Induction of labour

Induction of labour is the process of stimulating your uterus to begin labour. Sometimes, before inducing labour, you might first need cervical ripening. This means softening, thinning and opening your cervix.

Labour normally starts naturally between 37 and 42 weeks of pregnancy.

During labour:

• your cervix softens and starts to open
• you will have contractions
• your waters may break

In an induction of labour (induced labour), these processes are started by a member of your healthcare team. There are different ways to induce labour. Induction might involve:

• mechanically opening your cervix (for example, with a balloon catheter)
• breaking your waters
• using medicine to start contractions

Sometimes a combination of methods is used. Together with your midwife or obstetrician (specialist doctor), you can discuss your options. You will talk about why you have been recommended an induction of labour, and the risks and benefits involved. This will help you decide what is best for you.

At each step, your doctor and midwife will explain what is happening. Before each test, examination or medicine is given, you will have the opportunity to ask questions and discuss your preferences in a shared decision-making process, before gaining your consent to do so.

Induction of labour usually happens in hospital. With some methods, you can have an induction as an outpatient. You might also be able to go home and wait for labour to start, or until another method is needed.

In natural labour, your contractions usually build up slowly and in induced labour they can become stronger quickly. An induced labour can sometimes be more intense and painful than a natural labour.

If you have an induction, there is a higher chance of needing other interventions during your birth, including:

• needing continuous monitoring of your baby's heart rate and contractions
• having more vaginal examinations
• seeking pain relief sooner

Research has also shown that when labour is induced, compared to when it starts naturally:

• your baby is less likely to need care in the neonatal intensive care unit (NICU)
• fewer babies are stillborn
• your baby is likely to have a higher Apgar score

When labour is induced, compared to when it starts naturally, there is no difference in:

• how often forceps or vacuum is used
• tearing during birth
• the rate of breastfeeding

Inductions may also limit how and where you give birth.

There is usually no restriction on the type of pain relief you can have if your labour is induced.

During the late stages of your pregnancy and only with your consent, your healthcare team will carry out regular checks on your health and your baby's health. These checks help assess if it is better to induce labour or to keep your baby inside.

Always tell your doctor or midwife if you notice your baby is moving less than normal.

If you and your doctor or midwife agree on an induction of labour, they will do an internal examination. They will feel your cervix to see how ready it is for labour. This examination will also help work out the best method of induction for you. Once your induction has started, it can take a few hours or more than 24 hours until your baby is born. It depends how your body responds to the induction.

There are different ways to induce labour. Your doctor or midwife will recommend the best method for you after they examine your cervix.

You may need a combination of these induction methods to start labour. You will need to give written consent before the procedure begins.

Prostaglandins

A synthetic version of the hormone prostaglandin can be inserted into your vagina to soften your cervix and prepare your body for labour. It can be in the form of:

• a gel, which may be given in several doses (usually every 6 hours)
• a pessary and tape (like a tampon), which slowly releases the hormone over 12 to 24 hours

After the prostaglandin is inserted:

• you will be asked to lie down on your left side for 30 to 40 minutes
• your baby will be monitored for 20 minutes and then every 4 hours, or more often if contractions begin
• your doctor or midwife will assess you after 12 to 18 hours to check if your cervix is softening and opening enough to break the waters in preparation for the next stage of the induction
• you will need to stay in hospital until your baby is born

Prostaglandins are often the preferred method of inducing labour since it is the closest to natural labour. An oral prostaglandin tablet has also recently been approved and may be used in some situations.

Balloon catheter

A cervical ripening balloon catheter is a small tube attached to a balloon that is inserted through your cervix. The balloon is filled with water. The other end of the catheter is taped to your inner thigh to create tension (traction) to help the balloon slowly move down. The pressure of the balloon on the cervix causes the release of hormones in the body, which help soften and open the cervix.

A balloon catheter is the preferred way to ripen your cervix if you have previously had a caesarean, you have given birth more than 5 times, or your baby measures small for their age.

You cannot have a balloon catheter if:

• your waters have broken
• you have bleeding without a clear diagnosis
• your baby's monitoring is not as expected, for example their heart rate or movements

After your balloon is inserted:

• You and your baby will be monitored for about 20 minutes or more.
• You may be able to leave the hospital after monitoring, and return 12 hours later (depending on your local health service policies).
• If your waters break or your contractions become too strong, the balloon catheter will be removed.
• After 12 hours, your health team will reassess your labour and may suggest another balloon catheter or another method of induction.

Artificial rupture of membranes (breaking your waters)

Artificial rupture of membranes (ARM) is used when your waters do not break naturally.

Your doctor or midwife will only break your waters if your cervix is ripened (softened and opened enough) and with your consent.

Your doctor or midwife will insert a small hook-like instrument during a vaginal examination to make a hole in the membrane sac that is holding the amniotic fluid.

This will help by allowing the baby's head to come lower into the pelvis increasing the pressure of your baby's head on your cervix, which may be enough to get labour started.

Oxytocin

A synthetic version of the hormone oxytocin (a hormone your body naturally produces in labour) is given to you via a drip in your arm to start your contractions. You will only get oxytocin when your cervix is ripened and your waters have broken.

When your contractions start, the amount of oxytocin is adjusted so you keep on having regular contractions until your baby is born. This whole process can take several hours.

Sometimes there isn't enough time between contractions, which can affect the baby's heart rate. This can be controlled by slowing down the oxytocin drip or giving you another medicine to stop your contractions.

After your induction has begun, tell your doctor or midwife straightaway if you:

• start bleeding
• feel your baby moving less

There are some risks if you have an induced labour. Each method used to induce labour has its own risks. Your risks depend on:

• the reason for your induction
• the method of induction
• your individual circumstances

Your midwife or doctor will discuss these risks with you — and the chance of you experiencing any of them — during a shared decision-making conversation before your induction begins.

Risks with prostaglandins

Risks associated with prostaglandins include:

• vaginal pain
• fetal distress
• stimulation of your uterus, causing contractions that are too strong and too frequent
• nausea, vomiting, low blood pressure or tachycardia (fast heart rate)

Risks with artificially rupturing membranes

Risks associated with artificially rupturing your membranes include:

• cord prolapse or compression
• rupture of vasa praevia
• pain and discomfort

Risks with balloon catheter

Risks associated with balloon catheters include:

• placental abruption (when the placenta partially or completely separates from the wall of the uterus)
• rupture (tear) of your uterus
• discomfort after insertion
• difficulty passing urine
• bleeding
• damage or trauma to your cervix

Risks with oxytocin

Risks associated with oxytocin include:

• nausea and vomiting
• overstimulation of your uterus, causing contractions that are too frequent

You may be offered to have your labour started early (induced) if staying pregnant is riskier for you or your baby's health.

Your doctor or midwife might recommend inducing your labour for your health if:

• you are overdue (41 to 42 weeks pregnant)
• you are living with a condition that puts you at risk of complications — for example: diabetes, gestational diabetes, kidney disease or obesity
• you are having problems with your blood pressure — such as pre-eclampsia, eclampsia, HELLP syndrome.
• your waters have broken and contractions have not started naturally within 24 to 48 hours
• you have Group B strep and your waters have broken
• you have a multiple pregnancy (twins or more) — depending on your situation
• you have chorioamnionitis
• there is a concern your placenta is not working as it should

Your doctor or midwife might recommend inducing labour for your baby's health, if:

• they are worried about your baby's growth — for example your baby is measuring small for its age, moving less than expected or there is not enough amniotic fluid
• your baby has a birth difference — a health condition from birth, sometimes called a congenital anomaly
• you are having a stillbirth

As part of shared decision making, your doctor or midwife will explain why they recommend an induction of labour. They will also explain the risks and benefits. Your doctor or midwife will consider your personal preferences and values. This will help you make an informed decision.

Remember, the decision to have an induction is always up to you. Your health team will explain the benefits and risks to help you. You can change your mind at any time. You also have the right to seek a second opinion if you wish.

Every person's induction experience is unique. Research shows that if you have an induction, there is a chance you may feel less satisfied with your birth. This is especially true if you wanted a more 'natural' experience. These feelings are valid and normal.

You can reach out for support from your doctor, midwife or a counsellor. They can help you process your experience.

Here are some examples of questions you can ask your doctor or midwife. These can help you understand inductions better, and make a decision that is right for you and your baby:

• Why do I need an induction?
• How will it affect me and my baby?
• What will happen if I do not have the induction? What are my other options?
• How will you induce my labour?
• How will you care for me and my baby?
• What are the risks of an induction?
• What are my options for pain relief?

Clear communication with a trusted healthcare professional can help you with your decisions.

If you are overdue, ask your health team how quickly you need to make a decision on induction. You might want to check if you have the option to wait and see if labour will start naturally. Your doctors might ask you to consider that there is a higher risk of stillbirth or other problems the longer your pregnancy goes past term.

If you have experienced complications in your pregnancy, either due to yours or your baby's health, you may be advised to consider an induction of labour before your due date.

Sometimes you will not be offered an induction because it may not be safe for you or your baby. The reasons for this are usually the same as those that can make a vaginal birth unsafe for your or your baby.

Some of these reasons are 'absolute contraindications' — this means that an induction is not an option under any circumstances. Others are 'relative contraindications' — this means that your doctor will consider your personal situation and your preferences to decide if you and your baby can safely have an induction.

Absolute contraindications for induction of labour include:

• you have placenta praevia (where the placenta covers your cervix)
• you have vasa praevia (where your baby's blood vessels are near your cervix)
• when your baby is very large, or your pelvis is too small for your baby to come out through your birth canal
• cord presentation

Relative contraindications for induction of labour include:

• you have previously had a caesarean section
• you have active genital herpes
• you are living with HIV (human immunodeficiency virus)
• you or your baby have health conditions that need specialist care

It is important to know that not all induction methods will work for everyone. If your induction does not work, your midwife or doctor may suggest another method or recommend a caesarean section. They will discuss all the options with you.

• The Royal Women's Hospital has information on induction of labour in different languages.
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has more information about induction of labour.
• Learn more about the different stages of labour on the Queensland Government website.
• Stronger Bubba Born provides support so you can yarn with your healthcare team about the best and safest timing of birth.