Induction of Labour (IOL)
Date issued: April 2022
For review: April 2024
Ref: B-122/SF/Mat/Induction of Labour v6
PDF: Induction of labour final May 2018 v4.pdf[pdf] 207KB
What is Induction of labour?
Your team of doctors & midwives feel that there is a need to start your labour. Although the reasons for this will have been discussed with you please feel free to ask again if you are in any doubt or have further questions.
Induction of labour (IOL) is the process of starting labour artificially. Over 36% of the births at Derriford Hospital are induced (this is similar to other parts of the UK). On average, 81% of these women who are induced achieve a vaginal delivery at Derriford Hospital.
Your labour will be induced by using one of the following methods:
• Propess (Hormone Pessary)
• Cervical Ripening Balloon (CRB)
• Artificial Rupture of Membranes (ARM)
• Oxytocin (Intravenous Hormone Infusion)
Complications of Induction are rare, although all inductions carry risks. These can be failure to induce the labour or causing your uterus to contract too much. Induction is also associated with a longer hospital stay and a greater demand for epidurals in labour.
Prior to induction
Membrane Sweep
A membrane sweep can be performed during a vaginal examination. The midwife or doctor will insert two fingers into the cervix and perform a circular sweeping motion to encourage the membranes to separate from the cervix. It can be uncomfortable and you may experience a small amount of bleeding following the examination.
A membrane sweep may increase your chances of going into labour on your own and therefore avoid a formal induction of labour that we frequently recommend to prevent you from going too far overdue. If you do not go into labour on your own, your midwife or doctor may arrange for you to come into hospital to try an alternative method of induction.
Membrane sweeps are offered around your due date, 40 weeks if it is your first baby and at 41 weeks if you have had a vaginal birth before. They can be performed before this time but there is less chance of it being successful.
A membrane sweep may be performed in the community or hospital. Depending on your individual circumstances you are not required to be admitted to hospital following a sweep.
Methods of induction
Propess Pessary
Propess is a thin flat pessary which contains a hormone to help induce your labour. The pessary is inserted by your midwife into the vagina and can stay in for up to 30 hours. The pessary has a string attached to it so it can be removed easily if required but you need to be careful that you do not remove it by mistake, especially when going to the toilet, moving around the bed or when washing. The string can be safely tucked inside the vagina. Propess works by ‘ripening’ your cervix (neck of your womb), encouraging it to soften, shorten and begin to open. It is normal to experience some period type pain, back ache and tightening’s and we recommend regular paracetamol, mobilising and a warm bath to help ease this discomfort. Some people may experience mild side effects such as nausea, dizziness and palpitations.
Before having the pessary your midwife will monitor the baby’s heartbeat using sensors attached to your abdomen (CTG). The CTG will be repeated when you start having painful contractions. After the pessary is put in you will be asked to stay in bed for half an hour, after this you will be free to move around or even go home if this is what you have chosen.
You will be reassessed vaginally to see if there is any change in your cervix (e.g. whether it has shortened in length or opened/dilated) at 24 hours following insertion to check that it is possible to break your waters. If it is not possible to break the waters then we may use a different method of induction or even discuss a caesarean section. Occasionally if there are delays in transferring you to central delivery suite you may be offered a second pessary or even the opportunity to go home.
Occasionally the pessary is all that is required for you to go into labour.
Cervical Ripening Balloon
A Balloon catheter is a mechanical device which helps to ripen and dilate your cervix by applying constant and gentle pressure using two fluid filled balloons. Some women prefer this option as it does not involve any medication initially.
The device is inserted vaginally, generally with the use of a speculum and stays in for 12-18 hours. The balloon catheter can be used as an alternative to Propess or may be recommend if a Propess is not clinically suitable and we cannot already perform an artificial rupture of membranes (break your waters).
Most women only report minimal discomfort during insertion but you can ask for Entonox (gas and air) if you wish. Following insertion you are able to mobilise as normal and rest as needed. The tail end of the balloon can be tucked into your underwear; some women wear two pairs on knickers with the tail tucked in between them so that it does not rub against their skin.
Some women who are thought to be suitable chose to go home with the balloon catheter in.
The balloon catheter may occasionally fall out and this often means that your cervix has opened up enough for the membranes to be broken. If it does not fall out the balloon is removed by simply releasing the fluid.
Artificial Rupture of Membranes (ARM)
An ARM may be performed to either start or continue your induction (e.g., if you have Propess or a cervical ripening balloon beforehand).
It is performed during a vaginal examination by a midwife or a doctor on Delivery Suite. Your cervix has to be open or dilated to be able to perform an ARM. The aim is to make a hole in the membranes to release some of the amniotic fluid surrounding baby. It is hoped that this will stimulate your labour and make your contractions stronger.
If we cannot perform an ARM we may try an alternative method of induction of labour.
Oxytocin
Oxytocin is a hormone which is given via a drip to help stimulate your uterus/womb to start contracting. The level of Oxytocin can be adjusted so that your contractions occur regularly until your baby is born.
You and your baby will be continuously monitored on Delivery Suite by midwives and doctors. Although you will have an intravenous infusion and fetal heart monitor attached to you - you will still be able to be move into different positions in labour and this is something that we would encourage.
Frequently asked questions
Where will the Induction of Labour take place?
Where your induction of labour takes place depends upon different factors about you and your baby. Apart from a membrane sweep (which you can have in the community) the induction process will be started on Day Assessment, Argyll Ward or Delivery Suite.
After the induction process has been started most women will then either be offered the chance to go home or be admitted to Argyll Ward if necessary. If you are suitable to continue the early stages of your induction at home we will provide you will a follow up appointment and relevant contact numbers if you have any questions or concerns. Some women are not offered the choice of going home for various reasons such as living too far away or being too high risk.
If you need more frequent monitoring during the induction process you may be cared for on Delivery Suite.
How long does Induction of Labour take?
Induction of labour can be a lengthy process which can sometimes take several days, labour and birth can be unpredictable. If you are ready to go to Delivery Suite and it is busy, there may be a delay with your transfer. We will make sure that you are comfortable and you and your baby are safe until Delivery Suite can accept you. If you have any questions or concerns just ask your midwife.
Does Induction of Labour hurt?
You may find vaginal examinations uncomfortable but this should only be during the examination itself. The induction process may initially cause uterine contractions similarly to if you went into labour yourself. As labour naturally progresses or as the hormone drip is increased, women do experience increased pain.
You will have different pain relief options available to you and you should discuss these with your midwife.
Will my birthing partner be able to stay with me if I stay in?
Your partner will be able to be present with you when the Induction of labour process is started. Women who need to remain in hospital are then moved to Argyll Ward where we welcome one birthing partner to stay with you for support overnight. Please note at present, only a comfortable chair for a few can be offered for rest. You may need your birth partner more once your labour establishes and we cannot provide much comfort for them, sometimes it is better for them to be well rested at home.
Please be aware that all meals and refreshments for partners are not provided and showering facilities are for patient use only. Partners are reminded to keep noise to a minimum and be respectful; other women who have been admitted with complications, early labour or just given birth may not be so pleased to see them on the ward as you. We ask that partners limit their access to the ward as on every occasion, the call bell must be activated and this takes staff away from performing their regular duties.
Visitors to Argyll other than birth partner:
2 visitors only between 4pm – 7pm
Own children: 8am – 10pm
(No other children permitted on the ward under the age of 16 due to infection control)
Please note restrictions due to Covid-19. Refer to the Trust web page for updated visiting arrangements
Delays
Due to the nature of maternity care, there are occasions when your induction of labour has to be delayed or postponed, or there may be some delay in transferring you to the delivery unit. This is because it is impossible to predict the number of women who will go into labour at any one time, or when emergency admissions occur. If this happens we will keep you informed as much as possible and try to continue with your induction as soon as we can. We may offer monitoring of your baby while you are waiting to be admitted.
We therefore advise that you make preparations and childcare arrangements not just for the day of your induction but for several days afterwards
What to expect
What happens on the day?
You will be given a date and time to attend Day Assessment Ward on level 6 (through the Lancaster Suite), Argyll Ward on level 7 or Delivery Suite on level 4.
Please bring your hospital notes with you for every visit and bring your hospital bag in case you need to stay in.
During your visit to the hospital you will have a heart trace of baby (CTG) that will last at least 30 minutes and a full antenatal check including observations, palpation of your abdomen and an internal vaginal assessment. The midwife will need to check through your notes and complete a checklist on the induction process.
On completion of this assessment you will either be sent home with clear instructions, a follow up appointment and relevant contact numbers or admitted to Argyll ward.
Things that may help when you start to contract
• Make sure you eat and drink as usual
• Rest and sleep as much as possible, an induction is frequently a slow process
• Keep an adult with you at all times if you go home
• Make sure your phone is charged, accessible and in service at all times
• Make sure that you pass urine regularly
How to cope with contractions
• Have a warm bath (be careful with the pessary)
• Take long deep breaths through the contractions, focus on breathing out
• Try sitting on a birth ball
• Emotional and physical support from your birth partner can help
• Listen to music
• Stay mobile & change positions. Allow gravity to aid your labour.
What and when to report
If you experience any of the following you must advise a midwife on the ward (inpatient) or call Maternity Triage 01752 430200 if you are at home:
• Bleeding (more than a show which is a mucous pink loss).
• Ruptured membranes (waters broken)
• Concerns with the baby’s movements
• Contraction pain that you cannot cope with (feel free to take paracetamol at home)
• Constant pain (occasionally your uterus can contract too much, you may experience prolonged contractions that last over 2 minutes or that occur more than 5 times every 10 minutes).
• If you feel particularly anxious and feel that you need support.
• Concerns over the side effects from the pessary (it can occasionally cause some nausea, dizziness and palpitations which are normally mild, if you feel worried or feel unwell then please let us know.)
• If your Propess or balloon catheter falls out.
If you are an outpatient, you may be asked to return to the hospital for assessment sooner than originally planned. Please return to triage on level 4 where you will be reviewed by a midwife and your induction of labour will continue.
Induction of Labour following spontaneous rupture of membranes (SROM)
Pre labour spontaneous rupture of membranes at term (37-42 weeks) occurs in 8-10% of all pregnancies. On average, 60% of women will go into spontaneous labour within 24 hours of waters breaking. A full assessment of you and your baby will be undertaken including observations, abdominal palpation and fetal heart rate. A management plan will be made by a midwife or doctor and if appropriate, you may be offered one of the following options:
• Active management with induction of labour. Induction starts as soon as possible with a Propess pessary. This pessary would stay in for 6 hours and you would be moved to Delivery suite as soon as possible. Delays can occur and the pessary may stay in for up to 24 hours with safe and appropriate care on Argyll ward. Upon transfer, if labour has not progressed, a drip will be inserted and Oxytocin will be commenced to continue the Induction.
• Expectant management - You will return home and await labour to progress. A designated time will be given to you to re attend 18- 24 hours after your waters have broken for induction (as detailed above) with a Propess pessary. Whilst you are at home you will need to monitor your baby’s movements and report any signs of infection. This could mean that you feel generally unwell, becoming hot or shivery with flu like symptoms. You will be provided with disposable thermometers to monitor your temperature 4 hourly. The colour of your waters may also change to be brown/ green or heavily blood stained or may even smell. If you notice any of these changes, you must call triage and come back in. You would also call triage if you start to contract regularly.
• You may change your mind whilst at home and decide to have active management. Please call maternity triage and they will discuss and arrange this for you.
Please see the table below for the risk factors for both expectant and active management of ruptured membranes.
Immediate management Expectant management
Pain experienced Increased Decreased
Risk of Neonatal infection 0.50% 1%
Risk of Caesarean section or instrumental delivery No Difference No difference
Length of stay in hospital If delivered within 24 hours can go home If delivered after 24 hours will need to stay for neonatal observations
Mum and baby will both be observed for at least 12 hours for any signs of infection after delivery if the time period of ruptured membranes to delivery is greater than 24 hours.
Date to come in for IOL:________________________
Time to come in:______________________________
Where to attend:______________________________
If you have gone home for the early stages of your induction, please report any of the following:
• Contractions
• Constant pain
• Concerns regarding fetal movements
• Feeling unwell
• Bleeding
• If your waters break and/or the colour of your waters is brown/green or heavily blood stained
• If the pessary or balloon catheter falls out
Please contact Maternity Triage on: 01752 430200
Date to return for reassessment:_________________
Time to come in for reassessment:_______________
Where to attend:____________
