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• 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The import licence for Angusta tablets has not been withdrawn despite approval of Misodel since authorities do not consider them to be alternatives due to different route of administration

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

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

• Intravaginal PGE2 (regardless of route of administration) is considered equally effective with no significant adverse events

Treatment with PGE2 must be extended up to 24 hours
Intravaginal PGE2 administration is preferred to IV oxytocin since it is associated with a lower incidence of PPH
Misoprostol and mifepristone must be used only in clinical studies or cases of fetal death

Cervical ripening
• Bishop score ≤4: Propress
• Premature rupture of membranes: Propess (1 pessary for 24 hours)
• Bishop score >5: Prepidil (1 or 2 mg)

Prepidil is considered too difficult to use
Cook balloon is considered expensive, invasive and difficult to use
Misoprostol is only used in a few hospitals (25 mcg every 4 hours)
Foley balloon is not recommended in case of an unfavourable cervix since insertion is painful for the patient

Induction of labour
1. Oxytocin: start dose IV 2–8 drops/min (up to 40 drops/min)
2. Prepidil: Misoprostol is only used in a few hospitals (25 mcg every 4 hours)

• 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

• Misoprostol tablets 25 mcg every 6 hours
• Endocervical get/tablets
• Amniotomy
• Oxytocin

Misodel will be included in the next edition of the national guidelines

• Oxytocin 20 IU/mL

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

• 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

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

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)

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

• Oxytocin, PGF2 or PGE2 tablets

Factors affecting first line treatment
Fetal factors
1. Life-threatening situations for the unborn baby
2. Diabetes complication
3. Post-date pregnancy or prevention
4. Giant baby
5. Fetal death

Maternal factors
1. Weak labour
2. Early rupture of membrane
3. Pregnancy hypertension
4. Precipitate delivery
5. Potential harm to the mother

Terms for prescription
• Physicians must receive patient consent for prescription of oxytocics
• Fetal monitors should be set before prescribing

• 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

n/a

Unfavourable cervix
• Transcervical catheter or prostaglandins

Favourable cervix
• Oxytocin and artificial rupture of the membranes

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

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

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])