Cytotec Labor Induction: What to expect?

There are a few medication options when you are planning to start lab (called induction of labor). Cytotec is one of the most popular due to its low cost and relative risk and benefits. Today we’ll talk about what to expect at a cytotec induction, how it’s different and why it’s not actually FDA approved for it.

Fun facts: I have started hundreds of cytotec inductions (since 2001) and have also seen all the stupid things people say about it online, so I am a good one to chat about what to REALLY expect.

And, before we get going — grab my induction question checklist. EVERY patient who is being induced (regardless of the reasons) should know the answers to these quesitons:

Cytotec Induction

Keep in mind that Cytotec is not normally given until close to your due date. Although there are reasons you might be induced early. Most women don’t get this until 37-40 weeks pregnancy. Prior to 39 weeks of pregnancy they would need a reason to be induced early. After 39 weeks gestational age, some providers or pregnant women choose have an induction (which is called an elective induction).

The main reason we would give it, is to increase your chance of a vaginal birth (vs a cesarean delivery), and a healthy mom & baby.

FYI, the generic name of Cytotec is Misoprostol. It really depends on your unit which word they use but they’re the same (like Tylenol vs Acetaminophen).

What is Cytotec

It is a synthetic prostaglandin — which is a fancy name for a hormone. It is most often in a pill or suppository (but the pill is used for induction). It’s actually FDA approved for stomach issues — like gastric ulcers, but has also been found to induce labor.

FDA Cytotec Guidance about Cytotec

At this writing, as far as I can tell — the FDA has not approved Cytotec for the induction of labor. However, it is a proven and safe method of induction. We have been using it since I started in 2001 and I know it was used before I started in labor and delivery

Some hospitals may have you sign an extra consent form saying you understand the risks (which can be scary, but just think of it as paperwork).

In 2002 Cytotec was removed as an “absolute contraindication during pregnancy” guidance from the FDA. Keep in mind the use of Cytotec started well before I started being an OB nurse in 2001.

Also The American College of Obstetricians (ACOG), the professional organization of OB’s in the united states has said it is a safe and effective way to start an induction.

I don’t want you to freak out at this FDA guidance (although people online love to do this). We’re going to talk about why it isn’t FDA approved for this, and also a reminder that MANY drugs commonly used for things aren’t FDA approved for how they’re being used. This isn’t uncommon at all.

Because Cytotec is sometimes used for abortions — the pill is controversial (which is why I think it’s not approved for so long). We’ll chat more about that in a second.

Also, because it is a drug meant for stomach issues — some patients experience stomach issues and side effects (diarrhea or abdominal pain) — although this is rare, I haven’t seen it much at all.

You may think that because it isn’t approved it has not been studied, but here is an NIH review with ALL uses of Cytotec for obstetrics, including many clinical trials.

And if your head is spinning right now (honestly, I don’t blame you — that whole FDA thing is confusing)….

Why is Cytotec not FDA approved for induction of labor?

I honestly have no idea. It has been used for so long, and has been found safe for use. It is also used after delivery to prevent hemorrhaging (we often have it on hand if a woman is at risk for it). Honestly, it is one of our best tools for postpartum hemorrhage, so the fact that it is not approved is really bothersome to me. It is inexpensive, doesn’t need to be refrigerated and is easily given.

I also believe it can be used for an abortion and that is probably why it is not approved. But honestly, I have no idea. There are so many scary articles out there. I liked what this one had to say.

• It has been found to have risks associated with it (as do all drugs, especially in something as important as labor — all inductions have risks)
• It has been found to be more effective than just pitocin to have the baby in less than 24 hours
• C-section rates are lower than when used with just pitocin.

It also notes that it often has better outcomes when the induction starts with an unfavorable cervix — which I discuss in this post about how long your induction might take.

After 20 years of practice I am a fan of Cytotec if an induction is indicated. However, all inductions come with risks, so be sure to talk with your provider about which option is best for you.

If you’re considering an induction, you may think it’s too late to get prepared for birth, but you’re WRONG! This class can help you feel so much confident and less nervous about your birth (it only takes 3 hours!!!!):

Benefits & Risks of a Cytotec (Misoprostol) Induction

As with most induction agents, there is always a risk of your uterus contracting too much, possibly uterine rupture and a risk of allergy to the medication (which is pretty rare). Be SURE to discuss with your provider the risks of the medicine before your induction!

Remember, informed consent should include:

1. Risks
2. Benefits
3. Any alternatives

And then it should be up to you what your next step should be — by weighing the potential risks with the benefits. And frankly, for every person that is going to be different (so I can’t cover all of it in here).

Benefits of a Cytotec Induction

As I mentioned above when used in conjunction with Pitocin (instead of JUST Pitocin) it is associated with quicker deliveries. If your cervix isn’t super ripe and you need to have a baby, it is one of your best options.

Cytotec, when given after birth, can also help postpartum hemorrhages (where you bleed out after the baby, and this is one of the greatest risks of labor).

It is also very cheap. Usually the pills cost under $1.00, vs Cervidil which can be several hundreds

It also doesn’t have to be refrigerated (can be kept at room temperature), it has a long shelf life (meaning we can keep a lot on hand) and is readily available. The use of misoprostol happens all over the world because of this reason.

While we’re here talking about induction — have you made your birth plan yet? Let me help you out:

Cytotec vs Cervidil

Cervidil is similar and also uses prostaglandins to help soften your cervix for induction. However, it is more expensive, it does have to be refigerated and I find that practitioner skill, along with the patient’s vaginal canal can play a big difference in how well it works.

If Cervidil isn’t place correctly, it isn’t absorbed by the Cervical tissues (the tissues at the end your uterus) and we end up wasting time. Things that can affect our ability to place it:

• Skill of the practitioner placing it
• Difficulty of reaching the cervix (which can be affected by how many babies you’ve had, patient weight and pelvic opening)
• Difficulty of the patient to tolerate a more-prolonged vaginal exam as it is being placed.

Risks of Cytotec

The main risk is that your uterus contracts too much (called uterine hyperstimulation).

If it does, it can disrupt blood flow to the baby (obviously problematic).

However, as we monitor you closely, there are also medications we can give to counteract that.

There is also the possibility of uterine rupture with strong uterine contractions (which is why we don’t give it to VBAC’s who are at a greater risk for uterine rupture). That would require a cesarean section (but we aim for a vaginal delivery).

The main problem is that Cytotec, once placed is hard to fish out (although I have)… it dissolves fairly quickly so vs Cervidil (where you can just pull it out) walking it back isn’t always an option.

Of course, baby and mom’s health is always MOST important — so both will be monitored during the induction of labour.

Wondering more about what will go on in the hospital as far as monitoring, and what your nursing staff will do for you. Learn from an expert — in just a few hours you can get prepared!

What to expect at a Cytotec Induction

A Cytotec induction will start in a very similar to way to any hospital induction. Many questions, a vaginal exam to see how favorable your cervix is. Pregnant women should also expect an IV to be placed with any induction as they are at an increased risk.

Really quick — do you love knowing what’s going to happen at something that’s new? People LOVE this class because I go over just what to expect at your hospital visit and it makes them feel SO much more prepared.

Most hospitals will require an IV or at least a saline lock (where the IV tubing is in your arm but the fluid isn’t hooked up, so you can have easier movement) when you are being induced.

We also make sure that you fall within the Cytotec guidelines of our policies. That includes a good fetal health rate monitoring strip, and no contraindications (like previous uterine surgery).

Keep in mind that Cytotec is really a cervical ripening agent (meaning it softens your cervix and helps it to get to around 2-3 centimeters — likely given Pitocin (the synthetic of the naturally-occurring hormone oxytocin) afterwards for continued labor contractions). There are a few other cervical ripening agents, but there isn’t too much of a significant difference between them.

That doesn’t mean it can’t be painful. Many women end up asking for pain medication during the use of misoprostol. You can use a few methods for pain relief.

Some doctors use misoprostol along with the use of a Foley catheter that helps to open your cervix manually at the same time.

Misoprostol Guidelines

The guidelines say that we should give Misoprostol 25 mg every 3-4 hours. for induction. There are a few induction methods with Cytotec (different ways of drug administration):

Oral Cytotec

This is when cytotec is given as a pill with water. Patients can’t eat with this placement as it can affect your absorption of the medicine.

Absorption is a bit quicker than with Vaginal cytotec

Buccal Cytotec

This is where the pill is placed between your gums (we use the word “buccal” for gums in medicine, prounounced just like buckle — I’m not sure why) and your cheek, and allowed to disolve and absorb.

This seems to be the most consistent way for absorption, however a lot of patients don’t like the taste and it can take a bit of time to dissolve.

Sublingual Cytotec

This is where the pill is placed under your tongue for dissolving. Similar complaints to the taste (and not being able to drink until it disappears). This study showed this was similarly effective to it being given vaginally — in fact, it reduced the amount of time to delivery for about an hour.

Vaginal Cytotec

The pill is placed by your care provider or nurse in your posterior vaginal fornix — that means at the end of your vaginal canal with a gloved finger.

If your water is broken, and there is amniotic fluid in your vagina — it can increase your risk of infection to use vaginal misoprostol (bacterial can now get through the amniotic membrane). So, they might choose another method

The absorption for the medicine in your vagina can vary a lot depending on the woman, and there isn’t really a way to predict that in advance. However, it’s more “long-acting” when given vaginally than orally (orally tends to absorb faster, peak faster and then go down where as vaginal dissolves slower).

Since Cytotec can be given in several doses, many women complain that their cervical exams get more and more painful as the tissues seem to be more sensitive with the medication.

Personally, I have given most patients the medication vaginally. However, I prefer giving it bucccal or sublingual as their vagina doesn’t get as painful. However, it depends on your healthcare provider’s preferences. Many people aren’t giving it orally at this time. As it isn’t FDA approved, the methods of giving it aren’t totally standard.

Misoprostol can also be given rectal, but is not used that way in labor (that I know of) — but is given that way during a postpartum hemorrhage.

I have a whole post that dives more into how Cytotec is given that you might want to check out (gives more pro’s and con’s of each method.

Medical Reasons Cytotec Can’t Be Given

• Previous Uterine Surgery including cesarean deliveries
• Baby not positioned for delivery (like a breech presentation)
• Any fetal heart rate distress (if baby doesn’t look good on the monitor)
• Herpes
• Placenta Previa (your placenta is in the way of your cervix — these must be delivered cesarean section), and other placental medical conditions
• Any contraindication to having the baby vaginally at this time (for instance, an ill mother or an active vaginal infection).
• Other pregnancy complications may mean your provider picks a different medication.

Next we’re going to talk about how long it takes — but first, grab my hospital back packing list because if you’re being induced it’s extra important to bring the right things to the hospital (but not too much):

How Long does it take for Cytotec to induce labor?

It is hard to say because it really varies person to person.

A lot of it depends on how favorable your cervix is << I talk about that a lot in that post on how long an induction will take, but it mostly is:

• How soft your cervix is (the harder and more rubber-like it is, the less likely is to open quickly)
• How open it is (gives it less to do)
• How thick it is (the cervix thins out as the baby advances towards it)
• How high the baby is in your pelvis.

These items are all considered in the bishop score (a numerical value of how “ripe” your cervix is). which helps us decide how is best for your induction (especially if medically necessary).

That all being said, sometimes it works really well, and sometimes that doesn’t. I figure that depends on:

• The skill of the person inserting it (making sure they get it in a good spot — although, misoprostol is not too difficult to place
• Your body’s absorption of it
• How your body reacts to it (some contract more than others)

As I say in that article I linked, the textbook case — once you are in ACTIVE labor (active being that your cervix is actively dilating — usually about a centimeter/hour) it takes 1 cm/hour plus pushing time.

The first few centimeters tend to take longer than the last few.

Some people only need one of dose of Misoprostol to get to 3 cm, and some people need several doses. Most places I’ve seen/worked we can give up to 8 doses.

And yes — worrying about how long your induction will take is SO normal. I talk about how you can get a better idea of how long of a road you’re in for in (and how to make it shorter) in The Online Prenatal Class for Couples.

Long long does it take for Cytotec to work (make you start contracting)?

While this definitely still depends on how your body absorbs and reacts to the Cytotec, most people see it within the first couple of doses — which is 6-8 hours. Some people feel some mild cramping initially, and then it progresses from there. However, I’ve had patients who needed 4 doses before they really start to see something (which would be 12-16 hours of an induction).

How many doses of Cytotec to induce labor?

As I said in above, it really depends. Hospitals should have a protocol in which they will only have 6-12 doses of Cytotec before they encourage providers to move on to something else. Most people really need less than 4 doses, but if you have a very unfavorable cervix it can take quite a while.

Do I have to stay on the fetal monitor during a Cytotec induction?

We require that you stay in bed at no more a slight incline for the first hour (that’s mostly so the pill doesn’t fall out).

The 2nd hour you can get up to pee, but we require you to be monitored that 2nd hour.

The 3rd hour we allow you to get up and walk.

That is one of the benefits of Cytotec.

We also allow you to eat (as long as you are not taking the medicine orally).

Frequently Asked Questions About Cytotec

What Happens After Cytotec?

Normally, Cytotec is given to get your cervix to soften and get to approximately 3 centimeters. Once you get to 3 cm, we usually switch to Pitocin Rarely your body just goes into labor on its own and it just progresses from there.

Sometimes Cytotec is given, your water breaks and things progress quickly from there — you never know!

Pitocin is given IV and is considered more high risk than Cytotec (but it is FDA approved). Patients must be monitored continuously and are not normally “allowed” to eat (although, frankly — you can do whatever you want, it’s just a doctor’s order for the nurse).

I talk all about the possible outcomes of an induction (including possibly going home) in The Online Prenatal Class for Couples. Seriously, just check it out:

• So easy, you’ll be prepared before you know it.
• Easy bite-sized chunks so you’re not overwhelmed by any lesson
• Great price point for every budget.

And, if you’re not quite sure you’re ready for that whole thing, check out my free prenatal class. It’s your first step toward getting in the driver’s seat of your birth.