Some assessments and interventions may be needed during your labour and birth. Talk to your health care provider during your pregnancy to make sure that you understand why these assessments and/or interventions may be done.
Understanding why assessments and interventions may be needed during your labour and birth can help you make decisions that are best for you and your baby.
You may find it helpful to discuss the following with your health care provider:
|B||What are the benefits?|
|R||What are the risks?|
|A||Are there any alternatives?|
|I||What your intuition or inner voice is telling you.|
|N||What if you say no or not right now?|
A variety of assessments offered during labour and birth are considered to be a routine part of your care. They are offered to ensure the well-being of you and your baby and to assess how your labour is progressing.
Some routine assessments you can expect during labour include:
- Regular checks of your temperature, blood pressure, heart rate, and breathing rate.
- Regular checks of your babyâs heart rate.
- Regular checks of the strength, length, and frequency of your contractions.
- Vaginal examinations of your cervix as needed to assess progress.
During your labour, a sample of blood may be taken.
The reasons for needing a sample of blood taken during labour are:
- To double-check your blood type and to make sure that there is blood matching your blood type in case you need it.
- To determine your bodyâs ability to make blood clots.
- To determine levels of certain components in your blood before and after birth (e.g., to check for low iron levels).
During labour, you may need an intravenous (IV) line.
You may need an IV line during labour if you:
- Are Group B Streptococcus (GBS) positive so that you can receive antibiotics.
- Desire certain pain medications such as an epidural.
- Need oxytocin medication to assist with your labour progress.
- Are unable to drink fluids because you feel nausea and/or are vomiting excessively.
Your babyâs heart rate may be assessed more closely during your labour if there is a concern about your baby or if you are being induced with oxytocin.
During most labours, the babyâs heart rate is monitored using a hand-held device. This is done every 15 minutes in active labour.
Continuous monitoring of the babyâs heart rate and your contractions will be started if there is a concern for you or your baby or if you are receiving oxytocin medication. Soft belts will hold two small, flat monitors in separate places on your abdomen. One monitor will record your babyâs heart rate, and the other one will record when you have a contraction. When your babyâs heart rate is being monitored this way, your ability to walk around may be limited unless your hospital has a wireless monitoring system.
If it is hard to monitor your babyâs heart rate with an external monitor, an internal monitor may be used. A small probe will be placed inside your vagina and attached to the top of your babyâs head to do this.
Rarely, uterine contractions are monitored internally with a small catheter that accurately measures the pressure changes in the uterus.
Around the time of your expected due date, your health care provider may suggest ways to try to help your labour start.
To help your labour to start and to possibly prevent an induction, your health care provider may offer to do a membrane sweep during a vaginal examination. A membrane sweep involves your health care provider using a gloved finger to separate the amniotic sac away from the wall of the lower part of your uterus. This can cause your body to release hormones that can cause your labour to begin.
A membrane sweep can also cause:
- Discomfort and pain.
- Accidental rupture of membranes.
A membrane sweep can be repeated after a few days if your labour does not begin.
Home remedies to help labour begin may not be safe for you or your baby. Check with your health care provider first before trying a home remedy.
Your health care provider may recommend inducing your labour.
Induction of labour is the process of medically starting your labour. If you do not go into labour on your own by 41 weeks or if there is a concern about you or your baby, your health care provider may recommend inducing your labour. If you choose to wait for labour to begin naturally, your health care provider will recommend increased monitoring of your babyâs well-being. An induction will be needed if monitoring suggests your baby is no longer thriving.
If your cervix is not ready for labour and needs to be softened, your health care provider can do this by:
- Inserting a Foley catheter through your cervix into the lower part of your uterus to act as a balloon. This puts pressure on the cervix to release hormones.
- Inserting a medicated fabric ribbon such as Cervidil into your vagina.
- Inserting prostaglandin gel into your vagina.
- Giving you oral prostaglandin tablets called misoprostol.
With any of these methods, you may start to feel labour contractions within hours. If not, it may need to be repeated a few times before your labour begins. Learn about the signs to call or return to your birth setting if you leave for a period of time after any of these interventions.
If your cervix is ready for labour, your health care provider can induce your labour by:
- Giving you oxytocin medication via an IV pump in very small, gradually increasing amounts.
- Breaking your water (called an amniotomy) with a plastic hook and giving you oxytocin medication.
Your health care provider may suggest ways to improve your labour progress.
Natural ways to help your labour progress include:
- Urinating often.
- Changing your position often.
Medical ways to help your labour progress are similar to methods of labour induction and include:
- Giving you oxytocin medication via an IV pump in small, gradually increasing amounts.
- Breaking your water for you, called an amniotomy, and then giving you oxytocin medication.
Your health care provider may suggest assisting you with the birth of your baby if you become too tired to push any longer or if there is a concern about your babyâs well-being.
To assist you to give birth, your health care provider may:
- Place a small suction cup on your baby headâs and, when you push, apply traction. This is called a vacuum-assisted birth.
- Place two metal, spoon-like instruments on either side of your babyâs head and gently but firmly pull with them when you feel the urge to push. This is called a forceps-assisted birth.
- Make a small cut in the tissue to the side of the vaginal opening. This is called an episiotomy. It is not done unless there is a need to give birth quickly. Sometimes it is done when the tissue between your vagina and anus (the perineum) does not stretch to allow the birth of the babyâs head.
There are risks associated with having an assisted vaginal birth. The above techniques can cause injury to your baby and/or injury to your birth canal. If the methods are unsuccessful, a caesarean birth would be necessary.
Your health care provider may suggest assisting you with the birth of your placenta if it does not come out by itself.
The placenta normally separates from the wall of your uterus by itself within eight to ten minutes after the birth of your baby. It can take a bit longer. If it takes longer than 30 minutes, it may cause you to bleed too much. Your health care provider may:
- Give you medication to help the uterus to contract.
- Apply gentle traction to the umbilical cord.
- Manually remove the placenta if the above methods fail.
Learn more about interventions in labour.
You can find out more about interventions in labour from the following resources. More suggestions can be found in the Resources and Links section.
About Interventions in Labour
Labour is a natural process that does not normally require any medical interventions.1,2,3 Routine assessments are often done during labour and birth to ensure that a woman and her fetus are doing well and if it a woman has experienced a low-risk pregnancy no further assessments or interventions are generally warranted.2,4,5,6 Medical interventions are appropriate prior to or during labour and birth if there is a valid concern related to the well-being of a woman or her fetus. The projected benefits of a medical intervention should always outweigh its risks.3,4 For a health care provider to be able to perform a medical intervention for a woman and/or her fetus during labour and birth, the woman needs first to give her informed consent.3,7,8,9
Women have reported feeling uncertain and unprepared when asked to make decisions about interventions during their labour and birth.7,9 Women who did not fully understand the purpose of interventions experienced during their labour and birth have reported experiencing a difficult time coping in the postpartum period as well as prior to their next pregnancy or birth experience.7 For these reasons, it is important that women be given education during their pregnancy about assessments and possible interventions that they may experience during their labour and birth.
For women to be able to make informed decisions, information needs to include the benefits as well as the risks associated with interventions during labour and birth. Women and their support person(s) should also be encouraged to ask as many questions as needed about assessments or interventions with their health care provider prior to and during labour.3,7,8,9
When asked to make a decision pertaining to a medical intervention prior to or during labour and birth, women and their support person(s) may find the use of the mnemonic BRAIN to be helpful for them. This acronym involves them remembering to ask about the benefits of the intervention, the risks associated with the intervention, and if there are any alternatives to the intervention. It can also help them to remember to listen to what their intuition or inner voice is telling them to do in the decision-making process and that it is okay if their decision is no or not right now.
For more information about making informed decisions, see the file on Labour Support.
Intravenous use during labour
From the results of a 2007 survey of hospitals across Canada that had at least 10 births per year, it was found that 17 percent of hospitals had a policy to start routine intravenous (IV) infusions for all women in labour. This is increased from 1993 when only 14 percent of hospitals had this policy. 10 Although an IV may be needed for a woman during labour and there may be benefits of having an IV during labour such as added hydration, it is not recommended that all women have an IV during labour.11,12
See the section below on Intravenous initiation for more information on this topic.
Fetal heart-rate surveillance
If a woman has a low-risk pregnancy, and there are no health concerns about her or her fetus, intermittent auscultation of the fetal heart rate is recommended.13,14 In the 2006 Maternity Experiences Survey, 90.8 percent of women reported that external fetal monitoring (EFM) was performed at some time during labour, and 62.9 percent reported experiencing continuous EFM.15 This may be due to the high prevalence of EFM upon admission to a hospital labour and birth unit.
In 2007, it was found that 74 percent of hospitals had policies that specified that EFM be performed at the initial assessment of all women. This practice is increased from 1993 when only 65 percent of hospitals performed EFM upon initial assessment.10 There have been no proven benefits of an initial EFM assessment for women who have a low-risk pregnancy and who present to their labour and birth setting with no adverse conditions. It is best practice to perform continuous EFM during labour only if there are concerns about maternal or fetal well-being. Women should question the need for EFM during labour if they are uncertain.13,14
See the section below on Continuous fetal heart-rate monitoring for more information on this topic.
Induction and augmentation of labour
In developed countries, up to 25 percent of all births now involve the induction of labour.16 The rate of induction in Canada increased from 12.9 percent in 1992 to 19.7 percent in 2000.17,18 It reached a high of 23.7 percent in 2002 and then slightly decreased to 21.8 percent in 2005.18,19
In 2006 in Canada, 44.8 percent of women reported that their labour was medically induced, and 37.3 percent reported that their health care provider tried to speed up their labour. In 2006, 65.0 percent of women who had their labour induced had a caesarean birth.15
Assisted vaginal birth
The rate of assisted vaginal birth has decreased in Canada. It was 16.3 percent in 1996 and was further decreased in 2006 to 11.9 percent.15,19 In 2010 â 2011, the overall rates of assisted vaginal births, vacuum-assisted births, and forceps-assisted births in Canada were 13.5 percent, 9.6 percent, and 3.2 percent respectively. The rate of forceps-assisted births continues to decline from a rate of 4.6 percent in 2004 â 2005. There is considerable provincial variation within Canada as well as variation between selected western countries.20
In 2007 in Canada, 17 percent of hospitals had an explicit policy to avoid episiotomies.10 In 2006 in Canada, it was reported that 20.7 percent of woman received an episiotomy. Primiparous women were more likely to receive an episiotomy.15
See the section on assisted vaginal birth for more information and current recommendations.
Shaving and enemas
It is no longer the norm for women to receive a perineal shave prep or an enema prior to or during labour. In 2007 in Canada, 96 percent of hospitals had a policy stipulating that there should be no perineal shaves on admission, and in 1993 only 63 percent of hospitals had this policy. In 2007 in Canada, 88 percent of hospitals had a policy stipulating that no women should receive an enema or suppository, and in 1993 only 37 percent of hospitals had this policy.10
Routine Assessments during Labour
A variety of routine assessments are done to ensure the well-being of a woman and her fetus throughout labour and birth and to assess labour progress. If assessment results are deemed as abnormal, further assessments or interventions may then be warranted. It can be helpful for women to be aware of routine assessments prior to their labour and birth so that they can expect them and realize that they are routine and normal.2,5,6
Upon arrival at the birth setting, routine assessments can include:6
- The collection of a urine sample. Examining a womanâs urine is an easy way for a health care provider to determine if a woman may be dehydrated (indicated by the presence of ketones); has an infection (indicated by the presence of white blood cells); or may be at risk of experiencing complications due to high blood pressure (indicated by the presence of protein).
- A variety of assessment questions related to the womanâs contraction pattern, the amount of fetal movement she had been feeling, and if she thinks she has ruptured her membranes.
- A variety of assessment questions pertaining to the womanâs present pregnancy and any past pregnancies.
- An assessment of the fetal heart rate.
- An assessment of the womanâs vital signs (blood pressure, pulse, breathing rate, and temperature).
- An assessment of the womanâs contractions (strength, frequency, and duration).
- A vaginal examination to assess for any changes in the womanâs cervix or the position of the fetus.
These assessments help health care providers establish a baseline for future assessments during labour and birth. In a hospital setting, a labour and delivery nurse will usually perform these assessments. Either the nurse or the primary health care provider will perform the vaginal examination. 6
Additionally, upon admission to a hospital, a woman will be asked to wear a hospital band with identifying information and an allergy band if she has any allergies. She may also be offered a hospital gown.6
Women can expect to have their blood pressure, heart rate, breathing rate, and temperature checked approximately every four hours. These timelines are guidelines only. A womanâs vital signs may be assessed more or less frequently depending on the circumstances. After a womanâs membranes rupture, her temperature is likely to be assessed more often to rule out a fever because of the increased risk of infection.6
Intermittent fetal heart-rate monitoring
The fetal heart rate can provide information about the well-being of the baby during labour. Listening to the fetal heart rate throughout labour is used to decrease the risk of adverse neonatal outcomes. The fetal heart rate can be assessed intermittently using a doptone (a hand-held ultrasound transducer that will make the fetal heart audible).13,14,21
To listen to the fetal heart rate, the health care provider will:6,13
- Palpate the womanâs abdomen to assess the fetusâ position. This will determine the best place to listen to the fetal heart rate.
- Place a small amount of gel on this area.
- Listen with the device during and after a contraction to determine the heart rate and how the fetus is coping with the contractions. The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines state to listen to the fetal heart rate for a full minute after a contraction.
Intermittent auscultation during labour is recommended for women with low-risk pregnancies and labour as opposed to continuous monitoring throughout labour. Intermittent auscultation during labour can prevent adverse fetal outcomes, unnecessary medical interventions, use of analgesia, and caesarean births.13,14,21,22
Women can expect the fetal heart rate to be assessed13,14
- Every hour during the early phase of labour or if any change occurs in labour, such as the rupture of membranes.
- Every 15 to 30 minutes in active labour and the transition phase.
- Every five minutes during pushing in the second stage of labour.
For more information, see the Labour Progress file where the stages of labour are defined and discussed.
In addition, women can expect the fetal heart rate to be assessed:13,14
- After the rupture of membranes (and before and after amniotomy).
- Before the administration of medications.
A fetal heart rate is typically between 110 and 160 beats per minute and tends to increase with fetal movement. If there are concerns about the fetal heart rate or the fetus in general, continuous fetal monitoring will be used. Otherwise, the fetal heart rate will be listened to intermittently throughout labour and birth.13,14
Throughout labour, a woman can expect a health care provider to regularly check her contraction pattern. This will involve the health care provider asking her questions about how strong her contractions are, how long the contractions last, and how far apart they are. Timing and assessment of the strength of contractions can be done by palpation ( i.e. placing a hand on the fundus of the uterus).6
For more information on assessing contractions, see the Labour Progress file.
If a woman has experienced a low-risk pregnancy and nothing concerning has occurred in her labour, her health care provider will assess her contractions using abdominal palpation and the womanâs feedback. Continuously monitoring of a womanâs contractions with an external or internal monitor in conjunction with continuous fetal heart-rate monitoring is not routinely done during labour.6,13,14
See the section below on Continuous fetal heart-rate monitoring for more information on this topic.
Vaginal examinations are performed during labour to track labour progress. After the initial assessment, a vaginal examination may be repeated every four hours or be done if there is any perceived or actual change in labour.6,23 If the vaginal examination is to be done to assess labour progress, a woman may ask to defer it.
Examples of situations that warrant a vaginal examination include:6
- Rupture of the amniotic sac.
- To ensure labour is progressing well.
- Before pain medication is given.
- Abnormal fetal heart rate.
- To insert an internal monitor.
- Increased pressure in the perineum or rectum.
The Labour Progress file has more information about vaginal assessments during labour, including cervical dilation and effacement and station of the fetus.
At the beginning of labour or during labour, a woman may have a sample of blood taken. One of the predominant reasons that this is done is to verify a womanâs blood type. Many birthing facilities do this to ensure that they have a sufficient amount of a womanâs blood type on hand should she lose an excessive amount of blood and require a blood transfusion.6,24
A womanâs hemoglobin level will often also be determined from the sample of blood taken. If a woman loses an excess amount of blood during birth, her hemoglobin level prior to and following the birth can be then compared. If this level is much lower following birth, and she experiences symptoms associated with a significant blood loss (e.g., weakness), this may indicate that she needs a blood transfusion. If her hemoglobin level is not much lower, and she is stable, she may be prescribed increased fluids, rest, and iron supplements to help her recover.24,25,26
For more information about lochia and coping with excess blood loss following birth, see the Recovery after Birth file.
During labour, some women will require an IV line.
Reasons for initiating an IV include the delivery of:11,12,16,18,27,28,29,30
- Antibiotics for women who are Group B Streptococcus (GBS) positive.
- Oxytocin medication for induction or augmentation of labour.
- Pain medication in labour or after the birth.
- Fluids for a woman who is nauseous and/or is vomiting to ensure that she remains hydrated.
If a woman only needs an IV to receive antibiotics for GBS prophylaxis during labour, her health care provider can disconnect the long tubing so that she only has a small IV access point attached to her called a saline lock. This will allow her to move around more easily during labour.
Continuous Fetal Heart-Rate Monitoring
Continuous fetal heart-rate monitoring (as opposed to intermittent fetal heart-rate monitoring) is recommended for women who experience risk factors in their pregnancy and/or labour.13,14,21,22
Continuous fetal heart-rate monitoring may be recommended for some women include if they:14
- Have a pre-existing medical disease.
- Experienced a motor vehicle accident or other physical trauma during pregnancy.
- Experienced excessive bleeding during pregnancy.
- Have a high body mass index and there is a concern whether the fetal heart rate can be adequately heard through adipose tissue.
- Have pre-existing diabetes mellitus or gestational diabetes.
- Have a hypertensive/blood pressure disorder of pregnancy.
- Have had a previous caesarean birth.
- Are carrying a fetus in the breech position.
- Are carrying multiple fetuses.
- Experience bleeding during labour.
- Are having their labour induced with oxytocin.
- Are having their labour augmented with oxytocin.
Continuous fetal heart-rate monitoring is recommended for women who are giving birth to a fetus that may be faced with the following challenges: 14
- Intrauterine growth restriction (IUGR).
- Reduced amniotic fluid (i.e., oligohydramnios).
- Meconium staining of the amniotic fluid.
- Prolonged rupture of membranes (i.e., greater than 24 hours).
- Infection or chorioamnionitis.
These lists are not exhaustive. If a health care provider is concerned with the fetal heart rate during labour, they may choose to continuously monitor the fetal heart rate for a period of time or throughout the duration of labour.13,14
There are two types of continuous monitoring: external and internal. Both methods involve continuous electronic monitoring of both the fetal heart rate and the womanâs contraction pattern. A womanâs contraction pattern needs to be monitored along with the fetal heart rate to determine how the fetal heart rate responds during and after a contraction.13,14
External fetal monitoring
External fetal monitoring (EFM) has been used since the 1960s. Since s introduction, it has become the most widely-used method of continuous fetal monitoring. It was initially introduced to decrease the morbidity and mortality rates for babies.6,14,22,31 EFM has not been found to decrease the risk of conditions such as cerebral palsy or neonatal mortality when used to monitor low-risk pregnant women. In fact, when used to monitor low-risk pregnancies, continuous monitoring can increase the risk of women having an assisted vaginal birth and/or a caesarean birth.21,22
To use EFM to monitor the fetal heart rate of a woman in labour, a health care provider will:6,14,21
- Palpate her abdomen to determine the best possible spot to listen to and record the fetal heart rate (usually over the fetal back).
- Place a small, flat monitor with transducer ultrasound gel over this area and use a soft belt to keep it in place.
- Palpate the womanâs abdomen during a contraction to determine where it becomes hard (usually at the top or fundus of the abdomen).
- Place a small, flat monitor (called a tocotransducer) over this area and use another belt to keep it in place.
For continuous fetal monitoring, the two monitors are typically attached via a cord to a small machine at the bedside called a cardiotocograph (CTG). This machine records the fetal heart rate and contraction pattern on graph paper for the health care provider to watch and examine. In some facilities, the fetal heart rate and contraction pattern can be seen in a central monitoring area as well as at the bedside. EFM is not able to monitor the strength of contractions. When using EFM, palpation of the abdomen and the womanâs report of pain intensity are still used to determine the strength of contractions.6,13,14,21
Internal fetal monitoring
Internal fetal monitoring is used when it is difficult to adequately monitor the fetal heart rate by EFM. It is often able to provide a more accurate assessment of the fetus than EFM and is not affected by maternal or fetal movement. Internal fetal monitoring involves the placement of an internal monitor probe on the presenting part of the fetus (typically the fetusâs head). This method can only be used when the amniotic membrane has already ruptured, and a womanâs cervix is dilated 2 cm to 3 cm. Risks include injury to the presenting part of the fetus at the place of attachment of the electrode. Contraindications for internal monitoring include placenta previa, face presentation, unknown presentation, HIV seropositivity, active genital herpes, a history of hemophilia or other bleeding disorder.6,14
The tocotransducer is not typically removed when internal continuous fetal monitoring is used. If a more accurate assessment of the contractions is required, an intrauterine pressure catheter (IUPC) can be used. An IUPC is a catheter with a pressure-sensitive tip. It is placed inside a womanâs uterus through her vagina between the fetus and the wall of the uterus. During a contraction, the CTG records the pressure exerted (on the tip of the IUPC) to measure when a contraction occurs and how strong it is. This method can only be used when the amniotic membrane has already ruptured, and a womanâs cervix is dilated 2 cm to 3 cm. Although this method of monitoring contractions is possible, it is rarely used in Canada.6,14
Coping with continuous fetal monitoring
One of the most problematic aspects of continuous monitoring for a woman during labour is that it restricts her ability to move and change positions as desired. Some birth settings have portable telemetry units allowing a woman to move around without being attached to the CTG machine. Even with telemetry, however, women can find the monitors and belts restrictive. For this reason, if a normal fetal heart-rate pattern has been observed, some hospitals have a policy that continuous monitoring may be interrupted for up to 30 minutes to allow a woman to walk around, change positions, use the toilet or use the bath or shower if appropriate.
If continuous fetal monitoring is interrupted:14
- The woman and the fetus must have normal vital signs prior to doing so.
- The infusion rate of oxytocin cannot be increased prior to or during this time.
Besides the physical discomfort associated with continuous fetal monitoring, it can also be difficult for a woman psychologically. This can especially be true if a woman was not expecting to need continuous fetal monitoring during her labour. Labour support is vitally important for a woman who requires continuous fetal monitoring during labour and birth.6,21
With continuous fetal monitoring, if there is an atypical fetal heart-rate pattern, and there are concerns about fetal well-being, digital fetal scalp stimulation may be performed. A health care provider does this by gently stroking the presenting part of the fetus for 15 seconds during a vaginal examination to try to elicit a fetal response. The expected response is fetal heart-rate acceleration/increase.14
To help determine the best plan of care when an abnormal heart-rate pattern is observed, a health care provider may suggest taking a sample of blood from the fetus to test its pH level. For the sample to be taken, the womanâs legs are placed in stirrups, and a white cone is placed inside her vagina. A small abrasion is then made on the fetusâs head with a special instrument designed for this to collect the sample. If the pH level of the blood is not within normal range, a caesarean birth will likely be recommended to avoid any undue harm to the fetus. And, conversely, if the pH level is normal it can prevent an unnecessary caesarean birth. Not all facilities or health care providers are equipped to do fetal blood sampling. Additionally, it is contradicted if there is a family history of hemophilia, a fetal bleeding disorder is suspected, or if there is a face presentation.14
Please also note that fetal lactate level testing is currently undergoing approval as an alternative, easier test. This method of blood sampling may be available soon.
Cervical Ripening and Induction of Labour
Induction of labour is referred to as the artificial stimulation of labour before its spontaneous onset. The outcome of a successful induction is a vaginal birth within 24 to 48 hours of the initiation of induction. A health care provider may suggest induction of labour for a woman before her expected due date if they are concerned about her well-being and/or the well-being of her fetus.16,18
Alternatively, if a woman continues her pregnancy beyond her due date, to prevent adverse events from occurring, it is likely that a health care provider will offer induction of labour. Induction of labour is encouraged for women who with known certainty have gone beyond 41 weeks (> 40 weeks + 7 days) of gestation.16,18,32
Induction of labour is recommended for post-dates pregnant women because:16,18,33,34,35,36,37
- The amount of amniotic fluid can decrease, which can cause complications or death of the fetus.
- A fetus is at increased risk of passing meconium and suffering from meconium aspiration syndrome at birth.
- A woman is at increased risk of needing an assisted vaginal birth or a caesarean birth.
Note that women over 40 and in some instances over 35 are being induced earlier due to concerns that their placentas are aging more quickly. The SOGC is expected to provide more information about this soon.
A woman should be encouraged to discuss the reason for induction with her health care provider if induction is recommended. Before giving informed consent for induction, a woman should be encouraged to understand all of the risks and benefits of induction of labour. Induction of labour should only be initiated when there is a clear medical indication, and the expected benefits outweigh the risks.16,18
Induction of labour can include the following risks:6,16,18,33,38
- Failure to achieve labour.
- Excessive uterine activity or tachysystole.
- Atypical or abnormal fetal heart-rate pattern.
- Rupture of the uterus.
- Cord prolapse.
- Assisted vaginal birth.
- Postpartum hemorrhage.
- Inadvertent birth of a preterm infant in the case of an incorrect expected due date.
- Caesarean birth due to some of the risks listed above.
If a woman has a low-risk pregnancy, and she has reached her expected due date, she may decide to try to stimulate labour on her own to avoid the need for medical induction of labour. There is no conclusive evidence that natural methods stimulate labour, and some natural methods are unsafe. Women should be encouraged to discuss methods with their health care provider before trying them.16,39,40,41
If a woman regularly rubs and tugs her nipples around the time of her expected due date, this may cause her labour to begin. It is believed that nipple stimulation releases natural oxytocin in a womanâs body. This is the hormone released in a womanâs body during labour that causes contractions to occur. This method does not work for all women. As well, some adverse events have been reported with nipple stimulation preceding and during labour. Women who have experienced a high-risk pregnancy should avoid this method to try to stimulate labour.39,42
Engaging in sexual intercourse may cause natural oxytocin to be released in a womanâs body. In addition, a hormone referred to as prostaglandin found in a manâs semen can potentially soften a womanâs cervix. Using sexual intercourse to stimulate labour is not effective for all women but women with low-risk pregnancies may wish to discuss this option with their health care provider.18,39,43
Going for a walk
Light activity such as going for a walk has not been shown to help stimulate a womanâs labour. However, it can be helpful in encouraging a fetus to descend into the birth canal due to the effects of gravity. If a woman is feeling impatient as she waits for her labour to begin, going for a walk or doing light exercise can be beneficial for her physical and emotional well-being. Women should be cautioned against doing any strenuous activity to try to stimulate labour as this is neither effective nor safe.6,39
Drinking red raspberry leaf tea
The use of red raspberry leaf tea often comes up in discussions of home remedies to start labour. Some women have reported that drinking red raspberry leaf tea has helped them begin labour. It is not clear why but drinking red raspberry leaf tea may have a stimulatory effect on the uterus. It is important to note that red raspberry leaf tea products can vary widely and research has shown that red raspberry leaf tea and its associated products can lead to excessive uterine activity and potentially compromise fetal well-being.
Overall, more research is needed to make a recommendation for women concerning drinking red raspberry leaf tea during pregnancy. Women should always talk with their health care provider first before drinking red raspberry leaf tea or using other red raspberry leaf tea products during pregnancy.40,44
In considering natural methods to stimulate labour, women should be aware that they may or may not be effective. Some could also cause harm. Women with low-risk pregnancies may consider different natural methods to stimulate labour as long as they check with their health care provider first to ensure that the method is safe for them.39,40,41
If a woman reaches 41 weeks in her pregnancy, she should undergo twice-weekly assessment to ensure fetal well-being.18
These assessments typically include:32
- A 20-minute, external continuous fetal monitoring assessment referred to as nonstress test (NST).
- An ultrasound called a Biophysical Profile (BPP), which checks that the baby is moving, has good overall tone, and is making practice breathing movements. The BPP also measures the amount of amniotic fluid surrounding the fetus.
Other assessments may be done as well.
Women should be encouraged to do fetal movement counts during this period and to report to their health care provider if they feel less than six movements in two hours or are generally concerned about the amount of fetal movement that they feel. Fetal counts are ideally done in the evening, with the woman is lying down or semi-recumbent.1,4
Between 38 and 41 weeksâ gestation, a health care provider may offer to do a membrane sweep to help stimulate labour.18,32,36 This is not an actual method of induction, but it can cause changes to occur and reduce the need for a formal method of induction.16,18,36
A membrane sweep is a simple procedure completed during a vaginal examination. To perform a membrane sweep, a health care provider extends his or her forefinger into the entrance of the cervix (called the cervical os) and does circular sweeps to separate the amniotic sac away from the cervix. When the cervix is completely closed, a health care provider can alternatively massage the entry to the cervix with his or her forefinger and middle finger for 15 to 30 seconds. It is believed that both techniques result in an increase of local prostaglandins that are the hormones needed to soften the cervix for labour.18,32,45
The risks associated with a membrane sweep include discomfort during the vaginal examination, premature rupture of membranes, and vaginal bleeding.16,18,32 While the procedure can be uncomfortable, one study reported that 88 percent of women would choose to have it done again in a subsequent pregnancy.45
When labour does not begin spontaneously, different methods can be used to initiate contractions and labour. The method used will depend on the state of the cervix. If the cervix is firm and not dilated (called an unfavourable or not ripe cervix), the health care provider must use a method to soften the cervix before attempting to initiate contractions. Sometimes, but not always, methods to soften the cervix may also initiate contractions. If the cervix is already soft and beginning to dilate (usually referred to as favourable or ripe cervix), the health care provider may use a method of labour induction.
Health care providers use a score called a Bishopâs score to determine if a womenâs cervix is favourable or not. A vaginal exam is used to determine this, and the following is assessed:16,18,38
- Cervical softness.
- Cervical dilation.
- Cervical position (anterior vs. posterior).
- Cervical effacement.
- Engagement of the presenting part of the fetus.
From these assessments, a low Bishopâs score would indicate an unfavourable cervix and the need to use a method of cervical ripening first. A higher Bishopâs score would indicate that a method of labour induction could be used to initiate labour.16,18
Mechanical methods for cervical ripening
A mechanical method of cervical ripening for a woman whose cervix is unfavourable involves the use of a Foley catheter. For this method, the catheter used is similar to a catheter used to drain a personâs bladder. It is a narrow plastic tube with an inflatable balloon at one end. To use the Foley catheter for cervical ripening, a health care provider inserts it into the lower part of a womanâs uterus through her cervical opening using a sterile technique and then inflates the balloon with approximately 60 mL of water. The catheter is pulled back against the cervix and then often taped to the womanâs thigh. It is left in until it falls out on its own or after 24 hours. The purpose of this method is to stretch the cervix and cause a local release of prostaglandins. Prostaglandins are the hormones responsible for softening and thinning a womanâs cervix. Hormones may also be released to cause a womanâs uterus to begin to contract.16,18,38
There are some noted benefits associated with this method. It is a fairly simple procedure and it can be performed in an outpatient setting. As well, when compared to other methods of cervical ripening, using a Foley catheter poses less risk of side effects such as excessive uterine activity of the uterus.16,18 The Foley catheter method is also acceptable for women who are attempting a vaginal birth after caesarean (VBAC).18 Contraindications for using this method include a low-lying placenta, rupture of membranes, and a lower genital tract infection.18
See the Vaginal Birth after Caesarean Birth (VBAC) file for more information about planned VBAC.
A pharmacological method of cervical ripening involves the use of a medicated insert called Cervidil. Cervidil is the trade name of this medication. The insert is a soft, fabricated ribbon that contains a prostaglandin-related medication called dinoprostone. The insert is kept frozen until ready to use as it is only effective at colder temperatures. The insert is placed inside a womanâs vagina just behind her cervix in an area called the posterior fornix. It is left in until it falls out on its own, until a contraction pattern typical of labour is achieved, or after 12 to 24 hours.
The insert releases medication gradually and works to soften a womanâs cervix, after which additional hormones may be released in womanâs body to cause uterine contractions. The insert can be pulled out if contractions become too long or too close together, but as it releases medication gradually, it often takes time for a womanâs labour to begin.6,16,46
A second pharmacological method of cervical ripening involves the use of a gel containing a prostaglandin-related medication called dinoprostone. A prostaglandin gel called Prostin (trade name) can be inserted into a womanâs vagina or, alternatively, a prostaglandin gel called Prepidil (trade name) can be inserted into her cervix. The gel is inserted with the use of a syringe. The vaginal route is often preferred as it is easier to administer and it can result in a more timely birth.
Overall, some feel that using a prostaglandin gel can cause labour to be initiated quicker than with a controlled-release insert such as Cervidil. However, if a womanâs contractions become too long or too close together, removing the gel is much more difficult.6,16,18
Another pharmacological method to ripen a womanâs cervix involves the use of oral medication containing a prostaglandin-related medication called misoprostol. As the risk of excessive uterine stimulation is high, misoprostol is not used vaginally to induce labour.16,18
When the oral form of misoprostol is used, it is important that this medication be swallowed with water to prevent its absorption sublingually. If it is absorbed sublingually, a womanâs uterus is at increased risk of excessive uterine activity.16,18
Monitoring during cervical ripening
Prior to cervical ripening, the fetal heart rate is monitored continuously for 30 minutes, and a womanâs vital signs are assessed. Following the initiation of a method to ripen a womenâs cervix, the fetal heart rate is monitored for an additional 60 minutes to ensure fetal well-being. A womanâs contraction pattern is also very closely monitored to ensure that her uterus does not experience excessive uterine activity.
In the event of an abnormal fetal heart-rate pattern, excessive uterine activity, or abnormal maternal vital signs, attempts will be made to remove the mechanical or pharmacological source. If this is not sufficient, a woman may be given a medication via a spray, a pill, or intravenously to help slow down her contractions; this medication may include nitroglycerin. Nitroglycerin acts to widen and relax a personâs blood vessels. This can be helpful when a woman is having too many contractions.16,18,47
Responses to cervical ripening vary. Some women may start to feel contractions immediately; others may start to feel contractions within a few hours; and others may need two or three trials or doses of a mechanical or pharmacological method before anything occurs for them.6,16,18 If after a method of cervical ripening is performed and a woman is physically stable and her fetusâ heart rate is deemed normal, she may be permitted to leave the birth setting for a period of time.
If a woman decides to leave the birth setting, she should stay relatively close by and call or return to the birth setting if:6,16,18,48
- Her contractions become very frequent (more than four contractions occur in a 10-minute period).
- Her contractions become very long (i.e., last longer than 60 seconds).
- Her contractions become very painful.
- She experiences vaginal bleeding.
- Her membranes rupture, and there is meconium present.
- Her Cervidil or Foley catheter falls out.
- If she has any concerns.
If a womanâs cervix is showing signs of readiness for labour (either on its own or after cervical ripening methods), there are methods of induction a health care provider can use.16,18
Oxytocin infusion for induction of labour
Oxytocin is a hormone that is produced naturally in a womanâs body. When it is released in a womanâs body during labour, it binds to receptors in her uterus to cause contractions. To induce labour, a synthetic form of this hormone has been commonly used since the 1950s.16,18,49
To use oxytocin to induce labour, a woman needs to have:6,16,18
- An IV initiated and attached to an IV pump.
- Continuous fetal monitoring throughout labour and birth.
- Constant one-to-one care provided by a health care provider.
Oxytocin is capable of producing very strong and frequent contractions for a woman in labour which is why its administration needs to be so closely monitored. When oxytocin is being infused during labour, every precaution needs to be taken to avoid excessive uterine activity. Most hospitals have specific protocols that guide the administration of oxytocin for induction of labour.
Oxytocin is administered using a pump, using gradually increasing doses of the medication. The dose may be increased several times or only a few times depending on how a woman reacts to the oxytocin. A health care provider may increase the dose every 30 minutes. The goal is to achieve a regular contraction pattern that is typical of labour. Before the health care provider increases the dose of oxytocin, they will assess the womanâs vital signs, her contraction pattern, and the fetal heart rate to ensure all are within normal ranges.6,16,18
Using oxytocin for the induction of labour may decrease a womanâs ability to move around and change positions considerably because she requires continuous fetal monitoring. Labour support is often very important for a woman receiving oxytocin. As oxytocin can cause very strong and frequent contractions for a woman, a woman may also need additional pain management when receiving oxytocin.6,49
Amniotomy for induction of labour
If a womanâs cervix is favourable, a health care provider may perform an amniotomy as a method of labour induction. An amniotomy refers to the artificial rupture of the amniotic membrane surrounding the fetus. It can cause a woman to experience strong contractions and cause her cervix to dilate which is why it is used for labour induction. Performing an amniotomy is only to be done for a convincing and compelling reason as it commits a woman to giving birth. Following an amniotomy, to ensure that a womanâs labour proceeds and to reduce the risk of infection if prolonged labour were to occur, it is recommended that an oxytocin infusion always be initiated as well.6,16,18
To perform an amniotomy a health care provider will use a long plastic rod with a tiny plastic hook on its end called an AmnihookÂŽ. With this hook, he or she will gently nick the amniotic sac during a vaginal examination and let the amniotic fluid flow freely. For a health care provider to be able to do this, the fetus must be well engaged in the birth canal to avoid the risk of a cord prolapse. Although the vaginal examination can be uncomfortable, the procedure does not typically cause pain for a woman or her fetus. Before and after the procedure the fetal heart rate will be monitored to ensure fetal well-being.6,16,18
Augmentation of Labour
Augmentation of labour refers to the act of speeding up the progress of labour for a woman.50 It involves trying to increase the frequency, duration, and intensity of contractions once they have already started so that the fetus will further descend into the birth canal, and a womanâs cervix will further dilate. This can be necessary if there are signs that a prolonged labour may negatively affect the well-being of a woman and/or her fetus. 50,51
Some of the risks associated with prolonged labour are:50,51
- Maternal exhaustion and dehydration.
- Maternal or fetal infection.
- The need for an assisted vaginal birth.
- The need for a caesarean birth.
- Poor fetal outcomes.
- Postpartum hemorrhage.
The primary reasons for prolonged labour include issues with the power (strength, length, frequency of contractions), the passenger (fetal position, size), the passageway (maternal pelvis size) and maternal psyche (anxiety, pain). Identification of the specific issue causing the delay and subsequent steps to correct, if possible, may allow labour to move forward.6,51
See the Labour Progress file for more information about factors affecting labour progress.
There are also risks associated with the augmentation of labour and it should only be performed when the expected benefits outweigh the risks.50
Before medical interventions are performed to augment labour for a woman, she can be encouraged to try non-invasive methods.50,51,52
If a woman has a full bladder, this can prevent her fetus from fully descending into the birth canal. Frequent urination can help speed of the process of labour. If a woman is unable to go to the bathroom to urinate, she may be offered a bedpan or a health care provider may insert a catheter into her bladder to drain the urine.53
Comparatively, maintaining adequate hydration during labour may be beneficial in helping a woman progress through labour. Adequate hydration is needed for the body to perform strenuous activities such as uterine contractions.11,50,51
Ambulation and frequent position changes
Ambulation and positions changes do not speed up the labour progress but during labour if a woman regularly walks and changes position it can encourage her fetus to descend further into the birth canal. An upright position may also enhance blood flow throughout a womanâs body.50,51,54,55
Having a good support system and taking part in relaxation activities may also be able to increase the speed of labour progress.50,51,52
See the Labour Support file for more information on non-pharmacological coping measures.
The medical methods to increase the speed of a womanâs labour are similar to the methods of induction for a woman with a favourable cervix.50,56,57
Oxytocin infusion for augmentation of labour
Oxytocin can be used for both induction and augmentation of labour. The process and the risks of administering oxytocin for the augmentation of labour are the same as for when it is used for the induction of labour. Close monitoring of the administered dose, the womanâs contractions pattern, and the fetal heart rate are all needed to prevent the risk of excessive uterine activity.50,56,57
Amniotomy for augmentation of labour
The process and the risks of performing an amniotomy for the augmentation of a womanâs labour are the same as for when it is used for the induction of labour. The use of amniotomy alone for the augmentation of labour is not recommended. If an amniotomy is performed to speed up the process of womanâs labour, it must be accompanied or followed by the administration of oxytocin to prevent the risk of infection with prolonged labour after the rupture of membranes.18,50
Assisted Vaginal Birth
During a vaginal birth, a woman may need assistance with birth if:58
- She has difficulty pushing the fetus out of her vagina and is becoming exhausted from trying.
- She has a cardiac condition or other significant medical condition and strenuous pushing needs be avoided for her well-being.
- The fetal heart rate is abnormal, and a quick delivery is needed to ensure fetal well-being.
Prior to an assisted vaginal birth, it must be confirmed that:58
- The womanâs cervix is fully dilated.
- The membranes have been ruptured.
- The womanâs pelvis is believed to be able to accommodate the birth of the fetus.
- The womanâs bladder is empty.
- The head of the fetus is fully engaged in the birth canal.
- There is appropriate pain medication available if needed.
- There is a backup plan for birth if the method is unsuccessful.
- Informed consent for the procedure has been obtained.
The method chosen to assist with birth depends on the individual situation. There are risks associated with all of the methods. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other. The benefits of the chosen method should outweigh its risks.6,58
For a vacuum-assisted birth, the health care provider places a small suction cup on the fetusâ head. When the woman feels the urge to push, traction is applied to help bring the baby down into the birth canal. For this technique, the womanâs legs are often elevated in stirrups, and the foot end of the birthing bed is removed. This position also enables the health care provider to have proper body mechanics for during the procedure.
A vacuum-assisted birth may help avoid a caesarean birth. Only a health care provider with specific training may perform a vacuum-assisted birth.6,58
Risks associated with a vacuum-assisted birth for a baby can include:6,58
- Scalp lacerations and bruising.
- Facial nerve palsy.
- Cephalohematoma (i.e., bleeding between an inner layer of skin and the skull).
- Intracranial and/or retinal hemorrhage.
- Skull fractures.
- Neonatal jaundice.
- Fetal or neonatal death, although very rarely.
Risks associated with a vacuum-assisted birth for a woman can include:6,58
- Lacerations and bleeding.
- Bladder and/or bowel dysfunction.
- Failure to help her give birth vaginally.
Reasons to reassess the use of vacuum and possibly try another method include if:6,58
- Birth has not occurred after using a vacuum with four contractions.
- There is no progress after two pulls with a properly inserted cup with good traction.
- There are three pop-offs that occur without an obvious cause.
- After 20 minutes have elapsed, birth is still not imminent.
The decision to use forceps is based on the position of the fetal head and the preference of the health care provider. For a forceps-assisted birth, the health care provider will place two curved metal blades that look like large spoons inside a womanâs vagina and place them on either side of the fetusâ head. Each blade will be inserted one at a time and then locked together. Forceps are attached by groove attachment so that they are unable to compress the head of a baby during birth. There are many different shapes and sizes of forceps. A health care provider will choose the variety that will best reach and surround the fetusâ head. If the head of the fetus is not in an occipitoanterior position, the forceps will first be used to rotate the head to this position. When a woman pushes, the health care provider will then gently pull with the forceps to help her give birth.6,58
Risks associated with a forceps-assisted birth for a baby can include:6,58
- Injury to the head, face, neck, and/or eyes.
- Scalp lacerations.
- Skull fractures.
- Facial nerve palsy.
- Cephalohematoma (i.e., bleeding between an inner layer of skin and the skull).
- Intracranial and/or retinal hemorrhage.
- Skull fractures.
- Neonatal jaundice.
- Fetal or neonatal death, although very rarely.
Risks associated with a forceps-assisted birth for a woman can include:6,58
- Lacerations and bleeding.
- Bladder and/or bowel dysfunction.
- Failure to help her give birth vaginally.
An episiotomy refers to an incision made in the outside wall of a womanâs vagina to allow more space for her to be able to give birth. An episiotomy is not a routine procedure during the process of birth.2,5,6,30 Current best practice is to support the perineum and allow it to tear naturally rather than to perform an episiotomy. Tears are often smaller, are repaired more easily or not at all, heal more quickly, and are less painful than an episiotomy. An episiotomy will only be considered if birth needs to occur quickly or if a very large tear can be prevented by doing an episiotomy. If an episiotomy is needed, a diagonal mediolateral incision is made. An incision made here has been shown to decrease the risk of extensive tearing.2,6,30
Manual removal of a retained placenta
If a womanâs placenta does not spontaneously separate from the uterine wall, it can lead to postpartum hemorrhage. If medication to increase uterine contractions and gentle traction on the umbilical cord do not encourage the separation of the placenta from the uterine wall, manual removal may be necessary. The woman will typically be taken to an operating room and be given pain medication; if she has an epidural, this may not be necessary. To remove the placenta manually, her legs may be put in stirrups and the health care provider will place his or her hand up into her uterus through her vagina and remove the placenta (or any retained pieces of placenta) and blood clots. A woman will likely receive IV antibiotics after this is done to prevent infection.59,60
Interventions Not Recommended during Labour
Some interventions are not done routinely any longer as research has shown that they are not effective and may even be harmful.2,6,30,61,62
Historically, women had their pubic hairs shaved prior to labour. It was believed that shaving would reduce a womanâs risk of infection if a perineal tear occurred, or an episiotomy was done. Conversely, shaving can actually cause some women to experience irritation, redness, superficial scratches from razor burn, burning, and itching. Shaving, therefore, is not recommended.6,30,61
An enema involves filling a personâs rectum with medicated fluid to cause him or her to have a bowel movement. Historically, an enema was given to a woman at the beginning of her labour as it was thought that emptying her rectum of stool would allow more room for her baby to be born. Research indicates that during labour, a womanâs bowels typically slow down, and the amount of bowel movements that she experiences are reduced. If a woman experiences a bowel movement during birth, it can be promptly discarded to avoid any embarrassment.6,30,62
Referrals may be warranted if a woman and/or her support person(s) are:
- Overly anxious or fearful about possible assessments and/or interventions during labour.
- Require more information about assessments and/or interventions during labour.
Women and/or their support person(s) who require more information and/or support leading up to labour and birth can be referred to the following sources:
- Their health care provider (obstetrician, family physician, Nurse Practitioner, or midwife).
- Prenatal education classes, if not already enrolled.
- Their local public health unit.
Resources & Links
- Association of Ontario Midwives (AOM)
- Provincial Council for Maternal Child Health & Ministry of Health and Long-Term Care
- Society of Obstetricians and Gynaecologists of Canada (SOGC)
- Clinical Practice Guideline: Guidelines for Operative Vaginal Birth (2004)
- Clinical Practice Guideline: Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks (2008)
- Clinical Practice Guideline: Induction of Labour (2013)
- Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline (2007)
- Joint Policy Statement on Normal Childbirth (2008)
- Joint SOGC/CAR Policy Statement on Non-medical Use of Fetal Ultrasound (2014)
- World Health Organization (WHO)
- Klein, M. C., Kaczorowski, J., Hearps, S. J., Tomkinson, J., Baradaran, N., Hall, W. A., . . . Fraser, W. D. (2011). Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. Journal of Obstetrics and Gynaecology Canada, 33(6), 598-608. Retrieved from http://www.jogc.com
- Ontario Public Health Association
- Public Health Agency of Canada
- Middlesex-London Health Unit
- Society of Obstetricians and Gynaecologists of Canada (SOGC)
- The MotHERS Program
Prenatal Education Provider Tools
- Best Start Resource Centre
Client Resources and Handouts
- Best Start Resource Centre (BSRC)
- Buckley, S. J. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, DC: Childbirth Connection Programs, National Partnership for Women and Families. Retrieved from http://www.childbirthconnection.org/resources/resources-q-a/advocates-and-professionals.html
- Health Canada. (2000). Chapter 5: Care during labour and birth. Family-centred maternity and newborn care: National guidelines (pp.5-49). Ottawa, ON: Author.
- Society of Obstetricians and Gynaecologists of Canada. (2008). Joint policy statement on normal childbirth. Journal of Obstetrics and Gynaecology Canada, 30(12), 1163-1165. Retrieved from http://www.jogc.com/
- Canadian Association of Midwives. (2010). Position statement: Midwifery care and normal birth. Montreal, QC: Author. Retrieved from http://www.canadianmidwives.org/DATA/DOCUMENT/CAM_ENG_Midwifery_Care_Normal_Birth_FINAL_Nov_2010.pdf
- Hofmeyr, G. J. (2005). Evidence-based intrapartum care. Best Practice & Research Clinical Obstetrics & Gynaecology, 19(1), 103-115. doi: 10.1016/j.bpobgyn.2004.10.009
- Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Unit 4: Childbirth. In C. Sams & L. Keenan-Lindsay (Eds.). Maternal child nursing care in Canada (pp. 378-488). Toronto, ON: Elsevier Canada.
- Murphy, D. J., Pope, C., Frost, J., & Liebling, R. E. (2003). Women’s views on the impact of operative delivery in the second stage of labour: Qualitative interview study. BMJ, 327(7424), 1132-1136. http://dx.doi.org/10.1136/bmj.327.7424.1132
- O’Cathain, A., Thomas, K., Walters, S. J., Nicholl, J., & Kirkham, M. (2002). Women’s perceptions of informed choice in maternity care. Midwifery, 18(2), 136-144.doi: 10.1054/midw.2002.0301
- Klein, M. C., Kaczorowski, J., Hearps, S. J., Tomkinson, J., Baradaran, N., Hall, W. A., . . . Fraser, W. D. (2011). Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. Journal of Obstetrics and Gynaecology Canada, 33(6), 598-608. Retrieved from http://www.jogc.com/
- Public Health Agency of Canada. (2012). Canadian hospitals maternity policies and practices survey. Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/index-eng.php
- Dawood, F., Dowswell, T., & Quenby, S. (2013). Intravenous fluids for reducing the duration of labour in low risk nulliparous women. Cochrane Database of Systematic Reviews, 6(CD007715), 1-57. doi: 0.1002/14651858.CD007715.pub2
- Lothian, J. A. (2014). Healthy birth practice# 4: Avoid interventions unless they are medically necessary. The Journal of Perinatal Education, 23(4), 198-206. http://dx.doi.org/10.1891/1058-1243.23.4.198
- Lee, L., Sprague, A., Yee, J., & Ehman, W. (Eds.). (2009). Fundamentals of fetal health surveillance (4th ed). Vancouver, BC: British Columbia Perinatal Health Program.
- Liston, R., Sawchuck, D., & Young, D. (2007). Fetal health surveillance: Antepartum and intrapartum consensus guideline. Journal of Obstetrics and Gynaecology Canada, 29(9 Suppl 4), S3-56. Retrieved from http://sogc.org/
- Public Health Agency of Canada. (2009). What mothers say: The Canadian maternity experiences survey. Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/rhs-ssg/survey-eng.php
- World Health Organization. (2011). WHO recommendations for induction of labour. Geneva, CH: Author. Retrieved from http://whqlibdoc.who.int/publications/2011/9789241501156_eng.pdf
- Health Canada. (2003). Canadian perinatal health report. Ottawa, ON: Government of Canada. Retrieved from http://publications.gc.ca/site/eng/252200/publication.html
- Leduc, D., Biringer, A., Lee, L., & Dy, J. (2013). Induction of labour. Journal of Obstetrics and Gynaecology Canada, 35(9), 840-860. Retrieved from http://www.jogc.com/
- Health Canada. (2008). Canadian perinatal health report. Ottawa, ON: Government of Canada. Retrieved from http://www.phac-aspc.gc.ca/publicat/2008/cphr-rspc/index-eng.php
- Canadian Institute for Health Information. (2012). Highlights of 2010-2011 selected indicators describing the birthing process in Canada. Ottawa, ON: Author. Retrieved from https://secure.cihi.ca/free_products/Childbirth_Highlights_2010-11_EN.pdf
- Alfirevic, Z., Devane, D., & Gyte, G. M. L. (2013). Comparing continuous electronic fetal monitoring in labour (cardiotocography, CTG) with intermittent listening (intermittent auscultation, IA). Cochrane Database of Systematic Reviews, 5(CD006066). doi: 10.1002/14651858.CD006066.pub2
- Graham, E. M., Petersen, S. M., Christo, D. K., & Fox, H. E. (2006). Intrapartum electronic fetal heart rate monitoring and the prevention of perinatal brain injury. Obstetrics & Gynecology, 108(3, Part 1), 656-666. doi: 10.1097/01.AOG.0000230533.62760.ef
- Borders, N., Lawton, R., & Martin, S. R. (2012). A clinical audit of the number of vaginal examinations in labor: A NOVEL Idea. Journal of Midwifery & Womenâs Health, 57(2), 139-144. doi: 10.1111/j.1542-2011.2011.00128.x
- Jansen, A. J., van Rhenen, D. J., Steegers, E. A., & Duvekot, J. J. (2005). Postpartum hemorrhage and transfusion of blood and blood components. Obstetrical & Gynecological Survey, 60(10), 663-671. doi: 10.1097/01.ogx.0000180909.31293.cf
- Markova, V., NĂ¸rgaard, A., JĂ¸rgensen, K. J., & LanghoffâRoos, J. (2013). Treatment for women with postpartum iron deficiency anaemia. Cochrane Database of Systematic Reviews, 12(CD01086110), 1-10. doi: 1002/14651858.CD010861
- Prick, B. W., Jansen, A. J. G., Steegers, E. A. P., Hop, W. C. J., EssinkâBot, M. L., Uylâde Groot, C. A., . . . Duvekot, J. J. (2014). Transfusion policy after severe postpartum haemorrhage: A randomised nonâinferiority trial. BJOG: An International Journal of Obstetrics & Gynaecology, 121(8), 1005-1014. doi: 10.1111/1471-0528.12531
- Fairlie, T., Zell, E. R., & Schrag, S. (2013). Effectiveness of intrapartum antibiotic prophylaxis for prevention of early-onset group B streptococcal disease. Obstetrics & Gynecology, 121(3), 570-577. doi: 10.1097/AOG.0b013e318280d4f6
- Lin, F. Y. C., Weisman, L. E., Azimi, P., Young, A. E., Chang, K., Cielo, M., . . . Robbins, J. B. (2011). Assessment of intrapartum antibiotic prophylaxis for the prevention of early-onset group B Streptococcal disease. The Pediatric Infectious Disease Journal, 30(9), 759-763. doi: 10.1097/INF.0b013e31821dc76f
- AnimâSomuah, M., Smyth, R., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews, 12(CD000331), 1-120. doi: 10.1002/14651858.CD000331.pub3
- Schuurmans, N., Senikas, V., & Lalonde, A. (2009). Healthy beginnings: Giving your baby the best start from preconception to birth (4th ed.). Etobicoke, ON: John Wiley and Sons Canada Ltd.
- Gray, J. (1983). Handbook of fetal heart rate monitoring. Halifax, NS: Seaview Publishing.
- Delaney, M., & Roggensack, A. (2008). Guidelines for the management of pregnancy at 41+ 0 to 42+ 0 weeks. Journal of Obstetrics and Gynaecology Canada, 30(9), 800-823. Retrieved from http://www.jogc.com/
- Doherty, L., & Norwitz, E. R. (2008). Prolonged pregnancy: When should we intervene? Current Opinion in Obstetrics and Gynecology, 20(6), 519-527. doi: 10.1097/GCO.0b013e328314b6f8
- GĂźlmezoglu, A. M., Crowther, C. A., & Middleton, P. (2006). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews, 4(CD004945). doi: 10.1002/14651858.CD004945.pub2
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