Induction of Labor: The Misoprostol Controversy

Conclusion

Where does this leave us when faced with a woman with no prior cesareans who requires induction of labor with an unfavorable cervix? First, we are obligated to question whether induction of labor, with any agent, is absolutely necessary. The risks of induction must be carefully weighed against the risks of allowing the pregnancy to continue and not inducing labor. If induction of labor is required, we are obligated to inform patients that induction of labor with any agent and an unfavorable cervix is not risk-free, especially in nulliparous patients.^[40] Women requiring induction of labor with unfavorable cervices have higher rates of cesarean delivery than women who enter labor spontaneously and women who begin their labor induction with favorable cervices.^[41] Cervical ripening with prostaglandins shortens the duration of labor and increases the likelihood of vaginal delivery compared to induction with oxytocin alone.^[6,42] Based on absolute numbers, significant morbidity or mortality is extremely rare from induction of labor at term, and all prostaglandin preparations currently in our armamentarium are safe if used properly. Nonetheless, amidst controversy, measures should be taken to minimize risk ( Table 1 ).^[31]

The relative risk of major complications from the use of misoprostol to induce labor, when used as currently recommended by the American College of Obstetricians and Gynecologists, compared with other prostaglandin preparations used in similar patient populations is unknown. Compared with other prostaglandin preparations, misoprostol in low doses is at least equivalent, if not more effective at inducing vaginal delivery and it is much less expensive. Generally, when two medications are equivalent and one is less expensive, it is cost-effective to use the less-costly agent. Which prostaglandin preparation offers the best overall risk-cost-benefit profile remains to be determined.

Funding information

Partial salary support for Alisa Goldberg, MD, MPH, is from the Women's Reproductive Health Research Scholars Program, National Institutes of Health #K12 HD01262.

Reprint Address

Dr. Alisa B. Goldberg, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, 75 Francis Street, PB-5-506, Boston, MA, USA 02115.

Cite this: Induction of Labor: The Misoprostol Controversy - Medscape - Jul 01, 2003.

Table 1. Table 1. Guidelines for Minimizing Risk When Using Misoprostol for Induction of Labor
1. Use a standardized, hospital-based, or institution-based approach, which includes the following:
a. Appropriate indications for use
b. Clear definitions of patients who should be excluded from use ACOG committee opinion states that misoprostol should not be used for patients with a previous cesarean delivery or uterine scar and that there are insufficient data on safety for use in women with multiple gestations or suspected fetal macrosomia.^[3]
c. An evidence-based dosing regimen ACOG committee opinion recommends 25 µg of vaginal misoprostol administered not more frequently than every 3-6 hours.^[3]
d. Criteria for repeated misoprostol doses and maximum allowable number of doses
e. A minimum 4-hour waiting period between the last misoprostol dose and the initiation of oxytocin, if necessary^[3]
f. Continuous fetal heart rate and uterine contractility monitoring
g. Management options for uterine hyperstimulation and fetal heart rate abnormalities
h. Criteria for physician consultation and referral
2. Obtain and document informed consent from the patient.
3. Use a standard approach to pill preparation.
4. Monitor outcomes of women receiving misoprostol in comparison with women receiving other uterotonic agents at your institution.

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Induction of Labor: The Misoprostol Controversy

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