There are multiple alternative and other therapies described in literature as alternative methods for induction of labour.  Currently, available guidance from NICE does not support the use of non-pharmacological methods for induction of labour including herbal supplements, acupuncture, homeopathy, castor oil, hot baths, enemas, sexual intercourse. The main reasons for this are due to the lack of available evidence in evaluating the effectiveness of these methods.(1) 

Herbal supplements:
Herbal medications have been proposed to increase oxytocin levels and increase muscle contractility. However, most studies that have trialled the use of herbal medicines were provided at a safe environment i.e. carried out in a health facility and monitored by staff.(2)

The Guideline Development Group (NICE) considered that the unsupervised use of herbal preparations, which may contain active ingredients with undesirable effects, should be treated with caution. Further research is required to evaluate the effectiveness, safety and maternal satisfaction of the use of herbal supplements as a method of induction of labour.(1,2)

NICE therefore does not support the use of herbal medicines as an alternative method for the induction of labour until further safety concerns and precautions are understood (1,2)

Acupuncture/Acupressure:
Acupuncture has shown some benefit in improving cervical maturity and may increase uterine contractility and alleviate labour pain.(3)

Acupressure uses the same points as acupuncture but applies manual pressure, usually with the finger or thumb, on these points rather than the insertion of a needle.(3)

Many acupuncturists argue that to achieve the optimal effect of acupuncture, it is important that the treatment be customised according to the diagnostic process that is integral to the traditional Chinese system of medicine.(4)

However, the available evidence is insufficient to determine the effectiveness of acupuncture in cervical priming/induction of labour.(3,4) NICE therefore does not support the use of acupuncture as an alternative method for induction of labour.(1)

Homeopathy:
Homeopathy involves the administration in dilution of substances aimed at the alleviation of symptoms that the same substances generally cause in their undiluted form.

It has been suggested that the herbs belonging to the Caulophyllum genus are useful in establishing labour, when uterine contractions are short and/or irregular or when they stop.(5)

However, there is not enough evidence to show the effect of homoeopathy for inducing labour. NICE therefore does not support the use of homeopathy as an alternative method for induction of labour. (1)

Castor oil, hot baths and enemas:
Castor oil has been widely used as a traditional method of initiating labour in midwifery practice. However, the mechanism is poorly understood. Evidence from a Cochrane systematic review and a randomised control trial suggested that women given castor oil for induction of labour achieve similar maternal and fetal outcomes as women given placebo. One small, randomised control trial reported improved “Bishop scores” (hyperlink) in women given castor oil. However, both studies reported that castor oil was associated with nausea. (6,7)

There is limited and conflicting evidence relating to the effects of castor oil for cervical priming and induction of labour. Castor oil is unpleasant to ingest and causes nausea.

There is no available evidence relating to hot baths or enemas as induction agents.

NICE does not support the use of these methods for induction of labour. (1)

Sexual intercourse:
The role of sexual intercourse in stimulating labour is not well understood. It has been suggested that human semen is a biological source of high prostaglandin concentrations and the action of sexual intercourse may ripen the cervix and stimulate uterine contractions. There may be an endogenous release of oxytocin as a result of orgasm. A Cochrane small study with limited data found no significant difference in labour outcomes between sexual intercourse and no sexual intercourse. (8)

There is not enough evidence to show whether sexual intercourse is effective or to show how it compares with other methods. More research is needed.

NICE does not support sexual intercourse as a method for induction of labour.(1)

Breast/nipple stimulation:
Breast stimulation results in the production of endogenous oxytocin in both pregnant and non-pregnant women, causing uterine contractions.(9,10) Evidence from a Cochrane systematic review suggested that breast stimulation appears to be beneficial in increasing the number of women in labour by 72 hours and in reducing postpartum haemorrhage rates when compared with control.(11)  Caesarean birth rates were similar between breast stimulation and intravenous oxytocin.

There is evidence that breast stimulation may be effective as a method of induction. However, interpretation of the results should be used with caution given inconsistencies with the findings and the evidence being low-quality.

Further research is required to evaluate the effectiveness, timing, methods, frequency, safety and maternal satisfaction of breast stimulation as a method of induction of labour. NICE therefore currently does not support its use as a method for induction of labour. (1)

Hypnosis:
Hypnosis is a relaxation technique in which the person closes down their awareness of external distractions to concentrate on a specific image, thoughts or feelings.

Hypnosis has long been used to reduce pain perception during labour and hypnotic relaxation may be beneficial for women who are anxious about giving birth.

A Cochrane review (2014) found no randomised control trials of acceptable quality and therefore concluded that further evidence from RCTs is required to evaluate the effectiveness and safety of this intervention for labour induction. The review also states how hypnosis may delay standard care (in case standard care is withheld during hypnosis), and its use in induction of labour should be considered on a case‐by‐case basis.(12) No guidance has been provided specifically on hypnosis as a method for induction of labour by NICE.

Raspberry leaf tea:
Raspberry leaf is frequently used during pregnancy and labour to strengthen and tone the uterus, theoretically assisting contractions and preventing excessive bleeding (haemorrhage). While there is a long history of raspberry leaf use in pregnancy there is little research contributing to the evidence base especially in relation to its mechanism of action, efficacy or potential harmful effects.

Raspberry leaf has demonstrated both stimulatory and relaxation effects on smooth muscle depending on a variety of factors including herbal preparation used, method of extraction, type of tissue and animal, baseline muscle tone and pregnancy status of uterus or uterine tissue. However, raspberry leaf may interact with other drugs particularly how they are broken down (metabolised) in your body.

The evidence of raspberry leaf use in pregnancy does not show any benefit. Further research is required to provide this information.(13)

Curry:
Spicy foods (e.g. curry) are sometimes thought to stimulate the gut, which could hypothetically lead to uterine contractions through increased production of prostaglandins (hormones involved in labour). However, the link between dietary intake of spicy foods and significant changes in prostaglandin levels is not well-supported by research. Studies have focused on direct medical application, such as prostaglandin gels or tablets not dietary influences.

Aromatherapy:

Aromatherapy involves the use of the essential oils, which are volatile, fragrant organic compounds obtained by distillation for plant material derived from roots, leaves, bark, seeds and flowers.

Aromatherapy can help in relieving maternal anxiety and pain during labour.(14) However, there is insufficient evidence about the effectiveness of aromatherapy on pain management in labour or any primary or secondary outcome from two randomised controlled trials comparing essential oils with an active control or standard care.(15) Additionally, there is no peer-reviewed evidence to suggest that it can be used as an alternative method for inducing labour.

Keeping active/walking:
Maternal exercise has been shown to increase uterine activity.(16) It has also been demonstrated that patients who are more physically active during pregnancy have a shorter duration of active labour (17)

According to the results from a randomised control trial , walking could be recommended to low-risk pregnant women to improve some of the significant outcomes of labour and delivery such as cervix preparation and Bishop Score, increasing the cases of spontaneous labour, and decreasing the cases of induction of labour and caesarean section without causing any undesirable effects on the neonate's Apgar score. The trial found that walking 40 minutes a day four times per week starting at 34 weeks improved spontaneous labour rates in 90% of women.(18) However, the NICE and RCOG guidelines on induction of labour do not formally recommend walking as an evidence-based method to induce labour.

Vaginal douching (washing) prior to induction:
The theory of vaginal douching (washing) before induction is associated with the aim of making your vagina more alkaline (increasing its pH), which may be associated with induction leading to active labour.  There is conflicting evidence regarding vaginal douching (washing) before induction of labour.(19,20)

The NICE guideline on induction of labour does not mention vaginal washing or douching as a method for induction.

Reflexology:
Reflexologists propose that there are reflex points on the feet corresponding to organs and structures of the body and that pain may be reduced by gentle manipulation or pressing certain parts of the foot.(21) Pressure applied to the feet has been shown to result in an anaesthetizing effect on other parts of the body.(22) It has also been shown to potentially be effective and safe on labour pain, duration of labour, and anxiety in pregnancy.(23,24) However, in terms of inducing labour, robust clinical trials are lacking and it is not yet an established method for inducing labour. There is also no guidance provided by NICE or RCOG related to reflexology.

Primrose oil:
The vaginal use of evening primrose oil could be considered as a safe and efficient approach for cervical ripening in low‐risk term pregnant women.(25) The results of a systematic review showed that evening primrose oil could significantly improve Bishop score. It is believed that gama-linoleic acid in evening primrose oil facilitates the making of prostaglandin and that prostaglandins play the most important role in the process of cervical ripening, as determined by Bishop score. (26)

There is some evidence suggesting that evening primrose oil improves cervical ripening when comparing it with a placebo or with usual induction medication.(27,28)

However NICE and RCOG guidelines do not provide guidance on the use of evening primrose oil for induction of labour.

Eating 6 dates a day:
Consumption of dates may decrease the need for induction of labour and shorten the length of the latent phase of labour.  The theory is that date fruit is high in saturated and unsaturated fatty acids which may contribute to the production of prostaglandins needed for cervical ripening and labour.  The high sugar content provides nutritional value during labour, but caution is advised amongst those with diabetes mellitus (gestational, type 1 or type 2).  There is low-quality evidence to support the consumption of dates for induction of labour. (29,30)

Fresh pineapple:
Historically, pineapple is reputed to act as a means of inducing labour to avoid medical intervention of post-dates pregnancy.

Several reports and studies have claimed labour-induing qualities of pineapple fruit (ripe or unripe) in many parts of the world. Some research studies have indicated that pineapple has some potential effects on uterine contractions, which could theoretically be related to labour induction. However, these studies were conducted in a laboratory setting therefore do not translate to clinical significance for induction of labour in humans.(31,32)

NICE or RCOG does not include any guidance on eating fresh pineapple for induction of labour.

References:

1. National Institute for Health and Care Excellence: Guidelines.  Inducing labour. London: National Institute for Health and Care Excellence (NICE) Copyright © NICE 2021.; 2021.

2. Zamawe C, King C, Jennings HM, Mandiwa C, Fottrell E. Effectiveness and safety of herbal medicines for induction of labour: a systematic review and meta-analysis. BMJ Open. 2018;8(10):e022499.

3. Smith CA, Armour M, Dahlen HG. Acupuncture or acupressure for induction of labour. Cochrane Database of Systematic Reviews. 2017(10).

4. Harper TC, Coeytaux RR, Chen W, Campbell K, Kaufman JS, Moise KJ, et al. A randomized controlled trial of acupuncture for initiation of labor in nulliparous women. J Matern Fetal Neonatal Med. 2006;19(8):465-70.

5. Smith CA. Homoeopathy for induction of labour. Cochrane Database Syst Rev. 2001;2003(4):Cd003399.

6. Kelly AJ, Kavanagh J, Thomas J. Castor oil, bath and/or enema for cervical priming and induction of labour. Cochrane Database of Systematic Reviews. 2013(7).

7. Azhari S, Pirdadeh S, Lotfalizadeh M, Shakeri MT. Evaluation of the effect of castor oil on initiating labor in term pregnancy. Saudi Med J. 2006;27(7):1011-4.

8. Kavanagh J, Kelly AJ, Thomas J. Sexual intercourse for cervical ripening and induction of labour. Cochrane Database Syst Rev. 2001;2001(2):Cd003093.

9. Amico JA, Finley BE. Breast stimulation in cycling women, pregnant women and a woman with induced lactation: pattern of release of oxytocin, prolactin and luteinizing hormone. Clin Endocrinol (Oxf). 1986;25(2):97-106.

10. Christensson K, Nilsson BA, Stock S, Matthiesen AS, Uvnäs-Moberg K. Effect of nipple stimulation on uterine activity and on plasma levels of oxytocin in full term, healthy, pregnant women. Acta Obstet Gynecol Scand. 1989;68(3):205-10.

11. Kavanagh J, Kelly AJ, Thomas J. Breast stimulation for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews. 2005(3).

12. Nishi D, Shirakawa MN, Ota E, Hanada N, Mori R. Hypnosis for induction of labour. Cochrane Database of Systematic Reviews. 2014(8).

13. Bowman R, Taylor J, Muggleton S, Davis D. Biophysical effects, safety and efficacy of raspberry leaf use in pregnancy: a systematic integrative review. BMC Complementary Medicine and Therapies. 2021;21(1):56.

14. Tabatabaeichehr M, Mortazavi H. The Effectiveness of Aromatherapy in the Management of Labor Pain and Anxiety: A Systematic Review. Ethiop J Health Sci. 2020;30(3):449-58.

15. Smith CA, Collins CT, Crowther CA. Aromatherapy for pain management in labour. Cochrane Database of Systematic Reviews. 2011(7).

16. Spinnewijn WEM, Lotgering FK, Struijk PC, Wallenburg HCS. Fetal heart rate and uterine contractility during maternal exercise at term. American Journal of Obstetrics & Gynecology. 1996;174(1):43-8.

17. Watkins VY, O'Donnell CM, Perez M, Zhao P, England S, Carter EB, et al. The impact of physical activity during pregnancy on labor and delivery. Am J Obstet Gynecol. 2021;225(4):437.e1-.e8.

18. Shojaei B, Loripoor M, Sheikhfathollahi M, Aminzadeh F. The effect of walking during late pregnancy on the outcomes of labor and delivery: A randomized clinical trial. J Educ Health Promot. 2021;10:277.

19. Yayla Abide Ç, Kurek Eken M, Ozkaya E, Yenidede I, Bostanci Ergen E, Kilicci C, et al. Effect of vaginal washing before intravaginal dinoprostone insertion for labor induction: A randomized clinical trial. J Obstet Gynaecol Res. 2018;44(12):2149-55.

20. Verma ML, Pandey M, Singh U, Sachan R, Sankhwar PL. Effect of vaginal douching with normal saline before insertion of dinoprostone vaginal insert for labor induction. J Family Med Prim Care. 2024;13(1):265-70.

21. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev. 2006;2006(4):Cd003521.

22. Ernst E, and Köder K. An overview of reflexology. European Journal of General Practice. 1997;3(2):52-7.

23. Dolatian M, Hasanpour A, Montazeri S, Heshmat R, Alavi Majd H. The effect of reflexology on pain intensity and duration of labor on primiparas. Iran Red Crescent Med J. 2011;13(7):475-9.

24. Liang X, Wu S, Li K, Zhang H, Yang F, Wang X, et al. The effects of reflexology on symptoms in pregnancy: A systematic review of randomized controlled trials. Heliyon. 2023;9(8):e18442.

25. Ariana S, Amjadi N, Kazemi SN, Ahmadli Z. The Use of Evening Primrose Oil for Cervical Ripening in Low-Risk Women with Term Pregnancy: A Randomized Double-Blinded Controlled Trial. Complement Med Res. 2024;31(3):215-21.

26. Shahinfar S, Abedi P, Jahanfar S, Khajehpoor M, Chashmyazdan M. The effect of evening primrose oil on cervical ripening and birth outcomes: A systematic review and meta-analysis. Heliyon. 2023;9(2):e13414.

27. Bahmani S, Shahoei R. The effect of misoprostol with and without evening primrose oil on labor progress and neonatal Apgar score in post-term pregnancies: a clinical trial study. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2023;26(3):43-52.

28. Azad A, Pourtaheri M, Darsareh F, Heidari S, Mehrnoush V. Evening primrose oil for cervical ripening prior to labor induction in post-term pregnancies: A randomized controlled trial. European Journal of Integrative Medicine. 2022;51:102123.

29. Sagi-Dain L, Sagi S. The effect of late pregnancy date fruit consumption on delivery progress - A meta-analysis. Explore (NY). 2021;17(6):569-73.

30. Al-Kuran O, L. A-M, H. B, S. B, and Amarin Z. The effect of late pregnancy consumption of date fruit on labour and delivery. Journal of Obstetrics and Gynaecology. 2011;31(1):29-31.

31. Monji F, Adaikan PG, Lau LC, Bin Said B, Gong Y, Tan HM, et al. Investigation of uterotonic properties of Ananas comosus extracts. Journal of Ethnopharmacology. 2016;193:21-9.

32. Monji F, Adaikan PG, Lau LC, Siddiquee AA, Said BB, Yang LK, et al. Role of the serotonergic pathway in uterotonic activity of Ananas comosus (L.) Merr. - An in vitro and in vivo study. Phytomedicine. 2018;48:32-42.