Essential Intrapartum and Newborn Care

Intrapartum – during the delivery of the baby

Traditional Practice:
 Immediately bring the baby to the nursery after delivery for routine nursery care, which includes
application of oil bath, followed by full bath and immediate dressing of the baby.
WHO (EINC)
 The baby is only allowed to be bath after 6 hours because when the baby is bath immediately after
the delivery, it causes stress resulting him/her to be prone to infection due to abrupt change of
environment, particularly the temperature and fragrant of the amniotic fluid inside the uterine cavity.
 Bath the baby after 6 hours of delivery so that it will still have time to adjust to the new
environment.
 The warmth of the mother is more than enough to provide warmth to the baby rather than putting the
baby under a droplight or incubator. (Kangaroo Mother Care)
 Babies are placed on the chest of the mother using a tube/cloth for skin-to-skin contact with the
mother (unang akap/ first embrace)
 If the baby is premature, limit handling the baby thus limiting possibility for infection.
 Provide warmth because the baby could hardly maintain their body temperature as their
organs are not yet fully developed.
 Airway, breathing, and circulation. Consider also their body temperature (maintaining body
temperature of the baby, providing warmth)
 Dry baby within 30 seconds
s Count 1-5 in the baby’s face
s Count 1-5 in the pelvic
s Count 1-5 in front of the body
s Count 1-5 at the back
s Count 1-5 at the lower extremities, front and back
 Do not totally dry the baby, and leave some secretions/ amniotic fluid in the body for the
baby to have something to smell as if it is under the mother’s womb
 Put immediately the bonnet so that the temperature of the baby will not evaporate.
 Place the baby on top of the chest of the mother after cutting the cord.
s Cord clamp - 2 cm from the base
s After putting the cord clamp, measure 3 cm from the cord clamp to the straight cord
forceps.
s Total of 5 cm (estimate the placement of the cord clamp and cord forceps using the
fingers)
 Prior to attending the delivery of the baby
1. Do handwashing (1-5 steps)
2. Dry hands using a special towel/ dryer.
3. Wear 2 sets of gloves
s 1st gloves – used for handling the mother for delivery
s 2nd gloves – after delivery of the baby, remove the first gloves | touching the
umbilical cord of the baby (cutting), not to contaminate the cord of the baby.
 If using the same gloves, there is a tendency to contaminate the cord of the
baby because there are some mothers that the pushing/ delivery of stools
goes with the delivery of the baby.
 Before the delivery of the baby, do internal examination to check if the baby is near the vaginal
opening/ internal os/ internal opening (if assisting for cervical dilatation and effacement; only during
active labor)
1. Wash hands
2. Wear pair of gloves
Routine Activity for Prenatal Checkup
  Check for the vital signs
 Compute for the AOG and EDC
 Count the fetal heartbeat
 Check for the Benedict’s test/ acetic acid test (check for the presence of protein or sugar | if tracing
for pre-eclampsia in hypertensive patients, specimen would be the patient’s urine)
 Weigh the patient
 1st trimester (1-3 months) – 5 lbs.
 2nd trimester (4-6 months) – 11 lbs.
 3rd trimester (7-9 months) – 11 lbs.
 Health teachings
s Advice the mother if she is gaining weight within the normal weight gain during the 9
months pregnancy that could be a complication/ possibility for preeclampsia or eclampsia
(hypertension during pregnancy)
s Any form of bleeding (spotting, etc.) during the time of pregnancy from the 1 st day to the
last is considered abnormal; may be a sign of abortion | encourage to go to a clinic.
s Around 4-5 months, you could already feel the movement of the baby (quickening).
Leopold’s Maneuver
 If the mother admitted is not yet fully dilated/ not in active labor/ do LM to easily count the fetal
heartbeat.
 Taken from Dr. Christian Gerhard Leopold; way of identifying the presentation and position of the
baby.
 Easier way of locating the fetal back of the baby in placing the stethoscope.
 Presentation
 Cephalic – head is the presenting part
 Breech – buttocks is near/ in the cervical os
 Transverse – shoulder is the presenting part
 Position
 Longitudinal lie
 Right occipito anterior
s Basis: anterior or posterior fontanel placement (palpate)
s Occiput – posterior fontanel
1. Wash hands
2. Instruct the mother to urinate so that during the palpation in the abdominal area, there is no tendency
that she will voluntarily/unconsciously urinate because of pressing of the bladder. (anatomical
position – in front of the uterus: bladder | back of the uterus: rectum)
3. Explain the procedure to the patient that you are going to do the physical examination/ LM
4. Lie on supine position
5. Slightly flexed the knees to relax the abdomen (muscles)
6. Tell the mother that you’re going to do the palpation.
s Physical examination
 Inspection: inspect the abdomen of the patient (presence of edema)
 Auscultation: stethoscope
 Palpation
7. Have the patient positioned in a comfortable position in a bed/ examination table and drape the
patient (to provide privacy). Just expose the area to be examined.
8. 4 steps
s After handwashing, warm your hands
s Fundal grip
 Palpate the fundus of the mother
 Place hands on top, then slide your hands (try to feel if it is hard or soft), then slide
sideways (try to compare the right and left side of the abdomen which is harder –
 indicate the cervical column of the baby: proper placement of the stethoscope/
doppler)
s Umbilical grip – side
s Pawlick's Grip
 Confirm if it is soft and irregular (buttocks); hard and rounded (head)
 If the baby is still floating (above the pelvic brim/bone - touch the head of the baby
and it is moveable)
 Once the baby is engaged, it is not moveable because it is already inside the pelvic
cavity.
 If the baby is moveable, it is still on the upper part (floating)
s Pelvic Grip
 Facing the foot part of the mother, try to estimate the degree of descent of the baby.
9. After LM, do anthropometric measurement/ measurement of the fundus.
s From symphysis pubis (mons pubis – just above the vulva), insert two finger in between the
tape measure and get the end of the hardest part of the mother’s abdomen (end of the baby).
(Get the curvature/ hardest end of the fundus of the mother).
s Transverse – lower part of the umbilicus
10. Proper placement of the stethoscope on the hard part found during the umbilical grip.
s In counting the fetal heartbeat, you can feel two sounds:
 Fetal heartbeat – 120 – 160 beats per minute.
 Uterine soufflé – passage of the flow of blood from the mother going to the baby
via umbilical cord.
 If not sure about the sounds heard, place the stethoscope on the sound heard and get
the pulse of the mother. If the sounds heard from the abdomen and the pulse of the
mother are synchronized, it is the uterine soufflé.
Gloving technique
1. Wash hands
2. Touching the wrong side, place sterile gloves inside.
3. Avoid touching the skin as it would contaminate the gloves
Catheterization
1. Handwashing
2. Wear sterile gloves
3. Put some lubricant
4. Separate the labia majora and minora then locate for clitoris.
5. Locate for urethral opening/ meatus.
6. Get the catheter (for the mother to easily deliver the baby using the straight foley catheter | try to
remove first the urine for the baby to easily enter the vaginal canal) – if the bladder is full of urine,
and the rectum is full of stools (enema or insert 2 dulcolax/ suppositories to soften the stools and
will be out prior to delivery of the baby), it will give a very delayed/ slowed progress of the descent
of the baby.
7. Insert the catheter to the urethra then insert until the urine is already flowing.
8. After catheterization, assist to deliver. (IE)
IE
9. Insert 2 fingers in the vaginal opening until you reach the cervix
10. Estimate the degree of cervical dilatation by gradually opening the fingers.
11. Inform the patient in the progress of labor.
* Fully dilated - bear down once the abdomen becomes firm/ contracted.
* Two ways of bearing down – force at the neck or force in abdomen as if constipated and trying to defecate.
EINC – ASSISTING THE MOTHER DURING DELIVERY
4 Stages of Labor
  1st stage – cervical dilatation; starts from true labor pain to complete dilatation.
 2nd stage – complete dilatation of the cervix to complete expulsion of the baby
 3rd stage – placental separation
 4th stage – puerperium period – the uterus will return to its pre-pregnancy state; very slow returning
back of the uterus; the uterus will gradually return to its pre-pregnancy state within 14 days.
1. Do handwashing
2. Wear two sets of sterile gloves
3. Provide privacy to the mother by draping (only bring out the vagina/vulva of the mother)
4. Lithotomy position
5. Assume that the mother already urinated.
6. Instruct the mother on the progress of labor (tell the mother to bear down once the uterus becomes
contracted as if she is constipated and trying to defecate)
7. Assess the vulva for crowning
8. Turn off electric fan or aircon in the delivery room to provide warm for the baby once it is out. Check
for room temperature (25-25° C)
9. Instruct the mother to urinate/ catheterize to deflate the bladder and have an easier descent of the baby.
10. Assess for the passing of the baby (7 mechanism of labor)
11. Prepare the necessary equipment and dressing of the baby.
 Tissue forceps – used during repair of lacerations (episiotomy – artificial laceration of the
perineum; easier for the baby to be out especially in 1st babies)
 Forceps
 Needle holder – during repair of lacerations (nurses and midwife – 1 st and 2nd degree lacerations)
 Scissor
s Prepare 2 scissors if the patient is primi
 1st – used for cutting the perineum during episiotomy
 2nd – used for cutting the cord
s Multiparous – 1 scissor only and it is not needed to prepare needle holder because it is
seldom that they have lacerations.
 Cord forceps
 Catheter
 Syringe for local anesthesia (for repair of lacerations)
 Cotton balls with betadine
 Cord clamp – the assistant should be the one opening the cord clamp; drop the cord clamp in the
sterile area.
 Chromic 2.0 – used for repair of laceration (sutures); placed in needle holder
 Linen
s Prepare according to use; get 3 sets of baby’s towel.
s 2 towel is used for drying the baby and the 3rd towel is used to wrap the baby
s Bonnet
 Use special cloth that is sterile; leggings for the patient; place the sterile cover of the gloves.
12. Assuming that the baby is coming out, place hands/ 2 fingers over the nape of the baby
13. Press the baby downward, placing the hands over the face and the other over the nape of the baby
14. Putting a little pressure downward until the anterior shoulder of the baby is already out.
15. Once the anterior shoulder of the baby is already out, pull the baby upward.
16. Immediately get the 2 feet/ legs. Then place it on top of the mother’s abdomen
17. Get the towel and wipe the baby (30 seconds) then discard the 1 st towel.
18. Put the bonnet
19. If alone, instruct the mother to hold the baby then get the injection.
20. 1st before injecting the oxytocin, try to palpate the abdomen if there is no more 2 nd baby. Once
ascertained that there is no more 2nd baby, inject oxytocin while waiting for 3 mins. for the cord
pulsation to stop / cord clamping.
21. Inject oxytocin (if alone attending deliveries, you could use the thighs | if there is a companion, you
could ask the companion to inject oxytocin over the deltoid)
22. Remove your first glove
23. Palpate/ feel for the pulsation of the cord. Wait for 3 mins. for the blood to pass from the umbilical cord
going to baby.
s The baby still needs 100-150 mL of blood from the mother going to the baby to avoid neonatal
anemia.
24. Wait for the pulsation to stop (3 mins.) then clamp from the base, estimate 2 cm and place the cord
clamp, then get the forcep (from the plastic cord, estimate 3 cm and place the forceps), get scissors and
cut just above the plastic cord clamp.
25. Bring the baby on top of the mother’s abdomen and instruct the mother to hold her baby.
26. Feel the abdomen of the mother
Placenta
27. Place instrument above the placenta
28. Apply controlled traction with counter traction. Push the abdomen/ the uterus upward while applying
pressure downward for the placenta to be out.
29. Gradually/ slowly pull the placenta giving pressure upward over the uterus to prevent inversion of the
uterus.
s One hand pulling the placenta and the other hand is pushing back the uterus.
30. After the placenta is out, turn it to ensure that there is no placenta left in the uterus.
31. Use plastic and give it to the watcher then instruct the watcher to bring it home. Ideally, the placenta
should be kept in the hospital for proper waste disposal.
2 Parts of Placenta
 Fetal surface – portion near to the baby
 Maternal surface – slightly attached over the fundus of the mother
s Remove surface of placental membrane, count for cotyledons – 20-21 cotyledons; check if complete.
However if the placenta is enclosed by the membrane, don’t need to count the cotyledons.
s Get gauze if there is still placenta left in uterus.
s Schultze mechanism – most common way of delivering the placenta
s Matthews-Duncan mechanism
32. Tone - After having the placenta out, check for uterus if it is contracted or not. Feel for the abdomen of
the mother. The uterus should be firm.
33. Tissue - if the mother is still bleeding; check for placenta if it is complete;
34. Trauma - check for lacerations in the perineum or cervix.
35. Thrombin – check for thrombin if the patient is still bleeding.
36. After checking, put on the diaper on the patient and check blood pressure.
37. Leave the baby 45 mins. – 1 hour over the chest of the mother
38. Do anthropometric measurements in nursery after 45 mins. and inject vitamin K and hepa B. (both
thigh)
39. Vitamin K – use tuberculin syringe and inject over the right thigh; aspirate first to check if you don’t hit
any blood vessels. If blood vessels were hit, do not introduce the medicine and discard the syring and
transfer injection.
40. Hepatitis B – injected over the left thigh (compressing muscles)
41. Crede’s prophylaxis – placement of gentamycin ointment over the eyes to prevent eye infections that
could possibly cause blindness.