Induction of Labour (IOL)

Why are you being induced? 
Has something happened?  EARLY LABOUR or POST DATES?

How?    Check cervix – ripe / unripe – it’s not very positive language 
Pessary gel – how many doses?
Break waters- is this possible?

Syntocin drip – stiimulates contractions – can overstimulate
Epidural to cope with chemical contractions? 
Instrumental – ventouse / forceps
Caesarean section – why? what happens. 

One of the most common interventions pregnant women face is induction i.e. artificially initiated labour. According to the World Health Organisation (WHO) 25% of all ‘deliveries’ at term are induced (2011).
The healthcare trust determines when you will be ‘offered’ induction (although many women are made to feel as though there is no choice.)

Sara Wickham has written “Inducing labour – making informed decisions” which is a good resource. In our culture being overdue is a common reason why women are offered an induction of Labour.

The actual due date is very difficult to determine, as is the individual’s natural gestation period.

There is no actual evidence to support the belief that Naegele’s rule (the little wheel midwives use to calculate due date, based on the first day of your last menstrual period) is accurate.
Nor is there robust evidence to say being induced before 42 weeks is unequivocally safer for the baby (Wickham, 2018).
However, a lot of these practices have been happening for so long, they’ve become entrenched. This is known as practice-based preaching as opposed to evidence-based teaching.

The issue with induction when it is on a ‘just in case’ basis is if the body and baby are not ready to go into labour, it to go into labour, it can lead to a long drawn out process, considerably more uncomfortable than when a woman goes into spontaneous labour. There is also a massively increased chance that IOL can lead to instrumental birth, tearing, episiotomy and/or caesarean because of the cascade of intervention.
One study found induction increases the chance of Caesarean by 20% for first time mothers (Reed, R., 2016.)
It has become common practice for women to be offered a stretch and sweep from about 37 weeks, when midwife or doctor during a vaginal examination, sweep a finger around or within the opening of the cervix, in an attempt to stimulate the body’s natural Prostaglandin production.  REMEMBER – YOU MUST GIVE CONSENT … if they do an internal examination and as they come out they say “ohh I just did a quick sweep whilst I was in there” … that’s ASSAULT and you should definitely ask for the senior midwife on duty and ask for a change of midwife … THEY MUST SEEK YOUR CONSENT BEFORE DOING A SWEEP … 

However, research has shown a sweep does not seem to produce “clinically important benefits” (Boulvain et al 2005:2). It comes down to personal choice whether to have one or not, but I usually remind my clients to advise their care givers that if the cervix is not easily found (remember it points backwards during pregnancy and only starts to come forward when the time is right) they should refrain from looking for it! If the mother agrees to an induction the first stage (depending on what is happening with the cervix already) is synthetic Prostaglandin, generally in the form of a pessary, tablet or gel which is placed high in the vagina during a vaginal examination. Some hospitals use a version of Prostaglandin, known as Propess, which looks like a very small tampon and has a similar string to pull it out if and when it needs to be removed.
Prostaglandins can sometimes cause strong contractions very quickly which the baby (and the mum!) could find very stressful so there is usually a period of electronic foetal monitoring for 30-60 minutes after insertion to check that baby’s heartbeat remains within normal limits. Depending on whether a woman has had a baby before, or how ready or not her body is to go into labour, affects how many doses of Prostaglandin she may require. Sometimes women are permitted to go home in between insertion and re-examination, other times they are asked to stay in hospital. As with any form of intervention, there are risks such as uterine hyperstimulation (extremely strong and frequent contractions), foetal distress, increase in maternal temperature, infection etc.

Some hospitals will use a device called a Cooks Balloon which is inserted through the neck of the cervix and then inflated. The idea is it puts pressure on the cervix to encourage dilation. There is less risk of uterine hyperstimulation with this method, but it can be fairly uncomfortable and a small number of women can experience severe discomfort, bleeding and vomiting. If there has been some dilation within the cervix the waters can then be broken.

Sometimes if a woman has had a baby before, or the cervix is already dilated enough there may not be any need for the cervical ripening stage, as the caregivers can already get to the bag of waters. This process is known as ARM which means Artificial Rupture of Membranes and it is performed during a vaginal examination with a piece of equipment known as an amnihook. The hook is rounded at the top, so it can be inserted without causing any harm to the mother and has a little hook on the underside which is used to rupture the membranes. The actual rupturing bit is not painful because there are no nerves in the amniotic sack (it’s a bit like cutting fingernails or hair) but the internal examination involved can be a bit uncomfortable.

Again, there are risks; baby can get distressed, contractions can be more painful than they would have been had the membranes been allowed to rupture spontaneously, but the biggest issue with breaking the waters is the baby is now vulnerable to infections because their protective barrier is no longer there. This becomes more of an issue in hospital because there are so many more germs floating around than if you waters had broken and you were still at home. Because of the risk of infection, once the waters have been broken, hospital policy is usually to go straight to using Syntocinon which is artificial Oxytocin, to induce or speed up the contractions. If you’re reading any American books, they refer to it as Pitocin, but it is the same thing.

Syntocinon is administered directly into the blood stream via an intravenous drip. Even though the synthetic form of the hormone is a pretty similar match to the physical makeup of the natural hormone, they couldn’t be more different in the way they work (Wickham, 2018). When we produce natural Oxytocin, it comes from the pituitary gland in the brain and crosses into the blood from there, benefiting us with both its physical effects and emotional benefits, as well as communicating with our brains to produce more. When Syntocinon is used, it goes directly into the blood stream, by-passing the blood-brain barrier and therefore only works on the uterus ‘forcing’ it to contract. There is no feedback system from that physical act, no communication to produce more hormones of any kind, other than Adrenalin which is a response to the contractions feeling much more painful than they would normally. For this reason, many women (although not all) opt for an epidural. The Syntocinon drip is started at a slow rate and will be gradually increased over time until the contractions reach the desired pattern (they are aiming for 4 contractions within a 10-minute period – known as 4 in 10). The mother and baby will be continuously monitored, because the hormone drip can cause hyperstimulation of the uterus and lead to foetal distress.

Inductions can work well for some women and not so well for others. It can take a long time, as in days, for anything to happen and for others the process can be much quicker. So, ask questions and use your BRAINS!!!!


Here in the UK they may start with a pessary (24 hour) or if you are already in labour your caregiver may augment. I would explore your options here as some clients have said that they needed to re-evaluate their intensity relief options (noticed I’ve avoided the P word here) resulting in them opting for an Epidural. Again we need to weigh up the positives and negatives for this option. I have supported positive births where clients have opted to have an epidural and it gave them the space and time for their baby to move down through the birth canal, I have been at births where the epidural did very little due to how it was sited and I have supported births where it didn’t help and the client choose to go to an elective section.
Notice, I don’t say emergency here as when the client is at this point and there is no medical emergency then she is electing to choose this route. It may be an emergency if there were other indicators as in baby was distressed so there would be an urgency to go to theatre.

To explore the pathway for Induction please click here

The pathway is very clear. The following has been copied from the NICE Guidelines pathway from the above link. Please do look at this pathway in depth as the drugs used for stimulation of the cervix are named and you may wish to do some research on this further. Link

Wherever induction of labour is carried out, facilities should be available for continuous electronic fetal heart rate and uterine contraction monitoring. Before induction of labour is carried out, YOUR Bishop score should be assessed and recorded, and a normal fetal heart rate pattern should be confirmed using electronic fetal monitoring. Once active labour is established, maternal and fetal monitoring should be carried out as described in the NICE recommendations on intrapartum care. To reduce the likelihood of cord prolapse, which may occur at the time of amniotomy precautions should be taken.  Please discuss this with your caregivers.

Monitoring and assessment

  • Before induction, engagement of the presenting part should be assessed.
  • Obstetricians and midwives should palpate for umbilical cord presentation during the preliminary vaginal examination and avoid dislodging the baby’s head.
  • Amniotomy should be avoided if the baby’s head is high.

Healthcare professionals should always check that there are no signs of a low-lying placental site before membrane sweeping and before induction of labour.
Sources The NICE guidance that was used to create this part of the interactive flowchart. Inducing labour (2008) NICE guideline CG70
This may be helpful in asking the questions you have with regards to your care.
Link Intrapartum care – Latent First Stage