Induction of Labour

Induction is when we start your labour artificially rather than you going into labour by yourself. There are certain scenarios in which we might suggest that you are induced, when we think that it would be safer for you or your baby for your baby to be born. Some of the reasons we may think this are:

• You’ve had a normal healthy pregnancy but your baby has not been born by 7-14 days after your due date.
• You have developed complications in your pregnancy.
• Your waters have broken but you haven’t gone into labour (we may wait for up to 24 hours after your waters have broken).

If you haven’t given birth to your baby by a week past your due date we will offer you induction of labour, usually between 7 and 14 days past your due date. The risk to the baby increases very slightly the longer that the pregnancy continues, although it is important to remember that the risk of problems remains very small.

However, you may still prefer to wait and let labour start naturally. If you do want to wait more than 14 days past your due date we will suggest a scan to check that the placenta is still working well. We will then see you every couple of days to make sure that you and your baby are remaining well. You can change your mind at any time and opt for induction, or decline after a thorough discussion with a senior obstetrician. Complications of Pregnancy

Sometimes problems develop in pregnancy that mean there’s a greater risk to you or your baby from the pregnancy continuing than if your baby is born, even if that means your baby is born early. You may have developed high blood pressure, gestational diabetes, other medical conditions or your baby may not be growing as well as we would expect. If you have developed complications in pregnancy you may be offered induction. Although there will be good reasons why we are offering you induction, it is always important that you fully understand what these reasons are and what the whole process of induction involves. Please ask as many questions as you need

Induction of labour may be perceived as more painful than spontaneous labour as the contractions do sometimes get quite strong quite quickly as opposed to a more gradual build up if you were to go into labour spontaneously. We have many options available to help you to best cope with this.

Induction of labour can sometimes take a few days, and it can become quite frustrating if nothing seems to be happening. It is very important that you remember that it is unlikely that your baby will be born on the same day that you come into hospital to begin the induction process. Induction of labour is easier when your cervix (the neck of the womb) has already started to soften and open up. If this hasn’t begun to happen when you are induced, the induction is likely to take longer and may potentially be unsuccessful. This can mean that sometimes we can’t actually get you into labour and may have to consider either waiting a bit longer or delivering your baby by caesarean section instead. We can never predict how long the induction will take or when your baby will be born.

As some women find induction more painful and/or tiring, more women choose an epidural for pain relief following induction of labour. This increases the risk of needing an instrumental birth (forceps or ventouse) especially for a first baby. Sometimes the medication used to induce labour can cause too many contractions (hyperstimulation). This can sometimes affect the baby’s heart rate. We used to think that induction increases the risk of needing an emergency caesarean section to deliver your baby. However current evidence suggests that in many cases the risk of emergency caesarean section is the same or lower, depending on the reason for induction and how many births you have had before. Please ask your obstetrician for more information. Sometimes induction does not work, particularly if you are being induced several weeks before natural labour would have started for you. If you’ve had a caesarean section before or you’ve had more than five babies, there are slightly more risks associated with induction, and your doctor will discuss the risks and benefits with you thoroughly.

You are welcome to bring your birth partner with you when you come to the hospital for induction and they can stay with you during the day* If you are staying in hospital and nothing is happening at bedtime we will suggest that s/he goes home to bed – we will ring them immediately if something happens overnight. We appreciate that family members and friends will be anxious to hear that you are well, but due to patient confidentiality and our commitment to safety, we are unable to give out any information, so it is important that your birth partner keeps them informed

*please review the current visiting arrangements on the Trust website

There are two main ways used to start off your labour – prostaglandins (where Propess pessary or Prostin tablets are placed in your vagina behind your cervix), and ARM (artificial rupture of membranes) and syntocinon drip. You will usually be offered a “stretch and sweep” before induction, performed during a vaginal examination by your midwife or doctor. This examination involves the midwife or doctor placing one or two fingers into the cervix and trying to stretch it open further. It can be uncomfortable but is not harmful to you or your baby. This examination is sometimes enough to start you in labour, and if this is the case you are most likely to go into labour in the first 48 hours following the sweep. If not, it may be enough to soften your cervix to then make induction easier. On admission to hospital you may need a cannula (drip) placed in your hand depending on the reason for induction.

Our most common technique for inducing labour is to use Propess. This is a very small pessary on a string, a bit like a tiny tampon. It contains a naturally occurring hormone that helps to start off labour. We place it as high in your vagina as possible, behind the cervix. The hormone in the Propess is released slowly over a period of 24 hours, softening and opening your cervix so that we should then be able to break your waters, or it may even put you into labour. Before you are given Propess, we will monitor your baby’s heartbeat for 30 minutes to ensure that your baby is well. After the Propess is inserted you will need to remain on the monitor for at least 30 minutes to ensure baby remains well. We will monitor you regularly throughout the induction process, usually every six hours, or more frequently if you start having contractions, your waters break or you report baby isn’t moving as well as they would usually. We will remove the Propess if you go into labour, or after 24 hours if no changes take place in that time. We will perform another vaginal examination to see if it is possible at this point to break your waters or not.

If following removal of the Propess it is not possible to break your waters, we will either insert another Propess or give you a Prostin tablet/gel. This tablet/gel is placed the same as the Propess, high in the vagina behind the cervix, and is dissolvable. It remains in place for six hours, after which point we will perform another vaginal examination. If at this point it is still not possible to break your waters, we may administer another Prostin tablet/gel. Again, this remains in place for a further six hours. You will be examined by a doctor at this point to assess whether it is possible to break your waters. If it is not, we will discuss your options with you – either a rest day and then further prostaglandins if required, or delivery by Caesarean section. We will monitor baby after Prostin in exactly the same way as with Propess. Prostin can also be given if your waters have already broken and your cervix has not softened and opened. Sometimes Prostin and Propess can cause some vaginal soreness. Very occasionally, the prostaglandins can make your uterus contract too frequently, which can affect your baby’s heartbeat. If this happens we will take the Propess out and you may be given some drugs and fluids through a drip.

We will perform an ARM to start off your labour if your cervix has already opened up, or if we’ve given you Propess or Prostin to open up your cervix. Releasing the water from around your baby makes it more likely that you will produce oxytocin, the hormone that makes your uterus contract. Your baby’s heartbeat will be monitored before we perform the ARM, and for half an hour following. After your waters have broken, you will be aware of the fluid leaking up until your baby is born – this is normal. Sometimes we wait for a couple of hours to see if breaking your waters is enough to start your labour, particularly if you have had babies before. Sometimes we will start the hormone drip straight away.

If you are induced with prostaglandins or by having your waters broken, you will often need a hormone infusion to make the contractions strong enough to start labour effectively. The drip contains a synthetic form of the hormone oxytocin, which is what your body produces naturally to make your uterus contract. If it is necessary to start the drip, we will monitor your baby’s heartbeat continuously to ensure that baby remains happy with this. It is very important to remember that even though you will have the monitor and the drip connected, you are not attached to the bed, and we encourage you to remain as mobile as possible to help labour to progress effectively. We will sometimes recommend monitoring your baby’s heartbeat by attaching a clip to their head to ensure we have a good recording. This is not harmful to baby and gives you more freedom in remaining active, as well as ensuring we can monitor your baby’s wellbeing effectively. If you do need to start the Syntocinon drip, we will wait at least 30 minutes after removing the Propess, or at least 6 hours after you last had Prostin administered.

With Propess/prostin you can sometimes have quite strong contractions but not yet be in established labour. At this early stage you are unable to have an epidural. However we have many options to help you cope, please discuss these options with your midwife. After your waters have been broken and/or you are on the syntocinon drip you have the option of an epidural along with all other forms of pain relief. Please see our information leaflet ‘Pain Relief in Labour’

If your pregnancy has been completely straightforward, you and your baby are well, there are no concerns with your baby’s movements and you are not being induced because of a medical condition, you may be able to go home after you have been given Propess.

• Low risk pregnancy (no significant maternal or fetal risk factors)
• Post-dates (7-12 days after your due date)
• Singleton pregnancy
• Cephalic presentation (baby in head down position)
• Have had 3 babies or less
• Bishops score less than 7 (we determine this from your stretch and sweep)
• No previous uterine surgery or caesarean section
• Has a home or mobile telephone
• Intact membranes
• Willing for out-patient induction
• Normal pre and post prostaglandin fetal heart monitoring
• Speak English
• Access to immediate transport

If you fit these criteria, you will have outpatient induction discussed. Please see Induction of Labour at Home Leaflet for more information.

Sometimes we can’t go ahead with your induction on the date we had planned for you. Delays in starting your induction can happen when the situation on Labour Ward or Ward 4 means starting your induction would be unsafe, or there are no available beds to admit you into. When this happens we may have to ask you to come into hospital a bit later than planned. If we are not able to admit you on your planned date we will ask you to attend Maternity Assessment Centre at CRH or ANDU (Mon-Fri) for us to monitor your baby’s wellbeing.

We understand that it can be frustrating if your induction is delayed but please be reassured we will get you in as soon we can. To reduce delays we offer a 24-hour rolling programme for admission – please inform us if you want to opt out of being contacted at night to come in if a bed becomes available. On the other hand, occasionally we have a bed available the day before your planned induction and we may contact you to see if you are able to come in sooner than originally planned. We will keep you informed regularly by telephone about what is happening as result of any delays to your admission.

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