Induction of labour

The cervical ripening catheter (balloon) is an option to induce your labour.

It allows your cervix to be dilated mechanically, which helps with the artificial rupture of your membranes. The balloon has minimal side effects and does not need you to be monitored as closely as when using a medical method.

The procedure involves a catheter (a soft silicone tube) being inserted into your cervix. 

It has a balloon near the tip and when it is in place the balloon is filled with a sterile saline (salt water) fluid. 

The catheter stays in place for 12 hours, with the balloon putting gentle pressure on your cervix. The pressure should soften and open your cervix enough to start labour or to be able to break the waters around your baby.

The balloon catheter may fall out by itself or will be removed by a midwife the following day. 

During the time the balloon is in place, you can carry out normal activities, such as showering, bathing or walking. After going to the toilet, please wash your hands, make sure the catheter is clean and change underwear regularly.

Please report any of the following to your midwife:

• bleeding
• contractions
• concerns about the baby’s movements
• if you feel unwell
• if the waters around the baby break
• if the balloon falls out

We use a ‘Dinoprostone 10mg pessary’ (Propess) which is inserted into your vagina and allows for the slow release of prostaglandin over 24 hours. It prepares the neck of the womb for labour. You may also get contractions during this process.

We will advise you to keep the pessary in for 24 hours. The pessary may need to be removed if:

• you are in real labour (which is when you have regular, three or four contractions every 10 minutes and the neck of your womb is opened 3cm or more).
• you are having too many contractions (five or more contractions every 10 minutes)
• you are having too long contractions (one contraction lasting about two minutes)
• your baby’s heartbeat is no longer normal
• you start bleeding. It is normal to get a tiny amount of blood with some mucous discharge after an internal examination

The following are all possibilities of what might happen once the prostaglandin pessary is inserted:

• You may go into labour and the neck of your womb may start opening. If this happens, we will remove the pessary.
• Your waters may break without you being in labour. If this happens, you will need an oxytocin infusion drip to start the contractions. The prostaglandin pessary may be left inside while you are waiting for the drip.
• The neck of your womb will soften and shorten, but you may not have gone into labour. If this happens, your waters will need to be broken and you will need an oxytocin infusion drip to start the contractions.

Some women may require more than one method to prepare the neck of the womb for labour.
 

This is also known as ‘breaking the waters’ and can be used if the cervix has started to ripen. 

A small hole is made in the membranes using a slim, sterile, single use plastic instrument during an internal examination. It is performed by the midwife or obstetrician. 

Having your membranes broken should encourage more effective contractions.

Sometimes, prostaglandins and/or breaking the waters are sufficient to start labour, but many women require oxytocin. This drug is given via a drip into a vein in the arm. 

It causes the womb to contract and is usually used after the membranes have broken either naturally or artificially. The dose can be adjusted according to how your labour is progressing. The aim is for the womb to contract regularly until you give birth.

When using this method of induction, it is advisable to have your baby’s heart rate monitored continuously using a cardiotocograph machine. 

The contractions can feel quite strong with this type of induction — the midwife will ask you how you are coping and offer different methods of pain management.

Induction promotes birth before your body is ready for labour. Therefore, compared to natural labour, some side effects are more common.

These include:

• increased length of labour
• increased need for pain relief, including an epidural
• the possibility of too many or prolonged contractions, which can diminish your baby's oxygen supply and lower your baby's heart rate. This is very rare, affecting less than 1% of women
• increased need for an instrumental birth (for example the use of forceps or suction). About 10% of women nationally experience an instrumental delivery following spontaneous labour compared to 15% for those who have had an induced labour. This figure is slightly higher in our maternity units as more women choose to use epidurals for pain relief
• increased need for a caesarean section

If induction of labour does not work, we will discuss other options with you, one of which is a caesarean section delivery. Induction of labour is only recommended if the benefits outweigh the risks.
 

If your labour is induced, you will not be able to have your baby at home, but if you go into labour following use of just the cervical ripening balloon or pessary , you can have your baby in the birth centre — our midwifery-led unit alongside the labour ward — providing you are within the criteria for midwifery-led care.

If you do not go into labour after induction, your midwife and obstetrician will discuss your options with you and check you and your baby thoroughly. This happens in about 5-10% of women having. 

Depending on your wishes and circumstances, we may offer you:

• another method of induction
• defer the induction for a later date if circumstances allow
• caesarean section delivery

Your obstetrician will explain in detail the reasons why he/she recommends induction of labour. 

However, if you do not wish to be induced at this time, you should tell your midwife or obstetrician. We will then ask you to come to the hospital for monitoring so we can check how you and your baby are.

We will check your baby’s heartbeat and you will have a scan to check the water around your baby. 

Please note, this type of monitoring is not very reliable in showing us which pregnancies are at a high risk of stillbirth. Because of these limitations, we offer induction of labour to all pregnancies before 42 weeks’ gestation (two weeks after your expected date of delivery).

How often you come to the hospital for monitoring depends on your situation, and the midwife and obstetrician will discuss this with you.

We understand that if your induction is delayed, you may feel distressed and upset. 

However, the midwife or obstetrician will give you reassurance and try to keep you informed about arrangements for your induction. The arrangements are dependent on your individual circumstances and those of the labour ward.

Your induction of labour may be delayed if all midwives are busy caring for other patients at that time and/or there is no bed available. Birth is unpredictable and we have women arriving as emergencies 24 hours a day. 

We, as midwives and obstetricians, have a responsibility to care for mothers and babies on our unit and ensure safe deliveries. This may impact on the plan for your induction of labour, either delaying the start of your induction, or delaying the process of your induction if it has already started. 

If you are unhappy at any time, please ask to speak to the senior midwife on duty.