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Guideline Summary
Guideline Title
Induction of labor.
Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Induction of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Aug. 12 p. (ACOG practice bulletin; no. 107). [90 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Induction of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 Nov. 10 p. (ACOG practice bulletin; no. 10). [70 references]

Scope

Disease/Condition(s)

Maternal and Fetal Conditions

  • Abruptio placentae
  • Chorioamnionitis
  • Fetal demise
  • Gestational hypertension
  • Preeclampsia, eclampsia
  • Premature rupture of membranes
  • Postterm pregnancy
  • Maternal medical conditions (e.g., diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
  • Fetal compromise (e.g., severe fetal growth restriction, isoimmunization, oligohydramnios)

Other Conditions

  • Risk of rapid labor
  • Distance from hospital
  • Psychosocial indications
Guideline Category
Assessment of Therapeutic Effectiveness
Counseling
Evaluation
Management
Risk Assessment
Clinical Specialty
Obstetrics and Gynecology
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Guideline Objective(s)

  • To aid practitioners in making decisions about appropriate obstetric and gynecologic care
  • To review current methods for cervical ripening and induction of labor and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research
  • To classify the indications for and contraindications to induction of labor, describe the various agents used for cervical ripening, cite methods used to induce labor, and outline the requirements for the safe clinical use of the various methods of inducing labor

Target Population

Pregnant women requiring induction of labor

Interventions and Practices Considered

Assessments

  1. Assessment of gestational age and consideration of potential risks to the mother or fetus
  2. Patient counseling regarding the indications for induction, the agents and methods of labor stimulation, and the possible need for repeat induction or cesarean delivery
  3. Cervical and pelvic assessment and assessment of fetal size and presentation

Interventions

  1. Cervical ripening
    • Mechanical dilation methods including hygroscopic dilators, osmotic dilators (Laminaria japonicum), Foley catheters, double balloon devices 
    • Administration of synthetic prostaglandin E1 (PGE1, misoprostol) or prostaglandin E2 (PGE2, dinoprostone)
  2. Labor induction
    • Oxytocin, low or high dose regimens
    • Nonpharmacologic methods including stripping the amniotic membranes, amniotomy, and nipple stimulation
  3. Continuous monitoring of uterine activity and fetal heart rate
Major Outcomes Considered

  • Time to cervical ripening and labor induction
  • Time to delivery
  • Rate of uterine contraction after cervical ripening and labor induction
  • Rate of maternal complications from various methods of cervical ripening and labor induction (e.g., tachysystole, membrane rupture, gastrointestinal side effects of drugs)
  • Changes in fetal heart rate
  • Degree of labor-associated pain
  • Rates of vaginal delivery after labor induction

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and January 2009. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force.

I: Evidence obtained from at least one properly designed randomized controlled trial

II-1: Evidence obtained from well-designed controlled trials without randomization

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician-gynecologists were used.

Rating Scheme for the Strength of the Recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Recommendations

Major Recommendations

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

  • Prostaglandin E analogues are effective for cervical ripening and inducing labor.
  • Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor is indicated (see Table 2 in the original guideline document).
  • Before 28 weeks of gestation, vaginal misoprostol appears to be the most efficient method of labor induction regardless of Bishop score, although high-dose oxytocin infusion also is an acceptable choice.
  • Approximately 25 micrograms of misoprostol should be considered as the initial dose for cervical ripening and labor induction. The frequency of administration should not be more than every 3–6 hours.
  • Intravaginal prostaglandin E2 (PGE2) for induction of labor in women with premature rupture of membranes appears to be safe and effective.
  • The use of misoprostol in women with prior cesarean delivery or major uterine surgery has been associated with an increase in uterine rupture and, therefore, should be avoided in the third trimester.
  • The Foley catheter is a reasonable and effective alternative for cervical ripening and inducing labor.

The following recommendation is based on evidence that may be limited or inconsistent (Level B):

  • Misoprostol (50 micrograms every 6 hours) to induce labor may be appropriate in some situations, although higher doses are associated with an increased risk of complications, including uterine tachysystole with fetal heart rate (FHR) decelerations. 

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial

II-1: Evidence obtained from well-designed controlled trials without randomization

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Safe clinical use of various methods of inducing labor

Potential Harms

  • The use of prostaglandins, oxytocin, and misoprostol is associated with an increased risk of tachysystole with or without fetal heart rate (FHR) changes. See the original guideline document for details of incidence.
  • The use of misoprostol in women with prior cesarean delivery or major uterine surgery has been associated with an increase in uterine rupture and, therefore, should be avoided in the third trimester.
  • Maternal side effects from the use of low-dose prostaglandin E2 (PGE2) (fever, vomiting, and diarrhea) are quite uncommon.
  • An increase in meconium-stained amniotic fluid has been reported with misoprostol use.
  • The manufacturers recommend that caution be exercised when using PGE2 in patients with glaucoma, severe hepatic or renal dysfunction, or asthma.
  • Increased maternal and neonatal infections have been reported in connection with the use of Laminaria japonicum and hygroscopic dilators when compared with the PGE2 analogues.
  • The Foley catheter can cause significant vaginal bleeding in women with a low-lying placenta; as well as other reported complications such as rupture of membranes, febrile morbidity, and displacement of the presenting part.
  • Uterine rupture secondary to oxytocin use is rare even in parous women.
  • In patients after 28 weeks of gestation, cervical ripening with a transcervical Foley catheter has been associated with uterine rupture rates comparable to spontaneous labor.

Contraindications

Contraindications

The individual patient and clinical situation should be considered in determining when induction of labor is contraindicated. Generally, the contraindications to labor induction are the same as those for spontaneous labor and vaginal delivery. Contraindications to labor induction include, but are not limited to, the following situations:

  • Vasa previa or complete placenta previa
  • Transverse fetal lie
  • Umbilical cord prolapse
  • Previous classical cesarean delivery
  • Active genital herpes infection
  • Previous myomectomy entering the endometrial cavity

Qualifying Statements

Qualifying Statements

  • These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
  • The majority of literature cited in this Practice Bulletin was published prior to the 2008 National Institute of Child Health and Human Development (NICHD) definitions and interpretations of fetal heart rate tracings (FHR). Consequently, it is difficult to generalize the results of the cited literature, which used nonstandardized and ambiguous definitions for FHR patterns.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Foreign Language Translations
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Induction of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Aug. 12 p. (ACOG practice bulletin; no. 107). [90 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1999 Nov (revised 2009 Aug)
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics

Composition of Group That Authored the Guideline

American College of Obstetricians and Gynecologists (ACOG) committees are created or abolished and their overall function defined by the Executive Board. Appointments are made for one year, with the understanding that such appointment may be continued for a total of three years. The majority of committee members are Fellows, but Junior Fellows also are eligible for appointment. Some committees may have representatives from other organizations when this is particularly appropriate to committee activities. The president elect appoints committee members annually.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Induction of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 Nov. 10 p. (ACOG practice bulletin; no. 10). [70 references]

Guideline Availability

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Availability of Companion Documents

Proposed performance measures are included in the original guideline document.

Patient Resources

The following is available:

  • Labor induction. American College of Obstetricians and Gynecologists (ACOG); 2009.

Available from the American College of Obstetricians and Gynecologists (ACOG) Web site External Web Site Policy. Copies are also available in Spanish External Web Site Policy.

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on January 14, 2005. This NGC summary was updated by ECRI Institute on November 16, 2009.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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