OB Guideline 16: Induction of Labor

Indications for the induction of labor^1,2 should take into account birthing person and fetal conditions, gestational age, cervical status, and other factors. Criteria for confirmation of fetal lung maturity should be met in these circumstances (see Guideline 14). Labor may be induced for non-medical reasons after 39 weeks gestation.

The risks and benefits of induction should be discussed and documented in the patient’s medical record. In general, the contraindications to induction are the same as those for spontaneous labor and vaginal delivery. For patients with a previous cesarean birth, see Guideline 25.

Prior to the Induction of Labor

1. Assess the pelvis; and fetal size, position, and presentation. The clinical rationale for the induction should always be documented in the patient’s medical record.^3,4
2. Confirm gestational age. (See Guideline 7.)
3. Counsel the patient regarding potential risks to them or the fetus, agents and methods of cervical ripening, and labor stimulation.
4. Evaluate fetal status with a non-stress test.
5. Select the method of induction based on the indications and assessment.
6. Documentation in the patient’s medical record should include the following:
   • the risks and benefits of induction, and the risks of continuing the pregnancy without induction, that have been discussed with the patient and the patient’s stated understanding;
   • the reason for indicated or elective induction, and the clinical rational;
   • the patient’s gestational age and fetal status;
   • the method of induction planned; and
   • the method of cervical ripening when the cervix is unfavorable.

Methods of Induction

1. Amniotomy
2. Oxytocin (e.g., Pitocin): Each obstetrical unit shall develop guidelines for the administration of oxytocin which, at a minimum, should include:
   • preparation and administration via a controlled infusion device,
   • monitoring of the birthing person and fetus,
   • management of uterine tachysystole,
   • description of training and competency of personnel administering oxytocin, and
   • readily available physician who has privileges to perform cesarean births.

   Adequate documentation of clinical reasoning is required when oxytocin infusion rates rise above 20 mu/min.

3. Synthetic prostaglandin E1 or E2 (e.g., misoprostol/Cytotec; or dinoprostone/Cervidil, Prepidil or Prostin E2): Each obstetrical unit shall develop guidelines for the administration of prostaglandin, which, at a minimum, should include:
   • indications and contraindications;
   • procedure, including dosage, frequency of administration, maximum number of doses, and the duration of fetal monitoring; and
   • options for treatment of uterine tachysystole.
4. Mechanical methods of cervical ripening: if the status of the cervix is unfavorable, mechanical cervical dilators may be used. Each obstetrical unit shall develop guidelines for the use of mechanical or osmotic dilators, such as: hygroscopic dilators, osmotic dilators (e.g., laminaria), and Foley catheter bulb.

Institutional Responsibility

Each obstetrical institution is responsible for establishing standard policies and procedures for scheduling induction of labor, gestational age, and the indication and method for induction of labor, including the preparation and use of oxytocin and use of cervical ripening agents.

1. Induction of labor. ACOG Practice Bulletin No. 107. August 2009, Reaffirmed 2020. American College of Obstetricians and Gynecologists.
2. ACOG/ACP Guidelines for Perinatal Care, Seventh Edition. Washington DC, October 2012.