This document provides guidelines for induction of labor, including: 1. Recommending inpatient and outpatient Cytotec inductions arrive at 7:00 PM to facilitate admission/discharge decisions and additional Cytotec doses if needed. 2. Inpatient Pitocin-only inductions should arrive at 6:00 AM to start Pitocin before 7:00 AM. 3. Favorable criteria for induction include a modified Bishop score of 6 or more and cervical dilation of 3-4 cm for nulliparous patients.

1. SUMMARY RECOMMENDATIONS AND CHANGES TO INDUCTION GUIDELINES INPATIENT ( IP ) & OUPATIENT ( OP ) October 2010

2. DILATION SCORE 0 0 cm 2 1-2 cm 4 3-4 cm 6 >4 cm CERVICAL LENGTH SCORE By digital PALPATION 0 3 cm 1 2 cm 2 1 cm 3 0 cm STATION SCORE In relation to spines 0 -3 1 -2 2 -1/O 3 + 1/+2

3. ARRIVE EARLIER Out Patient and In Patient CYTOTEC INDUCTIONS all scheduled to Arrive @ 7:00 PM This will facilitate a decision re Admission/Discharge prior to 8:30 AM the following morning This will provide the opportunity for an In Patient Induction admitted the night before for Cytotec the opportunity for additional Cytotec dosing if appropriate AND more time for cervical ripening During board rounds @ 5:30 PM a discussion between the OB 1 & 2 regarding the status of L&D and whether or not the inductions ( 2 max of 3) can arrive @ 7 PM OR if the Patient is to call back later @ a time To Be Determined by the OB 1 & 2 for arrival as early as it appears reasonable. The decision made by the OB 1 & 2 will then be discussed with the charge nurse prior to the patient calling @ 6 PM to have their scheduled 7 PM arrival time approved. 2) In Patient Pitocin only induction ARRIVES @ 0600 in an effort to start Pitocin Induction prior to 7 AM .

4. ACTIVELY MANAGE 1) Consider 3rd dose of Cytotec for an In Patient Cytotec start induction 2) Active management of labor Validated to improve the Success of Induction & Decrease C/S rate Consider Foley Bulb OR Amniotomy as early as possible

5. Use Modified Bishop Score Decide to induce Postterm as early as 41w0d (Score 6) Decide to induce Postterm @ 41w3d or 41w4d as an Outpatient ( Modified Bishop Score 5 or less) If you have decided to induce Postterm @ 41weeks the Modified Bishop Score will help you decide which protocol to utilize (ie Cytotec Start vs Pitocin Only) Bishop Score of 6 is favorable for Multiparous . OK for AM Pitocin Induction patients starting @ 41w 0d For Nulliparous patients a Modified Bishop Score of 6 is favorable ; However a cervical dilation of 3-4 cm is a prerequisite for Pitocin only AM induction. Recommend Cytotec start @ 41w0d-41w 6d with a score of 6 and cervix @ 1-2 cm

6. INDICATIONS for INPATIENT INDUCTION Postterm @ 41 weeks (41w0d-41w6d) - With a favorable cervix Early AM Pitocin Induction protocol Modified Bishop Score of 6 that must include cervical dilation of 3-4 cm in a Nulliparous patient Postterm @ 41w0d- 42w0d Cytotec Induction as Discussed Medical Indications ( In control with Reassuring NST) in General no later than 41w0d GDM with a favorable cervix as early as the 39 th week up 41w0d Pre Gestational Diabetes as early as 39w0d no later than 40w0d Gestational HTN / Preeclampsia “ 37 th week – 38 th week” CHTN 39w0d – 40w +/-2days SOCIAL INDICATIONS: ONLY By provider with Score of 6

7. INDICATIONS for OUTPATIENT INDUCTION Postterm @ 41w3d - 41w4d with an UNFAVORABLE CERVIX ( 5 or less )

8. RIVERSIDE CYTOTEC GUIDELINES Patients arrive @ 7 PM . Initial Cytotec dose is 25 micrograms placed Intravaginal followed by Either: 50 micrograms PO with a 6 hour interval OR 25 microgram intravaginal dose within a 4-6 hour interval AND IF APPROPRIATTE An Opportunity for 3 rd dose by either route. Most important for an IP Cytotec induction The pharmacokinetics of a PO dose have a higher peak concentration within a shorter time frame and a shorter duration of action than the intravaginal dose. The tail end of the intravaginal dose may act synergistically with an early onset peak of the PO dose resulting in uterine hyperstimulation. See Pharmacokinetics graph

10. RIVERSIDE OP CYTOTEC GUIDELINES 2nd dose of Cytotec If During the 5 th hour of the 6 hour trial period after the intravaginal 25 microgram Cytotec: Nurse may administer a 50 microgram PO dose of Cytotec without notifying the provider if the following criteria are met 1) Contractions occurring every 5 minutes or further apart 2) Contraction Strength mild-moderate intensity (not requiring pain meds) 3) Category 1 fetal heart tones present throughout the trial OR The provider may choose a 4 hour interval with a second intravaginal dose

11. RIVERSIDE OP CYTOTEC GUIDELINES 2nd dose of Cytotec If at any time after the first dose of the intravaginal 25 microgram Cytotec Contractions are painful ( requiring pain medication ) OR category 2 fetal heart rate pattern is present OR SROM occurs the provider is to be notified @ that time. IN THIS SITUATION ONE OF 3 CHOICES MUST BE MADE NOW 1) Admission is mandatory for category 2 FHT or SROM SROM mandates 2 nd 4hr interval dose of vaginal Cytotec OR Pitocin start @ 4 hours from last Cytotec dose 2) Pitocin induction/augmentation which will mandate admission. Once Pitocin is started strongly consider simultaneous intrauterine Foley bulb placement OR Amniotomy As Soon As Possible. 3) Additional dose of Intravaginal or PO Cytotec as an outpatient no later than 6 hours from the first dose of Cytotec 4)Continued monitoring for spontaneous labor is NOT AN OPTION

12. RIVERSIDE OP CYTOTEC GUIDELINES Patients who are discharged home are to return @ 42 0/7 +/- 1 day for an inpatient induction and also be within 3-4 days of the outpatient failed induction N0 interval NST is indicated if a " reassuring FHT tracing " is present after failed attempt at outpatient induction. If you are concerned regarding any clinical information that became apparent during the outpatient induction ; ADMIT THE PATIENT and continue with induction or C/S. If the decision to Admit or Discharge a patient is not obvious @ 8 AM the oncoming OB 1 should be included in the decision.

13. INDUCTION ETIQUETTE It is not necessary to schedule a Medical Induction on an E xact day OR Arbitrary deadline unless you are on L&D in an attempt to be present for Delivery. Typically you will have a week or more to schedule the patient Remember to be considerate of your partners / CNM associates and try to schedule inductions when you are on, especially if it is an inpatient induction . If you are not on L&D call your partner / CNM associate who is on and request the favor of caring for your patient.

14. Do the Math 42weeks 0 days all patients delivered 3-4 day interval without NST/AFI is Ok if FHT/AFI reassuring during induction Postterm OP Induction 41 weeks and 3 or 4 days 41w 3days with a 4 day interval is delivered @ 42w0d 41w 4days with a 3 day interval is delivered @ 42w0d