Induction of labour
In order for a baby to be born the cervix (neck of the uterus) has to shorten, soften and open and there needs to be contractions. In most pregnancies this process happens naturally between 38 – 42 weeks and is known as ‘spontaneous labour’. Induction of labour is the process of starting labour artificially.
Reasons for induction
- Prolonged pregnancy – where pregnancy continues after 41 weeks
- Pre labour rupture of membranes – where the waters surrounding the baby break and labour does not start within 24 hours and there is a risk of infection
- Medical reasons – where it is felt there is increased risk to the health of your baby or you should the pregnancy continue
Does a diagnosis of gestational diabetes mean induction?
For many ladies with gestational diabetes, we may fall into the 3rd reason stated above (Medical reasons). According to the current NICE guidelines induction (or elective caesarean section) should only be considered before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications.
NICE (English & Welsh) guidelines:
Timing and mode of birth
- 1.4.1 Discuss the timing and mode of birth with pregnant women with diabetes during antenatal appointments, especially during the third trimester. [new 2015]
- 1.4.2 Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induction of labour, or by elective caesarean section if indicated, between 37+0 weeks and 38+6 weeks of pregnancy. [new 2015] N/A for gestational diabetes
- 1.4.3 Consider elective birth before 37+0 weeks for women with type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications. [new 2015] N/A for gestational diabetes
- 1.4.4 Advise women with gestational diabetes to give birth no later than 40+6 weeks, and offer elective birth (by induction of labour, or by caesarean section if indicated) to women who have not given birth by this time. [new 2015]
- 1.4.5 Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. [new 2015]
- 1.4.6 Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. 
- 1.4.7 Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section. 
SIGN (Scottish) guidelines:
National audit data in Scotland indicate that delivery in women with diabetes is generally expedited within 40 weeks gestation. No clear evidence was identified to inform the optimal timing for delivery. The timing of delivery should be determined on an individual basis. Women who are at risk of pre-term delivery should receive antenatal corticosteroids. If corticosteroids are clinically indicated for pre-term labour, supervision by an experienced team is essential to regulate diabetic control. Women with diabetes have a higher rate of Caesarean section even after controlling for confounding factors.
- Women with diabetes requiring insulin or oral glucose-lowering medication who have pregnancies which are otherwise progressing normally should be assessed at 38 weeks gestation with delivery shortly after, and certainly by 40 weeks.
- Women with diabetes should be delivered in consultant-led maternity units under the combined care of a physician with an interest in diabetes, obstetrician, and neonatologist.
- Women with diabetes should have a mutually agreed written plan for insulin management at the time of delivery and immediately after.
- The progress of labour should be monitored as for other high-risk women, including continuous electronic fetal monitoring.
- Intravenous insulin and dextrose should be administered as necessary to maintain blood glucose levels between 4 and 7 mmol/l.
HSE (Irish) guidelines:
5.4.4 Timing and mode of delivery
- In the setting of excellent glycaemic control, adherence to treatment and absence of maternal and fetal compromise, women with diabetes may await spontaneous labour up to 39-40 weeks gestation.
- Vaginal delivery is preferable unless obstetric or diabetes complications necessitate caesarean delivery.
- Macrosomia and shoulder dystocia occur more frequently in pregnancies that are complicated by diabetes; these risks should be taken into account when planning mode of delivery.
- Sonographic estimation of fetal weight should be combined with the clinical judgement of an obstetrician experienced in the management of pregnancies complicated by gestational diabetes when evaluating the most appropriate mode of delivery for the patient.
- The frequency of fetal monitoring should be increased if the pregnancy is allowed to progress beyond 40 weeks’ gestation.
- The delivery plan should be clearly documented within the patient record
Can I choose not to be induced?
If you do not want to be induced you should speak with your consultant and diabetes team; communication is key!
You have the right to refuse and no mother can be forced into having an induction, but it is advisable to make an informed decision, rather than just refusing based on hearsay or an impulsive gut reaction.
Ask your consultant why they want to induce YOU, about the risk factors involved and share your concerns, also ask about any other potential options.
If your hospital is advising against the current NICE recommendations of induction after 40+6 then ask for the reasons behind this decision and guidance in your particular case. If all is looking well with your baby, placenta, blood sugar levels and the pregnancy in general then discuss the options of expectant management, daily monitoring after an agreed gestation and the possible use of membrane stretch and sweeps.
If you were hoping for a water birth or home birth then these are options that should be discussed. We discuss water and home birth with gestational diabetes in more detail on our home or water birth page.
If you are advised to have an induction and feel it is the best option for you and your baby, there are still many steps you can take and implement to maximise your chances of having the birth you want such as staying mobile, having an optimal birth environment, possible use of a birthing pool or bath to help with pain relief and good support by preparing a clear birth plan and choosing the best birthing partners. Look into hypnobirthing breathing and relaxation techniques as these things can still be used to help you enjoy a better and positive birthing experience.
Discuss with your team how you can make your birth personal for you and your partner whichever birth plan is needed. It isn’t about the type of birth or which intervention may be needed, it is about the birth of your baby, the safest way possible with you feeling in control and being able to make informed choices.
Please scroll to the bottom of this page for research publication links which may help you make an informed decision around induction of labour.
Induction leads to more intervention and a terrible birth?
One of the biggest discussions in our Facebook support group is around induction, the fear of induction leading to more intervention (or a cascade of intervention), the necessity of induction and many ladies are scared after reading or hearing horror stories of induction, thinking induction means a more painful, medicalised labour and birth ending in trauma and emergency caesarean section.
Many mothers with gestational diabetes are advised to have inductions, however since the updates in the NICE guidelines in Feb 2015 we are seeing many mothers being offered induction at term (NICE guidelines are 40+6) rather than earlier gestations, after the mother has been able to gain good control over blood sugar levels and subsequently baby’s growth.
NICE guidelines state that uncomplicated cases of gestational diabetes may be left until 40+6 before induction is offered, however this is open to interpretation of your consultant and dependent on any other factors in the pregnancy, which is good! We don’t want one size fits all policies when it comes to bringing our babies into the world, we want individualised care. We frequently see mothers who control their gestational diabetes with the use of insulin be offered inductions at an earlier gestation, however please do not let this put you off taking insulin should you need it to help lower your blood sugar levels. The complications of uncontrolled gestational diabetes can be fatal and so although taking medication for gestational diabetes may alter the birth plans advised, these issues should be discussed and dealt with separately.
We’ve seen many mothers have successful inductions, with the only intervention being the induction of labour itself, following with pleasant ‘normal’ vaginal births. Obviously there will always be some births which may end in emergency situations or may be traumatic, much as any birth could. We have mothers that have had terrible birthing experiences with induction and others that have had better birthing experiences with induction after previous spontaneous labours. Recent research suggests that induction does not increase the risk of caesarean section.
Membrane sweep (stretch & sweep)
Membrane sweeps have shown to increase the chances of labour starting naturally within 48 hours of the procedure and can reduce the need for other methods of induction.
A sweep is a vaginal examination that involves the doctor or midwife putting a finger inside your cervix and making circular sweeping movements to separate the membranes from the cervix. This increases the production of hormones called prostaglandins, which encourage labour to start.
There may be some discomfort or bleeding following the sweep, but it does not cause any harm to you or your baby.
If a sweep has not been mentioned in your appointment, but it is something you feel would be beneficial prior to your induction, then you should discuss this with your consultant or midwife.
This information was taken from a survey in our Life After GD UK Facebook group (July 2017) for mothers who have had their babies
342 ladies responded
85 ladies had sweeps which led to natural labour, 257 found sweeps unsuccessful in causing induction of labour. It should be noted that whilst 75% of mothers having sweeps found they did not cause induction of labour, the process itself may have helped towards making them more favourable for the induction process.
Natural methods of induction
Don’t forget that you have gestational diabetes and so eating 10 pineapples or a hot tomato based curry when you can’t tolerate tomatoes will do nothing but push your blood sugar levels sky high!
Methods you may want to try and are said to have more impact are intercourse as semen contains natural prostaglandins which help to ripen, or soften, the cervix and having an orgasm can trigger the release of oxytocin. Nipple stimulation is also said to help and so why not try colostrum harvesting? It would be potentially beneficial for natural induction plus you are doing something that will only help your baby once born.
Methods of induction
Artificial rupture of the membranes (ARM)
When the cervix is open to around 2 or 3cm and the baby’s head has engaged, it should be possible to break the waters around the baby. This procedure is carried out by using a small plastic hook which releases the water and allows the pressure of the baby’s head to press on the cervix and stimulate contractions. It will not harm you or your baby. The procedure may be uncomfortable but it should not be painful.
Prostaglandin is vaginal pessary containing hormones. It is used when the cervix is not ready or ‘favourable’ to go into labour by softening and opening the cervix enough to either start labour or to do an ARM. A pessary known as ‘Propess’ will be inserted into the vagina by a midwife. It has a tape attached to aid removal, similar to a tampon. It stays in for 24 hours unless labour starts or there are any concerns about you or your baby’s health.
Sometimes a pessary known as ‘Prostin’ will be given instead of Propess; it is made from the same hormone. You will be re-examined 6 hours after the first Prostin pessary and if the cervix is still not ready for labour then a second Prostin will be given.
In both cases your baby will be monitored every few hours. In between monitoring you will be encouraged to walk about or use a ‘birthing ball’, as being active can help encourage labour to start.
Much the same as the pessary mentioned above, it works by causing softening and dilation of the cervix; but instead of a pessary it comes in a gel which is administered using a syringe, inserted high into the vagina by a midwife. A second dose of the gel may be administered if the first dose does not produce the desired response.
Cervical ripening balloon catheter, foley catheter, cooks balloon
This procedure involves a catheter which is similar to what is used in the urinary bladder in patients. The difference here is that the catheter is inserted into your cervix. It has a balloon at the tip and when it is in place, the balloon is filled with saline (a sterile fluid). The catheter stays in for 24 hours with the balloon putting gentle pressure on the cervix. The pressure should soften and open your cervix enough to start labour or to be able to perform an ARM. The balloon may fall out by itself or may need to be removed by a midwife.
This is an artificial form of the hormone that causes your uterus to commence contractions. This is given intravenously through a drip in the hand. It can only be given once your waters have been broken. The drip is increased slowly until your uterus is contracting regularly and strongly. Women respond differently to how well the drip works on contractions as it depends on how ready your body is for the labour process.
During the labour your baby’s heart rate will be monitored continuously by a CTG (cardiotocograph). You can still move, bounce on a birthing ball and walk around, but will be slightly more limited due to the drip.
Induction – a lengthy process
Be prepared and realistic… How well the induction process works, depends on how ready your body is for induction and so for some ladies it can be very fast and straight forward, but for others it could take several days! You should take comfortable clothes to wear, you do not need to be in night clothes or a hospital gown unless you’d prefer to be. Take plenty of things to occupy yourself: things to read, games to play, music to listen to etc. as well as plenty of GD friendly snacks!
If you go into hospital and just lay on your bed waiting for something to happen after the induction process has been started, then you could be in for a long wait.
To assist the induction process, it is best to remain as active as possible. Walking, climbing stairs and bouncing on a birthing ball all help to encourage labour to start. Our mantra to any Mums going in for induction in our Facebook support group is “bounce, bounce, bounce!”
Induction more painful than spontaneous labour
Some mothers may find that labour and contractions are brought on much faster with an induction and therefore can be more intense than if the body was to labour at it’s own pace spontaneously. That said, we have had many mothers have extremely pleasant birthing experiences with induction, many using breathing techniques, a tens machine and gas & air. Pain relief should be discussed with your health care professionals and detailed in your birth plan. Many mothers are upset to find they need a consultant led birth and may be told a water birth will not be possible. Diagnosis of gestational diabetes does not necessarily mean that a water birth is off the cards and many mothers have been able to use birthing pools and baths for pain relief. For more information on water births, read more here
The NICE guidelines for Induction of labour state:-
188.8.131.52 The opportunity to labour in water is recommended for pain relief
*Although it should be noted that this particular guideline does not cover diabetes in pregnancy.
Sliding scale (insulin & glucose)
Sliding scale is an IV drip with glucose and insulin (2 drips). It helps to stabilise blood glucose levels by adding glucose if your levels drop too low and adding insulin if your levels raise too high. They are commonly given to ladies who need steroid injections for inductions and planned c-sections before 38 weeks. Steroid injections are used for lung maturity as respiratory problems are higher risk with premature babies, those delivered by CS and babies born to mothers with gestational diabetes and the injections can cause very high blood sugar levels. Not all hospitals admit or use a sliding scale whilst giving steroid injections.
The other time sliding scales are used are during labour for some ladies with diabetes. Some hospitals will use them as per their Trust or hospital policy; diet, metformin or insulin control makes no difference. Other hospitals will only use them for insulin controlled mothers and some will only use them if they see blood sugar levels drop or spike to a certain level. If you have stable well controlled blood sugar levels throughout pregnancy and labour, then a sliding scale is not necessary.
For further information on insulin sliding scales, please read more here.
In some cases induction of labour is not successful following repeated attempts. Your management will be discussed with your consultant and a plan will be put into place which may include a decision for an elective caesarean section. You may want to detail in your birth plan, how many attempts of induction you would be happy with before you would want a caesarean section.
Induced VBAC (vaginal birth after caesarean)
1.4.6 Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. 
Many mothers with gestational diabetes have had successful VBAC inductions and spontaneous VBAC labours. VBAC and induced VBAC is something you should discuss with your consultant if you have had a previous caesarean section and would like to try for a vaginal birth.
Gestational diabetes diagnosis alone is not a reason to advise caesarean section. However it may be advised for complications related to gestational diabetes or following failure of induction.
Research on induction of labour with gestational diabetes
The charts below are results collated from a Google forms survey we posted on our social media accounts (Facebook, Instagram & Twitter) between 2016-2018
Of 1,348 responses, we found that 61.7% of women were advised to have their labour brought forward due to gestational diabetes. Of that 61.7%, 2.6% declined induction of labour.
1,350 responses: –
- 47.8% (645) Induction of labour
- 17.3% (233) Spontaneous birth
- 15.6% (211) Planned caesarean section
- 10% (135) Failure to progress with induction leading to caesarean section
- 9.3% (126) Emergency caesarean section due to other reasons
In our survey of 1,035 responses, we found 57.8% of women were induced, with 10% ending in caesarean section due to failure to progress from the induction. Therefore, our survey showed a 90% induction success rate in those who were induced.
In our survey with 829 responses, we found 50% of inductions resulted in giving birth within 24 hours and 76.3% within 48 hours
Induction of labour at 38 weeks pregnancy for women with diabetes treated with insulin lowers the chances of delivering a large baby.
Women with diabetes or gestational diabetes are more likely to have a large baby, which can cause problems around birth. Early elective delivery (labour induction or caesarean section) aims to avoid these complications. However, early elective delivery can also cause problems. The review found only one trial of labour induction for women with diabetes treated with insulin. Induction of labour lowered the number of large babies without increasing the risk of caesarean section. However, there was not enough evidence to definitively assess this intervention
Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.
Women whose labour was induced were less likely than those managed expectantly to have a cesarean delivery. In addition, the risk of fetal death and admission to neonatal intensive care unit were decreased in the induction group.
Induction of labor in women with mild gestational diabetes mellitus (GDM) does not increase the rate of cesarean delivery prior to 40 weeks gestation.
If gestational diabetes is the only abnormality, induction of labour before 41 weeks of gestations is not recommended. (Very-low-quality evidence. Weak recommendation.)
- Participants in the WHO technical consultation acknowledged that labour induction may be necessary in some women with diabetes – for example, those with placental insufficiency and uncontrolled diabetes
CONCLUSION: In women with uncomplicated insulin-requiring gestational or class B pregestational diabetes, expectant management of pregnancy after 38 weeks’ gestation did not reduce the incidence of cesarean delivery. Moreover, there was an increased prevalence of large-for-gestational-age infants (23% vs 10%) and shoulder dystocia (3% vs 0%). Because of these risks, delivery should be contemplated at 38 weeks and, if not pursued, careful monitoring of fetal growth must be performed.