Induction of Labour: Preparing for Induction

In this episode, Dr Rangi is joined again by midwife Erica Spessot to discuss induction of labour. 

This is the first of two episodes and focuses on the preparation phase: how the cervix ripens and how the body is prepared for the induction process.

We also hear from our producer, Sarah, who shares her lived experience of induction of labour (using both methods).

Stay tuned for the next episode, where Rangi and Erica (and Sarah) discuss the subsequent stages of the induction process in more detail.

Transcript

SPEAKER_00 0:01

Welcome to Prepare, the Mercy Perinatal podcast dedicated to helping parents prepare for the journey of pregnancy, childbirth, and early parenthood. Mercy Perinatal would like to begin by acknowledging the Wawundri Woiwarung people, traditional custodians of the land on which we gather today, and also the traditional custodians of the lands in which you're listening from today. We'd like to pay our respects to the elders past, present, and emerging, and we extend that respect to Aboriginal and Torres Strait Islander peoples listening today.

SPEAKER_02 0:31

Hi everyone, my name is Dr. Rangi. I'm an obstetrician and gynecologist and a researcher here at Mercy Perrinatal. And we are so excited to be joined again by our amazing midwife, Erica. We're going to be talking about induction of labour, but specifically the part of the induction preparing for the induction. So what we call ripening the cervix and preparing your body for the induction process. This is a first part in a two-part episode where we're talking about induction of labour. The next episode we're going to be talking about the actual process of induction when we're beginning the labour. So hopefully you find this interesting and informative. And thanks again to Erica for joining us. Hello. Hi, welcome back. Thank you. Thanks for having me back. We're so excited to have you. So, what exactly is induction of labour?

SPEAKER_01 1:26

So, induction of labour is when for a medical reason for either yourself or for your baby, we need to bring on your labour earlier than when your body would naturally go into labor. The other time that we use it is if you are becoming well past your due date. So, depending on your health service, that kind of looks like seven to ten days past your due date. Then we'll start talking about induction of labour. But it's about medically bringing on labour.

SPEAKER_02 1:55

Yes, that's right. So basically describes how we start the labour, doesn't it? Yeah. Yeah. As opposed to the outcome of labour or how you will birth. We're still aiming for a vaginal birth. Always. Always with an induction of labour. That's the important thing. But there are different ways we would do it, which we'll talk about in this episode. And of course, the different reasons why. And we'll also cover how it might feel and how it might differ from you going into labour by yourself and what some of the potential outcomes might be.

SPEAKER_01 2:32

Amazing.

SPEAKER_02 2:32

Yeah. So how would you usually describe the process of induction to your patient, Serenica?

SPEAKER_01 2:40

So if my patient was having an induction, we would talk about what the different methods are. So your cervix, if you've never seen a cervix before, you can Google a picture, but your cervix is long and closed and it's quite firm. So we need to do some preparation to what's called ripen the cervix or make it prepared for labour and later induction methods. So there's normally a couple of like cervical ripening methods that we might use, and that will depend on your clinical situation. So what's going on with your pregnancy and your baby? And that might look like a balloon, a hormone gel, or like a hormone tape or pessary. And then depending on the outcome of the pre-methods, then depends when we can start what we would call the actual induction. Yes.

SPEAKER_02 3:31

We kind of there's like a pre-induction and then an induction. That's right. There's a preparation phase and the actual induction. And as you said, what we use for that preparation phase to make the cervix suitable for us to start the induction or prepare the cervix really depends on you individually and usually how many weeks you might be, if you've had a baby before, and the position of the baby, lots of different things. So usually that would mean that we would do an internal or vaginal examination before the induction was planned to take place.

SPEAKER_01 4:09

Yeah.

SPEAKER_02 4:09

Normally when we start to talk about in clinic the week before. Kind of the week before. I think earlier than that is usually not very useful. And we always are trying to reduce the number of vaginal examinations we have to do because it's not the most comfortable thing all the time. So as close to the day of induction or the days of induction that we're thinking about would be when we would be doing that internal examination beforehand.

SPEAKER_01 4:36

To help us make the decision about what sort of cervical ripening we'll use.

SPEAKER_02 4:41

Exactly. And you might not need any. No, that's the other thing. That's the important thing. If your cervix is open and soft and short enough, then you might not need anything to open up that cervix for preparation for labour. Yes. But if it is what we would say long and not quite soft enough or even closed or not open enough, then we would want to prime your cervix so that you're in the best position for induction of labour and vaginal birth as possible.

SPEAKER_01 5:13

Yeah, you might hear the term, I don't like the term, but you might hear the term unfavourable. Yeah. That describes it. It's a bit of a negative term. It's a negative term and it's like nothing you can control. But we call the cervix unfavourable when it's like that long, thick, firm, and needs that like cervical ripening pre-preparation.

SPEAKER_02 5:30

Yes.

SPEAKER_01 5:30

Like all medical terms. Yes.

SPEAKER_02 5:33

Some are a bit good terms, they're a bit awkward and not very pleasant. So you mentioned that there's different ways of ripening or preparing the cervix. One of those is a balloon catheter, and that is a mechanical way of opening up the cervix. And there's a couple of different types of those as well. One is a single balloon that goes into the cervix. Another one is a balloon that has two balloons that sort of ripens the cervix by putting mechanical pressure from two different directions. And both of those are inserted using what we call a speculum, so similar to a PAPSME. And then we pop the balloon into the opening of the cervix and we inflate either the one or the two balloons with usually water. And then that would sit there, usually overnight, so that it gives enough time to prepare the cervix.

SPEAKER_01 6:27

Yeah, we kind of like that sort of 12-18-hour mark, but anywhere up to like 24 hours, even sometimes we leave them in.

SPEAKER_02 6:34

Yeah, that's right. That part can be quite uncomfortable for some patients. Particularly it when it first goes in.

SPEAKER_01 6:40

Yeah.

SPEAKER_02 6:41

That's the most uncomfortable. It is. Often you do get used to that strange feeling of pressure after a little while. So that first feeling of discomfort subsides a bit. And then over the time that it's sitting there, it's not as uncomfortable the whole time. But we are very good at talking you through the procedure and being guided by you and your levels of discomfort as to how the procedure's gonna go.

SPEAKER_01 7:07

Then you might feel some very normal to feel because we are, even before we've blown up the balloons, even just by touching the cervix can cause like abdominal cramping and back cramping. And so that's often the worst just as it goes in, and then it will ease off. Some health services offer some pain relief that you can take to try and ease off those cramps. Some health services send you home with some pain relief tablets if you're going home with the balloon. So definitely we'll talk you through and let us know what you're feeling. And we do have options to play with the level of fluid or water in the balloon if it becomes unbearable. That's right. But I would feel like that's quite rare that I would have to take fluid out.

SPEAKER_02 7:45

Yes, exactly. And we want to be trying to give you the best chance of having the best preparation for the induction as possible. So, as you mentioned, some people do have the opportunity to go home with that balloon in. Yeah. And in most cases, we would prefer that because we want you to be able to have a good rest at home, ideally in your own bed, in preparation for the big day that is to come for induction.

SPEAKER_01 8:09

Yeah. I think some people are nervous to go home, but if everything is well with you and baby and we've assessed that you're safe to go home, then it's definitely safe to go home. And if the balloon falls out at home, great. That means it's working. It's done its job. And so you just you don't need to panic if it falls out. You just call us and tell us, and we'll normally say, Great, chuck it in the bin, we'll see you in the morning. So it's nice to be in your own space, I think, particularly that night before everything is gonna kick off and your whole world's gonna change. It's nice to be in your own home. That's right.

SPEAKER_02 8:41

And there are some things that we might tell you to look out for, like, of course, if the balloon falls out, give us a call. If you have any pain that's really bad and it's not going away, we do want to know about it. Because sometimes a balloon can also stimulate the labour. It can. Because the cervix is changing too well, which is also great. Similarly, if you have any bleeding, leaking of fluid, or any decrease in movements, we still want to know about all of those things. So we'd want to get you to call us anytime. Definitely. Sometimes we might not want you to go home, and that might be if we're worried about either you or baby for any reason. So we might keep you in hospital and make sure that you're as comfortable as possible until your induction time in the morning. But usually we would try and send you home as much as we can.

SPEAKER_01 9:26

Yeah, I feel like 80% of women go home.

SPEAKER_02 9:29

Yeah, I think so. I think so. And then usually we would then either call you or you would call us in the morning of the day of induction, and we would invite you into the delivery suite to start the induction. And how does that usually go for patients?

SPEAKER_01 9:47

Normally we would call you or you would call us, depending on what you've decided with your healthcare provider. And you would come in with your bags, and we'd settle you in. If the balloon is still in, we would deflate it and remove it, and then we would do another internal examination, so vaginal examination, to see if the balloon has done the job that it should.

SPEAKER_02 10:11

Taking out that balloon does not require a speculum.

SPEAKER_01 10:14

No.

SPEAKER_02 10:15

It's much less of an uncomfortable procedure than putting it in. It's a big relief. It's a big relief, yeah.

SPEAKER_01 10:21

Big relief.

SPEAKER_02 10:22

So we also mentioned the other hormone methods of ripening or preparing the cervix. What are those two?

SPEAKER_01 10:29

So one is called prostin, and so that is a gel, so that's inserted vaginally, so via vaginal examination, so two fingers inside the vagina with the gel on it, and we aim to get it around the cervix. And then the other pharmacological one or medication one is called cervadil, is the like product name, but it looks like a long string, and it's got medication in it. It's probably only about two to three centimetres long. We again insert that via vaginal examination and we wrap it around the cervix. There's positives and negatives to both. I think the biggest thing with cervadil we might use is that we can take that out. So the cervadil, we might use it in women that we are worried might go into labour quite easily off the cervadil, or there's something else going on with your history. So then the cervadil, because it is like a tape, we can just pull it out. In saying that, the prostin, there are other medications we can give if unexpectedly you go too quickly into labour with the prostin, um, and we might need to stop bet. But yeah, there can be two kind of medication options.

SPEAKER_02 11:39

Yeah, and the the other difference with the cervadil is that it's just one thing that we put in that lasts that whole time while we're preparing until we break the waters. But the prostain or the prostaglandin is the hormone in that that usually requires either one or two, but sometimes rarely more doses, a few hours apart, usually six hours apart. And the way we would decide whether or not you need those extra doses is vaginal examinations to see if it's worked to prepare the cervix. Yeah. And because those hormones are starting to act on the cervix and potentially contractions, you would stay in hospital if you have either of those two things. So you wouldn't be going home.

unknown 12:24

Yeah.

SPEAKER_02 12:25

We want to just keep that closer eye on you. Yeah, and baby. And baby. Yeah. So we usually monitor the baby with a heart rate monitor or a CTG as well. Yeah. So one of the main questions people might have is why would you choose cervadil or prostaten or the balloon catheters? And that's a really important question. And that's actually something that we have a lot of research about in the field, and there's no perfect answer. But the things that we get most concerned about with the gel, either the prostaten or the cervodil, is that we might bring on contractions too quickly or too soon. And the baby has the potential to then, as a consequence, maybe get stressed. So that's something we might consider in particular situations. The balloon tends to be something we choose if we're worried that that might happen, that we might be causing contractions too quickly. But also it is something where we would consider if we want you to be able to go home as well. So another advantage of the balloon. So different health services are different in terms of what they most commonly offer and what they might be most comfortable doing. And that is because there's actually not a lot of really good quality evidence to guide us in any particular direction. We really individualise our treatment as to what works best for each individual person, their preferences, and their baby and their body.

SPEAKER_01 14:15

Sometimes, depending on your clinical situation with that vaginal examination, we'll consider breaking your waters at the same time, or that might be done in a separate examination, it just depends what's going on. But the next step of the induction is what we call breaking the waters or breaking the membranes. There's lots of different terms for it. But essentially, it means your baby is sitting in this balloon above your cervix. And if you imagine at the bottom of the balloon where the like opening is, if there was a ball sitting there, that's your baby's head sitting there. And so actually, most of the fluid is sitting behind your baby and behind the ball. And but in front of the ball, there's a tiny little pocket of fluid. And what we want to do is break that. Why I explain it like that is when we break it, it's not just one gush and all the waters go. You constantly have trickles throughout the labour till the baby's born. But we break the membranes in front of the baby's head. We do that with a vaginal examination, and most hospitals in Australia use what's called an amni hook, which is like looks like just a really long crochet hook. Like a really long yellow plastic hook with a tiny little curve on the end that's got a very little like sharp beat. And so we just use that to kind of nick the membranes. The actual breaking of the membranes themselves doesn't hurt, doesn't hurt you or baby, but the vaginal examination can be uncomfortable and getting access can be uncomfortable, but the actual breaking doesn't hurt, if that makes sense.

SPEAKER_02 15:47

Yeah, that's important to know because I think when you imagine someone sticking a hook into your vagina and cervix, and then near the baby's head, it's it can be concerning that you might be hurting either you or the baby. So it's important to note that the way we do that using our fingers guarding your baby's head and your tissues down there is that we make sure that it doesn't hurt you and it doesn't hurt baby. And we're just, as you said, nicking the membranes.

SPEAKER_01 16:16

The membranes, yeah. It's the examination that is uncomfortable or hurts. It's not the little sharp bit on the hook. You won't feel that. What you'll feel is this huge gush of water. Sometimes you hear a little like pop or nick, depending how much pressure is going down there, but then then you'll feel this like huge warm sensation, like you've just wet your pants. Yeah. And that will not go away until you've had the baby.

SPEAKER_02 16:38

Yeah, and I think people often describe that as a strange sensation that you you just have no control over the fluid that's leaking and it keeps coming. Yeah. But that's normal.

SPEAKER_01 16:47

Very normal. And we look at the colour of the fluid. So we're happy with anything that's clear or a bit pinky sometimes, depending on the context. But then we look out for concerning things like if it looked yellow or green or had fresh blood in it or anything like that, then we would have that conversation with you as well about what that meant. But generally, it's kind of clear pink lycore, and that's normal. And lycore is the waters.

SPEAKER_02 17:14

Yes, that's the technical term for the technical term for the waters around babies in the womb. If it was yellow or green, what we'd be most concerned about is that the baby may have done a poo inside. And obviously, we don't like the baby to be swimming around in that fluid with the poo in there, and it can be potentially damaging to baby's lungs if it does get in. So we ideally don't like baby to be uh in there for too long if we know that's happened. And there are some reasons why that might be the case. Usually it's most commonly if they're overdue, or it can be if they're a bit stressed, sometimes it can be because of infection. But it is something, as you said, Erica, that we'll talk to you about and we'll keep a really close eye on how happy the baby is, and ideally not want that labour to go on for too long because we don't want the baby to be in that environment for too, too long. Yeah. It's one thing to talk about the experience of ripening and the different methods, but I think it's really useful to hear from someone who's actually experienced it themselves. So I'd really love to welcome Sarah back onto our podcast. Hi, Sarah.

SPEAKER_03 18:25

Hi, everyone.

SPEAKER_02 18:26

Hi, Ray. Hi, Erica. Hi Sarah. And the beautiful Sarah has had two beautiful daughters and two methods of induction. Both of your labours were induced. Are you happy to talk us through a why they were induced and what methods you had to help prepare your servings?

SPEAKER_03 18:46

Yeah, so cholestasis is the answer for induction. I had it with Emily more severely than Sophie, but Sophie was still experiencing a bit of cholestasis, so it was safer to get them out.

SPEAKER_02 18:57

And we will have another episode in future about cholestasis.

SPEAKER_03 19:01

And I might be back for that.

SPEAKER_02 19:02

I think you will be.

SPEAKER_03 19:05

And so with Emily, I had the balloon inserted, and we went down to births. We had inserted. And actually, funny story is um my partner, he sat on the big comfy chair and he thought, yeah, I I could do this. The common joke about the uncomfortable partnership. He goes, Oh, this is fantastic. He got that chair, and then we went and moved to a different room on the next day, and he was stuck with a little like not a climb, but the little just simple backline is like, oh, I'm suffering, yeah, you're suffering.

SPEAKER_01 19:36

It was not the thing to say, by the way. And then we put those chairs in there on purpose.

SPEAKER_03 19:43

And then somebody had the balloon put in and then was sent home. And I found the procedure uncomfortable, maybe a little bit of pain, but nothing. I that was, you know, astronomical. It was pain. It was a bit of uncomfortableness. Yeah. And then, but when I got home, they sent me with some coding. Yeah, coding is usually what we send you home. Thank goodness. Because I had the most intense back cramps I've ever had in my life, like period pain on the next level. And steroid. I couldn't even sit down. I was walking around in the table and thinking, what's happening? And then I took one of those bad boys and I was back to watching Netflix. This is fine. So I don't think that's necessarily what can happen, but it could happen. Yeah. It could happen. And it happened to me, and so that was all fine, and then went in the next day for the induction. And then with Sophie, I had the gel. I can't quite remember the reason between the two why one was balloon, one wasn't, but the Maybe your civics was a bit different the second time. Potentially, but they assessed me, and that was their judgment, and they had the gel put in. I thought, okay, I'm seeing. No, no, no, no, you're staying here. What do you mean I'm staying here? And so it actually was quite nice because at that point I had a toddler at home and it was a holiday.

SPEAKER_02 20:57

I think I could sleep in a bed without her.

SPEAKER_03 20:59

Exactly, exactly. So then, you know, in the morning woke up, and then they just wheeled me into the next room, and then we started the day. But it's funny because, you know, sitting behind these microphones, I was listening to your conversations, particularly the latent phase of labour, and I was sitting there in aug thinking, oh wow, that's all brand new information. I didn't know any better.

SPEAKER_02 21:16

Because you didn't experience that.

SPEAKER_03 21:18

I didn't experience any of that. It was um that was quite interesting stuff. I was enjoying listening to that episode.

SPEAKER_02 21:24

And so how did you find the experience between the balloon versus the gel?

SPEAKER_03 21:30

Um I think the balloon it was a little bit more discomfort. Um, just you know, every time you go into the bathroom, you're kind of checking because it's dangles down.

SPEAKER_02 21:38

Um and it's usually taped to the inside of your leg.

SPEAKER_03 21:40

And it's taped to the inside of your leg. So it's not comfortable. It's not painful. It's just it's not a bit strange. Yeah. Yeah. That I found was a bit more discomfort and then, you know, the pain as a result of that. But then once I had the coding, that was all fine. Whereas the gel, I don't remember any pain, any anything like that. I think it was all more chill.

unknown 22:03

Cool.

SPEAKER_03 22:03

Does that make sense? It was pretty uneventful, the gel and set up the iPad and the snacks and just letting them in the floop spa too.

SPEAKER_02 22:15

Awesome. Sounds like you had a pretty good experience with your cervical ripening. Yeah. Awesome. Thank you so much, Sarah, for talking us through what it's like to actually go through that cervical ripening with both the balloon and the gel. I think it's really useful to hear from that perspective. Cool. We're going to be talking about the next steps of induction in our next episode, so please tune in for that.

SPEAKER_00 22:41

Thanks so much, Erica. Thanks again. Every pregnancy is unique. The information provided in today's podcast is for educational and general purposes only. It is not intended to be substitute for professional medical advice. It is important that you always seek the guidance of the qualified health professionals with any questions you may have regarding your health, pregnancy, or any medical conditions.