A cohort study involving 472,520 low-risk pregnant women in Queensland by Crawford et al., [3]. concluded that planned birth at 39 weeks could lower the risk of perinatal mortality and other adverse outcomes. Compared to expectant management, planned induction of labour at 39 weeks was associated with lower odds of severe perinatal trauma, shoulder dystocia and caesarean birth. However, the urgency of the delivery changes based on many factors, thus some pregnancies should be induced sooner than anticipated and sometimes sooner than others. This often challenges the service delivery as postponing IOL is associated with adverse maternal and perinatal outcomes3. Basically, any pregnancy complication that occurs in the third trimester could happen during this period of waiting and hence is liable for litigation unless it is managed appropriately. Although the induction of labour is common, there is no established system to prioritise the urgency of IOL. The following categorisation system of the urgency of IOL (Figure 1) might mitigate this issue [4,5].

We suggest commencing IOL within the following time frame (Table1) from the decision time: by 41+3 gestation at the latest. Obviously, category can change with time and it should be re-visited as necessary. At times, urgency of birth (delivery) can change significantly. For example, a category-4 IOL can be upgraded to category-1 IOL and even a category 1-3 caesarean birth.

We adapted the principles of classification of urgency for caesarean birth (Table 2) [2] in developing this induction counterpart as the objectives would be similar.

Only pregnancies that are competent to withstand the induction process will go through the lengthier process of induction, and hence, the time frame is in days rather than hours in cases of caesarean deliveries. The principles of categorisation would be similar between caesarean and induced deliveries (Table 3).

Streamlining the IOL process through appropriately categorising its urgency can bring many benefits. Adhering to a systematic approach could potentially:

1. Lower the prevalence of exaggerated symptoms of pregnancy such as discomfort, musculoskeletal pain, respiratory symptoms, etc.
2. Lower the prevalence of maternal complications of advanced gestation such as pre-eclampsia and mental health issues in pregnancy.
3. Lower the prevalence of perinatal mobility and mortality caused by abruption, cord accidents (and consequences of hypoxia), bacterial sepsis, meconium aspiration and unexplained stillbirth.
4. Reduce the risk of a caesarean birth and its potential complications.
5. Reduce the length of hospital stays and their consequences (for the patient, family, and healthcare providers).
6. Social issues such as domestic and family violence, lack of access to carers and financial issues
7. Reduced rates of being born before arrival and its complications
8. Reduced chance of rushed emergency admissions and consequences (transfusions of un-cross matched blood, category-1 caesarean deliveries etc).
9. Reduced risk of complaints and hence, litigation.
10. Improved openness, transparency and hence, patient satisfaction.
11. Less stress on healthcare workers and its consequences.

The decision (date and time) is agreed upon between the clinician and patient based on many factors. This may be decided a long time in advance. This categorisation can also be used to define how long the pre-agreed date can be deferred, for triaging purposes. For example, IOL for a woman with type 1 diabetes may be booked as a category 2 or 3 IOL at 37+3 gestation. If so, the healthcare team can move the date by 1-3 days. The same pregnancy could be booked as category 2 at 37+5 in advance, so that the non-clinician administrators could manage the IOL appointments safely and effectively.

Potential disadvantages are minimal. This is not about the timing of induction, rather the streamlined method of making it happen. Therefore, adverse outcomes are negligible if clinicians ‘decision time’ is correct. This approach should share similar advantages and disadvantages of classification of urgency for caesarean birth if categories are appropriately used.

References
1. Gurol-Urganci I, Jardine J, Carroll F, Alissa Frémeaux, Patrick Muller, et al. Use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services: a national hospital-level study. BJOG. 2022; 129(11): 1899-1906. doi: 10.1111/1471-0528.17193
2. Sanchez-Ramos LS, Levine LD, Sciscione AC, Ellen L Mozurkewich, Patrick S Ramsey, et al. Methods for the induction of labour: efficacy and safety. Am J Obstet Gynecol. 2024; 230(3S): S669-S695. doi: 10.1016/j.ajog.2023.02.009
3. Caughey AB, Sundaram V, Kaimal AJ, Yvonne W Cheng, Allison Gienger, et al. Maternal and neonatal outcomes of elective induction of labor. Evid Rep Technol Assess. 2009; (176): 1-257. https://pubmed.ncbi.nlm.nih.gov/19408970/
4. Crawford Kylie, Waldemar A Carlo, Anthony Odibo, Aris Papageorghiou, William Tarnow-Mordi, et al. Perinatal mortality and other severe adverse outcomes following planned birth at 39 weeks versus expectant management in low-risk women: a population-based cohort study. EClinicalMedicine. 2025; 80: 103076. doi: 10.1016/j.eclinm.2025.103076
5. National Institute for Health and Care Excellence. Caesarean birth. NICE guideline [NG192]. London: NICE; March 2021, Updated June 2025 [www.nice.org.uk/guidance/ng192/resources]. Accessed 31 December 2025.