A novel method for giving misoprostol to induce labor: patient considerations and clinical utility

Noah Jonson^*

Department of Pharmacology, University of Milan, Italy

Abstract

One of the most common obstetric procedures is inducing labor, and as the reproductive population in developed nation’s changes, this procedure is likely to become more common. There is a constant search for more effective methods to induce labor while maintaining fetal and maternal safety and patient satisfaction as the proportion of women undergoing induction increases. Methods for achieving active labor and vaginal delivery are constantly under investigation due to the fact that nearly half of induced labors necessitate cervical ripening. Prostaglandins have been shown to be effective inducing labor, and specifically vaginal misoprostol, which can be used without a prescription to start cervical ripening and active labor, has been widely used. The difficulty lies in accurately administering this medication while maintaining the ability to stop taking it when necessary. Utilizing a delivery system that regulates the release of the medication and can be quickly removed, the misoprostol vaginal insert initiates cervical ripening. The misoprostol vaginal insert’s design, development, and clinical utility for inducing labor are examined in this paper, as are patient concerns regarding the delivery method.

One of the most common obstetric procedures is inducing labor, and as the reproductive population in developed nation’s changes, this procedure is likely to become more common. There is a constant search for more effective methods to induce labor while maintaining fetal and maternal safety and patient satisfaction as the proportion of women undergoing induction increases. Methods for achieving active labor and vaginal delivery are constantly under investigation due to the fact that nearly half of induced labors necessitate cervical ripening. Prostaglandins have been shown to be effective inducing labor, and specifically vaginal misoprostol, which can be used without a prescription to start cervical ripening and active labor, has been widely used. The difficulty lies in accurately administering this medication while maintaining the ability to stop taking it when necessary. Utilizing a delivery system that regulates the release of the medication and can be quickly removed, the misoprostol vaginal insert initiates cervical ripening. The misoprostol vaginal insert’s design, development, and clinical utility for inducing labor are examined in this paper, as are patient concerns regarding the delivery method.

Keywords

Reproductive population • Active labor• Vaginal delivery• Cervical ripening• Maternal Safety

Introduction

Obstetricians, nursing units, and most importantly mother-baby pairs have faced difficulties for decades with induction of labor, also known as the iatrogenic provocation of contractions prior to the onset of spontaneous labor in order to achieve a vaginal delivery. This rate has consistently increased in the UK, with rates of induction at around 23% in England, Scotland, and Wales in 2012, and this trend is predicted to continue.3–5 Although previously thought to increase the cesarean delivery rate, more recent literature demonstrates that induction of labor is not associated with increased cesarean rates.6–8 While no large prospective trials have been conducted to confirm this, some authors of retrospective reviews comment that induction of labor may be associated with a decreased cesarean delivery rate, with no difference The results of this trial may lead to more women being offered induction earlier in the term and late in the term, even though no changes to current guidelines have been made as of yet [1].

Maintaining the flow of patients from labor and delivery to the postpartum unit while providing quality, patient-centered care can be difficult, and this balance may become more difficult as the number of women undergoing induction continues to rise. Labor induction can frequently be a lengthy procedure. Induced labors, regardless of the indication, can last several days and necessitate extensive discussion to manage patient expectations. The impact of a failed induction must also be acknowledged, despite the ongoing debate regarding the connection between induction and cesarean delivery. For unsuccessful induction, 10% of cesarean deliveries in the United States are performed [2, 3].

There are hopes that the rate in the United States will decrease as a result of a workshop with the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists proposing a more explicit definition of induction failure. The likelihood of a vaginal delivery is lower after induction compared to spontaneous labor, particularly in primiparous women who have an unfavorable cervix [4, 5].

Description

Misoprostol insertion procedure

Misoprostol, the active ingredient, is dispersed throughout the polymer matrix of the MVI, which is a single-application, removable, controlledrelease vaginal delivery system. It is made from a hydrogel polymer that is not biodegradable. After that, an inert, woven retrieval tape houses this polymer. This is the same polymer that is utilized in the retrieval tape that is currently licensed for delivery of dinoprostone and is marketed as the dinoprostone vaginal insert [6]. The reservoir of 200 g of misoprostol is released at a mean rate of approximately 7 g/hour while the insert remains in place. This enables constant dosing over a 24-hour period with the benefit of being able to quickly and easily Misoprostol’s pharmacodynamics and metabolism are discussed, as well as labor physiology and the drug’s mechanism of action [8, 7].

Patients perception

When choosing an induction method, patient satisfaction should be taken into consideration because labor induction can be a lengthy and exhausting process for women. Women’s experiences with induction of labor are understudied. Women who were induced were less likely to be satisfied with their birth experience, and they cited staff shortages along with feelings of neglect, pain, and anxiety in relation to starting the induction. They also reported feelings of plans not being followed, wasted effort, and pain, as well as feeling let down and disappointed if unsuccessful. 40% of the women they surveyed felt that the speed of their induction was the most important aspect they would change if they needed to undergo another induction [9, 10].

Conclusion

It is critical to improve and develop faster and more effective methods of induction as the percentage of women undergoing it continues to rise. Staffing, timing, safety, and the patient experience of induction of labor can be difficult, so it’s important to find ways to speed up delivery while still keeping the mother and baby safe. Misoprostol’s effectiveness as a labor induction agent is well known, but the current dosage methods are flawed because they cannot be completely accurate or discontinued. The 200 g MVI is a safe and effective delivery system for women undergoing induction of labor who have an unscarred uterus and is a valuable alternative to the labor induction agents that are currently available. It provides controlled release of misoprostol that can be interrupted immediately.

References

1. Kolas T, Hofoss D, Daltveit AK et al. Indications for cesarean deliveries in Norway. Am J Obstet Gynecol. 188, 864-870 (2003).

Indexed at, Crossref, Google Scholar

2. Spong CY. Defining “term” pregnancy: recommendations from the Defining “Term” Pregnancy Workgroup. JAMA. 309, 2445-2446 (2013).

Indexed at, Crossref, Google Scholar

3. Caughey AB. Induction of labour: does it increase the risk of cesarean delivery? BJOG. 126, 658-661 (2014).

Indexed at, Crossref, Google Scholar

4. Mealing NM, Roberts CL, Ford JB et al. Trends in induction of labour, 1998–2007: a population-based study. Aust N Z J Obstet Gynaecol.  49, 599-605 (2009).

Indexed at, Crossref, Google Scholar

5. Vrouenraets FP, Roumen FJ, Dehing CJ et al. Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Am J Obstet Gynecol. 105, 690-697 (2005).

Indexed at, Crossref, Google Scholar

6. Powers BL, Wing DA, Carr D et al. Pharmacokinetic profiles of controlled-release hydrogel polymer vaginal inserts containing misoprostol. J Clin Pharmacol. 48, 26-34 (2008).

Indexed at, Crossref, Google Scholar

7. Castaneda CS, Izquierdo Puente JC, Leon Ochoa RA et al. Misoprostol dose selection in a controlled-release vaginal insert for induction of labor in nulliparous women. Am J Obstet Gynecol. 193, 1071-1075 (2005).

Indexed at, Crossref, Google Scholar

8. Ewert K, Powers B, Robertson S et al. Controlled-release misoprostol vaginal insert in parous women for labor induction: a randomized controlled trial. Obstet Gynecol. 108, 1130-1137 (2006).

Indexed at, Crossref, Google Scholar

9. Wing DA, Miller H, Parker L et al. Misoprostol Vaginal Insert Miso-Obs-204 Investigators. Misoprostol vaginal insert for successful labor induction: a randomized controlled trial. Obstet Gynecol. 117, 533-541 (2011).

Indexed at, Crossref, Google Scholar

10. Facchinetti F, Fontanesi F, Del Giovane C. Pre-induction of labour: comparing dinoprostone vaginal insert to repeated prostaglandin administration: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 25, 1965-1969 (2012).

Indexed at, Crossref, Google Scholar