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Induction of Labour

Most guidelines recommend PGE2 in the form of tablets, gel or controlled release pessary for cervical ripening prior to labour induction. Dinoprostone gel via the intracervical route is also favoured in Italy.  Recommendations with regard to misoprostol vary from “recommending with care” (Spain), noting that its use is “off label” (Germany) to “contraindicated” (France and Italy). In the UK misoprostol is only recommended for use in the presence of a dead fetus.  In most guidelines cervical ripening by catheter is mentioned but not recommended. The exception is the Netherlands where the Foley catheter is recommended.

Available guidelines

Region Country Date Source url First line treatment
Europe Austria 2010 n/a PGE2 tablets, gel or controlled release pessary.
Europe Belgium 1999 Link Consensus dated 1999
• Bishop score <4: Prostaglandins
• Bishop score >7: Amniotomy
Europe Czech Republic 2016 Link • Pre-induction with prostaglandins PGE2 or PGE1. Induction with oxytocin or prostaglandins PGE2 or PGE1
Europe Denmark 2014 Link PGE2 t

• Misoprostol (25–50 mcg PO every 2–4 hours, depending on patient profile and safety considerations)

For PROM without contractions, induction with oxytocin or oral misoprostol is recommended
Misoprostol (Cytotec) tablets have been largely replaced by Angusta (50 mcg) tablets
The import licence for Angusta tablets has not been withdrawn despite approval of Misodel since authorities do not consider them to be alternatives due to different route of administration

Europe Finland n/a n/a • Catheter/balloon is used in 20–40% of cases
• Off-label misoprostol (25–50 mcg PO or vaginally every 4 hours) is used in 40% of cases with unfavourable cervix
• Oxytocin is used in 20% of cases with misoprostol
Europe France 2008 Link

Favourable cervix
• Oxytocin or intravaginal PGE2 is recommended

Unfavourable cervix
• Intravaginal PGE2

Expert opinion 2013
• Unfavourable cervix: 25 mcg intravaginal misoprostol tablets every 3–6 hours could be an alternative option to PGE2 for cervical ripening

Misoprostol 25 mcg is not available, pharmacists must prepare it for labour induction

Europe Germany 2008 Link

1. 0.5 mg PGE2 gel is indicated for labour induction and unripe cervix (Bishop score ≤5)
2. 1 and 2 mg PGE2 gel is indicated for Bishop score ≥4
3. 1 and 2 mg PGE2 gel is indicated for nulliparous and unripe cervix (Bishop score <4)
4. 10 mg PGE2 vaginal insert is indicated for labour induction and cervical ripening at >37 weeks of pregnancy, independent of Bishop score
5. 3 mg PGE2 vaginal insert is indicated for ripe cervix for labour
6. Misoprostol: Off-label use (25 mcg intravaginally every 4–6 hours)

Prostaglandins are preferred to oxytocin for induction of labour, independent of cervical ripening and parity
Intravaginal PGE2 is preferred over intracervical PGE2, as it is less invasive
There is no significant difference in efficacy between PGE2 vaginal insert and PGE2 gel or PGE2 tablet for induction of labour

Europe Greece 2014 Link

• Dinoprostone Vaginal tablet (3 mg) or vaginal insert (10 mg) are the treatment of choice unless the maternal health does not allow (Grade of recommendation A). Misoprostol, mifepristone, Folley catheters or Laminaria japonicum are strongly not recommended.

Europe Italy 2016 Link
  • Bishop score ≤4: PGE2 vaginal pessary or PGE2 vaginal gel for ripening and induction (with/without PROM). Neverthless misoprostol is associated with higher risk of uterine tachysystole, it could be considered as an alternative to PGE2. PGE1 vaginal pessary represents a new choice but more evidence are required to get final conclusion about efficacy/safety comparison with others PGE drugs.
  • Bishop score ≤4: mechanical methods for ripening with previous C-section without PROM. As an alternative is it possible to use PGE2 informing patient about higher utero rupture risk than spontaneous labour outcome.
  • Bishop score 5-6: PGE2 vaginal gel (1- 2 mg) for induction
  • Bishop score > 6: oxytocin for induction
Europe The Netherlands 2006 Link

• Transcervical Foley catheter

PGE2 (gel or Propess) and broken PGE1 tablets are used in some hospitals
Physicians primarily use the Foley catheter due to the data from the PROBAAT studies

Europe Norway 2014 Link

• Catheter

• Prostaglandins (Minprostin, Prostin E2, Misodel, Angusta, Cytotec)

• Oxytocin

Europe Romania 2009 Link • Oxytocin
Europe Russia 2013 Link

• Oxytocin 20 IU/mL

Dinoprostone (0.5 mg) and misoprostol (600 mg) are used in approximately 10% of cases

Europe Spain 2013 Link

• Dinoprostone or misoprostol 25 mcg

Dinoprostone vaginal device has a better safety profile with similar efficacy, compared with vaginally-administered misoprostol 25 mcg
Higher doses of misoprostol are associated with higher rates of successful induction of labour, but also greater risk of adverse events
There is no difference in the rate of caesarean section between dinoprostone and misoprostol

Europe Sweden n/a n/a 1. Misoprostol is recommended as first line treatment by the Swedish Society of Obstetrics and Gynaecology
2. Dinoprostone vaginal gel is considered equally effective as Propess. The price is similar, depending on dose. Dinoprostone gel and Propress are used to approximately the same extent, depending on therapy tradition.
3. Foley catheter is also used and have about 30% of the market share
Europe United Kingdom 2014 Link

At the 40- and 41-week antenatal visits, nulliparous women should be offered a vaginal examination for membrane sweeping
At the 41-week antenatal visit, parous women should be offered a vaginal examination for membrane sweeping
When a vaginal examination is carried out to assess the cervix, the opportunity should be taken to offer the women a membrane sweep. Additional membrane sweeping may be offered if labour does not start spontaneously

Pharmacological methods
• One cycle of vaginal PGE2 tablets or gel: one dose followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses)
• One cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours

South America Brazil n/a n/a

Cervical ripening
• Vaginal misoprostol (25 mcg every 6 hours)
• Oxytocin if Bishop score ≥6

Induction of labour
• Oxytocin: start IV dose of 2–4 mIU/min (up to 32 mIU/min)

South America Chile 2015 Link

No first-line recommendation

  • Misoprostol (25-50 mcg tablets)-* Argues the use of Misoprostol on the basis of international clinical and scientific evidence and its is recommended for use under strict medical supervision.
  • Vaginal dinoprostone ovule, 10mg
  • Vaginal dinoprostone gel, 1 a 2 mg (not in the market)
South America Mexico 2009 Link

Cervical ripening
• PGE2 administered as gel, tablet or controlled delivery system

Induction of labour
• Misoprostol should only be used in the induction of labour in women with intrauterine fetal death

Asia China 2008 Link • Prostaglandins are recommended, including PGE2 (Propress) and PGE1 (misoprostol) if Bishop score <6
• Foley catheter balloon can also be used
Asia Japan 2014


In the case unfavorable cervical ripening: Bishop score <6 
Should NOT use oxytocin in principle

1st line: Mechanical methods (Metreurynter balloon, Laminaria, Foley catheters)
2nd line: PGE2 (oral tablet as off-label use)

Asia Malaysia 2009 Link

• Dinoprostone gel or PGE2 (Prostin) vaginal tablet

If labour is not established after the use of PGE2, induction can  be undertaken with amniotomy or pitocin augmentation

Asia South Korea 2010 Link

1st line recommendation as a standard of treatment: Dinoprostone vaginal pessary
Alternatives: oral misoprostol, cervical dinoprostone, oxytocin, laminaria, transcervical foley catheter

Asia Taiwan n/a n/a 1. Prostaglandins
2. Oxytocin for women with ruptured membrane
Asia Vietnam 2009


• Oxytocin for women with ruptured membrane
Australasia Australia 2011 Link

Unfavourable cervix
• Transcervical catheter or prostaglandins

Favourable cervix
• Oxytocin and artificial rupture of the membranes

Australasia New Zealand n/a n/a • Oxytocin
North America Canada 2013 Link

Cervical ripening is warranted prior to labour induction with an unfavourable cervix (Bishop score ≤6)

Pharmacological methods
• PGE2 (intracervical, intravaginal or controlled-release insert)
• Misoprostol

Intravaginal preparations are easier to administer than intracervical preparations, while the controlled-release insert allows for easier removal

Mechanical methods
• Intracervical Foley catheters are acceptable agents
• Double lumen catheters may be considered a second-line alternatives

North America United States 2009 Link • Misoprostol (25 mcg every 3–6 hours), Foley/Cook catheter or Cervidil
Middle East Israel 2013 Link • Bishop score <5: Oxytocin, PGE1, PGE2 or cervical dilator balloon
Middle East Saudi Arabia 2013 Link • Vaginal PGE2 (tablets or gel): one dose followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses)
Worldwide World Health Organization 2011 Link

Pharmacological methods
• Misoprostol (25 mcg every 2 hours [oral] or every 6 hours [vaginal]). However, misoprostol is not recommended for women with previous caesarean section
• Vaginal PGE2 is also recommended
• Oxytocin IV alone is recommended if prostaglandins are not available

Non-pharmacological methods
• Membrane sweeping is recommended for reducing formal induction of labour
• Balloon catheter is recommended  alone or in combination with oxytocin if prostaglandins are not available or contraindicated

Worldwide International Federation of Gynecology and Obstetrics n/a Link

Cervical ripening
• Misoprostol (400 mcg 3 hours [vaginal] or 2–3 hours [sublingual] before procedure)

Induction of labour
• Misoprostol (25 mcg every 6 hours [vaginal] or every 2 hours [oral])