Delivery dilemmas: The latest on induction drugs, VBACs and when to hit the hospital – Labor & Delivery – Brief Article
Laura Roe Stevens
Whether you are expecting your first child or your third, chances are good that you re concerned about your upcoming labor and delivery. For example, if you’re induced, is the drug Cytorec safe? Is choosing a vaginal delivery safe if you’ve had a Cesarean section? When your water breaks, can you wait awhile before you go to the hospital? Some medical practices that have long prevailed are being re-evaluated; here’s a look at three of them.
A drug debate>Cyrotec, a drug cleared by the U.S. Food and Drug Administration (FDA) only for treating peptic ulcers, has been used for years to induce labor, and it has recently come under close scrutiny. The controversy began early last year, when Mother Jones magazine reported that FDA documents linked Cyrotec (generic name: misoprostol) to 30 cases of uterine rupture and eight fetal deaths since 1997. (The FDA confirms this link but points out that any drug that intensifies uterine contractions raises the risk of these events.) Despite such reports, many doctors continue to use Cytotec to induce labor, maintaining that it’s safe if used properly; and the American College of Obstetricians and Gynecologists supports that use for certain women.
The reported problems with Cytotec stemmed from the use of too-large doses, says Khalil Tabsh, M.D., chief of obstetrics for UCLA Medical Centers. “Cytorec must be given in proper doses, and it shouldn’t be used with other induction drugs,” he says. A woman who is given Cyrotec must be continuously monitored, he adds, and the drug should never be administered to a woman who has had a C-section or whose unborn baby may be underweight.
Even though several other induction drugs are available, Cytorec is still used for a couple of reasons: It costs less than some of the other drugs; and it stimulates more intense contractions, so it’s thought to result in a shorter labor, according to Tabsh. However, because of the potential for complications, some doctors opt for other alternatives. The decision will be up to you and your physician.
The VBAC controversy continues>Researchers recently reported in The New England Journal of Medicine that vaginal birth after Cesarean, or VBAC, is riskier than previously thought, especially for women who are given labor-inducing hormones. Women who underwent a VBAC and received prostaglandin hormones (usually in gel form applied to the cervix) had a 15-times greater risk of uterine rupture than those who had repeat C-sections, while women who received different labor-inducing drugs had a five-fold increase in risk. The uterine-rupture rate for women who had a VBAC with no induction drugs was three times higher than for those who had repeat C-sections. Despite these increased risks, however, there was still only a 0.5 percent overall chance of uterine rupture with a VBAC.
Does any increased risk mean that you should avoid a VBAC at all costs? Many doctors say no, as long as labor is not induced. But the most important precaution is choosing a hospital that is prepared to handle VBAC-related emergencies, says obstetrician-gynecologist Robert F. Katz, M.D., an attending physician at Cedars-Sinai Medical Center in Los Angeles. “In the right setting, VBAC can be safe,” says Katz, who also recommends that before attempting a VBAC, a woman should consult with her doctor, taking into consideration such factors as why she needed a C-section before and the kind of incision she had.
When your water breaks>In the movies, pregnant women gasp as fluid gushes onto their feet, then fall to their knees in the grip of a labor contraction. This is largely a Hollywood scenario; in reality, labor rarely starts right after the membranes that enclose the amniotic fluid rupture. Nonetheless, many doctors advise women to come to the hospital immediately to have labor induced; the most common reason given is to prevent infection. In most cases, however, experts say this is not medically necessary, and the practice may be changing.
Infection typically isn’t a risk until 12 to 24 hours after the membranes rupture, and labor most likely will begin on its own before then, says Robert T. Gunby Jr., M.D., medical director of labor and delivery for Baylor University Medical Center in Dallas. “Inducing labor immediately is not necessary, but many doctors want their patients to come to the hospital quickly to make sure the baby is OK,” Gunby says.
That’s because of a rare but more dire concern: umbilical cord prolapse. The more amniotic fluid a woman loses, the greater the chance that the cord will slip into the vagina, potentially cutting off the baby’s blood supply and causing death. Because of this possibility, Gunby advises his patients, especially those who are preterm (34 weeks or earlier), to go to the hospital immediately for monitoring. So if your water breaks and contractions do not set in right away, don’t panic; instead, call your doctor and discuss your options.
Laura Roe Stevens writes for The New York Times and the Los Angeles Times. She lives in Los Angeles end had her first child in November.
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