Cytotec?!? (x-posted in my ddc) - Page 2

[ZoeyZoo]

Here's a link to Henci Goer's site. She has articles on both Cytotec and induction:
http://www.hencigoer.com/articles/

IMO I wouldn't be pushed into an unwanted induction for being post dates but it's your decision. Before even seriously considering it, please find out your Bishops score you you have a better idea of whether an induction would even have a decnt chance of suceeding. Hopefully having some more information will help your decision.

[mwherbs]

often using a prostgalandin for induction (cervadil or cytotec) is because cervical ripening needs to be done--

I have a few other recommendations that would be for the OP since it looks like this is baby # 3 there are things like belly binding that may help hold a baby in more so that he/she puts more pressure on the cervix- I would want to rule out any cervical scar tissue that is from HPV/displasia treatments, in which case breaking up adhesions may be in order-, go over your dates- including timing of ultrasounds if any. walking, dancing, belly dancing- anything that may help a baby find position, -- you mention you are already doing the typical stuff- so I am not going into that--

I have been around all types of inductions and I think that there are some already permitted uses for cytotec that are important-

there are no easy answers - and there are the extremes of viewpoints, there is some evidence and good advice on not having so many inductions on the other hand 43 + weeks does have greater risks - and very different consideration than a 40 week induction - an option may be to have NSTs and work with your providers until spontaneous labor -- that you mw has not brought this up until now I give her credit because it is very common to offer this level of intervention at 41 weeks--
take care and good birth

[maxmama]

Originally Posted by georgia

And any medication has the potential for abuse and has potentially dangerous side effects. I'd rather a mother be informed and know the risks rather than think, well, they use it many, many times so I guess it's safe.

Actually, ACOG requires informed consent before using miso, because of the off-label use. And I find it hard to get involved in this misoprostol paranoia, especially when I would guess that few if any of the posters have actually ever seen it used.

[etoilech]

Originally Posted by maxmama

A lot of things are contraindicated in pregnancy. Pretty much, oh, everything. But they are still used for some indications. It's not financially viable for the manufacturer to do testing on miso for induction or for PPH, because it's been off-patent forever. Who's going to do a trial involving pregnant women and the IRB review that would require for a medication that retails for 25 cents? That doesn't mean off-label use automatically is bad.

No, I am saying it's contraindicated and if I were to use it on a patient *I* would be risking my license. Different places different rules and different perspectives.

Originally Posted by maxmama

Actually, ACOG requires informed consent before using miso, because of the off-label use. And I find it hard to get involved in this misoprostol paranoia, especially when I would guess that few if any of the posters have actually ever seen it used.

I've seen it used. Not where I am, but I have seen it abroad. I didn't like how it was used, I think it is generally unnecessary, and causes more problems than it solves. Just my 2 cents.

I love to see *how* one would actually get informed consent and how risk benefit is framed for the woman potentially being induced. Just b/c ACOG requires it doesn't mean it's done and is probably roped into consent forms you sign when you enter the hospital. Just my guess. I've been wrong before. I find informed consent is an often talked about and brandished around regarding interventions, but it's rarely properly implemented. I find "coerced consent" more fitting, generally.

Originally Posted by maxmama

Actually, ACOG requires informed consent before using miso, because of the off-label use. And I find it hard to get involved in this misoprostol paranoia, especially when I would guess that few if any of the posters have actually ever seen it used.

Thanks for the re-cap.

[maxmama]

Originally Posted by etoilech

No, I am saying it's contraindicated and if I were to use it on a patient *I* would be risking my license. Different places different rules and different perspectives.



I've seen it used. Not where I am, but I have seen it abroad. I didn't like how it was used, I think it is generally unnecessary, and causes more problems than it solves. Just my 2 cents.

I love to see *how* one would actually get informed consent and how risk benefit is framed for the woman potentially being induced. Just b/c ACOG requires it doesn't mean it's done and is probably roped into consent forms you sign when you enter the hospital. Just my guess. I've been wrong before. I find informed consent is an often talked about and brandished around regarding interventions, but it's rarely properly implemented. I find "coerced consent" more fitting, generally.

I do the informed consents for my patients. You can ask them if they feel coerced.

I used to be anti-miso. Then I saw it used, and it works very, very well for some women who have not been successfully induced otherwise. We don't do elective inductions, so all our inductions are for medical indications -- usually PIH. It's perfectly legal in the US for providers to use it off-label.

Is it still illegal for you to use it for PPH? Because it works like turning off a faucet for most women, especially since many of my patients don't have IVs and we can't run pit.

[georgia]

I do the informed consents for my patients. You can ask them if they feel coerced.

And this is why it's good news to have thoughtful, considerate, mother-friendly birth advocates in institutions. I can tell you from personal experience and many years of natural birth advocacy IRL and online, that informed consent leaves a lot to be desired in many instances.

[etoilech]

Originally Posted by maxmama

I do the informed consents for my patients. You can ask them if they feel coerced.

That is fantastic. I really wonder about some of the forms, I've seen. I am glad that they are letting midwives (or student midwives) or ob nurses write consent forms (I can't remember, but I thought you were an ob nurse studying to be a CNM... I am have a crap memory, sorry if I am mistaken). Do you work directly with policy too (setting up guidelines for use, etc)? What kind of hoops do you have to go through with your trust or board and legal team? I can imagine it's a pain in the arse. I would be very interested in your experiences in writing consent forms. It's a tough area but, it's a pet subject of mine.

Originally Posted by maxmama

I used to be anti-miso. Then I saw it used, and it works very, very well for some women who have not been successfully induced otherwise. We don't do elective inductions, so all our inductions are for medical indications -- usually PIH. It's perfectly legal in the US for providers to use it off-label.

I'm not pro or anti anything. We're just plain not permitted to use it for induction. I haven't been impressed with it's track record or the way it's been used when I was watching. Know there are no real guidelines for use, so that is a problem. I have heard some things about titrating it and having safer and better inductions with it... though, I've no personal experience with it. Glad to hear it's not not used for non-medically indicated induction. I just have mixed feeling with induction in general. I works best when it's least needed. Typical conundrum.

Originally Posted by maxmama

Is it still illegal for you to use it for PPH? Because it works like turning off a faucet for most women, especially since many of my patients don't have IVs and we can't run pit.

Still up in the air. We've heard good things about using it for PPH. I've seen it work, very well... but again abroad. We expect to have a ruling on PPH use soon.

[maxmama]

Originally Posted by etoilech

That is fantastic. I really wonder about some of the forms, I've seen. I am glad that they are letting midwives (or student midwives) or ob nurses write consent forms (I can't remember, but I thought you were an ob nurse studying to be a CNM... I am have a crap memory, sorry if I am mistaken). Do you work directly with policy too (setting up guidelines for use, etc)? What kind of hoops do you have to go through with your trust or board and legal team? I can imagine it's a pain in the arse. I would be very interested in your experiences in writing consent forms. It's a tough area but, it's a pet subject of mine.

I don't write the consents, and we don't have a specific miso consent (it's part of the general consent). But because it's off-label, we do have to review the indications and risks at the time of consent to miso (which may or may not be when it's actually administered; there's often a holdup).

Fantastic that you may be able to use miso for PPH. It's not been linked to any UR when used PP, and in fact we will sometimes use it for a fresh section who isn't responding to pit. It really does work well; we don't generally use it in women with severe asthma and you want to keep an eye out for fever after use (it doesn't last long), but otherwise it's an excellent tool to have for PP bleeds.

[etoilech]

Originally Posted by maxmama

I don't write the consents, and we don't have a specific miso consent (it's part of the general consent). But because it's off-label, we do have to review the indications and risks at the time of consent to miso (which may or may not be when it's actually administered; there's often a holdup).

Fantastic that you may be able to use miso for PPH. It's not been linked to any UR when used PP, and in fact we will sometimes use it for a fresh section who isn't responding to pit. It really does work well; we don't generally use it in women with severe asthma and you want to keep an eye out for fever after use (it doesn't last long), but otherwise it's an excellent tool to have for PP bleeds.

It's good to hear it's not linked to UR when used PP. I am sure that will bode well for its use for PPH. Good to know what are issues to look out for too (hopefully it will be approved and I'm not jumping the gun, lol), thanks.

So, with the consent for miso, you do an oral review of indication and risks due to the off label use? How do you frame it? I can imagine it's hard not to interject your own views, while still informing of the potential risks. I find it difficult myself with syntocinon. May I ask about your protocol for using miso and if in your experience it's a better or safer way of using it? Just trying to get a feel for miso's use in a more moderate environment.

[maxmama]

Originally Posted by etoilech

It's good to hear it's not linked to UR when used PP. I am sure that will bode well for its use for PPH. Good to know what are issues to look out for too (hopefully it will be approved and I'm not jumping the gun, lol), thanks.

So, with the consent for miso, you do an oral review of indication and risks due to the off label use? How do you frame it? I can imagine it's hard not to interject your own views, while still informing of the potential risks. I find it difficult myself with syntocinon. May I ask about your protocol for using miso and if in your experience it's a better or safer way of using it? Just trying to get a feel for miso's use in a more moderate environment.

Generally, we use 25-50 mcg, either PO or PV, q 4 hours x 3. They are continuously monitored for the first 2 hours, but since we usually use miso at night, most of the time they stay on the monitor the whole time to maximize their sleep. (Otherwise we're waking them every 2 hours.)

As far as framing the risks of miso, I always discuss that miso cannot be removed once started, and if there was uterine hyperstim, we would use tocolytics (obviously, not in those words). We don't use miso for induction in a mom who's contracting (the max is 6/hour) or in a mom whose baby doesn't look pretty great, because it can't be d/c'd. I do talk about it being an off-label use, and that some studies have shown an increased risk of complications (we usually talk about these briefly or in detail if she's interested). Really, it's not much different than how I talk about any med I'm giving -- I don't put meds into someone unless we've discussed it or I know another nurse or provider has discussed it with them. I think what has been key to the positive experiences I've had with miso is patient selection -- with a borderline baby, we're likely to use cervidil because it can be d/c'd. We're very stringent on the issue of contracting prior to miso administration. I will hold miso for frequent ctx, even if they're not strong, and see what she does for a bit. It's a drug I have a lot of cautious respect for, but not fear of, if that makes sense. It's not like I think it should go in the water supply or anything; I just think clinical judgment about who might be a good candidate for miso is important.

Oh! For PPH we use 800mcg PR. And some providers are using it for cervical softening prior to placing an IUD (esp. in a nullip). Not sure what dosage they're using but I think it's 25mcg PV

[mwherbs]

The US clinical trial on vaginal inserts just finished in Sept 07, there is a recently published clinical trial on the use of titrated oral doses vs vaginal pill application-- their results say 11% hypterstimulation in their trial when pills were used vaginally---- this type of oral dosage is not available here it is a trial to see-- but if gives you an idea of how frequently hyperstimulation can happen with the vaginal dosage that you can't stop---

Obstet Gynecol. 2008 Jan;111(1):119-25.

Titrated oral compared with vaginal misoprostol for labor induction: a randomized controlled trial.

Cheng SY, Ming H, Lee JC.

Departments of Obstetrics and Gynecology, China Medical University Beigang,
Hospital, Beigang, Yunlin; and China Medical University Hospital, Taichung,
Taiwan.

OBJECTIVE: To compare the efficacy and safety of titrated oral misoprostol and vaginal misoprostol for labor induction. METHODS: Women between 34 and 42 weeks of gestation with an unfavorable cervix (Bishop score less than or equal to 6) and an indication for labor induction were randomLy assigned to receive titrated oral or vaginal misoprostol. The titrated oral misoprostol group received a basal unit of 20 mL misoprostol solution (1 mcg/mL) every 1 hour for four doses and then were titrated against individual uterine response. The vaginal group received 25 mcg every 4 hours until attaining a more favorable cervix. Vaginal delivery within 12 hours was the primary outcome. The data were analyzed by intention-to-treat. RESULTS: Titrated oral misoprostol was given to 101 (48.8%) women and vaginal misoprostol to 106 (51.2%) women. Completed vaginal delivery occurred within 12 hours in 75 (74.3%) women in the titrated oral group and 27 (25.5%) women in the vaginal group (relative risk [RR] 8.44, 95% confidence interval [CI] 4.52-15.76). The incidence of hyperstimulation was 0.0% in the titrated oral group compared with 11.3% in the vaginal group (RR 0.08, 95% CI 0.01-0.61). Although more women experienced nausea (10.9%) in the titrated oral group (RR 27.07, 95% CI 1.57-465.70), fewer infants had Apgar scores of less than 7 at 1 minute in the titrated oral group than in the vaginal group (RR 0.10, 95% CI 0.01-0.76). CONCLUSION: Titrated oral misoprostol is associated with a lower incidence of uterine hyperstimulation and a lower cesarean delivery rate than vaginal misoprostol for labor induction in patients with unfavorable cervix.
CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov,
NCT00529295 LEVEL OF EVIDENCE: I.

PMID: 18165400 [PubMed - in process]
------------------------------------------------
to be clear the vaginal insert trial has not been written up or published yet- a year or so ago I wrote to the researchers --but in looking at the trials I saw that the above one was published....

[etoilech]

Great information, thanks. I'm going to see if I can access the full articles through MIDIRS.

[herbsgirl]

I just want to say that I have had two WONDERFUL birth experiences with Cytotec. The secret in that is that my doctor was slow to administer it and in tiny amounts. She did not hurry it along really, just gave it time, and was cautious. She said I get along with it really well.



ON THE OTHER HAND, I had a different doctor deliver my first with cytotec and it was horrible, They put way too much in too close together, and I had hyperstimulation of the uterus. My contractions came almost right ontop of each other. My son came out blue, and had to be bagged and worked on for 1/2 hour.

I think we need to be cautious with it. But as my experiences say, Being cautious, slow with administering, it is alot safer, and I would much rather use Cytotec with the doctor I have now than use Oxytocin drip.

[juliabas]

I was induced with cytotec at 42 weeks. It was given at 25 mcg doses every 4 hours which is a very cautious administration. They monitored me for two hours after each dose was given. Probabaly more than was necessary. My nurse mid-wife told me that it usually took three doses to get labor going and sure enough it did. After the third dose I was monitered for the two required hours and then only monitored intermittently. So in other words once labor was started I didn't have to be hooked up and ended up having my baby in the hospital bath tub standing up. How cool is that!