Induction of Labour

Some women will go into labour naturally from 37 weeks, whilstothers will not go into labour until 42 weeks. If labour has not started naturally around one week after your due date then you may be offered a date for IOL. If IOL is
offered, the midwife or doctor will explain the reasons why this is advisable for you, and they will make sure that you understand the reasons and answer any questions you might have.

IOL may also be offered 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. Your midwife will advise you in this situation.

If you have not given birth by your due date, you will be given anappointment 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 fetal movements. She or he may then suggest you have an internal examination to assess the cervix (neck of the womb), and offer you a ‘membrane sweep’.

The cervix is the opening of the womb. A membrane sweep is a process whereby 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. Performing a membrane sweep increases the chances of labour starting
naturally within the following 48 hours.

A membrane sweep should be the first method used if IOL is advisable, unless your membranes have already broken. 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 urgent advice if heavy bleeding occurs.

The midwife or doctor will request for you to have an induction of labour in case you do not go into labour naturally. This request is sent to a member of the admin team, you will receive a phone call or letter with the date of your induction. In the letter, you will be provided with the telephone numbers you may need if you have any questions about your induction.

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

If you have a Dinoprostone pessary (previously Propess®)

Your baby’s heartbeat will be monitored using a cardiotocograph (CTG) machine. A CTG machine consists of two discs which are held in place by elasticated belts. One disc is placed at the top of your tummy to monitor how often your womb contracts. The other is held in place where your baby’s heartbeat can be heard clearly. The belts are not uncomfortable. The CTG machine produces a printed graph (often called a ‘trace’) to show the pattern of your baby’s heart rate.

The pessary will be inserted by a midwife, and then your baby will be monitored for about half an hour afterwards. Once the pessary is in place it will swell, which keeps it in place. You can walk around, shower, eat and drink normally. Your midwife will continue to check on both you and your baby over the next few hours. Women who have had a normal pregnancy may be suitable to go home after a short period of monitoring after insertion (this is known as outpatient induction of labour).

If you are suitable for an outpatient induction your midwife will discuss
this with you.

If you are suitable for outpatient IOL then you will be advised by your midwife when you need to return and to ring back if you have any concerns.

If the string from the pessary moves to the outside of your vagina you must be careful not to pull or drag on it, as this may cause it to come out.

Please take special care:

• Wiping yourself after going to the toilet
• Washing yourself
• Getting on and off the bed

In the unlikely event that the pessary should come out, pleasetell the midwife straight away – she can then make sure it issafely repositioned. If you are at home you will have beenadvised which telephone number to ring if this should happen.

The pessary releases the hormones slowly over 24 hours.

You are unlikely to need another internal examination until the pessary needs to be removed – either because you are advancing in labour, or for one of the following reasons:

• Your waters break
• You have some vaginal bleeding
• You have diarrhoea, vomiting or nausea
• The midwife or doctor is concerned about your baby’s heart
  rate
• Your contractions come very close together
• You have had the Pessary in for 24 hours, even if labour has not started

However if after six hours you are not experiencing any period pains/contractions your midwife may offer to examine you again to check that the pessary is still in the correct position. This is important because it will increase the chance of it working.

If you have a Dinoprostone tablet:

If you are being induced because your waters have already broken then you will be given a Dinoprostone tablet rather than the pessary. Your baby’s heartbeat will be monitored using the CTG machine before the tablet is inserted by a midwife and then for about half an hour afterwards. After that you can walk around and eat and drink as usual. Sometimes the Dinoprostone tablet is enough to start labour, but if labour has not started you will need another internal examination after six hours. Your midwife will check on both you and your baby during this time.

Following 24 hours of the pessary or 6 hours of the Dinoprostone tablet it would be expected that your cervix would start to shorten. If this is the case then the next stage of the induction would be possible—this involves breaking your waters.

There is a chance, however, that even after 24 hours of Dinoprostone pessary it may not be possible to break the waters and the midwife and doctor will discuss the options with you. These may include having a Dinoprostone tablet, a period of waiting, followed by trying the process again or delivery by Caesarean Sometimes vaginal prostaglandin is not necessary, because the cervix is already thin enough and open at the start of the IOL process and it’s possible to ‘break the waters’ without any prostaglandin.

Why can’t I just be started on an oxytocin infusion to get my contractions going?

We can’t start the oxytocin infusion (the drug which helps to stimulate contractions) until your waters have broken. If your cervix is less than 2-3 cm dilated it makes it difficult to “break your waters”. This is why you will be offered either the pessary, vaginal Dinoprostone tablet or DILAPAN–S®

DILAPAN–S® is the non-hormonal method for inducing you. It is very unlikely that you will have strong uterine contractions with DILAPAN–S®, which is also safer for your baby.

How does DILAPAN–S® work?

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

Can I have DILAPAN–S® if I have any systemic disease or I have had a previous Caesarean section?

Yes. If you have had previous surgery to your uterus such as caesarean section, you may be recommended to have DILAPAN–S® over Dinoprostone pessary or vaginal prostaglandin tablet.

How will DILAPAN–S® be inserted and is it painful?

You will lie down and may need to have a speculum examination so we can see your cervix. Then a doctor or midwife will insert the DILAPAN–S® dilators. It will take approximately 5 - 10 minutes.

The procedure can be slightly uncomfortable, it is generally well tolerated by most patients. Shortly before and after the procedure, your baby’s heartbeat might be monitored. A small amount of bleeding might occur during or after insertion, but this is common and should not be a concern.

Which regular activities CAN I do with DILAPAN–S® inserted?

You can go to the toilet, shower normally and perform your normal daily activities. With DILAPAN–S® we advise you do not have a bath. We encourage you to move around when you’re not resting, as this helps prepare you for labour. It’s also good to try and get some sleep as this will also help prepare you for labour. Please report to your clinicians immediately if there is any
excessive bleeding, pain or other concerns that occur during the ripening process.

This is also known as ‘breaking the waters’, and can be used if the cervix has started to ripen and dilate either by itself or by using vaginal prostaglandin. A midwife will carry out an internal examination and will make a small hole in the membranes using a slim plastic instrument with a tiny hook on the end. Having the membranes broken should encourage more effective contractions. If you are being induced because your waters have already broken the midwife will check to see if there is still a bag of waters in front of the baby’s head. If so then they will break these.

Sometimes prostaglandin and/or breaking the waters is enough to start a labour, but many women require oxytocin. This medicine is given using a drip into a vein in the back of your hand. It causes 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. 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.

There are many benefits for you if you have an outpatient Induction. These include:

• The amount of time you will need to spend in hospital before you go in to labour is much less.
• You may be more relaxed and comfortable in your own home and are therefore more likely to go in to labour sooner.
• This induction of labour process may feel more natural to you, like you are going in to labour yourself.

You may be offered an outpatient induction if:

• Your pregnancy is ‘low risk’. This means you have generally been healthy during your pregnancy, your baby is head down and is well grown.
• You have no medical or obstetric problems or agreed with individual consultant on a case by case basis.
• You have a good understanding of English.
• You have a birth partner who will stay with you whilst you are at home after insertion of the Dinoprostone pessary or Dilapan-S
• You are over 18.
• You have access to a phone with credit.
• You have transport available to bring you to and fromhospital.
• Your BMI is less than 35 (your BMI tells us if you have a healthy weight for your height).
• You are happy to have an outpatient induction.

If you think you may be suitable to undergo induction of labour as an outpatient and would like to be considered please speak to your midwife or doctor, who can advise you further.

On the day of your induction you will be called by the midwife to come to the induction lounge. You will be seen by a midwife who will check you and your baby over.

The midwife will monitor your blood pressure, temperature and pulse and will require a urine sample from you. She will then monitor your baby’s heartbeat with a machine called a CTG. Once the midwife is happy with your observations and the CTG

monitoring she will ask your permission to perform an internal examination to assess the neck of your womb (cervix) and to insert the Vaginal dinoprostone pessary or Dilapan-S The pessary has a ribbon attached to it in order to remove it easily. This will be tucked up inside your vagina once it has been inserted.

Please take care not to dislodge the pessary when wiping yourself after you have been to the toilet or after washing. If this happens, the pessary will no longer be in the correct place, and will not work.

If you think you have dislodged it, please contact the Hospitalvia the maternity advice line on: 01159709777

Once the pessary or Dilapan-S has been inserted, the midwife will continue to monitor your baby’s heartbeat with the CTG monitor for 30 minutes.

If your baby remains well, she will stop the monitoring after this time. You will then be asked to go and take a walk around for an hour and return to the induction lounge for the midwife to check on you and your baby.

If she is happy that everything is OK and you would still like to go home, you will be able to do so. The Midwife will check she has the correct telephone number for you, as she will contact you 6 hours after the Dinoprostone pessary or Dilapan-S has been inserted to check you are feeling well. There may however be occasions when circumstances have changed and you will be advised it is no longer appropriate to go home. The reasons for this will be explained to you.

The pessary and Dilapan-S affect everyone slightly differently. You may start to feel some period type pains, mild backache or maybe even a dull ache at the tops of your legs. You may also notice some mild, irregular tightening of the muscles in your womb. These are all positive effects of the prostaglandin
working as it ripens your cervix.

Whilst you are at home, you can continue with your normal day to day activities and you should eat and drink well, this means eating little and often. Over a period of time, you may notice that the period pains and mild tightening that you have been having become more regular. If this is the case, you should start to time them. You are looking for a regular pattern of contractions, that all last the same amount of time (around 60 seconds) and all feel as intense as
each other. Once you are having 3 regular contractions in a 10 minute period, you should contact the hospital where you are booked for advice.

During this time, it is okay for you to shower with your pessary or Dilapan-S in situ and use a TENS machine if you would like to as you mobilise or rest. Being as upright and as active as possible will encourage your labour to progress well.

The dinoprostone pessary can occasionally produce mild side effects such as feeling or being sick, diarrhoea, a raised temperature or vaginal irritation. Rarely, the pessary may make you have contractions which are very frequent and strong. If you experience any of these side effects, please contact the hospital
for advice:

Maternity advice line: 0115 970 9777

You may find that your pessary or Dilapan-S falls out. This isn’t very common, but if it does happen, you should contact the hospital to arrange to come back and have it reinserted. You should also contact the hospital where you are booked if you experience any of the following:

• Any fresh red bleeding from your vagina, that is not part of
  your show (the sticky mucous plug).
• If you think your waters have broken.
• If you have severe, constant pain in your stomach.
• If you are concerned that your baby is not moving as much as they normally would.
• If you have any questions about your induction of labour

On some occasions when you contact the hospital for advice, the midwife may ask you to remove the pessary yourself. If you need to do this we will guide you on when and how to do it.

You may think that nothing much has happened at all whilst you have been at home. This can be normal too, it doesn’t mean that the pessary has not been working, it can often ripen your cervix without you even realising it.

You will be given an appointment time to return to the hospital where you are booked in 24 hours after the pessary or 12-15 hours after Dilapan-S was inserted. The midwife will examine your cervix and remove the pessary. She will discuss with you her findings and continue with your induction process on the induction suite, or arrange for you and your birth partner to be transferred to the labour suite.

Sometimes, the labour suite can be busy which may lead to a delay from the pessary or Dilapan-S® being removed and being transferred to the labour suite. Dilapan-S® and Dinoprostone is safe to remain in the cervix for up to 24 hours. On the day, if there are any potential delays to your induction a midwife will discuss this with you.

• IOL may relieve a medical condition (such as pregnancy-induced hypertension) which may otherwise get worse.
• Pregnancy is not prolonged beyond a date when the placenta may not function as well as it did earlier in the pregnancy.
• IOL may be performed to prevent you and your baby getting an infection if your waters have broken and labour has not started.

• The process of IOL may not work, in which case the midwife and doctor will discuss the options with you.
• Over-contracting of the womb may occur with either prostaglandins or oxytocin. Drugs can be given to reverse over-contracting in extreme cases, and if related to the Dinoprostone pessary, this will be removed.
• IOL is often a long process and it may take 2-3 days before you birth and may involve more vaginal examinations.

If you don’t want to be induced at the time at which it is recommended, you should tell your midwife or doctor. However, it will be recommended to you that you attend the hospital for the team to check how you and your baby are.

This may be done using the CTG, and may involve you having a scan to check the water around the baby. How often you come to the hospital depends on your situation, and the midwife and doctor will discuss this with you.

Midwives and doctors understand that when your induction is postponed it can make you feel quite upset. However, they will give you reassurance depending on your circumstances you may be invited into the hospital for additional monitoring of you and your baby.

The midwives and doctors have to prioritise mothers and babies for IOL based on individual circumstances. Your IOL may be postponed if another mother or baby has a greater need at the time you have been given. Your IOL 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. Our priority is to ensure that when we start your IOL we can look after you and your baby safely.

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. This is because your body has not had as long to build up your endorphins (natural painkillers) as they would have if you
had gone in to labour naturally. Women describe labour pain in different ways (see the leaflet – ‘Positive ways to manage pain in labour’).

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 gradually to avoid too many contractions happening too quickly. You will always be cared for by a midwife, and she will support you in your choice of coping skills and pain management.

On the day of your induction, please await a phone call from the midwife in the hospital. Please be ready to attend hospital for your IOL from 07:00 onwards in case we are able to bring you in immediately. If you have not heard from the hospital by 17:00 please call the maternity advice line who will transfer your call to the induction lounge to speak to a midwife.

If you ring us after 17:00, ask to speak to the Induction midwife, and please remember that your IOL may be delayed. If your induction has been delayed, the midwives will explain this to you and may offer you to come in for additional monitoring depending on the reason that you are being induced. Make sure you have something to eat and drink before you come into hospital. We kindly ask that on the day of your IOL you are ready to leave for the hospital prior to ringing us. This includes having made arrangements for your other children/dependents. If you are delayed arriving at the hospital it may be that circumstances have changed since you rang which may then result in further
delay to starting your IOL.

While there is a chance your IOL may be delayed there may also be occasions where we can accommodate you the day before. If we are able to do so we will ring you to discuss this.

Maternity advice line: 0115 970 9777