Volume 66, Number 11

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2011
by Lippincott Williams & Wilkins CME REVIEWARTICLE 33
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA Category 1 CreditsTM can be earned in 2011. Instructions for how CME credits can be earned appear on the
last page of the Table of Contents.

Failed Induction of Labor: Strategies to

Improve the Success Rates
Vikram S. Talaulikar, MD, MRCOG,*
and Sabaratnam Arulkumaran, MD, PhD, FRCS, FRCOG†
*Clinical Research Fellow, †Professor and Head of Department, Department of Obstetrics and Gynaecology,
St. George’s Hospital Medical School, Cranmer Terrace, London

The rates of induction of labor (IOL) are rising all over the world. In developed countries, one of every
4 babies is born after IOL at term. The recent World Health Organization guidelines on IOL recommend
that failure of induction does not necessitate cesarean delivery [WHO recommendations for induction
of labor. World Health Organization, 2011]. These guidelines come when there are concerns that failed
primary inductions in nulliparous women, which have led to escalation of the cesarean delivery rates.
Obstetricians must recognize the risks associated with IOL (including failure and need for cesarean
delivery) and avoid inductions for borderline indications, which are not evidence based. The issue of
“failed induction of labor” is topical, and there is a need to define this entity and offer alternatives to
cesarean delivery in the management of this group of women. Research is required to develop a test
to accurately identify those fetuses most at risk of morbidity or stillbirth who would truly benefit from
an early IOL and assess the cost-effectiveness of policies of routine IOL. In this review, we summarized
the current recommendations for best practice in the area of IOL, defined “failed induction,” and
described options to improve the success rate after “failed primary induction of labor.”
Target Audience: Obstetricians & Gynecologists and Family Physicians
Learning Objectives: After the completing the CME activity, physicians should be better able to
classify the factors determining success or failure of induction of labor, counsel women about risks and
benefits of various methods of induction of labor, and compare the options of management available after
failed primary induction of labor.

Induction of labor (IOL) is a process of artificial
stimulation of uterine contractions after the age of
fetal viability and before spontaneous onset of natu-
ral labor, with the aim of achieving a vaginal deliv-
ery. Acquisition of the ability to artificially induce
labor and control the timing of birth has been one of
the most striking accomplishments in the field of
The authors, faculty and staff in a position to control the content
of this CME activity and their spouses/life partners (if any) have
disclosed that they have no financial relationships with, or financial
interest in, any commercial organizations pertaining to this edu-
cational activity.
Correspondence requests to: Vikram Sinai Talaulikar, MD,
MRCOG, Department of Obstetrics and Gynaecology, St.
George’s Hospital Medical School, Cranmer Terrace, London
SW17 0RE. E-mail: vtalauli@sgul.ac.uk.
www.obgynsurvey.com | 717
Obstetrics and that of mankind in a broader perspec-
tive. More than 22% of all gravid women undergo
IOL in the United States, and the overall rate of IOL
in the United States had more than doubled since
1990 to 2006.1 In the United Kingdom, 19.8% of all
deliveries were induced during 2004–2005.2 Where
labor was induced by drugs, whether or not surgical
induction was also attempted, fewer than two-thirds
of women gave birth without further intervention,
with about 15% having instrumental births and 22%
having emergency cesarean deliveries.3
Concerns have been raised about rising rates of
cesarean deliveries due to failure of inductions espe-
cially in cases where indications for IOL have been
borderline. Therefore, it is important that the decision
718 Obstetrical and Gynecological Survey
to induce labor should not be taken lightly because
the process of induction has its own risks. There
should be a clear indication and benefits to either
mother or fetus should outweigh the potential risks. It
should be tailored to meet the expectations of women
in their unique circumstances.
FACTORS DETERMINING SUCCESS
OF IOL
Success of IOL mainly depends on (1) parity, (2)
cervical score, (3) position of vertex (occipitoanterior
vs. occipitoposterior), and (4) method of induction.
Parity and Cervical Score
The changes in the cervix, which prepare it for
dilatation in labor, are known as cervical ripening,
and they result from a series of biochemical reac-
tions, involving various hormones, cytokines, en-
zymes, and other biological molecules. During
ripening, there is progressive softening and increase
in vascularity as well as water content of the cervix.
Cervical ripening increases the chances of success of
IOL, and various pharmacological/mechanical agents
are in use to achieve the same. However, some of
these agents may themselves induce labor during the
process of ripening, and the boundary between rip-
ening and induction often becomes clinically indis-
tinguishable. The ripeness of the cervix is commonly
assessed using a modified Bishop score (Table 1) in
clinical practice.4 A score ⱕ5 represents an unfavor-
able cervix, whereas a score ⱖ6 indicates a ripe
cervix. Clinical experience as well as studies that
have evaluated the total uterine work needed to
achieve full dilatation, suggest that labor is difficult
when induction is attempted with a poor cervical
score. Nulliparous women with a cervical score of 3
out of 10 or less had a 65.4% cesarean delivery rate,
of which more than two-thirds were for failed IOL
(with artificial rupture of membranes and oxytocin
infusion).5 However, another study showed that nul-
TABLE 1
Modified bishop cervical score
Score 0 1 2 3
Cervical dilation 0 1–2 3– 4
(cm)
Cervical length ⬎4 3– 4 1–2
(cm)
Station of ⫺3 ⫺2 ⫺1, 0 ⫹1 or more
presenting part
Consistency Firm Medium Soft
Position Posterior Mid Anterior
liparous women with a poor cervical had to perform
uterine activity nearly 4 times compared with mul-
tiparous women with a good score.6 It was estimated
that nulliparous women with a score of 3 out of 10 or
less have nearly a 1 in 2 chance of failed induction,
and this is reduced to 1 in 10 if the cervical score was
4 to 6 out of 10.5
Position of Vertex
Persistent occipitoposterior position has been asso-
ciated with increased chance of failure of IOL.7
Methods of IOL
Vaginal Prostaglandin Dinoprostone
(Prostaglandin E2)
This is the recommended method of IOL in the
absence of any contraindications or risk of hyper-
stimulation.2 Prostaglandin E2 (PGE2) may be admin-
istered as a gel, tablet, or slow release pessary. Each
3-g gel contains 1- or 2-mg dinoprostone, whereas
tablets contain 3-mg dinoprostone. The first dose is
administered high into the posterior fornix. The pa-
tient is then instructed to remain recumbent for at
least 30 minute. A second and, if required, third dose
may be administered at interval of 6 hours following
cervical assessment. Adverse reactions are uncom-
mon and include vomiting, nausea, and diarrhea.
Rarer adverse reactions include uterine hyperstimu-
lation, fetal distress, maternal hypertension, broncho-
spasm, backache, rash, and extremely rarely amniotic
fluid embolism.4 National Institute for Health and
Clinical Excellence (NICE) guidelines recommend 1
cycle of vaginal PGE2 tablets or gel: first dose fol-
lowed by a second dose after 6 hours if labor is not
established (up to a maximum of 2 doses), or 1 dose
of vaginal PGE2 controlled-release pessary over 24
hours.2 If oxytocin is used after PGE2, 6 hours should
elapse after the last dose of PGE2 to reduce the risk
of hyperstimulation.
Evidence. A 2009 Cochrane systematic review,
including 69 trials (10,441 women), found that vag-
inal PGE2 compared with placebo or no treatment
⬎4 reduced the likelihood of vaginal delivery not being
achieved within 24 hours (18.1% vs. 98.9%, risk
⬍1
ratio [RR] 0.19, 95% confidence interval [CI]: 0.14–
0.25, 2 trials, 384 women). The risk of the cervix
remaining unfavorable or unchanged was reduced
(21.6% vs. 40.3%, RR: 0.46, 95% CI: 0.35–0.62, 5
trials, 467 women); and the risk of oxytocin augmen-
 Failed Induction of Labor Y CME Review Article
tation reduced (35.1% vs. 43.8%, RR: 0.83, 95% CI:
0.73–0.94, 12 trials, 1321 women) when PGE2 was
compared with placebo. There was no evidence of a
difference between cesarean delivery rates, although
the risk of uterine hyperstimulation with fetal heart
rate (FHR) changes was increased (4.4% vs. 0.49%,
RR: 4.14, 95% CI: 1.93–8.90, 14 trials, 1259
women). PGE2 tablet, gel, and pessary appeared to be
as efficacious as each other, and the use of sustained
release PGE2 inserts was associated with a reduction
in instrumental vaginal delivery rates (9.9% vs.
19.5%, RR: 0.51, 95% CI: 0.35–0.76, number needed
to treat [NNT]: 10 [6.7–24.0], 5 trials, 661 women)
when compared with vaginal PGE2 gel or tablet. The
authors concluded that PGE2 increases successful
vaginal delivery rates in 24 hours and cervical fa-
vorability with no increase in operative delivery
rates.8 Another Cochrane review in 2008, which in-
cluded 56 trials (7738 women), reported that intra-
cervical prostaglandins were effective compared with
placebo but appeared inferior when compared with
intravaginal prostaglandins.9 Recent World Health
Organization (WHO) guidelines have provided fur-
ther evidence in support of PGE2 and confirmed that
PGE2 preparations are more effective than placebo
for IOL at term. There is a reduced risk of vaginal
births not achieved within 24 hours (2 trials, 384
participants, RR: 0.19, 95% CI: 0.14–0.25) and fewer
caesarean births (34 trials, 6399 participants, RR:
0.89, 95% CI: 0.79–1.00). A higher risk of uterine
hyperstimulation with FHR changes has been ob-
served (14 trials, 1259 participants, RR: 4.14, 95%
CI: 1.93–8.9) but without additional adverse mater-
nal and perinatal outcomes.10 Low-dose PGE2 has
been compared with high-dose protocols, and the use
of lower doses seems to have comparative advan-
tages like (a) lower risk of uterine hyperstimulation
with FHR changes and (b) a trend toward reduced
risk of neonatal admission to intensive care unit.
WHO thus recommends low doses of vaginal pros-
taglandins for IOL.10 A recent UK randomized con-
trolled trial (RCT), involving 165 women, compared
vaginal PGE2 gel with tablets for IOL. The mean
induction to delivery interval was significantly
shorter in women who received the gel (1400 min-
utes (690–2280 minutes) versus 1780 minutes (960–
2640 minutes); P ⫽ 0.03). The rate of failed IOL was
significantly higher in women who received tablets
(10.84% vs. 1.22%; P ⫽ 0.01). There were no dif-
ferences in adverse maternal and neonatal outcomes.
The authors concluded that PGE2 vaginal gel is su-
perior to vaginal tablets for IOL.11
719
Use of PGE2 for IOL in women with previous ce-
sarean delivery. The NICE guidelines recommend
that if delivery is indicated, women who have had a
previous cesarean delivery may be offered IOL with
vaginal PGE2, cesarean delivery, or expectant man-
agement on an individual basis, considering the
woman’s circumstances and wishes.2 However,
women with previous cesarean deliveries should be
counseled regarding the increased risk of need for
emergency cesarean delivery/uterine rupture.
Misoprostol (PGE1)
Misoprostol is available for use as tablets, which
may be administered through oral or vaginal route for
IOL. It is currently available in the form of 200 mg
tablets. Although WHO recommends oral misopros-
tol in a dose of 25 ␮g, 2 hourly (moderate quality
evidence—strong recommendation),10 other authors
have advocated use of low-dose vaginal misoprostol,
i.e., 25 ␮g, 3 to 6 hourly.12 It is suggested that rather
than breaking the 200 mg tablet into 8 pieces using a
pill cutter, the tablet should be dissolved into 200 mL
of water, and 25 mL of that solution be administered
as a single dose.10 In the third trimester, in women
with a dead or an anomalous fetus, oral or vaginal
misoprostol are recommended for IOL.10 Misoprostol
is, however, not recommended for IOL in women
with previous cesarean delivery. The United States
Food and Drug Administration has not yet approved
use of misoprostol for IOL.
Evidence. Compared with either placebo or expect-
ant management, vaginal misoprostol has been asso-
ciated with a reduced risk of not achieving vaginal
birth within 24 hours of labor induction (5 trials, 769
participants, RR: 0.51, 95% CI: 0.37–0.71).10 When
compared with intravenous oxytocin alone, vaginal
misoprostol has a reduced risk of vaginal births not
achieved within 24 hours (9 trials, 1200 participants,
RR: 0.62, 95% CI: 0.43–0.9), fewer cesarean deliv-
eries (25 trials, 3074 participants, RR: 0.76, 95% CI:
0.60–0.96), and fewer infants with Apgar score be-
low 7 at 5 minutes of life (13 trials, 1906 participants,
RR: 0.56, 95% CI: 0.34–0.92).10 Compared with
other prostaglandins, vaginal misoprostol is associ-
ated with a higher chance of vaginal birth achieved
within 24 hours (vaginal and intracervical PGE2),
fewer cesarean deliveries (vaginal PGE2), and in-
creased risk of uterine hyperstimulation with FHR
changes but without increased risk of other adverse
perinatal outcomes (vaginal and intracervical
PGE2).10 Compared with higher doses of vaginal
720 Obstetrical and Gynecological Survey
misoprostol, lower doses (25 ␮g, 6 hourly) are asso-
ciated with a reduced risk of uterine hyperstimulation
with FHR changes. Use of oral misoprostol also is
associated with higher rate of vaginal birth within 24
hours, lower risk of cesarean delivery when com-
pared with placebo, expectant management, or
vaginal PGE2. When oral and vaginal routes of ad-
ministration were compared, oral misoprostol was
associated with lower risk of poor Apgar score at 5
minutes of life.10 A 2010 Cochrane review, which
included 121 trials, concluded that compared with
placebo, misoprostol was associated with reduced
failure to achieve vaginal delivery within 24 hours
(average relative risk: 0.51, 95% CI: 0.37–0.71).
Uterine hyperstimulation, without FHR changes, was
increased (RR: 3.52, 95% CI: 1.78–6.99). Compared
with vaginal PGE2, intracervical PGE2, and oxytocin,
vaginal misoprostol was associated with less epidural
analgesia use, fewer failures to achieve vaginal delivery
within 24 hours, and more uterine hyperstimulation.
Compared with vaginal or intracervical PGE2, the need
for oxytocin augmentation was less common with mi-
soprostol but meconium-stained liquor was more com-
mon with the use of misoprostol.13
Oral versus vaginal misoprostol. A Cochrane re-
view in 2010 showed that the oral route of adminis-
tration is preferable than the vaginal route. In 10
trials comparing oral misoprostol with vaginal dino-
prostone (3368 participants), women given oral mi-
soprostol were less likely to need a cesarean delivery
(RR: 0.87, 95% CI: 0.77–0.98). There was some
evidence that they had slower inductions, but there
were no other significant differences. Twenty-six
trials (5096 participants) that compared oral and vag-
inal misoprostol found that there were fewer babies
born with a low Apgar score in the oral misoprostol
group (RR: 0.65, 95% CI: 0.44 to 0.97). The authors
recommended that clinicians should use a dose of 20
to 25 ␮g of misoprostol in solution and that the oral
regimens are recommended over vaginal regimens.14
Oxytocin
WHO recommends that when prostaglandins are
not available, intravenous oxytocin alone should be
used for IOL.10 However, NICE guidelines do not
support the use of intravenous oxytocin alone for
IOL.2 Both guidelines acknowledge that there is a
higher chance of vaginal birth within 24 hours with
use of prostaglandins as compared with oxytocin
alone. In clinical practice, in the case of ruptured
membranes, intravenous oxytocin is often recom-
mended as an alternative initiating agent to prosta-
glandins. Oxytocin is used as an intravenous infusion
of a dilute solution (10 mU/mL) and has a time to
uterine response of 3 to 4 minutes. Steady levels are
achieved by 40 minutes. Generally, the dose is
titrated with increasing doses administered every 30
minute until regular contractions occur of approxi-
mately 45 seconds to 1 minute duration and 3 to 4 in
number every 10 minutes.
Evidence. A Cochrane review in 2009 included 61
trials (12,819 women) and found that when oxytocin
inductions were compared with expectant management,
fewer women failed to deliver vaginally within 24
hours (8.4% vs. 53.8%, RR: 0.16, 95% CI: 0.10–0.25).
There was a significant increase in the number of
women requiring epidural analgesia (RR: 1.10, 95% CI:
1.04–1.17). Fewer women were dissatisfied with oxy-
tocin induction in the 1 trial reporting this outcome
(5.9% vs. 13.7%, RR: 0.43, 95% CI: 0.33–0.56). Com-
pared with vaginal prostaglandins, oxytocin increased
unsuccessful vaginal delivery within 24 hours in the 2
trials reporting this outcome (70% vs. 21%, RR: 3.33,
95% CI: 1.61–6.89). There was a small increase in
epidurals when oxytocin alone was used (RR: 1.09,
95% CI: 1.01–1.17). When oxytocin was compared
with intracervical prostaglandins, there was an increase
in unsuccessful vaginal delivery within 24 hours
(50.4% vs. 34.6%, RR: 1.47, 95% CI: 1.10–1.96) and
an increase in cesarean deliveries (19.1% vs. 13.7%,
RR: 1.37, 95% CI: 1.08–1.74) in the oxytocin group.
The reviewers concluded that in comparison with pros-
taglandins, oxytocin reduced the chances of achieving
vaginal birth within 24 hours.15
Mechanical Methods
Mechanical methods for IOL include insertion of a
balloon catheter, extraamniotic saline infusion, and
hygroscopic dilators. The advantages of mechanical
methods include a low risk of FHR abnormalities,
low risk of hyperstimulation, and other systemic side
effects and convenient storage, whereas the disad-
vantages include discomfort during insertion and the
potential to cause antepartum hemorrhage due to a
low-lying placenta. It appears that in the absence of
prelabor rupture of membranes, mechanical methods
for IOL do not result in an increase in the risk of
ascending infection and chorioamnionitis.
Insertion of intracervical 30 mL to 50 mL Foley
catheter filled with saline is the most common me-
chanical mode of IOL. The catheter may be inserted
using a ring forceps, the balloon is then inflated, and
 Failed Induction of Labor Y CME Review Article
the catheter is retracted firmly against the cervix. The
balloon results in pressure to the lower segment of
the uterus, and the cervix resulting in local produc-
tion of prostaglandins. Generally, the catheter is in-
serted, inflated, and left in situ for 12 to 24 hours.
Evidence. A Cochrane review in 2009, including
45 studies, compared mechanical methods with
placebo/no treatment for IOL. Only one study with
48 participants reported on vaginal delivery not
achieved in 24 hours (69% with mechanical methods
vs. 77% with placebo/no treatment, RR: 0.90, 95%
CI: 0.64–1.26). Hyperstimulation with FHR changes
was not reported. The risk of cesarean delivery, re-
ported in 6 studies including 416 women, was similar
between groups (34%, RR: 1.00, 95% CI: 0.76–
1.30). Comparing mechanical methods with vaginal
PGE2, only one trial (109 women) reported on vag-
inal delivery not achieved in 24 hours (73% vs. 42%,
RR: 1.74, 95% CI: 1.21–2.49). Compared with intra-
cervical PGE2, only one trial (100 women) reported
on vaginal delivery not achieved in 24 hours (68%
vs. 40%, RR: 1.70, 95% CI: 1.15–2.51). Compared
with misoprostol, the effectiveness of mechanical
methods was similar (34% vs. 30%, RR: 1.15, 95%
CI: 0.80–1.66). The use of mechanical method re-
duced the risk of hyperstimulation with FHR changes
when compared with prostaglandins: vaginal PGE2
(0% vs. 6%, RR: 0.14, 95% CI: 0.04–0.53), intracer-
vical PGE2 (0% vs. 1%, RR: 0.21, 95% CI: 0.04–
1.20), and misoprostol (4% vs. 9%, RR: 0.41, 95%
CI: 0.20–0.87). There was no difference in the risk of
cesarean delivery between mechanical methods and
prostaglandins. Serious neonatal (3 cases) and mater-
nal morbidity (1 case) were infrequently reported.
When compared with oxytocin, use of mechanical
methods reduced the risk of cesarean delivery (4
trials, 198 women, 17% vs. 32%, RR: 0.55, 95% CI:
0.33–0.91). There were no reported cases of serious
maternal morbidity, and severe neonatal morbidity
was not reported. These results are similar whatever
specific mechanical method was used, except with
extraamniotic infusion. When comparing extraamni-
otic infusion with any prostaglandins, women were
more likely to not achieve vaginal delivery within 24
hours (57% vs. 42%, RR: 1.33, 95% CI: 1.02–1.75),
the risk of cesarean delivery was increased (31% vs.
22%, RR: 1.48, 95% CI: 1.14–1.90), without a re-
duction in the risk of hyperstimulation. The authors
concluded that there is insufficient evidence to eval-
uate the effectiveness, in terms of likelihood of vag-
inal delivery in 24 hours, of mechanical methods
compared with placebo/no treatment or with prosta-
721
glandins. The risk of hyperstimulation was reduced
when compared with prostaglandins (intracervical,
intravaginal, or misoprostol). Compared with oxyto-
cin in women with unfavorable cervix, mechanical
methods reduce the risk of cesarean delivery.16
WHO recommends the use of balloon catheter for
IOL and cites evidence in its support, including a
systematic review that evaluated comparison of the
balloon catheter with prostaglandins, oxytocin, and
placebo. Compared with prostaglandins, the balloon
catheter was associated with a lower risk of uterine
hyperstimulation with FHR changes (7 trials, 823
participants, RR: 0.51, 95% CI: 0.30–0.86) and the
risk of cesarean delivery with the 2 methods was
similar (19 trials, 2050 participants, RR: 1.01, 95%
CI: 0.88–1.17).10 Compared with oxytocin, the bal-
loon catheter was associated with a lower risk of
cesarean delivery (2 trials, 125 participants, RR:
0.43, 95% CI: 0.22–0.83). In the comparison of bal-
loon catheter plus oxytocin with misoprostol, the
combination approach was associated with higher
chance of vaginal birth achieved within 24 hours.10
A recent meta-analysis has compared intravaginal
misoprostol with Foley catheter for labor induction
(9 studies, 1603 patients) and found no significant
differences in the mean time to delivery (mean dif-
ference, 1.08 ⫾ 2.19 hours shorter for misoprostol,
P ⫽ 0.2348), the rate of caesarean delivery (RR:
0.991, 95% CI: 0.768, 1.278), or in the rate of cho-
rioamnionitis (RR: 1.130, 95% CI: 0.611, 2.089)
between women who received misoprostol compared
with transcervical Foley catheter. Patients who re-
ceived misoprostol had significantly higher rates of
tachysystole compared with women who received a
transcervical Foley catheter (RR: 2.844, 95% CI:
1.392, 5.812).17
The opinion of professional organizations differs
with regard to use of mechanical methods of IOL.
The balloon catheter is recommended by WHO for
IOL. The combination of balloon catheter plus oxy-
tocin is recommended as an alternative method of
IOL when prostaglandins are not available or are
contraindicated.10 NICE guidelines, however, recom-
mend that mechanical procedures (balloon catheters
and laminaria tents) should not be used routinely for
the IOL citing limited evidence for their efficacy and
possibly increased risk of neonatal infection.2
Other methods of mechanical induction include
hygroscopic dilators like laminaria tents, which may
be placed in the cervix and dilate secondary to water
absorption. Several dilators may be inserted into the
cervix, and they expand during 12 to 24 hours. The
evidence regarding the use of hygroscopic dilators is
722 Obstetrical and Gynecological Survey
limited, and they do not appear to improve the out-
come of IOL.
Other Methods
Amniotomy (ARM) involves rupturing of the mem-
branes using an amnihook. In the past, ARM was
often used to prime the cervix and to induce labor.
About 80% to 90% of women may enter labor
within 24 hours of rupture of membranes. ARM
alone or in combination with oxytocin should not
be used as a method for IOL unless the use of
PGE2 is contraindicated as per NICE guidelines.2
Sweeping of membranes is recommended for reduc-
ing formal IOL.10 The membranes can be stripped
from the internal os and the lower uterine segment
by passing a finger and sweeping the membranes
around the presenting part leading to release of
local prostaglandins. The membrane sweep is usu-
ally offered at 41 weeks in the antenatal clinic
before a planned IOL. Some women may find this
procedure uncomfortable, and they should be
aware of possibility of having blood-stained vag-
inal discharge for the next 2 to 3 days. There is no
evidence of increased risk to the mother or fetus
from this procedure. A systematic review consist-
ing of 21 studies suggests that membrane sweep-
ing might allow fewer women to be induced within
1 week, as some may enter labor during the next
few days.18
Mifepristone is a very effective antiprogesterone and
antiglucocorticoid. Randomized trials have shown
it to be very effective in inducing labor. The use of
mifepristone is only recommended following in-
trauterine fetal death.
The following methods for IOL are not presently
recommended: oral or intravenous or intracervical
PGE2, hyaluronidase, corticosteroids, estrogen, and
vaginal nitric oxide donors. There is also insufficient
evidence to recommend any of the following non-
pharmacological methods of IOL: herbal supple-
ments, acupuncture, castor oil, homeopathy, sexual
intercourse, breast stimulation, curries, enemas, and
hot baths.
INDICATIONS AND CONTRAINDICATIONS
FOR IOL
Some of the common indications and contraindi-
cations for IOL are listed in Table 2. Caution is
advised when considering IOL in cases of multiple
pregnancies, unstable lie, polyhydramnios, grand
TABLE 2
Common indications and contraindications for IOL
Indications for induction of labor
Prolonged pregnancy
Preterm/prelabor rupture of membranes
Intrauterine growth restriction
Maternal conditions like preeclampsia, diabetes, cholestasis,
or SLE
Abnormal antenatal fetal surveillance test
Contraindications for induction of labor
Maternal contraindications
Previous classical or multiple caesarean sections
Infections like HIV, active genital herpes
Previous traumatic delivery
Major placenta previa
Fetal contraindications
Malpresentations such as transverse lie, face, or brow
Severe fetal compromise (preterminal CTG or severe
Doppler abnormalities)
Cord prolapse
Vasa previa
IOL indicates induction of labor; SLE, systemic lupus erythem-
atosus; CTG, cardiotocograph.
TABLE 3
Risks associated with induction of labor
Maternal discomfort and increased need for analgesia
Failure of induction and need for operative delivery
Water retention and hyponatremia with prolonged use of oxytocin
Uterine rupture
Abruption
Postpartum hemorrhage
Iatrogenic prematurity
Fetal compromise due to uterine hyperstimulation
Cord prolapse
Chorioamnionitis
Neonatal jaundice with prolonged use of oxytocin
multiparous women, and previous one low transverse
cesarean delivery. The last 2 are associated with
increased risk of uterine rupture. These pregnancies
require close fetal and maternal monitoring through-
out the induction process.
RISKS ASSOCIATED WITH IOL
Risks associated with the process of IOL are sum-
marized in Table 3. It is critical to ensure that women
are counseled adequately regarding the risks and
benefits of the process before IOL and that this is
documented appropriately in the notes.
EVIDENCE FOR IOL IN VARIOUS
OBSTETRIC SITUATIONS
Given the risks associated with the process of
induction and likelihood of 1 in 5 IOL ending up
 Failed Induction of Labor Y CME Review Article
with a caesarean delivery, it is mandatory that
benefits from IOL outweigh these risks. Analysis
of indications for IOL has revealed that while there
is high-quality evidence for IOL in cases of pro-
longed pregnancies or premature rupture of mem-
branes (PROM) at term, a fair number of inductions
have debatable obstetric indications.19
Prolonged Pregnancy
Prolonged gestation complicates 5% to 10% of all
pregnancies and has been associated with increased
risk to both the mother and fetus. Postterm pregnancy
(beyond 42 completed weeks) has been associated
with higher rates of stillbirth, macrosomia (birth
weight, ⬎4000 g), birth injury, and meconium aspi-
ration syndrome. The risk of stillbirth has been esti-
mated as 1 per 3000 at 37 weeks to 3 per 3000 at 42
weeks and 6 per 3000 at 43 weeks. Maternal risks
include dysfunctional labor, shoulder dystocia, ob-
stetric trauma, increased operative delivery rates, and
postpartum hemorrhage. Prolonged pregnancy is one
of the most common indications for IOL throughout
the world, and the rates vary between different coun-
tries and birthing units based on their individual
induction policies.
A Cochrane review, which included 19 trials (7984
women), found that a policy of labor induction at 41
completed weeks or beyond was associated with
fewer (all cause) perinatal deaths (1/2986 vs. 9/2953,
RR: 0.30, 95% CI: 0.09–0.99). There was no evi-
dence of a statistically significant difference in the
risk of cesarean delivery (RR: 0.92, 95% CI: 0.76–
1.12; RR: 0.97, 95% CI: 0.72–1.31) for women in-
duced at 41 and 42 completed weeks, respectively.
Women induced at 37 to 40 completed weeks were
less likely to have a cesarean delivery than those in
the expectant management group (RR: 0.58, 95% CI:
0.34–0.99). There were few babies with meconium
aspiration syndrome (41⫹: RR: 0.29, 95% CI: 0.12–
0.68, 4 trials, 1325 women; 42⫹: RR: 0.66, 95% CI:
0.24–1.81, 2 trials, 388 women).20
Although there have been arguments that there is
no conclusive evidence that prolongation of preg-
nancy “per se” is the major risk factor for perinatal
deaths and that other specific risk factors like intra-
uterine growth restriction and fetal malformations
may play a significant role,21 the current best evi-
dence suggests that IOL in the clinical settings of
postterm pregnancy reduces meconium aspiration
syndrome and perinatal deaths. Caesarean deliveries
are not increased by a policy of IOL at or beyond 41
weeks of gestation. NICE guidelines recommend that
723
women with uncomplicated pregnancy should be of-
fered IOL between 41 and 42 weeks of gestation.
Should a woman decline IOL following 42 weeks’
gestation, it is recommended that the women be
offered at least twice weekly cardiotocograph (CTG)
monitoring and ultrasound assessment of the maxi-
mum amniotic fluid pool depth.2 WHO recommends
IOL for women who are known with certainty to
have reached 41 weeks.10
PROM at Term
A Cochrane review, which included 12 trials (total
of 6814 women), detected no differences for mode of
birth between planned and expectant groups: RR of
cesarean delivery, 0.94, 95% CI: 0.82 to 1.08 (12
trials, 6814 women); RR of operative vaginal birth,
0.98, 95% CI: 0.84 to 1.16 (7 trials, 5511 women).
Significantly fewer women in the planned compared
with expectant management groups had chorioam-
nionitis (RR: 0.74, 95% CI: 0.56–0.97, 9 trials, 6611
women) or endometritis (RR: 0.30, 95% CI: 0.12–
0.74, 4 trials, 445 women). No difference was seen
for neonatal infection (RR: 0.83, 95% CI: 0.61–1.12,
9 trials, 6406 infants). However, fewer infants under
planned management went to neonatal intensive or
special care compared with expectant management
(RR: 0.72, 95% CI: 0.57–0.92, number needed to treat
20; 5 trials, 5679 infants). In a single trial, significantly
more women with planned management viewed their
care more positively than those expectantly managed
(RR of “nothing liked”: 0.45, 95% CI: 0.37–0.54, 5031
women).22 IOL for PROM at term reduces chorioam-
nionitis, endometritis, and NICU admissions, without
increasing caesarean deliveries.
Fetal Macrosomia
IOL does not improve outcomes in the setting of
suspected fetal macrosomia but may increase caesar-
ean deliveries.19 Unreliability of ultrasound estima-
tion of the fetal weight adds to the complexity of
decision making.
OVERT DIABETES AND GESTATIONAL
DIABETES MELLITUS
A Cochrane systematic review,23 which included 1
RCT24 that assigned 200 women with insulin-
requiring gestational diabetes mellitus or preexisting
type II diabetes to either induction at 38 weeks of
gestation or expectant care, found no difference in
the rate of caesarean delivery between these ap-
724 Obstetrical and Gynecological Survey
proaches but found that fetal macrosomia, defined as
birth weight ⬎4000 g was significantly reduced by
IOL (RR: 0.56, 95% CI: 0.32–0.98, NNT: 8). The
birth weight of 23% of the babies born to expectantly
managed women was at or above the 90th percentile
compared with 10% of the babies born to induced
women. There were more cases of shoulder dystocia
in the expectantly managed group, but this difference
was not statistically significant. There were no dif-
ferences in other fetal or maternal morbidities. In
cases of gestational diabetes mellitus with good gly-
cemic control, no significant differences in perinatal
outcomes or caesarean rates have been observed
when expectant management up to expected date of
delivery and IOL are compared. However, IOL is
recommended if there is evidence of placental insuf-
ficiency or poor glycemic control.
Preeclampsia
In their review of best evidence in 2009, Mozurke-
wich et al19 suggested that expectant management for
severe preeclampsia remote from term increased
birth weight and reduced neonatal morbidity and that
IOL in this situation was associated with high rates of
intrapartum cesarean delivery but no increased harm
when compared with elective caesarean. Recently,
investigators of the HYPITAT (pregnancy-induced
hypertension and preeclampsia after 36 weeks: IOL
vs. expectant monitoring: a comparison of maternal
and neonatal outcome, maternal quality of life, and
costs) randomized trial25 evaluated maternal and neo-
natal complications in patients at 36 to 40 weeks’
gestation who were randomized to either IOL or
expectant monitoring. The results of this trial
revealed that IOL at or after 37–0 weeks was asso-
ciated with lower rate of maternal complications
without increased rates of either cesarean delivery or
neonatal complications. In contrast, the optimum
management for those with mild hypertension/
preeclampsia with stable maternal and fetal condi-
tions at 34–0/7 to 36–6/7 weeks remains uncertain.26
Intrauterine Growth Restriction
It has been suggested that in preterm pregnancies
with suspected intrauterine growth restriction, IOL
did not reduce perinatal deaths or overall long-term
disability; however, more evidence is needed to
make strong recommendations.19 The DIGITAT mul-
ticenter randomized trial allocated 321 pregnant
women to induction and 329 to expectant monitor-
ing. Induction group infants were delivered 10 days
earlier (mean difference: ⫺9.9 days, 95% CI: ⫺11.3
to ⫺8.6) and weighed 130 g less (mean difference:
⫺130 g, 95% CI: ⫺188 to ⫺71 g) than babies in the
expectant monitoring group. A total of 17 (5.3%)
infants in the induction group experienced the com-
posite adverse neonatal outcome, compared with 20
(6.1%) in the expectant monitoring group (differ-
ence: ⫺0.8%, 95% CI: ⫺4.3% to 3.2%). Cesarean
deliveries were performed on 45 (14.0%) mothers in
the induction group and 45 (13.7%) in the expectant
monitoring group (difference: 0.3%, 95% CI: ⫺5.0%
to 5.6%). The authors concluded that in women with
suspected intrauterine growth restriction at term, we
found no important differences in adverse outcomes
between IOL and expectant monitoring. Patients who
are keen on nonintervention can safely choose ex-
pectant management with intensive maternal and fe-
tal monitoring; however, it is rational to choose
induction to prevent possible neonatal morbidity and
stillbirth.27
Other Indications
Induction for macrosomia, social circumstances,
maternal request, or precipitate labor do not have a
strong evidence base to support them. These induc-
tions for “social indications” are often undertaken
electively at 38 to 39 weeks of gestation when IOL
can be harmful to both mother (increased chances of
failure and operative interventions) and the baby
(higher risk of respiratory distress).
A study analyzed 7430 women with a single baby
in vertex presentation and delivering between 38 and
40 weeks of pregnancy. Among these women, 3546
were excluded for prelabor pregnancy complications.
Relative risks (RR), adjusted for parity, were com-
puted to compare 3353 women who went into labor
spontaneously with 531 women whose labor was
induced. IOL was found to be associated with a
higher risk of cesarean delivery [RR: 2.4, 95% CI:
1.8, 3.4]. Use of nonepidural [RR: 1.5, 95% CI: 1.2,
1.8] and epidural analgesia [RR ⫽ 1.4, 95% CI: 1.1,
1.7] was more frequent after labor induction. Resus-
citation [RR ⫽ 1.2, 95% CI: 1.0, 1.5], admission to
the intensive care unit [RR ⫽ 1.6, 95% CI: 1.0, 2.4],
and phototherapy [RR ⫽ 1.3, 95% CI: 1.0, 1.6] were
more frequent after IOL. Results were similar
when controlling simultaneously for parity, mater-
nal age, gestational age, year of delivery, birth
weight, and the physician in charge of delivery in
a logistic regression analysis. The results sug-
gested that IOL is associated with a higher risk of
cesarean delivery and some perinatal adverse out-
 Failed Induction of Labor Y CME Review Article
comes. IOL should be therefore be reserved for
cases where maternal and perinatal benefits out-
weigh the risk of these complications.28
Although there are few studies suggesting benefits,
there is lack of adequate robust evidence to guide
practice in cases of oligohydramnios, twin preg-
nancy, preterm PROM, and intrahepatic cholestasis
of pregnancy, and further research is necessary to
identify appropriate timing as well as potential risks
and benefits of IOL in these settings.
Place of IOL
Recent WHO guidelines stress that wherever IOL
is carried out, facilities should be available for as-
sessing maternal and fetal well-being and women
receiving oxytocin, misoprostol, or other prostaglan-
dins should not be left unattended.10 It is good
practice to carry out CTG trace for 1 hour before
induction and at least for another 1 hour after intro-
duction of vaginal prostaglandins or throughout labor
if oxytocin is used. Wherever possible, IOL should
be carried out in facilities where cesarean delivery
can be performed.10
FAILED IOL
With rising rates of IOL, the concept of “failed
induction of labor” has grown in importance. There
is a need for uniformity in its definition and manage-
ment. It is very important that before IOL, women
should be counseled regarding this possibility.
Definition
Over the years, there have been several definitions
of failed IOL proposed by various authors. MacVicar
defined failed induction as those cases where the
uterus failed to contract after ARM and adequate
stimulation or the uterus contracted abnormally and
the cervix did not dilate completely.29 Duff et al
defined failed induction as the failure to enter the
active phase of labor after 12 hours of regular uterine
contractions.30 Few other definitions include failure
to achieve dilation ⱖ4 cm after trial of oxytocin to a
maximum of 20 mU/min,31 failure to enter the active
phase of labor within 12 hours after IOL was be-
gun,32,33 failure to enter the active phase of labor
(Bishop score ⬍8) after 24 hours of IOL,34 failure to
achieve the active phase (3 cm and completely ef-
faced) after a maximum of 12 hours of oxytocin
administration,35 and failure of sufficient ripening of
the cervix to allow ARM, following the use of re-
725
peated doses of prostaglandin, leading to delivery by
cesarean delivery. The shear variety of definitions
demonstrates the clinical uncertainty in diagnosis of
failed induction. Lin and Rouse in their review indi-
cated that a definition for IOL failure should maxi-
mize the number of women progressing to the active
phase of labor (and ultimately delivering vaginally)
while maintaining a low incidence of adverse mater-
nal and neonatal outcomes. Their proposed definition
was the inability to achieve a cervical dilatation of
4 cm and 90% effacement or at least 5 cm (regard-
less of effacement) after a minimum of 12 to 18
hours of membrane rupture and oxytocin adminis-
tration (with a goal of 250 MonteVideoUnits or 5
contractions/10 min).36
In current practice, failed induction is diagnosed
when the woman does not enter active labor or the
cervical score does not improve or the cervix does not
dilate ⬎3 cm after a 12-hour period of artificial rupture
of membranes and good uterine activity with oxytocin
infusion.5 Failed IOL needs to be differentiated from
failure of progress in active phase of labor due to
cephalopelvic disproportion or malposition.
Reasons for failed induction
1. Cervical and pelvic factors—IOL with an un-
favorable cervix is likely to fail more often than
ripe cervix. The uterine work needed to over-
come resistance offered by a firm cervix is
much higher consequently increasing chances
of failure of induction.6
2. Fetal factors—macrosomia.37
3. Persistent occipitoposterior position— has been
associated with increased chance of failure of
IOL.7
4. Improper assessment of gestation may contrib-
ute to failure of induction. This is a major
problem in developing countries where early
pregnancy scan may not be available to confirm
gestation accurately. Induction below 41 weeks
may thus lead to failure of IOL. The use of
ultrasound for assessment of gestational age
has been shown to decrease the incidence of
postterm pregnancy from 12% to 3%.38
Failed IOL—Suggestions to Improve the
Vaginal Delivery Rates
As discussed previously, a number of common
indications for IOL do not have a strong evidence
base from which to guide practice, whereas many
others have shown no major benefits for women. A
726 Obstetrical and Gynecological Survey

strict policy of IOL for indications where benefits
clearly outweigh the risks can contribute to reduction
in the induction rates.
Sweeping of membranes is recommended for re-
after IOL for prolonged pregnancy in absence of any
ducing formal IOL. A membrane sweep should be
obvious fetal or maternal complications. If IOL was
offered to all women unless there are specific clinical
performed for medical indications, the severity of
concerns like a low-lying placenta or if the woman
fetal or maternal compromise will determine which
does not wish to have it.
option takes the priority.
Tailoring IOL to the parity, cervical score, and
indication might reduce the cesarean delivery rate for
failed IOL. Cervical ripening is crucial before the
process of induction and the use of PGE2 or PGE1 to
ripen cervix, and further, induce labor has already
been shown to be more successful approach over the
traditional methods like ARM or oxytocin infusion.
Once the woman enters active labor, appropriate
management to ensure adequate uterine activity and
if required augmentation with oxytocin is equally
important.
There is some evidence that sonographic assess-
ment of preinduction cervical length and the position
of the fetal occiput in addition to maternal character-
istics, including parity, gestational age, maternal age,
and body mass index, provide useful prediction of
the likelihood of success of induction.39–41 The odds
of cesarean delivery increase by about 10% with
each increase of 1 mm in cervical length above 20
mm and the odds are about 75% lower in multip-
arous women compared with nulliparous women
with the same cervical length.42 However, in the
absence of rigorous RCT-based evidence of its
cost-effectiveness and impact on clinical out-
comes, routine use of ultrasonography before IOL
cannot be recommended at present.
Management
Antenatal Counseling
Failed IOL does not necessarily indicate cesarean
delivery. The mother and fetus should be completely
reassessed. A repeat attempt at IOL after variable
length of time may be considered. The repeat in-
duction can be attempted either with the same or
different prostaglandin or mechanical method of
induction. The woman should be appropriately
counseled about the options of repeat IOL versus
cesarean delivery, and her choice should be re-
spected at all times. Advanced antenatal education
of the possibility of repeat induction may help
more women to accept repeat induction and im-
prove chances of vaginal birth.
Suggested Management Options After Failed
Primary Induction
These options mainly apply to failed induction
One of the following options may be considered:
1. Expectant management—perform CTG and ul-
trasonography (USG) scan for liquor volume. If
both are reassuring, the woman may be given
an option of expectant management for up to 3
days based on her preference. She then follows
up for CTG and liquor volume assessment in 72
hours if spontaneous labor has not set in by this
time. Reconsideration of all the options may be
done based on cervical score at the next visit,
and a decision for repeat induction or caesarean
be made taking the woman’s wishes on board.
2. Repeat induction with same prostaglandin
regime—perform CTG and USG scan for liquor
volume. If both are reassuring, repeat induction
with same prostaglandin (usually PGE2) after a
gap of 48 hours.
3. Repeat induction with alternative PG regime—
perform CTG and USG scan for liquor volume. If
both are reassuring, repeat induction with alterna-
tive prostaglandin (PGE1) after a gap of 48 hours.
4. Repeat induction with mechanical method—
perform CTG and USG scan for liquor volume.
If both are reassuring, repeat induction with
mechanical method after gap of 48 hours
(Foley balloon catheter is inserted into the cer-
vix, and the balloon distended. Patient is then
allowed home and instructed to come back if
(a) catheter falls off, (b) she starts contracting
or notes leakage of fluid/blood per vaginum or
any other concerns. If there are no concerns,
she follows up after further 48 hours for reas-
sessment of cervical status).
5. Cesarean delivery if induction is not accept-
able—perform CTG and USG scan for liquor
volume. If both are reassuring, repeat CTG and
USG scan after 48 to 72 hours to assess chance
of success of repeat induction based on assess-
ment of cervical length and position of occiput.
For women not willing for conservative man-
agement or repeat prostaglandins with a poor
cervical score and unfavorable ultrasound find-
ings, cesarean delivery may be offered.
 Failed Induction of Labor Y CME Review Article
A study that used an alternative method (intracer-
vical Foley catheter) for repeat IOL after failure of
primary induction with PGE2 tablets found that 75%
of these patients delivered vaginally.43
NEED FOR FURTHER RESEARCH
INTO IOL
Some of the key aims for research in area of IOL
are—(1) to develop a good vehicle for delivering
vaginal prostaglandins, (2) to develop a test to accu-
rately identify those fetuses most at risk of morbidity
or stillbirth who would truly benefit from an early
IOL, (3) to study whether induction with vaginal
prostaglandin may increase risk of infection for
mother and baby in women with prelabor rupture of
membranes, (4) to develop a tool to identify of those
women most likely to have a successful induction,
and (5) to gather more high-quality RCT-based evi-
dence for various indications for IOL where there is
clinical uncertainty with regards to risks versus benefits.
Efforts need to continue to achieve better assessment of
fetal weight as well as to undertake the cost-analysis of
policies of IOL for various indications.
SUMMARY
Rates of IOL are rising worldwide. The availability
of prostaglandins, which act as both cervical ripening
and inducing agents, has improved the success rates
of inductions as compared with the traditional ap-
proaches of ARM and oxytocin infusion. Prolonged
pregnancy is one of the most common indications for
IOL. Up to 20% of inductions fail and need delivery
by cesarean delivery. The process of induction itself
is associated with significant risks of complications,
like hyperstimulation, rupture uterus, and increased
risk of operative deliveries. The decision to induce
labor therefore should not be taken lightly, and the
woman should be involved in decision-making pro-
cess after appropriate counseling. Induction for bor-
derline indications not justified by current evidence
should be avoided. The increasing rates of cesarean
deliveries are a cause for concern, and the issue of
failed induction needs to be addressed as a priority.
Uniformity in its definition and management strategy
are urgently needed. The recent guidelines from
WHO stress that failed induction does not necessarily
indicate cesarean delivery. In the absence of fetal or
maternal complications, either a repeat attempt at
induction with prostaglandins/mechanical methods
after 48 hours or expectant management with fetal
surveillance for additional 48 to 72 hours may be
727
worth considering to improve the vaginal delivery
rates in women with failed primary induction.
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