Cytotec (Misoprostil) Induction

There are a few medication options in the United States when you are planning an induction. 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 Misoprostil (the generic name) induction.

How do I know all of this? I’m Hilary — I’m an L&D RN and I’ve worked in labor and delivery since 2001. I’ve given Cytotec thousands of times and I am excited to share some info with you before your induction! I’d love it if you let me join you during your pregnancy:

Cytotec Induction

Before we jump into this, I bet you are reading this article because you are likely close to your due date and might have an induction and are researching your options.

Unless you’re in labor RIGHT NOW (which you likely wouldn’t be researching induction options) you have time for a prenatal class. I have created an accurate, quick-paced way to get prepared for your delivery in The Online Prenatal Class for couples.

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 to use it as 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.

What is Cytotec (generic: Misoprostil)

It is a form of a 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, but has been found to induce labor

FDA Cytotec Guidance

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.

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 (ACGO), the professional organization of OB’s in the united states has said it is a safe and effective way to start an induction.

Because cytotec is sometimes used for an induction abortion — the pill is controversial (whichi s why I think it’s not approved for so long).

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.

Why is Cytotec not 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).

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 one has a favorable cervix — which I discuss in this post.

After 20 years of practice I am a fan of Cytotec if an induction is indicated. However, all inductions come with risks and I do prefer natural labor vs induced labor.

Risks of a Misoprostil 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 benfits:

Benefits of a Misoprostil Induction

As I mentioned above when used in conjunction with pitocin (instead of JUST pitocin) it is associated with quicker deliveries.

It 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 misoprostil happens all over the world because of this reason.

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.

If it does, it can distrupt blood flow to the baby (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.

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

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. BTW, I go over the ENTIRE admission and induction process in here.

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).

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.

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.

Misoprostil Guidelines

The guidelines say that we should give Misoprostil 25 mg every 4-6 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

Buckle Cytotec

This is where the pill is placed between your gums 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).

Vaginal Cytotec

The pill is placed by your 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 imght 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 disolves 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, but I think it depends on your healthcare provider’s preferences.

Misoprostil 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.

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.

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How Long does a Misoprostil Induction Take?

It is hard to say.

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” 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, misoprostil 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 Misoprostil to get to 3 cm, and some people need several doses. Most places I’ve seen/worked we can give up to 8 doses.

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).

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).