9. Alterations affecting protective function
   1. Induction of labor-deliberate initiation of uterine contractions.
      1. Indications for:
         1. History of rapid or silent labors, precipitate birth.
         2. Woman resides some distance from hospital (controversial).
         3. Coexisting medical disorders:
            1. Uncontrolled diabetes.
            2. Progressive preeclampsia.
            3. Severe renal disease.
            4. Cardiac disease.
         4. PROM-spontaneous rupture of membranes before onset of labor and less than 37 weeks from last menstrual period.
            Hazards:
            1. Maternal-intrauterine    infection(chorioamnionitis, endometritis).
            2. Fetal-sepsis; prolapsed cord.
         5. Rh or ABO incompatibility, fetal hemolytic disease.
         6. Congenital anomaly (anencephaly).
         7. Postterm pregnancy with nonreactive nonstress test (NST), or oligohydramnios.
         8. Intrauterine fetal demise.
      2. Criteria for induction:
         1. Absence of CPD, malpresentation, or malposition.
         2. Engaged vertex of single gestation.
         3. Nearing, or at term.
         4. Fetal lung maturity.
            1. Survival rate-better at 32 weeks or more.
            2. Lecithin/sphingomyelin ratio greater than 2:1.
            3. Diabetic mother-PG is present in amniotic fluid.
         5. “Ripe” cervix-softening, partially effaced, or ready for effacement/dilation (if not already present). Note: Intravaginal or paracervical application of prostaglandin gel, or misoprostol may be used to prepare cervix for labor.
      3. Methods:
         1. Amniotomy-artificial rupture of membranes with fetal head engaged and dilation of cervix.
         2. Intravenous oxytocin infusion.
      4. Potential complications:
         1. Amniotomy-irrevocably committed to birth. Hazards:
            1. Prolapsed cord.
            2. Infection.
         2. IV oxytocin infusion:
            1. Overstimulation of uterus.
            2. Decreased placental perfusion/fetal distress (neonatal jaundice).
            3. Precipitate labor and birth.
            4. Cervical/perineal lacerations.
            5. Uterine rupture.
            6. Postpartum hemorrhage.
            7. Water intoxication-if large doses given in D/W over prolonged period (antidiuretic effect increases water reabsorption).
            8. Hypertensive crisis.
      BEFORE INDUCTION
      5. Assessment-before induction:
         1. Estimate of gestation (EDB, fundal height, cervical status).
         2. Bishop score: evaluation of cervical inducibility
         3. General health status:
            1. Weight, vital signs, FH R, edema.
            2. Status of membranes.
            3. Vaginal bleeding.
            4. Coexisting disorders.
         4. History of previous labors, if any.
         5. Emotional status.
         6. Knowledge/understanding of anticipated procedures:
            1. Amniotomy (artificial rupture of membranes).
            2. IV oxytocin infusion.
            3. Fetal monitoring
         7. Preparation for childbirth (Lamaze, etc.); coping strategies. Identify support person.
      6. Analysis/nursing diagnosis:
         1. Knowledge deficit related to process of induction.
         2. Anxiety/fear related to need for induction of labor.
         3. Ineffective individual coping related to psychological stress.
         4. Pain related to uterine contractions.
      7. Nursing care plan/implementation:
         1. Goal: health teaching.
            1. Explain rationale for procedures:
               1. Amniotomy.
                  1. Induces labor.
                  2. Relieves uterine overdistention.
                  3. Increases efficiency of contractions, shortening labor.
               2. Oxytocin infusion.
                  1. Induces labor.
                  2. Stimulates uterine contractions.
               3. Internal fetal monitor.
                  1. Provides continuous assessment of uterine response to oxytocin stimulation.
                  2. Provides continuous assessment of fetal response to physiological stress of labor.
            2. Describe procedure-to reduce anxiety and increase cooperation.
            3. Explain advantages/disadvantages- to ensure “informed consent.”
         2. Goal: emotional support-encourage verbalization of concerns, reassure, as possible.
      8. Evaluation/outcome criterion: woman verbalizes understanding of process, rationale, procedures, and alternatives.
      DURING INDUCTION AND LABOR
      9. Assessment-during induction and labor:
         1. Amniotomy-same as for spontaneous rupture of membranes:
            1. Observe fluid-note color, amount.
            2. Monitor FHR; assess for fetal distress.
            3. Observe for signs of prolapsed cord.
            4. Assess fetal activity.
               1. Excessive activity may indicate distress.
               2. Absence of activity may indicate distress or demise.
         2. IV oxytocin infusion:
            1. Continually assess response to oxytocin stimulation/flow rate; always given by controlled infusion.
               1. Uterine contractions.
               2. Maternal vital signs, FHR.
            2. Identify signs of:
               1. Deviation from normal patterns:
                  1. Lack of response to increasing flow rate.
                  2. Uterine hyperirritability (contractions-less than 2 minutes apart).
                  3. Lack of adequate uterine relaxation between contractions.
               2. Side effects of oxytocin: diminished output-potential water intoxication.
               3. Hazards to mother or fetus:
                  1. Sustained (over 90 seconds) or tetanic (strong, spasmlike) contractions-potential abruptio placentae, uterine rupture, fetal hypoxia/ anoxia/death.
                  2. Fetal arrhythmias, decelerations.
                  3. Maternal hypertension- potential for hypertensive crisis, cerebral hemorrhage.
      10. Nursing care plan/implementation:
          1. Same as for other women in labor.
          2. If indications of deviations from normal patterns:
             1. Change maternal position.
             2. Stop oxytocin infusion, maintain IV with Ringer’s lactate, etc.
             3. Begin oxygen per mask; up to 8-10 L/min.
             4. Notify physician promptly.
             5. Check maternal blood pressure and pulse rate.
          3. Anticipatory guidance: may have strong contractions soon after induction starts.
      11. Evaluation/outcome criteria:
          1. Demonstrates response to oxytocin stimulation.
             1. Establishes desired contraction pattern, not hyperstimulated.
             2. Progresses through labor-within normal limits:
                1. Normotensive.
                2. Voids in adequate amounts.
                3. No evidence of deviation from normal contraction patterns.
          2. No evidence of fetal distress.
          3. Experiences normal vaginal birth of viable infant.