Induction Rate Doubles as ACOG Issues New Guidelines Misoprostol should not be used for inducing labor in women with a history of uterine surgery or a priorcesarean delivery, according to new guidelines issued by the American College of Obstetricians andGynecologists (ACOG). Action Points
Explain to interested patients that a number of clinical conditions affecting the mother or fetus orboth may require the induction of labor.
Explain that logistical concerns such as the distance to the hospital, or the risk of rapid labor, mayalso contribute to the decision to induce labor.
Note that the recommendations issued by ACOG are based on evidence from clinical studies and therecommendations are graded by the level of that evidence.
Use of misoprostol in those women "has been associated with an increase in uterine rupture," the guidelinesstate. The practice of inducing labor has become more common. More than 22% of pregnant women undergolabor induction, ACOG says, and the overall rate doubled from 1999 to 2006. At the same time, there have been a number of reports linking the induction of labor with increased risk ofadverse events including uterine rupture and meconium-stained amniotic fluid. One of the areas of controversy is dosing of misoprostol. 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 initialdose for cervical ripening and labor induction." The recommended frequency is "not more than every 3-6hours." ACOG said that the data on the safety of high-dose misoprostol (50 mcg every six hours) were "limited orinconsistent", making its recommendation on high-dose misoprostol an evidence level "B" recommendation. High-dose misoprostol, the guideline states, "may be appropriate in some situations, although higher dosesare associated with an increased risk of complications, including uterine tachysytole with [fetal heart rate]decelerations." In addition to the cautions on misoprostol in high risk populations and concerns about dosing of the drug, theguidelines include these "A" level recommendations: Prostaglandin E analogues are effective for cervical ripening and inducing labor. Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor isindicated. Before 28 weeks of gestation, vaginal misoprostol appears to be the most efficient method of laborinduction regardless of Bishop score, although high-dose oxytocin infusion is also an acceptablechoice. Intravaginal prostaglandin E2 for induction of labor in women with premature rupture of membranes The Foley catheter is a reasonable and effective alternative for cervical ripening and inducing labor. ACOG also states that the assessment of "gestational age and consideration of any potential risks to themother or fetus are of paramount importance for appropriate evaluation and counseling before initiatingcervical ripening or labor induction." Gestational age should be confirmed by ultrasound measurement, documented 30-week fetal heart tones by Doppler ultrasonography, or confirmation that it has been 36 weeks since a positive serum or urine humanchorionic gonadotropin pregnancy test result. The recommendation writers also reviewed the use of methods for induction of labor with intrauterine fetaldemise in the late second or third trimester. Based on limited data, they wrote, "the use of misoprostol between 24 to 28 weeks of gestation alsoappears to be safe and effective. Before 28 weeks of gestation, vaginal misoprostol appears to be the mostefficient method of labor. After 28 weeks of gestation, induction of labor should be managed according tousual obstetric protocols." They recommend against cesarean delivery for fetal demise, noting it "should be reserved for unusualcircumstances because it is associated with potential maternal morbidity without any fetal benefit."



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