Sunday, August 30, 2009


Ok....another rant guys.

Is it too much to friggin' ask that staff not go in and out of rooms without knocking and/or identifying themselves...especially during a delivery. I was in a delivery early this morning. The woman was pushing, she's muslim and very private. In ten minutes time, while she was pushing, 4....yes 4 staff members walked in and out of the room for various reasons. I was livid!!!!!

After the delivery was over I went to the charge nurse and raised hell....she was one of the guilty ones to have walked in that room. She apologized and promised that that issue would get addressed. I told her this happened many times before. It's very distracting when women are going sometimes interrupts their 'zone'. But even simpler, it's basic common courtesy. Knock, wait for an answer, stayt behind the curtain and say what you need. It's not that hard!

Saturday, August 29, 2009

Pages received

I have had a quiet call so far other than my pager having a touch of's what that looks like!

8:30pm - I have dizziness and heart palpitations, 1st trimester, started a new blood pressure med this past week. Oh and very anemic.

10pm - I have a cold, what can I take?

10:30pm - I'm having urinary symptoms, can I take these antibiotics from over a year ago

6:30am - had sex, now spotting and cramping

9:30am - I'm throwing up, having SOB, pelvic pain and pressure, low back pain (this one has called and been to triage more times than I can count)

10am - triage - needing orders for someone with midepigastric pain, pelvic pressure, and low back pain

10:45am - triage - needing orders for the pt that called at 9:30am

1115am - triage - more orders and report on one of the previous patients

1200 - triage - more orders and report on the other lady

Friday, August 28, 2009

ACOG gradually getting with the evidence

ACOG released a new comittee opinion on oral intake during can check it out here. It's really nice to see that ACOG is gradually catching up with the evidence. They must be behind on their journal reading like I am :p

Midwives have long encouraged women to eat and drink to comfort during labor. However, hospitals and ob/gyns enforced a policy of no food and only ice chips. The concern being that if a woman had to have an emergency section, she could aspirate the contents of her stomach, causing aspiration pnuemonia, which is no joke.

ACOG now 'gives permission' for women to have 'moderate' amounts of clear fluids during labor. Wow. That's pretty frickin' generous of them! They are so kind and benevolent. :pppp

So I'd like to make a couple points...

1. When women are 'allowed' only water and ice chips, the contents of their stomachs become more if they were to aspirate these contents, this would only increase the damage and severity (imagine pouring acid into your lungs).

2. Simple carbs are often beneficial to women in providing energy for labor.

3. The article states that N&V is quite common in women in labor so therefore women won't want to eat. In my experience, rarely do I see pukers! Now granted, many women in labor do not want to eat once they get pretty active. But that's not the point! The point is that women should have that choice.

4. The concern of aspiration is pertinent when general anesthesia is used. I can count on one hand how many time in 6 years I have seen general anesthesia used. It's not common. Bad for baby. So the risk of aspirating is minimal (can't quote a percentage here off the top of my head but have read research on this).

Highlights and bummers from the office

I followed up with a new patient who had come to me for midwifery care, even though she had a history of 4 sections and would have to have one with this baby. Unfortunately she miscarried :(

I followed up with another lady who also miscarried. I had just caught her last baby in April and was very much looking forward to spending another pregnancy with her :(

"Drink more water"

I saw a 16-year-old, who is pregnant. She informed me that she only wanted to see me and hoped that I would be at her birth. Aw shucks :)

I saw a patient who disappeared for 6 weeks during her third trimester. It was nice to re-connect with her...she's such a sweetie.

I'm seeing a primip who is absolutely adorable. We discussed her birth plan.

"Drink more water"

Wednesday, August 26, 2009

Vaginal Exams

I was on call recently and had a woman attempting a VBAC. She had gotten an epidural and so I went to lie down for a bit. I slept almost two hours then got up to go check on her and my other patient. In a three hour period, my patient had been checked 6....yes, 6 times by the nurse! And she was ruptured! I asked the nurse why she felt the need to check the patient 6 times in a three hour period and she told me she did it because the patient would ask! Give me a break! It's her first baby won't fall out (and if it does - great, that's the point!). We were assured of her progress. There was nothing on the strip indicating the need for a vaginal exam. Are you fer real????

I rarely ever do that many vaginal exams in a woman's entire labor!!!!

There is research that shows after the fifth exam (one membranes are ruptured), a dramatic increase in the risk of infection. So keep your damn fingers out of there please!

Some nurses are really good about this but others drive me nuts. I have written as an order, no vaginal exams without checking with me first. I just can't always rely on the nurses' judgement as to when a vag exam might be appropriate. Really, some of these nurses have been doing this as long as I have been alive. You really ought to be able to look at a patient and tell a lot about where she's at based on how she behaves, what she says, etc. If the patient is smiling and laughing during a contraction and is ruptured...I don't care if she's a grand's not likely to fall out - don't check her!

I was always taught that you should only do a vag exam if it will change your managment. I try very hard to stick to that, I think it's a great rule!

Monday, August 24, 2009

One of those spells

Hmm, I'm on the third day of a three day weekend and I'm having one of those spells.

For those of you not in the know yet, I have some autoimmune issues...not RA so don't ask. Mostly I just experience wandering joint pain and fatigue. You know, not all joint pains that wander are lost. Haha. I wish they would get lost.

Anyhoo, I take medicine for these Tolkien joint pains and fatigue. One I call poison - methotrexate. The other is a nice little shot in the belly couple times a month. These meds help a great deal. I shouldn't complain because I can remember the time before being diagnosed, when I couldn't turn a doorknob to get out of my bedroom in the moring, due to so much pain in my wrists.

But I digress...

The spells consist of low grade temps, generalized achiness and malaise. That's it, nothing else. Because I am considered immunosupressed one might think that these are signs of infection. A couple times they were - UTIs. Most of the time, no other symptoms. I have even had bloodwork done during a particularly tenacious spell (lasted two weeks on and off!!!!!) and it was ok. They normally last 2-3 days then go away just like that. They occur randomly...the last spell was a couple months ago. But then I might have two in a month. Very random.

So, thoughts anyone?

And I quit my old rhuem so manybe now is a good time to find a new one and set up an appointment eh?

Saturday, August 22, 2009

So I thought... last call was crazy. Wrong! My most recent call was absolutely stunning in terms of craziness! And it was only twelve hours...

I had to catch a fetal demise :( That was the start of my day.

Then I had another patient who was on mag for preeclampsia and on pitocin as well. She had to push for about an hour and a half but delivered a cute little baby over an intact perineum (with some asynclitic molding - no surprise because the baby was not that big and should have come a lot easier than it did).

Then I had a lady doing natural childbirth. She came in smiling at 7-8 cms. Her first two babies came really fast, especially once her water broke. So we broke her water and anticipated a baby really soon. Noooooo.....she delivered four hours later! I finally convinced her to try the tub and that's all it took!

Then I had taken over the doctor's primip that had been laboring all day naturally. As I took over, she was getting an epidural. I asked the nurse why she didn't try the tub when she was talking about how tense the patient was. She looked surprised and kinda stumbled over her answer. *sigh* It's a shame when women who want natural childbirth see the docs....unless they get lucky and get one of the nurses who are really supportive of that, they get no labor support. Anyway, the patient was kinda stuck at 8cms from what I had gathered so we put her on her side and put the peanut between her legs. The peanut looks really ridiculous but works everytime. It's just one of those tried and true tricks, like the tub. I re-check her and she's complete and feeling pressure. She pushes for twenty minutes and pops out this adorable 8 pound little girl over a few skidmarks! Pretty darn impressive for a first-timer :)

And I did all this while not feeling good :p Nothing like birth though to cheer a girl up.

Slack Nursing Care

Ok, I'm sure I have ranted before about this topic...but it's boiling up again so here goes...

1. If a patient is there for pitocin for an induction - you have to turn the pitocin up from time to time. There's every reason to believe that if you would just increase the pitocin in a timely fashion, the patient would deliver before I go off call. That's what both myself and the patient want. But becuase the nurse doesn't want a delivery, because she's the f*cking laziest nurse I have ever met....not to mention scary and totally clueless, an hour and half will go by before she increases the pitocin. And I looked at the strip during that time....contractions were spaced out, baby looked reason not turn the damn pit up. The goal is to have a baby. But apparently just not on her shift.

2. The patient is there for induction due to preeclampsia, on mag. She had a foley bulb in through the night and pitocin started early in the morning. The day shift nurse checks her at 7:30am when the foley bulb falls out and her water breaks (the patients' not the nurse). I sit down to chart on the patient at 10:00 am. I look at vital signs....last temp was done at 9pm the night before! Uh hello, temp for baseline when her water breaks and then every two hours thereafter is the policy I believe?????

3. Pericare - if a woman is sitting in sh*t when she's pushing, do you think you might wanna clean it off from time to time? Or a puddle of fluid and blood-tinged mucusy stuff...maybe clean it up before I come in the room and start doing it myself? Hey nurse, if you were the patient, would you want to sit in that stuff for hours? If this was your family member, would you be ok with that? Clean the sh*t up then please...(literally)

4. So there's this sheet in the chart that says physician orders (I know, it irks me to, wish it said provider orders or something). It doesn't say physician suggestions. Orders. That means you have to read them and follow them. What a concept. If a provider orders labs for a certain time, maybe instead of just noting the orders off, you should read them first so as to not miss important information like mag levels and PIH labs. Hmmm...

I swear, I have to come in and be the nurse as well as the midwife. And please don't get me wrong, I like to help out but dayyyyummmm. Could you just do your job.

I used to think that it was because I am a CNM that some nurses felt like I would handle those things. I remember a nurse (lazy a$$ nurse mentioned in #1) telling me "oh I love midwife patients because then I don't have to do anything". Uh no. You still have to do your job.

Your job = basic nursing care
My job = labor support and management
You doing your job = priceless

But I really think that some of these nurses provide just as crappy care to doctor patients.

Wednesday, August 19, 2009

The latest call

My most recent call was crazeee buzeee boy-a!

I laborsat for 9 hours (see this post and this post). We finally got to see a baby late afternoon. The problem? The baby persistently stayed LOT. We did lots of positions, tub, walking, etc. Just a very slow labor (she was 5cms when I arrived to take over from the off-going midwife). Finally, hands and knees worked - the baby went to LOA and was out after 30 minutes of pushing. This first-time momma did it with no pain meds, epidural, or a drop of pitocin (I'm kinda proud of myself for not being tempted to jump on some pitocin). The only intervention was AROM.

Then I went home....

Then I went back to the hospital, where all hell was breaking loose! The entire L&D was crammed full with three women having to labor in triage. Oh that's sucky! One of those ladies was mine. So she got a spinal and then had a baby (please don't ask about the spinal). It wasn't too bad other than the baby had to go to the nursery because there are no warmers in triage. I mean, god forbid we just put the baby skin to skin. But frankly, I think this momma was ok with getting a chance to sleep for a little bit, she was exhausted and she didn't want to breastfeed :(

Then I was asked by the doc on call (Dr I-Don't-Like-To-Get-Out-of-Bed-For-Anything) to go evaluate his patient in labor who was having some issues - like prolonged ROM, failure to progress kinda issues. Suuuurrrreeee, when I asked him one time about whether I ought to mag a pretermer or not I get "You need to come up here and evaluate your own patient and then give me a report". But now that it's 2am and you don't want to get out of bed, it's ok for me to evaluate your patient. :ppppppp So I hang around to first assist on a couple sections.

Home and asleep about 5:30am. Lovely.

Show some intelligence!

Scenario: I'm sitting at the drive through at the pharmacy with my son. I just need to drop off his prescritpion and don't need to pick it up for a couple days. There's a lady in the other lane, who was there first.

Plot: The lady in the next lane has a couple different prescriptions she is picking up and has insurance issues she is discussing with the pharm tech. She puts me on hold when I hit the call button without asking me whether I am dropping off or picking up. I sit patiently for about two seconds (keep in mind I was up all night and have had a couple hours of sleep this morning). I actually sat there for about 5 minutes when I hit the call button again. Before the tech can hang up after telling me to wait, I ask her to send the stupid thingy so I can just drop my Rx and go. She says "I'm not by the thingy, but am by the pharmacist. When I go back over there, I will send it." A few seconds later she walks over there and sends the thingy. I put my Rx in it and take off (it has everything she will need to process it already written on it).

C'mon, would it have been so damn hard to send me the stupid thingy when i first pulled up?????

Ok, so maybe I'm a little crabby. So sue me.

Tuesday, August 18, 2009

Making a move?

She might be making a move. She's starting to say she can't do it. She doesn't want to be touched so just hanging out. It's hard because the nurse and I are the only female support she has. Otherwise it's her husband. Although he does whatever I tell him :)

Is it bad?

Is it bad of me that I wish a patient would get an epidural? First baby and labor progressing very slow. I am tired after doing labor support for 6 hours now. I just want a nap. Although even if she got an epidural, I would then have to go see patients in the office. So no rest for the weary either way. In the meantime, will continue supporting her and maybe get some coffee (she's in the tub right now, which is why I am blogging right now).

There's a patient in triage for foot pain. A pregnant women with foot pain. No OB related complaints. Just twisted her ankle. That's all. C'mon ER, get over this phobia about pregnant women. The baby could be halfway out and they would run the patient up here willy-nilly, in their effort to avoid catching a baby.

*sigh* I'm bored and tired. And I feel kinda guilty that I feel that way.

Saturday, August 15, 2009

Things to NOT say...

Things to not say to a pregnant woman...

1. Honey, you are getting so big!
2. When you wear that black dress, it reminds me of a black hole.
3. Healthcare provider upon first pelvic exam - "Wow. I've never seen anything quite like that."
4. HCP at first exam, 6 weeks pregnant - "Well that sure isn't coming out of there!"
5. Wow, you must be having twins....said to the woman with a singleton.

Things to not say to a laboring woman...

1. C,mon babe, it's not that bad!
2. It's like mentrual cramps.
3. It gets worse than this!
4. Don't you want jusst a little pain medicine?

Things to Not say to a birthing woman or right after birth...

1. OMG, that's coming out of there???
2. Honey, I'll never look at your vajayjay the same.
3. HCP - "oops" - not appropriate at any time.
4. Can you throw in an extra stitch or two doc? Guess who will never get a chance to try it out?
5. Honey, I can't wait to have 3 or 4 ore of these.

Things not to say postpartum...

6 months postpartum..."Oh when are you due?"

Tuesday, August 11, 2009

Pull Over

I was on my way home late last night when I was pulled over for turning right on a red (where there's a sign that says not to do that). I was on call, and hanging out at a friend's house all evening. I was in my pajamas though. I wasn't anticipating anyone but my friend seeing my pajamas. My mistake!

Fortunately, the officer was very kind and I was easily able to work the fact that I was a midwife and on call into the convo. Turns out his wife is pregnant and has a midwife alos. Cool!

So, he very nicely just gave me a warning :)

Sunday, August 9, 2009

School tomorrow

The kids start school tomorrow...I'm sad and relieved at the same time. It's sad to have the summer ending and spending extra time with them. But it's also a relief to be able to have some more downtime and not feel like an entertainment director.

I took them for haircuts yesterday. I have all the school supplies ($66 worth) and am working on getting everything labeled and sorted into appropriate backpacks. Fun :p

I'm also enjoying this weekend off. I have been a bit run down from all the call this past week (another midwife is on call) and I seem to have been a bit of a baby magnet! I have been catching up on blogging as you can probably see. Been working on some projects, etc. And reading and watching movies and swimming. Very nice.

Guidelines on Labor Induction From Medscape

July 24, 2009 — On July 21, the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines on when and how to induce labor in pregnant women. The updated recommendations are published as a Practice Bulletin, "Induction of Labor," in the August issue of Obstetrics & Gynecology. The bulletin aims to guide physicians regarding their choice of induction methods that may be most suitable in specific settings and to elucidate the safety requirements, risks, and benefits of various regimens to induce labor.

Benefits vs Risks of Labor Induction
For the last 2 decades, the rate of labor induction in the United States has more than doubled, with more than 22% of all pregnant women in 2006 having labor induced. This increase in use necessitates a careful review of indications, risks, and benefits.
The goal of labor induction is to stimulate uterine contractions before the spontaneous onset of labor, resulting in vaginal delivery. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. When the benefits of expeditious delivery are greater than the risks of continuing the pregnancy, inducing labor can be justified as a therapeutic intervention.

"There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut," coauthor Susan Ramin, MD, from the University of Texas Medical School in Houston, said in a news release. "And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home."

Recommendations Based on Sound Evidence
Based on evidence from methodologically sound outcomes-based research, the bulletin attempts to review current methods for cervical ripening and for inducing labor and to summarize the efficacy of these approaches. Also highlighted are indications for and contraindications to inducting labor, pharmacologic characteristics of various agents used for cervical ripening, regimens used for labor induction, and the requirements for safe clinical use of these techniques.
The bulletin authors searched the MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents to identify pertinent English-language articles published between January 1985 and January 2009. Although articles reporting results of original research were given priority, review articles and commentaries were also consulted, as were guidelines published by organizations or institutions such as ACOG and the National Institutes of Health. However, abstracts of research presented at symposia and scientific conferences were excluded. Expert opinions from obstetrician-gynecologists were used when reliable research evidence was not available.

Indications for Labor Induction
Possible indications for labor induction may include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy. However, physicians should decide whether labor induction is warranted on a case-by-case basis, after consideration of maternal and infant conditions, cervical status, gestational age, and other factors.

Contraindications to labor induction include transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and a history of previous myomectomy.
When labor induction is deemed necessary, the gestational age of the fetus should be determined to be at least 39 weeks, or there must be evidence of fetal lung maturity.
The first step in labor induction is cervical ripening using drugs or mechanical cervical dilators to dilate the cervix sufficiently before labor is induced. The next step is to induce labor using oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation.
Misoprostol, which is approved for treatment of peptic ulcers, is often used off-label for cervical ripening as well as for labor induction. In women who have had any previous cesarean delivery, however, inducing labor with misoprostol may increase risk for uterine rupture and should therefore be avoided.

Clinical Recommendations

Specific clinical recommendations and conclusions, all based on good and consistent scientific evidence (level A), are as follows:

  • For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.
  • When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.
  • Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.
  • For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.
  • For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.
  • In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.
  • The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.
  • An additional clinical recommendation, based on limited or inconsistent evidence (level B), is that misoprostol, 50 µg every 6 hours, to induce labor may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.

"A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," Dr. Ramin concluded. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."

Obstet Gynecol. 2009;114:386-397.

Clinical Context
Labor induction occurs in more than 22% of pregnant women in the United States and has doubled in rate between 1990 and 2006, according to Martin and colleagues in the January 7, 2009, issue of National Vital Statistics Reports. Cervical ripening methods include mechanical dilation, synthetic PGE1, and PGE2. Mechanical dilation methods are hygroscopic dilators, osmotic dilators, Foley catheters, double-balloon devices, and extra-amniotic saline infusion. The PGE1 analogue, misoprostol, can be used for cervical ripening and labor induction. PGE2 is available as dinoprostone gel or as a vaginal insert. Methods of labor induction include oxytocin, membrane stripping, amniotomy, and nipple stimulation.
This guideline from the ACOG describes the indications for and contraindications to labor induction, methods for cervical ripening, methods for labor induction, and recommendations for use of these methods.

Study Highlights
Indications for labor induction include abruptio placentae, chorioamnionitis, fetal demise, gestational hypertension, preeclampsia, eclampsia, premature rupture of membranes, postterm pregnancy, maternal medical conditions, and fetal compromise.
Labor might be induced for logistic reasons if term gestation is confirmed.
Contraindications to labor induction include vasa previa or complete placenta previa, transverse fetal lie, umbilical cord prolapsed, previous classic cesarean delivery, active genital herpes infection, and previous myomectomy entering the endometrial cavity.
Criteria for cervical ripening or labor induction are assessment of gestational age and risk to mother or fetus; assessment of cervix, pelvis, fetal size, and presentation; FHR and uterine contraction monitoring; patient counseling; and capability for cesarean delivery.
PGE analogues are effective methods for cervical ripening and inducing labor.
An effective alternative for cervical ripening and inducing labor is a Foley catheter, which reduces the duration of labor and risk for cesarean delivery.
Misoprostol initial dose is 25 µg every 3 to 6 hours intravaginally.
Misoprostol doses of 50 µg every 6 hours might be indicated but are linked with the risk for uterine tachysystole with FHR decelerations.
Buccal and sublingual misoprostol for cervical ripening or labor induction are not recommended because of lack of safety data.
Misoprostol should be avoided in the third trimester in women with prior cesarean delivery or major uterine surgery because of an increased risk for uterine rupture.
Dinoprostone can be administered intracervically or intravaginally.
Uterine tachysystole with or without FHR changes occur more commonly with vaginal misoprostol vs vaginal or intracervical PGE2 and oxytocin.
The management of uterine tachysystole and category III FHR tracing includes maternal repositioning, supplemental oxygen, subcutaneous terbutaline, and decrease or discontinuation of oxytocin.
Cesarean delivery might be necessary for persistent tachysystole or FHR abnormalities.
After PGE use, surveillance should include initial continuous FHR and uterine activity monitoring and recumbent position for the pregnant patient.
Limited data show that outpatient use of intravaginal PGE2 gel for 5 days, controlled-release PGE2, and a Foley catheter appear to be effective and safe.
Oxytocin for labor induction can be given as low dose (initial 0.5 - 2 mU/minute with incremental increases of 1 - 2 mU/minute) or high dose (initial 6 mU/minute with increases of 3 - 6 mU/minute).
The maximal oxytocin dose is unknown.
The main adverse effects of oxytocin are dose-related uterine tachysystole and category II or category III FHR tracings.
The risks for amniotomy are umbilical cord prolapse, chorioamnionitis, umbilical cord compression, vasa previa rupture, and the risk for vertical transmission of HIV.
Amniotic membrane stripping risks include bleeding from placenta previa or low-lying placenta and amniotomy.
Breast stimulation is linked with uterine tachysystole with FHR decelerations and increased trend in perinatal death.
In women with premature rupture of membranes at term, labor can be induced with oxytocin or PGE, but there are insufficient data on mechanical dilator use.
Management of intrauterine fetal demise depends on gestational age, uterine scar, and maternal preference.
For intrauterine fetal demise in the second trimester, dilation and evacuation is an option.
For intrauterine demise before 28 weeks' gestational age, misoprostol is the most efficient method; high-dose oxytocin is also an option.
Clinical Implications
In pregnant women who require cervical ripening and labor induction, PGE analogues are effective, and the Foley catheter is an effective alternative. Labor can be induced with low-dose or high-dose oxytoxin regimens.
For intrauterine fetal demise before 28 weeks of gestation, the most efficient method of labor induction is vaginal misoprostol. Misoprostol use should be avoided in the third trimester in women with previous cesarean delivery or major uterine surgery because of a link with an increased risk for uterine rupture.


There's been some discussion and concern about my use of cytotec for an induction so just wanted to share some research about cytotec. Here are abstracts with references. Enjoy!

1. Abstract
Misoprostol (Cytotec) is safe and effective for induction of labor, although it is not approved by the Food and Drug Administration (FDA) for use in pregnancy. In August 2000, the manufacturer of misoprostol warned against its use in pregnancy because of its abortifacient properties and cited reports of maternal and fetal deaths when misoprostol was used to induce labor, fueling the misoprostol controversy. More than 45 randomized trials including more than 5400 women have found vaginal misoprostol to be more effective than oxytocin or vaginal prostaglandin E2 at effecting vaginal delivery within 24 hours. Cesarean delivery rates with vaginal misoprostol are lower than with oxytocin alone, but similar to prostaglandin E2. There have been no significant differences in the frequency of serious adverse maternal or neonatal outcomes with low-dose misoprostol compared with oxytocin or prostaglandin E2; however, the relative risk of rare adverse outcomes with misoprostol is unknown. The data suggest that absolute risks are low when misoprostol is used appropriately. We recommend 25 mcg vaginally every 4 to 6 hours for carefully selected patients in closely monitored settings. Whether misoprostol will prove to be the most cost-effective agent for inducing labor in women with an unfavorable cervix remains to be determined.

Induction of labor: the misoprostol controversy Alisa B. Goldberg, Deborah A. Wing Journal of Midwifery & Women's Health July 2003 (Vol. 48, Issue 4, Pages 244-248)

2. Misoprostol - a stable prostaglandin E1 analogue- is effective and safe in the induction of labour. There is paucity of information about the use of misoprostol for labour induction in Nigeria. OBJECTIVE: To evaluate the efficacy of misoprostol in the induction of labour in the third trimester. METHODS. Consecutive patients for induction of labour were randomized into misoprostol or oxytocin study groups. The misoprostol group received intravaginal 50 microg 6- hourly to a maximum of four doses. Those in the oxytocin group received a maximum of 48 iu/min. Outcome measures included induction-delivery interval, mode of delivery, Apgar score, perinatal death and maternal complications. RESULTS: Sixty-two patients were recruited into the study-34 received misoprostol while 28 received oxytocin. The modal gestational age and Bishop score prior at induction were >36 weeks and 5-7 respectively. Hypertension in pregnancy was the commonest indication for induction of labour followed by prolonged pregnancy. The overall induction-delivery interval was 12.2 +/- 5.2 hours; Misoprostol v oxytocin, mean(range): 12.1(7-27) vs 12.3(4-27) hours, p = 0.88). There were no significant differences in the mean Apgar score and perinatal mortality rate in the two study groups. There were two cases of primary postpartum haemorrhage in the oxytocin group but none in the misoprostol group. One case of ruptured uterus was encountered in the misoprostol group. No case of maternal mortality was recorded. Four patients in the misoprostol group had minor side effects mainly nausea and vomiting. CONCLUSION: The efficacy of misoprostol in the induction of third trimester labour is comparable to oxytocin. The risk of ruptured uterus associated with misoprostol appears higher than that of oxytocin in the induction of labour. Further studies are needed to verify this observation in our setting.

Efficacy and safety of misoprostol in induction of labour in a Nigerian tertiary hospital.
Abdul MA, Ibrahim UN, Yusuf MD, Musa H.
West Afr J Med. 2007 Jul-Sep;26(3):213-6.

3. BACKGROUND: Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue marketed for use in the prevention and treatment of peptic ulcer disease. It is inexpensive, easily stored at room temperature and has few systemic side effects. It is rapidly absorbed orally and vaginally. Although not registered for such use, misoprostol has been widely used for obstetric and gynaecological indications, such as induction of abortion and of labour. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. OBJECTIVES: To determine the effects of vaginal misoprostol for third trimester cervical ripening or induction of labour. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register (October 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002) and bibliographies of relevant papers. SELECTION CRITERIA: The criteria for inclusion included the following: (1) clinical trials comparing vaginal misoprostol used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS: A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. To avoid duplication of data in the primary reviews, the labour induction methods have been listed in a specific order, from one to 25. Each primary review includes comparisons between one of the methods (from two to 25) with only those methods above it on the list. MAIN RESULTS: Sixty-two trials have been included. Compared to placebo, misoprostol was associated with increased cervical ripening (relative risk of unfavourable or unchanged cervix after 12 to 24 hours with misoprostol 0.09, 95% confidence interval (CI) 0.03 to 0.24). It was also associated with reduced failure to achieve vaginal delivery within 24 hours (relative risk (RR) 0.36, 95% CI 0.19 to 0.68). Uterine hyperstimulation, without fetal heart rate changes, was increased (RR 11.7 95% CI 2.78 to 49). Compared with vaginal prostaglandin E2, intracervical prostaglandin E2 and oxytocin, vaginal misoprostol labour induction was associated with less epidural analgesia use, fewer failures to achieve vaginal delivery within 24 hours and more uterine hyperstimulation. Compared with vaginal or intracervical prostaglandin E2, oxytocin augmentation was less common, with misoprostol and meconium-stained liquor more common. Compared with intracervical prostaglandin E2, unchanged or unfavourable cervix after 12 to 24 hours was less common with misoprostol. Lower doses of misoprostol compared to higher doses were associated with more need for oxytocin augmentation, less uterine hyperstimulation, with and without fetal heart rate changes, and a non-significant trend to fewer admissions to neonatal intensive care unit. Use of a gel preparation of misoprostol versus tablet was associated with less hyperstimulation and more use of oxytocin and epidural analgesia. Information on women's views is conspicuously lacking. REVIEWER'S CONCLUSIONS: Vaginal misoprostol appears to be more effective than conventional methods of cervical ripening and labour induction. The apparent increase in uterine hyperstimulation is of concern. Doses not exceeding 25 mcg four-hourly of concern. Doses not exceeding 25 mcg four-hourly appeared to have similar effectiveness and risk of uterine hyperstimulation to conventional labour inducing methods.The studies reviewed were not large enough to exclude the possibility of rare but serious adverse events, particularly uterine rupture, which has been reported anecdotally following misoprostol use in women with and without previous caesarean section. The authors request information on cases of uterine rupture known to readers. Further research is needed to establish the ideal route of administration and dosage, and safety. Professional and governmental bodies should agree guidelines for the use of misoprostol, based on the best available evidence and local circumstances.

Cochrane Database 2003

4. OBJECTIVE: Our purpose was to compare vaginally administered misoprostol (Cytotec) with intravenous oxytocin for labor induction in women with premature rupture of membranes beyond 36 weeks' gestation. STUDY DESIGN: Two hundred subjects with rupture of membranes without labor were randomly assigned to receive vaginally administered misoprostol or intravenous oxytocin. Twenty-five micrograms of misoprostol (Cytotec) was placed in the posterior vaginal fornix. If cervical ripening (Bishop score of > or = 8 or cervical dilatation of > or = 3 cm) or active labor did not occur, a single repeat dose of misoprostol was given 6 hours later. Oxytocin was administered intravenously by a standardized incremental infusion protocol to a maximum dose of 22 mU per minute. RESULTS: Of the 197 subjects evaluated, 98 received misoprostol and 99 oxytocin. The average interval from start of induction to vaginal delivery was about 1 hour longer in the misoprostol group (811.5 +/- 511.4 minutes) than in the oxytocin group (747.0 +/- 448.0 minutes) (P = .65, log transformed data). Oxytocin administration was necessary in 37 of 98 (37.8%) of misoprostol-treated subjects. Vaginal delivery occurred in 85 misoprostol-treated subjects (86.7%) and 82 (85.9%) oxytocin-treated subjects (relative risk 1.17, 95% confidence interval 0.78 to 1.78, P = .45) with the remainder undergoing cesarean birth. There was no difference in the incidence of tachysystole (six or more uterine contractions in a 10-minute window for two consecutive 10-minute periods) or hypertonus between the two groups. There was no significant difference in frequency of abnormal fetal heart rate tracings between the two groups (29.6% in the misoprostol group and 28.9% in the oxytocin group, P = .91). Chorioamnionitis was diagnosed in 28 (28.6%) misoprostol-treated subjects and 26 (26.3%) oxytocin-treated subjects (P = .72, relative risk 1.06, 95% confidence interval 0.78 to 1.45). No significant differences were found in the incidence of fetal meconium (8.1% and 9.1%), 1- or 5-minute Apgar scores < 7 (11.0% and 10.2% of 1-minute Apgar scores, and 2.0% and 2.0% of 5-minute Apgar scores), neonatal resuscitation (24.5% and 27.6%), or admission to the neonatal intensive care unit (25.5% and 32.3%) between the two groups. CONCLUSIONS: Vaginal administration of misoprostol (Cytotec) is an effective alternative to oxytocin infusion for labor induction in women with premature rupture of the membranes near term. The incidence of untoward effects is similar with use of the two agents

Am J Obstet Gynecol. 1999 Jan;180(1 Pt 1):253-4

There's a lot more out there but frankly I was getting tired of weeding through it. The most common argument against the use of misoprostol is the risk of uterine rupture. So I guess I better stop doing VBACs also - after all there's a risk of uterine rupture with that too.

Saturday, August 8, 2009

One p*ssed off midwife

I had a patient who had come in with ROM prior to the start of labor. It had been twelve hours and she was 4cms but she was ready to get the show on the road. So the plan was epidural and pitocin, then baby. This would be her 5th baby. She did not want to do NCB, although she had done it with the first three. Go figure.

So the patient opts to get the epidural prior to the start of pitocin. She was having some irregular contractions with very little discomfort. I know the birth junkies are cringing as they read that! I'm cringing a little as I type it. But that's they way she and I decided we would do this.

I was at a friend's house about ten minutes away hanging out (and I let the nurse caring for my patient know this). I get a call a little later from the nurse to let me know that the patient is having a whopping prolonged variable (baby's heart rate was down in the 90's for about ten minutes before returning to baseline). She tells me the heart rate is coming back up and the drop seemed to be totally random as the baby's strip was reactive immediately prior to the variable. So anyway, I head on in to check things out. They had told me the patient was still only 4cms and there was a bag that they ruptured when they put the scalp electrode on.

I'm almost to the hospital when the nurse calls me back to tell me that someone paged the doctor on call, who said to get the OR ready. The nurse tells me that the heart rate has recovered and she isn't sure why the doctor was called. But he was called by the labor nurse who used to be a midwife with us (she 'resigned' from our practice - awkward). I tell her to call him back and tell him I am almost there, will evaluate and call him if I need him.

I was so freakin' p*ssed! It was not the responsibility of this labor nurse to be calling the doctor without discussing with me first. It's my patient, I am responsible. I get to make that judgement call...not the nurse who used to be a midwife with us and thinks she can still work in that role and no one is gonna say anything. I get mad just thinking about the incident. The director of the unit happened to be there and was involved. I went off on her and the nurse/midwife. I was given some excuse about miscommunication and I let it go at that. But I felt like I made my point clear!

Follow-up on Random Office Visit post

So I talked about this young mother (17) who I saw in the office not too long ago in this post.


I'm such a sucker. I made her wait until about three days after her due date then I gave in. Oh the pressure. Oh the looks she gave me. It was torture. So I brought her in for indcution starting with cytotec to be followed by pitocin.

She got two doses of cytotec, which worked nicely. Four hours after the second dose, she was 4/90/-1 - woohoo! She got her epidural and we gave just a smidge of pit (seriously, I don't think we ever went above 2mu/min!). She was 7cm by the time I go back from the office. So I broke her water and she delivered 20 minutes later. Very nicely done.

But dang I was a sucker.