Enter Patient Details
Complete all parameters in the sidebar to generate a personalised induction protocol
Instructions
- Enter gestational age (weeks + days)
- Select parity, indication, presentation
- Select liquor volume and CTG status
- Score the Modified Bishop Score
- Check any contraindications
About This Tool
- Based on NICE NG207, ACOG, and RCOG guidelines
- Covers all common induction indications
- Specific plans for PROM, PIH, GDM, FGR
- Accounts for parity and uterine scar status
🔬 Induction Methods Reference
Dinoprostone (PGE₂) — Prostin / Propess
Cervical ripening prostaglandin. Preferred for nulliparous women with unfavourable cervix and intact membranes. NOT to be used when membranes are already ruptured (risk of intrauterine infection and hyperstimulation without the fluid buffer). Available as vaginal gel (Prostin 1mg/2mg) or controlled-release pessary (Propess 10mg).
Gel Dose (Prostin)
Nullip: 1–2mg vaginally. Repeat after 6h if required. Max 3mg/24h (nullip) or 1mg/6h (multip)
Pessary (Propess)
10mg controlled-release pessary. Remove after 24h, in active labour, or at onset of tachysystole/CTG concerns
Oxytocin Interval
Wait minimum 6h after Propess removal or last Prostin gel dose before commencing oxytocin
Key Contraindications
Ruptured membranes, previous uterine scar (relative — use with caution), prior PGE₂ dose same admission, severe asthma, severe hepatic/renal/cardiac disease
Monitoring
CTG for 30–60 min post-insertion. Assess for hyperstimulation. Reassess Bishop at 6h intervals
Success Rate
~50% in established labour within 24h. Improves Bishop score by ~2–3 points per dose
Misoprostol (PGE₁) — Oral: Angusta 25mcg; Vaginal: 25mcg
More potent than PGE₂. Preferred for PROM at term (oral route). Higher risk of uterine hyperstimulation vs PGE₂. Oral route associated with lower hyperstimulation risk than vaginal. AVOID with previous uterine scar — significantly increased risk of uterine rupture. Safe to use when membranes are ruptured (unlike PGE₂).
Oral Dose (Angusta / PROM)
25mcg orally every 2h. Max 200mcg/day. Preferred route for PROM at term. Lower hyperstimulation risk than vaginal
Vaginal Dose
25mcg vaginally every 4–6h. Max 50mcg if Bishop <4. Avoid if membranes ruptured (not recommended — increased infection risk)
PROM-Specific
Oral misoprostol 25mcg 2-hourly is first-line for PROM at term with unfavourable cervix. If GBS+/unknown, commence IV antibiotics simultaneously
Oxytocin Interval
Wait 4h after last oral dose, 6h after vaginal dose before commencing oxytocin infusion
Antidote for Hyperstimulation
Terbutaline 250mcg SC stat, or GTN 400mcg sublingual spray. Remove from vagina if applicable. Continuous CTG
Key Contraindications
Previous uterine scar (avoid), prior PGE dose, severe asthma (relative). Caution with oxytocin <4h after last dose
Balloon / Foley Catheter — Mechanical Cervical Ripening
Safest option for women with a previous caesarean section or other uterine scar. No uterotonic effect — minimal risk of hyperstimulation. Can be used with ruptured membranes only with caution (increased infection risk) and is generally avoided if membranes are ruptured. Outpatient protocols exist.
Catheter & Insertion
14–18Fr Foley catheter. Insert past internal os. Inflate balloon with 30–60mL sterile water. Tape to inner thigh with gentle traction
Duration
Leave in situ 12–24h or until spontaneous expulsion. Expulsion usually indicates Bishop ≥6. Remove and reassess before ARM
Adjunct Options
Can combine with oxytocin infusion simultaneously (cook double-balloon technique). Add ARM when Bishop ≥6 post-removal
Contraindications
Ruptured membranes (relative — infection risk), APH, low-lying placenta, chorioamnionitis, active cervicitis, STI
Advantages vs PGE₂
No systemic drug effects. No hyperstimulation risk. Lower risk with uterine scar. Outpatient protocols possible at selected centres
Expected Outcome
Improves Bishop score by 3–4 points in ~70% of cases within 12–24h. Comparable efficacy to PGE₂ in multiple trials
Artificial Rupture of Membranes (ARM / Amniotomy)
Simple and effective when Bishop score ≥6. Irrevocable — once membranes are ruptured the clock starts. Requires confirmed cephalic presentation with engaged head, absent cord presentation, and excluded placenta praevia. Releases prostaglandins and allows head engagement. For PROM cases, the ARM step is already done — skip to oxytocin if no contractions within the designated interval.
Prerequisites
Bishop ≥6, confirmed cephalic, head engaged or engaged at ARM, no cord presentation, placenta praevia excluded, no vasa praevia
Technique
Amnihook through internal os under direct vision. Ensure FHR auscultated before and immediately after. Document time, colour and volume of liquor
Post-ARM Management
CTG for minimum 30 min. If no contractions established in 1–2h, commence low-dose oxytocin infusion per protocol
Liquor Assessment
Clear / lightly blood-stained: normal. Fresh blood: arterial — check fetal HR immediately. Thick meconium (grade 3): immediate senior review, consider emergency LSCS
Cord Prolapse
Risk ~0.3–0.5%. Highest with free-floating head. If suspected: immediate VE, head up, call crash team, emergency LSCS Category 1
Failure to Progress
If contractions adequate but no progress in 4–6h: senior/consultant review. If inadequate contractions: increase oxytocin per protocol. Consider LSCS if failed induction after 12–24h
Oxytocin (Syntocinon) — IV Infusion
Standard augmentation after ARM or for PROM (when membranes already ruptured). First-line when Bishop ≥6 and membranes ruptured with no or inadequate contractions. High-alert medication — must be administered via infusion pump only with continuous CTG. Use with EXTREME caution in previous CS (lower threshold to reduce/stop, increased surveillance for scar rupture signs).
Standard Dilution
10 IU Syntocinon in 500mL 0.9% NaCl (20mU/mL). Alternatively: 10 IU in 1000mL (10mU/mL). Use infusion pump only — NEVER bolus
Starting Dose
Low-dose: 1–2 mU/min. Increase by 1–2 mU/min every 30 min. Standard maximum: 20–32 mU/min (per local unit protocol)
Target Contractions
3–5 contractions per 10 min, each lasting 45–60 seconds. Do NOT increase rate if target already met. Reduce if tachysystole
Stop / Halve If
Tachysystole (>5 cx/10 min), prolonged cx (>90s), CTG category II/III, FHR deceleration, maternal hypotension, scar tenderness/signs of rupture
Monitoring
Continuous CTG throughout. Maternal vitals every 30 min. Strict fluid balance if infusion >12h (hyponatraemia risk). VE 4-hourly to assess progress
Previous Scar Precautions
Lower dose ceiling (discuss with consultant). Continuous CTG mandatory. Alert if maternal tachycardia, scar pain, haematuria, loss of uterine contour, FHR abnormality — all may indicate rupture
Membrane Sweep — Pre-Induction / Outpatient
Non-pharmacological outpatient method to reduce need for formal induction. Offered from 39 weeks (nulliparous) or 40 weeks (multiparous). Up to 3 sweeps at 48-hour intervals. Only appropriate with intact membranes and cephalic presentation. Reduces post-term induction rate by approximately 9%. Not a substitute for formal induction when indicated.
Timing
Nulliparous: offer at 39 and 40 weeks. Multiparous: offer at 40 and 41 weeks. Can be repeated every 48h up to 3 times
Technique
Circular movement of examining finger through internal os, separating membranes from lower segment 360° in a sweeping motion. If os too tight, gentle digital cervical massage only
Consent Points
Warn: discomfort during procedure, cramping and spotting for 24–48h, small risk of inadvertent membrane rupture. PROM post-sweep is rare but document if occurs
Prerequisites
Intact membranes confirmed, cephalic presentation, placenta praevia excluded, accessible cervix, informed consent documented
Document
Bishop score before and after. Accessibility of internal os. Patient pain score (NRS). Blood-stained discharge normal — heavy bright-red blood requires review
If Cervix Inaccessible
Cervical massage alone if os tight. Inform patient and document. Offer formal induction at next available date if ≥41 weeks. Refer to consultant if no progress
📊 Standard Induction Protocol — Step-by-Step
1
Confirm Indication, Gestation & Consent
Confirm gestation by USS (ideally first-trimester dating scan). Exclude contraindications. Senior review mandatory if <37+0 weeks, complex indication, or previous uterine surgery. Obtain written informed consent — include risks: failed induction, caesarean section, uterine hyperstimulation, cord prolapse.
Written Consent + Senior Review if Complex
2
Pre-Induction Assessment (CTG + Bishop Score)
CTG must be REASSURING before commencing any induction method. Perform vaginal examination and document Modified Bishop Score. If CTG non-reassuring: pause — senior review required before proceeding. If membranes already ruptured: document time of rupture, colour of liquor, any cord presentation.
CTG Must Be Reassuring Before Any Step
3
Choose Method Based on Bishop Score & Membrane Status
Membranes Intact + Bishop ≤5: Cervical ripening — PGE₂ (no scar) or balloon catheter (scar). Membranes Intact + Bishop 6–7: Consider ARM or further ripening. Membranes Intact + Bishop ≥8: Proceed to ARM. Membranes Already Ruptured (PROM/PPROM): ARM is NOT required — membranes are already open. Proceed directly to OXYTOCIN infusion (bishop ≥6) or oral misoprostol 25mcg 2-hourly (bishop <6). PGE₂ and balloon catheter are CONTRAINDICATED when membranes are ruptured.
PROM → Oxytocin or Oral Misoprostol Only — No ARM, No PGE₂, No Balloon
4
ARM (When Bishop ≥6 and Membranes Intact)
Confirm lie, presentation, station. Exclude cord presentation by careful VE before ARM. Document time, colour and volume of liquor at ARM. CTG for minimum 30 min post-ARM. Thick meconium: immediate escalation. If Bishop <6 post-ripening: reassess and repeat or escalate.
CTG Mandatory 30 Min Post-ARM
5
Oxytocin Infusion
For intact membranes: commence oxytocin if no contractions 1–2h post-ARM. For PROM (membranes already ruptured): oxytocin is first-line — commence within 1–4h of confirmed rupture, without ARM. Titrate to 3–5 contractions per 10 min. Continuous CTG mandatory. Previous CS: lower dose ceiling, anaesthetic team aware, consultant-led.
Pump Only | Continuous CTG | Strict Fluid Balance
6
Reassess, Escalate, or Abandon if Necessary
Failed induction: no cervical change after adequate contractions for 4–6h — consultant review, LSCS discussion. Tachysystole: stop oxytocin, give tocolysis (terbutaline 250mcg SC), continuous CTG. Abnormal CTG at any stage: immediate senior review, prepare for Category 1/2 LSCS. Document all decisions with time and rationale.
Low Threshold for Senior Review & LSCS
📡 Monitoring Requirements During Induction
Fetal Heart Rate
CTG Continuous
Post-ARM & throughout oxytocin; intermittent auscultation during ripening only if CTG reassuring
Contractions
Continuous / 30 min
Frequency, duration, strength. Alert if >5/10 min or lasting >90 seconds
Maternal BP & HR
30–60 min
Hourly during oxytocin; 4-hourly during ripening. More frequent if PIH/PET
Temperature
4-hourly
Especially post-PROM (>18h ROM). Rise ≥38°C suggests chorioamnionitis — urgent review
Cervical Assessment
Every 4–6h
Document Bishop score changes. If no progress after adequate contractions: senior review
Fluid Balance
Hourly (oxytocin)
Risk of hyponatraemia / water intoxication with prolonged oxytocin infusions. Limit IV fluids