This document summarizes guidelines for induction of labor from several sources. It discusses best practices for confirming gestational age, considering medical indications, accepting maternal request, proceeding over maternal refusal, timing of induction, and monitoring during labor induction. It also provides evidence-based recommendations on methods of induction such as membrane sweeping, cervical assessments, amniotomy, oxytocin administration, and fetal monitoring. The document synthesizes evidence from multiple systematic reviews and clinical guidelines to provide comprehensive guidance on safe and effective labor induction practices.

1. Evidence Based Medicine
Audit of current practice in IOL at
Gaza Strip Maternity Hospitals
By
Dr.Mohammad El-belbassy
Dr. AbdulRazek ElKurd

2. 01. Do you confirm
pregnancy date by U/S
in all patients before
IOL performed?

3. A policy of early pregnancy ultrasound reduced the
induction of labor for prolonged pregnancy .These
data were extracted from four trials which focused on
the use of ultrasound for early fetal assessment in
pregnancy.
Level Ia evidence

4. 02. Do you consider the
indication of IOL
when you time it ?

5. Induction of labor should be performed
only when there is a clear medical
indication for it and the expected
benefits outweigh its potential harms
WHO recomendation

6. 03. Do you consider
maternal request as a
valid indication for IOL?

7. Overview of available evidence
No evidence was identified that assessed the
effects of induction of labour at maternal
request. However, three RCTs from one
systematic review were identified that
assessed the effects of elective induction of
labour at term (37–40 weeks of gestation) in
women with no medical reasons but who were
randomised to the induction arm of the trial. The
GDG considered that this evidence could be
extrapolated to women who request induction of
labour for non-medical reasons.

8. Induction of labour versus expectant
management at 37–40 weeks of gestation
Meta-analysis of three RCTs included women at
37–40 weeks of gestation found no significant
difference in perinatal death between the
induction and expectant management group.
There were two deaths in the expectant
management group, one from a congenital heart
condition and one from cord compression.
However, the induction group was significantly
less likely to have caesarean birth but more
likely to require assisted vaginal birth
[EL = 1++]

9. Maternal request
Induction of labour should not routinely
be offered on maternal request alone.
However, under exceptional
circumstances (for example, if the
woman's partner is soon to be posted
abroad with the armed forces), induction
may be considered at or after 40 weeks.
NICE. Clinical Guideline July 2008
Induction of labour
(National Collaborating Centre for Women’s and Children’s Health)

10. 04. Do you proceed with
IOL despite maternal
refusal if you have
strong indication for
IOL?

11. Key recomendation
• the alternative options if the
woman chooses not to have
induction of labor
NICE. Clinical Guideline July 2008
Induction of labour
(National Collaborating Centre for Women’s and Children’s Health)

12. 05. Would you consider
IOL in in 41wk+ in
absence of risk factor?

13. Compared with expectant management,
induction of labour after 41 completed weeks
is associated with fewer perinatal deaths (0/2986
versus 7/2953), excluding congenital
abnormality. The absolute risk is extremely
small.
One large RCT included in the systematic
review reported a lower caesarean section rate
in the induction group when compared with
expectant management.
[EL = 1++]
[EL = 1+]

14. Births after 42 weeks of gestation are
associated with an increased risk of
intrapartum and neonatal deaths.
One study reported that women are less
likely to agree to expectant management at
41 weeks when compared with 37 weeks
(31% versus 45%), although the
majority would still want to await
spontaneous labour.
[EL = 3]

15. 06. In the presence of risk
factors, i.e., GDM – PIH,
Do you consider earlier
IOL?

16. a systematic review (11) of a single trial. The 200 participants in
that trial were women with either gestational diabetes or
diabetes type I or type II who were receiving insulin and who had
good metabolic control over their condition. There is paucity of
data related to the priority comparisons and outcomes. The trial
was considered to
have a moderate risk of bias and the effect was estimable for
only one priority outcome, namely caesarean section. The
finding for caesarean section was imprecise and not statistically
significant

17. 1. If GDM is the only abnormality
IOL befor41wk not recomended
1.IOL may be necessary in some
women with diabetes e.g those with
placental insufficiency &
uncontrolled diabetes
Evidence base for WHO recommendations for induction of labour 2011

18. 07. Would you consider IOL in a
patient with previous one
LSCS?
08. Do you use PG as a method
of IOL in a patient with previous
LSCS?
09. Do you use Oxytocin as a
method of IOL in a patient with
previous LSCS?

19. RCOG.Birth after previous caesarean birth.
"How should women with a previous caesarean birth
be advised in relation to induction of labour or
augmentation?
Women should be informed of the two- to three-fold
increased risk of uterine rupture and around 1.5-fold
increased risk of caesarean section in induced and/or
augmented labours compared with spontaneous
labours.
Women should be informed that there is a higher risk
of uterine rupture with induction of labour with
prostaglandins.

20. There should be careful serial cervical
assessments, preferably by the same person, for
both augmented and non-augmented labours, to
ensure that there is adequate cervicometric
progress, thereby allowing the planned VBAC to
continue.
The decision to induce, the method chosen, the
decision to augment with oxytocin, the time
intervals for serial vaginal examination and the
selected parameters of progress that would
necessitate and advise on discontinuing VBAC
should be discussed with the woman by a
consultant obstetrician."

21. There should be careful serial cervical
assessments, preferably by the same person, for
both augmented and non-augmented labours, to
ensure that there is adequate cervicometric
progress, thereby allowing the planned VBAC to
continue.
The decision to induce, the method chosen, the
decision to augment with oxytocin, the time
intervals for serial vaginal examination and the
selected parameters of progress that would
necessitate and advise on discontinuing VBAC
should be discussed with the woman by a
consultant obstetrician."

22. "The evidence base is too small and limited to inform the
GDG on the most effective method of induction in women
with previous caesarean section. One small RCT reported
that vaginal PGE2 may reduce the need for repeat caesarean
birth when compared with amniotomy plus intravenous
oxytocin. In addition, evidence from non-randomised
studies reviewed has a likelihood of bias owing to
confounders such as population groups with different cervix
favourability and membrane status, which could bias the
results in identifying the most effective induction methods
studied.
NICE. Clinical Guideline July 2008
Induction of labour
(National Collaborating Centre for Women’s and Children’s Health)

23. Not with standing the poor evidence
base, the GDG recognized that vaginal
PGE2 has been widely used in obstetric
practice to induce labor for over two
decades to good effect in women with a
history of previous caesarean section."
This guideline goes on to make the
following recommendation:

24. "If delivery is indicated, women who have had
a previous caesarean section may be offered
induction of labor with vaginal PGE2,
caesarean section or expectant management on
an individual basis, taking into account the
woman’s circumstances and wishes. Women
should be informed of the increased risks with
induction of labor:
increased risk of need for emergency caesarean
section
increased risk of uterine rupture."

25. American College of Obstetricians and
Gynecologists. Vaginal birth after previous
cesarean delivery
"Misoprostol should not be used for third
trimester cervical ripening or labor induction in
patients who have had a cesarean delivery or
major uterine surgery."
"Induction of labor for maternal or fetal
indications remains an option in women
undergoing TOLAC." [Trial of labor after
cesarean]"
(Evidence level IV)

26. Studies reported after these guidelines were
published have differing results with two
(Harper, Ouzounian) finding no increased risk of
uterine rupture after induction, and three (Al-
Zirqi, Dekker, Weimar) finding an increase.
Ziyauddin reports no difference in safety
and effectiveness of transcervicalfoley catheter
versus vaginal prostaglandin e2 gel; and Gomez
reports that dinoprostone vaginal insert and
oxytocin appear to be equally safe and effective.
(Evidence level III)

27. A Cochrane review of methods of
term labour induction for women
with a previous caesarean section
(Jozwiak) is currently in
preparation.

28. 10. Would you consider IOL in a
patient with previous
myomectomy?
11. If yes, Would you try to find
out whether uterine cavity was
entered during myomectomy?

29. Previous myomectomy by means of laparotomy
Nearly all uterine ruptures that involve uteri with
myomectomy scars have occurred during the third
trimester of pregnancy or during labor. Only 1 case of
a spontaneous uterine rupture has been reported before
20 weeks of gestation.Brown et al reported that among
120 term infants delivered after previous
transabdominal myomectomy, no uterine ruptures
occurred, and 80% of the infants were delivered
vaginally.In contrast, Garnet identified 3 uterine
ruptures among 83 women (4%) who had scars from a
previous myomectomy and who underwent elective
cesarean delivery because of previous myomectomy.

30. Such reports do not often delineate the
factors that were deemed important for
assessing the risk of subsequent uterine
rupture (eg, number, size, and locations
of leiomyomata; number and locations
of uterine incisions; entry of the uterine
cavity; type of closure technique).
Further studies to investigate these
issues are needed.

31. 12. Do you consider monitoring
of fetal wellbeing (by CTG, U/S,
kick charts), If the patient has
passed 40 wks.?
13. Do you perform CTG every 3
days for postdated pregnancy?

32. RCT in Sweden was identified that
Compared with serial antenatal
monitoring(cardiotocography and
amniotic fluid index every third day) ,
induction of labour at 41+2 weeks of
gestation results in comparable maternal
and fetal outcomes. There was one
neonatal death in the monitoring group
due to a knot in the umbilical cord.
[EL = 1+]NICE. Clinical Guideline July 2008
Induction of labour
(National Collaborating Centre for Women’s and Children’s Health)

33. Grade A recommendation (RCOG)
From 42 weeks, women who decline
induction of labour should be
offered increased antenatal monitoring
consisting of a twice weekly
CTG and ultrasound estimation of
maximum amniotic pool depth

34. 14. Do you offer sweeping of
membranes at 40 weeks?

35. In women with an unfavourable cervix, evidence
suggested that membrane sweeping and no
membrane sweeping achieve comparable maternal and
fetal outcomes including analgesia use. However,
membrane sweeping is associated with:
• reduced need for formal induction of labour,
especially in multiparous women
• increased rate of spontaneous labour, if performed
more than once from 38 weeks of
gestation; the most appropriate regimen is not clear
from the evidence [EL = 1++]
Evidence statements

36. • increased incidence of uncomplicated
bleeding
• increased reports of pain but most women
would still choose sweeping in a future
pregnancy and recommend it to friends.
Evidence also suggests benefits for repeated
sweeping attempts. There is also evidence that
one attempt may be sufficient.
Data were limited with regard to providing
evidence of benefits in comparisons between
sweeping and vaginal PGE2 or intravenous
oxytocin. [EL = 1++]

37.  Prior to formal induction of labour, women should be
offered a vaginal examination for membrane sweeping
 At the 40 and 41 week antenatal visits, nulliparous
women should be offered a vaginal examination for
membrane sweeping.
 At the 41 week antenatal visit, parous women should be
offered a vaginal examination for membrane sweeping.
 When a vaginal examination is carried out to assess the
cervix, the opportunity should be taken to offer the
woman a membrane sweep.
 Additional membrane sweeping may be offered if labour
does not start spontaneously.
NICE. Clinical Guideline July 2008
Induction of labour
(National Collaborating Centre for Women’s and Children’s Health)

38. 15. Do you perform cervical
examination to assess bishop
score before IOL?
16. Do you depend on bishop
score to determine the
method of IOL?
17. If the bishop score is >9, Do
you stop PG application?

39. PRE INDUCTION CERVICAL
ASSESSMENT
It is known that success of labor induction is
closely related to ripeness of the cervix.
systematic reviews, Cervical status was divided
into three groups: cervix unfavourable, cervix
favourable and cervix variable or undefined. The
cervix was assessed using a variety of cervical
scoring systems. The two main systems used were
the original and modified Bishop’s score , a cervix
was viewed as unfavourable if the derived score
was less than six.
(EL=1a)

40. Method of IOL
unfavorable cervix : mechanical CX
dilatation ass.with decrease CS rate
comparing with oxytocin alone. And
there is insufficientstudies comparing
with PG. but advantage of Foleycatheter
include low cost when comparing with
PG &reduce risk of uterine tachysystole
with or without FHR change

41. 18. Do you do ARM only at a
bishop score of >8 in
primigravida?
19. Do you do ARM only at a bishop
score of >5 in Multiparous?

42. One systematic review (one RCT involving
260 women, Bishop score ≥ 6, mixed parity;
and one quasi-RCT, 20 women, Bishop score ≤
4) evaluated the effects of amniotomy in
induction of labour in women near term.
For women with an unfavourable cervix,
there is limited evidence to determine the
effects of amniotomy alone as an effective
method of induction.
[EL = 1++]

43. For women with a favourable cervix, one
trial found that amniotomy was significantly
associated with oxytocin augmentation
when compared with vaginal PGE2.
Recommendations on amniotomy
Amniotomy alone should not be used as
a primary method of induction of labour
unless there are specific clinical reasons for
not using vaginal PGE2, in particular the
risk of uterine hyperstimulation.
[EL = 1++]

44. 21. Do you consider CTG as
essential after PG application?
22. If yes, would you consider
doing the CTG after 30mins?
20. Do you consider CTG as
essential before PG application?
24. Do you consider continuous
CTG for apatient on oxytocin
infusion?
23. If yes, would you consider
doing the CTGafter 60mins?

45. Evidence statements
No direct evidence was identified relating to
the most effective monitoring regimen for
women undergoing induction of labor& there
is expert opinion on the most appropriate
monitoring protocol for women at and/or
during induction of labor.
Research recommendation on monitoring of
induction of labour
Studies are needed to identify the most
effective way of monitoring women during the
induction of labour process.

46. 25. If you do ARM, would you consider
a minimum of 2 hours before starting
the oxytocin for augmentation?
26. Do you consider a minimum of 6hrs
from the last dose of PG before
oxytocin application?
27. Do you use 5 units in 500ml fluid of
oxytocin solution, at a rate of 2-4
drops/ min for IOL?
28. Do you allow 30mins before you
double the rate of oxytocin infusion?
29. Do you consider the maximum dose
of oxytocin infusion as 24 drops /min?

47. The trials use a variety of regimens
with differing starting doses of oxytocin
and different incremental rises and
intervals of increase. The maximum
dose used varied in a similar fashion.
Furthermore, the maximum dose of
oxytocin used was titrated against
frequency of contractions or uterine
pressures via an intrauterine pressure
catheter. (EL=1b)

48. Comparing ‘lower-dose’ regimens of oxytocin with
‘higher-dose’ regimens, the conclusions drawn
were:
• ‘lower-dose’ regimens were not associated with an
increase in operative delivery rates
• oxytocin regimens with incremental rises in
oxytocin dose more frequently than every 30
minutes were associated with a increase in uterine
hypercontractility
• ‘lower-dose’ regimens were not associated with an
increase in specified delivery intervals
• ‘higher-dose’ oxytocin regimens were associated
with an increase in the incidence of precipitate
labours. (EL=1b)

49. Two current sets of guidelines currently
recommend ‘low-dose’ oxytocin
regimens.
The licensed maximum dose is currently
20 milliunits per minute. Trials
have used regimens up to 32 milliunits
per minute. Most found that
adequate contractions can be achieved at
12 milliunits per minute
(EL=1b)

50. 30.Do you use balloon as a
method of IOL for patient with
low bishop score?
31. Do you consider ARM and
oxytocin infusion as a must
following balloon expulsion?

51. Evidence statements
One systematic review (45 RCTs
involving 2385 women, Bishop score
0–9, mixed parity)compared
mechanical methods versus placebo/no
treatment; versus vaginal or cervical
PGE2; and versus misoprostol and
oxytocin.

52. For women with an unfavourable
cervix, there is limited evidence to
assess the effectiveness of
intracervical/extra-amniotic balloon
catheter in terms of likelihood of
vaginal birth within 24 hours, or a
reduction in caesarean births when
compared with all routes of
prostaglandins, including misoprostol.
The likelihood of uterine
hyperstimulation may be reduced. [EL = 1++]

53. For women with a favourable cervix,
there was no available evidence to
determine the effects of mechanical
methods as an agent of induction of
labour.
Recommendation on mechanical
methods
Mechanical procedures (balloon
catheters) should not be used routinely
for induction of labour.
[EL = 1++]

54. 32. Do you use PGE2 for IOL in
your hospital?
33. If yes, Do you consider the
repeat dose of PGE2
(prostin) as 8 hrs?
34. Do you consider the
maximum daily dose of PGE2
as 6 mg?

55. Evidence from reasonably sized trials
suggested that, in women with an
unfavourable cervix, all regimens of vaginal
PGE2 are effective in improving cervical
status and reducing oxytocin augmentation
and meconium staining, when compared with
placebo or no treatment. However, one very
small trial reported no difference between
vaginal PGE2 and placebo in achieving
vaginal birth within 24 hours. All regimens of
vaginal PGE2 are associated with increased
uterine hyperstimulation. ([EL = 1++])

56. Compared with high-dose PGE2
(3.5–10 mg), uterine hyperstimulation
with FHR changes was significantly
less likely to occur with the use of low-
dose PGE2 (1–2.5 mg)
[EL = 1++]

57. The recommended regimens of vaginal PGE2
are(NICE):
• one cycle of vaginal PGE2: one dose, followed by a
second dose after
6 hours if labour is not established (up to a maximum of
two doses)
Research recommendation on vaginal PGE2
Research is needed to assess the effectiveness, safety,
maternal satisfaction and acceptability of different
regimens of vaginal PGE2, stratified by clinical
indications, cervical and membrane status, parity and
previous caesarean section.

58. Research question
What are the effectiveness, safety and maternal acceptability of:
• different regimens of vaginal PGE2, stratified by: clinical
indications; cervical and membrane status; parity; and previous
caesarean section
• different management policies for failed induction of labour with
vaginal PGE2 (additional PGE2, oxytocin, elective caesarean or delay
of induction, if appropriate)?
Why is this important?
Despite extensive studies carried out over the past 30 years to
determine the most effective
ways of inducing labour with vaginal PGE2, uncertainties
remain about how best to apply
these agents in terms of their dosage and timing. It would be
particularly useful to understand
more clearly why vaginal PGE2 fails to induce labour in some
women.

59. 35. Do you use PGE1, (cytotec) as a
method for IOL in your hospital?
36. If yes, Do you consider the
repeat of dose PGE1 , (cytotec)
every 6 hrs?
37. Do you consider a maximum
daily dose of PGE1, (cytotec) as
200 micg for IOL?

60. Evidence statements
Oral misoprostol
Evidence suggested that, irrespective of
cervical status, oral misoprostol is more
effective than placebo as an induction
agent. There is no significant difference
in maternal and fetal outcomes between
oral misoprostol (200 micrograms) and
intracervical PGE2.
[EL = 1++]

61. The use of oral misoprostol (100
micrograms) is more likely than oxytocin
to be associated with meconium-stained
liquor. Oral misoprostol 50 micrograms
or 100 micrograms achieve similar
maternal and fetal outcomes. Oral
misoprostol (50–100 micrograms) is less
likely than vaginal PGE2 to result in
caesarean birth (borderline significance).
[EL = 1++]

62. In women with an unfavourable
cervix, oral misoprostol 50
micrograms is less likely than
vaginal misoprostol 25 micrograms
to achieve vaginal birth within 24
hours. Oral misoprostol has similar
efficacy to vaginal PGE2 gel in
terms of vaginal birth within 24
hours. [EL = 1++]

63. Interpretation of evidence
1-misoprostol is not licensed for
induction of labour in the UK
2-if misoprostol is given orally, the dose
should not exceed 50 micrograms
3- higher doses are associated with
higher rates of uterine hyperstimulation
4-misoprostol 25 micrograms vaginal
tablet is not superior to vaginal PGE2 for
induction of labour

64. 5-when the cervix is unfavourable, doses
above 25 micrograms are associated with
higher rates of successful induction of labour
but at the expense of higher rates of uterine
Hyperstimulation
6- currently available preparations are 100
microgram and 200 microgram oral tablets;
tablets must be cut or made into suspension
to achieve lower doses (e.g. 25 micrograms
or 50 micrograms), but uniform
concentration and accurate drug delivery is
not guaranteed.

65. ACOG Guidelines (Level A Recommendation)
1-25mcg should be the initial dose for labor induction at
term , should not be administered more frequent than 3-6
hours , oxytocin should not be administered < 4 hours after
the last misoprostol use and the drug should be avoided in
patients with previous cesarean delivery or major uterine
surgery.
2- Use of higher dosage 50 mcg may be appropriate in some
situations and have a greater likelihood of vaginal delivery
within 12 hours, such doses increase the risk of
hyperstimulation and rupture.
There is at present insufficient clinical evidence to address
the safety of misoprostol in patients with multiple gestations
and suspected fetal macrosomia

66. 38. Do you stop further doses of PG if
the patient develop contractions?
39. If patient is not delivered after 24
hours of IOL, would you consider a
second course of IOL?
40. If yes, do you allow a rest day
(24hrs) in between the two courses?
41. Do you consider IOL to be failed if
no progress occurred after completed
two courses of IOL?
42. If No, would you consider a third
course?

67. 43. Do you use different methods of IOL
before it is considered as a failure?
44. Do you consider LSCS as a must If
IOL fails ?
45. Do you consider sending patient
home if her IOL fails?
46. Do you have to use Oxytocin before
labelling patient as failed IOL?

68. failed induction
failure to establish labour after one
cycle of treatment, consisting of the
insertion of two vaginal PGE2 tablets
(3 mg) at 6-hourly intervals,
Overview of available evidence
No evidence was identified relating to
management of failed induction.

69. Research recommendations on failed
induction
Research is needed to establish frequency and
interval of vaginal PGE2 to achieve
successful induction of labour.
Research is needed to examine different
management policies for failed vaginal PGE2
induction (additional PGE2, amniotomy,
oxytocin, elective caesarean section or
delay of induction if appropriate)

70. Reference is made to the NICE clinical guideline
on intrapartum care as supplementary evidence
If induction fails, healthcare professionals should
discuss this with the woman and provide support. The
woman's condition and the pregnancy in general
should be fully reassessed, and fetal wellbeing should
be assessed using electronic fetal monitoring.
If induction fails, the subsequent management options
include:
a further attempt to induce labour (the timing
should depend on the clinical situation and the
woman's wishes)
caesarean section

71. Questions????

72. Thank You