Outpatient Induction of Labour

Introduction

What

For the majority of women, labour is a spontaneous process, however for some women, induction of labour may be recommended. An induced labour, or induction, is where a woman receives some medical assistance to start labour. Induction of labour is a relatively common procedure: in 2019-2020 33% of women were induced in the UK.

An outpatient induction is an induction that can be started in hospital and then enables you to go home for some time. You will then return to the hospital for the birth of your baby. This is instead of an ‘inpatient induction’ where you would be required to stay in hospital for the whole duration.

Why

Most women will go into labour by 42 weeks, however if you are still pregnant at 40 weeks, your community midwife will offer you an induction at 41 weeks.  This is because there is evidence of increased complications and stillbirth beyond 42 weeks of pregnancy. This is often called a ‘post dates’ induction.

Outpatient induction of labour can be beneficial because it reduces the amount of time you are required to stay in hospital before your labour begins. This allows you to spend more time in your home environment or with your family. Research shows that outpatient induction of labour increases women’s satisfaction of the induction process. 

Who

 You will be offered the choice of an outpatient induction of labour if:

  • Your pregnancy is deemed ‘low risk’ (there are no concerns around yours or your baby’s health.
  • An induction of labour is being offered to prevent the pregnancy going beyond 41-42 weeks (a ‘post dates’ induction).
  • You have available transport and live within 30 minutes of the hospital
  • You have a working telephone or mobile with credit to ensure to you can easily contact the hospital
  • You have a good understanding and are able to speak English, to ensure communication between you and the hospital can be achieved
  • This is your first, second or third birth

It is always your choice whether you accept an induction of labour. If you choose to decline, an obstetrician will discuss this with you and you may be offered increased monitoring such as a cardiotocography (CTG) monitoring to observe baby’s heartbeat or ultrasound scan. Alternatively, if there is a part of the induction process which you wish to decline, please discuss this with an obstetrician or midwife.

Membrane sweep

Before your induction you may be offered a membrane sweep. This involves a midwife or obstetrician performing a vaginal examination where they will attempt to ‘sweep’ the membranes. This is done by inserting two fingers into the cervix and performing a circular motion to separate the membranes (baby’s sac) from the cervix. This aims to increase the production of hormones called Prostaglandins which increases the chance of you going into labour spontaneously. Sometimes this can be uncomfortable and can cause some light bleeding or cause your ‘mucus plug’ to come away. This often looks like a jelly or mucus discharge which can have some blood staining in it. If you notice fresh red bleeding following a sweep or have any concerns such as worries around your baby’s movements, please call the Pregnancy Assessment Unit for advice. It is possible to have more than one sweep if you wish, please discuss this with the obstetrician or your midwife. 

Day 1 – Attending Hospital

On the day of your induction we ask you to attend Maternity Reception at your allocated time. This will have been given to you by the Doctor or Midwife when your induction of labour was booked. 

When you arrive at the hospital, you will meet the midwife caring for you; they will fully explain the induction process and answer any questions that you have. She will then check your blood pressure, temperature and pulse, and will feel your bump to determine where the baby is lying. The midwife will listen to your baby’s heartbeat using sensors. This method of listening to your baby is called cardiotocography (CTG). It allows us to listen to your baby’s heart for a period of time and to assess any tightenings or contractions you may be experiencing. 

An obstetrician will then come and see you to perform an ultrasound scan to confirm which way your baby is lying prior to commencing the induction process.  When the CTG has been assessed as normal (this may take anywhere from 20 minutes to an hour) the doctor will gain your consent to commence the induction. 

Dilapan-S

‘Mechanical dilation’ is the name given to a process which aims to make your cervix more favourable without the use of artificial hormones; the method used at this hospital is called
Dilapan-S. Mechanical dilation of the cervix is successful in over 90% of women. 

The Doctor will gain your consent to perform a speculum examination so that they can insert between three and five slim rods made of synthetic gel into the cervix. These rods absorb the fluid from the surrounding tissue and begin to gently expand up for 14mm over 12 hours. When the rods grow, they dilate and soften the cervix to help you prepare for labour. It is unlikely you will begin to experience strong uterine contractions with Dilapan-S. Unfortunately, if you have a genital tract infection Dilapan-S cannot be used. 

Following the insertion of Dilapan-S we will listen to your baby’s heartbeat again with a CTG to ensure it is normal following the procedure. Then you will be discharged home with a time to return the following day. In total, the rods will be in place for 12-24 hours, depending on your allocated time to return. 

If you experience any of the following, you should contact the delivery suite and you will be invited to return to the hospital immediately:

  • Uterine contractions – this will feel like a ‘tightening’ where your abdomen tenses and then goes soft again
  • A change in your baby’s movements such as a reduction in the frequency of movements or a change in pattern
  • Any vaginal bleeding (this is different to a blood stained show or mucus plug, a midwife will assess this if you are unsure). 
  • Any pain in your abdomen, pelvis or vagina
  • You begin to feel unwell or like you have a fever 
  • You notice an offensive smelling discharge or your discharge changes colour
  • If you notice any Dilapan-S rods that have come out or feel dislodged 
  • You have any other concerns about your or your baby’s wellbeing

Following arrival at the hospital, we would remove the Dilapan-S rods early in the following situations;

  • An assessment of your cervix by vaginal examination finds that you have gone into spontaneous onset of labour (defined as regular uterine activity with cervical dilatation of more than 4cm)
  • There is any abnormal bleeding  
  • Concerns with your baby’s heart rate 
  • Spontaneous rupture of membranes (your waters breaking)
  • Some of the rods coming out themselves

Dilapan-S doesn’t interfere with going to the toilet, having a shower or moving around. However, you should not have a bath, use a vaginal douche or have sexual intercourse whilst they are in place. Please do not try to remove the rods yourself under any circumstances.

If you return to hospital with any of these problems a midwife and doctor will assess you and your baby’s wellbeing and discuss an appropriate plan with you. With your consent they would perform a vaginal examination to assess how ‘favourable’ (ready) your cervix is for labour. This will help to decide whether you require prostaglandin to help your cervix to change or if it is possible for an amniotomy to be performed. See both sections below for more information. 

Day 2 – Returning to hospital

The next day at your appointed time we ask you return to the hospital, you should bring your hospital bag as you will now be staying in hospital until your baby is born. Similarly to the day before, you will meet the midwife caring for you. She will check your blood pressure, temperature and pulse, and will feel your bump to determine where the baby is lying and then perform a CTG monitoring of baby’s heart and to assess any tightenings or contractions you may be experiencing. 

Vaginal Examinations 

When the CTG has been assessed as normal (this may take anywhere from 20 minutes to an hour) the midwife will ask your consent to perform a vaginal examination. She will remove the Dilapan-S rods and assess how favourable (‘ready’) your cervix is for labour. 

For some women, the dilapan-S will have made your cervix change enough that it is possible to perform an ‘amniotomy or ARM’ to break your waters, this is explained in section 8. However, for some women it may be that the cervix has not become favourable enough for this to be possible, so a medication called Prostaglandin will be administered to aid this.  

Prostaglandins

Prostin is a medication which releases a hormone called ‘prostaglandin’ that encourages your cervix to become softer, thinner and more open. This usually comes in a gel form and is inserted next to your cervix during a vaginal examination. Once the gel has been inserted, the midwife will then check your blood pressure and pulse again, and listen to your baby’s heartbeat using the CTG to ensure both you and baby remain well.  

As well as making your cervix more favourable for labour, Prostin gel may also cause your uterus to start tightening. This may feel like cramp in your lower abdomen, or a ‘tightening’ where your abdomen tenses and then goes soft again; this can be present and not painful, or can be painful. You can request pain relief, such as Paracetamol or Codeine tablets, from the midwife caring for you at any time. There is also a bath in the rooms that some women can find helps with this. Where painful uterine activity has begun, the hope is that this will aid the cervix to change. In some cases, women can go into labour from here (defined as regular uterine activity with cervical dilatation of more than 4cm). In some cases, your waters may break spontaneously. If this happens, it is possible that you may be going in to labour, so we would encourage you to spend some time moving around to encourage this. Providing there were no concerns with you or baby’s wellbeing, we would not assess your cervix until your next vaginal examination was due. If your cervix has not yet become favourable enough for labour, you may be given one further dose of Prostin, or if your cervix is favourable but uterine activity has not yet started, a Syntocinon drip will be recommended. This is explained further in section 9.  

Being upright and mobile can also help to encourage your cervix to change. We advise that during the period between having a Prostin gel and your next assessment, you try and keep upright and move around, for example, by walking around or using the birthing ball available in your induction room.

Six hours following the first assessment, the midwife will check your observations again, as well as your baby’s heartbeat on the CTG monitor. At this point, it may be possible to break your waters if there has been sufficient change to the cervix, or you may require another Prostin gel. If you receive a second dose of Prostin, the same observations will be carried out after this examination as were completed following your first Prostin gel.

If you received a second Prostin dose, there will be a resting period, usually overnight, prior to an assessment the next morning. We encourage you to try and get some rest, however the midwife may wake you to check on you and to listen to baby’s heartbeat every four hours.

The following morning, once again we will take your observations and commence a CTG monitoring of baby to ensure you are both well. Then with your consent, perform another vaginal examination to assess your cervix. If your cervix has become favorable enough we will break your waters. If the cervix hasn’t quite changed enough yet, the midwife and doctor will discuss your further options. These are;

  • A second cycle of Prostin which would compose of a third and fourth dose, starting 24 hours after your first dose the day before. 
  • Attempt to break your waters even though it may be difficult when your cervix remains ‘unfavourable’. This can make your labour last longer and often includes a longer time spent having an oxytocin infusion. There is also a higher chance of what is sometimes called a ‘failed induction’, where the induction methods fail to start labour. 
  • Choosing to discontinue the induction process and to have a caesarean section.

It is important to remember that inducing labour successfully takes a different amount of time for every woman. On average, the time between coming into hospital and having your baby is somewhere between 1 and 3 days, in some rare occasions it can still be unsuccessful after this time. 

Breaking your waters (amniotomy or ARM)

An amniotomy is completed by making a small hole in the bag of waters surrounding your baby using a plastic instrument called an ‘amnihook’. This allows the baby’s head to press firmly on your cervix and encourages contractions to begin. Breaking the waters will not be painful for you; however some people can find vaginal examinations uncomfortable, your midwife will support you with this. 

Once your waters have been broken with an amniotomy (ARM), it is possible that you may begin to experience uterine activity, if this happens, we will allow some time to see if these contractions are effective in making a change to your cervix to progress in to labour. If no or little change is made, or you do not experience uterine activity, you will be offered the hormone drip to help to progress your labour. 

Hormone drip (Oxytocin infusion)

This drip will run through a cannula in your hand, with a hormone called ‘Oxytocin’, to encourage your uterus to begin to contract. The drip will be started on a small dose, and will be gradually increased until you are experiencing contractions, occurring four to five times in 10 minutes. Whilst you are on the drip, we will monitor baby with a CTG at all times, to ensure that baby is not showing any signs of stress in labour. 

Whilst having a drip and a CTG monitor on throughout labour can limit your movement , your midwife will help you with being upright and mobile. The beds on Delivery Suite can change to support you in different positions, and the midwife can move the equipment around so you can stand up and lean on the bed or sit on a birthing ball. We also have peanut balls which can be used if you want to rest on the bed or are asked to remain on the bed due to concerns with baby’s heartbeat, these balls rest between both of your legs and help to widen your pelvis which can help baby to descend.

It is important to ensure that we have the right number of midwives and doctors to care for all women in the unit safely. Although inductions are scheduled, sometimes if more women arrive in spontaneous labour or there is an emergency situation, the midwives or doctors may need to be reallocated. In this situation, part of the induction process might be delayed. All decisions to delay an induction will also consider yours and your baby’s safety and will be discussed with you by a Doctor or Senior Midwife. You will be included in the discussion about this and we encourage you to raise any concerns about this you may have. 

Benefits and Risks

What are the benefits of Induction of Labour? 

Induction of labour allows us to bring on labour and birth for babies or women who might otherwise be at risk if the pregnancy continued. 

At the Queen Elizabeth hospital, we routinely offer all women who have a low risk pregnancy induction of labour from 41 weeks because, after this time, there is a small increase in the risk of a baby dying during pregnancy, labour or after birth: 

  • Before 41 weeks, the risk is less than 1 in 1000. 
  • After 41 weeks, the risk increases to 1-2 in 10002. 

We do not know for certain why the risk of a baby dying increases after 41 weeks, but it is thought that the placenta (which provides your baby with all of the oxygen and energy he/she needs to grow and survive) works less effectively after this time. 

It is important to remember that, if you have had a straightforward, low-risk pregnancy, the risk of this happening is very low whether or not you choose to have your labour induced3.  Some studies found that induction of labour reduced the number of babies admitted to a neonatal intensive care unit, fewer babies were born macrosomic (weighing more than 4500g) and the rate of caesarean section was lower4.

What are the risks? 

Some evidence shows that induction of labour increases the chance of women needing an instrumental delivery (with forceps or suction/ventouse) to deliver your baby, when compared to a labour that begins spontaneously. Although, more recent studies have shown that there was little difference, so the evidence is currently unclear. 

Evidence also suggests that induction of labour does not significantly change the caesarean section rate, which is around 25% of women in the UK.  However, induction of labour after 40 weeks is shown to reduce the caesarean section rate. 

Between the 1st November 2019 and 1st November 2020 at QE Gateshead Maternity department the statistics were;

  • 886 women were induced
  • 63% resulted in a spontaneous vaginal birth
  • 16% resulted in having a caesarean section
  • 17% resulted in having a forceps instrumental birth
  • 4% resulted in having a ventouse instrumental birth

When your waters are broken the risk of infection increases very slightly, from about 1 in 200 to 2 in 200. However, as your baby will usually be born within 24 hours of this procedure, the risk is very small. 

Induction of labour can increase the risk of hyperstimulation, this is when your uterus contracts too much. In some cases, you may need to be given some medication to stop the uterus from contracting, this is because hyperstimulation carries a risk to you and baby. The midwives and Doctors will monitor you closely for this. 

Frequently Asked Questions

How is an induced labour different from a normal labour? 

Induced labour may be more painful than spontaneous labour, this is because the Syntocinon drip is intended to make your contractions stronger6. The midwife caring for you will discuss all of the available pain relief options as your induction progresses. 

What pain relief is available and when can I have it? 

Throughout the induction process you will be offered regular pain relief in the form of paracetamol and codeine tablets. When your labour begins, or following amniotomy, you will be offered the full range of available pain relief. This includes gas & air (Entonox), strong injections (pethidine or diamorphine) and/or an epidural. For more information regarding pain relief in labour see ‘Pain Relief and Anaesthesia Choices for your baby’s birth’ on your Maternity Notes app or NHS ‘Pain Relief in Labour’ online. 

Can I use the birthing pool? 

The use of the birthing pool for labour and delivery is supported in women whose pregnancy has been low risk. For high risk pregnancies the birthing pool is not advised as continuous monitoring of baby with a CTG is recommended in labour. Therefore, if your induction is for medical reasons or because your pregnancy is classed as ‘high risk’, the birthing pool is not advised. 

If your pregnancy is low risk and your induction of labour is due to ‘post dates’ with no other concerns for yours or baby’s health, water birth may be an option for you. For example if you go in to labour following Dilapan-S or Prostin, you could use the pool. However, if you require the Syntocinon infusion, CTG monitoring is advised to observe for baby showing any signs of distress. Unfortunately CTG monitoring cannot be used in the pool, therefore we would not advise the pool in this instance. If you have any questions or wish to discuss this further, please discuss with an obstetrician or midwife.  

Can my birthing partner stay with me? 

Both our delivery suite and induction rooms allow one partner to stay with you as a reclining chair is provided. If you are required to stay on the antenatal ward as all the induction rooms are in use, unfortunately birthing partners cannot stay. Please be assured that this is rare and as soon as you are transferred to the Delivery Suite at any point, your birthing partners will be contacted to come and support you immediately.

What if induction does not work? 

If we are unable to break your waters after Dilapan-S and four doses of Prostin, a doctor will discuss this with you and make a plan that takes into account your own wishes, in addition to the wellbeing of yourself and your baby. Together, you may decide to re-start the induction process or to opt for a caesarean section. 

What happens if I choose not to be induced? 

Being induced is a decision that you, and those supporting you, should discuss. If you decide not to be induced, our doctors and midwives will fully support this decision and create an individualised care plan you. This usually involves attending the Pregnancy Assessment Unit for additional checks such as a CTG monitoring or an ultrasound scan.

How do I prepare for induction of labour?

Please read this information leaflet and share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are supporting you as the birth partner/s. We also recommend making family, especially children and those caring for them aware that the procedure can take a long time before the baby is born.

How will the Covid-19 pandemic affect my induction of labour?

Prior to the Covid-19 pandemic, you were able to have two birthing partners with you at all times through an induction and labour and birth. Unfortunately, out of necessity to keep our women, babies and staff safe, we have had to temporarily reduce this to allow just one birthing partner. Your birthing partner can come in with you from the very start of the induction and stay with you throughout, however we would ask them to refrain from coming and leaving the hospital, to attempt to reduce the possible transmission of the virus. They will also be asked to wear a surgical face mask when entering the hospital and when there is a staff member in the room. 

You will also have an arranged Covid-19 swab 48 hours prior to your induction. It is unlikely that the result of this would change your induction; however it is important for staff to know if you are Covid-19 positive so that we can keep you, baby and staff safe. 

Further Information:

If you have any additional queries please contact:

Your Community Midwife on:

East team: 0191 445 2140 (08:30-16:30)

West team: 0191 445 5306 (08:30-16:30)

The Pregnancy Assessment Unit on: 0191 445 2764 (24 hours)

Delivery Suite on: 0191 445 2150 (24 hours)

Further information can also be found through the following websites:

National Institute for Health & Care Excellence [NICE] (2008) Inducing labour: Information for the public.

National Institute for Health Research (2016) Choices When Pregnancy Reaches 41 Weeks.

NHS UK, Inducing Labour

NHS UK, Pain Relief in Labour.

Data Protection

Any personal information is kept confidential. There may be occasions where your information needs to be shared with other care professionals to ensure you receive the best care possible.

In order to assist us to improve the services available, your information may be used for clinical audit, research, teaching and anonymised for National NHS Reviews and Statistics.  

Further information is available via Gateshead Health NHS Foundation Trust website or by contacting the Data Protection Officer by telephone on 0191 445 8418 or by email ghnt.ig.team@nhs.net.

This leaflet can be made available in other languages and formats upon request