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Re: cytotecFrom: Barbara Nicol MD (blnicol@ix.netcom.com)Wed Nov 15 18:03:55 2000
In response to Dr. Bornstein: The RN gives the misoprostol at the physician's order, same as any other med. Our standing orders for miso indicate routine admission, verification of indication and orders for induction, heplock, baseline NST and labs, followed by placement of miso "well into vagina". We were initially using 25-50 q4 but the whole department has gone down to 25 q4 and the newest reprint of the orders reflects this. Continuous monitoring begins when regular contractions are present and continues until delivery. Misoprostol is repeated q4 until active labor; a vaginal exam is to be documented before each dose. Max 6 doses, stop when patient is greater than 4 cm. RN to notify practitioner at SROM and at SVE greater than 4cm. If hyperstimulation develops, call practitioner, start LR, reposition, give 6L O2 by mask, and have terbutaline ready in case practitioner orders it given. (It is up to the MD or CNM to obtain appropriate informed consent for induction and to choose agents for induction wisely, so the standing orders do not include any exclusions except nonreactive NST or SVE greater than 4 cm. Presumably either of these would be new information which would cause the MD or CNM to change the plan.) The "repeat every 4 hours" was based on the best pharmacokinetics we could find at the time indicating that this would give stable or slightly rising blood levels of drug. Therefore we do not instruct the RN to stop dosing when a regular pattern of contractions appears - that would be like turning down the pit just when it started to work. However, many of us stop misoprostol or change to oxytocin once the cervix is ripe enough for AROM. As I mention in my only other post, I've been following this debate with interest. Considering that many of us have RNs give terbutaline despite what it says in the PDR, I think we have a lot of precedent for the off-label use of (and RN administration of) misoprostol (which has the benefit of actual data showing safety and effectiveness, unlike terb). However, I've been asked to develop further nursing protocols for our hospital and an informed consent form specific to miso, so I've been following this list avidly seeking ideas. (We have a generic consent form for prostaglandin induction which was developed here back when PG gel was controversial. Some practitioners have been using this for miso as it doesn't specify which prostaglandin will get used.) I am saddened by those who are saying that since we have cervidil and prepidil, and the section rate isn't different between miso and other PG agents, therefore we shouldn't use miso. There is more to induction than the section rate. There's a lot of good data showing significant differences in start-to-del times - in the range of 6 to 8 hours - with misoprostol. Start-to-delivery times may not be important to us, but they sure might be important to our patients. At the minimum, we should offer patients an informed choice. Sorry this was so long - thanks for letting me vent...
-- Barbara Nicol MD Everett WA USA
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