The risks of being overdue: new NICE guidelines published on the induction of labour

Posted: 06/12/2021

The devastating impact of a stillbirth or neonatal death on a parent cannot be underestimated, and anything that can be done to reduce such an outcome is welcome.

The NHS Maternity Statistics, England 2019 – 2020, which includes data relating to delivery and birth episodes for the financial year ending March 2020, indicates that, statistically, some risks associated with a pregnancy continuing beyond 41 weeks’ gestation may increase over time. Specifically, there may be a higher likelihood of a caesarean section being required, the baby needing admission to a neonatal intensive care unit, or stillbirth and neonatal death.

These findings have been taken into account by the National Institute for Health and Care Excellence (NICE) when drafting new guidelines relating to the induction of labour, which were published on 4 November 2021.

An induced labour is one that is started artificially. Generally, this happens because the baby is overdue, or because there are risks to either the baby’s or the mother’s health.

The new guidance makes it clear that it should be explained to a pregnant woman (the person giving birth, whether they identify as a woman or not) that induction from beyond 41 weeks’ gestation may reduce the risks outlined above, but it can impact their birth experience. The NICE guidance also covers induction of labour in a number of different circumstances, including when:

• there has been preterm prelabour rupture of the membranes or prelabour rupture of membrane at term;
• there has been a previous caesarean birth;
• a maternal request for induction has been made;
• the baby is in a breech position;
• there is fetal growth restriction or suspected fetal macrosomia (a larger than average baby); and
• there is a history of precipitate (unusually rapid) labour or intrauterine death.

Key additional points made in the guidance are:

• A woman’s preferences about the mode of delivery should be discussed early in the pregnancy, and then confirmed towards the end of the pregnancy (and recorded in her notes).
• Induction of labour should be described as a medical intervention that will affect the birth options and the experience, with reference to: the examinations and monitoring required; the place of birth; the potential need for assisted vaginal birth (forceps or ventouse); and the risk of tears, hyperstimulation, and a longer hospital stay.
• When a woman is being offered an induction, the following should be discussed: the reasons for the induction; when, where and how it could be carried out; the arrangements for support and pain relief; the alternative options; the risk and benefits of the induction; and the options if the induction is not successful.
• The woman being offered an induction should have time to discuss the information provided with others, ask questions, and look at other information before making a decision, and it should be recognised that they can change their minds, with the decision(s) being recorded in her notes.

Induction may involve membrane sweeping and/or the use of pharmacological and mechanical methods (such as pessaries, gels, hormone drips, balloon catheters, osmotic cervical dilators, and the artificial rupture of the membranes).

The induction of labour should be considered in the context of the specific factors that apply to the pregnancy at hand, with clear explanations of the pros and cons of an induction if one is being considered.  

It is hoped that the new guidance, particularly relating to the option of induction at 41 weeks’ gestation, will help improve pregnancy safety and outcomes.

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