Handling and Assisting Deliveries

❖ Handling Delivery - is the actual handling of

the delivery of the fetus
❖ Assisting Delivery – handling the instruments
to the one handling the delivery
❖ Episiotomy – a surgical incision of the
perineum made to prevent tearing of the
perineum with birth and to release pressure of
the fetal head during delivery.
❖ Episiorraphy - repair tear of the episiotomy
with the use of sutures.
❖ Laceration - refers to the tearing of the vulvar,
vagina and sometimes rectal tissue during
birth.
❖ Four diameters of pelvic inlets
1. Anteroposterior (True Conjugate)
❖ ENGAGEMENT - occurs when the widest part 2. Diagonal Conjugate
of the fetal head has passed below the - Can be measured clinically.
maternal pelvic inlet. Essentially, the baby's 3. Obstetric Conjugate
head has officially entered its mother's pelvis. 4. Transverse Diameter
❖ DESCENT - downward movement of the
biparietal diameter of the fetal head to within
the pelvic inlet.
▪ FLOATING - fetal presenting part is not
engaged in pelvic inlet.
▪ FIXED - fetal presenting part has entered
pelvis.
▪ ENGAGEMENT – fetal presenting part
(usually biparietal diameter of fetal head)
has passed through pelvic inlet.
▪ Station 0 – presenting part has reached
level of ischial spines.
▪ Stations -1, -2, -3 - presenting part is 1,2,3
above the level of ischial spines.
▪ Stations +1, +2, +3 – presenting part is 1,2,3
below level of ischial spines. A station of
+4 indicates that presenting is on the
pelvic floor.

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 Handling and Assisting Deliveries
FLEXION
❖ Baby moves further downward and then head
meets obstruction at the pelvic floor causing
flexion.
❖ While descending through the pelvis, the fetal
head flexes so that the fetal chin is touching
the fetal chest. This functionally creates a
smaller structure to pass through the
maternal pelvis. When flexion occurs, the
occipital (posterior) fontanel slides into the
center of the birth canal and the anterior
fontanel becomes more remote and difficult to
feel. The fetal position remains occiput
transverse.
INTERNAL ROTATION
❖ In accommodating the birth canal, the fetal
occiput rotates anteriorly from its original
position toward the symphysis. The
movement results from the shape of the fetal
headspace available in the mid pelvis and
contour of the perineal muscles. The ischial
spines project into the mid pelvis causing the
fetal head to rotate interiorly to
accommodate to the available space.
❖ With further descent, the occiput rotates
anteriorly and the fetal head assumes an
oblique orientation. In some cases, the head
may rotate completely to the occiput anterior
position.
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EXTENSION
❖ As the fetal head descends further it meets
resistance from the perineal muscles and is
forced to extend. The fetal head becomes
visible at the vulvova ring; its largest diameter
is encircled (crowning) and the head then
emerges from the vagina.
❖ The curve of the hollow of the sacrum favors
extension of the fetal head as further descent
occurs. This means that the fetal shin is no
longer touching the fetal chest.
EXTERNAL ROTATION/RESTITUTION
❖ When head emerges, the shoulders are
undergoing internal rotation as they turn in
the mid pelvis to accommodate to the
projection of the ischial spines. The head, now
born, rotates the shoulders undergo this
internal rotation.
❖ The shoulders rotate into an oblique or frankly
anterior-posterior orientation with further
descent. This encourages the fetal head to
return to its transverse position.
EXPULSION
❖ Following delivery of the infant’s head and
internal rotation of the shoulders, the anterior
shoulder rests beneath the symphysis pubis.
The posterior shoulder is born, followed by the
anterior shoulder and the rest of the body
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 Handling and Assisting Deliveries
FIRST STAGE OF LABOR (STAGE OF DILATATION)
Onset of true labor to full cervical dilatation.
❖ LATENT PHASE - The first phase of the first
stage of labor when contractions are
becoming more frequent (usually 5 to 20
minutes apart) and somewhat stronger. The
cervix dilates (open approximately three or
four centimeters and effaces (thins out). Is
usually the longest and least intense phase of
labor.
❖ ACTIVE STAGE - the second phase of the first
stage is signaled by dilatation of the cervix
from 4 to 7 cms. Contractions become longer,
more severe, and frequent (usually 3 to 4
mins. apart)
❖ TRANSITION PHASE - the third phase and the
last phase. Cervix dilates from 8 to 10 cms.
Contractions are usually very strong lasting
60-90 seconds and occurring every few
minutes.
SECOND STAGE OF LABOR (STAGE OF EXPULSION)
Complete dilatation to expulsion of the
baby.
Ritgen’s Maneuver
1. Denotes extracting the fetal head, using one
hand to pull the fetal chin from between the
maternal anus and the coccyx, and the
other on the fetal occiput to control speed of
delivery. It is performed during the uterine
contraction.
2. Palpate for cord coil.
• Suction baby’s mouth and nose using
bulb syringes.
• Deliver the shoulder, wait for the
external rotation where one shoulder
is up and the other shoulder is down.
• With one hand at the back of the neck,
the other one grasping the extremities
and put the baby in the mother’s
abdomen and suction secretions.
THIRD STAGE (PLACENTAL STAGE)
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- Birth of the baby-expulsion of the placenta
- This stage of labor is the period from birth of
the baby through delivery of the placenta.
- This is considered a dangerous time
because of the possibility of hemorrhaging.
PLACENTAL SEPARATION
Calkin’s Sign
1. The uterus becomes globular in shape and
firmer, discoid to avoid, indicating placental
separation from the uterine wall.
2. Gushing of blood
- 2nd Sign
- Sudden gush of blood
3. Lengthening of the cord
- 3rd Sign
- The umbilical cord descends three (3)
inches or more further.
4. The uterus rises in the abdomen
Crede’s Maneuver
A method of expressing the placenta in
which body uterus is vigorously squeezed in order
to produce placental separation.
PLACENTAL EXPULSION
Brandt-Andrews Maneuver - a method of
expressing the placenta by grasping the umbilical
cord with one hand and placing the other hand on
the abdomen, application of the traction on the
cord by moving the force pup, down, left, right.
Schultze’s Mechanism - Shiny (Fetal Side) - a
mechanism or technique for the delivery with the
fetal rather than the maternal side surface
presenting the shiny and glistening side of the fetal
membrane.
Duncan Mechanism - Dirty or Rough (Maternal
Side) – a mechanism or technique for delivery with
the maternal rather than the fetal side surface
presenting the dirty or rough side.
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 Handling and Assisting Deliveries

❖ 10cc disp. Syringe with lidocaine anesthesia +

bandage scissors are used during episiotomy.
❖ 2 Kelly Forceps – used to clamp the umbilical
cord of the baby.
❖ Umbilical Cord Scissor - used to cut the
umbilical cord.
❖ Surgical Scissors - used to cut the umbilical
cord.
❖ Needle Holder - used to hold the round needle
with suture.
FOURTH STAGE (STAGE OF PHYSICAL RECOVERY)
❖ 1 Tissue Forceps with Teeth - used to hold the
- Delivery of the placenta up to 1-4hrs. after soft tissues in the perineal area during
delivery episiorraphy.

PREPARATION

1. Do medical and surgical hand washing

2. Perform gowning (per institution protocol)
and gloving (per institution protocol)
3. Do draping (per institution protocol)

ACTION

1. Drape the patient accordingly:

- Leggings (Left and Right)
- Abdominal Drape
- Perineal Drape
- Baby Drape
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 Handling and Assisting Deliveries
- Perineal Support
2. Encourage the woman to push/ bear down
once uterus is at the height of its contraction
and to do breathing exercises when it is not.
When the birth opening is stretching and the head
of the baby is crowning:
3. Ensure controlled delivery of the head of the
baby.
4. Keep one hand on the head as the head of
the baby advances.
- To keep the head from coming out
too quickly
5. Support the perineum with the other hand.
- To prevent perineal lacerations
6. Discard the pad when soiled.
- To prevent infection
7. During the delivery of the head encourage
the woman to stop pushing and breath
rapidly with mouth open.
Delivering the baby:
8. Sliding your hands into the neck of the baby,
gently feel if the cord is around the neck.
- If it is loosely around the neck, slip it
over the shoulders or the head.
- If it is tight, place a finger into the
cord, clamp and cut the cord, and
unwind it from around the neck.
When the face and head of the baby is delivered:
PREPARATION:
9. Gently wipe the baby’s mouth and nose
with clean gauze.
10. Wait for external rotation (within 1-2 min)
the head of the baby will turn sideways
bringing one shoulder just below the
symphysis pubis and the other facing the
perineum.
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11. Apply downward pulling motion to deliver
the top shoulder then lift the baby up to
deliver the lower shoulder. Gently deliver
the rest of the baby.
12. Place the baby to the mother’s abdomen in
prone position.
13. Cover the baby with dry towel. Thoroughly
dry the baby immediately. Wipe the baby’s
eyes.
14. Discard wet cloth.
15. Put the baby in prone position, in skin-to-
skin contact on the mother’s abdomen.
Keep the baby warm.
16. Palpate mother’s abdomen to determine if
there is a second baby.
17. Remove gloves (first set of gloves) or
change to new ones.
18. Deliver the placenta by controlled cord
traction (with counter traction on the uterus
above the symphysis pubis)
- Make sure the bladder is empty
19. Massage the uterus over the fundus.
20. Once delivered, place the placenta on the
bowl and inspect for completeness of its
parts.
21. Document the placental presentation.
1. Do medical and surgical hand washing
2. Perform gowning (per institution protocol)
and gloving (per institution protocol)
3. Prepare the materials, OB pack and
instruments set to be used in the delivery.
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 Handling and Assisting Deliveries
a. Materials include: to be obtained
from the accompanying
i. Maternity duster (per
institutional policy)
ii. Adult and newborn (per
institutional policy)
iii. Baby clothes and flannel
(per institutional policy)
b. Instruments set needs to be
anticipated whether to use
primi/multi set (per institutional
policy)
4. Anticipate the amount of anesthetic agent to
be use. Prepare the agent in the syringe.
ACTION
1. Serve the instruments to be used to the
physician in appropriate manner.
2. Assist in suturing the episiotomy. Anticipate
doctor’s need during suturing.
3. After suturing of the perineum is done, flush
the operative site with normal saline.
4. Apply betadine antiseptic solution, sanitary
pad/adult diaper and clean maternity
duster.
5. Do after care:
- Position the mother comfortably-
closed legs
- Removed stained drapes
- Take vital signs immediately
- Check the instruments if complete
- Wash the instruments if complete
and let it dry
- Pack clean equipment and auto-
clave
❖ This is a supervision checklist for Emergency
Obstetric and Newborn Care sites to help
monitor: (1) the infrastructure and
environment, (2) the equipment and material,
(3) the management of antenatal care clients,
patients during labor and delivery, as well as
Compiled by: Chielo monceda
postnatal mothers and babies, (4) family
planning, and (5) post abortion care.
INTRODUCTION
❖ Approximately 15% of expected births
worldwide will result in life-threatening
complications during pregnancy, delivery, or
the post-partum period [1]. The concept of
emergency obstetric and newborn care
(EmONC) was introduced by WHO, UNICEF,
and UNFPA in 1997 as an organizing framework
for the delivery of evidence-based clinical
services, as a critical component of any
program to reduce maternal and newborn
mortality [2]. Skilled birth attendants (SBAs) [3]
provide EmONC services within the context of
community-focused and facility-based health
systems, enabling timely prevention of and
intervention for these complications and saving
the lives of mothers and newborns.
❖ Universal access to EmONC is considered
essential to reduce maternal mortality and
requires that all pregnant women and
newborns with complications have rapid
access to well-functioning facilities that include
a broad range of service delivery types and
settings A set of seven key obstetric services ,or
“signal functions,” has been identified as critical
to basic emergency obstetric and newborn care
(BEmONC): administration of parenteral
antibiotics; administration of parenteral
anticonvulsants; administration of parenteral
uterotonics; removal of retained products
(manual vacuum aspiration);assisted vaginal
delivery; manual removal of the placenta; and
resuscitation of the newborn[5].
❖ Comprehensive emergency obstetric and
newborn care (CEmONC) includes all BEmONC
services and adds surgical capacity and blood
transfusion. This set of life-saving services
defines a health facility with regard to its
capacity to treat obstetric and newborn
emergencies [4]. The decision to include these
functions in a package of emergency obstetric
and newborn care services was based on
evidence from numerous quasi-experimental
or experimental studies and is summarized in
various systematic reviews [6], [7], [8], [9].
Recent global discussions have centered on
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 Handling and Assisting Deliveries
expansion of the original seven signal functions
to encompass activities related to routine care
for mothers and newborns because they enable
prediction, prevention, and early intervention to
mitigate life-threatening complications [10].
❖ These expanded functions include such services
as: infection prevention and management for
both mothers and infants; monitoring and
management of labor using the partograph;
active management of the third stage of labor;
and infant thermal protection, feeding, and HIV
prevention.

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Compiled by: Chielo monceda