Overview of Induction 

Labour normally starts between 37 to 42 weeks of pregnancy naturally but if there is a risk to the babies health, mum’s health or if the mother chooses to, labour can be induced through medical intervention. There are different types of induction, from natural forms of induction that have been used on society for hundreds of years and passed down through communities or medical intervention that is used in hospitals. There are different medical reasons for which induction may be recommended such as if there is meconium present, if your waters have broken and contractions  but I will leave that for another post. 

Some examples of natural remedies that have been known to kick start labour are dancing around and getting low, eating dates, prunes and castor oil, raspberry leaf tea, a bit of nipple play to get that oxytocin flooding in, and sex. 

Medical interventions to induce labour including breaking the membranes, using drugs such as cytotec, synthetic oxytocin or prostaglandin (hormones), Pitocin and Cervidil. I feel like sweeping the membranes is somewhere in the middle as it doesn’t involve a drug however can stimulate the body to produce its own prostaglandin. 

It should be noted that if labour is induced medically, there is a greater likelihood that other medical interventions will be necessary such as forceps or ventouse delivery. There is also an increased risk that this won’t work and you will go on to have a caesarean. Medically induced labour will also hurt more than normal labour because it will cause contractions a lot faster rather than the natural build up that would normally occur. 

This article in pregnancyandbirth.com states that in Australia 1 in 3 women will have an induced labour. https://www.pregnancybirthbaby.org.au/induced-labour 

What is Cytotec 

Cytotec (or misoprostol) was a drug developed by Searle, a drug company, to prevent and treat stomach ulcers. It is often used off-label to induce labour in pregnant women. It has synthetic prostaglandin in it which is a hormone that causes uterine contractions, to induce labour. It can be administered both vaginally or orally. 

Dangers of using Cytotec 

• Cytotec was intended to be a drug to treat stomach ulcers. Adequate testing has not been performed for its use as an induction drug. 

• Cytotec can be administered orally or vaginally. Once it is administered vaginally, you cannot stop it, unlike other induction drugs. It’s a catalyst in a process doctors have no control over. 

• The recommended dosage of cytotec for induction is quarter of the pill (25mcg). Cytotec was never intended to be scored (broken up and administered in half or quarter dosage of the pill). This means the composition of drugs in one quarter may be different to another quarter and the effects can be completely different. 

• The Cochrane studies suggest that there is still not enough data from randomised trials to determine the best dosage for safety. https://www.cochrane.org/CD001338/PREG_oral-misoprostol-induction-labour 

• Risks of taking Cytotec include neurological damage to babies, uterine rupture for the mother, amniotic fluid embolisms, and death (for either or both). 

• This website https://www.rxlist.com/cytotec-drug.htm#warnings lists risks associated with using Cytotec mainly in relation to its intended purpose, however it does mention that when tested on breeding rats, there was a general adverse affect on fertility. 

• In addition, the website states that when the drug is used to ripen the cervix and induce labour in pregnant women, there is a risk of impairment of uteroplacental blood flow, uterine rupture due to the tetanic contractions, potentially a hysterectomy, meconium in the passage, fetal bradycardia, maternal shock, maternal death, adverse fetal heart changes and fetal death. 

• The effect of later growth and development of a child on which cytotec has been used has not been established. 

Case Study 1 

Madeline Oden, mother of the late Tatia Oden and founder of The Tatia Oden French Memorial Foundation writes about the dangers of using this drug and the death of her daughter and granddaughter as a result of taking cytotec. Madeline states in her article “The off-label use of Cytotec (misoprostol) to induce labor and soften the cervix is an excellent example of an unnecessary intervention that is not supported by research (Enkin et al., 2000) (see Table) yet is rapidly becoming the standard of care, despite the evidence demonstrating the catastrophic events that can occur when it is used.” 

Tatia was coerced into taking the drug without being told about its side-effects, with comments like ‘you don’t want a dead baby do you’. 10 hours after it was administered she was dead. The article discusses the fact that the manufacturer for Cytotec, Searle, did not support the use of the drug to induce labour due to its side-effects. Why do we use a drug that was created for a completely different purpose, and rely on its side effect (uterine contractions) to assist in labour without testing the impact of that drug adequately first? 

Read the full study here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684033/ 

Case Study 2 

This medscape articule https://www.medscape.com/viewarticle/458959_4 discusses the controversy around using Cytotec for induction of labour. It states that “An earlier metanalysis from the Cochrane group suggested that labor induction with misoprostol was associated with more uterine hyperstimulation with associated fetal heart changes and more frequent meconium staining than induction of labor with prostaglandin E2.” and that more recent Cochrane studies found this to still be true. There are a lot of studies comparing Cytotec to Prostanlandin or to synthetic oxyticin, but what about comparison with a placebo? Retrospective studies of women attempting VBAC compared women who took off-label cytotec with those that didn’t and found an increase in uterine ruptures (5.6%) in the cytotec group compared to non-cytotec group (0.2%). The study states that although the reasons for this remain unclear, misoprostol should not be given for induction of labor in women with a uterine scar.

In Summary 

I have no doubt that many doctors administer a drug trusting in a regulatory body to review it adequately, they trust in the system and in their hospital. Is it to be expected that doctors would research a drug and its potential side effects before agreeing to use it? Can we expect doctors to be skilled in critical thinking when researching and understand the bias of clinical testing, the required sample size and wording of a study? I don’t know. 

But I do know that I wouldn’t expect a patient to. I would not expect to have to research all the side effects and risks of a drug I am being offered because I would think the experts would know this, and inform me of this. Increasingly, women are expected to be aware of drugs and procedures offered to them because of the lack of information provided by medical professionals. 

The first rule of being a doctor is Do no harm - surely this means that all women should be informed of the risks and benefits of any drug or procedure offered to them well before labour, so that they can ask any questions they want, go away and think about it, and make an informed decision on the risks they are willing to take when in labour. This means informing women of the history around the drug Cytotec, what it was originally manufactured for, and the risks of taking it, the results from studies about it or the lack of studies performed. 

We honour patient autonomy for all other patients, let’s honour autonomy for mothers as well.

Cover Image by Steve Buissinne from Pixabay