I wrote a reply on Amy Romano’s Science & Sensibility blog for Lamaze International. (By the way, wish me luck. I am trying to finagle a way to go hear her speak at the Lamaze Annual Conference.) She wrote a post asking if there was any profession guidelines to determine when an induction has failed.
I didn’t find anything on how to determine if they are way too off the Friedman Curve (which is a pile of junk as a guideline anyway, but that’s a whole ‘nother post). The other reason I would think an induction would fail would be fetal intolerance to the augmentation or induction agents, due to hyperstimulation. This is associated with both Cytotec and Pitocin, from what I understand.
Here is my reply:
There is some information in ACOG’s Practice Bulletin #106 on Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General management Principals. But, I don’t think it is exactly what you are looking for or anywhere near adequate.
At some point in the bulletin, the authors state that the term “hyperstimulation” and “hypercontractility” should be abandoned (both would be used to describe one of the complications of an induced labor). They prefer the term “tachysystole”. This is first of two times there is even a sideways referral to induction / augmentation of labor. They write: “The term tachysystole applies to both spontaneous and stimulated labor. The clinical response to tachysystole may differ depending on whether contractions are spontaneous or stimulated.”
Well, spontaneous onset of labor can still lead to stimulated contractions, since there is a difference between induction and augmentation. Induction usually involves continuous augmentation, and both can lead to hypercontractility and/ or tachysystole, but they should not be grouped together as if they were synonymous. The terms “induction” and “augmentation” do not appear in the document.
In fact, it does not appear in the section on patients who are “high risk” and should be candidates for continuous external fetal monitoring as opposed to intermittent monitoring. As far as I know, almost every labor and delivery unit in hospitals, even ones that allow intermittent monitoring, say augmentation with Pitocin mandates continuous external fetal monitoring. Well, not in this practice bulletin.
Neither do the words “Pitocin”, “Oxytocin” or “Cytotec” or “Misoprostol” show up anywhere in the document, for that matter. Interestingly, the section on drugs that may influence fetal heart tones has a noticeable lack of any of these induction or augmentation agents.
But, even more interestingly, the very first recommendation under the section on what can be done with non-reassuring (Category II or Category III) tracings is “Discontinuation of any labor stimulating agent.”
Really? Why would that be? Because according to the list of agents we should suspect, none of those agents have a high index of suspicion for affecting fetal heart tones. But, someone seems to think they have enough of an effect that the very first recommendation is that they should be immediately suspended.
You are also supposed to check her labor progression (dilation, effacement, station, etc). What to do with this information? Not a word.
And then what? Has the stimulation (which may be an induction) failed? Do you proceed to cesarean? Do you allow the drug to wash out and hope the fetus will recover with other techniques of intrauterine resuscitation? They discuss using tocolytic agents and beta agonists and amnioinfusion. I would think amnioinfusion would not be done if a cesarean was imminent.
Anyway, they talked around failed induction a lot without ever actually discussing it.