DELIVERY ROOM ROTATION 😉

 IM ADMINISTRATION FOR NEWBORN

The anterolateral thigh is the preferred site for IM injection in infants under 12 months of age. Medications are injected into the bulkiest
part of the vastus lateralis thigh muscle, which is the junction of the upper and middle thirds of this muscle.
Equipment:

 IM medication ampoule SPECIAL REMINDER:

 Large-bore needle for withdrawing medication from ampoule Vitamin K (0.1 mL)
 1 mL or 2 mL syringe - Given at the right vastus/thigh
 23-gauge 25 mm needle or 25-gauge 16 mm needle for preterm Hepatitis B vaccine (0.5 mL)
babies two months or younger (see table below) - Given at the left vastus/thigh
 Antiseptic swab if used must be allowed to dry before injection give
 Cotton wool swab
 Gloves for standard precautions
Recommended needle size, length, and angle for administering vaccines:

  Needle type Angle of needle insertion

Preterm babies (< 37 weeks' gestation) up to two 23 or 25-gauge, 16 mm 90° to the skin plane
months of age and/or very small infants in length

Infant, child or adult for IM vaccine 23 or 25-gauge, 25 mm 90° to the skin plane
in length

Subcutaneous injection in all infants 25 or 26-gauge, 16 mm 45° to the skin plane

in length

If using a narrow 25-gauge needle for an IM vaccination, ensure the vaccine is injected slowly over a count of five seconds
to avoid injection pain and muscle trauma.
NEEDLE LENGTH
The use of short needles for administering IM vaccines may lead to inadvertent SC injection and increase the risk of
significant local adverse events, particularly with aluminum-adjuvanted vaccines (for example, hepatitis B, DTPa, DTPa-
combination, or dT vaccines).
Procedure
Follow this procedure when administering IM injections to
newborns:
1. Make sure there is a written medication order on the
medication chart.
2. Check the correct drug/dose/time/interval/route/patient.
3. Draw the medication up into the syringe using the large
bore needle.
4. Change to the 23 g 25 mm needle or 25 g 16 mm needle.
5. Be aware that a second staff member to help position the
infant on his/her back on an appropriate surface may be required.
 6. Administer sucrose.
7. Undo the infant’s nappy to locate the junction of the upper and middle thirds of the vastus lateralis thigh muscle.
8. Place your forearm across the infant’s pelvis and secure the thigh between your thumb and forefinger if you are the
clinician performing the injection.
9. Position the limb to relax the muscle.
10. Pierce the skin at an angle of 90 degrees to the skin. Provided an injection angle of > 70 percent is used, the
needle should reach the muscle layer. The following figures of the thigh show the recommended injection site.
Note:
o As there are no large blood vessels in the recommended sites, aspiration before injection of vaccines (pulling back on
the syringe plunger after needle insertion but before injection) is not necessary.
o Slowly inject the medication for even distribution and to minimize the infant's discomfort.

o Remove the needle.

o Check the injection site for bleeding and apply a cotton wool ball if necessary. Observe the site for local inflammation.

o Dispose of the needles and syringe into a labeled puncture-proof container to prevent needle stick injury or reuse.

o Document the administration of the IM injection on the medication chart and/or child health record (where appropriate).

Practice points
Issue to note regarding the administration of IM injections:
1. Avoid subcutaneous and intramuscular injections when intravenous administration is a suitable alternative option.
Note: Vitamin K is preferably given intramuscularly as soon as possible after birth as endogenous endorphins are
present at high levels at the time of birth.
2. Alcohol and other disinfecting agents must be allowed to evaporate before injection of medication to reduce the
inactivation of live vaccinations and irritation at the injection site.
3. If an injection site is cleaned using a 70 percent alcohol / 2 percent chlorhexidine swab it must be swabbed for 30
seconds and allowed to air dry completely.
4. Current best clinical practice is not to swab an injection site (intramuscular (IM), subcutaneous (/c), and
immunization) with a 70 percent alcohol / 2 percent chlorhexidine swab if the site is visibly clean.
5. If the site is soiled in any way the clinician should clean the site with soap and water (as outlined by the World
Health Organization).
6. Never give an IM injection in the buttocks. Using the vastus lateralis muscle avoids the risk of sciatic nerve damage
from the gluteal injection. Also, the vastus lateralis muscle has a larger muscle mass than the gluteal region and
therefore has a reduced risk of severe local reactions. The deltoid in infants is not sufficiently bulky to absorb IM
medications adequately. The vastus lateralis muscle avoids the thicker layer of subcutaneous fat on the anterior
thigh.
7. Make sure that infants do not move during the IM injection. This is very important. However, excessive restraint can
increase the infant’s fear and can result in increased muscle tension.
8. The infant can be held in the ‘cuddle’ or semi-recumbent position on the lap of the parent/caregiver/health
professional.
9. Breastfeed the infant at the time of injection if appropriate.
 10. Oral sucrose may be given for relief of distress with parental consent.
11. The volume of the IM injection should not be more than 1 mL
When two IM injections are being administered, give one medication into the right thigh and the other into the left thigh.
There is currently insufficient evidence to support simultaneous injections by two providers demonstrating a difference in
pain response.

 VITAL SIGNS TAKEN FOR ADULTS & NEWBORN

NORMAL VALUES ADULT NEWBORN
HEARTRATE/PULSE RATE 60 – 100 bpm 120 – 150 bpm
RESPIRATORY RATE 16 – 20 cpm 30 – 60 cpm
TEMPERATURE 36.4 – 37.4 °C 36.4 – 37.4 °C
BLOOD PRESSURE 120/80 mmHg -----------
OXYGEN SATURATION 95 – 100 % 97% and above

 APGAR SCORING
- Means APPEARANCE, PULSE, GRIMACE, ACTIVITY (MUSCLE TONE), AND RESPIRATION
- In 1952, Dr. Virginia Apgar developed the APGAR score
- When: The APGAR score is done twice following the birth of the newborn. It is done 1 minute and 5 minutes after birth.
- This test is a very useful assessment.

APGAR SCORING
INDICATOR 0 pt 1 pts 2 pts
Appearance Cyanotic/ pale Peripheral cyanosis, Pink (normal)
pink body, blue
extremities
Pulse 0 bpm, Absent < 100 bpm 100 -140 bpm
Grimace (reflex activity) No response to Minimal response to Prompt response to
stimulation stimulation stimulation
Activity (muscle tone) Floppy active, Absent Some flexion, can flex Well flexed
arms and legs
Respiration Absent Slow, irregular Good, strong cry

 LABOR WATCH
CONTRACTIONS – is a rhythmic tightening of the musculature of the upper uterine segment that begins mildly and becomes very
strong late in labor
The duration of the uterine contraction is the time from the beginning of one contraction to the end of that same contraction
During labor, the duration of the contractions will start out short (25 to 35 seconds long) and ultimately get to 70 – 90 seconds long.
Real contractions follow a consistent pattern, while Braxton-Hicks contractions vary in duration and frequency.
FREQUENCY - The frequency of the contractions is measured from the beginning of one contraction to the beginning of the very next.
This not only includes the duration of one contraction, but also the rest period between the two. So if you have a contraction at 8 pm
and it lasts for 60 seconds, and then you have another contraction at 8:15 pm, the contractions have a duration of 60 seconds and a
frequency of 15 minutes.
INTENSITY - The intensity of the contractions also changes as labor progresses. Early labor contractions are often described as mild
menstrual cramps. Contractions in later labor, have been described by some stand-up comedians as feeling like your lower lip was
stretched up over your head! While this analogy is humorous, it is true that with normal labor, the intensity of the contractions does
increase, and this is a good sign that labor is progressing well.
INTENSITY
Mild - the uterus is contracting but does not become more than minimally tense (tip of the nose)
Moderate - the uterus feels firm (chin)
Strong - the contraction is so intense that the uterus feels as hard as wood at the peak of contraction (forehead)

 MEASURING THE HEAD, CHEST, ABDOMEN, & LENGTH OF THE NEWBORN

HEAD CIRCUMFERENCE:
- It is measured with a tape measure drawn across the center of the forehead and the most prominent portion of the posterior
head. (33 – 35 cm)
CHEST CIRCUMFERENCE:
- It is measured at the level of nipples and is about 2 cm less than head circumference. (30 – 33 cm)
ABDOMINAL CIRCUMFERENCE:
- Approximately the same as chest circumference (30 – 33 cm) and it is measured just above the level of the umbilicus.
LENGTH:
- Crown to heel length with infant supine/upside down/with the knees slightly pressed down to obtain maximum leg extension.
(47 – 50 cm)
WEIGHT:
- Average birth weight. (2.5 – 3.5 kg)

 SIGNS OF LABOR
DANGER SIGNS OF LABOR:
 Abnormal FHR
 Meconium staining of amniotic fluid
 Abnormal maternal contractions
 Development of an abnormal lower abdomen contour or increasing apprehension
PRELIMINARY SIGNS OF LABOR
 Lightening – or descent of the fetal presenting part (usually the fetal head) into the pelvis, occurs approximately 10 to 14 days
before labor begins. This fetal descent changes a woman’s abdominal contour because it positions the uterus lower and more
anterior in the abdomen.
 Increase in energy
 Slight loss of weight
 Backache
 Braxton hicks contractions
 Ripening of the cervix
SIGNS OF TRUE LABOR
 Uterine contractions
 Show – as the cervix softens and ripens, the mucus plug that filled the cervical canal during pregnancy is the pressure exerted
by the fetus. This blood mixed with mucus takes on a pink tongue and is referred to as “show” or “bloody show”
 Ruptured of the membranes
MATERNAL DANGER SIGNS OF LABOR
 High or low blood pressure – greater than 140 mmHg and a diastolic greater than 90 mmHg, or increase in systolic of more
than 30 mmHg or 15 mmHg
 Abnormal pulse – Most women have 70 – 80 bpm. A maternal pulse greater than 100 bpm during labor should be reported!
 Inadequate or prolonged contractions – uterine contractions lasting longer than 70 secs are becoming long enough to
compromise fetal well-being because this interferes with adequate uterine artery filling.
 Abnormal lower abdominal contour – if a patient has a full bladder during labor, a round bulge appears on her lower anterior
abdomen. To avoid a full bladder, ask the patient to try to void about every 2 hours during labor.
FETAL DANGER SIGNS OF LABOR
 High or low FHR – more than 160 bpm (fetal tachycardia), less than 110 bpm (bradycardia) is a sign of fetal distress.
 Meconium staining – is not always a sign of fetal distress but is highly correlated with its occurrence. Meconium staining a
green color in the amniotic fluid reveals the fetus had a loss of rectal sphincter control, allowing meconium to pass into the
amniotic fluid. Although meconium staining may be usual in a breech presentation because the pressure on the buttocks
causes meconium loss, it should always be reported immediately.
 Hyperactivity – a sign that hypoxia is occurring because of frantic motion is a common reaction to the need for oxygen
 Low oxygen saturation – oxygen saturation is normally 40 – 70%. If fetal blood is obtained by scalp puncture, the finding of
acidosis; blood pH lower than 7.2 suggests fetal well-being is becoming compromised and that further investigation is also
necessary.
ASSESSING FOR DANGER SIGNS OF LABOR
1. Increasing apprehension.
2. Pulse rate > 100 bpm
3. BP > 140/190 mmHg or decreasing, indicating shock
4. Contractions greater than 70 seconds duration
5. Meconium staining of amniotic fluid
6. Hyperactivity of fetus
7. Fetal acidosis (ph < 7.2)
8. FHR > 160 bpm or < 110 bpm
9. Full bladder

 SIGNS OF PLACENTAL SEPARATION

PLACENTAL SEPARATION
- Also called placenta previa
- As the uterus contracts down on an almost empty interior, there is a disproportion between the placenta and the
contracting wall of the uterus, that folding and separation of the placenta occur.
- Active bleeding on the maternal surface of the placenta begins with separation, which helps to separate the
placenta still further by pushing it away from its attachment site. As separation is completed, the placenta sinks to
the lower uterine segment or the upper vagina.
- The placenta has loosened and is ready to deliver when:
 There is the lengthening of the umbilical cord.
 A sudden gush of vaginal blood occurs.
 The placenta is visible at the vaginal opening.
  The uterus contracts and feels firm again.
Two Types of Placenta:
1. SCHULTZE PLACENTA (appears shiny and glistening from the fetal membranes)
- The separation of the placenta from the uterine wall during labor; begins at the placental center and leads to an
expulsion of the placenta after the delivery of the baby.
- If the placenta separates first as its center and lastly as its edges, it tends to fold on itself like an umbrella and
presents at the vaginal opening with the fetal surface evident. Approximately 80% of placentas separate and
present in this way.

2. DUNCAN PLACENTA (looks dirty, the irregular maternal surface shows)

- The expulsion of the placenta with the presentation of the maternal rough side first, rather than the usual fetal side
of the placenta.
- The placenta separates first at its edges, it slides along the uterine surface and presents at the vagina with the
maternal surface evident.
- This looks raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces evident.