Outpatient induction of Labour: (IOL) guidance for women (Propess®)

What is outpatient induction of labour?

Outpatient induction of labour (IOL) refers to returning home after the induction of labour process has been started and returning after 24 hours for re-assessment. If labour contractions begin before this, you will be advised to return to the hospital.

Why have an outpatient induction of labour?

• Reduces the amount of time you will need to stay in hospital before your labour begins.
• Allows you to stay at home and wait for labour to start.
• Makes the process of induction more ‘normal’.

Who can have outpatient induction of labour?

Your midwife will have a discussion with you about the outpatient IOL process and if you meet all the criteria you will be offered this method of induction.

You will be offered an outpatient IOL at The Rosie if:

• your pregnancy is considered ‘low-risk’.
• you have no relevant medical or obstetric problems.
• you have not had any uterine surgery.
• you have had no bleeding after 24 weeks of pregnancy.
• you have a telephone.
• you live within a 30-minute drive from Rosie Hospital.
• you have a relative who will be with you at all times.
• you have transport to bring you to the hospital.

What happens once the decision is made to induce my pregnancy?

You will be asked to attend Clinic 23 in the morning your induction is planned. The midwife will read your notes and confirm that you are suitable for outpatient IOL. She/he will also discuss the process of induction with you and answer any questions you may have.

The midwife will examine and measure your abdomen to check your baby’s size and the way the baby is lying. She/he will also check that your baby is well by monitoring the baby’s heartbeat on a cardiotocograph (CTG) machine for about 20 to 30 minutes. When the midwife is happy with the observations and the CTG monitoring, she/he will perform an internal examination (vaginal examination) to check the neck of the womb (cervix) to see if your cervix is ripe and beginning to open.

What does ‘ripe cervix’ mean?

Your cervix is the bottom part of your uterus (neck of the womb) that opens to allow the baby to move from your uterus and down the birth canal to be born. During pregnancy, your cervix is closed and firm. Towards the end of pregnancy, it softens, or ripens. As you go into labour it will soften even more, get shorter and open.

However, if your cervix is not quite ready, we will attempt to ripen the cervix using a pessary called Propess®. The pessary looks like a very small flat tampon, which is inserted into the vagina during internal examination by the midwife or doctor. The Propess® pessary contains the active ingredient dinoprostone, which is a naturally occurring female hormone also known as prostaglandin.

Once inserted into the vagina the pessary will stay there for 24 hours slowly releasing the hormone to ripen your cervix. There is a string attached to the pessary to allow us to remove it easily. The string will sit inside the vagina.

After the Propess® is inserted you will need to be monitored for 30 minutes on the CTG machine. During this time, the Propess® tampon will absorb moisture from your vagina which makes it swell slightly and settle into place. This reduces the chance of it falling out.

The Propess® string will lie just outside of your vagina and it is important that you do not pull or drag on it.

Please take special care when:

• Wiping yourself after going to the toilet
• Washing yourself
• Getting on and off the bed

When the CTG recording has completed the midwife will assess the monitoring. If it is a normal recording and you feel ok, you will be free to go home.

You can continue with your day-to-day activities and eat and drink as normal. We encourage you to be as mobile as possible. Please also monitor your baby’s movements.

The midwife will give you a time to ring Clinic 23 for and usually update 6 hours after discharge.

What to expect/what is ‘normal’?

You can expect to feel period-like pain/ache, backache, dull ache at the tops of your legs, and maybe some tightening (painless or mildly painful contractions of the uterus). These are the effects of the prostaglandin softening, shortening and beginning to open your cervix.

Are there any side effects?

Propess® can occasionally produce some side effects which are usually mild and include:

• Nausea, vomiting, dizziness or rarely palpitations and fever.
• There is a very rare chance that you may be very sensitive to Propess® and start contracting very frequently and strongly: more than 5 times in 10 minutes.
• A run of contractions each lasting more than two minutes.
• Severe abdominal pain.

If any of this happens you must phone 01223 217217 and you will be asked to come into hospital to have a full assessment.

When to contact the hospital

You must call the Rosie on 01223 217217 if any of the following occurs:

• If the Propess® falls out - If the Propess® falls out, you will need to return to the hospital. It may need to be reinserted. Do not worry! If the pessary has fallen into a ‘clean area’ (e.g., your underwear, the bed or chair, not on the floor) then telephone and bring it back to hospital with you, keeping it clean. If it has fallen onto a ‘dirty area’ e.g., the floor, then we may either insert another pessary or insert different medication depending on when it fell out and the condition of your cervix.
• Onset of labour - If your contractions are becoming very regular, frequent (more than one every three minutes), long and/or very painful, then we may ask you to come back to the hospital. Phone and talk to a midwife first.
• Fresh red bleeding from the vagina (other than a ‘show’ which is a bloodstreaked mucous discharge common and normal after a vaginal examination when the cervix is ‘ripening’) however if you are uncertain then please phone us to discuss.
• ‘Waters break’ – This is known as the membranes rupturing: the colour may be clear, tinged with pink if you have also had a show, or stained green/black indicating that the baby has passed the first stool
• Baby not moving - If you feel that your baby is not moving as much as normal.
• If you are worried and need advice on the telephone. 01223 217217

What happens if my labour does not start within 24 hours of the pessary being inserted?

If you have not started your labour within 24 hours of having Propess® you will be asked to ring Sara Ward the following day for admission. Following admission, the midwife will assess you and your baby’s wellbeing.

The midwife will also ask to examine you internally to feel your cervix. If your cervix is ripe and starting to open, you will be offered the option to have your waters broken on the delivery unit. If this does not make you go into labour, we may advise that you have an intravenous drip to make your contractions come.

If the neck of your womb is not ready, you will need to stay in the hospital and have more prostaglandin in the form of a vaginal tablet. If this is the case, you will be admitted to Sara Ward where your induction of labour will continue.

Time to ring Clinic 23 ………………………

Time to ring Sara Ward ………………………

Please feel free to ask any questions before you go home.

Useful telephone numbers

Clinic 23/ Delivery Unit 01223 217217

Antenatal Ward (Sara Ward) 01223 217671