NICE guideline - inducing labour - 2021

Question 1

What is the cumulative proportion of spontaneous labours that start before 37 weeks

Answer 1

7.7%

Question 2

What is the cumulative proportion of spontaneous labours that start before 40 weeks

Answer 2

50.3%

Question 3

What is the cumulative proportion of spontaneous labours that start before 41/40

Answer 3

82.8%

Question 4

What is the cumulative proportion of spontaneous labours that start before 41+6

Answer 4

99%

Question 5

What are the risks associated with a pregnancy continuing beyond 41 weeks

Answer 5

Increased likelihood of:
Caesarean birth
admission to NICU
stillbirth and neonatal death

Question 6

How should women be counselled regarding IOL at 41 weeks

Answer 6

IOL may reduce the risks but that they will also need to consider the impact of the induction on their birth experience.

Question 7

If women continue pregnancy beyond 42 weeks and wish to have monitoring they should be advised:

Answer 7

Monitoring only provides a snapshot and cannot reliably predict changes after monitoring ends
Adverse events inc. stillbirth cannot be predicted reliably or even prevented with monitoring
Monitoring might consist of twice weekly CTG and US estimation of LV

Question 8

In PPROM before 34/40 without additional obstetric indications when should expectant management be offered until

Answer 8

37/40

Question 9

If a woman has PPROM after 34/40 but before 37/40 discuss the options of

Answer 9

Expectant management until 37 weeks or induction of labour.

Question 10

If a woman has PPROM after 34/40 but before 37/40. when discussing options of IOL or expectant management take into consideration the following:

Answer 10

• Risks to the women (sepsis, need for LSCS)
• Risk to the baby (sepsis, prematurity)
• local availability of neonatal intensive care facilities
• the woman’s individual circumstances and preferences

Question 11

If a woman has PPROM after 34 weeks and has positive GBS at any time in their current pregnancy offer

Answer 11

Immediate IOL or caesarean birth

Question 12

Prelabour rupture of membranes at or after 37 weeks. Offer

Answer 12

• expectant management for 24hours, or
• IOL asap

For those who choose expectant management
offer IOL after 24hours if labour not started naturally

Question 13

Discussions re IOL with previous caesarean should cover

Answer 13

Increased risk of emergency CS
Risk of uterine rupture
Suitability of mechanical methods including infection
propess not licensed for IOL in those with uterine scar
Risks and consequences of caesarean birth

Question 14

Should IOL be offered if there is FGR with confirmed fetal compromise?

Answer 14

Caesarean birth should be offered instead

Question 15

what does the evidence show regarding benefits of IOL in women with fetal macrosomia without diabetes

Answer 15

There is uncertainty about the benefits of IOL compared to expectant management, but:
- IOL risk of shoulder dystocia is reduced
- IOL risk of 3rd or 4th degree tears is increased
- no difference in risk of perinatal death, BPI or need for EMCS

Question 16

In the event of IUFD if the woman is well, intact membranes with no evidence of infection or bleeding which management options can be discussed:

Answer 16

Expectant management, IOL or caesarean birth

Question 17

With IUFD and evidence of ruptured membranes, infection or bleeding

Answer 17

Offer immediate induction of labour or caesarean birth.

Question 18

IOL for IUFD with a non scarred uterus. Offer

Answer 18

Oral mifepristone 200mg followed by vaginal dinoprostone or oral or vaginal misoprostol OR
mechanical method of induction

Question 19

IOL for IUFD for women with previous caesarean birth. Discussion should cover

Answer 19

• IOL can cause uterine rupture,
• Suitability of mechanical methods inc risk of infection
• Unlicensed use of propess/misoprostol for women with a uterine scar
• risks and consequences of caesarean birth inc short and long term morbidity

Question 20

IOL for breech is not recommended. Consider IOL for babies in breech if…

Answer 20

• birth needs to be expedited
• ecv is unsuccessful, declined or contraindicated AND,
• the woman chooses not to have a planned LSCS

Question 21

What is the cut off bishop score below which propess or mechanical methods are offerred and above which ARM is offered?

Answer 21

6

Question 22

Women having an amniotomy can choose whether or not to have an oxytocin infusion, or can delay starting this but that this may mean…

Answer 22

labour takes longer and there may be an increased risk of neonatal infection.