Indications:  Post-dates (42+wks)  Late Term (41+ wks) Elective 39+wks  Diabetes Hypertension  Many more - check out ACOG Medically indicated delivery  39week induction ARRIVE Trial - Multicenter RCT showing benefit to 39wk IOL over expectant management to ~41wks  Included  Primips  No medical indications for IOL prior to 40+5   Results  IOL group had LOWER c-section rate than expectant group  Neonatal composite outcome had a trend (not statistically significant) toward lower neonatal compilations in IOL group  Conclusion IOL at 39wks is as safe as expectant management without increased risks Many pregnant people are now offered a 39wk IOL rather than waiting for spontaneous labor  The IOL Process:    Evaluate and Prep: Full H&P Ultrasound for position - Vertex VE for cervical exam: dilation/effacement/Station, also position and consistency  Calculate Bishops Score → help determine mode of IOL Options for IOL: if biship score <8 for prime or <6 for multip, ripen first!  Mechanical cervical ripening (balloon) Chemical cervical ripening (misoprostol or cervidil)  Best yet--both!    Contractions (pitocin)  Prime: Pitocin alone if Biship 8 or higher Mulitp: Pitocin alone if bishop 6 or higher    Augmentation: AROM    Failed IOL Failure to reach active labor after 18+hrs ruptured on pitocin (definition varies 12-24hrs ruptured on pitocin)  If reaches active labor (6+cm), no longer failed IOL, now arrest of dilation or descent