Methods for the induction of labor: efficacy and safety

Luis Sanchez-Ramos, Lisa D. Levine, Anthony C. Sciscione, Ellen L. Mozurkewich, Patrick S. Ramsey, Charles David Adair, Andrew M. Kaunitz, Jordan A. McKinney

Research output: Contribution to journalReview articlepeer-review

1 Scopus citations


This review assessed the efficacy and safety of pharmacologic agents (prostaglandins, oxytocin, mifepristone, hyaluronidase, and nitric oxide donors) and mechanical methods (single- and double-balloon catheters, laminaria, membrane stripping, and amniotomy) and those generally considered under the rubric of complementary medicine (castor oil, nipple stimulation, sexual intercourse, herbal medicine, and acupuncture). A substantial body of published reports, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PGE1) when used for cervical ripening and labor induction. Misoprostol administered vaginally at doses of 50 μg has the highest probability of achieving vaginal delivery within 24 hours. Regardless of dosing, route, and schedule of administration, when used for cervical ripening and labor induction, prostaglandin E2 seems to have similar efficacy in decreasing cesarean delivery rates. Globally, although oxytocin represents the most widely used pharmacologic agent for labor induction, its effectiveness is highly dependent on parity and cervical status. Oxytocin is more effective than expectant management in inducing labor, and the efficacy of oxytocin is enhanced when combined with amniotomy. However, prostaglandins administered vaginally or intracervically are more effective in inducing labor than oxytocin. A single 200-mg oral tablet of mifepristone seems to represent the lowest effective dose for cervical ripening. The bulk of the literature assessing relaxin suggests this agent has limited benefit when used for this indication. Although intracervical injection of hyaluronidase may cause cervical ripening, the need for intracervical administration has limited the use of this agent. Concerning the vaginal administration of nitric oxide donors, including isosorbide mononitrate, isosorbide, nitroglycerin, and sodium nitroprusside, the higher incidence of side effects with these agents has limited their use. A synthetic hygroscopic cervical dilator has been found to be effective for preinduction cervical ripening. Although a pharmacologic agent may be administered after the use of the synthetic hygroscopic dilator, in an attempt to reduce the interval to vaginal delivery, concomitant use of mechanical and pharmacologic methods is being explored. Combining the use of a single-balloon catheter with dinoprostone, misoprostol, or oxytocin enhances the efficacy of these pharmacologic agents in cervical ripening and labor induction. The efficacy of single- and double-balloon catheters in cervical ripening and labor induction seems similar. To date, the combination of misoprostol with an intracervical catheter seems to be the best approach when balancing delivery times with safety. Although complementary methods are occasionally used by patients, given the lack of data documenting their efficacy and safety, these methods are rarely used in hospital settings.

Original languageEnglish (US)
Pages (from-to)S669-S695
JournalAmerican Journal of Obstetrics and Gynecology
Issue number3
StatePublished - Mar 2024
Externally publishedYes


  • Dilapan-S
  • Foley catheter
  • acupuncture
  • amniotomy
  • castor oil
  • cervical ripening
  • dinoprostone
  • double-balloon catheter
  • grand multiparity
  • herbal supplements
  • hyaluronidase
  • hygroscopic cervical dilator
  • labor induction
  • mechanical
  • membrane stripping
  • membrane sweep
  • mifepristone
  • misoprostol
  • nipple stimulation
  • nitric oxide
  • oxytocin
  • pharmacologic
  • prostaglandins
  • relaxin
  • review
  • sexual intercourse
  • single-balloon catheter
  • twins

ASJC Scopus subject areas

  • Obstetrics and Gynecology


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