MOH/P/PAK/455.

21(GU)-e

GUIDELINES ON
INDUCTION OF
LABOUR

M I N I S T R Y O F H E A LT Y M A L A Y S I A
 Guideline on Induction of Labour
was developed by
Obstetricians & Gynaecologists of the Ministry of Health Malaysia,
in collaboration with
the Obstetric & Gynaecology and Paediatric Services Unit of the
Medical Services Development Section, Medical Development Division,
Ministry of Health Malaysia
www.moh.gov.my

Published in 2021

A catalogue record of this document is available from the Institute of Medical

Research, Ministry of Health;

MOH/P/PAK/455.21(GU)-e

And also available from the National Library of Malaysia;

ISBN 978-967-25780-0-0

9 7 8 9 6 7 2 5 7 8 0 0 0

All rights reserved.

No part of this publication may be reproduced or distributed in any form or any

means, or stored in a database or retrieval system, without prior written
permission of the Ministry of Health, Malaysia.

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 FOREWORD
BY DIRECTOR-GENERAL OF HEALTH MALAYSIA

Improving the quality of care is a complex and multifaceted process that requires
the simultaneous deployment of a combination of interventions. Therefore, a
policy document that empowers clinicians and those who are involved in the care
of pregnant women and labour will improve clinical practices at the frontlines.
Improved guidelines tailored to current and evidence-based clinical practices will
close the gap between actual and achievable performance in delivering quality
health care services.

The updated Guideline on the Induction of Labour, therefore, is a timely review

since its first publication in 2008. Apart from a revision of recommendations, this
review incorporates updated indications for the induction of labour and the
management of its complication. The updated guidelines will guide clinicians for
better and systematic handling of induction of labour which ensures good
maternal and neonatal outcomes despite the inherent risk to mother and foetus.

I wish to take this opportunity to thank all contributors and hope this review will
serve as a guide to improve the quality of clinical management and ensure patient
safety. On the same note, I would like to offer a distinguished commendation to
the editors, contributors, and all parties that were involved in making this revised
guideline a reality. Additionally, I urge the obstetrics fraternity to continue
strengthening the partnership between clinicians and patients that drives the
quality of care overall.

TAN SRI DATO’ SERI DR. NOOR HISHAM BIN ABDULLAH

DIRECTOR-GENERAL OF HEALTH MALAYSIA

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FOREWORD
BY DIRECTOR OF MEDICAL DEVELOPMENT DIVISION

Pregnancy and childbirth are the main cause of admission in Ministry Of Health
hospitals, comprising of 22.2% of all admissions. Meanwhile, the incidence of
labour induction, the artificial initiation of labour has continued to rise which may
pose risks to mothers and their babies. This update is necessary and timely in
view of there exist new evidence and clinical practices.

When undertaken for appropriate reasons and by appropriate methods, induction

is useful and benefits both mothers and newborns. The goal of induction is to
achieve a successful vaginal delivery that is as natural as possible. The
objectives of this guideline are to summarize the indication for induction, review
current methods of cervical ripening and labour induction, and evaluate the safety
and effectiveness of agents and methods used in cervical ripening and labour
induction. Treatment and care should take into account women’s individual needs
and preferences. Women who and having or being offered induction of labour
should have the opportunity to make informed choices about their care and
treatment with their healthcare providers.

I hope this updated guideline on induction of labour will be useful in improving

women’s health and will be fully utilized by all relevant health care professionals.

I would also like to congratulate and express my gratitude to everyone for their
support, dedication and contribution to the development of this guideline.

DATO’ DR NORHIZAN BIN ISMAIL

DEPUTY DIRECTOR-GENERAL OF HEALTH (MEDICAL)
MINISTRY OF HEALTH MALAYSIA

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 PREFACE
BY NATIONAL HEAD OF OBSTETRICAL AND GYNAECOLOGICAL SERVICES

Induction of labour (IOL) is one of the commonest procedures that is performed

in Obstetric Practice. The induction options have increased and newer modalities
with varied degrees of success are now available.

It is indeed very timely that this review of the “IOL guidelines” has been done. A
lot of hours have been spent to make sure that these guidelines are user friendly
and evidenced based. The team has endeavoured to make this guideline as an
easy read. Appropriate references are provided to make this document as
resourceful as possible.

As we are all aware that in the current times medical practice is very dynamic
with management options and treatment modalities being always reviewed and
updated. In the same manner this document has to be treated in the way it was
intended too, that is as a guideline and as the authoritative and exhaustive
manual on IOL.

Allow me to congratulate the entire team for the dedication on their excellent
piece of work.

DR. RAVICHANDRAN JEGANATHAN

NATIONAL HEAD OF OBSTETRICAL AND GYNAECOLOGICAL SERVICES
MINISTRY OF HEALTH MALAYSIA

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CONTENTS
Foreword by Director-General Of Health Malaysia .................................................... 2
Foreword by Director Of Medical Development Division ........................................... 3
Preface by National Head Of Obstetrical And Gynaecological Services ................... 4
Definitions .................................................................................................................. 7
Summary Of Recommendations ............................................................................... 8
1. Introduction ....................................................................................................... 12
2. Prerequisites For Induction Of Labour .............................................................. 13
3. Indications For Induction Of Labour ................................................................. 15
3.1 Post-Dated Pregnancy ............................................................................ 15
3.2 Term Pre-Labour Rupture Of Membranes .............................................. 16
3.3 Preterm Pre-Labour Rupture Of Membranes .......................................... 17
3.4 Gestational Diabetes (GDM)/Diabetes Mellitus (DM) .............................. 18
3.5 Hypertensive Disorders in Pregnancy ..................................................... 19
3.6 Twin Pregnancy....................................................................................... 19
3.7. Small-For-Gestational Age (SGA) & Intrauterine Growth Restriction
(IUGR) ..................................................................................................... 21
3.8 Intrauterine Fetal Death (IUFD) ............................................................... 22
3.9 Reduced Fetal Movement (RFM) ............................................................ 23
3.10 Oligohydramnios ..................................................................................... 23
3.11 Maternal Request .................................................................................... 24
4. Induction Of Labour In Previous Caesarean Section Scar ............................... 25
5. Contra-Indications For Induction Of Labour ..................................................... 26
6. Recommended Methods Of Induction Of Labour ............................................. 27
6.1 Membrane Sweeping And Stripping ........................................................ 27
6.2 Mechanical Method ................................................................................. 27
6.3 Surgical Method ...................................................................................... 28
6.4 Pharmacological Method ......................................................................... 29
7. Care In Induction Of Labour ............................................................................. 31
7.1 Setting And Timing .................................................................................. 31
7.2 Pain Relief ............................................................................................... 31
8. Managing Complications Of Labour Induction .................................................. 32
8.1 Uterine Hyperstimulation ......................................................................... 32
8.2 Failed Induction ....................................................................................... 33
8.3 Cord Prolapse ......................................................................................... 33
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 8.4 Fetal Distress .......................................................................................... 34
8.5 Uterine Rupture ....................................................................................... 34
8.6 Placental Abruption ................................................................................. 35
9. Conclusion ........................................................................................................ 35
References .............................................................................................................. 36
Appendix 1............................................................................................................... 42
Appendix 2............................................................................................................... 43
Appendix 3............................................................................................................... 44
Contributors ............................................................................................................. 45
Reviewers ................................................................................................................ 46
Secretariat ............................................................................................................... 47

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DEFINITIONS:

Definition from the original version of this guideline is maintained.

Labour : The process by which uterine contractions of

increasing frequency, amplitude and duration
together with the progressive effacement of the
uterine cervix and dilatation of the cervical os leads to
the gradual descent of the fetal presentation and the
birth of the baby.

Induction of labour : Artificial initiation of labour

Augmentation : Active intervention during labour to promote the

frequency, duration and amplitude of uterine
contractions.

Cervical favourability : A clinically assessed score of the uterine cervix used

(Bishop’s score) to predict success of induction of labour

Cervical ripening : A process to prepare an unfavourable cervix resulting

in softening and distensibility of the cervix

Post date : Beyond Expected Date of Delivery (EDD) or 40

weeks and above

Social induction of Induction of labour in the absence of a definite

labour : medical indication.

Uterine Excessive uterine contractions exceeding 5 or more

hyperstimulation : contractions in10 minutes in frequency, more than 90
seconds in duration or greater than 100 mmHg in
amplitude.

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 SUMMARY OF RECOMMENDATIONS

1. Mothers should be fully informed of the risks/benefits associated with

induction of labour and expectant management.(C)

2. Induction of labour should be recommended if delivery confers clear benefit

to mother and/or fetus in comparison to risks if pregnancy is allowed to
continue.(C)

3. Induction of labour should be performed by trained personnel who are able

to recognise complications of induction of labour.(C)

4. Induction of labour should be performed in facilities that can detect

complications of induction of labour and manage them appropriately.(C)

5. Assessment of fetal health should be performed prior to induction of

labour.(C)

6. Cervical ripening is recommended if the cervix is assessed to be

unfavourable prior to induction of labour.(A)

7. Vaginal prostaglandin is the agent of choice if cervical ripening is necessary

provided there is no contraindication.(B)

8. Electronic fetal heart monitoring and uterine activity monitoring facilities

should be available when labour is induced. (C)

9. Induction of labour with vaginal prostaglandin is superior to amniotomy with

oxytocin (but with a higher risk of scar dehiscence / rupture)

10. Membrane sweeping and stripping may be offered to all mothers awaiting
formal induction of labour for prolonged pregnancies.(A)

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11. Amniotomy alone should not be routinely used as method of induction of
labour.(A)

12. Amniotomy should be combined with immediate/early oxytocin infusion in

induction of labour.(A)

13. Oxytocin dosage should be titrated to response and individualised.(A)

14. Oxytocin is best administered by automated controlled infusion pump.(C)

15. Oxytocin infusion should be titrated by doubling at intervals of at least 30

minutes.(A)

16. Oxytocin may be used in the presence of pre-labour rupture of

membranes.(A)

17. In the presence of a favourable cervix, amniotomy with oxytocin infusion is

equally efficacious as the usage of prostaglandin.(A)

18. Concomitant use of prostaglandin and oxytocin is absolutely

contraindicated.(C)

19. Oxytocin infusion should be delayed by at least 8 hours after the last dose
of prostaglandin.(C)

20. In pre-labour rupture of membranes, prostaglandin may be used although

oxytocin is preferable.(A)

21. Close monitoring of the fetal heart rate should be performed throughout
induction.(C)

22. Routine early pregnancy ultrasound dating scan should be performed to

identify accurately post-date pregnancy.(A)
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 23. Routine induction of labour after 41 weeks should be performed to reduce
perinatal mortality.(A)

24. Every induction of labour should be appropriately documented.

25. Decision for Induction of Labour (IOL) should be made by specialist.

Note:

(i) Prostaglandin in this guideline refers to vaginal prostaglandin.

(ii) Clarification of the statement for Recommendation No. 23:

Induction of labour after 41 weeks refers to IOL done immediately after the duration
of pregnancy has reached 41 weeks.

(iii) Please refer Appendix 3 for grading of recommendations.

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ABBREVIATION

AFI Amniotic Fluid Index

CRC Clinical Research Centre

LSCS Lower Segment Caesarean Section

DM Diabetes Mellitus

GBS Group B Streptococcus

GDM Gestational Diabetes Mellitus

HDP Hypertensive Disorders in Pregnancy

IOL Induction of Labour

IUFD Intra-Uterine Fetal Death

IUGR Intra-Uterine Growth Restriction

IVF In Vitro Fertilization

MVP Maximum Vertical Pocket

NICU Neonatal Intensive Care Unit

O&G Obstetrics and Gynaecology

PPROM Premature Prelabour Rupture of Membrane

PROM Prelabour Rupture of Membrane

RCOG Royal College of Obstetrician and Gynaecologist

RCT Randomised Control Trial

RFM Reduced Fetal Movement

SCN Special Care Nursery

SGA Small for Gestational Age

WHO World Health Organization

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1. INTRODUCTION

This is a review version of guideline on induction of labour (IOL) following the first
guideline dated January 2008. This review was based on current changes in the
evidence-based clinical practice.

In 1985 the World Health Organization (WHO) set the optimal rate for Caesarean
Section (CS) at 10-15% of all births. A recent review showed a global CS rate
around 19% and some regional rates above 30%.

Malaysian public hospitals had a CS rate of 15.7% in 2006. The National

Obstetrics Registry, Malaysia had reported the CS section rate in 2010 at 23%,
in 2012 at 25.1% and in 2015 at 25.7% and this trend is on the rise. This rise in
CS rates have caused concerns, however striving to keep the rates low should
not jeopardize maternal and fetal health. It is timely to explore ways to reduce
this rising trend and IOL has been proven to reduce CS rates.

IOL is defined as artificial initiation of labour. This is a therapeutic option when

the benefits of expeditious delivery outweigh the potential maternal and fetal risks
of continuing pregnancy.

IOL carries inherent benefits and risks to both mother and fetus. As such, the
women and partner should be counselled and their concerns taken into
consideration in coming to a decision on IOL.

Even though there is no strong evidence that first trimester ultrasound dating can
reduce the rate of IOL (British Journal of Obstetrics and Gynaecology, 2006),
WHO (2011) regarded sweeping the membranes as an intervention aimed to
reduce the need for formal IOL. Thus, the following steps may be considered:
offer vaginal examination prior to formal IOL, offer the woman a membrane
sweep when vaginal examination is carried out to assess the cervix, and offer
membrane sweeping at the 40 weeks during antenatal visit for uncomplicated
pregnancies.

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2. PREREQUISITES FOR INDUCTION OF LABOUR

Good planning of the procedure, adequate communication between health care

providers and pregnant mothers and accurate dating of pregnancy are key to
success.

2.1 Prior to IOL, the following assessments must be carried out and the
following requirement must be looked into:

i) Review of maternal history.

ii) Confirmation of gestational age of fetus by reliable menstrual dates,

ideally supported by early ultrasound examination.

iii) Assessment of indications and contraindications of IOL.

iv) Abdominal palpation to confirm presentation and engagement.

v) Vaginal examination to assess the cervix (Bishop score/Modified

Bishop score) and assessment of membrane status (ruptured/intact).

vi) Assessment of fetal wellbeing. A normal fetal heart rate pattern

should be verified using electronic fetal monitoring.

vii) IOL should be performed in facilities with access to caesarean

section.

2.2 Information and decision.

2.2.1 Prior to IOL, the women and her partner or legal guardian should
be counseled and informed consent obtained.

2.2.2 Counseling should address the following:

i) Indication/reasons for considering IOL

ii) Method of IOL

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 iii) Potential risk (i.e. uterine hyperstimulation, antepartum
haemorrhage, scar dehiscence, fetal distress, uterine rupture,
amniotic fluid embolism)

iv) Success/failure rate

v) Timing and place of IOL

vi) Options for pain relief

vii) Options if IOL is unsuccessful

viii) Options if IOL is declined

This task can be undertaken by a medical officer/ registrar/

specialist/ consultant

2.2.3 Suggest departmental routine audit on IOL based on its incidences

and outcomes.

2.2.4 Proper documentation is recommended.

2.2.5 Decision for IOL be at the level of Specialist/ Consultant.

2.2.6 A quality initiative effort in the form of a checklist to facilitate

decision making may be useful to ensure IOL is performed only in
cases with appropriate indications.

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3. INDICATIONS FOR INDUCTION OF LABOUR

The risk and benefit of the common indications for IOL with recommendations
are summarized below. This can be used as a guide during communication with
women before IOL.

3.1 Post-Dated Pregnancy

Percentage of women remaining undelivered

i) At 41 weeks gestation – approximately 19.0%

ii) At 42 weeks gestation – approximately 3.5%
The risk of fetal death increases significantly with gestational age

i) At 38 weeks gestation – 0.25%

ii) At 42 weeks gestation – 1.55%

Risk and Benefit:

(a) IOL at 41 weeks or beyond compared to awaiting spontaneous labour

for at least one week is associated with:

i) Fewer perinatal deaths – 1/3285 (0.03%) versus 11/3238

(0.34%)

ii) No significant difference in the risk of caesarean section for

women induced at 41 and 42 weeks

iii) Lowers the risk of meconium aspiration syndrome as its at 42

weeks (4.7%), at 41 weeks (3.8%) and 38 weeks (1.31%)

(b) Most women preferred IOL at 41 weeks over serial antenatal

screening.

(c) There is evidence of the benefits of IOL at 39 weeks: ARRIVE

study (A Randomized Trial of Induction Versus Expectant

Management study) showed elective IOL in low risk nulliparae at 39

weeks lowers rates of caesarean delivery without significantly
increasing adverse perinatal outcomes. Thus, this benefit may be

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 offered or may be considered to women who conceived through IVF
or nulliparae with advanced maternal age.

Recommendation
a) For women with uncomplicated pregnancies, IOL at 40 weeks + 7 days.
b) Awaiting spontaneous labour beyond 42 weeks is not recommended.

3.2 Term Pre-labour Rupture of Membranes

Spontaneous labour commences:

i) within 24 hours in 70% of women

ii) within 48 hours in 85% of women

Risk and Benefit:

a) IOL (induction commenced within 24 hours after PROM) compared

with expectant management decreases:

i) admissions to the NICU from 17% to 12.6%

ii) chorioamnionitis from 9.9% to 6.8%

iii) postpartum endometritis from 8.3% to 2.3%

However, there is

i) no differences in LSCS rate

ii) no significant difference in neonatal sepsis

b) When associated with GBS (Group B Streptococcus) infection,

compared to expectant management and IOL with Prostaglandin E2,
IOL with oxytocin is associated with a lower rate of neonatal infection
(2.5% versus more than 8%).

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Recommendation
a) IOL is appropriate approximately 24 hours after pre-labour rupture of
membranes at term.
b) If the woman is known to be GBS positive, advise to expedite IOL.

3.3 Preterm Pre-labour Rupture of Membranes

Risk and Benefit:

a) Gestation between 34 - 36 weeks:

i) IOL versus expectant management

o Reduces chorioamnionitis

o Reduces maternal length of hospital stay

ii) Decreased neonatal intensive care unit (NICU) length of stay and
hyperbilirubinemia if delivery occurs after 34 weeks

b) Gestation less than 34 weeks:

i) Birth before 34 weeks is associated with increased neonatal

mortality, adverse neonatal outcomes including respiratory
distress syndrome, intraventricular haemorrhage, necrotising
enterocolitis and other long-term complications

ii) Neonatal mortality and morbidity increase with decreasing

gestational age

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 Recommendation
Gestation at 36 weeks
 IOL if spontaneous labour has not commenced within 24 hours.
 Oxytocin is preferred to vaginal prostaglandin due to shorter time interval
to birth and reduced rate of neonatal infection
Gestation between 34 – 35 week (+6 days)
 IOL is not recommended as a routine for gestations less than 36 weeks
unless there are maternal or fetal indications.
Gestation less than 34 weeks
 IOL is generally not recommended, with few exceptions following careful
consideration in highly individualized cases.

3.4 Gestational Diabetes (GDM)/Diabetes Mellitus (DM)

Twenty-seven percent of normally formed stillbirths in women with pre-

existing diabetes occur after 37 completed weeks. GDM/DM on diet control
is associated with good pregnancy outcome

Risk and Benefit:

In women with GDM on insulin, comparing IOL in the 38th week with
expectant management showed:

i) Reduced macrosomia in the IOL group (10% versus 23%)

ii) No difference in LSCS rates

iii) A non-significant increase in shoulder dystocia in the expectant group

Recommendation
a) Deliver at 37 – 38 week (+6 day) in women with diabetes requiring insulin.
b) Not to allow postdate for women with well-controlled GDM on diet, with no
evidence of fetal macrosomia.

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3.5 Hypertensive Disorders in Pregnancy

Risk and Benefit:

a) In non-severe hypertension, compared to IOL, expectant

management showed increased risk of poor maternal outcome:

i) 44% compared to 31% in IOL group

ii) No differences in neonatal outcome

Recommendation
a) Consider individual circumstances when determining timing and mode of IOL
for cases of HDP.
b) Generally, offer delivery at 37-38 weeks if well-controlled on
antihypertensive (Induction of labour versus expectant monitoring for
gestational hypertension or mild pre-eclampsia after 36 weeks' gestation
(HYPITAT) study).
c) Consider IOL at 40 weeks in well-controlled HDP not requiring
antihypertensive.

3.6 Twin Pregnancy

a) IOL in twin pregnancy is not routine.

b) Determination of chorionicity, presentation of fetuses, estimated fetal

weight and presence of previous uterine scar are important
parameters before considering IOL.

c) Optimal timing of delivery for uncomplicated twin pregnancy (either

monochorionic or dichorionic) is uncertain.

d) Spontaneous labour commences before 37 weeks in 60% of women

with twin pregnancy.

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 Risk and Benefit:

a) Retrospective studies demonstrated that

i) Perinatal mortality rate is lowest for birth at 37 weeks gestation

ii) Stillbirth rate increase from 38 weeks

iii) No statistically significant difference in caesarean section rate

comparing expectant management with IOL

b) The main determinant of risk in a multiple pregnancy is chorionicity

and this may influence decisions regarding timing of delivery in
individual cases

i) Evidence suggest consistently higher fetal death rate (at all

gestational ages) in monochorionic than if dichorionic
pregnancies; risk of IUFD increased with gestational age
(dichorionic diamniotic, 1:333 at 28 weeks to 1:69 after 39 weeks;
monochorionic diamniotic, 1:23 after 32 weeks)

ii) Risk of cord entanglement in monochorionic monoamniotic

pregnancies

Recommendation
Consider vaginal delivery in uncomplicated twin pregnancy, for
i) Monochorionic Diamniotic at 36 - 37 weeks.
ii) Dichorionic Diamniotic at 37 - 38 weeks.
For caesarean section after corticosteroid cover
i) Monochorionic Monoamniotic at 34 weeks

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3.7. Small-for-Gestational Age (SGA) & Intrauterine Growth Restriction
(IUGR)

3.7.1 SGA fetuses :

a) 50 - 70% are constitutionally small and healthy with predicted

normal outcome.

b) Suggest timing of IOL for SGA at 40 weeks with 2 weekly

umbilical artery (UA) Doppler and growth assessment.

c) Some studies suggest that SGA fetuses can be offered IOL at 37

– 39 weeks (RCOG Green Top Guidelines).

3.7.2 IUGR fetuses:

a) Approximately 10 to 15% are classified as IUGR with predicted

adverse perinatal outcome.

b) There is inadequate evidence to suggest timing of delivery when

IUGR has been diagnosed.

c) Use of umbilical artery and ductus venosus Doppler has been

shown to improve perinatal outcome.

3.7.2.1 Preterm IUGR:

Risk and Benefit:

The Growth Restriction Intervention Trial (GRIT) study

comparing expectant management versus immediate birth
(IOL and CS) between 24 and 36 weeks showed that

a) Perinatal survival of both (early delivery group and

expectant management group) were similar
b) There was also no difference in cognitive, language,
behaviour, or motor abilities at 6-12-year follow-up

The timing and mode of delivery are to be decided based

on individual cases.

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 3.7.2.2 Term IUGR:

Risk and Benefit:

Disproportionate Intrauterine Growth Intervention Trial at

Term (DIGITAT) comparing expectant versus immediate
birth at term, showed no significant difference in

i) Maternal morbidity

ii) Perinatal death

However, in view of small study cohort, timing for IOL cannot

be determined because of insufficient evidence.

Recommendation
a) A constitutionally small but healthy fetus is not to be allowed post-date.
b) Evidence is insufficient to guide timing of birth for IUGR. Delivery is generally
indicated when the risk of fetal death or morbidity is greater than the risk of
prematurity.
c) The plan should be individualized and the timing of IOL depends on the
severity of IUGR and the presence of evidence of fetal compromise.
d) Consider expediting birth when IUGR diagnosed at term.
e) IOL is not recommended for severe IUGR.

3.8 Intrauterine Fetal Death (IUFD)

a) There is no evidence addressing timing of delivery or intra-uterine fetal

death.

b) Majority of women go into spontaneous labour within 2-3 weeks of

IUFD.

c) Risk of coagulopathy is usually only a concern after 4 weeks of

diagnosis of fetal death.

d) Timing of IOL will depend on the woman’s’s wishes and presence or

absence of complication.
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Recommendation
a) Support the woman's preferences regarding timing of IOL.
b) Surgical method of IOL should not be recommended for IUFD.
c) Aim for vaginal delivery

d) Spontaneous labour can be waited for up to 4 weeks before considering IOL.

3.9 Reduced Fetal Movement (RFM)

Risk and Benefit:

a) 70% of pregnancies with a single episode of RFM are uncomplicated.

b) No study to determine whether intervention alters perinatal morbidity.

RCOG statement: Decision whether or not to consider IOL at term is by

individual preference.

Recommendation
a) IOL should not be routinely offered for uncomplicated pregnancy presenting
with single episode of RFM even at term
b) Consider IOL if recurrent RFM at term after discussion with the woman
c) Consider IOL if RFM at postdates (more than 40 weeks)

3.10 Oligohydramnios

Amniotic Fluid Index (AFI) is a better parameter to diagnose

oligohydramnios. Recent evidence suggested that compared to Maximum
Vertical Pocket (MVP), the use of AFI increases the rate of diagnosis of
oligohydramnios, the rate of IOL and the rate of LSCS for fetal distress but
without improvement in peripartum outcomes.

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 The increased perinatal mortality rate (PMR) is related to the underlying
aetiology, prematurity and sequelae of PPROM (principally to those with
mid-trimester membrane rupture).

Recommendation
Oligohydramnios
a) Timing and mode of delivery prior to term will depend on gestational age,
underlying aetiology and fetal wellbeing.
b) Consider IOL if oligohydramnios is diagnosed at term.

3.11 Maternal Request

Routine IOL on maternal request is not generally encouraged and the

benefits and risk of the procedure should be appropriately addressed and
discussed with the couple.

a) There are no studies that address this group specifically.

b) If the pregnancy is uncomplicated, consider the risk of neonatal

respiratory distress syndrome and related adverse effects if IOL is
carried out.

Recommendation
 IOL should not be encouraged on maternal request.
 Proper counselling of maternal and fetal risk should be emphasized.

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4. INDUCTION OF LABOUR IN PREVIOUS CAESAREAN SECTION
SCAR

One previous caesarean section scar is a relative contraindication to IOL.

The risk of uterine rupture with:

i) Spontaneous labour is 4/1000

ii) Augmentation with oxytocin is 9/1000

iii) IOL with prostaglandin with/without oxytocin is 14/1000

iv) IOL using mechanical methods with/without oxytocin is 9/1000

AHRQ meta-analysis and NICHD study concluded that IOL particularly in cases
with unfavourable cervix are associated with 3 folds increased risk of uterine
rupture.

In NICHD study, IOL with prostaglandin had 3 times higher risk of uterine rupture
compared to amniotomy or transcervical Foley catheter.

Cochrane review revealed insufficient evidence from RCT to suggest low dose
prostaglandin E2.

Recommendation
a) Women in this group should be adequately and appropriately assessed
before decision for IOL.

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5. CONTRA-INDICATIONS FOR INDUCTION OF LABOUR

IOL is contra-indicated mainly when vaginal route of delivery carries significant

maternal and fetal risk, for example in

1) Previous Classical Caesarean Section

2) Previous Inverted T

3) Previous J-incision (extension of lower segment incision laterally and

vertically into the upper segment)

4) Unknown uterine surgery

5) Previous Hysterotomy

6) Myomectomy with entry into uterine cavity / extensive dissection

7) Previous uterine rupture

8) More than one previous caesarean

9) Suspected fetal macrosomia (≥4000gm)

10) HIV positive mothers with viral load more than 50 copies/ml (abdominal
delivery results in lower risk of vertical transmission). Communication with
Infectious Disease Specialist is preferable.

11) Suspected cephalo-pelvic disproportion

12) Cord presentation

13) Breech

14) Active Herpes Genitalis

15) Fetal Malpresentation

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6. 6. RECOMMENDED
RECOMMENDED METHODS
METHODS OF INDUCTION
OF INDUCTION OF LABOUR
OF LABOUR
6. 6. RECOMMENDED
RECOMMENDED METHODS
METHODS OF INDUCTION
OF INDUCTION OF LABOUR
OF LABOUR
6.1 Membrane
6.1 Membrane sweeping
sweeping and stripping
and stripping
6.1 Membrane
6.1 Membrane sweeping
sweeping and stripping
and stripping

Membrane
Membrane sweeping
sweeping and stripping
and stripping is a separation
is a digital digital separation of membranes
of membranes
Membrane
Membrane sweeping
sweeping and stripping
and stripping is a separation
is a digital digital separation of membranes
of membranes
performed
performed during vaginal
during vaginal examination,
examination, usuallyusually
prior toprior
formalto IOL.
formal IOL.
performed
performed during vaginal
during vaginal examination,
examination, usually usually
prior to prior
formalto IOL.
formal IOL.

It istoused
• It is •used to promote
promote spontaneous
spontaneous labour
labour and and reduce
reduce the need
the need
Indication
Indication It istoused
• It is •used to promote
promote spontaneous
spontaneous labour
labour and and reduce
reduce the need
the need
Indication for medical
Indication for medical / surgical
/ surgical / mechanical
/ mechanical IOL. IOL.
for medical
for medical / surgical
/ surgical / mechanical
/ mechanical IOL. IOL.

• • Applicable
Applicable for bothfor both unfavourable
unfavourable and favourable
and favourable cervices.
cervices.
• • Applicable
Applicable for bothfor both unfavourable
unfavourable and favourable
and favourable cervices.
cervices.
• • toOffer
Offer to low
low risk risk women
women especially
especially multiparous
multiparous
• • toOffer
Offer to low
low risk risk women
women especially
especially multiparous
multiparous
BenefitBenefit Postdatism can be significantly reduced if doneifbetween
• Postdatism can be significantly reduced done between
39 39
Benefit Benefit•• • Postdatism
Postdatism can be can be significantly
significantly reducedreduced
if done ifbetween
done between
39 39
and Risk
and Risk and 40 and
weeks40 weeks
and Riskand Risk and 40 and
weeks40 weeks
• • No evidence
No evidence of increase
of increase maternalmaternal and neonatal
and neonatal infections
infections
• • No evidence
No evidence of increase
of increase maternalmaternal and neonatal
and neonatal infections
infections
• • Associated
Associated with discomfort
with discomfort and vaginal
and vaginal bleedingbleeding
• • Associated
Associated with discomfort
with discomfort and vaginal
and vaginal bleedingbleeding

6.2 Mechanical
6.2 Mechanical methodmethod
6.2 Mechanical
6.2 Mechanical methodmethod

Trans-cervical
Trans-cervical catheter
catheter / balloon
/ balloon Foley catheter
Foley catheter / Hygroscopic
/ Hygroscopic Stents Stents
Trans-cervical
Trans-cervical catheter
catheter / balloon
/ balloon Foley catheter
Foley catheter / Hygroscopic
/ Hygroscopic Stents Stents

• • Mechanical
Mechanical methodmethod is an alternative
is an alternative option
option for IOL for IOL
• • Mechanical
Mechanical methodmethod is an alternative
is an alternative option
option for IOL for IOL
• • Causes
Causes cervicalcervical dilatation
dilatation with release
with release of prostaglandin
of prostaglandin secretion.secretion.
• • Causes
Causes cervicalcervical dilatation
dilatation with release
with release of prostaglandin
of prostaglandin secretion.secretion.
• • Evidence suggests that double balloon is not
Evidence suggests that double balloon is not superior as compared superior as compared
to to
• • Evidence
Evidence suggestssuggests that double
that double balloonballoon is not superior
is not superior as comparedas compared
to to
single balloon
single balloon and theand the likelihood
likelihood of favourable
of favourable cervix following
cervix following single single
single balloon
single balloon and theand the likelihood
likelihood of favourable
of favourable cervix following
cervix following single single
balloonballoon Foley catheter
Foley catheter is greater
is greater with filling
with larger larger volume
filling volume
(60 mls(60 mls
balloonballoon Foley catheter
Foley catheter is greater
is greater with filling
with larger larger volume
filling volume
(60 mls(60 mls
versus versus
30 mls).30 mls).
versus versus
30 mls).30 mls).
 In cases In of cases of relatively
relatively high risk high
withrisk with such
PGE2 PGE2assuch as
Indication
Indication  In cases Inof cases of relatively
relatively high high
risk with risk withsuch
PGE2 PGE2 assuch as
Indication previous previous
caesareancaesarean
scar and scar andmultiparae
grand grand multiparae
Indication previous previous
caesarean caesarean
scar and scar andmultiparae
grand grand multiparae
 Women’s  Women’schoice choice
 Women’s  Women’schoice choice
 Ruptured Ruptured
membranesmembranes
 Ruptured Ruptured
membranesmembranes
 Active
Contra-indication
Contra-indication Active herpes
 herpes and GBS and GBS
 Active
Contra-indication
Contra-indication Active herpes
 herpes and GBS and GBS
 Antepartum
 Antepartum haemorrhage
haemorrhage
 Antepartum
 Antepartum haemorrhage
haemorrhage
 PROM/PPROM
 PROM/PPROM and highand high station
station
PROM/PPROM
 PROM/PPROM and high
 and high station
station

g27
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age
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 Risk
Risk and
and
Risk
Benefit
Benefit  No
and Benefit No evidence
evidence
No evidence
of
of increased
increased
of increased
infections
infections
infections
 Low
Lowrisk
risk
Low
of
of uterine
uterine
risk of uterine
hyperstimulation
hyperstimulation
hyperstimulation
 CTG
CTG  pre-insertion
CTG pre-insertion
pre-insertion and
and 11 to
toand
22 hours
1 to 2post
hours hours
post insertion
post insertion
insertion
Monitoring
Monitoring
Monitoring  Monitor
 Monitor
Monitor maternal
maternalmaternal
vital
vital signs
vitaland
signs signs
and uterine
and uterine
uterine contractions
contractions
contractions
 Review
 Review
Review within
within 12
within
12 –– 24
2412hours
– 24or
hours hours
or when
whenorcatheters
when catheters
catheters falls
falls falls
off.
off. off.

6.3
6.3 Surgical
Surgical Method
6.3 Surgical
MethodMethod

Amniotomy.
Amniotomy.
Amniotomy.

Amniotomy
Amniotomy alone
alone should
Amniotomy alone not
should not be
be considered
should considered aa primary
primary
not be considered method
a primary of
of IOL
IOL unless
methodmethod unless
of IOL unless
there
there are
are specific
specific
there clinical
clinical reasons.
are specific reasons.
clinical reasons.

Favourable cervix ––cervix

 Favourable
 Favourable cervix Bishop
Bishop score 77score
– Bishop
score or more
or more
7 or more
Indications
Indications
Indications
In cases
 In cases with
 Inwith
casesrelative
relative contraindication
with relative to PGE2
contraindication
contraindication to PGE2 to PGE2
Abnormal
Abnormal CTG, placenta/vasa
CTG,
Abnormal placenta/vasa praevia,praevia,
praevia,
CTG, placenta/vasa active genital
active genital
active genital
Contraindications
Contraindications
Contraindications
herpes herpes
herpes and intra-uterine
and intra-uterine fetal death.
fetal
and intra-uterine death.
fetal death.
CautionCaution
Caution High station
High station / presenting
presenting
High /station parts parts
/ presenting
parts
Cord prolapse
Cord prolapse // bleeding
bleeding
Cord prolapse // unintended
unintended
/ bleeding trauma trauma
/ unintended
trauma to fetal
to fetal to fetal
Risk
Risk Risk
scalp scalp
scalp
Mayreduce
 May reduce length of
May reduce
length of labour.
length of labour.
labour.
Benefit Benefit
Benefit
Reveal colour and
 Reveal
 Reveal colour and smell
colour
smell ofsmell
andof liquorof liquor
liquor
CTG CTG
 CTG
Monitoring
Monitoring
Monitoring
Maternal vital signs
 Maternal
 Maternal vital signs and
vitaland uterine
signs
uterine contraction
and uterine contraction
contraction
Adverse
Adverse effect effectDiscomfort
Adverse
effect Discomfort and bleeding
bleeding
Discomfort
and and bleeding

Notes Notes
Notes Recommended
Recommended to combine
Recommended
to combine with oxytocin
to combine
with oxytocin infusioninfusion
with oxytocin
infusion

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6.4 Pharmacological
6.4 Pharmacological
methodmethod

6.4.1 6.4.1
VaginalVaginal
prostaglandin
prostaglandin
(PGE2)(PGE2)

Indication
Indication Unfavourable
Unfavourable
cervix cervix
 Known
 Known hypersensitivity
hypersensitivity
 Sign of Sign
fetal of fetal compromise
compromise / maternal
/ maternal risk risk
Contra-indication
Contra-indication  Chorioamnionitis
 Chorioamnionitis
 Vaginal
 Vaginal bleeding bleeding
 toRefer
 Refer list oftocontraindications
list of contraindications
to IOL to IOL
  Multiple
Multiple pregnancy.
pregnancy.
 Highmore
High parity paritythan
more
5. than 5.
  Previous
Previous caesareancaesarean
scar. scar.
  Uncomplicated
Uncomplicated uterine uterine
surgery.surgery.
CautionCaution   Medical
Medical illness namely
illness namely bronchialbronchial
asthma,asthma,
cardiovascular
cardiovascular disease,disease,
epilepsyepilepsy and glaucoma.
and glaucoma.
  If oxytocin
If oxytocin infusioninfusion required,
required, start
start after after 8post-
8 hours hours post-
prostaglandin.
prostaglandin.
  Should
Should not be
not be used used
with with chlorhexidine.
chlorhexidine.
  Failure
Failure to maintain
to maintain coldmay
cold chain chain may reduce
reduce efficacy.efficacy.
  Gastro-intestinal
Gastro-intestinal upset
upset such assuch as nausea
nausea /vomiting
/vomiting
/diarrhoea
/diarrhoea
Risk Risk
  4%
4% risk risk of hyperstimulation
of hyperstimulation and with
and higher higher with oxytocin
oxytocin
used used
Benefit Benefit Ripening
Ripening and softening
and softening of cervixof cervix
Tablet
Tablet or gel (iforavailable)
gel (if available) or controlled
or controlled releaserelease
pessarypessary
(if (if
available)
available)
Suggested**
Suggested** regimenregimen of vaginal
of vaginal PGE23tablet
PGE2 tablet mg: 3 mg:
First
• First•dose 3 dose 3 mg followed
mg followed by second
by second dose 3 dose 3 mg
mg after 6 after 6
Dose Dose hours (ifhours
labour(if is
labour is not established).
not established).
• Maximum
• Maximum 2 doses2(one doses (one cycle).
cycle).
• Decision
• Decision for the
for the third third
dose dose
must bemust
made beafter
made after clinical
clinical
evaluation
evaluation of theby
of the cases cases by specialist
specialist / consultant.
/ consultant.
** Depending
** Depending on obstetricians,
on obstetricians, indications
indications and centers.
and centers.
 Ask patient
Ask patient to the
to empty empty the bladder.
bladder.
Pre-requisite
Pre-requisite
 CTG tracing
CTG tracing
  Remain
Remain recumbent recumbent
at leastat
30least 30 minutes
minutes after insertion
after insertion
 CTG monitoring
CTG monitoring 1 hour
1 hour post post PGE2.
PGE2.
Monitoring
Monitoring
  Maternal
Maternal vitaland
vital signs signs and uterine
uterine contraction
contraction monitoring
monitoring
  Reassess
Reassess Bishop Bishop
score 6score
hours6post
hours post prostaglandin
prostaglandin
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 6.4.2 Intravenous
6.4.2 Intravenous
oxytocinoxytocin
with amniotomy
with amniotomy

• Intravenous
• Intravenous
oxytocin oxytocin
with amniotomy
with amniotomy
should be
should
considered
be considered
a a
primary method
primary of
method
IOL. of IOL.

 Preferred
 Preferred
method ifmethod
Bishopifscore
Bishopmore
score
thanmore
6/13than 6/13
 Women’s
 Women’s
choice choice
IndicationIndication  Use in
 cases
Use inwith
cases
relatively
with relatively
high risk high
with risk
PGE2 with
such
PGE2 such
as previous
as previous
caesarean caesarean
scar, highscar,
station
highandstation and
increasedincreased
liquor volume.
liquor volume.
 Should Should
 not start not start
within within after
8 hours 8 hours after vaginal
vaginal
Caution Caution prostaglandin.
prostaglandin.
 Caution Caution
 in previousin previous
caesarean caesarean
scar scar
 Uterine Uterine hyperstimulation
 hyperstimulation is one of isknown
one ofcomplication
known complication
Risk andRisk and   Shortens
Shortens duration duration
of labour.of labour.
Benefit Benefit   May decrease
May decrease risk of chorioamnionitis
risk of chorioamnionitis and neonatal
and neonatal
infection infection in pre-labour
in pre-labour rupture ofrupture of membranes
membranes cases. cases.
 CTG  CTG
  Maternal
Maternal vital signvital
and sign andcontraction
uterine uterine contraction
Monitoring
Monitoring
 Caution Caution regarding
 regarding fluid as
fluid infusion infusion
it mayas it may
cause cause water
water
intoxication
intoxication
 Initial
Initial dose of dose of oxytocin
oxytocin is 1-2 milliunits/minute
is 1-2 milliunits/minute (refer (refer
appendixappendix
2) 2)
RegimenRegimen   Increase
Increase dose at dose at intervals
intervals of 30 minutes
of 30 minutes until gooduntil good
uterine contractions
uterine contractions
are achieved
are achieved
 Do not  exceed
Do notmaximum
exceed maximum
dose of 32
dose
milliunits/minute
of 32 milliunits/minute
for for
primiparae primiparae and 16 miliunits/minute
and 16 miliunits/minute for multiparae.
for multiparae.

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e |Page
7. CARE IN INDUCTION OF LABOUR

7.1 Setting and Timing

IOL should be carried out preferably in centres with specialists equipped

with 24 hours operation theatre and neonatal intensive care.

It is suggested that IOL of low risk women can be initiated in the antenatal
wards, however high risk cases should be induced in labour room / high
dependency area. Elective IOL should be carried out during daytime,
preferably in the morning, in order to improve maternal satisfaction as well
as for staff convenience.

7.2 Pain relief

The availability of pain relief options should be informed to women and

provided to them adequately and appropriately. Collaboration with pain
relief team lead by the anaesthetic department may be applicable in some
hospitals (please refer to local protocol).

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8. MANAGING COMPLICATIONS OF LABOUR INDUCTION

8.1 Uterine Hyperstimulation

Definition

Occurrence of uterine contractions lasting more than 90 seconds, or

occurrence of more than five contractions within 10 minutes, or greater than
100 mmHg in amplitude, regardless of the state of the fetus.

Prevention

If the pre-induction CTG shows contractions of 2-3 in 10 minutes, avoid

prostaglandins induction.

Management

i) Prompt recognition of uterine hyperstimulation is crucial.

ii) Anticipate fetal distress.

iii) Remove the prostaglandins if still in-situ (+/- flushing vagina with
normal saline) or stop oxytocin infusion immediately.

iv) Consider tocolysis if uterine hyperstimulation persist despite

immediate measures especially in the event of fetal distress. A single
dose of terbutaline 250 micrograms (0.25 mg) may be given
intravenously or subcutaneously.

v) The O&G specialist/consultant should be informed immediately.

vi) Adequate hydration.

vii) Adequate and appropriate pain relief.

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8.2 Failed Induction

Definition

Inability to achieve active phase of labour despite IOL.

Management

i) Specialist should discuss with the woman and provide support.

ii) The woman’s condition and the pregnancy in general should be

carefully reassessed by senior doctors/specialist, and fetal wellbeing
should be reassessed using electronic fetal monitoring.

iii) Decisions on further management should be made in accordance with

the woman’s wishes, and should take into account the clinical
circumstances.

iv) Subsequent management options include:

a) further attempt at IOL (the timing should depend on the clinical

situation and the woman’s wishes)

b) caesarean section

8.3 Cord Prolapse

Definition

Presence of the cord in the vagina when membrane is already ruptured.

Prevention

i) Amniotomy should be avoided if fetal head is high.

ii) In women with polyhydramnios, stabilising artificial rupture of

membranes (ARM) is advocated.

33 I Page
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 iii) The following precautions should be taken during amniotomy:

a) Before induction, engagement of the presenting part should be

assessed.

b) Exclude umbilical cord presentation during the preliminary

vaginal examination.

Management

In the event of cord prolapse, the managing team should manage as

emergency obstetrics event following local protocol.

8.4 Fetal Distress

Definition

Fetal distress in women undergoing IOL is diagnosed based on abnormal

fetal heart pattern or colour of liquor.

Management

Expedite delivery according to local protocol.

8.5 Uterine Rupture

Definition

Uterine rupture or scar dehiscence is a known complication of IOL. The

incidence increases in women with previous uterine scar and
grandmultiparae.

Management

i) Importance of early recognition of uterine rupture/scar dehiscence.

ii) In the event of suspected uterine rupture, expedite delivery after

maternal condition is stabilised.
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 8.6 Placental Abruption

Definition

Premature separation of the normally situated placenta

Anticipate placenta abruption in polyhydramnios and in patients with uterine

hyperstimulation.

Management

Management of abruption as per local protocol.

9. CONCLUSION

IOL is a fairly common procedure that is known to carry inherent maternal and
fetal benefits and risks. Thus, systematic and comprehensive planning followed
by adequate, appropriate and timely implementation of IOL are keys to quality
improvement in clinical management and safe practice.

35 I Page
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 APPENDIX 1
APPENDIX
APPENDIX
APPENDIX 1 1 1
THE MODIFIED BISHOP SCORE (JULY 2008)

THETHE
THE MODIFIED
MODIFIED
MODIFIED BISHOP
BISHOP
BISHOP SCORE
SCORE
SCORE (JULY
(JULY (JULY
2008)2008)
2008)
CERVICAL Modified Bishop Score

FEATURE
CERVICAL Modified
ModifiedBishop
Modified
BishopScore
Bishop
ScoreScore
CERVICAL
CERVICAL 0 1 2 3
FEATURE
FEATURE
FEATURE
0
0 0 11 1 2 2 2 3 3 3
DILATATION
<1 1-2 2-4 >4
(CM)
DILATATION
DILATATION
DILATATION <1 1-2 2-4 >4
(CM) <1 <1 1-2 1-2 2-4 2-4 >4 >4
(CM) (CM)

LENGTH OF
>4 2-4 1-2 <1
LENGTH OF
CERVIX (CM)
LENGTH
LENGTH
OF OF >4 2-4 1-2 <1
CERVIX (CM) >4 >4 2-4 2-4 1-2 1-2 <1 <1
CERVIX
CERVIX
(CM) (CM)
STATION
STATION
(RELATIVE TO -3 -2 -1 / 0 +1/+2
STATION
STATION
(RELATIVE TO -3 -2 -1 / 0 +1/+2
ISCHIAL SPINE)
(RELATIVE
(RELATIVE
ISCHIAL TO TO
SPINE) -3 -3 -2 -2 -1 / 0 -1 / 0 + 1 / ++21 / + 2
ISCHIAL
ISCHIAL
SPINE)
SPINE)
CONSISTENCY FIRM AVERAGE SOFT -
CONSISTENCY FIRM AVERAGE SOFT -

CONSISTENCY
CONSISTENCY FIRM FIRM AVERAGE
AVERAGE SOFTSOFT - -

POSITION POSTERIOR MID / - -

POSITION POSTERIOR MID / - -
ANTERIOR
ANTERIOR
POSITION
POSITION POSTERIOR MID / MID /
POSTERIOR - - - -
ANTERIOR
ANTERIOR

A FAVOURABLE
A FAVOURABLECERVIX
CERVIXISISDEFINED
DEFINEDASAS ONE
ONE WITH
WITH A MODIFIED
A MODIFIED BISHOP
BISHOP SCORE
SCORE OF >7
OF >7

A FAVOURABLE
A FAVOURABLE
CERVIX
CERVIX
IS DEFINED
IS DEFINED
AS ONE
ASWITH
ONE AWITH
MODIFIED
A MODIFIED
BISHOPBISHOP
SCORESCORE
OF >7 OF >7

42 | P42a |g Pe a g e

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 APPENDIX 2

Oxytocin : Dose Regime

30 unit oxytocin in 500ml sodium chloride 0.9% should be used. Thus, if infusion
rate is 1 ml/hour, the rate of oxytocin infusion dose is 1 mu/minute.

Dilution may be tailored to local practice such as 6 unit in 100ml or 3 unit in 50ml
(via syringe pump).

Commence infusion at 2ml/hour (=2 mu/min).

Increase infusion every 30 mins by 4 ml/hour.

Time after starting Oxytocin Dose Volume infused

(mins) (mU/min) (mls/hour)

0 2 2

30 4 4

60 8 8

90 12 12

120 16 16

150 20 20

180 24 24

210 28 28

240 32 32

Maximum dose of oxytocin

Multiparae - 16 ml/hour (16 mU/min)

Nulliparae - 32 ml/hour (32 mU/min)

If there is a need to increase oxytocin infusion higher than the above regimen, a
consultant must be informed.

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 APPENDIX
APPENDIX3 3

LEVELS
LEVELSOF
OFEVIDENCE
EVIDENCE

IaIa Evidence
Evidenceobtained
obtainedfrom
frommeta-analysis
meta-analysisofofrandomised
randomisedcontrolled
controlledtrials.
trials.

IbIb Evidence
Evidenceobtained
obtainedfrom
fromatatleast
leastone
onerandomised
randomisedcontrolled
controlledtrial.
trial.

Evidenceobtained
Evidence obtainedfrom
fromatatleast
leastone
onewell-designed
well-designedcontrolled
controlledstudy
study
IIaIIa
withoutrandomization.
without randomization.

Evidenceobtained
Evidence obtainedfrom
fromatatleast
leastone
oneother
othertype
typeofofwell-designed
well-designedquasi-
quasi-
IIbIIb
experimentalstudy.
experimental study.

Evidenceobtained
Evidence obtainedfrom
fromwell-designed
well-designednon-experimental
non-experimentaldescriptive
descriptive
IIIIII studies,
studies,such
suchasascomparative
comparativestudies,
studies,correlation
correlationstudies
studiesand
andcase
case
studies.
studies.

Evidenceobtained
Evidence obtainedfrom
fromexpert
expertcommittee
committeereports
reportsororopinions
opinionsand/or
and/or
IVIV
clinicalexperiences
clinical experiencesofofrespected
respectedauthorities.
authorities.

GRADEOF
GRADE OFRECOMMENDATION
RECOMMENDATION

Requiresatatleast
Requires leastone
onerandomized
randomizedcontrolled
controlledtrial
trialasaspart
partofof
AA Ia,Ia,IbIb the
the body
body ofof literature
literature ofof overall
overall good
good quality
quality and and
consistency
consistencyaddressing
addressingthethespecific
specificrecommendation.
recommendation.

Requiresavailability
Requires availabilityofofwellwellconducted
conductedclinical
clinicalstudies
studiesbut
but
BB IIa,IIb,
IIa, IIb,IIIIII
nonorandomised
randomisedtrials
trialsononthe
thetopic
topicofofrecommendation.
recommendation.

Requiresevidence
Requires evidenceobtained
obtainedfrom
fromexpert
expertcommittee
committeereports
reports
oror opinions
opinions and/or
and/or clinical
clinical experiences
experiences ofof respected
respected
CC IVIV
authorities.Indicates
authorities. Indicatesabsence
absenceofofdirectly
directlyapplicable
applicableclinical
clinical
studiesofofgood
studies goodquality.
quality.

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| P| aP ga eg e
 TECHNICAL COMMITTEE ON GUIDELINES ON INDUCTION OF LABOUR

CHAIRPERSON
1. Dr. Ravichandran Jeganathan
Senior O&G Consultant (Maternal Fetal Medicine)
Department of Obstetrics and Gynaecology
Hospital Sultanah Aminah, Johor Bahru

TECHNICAL DRAFTING COMMITTEE

2. Dr. Mohd. Zulkifli bin Mohd Kasim

Senior O&G Consultant
Department of Obstetrics and Gynaecology
Hospital Sultanah Nur Zahirah, Kuala Terengganu

3. Dr. Ravinderjit Kaur

Senior O&G Consultant (Maternal Fetal Medicine)
Department of Obstetrics and Gynaecology
Hospital Pulau Pinang

4. Dr. Wan Zahanim binti Wan Yusoff

Senior O&G Consultant
Department of Obstetrics and Gynaecology
Hospital Raja Perempuan Zainab II, Kota Bharu

5. Dr. Charnjeet Kaur

Senior O&G Consultant (Maternal Fetal Medicine)
Department of Obstetrics and Gynaecology
Hospital Selayang

6. Dr. Mohd Azam bin Mohd Yusof

Senior O&G Consultant
Department of Obstetrics and Gynaecology
Hospital Pekan

7. Dr. Muniswaran Ganesham

Senior O&G Consultant
Department of Obstetrics and Gynaecology
Hospital Tunku Azizah, Kuala Lumpur

8. Dr. Noor Aziah binti Zainal Abidin

Senior Principal Assistant Director
O&G and Paediatrics Services Unit
Medical Services Development Section
Medical Development Division
Ministry Of Health Malaysia

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 9. Dr. Arpah binti Ali
Senior Principal Assistant Director
O&G and Paediatrics Services Unit
Medical Services Development Section
Medical Development Division
Ministry Of Health Malaysia

10. Dr. Muhamad Aadiyat bin Abdul Hamid

Principal Assistant Director
O&G and Paediatrics Services Unit
Medical Services Development Section
Medical Development Division
Ministry Of Health Malaysia

11. Pn. Siti Rahmah binti Abdul Rashid

Registered Head Nurse
O&G and Paediatrics Services Unit
Medical Services Development Section
Medical Development Division
Ministry Of Health Malaysia

REVIEWERS:

1. Profesor Dr. Zaleha Abdullah Mahdy

Senior O&G Consultant
Department of Obstetrics and Gynaecology
Hospital Canselor Tuanku Muhriz UKM

2. Profesor Madya Dato’ Dr. Hamizah binti Ismail

Senior O&G Consultant
Department of Obstetrics and Gynaecology
Sultan Ahmad Shah Medical Centre (SASMEC@IIUM)
Universiti Islam Antarabangsa Malaysia, Kuantan, Pahang

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 ACKNOWLEDGEMENT

The Technical Committee On Guidelines On Induction Of Labour would like to

express their gratitude and appreciation to Medical Development Division,
Ministry of Health and all those who provided valuable input and support in the
development of this guideline.

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 MINISTRY OF HEALTH OF MALAYSIA

MEDICAL DEVELOPMENT DIVISION

Block E1, Parcel E, Federal Government Administrative Centre,
62590 Putrajaya, Malaysia.

Tel : 603-8883 1047 Fax : 603-8883 1427

http://www.moh.gov.my

ISBN 978-967-25780-0-0

9 7 8 9 6 7 2 5 7 8 0 0 0