induction

  1. Hello all, I am relatively new to these forums and am enjoying them! I have been an OB/L&D/Nursery RN for 5 years

    I am curious how other facilities do their inductions. We do quite a few, couldn't really give you a percentage. At the facility where I have worked for 5 years we usually use either cytotec (misprostol) 50mcg in posterior fornix, or cervadil. This is followed in 6 hrs by pitocin induction. Protocol is to start at 1mu and increased by 2 mu q30 min (3mu, 5mu,7mu etc.) until an adequate pattern of ctx are established. We are to go no higher than 16mu unless otherwise ordered. We have one doc than likes the pit 'doubled' until 16mu, ie 1mu,2mu,4mu,8mu,16mu again every 30 min to increase. Have seen some hyperstim with his pts.

    I have recently started working prn at another facility, there the main OB doc uses laminaria, placed in the cervix in his office. The next day he uses a prostin gel in the hospital. Then the pit.

    Look forward to reading what you all are doing!
    Thanks
    Greyhorse (my hobby, not my haircolor and size! Well maybe!)
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  2. 8 Comments

  3. by   SmilingBluEyes
    HI greyhorse and If I did not do so already, WELCOME TO THE FORUM. Glad you are joining us!

    This is generally how we do inductions (I work 2 hospitals):

    Inductions are done for several reasons, most non-medical, unfortunately. Most are "social" and a few are for "postdates" (40 weeks, is actually sited as "postdates" often). A few ARE done for LGA, PIH, Diabetic complications or potential problems such as low AFI or fetal indications.

    Most of the time, for unripe cercives, we do misoprostol (cytotec). At the one hospital it's oral cytotec, 50mcg q3 hours, unless otherwise indicated. We don't generally use cervidil or prostin anymore. At the other hospital, it's Cytotec, 25mcg in the posterior fornix of the cervix (such fun getting that wee lil pill in there). Same thing; q3 hours unless contra-indicated. If nothing changes, no labor/cervical changes--- and mom and baby are ok, they go home, usually w/orders to return in 2-3 days for a re-evaluation.

    If they stay, usually, the next morning at about 5 or 6--- after eating dinner and sleeping--- we begin LOW DOSE pitocin. We have become much more conservative w/pit use in both hospitals to avoid hyperstim situations. Usually, it's begun at 1 mu/min and go up by 1-2 mu each 30 minutes, NOT 15 or 20 minutes, anymore. NONE of our docs do the "rambo pit" of days gone by. You know, when you start at 6mu and go up by 6mu every 30 min. It got us into too much trouble. We generally look to have contractions q4-5 minutes that palpate moderate to strong. If I can possibly get an IUPC in there, I do. I prefer to pit by montevideo units for accuracy and safety. If not, I am very careful to watch the fetus for s/s of trouble due to hyperstim. The biggest challenge to me is the "fluffy" patient whose cervix is 2 miles high (so no internals) and how to guage accurately the amt. of pitocin is best. I am careful. Hyperstim is nothing to play with. If I see evidence of hyperstim, I back the pit down by 1/2, place O2 on and observe. If all is ok, then I creep up slowly again. If still problems, I turn it off and call the dr/midwife.

    The doctors DO like to use the Friedman curve to assess if labor is adequate. If they fall off, they are looking hard at a csection. Does the rise in induction rates correspond w/the rise in rate of csection? (close to 25% nationwide)? I think so, but it's not been proven absolutely. Very controversial.

    I did hear something interesting at a perinatal conference two days ago. The current recommendation ACOG is now looking to offer? A csection as an option to ALL expectant women (even those who are primip with NO KNOWN RISK FACTORS!), who desire NOT to go thru trial of vaginal labor/delivery. The wisdom? To avoid bladder and perineal trauma (which studies are saying occurs much earlier in labor than thought, NOT 2nd stage pushing but prolonged first stage). This would purportedly avoid subsequent problems and unnecessary GYN surgeries (such as bladder repair, uterine prolapse repair, etc), later on. Whether we come on line w/this or not in the USA remains to be seen. I will be watching and waiting to see what AWHONN has to say on this, too!
    Last edit by SmilingBluEyes on Jan 24, '03
  4. by   mother/babyRN
    Welcome also...We do the cytotec to pit, or plain pit induction, and have standing orders to be filled in with regard to the pit, how much to increase and when, depending on whether the uc are whatever, apart..Course, and thankfully, we can up it or down it based on nursing judgement. We do have one doc who likes to "pit the hell" out of them and really isn't concerned about the lack of resting tone...I am not concerned about his anger lapses either. Pt is first... We too have the occasional social induction who ends up with resp distress due to pre vs post dates. Can't stand those.....
  5. by   ShandyLynnRN
    quote:"I did hear something interesting at a perinatal conference two days ago. The current recommendation ACOG is now looking to offer? A csection as an option to ALL expectant women (even those who are primip with NO KNOWN RISK FACTORS!), who desire NOT to go thru trial of vaginal labor/delivery. The wisdom? To avoid bladder and perineal trauma (which studies are saying occurs much earlier in labor than thought, NOT 2nd stage pushing but prolonged first stage). This would purportedly avoid subsequent problems and unnecessary GYN surgeries (such as bladder repair, uterine prolapse repair, etc), later on. Whether we come on line w/this or not in the USA remains to be seen. I will be watching and waiting to see what AWHONN has to say on this, too!"

    very interesting
  6. by   elleRN
    we have a standard protocol for pitocin induction. it is 30 units in 500 cc LR, started at 2mu/min, and increased by 1-2 mu/min, q15-30mins, until adequate contractions occur, not to exceed 36 mu/min. for induction patients who are closed and thick we give cervidil around 2200 and take it out at 0600 and either start pit then or if necessary use another cervidil. the pit protocol leaves the nurses really in the drivers seat. it is our judgement that counts. i've had docs question why have you not increased the pit more etc, and i always do whats best for pt and not them. the docs know better to not even touch the pit. how often do you document on your patient who is on pit??? we document q15 for all pit patients...
  7. by   imenid37
    here's a great article written for the lay public in th ny times re. inductions
    http://www.nytimes.com/2003/01/14/he...cadbde8ed06214
    i think we are totally headed in the wrong direction w/ all of these unnecessary inductions.

    we user prepidil for unfavourable cervix. ususally 1-2 doses on consecutive days or 8-12 hrs. apart. example: pt. may come in mon a.m. to have it placed and may return mom afternoon/evening or tuesday a.m. for next dose. they are monitored for 1/2 hr. prior to insertion and at least 1 hr. post-insertion.

    for induction/augmentation (that's a joke in and of itself. it's aug. if pt is 2-3 cm w/ 1 uc per hr. according to one of our docs. they hate to call it induction.) we use 1-2 mu/min pit inc by 1-2 q 30 min. we have another dr. that likes 6 mu/min to begin and inc by 3-6 mu/ min q 15 min. concentration is 20u/1000 cc lr or 10 u/1000cc lr. our limit. there is none. i have seen 45 mu/min. not frequently, but on a couple of occasions.

    we use cytotec only for fdiu.
    Last edit by imenid37 on Jan 26, '03
  8. by   mark_LD_RN
    i personally hate inductions in leads us to more c/s. but back to your question.
    we do several induction methods . i like the cytotec one the best.
    the methods are as follows:
    a) low dose pit patient in at 5 pm get pit started at 1 mu up 1 mu every hr up to 6 mu ,followed by regular pit induction at 6 am
    b)cytotec 25 or 50 mcg vaginally or po initially then 25 mcg q4 hours after 2 to 3 doses they get regular pit induction
    c)regular pit induction start at 2 mu go up 2 mu every 15 minutes, up to 24, must get order to go above 24mu, our midwives will only go up to 30, we have a few docs that will go to 40 and a couple that will even go to 50 mu. even have one that will go higher but i will not,i let her run the pit and adjust the pump her self.
    d) we have active mamnagement pit induction we start them at 4 mu and go up 4 mu q 15 min up to 40.

    i find cytotec vaginally is the best method, low dose pit has been almost useless here,rarely ever works. i used to like the prostaglandin gel but we do not use it any more.

    hope this helps
  9. by   OBNurseShelley
    where i used to work, we used prostaglandin gel ALOT< they'd either come in at night for 2 doses 4 hours apart then regular pit around 6am, we RARELY used cytotec, only on IUFD's and a few docs, we almost NEVER used cervidil, too expensive! Occasionally we'd use low dose pit, they'd run around 2mu all night long then regular pit in the am. AND when we had a new perinatalogist come, he used a very interesting induction method that i've seen work and not work, it's called EASI cath, extra amniotic something induction, it's a LARGE foley catheter inserted into the cervix and hooked up to a pump running about 30cc/hour, it manually dilates the cervix and constantly strips the membranes, the cool thing about this is, aside from the insertion it is painless and they can get up to the bathroom, walk, etc. of course, they are monitored almost continuously and about 6-8 hours, it either works by falling out, and wala, they are 4cm dilated or it doesn't work it's removed and pit is started, either way, they are more ripe than they were to begin with and pit is started and is usually more successful, I had NEVER heard of this until this doc came, apparently it's becoming more popular tho, what do you guys think??
  10. by   greyhorse
    elleRN...we used to document on our pit pts every 15 min as well. Now that we are increasing it every 30 min instead of every 15 we document every 30. VS every 30 as well.

    I havent every heard of the IUFD! Very interesting.

    We have one doc that really likes the Cervadil because we can remove it. He uses the cytotec as well but prefers the cervadil.

    greyhorse

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