ACOG revises labor induction guidelines
(Originally posted July 2009. Information still relevant.)
ACOG released a press release today regarding a new practice bulletin revising labor induction guidelines. Though the practice bulletin is not available on the ACOG site, a detailed review is available by Medpage today. I hope to soon have the full copy to share.
Some high points I found in the explanation and review of the revision:
- Misoprostol (Cytotec) should not be used to induce any woman with a previous uterine surgery or cesarean due to the increased risk of uterine rupture.
- The Foley catheter is a reasonable and effective alternative for cervical ripening and inducing labor (as stated in my blog earlier this week).
- The recommendation for fetal demise is for induction rather than cesarean unless unusual circumstances present as it is associated with maternal morbidity without fetal benefit.
- ACOG also states that the assessment of “gestational age and consideration of any potential risks to the mother or fetus are of paramount importance for appropriate evaluation and counseling before initiating cervical ripening or labor induction.”
- Admitting to this fact – At the same time, there have been a number of reports linking the induction of labor with increased risk of adverse events including uterine rupture and meconium-stained amniotic fluid.
- “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,” notes Dr. Ramin. Although rare, there are potential complications with some methods of labor induction. (perhaps less inductions that are for lack of medical reason will be done if a physician must induction sit?)
- Post cervical ripening whether by medication or mechanical once the cervix is dilated, labor can be induced with oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation. (using an alternative like nipple stim interesting)
Some low points I found in the explanation and review in the revision:
- The new guidelines include seven recommendations based on “good and consistent scientific evidence” — considered the highest evidence level — including one that sanctions 25 mcg of misoprostol as “the initial dose for cervical ripening and labor induction.” The recommended frequency is “not more than every 3-6 hours.” (I want to see these studies)
- ACOG said that the data on the safety of high-dose misoprostol (50 mcg every six hours) were “limited or inconsistent,” making its recommendation on high-dose misoprostol an evidence level “B” recommendation. (again studies please)
- The practice of inducing labor has become more common. More than 22% of pregnant women undergo labor induction, ACOG says, and the overall rate doubled from 1999 to 2006. (once again – only 22% – this one I need to research)
- Rapid delivery or lack of access to good care at home as a potential reason to induce labor in rural areas.
More possible low points:
- Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor is indicated. (Pit to distress with high doses?)
So even ACOG says that induction needs to be taken seriously as there are risks and consequences associated. Definitely I am in agreement with that. It IS a very big deal and the risks to not having your baby immediately must outweigh the benefits of baby staying put a little longer.