Induction of labour (English, North Mid only)

Labour is a natural process that usually starts on its own between 37 and 42 weeks and leads onto the birth of your baby.

During pregnancy, your baby is surrounded by a fluid-filled membrane (sac), which protects your baby as it grows in the uterus (womb). The fluid inside the membrane is called amniotic fluid (your waters).

Towards the end of your pregnancy, the cervix (neck of the womb) softens and shortens. This is called the ’ripening of the cervix’. This process can occur over days or weeks.

Before, or more commonly during labour, the sac of amniotic fluid breaks. This is known as ’your waters breaking ‘. However, sometimes the baby is born in the sac.

At the beginning of labour, the contractions start, usually mildly and become strong and regular to open (dilate) the cervix.

Early labour or the ‘latent phase’ is when you have contractions, but they stop and start. This can go on for a day or two and can be frustrating! You can always call to speak to a midwife if you need help or advice and always call or come in if you are concerned about your baby’s movements.

Once your cervix is open to 4cm the contractions will be strong and regular and you baby will usually be born within 6-18 hours, usually quicker for women that have had a vaginal birth in the past. The uterus (womb) contracts to push your baby down and out of the vagina.

What is an induction of labour?

Induction of labour (IOL) means starting your labour artificially. About 30% of women in the UK have an induction.

An induction of labour might be recommended and offered:

• to reduce the small increased chance of stillbirth (when the baby dies inside the womb) if your pregnancy goes on longer than 41 weeks
• for indications such as diabetes or high blood pressure
• problems with the baby’s growth or a small baby
• to prevent infection if your waters have broken but you haven’t gone into labour.

If your pregnancy has been straightforward, you will be offered induction if labour hasn’t started naturally by 41-42 weeks. This is because the risk of a stillbirth (when a baby dies before it is born) increases over time and having an induction from 41 weeks may reduce this risk.

The quality of the evidence about whether there is an increased risk in these situations and if so whether induction would reduce it can vary, but the information in a recent (2019) UK review of stillbirth rates from 15 million births is the one most commonly used as a guide. This shows that the overall risk of stillbirth in every 1000 births is:

• At 40 weeks: 1 per 1000 or a 0.1% chance
• At 41 weeks: 1.8 per 1000 or a 0.2% chance
• At 42 weeks: 3.0 per 1000 or a 0.3% chance
• At 43 weeks: 6.5 per 1000 or a 0.7% chance

Although the stillbirth rate increases from 40 to 43 weeks, the actual risk remains very low. The risk of a baby dying after birth (neonatal death) also remains very low. 

Please note that there is variation in the number of stillbirths across different ethnic groups. Women from Black and Asian backgrounds have a higher chance of stillbirth compared to white women. Talk to your midwife or doctor if you would like to discuss this.

The reason for induction will be discussed with you on an individual basis including benefits versus risks.

Decision making

It is your decision whether to have an induction or not. Everyone is different and you can choose what is right for you and your baby.

When you need to make a decision about your care, the law says that your doctor or midwife should give you all the information you need to help you make decision that is right for you. This is informed consent.

If you decide not to have an induction of labour, talk to your midwife or doctor about alternative options. The options may include extra scans and monitoring. You could also request to be referred to the consultant midwife.

BRAIN can help you ask questions

B = What are the benefits
R = What are the risk?
A = What are the alternatives?
I = What does your intuition or your gut feeling tell you?
N = What happens if we do nothing for now?

Can we wait and take some time to think?

The BRAIN acronym helps you have conversations that will support you to make a decision.

Benefits of induction of labour

May reduce the chance of the stillbirth and other potential problems as discussed above.

An induction of labour at around 41 weeks may have the best chance of you achieving a vaginal birth and is not usually associated with an increased likelihood of caesarean birth.

Risks of induction of labour

• If you have an induction of labour, your choice of place of birth may be limited.
• You may be recommended interventions (for example, syntocinon infusion(hormone drip),
• continuous fetal (baby) heart rate monitoring and epidurals) that are not available for a home birth or in a midwife-led birth centre
• You may be less likely to be able to use a birthing pool
• You may be more likely to need an assisted vaginal birth (using forceps or ventouse), which has an increased risk of significant perineal tear (obstetric anal sphincter injury)
• An induced labour may be more painful than a spontaneous labour
• Your hospital stay may be longer than with a spontaneous labour
• You will likely have more vaginal examinations

You have decided to have an induction: What happens next?

There are usually three stages to an induction of labour:.

Induction of labour occurs in three stages; most women need all three stages to be able to give birth. This is particularly true with first babies.

The induction process needs to happen gradually, so it is common for induction of labour to take two or three days from the start of the induction to the birth of your baby.

Make sure you are prepared for a potentially long process. Bring in books, magazines and music with headphones.

Meals will be provided, but you may want to bring in snacks and drinks. (No meals are provided for partners). You may also wish to bring your own pillow or other home comforts.

Your birth partner can stay with you for the entire time. 

The three stages are:

1. The cervix (neck of the womb) needs to soften and open to 1-2cm. This is called cervical ripening.
2. The water in front of the baby’s head is broken (artificial rupture of membranes, or an ARM)
3. A hormone drip called syntocinon is started to stimulate contractions

First stage of induction: Cervical ripening

There are two methods that can be used to ripen the cervix:

1. Mechanical non-hormonal (inserted into the cervix), Dilapan is usually used at North Mid, but we also can use a ’Balloon’
2. Pharmacological (hormone) placed high in the vagina next to the cervix

A midwife or Doctor will offer to examine you and recommend which method may be better for you. At North Mid, we usually offer a mechanical method, Dilapan as the first choice.

Dilapan–S

Dilapan-S is a small rod that gradually increases in size and opens the cervix. It absorbs fluid from the tissues of the cervix, which softens and opens the cervix.

This method contains no pharmacological substances (medicine or drugs) and is known as mechanical induction.

Mechanical induction stimulates your cervix to release your own hormones (prostaglandins) that naturally ripen the neck of your womb.

The aim of Dilapan-S is to dilate your cervix so the water in front of the baby’s head can be released (broken).

The midwife or doctor will use a speculum to insert the Dilapan rods into the cervix, this may be uncomfortable and you can have pain relief if you need. Over the next 12- 15 hours the rods gently expand to open the cervix, you won’t be able to feel this. They can stay in place for up to 24 hours.

Removing the Dilapan

At the next assessment, the midwife will remove the Dilapan and assess the cervix. If the cervix is open, then you are ready to have the water broken. You will be offered a sweep, and asked to mobilise until the waters can be broken (this should be done within 6 hours).

If the cervix is not open, then you will be offered another Dilapan or Propess (see below).

Propess

This vaginal pessary releases hormones to ripen the cervix. It is placed high up in the vagina next to the cervix. It is like a small flat tampon. A string will be visible at your vaginal opening.

This stays in place for 24 hours, during this time you may have some contractions.

Common side effects (may affect up to 1 in 10 people):

• feeling of burning in the genital area
• Increased contractions of the womb
• The baby may become distressed and/or their heart rate could become faster or slower than normal (hyperstimulation)

We can treat this by removing the Propess and giving you medication to stop the contractions.

Removing the Propess

After 24 hours (unless reason there are reasons to do this earlier) the Propess will be removed and your cervix will be assessed. If the cervix is open by 1-2cm, then you are ready to have the water broken.

If the cervix is still not open after two rounds of induction agents, talk to the team about what you would like to do next.

Your options may include continuing with the induction, having a caesarean section or taking a break from the induction.

Second Step of Induction: Breaking the water

This is known as artificial rupture of membranes (ARM). A small hole is made in the bag of waters in

front of the baby’s head. This is done during a vaginal examination to release the amniotic fluid. It can be uncomfortable, so let your midwife or doctor know if you need pain relief. The procedure will be carried out on the Labour Ward. After the water has been released, you will be encouraged to mobilise. If contractions don’t start on their own, you will be offered the hormone drip.

Third Step of Induction: Hormone Drip

If the contractions do not start after the water is broken, synthetic oxytocin hormone (called Syntocinon) will be offered.

It is given through a cannula (plastic tube) in your vein. The syntocinon will be started very slowly and will be turned up until you are having strong, regular contractions. The midwife will turn up or turn down the syntocinon to get three to four contractions in ten minutes.

Whilst you are on the hormone drip, we will closely monitor the baby with continuous electronic

fetal monitoring (CEFM). It is important that we do this as the contractions can cause changes in the baby’s heart rate. Some women find the contractions with syntocinon more difficult and painful than with spontaneous labour. Discuss your needs with you midwife or doctor. You can also visit www.labourpains.org to read about pain relief options.

Pain relief and coping strategies

There are many ways in which women can cope with the strong powerful sensations of labour.

• Heat pack
• Breathing techniques
• Water: pool, bath, or shower
• Epidural
• Gas and air (entonox)

• Opioid injection (pethidine)

Outpatient induction

If you are assessed as suitable for an outpatient induction, you will usually be offered Dilapan-S. 

You will be asked to attend Maternity Triage at the North Middlesex Hospital for an initial well-being assessment for both you and your baby. 

The Dilapan-S rod(s) will be inserted using a speculum and you will be sent home for up to 12-15 hours with your Dilapan-S rods in place. 

If your pregnancy has complications that suggests an outpatient induction of labour is not recommended, you will be invited to stay at the hospital for additional checks. 

You can also choose to stay at the hospital if you would like to. 

What should I expect with the process of Dilapan-S induction of labour? 

On attendance, a midwife will: 

• Perform routine observations including blood pressure, pulse and temperature and ask you for a urine sample to test. 
• Feel your abdomen to check baby’s position and if the baby’s head is in the pelvis (engaged). 
• Perform a scan to check the baby is head down 
• Assess your baby’s wellbeing using electronic monitoring (CTG). 

If all is well to go ahead with the induction, the midwife or doctor will perform a vaginal examination in order to feel the cervix (neck of the womb). 

If your cervix is not already open enough to break the water, up to five rods of Dilapan-S will be inserted in the cervix. The rods will stay there for approximately 12-15 hours but can safely stay inside for 24 hours. 

Outpatient care 

If you are having an outpatient induction, then you will be advised to call maternity triage 12 hours after insertion of the Dilapan-S on 020 8887 3682. 

The midwife will then advise you when to come in. 

If you experience any of the following, please contact or come into maternity triage 

Tel: 020 8887 3682: 

• If you have any vaginal bleeding 
• If you have any concerns regarding your baby’s movements 
• If your waters have broken 
• If you begin to experience regular contractions 

• If you have any general concerns regarding you or your baby 

Please do not attempt to remove the Dilapan-S yourself. 

Please avoid bathing, vaginal douching and sexual intercourse while the Dilapan-S is in place. Showering is okay. 

When you come back to the hospital, the midwife will check to see if the cervix has opened enough to break the water. 

Once your cervix has dilated enough for your waters to be broken, you will be transferred to the Labour Ward to continue your induction of labour. 

When the membranes (sac of waters) around your baby are artificially broken, this may cause a surge of hormones that can cause contractions to start. You will be encouraged to mobilise for 2-4 hours after this procedure to encourage your body to start to labour. 

If labour or contractions do not start after the breaking of your waters, we will then offer the intravenous infusion of hormone (drip). This will build contractions over several hours. You and baby will be monitored closely during the process. 

If you have any questions, please don’t hesitate to ask your midwife or obstetrician.