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Protocols

 
TITLE: PROTOCOL FOR HIGH DOSE OXYTOCIN ADMINISTRATION AS MEANS OF ABORTION OR SECOND TRIMESTER LABOR INDUCTION FOR WOMEN WITH FETAL DEATHS
 
Developed 8/1/05
 
 
PURPOSE: To outline the management of patients receiving high dose oxytocin during second trimester abortion and for labor induction in the second trimester for women with a fetal death.
 
LEVEL: Interdependent (noted items require an order from a health care provider licensed to provide medical therapy)
 
SUPPORTIVE DATA: Oxytocin is a synthetic polypeptide hormone that acts on the smooth musculature of the uterus to stimulate rhythmic contractions, increase contraction intensity, and increase muscle tone. Its use at higher than customary levels has been well-documented to effect second trimester abortion or effect labor induction and delivery for women in the second trimester who have a fetal death.(1-3)
 
BACKGROUND
Some women have medical conditions that would make continuation of their pregnancies unsafe for their health or are carrying pregnancies complicated by severe fetal anomalies or severe fetal karyotype abnormalities. Furthermore, some women suffer fetal deaths during their second trimester.  For such events, those women may choose to end their pregnancies or will have to undergo labor and delivery.  For these situations, women have several options. The options include expectant management, surgical evacuation of the pregnancy, and labor induction.  Medications used for labor induction include prostaglandin E2, misoprostol, and high doses of oxytocin. This protocol describes the use of high dose oxytocin. As an adjunct to this method, the clinician may place osmotic dilators or a Foley catheter into the patient’s cervix to facilitate cervical dilation.
 
INDICATIONS (may include but are not limited to):
1)          Severe medical or obstetrical conditions for which pregnancy would severely jeopardize the patient’s health or substantially increase the risk of maternal death;
2)          Severe psychological conditions in which continuation of the pregnancy would severely jeopardize the patient’s mental health;
3)          Severe social conditions in which continuation of the pregnancy would further worsen the patient’s situation;
4)          Lethal fetal anomalies (Fetal anomalies not compatible with life);
5)          Fetal anomaly(ies) that would cause severe and lifelong disability for the newborn;
6)          Fetal anomaly(ies) that would cause a profoundly poor quality of life for the newborn;
7)          Lethal fetal karyotype  (fetal karyotype not compatible with life);
8)          An abnormal fetal karyotype that would cause severe and lifelong disability for the newborn;
9)          An abnormal fetal karyotype that would cause a profoundly poor quality of life for the newborn;
10)      Intrauterine fetal death in the second trimester.
 
RELATIVE CONTRAINDICATIONS
1)          Any maternal condition in which a vaginal delivery would place the mother at increased risk for morbidity;
2)          Inadequate personnel for supervision.
 
MAY BE USED BUT PROCEED WITH CAUTION
1)     This procedure may be used with caution in patients with previous classical or vertical uterine scar;
2)     Placenta previa or vasa previa.
 
MAXIMUM GESTATIONAL AGE FOR THIS PROCEDURE – 27 6/7 weeks.
 
EQUIPMENT
 

D5LR 1000 mLs                                
High doses Oxytocin solution(s)      
Red medication label
Primary anesthesia IV set
Infusion pump and tubing set
Y connecting tubing
Interlink threaded lock cannula (2)
Interlink injection site (2)
 


CONTENT
PRIOR TO ADMINISTRATION
  1. The physician or midwife should perform a physical exam to determine cervical status.
  2. The physician or midwife should explain the procedure to the patient and provide reassurance. They should discuss:
    1. Benefits, risks, and purpose;
    2. Potential complications;
    3. That the procedure may fail;
    4. Success may require more than one day;
    5. That the patient may require a dilatation and curettage for completion and/or removal of the placenta.
  3. The physician or midwife may place osmotic dilators or a Foley catheter into the patient’s cervix.
  4. (Physician or Midwife) Write order “High Dose Oxytocin Protocol.” So there is no ambiguity, the exact dosing must be written. These are the orders that are to be written.
    1. 50 units Oxytocin in 500 mL D5 ¼ NS over 3 hours; then discontinue for 1 hour (run maintenance fluids for this hour), then
    2. 100 units Oxytocin in 500 mL D5 ¼ NS over 3 hours; then discontinue for 1 hour (run maintenance fluids for this hour), then
    3. 150 units Oxytocin in 500 mL D5 ¼ NS over 3 hours; then discontinue for 1 hour (run maintenance fluids for this hour), then
    4. 200 units Oxytocin in 500 mL D5 ¼ NS over 3 hours; then discontinue for 1 hour (run maintenance fluids for this hour, then
    5. 250 units Oxytocin in 500 mL D5 ¼ NS over 3 hours; then discontinue for 1 hour (run maintenance fluids for this hour), then
    6. 300 units Oxytocin in 500 mL D5 ¼ NS over 3 hours; then discontinue.
5.          Begin primary infusion line with an 18-gauge catheter into one port of the “Y” connector.
6.          Start primary infusion of D5LR at 60 ml/hour. This does not require an infusion pump. (requires and order)
7.          Prime the pump set, and connect to the other “Y” port connector.
ADMINISTRATION
8.          Administer oxytocin intravenously.
9.          Use an infusion pump to control the fluid rate.
10.       Oxytocin should always be the primary on the pump alone. No secondary permitted
11.       Start the high dose oxytocin infusion. The rate will be 167 ml/hr (regardless of concentration.
12.       Follow oxytocin orders as written. Discontinue for 1 hour after every 3 hours. (This temporary discontinuation is done to decrease the risk of water intoxication.) Then increase oxytocin to next level.
13.       Use a separate port if other medications are given through same line.
ASSESSMENT
14.       Assess for contraction pattern every 15 - 30 minutes, Observe for:
    1. Contractions less than every 2 minutes;
    2. No uterine relaxation between contractions;
    3. Abdominal rigidity, bleeding or hypotension.
15.       Assess temperature as follows:
    1. Every 4 hours if intact membranes;
    2. Every 2 hours if ruptured membranes;
    3. Every hour if elevated.
16.       Assess blood pressure, pulse and respirations as follows:
    1. Every 4 hours if stable and not in labor;
    2. Every hour in active labor unless the patient’s medical condition requires more frequent monitoring.
17.       Monitor I/O hourly and observe for water intoxication:
    1. Headache;
    2. Nausea and vomiting;
    3. Mental confusion;
    4. Decreased urinary output;
    5. Hypotension;
    6. Tachycardia;
    7. Cardiac arrhythmias.
 
 
 
REFERENCES
 
1.   Winkler CL, Gray SE, Hauth JC, Owen J, Tucker JM. Mid-second-trimester labor induction: concentrated oxytocin compared with prostaglandin E2 vaginal suppositories. Obstet Gynecol 1991;77(2):297-300.
2.   Owen J, Hauth JC, Winkler CL, Gray SE. Midtrimester pregnancy termination: a randomized trial of prostaglandin E2 versus concentrated oxytocin. Am J Obstet Gynecol 1992;167(4 Pt 1):1112-6.
3.   Stubblefield PG, Carr-Ellis S, Borgatta L. Methods for induced abortion. Obstet Gynecol 2004;104(1):174-85.
 
 
 
CLINICAL REFERENCES:
DBC Clinical Practice Committee
Leo Brancazio, MD; Medical Director Duke Birthing Center
 
 
 
 
 
 
The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.
 
These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions.  We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.
The protocols remain the intellectual property of the Duke University Health System.  They cannot be reproduced in whole or part without the expressed permission of the Health System.
 
These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia.  Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.
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