Name: _Julianne B.

dela Cruz_________________________________________________ Date: January 5, 2021

Evaluator/Signature: ________________________________________________________ Grade: _____________

ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)

Description: essential intrapartum and newborn care represent the highest standard for safe and quality care for birthing mothers and healthy newborns in the 48 hours of the
intrapartum period and up to a week of life of the newborn. It's adoption helps reduce maternal and newborn morbidity and death

The recommended EINC practices during the intrapartum period include:

1. Continuous maternal support by having a companion of choice during labor and delivery
2. freedom of movement during labor
3. monitoring progress of labor using a partograph
4. non drug pain relief before offering labor anesthesia
5. position of choice during labor and delivery
6. spontaneous pushing in a semi upright position
7. non routine episiotomy
8. active management of the third stage of labor (AMTSL)

4 core steps in the essential newborn care:

1. Immediate and thorough drying
2. Early skin-to-skin contact
3. Properly timed cord clamping
4. Non-separation of the newborn and mother for early initiation of breastfeeding

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

Equipment:
 2 sterile gloves
 dry linens
 bandage/ surgical scissor
 0.5% chlorine solution
 2 kidney basins
 plastic cord clamp
 bonnet
 instrument clamp
 cherry balls soaked in an antiseptic solution

APGAR SCORING

Named after Virginia Apgar (1909-1974), an American obstetrical anesthesiologist who was interested in the side effects of anesthesia given to a mother during
labor on her newborn baby. In 1952, the Apgar Score at 1 minute was first planned as a guide to the need for resuscitation.

Nowadays, APGAR is a standard test for a quick newborn assessment. It helps identify babies that have difficulty breathing or have a problem that need further
care. It's a great method for evaluating the newborn's transition to life outside the womb.
5 simple criteria are used to evaluate your newborn baby's health. Each criteria is scored on a scale of 0 to 2 (2 being the best score) for a maximum of 10. Each
letter of the name Apgar became a way to retain information more easily:
 A for APPEARANCE. What is the skin coloration or complexion? The entire body is pink (score of 2). The body is pink and the extremities are blue (score of 1). 
The skin color is pale blue (score of 0).
 P for PULSE. What is the heart rate? Greater than 100 beats per minute (score of 2). Less than 100 beats per minute (score of 1). Absent (score of 0).
 G for GRIMACE. What is the reflex irritability? What is the response to stimulation such as a mild pinch? Grimacing
and/or a vigorous cry when stimulated (score of 2). Grimace or weak cry when stimulated (score of 1). No response (score of 0). 

 A for ACTIVITY. What is the muscle tone? Active motion, flexed arms and legs that resist extension (score of 2). Some muscle tone (score of 1). 
 Muscle loose and not tonus (score of 0)
 R for RESPIRATION. What is the breathing rate and effort? A good cry (score of 2). Respirations slow or irregular, weak, gasping (score of 1). No breathing (score of 0).   

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

VITAMIN K INJECTION

Description: Vitamin K plays a key role on helping the blood clot, preventing excessive bleeding

Equipment:
● Vitamin
● K (Phytonadione); Aquamephyton, Konakion, Mephyton 10 mg ampule ● Dry cotton ball
● Tuberculin syringe ● Plaster
● G25 needle ● Medication card
● Alcohol swab

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

HEPATITIS B VACCINATION

Description: Hepatitis B :Hep B) vaccine is given to protect the infant against Hepatitis B viral infection

Normal Course:
● Hepatitis B vaccine is very safe
● Most common side effects includes redness, swelling, and pain where the injection has been given. These side effects usually start within a day after the vaccine has been
given and last for one to three days
● Fever may occur for a short time after the vaccine has been given

Equipment:
● Hepatitis
● B Vaccine (dose: 0.5 ml)
● Tuberculin syringe with needle; 0.5 ml Auto-disable (AD) injection device
● G22/G23 needle
● Dry cotton ball
● Plaster
● Medication card

BCG VACCINATION

Description: Bacillus Calmette–Guérin vaccine is a vaccine against Tuberculosis (TB). This is given to a newly delivered infant to protect him/her from pulmonary TB in children
called primary complex

Normal Course:
● The wheal raised by the injection disappeared in about an hour
● After two weeks, a small, red, tender, swelling about 10mm across appears the injection site
● After 2-3 weeks, the swelling may become a small abscess which then ulcerated and heals by itself
● After about 12 weeks from vaccination, a raised scar is formed at the site of the injection and which is used as proof of prior immunization

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

Equipment:
● BCG Vaccine (dose: 0.05 ml)
● Tuberculin syringe
● G25 needle
● Alcohol swab
● Dry cotton ball
● Plaster
● Medication card

CREDE’S PROPHYLAXIS

Description: Crede’s prophylaxis is a method of applying eye drops on a newly delivered infant’s eyes to protect him/her against ophthalmia neonatorum

Purpose: To prevent bacterial infection of the newborn’s eyes

Recipient of Care: Mandatory, given to all

Time of Administration: Immediately after initial bonding between the mother and the infant

Equipment:
● Medication: Opthalmic ointment (Tetracyline 1%, Erythromycin 0.5%) or Opthalmic drops (Povidone-iodine 2.5%, Silver Nitrate 1%)
● Sterile water
● Syringe
● PPE, if indicated

DIAPERING

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

Description: To put or change a diaper and fastening it around the waist in an aseptic manner after cleaning the perineum

Purposes:

1. To retain uterine and stool adequately

2. Prevent spilling in the linens
3. Provide comfort for the infant to wear
4. To assess the newborn’s stool and urine for only abnormalities

Contraindication: Contraindicated when there is presence of diaper rash

Special Considerations:
Types of diapers
1. Disposable diapers - come in variety of sizes such as newborn, infant or toddler and may cause initiation to infants who develop sensitivity to paper and plastic produces.

May cause environmental concern because of disposal problems

2. Cloth diapers - can be softer and less irritating for most infants. They are usually prefolded and are available in different sizes

Cleansing at diaper changes

1. Wash with mild soap and water, then rinse thoroughly. Keep a washcloth and towel at the side of the crib
2. Use commercial disposable wipes that contain a nonallergenic agent baby oil or lotion for cleansing. Rinsing is not needed because no irritating substance is present,
although some babies may be sensitive to components of any cleaning solution

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 Fastening diapers
1. Disposable diapers come with attached tapes for fastening
2. Safety pins are also used but must be used with caution since open safety pins are always a hazard
3. Close pins as soon as they are removed and place them out of reached
4. Place the pin horizontally with the point toward the infant’s side
5. Place your hand between the infant and diaper your are pinning to prevent injury to the infant

Skin Problems
1. Diaper rash is a skin reaction that appears a s a macular solid redness in perineal area. It may be caused by prolonged contact with urine/feces and irritation from residual
detergents/cleansing agents in a diaper
2. Scald occurs rapidly and appears as a totally reddened are much like a burn

Ways to prevent diaper rash

1. Change diaper frequently and clean the skin with each change to remove residual urine or feces
2. Allow the infant to go without wearing a diaper for several hours a day
3. If the infant is wearing disposable diaper, a change to cloth diaper/inserting holes in the disposable ones may help control diaper rash

Equipment:
● Diaper
● Wet cotton sponge
● Clean gloves

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

NEWBORN BATHING

Description: Washing an infant using warm water and mild cleanser in a systematic manner

Purposes:
1. For removal of debris accumulated during the birthing process
2. For providing comfort of an infant
3. For performing of daily routine of cleaning and assessment of infant
Contraindication: Contraindicated to hypothermic patients (temperature below 36.5)

Special Considerations:
Safety: Everything must be within reach before beginning; one hand must remain in contact with the infant at all time to prevent falls. Care must be taken so that the

environment is free from draft and warm enough

Holding the infant:Any method of holding an infant must provide support for the head and neck and keep infant close to your body to lessen chance of injury or dropping. A

football holding does all of these things

Shampooing: This is usually done each time an infant is bathed to prevent a scale accumulation called cradle cap. Hold the infant football=style with head over the basin so

that the scalp can be gently scrubbed and thoroughly rinsed with strokes going away from the infant’s face

Eye care: Without soap, clean each eye from inner to outer canthus, using a clean area of washcloth for each eye so that the microorganisms are nor transferred form one eye to

the other

Folds: Infants may have creases and folds. Wash and dry carefully in all of them. Moisture left in the creases causes skin breakdown

Perineal Care: For the female infant, be sure to clean between the labia and in all folds from front to back. For the uncircumcised male infant, gently retract the foreskin only

as far as it will go easily, and return it to its normal position after cleansing the exposed surfaces. Secretions left under the foreskin may cause

irritation and infection with resulting adhesions

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 Cord Care: When the newborn has the cord stump in place, you must perform cord care. This includes carefully inspecting the base of the cord for signs of infection (such as

redness, drainage, or odor) and cleaning it with alcohol. The are is also kept dry, and the infant is not bathed in a basin or sink until the cord detaches

(in 1-4 wks)

Client Education: Advise parents that the infant’s ability to regulate body temperature has not fully developed and their body loses heat readily

Equipment:
● Basin
● with Lukewarm water ● Sterile cotton balls
● Soft comb or brush ● Clean towel
● Mild soap ● wrapper
● baby’s clothes
BREASTFEEDING

Description: breastfeeding is considered the safest simplest and less expensive way to provide complete infant nourishment. The American academy of pediatrics and the American
Dietatic Association recommended breastfeeding  exclusively for the first 4 to 6 months of the infant’s life and then in combination with infant foods until age 1.

Purpose: Helping the patient to latch the neonate properly. 

Principles: After the immediate care of the normal newborn delivered spontaneously, bring the baby to the mother for the first feeding.  In the hospital, rooming-

in policies support breastfeeding. (R.A. 7600: The RoomingIn and Breastfeeding Act of 1992).

Guidelines/ Special Considerations:

Breastfeeding is contraindicated if the mother:
● Has herpes lesions on her nipples 

● Is receiving certain medication, such as methotrexate or lithium, that pass into the breast milk and may harm the neonate.

● Is on restricted diet that interferes with adequate nutrient intake and subsequently affects the quality of milk produced 

 Has breast cancer

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

Equipment:
● Breastfeeding handouts/resources
● Bed pillows or breast-feeding pillows
● Cloth diaper

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 PERFORMED
ACTION RATIONALE REMARKS
YES NO
Prior to Patient’s Transfer to the Delivery Room
1. Ensure that the mother is on her position of choice The best position for a woman in labor is whatever she finds most c
when in labor. omfortable and which gives her the most control of her labor. 

2. Ask the mother if she wishes to eat or drink. To provide nourishment. A woman placed on a prolonged NPO

 can become dehydrated. 

3. Communicate with the mother. Inform her of the To minimize anxiety and promote cooperation. 

progress of labor, give reassurance and
encouragement.
Patient Already in the Delivery Room
A. Preparing for Delivery
1. Check temperature in the Delivery Room area. Ensure comfort
Appropriate room temp is 20-25 degree Celsius
Check for air draft.

2. Ask the patient if she is comfortable in the semi- The upright position has a favorable effect on uterine contractility a

upright position which is the default position. nd reduces pain and perineal trauma. 
3. Remove all jewelries.
Prevents harbor of microorganisms 

4. Wash hands thoroughly observing the proper Deters spread of infection 

procedure.
5. Arrange these things in a linear fashion: gloves, Organization facilitates ease in the performance of the task and faci
dry linen, bonnet, oxytocin injection, plastic litates a systematic progression of the procedure. 
clamp, instrument clamp, scissors, 2 kidney
basins.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 PERFORMED
ACTION RATIONALE REMARKS
YES NO
6. Clean the perineum with antiseptic solution. Use To reduce the number of microorganisms in the skin.
sterile gloves or working forceps to clean the
perineal area. Use cherry balls soaked with
antiseptic solution or 7% betadine solution.

a. Start prep with cleansing the pubis,

progressing downward over the vulva and
perineum and last over the anus.

b. The inner aspect of the thighs is cleansed

from the labia majora to the inner aspect of
the upper third of the thighs. Each sponge in
contact with the anus is discarded.
7. Prep the vagina last. To reduce the number of microorganisms in the skin.
8. Wash hands.
Deters spread of infection 

9. Put on 2 pairs of sterile gloves aseptically. (If To prevent spread of infection and protect the nurse from the body f

same worker handles perineum and cord). luids of the patient. 

At the Time of Delivery

1. Encourage the mother to push as desired. The natural urge to push is coupled with positioning,
breathing, and relaxation techniques to make effective use of the w
oman’s expulsive efforts. 

2. Apply perineal support and do controlled delivery Supporting the perineum will prevent laceration. 

of the head.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 PERFORMED
ACTION RATIONALE REMARKS
YES NO
3. Call out the time of birth and sex of baby. The time of delivery serves as the time of birth. It is the
responsibility of the nurse to check and record accurate
data especially the gender and time of birth.
4. Inform the mother of outcome. A nursing responsibility to inform the mother about the outcome to
ensure relief to the mother

B. First 30 Seconds
Maintains appropriate room temperature (20-25 Newborns are wet, so they lose a great deal of heat as
degrees Celsius) the amniotic fluid on their skin evaporates. 

1. Does immediate and thorough drying within the

first 30 seconds:

a. Puts on double gloves

b. Places 2 sterile towels/linens on mother’s

abdomen

c. Dries the newborn thoroughly by patting,

making sure that the vernix caseosa is not
removed

d. Does a quick check on the APGAR of the

newborn while drying. (Refer to illustration
for APGAR Scoring)

e. Removes the top most wet towel/linen

Note: Avoid bathing earlier than 6 hours of life.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 PERFORMED
ACTION RATIONALE REMARKS
YES NO
C. 1-3 Minutes
 

1. Early skin-to-skin contact:

● Maintains prone position of the newborn on
the mother’s abdomen
● Covers the back of the newborn with the
second towel/linen and head with bonnet
Facilitate bonding between the mother and her newborn through
 skintoskin contact to reduce likelihood of infection and hypoglyce
mia.  

● Observes initial crawling reflex

● Places ID band on ankle (indicate gender and

family name)

● Does not separate from mother unless

newborn is having severe chest in-drawing,
gasping or apneic.

2. Exclude a second baby by palpating the abdomen. To assess any signs of abnormalities
Use the wet cloth to wipe the soiled gloves.

3. Give IM oxytocin within 1 minute of baby’s birth To increase uterine contraction

(after confirmation of no succeeding baby).
Dispose the wet cloth properly.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 4. Remove the first set of gloves. (Decontaminate For decontamination
these properly by soaking in 0.5% chlorine
solution for at least 10 minutes.)

PERFORMED
ACTION RATIONALE REMARKS
YES NO
5. Properly timed cord clamping: Reduce the incidence of anemia in term newborns and intraventricu
lar hemorrhage in preterm newborns by delaying or nonimmediate 
a. Palpate umbilical cord to check for cord clamping.
pulsations.

b. After pulsations has stopped (1-3

minutes), put plastic clamp or tie tightly
around cord at 2cm and the forceps 5cm
from newborn’s abdomen

c. Cut near the plastic clamp (not midway).

d. Observe for oozing of blood; if blood

oozes, place a second clamp between the
skin and first clamp.

Perform the following steps of the active management

in the third stage of labor.
6. Wait for strong uterine contractions then apply Signs of placental separation are lengthening of the cord, a sudden 
controlled cord traction and counter traction on gush of blood and changing of the size of the lower abdomen 
the uterus, continuing until placenta is delivered.

7. Massage the uterus until it is firm. Keeping the uterus firm after placental delivery promotes uterine co

ntraction thereby prevents postpartum bleeding. 

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

8. Inspect the lower vagina and perineum for
lacerations/tears and repair if necessary.
9. Examine the placenta for completeness and
abnormalities.
ACTION
10. Clean the mother by flushing the perineum with
sterile water and apply perineal pad/napkin/cloth.
11. Check the baby’s color and breathing. Ensure that
the mother is comfortable and uterus is
contracting.
12. Dispose the placenta in a leak-proof container or
plastic bag.
13. Decontaminate instruments before cleaning
(soaked in 0.5% chlorine solution). Dispose 2nd
gloves appropriately.
14. Advise mother to maintain skin-to-skin contact.
Baby should be prone on mother’s chest or in
between the breasts with head turned to one side.
Perineal lacerations, if not properly repaired, can result in maternal 
health problems. 
To ascertain that placenta is intact and normal in
appearance and weight. Normally, a placenta is one
sixth of the weight of the infant
PERFORMED
RATIONALE REMARKS
YES NO
This will remove blood stains and promote comfort
Ensures the health condition and living condition of the body
To prevent the placenta from leaking allowing contamination
Bloody instruments must be properly cleaned to eliminate 
microorganism. After care will ensure a clean
environment for labor and childbirth. 
This position allows secretions to drain from the nose and mouth. 
MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37
D. 15-90 Minutes
1. Non-separation for early breastfeeding Facilitate the newborn’s early initiation to breastfeeding and transfe
r of colostrum through support and initiation of breastfeeding. 
a. Leave the newborn on the mother’s chest
in skin-to-skin contact.
b. Advise mother to observe for feeding
cues (e.g., opening of mouth, tonguing,
licking, and rooting).
c. Support the mother; give instruction on
proper positioning and attachment.
d. Observes for signs of good attachment
(e.g., chin touching the breast, mouth
wide open, lower lip turned outward,
more areola seen above than below the
mouth)

PERFORMED
ACTION RATIONALE REMARKS
YES NO
2. Eye Care (must be done within 1 hour after
birth)
To prevent bacterial infection of the newborn’s eye
a. Position newborn on supine.
b. Wipes both eyes with sterile OS (inner to
outer canthus) starting with the farther
eye.
c. Using the forefinger of the non-dominant To apply the ointment 1 drop properly
hand placed over cheekbone, gently pull
the lower lid down. Never apply drop or
ointment directly on the eyeball.
d. Using the dominant hand and holding the
dropper/tube, instill/apply:
● Ophthalmic drop into the center of the

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 lower conjunctival sac.
● Ophthalmic ointment from the inner
to the outer canthus of the lower eye
lid.
e. Observe care not to touch the eye with the
dropper or tip of ointment. To avoid contamination
f. If there is an order to give two
preparations (ointment and drops) give It is important to discard the first drop of ointment and drop
drops first. Wait for 3 minutes before because it is not sterile and to avoid infection
applying the ointment.
g. Close the eyelids.
h. Wipe excess medication in one sweep
from the inner to the outer canthus Do not
wash away the antimicrobial.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
3. Administer Vitamin K prophylaxis (IM-Right
thigh;0.1ml for full-term babies; 0.05ml for
pre-term babies)

a. Locate the site. Best site: Vastus Lateralis

(middle third, anterolateral or outer aspect To inject the medication in the right side
of the thigh); Alternate site: Rectus
femoris (mid anteromedial aspect of the
thigh)
b. Cleanse the site thoroughly by applying To avoid contamination
friction with an alcohol swab in an inner
to outer, circular motion. Let the site dry.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 c. Establish anatomic landmark.
d. Grasp the vastus lateralis and quickly
insert the needle at a 90-degree angle to
the thigh.
e. As soon as the needle is in place, use the
thumb and forefinger of your
nondominant hand to hold the lower end
of the syringe. Slide down your dominant
hand to the end of the plunger and
carefully inject the drug.
f. Swiftly remove the needle smoothly and
steadily at the same angle at which it was
inserted. Apply gentle pressure at the site
with an alcohol swab.
g. Press dry cotton ball into the injection site
and fix it with plaster.
h. Do not recap used needle. Dispose it To avoid reuse of syringe that may be a carrier of existing disease
properly according to agency policy. and to avoid cross- contaminatio

PERFORMED
ACTION RATIONALE REMARKS
YES NO
4. Administer Hepatitis B Vaccine (IM-Left
thigh; 0.5ml, except for pre-term babies)

a. Locate the site. Best site: Vastus lateralis To inject the medication at the right side
or anterolateral aspect of the thigh.
b. Cleanse the site thoroughly by applying
friction with an alcohol swab in an inner To clean the site
to outer, circular motion. Let the site dry.
c. Establish the anatomic landmark chosen.
d. Grasp the vastus lateralis and quickly

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 insert the needle at a 90-degree angle to
the thigh.
e. As soon as the needle is in place, use the
thumb and forefinger of your
nondominant hand to hold the lower end
of the syringe. Slide down your dominant
hand to the end of the plunger and
carefully inject the drug.
f. Swiftly remove the needle smoothly and
steadily at the same angle at which it was
inserted. Apply gentle pressure at the site
with an alcohol swab.
To stop the bleeding by applying pressure to the injection site
g. Press dry cotton ball into the injection site
and fix it with plaster.
h. Do not recap used needle. Dispose it To avoid the reuse of syringe that may cause cross- contamination
properly according to agency protocol.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
5. Administer BCG Vaccine ID (Intradermal) at
the right deltoid or upper arm. Intradermal
vaccine is injected into the top layers of the
skin

a. Locate the site. Best site: Right Deltoid or BCG is the only vaccine with this route of

right upper arm. administration. Intradermal injection of BCG vaccine reduces the ri
b. Cleanse the site thoroughly by applying sk of neurovascular injury.
friction with an alcohol swab in an inner
to outer, circular motion. Let the site dry.
c. Aspirate the equivalent of 0.05 ml of
BCG vaccine from the ampule.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

d. Locate the site. BCG vaccine is given at
the right deltoid of the arm of a newborn injecting the vaccine in the same place (upper right arm) for each c
intradermally. hild is to make it easy to find the BCG scar subsequently. This enab
e. Establish the anatomic landmark chosen. les you to check that the immunization has been effective.      
f. Hold the newborn’s arm with your non
dominant hand so that your hand is under  
the arm, your thumb and fingers come To prevent unnecessary movement.
around the stretched skin.
g. Hold the syringe using your dominant
hand with the bevel and scale pointing
upward.
h. Insert the tip of the needle – just the bevel
and a little bit more – into the skin,
keeping the needle flat with the bevel
facing upward.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
i. Place your non-dominant thumb over the To stabilize syringe
needle end of the syringe to hold it in
position Hold the plunger end of the
syringe between the index and middle
fingers of your dominant hand and press
the plunger in with your thumb.
j. Slowly inject the agent while watching for
a small wheal or blister to appear To lessen pain
k. Withdraw the needle gently. Gently blot
the site with a dry cotton. Do not massage
or rub the site.
l. Expose the arm completely, from the top

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 of the shoulder to the elbow; roll up the
sleeve or remove the shirt if needed.
m. Record accurately
n. Provide client education on what to expect
days after the injection.
To prevent application of pressure
6. Obtain anthropometric measurements: To gather baseline data for initial assessment
● Weight (Put protective liner cloth or
paper in place and adjust scale to 0
grams/kilograms/lbs/ounces)
● Height (measure height from top of head
to heel)
● Head (measure head at greatest
diameter: occipitofrontal circumference)
● Chest (measure at nipple line)
● Abdomen (measure above umbilicus)
● Mid-arm (measure the diameter of the
mid-arm)

PERFORMED
ACTION RATIONALE REMARKS
YES NO
5. 1. Obtain Vital signs To assess abnormal findings and report these findings in order to
avoid further complications. To monitor vital signs
● Obtain respiratory rate and effort; observe
respirations when infant is at rest; count
respirations for full minute
● Obtain heart rate and count for full minute
● Obtain body temperature

7. Assess the newborn for birth injuries, To document and report any abnormalities, malformation or defects
malformation or defects.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

8. Diaper the baby.

a. Place the infant in supine position. To make sure the infant is safe from falling. 

b. Lift the infant’s buttocks by grasping both
The infant must never be left alone with side rails down or out of th
ankles with one hand, and place a clean
diaper under the infant. For male infant, e crib.    
place a clean diaper over the penis to
protect against sudden voiding.
c. Pull the front of the diaper up between the To prevent contamination of the urinary meatus with bacteria from 
infant’s legs. Tape the adhesives. *** For the rectal area. 
soiled diaper Remove the soiled diaper,
using the clean portion of the diaper,
So that it fits snugly around the abdomen. 
wipe away the stool. Clean from anterior
region to posterior region using the
equipment for cleaning. To prevent contamination
d. Dress the baby.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
9. Advise optional/delayed bathing of the baby It helps to reduce risk of infection and stabilized infant blood sugar. 
and explain the rationale. Bathing must be Also, Vernix does more than act as a protective barrier from liquids 
done 6 hours after delivery. while in the uterus. It acts as an antioxidant, skin cleanser, moisturi
zer, temperature regulator, and a natural, safe antimicrobial for the 
a. Fill the basin with water and check the new baby post-delivery. 
temperature by using your elbow. Use
water 100º to 105ºF (37.7-40.5ºC). Place
it on a firm surface.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 b. With cotton balls, wash the infant’s eyes Moving from the inner to outer aspect of the eye prevents carrying 
from inner to outer canthus. Wash and dry debris to the nasolacrimal ducts. 
infant’s face. Soap is not needed.
c. Hold the infant securely in a football hold For safety purposes   
with head over the basin.
d. Shampoo the scalp. Use your fingertips
and massage firmly. If any loose skin are To prevent the formation of cradle cap     
present, remove them from the hair with a
fine, toothed comb. Do not hesitate to
wash over the fontanelles.
e. Rub the head with a towel. Drying prevents chilling   
f. Undress the infant.
g. Hold the infant securely as you place him
in the water. Use a towel in the basin to For safety   
decrease slipping.
h. Keep one hand securely on the infant To prevent injury
while bathing.
i. Wash and rinse the shoulders, arms and To clean the infant from less contaminated to the most 
chest and move down the body. contaminated 
j. Lift the infant out of water, and lay him or
To prevent unnecessary exposure 
her on the towel.
k. Wrap the infant while you dry.
l. Diaper and redress the infant. Prevents chilling 

PERFORMED
ACTION RATIONALE REMARKS
YES NO
10. Advise breastfeeding per demand and about
the danger signs for early referral.

a. Illustrate to the mother how to clean the

nipple. (With the wet cotton balls, clean
the breast, starting from the nipple, in a

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 circular motion towards the areola.)

b. Assist the mother find a comfortable

position. Popular feeding positions:

● Cradle Position – the mother cradles the The cradle position is most commonly used after the first

neonate’s head in the crook of her arm.
Instruct her to place a pillow on her lap  few weeks of breastfeeding. 
for the neonate to lie on. Offer to place a The cross cradle position gives you more control.         
pillow behind her back; this provides
comfort and may also assist with correct
positioning.

● Side-Lying Position – instruct the mother Many mothers find lying down to nurse comfortable position, espec

to lie in her side with her stomach facing
ially at night. Both mother and baby lie on their sides facing
the neonate’s. As the neonate’s mouth
opens, she should pull him toward the each other. You can use pillows behind your back and behind or bet
nipple. Inform her to place pillow or ween your knees to help get comfortable. 
rolled blanket behind the neonate’s back
to prevent him from moving or rolling
away from the best.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
● Football Position – Sitting with a pillow This is a good position for a mother who has had a Cesarean birth, 
in front of her, the mother places her hand as it keeps the baby away fromthe incision. Most newborns are very 
under the neonate’s head. As the comfortable in this position. It also helps when a mother has a
neonate’s mouth opens, she pulls the  
neonates head near her breast. This

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37

 position may be more comfortable for the forceful milk ejection reflex (let down) because the baby can handl
woman who has had a caesarean birth. e the flow more easily

11. In the first hour: check baby’s breathing and
color, mother’s vital signs, and massage uterus
every 15 minutes.
12. In the second hour: check mother-baby dyad
every 30 minutes to 1 hour.
To assess signs of abnormalities and to ensure comfort to the
mother
To assess the bonding and comfortability of the mother-child
relationship

13. Document the interventions and findings. Documentation serves as a means of communication and basis of ca

re and evaluation of patient outcomes

Learner’s Reflection: (What did you learn most of the activity? What is its impact to Instructor’s Comments:
you?)
I have learned about the importance of the EINC and the benefits that it could give to
the babies.

References:
Pillitteri, A. (2010). Maternal and Child Health Nursing: Care of the Childbearing & Childrearing Family 6th edition . Walnut St. Philadelphia: Lippincot Williams and
Wilkins .
Salustiano, R. (2011). Essential Procedures for Safe Maternity Care 3rd edition. Quezon City: C & E Publishing, Inc.
WHO (2016). Vaccine Safety Basics e-Learning Course,Module 2.
https://www.scribd.com/document/50591331/AO-2009-0025-Essential-Newborn-Care

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 37