Indication for induction: (choose one) ❏ Medical complication or condition (1): Diagnosis:_________________________________ ❏ Nonmedically indicated (1–3): Circumstances:___________________________________ Patient counseled about risks, benefits, and alternatives to induction of labor (1) ❏ Consent form signed as required by institution Bishop Score (see below) (1):_________ ❏ Pertinent prenatal laboratory test results (eg, group B streptococci or hematocrit) available (4, 5) ❏ Special concerns (eg, allergies, medical problems, and special needs):______________________ To be completed by reviewer: ❏ Approved induction after 39 0/7 weeks of gestation by aforementioned dating criteria ❏ Approved induction before 39 0/7 weeks of gestation (medical indication) ❏ HARD STOP – gestational age, indication, consent, or other issues prevent initiating induction without further information or consultation with department chair Date______________ Patient _______________________________ Date of birth___________ MR #___________ Physician or certified nurse–midwife______________________________ Last menstrual period__________________ Gravidity/Parity____________________________ Estimated date of delivery________________ Best estimated gestational age at delivery__________________ Proposed induction date_________________ Proposed admission time______________ ❏ Gestational age of 39 0/7 weeks or older confirmed by either of the following criteria (1): ❏ Ultrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater ❏ Fetal heart tones have been documented as present for 30 weeks of gestation by Doppler ultrasonography The American College of Obstetricians and Gynecologists Women’s Health Care Physicians ✓ Patient Safety Checklist SCHEDULING INDUCTION OF LABOR Number 5 • December 2011 (Replaces Patient Safety Checklist No. 1, November 2011) *Station reflects a −3 to +3 scale. Modified from Bishop EH. Pelvic scoring for elective induction. Obstet Gynecol 1964;24:266–8. Bishop Scoring System Factor Dilation Position of Effacement Station* Cervical Score (cm) Cervix (%) Consistency 0 Closed Posterior 0–30 -3 Firm 1 1–2 Midposition 40–50 -2 Medium 2 3–4 Anterior 60–70 -1, 0 Soft 3 5–6 — 80 +1, +2 — References 1. Induction of Labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:386–97. 2. Caughey AB, Sundaram V, Kaimal AJ, Cheng YW, Gienger A, Little SE, et al. Maternal and neonatal outcomes of elective induction of labor. Evidence Report/Technology Assessment No. 176. (Prepared by the Stanford University-UCSF Evidence-based Practice Center under contract No. 290-02-0017.) AHRQ Publication No. 09-E—5. Rockville (MD): Agency for Healthcare Research and Quality; 2009. 3. Clark SL, Frye DR, Meyers JA, Belfort MA, Dildy GA, Kofford S, et al. Reduction in elective delivery <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol 2010;203:449.e1–449.e6. 4. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Antepartum care. In: Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007. p. 83–137. 5. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Perinatal infections. In: Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007. p. 303–48. Standardization of health care processes and reduced variation has been shown to improve outcomes and quality of care. The American College of Obstetricians and Gynecologists has developed a series of patient safety checklists to help facilitate the standardization process. This checklist reflects emerging clinical, scientific, and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular checklist may be adapted to local resources, standardization of checklists within an institution is strongly encouraged. How to Use This Checklist The Patient Safety Checklist on Scheduling Induction of Labor should be completed by the health care provider and submitted to the respective hospital to schedule an induction of labor. The hospital should establish procedures to review the appropriateness of the scheduling based on the information contained in the checklist. A hard stop should be called if there are questions that arise that require further information or consultation with the department chair. Copyright December 2011 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to: Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. Scheduling induction of labor. Patient Safety Checklist No. 5. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1473–4.

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