Obstetrics - Induction of Labour

What is induction of labour?

Labour is usually a natural process that starts on its own between 37 and 42 weeks and leads to the birth of your baby.

During pregnancy, your baby is surrounded by a fluid-filled membrane (sac), which protects your baby as it grows in the uterus (womb). The fluid inside the membrane is called amniotic fluid (water around baby).

Towards the end of your pregnancy, the cervix (neck of the womb) softens and shortens. This is called the ’ripening of the cervix.’ This process can occur over days or weeks. Before or during labour, your sac of amniotic fluid ruptures. This is known as ’your waters breaking‘. During labour, your cervix dilates (opens) and your womb contracts to push your baby down and out.

Induction of labour (IOL) is a medical intervention intended to start labour. Your midwife or doctor may advise an induction if they think that you or your baby’s health would benefit from birthing sooner than the pregnancy continuing.

There are many reasons why induction of labour is offered or advised, and the timing will depend on this reason.

The most common reasons include:

• To reduce the risk of stillbirth (baby death) if your pregnancy is lasting longer than 41 weeks referred to as ‘overdue’ or ‘postdates’
• To reduce the risk of infection if your waters have broken but labour has not started
• Due to your baby’s movements have changed, or there are other concerns about your baby’s growth or wellbeing
• Pregnancy concerns e.g. diabetes, high blood pressure and/or protein in the urine (pre- eclampsia)

Deciding whether to have an induction

It is your choice whether to go ahead with an induction or not, but your doctor or midwife will explain why they are recommending or offering an induction of labour.

Mothers from Asian, Black, and minority ethnic backgrounds are at a higher risk of stillbirth. This should be considered when discussing your options around induction of labour.

When making your choices the BRAIN tool below can help you to talk to your midwife or doctor.

• Benefits - What are the benefits of induction for me and my baby?
• Risks - What are the risks of induction for me specifically?
• Alternatives - What are the alternatives?
• Intuition - How do I feel? What do my instincts tell me?
• Nothing - What if I decide to do nothing for now and wait and see? What happens next?

If you choose not to be induced, or to defer your induction, we will make an individualised plan of care with you. Options such as, extra appointments or the need for further ultrasound scan may be suggested to assess the fluid around your baby and monitoring your baby’s heartbeat.

This additional surveillance of baby wellbeing can help to tell you how your baby is at that time and visit, but unfortunately this cannot predict or avoid problems that might happen suddenly, and we cannot predict the risks of a stillbirth.
 
If you are choosing to watch and wait, please contact the maternity Triage Department if you have any concerns about your baby’s wellbeing or if you change your mind and would like an induction Telephone Triage 0161 627 8179.

The risks associated with an induction of labour

• Women who have an induced labour tend to provide lower patient experiences feedback
• Compared to women who go into labour spontaneously, IOL is associated with a longer hospital stay
• Induced labours are reported as feeling more painful than spontaneous labours and are associated with a higher likelihood of additional pain relief options, such as an epidural
• Early induction between 37-39 weeks is associated with a slightly increased risk for babies, compared to babies where labour is induced labour from 39 weeks onwards and some babies may require neonatal unit care. Therefore, we do not recommend inducing labour at 37-39 weeks unless there is a particular clinical concern that outweighs this risk
• With some methods of induction Tachysystole (a medical term describing excessively frequent uterine contractions during pregnancy, defined as more than five contractions per 10 minutes) and hyperstimulation (excessive contractions that can impact upon the baby’s wellbeing) can occur, this means the womb is over-contracting and can cause distress to you and / or your baby There is a medication that can be given by injection to treat this by relaxing the womb (terbutaline)
• Failure of induction - If despite different methods, it has not been possible to start your labour there are other options which are available. These include a 24-hour rest period, further attempts to start your labour or a caesarean section. The doctors will discuss these options with you when required
• Scar rupture - This risk is for those who have had a previous caesarean section. There is a 0.5% chance of rupture during labour when your body starts by itself, this increases 2-3 times when labour is induced. If there are any concerns regarding this, an emergency caesarean section will be done for the safety of you and your baby
• The induction might be unsuccessful and require another mode of delivery or caesarean section
• Instrumental birth - This is when instruments such as forceps or ventouse (vacuum cup) are used to help with the birth of baby. There is a 15% risk of using an instrument during a birth after being induced, this is a higher risk than births which start naturally

What happens before an induction

Membrane Sweep

Prior to an Induction of labour (IOL), you may be offered a membrane sweep to help you go into labour.

Your doctor or midwife will gently insert their gloved finger into the vagina and sweep around the neck of your womb (the cervix). The aim is to part the membranes of the amniotic sac that surrounds your baby from the cervix itself. It may feel bit like an internal examination.

This can cause your body to release hormones called prostaglandins. These hormones can help to kickstart labour by softening and ripening the cervix and stimulating contractions to start.

If your cervix is closed, and your midwife or doctor cannot do the sweep, they may massage the cervix instead. It may cause discomfort, pain, mucous discharge or light bleeding.

It will not cause any harm to your baby and will not increase the chance of you or your baby getting an infection. Membrane sweeping is not recommended if your membranes have ruptured (waters broken). You can be offered more than one membrane sweep.

It only takes a few minutes, but a membrane sweep can feel unpleasant. Some people find it painful. You may feel some cramping and discomfort. Afterwards, you may have more cramping and some light bleeding.

It may be worth knowing that although some people find the procedure uncomfortable, most would recommend it as an effective, drug-free way to get labour started.

What happens during an induction?

Induction of labour occurs in stages or as a ‘stepped’ approach. The induction process needs to happen gradually, if the womb is hyper-stimulating it may need to be paused, so it is common for induction of labour to take two or three days (and up to five days) from the start of the induction to the birth of your baby.

• Step 1: Prepare or soften (‘ripen’) the cervix, typically performed on the antenatal ward
• Step 2: Break the bag of waters around your baby (called ‘ARM’ artificial rupture of membranes) this can only occur on labour ward and requires one to one midwife care
• Step 3: Stimulate contractions with an oxytocin hormone drip into a vein in the arm, this can only be performed on the Labour ward

Monitoring your baby

Before commencing the IOL process, we recommend monitoring your baby’s heartbeat. Two monitoring pads are positioned on your bump and held in place using wide elastic bands. The monitoring pads are attached to a cardiotocograph (CTG) machine, which records your baby’s heart rate and your contractions.

Examinations

The midwife or doctor will usually offer a vaginal examination at the start of the induction and then at a few points throughout the induction process to check how prepared for labour your cervix is. This includes assessing how soft and stretchy your cervix is, how open it is, how long (‘effaced’) it is and how low down your baby’s head is. If your cervix is already ‘ready for labour’ (this is more likely if you have had vaginal births before), you may be ready to proceed directly to step two and have your waters broken.

If your cervix is not ready for the waters to be broken, there are a variety of methods that can be used to prepare the cervix. Your options will depend on your individual circumstances and preferences.

Step 1: Preparing your cervix

Your doctor or midwife will talk to you about your options for where this first step can take place.

You may have the option of starting your induction in hospital and then going home until the first step is complete rather than remaining in hospital (this is called ‘outpatient induction of labour’).

Outpatient Induction of Labour

• This is available if your pregnancy is low risk
• You will be given an early morning appointment where a Propess pessary is inserted
• You will be reviewed back in Antenatal ward 24 hours after the pessary was inserted

Seek advice if

• Contractions begin
• Your waters break
• You have bleeding from your vagina
• You have reduction or change in your baby’s movements
• You have pain
• The pessary falls out

There are two approaches to preparing the cervix:

Mechanical

Dilapan-S (R) is the first-choice treatment for the mechanical approach. Dilapan are thin hydrogel rods that absorb fluid from the cervical tissue and expand within your cervix.

Similar to how a tampon expands with moisture, but it expands in your cervix to dilate it. A midwife or doctor uses a speculum (as used for cervical smear tests,) to see the cervix and insert up to five rods.

These can remain inside the vaginal for up to 24 hours but typically for 12 to 18 hours. They are then removed during a vaginal examination. The rods contain no medicine or drugs, and you will not need any medicines or drugs for this treatment, the focus is on expanding your cervix without them. Mechanical induction may stimulate your cervix to release hormones (prostaglandins) that naturally ripen the neck of your womb.

Cook’s Balloon Catheter

A thin flexible tube is inserted through the cervix with or without the use of a speculum. Two balloons sit at the top and bottom of the cervix and inflate with water to about the size of a golf ball. It can remain in place for 12 to 24 hours although it may fall out before this time as the cervix dilates. Again, there are no medicines involved and it is intended to help your cervix releases hormones that naturally ripen the neck of your womb.

The cook’s balloon is advocated to use for people who have had a previous caesarean section.

Risks of the mechanical method:

• The rods or tube could be uncomfortable to insert
• There’s a higher likelihood of needing an oxytocin drip and a longer time on drip
• Small risk of cord prolapse (the cord comes through the vagina before the baby is ready to be born and is a medical emergency) or pushing baby’s head up out of pelvis with the balloon

Benefits:

• Least risk of hyperstimulation or scar rupture if planning a vaginal birth after previous caesarean section birth
• Can be used more widely for outpatient induction (where you go home after the treatment and don’t need to stay overnight in hospital)

Hormonal

Prostin tablets are usually recommended as first choice approach for those with a hospital IOL. Propess is used if you are having your induction as an outpatient (not staying overnight in hospital).

Prostin: tablet inserted into the vagina at the neck of the womb (cervix) to soften and dilate (widen). It has the lowest likelihood of hyperstimulation. But if contractions do occur too frequently, they can be difficult to stop.

Prostin may be repeated up to two more times if you aren’t having regular tightening’s/contractions. Then we may consider a rest period before trying another Prostin for the last time.
 
Propess: a vaginal pessary (10mg Dinoprostone) which continually releases low doses of hormone to prepare the cervix. It looks like a small tampon and is inserted by a midwife or doctor in the same way as an applicator-less tampon. The tape of the Propess can be felt at the opening of the vagina for easy removal and is intended to remain in place for 24 hours.

Propess has a higher likelihood of causing hyperstimulation than Prostin gel but has the advantage of being removable if this does occur.

Risks of the hormonal method (Prostin or Propess):

• Hyperstimulation (uterus has too many contractions and may need treating with medication to slow them down)
• Not always suitable for an induction if you don’t want to stay overnight in hospital
• Occasionally causes vaginal irritation and tenderness or other side effects
• Baby heart monitoring can become abnormal and require expediting birth.

Benefits:

• Less discomfort at insertion
• More chance of spontaneous contractions 

What happens next?

When you have completed step 1 (either on the antenatal ward or as an outpatient) and your midwife or doctor confirms your cervix is open enough to have your waters broken, we aim to transfer you to Labour ward as soon as safely possible.

Delays in transfer do occur as we cannot predict women already in labour on the Labour ward and how long each labour will take. We cannot predict emergencies arriving to our maternity unit via ambulance or which woman’s body will react to treatment and require expediting. When delays do occur, we will try to keep you informed of the reason for delays.

Sometimes the waters break, or established labour starts, earlier during the induction process. This might mean that you are ready to go to the Labour ward before the ‘end’ of step 1 of the induction. This may be for additional pain relief beyond that available on the antenatal ward (i.e., regional anaesthesia such as epidural), because of concerns for your baby’s wellbeing or because labour is progressing more quickly than anticipated.

It can be frustrating to see other women leaving the bay in labour when your contractions have not started, or women who arrived after you, going before you. Everyone responds differently to the induction process and if your labour progresses more slowly, this does not mean you are doing anything wrong.

Step 2: Breaking your waters

This takes place on the Labour ward during a vaginal examination. Your midwife or doctor will see if it is possible to break your waters, known as ‘artificial rupture of membranes’ or ‘ARM.’ A sterile plastic instrument is used to make a small hole in the membranes around your baby. May reduce the chance of needing a caesarean or assisted birth.

You will have your baby’s heart rate monitored using a CTG before the ARM is done. You may be offered time after this to move around and encourage contractions to start. Most people having an ARM for their first baby will need the hormone drip to make labour start (1 in 7 will labour after an ARM without needing the hormone drip).

If you have had a baby before (in the last 10 years), then about 1 in 3 or 4 will labour without needing the hormone drip.

Step 3: Hormone drip

A hormone is given intravenously through a blood vessel, (IV) via a ‘drip’ (plastic flexible tube called a cannula) on the Labour ward, with a midwife providing care. Oxytocin is a hormone naturally produced in your body and helps to make your womb contract and open your cervix. Syntocinon is the manufactured version of oxytocin that is used to stimulate your contractions during the third step of the induction process. Whilst you are on the drip, we advise monitoring your baby’s heart rate continuously. This can be done wirelessly so that you can move around and change position as you wish. Some movements or positions can interrupt the recording of your baby’s heartbeat so we will work with you to maintain safe mobility. It is not possible to use the birth pool or showers whilst on the oxytocin drip, but your midwife can help you find comfortable positions.

The baby’s heart rate monitor (CTG) is also used to record how often you have contractions. Your midwife will adjust the amount of oxytocin that you receive to produce contractions three to four times every 10 minutes, mimicking natural labour.

Everyone responds differently. For some people, a small amount is needed to begin having contractions whilst others need much higher doses. A small amount is given to start with and increased every 30 minutes to achieve a safe and effective rate of contractions. Therefore, the time taken from starting the drip to having regular contractions will vary and may take several hours.

Sometimes too many contractions can occur and affect your baby’s heart rate. If this happens you may be asked to change your position (usually to lie on your left side) to improve the blood flow to your placenta, the rate can be reduced, or the drip may be temporarily stopped.

Your midwife or doctor will answer any questions you might have regarding the hormone drip and support you to make a decision that is right for you. If you choose not to have the hormone drip, or delay starting it, it may mean your labour could take longer. If your waters have already been broken, then the longer the time between breaking your waters and having your baby can increase your baby’s chance of having an infection. If your waters have broken midwives will be undertaking regular observations to ensure you remain well. If your leaking water colour changes to blood stained or green meconium please tell your midwife.

Spending time at home during an induction (outpatient IOL)

Depending on the reason for your induction, you may be able to have the first stage of the induction (cervix preparation) in hospital as an outpatient and then go home once step 1 (cervical preparation) is started. This is called an outpatient induction.

You need to have another adult at home with you and a means of transport back to the hospital. If this is something that you would like to consider, ask your doctor or midwife if this option has not been offered.

The benefits of outpatient induction are:

• Being in your own home environment rather than in hospital helps to release natural hormones to aid the process
• Research suggests that people cope with early labour better at home
• People having an outpatient induction report a better birth experience than those remaining in hospital for the entire process

What happens during an outpatient induction?

You will be advised to attend the Maternity Triage and undergo checks of the fluid around your baby and monitoring of your baby’s heart rate (CTG). If these checks are normal, you will have either a Propess pessary or Dilapan inserted (depending on what you have discussed as appropriate with your doctor). You will have a further monitoring of your baby’s heart rate and then be able to go home.

If you have had Propess inserted, you will be advised to attend the hospital 24 hours after insertion unless you have concerns sooner.

If you have had a mechanical method of induction, you will be given a time to attend hospital approximately 12-18 hours later.

It is important that you contact the maternity unit as soon as possible if:

• Your waters break
• You have any vaginal bleeding
• You are concerned about your baby’s movements
• You have regular, painful contractions
• You cannot pass urine
• Your pessary falls out
• You feel unwell or have any sudden onset of pain

Can I still give birth on the Birth Centre?

You may be able to give birth at the Birth Centre if active labour has started during the first step of the induction process and you have no significant risk factors, and there are no baby wellbeing concerns. You can discuss this in advance with your doctor or midwife. If you don’t meet the criteria above, national guidance (NICE) recommends that you have your baby on a consultant-led Labour ward.

How long does an induction take?

The length of induction is different for every person and depends on how ready the neck of womb is for birth. In general, it may take two to five days from the start of the induction for your baby to be born.

There may be delays in the induction of labour process as we need to ensure safety in terms of staff availability and bed capacity before proceeding at each step of the induction process. If there is a high level of activity across the Maternity Unit or pressure on bed capacity, we may delay starting your induction until it is safe to do so.

If delays to break your waters persist greater than 48 hours you may be offered an alternative, such as moving to another hospital. This is because we work closely with all Greater Manchester maternity units at times of high activity.

Once your cervix has opened enough for your waters to be broken, there may be a wait before moving to the Labour ward. This is because a room and a midwife need to be available to look after you.

Transfers to the Labour ward are based on clinical need and safety, not just how long someone has been waiting.
 
The Labour ward can be very busy, especially as it also cares for people arriving in spontaneous labour or with urgent medical needs. It’s impossible to predict how long any delay may be. While we try to minimise delays, they do happen. We’ll always keep you informed and continue to monitor you and your baby closely.

What to do on the day of induction

When you are admitted for your induction you will have your blood pressure, pulse and temperature checked. Your baby’s heartrate will be monitored using a CTG before the induction starts.

Your birth partner can be at your initial induction assessment with you on the ward and stay with you during the day – please refer to visiting times. They can be with you 24 hours a day during your labour care on the Labour ward.

If you are staying in hospital on the antenatal ward for your induction, you will start in a four bedded bay area with other birthing people who may also be having an induction of labour. Once the induction has started, you are free to move around the ward and hospital area. We ask that you keep your midwife informed if you leave the ward.

You will be given a call bell to alert a member of staff if you need. Please let your midwife know immediately if:

• You have any pain or tightening in your womb
• Your waters break or they change colour
• You have any vaginal bleeding
• You are concerned about your baby’s movements
• You cannot pass urine
• Your Propess or balloon falls out
• You have any other symptoms or concerns

What to bring into hospital with you

You may be in the hospital for several days during the induction process and you will spend time waiting, so please bring a book or something you can do while you wait.

Please bring your hospital bag with you when you come (even if you are planning an outpatient induction where you can go home afterwards).

You will be provided with breakfast, lunch and dinner as well as water, tea and coffee while you are staying in hospital. If you’d like specific snacks or drinks, please bring them.

The next steps if the induction doesn’t work

If your cervix remains closed (not prepared for labour) and it is not possible to break your waters following a mechanical or hormonal approach in step 1 of the induction, your midwife and doctor will discuss your options with you.

Depending on your wishes and circumstances you may be offered:

• Stop the induction and try again after a break (the next day or later, if appropriate)
• An alternative induction approach
• A caesarean delivery

Other resources

NHS England - Inducing Labour: NICE Guidance for the Public:
www.nice.org.uk/guidance/ng207/informationforpublic