Policy: l-80

Cytotec will be used only for induction of fetal demise or control of post partumhemorrhage.
To define the use of Cytotec in OB at MMSC.
Additional Information:
1. ACOG has affirmed that Cytotec is a safe and effective agent for cervical ripening and labor induction when used appropriately.
2. ACOG has affirmed that Cytotec is an effective treatment for post partum hemorrhage in the presence of uterine atony.
3. Oxytocin should not be administered within 4 hours after the last dose of 4. April 2003, the FDA acknowledged the wide spread off label use of Cytotec in 5. Misoprostol (Cytotec) should not be used in patients with a previous cesarean delivery or prior major uterine surgery.
6. Cytotec can be given vaginally (posterior fornix) or orally for induction and rectally for control of PP hemorrhage.
7. Contraindications for the use of misoprostol (Cytotec) include: 8. Cytotec (misoprostol) is absorbed effectively from the rectal as well as oral and vaginal mucosa thus providing a rapid, effective made of delivery for post-partum hemorrhage.
9. Studies shown Cytotec produces sustained uterine contraction within three minutes of rectal administration without the significant side effects associatedwith ergotomine.
10. Reported side effects include nausea, vomiting, and diarrhea due to stimulation of GI smooth muscle, hypotension, fever, headache and abdominal pain, uterinehyperstimulation, and tachysystole.
Equipment List:
Misoprostol (Cytotec) 400 mcg intra vaginal or P.O. for fetal demise InductionMisoprostol (Cytotec) 200 mcg tablet, one to five as orderedSterile GlovesBP Monitoring CYTOTEC USE IN OBSTETRICS – Page 2
Procedure For Induction Of Fetal Demise:
1. Using 2 identifiers, identify correct patient.
2. Patient History and physical assessment:
a) Review the patient’s prenatal record for pertinent medical and surgical history. Obtain patient’s age; gravidity, parity, EDD, h/o fetal movement, and specific information regardingany complaints. Assess for signs and symptoms of pre-eclampsia.
b) Obtain maternal vital signs.
c) Confirm specific indications for induction.
3. Explain medication and procedure to patient and answer questions.
4. Obtain correct dosage of Misoprostol tablet.
5. Obtain IV access using #18 angiocath prior to initial dosing.
6. Vaginal Dosing a) Assist physician in inserting Misoprostol 400 mcg into the posterior fornix.
b) Encourage 30 minutes of side lying after insertion.
c) Continuously monitor contractions.
d) Repeat dose every 2-4 hours x 6 doses.
e) Withhold repeat dose if i) Uterine tachysystoleii) Contrations are regular, organized, patterned, palpable and causing discomfort (activelabor) f) Pitocin may be started 4 hours after last dose of Misoprostolg) Notify physician for signs of tetanic contractions.
a) Administer Misoprostol 400 mcg P.O.
b) Continue giving Misoprostol 400 mcg P.O. every 2 hours as needed until active labor.
c) Withhold repeat dose if: i) Uterine tachysystoleii) Contractions are regular, organized, patterned, palpable and causing discomfort (active d) Pitocin may be started 4 hours after last dose of Misoprostol.
e) Notify physician for signs of tetanic contractions i) Hyperstimulation may be treated by lateral positioning.
ii) IV fluid bolus of 400 cc and Terbutaline 0.25 mg subq may be used if conservative 8. Patient may ambulate if absence of uterine hyperstimulation two hours after dosing.
9. Patient status (VS) should be assessed at least every 4 hours after insertion of medication.
Uterine activity should be assessed at least every 1-2 hours as indicated by uterine activity andpatient condition. Once labor is initiated monitor VS, FHR and contractions in accordance withunit policy.
10. Monitor patients level of pain and intervene appropriatley.
Originated by: Women’s Care CenterEffective date: 7/03Authorized by: OB/GYN Authorized by: ____________________________________________ Revision date: 1/05Review date: 6/08Distribution: References:
1. Bennett, K.A., Butt, K., Crane, J.M., Hutchens, D., & Young, D.C. (1998). A masked randomized comparison of oral and vaginal administration of misoprostol for labor induction.
Obstetrics and Gynecology, 92 (4), Part 1, 481-486.
2. Kolderup, L., McLean, L., Grullon, K., Safford, K., & Klipatrick, S. J. (1999) Misoprostol is more efficacious for labor induction than prostaglandin E2, but is it associated with more risk?American Journal of Obstetrics and Gynecology, 180 (6), Part 1, 1543-1550.
3. Kramer, R. L., Gilson, G. J., Morrison, D. S., Martin, D., Gonzales. J., & Qualls, C. R. (1997). A randomized trail of misoprostol and oxytocin for induction of labor: safety and efficacy.
Obstetrics and Gynecology, 89 (3), 387-391.
4. Plaut, M. M., Schwartz, M. L., & Luarsky, S. L. (1999). Uterine rupture associated with the use of misoprostol in the gravid patient with previous cesarean. American Journal of Obstetrics andGynecology, 180 (6), Part 1, 1535-1542.
5. Windrim, R., Bennett, K., Mundle, W., & Young, D. C. (1997). Oral administration of misoprostol for labor induction: a randomized controlled trail. Obstetrics and Gynecology, 89(3), 392-397.
1. Wing, D. A. & Paul, R. H. (1996). A comparison of differing dosing regimens of vaginally administered misoprostol for preinduction cervical ripening and labor induction. AmericanJournal of Obstetrics and Gynecology, 175 (1), 158-164.
7. Bamigboye, A.A.; Hofmeyr, G.H.; Merrell, D.A. (1998) Rectal misoprostal in the prevention of post-partum hemorrhage: a placebo-controlled trial. American Journal of Obstetrics andGynecology. 179 (4): 1043-6.
8. Bamigboye, A.A.; Merrell, D.A.; Hofmeyr, G.J.; Mitchell, R. (1998) Randomized comparison of rectal misoprostol with Syntometrine for management of third stage of labor. Acta ObstetGynecol Scand.
9. Diab, K.M.; Ramy, A.R.; Yehia, M.A. (1999) The use of rectal misoprostol as active pharmacological management of the third stage of labor. Journal of Obstetric Gynecology Res.
25(5): 327-32.
10. O’Brien, P; El-Rafaey, H.; Gordon, A.; Geary, M.; Rodeck, G.C. (1998) Rectally administered misoprostol for the treatment of post-partum hemorrhage unresponsive to oxytocin andergometrin: a descriptive study. Obstet. Gynecolo. 92 (2): 212-4.

Source: http://intranet.everydaychampions.org/policies/items/10/L-85-Cytotec_Use.pdf


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