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Induction of labour

About

What is covered

This interactive flowchart covers the policy and methods of induction, and the care of women being offered and having induction.
In 2004 and 2005, one in five deliveries in the UK was induced. Induced labours have an impact on the birth experience of women, and on their health and that of their babies.

Updates

Updates to this interactive flowchart

6 April 2016 Restructured, and summarised recommendations replaced by full recommendations.
21 July 2015 Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section (NICE interventional procedures guidance 528) added.
16 April 2014 Inducing labour (NICE quality standard 60) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on inducing labour in an interactive flowchart

What is covered

This interactive flowchart covers the policy and methods of induction, and the care of women being offered and having induction.
In 2004 and 2005, one in five deliveries in the UK was induced. Induced labours have an impact on the birth experience of women, and on their health and that of their babies.

Updates

Updates to this interactive flowchart

6 April 2016 Restructured, and summarised recommendations replaced by full recommendations.
21 July 2015 Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section (NICE interventional procedures guidance 528) added.
16 April 2014 Inducing labour (NICE quality standard 60) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Intrapartum care for healthy women and babies (2014 updated 2017) NICE guideline CG190
Inducing labour (2008) NICE guideline CG70
Antenatal care for uncomplicated pregnancies (2008 updated 2017) NICE guideline CG62
Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section (2015) NICE interventional procedure guidance 528
Inducing labour (2014) NICE quality standard 60
Induction of labour: misoprostol vaginal delivery system (2014) NICE evidence summary ESNM38
Induction of labour in late intrauterine fetal death: vaginal misoprostol (after oral mifepristone) (2013) NICE evidence summary ESUOM11

Quality standards

Inducing labour

These quality statements are taken from the inducing labour quality standard. The quality standard defines clinical best practice for induction of labour and should be read in full.
1Women's involvement in decisions about induction of labour
2Safety and support for women having labour induced as outpatients
3Pain relief

Quality statements

Women's involvement in decisions about induction of labour

This quality statement is taken from the induction of labour quality standard. The quality standard defines clinical best practice for induction of labour and should be read in full.

Quality statement

Women who are being offered induction of labour are given personalised information about the benefits and risks for them and their babies, and the alternatives to induction.

Rationale

The quality of the information-giving process, and the provision of information about induction of labour at the most appropriate time, can ensure effective choices by women about whether and when they have their labour induced. Women can use this information to consider their options, to ask questions and to reach a decision with the support of their healthcare professionals.

Quality measures

Structure
Evidence of local arrangements to ensure that women who are offered induction of labour are provided with personalised information about the benefits and risks for them and their babies, and the alternatives to induction.
Data source: Local data collection.
Process
Proportion of women who are offered induction of labour who receive personalised information about the benefits and risks for them and their babies, and the alternatives to induction.
Numerator – the number of women in the denominator who received personalised information about the benefits and risks for them and their babies, and the alternatives to induction.
Denominator – the number of women who are offered induction of labour.
Data source: Local data collection.
Outcome
Women who are offered induction of labour feel that they were given sufficient information to enable them to choose to have their labour induced.
Data source: Local data collection. NICE audit support for induction of labour; NICE questionnaire for women for induction of labour.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that personalised verbal and written information is available for women who are offered induction of labour that explains the reasons for induction of labour, the benefits and risks for them and their babies, and the alternatives to induction.
Healthcare professionals ensure that they provide women who are offered induction of labour with personalised information explaining the reasons for induction of labour, the benefits and risks for them and their babies, and the alternatives to induction.
Commissioners ensure that they commission services that provide women who are offered induction of labour with personalised information explaining the reasons for induction of labour, the benefits and risks for them and their babies, and the alternatives to induction.

What the quality statement means for women offered induction of labour and their partners, families and carers

Women who are offered induction of labour (labour that is artificially started using a pessary, tablet or gel) are given personalised information by their healthcare professionals about the reasons for induction of labour, the benefits and risks for them and their babies, and the alternatives to induction.

Source guidance

  • Induction of labour (NICE clinical guideline 70), recommendations 1.1.1.1 and 1.1.1.2 (key priorities for implementation), and 1.1.1.3.

Definitions of terms used in this quality statement

Personalised information
For women who are offered induction of labour personalised information includes the reasons why induction may be clinically appropriate, and alternative options; when, where and how induction may be carried out (including pain relief options); and the risks and benefits of induction of labour relevant to the woman's own circumstances. [Adapted from NICE clinical guideline 70, recommendation 1.1.1.2]

Equality and diversity considerations

Personalised information about the reasons for induction of labour, the benefits and risks and the alternatives, should be in a form that can be understood by all women so that they can make informed choices. Information should be provided in an accessible format, including for women with physical, sensory or learning disabilities and women who do not speak or read English.

Safety and support for women having labour induced as outpatients

This quality statement is taken from the induction of labour quality standard. The quality standard defines clinical best practice for induction of labour and should be read in full.

Quality statement

Women only have their labour induced as outpatients if safety and support procedures, including audit, are in place.

Rationale

Women who have their labour artificially started using pharmacological techniques sometimes leave hospital to return home (or to a setting where they do not have immediate access to the hospital), but they will return to the hospital for the delivery. Women should only leave hospital after induction is started if it is in their interests and if there are safety and support procedures in place. Continual audit of the practice of induction of labour for women who return home will allow service providers and clinical teams to ensure that this process is used for clinically appropriate reasons and to monitor outcomes for women and their babies.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women who have their labour induced as outpatients are induced with safety and support procedures in place.
b) Evidence of local arrangements to ensure that the practice of outpatient induction is audited continually.
Data source: Local data collection.
Process
a) Proportion of women who are induced as outpatients who are monitored for a period of time before they go home.
Numerator – the number of women in the denominator who are monitored for a period of time before they go home.
Denominator – the number of women who are induced as outpatients.
b) Proportion of women who are induced as outpatients who are given instructions on who to contact if they experience regular contractions or have concerns.
Numerator – the number of women in the denominator who are given instructions on who to contact if they experience regular contractions or have concerns.
Denominator – the number of women who are induced as outpatients.
Data source: Local data collection.
Outcome
a) Maternal safety.
b) Newborn safety.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that safety and support procedures, including audit, are in place for women who have their labour induced as outpatients.
Healthcare professionals follow the safety and support procedures that are in place for women who have their labour induced as outpatients and take part in continual audit of the process of induction.
Commissioners ensure that they commission services from providers that can demonstrate that safety and support procedures, including audit, are in place for women who have their labour induced as outpatients.

What the quality statement means for women offered induction of labour and their partners, families and carers

Women who have induction of labour (labour that is artificially started using a pessary, tablet or gel) started in a hospital maternity unit and then go home to wait for the induction to work are offered monitoring for a time before they leave the unit, and given information about who to contact if contractions start or they have any concerns, and about the types of pain relief available.

Source guidance

Definitions of terms used in this quality statement

Outpatient
Outpatient in this context refers to women who start the process of having their labour induced in hospital and are then discharged either to home or to a setting without immediate access to inpatient care (such as an outreach antenatal clinic or a birthing centre). Women will return to hospital for delivery of the baby. [Expert consensus]
Safety and support procedures
When women have their labour induced as outpatients, safety and support procedures should include:
  • Monitoring women for a period of time before they go home.
  • Giving women instructions on who to contact (and ensuring they have immediate access to advice) if they experience contractions, if they do not experience contractions after 6 hours, or if they have any concerns.
  • Ensuring that women are told about the pain relief options available in different settings.
  • Continual audit of the process of induction.
[Adapted from Induction of labour (NICE full clinical guideline 70)]

Pain relief

This quality statement is taken from the induction of labour quality standard. The quality standard defines clinical best practice for induction of labour and should be read in full.

Quality statement

Women who have their labour induced have access to pain relief that is appropriate to their level of pain and to the type of pain relief they request.

Rationale

It is important for all women in labour that they receive appropriate pain relief within a suitable timeframe. As induced labour is usually more painful than spontaneous labour, women whose labour is induced may need pain relief earlier than women whose labour starts spontaneously. Women's needs for pain relief, and for different types of pain relief, may vary. Pain relief that is appropriate and suitable for the woman should be available, along with comfort and support that may be provided by partners, family members and others.

Quality measures

Structure
Evidence of local arrangements for women who have their labour induced to have access to pain relief that is appropriate to their level of pain and to the type of pain relief they request.
Data source: Local data collection.
Outcome
Women who had induction of labour are satisfied that the pain relief they received was appropriate to their level of pain and to the type of pain relief they requested.
Data source: Local data collection. NICE audit support for induction of labour; NICE questionnaire for women for induction of labour.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that access is available, for women whose labour is induced, to pain relief that is appropriate to their level of pain and to the type of pain relief they request.
Healthcare professionals ensure that women whose labour is induced have access to pain relief that is appropriate to their level of pain and to the type of pain relief they request.
Commissioners ensure that they commission services that provide women whose labour is induced with access to pain relief that is appropriate to their level of pain and to the type of pain relief they request.

What the quality statement means for women offered induction of labour and their partners, families and carers

Women who have induction of labour (labour that is started artificially using a pessary, tablet or gel) are offered pain relief that is appropriate for the amount of pain they are experiencing and the type of pain relief they request.

Source guidance

  • Induction of labour (NICE clinical guideline 70), recommendation 1.6.2.3.

Definitions of terms used in this quality statement

Appropriate pain relief
Induced labour is usually more painful than spontaneous labour. It follows that 'appropriate' in this context refers to whether the type of pain relief is satisfactory and if it is given within a suitable timeframe. [Adapted from Induction of labour (NICE full clinical guideline 70) and expert opinion]
Pain relief
For women who are offered induction of labour the pain relief options available are those outlined in sections 1.4 and 1.5 of Intrapartum care (NICE clinical guideline 55), along with comfort that may be provided by partners, family members and others.

Equality and diversity considerations

All women, including those with physical, sensory or learning disabilities and women who do not speak or read English, should have access to support such as an interpreter or advocate to help them express their needs for pain relief.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.
Intrapartum care for healthy women and babies
Inducing labour
Antenatal care for uncomplicated pregnancies
Inducing labour
Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section
Induction of labour in late intrauterine fetal death: vaginal misoprostol (after oral mifepristone)

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

membrane sweeping involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua – if the cervix will not admit a finger, massaging around the cervix in the vaginal fornices may achieve a similar effect; for the purpose of these recommendations, membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction
the Bishop score is a group of measurements made by doing a vaginal examination, and is based on the station, dilation, effacement (or length), position and consistency of the cervix; a score of eight or more generally indicates that the cervix is ripe, or 'favourable' – when there is a high chance of spontaneous labour, or response to interventions made to induce labour
summary of product characteristics

Paths in this pathway

Pathway created: November 2011 Last updated: March 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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