Suzzie Vehrs is a Birth Arts International Certified Birth Doula passionate about helping moms create healthy, happy birth experiences + have a full recovery afterwards.

What Is Misoprostol?

Misoprostol is a medication often used to start labor. It is usually given as a small pill orally, but sometimes the pill is given vaginally instead.

Misoprostol is a synthetic prostaglandin. A prostaglandin is a hormone-like substance that the body produces naturally. But in the case of misoprostol, it is created by a drug company. Prostaglandins play a vital role in regulating human physiology.

Prostaglandins can affect many bodily functions, including:

Blood flow, Blood clot formation, Healing, Inflammation, Labor induction, and Pain.

Want to know something interesting? Human sperm also contains a high amount of prostaglandins. Prostaglandins were first discovered in semen – which is why they are named after the prostate.

This is also why it has been suggested that sexual intercourse may be an effective means of starting labor or improving your Bishop Score – which is a number that tell you how likely an induction is to succeed.

If you are looking for a more natural induction route, sex may be part of a natural induction process.

But, right now, we are exploring misoprostol.

Misoprostol is used to encourage early labor. Once moms begin to have regular contractions, or reach about 4 cm dilated, or a Bishop Score between 4-6, usually the second part of labor is managed with another drug called Pitocin.

Are There Risks To Using Misoprostol To Induce Labor?

As we talk about the medicines used in labor, you may be surprised by some of the risks found here. You may also be surprised at how little their risks are discussed or how rarely they are acknowledged as they are offered to moms, especially as routine interventions.

One of the most common drugs used to start labor is called Cytotec. The generic name for this drug is Misoprostol. Either way you’re getting the same thing.

Guess what, though there are plenty of studies showing misoprostol can start labor, it’s actually used off label for this purpose. Cytotec/Misoprostol is actually only FDA approved to treat stomach ulcers! It is not FDA approved to induce labor.

Here are 3 things on the FDA Safety Sheet you should be aware of:

Misoprostol is sometimes used to soften the cervix or induce contractions to begin labor. Misoprostol is sometimes used to decrease blood loss after delivery of a baby. These uses are not approved by the FDA.
No company has sent the FDA scientific proof that misoprostol is safe and effective for these uses.
There can be serious side effects, including a torn uterus (womb), when misoprostol is used for labor and delivery.
A torn uterus may result in:
>severe bleeding,
>having the uterus removed (hysterectomy),
>and death of the mother or baby.

These side effects are more likely in women who have had previous uterine surgery, a previous Cesarean delivery (C-section), or several previous births.

While there are certainly points in time where induction with Misoprostol is the right choice, I firmly believe that each mother does deserve to know these risks.

Especially if an induction conversation is about an elective induction – just because she is at or nearing her due date and otherwise the picture of health. Let’s explore how often these catastrophes could happen when using misoprostol for induction.

How Common Are Catastrophic Events For A Mother After Misoprostol Induction?

There’s actually not a lot of detailed studies on the rare outcomes of misoprostol when used for an induction. Especially in full term mothers. But, we do have studies on what happens when miso is used in the second trimester for abortions. This gives us a much clearer picture of what the risk of a catastrophic or life threatening event is.

In one study, patients were categorized based on the history of C-section:

patients without history of C-section,
with one C-section
and more than one C-sections.

Uterine rupture occurred in 0.8% of the patients without C-section history, 1.4% in women with one previous c-section and 3.3% of women with more than one previous surgery.

You can see that these risks are rare. Another way to say that is that in 99.2% of cases, moms who have not had any prior surgeries will not encounter a uterine rupture, which is the main life threatening risk of using misoprostol for an induction.

Another way to say that is 1 out of 125 women using misoprostol for their induction without prior history of surgical births is likely to face a uterine rupture.

What Do These Numbers Look Like In Real Life?

But that said, In 2018, 27.1% of all births in the United States were induced. This is a dramatic increase from 9.5% in 1989 (the first year for which data are available). If we look at that year, almost 3.8 million women delivered a baby.

That means about 1,029,800 women potentially started labor with miso. If none of these women had previous surgical births (which we know is not true) more than 8,000 women faced a life threatening situation as a direct result of using the little pill used to start their labor.

It is important to note that not common is not the same as not impossible. And it is one of the reasons that it is important that inductions with misoprostol take place at the hospital where help is readily available in the event of an emergency.

What About Catastrophic Risks For Babies With A Misoprostol Induction?

In birth, we are always looking at risks to mothers and babies. It is one of the only places in medicine where there are two patients who may have needs that are sometimes aligned and sometimes conflicting.

Urgent and catastrophic risks to a baby after using misoprostol are quite low, but also, not impossible.

Urgent delivery after a mother taking her first dose of misoprostol happens in about 0.1% of cases. This would be caused by fetal distress that happens immediately after miso is given.

Again, with 3.8 million babies, 27% being induced, that’s just over 1,000 babies whose lives were in danger because of the choice to induce with miso. It’s a small percentage – but, each story is important and therefore it is important that these risks are disclosed.

Risk is an interesting thing to try to weigh. Some mothers can proceed confidently, knowing these risks are so small they are unlikely to affect them.

But, on the other hand, if you do end up as one of these mothers and were never told it was a possibility, you may rightly feel blindsided.

An Almost Urgent Delivery Birth Story After Misoprostol

My client Angie was one of the mothers whose baby had a strong and immediate reaction to misoprostol. Angie’s water had broken at 36 weeks. Right away, she came to the hospital. Upon arrival, her baby had a strong and encouraging heartbeat, and she was having contractions that were strong enough the monitor could see them, but she couldn’t yet feel them.

Her doctor recommended that she take miso to hopefully get her labor going a bit faster.

She had a lot of decisions to weigh. Since she was technically already having contractions, would walking and moving around be enough to get things going? What risks would increase as more time went by before her baby was born? She asked a lot of really good questions and ultimately decided Miso was her best option.

After she took the first dose. Within minutes, her body started having one long and strong contraction that her baby did not like. Her baby’s heart rate tanked during it. Her medical team immediately began to bring her back to the OR for surgery, while at the same time giving her a tocolytic, a medicine to stop contractions.

Luckily, by the time she was back to the OR, the medication to stop her contractions worked, and her baby stabilized.

But Angie’s Story Didn’t End In The OR

The OB knew she had hoped for a natural birth, and was quite supportive. Once her baby was stabilized, they ended up bringing her out of the OR, without surgery.

Once back in the delivery room, her labor picked up at a normal pace. She labored naturally for the rest of the evening. She didn’t have any more contractions that were too long or too strong, and her baby remained the picture of health through delivery. She delivered a healthy, and small little 36 week old baby without more miso or medication of any other kind, not even an epidural.

I was glad her team acted fast, and also happy for her that her natural birth plan ultimately worked out. Of course, surgery is preferable to significant fetal distress throughout labor. But, she didn’t have to face a choice between the two. Her baby had a moment of distress which was properly managed and returned to stable.

This was my first time seeing urgent fetal distress immediately after receiving misoprostol in an induction. While I am used to inductions being potentially long and slow with lots of ups and downs, this was a new experience for me.

Less Urgent Risks Of Misoprostol For Induction

Now, let’s talk about the more common, but less urgent risks of misoprostol for induction. The two most common risks when miso is used for an induction are increased incidence of dose-dependent tachysystole (too many contractions) and a nonreassuring fetal heart rate (FHR).

Recent studies have shown that these non reassuring heart rate patterns begin in up to 32% of patients in the first four hours of monitoring post-misoprostol.

To me that is quite a lot. 1 in 3 babies will have their heart rate patterns altered when using misoprostol for induction.

But, that doesn’t necessarily mean that these babies are in imminent danger.

Understanding A Baby’s Heart Rate Basics

You see, a baby’s heart rate tells us a lot about how they are doing.

As they are monitored, their heart rate can be ranked in three different categories.

Category 1 means a baby is doing very well, and is quite healthy.

Category 2 means this baby needs to be watched closely, but is generally likely safe to proceed.

Category 3 means they are in quite a bit of distress. Surgical birth is often the right decision for babies that are here.

If babies move from category 1 to category 2, they may still go on to be born vaginally. It is also possible that some babies that become category 2 can move back to category 1 with a break from contractions (like Angie’s baby who actually moved from category 1 to 3 then back to 1!)

But, if a baby is category 3, it may become appropriate to switch to a surgical birth plan.

Now you can see the dance we talked about in our cascade of intervention article. Unfortunately, it is nearly impossible to know before you start an induction with misoprostol how you and your baby will react.

Another positive note is that fetal heart rate abnormalities typically show up pretty quickly. Researchers have concluded that patients with no fetal heart rate abnormalities in the first hour after receiving misoprostol are at a low risk of developing adverse outcomes or to develop abnormalities as time goes by.

However, babies with any type of deceleration in the first hour are at higher risk of adverse outcomes and more fetal heart rate abnormalities.

What Is A Typical Misoprostol Induction Like – The Most Common Long And Slow Experience

So what if you are one of the 2/3rds of people whose babies and body doesn’t seem to mind misoprostol at all?

One of the most common ways people labor after misoprostol is for nothing to happen for quite a while.

I’ve had many clients who have started an induction in the evening who are able to mostly sleep through the night, being woken to take their next dose every 4 hours.

If a baby is healthy and doing well, these parents often fill the nighttime hours sleeping and their daytime hours by reading, drawing, watching shows, walking around the labor and delivery unit or pacing in their room, playing video games and ultimately just waiting for labor to start.

It can feel strange to have hours or days long wait for labor to start. But it is not abnormal at all.

What Are Different Ways Contractions Can Start After An Induction With Misoprostol?

Once contractions start, mothers must then change their focus from staying distracted and occupied to working through contractions. But, even then, everyone will not have the same experience.

It’s very normal for mothers to wonder what contractions will feel like.

Often contractions start of easy and inconsistent. Often these feel like period cramps. Sometimes the only reason a mom knows she is having contractions in the beginning is because the monitor is picking them up.

Sometimes moms will have a spurt of consistent contractions that last for a few hours, but seem to fade as the misoprostol moves out of her system and then pick up again after the next dose of miso is given.

Sometimes, it only takes one dose of misoprostol and a moms contractions will pick up and she will be in full on active labor. But this one doesn’t happen as often.

However, there is not a clear guideline to know if you will be in the group that starts right away or the group that has a significant waiting period before contractions pick up or if you will be in the group that has significant contractions that then fade away while you enter another period of waiting.

A typical induction can last anywhere from 12 hours to 3 days. In a 3 day induction, usually most of the time is spent sitting around waiting for something to happen. Getting from 0-5 cm dilated can take it’s time and that is just a part of the process.

What Is A Typical Misoprostol Induction Like When Contractions Start Soon

Every now and then, I will meet a family at the hospital at the beginning of a misoprostol induction, wait through the first hour to make sure all is well, then plan on taking off while they sleep.

Occasionally, I get a call back saying, guess what? That first dose worked and we’re having contractions!

Of course, as their doula and coach for contractions, I head back right away. Sometimes, these moms don’t even need to move on to Pitocin, because their body took the nudge into labor and their body takes over.

However, when it comes to inductions, I think most families expect to have this experience. When in my experience it is the exception to the rule.

Most families hope that labor will start right away.

But, in general, it is quite normal to have a pretty decent waiting period before contractions start or to have a pretty long waiting period after a series of contractions seemed to get labor started, but then contractions faded away or became less strong and efficient.

If things do start quickly, that great! But nothing is wrong or out of the ordinary if it takes a while for things to get going.

Does My Bishop Score Tell Me If My Induction Will Go Well Or Not?

Your doctor will likely begin an induction by checking your Bishop Score. This is a number calculated by seeing the position, consistency and dilation of your cervix. Typically, if you have a low Bishop score, providers start an induction with misoprostol. If you have a high Bishop score you may skip straight to Pitocin.

However, your Bishop Score might let providers guess about how your labor might unfold. But it is not a crystal ball that tells the future.

Take for example Renee and Poojabi. Both these women started their inductions with high Bishop Scores and at 4 cm dilated.

Renee labored for 8 hours and had a healthy baby. Poojabi still took 24 hours to be in active labor and ultimately choose a c-section when her baby’s heart rate was less than ideal hours after that.

Even though they started in very similar places, their experiences were very different.

Take another group of women, Madura, Cassie and Amy. These three all started labor with low Bishop scores. Madura and Cassie went from a tight 0 cm dilated, to a baby in about 12 hours! YAY! Amy also made it all the way through labor. Only it took 2 1/2 days. Again, they started in similar places, and had very different stories.

Looking at your Bishop Score may be good information, especially for your provider in determining which medication is most appropriate for you. But, it doesn’t really tell you what your future will be. I always encourage my moms to approach an induction with appreciation and wonder for how their body will find its way through the labor process.

Should I Choose An Induction With Misoprostol?

I wish I could tell you for certain whether you should or should not choose an induction.

Unfortunately, when it comes to labor, there are a lot of unknowns. There are absolutely times when an induction is a life saving gift. There are other times where the risk is not worth saving a few days of waiting for labor to start on it’s own.

I hope you will use this article to gather information and understand the wide range of normal when it comes to inductions.

I also hope it helps you engage in quality conversations with your specific health care provider who can advise you based on your specific situation.

What Are Alternatives To Misoprostol For Induction

You may be curious about what your other options are to start labor. And that will depend on what your goals are. If you are healthy, and want to simply increase your Bishop Score or hopefully nudge your body to go into labor a little bit sooner, there are simple things you can do to help with this goal. Walking 40 minutes a day, most days of the week, eating 6 dates a day, and expressing colostrum have all been shown to increase the Bishop Score and reduce the need for inductions.

If you are looking for methods that are more likely to start labor in the next 24 hours, you could explore membrane sweeps, castor oil and nipple stimulation.

Click on any of them to read a comprehensive article and gather information on each topic.

But please, make any decisions about induction with the help of your specific health care provider. It is impossible to know what is safe for any individual person or if any of these methods are safe for you or your baby specifically based on an article here on the web.

And remember, I am only a doula, not a midwife or doctor. These guides are strictly to help you gather information and help you engage in more detailed conversations with your provider.

Misoprostol For Induction Conclusion

Some things in life are both safe and inherently risky. Driving is one of those things. We know every time we get in a car we are taking a risk. But, the most reasonable expectation is that if we made judicious decisions along the way, we are likely to reach the end without trouble.

I feel the same way about Misoprostol for induction. It is rare to get in a life threatening situation when misoprostol is used judiciously.

But, just like driving, you can do everything right and unfortunately be the person that gets in an accident. It’s not impossible. Which is why it’s important for risks to be disclosed and for mothers to decide if it is really the best time for them to induce. After they’ve been counseled on all their options.

It is also quite common to have a bumpy or stressful road during an induction. But, like checking the weather before you leave on a road trip, you also know pretty early on if you are that 1 in 3 that has any fetal heart rate abnormalities in the first hour. If you make it past that, you’re likely in the clear for the time you are using miso.

And a bumpy road doesn’t necessarily mean danger, the end of the road or that things won’t work out. But it might. Surgical births can become the best option in inductions. And it is always an option available to you.

On the other hand, if you get past that first hour after miso with no changes, you can be pretty confident you will be make it through early labor just fine. In that case, sit back, have fun, and find things to enjoy until labor picks up!

Sources

Kavanagh, J, et al. “Sexual Intercourse for Cervical Ripening and Induction of Labour.” The Cochrane Database of Systematic Reviews, U.S. National Library of Medicine, 2001, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7017007/.

Center for Drug Evaluation and Research. “Misoprostol (Marketed as Cytotec) Information.” U.S. Food and Drug Administration, FDA, http://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/misoprostol-marketed-cytotec-information. Accessed 18 June 2024.

Jamali M, Bakhtiyari M, Arab F, Mirzamoradi M. Misoprostol complications in second-trimester termination of pregnancy among women with a history of more than one cesarean section. Obstet Gynecol Sci. 2020;63(3):323-9. [DOI:10.5468/ogs.2020.63.3.323] [PMID] [PMCID]

Golshahi, Fatemeh, et al. “Journal of Obstetrics, Gynecology and Cancer Research.” Home Browse Journal Info For Authors Submit Manuscript For Reviewers and Editors Contact Us Lessons Learnt from Cases of Misoprostol-Based Pregnancy Termination Followed by Uterine Rupture: Report of 3 Cases, Department of Obstetrics and Gynecology, Yas Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran 2 Department of Obstetrics and Gynecology Surgery, Yas Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran, 25 Oct. 2021, http://www.jogcr.com/.

Kandahari, Nazineen, et al. Fetal Heart Rate Patterns and the Incidence of Adverse Events after Oral Misoprostol Administration for Cervical Ripening among Low-Risk Pregnancies, The Journal of Maternal-Fetal & Neonatal Medicine , 9 Apr. 2023, http://www.tandfonline.com/doi/full/10.1080/14767058.2023.2199344.

Births: Provisional Data for 2018, http://www.cdc.gov/nchs/data/vsrr/vsrr-007-508.pdf. Accessed 18 June 2024.

Understanding Misoprostol For Induction: A Mom’s Guide