Download certified nurse midwife

CERTIFIED NURSE MIDWIFE
SCOPE OF PRACTICE & PROTOCOLS
Renown Medical Center
Reno, Nevada
Approved 10/28/96
Revised 2/18/97
TABLE OF CONTENTS
I.
OVERVIEW…………………………………………………………………..1
II.
QUALIFICATIONS FOR CERTIFIED NURSE MIDWIVES……………….1
III.
BASIC RESPONSIBILITIES…………………………………………………4
IV.
DETERMINATION OF PRACTICE PRIVILEGES………………………….5
V.
PROCTORING REQUIREMENTS FOR CERTIFIED NURSE MIDWIVES
(CNM)….………………………………………………………………………5
VI.
GENERAL PROVISIONS…………………………………………………….7
VII.
SCOPE OF PRIVILEGES……………………………………………………..8
VIII.
PATIENT CRITERIA.………………………………………………………..10
IX.
ACKNOWLEDGMENT OF CONSENT……………………………………..14
X.
PROTOCOLS…………………………………………………………………15
XI.
FORMULARY………………………………………………………………..22
2
POLICIES AND PROCEDURES
GOVERNING THE PRACTICE OF
CERTIFIED NURSE MIDWIVES (CNM’S)
I.
OVERVIEW:
Renown Regional Medical Center supports and will participate with Certified
Nurse Midwives in the utilization of the hospital for the provision of obstetrical
care. The practice of Certified Nurse Midwives shall be under the supervision of
the Medical Staff and, therefore, Certified Nurse Midwives shall be subject to the
Bylaws and Policy and Procedures of the Medical Staff. These Policies and
Procedures governing the Practice of Certified Nurse Midwives have been
formulated in accordance with the Medical Staff Rules and Regulations.
Certified Nurse Midwives are not eligible for Medical Staff membership, but are
eligible for practice privileges as delineated by the Board of Directors for
Specified Professional Personnel.
II.
QUALIFICATIONS FOR CERTIFIED NURSE MIDWIVES:
2.1
Basic Qualifications
Practice privileges shall be extended only to professionally competent
certified nurse midwives who continuously meet the qualifications,
standards and requirements set forth in these Policies and Procedures and
the Medical Staff Bylaws. No nurse midwife shall provide services to
patients in the hospital unless he/she has been granted privileges in
accordance with the procedures set forth in the Specified Professional
Personnel Policy.
2.2
Specific Qualifications
A Certified Nurse Midwife Currently licensed to practice in the State of
Nevada shall be qualified for practice privileges if the following criteria
are met:
(a) Submit documentation of experience, background, training,
Judgment, demonstrated ability and, upon request, a physical and
mental health status with sufficient adequacy to demonstrate to the
Medical Staff and the Board that any patient treated by him/her will
receive care of the generally recognized professional level of quality
and efficiency and that he/she is qualified to provide a needed service
within the hospital, and
(b) It is determined, on the basis of documented references, that he/she
adheres strictly to the ethics of the profession, works cooperatively
with others, and is willing to participate in the discharge of the
appropriate responsibilities, and
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(c) Has successfully graduated from a nurse midwife program approved
by the American College of Nurse Midwives, and has performed a
minimum of 20 deliveries, and
(d) Has successfully completed the Certification Examination of the
American College of Nurse Midwives, and
(e) Provides evidence of adequate professional liability insurance
coverage as required by RRMC at the same limits as required of
physicians, and
(f) Provides documentation of successful completion of a NALS course
and re-certification each 2 years and documentation that he/she has
demonstrated competency in newborn resuscitation.
2.3
Exceptions to Specific Qualifications:
(a) Nurse midwives who meet the specific qualifications outlines in
section 2.2 (a), (b) and (c) and who have taken the Certification
Examination of the American College of Nurse Midwives, but have
not yet received notification of the results of that examination, may be
granted limited privileges (as defined below)
(b) Limited privileges may be granted until the results of the examination
are known. If the nurse midwife receives notification that he/she has
passed the examination, he/she shall be qualified for expanded
privileges. If he/she is notified that he/she has not passed the
examination, his/her limited privileges shall immediately terminate.
Limited privileges may be granted, however, for no more that six (6)
months, at which time the nurse midwife shall provide evidence that
he/she has passed the examination. Failure to provide such evidence
shall result in automatic termination of his/her privileges.
(c) The scope of limited privileges shall allow the individual to follow
patients in labor only but does not allow them to deliver.
III.
BASIC RESPONSIBILITIES OF INIDIVIDUAL CERTIFIED NURSE
MIDWIVES:
Each certified nurse midwife granted practice privileges at the hospital shall:
3.1
Provide patients with care at the generally recognized professional level of
quality and efficiency.
3.2
Abide by the Specified Professional Personnel Policy, the Rules and
Regulations Governing the Practice of Certified Nurse Midwives, and by
all other lawful standards, policies and rules of the hospital.
3.3
Prepare and complete in timely fashion the medical and other required
records for all patients to whom care is provided in the hospital.
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IV.
3.4
Retain responsibility within his/her area of professional competence for
the continuous care of each patient in the hospital for whom services are
provided.
3.5
Arrange for a collaborating obstetrician who shall be responsible for and
provide consultation and back up to the Certified Nurse Midwife. The
qualified collaborating obstetrician has completed an ACGME-approved
OB-GYN residence-training program. Additionally, he or she is an Active
Staff physician (or Associate Staff physician who has been released from
mentoring) who has assumed responsibility for the certified nurse midwife
as defined in the Scope of Practice and these Protocols. The collaborating
physician will be a member of the CNM’s employing group or will be a
physician who has an arrangement to cover call for the employing
physician’s group.
DETERMINATION OF PRACTICE PRIVILEGES:
Each Certified Nurse Midwife shall be entitled to exercise only those practice
privileges specifically granted by the Board of Governors of RRMC. Said
privileges must be within the scope of the license, certificate or other legal
credential authorizing practice in the State of Nevada and consistent with any
restrictions thereon.
V.
PROCTORING REQUIREMENTS FOR CERTIFIED NURSE
MIDWIFES:
Policy:
5.1
Except as otherwise determined by the Board of Directors, each CNM
initially granted privileges shall complete a period of proctoring to
determine eligibility for exercising the privileges initially granted.
5.2
Responsibility for overseeing the proctoring process shall lie with the
Chief of the OB-GYN Department.
5.3
Proctoring shall include direct observation of the CNM’s performance and
chart review by a physician proctor and shall begin immediately.
5.4
The proctoring period shall extend for a minimum of 6 months and for no
more than 24 months. If a CNM fails to successfully complete the
proctoring, the practice privileges shall automatically terminate.
5.5
The proctor is responsible only for observation and evaluations of the
labor and delivery management process. The proctor may also provide
consultation or co-management, if desired.
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Purpose:
To provide a mechanism for ensuring that the CNM is competent and eligible to exercise
those privileges initially granted.
Procedure:
5.6
The Renown Regional Medical Center OB-GYN Department Chief shall
designate the proctor(s) for each CNM, which must be a staff obstetrician
(ref. 3.5) who has agreed to do so. At least one of the proctors will not be
in the group, which employs the midwife, and at least five of the twentyproctored cases will be proctored by the non-employer(s).
5.7
The minimum requirements for proctoring of a CNM will include direct,
in-room observation/supervision of the first 10 consecutive vaginal
deliveries, with chart review of those cases, as well as chart review of an
additional 10 vaginal deliveries, for a total of 20 proctored deliveries
performed by the CNM during the initial 6-month provisional status. A
10-minute response time will be provided during office hours, with inhouse OB coverage provided after office hours.
5.8
The CNM being proctored shall be responsible for contacting the
proctor(s). The proctor shall be responsible for responding promptly when
notified.
5.9
For each case proctored, the proctor shall submit a written report in a
timely manner (i.e. 72 hrs) to the Chief of the Renown Regional Medical
Center Ob-GYN Department. For at least the first 10 consecutive cases,
the proctor shall provide direct, in-room observation/supervision for the
delivery and shall review the chart, including prenatal record, to determine
that the case was appropriately managed.
5.10
Each certified nurse midwife shall remain subject to proctoring until a
statement has been furnished to the OB-GYN Department, signed by the
proctor, which:
(a)
(b)
(c)
5.11
Describes the types and numbers of cases which were proctored;
States the proctor’s evaluation of the certified nurse midwife’s
performance and
States that the certified nurse midwife has satisfactorily
demonstrated the ability to exercise the privileges initially granted
and has discharged all of the necessary responsibilities.
At the completion of a minimum of 20 proctored and chart reviewed cases
and 6-months, the Chief shall review the reports from the proctor(s) and
shall determine if proctoring need continue during the remainder of the
provisional period.
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5.12
Terms of Proctoring Period
The proctoring period shall begin immediately and shall extend for no
more than twenty-four (24) months. If a certified nurse midwife fails to
successfully complete the proctoring, the practice privileges shall
automatically expire. An OB proctor must be present for and review the
charts of a minimum of the first 10 consecutive vaginal deliveries plus
review charts of 10 additional cases performed in the initial 6-months.
The proctor must also be available for 24-hour consultation/referral, with
in-house OB coverage after hours and 10-minute response time during
office hours.
5.13
Duration of Approval
The initial approval of practice privileges for Certified Nurse Midwives
shall be for a maximum period of twenty-four (24) months. Certified
Nurse Midwives shall be assigned to the supervision of the Department of
OB-GYN. All renewals of practice privileges shall be for a period not to
exceed two (2) years.
VI.
GENERAL PROVISIONS:
6.1
Medical Care Evaluations:
The Department of OB-GYN shall conduct retrospective patient care
performance indicator monitoring for the purpose of measuring, assessing
and improving the quality of care rendered by the Certified Nurse
Midwives. In addition, the department shall monitor adherence by the
Certified Nurse Midwives to: (1) Medical Staff and Hospital Bylaws,
policies and procedures; (2) requirements for consultations and transfers
of patient care; and (3) sound principles of clinical practice. These
functions shall be carried out in accordance with the Medical Staff Rules
and Regulations.
6.2
Informed Consent:
Informed consent shall be obtained by the collaborating obstetrician or by
the Certified Nurse Midwife. Informed consent shall include those items
specified by Medical Center policy. In addition, it shall specifically
include informing the patient that the Certified Nurse Midwife deals only
with the uncomplicated birth process and that a physician my not be
immediately available in the event of an emergency. The OB Consultant
is available for emergencies per ACOG Guidelines (see attached).
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VI.
SCOPE OF PRIVILEES:
The practice of midwifery by a Certified Nurse Midwife shall be limited to, and in
accordance with, the scope of privileges as outlined below:
7.1
Responsibilities:
The Certified Nurse Midwife shall: (during proctoring and following
proctoring):
7.2
(a)
Arrange for a qualified obstetrician who will be the admitting
physician, and who will be responsible for the care rendered by the
Certified Nurse Midwife, and will provide backup physician
coverage and supervision. A qualified obstetrician has completed
an accredited OB-GYN residency-training program and is willing
to be in-house for coverage after office hours and to provide a 10minute response time during office hours.
(b)
Notify the collaborating obstetrician when the patient is admitted
to the hospital, obtain confirmation that the physician is available
as specified in 7.1 (a) above.
(c)
Communicate to the collaborating obstetrician regarding the
physical assessment of the patient and the status of the labor;
(d)
Immediately notify the collaborating obstetrician when any of the
conditions specified in Section VIII of these Policies and
Procedures become evident and document in the progress notes
that the physician was notified and the time of the notification.
The physician and the Certified Nurse Midwife shall then follow
the procedures established in Section VIII.
(e)
When a woman requires hospitalization during pregnancy, but is
not in labor, immediately notify and transfer the management of
the care of the patient to the collaborating obstetrician.
(f)
Provide only inpatient prenatal services.
Intrapartum Procedures:
With notification of the collaborating obstetrician, the Certified Nurse
Midwife may:
(a)
Assess the patient on admission; write admitting orders to be
signed within 72 hours by collaborating obstetrician.
(b)
Obtain and record medical/obstetrical history;
(c)
Perform and record physical/obstetrical examinations;
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(d)
Record indicated progress notes;
(e)
Observe and assess the physical progress of labor;
(f)
Order indicated laboratory tests, analgesics, sedatives and
tranquilizers in accordance with the approved protocols, which are
attached. All orders shall be co-si9gned by the collaborating
obstetrician within 72 hours;
(g)
Administer pudenal or local anesthesia in accordance with the
approved protocols, which are attached.
(h)
Perform amniotomy as indicated;
(i)
Perform and repair routine episiotomy and vaginal or perineal
lacerations; all 3rd and 4th degree lacerations, cervical lacerations,
and sulcus tears must be repaired by an obstetrician;
(j)
Order intravenous therapy to maintain hydration of the patient;
(k)
Apply the fetal monitor when appropriate and evaluate the fetal
heart rate in accordance with the approved protocols, which are
attached. Place IUPC (Intrauterine Pressure Catheter) when
appropriate and evaluate uterine activity.
(l)
Perform vaginal delivery of vertex presentation if none of the
conditions specified in Section VIII of these Policies and
Procedures are present. The collaborating obstetrician must be
physically available as per these guidelines.
(m)
Establish neonatal respiration by clearing the airway or other
standard procedures as indicated;
(n)
Clamp and cut the umbilical cord;
(o)
Obtain specimen of cord blood;
(p)
Deliver and inspect placenta and membrane;
(q)
Inspect the vagina, cervix and rectum for lacerations;
(r)
Administer oxytocic medications as appropriate after delivery
according to the approved protocols which are attached;
(s)
Manage the care of the mother during the immediate postpartum
period;
(t)
Complete the medical record for delivery, including:
(1)
Labor and Deliver Summary;
(2)
Written postpartum orders;
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(3)
(4)
7.3
Signing of the birth certificate;
Dictation of the discharge summary for uncomplicated OB
patients.
Postpartum Procedures:
With notification of the collaborating obstetrician, the certified nurse
midwife may:
VIII.
(a)
Order laboratory tests, medications and treatment for relief of
common postpartum discomfort in accordance with the approved
protocols, which are attached. All others shall be co-signed by the
collaborating obstetrician within 72 hours;
(b)
Manage the care of the postpartum mother;
(c)
Perform physical assessment of postpartum patients (including
speculum examination, if indicated);
(d)
Discharge the postpartum mother, if indicated.
PATIENT CRITERIA
8.0
Conditions Requiring Consultation with the Collaborating Physician
Consultation is defined as review of the chart and/or physical examination
by the collaborating physician. The following antepartum, intrapartum
and post partum conditions require immediate consultation with the
collaborating physician and a determination as to whether the
collaborating physician will assume care of the patient or continue in the
collaborative role:
(a)
Major medical conditions such as congenital abnormalities which
might affect childbirth, diabetes, cardiopulmonary or renal
involvement, psychiatric disorders, alcoholism, drug addiction,
epilepsy and Rh sensitization;
(b)
Previous C-Section or uterine surgery;
(c)
Multiple gestation;
(d)
Parity of six or more;
(e)
Hematocrit less than 30%;
(f)
Pre-eclampsia or eclampsia;
(g)
Abnormal vaginal bleeding;
(h)
History of genital herpes in last month;
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(i)
Polyhydramnios or oligohydramnios;
(j)
Documented or suspected intrauterine growth retardation or
macrosomia;
(k)
Suspected cephalopelvic disproportion;
(l)
Post dates (more than 42 weeks after the last menstrual period);
(m)
Rupture of membranes before 36 weeks;
(n)
Spontaneous rupture of membranes greater than 6 hours and no
labor;
(o)
Induction or augmentation of labor;
(p)
Premature labor – less than 37 weeks;
(q)
Malpresentation other than occipito-posterior making progress;
(r)
Unusual symptomatology, e.g., unexplained abdominal pain;
(s)
Uterine tetany;
(t)
Primigravida in active labor with station higher –2;
(u)
Failure to progress in labor;
(v)
Cord prolapse;
(w)
Suspected infection;
(x)
Need for anesthesia other than pudendal block and local. The
provision of services by members of the Department of Anesthesia
shall require consultation between the obstetrician and the
anesthesiologist and shall require the supervising obstetrician to be
present at delivery; patients requiring an epidural are to be treated
by an obstetrician; in no case will the anesthesiologist be involved
in collaborative care;
(y)
Suspected fetal distress or abnormal tracing to include meconium
stained amniotic fluid;
(z)
Second stage greater than 1.5 hours in multipara and 2 hours in
nullipara;
(aa)
Retained placenta with excessive bleeding and/or greater than 20
minutes since delivery of infant;
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(bb)
Any difficult laceration including 3rd and 4th degree lacerations,
cervical lacerations and sulcus tears must be repaired by an
obstetrician;
(cc)
Postpartum blood loss estimated at greater than 500 cc’s;
(dd)
Maternal temperature greater than 101 on two occasions;
(ee)
Question of thrombus or phlebitis;
(ff)
Symptoms of endometritis or other serious infection;
(gg)
Evidence of hypertension not previously reported or not resolved;
(hh)
Arrest of labor as defined by Friedman;
(ii)
Oxytocin challenge testing;
(jj)
Nipple stimulation testing;
(kk)
Previous shoulder dystocia;
(ll)
Fetal distress;
(mm) Intrapartum/postpartum fever;
(nn)
Intrauterine pressure monitoring;
(oo)
Breech presentation;
(pp)
Face, Brow, shoulder presentation;
(qq)
Previous cerclage;
(rr)
All antepartum admissions;
(ss)
Third trimester bleeding;
(tt)
Hypertension: chronic or pregnancy induced;
(uu)
Confirmed fetal demise or congenital anomalies;
(vv)
Cesarean delivery;
(ww) Missed abortion, threatened abortion;
(xx)
Gestational diabetes requiring insulin;
(yy)
Hydatidiform mole;
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(zz)
Serious cardiac, renal, collagen, vascular or hematologic disease;
(aaa)
Infected abortion;
(bbb) Diagnosed placenta previa;
(ccc)
Confirmed placental abruption
(ddd) Any other abnormal findings, which would adversely affect fetal or
maternal well-being.
I have read and agree to abide by the above Scope of Practice for Certified Nurse
Practitioner.
Applicant’s Name Printed
Applicant’s Signature
Date
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Renown Regional Medical Center
The clients will be educated as to the role, education and focus of a certified nurse
midwife. If the client is appropriate for midwifery care and agrees to receive her care
through the midwifery service the following consent will be signed.
ACKNOWLEDGMENT OF CONSENT
(Midwifery Care)
The role, education and focus of certified nurse-midwifery care has been explained to me,
and I have to the best of my ability given an accurate medical/obstetrical history which
identifies me as appropriate for care in the midwifery practice. My physician and/or
nurse midwife has explained my current medical/obstetrical condition to my satisfaction,
and I have had an opportunity to have my questions answered. My proposed
medical/obstetrical course of action and the alternative (both for obstetrical and
midwifery care) have been explained to me. I have been given information regarding the
risks and benefits of this proposed course of action.
I understand the role and focus of nurse-midwifery care and consent to being cared for by
a certified nurse-MIDWIFERY CARE AND CONSENT TO BEING CARED FOR BY
A CERTIFIED NURSE-MIDWIFE AT Renown Regional Medical Center. I understand
that a certified nurse midwife provides complete maternity care to medically low risk
families and that a collaborating physician is available at all times for consultation.
I also understand that collaborating physicians may become involved in my care if
necessary.
Proposed course of action:
_______________________ _____________________ ________________________
(Witness)
(Patient’s Signature)
(Date)
Essential elements of the specific information provided my include:
Diagnosis of any known conditions
General nature of contemplated care or treatment
Risks involved
Prospects for success
Prognosis if the care or treatment is refused
Alternative care or treatment, if any
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PROTOCOLS
A.
PROTOCOL FOR FETAL AND MATERNAL MONITORING
1. Patients who present without complications and do not develop evidence of
fetal distress or maternal failure to progress may be monitored intermittently
according to Labor and Delivery policy after an initial twenty minute fetal
monitor strip validates normalcy;
(a)
Fetal heart tone (FHT) will be taken by stethoscope or doppler according
to ACOG criteria during first stage, with FHT auscultation occurring
before, during and following contractions.
(b)
FHT every 5 minutes during second stage per ACOG Technical Bulletin
#207 July 1995, guidelines for low-risk patients.
2. *If there is question of fetal distress, continuous electronic monitoring will be
used to validate fetal status. If status is questionable or abnormal, continuous
electronic fetal monitoring will continue. If status is normal, the patient may
return to intermittent monitoring.
3. If maternal status indicates need for pitocin augmentation, consult is
mandatory prior to initiation of pitocin and both fetus and contractions will be
constantly monitored electronically.
4. *Continuous electronic monitoring will be used after administration of labor
anesthesia.
5. When continuous electronic monitoring is used, the CNM may order or apply
internal or external monitoring devices.
*Covering physician will be consulted prior to conditions described in #2 and #4
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B.
PROTOCOL FOR MANAGEMENT OF Rh BLOOD FACTOR
Definition:
Non-immunized Rh negative women after delivery of Rh positive
infant or after miscarriage.
Treatment:
Rh immune globulin intramuscularly within 72 hours of delivery
or miscarriage.
Consultation is required if there is evidence of sensitization in blood evaluation.
C.
PROTOCOL FOR MANAGEMENT OF POSTPARTUM CARE
1.
2.
The CNM will see the postpartum patient daily during hospital stay.
During that time the CNM MAY:
(a)
Manage the postpartum care unless those conditions specified in
Section 8.5 of these Policies and Procedures become evident.
(b)
Consult with the supervising obstetrician regarding deviations
from normal.
(c)
Order medications and treatments for relief of common postpartum
discomfort according to the Protocol for Postpartum Medications
and Treatments.
(d)
Perform physical assessment of postpartum patients (including
sterile vaginal or speculum examination when indicated).
(e)
Order culture and sensitivity of blood, urine, lochia, or other
discharge as indicated.
(f)
Evaluate intrapartum blood loss and order administration of Rh
immune globulin to mothers as indicated.
Severe infection not responding satisfactorily to medication within 24
hours necessitates consultation with supervising obstetrician.
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D.
PROTOCOL FOR POSTPARTUM MEDICATIONS AND TREATMENTS
1.
Increased Maternal Bleeding
Definition:
Mild increase in maternal bleeding in the postpartum period
secondary to poor uterine contractility.
Etiology:
Poor uterine contractility secondary to:
Treatment:
1.
2.
3.
4.
5.
Over-distention of uterus
Multiparity
Prolonged labor
Anesthesia
Retained secundines
1.
2.
3.
4.
Massage fundus to express clots
Empty bladder
Methergine 0.2 mg IM
Start IV or if IV in place infuse LR or D5LR
1000cc+20u pitocin – titrate infusing to bleeding
Methergine 0.2 mg P.O. q4h X doses may be
repeated.
Prostaglandin 250mcg.IM
5.
6.
Consultation is required with supervising obstetrician if maternal bleeding
does not respond to treatment or if bleeding is excessive and causes
changes in pulse or blood pressure.
2.
Pain Relief in the Postpartum Period
Etiology: Pain Secondary to:
(a)
(b)
(c)
Episiotomy
Afterpains
Breast engorgement
Treatment: Episiotomy pain
(a)
(b)
(c)
(d)
(e)
(f)
Sitz baths
Tucks
Inflated doughnut
Topical ointment or spray
Ice Pack
Medications as specified in #4 below
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Treatment: Afterpains
(a)
(b)
(c)
Uterine massage to keep uterus well contracted
Empty bladder every 2 hours
Medications as specified in Formulary
Treatment: Breast Engorgement
(a)
3.
If nursing:
-
Frequent nursing
Heat
Manual expression
(b)
If not nursing:
- Minimal expression of milk
- Cold packs
(c)
Medication as per Formulary
(d)
Analgesics as indicated up to level 2 DEA regulations
Sleeping Difficulties
Definition:
Insomnia during the hospital postpartum stay.
Etiology:
Physical or emotional fatigue
Treatment:
(a)
(b)
(c)
(d)
(e)
E.
Warm shower
Back rub
Avoid stimulants
Medications
Sedatives as indicated
PROTOCOL FOR POSTPARTUM DISCHARGE
Mothers will be considered eligible for discharge provided they have all of the
following characteristics:
1.
2.
3.
Normal blood pressure
Afebrile with pulse and respirations of normal quality and rate
Appropriate color and amount of lochia, normal fundus
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4.
5.
6.
7.
8.
9.
10.
F.
Absence of historical or physical factors which would dispose patient to
late postpartum (second or third day) hemorrhage or infection .
Adequate urinary output
Minimal edema about site of repair
Asymptomatic ambulation
Able to assume basic care of infant
No questionable physical or emotional findings
Continued desire in the family for early discharge
INDUCTION AND AUGMENTATION OF LABOR
Induction and augmentation of labor will be supervised by the physician.
G.
PROGRESSION OF LABOR
1.
DEFINITION:
Labor is a dynamic process in which variability is the rule rather than the
exception. Though Friedman attempted to specify “normal” parameters,
he also admitted to the variability from case to case. According to him,
the most objectively measurable parameters of progression in labor are
dilatation of the cervix and descent of the presenting part.
2.
ETIOLOGY:
As mentioned above, many factors are involved in the progress of labor.
Some of the factors that may affect labor include:
(a)
Maternal position
(b)
Maternal ambulation
(c)
Sedation, analgesia, anesthesia
(d)
Fetal size, lie, presentation and position
(e)
Pelvic architecture
(f)
Uterine contractility
(g)
Maternal emotional state
(h)
Status of the membranes
(i)
Maternal age and parity
3.
CLINICAL FEATURES:
(a)
Labor parameters and their limits (Friedman)
Minimum slope of dilatation (cm/hr)
Deceleratioin phase (hrs)
Minimum slope of decent (cm/hr)
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Nulliparas
1.2
3.0
1.0
Multiparas
1.5
1.0
2.0
(b)
Labor disorders and their dignostic criteria (Friedman)
Protracted active phase dilatation
Protracted descent
Prolonged deceleration phase
Secondary arrest of dilatation
5.
Nulliparas
Multiparas
<1.2 cm/hr
<1.5 cm/hr
<1 cm/hr
<1 cm/hr
<3 hrs
>1 hr
No change for > 2 hours
TREATMENT:
(a)
Prolonged latent phase (with no signs of fetal distress and
membranes intact and no evidence of infection).
(1)
Therapeutic rest (unless patient is >42 weeks gestation or
refuses)
(2)
Start IV if needed for hydration
(b)
If no relief with above treatment – consult obstetrician
(1)
Medications per consulting physician
(c)
Protracted Dilatation/Descent (with no signs of fetal distress)
(1)
Consult with M.D.
(d)
Arrested Dilatation/Descent (with no signs of fetal distress)
(1)
Consult with MD – generally management includes ruling
out disproportion and oxytocin stimulation or cesarean
delivery if disproportion is present.
(2)
Rest and expectant management if no ROM after
consultation with MD
(3)
Medicate for pain relief and Sedation after consultation
with MD
(4)
Labor pattern abnormality associated with fetal distress
requires immediate MD consult
(e)
Pain Relief In The Active Phase Of Labor
1.
Treatment:
(a)
Comfort measures
1.
Ambulation
2.
Position changes
3.
Massage or effleurage
4.
Pyscholprophylaxis
(b)
Medication protocol to be submitted by consulting
physician
2.
Anesthesia
(a)
By anesthesiologist following obstetrician’s
assumption of case management
(b)
Pudendal block – 1% lidocaine or nesacaine
locally, infiltrate 5 cc on each side.
20
(f)
Postpartum Hemorrhage/immediate Consultation is required
3.
Postpartum hemorrhage is defined as an estimated blood
loss over 500 cc
4.
Administer 20 to 40 units Pitocin in existing IV or 10 to 20
units Pitocin IM while IV is being started
5.
Use bimanual compression, manual removal of the placenta
and/or manual exploration of the uterus to help control
bleeding in emergency situations; immediate consult is
required;
6.
Examine the cervix and vaginal walls for lacerations
7.
May use metherine 0.2 mg IM if patient is not hypertensive
8.
If the bleeding continues, notify the collaborating physician
and administer Prostin 250 micrograms IM, if not
contraindications.
9.
Monitor postpartum hematocrit every 6 to 24 hours until
stable.
(g)
Premature Rupture of Membranes
1.
A sterile speculum exam is done to:
(a)
Confirm rupture of membranes
(b)
Obtain cultures for group B strep, chlamydia and
GC (if indicated)
(c)
Avoid digital vaginal exam
(d)
Obtain fluid for fetal maturity studies in
pregnancies less than 37 weeks
2.
Fetal heart rate tracing
3.
If the patient has an otherwise normal pregnancy (i.e.>37
weeks gestation, vertex presentation, clean amniotic fluid,
no PIH, and no suspected IUGR), she may be managed
conservatively for 4 hours.
4.
If the patient is not having regular contractions with
cervical change within 4 hours, the back-up physician will
be consulted.
5.
If patient does not meet the criteria outlined above,
management will be determined in consultation with the
back-up obstetrician.
(h)
Shoulder Dystocia
1.
Call the obstetrician and anesthesiologist immediately
2.
Position patient appropriately (McROBert’s maneuver)
3.
Cut generous episiotomy
4.
Suprapubic pressure (no fundal or abdominal pressure)
5.
Rotate shoulders into one of the oblique diameters
6.
Wood’s screw
7.
Grasp posterior arm and deliver arm across chest
(i)
Subinvolution and Thrombophlebitis and Thromboemboli Disease
Consult with obstetrician in all cases.
21
FORMULARY
The following list of medications or classifications of medications includes but is not
limited to those which may be prescribed/utilized by the Certified Nurse Midwives at
Renown Regional Medical Center:
Ampicillin
Amoxicillin
Ansaid
Antiacids
Anusol HC Suppository/Cream
ASA
Azithromycin (Zithromax)
Ibuprofen (Advil, Motrin)
Indomethacin (Indocin)
IV Solutions
LR
L5LR
.45% NS
NS
D5W
Bacitracin
Benadryl
Betadine
Benzocaine Gell 20% (Anbesol)
Keflex
Macradantin/Macrobid
Metro Gel vaginal gel
Metronidazole (Flagyl)
Methergine
Monistate(Miconazole vaginal cream)
Monistate Derm Cream
Mycolog
Monostate Dual Pack
Carafate
Cefiximine
Ceftriaxone
Cefazolin sodium (Ancef)
Ciprofloxacin
Co-trimoxazole (Batrim,Septra/SeptraDS)
Colace/Pericolace
Neosporin Ophthalmic Solution
NSAID’s
Norethinedrone
Nubain
Depo-Provera
Demoral
Dicloxacillin
Doxycycline
Ofloxicin
Oral Contraceptives
Erythromycin
Epinephrine
Paxil
Percodan
Percocet
Penicillin
Phernergan
Phenergan suppositories
Pitrocin
Prenatal vitamins
Proctofoam HC
Prozac
Pyridium
Prostaglandin E2 Gel
Ferrous sulfate
Ferrous fumerate
Ferrous gluconate
Fiorocet/Fiorinal
Fluconazole
Gantrisin (sulfisoxazole)
Gentamycin
Gentamycine Ophthalmic Gtts
Hydrocortisone cream .5%/1%
22
FORMULARY (Continued)
Robitussin
RhoGam
Rubella vaccine
Seldane
Sodium floride
Spermacidal agents
Stadol
Sudaffed
Sulindac
Surfak
Terconazole
Terbutaline Sulfate
Tetracycline
Tylenol
Tylenol #3
Vistaril
Xylocaine 1% with/without
Epinephrine Nesacaine
Zoloft
2