Induction of labour

This has been provided to help answer some of the questions you and your family may have about induction of labour (IOL) and to help you make an informed decision about your IOL.

It is based on national evidence-based clinical guidelines on induction of labour (NICE, 2008).

What is induction of labour?

Labour is a natural process that usually starts on its own. Sometimes labour needs to be started artificially and this is called ‘induction of labour’. About 20 per cent of pregnant women are currently induced in the UK (Hospital Episode Statistics, 2017).

Why might I be offered an induction?

Your doctor or midwife will only recommend an induction if it benefits you and your baby. There are several reasons why you might be offered an induction when your waters are intact:

  1. To avoid prolonged pregnancy, which is when pregnancy lasts 42 weeks or longer (14 days or longer than your expected date of delivery). This is the most common reason for induction. The placenta, which is where oxygen and food is transferred from the mother's blood to the baby's blood during pregnancy, may become less efficient with prolonged pregnancy and result in stillbirth, although the overall risk of stillbirth remains low. IOL is therefore recommended routinely to all women between 41 and 42 weeks if their labour has not started naturally (NICE, 2008), as there is no precise way to identify pregnancies at risk of stillbirth.
  2. Advanced maternal age. There is some evidence that the stillbirth rate increases with advanced maternal age. The risk of stillbirth approximately doubles if you are 40 years old or older (NHS Litigation Authority, 2009). For this reason, it is recommended that women of this age or above have a planned IOL at 40 weeks of pregnancy (gestation). We will discuss this with you in detail at the antenatal clinic.
  3. If you or your baby’s wellbeing is causing concern. Delivering your baby may be beneficial in certain circumstances such as having diabetes, high blood pressure, growth problems of the baby and other conditions.

What is membrane sweeping?

You will be offered a membrane sweep to help you go into labour naturally before 42 weeks. This involves your obstetrician or midwife placing a finger into your cervix and making a circular, sweeping movement to separate the membranes that surround your baby, or massaging your cervix if this is not possible.

Membrane sweeping does not cause any harm to you or your baby but it may cause some discomfort, pain or bleeding. It may stimulate the natural production of prostaglandins (hormones), which might promote softening of the cervix and in time, trigger active labour.

You will be offered a membrane sweep before 42 weeks at your antenatal appointment to reduce the need for induction of labour. If labour does not start after this, you can ask for additional membrane sweeps.

What happens if I need to be induced?

Your midwife or obstetrician (doctor) will explain in detail the reasons why they recommend induction of labour. It is important that you understand the IOL process and ask any questions you may have.

Your assessment will include examination of your tummy (abdomen) to see how your baby is lying in your womb and listening to your baby’s heartbeat. Following this, you will most likely be offered an internal examination to assess your cervix (neck of the womb), and a ‘membrane sweep’. We will then arrange a date of IOL for you.

How long should IOL last?

It is different for each woman and depends on how ready the neck of your womb and your baby are for birth. In general, if this is your first pregnancy (you have not given birth before) and the neck of your womb is not ready (cervix is closed and hard) it may take up to four days from the start of the IOL to the birth of your baby.

How will I be induced?

Cervical ripening balloon

The cervical ripening catheter (balloon) is an option to induce your labour.

The balloon allows your cervix to be dilated mechanically, which helps with the artificial rupture of your membranes. The balloon has minimal side effects and does not need you to be monitored as closely as when using a medical method (Ref: Henry, 2011).

The procedure involves a catheter (a soft silicone tube) being inserted into your cervix. It has a balloon near the tip and when it is in place the balloon is filled with a sterile saline (salt water) fluid. The catheter stays in place for 12 hours, with the balloon putting gentle pressure on your cervix. The pressure should soften and open your cervix enough to start labour or to be able to break the waters around your baby.

The balloon catheter may fall out by itself or will be removed by a midwife the following day. During the time the balloon is in place, you can carry out normal activities, such as showering, bathing or walking. After going to the toilet, please wash your hands, make sure the catheter is clean and change underwear regularly.

Please report any of the following to your midwife:

  • bleeding
  • contractions
  • concerns about the baby’s movements
  • you feel unwell
  • the waters around the baby break
  • if the balloon falls out.

Prostaglandins

We use a ‘Dinoprostone 3 mg pessary’ (a type of tablet) which is inserted into your vagina and allows for the slow release of prostaglandin over 24 hours. It prepares the neck of the womb for labour. You may also get contractions during this process.

We will advise you to keep the pessary in for 24 hours. The pessary may need to be removed if:

  • You are in real labour (which is when you have regular, three or four contractions every ten minutes and the neck of your womb is opened 3 cm or more)
  • You are having too many contractions (five or more contractions every ten minutes)
  • You are having too long contractions (one contraction lasting about two minutes)
  • Your baby’s heart beat is no longer normal
  • You start bleeding. It is normal to get a tiny amount of blood with some mucous discharge after an internal examination.

The following are all possibilities of what might happen once the prostaglandin pessary is inserted:

  • You may go into labour and the neck of your womb may start opening. If this happens, we will remove the pessary.
  • Your waters may break without you being in labour. If this happens you will need an oxytocin infusion drip to start the contractions. The prostaglandin pessary may be left inside while you are waiting for the drip.
  • The neck of your womb will soften and shorten but you may not have gone into labour. If this happens, your waters will need to be broken and you will need an oxytocin infusion drip to start the contractions.

Some women may require more than one method to prepare the neck of the womb for labour.

Artificial rupture of the membranes

This is also known as ‘breaking the waters’ and can be used if the cervix has started to ripen. A small hole is made in the membranes using a slim, sterile, single use plastic instrument during an internal examination. It is performed by the midwife or obstetrician. Having your membranes broken should encourage more effective contractions.

Use of oxytocin

Sometimes prostaglandins and/or breaking the waters are sufficient to start a labour, but many women require oxytocin. This drug is given via a drip into a vein in the arm. It causes the womb to contract, and is usually used after the membranes have broken either naturally or artificially. The dose can be adjusted according to how your labour is progressing. The aim is for the womb to contract regularly until you give birth (NICE, 2007).

When using this method of induction, it is advisable to have your baby’s heart rate monitored continuously using a cardiotocograph machine (CTG). The contractions can feel quite strong with this type of induction – the midwife will ask you how you are coping and offer different methods of pain management.

What are the risks or disadvantages of IOL?

Induction promotes birth before your body is ready for labour. Therefore, compared to natural labour, some side effects are more common.

These include:

  • increased length of labour
  • increased need for pain relief, including an epidural
  • may provoke too many or prolonged contractions, which can diminish your baby's oxygen supply and lower your baby's heart rate. This is very rare, affecting less than 1% of women.
  • increased need for an instrumental birth (for example with the use of forceps or suction). 10% of women nationally experience an instrumental delivery following spontaneous labour compared to 15% for those who have had an induced labour. This figure is slightly higher in our maternity units as more women choose to use epidurals for pain relief.
  • increased need for a caesarean section (NICE, 2007).

If the process of IOL does not work, we will discuss other options with you, one of which is a caesarean section delivery. Therefore, IOL is only recommended if the benefits outweigh the risks.

Can I be induced and still have a home birth or go to the birth centre?

If your labour is induced you will not be able to have your baby at home, but if you go into labour following use of just the cervical ripening balloon or pessary, you can have your baby in the birth centre – our midwifery-led unit alongside the labour ward – providing that you are within the criteria for midwifery-led care.

What happens if induction does not work?

If you do not go into labour after induction your midwife and obstetrician will discuss your options with you and check you and your baby thoroughly. This happens in about 5-10% of women having IOL. Depending on your wishes and circumstances, we may offer you:

  • another method of IOL
  • defer the IOL for a later date if circumstances allow
  • caesarean section delivery.

Can I choose not to be induced?

Your obstetrician will explain in detail the reasons why he/she recommends IOL. However, if you do not wish to be induced at this time, you should tell your midwife or obstetrician. We will then ask you to come to the hospital for monitoring so that we can check how you and your baby are.

We will check your baby’s heart beat using a CTG and you will have a scan to check the water around your baby. Please note, this type of monitoring is not very reliable in showing us which pregnancies are at a high risk of stillbirth. Because of these limitations, we offer IOL to all pregnancies before 42 weeks gestation (two weeks after your expected date of delivery).

How often you come to the hospital for monitoring depends on your situation, and the midwife and obstetrician will discuss this with you.

Why might my induction be delayed?

We understand that if your induction is delayed, you may feel distressed and upset. However, the midwife or obstetrician will give you reassurance and try to keep you informed about arrangements for your induction. The arrangements are dependent on your individual circumstances and those of the labour ward.

Your IOL may be delayed if all midwives are busy caring for other patients at that time and/or there is no bed available. Birth is unpredictable and we have women arriving as emergencies 24 hours a day. We, as midwives and obstetricians, have a responsibility to care for mothers and babies on our unit and ensure safe deliveries. This may impact on the plan for your IOL, either delaying the start of your induction, or delaying the process of your induction if it has already started. If you are unhappy at any time, please ask to speak to the senior midwife on duty.

Barnet Hospital arrangements for induction of labour

We will give you a date to come to the hospital. Your midwife will advise you where your induction will take place and whether your pregnancy is high or low risk.

If your pregnancy has been identified as increased or high risk, please ring Victoria ward at 6am on the day of your planned induction and ask to speak to the team leader. S/he will be able to give you a time to come to Victoria ward, which is where you will be cared for during your induction of labour.

If your pregnancy has been identified as low risk, you will be suitable for an out-patient induction of labour. You will need to arrive at an allocated time to the maternity day unit. If all is well and you live close to the hospital (no more than one hour travel time) you may be allowed to go home.

If you are allowed to go home:

You will be advised by your midwife to return to the maternity triage unit 12 hours after the start of your induction to continue with the process.

You should contact the maternity triage unit on 020 8216 4408 if:

  • contractions become painful or regular (every five minutes)
  • you experience vaginal bleeding
  • baby’s movements change or become less frequent
  • the pessary falls out
  • you have any other concerns
  • if your waters break. If this is confirmed when you come to hospital, you will be admitted as an in-patient to the maternity ward.

If you have a pessary as a method of IOL, you will be shown how to remove it in the event of vaginal bleeding and excessive painful contractions. In these circumstances, you should also contact triage immediately.

Useful contacts (Barnet Hospital)

Victoria ward

Located on the second floor of Barnet Hospital (opposite the delivery suite).

Telephone: 020 8216 5218/9

Maternity day unit

Located in the Wellhouse women’s clinic (antenatal clinic) at Barnet Hospital on the second floor.

Telephone: 020 8216 5144

Royal Free Hospital arrangements for induction of labour

We will give you a date and a time to come to the hospital. On the day of your appointment you will need to attend the day assessment unit. If your pregnancy has been identified as low risk, you will be suitable for an out-patient induction of labour and be allowed to return home. If your pregnancy is high risk, you will be admitted to the antenatal ward.

If you are allowed to go home:

You will be advised by your midwife to return to the maternity day assessment unit or labour ward 12 hours after the start of your induction to continue with the process.

You should contact the day assessment unit or labour ward if:

  • contractions become painful or regular (every five minutes)
  • you experience vaginal bleeding
  • baby’s movements change or become less frequent
  • the pessary falls out
  • you have any other concerns
  • if your waters break. If this is confirmed when you come to hospital you will be admitted as an inpatient in the maternity ward.

Useful contacts (Royal Free Hospital)

5 South antenatal ward

Located on the fifth floor of Royal Free Hospital.

Telephone: 020 7794 0500 ext 33845/34537

Day assessment unit

Located on the fifth floor of Royal Free Hospital and is open 8am to 6pm, weekdays.

Telephone: 020 7794 0500 ext 33873 or 33846

Triage

Located on the fifth floor of Royal Free Hospital in the delivery suite area.

Telephone: 020 7794 0500 ext 36208

Labour ward

Located on the fifth floor of Royal Free Hospital. Telephone: 020 7794 0500 ext 33850/33849

Further questions or concerns

Your midwife and obstetrician (doctor) will be happy to talk through any concerns about the induction process with you and your partner.