Induction of Labour

What is induction of labour?

Labour is a natural process that normally starts on its own but sometimes there are reasons for it to be started artificially. This is called induction of labour.
It’s your choice whether to have your labour induced or not.

How is natural labour encouraged?

Before you are offered induction, you may be offered a membrane sweep. A “sweep” has been shown to increase the likelihood of you going into labour naturally in the 48 hours after it is performed. A membrane sweep only takes a few minutes and can be carried out at your home, in clinic or on the ward.

A membrane sweep involves a vaginal examination by your Midwife or Doctor. This is an internal examination, where a finger is gently put inside your vagina and just inside the cervix (neck of the womb). The finger is moved in circular, sweeping movements touching the membranes (bag of waters) that surround your baby.

This can stimulate the cervix to release labour inducing hormones which are naturally produced by the body called prostaglandins. Despite being gentle, you may find a membrane sweep uncomfortable or painful. You can ask the midwife or doctor to stop at any time. You may also feel some period type pains afterwards.

It is very common to notice some blood staining or a “show” especially on wiping yourself or after going to the toilet. This is not harmful and should stop after a few hours. After the sweep you will be able to continue your usual daily activities. You may have more than one membrane sweep or none at all

What are the benefits and risks of induction of labour?

You may be offered an induction if:

• You are overdue.
• Your waters have broken.
• You or your baby have a health problem.

Your doctor or midwife will discuss with you your individual reason for induction of labour.

Labour usually starts before 42 weeks. In Leeds we offer induction of labour from 41 weeks.

Pregnancies that last longer than 41 weeks have an increased chance of:

• Birth by Caesarean Section.
• Your baby needing admission to a Neonatal Intensive Care Unit.
• Stillbirth or neonatal death.

Your doctor or midwife will explain by how much the chances of each of these outcomes increases past 41 weeks, to help you weigh up the risks and benefits of accepting an induction.

Offering induction of labour at 41weeks of pregnancy may reduce these risks, but induction is not without risk and can affect your baby and your birth experience.

Labours started by induction have an increased chance of:

• Reduced choice of where to have your baby, including the ability to use a birthing pool.
• Requiring more monitoring (e.g. continuous monitoring while lying on a bed).
• Being offered more frequent vaginal examinations.
• A longer stay in hospital.
• A labour that may be more painful than a spontaneous labour.
• Experiencing contractions that are too frequent and too long lasting (if using hormonal induction methods). This can result in stress for your baby, causing changes to their heart rate. This may be worrying and need closer monitoring.

An Induction of labour, when compared to waiting for spontaneous labour in lower risk pregnancies, does not significantly alter the way your baby is born. Most studies suggest no difference in the rate of emergency Caesarean section, with some suggesting slightly lower Caesarean rates, with a possible small increased chance of instrumental birth (ventouse or forceps). Instrumental births have an increased risk of complex vaginal tear which required repair in theatre as they involve the anal sphincter (bottom).

If an induction of labour has been recommended you will be informed of the reason why. The risks and benefits of this and any alternative options will be discussed with you to enable you to make a fully informed decision.

What if I decide I dont want to be induced

If you decide not to be induced an individual management plan will be made between you and your doctor or midwife which will be personalised to your needs. This may be waiting longer than 41 weeks for your labour to start spontaneously with the option of additional monitoring for you and your baby or you may choose to have an elective Caesarean section. In Leeds we offer induction of labour from 41 weeks as the risk of having a Caesarean, a stillbirth or neonatal death, or your baby being admitted to the neonatal unit increases in pregnancies that last longer than 41 weeks.
If you have decided not to have an induction of labour but have changed your mind, do not wait until your next appointment to tell us.

What happens on the day the induction starts?

Induction of labour is usually started on our Antenatal ward or Delivery Suite. You will receive a phone call on the day of your induction with a time to attend the ward to start your induction of labour. You may be suitable for induction as an outpatient.

Once you are on the ward, some routine checks will be performed on you and your baby including:

• Reviewing your pregnancy history and any test results.
• Checking your temperature, pulse, urine and blood pressure.
• Examining your abdomen to check the size and position of the baby.
• Monitoring your baby’s heart rate, with a CTG machine, usually around 20 minutes.

Next your midwife will:

• Discuss with you why induction has been recommended.
• Make sure you understand your plan of care.
• Answer any questions or concerns you may have.

How is labour started?

When trying to start labour the cervix needs to be open enough to break the waters around the baby (artificial rupture of the membranes). If your cervix is not open enough to allow us to do this, we have two methods to help your cervix open enough:

• Non-hormonal/mechanical dilator (Dilapan-S®).
• Hormonal pessary (Propess®).

What does induction with Dilapan-S® involve?

Dilapan-S® is a small rod. 3-4 rods are placed inside your cervix during an internal examination, sometimes a speculum is used.

It takes around 5-10 minutes to put the Dilapan rods in. You may find this uncomfortable or painful. You can ask your midwife to stop or pause at any time. You will be asked to lie down for 20-30 minutes after the rods have been put in place, after this you can move around and carry on as normal. We recommend you don’t have a bath whilst you have the rods inside. You may leave the ward for short period of time, but we ask you not to leave the hospital unless you are having an outpatient induction(see below). If you are leaving the ward, it is important you tell your midwife where you are going. Whilst the Dilapan-S® rods are in place you should not be aware of them. You should let the midwife know if you think the rods are falling out.

The Dilapan rods will stay in place for 12 hours. During this time they expand helping the cervix open slowly. After 12 hours they are removed and a repeat vaginal examination is recommended to see if your cervix is open enough for your waters to be broken. Your waters can be broken once there is availability for your care to continue on Delivery Suite.
At busy times there can be delays waiting for your waters to be broken. If delays occur, you will be kept up to date and you and your baby will continue to be monitored.

What does an induction with Propess® involve?

Propess is a prostaglandin pessary that is put inside the vagina, near the back of the cervix. Prostaglandins are naturally occurring hormones released when the body labours and after a membrane sweep. The aim of the Propess pessary is to soften and open the cervix, so the waters are able to be broken.

A Propess® pessary is put inside the vagina during an internal examination. A Propess pessary is a bit like a small tampon. It has a tape so that it can be easily removed.
Once the Propess pessary is inside we recommend you stay on the bed for 30 minutes. After this time, we encourage you to mobilise as this can help stimulate active labour. The Propess pessary has a string so please take care washing and going to the toilet so not to dislodge the pessary. You can get dressed and eat and drink as normal. You may leave the ward for short periods but check with your midwife that it is safe to do so and let them know when you will return.

You may be aware of period type pains which are less intense than contractions. These may get stronger or stop. If you are feeling uncomfortable, talk to the ward Midwife who will advise on what pain relief is available for you. The Propess pessary is removed once labour starts, at the end of the treatment time (24 hours) or earlier if required. After having the Propess pessary in for 24 hours an internal examination will be recommended to see if your cervix is open enough for your waters to be broken.

During this time the Midwife will review you regularly by:

• Checking your temperature, pulse and blood pressure.
• Asking about any pain or vaginal loss.
• Asking about your need for pain relief.
• Listening to your baby’s heartbeat.
• Continuous monitoring may be recommended for a time.

What is the difference between Dilapan-S® and Propess®

Dilapan and Propess are available for you to choose. However, sometimes one may be recommended over the other.

The main differences are:

• Dilapan-S® does not usually cause contractions, as it ‘mechanically’ dilates (opens) the cervix. This can be a less painful induction than Propess pessary induction.
• Dilapan does not contain any drugs or hormones- This may be recommended if you have had a Caesarean before, if you have had more than two children or if your baby is small and we are more concerned about the impact of contractions on your baby.
• Dilapan-S® seems to have a more reliable effect. On one hand this means we are more likely to be able to break your waters after 12-24 hours of its use when compared to Propess®. However, because it does not usually cause contractions it won’t start off labour, which can sometimes occur with Propess®. This means you are more likely to be recommended synthetic oxytocin through a drip to help with the contractions.
• The time from starting induction of labour to your baby’s birth is similar with both Dilapan and Propess pessary.
• Mode of delivery is similar for both Dilapan and Propess pessary.

If you have Dilapan or Propess pessary for your induction of labour it is important you tell the Midwife if you have any vaginal bleeding, think your waters have broken or feel unwell in any way.

Please be aware that if you begin the induction of labour process and require a hormone (oxytocin) through a drip, there is an increased chance that your baby’s heartrate will be affected. Therefore, your midwife will recommend continuous monitoring for your baby. Continuous monitoring cannot be performed while you are in a birthing pool, so we would not recommend you have a water birth.

What happens if the Dilapan-S® or Propess® doesn’t work?

If we are not able to break your waters then an individual plan will be made with you taking into consideration your personal circumstances and wishes. You may be offered a repeat treatment with either Dilapan,or Propess, or a hormone gel called Prostin. There is also the option of a period of rest before starting the induction again or you may be offered a Caesarean section delivery.

Outpatient induction of labour

You may be offered an outpatient induction. This gives you the opportunity to reduce the amount of time you spend in the hospital during the induction process.

You may be offered an outpatient induction if you meet the following criteria:

• You and baby are both well and observations are normal.
• You have previously had three babies or fewer.
• You have never had a Caesarean or other uterine surgery.
• You live within 30 minutes driving distance of the hospital and have access to a phone and transport.

If you are having an outpatient induction, you would come into the hospital on the day of your induction to have an assessment with a midwife. They will check that you and your baby are both well before starting the induction with either Propess or Dilapan. After this is inserted, if you and your baby are both well and you meet the outpatient induction of labour criteria, you will be able to go home for between 12 and 24 hours. After this time, you would return to the hospital and stay in for the rest of your induction until your baby is born. You can come back to hospital sooner if:

• You go into labour (having regular contractions).
• Your waters break.
• You have any vaginal bleeding.
• You have concerns about your baby’s movements.
• You feel unwell ,such as dizziness, vomiting, palpitations or fever.
• The Propess® pessary or Dilapan rods falls out.

If you have any concerns or questions whilst at home about your outpatient induction ring the Antenatal Ward at any time.

Antenatal Ward phone numbers (24 hours)

When you return to the Antenatal Ward you will be offered a vaginal examination to see if your cervix is open enough to have your waters broken or if further treatment is required.

What does breaking the waters involve?

If your cervix is open and the bag of waters (membranes) surrounding your baby can be felt then it is usually possible to break your waters. This is also called Artificial Rupture of Membranes (ARM).

Before breaking your waters, your baby’s heart rate will be monitored for about 20 minutes or longer if required. To break your waters, you would have an internal, vaginal examination. A long plastic device is gently inserted through the cervix alongside the examining finger.

This device has a specially designed tip which makes a hole in the membranes surrounding the baby and releases the fluid inside the womb. The midwife will check the fluid is clear and listen to baby’s heartbeat.

Once the waters are broken and baby’s head descends onto the cervix, some women may start to feel period type pains which may increase in intensity and continue to become contractions.

What is a Syntocinon® drip?

If your labour doesn’t start after having your waters broken, we would recommend you have a drug called Syntocinon®. This is given continuously into a vein in your arm through a ‘drip’ (cannula). Syntocinon® is an artificial version of the hormone oxytocin produced in your body. Oxytocin plays a part in helping contractions start.

The syntocinon® drip is administered on delivery suite so the midwife and Doctors can monitor your contractions and your baby’s heart rate closely. The Syntocinon® drip is started on a very small dose and increased gradually until you are having regular contractions. For your labour to progress we aim for you to have 4-5 contractions in every 10 minutes.

Sometimes syntocinon® drip can cause a lot of contractions close together. For this reason, we recommend your baby’s heart rate is continuously monitored with a CTG machine when you are having the syntocinon drip.

Sometimes Syntocinon® can make your womb contract too frequently which may affect your baby’s heart rate. If this happens the drip will be reduced or stopped to allow your contractions to slow down.

If this is your first pregnancy it is recommended that Syntocinon® is started as soon as we have broken your waters because it can take some time for your labour to start. If you have had a baby before it is recommended that the Syntocinon® drip is started 2-4 hours after your waters have been broken if your labour hasn’t started.

If you have any concerns or questions about this, please speak to your midwife.

How long will my induction take?

The induction process can vary a lot from person to person. It can take anything from a few hours to a few days from starting your induction until your baby is born.
Once your induction has started, we aim to continue your induction until your baby is born.

At times when the Delivery Suite is very busy, there may be a delay in your induction. This delay is necessary to make sure everyone receives safe care. You and your baby will continue to be offered monitoring during any delay to ensure your safety.

Your induction will re-start as soon as possible. If your induction is delayed you will be kept updated by your midwife or doctor. Should a delay occur, we apologise in advance and thank you for your patience.

What should I bring into hospital with me?

The induction process may take a number of days and to make your stay more comfortable you may wish to bring some additional items with you when you come into hospital, including:

• Hospital bag (containing your clothing).
• Toiletries.
• Books or magazines.
• Isotonic drinks.
• Snacks.
• Eye mask and ear plugs to help with sleeping on the antenatal ward.
• Your own pillow.
• Dressing gown.
• Slippers.
• Baby bag – include nappies and clothing, formula milk if you choose to bottle feed, hats, cotton wool.

Please only bring your car seat into hospital after your baby is born as space in the rooms is limited. It is important you do not bring valuables into hospital with you as they may get lost.

Is car parking available?

Car parking is available at both St James’s University Hospital and the Leeds General Infirmary. Parking is limited and expensive. We would advise that you ask a family member or friend to bring you to the hospital and, if possible, arrange for someone to take you home.

Will I get any meals provided?

Meals are provided for you while you are in hospital at the following times. You will be asked about your food preference and any dietary requirements. Meals are provided for you while you are in hospital at the following times. You will be asked about your food preference and any dietary requirements.

• Breakfast: 08.00 – 08.30
• Lunch: 12:00 – 12:30
• Tea: 17:00-17:30

Unfortunately, we do not provide meals for your partner, supportive adult or visitors. There are many cafés and shops where food and drink can be bought.

There are kitchen facilities on the ward where you can help yourself to tea, coffee and water.

Visiting Times on the Ward

Contact Details

Further reading