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Service Line Policy Code: SL:PC-3004 Entity: Fairview Health Services Department: Policy and Procedure Category: Provision of Care, Treatment of Services Subject: Cervical Ripening for Induction of Labor (Prostaglandin Agents or Mechanical Devices) Bishop’s Score: Definitions: Sign 0 1 2 3 Dilation of Cervix 0 1-2 3-4 5-6 Effacement 0-30% 40-50% 60-70% 80% Consistency Firm Average Soft --- Position Posterior Mid Anterior --- Station -3 -2 -1/0 +1/+2 Uterine tachysystole is defined as 5 or more contractions in three 10 minute segments over a 30 minute timeframe. Purpose: To provide guidelines for administration of prostaglandin agents and use of mechanical devices to promote cervical ripening. These agents are indicated for ripening an unfavorable cervix in pregnant women with a medical and/or obstetric need for induction of labor. Policy: A. Documentation in the medical record indicates that a discussion was held, to the full extent that was feasible, between the pregnant woman and her health care provider about the indications; the agents and methods of labor induction, including the risks, benefits, and alternative approaches; and the possible need for repeat induction or cesarean birth. B. Cervical ripening agents are administered where uterine activity and Fetal Heart Rate (FHR) can be frequently monitored. (See also Fairview System Policy, “Fetal Monitoring”). C. Cervical ripening agents are only appropriate in medically indicated inductions before 41.0 weeks. D. Following administration of agent or placement of device, patient will be monitored and assessed for signs of uterine tachysystole. E. A physician and surgical/anesthesia team capable of performing a cesarean birth is readily available. F. FHR and uterine contractions are monitored per Cervical Ripening order set. G. Reassuring fetal status must be established prior to administration of agent. In clinical situations involving fetal demise or medical condition Page 1 of 6 that necessitates immediate delivery, the condition of the fetus will be documented in the progress notes. H. Provider or RN may administer Cervidil or Misoprostol I. Provider places mechanical device for cervical ripening. J. Use of a mechanical device (i.e.: Foley catheter) may be an appropriate method in women for whom pharmacologic agents are contraindicated, have experienced tachysystole with pharmacologic agents, and for those who have an increased risk of uterine rupture, i.e. history of uterine scar, who are attempting a trial of labor. Procedure: I. Preparation for Cervical Ripening: A. Verify that the provider has discussed the indications and potential risks and benefits of induction or augmentation with the pregnant woman. The provider will be contacted if the pregnant woman has any questions regarding the procedure. B. The provider must document the following in the induction plan and/or admission note: 1. Gestational age and method of determination of gestational age 2. Medical or Obstetrical indication 3. Estimated fetal weight (EFW) 4. Pelvic exam and Bishop Score 5. Consent to indicated procedure by the patient including her understanding of risks, benefits, and alternatives C. RN will notify the physician for a Bishop score on admission greater than or equal to 5 for multiparous women and greater than or equal to 8 for nulliparous women. D. The RN evaluates the fetal status electronically for at least 20 minutes. If fetal status is reassuring, the provider or RN will place ripening agent. Notify provider if the FHR is non-reassuring. (See also Fairview System Policy, “Fetal Monitoring”). II. Placement of Ripening Agents / Medical Device A. Prostaglandins 1. Contraindications a. Breech, face or transverse presentation b. History of placenta previa or undiagnosed uterine bleeding c. Previous cesarean or uterine surgery d. Asthma or glaucoma e. Maternal cardiac lesion f. Bishop score greater than or equal to 5 for multiparous women g. Bishop score greater than or equal to 8 for nulliparous Page 2 of 6 women h. Non-reassuring fetal heart rate tracing i. Tachysystole j. RELATIVE CONTRAINDICATION: Ruptured membranes 2. Cervidil placement a. See Cervical Ripening order set b. The ribbon end of the retrieval system may be allowed to extrude distally from the vagina or tucked in the vagina. c. Once placed, the Cervidil absorbs moisture, swells and releases dinoprostone at a rate of 0.3 mg/hour. d. Removal of cervidil should be documented in the MAR and accounted for in the final delivery count. 3. Misoprostol placement a. See Cervical Ripening order set B. Foley Catheter or Cervical Ripening Balloon placement 1. Contraindications a. Latex Allergy (Use Silicone Catheter if Latex Allergy Present) b. Placenta Previa or low lying placenta c. Abnormal uterine bleeding d. Fetal Malpresentation e. Umbilical Cord prolapse f. Unengaged Vertex (relative for multiparous patient) g. Non reassuring fetal status (relative) h. Rupture of Membranes 2. Equipment needed a. Foley Catheter French 16 with 30 cc Balloon or Foley Catheter French 26 with 30 cc Balloon or cervical ripening balloon. Silicone catheter if latex sensitivity or allergy. b. Sterile Speculum c. Sterile ring forceps d. Betadine Swabs e. Sterile Saline in a 30cc syringe f. Lubricating gel Page 3 of 6 g. IV tubing as ordered h. 1000 cc NS as ordered i. Catheter adapter as needed j. IV controller as needed 3. Procedure for Foley Catheter or Cervical Ripening Balloon placement a. Position patient for speculum placement. b. Nurse assists provider with the following: 1) Provider places speculum to visualize the cervix and swabs with Betadine. 2) Lubricate foley tip with gel and gently grasp approximately 1-1.5 centimeters below the balloon with the ring forceps. Carefully and gradually insert the foley into the cervical os. 3) After insertion stabilize the foley with the ring forceps. Do not grasp too firmly so as not to obstruct the inflation of the balloon. 4) Inject 30cc of sterile saline into the foley balloon. If unable to inflate, or the patient experiences pain, it is likely that the balloon is not past the cervical os. Deflate the balloon, advance the foley further, then attempt to inflate again. 5) After the catheter is placed, tug gently on the foley to secure placement. c. If requested, the nurse applies traction by taping the end of the catheter to the patient’s thigh, so that traction is gently, but firmly applied. Gently tug to validate catheter placement/retention approximately every 4 hours d. If the foley is not expelled in 12 hours, notify the provider. Page 4 of 6 e. Administer oxytocin per order set if provider orders. f. Removal or expulsion of foley bulb/cervical ripening balloon should be accounted for in the final delivery count. III. Management of Tachysystole A. Management of uterine tachysystole with reassuring FHR pattern: See also FHS Management of Tachysystole Algorithm. 1. Repositioning patient (left or right lateral position) 2. IV fluid bolus of at least 500 mL lactated Ringers solution 3. If tachysystole persists after above interventions for 30 minutes, notify provider for possible removal of agent. B. Management of uterine tachysystole with non-reassuring fetal heart rate patterns: See also FHS Management of Tachysystole Algorithm. 1. Remove cervical ripening agent if possible 2. Reposition patient (right or left lateral position) 3. Administer oxygen at 10 L/min per face mask (non-rebreather) 4. IV Bolus of at least 500 mL of Lactated Ringers 5. If no response, provider may order 0.25 mg terbutaline, subcutaneously. 6. Notify provider C. Management of uterine tachysystole with diagnosed fetal demise 1. Notify provider of maternal intolerance, active bleeding and unresolved, persistent uterine tachysystole greater than 30 minutes. External Ref: ACOG Practice Bulletin, Induction of Labor, Number 10, November 1999 AWHONN: Cervical Ripening and Induction and Augmentation of Labor, 2nd edition Kathleen Rice Simpson; 2008 ACOG, “Cardiotocographic Abnormalities Associated with Dinoprostone and Misoprostol Cervical Ripening”, P Ramsey, L Meyer, B Walkes, D Harris, P Ogburn, R Heise, K Ramin; 2005 Internal Ref: Fairview System Policies: Fetal Monitoring Unintentionally Retained Foreign Object Prevention in Vaginal Deliveries Source: Fairview System Perinatal Policy Group Approved by: Fairview System Zero Birth Initiative Committee Date Effective: January 12, 2009 Date Revised: Date Reviewed: Page 5 of 6 Tachysystole Definition of Tachysystole: 5 or more contractions in three 10 minute segments over a 30 Is the FHR reassuring? minute timeframe (Moderate variability and absence of recurrent late/variable decelerations) Yes No Reposition patient to left or right lateral position Discontinue the oxytocin infusion if running IV fluid bolus of at least 500mL lactated Ringers solution Reposition patient to left or right lateral position Increase frequency of assessment Administer oxygen 10 L/min tight mask (non-rebreather) IV fluid bolus of at least 500mL lactated Ringers solution If no response, obtain order for Terbutaline 0.25mg SQ x1 Notify the provider and document report and interventions Did tachysystole resolve after used to resolve the clinical situation. 10-15 minutes observation? Yes No How long until FHR reassuring and resolution of tachysystole? Manage oxytocin Decrease the pitocin by ½. infusion as ordered to Continue to observe for an If oxytocin has been If oxytocin has been achieve contractions additional 10-15 minutes discontinued for less than 30 discontinued for more every 2-3 minutes min., resume oxytocin at no than 30 min., resume with 60 seconds more than ½ the previous rate oxytocin at the initial resting tone between If tachysystole does not resolve 30 that caused uterine dose per order. contractions. minutes after initial inventions, tachysystole discontinue oxytocin infusion and notify the provider. Provider may consider Terbutaline. Gradually increase oxytocin rate as ordered and monitor maternal-fetal status Repeat steps per algorithm as needed. Repeat steps per algorithm as needed Page 6 of 6
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