The purpose of induction of labor is to stimulate uterine contractions before onset of spontaneous labor for vaginal delivery. The rates of induction of labor have significantly increased during the last decades. In 1990, less than 10% of pregnancies underwent induction of labor, vs 30% by 2019. Currently, induction of labor is one of the most frequently performed obstetric procedures. A recent RCT comparing elective induction of labor at 39 weeks gestation with expectant management in nulliparous people (the ARRIVE trial – see below in ‘Related ObG Topics’), showed no increase in perinatal morbidity and mortality rates with lower rates of cesarean delivery. These results may lead to an increase in induction rates in the near future.
Indications include but are not limited to the following
Risk of rapid labor | Distance to hospital | Psychosocial indications
Note: See summary of guidance on timing of delivery for medical indications below in ‘Related ObG Topics’
Similar to contraindications for vaginal delivery
Vasa previa or complete placenta previa
Transverse fetal lie
Umbilical cord prolapse
Previous classical cesarean delivery
Active genital herpes infection
Previous myomectomy entering endometrial cavity
A Bishop score of ≤6 is associated with low rate of successful induction with oxytocin alone, and the use of cervical ripening agents are recommended
Cervical Ripening Agents
Misoprostol (PGE1 analogue) given intravaginally, orally or sublingually
Initial dose: 25 mcg every 3 to 6 hours
Delay oxytocin 4 hours after last dose
Available evidence supports safety and efficacy
Higher rates of tachysystole
When compared to PGE2
With dosing ≥50 mcg
Contraindications: Prior cesarean and/or uterine surgery due to risk for uterine rupture
Dinoprostone (PGE2 preparations) given vaginally via gel or insert
0.5 mg in 2.5 ml syringe gel or 10 mg vaginal insert
Second dose after 6 to 12 h (maximum dose of 1.5 mg in 24 hours)
Delay oxytocin 6 to 12 hours after last application of gel or 30 to 60 min after insert
Note: After prostaglandin use (misoprostol or dinoprostone), patient should remain recumbent for at least 30 minutes | Fetal heart tracing should be monitored continuously for 30 minutes to 2 hours | FHR monitoring should be continued if regular uterine contractions are persistent
Foley catheter ( 30 to 80 ml): Reasonable and effective option for cervical ripening
The ARRIVE Trial and Professional Guidance: Elective 39 Week Induction to Reduce the Risk of Cesarean Section
The ARRIVE study (A Randomized Trial of Induction Versus Expectant Management), authored by Grobman et al. (NEJM, 2018), was undertaken to determine if elective induction of labor (IOL) of low-risk nulliparous women at 39 weeks reduces adverse perinatal and neonatal morbidity compared to expectant management. SMFM released a statement, endorsed by ACOG, addressing the ARRIVE findings.
It is reasonable to offer elective IOL to low-risk, nulliparous women at or beyond 39 weeks and 0 days of gestation. We recommend that providers who choose this approach ensure that women meet eligibility criteria of the ARRIVE trial.
We recommend against offering elective IOL to women under circumstances that are inconsistent with the ARRIVE study protocol unless performed as part of research or quality improvement.
We recommend that further research be conducted to measure the impact of this practice in settings other than a clinical trial.
At least 12 hours after completion of cervical ripening, rupture of membranes, and use of a uterine stimulant
Cesarean decision left to patient’s physician’s discretion
Additional SMFM recommendations
Shared decision making is ‘critical’
All women in this study had ultrasound dating, early in pregnancy
Certain LMP: <21 weeks
Uncertain LMP: First trimester ultrasound
ACOG has also released a Practice Advisory related to ARRIVE (see ‘Learn More-Primary Sources’ below) that also highlights the importance of shared decision making as well as taking in to account “resources available (including personnel), and the setting in which the intervention will be implemented”
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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