Hello,

I am 19 weeks pregnant and trying to get all my ducks in a row--asking questions and writing a birth plan. I am using a midwife group that I so far feel really comfortable with to deliver in a large university hospital (which I am not so comfortable with).

Anyway, I asked what medication of choice they use for induction--if that were to become an issue for me. The midwife said they prefer to use Misoprostol 25mg. She seemed to indicate that it does better without the negatives of oxytocin induction--was more gentle. However, what I had read was that cytotec was very bad--I've even seen the medication fine print that lists many negative effects (some deadly) and the specific manufacturer warning NOT to use it to induce labor. Admittedly, that was for the 100mg dose.

So my question is, in my preparation for birth, what should be the best choice for induction if it is necessary. I want to have a plan in place before it ever becomes a possibility. In your reading, is misoprostol only a problem for induced VBACs? Or is it only a problem in 100mg doses? Is there new information out that I haven't found that shows that it is ok?

Thank you for your time.

Melanie

Since I am not a clinician, there are very few issues on which I will make a direct statement. Cytotec (misoprostol) is one of them:  Just say "no." It is not true that Cytotec is only a concern in VBAC labors, and it is not true that it is only a problem in 100 mg doses. Here is what the FDA has to say:

"Cytotec can induce or augment uterine contractions. Vaginal administration of Cytotec, outside of its approved indication, has been used as a cervical ripening agent, for the induction of labor and for treatment of serious postpartum hemorrhage in the presence of uterine atony. 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), or amniotic fluid embolism [maternal and infant mortality rate is very high from this]. Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia [profound slowing of the baby's 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.

"The effect of Cytotec on the later growth, development, and functional maturation of the child when Cytotec is used for cervical ripening or induction of labor have not been established. Information on Cytotec’s effect on the need for forceps delivery or other intervention is unknown."

Cytotec's only advantages are that it is dirt cheap and it tends to work faster than prostaglandin E2 (Cervidil, Prepidil). Neither of those are benefits to you. You get more vaginal births within 24 hours, but overall cesarean rates are virtually identical. (Hofmeyr GJ, Gulmezoglu AM. Vaginal misoprostol for cervical ripening and induction of labour. Cochrane Database Syst Rev 2002(2):CD000941.)

It is also not true that Cytotec is gentler than oxytocin. Oxyocin's effects can be controlled. Cytotec's cannot. Once you give Cytotec, you are stuck with whatever contractions it produces. With oxytocin, if contractions are too strong and close together, the IV drip can be turned down, and because oxytocin is rapidly metabolized, effects dissipate within a few minutes. Once active labor kicks in, it may also be possible to turn the oxytocin drip off.

You are right to be planning ahead. Your midwives should be willing to accommodate your preferences. If they are not, better to find it out now.

-- Henci

P.S. I don't know if you have already asked this, but were I you, I would want to know how often and for what reasons your midwives recommend inducing labor. This is an important issue because, as a first-time mother, inducing labor roughly doubles your chances of cesarean surgery. You don't want to do it for less than compelling medical reasons. The World Health Organization recommends an induction rate of no more than 10%. As for reasons, the research does not support induction for nonmedical reasons such as convenience or because a big baby is suspected. Inducing because membranes have ruptured does not prevent newborn infections. (Dare MR, Middleton P, Crowther CA, et al. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2006(1):CD005302.) Inducing because the pregnancy has reached 41 weeks is more controversial, but the studies on which that recommendation is based are problematic. I deconstruct a key trial and a review of trials at http://www.lamaze.org/Research/WhenResearchisFlawed/tabid/121/Default.aspx.