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What is IOL?
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% of pregnant women are currently induced in the UK.
Why might I be offered an induction?
An obstetrician (doctor) or midwife will only recommend an induction if it benefits you and/or your baby. There are several reasons why you might be offered induction when your waters are intact:
To avoid prolonged pregnancy
The most common reason for induction is to avoid prolonged pregnancy, which is when the pregnancy lasts 42 weeks or longer.
The placenta is where oxygen and food are transferred from the mother's blood to the baby's blood during pregnancy. This process may become less efficient with prolonged pregnancy and result in stillbirth, although the overall risk of stillbirth remains low. IOL is recommended routinely to all women between 41 and 42 weeks, if their labour has not started naturally.
Advanced maternal age
There is some evidence that the stillbirth rate increases with advanced maternal age: the risk of still birth approximately doubles if you are 40 years old or older. For these women, IOL between 39-40 weeks of pregnancy (gestation) is recommended. We will discuss this with you in detail in the antenatal clinic.
If your water breaks before labour
When the waters around your baby break prior to labour starting, you will be offered an IOL. We offer a choice of either starting your IOL as soon as possible or waiting up to 24 hours for labour to start naturally.
Following discussion with your clinician you may prefer to wait for labour to start naturally. In this instance we would recommend that you receive antibiotics within 18-24 hours following your waters breaking, as this will reduce the risk of infection to both you and your baby. During this time, we will also monitor your baby`s heartbeat and observe you for signs of infection.
If you choose to wait for labour to start naturally and return home, we advise that you monitor your temperature at home and the colour of the fluid draining every four hours. If the colour of your waters develops an offensive odour or if your temperature rises above 37.5C, please contact the hospital immediately.
If you are a group b streptococcus (GBS) carrier
If you are known to be a GBS carrier we recommend that we start the IOL process as soon as possible. Your clinician will discuss this with you in detail.
Wellbeing concerns
If you or your baby’s wellbeing is causing concern then delivering your baby may be beneficial in certain circumstances, such as 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 at 39 weeks at your antenatal appointment, to reduce the need for IOL. This involves your obstetrician or midwife placing a finger into your cervix (neck of the womb) and making a circular, sweeping movement to separate the membranes that surround your baby, or massaging your cervix if this is not possible.
If labour does not start after this, you can ask for additional membrane sweeps. Membrane sweeping does not cause any harm to you or your baby, although it may cause some discomfort, pain, or bleeding. It may stimulate the natural production of hormones, which might promote softening of the cervix and in time trigger active labour.
Membrane sweeps may be offered before your IOL date, following discussion with your clinician.
What are the risks or disadvantages of IOL?
Induction promotes birth before your body is ready for labour. Therefore, compared to natural labour, some interventions are more common.
You may experience:
- Increased length of labour.
- Increased need for pain relief including an epidural.
- Increased need for an instrumental birth.
- Increased need for caesarean section in first time mums.
If induced with Propess, this may provoke too many or prolonged contractions. This can diminish your baby's oxygen supply and lower your baby's heart rate however this is very rare (less than 1%). If this was to occur, there is medication available to stop the contractions.
If induced with the cervical ripening balloon, the risk of too many or prolonged contractions has been shown to be greatly reduced.
If you have a cervical ripening balloon, you are more likely to have vaginal delivery compared to an emergency caesarean section and a reduced length of hospital stay.
If the process of IOL does not work, we will discuss other options with you, one of which is a caesarean section delivery. IOL is only recommended if the benefits outweigh the risks.
What happens if I need to be induced?
Your midwife or obstetrician will explain in detail the reasons why they recommend IOL. It is important that you understand the IOL process and ask any questions you might have.
Your assessment will include an 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 to undertake a membrane sweep. We will then arrange a date of IOL for you.
How long should IOL last?
It is different for each pregnant woman and depends on how ready the cervix and your baby are for birth. In general, if this is your first pregnancy (you have not given birth before), and the cervix is not ready (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
A cervical ripening balloon is a first choice IOL agent at the Royal Free London. The cervix will need to be open for the IOL with a cervical ripening balloon to proceed.
Why is a cervical ripening balloon our first-choice agent?
- It does not involve medication.
- It is safer for you and your baby because it is does not cause your womb to over contract.
- It increases your chances of having a vaginal delivery.
- It reduces your length of stay in hospital.
The cervical ripening catheter allows your cervix to be dilated mechanically, allowing the artificial rupture of your membranes to take place. It has minimal side effects and does not need you to be monitored as closely as when using a medical method.
The procedure involves a catheter (a soft silicone tube) being inserted into your cervix. It has two balloons near the tip and when they are in place, the balloons are filled with a sterile saline (salt water) fluid. One balloon will sit on top of and below the cervix, providing a gentle pressure.
The catheter stays in place for 12 hours, with the balloons 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 12 hours later.
While the balloon is in place, you can do things as you would normally, for example, 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 a midwife:
- Difficulty passing urine
- Bleeding
- Contractions
- Concerns about the baby’s movements
- Feeling unwell
- Waters around the baby break
- The balloon falls out.
Prostaglandin pessary
We use a prostaglandin pessary which is a slow-release prostaglandin hormone inserted into your vagina once which works over 24 hours. It prepares the cervix for labour. You may also get contractions during this process.
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 cervix will soften and shorten but you may not have gone into labour. If this happens, your waters will need to be broken and then you will need an oxytocin infusion drip to start the contractions.
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 (regular, three or four contractions every ten minutes and the cervix has opened three centimetres 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 heartbeat 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.
Artificial rupture of membranes (ARM)
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 plastic instrument during an internal examination 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 the hormone oxytocin. This drug is given using 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.
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 tell you about different methods of pain management.
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. If you go into labour following the cervical ripening balloon or pessary only, and this is not your first pregnancy, you can have your baby at the Birth Centre. This is our midwifery led unit, and you will need to be within the midwifery led criteria.
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 suggest:
- Another method of IOL
- Deferring 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 they recommend 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 heartbeat using a CTG and you will have a scan to check the water around your baby. How often you come to the hospital for monitoring depends on your situation, and the midwife and obstetrician will discuss this with you.
Please note that these methods are not very reliable to show us which pregnancies are at high risk for stillbirth. Because of these limitations, we offer IOL to all pregnancies before 42 weeks gestation (two weeks after your expected date of delivery).
Why might my induction be delayed?
We understand that when your induction is delayed, this can make you 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 IOL arrangements
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, you need to ring Victoria Ward at 6am on the day of your planned induction and ask to speak to the team leader. They will be able to give you a time to come to Victoria Ward. During your induction of labour, you will be cared for on Victoria Ward.
If your pregnancy has been identified as low risk, then you will be suitable for outpatient’s IOL. You will need to arrive at an allocated time to the maternity day unit. If all is well and you are living close to the hospital (no more than one hour travel time) you may be allowed to go home.
If you go home
A midwife will contact you at home 12 hours after the start of your induction to find out how you are. We will also ask you to come back for assessment 24 hours later if you are having Propess induction and 12 hours following a cervical ripening balloon.
You should contact triage on 0208 216 4408 if you experience:
- Contractions become painful or regular (every five minutes)
- Vaginal bleeding
- Change in baby’s movements or they become less frequent
- The pessary falls out
- Any other concerns.
If your waters break and this is confirmed when you come to hospital, you will be admitted as an inpatient in the maternity ward.
You will be shown how to remove the pessary in the event of vaginal bleeding or excessive painful contractions. You should also then contact triage immediately.
Royal Free Hospital IOL arrangmenets
We will give you a date and a time to come to the hospital. On the day of your appointment, you will attend the day assessment unit (DAU).
If your pregnancy has been identified as low risk, then you will be suitable for outpatient’s induction of labour.
If your pregnancy is high risk, you will be admitted to the antenatal ward.
If you go home
We will also ask you to come back for assessment 24 hours later if you are having Propess induction and 12 hours following a cervical ripening balloon.
You should contact DAU or labour ward if:
- Contractions become painful or regular (every five minutes)
- Vaginal bleeding
- Change in baby’s movements or they become less frequent
- The pessary falls out
- Any other concerns.
If your waters break and this is confirmed when you come to hospital, you will be admitted as an inpatient in the maternity ward.
Further questions or concerns?
Your midwife and obstetrician will be happy to talk through any concerns about the induction process with you and your partner.