National Institute for Health and Clinical Excellence (NICE)
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Updated NICE guideline published on the support women should receive when induction of labour is offered

The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Women’s and Children’s Health have today (23 July 2008) issued updated guidance to doctors and midwives on how to support and care for women being offered and undergoing induction of labour. The guidance revises areas where new information has become available since the original guidance was published in 2001. It recommends that midwives and doctors provide women with evidence-based information about a range of key issues such as why induction is being offered, the risks and benefits of induction and different pain relief options, so they can make decisions that are right for them and their baby.

Key recommendations from the guideline include:

• Women should be informed that most women will go into labour spontaneously by 42 weeks. At the 38 week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 42 weeks, and their options.

• Healthcare professionals should explain the following points to women being offered induction:

− The reasons for induction being offered
− When, where and how induction should be carried out
− The arrangements for support and pain relief
− The alternative options if the woman chooses not to have induction of labour
− The risks and benefits of induction of labour in specific circumstances and the proposed induction methods
− That induction may not be successful and what the woman’s options will be.

• Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy

• If a woman has preterm rupture of the membranes after 34 weeks, the maternity team should discuss the following factors with her before a decision is made about whether to induce labour, using vaginal prostaglandin E2 (PGE2)

− Risks to the woman (e.g. sepsis, possible need for caesarean section)
− Risks to the baby (e.g. problems relating to pre-term birth)
− Local availability of neonatal intensive care facilities.

• Vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it. It should be administered as gel, tablet or controlled-release pessary. For doses, refer to summaries of product characteristics (SPC’s). The recommended regiments are:

− One cycle of vaginal PGE2 tablets or gel: one dose followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses)
− One cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours

• If induction fails, the subsequent management options include:

− A further attempt to induce labour (timing should depend on the clinical situation and the woman’s wishes)
− Caesarean section.

Dr Gillian Leng, NICE Deputy Chief Executive, and Executive Lead for this guidance says: “Having a baby is a very special time in the life of a woman and her family and healthcare professionals want to make sure this is a good and safe experience. This guideline now provides the most up-to-date information on best care in induction of labour, and will ensure that health professionals offer women all the support and information they need to make decisions about their care that are right for them and their babies.”

Professor Andrew Calder, Head of Division of Reproductive and Developmental Sciences, University of Edinburgh and Guideline Development Group chair says: “Although it is the hope of most women and their carers that pregnancy should follow a normal course and end with the spontaneous onset of labour, there are a number of clinical circumstances where it is in the interest of the woman, her baby or both that the pregnancy should be interrupted. Sometimes the appropriate form of interruption is direct resort to caesarean section but more often it is induction of labour. The revised guideline provides a set of clear recommendations on how induction of labour should be offered, with particular emphasis on the need for intimate involvement and participation of the woman in the decision and its implementation. A number of recommendations for further research have also been included in this guideline, because although the methods recommended have been improved and simplified over recent years, there is still scope for progress in developing better methods.”

Richard Tubman, Consultant Neonatologist and Guideline Development Group member says: “These guidelines will be very reassuring to women as they make it clear that induction is not something they must have but something that can be ‘offered’ by their doctor or midwife. Importantly, the guideline recognises that many women want to go into labour naturally without being induced – to increase the likelihood of this, the guideline recommends that all women should be offered a membrane sweep before any formal methods of induction are used.”
Mary Stewart, Midwife and Guideline Development Group member says: “As a midwife, I know that this guideline will really benefit the midwives and doctors looking after women in their labour, as well as the women themselves. Women are already receiving good induction of labour care but this guideline will bring it up to a gold standard and ensure that all women are receiving the same high quality care. For example, it will ensure that healthcare professionals provide women with consistent information about the slight increase in risk associated with a prolonged pregnancy. By giving women good information about induction early enough at the 38 week antenatal appointment, they will feel more in control of their labour.”

Judith Green, Service User Representative and Guideline Development Group member says: “From the woman’s perspective, induced labour is likely to be very different from spontaneous labour - it may be longer, more painful, and may mean spending a long time in hospital getting into labour, perhaps on her own. As it has significant interference in pregnancy, induction should only be offered when the benefits are clear. In looking at research for the guidelines we found that many women are dissatisfied with the level of information they receive about induction when it is offered. The good news is that this guideline places women at the centre of decision making about their care - all women should be given clear information, have the opportunity to discuss their concerns and then decide for themselves whether induction is right for them, having weighed up the pros and cons in their particular circumstances.”

Notes to Editors

1. The guidance is available at www.nice.org.uk/CG70.

2. Labour is a natural process that usually starts on its own. Sometimes labour needs to be started artificially; this is called ‘induced labour’.

3. Vaginal PGE2 has been used in UK practice for many years in women with ruptured membranes. However, the SPCs (July 2008) advise that in this situation, vaginal PGE2 is either not recommended or should be used with caution, depending on the preparation (gel, tablet or pessary). Healthcare professionals should refer to the individual SPCs before prescribing vaginal PGE2 for women with ruptured membranes, and informed consent should be obtained and documented.

About NICE

1. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.