Table 1 Misoprostol dose escalation design
Scenarios | Oral Misoprostol | Vaginal Misoprostol | Vaginal Dinoprostone |
|---|---|---|---|
No or little uterine activity (UA) | Increase dose according to the regimen: 3 h on + 1 h off (Example 1) | Maintain regimen | Maintain regimen |
Optimal UA | Maintain the dose and continue with the regimen (3 h on + 1 h off) (Example 2) | Maintain regimen | Maintain regimen |
Active labour | Maintain the dose and continue with the regimen (3 h on + 1 h off) (Example 2) | Maintain regimen | Maintain regimen |
Loss of UA after optimal UA | - When “off” drug: respect the period of rest and restart with dose depending on the previous level of UA (following the 3 + 1 regimen) (Example 3) - When “on” drug: increase the dose and follow the 3 + 1 regimen (Example 4) | Maintain regimen | Confirm the presence of the drug in vagina: |
- Lack of drug: administer additional dose. - Presence: maintain regimen. | |||
Active labour + loss of UA after optimal UA | When in combination with a lack of progression of labour, STOP treatment + oxytocin protocol | ||
Active labour + no progress | STOP treatment + oxytocin protocol | ||
Non-reassuring cardiotocographic pattern | STOP treatment + oxytocin protocol | ||
Uterine tachysystole or hypertonicity | STOP treatment (if later UA falls below optimal levels, restart treatment with a lower dose than before the episode of hyperstimulation) (Example 5) | STOP treatment (if later UA falls below optimal levels, restart treatment) | STOP treatment (if later UA falls below optimal levels, start oxytocin protocol) |
End of treatment without UA | Oxytocin protocol | ||
End of treatment with UA | Watchful waiting + oxytocin protocol if loss of UA | ||