 42 weeks offer at least twice weekly assessment for fetal
+0
Plan care 9,16 1
wellbeing , including :
o Cardiotocography (CTG)
o Ultrasound scan (USS) assessment of amniotic fluid volume using
estimation of deepest vertical pocket
o Refer to Section 2.1 Prolonged pregnancy prevention
• Advise the woman to contact her health care provider/facility if concerned
about her wellbeing or that of her baby (including not to wait until the next
17
day )
• Provide verbal and written information about fetal movements
17
• Document the discussion, assessment and plan in the health record
1.3 Clinical standards

Table 3. Clinical standards

• Provide care in the context of the Clinical Services Capability Framework
18
• Ensure availability of health care professionals appropriate to the

circumstances
Service • Continuous electronic fetal heart monitoring and uterine contraction
3
capabilities monitoring is required for IOL with oxytocin and prostaglandin
• Establish quality and safety programs and tools to monitor care (e.g. IOL
safety audits and reviews)
• Provide care in accordance with the national consensus statement
19
• There is insufficient evidence to determine if IOL is effective and safe in

20
outpatient settings
• If a facility provides outpatient IOL prior to the onset of established labour
(e.g. for cervical ripening), develop local protocols to support:
Outpatient setting o Appropriate clinical governance, clinical indications, inclusion/exclusion
criteria, written information for women, observation/monitoring protocols
and adequate follow-up and support for women
o In the outpatient setting, IOL with balloon catheters may be safer than
IOL with prostaglandins as studies show less uterine hyperstimulation
21
during the cervical ripening phase

2 Specific indications and circumstances

Refer to associated Queensland Clinical Guidelines, which include IOL considerations for the specific
maternal circumstances of:
• Hypertensive disorders of pregnancy
22
• Gestational diabetes mellitus

23
• Obesity in pregnancy
24
• Vaginal birth after caesarean (VBAC)

25
• Early onset Group B Streptococcal disease (EOGBSD) , includes information related to:
26
o Prelabour rupture of membranes

o Preterm prelabour rupture of membranes
• Stillbirth care
8
• Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium

27
• Perinatal substance use: maternal

28
Considerations for other IOL indications and circumstances are outlined in the following sections.
2.1 Prolonged pregnancy prevention

Table 4. Prolonged pregnancy
Prevention of prolonged pregnancy

• No form of increased antenatal monitoring has been shown to reduce
15
perinatal mortality associated with prolonged pregnancy
• IOL from 41 weeks, compared with expectant management, is
+0
15
associated with :
Risk/Benefit o Fewer perinatal deaths [0.4 versus 3.2 per 1000 women]
o Less meconium aspiration syndrome [40 versus 66 per 1000 newborns]
o No difference in neonatal intensive care (NICU) admissions
o Fewer caesarean sections (CS) [168 versus 225 per 1000 women]
14
o Most women prefer IOL at 41 weeks over serial antenatal monitoring
• For uncomplicated pregnancies, recommend IOL after 41 weeks
+0 1,16,29
Clinical practice • Exact timing depends on the specific risk of stillbirth, individual
1
point preferences and local circumstances
• Waiting after 42 weeks is not recommended
+0 1,30
2.2 Concern for fetal wellbeing

Concern for fetal wellbeing may arise with FGR/small for gestational age [refer to Table 5],
decreased fetal movements, oligohydramnios, non-reassuring fetal surveillance test, fetal
abnormality, or isoimmunisation. The timing of birth may depend on gestational age, severity of
concern and results of tests of fetal wellbeing. Increased fetal surveillance may be required with
expectant management [refer to Section 1.2 IOL declined or postponed].
Table 5. Fetal growth restriction
Fetal growth restriction

• Although underpowered to show differences in late pregnancy loss, for
term FGR, comparing IOL with expectant monitoring, studies show no
31,32
significant difference in
Risk/Benefit
o Rate of obstetric interventions (e.g. CS)
o Maternal or neonatal morbidity and mortality
o Admission to a neonatal unit if birth occurred after 38 weeks gestation
• For babies with FGR, use of umbilical artery, middle cerebral and ductus
venosus Doppler may assist in improving perinatal outcome through more
33,34
appropriate timing of birth
Clinical practice
• Severity affects the decision concerning mode and timing of birth
35
point
• If recommending expectant management, increase fetal surveillance [refer
to Section 1.2 IOL declined or postponed]
• IOL at term to prevent stillbirth is appropriate

2.3 Twin pregnancy

Table 6. Twin pregnancy
Twin pregnancy
• Based on data from the United States, the fetal/infant mortality per
36
additional week of expectant management at :
o 37 weeks is 4.39 per 1000 women 95% CI 4.07 to 4.70
o 38 weeks is 5.92 per 1000 women 95% CI 5.40 to 6.43
• A Cochrane review of elective birth at 37 weeks compared to expectant
37
management demonstrated :
Risk/Benefit
o No statistically significant differences in CS, perinatal death or serious
morbidity, maternal death or serious maternal morbidity
o Significant reduction in risk of babies being born with a birth weight less
than the third percentile [one study; RR 0.30; 95% CI 0.13 to 0.68]
• Monochorionic twins are at increased risk of stillbirth in the third trimester
38
compared to dichorionic twins
• In uncomplicated twin pregnancies (monochororioic
39,40
Clinical practice or dichorionic),
+0 36,37,41
point plan birth after 37 weeks
2.4 Fetal macrosomia

Table 7. Suspected fetal macrosomia
Fetal macrosomia
• In a Cochrane review, comparing IOL at 37–40 weeks to expectant
42
management, there were :
o No significant differences in:
 CS rate or instrumental birth
Consideration
 Measures of neonatal asphyxia
o Lower risks of shoulder dystocia, and (any) fracture (NNT=60)
o Lower birth weights [178.03 g, 95% CI 40.81 to 315.26]
o Higher incidences of third and fourth degree perineal tears (one study)
• IOL on the basis of clinical suspicion of macrosomia alone is not
1
recommended
• USS for estimated fetal weight (EFW) is advised
43
• With a suspected large for gestation age baby based on clinical

Clinical practice assessment (e.g. symphysio-fundal height equals 3 cm more than
43
point expected from 36 weeks), offer an USS to measure EFW
• Discuss IOL after 38 weeks if EFW greater than :
+0 43
o 3500 g at approximately 36 weeks

2.5 Advanced maternal age

Table 8. Advanced maternal age
Advanced maternal age

• Advanced maternal age is an independent risk factor for stillbirth
44,45,46
o Nulliparous women may be at higher risk of stillbirth, but evidence is

45,47
inconsistent
Risk/Benefit
• IOL at 39 weeks for advanced maternal age, compared to expectant
management, had no significant effect on the CS rate and no adverse
48
short-term effects on maternal and neonatal outcomes
• For women aged 40 years or older, offer IOL at 39 –40 weeks
+0 +0
Clinical practice
45,49
point gestation

2.6 Obstetric cholestasis (intrahepatic cholestasis of pregnancy)

Table 9. Obstetric cholestasis
Obstetric cholestasis
• Associated with:
50,51
o Stillbirth
 Approximately 1.2% after 37 weeks gestation (although this may be
52
consistent with population stillbirth rates )
 Increases with increasing gestational age and bile acid levels
50,51
o Meconium stained liquor
Risk/Benefit 50,51
o Preterm birth
• No quality evidence exists to guide timing of birth
50,53
although IOL is often
54
recommended between 37 to 38 weeks due to risk of stillbirth
• Identified as a medical indication for late preterm (34 –36 weeks
+0 +6
+0 +6
gestational age) or early term (37 –38 weeks gestational age) birth by
55
American College of Obstetricians and Gynaecologists
• Consider IOL between 37 and 37 weeks gestation as relevant to :
+0 +6 53
o Individual circumstances—case for intervention is stronger with more

severe biochemical abnormalities
o Risk of stillbirth—cannot predict if pregnancy continues
Clinical practice
o Higher risk of neonatal respiratory morbidity from early intervention
point
• Offer continuous fetal monitoring during labour
• Consider IOL around 36 weeks for severe cases with jaundice,
progressive elevations in serum bile acids and liver enzymes, and
56
suspected fetal compromise
2.7 Maternal ethnicity

Table 10. Maternal ethnicity
Maternal ethnicity
• Differences in ethnicity have been reported in perinatal mortality data
57-63
but whether this is entirely attributable to genetic factors is unclear

• In one retrospective study, South-Asian born women (country of birth
Consideration India, Sri Lanka, Bangladesh, Pakistan) compared to Australian-born
women:
o Had a higher antepartum stillbirth rate [2.4 times more likely, 95% CI
1.4 to 4.0] with risk increasing progressively with gestation
o Were twice as likely to have a low birthweight baby (less than 2500 g)
• Insufficient evidence to recommend IOL based on maternal ethnicity alone
Clinical practice
point • Consider a woman’s ethnicity in the context of other risk factors when
determining timing of IOL
2.8 Maternal request

Table 11. Maternal request
Maternal request
• For low risk women elective IOL at term is not associated with an
64
increased risk of CS
• The long term population consequences of a significant proportion of low
risk women receiving elective IOL are unknown
Risk/Benefit • IOL requires more intensive clinical resources than spontaneous onset of
labour in low risk women
• Retrospective and population based studies suggest a possible
association between birth prior to 39 weeks and developmental/early
65-68
childhood health problems
• Consider IOL at term based on exceptional circumstances of the woman
Clinical practice
and her family (i.e. not solely because of patient or health care provider
point 9
preference )

3 Pre IOL assessment

Immediately prior to IOL:
• Review maternal history
• Confirm gestation
• Perform baseline maternal observations (e.g. temperature pulse, respiratory rate and
blood pressure)
• Perform abdominal palpation to confirm presentation, attitude, lie, position, and
engagement
• Assess membrane status (ruptured or intact)
9
• Vaginal examination (VE) to assess the cervix [refer to Section 3.1 Cervical assessment]
• Assess fetal wellbeing:
o FHR
1
o Confirm CTG is normal
o If CTG abnormal, escalate as per local protocols
69
o Refer to Queensland Clinical Guideline: Intrapartum fetal surveillance
• Assess for contraindications to IOL
• Consider urgency for IOL
3.1 Cervical assessment

The Bishop score is commonly used to assess the cervix and to inform the choice of method of IOL.
70
Each feature of the cervix is scored and then the scores are summed [refer Table 12]. The state of
9
the cervix is one of the important predictors of successful IOL. The cervix is unfavourable if the MBS
9
is 6 or less.
Table 12. Modified Bishop score

Score
Cervical feature
0 1 2 3
Dilation (cm) <1 1–2 3–4 >4
Length of cervix (cm) >3 2 1 <1
Station (relative to ischial spines) −3 −2 − 1/0 + 1/+ 2
Consistency Firm Medium Soft –
Position Posterior Mid Anterior –

3.2 Membrane sweeping

Membrane sweeping refers to the digital separation of the fetal membranes from the lower uterine
segment during VE. This movement helps to separate the cervix from the membranes and stimulate
the release of prostaglandins.
Table 13. Membrane sweeping
Membrane sweeping
Indication • Reduce the need for IOL by encouraging spontaneous labour
• Consistent with contraindications for vaginal birth
71
Contraindication
• Preterm gestation
• Reduced need for IOL, particularly in multiparous women
72
• Optimal gestation at which to commence is controversial

71
• Optimal frequency is unknown

71
o Serial membrane sweeping (every 2 days) reduced the number of

72
pregnancies reaching 42 weeks [NNT=6 ]
o When performed at the onset of formal induction, membrane sweeping
resulted in shorter induction to birth interval, shorter duration of oxytocin
73,74
infusion and improved birth process satisfaction
• No evidence of increased risk of maternal or neonatal infection
71,75
Risk/Benefit
o Is as safe in Group B Streptococcus (GBS) positive women as for
71,76
women whose GBS status is unknown or negative
71
o No data available on HIV or hepatitis C
• Associated with discomfort
72,75
, vaginal bleeding and irregular
75
contractions
• Some studies have shown no difference in cervical length, time to onset of
labour, or duration of the active phase of labour, where VBAC is
71,77,78
planned
• Discuss the benefits of membrane sweeping in the antenatal period
• Offer prior to formal IOL
71
Clinical practice
point • If the cervix is closed and membrane sweeping is not possible, cervical
1
massage in vaginal fornices may achieve similar effect

4 Methods of IOL
Table 14. Methods of IOL
Aspect Recommendation
Cervical • Mechanical: balloon (transcervical) catheter (e.g. Foley, Cook cervical
ripening for ripening balloon)
unfavourable • Pharmacological: dinoprostone preparations (prostaglandin E2/prostin gel,
cervix cervidil)
After cervical
ripening/ • Artificial rupture of membranes (ARM)
cervix • Oxytocin
favourable
• If primary method was:
If primary o Balloon catheter consider Dinoprostone gel/pessary
cervical
o Dinoprostone gel up to 3
ripening consider Balloon catheter
doses
method is
unsuccessful Dinoprostone gel or balloon
o Dinoprostone pessary consider
catheter
• For IOL–there is insufficient evidence to support Laminaria tents,
79,80 81
Insufficient breast/nipple stimulation (particularly if high risk ), acupuncture ,
82,83 1 84
evidence sexual intercourse , evening primrose oil, homeopathy , castor oil ,
85 1 1 1
nitric oxide donors , hyaluronidase , oestrogen , and corticosteriods
• Compared with placebo, misoprostol (sustained release vaginal pessary,
vaginal tablet, buccal/sublingual and oral tablet) had higher odds of
uterine hyperstimulation with FHR changes than 31 other active
86
Misoprostol interventions (180 studies)
• Not currently recommended for IOL where a live birth is expected
o Not included on the Queensland Health List of Approved Medicines
(LAM) for IOL with a viable baby

4.1 Balloon (transcervical) catheter

Balloon catheters (e.g. Foley, Cooks) are used to ripen the cervix through applying pressure on the
internal os of the cervix, thereby stretching the lower uterine segment and increasing local
9
prostaglandin secretion.
Table 15. Balloon catheter considerations
Aspect Clinical practice point

• Unfavourable cervix (MBS of 6 or less)
• May be considered with previous CS
Indications • May be used following dinoprostone when there has been no/minimal effect
on cervical ripening and ARM is not technically possible
• May be preferred where a reduced risk of uterine hyperstimulation is
29
desirable (e.g. SGA, grand multipara, scarred uterus )
• Any contraindication to vaginal birth (e.g. malpresentation, abnormal
placentation, HIV, active genital herpes)
• Any contraindications to IOL
Contraindication • Undiagnosed bleeding
• Simultaneous use of prostaglandins and/or oxytocin
87
• Low lying placenta

9,87
• Polyhydramnios
• Abnormal FHR auscultation or CTG
• Antepartum bleeding
9
Relative
• Lower tract genital infection
9
contraindications
• Fetal head not engaged (4/5 or 5/5 above the pelvic brim)
9
• When compared to vaginal prostaglandins:

21
o Less uterine hyperstimulation and tachysystole
o No difference in CS rate
87 o No difference in overall number not achieving vaginal birth within 24
Benefit
hours, although among multiparous women the risk of not birthing within
24 hours was higher
• Low cost and no specific storage or temperature requirements
• No evidence of an increased risk of infection although data is limited
• Placental abruption
• Uterine rupture
• Device entrapment
Risk • Maternal discomfort during and after insertion
• Failed dilatation and inability to perform ARM
• Cervical laceration or ischaemia (if prolonged use)
• There is limited data comparing single to double balloon catheter
87,88

4.1.1 Balloon (transcervical) catheter insertion
Table 16. Balloon catheter insertion procedure

• Speculum
• Balloon catheter, either
o 16/18 gauge catheter with double balloon (e.g. Cook cervical ripening
balloon)
o 26 French gauge Foley catheter
• Sponge forceps
• Sterile water or 0.9% sodium chloride (200 mL)
Equipment
• Syringe (20 mL)
• Sterile lubricating gel
• Swabs
• Tape
• CTG monitor
• Bed with stirrups
• Chlorhexidine
• Prior to commencement
o Ensure pre IOL assessment complete including baseline observations
Procedure o Encourage voiding
• Performed by competent medical or midwifery staff
• Contact a more experienced clinician if there are 2 unsuccessful attempts
• Stylet used with double balloon:
o Loosen the fitting on the proximal hub of the stylet so that the distal tip
Prepare the
of the stylet is even with the distal tip of the balloon
balloon catheter
o Tighten the fitting so that the wire does not move during manipulation
o Seat the adjustable handle firmly into the blue port labelled “S”
• Digital placement of the catheter is less painful than using a speculum
• Pass the balloon catheter through the internal os of the cervix using
sponge forceps to assist
• If insertion is technically difficult:
Insertion o Consider the lithotomy position
o Insert speculum and visualise the cervix
o Clean the cervix with chlorhexidine
o Pass the catheter through the cervix (using sponge forceps) until both
balloons have entered the cervical canal
• Once the catheter has traversed the cervix and the uterine balloon is
above the internal os, remove the stylet (if used) before advancing the
catheter further
• Inflate the uterine balloon with 40 mL of sterile water or 0.9% sodium
chloride
• Gently pull the catheter back until the uterine balloon is against the
Double balloon
internal cervical os
inflation
• The vaginal balloon is now visible/palpable outside the external cervical os
and is inflated with 20 mL of water or 0.9% sodium chloride
• Once the balloons are situated on either side of the cervix, remove the
speculum (if used) and add water or 0.9% sodium chloride up to a
maximum of 80 mL per balloon
• Document the inflation volume
• Spigot the catheter
• Inflate the balloon with 30–80 mL sterile water or 0.9% sodium chloride
Single balloon • Gently withdraw the catheter until the balloon rests against the internal os
inflation • Proximal end of the catheter may be taped to the thigh to provide
constant, moderate tension of the balloon
• Document the inflation volume

4.1.2 Balloon (transcervical) catheter post insertion care
Table 17. Post balloon catheter insertion

• Pulse, BP, FHR, uterine activity, engagement of the fetal head and vaginal
loss:
o Immediately following balloon catheter insertion
o At 30 minutes post balloon catheter insertion
o Medical review required if malpresentation or fetal head 5/5 palpable
after insertion
Monitoring
• CTG not required, unless other indications (e.g. uterine activity)
• Ongoing monitoring as for latent first stage of labour while:
89
o Observations are normal

o No contractions
o Not otherwise indicated
89
 Refer to Queensland Clinical Guideline: Normal Birth
• Schedule assessment 12 hours after insertion with plan to ARM
• If the balloon catheter has not spontaneously fallen out and ARM is
unsuccessful:
12 hour o Obstetric review is indicated
reassessment o Continuing IOL may involve dinoprostone or reinsertion of another
balloon catheter after 24 hours
• If there is a delay in the scheduled 12 hour assessment, remove the
balloon catheter no later than 18 hours after insertion
• Observations abnormal
Indications for • Persistent pain and discomfort
birth suite care • Spontaneous rupture of membranes
• Labour commences
• Assess for labour
• Reduce balloon volume (discuss with experienced clinician as required):
o Foley catheter: remove maximum of 10 mL
o Double balloon catheter: remove 10 mL from each vaginal and uterine
balloon (from green stopcock marked ‘V’ and from red stopcock marked
‘U’)
Moderate or
o Reassess and repeat ensuring a minimum of 50 mL of residual volume
severe
remains in each balloon
discomfort
o Document the volume removed
• Offer analgesia and sedation if woman not in labour and continues to
experience moderate to severe discomfort despite balloon deflation
• If persistent pain and discomfort following oral analgesia
o Review by an obstetrician, or
o Transfer to birth suite for further assessment
Indications for • Spontaneous rupture of membranes (SROM)
early removal of • Uterine hyperstimulation
balloon catheter • Maternal request
• Offer appropriate analgesia and comfort aids
Difficulty passing • If still unable to void, consider removing 10 mL of fluid from each of the
urine uterine and vaginal balloons
• Note: Balloon may be in the vagina
• Transfer to birth suite
If balloon • Perform VE
catheter falls out o Plan ARM and oxytocin as soon as possible (due to the temporary
dilatory effect of balloon catheters)
• After 12 hours remove the balloon catheter by completely deflating the
balloon(s) using an appropriately sized syringe (do not leave balloon
Removal of
catheter insitu longer than 18 hours)
balloon catheter
• Once the balloon catheter has been removed, perform an ARM and
commence an oxytocin infusion

4.2 Dinoprostone
90
Prostaglandins promote cervical ripening and stimulate uterine contractions. Dinoprostone is the
90
most commonly used prostaglandin agent in third trimester IOL. Dinoprostone preparations include:
• Vaginal gel (prostaglandin E2, (prostin) 1 mg and 2 mg
• Controlled release vaginal pessary (cervidil)
• Refer to Table 18 and Table 19
Table 18. Dinoprostone considerations and dose

• Unfavourable cervix
91
Indication • May be used following balloon catheter when there has been no/minimal
effect on cervical ripening and artificial rupture of membranes (ARM) is not
technically possible
• Known hypersensitivity to dinoprostone
• Grand multiparity
Contraindication
91,92,93 • Previous CS or any uterine surgery
• Malpresentation/high presenting part
• Unexplained PV bleeding during current pregnancy
• Abnormal CTG/fetal compromise
• Multiple pregnancy
• Asthma, chronic obstructive pulmonary disease—may cause
bronchospasm
• Epilepsy
91
Cautions
• Cardiovascular disease
• Raised intraocular pressure, glaucoma
• Avoid combining with oxytocin [refer to Section 4.4 Oxytocin]
• Nausea, vomiting and diarrhoea may occur soon after insertion
91
• Vaginal PGE2 compared to a placebo or expectant management :

90
o Increased vaginal birth within 24 hours with repeated doses

Risk/benefit o Increased hyperstimulation with FHR changes (4.8% versus 1.0%, RR
3.16, 95%CI 1.67 to 5.98)
o Did not appear to reduce CS rate, NICU admission, serious
maternal/newborn morbidity/mortality
Before • Ensure pre IOL assessment complete
administration • Encourage to empty bladder
Initial dose:
• Nulliparous: 2 mg PV
• Multiparous: 1 mg PV
Dinoprostone gel Repeat dose (if clinically indicated and only after 6 hours)
dose • Nulliparous: 2 mg
• Multiparous: 1–2 mg
Do not give the repeat dose within 6 hours of the initial dose (i.e. so the
maximum dose of 3 mg in a six hour period is not exceeded)
• 10 mg PV (released at a rate of approximately 4 mg in 12 hours)
93
Dinoprostone
pessary dose • A second dose is not recommended

4.2.1 Dinoprostone administration
Table 19. Dinoprostone administration
Aspect Dinoprostone administration

• Maternal and fetal safety outcomes do not seem to differ whether
prostaglandins are administered in the morning or evening, but women
94
Administration may prefer morning administration
• Pessary use may avoid repeated application of the gel
• Gel may be more appropriate where cervix is favourable
1
• Use water soluble lubricants (not obstetric cream)

• Remove from refrigeration and stand at room temperature for at least 30
Dinoprostone minutes prior to use
92
gel • Insert high into the posterior fornix of the vagina
• Not for intracervical administration
• Advise recumbent or left lateral position for 30 minutes after insertion
• Remove from freezer or fridge immediately prior to use
• Can be stored in the refrigerator for up to one month (2–8 C) after
O
removal from the freezer

• Warming is not required
• Open only after decision has been made to use the pessary
Dinoprostone • Use water soluble lubricant (not obstetric cream)
93
pessary • Insert and position transversely in the posterior fornix of the vagina:
o To minimise potential for the pessary to fall out and subsequent
insufficient dinoprostone exposure
• Ensure sufficient tape outside vagina to allow removal
• Woman to remain recumbent for 30 minutes
• Advise to report if pessary falls out
• Temperature, pulse, respiratory rate, BP, FHR, uterine activity, and
vaginal loss
o Immediately after insertion
o Hourly for 4 hours
• Perform CTG after insertion (minimum 30 minutes)
Monitoring post • Advise to inform staff as soon as contractions commence
insertion • Ongoing monitoring as for latent first stage of labour while:
o Observations are normal
o No contractions
89
 Refer to Queensland Clinical Guideline: Normal birth
• When in active labour–continuous CTG
69
• Reassess the MBS:

91
o Gel–wait at least 6 hours after insertion
91
Assessment of o Pessary–wait at least 12 hours after insertion
• Irrespective of MBS, recommend ARM if technically possible
95,96
progress
• If ARM not possible, repeat gel dose may be required (following
reassuring CTG)
• Onset of regular, painful uterine contractions, occurring every 3 minutes
irrespective of any cervical change
• Membranes rupture (spontaneous or ARM)
Indications for
• Fetal distress
removal:
• Uterine hyperstimulation or hypertonic uterine contractions
dinoprostone
pessary
93 • Maternal systemic adverse PGE2 effects (e.g. nausea, vomiting,
hypotension, tachycardia)
• If starting oxytocin infusion–remove at least 30 minutes prior to starting
• Insufficient cervical ripening after 12 hours

4.3 Artificial rupture of membranes

Table 20. Artificial rupture of membranes

• Favourable cervix (MBS of 7 or more)
9,97
• ARM alone is not recommended as time to onset of contractions is

9
Indication unpredictable , particularly in nulliparous women [refer to Section 4.4
Oxytocin]
• To observe the colour and amount of liquor when clinically indicated
• Poor application of the presenting part/unstable lie
9
Relative
• Fetal head not engaged (5/5 above the pelvic brim)
9
contraindication
• Risk of: cord prolapse or compression , rupture of vasa praevia , pain
9 36 97
97
and discomfort [refer to Section 5]
• ARM and immediate oxytocin compared to ARM and delayed oxytocin
(commenced 4 hours post ARM) showed shorter ARM to birth interval in
98,99 100
nulliparous and parous women
Risk/benefit
• Compared to amniotomy alone, ARM and oxytocin resulted in fewer
97
women not birthing vaginally at 24 hours
• Following cervical priming, early ARM (performed regardless of MBS) has
been associated with a decrease in IOL to birth interval and no difference
96,98
in other outcomes
• If no other IOL procedure before ARM, perform pre IOL assessment
• Encourage to empty bladder
• Abdominal palpation to determine descent , position and presentation
101
Before procedure • VE to determine stage of labour, MBS, presentation, position and descent,
possible cord or malpresentation, identify membranes
• Consult obstetrician if the head is not engaged , or cord presentation,
101
malpresentation, unstable lie or polyhydramnios

• Maintain digital contact with presenting part
• Insert amnihook–amnicot, using examining finger as guard to hook
• Rupture forewaters–avoid ARM over fontanelle or face
• Remove amnihook–amnicot, guarding it against index finger
Procedure • Confirm passage of fluid and check for presence of blood or meconium
(continuing on • Sweep membranes from presenting part
from assessment • Ensure good application of presenting part before completing VE
VE) • Apply fetal scalp electrode, only if clinically indicated
69
• Following ARM for IOL, recommend commencement of oxytocin
9
immediately
• Document abdominal palpation and VE findings
• FHR, uterine activity, and vaginal loss (liquor amount, colour and
consistency) immediately after ARM
• If oxytocin commenced immediately after ARM, then monitor as for
oxytocin [refer Section 4.4 Oxytocin]
• If oxytocin not commenced immediately after ARM (e.g. woman wishes to
await onset of contractions), then ongoing monitoring as for latent first
stage of labour while:
Post ARM o Observations are normal
monitoring o No contractions
89
 Refer to Queensland Clinical Guideline: Normal birth
• If FHR or liquor abnormalities (e.g. meconium/blood stained or no liquor):
o Perform CTG
o Discuss/refer/consult as indicated
69
• Encourage mobilisation to promote onset of uterine contractions

4.4 Oxytocin
Oxytocin stimulates the smooth muscle of the uterus to produce rhythmic contractions.
Table 21. Oxytocin

Indication • IOL in the setting of ruptured membranes
• Due to the additive uterine effects, do not commence oxytocin within :
91
o Six (6) hours of dinoprostone vaginal gel administration

o 30 minutes of removal of dinoprostone vaginal pessary
• Discuss with an obstetrician prior to commencement with:
Cautions o Previous uterine surgery (e.g. CS) [refer to Queensland Clinical
25
Guideline: Vaginal birth after caesarean section ]
o Multiple pregnancy
o Greater than four previous births
o Cardiovascular disease
• Tachysystole or hypertonus with/without signs of FHR abnormalities
• Nausea and vomiting (0.1 to 1%)
91
Risk/benefit • Rarely (less than 0.1%): arrhythmias, anaphylactoid reaction, severe

(tetanic) uterine contraction leading to uterine rupture, flushing,
electrocardiograph (ECG) changes (including prolonged QT interval),
transient hypotension, reflex tachycardia (common with rapid IV
102
injection)
• The standard oxytocin preparation and administration regimen is
recommended for all Queensland facilities as outlined in Section 4.4.1
Medication safety Oxytocin regimen administration
• If required, the same infusion solution can be continued for PPH
management and as PPH prophylaxis following CS
• Verify CTG normal
Before
• If membranes are not ruptured, perform ARM prior to oxytocin infusion
administration
• If SROM ensure forewaters are ruptured
• Provide one-to-one midwifery care
103
• Commence the intrapartum record when infusion is commenced

• Maternal and fetal observations as per first stage of active labour [refer to
89
Queensland Clinical Guideline: Normal birth ]
• Commence continuous CTG at the onset of first contractions
Monitoring 69
• Maternal pulse and FHR prior to any increase in the infusion rate
102
• Monitor fluid balance as water intoxication/hyponatraemia may result from

102 104
prolonged infusion (rare with the use of isotonic solutions )
• Planned VBAC—maintain vigilance for uterine dehiscence and rupture

4.4.1 Oxytocin regimen administration
Table 22. Oxytocin administration

• Add oxytocin 30 International units to a 500 mL bag of either 0.9% sodium
chloride or compound sodium lactate (Hartmann’s solution)
o 1 milliunit/minute = 1 mL/hour
• Use a volumetric pump to ensure an accurate rate of infusion
103
o Program delivery pumps for correct infusion concentrations

o Administer oxytocin by sideline/secondary IV access (as oxytocin
infusion initiated at low volume)
• Record the dose in milliunit per minute
9
Administration
• Increase dose at 30 minute or longer intervals
102
• Aim for 3–4 contractions in a 10 minute period with duration of 40–60

seconds and resting period not less than 60 seconds
• Titrate dose against uterine contractions and FHR
102
• Use the minimum dose required to establish and maintain active labour
• Mark changes to dose clearly and contemporaneously on the intrapartum
record and/or CTG
• After labour is established (cervical dilation greater than or equal to 5 cm)
oxytocin infusion may be electively discontinued
o Reduced incidence of FHR abnormalities and uterine hyperstimulation
105
reported
Discontinue/ o Inconsistent evidence about effect on active phase duration (possibly
105-107
recommence increased)
• If recommencing infusion and no local protocol, use the following guide:
o If ceased for less than 30 minutes, recommence at half previous rate
o If ceased for longer than 30 minutes, recommence at initial starting
103
dose (due to short half-life )
• Prior to exceeding 20 milliunit/minute (manufacturer recommended
103
maximum )
Obstetrician
• At the maximum regimen dose of 32 milliunit/minute and labour not
102
review
commenced
• If infusion ceased or recommenced
• The ideal dosing regimen of oxytocin is unknown but there are well
9
recognised complications
Variation to • Only vary the regimen (milliunit/minute, rate of increase and/or maximum
regimen dose) following an assessment by an obstetrician of the individual clinical
circumstances and progress of labour
o Processes and systems that facilitate routine variation are not
recommended
Table 23. Oxytocin regimen
Infusion: oxytocin
(30 International units in 500 mL)
1 milliunit/minute is equal to 1 mL/hour
Time after starting Dose
(minutes) (milliunit/minute)
0 1
30 2
60 4
90 8
120 12
150 16
180 20
Prior to exceeding 20 milliunit/minute:
Obstetrician review required
210 24
240 28
270 32

5 Risks and benefits associated with IOL

Table 24. Risks and benefits associated with IOL
Risk Clinical practice point

• The criteria for failed IOL are not generally agreed
• Review the individual clinical circumstances
• Assess fetal wellbeing using CTG
• Discuss options for care
Failed IOL
1 • The likelihood of vaginal birth is significantly lower if not in active labour
108
after 12 hours of oxytocin
• If appropriate consider:
o An alternative IOL method, and/or
o Discharge home for 24 hours followed by second attempt at IOL
o Caesarean section
• Escalate as required and according to local protocols
• Continuous CTG
• Attempt removal of any remaining dinoprostone gel
• Remove dinoprostone pessary if still in situ
91
• Cease/reduce rate of oxytocin infusion while reassessing labour and fetal

1
Tachysystole or state
hypertonus • Position left lateral
(without FHR • Record maternal observations, including BP
abnormalities) • Commence intravenous (IV) fluids via new administration set
OR • VE to assess cervical dilation and exclude cord prolapse
• If persists, consider use of tocolytic :
1
Uterine
hyperstimulation o Terbutaline: 250 micrograms subcutaneously or
3
(with FHR o Terbutaline: 250 micrograms in 5 mL IV over 5 minutes
3
abnormalities) o Salbutamol: 100 micrograms by slow IV injection
3
o *Sublingual Glyceryl Trinitrate (GTN) spray 400 micrograms
o Excessive uterine activity in the absence of evidence of fetal
3
compromise is not in itself an indication for tocolysis
• If clinically indicated, prepare for instrumental birth or CS (e.g. FHR does
1
not return to normal)

• A potential risk at the time of membrane rupture especially when the
membranes are ruptured artificially
• To reduce the likelihood of cord prolapse:
1
Cord prolapse o Before ARM, assess engagement of the presenting part
o If the baby’s head is high, avoid ARM
o Palpate for umbilical cord presentation during the VE
o Avoid dislodging the baby’s head during the VE
• An uncommon event with IOL
1
Uterine rupture • A life-threatening event for mother and baby

• If suspected, prepare for an emergency CS, uterine repair or hysterectomy
1
• IOL with oxytocin has been associated with an increased risk of PPH
109
PPH • Refer to Queensland Clinical Guideline: Primary postpartum

109
haemorrhage
• Compared with spontaneous labour, IOL may be associated with a higher
incidence of additional interventions (e.g. electronic fetal monitoring,
110-112
analgesia usage), although there is no increase in instrumental births
Increased 113-116
or CS in randomised controlled trials
intervention
• Compared with expectant management, no association found between IOL
and increased rates of adverse perinatal outcomes of neonatal unit
8-10
admission, maternal death, or meconium stained amniotic fluid
• When performed for a valid indication, IOL should result in a reduction in
perinatal morbidity/mortality
Benefits
• Limited evidence suggests women may prefer IOL to expectant
14
management (serial antenatal monitoring) beyond 41 weeks
*Not currently listed on the Queensland Health List of Approved Medications (LAM), not Therapeutics Good
Administration (TGA) approved for this purpose

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Acknowledgements
Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and other
stakeholders who participated throughout the guideline development process particularly:
Working Party Clinical Lead
Dr Michael Beckmann, Director Mothers Babies and Women’s Health Services, Mater Health, Brisbane
Queensland Clinical Guidelines Program Officers
Ms Lyndel Gray, Clinical Nurse Consultant
Ms Jacinta Lee, Program Manager
Working Party Members
Mrs Emma Archer, Clinical Midwife, Group Practice, Beaudesert Hospital
Ms Rukhsana Aziz, Clinical Midwifery Consultant, Maternity, Ipswich Hospital
Ms Rita Ball, Midwifery Educator, Cairns Hospital
Mrs Stephanie Bethel, Caseload Midwife, Mareeba Hospital
Dr Elize Bolton, Clinical Director, Obstetrics and Gynaecology, Bundaberg Hospital
Miss Samantha Borchers, Registered Midwife, Maternity/Birth Suite, Gold Coast University Hospital
Mrs Anne Bousfield, Clinical Midwifery Consultant, Maternity, Roma Hospital
Dr Huba Brezovsky, Consultant Obstetrician and Gynaecologist, Mackay Base Hospital
Ms Georgina Caldwell, Registered Midwife, Amity Midwifery Group Practice, Redcliffe
Ms Jackie Chaplin, Nurse Educator Midwifery and Neonatal, West Moreton Hospital and Health Services
Dr Lindsay Cochrane, Staff Specialist, Obstetrics and Gynaecology, Caboolture Hospital
Mrs Kelly Cooper, Registered Midwife, Maternity, Caboolture Hospital
Mrs Catherine Cooper, Practice Development Midwife, Mater Health, Brisbane
Mrs Allison Davis, Midwife, Birth Centre, Mackay Base Hospital
Dr Wendy Dutton, Director of Obstetrics and Gynaecology, Redland Hospital
Miss Samantha Feltis, Midwife, Maternity, Mount Isa Hospital
Ms Judy Foote, Midwife, RN, Child Birth Educator/Child and Family Health Nurse, The Townsville Hospital
Dr David Freidin, Intra-Partum Clinical Lead, Royal Women's and Brisbane Hospital
Dr Nelson Gonzalez, Obstetrician and Gynaecologist, Gold Coast University Hospital
Mrs Marceline Green, Consumer Representative, Maternity Consumer Network, Toowoomba
Ms Marnie Griffiths, Midwifery Lecturer, Bachelor of Midwifery, Griffith University, Brisbane
Mrs Pam Harsant, Nurse Unit Manager, Maternity, Hervey Bay Hospital
Ms Jacinta Hay, Midwife, Birth Suite, Logan Hospital
Ms Louise Homan, Nurse Unit Manager, Birth Suite, Cairns Hospital
Ms Debbie Humbley, A/Midwifery Unit Manager, Maternity Unit, Caboolture Hospital
Mrs Fiona, Kajewski, Clinical Midwife Consultant, Maternity Services, Toowoomba Hospital
Dr Christopher, King, Director of Obstetrics and Gynaecology, Mount Isa Hospital
Mrs Sarah Kirby, Midwifery Unit Manager, Birth Suite, Royal Brisbane and Women's Hospital
Ms Janelle Laws, Nurse Educator, Royal Brisbane and Women's Hospital
Mrs Gemma Macmillan, Clinical Midwife/Project Officer, The Townsville Hospital
Dr Brian McCully, Director of Obstetrics and Gynaecology, Ipswich Hospital
Mrs Michelle McElroy, Midwifery Educator, Maternity/Education, Mount Isa Hospital
Miss Tina Meynell, Midwife, Birth Suite, Caboolture Hospital
Ms Lyndall Mollart, Clinical Midwifery Consultant, Maternity Services, Rockhampton Hospital
Mrs Marcia Morris, Midwifery Educator, Royal Brisbane and Women's Hospital
Ms Lillian Newman, Clinical Midwife, Women and Birthing, Redland Hospital
Ms Jacqueline O'Neill, Midwife, Women's and Children's Service, Toowoomba Hospital
Dr Gino, Pecoraro, Obstetrician and Gynaecologist, Mater Health Services, Brisbane
Ms Jenny Ramsay, Consumer Representative, Friends of the Birth Centre, Brisbane
Miss Georgia Roehrig, Student Midwife, Maternity, Redland Hospital
Ms, Pamela, Sepulveda, Clinical Midwifery Consultant, Birthing Suites, Logan Hospital
Ms Alecia Staines, Consumer Representative, Maternity Consumer Network, Toowoomba
Mrs Angela Swift, Clinical Midwife Consultant, Mossman MPHS
Mrs Bethan Townsend, Clinical Facilitator, Education Department, Gold Coast University Hospital
Ms Nicole Utley, Midwife, Birth Centre, Royal Brisbane and Women's Hospital
Dr Karen Whitfield, Senior Pharmacist, Royal Brisbane and Women's Hospital
Queensland Clinical Guidelines Team
Associate Professor Rebecca Kimble, Director
Ms Jacinta Lee, Manager
Ms Cara Cox, Clinical Nurse Consultant
Ms Lyndel Gray, Clinical Nurse Consultant
Ms Stephanie Sutherns, Clinical Nurse Consultant
Dr Brent Knack, Program Officer
Steering Committee
Funding: This clinical guideline was funded by Healthcare Improvement Unit, Queensland Health

Induction of Labour: Maternity and Neonatal Clinical Guideline

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Induction of Labour: Maternity and Neonatal Clinical Guideline

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Queensland Health

Maternity and Neonatal Clinical Guideline

Document title: Induction of labour

© State of Queensland (Queensland Health) 2017

Refer to online version, destroy printed copies after use Page 2 of 30

Flow Chart: Method of induction of labour

Induction of labour Method

Indication Pre IOL assessment

Modified Bishop Score (MBS)

Queensland Clinical Guidelines: F17.22-1-V5-R22

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Flow Chart: Balloon catheter

Indications Insertion procedure

If not in labour, offer analgesia

Continue IOL Obstetric review

Queensland Clinical Guidelines: F17.22-2-V6-R22

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Flow Chart: Prostaglandin E2 (dinoprostone)

Indications Pre dinoprostone insertion

Post dose care ARM Yes

PESSARY removal indications

Queensland Clinical Guidelines: F17.22-3-V5-R22

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Flow Chart: Artificial rupture of membranes

Queensland Clinical Guidelines: F17.22-4-V5-R22

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Flow Chart: Oxytocin

Pre oxytocin commencement:

Queensland Clinical Guidelines: F17.22-5-V5-R22

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• Therapeutic termination of pregnancy

• Perinatal care at the threshold of viability

1.1 Communication and information

Table 1. Communication and information-

Aspect Good practice points

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1.2 IOL declined or postponed

Aspect Good practice points

• Document the discussion, assessment and plan in the health record

1.3 Clinical standards

Aspect Good practice points

• Ensure availability of health care professionals appropriate to the

• There is insufficient evidence to determine if IOL is effective and safe in

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2 Specific indications and circumstances

• Gestational diabetes mellitus

• Vaginal birth after caesarean (VBAC)

o Prelabour rupture of membranes

• Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium

• Perinatal substance use: maternal

2.1 Prolonged pregnancy prevention

Prevention of prolonged pregnancy

2.2 Concern for fetal wellbeing

Table 5. Fetal growth restriction

Fetal growth restriction

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2.3 Twin pregnancy