Including outpatient induction of labour and what to do if your waters break and you are not contracting.
What are the reasons for induction of labour (IOL)?
Induction of labour is a common procedure. Labour is induced when it is thought that the outcome of the pregnancy will be better if labour is artificially started rather than waiting for labour to start naturally. The reasons to start off a labour can be variable and sometimes more urgent than others.
It is important that you talk to the midwife or doctor about the reasons to start the labour and what are the risks and benefits of starting the labour compared with continuing with the pregnancy. It is your decision and it is important that you know why it is being advised.
Induction of labour does make it a different experience compared to a labour that starts naturally and it is important you have thought about this too. We know that starting off a labour can make the labour longer and more painful. We also know that women being induced are more likely to have an epidural for pain relief and an assisted birth (ventouse or forceps). It is a good idea to discuss your birth plan with the midwives.
When IOL of labour is being considered, your doctor or midwife will fully discuss your options before a joint decision is reached. This should include explaining the procedures and the care that will be involved and whether there are any risks to you and your baby.
If you are healthy and have had a trouble-free pregnancy, IOL may be offered if:
- Your pregnancy is more than 12 days over your due date
- If your waters break before labour starts.
There may be a medical reason why you are being advised to have your labour induced e.g. if you have diabetes or you have developed Pre-eclampsia (high blood pressure and proteinuria), if you have a baby over 4000g or 9Ib (pregnancy.cochrane.org) or you are showing signs of growth failure on ultrasound.
If you decide not to be induced when you are past your due date you will be offered:
- Discussion with a doctor to discuss any risks verses any benefits of the IOL
- An ultrasound scan
- Increased antenatal monitoring thereafter which includes daily CTGs –electronic monitoring of the baby’s heart.
What are my options for IOL?
Before IOL of labour is offered, you should be offered a Membrane Sweep to help you go into labour before 42 weeks. This is usually performed by your community midwife.
To start a labour there are medical interventions we can use:
- Prostaglandin – this is often the first stage of starting a labour. It helps to make the cervix ready for labour. At Southmead we use a Propess pessary which releases the prostaglandin slowly over 24 hours.
- Artificial Rupture of Membranes (ARM) – this can be the first stage for women whose cervix is already dilated. This is performed by an internal examination. By breaking the sac that surrounds the baby the fluid is released and this can sometimes start the contractions of labour.
- Syntocinon infusion – this is used once the waters around the baby have broken and is a hormone drug that is given into a drip in the arm. This hormone (oxytocin) will start the contractions of labour.
- Cook Cervical Ripening Balloon - this can be used to help dilate the cervix ready for an ARM. The balloon stays in place for 12 hours.
What is the process for IOL?
On the day of your IOL, you will be asked to attend Quantock Ward which is based within the maternity unit at Southmead Hospital.
Once you have given consent for the IOL, the midwife will perform a full antenatal assessment which will include recording your temperature, pulse, and blood pressure and a recording of your baby’s heartbeat using an electric machine, for approximately 30 minutes. The midwife will examine you vaginally to establish whether your waters are able to be broken or if you need a prostaglandin (Propess) to help prepare your cervix for labour.
If your waters can be broken, you will need to be transferred to the Central Delivery Suite. Sometimes there is a delay due to the activity on the Delivery Suite. If this occurs, the midwife will ensure that you have no risk factors and you may be asked to go home and wait for a bed to become available. If you do go home, your contact details will be taken so that the Central Delivery Suite can contact you as soon as a room/midwife becomes available. Women are prioritised to their clinical need for induction of labour.
Once your waters have been broken, you will be encouraged to walkabout for about one hour. If you do not start contracting after this time, the doctor will discuss with you starting a drip which contains Syntocinon - a drug that encourages contractions and given via a drip in your hand/arm.
If the midwife is unable to break your waters, a Propess will be inserted into your vagina. You will then be encouraged to mobilise. At this stage you may be able to go home if you have no risk factors. The Propess will remain in the vagina for 24 hours. If you go into labour during this 24 hours you may be suitable to use Mendip Birth Centre if there are no other risk factors, this should be discussed with you antenatally.
After 24 hours, if you have not gone into labour, you will be transferred to the Central Delivery Suite, according to clinical need.
A doctor or midwife will review you on the Central Delivery Suite to see if your waters can be broken. If there is any delay in transferring to the Delivery Suite, then the midwife on the ward will check your blood pressure, pulse and temperature as well as the baby’s heartbeat. If all the observations are normal, consideration maybe given to leaving the Propess in the vagina for a further six hours.
If your waters break when the Propess is in your vagina, you will need to inform the midwife so that she can check you and your baby.
The Propess may be removed before 24 hours if:
- You are experiencing painful tightenings
- If we are able to break your waters
- If your womb starts to contract very frequently (known as hyperstimulation)
- If your baby shows signs of any distress.
It is possible to have an outpatient IOL if you meet the following criteria:
- If you or your baby have no risk factors
- The Bishop Score of your womb is seven or less (your midwife or a doctor will explain this further to you)
- You have transport to take you home and bring you back when you require
- You have a telephone
- The waters around your baby is within normal limits
- If your waters have not broken
- If the electronic monitoring of your baby is normal.
If you meet the above criteria, once you have been given the Propess you will be advised to go home.
Once you are at home, you will be asked to return to the Quantock Assessment Unit if you experience any of the following:
- Regular painful contractions
- If you require any pain relief
- If you have any vaginal bleeding
- If your waters break
- If you think that your baby’s movements are as many as normal
- Any other concerns you may have
- If you experience a lot of bleeding, the midwife will advise you to remove the Propess (which is like removing a tampon).
When you are at home, you will be contacted by a member of staff from the Quantock Assessment Unit at 12 hours to see how you are. After 24 hours, you will be asked to return to for a review and further plan for your on-going IOL.
It is safe to have a shower or bath following the insertion of a Propess although care should be taken that not too much soap is used around the vaginal area and not to pull on the tape.
What are the possible side effects of Propess?
Vaginal prostin, which is controlled-release, is the preferred method of IOL at Southmead Hospital and is recommended by NICE (2008, 2014). This method of IOL of labour has been found to be safe for both mother and baby. However some women have noticed very minor side effects such as nausea and diarrhoea, and frequent contractions. In very rare cases, the frequent contractions can cause stress for the baby which may need urgent attention.
If your waters break and you do not start to contract
If your waters break and you do not start contracting you will need to ring the Maternity Unit for advice and probably be asked to come in for assessment. If it is confirmed that your waters have broken, you will either be offered an IOL immediately (depending on the activity and room availability on the Central Delivery Suite) or you could wait until 24 hours to see if you go into labour on your own.
If you give birth after 24 hours of your waters breaking, your baby will require observations for 24 hours and you will be asked to stay in hospital for this duration.
Can my birthing partners be with me?
On admission to the Quantock Assessment Unit, you may bring one birthing partner with you for support. Bed spaces are quite small so it is difficult to easily and comfortably accommodate more than one. Please keep your belongs to a minimum too. All items for your baby can be kept in your car or at home until it is required.
If you are not in labour, your birthing partner will be advised to go home at 8pm.
If you are in early labour and would like your partner to stay to support you, then please ask the person in charge. Unfortunately we are unable to provide a bed for your partner.
When you are transferred to the Central Delivery Suite to have your waters broken or if you are in established labour, you can invite another birthing partner to be with you.
What are the benefits of IOL?
- 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 getting an infection if your waters have broken and labour has not started.
What are the risks or disadvantages of IOL?
- 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 Syntocinon. Drugs can be given to reverse over-contracting in extreme cases, and if related to the Propess®, this will be removed
- IOL may take up to 72 hours to achieve and may involve more vaginal examinations.
Who can have an outpatient IOL?
You may be offered an outpatient induction of labour if:
- Your pregnancy is ‘low risk’.
- You have no medical or obstetric problems.
- You have transport to bring you to the hospital.
Your midwife or doctor will have a conversation with you about the outpatient induction of labour process and if you meet all the criteria you will be offered this method of induction.
Why have an outpatient IOL?
An outpatient induction of 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.
- Makes the process of going into labour more normal.
What happens on the day of an outpatient IOL?
Your midwife or doctor will book an appointment for you to attend the Quantock Ward at Southmead Hospital for your induction of labour.
Please remember to bring your hand-held yellow notes with you and an overnight bag, just in case you need to stay in hospital.
You will have your pulse, blood pressure, temperature and urine checked. The midwife will also read you notes and ensure you meet the criteria for outpatient induction of labour.
The midwife will discuss the process with you and answer any questions you may have.
The midwife will also examine and measure your tummy to check your baby’s size and the way your baby is laying. Your baby’s heartbeat will then be monitored for 30 minutes using a CTG machine.
Once the midwife is happy with the observations and CTG she will ask if it is ok to perform an internal vaginal examination to check your cervix. At this point a membrane sweep may be offered.
The midwife is checking your cervix to see how ‘favourable’ it is. This means how dilated, soft and thick the cervix is, as well as how deep the baby is in the pelvis. The midwife will discuss findings with you and if appropriate will insert the Propess into the vagina. Propess is a very small flat tampon which slowly releases prostaglandins over 24 hours. A second CTG will be performed for 30 minutes to ensure your baby’s heart rate is ok.
The Propess string will lie just outside the vagina and it is important that you take care not to pull or drag on it. You will also need to take care when:
- Wiping yourself after going to the toilet.
- After washing.
- Getting on and off the bed.
If the midwife is happy with observations and CTG monitoring you will be discharged home. You can continue with your day to day activities and eat and drink as normal.
If there are no concerns whilst you are at home, a Midwife from Quantock Ward will contact you 12 hours after the insertion of your Propess for a telephone assessment. If no concerns at 12 hours you are to return to Quantock Ward 24 hours following the insertion of the Propess.
What happens when I go home from an outpatient IOL?
The Propess works by ‘ripening’ your cervix, encouraging it to soften, shorten and begin to open. It is normal to experience some period type pain, back ache and tightening and we recommend regular paracetamol, mobilising and a warm bath at home.
- Your tummy starts to tighten painfully every five minutes.
- Severe abdominal pain.
- A run of contractions which are occurring more than 4 in a 10 minute period.
- Any vaginal bleeding.
- If you think your waters have broke.
- Reduced or absent fetal movements.
You may be advised to take the Propess out immediately by pulling on the string and will be required to come to Quantock Ward or Quantock Assessment Unit.
Are there any side effects of an outpatient IOL?
Propess can occasionally produce some side effects which are usually mild and can include:
If any of these occur to a distressing level please contact the Quantock Ward.