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Induction of labor (IOL) is the process of artificially stimulating the uterus to start labor. IOL should be considered only in cases where there is a clear medical indication and the expected benefits of an earlier delivery outweigh the potential harms. A careful and well-documented discussion should occur between the health care provider and the patient and should include the reason for induction, method of induction, and risks associated with IOL. Depending on the indication for induction, IOL has been associated with higher rates of complications such as bleeding, operative vaginal deliveries, cesarean deliveries, uterine hyperstimulation, and adverse perinatal outcomes.

Some common indications and contraindications for IOL are discussed below.


  • PRELABOR SPONTANEOUS RUPTURE OF MEMBRANES (PROM) If membrane rupture occurs beyond 37 weeks and labor does not begin within 24 hours of PROM, IOL is appropriate and recommended to reduce the risk of infection to both the mother and the baby. In the case of maternal GBS colonization, IOL should be considered immediately rather than choosing expectant management.

  • PRETERM PRELABOR RUPTURE OF MEMBRANES (PPROM) If membrane rupture occurs prior to 37 weeks gestational age, IOL should be considered after 34 weeks in the context of the patient’s complete clinical picture.

  • PREECLAMPSIA IOL should be considered in women with severe preeclampsia at any gestational age. IOL should also be considered for patients with gestational hypertension ≥38 weeks in the context of other clinical findings.

  • ANTEPARTUM BLEEDING IOL may be indicated in cases of significant but stable antepartum bleeding.

  • MATERNAL DIABETES Insulin-dependent diabetes is associated with an increased risk of in utero fetal death during the later weeks of pregnancy. In cases of preexisting diabetes, insulin-dependent diabetes, or in the presence of complications associated with diabetes, labor induction is indicated. Maternal glucose control may dictate the urgency of IOL. The timing of induction should be individualized. Unless otherwise indicated, IOL for gestational diabetes (GDM) that is controlled with diet and exercise only should not occur before 39 weeks.

  • INTRAUTERINE FETAL DEATH (IUFD) In cases of IUFD where there is evidence of ruptured membranes, infection, bleeding, or coagulopathy, immediate IOL is recommended. If the woman is otherwise well, labor induction may be delayed. IOL may also be considered in women with a history of IUFD near term in past pregnancies. The timing of induction should be individualized but is usually carried out 1 week prior to the gestation of a previous stillbirth.

  • ADVANCED MATERNAL AGE (AMA) AMA is associated with an increase in antenatal and intrapartum stillbirth. The risk at 39 weeks in a 40-year-old is equivalent to the risk at 41 weeks in a 24- to 29-year-old, although the absolute risk is still low. IOL should be offered at 39 weeks for mothers above the age of 40.

  • CHOLESTASIS OF PREGNANCY Due to the increased risk of stillbirth associated with obstetrical cholestasis, IOL should be offered at 37 weeks gestational age.


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