Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Hand washing
- Ian A Laing (6 March 2006)
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Misoprostol for Induction of Labour; time for the Royal College to respond.
- Rajvinder Khasriya, Amali U. Lokugamage. Consultant Obstetrician and Gynaecologist, The Whittington Hospital. (20 May 2006)
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Ian A Laing, Consultant Neonatologist Simpson Centre for Reproductive Health, Edinburgh EH16 4SU
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Dear Authors Congratulations on your article. My response is actually to the photograph on the front cover of the British Medical Journal, and I have e-mailed the following to the Editor. Best wishes Ian Laing Dear Editor In the Neonatal Intensive Care Unit we demand that all staff remove their jewellery at the beginning of each shift. Anyone wearing a watch or dress ring is deemed not to have washed his/her hands. "Naked from the elbows down" is the _expression in common usage. Visiting surgeons and all other disciplines now comply with our regulations. It was therefore with some disappointment that I viewed the cover photograph of the BMJ showing a mother squatting in labour. The midwife's watch on her left wrist is disappearing into the groin of the labouring woman. When will we take this subject seriously? Yours sincerely Ian Laing Competing interests: None declared |
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Rajvinder Khasriya, Specialist Registrar in Obstetrics and Gynaecology The Whittington Hospital, Amali U. Lokugamage. Consultant Obstetrician and Gynaecologist, The Whittington Hospital.
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We were interested to read the article “Misoprostol for induction of labour at term: randomised controlled trial” by Dodd et al. In recent years there has been a great interest in the use of misoprostol for induction of labour. This research article highlights some very important issues; the best dose regimen to use, tailoring dose to patient characteristics, safety issues, patient approval of route of administration and cost effectiveness. A safe yet effective dose regimen of misoprostol remains to be determined. Doses of 20 mcg, 25mcg, 50mcg, 100mcg have all been studied. The 50mcg vaginal dose results in a shorter induction to delivery time1,2, however, the American College of Obstrecians and Gynaecologists have recommended a vaginal dose of 25mcg for induction of labour due to a lower incidence of uterine hyper-stimulation. They also suggested a 3-6 hour dosing regimen; that oxytocin should not be administered less than four hours after the last misoprostol dose; induction of labour to be managed in a hospital; and that misoprostol should not be used for cervical ripening in patients with a uterine scar.3 This study did not take into account dosing regimens tailored to patient characteristics, which are predictors of the likelihood of success. Doses may have to be tailored to parity, initial cervical dilatation and gestational age.4 Sublingual doses may lead to a reduction in the total dose delivered.5 Administration of smaller doses remains a difficult task as currently misoprostol is prepared in 100mcg or 200mcg tablets and subsequently these tablets need to be divided, giving rise to possible inaccuracies in administration. Licensing of pre-prepared smaller doses is imperative for safe usage of this drug. A good experience of the induction process and labour is of paramount importance. The patients using misoprostol in this trial gave better feedback about their experience of induction. Oral misoprostol offers a less invasive alternative for induction of labour. In addition, oral misoprostol could potentially reduce the rate of iatrogenic chorioamnionitis by reducing the number of vaginal examinations. It is interesting to note that more than 60 systematic reviews6 have assessed the use of misoprostol in Obstetrics and is now recognised by the Food and Drug Agency for its use in induction of labour. With such burgeoning interest in the drug and increasing use, we feel it is necessary for the Royal College of Obstetricians and Gynaecologists to produce contemporary guidelines on the use of misoprostol. References 1.Garry D, Figueroa R, Kalish RB, Catalano CJ, Maulik D. Randomized controlled trial of vaginal misoprostol versus dinoprostone vaginal insert for labor induction. J Matern Fetal Neonatal Med 2003; 13(4):254- 259. 2.Lokugamage AU, Forsyth SF, Sullivan KR, El Refaey H, Rodeck CH. Dinoprostone versus misoprostol: a randomized study of nulliparous women undergoing induction of labour. Acta Obstetricia et Gynecologica Scandinavica 2003; 82(2): 133-137. 3.ACOG Committee Opinion. American College of Obstetrician and Gynecologist. ACOG Committee Opinion. Number 283, May 2003. New U.S. Food and Drug Administration labelling on Cytotec ( misoprostol) use and pregnancy. Obstetrics & Gynecology 2003; 101 (5 Pt 1): 1049-1050. 4.Wing DA, Tran S, Paul RH. Factors affecting the likelihood of successful induction after intravaginal misoprostol application for cervical ripening and labor induction. American Journal of Obstetrics & Gynecology 200; 186(6):1237-1240. 5.Shetty A, Mackie L, Danielian P, Rice P, Templeton A. Sublingual compared with oral misoprostol in term labour induction: a randomised controlled trial. British Journal of Obstetrics & Gynaecology 2002; 109(6):645-650. 6.Khan RU, El Refaey H. Pharmacokinetics and adverse-effect profile of rectally administered misoprostol in the third stage of labor. Obstetrics and Gynecology 2003; 101 (5 Pt 1):968-974 7.Reference to 60 systematic reviews from Cochrane database of systematic review. Competing interests: None declared |
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