new med order

[nursey_girl]

today in our unit we have a 24 week fetal demise attempting to deliver. the doctor has ordered high doses of oxtocin for induction. the order reads, " 200 units in 500 ml saline at 50 cc per hour. observe for s/s of h2o intoxication and maternal elec. concentrations..." is this something is totally new or have i been out of the loop. seems scary esp. since she is a prev. c section. stranger thing is, she is barely contraction with this infusion....???

[sirI, MSN, APRN, NP]

There is such a thing as a "high dose pitocin protocol". Several large teaching hospitals investigated it and use it, and our residents use it.

In our hospital it is only used for 2nd trimester demise/placenta detachment.

Our protocol is: 500 cc of NS with 50u of pitocin, run over 3 hr. with one hour rest.

Next bag: 100u of pit in 500 cc of NS, run over 3 hr, one hour rest.

If no response after the one hr rest, notify MD to examine.

SOMETIMES (rarely) we have had to go to 150u of pit in 500 cc, run over 3 hr. with one hour rest.

USUALLY placenta or POC are out during the second bag infusion.

STRICT I&O is necessary. If the patient has any significant medical problem (especially endocrine) she is not a candidate for this type of infusion.

We do apply toco to record contractions, but this is not always done in other hospitals. Again, it is a second trimester procedure and the difference between a second and a third trimester uterus make it an alternative.

I've never seen a problem such as rupture with it, but have had low output and fluid retention from pitocin (in which case it is stopped).

Hello, midwife2b,:balloons:

Do ya'll use this protocol with previous C-sections?

[babyktchr, BSN, RN]

Hello, midwife2b,:balloons:

Do ya'll use this protocol with previous C-sections?

:yeahthat:

[SmilingBluEyes]

we sure as heck would never do that.

[midwife2b]

Don't think so. But I will ask around...

[acuteobrn]

I work at an institution where this is a standard option for 2nd trimester IUFD inductions. It works very well as another poster mentioned above, the POC and placenta were delivered sometime during the second bag. This is a viable option for those w/o CI. We tend to run standard AMOL on s/p c/s patients, dependant on their incision type and dating.

I realise that when this is not your standard of practice it can be intimidating to use, however, if you were to research this, you will find that this is actually a safe alternative to several days worth of prosteglandins and eventual pitocins, which has a higher rate of retained placenta and hemorrhage. The key is the rest period between bags and that there is no viable fetus to be conserned about FHR with.

Just remember to watch for water tox and use a toco & strict I&Os. These patients tend to do very well.

[pebbles1977]

On the floor where I used to work we did TAs (therapeutic abortions). At one time we did them up to 24 weeks, but by the time I left anything over 20 weeks was subject to a board review.

That being said, our protocol was as follows:

240 units of pitocin in 1000 cc fluid. Start at 50 cc/hr, then up by 25 cc/hr every 8 hrs. If you had to go over 100 cc/hr you called the doc. Granted, at that time they injected urea or saline into the amniotic fluid beforehand to ensure fetocide, but the last time I checked they were no longer doing that. The standing orders read something like, call for hyperstim (we were never trained on how to recognize this, but I guess it was not an issue bc in my 4 years there we never saw it) or fluid intox (same deal there). Now that I'm on L&D I realize how much risk Pit carries, and it amazes me we never killed a pt doing those TAs. But we had a very prominent AB doc (nationally renowned) with all his research to back us up.

But now that I know what I know, I don't really even follow the OB docs orders to increase pit 2 q 15. Which is against our protocol.

[SmilingBluEyes]

Again, folks, we need to remember one thing: this is being done on a woman with a previous csection scar that could rupture! Most of us are aware of high-dose pitocin protocols for IUFDs, but in question here is not only fluid/electrolyte imbalances and related complications, but the fact this is like a VBAC here---would any of you do this for a VBAC situation, whether a stillbirth or live newborn? I would hope not.

[cnm in progress]

The risk of uterine rupture in a 24 week uterus is really low. Risk of rupture becomes more of an issue as the uterus is stretched to its maximum. That's why this protocol (and high dose misoprostol) are both safe in prior c/s patients.

[shortstuff31117]

How do we know risk of rupture in a 24 week uterus is low? Are there studies?

We use a regular old titration rate where I work, and I've never seen a problem, they deliver just fine.

[cnm in progress]

At 24 weeks gestation, the lower uterine segment is still quite thick.

[SmilingBluEyes]

I guess I don't get why you have to have so much medication. I see people deliver fine with the usual pitocin doses with IUFD in any event. It rarely takes all that long.

[cnm in progress]

I don't quite understand the rationale for such high-dose protocols, but not because of uterine rupture issues. A 24 week uterus doesn't have many pitocin receptors, so what are we accomplishing with such a high dose? Even a full-term uterus doesn't have the ability to do anything with such a high concentration... it would definitely become tetanic, but it doesn't require such a high dose. The only rationale I can come up with is because at such an early gestation there can be issues with placental separation and it is often preferable to have the fetus, amniotic sac, and placenta deliver as 1 single unit to aid in this process. High-dose misoprostol works very nicely for this... but it can cause severe diarrhea as well.