Induction of Labour Recommendations

Medical and Obstetric Indications

The American College of Obstetricians and Gynecologists recommends induction of labour for medical or obstetric indications where continuing pregnancy poses greater risks than delivery, including gestational hypertension/preeclampsia at ≥37 weeks, post-term pregnancy at ≥41 weeks, premature rupture of membranes, maternal diabetes with poor control, and Rh disease 1, 2
Induction should be advised for women with gestational hypertension or mild preeclampsia at 37 weeks' gestation to improve maternal outcomes 2
Induction at 39 weeks in low-risk nulliparous women reduces hypertensive disorders from 14.1% to 9.1% (RR 0.64) 1

The American College of Obstetricians and Gynecologists recommends elective induction at 39 weeks 0 days for low-risk nulliparous women to reduce cesarean delivery and hypertensive complications 1
Cesarean delivery rate is reduced from 22.2% to 18.6% (RR 0.84) with elective induction at 39 weeks, with a number needed to treat of 28 1
Hypertensive disorders are reduced from 14.1% to 9.1% (RR 0.64) with elective induction at 39 weeks 1
Elective induction at 39 weeks does not increase adverse neonatal outcomes 1

The American Academy of Family Physicians states that suspected fetal macrosomia is not an indication for induction, as it doubles cesarean risk without reducing shoulder dystocia or neonatal morbidity 3
Elective induction should not be performed before 39 weeks 0 days gestation due to increased respiratory morbidity 1, 4
Previous cesarean delivery with misoprostol use is a contraindication due to a 13% uterine rupture risk 5

The American College of Obstetricians and Gynecologists recommends using mechanical methods for cervical ripening in patients with cardiac disease or cyanosis to avoid systemic vascular resistance drops 5
Misoprostol should be avoided in patients with advanced liver failure due to its hepatic metabolism 5
Dinoprostone should be avoided in patients with active cardiovascular disease due to its profound blood pressure effects 5

Women receiving prophylactic low-molecular-weight heparin (LMWH) should be allowed spontaneous labor rather than scheduled induction when possible, according to guidelines from the American Society of Hematology 6
For therapeutic-dose anticoagulation, individualized multidisciplinary planning is required regarding delivery timing and neuraxial anesthesia access, as recommended by the American College of Obstetricians and Gynecologists 7, 8

For Fetal Growth Restriction (FGR) with normal umbilical artery Doppler and estimated fetal weight between 3rd-10th percentile, delivery is recommended at 38-39 weeks 9
For FGR with abnormal Doppler (elevated resistance but preserved end-diastolic flow), delivery is recommended by 37-38 weeks depending on severity 10, 11, 12
The American College of Obstetricians and Gynecologists recommends delivery at 38+0 to 39+6 weeks for FGR with no additional abnormal parameters 11
The New Zealand guidelines recommend delivery by 38 weeks if umbilical artery Doppler >95th percentile, middle cerebral artery <5th percentile, or cerebroplacental ratio <5th percentile 11