Induction of Labour (IOL)
Clinical detail
Additional detail checked 2026-10-17 against the linked sources. This check covers the section below; the rest of the module retains its displayed verification status.
Induction is a planned process with a clinical indication, a cervical assessment, fetal assessment and a response plan—not just a choice of ripening medicine.
Assessment & interpretation
- Confirm gestation, presentation, the indication and the Bishop score. Discuss expected duration, alternatives and the patient’s preferences.
Decisions that change management
- Choose a method using cervical readiness and clinical risks. Prostaglandins can cause hyperstimulation; mechanical methods may be preferable when that risk or a uterine scar matters.
- If hyperstimulation develops, stop further induction treatment, remove a removable preparation when possible, assess the fetus and obtain obstetric review.
Follow-up & safety-netting
- Document response, fetal surveillance and what unsuccessful induction will mean for the next decision.
Admission & discharge
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Maternal/fetal risk, abnormal assessment, labour, membrane rupture, bleeding, a concerning response to ripening or inability to return promptly requires inpatient care. Oxytocin infusion requires a monitored maternity setting.
When clinic, day care or home care may be suitable
- NICE permits selected outpatient induction with vaginal dinoprostone or a mechanical method after full assessment, discussion and safety planning; this is not automatic permission for every drug or high-risk pregnancy.
Before going home
- For outpatient ripening, maternal/fetal assessment is reassuring, the exact method and reassessment time are recorded, and contact/transport support is reliable.
- After birth use the appropriate vaginal/caesarean and complication-specific criteria; completing cervical ripening is not the same as completing maternity care.
Discharge medicines and treatment changes
- Document which induction agent/device was used and when; the patient must not independently repeat a dose at home.
- Reconcile regular medicines and the planned next induction step.
Tests, pending results and their reviewer
- Record pre-induction fetal assessment and the scheduled repeat/return assessment.
Home care and counselling
- Give the planned return time and instructions for pain/contractions, bleeding, membrane rupture, side effects and reduced movements.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
At the exact agreed induction reassessment time | Review cervix, maternal/fetal wellbeing and the next step; do not leave an open-ended return plan. |
After birth | Follow the relevant postnatal schedule and any additional maternal/newborn review. |
Return urgently
- Return with contractions, rupture of membranes, bleeding, reduced movements, severe pain or other concerning symptoms rather than waiting for the booked time.
Open the complete discharge checklist →
Treatment
① Immediate stabilization — first minutes
Not applicable - structured pathway.
③ First-line treatment & drug regimens
| Situation | Method |
|---|---|
Term, any | MEMBRANE SWEEP offered (reduces formal IOL need) |
Unfavourable cervix (<7) | Choose ONE ripening regimen: the specific 3 mg dinoprostone VAGINAL TABLET card or the separate oral misoprostol card. Gel and controlled-release inserts have different schedules. |
Unfavourable cervix | OR transcervical Foley/balloon 30-80 mL inflated with gentle traction - lower hyperstimulation; preferred with prior caesarean/high parity |
Favourable >=7 or ripened | Amniotomy -> oxytocin titration |
Prior caesarean | Balloon preferred; prostaglandins avoided (rupture risk) |
- Unscarred uterus, live fetus and an approved hospital induction indication; cited 25-microgram product is for ≥37 weeks
- Vaginal and sublingual regimens have different intervals; do not copy this two-hour oral schedule to another route.
- Fetal heart rate and uterine contractions; hospital staff and emergency birth facilities available
④ Drug treatment detail (2 agents)
- Indication: Hospital induction in an eligible unscarred uterus after cervical/fetal assessment; alternative to other ripening medicines
- Do not give together with misoprostol or oxytocin as a stacked ripening regimen; asthma and major cardiac/renal/hepatic disease require assessment.
- Uterine activity and fetal heart rate, maternal observations, hypertonus/tachysystole and signs of rupture; emergency obstetric cover
- Indication: Inadequate contractions after obstetric assessment; exclude obstruction and contraindications to vaginal birth
- Continuous fetal monitoring and contraction frequency; target 3–4 contractions/10 min
- Stop/reduce for excessive contractions or abnormal fetal heart rate; evaluate immediately
Definitive treatment
- Labour onset -> labour-care pathway
- FAILED INDUCTION: no regular contractions/progressive change after full protocol cycles -> options: repeat selected courses, rest-and-rescan, or caesarean by shared informed decision
Monitoring
| Phase | Monitoring |
|---|---|
Post-prostaglandin | CTG 30-60 min; no repeat dosing during regular contractions |
Oxytocin | Continuous CTG; stop for tachysystole; fluid balance |
Balloon | Falls out at dilation; dislodgement checks |
Treatment failure
- Hyperstimulation + abnormal CTG: STOP agent, left-lateral, IV bolus, terbutaline 250 mcg SC slow if persists, reassess for emergency caesarean
Escalation
- Scarred-uterus inductions: consultant supervision documented
- Failed-induction counselling documented jointly
⑮ Complications & their management
Uterine hyperstimulation
Intrauterine resuscitation sequence above
Uterine rupture (scarred)
Emergency laparotomy; MTP standby
Water intoxication (prolonged oxytocin)
Restrict maintenance fluids; check Na+ if confusion/seizure
Post-treatment care
- Standard third/fourth-stage care
- Document total oxytocin dose + outcome for audit
Diagnosis & assessment
- Hyperstimulation with abnormal CTG -> stop agent + intrauterine resuscitation + tocolysis if needed
- Rupture signs in prior-scar inductions
- Cord prolapse after amniotomy
Definition: Artificial initiation of labour before spontaneous onset for maternal/fetal benefit after weighing continuation risks.
Initial assessment
- Confirm indication + gestation; document consent incl. failure/caesarean rates
- Contraindications: malpresentation, praevia/vasa previa, prior classical scar, fetal compromise where birth not beneficial
- Bishop score (dilation/effacement/station/consistency/position)
- CTG baseline normal before prostaglandins
Investigations
| Test | Looking for |
|---|---|
CTG pre-induction | Reassurance before agents |
Presentation US if uncertain | Exclude malpresentation |
Algorithm
Principles & follow-up
Management principles
Sources (11)
2023-09-29 · updated 2026-06-09 · checked 2026-08-23 · verified-live
Open source ↗
NICE overview + Update information page (dates above confirmed)
04 November 2021 · checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for iol, prom-term. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admission/discharge c…
· checked 2026-10-17 · verified-live
Open source ↗
25 micrograms orally every 2 hours or 50 every 4 hours, 200 micrograms/24-hour ceiling, hospital monitoring, ≥4-hour separation from oxytocin, and no casual tablet splitting.
· checked 2026-10-17 · verified-live
Open source ↗
One 3 mg vaginal tablet, possible single repeat after six/eight hours, total maximum 6 mg; ≥6-hour oxytocin separation, formulation/route identity, uterine scar/fetal/obstetric contraindications and continuous clinical/fetal assessment.
· checked 2026-10-17 · verified-live
Open source ↗
Term-labour induction/augmentation dose increments, pump-compatible dilution, 20 milliunits/minute regimen ceiling, contraction/fetal monitoring and rapid-bolus risk.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary PDF downloaded; term prelabour rupture, selected expectant care and induction around 24 hours, temperature/return precautions, maternal post-birth assessment and newborn observation after prolonged membrane rupture checked. This is scoped to the implemented admission/transfer recommenda…
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.