OB-GYN-L Messages for May, 2000: Re: new case

Re: new case

From: Steve & Eryl Raymond

eryl@intekom.co.za

Tue May 30 15:12:24 2000

It seems very likely to me that the rupture occurred after the second dose and just before the contractions stopped. The sequence of events is typical: - Strong contractions - Pain - Tachycardia - Cessation of labour

I can see how the interpretation of the lack of contractions to mean a need for oxytocin can come about. However, we can all learn from this case - be very aware that Misoprostol has had some studies showing an increase in incidence of rupture. These probably can be explained by using too large or frequent a dose in the early days of experience. This means looking out for the signs whenever it is used. (And not using oxytocin within 7 or 8 hours of the last dose - which was not the case here). >
> these are the facts. The woman received 2 25 mcg doses of misoprostil,
> 4-6 hours apart. Our institutional protocols state that doses will not
> be repeated if contractions are more frequent q 3-4 minutes. The
> second dose was given only because she was *not* contracting. After
> the second dose she had a brief period of very painful contractions,
> and developed tachycardia. The contractions then stopped. Not
> detectable on the monitor and not reported by the woman. At the time
> of the next dose, the cervix was 4cm, so the miso was not given. She
> was transferred to the labor floor. At this point it is about 7 hours
> after the last miso dose, she was not contracting, cervix was 4cm. I
> do not think pitocin was an unreasonable plan....remember, this was a
> dead fetus. Would like to know what other list members would have
> done.

We delivered 8000 babies last year and have a regular occurrence of uterine rupture in both scarred and unscarred uteri. For this reason all the staff know the signs and have a high index of suspicion about someone who stops contracting. This means a low threshhold to do a Caesar, and a very healthy respect for induction by whatever means. Lately we have had good results with oral misoprostol - 200 ug dissolved in 200ml and administered at a dose of 20 ml two hourly for three doses followed by 40 ml two hourly for another three doses if not contracting. We use this for multipara for whom we would never use intra vaginal administration > I can only speak for the experience of my practice. Have no idea what
> the institutional experience is. I have worked in this collaborative
> practice for 16 years, and we've averaged 600+ births/year during that
> time. So, let's round it off to 10,000 births for which I have
> personal knowledge.
>

Using oxytocin to induce someone with a scarred uterus is asking for trouble. In fact a good question is, why induce a "VBAC" at all. I still think a trial of scar should be spontaneous labour. > This was the only rupture in an "unscarred" uterus. In the past 6
> months I have had 2 uterine ruptures in VBAC attempts....both were
> induced with pitocin for fetal indications. Also during my tenure with
> this group we have had 1 spontaneous rupture, at home, in a woman with
> prior C/S during early labor. No other ruptures.

A healthy respect for misoprostol until the right regime is clearly worked out is required.

Dr. Steve Raymond Head of Department of O & G Empangeni Hospital Empangeni SOUTH AFRICA 3880 Ph:(+27)(035)77721111

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