Options discussed with patient

• Full discussion with Consultant Obstetrician.
• Green TOP form completed if TOP.

Administer Mifepristone 200mg orally

• Administered in hospital (usually Day Care).
• Patient to remain in hospital for one hour after taking medication.
• Patient advised to avoid non‐steroidal analgesics.
• Patient advised to attend if vaginal bleeding or any other concerns.
• Patient admitted 24 ‐ 48 hours later to Labour Ward.
• Commence partogram to ensure regular maternal observations (ideally, at least 3 hourly – prior to each vaginal examination)

Commence misoprostol 800 micrograms vaginally, followed by 400 micrograms 3 hourly per vagina (max 5 doses)

• Administration of misoprostol can be by midwife allocated to care for woman by the co‐ordinator midwife.
• Cochrane Review stated that the optimal route of administration of misoprostol is vaginally, but it can be given orally or sublingual.
• If patient not delivered after completing the course of misoprostol a further dose of mifepristone 200mg orally can be given 3 hours after the last dose of misoprostol .
• If after a further 12 hours the patient has not delivered then a vaginal examination should be performed by the Middle Grade Obstetrician. The misoprostol regime can then be repeated.

Discuss with Consultant if two courses fail.

• Do not perform ARM.
• Delivered products should be inspected by midwifery staff. If products appear complete, and bleeding is minimal, surgical intervention is not necessary. If any doubt or bleeding persists, evacuation under general anaesthesia should be arranged as an emergency.
• Relevant bloods must be obtained prior to discharge, General Practitioner contacted and follow‐up arranged. The patient’s named Consultant should be informed.
• If patient is Rhesus negative, Anti‐D must be administered.
• Cabergoline (Dostinex ®) 1mg orally stat may be required to suppress lactation.  Contraindications include pre‐eclampsia, cardiac valulopathy, history of fibrotic  disorders(pericardial/pulmonary/retroperitoneal), history puerperal psychosis.