UNCOMPLICATED ACTUAL NORMAL SPONTANEOUS VAGINAL DELIVERY BY HANDLE,

ASSIST AND CORD CARE NURSE (HOSPITAL SETTING) WITH INTEGRATION OF

ESSENTIAL NEWBORN CARE (ENC)
FOR SIMULATION
Purpose

 To facilitate a successful delivery with least discomfort on the part of the mother.
 To safeguard mother and baby against infection.
 To prevent maternal hemorrhage.
Equipment
INTRAPARTUM CARE SET

 DR Bed with stirrups, and side grip

 Perineal Flushing set
 Yellow plastic waste bag
o Sterile gown (varies on hospital protocols)
o Sterile Gloves (1 pair for the Handle and 1 pair for the Cord Care)
o Working Gloves (1 pair for the Assist)
o a Sterile Primi set containing the following instruments and materials.
o placed on the DR Table:
1. Sterile gloves (1 pair for the Simulation Doctor/Midwife)
2. 2 sterile dry linen (for the baby)
3. 1 bonnet
4. 2 sterile lining (for abdomen and buttocks)
5. 2 sterile leg drapes
6. 1 plastic cord clamp/clip (for cord dressing)
7. 1 sterile urethral straight catheter
8. 1 Mayo scissors (for episiotomy)
9. 1 Bandage scissors (for cord cutting)
10. 1 big artery clamp/ 1 big forceps
11. Sterile gauze (at least 5 pieces)
12. 2 Sterile Kidney basins
13. 1 Needle holder
14. Sterile syringe with needle (5 cc)
15. 2% of Lidocaine
16. Chromic 2-0 (double needle: round and cutting)
17. 1 tissue forceps
 a Sterile Multipara set same with primi set but without #12 - 16 materials above.
 Pail/ basin (for placental disposal)
 Adult Diaper
NEWBORN CARE SET: (See also NON-TIME BOUND CARE of the NEWBORN)

 Resuscitation equipment
 Identification band (Blue for Baby Boy; Pink for Baby Girl)
 Eye Ointment
 Stethoscope (to symbolize Physical Examination of the newborn)
 Vit K Injection (ampule form)
 Hepatitis B Injection (vial form)
 2 sterile Tuberculin Syringes with needle
 1 sterile aspirating needle
 Cotton balls with alcohol
 Cotton balls with sterile water or saline water
 Digital rectal thermometer
 Baby's Diaper

Notes by: Sittie Shareena Sandigan| BSN 2 | 1ST Semester 2023-2024

Ateneo de Davao University | SON
 Clean Cloth/ baby's layette
Patient position: Lithotomy position

Procedure
1. Gather the necessary equipment. Prepare
the birthing instrument set per hospital
protocol. Place yellow plastic waste bag
on the DR table (specifically where the
buttock of the patient is); Prepare
Primi/Multipara.
Rationale
Preparing the equipment saves time and
effort and for assuring the correct and
completeness of equipment needed.
The yellow plastic waste bag is used to
dispose bloody and infectious wastes.

Set on the Mayo tray. The room must be set to an environment free
of air draft and regulated temperature in
 Check room temperature of the DR must preparation for baby's thermoregulation.
be at 25-28°C and free of air draft.
 Notify appropriate staff to assist in the
 Check resuscitation equipment
2. Assist the client in lithotomy position and Lithotomy position is a common position of
the ASSISTING NURSE performs childbirth. Perineal prep is best done through
perineal flushing. perineal flushing.
3. 3. Wash hands with clean water and Handwashing is the single and most effective
soap, or scrub hands for at least 40-60 way in deterring the spread of
secs (according to WHO 1- 2-3-4-5) microorganisms.
4. The HANDLE NURSE and the CORD To prevent cross-contamination and assure
CARE NURSE don gown (per protocol) asepsis.
and sterile gloves. Double gloving per
hospital policy. The HANDLE NURSE  Oxytocin preparation prior to the delivery
arranges the sterile set in Mayo tray in a will help the assist nurse with ease in the
linear fashion. procedure.
 Assisting nurse prepares the Oxytocin IM
in a medication tray.
NOTE: Oxytocin preparation is not a sterile
material.
5. When the perineum bulges, the HANDLE This prevents injury/laceration while the
NURSE protects it with an operating perineum is stretching and to prevent sudden
sponge and applies moderate pressure at expulsion.
the perineum and on the fetal head.
(Ritgen's maneuver)
6. Coach the patient to bear down when Bearing down is effective when there is
there are contractions until the head is contraction.
out, when contraction stops, instruct the
patient to catch up breathe by opening
and breathing through the nose.
7. The HANDLE NURSE places the 1st dry The first sterile and dry linen is used for
sterile linen on top of the abdomen of the drying the baby. Preparing this ahead will
mother. help ease the drying of the baby.
8. Watch for cord coil around the neck of To prevent compression of the cord.
baby. If present, insert finger to ease
pressure, skip coil down baby's shoulder.
9. Wait for external rotation. The HANDLE Forcing the delivery of the baby may cause
NURSE eases the expulsion of the head the laceration of the cervix or the vaginal wall.
by slowly pulling head up and down by
interlocking neck/mandible area of the
baby in between index and middle fingers
of both hands until the anterior shoulder
comes out, then the posterior shoulder
next and the rest of the body.
10. The CORD CARE NURSE calls out and It is important to loudly tell the time of birth-
note for the time of delivery and sex of the this helps in accurate recording of the time

Notes by: Sittie Shareena Sandigan| BSN 2 | 1ST Semester 2023-2024

Ateneo de Davao University | SON
 baby. A child is considered born when the
whole body is delivered. "Baby (Girl/Boy)
out! (time)!"
FOUR CORE STEPS OF ESSENTIAL
NEWBORN CARE
I. Within first 30 seconds: Immediate
Thorough Drying
11. Place the newborn on top of the mother's
abdomen. The ASSISTING NURSE dries
newborn using 1 dry linen/cloth
thoroughly for at least 30 sec. Wipe eyes,
face, head, front, back & arms, legs.
Remove wet cloth. Replace with a new one.
Do a rapid assessment of the baby noting the
breathing (baby's cry) while drying.
Note during the 1st sec.
 Do not ventilate unless baby is floppy /
limp & not breathing.
 Do not suction unless mouth / nose is
blocked with secretions.
 Do not wipe off vernix Do not bath
newborn.
 No slapping.
 No hanging upside down.
 No squeezing of chest.
II. After 30 seconds of drying: Early Skin-to-
Skin Contact (SSC)
12. If newborn is breathing or crying, the
ASSISTING NURSE:
a. Positions the newborn prone on the
mother's abdomen or chest (between the
breasts) with head on the side
b. Instructs the mother to hold the baby
("Kangaroo care") while assuring safety by
supporting the baby's back.
c. Covers the newborn back with baby's linen
or blanket.
d. Covers the newborn head with a bonnet.
e. Place identification bond on ankle (not
wrist)
Notes by: Sittie Shareena Sandigan| BSN 2 | 1ST Semester 2023-2024
and more importantly, alerts other personnel
in case any help is needed.
During the first 30 seconds of birth,
thermoregulation in a newborn is easily
disturbed because their neurological systems
are not fully developed at birth. Certain
characteristics such as low subcutaneous fat,
exposure of baby to cold and low birth weight
increase the risk of hypothermia. Washing or
bathing the baby may also lead to infection
and hypothermia.
At the time of drying itself, the baby's
breathing should be assessed. A normal
newborn should be crying vigorously or
breathing regularly at a rate of 40-60 breaths
per minute. If the baby is not breathing well,
then the steps of resuscitation must be
carried out.
If after 30 seconds of thorough drying
newborn is not breathing or is gasping the
following actions are recommended:
a. Reposition, suction, and ventilate
b. Clamp and cut the cord immediately
c. Call for help
d. Transfer to a warm, firm surface
e. Inform the mother that the newborn. has
difficulty breathing and that the nurse will help
the baby to breathe.
f. Start resuscitation protocol
Early skin-to-skin contact promotes more
stable and normal skin temperatures, more
stable and normal heart rates and blood
pressures, higher blood sugars. They are
more likely to breastfeed exclusively longer. It
allows the "good bacteria" from the mother's
skin to colonize the newborn.
It also allows the mother to bond, and to
promote uterine involution/contraction.
This helps in easy identification of the baby,
avoiding any confusion.
Ateneo de Davao University | SON
Note:

 If the baby is crying and breathing

normally, avoid any manipulation by
routine suctioning that may cause trauma
or suctioning infection
 SSC is performed / doable also for
Cesarean Section newborn
 Do not separate the newborn from the
mother, as long as the newborn does not
exhibit severe chest in-drawing, gasping
or apnea, and the mother does not need
urgent medical stabilization.
 Do not put the newborn or cold/wet
surface.
 Do not wipe off vermix if present.
 Do bath the baby after 24 hours of life.
 Do not do foot printing.

13. When the handle nurse palpates the
abdomen and ensures that there is no
second baby, and 1 minute after baby's
birth, the ASSISTING NURSE administers
Oxytocin 10 units (1mL) IM at the deltoid
of the patient (mother).
Oxytocin administration is the 1st step in the
AMTSL to reduce postpartum blood loss, and
to enhance detachment of the placenta to the
lining of the uterus.

III. 1-3 minutes: Properly timed Cord

Clamping

14. Meanwhile, the CORD CARE NURSE
wearing sterile gloves waits until cord
pulsation stops or withing 1-3 minutes
after birth while also noting the APGAR
Scoring.
a. Clamp the cord with the sterile plastic cord
clamp/cord clip (1st clamp), 1 inch (2 cm)
above the umbilical base.
Delaying cord clamping 1-3 minutes after
birth or waiting until the umbilical cord has
stopped pulsating has been shown to
increase newborn's iron reserves. It also
reduces the risk of iron-deficiency anemia,
improves blood circulation, and prevents
hemorrhage. APGAR Score describes the
newborn health condition after birth

b. Milk the cord or strip the cord of blood

away from the newborn once, and then apply
the 2nd clamp at least 5 cm from the base
using a forceps.

c. Cut the cord using the Mayo scissors, 0.5

inch from clamped cord or half inch away
from the cord clip and in between cord clip
(1st clamp) & forceps (2nd clamp). Observe
for oozing blood.

Note: The HANDLE NURSE holds the

forceps (2nd clamp) waiting for the placenta
to be delivered.
15. The HANDLE NURSE places a sterile
lining over the mother's abdomen and
delivers the placenta by controlled cord
traction and countertraction of the uterus
within 20 mins. After 20 minutes if the
A sterile lining ensures maintenance of
sterility of the handle nurse, while doing the
controlled cord traction down the placenta
and countertraction on the uterine fundus.
This is the 2nd step in the AMTSL that helps

Notes by: Sittie Shareena Sandigan| BSN 2 | 1ST Semester 2023-2024

Ateneo de Davao University | SON
 placenta is difficult to deliver, refer to the
physician or midwife.
16. After the placenta is out, the HANDLE
NURSE massages the uterine fundus
firmly and gently.
IV. Within 90 minutes (1%½ hour) after
birth - Non- separation of Newborn from
Mother for Early Breastfeeding
reduce postpartum hemorrhage and uterine
prolapse.
Uterine massage promotes uterine
contraction from the established Oxytocin
administration and reduces the incidence of
postpartum hemorrhage.

17. Meanwhile, after ensuring that the cord is Breastfeeding within the first hour of life
properly clamped and cut, the CORD prevents neonatal deaths. Delaying the start
CARE NURSE replaces the ASSISTING of breastfeeding makes the newborn prone to
NURSE in supporting the newborn's infection.
back. Ascertain non- separation of
newborn from the mother for early
breastfeeding or "latching on".
The CORD CARE NURSE educates the
mother about breastfeeding.
Note:
 leave newborn on SSC to mother's
chest/abdomen.
 observe for feeding cues: licking, rooting.
 encourage mother to nudge newborn
towards the breast counsel on proper
positioning & attachment minimize
handling by health workers.
 Do not give sugar water, formula or other
prelacteals.
 Do not give bottles or pacifiers.
 Do not throw away colostrums.
 Postpone washing until at least 6 hours.
 Postpone bathing of baby until at least 6
hours after birth

18. Meanwhile, the HANDLE NURSE

inspects the placenta for completeness of
cotyledons. Gently place the placenta in
the placental pail/basin. The gloved
hands and the clamp/forceps must not
come in contact with any part of the
container. Once the placenta is secured in
the container, remove the clamp attached
to the distal end of the cord, and place
where appropriate or in a leak-proof
container.

NOTE: For Muslim clients, the placenta is to

be handed over to the patient or watcher
19. When the placenta is visible within the Receive it with the non-dominant hand,
vaginal canal, gently pull, until it is maintaining sterility.
delivered completely.
20. Observe for signs of placental Separation: Retained placental fragments may cause
bleeding.
a. Calkin's sign (change of uterus from
discoid to avoid)
b. Lengthening of the cord
c. c. Sudden gush of blood
21. Meanwhile, the HANDLE NURSE holds
the forceps waiting for the placenta to be

Notes by: Sittie Shareena Sandigan| BSN 2 | 1ST Semester 2023-2024

Ateneo de Davao University | SON
 delivered. Check for the vessels in the
distal cord in reference to the placenta.
(2 arteries, 1 vein = AVA)

22. Inspect the placenta for completeness of

cotyledons. Gently place the placenta in
the placental pail/basin. The gloved
hands and the clamp/forceps must not
come in contact with any part of the
container. Once the placenta is secured in
the container, remove the clamp attached
to the distal end of the cord
23. The ASSITING NURSE shall take the The placental delivery poses risk for bleeding
patient’s blood pressure immediately after and hemorrhage. Taking the vital signs, esp.
the delivery of the placenta and inform the BP q 5 mins for the first 15 mins will ensure
handle nurse/doctor/midwife. assessment of the hemodynamic stability of
the client.
24. Using sterile gauze, the HANDLE NURSE Inspection can help in identifying any
inspects the vagina and the perineum. laceration or bleeding.
25. If there is no laceration, proceed with the The physician only performs episiorrhaphy
immediate post-partum care. If there is a under any circumstances, The nurse
laceration (2nd – 4th degree), and ascertains the need of the physician during
episiotomy, the HANDLE NURSE the procedure.
prepares in assisting for an episiorrhaphy
by the physician.
26. After episiorrhaphy, perform perineal To cleanse and to reduce the risk of infection
care. on the perineal area.
27. Dry the perineal area and the buttocks. To maintain cleanliness and avoid post-op
Apply a perineal pad. The perineal pad wound infection.
should be checked if soaked, every 15
minutes for the first hour postpartum.
28. The HANDLE NURSE washes and dries
all instruments from the decontaminated
solution with antiseptic soap and water.
Used sutures and sharp needles are
disposed properly in sharps container.
29. The ASSIST NURSE continues to monitor Monitoring stability of the vital signs helps in
the mother and the baby dyad every 15 ensuring that the mother and baby dyad is
mins for the first hour, and 30 mins after safe and if complications arise, this can be
second hour, 1 hour thereafter. referred immediately.

NOTE: Refer any unusuality in the vital signs

30. Remove gloves and dispose properly.
Perform proper handwashing.
31. Document
After care must be observed for safety
against communicable disease spread
through blood and secretions, and to deter
spread of microorganisms.
Nursing documentation is a principle that
allows all interventions are properly planned
and delivered to the client legally.

Notes by: Sittie Shareena Sandigan| BSN 2 | 1ST Semester 2023-2024

Ateneo de Davao University | SON