Induction of labour is a common procedure. Labour is induced when it is thought that the outcome of the pregnancy will be better if labour is artificially started rather than waiting for labour to start naturally. The reasons to start off a labour can be variable and sometimes more urgent than others.
It is important that you talk to the midwife or doctor about the reasons to start the labour and what are the risks and benefits of starting the labour compared with continuing with the pregnancy. It is your decision and it is important that you know why it is being advised.
Induction of labour does make it a different experience compared to a labour that starts naturally and it is important you have thought about this too. We know that starting off a labour can make the labour longer and more painful. We also know that women being induced are more likely to have an epidural for pain relief and an assisted birth (ventouse or forceps). It is a good idea to discuss your birth plan with the midwives.
When IOL of labour is being considered, your doctor or midwife will fully discuss your options before a joint decision is reached. This should include explaining the procedures and the care that will be involved and whether there are any risks to you and your baby. If you are healthy and have had a trouble-free pregnancy, IOL may be offered if:
- Your pregnancy is more than 12 days over your due date
- If your waters break before labour starts
There may be a medical reason why you are being advised to have your labour induced e.g. if you have diabetes or you have developed high blood. If you decide not to be induced when you are past your due date you will be offered:
- Discussion with a doctor to discuss any risks verses any benefits of the IOL
- An ultrasound scan
- Increased antenatal monitoring thereafter which includes daily CTGs –electronic monitoring of the baby’s heart
Before IOL of labour is offered, you may be offered a membrane sweep to help you go into labour before 42 weeks. This is usually performed by your community midwife.
To start a labour there are medical interventions we can use:
1. Prostaglandin – this is often the first stage of starting a labour. It helps to make the cervix ready for labour. Propess pessary is used which releases the prostaglandin slowly over 24 hours.
2. Artificial Rupture of Membranes (ARM) – this can be the first stage for women whose cervix is already dilated. This is performed by an internal examination. By breaking the sac that surrounds the baby the fluid is released and this can sometimes start the contractions of labour.
3. Syntocinon infusion – this is used once the waters around the baby have broken and is a hormone drug that is given into a drip in the arm. This hormone (oxytocin) will start the contractions of labour.
4. For women who have had a previous caesarean section. At Warrington, we currently use one dose of Prostin as a tablet, which is inserted into the vagina. Following this, you will be examined 6 hours later to see whether the cervix (neck of the womb) has dilated enough to break your waters. There are increased risks with induction of labour if you have had a previous caesarean section delivery and this should be discussed with you before induction of labour.
On the day of your IOL, you will be asked to attend the Delivery Suite, on the first floor of Croft Wing.
A midwife will perform a full antenatal assessment which will include recording your temperature, pulse, and blood pressure and a recording of your baby’s heartbeat using an electric machine, for approximately 30 minutes. The midwife will examine you vaginally to establish whether your waters are able to be broken or if you need a prostaglandin (Propess) to help prepare your cervix for labour.
If your waters can be broken, you will need to be transferred to the Delivery Suite. Sometimes there is a delay due to the activity on the Delivery Suite. If this occurs, the midwife will ensure that you have no risk factors and you may be asked to go home and wait for a bed to become available. If you do go home, your contact details will be taken so that the Delivery Suite can contact you as soon as a room/midwife becomes available. Women are taken to the Delivery Suite based on their clinical need for induction of labour. There can be some delay depending on how busy the delivery suite is.
Once your waters have been broken, you will be encouraged to walkabout for about one hour. If you do not start contracting after this time, the doctor will discuss with you starting a drip which contains Syntocinon - a drug that encourages contractions and given via a drip in your hand/arm.
If the midwife is unable to break your waters, a Propess will be inserted into your vagina. You will then be encouraged to mobilise. At this stage you may be able to go home if you have no risk factors. The Propess will remain in the vagina for 24 hours. If you go into labour during this 24 hours you may be suitable to have midwifery led care, if there are no other risk factors, this should be discussed with you antenatally. After 24 hours, if you have not gone into labour, you will be transferred to the Delivery Suite as soon as possible.
A doctor or midwife will review you on the Delivery Suite to see if your waters can be broken. If there is any delay in transferring to the Delivery Suite, then the midwife on the ward will check your blood pressure, pulse and temperature as well as the baby’s heartbeat.
If your waters break when the Propess is in your vagina, you will need to inform the midwife so that she can check you and your baby. The Propess may be removed before 24 hours if:
- You are experiencing painful tightenings
- If we are able to break your waters
- If your womb starts to contract very frequently (known as hyperstimulation)
- If your baby shows signs of any distress.
It is possible to have an outpatient IOL if you meet the following criteria:
- If you or your baby have no risk factors
- The Bishop Score of your womb is seven or less (your midwife or a doctor will explain this further to you)
- You have transport to take you home and bring you back when you require
- You have a telephone
- The waters around your baby is within normal limits
- If your waters have not broken
- If the electronic monitoring of your baby is normal
If you meet the above criteria, once you have been given the Propess you will be advised to go home. Once you are at home, you will be asked to return to the Delivery Suite if you experience any of the following:
- Regular painful contractions
- If you require any pain relief
- If you have any vaginal bleeding
- If your waters break
- If you think that your baby’s movements are as many as normal
- Any other concerns you may have
- If you experience a lot of bleeding, the midwife will advise you to remove the Propess (which is like removing a tampon)
After 24 hours, you will be asked to return to for a review and further plan for your on-going IOL.
It is safe to have a shower or bath following the insertion of a Propess although care should be taken that not too much soap is used around the vaginal area and not to pull on the tape.
What are the possible side effects of Propess?
Vaginal prostin, which is controlled-release, is the preferred method of IOL at Southmead Hospital and is recommended by NICE (2008, 2014). This method of IOL of labour has been found to be safe for both mother and baby. However some women have noticed very minor side effects such as nausea and diarrhoea, and frequent contractions. In very rare cases, the frequent contractions can cause stress for the baby which may need urgent attention.
If your waters break and you do not start contracting you will need to ring the Delivery Suite for advice and probably be asked to come in for assessment. If it is confirmed that your waters have broken, you will either be offered an IOL as soon as possible (depending on the activity and room availability on the Delivery Suite) or you could wait until 24 hours to see if you go into labour on your own. If you give birth after 24 hours of your waters breaking, your baby will require observations for 24 hours and you will be asked to stay in hospital for this duration.
Can my birthing partners be with me?
You may bring one birthing partner with you for support. If you are not in labour, your birthing partner will be advised to go home at 8pm. Unfortunately we are unable to provide a bed for your partner. When you are transferred to the Delivery Suite to have your waters broken or if you are in established labour, you can invite another birthing partner to be with you.
IOL may relieve a medical condition (such as pregnancy-induced hypertension) which may otherwise get worse
- Pregnancy is not prolonged beyond a date when the placenta may not function as well as it did earlier in the pregnancy
- IOL may be performed to prevent you getting an infection if your waters have broken and labour has not started.
You may be offered an outpatient induction of labour if
- Your pregnancy is ‘low risk’
- You have no medical or obstetric problems
- You have transport to bring you to the hospital
Your midwife or doctor will have a conversation with you about the outpatient induction of labour process and if you meet all the criteria you will be offered this method of induction.
An outpatient induction of labour:
- Reduces the amount of time you will need to stay in hospital before your labour begins
- Allows you to stay at home and wait for labour to start
- Makes the process of going into labour more normal
Step 1
You will have your pulse, blood pressure, temperature and urine checked. The midwife will also read you notes and ensure you meet the criteria for outpatient induction of labour.
The midwife will discuss the process with you and answer any questions you may have. The midwife will also examine and your abdomen toc heck on baby’s size and how the baby is lying. Your baby’s heartbeat will then be monitored for 30 minutes using a CTG machine.
Step 2
Once the midwife is happy with the observations and CTG she will ask if it is ok to perform an internal vaginal examination to check your cervix. At this point a membrane sweep may be offered.
The midwife is checking your cervix to see how ‘favourable’ it is. This means how dilated, soft and thick the cervix is, as well as how deep the baby is in the pelvis. The midwife will discuss findings with you and if appropriate will insert the Propess into the vagina. Propess is a very small flat tampon which slowly releases prostaglandins over 24 hours. A second CTG will be performed for 30 minutes to ensure your baby’s heart rate is ok.
The Propess string will lie just outside the vagina and it is important that you take care not to pull or drag on it. You will also need to take care when:
- Wiping yourself after going to the toilet
- After washing
- Getting on and off the bed
Step 3
If the midwife is happy with observations and CTG monitoring you will be discharged home, if you are having an outpatient induction. You can continue with your day to day activities and eat and drink as normal.
The Propess works by ‘ripening’ your cervix, encouraging it to soften, shorten and begin to open. It is normal to experience some period type pain, back ache and tightening and we recommend regular paracetamol, mobilising and a warm bath at home.
If you experience any of the following whilst you are at home please contact the Delivery Suite immediately on 01925 662334 or 01925 66209.
- You have painful tightenings every five minutes
- Severe abdominal pain
- A run of contractions which are occurring more than 4 in a 10 minute period
- Any vaginal bleeding
- If you think your waters have broken
- Reduced or absent fetal movements
You may be advised to take the Propess out immediately by pulling on the string. Are there any side effects of IOL?
Propess can occasionally produce some side effects which are usually mild and can include:
- Nausea
- Vomiting
- Dizziness
- Palpitations
What if induction doesn’t work?
If you don’t start to labour after induction or it is not possible to break your waters a doctor will discuss the options with you and the options available may depend on the reason that you were being induced. Options can include examining you again after 24 hours o and retry with the methods discussed in this leaflet, or considering a caesarean section delivery.
From 40 weeks pregnant, if you are a first time mum and 41 weeks for subsequent pregnancies, at the discretion of your midwife you will be offered a vaginal examination to perform a membrane sweep.
What is a membrane sweep?
Membrane sweeping involves your midwife or doctor placing a finger just inside your cervix (neck of the womb) and making a circular, sweeping movement to separate the membranes from the cervix. This has been shown to increase the chances of labour starting naturally within the next 48 hours and can reduce the need for other methods of induction of labour. It may be carried out at home, during an antenatal appointment or in hospital.
The procedure may cause some slight discomfort, slight bleeding or a ‘show’ and/or tightening of the womb. All of these are normal, and will not cause any harm to you or your baby. It will not increase the chance of your baby getting an infection. Membrane sweeping is not recommended if your waters have broken.
Whether you have decided to have a membrane sweep or not, you will always be offered a date to have your labour induced (started off). We will ensure you are offered an appointment to attend the hospital between 41 and 42 weeks of pregnancy for a review and to commence your induction of labour.
Can I choose not to have a membrane sweep?
If you decide not to have a membrane sweep, this is not a problem as it is your choice. However, if your pregnancy continues beyond the recommended 12 – 14 days past your due date, you will be invited to attend the Delivery Suite for further review to ensure that both you and your baby remain well whilst awaiting the onset of natural labour.
At this appointment a midwife will talk to you about how you are feeling, and perform a full antenatal check which will include taking your blood pressure, testing your urine and examining your abdomen to assess the growth and position of your baby. Your baby’s heartbeat will be monitored for a minimum of 20 minutes and you may be offered an ultrasound scan to assess how much water (amniotic fluid) is surrounding your baby where appropriate.
This information will help us when discussing the future care of your pregnancy and possible induction of labour with you.
Sometimes a woman’s waters break before labour starts. This is known as pre-labour rupture of membranes. If you think your waters have broken it is important you discuss this with a midwife.
You may be invited to attend the hospital for an antenatal check to assess both your well-being and that of your baby and to confirm that your waters have broken. If your waters have broken but you have not gone into labour you will be offered the choice of either:
- A ‘wait and see’ approach to await the onset of natural labour if all remains well. 9 out of 10 women whose waters break before labour starts will go into labour naturally within 24 hours of the waters breaking.
- Induction of labour if there are concerns about either your well-being, or that of your baby.
These options will be discussed with you at the time so that you can make a decision on which you would prefer. One of the functions of the membranes is to provide a sterile environment for your baby. The longer the time interval between your membranes breaking and the birth of your baby, the more likely it is that an infection will develop. Due to this fact, we currently recommend a ‘wait and see’ approach of no more than 24 hours following the breaking of your waters. If labour has not started naturally during this time, induction of labour will be recommended. It is important that you are happy with the choices you make for your care.
The National Institute for clinical Excellence (NICE) website www.
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NICE Inducing Labour (CG70) 2008 Royal College of Obstetricians and Gynaecologists
Royal College of Midwives (information on active birth)