Getting labour started

Induction means having your labour started artificially with medication at the hospital. It seems to be one of the most worrisome and controversial procedures offered in the world of maternity care, and yet around 1 in 5 births in the UK will follow an induction of labour. This figure is a source of frustration to some, but if you are anticipating an induction, hopefully you can take comfort in the fact that it is a very common process that staff are used to managing, and the majority of them go according to plan.

Sometimes induction of labour is done because there is solid proof that doing so will protect mothers, such as those with gestational diabetes or pre-eclampsia, and their babies from harm. Sometimes it is done on the balance of risk, and your doctor is offering it rather than recommending it (for instance, if your pregnancy has lasted beyond 41 weeks).

Different hospitals will have different ways to induce women into labour, but they usually follow a similar pattern:

1. You come into hospital and have your baby monitored. Often the induction area will be a shared bay.
2. Your doctor or midwife performs a vaginal examination and inserts a pessary, gel or tablet into your vagina, high up next to your cervix. After this, your baby’s heartbeat will be monitored.
3. Depending on the type of medicine used, they will repeat the exam after 6 hours (if a tablet or gel has been used) or 24 hours (if a pessary) and they will use a stick with a small hook on the end to break your waters (amniotomy or ARM).
4. You’re moved to your own labour room, have a cannula put into your hand or arm and start a drip called oxytocin that starts your contractions. This is gradually turned up until you are contracting 3-4 times every 10 minutes.

A small number of hospitals are starting to use mechanical methods of induction such as small balloons or absorbent sticks that expand and open the cervix. These are less common and usually suited to women who have had caesarean sections in the past. Certain units have offered the first part of the induction process as an outpatient, but as of yet there is not enough evidence available to recommend this¹, although it may still be offered after a discussion.

These steps take time and can sometimes be delayed by emergencies or a very busy labour ward, so if you go to hospital for induction, bring books, snacks, magazines, a phone charger, a laptop, tablet or anything else you might need to stop you getting bored.

Because doctors are starting your labour, and because it’s possible to cause too many contractions with the drip if not carefully monitored, anyone who is being induced will need to have their baby’s heartbeat constantly monitored when they’re having regular contractions. If the only reason for your induction is that you are past your due date and you labour after your waters have broken without needing the drip, you should be offered intermittent auscultation as an alternative to continuous fetal monitoring.

Won’t I end up with forceps or caesarean section if I’m induced?

It used to be assumed that your chances of intervention in labour were much higher if you were induced compared to if you went into labour naturally. Certainly, interventions like needing continuous monitoring, having a cannula in and the limitations that come with this will affect your experience of labour. For instance, you’re unlikely to be offered the use of the birthing pool if you need to have the oxytocin drip.

However, many women are induced because of a medical problem, and these medical problems come with higher risks of needing intervention such as instrumental or caesarean delivery anyway, whether or not labour is induced. A recent large study has shown that when you take account of this and look at women with no other problems, induction itself doesn’t seem to significantly increase your chances of having either an instrumental delivery or a caesarean. (If it has any effect, it may slightly reduce the chance of a caesarean but slightly increase the chance of needing forceps.)

Isn’t it a lot more painful to be induced?

This is a hard question to answer as the experience of pain differs so much from person to person. Some women will be induced and only need gas and air; others will have a spontaneous labour but find the experience to be very painful from start to finish and they will want stronger painkillers (analgesia). Women do seem to report that an induced labour is more painful than a natural labour, but it’s important to remember that contractions may come on thick and fast if induced, compared to a spontaneous labour which often starts slowly and works up. Because of this, the speed at which regular strong contractions are reached may be a factor in how the pain is perceived.

All the pain relief options available during a natural labour are also available for an induced labour.

Do I have to be induced? What happens if I don’t want to be?

This is a great question to ask in conjunction with reading our page on consent.

Some complications that arise during pregnancy can pose a clear and significant risk to you or your baby. Other conditions are thought to pose a risk, but how big a risk is not yet understood. Your doctor should explain to you what the risks of the situation are, the risks of the induction, and what would happen if you do nothing.

Often, the aim of induction is to prevent stillbirth, either due to a medical issue or due to being well beyond your due date. This is a difficult and emotive conversation. Doctors have been accused of trying to scare women into procedures like induction by quoting stillbirth as a risk of not being induced. Unfortunately this criticism is sometimes justified.

However, there does seem to be evidence that a pro-active induction policy can prevent stillbirths², but the trade-off is the mother’s experience of labour, which is inevitably medicalised. Between 400-500 inductions of otherwise low-risk women would need to take place to prevent one death³. This sounds like a lot, yet this is no comfort to those women whose babies are stillborn and who would have done anything to prevent it.

Trying to weigh up the risks and benefits of undergoing a procedure to prevent a rare but tragic complication, and how much discomfort or loss of a positive birth experience is worth the reduction in risk, is an intimidating task for both mother and doctor. Often, there is no clear right or wrong answer.

If induction has been recommended but you don’t feel it’s right for you, your maternity healthcare team should give you options for extra monitoring of your baby until you go into labour naturally or choose to accept induction of labour. This might be with scans or with regular fetal heartbeat monitoring. However, it’s important to be clear that while these are done for reassurance and for opportunities to pick up any developing problems, there is no evidence that such extra monitoring can prevent stillbirth or reduce the risk in the same way induction can.

What if my induction fails?

Sometimes women will not go into labour despite the medications they receive. Usually this is because the cervix does not open enough for the doctor to break the waters. Your doctor will discuss the options with you, taking into consideration the reason for induction, how soon your baby needs to be delivered and the likelihood of success with repeated attempts. The two main options are to repeat the process after a day of rest or to proceed with a caesarean section.

Although the pros and cons of induction will very much depend on why it is being offered, the chart below compares some of them side by side:

Positives of Induction	Negatives of Induction
You avoid dangerous medical complications if you have a particular condition.	Your birth is more medicalised, meaning more vaginal examinations, medications and time in hospital.
If you’re worried about your baby’s wellbeing, they’re born sooner rather than later.	Labour is more sudden, which some women experience as more painful.
Your baby’s heartbeat will be monitored throughout labour. This has pros and cons of its own, and for some women it feels like a good thing while others won’t want it.
Induction on its own does not significantly increase the risk of needing an instrumental delivery (forceps or suction cup), or a caesarean section. However, some reasons for which you might be induced do, such as gestational diabetes.

 

Main Points

• Induction means having your labour started artificially with medication.
• Around 1 in 5 births will follow an induction of labour.
• Doctors may recommend the induction of labour if you’ve had a complicated pregnancy that threatens your and your baby’s wellbeing- for instance, if it’s been affected by diabetes or pre-eclampsia – or if the pregnancy lasts over 41 weeks.
• Although different hospitals have different ways of inducing labour, if often follows a similar pattern: during an examination, your midwife or doctor inserts a pessary, gel, or tablet into your vagina. They will then repeat the examination hours later and then use a stick with a small hook at the end to break your waters. You’re then moved to your own labour room and given an oxytocin drip which will help start contractions.
• Another way of inducing labour is through the use of small balloons or absorbent sticks that expand and open the cervix. These are usually suited to women who’ve had a caesarean section in the past.
• Some units may offer an outpatient induction of labour. This option may be discussed with you if you’re a suitable candidate.
• The process of inducing labour can often take time, so be sure to take a laptop, phone, books, and food to the hospital with you so you can occupy yourself.
• During the process of inducing labour, your baby’s heartbeat will need to be monitored because it’s possible for the oxytocin drip to cause too many contractions.
• It has been assumed that the induction of labour brings with it the higher likelihood of needing intervention, such as an instrumental delivery, but induction often happens because of a medical condition, and these often carry a higher risk of intervention anyway. Taking this into account, induction itself does not seem to significantly increase your chances of requiring intervention.
• Because induced labour is sudden and strong contractions tend to be reached quickly, it is often thought to be more painful than a natural labour, but remember that all pain relief options available during a normal labour are also available for an induced labour.
• The decision to have an induced labour is often based on whether you have had a complicated pregnancy. The risks of induction should be weighed against the risks that the complications pose to you and your baby. If induction is recommended but you decide against it, the maternity team should provide you with options for extra monitoring of your baby until you go into labour naturally.
• There is evidence that a hospital’s pro-active induction policy can prevent stillbirth, but it means the mother’s labour is medicalised. Sometimes induction fails because the cervix does not open enough to break the waters. In this case, the two main options are to attempt induction again after a day of rest or to proceed with a caesarean section. Your doctor will discuss the options with you and help you decide which is best.

References

1- Kelly AJ, Alfirevic Z, and Ghosh A, Outpatient versus inpatient induction of labour for improving birth outcomes. Cochrane Database Syst Rev. 2013 Nov 12;(11):CD007372

2 – Hedegaard M, Lidegaard Ø, Skovlund CW, Mørch LS and Hedegaard M, Reduction in stillbirths at term after new birth induction paradigm: results of a national intervention. BMJ Open. 2014 Aug 14;4(8):e005785

3 – Middleton P, Shepherd E, and Crowther CA, Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2018 May 9;5:CD004945
National Institute for Health and Care Excellence (2008) Inducing Labour (NICE Clinical Guideline 70)

Farnworth, A. et al. (National Institute for Health Research 2016) Choices when pregnancy reaches 41 weeks (Patient Information Leaflet), available at: https://www.nhs.uk/Conditions/pregnancy-and-baby/Documents/IOL-leaflet-40plus-weeks.pdf