Inpatient Induction of Labour

Dilapan-S® is a small synthetic rod that absorbs fluid and expands. Usually 4 rods are placed inside the cervix during a speculum or vaginal examination, and over 12-24 hours they expand and dilate/soften the cervix gradually. After this time they are removed and a repeat vaginal examination is performed and most of the time (in over 90%) it is then possible to break the waters. The waters can be broken once there is a midwife on delivery suite available to continue your care.

The insertion takes around 5-10 minutes, and can be uncomfortable, but most patients tolerate it well. Minor bleeding can occur afterwards, but this is not a concern. You will be asked to lie down flat after their insertion for 30 minutes, but after this you can move around and go about daily activities normally (with the exception that having a bath is not recommended). You may leave the ward, but not the hospital (unless outpatient induction has been agreed), for short periods but check with your midwife that it is safe to do so and let them know when you will return.

There is a risk of the rods migrating up into your uterus but this is very rare

In previous instances where this has happened, the women concerned went on to have an unplanned Caesarean birth, for other reasons, and the rods were removed at the time of the surgery. However, most women who are induced will go on to have a vaginal delivery and it is likely that any migrated rods will deliver at the same time as the placenta. If they do not, then the rods would retrieved using a fine instrument passed into your vagina and through your cervix.

Whilst the Dilapan-S® rods are in place most patients are not aware of them, and they do not usually cause contractions so there is not usually any pain. You should let the midwife know if you think the rods are falling out.

Prostaglandins are naturally occurring hormones released by the body in normal labour. The aim of the pessary (synthetic prostaglandin) is to soften and open the cervix, so the waters are able to be broken.

A Propess® pessary is inserted into the vagina during examination. Once in place, it sits behind the cervix and slowly releases prostaglandins that cause the cervix to soften and the womb to contract. It is a bit like a tampon and has a tape so that it can be easily removed; either once labour starts, at the end of the treatment time (24 hours) or earlier if complications arise.

After the pessary is inserted you will need to stay on the bed for an hour, then you will be encouraged to mobilise as this helps stimulate active labour. Take care after washing and going to the toilet so as to not dislodge the pessary. You can remain dressed and eat and drink as normal. You may leave the ward, but not the hospital (unless an outpatient induction has been agreed), for short periods but check with your midwife that it is safe to do so and let them know when you will return.

Sometimes you will be aware of period type pains which are less intense than contractions. These may build up to proper labour pains or fade away as the effect of the medication wears off. If you are feeling uncomfortable, discuss with your Midwife what pain relief you would like. There is a range of options even in the very early stages of labour including gentle mobilisation, lying in a warm bath, pain relieving tablets or a TENS machine (if you have one).

During this time the Midwife will review you regularly by:

• Checking your temperature, pulse and blood pressure
• Asking about any pain or vaginal loss
• Asking about your need for pain relief
• Listening to your baby’s heartbeat, this may involve being continuously monitored for a time

Some women can develop unwanted side effects from the Propess, including:

• Vaginal bleeding
• Diarrhoea / vomiting
• Contractions too close together (hyperstimulation).

• This method of induction is offered only in specific circumstances by an Obstetric Consultant. This would be offered if other methods of Induction have not been successful
• It involves insertion of a soft, flexible tube called a Foleys catheter with a small balloon on the end. Once the tube is inserted inside the cervix, the balloon is then inflated with sterile water. The catheter balloon helps to dilate/open the cervix by gently putting pressure on the cervix.
• The catheter is inserted on the maternity ward; during insertion your legs would be placed into stirrups, similar to a routine gynaecological exam. The doctor will use a speculum to check your cervix, will insert the tip of the catheter into your cervix and then inflate the balloon with up to 30mls of saline solution.
• Having a catheter inserted can cause discomfort similar to contraction pains
• Once the catheter balloon is in, it can be likened to the sensation of a large tampon. The insertion takes approximately 10 minutes to perform
• The catheter will then be taped or strapped to your thigh so that it does not pull downwards.
• The aim is for the inflated balloon to put enough pressure on your cervix to encourage it to dilate and for labour to start. This could take up to 12 hours or more. The catheter balloon is likely to fall out once your cervix begins to dilate.
• Once the catheter is removed or if it does fall out, a vaginal examination will be performed to assess the dilatation of your cervix. Labour contractions may have already commenced and no further intervention necessary but if you haven’t had any contractions, the next step would be to break your waters and commence an intravenous drip to try to start your contractions.

Usually both of these methods are available for you to choose. There is insufficient evidence to say which one is better. Dilapan is a relatively new induction method. In some cases one method might be recommended as a safer option for you and your baby. The main differences are:

• Mechanical induction does not usually cause contractions, it mechanically dilates the cervix. This is a safer method of induction if you have had previous caesarean sections
• Mechanical induction is anticipated to cause less pain during the induction as it causes fewer contractions.
• Mechanical induction does not usually cause contractions so it won’t start off labour, which can sometimes occur with Propess®. This means you are more likely to need synthetic oxytocin through a drip to help with the contractions (this is needed in around 95% of inductions with mechanical induction, and 70% with Propess®).

If we are unable to break the waters after Dilapan or Propess then you would be offered a repeat treatment with the same agent, or a different agent (like Foleys catheter). If this is unsuccessful then sometimes a hormone gel can be used rather than a pessary (called Prostin).

Other options will include resting for a period of time before trying again or having a caesarean section.

Caesarean section

An unplanned C section is a potential risk with all inductions. This could be due to your cervix not opening despite the induction process, or more rarely, if concerns develop surrounding the wellbeing of your baby when a heart tracing is undertaken’

Prostin Gel

If, after the Propess, your cervix has changed enough for you to have your waters broken, you will be transferred to Delivery Suite when there is a bed available for you. If there are no significant changes, you may be offered one of the mechanical options like foleys catheter.

The Prostin gel has the same hormone as the Propess but it works slightly differently. The gel is inserted close to your cervix using an applicator. Your baby’s heart beat will be monitored for 30 minutes before Prostin and at least an hour following the Prostin.

After this time, you can continue to eat and drink normally. You may shower or bathe and you can leave the ward for short periods if you wish to. Your baby will be monitored using the CTG machine and after 6 hours you will be assessed internally again. If your cervix is still unchanged, you can have another Prostin gel.

If, after the second Prostin, your cervix is still closed, a doctor will come and discuss your options. They may suggest waiting for 24 hours to see if labour begins or trying a third Prostin. They will be able to answer any questions you may have and they will explain everything in detail for you.

If your cervix has dilated enough to enable us to break your waters, you will be transferred to Delivery Suite. However, there may be a delay whilst a bed is made available for you.

Once you are on Delivery Suite a midwife will break your waters using an Amnihook. This procedure can be uncomfortable for you but is not harmful to your baby. If your contractions have not started after 1-2 hours then you will have an intravenous infusion (IV) called Syntocinon. This IV contains hormones that artificially starts contractions. It is administered through a pump and during this time your baby will be continuously monitored on the CTG machine. Although this may limit your ability to mobilise, you can still alter your position to aid your comfort and promote the progress of labour. There are a range of pain relief options available to you that you can discuss with your midwife.

Yes, if you don’t want to be induced at the time when the doctor or midwife is suggesting, you can talk through your options. The doctor or midwife will answer any questions you have and give you information for you to make an informed decision.

If you are being induced because your baby is overdue and you are otherwise low risk, please speak to your midwife about the possibility of having an OUTPATIENT induction of labour. This means you can be at home for the first stage of your IOL.

For some women IOL can take several days. It is important to arrange child care for your other children should this happen.

It is possible for you to have one person staying with you throughout the induction process.

All of your meals and drinks will be provided for you, but your birth partner will have to bring their own.

Car parking fees are not controlled by the hospital, any queries regarding parking should be directed to the car parking kiosk in the main car park.

​Can someone stay with me in the hospital?

Yes, one designated birth partner can remain with you at all times. Please note, we do not allow the swapping of birth partners.

Can I still go to the Birth Centre?

The Birth Centre is only suitable for women who have had an uncomplicated pregnancy. If you were planning to have your baby on ‘The Birth Centre’ but have now been advised that you need to have an Induction of Labour, it is unlikely that the Birth Centre will be suitable for you.

This is because of how your baby is monitored in labour. On The Birth Centre babies are monitored using intermittent auscultation which is only suitable in uncomplicated pregnancies. If you are being induced for any other reason than postdates it is because we have concerns for your health or your babies. This means your baby needs to be continuously monitored once you are in established labour which can only be undertaken on Delivery Suite. This also means that a waterbirth is no longer suitable for you.

If the only reason you are being induced is because you are overdue this can be an inpatient or outpatient induction. You will still be suitable to come to The Birth Centre once you are in established labour if you go into labour in the 24 hours following the insertion of the Propess. If the induction of labour requires further intervention then you will be transferred to Delivery suite.

Will the examination hurt?

It can be uncomfortable during the insertion of the Prostagladgins or Dilapan as it is important for it to be in the right place. This will ease once the examination has finished.

Is induced labour more painful?

Induced labour can be more painful for some women, please ensure you speak to the midwife caring for you about pain relief options.

How long will induction take?

This depends on which method of IOL you choose and how quickly your body responds to prostaglandins - but for many women it can take between 24-72 hours. The process is thought to be shorter using mechanical methods as the device is in for a shorter time.