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Induction of Labour at John Hunter Hospital

John Hunter Hospital
Project Added:
21 March 2013
Last updated:
20 October 2016

Induction of Labour at John Hunter Hospital

by Marianne Knox and Mandy Hunter, Hunter New England Local Health District


As part of working towards meeting clinical indicators for Towards Normal Birth, John Hunter Hospital (JHH) recently undertook an audit of Induction of Labour (IOL) over a six month period (from 23/5/2011 – 18/11/2011).

The number of women who embark on a labour and/or go into labour spontaneously needs to increase.

Towards Normal Birth Policy Directive, 2010

Audit results

The audit looked primarily at the number, outcome and indications for IOLs. During this period:

  • 42% of women (n=822) were booked for IOL, just over half of these women were nulliparous
  • 48% (n=352) of women booked for IOL birthed prior to induction
  • 52% (n-470) were induced
  • on average at JHH there were 3 IOLs per day, 7 days per week.

Surprisingly, the audit revealed 83 different indications for inducing women. 

The overall caesarean section (C/S) rate for the women who were induced = 27% (n=125), however 74% (n=92) of these women were nulliparous. Therefore the overall C/S rate for nulliparous women who were induced (n=243) was 38%.

Graph showing ceasarean section of 26% multi and 74% primip
Graph of reasons for C/S following IOL

Graph results: Did not establish=31%, Slow progress 1st stage=31%, Susp/path CTG = 15%,  Slow progress 2nd stage=11%, Elective=7%

Service improvements

The IOL audit findings were presented at a weekly multidisciplinary forum for midwives and doctors where a decision was made to review some of the evidence relating to 9 of the main indications for IOL.

It was also agreed to review the process of IOL in nulliparous women.

Midwives and doctors nominated themselves to be part of individual multidisciplinary working groups to review the current literature around each indication. The group results were presented to the multidisciplinary forum over a five week period and the forum then agreed on a level of priority of classification for each of the indicators - high, medium, low or not medically indicated.

Current evidence showed that three of the commonly cited reasons for IOL: Increased BMI; Macrosomia, and VBAC, were not appropriate indications and were therefore given a priority classification of 0. 

Classification schedule (PDF File pdf - 109 KB)

Urgent IOL for maternal medical or fetal conditions requires direct booking by a consultant obstetrician. IOL for other indications will also require direct booking by a consultant obstetrician until these indications have been reviewed and presented in the same multidisciplinary format.

Implementation of the new booking system commenced on 13 November 2012. Inductions occur based on priority classification.

As a result of the review of current evidence on IOL in nulliparous women, the forum agreed to:

  • routinely offer nulliparous women membrane sweeping at 40-41 weeks
  • recommend nulliparous women have cervical ripening for bishop scores <7, as well as reassessment of bishop score after cervical ripening with view to consideration of further ripening or postponement of IOL if still unfavourable.

This project is ongoing. It is planned that after 3 months a repeat audit of all IOLs will be conducted and the results will be compared to the first audit. Hopefully, this project will demonstrate a benefit of reducing the number of women who have unnecessary interference in the natural process of pregnancy and birth, thereby increasing the incidence of women who go into labour spontaneously at JHH Birthing Service.


Manager, Maternity and Gynaecology
Level II Delivery Suite, John Hunter Hopsital
Hunter New England Local Health District
Phone: 02 4921 4353

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