Protocol: Misoprostol (Cytotec) for Cervical Ripening and Induction of Labor

by Myer S. Bornstein, M.D. and Don Shuwarger, M.D., F.A.C.O.G., OBGYN.net Editorial Advisors

I. Misoprostol (Cytotec) is a synthetic PGE1 analogue. It's FDA approved indication is for the prevention of stomach ulcers in patients taking nonsteroidal anti-inflammatory drugs. Because of its prostaglantin activity it is also very useful for cervical ripening and induction of labor. Misoprostol has much the same mechanism of action, benefits, complications, indications, adverse reactions and contraindications as other cervical/vaginal prostaglandin products (e.g. Prostin¨ gel, Prepidil¨ , and Cervidil¨ ). Multiple studies have been done in multiple U.S., Canadian and European centers all showing the effectiveness and safety of Misoprostol for cervical ripening and induction of labor.

II. The pregnancy should have:

• completed 38 weeks gestation by reliable dating, or
• lung maturity as evidenced by a L/S > 2.0 or a positive phosphotidyl glycerol test, or
• completed 36 weeks gestation with a maternal or fetal medical indication for induction of labor.

III. There should be the absence of acute fetal distress, abruptio placenta, placenta previa or unexplained vaginal bleeding.

IV. The patient should be examined prior to the administration of misoprostol. The fetus should be in vertex presentation. Multifetal pregnancies are not excluded as long as the leading fetus is vertex.

V. Misoprostol can be used with intact or ruptured membranes.

VI. From the literature, listed below are just two possible protocols for the use of Misoprostol for cervical ripening and induction of labor:

Protocol 1 Vaginal Dosing

1. Do NST, notify physician if nonreactive.
2. Insert one half of a 100 mcg. misoprostol tablet in vagina
3. Monitor vital signs in accordance with unit policies.
4. Monitor fetal heart rate and contractions in accordance with unit policy and ACOG guidelines.
5. Can repeat dose every four hours up to a total of 6 doses.
6. Pitocin can be started four hours after last dose.
7. After three to four hours patient can ambulate.
8. Notify physician for signs of fetal distress or tetanic uterine contractions

Protocol 2 Oral Dosing

1. Do NST, notify physician if nonreactive.
2. Give 100 mcg. misoprostol tablet orally.
3. Monitor vital signs in accordance with unit policies.
4. Monitor fetal heart rate and contractions in accordance with unit policy and ACOG guidelines.
5. Pitocin can be started four hours after last dose.
6. Notify physician for signs of fetal distress or tetanic uterine contractions

For both of the above protocols:
After two hours observation, patient can be discharged home to return if labor ensues or the next day for induction.

VII. Intravaginal or oral misoprostol can be administered by physician, RN or LPN.