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 | ||
Optimal UA: at least 3 contractions lasting more than 60 s every 10 min
Little UA: less than 3 contractions every 10 min
Active labour: at least 4 cm of dilatation with optimal UA
No progress of labour: The following criteria must be met:
- Latent phase of labour completed and active phase of labour started (cervical dilation of 4 cm or more)
- Contraction pattern of 3 contractions every 10 min with adequate intensity for 4 h without cervical changes
Non-reassuring cardiotocographic trace:
- Recurrent late decelerations lasting for 30 min or more
- Atypical variable decelerations in more than 50% of the contractions for 30 min or more
- Prolonged decelerations: decrease in foetal heart rate (FHR) by ≥15 beats per minute (bpm) for 2 to 10 min
- Foetal bradycardia: FHR < 100 bpm for more than 10 min
- Reduction in variability indicating a need for intervention
- Sinusoidal FHR pattern
Uterine tachysystole: Six or more contractions in 10 min for at least 30 min
Hypertonicity: Sustained uterine contractions for more than 2 min without complete uterine relaxation
Uterine hyperstimulation: Excessive uterine activity with abnormal FHR