Generally, when I have a cytotec induction, things go pretty smoothly. Last night, however, was a different story. Coming on at 7 pm, I learned in report that my pt was due for her third dose. The day RN told me she was difficult to monitor because the TOCO kept flipping over, there just wasn't a good spot to pick up the contractions, etc. etc. So despite the fact that the EFM had not recorded contractions for at least 30 min or so, she proceeded to insert the third dose. Pt was 3/90/-1 (from closed, thick, and high at 3 pm)
Personally, I would not have felt comfortable putting Cytotec in a pt when I could not determine her contraction pattern. Anyway, she put the Cytotec in about 1920. At 1940, I was palpating moderate to strong contractions q 2 min. And easily got the TOCO to record, I might add.
Needless to say, pt was really uncomfortable, c/o pain rated 10, and still at 3 cm at 9 pm. I was just hoping she could hurry and get to 4 so we could get her some relief through an epidural. At 9:30, she c/o feeling something leaking. SROM with clear fluid.
At 10:10, her husband called out that she needed the nurse. Pt states "I feel fluid coming out and like the baby is trying to come out. SVE. Sure enough she is complete. As we make a mad dash to set up the delivery table and a stabilette and page all the right people (she was a midwife pt comanaged by the MD because of PIH) Mom was coaching opt to breathe through contractions. At 10:22, MD was in, instructed pt to start pushing. At 10:24, delivery of viable, 4 lb 12 oz, 36 wk baby girl. (She was induced for preeclampsia)
The midwife walked in about 5 min later. She had actually called back after we called her, to ask wasn't she just 3 cm?
Needless to say, I was not very happy with the day shift nurse, at all. IMO, she did not perform an adequate assessment before placing the Cytotec. I went back and checked her charting. She charted that contractions were moderate, and irregular. ??? They weren't even recording!!!
So, anyway, here's an example of how Cytotec and hyperstim can blow out a kid in just a couple hours (3 to complete in an hour and 10 min).
Btw, it's not just Cytotec. We had a pt last week who hyperstimed on Cervidil. It was pulled. She went from 4 to complete in 45 min. Luckily, the doc was in house for that one.
By the way what dosage of Cytotec was prescribed? No wonder the package insert says 'not to be taken by pregnant patients'
25 mcg
Some of our docs are more conservative with Cytotec. For instance, I had a Cytotec induction last night. The order was for q 4 hours up to 3 doses unless contractions were less than q 10 min. One dose later, this pt was contracting q 7-8 min, so she got no more Cytotec.
Some of the midwives, are not so conservative. This particular pt had an order for up to 5 doses. I have never, ever seen anyone need 5 doses. In all reality, if you looked back at the strip, she probably shouldn't have gotten the second dose because she was contracting less than q 10 min. But if they are not consistent, a couple of the midwives still want the Cytotec. It's up to the nurse's judgement to decide if she is going to place it or not.
Docs have to place the Cytotec in out hospital- nurses were going to but then a doc started yelling at a nurse in front of a patient during hyperstim that the RN had put it IN the cervix instead of under it. Now docs must break up their busy day and come in
Wouldn't it be nice if everyone thought like that! I have seen docs start Pit on an unripe cervix more often than not.
Some say low dose Pit, has the same effect as Cytotec or Cervidil, but I haven't seen good outcomes. If the cervix isn't ready, it's just not ready.
I think docs inserting Cytotec would be the best option, although they wouldn't like coming in, in the middle of the night to do it. At least, that takes the liability off the nurse.
I think you are so right. Sometimes I think people just jump the gun about having an induction, isn't as easy as some make it seem.
The 2 places that I have worked that use Cytotec have in the policy the pharmacy breaks the pill into 25mcg pieces and the doc has to be the one to insert it. I think that is the way it should be.
Is it protocol where anyone works to have IV access while using Cytotec? Where I work right now doesn't and I think it is necessary, or at least a heplock... what do you think?
The 2 places that I have worked that use Cytotec have in the policy the pharmacy breaks the pill into 25mcg pieces and the doc has to be the one to insert it. I think that is the way it should be.
Is it protocol where anyone works to have IV access while using Cytotec? Where I work right now doesn't and I think it is necessary, or at least a heplock... what do you think?
That's the way ours is stocked in our Pyxis. It comes from the pharmacy, 1/4 pill in a dissolvable capsule. Some of the docs prefer to place the first does, but let the nurses place the next doses. And most of them prefer to at least have a saline lock.
Docs have to place the Cytotec in out hospital- nurses were going to but then a doc started yelling at a nurse in front of a patient during hyperstim that the RN had put it IN the cervix instead of under it. Now docs must break up their busy day and come in
My place doesn't use Cytotec much, most docs order Cervadil.
But, we have three docs know for placing it in the cervix. Twice in my short L and D experience thus far I have seen it happen, one was a pt of mine, my preceptor was able to slide it out and under the cervix.
The other wasn't quite so lucky. 5 minutes after placment, the MD couldn't be sure why his pt was hyperstiming, so he crash sectioned her. The Cervadil was nice and bloody from sitting right in that cervix.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
giving patients cytotec PO is easier than in the posterior fornix of the cervix, and it is JUST as effective, so why don't they ALL do this????????????????????????????
we don't use cervidil anymore.......cost is the FACTOR, I am sure....sigh.
and yes, we don't pit unripe cervices, either......we use cytotec FIRST then pit, if cervix becomes soft.
We do not use the bishops score-I have never heard of it!
Can someone please tell me about it-I would love anything else I can use to document about re: cytotec, as I really dispise using it, and worry every morning waiting for our Midnoc cytotec induction!
Thanks!
PS-I have to thank you all! I am a newer RN, and I learn so much from you all! Thanks again!
The Bishop's score is used to determine inducibility. It's a chart that assigns a number for each of several categories, effacement, dilatation, station, etc., etc. I think there are 5 categories. I'd have to look again, since the docs are responsible for filling them out. I believe that a score of 9 or higher is recommended for induction (Correct me if I'm wrong)
But, a low Bishop score is an instance when Cytotec would be chosen over Pit., due to it's use in ripening the cervix. There should be an example in any OB text book.
I am wondering if our OB's EVER even take that into consideration? Reading that, I bet at least 60-70% of our Cytotec inductions would have a score of 7 or below....
I am wondering if our OB's EVER even take that into consideration? Reading that, I bet at least 60-70% of our Cytotec inductions would have a score of 7 or below....
L&D_RN_OH
288 Posts
25 mcg
Some of our docs are more conservative with Cytotec. For instance, I had a Cytotec induction last night. The order was for q 4 hours up to 3 doses unless contractions were less than q 10 min. One dose later, this pt was contracting q 7-8 min, so she got no more Cytotec.
Some of the midwives, are not so conservative.
This particular pt had an order for up to 5 doses. I have never, ever seen anyone need 5 doses. In all reality, if you looked back at the strip, she probably shouldn't have gotten the second dose because she was contracting less than q 10 min. But if they are not consistent, a couple of the midwives still want the Cytotec. It's up to the nurse's judgement to decide if she is going to place it or not.