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02 – Newborn Concept
LESSON 1: The Labor Process
Four Stages of Labor:
Stage of Dilatation
 It begins with true labor pains and
ends with complete cervical
dilatation.
 Involuntary uterine contractions
cause this stage to PROGESS.
Three Phases in the Stage of Dilatation:
a. Latent Phase
 is the EARLY TIME in labor.
Cervical dilatation here is VERY
MINIMAL because effacement is
occurring.
 The cervix dilates at an average of
three (3) to four (4) cm only.
 The contractions are short in
duration and occur REGULARLY at
five (5) to ten (10) minutes apart.
 The mother is excited, with some
degree of apprehension but still
has the ability to communicate.
 This phase takes up eight (8) of the
twelve (12) hour first stage.
b. Active Phase
 It is the accelerated phases.
 The cervical dilatation reaches four (4)
to eight (8) centimeters.
 There is a RAPID INCREASE in
duration, frequency and intensity of
contraction.
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 This stage becomes difficult for the
mother as contractions are getting
STRONGER and LONGER making her
feel more discomfort.
c. Transition Phase
 has contractions that reach peak
intensity occurring every two (2) to
three (3) minutes with DURATION of
sixty (60) to seventy (70) seconds
leading to full cervical dilatation.
 At this point the mother fears of losing
control of herself and may experience
nausea and vomiting.
 Nursing care during this stage of labor
includes:
o Monitoring cervical dilatation
and effacement
o Monitoring fetal heart tone and
movement
o Assist in ambulation during early
labor
o Encourage proper breathing
technique
o Empower the women in labor
o Respect contraction time
o Promote change of positions
o Promote voiding and bladder
care
Stage of Expulsion
 It begins with complete dilatation of
cervix and ends with the delivery of
the baby.
 Combinations of involuntary uterine
contractions and contractions of the
diaphragmatic and abdominal
muscles cause this stage of labor to
PROGRESS.
 The baby is now being DELIVERED.
From the pelvic outlet, the baby travels
down in series of movement called the
Cardinal Movements of Labor or
simply the Mechanisms of Labor:
i. DESCENT occurs when the fetal
head extrudes beyond the dilated
cervix and touches the posterior
vaginal floor
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ii. FLEXION. As descent occurs,
pressure from the pelvic floor
causes the fetal head to bend
forward (FLEX) onto the chest.
iii. INTERNAL ROTATION. During
descent, the head enters the pelvis
with the fetal antero-posterior
head diameter in a diagonal or
transverse position.
The head FLEXES as it TOUCHES
the pelvic floor, and the occiput
ROTATES until it is superior, or just
below the symphisis pubis, bringing
the head into the best diameter for
the outlet of the pelvis.
iv. EXTENSION. As the occiput is
BORN, the back of the neck stops
BENEATH the pubic arch and acts
as a pivot for the rest of the head.
The head thus extends, and the
foremost parts of the head, the
face and chin, are BORN.
v. EXTERNAL ROTATION. Almost
imediately after the head of the
infant is born, the head rotates
BACK to the diagonal or
transverse position of the early part
of labor. T
The after-coming shoulders are
thus brought into an antero-
posterior position, which is best for
ENTERING the outlet
vi. EXPULSION. Once the shoulders
are born, the rest of the baby is
BORN easily and smoothly
because of its smaller size.
D’ F I R E E R E
Descent Extension
Flexion External Rotation
Internal Expulsion
Rotation
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Nursing Care During Stage of Expulsion
 Preparing the delivery room
 Positioning for birth, that is lithotomy
position
 Provide perineal cleaning
 Prepare two baby blankets, one placed
on the mother’s abdomen and another
on one side for drying the infant later.
 As soon as fetal head crowns, instruct
the mother not to push but to pant
instead
 Assist in episiotomy, if warranted.
o Prevent prolonged and severe
stretching of muscles supporting
the bladder or rectum
o Reduce duration of second
stage when there is
hypertension of fetal distress
o Enlarge the outlet
Types:
1. Median – from middle portion of the
lower vaginal border directed towards
the anus
2. Mediolateral – begun in the midline but
directed laterally away from the anus
 Apply Modified Ritgen’s Maneuver to
deliver the presenting part.
o Cover the anus with sterile cloth
and exert upward and forward
pressure on the fetal chin, while
exerting gentle pressure with
two fingers on the head to
control emerging head.
o Ease the head out and
immediately wipe the nose and
mouth of secretions to establish
a patent airway.
o Insert 2 fingers into the vagina
so as to feel the presence of a
cord loop around the neck
(nucchal cord).
o As the head rotates, deliver the
anterior shoulder by exerting a
gentle downward pull and then
slowly give an upward lift to
deliver the posterior shoulder.
o While supporting the head and
the neck deliver the rest of the
body.
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 Immediately after delivery, call out the
time of birth including the gender of the
baby.
 Place the newborn over the mother’s
abdomen. The weight of the baby will
help contract the uterus.
 Do a quick check of breathing and
perform initial APGAR Scoring.
 Dry the baby well for at least 30 seconds
by wiping the eyes, face, head, front and
back, arms and legs.
 Remove wet cloth. Cover with dry cloth
 Leave baby on mother’s chest in skin to
skin contact.
 Place identification labels on baby.
 Cut and clamp the cord.
 Perform subsequent APGAR Scoring.
 Leave the newborn in skin-to-skin
contact with the mother for 90 minutes
for the initiation of early breastfeeding.
Placental Stage
 It begins with the delivery of the baby
and ends with the delivery of the
placenta.
 Before pulling the cord, you need to
watch out for the different signs that
indicate that the placenta is separating
from the endometrial lining. These
include:
o Calkin’s Sign indicates that
uterus is CONTRACTED. The
uterus becomes round and
firm, rising high to the level of
the umbilicus.
o Sudden gush of blood from the
vagina, and
o Lengthening of the cord from
the vagina
There are two types of placental
delivery. These are:
o Schultz is a type of delivery of
the placenta for which it
separates at the center,
presents the FETAL SURFACE
and is SHINY when delivered.
o Duncan type delivers the
placenta as it separates at its
edges, presents MATERNAL
SURFACE which is RAW, RED,
BEEFY, and IRREGULAR in
shape.
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Nursing Care During Placental Stage
 Do not hurry the expulsion of the
placenta, just watch for the signs of
placental separation
 Tract the cord slowly, winding it around
the clamp until placenta spontaneously
comes out, rotating it slowly so that no
membranes are left inside the uterus
(Brandt-Andrews Maneuver)
 Placenta should be delivered within 20
min after the delivery of the baby
 Inspect for completeness of cotyledons
 Palpate the uterus for determining
degree of contraction. If relaxed, boggy
or non-contracted, your first nursing
action should be massaging the uterus
gently and properly. An ice pack over
the abdomen will also help.
 Inject oxytocics after placental delivery
 Inspect the perineum for lacerations –
bright red vaginal bleeding
 Provide perineal and personal care to
the mother.
 Position mother flat on bed
Recovery Stage
 Refers to the first one (1) to two (2)
hours AFTER delivery.
 Is the most critical stage for the mother
because of UNSTABLE vital signs.
 The fundus is checked every fifteen
(15) minutes for one (1) hour, then
every thirty (30) minutes for the next
four (4) hours.
 Fundus should be FIRM, and positioned
at MIDLINE.
 During the first twelve (12) hours
POSTPARTUM, the fundus should be
palpated a little above the umbilicus.
Nursing Care During Recovery Stage
 Transfer for delivery room to recovery
room.
 Monitor vital signs
 Monitor for lochial discharge. Lochia
should be MODERATE in amount
o Lochia Rubra – RED in color
and can be seen at one to
three days postpartum. It
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contains blood, fragments of
decidua, and mucus
o Lochia Serosa – PINK in color
and can be observed around
four to ten days postpartum.
This contains blood, mucus
and invading leukocytes.
o Lochia alba – WHITE in color
and may be seen until six
weeks postpartum. These are
largely mucus and have high
leukocyte count.
02 – Newborn Concept
LESSON 2: Unang Yakap
Essential Newborn Care Protocol
 Developed to address issues on the still
INCREASING neonatal mortality
despite the advancement in science and
health care.
Interventions Against Infection Related
Mortality:
1. drying
2. skin-to-skin contact
3. delayed cord clamping
4. breast feeding and delayed bathing
Nursing Responsibilities:
1. Prepare for delivery (At perianal
bulging)
 Check temperature of the delivery
room (25 – 28C)
 Notify appropriate staff
 Arrange needed supplies in linear
fashion
 Check resuscitation equipment
 Wash hands with clean water and
soap
 Double glove just before deliver
2. Immediate and thorough drying
(within the 1st 30 seconds)
 Call out the time of birth
 Dry the newborn thoroughly for at
least 30 seconds by wiping the
eyes, face, head, front and back,
arms and legs
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 Remove the wet cloth
 Do a quick check of breathing while
drying o Do not ventilate unless the
baby is floppy/limp and not
breathing o Do not suction unless
the mouth/nose are blocked with
secretions or other material
 Do not wipe off vernix and do not
bathe the newborn
 No footprinting, slapping, hanging
upside – down and squeezing of
chest
3. Early skin-to-skin contact (after 30
seconds of drying)
 If newborn is breathing or
crying, position the newborn
prone on the mother’s abdomen
or chest
 Cover the newborn’s back with
a dry blanket and his head with
a bonnet
 Place identification band on
ankle
4. Properly-timed cord clamping (1 to 3
minutes)
 Remove the first set of gloves
 After the umbilical pulsations
have stopped, clamp the cord
using a sterile plastic clamp at 2
cm from the umbilical base, strip
the cord away from the newborn
and apply the 2nd clamp at 5
cm from the base
 Cut the cord close to the plastic
clamp so that there is no need
for a second trim. 5. Non-
separation of the newborn from
the mother for early
breastfeeding (within 90
minutes)
 Leave the newborn in skin-to-
skin contact
 Observe for feeding cues,
including tonguing, licking,
rooting and point these out to
the mother and encourage her
to nudge the newborn towards
her breast
 Weighing, bathing, eye care,
examinations, anthropometric
measurements, and injections
should be done after the first full
breastfeed is completed
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 Postpone bathing until at least 6

hours As respiration activity is established, RATE
settles to an average of 30-60 breaths per
minute. Newborns are obligatory nose
02 – Newborn Concept breathers. However, periods of apnea are
considered NORMAL.
LESSON 3: Newborn Care and Assessment
A crying infant is a BREATHING INFANT.
Introduction Stimulate baby to cry if baby does not cry
spontaneously or if baby’s cry is weak. Never
Newborn’s transition to extrauterine life: a phase slap the buttocks like those you see in movies,
INSTABILITY (vital signs and activity you can rub the soles of the feet. STIMULATE
changes rapidly) to cry only after secretions are removed to
prevent aspiration. The normal infant cry is loud
During thirty minutes of life: and lusty. Oral mucus may cause newborn, to
 rapid respiration choke, cough or gag during the first 12 to 18
 transient nostril flaring hours of life
 retraction and grunting
 heart rate may reach up to 180 beats APGAR Score
Then, the newborn may become:
 quiet It is taken at one (1) minute and five (5)
 relaxes minutes after birth. With DEPRESSED infants,
 falls asleep repeat scoring every five minutes as needed.
AFTER two to six hours, the newborn: The ONE MINUTE SCORE indicates the
 awakens necessity for resuscitation. The FIVE-MINUTE
 become even more responsive to stimuli SCORE is more reliable in predicting mortality
 skin color changes form pink to slightly and neurologic defects.
cyanotic
 has rapid heart rate. The MOST IMPORTANT area of assessment in
the APGAR score is the heart rate followed by
the respiratory rate, the muscle tone, reflex
Nursing Responsibilities in Newborn Care
ability and color in a decreasing order. A heart
1. Establishing respiration and
maintaining clear airway

Most Important Need: CLEAR AIRWAY (to

breathe effectively)
 wiping the face of the newborn.

Eighty (80) breathes per minute – respiratory

rate of newborn (in first few mins.)

Aspirator bulb – used if there are sections in

the airway; routing suctioning is no longer used.
 Compress bulb syringe before inserting
to prevent air from forcing mucus back
into the bronchi and alveoli.
 Suction mouth first, then, nose to
prevent the baby from having a sudden rate below 100 signifies an asphyxiated baby
inspiratory gasp which could result in and heart rate above 160 signifies distress.
aspiration of secretions an amniotic fluid
into the lungs. Scores may be interpreted as:
 Insert bulb syringe on one side of the
mouth. Inserting the bulb syringe at the  7-10 is a normal and signifies good
center will stimulate the gag reflex. adjustment

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 4 – 6 score indicates a moderately 4. Performing anthropometric

depressed infant, needs airway measurements
clearance This includes head, chest, abdomen,
 3 and below indicates a critical length and weight measurements.
assessment of a severely depressed
infant and is in need of resuscitation.
HEAD MEASUREMENT
Infant resuscitation will be discussed in
the succeeding semester.  To do this, measure the head
circumference at the level of the
2. Temperature (Heat) Regulation EYEBROWS to the most prominent
 is the second most important task a portion of the infant’s head with the use
newborn must achieve after birth. of the tape measure
 It is achieved by maintaining BALANCE  The head measurement ranges from
between heat loss and heat 33-35 centimeters at an AVERAGE of
production – by immediate and 35 centimeters. This INCREASES at
thorough drying and early skin-to-skin approximately one centimeter a
contact with the mother. DELAYING month.
initial bath until temperature has  The head circumference is usually
stabilized for at least six (6) hours is greater than chest circumference by 2
ideal. cm. This is about a quarter of the total
 Newborn temperature is about 37.2C at body length.
BIRTH and fluctuates due to immature  At BIRTH, head circumference may be
temperature regulating mechanism. equal or greater than chest
 Normal newborn axillary temperature circumference.
average is 37 C.
 Rectal temperature is 0.2 to 0.8C CHEST CIRCUMFERENCE
higher.
 The chest circumference is measured at
 Previous routine in newborn care uses
the level of the NIPPLE using a tape
rectal (mercurial) thermometer to measure. (See B in figure 29).
check for core temperature and to
 The normal chest circumference ranges
assess patency of the anus at the same
from 30 to 32 centimeters. A chest
time.
circumference less than 30
centimeters indicates PREMATURITY.
3. Caring for the cord
An enlarged heart may make the left
 AVOID wetting the cord.
side of the chest larger.
 Fold diaper below so it does not
cover the cord. ABDOMINAL CIRCUMFERENCE
 Leave cord exposed to air.
 Do not apply dressing or  The abdominal circumference is
abdominal binder over it. measured just BELOW THE
 Tub bathing is NOT allowed AMBILICUS. (See D in figure 29).
until cord FALLS off.  This circumference is approximately the
 This usually takes about five (5) same as chest circumference.
to seven (7) days postpartum.  The neonate’s abdomen usually
 Do not apply anything on the ENLARGES after feeding due to lax
cord except the prescribed abdominal muscles.
antiseptic solution which is 70%
LENGTH
alcohol.
 This is measured by taking the newborn
length from top of the head to heel
using a tape measure. (See C in figure

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29). Newborn length ranges from 45 to factors (II,VII, IX and X) and is

55 centimeters and an AVERAGE is 50 PRODUCED by microorganisms in the
centimeters. intestinal tract.
 FEMALE infants generally are ½ inch  This is given parenteral via
shorter than male infants. intramuscular (IM) route at the right
 The average length of BOYS is 50 vastus lateralis. DOSAGE of
centimeters and the GIRLS are 49 administration depends on the birth
centimeters. A length of less than 47 weight of the infant. It usually ranges
centimeters is a sign of from 0.5 to 1.0 mg IM one time
PREMATURITY. immediately AFTER BIRTH.
 Possible adverse reaction may include
WEIGHT LOCAL IRRITATION, such as pain and
swelling at the site of injection.
 The birth weight of a full-term
 Part of your responsibilities in drug
newborn infant ranges from 2500 to
administration is to assess for signs of
4000 grams and an AVERAGE
bleeding, such as black tarry stools,
3500 grams.
hematuria, decreased hemoglobin
 The average FEMALE infant birth
and hematocrit levels, and bleeding
weight is around 7 pounds while a
from any open wounds or base of the
MALE infant is around 7.5 pounds.
cord. The procedure for this skill is found
 BOYS are usually heavier than girls
on Unit 6 Pharmacology Concepts.
by 100 grams or ounces.
 Average birth weight of Filipino
infants is 3000 grams. Be familiar
with the policies of a particular
institution as hospitals have different
policies in recording weight.

5. Medication Administration
EYE CARE
 All infant are REQUIRED to be given the
Crede’s Prophylaxis.
 This is done to prevent Opthalmia
neonatorum or gonorrheal
conjunctivitis. This is defined as any
conjunctivitis with discharge occurring
during the FIRST TWO weeks of life. It
typically appears 2-5 days during the
first two weeks of life where both eyes
become swollen and red with purulent
discharge.
 Corneal damage with ulceration and
perforation develop if there is DELAY
in treatment. Erythromycin is the drug
of choice.

VITAMIN K ADMINISTRATION
 Vitamin K is used to prevent and treat
hemorrhagic diseases in newborn. It is
a necessary component for the
production of certain coagulation