Abstract
Objectives
This guideline presents evidence and recommendations for cervical ripening and induction
of labour. It aims to provide information to birth attendants and pregnant individuals
on optimal perinatal care while avoiding unnecessary obstetrical intervention.
Target Population
All pregnant patients.
Benefits, Risks, and Costs
Consistent interprofessional use of the guideline, appropriate equipment, and trained
professional staff enhance safe intrapartum care. Pregnant individuals and their support
person(s) should be informed of the benefits and risks of induction of labour.
Evidence
Literature published to March 2022 was reviewed. PubMed, CINAHL, and the Cochrane
Library were used to search for systematic reviews, randomized control trials, and
observational studies on cervical ripening and induction labour. Grey (unpublished)
literature was identified by searching the websites of health technology assessment
and health technology related agencies, clinical practice guideline collections, clinical
trial registries, and national and international medical specialty societies.
Validation Methods
The authors rated the quality of evidence and strength of recommendations using the
Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).
Intended Audience
All providers of obstetrical care.
SUMMARY STATEMENTS
Misoprostol
- 1.Oral misoprostol is both as or more effective and safe than other methods of induction of labour. Misoprostol in solution is easy to prepare and administer, has an advantageous 2 hour half-life, and allows for titratable dosing while maintaining a maximum dose in the low dose range (≤ 50 μg) (high).
- 2.Like oxytocin, there is no single best dose of misoprostol. The dose should be started at 20–25 μg and titrated to contractions, allowing each patient to have a customized regimen (moderate).
- 3.Continuous electronic fetal monitoring (EFM) is recommended for at least 20 minutes post administration. If there are no signs of active labour after 30 minutes, encourage patient ambulation until the next dose (moderate).
- 4.When signs of active labour present, establish EFM. Continue ambulation as per fetal health surveillance guidelines (high).
- 5.Consider intravenous (IV) access once the patient is in active labour (moderate).
- 6.Once active labour has commenced and/or once the membranes are ruptured, the clinician is not required to switch from misoprostol to oxytocin, as continuing with misoprostol may be more effective (high).
Oxytocin
- 1.Oxytocin can increase the risk of postpartum hemorrhage, volume overload, and/or hyponatremia with prolonged or high maximal dose use (high).
- 2.There are no data to support maintaining the rate of oxytocin at any particular dose threshold rather than continuing the titration every 30 minutes when contractions are not adequate. Consider an intrauterine pressure catheter if contractions are difficult to monitor. Ongoing diligence by the most responsible physician is required when titrating oxytocin at any rate (moderate).
- 3.Caution is needed when using oxytocin in a patient with previous cesarean delivery or uterine surgery (high).
- 4.Reducing the rate of oxytocin infusion after achieving active labour and cervical dilation of at least 5 cm may be considered (low).
RECOMMENDATIONS
- 1.Oral prostaglandin E1 or intravenous oxytocin with amniotomy is the preferred method of induction of labour when the Bishop score is 7 or greater (strong, high).
- 2.Health care providers can use prostaglandin E1 concurrently with, or sequentially after, insertion of a balloon catheter (strong, moderate).
- 3.Health care providers may use prostaglandin E2 gel or insert to induce labour when the Bishop score is 7 or greater (strong, moderate).
- 4.Health care providers may perform an amniotomy once the modified Bishop score is 7 or greater (strong, high). An amniotomy is most effective when combined with an induction agent (oxytocin or prostaglandin E1) (strong, high).
- 4.Health care providers may perform an amniotomy once the modified Bishop score is 7 or greater (strong, high). An amniotomy is most effective when combined with an induction agent (oxytocin or prostaglandin E1) (strong, high).
- 5.Health care providers should only use oxytocin for induction of labour when the modified Bishop score is 7 or greater, except in the setting of term pre-labour rupture of membranes (strong, moderate). Oxytocin is best combined with amniotomy (strong, high).
- 6.Health care providers should record oxytocin infusion rates in mU/min (strong, moderate).
- 7.A local institutional protocol for oxytocin use with a safety checklist is required, regardless of infusion rate (strong, moderate).
- 8.Health care providers should start oxytocin no earlier than: 30 minutes post prostaglandin E2 vaginal insert removal, 6 hours post prostaglandin E2 vaginal gel insertion, 2 hours post oral prostaglandin E1, and 4 hours post vaginal prostaglandin E1 insertion (strong, high).
- 9.Electronic fetal monitoring is recommended when using oxytocin or repeated doses of prostaglandin E1 for induction of labour (strong, high).
Key Words
Abbreviations:
CD (cesarean delivery), EFM (electronic fetal monitoring), FHR (fetal heart rate), IOL (induction of labour), IV (intravenous), PGE1 (prostaglandin E1), PGE2 (prostaglandin E2), PROM (pre-labour rupture of membranes), TOLAC (trial of labour after cesarean)To read this article in full you will need to make a payment
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Article info
Publication history
No. 432c, January 2023 (Replaces No. 296, September 2013)
Footnotes
This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Patients have the right and responsibility to make informed decisions about their care, in partnership with their health care provider. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and personalized. The values, beliefs, and individual needs of each patient in the context of their personal circumstances should be considered and the final decision about care and treatment options chosen by the patient should be respected.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women’s health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person’s needs.
Identification
Copyright
© 2022 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
