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Identify on admission and as labor progresses: patient caregiver birth plan expectations of care plan for pain management Monitor fetal heart tones per Monitoring: Maternal Fetal Protocol Monitor: CBC Type Screen only valid for 72 hours from draw ; Dipstick urine for protein, ketones, glucose, leukocytes, blood. After Delivery: Draw Arterial blood gas from a umbilical cord segment supplied by the delivering practitioner. Send the Arterial Blood Gas to the Blood gas Lab tube #31 ; within 30 minutes of delivery Only if; The delivering practitioner requests or The 5 minute Apgar score is less than 7 Notify M.D. for: BP 140 90 or 90 50mmHg Pulse 120 or 60bpm Temperature 38C Respiration 10 minute Abnormal lab findings Vaginal bleeding 1 saturated pad every 15 minutes ; Inability to void in 4 hours and or urine output 30ML hr Spontaneous rupture of membranes Patient request for pain management Abnormal uterine activity Abnormal progression of labor Non-reassuring or abnormal fetal heart rate patterns per Monitoring: Maternal Fetal Protocol Readiness for delivery Discuss patient caregiver expectations for birth. Start medlock IV fluids with 18 gauge angiocath. Provide ice chips, sips of clear liquids, or hard candy. Encourage voiding q 2 hours. Dipstick urine for protein, ketones, glucose, leukocytes, blood. Offer appropriate comfort measures as needed: frequent position changes and backrubs ambulation relaxation and breathing techniques for pain relief Encourage expression of fears and concerns. Maintain lateral position or hip wedge when lying down or pushing. Confirm complete dilatation by vaginal exam when there is an urge to push. Encourage not to push prior to complete dilatation. Give feedback regarding her pushing efforts. Encourage the use of gravity and alternative positions to assist pushing.

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Fig. 3 Illustration of the Fraxel treatment which employs a blue dye and protective eyewear. HOW IS THE TREATMENT PERFORMED? Your skin is gently cleansed and an anesthetic gel is then applied to the treatment area s ; . After 45-60 minutes, your skin will be tested to insure adequate anesthesia. A blue dye that interacts with the laser is then applied. Next, eyewear is placed over the eyes and the treatment commences when the laser hand piece is passed back and forth over the skin. A warm and faint prickling sensation is felt during the treatment, which requires, on average, 20-30 minutes for a full face. After the treatment, the skin is cleansed with a warm towel and a moisturizer is applied. We do advise you to use caution in the sun for the first 24 hours after the procedure has been performed. ARE THERE ANY SIDE EFFECTS FROM THE FRAXEL LASER PROCEDURE? Not many. During the first 24 hours after treatment, your skin may feel as though it is sunburned, and it will appear pink or red. Dr. Harvey and staff will provide you with our "Post Laser Skin Care Kit" to alleviate your discomfort. Motron or Aleve can help if pain persists but this is rarely needed. Your skin will naturally bronze over the next week or two. As you continue with treatments, the sunburned to bronze conditions will repeat. Just like a natural sunburn, your skin will flake and exfoliate. Residual redness lasts for only a few days.