a best-evidence review
E Mozurkewich,a J Chilimigras,a E Koepke,a K Keeton,a VJ Kingb
a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
b Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
Correspondence: Dr E Mozurkewich, F4835, PO Box 0264, Mott Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0264, USA.
Accepted 2 November 2008. Published Online 4 February 2009.
Background Rates of labour induction are increasing.
Objectives To review the evidence supporting indications for
Search strategy 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.
Selection criteria 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.
Main results 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.
Authors’ conclusions Research is needed to determine risks and
benefits of induction for many commonly advocated clinical
Keywords Best evidence, indications, induction.
Please cite this paper as: Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King V. Indications for induction of labour: a best-evidence review. BJOG 2009;116:626