University of Michigan Health System

Womens, Childrens and Behavioral Health Nursing Services

Womens Hospital Birth Center Triage

Laminaria / Dilapan Placement for Mid-trimester Loss or
Termination

Guideline #WHBC-03-078A
Date of Origin: February 2003
Date of Last Review: February 2003, April 2004, February, 2007
Projected Date of Next Review: February, 2009

I. Statement of purpose:
To provide guidelines for the safe management of patients requiring Laminaria/Dilapan
placement.

II. Introduction:
Laminaria/Dilapan are used to assist with cervical dilation prior to D & C, D & E or
induction of labor in those women who have either experienced a recent IUFD, an
incomplete spontaneous abortion, missed abortion or those who desire termination of
pregnancy prior to 24 weeks.

III. General information:
A. Documentation of ABO type and Rh status, medication allergies, current
medications, weeks gestation and any current health problems on
Laminaria/Dilapan worksheet.
B. Women weighing greater than 300#are not candidates for D & E.
C. Women with large fibroids, uterine scars/anomalies, bleeding problems, etc. need
individual review by the attending physician.
D. State of Michigan Termination paperwork must be signed >24 hours prior to the
placement of Laminaria/Dilapan/Cytotec and available on chart in cases where the
fetus is alive.
E. D & E Procedures will be scheduled in the WHBC-OR on Tuesday afternoons
starting at 1300 with a maximum of 3 procedures per day. Scheduling at other
times is discouraged unless there are pressing reasons.
F. Paracervical block will be offered to women for Laminaria/Dilapan insertion (See
Exhibit Pain Control for First Trimester Abortion Gabbe, et al).
G. Ultrasound should be considered to confirm placement of Laminaria/Dilapan
through the cervical os.
H. Recommendations for preparation of cervix for D & E by gestational age:
1. Between 12 weeks +0 days and 14 weeks +0 days
Laminaria/Dilapan generally not needed.
Cytotec 400 mcg (self-administered) to be dissolved in side of mouth 2 hours
prior to D & E.
2. Between 14 weeks +1 day and 17 weeks +0 days
On day prior to surgery Place a minimum of 10mm of Laminaria or Dilapan.
Start Doycycline 100 mg by mouth q 12 hours x 5 days.
Cytotec 400 mcg (self-administered) to be dissolved in side of mouth, 2 hours
prior to D & E.
- or-
University of Michigan Health System
Womens, Childrens and Behavioral Health Nursing Services
Womens Hospital Birth Center Triage

Same as above, except may insert Dilapan (minimum of 10mm) the morning
of surgery for minimum of 4 hours.
3. Between 17 weeks +0 days and 20 weeks +6 days
On day prior to surgery Insert Dilapan (10mm minimum). After 4 hours,
remove Dilapan and insert Laminaria (minimum 20 mm).
Start Doycycline 100 mg by mouth q 12 hours x 5 days.
Cytotec 400 mcg (self-administered) to be dissolved in side of mouth, 2 hours
prior to D & E.
I. Recommendation for preparation of cervix for medical induction by gestational
age:
1. Between 12 weeks +0 days and 14 weeks +0 days
Consider Laminaria /Dilapan as below
2. Between 14 weeks +1 day and 17 weeks +0 days
On day prior to induction Place a minimum of 10mm of Laminaria or
Dilapan.
- or-
May insert Dilapan (minimum of 10mm) the morning of induction for
minimum of 4 hours.
2. Between 17 weeks +0 days and 23 weeks +5 days
On day prior to induction Insert Dilapan (10mm minimum). After 4 hours,
remove Dilapan and insert Laminaria (minimum 20 mm).

IV. Intervention:
A. Administer Ibuprofen 600 mg po and/or other pain medication to the woman for
her comfort as ordered by the CNM or MD (review allergies).
J . Assist CNM or MD with setup needed for laminaria placement. Collect the
following items:
1. assortment of Laminaria, ranging from 3 9mm; Dilapan 3mm x 55mm,
4mm x 55mm and 4mm x 65mm.
2. ring forceps
3. tenaculum forceps
4. paracervical kit and 1% lidocaine
5. sterile lubricant
6. 6 - 8 sterile 4X4 sponges
7. betadine solution
8. speculum
9. exam light
10. warm saline
11. other items the MD/CNM may request.
K. Assist with positioning of woman into lithotomy position.
L. Provide emotional support to woman and significant other during procedure.
M. Assist CNM or MD as necessary during the procedure.
N. Maintain an accurate count of both the number of Laminaria/Dilapan and the
number of 4X4 sponges placed and record on the worksheet.
O. If necessary, facilitate a pre-operative workup with both the OB Resident and OB
Anesthesia if surgery is to follow the laminaria placement.
P. Additional medications that may be ordered by CNM/MD after review of patient
allergies:
University of Michigan Health System
Womens, Childrens and Behavioral Health Nursing Services
Womens Hospital Birth Center Triage

1. Doxycycline 100 mg by mouth q 12 hours x 5 days. (Prophylactic antibiotics
for women planning D & E. Start with Laminaria/ Dilapan placement, may
take morning of surgery with sip of water).
2. Cytotec 200 mcg x 2 tablets (total of 400 mcg), woman to dissolve in side of
mouth 2 hours prior to scheduled D & E procedure.

V. Health Education:
A. Have patient call Triage if she develops a fever >100.4.
B. Instruct patient that she is likely to have cramping and bleeding following the
laminaria placement. Encourage patient to take Ibuprofen 600mg every 6 hours
for cramping pain as needed (review allergies).
C. Have patient call Triage, if she begins to experience active bleeding (soaking >1
pad an hour) or if she experiences constant abdominal cramping that lasts longer
than 3 minutes or signs of ruptured membranes.
D. Instruct patient to save and bring with her on her return visit any products of
conception, laminaria and/or gauze that have been expelled at home.
E. Give written information to patient regarding time of scheduled surgery, time
patient needs to arrive on unit, NPO after midnight (if having D&C or D&E).
Also give patient the Triage number to call with any questions/concerns before
her return visit.

VI. References:
AWHONN Perinatal Nursing _ Lippincott; Simpson, K.R. and Creehan, P.A.. Edition 2,
2001
Gabbe, et al. Obstetrics: Normal and Problem Pregnancies

VII. Author(s)
Van de Ven, Cosmas, MD
Harris, Lisa, MD
Murtland, Terri , CNM
Iamarino, Dannielle RN, BSN


VIII. Exhibits:
Patient Educational Handout - Laminaria Placement
Pain Control for First Trimester Abortion Gabbe, et al.
Laminaria/Dilapan Worksheet

IX. Signatures:


__________________________________ ________________________________
Margay Britton, MS, RN Cosmas Van De Ven, MD
Director, Patient Care Services Director, MFM Division



__________________________________
University of Michigan Health System
Womens, Childrens and Behavioral Health Nursing Services
Womens Hospital Birth Center Triage

Terri L. Murtland, RN, MSN, CNM
Triage Coordinator