The RCM response to the NICE induction of labour 2021 guideline

By Lia Brigante, RCM Quality & Standards Advisor on 10 November 2021 Maternity Services RCM Research Induction NICE - The National Institute for Health and Care Excellence Safe high quality care Antenatal / Prenatal Caesarean Section Interventions

The NICE draft guideline on induction of labour that was out for consultation during the summer, causing concerns and a striking number of responses, has now been finalised and it is available here. Our long and detailed response was considered and several of our proposed suggestions have been included in the new guideline. The draft guideline included some controversial recommendations, such as earlier offer of induction of labour at 41 weeks to all healthy women and birthing people and at 39 weeks to those identified at ‘higher risk’ such as Black, Asian, mixed and minority ethnic women, those with an increased BMI or aged over 35. The final guideline has moved from these recommendations, which we welcome.

The tone of the final guideline shifted with the re-introduction, as suggested in our response, of the recommendation to ‘give women with uncomplicated pregnancies every opportunity to go into spontaneous labour’ and explain to all women that labour usually starts naturally before 42+0 weeks.

However, the recommendation to discuss induction of labour, expectant management and planned caesarean birth early in pregnancy remains in this draft and its benefits are questionable. We have argued that information should be tailored to each woman’s specific and individual circumstances. Midwives know that the timing and content of antenatal care should be based on each woman’s individual needs, including the discussion on preference for birth (which may involve the listed options of expectant management, offer of IOL, or planned caesarean). For some, discussing those options may be upsetting and contribute to anxiety and lack of self- confidence while others will want to discuss those options earlier on. The same applies to routine offer of membrane sweeping and induction timing.

The RCM Blue Top Guideline on induction of labour states that ‘Midwives should ensure women and their families know that they have a choice about having an induction of labour’ and ‘unless the clinical situation changes, midwives should not make frequent offers of this intervention’. This is because there is evidence that women can feel pressured into accepting an induction (or other intervention), if this offer or recommendation is repeated.  Detailed, evidence-based discussion is essential to support women to make the choices that are right for them. Some women may not understand the process of induction fully and risk not feeling involved in the decision-making process, which will negatively impact on their birthing experience.  

The removal of a set of recommendations based on the ‘experience and knowledge’ of the committee is welcomed by the RCM and the final guideline is overall more balanced than the initial draft. It remains crucially important to prioritise individual informed choices, provide all available evidence including those on long-term outcomes for women and babies, mental health and experience of care. Only by providing detailed information to women in clear absolute risk terms, will we enable truly informed, safe and personalised care.