Reply turned post, failed induction style

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.


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4 responses to “Reply turned post, failed induction style

  1. doctorjen

    Usually the term “failed induction” implies not so much fetal intolerance of (induced) labor, but failure to get the patient in active labor. I agree that there is not too much data on how to determine a “failed induction” or even how long one should keep trying before declaring the whole procedure failed. I’ve seen a whole lot of variation in clinical practice. I personally tell my clients that 3 things can happen with an induction. 1. You will go into labor and deliver a baby 2. You won’t go into labor – we’ll give whatever agent(s) we’re giving and the cervix will not dilate. 3. You’ll go into labor, but at some point after labor is established, things will stop, and you’ll be stuck at 5 cms, or whatever. I personally call either #2 or #3 a failed induction, but what you do about them may be different. With #2, you have the option to call it all off and come back another day if the reason for induction isn’t urgent. With #3 you may well be stuck and at some point have to move to surgical delivery if nothing works to get things moving again. I’ve read estimates that for a first time mom, induction increases the risk of surgical delivery by two-fold, mostly due to these “failed induction” scenarios. So, I try to make sure my reason (or my client’s reason) for inducing labor is sufficiently strong that if #2 or #3 happen, we are willing to accept that outcome.

    In practice, I have seen other docs call a failed induction after just a few hours of pitocin, or call “failure to progress” when a client is 2 cms dilated and never in active labor. I’ve also, though, seen a client with severe pre-eclampsia have a 3 day induction (and not getting into active labor until the last 12 hours) with close monitoring and eventually birth vaginally, so the variation of what will be called a failed induction is huge!

    • MomTFH

      Yeah, I jumped into that bulletin because I knew that they had something about inductions, and then realized it didn’t have anything about stalled labor. So, it wasn’t exactly the same thing.

      I looked up a study about elective induction, and they said dystocia (stalled labor) is the leading indication for cesarean after induction in their study, and in general in the United States regardless of induction. But, in this study, they didn’t use any Cytotec to induce.

      Failure or dystocia were up to the discretion of the midwife or physician managing the labor.

      This article mentioned looking into how failed induction is defined, but it’s not in the very long abstract, and I don’t have full text access.

      This review has an analysis of a few articles. They had some inductions with Cytotec. One reported more fetal distress, but the numbers were low. The other didn’t report that as an outcome. And, the two studies with Cytotec had much lower cesarean rates in the induction groups than the spontaneous groups, and that was not true for the studies with other methods of induction.

      The few that reported “prolonged” first stage of labor reported pretty low numbers for that, too. But, higher than the fetal distress numbers, which I am guessing they would put hyperstimulation or tachysystole or whatever you want to call it.

      Anyway, thanks for weighing in.

  2. ACOG has a new guideline on induction, too, in case you haven’t seen it, in the October issue.

  3. Pingback: Lamaze blog carnival is up « Mom’s Tinfoil Hat

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