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Re: CytotecFrom: Dr. P. Peterman (peterman@proteus.com)Mon Mar 15 11:48:05 1999
At Mon, 15 Mar 1999, Latisha Lochabay, CNM, MSN wrote: >What selection criteria do you use? Primip? Multip? VBAC? Bishop score?
Use the same selection criteria for labor induction you use for other
prostaglandins (SROM, post dates, hypertension, etc...). No VBACs, yet.
Two centers are looking at this (UC-Davis and UF-Jacksonville). The
California group actually enrolled patients with UNDOCUMENTED scars and
then bailed on their study when three patients had complications: which
may or may not have been related to misoprostol as much as it was labor
induction. We will have to wait and see what the UF group publishes).
Use misoprostol for Bishop <6.
>
You don't need a reactive strip. Non-reassuring fetal monitoring can be
a valid reason for labor induction in the first place! In those cases,
you want them delivered as quickly and safely as possible. Misoprostol
is perfect for that. You don't send them home. Ever. Once you start
the induction process with misoprostol, you deliver them. There are
different published protocols regarding intrapartum fetal monitoring
(continous, intermitant). Many center utilize continous fetal
monitoring for at least the first two hours.
> There are nearly 40 randomized control trials on the use of misoprostol for cervical ripening and labor induction. MANY dosing regimens have been published. It has been given rectally, orally and intravaginally. Most U.S. centers use 25-50mcg intravaginally every 3-6 hours for a maximum of 24 hours. Most patient deliver after one dose (50-75%) and most do not require pitocin augmentation. I have seen patients deliver hours after one dose, and some deliver after 8 doses and pitocin augmentation. For fetal demise, I guess it depends on the gestational age. For second trimester: 100mcg every 12 hours. I have also used 200mcg to start, then 100mcg every 12 hours. Patient rarely require more than two doses, and most deliver in 24 hours. For third trimester gestations: I have used 100mcg every 12 hours. All doses intravaginal.
> I have used terb many times when there is evidence of tachysystole or hyperstimulation (it was part of a hospital protocol). If hyperstimulation (tachysystole resulting in fetal distress) occurs and does not respond to oxygen, position change, IV fluids, terbutaline... then I douche the misoprostol out of the vagina.
>Thanks in advance for any assistance you may be able to offer. By the way, I have used misoprostol for the last 5 years, many hundreds of patients, and have initiated its use at a hospital I just started working at. I have found it to be safe and effective and have witnessed problems only when it is misused. My advice is to write a protocol, have it approved by your department, and then stick to it. Our dear friend Luis Sanchez-Ramos must be on vacation. P.Peterman.
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