1.

Introduce self, establish rapport

- “Hello po ako po si sitti ang inyong student nurse ngayong araw.”

2. Utilizes therapeutic communication to facilitate the intervention.

“Ako po ay gagawa ng ibat ibang interbensyon para sa bagong silang na sanggol upang
matiyak ang pinakamahusay na kalusugan para sa sanggol at para narin po sainyo.

3. Work with the client and support group based on trust, respect and share relevant
information of the patient's condition.
“Gagabayan ko po kayo sa processong ito at iuupdate ko po kayo sa inyong kalagaya at
pati sa kalagayan ni baby.”

Preparation phase:
4. Prepare a decontamination solution by mixing chlorine and water to provide
chlorine solution.
5. Place the mother in the position of choice while in labor.
• Comfortable na po ba kayo sa position niyo or gusto niyo po ibahin” “pwede po kAYO
tumayo o maglakad habang di pa po ready lumabas si baby”
6. Ask the mother if she wishes to eat/drink or void
• “Gusto niyo po ba ng makakain o maiinom habang kayo ay nagpapaanak”
• “Kailangan niyo pa ba umihi bago kayo mag paanak”
7. I’ll make sure to Inform the mother the progress of labor & provide a reassuring
words and encouragement
• “siguro mga isang oras o kalahati ay magiging ready na lumabas si baby”
• “relax lang po kayo haha”
Implementation phase:
8. Maintain a temperature of 25-28 degrees celsius; free of air draft
9. Validate if the client is comfortable in semi-upright position
10. Ensure the patient privacy
• Close the doors and windows
11. Remove all jewelry and do handwashing
12. Prepare a clean, clear newborn resuscitation area
• Ensure all delivery equipment and supplies, including newborn resuscitation equipment,
are available
• Line up materials for delivery acc to sequence of use, make sure they are within easy
reach
Materials: gloves, bonnet, dry linen, oxytocin injection, plastic clamp, intrument clamp, scissors,
2 kidney basins
13. I’ll also prepare eye ointment, vit k, hepatitis b & bcg vaccine to be administered
After one full breastfeeding
14. Drape the client in preparation for the labor
15. Clean the perineum with antiseptic solution.
16. Wash hands and put 2 sterile gloves
** during labor:
17. place dry linen over the mother’s abdomen in preparation for drying the baby
17. Encourage the client to push as desired
• Maam inhale, exhale then push; 1,2,3 then push
18. Apply perineal support & control delivery of the head
19. Call out time and gender
“Baby boy out! 12:30 pm”
20. Inform the mother of the outcome-
“congratulations u have a baby boy”

Provide appropriate intervention

21. First 30 sec: rapidly dry the baby in supine position by wiping from the face going down
the trunk & extremities
• Do a quick check of the breathing while drying
• Remove wet cloth
22. After 30 sec: (nb is crying & breathing) Place baby in skin-to-skin contact on
mother’s abdomen
• Cover the baby with dry cloth and the baby’s head with a bonnet.
• Exclude a 2nd baby by palpating the abdomen in preparation for giving oxytocin
• Wipe the soiled gloves; give IM oxytocin within 1min of birth (prevent hemorrhage or
excessive bleeding after birth)
• Dispose wet cloth
*rationale: prevent hypothermia, protection from hypoglycemia, promote mother & child bond,
exposure to maternal flora,

23. Within 1-3 mins

• Remove first set of gloves & decontaminate them properly in chlorine solution
• Palpate umbilical cord to check for pulsations
• After pulsations stopped, Clamp using plastic clamp: 2cm from the base; instrument
clamp: 5 cm from the base)
• Cut the cord near plastic clamp (check breathing/apgar)
• Wait for strong uterine contractions then apply controlled cord traction and counter
traction on the uterus, continuing until delivery of placenta.

Monitor the mother & baby during the first hour after delivery of placenta
24. Massage the uterus until it is firm (prevent postpartum hemorrhage)
25. Inspect the lower vagina & perineum for lacerations & tears
26. Examine the placenta for completeness & abnormalities
- “the placenta is complete and has no abnormalities”
27. Clean the mother; flush perineum and apply perineal pad
- Perineal care will help the perineum heal fster, feel better & help prevent infection
28. Check baby’s color & breathing again; make sure the mother is comfortable &
uterus is contracted
29. Dispose placenta in a leak-proof container
30. Decontaminate instruments for at least 10 mins in chlorine solution
31. Leave the baby in the mother's chest in skin-to-skin contact, should be prone w
head turned to one side. But never leave them alone in the room

32. Within 15-90 mins:

33. Tell the mother to observe for feeding cues
- “maam panatilihin niyo po ang skin-to-skin contact at tingnan ang mga senyales
na gutom na ang inyong sanggol tulad ng pagbuka ng bibig, pagdila at paglapit
ng kamay sa bibig.
• Assist the mother and instruct on proper positioning and attachment.
• Let the baby feed as long as he wants (can delay tasks)
• After breastfeeding, we will administer eye ointment, then thorough physical
examination, Vitamin K, Hepatitis B and BCG injections
 • Explain why there should be a delay for 6 hours in giving bath to the baby.
- “Provides more skin-to-skin contact, and prevents hypothermia that can lead to
infection and defects”
• Explain the benefits of breastfeeding (contains antibodies, lowers risk of
asthma/allergies)
33. In the first hour, we are to assess the newborn for normal growth and
development by using the Ballard scoring. (based on neonate’s physical & neuromuscular
activity)
34. In Performing physical assessment, Check baby’s:
• Breathing and color
• Vital signs
• Anthropometric measurements such as the weight, length, head, and chest
35. Also in the first hour we will monitor mother’s vital signs and massage uterus
every 15 minutes (encourage the uterus to contract & prevent hemorrhage)
36. In the second hour, monitoring is done every 30 minutes to one hour for both the
mother and the baby.
(breathing & warmth)
37. Do the ff aftercare:
• Place the client in a comfortable position
• Reevaluate the client’s motherhood concerns (develop care routine/interventions)
- “meron pa po ba kayong tanong o kailangan, nasa nurse’s station lang po ako”
• Ensure that equipment is properly maintained
• Hand wash
38. Document relevant data & findings (specifically apgar/ballard/dyad monitoring
sheet)
39. Endorse accordingly to healthcare team