Tuesday, June 30, 2009

Indications for induction of labour

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.

Email mozurk@umich.edu

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

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