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Q&A with MONIQUE MAITLAND | REGISTERED MIDWIFE & CHILDBIRTH EDUCATOR I MIDDEE SOCIETY | MIDDEE PODCAST
We asked Clinical midwife Monique Maitland some key questions to help you prepare for your birth and her tips on having a positive induction.
1. Many women worry about being induced. What do you want them to know?
Induction doesn't have to be negative. As a midwife, I have supported many women during their induction. I can assure you that a positive experience is possible.
2. What is induction of labour?
Induction of labour is the process of initiating labour through pharmacological or mechanical means by causing uterine activity. In Australia this is via the synthetic hormone called syntocinon which is given intravenously. It is important to mention that induction of labour always requires your informed consent.
3. Why might you need to be induced?
Induction of labour is performed for a number of reasons related to either the mother and/or the fetus. Some common examples include:
- Postdates (pregnancy that has extended beyond 42 weeks)
- Decreased Fetal Movements
- Group B Strep (GBS+) infection with Rupture of membranes
- Gestational diabetes with insulin requirements
- Large for gestational age
- Small for gestational age
4. Can you decline induction?
Yes, you can always decline any intervention, but it's important to have the facts and resources to make an informed decision based on the risks and benefits. Take the time to gather information and understand your options. It is always okay to ask for space and time, when making a decision that is the best for both you and your baby.
5. How long will the induction take?
Great question - sadly there is no “one size fits all” answer. Why? Because every woman’s body is different & their inductions do not all follow the same pattern.
The duration of induction varies for each woman as it depends on individual factors. The goal is to achieve regular, strong contractions that meet certain criteria for active labor. The time required for dilation and birthing also varies.
When women are induced, we aim to cause contractions that occur 3-4 times in 10 minutes, that last approximately 60 seconds, and that are strong.
The amount of hormone (syntocinon) each woman needs to get into active labour varies. Some are receptive to the medication and have contractions instantly. Others can take hours before feeling anything.
Labour is diagnosed in the presence of regular, strong contractions with full effacement of the cervix (when your cervix is totally thinned out) and where the cervical dilation is ≥5cm. For a woman diagnosed in labour at 5cm it is suggested to allow up to 12 hours for a first-time mum and 10 hours for multiparous women (previously had a baby).
However, these timeframes may vary if diagnosis has been made at a greater dilatation. The pushing phase (active second stage) of birth also takes time. You can expect to allow up to 2 hours for a first time Mum and an hour for a multiparous woman to birth her baby.
6. How does the process work?
The process typically involves four steps:
- INFORMED CONSENT - You should always make an informed decision about induction.
- CERVICAL PRIMING - Cervical priming refers to dilating or softening of the cervix by mechanical or medical means before intervention. The aim of cervical priming is to soften and dilate the cervix to allow your waters to be broken easily.
- Determining if cervical priming is needed - We determine whether a woman requires cervical priming by performing a Bishop score. This is a vaginal examination (with consent) to assess the current state of the cervix.
- The Bishop Score takes into account several factors to determine the cervical readiness, including
- cervical dilation (extent to which the cervix has opened or dilated)
- cervical effacement (thinning and shortening of the cervix)
- cervical consistency (firmness or softness of the cervix)
- cervical position (position of the cervix in relation to the baby’s head)
- fetal station (the level of the baby’s presenting part in the birth canal).
- Each of these factors is assigned a score ranging from 0 to 3 or 4, depending on the specific scoring system used. The scores are then added together to obtain the Bishop score, which ranges from 0 to 13 or 15. A higher score indicates a more favorable cervix for labour induction or the likelihood of spontaneous labour.
- The Bishop score helps healthcare providers determine the most appropriate methods and timing for labour induction. A higher score suggests a higher chance of successful induction.
- What are the different types of cervical priming? Each hospital will have different induction policies. So, it is always important to discuss with your own healthcare provider.
- Balloon (Cooks Catheter) - A thin tube called a catheter is inserted into your cervix. This is done whilst your legs are in stirrups and is inserted with a speculum to have good visualization of the cervix.
- This catheter has two balloons on the end. Once in the correct position these balloons are then inflated with roughly 60-80mls of water on either side of your cervix. One in the uterus and one in the vagina. The pressure applied to your cervix then causes prostaglandin release to help soften and dilate the cervix.
- Some additional things you should know about Balloon
- The catheter is left in place for up to 12 - 18 hours - needs to be removed.
- Can cause cramping requiring pain relief.
- You can move around normally while it is in place.
- Some women have some light bleeding after the catheter has been put in.
- As this has no medication the balloon can be removed if necessary.
- Dependent on hospital policy some women can go home.
- If required can be offered pain relief.
- Can fall out prior to removal.
- Prostaglandin (Prostin + Cervidil)
- Prostin: A gel containing prostaglandins is inserted into your vagina via a vaginal examination. When prostaglandin is in place, you will need to lie down for at least 30 minutes and remain in the hospital usually until labour begins.
- Cervidil: Cervidil is also a prostaglandin in tablet form. It is a tablet attached to a tape. It looks like a tampon. It is inserted via a vaginal examination.
- Some additional things you should know about Prostaglandin:
- May experience reactions such as nausea, vomiting or diarrhea.
- As these are medications, sometimes they can cause the uterus to contract too frequently. You will be given medication to relax the uterus if this happens.
- Can cause cramping that may require pain relief.
- Requires CTG monitoring before and after administration.
- Sometimes more than one dose of the Prostin gel is needed, especially if this is your first labour. A few women do go into labour after the insertion of the prostaglandin.
- Most women will feel some soreness in the vagina for a while after the prostaglandins have been put in.
- Cervidil stays in place for 12 hours Can be removed easily like a tampon.
- ARTIFICIAL RUPTURE OF MEMBRANE (ARM) - Commonly known as breaking your waters. When your cervix has opened enough to perform an ARM your doctor or midwife will use a small instrument called an amnihook to break your waters via a vaginal examination.
- Some additional things to know about ARM.
- A CTG monitor will be in place prior to ARM.
- The amniotic sac does not have any nerves in it. There should not be pain however the vaginal examination can be uncomfortable.
- An IVC will be inserted (with consent).
- Once your waters have broken, they will continue to leak until the birth of your baby.
- It is rare but there are always risks associated with ARM for example cord prolapse.
- Midwife Tip:
- Relax your muscles as much as you can.
- Try and use breathing techniques to slow your breath.
- Utilise the nitrous oxide if you need it.
- OXYTOCIN DRIP - As previously mentioned, uterine activity is stimulated via the use of the synthetic hormone syntocinon, that mimics the effects of oxytocin. Syntocinon is given intravenously (IV), and the amount is controlled by an IV pump.
- Some additional things to not about oxytocin drips
- You will be connected to an IV pump the entire induction, up until your baby is birthed.
- 1ml of sytocinon is put into a 1000ml bag of fluid. You also have another fluid bag which runs at the same time.
- The rate at which you receive the medication is controlled by your midwife. The hormone drip is started at a low rate and is gradually titrated up according to a few things:
- Uterine activity
- Resting tone
- Fetal wellbeing
- Maternal wellbeing
- Midwife tip: During an induction you will receive a significant amount of fluid which can cause additional swelling to your limbs (Yep, even more swollen than they might already be!). It is beneficial to think about using graduated compression socks which can help reduce fluid retention throughout your labour. They can also be used again postpartum.
7. What type of fetal monitoring do I require?
As your labour has been artificially started continuous monitoring of fetal heart rate and uterine activity is recommended during induction. This is typically done using cardiotocography (CTG), which provides real-time information about the baby's heart rate and uterine contractions.
A CTG (cardiotocography) continuously records the fetal heart rate via an ultrasound transducer and uterine activity via a toco placed on the mother's abdomen. It provides your healthcare team with a live trace of your baby’s heartbeat.
To note about a CTG:
- Requires consent.
- Wireless but monitors are secured by 2 straps around your abdomen.
- A CTG Should never restrict your movement. Your Midwife should always work around you.
- You should be able to use the CTG in the shower (Some hospitals may allow you to use it in the bath).
8. Can you still have a positive birthing experience with induction?
Yes, and these are my tips for a positive induction.
- Have trust in your midwife: It is our job to ensure you have enough resting tone between contractions. You will always get a rest between contractions & just like spontaneous labour, the contractions don’t change; they are like a bell curve. They gradually increase, hit a peak then go back down.When your uterus is relaxing (no contraction) it is so important that during this time you rest. Remember that you do need strong & powerful contractions to have a baby, it is okay for the intensity of the contractions to increase throughout the induction process this is normal & a positive thing!
- Remind yourself in tougher times, that this is only temporary: During this point use the most powerful tool of all, your breath and mind. Don’t tell yourself you can’t, tell yourself you can! Don’t waste your energy on something that is out of your control. Focus on what you can control. Utilise all your labour tools. Just because you are being induced doesn’t mean you can’t use all your nonpharmacological pain relief options first such as the shower.
- Educate yourself & your support person: Education allows you to make those informed decisions regarding your care. as you have more of an understanding of if you say yes to a type of intervention what some of the limitations are to that.
- Last but not least have trust in your own body & listen to your body: Ensure you are getting a rest between contractions. If you feel as though you are not getting a break, please let your midwife know. You know your body better than any of us.
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Monique Maitland is a Registered Midwife/Nurse from Melbourne, founder of The Middee Society The Middee Society provides Childbirth Education and Classes.
Monique hosts podcast series ‘Middee’ providing modern-day midwifery, pre and post-natal community education. For more info about inductions is in her episode on induction of labour. “Help, I’m being induced- can I still have a positive experience?"
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