Induction of Labour (with intact membranes)

If there is anything you would like more information on, or don’tunderstand, please ask your midwife or obstetrician who willanswer any questions you might have at any stage.Women & Children’s DirectorateWe continually strive to improve the quality of information given topatients. If you have any comments or suggestions regarding thisinformation booklet, please contact:Head of Midwifery, Women & Children’s Directorate BuckinghamshireHealthcare NHS TrustStoke Mandeville HospitalMandeville Road, Aylesbury, Buckinghamshire, HP21 8ALApprovals: Maternity Guidelines Group: V1 Nov 2010. V2 July 2012Divisional Board: V1 Mar 2011. V2 Sep 2012Clinical Guidelines Subgroup: V1 Apr 2011. V2 4.10.12MSLC: V1 Jan 2011. V2 July 2012Equality Impact Assessment: V1 Dec 2010. V2 Dec 2012Patient Experience Group: V2 Aug 2011.How can I help reduce Healthcare AssociatedInfections?Infection control is important to the wellbeing of our patients,and for that reason we have infection control procedures inplace.Keeping your hands clean is an effective way of preventingthe spread of infections. We ask that you, and anyonevisiting you, use the hand rub (special gel) available at themain entrance of the hospital and at the entrance to everyward before coming into and after leaving the ward orhospital. In some situations hands may need to be washedat a sink using soap and water rather than using the handrub. Staff will let you know if this is the case.www.buckshealthcare.nhs.ukIf you require an interpretation of this leaflet please contactyour midwife or doctorInduction of Labour(with intact membranes)Information for pregnant women their partners andtheir familiesThis leaflet has been written to help you and your partnerunderstand what might happen during an induction of labour.Author: G SuriIssue date: March 2013Review date: March 2016Leaflet code: WZZ1387Version: 2Where your needs always come first

What is induction of labour?Most women will start labour spontaneously by 42 weeks of pregnancy.Induction of labour is the process designed to start labour artificially. Onaverage approximately 1 in 5 labours are induced. There are a numberof reasons why induction may be offered and recommended. Forexample, if you have a medical condition in pregnancy such as diabetesor high blood pressure (pre-eclampsia) and there comes a time when itis clinically indicated that giving birth would benefit the health of you oryour baby. The most common reason for induction of labour is to avoidthe risks associated with a prolonged pregnancy (a pregnancy lastinglonger than 42 weeks).How your body prepares to give birthDuring pregnancy your baby is surrounded by amniotic fluid, often calledthe ‘waters’ and these are contained within the membranes (the sac)which offers protection to your baby whilst developing in the womb(uterus).In preparation for labour the neck of the womb softens and shortens.This is sometimes referred to as ‘ripening of the cervix’ and cansometimes take a few days to occur.Before or during labour the membranes break (rupture) releasing thefluid. This is often referred to as your ‘waters breaking’.The process of labour involves the cervix opening (dilating) and theuterus contracting to push your baby out.When is induction recommended?At the 38 week antenatal visit your midwife or obstetrician should offer todiscuss the induction process with you and the clinical indications forinduction (eg avoiding a prolonged pregnancy). They should talk to youabout the risks and benefits of induction, explain the alternatives andadvise you about further sources of information. This gives you plenty oftime to discuss induction with those close to you and ask any questionsbefore the possibility of induction of labour is recommended.If you have had a healthy uncomplicated pregnancy, induction of labourwill be offered at 40 weeks plus 12 days in order to give you time in yourpregnancy to start labour naturally.membranes. If it is possible to rupture the membranes you will betaken to the Labour Ward as soon as they are able to accept you. IfLabour Ward is very busy and are unable to accept you at that time,you should be aware that the next step of your induction processcould be delayed for a few hours or even until the next day. We willkeep you informed of events at all times. Once the induction processhas started we would advise you to remain in hospital until you havedelivered your baby. During this time we will continue to monitor youand your baby regularly.• Women having their first baby are advised to start intravenousoxytocin immediately after your membranes have been ruptured. Ifyou have had a baby before, you could wait up to 2 more hoursbefore starting oxytocin.• It is important that you are fully aware that not every woman givesbirth on the day of their induction (particularly first time mothers).Induction of labour can take a few days. We would advise you tobring books, magazines etc to keep you occupied.Further Information: For further information about induction oflabour and all other aspects of pregnancy and childbirth talk toyour midwife or doctor.Antenatal Clinic on: 01296 316140 01494 425569(Stoke)(Wycombe)Labour Ward on: 01296 316103/4(Stoke)• MIDIRS Informed Choice leaflets can be found atwww.infochoice.org. These are downloadable information leaflets onmany aspects of labour and birth, including induction.• Royal College of Obstetricians and Gynaecologists website atwww.rcog.org.uk/resources/public/pdf/rcog induction_of_labour.pdfhas the full induction of labour guideline including sources ofevidence.• NICE website at www.nice.org.uk/page.aspx?o=17330 has the fullpatient information leaflet.2 7Where your needs always come first

Steps in the induction process• The reason(s) for inducing your labour will have been discussed withyou and, with your agreement, a date for induction will be given toyou.• If it is your first baby you will be admitted at 0800hrs and if it is asecond or subsequent pregnancy you are admitted at 1100hrs.• You will be welcomed by the ward staff and shown to your bed. Onceyou have settled in, the facilities of the ward will be shown to you andyou will be given any other information that is relevant to your stay inhospital. The midwife will monitor your baby’s heartbeat for 30minutes and record other observations, e.g. blood pressure,temperature and pulse rate. You will be seen by a member of thematernity team and the type of induction that is suitable for you willbe confirmed. This is a good time to ask any questions you or yourpartner may have.• Women who are having their first baby. An internal examinationwill be performed with your consent. If you require prostaglandins apessary (Propess®) will be inserted into the vagina. This will stay infor 24 hours and be removed the following morning (sooner if you gointo labour before then). This will take place on the Antenatal Wardunless you have been told you will need to have Propess® on theLabour Ward.• Women who have had a baby before. An internal examination willbe performed with your consent and, if needed, a Prostin® tablet willbe inserted into the vagina. This will usually take place on theAntenatal Ward. After approximately 6 hours you will be assessedagain including an internal examination and, if needed, a secondProstin® tablet may be given.• You will be encouraged to sleep overnight and will need to stay inhospital. If you are not in active labour at the end of visiting hoursyour partner will be asked to go home and will be telephoned whenyou start to go into established labour. This enables you both to rest.• If you have not already gone into labour, then 6 hours after your lastProstin® tablet or when the Propess® pessary is removed, you willbe examined to determine if it is possible to rupture yourIf your pregnancy is more than 41 weeksInduction of labour is recommended from 40 weeks plus 12 daysbecause the risk of your baby developing health problems begins toincrease from 42 weeks. The risk of stillbirth is 3 babies in every 3000births after 42 weeks compared to 1 in 3000 at 37 weeks. If you choosenot to be induced at this stage, you and your obstetrician will make aplan of care from 42 weeks which at a minimum will include:• Twice weekly checks of your baby’s heartbeat using a piece ofequipment called an electronic fetal heart rate monitor orcardiotocograph (CTG).• An ultrasound scan to check the amount of water (amniotic fluid)surrounding your baby.An induction because you are overdue does not increase thechance of you needing a Caesarean section.Membrane SweepingBefore you are offered an induction you should be offered a membranesweep. This has been shown to increase your chance of starting labournaturally within 48 hours and can reduce the need for other methods ofinduction of labour.Membrane sweeping involves a vaginal examination during which yourmidwife or doctor will place a gloved finger just inside your cervix andmake a circular, sweeping movement to separate the membranes fromthe cervix. It can be carried out at home, at an outpatient appointment orin hospital.Membrane sweeping may cause some discomfort or light bleeding butwill not cause any harm to your baby. You should be offered amembrane sweep at your 40 and 41 week antenatal appointmentsduring your first pregnancy or your 41 week antenatal appointment if youhave had a baby before. Membrane sweeps should not be performed ifyour waters have broken.How is labour induced?There are a variety of methods that can be used to induce labour. Youmay be offered one or all of the methods described, depending on yourindividual circumstances. Once started, the induction process continuesuntil your baby is born.Where your needs always come first6 3

ProstaglandinsProstaglandins are drugs that act like natural hormones to start labour.They are either given as a tablet known as Prostin® (dinoprostone 3 mg)or as a pessary known as Propess® (dinoprostone 10 mg), either ofwhich is inserted into the vagina. This is undertaken in hospital on theantenatal ward or labour ward depending on the reason for yourinduction.Before being given any prostaglandins your baby’s heartbeat will bechecked for approximately 20-30 minutes using a cardiotocographmonitor (CTG). This will be repeated after the prostaglandin medicationhas been given. We will also monitor your baby’s heartbeat oncecontractions start.First time mothers are given the Propess® vaginal pessary which willstay in place for 24 hours. It is removed if active labour starts.If you have had a baby before, you will be given a Prostin® vaginaltablet. However, more than one dose may be needed to induce yourlabour. A second dose of the Prostin® tablet can be given 6-8 hourslater if needed.Induced labours may be more painful than spontaneous labour andoccasionally Prostin® can cause vaginal soreness. Pain managementoptions will be discussed with you at your antenatal appointment and youwill be supported with your pain management choices in labour.Very occasionally prostaglandins can cause the uterus to contract toomuch which may affect the pattern of your baby’s heartbeat. If thishappens you will be asked to lie on your left side. You may be givenother medication to help relax the uterus and any tablet/pessaryremaining in your vagina will be removed.The aim of the prostaglandins is to either start your labour or to dilate thecervix enough that the membranes can be artificially ruptured (the watersbroken). Occasionally, despite being given two Prostin® tablets or aPropess® pessary, the cervix does not dilate sufficiently to be able torupture the membranes. In this circumstance the obstetrician willdiscuss the options with you. This may include offering you anotherdose of prostaglandins.Artificial rupture of the membranes (ARM) or amniotomy(breaking of the waters)If your waters have not broken a procedure called an amniotomy(ARM) will be recommended. This is when your midwife or doctormakes a hole in the membrane to release (break) the waters.This procedure is performed during a vaginal examination using asmall plastic disposable instrument. This will cause no harm to youor your baby, but the vaginal examination needed to perform thisprocedure may cause you some discomfort. This procedure isperformed on the labour ward.Oxytocin Intravenous Infusion (hormone drip)If active labour does not start following the rupture of membranes adrip containing synthetic oxytocin will be given to you through aplastic tube inserted into a vein. Oxytocin in this form is a drug thatmimics the natural hormones that cause contractions and thereforestart labour.The amount of synthetic oxytocin you receive will be increased toensure you are contracting regularly (approximately 3-4 contractionsin 10 minutes). If you start to contract too much the infusion rate canbe reduced.Whilst being given intravenous oxytocin your baby’s heartbeat will bemonitored continuously by a CTG. The oxytocin drip can limit yourability to move around. Whilst it may be okay to stand up or sit down,it will not be possible to have a bath or move from room to room.Women who have intravenous oxytocin are more likely to ask for anepidural in labour. An epidural is a form of pain relief provided by ananaesthetist (please discuss with your midwife if you need moreinformation related to epidurals).Where your needs always come first4 5