Why am I being given this leaflet?
You are being given this leaflet as you may be offered an Induction of
Labour (IOL) at some point during your pregnancy, and it is important
that you have all the information need to make decisions that you feel
are right for you.
You may be offered an induction for a number of reasons such as
having high blood pressure or diabetes or for simply going overdue
(also known as being postdates). A postdates pregnancy is one that
progresses to more than 41 weeks of pregnancy. IOL may also be
offered if continuing a pregnancy may be a risk to a mother or baby’s health and wellbeing.
Decision making – using the BRAIN acronym – how can this help?
The BRAIN acronym is a decision-making tool that will help you gather
the information you need to make informed decisions about you and
your baby’s health.
B – Benefits
What is the benefit of having the procedure/intervention?
R – Risks (or disadvantages)
What is the alternative to this procedure – is there a different care
pathway?
A – Alternative
What is the alternative to this procedure – is there a different care
pathway?
I – Instinct
What do you feel is right for you, what feels safest, what does your gut
instinct tell you?
N – Nothing
What happens if I do nothing of if I need more time to decide?
What do I need to know about Induction of Labour (IOL)?
IOL means is the process of starting labour artificially. Most people
will start to labour spontaneously (naturally/by themselves) between
37 and 41 weeks, leading to the birth of the baby. A Doctor or midwife
will discuss your options with you to help you decide about induction of
labour. You can also use the BRAIN tool to help form your discussion.
IOL is discussed and offered for a variety of reasons, some of these
reasons are more urgent that others and the timing of your induction
of labour will depend on the reason it is being offered:
• You may have a medical condition such as diabetes or pregnancy
related blood pressure issues.
• There may be concerns regarding the wellbeing of your baby.
• Your waters may have broken, and labour has not started naturally
after 24 hours.
• Your pregnancy has gone past your due date. Evidence has
shown that IOL at 41 weeks of pregnancy may reduce the
chance of baby being stillborn or being born in poor condition
and needing admission to the Neonatal Unit.
What happens if I need to be induced?
At Blackpool we offer 2 options for IOL. You can either have IOL as an
inpatient where you will be admitted to Ward D or an outpatient where
you will be able to go home. It may be that one option is not offered
to you due to your medical or birthing history (for example if you have
had a previous caesarean section). Your midwife or doctor will talk to
you about what they would recommend and why.
How is labour induced?
During pregnancy the cervix stays closed, however during Induction
of labour the aim is for the cervix to start to open – but it isn’t all about
dilatation! Before labour starts, the cervix is very far back (posterior).
It is around 3-4cm long, it feels firm, it is closed and the baby’s head
is normally just starting to engage into the pelvis.
During induction, the aim is to bring the cervix forward, shorten it,
make it softer, and start to make it open (dilate), and bring baby’s head
down.
There are a variety of methods that can be used to induce labour. For
some women one method can induce labour, but for others it may be
necessary to use a variety of the methods described below.
This will depend on your individual circumstances. IOL can be a long
process, and in some cases, it can take up to a few days before being
ready to be transferred to delivery suite for your waters to be broken.
The following methods can be used to induce your labour:
Membrane stretch and sweep
This is a procedure offered to try and encourage labour to start
spontaneously (naturally/on its own). It is carried out by a midwife
or doctor as part of an internal examination. It involves inserting two
lubricated, gloved fingers into your vagina to locate your cervix (neck
of the womb). During the membrane sweep, the index finger is gently
inserted into the opening of the cervix.
A circular, sweeping movement is used to try and separate the
membranes from the amniotic sac (that surround your baby), from
your cervix. The action releases hormones called prostaglandins that
soften the cervix and may help to start labour.
If your cervix has not started to soften and open, it would not be
possible to perform a stretch and sweep.
A membrane sweep can be carried out at home, at an antenatal clinic
appointment or in hospital. The baby’s heartbeat will be listened to
before and after the procedure. It does not hurt the baby but it can
cause mild discomfort for you. If there is any bleeding following the
procedure, you must contact the hospital for advice.
A bishops score – what does this mean?
When your midwife or doctor completes a vaginal examination during a
stretch and sweep or as part of an IOL assessment they will complete
something called a bishops score.
They will be checking the position of your cervix, the consistency/
how it feels, how long it is and how dilated it is. They will also be
checking the station (how high or low) the baby’s head is in the
pelvis. All these findings when considered together will create a
bishops score. This score is then used to help guide you and your
midwife/doctor in the decision making around the most appropriate
IOL options for you. For example, if a bishops score is 7 or more,
we wouldn’t recommend a pessary for IOL.
We will explain your individual situation and discuss your options with you at the time of the induction of labour.
Prostaglandins
Prostaglandin is used to soften (ripen) and dilate (open) the cervix.
Your baby’s heartbeat will be monitored before the administration of
the prostaglandin which can be given either as a pessary or a gel.
The insertion of the prostaglandin is a procedure that is carried out by
a midwife or doctor as part of an internal examination. It involves two
lubricated, gloved fingers being inserted into your vagina to locate the
cervix (neck of the womb).
The pessary or gel is introduced until it reaches behind the cervix.
The prostaglandin acts on the cervix, preparing it for birth by making
it thinner, softer and more stretchy.
A pessary will be removed after 24 hours and sometimes you need
a gel afterwards.
If you require more than one prostaglandin gel, this will be given
6 hours apart. For some people, a third prostaglandin gel may be
offered but this will depend on individual circumstances.
Disadvantages of prostaglandins
Some people have no side effects and do not experience any pain until
labour contractions begin, sometimes (not often) labour contractions
start after the prostaglandin is inserted.
Some people develop ‘prostaglandin’ contractions, which can
feel painful but are not established labour contractions. You can
try mobilising (moving round/changing positions), sitting/rocking
on a birthing ball and/or a TENS machine (trans-electrical nerve
stimulation) to help relieve the early labour type contractions that
will probably develop after a prostaglandin is given.
Side effects (not common) can include nausea, vomiting, dizziness,
palpitations and fever. The midwife will be available during your IOL
and will check your observations and listen to the baby’s heartbeat.
Occasionally some people develop a prolonged (extra-long) contraction
or start to experience contractions that are coming too frequently
(often). This is known as hyperstimulation. If this happens, the baby
may become distressed. Hyperstimulation occurs in approximately 5
in every 100 people who have a prostaglandin IOL. This may result in
you being offered an emergency caesarean section. Medication can
be given to reduce the frequency of contractions happening if needed.
If this is the case, you will be transferred to the delivery suite when it
is appropriate.
Having the prostaglandin pessary/gel may not be successful at
inducing labour.
THIS METHOD OF INDUCTION IS NOT RECOMMENDED FOR
PEOPLE WHO HAVE HAD A PREVIOUS CAESAREAN SECTION.
Mechanical Method
Induction of labour can be carried out mechanically by inserting a
device called a catheter. The catheter is a non-hormonal way of
opening the cervix. The procedure is carried out by a midwife or
doctor as part of an internal examination. A tube with a small balloon
is inserted into the vagina and into the cervix. The balloon is then
inflated using some sterile fluid. This applies internal pressure to the
cervix, which increases the amount of natural prostaglandin in the
cervix. The prostaglandin acts on the cervix, preparing it for birth by
making it thinner, softer and more stretchy.
IOL with a catheter is a safe option for people who prostaglandins
may not be suitable. After insertion of the catheter, your baby’s heart
rate will be monitored. The catheter will be removed 24 hours after insertion. If your induction of labour has not been successful following
prostaglandin or balloon catheter, the doctor will discuss different
options with you.
Another mechanical method is the use of osmotic dilators. These
are small rods made of gel, multiples of these small rods are usually
used and placed into your cervix via a vaginal examination, they open
your cervix slowly as they expand due to the absorption of the fluid in
the cervix. Normally, 3-5 rods are inserted at one time and each rod
expands to 1cm each to help open the cervix.
Disadvantages of mechanical method
There is a slight chance that the membranes (waters) may break
during the procedure.
Some people may find the procedure uncomfortable, and a few are
unable to tolerate it at all. If this was to happen, we stop the procedure
and discuss your options with you.
Having the catheter/rods may not be successful at inducing labour.
Artificial rupture of membranes (ARM)
An ARM is also known as breaking the waters. This procedure
is carried out by a midwife or doctor as part of an internal vaginal
examination.
If your cervix is starting to thin out and dilate (this may or may not be
following prostaglandin or mechanical induction methods), an amnihook
(pictured below) will be used to create a hole in the membrane sac to
release your amniotic fluid/waters. This action, which helps to release
prostaglandins, helps to prepare the cervix for birth and may also
start labour. An ARM means the bag of waters in front of your baby’s
head is released which allows the baby’s head to move down onto the
cervix more easily. The pressure of the baby’s head pushing down on
the cervix often causes it to open more efficiently. Being upright and
mobile (active) helps this process even more!
After the ARM, we recommend waiting 2-4 hours to see if labour gets
going (the medical term for this is established labour). If this does
not happen, we recommend commencing the oxytocin drip (artificial
hormone).
An ARM is only completed on Delivery Suite and sometimes there may
be a delay in waiting for this procedure. Your baby will be monitored
regularly, and you will be updated regarding any possible delays.
Disadvantages of an ARM
There is a small chance of a cord prolapse during or after an ARM.
This is when part of the baby’s umbilical cord slips down in front of the
baby’s head and through the cervix after the waters have broken (the
chance of this is higher if the baby’s head is not engaged/deep in the
pelvis). This is a rare event and more commonly happens in labour.
This is an obstetric emergency that requires the immediate birth of the
baby – usually by emergency caesarean section.
Labour may not start without further intervention (oxytocin drip) by ARM alone.
Oxytocin infusion (also known as oxytocin drip)
Oxytocin is an artificial hormone that is given as an infusion. This helps
to increase strength and frequency of your contractions. The oxytocin
drip is given through a cannula (a small tube that is placed into a vein
in your arm/wrist/hand). The oxytocin drip is started very slowly, which
allows the contractions to build gradually over time. The drip rate is
started slowly and increased over time until you are contracting every
2-3 minutes. Sometimes the rate of the drip needs to be reduced or
stopped – for example, if your contractions are coming too frequently
(often).
Sometimes the baby’s heartrate may be affected during induction
of labour with an oxytocin drip in a way that may suggest the baby
is distressed. Your baby will be monitored continually whilst on the
oxytocin drip. This combined with the oxytocin drip is likely to limit
your mobility in labour. However, we do try (where possible) to use
wireless monitoring to help you stay as active and mobile as you wish.
Oxytocin is only used on Delivery Suite where the CTG monitors are
available.
An active 3rd stage is recommended if you have an oxytocin drip in
labour, to help your uterus stay well contracted and minimise bleeding
afterwards. An active 3rd stage is when an injection of either artificial
oxytocin or a drug called Syntometrine is given into the muscle of your
thigh after the baby is born.
If the oxytocin infusion is unsuccessful in helping you go into
established labour, the doctor will discuss your options with you. It may be that a caesarean birth is recommended.
Can I choose not to be induced?
If you choose not to be induced, or to defer your induction, we will
make an individualised plan with you. You may be offered the option
of some extra appointments at the hospital, including an ultrasound
scan to assess the fluid around your baby and monitoring your baby’s
heartbeat. This can help to tell you how your baby is at the time, but
unfortunately cannot predict or avoid problems that might happen
suddenly and cannot predict the risk of a stillbirth.
If you are choosing to watch and wait, please contact the maternity
unit as soon as possible (01253 953618) if you have any concerns
about your baby’s wellbeing or if you change your mind and would like an induction.
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. 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. There
may be a delay once your cervix has opened enough for your waters
to be broken and you are waiting for a bed on labour ward for the next
stage.
Moving to labour ward can only occur when there is both a room and
a midwife available to look after you. The order in which people are
transferred to labour ward is based on an assessment of their whole
clinical background and prioritisation of safety rather than just length
of time since admission.
Whilst every effort to minimise delays are taken when they do happen,
we always aim to keep you fully informed, whilst continuing to monitor
both you and your baby’s health. In some cases where delays are
recognised, we may offer you transfer to another hospital to continue
your IOL journey, however this is rare. Please feel free to talk to any
midwife and they will do their best to resolve any concerns you may have.
Coping mechanisms available during the induction of labour process:
• Heatpack
• Warm bath
• Gymball and space to mobilise
• Paracetamol (for mild to moderate pain relief)
• Dihydrocodeine (an opiod painkiller for moderate to strong pain
relief)
• TENS machine (this is not provided by the hospital)
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 prostaglandin
approach, 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
Please discuss pain relief options with your midwife.
Top IOL tips for you
(Recommended by people who have previously experienced the IOL
process)
1. Be kind to yourself. This is probably not the birth plan you had in
mind – give yourself time and space to process the information
and situation you are in.
2. Bring a speaker or headphones to listen to music/podcasts.
3. Bring an Ipad or equivalent to watch TV.
4. Bring snacks, cereal bars, sweets, fruit, drinks.
5. Be prepared for a lot of waiting.
Useful links/websites:
Inducing Labour: Reasons, Methods & Side Effects | Tommy’s
(tommys.org)
https://www.tommys.org/pregnancy-information/giving-birth/
inducinglabour
Inducing labour – NHS (www.nhs.uk)
https://www.nhs.uk/pregnancy/labour-and-birth/signs-of-labour/
inducing-labour/
Overview | Inducing labour | Guidance | NICE
https://www.nice.org.uk/guidance/ng207
Maternity | Blackpool Teaching Hospitals NHS Foundation
Trust (bfwh.nhs.uk)
https://www.bfwh.nhs.uk/our-services/maternity/
1. National Institute for Health and Care Excellence (NICE).
Inducing Labour: NICE guideline [NG207]. 04 November 2021.
Available: https://www.nice.org.uk/guidance/ng207 (Last accessed 22-Jan-2022)
