What is the comparative effectiveness of 3 methods, Prostaglandin E2 (dinopristone) vaginal gel, intracervical foley catheter insertion and sweeping of membrane for induction of labour in multiparous women?

Consenting participants meeting inclusion/exclusion criteria will be allocated to four arms using block randomization. All the induction methods will be carried out from 40+4 weeks of gestation onwards.

Arm 1 (prostaglandin group): Dinoprostone gel be 2mg will be inserted following initial cervical assessment. If the cervix is unfavourable after six hours a second dose of prostaglandin (2mg) will inserted. Fetal wellbeing will be monitored by CTG at three hours and five hours after insertion of prostaglandin.

Arm 2 (foley catheter group): The foley catheter balloon will inserted through the cervical canal and the catheter bulb dilated with 60 ml of normal saline done. Sufficient cervical dilatation will result in the catheter dropping out. The foley catheter will be kept for a maximum of 48 hours. Fetal well being will be monitored by CTG and daily Doppler assessment.

Arm 3 (membrane sweeping group): The sweeping of membrane will done once daily till 41 weeks. Fetal well being will be monitored by CTG at 3 hours after membrane sweeping and daily Doppler assessment.

Arm 4 (control group): Spontaneous onset of labour will be awaited with fetal monitoring done daily by 20 minutes CTG and daily Doppler assessment.

All the cervical assessments will be done by the first senior house officer (SHO) and introduction of the cervical ripening induction method done by the second senior house officer. Fetal wellbeing (assessment of CTG, Doppler) will be by the third senior house officer.

Patients may exit the trial on their preference and will be excluded on development of dribbling or any life threatening complication to the mother or baby. Such situations will be managed according to standard protocols and unit policy. Grossly unfavourable induction of labour at 48 hours after intervention will be managed according to standard protocols and unit policy.

1. Multiparous women undergoing induction of labour at the study setting.
2. Gestation more than 40+4 weeks
3. Singleton pregnancy with cephalic presentation
4. Unruptured membrane
5. Modified Bishop Score (MBS) less than 8

1. Primiparity
2. Malpresentation and unstable lie.
3. Favourable cervix (MBS of 8 or above)
4. Any contraindication to vaginal birth, with previous uterine surgery (including caesarean section, placenta previa and other placental anomalies)
5. Age less than 18 years
6. Lethal fetal congenital anomaly
7. Known allergy to any of the interventional products