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Week by Week
Cytotec/Misoprostal Inductions
Title
Comparison of labor induction with misoprostol vs. oxytocin/prostaglandin E2 in term pregnancy.
Author
Kadanali S; Küçüközkan T; Zor N; Kumtepe Y
Address
Department of Obstetrics and Gynecology, Atatürk University, Erzurum, Turkey.
Source
Int J Gynaecol Obstet, 1996 Nov, 55:2, 99-104
Abstract
OBJECTIVE: To compare the efficacy and safety of intravaginal and oral misoprostol vs. oxytocin/prostaglandin E2 (PGE2) gel for third trimester labor induction. METHODS: Two hundred twenty-four pregnant women were randomized to induction of labor either with misoprostol or oxytocin and PGE2 gel. Patients in the misoprostol group (n = 112) received 100 micrograms intravaginal misoprostol followed by 100 micrograms p.o. every 2 h. The oxytocin/PGE2 group consisted of 112 patients who underwent PGE2 cervical instillation 6 h before continuous oxytocin infusion. The perinatal, intrapartum and neonatal characteristics of both groups were determined. RESULTS: Induction to active phase of labor was successfully achieved in 96 women (85.7%) in the misoprostol group vs. 86 women (76.8%) in the oxytocin/PGE2 group, but the drug initiation-delivery interval was significantly shorter in the misoprostol group (9.2 +/- 2.4 h) than in the oxytocin/PGE2 group (15.2 +/- 3.2 h, P < 0.001). The incidence of adverse intrapartum outcomes was similar for both methods. Intravaginal misoprostol 100 micrograms followed by a single oral dose of 100 micrograms misoprostol safely produced labor and a vaginal delivery in 70% of patients. More than three tablets were required in only 10% of patients. There was a higher prevalence of cesarean section for failed induction in the oxytocin/PGE2 group than in the misoprostol group (13.4 vs. 6.3%, P < 0.001). The neonatal outcomes of both groups were also similar. CONCLUSION: Misoprostol is significantly more effective for labor induction than oxytocin/PGE2 gel. The maternal intrapartum and neonatal outcomes were the same for both induction regimens. From a clinical and perinatal perspective, misoprostol is an acceptable choice for labor induction.
Title
Labor induction with the prostaglandin E1 methyl analogue misoprostol versus oxytocin: a randomized
trial.
Author
Sanchez-Ramos L; Kaunitz AM; Del Valle GO; Delke I; Schroeder PA; Briones DK
Address
Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville.
Source
Obstet Gynecol, 1993 Mar, 81:3, 332-6
Abstract
OBJECTIVE: To compare the safety and efficacy of intravaginal misoprostol versus intravenous (IV)
oxytocin infusion for labor induction. METHODS: One hundred thirty patients were randomly assigned
to one of two induction groups: 1) intravaginal misoprostol or 2) IV oxytocin by continuous infusion, with
prior cervical ripening using prostaglandin (PG) E2 gel if necessary. RESULTS: Among 129 patients
evaluated, 64 were allocated to the misoprostol group and 65 to the oxytocin group. Prostaglandin E2
gel was administered to 29 patients (45%) in the oxytocin group with unripe cervices. Uterine
tachysystole occurred more frequently in patients in the misoprostol group (34.4%) than in the oxytocin
group (13.8%) (P < .05). Nevertheless, no statistically significant differences were noted between the
groups in intrapartum complications including uterine hyperstimulation syndrome, mode of delivery, and
neonatal or maternal adverse outcomes. The interval from induction to vaginal delivery was significantly
shorter in the misoprostol group (11 versus 18 hours; P = .004). In 74% of patients in the misoprostol
group, only one intravaginal dose was required for successful labor induction. CONCLUSIONS:
Intravaginal administration of misoprostol safely and effectively induces labor while minimizing the
expense associated with IV oxytocin infusion. The higher frequency of uterine tachysystole associated
with the use of misoprostol did not increase the risk of adverse intrapartum or perinatal outcomes. The
use of PGE2 gel for cervical ripening contributed to the longer induction-to-vaginal delivery interval
noted in the oxytocin group. Clinical trials appear warranted to detail misoprostol's optimal route, dose,
and schedule for labor induction and its safety.
Title
Induction of labour with intravaginal misoprostol in the second and third trimesters of pregnancy.
Author
Merrell DA; Koch MA
Address
Department of Obstetrics and Gynaecology, Natalspruit Hospital, Johannesburg.
Source
S Afr Med J, 1995 Oct, 85:10 Suppl, 1088-90
Abstract
OBJECTIVE: To confirm the effectiveness of misoprostol as a labour-induction agent. DESIGN AND
SETTING: One hundred and ten consecutive second- and third-trimester hospital patients. Patients with
intra-uterine deaths (group A) received 100 micrograms misoprostol 4-hourly and those with live
fetuses (group B) 50 micrograms misoprostol 4-hourly until labour commenced. SUBJECTS:
Forty-eight patients in group A (group A1 second trimester 27, group A2 third trimester 21); 62 mainly
hypertensive patients in group B. OUTCOME MEASURES: These were the amount of misoprostol
required to induce labour; duration of induction and labour; success and completeness of vaginal
delivery; neonatal outcome; and cost. RESULTS: In group A1, labour was successfully induced in
21/27 (77.8%) patients with 157.4 micrograms misoprostol; and in 19/21 (90.5%) patients in group A2
with 128.9 micrograms misoprostol. Cost per successful induction was R0.55 and R0.44 respectively.
Mean induction times were 13.2 hours and 13.4 hours respectively. All patients delivered vaginally but
incompletely in 7/21 group A1 and 1/19 group A2 patients. In group A2, the mean duration of labour
was 5.97 hours. In group B induction was successful in 51/62 (82%) with 95.1 micrograms of
misoprostol; the mean cost was R0,32. Twelve out of 51 (23%) received oxytocin and 44/51 delivered
vaginally. Mean duration of induction was 11.4 hours and of labour 5.4 hours. Two babies had low
Apgar scores. There were two stillbirths (perinatal mortality rate 39.2/1000), both apparently unrelated
to misoprostol. CONCLUSIONS: Misoprostol is an effective, easy to use, apparently safe and cheap
drug for the induction of labour.
Title
A randomized trial of misoprostol and oxytocin for induction of labor: safety and efficacy.
Author
Kramer RL; Gilson GJ; Morrison DS; Martin D; Gonzales JL; Qualls CR
Address
Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, USA.
Source
Obstet Gynecol, 1997 Mar, 89:3, 387-91
Abstract
OBJECTIVE: To compare the safety and efficacy of misoprostol and oxytocin for induction of labor.
METHODS: One hundred thirty women requiring induction of labor were randomized to receive either
intravenous oxytocin or 100 micrograms misoprostol, administered intravaginally every 4 hours until
labor was established. RESULTS: Compared with women receiving oxytocin, a greater percentage of
women in the misoprostol group had Bishop scores of 3 or less (58 versus 38%, P < .05). Nonetheless,
the median induction-to-delivery interval was significantly shorter (585 versus 885 minutes, P < .001) in
the misoprostol group. Women in the misoprostol group were more likely to deliver vaginally within 24
hours of the start of induction (77 versus 55%, P < .002). Epidural analgesia was used more frequently
in women receiving oxytocin than in those receiving misoprostol (73 versus 50%, P = .025). The total
percentage of cesarean deliveries was not significantly different, although the percentage of cesarean
deliveries for dystocia was lower in the misoprostol group (8 versus 21%, P = .02). Uterine
tachysystole was significantly more common (70 versus 11%, P < .001) and hospital charges
significantly less with misoprostol. CONCLUSION: Compared with oxytocin for labor induction,
misoprostol results in a shorter induction-to-delivery interval, a reduction in the rate of cesarean delivery
for dystocia, and a decreased use of epidural analgesia. Uterine tachysystole is significantly more
common with the use of misoprostol.
Title
Misoprostol for cervical ripening and labor induction: a meta-analysis.
Author
Sanchez-Ramos L; Kaunitz AM; Wears RL; Delke I; Gaudier FL
Address
Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville
32209, USA.
Source
Obstet Gynecol, 1997 Apr, 89:4, 633-42
Abstract
OBJECTIVE: To analyze published randomized trials assessing the safety and efficacy of misoprostol
for cervical ripening and labor induction. DATA SOURCES: We supplemented a search of entries in
electronic data bases with references cited in original studies and review articles to identify randomized
trials of misoprostol for cervical ripening and labor induction. METHODS OF STUDY SELECTION:
Two blinded investigators performed independent trial quality evaluation and data abstraction of
randomized clinical trials assessing the efficacy of misoprostol as a cervical ripening and labor-inducing
agent. TABULATION, INTEGRATION, AND RESULTS: We calculated an estimate of the odds
ratio (OR) and risk difference for dichotomous outcomes, using both a random- and fixed-effects
model. Continuous outcomes were pooled using a variance-weighted average of the within-study
difference in means. Of 16 studies identified, eight met our criteria for meta-analysis. These eight trials
included 966 patients (488 received misoprostol and 478 were controls). Women who received
misoprostol for cervical ripening and labor induction had a significantly lower overall cesarean rate (OR
0.67, 95% confidence interval [CI] 0.48, 0.93) and a higher incidence of vaginal delivery within 24
hours of misoprostol application (OR 2.64, 95% CI 1.87, 3.71). Use of misoprostol was associated with
a higher incidence of tachysystole (OR 2.70, 95% CI 1.80, 4.04) but not hyperstimulation (OR 1.91,
95% CI 0.98, 3.73). The incidences of abnormal 5-minute Apgar scores and admissions to the neonatal
intensive care unit were similar in the misoprostol and control groups. The pooled estimate of the mean
interval from start of induction to delivery was 4.6 hours fewer (95% CI -3.5, -5.7) in the misoprostol
group. CONCLUSION: Published data confirm the safety and efficacy of intravaginal misoprostol as
an agent for cervical ripening and labor induction.
Title
Oral administration of misoprostol for labor induction: a randomized controlled trial.
Author
Windrim R; Bennett K; Mundle W; Young DC
Address
Department of Obstetrics and Gynecology, Grace General Hospital, St. John's, Newfoundland, Canada.
Source
Obstet Gynecol, 1997 Mar, 89:3, 392-7
Abstract
OBJECTIVE: To evaluate the effectiveness, safety, and gastrointestinal tolerance of misoprostol taken
orally for induction of labor, against our established protocol, with the interval from induction to vaginal
birth as the primary outcome measure. METHODS: Two hundred seventy-five women who presented
with indication for induction of labor were assigned randomly to receive either 50 micrograms of
misoprostol orally every 4 hours as needed or treatment according to our established protocol
(physician-chosen combinations of intracervical or vaginal prostaglandins every 4-6 hours, artificial
rupture of membranes, and oxytocin infusion). Sample size was calculated with a two-tailed alpha = .05
and power of 95%. RESULTS: The mean time (+/-standard deviation) to vaginal birth with oral
misoprostol was 926 +/- 521 minutes versus 909 +/- 585 minutes with the established protocol, a
nonsignificant difference. There were no clinically or statistically significant differences in maternal
secondary outcome measures (cesarean rate, frequency of epidural use, perineal trauma, or manual
removal of the placenta). There was no difference in frequency of maternal gastrointestinal side
effects. Neonatal outcomes, including cord blood acid-base analysis, were not different.
CONCLUSIONS: Oral misoprostol may be a new option for labor induction. It appears to be no less
effective or safe than our usual regimen for induction of labor at term and is well tolerated. Further
studies are warranted to confirm the safety of this approach and to determine optimal dose and
frequency of administration.
Vaginal misoprostol for induction of labor: a randomized controlled trial.
Author
Mundle WR; Young DC
Address
Department of Obstetrics and Gynecology, Grace General Hospital, Newfoundland, Canada.
Source
Obstet Gynecol, 1996 Oct, 88:4 Pt 1, 521-5
Abstract
OBJECTIVE: To evaluate the effectiveness and safety of the vaginal application of misoprostol for
induction of labor at term, with the interval duration from labor induction to vaginal birth as the primary
outcome measure. METHODS: Two hundred twenty-two women with indications for induction of labor
at term were randomized to receive either misoprostol 50 micrograms per vagina every 4 hours as
needed or our standard approach (physician-chosen combinations of intracervical or vaginal
dinoprostone every 6 hours, artificial rupture of membranes, and oxytocin infusion). RESULTS: Mean
(+/-standard deviation) time to vaginal delivery was 753 +/- 588 minutes for misoprostol versus 941 +/-
506 minutes for the physician-chosen combination (P = .018). Oxytocin infusion was used less
frequently (relative risk [RR] 0.48, 95% confidence interval [CI] 0.31-0.74). There was no significant
difference in cesarean rate or maternal morbidity. Neonatal outcomes, including cord-blood acid-base
analysis, were not significantly different. The estimated cost per patient in Canadian dollars for
prostaglandins was $0.22 with misoprostol and $70.00 with standard therapy. CONCLUSION: Vaginal
misoprostol is a cost-effective alternative to current labor-induction protocols. We found no evidence of
harm to mother or newborn in substantive outcomes.
Title
A comparison of differing dosing regimens of vaginally administered misoprostol for preinduction
cervical ripening and labor induction.
Author
Wing DA; Paul RH
Address
Department of Obstetrics and Gynecology, University of Southern California School of Medicine, USA.
Source
Am J Obstet Gynecol, 1996 Jul, 175:1, 158-64
Abstract
OBJECTIVE: Our purpose was to compare two dosing regimens of vaginally administered misoprostol
for preinduction cervical ripening and induction of labor. STUDY DESIGN: Five hundred twenty-two
patients with indications for induction of labor and unfavorable cervices were randomly assigned to one
of two dosing regimens of vaginally administered misoprostol. Twenty-five microgram tablets of
misoprostol were placed in the posterior vaginal fornix either every 3 hours to a maximum of eight
doses or every 6 hours to a maximum of four doses. The maximal period of cervical ripening was 24
hours regardless of the number of misoprostol doses administered. Medication was not given after
either spontaneous rupture of membranes or the beginning of active labor. RESULTS: Among 522
patients enrolled, 261 were randomized to receive misoprostol every 3 hours and 261 to receive
misoprostol every 6 hours. The average interval from start of induction to vaginal delivery was shorter
in the 3-hour dosing group (903.3 +/- 482.1 minutes) than in the 6-hour dosing group (1410.9 +/- 869.1
minutes) (p < 0.001). Oxytocin augmentation of labor occurred more commonly in the 6-hour dosing
group (51.4%) than in the 3-hour dosing group (41.8%) (p < 0.05). There were no significant
differences between routes of delivery. Overall, 108 patients (20.8%) were delivered by cesarean
section. There was a slightly higher prevalence of tachysystole (six or more uterine contractions in a
10-minute window for two consecutive 10-minute periods) in the 3-hour group (14.6%) than in the
6-hour group (11.2%), but this difference was not statistically different. There were no significant
differences in the frequency of uterine hyperstimulation or hypertonus. There was no significant
difference between groups in the frequency of abnormal fetal heart rate tracings, meconium passage,
1- or 5-minute Apgar scores < 7, neonatal resuscitations, or admissions to the neonatal intensive care
unit. CONCLUSIONS: Vaginally administered misoprostol is an effective agent for cervical ripening
and induction of labor. Patients with the 6-hour dosing schedule had longer intervals to delivery, more
frequently required oxytocin augmentation, and had more failed inductions than did patients with 3-hour
dosing. Further investigation to characterize the safety of misoprostol is needed.
Title
Labor induction with intravaginal misoprostol versus intracervical prostaglandin E2 gel (Prepidil gel):
randomized comparison.
Author
Chuck FJ; Huffaker BJ
Address
Department of Obstetrics and Gynecology, Kaiser Foundation Hospital, Los Angeles, CA 90027, USA.
Source
Am J Obstet Gynecol, 1995 Oct, 173:4, 1137-42
Abstract
OBJECTIVE: Our purpose was to compare the safety and efficacy of intravaginal prostaglandin E1,
misoprostol, with that of intracervical prostaglandin E2 (Prepidil gel) for labor induction. STUDY
DESIGN: One hundred three patients with an indication for induction of labor were randomly assigned
to induction with prostaglandin E1, 50 micrograms intravaginally, or with Prepidil gel, 0.5 mg
intracervically, every 4 hours until active labor. RESULTS: Four patients were excluded, leaving 49
patients who received prostaglandin E1 and 50 who received prostaglandin E2. The time from start of
induction to vaginal delivery was significantly shorter in the prostaglandin E1 group (11.4 vs 18.9 hours,
p < 0.001), and fewer patients in the prostaglandin E1 group required oxytocin augmentation (23% vs
55%, p < 0.005). No significant differences were noted in mode of delivery or in adverse maternal,
fetal, or neonatal effects. CONCLUSION: Intravaginal prostaglandin E1 is a more effective,
lower-cost agent for induction of labor than is intracervical prostaglandin E2 gel and is comparable in
safety.
Title
Low-dose vaginal misoprostol for induction of labor with a live fetus.
Author
Bugalho A; Bique C; Machungo F; Faúndes A
Address
Department of Gynecology and Obstetrics, Maputo Central Hospital, Mozambique.
Source
Int J Gynaecol Obstet, 1995 May, 49:2, 149-55
Abstract
OBJECTIVE: To test the effectiveness and safety of low-dose vaginal misoprostol for induction of
labor with a live fetus. METHODS: Labor was induced in 666 pregnant women with a live fetus in the
cephalic position, who had no medical complications and no history of uterine surgery. One-fourth of a
200-micrograms tablet of misoprostol (50 micrograms) was placed in the posterior vaginal fornix every
12 h for a maximum of four doses or until active labor commenced. Time from induction to delivery,
side effects and neonatal outcome were evaluated. RESULTS: Labor was successfully induced in all
cases. The mean time from induction to delivery was 10.4 h. The cesarean section rate was 7.8%.
There were eight perinatal deaths, six of which occurred in low birth weight fetuses. There was one
case of abruptio placenta, which was less than that expected in the study population. CONCLUSION:
Vaginal misoprostol, in very low doses, was a remarkably efficient and safe method for induction of
labor with a live fetus.
Title
Labor induction with intravaginal misoprostol in term premature rupture of membranes: a randomized
study.
Author
Sanchez-Ramos L; Chen AH; Kaunitz AM; Gaudier FL; Delke I
Address
Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville,
USA.
Source
Obstet Gynecol, 1997 Jun, 89:6, 909-12
Abstract
OBJECTIVE: To evaluate the safety and clinical effectiveness of intravaginal misoprostol, a synthetic
prostaglandin E1 analogue, for labor induction in gravidas with premature rupture of membranes
(PROM) at term. METHODS: One hundred forty-one pregnant women with term PROM were
assigned randomly to one of two induction groups: 1) intravaginal misoprostol or 2) intravenous oxytocin
by continuous infusion. RESULTS: Seventy subjects were allocated to the misoprostol group and 71 to
the oxytocin group. The mean (+/- standard deviation) interval from induction to delivery was
significantly shorter in the misoprostol group (416 +/- 276 compared with 539 +/- 372 minutes; P = .04).
In 85.7% of patients in the misoprostol group, only one dose was required. Intrapartum complication
rates, mode of delivery, and neonatal or maternal adverse event rates were similar in the two treatment
groups. Uterine tachysystole occurred more frequently with misoprostol than with oxytocin (28.6%
compared with 14.0%; P < .04). CONCLUSION: Intravaginal administration of misoprostol induces
labor safely and effectively in patients with PROM at term.
Title
Randomized comparison of misoprostol and dinoprostone for preinduction cervical ripening and labor
induction.
Author
Chang CH; Chang FM
Address
Department of Obstetrics & Gynecology, National Cheng Kung University Hospital, Tainan, Taiwan
ROC.
Source
J Formos Med Assoc, 1997 May, 96:5, 366-9
Abstract
This study attempts to evaluate the clinical effects of prostaglandin (PG) E analogues in preinduction
cervical ripening and labor induction and to compare the perinatal outcomes of these medications. Sixty
women with term singleton pregnancies were randomized to receive dinoprostone vaginal tablets (group
I) or misoprostol vaginal tablets (group II). The Bishop scores were evaluated before drug insertion and
every 4 hours during induction. Clinical data and perinatal outcomes were also recorded. There were no
significant differences in the preinduction conditions on mean initial Bishop scores between these two
groups. Twelve hours after drug insertion, the mean Bishop scores were significantly better in group II
(9.7 +/- 3.1 vs 7.3 +/- 2.5, p < 0.05). The mean time from insertion to delivery was shorter in group II
(16.5 +/- 2.7 h vs 25.7 +/- 3.8 h, p < 0.001). There were no significant differences in spontaneous labor
rate, need for oxytocin augmentation, type of delivery, and Doppler flow velocity waveforms of the
umbilical artery. The average number of doses given per patient was 1.8 +/- 1.4 in group II vs 2.7 +/-
0.3 in group I (p < 0.05). The perinatal outcome was similar in the two groups. In conclusion,
misoprostol not only appears to be a safe and effective agent for cervical ripening and labor induction
but is also more efficient than dinoprostone.
Title
Comparison of intracervical and intravaginal misoprostol for cervical ripening and labour induction in
patients with an unfavourable cervix.
Author
Srisomboon J; Piyamongkol W; Aiewsakul P
Address
Department of Obstetrics & Gynaecology, Faculty of Medicine, Chiang Mai University, Thailand.
Source
J Med Assoc Thai, 1997 Mar, 80:3, 189-94
Abstract
OBJECTIVE: To compare the efficacy of intracervical versus intravaginal misoprostol for cervical ripening and labour induction at term in patients with an unfavourable cervix. METHOD: A total of 100 pregnant women with indications for induction of labour and unfavourable cervix (Bishop score < or = 4) were randomly assigned to receive either 100 ug misoprostol administered intracervically (50 cases) or intravaginally (50 cases). RESULTS: No significant differences were noted between intracervical and intravaginal misoprostol in terms of Bishop score change, (score 7.2 vs score 7.5), interval from gel insertion to vaginal delivery (17.0 hours vs 16.4 hours), meperidine as analgesic requirement (80% vs 76%), route of delivery and perinatal outcome. Uterine tachysystole occurred in 24 per cent and 32 per cent in the intracervical and intravaginal groups respectively which did not significantly differ, however, all could be rapidly resolved by terbutaline injection. No evidence of fetal distress was noted in these events. Spillage of gel out of the cervix was observed in 70 per cent of patients receiving intracervical misoprostol. Fever was observed in one patient of each group. No other serious side effects were found in both groups. One patient in the intravaginal group had postpartum hemorrhage due to delayed placental separation and uterine atony. CONCLUSION: The two routes of misoprostol gel application appear to be safe and equally effective in ripening cervix and inducing labour, however, the intravaginal application is more convenient to administer practically compared with the intracervical.
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