PRESENTED BY:

ROSELLE JOY C. BALAQUIT, RN

What is labor?
• Labor is the series of events by which uterine
contractions and abdominal pressure expel a
fetus and placenta from a woman’s body.
• Regular contractions cause progressive
dilatation (enlargement or widening of the
cervical canal) and create sufficient muscular
force to allow a baby to be pushed from the
birth canal (or vagina).
• It is a time of change, both an ending and a
beginning, for a woman, a fetus, and her family.
What is labor?
• Labor and birth require a woman to use all
the psychological and physical coping
methods she has available.
• Regardless of the amount of childbirth
preparation or the number of times she has
been through the experience before, family-
focused nursing care is needed to support the
family as they mark the beginning of a new
family structure.
NURSING CARE PLANNING BASED ON 2020 NATIONAL
HEALTH GOALS
Because labor and birth are potentially high rish times for both a
fetus and a mother, a number of 2020 National Health Goals speak
directly to these:
 Reduce the rate of maternal deaths to no more than 11.4 out of
100,000 livebirths from a baseline of 12.7 out of 100,000 live
births.
 Reduce maternal illness due to pregnancy complications
developed during hospitalized labor and delivery from a baseline
of 31.1% to a target of 28.0%.
 Reduce caesarean births among low-risk (full-term, singleton,
vertex presentation) women from a baseline of 26.5% to a target
of 23.9%
 Reduce the rate of fetal deaths at 20 or more weeks gestation to
no more than 5.6 out of 1,000 live births from a baseline of 6.2
out of 1,000.
NURSING CARE PLANNING BASED ON 2020 NATIONAL
HEALTH GOALS (con’t)
 Reduce the rate of fetal and infant deaths during the perinatal
period (28weeks gestation to 7 days after birth) to o more than 5.9
our of 1,000 live births from a baseline of 6.6 out of 1,000 live
births (U.S. Department of Health and Human Services, 2010)

Nurses can help the nation achieve these goals by closely monitoring
women during labor and birth and by teaching women as much as
possible about labor so they are able to use as little analgesia and
anesthesia as possible. The less anesthesia and analgesia used, the fewer
complications that occur, resulting in reduced fetal and maternal death.
Theories of Why Labor Begins
• Labor normally begins when a fetus is
sufficiently mature to cope with extrauterine
life yet not too large to cause mechanical
difficulty with birth. (37 to 42 weeks)
• Several theories including a combination of
factors originating from both the woman and
fetus have been proposed to explain why
progesterone withdrawal begins:
Theories of Why Labor Begins
1. Uterine muscle stretching, which results in rele ase of
prostaglandins
2. Pressure on the cervix, which stimulates the release of
oxytocin from the posterior pituitary
3. Oxytocin stimulation, which works together with
prostaglandins to initiate contractions
4. Change in the ratio of estrogen to progesterone (increasing
estrogen in relation to progesterone, which is interpreted as
progesterone withdrawal)
5. Placental age, which triggers contractions at a set point
6. Rising fetal cortisol levels, which reduces progesterone
formation and increases prostaglandin formation
7. Fetal membrane production of prostaglandin, which
stimulates contractions
The Components of Labor
A successful labor depends on four integrated concepts:
1. The passage (a woman’s pelvis ) is of adequate size and
contour.
2. The passenger (the fetus) is of appropriate size and in
an advantageous position and presentation.
3. The powers of labor (uterine factors) are adequate.
(The powers of labor are strongly influenced by the
woman’s position during labor.)
4. The psyche, woman’s psychological state which may
either encourage or inhibit labor. This can be based on
her past life experiences as well as her present
psychological state.
PASSAGE
• refers to the route a fetus must travel from the uterus
through the cervix and vagina to the external
perineum
• the cervix and vagina are contained inside the pelvis,
a fetus must also pass through the bony pelvic ring
• Two pelvic measurements are important to
determine the adequacy of the pelvic size: the
diagonal conjugate (the anteroposterior diameter of
the inlet) and the transverse diameter of the outlet.
• At the pelvic inlet, the anteroposterior diameter is
the narrowest diameter; at the outlet, the transverse
diameter is the narrowest
PASSENGER
• The passenger is the fetus.
• Head- widest diameter
• Whether a fetal skull can pass depends on
both its structure (bones, fontanelles, and
suture lines) and its alignment with the
pelvis.
Structure of the Fetal Skull
• Cranium- the uppermost portion of the skull
- composed of eight bones
-four superior bones—the frontal
(actually two fused bones), the two parietal, and the
occipital
-other four bones of the skull (sphenoid,
ethmoid, and two temporal bones) lie at the base of
the cranium so are of little significance in childbirth
because they are never presenting parts.
- chin, mentum, can be a presenting part.
• Suture lines
sagittal- joins the two parietal bones
coronal- the line of juncture of the
frontal bones and the two parietal
bones
lambdoid- juncture of the occipital
bone and the two parietal bones
***allow the cranial bones to move and
overlap, molding or diminishing the size of
the skull
• Fontanelles- membrane-covered spaces found at the
junction of the main suture lines
anterior fontanelle (bregma)- junction of the
coronal and sagittal sutures
-diamond shaped
-AP diameter 3 to 4 cm; transverse
diameter, 2 to 3 cm
-closure: 12-18mos of age
posterior fontanelle (Lambda)- at the junction of
the lambdoidal and sagittal sutures
-triangular shaped
-measuring approximately 2 cm across its
widest part
-closure- 2mos of age
***Fontanelle spaces compress during birth to aid in
molding of the fetal head
Diameters of the Fetal Skull
1. Transverse diameter
• biparietal – widest transverse diameter - 9.25cm
• bitemporal - 8 cm
• bimastoid - smallest transverse diameter - 7cm

2. Anteroposterior (AP) diameter – wider than the transverse

diameter of the head
• Suboccipitobregmatic –from below the occiput to the
anterior fontanel; complete flexion – 9.5cm
• Occipitofrontal – from occiput to midfrontal (bridge of
the nose) bone; partial flexion - 12cm
• Occipitomental – from occiput to the chin;
hyperextension ; widest AP diameter; 13.5cm
• Submentobregmatic - face presentation; poor flexion
Molding
a change in the shape of the fetal skull
produced by the force of uterine contractions
pressing the vertex of the head against the not-
yet-dilated cervix
molding only lasts a day or two and is not a
permanent condition
no skull molding occurs when a fetus is breech
Fetal Presentation and Position
Attitude
-the degree of flexion a fetus assumes
during labor or the relation of the fetal parts to
each other
A fetus in good attitude is in complete flexion:
the spinal column is bowed forward, the head is flexed
forward so much that the chin touches the sternum, the
arms are flexed and folded on the chest, the thighs are
flexed onto the abdomen, and the calves are pressed
against the posterior aspect of the thighs
Vertex (full flexion)
 advantageous for birth
because it helps a fetus
present the smallest
anteroposterior diameter
of the skull to the pelvis
and also because it puts
the whole body into an
ovoid shape, occupying
the smallest space
possible.
Moderate flexion (military position)
 if the chin is not
touching the chest
 later mechanisms of
labor (descent and
flexion) force the fetal
head to fully flex
Partial flexion (brow Face presentation
position)  presents too wide a skull diameter
to the birth canal for normal birth
 presents the “brow”  may occur if there is less than the
of the head to the normal amount of amniotic fluid
birth canal (oligohydramnios)
 may reflect a neurologic
abnormality in the fetus causing
spasticity
Fetal Presentation and Position
Engagement
-refers to the settling of the presenting
part of a fetus far enough into the pelvis to be at the
level of the ischial spines, a midpoint of the pelvis
-in a primipara, nonengagement of the head at
the beginning of labor indicates a possible
complication, such as an abnormal presentation or
position, abnormality of the fetal head, or
cephalopelvic disproportion
-in multiparas, engagement may or may not be
present at the beginning of labor.
*** “floating”- presenting part that is not engaged
*** “dipping”- descending but has not yet reached
the ischial spines
Fetal Presentation and Position
Station
-refers to the relationship of the presenting
part of a fetus to the level of the ischial spines
Fetal Presentation and Position
Fetal Lie
-is the relationship between the long
(cephalocaudal) axis of the fetal body and the
long (cephalocaudal) axis of a woman’s body
-horizontal (transverse)
-vertical (longitudinal)
classification: cephalic or breech
Types of Fetal Presentation
• Cephalic Presentation
-is the most frequent type of presentation (95%)
-the fetal head is the body part that will first contact
the cervix
Types of Fetal Presentation
• Breech Presentation.
-either the buttocks or the feet are the
first body parts that will contact the cervix
-the fetal head is the body part that will
first contact the cervix
-occur in approximately 3% of births
and are affected by fetal attitude
Complete breech presentation
 Good (full flexion)
 Longitudinal lie
 The fetus has thighs
tightly flexed on the
abdomen; both the
buttocks and the tightly
flexed feet present to the
cervix.
Frank breech presentation
 Moderate flexion
 Longitudinal lie
 Attitude is moderate
because the hips are
flexed but the knees are
extended to rest on the
chest. The buttocks
alone present to the
cervix.
Footling presentation
 Poor flexion
 Longitudinal lie
 Neither the thighs nor
lower legs are flexed. If
one foot presents, it is a
single-footling breech; if
both present, it is a
double-footling breech.
Types of Fetal Presentation
• Shoulder Presentation (Fewer than 1%)
-presenting part is usually one of the shoulders
(acromion process), an iliac crest, a hand, or an elbow
-causes: grand multiparity (allow the unsupported
uterus to fall forward) , pelvic contraction (horizontal space
is greater than the vertical space), placenta previa (obscuring
some of the vertical space, may also limit a fetus’s ability to
turn)
Types of Fetal Position
• Position
-the relationship of the presenting part to a specific
quadrant of a woman’s pelvis.
-divided in four quadrants according to the mother’s right
and left: (a) right anterior, (b) left anterior, (c) right posterior, and
(d) left posterior
-four parts of a fetus have been chosen as landmarks to
describe the relationship of the presenting part to one of the
pelvic quadrants
-vertex presentation: occiput
-face presentation: chin (mentum)
-breech presentation: sacrum
-shoulder presentation: scapula or the acromion
process
Possible Fetal Positions
Vertex Presentation (occiput) Face Presentation (mentum)
LOA, left occipitoanterior LMA, left mentoanterior
LOP, left occipitoposterior LMP, left mentoposterior
LOT, left occipitotransverse LMT, left mentotransverse
ROA, right occipitoanterior RMA, right mentoanterior
ROP, right occipitoposterior RMP, right mentoposterior
ROT, right occipitotransverse RMT, right mentotransverse
Breech Presentation (sacrum)
LSaA, left sacroanterior Shoulder Presentation
(acromion process)
LSaP, left sacroposterior
LAA, left scapuloanterior
LSaT, left sacrotransverse
LAP, left scapuloposterior
RSaA, right sacroanterior RAA, right scapuloanterior
RSaP, right sacroposterior RAP, right scapuloposterior
RSaT, right sacrotransverse
• During labor process, the fetal head and body must change
position to accommodate the irregular maternal pelvis

• This positional changes are termed the “Cardinal movements”

otherwise called the mechanism of labor, namely:

• ENGAGEMENT

o This is the mechanism by which the greatest transverse

diameter of the fetal head (biparietal diameter) passes
through the pelvic inlet; head fixed in the pelvis
1. DESCENT
oThis is the requisite for the birth of the baby
oThe progression of the fetal head through the
pelvis
oIn primigravidas, descent occurs before onset of
labor
oIn mutiparas, descent may not occur until labor is
advanced
oThe degree of descent is measured by STATION
oFour (4) Forces to DESCENT
 Amniotic fluid pressure
 Direct pressure of the contracting
fundus/uterus
 Effects of contractions on the diaphragm and
abdominal muscle contraction
 Fetal body extension and straightening
Mechanism of Labor (ED FIRE ERE)
E -ngagement
D-escent
F-lexion
I-nternal R-otation
E-xtension
E-xternal R-otation
E-xpulsion
2. FLEXION
oMechanism occurs when the head meets
resistance from the cervix, pelvic floor and
pelvic walls causing the head to flex so that
the chin is brought in contact with the chest
oFlexion results in the smallest
anteroposterior diameter of the fetal head
(suboccipitobregmatic diameter: 9.5cm) to
present into maternal pelvis
3. INTERNAL ROTATION

o This mechanism is the turning of the fetal head from

left to right

o Aligning it with the long axis of the maternal pelvis

and causing the occiput to move anteriorly toward the
symphysis pubis

o In internal rotation, the fetal skull rotates from

transverse to anteroposterior at pelvic outlet;
associated with descent

o After internal rotation, the occiput is just under the

symphysis pubis
4. EXTENSION

o This is the delivery of the head in vertex

presentation or when the head leaves the pelvic outlet

o There is a gradual emergence of the occiput under

the symphysis pubis, followed by the face and then by
the chin (SAFETY ALERT: as soon as the head is
out, even before the chest is born, the mouth and then
the nose are suctioned gently and shallowly using
bulb syringe in order to prevent MECONIUM
ASPIRATION
5. EXTERNAL ROTATION

oHead undergoes restitution (rotation of head back

to its original position in direction opposite that of
internal rotation)

oThe shoulders align to the anteroposterior

diameter, causing the fetal head to continue to
rotate

oThe trunk navigates through the pelvic cavity

with the anterior shoulder descending first
6. EXPULSION

o Final birth of the baby

o Gentle but firm downward pressure/traction of the

head is done to deliver the anterior shoulder

o The head is gently raised to deliver the posterior

shoulder and the entire body follows without difficulty

o The head is the biggest part of the baby; after the head
passes out, the rest of the body follows with no
difficulty

o When the entire body of the baby emerges from the

birth canal, birth is complete
Importance of Determining Fetal
Presentation and Position
help predict fetus at risk
labor is invariably longer because of ineffective descent of
the fetus, ineffective dilatation of the cervix, irregular and
weak uterine contractions
may also lead to early rupture of membranes-->infection,
fetal anoxia, and meconium staining, complications that
lead to respiratory distress at birth and may require
cesarean birth
Four methods are used to determine fetal position,
presentation: (a) combined abdominal inspection and palpation,
called Leopold’s maneuvers; (b) vaginal examination; (c)
auscultation of fetal heart tones; and (d) ultrasound
UTERINE CONTRACTION
(PRIMARY POWER)
• the forces acting to expel the fetus & placenta
• A process that causes cervical dilatation and
expulsion of the fetus from the uterus
• Characteristics
Involuntary, rhythmical, regular activity of
uterine musculature
Occurs intermittent by allowing for a period
of uterine relaxation between contractions –
for maternal/uterine relaxation and sustained
fetal oxygenation
» LECTURER: ROSELLE JOY C. BALAQUIT, RN
• Purposes:
Propel presenting part downward/forward
Effacement of the cervix – thinning and shortening of the
cervical canal
Dilatation of the cervix – widening of the cervical os
diameter from 0 to 10 cm
• Effects of contractions:

Increased BP due to increased peripheral arteriole

pressure (check maternal BP between contractions)

Myometrial contractions constrict blood vessels

decreasing utero-placental circulation

Prolonged uterine contractions can cause fetal hypoxia

Cervical dilatation during the first stage

Contractions with pushing/bearing down, expel the

fetus and the placenta during the second and third stages
of labor

» LECTURER: ROSELLE JOY C. BALAQUIT, RN

• 3 phases of uterine contractions

Increment (Crescendo) – the phase of

increasing intensity or “building up” of
contractions; the first phase; the longest phase

Acme (apex) – the height/peak of uterine

contractions

Decrement (decrescendo) – the phase of

decreasing intensity of contraction; “letting up”
the last phase
» LECTURER: ROSELLE JOY C. BALAQUIT, RN
• DURATION

The period from the beginning of the increment to the

completion of decrement of the same contraction

Express in “seconds”

Maximum duration under normal circumstances is 90

seconds

• FREQUENCY

The period of time from the beginning of one

contraction to the beginning of the next contractions

Expressed in “every minutes”

• INTERVAL
The period from the decrement of the first to the
increment of the second contraction

The time for checking maternal BP, FHT, delivering the

fetal head in precipitate labor to prevent lacerations; the
time for maternal sleep and relaxation during labor
• Intensity – refers to the strength of
uterine contraction during acme; can be
determined by palpation
• Palpation – placing the hand lightly on
the fundus with the fingers spread;
described as mild, moderate and strong by
judging the degree of indentability of the
uterine wall during acme
STRONG – fundus is very firm;
cannot be indented with fingers
MODERATE – fundus is difficult to
indent
MILD – fundus is tense but can be
indented easily with fingertips
• When the uterus contracts, the following
uterine changes occur:
Upper uterine segment becomes thicker and
shorter
Lower uterine segment becomes thinner and
longer
MATERNAL BEARING DOWN/
PUSHING(SECONDARY
POWER)
• Readiness for pushing:
 Cervical dilation: 10 cm; fully dilated
 Fetal station: +1
 Correct pushing: take a deep breath as soon as the next
contraction begins and then with breath held, exert a downward
pressure exactly as though she were straining at stool
 Discouraged prolonged maternal breathing holding of more than
6 seconds, during pushing
 Have four or more pushes per contraction
PSYCHE
-refers to the psychological state or feelings that a woman
brings into labor
Pregnant women's psychologic responses to uterine
contractions
Fear and anxiety affect labor progress
Woman who is relaxed, aware of and participating in the
birth process usually has a shorter, less intense labor
Other factors that affect psychologic response of the mother
inc:
Childbirth preparation process (classes) – decreases need for
analgesic in labor
Support system – husband presence in the labor and delivery
unit can provide emotional support – less anxiety – less
emotional tension – less pain perception
Labor is traditionally divided into three stages:
The first stage of dilatation, which begins with
the initiation of true labor contractions and ends
when the cervix is fully dilated.
 The second stage, extending from the time of
full dilatation until the infant is born.
 The third or placental stage, lasting from the
time the infant is born until after the delivery of
the placenta.
The first 1 to 4 hours after birth of the placenta
is sometimes termed the “fourth stage” to
emphasize the importance of the close maternal
observation needed at this time.
THE FIRST STAGE
• Dilatation stage
• Description: this is the stage from the
onset of the first true labor
contraction up to full cervical dilation
and effacement
• 3 phases of the first stage:
Latent
Active
Transition
• Cervical dilation: 0-3 cm
• Frequency of contraction: q5-10 minutes
• Duration of contraction: 20-40 seconds
• Intensity of contractions: mild
• Maternal discomfort: backache, abdominal
cramps
• Maternal behavior: apprehensive, excited
but can communicate
• Nursing interventions:
Proper positioning – sidelying
Provide backrubs
Encourage walking to shorten first
stage of labor
Encourage to void every 2-3 hours
because a full bladder inhibits uterine
contractions
Support system can include husband
to stay with the client to provide
support
• Cervical dilation: 4-8 cm
• Frequency of contraction: q3-5 minutes
• Duration of contraction: 40-60 seconds
• Intensity of contractions: moderate
• Maternal behavior: less talkative, more
anxious, may not want to be alone, fear of
losing control, restless, increasing anxiety
with skin warm and flushed
• Maternal problem:
HYPERVENTILATION
Due to direct effect of progesterone on the
respiratory center in the brain during labor
Hyperventilation is related to uneven
breathing pattern with uncontrolled
breathing during contractions and rapid
breathing over a prolong period of time
causing imbalance in carbon dioxide and
oxygen
Too much carbon dioxide is expired
Signs of hyperventilation:
oTingling sensation, numbness of the nose
or lips, finger tips or toes
oPallor
oDizziness, lightheadedness
oSpots before the eyes
oCarpopedal spasms (spasm of hands and
feet)
• Nursing interventions:
Encourage woman to slow her
breathing and take shallow breath
Offer client a paper bag where she
can breathe into or instruct her to
breath into her cupped hands until
signs abate
Stay with the woman to keep her at
ease
EFFECT OF UNMANAGED
HYPERVENTILATION
•Respiratory Alkalosis
•The mother in active phase of labor
may benefit from breathing and
relaxation techniques and proper
coaching to prevent hyperventilation
• Cervical dilation: 8-10 cm
• Frequency of contraction: q2-3 minutes
• Duration of contraction: 60-90 seconds
• Intensity of contractions: strong
• Maternal behavior: with increased perspiration,
nausea and vomiting, cramps, restlessness, panic,
irritability, has lost control of labor, tends to push
during contractions, with circumoral pallor and
increased show
• Maternal problems: backache, pressure on bladder
and rectum and leg trembling
• The mother in this phase have a strong desire to
push but she should not!
• Pushing when the cervix is not yet fully dilated
can result to caput succedaneum
• Suggest pant-blow pattern of chest breathing to
eliminate the tendency to push
• Nursing interventions:
Provide physical comfort with dry linens and
cool clothes
Provide backrub
Coach breathing techniques: Pant-blow
pattern of breathing in the transition phase
Provide psychologic comfort: Don’t leave
client alone; help focus on task; inform of
progress; be understanding of her irritability
NURSING IMPLEMENTATION:
FIRST STAGE OF LABOR
• On admission to the labor unit:
Greetings. Introduce self
Admit client; orient to physical setting; review common
procedures so the patient knows what to expect
Take history; determine
o Expected date of birth
o Frequency, duration, and intensity of contractions
o Amount and character of show
o Whether rupture of membranes has occurred
o Time the woman last ate
oAny known drug allergies
oPast pregnancy and previous pregnancy history
oHer birth plan or what individualized measures
she has planned, such as no analgesia or who will
cut the umbilical cord
oAssess:
Vital signs—temperature, pulse, respirations, and
blood pressure (assessed between contractions)
Contractions (frequency, duration and intensity)
Her preparedness and readiness for labor
• Do Leopold’s Maneuver (LM):
1) Explain the procedure and instruct the client to void to
empty her bladder.
2) Wash hand using warm water.
3) Ensure privacy.
4) Position the woman supine with knees slightly flexed.
Place a small pillow or rolled towel under her left side.
If the nurse is R handed, stand at the woman’s R side facing
her for the first 3 steps, then turn and face her feet for the last
step (L handed, left side).
5) Observe the woman’s abdomen as to which is the lonest
diameter and where fetal movement is apparent.
First Maneuver –(Fundal grip)
 Facing the mother, palpate the
fundus with both hands
– Assess for shape, size, consistency and
mobility
 Fetal head: firm, hard, and round
– Moves independently of the rest
– Detectable by ballotement
 Breech/buttocks: softer and has bony
prominences
– Moves with the rest of the form
First Maneuver –(Fundal grip)
Second Maneuver –
(Lateral and umbilical grip)
Determine position of the back.
 Still facing the mother, place both palms on the
abdomen
o Hold R hand still and with deep but gentle
pressure, use L hand to feel for the firm,
smooth back
o Repeat using opposite hands
 Confirm your findings by palpating the fetal
extremities on the opposite side
o small protrusions, “lumpy”
Second Maneuver –
(Lateral and umbilical grip)
Third Maneuver- (Pawlick’s grip)
1. Determine what part is lying above the inlet.
2. Gently grasp the lower portion of the abdomen
(just above symphisis pubis) with the thumb and
fingers of the R hand
3. Confirm presenting part (opposite of what’s in
the fundus)
4. Head will feel firm
5. Buttocks will feel softer and irregular
6. If it’s not engaged, it may be gently pushed back
and forth
7. Proceed to the 4th step if it’s not engaged…
Third Maneuver- (Pawlick’s grip)
Fourth Maneuver –(Pelvic Grip)
1. Locate brow.
2. Assess descent of the presenting part.
 Turn to face the woman’s feet
 Move fingers of both hands gently down the sides
of the abdomen towards the pubis
- Palpate for the cephalic prominence (vertex)
3. Prominence on the same side as the small parts
suggests that the head is flexed (optimum)
4. Prominence on the same side as the back suggests
that the head is extended
Fourth Maneuver –(Pelvic Grip)
NURSING IMPLEMENTATION: FIRST
STAGE OF LABOR
• Perineal preparation; observe principles of asepsis
• Render enema if ordered – never a routine
procedure; done to prevent – infection, retardation of
labor progress, Postpartum discomfort
• Obtain specimens for lab test:
urine for sugar (negative in labor), protein
(negative), acetone (negative)
blood for hemoglobin (Hgb), hematocrit (Hct),
white blood cells (WBC)
Venereal disease research laboratory (VDRL)
Cross matching
• Monitoring:
Uterine contractions (progress of labor)
Bladder
FHT
Perineum – show, rupture of bow, presenting
part, bulging, cord prolapse, bleeding
BP, PR and RR: every hour in the latent and
active phases and every 30 mins in the transition
phase if in normal range
Temperature: every 4 hours if in normal range;
every hour if above 37.5C or if membranes
rupture (leading complication of prolonged
rupture of the bag of water is infection
• FHR Monitoring
FHR: every 30 minutes in the latent phase and
every 15 minutes in the active and transition
phases if normal characteristics are present
• Prevent supine hypotensive syndrome; position client
on left lateral recumbent
• Provide physical and psychologic comfort and
support
Comfort measures: assisting with positional
change, keeping clean and dry, promoting sleep
and adequate rest
Distraction is one of the methods to increase
relaxation and cope with discomfort of labor when
contractions are mild to moderate
• Forms of distraction include:
Conversation
Light activities as reading, card play, table
games
Ambulation not only distracts effectively
but also enhances labor progress
Concentration on a pleasant experience
Massage: Effleurage – a light abdominal
stroking (may be used in the first stage of
labor for mild to mod, pain)
Firm pressure on the lower back or sacral
area to relieve back pain
• Promote safety; monitor for danger signs:
Strong or weak contractions (hypertonic
or hypotonic)
Bleeding (placenta previa, abruptio
placenta, uterine rupture)
Passage of meconium-stained amniotic
fluid in cephalic presentation (fetal
distress)
Severe headache, dizziness, blurring of
vision (pregnancy-induced hypertension)
FETAL ASSESSMENT
Auscultation of Fetal Heart Sounds
 in a vertex or breech presentation, fetal heart sounds
are usually best heard through the fetal back
 in a face presentation, the back becomes concave so the
sounds are best heard through the more convex thorax
 in breech presentations, fetal heart sounds are heard
most clearly high in the uterus, at a woman’s umbilicus
or above
 In cephalic presentations, they are heard loudest low in
the abdomen
 In an ROA position, the sounds are heard best in the
right lower quadrant
 in an LOA position, in the left lower quadrant
 In posterior positions (LOP or ROP), heart sounds are
loudest at a woman’s side.
ELECTRONIC
MONITORING
 Observing the FHR on a
monitor is easier than
listening with a stethoscope,
fetoscope, or Doppler.

EXTERNAL ELECTRONIC
MONITORING
 Contractions are monitored
by means of a pressure
transducer or
tocodynamometer (toko is the
Greek word for
“contraction”).
INTERNAL
ELECTRONIC
MONITORING
 the most precise method
for assessing FHR and
uterine contractions
 pressure-sensing
catheter is passed
through the vagina, into
the uterine cavity, and
alongside the fetus, after
the membranes have
ruptured and the cervix
has dilated to at least 3
cm
TELEMETRY
 allows monitoring of both FHR and
uterine contractions to be carried out free
of connecting wires that could hamper
the woman’s movements in labor
 An internal pressure uterine lead is
inserted, as in internal monitoring, and a
fetal scalp electrode is also attached
 miniature radio transmitter is then placed
in the vagina to transmit the FHR and
uterine contraction signals to a distant
monitor
LABOR WATCH
THE PARTOGRAM
-is a graph used in labor to
monitor the parameters of
progress of labor, maternal and
fetal wellbeing, and treatment
administration
PRACTICAL VALUE OF USING THE
PARTOGRAM
• Offers an objective basis for overtime
monitoring the progress of labour,
maternal and fetal wellbeing.

• Enables early detection of

abnormalities of labour
 Prevention of obstructed labour
and ruptured uterus.
• Complications of obstructed labour and
ruptured uterus contribute up to 30%
of maternal deaths in some areas.
• Proper use of partogram has proved so
useful in reduction of both maternal
and perinatal mortalities and morbidities
RECOMMENDATIONS ON THE USE OF
PARTOGRAM

Based on the evidence-based reports

on its effectiveness in monitoring of
labour.

WHO
Recommends its use in all labour
wards and for all women (WHO 1994)
PRINCIPLES USED TO DESIGN THE
PARTOGRAM

The partogram depends on the principles that;

1. The latent phase should not last longer
than 8 hours
2. The latent phase ends and active phase
starts when the cervix is 3cm (4cm is
sometimes used)
3. During active phase – the cervix should
dilate at not less than 1 cm per hour
4. A lag time of 4 hours is usually
acceptable the slowing of labour
and the need to intervene; this is the
distance between alert line and the
action line.
Components of the partograph
• Part I : fetal condition ( at top )
• Part II : progress of labor (at middle )
• Part III : maternal condition
( at bottom )
• Outcome : ………………
PART I : FETAL
CONDITION
 this part of the graph is used to monitor
and assess fetal condition
 1 - Fetal heart rate
 2 - membranes and liquor
 3 - moulding the fetal skull bones
 Caput
1) FETAL HEART RATE
Basal fetal heart rate
• > 160 beats/mi n=tachycardia
• <120 beats/min = bradycardia
• <100 beats/min = severe bradycardia

Decelerations? yes/no

Relation to contractions?
Early
Variable
Late -----Auscultation - return to baseline
> 30 sec contraction
----- Electronic monitoring
peak and trough
> 30 sec
2) MEMBRANES AND LIQUOR
• intact membranes ………………………..I
• ruptured membranes + clear liquor …….C
• ruptured membranes + meconium- stained
liquor ……………………………………....M
• ruptured membranes + blood – stained
liquor ………………………………………B
• ruptured membranes + absent
liquor…………………………………….....A
3) MOULDING THE FETAL SKULL BONES
 Molding is an important indication of how
adequately the pelvis can accommodate the fetal
head
 increasing molding with the head high in the
pelvis is an ominous sign of cephalopelvic
disproportion
• separated bones . sutures felt easily ………….O
• bones just touching each other …..…………..+
• overlapping bones ( reducible 0 ……….……..++
• severely overlapping bones (non – reducible) +++
PART II – PROGRESS OF LABOUR
1) Cervical dilatation
2) Descent of the fetal head
3) Fetal position
4) Uterine contractions
 • this section of the paragraph has as its
central feature a graph of cervical
dilatation against time
 • it is divided into a latent phase and an
active phase
A) LATENT PHASE
 it starts from onset of labour
until the cervix reaches 3 cm
dilatation
 once 3 cm dilatation is reached ,
labor enters the active phase
 lasts 8 hours or less
 each lasting < 20 seconds
 at least 2/10 min contractions
B) ACTIVE PHASE
• Contractions at least 3 / 10 min
• each lasting < 40 seconds
• The cervix should dilate at a
rate of 1 cm / hour or faster
**Alert line (health facility line)
 The alert line drawn from 3 cm dilatation
 represents the rate of dilatation of 1 cm /
hour
 Moving to the right or the alert line means
 referral to hospital for extra vigilance

**Action line (hospital line)

 The action line is drawn 4 hour to the right
of the alert line and parallel to it
 This is the critical line at which specific
management decisions must be made at the
hospital
1) Cervical dilatation
 It is the most important information and the
surest way to assess progress of labor , even
though other findings discovered on vaginal
examination are also important
 when progress of labor is normal and
satisfactory , plotting of cervical dilatation
remains on the alert line or to left of it
 if a woman arrives in the active phase of labor ,
recording of cervical dilatation starts on the
alert line
 when the active phase of labor begins , all
recordings are transferred and start by plotting
cervical dilatation on the alert line
2) Descent of the fetal head
 It should be assessed by abdominal
examination immediately before doing a
vaginal examination, using the rule of fifth to
assess engagement
 The rule of fifth means the palpable fifth of
the fetal head are felt by abdominal
examination to be above the level of symphysis
pubis
 When 2/5 or less of fetal head is felt above the
level of symphysis pubis , this means that the
head is engage , and by vaginal examination ,
the lowest part of vertex has passed or is at
the level of ischial spines
Assessing descent of the fetal head by vaginal
examination;
0 station is at the level of the ischial spine
3) Fetal position
4) Uterine contractions
 Observations of the contractions are made
every hour in the latent phase and every
half-hour in the active phase frequency how
often are they felt ?
 Assessed by number of
contractions in a 10 minutes period
 duration how long do they last?
 Measured in seconds from the time
the contraction is first felt
abdominally , to the time the
contraction phases off
 Each square represents one contraction
PART III: MATERNAL CONDITION
Name / DOB /Gestation
Medical / Obstetrical issues
Assess maternal condition regularly by
monitoring :
• drugs , IV fluids , and oxytocin , if labour is
augmented
• pulse , blood pressure
• Temperature
• Urine volume , analysis for protein and
acetone
FETAL HEART RATE AND UTERINE
CONTRACTION RECORDS

 monitors trace both the FHR and the duration and

interval of uterine contractions onto an oscilloscope
screen and produce a permanent record on paper rolls.
Fetal Heart Rate Patterns:
 Baseline Fetal Heart Rate
 Variability
 Periodic Changes
Accelerations.
Accelerations.
Late Decelerations.
Prolonged Decelerations.
Variable Decelerations.
 Sinusoidal Fetal Heart Rate Pattern
Baseline Fetal Heart Rate- determined by
analyzing the range of fetal heartbeats
recorded on a 10-minute tracing that was
obtained between contractions.
- normal rate is 120 to 160 bpm
- fluctuates slightly (5 to 15 bpm) when
a fetus moves or sleeps
- abnormal patterns in the baseline rate
include fetal bradycardia and fetal
tachycardia
- moderate bradycardia of 100 to 119bpm is
not considered serious and is probably because of
a vagal response elicited by compression of the
fetal head during labor
- marked bradycardia (less than 100 bpm) is a
sign of possible hypoxia and is potentially
dangerous
- moderate tachycardia is 161 to 180 bpm
- marked fetal tachycardia may be caused by
fetal hypoxia, maternal fever, drugs, fetal
arrhythmia, or maternal anemia or
hyperthyroidism
Variability- the variation or differing
rhythmicity in the heart rate over time and is
reflected on the FHR tracing as a slight
irregularity or “jitter” to the wave
Variability- the variation or differing
rhythmicity in the heart rate over time and is
reflected on the FHR tracing as a slight
irregularity or “jitter” to the wave
Periodic Changes

Accelerations-Nonperiodic accelerations are

temporary normal increases in FHR caused
by fetal movement change in maternal
position, or administration of an analgesic.
Periodic Changes

Early Decelerations- are normal periodic

decreases in FHR resulting from pressure on
the fetal head during contractions

Late Decelerations- are delayed until 30 to

40 seconds after the onset of a contraction
and continue beyond the end of a
contraction
Periodic Changes

Prolonged Decelerations- are

decelerations that last longer than 2 to 3
minutes but less than 10 minutes

Variable Decelerations- refers to

decelerations that occur at unpredictable
times in relation to contractions
Sinusoidal Fetal Heart Rate Pattern

-a fetus who is severely anemic or hypoxic,

central nervous system control of heart
pacing may be so impaired that the FHR
pattern resembles a frequently undulating
wave
Other Assessment
Techniques

Scalp Stimulation-
is done by applying
pressure with the
fingers to the fetal
scalp through the
dilated cervix
Fetal Oxygen Saturation Level
-may be measured by an oxygen saturation
sensor that is introduced into the uterus and
placed beside the fetus’ cheek after
membranes have ruptured

Fetal Blood Sampling

- reveal hypoxia in a fetus before it becomes
apparent on an electrocardiogram or
external monitoring system
CARE OF A WOMAN DURING THE FIRST STAGE
OF LABOR
Six major concepts to make labor and birth as natural as
possible are:
1. Labor should begin on its own, not be artificially induced.
2. Women should be able to move about freely throughout
labor, not be confined to bed.
3. Women should receive continuous support during labor.
4. No interventions such as intravenous fluid should be
used routinely.
5. Women should be allowed to assume a nonsupine (e.g.,
upright, side-lying) position for birth.
6. Mother and baby should be together after the birth, with
unlimited opportunity for breastfeeding (Amis & Green,
2007).
 Respect Contraction Time.
-Do not interrupt a woman who is in the middle of
breathing exercises during labor because, once her
concentration is disrupted, she will feel the extent of the
contraction
 Promote Change of Positions.
-woman whose membranes have ruptured should
lie on her side until a fetal monitor shows good baseline
variability and no variable decelerations or until she has
been checked by a physician or nurse-midwife, because,
unless the head of the fetus is well engaged (firmly fitting
into the pelvic inlet), the umbilical cord may prolapse into
the vagina if she walks
 Promote Voiding and Provide Bladder
 Support a Woman’s Pain Management Needs.
• Description: from fully dilated cervix to the
delivery or expulsion of the baby
• Powers: Primary and Secondary powers
Contractions:
oStrong
oDuration: 60-90 seconds
oFrequency: q2-3 minutes, same features as
those of transition phase
Spontaneous pushing with
contractions; panting at intervals and at
crowning time
oCrowning is the hallmark of the
second stage
oWhen the head crowns, the mother
pants and does not push to affect
gradual extension of fetal head to
prevent meconium aspiration and
perineal laceration
• Maternal behavior: progresses from
irritability to participation, eagerness and
excitement
With need to bear down so she pushes
with uterine contractions spontaneously
Perineum bulges; grunting sounds
Increased blood show: with leg cramps
Bag of water (BOW) ruptures
oThe early second stage is the best time
for the BOW to rupture
oFIRST nursing action after rupture
of the BOW – CHECK the FHT
• Nursing Implementation:
Continue to offer psychological support; inform of
progress
o P – raise
o R – assurance
o E – ncouragement
o I – inform mother of progress
o S – upport system
o T – ouch
• Assist/coach: Bear down only when needed, during
contractions
Monitor FHT at intervals (midway between
contractions); if there is continuous fetal heart
electronic monitor, check FHT during and after a
contraction; BE ALERT FOR LATE
DECELERATIONS
When to transfer patient to delivery room?
oPrimigravida: Cervix 10 cm with certain
degree of bulging with contractions
oMultigravida: cervix 8-9 cm
Proper position: Lithotomy. Some considerations
oPadded stirrups
oNo pressure on popliteal region
oEqual height of legs
• Proper position: Lithotomy. Some considerations
Simultaneous placing of legs on the stirrups
oAlternate positions: Fowler’s, side-lying, or squatting,
as desired, indicated or supported by unit policy
• Perineal preparation: front to back motion
• Provide assistance to the health provider in attendance or
assist with delivery as indicated
With extension of the head – Right away
oFeel the nape for any cord coil (lift cord and pass over
the head of the baby if present, double clamp and cut
if tight)
oClear mouth and nose with shallow suctioning using
a bulb syringe to prevent meconium aspiration
• With expulsion: Delay clamping and cutting of
the umbilical cord until cord pulsations disappear
• Dry and wrap infant in a warm towel to keep him
warm; placing the wrapped newborn on the
maternal abdomen can:
Warm the newborn as the mother’s abdomen
has the same temperature as the incubator
Contract the uterus because of the baby’s
weight
Promote mother – child closeness or bonding
• Show baby to mother: ensure eye to eye contact
for bonding; verbalize similarities; allow
touching, stroking
• Proper Identification is done before
transferring newborn to the nursery
or before separating from the mother;
a legal and ethical responsibility of the
nurse
• Description: the placental stage is the period from the
delivery of the baby to the delivery of the placenta
• Powers
Strong uterine contractions in the third stage cause
placental separation from uterine wall
When placenta is fully detached, maternal pushing can
affect final delivery of the placenta
• Signs of PLACENTAL SEPARATION:
Calkin’s sign – the first sign; when uterus changes in
shape (from discoid to globular) and consistency ( from
soft to firm)
• Signs of PLACENTAL SEPERATION:
Uterus becomes mobile – it rises up into the
uterus
oImmediately after placenta detaches, the fundus
is at midway between the symphysis pubis and
umbilicus, then rises to the level of the
umbilicus – midline
oDisplacement of the uterus to the sides would
mean distended bladder, so the first thing to do
if the uterus is not in the midline is to feel the
lower abdomen for a distended bladder;
stimulate voiding if bladder is distended
Sudden gushing of blood –
distinguish between the normal sudden
gushing of bleeding and the abnormal
increasing bleeding

Slight lengthening of the cord –

most definitive sign that the placenta
has detached
Schultze Mechanism
oMore common; present in 80% of cases
oShiny, “clean” bluish side is first delivered
oLess external bleeding because blood is
usually concealed behind the placenta
oThe type where separation starts at the
center, then to the edges, causing inverted
umbrella shape
Duncan’s Mechanism
oLess common; present in 20% of cases
oRough, “dirty”, reddish maternal side out first
oMore external bleeding, so it appears “bloody”
oThe amount of blood loss in delivery is
250-300 ml; blood loss of 500ml or above is
considered POSTPARTAL HEMORRHAGE,
the leading cause of maternal mortality
oUmbrella-shaped placenta delivered sideways
• Nursing Implementation
Observe the principle of placental delivery stage;
watchful waiting (watch and wait for signs of
placental separation) and not doing fundal pressure
with pull at the cord, especially if the uterus is
relaxed; this may lead to uterine inversion causing
hemorrhage in the third stage of labor
Gradual delivery of the placenta
Inspect the placenta for completeness (first nursing
action after placenta is delivered)
oComplete cotyledons
oComplete cord vessels: 1 vein and 2 smaller arteries
oComplete membranes
• Nursing Implementation
Feel the fundus for contraction or
firmness; the terms “soft”, “boggy”, and
“non-palpable” means uterine atony; the
initial activity of the nurse is to
massage fundus until firm; ice cap may
applied to further contract the uterus
but NEVER HOT WATER BAG
INJECT ORDERED OXYTOCIN
AFTER PLACENTAL DELIVERY
oCommonly used drugs: Methylergonovine
maleate (Methergine), Ethylergonovine maleate
(Ergotrate)
oMethergine prevents excessive bleeding after
delivery; check BP because it may cause
hypertension; administered IM/IV
oOxytocin maintains uterine contractions post
delivery to prevent bleeding; administered via IV
piggyback-(10 to 40 U/L in intravenous fluid) or
given as 10 U intramuscularly (Karch, 2009)
• Inject ordered oxytocin after placental delivery
oAction: to increase uterine motor activity by
direct stimulation
oTarget: uterine musculature
oIndication: to prevent postpartum bleeding
from uterine atony and subinvolution
oEvaluation of its effects: look for a firm
fundus
oSide effects: nausea, vomiting, dizziness,
headache, hypotension, tinnitus,
hypersensitivity
ASSESS VS, PRESENCE OF LACERATIONS,
COMPLETE PLACENTA, BLEEDING
• Lower legs slowly
• Perineal Repair
• If allowable by hospital policies, allow
mother time with infant to promote
attachment or bonding; breastfeeding
right on the delivery table
Episiotomy
• Prevent laceration
• Widen the vaginal canal
• Shortens the 2nd stage of labor
2 types
• MEDIAN
• Less bleeding
• Less pain
• Easy repair
• Possible urethroanal fistula
 major disadvantage
• MEDIOLATERAL
• More bleeding
• More pain
• Hard to repair and slow
healing
• Description: the period of
recovery, stabilization or
homeostasis, usually 1 to 2 hours
or at most up to 4 hours
• Power: Uterine contractions
prevents bleeding from placental
site
Nursing implementation:
Monitor VS, every 15 minutes until
stable; report abnormal fluctuations
oBlood loss during delivery
averages 250 ml with the normal
upper limit of 500 ml; postpartal
hemorrhage is defined as the lost
of 500ml of blood and more
• Nursing implementation.
Monitor VS, every 15 minutes until
stable; report abnormal fluctuations
oBecause of the blood loss and the
lifting of the gravid uterus from
surrounding vessels, blood is
redistributed into the venous beds; this
results to a moderate drop in both
systolic and diastolic pressure,
increased pulse pressure and light to
moderate tachycardia
Palpate fundus every 15 minutes;
check fundal height, position in relation
to the umbilicus before fundal palpation
is done, ask the mother to void to ensure
an empty bladder; this will not only
promote maternal comfort but will favor
accurate findings from palpation
• Palpate fundus every 15 minutes; check fundal
height, position in relation to the umbilicus
oIn the recovery stage, the fundus is firm, at
midline and at the level of umbilicus
If relaxed, massage until firm; do not over
massage as this can tire the uterine
muscles, causing relaxation
If displaced to the side, the first nursing
action is to feel the lower abdomen for a
distended bladder; when the bladder is
distended, stimulate voiding
A full bladder can lead to uterine atony
leading to hemorrhage
• Assess the lochia;
in the fourth stage, lochia is bright red
and can saturate 1-2 perineal pads in one
hour;
a reddish color may be maintained for
more than 2 weeks;
when it persists for more than 2 weeks, it
indicates either the retention of small
portions of the placenta or imperfect
involution of the placenta site or both
• LOCHIA- is a post-partum vaginal
discharge, containing blood, mucus and
placental tissue
• Check for full bladder distention;
determine first voiding and voiding
pattern. A full bladder displaces the uterus
to the side, a factor to uterine atony
• Checking the perineum; note general
appearance, redness, swelling, bruising,
vaginal and suture line bleeding
Observe perineum for REEDA –
Redness, Edema, Ecchymosis,
Discharges, Approximation
• Presidential Decree No. 651 dictates the registration with
the Civil Registrar of all births within 30 days ( PD 651)
• The birth certificate is a very important legal document that
must be accomplished completely and accurately, devoid of
any erasures
• The birth certificate is a document that is an essential proof
of birth and nationality needed during civil activities such
as:
Entrance to school
Application for a job
Marriage
Securing a passport
PREPARING AND
ASSISTING FOR
DELIVERY
PREPARING FOR DELIVERY
• Prepare workplace.
• Maintain ideal room temperature at 25-28C to
prevent cold stress and hypothermia in the
baby
• Prepare necessary equipment
• Check resuscitation equipment
• Perform hand hygiene
• Wear sterile gloves
A. PREPARE WORKPLACE
• Make sure all necessary equipment
and supplies are available
• Adequate space for working rid of
any accidents
• Proper documentation
• Adequate personnel needed for the
conduct of delivery
B. MAINTAIN IDEAL ROOM
TEMPERATURE AT 25-28C
• Check room temperature using a room
thermometer
• Close windows, draw curtains, turn off electric
fans to eliminate air drafts
• Turn off the air-conditioning unit at the time of
delivery
• If air-conditioning is centralized, adjust the
thermostat setting prior to the delivery
C. PREPARE NECESSARY
EQUIPMENT
• DELIVERY INSTRUMENTS:
Handwashing implements
Sterile gloves- 2 sets, cap, mask
Warm towels and linens
Bonnet
Sterile plastic cord clamp
Sterile instrument clamp
Sterile pair of scissors (separate from that used for
episiotomy, if done)
Oxytocin 10 IU and sterile syringe for IM injection
Receptacle for placenta
C. PREPARE NECESSARY
EQUIPMENT
• NEWBORN CARE INTERVENTIONS/
SUPPLIES:
Eye prophylaxis- erythromycin or tetracycline
ointment, gentamycin drops
Vitamin K ampule; cotton balls; sterile syringe
for IM injection
Anti-Hepatitis B vaccine; cotton balls; sterile
syringe for IM injection
BCG vaccine; cotton balls; sterile syringe for ID
injection
C. PREPARE NECESSARY
EQUIPMENT
• SLPH INSTITUTIONAL VARIATION:
DELIVERY PACK (includes: drapes, lap sponge,
forceps, surgical scissors, episiotomy scissors,
needle holder)
Cord clamp, syringe, gauze pads, antiseptic,
suture are placed upon preparation of delivery set
for the case
Ask patient’s SO for the ff: baby clothes with
swaddling linen, diapers (1 NB, 1 adult), linen
sheet
D. CHECK RESUSCITATION
EQUIPMENT
• Resuscitation equipment should be clean and
functional, and within reach at every delivery
E. PERFORM HAND HYGIENE
F. WEAR STERILE GLOVES
SPONTANEOUS VAGINAL
DELIVERY
SPONTANEOUS VAGINAL DELIVERY
ESSENTIAL
NEWBORN CARE
Essential Newborn Care

• Philippines is one of the 42 countries

accounting for 90% of all global deaths
under 5 year old children
• Highest number of newborn deaths
occur in the first 2 days of life
• ENC implementation has the potential to
avert approximately 70 percent of
newborn deaths that are due to
preventable causes
Time-Bound Interventions

1. Immediate and thorough drying of

the newborn
2. Early skin to skin contact between
mother and newborn
3. Properly-timed cord clamping and
cutting
4. Non-separation of newborn and
mother for early breastfeeding
I. IMMEDIATE AND
THOROUGH DRYING OF
THE NEWBORN

• Immediate and thorough drying

for 30 seconds to one minute
warms the newborn and stimulates
breathing
1)Call out the time of birth
2)Dry the newborn thoroughly for at least 30
seconds (wipe the eyes, face, head, front and
back, arms and legs
3)Remove the wet cloth
4)Do a quick check of breathing while drying
NOTE:
-during the 1st seconds:
Do not ventilate unless the baby is floppy/ limp
and not breathing
Do not suction unless the mouth/ nose are
blocked with secretions or other material
II. EARLY SKIN TO SKIN
CONTACT BETWEEN
MOTHER AND NEWBORN

• Early skin-to-skin contact between

mother and newborn and delayed
washing for at least six hours prevents
hypothermia, infection and
hypoglycemia
NOTES:
Do not wipe vernix
Do not bathe the newborn
Do not do footprinting
No slapping
No hanging upside-down
No squeezing of chest
If newborn is breathing or crying: position
the newborn prone on the mother’s
abdomen or chest, cover with a dry blanket,
cover the newborn’s head with bonnet
III. PROPERLY-TIMED CORD
CLAMPING AND CUTTING

• Properly-timed cord clamping and

cutting prevents anemia and protects
against brain hemorrhage in premature
newborns.
• This means waiting for the cord
pulsations to stop (between 1 to 3
minutes)
1) Remove the first set of gloves
2) After the umbilical pulsations have stopped,
clamp the cord using a sterile plastic clamp
2cm from the umbilical base
3) Clamp again at 5cm from the base
4) Cut the cord between ties

NOTES:
 Do not milk the cord towards the baby
 After the first clamp, you may “strip” the cord
of blood before applying the second clamp
 Do not apply any substance onto the cord
IV. NON-SEPARATION OF
NEWBORN AND MOTHER FOR
EARLY BREASTFEEDING
• Continuous non-separation of
newborn and mother for early
breastfeeding protects infants from
dying from infection
• The first feed provides colostrum
Leave the newborn in skin-to-skin contact
Observe for feeding cues including tonguing,
licking or rooting
Counsel on positioning:
Newborn’s neck is not flexed nor twisted
Newborn is facing the breast
Newborn's body is close to mother's body
Newborn’s whole body is supported
Counsel on attachment and suckling:
Mouth wide open
Lower lip turned outwards
Baby’s chin touching the breast
Suckling is slow, deep with some pauses
NOTES:
 Minimize handling by health workers
 Do not give sugar water, formula
 Do not give bottles or pacifiers
 Do not throw away colostrum
 Weighing, bathing, eye care,
examinations, injections (hepatitis B, Vit.
K, BCG) should be done after the first
full breastfeed is completed
 Postpone washing until at least 6 hours
NEONATAL
ASSESSMENT
APGAR:
Purpose of 1st APGAR (1st min)- to detect cardiorespiratory- nervous functioning–
initial adaptation to extrauterine life
Purpose of 2nd APGAR (5mins)- to plan the care and check the overall status
INTERPRETATION:

7-10 GOOD CONDITION

4-6 FAIR CONDITION: NEEDS SUCTIONING

AND OXYGENATION

0-3 DANGER, NEEDS RESUSCITATION

PHYSICAL ASSESSMENT:
GENERAL MEASUREMENTS:
HEAD- 33-35cm (about 2cm larger than chest)
CHEST- 30-33cm
HEIGHT- (head to heel) 45-55cm (ave:50cm)
WEIGHT- 2700 to 4000g
VITAL SIGNS:
Temp- 36.5-37C
HR- 120-140bpm
RR- 30-60cpm
BP- 65/40mmHg in arm and calf (6-9mmHg
less than in calf indicates COARCTATION of
AORTA)