Why an induction of labour may be offered or advised

When and why an induction of labour may be offered

When and why an induction of labour may be offered

Sometimes we offer to start your before this happens naturally, this is called induction of labour.

In the UK, about 30 in 100 women have an induction of labour.

You might be offered induction of labour in the following circumstances:

  1. If you are overdue – Induction will be offered if you do not go into labour naturally by 41 weeks, as risks associated with continuing pregnancy beyond 41+0 weeks as at this time risks include increased likelihood of caesarean birth, your baby needing admission to a neonatal intensive unit and increased likelihood of stillbirth and neonatal death.


  2. If your waters break before labour: (pre-labour rupture of membranes)

    1. At term (at or after 37+0 weeks)– If your water breaks more than 24 hours before labour starts there is increased risk of infection to you and your baby, and you will be offered induction of labour

    2. If your water breaks after 34+0 weeks, but before 37+0 weeks, you will be given the choice of induction of labour or expectant management until 37+0 weeks.

    3. If your waters break after 34+0 weeks and you have had a positive group B streptococcus test at any time in your current pregnancy, you would be offered induction of labour immediately

    4. If your waters break earlier than 34+0 weeks, you will be offered induction of labour at 34+0 weeks unless there are additional indications such an infection or problems with your baby.


  3. If you have certain health conditions – you may be offered induction of labour if you have a health condition that means it will be safer to have our baby sooner, for example:

    a. High blood pressure in pregnancy – the recommended timing of induction will depend on numerous factors including control of your blood pressure, baby’s and your clinical condition, results of your blood and wee (urine) tests.

    b. Diabetes in pregnancy– the recommended timing of induction will depend on the type of diabetes, your blood sugar control, you and your baby’s wellbeing.

    c. Intrahepatic cholestasis of pregnancy- the recommended timing of offering induction will depend on the level of bile acids in your blood.


  4. If there are concerns about your baby’s health such as

    1. Your baby is smaller than expected (small for gestational age).

    • If your baby is thought to be small on the ultrasound scan and your obstetric doctor does not think your baby has a condition called fetal growth restriction and there are no other problems, induction of labour will be offered around 39 +0 weeks aiming for birth by 39 +6 weeks.

    • If your baby has the condition fetal growth restriction before 32+0 weeks, you will be cared for by specialist doctors and timing of birth will be advised by your team.

    • If your baby has fetal growth restriction after 32+0 weeks, you may be offered induction of labour from 37+0 weeks to be completed by 37+6 weeks or sometimes earlier depending on the ultrasound scan.

    b. Recurrent episodes of reduced fetal movements - Women who present on two or more occasions with reduced fetal movements are at increased risk of problems like; stillbirth, fetal growth restriction or preterm birth compared with those who attend on only one occasion. If you have reduced fetal movements at term, with normal ultrasound scan findings of fetal growth and a normal CTG, you will be offered induction of labour, and you can discuss the pros and cons with your obstetric team


  5. If you are pregnant with twins and the first twin is head down in your pelvis (cephalic presentation)

    a. In twins who do not share a placenta – you will be offered induction of labour at around 37+0 weeks aiming to give birth by 37+6 weeks.

    b. In twins who share a placenta but have 2 different amniotic sacs – you will be offered induction of labour at 36+0 weeks aiming to give birth by 36+7 weeks.

    c. Twins that share a common amniotic sac or if you are pregnant with triplets or more, as it is recommended to have caesarean section.

    Note – you will not be offered induction of labour if the first twin is bottom down in your pelvis (breech presentation).


  6. If you are 40 years or older

    Stillbirth increases later in pregnancy if you are pregnant and you’re 40 years or older.  However, evidence is still inconclusive to recommend earlier induction of labour.  You can discuss with your consultant regarding your options and make an informed choice.


  7. If you request induction of labour without medical indication – in this situation, your obstetric team can discuss the benefits and risks with you, considering your preferences and circumstances and then you make an informed choice.


  8. There are other times where you may be offered induction of labour such as maternal chronic health conditions (for example – heart disease, kidney disease) or if you have a minor vaginal bleed (less than 50mls) around your due date (40 weeks) with no signs at the time, that your baby is in distress.


References:

  1. National Institute for Health and Care Excellence: Inducing labour [NG207] [Internet]. NICE, London; 2021 [cited 2024 Aug 14]. Available from: https://www.nice.org.uk/guidance/ng207

  2. National Institute for Health and Care Excellence: Hypertension in pregnancy: diagnosis and management. [NG133] [Internet]. NICE, London; 2019 [cited 2024 Aug 14]. Available from: https://www.nice.org.uk/guidance/NG133

  3. National Institute for Health and Care Excellence: Diabetes in pregnancy: management from preconception to the postnatal period [NG3] [Internet]. NICE, London; 2015 [cited 2024 Aug 14]. Available from: https://www.nice.org.uk/guidance/ng3

  4. Girling J, Knight CL, Chappell L, the Royal College of Obstetricians and Gynaecologists. Intrahepatic cholestasis of pregnancy: Green‐top Guideline No. 43 June 2022. BJOG Int J Obstet Gynaecol [Internet]. 2022 Dec [cited 2024 Aug 14];129(13). Available from: https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.17206

  5. Morris RK, Johnstone E, Lees C, Morton V, Smith G, the Royal College of Obstetricians and Gynaecologists. Investigation and Care of a Small‐for‐Gestational‐Age Fetus and a Growth Restricted Fetus (Green‐top Guideline No. 31). BJOG Int J Obstet Gynaecol [Internet]. 2024 Aug [cited 2024 Aug 14];131(9). Available from: https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.17814

  6. RCOG [Internet]. [cited 2024 Aug 14]. Reduced Fetal Movements (Green-top Guideline No. 57). Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/reduced-fetal-movements-green-top-guideline-no-57/

  7. National Institute for Health and Care Excellence: Twin and triplet pregnancy [NG137] [Internet]. NICE. London; 2019 [cited 2024 Aug 14]. Available from: https://www.nice.org.uk/guidance/NG137

  8. RCOG [Internet]. [cited 2024 Aug 14]. Induction of Labour at Term in Older Mothers (Scientific Impact Paper No. 34). Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/scientific-impact-papers/induction-of-labour-at-term-in-older-mothers-scientific-impact-paper-no-34/

  9. NHS Maternity Statistics, England, 2023-24 - NHS England Digital

Pregnancy care after your due date

Your likelihood of going into spontaneous labour varies according to how far along the pregnancy is.  As your pregnancy progresses you are more likely to go into spontaneous labour.

You can choose to wait and not be induced. If this happens, you may go into spontaneous labour or you might not. If you don’t go into spontaneous labour by 41 weeks of pregnancy, there are some additional risks. These include:

  • A higher likelihood of a caesarean birth

  • A higher likelihood of baby needing to spend time in the neonatal intensive care unit (NICU).

  • An increased likelihood of stillbirth

  • An increased chance of your baby dying just after they are born (neonatal death).

If you do not go into labour by 42 weeks of pregnancy, the risks listed above increase further. If you choose not to be induced, you may be offered extra monitoring of your baby.

This monitoring cannot reliably predict any changes that happen after the monitoring ends but can help to see how the baby is in that moment and even help with decision making for birth options. Complications that happen to the baby cannot be predicted or prevented with monitoring.

Weeks of pregnancy

Proportion of spontaneous labours started by this gestational age

Obstetric care to expect at this point in pregnancy

At 41 weeks (1 week overdue)

83 in 100 women/birthing people will have gone into labour by this point.


Your team will offer to plan a date for induction. This is due to increasing chances of:


  • Caesarean birth

  • Stillbirth

  • Neonatal admission

  • Neonatal death


You can choose to wait for spontaneous labour if you wish.

Up to 42 weeks

99 in 100 women/birthing people will have gone into labour by this point.


If you wish to wait for spontaneous labour beyond 42 weeks - extra monitoring may be offered, but it cannot always predict or prevent stillbirth or other complications.