August 29, 2001
Volume 3, Issue 35
Midwifery Today E-News
“Misoprostol”
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News Flashes

Researchers planned to compare misoprostol to oxytocin for induction of labour in mothers attempting a VBAC. After two uterine ruptures among just 17 mothers receiving misoprostol, the trial was stopped on safety grounds. They concluded: "When misoprostol is used in women with previous cesareans, there is a high frequency of disruption of prior uterine incisions."

- Obstet Gynecol 1998 May; 91(5 Pt 2):828-30 [Thank you to: http://www.homebirth.org.uk/misoprostol.htm]

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Department of Obstetrics, Northwest Permanente PC, British Columbia, Canada.
Out of 89 women attempting VBAC whose labours were induced with misoprostol, 5 suffered uterine ruptures. However, among 423 women attempting VBAC who did not receive misoprostol, only one suffered a rupture. The rupture rate for VBAC candidates after misoprostol induction was therefore 5.6%, compared to 0.2% otherwise.

- Am J Obstet Gynecol 1999 Jun; 180(6 Pt 1):1535-42 [Thank you to: http://www.homebirth.org.uk/misoprostol.htm]

Misoprostol Induction

The common medical methods of induction in the United States today include intravenous oxytocin infusion, intravaginal or intracervical dinoprostone, and misoprostol. Each of these can cause excessive uterine contractility: contractions may be too forceful, too close together, or too long. When this happens, maternal perfusion of the placenta is reduced, and the baby may not receive enough oxygen. The degree of fetal compromise depends on several factors, including the health of the placenta, the fetal reserves, and the degree of uterine overactivity. Uterine overactivity also poses risks to the mother. There is a risk of rupture in even the unscarred uterus. Cervical lacerations are possible. A precipitous second stage can cause severe vaginal and perineal tears. Excessive contractility can also cause placental abruption.

When uterine overactivity occurs, an attempt must be made to remove the drug that is causing the problem. Turning off an oxytocin infusion is fast and easy and usually results in a rapid return to more normal uterine activity. Some dinoprostone products are made with a string and are easy to remove quickly. When dinoprostone gel is used, attempts can be made to flush it from the vagina with sterile saline-clearly a slower and less effective procedure. With misoprostol, attempts can be made to remove the pill if it has not yet been absorbed. More often than not, the pill has already been completely absorbed. In this case there is no choice but to ride out the excessive contraction pattern with careful monitoring and measures to maximize the supply of oxygen to the fetus.

- Jennifer Enoch, excerpted from "Misoprostol (Cytotec): A New Method of Inducing Labor," Midwifery Today Issue 49

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Midwifery Today Issue 49 can be ordered from the Midwifery Today storefront
Jennifer Enoch's article is comprehensive and includes nine abstracts of studies on misoprostol and numerous references.

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An induction with Cytotec should never be attempted anywhere, most especially in out-of-hospital settings. Incredibly, the American College of Obstetricians and Gynecologists (ACOG) recently approved Cytotec induction: 1) in spite of lack of FDA approval; 2) in spite of a letter to doctors earlier this year from Searle (which manufactures Cytotec) imploring doctors not to use it for induction; 3) in spite of lack of approval from the Cochrane Library (the best scientific opinion); and 4) in spite of the fact that it is not approved nor used for induction in any country in Western Europe.

Recent articles in prestigious medical journals like The Lancet have questioned the validity of standards of practice from professional organizations like ACOG, because its goal of protecting the health of women through using scientific evidence to guide members toward best practices too often conflicts with its other role as a trade union representing the interest of its members. As a result of this "trade union" role, ACOG recommendations are too often compromised by the needs of the obstetricians. A classic example of putting the doctors' needs ahead of the families' needs is the ACOG recommendation not to permit videotaping by families of a hospital birth.

So ACOG quotes studies of Cytotec induction, none of which have a sufficient number of research subjects, and consequently, none of the studies quoted have sufficient statistical power to detect small but potentially important risks such as uterine hyperstimulation and uterine rupture. Furthermore, because published studies of Cytotec induction have such wide methodological variability, meta-analysis is impossible and the published attempts at such meta-analysis are seriously flawed. But Cytotec is a godsend for busy obstetricians because its use allows them to schedule the woman's labor at a convenient time and speeds up the labor, resulting in a return to "daylight obstetrics"--pharmacological induction of labor has increased from 10 percent to 20 percent in the past decade in the United States. So with their members' needs in mind, ACOG plows ahead, ignoring the best scientific evidence as well as the recommendations of the best scientific bodies, of government agencies not only in the United States but in every country in Western Europe, and of the pharmaceutical company. Instead, ACOG uses weak, inadequate evidence to approve Cytotec induction. Midwives should stay as far away as possible from such vigilante obstetrics-obstetricians taking matters into their own hands while ignoring the recommendations of the real judges.

- Marsden Wagner, MD excerpted from "Midwives and Cytotec: A True Story," www.midwiferytoday.com

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Question(s) of the Quarter for Midwifery Today Issue 60

What are strengths and weaknesses of your path to becoming a midwife? How does the current controversy over the various pathways to becoming a midwife affect your practice, or your hopes for a practice? Do you have any specific thoughts about midwifery education?

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International Connections

INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to "International Connections." We're here to help you!

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I am 24 weeks pregnant and just discovered by ultrasound that I have a placenta previa. I know that doesn't necessarily mean I will still have a previa at full term but I am wondering if anyone has the statistics on this. I have seen the statistics before but I cannot remember where. I will have another ultrasound closer to term to determine whether it is still an issue, but in the meantime I would love to have a little peace of mind. Any words of wisdom?

- Anon.

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Anon, who required a transport to hospital [Issue 3:33] appears to have several issues she needs to address. If she had problems with that particular hospital she should take them up with that hospital. The management of the hospital may be able and willing to address them. If not, she owes it to herself and her community to publicize her experience locally. A global generalization does not help her community and offends those hospital workers who make every effort to help a diverse clientele and to treat all support persons regardless of their level of expertise with dignity and respect.
Without knowing your exact situation I can think of a number of reasons for each of your concerns--some of them unavoidable, some of them within the realms of negligence. For yourself and your community, talk to them.

- Jacinta Muller, registered midwife
Australia

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I am 26 weeks pregnant with my third child. I have to have hospital births with an OB because of a vertical incision from a c-section with my first. For my first two children there was concern about low body temperatures (I am told this is a side effect of c-sections) and I want to do what's best to avoid separation if it occurs again and warm my child myself. Last time I did skin to skin contact and it worked well enough that the heating lamps weren't needed. Do you feel skin to skin is best or would it be better to first dress the baby in wool and then place her in my gown against my breasts?

- Barbara

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