2.  Membranes are ruptured during a vaginal exam › With a crochet-like long hook › With a “finger-cot”  Head needs to be well engaged › Prevents cord prolapse  Typically rupture during a contraction › Again, to prevent cord prolapse

3.  Need to further evaluate fetal status with a fetal scalp electrode  Need to monitor uterine contractions with an IUPC  Controversy over whether it is effective as a 1 st step in labor augmentation  AROM DOES allow you to assess the fluid for blood or meconium which might allow you to prepare for labor differently.

4.  October 5, 2011 cochrane review: › 15 studies, 5583 women › No shortening of 1 st stage of labor › Possible increase in cesarean rate › Thus, per cochrane, routine amniotomy not recommended for labors progressing normally, OR for labors which have become prolonged.

5.  active hepatitis B,  Active hepatitis C,  Active HIV infection  Active Herpes (may consider c-section anyway) (in order to minimize exposure of the fetus to ascending infection)  Anything that would contraindicate vaginal delivery › Non-vertex position › Placenta previa or vasa previa  Inadequate dilation to allow rupture (need to be AT LEAST 1 and 1 is hard…2 to 3 is better)  Positive GBS carrier status is not a contraindication to amniotomy

6.  Cord prolapse  Prolonged rupture of membranes (if pt has labor distocia) leading to increased risk of infection  Scratching the baby! Yikes…

7.  Confirm presenting part is the vertex and ensure adequate cervical dilation with sterile vag exam.  Amniotomy if membranes are still intact  Aseptically handle the scalp electrode and introducer  Free the tail wire to allow free rotation of the electrode in the introducer  Place tip of applicator tube between pads of index and long fingers of hand used for vag exam, keep electrode spiral down inside introducer  Do the vag exam, wait for the next contraction › Make sure not to place the electrode on either fontanelle OR on the face › Apply over skull plates only  Turn outer handle of electrode clockwise until tip stops turning (usually 2 turns)  Gently retract handle while leaving exam hand in place to make sure tip does not pull free.  Palpate around electrode to ensure it isn’t applied to the maternal cervix  Release wire ends and remove applicator  Await connection and good tracing

9.  Poor quality external fetal heart-rate tracing  Sometimes used for births that are expected to be complicated to allow close monitoring of FHR during 2 nd stage (when its hardest to use external monitors)  Cervix needs to be dilated to 2-3 cm to allow

10.  Anything that would prevent amniotomy (active hepatitis B, Active hepatitis C, Active HIV infection, Active Herpes)  Known or suspected fetal coagulation disorder  Presentation other than vertex

11.  Potential for fetal scalp abscess  Cephalohematoma  CSF leak  CSF seeding with GBS and increased mortality rate if untreated for early neonatal GBS sepsis  Trauma to structures other than the scalp if mis-placed

12.  Up to date  Internet google search images  Pfennninger and Fowler. Procedures for primary care 2 nd edition.