Medical Induction

So induction?

The WHO (World Health Organisation) recommends that no woman go beyond 42 weeks of pregnancy.  If the baby is showing no signs of coming out by then, it is felt to be best for her and the baby that she be delivered. There have been women go longer but it is generally advised to be safe rather than sorry.  A 2018 study found that women induced at 39 weeks had a reduced likelihood of caesarean section.  81% of women induced at 39 weeks had a vaginal birth. 

So why be induced?

If you have any of the following then induction may be suggested:-

  • Pre-eclampsia – this is determined by a urine test which is taken detect protein.  There may also be swelling in feet or ankles. 
  • If your waters have broken but labour not started within 24 hours.
  • If the baby is too big or too small
  • If the baby has died whilst en utero
  • If you have developed an illness that can compromise you or the baby.
  • If there is not enough fluid surrounding the baby as this can then cause the baby growth to slow.
  • You may wish the baby to be born on a certain date so you choose to be induced.
  • Maternal diabetes or renal issues. 

It is worth noting that when you are induced the contractions can be stronger and more intense.  They are also unlike natural contraction in that they will build very quickly  and can be hard to cope with.  

Before an induction is attempted a woman will be assessed by medical personal to check the condition of her cervix as well as the position of the baby – this is the Bishop score. Depending on the surgeon if you have had a previous caesarean then you may not be eligible for induction.  As it is a medical intervention you will need continuous monitoring and there will be a time schedule.  

How can a woman be indued by a medical professional?

Sweep 

An internal examination (or stretch and sweep) is given and the doctor or midwife sweeps their fingers over the cervix.  This action should separate the membranes of the amniotic sac surrounding the baby from the cervix. It can be uncomfortable and some women do bleed afterwards. A type of hormone called prostaglandins are released which may then kick start labour. NICE (the National Institute for Health and Care Excellence) a UK regulatory body recommends that women be offered a sweep at 41 weeks.  Women generally go into labour 2-3 days after a sweep but with some it can happen straightaway or just after a few hours.  The good thing about a sweep is that it is a non medical way to get things going without any medical interventions.  The downside is that it can be disheartening if it doesn’t work, it can be painful and in rare cases the amniotic sac can burst which does mean from that point on your labour will have to actively managed.   

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Foley catheter

This is where a doctor inserts a small balloon into the cervix to help it dilate faster.  It is a long rubber tube with a small balloon at the end.  Water is passed through the tube to make the balloon expand and stretch the cervix which in turn causes contractions to start.  Once the baby heart rate and position have been checked the balloon will be inserted and then inflated with sterile water, the tube is taped to the woman thigh.  When you have dilated to three cms the balloon should fall out.  

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Prostin 

A prostaglandin gel is inserted either as a gel, pessary or propess (bit like a tampon) is inserted into the vagina and you are then asked to remain in bed for about an hour afterwards to enable their absorption.  Contractions may take a while to start as the cervix needs to soften.  You will be on a fetal heart monitor to check the baby heartbeat as your uterus may become overstimulated which can in turn cause the baby to become distressed.  You may be given the option of going home as these can take a while to work – you will need to come back for a top up dose.

If you have not gone into labour  then a second dose can be inserted and again you will need to rest in bed for an hour afterwards.  If the cervix has ripened (softened) and you have begun to dilate then your waters may be broken which can cause the baby to move further down the cervix and trigger more contractions.  If contractions have still not started after your waters have broken then you will probably be put on an oxytocin drip.

 Breaking the waters

The official name for having your waters broken is an amniotomy.  This is usually done at the bedside in labour or in the delivery suite.  A long needle similar to a crochet hook is inserted into your vagina and cervix by a midwife or registrar and a small nick made in your amniotic sack which allows your water to come out.  You have to be on your back for this to happen.

Breaking the waters can help speed up a labour that has stalled as well as assist in induction.  Research has shown that it does work to speed things up and does help your baby head descend down the birth canal.  It can also cause labour to suddenly get much faster which can be difficult for mother and baby as well as need one or both of them to require medical help.  It should also be noted that if the waters have been broken and labour NOT started in 24 hours then the baby will need to be delivered, most likely by caesarean section to minimise the risk of infection.

You do not need to have your waters ruptured if your baby heart rate is normal and if your labour is progressing well.

A recent study by Cochrane has shown that breaking of the waters does NOT speed up labour and does increase the chances of C-section.

Syntocinon/Pitocin

This is an artificial form of oxytocin, a hormone normally produced by the brain to help with labour.  Given intravenously to start or speed up labour it can cause your contractions to be stronger than those from normal labour.  The drip is started slowly and will gradually be increased over time. The baby’s heart beat will need constant monitoring as the stronger, more regular contractions can cause the baby to go into distress.  

Syntocinon should not be given if you have had vaginal prostaglandin in the six hours before. Caution should be advised if you are over 35, have a small pelvis where vaginal delivery is difficult, have had a previous c-section, pre-eclampsia or heart disease.  If you are having unusually strong contractions, the baby is in distress, there is an obstruction to vaginal delivery, or a low lying placenta, scarring or have a small pelvis than syntocinon is not recommended.  

Links for further information

https://www.cochrane.org/CD006167/PREG_amniotomy-for-shortening-spontaneous-labour?fbclid=IwAR2oKgfUTS1MiVNFPfdx8LGRSfxn3-IeR7wgZsPdtzlYXdrZkbbI8NP7KPE