Obstetrics and Gynecology
Induction of Labor: A Review
kavita goel*, jaya k gedam†, DISHA A RAJPUT †, MINAL V BHALERAO*
Abstract
Induction of labor is a common obstetric procedure, and is indicated when the benefits to either mother or fetus outweigh those
of continuing the pregnancy. Cervical assessment (Bishop score) at the time of initiation is the best independent predictor of
induction success. Although multiple agents are available for labor induction, the most commonly used methods are mechanical
methods, prostaglandins and oxytocin. Indication for induction of labor, clinical presentation, safety, cost and patient preference
may be used in selecting the method of induction. The goal of labor induction must always be to ensure the best possible
outcome for mother and newborn.
Keywords: Labor, induction of labor, oxytocin, prostaglandins
O
ver the past several decades, obstetricians are
fascinated with the process of parturition.
Thus, the concerns for maternal well-being and
timing of birth have been extensively studied to
generate multiple approaches to initiate labor. Some of
the methods are still used in current practices. Other
methods such as vaginal or uterine douches, stimulant
injections thrown into the rectum, and the use of
ergot alkaloid have been abandoned because of their
“ineffectiveness or poisonous effects on the infant”.1
The incidence of labor induction has continued to rise
over the past several decades.2 In developed countries,
the number of infants delivered at term following
induction of labor can be as high as one in four
deliveries.3-5 The World Health Organization (WHO)
Global Survey on Maternal and Perinatal Health,
conducted in 24 countries which included nearly
3,00,000 observations, showed that 9.6% of them were
delivered by labor induction. The survey found that
African countries have lower rates of induction of labor
(lowest: Niger 1.4%) compared with Asian and Latin
American countries (highest: Sri Lanka 35.5%).6
Induction of Labor
Induction of labor refers to artificial stimulation
of uterine contractions before the true onset of
spontaneous labor in order to achieve vaginal delivery
*Senior Resident
†Associate Professor
Dept. of Obstetrics and Gynecology
ESI-PGIMSR, MGM Hospital, Parel, Mumbai, Maharashtra
Address for correspondence
Dr Jaya K Gedam
Dr SS Rao Road, ESI-PGIMSR, MGM Hospital, Parel, Mumbai - 12, Maharashtra
E-mail: jayagedam@gmail.com
by medical or surgical means. Augmentation of labor
refers to increasing the frequency and the intensity of
already existing uterine contractions in a patient in true
labor but progressing inadequately, in order to achieve
vaginal delivery.
Indications and Contraindications
For induction of labor, the benefits of early delivery
to either mother or fetus should outweigh the risks
of pregnancy continuation.7 The indications and
contraindications for induction of labor are given in
Tables 1 and 2, respectively. Before labor induction,
thorough examination of the maternal and fetal condition
is necessary (Table 3). Indications and contraindications
for induction should be reviewed. Risks and benefits of
labor induction should be discussed with the patient
and relatives including the risk of cesarean delivery.
Confirmation of gestational age is very important
and fetal lung maturity status should be performed if
indicated (Table 4).7,8 A cervical examination should
be performed and documented (Bishop score). Fetal
presentation and position should be confirmed. Clinical
pelvimetry should be performed and cephalopelvic
disproportion (CPD) should be ruled out. According to
WHO guidelines, labor induction should be performed
at a center, where qualified staff and OT facilities are
available for cesarean section. Uterine activity and
electronic fetal monitoring (EFM) should be done for
all patients undergoing labor induction.
Prediction of Labor Induction Success
Bishop’s Score
In 1964, Bishop developed a scoring system to evaluate
multiparous women for elective induction at term
(Table 5).9,10
Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1057
Obstetrics and Gynecology

Table 1. Indications for Labor Induction Table 4. Criteria for Confirmation of Gestational Age
Absolute indications and/or Fetal Pulmonary Maturity
Hypertensive disorders: Pre-eclampsia/Eclampsia
Parameters
Postdated pregnancy
Premature rupture of membranes Confirmation of Fetal heart tones have been
gestational age documented as present for ≥30 weeks
Chorioamnionitis
by Doppler ultrasound.
Intrauterine growth restriction
Fetal complications: Isoimmunization, oligohydramnios, ≥36 weeks have elapsed since
nonreassuring fetal status a positive serum or urine human
chorionic gonadotropin pregnancy test.
Maternal medical complications: Diabetes mellitus, renal
disease, chronic pulmonary disease Ultrasound measurement at
Intrauterine fetal death <20 weeks of gestation supports
Relative indications gestational age of 39 weeks or
Hypertensive disorders: Chronic hypertension greater.
Polyhydramnios Fetal pulmonary If term gestation cannot be confirmed
Fetal anomalies requiring specialized neonatal care maturity by two or more of the above
Psychosocial conditions: Previous precipitate labor, distance obstetrical, clinical or laboratory
from hospital criteria, amniotic fluid analyses can
Previous stillbirth be used to provide evidence of
fetal lung maturity. A variety of tests
are available. The parameters for
Table 2. Contraindications for Labor Induction evidence of fetal pulmonary maturity
are as follows:
Absolute contraindications
Vasa previa or complete placenta previa yy Lecithin/sphingomyelin (L/S) ratio
Transverse or oblique fetal lie >2.1
Umbilical cord prolapse yy Presence of phosphatidylglycerol
(PG)
Prior classical uterine incision or transfundal uterine surgery
yy TD x FLM assay ≥70 mg
Active genital herpes infection
surfactant/1 g albumin present
Absolute cephalopelvic disproportion, contracted pelvis yy Presence of saturated
Relative contraindications phosphatidylcholine (SPC) ≥500
Malpresentation (breech) ng/mL in nondiabetic patients
Cervical carcinoma (≥1,000 ng/mL for pregestational
diabetic patients)
yy Lamellar body count exceeding
30,000/µL
Table 3. Criteria for Induction of Labor
Maternal criteria Fetal criteria Modified data from Induction of Labor. ACOG Practice Bulletin No
107. American College of Obstetricians and Gynecologists. Obstet
Confirm indication Confirm gestational age Gynecol 2009;114:386.
Rule out contraindications Assess fetal lung maturity Fetal Lung Maturity. ACOG Practice Bulletin No. 97. American College
status if required of Obstetricians and Gynecologists. Obstet Gynecol 2008;112:717.
Perform clinical pelvimetry Estimate fetal weight
to rule out cephalopelvic (clinically or USG)
disproportion associated with failure of induction in nulliparous
Assess cervical condition Confirm fetal presentation women at term with low Bishop score is well-
(Bishop score) and lie established in the literature.
Discuss risks and benefits with Confirm fetal well-being
patient and relatives Cervical Length
Cervical length may predict the success of spontaneous
onset of labor post-term. This has been evaluated in
The higher the Bishop score, the more ‘ripe’ or ‘ numerous studies by sonography. However, results
favorable’ the cervix is for labor induction. Most showed sonographic cervical length assessment to
studies define an unfavorable cervix as a Bishop perform poorly compared to Bishop score for predicting
score of 6 or less. The higher risk of cesarean delivery a successful induction.11

1058 Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014
 Obstetrics and Gynecology

Table 5. Modified Bishop Score Table 7. Standardized Oxytocin Regimen

Score 0 1 2 3
Parameter         yy Dilution: 10 U oxytocin in 1,000 mL normal saline for
Dilation (cm) Closed 1-2 3-4 5 or more resultant concentration of 10 mU oxytocin/mL
Effacement (%) 0-30 40-50 60-70 80 or more yy Infusion rate: 2 mU/min or 12 mL/hr
Length* (cm) >4 2-4 1-2 1-2
Station -3 -2 -1 or 0 +1 or +2 yy Incremental dose: 2 mU/min or 12 mL/hr every 45 minutes
Consistency Firm Medium Soft   until contraction frequency adequate
Cervical
Posterior Mid-position Anterior yy Maximum dose: 16 mU/min or 96 mL/hr
position
Bishop EH. Pelvic scoring for elective induction. Obstet.Gynecol Hayes EJ, Weinstein L. Improving patient safety and uniformity of
1964;24:266. care by a standardized regimen for the use of oxytocin. Am J Obstet
Gynecol 198:622.
*Modification by Calder AA, Brennand JE. Labor and normal
delivery: induction of labor. Curr Opin Obstet Gynecol
1991;3:764.
This modification replaces percent effacement as one of the
Table 8. Labor Stimulation with Oxytocin: Examples
parameters of the Bishop Score.10
of Low- and High-dose Oxytocin Dosing Regimens
Regimen Starting Incremental Dosage
dose dose interval
Table 6. Methods of Cervical Ripening
(mU/min) (mU/min) (min)
Mechanical methods Surgical methods Medical methods
Low-dose 0.5-2.0 1-2 15-40
Membrane stripping Amniotomy Oxytocin
High-dose 6 3-6* 15-40
Mechanical dilators Prostaglandins
Hygroscopic dilators yy E2 (Dinoprostone) Induction of Labor. ACOG Practice Bulletin No 107. American College
yy E1 (Misoprostol) of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:386.
yy Laminaria tents
*The incremental increase is reduced to 3 mU/min in the presence
yy Lamicel
Foley balloon Progesterone of hyperstimulation and reduced to 1 mU/min with recurrent
catheter receptor hyperstimulation.

yy Without extra antagonists

amniotic saline (Mifepristone)
finally leading to thinning and dilatation of the
infusion Nitric oxide
yy With extraamniotic donors cervix.14 There is enzymatic dissolution of collagen
saline infusion fibrils of cervix, along with an increase in water
Estrogen
content or swelling. These changes are induced by
Relaxin
hormones (estrogen, progesterone, relaxin), as well as
Hyaluronic acid cytokines, prostaglandins and nitric oxide synthesis
enzymes.15  Methods used for cervical ripening include
mechanical and pharmacologic methods (Table 6).
Fetal Fibronectin
Mechanical Methods
An elevated fetal fibronectin (FFN) concentration in
Mechanical methods of cervical ripening were among
cervicovaginal secretions has been used to predict
the first methods used for labor induction and have
success of labor induction. An elevated FFN may be
been used for centuries. They are often less costly,
caused by disruption or inflammation of the chorionic-
result in less hyperstimulation, are easy to store and
decidual interface. A prospective trial concluded that
may result in fewer side effects for mother and fetus
FFN does not predict vaginal delivery in nulliparous
are the advantages.16 Risk of infection, disruption of a
women.12 Only obstetric history and digital examination low-lying placenta and some maternal discomfort on
predicted accurately vaginal delivery within 24 hours.13 manipulation of the cervix are some disadvantages.
Cervical Ripening Membrane Stripping
Cervical ripening is an important predictor of labor Stripping or sweeping of the fetal membranes is
outcome. It is a complex chemical change resulting digital separation of the chorioamniotic membrane
in physical softening and distensibility of the cervix, from the wall of the cervix and lower uterine segment.

Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1059
Obstetrics and Gynecology
This causes the release of endogenous prostaglandins
from the adjacent membranes and decidua, as well as
from the cervix.16 Numerous studies have conducted
routine membrane stripping at 38 or 39 weeks to
either prevent prolonged or post-term pregnancies.17
Complications include rupture of membranes,
hemorrhage from disruption of an occult placenta
previa and the development of chorioamnionitis.
Mechanical Dilators
Mechanical dilators include hygroscopic dilators
(laminaria or lamicel), balloon (Foley catheter) and
balloon with extra-amniotic saline infusion (EASI).
Hygroscopic Dilators
Cervical dilators are made from organic seaweed
(laminaria) or synthetic hydrophilic materials (lamicel-
polyvinyl alcohol polymer). They are introduced into
the cervical canal and left in situ for 6-12 hours where
they increase in diameter because of their hydrophilic
properties, achieving a gradual stretching, dilatation
and effacement of the cervix.
In the last two decades, there has been a reduction
in the use of hygroscopic and osmotic dilators for
the induction of labor in favor of the mechanical and
pharmacologic agents. Risk of maternal and fetal
infections with hygroscopic and osmotic dilators is
more as compared with the use of other pharmacologic
agents.18 They are contraindicated in cases of ruptured
membranes. Placement of dilators also requires
additional training and may be associated with rupture
of membranes, vaginal bleeding and patient discomfort
or pain.
Extra-amniotic Balloon and Extra-amniotic Saline
Infusion
The Foley catheter affects cervical ripening in two
ways: Gradual dilatation and separation of the
deciduas from the amnion stimulating prostaglandin
release. Foley catheters of size 14-26 F with inflation
volume of 30-80 mL, and the EASI with infusion rates
of 30-40 mL/hour have been shown to be safe and
efficacious. The advantages of Foley catheter when
compared with prostaglandins include lower cost,
stability at room temperature, reduced risk of uterine
tachysystole with or without fetal heart rate (FHR)
changes, and applicability in an outpatient setting.
It seems that higher insufflations volumes (80 mL) may
be more efficacious than lower volumes (30 mL).19,20
The concomitant use of oxytocin with Foley catheter
does not seem to shorten the duration of labor.21
1060 Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014
The mean induction to delivery time was shorter
with the concomitant use of Foley catheter with
vaginal misoprostol. There was no increase in labor
complications or adverse perinatal outcomes.22
A meta-analysis of randomized controlled trial (RCT)
concluded that there was no significant difference
between Foley catheter balloon and locally applied
prostaglandins in cesarean delivery rates. However,
prostaglandins had a significantly increased risk of
excessive uterine activity.23 A RCT concluded that
induction of labor using mechanical methods compared
to prostaglandins resulted in similar cesarean section
rates along with a lower risk of excessive uterine
activity. Mechanical methods compared with oxytocin
had lower risk of cesarean section.24 The Foley catheter
can be associated with risks of rupture of membranes,
vaginal bleeding in women with a low-lying placenta,
febrile morbidity and displacement of the presenting
part.25
Surgical Method of Induction
Amniotomy
Amniotomy, artificial rupture of membranes, is a
procedure carried out by iatrogenic rupture of the
chorioamniotic membranes by either toothed clamp
(Allis or Kocher’s clamp) or multiple punctures with
some pointed structure like 26-guage needle. It is
commonly performed in multiparous women with
favorable Bishop score with success. However, to
minimize the risk of cord prolapse, fetal vertex should
not be floating and be well-applied to the cervix.
The FHR should be assessed before and after the
procedure, and the character and color of the amniotic
fluid should be recorded. The concomitant use of
amniotomy and intravenous (IV) oxytocin is more
effective compared with amniotomy alone, with most
women delivering vaginally within 24 hours.26
Pharmacologic Techniques
Prostaglandins
As stated earlier in mechanism of cervical ripening,
prostaglandins act on cervix by dissolution of collagen
fibrils and an increase in water content of the cervix.
Also, prostaglandins increase intracellular calcium
levels, causing myometrial contractions. Prostaglandins
are already found in the myometrium, deciduas and
fetal membranes during pregnancy. Initially given
by intramuscular and oral routes, nowadays locally
applied prostaglandins, vaginally or intracervically,
are the routes of choice because of patient acceptability

with fewer side effects. Side effects include fever, chills,
vomiting and diarrhea, etc.
Overall, induction with prostaglandins was associated
with an increase in successful vaginal delivery within
24 hours, a reduction in the rate of cesarean delivery
and an increase in the risk of uterine tachysystole
with FHR changes.27 Prostaglandins should not be
used in women with a prior cesarean delivery or
myomectomy because of an increased risk of uterine
rupture.28 Uterine activity and FHR monitoring should
be maintained after administration of prostaglandins
for cervical ripening.7
PGE2 Dinoprostone
Local application of prostaglandin E2 (PGE2) is
commonly used for cervical ripening. Its gel form
(Prepidil) is available in a 2.5 mL syringe containing
0.5 mg of dinoprostone. With the woman supine,
the tip of pre-filled syringe is placed intracervically
to deposit the gel just below the internal cervical os.
After administration, she remains supine for at least 30
minutes. Doses may be repeated every 6 hours with a
maximum of two doses in 24 hours recommended.
A 10 mg dinoprostone vaginal insert (Cervidil) is also
approved for cervical ripening. This is a thin, flat,
rectangular polymeric wafer held within a small, white
mesh polyester sac with long attached tail. It provides
slower release of drug (0.3 mg/hr). It is used as a single
dose placed transversely in posterior vaginal fornix.
Following insertion, a woman should remain supine
for at least 2 hours. The insert is removed after 12 hours
or with labor onset. These two preparations are costly,
and need refrigerated storage to remain stable.
Prostaglandin E1
Misoprostol (Cytotec) is a synthetic prostaglandin E1
(PGE1) analog initially used with nonsteroidal anti-
inflammatory drugs (NSAIDs) to prevent gastric ulcers
and is available as 100 and 200 µg tablets. Misoprostol
for preinduction cervical ripening is an ‘off-label’ use.29
Misoprostol is less costly, safe and is also stable at room
temperature. Misoprostol can be administered orally
or placed vaginally with few systemic side effects.
A Cochrane meta-analysis of trials revealed that
vaginal misoprostol improved cervical ripening with
an increased rate of vaginal delivery within 24 hours
compared with placebo.30 Compared with PGE2 also, it
gave similar results. However, uterine tachysystole with
fetal heart changes was more common. Most studies
suggested that restricting the dose of misoprostol to
25 µg every 4 hours significantly reduced the above
risk.31
Obstetrics and Gynecology
In a meta-analysis, oral misoprostol use was found
clearly superior to placebo, as women administered 25
and 50 µg oral misoprostol dosages were more likely to
deliver vaginally within 24 hours, needed less oxytocin
and had a lower cesarean rate.32
Some investigators have described titrating oral
misoprostol to its desired effect with less uterine
overactivity compared to vaginal misoprostol.33
Low- dose oral misoprostol (20 µg) is achieved by
making a solution (e.g., dissolving a 200 µg tablet in
200 mL tap water) and administered every 2 hours.
Other modes of administration include buccal and
sublingual route of misoprostol administration.34
A systematic review concluded that the sublingual route
of misoprostol administration is equally efficacious
as the vaginal one for labor induction. However, the
concerns regarding safety, dosing, side effects and
adverse maternal and neonatal outcome need to be
studied in future trials for routine recommendation in
obstetrics.35
Progesterone Receptor Antagonists
RU-486 (Mifepristone) is a more selective progesterone
receptor antagonist and has been used for early
pregnancy termination. Because of its action, trials
had been undergoing for its applicability in cervical
ripening and labor induction. The studies suggested
that mifepristone reduced the rate of cesarean section
as compared to placebo. Therefore, future trials are
needed to compare mifepristone with other established
cervical ripening agents.36
Nitric Oxide Donors
Nitric oxide donors act by increasing the expression
of cyclooxygenase-2 (COX-2) in the cervix, thus
improving cervical distensibility without causing
uterine contractions. Benefits include its use in the
outpatient setting, low-cost and ease of administration.
Side effects may include maternal hemodynamic
changes associated with a vasodilator, including
hypotension and tachycardia. Women reported
headaches and palpitations as the most common
side effects of intravaginal administration of isosorbide
mononitrate, 40 mg.37 A trial comparing isosorbide
mononitrate with placebo resulted in no difference in
admission to delivery interval despite a clinical effect
on cervical ripening.38 Therefore, further trials are
needed for isosorbide mononitrate use as a cervical
ripening agent before its acceptance.
Several other approaches to cervical ripening have been
documented in literature, including estrogen, relaxin
Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1061
Obstetrics and Gynecology
and hyaluronic acid, etc. None of them were found to
be clinically useful and they have now been superseded
by the use of mechanical methods and prostaglandins.
Medical Methods of Induction
Oxytocin
Oxytocin is a polypeptide neurohormone originating
from the hypothalamus and secreted from the posterior
lobe of the pituitary gland, representing the agent most
frequently used for labor induction. Gestational age is
a major factor affecting the dose response to oxytocin
with the uterus responding to oxytocin at approximately
20 weeks gestation, with increasing responsiveness
with advancing gestational age primarily due to
an increase in myometrial oxytocin binding sites.
Thereafter, myometrial sensitivity to oxytocin remains
more or less same from 34 weeks to term till active
labor commences, and the sensitivity increases many
fold. Due to this mechanism, oxytocin is better in
augmenting labor than in inducing labor, and even less
efficacious as a cervical ripening agent.
Oxytocin is mainly given by IV infusion. It is not
active orally because it is degraded by gastrointestinal
enzymes. The plasma half-life is short, around 3-6
minutes and steady state concentrations are reached
within 30-40 minutes of continuous IV infusion. It is
prepared by diluting 10 units in 1,000 mL of an isotonic
solution. The standardized dosing regimen consists
of infusion rate of 2  mU/min or 12  mL/hour with an
incremental dose of 2 mU/min or 12 mL/hour every 45
minutes until contraction frequency is adequate (Table 7).
Maximum dose is 16 mU/min or 96 mL/hour. IV oxytocin
is considered superior to placebo with a significant
number of women delivering vaginally within
24 hours.39 Two regimes of oxytocin administration are
commonly practiced. The low-dose regimen consists of
a starting dose of 0.5-2 mU/min with an incremental
dose of 1-2 mU/min every 15-40 minutes and the high-
dose regimen has a starting dose of 6 mU/min and an
incremental dose of 3-6 mU/min every 15-40 minutes
(Table 8). Which regimen of oxytocin is superior is
debatable; however, both regimens are acceptable for
the induction of labor.40 The high-dose protocol was
not only associated with significant shorter induction
to delivery time but was also associated with a higher
incidence of uterine hyperstimulation and need for
oxytocin discontinuation. Whatever regimen is decided
upon, each hospital should develop protocols for their
administration as per their own experience and safety,
and should revise it from time to time. This has reduced
mean maximum oxytocin infusion rate and improved
1062 Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014
neonatal outcomes without increasing cesarean delivery
rate.41 WHO recommended if prostaglandins are not
available, IV oxytocin alone can be used for induction
of labor.2 The comparison of oxytocin with PGE2
revealed that prostaglandins decrease the induction to
delivery time. Oxytocin induction may increase the rate
of interventions in labor.
Complications Associated with Induction
of Labor
Uterine Overactivity
This is the most frequently encountered complication
of oxytocin or prostaglandin administration. The most
commonly used terms to describe are hyperstimulation,
tachysystole and hypertonus. The American College
of Obstetricians and Gynecologists (ACOG) offers the
following definitions:
ÂÂ Tachysystole can be defined as a persistent pattern
of ≥ 5 contractions in 10 minutes.
ÂÂ Hypertonus is described as a single contraction
lasting longer than 2 minutes.
ÂÂ Hyperstimulation is described as tachysystole or
hypertonus associated with FHR abnormalities.42
One of the advantages of oxytocin administration
is that if uterine hyperstimulation is noticed, the
infusion can quickly be stopped. This usually results
in the resolution of such uterine overactivity. In
addition, placing the woman in the left lateral position,
administering oxygen and IV fluids may be of benefit.
If FHR tracing abnormalities persist and uterine
hyperstimulation is ongoing, the use of a tocolytic
such as terbutaline may be considered.
Failed Induction
There are currently no criteria for a failed induction.
The obstetrician should understand that cervical
ripening itself can take some time, and that the
establishment of an active labor is important to label
labor as failed induction. A study concluded that 40%
of the women who remained in the latent phase after
12 hours of oxytocin and membrane rupture were
delivered vaginally. Therefore, it is important not to
label labor induction a failure in the latent phase until
oxytocin has been administered for at least 12 hours
after membrane rupture.43 Failed induction is not
necessarily an indication for cesarean section. Other
options include a further attempt to induce labor (the
timing should depend on the clinical situation and the
patient’s wishes) or waiting for spontaneous labor.

Cesarean Section
Increasing incidence of labor induction has contributed
to the increasing cesarean section rate. Compared to
spontaneous onset of delivery, induction of labor
is associated with an increased risk for emergency
cesarean section both among nulliparous and
multiparous women.44-46
Greater Need for Pain Relief
Induced labor significantly differs from the
physiological spontaneous onset labor, with a longer
and often painful latent phase. Prostaglandins may
be associated with significant discomfort. Simple
analgesia may suffice, but some women will require
stronger opiate/epidural analgesia.
Uterine Rupture
Uterine rupture is rare and in most instances occurs
in women with prior uterine surgery such as cesarean
delivery or myomectomy. Other risk factors are grand
multiparity, marked uterine overdistension either with a
macrosomic fetus, multiple gestation, polyhydramnios,
or fetal malpresentation. Most studies suggest that the
use of oxytocin for labor induction or augmentation
is not associated with a significant increase in the risk
of uterine rupture in women with a prior cesarean
delivery. The ACOG states that the use of misoprostol
in women with prior cesarean delivery or major uterine
surgery has been associated with an increase in uterine
rupture and, therefore, should be avoided in the third
trimester.
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