Here is some information for you about the different stages during induction of labour
----Membrane sweep
When induction of labour has been planned, you may be offered a vaginal examination a few days before your induction. The examination can include having a membrane sweep. This can help you to avoid a 'formal' induction of labour, as labour may start on it's own after a sweep. The examination/sweep will allow the health professional to recommend the most appropriate method for induction.
A membrane sweep is a vaginal examination where the health professional attempts to place a finger within your cervix opening and 'sweep' around the inside of the cervix opening which can release natural oxytocin (a hormone) which may encourage your contractions to begin.
There are two stages of formal IOL
Step 1 Initially the cervix needs to 'ripen'. This requires the cervix to soften, thin and start to open.
Step 2 Once the cervix starts to open, the membranes can be ruptured and a synthetic hormone drip (oxytocin) can be started which should start contractions of the womb, and allow labour to establish.
Established labour is when the cervix has opened to 4cm and you are experiencing regular strong contractions (usually lasting 40seconds or more each time)
We cannot tell how long each step of the induction process will take, or how long your labour will take.
--- What to bring
Please remember to bring your hand-held notes with you and an overnight bag.
It may also help to bring healthy snacks, such as bananas, and 'isotonic' sports drinks - avoid 'high sugar' fizzy drinks, which can be marketed as 'energy' drinks. Snacks for partners
As IOL can take time, being prepared can help you to cope – this can include resting and trying to sleep, eating and drinking plenty of water to ensure you are hydrated.
---What happens on the day
- When you arrive your pulse, blood pressure and temperature will be checked and recorded.
You will have the opportunity to discuss the process of induction of labour with us and we will answer any questions you may have.
An examination of your abdomen will be performed to check your baby's size and possibly an ultrasound to check how they are lying. The midwife will also check your baby is ok by monitoring their heartbeat on a CTG machine. The machine also measures your contractions.
- When the midwife is happy with the observations and CTG monitoring they will ask if it is ok to perform an internal examination (vaginal examination) to check the neck of the womb (cervix).
- If your cervix is open enough to be able to break your waters, this will be discussed with you. If the cervix is closed, then the induction method will be inserted (Step 1 – see below)
- After the induction method has been inserted, your baby's heart rate will be monitored again for 30-60 minutes.
If your waters break, you experience any tightening's of your womb, bleeding or if you have any concerns, you should inform staff looking after you.
Step 1 - Cervical Ripening
Induction Suite (Harmony Suite)
For Step 1 generally you will be invited to come into hospital to Harmony Suite (Induction of Labour Suite) – you will be given a time to attend, usually between 09.00-18.00.
Sometimes when the unit is very busy, a midwife may contact you beforehand by telephone, because it may be necessary to delay the time for your induction of labour to start.
The midwife may advise that it would be better to wait at home, rather than waiting in the hospital. If this happens, please be assured that if you develop any concerns about your pregnancy, the triage unit will still be available to discuss your concerns.
The Harmony Suite has 3 individual bays. It has been developed, aiming to improve safety and your experience of IOL. The midwife in this area will be looking after fewer women than midwives on the ward, and there is closer availability of Delivery Suite Staff, Shift Leaders and the Medical team. There is quick and easy access to additional pain relief options, such as a bath, entonox (gas and air) or stronger injections for pain relief.
Maternity Ward
Occasionally if the unit is very busy, we may sometimes need to delay continuing your induction after step 1 so you may be transferred to the maternity ward to be cared for until a midwife is available to look after you for step 2. Sometimes we are unable to start step 1 until the next day if our unit is very busy and it may be recommended you stay on the maternity ward for monitoring depending on your pregnancy.
Home / Outpatient Induction of Labour
If your pregnancy has been straightforward, with no or minimal complexities, you may be suitable to have Outpatient Induction of Labour. See Section below.
Delivery Suite
Sometimes you may need individual care from the midwives and closer observation of you and / or your baby throughout the whole IOL process.
One example may be if you have severe pre-eclampsia. In this situation you will be cared for in a Delivery Suite Room.
--- Step 1: Cervical Ripening
There are 2 possible choices for Step 1 of Induction of Labour, these are :
Cervical Ripening Balloon (CRB) or
Propess® vaginal pessary.
Cervical Ripening Balloon (CRB)
Although using a Foley catheter has not been licensed for use in this way, it has been extensively in other units, and has been introduced at Arrowe Park. A Foley catheter is a sterile medical device and experience from extensive use in other units has shown it is safe.
It involves inserting a long silicone tube (Foley catheter) with an inflatable balloon on one end that can be filled with water. During a vaginal examination the device will be gently inserted through the cervix. The examination may require either a speculum examination (similar to having a smear test), or the doctor or midwife may be able to place it through your cervix with their fingers. The balloon will be inflated with water to hold the device in place, and the device taped to the inside of your thigh.
The CRB puts some slight pressure on the opening of your cervix which causes thinning (effacement) and dilation of the cervix. It also helps your body to release natural hormones of oxytocin and Prostaglndins
You will need to take care when:
- Wiping yourself after going to the toilet
- After washing
- Getting on and off of the bed
The CRB stays in for between 12-24hours. After it is removed, you may be offered a further cervical sweep, which can help your contractions to start.
Sometimes the balloon may fall out earlier than 12 hours- this often means that the cervix is starting to open.
Can anyone have a CRB?
It can be used in most women where vaginal birth is planned.
We would not offer it if your membranes have broken - this may increase the risk of infection, and we would advise using Propess®
Occasionally it may not be possible to insert the CRB through the cervix - alternative options, including Propess® would be discussed with you.
A trained professional will need to be available to insert the CRB see below
Are there any side effects?
After the examination you may experience a small amount of vaginal bleeding or pink loss. This can be quite normal after a cervical examination.
There can be some discomfort whilst the CRB is inserted, and some pain afterwards similar to period type pain.
You should inform your midwife if any pain becomes severe or bleeding is heavy.
Vaginal Prostaglandin Pessary
Propess® or Dinoprostone is the method of induction of labour that we have used in Wirral Women and Children's Hospital have used for induction of labour for 10+years.
This is a small flat tampon (pessary) which contains the inducing medication and will remain inside your body for 24 hours. The wider part of the Propess® (as pictured) is inserted into the vagina and behind the cervix.
The Propess® tampon will absorb the moisture from your vagina which makes it swell and settle in place. This reduces the chance of it falling out.
After the Propess® tampon is in place, you will need to lie down for about 30 minutes. The string of the tampon will lie just outside your vagina.
It is important that you take care not to pull or drag on it.
Propess® usually works by stimulating some contractions, which will help your cervix to start to open. Sometimes women may require pain relief during this time, before labour becomes formally established. Usually simple pain relief such as paracetamol and / or codeine will be offered first.
Further pain relief can sometimes be needed such as entonox or an injection of a stronger pain killer such as pethidine or diamorphine.
A doctor may be asked to review you if stronger pain relief is needed – this is to check that there are no complications for you or baby
If you are being induced because your membranes have ruptured (waters have broken), the Propess® will stay in situ for a maximum of 6 hours.
Which choice? – CRB or Propess®?
We have used Propess® for many years, so have gained lots of experience. Since we have recently introduced the CRB,
Inserting the CRB can sometimes be a bit more difficult than inserting Propess®; a CRB may require both a digital examination with fingers, and possibly a speculum examination. We are working hard to train more staff to insert the CRB – currently we cannot absolutely guarantee that there will be a trained member of staff who is available on the day of your induction of labour; please discuss this with us if CRB is your preferred choice.
CRB may cause cervical change more quickly than Propess®, and therefore sometimes can be removed after 12hours; Propess® usually remains in the vagina for 24hours. Potentially this means that the process may be quicker with CRB than with Propess®.
Less pain may be experienced during cervical ripening with the CRB compared to Propess®.
The CRB does not
- involve using synthetic hormones to ripen the cervix,
- may be less likely to initiate labour because it causes less contractions.
- you may be more likely to require Aritificial Rupture of Membranes (ARM)
- you may more likely to oxytocin than with Propess®
- the cervix often changes more with the CRB than with Propess,
- when oxytocin is started, labour may establish more quickly.
If you have had a caesarean section previously, Propess® would not usually be offered to you, as this has a higher risk of causing a problem of uterine rupture (see below). If you have agreed to go ahead with IOL, a CRB could be used.
---- Step 2: ARM - Artificial Rupture of Membranes (Breaking your waters)/Oxytocin drip
Where does Step 2 of Induction of Labour happen?
When a midwife on labour ward is available to look after you safely, you will be transferred to an individual room, and Step 2 of the induction process can commence.
We want to look after all our women and babies safely. At times our midwives will already be looking after other women in labour or women who are unwell. We also sometimes have to manage emergency situations.
This may mean that a midwife is not available straight away to continue your IOL.
Sometimes we may have to ask you to wait (sometimes a number of hours, or occasionally for over 24hours). We ask for your patience if this happens to you.
If there is a delay, we will make a plan with you about how often to monitor you and your baby to ensure that you both remain safe. We will aim to keep you informed of the situation, but we may not be able to guarantee exactly when the next step will be possible.
Delivery Suite
For Step 2 of the process (or if your cervix is already 'favourable', and your waters can already be broken) you will come to an individual room for labour. For most women this will be in the Delivery Suite. Because induction of labour is usually recommended when there is a complexity to your pregnancy, your baby's heart-rate can be continuously monitored throughout labour.
Eden Suite
If you have no complications relating to your pregnancy, and no changes have developed during Step 1 of the Induction process, it may still be possible for labour to happen on the Eden Suite. This would be appropriate if labour establishes with just the induction method (CRB or Propess®), or if your cervix is favourable after the induction method it may be possible to break your waters on the Eden Suite to see if labour occurs without the need for an oxytocin drip.
Artificial Rupture of Membranes (ARM) : Breaking your Waters
Rupturing your membranes (Breaking waters) is done with an instrument, called an Amnihook. This is inserted during a vaginal examination and used to create a hole in the membrane sac at the opening of your cervix.
Breaking your waters will stimulate oxytocin (a labour inducing hormone) to surge and can encourage your contractions.
The presenting part (usually the baby's head) will also come down into the birth canal after breaking waters to apply well to the cervix which will then encourage the cervix dilate.
Your waters will continue to drain during your entire labour. If your cervix is 'favourable' and ready for labour to happen, or you are already having some contractions, labour could start soon after your waters have been broken. The midwife and/or labour ward team will discuss how long they may wait to see if labour starts (usually up to 2hours).
If your cervix is not favourable, then oxytocin may be started 30minutes after your waters have been broken.
IV Oxytocin infusion (hormone drip)
A cannula is a tube that can be inserted into a vein, often for the delivery of fluid or for the gathering of blood samples, or sometimes both. The oxytocin infusion is a synthetic hormone will be administered through your cannula.
Fluid which is run through a cannula over a period of time is called an infusion. Once an oxytocin infusion is started, we recommend that labour takes place on the delivery suite (rather than the Eden Suite), so that continuous monitoring of your baby's heart beat can occur.
The midwife looking after you will monitor the amount of contractions you have along with your baby's heart rate and adjust the infusion amount accordingly. Although the oxytocin infusion is gradually increased sometimes contractions can happen too frequently or the baby's heart-rate may be affected by the contractions
When being induced using the infusion, contractions can feel more intense than if you were labouring spontaneously. The infusion will usually continue until your baby is born..
---- Outpatient Induction of Labour
When Outpatient IOL could be offered?
You may be offered Outpatient Induction of labour for Step 1 if:
- Your pregnancy has had no or minimal complications
- You have no significant medical problems
- You can speak English fluently or have a good understanding of English
- Have access to a phone.
You have a relative/partner/friend who will stay with you at home on that day
- You have transport to bring you to the hospital
- You live within 30 minutes (driving distance) from Wirral Hospital
The COVID-19 pandemic created the opportunity to introduce outpatient induction of labour, which can reduce the amount of time you spend in hospital. This is suitable for women with no or minimal complications of the pregnancy, and it must be confirmed that is it suitable for you before you go home.
What are the benefits of an Outpatient Induction of Labour?
An outpatient labour:
Reduces the amount of time you will need to stay in hospital before your labour begins
Allows you to stay at home and wait for labour to start. This may help with relaxation and pain relief.
Makes the process of induction more normal
What happens on the day?
Your midwife or doctor will book an appointment for you to attend the unit usually in the afternoon (most likely they will advise you to come to the Induction Suite, but occasionally they may see you in an alternative location).
In general, CRB is the preferred method for Outpatient Induction because it seems to cause less pain and have less risk of causing your womb to contract too frequently compared with Propess®. If you feel that you might wish to choose Outpatient induction with Propess®, please discuss this on an individual basis with your doctors and midwifes.
Prior to going home, you will be given the opportunity to ask any questions and if everything is ok you will be able to go home.
What happens when I go home?
When you have left the hospital, you can continue with your day to day activities and eat and drink as normal. You may feel some discomfort or contraction type pains, which may require pain relief – paracetamol is suitable for this. If you feel your pain is not managed with paracetamol you should call for advice.
When should I call back?
You should contact the labour ward if you experience any of the following:
- Your tummy starts to tighten every 5 minutes (contractions)
- You have any vaginal bleeding
You think your waters have broken
The induction method falls out
- You are concerned about your baby's movements
- You are unable to pass urine
- You are worried about anything else.
- What happens next?
Step 2 of Induction
This would usually be in hospital, to break your waters. You will need to call back and speak to Shift Leader the following day.
Cervical Ripening Balloon – please call at 08.00 the following day – the Shift Leader will plan an appropriate time for you to return, to progress to Step 2 of the process.
If there is likely to be a delay in this, the shift leader will discuss this with you and may ask you to return to the hospital to the maternity ward to remove the induction device by 24hours after insertion.
Breaking your waters may be enough for you to go into labour. If contractions do not start after 2hours, then a drip would usually be offered.
Contact details for Outpatient Induction of Labour:
Labour ward 0151 6785111 (switchboard) ext 7117 or 7116;
Harmony Suite ext 7492
Maternity Triage 0151 6047111
If you have any questions please speak to your midwife/member of the team.
Useful link
Glossary
ARM - Artifical Rupture of Membtanes
CRB - Cervical Ripening Balloon
CTG - Cardiotocogtaphy
IOL- Induction of Labour
IV - Intravenous