According to most hospitals there are three steps to most inductions. (I would argue there’s actually 5!). Every step can be treated as a new decision, and if an when to accept a new step is ultimately up to you!
All hospitals should follow the NICE guidelines when offering induction, which can be found here. Use your decision making tools to help you decide in and when induction feels like a positive choice for you.
Before any method of induction a midwife will assess your cervix with a vaginal examination (with your consent) to give you something called a ‘Bishop Score’. A Bishop Score gives you a reasonable idea as to how ‘successful’ an induction is likely to be. A score of over 7 would be considered ‘favourable’ for induction. (Obviously there’s no fully reliable method of knowing what is to come!). You can ask your midwife to talk you through your Bishop Score and what it may mean moving forwards.
Step One- a Stretch and Sweep
You may offered a sweep at your 40 week and 41 week appointment as well as prior to any medical induction. You can either accept or decline this offer, so make sure you feel fully informed before deciding!
A membrane sweep involves a vaginal examination, where your midwife or doctor will insert a finger into your cervix (so an effective sweep requires your cervix to be open at least a little), sweep their finger around the inside of the cervix, in order to separate the membranes (or sac) surrounding your baby, and potentially stimulate the cervix enough to bring on contractions. More on the risks and benefits of a sweep here.
Step Two- Prostaglandin Gel/ Pessary.
This is usually considered the first step of a medical induction. If you are having an induction after a previous cesarean, you will likely be offered a ‘foley bulb’ instead of this step due to the risk of uterine hyperstimulation (having too many contractions).
A pessary (like a small tampon with prostaglandin hormones in) is inserted into the vagina and placed behind the cervix. The idea is that the hormones on the pessary will cause the cervix to soften enough to begin to open. For some women this stage will be enough to kick start labour, for others enough to open the cervix a little and for others not much will change at all.
If you have started having contractions, this could be the final step of the induction process and labour can continue as normal. Depending on the reason for the induction you may still be able to go home at this point or use a birth centre.
If your cervix has started to open, but contractions have not started, you may be offered the next stage of the induction process.
If there has been no cervical change you may be offered a ‘rest’ where they take it out, and then a second pessary after 24 hours.
Step Three- Artificial Rupture of Membranes
‘Breaking your waters’ (you may see this written in your notes as ARM). Once your cervix is open a little, a midwife or doctor may offer to break your waters. This may happen after step 1 and 2, OR you may be offered this stage right away (particularly for second births or if your cervix is open naturally already- consider the pros and cons of jumping ahead and discuss this with your midwife. You can always take the ‘next’ step, but you can’t jump back a step!).
They do this using a long, thin hook (it looks a bit like a crochet hook). It shouldn’t be a painful procedure, but it can bring labour on very quickly. The idea is that once the waters have released, your baby’s head may press harder on the cervix and cause it to dilate.
This may be enough to put you into ‘active’ labour and things can continue as normal. Depending on the reason for breaking your waters, you may well be able to continue with your home birth or on a birth centre.
There is a chance that once your waters have been broken, you may not go into active labour. After a period of 24 hours most hospitals will offer you the next stage of the induction process. (Depending on the reason for induction and your own preference this time period may be shorter or longer, so discuss it with your health care team).
Step Four- Syntocinon Drip
The final step of a medical induction is the us of a syntocinon drip. Sytocinon is an artificial version of your body’s natural hormone ‘oxytocin’, which is essential for labour and birth. The hormone drip is turned up until you are having three strong surges in 10 minutes.
You may also be offered this stage on induction if your waters have broken and then you havent gone into labour (current guidelines say after 24 hours, though the increased risk of infection actually only occurs after 72 hours). Or, if you have been in active labour and things have stalled or slowed down. As with an decision, this should always be yours to make, so be sure to used the decision making tools from Positively Birthing Online to help with this!
Step Five: C-Section
If the above methods of induction do not cause your cervix to dilate or put you into active labour, the final thing you may be offered is a cesarean. This ‘step’ isn’t usually listed as part of the ‘induction process’ but actually, may be something you are offered in these circumstances. ‘On paper’ it would be called an ‘emergency cesarean’, but in practice it’s usually as calm and positive an experience as a planned c-section.
There are risks and benefits to the entire induction process and its important to discuss with your healthcare team what these look like for your own personal circumstances. It is however important to understand that induction is a serious intervention and should only be used when there is a real clinical indication for it.
The NICE guidelines state that it important to understand an induction is ‘likely to be more painful’ than a natural/spontaneous labour. This is likely down to your body not producing endorphins (pain relieving hormone) in the same way that it would in a spontaneous labour. For this reason many women may reach for stronger methods of medicinal pain relief such as epidurals, which in themselves have their own risks attached. Before accepting the offer of an induction, consider all your options carefully, using the Positively Birthing Online decision making tools to help! If, having done that, you decide that YES, an induction feels like the right choice for you, then there’s lots you can do to make it a really positive experience!
https://www.bsuh.nhs.uk/wp-content/uploads/sites/5/2016/09/Information-about-having-your-labour-induced.pdf (accessed 28/12/2018)