Induction of labour

Supporting you: We want to help you have a positive pregnancy, labour and birth experience. You will be able to discuss your options with your midwife and/or obstetrician and ask any questions you wish.

What is induction of labour?

Induction of labour (IOL) is the process of starting labour artificially. About 1 in 4 pregnant women in the UK are induced.

Why am I being offered induction of labour?

In a healthy pregnancy, with no complications it may be safer to offer induction of labour as you reach 41 weeks and 5 days. There are advantages and disadvantages to inducing labour and you do not have to accept this offer. This leaflet is designed to help you make informed choices. If you decide not to be induced at 41 weeks and 5 days pregnant then the offer of induction remains open. The decision to induce a normal pregnancy can only be taken by you in discussion with your obstetrician or midwife.

Reasons for offering or recommending induction of labour before 41 weeks and 5 days

As you get nearer the end of pregnancy, your obstetrician or midwife will sometimes offer or recommend induction of labour. The main reasons are:

medical conditions (such as high blood pressure, pre-eclampsia or diabetes)
multiple pregnancy
concerns with your baby’s growth & wellbeing (baby smaller than expected, no longer growing or baby’s growth accelerating out of the normal range)
24 hours after your waters breaking without you going into labour spontaneously
if you are aged 40 or over

If there is a concern about you or your baby and you are offered induction of labour within the next few days but there is no capacity at the maternity unit you are booked at, we will liaise with the other maternity units in MFT (North Manchester General Hospital, St Mary’s Hospital Oxford Road Campus and St Mary’s Hospital at Wythenshawe) and you may be asked whether you wish to go to one of these maternity units to start the induction process.

Advantages and disadvantages of induction of labour vs awaiting natural labour

When induction of labour is offered, it is largely when the benefits of induction of labour to deliver the baby are greater than prolonging the pregnancy and awaiting natural onset of labour.

In general, most babies will be healthy when they are born. However, there is always a small risk of stillbirth at any stage in pregnancy and this risk increases as you go further past the due date. The current NICE guideline on Induction of Labour states that the average risk of stillbirth at 40 weeks is approximately 1 in 800 pregnancies and that this risk has doubled by 42 weeks when the risk is around 1 in 400 pregnancies.

Induction of labour is different to labour starting on its own. Induced labour may involve more vaginal examinations and a longer period of time in hospital whilst waiting for the induction process to work and for labour to start. Some women report induction to be more painful than spontaneous labour. Whilst some women go into labour quickly after one pessary, for other women it can take longer and increase the amount of intervention and pain relief required. There may be other risks to consider for some women. These will be discussed with you on an individual basis, taking into account your medical history, previous pregnancies and current pregnancy.

There is a small chance that the induction of labour process will not work. If this happens a doctor will discuss your options with you and you will be able to decide how to proceed.

If you decide that you would not like an induction of labour when it is offered or recommended, your midwife will discuss your options with you. This may include seeing a doctor to agree an individual management plan which may include arranging electronic heart rate monitoring and more frequent ultrasound scans to check on your baby’s wellbeing.

What if I choose not to have an induction of labour?

What does induction of labour involve?

Prior to induction of labour

Membrane sweep: This will be offered routinely at 40-41 weeks, usually in the community by your midwife. It may also be offered by a doctor in antenatal clinic, Day Care Assessment Unit, Antenatal Assessment Unit or Triage a few days before a planned induction of labour. It involves a simple examination where two fingers are gently inserted inside the neck of your womb (cervix) and circular sweeping movements are made to separate the membrane of the fluid filled sac your baby is in from the cervix. This can increase the number of women who go into labour without being induced. It can cause some discomfort or a small amount of blood on wiping, this should settle down and usually becomes brown in colour. A membrane sweep will not cause any harm to you or your baby.

Induction of labour process

Prostaglandin tablet (Prostin): If your labour is induced in hospital you will be admitted to the antenatal ward C3 at St Mary’s at Wythenshawe or ward 65 at St Mary’s Oxford Road Campus. Your heart rate, blood pressure, temperature, breathing rate and oxygen levels will be checked. The midwife will feel your tummy to check which way your baby is lying. Your baby should be in a head first (cephalic) presentation. Your baby’s heart rate will be recorded on an electronic monitor (CTG). You will then have an internal examination. If it is not possible to break your waters a Prostin tablet will be gently inserted into the vagina. The tablet releases a hormone slowly over 6 hours. Repeat doses of the tablet may be required. These can be given every 6 hours up to a maximum of 3 doses. If you are experiencing contraction type pains or we are concerned about your baby’s heart monitoring trace (CTG) then there may be a delay in the next dose being given. Inserting the prostaglandin tablet may be uncomfortable and you may experience soreness in and around the vagina. You may start to feel mild or painful tightenings before effective contractions start. This is the normal process so please do not worry, we have different options of pain relief to offer and your midwife will discuss this with you. Having prostaglandin tablets involves several internal examinations and it can take up to three days for the cervix to soften and open enough for your waters to be broken. Once you get to the point where your waters can be broken, there can be an additional wait on the antenatal ward for a bed to become available on the delivery unit. Having your waters broken happens on the delivery unit and how busy the delivery unit is will determine how long you wait. This can be an additional wait of 24 to 48 hours. If the wait is more than 48 hours in one maternity unit but there is a bed available in another maternity unit within MFT, you may be asked if you wish to transfer to the other maternity unit to continue the induction process. You can remain mobile, bath or shower and eat and drink as usual whilst on the ward during the induction process.

Prostaglandin pessary (Propess): If you are suitable to have your labour induced at home (Outpatient Induction of Labour) then this is the method you will be offered. You will be asked to attend the Antenatal Assessment Unit (AAU) or the Day Assessment Unit (DAU) prior to your induction of labour for an ultrasound scan of your baby. Once this has been performed, providing all remains well with yourself and your baby, you will then have your observations recorded, your baby’s heartrate will be monitored and then you will be offered a vaginal examination to gently insert the pessary. You and your baby will then continue to be monitored before being discharged home to await events. At the Wythenshawe site, the prostaglandin pessary will be inserted during a visit to the Day Care Assessment Unit. At the Oxford Road site, you will attend Ward 65 and have the pessary inserted whilst there. You will be monitored following this and if everything is reassuring you will be able to go home.

At home you can do all normal activities; eat, drink, have a walk, take a bath, go to sleep etc. If your contractions start, your waters break, you have any bleeding, feel unwell or you are concerned about your baby’s movements, then you will be asked to call triage who will advise you accordingly. If after 24 hours you have not gone into labour you will return to the hospital. You will be offered an examination and the pessary will be removed. If we are able to break your waters at this point then the delivery unit will be informed and you will await a bed becoming available – you may be able to go home again whilst you wait to have your waters broken. If your cervix has not changed enough to be able to break your waters, then you will be offered prostaglandin tablets as outlined above. You will need to remain in hospital for these.

Cervical Ripening Balloon Catheter: This is another method to induce your labour. At present this is mostly offered to women who have had a caesarean section in the past. A thin tube is gently inserted into your cervix. This has a balloon near the tip. When it is in place the balloon is filled with sterile water. The balloon puts gentle pressure on your cervix for 12 hours. Hopefully, the pressure of this balloon should soften and open your cervix enough to start labour or so that the waters around your baby can be broken. It can be uncomfortable, but it should not be painful. There is a very small risk of infection with this method.

What happens next?

You may also be able to have the waters around the baby broken (ARM) as the first step in inducing your labour and not actually need any of the hormone pessaries discussed above if your cervix is favourable (soft, short, central and dilated) at the start of the process. Some women do find breaking the waters uncomfortable but your midwife will support you through this. A syntocinon drip may then be offered to you aiming to establish regular contractions if needed. During this time, you may feel more restricted in moving around with the drip connected, however, your midwife will be there to support you. Whilst you are on the drip your baby’s heartbeat will need to be monitored continuously. Though not available to all women or in every delivery room, there is the possibility of a mobile fetal heart monitor (also known as a Telemetry machine) if you wish to remain mobile during your labour. You are also able to stand, use your birthing ball and adopt several different positions during your labour and still be monitoring your baby’s heartbeat. Whilst on the syntocinon drip, it is important to remain hydrated, but we recommend you do not eat and will offer an antacid tablet to reduce stomach acid in case of the need for sudden intervention or transfer to theatre for birth.

What happens if the process does not work?

If it is not possible to break your waters after the prostaglandin tablets / pessary then a doctor will discuss further options with you, which will include a further Prostin tablet after a 24-hour rest day, using other methods to induce labour or to have a caesarean section.

What Next?

If you decide that you would like induction of labour when indicated, your midwife can arrange a date for this. You will be given further information regarding what to expect on the day.

References

Cochrane Database Systematic Review (2018) Induction of labour in women with normal pregnancies at or beyond term. Middleton P, Shepherd E, Crowther CA. Published May 2018. Accessed July 2020. https://www.cochrane.org/CD004945/PREG

Gülmezoglu et al (2019). Induction of labour at 41 weeks versus expectant management and induction of labour at 42 weeks (SWEdish Post-term Induction Study, SWEPIS). BMJ 2019

Wennerholm et al (2017). NICE Guideline 70: Inducing labour. 2008 (revised 2017). nice.org.uk/guidance/cg70