Vaginal Birth

Induction of Labour Options

Induction of labour is a choice that more and more parents are being asked to consider. As with everything we do, this article has been written to educate about what induction of labour is, what options there are and how...

Emiliana Hall

Induction of labour is a choice that more and more parents are being asked to consider. As with everything we do, this article has been written to educate about what induction of labour is, what options there are and how to make an informed decision on whether to accept an induction.

It is worth noting not all methods will be available in all hospitals, and certain methods may not be suitable for their circumstances. But it is a good idea that they know all of their options so they can work through them with their care providers.

Use BRAIN acronym to have a conversation with your medical team and make sure you have all of the information to make an informed decision about your care:

B – Benefits, what are they? (proven benefits are needed here)

R – Risks, what are they? (we need pure numbers and not just ‘the risk increases’)

A – Alternatives, what are they? (there are always alternatives available)

I – Instinct / intuition, what is yours saying, now that you know the above?

N – Nothing, what if you were to do nothing and wait for a few minutes, hour, days or weeks?


Let’s go through the types of induction and things to consider:

 

Non-Medicated Options:

Stretch and sweep

The cervix is the opening of the uterus and the part that opens, or ‘dilates’ when labour starts. Imagine a balloon as the uterus, and the opening of the balloon is the cervix. Vaginal examinations are offered to feel whether or not the cervix has started to soften and open. If it is not open or ‘ripe’, you may then be offered a ‘stretch and sweep’ where the midwife would use 2 fingers to sweep across the cervix to stimulate it to open and start labour. This usually happens at your doctor’s surgery or wherever you have your antenatal appointments and you are then allowed to return home. This process can be repeated if you wish.

Things to be aware of:

This option is sometimes framed as a ‘quick sweep’ which can make it feel like there can be no harm in doing it. In some cases, this may well be true. In others, it could interfere with the steady hormonal build up to labour and have an impact on how it then starts and progresses. It can feel very intrusive at a time when we need to be feeling safe and supported. There is also a risk of introducing infection or breaking waters prematurely, despite the fact your midwife should be taking every care to avoid both of these risks.

We cannot know how many people go into labour because of a sweep vs how many would have gone into labour anyway as it is a very difficult area to study. As will all options, consider why you are being offered a sweep and whether there is a good reason to accept one vs. the risks involved.

Dilapan rods

Dilapan-S® is a slim rod made of a synthetic firm gel. Usually 3 – 5 rods are gently inserted together into the cervix and absorb the fluid from the surrounding tissue. Each thin rod will gently expand up to 14 mm over 12 hours. When the rods grow, they dilate and soften the cervix to help prepare for labour.

Parents can go home with this method as it is non-medicated.

Things to be aware of:

We cannot know how many people go into labour because of the use of the rods vs how many would have gone into labour anyway as it is a very difficult area to study. As will all options, consider why you are being offered an induction and whether there is a good reason to accept one vs. the risks involved.

Artificial rupture of membranes (ARM)

If your cervix has started to open but waves (contractions) are still not strong and regular, you could be offered to have your waters broken.

For those who don’t need the vaginal hormone, or particularly those who have birthed before (the cervix sometimes remains open a little), they could begin with this stage and skip the cervical ripening stages of induction.

To break the waters, the midwife uses a plastic hook, a bit like a crochet needle, which is inserted into the vagina and carefully through the cervix, to break the amniotic sac around baby, at which point the parent will feel a gush of warm amniotic fluid being released.

Things to be aware of:

Although breaking your waters is usually a straightforward process, it can increase the risk of cord prolapse, bleeding and infection. It can also cause distress to baby. Your doctor or midwife will take care to avoid these things from happening and are trained to deal with any emergency that might happen. But it is so important to decide on whether you go ahead using the BRAIN acronym.

Foley bulb / balloon catheter

Another non-medicalised method of induction at this stage is a Foley bulb induction. It involves inserting a device into the cervix to help it open so that the baby can pass through the birth path. It is a long, rubber tube with an inflatable balloon on one end that a doctor can fill with air or sterile water. It puts pressure on the cervix to open and encourage surges. This cannot be used if waters have released.

https://www.buckshealthcare.nhs.uk/birthchoices/pifs/induction-of-labour-with-cervical-balloon-foleys-catheter/

 

Hormonal Medicated Options:

Prostin (prostaglandin hormone) tablet or gel

If your cervix is closed, another way to encourage the cervix to soften and open is a prostaglandin hormone being placed into the vagina either as a tablet or gel which slowly releases the hormone over 24 hours.

This is done at hospital. Before giving you Prostaglandins your Midwife will check your baby’s heartbeat; this is done using an electronic fetal heart rate monitor known as a CTG for at least 20 minutes. Depending on the reason for your induction this will be repeated at intervals throughout the induction process.

The Prostin Gel or Prostin Tablets are given every 6-8 hours and are very safe, although most people will unfortunately experience some pain/discomfort following the administration of the Prostin. For a small number of people the pain can be more severe.

Things to be aware of:

Prostaglandin sometimes causes vaginal soreness.

A small number of people experience some reactions such as nausea, vomiting or diarrhoea.

Very occasionally, prostaglandin can cause the uterus (womb) to contract too much. If this happens, you will be given further medication to relax the uterus.

A small number of people will not respond at all to the Prostaglandins and it would be deemed as the “induction failing”, (note it is the induction that has failed, and not you). In this instance the medical team should discuss your options with you. These will very much depend on you and your baby’s wellbeing.

Propess (prostaglandin hormone) pessary

If your cervix is not quite ripe, a pessary called Propess could be offered to try and ripen it. The pessary looks like a small tampon, which is inserted into the vagina during an internal examination by the midwife or doctor. The Propess pessary contains the active ingredient dinoprostone, which is a naturally occurring female hormone also known as prostaglandin. Once inserted into the vagina the pessary will stay there for 24 hours slowly releasing the hormone to ripen your cervix. There is a string attached to the pessary to allow for easy removal. The string sits inside your vagina.

After the pessary has been inserted into your vagina you will be asked to lie on your side for 30 minutes. This allows the pessary to absorb moisture from your vagina, which will make the pessary swell and prevent it from falling out.

Before and after the Propess has been inserted we will check your baby’s wellbeing by monitoring his or her heart rate pattern using a machine called a Cardio Toco Graph (CTG). After about 60 minutes if all is well, you can move around and then after a few more minutes you may go home and wait for your labour to start.

You will be asked to return to the ward about 24 hours after the Propess was inserted for another assessment should you not go into labour spontaneously.

The hospital will recommend that once your labour starts you should come back to the maternity unit so they can support you during your labour and birth. They would not recommend you have a home birth if you are having your labour induced as you have been given medication it is important that we monitor you and your baby for the possible side effects.

This information has been sourced from the link below, where you can find further information on this option:

https://www.esht.nhs.uk/wp-content/uploads/2017/06/0512.pdf

What are the benefits of using Propess pessary rather than using Prostin tablets?

Prostin tablets are inserted behind the cervix during an internal examination at frequent intervals until your cervix is open enough to have your waters broken or you have gone into labour. However; the main advantage of Propess is that you will have less vaginal (internal) examinations, minimising discomfort. Once Propess is inserted if all is well with you and baby, you can go home and await labour to start although it will be recommended that you return to the maternity unit to birth baby so you and baby can be monitored.

This is a helpful article that goes more in depth to the differences too:

https://www.britishjournalofmidwifery.com/content/research/propess-versus-prostin-there-is-an-alternative-way-to-induce-labour/

 

Hormone drip ( known as the brands Pitocin® or Syntocinon®)

If the previous methods do not bring labour on or are not suitable for your circumstances, you may be advised to move to a medicalised induction and have a continual drip of a synthetic form of the oxytocin hormone which goes into a vein in the hand.

This should increase the strength and length of waves (contractions) until your cervix is fully open. The synthetic hormone is a strong drug and baby will need close monitoring of their heartbeat to make sure that they remain happy throughout labour.

Things to be aware of:

– Your ability to move around will be limited by the drip and CTG machine.

– Very occasionally, oxytocin can cause the uterus to contract too much too quickly. If this happens, you will be asked to lie on your left side and the drip will be adjusted or stopped. Another drug may be given to reduce the contractions. This may be done if there are concerns about baby’s heartbeat. Doctors and midwives are trained to deal with these issues but it is also important to consider the emotional effect that these risks can have.

– If your induction is with oxytocin, you will be unable to have a water birth which is important to consider if this was your preference.

 

As with every intervention that is offered during birth, encourage parents to use their BRAIN, have the conversation and make sure they feel completely comfortable and at ease with their decision.


Commonly asked questions:

A decision may be made to change your method of induction on the day of your induction. After a vaginal examination, changes to your cervix may mean that another method of induction is more appropriate. Your doctor or midwife will discuss this with you.

How long will it take?

There is absolutely no way anyone can say how long it will take for about to start (or how long the labour will last) with any of these options. Once a medicalised induction has started, you would be monitored regularly. You can walk around but you must not leave the hospital. Your cervix is assessed regularly to check its progress. Induction is not a quick process. Once it has started, it may take more than 24 hours until your baby is born. If your cervix needs to be primed, it may take much longer.

Can you change your mind after induction has started?

Once a medicalised induction has commenced, it is expected to continue until baby is born but it is of course completely up to the parent to make that decision.

Will it be more painful than labour without an induction?

Every labour is different. For some, an induced labour is more painful than a labour that starts on its own, however this is not true for everyone. Epidurals are often offered and should be available if needed.

Will it work?

Sometimes induction does not work and you may not go into labour. If this happens and all options have been tried, a caesarean abdominal birth may be offered. Baby’s can react adversely to the induction process- perhaps because the process has been pushed along too quickly or any continual monitoring has restricted the parents positioning and not given them the space to move down the birth path. It is a very complex process that should not be accepted lightly, as we just don’t know how the interventions may impact the process at the later stages.

 


Recommended reading, if you are considering any methods of induction:

The National Institute for Health and Care Excellence (NICE) provide national guidance and advice to improve health and social care. Before reading about the methods, please read the NICE guidelines on induction here:

https://www.nice.org.uk/guidance/ng207 (approx 30-45 min read)

 

Dr Sara Wickham’s resources:


How we support induction education in our courses:

– We cover induction in our group and private courses.

– You also get access to your teacher via WhatsApp to ask any questions closer to the birth as usually, you won’t be needing to make a decision on induction methods until you are much closer to your estimated due date.

– We have a whole library of recommended links and resources in relation to induction methods to help you to make an informed decision and have a positive induction experience if you choose to accept one.

Find a course with us to support your personal birthing and postnatal experience here.

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