OB Policy and Procedures " HELP PLEASE"

binky · Aug 17, 2000

Originally posted by Caseyrnbsn:
I am in great need of where to go find written policy and procedures for the OB setting. Any hints on where to go would greatly be appreciated. CYTOTEC is one that I am looking for right now amooong others .Thanks for any replies.
Karen

I have recently found a wonderful place for OB policy and procedures....It is Joint Commission accredited.....It is through MSN i will be more than happy to dend you the address if u still need it..............binky

HazeK · Aug 21, 2000

In Nevada, state board of nursing will allow RNs to place cytotec lady partslly as an induction agent on stillborns & non-viable terminations of pregnancies...but NOT as a cervical ripening agent or as an induction agent on viable, term pregnancies.

Our MDs from east coast say Cytotec has been in use longer out there. One MD from Florida has used it for 10+years, so he says. Perhaps Florida state board of nursing could give you some guidelines...

Also, have you checked out the OB "bibles?" (AWHON Perinatal Guidelines + JOGN)

hope this helped. :-) haze

bbnurse · Aug 21, 2000

Are you wanting info' on oral or lady partslly administered misoprostol?

Article in latest Ob.Gyn. News about it . Vol. 35, No. 16.

ACOG is releasing guidelines on it too.

Am. J. Obstect. Gynecol has several articles since 1996 published on Misoprostol.

There is also a guide book for policies development for womens services at Aspen Publishing Co. which helps some.

Your local hospital "friends' networks" usually will share some policies if you ask or your hospital insurance carrier may offer some they consider "good". But don't count on it, totally. Good searching.

princess2 · Feb 4, 2005

I have recently found a wonderful place for OB policy and procedures....It is Joint Commission accredited.....It is through MSN i will be more than happy to dend you the address if u still need it..............binky

I am looking for OB policies and procedures, specifically on cytotec induction of labor. Please assist if you can. Princess2

SmilingBluEyes · Feb 4, 2005

Don't forget AWHONN, a very good resource that outlines standards of care for ALL obstetric nurses nationwide.

http://www.awhonn.org

they are the standards to which we are all held. I would try looking there.

Where I work, we nurses DO place cytotec, after a reassuring strip/NST is obtained. We place 25mcg, in the fornix of the os. The mom is then asked to lay on her side, being monitored, for 2 hours after the cytotec is placed. Vital signs are taking on mom q 15 min x4 after insertion. If no problems, after 2 hours, they can get up and walk, move about at will.

3 hours later, if uterine contractions are mild and not more frequent than 6 an hour, we place another 25 mcg in similar manner, monitoring the same way. We may use up to 3 doses (75mcg) to ripen the cervix.

Typically cytotec is VERY unpredictable. I have found it either works too well or not enough. I do keep Terbutaline (Brethine) in my pocket in case it's needed for hyperstimulation (which sometimes DOES happen with cytotec or other cervical ripening agents).

If hyperstimulation occurs, we are instructed to give Terb, 0.25 mg, SQ and continue monitoring. If non reassuring FHT's occur, (repeated late decelerations), additionally, we give O2 by mask, lay mom on left side, and start an IV, give a fluid bolus, as per intrauterine resus. procedures. And yes, this does happen from time to time, so a nurse administering cytotec better be on his or her TOES!

Just an aside, I would prefer we administer the drug PO versus lady partslly. The efficacy is the same in my experience, it either works or not. Obviously, PO is more comfortable for mom, and does not make it necessary for her to lay on her side, nearly flat. And if you have not done it, you don't know how HARD it is to put that TINY pill in the cervical fornix! WHAT A PAIN!!!! We used it PO where I used to work. And the result was identical; it either worked or not. Getting our docs on board to give PO is not easy, however. They think it's more effective lady partslly. I need to find some studies on this.

Anyhow, I digressed. Typically, we do cytotec ripening on night shift, and pitocin, if needed, is started the next morning.

Lots of discussion regarding cytotec policies, hazards and benefits, is found here:

http://listserv.acsu.buffalo.edu/archives/pnatalrn.html

Do a search and you will find a LOT about this drug and what nurses nationwide have to say about it.

Good luck. I know I did not help too much, but hopefully, gave you some direction.

We

JaneyW · Feb 4, 2005

Cytotec is placed by RNs in California: 25mcg in the vag fornix. It is difficult to do. I have found it easier when using surgical gloves that are tight as opposed to exam gloves. I attended a local AWHONN meeting about inductions and our speaker was an MD from UC Irvine Medical Center who is the lead researcher for getting Cytotec FDA approved for cervical ripening. She is also developing a pessary so that it can be removed like when we put in Cervidil.

I have found Cytotec to be unpredictable. Our P&P states we can place it every 4-6 hours times three. They have to have less than 7 UCs in an hour to place it in the first place. I am very careful and make sure I get that full hours' UC count before placing but some of my co-workers place it without as much. I have only been out of school about 2 1/2 years and am married to a lawyer so maybe I am bit over-cautious. I don't want to be the one on the stand explaining why I didn't follow P&P. If they have more than 7 UCs, I will call the MD and ask if we can do Cervidil instead.

We also have guidelines for Gravid #. No Cytotec for over Gravid 4. I had a patient the other night that was there for a Cytotec induction. Only 2 UCs in an hour, but GP 6/4. VE was 2/th/-3. I called and pointed out to the MD that I couldn't place the Cytotec because it was her 6th pregnancy. She (the MD) thought I was nuts but changed the order to Cervidil. Well, I placed the Cervidil and within 20 mminutes she was contracting q 1 1/2 to 2 1/2 and I pulled the Cervidil about 45 minutes later. Baby looked great throughout and she delivered about 4 hours later. Can you imagine if I had placed the Cytotec?

palesarah · Feb 4, 2005

placing those tiny little bits of pill lady partslly is tough! We don't administer it much on night shift though so I don't often have to wrestle with those little pills.

Our P&P for cytotec is similar to Deb's. RNs can place it, although the CNM or OB usually places the first dose duing their initial assessment. NST & 1/2 hour on monitor prior, dose is placed, pt in bed on monitor for two hours with frequent vital signs. Pt then allowed to get up and walk, we doptone/get vitals at the 3 hour mark, pt back on monitor at 3 1/2 hour mark and another dose is placed 4 hours later. Pts can recieve up to 6 doses in 24 hours, though that happens infrequently- depending on the reason for induction and assuming mom/baby are stable, we usually allow them to sleep after placing the last dose at 10pm or so.

Mermaid4 · Feb 6, 2005

We were using this years ago when our OB chief downloaded an article from the internet. Needless to say, without a policy we were adamant we weren't doing anything with it until we knew more. Cytotec seems to work well in my experience, although we rarely use it in my current setting except for fetal demises. I am accustomed to using it rectally for post partum hemorrages, and in early inductions.

princess2 · Feb 10, 2005

Thank you

I am very familiar with the standards and have been using cytotec for years. We are just trying to support our policy/procedure with research based info and was having difficulty finding current literature.

FYI there are applicators available that make placing cytotec a breeze no matter where that cervix is located--you can get it in the fornix with these.

We used it lady partslly where I worked last. The physicians preferred it because you could remove the undissolved portion if hyperstimulation resulted.

Thanks again,

Princess2

Don't forget AWHONN, a very good resource that outlines standards of care for ALL obstetric nurses nationwide.
http://www.awhonn.org
they are the standards to which we are all held. I would try looking there.
Where I work, we nurses DO place cytotec, after a reassuring strip/NST is obtained. We place 25mcg, in the fornix of the os. The mom is then asked to lay on her side, being monitored, for 2 hours after the cytotec is placed. Vital signs are taking on mom q 15 min x4 after insertion. If no problems, after 2 hours, they can get up and walk, move about at will.
3 hours later, if uterine contractions are mild and not more frequent than 6 an hour, we place another 25 mcg in similar manner, monitoring the same way. We may use up to 3 doses (75mcg) to ripen the cervix.
Typically cytotec is VERY unpredictable. I have found it either works too well or not enough. I do keep Terbutaline (Brethine) in my pocket in case it's needed for hyperstimulation (which sometimes DOES happen with cytotec or other cervical ripening agents).
If hyperstimulation occurs, we are instructed to give Terb, 0.25 mg, SQ and continue monitoring. If non reassuring FHT's occur, (repeated late decelerations), additionally, we give O2 by mask, lay mom on left side, and start an IV, give a fluid bolus, as per intrauterine resus. procedures. And yes, this does happen from time to time, so a nurse administering cytotec better be on his or her TOES!
Just an aside, I would prefer we administer the drug PO versus lady partslly. The efficacy is the same in my experience, it either works or not. Obviously, PO is more comfortable for mom, and does not make it necessary for her to lay on her side, nearly flat. And if you have not done it, you don't know how HARD it is to put that TINY pill in the cervical fornix! WHAT A PAIN!!!! We used it PO where I used to work. And the result was identical; it either worked or not. Getting our docs on board to give PO is not easy, however. They think it's more effective lady partslly. I need to find some studies on this.
Anyhow, I digressed. Typically, we do cytotec ripening on night shift, and pitocin, if needed, is started the next morning.
Lots of discussion regarding cytotec policies, hazards and benefits, is found here:
http://listserv.acsu.buffalo.edu/archives/pnatalrn.html
Do a search and you will find a LOT about this drug and what nurses nationwide have to say about it.
Good luck. I know I did not help too much, but hopefully, gave you some direction.
We

SmilingBluEyes · Feb 10, 2005

Thank you
I am very familiar We used it lady partslly where I worked last. The physicians preferred it because you could remove the undissolved portion if hyperstimulation resulted.
Thanks again,
Princess2

really? I can't imagine how...they are so tiny and sink right into the fornix once applied. NEVER have I heard of or seen anyone retrieve a pill from the posterior fornix of the cervix.

palesarah · Feb 10, 2005

really? I can't imagine how...they are so tiny and sink right into the fornix once applied. NEVER have I heard of or seen anyone retrieve a pill from the posterior fornix of the cervix.

it's in our policy to attempt to do so in the case of hyperstim... I think someone was successful once. Just the one time though. Those pills are so tiny I can barely get them in, never mind out!