TBT: Obstetrical History: Labor induction, Part 5, What Our Grandmas Did To Bring Labor On

Labor usually comes on its own when the baby is ready. In most cases its an onset of contractions, in only 8% do we find that the membranes spontaneously rupture on their own. The baby hasn't come yet, although your due date is nearing, or just passed, and you may find your self still wondering: what did your mom do to bring labor on? Or did Grandma try any of these "time-honored ritual of castor oil, enema, hot bath with or without quinine?" And even our grandmother's mother may have tried these things without medical supervision. Not only were these  usually a prolonged and uncomfortable ordeal, but I was often useless and could be harmful to both mother and fetus. Now days it's a matter of what is best for both mom and baby, and done with a variety of medications, typically beginning with a prostaglandin cervical ripening. Still the most commonly used medication for inducing contractions is oxytocin, and the study of the use of  oxytocin is more than a half a century old. The medication cause of much discussion as to safety, which has been enhanced by progressing pitocin treatment dosage and delivery systems. By the 1920s writings quoting the obstetrician Mior, he admirably summed up the position regarding medical induction: "I have long regarded medical induction before term as a waste of time, energy, and suffering." W.J. Garrett working in Oxford has reviewed 600 cases of induction of labor. Regarding medical induction, he found only 5 percent successful (that is, labor starting within 24 hours) in patients before term. In contrast, 20 percent of medical inductions were successful after term. The addition of pituitary extract injections increased the success rates to 18 percent and 35 percent respectively." (American Journal of Obstetrics and Gynecology; Old and New Methods for Induction of Labor and of Premature Labor; 1959; pages 396-97). But times were changing as we get farther into the 20th century and enter the study of ecbolics, and the more highly effective Oxytocin "Drip" (Theobald 1948), which is now administered by very highly controlled protocols and sophisticated steady drip pumps.  Oxytocin is considered a "physiologic" uterotonic agent because it is a hormone naturally released by women in labor from her body and the use of promotes regular intermittent uterine contractions (when used at normal therapeutic doses) that in timing and force mimic normal labor contractions. The first regimens were administered in a pill or pellet form, which was designed to be placed buccally for slow absorption. In the past two decades, the specific effects (of oxytocin and scientific studied of the chemistry of how it acts as a medicine or the pharmacokinetics) have been known. Standard dosing schemes now are done with well controlled formulas and generally are standardized to 10-U dilution in a 1,000 ml of an isotonic electrolyte solution. With the use of controlled infusion devised and standardized dilution protocols, the administration of continuous oxytocin is generally a safe and effective labor-induction technique. Most obstetricians still follow standard dosage protocols. However, a number of alternatives have come into play recently. Because of new understanding of the physiology of oxytocin, new approaches to induction and augmentation have come about. Dawood was one of the first to describe the use of oxytocin given in pulsatile fashion for the induction of labor. In a small prospective study of patients undergoing labor induction with pulsatile vs. continuous administration of oxytocin, the total dose, the average dose per minute, and the peak dose required per minute were significantly reduce with pulsatile oxytocin compared with continuous oxytocin infusion. Additional large-scale, prospective and randomized studies are still being done on labor induction, but we now know that intermittent pulsatile dosing because it allows for both the physiologic activity of oxytocin as well as providing a margin of safety in cases of uterine over activity or fetal heart rate compromise, or both. Other randomized trials suggest that there are a number of different dosing schemes, which can be used successfully, in the induction of labor. However, no single method is convincingly preferable to another.With the exception of some active management of labor protocols, most physician start doses with small amounts of oxytocin (0.5-2.0 mU/min). They then increase to 1-2 mU/min) every 30-60 minutes. Active management labor protocols were developed first in Ireland and were confirmed in prospective studies in the United States. These protocols suggest a more aggressive use of oxytocin, and in certain setting this is very safe. The Consortium for Safe Labor in the US studying over 5000 women at Washington University recently looked at their statistics and found that its important to not assume that the labor pattern in induced pregnancies is the same as in spontaneous labors. It does take longer to get into the the active phase which in their studies they defined as greater than 6 cm. More than half their patients took over a full day to get to that active stage. They also fond that being more patient between that 4-6 cm stage helped to avoid c-sections. Prior to 6 cm it can take over 10 hours for each cm of progress, but after 6, as long as women are progressing every 1-2 hours they are normal. Once the induction successfully gets a woman to 6 cm she is very likely to have a vaginal birth, and that methods which began more than half a century ago are now more effective than ever in achieving a safe vaginal birth!

Comments

  1. nice posting.. thanks for sharing..

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  2. Obstetrics is a practice that involves providing women with prenatal care during pregnancy, along with assisting with the birthing process. Obstetrics Boynton Beach

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