The aim of all antenatal care is to promote natural childbirth. There may however be factors in both the mother, the baby or both that make it safest to get childbirth started.
Induction of labour is always done following a thorough assessment, and it is only done when it is assessed to be the best treatment for you and your baby.
How long does it take?
When we induce labour, we want to bring on labour before the body is ready for it. Getting labour started can therefore take several days for some women, while for others it may take just a few hours.
If your labour is induced, you should be prepared that it may take time before your contractions start and you give birth.
It is never possible to say exactly how long delivery will take. At what stage in the pregnancy labour is induced, whether you have contractions or your waters have broken and whether you have given birth before are all factors that can influence how long it takes to deliver your baby. We do not know how your body will respond to the induction method used until treatment is started.
Full term check-up (week 41 check-up)
All pregnant women are offered a full term check-up in the maternity ward where they are scheduled to give birth when they are 6-9 days over the full term date determined by ultrasound. You are not overdue at this stage.
Birth is considered to be overdue when pregnancy lasts more than 42 weeks (>294 days), or 11 days beyond the full term date determined by ultrasound.
The midwife at the health centre or your GP will refer you for this check-up. The full term check-up can be arranged for the first weekday which is practically feasible.
What happens during the full term check-up?
The full term check-up is an extended pregnancy check-up. Remember to take with you the Antenatal health card and other papers you have been given by your midwife or doctor for check-ups.
Bring a urine sample with you just as for an ordinary antenatal check-up.
In addition to the usual examinations that are done at an antenatal check-up, you will also have:
- A cardiotocograph (CTG), using an electronic foetal heart monitor, to assess your baby’s heartbeat and activity. A CTG takes about half an hour.
- An ultrasound scan to assess the amount of amniotic fluid and check your baby’s movements and size.
- A vaginal examination may also be helpful to do.
Based on the checks that are done, a talk with you about the options, and an assessment of your condition and that of your baby, a plan will be made for further treatment and follow-up. If it is decided that your labour is to be induced, the doctor will decide which induction method is best for you and your baby.
Most women go home after the first full term check-up with a new appointment in 2-3 days and with an agreement to induce no later than week 42+0.
Different methods for inducing labour
During pregnancy, the cervix (neck of your womb) is firm and several centimetres long. As you approach birth, your cervix gradually ripens. This means that it becomes softer and shorter and begins to dilate (open).
There are various methods that can be used to stimulate childbirth. The method that is best for you is decided by a doctor or midwife based on an individual assessment, including of how ripe your cervix is. This is assessed by doing an internal vaginal examination.
Ripening of the cervix using a Foley bulb catheter
If the cervix is not ripening, induction often starts with the insertion of a Foley bulb catheter, also known as a Foley balloon catheter. A Foley bulb catheter is a soft rubber tube with a balloon at the end that is otherwise used to drain urine from the bladder (catheterisation).
What happens during this procedure?
The doctor inserts the catheter into the uterus via the vagina and through the cervix. While the catheter is being placed you will be lying back with your legs in stirrups.
Once the catheter is in place, the balloon at the end of the catheter is filled with sterile saline (salt water). Part of the catheter/rubber tube remains hanging out of your vagina. This is fastened to your thigh with tape, and does not prevent ordinary activity such as moving around and going to the toilet. It is common for discharge mixed with some fresh blood to leak from the vagina or into the tube after the catheter has been placed.
How does the catheter work?
Irritation and pressure from the balloon against the cervix stimulates release of the hormone prostaglandin. Prostaglandin helps to ripen the cervix.
What happens after the procedure?
Most women can go home after the catheter is placed. If you or your baby have any condition that needs extra monitoring, admission to hospital will be considered.
The catheter is usually left in place for about 18 to 24 hours, if it does not fall out by itself. Soon after the catheter is inserted, you may experience some uterine contractions. These contractions vary in intensity and strength and you may experience menstruation-like pain in your belly and lower back. They can last for several hours and are a sign that the procedure is effective. In some women, these will progress to labour contractions and childbirth.
Before you leave the hospital, you will receive information about what to do at home. If the catheter falls out after you have left the hospital, you should contact the maternity ward. You should also do this if you are bleeding or your waters break, or if you get a fever or experience other changes in your body. You must call the maternity ward if you notice less foetal movement than is normal for your baby.
When you leave, the maternity ward will tell you when and how to return for further treatment.
Cervical ripening using hormone
The aim of this treatment is to ripen the cervix and stimulate contractions and labour. The synthetic hormone prostaglandin is used to achieve this effect. Prostaglandin is given in the form of a pill you swallow or a small tablet or capsule inserted into the vagina. In some cases, the hormone is given as a vaginal pessary (vaginal insert).
What happens during this procedure?
For this treatment, you are admitted to hospital. Before starting treatment, a doctor or midwife will do a vaginal examination to assess how ripe your cervix is.
A CTG of your baby will be done both before and regularly during the treatment. CTG (cardiotocography) is an electronic monitoring of the foetal heartbeat, in addition to the mother's contractions.
If the tablets are to be inserted into the vagina, you will be recommended to empty your bladder first. When the tablets are in place, you will need to stay in bed for a while to prevent them falling out.
How long does the treatment take?
You will be given new tablets every 2-4 hours (depending on the method and dosage), until your cervix has ripened or you get contractions. The number of tablets needed to achieve cervical ripening varies from one woman to the next.
The effect of the treatment will be assessed continuously, including by examining how ripe the cervix is. You will have regular vaginal examinations, and if you get contractions, the strength and frequency of the contractions will be assessed on a regular basis. From these assessments, the midwife and/or doctor will plan further treatment and follow-up.
Some women get frequent, troublesome contractions of the uterus from this treatment, but without the labour contractions getting started. If these contractions do not trigger the cervix to start dilating, then they still have an important function in ripening the cervix.
Amniotomy — artificially breaking the waters
If it is ripe enough, the midwife or doctor uses a small plastic hook to gently puncture the foetal membrane and release your waters (amniotic fluid). This is called an amniotomy. This will not hurt you or your baby. Releasing your waters can also stimulate contractions and induce labour.
A drip to stimulate contractions
Once your waters have broken and your cervix has ripened and is ready to start to dilate (open), an oxytocin drip is often chosen as the method of inducing labour.
Oxytocin is a hormone that causes muscle fibres in the uterus to tighten and relax and thus stimulate contractions. These contractions cause the cervix to dilate so that the baby can pass through the birth canal.
What happens during this procedure?
The midwife places an intravenous cannula, often called a Venflon, in one of the blood vessels on your hand. A cannula is a thin plastic tube that is left inside the vein, and the medicine is given through this. The tube is fastened well using plasters, and you can use your hand as usual during childbirth.
You will be given the hormone oxytocin through the cannula. The amount of oxytocin drip you are given is adjusted and assessed continuously. It always starts at a low dose and is gradually stepped up, until you get contractions that cause your cervix to open and get the birth started.
Some women need to have the drip connected until their baby is delivered, but often the drip can be reduced or removed because the body takes over the production of oxytocin. The body's natural contractions then get started and take over from the drip.
When labour is induced by drip, your baby's heartbeat and your contractions are closely monitored. You are therefore connected to a CTG device monitoring your baby’s heartbeat.
In some cases, contractions do not get started even if you have a drip. You can have some contractions that do not cause the cervix to open or do not stimulate labour. If so, it may be appropriate to take a break or to discontinue treatment. Some women get natural contractions after we shut off the drip, but if that does not happen, a new drip will be considered after a break. If labour cannot be induced, a caesarean section will be considered.