Inductions and the use of drugs in labor and delivery

We received many comments after posting a recent blog on a woman who died a couple years ago in the US after being induced with an off-label drug during childbirth, and asked our friend, labor & delivery nurse, Jeanne Faulkner to provide more background on inductions and the usage of drugs during labor and delivery. Below is what Jeanne had to say:

Induction of labor is a controversial subject and one that deserves a lot of discussion.  There’s no doubt that unnecessary inductions are a major contributor to our ever-increasing C-section rate and a serious consideration in any examination of maternal/neonatal mortality.  There’s also no doubt though, that some women need to be induced.  They or their baby have medical conditions or pregnancy complications that make continuing the pregnancy dangerous.  Sometimes an induction is the only safe way to deliver a healthy baby to a healthy mother. The problem is too many doctors, midwives and patients sign on for inductions that aren’t medically necessary.  That’s when we see increases in tragic outcomes that are disturbing and oftentimes preventable. 

When the decision to induce has been made, here’s how that induction often proceeds: 

A successful induction starts with a ripe cervix, which feels soft, stretchy, thin, and oh-so-ready for dilation. The chances for a vaginal delivery are much lower if the cervix isn’t ready to get the labor show on the road. If her cervix is not “ripe,” it’s sometimes best to postpone the induction until Mom’s body is more prepared for birth.  If stalling the induction isn’t appropriate though, cervical ripeners like Cytotec are provided to do the labor prep work overnight that Mother Nature usually does in the last days/weeks of pregnancy. 

 Sometimes, Cytotec is so effective women go into active labor without needing IV Pitocin.  Usually, however, after one or two Cytotec doses, a mom needs Pitocin to generate strong contractions and deliver her baby.  Too often however, with or without cervical ripeners, induced labors don’t progress adequately and Mom gets a C-section.  Her cervix simply wasn’t ready to dilate. 

Very rarely, drugs used to induce labor can cause severe contractions that can cause maternal and fetal distress. Even more rarely, they have been associated with uterine rupture and death. That almost never happens because when a woman has too many contractions, we don’t give more Cytotec or start Pitocin until things are under control. If necessary, we stop contractions with a fast-acting medication called Terbutaline.  If we’re seriously worried about any mother, we go to the OR. 

There are other cervical ripeners, like Cervidil and Prepadil, but Cytotec is easier to use, cheaper (pennies compared to hundreds of dollars) and both more convenient and more effective.

There’s a lot of concern that the FDA doesn’t specifically approve Cytotec, (which is used “off label,”) for induction. Desiree Bley MD, an obstetrician in Portland, OR says, “There aren’t any drugs FDA-approved for obstetric use. You can’t test anything on pregnant women so everything is off label.” (Off-label drug use is legal in the United States and very common). 

It’s a tragedy that too many women are induced unnecessarily. Susan Thomforde, CNM who delivers at North Shore Birth Center in Massachusetts, says, “It’s important to use any medication judiciously and only induce women with a compelling medical reason to do so.”

All medical interventions involve risk, but refusing interventions can be risky too. Doctors and midwives take these risks very seriously, as should patients. Unfortunately, even with excellent medical care, some patients react badly to some interventions.  Some practitioners fail to practice safely.  It’s a tragic and disturbing reality that sometimes, mothers die and it’s devastating every time.  And not a single one of these deaths is acceptable. That’s why conversations and research about medical interventions used on pregnant mothers are of the utmost importance. Until all mothers can deliver safely, we must strive to do better.

If your doctor recommends induction, ask questions.  Weigh the risks versus benefits.  If there’s no good reason, don’t do it.  If you’re worried about using any medication, including Cytotec, ask your provider to prescribe something you’re more comfortable with.  But, if your health factors indicate you need to deliver sooner than later, rest assured that induction, if medically necessary, is a trusted effective option. As with all things to do with your health, it’s just important to know the facts and take an active part in making that decision with your health provider. 

-Jeanne  

About Jeanne Faulkner

Jeanne is a writer, health journalist, blogger and registered nurse.  She’s FitPregnancy.com’s “Ask The Labor Nurse” blogger and contributes regularly to Fit Pregnancy magazine.  She also writes about health, wellness, global poverty, fitness, women’s lifestyle issues and parenting for many websites and magazines.  Her big passion is global women’s health so she’s active with CARE, the humanitarian organization, as their state representative for Oregon.  Jeanne lives in Portland, OR with her family and dogs in a big old house.  Her website is: www.jeannefaulkner.com.

--

For further reading on inductions and drug use in labor and delivery:

Childbirth Connection: Induction of Labor

The American College of Obstetricians and Gynecologists: ACOG Issues Revision of Labor Induction Guidelines

The American College of Nurse-Midwives' Position Statement: Induction of Labor