Induction
Page Contents:
Obstetric Induction of Labour (IOL) – Written by Rachael Austin, Midwife - Australia
OBSTETRIC INDUCTION OF LABOUR (IOL)
Written by, Rachael Austin, Midwife - Australia
It is a common phenomenon that towards full term pregnancy women begin to feel more uncomfortable with the growing weight of the baby. There is almost always the growing concern that when the due date arrives and the days slip by the growing pressures to have a baby both by family and health professionals. You may hear your midwife or obstetrician talk about inducing labour. Induction of labour or IOL simply means a process that is designed to start labour artificially. It can sound quite appealing when you are so exhausted of being pregnant. However, it is something that should be carefully approached especially when the pregnancy is considered normal and there is no compromise to mother or baby. The risks associated with an IOL must be weighed against the benefits
While there is much debate by health professionals what constitutes as over due, it is generally accepted that 10 to 14 days over your due date is considered over due or post dates. The risks of foetal comprise due to the placenta being “old” and not working as well increases slightly and induction will most likely be discussed from 41 weeks. However, there are other less commonly known medically indicated reasons for an IOL, fortunately they are relatively rare.
It is vital to remember that once the process of induction has commenced that there is no stopping or turning back. One induction method can easily lead to requiring one procedure, then another, then another. The process of induction and the process of intervention may be unstoppable until the baby is born. It is also possible that you might have a failed induction due to failure to progress (dystocia) or the baby becomes distressed which will result in caesarean section.
The risk to your baby also increases with induction of labour with a trend towards greater need for resuscitation, admission to a neonatal intensive care nursery or special care nursery, and an increased likelihood on needing phototherapy. Sometimes, estimated due dates are incorrect and the when the baby is born it may be more premature than first thought. Furthermore, because of the higher need for obstetrical pain relief during labour or caesarean section establishing breastfeeding may be more difficult in the first week of birth for both mother and baby.
Having said that, sometimes induction is clinically indicated and there is a number of ways that you could be induced by your midwife or obstetrician. It is important that you understand each method and the potential side effects and make an informed choice and decide which method is most suitable to you and your baby given your unique circumstances.
Sweeping of the Membranes (Strip and Stretch)
Your midwife or obstetrician may offer you a strip and stretch as the first alternative to inducing labour without drugs. A strip and stretch is associated with fewer side effects than using drugs to induce labour. This involves the membranes being striped from the cervix. The cervix is also stretched at the same time to stimulate the natural hormones of labour. It’s not usually painful but may be uncomfortable and may result in some vaginal bleeding afterward the procedure is finished. Labour often, but not always, commences after 48 hours of a strip and stretch.
Common Side effects: increases risk of infection, and premature rupture of membranes.
Foley Catheter
The use of a Foleys catheter isn’t used much for induction of labour these days. However, if there is a medical contraindication to the use of Prostin gel it is an alternative way of inducing labour without drugs. It involves a vaginal examination and the use of a lever (the same one used in a pap smear) to open the vagina so that the obstetrician can see the cervix. The Foley catheter is then passed up into the cervix and inflated like a balloon. This method of induction allows you will be able to walk around freely. This stretches the cervix open and the catheter eventually falls out. This can take 6-12 hours and usually indicates the commencement of labour.
Common Side effects: infection, ruptured membranes, haemorrhage
Prostaglandin Gel
If the cervix is not ready and is still closed, the use of vaginal prostaglandin gel (Prostin) may be suggested. (Prostaglandins are hormones which normally ripen the cervix and are found naturally in semen). It requires a small tube of the gel that is squeezed into the vagina. The ripening process usually takes 6-18 hours after the gel is inserted and then labour may begin. Sometimes a second dose of gel may be given after six hours.
Common Side Effects: nausea, vomiting, diarrhoea, hot flushes, hypertonic uterus (when the uterus contracts and won’t release)
Cervadil (Slow Release Pessary)
Cervadil is a pessary is similar to a tampon and also has a tape that hangs down for easy removal. The pessary is inserted into the vagina and placed behind the cervix. Following the removal or it voluntarily falling out, you may be recommended to have an artificial rupture of membranes (ARM), (see below) if they haven’t already ruptured spontaneously and/or be put on a Syntocinon drip (see below).
Common Side effect:Nausea, vomiting, diarrhoea
Amniotomy (Artificial Rupture of the Membranes: ARM)
ARM is done used by a similar looking needle to a crochet hook. The needle is then inserted and pricks the membranes allowing the fluid to escape. Once the watery cushion is gone the baby’s head is forced onto the cervix and subjected to the forceful contractions. Also, once the membranes are ruptured, birth of the baby must be within 48-72 hours, depending on hospital protocol. One possible reason for this is that ARM increases the likelihood of infection travelling into the uterus. If labour hasn’t commenced within 4 hours after ARM then it is likely that an intravenous Oxytocin drip will be commenced.
Common Side effects: increased pain with contractions, increased risk of infection.
Oxytocin Drip (Syntocinon)
This procedure demands that you be bed bound until birth. You will be required to have a cardiotocograph (CTG) attached to your belly to monitor the regularity, duration and intensity of your contractions and how the baby’s heart rate is coping with the induction. It is important to remember that an artificially induced labour produces much stronger and faster contractions compared to a spontaneous labour and therefore increases the likelihood of you requiring obstetric pain relief.
Common side effects: hypotension (low blood pressure), water intoxication, hypertonic uterus, uterine rupture, uterine inversion, asphyxia, nausea, vomiting, diarrhoea, rash, headaches, and increases likelihood of an asthma attack.
How Long Will It Take To Get Labour Established?
This will vary widely depending on how favourable your cervix is, how many babies you have had and the method or methods by how you are induced. Second and subsequent labours are generally shorter than they are for first time mums.
What If I Do Not Want An IOL, Am I Putting My Baby At Risk?
First time mothers have a slightly longer length of pregnancy than they do in subsequent pregnancies and this should be considered fully when discussing an IOL. Providing you have had a normal pregnancy and have a healthy baby, expectant management is generally safe. Your midwife or obstetrician may suggest a biophysical profile to confirm the well-being of the baby. This includes an ultrasound that looks at both the baby and the placenta. You can also start a baby kick chart, carefully documenting baby’s movements.
In Summary
An IOL may be a valuable tool for reducing neonatal death when the pregnancy is post dates and there is foetal compromise or there is an underlying medical condition. However, the procedure significantly increases the risk of caesarean section. A social IOL that is done for non medical reasons puts mother and baby at an increased risk of the hazards of induction. Therefore the benefits of an IOL must outweigh the risks.
References:
1. Boulvain, M., Kelly, A., Lohse, C., Stan, C & Irion, O., Mechanical methods for induction of labour”, The Cochrane Database of Systematic Reviews”, 2001, Issue 4.
2. Menticoglou, S & Hall, P., 2002, “Routine induction of labour at 41 weeks gestation: nonsenus consensus”, BJOG, Vol. 109, pp.485-91.
3. Mittendorf, R, Williams, M., Berkey, C., and Cotter P., 1990, “The length of uncomplicated human gestation”, Obstet Gynecol, Vol. 75, Issue 6, pp. 929-32
Rachael Austin, Midwife - Australia
Website: www.gentlebirth.com.au
back to the top
Obstetric Induction of Labour (IOL) – Written by Rachael Austin, Midwife - Australia
OBSTETRIC INDUCTION OF LABOUR (IOL)
Written by, Rachael Austin, Midwife - Australia
It is a common phenomenon that towards full term pregnancy women begin to feel more uncomfortable with the growing weight of the baby. There is almost always the growing concern that when the due date arrives and the days slip by the growing pressures to have a baby both by family and health professionals. You may hear your midwife or obstetrician talk about inducing labour. Induction of labour or IOL simply means a process that is designed to start labour artificially. It can sound quite appealing when you are so exhausted of being pregnant. However, it is something that should be carefully approached especially when the pregnancy is considered normal and there is no compromise to mother or baby. The risks associated with an IOL must be weighed against the benefits
While there is much debate by health professionals what constitutes as over due, it is generally accepted that 10 to 14 days over your due date is considered over due or post dates. The risks of foetal comprise due to the placenta being “old” and not working as well increases slightly and induction will most likely be discussed from 41 weeks. However, there are other less commonly known medically indicated reasons for an IOL, fortunately they are relatively rare.
It is vital to remember that once the process of induction has commenced that there is no stopping or turning back. One induction method can easily lead to requiring one procedure, then another, then another. The process of induction and the process of intervention may be unstoppable until the baby is born. It is also possible that you might have a failed induction due to failure to progress (dystocia) or the baby becomes distressed which will result in caesarean section.
The risk to your baby also increases with induction of labour with a trend towards greater need for resuscitation, admission to a neonatal intensive care nursery or special care nursery, and an increased likelihood on needing phototherapy. Sometimes, estimated due dates are incorrect and the when the baby is born it may be more premature than first thought. Furthermore, because of the higher need for obstetrical pain relief during labour or caesarean section establishing breastfeeding may be more difficult in the first week of birth for both mother and baby.
Having said that, sometimes induction is clinically indicated and there is a number of ways that you could be induced by your midwife or obstetrician. It is important that you understand each method and the potential side effects and make an informed choice and decide which method is most suitable to you and your baby given your unique circumstances.
Sweeping of the Membranes (Strip and Stretch)
Your midwife or obstetrician may offer you a strip and stretch as the first alternative to inducing labour without drugs. A strip and stretch is associated with fewer side effects than using drugs to induce labour. This involves the membranes being striped from the cervix. The cervix is also stretched at the same time to stimulate the natural hormones of labour. It’s not usually painful but may be uncomfortable and may result in some vaginal bleeding afterward the procedure is finished. Labour often, but not always, commences after 48 hours of a strip and stretch.
Common Side effects: increases risk of infection, and premature rupture of membranes.
Foley Catheter
The use of a Foleys catheter isn’t used much for induction of labour these days. However, if there is a medical contraindication to the use of Prostin gel it is an alternative way of inducing labour without drugs. It involves a vaginal examination and the use of a lever (the same one used in a pap smear) to open the vagina so that the obstetrician can see the cervix. The Foley catheter is then passed up into the cervix and inflated like a balloon. This method of induction allows you will be able to walk around freely. This stretches the cervix open and the catheter eventually falls out. This can take 6-12 hours and usually indicates the commencement of labour.
Common Side effects: infection, ruptured membranes, haemorrhage
Prostaglandin Gel
If the cervix is not ready and is still closed, the use of vaginal prostaglandin gel (Prostin) may be suggested. (Prostaglandins are hormones which normally ripen the cervix and are found naturally in semen). It requires a small tube of the gel that is squeezed into the vagina. The ripening process usually takes 6-18 hours after the gel is inserted and then labour may begin. Sometimes a second dose of gel may be given after six hours.
Common Side Effects: nausea, vomiting, diarrhoea, hot flushes, hypertonic uterus (when the uterus contracts and won’t release)
Cervadil (Slow Release Pessary)
Cervadil is a pessary is similar to a tampon and also has a tape that hangs down for easy removal. The pessary is inserted into the vagina and placed behind the cervix. Following the removal or it voluntarily falling out, you may be recommended to have an artificial rupture of membranes (ARM), (see below) if they haven’t already ruptured spontaneously and/or be put on a Syntocinon drip (see below).
Common Side effect:Nausea, vomiting, diarrhoea
Amniotomy (Artificial Rupture of the Membranes: ARM)
ARM is done used by a similar looking needle to a crochet hook. The needle is then inserted and pricks the membranes allowing the fluid to escape. Once the watery cushion is gone the baby’s head is forced onto the cervix and subjected to the forceful contractions. Also, once the membranes are ruptured, birth of the baby must be within 48-72 hours, depending on hospital protocol. One possible reason for this is that ARM increases the likelihood of infection travelling into the uterus. If labour hasn’t commenced within 4 hours after ARM then it is likely that an intravenous Oxytocin drip will be commenced.
Common Side effects: increased pain with contractions, increased risk of infection.
Oxytocin Drip (Syntocinon)
This procedure demands that you be bed bound until birth. You will be required to have a cardiotocograph (CTG) attached to your belly to monitor the regularity, duration and intensity of your contractions and how the baby’s heart rate is coping with the induction. It is important to remember that an artificially induced labour produces much stronger and faster contractions compared to a spontaneous labour and therefore increases the likelihood of you requiring obstetric pain relief.
Common side effects: hypotension (low blood pressure), water intoxication, hypertonic uterus, uterine rupture, uterine inversion, asphyxia, nausea, vomiting, diarrhoea, rash, headaches, and increases likelihood of an asthma attack.
How Long Will It Take To Get Labour Established?
This will vary widely depending on how favourable your cervix is, how many babies you have had and the method or methods by how you are induced. Second and subsequent labours are generally shorter than they are for first time mums.
What If I Do Not Want An IOL, Am I Putting My Baby At Risk?
First time mothers have a slightly longer length of pregnancy than they do in subsequent pregnancies and this should be considered fully when discussing an IOL. Providing you have had a normal pregnancy and have a healthy baby, expectant management is generally safe. Your midwife or obstetrician may suggest a biophysical profile to confirm the well-being of the baby. This includes an ultrasound that looks at both the baby and the placenta. You can also start a baby kick chart, carefully documenting baby’s movements.
In Summary
An IOL may be a valuable tool for reducing neonatal death when the pregnancy is post dates and there is foetal compromise or there is an underlying medical condition. However, the procedure significantly increases the risk of caesarean section. A social IOL that is done for non medical reasons puts mother and baby at an increased risk of the hazards of induction. Therefore the benefits of an IOL must outweigh the risks.
References:
1. Boulvain, M., Kelly, A., Lohse, C., Stan, C & Irion, O., Mechanical methods for induction of labour”, The Cochrane Database of Systematic Reviews”, 2001, Issue 4.
2. Menticoglou, S & Hall, P., 2002, “Routine induction of labour at 41 weeks gestation: nonsenus consensus”, BJOG, Vol. 109, pp.485-91.
3. Mittendorf, R, Williams, M., Berkey, C., and Cotter P., 1990, “The length of uncomplicated human gestation”, Obstet Gynecol, Vol. 75, Issue 6, pp. 929-32
Rachael Austin, Midwife - Australia
Website: www.gentlebirth.com.au
back to the top
