SOGC Clinical Practice Guideline| Volume 45, ISSUE 1, P70-77.e3, January 2023

Guideline No. 432c: Induction of Labour



      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.


      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 Grey (unpublished) literature was identified by searching the websites of health technology assessment and health technology related agencies, clinical practice guideline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.


      • 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).


      • 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).


      • 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


      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

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kerr R.S.
        • Kumar N.
        • Williams M.J.
        • et al.
        Low-dose oral misoprostol for induction of labour.
        Cochrane Database Syst Rev. 2021; 6: CD014484
        • Alfirevic Z.
        • Keeney E.
        • Dowswell T.
        • et al.
        Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis.
        Health Technol Assess. 2016; 20: 1-584
        • Chatsis V.
        • Frey N.
        CADTH rapid response reports. Misoprostol for cervical ripening and induction of labour: a review of clinical effectiveness, cost-effectiveness and guidelines.
        Canadian Agency for Drugs and Technologies in Health, Ottawa (ON)2018
        • Dy J.
        • DeMeester S.
        • Lipworth H.
        • et al.
        No. 382-trial of labour after caesarean.
        J Obstet Gynaecol Can. 2019; 41: 992-1011
        • Alfirevic Z.
        • Aflaifel N.
        • Weeks A.
        Oral misoprostol for induction of labour.
        Cochrane Database Syst Rev. 2014; 2014: CD001338
        • Wang X.
        • Yang A.
        • Ma Q.
        • et al.
        Comparative study of titrated oral misoprostol solution and vaginal dinoprostone for labor induction at term pregnancy.
        Arch Gynecol Obstet. 2016; 294: 495-503
        • Alfirevic Z.
        • Keeney E.
        • Dowswell T.
        • et al.
        Labour induction with prostaglandins: a systematic review and network meta-analysis.
        BMJ. 2015; 350: h217
        • Wallstrom T.
        • Jarnbert-Pettersson H.
        • Stenson D.
        • et al.
        Labor induction with orally administrated misoprostol: a retrospective cohort study.
        Biomed Res Int. 2017; 20176840592
        • Kashanian M.
        • Eshraghi N.
        • Rahimi M.
        • et al.
        Efficacy comparison of titrated oral solution of misoprostol and intravenous oxytocin on labour induction in women with full-term pregnancy.
        J Obstet Gynaecol. 2020; 40: 20-24
        • Yehia A.H.
        • Abd El Fattah I.
        • Bayoumy K.M.
        • et al.
        Titrated misoprostol versus dinoprostone for labor induction.
        J Basic Clin Reprod Sci. 2016; 5: 75-81
        • Souza A.S.
        • Amorim M.M.
        • Feitosa F.E.
        Comparison of sublingual versus vaginal misoprostol for the induction of labour: a systematic review.
        BJOG. 2008; 115: 1340-1349
        • Nassar A.H.
        • Awwad J.
        • Khalil A.M.
        • et al.
        A randomised comparison of patient satisfaction with vaginal and sublingual misoprostol for induction of labour at term.
        BJOG. 2007; 114: 1215-1221
        • Zahran K.M.
        • Shahin A.Y.
        • Abdellah M.S.
        • et al.
        Sublingual versus vaginal misoprostol for induction of labor at term: a randomized prospective placebo-controlled study.
        J Obstet Gynaecol Res. 2009; 35: 1054-1060
        • Alfirevic Z.
        • Kelly A.J.
        • Dowswell T.
        Intravenous oxytocin alone for cervical ripening and induction of labour.
        Cochrane Database Syst Rev. 2009; 2009: CD003246
        • Battarbee A.N.
        • Sandoval G.
        • Grobman W.A.
        • et al.
        Maternal and neonatal outcomes associated with amniotomy among nulliparous women undergoing labor induction at term.
        Am J Perinatol. 2021; 38: e239-e248
        • Battarbee A.N.
        • Palatnik A.
        • Peress D.A.
        • et al.
        Association of early amniotomy after foley balloon catheter ripening and duration of nulliparous labor induction.
        Obstet Gynecol. 2016; 128: 592-597
        • Battarbee A.N.
        • Glover A.V.
        • Stamilio D.M.
        Association between early amniotomy in labour induction and severe maternal and neonatal morbidity.
        Aust N Z J Obstet Gynaecol. 2020; 60: 108-114
        • Varvoutis M.S.
        • Sayres L.C.
        • Dotters-Katz S.K.
        Is early amniotomy associated with higher likelihood of vaginal birth after cesarean?.
        AJP Rep. 2020; 10: e37-e41
        • Drugbank online
        (Available at:) (Accessed on September 16, 2022)
        • Bell A.F.
        • Erickson E.N.
        • Carter C.S.
        Beyond labor: the role of natural and synthetic oxytocin in the transition to motherhood.
        J Midwifery Womens Health. 2014; 59 (: quiz 108): 35-42
        • Dore S.
        • Ehman W.
        No. 396-fetal health surveillance: intrapartum consensus guideline.
        J Obstet Gynaecol Can. 2020; 42: 316-348.e9
        • Selo-Ojeme D.O.
        • Pisal P.
        • Lawal O.
        • et al.
        A randomised controlled trial of amniotomy and immediate oxytocin infusion versus amniotomy and delayed oxytocin infusion for induction of labour at term.
        Arch Gynecol Obstet. 2009; 279: 813-820
        • Pettker C.M.
        • Pocock S.B.
        • Smok D.P.
        • et al.
        Transcervical foley catheter with and without oxytocin for cervical ripening: a randomized controlled trial.
        Obstet Gynecol. 2008; 111: 1320-1326
        • Schoen C.N.
        • Grant G.
        • Berghella V.
        • et al.
        Intracervical foley catheter with and without oxytocin for labor induction: a randomized controlled trial.
        Obstet Gynecol. 2017; 129: 1046-1053
        • Boie S.
        • Glavind J.
        • Velu A.V.
        • et al.
        Discontinuation of intravenous oxytocin in the active phase of induced labour.
        Cochrane Database Syst Rev. 2018; 8: CD012274
        • Vernekar M.
        • Rajib R.
        Unscarred uterine rupture: a retrospective analysis.
        J Obstet Gynaecol India. 2016; 66: 51-54
        • Zhang H.
        • Liu H.
        • Luo S.
        • et al.
        Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies.
        BMC Pregnancy Childbirth. 2021; 21: 11