Saturday, August 8, 2009

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.


Jan Andrea said...

Please don't take this the wrong way, but I'm really surprised to hear that you're using Cytotec, knowing that it's not an approved use and has a massively increased risk of hyperstimulation and uterine rupture... it doesn't seem like a MW thing to use. I'm just curious to know why you'd go that route.

Ciarin said...

Jan - no problem to ask why I use it :) First of all, I rarely do inductions. However, when I do induce with a thick cervix, cytotec typically works far better than cervidil (the hospital won't let us use prostaglandin gels - we can do cervidil or cytotec). I used to use only cervidil but had so many scenarios where I was having to do two and three cervidils to get anywhere. It's almost like cervidil is too gentle. Cytotec typically works every time.

Cytotec is actually very commonly used across the country. It is not an approved use however neither is terbutaline but we use that all the time as well with good therapuetic effect in most cases. There are risks to any drug and any induction, which is why I minimize inductions.

There can be an increased risk for hyperstimulation (correct terminology is now tachysystole) however, stucdies have shown that outcomes were not worse than other forms of inductions. The risk of uterine rupture in a woman with a history of no surgeries on her uterus does exist but is minimal. And of course, I would never use this with a TOLAC woman.

I'm curious...what do you think I should use for an un-ripe cervix in a necessary induction? Herbs? Unfortunately I am not trained in herbology...yet. That's something I plan to do soon. But until then I am not qualified to use many herbal remedies safely. And I always like to remind people that herbs are not always safe or regulated for that matter.

Thanks for your inquiry! :)

Anonymous said...

Tell this to my friend, a primip, with no previous surgeries of any kind! Her son has CP and is tube-fed and wheelchair bound! The nurses thought she was being "whimpy" when her pain level was out of control at 3 centimeters. Good luck...but please, never, never, never minimize a woman's level of pain when using cytotec!

Ciarin said...

Sorry to hear about your friend's child!

Believe me , I don't minimize women's pain. I don't see that I did that anywhere here in this post or my response?

I'm not really sure from your response - did your friend have a uterine rupture after cytotec use? That is awful.

Jan Andrea said...

Well, I guess I wouldn't have classified this young woman's induction as "necessary" to begin with. If there was a medical reason for it, you didn't state it; only that she wanted it. I'm not a big fan of elective inductions; my philosophy is that babies come when they're actually ready and that interfering with that can cause more problems that it solves with the majority of cases. I wouldn't suggest herbs or any other method; it's just that I've heard some terrible, terrible stories about cytotec, and the manufacturer specifically states on the label that it's not to be used for induction. That seems pretty cut and dried to me.

Ciarin said...

This induction was done primarily because the girl wanted it done. However there were some issues regarding blood sugars that I chose not to go into here due to HIPPA.When she pushed for the induction, I felt I had enough reason to reasonably go along with it.

I hate to bust your bubble darlin' but cytotec being used for induction is an off-label's used all over this country on a pretty regular basis.

And babies do come when ready....and as I said, we rarely do inductions due to our belief that babies will come when ready. Your statement that interfering causes more problems than it solves in a majority of cases is a little erronous (sp). If that were the case I would imagine my c/s rate (even when managing the doctor's inductions) wouldn't be below 6% with excellent outcomes. How many inductions have I scheduled so far this year? I can count them on one hand. How many babies have you caught? What's your c/s rate?

I guess I am getting a little testy here - I just feel like I can hear that judgemental tone in your words? I don't mind discussing stuff but when you start using blanket statements (i.e. majority of of cases, etc) I get a little irritated I guess.

See my next post for more info on cytotec.

Jan Andrea said...

I'm sorry, I don't mean to offend. I also don't think that "it's done on a regular basis" is a good reason to do anything. I prefer evidence-based practice from health care providers, and to my knowledge, the evidence does not favor cytotec for inductions. Your readers can see for much more information. Midwifery Today also has an article:
I'm glad you don't induce often, and that there was a medical reason for the induction. I'm not a medical professional, just a birth junkie, so yes, your credentials and experience are far greater than mine. However, Cytotec is not just off-label; it's on-label contraindicated (not for use on pregnant women) and I think that really speaks volumes. Just because a lot of people do it doesn't mean it's okay.

Ciarin said...

You have a good point about EBP - that is something I do strive for. Evidence does support cytotec as a cervical-ripening agent. I did look at the two sites you mention when I was researching the cytotec refs. I know there is a bias against cytotec. And that's ok. It's a very controversial topic.

In regard to the label by the manufacturers - the label was changed to address only women attempting to get pregnant, early in pregnancy. The use of cytotec for induction in term pregnancy was removed from the warning label. I looked at the label myself. It is warning that this medication may cause a miscarriage. That's all.

And just because a lot of people do it doesn't mean it's are correct. In circumstances such as these, one is better off following EBP. And there is evidence to support the use of cytotec. Informed consent is critical when using this drug. As with any induction I schedule, informed consent is a key component of that. I discuss the method I recommend using. I give women the option of choosing between cervidil and cytotec (if they are even necessary). I discuss pitocin. I tell women that induction increases the risks of needing a c/s, etc. I feel my informed consent is truly that. So I guess what i am saying here is that I feel like I am a responsible provider, using tools appropriately and not just out of convinience or impatience.

FYI, not all of the providers in my practice feel the same way - some use cytotec and others don't. And that's ok.

Jan Andrea said...

Thank you for your further discussion. Informed consent is certainly vital when using an off-label drug.

Marissa L. Swinghammer said...

My NP Midwife at Bringham and Womens Hospital used cytotec and it worked out wonderfully for my birth. I am convinced that it prevented me from having a C section.

I was 12 days late in a state that requires induction after 14 days. Plus my blood pressure had been up and down. When I was 2 or 3 days late I called up my midwife begging for an induction and she talked me out of it and scheduled me for one when I would be 13 days late because she was working that day. She scheduled a "pre-induction treatment" at the hospital the day before. But she said the baby would probably come before that time and reassured me.

The baby did not come so I went to my treatment with my husband. My cervix was thick and not dilating. After my first treatment nothing happened but after the second I was having contractions within a half hour or so. It is kind of a blur from there. My cervix had only dilated a bit more, not enough for them to admit me so I chose to go home so I could take a bath and be more comfortable. My midwife told me that these contractions could be labor or could be side effects from the drug.

I went to the hospital a few hours later and had my baby 45 minutes after pulling up. My water broke right as the nurse was helping get me into a gown. When I got there I was screaming and begging for pain meds and when the nurse told me the midwife had to look at me first I started to cry. But when the midwife looked she told me the baby was already here and I could wait an hour for drugs to get there (my original plan all along had been to get an epidural) or I could just start pushing and have the baby. Fourteen minutes later my healthy daughter was born.

My midwives and cytotec probably saved me from a C section and it definitely saved me from an epidural and allowed me to experience giving birth and I thank them for that. I don't think you did anything wrong!