Induction of Labour

What is induction of labour?

During pregnancy, your baby is surrounded by a fluid filled membrane (sac), which offers protection while he or she is developing in the uterus (womb). The fluid inside the membrane is called amniotic fluid (See diagram).

Towards the end of your pregnancy, the cervix (neck of the womb) softens and shortens. This is sometimes called “ripening of the cervix”.

Before or during labour, the membranes rupture (break). This is often known as “your waters breaking”. During labour, your cervix dilates (widens) and the uterus contracts to push your baby out.

In most pregnancies, labour starts naturally between 37 and 41 weeks, leading to the birth of your baby. If labour does not start naturally, then your labour may need to be induced.

Induction of labour is a process designed to start labour artificially.

Induction of labour can only be started at the University Hospital of North Tees. Here Doctors are readily available, if needed.

The ultrasound scan taken in early pregnancy (dating scan), helps to decide your baby’s due date more accurately. This is the date that will be used when planning an induction of labour.

When is induction of labour advised?

If it is felt that your health or your baby’s health is likely to benefit, your Midwife or Doctor may offer and advise induction of labour. On average about 1 labour in every 5 labours are induced.¹

When induction of labour is being considered, your Doctor or Midwife will discuss your options with you before any decision is reached. This will include explaining the procedure and any risks to you or your baby.

Why might my labour be induced?

There are several reasons why induction may be offered or advised. Some reasons include:

• If you have diabetes.
• If you have pre-eclampsia (high blood pressure).
• To avoid your pregnancy lasting more than 41 weeks (overdue).
• If your waters break before labour starts.
• If your baby is expected to be small for gestational age on ultrasound scan.
• If you are expecting more than 1 baby.
• There are concerns around your baby’s movements.

There are times when induction of labour is not offered, as it is not the safest option for you and your baby. Reasons why labour may not be induced include:

• If you have had a previous caesarean section with complications.
• If your baby is larger than expected.
• For social reasons that are not medically indicated. You can discuss this further with your Midwife or Doctor.

If your pregnancy lasts longer than 41 weeks

Even if you have had a healthy, trouble-free pregnancy, you will be offered induction of labour. This usually happens around 41 weeks. After this time, the risk of your baby developing health problems increases.

Being induced because you are overdue does not increase the chance of you needing a Caesarean section.¹

If you choose not to be induced from 41 weeks, you will be offered:

• Twice-weekly checks of your baby’s heartbeat, using an electronic fetal monitor (called a Cardiotocography (CTG) monitor).
  
• An ultrasound to check the amount of amniotic fluid around your baby and the blood flow through the umbilical cord from the placenta to your baby.

What if my waters break before labour starts?

Sometimes your waters may break before labour starts. This happens in about 1 in every 20 pregnancies and is known as Pre-labour Rupture Of Membranes (PROM).²  The longer the time between PROM and the birth of your baby, the higher the risk of infection to you or your baby.²

If you are more than 37 weeks pregnant and your waters have broken, but you have not gone into labour you will be offered:

• Immediate Induction of labour

or

• A ‘wait and see approach’ (also known as expectant management) to see if labour starts naturally.  6 in every 10 women will go into labour themselves within 24 hours of the waters breaking.²

As a ‘wait and see approach’ carries a slightly higher risk of infection to you and your baby, you will need to check:

• Your temperature and heart rate every 4 hours when awake.
• For changes in the colour or smell of your amniotic fluid.
• Any other signs of fever, for example, shivering or feeling hot and cold.
• Any changes in your baby’s normal pattern of movements.

To minimise the chance of infection to you and your baby, induction is strongly advised if you have not started having regular contractions within 12 – 18 hours of your waters breaking.

If your waters have broken, you will be given a leaflet, ‘Spontaneous rupture of membranes before labour’. The leaflet explains about this in more detail.

How is labour induced?

There are a number of methods which can be used to induce labour. You may be offered 1 or all of the methods described in this leaflet.

Membrane sweep

This has been shown to increase the chances of labour starting naturally and can reduce the need for other methods of induction of labour. Membrane sweeping is usually offered routinely once your pregnancy is considered as being overdue.

Membrane sweeping involves a vaginal examination; your Midwife or Doctor then places a finger just inside your cervix. They will make a circular, sweeping movement to separate the membranes in front of your baby’s head from the cervix. It can be carried out at home, at an outpatient appointment in the community or in hospital.

The procedure can be a little uncomfortable and afterwards some women may have some slight mucus or blood stained loss from the vagina. This is referred to as a ‘show’ and will not cause any harm to you or your baby, nor will it increase the chance of infection.

There are some situations when membrane sweeping is not advised, for example, if your Midwife or Doctor suspects your membranes may have already ruptured.

If you have any concerns before or after a membrane sweep is performed, please contact your Community Midwife or the Maternity Unit for advice at any time. The contact numbers are in your hand held records and later on in this leaflet.

Using prostaglandins

Prostaglandins are drugs (also known as a pessary or vaginal tablet). They help to induce labour by encouraging your cervix to soften and shorten. This allows your cervix to open and contractions to start.

Prostaglandins are usually the first method of a medical induction.  

Your Midwife or Doctor will perform a vaginal examination and insert a pessary at the back of the vagina, behind the cervix. This is done in hospital, on either the Antenatal Ward or the Delivery Suite.

More than 1 dose may be needed to induce labour.  Doses can only be given at a minimum time of 6 hours apart. Only 2 doses can be given in a 24 hour period. Each woman responds differently to the prostaglandin. Some women only need 1 dose, others may need more.

Your baby’s heart rate will be closely monitored (checked) both before and after the prostaglandins are given, using an electronic fetal monitor known as a ‘CTG monitor’.

If there are no concerns with your baby’s heartbeat after 1 hour of the CTG monitoring, it will be stopped and you will be able to get up and move around as normal.

There is no evidence to suggest that labour induced with prostaglandins is any more painful than labour that has started naturally.¹

However, giving prostaglandins sometimes causes vaginal soreness, as they take effect you may feel some strong contractions of your uterine muscles. This may not mean labour has started, just that the prostaglandins are having an effect.

Your Midwife will help you decide what you can do to relieve any discomfort. Often keeping active, adopting different positions or having a warm bath may help.

A Transcutaneous Electrical Nerve Stimulator (TENS) machine (a handheld machine that delivers small electrical impulses to the body through electrodes placed on the skin that helps to reduce pain), or medications such as paracetamol or an injection may also be used.

If your labour does not start within 6 hours of having the prostaglandin, you will be examined to see if your waters can be broken artificially to stimulate (start) labour further. If this is not possible, a further dose of the prostaglandin will be given.

If after 2 doses of prostaglandin there is no sign of your labour starting or your cervix being open enough to break your waters, the on-call Consultant or senior Doctor will discuss with you when to restart the induction process.

This usually happens 24 hours after the first pessary was given. You will usually be advised to remain in hospital throughout the induction.

Depending on the reason for your induction, once regular contractions start your baby’s heartbeat will be either monitored intermittently using a doptone (hand-held baby monitor). Or by continuously using a CTG machine. Your Midwife will discuss the reason for this further with you.

Very occasionally, prostaglandins can cause the uterus to contract too much, which may affect your baby’s heartbeat. If this happens, your baby’s heartbeat will be monitored closely using a CTG machine. You may be asked to lie on your left side.

Sometimes medication is given to help relax your uterus and where possible, any prostaglandin remaining in your vagina will be removed.

Regular medicine rounds are carried out on the ward. If you require further pain relief outside of these times please ask your Midwife.

Amniotomy (artificial rupture of membranes or ARM)

Amniotomy is a way of artificially breaking your waters. You will not normally be offered an amniotomy as a first line management of induction unless your Doctor or Midwife thinks there may be problems with using prostaglandins.

You will be moved to a single room on the Delivery Suite for amniotomy.  An amniotomy is when your Midwife or Doctor makes a hole in your membranes to break the waters. This involves a vaginal examination. The Midwife or Doctor will insert a small instrument through your cervix and ‘pop’ your waters.

This will cause no harm to you or your baby, but may feel a little uncomfortable. Your Midwife will offer you Entonox (gas and air). This is to help with the discomfort if you feel you need it.

Your baby’s heartbeat will be monitored closely both before and after amniotomy. This is performed using a CTG machine.

Oxytocin

If your contractions do not start, a drug called Oxytocin is given once your membranes have broken; this encourages contractions.   Oxytocin is given through a cannula (a fine tube) inserted into a vein on the back of your hand or arm using a small fine needle.

Once contractions have started, the rate of the Oxytocin drip will be adjusted so your contractions are regular, until your baby is born.

If you have Oxytocin, you may wish to consider having an epidural to help with your pain. Your Midwife will discuss this with you.   Having Oxytocin will limit your ability to move around, you will be able to stand, sit in a chair or lie on your side, but will not be able to use the bath or leave the delivery room.

Your baby’s heartbeat will be monitored continuously while you are being given the Oxytocin.

Very occasionally, Oxytocin can cause your uterus to contract too much, which may affect your baby’s heartbeat. If this happens, you will usually be asked to lie on your left side and the Oxytocin drip will be turned down, or off to reduce your contractions.

Your Midwife will closely observe your baby’s heart beat on the CTG monitor and will inform the Doctor if she is concerned.

If you have already had prostaglandins, Oxytocin should not be given for at least 6 hours. Your Doctor or Midwife will discuss this with you before any decision is made. He or she will explain the procedure and any risks to you or your baby.

Your baby’s pattern of movement should not slow down or change. If you are concerned, please let the Midwife know immediately.

What if induction does not work?

If you do not go into labour after induction, your Midwife or Doctor will discuss this with you and make sure that your baby’s heartbeat and your vital signs (blood pressure, heart rate, temperature etc.) are normal.

Depending on your wishes and the situation, you may be offered another dose of prostaglandin or a Caesarean Section. The Caesarean Section may not be offered on the same day, this will depend on the well-being of you and your baby at the time.

If you are less than 39 weeks pregnant and decide you would like to opt for a caesarean section, you may be offered steroid injections to help mature your baby’s lungs.

The steroids reduce the risk of breathing problems that are more common for babies born by Caesarean Section. The steroids are given to you by injection; you will need 2 doses, 12 – 24 hours apart.

Eating and drinking

It is important that you maintain your strength during induction of labour, but large meals are not advised. Frequent, high carbohydrate, low fat meals and drinks are recommended.

If you feel nauseous (feel sick), you should try to sip fluids.  Water is fine, but non-fizzy isotonic drinks (such as Lucozade Sport) are a good source of carbohydrates. You will need to provide your own isotonic drinks.

Once you are in labour, you will be advised not to eat and will be given antacids (small oral tablets) to reduce the amount of acid in your stomach.

How can I keep my family and friends updates on my progress?

If your family or friends would like to make enquiries about your progress, it would be helpful if they could contact you directly.

Due to patient confidentiality, ward staff cannot discuss your personal information, nor how the induction of labour is progressing. 

You can use mobile phones on the Antenatal Ward but please respect other patients; mobile phones should be on silent at all times.

You can use Hospedia, a radio system at your bedside, which has a telephone, television, radio and internet. Some services are available free of charge. Hospedia cards can be purchased from machines in the main hospital corridors.

Is there anything I need to do before coming to hospital on the day of my induction?

Please telephone the hospital at between 7.00am – 7.30am on the morning of your induction of labour to confirm the time of your admission. See contact numbers at the end of this leaflet.

Is there any chance my induction may be delayed?

Although you are given a date and time for your induction to start, this may need to be changed, sometimes at short notice. If we are dealing with emergencies, or are very busy, any planned inductions may have to be delayed for a short time.

If this does happen, we will explain and rearrange as soon as possible. Please make sure that you provide the Midwife with your correct contact number at the time of booking your induction.

Some women may have problems and their induction may need to be started before others, please understand that staff will not be able to discuss other patients with you.

Please be assured, we only delay inductions in the interest of safety of all mothers and babies who we are providing care for.

Contact

If you have any further questions about your induction, please do not hesitate to ask your Community Midwife or telephone the Antenatal Ward or Delivery Suite.

University Hospital of North Tees

Community Midwives

Monday – Friday, 8.30am – 9.30am

Non-urgent messages can be left on the answering machine and will be picked up throughout day. If your call is urgent, you should contact the hospital where you are due to have your baby.

All women who live in the North Tees area, please phone Endurance House on one of the below numbers
Telephone: 01642 383440
Telephone: 01642 383439

Maternity Assessment Unit

Monday – Friday, 8.30am – 8.00pm
Saturday & Sunday, 9.00am – 5.00pm

Outside of these hours, calls are automatically transferred to Delivery Suite, North Tees.

Telephone: 01642 624239

Delivery Suite

24 hours a day, 7 days a week
Telephone: 01642 382718

Antenatal/Postnatal Ward

24 hours a day, 7 days a week
Telephone: 01642 382722

University Hospital of Hartlepool

Community Midwives

7 days a week, 9.00am – 10.00am
Non-urgent messages can be left on answering machine.
Telephone: 01429 522279

East Durham

Based at Peterlee Community Hospital
Monday – Friday, 9.00am – 10.00am
Telephone: 01429 522270

Maternity Assessment Unit 

Monday – Friday, 9.00am – 5.00pm
When the Unit is closed, calls are transferred to the Delivery Suite, North Tees.
Telephone: 01429 522879

Further Information

Royal College of Obstetricians and Gynaecologists
Telephone: 020 7772 6200
Website: www.rcog.org.uk

National Institute of Health and Care Excellence
Telephone: 0300 323 6200
E Mail: [email protected]
Website: www.nice.uk

References

1. Clinical Guideline 70, Induction of Labour, National Institute for Health and Care Excellence, London (2008) https://www.nice.org.uk/guidance/cg70

• Clinical Guideline 190, Intrapartum Care for healthy women and babies, National Institute for Health and Care Excellence (2017) https://www.nice.org.uk/guidance/cg190

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Leaflet feedback

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Leaflet Reference: PIL1089
Date for review: 22/07/2024