Instruments in the Delivery Room (Their Purposes) and ENS:
Rationales of Each Step (Prepared by Prince Kiefer D. Cabillar, SN) [Sean]
DISCLAIMER: This material is a collaboration of various notes from C.I.’s
(Ms. Donna S. Carcueva, MN, RN, USRN, LPT, RM); and are based on the
author (Prince [Sean] Kiefer’s) Knowledge, and with the help of a registered
nurse (Rachel D. Cabillar, RN), and
Delivery Room (DR) Instruments
• Delivery room instruments are medical tools used during childbirth
to help safely deliver babies. Examples include forceps and vacuum
extractors for assisting in delivery, fetal monitoring equipment to
track the baby's well-being, episiotomy scissors for making incisions
if needed, umbilical cord clamps and scissors for cutting the cord,
suction devices for clearing the baby's airways, and sterile gloves
and gowns for maintaining a clean environment. Other tools like
perineal massage instruments and amniotomy hooks may also be
used.
The Instruments
10cc Syringe
• This syringe is used primarily for the aspiration and the use of the
drug “lidocaine”.
• Lidocaine is occasionally administered into the spinal fluid or the
area surrounding the spinal cord, known as an 'epidural,' to alleviate
pain during labor or surgical delivery. Pain-relieving drugs can assist
in managing labor and delivery discomfort. These medications
utilized for pain relief during childbirth do not result in any lasting
impacts on the baby, nor do they influence a child's subsequent
development.
• Given: At episiotomy site; at 5mL
Allis Forceps
• The Allis tissue forceps, equipped with sharp teeth like feature, are
surgical tools utilized for gripping or holding dense tissue.
Cord Clamp
• After birth, the umbilical cord is typically clamped and cut near the
baby's navel to prevent bleeding from the cord's blood vessels.
Cutting the Cord:
o First, check for pulsations in the umbilical cord. Once
pulsations have stopped, use a plastic clamp to secure the
cord approximately 2 cm from the base.
o Then, with your dominant hand, grasp the cord clamp,
and with your non-dominant hand, gently squeeze the
cord away from the base.
o Next, using your dominant hand, apply Kelly forceps
about 5 cm from the base of the cord.
o Proceed to cut the cord close to the cord clamp, between
the clamp and the Kelly forceps.
o Finally, advise the mother to watch for feeding cues,
provide examples of these cues, and instruct her on
proper positioning and attachment for feeding.
Curved Kelly Forceps
• Same as the purpose served by the straight Kelly’s. They are
indispensable in any tactical medical kit. They serve multiple
purposes, including clamping large blood vessels, handling dense
tissue, and dissecting soft tissue.
Foley Catheter
• A Foley catheter, which is a small plastic tube, might be inserted into
a pregnant PT’s bladder to facilitate urine drainage, as PT may be
unable to move to the bathroom independently.
Kidney Basin
• A Kidney Basin is a shallow receptacle with a kidney-shaped bottom
and inclined walls employed in medical and surgical settings to
collect used dressings and other medical refuse.
• Additionally, the placenta is often positioned on the kidney basin for
examination to ensure it is whole and undamaged. (Please consult
Chapter 15 of your Maternal 1 and Maternal 2, Chapters 20-21,
regarding the placenta and the potential risks associated with
retained fragments.)
Needle Holder
• A needle holder, alternatively known as a needle driver, crafted from
stainless steel, is utilized to grasp a suturing needle throughout
surgical interventions.
• It finds application in the following surgical procedures:
o Episiotomy
o Perineorrhaphy (and etc.)
Ovum Forceps
• At Surgical Holdings, Ovum Forceps are offered to grasp,
manipulate, and extract tissue from the uterus, including the ovum
and placenta.
Scissors
• Scissors serve their primary function of cutting, with multiple pairs
typically available in the Delivery Room. One pair is designated for
cutting the baby's umbilical cord, while another may be used for
procedures such as episiotomies.
Sharp Uterine Curette
• Sharp Curettes are designed to biopsy or excise tough tissue from
the uterine lining. Featuring a sharp loop tip, they come in rigid or
malleable forms to suit various cases. In D&C procedures, which
involve removing tissue from the uterus, Sharp Curettes are
commonly employed for diagnosing unexplained bleeding or
managing incomplete abortions. However, their use may carry risks
such as uterine wall injury and increased susceptibility to conditions
like placenta previa.
Straight Kelly Forceps
• Same as the purpose served by the curved Kelly’s. They are
indispensable in any tactical medical kit. They serve multiple
purposes, including clamping large blood vessels, handling dense
tissue, and dissecting soft tissue.
Suture
• (Consult Chapter 15 of your textbook for information on various
sutures for vaginal tears in pregnant clients.) Tears commonly occur
after delivery, necessitating suturing, such as in cases of third-degree
episiotomy tears.
Tissue/Thumb Forceps (with teeth)
• Thumb Tissue Forceps allow for precise tissue manipulation and are
particularly suited for grasping firm tissues like fascia or for closing
abdominal walls.
Tissue/Thumb Forceps (without teeth)
• Thumb/Tissue Forceps with teeth are employed to secure tissues
during suturing, gently reposition tissues during exploratory surgery,
and facilitate dressing or draping adjustments without direct manual
contact.
Uterine Sound
• Uterine Sounds aid in gauging the depth and orientation of the
uterine cavity, aiding in procedures like IUD placement. Inserted
through the cervix, they help determine uterine length, canal
direction, and dilation status.
Vaginal Speculum
• Vaginal Speculums widen the vaginal walls to enable examination
of the vagina and cervix, commonly used in gynecological
examinations, pap smears, and D&C procedures.
ENS (Essential Newborn Care)
PREPARING FOR DELIVERY
“Unang Yakap”
• Skin-To-Skin Contact
o Improves oxygen saturation.
o Reduces cortisol (stress) levels, particularly following painful
procedures.
o Encourages pre-feeding behavior.
o Assists with growth. may reduce hospital stay.
TIME BAND: At perineal bulging PREPARE for the Deliverry
• Check the temperature of the delivery room
o 25-28°Celsius
o Free of Air Drafts
• Notify appropriate staffs
• Arrange needed supplies in linear fashion
• Check resuscitation equipment
• Wash hands with clean water and soap
• Double glove just before delivery
FOUR CORE steps of Essential Newborn Care
• Immediate and thorough drying
• Early skin-to-skin contact
• Properly timed cord clamping
• Non-Seperation of the newborn and mother for early initiation of
breastfeeding
1|Page
 Instruments in the Delivery Room (Their Purposes) and ENS:
Rationales of Each Step (Prepared by Prince Kiefer D. Cabillar, SN) [Sean]
TIME BAND: Within 1ST 30 SECS Immediate thorough drying • Early-Skin-to-Skin contact
• Properly Timed Cord Clamping
• Call out the time of birth • Non-Separation of Newborn from Mother for Early Breastfeeding
• Dry the newborn thoroughly for at least 30 seconds
o Wipe the eyes, face, head, front and back, arms and legs
• Remove the wet cloth
• Do a quick check of breathing while drying ENC Time-Bound INTERVENTIONS
• Notes:
o During the 1st secs: PLANNING INTERVENTION
▪ DO NOT ventilate unless the baby is Within 30 seconds - Put on double gloves
floppy/limp and noth breathing Objective: - Dry thoroughly
▪ DO NOT SUCTION unless the mouth/nose - To stimulate breathing, - Remove wet cloth
are bocked with secretions o other material provide warmth - Quick check of NB’s
breathing
TIME BAND 0-3 mins: Immediate, thorough drying
- Suction ONY IF
• DO NOT wipe of Vernis NEEDED
• DO NOT bathe the newborn AFTER thorough drying - Put prone on
• DO NOT do footprinting Objective: chest/abdomen skin to
• NO slapping - To provide warmth, skin
• NO Hanging upside-down bonding, prevent - Cover with nlanket,
• NO squeezing of the chest infection, hypoglycemia bonnet

Time Band: After 30 secs of drying early skin-to-skin contact - Place Identification on
ankle
• If newborn is breathing or crying: - DO NOT remove vernix
o Position the newborn prone on the mother’s abdomen or Up to 3 minutes Post-delivery - Remove 1st set of gloves
chest Objective: - Clamp and cut cord
o Cover the newborn’s back with a dry blanket - To reduce anemia in safter cord pulsations
o Cover the newborn’s head with a bonnet term & preterm; IVH & stop (1-3 mins)
Transfusions in preterm
Notes: - Do not milk cord
- Give oxytocin 10 mg IM
• AVOID any manipulation, e.g. routine suctioning that may cause to mother
trauma or infection WITHIN 90 minutes of age - Uninterrupted skin to
• PLACE identification band on ankle (not wrist) Objective: skin contact
• SKIN-TO-SKIN CONTACT is doable even for cesarean section - To facilitate initiation of - Observe NB for feeding
newborns breastfeeding through cues
sustained contact. - Counsel on positioning
TIME BAND: 1-3 Mins properly-timed cord clamping & attachment
- DO eye care, injections
• Remove the first set of gloves etc. after 1st breastfeed
• After the umbilical pulsations have stopped, clam the cord using a
sterile plastic clamp or tie at 2cm from the umbilical base
• Clamp again at 5 cm from the base (Kelly forceps or another cord THE STEPS:
clamp)
• Cut the cord close to the plastic clamp 1. Checked temperature in DR area to be 25-28 °Celsius; eliminated air
draft.
NOTES:
Rationale: After residing in a consistently stable and thermoneutral
• DO NOT mik the cord towards the baby environment within the uterus throughout pregnancy, the newborn is exposed
• After the 1st clamp-you may strip the cord of blood before applying to cooler surroundings upon birth, leading to potential heat loss and
the 2nd clamp hypothermia in the initial moments of life.
• Cut the cord CLOSE to the plastic clamp so that there is no need for
a 2nd “trim” 2. Removed all jewelry then washed hands thoroughly
• DO NOT apply any substance onto the cord
Rationale: Wearing jewelry can transfer bacteria accumulated from daily wear
TIME BAND: Within 90 mins non-separation of newborn from mother for to the surgical site, heightening the risk of infection.
early breastfeeding
3. Prepared newborn resuscitation area and checked that resuscitation
equipment are clean and functional
• Leave the newborn in skin-to-skin contact
• Observe for feeding cues, including tonguing, licking, rooting Rationale: Regular equipment checks are conducted to ensure functionality
• Point these out to the mother and encourage her to nudge the and readiness, particularly in anticipation of potential emergencies requiring
newborn towards the breast CPR, thus optimizing efficiency and accessibility.
Counsel on Positioning: 4. Prepared materials for routine newborn procedures
• Newborn’s neck is not flexed nor twisted Rationale: Efforts to enhance efficiency and speed of work are also
• Newborn is facing the breast undertaken to safeguard the baby's well-being within their surrounding
• Newborn’s body is close to mother’s body environment.
• Newborn’s whole body is supported

Counsel on attachment and suckling:

CROWNING
• Mouth wide open
• Lower lip turned outwards 5. Don 2 sterile gloves.
• Baby’s chin touching breast
Rationale: Utilizing two surgical gloves notably diminishes the risk of
• Suckling is sow, deep with some pauses
infection among operating room staff. The additional glove serves as a barrier
NOTES: against bloodborne pathogens in case the outer glove is punctured. Double-
gloving, at a relatively minimal expense, offers a heightened level of
• MINIMIZE handling by health workers safeguarding, particularly against risks like potential transmission of Hepatitis
• DO NOT give sugar water, formula, or other pre-lacteals B from an infected pregnant mother.
• DO NOT give bottles or pacifiers
• DO NOT throw away colostrum
• Weighing, bathing, eye care, examinations, injections (HEP B, FIRST 30 SECONDS AFTER DELIVERY
BCG) should be done after the first full breastfeed is completed
• Postpone washing until at least 6 hours 6. Perform thorough drying and continued for 30 seconds, starting from
the face and head, going down to the trunk and extremities while
performing a quick check for breathing.
THE EVIDENCE IS SOLID: Rationale: A newborn infant, damp from the amniotic fluid, is susceptible to
chilling. Prompt drying of the baby and application of warm blankets and heat
THE FOLLOWING Newborn Care Practices will SAVE LIVES: lamps (in the warmer) can mitigate heat loss.
• Immediate and thorough drying
2|Page
 Instruments in the Delivery Room (Their Purposes) and ENS:
Rationales of Each Step (Prepared by Prince Kiefer D. Cabillar, SN) [Sean]
Failure to promptly address labored breathing in a newborn poses a risk of
severe complications. Rapid or slow breathing patterns may indicate an
infection or another underlying condition.
1 - 3 MINUTES
7. Removed the wet cloth and replace with clean dry linen
Rationale: A newborn infant, damp from the amniotic fluid, is susceptible to
chilling. Prompt drying of the baby and application of warm blankets and heat
lamps (in the warmer) can mitigate heat loss.
8. Placed baby in skin-to-skin contact on the mother’s abdomen or chest.
Rationale: Skin-to-skin contact offers several advantages for infants in the
neonatal unit, including improved oxygen saturation, reduced cortisol (stress)
levels, particularly after painful procedures, and promotion of pre-feeding
behaviors. (THIS IS STILL DOABLE even if Cesarean Section)
9. Covered baby’s head with a bonnet.
Rationale: Bonnets play a crucial role in keeping newborns warm, especially
as they may struggle to regulate their body temperature initially, while also
providing protection for the baby's head.
10. Remove 1st gloves
Rationale: Preparing to cut the cord involves ensuring that no fluids from the
mother come into contact with the newborn to minimize the risk of infections
and diseases.
11. Palpated umbilical cord to check for pulsations.
Rationale: This preparation includes monitoring for when pulsations in the
umbilical cord cease to anticipate the optimal timing for cord cutting.
12. Once palpation has ceased, clamped cord using the plastic clamp 2 cm
from the base.
Rationale: Immediate umbilical cord clamping, typically performed alongside
other active management strategies during the third stage of labor, aims to
reduce postpartum hemorrhage by halting the flow of blood between the baby
and the placenta. Once clamped, the placenta detaches from the uterus and is
delivered, as it no longer serves a significant function for the newborn.
13. With dominant hand, hold cord clamp and with non-dominant hand,
milk cord away from base.
Rationale: Milking the umbilical cord has been observed to enhance various
health indicators in hypoxic neonates, including weight parameters, blood
volume, hematocrit, hemoglobin, iron levels, red blood cell count, blood
pressure, right ventricular output, left ventricular functions, cerebral
oxygenation, urine output regulation, cognitive abilities, antioxidant levels,
and overall improved outcomes in infant resuscitation, ultimately contributing
to lower Infant Mortality Rates.
DO NOT MILK CORD TOWARDS THE BABY.
Milking is sometimes avoided as it increases RISK FOR SEVER
INTRAVENTRICULLAR HEMORRHAGE (STRONG AND MODERATE)
14. Using dominant hand, clamp Kelly forceps 5 cm from base
Rationale: Clamping the cord serves to halt the blood flow from the three
vessels that run from the placenta through the umbilical cord.
15. Cut cord close to cord clamp, in between cord clamp and Kelly
forceps
Rationale: Immediate umbilical cord clamping, typically performed alongside
other active management strategies during the third stage of labor, aims to
reduce postpartum hemorrhage by halting the flow of blood between the baby
and the placenta. Once clamped, the placenta detaches from the uterus and is
delivered, as it no longer serves a significant function for the newborn.
CUTTING close to clamp is good to avoid ‘2nd Trimming’
DO NOT APPLY ANYTHING on the Cord, to avoid adverse reactions or
infections.
16. Advised mother to observe for feeding cues and cited examples of
feeding cues, instructed her on positioning and attachment.
Rationale: BASIC MATERNAL PATIENT EDUCATION. Providing
education to the client is crucial, particularly when the patient lacks sufficient
knowledge about postpartum care. This is essential to ensure that the mother
understands when to feed her baby, including recognizing hunger cues such as
different types of cries that newborns exhibit to express their needs.
Additionally, educating the client on proper positioning during feeding can
help prevent aspiration and reduce the risk of Sudden Infant Death Syndrome
(SIDS).
17. Apply ID Badge
Rationale: This is so we could identify if this is the client’s newborn and to
avoid situations such as where the newborn is taken from the mother, and to
avoid mixing with other’s infants when placed in areas such as NICUs.
AFTER 60 - 90 MINUTES SKIN-SKIN CONTACT
18. Weigh baby fast and accurately
Rationale: It is imperative to swiftly assess and gather essential data,
including a newborn's weight, to ensure the baby's well-being and maintain
warmth, especially considering the potentially hazardous environment. (Refer
to Chapter 18 for additional information on heat loss in newborns.)
19. Check rectal temperature
Rationale: This method provides accurate and rapid measurement of the
baby's internal temperature, while also checking for imperforated anus and the
passing of meconium. (See Chapter 9 for details on Meconium.)
20. Obtain Head Circumference, Chest Circumference, Abdominal
Circumference and Mid-Arm circumference
Rationale: Measuring the circumference of various body parts enables
detection of abnormalities such as microcephaly in head size, barrel chest in
chest circumference, or abdominal distention, establishing a baseline for the
baby's health record.
21. Apply newborn diaper
Rationale: Diapers are essential for keeping the baby clean, dry, and
comfortable.
22. Apply newborn clothes (do not close front for skin-to-skin contact)
Rationale: Leaving the front of the newborn's clothing open allows for skin-
to-skin contact with the mother, promoting warmth.
23. Apply mittens and booties
Rationale: Mittens prevent scratching of the face and helps maintain warmth
in their hands.
24. Apply eye ointment from inner to outer canthus starting from farther
eye
Rationale: Application of antibiotic eye drops or ointment post-birth
safeguards against bacterial eye infections, commonly known as pink eye,
which can occur during delivery.
25. Apply injections: BCG (Right deltoid ID), Hep B (Right Vastus
lateralis IM), Vit K (Left Vastus lateralis IM)
Rationale for BCG: The BCG (Bacillus Calmette-Guérin) vaccine guards
against tuberculosis (TB) infection. (Aspirate 0.05)
Rationale for Hep B: The Hepatitis B (Hep-B) injection typically confers
lasting immunity. Administration of the Hep-B series in infancy usually
provides protection against hepatitis B infection well into adulthood. (Aspirate
0.5)
Rationale for Vit. K: Hemorrhagic disease, a bleeding disorder occurring in
newborns, is attributed to low levels of vitamin K at birth. Vitamin K is
essential for blood clot formation and preventing bleeding. Since infants are
born with minimal vitamin K reserves, they are susceptible to a severe
bleeding condition known as vitamin K deficiency bleeding. (Aspirate 1mL)
THESE are done after first full breastfeed is completed
POSTPOSE WASHING until at least 6 Hours.
26. Position of comfort
Rationale: This practice aims to provide comfort to the mother, facilitating her
recovery and rest during the postpartum period. The recommended position
for her is the left lateral position, as detailed in your Med-Term 2 Notes or
PowerPoints on Client Positioning.
27. Observe for unusuality
Rationale: This procedure benefits both the mother and the fetus, involving
the monitoring of vital signs to detect any abnormalities. A drop in blood
pressure, for instance, may indicate bleeding in the mother. For the newborn,
the APGAR scoring system is utilized, with scores of 9 and 10 considered
optimal. Refer to the Health Assessment Notes for guidance on assessing
newborns and APGAR scoring, as well as Maternal 1; Chapter 18.
28. Document
Rationale: Documentation serves multiple purposes, enabling nursing staff to
access patient information and aiding in future diagnosis (prognosis) of any
abnormalities noted. This comprehensive record also guides potential
interventions in case the mother or infant encounters difficulties, ensuring
appropriate referral to a physician if necessary.
PATIENT EDUCATION
A good latch for breastfeeding should:
• Not cause you pain
• Allow your baby to get enough milk to support healthy weight gain
3|Page
 Instruments in the Delivery Room (Their Purposes) and ENS:
Rationales of Each Step (Prepared by Prince Kiefer D. Cabillar, SN) [Sean]
• Involve your child latching on to your entire nipple plus some of • Earlier discharge from the hospital after birth
the surrounding areola
• Be comfortable and pain-free
• Allow your baby's chest and stomach to rest against your body, so
that baby's head is straight, not turned to the side Improved Neurodevelopmental Outcomes
• Involve your baby's chin touching your breast
• Involve your baby's mouth opening wide around your breast, not • Breast milk contains long-chain polyunsaturated fatty acids that
just the nipple help the infant’s brain develop. These are normally provided by the
• Involve your baby's lips turning out mother in late pregnancy, therefore preterm infants miss this.

BREAST ANATOMY: Nipple Variations LONG-TERM BENEFITS

EVERTED (Best) • Functionally competent immune system

• Protective against autoimmune disorders; Type 1 diabetes and IBD
• Nipple pokes out so baby can latch on • Decreased risk of childhood leukemia
• Optimal growth and development
MAY ENCOUNTER PROBLEMS:
• Normal development of mouth and jaw
FLAT • Decreased prevalence of being overweight/obese, Type 2 diabetes
• Decreased risk of dental malocclusion and cavities
• Nipple is flush with the areola • Delayed onset of ovulation
• Difficult for baby to latch • Decreased risk of breast, ovarian, and uterine cancers
• May need nipple shield • Decreased risk of central obesity and metabolic syndrome
• Financial Costs
INVERTED • Decreased medical care costs
• Nipple is turned inward
• Difficult for baby to latch
• May need nipple shield as well CONTRAINDICATIONS for breastfeeding

BEST ALTERNATIVES TO BREASTFEEDING: Mothers with:

Donor Milk • HIV

• Human T-cell lymphotropic virus Type I/II
• contains many of the protective factors (such as immunoglobulins) • Herpes lesions on breasts
which help protect premature babies from infection and are not • Substance misuse
present in formula which is prepared from cow’s milk.
• Type 1 galactosemia infants
Expressed Milk • Tuberculosis and Varicella

• taking milk from the breasts without baby needing to breastfeed

directly (via pumping)

Other Facts about Breastfeeding “The lesson I've learned the most often in life is that you're always going to
know more in the future than you know now.”
• Effective breastfeeding is noted by weight gain and more than 6
wet diapers and 2 stools a day by day 4.
• Breast milk should never be microwaved. ― Taylor Swift
• The bottle should be held at an angle so that the nipple stays full
• Bottle-fed babies should feed every 3-4 hours.

BREASTFEEDING POSITIONS:

• Cross-Cradle
• Cradle
• Clutch/Football
• Side-Lying

BENEFITS OF BREASTFEEDING:

COLUSTRUM

• Defends against infection

• HIGH in protein
• Offers immunity

MATURE MILK (3rd Stage in Maturing Breastmilk)

• Digests easily
• Provides antibodies that protect against common illnesses and
infections
• Decreases RISK of Sudden Infant Death Syndrome
• Assists with dental and facial development
• Increases mental development
• Reduces the risk of developing allergies

BREASTMILK reduced morbidity and mortality from infections on the

following:

• Respiratory
• Gastrointestinal
• Urinary
• Ear
• Sepsis

Benefits for Premature NB’s

• Decreased necrotizing enterocolitis

• Protection against chronic lung disease
• Decreased retinopathy of prematurity
• Decreased infection rates
• Better able to tolerate feedings
4|Page