1. Done By: Ibtesam.U.Jahlan

2. Is the planned initiation of labor prior to the onset of spontaneous labor. It is an obstetric intervention that should be used when elective birth beneficial to mother and baby. *It includes several methods: Medical and Surgical methods. Induction of labor:

3. Augmentation of labor: *Is refers to intervention to correct slow progress in labor. * Correction of ineffective uterine contraction includes Amniotomy and/or Oxytocin infusion.

4. Indications for induction of labor: Maternal indications: *Post-term (main indication) *P.I.H (Timing depend )on the severity) *Diabetes Mellitus (increase risk of baby loss and mortality rate) *Medical conditions (as renal, respiratory and cardiac diseases) *Placenta insufficiency (as moderate or sever placenta abruption but commonly C.S) *Prolonged pre-labor rupture of membranes. *Rheuses isoimmunization. *Maternal request.

5. Continue Indications for Induction of Labor: Fetal Indications: * Suspected fetal compromise (I.U.G.R ) *Intrauterine death (I.U.F.D).

6. Before Induction, the following conditions must be present: Sure estimation of weeks of gestation. Evidence of fetal maturity. Absence of cephalopelvic disproportion. An engaged head in longitudinal lie. Cervix is ready for delivery. High score Bishop's score.

7. Apply Induction with cautiously with the following conditions: Multiple pregnancy. Hydraminos. Grand parity. Maternal age of >35years. Previous cesarean section. *Those conditions are at risk for ruptured of uterus.

8. Contraindications for I.O.L: Placenta previa. Cord presentation or cord prolapse. Cephalopelvic disproportion. Severe fetal compromise.

9. Continue Contraindications for I.O.L: Malpresentation (as transverse or compound presentation) Active genital herpes infection. Psychological.

10. The Bishop score: Bishop score is producing a scoring system to quantify the state of readiness of the cervix and fetus. High scores (a favourable cervix) are associated with an easier shorter induction. ScoreCervix 3210 5 or more 3 or 41 or 20Dilatation of cervix -softMediu m FirmConsistency of cervix <0.51-0.52-1>2 Length of cervix (cm) -AnteriorMidPosterior Position of cervix +1_+2-1_0-2-3 Station of presenting part

11. Methods of Induction of Labor: A)-Medical: 1-Prostaglandins. 2-Oxytocin Infusion. B)-Surgical: 1-Amniotomy (ARM).

12. A)-Prostaglandins: Prostaglandins used when the cervix closed. Prostaglandins Preparations are available Vaginal (gel or tablets form), extra-aminiotic, Intravenous, Oral. How? It is inserted close to the cervix within the posterior fornix of the vagina, then it is absorbed. Results: Prostaglandins results in changes which can be assessed on vaginal examination, increasing the Bishop's score. PGE2 dose should not exceed 6 mg.

13. Nursing Interventions: 1-Review patient history before admenistiration (to ensure there are no contraindications or any caution). 2-Fetal heart rate and uterine contractions should be monitored continuously for 30-60minutes after administration. (there is a risk of uterine hyperstimulation and ruptured of uterus with or without fetal distress) 3-Instruct woman to pass urine before administering prostaglandin (because she will stay for long time in bed) 4-The mother should remain in lateral or supine position with hip tilt for 30 to 60minutes after administration of gel, for 2 hours after insertion of vaginal tablets. (to minimize leakage and improve effectiveness).

14. 5-Assess cervical dilatation 6 hours after insertion. (If no cervical response and no adverse effects, the dose may be repeated) 6-Monitor side effects of prostaglandins: Pyrexia, warm feeling in vagina, vomiting, diarrhea, and back pain. 7-It is necessary to allow at least 2 hours to elapse between the last prostaglandin dose and starting Syntocinon infusion, (because Prostaglandin increase the sensitivity of the uterus to Syntocinon). 8-If any adverse reactions occur notify doctor to remove gel or suppository if possible. Continue Nursing Interventions:

15. B)-Amniotomy (ARM): It involve the splitting liquor. It can be used alone or in combination with Oxytocin. of the amnion and chorion to release the How? ARM carried out during a vaginal examination using an amnihook, a tool with a small hook at one end, or specialized gloves contain in one finger hook. Why? performed to induce labor, to augment contractions, to shortening the duration of labor, to visualize the color of the liquor, or to attach a fetal scalp electrode for the fetal heart rate. When? ARM done when the cervix is favorable (high Bishop's score)

16. Nursing Interventions: Before ARM: 1-Informed consent obtain. 2-Do abdominal palpation to confirm fetal presentation, position and degree of engagement of the presenting part. 3-Fetal heart rate and uterine contraction should be noted and recorded in patient record. 4-Apply Aseptic technique.

17. Continue Nursing Interventions: After ARM: 1-The midwife should exclude the presence of cord prolapse. 2-Note color, odor, consistency, and quantity of amniotic fluid (to identify if there is any meconium or blood in liquor). 3-Note presentation, position and station. 4-Monitor temperature q2h (to detect developing infection).

18. Continue Nursing Interventions: After ARM: 5-Clean and dry the perineum and change the disposable underpad (to remove warm, moist medium suitable for infection). 6-Monitor strict sterile technique during vaginal examination and keep vaginal examination at minimum (to Prevent infection). 7-Maintain bed rest (to decrease chance for cord prolapse and infection). 8-Monitor ARM hazards: intrauterine infection, early deceleration, cord prolapse, bleeding (low-lying placenta).

19. C)-Oxytocin Infusion: Oytocin infusion in an isotonic solution is used to stimulate uterine contractions after rupture of the membranes. The dose and increasing rate depend on each agency protocols. Example as P.S.F.H.protocol: Rate of 5U Oxy. In 500 ml normal saline Time (minutes) 6ml/hr0 12 ml/hr30 24 ml/hr60 48 ml/hr90 96 ml/hr120

20. Oxytocin (Syntocinon): Nursing roleSide effectsAction 1-Assess: -respiration, BP, Pulse, -length, intensity, duration of contraction. -FHR (acceleration, deceleration, distress) -Signs of water intoxication: (confusion, anuria, drowsiness, headache. 2-Teach patient to: report increase blood loss, abdominal cramp, fever, foul-smelling lochia. Hypo- or hyper-tention, dysrhythmia, Abruptio placenta, decreases uterine blood flow, convulsions, nausea, vomiting, Asphyxia for baby. Acts directly on myofibrils, producing uterine contraction. Stimulate milk ejection by the breast.

21. Oxytocin Infusion: Preparing And Administering: RationalInterventions 1-to reduce anxiety1-Explain procedure. 2-To establish baseline and ensure fetal activity. 2-Apply fetal monitor and monitor FHR. 3-To minimizes the risk of water intoxication. 3-Start an electrolytes solution I.V infusion (primary line)

22. Continue Oxytocin Infusion: RationalInterventions 4-Oxytocin must be administered with an infusion pump to ensure accurate dose administration. 4-Prepare a second I.V and add the prescribed amount of oxytocin (usually 10U/1000ml). The I.V tubing is inserted into I.V pump. 5-If there is an indication to stop the oxytocin infusion, it can be done without affecting the primary fluid infusion. 5-Connect the secondary line to the primary line at the port closest to the needle insertion site and turn on at the prescribed rate.

23. Continue Oxytocin Infusion : RationalInterventions 6-If uterus become hyperstimulated, blood flow to uteroplacental site will be decreased and fetus will suffer from hypoxia. 6-Monitor FHR, uterine contraction (frequency, duration, and intensity), BP,and Pulse and record at intervals comparable to the dosage regimen. All observation and increases or decreases in oxytocin are documented on the fetal heart tracing and mother chart. 7-Sensitivity to oxytocin increases as labor progresses. These results indicate that the pattern of normal labor has been established. 7- Once the desired frequency of contractions has been reached (every 2 to 3 minutes and 45 to 60 second's duration. oxytocin may be stop or reduced the increases of the rate.

24. Signs of Hyperstimulation of the uterus: Contraction occur more frequently than every 2 minutes. Duration of contraction is longer than 90 seconds. Elevation of resting tone of uterus is greater than 15 to 20 mmHg over her baseline of intrauterine pressure. Blood pressure increases when contractions increase in frequency, duration, and intensity because of decrease in uteroplacental circulation. Client experience increasing pain because of increased frequency, duration, and intensity of contractions. Sustained tetanic contractions occur.

25. Signs of Fetal Distress: Tachycardia or bradycardia. Late decelerations, variable decelerations, or prolonged deceleration. Loss of variability. Increased fetal activity. Excessive molding or caput- succedaneum formation. Meconium stained amniotic fluid in cephalic presentation.

26. Nursing Interventions if Uterine Hyperstimulation or Fetal Distress Occur: RationalInterventions 1-To prevent fetal anoxia and uterine rupture. 1-Turn off immediately oxytocin infusion 2-To improve fetal- placental blood flow. 2-Turn woman on her left side. 3-To provide adequate intravascular volume, support maternal BP, and I.V route for emergency medications. 3-Increase primary I.V rate up to 200 ml/hr unless contraindicated.

27. Continue Nursing Interventions if Uterine Hyperstimulation or Fetal Distress Occur: RationalInterventions 4-To saturate the blood with oxygen as much as possible to prevent fetal anoxia. 4-Give oxygen 6 to 10 l/min ( per protocol) by face mask. 5-This indicate induction failed. If membrane intact discontinue induction and try again later. If membrane ruptured cesarean birth may be necessary. 5-Notify doctor

28. Other Complications may Occur during Oxytocin Infusion: In addition to hyper-stimulation of uterus and fetal distress those complications may occur: Ruptured uterus as a result of over- stimulation if any cephalopelvic disproportion present. Amniotic fluid embolism is rare which may caused by strong, tumultuous contractions. (usually occur in 3 rd stage after placenta separation and with tetanic condition of uterus)