Inductions and interventions in labour

Sometimes, extra help may be recommended by your midwife or doctor so that you can give birth to your baby safely. You might hear this help referred to as ‘interventions’. Below we describe the different types of interventions in labour and why they might be needed, so you can feel prepared for different scenarios.

Remember that you can always talk to your midwife at one of your antenatal appointments if you are feeling worried or have any questions, and it can be a good idea to include some information about your preferences if you are recommended interventions in your birth plan.

What is an induction of labour?

An induction is when your labour is started artificially through the use of a pessary, gel, hormone drip or breaking of your waters.

A quarter of all pregnant women are induced in England, and the numbers are increasing year by year, according to NHS maternity statistics.

Inductions are started in the hospital, and if you’ve been induced you’re likely to be admitted as a patient until you give birth, on the labour ward.

This is so health professionals can make sure both you and your baby are doing OK throughout the process and have access to extra medical help, should you need it.

Why might I be offered an induction?

Labour can be induced for many reasons, but the most common are:

• You’re more than 41 weeks pregnant. Your baby is at a slightly higher risk of stillbirth or other problems if you are pregnant for more than 42 weeks, so as a precaution the recommendation is to induce labour at 41 weeks.
• Your waters have broken but contractions have not started. You’re at higher risk of infection the longer your waters are broken without your baby being born, so the official advice is to offer an induction 24 hours after your waters break if you’re full-term.
• Giving birth is safer than letting the pregnancy continue. This can be due to a number of reasons, for either you or your baby’s safety. For example, it’s common to be offered an induction if you have been diagnosed with pre-eclampsia or gestational diabetes, or if your baby seems to have stopped growing.

How will I be induced?

There are several different ways to start labour, and which one you’ll be recommended depends on your pregnancy, health and any previous births you’ve been through.

It’s not unusual to start with one method of induction and move on to another method later if the first doesn’t bring on labour on its own.

• Balloon catheter: A soft silicone tube with a balloon near the tip is inserted into your cervix and filled with a sterile salt water fluid. This puts pressure on your cervix to soften and open enough to start labour, or for your midwife or doctor to be able to break your waters.
• Pessary or gel: A small almond-shaped tablet or gel is inserted into your vagina to slowly release a substance that should soften your cervix and encourage contractions.
• Breaking your waters: Your waters may be broken by your midwife inserting a hook through your cervix to pierce the membrane sack to get contractions started. This is also known as ‘artificial rupture of membranes’.
• Hormone drip: A cannula is inserted into your hand which gives you an artificial oxytocin drip to get your contractions started. You’ll need to be monitored continuously while receiving the drip to make sure your baby’s coping with the contractions.

How long does induction of labour take?

The time it takes for labour to begin after induction will depend on the methods used and how your body responds to them. It can take hours or days depending on your situation. If this isn’t your first baby and you have gone into labour naturally before, your body will generally react faster than if this was your first baby.

Are there any problems caused by being induced?

Yes, there are specific considerations that it’s good to be aware of when deciding whether to accept an offer of induction.

• Higher chance of emergency c-section: Women who are induced are twice as likely to have an emergency caesarean section as women whose labour starts spontaneously, according to NHS maternity statistics.
• Labour may be more painful: Induced contractions are often different, stronger and possibly more painful than contractions that start naturally. This may lead to you needing pain relief such as an epidural, which may not have been something you originally planned for.

Can I say no to being induced?

Yes, it’s your choice whether to have an induction or not. If you decide that you don’t want to be induced, your wish has to be respected.

You should always have the opportunity to discuss things with your health professionals before making a decision, including the reasons why an induction is being recommended and what is in the best interest of you and your baby.

It’s a good idea to ask your midwife or consultant for the specific risks and benefits of an induction in your situation. Every pregnancy and birth is unique, so it’s important that you’re able to make a decision that’s right for you.

For example, if you’re told your baby’s at higher risk of stillbirth if you’re not induced as you’re over the age of 40, ask for specific numbers of how much the risk is increased by not being induced – then compare that to the statistical risks of induction.

What are the alternatives to induction?

There are two main alternatives to having an induction:

• Waiting for labour to start naturally
• Having an elective c-section.

If you’ve been recommended to be induced because you’re more than 42 weeks pregnant (overdue), you should be offered increased monitoring as an alternative if you don’t want to be induced.

The charity AIMS has a useful list of facts to consider when deciding whether or not to have an induction or membrane sweep.

What is an assisted birth?

When instruments like forceps or ventouse are used during the second stage of a vaginal birth, it’s known as an assisted delivery. One-in-eight babies in England are born with the help of forceps or ventouse.

Having an assisted birth is no-one’s first choice, but being aware of why and how assisted births happen can help you feel more prepared and able to make informed decisions when you go into labour.

Forceps

Forceps are a surgical instrument that looks like large tongs. They come in two halves; each half is carefully placed around your baby’s head while it is in the birth canal, and the two handles fit together.

The doctor pulls the forceps at the same time as you push to help deliver your baby.

Ventouse cap (vacuum)

A ventouse is a silicone cap attached to a suction pump. The cap is fitted on your baby’s head while it is in the birth canal, and it’s kept in place using suction.

The ventouse is then pulled by a doctor or midwife during contractions to help the baby be born, while you’re pushing at the same time.

Why might I have an assisted birth?

These are some of the reasons why you may be recommended to have an assisted delivery:

• You’re too exhausted: after a long labour, particularly a long second stage, you may not have the energy left to push the baby out all by yourself.
• Your baby’s in an awkward position: if your baby’s head is in an awkward position, it may not be able to descend into the birth canal without the use of forceps to turn it around.
• Concerns about your baby’s heart rate: if you’re dilated and your baby needs to be born quickly, having an assisted birth may be recommended over a c-section.
• For your health: in rare cases, you may have been told in advance that you shouldn’t push during the birth.

Forceps or ventouse – which is better?

Both forceps and the ventouse cap are used during the second stage of labour. The decision about which to use will depend on the circumstances of your birth and the clinical judgement of the midwives or doctors involved.

Generally speaking, a forceps birth is more likely to be successful in allowing the baby to be born without need for a c-section, but a ventouse is gentler and is less likely to lead to a severe tear for the woman in labour.

Are there any risks with a forceps or ventouse delivery?

Like all birth intervention, an assisted birth comes with some potential complications for both you and your baby.

Possible complications for your baby

There are some risks of injury to the baby with forceps and ventouse cap, but they’re usually only temporary. You may notice:

• A mark on your baby’s head or face from the instrument: this usually disappears within a couple of days
• Small cuts on your baby’s face or head: these are very common but heal quickly.
• A bruise on your baby’s head: this also disappears in time, but it can cause an increase in jaundice in the early days. Talk to your midwife if you’re concerned.

Possible complications for you

With an assisted birth, you’re more likely to experience severe tearing and blood clots, as well as urinary and anal incontinence, compared to if you have a straightforward vaginal birth.

1% of women who have an unassisted birth suffer severe tearing, compared to 8-12% who have a forceps birth.

However, it can be worth bearing in mind that sometimes the only safe alternative to forceps or ventouse is an emergency caesarean section, which comes with risks of its own.

In other cases, the baby is already so far down the birth canal that it would be very difficult to even have a c-section at that point.

Can I avoid an assisted birth?

Birth is unpredictable and complications can occur in any situation. However, where and how you plan to give birth can affect your likelihood of needing interventions like forceps or ventouse.

Choosing where to give birth

A 2011 study found that you’re less likely to have an assisted birth if you plan to give birth at home or in a freestanding midwife-led birth centre.

Low risk, first-time mothers planning to give birth in a labour ward were almost twice as likely to have a forceps or ventouse delivery compared to those opting to have their baby at home or in a freestanding birth centre.

For women who’d had a baby in the past, the difference was even more pronounced: low-risk women who planned to give birth in the labour ward were more than four times more likely to have an assisted birth compared to those who were planning to have a home birth.

• Use our Choosing where to give birth tool if you’re still weighing up your options for where to have your baby. The tool lets you put in your personal circumstances and preferences to see whether giving birth at home, in a birth centre or in the labour ward might be the best option for you.

Preparing for birth

Beyond choosing where to have your baby, there are other things you can do to reduce the likelihood of an assisted birth, although not all of them are within your control.

Here are some of the things that have been shown to reduce the likelihood of having an assisted birth:

• Knowing the midwife who looks after you in labour
• Having good continuous support, preferably from both a midwife and a birth partner
• Being in upright positions or lying sideways when giving birth
• Avoiding having an epidural for pain relief if possible.

Why might I be transferred when giving birth?

If you’re giving birth at home or in a birth centre, you’ll be recommended to transfer to the nearest labour ward if your midwife is concerned for you or your baby’s health, or if you request stronger pain relief which can only be given in the hospital.

You may be transferred to hospital if:

• Your labour is stalling (in the first, second or third stage).
• You want extra pain relief, such as an epidural, which isn’t available in the birth centre or at home.
• It seems like your baby may not be coping well with labour, for example if their heart rate is slowing or meconium is found in your waters when they break.
• You need more help after the birth, for example if you’ve had severe tearing or the placenta doesn’t come out in one piece.
• Your baby needs to be admitted to a special baby care unit at the hospital for monitoring or treatment.

It can be comforting to know that most transfers are precautions rather than emergencies.

How does a transfer happen?

Once the decision to transfer has been made, your midwife will call an ambulance to take you to the hospital, although in some cases you may be able to go in your own car. If you’re in an alongside birth centre, you can go to the labour ward in a wheelchair.

You won’t have to travel in the ambulance on your own – your midwife and birth partner will come with you. Once you’ve arrived at the hospital, your midwife may be able to stay with you, or your care will be handed over to a midwife who works on the labour ward and is more experienced in hospital births.

If you or your baby need more help after the birth, you’ll travel together to the hospital by ambulance. If you need to be admitted to the postnatal ward for overnight care, your baby will stay with you the whole time.

In this video, a consultant midwife explains what being transferred means in practice:

How likely am I to be transferred?

Regardless of where you plan to give birth, you’re more likely to need to be transferred to the labour ward if you’re having your first baby, compared to women who have given birth before.

If you’ve had a baby before

You have a good chance of not needing to be transferred from your planned place of birth if you’re at low risk of complications and have had a baby before.

Just one in ten mothers who have had at least one baby previously have to be moved from a birth centre or their home during labour or shortly after the birth, according to The Birthplace Study.

If you’re having your first baby

The same study found that you have a fairly high chance of having to go the hospital at some point during the birth if you’re pregnant with your first baby.

Almost half of first-time mothers planning a home birth and just over a third of those wanting to be in a freestanding birth centre have to transfer to the labour ward.

Caesarean birth

A caesarean section is an operation to allow your baby to be born without going through the birth canal, and instead they’re born through a cut in your abdomen.

Find out more about caesarean births and what to expect when you’re recovering from a c-section.

Coronavirus and giving birth

If you go into labour, call your maternity team for advice. 

Let them know if you have suspected or confirmed coronavirus. If you have mild symptoms and are self-isolating, you will be encouraged to remain self-isolating at home in early labour, in line with standard practice.

If you have suspected or confirmed coronavirus, when the time has come to go to hospital, you are advised to get there by private transport where possible.

When you arrive you should notify them of your attendance but before entering the hospital. You will be met at the maternity unit entrance and be provided with a surgical face mask, which will need to stay on until you are isolated in a suitable room.

Your maternity team have been advised on ways to ensure that you and your baby receive safe, quality care that respects your birth choices as closely as possible.

Also, your birthing partner will still be able to stay with you throughout your active labour and birth, although there are currently restrictions on them staying with you on antenatal or postnatal wards. If you need more information on this, check with your maternity team.

As it stands, if you have suspected or confirmed coronavirus infection, there is currently no evidence to suggest you can't give birth vaginally or that you must have a caesarean.

It may be that if you have chosen to give birth at home or in a midwife-led unit that isn’t co-located with an obstetric unit, your local trust or board might not be able to provide these services.

This is because these services rely on the availability of ambulance services to allow for rapid transfer to hospital and the right number of staff to keep you safe.

Pregnant women with suspected or confirmed coronavirus are being advised to give birth in a hospital obstetric unit for the safety of both mum and baby, even if they had been planning delivery at home or in a midwife-led centre.

If you have suspected or confirmed coronavirus, it isn't recommended you use a birthing pool in hospital as the virus can sometimes be found in faeces so it may be difficult for healthcare staff to use adequate protection equipment. 

You can still have an epidural or spinal analgesia or anaesthesia (a spinal block) if you have suspected or confirmed coronavirus.

In fact, The Royal College of Obstetricians and Gynaecologists (RCOG) says an epidural should be recommended before or in early labour to these women to minimise the need for a general anaesthetic if urgent delivery is needed.

Entonox is still an option, too. It had previously been suggested that the use of Entonox might increase aerosolisation and spread the virus but this has now been disproven and it can be used.

Page last updated 02/06/20. Please check out Royal College of Obstetricians and Gynaecologists for any more recent updates.