INTRAPARTUM : DELIVERY ROOM TECHNIQUE

Purpose:
1. To strengthen woman’s coping with active labor and transition
2. To promote comfort
3. To provide safe environment for the mother and new born.
4. To practice strict aseptic technique throughout the procedure.
5. To promote initial mother and child bonding.

Materials/ Instruments Needed:

1. (1) Allis forceps
2. (1) Curve Kelly forceps
3. (1) Straight Kelly forceps
4. (1) Curve mayo scissor
5. (1) Straight mayo scissor
6. (1) Kidney basin with dry cotton balls ( to be poured with betadine for perineal prep)
7. (1) Straight catheter
8. (1) Suction bulb 12. Sterile OS
9. (1) Pair of leggings / drape 13. Pail / Basin
10. (2) Sterile towels 14. Kelly Pad
11. (1) adult diaper

IF WITH EPISIOTOMY OR LACERATION:

1. (1) Needle holder
2. (1) Thumb forceps
3. (1) 5 cc syringe with needle ( for local anesthesia)
4. (1) Poly/amp. Lidocaine 2%
5. Sterile OS or napkin (per agency policy)
6. Chromic 2/0 (cutting and round)

Assessment:
Assessment should focus on the following:
1. Assess if the patient is the transitional phase of the first stage of labor process.
2. Assess for fetal condition by auscultation of the fetal heart tone.

Nursing Diagnosis:
Nursing Diagnosis may include the following:
MOTHER
1. Anxiety related to impending delivery
2. Acute pain related to uterine contraction/ descent of the fetus.
3. Ineffective coping related to discomfort
4. Impaired urinary elimination related to pressure of the fetus
5. Ineffective breathing patter related to pain and fatique.
6. Risk for infection related to rupture of membranes/episiotomy and tissue trauma
7. Impaired tissue integrity related to placental separation.
8. Risk for injury related to potential hemorrhage

NEWBORN DIAGNOSIS
1. Ineffective airway clearance related to nasal and oral secretions from delivery
2. Ineffective thermoregulation related to environment and immature ability for adaptation.
3. Risk for injury related to immature defense of the neonate.

Outcome Identification and Planning:

1. Accomplish hand washing correctly
2. Informs mother regarding the maintenance of aseptic technique
3. Slowly and clearly explains the events and changes occurring as labor progresses
4. Wears prescribed DR attire which includes cap, mask, and rubber slippers.
5. Prepares the instruments and turns on the necessary lights.
6. Identifies procedure correctly.

Desired outcome includes the following:

 MOTHER:
1. Client will verbalize positive statements about delivery outcome
2. Client will report pain is decreased from comfort strategies.
3. Client’s bladder will remain non-distended.
4. Client will remain free from signs of infection
5. Client will use breathing techniques during contraction
6. Client will deliver an intact placenta
7. Client’s blood loss will be controlled and hemorrhage prevented
8. Client’s vital signs will remain stable and uterus remain firm at midline
9. Client will interact with her newborn.

IMPLEMENTATION
Nursing Action
1. Assist patient into a lithotomy position
(or other alternative birth position per
agency policy)
2. Checks bladder for fullness and
encourage voiding or catheterize as
needed.
3. Cleans the perineum using correct
technique.
4. Don/wear gloves.
5. Drapes the client properly.
6. Instruct to bear down properly (push with 
contractions), coaches to take deep
breaths as soon as contraction begins.
7. Encourages to keep both legs flexed 
and firm on the stirrup.
8. Performs Ritgen’s maneuver properly/ 
safely while fetal head is being delivered.
9. Checks for nuchal cord, loosen and slip 
over the head if possible; if cord cannot be
slipped over the head, it is clamped using
two clamps and cut between the clamps.
10. Notes and records time the baby was 
delivered and the gender.
11.Thoroughly dries baby for at least 30 
seconds starting from the face and head,
going to the trunk and extremities while
performing a quick check for breathing;
evaluate the APGAR score 1 min. and 5
min. after birth
12. Places neonate on the maternal 
abdomen.
Rationale
 Provides the best position for
performing an episiotomy and for
viewing the perineum to detect
laceration or other problems at birth.
 A full bladder or bowel can impede
fetal descent.
 Perineal care helps to remove any
possible drainage or secretions from
the birth canal that may pose a risk
for infection.
 To prevent exposure to client’s
body secretion.
 To create a sterile field and provide
patient’s privacy.
Promotes effective second-stage
pushing.
To promote comfort; avoid ligament
strain, backache or injury
To control the rate at which the
head is born and prevent laceration of
the perineum.
Umbilical loop could tear and
interfere fetal oxygen supply.
For proper identification
To prevent hypothermia, stimulate
breathing and determine the ability to
adjust in the extrauterine life.
To initiate parent-child bonding.

13. Clamps cord using 2 Kelly hemostats, 
support and cut in between them using
mayo scissor. (Follow agency policy on
cord length.)
14. Delivers the placenta when signs of 
placental separation is observed and note
the time.
15. Checks placenta for presentation 
(Schultz or Duncan). Assess amount of
Clamping the cord is part of the
stimulus that initiate a first breath. The
infant’s most important transition to the
outside world establishing of
independent respiration is made.
Delivery of the placenta should not
take more than 30 min.
Duncan placental presentation
carries a slightly increased risk of
blood loss. retained placental fragments due to
incomplete separation. To check if
placenta is complete or intact.
16. Palpates and massages the  To ensure uterus is firm and
hypogastric area (fundus of the uterus) contracted and prevent bleeding.
17. Inspects perineum for presence and  To prevent bleeding.
degree of laceration. Assists in repair of
laceration.
18. Cleans the perineum and buttocks  To minimize risk of infection and
area. promote comfort.
19. Do after care of the instruments used  To restore cleanliness and
and unit of responsibility. orderliness of the unit.

INTRAPARTUM: PERFORMING NORMAL SPONTANEOUS VAGINAL

DELIVERY TECHNIQUE

IMPLEMENTATION
Nursing Action Rationale
1. Places client’s hand on handgrip and  Tug of war pushing technique uses the
explains its purpose (elbow out technique) natural bearing down effort of the
abdominal muscles. This method also
causes minimal change in the maternal
blood pressure and relaxes the perineum.
To get force during bearing down effort.
2. Checks client’s necessary articles needed  To maintain adequacy of supplies as
for delivery. delivery progresses; manage resources,
equipments and environment.
3. Monitors fetal heart tone.  To identify non-reassuring or
unfavorable fetal heart rate characteristics
that may indicate a fetus at risk for
asphyxia.
4.Instructs to bear down properly, coaches to  Promotes effective second-stage
take deep breaths as soon as contraction pushing; the birth process expense a great
begins(Proper pushing and breathing deal of energy. Encouraging proper
techniques). pushing and breathing techniques
conserves maternal energy.
5. Wipe mucous from face, mouth and nose,  To remove secretion from the neonate’s
establishes initial airway clearance using bulb mouth and nose.
suction.
6. Using a sterile blanket, hold newborn firmly  To avoid slipping of the baby; prevent
and close to the introitus with head in a slightly tension to the cord and to allow secretion to
dependent position. drain from the mouth and the nose.

7. Safely lay the infant on the radiant heat  To facilitate thermoregulation.

warmer.
8. Provide immediate newborn care:
A. Maintains airway by suctioning mouth first
then the nose.
B. Maintains body temperature
 Dries the neonate immediately after
delivery
 Cover neonates head with towel or cap
 Wrap neonate snugly with warm towel
C. Place Identical identification bracelets on
the mother and the neonate ( follow agency
policy)
9. Performs immediate cord care and notes the
cord vessels.
10. Places ice pack over the uterine fundus
 Gentle suctioning removes secretions
that may collect in these areas. Suctioning
mouth before the nose prevents possible
aspiration of oral secretion.
 Newborns have difficulty conserving
body heat. Exposure to cold increases the
metabolic rate, increasing the need for
oxygen and further the respiratory rate.
 To prevent risk of switching babies and
kidnapping.
 To minimize bacterial colonization and
identify congenital anomalies.
 To promote uterine contraction and
 prevent bleeding.
11. Monitors maternal vital signs every 15 min.  To evaluate maternal post partum
for 1 hour until stable. condition and prevents complications.
12. Places adult diaper and change soiled  To promote comfort.
gown.
13. Assists in the after care of the unit.  To restore cleanliness and orderliness
of the unit.
14. Safely transfers mother to the stretcher per  To prepare transport to post partum
doctor’s order. unit.

birth of the head with application of

modified Ritgen maneuver

Third Stage of labor- Placenta

Evaluation:

MOTHER
1. Client verbalizes positive statements about delivery outcome.
2. Client reports pain is minimized from comfort strategies.
3. Client’s bladder remained non-distended.
4. Client shows no signs of infection.
5. Client utilizes breathing techniques during contraction
6. Client delivers an intact placenta
 7. Client’s blood loss was controlled and hemorrhage prevented.
8. Client’s vital signs remained stable and uterus is firm at midline.
9. Client bonds with her newborn.

NEWBORN
Objectives of immediate newborn care
1. To establish, maintain and support respirations
2. To provide warmth and prevent hypothermia.
3. To ensure safety, prevent injury and infection.
4. To identify actual or potential problems that may require immediate attention.

DOCUMENT
1. Newborn transitions appropriately as evidenced by an APGAR score of 7 -10
2. Newborn’s temperature remained within normal limits
3. Newborn has ID bracelet on and newborn care completed.

Instruction to the mother on cord care:

1. No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that cord does not get
wet by water or urine.
2. Do not apply anything on the cord such as baby powder or antibiotic, except the prescribed antiseptic
solution which is 70% alcohol.
3. Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when
the diaper soaks with urine.
4. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and
separates more rapidly if it is exposed to air.
5. If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose and fasten.
6. Report any unusual signs and symptoms which indicates infection.
 Foul odor in the cord
 Presence of discharge
 Redness around the cord
 The cord remains wet and does not fall off within 7 to 10 days
 Newborn fever

THE APGAR SCORING SYSTEM

The APGAR Scoring System was developed by Dr. Virginia Apgar as a method of assessing the
newborn’s adjustment to extrauterine life. It is taken at one minute and five minutes after birth. With depressed
infants, repeat the scoring every five minutes as needed. The one minute score indicates the necessity for
resuscitation. The five minute score is more reliable in predicting mortality and neurologic deficits. The most
important is the heart rate, then the respiratory rate, the muscle tone, reflex irritability and color follows in
decreasing order. A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160 signifies
distress.
DOCUMENTATION:

The following should be noted on the client’s chart:

1. Clients Post partum condition:

 Vital signs
 Uterine fundal tone, height and position
 Amount of vaginal bleeding
 Perineum of edema, discoloration, bleeding or hematoma formation
 Episiotomy for intactness and bleeding

2. Neonate’s APGAR score, sex, time of delivery, time placenta was delivered.

Signs 0 1 2
Respiratory Rate Absent Slow ,weak Good cry
cry
Reflex irritability No Grimace Cry
response
Pulse , heart rate Absent Slow >100
(<100)
Skin Color Blue Body pink Completely Reference:
pale extremities pink
blue 
Silbert-Flagg and Pillitteri
Muscle Tone Flaccid Some Well flexed (2018).Maternal & Child Health Nursing,
flexion of Care of the Childbearing and
extremities
Childrearing Family 8th Ed.
 Pillitteri, Adele (2014). Maternal & Child Health Nursing, Care of the Childbearing and
Childrearing Family 7th Ed.
 Pilliteri A. (2007) Care of the Child Bearing and Child Rearing Family. 5 th Edition Lippincott
Williams & Wilkins.
 Doenges, H. & M. ( 2006). Nurses Pocket Guide Diagnoses Prioritized Intervention and
Rationale 10th Edition.
 Smith T., Jean & Johnson, Young, J. (2006). Nurses Guide to Clinical Procedures. 5 th Edition.
Philadephia: Lippincott Williams & Wilkin.
 Woodring B.C. (2005)Pediatric Nursing Made Incredibly Easy. Lippincott, Williams & Wilkins.
 Udan Q.J. (2004) Mastering Fundamentals of Nursing Concepts and Clinical Application 2 nd
Edition. Educational Publishing House.
 Engstrom, J. ( 2004). Maternal-Neonatal Nursing, Made Incredibly Easy. Lippioncott Williams
& Wilkins.

PERFORMING NORMAL SPONTANEOUS VAGINAL

DELIVERY TECHNIQUE
Evaluation Tool

PRIOR TO WOMAN’S TRANSFER TO THE DR 1 2 3 4 5

1. Ensured that mother is in her position of choices while in labor
2. Asked mother if she wishes to eat /drink or void
3. In the absence of active labor, check for an empty bladder.
4. Communicated with the mother – informed her of progress of
labor , gave reassurance and encouragement
WOMAN ALREADY IN THE DR
5. Check temperature in DR area to be 25-28 º Celsius; eliminated
cold air draft.
6. Asks woman if she is comfortable in the semi-upright position
(the default position of delivery table)
7. Ensures the woman’s privacy
8. Removes all jewelry then washed hands thoroughly observing
the WHO 1-2-3-4-5 procedure.
9. Prepares a clear, clean newborn resuscitation area. Checked
the equipment if clean, functional and within easy reach.
10. Arrange materials /supplies in a linear sequence ;Gloves ,
dry , linen, bonnet , oxytocin injection , plastic clamp, instrument
clamp , scissors , 2 kidney basins , In a separate sequence , for
the 1st breastfeed. Eye ointment,
11. ( Stethoscope to symbolize PE) Vit K, hepatitis B and BCG
vaccines (plus cotton balls, etc.) Note: Apply aseptic technique
by segregating sterile and unsterile instruments.
12. Cleanse the perineum with antiseptic solution
13. Places patient’s had in hand grip and explain the purpose
14. Washes hands and put on 2 pairs of sterile gloves aseptically ,
( if same worker handles perineum and cord) .
AT THE TIME OF DELIVERY
15. Drapes the clean , dry linen over the mother’s abdomen or
arms in preparation for drying the baby
16. Encourage woman to push as desired
17. Instruct to bear down properly coaches to take deep breath
as soon as the contraction begins.
18. Encourages to push her flexed legs against the stirrups.
19. Performs Ritgen’s maneuver properly (Support the perineum )
20. Notes / record the time the baby was delivered and the
gender.
FIRST 30 SECONDS
21. Thoroughly dried baby for at least 30 at least 30 seconds ,
starting from the face and head , going do to the trunk and
extremities while performing a quick check for breathing .
Checks baby’s APGAR score for the first 1 minute and repeat
5 minutes after.
1-3 MINUTES
22. Remove the wet cloth
23. Place baby in skin –to-skin contact on the mother’s abdomen
or chest.
24. Covers baby with the dry cloth and the baby’s head with a
bonnet
25. Exclude 2nd baby by palpating the abdomen in preparation for
giving oxytocin
26. Used wet cloth to wipe soiled gloves. Administer IM oxytocin
within one minute of baby’s birth . Disposed of wet cloth
properly.
27. Removed 1st set of gloves and decontaminated them properly
( In 0.5% chlorine solutions for least 10 mins.)
28. Palpates umbilical cord to check for pulsations.
29. After pulsations stopped , clamped cord using the plastic
clamp or cord tie 2 cm from the base
30. Place the instrument clamp 5 cm from the base
31. Cut near plastic clamp ( Not Midway ) or first instrument clamp
32. Performs the remaining steps of the AMTSL :(active
management third stage of labor)
33. Waited for strong uterine contractions then applied controlled
cord traction and counter traction on the uterus, continuing until
placenta was delivered .
34. Notes the time of placenta delivery and presentation
35. Massage the uterus until it is firm
36. Observe for any signs of vaginal bleeding
37. Inspects the lower vagina and perineum for lacerations/ tears
 and repaired lacerations/ tears , as necessary .
38. Examines the placenta for completeness and abnormalities .
39. Cleanse the mother; flushed perineum and applied
pad/napkin/cloth.
40. Checks baby’s color and breathing; checked that mother was
comfortable, uterus contracted.

41. Decontaminated (soaked in 0.5% chlorine solution) instruments

before cleaning; decontaminated 2nd pair of gloves before
disposal, stating that decontamination lasts for at least 10
mins.
42. Advises mother to maintain skin-to –skin contact. Baby should
be prone on mother’s chest/in the breast with head turned to
one side.
15-90 MINUTES
43. Advises mother to observe for feeling cues and cited
examples of feeding cues.
44. Supports mother, instructed her on positioning and
attachment.
45. Waits for FULL BREASTFEED to be completed
46. After a complete breastfeed, administered eye ointment
( first , did through physical examination , then did Vit K,
hepatitis B and BCG injections ( simultaneously explained
purpose of each intervention )
47. Advises OPTIONAL/DELAYED bathing of baby ( and was
able to explain the rationale) for 6 hours
48. Advises breastfeeding per demand
49. In the first hour. Check baby’s breathing and color, and
checked mother’s vital signs and massage uterus every 15
minutes .
50. In the second hour; checked mother-baby dyad every 30
minutes to 1 hour
51. Complete all Records
Total : 255

Legend: (5) Performs the task excellently

(4) Performs the task Very Satisfactory
(3) Performs the task Satisfactory
(2) Performs the task fairly
(1) Performs the task poorly