GROUP 2 ABDULMALIK, ARROYO, CADER,

DAPANAS, LANGILAO, MEJIA, MADELO, OBINAY, SABAC,

TOMAMBILING
 PRIMI SET
REPARATION OF DELIVERY ROOM SET OF INSTRUMENTS MULTI PARA:

1. 1 Mayo scissors
-use to cut the umbilical cord

2. 1 Kelly clamp (curve) with latex band

- use to clamp the cord towards the baby
3. 1 Kelly clamp (straight)
- use to clamp the cord towards the placenta
4. Rubber suction bulb
- Suction oral and nasal secretions of baby
5. Several sterile gauze
6. Sterile towel
7. Pair of gloves
8. Mayo table
- where all instruments are placed
PRIMI PARA
1. 1 Mayo scissors
- use to cut the cord and to cut the perineum during episiotomy
2. 1 Kelly clamp (curve) with latex band
3. 1 Kelly clamp (straight)
4. Rubber suction bulb
5. Several sterile gauze
6. Sterile towel
7. Pair of gloves
8. Mayo table
ADDITIONAL:
1. 1 Metz
- use to cut suture during episiorraphy
2. 1 needle holder
- use to hold the needle
3. 1 tissue forceps
4. 1 suture (chromic 2-0)
5. Xylocaine 2% (5cc)
-use as anesthesia during episiorraphy
6. 1 syringe (5cc with g23 needle)
APGAR SCORING
•Apgar is a quick test performed on a 1 and 5
minutes after birth. The 1 minute score
determines how well the baby tolerated the
birthing process.
•The 5 minute score tells the health care
provider how well the baby is doing outside
the mother’s womb. In cases where there are
still concerns about the baby’s condition may
be given again.
 HOW APGAR TEST IS PERFORMED?
The Apgar test is done by a doctor, midwife, or nurse. The provider examines
the baby's:
1. Breathing effort
2. Heart rate
3. Muscle tone
4. Reflexes
5. Skin color
Each category is scored with 0, 1, or 2, depending on the observed
condition, the higher the score the better the baby’s doing.
Rare to have perfect perfect 10 because most babies have acrocyanosis.
APPEARANCE (SKIN COLOR)
• If the skin color is pale blue, the infant scores 0 for color.
• If the body is pink and the extremities are blue, the infant scores 1 for color.
• If the entire body is pink, the infant scores 2 for color.

PULSE (HEART RATE)

Heart rate is evaluated by stethoscope. This is the most important assessment:
• If there is no heartbeat, the infant scores 0 for heart rate.
• If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate.
• If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.
GRIMACE
Grimace response or reflex irritability is a term describing response to stimulation, such as a
mild pinch:
• If there is no reaction, the infant scores 0 for reflex irritability.
• If there is grimacing, the infant scores 1 for reflex irritability.
• If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex
irritability.

ACTIVITY (MUSCLE TONE)

• If muscles are loose and floppy, the infant scores 0 for muscle tone.
• If there is some muscle tone, the infant scores 1.
• If there is active motion, the infant scores 2 for muscle tone.
RESPIRATION (BREATHING ABILITY)
• If the infant is not breathing, the respiratory score is 0.
• If the respirations are slow or irregular, the infant scores 1 for
respiratory effort.
• If the infant cries well, the respiratory score is 2.
 Normal Results

• TheApgar score is based on a total score of 1 to 10. The

higher the score, the better the baby is doing after birth.
• A score of 7, 8, or 9 is normal and is a sign that the newborn is
in good health. A score of 10 is very unusual, since almost all
newborns lose 1 point for blue hands and feet, which is
normal for after birth.
 What Abnormal Results Mean

•Any score lower than 7 is a sign that the

baby needs medical attention. The lower
the score, the more help the baby needs
to adjust outside the mother's womb.
 Most of the time a low Apgar score is
caused by:
• Difficult birth
• C-section
• Fluid in the baby's airway
• A baby with a low Apgar score may need:
• Oxygen and clearing out the airway to help with breathing
• Physical stimulation to get the heart beating at a healthy
rate
 INTERVENTION BASED ON SCORE
•7 – 10 ROUTINE POST DELIVERY CARE

•4 – 6Some resuscitation (oxygen, suction,

stimulates the baby, rub back)

•0 – 3 full resuscitation
ANTHROPOMETRIC
MEASURES
The term Anthropometric refers to comparative measurements of the human body. The anthropometric
measurements commonly used as indices of growth and development for infants include length, weight,
and head and chest circumference.
• WEIGHT
 A newborn's weight is important because it helps to determine maturity as well as establish a
baseline against which all other weights can be compared.
 The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and
genetic factors that were present during conception and pregnancy.

 Weight in relation to the gestational age should be plotted on a standard neonatal graph,
(such as those available at the CDC website based on WHO growth standards)
Plotting weight this way helps identify newborns who are at risk because they are less than the
usual age. This information also separates those who are small for gestational age from preterm
infants.
 Plotting weight in conjunction with height and head circumference is also helpful because it
highlights disproportionate measurements
According to CDC 2010 Growth Chart data:
• The average birth weight ( 50th percentile) for a mature female newborn is 3.4 kg (7.5 lb.)
• For mature male newborn is 3.5 kg (7.7 lb.)
• The arbitrary lower limit of expected birth weight for all newborns is 2.5 kg ( 5.5 lb.)
• If a term newborn weights more than 4.7 kg the baby is said to be macrosomic.
• Birth weight exceeding 4.7 kg (10 lb) is unusual.

During the first few days after birth, a newborn loses 5% to 10% of birth weight (6 to 10
oz). This weight loss occurs because a newborn is no longer under the influence of salt-
and fluid- retaining maternal hormones.
After this initial loss of weight, a newborn has about 1 day of stable weight and then
begins to gain weight. All infants begin to gain about 2 lb. per month (6 to 8 oz per week)
for the first 6 months of life.
LENGTH
• A newborn length at birth in relation to weight is second important determinant used to confirm
that a newborn is healthy.  
 The average birth length (50th percentile) of mature female newborn is 49 cm (19.2in.)
 For mature males, average birth length is 50 cm (19.6 in.)
 The lower limit of expected birth length is at 46 cm (18 in) °
 Although rare, babies with length as great as 57.5 cm (24 in.) have been reported.

HEAD CIRCUMFERENCE
• Head circumference is measured with a tape measure drawn across the center of the forehead
and then around the most prominent proportion of the posterior head (the occiput).

 In a mature newborn, the head circumference is usually 34 to 35 cm (14.5 to 14in.)

 A mature newborn with a head circumference greater than 37 cm (14.8 in) or less than 33
cm (13.2 in.) should be carefully assessed foe neorologic involvement, although some well
newborns have these measurements.
CHEST CIRCUMFERENCE
• Chest circumference is measured at the level of the nipples. If a large
amount of breast tissue or edema of the breasts is present, this
measurement will not be accurate until the edema has subsided.

 The chest circumference in a term newborn is about 2 cm (0.75 to

1in.) less than head circumference.
 
 HEP B AND VIT K
INJECTIOND AT BIRTH
Hepa B shot at birth
What is hepatitis B and why do I need to protect my baby now?
• HepatitisB is a serious disease caused by the hepatitis B virus. The
virus can enter the bloodstream, attack the liver, and cause serious
damage. When babies get infected, the virus usually remains in the
body for a lifetime (this is called chronic hepatitis B).
• About 1 out of 4 infected babies will die of liver failure or liver cancer
as adults. Hepatitis B is a deadly disease – but it’s preventable with
vaccination.
The anterolateral thigh muscle is the recommended site of
administration for neonates (aged <1 month)
VITAMIN K
• All babies are born with low levels of vitamin K
• Vitamin K is essential for blood clotting
• Prevents Vitamin K Deficiency Bleeding (VKDB)
 Vitamin K at birth
• Vitamin K helps the blood to clot and prevents serious bleeding. In
newborns, vitamin K injections can prevent a now rare, but potentially
fatal, bleeding disorder called 'vitamin K deficiency bleeding' (VKDB),
also known as 'haemorrhagic disease of the newborn' (HDN).
• Babies can be given the injection in hospital after they're born.
Injections in public hospitals are covered by public funding and are free.
If you are giving birth in a private hospital, make sure you ask when you
are making your booking if there is a cost involved.
• Vitamin K is needed by humans for blood clotting. Older children and adults get most of
their vitamin K from bacteria in the gut, and some from their diet. Without enough vitamin
K, small cuts can go on bleeding for a very long time and big bruises can happen from small
injuries. Bleeding can also occur in other parts of the body, such as the brain (causing one
type of stroke).

• Babies have very little vitamin K in their bodies at birth. Vitamin K does not cross the placenta
to the developing baby, and the gut does not have any bacteria to make vitamin K before birth.
After birth, there is little vitamin K in breast milk and breastfed babies can be low in vitamin
K for several weeks until the normal gut bacteria start making it. Infant formula has added
vitamin K, but even formula-fed babies have very low levels of vitamin K for several days.

• With low levels of vitamin K, some babies can have very severe bleeding - sometimes into
the brain, causing significant brain damage. This bleeding is called haemorrhagic disease of
the newborn (HDN).
 Why is vitamin K important for my
baby?
• Vitamin K helps blood to clot. It is essential to prevent serious
bleeding. Babies do not get enough vitamin K from their
mothers during pregnancy, or when they are breast feeding.
Without vitamin K, they are at risk of getting a rare disorder
called 'vitamin K deficiency bleeding' (VKDB). VKDB can cause
bleeding into the brain, and may result in brain damage or even
death. VKDB can be prevented by giving new babies extra
vitamin K. By the age of about 6 months, they have built up
their own supply. 
 How is vitamin K given?
• The easiest and most reliable way to give babies vitamin K is
by injection. One injection just after birth will protect a baby
for many months. Since about 1980, most newborn babies in
Australia have been given a vitamin K injection. Vitamin K can
also be given by mouth. Several oral doses are essential to
give enough protection, because vitamin K is not absorbed as
well when it is given by mouth and the effect does not last as
long.
Things to remember
• Vitamin K is needed for blood clotting.

• Newborn babies are given vitamin K injections to prevent a

serious disease called haemorrhagic disease of the newborn
(HDN).

• Vitamin K can be given by mouth if preferred, but oral doses

aren’t as effective.
 VITAMIN K PROPHYLAXIS
(Phytomenadione)
• Single dose: 1mg

•Route: Intramuscular (IM)

• Site: Anterolateral thigh

NURSING CARE PLAN
 NURSING NURSING
ASSESSMENT DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION
S
SUBJECTIVE DATA: Within our care, the • Assess and report • Further signs and symptoms could At the end of our care, the
N/A Ineffective breathing newborn will have an further sings of lead to complications which may newborn achieved effective
pattern r/t aspiration effective breathing pattern respiratory distress result to chronic hypoxia and breathing pattern as
of meconium during as evidenced by; acidosis, increasing the risk of CNS evidence by:
OBJECTIVE DATA: • This helps remove accumulated
Presence of thick birth • Absence of respiratory • Clear the newborns fluid, respiratory effort and helps RR= 58 cpm fast and shallow
(dark) meconium distress such as flaring airway by suctioning prevent further aspiration
of the ala nasi, the mouth using a bulb • Initially, a strong cry increases Flaring of the ala nasi not
during suctioning (in cyanosis, dyspnea and Syringe alveolar pressure of oxygen and observed anymore
nose and mouth) abnormal breath sound produces the necessary chemical
• RR should be within • Note the pitch and changes to convert fetal to neonatal Nose and mouth wre free of
APGAR <7 at 1 and 5 normal range(30 – intensity of the cry of circulation, so that the heart rate mucus secretions
minutes and thick 60cpm) the newborn increase to 175-180 uterus
meconium • Determine any abnormal chnages, Good cry was initiated
raise in temperature may indicate
Within ourcare, the new • Monitor vital signs infection At the end of our care the
Vital signs: born will; • Allows recognition of abnormal newborn;
Temp. = 36.8 C vital signs within normal • washing hands before findings and allow prompt Vital signs remained within
HR = 125bpm range and after providing care intervention if complication occurs normal range
RR = 63cpm T = 34 C • Hand washing is the single best way Temp.= 37C
PR = 120-160 bpm • wearing gloves to to avoid spreading pathogen HR= 139bpm
RR = 30-60 cpm maintain asepsis when • Gloves reduce the possibility of RR= 58cpm
•manifest no signs of providing direct care transmitting disease
infections like fever & chills and when in contact • Indicates increased production of Newborn is free of signs and
leukocytes by bone marrow, usually symptoms of infection such
with blood or body in response to the presence of as fever and fatigue
secretions bacterial pathogens
• Colostrum and breast milk contain Mother had fully understood
high amount of immunoglobulin A, the importance of
which provides passive immunity and breastfeeding in relation to
helps reduce infection strengthening the immunity

 

ASSESSMENT
SUBJECTIVE DATA:
NA
 
 
OBJECTIVE DATA:
 
 Loss more than 10% of
birth weight compared
to the weight obtained
within 3-4 days of birth.
 
 Apathetic feeding at the
breast, falling asleep at
the breast, difficult to
wake for feeds.
 
 Dry skin and mucous
membranes with poor skin
turgor.
NURSING NURSING
DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
1. Ensure minimum 8 feeds in 1. 10 feedings per 24 hours, as opposed After 2-3 hours of nursing
The infant will 24 hours to 7 feedings to per 24 hours) lead to intervention in effective
Risk for greater milk intake and weight gain positioning and attachment.
dehydration exhibit no signs of 2. Educate and ensure the in newborns (De Carvalho et al Full breastfeeding, effective
related to dehydration and mother for effective positioning 1983). suckling pattern, observe for
will regain and attachment. 2. Effective attachment is the key milk transfer was achieved.
abnormal loss appropriate
to successful breastfeeding as it
of weight. birthweight by 10- 3. Assess for further signs enables baby to get enough milk and After 24 hours of nursing
14 days. of dehydration such as poor skin helps to protect mother's milk intervention in ensuring feed,
turgor, depressed fontanelles, supply. the baby settles well after
sunken eyes, decreased urine 3. Fluid-volume deficit may cause liquid each feed and is generally
output, weight loss. stools and increased insensible water contented. Good skin colour
loss, which increases risk and perfusion, bright eyes
4. Monitor daily weight. of dehydration. were achieved.
  4.  Increased fluid excretion in the  
5. Assess quantity and stools and a decrease in fluid intake Evaluation of bowel motions:
characteristics of each stool and may put the newborn at risk for Changing stool by day 4.
urine. another weight loss. Daily weights Breast milk bowel motion
  can provide accurate determination regularly by day 7.
6. Provide comfortable fluid intake and insensible water loss
environment by covering the that is caused by dehydration. Evaluation of the loss weight:
baby with light comfortable 5. 5. Loose stools indicate fluid loss Patient gains 140 - 170 grams
sheets which may lead to a fluid volume per week. And regains
deficit. With an increase in stools per birthweight by 10-14 days.
day, dehydration is present.
6. 6. Drop situations where the baby
can experience overheating to
prevent further fluid loss.
 NURSING NURSING
ASSESSMENT DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE DATA INDEPENDENT
After 48 hours of nursing • Encourage and assist
N/A Fatigue related to client to the bedside • To help relieve the After 48 hours of
reduced metabolism by intervention, the patient chair 3 times a day. pain without causing
OBJECTIVE DATA will be able: stress. nursing intervention,
liver as evidence by • Encourage and assist
a. INSPECTION patient has diagnosis of   the patient with the patient was:
Hepatitis B. performing bedside • To help relieve the
- Facial Grimace with pain
pain scale  To regulate his exercises.
caloric intake to a • Assess the client’s
- Behavior of nausea,
recommended daily energy level before • To record progress • Back to regulate his
lethargy, stomach or persistence of caloric intake.
caloric intake. and after each
pain, vomiting nursing shift. the condition.
- Inspect anorexia  • To experience a • Relieved from
decrease in COLLABORATIVE nausea/vomiting
b. PALPATION nausea/vomiting
- Palpate at right • Collaborate with • To regulate back the
within 24 hours. nutritionist about
upper quadrant of caloric intake and
abdomen (tender to patient’s current recommended caloric
touch) caloric intake. intake on day 1 of
• Administer Zofran 4 patient’s
c. LAB/DIAGNOSTIC TESTS mg IV every 8 hours hospitalization.
- Metabolic testing as ordered (provide
(caloric intake is exact dose; route) • To reduce
1000 calories less persistence of
than his nausea and
recommended daily vomiting
value)
 
 NURSING NURSING
ASSESSMENT DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE DATA: After 48 hours of nursing INDEPENDENT
N/A Risk for vitamin K deficiency intervention, the patient
bleeding (VKDB) related to • Assess for signs and • G.I tract is the most After 48 hours of nursing
will: common source of
OBJECTIVE DATA: inadequate prenatal symptoms of GI bleeding. intervention, the patient
a. INSPECTION storage and deficiency of  remain free from signs Check for secretions. bleeding due to its will:
  vitamin K in breast milk. of bleeding Observe color and mucosal fragility.
- Blood in newborn’s consistency of stool and  Have a stable
The patient will have a vomitus. • Clotting factors may be hemoglobin and
bowel movements. stable hemoglobin and altered and cause easy hematocrit status
- Blood in newborn’s • Observe for presence of
hematocrit during the echymoses, bleeding in bruising and bleeding.
urine. hospital stay Have no signs of easy
- Oozing of blood from one or more sites • An increase in pulse rate bruising or bleeding
around newborn’s • Monitor vital signs. BP and decrease in blood
and pulse.
umbilical cord or pressure may indicate
circumcision site. loss of circulating blood
- Bruising volume.
- Unusual, excessive • Administer Vitamin k to
sleepiness or • To protect against
new born within the first bleeding that could occur
fussiness. 24 hours post birth.
because of low levels of
a. LAB/DIAGNOSTIC this essential vitamin
TESTS
prothrombin time (PT),
activated partial
thromboplastin time (aPTT), COLLABORATIVE
• Collaborate with • Supplements or a change
fibrinogen levels and a of diet may increase milk
platelet count nutritionist for mother`s
diet vitamin k levels in
breastfeeding.