6Setting and timing for induction of labour

6.1. Setting and timing for induction of labour

Clinical questions

  • What are the effects (harms and benefits) when induction of labour is carried out in different settings (outpatient, inpatient)?
  • What are the effects (harms and benefits) when induction of labour is carried out at different days of week and at different times of day?

Overview of available evidence

Two RCTs comparing inpatient and outpatient induction were included. One audit study examining the potential for outpatient induction was identified. Two RCTs and a cohort study comparing effects of induction in mornings and evenings were included. No comparative studies were identified relating to induction at home.

Outpatient versus inpatient induction of labour: vaginal PGE2

One RCT in Canada compared the effects of inpatient (n = 150) and outpatient (n = 150) induction of labour with controlled release PGE2 in women with uncomplicated pregnancy at term with a Bishop score = 6. Women in the outpatient group were monitored for 1 hour after controlled release PGE2 insertion and then allowed to go home with instructions to report to the fetal assessment unit by telephone if they experienced regular contractions, ruptured membranes, vaginal bleeding, reduced fetal movements or tachysystole. They were also instructed how to remove the insert if necessary. There were no significant differences between the two groups in any maternal or fetal adverse outcomes. Maternal satisfaction was significantly higher in the outpatient group (56% versus 39%, P = 0.008) and ratings of pain and anxiety during the first 12 hours of induction were similar.174 [EL = 1+]

One US RCT compared the feasibility and efficacy of inpatient cervical priming (n = 50) and outpatient cervical priming (n = 61) with transcervical Foley catheter in women with uncomplicated pregnancy at term and a Bishop score of < 5. Women in the outpatient group were given detailed written and oral instructions before discharge. These included 24 hour telephone access to a physician or nurse for any questions or concerns, such as vaginal bleeding, rupture of membranes, painful contractions and extrusion of the catheter. There were no significant differences in any maternal or fetal outcomes, including maternal discomfort. There were no adverse events in either group.175 [EL = 1+]

A UK clinical audit of outpatient cervical priming (n = 100, 86% induced for post maturity, induction methods not specified) suggested that elective admissions to birth ward were reduced by 75% with the introduction of outpatient cervical priming, thus allowing more efficient use of major resources. The experience improved women’s perception of the process of induction of labour.176 [EL = 3]

Inpatient induction of labour: morning versus evening

One RCT in Australia (part of a trial comparing oral misoprostol with vaginal PGE2) compared the effects of morning admission (8 a.m.) for induction of labour (n = 280) with evening admission (8 p.m.) (n = 340) in women at or after 36+6 weeks of gestation. There were no significant differences in outcomes such as achieving vaginal birth within 24 hours, incidence of uterine hyperstimulation with FHR changes or caesarean birth rates between admission and commencing induction of labour in the morning or in the evening. However, women in the morning induction group were significantly less likely to require oxytocin infusion (45% versus 54%; RR 0.83, 95% CI 0.70 to 0.97). Nulliparous women induced in the morning were also less likely to need operative vaginal birth (16% versus 34%; RR 0.45, 95% CI 0.25 to 0.90). Maternal and fetal complications were comparable between the two groups. Overall, women were satisfied with the care they received but disliked the lack of sleep associated with evening induction (4.4% versus 0.4%; RR 0.08, 95% CI 0.01 to 0.61).177 [EL = 1+]

One RCT in the Netherlands compared the effects of inpatient induction of labour with endocervical PGE2 gel 0.5 mg in the morning between 8 and 9 a.m. (n = 58, 30 nulliparous) and the evening between 10 and 11 p.m. (n = 68, 46 nulliparous) in women at term (Bishop score < 6) scheduled for induction of labour. Administration of PGE2 gel in the evening did not significantly reduce birth between 11 p.m. and 8 a.m. No multiparous woman induced in the evening delivered between 6 p.m. and 11 p.m. A greater number of nulliparous women induced in the evening delivered by vacuum or forceps (19 versus 3; RR 4.2, 95% CI 1.4 to 13). More women induced in the morning were satisfied with the timing of gel administration than women induced in the evening (77% versus 62%). Dissatisfaction with the time of gel administration was reported by 4% of women in the morning group and 20% in the evening group (RR 4.8, 95% CI 1.1 to 20). Quality of sleep was reported to be bad in 34% of the morning group as compared with 73% of the evening group (RR 1.7, 95% CI 1.1 to 2.5). The wish to choose another time for induction of labour in a future pregnancy was 8% in the morning group and 23% in the evening group (RR 2.4, 95% CI 0.86 to 6.6).178 [EL = 1+]

A UK study compared the outcomes of induction of labour with vaginal PGE2 gel 2 mg inserted at 10 p.m. (n = 40) and at 2 p.m. (n = 40) in women at 37–42 weeks of gestation scheduled for induction of labour. Inductions earlier in the day at 2 p.m. were associated with significantly shorter hospital stay (4.4 versus 5.3 days, P < 0.01) and reduced overall cost of admission. Other maternal outcomes were similar between the two groups. No fetal outcomes were reported.179 [EL = 2+]

Evidence statements

Evidence from two RCTs suggested that inpatient and outpatient induction achieve comparable maternal and fetal outcomes. Maternal satisfaction was higher in the outpatient induction group. [EL = 1+] Outpatient cervical priming has the potential to reduce admission to delivery wards and improve women’s perception of induction of labour. [EL = 3]

Evidence from one RCT suggested that induction of labour carried out in the morning or in the evening achieve similar outcomes and in terms of preventing birth during evening and night shifts. One RCT reported that morning induction is associated with a reduced need for oxytocin and operative vaginal birth, the latter in nulliparous women. There may be an increased risk of instrumental birth when induced in the evening. Women’s satisfaction was significantly higher when induction of labour took place in the morning. [EL = 1+]

Induction (vaginal PGE2) at 2 p.m. reduces the duration of hospital stay and admission costs when compared with induction at 10 p.m. [EL = 2+]

Interpretation of evidence

The GDG is aware that outpatient induction of labour is commonly offered to women with prolonged pregnancy. Evidence from the UK setting is very limited and more safety data are needed.

The available evidence from other countries appears to support induction of labour for this group of women in the outpatient setting. However, these data may not be generalisable to the UK setting.

There is evidence to favour morning admission for induction if vaginal PGE2 is used. Women were more satisfied when induction of labour took place in the morning. Small cost savings to the NHS might be realised as a result of reduced length of stay and lower admission costs.

Recommendations on setting and timing for induction of labour

In the outpatient setting, induction of labour should only be carried out if safety and support procedures are in place.

The practice of induction of labour in an outpatient setting should be audited continuously.

In the inpatient setting, induction of labour using vaginal PGE2 should be carried out in the morning because of higher maternal satisfaction.

Research recommendation on setting for induction of labour

Studies are needed to assess the safety, efficacy and clinical and cost-effectiveness of outpatient and inpatient induction in the UK setting, taking into account women’s views.

Research question

Is it safe, effective and cost-effective to carry out induction of labour in an outpatient setting? What are the advantages and disadvantages of such an approach, taking into account women’s views?

Why is this important?

In line with the way healthcare has developed in many areas of acute care, there is an increasing desire to reduce the time women spend in hospital. Several units are already exploring outpatient induction of labour policies and there is a need to study this approach in order to determine relative risks and benefits, as well as acceptability to women.