INTRAPARTUM : DELIVERY ROOM TECHNIQUE

Purpose:
1. To strengthen woman’s coping with active labor and transition
2. To promote comfort
3. To provide safe environment for the mother and new born.
4. To practice strict aseptic technique throughout the procedure.
5. To promote initial mother and child bonding.

Materials/ Instruments Needed:

1. (1) Allis forceps
2. (1) Curve Kelly forceps
3. (1) Straight Kelly forceps
4. (1) Curve mayo scissor
5. (1) Straight mayo scissor
6. (1) Kidney basin with dry cotton balls ( to be poured with betadine for perineal prep)
7. (1) Straight catheter
8. (1) Suction bulb 12. Sterile OS
9. (1) Pair of leggings / drape 13. Pail / Basin
10. (2) Sterile towels 14. Kelly Pad
11. (1) adult diaper

IF WITH EPISIOTOMY OR LACERATION:

1. (1) Needle holder
2. (1) Thumb forceps
3. (1) 5 cc syringe with needle ( for local anesthesia)
4. (1) Poly/amp. Lidocaine 2%
5. Sterile OS or napkin (per agency policy)
6. Chromic 2/0 (cutting and round)

Assessment:
Assessment should focus on the following:
1. Assess if the patient is the transitional phase of the first stage of labor process.
2. Assess for fetal condition by auscultation of the fetal heart tone.

Nursing Diagnosis:
Nursing Diagnosis may include the following:
MOTHER
1. Anxiety related to impending delivery
2. Acute pain related to uterine contraction/ descent of the fetus.
3. Ineffective coping related to discomfort
4. Impaired urinary elimination related to pressure of the fetus
5. Ineffective breathing patter related to pain and fatique.
6. Risk for infection related to rupture of membranes/episiotomy and tissue trauma
7. Impaired tissue integrity related to placental separation.
8. Risk for injury related to potential hemorrhage

NEWBORN DIAGNOSIS
1. Ineffective airway clearance related to nasal and oral secretions from delivery
2. Ineffective thermoregulation related to environment and immature ability for adaptation.
3. Risk for injury related to immature defense of the neonate.

Outcome Identification and Planning:

1. Accomplish hand washing correctly
2. Informs mother regarding the maintenance of aseptic technique
3. Slowly and clearly explains the events and changes occurring as labor progresses
4. Wears prescribed DR attire which includes cap, mask, and rubber slippers.
5. Prepares the instruments and turns on the necessary lights.
6. Identifies procedure correctly.

Desired outcome includes the following:

 MOTHER:
1. Client will verbalize positive statements about delivery outcome
2. Client will report pain is decreased from comfort strategies.
3. Client’s bladder will remain non-distended.
4. Client will remain free from signs of infection
5. Client will use breathing techniques during contraction
6. Client will deliver an intact placenta
7. Client’s blood loss will be controlled and hemorrhage prevented
8. Client’s vital signs will remain stable and uterus remain firm at midline
9. Client will interact with her newborn.

IMPLEMENTATION
Nursing Action Rationale
1. Assist patient into a lithotomy position  Provides the best position for
(or other alternative birth position per performing an episiotomy and for
agency policy) viewing the perineum to detect
laceration or other problems at birth.
2. Checks bladder for fullness and  A full bladder or bowel can impede
encourage voiding or catheterize as fetal descent.
needed.
3. Cleans the perineum using correct  Perineal care helps to remove any
technique. possible drainage or secretions from
the birth canal that may pose a risk
for infection.
4. Don/wear gloves.  To prevent exposure to client’s body
secretion.
5. Drapes the client properly.  To create a sterile field and provide
patient’s privacy.
6. Instruct to bear down properly (push with  Promotes effective second-stage
contractions), coaches to take deep pushing.
breaths as soon as contraction begins.
7. Encourages to keep both legs flexed  To promote comfort; avoid ligament
and firm on the stirrup. strain, backache or injury
8. Performs Ritgen’s maneuver properly/  To control the rate at which the head is
safely while fetal head is being delivered. born and prevent laceration of the
perineum.
9. Checks for nuchal cord, loosen and slip  Umbilical loop could tear and interfere
over the head if possible; if cord cannot be fetal oxygen supply.
slipped over the head, it is clamped using
two clamps and cut between the clamps.
10. Notes and records time the baby was  For proper identification
delivered and the gender.
11.Thoroughly dries baby for at least 30  To prevent hypothermia, stimulate
seconds starting from the face and head, breathing and determine the ability to
going to the trunk and extremities while adjust in the extrauterine life.
performing a quick check for breathing;
evaluate the APGAR score 1 min. and 5
min. after birth
12. Places neonate on the maternal  To initiate parent-child bonding.
abdomen.

13. Clamps cord using 2 Kelly hemostats,  Clamping the cord is part of the
support and cut in between them using stimulus that initiate a first breath. The
mayo scissor. (Follow agency policy on infant’s most important transition to the
cord length.) outside world establishing of
independent respiration is made.
14. Delivers the placenta when signs of  Delivery of the placenta should not
placental separation is observed and note take more than 30 min.
the time.
15. Checks placenta for presentation  Duncan placental presentation carries
(Schultz or Duncan). Assess amount of a slightly increased risk of retained
blood loss. placental fragments due to incomplete
separation. To check if placenta is
complete or intact.
16. Palpates and massages the  To ensure uterus is firm and
hypogastric area (fundus of the uterus) contracted and prevent bleeding.
17. Inspects perineum for presence and  To prevent bleeding.
degree of laceration. Assists in repair of
laceration.
18. Cleans the perineum and buttocks  To minimize risk of infection and
area. promote comfort.
19. Do after care of the instruments used  To restore cleanliness and orderliness
and unit of responsibility. of the unit.

INTRAPARTUM: PERFORMING NORMAL SPONTANEOUS VAGINAL

DELIVERY TECHNIQUE

IMPLEMENTATION
Nursing Action Rationale
1. Places client’s hand on handgrip and  Tug of war pushing technique uses the
explains its purpose (elbow out technique) natural bearing down effort of the
abdominal muscles. This method also
causes minimal change in the maternal
blood pressure and relaxes the perineum.
To get force during bearing down effort.
2. Checks client’s necessary articles needed  To maintain adequacy of supplies as
for delivery. delivery progresses; manage resources,
equipments and environment.
3. Monitors fetal heart tone.  To identify non-reassuring or unfavorable
fetal heart rate characteristics that may
indicate a fetus at risk for asphyxia.
4.Instructs to bear down properly, coaches to  Promotes effective second-stage pushing;
take deep breaths as soon as contraction the birth process expense a great deal of
begins(Proper pushing and breathing energy. Encouraging proper pushing and
techniques). breathing techniques conserves maternal
energy.
5. Wipe mucous from face, mouth and nose,  To remove secretion from the neonate’s
establishes initial airway clearance using bulb mouth and nose.
suction.
6. Using a sterile blanket, hold newborn firmly  To avoid slipping of the baby; prevent
and close to the introitus with head in a slightly tension to the cord and to allow secretion to
dependent position. drain from the mouth and the nose.

7. Safely lay the infant on the radiant heat  To facilitate thermoregulation.

warmer.
8. Provide immediate newborn care:  Gentle suctioning removes secretions that
A. Maintains airway by suctioning mouth first may collect in these areas. Suctioning
then the nose. mouth before the nose prevents possible
aspiration of oral secretion.
B. Maintains body temperature  Newborns have difficulty conserving body
 Dries the neonate immediately after heat. Exposure to cold increases the
delivery metabolic rate, increasing the need for
 Cover neonates head with towel or cap oxygen and further the respiratory rate.
 Wrap neonate snugly with warm towel
C. Place Identical identification bracelets on  To prevent risk of switching babies and
the mother and the neonate ( follow agency kidnapping.
policy)
9. Performs immediate cord care and notes the  To minimize bacterial colonization and
cord vessels. identify congenital anomalies.
10. Places ice pack over the uterine fundus  To promote uterine contraction and prevent
bleeding.
11. Monitors maternal vital signs every 15 min.  To evaluate maternal post partum condition
for 1 hour until stable. and prevents complications.
12. Places adult diaper and change soiled  To promote comfort.
gown.
13. Assists in the after care of the unit.  To restore cleanliness and orderliness of
the unit.
14. Safely transfers mother to the stretcher per  To prepare transport to post partum unit.
doctor’s order.

birth of the head with application of

modified Ritgen maneuver

Third Stage of labor- Placenta

Evaluation:

MOTHER
1. Client verbalizes positive statements about delivery outcome.
2. Client reports pain is minimized from comfort strategies.
3. Client’s bladder remained non-distended.
4. Client shows no signs of infection.
5. Client utilizes breathing techniques during contraction
6. Client delivers an intact placenta
7. Client’s blood loss was controlled and hemorrhage prevented.
8. Client’s vital signs remained stable and uterus is firm at midline.
9. Client bonds with her newborn.

NEWBORN
Objectives of immediate newborn care
 1. To establish, maintain and support respirations
2. To provide warmth and prevent hypothermia.
3. To ensure safety, prevent injury and infection.
4. To identify actual or potential problems that may require immediate attention.

DOCUMENT
1. Newborn transitions appropriately as evidenced by an APGAR score of 7 -10
2. Newborn’s temperature remained within normal limits
3. Newborn has ID bracelet on and newborn care completed.

Instruction to the mother on cord care:

1. No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that cord does not get
wet by water or urine.
2. Do not apply anything on the cord such as baby powder or antibiotic, except the prescribed antiseptic
solution which is 70% alcohol.
3. Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when
the diaper soaks with urine.
4. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and
separates more rapidly if it is exposed to air.
5. If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose and fasten.
6. Report any unusual signs and symptoms which indicates infection.
 Foul odor in the cord
 Presence of discharge
 Redness around the cord
 The cord remains wet and does not fall off within 7 to 10 days
 Newborn fever

THE APGAR SCORING SYSTEM

The APGAR Scoring System was developed by Dr. Virginia Apgar as a method of assessing the
newborn’s adjustment to extrauterine life. It is taken at one minute and five minutes after birth. With depressed
infants, repeat the scoring every five minutes as needed. The one minute score indicates the necessity for
resuscitation. The five minute score is more reliable in predicting mortality and neurologic deficits. The most
important is the heart rate, then the respiratory rate, the muscle tone, reflex irritability and color follows in
decreasing order. A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160 signifies
distress.

DOCUMENTATION:

The following should be noted on the client’s chart:

1. Clients Post partum condition:

 Vital signs
  Uterine fundal tone, height and position
 Amount of vaginal bleeding
 Perineum of edema, discoloration, bleeding or hematoma formation
 Episiotomy for intactness and bleeding

2. Neonate’s APGAR score, sex, time of delivery, time placenta was delivered.

Signs 0 1 2
Respiratory Rate Absent Slow ,weak Good cry
cry
Reflex irritability No Grimace Cry
response
Pulse , heart rate Absent Slow >100
(<100)
Skin Color Blue Body pink Completely Reference:
pale extremities pink
blue 
Silbert-Flagg and Pillitteri
Muscle Tone Flaccid Some Well flexed (2018).Maternal & Child Health Nursing,
flexion of Care of the Childbearing and
extremities
Childrearing Family 8th Ed.
 Pillitteri, Adele (2014). Maternal & Child Health Nursing, Care of the Childbearing and
Childrearing Family 7th Ed.
 Pilliteri A. (2007) Care of the Child Bearing and Child Rearing Family. 5 th Edition Lippincott
Williams & Wilkins.
 Doenges, H. & M. ( 2006). Nurses Pocket Guide Diagnoses Prioritized Intervention and
Rationale 10th Edition.
 Smith T., Jean & Johnson, Young, J. (2006). Nurses Guide to Clinical Procedures. 5 th Edition.
Philadephia: Lippincott Williams & Wilkin.
 Woodring B.C. (2005)Pediatric Nursing Made Incredibly Easy. Lippincott, Williams & Wilkins.
 Udan Q.J. (2004) Mastering Fundamentals of Nursing Concepts and Clinical Application 2 nd
Edition. Educational Publishing House.
 Engstrom, J. ( 2004). Maternal-Neonatal Nursing, Made Incredibly Easy. Lippioncott Williams
& Wilkins.

PERFORMING NORMAL SPONTANEOUS VAGINAL

DELIVERY TECHNIQUE
Evaluation Tool

Purpose:
1. To strengthen woman’s coping with active labor and transition
2. To promote comfort
3. To provide safe environment for the mother and new born.
4. To practice strict aseptic technique throughout the procedure.
5. To promote initial mother and child bonding.

PRIOR TO WOMAN’S TRANSFER TO THE

RATIONALE
DR
1. Ensures that mother is in her position of
choices while in labor
2. Assist patient into a lithotomy position or Provides the best position for
other alternative birthing position as per performing an episiotomy and for
agency policy. viewing the perineum to detect
 laceration or other problems at birth.
3. Asks mother if she wishes to eat /drink or
void
4. In the absence of active labor, checks for an A full bladder or bowel can impede
empty bladder. fetal descent.
5. Communicates with the mother – informed
her of progress of labor , gave reassurance
and encouragement
WOMAN ALREADY IN THE DR RATIONALE
6. Checks temperature in DR area to be 25-28 º This will prevent hypothermia of the
Celsius; eliminated cold air draft. baby.
7. Asks woman if she is comfortable in the
semi-upright position (the default position of
delivery table)
8. Ensures the woman’s privacy by closing
windows or providing screen.
9. Removes all jewelry then washed hands
thoroughly observing the WHO 1-2-3-4-5
procedure.
10. Prepares a clear, clean newborn This is needed to ensure the safety of
resuscitation area. Checked the equipment if the baby
clean, functional and within easy reach.
11. Arranges materials /supplies in a linear
sequence ;
 2 pairs of sterile gloves , dry linen,
bonnet , oxytocin injection , plastic
clamp, instrument clamp , scissors , 2
kidney basins

 In a separate sequence for the first

breastfeed: Eye ointment,
( Stethoscope to symbolize PE) Vit K,
hepatitis B and BCG vaccines (plus
cotton balls, etc.)

12. Applies aseptic technique by segregating

sterile and unsterile instruments.
13. Cleanse the perineum with antiseptic Perineal care helps to remove any
solution. In cleaning the perineum, we will possible drainage or secretions from
start from the outside going in. Using cotton the birth canal that may pose a risk
balls and antiseptic solution we will now for infection.
clean the perineum.
14. Places patient’s had in hand grip and Handgrip is use by asking the patient
explain the purpose (elbow out technique) to put her hand on it in pushing and
bearing down.

Tug of war pushing technique uses

the natural bearing down effort of the
abdominal muscles. This method
also causes minimal change in the
maternal blood pressure and relaxes
the perineum. To get force during
bearing down effort.
14. Washes hands and put on 2 pairs of sterile Gloving prevents exposure to client’s
gloves aseptically , (if same worker handles body secretion thus preventing
perineum and cord) . infection.

The first pair of gloves is used for the

delivery of the baby. The second
gloves is used for handling and
cutting the cord of the baby
AT THE TIME OF DELIVERY RATIONALE
15. Drapes the clean , dry linen over the To create a sterile field and provide
mother’s abdomen or arms in patient’s privacy.
preparation for drying the baby
16. Encourages woman to push as desired
17. Instructs mother to bear down properly, Promotes effective second-stage
coaches to take deep breath as soon as pushing. the birth process expense a
the contraction begins. (Proper pushing great deal of energy. Encouraging
and breathing technique) proper pushing and breathing
techniques conserves maternal
energy.
18. Encourages to push her flexed legs against To promote comfort; avoid ligament
the stirrups. strain, backache or injury
19. Performs Ritgen’s maneuver properly To control the rate at which the head
(Support the perineum ) once the head is is born and prevent laceration of the
visible and about to crowning. perineum.

As we can see now that the baby’s

head is crowning, continue
performing Ritgen’s maneuver until
the head of the baby is delivered.

Once the baby’s head is delivered,

we have to wait for the baby to
externally rotate, then maneuver
down (to deliver the anterior
shoulder), and then maneuver up (to
deliver the posterior shoulder) and
we support the back until the baby is
completely born.
20. Notes / records the time the baby was This is done for proper identification
delivered and the gender.
FIRST 30 SECONDS RATIONALE
21. Thoroughly dries baby for at least 30 To remove secretion from the
seconds , starting from the face and head , neonate’s mouth and nose.To
going down to the trunk and extremities prevent hypothermia, stimulate
while performing a quick check for breathing and determine the ability to
breathing . Checks baby’s APGAR score for adjust in the extrauterine life.
the first 1 minute and repeat 5 minutes
after.
1-3 MINUTES RATIONALE
22. Removes the wet cloth
23. Places baby in skin –to-skin contact on the To initiate parent-child bonding
mother’s abdomen or chest.
24. Covers baby with the dry cloth and the To prevent hypothermia, stimulate
baby’s head with a bonnet breathing and determine the ability to
adjust in the extrauterine life.
25. Excludes 2nd baby by palpating the abdomen It is important that we check that
in preparation for giving oxytocin there is no 2nd baby before oxytocin is
given or administered, since it can
lead to uterine contractions causing
baby to be trapped in the uterus
26. Uses wet cloth to wipe soiled gloves. Oxytocin will help uterine
Administers IM oxytocin within one minute contractions
of baby’s birth . Disposed of wet cloth
properly.
27. Removes 1st set of gloves and
decontaminated them properly ( In 0.5%
chlorine solutions for least 10 mins.)
28. Palpates umbilical cord to check for
pulsations.
29. After pulsations stopped , clamps cord Clamping the cord is part of the
using the plastic clamp or cord tie 2 cm stimulus that initiate a first breath.
from the base The infant’s most important transition
to the outside world establishing of
independent respiration is made.
30. Places instrument clamp 5 cm from the
base
31. Cuts near plastic clamp ( Not Midway ) or If we are using a cord tie, we have to
near the first instrument clamp. carefully transfer the cord tie from the
first clamp to the cord and remove
the first instrument clamp
32. Performs the remaining steps of the
AMTSL :(Active Management for the Third
Stage of Labor)
33. Waits for strong uterine contractions then
applies controlled cord traction and counter
traction on the uterus, continuing until
placenta was delivered .
34. Notes the time of placenta delivery and Delivery of the placenta should not
presentation take more than 30 min. Duncan
placental presentation carries a
slightly increased risk of retained
placental fragments due to
incomplete separation.
35. Massages the uterus until it is firm/contracted To ensure uterus is firm and
contracted and prevent bleeding.
36. Observes for any signs of vaginal bleeding
37. Inspects the lower vagina and perineum for To prevent bleeding.
lacerations/ tears and repaired lacerations/
tears , as necessary .
38. Examines the placenta for completeness and To check if placenta is complete or
abnormalities . intact.
39. Cleanse the mother; flushed perineum and To minimize risk of infection and
applied pad/napkin/cloth. (When cleaning we promote comfort.
actually start from the middle going out)
40. Checks baby’s color and breathing; checked
that mother was comfortable, uterus
contracted.

41. Decontaminates (soaked in 0.5% chlorine To restore cleanliness and

solution) all instruments before cleaning; orderliness of the unit.
decontaminates 2nd pair of gloves before
disposal, stating that decontamination lasts
for at least 10 mins.
42. Advises mother to maintain skin-to –skin
contact. Baby should be prone on mother’s
chest/in the breast with head turned to one
side.
15-90 MINUTES AFTER BIRTH RATIONALE
43. Advises mother to observe for feeding cues
and cited examples of feeding cues.
(tonging, licking and sucking)
44. Supports mother, instructed her on
positioning and attachment during
breastfeeding.
45. Waits for FULL BREASTFEED to be
completed
46. After a complete breastfeed, administers Hepatitis B and BCG injections are
eye ointment first, then Vit K, hepatitis B the first immunizations that the baby
and BCG injections ( simultaneously receives.
explained purpose of each )
47. Performs thorough physical examination
48. Advises OPTIONAL/DELAYED bathing of
baby ( and was able to explain the
rationale) for 6 hours
49. Advises breastfeeding per demand
50. In the first hour. Checks baby’s breathing
and color, and checked mother’s vital signs
and massage uterus every 15 minutes .
51. In the second hour; checks mother-baby
dyad every 30 minutes to 1 hour
52. Completes all records
255
Total :

Legend: (5) Performs the task excellently

(4) Performs the task Very Satisfactory
(3) Performs the task Satisfactory
(2) Performs the task fairly
(1) Performs the task poorly