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REVIEW: ACOG Committee Opinion on Approaches to Limit Intervention During Labor and Birth

Posted on March 7, 2017 at 6:24 PM Comments comments (238)
Note: all words in this piece that are in “quotation marks” are excerpts or quotes from the ACOG Committee Opinion published February 2017.  HERE is that article.

The American College of Obstetrics and Gynecology just came to a very important conclusion in THIS Committee Opinion that was published in February 2017:
“Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. In addition, some women may seek to reduce medical interventions during labor and delivery. Satisfaction with one’s birth experience also is related to personal expectations, support from caregivers, quality of the patient–caregiver relationship, and the patient’s involvement in decision making (57). Therefore, obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor.”
Yes, it is a little frustrating that it has taken years for the doctors who manage pregnancy, labor and birth to acknowledge that less intervention is best for birth outcomes.  However, I am grateful that ACOG has caught up with Dr. Bradley and all the other proponents of dignity in birth that know “It’s not nice to fool Mother Nature.”
The part that interests me the most as a childbirth educator is how they treat the topic of pain relief and coping techniques in labor.  There is the acknowledgement that, “pharmacologic methods mitigate pain, but they may not relieve anxiety or suffering. “
And then this statement:
“None of the nonpharmacologic techniques have been found to adversely affect the woman, the fetus, or the progress of labor, but few have been studied extensively enough to determine clear or relative effectiveness.”
So there is finally the recognition that nonparmacologic techniques do not adversely affect the woman, the fetus or the progress of labor. And to CYA, they have to state that there is no conclusive study to determine effectiveness.  Be that as it may, it doesn’t matter to me as a childbirth educator if a study can measure the effectiveness.  What I do know as an educator and a doula is that if the mother perceives a pain coping practice as effective, it is being effective for her in that moment.
The key to continuing that pain coping practice hinges on two questions: “Is the mother okay? Is the baby okay”” As long as both the mother and the baby continue to tolerate the intensity of labor, then the conclusion effectively says LEAVE THEM ALONE.
In the article there are two distinctions between pain coping practices:
The pain coping practices that have been studied and, “have all demonstrated statistically significant reductions in pain in many studies”
Water immersion consistently has been found to lower pain scores (8, 34).
Intradermal sterile water injections
Relaxation techniques
“Other techniques may help women cope with labor more than directly affect pain scores”
Childbirth education
Transcutaneous electrical nerve stimulation [TENS]
Here are some more areas of discussion in the committee opinion that bring obstetric care into the humane versus management for their convenience.  I have included the corresponding bullet points from the summary and also provided some lay-person translation as needed.
Latent Labor: Labor Management and the Timing of Admission
·       “For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.”
IN OTHER WORDS: If your baby is head-down when you start labor, then your labor management can be individualized and include intermittent fetal monitoring (freedom to move as labor indicates) instead of continuous fetal monitoring (thus anchored to the bed) AND mother is free to try any method of pain relief of non-drug pain relief that she would like to try.
·       “Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.”

IN OTHER WORDS: If your labor has started and your bag of waters is intact, there is no rush to admit you to the labor and delivery ward.  If the mother is okay and the baby is okay, phone contact and support from your care provider is the order of the day, and the mother is free to continue with any non-drug pain coping practice that is working for her.
Term Premature Rupture of Membranes
·       Obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term premature rupture of membrane (PROM [also known as prelabor rupture of membranes]) who are considering a period of expectant care of the potential risks associated with expectant management and the limitations of available data. For informed women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for a period of time may be appropriately offered and supported. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.
If your bag of water breaks and you are not GBS-positive, you as the patient can decline immediate induction and this committee opinion instructs the care provider to support the patient in that choice.  If you are informed, you also know this includes declining vaginal exams that have the potential to introduce infection and that water immersion is an available pain coping practice (see Henci Goer’s Thinking Woman’s Guide to a Better Birth”).
What bothers me a little is that if a woman is not informed, it sounds like they are going to railroad her into the immediate induction route.  Yuck.
As for women who are GBS-positive, the recommendation is to admit the patient and start the administration of antibiotics.  The committee says that the preference is for immediate induction, but it doesn’t say one way or the other that it is the best practice.  You can go back to those two important questions, “Is mom okay? Is baby okay?” If you get YES answers to both of those questions, you may think about getting the antibiotics and then postponing anything else that is offered until there is a medical indication “to do something”.
Continuous Support During Labor
·       “Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor.”
Routine Amniotomy
·       “For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.”
IN OTHER WORDS: Amniotomy is the artificial breaking of the bag of waters.  You can read the info sheet on this procedure HERE. What this committee opinion states clearly is that THERE IS NO REASON to break the bag of waters if labor is progressing and there is no evidence of fetal compromise.  Not to “help things along”.  Not to “speed labor”.  Not “to see what happens”. NONE. DO NOT break the bag of waters.
The only reason stated for breaking the bag of waters is in the case of the need of an internal fetal monitor. This monitor is screwed into the baby’s fontanel, so in order to facilitate access to said fontanel, the bag of waters needs to be out of the way.
Intermittent Auscultation
·       “To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor.”
IN OTHER WORDS: Get with the program and learn how to do labor evaluation with a hand-held Doppler device.  P.S.: Midwives have been doing this for years.
There are many risks associated with continuous fetal monitoring – for more information I recommend you read THIS Cochrane review that shows how a decrease in fetal monitoring increases positive birth outcomes.  There are many cases of false positives with continuous fetal monitoring.  These false positives result in a more aggressive management of labor that often leads to an increase in unnecessary cesarean birth outcomes.  While there is a time and a place and much gratitude for cesarean births that are needed, it is devastating for a mother to read her operative report and realize that her cesarean birth could have been avoided with a different approach to her care.
Techniques for Coping With Labor Pain
·       “When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.”
IN OTHER WORDS: Don’t push the epidural if the patient wants to try some other things first.
·       “Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions to best meet the needs of each woman.”
IN OTHER WORDS: Treat your patients as individuals!! What works for one does not work for all.  And pain is not the only marker for labor management.  As stated in the committee opinion, “pharmacologic methods mitigate pain, but they may not relieve anxiety or suffering.“  If the mother can handle the pain and is doing something that does reduces anxiety or suffering, that is ok.  It may be hard to watch, however, doing nothing is fine as long as the mother and the baby are doing well.
Hydration and Oral Intake in Labor
“Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. Although safe, intravenous hydration limits freedom of movement and may not be necessary.”
IN OTHER WORDS: Routine use of IV fluids is out!! Yeah!! The whole tone of this committee opinion is to treat patients as individuals, so if there is no medical indication and the patient declines routine IV, then leave her to labor without IV fluids.
HERE  is the summary of research presented at the Anesthesiology® 2015 Annual Meeting.  It states that, “most healthy women can skip the fasting and, in fact, would benefit from eating a light meal during labor…improvements in anesthesia care have made pain control during labor safer, reducing risks related to eating”.
Maternal Position During Labor
·       “Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.”
IN OTHER WORDS: As long as labor is progressing and mom and baby are well, let a mom labor in whatever position she deems useful.  When it’s time to monitor the baby, any position that allows for monitoring to happen is still acceptable. The easiest for the nurse and the most uncomfortable position for the mother/baby is to have the mother lie on her back (supine).  According to this committee opinion, other positions are now within range of acceptable.  Positions such as side lying, hands and knees, or tailor sitting are all examples of other positions that allow for fetal rotation and engagement in the pelvis while keeping the mother still enough to undergo fetal monitoring.
Second Stage of Labor: Pushing Technique
·       “When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding outcomes of spontaneous versus Valsalva pushing, each woman should be encouraged to use the technique that she prefers and is most effective for her.”
IN OTHER WORDS: Don’t tell a woman how to push.  If she follows her instincts, the baby will come out.  Valsalva pushing is when a woman is directed to do forceful pushing during a contraction for a certain count with no regard to what her body is doing physiologically.  Physiological pushing allows for a woman to work with her contractions: as she feels the peak, she will push as long as is comfortable. End of story.
Immediate Versus Delayed Pushing for Nulliparous Women With Epidural Analgesia
·       “In the absence of an indication for expeditious delivery, women (particularly those who are nulliparous with epidural analgesia) may be offered a period of rest of 1–2 hours (unless the woman has an urge to bear down sooner) at the onset of the second stage of labor.”
IN OTHER WORDS: “Nulliparous” means a woman that has not given birth before.  Unless there is a medical reason for the baby to be born as soon as possible, women, including those who have epidural analgesia, are to be allowed a time period between the time they are completely dilated (10 cm) and pushing.  If the woman is monitored and both she and baby are shown to be well, up to two hours can be allowed for the baby to descend into a position that creates the urge to push, thus making the pushing phase more effective.
Sometimes the cervix is open and the baby is still high in the pelvis, thus there is no urge to push.  When the pushing phase begins before there is an urge to push, this effectively “starts the clock” by which a care provider or hospital policy may deem it necessary to intervene with a vaginal operative birth (vacuum or forceps delivery) or a cesarean birth. 
I hope this little review offers you the confidence as a consumer to advocate for what you know is right for you and your baby.  Our inner wisdom about birth is present and powerful if we can allow it a voice in our labor space.

The material included in this blog is for informational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation.  Krystyna and Bruss Bowman and Bowman House, LLC accept no liability for the content of this site, or for the consequences of any actions taken on the basis of the information provided.  This blog and video contain information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained in this video and on our blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.
Birthing From Within and Bradley Method® natural childbirth classes offered in Arizona: convenient to Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale

Info Sheet: Amniotomy

Posted on February 6, 2015 at 9:23 AM Comments comments (663)
Amniotomy, Artificial Rupture of the Membranes, AROM - Info sheet for Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, Payson
Amniotomy, also known as Artificial Rupture of the Membranes (AROM) is the surgical rupture of fetal membranes to induce or expedite labor.

American Heritage Medical Dictionary

Amniotomy is used to start or speed up contractions and, as a result, shorten the length of labour.
Artificial rupture of the amniotic membranes during labour, sometimes called amniotomy or ’breaking of the waters’ was introduced in the mid-eighteenth century, first being described in 1756 by an English obstetrician, Thomas Denman (Calder 1999). Whilst he emphasized reliance on the natural process of labour, he acknowledged that rupture of the membranes might be necessary in order to induce or accelerate labour (Dunn 1992). Since then, the popularity of amniotomy as a procedure has varied over time (Busowski1995), more recently becoming common practice in many maternity units throughout the UK and Ireland (Downe 2001; Enkin 2000a ; O’Driscoll 1993) and in parts of the developing world (Camey 1996; Chanrachakul 2001; Rana 2003). The primary aim of amniotomy is to speed up contractions and, therefore, shorten the length of labour.
The first recorded use of amniotomy in the United States was in 1810; it was used to induce premature labor. Amniotomy and other mechanical methods remained the methods of labor induction most commonly employed until the 20th century. Amniotomy, or artificial rupture of the amniotic membranes, causes local synthesis and release of prostaglandins, leading to labor within 6 hours in nearly 90% of term patients. Turnbull and Anderson found that amniotomy without additional drug therapy successfully induced labor in approximately 75% of cases within 24 hours.
  • Amniotomy was associated with a reduction in labour duration of between 60 and 120 minutes in various trials
  • There was a statistically significant association of amniotomy with a decrease in the use of oxytocin: OR = 0.79; 95% CI = 0.67-0.92 in several randomized trials
  • AROM does not involve any type of medication to mom or baby and is considered by some to be the most “natural” means of induction in a hospital setting.
  • In several randomized trials there was a marked trend toward an increase in the risk of Cesarean delivery: OR = 1.26; 95% Confidence Interval (CI)=0.96-1. 66.
  • Trial reviewers suggest that amniotomy should be reserved for women with abnormal labour progress.
  • In 15 studies containing 5583 women there was no clear statistically significant difference between women in the amniotomy and control groups in length of the first stage of labour
  • Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged.
  • [Once membranes are broken} most obstetricians want the baby birthed as soon as 6 hours post-onset to reduce the risk of infection from the introduction of bacteria into the vagina due to repeated vaginal exams. Some obstetricians will wait as long as 24 hours but that is less common. In contrast, midwives, who do not routinely perform cervical checks unless specifically indicated or requested, thus limiting the chance of infection, will often allow up to 36-48 hours as long as no indications of an active infection are present.
  • A large study of 3000 women’s opinions of the intervention was conducted by the National Childbirth Trust (1989). Two thirds of the women in this study reported an increase in rate, strength and pain of contractions following membrane rupture; they found these contractions more difficult to cope with, needed more analgesia and felt that the physiology of labour was disturbed.
  • When there is concern that labour is slowing down, benign measures to intensify contractions such as positional changes and movement may prevent the need for more invasive interventions (Simkin 2010). The Cochrane review of maternal positions and mobility during first stage labour supports the positive impact mobility has in shortening labour (Lawrence et al. 2009).
  • Smyth et al. 2007 studies showed that amniotomy is not an effective method of shortening spontaneous labour and increases the risk of caesarean section and more fetal heart abnormalities

*Link List
 For further exploration on your part

What do you think? Is this an option you would consider, or that you chose for during your birth?

Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, PaysonDisclaimer: 
The material included on this site is for informational purposes only.
It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation.  Krystyna and Bruss Bowman and Bowman House, LLC accept no liability for the content of this site, or for the consequences of any actions taken on the basis of the information provided.  This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.


Info Sheet: Stripping Membranes

Posted on April 18, 2014 at 7:04 PM Comments comments (213)

The information below is paraphrased and/or quoted from the listed sources.

*Definition of the procedure
Stripping Membranes
Stripping membranes, sometimes called "sweeping of the membranes" or "membrane sweeping", is a method used to try to start labor. The health care provider puts her or his finger into the cervix – the mouth of the uterus – and uses the finger to separate the bag of waters from the side of the uterus near the cervix. This releases local prostaglandins/hormones that can trigger contractions. It can be done in your doctor or midwife's office.
The National Institute for Health and Clinical Excellence (NICE) notes that for the purpose of it's guideline, membrane sweeping is regarded as an adjunct to induction of labor rather than an actual method of induction.
  1. http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000000669/Stripping%20Membranes.pdf
  2. http://www.medscape.com/viewarticle/703499
  3. http://www.webmd.com/baby/guide/inducing-labor?page=2
  4. http://www.guideline.gov/syntheses/synthesis.aspx?id=24079
Sweeping (or stripping) the membranes (sometimes referred to as a 'strip and stretch') is an old method of induction that was first documented in the year 1810.

The available evidence suggests that sweeping the membranes promotes the onset of labor. For women thought to require induction of labor, a reduction in the use of more formal methods of induction could be expected. For women near term (37 to 40 weeks of gestation) in an uncomplicated pregnancy there seems to be little justification for performing routine sweeping of membranes. Sweeping of the membranes is probably safe, provided that the intervention is avoided in pregnancies complicated by placenta praevia or when contraindications for labor and/or vaginal delivery are present. There is no evidence that sweeping the membranes increases the risk of maternal and neonatal infection, or of premature rupture of the membranes. However, women’s discomfort during the procedure and other side-effects must be balanced with the expected benefits before submitting women to sweeping of the membranes.
According to the American College of Obstetricians and Gynecologists (ACOG), stripping membranes increases the likelihood of spontaneous labor within 48 hours and reduces the incidence of induction with other methods.
  1. http://www.birth.com.au/induced-labour/sweeping-the-membranes-for-induction-about#.UydpR_0q6DE
  2. http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CC4QFjAB&url=http%3A%2F%2Fwww.update-software.com%2Fpdf%2Fcd000451.pdf&ei=42knU-W_B8vwoASYlIDYAw&usg=AFQjCNG1TDfgdKgCsUPnWdnaq63XUBCU6w&bvm=bv.62922401,d.cGU


  • It is a drug free…method of stimulating labor
  • It may mean you avoid further intervention
  • You can have it performed at home or in your health care providers office
  • Spontaneous delivery is more likely
  • Has been found to reduce the risk of post term gestation, or pregnancy continuing past 41 weeks.


  1. http://www.birth.com.au/induced-labour/sweeping-the-membranes-for-induction-about#.UydpR_0q6DE
  2. http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CC4QFjAB&url=http%3A%2F%2Fwww.update-software.com%2Fpdf%2Fcd000451.pdf&ei=42knU-W_B8vwoASYlIDYAw&usg=AFQjCNG1TDfgdKgCsUPnWdnaq63XUBCU6w&bvm=bv.62922401,d.cGU

In a randomized trial of 274 women, the women who underwent membrane sweeping had:

  • Higher spontaneous vaginal delivery rate (69% vs 56%, P=.041)
  • Shorter induction-to-delivery interval (mean 14 vs 19 hours, P=.003)
  • Fewer requirements for oxytocin (46% vs 59%, P=.037)
  • Shorter duration of oxytocin infuson (mean 2.6 vs 4.3 hours, P=.001)
  • Greater satisfaction with the birth process

Source: http://www.obgmanagement.com/home/article/membrane-sweeping-and-gbs-a-litigious-combination/08f78b0aa97dff9559c698c2bc0658ba.html#1809OBGM_Article2-box1

  • Possible discomfort during procedure
  • Possible discomfort after procedure
  • Possible abdominal cramping after procedure
  • Possible spotting after procedure
  • The cramping that may occur in the 24 hours after your membranes are stripped can make it hard to rest or sleep; this means that you might lose some sleep before actually going into labor. 

  • Some people worry that membrane stripping may cause the bag of water to break or cause mothers or babies to become sick. Studies have found that membrane stripping does not make them more likely.
  • Possible risk of spreading infection for mothers that are GBS positive

Source: http://www.medscape.com/viewarticle/703499
*Links with other options to explore

Was this intervention part of your birth story? What is your insight? 
Please leave us a comment - it will be moderated and posted. 
Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, PaysonThe material included on this site is for informational purposes only.
It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation.  Krystyna and Bruss Bowman and Bowman House, LLC accept no liability for the content of this site, or for the consequences of any actions taken on the basis of the information provided.  This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.


Warning Labels: Drugs Used for Augmentation

Posted on June 21, 2013 at 11:07 AM Comments comments (133)
When looking up the drugs used that stimulate uterine contractions, Oxytocics, I also noticed that this post needs to include the drugs that are used to reverse the effect of those drugs, a group called Tocolytics.  As with the two previous posts in this series, I have listed the FDA Pregnancy category, included links to the complete drug profiles, and then pulled out the warning, adverse reaction, and contraindication sections for you to read right here and right now.

To be clear – we are not anti-care provider or anti-drug.  We are grateful for modern medicine that saves lives in circumstances when Mother Nature needs help.  It exists for a reason, and we are thankful for the opportunity to meet all the Healthy Moms and Healthy Babies when we hold a class reunion.

We are passionate about helping families have their Best Possible Birth.  By that we mean the path that leads each individual family to a Healthy Mom, Healthy Baby outcome.  We want families to have a toolbox full of tips and techniques that help them manage the ebb and flow of labor.  We want them to be comfortable with the path of a normal, low-risk labor.  We want them to have true informed consent by having an open line of communication with their care providers.

To that end, I am sharing the information below in the interest of furthering our goal that all our students have true informed consent: knowing all the benefits and risks of a drug or procedure.  It is very rare for anyone to read the drug information insert that comes in all drug packages.  To save you time and squinting, we are already researched Epidural Drugs and Induction Drugs.  To conclude the “Warning Label” Series, here are the drugs used for Augmentation and to counteract the strong contractions they have the potential to stimulate.

PITOCIN: Pregnancy Category X
“Antepartum [before delivery] use of Pitocin is contraindicated in any of the following circumstances:
Where there is significant cephalopelvic disproportion;
In unfavorable fetal positions or presentations, such as transverse lies, which are undeliverable without conversion prior to delivery;
In obstetrical emergencies where the benefit-to-risk ratio for either the fetus or the mother favors surgical intervention;
In fetal distress where delivery is not imminent;
Where adequate uterine activity fails to achieve satisfactory progress;
Where the uterus is already hyperactive or hypertonic;
In cases where vaginal delivery is contraindicated, such as invasive cervical carcinoma, active herpes genitalis, total placenta previa, vasa previa, and cord presentation or prolapse of the cord;
In patients with hypersensitivity to the drug.”

“When properly administered, oxytocin should stimulate uterine contractions comparable to those seen in normal labor. Overstimulation of the uterus by improper administration can be hazardous to both mother and fetus. Even with proper administration and adequate supervision, hypertonic contractions can occur in patients whose uteri are hypersensitive to oxytocin. This fact must be considered by the physician in exercising his judgment regarding patient selection.”

“Except in unusual circumstances, oxytocin should not be administered in the following conditions: fetal distress, hydramnios, partial placenta previa, prematurity, borderline cephalopelvic disproportion, and any condition in which there is a predisposition for uterine rupture, such as previous major surgery on the cervix or uterus including cesarean section, overdistention of the uterus, grand multiparity, or past history of uterine sepsis or of traumatic delivery. Because of the variability of the combinations of factors which may be present in the conditions listed above, the definition of "unusual circumstances" must be left to the judgment of the physician. The decision can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.
Maternal deaths due to hypertensive episodes, subarachnoid hemorrhage, rupture of the uterus, and fetal deaths due to various causes have been reported associated with the use of parenteral oxytocic drugs for induction of labor or for augmentation in the first and second stages of labor.”

“Oxytocin has been shown to have an intrinsic antidiuretic effect, acting to increase water reabsorption from the glomerular filtrate. Consideration should, therefore, be given to the possibility of water intoxication, particularly when oxytocin is administered continuously by infusion and the patient is receiving fluids by mouth.
When oxytocin is used for induction or reinforcement of already existent labor, patients should be carefully selected. Pelvic adequacy must be considered and maternal and fetal conditions evaluated before use of the drug.”

Adverse Reactions
“The following adverse reactions have been reported in the mother:

  • Anaphylactic reaction
  • Premature ventricular contractions
  • Postpartum hemorrhage
  • Pelvic hematoma
  • Cardiac arrhythmia
  • Subarachnoid hemorrhage
  • Fatal afibrinogenemia
  • Hypertensive episodes
  • Nausea
  • Rupture of the uterus
  • Vomiting
  • Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.”

“The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug.”

“Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.”

“The following adverse reactions have been reported in the fetus or neonate:
Due to induced uterine motility:

  •   Bradycardia
  •   Premature ventricular contractions and other arrhythmias
  •   Permanent CNS or brain damage
  •   Fetal death
  •   Neonatal seizures have been reported with the use of Pitocin.
Due to use of oxytocin in the mother:
  • Low Apgar scores at five minutes
  • Neonatal jaundice
  • Neonatal retinal hemorrhage

Related drug SYNTOCINON® - most of the information is identical

ERGOTRATE (ERGONOVINE) – Pregnancy: Should not be administered prior to delivery or delivery of the placenta
“Use of ergonovine is contraindicated during pregnancy…Tetanic contractions may result in decreased uterine blood flow and fetal distress.”

Labor and delivery—
“High doses of ergonovine administered prior to delivery may cause uterine tetany and problems in the infant (hypoxia, intracranial hemorrhage) {03}. Ergonovine should not be administered prior to delivery of the placenta…Administration prior to delivery of the placenta may cause captivation of the placenta…or missed diagnosis of a second infant, due to excessive uterine contraction.”

“Problems in humans have not been documented. However, ergot alkaloids are excreted in breast milk…Although inhibition of lactation has not been reported for ergonovine, other ergot alkaloids inhibit lactation. Also, studies have shown that ergonovine interferes with the secretion of prolactin (to a lesser degree than bromocriptine) in the immediate postpartum period…This could result in delayed or diminished lactation with prolonged use.”

“Ergot alkaloids have the potential to cause chronic ergot poisoning in the infant if used in higher-than-recommended doses or if used for a longer period of time than is generally recommended.”

"Elimination of ergonovine may be prolonged in newborns...Neonates inadvertently administered ergonovine in overdose amounts have developed respiratory depression, cyanosis, seizures, decreased urine output, and severe peripheral vasoconstriction."

“For routine management after delivery of the placenta; postpartum atony and hemorrhage; subinvolution. Under full obstetric supervision, it may be given in the second stage of labor following delivery of the anterior shoulder.”

"Hypertension; toxemia; pregnancy; and hypersensitivity."

MAGNESIUM SULFATE: Pregnancy Category A
“Studies in pregnant women have not shown evidence of fetal risk if magnesium sulfate is administered during any trimesters of pregnancy. However, because studies cannot completely rule out the possibility of harm, magnesium sulfate injection is only recommended for use during pregnancy when benefit outweighs risk.”

“Newborns may show signs of magnesium toxicity (i.e. respiratory and/or neuromuscular depression) if the mother has received intravenous magnesium sulfate prior to delivery (especially if for a period of longer than 24 hours). Equipment for assisted ventilation as well as intravenous calcium should be immediately available for the first 24 to 48 hours after delivery. One study has reported that maternal magnesium sulfate treatment is associated with reduced brain blood flow perfusion in preterm infants. However, intravenous magnesium sulfate did not lead to lower neonate Apgar scores in a study of women treated for preeclampsia even though the newborns cord level indicated hypermagnesemia.”

TERBUTALINE (BRETHINE): Pregnancy Category B
“Terbutaline has been shown to cross the placenta, and the fetus may experience the general adverse effects reported in the mother. Pulmonary edema has been associated with the intravenous use of terbutaline in pregnant women. Myocardial necrosis in one infant was thought to be associated with terbutaline given at a rate of 0.5 mg/hr for 12 weeks by subcutaneous infusion. In one retrospective review of 8,709 patients receiving continuous low-dose subcutaneous infusion of terbutaline to arrest preterm labor, only 47 (0.54%) had one or more cardiopulmonary problems. Pulmonary edema was reported in 28 patients (0.32%), 17 of whom had been treated concurrently with large amounts of IV fluids or one to three tocolytic agents and four of whom had been diagnosed with pregnancy-induced hypertension and/or multiple gestation. Other cardiovascular effects occurred in 19 patients (0.22%), including electrocardiogram changes, irregular heart rate, chest pain, or shortness of breath. However, 7 of these patients had a history of cardiac problems. Use of terbutaline in pregnant women for the relief of bronchospasm may interfere with uterine contractility. For the treatment of asthma, administration by metered dose inhaler results in lower plasma concentrations and consequently fewer adverse effects for the mother and fetus. Hepatitis has been reported in at least two patients receiving terbutaline to control premature labor.”

“Terbutaline has been assigned to pregnancy category B by the FDA. Animal studies have failed to reveal evidence of teratogenicity. Terbutaline is only recommended for use during pregnancy when benefit outweighs risk.”

INDOMETHACIN (NSAID): Pregnancy Category C
“Animal studies have failed to reveal evidence of teratogenicity or fetal harm except at doses which result in significant maternal toxicity. There are no controlled data in early human pregnancy. Indomethacin has been used in the management of premature labor. However, fetal hemodynamic changes, premature closure of the ductus arteriosus resulting in neonatal primary pulmonary hypertension, and neonatal oliguric renal failure, oligohydramnios, hemorrhage, and intestinal perforation have been reported as a result of this tocolytic therapy. Indomethacin is only recommended for use during pregnancy when benefit outweighs risk.”

“Indomethacin crosses the placenta. In one study, 26 pregnant patients were administered indomethacin 50 mg orally one time approximately six hours prior to scheduled cordocentesis, at a gestational age of 23.6 to 36.6 weeks. At the time of the procedure, maternal serum indomethacin concentrations ranged from 42 to 690 ng/mL (mean 218 ng/mL) while fetal concentrations ranged from 87 to 496 ng/mL (mean 219 ng/mL). The mean maternal to fetal serum concentration ratio was 0.97. There was no correlation between gestational age and maternal/fetal ratio. Amniotic fluid concentrations averaged 21 ng/mL. Indomethacin has been used successfully in the treatment of premature labor as well as polyhydramnios. In several studies, indomethacin was as effective and better tolerated than beta-agonists for premature labor. However, while earlier reports and studies suggested indomethacin was safe for the fetus or neonate, especially when use was confined to pregnancies of 34 weeks gestation or less, more recent data suggest a substantial increase in the risk of serious fetal or neonatal side effects. Eronen (1993) studied the effects of indomethacin or nylidrin on the fetal and neonatal ductus arteriosus and tricuspid valve function. A total of 84 pregnancies (94 fetuses) with premature labor between 22.9 and 34.0 weeks gestation were evaluated. Ductal constriction occurred in 46/49 (86%) of fetuses (gestational age 24.0 to 34.0 weeks) treated with indomethacin. The gestational age of the fetuses without ductal constriction ranged from 24.3 to 28.6 weeks. Eleven fetuses with ductal constriction also had tricuspid regurgitation. Data from this study suggest increasing reactivity of the ductus with increasing gestational age; although, ductal constriction occurred in one fetus at 22.9 weeks gestation. In addition to hemodynamic changes, other serious sequelae of maternal indomethacin use have been documented. One study compared 57 infants delivered at or before 30 weeks gestation whose mothers received indomethacin for the treatment of premature labor with 57 infants whose mothers had not received indomethacin. The total dose of indomethacin ranged from 50 to 6000 mg (median 425 mg) and the duration of therapy ranged from 1 to 79 days (median 3 days). Necrotizing enterocolitis occurred in 29% of infants exposed to indomethacin compared with an 8% incidence in the control group (p=0.005). Intracranial hemorrhage occurred in 28% of infants in the indomethacin group compared with only 9% in the control group (p=0.02). Maternal use of indomethacin has resulted in reduced fetal urine output and subsequent oligohydramnios, neonatal renal failure, fetal pleural effusion, and ileal perforation. In addition, at least two cases of neonatal lower limb ischemia have been reported following prolonged intrauterine exposure to indomethacin. Fetal echocardiograms after 24 hours of maternal indomethacin therapy and then weekly, thereafter, if long-term therapy is necessary, have been recommended. In addition, assessment of amniotic fluid volume is also recommended.”

RITODRINE (YUPOTAR): Pregnancy Category B
“There are no controlled data in human pregnancy. Neonatal hypoglycemia, tachycardia, and ileus have been reported. Rarely, ketoacidosis resulting in fetal death has been reported. Ritodrine is only recommended for use during pregnancy when benefit outweighs risk.”

The material included on this site is for informational purposes only.
It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation.  Krystyna and Bruss Bowman and Bowman House, LLC accept no liability for the content of this site, or for the consequences of any actions taken on the basis of the information provided.  This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.
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