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Induction of Labour (562)

Objectives

The aim of this guideline is to provide a framework for offering, facilitating and managing induction of labour within NHS GG&C.

Audience

This guideline is for use by obstetricians and midwives within NHS GG&C Maternity Service.

Please report any inaccuracies or issues with this guideline using our online form

Induction of labour (IOL) is indicated when the benefits of expediting birth outweigh the benefits of expectant management of labour. Concerns about a woman’s wellbeing, or concerns about the wellbeing of the fetus are indications for offering induction of labour. This guideline provides links to recommendations included in other GG&C guidance about when to offer IOL depending on different clinical and pregnancy related conditions.

Roles / Responsibilities

All members of the multidisciplinary team caring for women during the antenatal and intrapartum period should be familiar with this guideline. It can be used it to support and inform conversations with women about a plan for their labour and birth in NHS GG&C. Women and families should be provided with all the information they need to make an informed choice to accept or decline IOL. Women’s individual preferences should always be respected.

Individualised plans for induction of labour should be documented in the Management Plan on Badger. These should reflect care provided by other members of the multi-professional team, such as MNPI, Perinatal Mental Health Team, or Blossom Team.

Cervical assessment and membrane sweeping

A cervical assessment should be offered to all women as part of planning an induction of labour. The findings of this assessment may inform the induction method of choice. In addition to a cervical assessment, women can be offered a membrane sweep.

A membrane sweep may make labour more likely to start without any further intervention. Membrane sweeps from 39 weeks' gestation should be offered to any woman planning a vaginal birth, with the offer of repeated sweeps (NICE 2021). In the context of IOL membrane sweeps may shorten overall the induction process. Sweeps may be offered earlier than 39 weeks if earlier IOL is clinically indicated.

Verbal consent to a membrane sweep should always be obtained.

Women should be advised that pain, discomfort and vaginal bleeding are common after a membrane sweep and given clear advice on when to self-refer to Maternity Triage after a membrane sweep.

Membrane sweep for prolonged pregnancy (412) | Right Decisions

Indications for induction of labour

This list is not exhaustive. It aims to align all GG&C maternity guidance to support MDT conversations with women and their families and therefore empower women to be able to reach informed decisions about whether to accept induction of labour, await spontaneous onset of labour or request a caesarean birth. Consideration should always be given to the full clinical picture, including whether induction of labour is the appropriate intervention.

If a vaginal birth is not a suitable option for the woman, or her baby, then IOL should not be offered.

Indication

Brief guidance – refer to full NHSGGC for more detail

Link to NHSGGC guidance

Suitability for inpatient or outpatient balloon as first line for IOL

Prolonged Pregnancy (<42 weeks)

 

Give every opportunity to go into spontaneous labour. Offer IOL from 41+0 weeks onwards. Use the table in appendix to share information with women about prolonged pregnancy.

Appendix A: Risks associated with different induction of labour timing strategies | Tools and resources | Inducing labour | Guidance | NICE

Outpatient

Prolonged pregnancy (≥42 weeks)

If an IOL commences at or beyond 42 weeks inpatient fetal monitoring is recommended.

 

Inpatient

Pre-labour rupture of membranes ≥37 weeks

Women should be offered two choices following pre-labour rupture of membranes at term. Consider Group B streptococcus status.

1. Expectant management at home or as inpatient, and for IOL 24 hours later.

2. Immediate IOL with syntocinon, unit activity permitting.

NHSGGC. Prelabour rupture of membranes at term (450)

 

Outpatient

Not suitable - balloons are contraindicated for women with pre-labour rupture of membranes

Group B Streptococcus

A recommendation for GBS prophylaxis alone is not an indication for induction. However, women eligible for prophylaxis with an indication for IOL that is suitable for OP IOL, may return home, but should be clearly advised to attend the hospital immediately if the membranes rupture to commence intravenous antibiotic prophylaxis.

NHSGGC. Group B Streptococcal Prophylaxis (570)

 

Fetal growth restriction (FGR)

Evidence of FGR is AC/EFW <3rd or <10th with abnormal dopplers or crossing > 50 centiles on USS

Offer IOL at 37+0 weeks (or earlier if indicated by AN monitoring)

NHSGGC. Monitoring and Management of Suspected Fetal Growth Restriction (414)

Inpatient

Small for gestational age

Small for gestational age (SGA) is consistent growth trajectory with AC/EFW 3rd-10th centile without abnormal dopplers

Offer IOL at 39+0 weeks (or earlier if indicated by AN monitoring)

NHSGGC. Monitoring and Management of Suspected Fetal Growth Restriction (414)

Inpatient

Tailing growth

Refer to Fetal Growth Restriction

Evidence of FGR is AC/EFW <3rd or <10th with abnormal dopplers or crossing > 50 centiles on USS

NHSGGC. Monitoring and Management of Suspected Fetal Growth Restriction (414)

Inpatient

EFW >97th centile not diabetic

 

 

 

 

Counsel woman about the risks and benefits to the mother and the fetus of IOL or expectant management beyond 39+0 weeks.

Comprehensive documentation of the discussion is important.

Appendix B: Risks and benefits of induction of labour compared to expectant management for suspected fetal macrosomia (in women without diabetes) | Tools and resources | Inducing labour | Guidance | NICE

Outpatient

Maternal Age ≥ 40 years at booking

 

 

 

There is a correlation between an increased incidence of stillbirth (SB) and higher maternal age.

For women ≥40 years of age at 40 weeks' gestation the incidence of SB is 2:1000. For women <35 years of age the incidence is 1:1000. Therefore, induction can be offered between weeks 39-40 to reduce that risk.

An individualised plan of care should be agreed with each woman.

Induction of Labour at Term in Older Mothers (Scientific Impact Paper No. 34) | RCOG

Outpatient

Assisted conception – IVF or ICSI

An individualised plan of care should be agreed with each woman.

There is no evidence for routine IOL prior to 41 weeks.

 

 

Outpatient

Antenatal thromboprophylaxis with low molecular weight heparin (LMWH)

Antenatal prophylaxis with LMWH is not an indication on its own for IOL.

Women should be informed that regional anaesthesia (epidural or spinal) cannot safely be administered within 12 hours of a prophylactic dose of LMWH. However, should they labour, there are alternatives for effective analgesia during that 12 hour period.

Where IOL is indicated for another reason, and a woman is on prophylactic LMWH, an individualised plan of care should be agreed with each woman.

 

Depends on primary indication for IoL

Antenatal treatment for VTE/PE with LMWH

Women prescribed a therapeutic dose of LMWH require 24 hours before regional anaesthesia can be administered.

In the absence of other indications for IOL, but where a woman wishes to have an epidural or avoid a GA for an unplanned CB, then it is reasonable to offer IOL in a “heparin-free window”.

Some women may prefer to await spontaneous onset of labour, accepting the restrictions on regional anaesthesia, and should be supported to do so.

 

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Antepartum haemorrhage

In women with APH >37+0 weeks gestation consider expediting delivery.

NHSGGC. Antepartum haemorrhage (APH) (1036)

Not suitable for balloon if APH within past 2 weeks. Use prostin as inpatient as an alternative

Maternal request/ Social reasons

 

Consider IOL requests for maternal indications such as pelvic girdle pain, but only after full discussion of the risks and benefits of IOL.

Offer membrane sweep from 39 weeks.

Comprehensive documentation of the discussion is important.

Recommendations | Inducing labour | Guidance | NICE

Outpatient

Reduced or altered fetal movements (RFM or AFM)

 

Women who present on two or more occasions with RFM are at increased risk of a poor perinatal outcome.

The decision whether or not to induce labour at before 39+0 weeks in a woman who presents recurrently with RFM when the growth, liquor volume and CTG appear normal must be made after careful senior obstetric led counselling of the pros and cons of induction on an individualised basis.

Reduced Fetal Movements (Green-top Guideline No. 57) | RCOG

Inpatient

Pregnancy Induced Hypertension / Preeclampsia (PIH/PET)

 

 

Do not routinely offer planned early birth before 37+0 weeks to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, unless there are other medical or obstetric indications

For women with chronic hypertension, with or without antihypertensive medication, with stable blood pressure, delivery should be offered around 39-40 weeks following discussion with the woman and a full assessment of maternal and fetal factors.

NHSGGC. Hypertension, Antenatal & Day Care (517)

Inpatient

Diabetes

 

 

Women with Type 1 or Type 2 Diabetes Mellitus should usually be offered elective birth either by IOL or CB between weeks 37+0 and 38+6 depending on their individualised care plan.

Individualised care plans should be documented in the Management Plan on Badger.

Women with uncomplicated GDM and no other fetal or maternal concerns should give birth by 40+6 and then be offered elective birth (IOL or PCB) at 41 weeks.

SIGN 171 Management of diabetes in pregnancy

NHSGGC. Diabetes Management for Women during Labour and Birth (359)

Outpatient  uncomplicated GDM

Inpatient for complicated diabetes

Intrahepatic  Cholestasis of Pregnancy

 

Timing of delivery should be based on peak bile acid concentration.

Mild ICP (bile acids 19-39) – Consider birth at 40+0 weeks or ongoing AN care as no increased risk of stillbirth

Moderate ICP (bile acids 40-99) – consider birth at 38-39 weeks

Severe ICP (bile acids >100) – consider planned birth at 35-36 weeks

NHSGGC. Intrahepatic Cholestasis (1137)

Mild- Outpatient

Moderate or Severe – Inpatient

Planning for a vaginal birth after a previous caesarean birth

Women should be made aware that there is an increased chance of uterine rupture with induction of labour after a previous caesarean birth, or other uterine surgery. With mechanical methods (cervical ripening balloon, or amniotomy) the chance of rupture is 80 per 10,000. If prostaglandins are used the chance of rupture is 240 per 10,000.

In the absence of other risk factors, women can be offered IOL as per prolonged pregnancy at 41+0 weeks. 

NHSGGC. Vaginal Birth after Caesarean Section (VBAC) (415)

Inpatient IOL is recommended as Cook’s Balloons are not licenced for IOL after a previous CB.

HIV

HIV in isolation is not usually an indication for offering IOL. An individualised care plan should be agreed with the woman.

Amniotomy is considered safe but attention should be paid to timing to reduce length of ruptured membranes. In the case of induction of labour where the cervix is unfavourable then additional vaginal prostaglandins may be preferable to an early ARM. Birth should occur within 24hrs of rupture of membranes.

NHSGGC. HIV in Pregnancy and Prevention of Vertical Transmission (441)

 

BMI above 40

 

BMI in isolation is not an indication for offering IOL. Women should be offered induction of labour in line with universal antenatal care pathway from 41+0 weeks. Women should be booked for induction of labour from Sunday -Thursday where possible.

NHSGGC. Obesity, Management in Pregnancy (574)

Outpatient

Low PAPP-A

 

Low PAPP-A in isolation is not usually an indication for offering IOL. Women with reassuring fetal growth on serial scans (offered as a result of low PAPP-A) can be advised to wait for spontaneous onset of labour. Offer 4 weekly scans whilst waiting for spontaneous labour or until IOL.

If concerns about fetal growth have been identified, refer to the guidance above.

 

Inpatient

Late booking (>22 weeks)

 

 

Offer induction of labour for usual obstetric reasons or if the pregnancy has reached 41+0 weeks by the best clinical estimate.

NHSGGC. Late booking in pregnancy: management of women who book after 22+0 weeks gestation (629)

Outpatient

Confirmed prolonged latent phase of labour

Ensure cephalic presentation. Refer to guideline for latent phase for ongoing management.

NHSGGC. Latent phase labour (409)

Inpatient

Care in active labour following induction of labour

Indications for AMU/CMU and CLU

Where induction of labour is for post expected date of birth (≤ 42 weeks), or for maternal request (including pelvic girdle pain), and labour establishes after ≤ 2 prostins or a double balloon catheter, AMU/CMU care can be offered to women.

Women who have had prostin should have a 20 minute period of CTG monitoring prior to AMU/CMU admission. If the CTG monitoring is normal intermittent auscultation (IA) during labour can be commenced. CTG monitoring should be recommenced at any point if IA indicates fetal heart rate concerns.

Refer to NHSGGC guidance on birth setting

Women who decline induction of labour

Some women may decline IOL. It is essential that a plan of ongoing care is discussed and agreed with the woman. There should be MDT involvement in these discussions and the plan clearly documented. Expectant management usually includes the offer of twice weekly CTG monitoring and weekly USS.

Refer to NHS guidance of personalised maternity care Guide to Safe, personalised maternity care

Methods of IOL

Cooks balloon is first line for all inpatient inductions unless there are contraindications. If a balloon is contraindicated prostaglandins may be suitable.

In the outpatient setting only Cooks balloon is suitable. Women should live, or be staying in accommodation, within 1 hour travel time to the hospital.

Offer outpatient IOL for

Offer Inpatient IOL using Cooks Balloon

Not eligible for Cooks Balloon
  • Post dates pregnancy (41 weeks +)
  • Maternal Age ≥ 40
  • Maternal/Social requests
  • Controlled PIH
  • Uncomplicated GDM with a normally grown baby
  • Uncomplicated well controlled GDM on metformin with a normally grown baby
  • Raised BMI
  • IVF
  • Individualised decision by named consultant
  • Mild Obstetric Cholestasis
  • Pre-eclampsia needing 4 hourly BP monitoring
  • Insulin dependent diabetes
  • Complicated GDM
  • Reduced fetal movements
  • FGR: EFW below 3rd centile, or below 10th with abnormal dopplers or more than 50 centiles drop in growth.
  • SGA with consistent growth trajectory with AC/EFW 3rd-10th centile without abnormal dopplers
  • VBAC or previous uterine surgery
  • Moderate or Severe Obstetric Cholestasis
  • No ability to return to hospital ie no birth partner/no funds
  • Multiple pregnancies
  • Indication suitable for outpatient IOL but woman lives more than 1 hour from the hospital
  • Polyhydramnios above 8cm DVP (deepest vertical pool)
  • Fetal head not within the pelvis (ballotable) 
  • PROM
  • Women not suitable for a trial of vaginal birth (including non-cephalic presentation, placenta praevia, previous CB with a vertical incision)
  • Unable to tolerate vaginal examinations
  • Cervix already more than 3cm open

Please refer to IUD (Intrauterine Fetal Death) (658) for the appropriate management of labour when there is an IUD.

Booking IOLS

All community midwife referrals for IOL can be OP IOLs.

  • Ensure woman understand the process of IOL with verbal explanation and IOL booking form completed on Badgernet.
  • Encourage patient engagement and informed decision making.
    • Provide patient information leaflet, direct towards podcast and other information sources
  • Offer cervical assessment and membrane sweep routinely between 1 week and 48 hours prior to IOL.
    • All women should be offered a VE for cervical assessment prior to booking IOL. When consenting women to the cervical assessment the option of a membrane sweep at the same time should be discussed. Women should be made aware that membrane sweeps may shorten the IOL process and are therefore recommended.

On admission for IOL both Outpatient and Inpatient

Each woman’s medical and obstetric history should be reviewed on admission. The plan for IOL should be discussed and confirmed with her and documented in BadgerNet.

A full antenatal assessment should be completed:

Cooks Balloon Insertion

This can be done by an appropriately trained MW with support from either another MW or HCSW. Appropriately trained medical staff can also insert balloons with support from a MW or HCSW.

  1. Once all initial checks complete and satisfactory place woman on bed in lithotomy position
  2. Ask woman to place hands behind buttocks if needed for cervical tilt
  3. Offer Entonox to woman for insertion and complete vaginal wash prior to examination
  4. Either using a speculum or using two digits locate the cervix
  5. Using the stylet pass the balloon catheter through the external os and once reaching the internal os remove the stylet
  6. Advance the catheter into the uterine space
  7. Fill the Uterine balloon via the U port with 40mls sterile water and gently pull back to bring vaginal balloon below cervical os
  8. Inflate Vaginal balloon via the V port with 20mls sterile water – reassure woman throughout
  9. Now the device is fixed in place remove speculum or fingers and inflate 20mls into each alternate port until 80mls inside each balloon.
  10. Once complete listen to the FH for 1 min post insertion and then slowly assist the woman to stand. Inform her she may experience cramping and have a small amount of bleeding post insertion due to the manipulation of the cervix. Encourage to pass urine, if unable to at time make aware will need to contact Maternity Triage for deflation of balloons by 20mls to help if unable to pass urine in 6 hours.

Resources: Cook® Cervical Ripening Balloon with Stylet | Reproductive Health - this is an animation of insertion via speculum

If OUTPATIENT then can offer analgesia (paracetamol and dihydrocodeine if needed for cramping) ensure has IOL diary leaflet and is aware they will receive a phone call to attend Labour Ward (LW) from 12 hours post insertion which could be any time overnight.

Consider indication for induction, and discuss suitability for CMU/AMU care in labour with the woman prior to discharge home. Clearly document any preferences.

 

Offer advice that women can use baths, birthing ball, simple analgesia, and TENS machines at home.

Highlight when to call Maternity Triage, referring to IOL leaflet

  • Balloon falls out (these women may be able to attend Labour ward directly for an ARM unit activity permitting);
  • Abdominal Pain
  • Reduced Fetal movement
  • Heavy fresh red bleeding
  • Labour
  • SROM
  • Unable to pass urine in 6 hours - may need the balloons slightly deflated
  • Any other concerns

Outpatient Balloon midwife will then update LW with timings for balloon removal.

If the woman is attending Maternity Triage for reasons outlined above the balloon can be removed by deflating via the U and V ports. They should be offered a VE to assess suitability for ARM. If reduced FM with normal CTG on discussion with on call team the balloon may be left in place and the IOL process continued as an inpatient.

If INPATIENT the woman can mobilise around the ward, use birthing balls or bath and can be offered analgesia if requested. AN ward midwife to update LW co-ordinator on balloon insertion and when due for removal.

Women will be given an appointment to return to LW from 12 to a maximum of 24 hours later for balloon removal and ARM. If unable to facilitate this on LW it must be escalated as per unit escalation policy as Cooks balloons must be removed 24 hours after insertion. NHSGGC Site Activity Escalation and potential divert process for Maternity (407)

 

On arrival to Labour Ward including patients with Pre Labour Rupture of Membranes Prelabour Rupture of Membranes at Terms (450):

  1. Full antenatal assessment. Confirm indication for IOL, consider suitability for AMU care when established in labour, and any previously documented preferences for labour and birth. If suitable for AMU care transfer to AMU room for intrapartum care.
  2. Check Group B strep status and prepare antibiotics if needed as per GBS policy Group B Streptococcal Prophylaxis (570)
  3. The balloon will be removed by deflating the balloons via the U and V ports ensure all water is removed
  4. CTG to assess fetal well being
  5. Vaginal examination and ARM with amnihook (Be aware it is normal post balloon for a cervix to feel soft and stretchy but not effaced).
  6. If primiparous and liquor clear can remove CTG and encourage 1 hour to mobilise
  7. If multiparous and liquor clear can remove CTG and encourage 2 hours to mobilise

After ARM and mobilisation:

  1. IF contracting regularly, AND there are no fetal or maternal concerns (ie. no indication for continuous fetal monitoring (CTG)), a woman could be cared for as a spontaneous labourer and offered IA in the AMU/CMU Birth setting for women in labour in the hospital or homebirth environment (1100). Suitability for AMU/CMU care should have already been considered and prepared for by admission to an AMU/CMU room.
  2. If not contracting regularly place 16G grey IV cannula
  3. Consent woman to commencing syntocinon – Prescribed on Hepma
  4. Commence continuous CTG
  5. Commence syntocinon regime as outlined in Oxytocin (Syntocinon) (598) guideline until contracting 3:10

Dinoprostone Gel (Prostin)

This is 2nd line choice for IOL in GG&C unless for indicated reason. It can only be commenced in an inpatient setting. Be aware prostin can cause vaginal dryness and tenderness. Offer entonox for each examination and administration to ease maternal discomfort. Prostin gel should be used in the first instance, however if unable to source can use Dinoprostin tablets- PGD: Dinoprostone vaginal tablets prostin e2 v3 pgd

  1. Once initial observations and fetal monitoring complete assess cervix. If the Bishop Score (BS) is <5:
    1. For primiparous women: administer 2mg dinoprostone gel in posterior vaginal fornix. .
    2. For multiparous women: administer 1mg dinoprostone gel
  2. Commence CTG for minimum 20 minutes post administration. If normal, remove CTG and encourage mobilisation
  3. 6 hours later commence CTG and if normal assess cervix for change - if Bishop’s score 5-9: suitable for ARM on LW. if not administer 1mg dinoprostone gel
  4. 6 hours later commence CTG and if normal assess cervix for change - if Bishop’s score between 5-9 for ARM on LW if not administer 1mg dinoprostone gel
  5. 6 hours later commence CTG and if normal assess cervix for change- If Bishop’s score between 5-9 for ARM on LW if not for obstetric review by registrar or consultant
  6. Discuss options of Cooks balloon insertion for 12 hours or rest for 24 hours then commence protocol again under guidance from senior obstetrician

Editorial Information

Last reviewed: 06/05/2025

Next review date: 31/05/2028

Author(s): Charlee Crammond , Sharon Cartwright , Alison Anderson.

Version: 3

Approved By: Maternity Clinical Governance Group

Document Id: 562

References

Pergialiotis V, Bellos I, Vrachnis N, et al. Early versus delayed oxytocin infusion following amniotomy for induction of labor: a meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med. 2022;35(25):4889–96

BOND, D.M., et al, 2017. Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome. Cochrane Database of Systematic Reviews, (3)

Jones MN, Palmer KR, Pathirana MM, et al. Balloon catheters versus vaginal prostaglandins for labour induction (CPI Collaborative): an individual participant data meta-analysis of randomised controlled trials. Lancet. 2022;400(10364):1681–92.

De Vaan M, ten Eikelder M, Jozwiak M, et al. Mechanical methods for induction of labour. Cochrane Database of Systematic Reviews. 2023(3)

Boulvain M, Thornton JG. Induction of labour at or near term for suspected fetal macrosomia. Cochrane Database of Systematic Reviews. 2023(3)

Zhao G, Song G, Liu J. Outpatient cervical ripening with balloon catheters: A Bayesian network meta-analysis of randomized controlled trials. Int J Gynaecol Obstet. 2024;166(2):607–16.

Rashid A, Imran M, Ali S, et al. Six versus 12-Hours Balloon Catheter Placement for the Induction of Labor: A Systematic Review and Meta-analysis of Randomized Controlled Trials. American Journal of Obstetrics & Gynecology MFM. 2024;101474

Mustafa M, Babiker M, Abusin F, et al. Outcomes of Outpatient Versus Inpatient Induction of Labor: A Systematic Review and Meta-Analysis. Cureus. 2024;16(9):e69535.

Diab YH, Diab M, Horgan R, et al. Early vs. delayed amniotomy in individuals undergoing pre-induction cervical ripening with transcervical Foley balloon: a meta-analysis. Am J Obstet Gynecol MFM. 2024;6(8):101408

Baradwan S, Alshahrani MS, AlSghan R, et al. Digital versus speculum insertion of Foley catheter for labor induction: A systematic review and meta-analysis of randomized controlled trials. J Gynecol Obstet Hum Reprod. 2024;53(5):102770

Al-Matary A, Alsharif SA, Bukhari IA, et al. Cervical Osmotic Dilators versus Dinoprostone for Cervical Ripening during Labor Induction: A Systematic Review and Meta-analysis of 14 Controlled Trials. Am J Perinatol. 2024;41(S 01):e2034–46.

Evaluating misoprostol and mechanical methods for induction of labour (Scientific Impact Paper No. 68) | RCOG

Overview | Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section | Guidance | NICE