Breast stimulation and electroacupuncture help, while other common remedies that have been studied are ineffective, possibly unsafe, or both. Unilateral breast stimulation shortens the time until the onset of labor in women at term (strength of recommendation [SOR]: A, systematic review). Electroacupuncture also may stimulate the onset of labor (SOR: C, observational studies)

Kelsberg, Gary

Murray, Tracy

Safranek, Sarah

University of Missouri: MOspace

CLINICAL INQUIRIES Evidence Based Answers from the Family Physicians Inquiries Network542 VOL 57, NO 8 / AUGUST 2008  THE JOURNAL OF FAMILY PRACTICEFAST TRACK  Do any folk remedies or herbals help induce labor?Evidence-based answerYes, some do. Breast stimulation and electroacupuncture help, while other common remedies that have been studied are ineffective, possibly unsafe, or both. Unilateral breast stimulation shortens the time until the onset of labor in women at term (strength of recommendation [SOR]: A, systematic review). Electroacupuncture also may stimulate the onset of labor (SOR: C, observational studies).  Sexual intercourse doesn’t appear to ripen the cervix or stimulate labor (SOR: C, 1 observational study). Castor oil universally produces nausea and doesn’t promote labor (SOR: C, low-quality case-control study). Red raspberry leaf is likely safe but ineffective (SOR: B, 1 small randomized controlled trial); evening primrose oil is ineffective and possibly unsafe (SOR: B, 1 small retrospective cohort study); black cohosh and blue cohosh lack evidence of effi cacy and may be unsafe (SOR: C, expert opinion and case reports).Clinical commentarySo many remedies, so little knowledge Obstetrics seems to have more folk remedies than any other area of medicine—castor oil, teas, magnets, exercises, herbs, incantations, moxibustion, and so on. When I was a younger doctor, 5 of my patients tried castor oil to induce labor at term. Four had the baby within 2 days, but all were so sick with nausea and diarrhea that they swore off castor oil for future pregnancies.  Therein lies the rub with many folk remedies—not only do we know little about their benefi ts, but we don’t know their harms either. As a result of this review, I can now prescribe breast stimulation in good faith, and I’ll continue to advise against castor oil. Paul Crawford, MDNellis Family Medicine ResidencyLas Vegas, Nev❚ Evidence summaryBreast stimulation worksA systematic review of 6 trials with a total of 719 participants compared unilateral breast stimulation with no intervention to induce labor in women at term.1 In 2 trials, the 300 participants stimulated 1 breast for 1 hour a day for 3 days; in the other 4 trials, 419 women stimulated ei-ther breast alternately for 3 hours a day. Breast stimulation signifi cantly re-duced the number of women who hadn’t gone into labor at 72 hours compared with nonintervention (62.7% vs 93.6%; relative risk [RR]=0.67; 95% confi dence interval [CI], 0.60-0.74; number needed to treat [NNT]=3.2). This result remained signifi cant when primiparous and mul-tiparous women were analyzed separate-ly, but not in the 1 trial (37 participants) Most common remedies to induce labor—except breast stimulation and electro-acupuncture—are not effective, possibly unsafe, or bothTracy Murray, MD, and Gary Kelsberg MDValley Family Medicine Residency, Renton, WashSarah Safranek, MLISUniversity of Washington Health Sciences Library, Seattle542_JFP0808   542 7/17/08   2:42:35 PMCopyright® Dowde  Health Media  For pers nal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.FAST TRACK VOL 57, NO 8 /AUGUST 2008 543www.jfponline.comthat reported on women with an unfa-vorable cervix.1 Breast stimulation also reduced postpartum hemorrhage (0.7% vs 6%; RR=0.16; 95% CI, 0.03-0.87; NNT=18.8). None of the trials documented uterine hyperstimulation or meconium-stained fl uid, and they didn’t fi nd signifi cant differ-ences in the rates of cesarean section (9% vs 10%; RR=0.90; 95% CI, 0.38-2.12). One trial reported 4 perinatal deaths in a high-risk population—3 in the breast stimulation group and 1 in the control group—but this fi nding was not replicated in any other trials.1Acupuncture may also helpA Cochrane systematic review evaluating acupuncture for inducing labor identifi ed 1 randomized trial with methodologic fl aws (allowing no conclusion), 3 case se-ries, and 2 nonrandomized trials. The fi rst case series used electroacupuncture at 38 to 42 weeks to successfully induce labor in 21 of 31 women. The second series, us-ing acupuncture with and without electri-cal stimulation, induced labor in 10 of 12 women at 19 to 43 weeks. The third study induced labor with electroacupuncture in 78% of 41 women—34 term and post-term patients and 7 with a fetal demise. In the fi rst nonrandomized trial, 20 of 27 women at term who received elec-troacupuncture gave birth between 39 weeks 3 days and 40 weeks, compared with 47 of 102 women in the control group. In the second study, 31 of 35 wom-en who received electroacupuncture re-ported increased intensity of contractions compared with none of the 35 women in the control group.2Sexual intercourse induces pregnancy, not laborA Cochrane systematic review found 1 observational study of the effect of sex-ual intercourse on cervical ripening and induction of labor among 28 women at term. The study evaluated cervical Bishop scores after sexual intercourse with intravaginal semen deposition for 3 consecutive nights compared with no intercourse. The difference in Bishop score was not signifi cant (1.0 with coitus vs 0.5 controls; P>.05) and no difference in the number of women who delivered within 3 days was noted in the 2 groups (RR=0.99; 95% CI, 0.45-2.20).3Castor oil made women nauseous A Cochrane systematic review included 1 study of women at term with intact mem-branes who received 1 dose of castor oil to induce labor (n=52) compared with no treatment (n=48). All women who received castor oil felt nauseous, but no other differences were noted between the castor oil group and controls in rates of cesarean section, meconium-stained fl uid, or Apgar scores less than 7 at 5 minutes.4 Herbal preparations raise many questions—and some concernsA prospective controlled trial that ran-domized 192 women to receive either red raspberry leaf tablets (1.2 g twice daily beginning at 32 weeks) or placebo found no signifi cant differences in duration of the fi rst stage of labor or birth outcomes. Symptom surveys of 108 women revealed no adverse effects.5A retrospective cohort study com-pared pregnancy outcomes in 54 women who took evening primrose oil (500 mg 3 times a day beginning at 37 weeks) with a matched group of 54 women who did not take it. The study found no signifi cant differences between the groups in mater-nal age, Apgar scores, or days of gesta-tion. However, the women taking evening primrose oil tended to have protracted active phase of labor, prolonged rupture of membranes, arrest of descent, and oxy-tocin augmentation (none of which were statistically signifi cant).6A systematic review of the literature on black cohosh in pregnancy found no trials that evaluated its effi cacy for induc-ing labor.7 A review of herbal preparations used by midwives reported a case of an infant with low Apgar scores after black cohosh use.8 Both articles described black Evening primrose oil, black cohosh, and blue cohosh may be unsafeIMAGE © KIMBERLY MARTENS543_JFP0808   543 7/17/08   2:42:39 PMCLINICAL INQUIRIEScohosh as potentially unsafe because of the lack of trials demonstrating safety and possible deleterious estrogenic effects.A systematic review of the literature on blue cohosh found only in vitro stud-ies of effi cacy (increased estradiol-induced transcription in estrogen-responsive cells and increased tone in excised guinea pig uteri) and 3 case reports of maternal ad-verse events after ingestion (perinatal stroke, congestive heart failure with shock, and multiorgan hypoxic injury).9 In vitro evidence presented in the review suggests that blue cohosh may have teratogenic, embryotoxic, and oxytocic effects. RecommendationsWe found no recommendations from professional organizations regarding folk methods to stimulate labor. The au-thors of a survey of herbal preparations used by midwives do not advocate their use in pregnancy because of unknown risks to the fetus, although “raspberry leaf tea does not seem to have any sig-nifi cant pharmacologic activity and is probably safe.”8 ■•  Timely postings updated daily  •  Great array of positions in your specialty  •  Customizable job searches that let you search by specialty, location, keyword, and other important criteria  •  Tools to save searches and to create search alerts that e-mail you when the right jobs are posted  •  Quick and easy creation and storage of CVs and cover letters  •  Up-to-the-minute application tracking to manage your search  •  Updates on how often your CV is viewed by employers  •  Backed by the reputation of a leading journal in your ﬁ eldOur new medical career Web site letsyou ﬁ nd the right job—quickly and eﬃ  cientlyFinding your new job just got easier!The journal you trust now has the recruitment Web site you need Visit MEDopportunities.com today  WHERE MEDICAL PROFESSIONALS AND JOB OPPORTUNITIES MEETFor advertising information, e-mail sales@MEDopportunities.com or call (866) 698-1919References 1.  Kavanagh J, Kelly AJ, Thomas J. Breast stimu-lation for cervical ripening and induction of la-bour. Cochrane Database Syst Rev. 2005;(3):CD003392.  2.  Smith CA, Crowther CA. Acupuncture for induction of labour. Cochrane Database Syst Rev. 2004;(1): CD002962.  3.  Kavanagh J, Kelly AJ, Thomas J. Sexual inter-course for cervical ripening and induction of labor. Cochrane Database Syst Rev. 2001;(2):CD003093. 4.  Kelly AJ, Kavanagh J, Thomas J. Castor oil, bath and/or enema for cervical priming and induction of labour. Cochrane Database Syst Rev. 2001;(2):CD003099.  5.  Simpson M, Parsons M, Greenwood J, Wade K. Raspberry leaf in pregnancy: its safety and effi cacy in labor. J Midwifery Womens Health. 2001;46:51-59.  6.  Dove D, Johnson P. Oral evening primrose oil: its effect on length of pregnancy and selected intra-partum outcomes in low-risk nulliparous women. J Nurse Midwifery. 1999;44:320-324. 7.  Dugoua JJ, Seely D, Perri D, Koren G, Mills E. Safety and effi cacy of black cohosh (Cimicifuga racemosa) during pregnancy and lactation. Can J Clin Pharmacol. 2006;13:e257-e261.  8.  McFarlin BL, Gibson MH, O’Rear J, Harman P. A national survey of herbal preparation use by nurse-midwives for labor stimulation. Review of the lit-erature and recommendations for practice. J Nurse Midwifery. 1999;44:205-216. 9.  Dugoua JJ, Perri D, Seely D, Mills E, Koren G. Safety and effi cacy of blue cohosh (Caulophyllum thalictroides) during pregnancy and lactation. Can J Clin Pharmacol. 2008;15:e66-e73.544_JFP0808   544 7/17/08   2:42:45 PM

Do any folk remedies or herbals help induce labor?

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