Inducing labor using Cytotec
July 20, 2012 7:24 AM   Subscribe

My wife will likely have labor induced in the first part of next week. Her doctor is talking about using Cytotec (Misoprostol). There are some troubling reports about possible uterine hyperstimulation from the use of Cytotec, but there are also valid reasons to use it. As we try to make a decision about how to proceed, what factors should we be considering (about the med choice or about induction in general)?

I've read the other threads on induction, and I've read the easily available PubMed papers about Misoprostol (which basically say that it's basically safe, but that there may be infrequent major adverse events). I guess my wife and I are looking for things we should consider and discuss with our doctor.

FWIW, she is full term, and a candidate for induction because of her age and a couple of other factors. The docs at her practice seem pretty set on induction very close to the due date, and right now it is scheduled for the day after.
posted by OmieWise to Health & Fitness (25 answers total) 1 user marked this as a favorite
OmieWise, I used to work for a malpractice firm, and we had quite a few Cytotec cases. You can feel free to MeMail me if you want to discuss further.
posted by roomthreeseventeen at 7:30 AM on July 20, 2012

If she is planning on having a drug-free birth, she may want to talk to the doctor about the difference in experience/pain between naturally occurring labor and induction, and whether she wants to think about options for pain relief.
posted by chesty_a_arthur at 7:32 AM on July 20, 2012 [3 favorites]

Be prepared for c-section. That's a likely outcome of induction.

My doctor started induction with a Foley catheter, did your doctor consider this? Feel free to ask.
posted by crazycanuck at 7:33 AM on July 20, 2012 [10 favorites]

With our second child, my wife had an induced delivery, and it worked really well (you would have to ask her though because she had to experience it!)

I think it was a great alternative to a C-section, which was definitely being talked about that day.
posted by KokuRyu at 7:40 AM on July 20, 2012

Post preview - regarding a drug free birth - if this was on the table before, I suggest you rethink this stance. I tried it. Having an internal female monitor inserted while you are having contractions hurts like a motherfucker. Also, it is easier for your wife to participate in decisions such as choosing a c-section when she is not struggling against painful contractions. Ymmv
posted by crazycanuck at 7:48 AM on July 20, 2012 [1 favorite]

One more reference: These British government guidelines to Induction of Labor, which say "Misoprostol should only be offered as a method of induction of labour to women who have intrauterine fetal death (see section 1.2.9) or in the context of a clinical trial."
posted by Mr.Know-it-some at 7:57 AM on July 20, 2012 [6 favorites]

Have you tried acupuncture as a means to induce? It can work and you could avoid any of the worries associated with induced labor. My wife and I had our first baby (she is 37) just a few months ago and she opted for a natural birth with limited monitoring during the labor. It was intense, but the hospital was pushing for drugs and monitoring at every stage. I don't know what your birthing plan is, but if you are trying to minimize the amount of hospital interference be prepared to act as a an intermediary between your wife and the hospital staff. Good luck on your inevitable life changer!
posted by Odinhead at 8:04 AM on July 20, 2012 [1 favorite]

I once posted an anonymous AskMe about being a million years pregnant and done with it and nearly all the suggestions recommended induction.

I was having a homebirth, so induction wasn't an option, and it was a VBAC, so a chemical induction was completely off the table.

I went into labor at 41.5 weeks with my second baby.

She will go into labor on her own eventually, and that, barring something like preeclampsia or troubling heart tones or anything of that nature, is the better for her and for the baby. Inductions are overused and used improperly. Be cautious.
posted by zizzle at 8:08 AM on July 20, 2012 [5 favorites]

Response by poster: We are using other methods of trying to induce.

She will go into labor on her own eventually, and that, barring something like preeclampsia or troubling heart tones or anything of that nature, is the better for her and for the baby. Inductions are overused and used improperly. Be cautious.

We are being cautious, hence this question. Our OB/GYN has a much better handle on what the specific risk factors are here, some of which I alluded to, so we feel reasonably comfortable with her intent to induce, although of course we would prefer a natural labor.
posted by OmieWise at 8:31 AM on July 20, 2012 [2 favorites]

On the other side of induction - my kid was induced because of some risks. I pushed them not to induced after being asked if I wanted to. My kid was induced a week after I was first asked. He ended up in NICU anyway.

The hospital I was at and my OB weren't heavy inducers.

I wish I would have induced when my OB first asked.
posted by k8t at 8:40 AM on July 20, 2012

I was induced, for a variety of medical reasons, but they used pitocin.

I had a really easy birth following the induction. I was petrified that i was going to have to go through all the hard labor and then have a c-section; fortunately that did not happen. My doctor, and the nurse midwife, both indicated that they believed that the induction was a success, and so easy, because I was basically already ready for labor - I was slightly dilated and effaced and the baby was dropping. So with respect to induction, generally, those are the kinds of questions I would ask - if her body shows no signs of getting ready otherwise, what is the likelihood that inducing is going to end up in a c-section anyway (if the chance is high, maybe schedule the c-seciton instead of using a controversial drug?). Why not try pitocin? Is the doctor going to break her water, and if so, does that increase the likelihood of a csection (because if your water is broken, and they start the drugs, they can't as easily just stop the drugs, I think?)

I had a truly wonderful experience even though I was induced. I always feel the need to tell people that, because there are lots of horror stories. They started pitocin at 9:30 and my daughter was born at 4:15 without any drama or complications. So if your doctor believes its necessary, it isn't necessarily going to be awful.

Good luck!
posted by dpx.mfx at 8:43 AM on July 20, 2012 [4 favorites]

In May, I was induced the day before my due date because of a background medical condition. (I'm also elderly, at 40, but this didn't impact the dr's decision to induce.). I would have preferred to go into labor naturally, but trusted my dr's ability to weigh the risks.

I wasn't dilated at all, which makes induction less likely to work. (Google 'bishop score'). He administered cytotec twice (second dose 4 or 5 hours after the first), then broke my water when I was dilated to 1cm. He also started pitocin, but only at what he called a "homeopathic dose" -- that way the nurses could increase the dose if necessary, but in my state nurses aren't allowed to start new medications, and the doctor wasn't going to be around (unless there was a problem or until I was ready to push.) I delivered a perfectly healthy daughter about 4 or 5 hours later.

With an epidural. I went from "this isn't THAT bad" to throwing up from pain about 5 minutes after he broke my water.

I know that's all anecdotal, and I wasn't sure I felt great about cytotec either. But it works.
posted by kestrel251 at 9:06 AM on July 20, 2012 [1 favorite]

Just ask lots of questions. Why Cytotec, versus cervidil or pitocin? I was induced for my first, which ended in a C-section because he wasn't tolerating even mild labor, which we knew was a risk going in. Cervidil as I vaguely understand it, is a milder start to induction than going with Pitocin straight off the bat. I've never even heard of Cytotec, so I would be asking why. Assuming you are OK with the idea of inducing, then ask why this drug? What's the risk for inducing with this versus the others? What's the risk of not inducing? Don't be afraid to badger with lots of questions. You're not questioning your doctor's choices, you're trying to understand your doctor's choices. If you feel like you aren't getting clear answers then push back. This may very well be the best choice, but its your right (your wife's right) to understand that and feel confident.
posted by Joh at 9:32 AM on July 20, 2012 [3 favorites]

I was induced using a Foley catheter, cytotec [applied twice over the course of a day], [a full day of] pitocin, and finally an attempt to break my water. None of these led anywhere and I had a c-section. Of those, for me personally, only the Foley catheter actually did any good. So, I second taking a look at the Foley catheter option. My induction (started) well over a week before my due date, though, so I feel that my body was really not ready, and your wife's body may be much more ready.

Keep in mind when learning about cytotec that induction is an off-label usage, and that your doctor will be taking what is meant to be an oral gelcap, opening the gel cap, and then applying the contained powder manually (unless something has changed, so of course check that this is still the case). The nurses at the hospital mentioned to me that my doctor was "very good" at doing this. I don't know how much there truly is a skill factor, or if anyone will tell you anything about your wife's doctor's alleged skill at it, but it might be worth asking about that.
posted by freezer cake at 10:13 AM on July 20, 2012

It lasted 21 hours, was exceptionally painful, ended in a c-section, and I wish I had not agreed to it.

I suspect the people it works for were on their way towards an easier labor, anyway.

My answer here is to seek alternatives.
posted by jbenben at 10:14 AM on July 20, 2012 [4 favorites]

I think it's a great idea to ask more questions about the reasoning for induction and about the method of preference. Others' personal anecdotes are really useless though except to give you information about the answerer's personal prejudice on the question.

In considering things like rare negative outcomes to a procedure you have to question whether you are giving equal weight to the rare negative outcomes of the alternative of extending the pregnancy past the due date, which I think tends to not be looked at as closely because of a generic "natural = better" assumption.

When my wife and I accepted medically advised induction of our very premature child it was based on the medical team leader being able to convincingly explain to us why based on their extensive experience in our situation they were confident it offered the best outcomes. In retrospect I'm convinced waiting would have seriously endangered both lives. Obviously this is a significantly different situation than yours, but I do think you should look for the confidence from what your doctors have to say to you, not anecdotes or internet research (unless understanding medical research is really in your field).
posted by nanojath at 11:10 AM on July 20, 2012 [4 favorites]

nthing those who recommended talking to the doctor about pain management options—including a backup plan if your selected option falls through.

Labor was induced for both my kids. For my first, Pitocin was used several hours after breaking my water. My plans for minimal pain management were out the window within about three hours. Unfortunately for me, by the time I threw in the towel, the anesthesiologist on duty was tied up with another patient. I waited at least 2 hours for the epidural—i.e., 2 hours after I had reached what I thought was my absolute limit regarding pain.

Three years later when I was admitted for the second induced labor, just seeing the label "Pitocin" on a cabinet drawer made me nauseous and light-headed. Fortunately, labor started after the doctor broke my water and I delivered my (10lb 5oz) son with no more than an injection of Demerol.

(Note: my kids are 20 and 23, but it appears that little has changed since my experience. The advice you are getting here is basically the same I received.)
posted by she's not there at 11:19 AM on July 20, 2012

We were 16 (17?) days late after a 3 day labor that was induced with pitocin. The lesson we got is that it's REALLY difficult to convince a womans body to give birth when it doesn't want to yet. Doing it againwe would have waited another week. We ended up with an epidural on day three, but no c-section. All in all healthy mom and healthy baby is the outcome you want, be prepared to shift gears as you go. You can't back away from an induction, once it starts you're on some sort of intervention path.
posted by iamabot at 11:44 AM on July 20, 2012 [1 favorite]

I was induced with Pitocin for my second child, and it was a textbook, 8-hour labor and delivery, no further interventions other than the one I wanted (an epidural). I was, however, 3 cm dilated and 90% effaced before it started, and I'd been that way for a couple of weeks, which I'm sure helped. I was not past my due date, though. I'm glad I did it.

Is there a reason your wife's OB prefers Cytotec to Pitocin? It seems like Pitocin is much more widely used for this purpose.
posted by palliser at 12:51 PM on July 20, 2012

Response by poster: Is there a reason your wife's OB prefers Cytotec to Pitocin? It seems like Pitocin is much more widely used for this purpose.

Sorry this wasn't clear from how I wrote it. Cytotec is used to prepare the cervix, pitocin is used to actually initiate labor. The chances of having a fruitful labor if your cervix is not "ripe" is fairly low. Pitocin would be on the menu for my wife as well, but the med of concern here to us is the Cytotec.
posted by OmieWise at 1:03 PM on July 20, 2012

Best answer: I've been a labor and delivery RN for my entire career, and I have worked in a variety of hospital-based settings (a high-volume urban safety-net teaching hospital, a big well-known research hospital with lots of Nobel winners and a "Ripley's Believe It or Not" of pregnancy kind of patient population, and a small community hospital with mostly midwife-attended deliveries and docs on call for emergencies).

In each of these hospitals, I administered, monitored, and educated women and their partners about misoprostol for induction. What follows is obviously anecdotal information based on my single experience, but I have seen thousands of babies born and never a single bad outcome from the appropriate use of misoprostol.

I'm sure you already know this, but: misoprostol is absolutely contraindicated for use in the setting of previous uterine surgery of any kind, including cesarean section. My understanding is that the catastrophically bad outcomes that gave misoprostol its bad reputation as an induction agent were because of its use with women who'd had previous myomectomy or previous cesarean section and who then suffered a uterine rupture. Spontaneous uterine rupture with no previous history of uterine surgery is vanishingly rare in either induced or spontaneous labor.

In my experience, uterine hyperstimulation is more likely (though still quite rare) when misoprostol is given to multiparous women.

If your wife is being induced for pregnancy complications, she will need continuous electronic fetal monitoring and uterine contraction monitoring (tocodynamometry; the little device is frequently called "the toco"). This is, to be frank, a pain in everyone's ass, but it is non-negotiable during induction of labor and is, I think, the best way of reassuring yourself about your baby's well-being and the lack of uterine hyperstimulation.

Terbutaline (0.25mg SQ) is given for uterine relaxation (mostly for preterm labor), and does a great job of resolving non-reassuring fetal heart rates due to uterine tachysystole. If your wife does experience uterine hyperstimulation due to misoprostol, terbutaline can be given as needed to resolve it.

The lowest effective dose of misoprostol is 25 mcg PV. Some places use 50 mcg PV, but if you are concerned about hyperstimulation, you can insist upon the 25 mcg dose. 100 mcg tablets can absolutely be cut accurately into quarters. I've done it myself and pharmacies all over are doing it. 50 mcg is an appropriate dose when given PO, but few hospitals give misoprostol PO for labor induction.

You can also be conscious about correct placement of the uterine contraction monitor. If your wife changes from a sitting to a side-lying position, the toco position should be changed to accurately register contractions. Your nurse will know how to do this, and should come in and out of the room frequently to make adjustments, even in the middle of the night. (See also: pain in everyone's ass.)

Please feel free to MeMail me with any other questions about induction in general or misoprostol in specific. My take-home message is that its risks for use in nulliparous women with no history of previous uterine surgery and a term singleton vertex fetus are far, far less than the potential complications that are causing your wife's doctors to recommend induction of labor.
posted by jesourie at 1:32 PM on July 20, 2012 [8 favorites]

Not to derail, but jesourie - I'm curious as to your take on cervadil vs. misoprostol for this purpose.
posted by judith at 2:03 PM on July 20, 2012

judith, that's a good question. I like misoprostol better than Cervidil in general for a couple of reasons, the first being that it was what I used when I was being trained, so I have more experience with it and its effects.

Secondly, it's far less expensive than Cervidil. The hospital I worked for as a new grad was a Medicaid disproportionate share hospital that was always in the red, and they never used Cervidil because it's so expensive. (I'd never even heard of it until I started working at a better-resourced hospital!) Miso, on the other hand, is dirt cheap--so cheap that it's the first line of defense against postpartum hemorrhage in developing countries.

Thirdly, I think miso simply works better. Cervidil is placed for twelve hours and is frequently used for the convenience of doctors or midwives who don't want to get up in the middle of the night to reassess progress. (To be fair, this can be good for the patient, too, as they get a more-or-less complete night's sleep while the medicine is in place.) The problem is that when the Cervidil is removed the next morning, very often the cervix hasn't changed and that was twelve hours of very expensive inpatient hospital care for nothing.

Miso, on the other hand, is dosed every 4-6 hours, requiring frequent reassessments of progress (which in my experience happens faster than with Cervidil) and a quicker realization that the cervix is ripe and it's time to start pitocin. Induction of labor can take many days, and it's a kindness to take a few hours off of those days whenever safely possible.
posted by jesourie at 12:45 PM on July 21, 2012 [1 favorite]

Yes, my OB mentioned the cost issue too. I forget the actual numbers, but it was something like 50 cents vs. 500 dollars; roughly that order of magnitude.
posted by kestrel251 at 2:52 PM on July 21, 2012

posted by palliser at 1:07 PM on July 29, 2012

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