INTRAPARTUM: DELIVERY ROOM TECHNIQUE

Purposes
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 basic with dry cotton balls ( to be poured with beta dine for perineal prep)
7. (1) Straight catheter
8. (1) Suction bulb
9. (1) Pair of leggings / drape
10. (2) Sterile towels
11. (1) adult diaper
12. Sterile OS
13. Pail/ Basin
14. Kelly Pad

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/ampule of Lidocaine 2%
5. Sterile OS or napkin (per agency policy)
6. Chronic 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 fatigue.
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
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 NEWBORN
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

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 Rationale

1. Assist patient into a lithotomy position (orProvides the best position for performing an
other alternative birth position per agency episiotomy and for viewing the perineum to
policy) detect laceration or other problems at broth.
2. Checks bladder for fullness and encourage A full bladder or bowel can impede fetal
voiding or catheterize as needed. descent.
3. Cleans the perineum using correct Perineal care helps to remove any possible
technique. drainage or secretions from the birth canal that
may pose a risk for infection.
4. Don/wear gloves. To prevent exposure to client’s body secretion.
5. Drapes the client properly. To create a sterile field and provide patient’s
privacy.
6. Instruct to bear down properly (push with Promotes effective second-stage pushing.
contractions), coaches to take deep breaths as
soon as contraction begins.
7. Encourages to keep both legs flexed and To promote comfort; avoid ligament strain,
firm on the stirrup. backache or injury
8. Performs Ritgen’s maneuver properly/ To control the rate at which the head is born
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safely while fetal head is being delivered. and prevent laceration of the perineum.
9. Checks for nuchal cord, loosen and slip Umbilical loop could tear and interfere fetal
over the head if possible; if cord cannot be oxygen supply.
slipped over the head, it is clamped using two
clamps and cut between the clamps.
10. Notes and records time the baby was To evaluate the APGAR score 1 min. and 5
delivered. min. after birth, thus determine the ability to
adjust in the extrauterine life.
11. Places neonate on the maternal abdomen. To initiate parent-child bonding.
12. Clamps cord using 2 Kelly hemostats, Clamping the cord is part of the stimulus that
support and cut in between them using mayo initiate a first breath. The infant’s most
scissor. (Follow agency policy on cord important transition to the outside world
length.) establishing of independent respiration is
made.
13. Delivers the placenta when signs of Delivery of the placenta should not take more
placental separation is observed and note the than 30 min.
time.
14. Checks placenta for presentation (Schultz Duncan placental presentation carries a
or Duncan). Assess amount of blood loss. slightly increased risk of retained placental
fragments due to incomplete separation. To
check if placenta is complete or intact.
15. Palpates and massages the hypogastric To ensure uterus is firm and contracted and
area (fundus of the uterus) prevent bleeding.
16. Inspects perineum for presence and degree To prevent bleeding.
of laceration. Assists in repair of laceration.
17. Cleans the perineum and buttocks area. To minimize risk of infection and promote
comfort.
18. Do after care of the instruments used and To restore cleanliness and orderliness of the
unit of responsibility. 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 natural
explains its purpose (elbow out technique). 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 delivery
for 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.

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4. Instructs to bear down properly, coaches to Promotes effective second-stage pushing; the
take deep breaths as soon as contraction birth process expense a great deal of energy.
begins (proper pushing and breathing Encouraging proper pushing and breathing
techniques). techniques conserves maternal energy.
5. Wipe mucous from face, mouth and nose, To remove secretion from the neonate’s mouth
establishes initial airway clearance using bulb and nose.
suction.
6. Using a sterile blanket, hold newborn To avoid slipping of the baby; prevent tension
firmly and close to the introitus with head in a to the cord and to allow secretion to drain from
slightly dependent position. the mouth and the nose.
7. Safely lay the infant on the radiant heart To facilitate thermoregulation.
warmer.
8. Provide immediate newborn care: Gentle suctioning removes secretions that may
A. Maintains airway by suctioning mouth collect in these areas. Suctioning mouth before
first then the nose. the nose prevents possible aspiration of oral
secretion.
B. Maintains body temperature Newborns have difficulty conserving body
- Dries the neonate immediately after delivery heat. Exposure to cold increases the metabolic
- Cover neonates head with towel or cap rate, increasing the need for oxygen and further
- Wrap neonate snugly with warm towel the respiratory rate.
C. Place Identical identification bracelets To prevent risk of switching babies and
on the mother and the neonate (follow agency kidnapping.
policy).
9. Performs immediate cord care and notes the To minimize bacterial colonization and
cord vessels. identify congenital anomalies.
10. Places ice pack over the uterine fundus. To promote uterine contraction and prevent
bleeding.
11. Monitors maternal vital signs every 15 To evaluate maternal post partum condition
min. for 1 hour until stable. 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 unit.
doctor’s order.

birth of the head with

application of modified
Ritgen maneuver

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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.

Care of the Cord

The cord is clamped and cut approximately within 30

seconds after birth. In the delivery room, the cord is clamped
twice about 8 inches from the abdomen and cut in between.
When the newborn is brought to the nursery, another clamp
is applied ½ to 1 inch from the abdomen and the cord is cut
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at second time. The cord and the area around it are cleansed with antiseptic solution. The
manner of cord care depends on hospital protocol. What is important is that the principles are
followed. Cord clamp maybe removed after 48 hours when the cord has dried. The cord
stump usually dries and falls within 7 to 10 days leaving a granulating area that heals on the
next 7 to 10 days.

Document
1. Newborn transitions appropriately as evidenced by an APGAR score of 7 to 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 indicate 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

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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 Slow, weak
Absent Good cry
Rate cry
Reflex No
Grimace Cry
Irritability Response
Pulse, Heart Slow
Absent >100
Rate (<100)
Body pink
Completely
Skin Color Blue Pale extremities
pink
blue
Some
Muscle
Flaccid flexion of Well flexed
Tone
extremities

References:

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  Udan Q.J. (2004) Mastering Fundamentals of Nursing Concepts and Clinical
Application 2nd Edition. Educational Publishing House.
 Engstrom, J. ( 2004). Maternal-Neonatal Nursing, Made Incredibly Easy. Lippingcott
Williams & Wilkins.
 Fairchild S.S. Perioperative Nursing, Principles and Practice. Joans and Barlett
Publishers, Corporated.
 Pilliteri A. (2007) Care of the Child Bearing and Child Rearing Family. 5 th Edition
Lippincott Williams & Wilkins.
 Woodring B.C. (2005)Pediatric Nursing Made Incredibly Easy. 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. Philadelphia: Lippincott Williams & Wilkin.
 Nettina, S.M. ( 2001) The Lippincott Manual of Nursing Practice. 7 th
Edition.Lippingcott: Williams & Wilkins.

PERFORMING NORMAL SPONTANEOUS VAGINAL DELIVERY TECHNIQUE

NURSING ACTIONS YES NO REMARKS

PRIOR TO WOMAN’S TRANSFER TO THE DR
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,
(Stethoscope to symbolize PE) Vitamin K, hepatitis B and
BCG vaccines (plus cotton balls, etc.).
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 Note: Apply aseptic technique by segregating sterile and
unsterile instruments.
11. Cleanse the perineum with antiseptic solution.
12. Places patient’s had in hand grip and explain the purpose.
13. Washes hands and put on 2 pairs of sterile gloves aseptically,
(if same worker handles perineum and cord).
AT THE TIME OF DELIVERY
14. Encourage woman to push as desired.
15. Drapes the clean, dry linen over the mother’s abdomen or
arms in preparation for drying the baby.
16. Instruct to bear down properly coaches to take deep breath
as soon as the contraction begins.
17. Encourages to push her flexed legs against the stirrups.
18. Performs Ritgen’s maneuver properly (Support the
perineum )
19. Notes / records the time the baby was delivered.
FIRST 30 SECONDS
20. 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 .
1-3 MINUTES
21. Remove the wet cloth
22. Place baby in skin-to-skin contact on the mother’s abdomen
or chest.
23. Covers baby with the dry cloth and the baby’s head with a
bonnet
24. Exclude 2nd baby by palpating the abdomen in preparation for
giving oxytocin.
25. Used wet cloth to wipe soiled gloves. Gave IM oxytocin
within one minute of baby’s birth . Disposed of wet cloth
properly.
26. Removed 1st set of gloves and decontaminated them properly
(In 0.5% chlorine solutions for least 10 minutes).
27. Palpates umbilical cord to check for pulsations.
28. After pulsations stopped , damped cord using the plastic
clamp or cord tie 2 cm from the base
29. Place the instrument clamp 5 cm from the base
30. Cut near plastic clamp ( Not Midway )
31. Performs the remaining steps of the AMTSL :(active
management third stage of labor).
32. Waited for strong uterine contractions then applied controlled
cord traction and counter traction on the uterus, continuing
until placenta was delivered.
33. Notes the time of placenta delivery and presentation.
34. Massage the uterus until it is firm.
35. Observe for any signs of vaginal bleeding.
36. Inspects the lower vagina and perineum for lacerations/ tears
and repaired lacerations/ tears , as necessary.
37. Examines the placenta for completeness and abnormalities.
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38. Cleanse the mother; flushed perineum and applied
pad/napkin/cloth.
39. Checks baby’s color and breathing; checked that mother was
comfortable, uterus contracted.
40. 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 minutes.
41. 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
42. Advises mother to observe for feeling cues and cited
examples of feeding cues.
43. Supports mother, instructed her on positioning and
attachment.
44. Waits for FULL BREASTFEED to be completed
45. 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 )
46. Advises OPTIONAL/DELAYED bathing of baby ( and
was able to explain the rationale)
47. Advises breastfeeding per demand
48. In the first hour. Check baby’s breathing and color, and
checked mother’s vital signs and massage uterus every 15
minutes .
49. In the second hour; checked mother-baby dyad every 30
minutes to 1 hour
50. Complete all Records
Total : 250 ITEMS

Total Score :_________________

Rating: _____________________

Student Signature : ____________

C.I. Signature : _________________

Date : _____________________

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