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ACOG’s 2009 Induction Guidelines: Spin Doctoring Misoprostol (Cytotec)

Cytotec (Misoprostol)

Ahh, the new ACOG induction guidelines, so much to dislike, so little time. Still, others are also commenting, so I will focus on debunking ACOG’s portrayal of misoprostol.

ACOG STATEMENT: “There is . . . a large body of published reports supporting (misoprostol’s) safety and efficacy when used appropriately” (p. 387).

FACT: None of the studies have been big enough either alone or in the aggregate to detect differences in rare, catastrophic events, a point acknowledged by a Cochrane systematic review, and it is those rare, catastrophic events that are the issue with “miso.” And while more disasters will occur with higher doses and in women with prior cesareans, there is no “appropriate” use of misoprostol in terms of safety.

ACOG STATEMENT: “No studies indicate that intrapartum exposure . . . has any long-term adverse health consequences to the fetus in the absence of fetal distress [emphasis mine]. . . .” (p. 387).

FACT: Well, that’s the catch, isn’t it? The long-term adverse health consequences to the fetus occur in the presence of fetal distress subsequent to uterine rupture—including in unscarred uteruses and with moderate doses of misoprostol—and amniotic fluid embolism. In some cases, of course, the fetus doesn’t survive to experience long-term consequences.

ACOG STATEMENT: “Although misoprostol currently is approved by the U.S. Food and Drug Administration (FDA) for the prevention of peptic ulcers, the FDA in 2002 approved a new label on the use of misoprostol during pregnancy for cervical ripening and for the induction of labor. This labeling does not contain claims regarding the efficacy or safety of misoprostol” (p. 387).

FACT: A reader can be forgiven for assuming from this convoluted phrasing that the FDA now approves of using misoprostol to induce labor. The reader would be wrong. The FDA removed the “black box” designation prohibiting use in pregnant women, but it takes a much dimmer view of “miso” than merely not claiming it is safe. Here is an excerpt from the FDA’s 2002 statement (PDF):

A major adverse effect of the obstetrical use of Cytotec is hyperstimulation of the uterus which may progress to uterine tetany [uterus contracts and doesn't let go] with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy [removal of the ovaries and Fallopian tubes]), or amniotic fluid embolism [maternal and infant mortality is very high from this]. Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia [profound slowing of the fetal heart], and fetal and maternal death have been reported.

There may be an increased risk of uterine tachysystole [contractions coming too fast], uterine rupture, meconium passage, meconium staining of amniotic fluid, and Cesarean delivery due to uterine hyperstimulation with the use of higher doses of Cytotec; including the manufactured 100 mcg tablet. The risk of uterine rupture increases with advancing gestational ages and with prior uterine surgery, including Cesarean delivery. Grand multiparity [usually defined as more than four births] also appears to be a risk factor for uterine rupture.

What actually happened was this: ACOG held that “misoprostol is one of the most important medications in obstetrical practice. . . . The real victims in this scenario [i.e., prohibition in pregnancy] are pregnant women who receive treatment in hospitals that will not allow the use of misoprostol” (Hale 2001, p. 59). Lobbied by ACOG, the FDA rescinded the black box designation on the grounds that obstetricians were using it to induce labor, a rationale that amounts to “but all the kids are doing it.”

ACOG STATEMENT: “The majority of adverse maternal and fetal outcomes associated with misoprostol therapy resulted from the use of doses greater than 25 mcg” (p. 387).

FACT: The “majority” of adverse outcomes is hardly reassuring. What about the minority? Not to mention that obstetricians may ignore recommended dosages, and even the guidelines say “Misoprostol in higher doses (50 mcg every 6 hours) may be appropriate in some situations” (p. 390). In any case, misoprostol is formulated in 100 mcg tablets for use as an oral ulcer medication. Getting a 25 mcg dose means cutting an unscored tablet in quarters. It’s anybody’s guess what dosage is really delivered.

The real kicker is that according to the Cochrane systematic review, misoprostol is no more effective than the FDA approved medication, PGE2 (a.k.a dinoprostone, trade names Cervidil and Prepidil). More vaginal deliveries happened within 24 hours after administration, but cesarean rates overall did not differ between groups. Cesarean rates in trials comparing misoprostol with with intravenous oxytocin (trade names Pitocin or “Pit” and “Syntocinon”) were more variable, but not all of them found reductions in cesarean rates with misoprostol. Meanwhile, misoprostol results in higher rates of uterine hyperstimulation and uterine hyperstimulation with adverse changes in the fetal heart rate than other agents. And misoprostol has yet another major disadvantage: Oxytocin has a short half-life. If contractions get too strong or too close together, turn the I.V. drip down or off, and within a little while, contractions fade. If misoprostol hyperstimulates the uterus, you are stuck. Moreover, lurking in the “miso works faster” benefit is a problem not captured in the trials because they only measure major morbidity: some women are thrown into violent labors. These labors should have given researchers pause, though, if for no other reason than they are the precursor, the shark fin in the water, of misoprostol’s potential for severe fetal distress, massive hemorrhage, uterine rupture, and amniotic fluid embolism.

Why, then, are obstetricians so enamored of misoprostol? The answer is summed up by this obstetrician enthusiast:

The best part about it is that you can block-schedule your nurses so that you have enough on hand. . . [I]f we start our inductions at 7 a.m., we know that we’re going to have X number of patients in labor being admitted by 4 p.m. That’s helped our hospital tremendously, . . . [Cytotec is] a great agent. It works very, very efficiently. . . . And it’s ungodly inexpensive: 27 cents per tablet.

In other words, Cytotec’s real benefits are convenience for obstetricians and helping the hospital’s bottom line. For women and babies, though, it’s a roll of the dice. Most times things go fine, but sometimes the dice come up snake eyes.

Reference:

Hale, R. W., & Zinberg, S. (2001). Use of misoprostol in pregnancy. N Engl J Med, 344(1), 59-60.

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  1. August 17th, 2009 at 17:39 | #1

    The use of cytotec for labor augmentation and induction is so disturbing!

  2. August 17th, 2009 at 19:12 | #2

    I am sure I will get slammed for this, but I have used miso with very good results. Misoprostol has a horrible history because of very devastating effects from it’s misuse back in the early 90s (perhaps earlier); I use FIGOs guidelines for dosing, and I will state again- have not had any problems. I’ve come across a lot of research while in school when doing some personal research on the controversies of misoprostol, and found the studies in which Winger et al (I think that was her last name) has done help support FIGOs guidelines.

    However I do understand that ACOG has a history of practice guidelines/bulletins that are not necessarily evidenced based, so can see how this one could get picked on. And as far as induction, I’ve not used it for induction but rather cervical ripening before starting Pitocin.

  3. August 17th, 2009 at 19:53 | #3

    How did you find that ungodly gem of an article?! Here’s another quote from the enthusiast:

    “Then we make them walk for 2 hours. They can stay in the hospital, go to the mall, I don’t care. Just don’t rest them during an induction. You’re killing your hospital financially if you do that, just killing them. It’s not fair to the hospital, and it’s certainly not fair to the patient,” Dr. Maslow said.”

    A two hour walk is such a great way to save your energy for the demands of labor.

    Three times he says it’s not fair to the hospital, then adds that it’s not fair to the patient.

    Nice.

    What I hear over and over about Cytotec is failure to inform the patient of the risks involved. I think it’s strange that I’ve heard so many times that doctors tell their patients, “We’re just going to put a little pill on your cervix.” That is the extent of the info they receive… and, oddly, always the same line almost verbatim.

  4. August 17th, 2009 at 22:37 | #4

    Amazing stuff–I am very uneasy about Cytotec being used to cavalierly with such non-reassuring evidence, and now included in guidelines as an offlabel use with dosage instructions that aren’t possible given the shape of the pill?! Honestly, what can they be thinking?

  5. August 18th, 2009 at 09:56 | #5

    Labor Nurse, CNM :I am sure I will get slammed for this, but I have used miso with very good results. Misoprostol has a horrible history because of very devastating effects from it’s misuse back in the early 90s (perhaps earlier); I use FIGOs guidelines for dosing, and I will state again- have not had any problems. I’ve come across a lot of research while in school when doing some personal research on the controversies of misoprostol, and found the studies in which Winger et al (I think that was her last name) has done help support FIGOs guidelines.
    However I do understand that ACOG has a history of practice guidelines/bulletins that are not necessarily evidenced based, so can see how this one could get picked on. And as far as induction, I’ve not used it for induction but rather cervical ripening before starting Pitocin.

    Well, catastrophes with miso are rare, which means it may take many, many inductions to see one. This can give people using it a false sense of security. If you follow the link to the malpractice suits, you will see that Cytotec disasters have occurred with dosages not considered “misuse” today. And, of course, some women will have had extremely unpleasant, even traumatizing, labors, but you would not know what their experience was like unless they came back to the hospital and told you, an extremely unlikely proposition. If your goal is ripening the cervix, why not use a Foley catheter? The ACOG induction guidelines cite a review finding that it is safe and effective–and in this case, that’s true–and it’s cheap too.

  6. avatar
    Miranda
    August 18th, 2009 at 11:12 | #6

    “And as far as induction, I’ve not used it for induction but rather cervical ripening before starting Pitocin.”

    Aren’t those the same thing? Induction is induction no matter how you start it.

  7. August 18th, 2009 at 12:08 | #7

    Labor Nurse, CNM :I am sure I will get slammed for this, but I have used miso with very good results. Misoprostol has a horrible history because of very devastating effects from it’s misuse back in the early 90s (perhaps earlier); I use FIGOs guidelines for dosing, and I will state again- have not had any problems. I’ve come across a lot of research while in school when doing some personal research on the controversies of misoprostol, and found the studies in which Winger et al (I think that was her last name) has done help support FIGOs guidelines.
    However I do understand that ACOG has a history of practice guidelines/bulletins that are not necessarily evidenced based, so can see how this one could get picked on. And as far as induction, I’ve not used it for induction but rather cervical ripening before starting Pitocin.

    I would like to say hear hear to Henci’s reply. Frankly just because something works without catastrophic outcome all the time, doesn’t mean it doesn’t routinely cause labor and delivery trauma and morbidity for both mothers and babies. It is being lulled into a false sense of security just like routine labor induction overall is viewed this way. It is NOT harmless. Even using miso for a true medical ripening prior to induction or for the indution and ripening, the perception is that is has no risk only value, this is not true. The risks are always there and frankly in an unscored pill the medication can be all in one quarter of that little pill. I have seen the results of this. An almost violent labor. Incredible pain.

    As for ripening, as Henci also asked why not use a foley catheter? It has the equivalent success rate of misoprostol but doesn’t have any of the side effects or risks.

    Just because we can, should we???????

  8. August 18th, 2009 at 17:38 | #8

    Miso is not the only ripening agent I’ve used…cervidil, foley caths, and prepidil gel are used as well. I do understand just because I have not seen a bad outcome doesn’t mean it can’t happen or isn’t out there; and I feel I do a very good job explaining miso, its risks, its off label, etc to women. I tell them there are other options and explain them. Do all women get this type of informed consent? Unlikely. The doses I’ve read about as causing devastating problems were doses of 100mcg; this is well over the recommendations by FIGO and ACOG.

    I’d like to make it clear I don’t condone the quotes by the physician in the article Amy cites. My use of miso is not a time issue by any means, although part of my education was in clinical areas were time was definitely money and drove clinical decisions. Not sure I was being connected to that, just wanted to make that clear.

    And thank you for respectful replies.

  9. August 19th, 2009 at 22:17 | #9

    @Labor Nurse, CNM
    I’m glad to see this great discussion. (And for those who haven’t seen it, there’s commentary at Woman to Woman CBE.) I just wanted to clarify to Labor Nurse that Henci Goer wrote this post, not me. I’m working on adding avatars to posts so that it’s more clear which contributor authored which posts. We’ll be adding a couple more regular contributors over the next several weeks and have several more guest posts in the hopper, so look out for posts from lots of great authors.

  10. August 23rd, 2009 at 13:23 | #10

    @Miranda
    There may be a slight difference to some people, and a big difference to others. What I see from a comment about Cytotec being used for ripening, not induction, is that some doctors may use Cytotec repeatedly or in bigger doses until labor ensues, which may end up having a higher dosage of the drug than what might be used when the desire is merely that the cervix effaces. Although some women might be thrown into labor from a single, small dose of Cytotec, this kind of outcome is more likely with higher doses, with the smaller doses apparently having a milder effect, usually. Inducing labor with an unfavorable cervix is tempting a C-section. You can check out information about the “Bishop’s score” for more information, but basically, an induction is likely to succeed if your cervix is favorable (already starting to dilate and/or efface), while is more likely to fail and/or end in C-section with an unfavorable cervix. There is a middle ground in which the cervix is not “ripe” but can be ripened and still have good success with an induction.

  11. August 23rd, 2009 at 13:57 | #11

    Hi Henci,
    Thanks so much for this post! I’ve highlighted it on the ICAN blog’s weekly feature “Best of the Birth Blogs” for the week ending today (8/23): http://ican-online.org/community/users/ican-blog/blog/best-birth-blogs-week-ending-august-23rd

    All best,
    Sarah

  12. August 24th, 2009 at 11:19 | #12

    To the CNM who uses miso and “has not had any problems”, I think this is the issue–how do you define problems? How do you define healthy mother/baby?
    The fact that you can deep suction a baby or give them oxygen when you throw the mother/baby into labor is part of the sad paradigm. Just because a mother/baby can tolerate all that is done to them-often causing issues that must be “resolved” and are considered “safe and routine” is part of the illusion of safety in hospital birth. I wish we would stop calling it a model of “care” and start calling it a model of management.

  13. September 2nd, 2009 at 09:27 | #13

    sorry for posting so late to this. I totally agree with Henci’s post, and would also add that, because Cytotec is not created to be used for induction and not meant to be scored ( cut up), it is a shot in the dark as to which mom gets which combination of chemicals… and therefore how she reacts. In my case , the result was that BOTH my daughter and granddaughter died due to Cytotec induction. The violent contracts caused an AFE…. and , as has already been said, once inserted, it dissolves and there is no turning back…. no way to slow down the contractions, as with pit or cervidil. And regarding law suits…. when a catastrophic event occurs, the thought may cross your mind to SUE…. however, with the morbidity and mortality outcomes… most families who are left in the aftermath of cytotec inductions can barely get out of bed.

  14. December 1st, 2009 at 20:40 | #14

    Interesting post, though I feel that the interpretation of the data is clouded by a pre-existing feeling against the use of misoprostol. I have used miso throughout my career and have found it to be very effective in ripening the cervix prior to induction. In 25mcg doses it has not been shown to lead to adverse fetal outcomes, at least not any outcomes that can be measured objectively.

    I cannot speak to the dangers of suctioning a baby or giving them oxygen or what not, I suppose you just have to believe what you are going to believe on this one.

    Henci made a great point, which was that miso does not lead to vaginal delivery any more often than other induction agents. That’s completely true, and this is a common misconception people have (including many OBs). I don’t believe any cervical ripening agent has been shown to reduce cesarean delivery rates in randomized trials. Cesarean delivery rate appears to be most linked to parity and bishop score at time of induction. What ripening agents _have_ been shown to do is decrease total induction to delivery time, which if you are a hospital or doctor is a good thing, and if you are a patient may or may not be a good thing. Depends on the patient I suppose. (see Ramsey et al Am J Obstet Gynecol 2003 188(2): 560-565)

    The comment about Cervidil is also a good one. Miso clearly reduces delivery time when compared to cervidil, when they are used as ripening agents. In fact, cervidil is no more effective than pitocin alone. The only real benefit of Cervidil, in my opinion, is that in most hospitals it can be used with the physician out of the hospital, while most hospitals require the physician to be on site if the mother is on pitocin. Cervidil is not a very strong agent. Miso on the other hand, is much stronger of a prostaglandin, causes more contractions than cervidil, and thus works better. It also is more likely to cause tachysystole and sometimes tetanic contractions.

    Overall I think miso is safe and effective, but you do have to pick the patients a bit. I like miso when I believe the baby is healthy, but tend to avoid it if I think the baby is compromised in some way (and thus may not be able to tolerate the rare tachysystole that may occur). I also like miso when there is fluid around the baby. Oligohydramnios is usually a sign of poor maternal fetal circulation, and thus may indicate a baby that may not tolerate miso. I definitely do not use miso when there is a uterine scar (not cervidil either.)

    As for the “irregular dosing”, I really don’t think that’s an issue. Its really not so hard to break a 100 mcg miso tab into an approximately 25 mcg piece. FDA allows generic miso to be up to 20% off on the dosing, so its not like the little bit of variance you might get from breaking the tab is within significant figures.

    There is no evidence to suggest that miso is more associated with AFE. AFE is a horrible complication that fortunately is extremely rare. Any claimed association between miso and AFE is pure speculation, and will probably always remain so given the rarity of the disease. Perhaps someone will do a good matched case-control on the subject.

    —–

    I think the big issue is whether or not you believe in induction at all. Most folks on this site tend to believe that many inductions are unneccesary, while most OBs are pretty comfortable with induction. If you are OK with induction, you already need to accept that it has a higher rate of adverse outcome that spontaneous labor. You are trading that risk for whatever benefit you get from delivering. In cases where mom has severe pre-eclampsia or the baby has reversed end diastolic flow and is at risk for fetal demise, the induction is well justified. In cases where the mother wants to deliver before the tax year is out (or the OB is going out of town,) maybe not so much.

    If you are going to induce, cervical ripening is a good thing, and miso is an effective ripening agent.

    Nicholas Fogelson, MD

  15. December 1st, 2009 at 21:36 | #15

    Yipes. I’m about to break one of my cardinal rules which is to never post on a blog that is more than one week old. But, I figure since my friend Nick Fogelson has weighed in, I’ll give my opinion as well.

    The points made above are all well taken. Ultimately reasonable people may choose to disagree where the evidence is less than optimal.

    I will highlight some areas of agreement with Dr. Fogelson first.
    #1: Misoprostol (or any ripening agent) does NOT reduce the incidence of cesarean delivery. This is commonly mis-understood my MANY OB-GYNs. In fact I have gotten into heated discussions with people when I see them “teaching” this to residents. No such evidence exists.
    #2: I have jokingly said for years that the one thing that Cervidil is good for is as a sleeping aid. The attending places it in at night and he or she is then able to get a restful night sleep until the actual induction process begins the next day. All jokes aside, I see limited benefit in this medication. Although the people who market it have done a masterful job of placing it at the top of the hit parade for MDs.
    #3: I do not feel that irregular dosing is a significant problem with misoprostol.
    #4: Amniotic fluid embolism is a tragic complication. I agree with Nick that there is no data to support a causal relationship with misoprostol. If there were such data I would stop using miso immediately. Period.

    This brings me to my final point which Dr. Fogelson also touched on.

    In a recent blog post/rant, I mentioned the reasons why it is better to avoid an unnecessary induction in the first place: http://onyeije.posterous.com/pregnancy-the-anticipation-game

    One of the things I tell my residents all the time is that a clinician should always ask “Why” rather than “Why not”. This embodies the concept that we must have a reason for everything we do rather than just reflexively doing something (anything). With regard to induction of labor, the first question to ask is not what agent to use, but rather the reason for the induction itself is proper. That being said, if the reason for the induction is clear; and the risks, benefits and alternatives are clearly laid out for the patient; I do believe that in those limited cases, that miso can be a useful agent in properly selected patients.

    Thanks for letting me share.

    Kindest regards,

    Chukwuma Onyeije, M.D.
    http://onyeije.net/blog

  16. December 5th, 2009 at 15:31 | #16

    Thank you for making the important point that women induced with an unripe cervix are at higher risk for cesarean regardless of whether cervical ripening agents are used. This is almost certainly because there are more complex interactions and feedback mechanisms going on in starting and maintaining effective labor than merely softening and effacing the cervix. For example, gap junctions need to form connecting the muscle fibers so that uterine contrax are coordinated and can work together to dilate the cervix. The muscle fibers also develop more oxytocin receptors. Labor onset–and particularly the shift from latent to active labor–is much more a matter of increasing sensitivity to oxytocin, not an increase in oxytocin levels. The irony of inducing labor is that it is much more likely to work when the woman will shortly go into labor on her own, in which case, unless there are compelling reasons to do otherwise, why not wait? Even when there are, induced contrax are likely to be more stressful for a compromised fetus than spontaneous labor, especially in combination with early amniotomy, which is pretty much routine when inducing. I have no doubt that in at least some of the sequences of induced labor leads to fetal distress leads to cesarean delivery leads to “Thank God we induced or your baby might have died,” the distress resulted from the induction, not the underlying problem. Not being a clinician, I don’t have to deal with the conundrum of induce or wait in such situations, but your teaching residents to start with asking “Why” rather than “Why not” would certainly seem the better way to go in deciding.

    As for associations between amniotic fluid embolism and misoprostol, as noted in my blog post, that complication is exceedingly rare. RCTs and systematic reviews of RCTs are way underpowered to detect them, which the Cochrane review notes. And because it is rare, the fact that any individual practitioner or group of practitioners has not seen one after using misoprostol is not surprising. We do, in fact, have a study finding an association between induction using pharmacologic agents and AFE in general: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17055946. Whether some of these involved misoprostol is unknown, and, of course, the FDA label notes the association in the case reports of Cytotec disasters.

    In short, misoprostol makes me think of the little girl in the nursery rhyme: “When it is good, it is very, very good, but when it is bad, it is horrid.” For this reason, while I agree with you and Nicholas that induction should be used cautiously, we differ in that I think that when inducing, other agents and techniques with lower risk profiles are preferable.

  17. avatar
    Nancy
    February 22nd, 2010 at 21:27 | #17

    My 26 year old daughter wanted a natural birth for her child. She exercised, went to all her OBGYN checkups. attended prenatal classes with her husband. She was a PE teacher and taught her students that PE was “taking care of your mind body and spirit.” My daughter practiced what she taught. She was so happy and ready to be a mommy .She was “post date” She given cytotec and not told of the serious risks. nor of the “off label” usage. She gave birth to a beautiful healthy child. A few hours later my daughter passed away. Cause of death,,,AFE

  18. February 23rd, 2010 at 01:43 | #18

    @Nancy
    I am so sorry for your tragic loss. You and your family have my deepest sympathy.

  19. March 7th, 2010 at 15:36 | #19

    The comments from the doctors and nurses on here are really disturbing. No one is acknowledging that birth works all by itself. nature has perfected birthing in humans, and EVERY intervention carries risk. Why would a caregiver deliberately inflict a treatment upon a woman without that awareness? No mention has been made of the fact that if the woman’s cervix isn’t ripe, perhaps she should NOT BE in labor. Forcing a woman into labor before her body decides it’s time is simply wrong. it’s unethical. And the idea of scheduling staff around the inductions, rather than allowing nature to run its course, is despicable. I’m so glad my births were natural.

  20. avatar
    Harley
    April 24th, 2010 at 06:02 | #20

    Just seems like convenience is replacing ethical decisions.

  21. April 25th, 2010 at 10:38 | #21

    Your comment assumes that at some point in the past, it was different. “Daylight obstetrics,” the idea of inducing electively in the morning so that the doc could be home in time for dinner, was popular back in the 1950s and 60s. Cytotec inductions are merely daylight obstetrics redux.

  22. avatar
    karen
    August 12th, 2010 at 12:29 | #22

    I’m reading this with interest as due to being type 2 diabetic and on insulin, I’m facing an induction next Tuesday. The CNM and OB both want to use Cytotec… or as the CNM said, “just a little pill.” I said…”What Cytotec? Doesn’t that have an increased risk of uterine rupture and meconium-staining?” She replied, “Not more than any other induction method.” Not true–as far as I can tell. I’ve had insulin-dependent GD for three prior pregnancies, so induction isn’t new to me–but in previous inductions, have used Pitocin. My HbA1c is 5.1%, baby is in the 53rd percentile for growth. My MFM is comfortable with my going to 40 weeks–and all of the BPPs and NSTs have been fab. Well, now I’ll be 40 weeks on Monday. I’m tempted to skip my induction. I’m tempted to push for another week and maybe ask if we can do three NSTs rather than two. I.do.not.want.Cytotec. Yet, it seems like I don’t have much choice with this group–which is supposed to be so natural birth friendly. Argh.

  23. August 14th, 2010 at 13:17 | #23

    It may feel like you have no choice, but you do. All people, pregnant women not excepted, have the right to make informed decisions about their medical care, and while that doctrine is termed “informed consent,” the concept is meaningless unless it also incorporates informed refusal. So you have the right to refuse induction until such time as you are convinced that inducing labor would be in your baby’s best interest, and you have the right to refuse Cytotec as a method of induction.

    As long as I’m at it, I’ll add some advice about induction as well because I’m just finishing up the chapter on it for the new edition of Obstetric Myths Versus Research Realities. Based on the research:

    (1)Unless there is compelling reason to do otherwise, wait for cervical ripening. Even women with prior births and no cesareans are at increased risk for cesarean if they are induced with Bishop scores less than 6 REGARDLESS of whether cervical ripening agents have been used. And, of course, if the cervix is ripe, there is no need for cervical ripening agents; you can go straight to oxytocin.

    (2)Insist on a low-dose oxytocin (Pitocin) regimen where doses are increased at no less than 30 minute intervals. (The oxytocin package instructions describe this regimen.) Labor takes longer, but cesarean rates are similar and there is less uterine hyperstimulation with accompanying abnormal fetal heart rate. Insist, too, that the oxytocin drip be turned off once you are in active labor. In the majority of cases, women continue under their own steam with their own natural contractions. For those who don’t, no big deal, the drip can be turned back on.

    (3)Refuse membrane rupture as part of the induction process. There is NO evidence that it decreases likelihood of cesarean, AND it has harms, which makes breaking the bag of waters a “batting 0 for 2″ proposition. First and foremost, unlike any other agent or technique, it commits to delivery. With intact membranes, if the induction doesn’t “take” you can quit and try another day. In addition, rupturing membranes opens the door to ascending infection; removes the protective cushioning of the amniotic fluid, which makes contractions more stressful on the baby; and creates the potential for umbilical cord prolapse (the umbilical cord comes down ahead of the baby), an obstetric emergency requiring cesarean surgery.

    I’d love to hear what you decide to do and how it goes.

  24. avatar
    hilary
    August 15th, 2010 at 22:12 | #24

    well this is nice. i feel like im on death row or something. im scheduled for an induction (GD) on the 22nd of august (this sunday/saturday) the ob plans to start me on 25 mg every three hours—orally. then in the morning pitocin. i was measured at 1.5 cm dilated this past friday. my ob is on vacation until sunday when i go in, so i have no one else to re-discuss this with. reading all these posts is scaring me…and i dont know what to do. i guess if i survive it, ill let all of you know.

  25. August 19th, 2010 at 21:09 | #25

    Please read the previous post to yours (# 23). It is my response to another woman in a similar position to yours and applies to you as well.

  1. August 19th, 2009 at 19:22 | #1
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