Induction of labour… This was too long for an Instagram post, so I thought I’d delve into this here.
Firstly, this is a subject which needs to be individualised and discussed in depth with you if you are being advised to have an induction of labour (IOL). There are many reasons why an IOL is absolutely the right decision – such as very severe pre-eclampsia, uncontrolled diabetes or maternal choice! But there are also many scenarios when IOL may not be the right choice for you and it’s important that your care providers give you the time and balanced information to make an informed choice.
In this blog post, I’m going to write about the process of induction of labour and what this may or may not entail, rather than the reasons why IOL may be offered and the pro’s/con’s of this… Otherwise you might be here reading until Christmas!
IOL is, as quoted from the NICE guidelines (2021), “a medical intervention that will affect their birth options and their experience of the birth process”. It also goes on to advise that IOL could include:
· The need for vaginal examinations.
· A limit on the choice of place of birth.
· Limitations on using a birth pool.
· The need for assisted vaginal birth – forceps or ventouse, which increases chance of 3rd/4th degree tears.
· Potential for changes in fetal heart rate and fetal compromise.
· A more painful experience than spontaneous birth.
· A longer hospital admission than that of a spontaneous birth.
The process of IOL can be a long one and it is unpredictable as to how long it will take if you choose this option.
Firstly – a “stretch and sweep” is a form of induction. You may find healthcare providers who tell you that it isn’t… Direct them to the NICE (2021) guidance which says “membrane sweeping” under the first point of IOL methods, section 1.3 if you want to be precise. You may be offered a stretch and sweep from 39 weeks, so it’s worth considering if this is acceptable to you or not.
In my opinion, and from what I’ve seen from years of practice, sweeps will only work if you are on “the edge” of going into labour, and the chances are that you would have probably laboured without it anyway. There are risks of infection with repeated vaginal examinations (VE’s) and a small risk of your waters being broken with a sweep, which may then lead you down the full intervention pathway if you don’t labour after this. What I’ve also noticed is that usually sweeps end with a couple of days of “niggly” pains, that don’t really lead to anything other than a tired woman and lowered expectations of their body’s ability to go into labour. Not what we want for those happy hormones for spontaneous labour!
There are several ways an IOL can be done in the hospital, and each NHS trust will have a different policy and procedure. So I’m going to give a general overview of the different methods and processes, but it may be worth asking your care providers what sort of IOL do they offer when making your decisions.
With the IOL process, the general aim is to be able to break the amniotic sac and release the waters around baby. This then encourages the baby’s head to press on your cervix and hopefully stimulate the contractions. If contractions don’t start then you may be offered the oxytocin drip, but I will come onto that in a bit.
Pharmacological methods include…
Vaginal pessaries - like a tiny tampon on a long piece of string with the artificial hormones to stimulate cervical effacement (thinning out) and dilation (opening of the cervix). This would stay in your vagina for 24 hours (unless you go into labour) and some hospitals may offer for you to go home during this time if you are a “low risk” induction – ie: you’re being induced because you are over your due date and there are no other risk factors.
Vaginal tablets/gels – these are usually given every 6-8 hours (medication and trust guidelines dependent) and from what I’ve seen in practice usually up to three times.
The risks of pharmacological methods include hyperstimulation (where you get too many contractions) which can lead to fetal heart rate concerns.
Non-pharmacological methods include…
Balloon catheter. This is the same as a catheter that would be put into a bladder for urinary purposes, but the catheter is put through the cervix and then the balloon (which holds the catheter in the bladder usually) is inflated with water in order to put pressure onto the cervix. The idea is that this effaces and dilates the cervix to then to be able to break the waters.
Osmotic cervical dilator. You might have heard it called “cervical rods” – a device which expands and dilates the cervix by absorbing fluid from the surrounding tissue (think like a tiny tampon!).
Pharmacological methods are often used in inductions for women who have had a previous caesarean or when your “bishops score” is below 6 (NICE 2021).
Once you have had the initial induction, the hope is that the midwife or doctor is able to break your waters and then start the oxytocin drip if required. Sometimes this will happen naturally after IOL, or maybe you will labour without the need for your waters to be broken but quite often in induction waters are broken and oxytocin drips are needed. One consideration here is that for your waters to be broken and you starting the drip, there needs to be a bed available on labour ward as 1:1 care is essential at this point. So, there is the potential for delays in the IOL process should there be bed or staffing issues on labour ward.
Now the tricky bit is that you could have some of the methods, all the methods or none of the methods!! It really is an unknown until you start your induction, and once it is started it is usually unlikely to be able to stop it.
Here’s how an IOL would potentially look:
1) Admittance to antenatal ward, CTG monitoring of baby’s heart rate and observations on yourself. VE done by a midwife/doctor and your “Bishops score” is calculated. The bishops score is a scoring chart used to assess your cervix’s readiness for labour – the higher the score the more effaced/dilated/“well positioned” your cervix is.
2) Decision for pharmacological or non-pharmacological methods as above, dependent on your local NHS trust guidance and your preference.
3) Review every 6 hours (again trust guidance dependent) with a CTG of baby’s heart rate. Usually, you are allowed to walk around the hospital, go and get a coffee etc as long as you aren’t deemed “high risk” to leave the ward.
4) Review either 24 or 6 hours after induction – depending on which method and what medication is used. Then decision as to whether further medication is needed, or if your waters can be broken.
5) Breaking of the waters and then moving to labour ward.
6) Review in 2 hours, if little or no contractions then usually the oxytocin drip is advised – which is increased until regular contractions are felt.
It could be that you have a quick induction and birth and you’re out of hospital within 24 hours, or it could be that the IOL goes on for several days and you’re in for a long admission. It really is an unknown factor and something that needs to be considered when you are making the decision as to whether this is right for you or not. It is also not unheard of for women to be given “breaks” in their induction if it’s not happening… Ie: admitted and given a 24 hour pessary, then 2x rounds of the 6 hour vaginal gel – for no cervical change to have happened. At this point you may be offered to go home and come back to repeat things in 24 hours.
Things to consider…
Use your BRAIN acronym for decision making… Benefits, risks, alternatives, intuition and nothing… There’s a post way back on my Instagram about this.
If you aren’t sure about the guidance you’re being given, ask for a second opinion! It is totally fine to do this.
Ask for more time, IOL shouldn’t usually be a big rush, unless there are any severe medical complications going on… And in this case is and IOL appropriate?
Take in your home comforts, and things to keep your mind occupied! Think your own pillows, some nice snacks… We never did finish the game of scrabble that we started when my IOL with my daughter went from nothing happening to full blown labour in 3 hours!!
Ask what your birthing options are at what stage of the IOL – some hospitals guidelines will “allow” a woman to use the pool if they go into labour after the 24 hour pessary (and nothing else), but other hospitals may not agree. Each hospital has different guidelines and it’s worth discussing your plans with the care providers and advising them what you want. Remember everything is your choice and and be based on decisions YOU should make.
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