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Induction of labour

In this booklet you will find information about induction of labour to help you come to a decision about what is best for you and your baby

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(Inside front page) This leaflet:

• gives information to help you make choices about induction of labour

• presents the risks and benefits of induction of labour

• provides information on how labour is induced

It is your right to be fully informed and to take an active part in the decisions about what happens to you and your baby. If you would prefer to be examined by a female doctor, please ask, but this cannot be guaranteed. Questions you might want to ask your healthcare team when discussing the possibility of having an induction of labour: • Why am I being offered an induction of labour? • What are the alternatives ? • What happens if I choose not to be induced ? • What are the benefits of an induction to me or my baby? • What are the risks of an induction to me or my baby, and how likely are they? • Does it mean I will have more examinations by doctors and midwives ? • Can I be induced at home? • How is an induced labour different from a normal labour? • What pain relief is available and when can I have it? • Where can I find scientific research and evidence to help me make a decision?

If after discussing your options with your midwife and your doctor you feel you would benefit from more advice or support, your midwife can arrange for you to be seen by another member of the maternity care team.

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What is induction of labour ? Induction of labour is when labour is started artificially. Why is labour induced? Your estimated due date is a marker of the time when the majority of babies are born (40 weeks). Pregnancy length, however, is anything from 37 to 42 weeks with some babies being born before and after that time.

The risk of stillbirth is very low in pregnancy (around 2 in 2000 at 40 weeks). Beyond 42 weeks, the risk remains low but increases to around 6 in 1000.

If labour has not started naturally by your estimated due date then induction of labour will be discussed with you. The midwife or doctor will explain the reasons why they think induction of labour is advisable and they will make sure that you understand their reasons and answer any questions you might have. They will discuss any other options that you have. You may find the questions listed at the beginning of this leaflet helpful when discussing the options with your midwife or doctor.

Induction of labour may also be offered towards the end of your pregnancy if:

• You have a medical condition such as pregnancy-induced hypertension (high blood pressure) or diabetes.

• There is concern over the well-being of your baby.

• The membranes (waters) have broken. Often labour will start when this happens. If labour has not started after 24 hours this may increase the risk of infection to you and your baby and so induction of labour will be offered to you.

• You are aged 40 years or over.

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What happens if I choose not to be induced?

If you do not want to be induced at the time at which it is recommended, you should tell your midwife or doctor. You will be invited to attend the clinic or hospital for the team to check how you and your baby are. How often you come to the hospital depends on your situation. The midwife and doctor will discuss this with you.

You may be offered a membrane sweep to try and help you go into labour by yourself. Like any other intervention, this is your choice and you will be able to ask any questions you may have about the benefits and risks.

If you do not go into labour and decide to have an induction later, you may have to stay in hospital during your induction for regular checks and monitoring.

What is a membrane sweep?

You will be given an appointment to see your community midwife or a hospital appointment to see a doctor. At this appointment the midwife or doctor will assess your general wellbeing, and that of your baby. She or he will feel your abdomen to see how your baby is lying and will ask about your baby’s movements. She or he may then suggest you have an internal examination to assess the cervix (neck of the womb), and may offer you a ‘membrane sweep’.

During a membrane sweep the midwife or doctor places a finger just inside the cervix and makes a circular movement. This is to separate the membranes from the cervix. This increases the chances of labour starting naturally within the following 48 hours.

A membrane sweep may be uncomfortable, and you may have a ‘show’ later in the day. The ‘show’ is a plug of mucus, (sometimes brown or spotted with blood) which is released as the cervix begins to open. It should not cause heavy bleeding, and you should seek advice if heavy bleeding occurs.

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How is labour induced?

The following methods can be used:

1. Vaginal prostaglandin 2. Double balloon catheter 3. Artificial rupture of the membranes (breaking your waters) 4. Intravenous oxytocin to start your contractions and to keep your

uterus contracting.

1. Vaginal prostaglandin

Prostaglandin induces labour by encouraging the cervix to soften and shorten (known as ‘ripening’). It can be given in a slow-release pessary, which looks like a tiny tampon, or as a tablet or in gel form which are placed high in the vagina.

Two different types of pessary (Mysodelle or Propess) can be used depending on various individual circumstances. This will be explained and fully discussed with you at the time.

If you are given the pessary

Your baby’s heartbeat will be monitored using a cardiotocograph (CTG) machine before the pessary is inserted by a midwife and then for about half an hour afterwards. The CTG machine produces a printed graph (often called a ‘trace’) to show the pattern of your baby’s heart rate.

Once the prostaglandin is in place you can walk around, shower, eat and drink normally. Women who have had an uncomplicated pregnancy may be suitable to go home after a short period of monitoring (this is known as outpatient induction of labour). If you are suitable for outpatient induction of labour then there will be a telephone review after around 12 hours to check out how you are.

After 24 hours, if your labour has not started, you will be asked to return to the hospital where you will be examined. If your cervix is 2 cm or more dilated (opened), you will be transferred to the labour ward for your waters to be broken. If your cervix is not dilated, you will have a prostaglandin tablet or gel inserted as described below.

If you have a prostaglandin tablet or gel:

Your baby’s heartbeat will be monitored using the CTG machine before the tablet/gel is inserted by a midwife and then for about half an hour afterwards.

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After that you can walk around and eat and drink as usual but you will have to remain in hospital.

Sometimes the prostaglandin tablet/gel is enough to start labour, but if labour has not started after 6 hours you will need another vaginal examination. Your midwife will check on both you and your baby during this time. Insertion of the tablet/gel can be repeated on several occasions with a gap of at least 6 hours.

The use of prostaglandin may cause the womb to contract, and you may experience some period-type pains initially, which may then slow down and disappear, but usually they build up to more painful contractions. Sometimes prostaglandin is sufficient to start off your labour and labour then progresses naturally.

If your labour does not start or your cervix is not dilated enough to consider breaking your waters, you will be seen by a doctor to discuss your options.

2. Double Balloon Catheter

This is a mechanical, drug-free method of ripening the cervix, ideal for women who have had a caesarean section in the past or more than 3 babies.

Your baby’s heartbeat will be monitored using the CTG machine before the double balloon catheter is inserted by a midwife or doctor and then for about half an hour afterwards. If all is well you can go home once the double balloon catheter is in. You will be able to walk about, shower, eat and drink as usual.

You may feel some discomfort when the midwife or doctor puts the double balloon catheter in place but the procedure is not usually painful. You will be lying on our back during the procedure. Once the double balloon catheter is in place, one balloon will be inside the uterus (womb) and the other will be in the vagina. The balloons will then be blown up (by being slowly filled up with sterile fluid) and left in place for up to 24 hours.

After 24 hours, if your labour has not started, you will be asked to return to the hospital where the double balloon catheter will be taken out and you will be examined. If your cervix is 2 cm or more dilated, you will be transferred to the labour ward for your waters to be broken. If not, you will be seen by a doctor to discuss your options.

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3. Artificial rupture of the membranes

This is also known as ‘breaking the waters’, and can be used if the cervix has started to ripen and dilate to around 2 cm or more. A midwife will carry out an internal examination and will make a small hole in the membranes using a slim plastic instrument. Having the membranes broken should stimulate contractions.

4. Intravenous oxytocin

Oxytocin is a hormone given using a drip into a vein in the arm. It helps the womb to contract, and is usually used after the membranes have broken either naturally or artificially, and if contractions don’t start by themselves or are irregular. 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 CTG. The contractions can feel quite strong with this type of induction, but the midwife will be able to discuss with you how you are coping, and give you information about different methods of pain management.

How long does it take for labour to start ? Induction can be a slow process and it will often take a few days before labour starts. On the other hand, you should know that for some women labour starts and progresses very quickly. You may want to bring in books, magazines or a music/ film player to keep yourself occupied and relaxed during your time in hospital. You can also bring a mobile phone with you to keep in touch with your birthing partner. Does induction of labour make labour more painful ? Labour pains usually start slowly and build up to become closer together and more painful towards birth. Induced labours are likely to be more painful than a labour which has started by itself. There is some evidence that the natural painkillers (endorphins) produced by your body do not build up in the same way as they would have done if you had gone into labour by yourself.

The pain with prostaglandin is likely to be similar to the pain in early labour. As your labour establishes, the pain will become stronger. If you need to have an oxytocin drip the midwife will make sure it is increased appropriately depending on how your labour is progressing and how you are. You will always be cared for

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by a midwife, and she will support you in your choice of coping skills and pain management.

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What about my baby?

Plans will be made according to your individual circumstances to monitor your baby’s wellbeing throughout the induction procedure.

Can I have my baby in the Birth Centre if I have an induction ?

This is only possible for women with a pregnancy that is considered low risk and who -: - are induced at the Royal Infirmary of Edinburgh as outpatients - are induced because they are beyond their estimated due date - come back to the hospital in established labour with no complications

Can I have a water birth? Women who have an oxytocin drip cannot use the pool for birth.

Can I have an epidural before going to the labour ward? No. Epidurals can only be administered in the labour ward.

What happens if induction does not work?

If your labour does not start a doctor will discuss this with you. Your wishes and circumstances will be considered. You may be offered another course of induction. In some circumstances, you may be offered a caesarean section.

Where can I find references to guidelines? National Institute for Health and Clinical Excellence (NICE) - Guidance on induction of labour and Guidance on insertion of a double balloon catheter for induction of labour. www.nice.org.uk

Royal College of Obstetricians and Gynaecologists (RCOG) – scientific impact paper No 34 on induction in older mothers. www.rcog.org.uk

Where can I find more information? National Childbirth Trust (NCT) www.nct.org.uk Association for Improvements in Maternity Services (AIMS) www.aims.org.uk Birthrights www.birthrights.org.uk

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A summary: the benefits and risks of induction

Benefits of induction of labour

Induction of labour may relieve a medical condition (such as pregnancy- induced hypertension) which may otherwise get worse.

Pregnancy does not go beyond a date when the placenta may not function as well as it did earlier in the pregnancy.

Induction of labour may be performed to prevent you or your baby getting an infection if your waters have broken and labour has not started.

Risks or disadvantages of induction of labour

Once the process of induction is started it is not possible to go back. All the methods listed in this leaflet may be used.

It can take several days from starting the induction process to the start of your labour and then the birth of your baby

You may have several vaginal examinations.

The monitoring of your baby could restrict your movements and comfort. You may be able to stay more active if mobile monitoring is available, although this is also restrictive.

Labour could be more painful.

The process of induction of labour may not work, in which case the midwife and doctor will discuss the options with you, one of these could be a caesarean section.

Both prostaglandin and an oxytocin drip can cause the womb to contract too much. Drugs can be given to relax the womb but if they do not work you may have a caesarean section.

Women who have an induction have a higher rate of forceps or ventouse deliveries and a higher rate of caesarean sections but it is difficult to know if that would have happened anyway if they had gone into labour naturally.

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Sometimes your induction may have to be postponed – this is why:

Midwives and doctors understand that when your induction is postponed it can make you feel quite upset. When this happens it is usually because another woman or baby has an urgent need of care. Your induction of labour may also be postponed if the workload on the labour ward means there is no midwife available to care for you at the time you have been given. Circumstances in the maternity unit can change at any point in time and midwives and doctors will do their best to keep you informed. Our priority is to ensure that when we start your induction of labour we can look after you and your baby safely.

Sometimes if your booked hospital is too busy you may be asked to attend one of the other hospitals :

Royal Infirmary of Edinburgh: 51 Little France Crescent, Edinburgh EH16 4SA,

0131 242 1194

St John’s Hospital: Howden Road West, Howden, Livingston EH54 6PP, 01506 523000

Borders General Hospital: Huntly Burn, Melrose TD6 9BS, 01896 826000

Wishaw General hospital: 50 Netherton St, Wishaw ML2 0DP, 01698 361100

Forth Valley Royal Hospital: Stirling Road, Larbert FK5 4WR, 01324 566000

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What parents are saying -

“I was taken by surprise when I attended a routine appointment to check my blood pressure and was advised that I would have to be admitted immediately for induction. I felt better once I had been able to contact my partner who came straight away. It was a few days though before labour started and then I had to wait for a while before I could be transferred to labour ward as it was busy. The midwives were keeping us informed and it was not too bad. I am very happy with the care and support I received during labour and I was lucky our little boy was born without the need for any further interventions.”

“As my wife was overdue and there were still no signs of labour in spite of all our efforts (we never did so much walking!) we had a long discussion with the doctor and decided that it would be better for our baby to go in for an induction. The worst bit was all the hanging around waiting for labour to really start. We never thought it would be so slow! Once things got going it was amazing and I was able to hold our baby straight away … no words can describe what I felt.”

“In each of my pregnancies, my babies were born around 42 weeks. I was offered but declined induction each time as I felt that my baby was safe and that induction was unnecessary. I did regularly attend the hospital for checks to make sure that all was well with my placenta and with my baby. It was reassuring to see a midwife and know that everything was fine. In this way I could feel confident that I was making a safe choice for my baby. All my children were born safely and well, in their own time.”

“I had always hoped for a ‘normal’ birth but it was not to be as the doctors were worried about my baby. I was terrified and very disappointed when I knew that I was going to be induced. But I had a long conversation with the midwife and doctor and was able to ask all the questions I wanted, which helped me to relax. In the end, and even though I had a section, the whole experience of having my first baby was unbelievable and my little girl is fine and healthy.”

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Table of contents

What is induction of labour? Page 1 Why is labour induced ? Page 1 What happens if I choose not to be induced? Page 2 What is a membrane sweep ? Page 2 How is labour induced? Page 3 1. Vaginal prostaglandin Pages 3 & 4 2. Double balloon catheter Page 4 3. Artificial rupture of the membranes Page 4 4. Intravenous oxytocin Page 4 How long does it take for labour to start? Page 5 Does induction of labour make labour more painful? Page 5 What about my baby? Page 5 Can I have my baby in the birth centre if I have an induction? Page 6 Can I have a water birth? Page 6 Can I have an epidural before going to the labour ward? page 6 What happens if induction does not work? Page 6 Where can I find more information? Page 6 Summary: the benefits and risks of induction of labour Page 7 Why your induction of labour may be postponed Page 8 If your booked hospital is too busy Page 8 Parents’ testimonies Page 9

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Maternity Units phone numbers Royal Infirmary of Edinburgh: 0131 242 2657 St John’s Hospital: 01506 524 125 LOT270 Readability & Layout approved by NHSL Patient & Carer Information Group June 2018-Review June 2021