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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:
                              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
                      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
                               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
                               g. Bishop score greater than or equal to 8 for nulliparous

                                                                                                    Page 2 of 6
         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
         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
         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
      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

                                                                      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
                 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,
                             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

       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
                                                                                                             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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