the uterus as well as fetal distress. Uterine hyperstimulation is effectively treated by stopping use of prostaglandin E2. Other monitoring parameters include sustained uterine contractions and fetal distress. In babies there may be decreased breathing and low blood pressure. Care should be taken in people with asthma or glaucoma and it is not recommended in those who have had a prior C-section. Mechanism of action Prostaglandin E2 binds to G protein-coupled receptors (GPCRs) EP1, EP2, EP3, and EP4 to cause various downstream effects to cause direct contractions in the myometrium. In addition, PGE2 inhibits Na+ absorption within the Thick Ascending Limb (TAL) of the Loop of Henle and ADH-mediated water transport in collecting tubules. As a result, blockage of PGE2 synthesis with NSAIDs can limit the efficacy of loop diuretics. Administration Prostaglandin E2 (PGE2) should only be administered by, or under the direct supervision of, a physician and careful monitoring should be performed. PGE2 comes in many dosage forms with varying pharmacokinetic properties. For example PGE2 can come in a gel formulation that requires six hour dosing or it can come as a slow release dinoprostone pessary that does not need to be re-administered and can be taken out if necessary. In a quality improvement project done in UK, the switch from prostaglandin gel to the slow release dinoprostone pessary was able to lower cesarian section rates in women undergoing induction of labor in maternity care. For the vaginal insert (brand name Cervidil), the manufacturer recommends keeping the medication frozen until use since it does not need to be warmed to room temperature. Once the package is open, a water miscible lubricant may be used to insert the medication, using your finger place the device into the vagina and position the device transversely in the posterior vaginal fornix. The person receiving the drug should remain laying down for two hours after administration of the insert is complete. The manufacturer also recommends waiting 30 minutes after removal of insert before starting oxytocin. The vaginal gel (brand name Prostin E2, Canada) is administered through a prefilled syringe and the medication is placed in the posterior fornix of the vagina. After administration people should stay laying down for at least 30 minutes after they have received the drug. Contraindications Contraindications to a medication are any reasons to not use the drug. Prostaglandin E2 (PGE2) is used to induce labor and should not be