Show Notes
Induction of labor now accounts for roughly 1 in 3 deliveries in the U.S., so as an intern you'll be part of inductions almost every shift, whether scheduled or a same-day plan from triage. In this episode, Dr. Veena Bhagavathi walks through who gets induced and why, how to use the Bishop score, the cervical ripening options, what to do once the cervix is favorable, and how long to wait before calling an induction "failed." Indications & Contraindications
Elective induction means induction at 39 weeks without a medical indication. 39 weeks is the cutoff because the neonatal risks of late-preterm and early-term birth are well established. ARRIVE trial: in low-risk nulliparas, induction at 39 0/7–39 4/7 weeks reduced cesarean delivery (18.6% vs 22.2%, RR 0.84) and hypertensive disorders of pregnancy (9.1% vs 14.1%, RR 0.64), with no significant difference in neonatal outcomes. Induction between 41 0/7 and 42 0/7 weeks can be considered; induction by 42 6/7 weeks is recommended given increased perinatal morbidity and mortality beyond that. Don't defer delivery to 39 weeks if there's a medical or obstetric indication for earlier delivery — always run the risk-benefit calculation. Medically indicated induction, maternal: chronic HTN, gestational HTN, preeclampsia (with or without severe features), diabetes. Medically indicated induction, fetal: growth restriction, multiple gestation, PPROM/PROM. PPROM delivery timing has an interim ACOG update (Committee Opinion 831). Pull the current ACOG page before finalizing a plan, and discuss and document the added neonatal risk of prolonged expectant management with unknown or positive GBS status. Contraindications are essentially any contraindication to vaginal delivery: placenta or vasa previa, malpresentation or non-cephalic lie, prior classical cesarean, active herpes infection, and severe fetal or maternal compromise requiring faster delivery.
The Bishop Score
Dilation, effacement, and station are scored 0–3; consistency and position are scored 0–2. Total range: 0–13. Score ≥8 → favorable ("ripe") cervix, with a good chance of vaginal delivery on induction. Score ≤6 → unfavorable ("unripe") cervix, with a lower chance of vaginal delivery; cervical ripening is indicated. A simplified Bishop score using only dilation, station, and effacement may be just as predictive — a simplified score of 5 performs similarly to a full score >8. Ask the patient if she's had a cervical exam before, or what her prior inductions looked like. Parity and history both factor in, and the vast majority of people undergoing induction will need some form of cervical ripening.
Cervical Ripening Methods
Before using prostaglandins, check the contraction pattern (no more than 3 contractions in 10 minutes, averaged over 30 minutes) and consider fetal status (decels, severe FGR). Foley balloon — mechanical. Supplies: speculum, ring forceps, betadine swabs, flushes, chux. Cook catheter — mechanical double-balloon device, sometimes used with a stylet. Misoprostol (PGE₁) — oral 20–25 mcg q2h, or vaginal 25 mcg q3–6h (ACOG CPG No. 9, 2025); can be given vaginally or buccally. AVOID in prior cesarean or uterine surgery entering the cavity (e.g., myomectomy) because of uterine rupture risk. Dinoprostone (PGE₂) — vaginal insert (Cervidil) or gel. Osmotic dilators — mechanical alternative, less commonly first-line. Outpatient cervical ripening — an option in select low-risk candidates; discuss with your team. Membrane stripping/sweeping — a gloved finger sweeps over the membranes (requires partial cervical dilation) and may release natural prostaglandins. If a patient presents already ruptured and not dilated, and no balloon...
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