Monday, December 27, 2004

Cytotechnically speaking

Usually during my second prenatal meeting with a doula client I give them Ina May Gaskin’s article from Mothering magazine on Cytotec. I do so hesitantly, because I do not think pregnant women should read scary birth stories. Yet I believe a doula’s role is to educate parents. The Gaskin article lays out fully all the information parents are not likely to get from the hospital staff.

If you aren’t familiar with Cytotec (generic name Misoprostol), it is an ulcer medication. Its packaging carries strong and extensive warnings against pregnant women’s using it because it can cause premature labor, abortion and miscarriage. It is used to induce labor, especially in women whose cervices are not ripe (i.e. not very thinned or dilated).

From the warning label (page 8):

"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 with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism. Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia, and fetal and maternal death have been reported.

"There may be an increased risk of uterine tachysystole, 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 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."

As Ina May reports in her article and I have observed with several clients, Cytotec is administered by breaking a single pill into smaller parts. One or more of these parts (exact dose unknown) is vaginally inserted into the cervix. After some amount of time (I think it was four hours for my one client), they check dilation and labor pattern and, if necessary, administer another portion of the pill. This continues until the client is in active labor.

Patients are not told that the drug is being used off label. Nor are they told that there are no official studies of the drug as a labor inducer. For a recent example, read what the CBS Evening News broadcast a few weeks ago.

I had given the Ina May article to a client of mine a few weeks before her water broke at 37 weeks. When she arrived at the hospital, several hours later, not contracting, the resident checked her and said she was fingertip dilated and 20% effaced. He said the usual business about risk to the baby from her being ruptured and the need to move labor along. He said “because your cervix is still so thick and closed, we’re going to put a pill inside you to help get labor going.”

She asked “what is the pill called?” He said “Misoprostol.” She said, “Isn’t that the same thing as Cytotec?” He said, “No, I don’t think so. They are similar, from the same family of drugs…well, wait, let me think…Oh, yes, they are the same.” But, he immediately went on to say, it’s very safe and the best thing really when “your cervix is saying ‘I don’t want to do this.’”

The mother asked to speak with HER doctor, who essentially said the same thing. She said the drug is controversial because it is an ulcer drug being used for labor, but that it’s the best thing when “you’re just not ready to have a baby.”

Obviously there were other issues with this particular labor and the messages my client received, but related to Cytotec what I noticed was the complete unwillingness of the doctors to discuss any potential harms that could come from using it. They did not want to say it hadn’t been tested or that women had died from uterine rupture while on it.

In Ina May’s article she discusses some of the reasons physicians and nurse-midwifes like the drug. It is very efficient at moving an unripe cervix along. And in fairness, the labors I’ve been at where it was used, it was precisely to initiate labor in a woman whose body seemed caught off guard by labor’s arrival.

What I cannot understand and cannot abide, however, is its use without any comprehensive documentation of its affects. Doctors will review 19,000 women to see if VBACs are safe, but they won’t keep records on what happens to women on Cytotec.

When we terminated my first pregnancy, they induced labor at 20 weeks gestation using prostaglandin suppositories. It was around 12 hours from the administration of the first suppository and delivery. My cervix was completely closed and thick when they started. If they can get these results from a tested and documented chemical, why dabble with unregulated others?


Anonymous Lisa ( said...

I read the same article and gave birth to my first baby in the car!

6:37 PM  
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