Induction of labour

It is important that you have enough information to make the right choice for you because having an induction of labour may affect other birth choices, for example, where you can have your baby.

About a third of women in the UK have their labour started by IOL. We offer patients IOL based on medical indications using the available evidence in line with national guidance from NICE ‘Inducing Labour’ guideline 2021. If there are health risks to the mother or the baby by continuing the pregnancy, having an IOL may be the best option. This is because having your baby earlier may be beneficial for your health and/or the health of your baby compared to continuing the pregnancy and awaiting spontaneous labour.

Postdates inductions in pregnancies without complications or low risk women

Women also have IOL if they are overdue – past the expected due date. Having an induction may affect other birth choices for example having your baby on a Midwife Led Unit, so it is important that you have the right information before deciding whether to have an induction of labour.

Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour. Routinely we offer postdates induction from 41 weeks. Continuing pregnancy past 41+0 week may increase some risks over time, including:

• Increased likelihood of Caesarean birth
• Increased likelihood of the baby needing admission to a neonatal intensive care unit (NICU)
• Increased likelihood of still birth and neonatal death

These risks are small, however you should also be aware that 99% of labours will have started spontaneously by 42 weeks. You can discuss what timing is right for you with your midwife or your doctor. It may also be possible to offer further monitoring in order to support your decision (although it does not necessarily predict the outcome for your baby).

Prelabour rupture of membranes (PROM) at term, and induction of labour

Your baby is surrounded by amniotic fluid or ‘waters’ contained within a membrane bag (the amniotic sac) inside your uterus. Normally your waters break shortly before or during labour. This can occur with or without contractions and is known as prelabour rupture of membranes (PROM). Approximately 8% of women will have PROM (NICE 2023).

What should I do if my waters have broken?

If at any point in your pregnancy you believe your waters may have broken, please call the Midwifery-Led Unit (MLU) / Triage (see useful contact details on page 3). They will advise that you attend the hospital so we are able to assess you and your baby. It is a good idea to wear a sanitary pad so that staff are able to look at the colour and the amount of fluid loss (this is called liquor) as this can tell us a lot about the wellbeing of your baby.

A full antenatal examination, which will include listening in to your baby, will be undertaken which will include questions about when you thought your waters had broken. The midwife may ask to look at your pad to confirm that your waters have broken and to check the colour of the fluid. If it is not clear whether your waters have broken or not it may be necessary to perform a speculum examination or a swab test which will confirm if your waters have broken or not.

Will I go into labour?

Induction of labour studies show:

• 60% of women and birthing people will go into labour naturally within 24 hours
• 91% of women and birthing people will go into labour within 48 hours

If labour has not started naturally after 24 hours, we recommend inducing labour.

Why is it recommended that I am induced?

With intact membranes the risk of a serious neonatal infection is 0.5%, this could also be described as a chance of 1 in 200. This risk increases to 1% in incidents of PROM at 24 hours before spontaneous labour has started, increasing to a chance of 1 in 100. Evidence tells us that the longer the time between your waters breaking and the birth of the baby, the greater the risk of infection for mother and baby (NICE, 2017).

Induction of labour is associated with a lower risk of infection and has no clear impact on the type
of birth and it does not increase your chances of needing a Caesarean section.

Signs of potential infection

You and your baby will be closely monitored throughout the whole process for signs of
infection.

If there are any concerns, the midwife and doctors will discuss this with you and possibly offer antibiotics. The following signs may be suggestive/indicate that you have an infection developing:

You develop a temperature of more than 37.5°C. We recommend that you take your
temperature at home every 4 hours during hours that you are awake and report any
temperature higher than 37.5°C.
• You or your baby’s heart rate becomes raised.
• Meconium (baby’s poo) is seen within the waters.
• You develop an offensive discharge.
• You have any abdominal pain.
• Change in baby’s movements.
• You are feeling feverish or unwell.

What are my options following PROM?

Induction at 24 hours

If there are no additional concerns or risk factors in your pregnancy, and your waters are clear, then we recommend waiting for 24 hours to see if your labour starts on its own. An induction of labour will be booked for you for 24 hours after your waters broke, and this will be undertaken on the antenatal ward – Dacre Ward. If your labour starts before then, we will cancel the induction of labour for you.

Immediate induction

An immediate induction of labour may be recommended by your doctor if there are additional risk factors or concerns about you or your baby’s wellbeing. Examples of indications for immediate induction include known Group B Streptococcus, having meconium-stained liquor, having active herpes or maternal infections such as HIV.

If there are concerns that there are already signs of infection, such as a raised temperature or concerns about the babies heartbeat, a doctor will discuss your situation with you in more detail.

You may wish to choose to have an immediate induction of labour and, if this is the case, please let the staff caring for you know and they will arrange this for you.

Expectant management

Some women may want to wait longer than 24 hours. If there are no risk factors identified, your waters are clear and your observations are normal, you will be able to go home to await spontaneous labour. We recommend attending the hospital at 24 hours post PROM to have another full assessment of you and baby if labour has not yet started. We will put a personalised plan in place with you regarding the next steps in your care, including listening into the baby, bloods and observations.

What if I choose to go home

What should I do?
• Try to move around as much as you feel comfortable.
• Shower/bath can help to help relax you or to ease any contractions.
• Eat and drink as normal.
• Rest as you feel you need to.
PROM at term and IOL – Page 2 of 4
• Please remember it is recommended to monitor you own temperature every 4 hours during
waking hours and contact the unit if you have any temperatures above 37.5°C.

When do I come back?
An induction will be booked on Dacre ward for 24 hours from when your waters broke. The exact
date and time to return will be confirmed with you prior to you going home.

You should also attend if you have any of the following concerns:
• Regular contractions / think you may be in labour (3 contractions in 10 minutes for more
than an hour).
• Continuous pain.
• Blood or meconium (baby’s poo) is seen (red or green/yellow colour) in the waters.
• Unpleasant smelling waters or discharge.
• Raised temperature more than 37.5°C.
• Any change in baby’s movements.
• You are feeling feverish or unwell.
• Any other concerns you may have.

Telephone either the Midwifery-Led Unit (MLU) or Triage (see contact details on page 3).

How will I be induced?

The most common method for inducing labour after ruptured membranes is to have a once only vaginal prostin gel. This is administered via a vaginal examination on Dacre ward. This gel works over a 6-hour period to help the cervix ripen (become softer and stretchier). Some women will go into labour with the prostin gel alone. Once the gel has finished working (after 6 hours), if you have not gone into labour, we will transfer you to the Consultant-Led Unit (CLU) for oxytocin – the hormone drip which is used to bring on contractions.

The oxytocin drip is controlled very carefully by the midwife caring for you, how much is used will depend upon your contractions and your baby’s heart rate. You will be monitored using continuous fetal heart rate monitoring whilst on oxytocin. This means that we can monitor your baby very closely and ensure that there are not too many contractions.

Some women are recommended not to have the prostin gel, for example, those who have previously had a Caesarean birth and wish to aim for a vaginal birth. In these situations, induction with the oxytocin drip alone is discussed and personalised plan made for you.

What happens once baby is born?

• If your waters have been broken for longer than 24 hours, it is recommended that we complete 12 hours of observations for your baby to rule out any signs of infection. This includes the heart rate, respiratory rate, and temperature.
• Some babies will have multiple risk factors for infection. These babies are recommended to have the same observations, but for 24 hours.
• If anything abnormal arises on any of your baby’s observations, baby will be reviewed by the Neonatal team.

All babies are monitored very closely following birth. If you have any concerns about yours or your
baby’s health, please do speak to a midwife or doctor about these.

Further information

• Tommy’s https://www.tommys.org/pregnancy-information/birth
For information about pregnancy, birth and after.

Useful contact details

East and North Hertfordshire Teaching NHS Trust:
• Website www.enherts-tr.nhs.uk
• Telephone 01438 314333

Midwifery-Led Unit (MLU), Lister Hospital:
• Telephone 01438 286197

Maternity Triage, Maternity Unit, Lister Hospital:
• Telephone 01438 286168Women also have IOL if they are overdue – past the expected due date. Having an induction may affect other birth choices for example having your baby on a midwife led unit , so it is important that you have the right information before deciding whether to have an induction of labour. 

Induction and the timing with your Obstetrician and midwife. Personalised care plans can be agreed and your choices always respected.

Other examples of indications for IOL include:

• Pre-existing medical conditions such as diabetes, high blood pressure
• Pre-existing risk factors such as age over 40 years old
• Conditions that have developed in pregnancy – some examples include gestational diabetes, pre-eclampsia, high blood pressure or obstetric cholestasis
• If there are any concerns about your baby’s movements or with the growth of your baby

When an induction is offered and the timing discussed we take into consideration how long the process can sometimes take. If we did not believe induction was a safe option for you or your baby then we would recommend a caesarean birth instead.

Induction of labour is a choice. You can chose to wait longer to see if spontaneous birth occurs or choose to have a Caesarean birth instead.

If you do not feel that the recommended timing of induction is right for you, then a personalised care plan can be made and additional monitoring may be offered as part of that plan. If you feel have a further discucssion would be benfical to you then appointments can be made with consultant obstreicans or consultant midwifes.

Adverse effects on baby (including still birth) cannot be reliably predicted or prevented with monitoring as it only gives a snapshot of the current situation, and it cannot predict any changes after monitoring ends, but provides information on how your baby is at the moment and so may help make a decision on options for birth.  If you feel a caesarean birth is something you would like to consider instead of an IOL, then the risks and benefits of these options can also be discussed with the team looking after you.

Outpatient induction of labour is an option available to women who are having a low risk induction of labour. It is where you are able to go home after the insertion of either the propess or the balloon for the first 24 hours.

This is something you can ask about when you are booking your induction with either the midwife or the doctors. The midwife doing the induction will re-confirm whether you are still suitable for outpatient management on the day of induction.

Benefits of an outpatient induction of labour include:

•  Reducing the amount of time you will need to stay in hospital before your labour begins.
•  Allows you to stay at home for longer, be surrounded by your own home comforts and this helps your natural oxytocin to be produced.
•  Means you are likely to remain more active in the day and get better rest in the night.

During the time you are at home, you can do things as you would normally, such as showering, bathing or walking.  However, please avoid having sex (intercourse) as there is an increased risk of infection.

Before and after going to the toilet please wash your hands, make sure the pessary string or catheter is clean and change underwear regularly.

When to call the Maternity Unit if you are having an outpatient induction  

Call a midwife from the area in which you were induced:

Dacre Ward 01438 284072

CLU 01438 285126

Maternity Triage 01428 286168

If you experience any of the following:

•  Bleeding
•  Contractions
•  Constant abdominal pain
•  Any changes in the normal pattern of movement or concerns about the baby’s movements
•  You feel unwell
•  Leaking or you think the waters around the baby have broken
•  The pessary or balloon falls out
• Any other concerns

What induced labour feels like and pain relief

Induced labour may feel more intense than labour that starts on its own. Women who are induced are more likely to ask for pain relief.  Options for pain relief include paracetamol codeine phosphate, morphine and use of the bath.

Entonox is available on the ward for pain relief during vaginal examinations, but only for pain management for contractions on the Delivery Suite. Similarly, an epidural will only be available on the Consultant Led Unit. You can request additional pain relief or anti-sickness medication at any time.

If you are worried about the pains you are feeling whilst being induced then you can speak to the midwife looking after you and they can carry out further checks.

What to expect during the induction on the ward

You will have an allocated midwife looking after you for both day and night. If you have any concerns, please discuss with them at the time of the concern. There is a daily ward round with the Consultant Obstetrician every day.  You will have regular observations taken every 4 hours during your stay on Dacre Ward; this includes listening to your baby’s heartbeat and checking your blood pressure. You will have at least one computerised monitoring of the baby’s heartbeat each day, but this can be increased at any point if you have concerns about yourself or your baby. You can request further pain relief and anti-sickness medication at any time.

Visiting hours

One designated birth partner can stay with you day and night, 2 other visitors permitted between 3-9pm.

Meals

Meals are provided in the times listed below. We can cater for dietary needs at request on the day.

Breakfast – 07:30-08:30

Lunch -12:30-13:00

Dinner- 17:00-18:00

Occasionally the ward can become busy and noisy at times. You may like to bring in an eye mask and ear plugs to help you sleep.

A pillow will be provided but bring an extra one for comfort!

Car seats do not need to be brought in until after the baby is born.

Please be advised that extension leads are not permitted to be used on the wards.

Contact details

Dacre Ward 01438 284072

Consultant Led Unit 01438 285126

Maternity Triage 01438 286168

Whilst being induced you can do many of the things that will normally help you to relax such as : 

•  Going for a walk
•  Having a nap
•  Having a warm bath or shower (there is a bath available on the ward)
•  Listening to a playlist of your favourite music
•  Watching some TV
•  Ask your birth partner to give you a massage
•  Eat and drink as normal
•  Remain up and mobile where possible to allow gravity to work with you
•  Being upright and sitting forward/leaning forward rather than leaning back can help encourage baby into the best position, this is called “optimal fetal positioning”.  For example, try lying/resting on left side, sitting on a chair backwards, or sitting on an exercise ball.

One of your named birth partners can be without throughout the day and night whilst you are being induced. Please be aware there are no washing facilities for them. Recliner chair are available for partners, however, in busy periods we cannot guarantee a recliner for everyone. Your other children are welcome to visit you up until 9pm but please ensure that there is an adult to take responsibility for them at all times. Visiting hours for other friends and family is between 3-9pm only.

• IOL may impact on your birth experience. This includes where you give birth, as for most women the recommended labour care following an induction, such as continuous monitoring of the baby or the oxytocin drip, cannot be given on MLU or at a home birth. There may also be less opportunity to access a birthing pool.
• The usual IOL process can take several days and you are likely to need to stay into hospital for all or some of that time, especially if there are health concerns with either yourself or the baby. You and your baby’s wellbeing is checked regularly and you care is reviewed on the daily doctors ward rounds.
• During the induction process there will be a need to undertake multiple vaginal examinations to administer the induction agents and monitor progress. You can request gas and air for these examinations.
• There is a risk when using drugs to induce labour, that you can experience too many contractions or contractions that last too long. This is called hyperstimulation and can be painful. This can lead to changes in the baby’s heart rate. This is usually reversed by giving a drug to slow the contractions down.
• There is an increased chance of having a higher blood loss after delivery of the placenta.
• There may be delays in transferring your induction care to the labour ward during periods of high activity, increasing your overall waiting time.
• More women choose an epidural as induction may be more painful.
• There is a slight increase in the risk of instrumental delivery with induction of labour but it does not increase your chance of Caesarean birth in labour.
• Occasionally the induction process may be unsuccessful. This means we are unable to break your waters after the initial cervical ripening. If this happens the maternity team will discuss the options including having a Caesarean birth.

You can choose to proceed with, delay or stop an induction at any point during the process.

We offer mechanical induction with a balloon catheter (also known as a Foley balloon/catheter). It is fitted by a midwife during a vaginal examination. The catheter is guided into the opening of your cervix. Once it is in place, the balloon part of the catheter, which is near the tip, will be inflated with sterile water. You will have the catheter tube secured to your thigh. Occasionally a speculum is required to help insert the balloon catheter.

The catheter will stay in place for up to 24 hours and works by slowly putting pressure on your cervix to allow it to soften and open enough to either start labour or to allow us to break your waters. If your cervix is not open or difficult to access, and the balloon catheter cannot be placed, a Propess pessary maybe offered instead.

If your cervix does start opening or you go into labour, the balloon catheter may fall out by itself.  If this doesn’t happen, it will be removed by the midwife 24 hours after its insertion by deflating the balloon.

Due to the nature of the procedure it can be uncomfortable but should not be painful to insert. There is a very small risk of infection. Please feel free to discuss this with your midwife further.

The benefit of a balloon catheter, being that it’s not a medicine, is that it’s very unlikely to cause hyperstimulation (too many contractions).

Please note: The Foleys balloon catheter is not licensed for this use,  however they are widely used around the world to induce labour, the company have not sought a license for this indication.  There have been many research trials that have shown that this is a safe, effective method of induction.  If you would prefer not to have this treatment, you have the option of using a Propess pessary instead.

This is a small tablet on the end of a ribbon, similar to a tiny tampon. It is placed inside the vaginal by the midwife. It releases the hormone over 24 hours and helps to soften the cervix by bringing on contractions. You may experience some mild or moderate period like pain that may come and go. Some women will start to labour with the Pessary. You may feel soreness or have a more sensitive vagina.

This is the same hormone in the Propess pessary. The midwife inserts it into the vagina. It works over six hours.  This is offered if the cervix is not soft enough after either the Propess Pessary or the Balloon. You can have up to two prostin gels as part of the IOL process.

Induction of labour can take several days, particularly if the cervix is long and closed at the start of the process.  It can take up to 3 days to complete the full course of induction medications to soften and thin the cervix. If your waters break, it is likely you will go into labour yourself, without medical intervention.

If the labour has not started following these induction agents, the next step is to break your waters using a specially designed tool called an amnihook. There is often a wait for this stage in the induction as it requires a single room and a midwife who can provide you with one to one care on the CLU.

Because activity within the maternity unit is unpredictable, there may be times when continuing with the induction is unavoidably delayed. If this happens, please be assured that the midwifery team will ensure the safety of you and your baby by regular monitoring.  If you are worried or concerned at any time during your stay, please do not hesitate to speak to the midwife caring for you.

All women who are awaiting an artificial rupture of membranes (ARM) are reviewed on a daily basis by a midwife or an obstetrician to ensure the wellbeing of them and their baby.

Following the breaking of the waters it may be necessary to start a hormone drip, oxytocin, to induce contractions.  The dose of the drip is increased slowly until you are contracting every 2-3 minutes.  Your progress in labour will be assessed every 4 hours once regular contractions have established.

Oxytocin is a natural hormone that manages key aspects of the female reproductive systems and it is used to start or strengthen contractions to continue (augment) labour and to control bleeding after the birth of your baby.

• The medicine is administered through a cannula (transparent tube) in one of your veins and is diluted as an intravenous infusion (drip). An electronic pump is used to give the specific dose.

• Oxytocin is very commonly used on the labour ward. When making the decision to use a medicine, the risks must be weighed against the benefit. This is a discussion between you and the maternity team.

• Oxytocin can be very useful for helping labour by increasing the tone of the muscles in the uterus resulting in stronger contractions and increasing the number of contractions if labour progress is slow with an aim to you having a vaginal birth. All other reasons for slow progress in labour will be ruled out by the maternity team.

• In women who are unusually sensitive to its effects, these contractions may become too strong. Very strong contractions or very frequent contractions could cause the baby to become distressed. Because of this, the oxytocin starts at a very low dose (1 millilitre) and is gradually increased until you are contracting 3 or 4 times every 10 minutes. The baby is monitored continuously when oxytocin is used.

• The oxytocin can be stopped at any time and a medicine called Terbutaline can be given to relax the uterus and stop contractions.

• If, for any reason you do not wish to use oxytocin as part of your induction or to provide more contractions during your labour, the maternity team will support your decision. At this point a caesarean birth will be discussed with you.

• If you have been using oxytocin and wish to stop at any time, the maternity team will support your decision and options will be discussed. One of these options will be a caesarean birth.

• If you have chosen a caesarean section birth at any point in your labour, the maternity team will keep you informed of the timing we can facilitate this depending on the activity on the labour ward. This maybe some time following the decision and obtaining your consent however your midwife will keep you updated. This maybe the next day depending on the time of your decision, the reason for a caesarean birth and the safest time for the maternity team to support your choice. Emergency theatre cases will take priority.

• If there are any concerns with your health or your baby, an urgent caesarean birth will be undertaken