Picture a Thursday evening on labour ward. Four women are in established labour. Three more are in the early stages of induction, each requiring CTG assessment as contractions build. The coordinator is juggling seven women with five midwives — and the phone has just rung with another admission.
This is not an unusual night. It is an increasingly ordinary one.
In 2023, more than 173,000 women were induced across NHS maternity units in England, Scotland and Wales — one in every three births.¹ A decade ago, it was one in four. The number of inductions has surged. The number of midwives has not.² Workforce numbers are part of the problem. But so is this: how that limited time is being used.
The International Confederation of Midwives put it plainly when it named its theme for International Day of the Midwife 2026: the world needs one million more midwives.¹²
The monitoring cost of pharmacological ripening
Dinoprostone — the most widely used pharmacological cervical ripening agent in the UK — is effective.³ That is not in question. But it comes with a monitoring footprint that is easy to underestimate.
Because dinoprostone can stimulate uterine contractions, NICE guidance requires CTG assessment once contractions begin. If the fetal heart rate is abnormal or there is excessive uterine activity, continuous cardiotocography must follow.³ An individual patient data meta-analysis of four randomised trials involving 1,731 women (Saad et al., 2025) found that complications during the ripening phase — tachysystole, uterine hypertonus, non-reassuring fetal heart tracings and others — occurred in 47% of women receiving pharmacological agents, compared with 19% receiving mechanical method - synthetic osmotic dilators (Dilapan-S) (OR 0.28).⁴
Each of those episodes requires a midwife at the bedside. Each one draws attention away from the woman in the next room who is fully dilated and pushing.
Unlike pharmacological methods, mechanical approaches – synthetic osmotic dilators and balloon catheters, do not trigger the monitoring pathway that NICE requires when contractions begin — because, in the absence of exogenous hormones, contractions during the ripening phase are far less likely to occur.³
The woman can mobilise or sleep. And the midwife can be with the woman who needs her most.
Putting a number on it
A UK cost-consequence model (Walker et al., 2022) quantified this difference. Using data from the SOLVE randomised trial, the authors compared Dilapan-S with the dinoprostone vaginal insert (Propess) for inpatient induction:
- Midwife time reduced by 146 minutes per induction — nearly two and a half hours
- Obstetrician time reduced by 11 minutes — a 54% decrease
- Overall cost: neutral⁵
Now consider the arithmetic. Ten inductions per week shifted to mechanical ripening would reclaim roughly 24 midwifery hours weekly — more than half a full shift, returned to the ward.
What this looks like in practice
For some units, the shift to mechanical ripening has already redrawn what a normal induction shift looks like. Katie MacDonald, a Midwifery Sister at Kingston Maternity Unit in Southwest London, described the transition when her unit moved away from prostaglandin pessaries.
"We were seeing many cases of hyperstimulation," MacDonald noted. "This caused stress for the women and the staff. Since switching, those cases — which had been leading to early pessary removal, tocolysis, and emergency caesarean sections — were no longer a concern. The time from starting induction to reaching a favourable cervix fell by ten hours.“⁶
The difference for women was just as notable. When the ripening process is less likely to trigger contractions or require intervention, women are more comfortable — and more in control. Analgesia use during ripening fell by 70%.
"We were getting many complaints about how painful the induction process was," MacDonald noted. "The feedback since switching has been very different: 94% of women said they would recommend the process to a friend, compared to 62% with our previous method."⁶
Similarly the IPD analysis identified significantly lower pain levels >4 in the Dilapan-S group.4 Out of interest, consider how much time is involved in responding to a patient’s request for analgesic administration.
More than an operational choice
The stakes here go beyond efficiency. The Birthrate Plus standard requires one midwife to one woman in active labour — every monitoring task in a ripening bay competes directly with that ratio.⁷ The Ockenden report was explicit: staffing below minimum thresholds is directly linked to adverse outcomes.⁸
There is a structural advantage here too. Mechanical ripening can be initiated by midwives, reducing dependence on medical staff for the ripening step at a time when both workforces are stretched.⁹
The question we should be asking
We debate at length which method achieves the fastest delivery or the lowest caesarean rate. These matter. But perhaps the adjacent question deserves equal weight:
Which method allows the midwife to be a midwife?
2.4 hours per induction is not a footnote. It is a strategic choice — and it starts at the point of cervical ripening. Next month, we explore what happens when cervical ripening moves out of the hospital entirely.
For a wider conversation on the pressures reshaping UK induction pathways, the Induction: Labour of Love podcast features candid discussions between midwives and obstetricians navigating these very challenges. Further clinical evidence and resources are available at dilapan.com.
References
- National Maternity and Perinatal Audit. Induction of Labour Snapshot Audit, November 2025. Available at: https://maternityaudit.org.uk/
- Royal College of Midwives. RCM warns slowdown in midwifery workforce growth. 5 December 2025. Available at: https://rcm.org.uk/media-releases/2025/12/
- National Institute for Health and Care Excellence. Inducing labour. NICE guideline [NG207]. November 2021. Available at: https://www.nice.org.uk/guidance/ng207
- Saad AF et al. Dilapan-S vs standard methods for cervical ripening in term pregnancies: an individual patient data meta-analysis. Am J Obstet Gynecol MFM. 2025;7(1):101583. DOI: 10.1016/j.ajogmf.2024.101583
- Walker KF, Zaher S, Torrejon Torres R, et al. Synthetic osmotic dilators (Dilapan-S) or dinoprostone vaginal inserts (Propess) for inpatient induction of labour: a UK cost-consequence model. Eur J Obstet Gynecol Reprod Biol. 2022;278:72–76. DOI: 10.1016/j.ejogrb.2022.08.018
- MacDonald K. Midwife-led induction of labour with DILAPAN-S. Dilapan-S educational video, Kingston Maternity Unit, 2023. Available at: https://www.youtube.com/watch?v=lqHO_W9Twj8
- Royal College of Midwives. Birthrate Plus: what it is and why you should be using it. Available at: https://www.rcm.org.uk/media/2367/birthrate-plus-what-it-is-and-why-you-should-be-using-it.pdf
- Ockenden D. Final report of the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. March 2022. Available at: https://www.gov.uk/government/publications/final-report-of-the-ockenden-review/
- Saad A et al. A randomized controlled trial of Dilapan-S vs Foley balloon for preinduction cervical ripening (DILAFOL trial). Am J Obstet Gynecol. 2019;220(3):275.e1–275.e9. DOI: 10.1016/j.ajog.2019.01.008
- International Confederation of Midwives. Theme for International Day of the Midwife 2026: One Million More Midwives. Published 3 February 2026. Available at: https://internationalmidwives.org/theme-idm-2026-one-million-more-midwives/
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