Induction of Labour

Patient Information

Induction of Labour

When will I be admitted?

(Please note this is a provisional aim as commencing induction

will be dependent on activity on the unit at that time)

Date __________________________________________

Time __________________________________________

o Ward 11

o Central Delivery Suite (CDS)

Please ring Ward 11 (01493 452011) or CDS (01493 452480) if

you have any concerns or queries.

This leaﬂet has been designed to provide you with the

information required to make an informed decision, with your

clinician’s advice, about whether induction of labour is suitable

for you at this time. If you are unsure that you fully understand,

or would like more information as to why induction of labour

has been offered to you, please ask your midwife or doctor.

What will happen when I arrive on the

maternity unit?

When you arrive a midwife will give you a full examination,

this will include taking your temperature, pulse, blood pressure,

testing your urine and examining your abdomen. Your baby’s

heart beat will also be monitored using an electronic machine.

The induction of labour process will be explained to you. You

and your birthing partner will be given the opportunity to ask

any questions you may have.

What is Induction of labour?

In most pregnancies, labour starts naturally between 37 and 42

weeks’ gestation, leading to the birth of your baby. Induction

of labour or ‘being induced’ is a process that starts your labour

artiﬁcially.

What is the normal process of labour?

During pregnancy, your baby is surrounded by a protective,

ﬂuid-ﬁlled membrane also known as the amniotic sac,

containing amniotic ﬂuid. Your cervix or “neck of the womb”

is closed, thick and long at this time. Towards the end of

pregnancy, your cervix softens and shortens. This is sometimes

called “ripening of the cervix”.

When your body begins to labour, your cervix will also start

to dilate (open and widen). Everyone’s body is different as to

the rate that this occurs. Your waters may also break before

or during labour, releasing the amniotic ﬂuid which surrounds

your baby, allowing labour to occur. Six in 10 women will go

into labour naturally within twenty-four hours of their waters

breaking.

During labour the womb contracts regularly as the baby’s head

moves further down into the pelvis and the cervix dilates. When

the cervix is 10cms dilated, you have reached the second stage

of labour when you are ready to give birth to your baby.

How is labour induced?

When you and your baby have been checked over you will need

to have an internal vaginal examination to assess your cervix to

see how ready you are to go into labour. Your care will depend

on how soft and dilated (open) your cervix is when you are

examined. This examination may be performed by a midwife or

a doctor.

Membrane sweeping prior to induction

Prior to induction of labour your doctor or midwife may offer

you a membrane sweep also sometimes referred to as a stretch

and sweep.

Membrane sweeping involves your midwife or doctor

performing a vaginal examination and placing a ﬁnger just

inside your cervix and making a circular sweeping movement.

This has been shown to increase the chances of your labour

starting naturally within the next 48 hours and can reduce the

need for other methods of induction of labour.

This procedure is usually offered to you as the ﬁrst method to

try and start your labour at around 40- 41 weeks. You do not

need to come to hospital for a sweep; it is often performed by

your community midwife at a routine antenatal check, either

at home or in the clinic. We can offer up to three membrane

sweeps to try and start your labour naturally.

The procedure may cause some discomfort and slight bleeding,

but will not cause any harm to your baby and it will not increase

the chance of you or your baby getting an infection.

When am I in established labour?

‘Established’ labour is when your cervix is 4cms dilated and you

are experiencing regular, rhythmic contractions of the womb

every few minutes. You may experience some irregular, mild

contractions which are referred to as ‘tightenings’ prior to

established labour.

You may only require one type of intervention; however, it is

possible that you may require a combination of all the methods

to get you into labour. The midwife or doctor will discuss your

individual needs at each assessment. Please note that this can

take several days, and delays are not uncommon depending on

the activity on the delivery suite.

Formal methods of induction include:

1. Prostaglandin

Prostaglandin is a hormone that is naturally produced by your

body and can help to start labour. We use two methods to

deliver an artiﬁcial version of prostaglandin:

• A pessary known as “Propess®” is inserted into the vagina.

It releases the hormone needed to soften your cervix slowly

over 24 hours. There is a string attached to the pessary so

that it can be removed easily after 24 hours, or earlier if you

should go into labour or there are any concerns about you or

your baby’s health. If you have a low risk pregnancy, without

the need for regular monitoring at this stage, you may be

able to go home with the propess in place.

• A tablet known as “Prostin E2®” is inserted into the vagina.

You have another vaginal examination six hours after the

ﬁrst tablet. At that time, if the cervix has not ripened enough

to allow us to break your waters then a second tablet will

be given. If your cervix is still not open and soft enough or

“favourable” following this, a 24 hour rest and then a third

prostin may be given after a review from a doctor.

Artiﬁcial Rupture of Membranes (ARM)

When you are examined, if your cervix is soft (approximately

3cms dilated) and your baby’s head has gone down into your

pelvis, then it may be possible to break your waters. This is

done by using a small plastic hook which releases the water and

allows the pressure of the baby’s head to press on the cervix and

stimulate contractions.

The procedure may be uncomfortable but it should not be

painful. If you are on Ward 11 then you will be moved to the

delivery suite for this to be done and will require at least a 30

minute fetal heart rate monitoring prior to this.

Sometimes, when you are examined again on delivery suite,

your cervix may have changed and it is no longer possible to

break your waters. In this instance, it may be necessary to have

another prostaglandin. After this you would be returned to the

ward again until it is possible to break your waters.

Once the doctor or midwife has broken your waters, the ﬂuid

will leak out until your baby is born. You may ﬁnd that you

start to have regular contractions after your waters have been

broken. You are encouraged to move around to help start the

contractions. The midwife will listen to your baby’s heartbeat

regularly and offer you pain relief if you require it.

Oxytocin (Hormone Drip)

Once your waters have broken we hope that your contractions

will start. If contractions do not start within 2-4 hours, the

doctor will usually advise that you have a hormone drip to

help them start. This drip is a mild salt ﬂuid with the hormone

oxytocin added to it. Your body usually produces this hormone

during the birth process to bring on the contractions. It is given

through a tiny tube into a vein in your arm and once it is in

place the midwife will monitor your baby’s heart continuously

using an electronic machine. You are still encouraged to be

mobile and change positions regularly.

Non-Pharmacological methods of induction

Non-pharmacological methods such as herbal supplements,

acupuncture, homeopathy, castor oil, hot baths, spicy foods,

enemas and sexual intercourse have no available evidence to

support their use as induction of labour methods.

When is induction of labour recommended?

When it is felt that your health – or your baby’s health – is likely

to beneﬁt, the midwife or doctor will offer and recommend

induction of labour. On average, approximately 1:3 women are

offered induction of labour for various reasons, such as

• If your waters have broken for more than 24 hours

• If your pregnancy is prolonged, 40 weeks and 10 days

• Diabetes

• Pre-eclampsia, a complication in pregnancy that causes high

blood pressure

• A large or small baby is detected on the ultrasound

• A change in the pattern of your baby’s movements

• Any pregnancy induced or ongoing medical issues which

would beneﬁt from earlier delivery of your baby.

If your pregnancy is more than 41 weeks

Even if you have had a healthy, trouble free pregnancy, you will

be offered induction of labour at around 10 days over your due

date because from this stage the risk of your baby developing

health problems increases. This is in line with National Institute

for Clinical Excellence guidance (NICE).

What happens if I decide not to be induced?

If you decide to decline induction of labour you will need to

have a consultation with a doctor to discuss the possible risks

associated with continuing your pregnancy. It is important that

we have a conversation with you to provide all the information

and time that you need in order to make an informed choice.

You will require close and regular monitoring if you decline

induction of labour. The risk of stillbirth increases from one

in 1000 births at 42 weeks to two in 1000 births at 43 weeks.

This is because research has shown that the placenta, which is

supplying your baby with blood and oxygen, could become less

efﬁcient when pregnancy is prolonged to 42 weeks and over.

What are the risks of induction of labour?

Increased Discomfort – more frequent vaginal examinations

and prostaglandin pessaries can be uncomfortable and cause

soreness in and around the vagina. They can also cause painful

tightenings that are not always indicative of labour, but mean

that your body is getting ready for labour. Occasionally, if you

are particularly sensitive to the prostaglandin pessary, too many

tightenings can occur and can cause hyper stimulation.

Hyperstimulation – around 4-5% of inductions are complicated

by hyperstimulation. Prostaglandins can cause the uterus to

contract too frequently and this may affect the pattern of your

baby’s heartbeat. Having too many contractions can cause your

baby to become distressed as they may not get enough rest

between each contraction. This is usually treated by giving a

drug that helps the uterus relax. However, sometimes this is

not fully effective and if the uterus continues to contract too

frequently, we may need to perform an emergency caesarean

section to birth your baby safely.

Shoulder Dystocia – having your pregnancy induced can cause a

higher chance of your baby’s shoulders becoming stuck during

the birth. This is an emergency known as shoulder dystocia

which occurs in 0.4 % of all births and requires additional

physical manoeuvres from the midwife or doctor to deliver your

baby safely.

Instrumental delivery – there is a slight increase in the chance

of requiring assistance from the doctor at time of birth with a

suction cup, which may be referred to as a KIWI or ventouse

delivery. Alternatively, forceps may be required to assist the

birth of your baby.

Post-Partum Haemorrhage – there is an increased risk of heavy

bleeding following the birth of your baby. This is known as a

postpartum haemorrhage and is managed with drugs to help

contract the uterus after birth and/or stitching of any trauma

which may have caused the bleeding.

Failed Induction – sometimes, despite our best efforts, the

induction process may not be successful in getting you into

labour. If this happens you may require a caesarean section.

Cord Prolapse – during the induction, if an amniotomy is

required, and your waters are broken with a thin plastic hook.

There is a slight chance that the cord may drop (prolapse)

through the open cervix into the vagina ahead of the baby.

This can reduce the blood ﬂow and oxygen to your baby and is

considered as an emergency, which will require rapid delivery of

your baby.

Uterine Rupture – this is when the muscular wall of the uterus

tears during pregnancy or childbirth, most commonly from the

scar of a previous caesarean section. This is a complication of

induction. If uterine rupture is suspected at any point, the baby

should be delivered by emergency caesarean section.

Vaginal Birth After Caesarean (VBAC)

If you have had a previous caesarean section delivery, you

should have a detailed discussion with a senior obstetrician

about the potential risks, beneﬁts and success rate in your

individual situation, and whether induction of labour would

be appropriate for you. The scar on your uterus may separate

and/or tear (rupture). This can occur in 1 in 200 women. This

risk increases by 2 to 3 times if your labour is induced. If there

are warning signs of these complications, your baby will be

delivered by emergency caesarean section. Serious consequences

for you and your baby are rare (RCOG, 2016, Patient Information

Leaﬂet).

How long does it take to induce labour?

It is difﬁcult to predict how long your induction of labour will

take because it will depend upon which method of induction

is used as every birth is different. The neck of the womb has to

be soft and open before the labour starts. Some women may

be quicker than others and some women may take several days

to establish in labour. It is important that we do not rush the

induction process to allow your body and your baby to adjust to

the changes happening.

There are occasions where the maternity unit is very busy and

for your safety and the safety of your baby your induction may

be delayed. The staff on ward 11/delivery suite will try to keep

delays to a minimum, and if a delay should occur staff will keep

you fully informed about when you might expect to have your

labour induced. There are also occasions in which you may be

transferred to delivery suite to continue your induction, but on

arrival an emergency may occur or activity suddenly increases

which may mean transfer back to Ward 11 to prioritise safety for

all of our women and babies.

Will I be able to eat and drink?

You can eat and drink normally until you start to go into labour

or the hormone drip starts. Please check with the midwife if you

are unsure.

Can I move around once the pessary has been put

in?

After the pessary has been inserted you will be asked to lie on

your bed for 30 minutes. This will allow the pessary to absorb

moisture from your vagina, which will make it swell and prevent

it falling out. When this time is over you may move around

as normal. Staying active will help the process of induction of

labour.

What pain relief will I be offered?

It is recognised that the induction of labour process can be more

prolonged and uncomfortable. Depending on which stage of

the process you are in, your midwife will advise and offer you

pain relief as appropriate which can include; simple analgesia

such as paracetamol and codeine, pethidine injection and

epidural. Please speak to your midwife for more information

regarding this.

Can I still use the midwifery-led birthing unit

(Dolphin Suite) if my labour is induced?

There are many women who are still able to deliver on the

dolphin suite who have had their labour induced. However, if

you need the oxytocin drip or have any other risk factors which

mean we have to continuously monitor your baby’s heart beat

to ensure its well-being, then delivery suite would be the most

appropriate place for doctors and midwives to care for you.

Can I go home once induction has been

commenced?

Some low risk inductions with no other complications, may be

able to go home for approximately 24 hours following insertion

of Propess®, then return to the maternity ward for the rest of

the process. If you would like any further information regarding

this please speak to your midwife/doctor and see the separate

leaﬂet for outpatient induction.

What will I need to bring with me?

• Your maternity notes

• Clothes, nightclothes, toiletries, slippers, sanitary towels

• You may want to bring books, magazines, music or games to

keep yourself busy

• It is recommended that you pack a separate bag for your

baby’s items which your birthing partner can bring into the

hospital when you’re in labour as space on the ward is limited

Can my birthing partner stay with me?

When inducing labour it is recommended that partners stay

for ‘twilight hours’, up until midnight, if they wish and then go

home and get some rest before you go into full labour so that

they can support you when you need it most. Outside of these

hours we need to prioritise the comfort and safety of the whole

ward and have no facilities for partners to stay overnight –

therefore we regret that we cannot offer this service.

When you are established in labour and are transferred to the

delivery suite your partner can remain there with you for as

long as you are there. If you are transferred back to the ward

between the hours of 9pm and 9am your partner will be asked

to go home.

Colostrum

During your pregnancy, your body starts to produce the ﬁrst

milk known as colostrum, which contains all the nutrients your

baby needs as well as many health beneﬁts, such as reducing

the risk of jaundice and infection. It is present in a very small

volume, therefore some women may wish to hand express

colostrum from their breasts prior to delivery. It can then be

stored and ready if your baby requires any additional milk.

This can also be beneﬁcial to get feeding off to a good start.

Whichever method of feeding you choose, please speak to your

midwife if you would like any further information or assistance.

Please discuss any further questions you may have about

induction of labour with your doctor or midwife.

Write any questions you have below:

____________________________________________________________

Authors:

Alana Hunt, Midwife, Maternity and

Rachel King, Midwife

June 2019

James Paget University Hospitals NHS

Foundation Trust

Review Date: June 2022

MI 6 version 4

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communicating effectively with staff during your stay. Please let us know.

For a large print version of this leaﬂet, contact PALS 01493 453240

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