Labour Induction
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults, Updated for the 2023 Edition
Z35.9/Z51.2
If induction of labour is indicated, for medical reasons, for example pre-eclampsia, diabetes, or post-term pregnancy.
GENERAL MEASURES
Counsel the woman about the risks: failed induction or uterine hyperstimulation syndrome, which may require emergency Caesarean delivery.
Cervix favourable and confirmed HIV-uninfected mother
Artificial rupture of the membranes.
Cervix unfavourable (Bishop score <7)
Extra-amniotic Foley catheter with/without saline infusion:
- Pass a Foley catheter with 30 mL bulb through cervix with sterile technique.
- Inflate bulb with 50 mL water or sodium chloride 0.9%.
- Tape catheter to thigh with light traction.
- Alternatively, attach sodium chloride 0.9% 1 L with giving set to catheter, and infuse sodium chloride 0.9% at 50 mL/hour. Remove after 24 hours.
LoE:IVb
MEDICINE TREATMENT
Cervix unfavourable (Bishop score <7)
Extra-amniotic Foley catheter (as above) PLUS one of the options below:
LoE:IIbxxxix
Prostaglandins, e.g:
- Dinoprostone gel, intravaginally, 1 mg.
- Repeat after 6 hours.
- Do not exceed 4 mg.
OR
- Dinoprostone tablets, intravaginally, 1 mg.
- Repeat after 6 hours.
- Do not exceed 4 mg.
LoE:IIIbxl
OR
- Misoprostol, oral, 20 mcg 2 hourly until in labour, or up to 24 hours.
- Oral misoprostol may be given as freshly made-up solution of one 200 mcg tablet in 200 mL water, i.e. 1 mcg/mL solution. Give 20 mL of this solution 2 hourly.
- Stop misoprostol administration when in established labour.
- Maximum 24 hours.
- Never use oxytocin and misoprostol simultaneously.
- Misoprostol and other prostaglandins are contraindicated in women with previous Caesarean sections and in grand multiparous women.
LoE:IIIbxli
Note:
• Misoprostol in larger doses than indicated here for labour induction at term, may cause uterine rupture.
• Only to be prescribed by a doctor experienced in Maternal Health.
Non-stress test and cardiotocography:
Note:
Perform a non-stress test (NST), before starting the induction, and cardiotocography (CTG) within an hour of each dinoprostone insertion, to evaluate the foetal condition during labour induction.
- When using misoprostol, do a baseline NST before commencing IOL, followed by CTG 4-hourly (prior to every alternate dose).
- Repeat CTG once contractions have started, or more frequently only if clinically indicated.
LoE:IVb
Cervix favourable (Bishop score ≥7)
Amniotomy followed 2 hours later by:
- Oxytocin, IV, 2 units in 200 mL sodium chloride 0.9%.
LoE:IIIbxlii- Start at an infusion rate of 12 mL/hour (i.e. 2 milliunits /minute). If absent or inadequate contractions, increase infusion rate according to the table below:
| Time after starting (minutes) | Oxytocin dose (milliunits/minute) | Dilution: 2 units in 200 mL sodium chloride 0.9% (mL/hour) |
| 0 | 2 | 12 |
| 30 | 4 | 24 |
| 60 | 6 | 36 |
| 90 | 8 | 48 |
| 120 | 10 | 60 |
| 150 | 12 | 72 |
| 180 | 14 | 84 |
| 210 | 16 | 96 |
| 240 | 18 | 108 |
| 270 | 20 | 120 |
Note:
• It is safe to perform amniotomy in pregnant women living with HIV on ART who have an undetectable plasma VL at delivery.
LoE:IIIbxlii
• Avoid oxytocin in women with previous Caesarean section or parity ≥5.
• Continuous electronic foetal heart rate monitoring is essential.
• Aim for adequate uterine contractions (3–5 contractions in 10 minutes). Once adequate contractions achieved, do not increase rate further.
• Most women will experience adequate contractions at a dose of 12 milliunits/minute.
• If tachysystole develops (>5 contractions in 10 minutes), reduce or stop the oxytocin infusion to achieve 3-5 contractions in 10 minutes. If there are foetal heart rate abnormalities which persist despite stopping the oxytocin, administer salbutamol as above.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2025-9 Review_Version 2.0_26 March 2026
Chapter 6 Obstetrics_6.13 Labour Induction