Induction of labor with oxytocin

Official reprint from UpToDate® www.uptodate.com

©2025 UpToDate®

Induction of labor with oxytocin

Author: William Grobman, MD
Section Editor: Malavika Prabhu, MD
Deputy Editor: Vanessa A Barss, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2025. | This topic last updated: Dec 16, 2024.

INTRODUCTION

Clinicians recommend delivery when they believe the risk of allowing the pregnancy to
continue carries similar or more risk than the maternal, fetal, or newborn risk of terminating
the pregnancy by delivery. Induction (ie, the process of artificially stimulating uterine
contractions to accomplish delivery) and cesarean birth are the only available options.
Induction is generally preferred when there are no contraindications to labor and vaginal
birth, given the increased maternal risks associated with cesarean birth. (See "Cesarean birth:
Postoperative care, complications, and long-term sequelae".)

Use of oxytocin for induction in patients with an unscarred uterus will be discussed here.
Methods of cervical ripening (eg, prostaglandins, balloon catheter) and induction in patients
with a scarred uterus (eg, a previous cesarean birth or other extensive transmyometrial
surgery) are reviewed separately.
● (See "Induction of labor: Techniques for preinduction cervical ripening".)
● (See "Cervical ripening and induction of labor after a prior cesarean birth".)

PREVALENCE

The rate of labor induction in the United States was 32.1 percent in 2021, more than tripling
since 1990 when it was 9.5 percent [1].
- Page 1 of 41 -
Induction of labor with oxytocin

The rate of labor induction is also rising globally, though it varies among obstetric facilities
and countries [2-5]. The World Health Organization (WHO) noted that the rate is generally
lower in low- and middle-income countries but in some such settings, it can be as high as
those in high-income countries [6].

INDICATIONS AND CONTRAINDICATIONS

Medical and obstetric indications — Induction before the onset of spontaneous labor is
indicated when the maternal/fetal risks associated with continuing the pregnancy are
thought to be at least as great as the maternal/fetal/newborn risks associated with delivery
[7]. The risk of continuing the pregnancy is related primarily to the severity of the
maternal/fetal condition and the risk of delivery is related primarily to the gestational age (ie,
neonatal morbidity). The relative risk can rarely be determined with precision.

Examples of some common conditions where induction is often medically/obstetrically

indicated include, but are not limited to, the following [7,8]:
● Postterm pregnancy (see "Postterm pregnancy")
● Prelabor rupture of membranes (see "Preterm prelabor rupture of membranes: Clinical
manifestations and diagnosis" and "Prelabor rupture of membranes at term:
Management")
● Hypertensive disorders of pregnancy (see "Preeclampsia: Antepartum management and
timing of delivery" and "Eclampsia" and "HELLP syndrome (hemolysis, elevated liver
enzymes, and low platelets)" and "Gestational hypertension" and "Chronic hypertension
in pregnancy: Prenatal and postpartum care")
● Diabetes (see "Preexisting (pregestational) diabetes mellitus: Obstetric issues and
pregnancy management" and "Gestational diabetes mellitus: Obstetric issues and
management")
● Fetal growth restriction (see "Fetal growth restriction: Pregnancy management and
outcome", section on 'Delivery')
● Twins (see "Twin pregnancy: Labor and delivery")

- Page 2 of 41 -
Induction of labor with oxytocin
● Clinical chorioamnionitis (see "Clinical chorioamnionitis")
● Placental abruption (see "Acute placental abruption: Management and long-term
prognosis")
● Oligohydramnios (see "Oligohydramnios: Etiology, diagnosis, and management in
singleton gestations")
● Intrahepatic cholestasis of pregnancy (see "Intrahepatic cholestasis of pregnancy")
● Alloimmunization with fetal anemia (see "RhD alloimmunization in pregnancy:
Management" and "Management of non-RhD red blood cell alloantibodies during
pregnancy")
● Fetal demise (see "Stillbirth: Maternal care and prognosis")

Many other maternal disease states and fetal conditions also warrant labor induction. They
are discussed in UpToDate topics that review management of specific maternal and fetal
disorders.

Scheduled induction at 39 weeks — Scheduled induction of labor in low-risk patients at 39

weeks with well-dated pregnancies has been called "elective"; however, risk-reducing
induction is a more accurate term, given evidence that outcomes are equivalent, if not in
some cases better than, expectant management [9-11].

Compared with expectant management, potential advantages of induction at 39 weeks

include [12-20]:
● Reduction in cesarean birth
● Reduction in other adverse neonatal and maternal outcomes (eg, hypertensive
disorders of pregnancy)
● Reduction in macrosomia (and its consequences)
● Reduction in stillbirth
● Ability to control the time of birth when this could be important (eg, patients with a
history of rapid labor or who live far from the hospital and thus risk an out-of-hospital
birth)

The disadvantages of risk-reducing induction at 39 weeks versus expectant management are

a potentially longer duration on the labor unit and loss of the opportunity to experience a

- Page 3 of 41 -
Induction of labor with oxytocin

natural onset of labor, which is important to some individuals. Ultimately, the balance
between these advantages and disadvantages depends on an individual's values and
preferences.

Risk-reducing induction should be avoided before 39+0 weeks of gestation [21]. The
morbidity of birth before 37+0 weeks (ie, preterm birth) is well-established; early-term birth
(37+0 to 38+6 weeks) is also associated with greater neonatal morbidity and health care
utilization during the entire first year of life compared with birth at 39+0 to 40+6 weeks [22-
29]. To emphasize the importance of avoiding risk-reducing induction before 39+0 weeks, the
National Quality Forum, the Joint Commission, and the Leapfrog Group made risk-reducing
delivery prior to 39+0 weeks a maternal performance measure ("the 39 week rule") and
collect data from hospitals on risk-reducing deliveries performed at 37+0 to 38+6 weeks of
gestation [30].
● Evidence

• ARRIVE trial – In the multicenter randomized controlled trial, ARRIVE, which

evaluated the perinatal and maternal consequences of planned induction of labor at
39+0 to 39+4 weeks of gestation versus expectant management in over 6100 low-risk
nulliparous patients across the United States, induction resulted in [16]:
- Reduced risk of cesarean birth (18.6 versus 22.2 percent, relative risk [RR] 0.84,
95% CI 0.76-0.93). In a planned secondary analysis, the cesarean birth rate at 39,
40, and 41 to 42 weeks was 17.3, 22, and 37.5 percent, respectively [18-20].
- Reduced risk of hypertensive disorders of pregnancy (9.1 versus 14.1 percent, RR
0.64, 95% CI 0.56-0.74).
- Reduced risk of neonatal respiratory support (3.0 versus 4.2 percent, RR 0.71,
95% CI 0.55-0.93).
- Probable reduced risk of the composite outcome of perinatal death or severe
neonatal complications (4.3 versus 5.4 percent, RR 0.80, 95% CI 0.64-1.00). In a
planned secondary analysis, the composite adverse perinatal outcome at 39, 40,
and 41-42 weeks was 5.1, 5.9, and 8.2 percent, respectively [18-20]. The
composite outcome included death, respiratory support, five-minute Apgar score
3 or less, hypoxic ischemic encephalopathy, seizure, sepsis, meconium aspiration
- Page 4 of 41 -
Induction of labor with oxytocin

syndrome, birth trauma, intracranial or subgaleal hemorrhage, or hypotension

requiring vasopressor support.

Other outcomes of risk-reducing induction noted in planned secondary analyses

included [18-20]:
- Fewer antepartum visits, tests, and treatments
- Shorter postpartum maternal and neonatal hospital durations, though a longer
duration on the labor and delivery unit (by approximately six to seven hours)
- Similar total costs
• Other evidence – Data from meta-analyses of mostly observational studies support
the concept that risk-reducing induction of labor at 39 weeks in typical clinical
settings has an effectiveness similar to the efficacy demonstrated in the ARRIVE trial
[17,31]. Although no large-scale trials have been performed in low-risk parous
patients who have had a prior vaginal birth, observational studies in this population
have reported similar findings to the ARRIVE trial [32-34].

Long-term outcome data regarding the outcomes of children born after risk-reducing
induction versus expectant management are limited, but show similar
neurodevelopmental outcomes for both groups [35-37].
● Recommendations of selected groups

• The American College of Obstetricians and Gynecologists (ACOG) has concluded that
offering induction of labor to nulliparous patients without a medical indication for
delivery at ≥39+0 weeks of gestation is a reasonable option that patients and their
obstetric providers should discuss (eg, the person's desire for the timing and
approach to delivery) [38]. Furthermore, hospital systems should evaluate their
available resources to accommodate these inductions, with an active effort to
achieve/maintain equitable delivery of care. These recommendations apply to well-
dated pregnancies. ACOG recommends against risk-reducing induction of
suboptimally dated pregnancies [39]. (See "Prenatal assessment of gestational age,
date of delivery, and fetal weight", section on 'Suboptimally dated pregnancies'.)

ACOG has also stated that maternal anxiety or discomfort related to normal
pregnancy, the distance between the patient’s residence and the hospital, or a
- Page 5 of 41 -
Induction of labor with oxytocin

previous pregnancy with shoulder dystocia are not appropriate indications for early-
term induction (37+0 to 38+6 weeks) [40], although they may be appropriate reasons
for induction at ≥39+0 weeks.

• The Society for Maternal-Fetal Medicine (SMFM) also concluded that it is reasonable
to offer risk-reducing induction to low-risk nulliparous patients who are ≥39+0 weeks
of gestation and recommended that providers who choose this approach ensure that
patients meet the eligibility criteria of the ARRIVE trial [41].

Contraindications — In each of the following settings, there is general consensus that the
maternal/fetal risks associated with labor and vaginal birth, and therefore induction, are
greater than the risks associated with cesarean birth; therefore, induction of labor is
contraindicated.
● Prior classical or other high-risk cesarean incision (see "Choosing the route of delivery
after cesarean birth", section on 'Prior transfundal uterine incision')
● Prior uterine rupture (see "Choosing the route of delivery after cesarean birth", section
on 'Prior uterine rupture or dehiscence')
● Prior extensive complete transmural uterine incision (see "Uterine fibroids (leiomyomas):
Issues in pregnancy", section on 'Patients with prior myomectomy')
● Active genital herpes simplex infection (see "Genital herpes simplex virus infection and
pregnancy", section on 'Route of delivery')
● Placenta previa or vasa previa (see "Placenta previa: Management" and "Velamentous
umbilical cord insertion and vasa previa")
● Umbilical cord prolapse or persistent funic presentation (see "Umbilical cord prolapse")
● Transverse fetal lie (see "Transverse fetal lie")
● Invasive cervical cancer (see "Cervical cancer in pregnancy", section on 'Considerations
about delivery')
● Category III fetal heart rate (FHR) tracing (see "Intrapartum category I, II, and III fetal
heart rate tracings: Management", section on 'Category III pattern: Abnormal')

- Page 6 of 41 -
Induction of labor with oxytocin

PREINDUCTION ASSESSMENT AND PATIENT PREPARATION

Checklist — A thorough evaluation of maternal and fetal status is important before

undertaking labor induction to ensure the indication is appropriate and to confirm the
absence of contraindications to labor or vaginal birth:
● Review the data used to estimate gestational age and date of delivery. The gestational
age and the certainty of the estimate are factors that are considered in timing of
induction. (See 'Medical and obstetric indications' above and 'Scheduled induction at 39
weeks' above.)
● Determine fetal presentation. Noncephalic presentation can be an absolute or relative
contraindication to induction. (See "Transverse fetal lie" and "Compound fetal
presentation" and "Overview of breech presentation".)
● Estimate fetal weight. Consider the risks associated with induction of small or large for
gestational age fetuses. (See "Fetal growth restriction: Pregnancy management and
outcome" and "Shoulder dystocia: Risk factors and planning birth of high-risk
pregnancies".)
● Perform a cervical examination to decide whether a cervical ripening agent is indicated.
(See 'Clinical assessment' below.)
● Review the fetal heart rate (FHR) pattern to confirm that the use of ripening agents or
oxytocin is not contraindicated because of a nonreassuring pattern. (See "Intrapartum
category I, II, and III fetal heart rate tracings: Management".)

Patient preparation and laboratory tests — Patient preparation and laboratory tests are
generally the same as in patients in spontaneous labor (which includes a review for risk
factors for problems that may develop during labor and birth [eg, past history of shoulder
dystocia, postpartum hemorrhage]). (See "Labor and delivery: Management of the normal
first stage", section on 'Management of the first stage of labor'.)

In addition to standard preparation and testing,

● Discuss the indications for and alternatives to induction.
● Determine whether the cervix is favorable for induction (see 'Assessing the chance of a
- Page 7 of 41 -
Induction of labor with oxytocin

successful induction' below). If the cervix is favorable, oxytocin is administered without

cervical ripening. If the cervix is unfavorable, cervical ripening is recommended.
Procedures to promote cervical ripening, especially use of prostaglandins, may initiate
labor and obviate the need for oxytocin. (See "Induction of labor: Techniques for
preinduction cervical ripening".)
● Describe planned medications and procedures, including side effects and complications,
and the possibility of cesarean birth. (See "Informed consent in obstetrics".)

ASSESSING THE CHANCE OF A SUCCESSFUL INDUCTION

Clinical assessment

Basic principles — The likelihood that induction will result in vaginal birth depends on both
cervical and noncervical factors.
● A favorable cervix (eg, high Bishop score) is associated with a shorter duration of
induction and higher likelihood of vaginal birth whereas the converse is true when the
cervix is unfavorable [42,43] (see 'Bishop score' below). However, an unfavorable cervix
does not mean that avoiding labor induction and managing the patient expectantly will
result in a higher chance of vaginal birth; patients with unfavorable cervixes are still at
increased risk for cesarean birth with expectant management, and the ARRIVE trial
demonstrated that the cesarean birth rate was lower with induction regardless of
cervical status.
● Noncervical factors associated with a higher chance of successful induction (as well as
with higher chance of vaginal birth after spontaneous labor) include [44-47]:

• Multiparity
• Ruptured membranes
• Lower body mass index
• Taller height
• Lower estimated fetal weight
• Absence of comorbidities associated with placental insufficiency (eg, preeclampsia)
In preterm gestations, a study of labor induction using data from the National Institute of
- Page 8 of 41 -
Induction of labor with oxytocin

Child Health and Human Development Consortium on Safe Labor found that multiparity was
the best predictor of vaginal birth (multiparity versus nulliparity: odds ratio [OR] 6.8, 95% CI
6.4-7.2) [48]. Greater gestational age at induction was also predictive of vaginal birth.
Although patients <34 weeks of gestation were less likely to give birth vaginally than those
≥34 weeks of gestation, vaginal birth occurred in 57 percent of patients induced at 24 to 28
weeks, 54 percent of those induced at 28 to 31 weeks, and 67 percent of those induced at 31
to 34 weeks.

Bishop score — The Bishop score ( table 1) is the cervical assessment system most
commonly used in clinical practice in the United States [49]. It is based on the station of the
presenting part and four cervical characteristics: dilation, effacement, consistency, and
position. Cervical dilation is considered to be the most important of the five scoring elements
[44]. The scoring system was developed among individuals who were multiparous, ≥36 weeks
of gestation, and had a normal past and current obstetric history [49]; however, it is now
applied to all patients undergoing induction.

There is no universally accepted threshold for a favorable or unfavorable score. Higher Bishop
scores are associated with a higher chance of vaginal birth [49-52], while lower Bishop scores
have been associated with a higher chance of cesarean birth [45]. Using the Bishop scoring
system, many obstetricians consider a score ≥6 as favorable and a score ≤3 as unfavorable;
scores of 4 or 5 are in a gray zone.

Despite its limitations, the Bishop score appears to be as, or more, predictive of successful
induction than sonographic measurement of cervical length [53] or fetal fibronectin level [44].
Cervical scoring systems other than the Bishop score exist (eg, Fields system; Burnett, Caldor,
and Friedman modifications of the Bishop system [54]; simplified Bishop score [55]), but are
rarely used for predicting labor outcome.

Nonprognostic factors
● The time of day when induction is started does not appear to be an important
independent factor in success [56].
● Early administration of neuraxial analgesia does not appear to lower the chance of
vaginal birth [57]. (See "Adverse effects of neuraxial analgesia and anesthesia for
obstetrics", section on 'Effects on the progress and outcome of labor'.)

- Page 9 of 41 -
Induction of labor with oxytocin

Calculators — The benefit of using a calculator to predict induction outcome is unproved,

although several investigators have attempted to derive models to predict the chance that
induction will result in cesarean birth [58-61]. One group developed an internet-based
calculator to estimate this risk for patients at term with an unfavorable cervix [58]. A different
group developed a seven-variable calculator, which is also available online [59]. A third
group developed calculators for nulliparas with term and preterm pregnancies, which are
available as a mobile app [60]. The area under the curve (AUC) in an external validation cohort
of the first two models was 0.75 [59] and 0.77 [58] in a systematic review, and these were
among the three models with the best discriminative capacity [62]. (Note: A perfect test has
an AUC equal to 1.0, whereas a test that performs no better than chance would have an AUC
of 0.5).

The usefulness of these calculators in clinical practice remains uncertain. The overall
predictive value of the best models is modestly better than a coin toss. Also, they were
developed to evaluate the chance that a cesarean might occur if an induction were
undertaken and not to indicate which patients would have a higher chance of vaginal
birth if they were expectantly managed rather than induced. Similarly, they may not
provide information as to which patients would have lower morbidity by avoiding labor
altogether.

INDUCTION PROCEDURE

Uterine and fetal heart rate monitoring — Whenever oxytocin is administered, uterine
activity and fetal heart rate (FHR) should be continuously monitored so the dose can be
adjusted based on labor progress, uterine activity, and the FHR pattern.

Oxytocin administration — Synthetic oxytocin administration is the most common and

proven method of labor induction [63,64]. In a network meta-analysis of labor induction
methods, use of intravenous (IV) oxytocin plus amniotomy and use of vaginal misoprostol ≥50
micrograms were the two approaches most likely to result in a vaginal birth within 24 hours
[65].

Pharmacology/pharmakokinetics — Exogenous oxytocin administration produces periodic

uterine contractions first demonstrable at approximately 20 weeks of gestation. Myometrial
- Page 10 of 41 -
Induction of labor with oxytocin

responsiveness increases with advancing gestational age until 34 weeks, at which time it
levels off until spontaneous labor begins, when it increases rapidly [66]. Increases in
myometrial sensitivity are due primarily to increases in myometrial oxytocin receptor binding
sites [67]. Receptor activation triggers signaling events that stimulate contractions, primarily
by elevating intracellular calcium levels [68]. It also triggers synthesis of prostaglandins in the
decidua and chorioamniotic membranes via a local paracrine effect [69].

Oxytocin cannot be administered orally because the polypeptide is degraded into small,
inactive forms by gastrointestinal enzymes. When given intravenously, the plasma half-life
has been estimated to be three to six minutes [70]. Low-dose oxytocin protocols are based on
studies showing approximately 40 minutes are required for any particular dose of oxytocin to
reach a steady-state concentration and maximal uterine contractile response [71]. (See 'Side
effects' below.)

Synthetic oxytocin infused within the usual dose range are not likely to pass through the
placenta to the fetus or through the maternal blood-brain barrier [69].

Variations in genes related to the oxytocin receptor appear to be associated with the amount
of oxytocin required during induction and the duration of labor [72]. By comparison, during
spontaneous labor, progress is not related to increasing oxytocin concentration, uterine
contractions are not associated with changes in plasma oxytocin concentration, and
hypocontractile labor does not appear to be the result of a deficit of oxytocin [73].

Timing in patients who undergo cervical ripening — Timing of initiation of oxytocin

administration is only an issue in patients who have received prostaglandins for cervical
ripening. In such patients, oxytocin can be initiated, if indicated:
● Six to 12 hours after the final dose of dinoprostone gel
● 30 minutes after removal of dinoprostone insert
● Four hours after the final misoprostol dose

The reason for the delay is that tachysystole occurs more often with concurrent
administration of oxytocin and a prostaglandin since both drugs carry a risk of this
complication [74]. Data from human and animal studies show that prostaglandin
administration increases uterine sensitivity to oxytocin [75-79].

In patients who had cervical ripening with a balloon catheter, oxytocin can be initiated while
- Page 11 of 41 -
Induction of labor with oxytocin

the catheter is in place or after it has been removed. Oxytocin can also be initiated
concurrently with amniotomy. (See 'Early amniotomy' below and "Induction of labor:
Techniques for preinduction cervical ripening", section on 'Procedure'.)

Infusion — An infusion pump allows continuous, precise control of the dose administered.
Using a standardized regimen minimizes errors in administration [80-83]. A common regimen
is to make a solution of 60 units oxytocin in 1000 mL crystalloid (60 milliunits in one mL) to
allow the infusion pump setting (mL/hour) to match the dose administered (milliunits/minute)
(eg, a pump infusion rate of 1 mL/hour equals 1 milliunit/minute). (See "Reducing adverse
obstetric outcomes through safety sciences", section on 'Oxytocin administration'.)

Dosing — Oxytocin dosing regimens vary among and within facilities [84], differing in
initial dose, dose increments, time period between dose increments, maximum dose, and
cumulative dose [69,80,85,86]. The regimens are categorized as either high or low dose.
Examples are described in the table ( table 2) and the advantages and disadvantages of
each approach are discussed below. (See 'Choosing a low- versus high-dose regimen' below.)

For both high- and low-dose oxytocin regimens, the dose is typically increased until:
● Labor progress is normal or
● Contractions are at least moderately strong to palpation, occurring every two to three
minutes (three to four contractions per 10 minutes), and lasting at least 60 seconds. This
is approximately equivalent to at least 200 to 250 Montevideo units, the value expected
to lead to a normal rate of cervical change and fetal descent. (See "Use of intrauterine
pressure catheters", section on 'Interpretation of findings'.)

The occurrence of adverse effects, such as sustained FHR abnormalities or tachysystole,

should lead to a dose reduction until they resolve.

Maximum dose — Although many institutional regimens limit the infusion dose to no
more than 40 milliunits/minute during labor with a live fetus in the third trimester, doses as
high as 90 milliunits/minute have been used without adverse maternal or fetal effects in
randomized trials [85,86]. Given these data and the variability in uterine response to the
medication, we favor titrating the oxytocin dose according to the oxytocin responsiveness of
the individual patient, primarily based on their contraction and FHR patterns, without regard
to an arbitrary maximum dose.
- Page 12 of 41 -
Induction of labor with oxytocin

Choosing a low- versus high-dose regimen — For most patients, either a low- or high-
dose regimen is acceptable for induction (or augmentation) of labor. The decision should
depend on local factors (eg, provider or institutional preferences, local resources for patient
monitoring). For patients who have had a previous cesarean birth or other extensive
transmyometrial surgery, some UpToDate contributors suggest using a low- rather than high-
dose regimen, while others do not specifically avoid high-dose regimens in these patients.
The maximum safe dose in this setting is also unclear. Although many labor units use 20
milliunits/min in these patients, this is somewhat arbitrary, absolute risk differences between
this maximum and higher maximums appear to be relatively small, and confounding by
indication is possible. A prudent approach is to require the physician to be notified when 20
milliunits/min is reached. Patients who have had a previous cesarean birth or other extensive
transmyometrial surgery are discussed separately. (See "Cervical ripening and induction of
labor after a prior cesarean birth", section on 'Issues related to use of oxytocin'.)

Moderate- to high-quality evidence from randomized trials is insufficient to allow a clear

conclusion as to whether using a high- versus a low-dose regimen alters the cesarean birth
rate or substantively alters other maternal or neonatal outcomes [87-89]. High-dose regimens
modestly reduce the time from induction to birth by one to two hours on average and reduce
the risk for chorioamnionitis but result in a higher rate of tachysystole. Other maternal and
perinatal rates of adverse outcome are similar for both regimens.
● In a 2014 meta-analysis of randomized trials comparing high- versus low-dose oxytocin
regimens for induction of labor, using a high-dose regimen [87]:

• Possibly reduced the induction-to-delivery interval (mean difference in the overall

group: -0.90 hours, 95% CI -2.28 to + 0.49; mean difference on sensitivity analysis
limited to high-quality trials: -1.94 hours, 95% CI -0.99 to -2.89)

• Increased the frequency of tachysystole (47 versus 25 percent; relative risk [RR] 1.86,
95% CI 1.55-2.25) but did not increase the frequency of cesarean birth (18.9 versus
19.8 percent; RR 0.96, 95% CI 0.81-1.14) or maternal and perinatal complication rates.
● In a subsequent large randomized double-blind trial comparing high- (ie, initial and
incremental rates of 6 milliunits/min) with standard-dose (ie, initial and incremental
rates of 2 milliunits/min) oxytocin augmentation in 1002 nulliparous patients, the high-
dose group had a shorter mean labor duration (9.1 versus 10.5 hours; mean difference
- Page 13 of 41 -
Induction of labor with oxytocin

-1.4 hours, 95% CI -2.2 to -0.6) and lower incidence of chorioamnionitis (10.4 versus 15.6
percent; RR 0.67, 95% CI 0.48-0.92), with a trend toward less umbilical artery acidemia
(RR 0.55, 95% CI 0.29-1.01) [88]. The cesarean birth rate was approximately 14 percent
for both groups (RR 1.01; 95% CI 0.75-1.37).

Should oxytocin be discontinued in the active phase? — In patients who achieve a

desirable labor pattern and progress, there is no consensus about whether the oxytocin dose
should be discontinued or continued. Based on the evidence described below, either
discontinuation or continuation is reasonable, as long as labor is progressing and the FHR
pattern is reassuring. If discontinued, oxytocin can be restarted if labor progress slows. If
continued, continuous FHR monitoring is essential to identify potential tachysystole with FHR
changes requiring discontinuation or dose reduction.
● In a 2022 meta-analysis of randomized trials of continued versus discontinued oxytocin
in the active phase of induced labor at ≥36 weeks of gestation, the risk of cesarean with
discontinuation was statistically similar to that with continuation in the subgroup of
patients who actually reached the active phase and thus received the intervention (RR
0.82, 95% CI 0.60-1.10) [90]. Furthermore, there were no between-subgroup differences
in the indication for the cesarean births that were performed. Of note, the trials were
limited by many sources of bias and differences in the cervical dilation (4, 5, or 6 cm)
defining the onset of the active phase of labor.
● A subsequent open-label randomized trial that evaluated the impact of discontinuing
versus continuing oxytocin during active labor (cervical dilation ≥6 cm) on neonatal
morbidity found no significant difference between approaches [91].

Other approaches to dosing

● "Oxytocin rest" or break – We recommend not routinely stopping oxytocin and then
restarting the infusion after a period of time for the purpose of improving labor
progress. Oxytocin-induced desensitization of the oxytocin receptor has been
demonstrated in vitro, but the clinical value of this finding in patients who receive
prolonged oxytocin stimulation has not been demonstrated [92-94]. Although it has
been hypothesized that stopping oxytocin if labor is not progressing and then restarting
the drug several hours later will improve myometrial contractility, no randomized trials
have shown clear evidence of benefit of this approach.
- Page 14 of 41 -
Induction of labor with oxytocin
● Pulsatile dosing – Some investigators have described pulsatile administration of IV
oxytocin at 6- to 10-minute intervals as it theoretically could better simulate normal
labor than continuous oxytocin administration [95,96]. However, pulsatile administration
does not improve outcomes such as reducing the frequency of cesarean birth.
Furthermore, the time from the start of the infusion to delivery may be longer than with
continuous oxytocin administration. Pulsatile oxytocin administration requires special
equipment and is rarely used in contemporary obstetric practice.

Side effects
● Tachysystole – Tachysystole is the most common side effect. The frequency increases as
higher doses of oxytocin are used, but reported absolute rates vary widely [97-100].

The American College of Obstetricians and Gynecologists (ACOG) uses the term
tachysystole to describe >5 contractions in 10 minutes, averaged over a 30-minute
window [101]. The presence or absence of associated FHR changes should be noted.
When reviewing data on tachysystole, clinicians should be mindful of the different
terminologies that have been used in the literature. For example, the term "uterine
hyperstimulation without fetal heart rate changes" has been used to describe uterine
tachysystole (>5 contractions in 10 minutes for at least 30 minutes) or uterine
hypersystole/hypertonus (a contraction lasting at least 2 minutes) with a normal FHR.

• Consequences – Since uterine activity causes intermittent interruption of blood flow

to the intervillous space, a prolonged period of excessive uterine activity may result
in fetal hypoxemia and acidemia [102-106]. Rarely, tachysystole causes uterine
rupture; this is more likely to occur in multiparous patients [98,107].

• Management – The oxytocin dose should be reduced or discontinued until the

tachysystole resolves, even if unassociated with FHR changes. If FHR changes
potentially associated with acidemia are present, standard interventions should be
initiated (eg, left lateral position) [108,109]. (See "Intrapartum category I, II, and III
fetal heart rate tracings: Management", section on 'Approach to selected category II
patterns' and "Intrapartum category I, II, and III fetal heart rate tracings:
Management", section on 'General approach'.)

There is no consensus regarding the optimal approach to managing oxytocin

- Page 15 of 41 -
Induction of labor with oxytocin

administration once tachysystole is noted. Clinicians should assess the full clinical
scenario (fetal status, maternal status, access to emergency cesarean birth if
required) for decision-making in individual cases. For example, discontinuing
oxytocin may be the preferred approach for tachysystole with contractions occurring
approximately every minute, whereas reducing the dose by 50 percent may be
preferred for tachysystole that just meets criteria (five contractions over 9 minutes
and 50 seconds). Similarly, discontinuing oxytocin may be the preferred approach for
a patient receiving 2 milliunits/minute, whereas reducing the dose by 50 percent may
be preferred for a patient receiving 40 milliunits/minute since the absolute reduction
in this setting is relatively large. The presence FHR changes and, if present, their
relationship with fetal acidemia is also a factor. FHR changes associated with
acidemia favors oxytocin discontinuation rather than reduction and may also prompt
administration of a tocolytic such as terbutaline (eg, 0.25 mg subcutaneously) [110].
Of note, in a small randomized trial of patients in active labor receiving intravenous
oxytocin who developed tachysystole, the mean time to resolution after oxytocin
discontinuation was 35±27 minutes [111].

Similarly, the optimal approach to resuming the drug after reduction or

discontinuation for tachysystole is not known. One approach after discontinuation
resumes oxytocin at one-half the last infusion dose if it has been discontinued for
less than 30 minutes and at the initial infusion dose if it has been discontinued for
more than 30 minutes [112-114].
● Hypotension – Because oxytocin relaxes vascular smooth muscle, hypotension and
tachycardia can result from rapid IV injection. This has been observed at cesarean birth
when large IV oxytocin boluses (>5 units) were administered [115-119]. In a randomized
trial of 75 patients undergoing cesarean birth and assigned to one of five doses of
oxytocin postpartum, the prevalence of hypotension one minute after bolus injection of
0 units of oxytocin was 7 percent (one patient), 20 to 30 percent after bolus injection of
0.5 to 3 units, and 47 percent (seven patients) after bolus injection of 5 units [115].

We found no reports of hypotension with use of contemporary IV oxytocin infusion

doses for induction of labor. However, as discussed above, it is prudent to administer
oxytocin for induction by infusion pump to optimally control the rate of infusion and

- Page 16 of 41 -
Induction of labor with oxytocin

avoid adverse cardiovascular effects (arrhythmia, myocardial infarction, hypotension), as

well as tachysystole, nausea, vomiting, headache, and flushing [116].
● Hyponatremia – Oxytocin has a similar structure to vasopressin (antidiuretic hormone)
and can cross-react with the renal vasopressin receptor. If higher doses (eg, 50
milliunits/minute) of oxytocin are administered in a large volume (eg, over 3 liters) of a
hypotonic solution (eg, 5 percent dextrose in water [D5W]) over a prolonged period of
time (≥7 hours [120-122]), excessive water retention can occur and result in severe,
symptomatic hyponatremia, similar to the syndrome of inappropriate antidiuretic
hormone secretion [123-125]. This risk may be as high as 5 percent when the conditions
described above are met [124]. Excessive oral, rather than IV, intake of hypotonic liquids
can have the same effect.

Symptoms of severe acute hyponatremia include headache, anorexia, nausea, vomiting,

abdominal pain, lethargy, drowsiness, unconsciousness, generalized tonic-clonic
seizures, and potentially irreversible neurologic injury. (See "Manifestations of
hyponatremia and hypernatremia in adults".)

If water intoxication occurs, oxytocin and any hypotonic solutions should be stopped.
Hyponatremia must be corrected carefully and consists of restricting water intake and
cautious administration of hypertonic saline if the patient is symptomatic. (See
"Overview of the treatment of hyponatremia in adults".)
● Prolonged QT interval – Oxytocin can prolong the QT interval, but the dose at which
this becomes clinically relevant is uncertain [126-131]. There is no need to routinely
screen individuals with an electrocardiogram before the use of oxytocin; however,
clinicians should be aware of the potential for arrhythmia in patients with known long
QT syndrome [128]. To our knowledge, torsade de pointes has not been reported in a
pregnant patient receiving exogenous oxytocin. (See "Acquired long QT syndrome:
Definitions, pathophysiology, and causes" and "Acquired long QT syndrome: Clinical
manifestations, diagnosis, and management".)
● Pain – Whether induced labor is more painful than spontaneous labor is not well
understood. The answer is not straightforward given the many factors involved in an
individual's labor experience, including the physical circumstances surrounding labor
(eg, frequency and strength of uterine contractions, fetal presentation), as well as
- Page 17 of 41 -
Induction of labor with oxytocin

individual emotional, motivational, cognitive, and social circumstances [132].

Data from randomized trials suggest that intrapartum pain is not worse with induction
than expectant management. In a randomized trial comparing over 1700 individuals
with postterm inductions with a similar number of expectantly managed/monitored
postterm pregnancies, the rate of use of analgesia or anesthesia was similar for both
groups (approximately 91 percent) [133]. In a more contemporary randomized trial of
induction versus expectant management at 39 weeks among low-risk nulliparous
individuals, the induction group had a small reduction in overall and worst pain scores
during labor and more perceived control during childbirth; regional analgesia was used
in the large majority of both groups and with similar frequency [16].

By comparison, some observational studies have suggested a higher frequency of

epidural use among individuals undergoing medically-induced labor, although in many
settings its use is common regardless of how labor is initiated [134,135]. Also, whether
this finding reflects the presence of greater pain among those being induced is
uncertain because of the strong likelihood of selection bias and confounding by
indication (eg, those undergoing a medical induction are more likely to have medical
circumstances that would predispose to recommendation of neuraxial analgesia). As
with other outcomes, it is important to consider the difference between induction versus
expectant management in terms of counseling regarding management choices.

Early amniotomy — Induction using a combination of oxytocin administration and

amniotomy appears to shorten the time to vaginal birth compared with using oxytocin alone.
Amniotomy is performed as soon as feasible if the head is well apposed to the cervix; if not
well apposed, it is delayed to reduce the risk of cord prolapse. The best available evidence
suggests that early amniotomy is safe and effective.
● A 1995 randomized trial suggested that early amniotomy (defined as "soon as deemed
safe and feasible") during labor induction was associated with shorter labor (13.3 versus
17.8 hours) [136]. Although the risk of chorioamnionitis (22.6 versus 6.8 percent) was
increased, two different oxytocin protocols were used (oxytocin increments every 30 or
60 minutes as required) and a statistical increase was only seen in patients who received
oxytocin increments at ≥60 minutes, thus its relevance to contemporary practice where
increments are faster is not clear. Furthermore, subsequent trials have not consistently
- Page 18 of 41 -
Induction of labor with oxytocin

shown an increased risk of infectious morbidity with early amniotomy.

● In a 2020 meta-analysis of randomized trials of patients undergoing induction (four
trials, 1273 patients), early amniotomy after cervical ripening shortened the interval
from induction to delivery by approximately five hours (95% CI -8.12 to -1.78) with no
significant effect on the cesarean birth rate (31.1 versus 30.9 percent, RR 1.05, 95% CI
0.71-1.56) compared with usual care (late amniotomy or spontaneous rupture of
membranes) [137]. There were no clinically important between-group differences for
other obstetric or perinatal outcomes. Early amniotomy was defined as artificial rupture
of the membranes soon after successful cervical ripening (eg, expulsion of Foley balloon,
cervical dilation 3 cm, or favorable Bishop score); late amniotomy was defined as
artificial rupture of membranes after the onset of the active phase of labor.
● A subsequent secondary analysis of data from >2800 nulliparous patients participating
in a randomized trial of term labor induction found that amniotomy performed two or
more hours after oxytocin initiation was associated with lower odds of labor duration
>24 hours compared with leaving the membranes intact during the same time period
[138]. Amniotomy after oxytocin initiation was also associated with either lower or
similar odds of cesarean birth and other adverse outcomes (including chorioamnionitis)
compared with no amniotomy.
● In a 2024 meta-analysis of randomized trials of early versus delayed amniotomy in
individuals undergoing pre-induction cervical ripening with a balloon catheter (five
trials, 849 participants), early amniotomy resulted in a higher proportion of births within
24 hours (79.9 versus 67.1 percent; RR 1.19, 95% CI 1.04−1.36) and shorter intervals from
oxytocin to delivery (weighted mean difference [WMD] -1.5 hours; 95% CI -2.1 to -0.8),
catheter expulsion to vaginal birth (WMD -2.5 hours; 95% CI -4.8 to -0.1), and start of
oxytocin to vaginal birth (WMD -1.8 hours; 95% CI -3.2 to -0.4) [139]. Differences in other
outcomes (cesarean birth, chorioamnionitis, intrapartum fever, endometritis, cord
prolapse, neonatal sepsis) were not statistically significant.
● In a study of outcomes before and after implementation of an induction of labor
protocol, which included both standardized cervical ripening and early amniotomy, the
post-implementation period was associated with decreases in the times from the start of
induction to rupture of membranes (13.3 versus 10.4 hours) and the start of induction to
- Page 19 of 41 -
Induction of labor with oxytocin

delivery (21.2 versus 19.7 hours) [140]. There was little to no difference between groups
in complications such as chorioamnionitis and postpartum hemorrhage or in the
cesarean birth rate.

Complications of amniotomy (whether "early" or "late") include rupture of a vasa previa (if
present) and umbilical cord prolapse. These complications may occur at the time of
spontaneous rupture of the membranes, as well. (See "Velamentous umbilical cord insertion
and vasa previa" and "Umbilical cord prolapse".)

COMPLICATIONS

Uterine rupture — Oxytocin administration has been associated with an increased risk of
uterine rupture, but the absolute risk is very low in patients with an unscarred uterus. In a
series including over 226,000 births, 14 ruptures occurred in patients with unscarred
uteruses, but 12 of these were in patients exposed to oxytocin for induction or augmentation
of labor (two of the patients were nulliparous) [141]. Most uterine ruptures occur in laboring
patients with a scarred uterus. (See "Uterine rupture: Unscarred uterus" and "Uterine rupture:
After previous cesarean birth".)

Amniotic fluid embolism — Induction of labor with oxytocin or a prostaglandin appears to

be associated with an increased risk of amniotic fluid embolism compared with amniotomy
alone or spontaneous labor. In a population-based cohort study of amniotic fluid embolism,
amniotic fluid embolism occurred more commonly in patients who had medical induction of
labor than in those who did not (adjusted odds ratio [aOR] 1.8, 95% CI 1.2-2.7), but the
absolute risk difference was small (10.3 versus 5.2 per 100,000 births) [142]. Given that
patients were induced for medical indications, it is highly plausible that the amniotic fluid
embolism was causally related to the indication and not the induction itself. (See "Amniotic
fluid embolism".)

Postpartum hemorrhage — Oxytocin use, particularly when prolonged or at high dose, has
been cited as a risk factor for postpartum hemorrhage [143]; however, this is likely related to
cofounding by indication (eg, individuals receive oxytocin for augmentation in the setting of a
labor curve abnormality) rather than causal (ie, the oxytocin affects physiology in a manner
that increases the chance of hemorrhage). Longer labor and/or labor dystocia themselves are
- Page 20 of 41 -
Induction of labor with oxytocin

risk factors for postpartum hemorrhage [144-146]. In addition, in trials comparing induction
(where nearly 100 percent of participants receive oxytocin) versus expectant management
(small proportion of participants receive oxytocin), induction did not increase the risk of
postpartum hemorrhage [16,147-149].

Other issues
● Induction of labor at term does not appear to be a risk factor for spontaneous preterm
birth in the subsequent pregnancy [150,151].
● True allergic reactions to oxytocin are rare [152,153].
● There is no consistent evidence from well-designed studies that oxytocin administration
is associated with autism spectrum disorder, attention-deficit/hyperactivity disorder, or
any other long-term adverse outcomes in offspring [119,154]. Confounding by
indication and ascertainment bias are among the factors that limit the findings of
observational studies reporting an association.
● Induction of labor at term does not appear to be a risk factor for developing a severe
perineal laceration [155].

LABOR PROGRESS

The average duration of the latent phase of labor is longer in induced labor than in
spontaneous labor. (See "Labor: Overview of normal and abnormal progression", section on
'Normal progression in induced labors'.)

Once patients being induced enter active labor (cervical dilation ≥6 cm), progression appears
to be comparable to that in patients with spontaneous-onset active labor [156]. The duration
of the second stage is similar in induced and spontaneous labors as well [156-158]. Therefore,
active phase and second stage protraction disorders and arrest are diagnosed and managed
the same as in patients in spontaneous labor. (See "Labor: Overview of normal and abnormal
progression".)

DEFINITION OF FAILED INDUCTION

- Page 21 of 41 -
Induction of labor with oxytocin

There is no strong consensus as to the standard for defining a failed induction. We consider a
reasonable approach to reserve the diagnosis specifically for cesareans performed in the
latent phase because this phase has continued for an extended length of time and, in the
clinician’s judgment, the patient is unlikely to enter the active phase by continuing oxytocin
administration [159]. We would not use the term for inductions in which a cesarean is
performed to treat active phase protraction or arrest, prolonged second stage, nonreassuring
fetal status, or a maternal indication for prompt delivery; instead we use the terms that are
typically used for these indications. We would also not use the term for inductions that are
stopped and the patient sent home undelivered, which is a discontinued induction.

In 2024, the American College of Obstetricians and Gynecologists (ACOG)/Society for

Maternal-Fetal Medicine (SMFM) advised that if the maternal and fetal status remain
reassuring, oxytocin should be administered for at least 12 to 18 hours after membrane
rupture before considering induction failure and individualize the decision to continue past 18
hours [160]. This is a reasonable approach since approximately 70 percent of nulliparous
patients in a large multicenter trial exited the latent phase after 6 hours of oxytocin and
membrane rupture and 20 percent between 6 and 12 hours [161]. Among the 5 percent who
remained in the latent phase for more than 12 hours, 40 percent went on to give birth
vaginally. In another multicenter study of nulliparous patients undergoing induction of labor,
96 percent reached the active phase within 15 hours [162]. Similar results have been reported
in other studies [163-165]. Among multiparous patients, the ACOG/SMFM criteria essential
eliminate the occurrence of failed induction [159].

LABOR INDUCTION WITHOUT INITIAL USE OF OXYTOCIN

Amniotomy alone — In patients with a favorable cervix, use of amniotomy alone is an option
to initiate labor if the head is well apposed to the cervix; however, the combination of
amniotomy and intravenous (IV) oxytocin administration is more effective. In a meta-analysis
of randomized trials, this combination resulted in a substantial reduction in pregnancies
undelivered at 24 hours compared with amniotomy alone (2.1 versus 16.3 percent, relative
risk [RR] 0.13, 95% CI 0.04-0.41; two trials with a total of 296 participants) [166].

Prostaglandin E1 or E2 — In patients with unfavorable cervixes, prostaglandins are a proven

- Page 22 of 41 -
Induction of labor with oxytocin

method of cervical ripening and may initiate labor as a result of their uterotonic effects. (See
"Induction of labor: Techniques for preinduction cervical ripening", section on
'Prostaglandins'.)

In patients with favorable cervixes, however, there are inadequate data to determine the
safety and efficacy of using prostaglandins instead of oxytocin to initiate induction of labor.
Until such data are available, we avoid using prostaglandins to induce labor in patients with
favorable cervixes.

Membrane stripping — Membrane stripping to induce labor has not been associated with
demonstrable improvements in many clinically important outcomes (eg, lower cesarean rate,
more favorable neonatal outcome), and as such, the decision to perform it should be
individualized based on patient choice.

Stripping or sweeping of the membranes involves inserting the examiner’s finger beyond the
internal cervical os and then rotating the finger circumferentially along the lower uterine
segment to detach the fetal membranes from the decidua. It is typically performed during an
office visit when the cervix is partially dilated and the patient and clinician hope to hasten the
onset of spontaneous labor. Thus, it should be performed only in those planning a trial of
labor who are at least 39 weeks.

In a 2020 meta-analysis of 40 randomized trials (>6500 participants) comparing membrane

sweeping with no or a sham intervention, sweeping modestly reduced the rate of formal
labor induction (23 versus 31 percent, relative risk [RR] 0.73, 95% CI 0.56-0.94) and increased
the rate of spontaneous onset of labor (72 versus 60 percent, RR 1.21, 95% CI 1.08-1.34)
without affecting other maternal or neonatal outcomes [167]. Participants generally felt the
benefits outweighed the harms (eg, discomfort) and would recommend it to others.

Group B Streptococcus colonization is not a contraindication to membrane sweeping as there

is no direct evidence of harm. This issue is discussed in more detail separately. (See
"Prevention of early-onset group B streptococcal disease in neonates", section on
'Antepartum procedures'.)

Nonstandard approaches — There is a paucity of data regarding the safety and/or efficacy
of glucocorticoids, castor oil, hyaluronidase, isosorbide mononitrate, acupuncture, evening
primrose oil, herbal preparations, breast stimulation, or sexual intercourse for labor

- Page 23 of 41 -
Induction of labor with oxytocin

induction, and none of these can be recommended as an evidence-based approach to labor

induction [168-178].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Cervical ripening and
labor induction".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Labor and childbirth (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Indications for induction

• High-risk pregnancies – Induction is indicated when the maternal/fetal risks

associated with continuing the pregnancy are thought to be at least as great as the
maternal/fetal/newborn risks associated with delivery and there is no

- Page 24 of 41 -
Induction of labor with oxytocin

contraindication to labor and vaginal birth. The risks are influenced primarily by the
gestational age and severity of the maternal/fetal conditions, and can rarely be
determined with precision. Some of the most common indications are postdate
pregnancy, hypertensive disorders, prelabor rupture of membranes, and diabetes.
(See 'Medical and obstetric indications' above and 'Contraindications' above.)

• Low-risk pregnancies – Risk-reducing induction at 39 weeks of gestation is an

option for patients without other obstetric/medical indications for delivery. The
values and preferences of the patient and the resources available for procedure need
to be considered when making this decision. (See 'Scheduled induction at 39 weeks'
above.)
● Preinduction evaluation and management – Preinduction evaluation includes
reviewing the estimate of gestational age, determining fetal presentation, estimating
fetal weight, performing a cervical examination to decide whether to use a cervical
ripening agent, evaluating the fetal heart rate (FHR) pattern, and reviewing the patient's
pregnancy and medical history for risk factors for potential problems that may develop
during labor and delivery. (See 'Preinduction assessment and patient preparation'
above.)
● Cervical examination/Bishop score – Cervical status before oxytocin administration is
a key factor associated with the duration of induction. The Bishop score ( table 1) is
the best available tool for assessing cervical status. Most obstetricians consider a score
≥6 as favorable and a score ≤3 as unfavorable; scores of 4 or 5 are in a gray zone. (See
'Clinical assessment' above.)

Patients with unfavorable cervixes who are scheduled for induction can benefit from
preinduction cervical ripening, as discussed separately. (See "Induction of labor:
Techniques for preinduction cervical ripening".)

For patients with favorable cervixes who are scheduled for induction, we suggest
administration of oxytocin and amniotomy rather than amniotomy alone (Grade 2B).
The head should be well apposed to the cervix before amniotomy. (See 'Amniotomy
alone' above.)
● Oxytocin administration – Oxytocin is the standard medication for induction.

- Page 25 of 41 -
Induction of labor with oxytocin

• Dosing – Oxytocin is administered intravenously by an infusion pump.

Implementation of a standardized protocol can minimize errors in oxytocin
administration. A common regimen is to make a solution of 60 units oxytocin in 1000
mL crystalloid (60 milliunits in 1 mL) to allow the infusion pump setting (mL/hour) to
match the dose administered (milliunits/minute; ie, a pump infusion rate of 1
mL/hour equals 1 milliunit/minute). (See 'Infusion' above.)

Either a high- or low-dose oxytocin regimen is acceptable ( table 2). (See 'Dosing'
above.)

We increase the dose according to myometrial responsiveness in the individual

patient, primarily based on their contraction and FHR patterns, without regard to an
arbitrary maximum dose. The dose is typically increased until labor progress is
normal; however, the dose should be reduced if sustained FHR abnormalities or
tachysystole occurs. (See 'Dosing' above.)

• Timing of amniotomy – In patients receiving oxytocin, we suggest early rather than

delayed or no amniotomy (Grade 2B). The combination of oxytocin administration
and amniotomy appears to shorten the time to vaginal birth compared with using
oxytocin alone. The head should be well apposed to the cervix before amniotomy.
(See 'Early amniotomy' above.)

• Side effects – The most common side effect is tachysystole (>5 contractions in 10
minutes, averaged over a 30-minute window). Rare side effects include hyponatremia
and, if administered rapidly by IV bolus, hypotension. (See 'Side effects' above.)

• Discontinuation in the active phase – In patients who achieve a desirable labor

pattern and progress, there is no consensus about whether oxytocin should be
discontinued or continued in the active phase or second stage, and either approach
is reasonable as long as labor is progressing and the FHR pattern is reassuring. If
discontinued, oxytocin can be restarted if labor progress slows. If continued,
continuous FHR monitoring will identify tachysystole with FHR changes requiring
oxytocin discontinuation or dose reduction. (See 'Should oxytocin be discontinued in
the active phase?' above.)
● Labor progress – Once a patient undergoing induction has entered active labor (cervical

- Page 26 of 41 -
Induction of labor with oxytocin

dilation 6 cm), progression appears to be comparable to that with spontaneous active

labor. The duration of the second stage is similar in induced and spontaneous labors.
Therefore, active phase and second stage protraction and arrest disorders are
diagnosed and managed similarly to patients in spontaneous labor. (See 'Labor
progress' above.)
● Failed induction – There is no consensus for defining a failed induction. We use the
term for cesareans performed in the latent phase because this phase has continued for
an extended duration (at least 12 to 18 hours after membrane rupture) and, in the
clinician's judgment, the patient is unlikely to enter the active phase by continuing
oxytocin administration. The decision to administer oxytocin past 18 hours should be
individualized. (See 'Definition of failed induction' above.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Deborah A Wing, MD, MBA, who contributed to an
earlier version of this topic review.

REFERENCES

1. Osterman MJK, Hamilton BE, Martin JA, et al. Births: Final Data for 2021. Natl Vital Stat
Rep 2023; 72:1.

2. Swift EM, Gunnarsdottir J, Zoega H, et al. Trends in labor induction indications: A 20-year
population-based study. Acta Obstet Gynecol Scand 2022; 101:1422.

3. O' Sullivan C, Wilson E, Beckmann M. Five-year trends in induction of labour in a large

Australian metropolitan maternity service. Aust N Z J Obstet Gynaecol 2022; 62:407.

4. Coates D, Makris A, Catling C, et al. A systematic scoping review of clinical indications for
induction of labour. PLoS One 2020; 15:e0228196.
5. Zhu J, Xue L, Shen H, et al. Labor induction in China: a nationwide survey. BMC Pregnancy
Childbirth 2022; 22:463.

6. WHO recommendations: induction of labour at or beyond term. Geneva: World Health Or

ganization; 2018.

- Page 27 of 41 -
Induction of labor with oxytocin

7. ACOG Committee on Practice Bulletins -- Obstetrics. ACOG Practice Bulletin No. 107:
Induction of labor. Obstet Gynecol 2009; 114:386. Reaffirmed 2020.

8. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice,

Society for Maternal-Fetal Medicine. Medically Indicated Late-Preterm and Early-Term
Deliveries: ACOG Committee Opinion, Number 831. Obstet Gynecol 2021; 138:e35.

9. Voutsos L. Prophylactic induction. Am J Obstet Gynecol 2020; 222:290.

10. Ghartey J, Macones GA. 39-Week nulliparous inductions are not elective. Am J Obstet
Gynecol 2020; 222:519.
11. Berghella V, Al-Hafez L, Bellussi F. Induction for 39 weeks' gestation: let's call it what it is.
Am J Obstet Gynecol MFM 2020; 2:100098.
12. Ehrenthal DB, Hoffman MK, Jiang X, Ostrum G. Neonatal outcomes after implementation
of guidelines limiting elective delivery before 39 weeks of gestation. Obstet Gynecol
2011; 118:1047.
13. Mishanina E, Rogozinska E, Thatthi T, et al. Use of labour induction and risk of cesarean
delivery: a systematic review and meta-analysis. CMAJ 2014; 186:665.

14. Rosenstein MG, Cheng YW, Snowden JM, et al. Risk of stillbirth and infant death stratified
by gestational age. Obstet Gynecol 2012; 120:76.

15. Chen HY, Grobman WA, Blackwell SC, Chauhan SP. Neonatal and Maternal Adverse
Outcomes Among Low-Risk Parous Women at 39-41 Weeks of Gestation. Obstet Gynecol
2019; 134:288.

16. Grobman WA, Rice MM, Reddy UM, et al. Labor Induction versus Expectant Management
in Low-Risk Nulliparous Women. N Engl J Med 2018; 379:513.

17. Grobman WA, Caughey AB. Elective induction of labor at 39 weeks compared with
expectant management: a meta-analysis of cohort studies. Am J Obstet Gynecol 2019;
221:304.

18. Grobman WA, Sandoval G, Reddy UM, et al. Health resource utilization of labor induction
versus expectant management. Am J Obstet Gynecol 2020; 222:369.e1.

19. Einerson BD, Nelson RE, Sandoval G, et al. Cost of Elective Labor Induction Compared
With Expectant Management in Nulliparous Women. Obstet Gynecol 2020; 136:19.

- Page 28 of 41 -
Induction of labor with oxytocin

20. Tita ATN, Doherty L, Grobman WA, et al. Maternal and Perinatal Outcomes of Expectant
Management of Full-Term, Low-Risk, Nulliparous Patients. Obstet Gynecol 2021; 137:250.

21. Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination o

f Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (Californi
a Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed un
der contract #08-85012 with the California Department of Public Health; Maternal, Child
and Adolescent Health Division; First edition published by March of Dimes, July 2010.
22. Clark SL, Miller DD, Belfort MA, et al. Neonatal and maternal outcomes associated with
elective term delivery. Am J Obstet Gynecol 2009; 200:156.e1.
23. Dietz PM, Rizzo JH, England LJ, et al. Early term delivery and health care utilization in the
first year of life. J Pediatr 2012; 161:234.
24. Zhang X, Kramer MS. Variations in mortality and morbidity by gestational age among
infants born at term. J Pediatr 2009; 154:358.
25. Escobar GJ, Greene JD, Hulac P, et al. Rehospitalisation after birth hospitalisation:
patterns among infants of all gestations. Arch Dis Child 2005; 90:125.
26. Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical outcomes of near-term infants.
Pediatrics 2004; 114:372.

27. Wetta L, Tita AT. Early term births: considerations in management. Obstet Gynecol Clin
North Am 2012; 39:89.

28. Parikh LI, Reddy UM, Männistö T, et al. Neonatal outcomes in early term birth. Am J
Obstet Gynecol 2014; 211:265.e1.

29. Carlhäll S, Alsweiler J, Battin M, et al. Neonatal and maternal outcomes at early vs. full
term following induction of labor; A secondary analysis of the OBLIGE randomized trial.
Acta Obstet Gynecol Scand 2024; 103:955.

30. Main EK. New perinatal quality measures from the National Quality Forum, the Joint
Commission and the Leapfrog Group. Curr Opin Obstet Gynecol 2009; 21:532.

31. Hong J, Atkinson J, Roddy Mitchell A, et al. Comparison of Maternal Labor-Related

Complications and Neonatal Outcomes Following Elective Induction of Labor at 39 Weeks
of Gestation vs Expectant Management: A Systematic Review and Meta-analysis. JAMA
Netw Open 2023; 6:e2313162.
- Page 29 of 41 -
Induction of labor with oxytocin

32. Sinkey RG, Blanchard CT, Szychowski JM, et al. Elective Induction of Labor in the 39th
Week of Gestation Compared With Expectant Management of Low-Risk Multiparous
Women. Obstet Gynecol 2019; 134:282.

33. Souter V, Painter I, Sitcov K, Caughey AB. Maternal and newborn outcomes with elective
induction of labor at term. Am J Obstet Gynecol 2019; 220:273.e1.

34. Wagner SM, Sandoval G, Grobman WA, et al. Labor Induction at 39 Weeks Compared with
Expectant Management in Low-Risk Parous Women. Am J Perinatol 2022; 39:519.
35. Werner EF, Schlichting LE, Grobman WA, et al. Association of Term Labor Induction vs
Expectant Management With Child Academic Outcomes. JAMA Netw Open 2020;
3:e202503.
36. Lindquist A, Hastie R, Kennedy A, et al. Developmental Outcomes for Children After
Elective Birth at 39 Weeks' Gestation. JAMA Pediatr 2022; 176:654.
37. Yisma E, Mol BW, Lynch JW, et al. Elective labor induction vs expectant management of
pregnant women at term and children's educational outcomes at 8 years of age.
Ultrasound Obstet Gynecol 2021; 58:99.
38. Management of Full-Term Nulliparous Individuals Without a Medical Indication for
Delivery: ACOG Clinical Practice Update. Obstet Gynecol 2025; 145:e45.
39. Committee on Obstetric Practice. Committee Opinion No. 688: Management of
Suboptimally Dated Pregnancies. Obstet Gynecol 2017; 129:e29. Reaffirmed 2019.

40. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 561:
Nonmedically indicated early-term deliveries. Obstet Gynecol 2013; 121:911. Reaffirmed
2017.

41. Society of Maternal-Fetal (SMFM) Publications Committee. Electronic address:

pubs@smfm.org. SMFM Statement on Elective Induction of Labor in Low-Risk Nulliparous
Women at Term: the ARRIVE Trial. Am J Obstet Gynecol 2019; 221:B2.

42. Osmundson S, Ou-Yang RJ, Grobman WA. Elective induction compared with expectant
management in nulliparous women with an unfavorable cervix. Obstet Gynecol 2011;
117:583.

43. Osmundson SS, Ou-Yang RJ, Grobman WA. Elective induction compared with expectant

- Page 30 of 41 -
Induction of labor with oxytocin

management in nulliparous women with a favorable cervix. Obstet Gynecol 2010;

116:601.

44. Crane JM. Factors predicting labor induction success: a critical analysis. Clin Obstet
Gynecol 2006; 49:573.

45. Gibson KS, Waters TP. Measures of success: Prediction of successful labor induction.
Semin Perinatol 2015; 39:475.

46. Pevzner L, Rayburn WF, Rumney P, Wing DA. Factors predicting successful labor induction
with dinoprostone and misoprostol vaginal inserts. Obstet Gynecol 2009; 114:261.
47. Tolcher MC, Holbert MR, Weaver AL, et al. Predicting Cesarean Delivery After Induction of
Labor Among Nulliparous Women at Term. Obstet Gynecol 2015; 126:1059.
48. Feghali M, Timofeev J, Huang CC, et al. Preterm induction of labor: predictors of vaginal
delivery and labor curves. Am J Obstet Gynecol 2015; 212:91.e1.
49. BISHOP EH. PELVIC SCORING FOR ELECTIVE INDUCTION. Obstet Gynecol 1964; 24:266.
50. Vrouenraets FP, Roumen FJ, Dehing CJ, et al. Bishop score and risk of cesarean delivery
after induction of labor in nulliparous women. Obstet Gynecol 2005; 105:690.

51. Kolkman DG, Verhoeven CJ, Brinkhorst SJ, et al. The Bishop score as a predictor of labor
induction success: a systematic review. Am J Perinatol 2013; 30:625.

52. Teixeira C, Lunet N, Rodrigues T, Barros H. The Bishop Score as a determinant of labour
induction success: a systematic review and meta-analysis. Arch Gynecol Obstet 2012;
286:739.

53. Verhoeven CJ, Opmeer BC, Oei SG, et al. Transvaginal sonographic assessment of cervical
length and wedging for predicting outcome of labor induction at term: a systematic
review and meta-analysis. Ultrasound Obstet Gynecol 2013; 42:500.

54. Baacke KA, Edwards RK. Preinduction cervical assessment. Clin Obstet Gynecol 2006;
49:564.

55. Laughon SK, Zhang J, Troendle J, et al. Using a simplified Bishop score to predict vaginal
delivery. Obstet Gynecol 2011; 117:805.

56. Bakker JJ, van der Goes BY, Pel M, et al. Morning versus evening induction of labour for
improving outcomes. Cochrane Database Syst Rev 2013; :CD007707.

- Page 31 of 41 -
Induction of labor with oxytocin

57. Wong CA, McCarthy RJ, Sullivan JT, et al. Early compared with late neuraxial analgesia in
nulliparous labor induction: a randomized controlled trial. Obstet Gynecol 2009;
113:1066.

58. Levine LD, Downes KL, Parry S, et al. A validated calculator to estimate risk of cesarean
after an induction of labor with an unfavorable cervix. Am J Obstet Gynecol 2018;
218:254.e1.

59. Rossi RM, Requarth E, Warshak CR, et al. Risk Calculator to Predict Cesarean Delivery
Among Women Undergoing Induction of Labor. Obstet Gynecol 2020; 135:559.
60. Kawakita T, Reddy UM, Huang JC, et al. Externally Validated Prediction Model of Vaginal
Delivery After Preterm Induction With Unfavorable Cervix. Obstet Gynecol 2020; 136:716.
61. Hernández-Martínez A, Pascual-Pedreño AI, Baño-Garnés AB, et al. Predictive model for
risk of cesarean section in pregnant women after induction of labor. Arch Gynecol Obstet
2016; 293:529.
62. López-Jiménez N, García-Sánchez F, Hernández-Pailos R, et al. Risk of caesarean delivery
in labour induction: a systematic review and external validation of predictive models.
BJOG 2022; 129:685.
63. Alfirevic Z, Kelly AJ, Dowswell T. Intravenous oxytocin alone for cervical ripening and
induction of labour. Cochrane Database Syst Rev 2009; :CD003246.

64. Alfirevic Z, Keeney E, Dowswell T, et al. Which method is best for the induction of labour?
A systematic review, network meta-analysis and cost-effectiveness analysis. Health
Technol Assess 2016; 20:1.

65. Alfirevic Z, Keeney E, Dowswell T, et al. Methods to induce labour: a systematic review,
network meta-analysis and cost-effectiveness analysis. BJOG 2016; 123:1462.

66. Calderyro-Barcia R, Sereno JA. The response of human uterus to oxytocin throughout pre
gnancy. In: Oxytocin, Calderyro-Barcia R, Heller H (Eds), Pergamon Press, London 1959.

67. Fuchs AR, Fuchs F, Husslein P, Soloff MS. Oxytocin receptors in the human uterus during
pregnancy and parturition. Am J Obstet Gynecol 1984; 150:734.

68. Arrowsmith S, Wray S. Oxytocin: its mechanism of action and receptor signalling in the
myometrium. J Neuroendocrinol 2014; 26:356.

- Page 32 of 41 -
Induction of labor with oxytocin

69. Uvnäs-Moberg K. The physiology and pharmacology of oxytocin in labor and in the
peripartum period. Am J Obstet Gynecol 2024; 230:S740.

70. Rydén G, Sjöholm I. The metabolism of oxytocin in pregnant and non-pregnant women.
Acta Obstet Gynecol Scand Suppl 1971; 9:Suppl 9:37.

71. Seitchik J, Amico J, Robinson AG, Castillo M. Oxytocin augmentation of dysfunctional

labor. IV. Oxytocin pharmacokinetics. Am J Obstet Gynecol 1984; 150:225.
72. Grotegut CA, Ngan E, Garrett ME, et al. The association of single-nucleotide
polymorphisms in the oxytocin receptor and G protein-coupled receptor kinase 6 (GRK6)
genes with oxytocin dosing requirements and labor outcomes. Am J Obstet Gynecol
2017; 217:367.e1.
73. Thornton S, Davison JM, Baylis PH. Plasma oxytocin during the first and second stages of
spontaneous human labour. Acta Endocrinol (Copenh) 1992; 126:425.
74. Tan PC, Daud SA, Omar SZ. Concurrent dinoprostone and oxytocin for labor induction in
term premature rupture of membranes: a randomized controlled trial. Obstet Gynecol
2009; 113:1059.
75. Brummer HC. Interaction of E prostaglandins and syntocinon on the pregnant human
myometrium. J Obstet Gynaecol Br Commonw 1971; 78:305.

76. Gillespie A. Interrelationship between oxytocin (endogenous and exogenous) and

prostaglandins. Adv Biosci 1973; 9:761.

77. Wikland M, Lindblom B, Hammarström S, Wiqvist N. The effect of prostaglandin I on the

contractility of the term pregnant human myometrium. Prostaglandins 1983; 26:905.

78. Baguma-Nibasheka M, Wentworth RA, Green LR, et al. Differences in the in vitro
sensitivity of ovine myometrium and mesometrium to oxytocin and prostaglandins E2
and F2alpha. Biol Reprod 1998; 58:73.

79. Chan WY. Uterine and placental prostaglandins and their modulation of oxytocin
sensitivity and contractility in the parturient uterus. Biol Reprod 1983; 29:680.

80. Hayes EJ, Weinstein L. Improving patient safety and uniformity of care by a standardized
regimen for the use of oxytocin. Am J Obstet Gynecol 2008; 198:622.e1.

81. Clark S, Belfort M, Saade G, et al. Implementation of a conservative checklist-based

- Page 33 of 41 -
Induction of labor with oxytocin

protocol for oxytocin administration: maternal and newborn outcomes. Am J Obstet

Gynecol 2007; 197:480.e1.

82. Freeman RK, Nageotte M. A protocol for use of oxytocin. Am J Obstet Gynecol 2007;
197:445.

83. International Medication Safety Network. Oxytocin Safety Interest Group. Recommendati
ons for Global Implementation of Safe Oxytocin Use Practices. 2023. Available at https://
www.intmedsafe.net/wp-content/uploads/2023/05/IMSN-OxytocinSIG-Recommendations
-2023.pdf.

84. Daly D, Minnie KCS, Blignaut A, et al. How much synthetic oxytocin is infused during
labour? A review and analysis of regimens used in 12 countries. PLoS One 2020;
15:e0227941.
85. Son M, Roy A, Grobman WA, et al. Maximum Dose Rate of Intrapartum Oxytocin Infusion
and Associated Obstetric and Perinatal Outcomes. Obstet Gynecol 2023; 141:379.
86. Merrill DC, Zlatnik FJ. Randomized, double-masked comparison of oxytocin dosage in
induction and augmentation of labor. Obstet Gynecol 1999; 94:455.
87. Budden A, Chen LJ, Henry A. High-dose versus low-dose oxytocin infusion regimens for
induction of labour at term. Cochrane Database Syst Rev 2014; :CD009701.
88. Son M, Roy A, Stetson BT, et al. High-Dose Compared With Standard-Dose Oxytocin
Regimens to Augment Labor in Nulliparous Women. Obstet Gynecol 2021.

89. Reddy UM, Sandoval GJ, Tita ATN, et al. Oxytocin regimen used for induction of labor and
pregnancy outcomes. Am J Obstet Gynecol MFM 2024; 6:101508.

90. Jiang D, Yang Y, Zhang X, Nie X. Continued versus discontinued oxytocin after the active
phase of labor: An updated systematic review and meta-analysis. PLoS One 2022;
17:e0267461.

91. Girault A, Sentilhes L, Desbrière R, et al. Impact of discontinuing oxytocin in active labour
on neonatal morbidity: an open-label, multicentre, randomised trial. Lancet 2023;
402:2091.

92. Robinson C, Schumann R, Zhang P, Young RC. Oxytocin-induced desensitization of the

oxytocin receptor. Am J Obstet Gynecol 2003; 188:497.

- Page 34 of 41 -
Induction of labor with oxytocin

93. Phaneuf S, Rodríguez Liñares B, TambyRaja RL, et al. Loss of myometrial oxytocin
receptors during oxytocin-induced and oxytocin-augmented labour. J Reprod Fertil 2000;
120:91.

94. Phaneuf S, Asbóth G, Carrasco MP, et al. Desensitization of oxytocin receptors in human
myometrium. Hum Reprod Update 1998; 4:625.

95. Cummiskey KC, Dawood MY. Induction of labor with pulsatile oxytocin. Am J Obstet
Gynecol 1990; 163:1868.
96. Tribe RM, Crawshaw SE, Seed P, et al. Pulsatile versus continuous administration of
oxytocin for induction and augmentation of labor: two randomized controlled trials. Am J
Obstet Gynecol 2012; 206:230.e1.
97. Smith JG, Merrill DC. Oxytocin for induction of labor. Clin Obstet Gynecol 2006; 49:594.

98. Flannelly GM, Turner MJ, Rassmussen MJ, Strong JM. Rupture of the uterus in Dublin: An
update. J Obstet Gynaecol 1993; 13:440.
99. Wing DA, Ortiz-Omphroy G, Paul RH. A comparison of intermittent vaginal administration
of misoprostol with continuous dinoprostone for cervical ripening and labor induction.
Am J Obstet Gynecol 1997; 177:612.

100. Wing DA, Miller H, Parker L, et al. Misoprostol vaginal insert for successful labor
induction: a randomized controlled trial. Obstet Gynecol 2011; 117:533.

101. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 106:
Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general
management principles. Obstet Gynecol 2009; 114:192. Reaffirmed 2021.

102. Bakker PC, Kurver PH, Kuik DJ, Van Geijn HP. Elevated uterine activity increases the risk of
fetal acidosis at birth. Am J Obstet Gynecol 2007; 196:313.e1.

103. Jonsson M, Nordén-Lindeberg S, Ostlund I, Hanson U. Acidemia at birth, related to

obstetric characteristics and to oxytocin use, during the last two hours of labor. Acta
Obstet Gynecol Scand 2008; 87:745.

104. Simpson KR, James DC. Effects of oxytocin-induced uterine hyperstimulation during labor
on fetal oxygen status and fetal heart rate patterns. Am J Obstet Gynecol 2008;
199:34.e1.

- Page 35 of 41 -
Induction of labor with oxytocin

105. Peebles DM, Spencer JA, Edwards AD, et al. Relation between frequency of uterine
contractions and human fetal cerebral oxygen saturation studied during labour by near
infrared spectroscopy. Br J Obstet Gynaecol 1994; 101:44.

106. Heuser CC, Knight S, Esplin MS, et al. Tachysystole in term labor: incidence, risk factors,
outcomes, and effect on fetal heart tracings. Am J Obstet Gynecol 2013; 209:32.e1.

107. Catanzarite V, Cousins L, Dowling D, Daneshmand S. Oxytocin-associated rupture of an

unscarred uterus in a primigravida. Obstet Gynecol 2006; 108:723.
108. Sharma SK, Gajraj NM, Sidawi JE. Prevention of hypotension during spinal anesthesia: a
comparison of intravascular administration of hetastarch versus lactated Ringer's
solution. Anesth Analg 1997; 84:111.
109. Pullen KM, Riley ET, Waller SA, et al. Randomized comparison of intravenous terbutaline
vs nitroglycerin for acute intrapartum fetal resuscitation. Am J Obstet Gynecol 2007;
197:414.e1.
110. Hermesch AC, Kernberg AS, Layoun VR, Caughey AB. Oxytocin: physiology,
pharmacology, and clinical application for labor management. Am J Obstet Gynecol 2024;
230:S729.
111. Pacheco LD, Rosen MP, Gei AF, et al. Management of uterine hyperstimulation with
concomitant use of oxytocin and terbutaline. Am J Perinatol 2006; 23:377.

112. www.ihs.gov/medicalprograms/mch/f/documents/Tachysystole2.pdf (Accessed on May 2

4, 2012).

113. Care of the patient receiving oxytocin for labor induction or augmentation. University of
Michigan Hospital. November 2010. obgyn.med.umich.edu/sites/obgyn.med...edu/.../ind-
aug_labor.pdf (Accessed on May 24, 2012).

114. mail.ny.acog.org/website/OxytocinForInduction.pdf (Accessed on May 24, 2012).

115. Butwick AJ, Coleman L, Cohen SE, et al. Minimum effective bolus dose of oxytocin during
elective Caesarean delivery. Br J Anaesth 2010; 104:338.

116. Dyer RA, Butwick AJ, Carvalho B. Oxytocin for labour and caesarean delivery: implications
for the anaesthesiologist. Curr Opin Anaesthesiol 2011; 24:255.

117. Gregory SG, Anthopolos R, Osgood CE, et al. Association of autism with induced or

- Page 36 of 41 -
Induction of labor with oxytocin

augmented childbirth in North Carolina Birth Record (1990-1998) and Education

Research (1997-2007) databases. JAMA Pediatr 2013; 167:959.

118. Vintzileos AM, Ananth CV. Does augmentation or induction of labor with oxytocin
increase the risk for autism? Am J Obstet Gynecol 2013; 209:502.

119. Oberg AS, D'Onofrio BM, Rickert ME, et al. Association of Labor Induction With Offspring
Risk of Autism Spectrum Disorders. JAMA Pediatr 2016; 170:e160965.

120. Lilien AA. Oxytocin-induced water intoxication. A report of a maternal death. Obstet
Gynecol 1968; 32:171.
121. Bilek W, Dorr P. Water intoxication and grand mal seizure due to oxytocin. Can Med Assoc
J 1970; 103:379.
122. Moen V, Brudin L, Rundgren M, Irestedt L. Hyponatremia complicating labour--rare or
unrecognised? A prospective observational study. BJOG 2009; 116:552.
123. WHALLEY PJ, PRITCHARD JA. OXYTOCIN AND WATER INTOXICATION. JAMA 1963; 186:601.
124. Feeney JG. Water intoxication and oxytocin. Br Med J (Clin Res Ed) 1982; 285:243.

125. Bergum D, Lonnée H, Hakli TF. Oxytocin infusion: acute hyponatraemia, seizures and
coma. Acta Anaesthesiol Scand 2009; 53:826.

126. Guillon A, Leyre S, Remérand F, et al. Modification of Tp-e and QTc intervals during
caesarean section under spinal anaesthesia. Anaesthesia 2010; 65:337.

127. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia after oxytocin injection in
patients with prolonged Q-T interval syndrome--report of two cases. Acta Anaesthesiol
Sin 1998; 36:49.

128. Martillotti G, Talajic M, Rey E, Leduc L. Long QT syndrome in pregnancy: are vaginal
delivery and use of oxytocin permitted? A case report. J Obstet Gynaecol Can 2012;
34:1073.

129. Uzun M, Yapar K, Uzlu E, et al. QT interval prolongation and decreased heart rates after
intravenous bolus oxytocin injection in male and female conscious rabbits. Gen Physiol
Biophys 2007; 26:168.

130. Kreifels P, Bodi I, Hornyik T, et al. Oxytocin exerts harmful cardiac repolarization
prolonging effects in drug-induced LQTS. Int J Cardiol Heart Vasc 2022; 40:101001.

- Page 37 of 41 -
Induction of labor with oxytocin

131. Charbit B, Funck-Brentano C, Samain E, et al. QT interval prolongation after oxytocin

bolus during surgical induced abortion. Clin Pharmacol Ther 2004; 76:359.

132. Lowe NK. The nature of labor pain. Am J Obstet Gynecol 2002; 186:S16.

133. Hannah ME, Hannah WJ, Hellmann J, et al. Induction of labor as compared with serial
antenatal monitoring in post-term pregnancy. A randomized controlled trial. The
Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 1992; 326:1587.
134. Jacobsen LK, Haslund H, Brock C, Laursen BS. Medically induced labor: Epidural analgesia
and women's perceptions of pain in early labor. Eur J Midwifery 2018; 2:15.
135. Hildingsson I, Karlström A, Nystedt A. Women's experiences of induction of labour--
findings from a Swedish regional study. Aust N Z J Obstet Gynaecol 2011; 51:151.
136. Mercer BM, McNanley T, O'Brien JM, et al. Early versus late amniotomy for labor
induction: a randomized trial. Am J Obstet Gynecol 1995; 173:1321.
137. De Vivo V, Carbone L, Saccone G, et al. Early amniotomy after cervical ripening for
induction of labor: a systematic review and meta-analysis of randomized controlled trials.
Am J Obstet Gynecol 2020; 222:320.

138. Battarbee AN, Sandoval G, Grobman WA, et al. Maternal and Neonatal Outcomes
Associated with Amniotomy among Nulliparous Women Undergoing Labor Induction at
Term. Am J Perinatol 2021; 38:e239.

139. Diab YH, Diab M, Horgan R, et al. Early vs. delayed amniotomy in individuals undergoing
pre-induction cervical ripening with transcervical Foley balloon: a meta-analysis. Am J
Obstet Gynecol MFM 2024; 6:101408.

140. Suresh SC, Kucirka L, Chau DB, et al. Evidence-based protocol decreases time to vaginal
delivery in elective inductions. Am J Obstet Gynecol MFM 2021; 3:100294.

141. Porreco RP, Clark SL, Belfort MA, et al. The changing specter of uterine rupture. Am J
Obstet Gynecol 2009; 200:269.e1.

142. Kramer MS, Rouleau J, Baskett TF, et al. Amniotic-fluid embolism and medical induction of
labour: a retrospective, population-based cohort study. Lancet 2006; 368:1444.

143. Grotegut CA, Paglia MJ, Johnson LN, et al. Oxytocin exposure during labor among women
with postpartum hemorrhage secondary to uterine atony. Am J Obstet Gynecol 2011;

- Page 38 of 41 -
Induction of labor with oxytocin

204:56.e1.

144. Liu CN, Yu FB, Xu YZ, et al. Prevalence and risk factors of severe postpartum hemorrhage:
a retrospective cohort study. BMC Pregnancy Childbirth 2021; 21:332.

145. Nyfløt LT, Stray-Pedersen B, Forsén L, Vangen S. Duration of labor and the risk of severe
postpartum hemorrhage: A case-control study. PLoS One 2017; 12:e0175306.

146. Grobman WA, Bailit J, Lai Y, et al. Association of the Duration of Active Pushing With
Obstetric Outcomes. Obstet Gynecol 2016; 127:667.
147. Walker KF, Bugg GJ, Macpherson M, et al. Randomized Trial of Labor Induction in Women
35 Years of Age or Older. N Engl J Med 2016; 374:813.
148. Koopmans CM, Bijlenga D, Groen H, et al. Induction of labour versus expectant
monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation
(HYPITAT): a multicentre, open-label randomised controlled trial. Lancet 2009; 374:979.
149. Boulvain M, Senat MV, Perrotin F, et al. Induction of labour versus expectant
management for large-for-date fetuses: a randomised controlled trial. Lancet 2015;
385:2600.
150. Levine LD, Bogner HR, Hirshberg A, et al. Term induction of labor and subsequent
preterm birth. Am J Obstet Gynecol 2014; 210:354.e1.

151. Sciscione A, Larkin M, O'Shea A, et al. Preinduction cervical ripening with the Foley
catheter and the risk of subsequent preterm birth. Am J Obstet Gynecol 2004; 190:751.

152. Kjaer BN, Krøigaard M, Garvey LH. Oxytocin use during Caesarean sections in Denmark -
are we getting the dose right? Acta Anaesthesiol Scand 2016; 60:18.

153. Pant D, Vohra VK, Pandey SS, Sood J. Pulseless electrical activity during caesarean delivery
under spinal anaesthesia: a case report of severe anaphylactic reaction to Syntocinon. Int
J Obstet Anesth 2009; 18:85.

154. Lønfeldt NN, Verhulst FC, Strandberg-Larsen K, et al. Assessing risk of

neurodevelopmental disorders after birth with oxytocin: a systematic review and meta-
analysis. Psychol Med 2019; 49:881.

155. Sigdel M, Burd J, Walker KF, et al. Severe perineal lacerations in induction of labor versus
expectant management: A systematic review and meta-analysis of randomized controlled

- Page 39 of 41 -
Induction of labor with oxytocin

trials. Am J Obstet Gynecol MFM 2024; 6:101407.

156. Hoffman MK, Vahratian A, Sciscione AC, et al. Comparison of labor progression between
induced and noninduced multiparous women. Obstet Gynecol 2006; 107:1029.

157. Vahratian A, Zhang J, Troendle JF, et al. Labor progression and risk of cesarean delivery in
electively induced nulliparas. Obstet Gynecol 2005; 105:698.

158. Janakiraman V, Ecker J, Kaimal AJ. Comparing the second stage in induced and
spontaneous labor. Obstet Gynecol 2010; 116:606.
159. Rouse DJ, Owen J, Hauth JC. Criteria for failed labor induction: prospective evaluation of a
standardized protocol. Obstet Gynecol 2000; 96:671.
160. First and Second Stage Labor Management: ACOG Clinical Practice Guideline No. 8.
Obstet Gynecol 2024; 143:144.
161. Rouse DJ, Weiner SJ, Bloom SL, et al. Failed labor induction: toward an objective
diagnosis. Obstet Gynecol 2011; 117:267.
162. Grobman WA, Bailit J, Lai Y, et al. Defining failed induction of labor. Am J Obstet Gynecol
2018; 218:122.e1.

163. Simon CE, Grobman WA. When has an induction failed? Obstet Gynecol 2005; 105:705.

164. Kawakita T, Reddy UM, Iqbal SN, et al. Duration of Oxytocin and Rupture of the
Membranes Before Diagnosing a Failed Induction of Labor. Obstet Gynecol 2016;
128:373.

165. Ayala NK, Rouse DJ. Failed induction of labor. Am J Obstet Gynecol 2024; 230:S769.
166. Howarth GR, Botha DJ. Amniotomy plus intravenous oxytocin for induction of labour.
Cochrane Database Syst Rev 2001; :CD003250.

167. Finucane EM, Murphy DJ, Biesty LM, et al. Membrane sweeping for induction of labour.
Cochrane Database Syst Rev 2020; 2:CD000451.

168. Kavanagh J, Kelly AJ, Thomas J. Breast stimulation for cervical ripening and induction of
labour. Cochrane Database Syst Rev 2005; :CD003392.

169. Kavanagh J, Kelly AJ, Thomas J. Corticosteroids for cervical ripening and induction of
labour. Cochrane Database Syst Rev 2006; :CD003100.

170. Kavanagh J, Kelly AJ, Thomas J. Hyaluronidase for cervical ripening and induction of
- Page 40 of 41 -
Induction of labor with oxytocin

labour. Cochrane Database Syst Rev 2006; :CD003097.

171. Kavanagh J, Kelly AJ, Thomas J. Sexual intercourse for cervical ripening and induction of
labour. Cochrane Database Syst Rev 2001; :CD003093.

172. Tan PC, Yow CM, Omar SZ. Effect of coital activity on onset of labor in women scheduled
for labor induction: a randomized controlled trial. Obstet Gynecol 2007; 110:820.

173. Dove D, Johnson P. Oral evening primrose oil: its effect on length of pregnancy and
selected intrapartum outcomes in low-risk nulliparous women. J Nurse Midwifery 1999;
44:320.
174. McFarlin BL, Gibson MH, O'Rear J, Harman P. A national survey of herbal preparation use
by nurse-midwives for labor stimulation. Review of the literature and recommendations
for practice. J Nurse Midwifery 1999; 44:205.
175. Omar NS, Tan PC, Sabir N, et al. Coitus to expedite the onset of labour: a randomised
trial. BJOG 2013; 120:338.
176. Kelly AJ, Kavanagh J, Thomas J. Castor oil, bath and/or enema for cervical priming and
induction of labour. Cochrane Database Syst Rev 2013; :CD003099.
177. Smith CA, Crowther CA, Grant SJ. Acupuncture for induction of labour. Cochrane
Database Syst Rev 2013; :CD002962.

178. Ghosh A, Lattey KR, Kelly AJ. Nitric oxide donors for cervical ripening and induction of
labour. Cochrane Database Syst Rev 2016; 12:CD006901.

Topic 4476 Version 177.0

© 2025 UpToDate, Inc. All rights reserved.

- Page 41 of 41 -