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Induction of labour
About
What is covered
This NICE Pathway covers advice and care for pregnant women who are thinking about or having induction of labour, including the circumstances, methods, assessment, monitoring and pain relief for induction of labour.
Updates
Updates to this NICE Pathway
4 November 2021 Major update on publication of the inducing labour guideline update (NICE guideline NG207).
19 August 2021 Inducing labour (NICE quality standard 60) updated.
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
What is covered
This NICE Pathway covers advice and care for pregnant women who are thinking about or having induction of labour, including the circumstances, methods, assessment, monitoring and pain relief for induction of labour.
Updates
Updates to this NICE Pathway
4 November 2021 Major update on publication of the inducing labour guideline update (NICE guideline NG207).
19 August 2021 Inducing labour (NICE quality standard 60) updated.
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.
Inducing labour (2021) NICE guideline NG207
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, updated 2021) NICE quality standard 60
Induction of labour in late intrauterine fetal death: vaginal misoprostol (after oral mifepristone) (2013) NICE evidence summary ESUOM11
Novii Wireless Patch System for maternal and fetal monitoring (2020) NICE medtech innovation briefing 228
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.
Quality statements
Women's involvement in decisions about induction of labour
This quality statement is taken from the inducing labour quality standard. The quality standard defines clinical best practice for inducing 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
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.
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 in the denominator who receive 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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from surveys of women offered induction of labour.
What the quality statement means for different audiences
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.
Women who are offered induction of labour (labour that is artificially started, for example, 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
Inducing labour. NICE guideline NG207 (2021), recommendations 1.1.3, 1.1.4 and 1.1.5
Definitions of terms used in this quality statement
Personalised information
For women who are offered induction of labour, personalised information includes:
- explaining that induction of labour is a medical intervention that will affect their birth options and their experience of the birth process
- the reasons why induction may be clinically appropriate, and alternative options
- when, where and how induction may be carried out (including pain relief options)
- the risks and benefits of induction of labour relevant to the woman’s own circumstances.
[Adapted from NICE’s guideline on inducing labour, recommendations 1.1.3 and 1.1.4]
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 inducing labour quality standard. The quality standard defines clinical best practice for inducing labour and should be read in full.
Quality statement
Women only have their labour induced as outpatients if safety and support procedures 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.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that women who have their labour induced as outpatients are induced with safety and support procedures in place.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.
Process
a) Proportion of women who are induced as outpatients who agree a review plan before they go home.
Numerator – the number in the denominator who agree a review plan before they go home.
Denominator – the number of women who are induced as outpatients.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
b) Proportion of women who are induced as outpatients who are given information on when to contact their midwife, maternity unit or obstetrician.
Numerator – the number in the denominator who are given information on when to contact their midwife, maternity unit or obstetrician.
Denominator – the number of women who are induced as outpatients.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
Outcome
a) Maternal safety.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records. The NHS Digital Maternity Services Data Set includes data on maternal safety including a maternal critical incident indicator.
b) Newborn safety.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records. The NHS Digital Maternity Services Data Set includes data on newborn safety including a neonatal critical incident indicator.
What the quality statement means for different audiences
Service providers ensure that safety and support procedures 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.
Commissioners ensure that they commission services from providers that can demonstrate that safety and support procedures are in place for women who have their labour induced as outpatients.
Women who have induction of labour (labour that is artificially started, for example, using a pessary, tablet or gel) started in a hospital maternity unit and then go home to wait for the induction to work agree a review plan before they leave the unit. They are given information about contacting their midwife, maternity unit or obstetrician when contractions start, if there are no contractions, if their membranes rupture, if they develop bleeding or if they have any concerns. They are also given information about the types of pain relief available.
Source guidance
Inducing labour. NICE guideline NG207 (2021), recommendations 1.6.2, 1.6.3 and 1.6.4
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:
- Agreeing a review plan with the woman before she returns home.
- Giving women information about when to contact their midwife, maternity unit or obstetrician, such as:
- when contractions begin
- if there are no contractions (in an agreed timeframe, depending on the method used)
- if her membranes rupture
- if she develops bleeding
- if she has any other concerns (such as reduced or altered fetal movements, excessive pain or uterine contractions, side-effects or loss of the pessary or device).
- Ensuring that women are told about the pain relief options available in different settings.
[NICE’s guideline on inducing labour, recommendations 1.5.7, 1.6.3 and 1.6.4]
Pain relief
This quality statement is taken from the inducing labour quality standard. The quality standard defines clinical best practice for inducing 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
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.
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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from surveys of women who had induction of labour.
What the quality statement means for different audiences
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.
Women who have induction of labour (labour that is started artificially, for example, 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
Inducing labour. NICE guideline NG207 (2021), recommendation 1.5.8
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 NICE’s full guideline on inducing labour and expert opinion]
For women who are offered induction of labour the pain relief options available are those outlined in NICE’s guideline on intrapartum care, along with comfort that may be provided by partners, family members and others. This can include simple analgesia, labour in water and epidural analgesia. [Adapted from NICE’s guideline on inducing labour, recommendation 1.5.8]
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.
Membrane sweeping for prolonged pregnancy
This quality statement is taken from the inducing labour quality standard. The quality standard defines clinical best practice for inducing labour and should be read in full.
Quality statement
Pregnant women discuss the option of vaginal examination for membrane sweeping at their antenatal appointments after 39 weeks of pregnancy.
Rationale
A membrane sweep after 39 weeks of pregnancy might make it more likely that labour will start naturally, without the need for pharmacological or mechanical methods of induction. It is important to discuss the procedure with women and to obtain their consent.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that pregnant women discuss the option of vaginal examination for membrane sweeping at their antenatal appointments after 39 weeks of pregnancy.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.
Process
Proportion of pregnant women attending an antenatal appointment after 39 weeks of pregnancy who discuss the option of vaginal examination for membrane sweeping.
Numerator – the number in the denominator who discuss the option of vaginal examination for membrane sweeping.
Denominator – the number of pregnant women attending an antenatal appointment after 39 weeks of pregnancy.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
Outcome
a) Rates of induction of labour for women with prolonged pregnancy.
Data source: The NHS Digital Maternity Services Dataset collects data on the medical induction of labour, the method for delivering baby and neonatal death.
b) Mode of delivery for women with prolonged pregnancy including:
- spontaneous vaginal birth
- instrumental vaginal birth
- elective or emergency caesarean section.
Data source: The NHS Digital Maternity Services Data Set collects data on the medical induction of labour, the method for delivering baby and neonatal death.
c) Rates of stillbirth beyond 40 weeks of pregnancy (where there is no underlying medical cause).
Data source: The NHS Digital Maternity Services Data Set collects data on the medical induction of labour, the method for delivering baby and neonatal death.
What the quality statement means for different audiences
Service providers ensure that processes are in place to discuss the option of vaginal examination for membrane sweeping with pregnant women at antenatal appointments after 39 weeks of pregnancy. Service providers ensure that systems are in place to obtain the woman’s consent before carrying out membrane sweeping.
Healthcare professionals discuss the option of vaginal examination for membrane sweeping with pregnant women at their antenatal appointments after 39 weeks of pregnancy and obtain their consent before carrying out membrane sweeping.
Commissioners ensure they commission services that discuss the option of vaginal examination for membrane sweeping with pregnant women at their antenatal appointments after 39 weeks of pregnancy and obtain their consent before carrying out membrane sweeping.
Pregnant women discuss the option of a vaginal examination to carry out a membrane sweep, in which a healthcare professional moves a finger around the cervix or massages the cervix, to help start labour, at their antenatal appointments after 39 weeks of pregnancy. Pregnant women are asked to give their consent before they have a membrane sweep.
Source guidance
Inducing labour. NICE guideline NG207 (2021), recommendation 1.3.2
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NICE has written information for the public on each of the following topics.
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
The Bishop score is a numerical value obtained by doing a vaginal examination, and is based on the dilation, effacement (or length), position and consistency of the cervix and the station of the head with respect to the ischial spines of the pelvis. A score of 8 or more generally indicates that the cervix is ready to dilate, (previously the terms 'ripe' or 'favourable' were widely used) and when there is a high chance of spontaneous labour, or response to interventions made to induce labour. For the purposes of this guidance, a Bishop score of less than or equal to 6, or a score greater than 6, was used to help determine choice of pharmacological or mechanical methods to induce labour.
Dinoprostone is the international non-proprietary name for prostaglandin E2; previous versions of this guidance referred to prostaglandin E2, or PGE2, but in order to ensure uniformity with the naming conventions in the BNF, this version refers to this medication as dinoprostone.
This is overactivity of the uterus as a result of induction of labour. It is variously defined as uterine tachysystole (more than 5 contractions per 10 minutes for at least 20 minutes) and uterine hypersystole/hypertonicity (a contraction lasting at least 2 minutes). These may or may not be associated with changes in the fetal heart rate pattern (persistent decelerations, tachycardia or decreased short term variability).
Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) is a series of audits carried out with the aim of identifying causes of maternal and perinatal death and morbidity and making recommendations to inform maternity care and so reduce these poor outcomes.
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 of the uterus. If the cervix will not admit a finger, massaging around the cervix in the vaginal fornices may achieve a similar effect.
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 of the uterus. If the cervix will not admit a finger, massaging around the cervix in the vaginal fornices may achieve a similar effect.
Ensure facilities are available for cardiotocography wherever induction of labour is started.
Check that there is no evidence of a low-lying placenta on previous scans before membrane sweeping and before induction of labour.
Gestational age at which labour started, as a proportion of labours which started spontaneously
Gestation age (weeks) | Proportion of spontaneous labours that started at this gestational age | Cumulative proportion of spontaneous labours that started by this gestational age |
|---|---|---|
31 weeks and under | 2.4% | 2.4% |
32+0 to 36+6 weeks | 5.3% | 7.7% |
37+0 to 37+6 weeks | 5.1% | 12.8% |
38+0 to 38+6 weeks | 12.1% | 24.9% |
39+0 to 39+6 weeks | 25.4% | 50.3% |
40+0 to 40+6 weeks | 32.5% | 82.8% |
41+0 to 41+6 weeks | 16.2% | 99.0% |
42+0 weeks and over | 0.9% | 100% |
Glossary
(a management approach, also called 'wait and watch', when no medical or surgical treatment is given – the aim is to allow labour to begin naturally)
(defined as labour not starting after one cycle of treatment)
(a medical device used to dilate the uterine cervix by swelling as it absorbs fluid from surrounding tissue and swells)
(a labour that is very quick and short, and the baby is born less than 3 hours after the start of uterine contractions)
(a baby that is believed to be large for its gestational age, defined for the purposes of this guideline as an estimated fetal weight above the 95th percentile, at or after 36 weeks of pregnancy)
Paths in this pathway
Pathway created: November 2011 Last updated: November 2021
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