When Things Don’t Go To Plan

What does it mean to induce labour?

If your labour is started artificially this is induction of labour. You will be offered an induction if allowing your pregnancy to continue is a risk to you or your baby.

Most women go into labour naturally, and letting nature take its course is usually best but you may need a little help to get started.

Sweeping the membranes

Sweeping the membranes is a safe way of increasing your chance of going into labour yourself and reducing the risk of your labour requiring to be induced.
You do not have to have the procedure done, it is your choice.

How does it happen?
Sweeping the membranes increases the level of naturally occurring hormones, called prostaglandins, around the cervix (neck of the womb). These hormones cause your cervix to soften and dilate.

How is sweeping the membranes performed?
Membrane sweeping is carried out during a vaginal examination and involves placing a finger inside your cervix and making a circular sweeping movement to separate the membranes from the
cervix.

When can it be performed?
Sweeping the membranes can be performed in the week your baby is due.

Who does it?
Your midwife or doctor can carry out sweeping of the membranes during your routine antenatal clinic appointment.

He/she will discuss the procedure with you prior to your expected date of delivery.

Is it painful?
Some women can experience some discomfort, however the majority of women do not find it painful.

Is it dangerous?
Sweeping of the membranes is not associated with any increased risk of infection to either you or your baby; however there are some situations when the procedure cannot be carried out, for example when:

• Your babies head is too high
• The cervix is closed or too far back
• The afterbirth is lying low

What will happen after my membranes have been swept?
Most women will experience some irregular contractions, which may become uncomfortable. Some mothers may experience some slight vaginal bleeding, or notice the presence of some show (plug of mucous passed vaginally). This is quite normal and not necessarily a sign that labour has started. You should however contact your Hospital if you have any signs of labour e.g.

• If contractions become regular and are increasing in frequency
• If you have any fluid draining vaginally (ruptured membranes)

Why might my labour need to be induced?
You are likely to be offered an induction if:

• Your pregnancy has gone past 41 weeks or 42 weeks depending on your hospital policy. Going over your due date is the most common reason for induction
• If your waters have broken also known as a spontaneous rupture of membranes and labour does not start and you don’t go into labour within a day or so, there is an increased risk that you or your baby could develop an infection. So you’ll probably be offered an induction 24 hours after your waters break
• If you have a diabetes. If your baby is growing normally, it’s recommended that you’re offered an induction around your due date
• You have a condition, for example blood pressure problems such as preeclampsia or kidney disease that threatens your wellbeing, or the health of your baby

You may want your labour to be induced for personal reasons.

Or you may want an induction because you are worried about your pregnancy, or if you’ve previously had a pregnancy with complications.

The plan your doctor and midwife advise will be based on your individual circumstances.

How will my labour be induced?

Here’s the order in which you are likely to be offered induction of labour:

Prostaglandin
Prostaglandin is a hormone-like substance that causes the neck of your womb or cervix to ripen, and which may stimulate contractions. Your midwife or doctor will insert a tablet, pessary or gel containing prostaglandin into your vagina.

While you wait for prostaglandins to work you can usually stay up and about.

If this is your first baby, you may need a second dose of a tablet, pessary or gel after six hours.

Vaginal prostaglandin is the most commonly recommended way to induce labour. However there is a very small risk that using vaginal prostaglandins may cause your uterus to become over-stimulated
therefore you will be monitored very closely.

Artificial rupture of membranes (ARM)
Artificially rupturing the membranes (ARM), also called breaking the waters, isn’t recommended as a first method of induction unless vaginal prostaglandins can’t be used. However, some doctors or midwives may use ARM as part of the induction process or to speed up your labour if it’s not progressing.

This procedure can be carried out during an internal examination.

Your midwife or doctor makes a small break in the membranes around your baby. A long thin probe called an amnihook is used.

If your cervix feels ripe or soft it is easier to break your waters. It can sometimes be a bit uncomfortable, so you may be offered Entonox or gass and air to help you to relax.

ARM doesn’t always get labour started, and once your waters have been broken, your baby could be at risk of infection. Therefore it is not recommended as a method of induction on its own. It is best used once you have been experiencing contractions. If your midwife or doctor suspects an infection, you will be given antibiotics.

Syntocinon
Syntocinon is a synthetic form of the hormone oxytocin. You will only be offered it if a membrane sweep or prostaglandin hasn’t started your labour, or if your contractions aren’t effective. Your waters have to be broken before you can be given Syntocinon.

Syntocinon is given through an intravenous drip, allowing the hormone to go straight into your bloodstream through a tiny tube inserted into a vein in your arm. Once your contractions have begun, the rate of the drip can be adjusted. This allows contractions to happen often enough to make your cervix dilate, without becoming too powerful.

Syntocinon is started at a very low dose and increased gradually to prevent it from stimulating your uterus or causing your baby to become distressed.

Syntocinon can cause strong contractions so you will need to have continuous monitoring of you and your baby. The contractions brought on by Syntocinon may be more painful than natural ones.

Many women choose to have an epidural for induction.

How can I prepare for my induction?
Talk to your midwife or doctor. You have a choice about whether or not to have an induction, and about which methods are used. Your midwife or doctor may suggest that one method is better than
another, depending on how soft and ready your cervix is.

There’s some evidence that you are more likely to need instruments such as ventouse or forceps to help deliver your baby after an induction. This is regardless of the method. This may be due to the reason why you were induced for example pregnancy complication, or it may be due to problems caused by the induction itself.

Bishop Score – What is it?
The Bishop score assesses how ripe your cervix is. A mark is given, based on the condition and position of your cervix, and how far down in your pelvis your baby’s head is. A score of eight or more indicates that your cervix is ripe and ready for labour. At this stage, your baby is well down in your pelvis.

The Bishop score is used before and after your induction to see whether any progress has been made. Successful induction is very dependent on how ripe your cervix is. The riper it is, the more chance there is that labour will start.

A Bishop score of less than six indicates an unfavourable (unripe) cervix.

Before you go into labour, you may want to consider and discuss with the midwife what analgesia or pain relief you might like if the induction works and makes your contractions very strong and difficult to cope with.

Some women need assistance at birth, where ventouse suction cup or forceps are used to help the baby out of the vagina.

This can be because:

• Your baby is distressed
• Your baby is lying in the wrong position
• You are exhausted and not able to push

Both ventouse and forceps are safe and only used when necessary for you and baby.

A paediatrician may be present to check baby once it is born.

Before the procedure a local anaesthetic is given to numb the birth canal if you have not already had an epidural.

Sometimes you are moved into the operating theatre for an assisted delivery where a caesarean section can be carried out if the forceps is unsuccessful at getting your baby out.

As the baby is delivered, a cut (episiotomy) may be needed to make the vaginal opening bigger. A tear or cut will be repaired with stitches.

Depending on how you and your baby are, your baby can still be delivered on to your tummy and your partner may still be able to cut the cord if he wishes.

Ventouse (Vacuum)

A Ventouse (vacuum extractor) is an instrument that uses suction to guide the baby out. A soft or hard plastic cup is attached by a tube to a suction device. The cup fits firmly on to your baby’s head and with a contraction and you pushing, the obstetrician gently pulls to help deliver the baby.

The suction cup can leave a small mark on your baby’s head. A ventouse is not used if your baby is less than 34 weeks pregnant because your baby’s head is too soft.

Forceps

Forceps are smooth metal instruments that look like large spoons or tongs. They are curved and fit around the baby’s head. The forceps are carefully positioned around your baby’s head and joined together at the handles.

With a contraction and you pushing the obstetrician gently pulls to help to deliver the baby. Forceps can leave small marks on your baby’s face but these will disappear very quickly.

Sometimes during the birth process the doctor or midwife may need to make a cut into your perineum which is the area between to vagina and the anus.

This episiotomy makes the opening of the vagina a bit wider allowing your baby to come out more easily.

An episiotomy is only carried out if the baby is in distress and needs to be delivered more quickly or if there is a clinical need such as delivery by forceps or ventouse.

If you need an episiotomy the midwife or doctor will discuss this with you. Sometimes you can tear as the baby is coming out.

The tear or episiotomy will be repaired with dissolving stitches which do not need to be removed and should heal within one month.

You will probably experience pain around the episiotomy for a few weeks after the birth of your baby.

Why you might need an episiotomy

An episiotomy is usually recommended if your baby becomes distressed. Fetal distress is where the baby’s heart beat significantly increases and decreases before delivery of the baby. This may mean that the baby is not getting enough oxygen and needs to be delivered quickly to avoid any risks to the baby.

If a caesarean section cannot be carried out because the baby’s head is already moving down the birth canal an episiotomy can be the best way to speed the delivery up.

Another reason for an episiotomy is when it is necessary to widen your vagina so that instruments such as forceps or ventouse suction can be used to assist the delivery of your baby. This may
be necessary if you have been pushing in the second stage of labour for several hours and you are exhausted.

Or

You have a serious medical condition for example heart disease and it is recommended that delivery should be quick to minimise any further health risk.

How an episiotomy is performed

An episiotomy is usually a simple procedure. Local anaesthetic is used to numb the area around the vagina so you will not feel any pain. If you already have an epidural it can be topped up before the cut is made.

The doctor or midwife will make a small diagonal cut from the back of the vagina directed down and out to one side. Following the birth of the baby the cut is sutured with stitches that dissolve.

Recovering from an episiotomy

Episiotomy cuts are usually repaired within one hour of delivery. The incision may bleed a lot initially but with pressure and stitches this will soon stop.

Stitches should heal within one month of the birth.

After an episiotomy it is normal to feel pain around the cut for two to three weeks after giving birth, particularly when walking or sitting. Passing urine can also cause the cut to sting.

Coping with pain

Painkillers such as paracetamol can help to relieve pain and are safe to use if you are breast feeding.

It may be necessary to treat pain with stronger prescription only pain killers. It is unusual for pain to last more that two to three weeks.

Placing an ice pack or ice cubes wrapped in a towel on the cut can sometimes help to relieve pain. Avoid pacing ice directly on to the skin because this could damage it.

Exposing the stitches that were used to seal the cut to the fresh air can encourage the healing process. Taking off your under wear and lying on a towel on your bed for around 10 minutes once or twice a day may help.

Going to the toilet

Keep the cut and the surrounding area clean to prevent infection. Pouring warm water over the outer area of your vagina while you pass urine can also help to ease the discomfort.

You may find squatting on the toilet rather than sitting on it can reduce the stinging sensation while you are passing urine.

When your bowels move you may find it helpful to place a clean pad on the area of the cut and press gently as you go to the toilet.

This can also help to relieve pressure on the cut. Monitor your diet and avoid constipation is essential.

Pain during sex

After you have had your baby there are no rules on when to start having sex again. Many women feel sore and tired whether they have had an episiotomy or not. Don’t rush into it, if sex hurts it is important to stop, there will be no pleasure and it may only prolong your return to sex. Most women who have had an episiotomy have reported that resuming sex after the procedure was very painful but that the pain improves over time. Pain can sometimes be linked to vaginal dryness where you can try using a water based lubricant.

Use some kind of contraception every time you have sex after giving birth including the first time because you can get pregnant before your periods start back and while you are breast feeding.

You usually have an opportunity to discuss your contraceptive options before you leave hospital and at your 6 week post natal check.

If your cut becomes infected such as red, swollen skin discharge of pus or liquid from the cut, or persistent pain tell your GP. It is important to start treatment early for example antibiotics if you need them.

Strengthening the muscles around the vagina and anus by doing pelvic floor exercises can help promote healing and will reduce the pressure on the stitches and area around them.

If your baby is breech it means that your baby’s bottom is first in your pelvis. This makes delivery more complicated. Your obstetrician or midwife will discuss with you the best and safest way for your breech baby to be born.

What is a caesarean section?
A caesarean section involves having a surgical incision made through your abdomen and uterus to deliver your baby in cases where a vaginal delivery is not possible or advisable.

Why might it be necessary for my baby to be delivered by caesarean?
Caesarean sections are advised if your doctor feels that a normal vaginal delivery could threaten the health of you and/or your baby.

What happens during a caesarean section?
Prior to the operation an IV (intravenous – into the vein) infusion will be started to provide you with fluids; a urinary catheter will be inserted into your bladder to drain urine and you will be given an epidural or spinal anaesthetic.

A screen will be set up at the top of your abdomen so that you can’t see the operation taking place. If your partner is present he can sit behind the screen and remain with you.

A side-to-side cut is usually made just below your pubic hairline (bikini line). The incision will be either sutured or stapled. The sutures simply dissolve and do not have to be removed.

Although a caesarean section is a major abdominal operation it is usually fairly quick, taking only about 30-60 minutes.

Why would I need to have a general anaesthetic instead of an epidural/spinal?
Some women prefer to have a general anaesthetic instead of an epidural as they do not want to be awake during the procedure. A general anaesthetic may also be given if you need to have an
emergency caesarean section as it is usually quicker to administer.

Can I see my baby immediately after birth?
Unless you have had a general anaesthetic you will be able to see and hold your baby straight away. If your baby needs to be admitted to the special care baby unit you should still be able to
see him/her for a short time but you may not be able to hold your baby until later.

Will I be able to breastfeed?
Although you may experience localised pain and generally feel uncomfortable for the first few days after the operation, you will be able to breastfeed. If you have had a general anaesthetic,
however, you may not be able to breastfeed for the first couple of hours. Bear in mind that you will need some assistance initially to get into a comfortable position and to latch the baby on to your breast.

How long will I need to remain in hospital?
Most women are advised to remain in hospital for five days following a caesarean section although this varies from woman to woman.

Will I be able to have a normal vaginal delivery next time?

Vaginal birth after caesarean (VBAC)
If you have a baby by caesarean section, this does not mean that any baby you have in the future will have to be delivered by caesarean.

Many women who have caesarean sections for their first baby go on to have a normal vaginal delivery for subsequent pregnancies. Your chances of having a normal delivery may depend on why you had the first caesarean section. For example, if you have a small pelvis or if you have a condition that makes a caesarean section the safest option for you, your obstetrician may advise you to opt for a caesarean section in subsequent pregnancies also.