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National Collaborating Centre for Women's and Children's Health (UK). Induction of Labour. London: RCOG Press; 2008 Jul. (NICE Clinical Guidelines, No. 70.)

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Induction of Labour.

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7Monitoring and pain relief for induction of labour

7.1. Monitoring of induction of labour

Clinical question

The assessment of fetal wellbeing is an important component of care during labour, providing accurate information to prevent risks to both mother and baby. Induction of labour has unwanted effects, one of the most common being uterine hyperstimulation. Monitoring regimens will depend on the method of induction. The intensity of uterine contractions was reported to be lower in spontaneous labour than in elective induction in a cohort study.180 Uterine contractions after vaginal prostaglandins usually begin within the first few hours, reaching a peak at 5–6 hours after insertion. Across all the different preparations of induction methods reviewed in this guideline, there is level 1+ evidence that the incidence of uterine hyperstimulation with or without FHR changes ranged from 1% to 5%.

Overview of available evidence

No evidence on the effectiveness of the monitoring regimens during induction was identified. Reference is made to the NICE clinical guideline on intrapartum care, which provides guidance on maternal and fetal monitoring during labour.17

Evidence statements

No direct evidence was identified relating to the most effective monitoring regimen for women undergoing induction of labour.

Interpretation of evidence

While there is no direct evidence, there is expert opinion on the most appropriate monitoring protocol for women at and/or during induction of labour.

The GDG agrees and supports the recommendations made in the NICE intrapartum care guideline relating to maternal and fetal monitoring protocols once active labour begins.

Recommendations on monitoring of induction of labour

Wherever induction of labour is carried out, facilities should be available for continuous electronic fetal heart rate and uterine contraction monitoring.

Before induction of labour is carried out, Bishop score should be assessed and recorded, and a normal fetal heart rate pattern should be confirmed using electronic fetal monitoring.

After administration of vaginal PGE2, when contractions begin, fetal wellbeing should be assessed with continuous electronic fetal monitoring. Once the cardiotocogram is confirmed as normal, intermittent auscultation should be used unless there are clear indications for continuous electronic fetal monitoring as described in ‘Intrapartum care’ (NICE clinical guideline 55).

If the fetal heart rate is abnormal after administration of vaginal PGE2, recommendations on management of fetal compromise in ‘Intrapartum care’ (NICE clinical guideline 55) should be followed.

Bishop score should be reassessed 6 hours after vaginal PGE2 tablet or gel insertion, or 24 hours after vaginal PGE2 controlled release pessary insertion, to monitor progress (see Section 5.1.1).

If a woman returns home after insertion of vaginal PGE2 tablet or gel, she should be asked to contact her obstetrician/midwife:

  • when contractions begin, or
  • if she has had no contractions after 6 hours.

Once active labour is established, maternal and fetal monitoring should be carried out as described in ‘Intrapartum care’ (NICE clinical guideline 55).

Research recommendation on monitoring of induction of labour

Studies are needed to identify the most effective way of monitoring women during the induction of labour process.

7.2. Pain relief during induction of labour

Clinical questions

  • What is the evidence that induced labours are more painful than spontaneous labour?
  • What are the harms and effects of early (at induction) and late (active labour) administration of epidural analgesia?

Women may experience induced labour as being more painful than spontaneous labour. Each labour needs to be managed on a case-by-case basis.

Overview of available evidence

One RCT and one cohort study were identified relating to analgesic requirements in induced and spontaneous labour. Two RCTs compared early and late epidural. A systematic review of vaginal prostaglandins and oxytocin relating to epidural requirement was included. Reference is made to the NICE clinical guideline in intrapartum care as supplementary evidence.

No studies were identified that examined the use of satisfactory analgesia available to women who are progressing rapidly in labour after induction and whose birth is expected within 2–3 hours from the time of induction.

Analgesic requirements in induced and in spontaneous labour

One cohort study in Italy compared the effects of spontaneous (n = 31) and prostaglandin-induced labour (n = 30) on the minimum analgesic dose (MAD) of epidural sufentanil in the first stage of labour in women (at or after 37 weeks of gestation with cervical dilation 2–4 cm) requesting epidural pain relief in labour. The initial dose was sufentanil 25 micrograms and analgesic effectiveness was assessed using 100 mm visual analogue scale (VAS) pain scores. The MAD of sufentanil in spontaneous labour was 22.2 micrograms (95% CI 19.6 to 22.8 micrograms) and 27.3 micrograms (95% CI 23.8 to 30.9 micrograms) in induced labour, and the latter was significantly greater than that in spontaneous labour (P = 0.0014) by a factor of 1.3 (95% CI 1.1 to 1.5). Reported sedation/drowsiness effects were significantly higher in the induced group (P = 0.024). This suggests that prostaglandin induction of labour produces a greater analgesic requirement than does spontaneous labour.181 [EL = 2+]

Effects of epidural analgesia on induced labour

One RCT in Taiwan assessed the efficacy of epidural (fentanyl) (n = 60, Group A) and no epidural (n = 60, Group B) to relieve labour pain during the early period of the first stage of induced labour (intravenous oxytocin). Results were also compared with a control group (n = 198, Group C) who refused randomisation and did not receive analgesia during the entire labour course. There were no significant differences between the three groups in duration of labour, modes of birth or fetal outcomes. Throughout the entire labour course, particularly in the first 4 hours, pain scores assessed with VAS were significantly lower in Group A than in Groups B and C (P < 0.001) and analgesia quality, as assessed by the women, was significantly better in Group A than in Group B (80% versus 0% rated it ‘excellent’, P < 0.001).182 [EL = 1+]

One RCT in France compared the effects of epidural analgesia given at the beginning of induction (oxytocin) (n = 41) versus epidural analgesia given when labour entered the active phase (n = 47). There were no significant differences between the two groups in the length of labour or mode of birth.183 [EL = 1+]

One RCT in the USA compared the effects of early (n = 74) versus late (n = 75) administration of epidural analgesia in nulliparous women undergoing induction of labour with intravenous oxytocin at or after 36 weeks of gestation and cervical dilation 3–5 cm. There were no significant differences between early (bupivacaine) and late (intravenous nalbuphine followed by late epidural) administration of epidural analgesia in the interval between randomisation and the diagnosis of full cervical dilation (318 versus 273 minutes), incidence of spontaneous birth (39% versus 32%), instrumental vaginal birth (43% versus 49%) or caesarean birth rate (18% versus 19%; RR 0.94, 95% CI 0.48 to 1.84). Women in the early epidural group experienced lower pain scores between 30 and 120 minutes after randomisation, better quality analgesia and higher satisfaction, but they were more likely to experience transient hypotension. Apgar scores = 7 at 5 minutes were similar between the two groups.184 [EL = 1+]

Intravenous oxytocin versus vaginal PGE2

Data from one systematic review suggested that a significantly higher epidural usage was associated with induction of labour with intravenous oxytocin than with vaginal PGE2 (RR 1.11; 95% CI 1.04 to 1.19, nine RCTs) in women with different parity, cervical and membranes status.117 [EL = 1++]

Guidance on pain relief strategies for women during labour is provided in the NICE guideline on intrapartum care.17

Evidence statements

There is no evidence concerning analgesia requirement during the induction process and before the onset of labour.

Women in spontaneous labour are more likely to require a smaller minimum effective dose of epidural sufentanil than women after induction of labour. [EL = 2+]

Epidural analgesia was associated with lower pain scores and higher maternal satisfaction when compared with no epidural analgesia in women during the early stage of induced labour. [EL = 1+]

Early, rather than late, administration of epidural analgesia does not prolong labour or increase the incidence of instrumental or caesarean section births. There is no benefit in waiting until labour has started to give epidural. [EL = 1+]

Induction with oxytocin may be more painful than induction with vaginal PGE2. [EL = 1++]

Interpretation of evidence

Although there was no evidence of analgesia requirement during the induction process and before the onset of labour, women need the pain relief appropriate to them and their pain. This can range from simple analgesia to epidural analgesia.

There is evidence that women in whom labour is induced have greater analgesia requirements than those with spontaneous onset of labour.

Early compared with late administration of epidural analgesia does not prolong labour or increase the need for assisted birth in women whose labours were induced, but is associated with greater maternal satisfaction.

Oxytocin-induced labours may have greater analgesia requirements than those induced with vaginal prostaglandins.

The GDG agrees and supports the recommendations made in the NICE intrapartum care guideline relating to pain relief strategies during labour.

Recommendations on pain relief during induction of labour

Women being offered induction of labour should be informed that induced labour is likely to be more painful than spontaneous labour.

Women should be informed of the availability of pain relief options in different settings (see Sections 3.1 and 7.1).

During induction of labour, healthcare professionals should provide women with the pain relief appropriate for them and their pain (as described in ‘Intrapartum care’ (NICE clinical guideline 55)). This can range from simple analgesics to epidural analgesia.

Birth attendants (carers and healthcare professionals) should offer women support and analgesia as required, and should encourage women to use their own coping strategies for pain relief.

The opportunity to labour in water is recommended for pain relief.*


This recommendation is from ‘Intrapartum care: care of healthy women and their babies during childbirth’ (NICE clinical guideline 55). Available from www​

Research recommendations on analgesia consideration during induction of labour

Research is needed to evaluate the effects of regional analgesia on progress and outcome of induced labour, stratified for differing cervical status.

Studies are needed to assess the role support plays in alleviation of pain during induction of labour.

Copyright © 2008, National Collaborating Centre for Women's and Children's Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK []. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

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Bookshelf ID: NBK53623


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