NCM 107B

Name of Student: Marileth B. Jefferson

BSN -2
Maternal-Newborn Health Nursing Skills And Procedures (NCM107 B)
INDEX

PROCEDURE 1: Perform first physical examination

during pregnancy
PROCEDURE 2: Perform abdominal examination during
Unit 1 pregnancy using Leopold maneuvers
PROCEDURE 3: Assessing pitting edema
Antepartum Period

PROCEDURE 1: Assessment of Uterine Contractions (1st stage

of labor)
PROCEDURE 2: Auscultating fetal heart rate during
labor
Unit 2

Intrapartum Period PROCEDURE 3: Vaginal examination during labor

PROCEDURE 4: External electronic fetal monitoring

PROCEDURE 5: Handling and Assisting Delivery
PROCEDURE 6: Apgar scoring

PROCEDURE 1: Assessment of uterine fundus

Unit 3 Postpartum postpartum

PROCEDURE 2: Breast examination

Period
PROCEDURE 3: Breast care

PROCEDURE 4: Perineal

examination PROCEDURE 5:

Perineal care

PROCEDURE 6: Umbilical cord

care
Procedure 1.1 : The First Physical Examination during pregnancy
Performe Rationale
d
Preparation Yes N
o
1. Equipment
● Stethoscope
● Light measuring device
● Thermometer
● Sphygmomanometer
● Tongue depressor
● Weighing scale
● Urine testing facility
● Client record

Procedure
1. Prepare equipment To have an easy access in all the
equipment needed for the examination
and also to save time.
2. Welcome the woman In order for the woman to feel secure,
comfortable and to establish rapport.
3. Instruct her to evacuate the bladder Collecting the specimen of urine
and collect a midstream specimen of midstream helps ensure that a sterile
urine specimen is obtained.
4- Test urine for sugar ,protein and Ketone To assess bladder or kidney infections,
diabetes, dehydration, and Pre-
eclampsia.
5- Measure accurately woman’s weight Serves as a baseline data for future
without shoes comparison and identification of
factors that may place a client at risk
for pregnancy and labor.
6- Measure accurately woman’s height To assess risk during pregnancy and
without shoes labour. Baseline data for future
comparison.
7- Measure correctly her blood pressure Serves as a baseline data and to make
sure that high blood pressure is not
affecting the growth of the baby and
to check for a condition called pre-
eclampsia.
8- Measure correctly her pulse Serves a baseline data for future
comparison.
9- Please the woman on the To make our patient comfortable
examination couch on her back while performing the procedure.
10 Explain the procedure to her For awareness purposes and also to let
- the woman know how can she
participate in the procedure.
11 Drape the woman and keep the doors This is to provide privacy for the
- and curtains patient and to make her feel
closed comfortable during the execution of
the procedure.
12 Wash your hand To minimize the spread of
- microorganisms.
13 Stand at the right side of the woman To make the woman feel supported,
- we should maintain a supportive
manner to establish rapport.
14 Examine the head . To check for symmetry, normal
- contour and tenderness.
● Check hair for lice and nits To assess the general appearance of
● Check the face for pallor the pregnant woman to check for
,edema and facial expression normal and abnormal findings.
● Check conjunctiva for degree of
redness
● Note any pigmentation on forehead
and cheeks
Examine mouth for condition of gums
and teeth
Palpate the nodes below the posterior To assess if there any palpable nodes.
angle of the Jawbone.
Check the neck for the thyroid gland To monitor for low thyroid hormone
levels that could result to
hypothyroidism during pregnancy.
16 Examination the chest In order for us to detect and monitor
- respiratory diseases.

Assist with examination of the heart and To assess for respiratory rate and
lung by preparing the woman rhythm.

Examination the breast ,nipple and Assess any breast lumps, secretions,
areola pain upon palpation of the breast, or
tenderness. And also darkening of
areola and enlargement of the breast.
17 Examine the abdomen To check for any striae and linea
- negra, the size of abdomen, shape of
the uterus that is normally occur
during pregnancy. And also for some
abnormal findings that can be a risk to
pregnancy.

5 Positioning mother on her back on a firm So that mother is comfortable and feel
- bed or secure while the examiner doing the
examination table assessment.
6 Standing at the side of bed, facing the To have an easy and full access view
- mother during the first three maneuver good for performing Leopold’s
but in the last one the nurse reverses manuever
her position and faces her feet.
7 First Manuever
-
● Ascertaining the fundus and To determine fetal part lying in the
determined its level Gently palpate [Link] determine presentation.
the fundus with the tips of the
Fingers of both hands in oreder to
define
which fetal part is present in the
fundus
8- Second Manuever
Applying the palm of the hands on To identify location of fetal back. To
either side of the mother abdomen determine position.
gentle but deep pressure is exerted to
locate the back of the fetus in relation
to the right and left sides of the mother.
9- Third Manuever

Employing the thumb and fingers To determine engagement of

grasping the lower portion of the presenting part.
maternal abdomen, just above symphasis
pubis to determine if the presenting part
is engaged or not
10
-
- Facing the mother’s feet, using the tips To determine the degree of flexion of
of the first three fingers of each hand, fetal head. To determine attitude or
making deep pressure in the direction habitus.
of the axis of the pelvic inlet to
ascertain presenting part of the
engaged head.
- Identifying the fetal position correctly.
- identifying which best place to hear
the fetal heart tone.
- Hearing the fetal heart tone and count.

1 * Auscultation
1
-.
- Place the pinard fetal stethoscope at right angles Fetal heart rate monitoring
about 5 cm above the head on the side of abdomen measures the heart rate and
where the back was felt, keep the ear in firm rhythm of your baby (fetus).
This lets your healthcare
contact with the pinard, don't touch it while
provider see how your baby is
listening. Listen carefully and count for 60 doing.
seconds.
18 Examine the extremities To check for any varicosities, edema,
- and gait.
Check the color of the palms and nails To assess for pale fingernails and
some abnormalities such as jaundice.
Check swelling of fingers Checking for the swelling of fingers
because body produces approximately
50% more blood and body fluids to
meet the needs of the developing
baby.
Examine the legs ,ankles and feet for Note for any tenderness, swelling and
shape and unequal length edema for leg length discrepancy.
Check edema over the tibia ankle and Edema occurs in 80% of pregnant
feet women and is normal. But we should
include it to ensure that it is a normal
edema or a pitting edema,

Explain the procedure & its purpose to the The very important part of every
mother. procedure is to explain first what
assessment will be done. It is a great
way to establish rapport and also for
awareness purposes in order to the
pregnant woman how she can
cooperate with the assessment.
Screen the mother’s bed. We need to prepare the bed in order
for the pregnant woman to be
comfortable during the assessment.
Ask the women & family members if the To assess if the swollen part if it
women's associated with preeclampsia, allergy,
face or hands appear swollen. or any medical condition.
Inspect the women's face, extremities and Note for the color and edema and scale
sacral area it.
for signs of pitting edema
Press each area firmly with thumb or index To know if it is a pitting edema or
finger for non-pitting. And if it goes back
several seconds & release. directly after pressing the area.
Evaluate the Extensiveness of edema, Depth To give an exact grade or scale to the
of presence of edema.
depression & Length of time it takes to clear.
Grade the pitting edema according to the The grading of edema is determined
following scale by pit depth and recovery time from
1+ =minimal edema of lower grade 0-4. The scale is used to rate the
extremities severity.
2+ =marked edema of lower
extremities
3+ =edema of the lower extremities, face &
hands
4+ =generalized, massive edema
Record your findings & compare your Important part also of every
findings with assessment is to record normal and
those previously recorded abnormal findings for future
references. And also to prove that the
assessment has been performed.

Observe legs for dilated veins Varicose veins are common usually
harmless part of pregnancy. But if
veins feel hard, warm or painful and
also color looks red then it is not
normal and can be harmless
19 Assist with pelvic examination To assess on the health of both
- internal and external reproductive
system.
20 Check the woman for danger signs of To prevent risk and also to ensure
- pregnancy. safety in the part of the pregnant
woman and be fully aware of the do’s
and dont’s during pregnancy
21 Assist the woman to get down from To ensure pregnant woman’s safety
- examination table and redress her and to avoid shivering/colds.
clothes
22 Record findings and woman’s reaction For documentation purposes for future
- references.

23 Replace equipment’s For the benefit of the next client, to

- ensure that equipments are set for the
next user.
24 Wash hands To minimize the spread of
- microorganisms.
25 Give the woman the necessary In oreder for the pregnant woman to
- instruction and date of the next visit be aware and also for preparation
purposes.

26 Refer abnormal case Refer any unusualities to have

- immediate intervention towards it.
S. Procedure# 2.1: Assessment of Performan Rationale
NO Uterine Contractions ce
. ( First Stage)
Preparation of patient & Don Not
equipment’s e don
e
1. Explain procedure to the woman. In order for the woman to be aware
of the procedure that we are going to
do, how she can cooperate and why
it is necessary. To eliminate anxiety
also in the part of our patient and to
gain patient and family’s trust.
2. Ensure woman's bladder is empty. This promotes comfort in the part of
the patient during the procedure.
Because a full bladder can
intensifies pain during labor and can
delay fetal descent.
3. Assemble equipment’s: To have an easy access of the
● Screen needed equipment that promotes
smooth flow while performing the
● Wrist watch
procedure without interruptions.
● Stethoscope / Doppler And in order to save time also.

4. Put the mother in dorsal recumbent Comfortable and efficient. It also

position & screen the mother helps the woman relax her
bed. abdominal muscle to enhance
palpation.

5. Assist the woman to relax by This will offer the woman better
encouraging her to breathe naturally control during labor. The ability to
& to take deep breaths during relax will conserve energy
throughout the first stage of labor.
contractions.
Consciously relaxing between
contractions makes the breaks more
restful. It helps also during the
second stage of labor as the woman
will find more strength for the
second (pushing) stage of labor.
6. Place fingertips of one hand on Fingertips are more sensitive that is
uterus, keep fingertips relatively why it is use to feel the tightening of
still rather than moving them over the uterus.
uterus.
7. Note time when each
contraction begins & ends to Contractions occur at regular
determine- Frequency by intervals, but the interval between
calculation average time that each contraction gradually becomes
elapses from beginning of one
contraction until beginning of shorter. Contractions are expected to
next one increase in frequency, duration and
Duration by noting average time in intensity as labor progresses. So it is
seconds from beginning to end of very important to note findings. We
each contraction.
need also to note for the duration of
Interval by noting average time
each contraction as it gradually
between end of one contraction &
increases. Intensity also of
beginning of the next one.
contractions becomes stronger and
stronger.

8. Auscultate fetal heart rate after each Auscultating the fetal heart rate after
contraction reading. each contraction allows us to detect
if the fetal heart rate is within
normal range or abnormal range.
Fetal heart rate increases during
contractions and returns to normal
after baby moves or after a
contraction.
9. Monitor the vital signs for the To ensure vital signs remain within
woman. normal limits.
10. Observe the woman for any Uterine activity was found to affect
abnormal uterine contractions fetal heart rate in all participants. 
and fetal heart rate. The fetal heart rate may change as
your baby responds to conditions in
your uterus. An abnormal fetal heart
rate may mean that your baby is not
getting enough oxygen or that there
are other problems. 
11. Wash hands and document the This is to minimize the spread of
finding. microorganisms and also
documenting the findings and
procedures offered will serves as
future references and means of
communication to other healthcare
provider.
S. Procedure #2.2: Auscultating Performan Rationale
NO Fetal Heart Rate during Labor ce
.
Preparation of patient & Done No
equipments t
do
ne
1. Explain procedure to the woman. In order for the woman to be aware of
the procedure that we are going to do,
how she can cooperate and why it is
necessary. To eliminate anxiety also in
the part of our patient and gain trust.
2. Ensure woman's bladder is empty. This promotes comfort in the part of
the patient during the procedure.
Because a full bladder can make the
procedure be interrupted and
uncomfortable.
3. Assemble equipments: To have an easy access of the needed
● Doppler device equipment that promotes smooth flow
while performing the procedure
● Ultrasonic gel
without interruptions. And in order to
save time also.

4. Place the ultrasonic gel on the To have an access of the woman’s

diaphragm of the Doppler. abdomen that enables us to proceed
with the execution of the procedure.
5. Place the Doppler diaphragm on the This position is generally a good place
woman’s abdomen halfway to locate fetal heart sounds.
between the umbilicus and symphysis
and in the midline.
6. Check the woman’s pulse against the We need to reposition the Doppler
fetal sounds you hear. If the because we’re probably hearing the
rates are the same, reposition the mother’s heart sounds and need to
reposition the device for us to locate
Doppler.
fetal heart sound.
7. If the rates are not similar, count the We should count it for a full minute
FHR for 1 full minute. and listen closely for any increases or
decreases in rate.
8. Auscultate the FHR between, To identify any abnormal features and
during and for 30 seconds ensures normality. This is done to
monitor fetal heart rate as it increases
following a uterine contraction. during uterine contractions and need to
auscultate to check if FHR goes back to
normal following a uterine contraction.
9. This is for future references and also
Document the fetal heart rate count.
serves as a means of communication to
other healthcare provider to see how
the baby is doing and the procedures
that has been done.

S. Procedure 2.3 :Vaginal Perform Rationale

NO. Examination During Labor ance
Preparation of patient & D No
equipments o t
n do
e ne
1. Explain procedure to the woman & Maintaining privacy enable the woman
maintain privacy. to be comfortable during the procedure,
it also preserve the modesty of the
woman. And explaining the procedure
to the woman in order for her to be
aware of the procedure that we are
going to do, how she can cooperate and
why it is necessary. To eliminate
anxiety also in the part of our patient
and gain trust.
2. Ensure woman's bladder is empty. This promotes comfort in the part of
the patient during the procedure.
3. Assemble equipment’s: To have an easy access of the needed
● Sterile gloves equipment that promotes smooth flow
while performing the procedure
● Screen
without interruptions. And in order to
● Lubricating jelly
save time also.
● Antiseptic solution (Dettol /
savlon)
● Sterile pad
4. Assist woman into supine position This position provides better access to
on exam table with lower the genital tract than the other
extremities flexed and rotated positions.
outward, her heels should be
supported in stirrup which are level
with the table about 1 - 2 Ft
in front of her buttocks [Lithotomy
position].
5. Assist the woman to relax by This will offer the woman better
encouraging her to breathe control during labor. The ability to
naturally. relax will conserve energy throughout
the first stage of labor
5.. Expose the perineal area for This is to assess for any risks during
examination. delivery. Most commonly this is done
to help management of perineal trauma.
6. Prepare the area with antiseptic This prevents the spread of organisms
solution. from perineum to the birth canal.
7. Put on gloves, from standing position To maintain standard precautions and
using thumb & fore finger of non- also positioning hands in this way
dominant hand to spread the labia. allows for good perineal visualization.
8. Insert the well lubricated index & This method allows for inspection of
middle fingers of dominant hand into the vaginal walls during insertion and
the vagina until they touch the cervix, ensures that the cervix is found
using downward & upward direction
and keep thumb of dominant hand
upward
and supported on vulva.
9. Note presentation, position of fetus,
cervical dilatation& To identify whether there are any
effacement, station of fetal head, danger signs that could make labor and
status of membranes. delivery difficult and put the mother
and baby at risk. The baby is head
down at the time of birth.

10. Provide care with antiseptic solution To clean and prevent infection.
& put on sterile pad after To catch or this is where the lochias or
care. any dischrages will be placed.
11. Remove the equipment & gloves. To maintain standard precautions
gloves are generally the most
contaminated equipment and prevent
the spread of infection.
12. Wash hands and document the This is to minimize the spread of
finding. microorganisms and also documenting
the findings and the procedures offered
will serves as future references and
means of communication to other
healthcare provider.
S. Procedure 2.4 STEPS External Performance Rationale
NO. Electronic Fetal Monitoring
Preparation of patient & Done Not
equipments don
e
1 Explain procedure to the woman. Explaining the procedure to the
. woman in order for her to be
aware of the procedure that we are
going to do, how she can
cooperate and why it is necessary.
To eliminate anxiety also in the
part of our patient and gain trust.
2 Assemble equipments: To have an easy access of the
. ● Monitor needed equipment that promotes
smooth flow while performing the
● Two elastic monitor belts
procedure without interruptions.
● Tocodynamometer And in order to save time also.
● Ultrasound transducer
● Ultrasonic gel
Procedure
3 Turn on the monitor. So we can see what we are looking
. for during the ultrasound.
4 Place the two elastic belts around the These belts will detect the fetus’
. woman’s abdomen. heartbeat. Position it on the area
where the heartbeat is audible.
5. Place the tocodynamometer over the A tocodynamometer is a pressure-
uterine fundus off the midline on the sensitive device. Which placed
area palpated to be most firm during on the mother’s abdomen over the
area of strongest contractions to
contractions. Secure it with one of the
measure the length frequency and
elastic belts. strength of urine contractions.
Because both uterine contractions
and fetal heart rate are recorded at
the same time.
6. Note the uterine contraction tracing. The Uterine contractions:
resting tone tracing Every 3 to 4 min. lasting 60 to 8o
should be recording on the 10 or 15 mm sec. with an intensity of 75 to 90
Hg pressure line. mmHg and resting tone of 20 to 25
mmHg. Increased uterine resting
tone is called hypertonus and is
usually defined as resting tone
exceeding 20-25 mmHg or a
uterus that does not palpate as soft
if using palpation. Hypotonia an
abnormalities of the motor system
in infants. A decreased resting
tone.
7. Apply the ultrasonic gel to the Ultrasound waves have a hard time
diaphragm of the ultrasound travelling through the air and so
transducer. ultrasound gel is applied to skin
and the ultrasound transducer. The
gel acts as conductor of sound as it
echoes.
8. Place the diaphragm on the For this is the strongest contraction
maternal abdomen in the midline
between the umbilicus and the
symphysis pubis.
9. Listen for the FHR. Listen if the heartbeat is audible or
not. And then if not then find
another spot.
10. When the FHR is located, attach the Because the elastic belts may be
second elastic belt snugly to slight uncomfortable. You must lie
the transducer. still during some types of fetal
heart rate monitoring. 2 elastic
belts with sensors are placed
across your belly and 1 sensor
tracks your baby’s heart rate with
reflected sound waves (Doppler
ultrasound). While the other will
measure how long your
contraction are if you are having
any.
1 Place the following information on the This will serve as baseline data
1. beginning of the fetal and will be used for future
monitor paper: date, time, comparison or reference on the
progression of pregnancy.
woman’s name, gravida, para,
membrane status and name of
doctor & nurse- midwife.
12. Document about maternal and fetal For documentation purposes that
condition. could be used in the future.
PROCEDURE # 2.5: HANDLING AND Done Not Rationale
ASSISTING A DELIVERY Done

Newborn tray; cord clamp, identification band,

suction tube, alcohol swab, scissor, eye drop, towel.

1. Put on a bonnet and a mask. To avoid loose hair and to

protect oneself from infection
or contamination.

2. Do hand washing with soap and water. This is a universal precautions

to avoid the spread of
microorganisms.

PRIOR TO PATIENT’S TRANSFER TO THE

DR:

3. Ensure that mother is on her position of choice To provide comfort

when in labor.

4. Ask mother if she wishes to drink/ eat. In order to have energy if ever
she needs water.

5. Communicated with the mother - informed her of To provide emotional support

progress of labor, gave reassurance and and comfort, also to help
encouragement. patient feel in control and
build their confidence during
labor.

PATIENT ALREADY IN THE DR (Put check in It’s in the first stage of labor
the box if step was done) during transitional phase 8-10
cm.

Preparing for Delivery

6. Check temperature in the DR area, check for air Temperature should be 25-28
draft. degree, in checking the
airdrop get a piece of tissue if
the tissue is moving there’s
air, check if the doors and
windows are close. This is
also to avoid hypothermia to
the baby and chills to the
mother.

7. Ask patient if patient is comfortable in the semi- It provides flexibility for

upright position which is default position. continuous monitoring and
assist effectively. This allows
pelvic outlet and also good for
resting position.

8. Remove all jewelry. Because jewelry can harbor

microorganisms and prevent
scratches and bleeding.

9. Wash hands thoroughly observing the proper To avoid transfer of

procedure. pathogenic microorganisms
which can cause infection.

Arrange things in a linear fashion: This is for an easy access and

time efficient so you must
Gloves, dry linen, bonnet, oxytocin injection, plastic arrange them accordingly.
clamp, instrument clump, scissors, 2 kidney basins.

Clean the perineum with antiseptic solution. To reduce the number of

bacteria that is present
because it can move through
the uterus and in the wound
that causes infection.

Washed hands. To stop spread of bacteria.

AT THE TIME DELIVERY

Encourage woman to push as desired. To prepare for enough energy

for the baby to be pushed
outside the uterus.

Applied perineal support and did controlled delivery To help reduce the severity of
of the head. perineal tearing to make sure
that the head is defined.

Called out time of birth and sex of baby. So that it will be recorded by
the circulating nurse.

Informed the mother of outcome. So the mother will know the

condition of the baby.

First 30 Seconds

Placed the baby on a clean, dry cloth/ towel on the To prevent hypothermia, keep
mother’s abdomen. the baby warm, stimulate
breathing and to create bond.

Thoroughly dried baby for at least 30 seconds, This is to stimulate the baby
starting from the face and head, going down to the to breath. Do not wiope the
trunk and extremities. vernix caseosa because it will
protect the baby from
hypothermia.

1-3 Minutes

Remove the wet cloth. To prevent possible infection

since this is used cloth
already.

Placed the baby on skin-skin contact on the mother’s For bonding time. This also
abdomen. relaxes both the baby and the
mother.

Cover the baby with a clean, dry cloth/towel. To protect the baby and
provide warmth.

Covered baby’s head with a bonnet. To provide extra warmth.

Excluded a second baby by palpating the abdomen. To make sure there is no other
Used the wet cloth to wipe the soiled gloves. Gave baby in the uterus and
IM oxytocin within one minute of baby’s birth. oxytocin prevents bleeding
Disposed of the wet cloth properly. and stimulates contraction.

Remove the first set of gloves. To avoid infection. Make sure

to remove it before touching
the umbilical cord to avoid
infection.

Decontaminate this properly (by soaking in 0.5% To eliminate microorganisms

chlorine solution for at least 10 minutes.) before disposal.

Palpated umbilical cord to check for pulsations. To make sure pulsation stops
before clamping. Wait 1-3
min. until it stop to prevent
anemia and protect pre terms
from intraventricular
hemorrhages.
After pulsations stopped, clamp cord using the plastic To stop blood from going out.
cord clump at 2 cm from base. Also waiting for the
pulsations to stop allows
blood from the placenta to
continue being transferred to
the baby even after they are
born. Cutting the cord is part
of the stimulus that initiates
baby’s first breath.

Placed the instrument clamp 5 cm from the base. Proper clamping helps to
prevent anemia and lower rate
of intraventricular
hemorrhages.

Cut near plastic clamp (not midway). In order to not make it too
long.

Perform the remaining steps of the active Delivery of the placenta.

management of third stage of labor:

Waited for strong uterine contraction then applied This is to done the process
cord traction and counter traction on the uterus, easily and the delivery of
continuing until placenta was delivered. placenta.

Signs of placental
separation:

-lengthening of the umbilical

cord

-sudden gush of blood

-firm uterine contraction

-visible placenta at vaginal

opening

Placental Delivery:

S= Schultz (S for shiny)

D= Duncan (D for dirty)

Massage the uterus until it is firm. To prevent post-partum

hemorrhages.

Inspect the lower vagina and perineum for So we will know and be able
lacerations/ tears and repaired lacerations/ tears if to close lacerated skin to
necessary. bring back to its normal stage
through healing the wound.

Examine the placenta for completeness and Evaluating placental

abnormalities. completeness is of critical,
immediate importance in the
delivery room, this is to partly
to make sure that entire
placenta is expelled after birth
and it can also tell you so
much about your pregnancy
like your health.

Cleaned the mother: flushed perineum and applied To reduce the risk of
perineal pad/ napkin/ cloth. infections and use perineal
pad to absorb and retains
bloods.

Check baby’s color and breathing; checked that To ensure that there is no
mother was comfortable, uterus contracted. complications to both.

Disposed of the placenta in a leak- proof container or To prevent leaks or spillage of

plastic bag. blood.

Decontaminated (soaked in 0.5% chlorine solution) This helps in preventing

instruments before cleaning; decontaminated 2nd pair contaminations and spread of
of gloves before disposal. microorganisms.

Advise mother to maintain skin-to- skin contact. This calms and relaxes both
Baby should be prone to mother’s chest/ in between mother and baby and
the breast with head turn to one side. regulates baby’s HR and
breathing.

15-90 Minutes

Ask the mother to observe for feeding cues (cited Feeding cues such as rooting,
examples). licking, facial expression
changes, arm, leg and arms
movement, fussing.

Supported mother, instruct her on positioning and To seek out the nipple or help
attachment. mother to know how to breast
feed. And be familiar with
correct positioning.

Waited for full BREASTFEED to be completed. In order to ensure that the

baby drinks enough milk.
After a complete breastfeed, administered eye Eye ointment to prevent pink
ointment (FIRST), did through physical examination, eye in the 1st month of life or
gave Vit. K, hepatitis B and BCG (simultaneously ophthalmia neonatorum
explain purpose of each intervention).
Vit. K- blood clotting and
prevent bleeding (Im/Vl)

Hep B- prevent Hep B

BCG- prevent TB

Advise OPTIONAL/ DELAYED bathing of baby After 6 hours- this is to

( and was able to explain rationale). prevent hypothermia and
infection. To prevent vernix
caseosa from being wipped
off.

Advise breastfeeding for demand and about danger To acquire adequate nutrion.
signs for early referral. And for the mother to know
what to do if there is any
signs of danger.

In the first hour: checks baby’s breathing and color; 4th stage of labor: the recovery
and check mother’s vital signs and massage uterus stage. This is to ensure that
every 15 minutes. the baby is breathing normally
or to monitor vital signs.

In the second hour: check mother’s baby dyad every To provide care for the
30 minutes to 1 hour. mother and the baby while
they are in a optimally skin-
to-skin position

Complete all records: administered eye ointment, Vit To avoid baby from acquiring
K, hepatitis B and BCG. infections and diseases.

Total Score

Equivalent Grade

*With client

Signature of C.I.

Signature of Student

Date Performed
APGAR Scoring

Mother name: Date of Delivery:

Time of delivery: Sex of baby:

Procedure Steps Zero 1 2 1min 5min

1. Respiratory Absent Slow irregular Good cry

effort
2. Heart Rate Absent Below 100 B/M Over 100
B/M
3. Muscle tone Flaccid Some flexion of Well flexed
limbs
4. Reflex No response Grimace Cough or
sneeze
5. Color Blue or pale Body pink, limbs All pink
blue
Total

Apgar Score Risk:

1-4 H.R High Risk.

5-7 M.R Moderate Risk.

7-8 S.R Small Risk.

10 Normal
S. Procedure 3.1 : Assessment of Uterine Performa Rationale
NO. Fundus Postpartum nce
Preparation of patient & Do Not
equipment’s ne do
ne
1. Explain procedure to the woman & maintain In order for the woman to be
privacy. aware of the procedure, reduce
her anxiety, be comfortable
and also to establish trust.
Maintaining privacy allows
woman to be comfortable and
secure and also to protect
woman’s dignity since this
procedure we need to expose
woman’s private part.
2. Ensure woman's bladder is empty. We need to ensure woman’s
bladder is empty as it can
make woman uncomfortable
during the procedure.
3. Assemble equipment: This is to have an easy access
● Clean & Sterile gloves of all the equipment needed.
Have a smooth flow in doing
● Screen
the procedure.
● Antiseptic solution (Dettol / savlon)
● Sterile pad
4. Assist woman into supine position. This is to have a full access of
mother’s abdomen and areas
that needs to be assess.
5. Assist the woman to relax by encouraging In order for the woman to have
her to breathe naturally. better control and also to
eliminate discomfort during
the procedure.
Procedu
re
6. Gently place one hand on the lower This is for us to locate the top
segment of the uterus. Using the side of the of fundus to be examine.
other hand, palpate the abdomen until you
locate the top of the fundus.
7. Determine whether the fundus is firm. If it Determining whether the
is, it will feel like a hard round object in the fundus is firm or not will let us
abdomen. If it is not firm, massage the know what nursing
abdomen
intervention should be done. If
lightly until the fundus is firm.
it is not firm we will going to
massage it lightly not in a
vigorous manner in order to
make the fundus firm to avoid
bleeding or postpartum
hemorrhage.

8. Measure the top of the fundus in For us to know where exactly

fingerbreadths above, below or at the the top of the fundus located.
fundus.
9. Determine the position of the fundus in In order for us to know if
relation to the midline of the body. If it is fundus is place in the proper
not in the midline, locate it and then area. If it is not place on the
midline of the body, it means
evaluate the bladder for distention.
there is a presence of bladder
distension (then we will offer
NI afterwards).
10. If the bladder is distended, use nursing Nursing measures such as,
measures to help the woman turning on the faucet and let
void. the water flow and also offer
cold compress as it can also
trigger urination.
11. Measure urine output for the next few hours This is for us to know if
until elimination is mother is experiencing
established. oliguria. (we need to offer
urine cup to the mother and
then see later on if how many
ml. 30 ml per
hour(OLIGURIA)
12. Assess the lochia. For us to know if the lochia is
normal.
13. Remove bloody pads, clean perineum & Remove bloody pads in order
pads, clean perineum & apply to check for the lochia. And
sterile perineal pad. also clean perineum to avoid
future infection and then after
cleaning apply new sterile pad
to the woman for discharges.
14. Record consistency & location of the Record everything, the
fundus, bleeding & perineum. observation upon doing the
procedure, result of the
assessment for future
references and also it will
serves as a communication to
other healthcare provider.
15. Report a fundus that does not stay firm. If fundus does not stay firm
we need to report it to have
immediate intervention to
avoid serious complication in
the near future.
16. Make the woman comfortable and wash To make the woman feel our
hands. care and support and also
washing hands following the
medical way to minimize
transfer of the
microorganisms.
Performe
d Rationale
Preparation Y N
es o
1. Assess
● The breast tissues for lump and cysts that may
be require further medical evaluation
● Breast size ,shape and symmetry
● The elasticity of breast tissues
● Examination of the areola and nipple
● The nipple is assessed for evidence of blister
,cracks or fissures
● The nipple is also assessed for its type and size
Procedu
re
1. Prepare equipment
2. Welcome the woman
3. Put the mother in a sitting position.
4- Palpate the supra clavicle area.
5- Palpate axillary’s nodes: hold women's forearm in
your left palm while you check nodes with your
right
fingertips rotate in the other side.
6- Instruct woman to lie down with her right arm under
her head and place a small pillow under her
right shoulder.
7- With the flatten surface of 2 or 3 fingers gently
palpate breast tissue beginning at the upper outer
quadrant.
8- Repeat procedure for other breast.
9- Check the areola area for crustiness, nipple,
and discharge signs of infection.
10 Record finding and report abnormalities to the
- physician.
11 Instruct the mother to perform breast self-
- examination and encourage her to ask any questions
Procedure3.3: Breast Care Perform
ed Rationale
Y N
e o
s
1. Assess
● The breast tissues for lump and cysts that may
be require further medical evaluation
● Breast size ,shape and symmetry
● The elasticity of breast tissues
● Examination of the areola and nipple

● The nipple is assessed for

evidence of blister ,cracks or
fissures
● The nipple is also assessed for its
type and size
Equipment

● Water
● Disposable Gloves
● Cotton &gauze

1 Prepare equipments in suitable bed

. side table.
2 Wash hands with water & soap
.
3 Keep privacy of mother
-
4 Put the mother in a sitting position.
-
5 Expose the Mother's Breast and
- place Macintosh Under breast.
6 Inspect and palpate the Breast and
- nipple.
7 Massage the Breast from up to down
- toward the areola and nipple.
8 Express few drops of colostrum or
- Milk from the Breast.
9 Clean the Breast by warm water
- beginning with nipple and areola
and going outward in a circular
motion.
1 Dry the breast and apply a piece of
0 gauze on the nipple and areola.
-
1 Clean the other breast in the similar
1 manner.
-
1 In case of breast engorgement ask
2 mother to wear suitable bra and
- express the milk out as much as
possible.
1 Discard paper bag with wastes.
3
-
1 Cover the mother's Breast.
4
1S. InstructProcedure3. 4 Perineal
mother about importanceExamination
of Performa Rationale
5NO. Breast care and Breast feeding. nce
1 Preparation of patient &
Record observations. Do Not
6 equipments ne do
ne
1. Explain procedure to the woman &
maintain privacy.
2. Ensure woman's bladder is empty.
3. Assemble equipments:
● Screen.
● Sterile gloves
● Macintosh
● Flash light.
4. Request the mother to assume a Sims
position & flex her upper
leg & expose perineum.

5. Wash hands and wear gloves.

6. Place macintosh under mother's hips.
7. Lower the perineal pad & lift the superior
buttocks.
Use a flashlight.
8. Note the extent & location of edema or
bruising.
9. Examine the episiotomy or
laceration for (REEDA) Redness,
Ecchymosis, Edema, Discharge &
Approximation.
10. Note number & size of hemorrhoids.
11. Instruct mother to turn on back & cover
her.
12. Remove the equipments & wash hands.
13. Report any abnormalities.
S. Procedure 3.5 :   Perineal Care Performance Rationale
NO.
Preparation of patient & Done Not
equipments done
1. Explain procedure to the woman & maintain privacy.
2. Ensure woman's bladder is empty.
3. Assemble equipments:
 Sterile gloves.
 Macintosh
 Paper bag.
 Sterile Perineal Pad.
 Dressing set
 Sterile cotton swabs in bowl
 Antiseptic solution
 Bedpan (if required)
4. Position the mother in dorsal recumbent position.
Proce
dure
5. Wash hands and wear gloves.
6. Place macintosh under mother's hips.
7. Remove soiled pad from front to back.
8. Observe color, amount and odor.
9. Wrap soiled pad &throw it in paper bag.
10. Test the temperature of the antiseptic solution and pour
over vulva.
11. Use dressing set & swabs for cleaning according to the
following direction:
 Mons pubis from the level of clitoris upward to
the lower abdomen in a zigzag line.
 Both thighs from medial to lateral in a zigzag
line.
 Labia majora (both side) from upward
to downward in a single motion.
 Labia minora (both side) from upward
to downward in a single motion.
 The introitus from upward to downward in a
single motion.
 Anus downward in a single motion.
12. Dry the perineum using the same technique and put
sterile perineal pad
from up to down without touching the surface close to
the woman.
13. Rearrange bed, clothes & make the women comfort.

14. Remove screen & equipment from bed side and wash
hands.
15. Record and report the date & time of procedure,
discharge, genitalia
condition and any abnormalities.
Procedure 3.6 : Umbilical cord care
Perform Rationale
ed
Preparation Yes N
o
1 Equipment
. ● 2Sterile small iodine
● Sterile cotton sponges
● Antiseptic solution ,alcohol
60%
● Sterile forceps and\or gloves
● Ordered medicine if required
● Paper bag or kidney basin
Procedure
1 Prepare equipment
.
2 Explain the procedure to the
. mother
3 Prepare environment (tidy, clean,
. avoid air draft )
4 Prepare baby
-
5 Hold the umbilical cord away from
- the skin with
one hand
6 Wipe the stump and the area
- around the umbilicus by the other
hand ,using an antiseptic solution
,alcohol 60%
7 If the cord drops off, wipe the
- granulating area
(Stump) using antiseptic.
8 Dry the area carefully
-
9 Observe the cord for
- -Signs of bleeding
-Signs of infection
-Any other abnormality as hernia
-Abnormalities in the vein and
arteries.