INTRAPARTUM FETAL LIE

LABOR AND DELIVERY - Relationship of long axis of fetus

(spine) to long axis of the mother.
 Labor: is a physiological process
- Longitudinal Lie: if the two are
during which the products of
parallel. Nearly all 99.5%.
conception are expelled outside of
- Transverse Lie: if the two are at 90
the uterus.
degrees to each other.
 Labor is a clinical diagnosis: the onset
of the labor is defined as regular, FETAL ATTITUDE
painful uterine contractions resulting
- Degree of flexion of the fetus body
in progressive cervical effacement
parts to each other.
and dilation.
Types of Fetal Attitude
EFFACEMENT a) Complete Flexion: normal attitude in
cephalic presentation.
- Thinning and obliteration of the
b) Moderate Flexion: if fetus head is
cervical canal.
only partially flexed or not flexed.
- Expressed in percentage (%)
c) Poor Flexion: the fetus head is
- Described as THINNING, SHORTENING,
extended or bent backwards.
OR NARROWING.
d) Hyper extended: face or chin to
- 100% effacement: fully effaced cervix
present first in the pelvis.
where the cervical canal has become
a paper thin or already absent.
FETAL STATION
- 75%: ¼ of its original length.
- relationship between the presenting part of
- 50%: ½ of its original length.
the baby and ischial spines.
- 25%: ¾ of its original length.
-1 to -5: lies above the ischial spines.
- PRIMAGRAVIDA: effacement occurs
+1 to +5: below the ischial spines.
before dilation.
- MULTIGRAVIDAS: dilation may
FETAL PRESENTATION
precede effacement.
- The part of the fetus that is Presenting
at the cervix.
a. :
THE DELIVERY PROCESS IS DESCRIBED IN
normal, the head is at the
SOME TERMS:
symphysis pubis.
1. Occiput Anterior (OA): the easiest
Vertex Presentation: normal
position for the fetal head to traverse
the maternal pelvis. Face presentation: the face is at the opening.
2. Left Occiput Anterior (LOA): the fetal
Brow Presentation: the brow is at the
occiput is directed towards the
opening.
mother’s left, anterior side. Most
common fetal position. b. :
3. Right Occiput Posterior (ROP): abnormal. The buttocks is at
difficult delivery, more painful. the symphysis pubis.
4. Left Occiput Posterior (LOP): most
difficult to deliver, most painful. Frank Presentation: the legs are straight.
 c. : - Presence and absence of vaginal
the shoulder is present first bleeding.
and in transverse lie. - Baby lightening
- Monitor maternal VS.
- Check the progress of labor.
STAGES OF LABOR - Fetal well-being assessment (FHT)

: Begins with : begins with

regular uterine contractions and ends complete cervical dilation and ends
with complete cervical dilation at with the delivery of the fetus.
10cm. - Fetal head enters birth canal.
 Early Labor - Contractions becomes more intense
- cervical dilation of 0 to 3 cm. and frequent usually 2-3 minutes
- contraction every 5-20 minutes and apart.
lasting 30-45 seconds. - Bowel movement.
- Backache and mild discomfort. - Mucous plug is expelled from dilating
- First-time mother: 8 to 20 hours. cervix and discharged from vagina.
- Subsequent Births: 6 to 8 hours or less. - Presenting part of the fetus emerges
 Active Labor from vaginal opening.
- Cervical dilation of 4 to 8 cm. - Known as crowning.
- Contractions every 4-5 minutes and - Lasts 30 minutes or less in multipara.
lasting about 60 seconds.
- Beginning of intense contractions. Signs and Symptoms of False Labor
- May experience trembling, nausea, - Lightening
and vomiting. - Irregular contractions
- Usually lasts 1 to 2 hours. - Cervical changes.
 Transition Labor
- Cervical dilation of 8 to 10 cm. Signs and Symptoms of Imminent Delivery
- Contractions are about 2 to 3 minutes
- Regular contractions lasting 45-60
apart and lasting for about 60 to 90 seconds at 1-2minute intervals.
seconds.
- Bowel movement.
- Accompanied by rectal pressure.
- Large amount of bloody show.
- In many pregnancies, amniotic sac
- Crowning occurs.
ruptures.
- Lasting only 15 to 30 minutes on Mechanism of Labor
average.
 ENGAGEMENT: head fixed in the
Management of first stage of Labor pelvis.
 DESCENT: the progress of the fetal
- Obtain a verbal history and perform
head to the pelvis.
an assessment:
 FLEXION: pressure from pelvic floor
- Obstetric history.
causes head to flex towards chest and
- Assess the frequency, duration and
chin touches chest.
intensity of uterine contractions.
 INTERNAL ROTATION: fetal head
- Pain intensity of contractions.
rotate from left to right.
- Assess of the membranes are
 EXTENSION: delivery of the head.
ruptured.
- Fetus movements, and fetus
presentation.
  RESTITUTION EXTERNAL ROTATION: - After delivery, infant should be
head continue to rotate. Anterior positioned on side or with padding
shoulder first. under back if needed.
 EXPULSION: delivery of the posterior - Clear airway.
shoulder and then the whole body. - If no need for resuscitation, assign an
APGAR score at 1-5 minutes to
Management of the 2nd stage of Labor evaluate.
- Delivery area should be clean as
possible.  CESAREAN SECTION: a surgical
- Should be covered with absorbent procedure to deliver the baby through
material. incisions in the abdominal and uterine
- Mother should be placed in a Dorsal wall.
Lithotomy Position. Indications of Cesarean Section
- Knees are flexed and widely separated.
- Vagina area should be draped. - Cephalopelvic disproportion: head of
- Pillow or blanket should be placed fetus is too large.
beneath the mother’s buttocks. - Small pelvis.
- Evaluate mother’s VS. - Uterine inertia
- Monitor FHT for signs of fetal distress. - Placenta previa
- Deep breathing. - Premature separation of placenta.
- Malposition and malpresentation.
Aid in Delivery Infant - Pre-eclampsia
- Ritgen Maneuver: can be performed - Diabetes; causes oversize of the fetus.
to deliver the head. - Cardiac diseases.
- One hand: a towel draped, gloved - Vaginal Scaring
hand may be exert forward pressure - Multiple births.
on the chin of the fetus through - Cervical dystocia: failure of cervix to
perineum just in front of the coccyx. dilate.
- The other hand: pressure against - Prolapse of the umbilical cord.
occiput. - Fetal distress
- Check the fetus head for a wrapped - Previous cesarean sections
umbilical cord. - Maternal hypertension
- If the cord wrapped tightly, double - Types of CS: Vertical incision and
clamp then cut. transverse incision.
- Deliver the anterior shoulder. Complications of Cesarean Section
Clumping and cutting the cord
 Respiratory complications
- Clamp cord about 4-6 inches away - Encourage deep breathing exercises.
from the base. - Teach the patient to cough.
- Cut between two clamps with sterile  Excessive abdominal pain due to:
scissors. - Wound infection
- Examine cut ends of cord to ensure - Hematoma
there is no bleeding. - Excessive localized edema
 Intestinal complications
 Hemorrhage

Evaluation of the Infant

 Begins with  SCHULTZE MECHANISM: more
delivery of infant and ends with common, presenting 80% of cases.
placenta is expelled and uterus has - Shiny “clean” bluish side is first
contracted. delivered.
- Lasting from 5 to 30 minutes. - Less external bleeding because blood
usually concealed behind the placenta.
Delivery of the Placenta
 DUNCAN MECHANISM: less common,
- During this period, uterine contraction 20% of cases.
decreases basal blood flow. - Rough “dirty”, reddish maternal side
out first.
Signs of the 3rd stage of Labor - More external bleeding.
- Crush of Blood - Normal amount of blood loss is 250-
- Cord lengthening 500ml. more than 500ml is considered
- Globular and firm uterus postpartal hemorrhage, leading cause
- Uterus rises anteriorly. of maternal mortality.
 Should happen within 30 minutes of Episiotomy: is an incision on perineum to
delivery of infant. enlarge vaginal outlet.
Management of 3rd stage of Labor  Purposes of episiotomy
- Allow the placenta to deliver - Easier to repair.
spontaneously. - Postoperative pain is less.
- Excessive traction should not be - Healing improved.
applied to the cord apply the CCT
(Controlled Cord Traction).
- Administer OXYTOCIN for uterine
contraction and decrease bleeding.
- Placenta can be manually separated.
- Inspect for completeness and for the POSTPARTUM
presence of 1 umbilical vein and 2
 Nursing Care During the Fourth Stage
umbilical arteries.
of Labor
- When placenta is expelled, place in
- Transfer the patient from delivery
plastic bag or container for other
table.
purposes.
- Remove the drapes and soiled linen.
- Pieces of placenta can cause
- Remove both legs from the stirrups at
hemorrhage.
the same time and then lower both
- Palpate the patient’s abdomen to
legs down to prevent cramping.
confirm reduction in the size of the
- Assist the patient to move from the
uterus and its firmness.
table to te bed.
- Ongoing blood loss and boggy uterus
- Transfer the patient to the recovery
suggest uterine atony.
room.
- Initiate fundal massage to promote
- This will be done after you place a
uterine contraction.
clean gown on the patient, obtained a
- Monitor mother for signs of
complete set of vital signs, evaluated
hemorrhage or shock.
the fundal height and firmness, and
- Examine the birth canal.
evaluated the lochia.
2 types of placental Delivery
 Ensure Emergency Equipment is
available in the Recovery Room for
 Nursing Assessment of the
Possible Complications.
Postpartum Patient.
1. suction and oxygen in case patient
- Assess every 15 minutes for the first
becomes eclamptic.
hour.
2. Pitocin is available in the event of
- Assess every 30 minutes for the
hemorrhage.
second hour.
3. IV remains patent for possible use if
- Assess every 4 hrs for the first 24
complications develop.
hours.
 Check the Fundus
- Uterine tone
1. Ensure the fundus remains firm.
- Bleeding
2. Massage the fundus until it is firm if
- Perineum
the uterus should relax.
- Bladder status
 Massage the fundus every 15 minutes
- Vital signs
during the first hour.
- Temperature every 1-4 hours.
 Every 30minutes during the next hour.
- Fluid balance
 Every hour until the patient is ready to
- Circulation to extremities
transfer.
- Comfort/ level of consciousness.
3. Inform the physician if the fundus
- Newborn interaction.
remains boggy after being massaged.
 Postpartum Education
 Immediate Nursing Care
- Education of the postpartum family is
- Assess height, location, and tone of
an essential role of the postpartum
the fundus.
nurse.
- Note amount and consistency of
- New skills should be discussed,
vaginal bleeding.
demonstrated, and reinforced.
- Cleanse and apply ice pack to the
- Document education and validate
perineum.
knowledge through verbalization and/
- Provide clean linen under patient.
or return demonstration.
- Provide warm blanket: patients often
tremble/ shiver immediately.
 Postpartum Assessment and Nursing
Care
 remember the acronym BUBBLE.
 After the Birth
- Assess the vital signs. BREAST ASSESSMENT
- Assess level of consciousness/
- consistency: soft, filling, or firm.
comfort.
- Nipple type and integrity.
- Encourage bonding of mother and
- Type: inverted or everted.
infant.
- Integrity: bleeding, cracked, intact
- Assist with proper latch-on to initiate
- Redness
breastfeeding.
- Comfort
- Maintain IV fluids and additives as
- Breast care (lactating)
ordered.
- Patient should wear a supportive bra.
- Oxytocic medications.
- Soap should not be used on breasts.
- Promote uterine contractions.
- After feeding, leave colostrum/breast
- Decrease amount of vaginal blood
milk on nipples and expose the
loss.
breasts to air.
 - Engorgement: firm, tender breasts. - Process by which the size of uterus
- May occur on postpartum day 3-5, decreases in a predictable pattern.
when the volume of breastmilk - Documented in fingerbreadths above
increases. or below the umbilicus.
- Prevent engorgement with frequent - Postpartum Period Level of the
feedings; avoid skipping any feedings. Fundus Documentation.
- Immediately after at the umbilicus at
Treatment for engorgement
U or U/U birth.
- Express a small amount of breast milk - 12 hours 1 fingerbreadth (FB) 1/U
either manually or with a breast pump above the umbilicus.
so that the breast will soften, and - 24 hours 1 FB below the umbilicus
baby can latch. U/1.
- apply cold packs to breasts - Day 2 2 FB below the umbilicus U/2
intermittently. - Day 3 3 FB below the umbilicus U/3.
- Apply cleaned, cooled cabbage leaves - The fundus lowers one fingerbreadth
to breasts until warm/ wilted. below the umbilicus each day until
- Warm shower or warm compress right returning to pelvis (day 10-14).
before feeding.
Measures that promote uterine involution
Nutrition
- Breastfeeding
- 500 calories over nonpregnant diet. - Voiding
- Continue prenatal vitamins. - Fundal massage
- Stay well hydrated. - Oxytocin medications
- Avoid alcohol, smoking, or - Fundal massage
recreational drugs.
Teaching Tips: Uterine/ Vaginal Changes
- Consult with pediatrician before using
any OTC or prescription medication.  Normal Progression of Lochia
- Lochia progresses from bright red to
Pumping and Storing
brown to light pink with decreasing
- Demonstrate use of breast pump. amount.
- Discuss appropriate storage - If lochia returns to bright red or
containers. increases in amount, decrease activity.
- Write the date of expression on - Persistent bright red lochia or lochia
storage containers and use oldest milk with a foul odor should be reported.
first. - Report saturating one pad per hour or
- Length of storage dependent on passing golf-ball size clots.
location. - Post delivery
- Location Guideline - Sexuality
- Room temperature up to 8 hours. - Return of the menstrual cycle.
- Refrigerator freezer (with separate - Dependent on method of infant
door) 3 months. feeding.
- Deep freeze 6-12 months. - If breastfeeding, lactation
amenorrhea while exclusively
breastfeeding infant (first 6 months).
UTERUS ASSESSMENT - If bottle feeding, menses usually
returns 6-8 weeks postdelivery.
 Uterine Involution
BLADDER STATUS - Note time of last perineal pad change.
- Document amount of lochia on
- Postpartum women may have
perineal pad (scant, small, moderate,
difficulty voiding after birth due to:
large).
- Decreased urethral sensation from
- If weighing perineal pads, 1 gm 1ml of
pressure exerted by the passage of
blood loss.
the fetus.
- Assess the color of lochia.
- Side effects of local/ epidural
- Lochia Rubra (red): day 1-3
anesthesia.
- Lochia Serosa (brownish-pink): day 4-
- Delivery trauma to the perineum.
9.
- Palpate for bladder distention.
- Lochia Alba (yellow-white): day 10-14.
- Track fluid balance: intake and output.
- Document number and size of blood
- Assess for periurethral edema/
clots.
trauma.
- Turn patient to assess blood loss
- Catheterization may be necessary if
under buttocks.
unable to void o with urinary
retention.
- Postpartum diuresis, which occurs in
EPISIOTOMY ASSESSMENT
response to decrease in estrogen,
helps rid the body of extracellular Assessment of the Perineum
fluid and causes the bladder to fill
quickly. - Requires a direct light source and
- Starts within 12 hours of birth and positioning of the patient in side-lying
continues for up to 5 days. with top leg forward.
- Urine output may be 3,000 cc/day. - Assess Episiotomy or laceration.
- Redness
- Swelling
- Ecchymosis
BOWEL ASSESSMENT
- Color, consistency of discharge
- Auscultate for bowel sounds. approximated edges.
- Assess for abdominal distention. - Lacerations described by degree of
- Assess for presence/ status of tissue involvement.
hemorrhoids.
Degree Definition
- Educate on prevention of constipation.
- Increased roughage in the diet. - 1st vaginal mucous membrane and
- Increased oral intake of fluids. skin of perineum.
- Temporary use of prescribed stool - 2nd subcutaneous tissue of the
softeners. perineal body.
- 3rd involves fibers of the external
rectal sphincter.
LOCHIA ASSESSMENT - 4th through rectal sphincter exposing
the lumen of the rectum.
- Vaginal discharge after delivery called
- No enemas or rectal suppositories
lochia.
should be used with 3rd and 4th degree
- Blood loss with vaginal birth
lacerations.
approximately 500cc.
- Blood loss with cesarean birth Sexuality
approximately 1000cc.
- Assess the amount of lochia.
 - Sexual intercourse may be resumed - Intervention: re-position, suction and
after lochia ceased. ventilate
- Episiotomy healed; 4-6 weeks delay  Action:
generally recommended. - Clamp and cut the cord immediately.
- Vaginal lubrication may be diminished; - Call for help.
use water-soluble gel. - Transfer to a warm, firm surface.
- Female superior or side-lying position - Inform the mother that the newborn
may assist in comfort. has difficulty breathing and that you
- Discuss family planning methods. will help the baby to breathe.
- Start resuscitation protocol.
 B2. TIME BAND: if after 30 secs of
thorough drying, newborn is
breathing or crying.
ESSENTIAL NEWBORN CARE
- Intervention: do skin-to-skin contact.
2009-0025, December 1, 2009: ENC adopts in  Action:
government and private health Care Facilities. - If a baby is crying and breathing
normally, avoid any manipulation,
- A set of evidence-based practices such as routine suctioning, that may
which requires skills, knowledge to cause trauma or introduce infection.
provide appropriate care at the most - Place the newborn prone on the
vulnerable period in baby’s life. mother’s abdomen or chest skin-to-
What are the 4 time-bounded interventions skin.
involved in ENC? - Cover newborn’s back with a blanket
and head with a bonnet.
1) Immediate and thorough drying. - Place identification band on ankle
2) Early skin-to-skin contact. (not wrist).
3) Properly-time clamping and cutting  Within the 1st 30 seconds
of the cord after 1-3 minutes, and
rooming-in. Objective: dry and provide warmth to the
4) Non-separation of the newborn from newborn and prevent hypothermia.
the mother for early breastfeeding
- call out the time of birth.
initiation and rooming-in.
- Dry the newborn thoroughly for at
least 30 seconds.
- Wipe the eyes, face, head, front and
Immediate and Thorough Dring back, arms and legs of the newborn.
- Prevent hypothermia which is - Remove the wet cloth.
extremely important to newborn - Do a quick check of breathing while
survival. drying.
 During the first 30 seconds - do not put the newborn on a cold or
- Do not ventilate unless the baby is wet surface.
floppy/ limp and not breathing. - Do not bathe the newborn earlier
- Do not suction unless the mouth/nose than 6 hour of life.
are blocked with secretions or other
material. Note:
 B1. TIME BAND: if after 30 secs of - Do not wipe off vernix Caseosa.
thorough drying, newborn is not - Do not bathe the newborn.
breathing or is gasping. - Do not do foot printing.
- No slapping. hemorrhage in preterm newborns by
- No hanging upside-down. delaying or non-immediate cord clamping.
- No squeezing of chest.
- Remove the first set of gloves.
- After the umbilical pulsations have
stopped, clamp the cord using sterile
Early skin-to-skin Contact
plastic clamp or tie at 2 cm from the
- Keeping the mother and baby in
umbilical base.
uninterrupted skin-to-skin contact
- Clamp again at 5cm from the base.
prevents hypothermia, hypoglycemia,
- cut the cord close to the plastic clamp.
and sepsis, increases colonization with
protective bacterial flora and Notes:
improved breastfeeding initiation and
- do not milk the cord towards the baby.
exclusivity.
- After the 1st clamp, you may “strip”
 After thorough drying
the cord of blood before applying the
- Facilitate bonding between the
2nd clamp.
mother and her baby through skin-to-
- Cut the cord close to the plastic clamp
skin contact to reduce likelihood of
so that there is no need for a 2nd
infection and hypoglycemia.
“trim”.
 If newborn is breathing or crying:
- Do not apply any substance onto the
- Position the newborn prone on the
cord.
mother’s abdomen or chest.
- Cover the newborn’s back with a dry
blanket.
D. TIME BAND: WITHIN 90 MINUTES OF AGE
- Cover the newborn's head with a
bonnet. 1) intervention: provide support for
- Place the identification band on the initiation of breastfeeding.
ankle.
Action:
Notes:
- leave the newborn on the chest in
- Do not separate the mother and skin-to-skin contact.
newborn, as long as the newborn - Observe the newborn. Only when the
does not exhibit severe chest in- newborn shows feeding cues (e.g.
drawing, gasping or apnea and the opening of mouth, tonguing, licking,
mother does not need urgent medical rooting), make verbal suggestions to
stabilization e.g. emergent the mother.
hysterectomy. - Encourage her newborn to move
- Same on the other notes. toward the breast.
- If there is a 2nd baby, manage as multi-
fetal pregnancy.

Properly timed cord clamping Non-separation of Newborn from

- While on the skin-to-skin contact (up Mother for Early Breastfeeding.
to 3 minutes post-delivery.) Within 90 minutes
Objective: reduce the incidence of anemia - Facilitate the newborn’s early
in term newborns and intraventricular initiation to breastfeeding and
 transfer of colostrum through support - Provide extra blankets to keep the
and initiation of breastfeeding. baby warm.
- Allow the newborn to be in skin-to- - If mother cannot keep the baby skin-
skin contact with the mother. to-skin because of complications,
- Observe for feeding cues, including wrap the baby in a clean, dry, warm
licking, rooting. cloth and place in a cot. Cover with a
- Point these out to the mother and blanket. Use a radiant warmer if room
encourage her to nudge the newborn not warm or baby small.
towards her breast. - Do not bathe the small baby. Ensure
hygiene by wiping with a damp cloth
Counsel on positioning:
but only after 6 hours. Prepare a very
- Newbern’s neck is not flexed nor small baby (<1.5kg) or a baby born >2
twisted. months early for referral.
- Newborn is facing the breast.
- Newborn’s body is close to mother’s
body. TAKING ANTHROPOMETRIC MEASUREMENTS
- Newborn’s whole body is supported. AND VITAL SIGNS
- Wait until her mouth is opened wide.
 Length: 44-55cm
- Move her newborn onto her breast,
aiming the infant’s lower lip well  Head circumference: 33-35.5 cm
below the nipple.  Chest circumference: 30-33 cm (1-2
less than head).
Look for signs of good attachment and  Temperature: 36.5-37.5 degrees C.
suckling:  RR: 30-60 bpm
- Mouth wide open.  PR: 120-140 bpm
- Lower lip turned outwards.  Weight: 2.5-3.4 kg
- Baby’s chin touching breast.
- Suckling is slow, deep with some
pauses. Non-immediate Interventions

Note:  Do eye Care: to prevent ophthalmia

neonatorum through proper eye care.
- if the attachment or suckling is not  Action: administer erythromycin or
good, try again and reassess. tetracycline ointment or 2.5%
- Do not give sugar water, formula or povidone-iodine drops to both eyes
other prelacteals. after newborn has located breast. Do
- Do not give bottles or pacifiers. not wash away the eye antimicrobial.
- Do not throw away colostrum.
TIME BAND: from 90 minutes – 6 Hours
Intervention: provide additional care for a
small baby or twin Kangaroo Mother Care.  Intervention: give Vitamin K
prophylaxis.
Action:
- Action: wash hands, inject single dose
- For a visible small newborn or a of Vitamin K 1mg IM.
newborn >1 month early:  Intervention: inject Hepatitis B and
- Encourage the mother to keep the BCG vaccinations at birth.
small baby in skin-to-skin contact with - Action:
her as much as possible. - Inject Hep B vaccine IM and BCG ID
- Record
 - Examine the baby. - Refer to special treatment and/or
- Weigh the baby and record. evaluation if available.
- Check for birth injuries, - Help mother to breastfeed. If not
malformations, or defects. successful teach her alternative
feeding methods.
 Look for possible birth injury.
- If present:
- Explain to parents that this does not CORD CARE
hurt the newborn, is likely to
disappear in a week or two and does - Wash hands
not need special treatment. - Put nothing on the stump.
- Gently handle the limb that is not - Fold diaper below stump. Keep cord
moving. stump loosely covered with clean
- Do not force legs into different cloths.
position. - If stump is soiled, wash it with clean
water and soap. Dry it thoroughly
 Injection: Vitamin K and Vaccines with clean cloth.
- Explain the mother that she should
Vitamin K seek care if the umbilicus is red or
draining pus.
- 0.1 ml for term babies and 0.05ml for
 Teach the mother to treat local
preterm babies or small babies.
umbilical infection 3 times a day.
- Intramuscular or IM
- Wash hands with clean water and
- To prevent bleeding.
soap.
Hepatitis B - Gently wash off pus and crusts with
boiled and cooled water and soap.
- 0.5ml
- Dry the area with clean cloth.
- Intramuscular IM
- Paint with gentian violet.
- To prevent the baby from catching an
- Wash hands.
infection of the liver that can cause
- If pus or redness worsens or does not
cancer later in life.
improve in 2 days, refer urgently.
Bacillus Calmette Guerin or BCG
Notes:
- 0.05ml
- Do not bandage the stump or
- Intradermal or ID
abdomen.
- To prevent serious infections due to
- Do not apply any substances or
tuberculosis or TB.
medicine on the stump.
- Avoid touching the stump
 Look for malformations:
unnecessary.
- Cleft palate or lip.
- Club foot. Intervention:
- Odd looking, unusual appearance.
- Provide additional care for a small
- Open tissue on head, abdomen, or
baby or twin.
back.
- If the newborn is delivered 2 mos
- If present:
earlier or weighs <1500 g, refer to
- Cover any open tissue with sterile
specialized hospital.
gauze before referral and keep warm.
- If the newborn is delivered 1-2
months earlier or weighs 1500-2500 g
 (or visibly small where scale not
available) provide additional care for
Look for Danger Signs
small newborns.
 Look for signs of serious illness:
Note:
- Fast breathing: >60 bpm
- Do not discharge if baby is not feeding - Slow breathing: <30 bpm
well. - Severe chest in-drawing.
- Do not give sugar water, formula or - Grunting
other prelacteals. - Convulsions.
- Do not give bottles or pacifiers. - Floppy or stiff
- Fever: >38 C
Intervention: ensure warmth of the baby.
- Temperature <35 C or not rising after
Action: re-warming Umbilicus draining pus.
- More than 10 skin pustules or bullae,
- Ensure the room is warm (>25C and or swelling, or redness, or hardness of
draft-free). skin.
- Explain to the mother that keeping - Bleeding from stump.
the baby warm is important for the - Pallor
baby to remain healthy.
- Keep the baby in skin-to-skin contact
with the mother as much as possible.
Intervention: look for signs of jaundice and
- Dress the baby or wrap in soft dry
local infection
clean cloth. Cover the head with a cap
for the first few days, especially if Action:
baby is small.
 Look to the skin. Is it yellow?
Intervention: washing and Bathing (hygiene) - Refer urgently if jaundice present.
- On face of <24-hour old infant.
Action:
- Encourage breastfeeding.
- Wash your hands. - If feeding difficulty, give expressed
- Wipe the face, neck, underarms with breast milk by cup.
a damp cloth daily.  Look at the eyes:
- Wash the buttocks when soiled. Dry - Are they swollen and draining pus?
thoroughly. - If present, consider gonococcal eye
- Bathe when necessary. infection.
- If the baby is small, ensure that the - Give single dose of appropriate
room is warmer when changing, antibiotic for eye infection.
wiping or bathing. - Teach mother to treat eyes.
- Follow-up in two days. If pus or
Intervention: sleeping swelling worsens or does not improve
Action: refer urgently.
 Look at the umbilicus:
- Let the baby sleep on his/her back or - What has been applied to the
side. umbilicus? Advise mother proper cord
- Keep the baby away from smoke or care.
from people smoking. - If there is redness that extends to the
- Ensure mother and baby are sleeping skin, consider local umbilicus infection.
under impregnated bed net if there is
malaria in the area.
 - Teach mother to treat umbilical 5) Applying of alcohol, medicine
infection. and other substances in the cord
- If the umbilicus is draining pus then stump and bandaging the cord
consider possible serious illness. stump or abdomen.
- Give first dose of 2 IM antibiotics.
- Refer the baby urgently.
DISCHARGE INSTRUCTIONS

1) Advice the mother to return or go to

Advise for Newborn Screening
the hospital immediately if;
- Jaundice of the soles or any of the
following are present:
1) Routine Suctioning.
- Difficulty of breathing
- No benefit if the amniotic fluid is clear
- Convulsions.
and especially with newborns who cry
- Movement only when stimulated.
or breathe immediately after birth.
- Fast or slow or difficult breathing.
- Moreover, a dirty bulb can become a
- Temperature: >37.5 or <35.5
source of infection.
- Has been associated with cardiac
arrythmia.
- Indicated only if the mouth/ nose is
blocked with secretions or other 2) Advise the mother to bring her
materials. newborn to the health facility for
2) Early Bathing/ Washing routine check-up at the following
- Hypothermia which can lead to prescribed schedule:
infection, coagulation defects, - Postnatal Visit 1: at 48-72 hours of life.
acidosis, delayed fetal to newborn - Postnatal Visit 2: at 7 days of life.
circulatory adjustment, hyaline - Immunization Visit 1: at 6 weeks of
membrane disease, brain hemorrhage. life.
- Infection- the vernix is a protective 3) Advise additional follow-up visits
barrier to bacteria such as E. coli and appropriate to problem in the
group B strep; so is maternal bacterial following:
colonization. - 2 days: if with breastfeeding difficulty,
- No crawling reflex. low birth weight in the 1st week of life,
3) Foot printing red umbilicus, skin infection, eye
- Proven to be an inadequate technique infection, thrush, or other problems.
for newborn identification purposes. - 7 days: if low birth weight discharged
- Better identification techniques such more than a week of age and not
as DNA genotyping and human gaining weight adequately.
leukocyte antigen tests.
4) Giving sugar water, formula or
other prelacteals and the use of DIAPERING
bottles or pacifiers.
- Delayed initiation to breastfeeding - The following steps on diapering
has been linked to a 2.6-fold increase provide safety on the baby and
in the chances of newborn deaths due prevent nappy rash.
to infection.  When diapering and cleaning a baby
Girl:
- Always wipe from front to back to - Try switching to cloth diaper if you are
prevent germs from her bowel using disposables and find the rash is
movements getting into the urinary getting worse.
tract.
- Gently clean between the outer folds
of the labia. There is no need to clean Ways to keep babies warm.
inside the vagina.
 When diapering and cleaning a baby  Drying and warming the baby after
Boy: birth.
- Do not pull the foreskin back when - Wet skin can cause the baby to lose
cleaning the penis. Wash the are well heat quickly by evaporation.
and clean from front to back. - He or she can quickly lose 2-3 F.
- Before securing the diaper, ensure - If it is important to warm and dry the
baby’s penis in pointing down to void baby right away using warm blankets
pee streaming up the front of the and skin-to-skin, contact.
diaper. - Another source of warmth such as a
 Rash heat lamp or over-bed warmer, may
- Diaper rash is a red and painful rash also be used.
on the diaper area. Rashes can be  Open bed with radiant warmer.
cause by: - An open bed with radiant warmer is
 Irritation from dampness open to the room air and has a
caused by urine or stool on radiant warmer above.
the skin. - A temperature probe on the baby
connects to the warmer.
 Allergic reaction to soaps,
- This tells the warmer what your
perfumes oils that touch the
skin. baby’s temperature is so it can adjust
automatically.
 Yeast infection spread from
- When the baby is cold, the heat
the mouth or from stool. A
increases.
yeast infection can be
- Open beds are often used in the
developed after your baby has
delivery room for rapid warming.
had a rash several days.
- They also used right away in the NICU
and for a sick baby who need constant
attention and care.
 How to reduce diaper rashes:
- Keep the skin dry by changing diapers .
as soon as they are wet or soiled.
 Incubator/ Isolate
- Don’t use a soap.
- Incubators are walled plastic boxes
- Remove the diaper and expose the
with a healing system to circulate
rashy area to the air for 1-=15 minutes,
warmth.
three or four times a day. You can lay
- To lower the risk for sudden infants
your baby on an absorbent towel for
Syndrome (SIDS), the American
some play at this time.
Academy of Pediatrics advises that
- When the diaper area is clean and dry,
parents and caregivers not over
rub on a thin layer of petroleum jelly,
bundle, overdress, or cover an infant’s
or zinc-based cream.
face or head. This is to prevent the
- avoid using airtight plastic pants over
baby from getting overheated. In
the diaper.
addition, there should be no extra
 blankets or toys in the bed because appearance 0 1 2
Pale/ blue all acrocyanosis Pink all over
they could block the baby’s breathing. over

pulse absent <100 bpm >100 bpm

Grimace No response Grimace (no cry) Cry, active

LESSON 12: APGAR SCORING to to stimulation movement to
stimulation stimulation

- An easy and quick assessment tool Activity None-flaccid Same flexion of Arms and legs

used to assess the status of a arms and legs flexed

newborn baby after birth. Respiratory Absent Weak, irregular Strong

cry vigorous cry
- APGAR is a mnemonic that stands for:

Appearance: skin color Score 0-3

Pulse: heart rate - Needs full resuscitation.

Grimace: reflex irritability

Activity: muscle tone

Respiration: effort

- APGAR scoring is performed at 1

minute and 5 minutes after birth and
may be reassessed at 10 minutes (5
minutes later) after birth if the score
is 6 or less. FUNDAL MASSAGE
- Each category is scored 0-2 and added
up for a score 0-10. The higher the Definition:
score the better the baby is doing. - A technique used to reduce bleeding
and cramping of the uterus after
childbirth.

Purpose

- To encourage the uterus to contract

and to prevent postpartum
complications.

Equipment

- Gloves and absorbent pad.

Intervention based on APGAR scoring. Considerations
Score 7-10  Before
- No interventions, baby doing good - Do handwashing and don gloves.
just needs routine post-delivery.  During
- Provide privacy during the procedure.
Score 4-6 - Careful not to hurt the client.
 After
- Some resuscitation assistance
- Document the findings.
required, oxygen, suction, stimulate
the baby, run baby’s back. Things to document after the procedure:
- Document any findings while hands using slight downward
assessing and notify the physician for pressure against the lower hand.
any complications. - To flatten out the fundus while the
uterus is still firm.
9 Remove and observe the
1 Explain the procedure to the woman’s perineum for the
client. passage of clots and the amount
- To help the client participate in. of bleeding.
2 Provide privacy. - To check the discharges after being
- To alleviate the anxiety. massaged.
3 Ask the client to void (unless 10 Massage the uterus again to be
bleeding is extensive and more certain it remains firm, cleanse
rapid action seems necessary). the perineum, and apply perineal
- To have effective inspection on the pad.
fundal area. - To maintain the firmness of the uterus
4 Place the client supine with her and clean the perineal area as needed.
knees flexed and feet together. 11 Discard gloves and soiled pad.
- To make the client more comfortable. - To prevent spread of infections.
5 Put on gloves. 12 Document the results of the
- To prevent from infections. procedure. Notify the physician if
fundus does not remain firm or if
6 Place one hand on the abdomen bleeding continues.
just above the symphysis pubis. - To have references for the physician
Place the other hand around the and to have better treatment.
top of the fundus.

- To check the location of the fundus by

palpating around it.
7 Rotate the upper hand to
massage the uterus until it is firm,
being careful not to over
massage the uterus.

- To allow the uterus to relax after

massaging the fundus.
8 When the uterus is firm, gently
press the fundus between the