Indications for induction of labour: a best-evidence review

Rates of labour induction are increasing.

To review the evidence supporting indications for induction.

We listed indications for labour induction and then reviewed the evidence. We searched MEDLINE and the Cochrane Library between 1980 and April 2008 using several terms and combinations, including induction of labour, premature rupture of membranes, post-term pregnancy, preterm prelabour rupture of membranes (PROM), multiple gestation, suspected macrosomia, diabetes, gestational diabetes mellitus, cardiac disease, fetal anomalies, systemic lupus erythematosis, oligohydramnios, alloimmunization, rhesus disease, intrahepatic cholestasis of pregnancy (IHCP), and intrauterine growth restriction (IUGR). We performed a review of the literature supporting each indication.

We identified 1387 abstracts and reviewed 418 full text articles. We preferentially included high-quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised trials and observational studies.

We included 34 full text articles. For each indication, we assigned levels of evidence and grades of recommendation based upon the GRADE system. Recommendations for induction of labour for post-term gestation, PROM at term, and premature rupture of membranes near term with pulmonary maturity are supported by the evidence. Induction for IUGR before term reduces intrauterine fetal death, but increases caesarean deliveries and neonatal deaths. Evidence is insufficient to support induction for women with insulin-requiring diabetes, twin gestation, fetal macrosomia, oligohydramnios, cholestasis of pregnancy, maternal cardiac disease and fetal gastroschisis.

Research is needed to determine risks and benefits of induction for many commonly advocated clinical indications.