ACTUAL BIRTH SIMULATION (FACE TO FACE)

Sterile Procedures

 Sterile procedures are required before and during specific patient care activities to maintain an
area free from microorganisms and to prevent infection.
 Performing a surgical hand scrub, applying sterile gloves, and preparing a sterile field are ways
to prevent and minimize infection during surgeries or invasive procedures.

A. Application of Sterile Gloves

 Sterile gloves are gloves that are free from all microorganisms.
 They are required for any invasive procedure and when contact with any sterile site, tissue, or
body cavity is expected.
 Sterile gloves help prevent surgical site infections and reduce the risk of exposure to blood and
body fluid pathogens for the health care worker.
 Double gloving is known to reduce the risk of exposure and has become common practice, but
does not reduce the risk of cross-contamination after surgery.

B. Setting Up a Sterile Field

 Aseptic procedures require a sterile area in which to work with sterile objects.
 A sterile field is a sterile surface on which to place sterile equipment that is considered free
from microorganisms
 A sterile field is required for all invasive procedures to prevent the transfer of microorganisms
and reduce the potential for surgical site infections.
 Sterile fields can be created in the OR using drapes, or at the bedside using a prepackaged set
of supplies for a sterile procedure or wound care.
 Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile field.
 Sterile items can be linen wrapped or paper wrapped, depending on whether they are single-
or multi-use.
 Always check hospital policy and doctor orders if a sterile field is required for a procedure.

C. Perineal Care

 (Discussed during Midterms)

D. Controlled Delivery of the Fetal Head

 The head should be delivered in a controlled and slow manner reproducing the mechanism of
normal birth:

EDFIRE ERE

1. Engagement

2. Descent – entrance of the greatest biparietal diameter of the fetal head to the pelvic inlet

3. Flexion – the chin of the fetus touches his chest enabling the smallest diameter
(suboccipitobregmatic) to be presented to the pelvis for delivery
4. Internal Rotation – when the head reach the level of the ischial spine, it rotates from transverse
diameter to AP diameter so that its largest diameter is presented to the largest diameter of the outlet.
This movement allows the head to pass through the outlet.

5. Extension – the head of the fetus extend towards the vaginal opening. As the head extend, the
chin is lifted and then it is born.

6. External Rotation – when the head comes out, the shoulder which enters the pelvis in transverse
position turns to anteroposterior position for it become in line with the anteroposterior diameter of
the outlet & pass through the pelvis.

7. Expulsion – when the head is born, the shoulder & the rest of the body follows without much
difficulties.

 Duration of Second Stage: Primis – 50 mins

Multis – 20 mins

 Assessment: monitor FHT q 15 mins in normal case and every 5 mins in high-risk cases if not
yet delivered
 Transfer to the DR: Primis – cervix fully dilated

Multis – cervix is 8 cm dilated

Delivery Position

1. Lithotomy – used when forceps delivery & episiotomy are to be performed.

2. Dorsal Recumbent – head of the bed is 35 – 45˚ elevated, knees are flexed & feet flat on bed. This
position facilitates the pushing effort of the mother.

3. Left Lateral Position – indicated for woman with heart disease.

· Deliver of the head should usually be achieved within 3-4 contractions

· Descent should, however, be achieved with each contraction

E. Active Management of the Third Stage of Labor

Third Stage of Labor

 Birth of the baby and the delivery of the placenta and membranes
 Typically, 10 to 30 minutes
 If> 30 minutes, considered to be prolonged
 If lasts longer than 18 minutes, with significant risk of PPH
Process of Active Management of Third Stage of Labor

1. Uterotonic drug

2. CCT

3. Massaging the uterus

1. Uterotonic Drugs

 Enhance contraction of the uterus

 Facilitate Expulsion of the Placenta
 Decrease Blood loss and are;
 Given after delivery of the baby, after ruling out presence of another baby

Uterotonic Route Dosage Onset of Duration of Contraindicatio Storage

Agent Action Action Action n
Oxytocin IM 10 units 2-4 mins 20 mins Never give IV 15-30 deg.
bolus Celsius
Misoprostol Oral 600 mcg 12-15 mins 20-40 mins Room
temperature

2. Controlled Cord Traction (CCT)

 Technique to assist in expulsion of placenta

 Helps to reduce the chances of a retained placenta and subsequent bleeding i.e. PPH

How do you perform CCT?

1. Place the clamp near the woman’s perineum to make CCT easier

2. Place the palm of the other hand on the lower abdomen just above the woman’s pubic bone to
assess for uterine contractions.

If a clamp is not available, CCT can be applied by encircling the cord around the hand.

3. As the placenta is delivered, hold, and gently turn it with both hands until the membranes are
twisted.

4. Slowly pull to complete the delivery. Gently move membranes up and down until delivered.

5. Ensure that placenta is delivered complete with all membranes. If the placenta is not delivered
after 30 minutes of delivery- refer to FRU

6. Give information regarding drugs given, their dose and time of administration on referral slip

7. Never apply cord traction (pull) without contraction and without applying counter traction (push)
above the pubic symphysis with the other hand.

3. Uterine Massage

 Immediately after delivery of the placenta, massage the fundus of the uterus through the
woman’s abdomen until it is well contracted.
 Helps in contraction of the uterus and thus prevents PPH
 Ensure that the uterus does not become relaxed (soft) after the massage
 Watch for vaginal bleeding

F. Immediate Essential Newborn Care

- Time Bounded Interventions

1. Immediate and thorough drying

2. Early skin-to-skin contact

3. Properly timed cord clamping

4. non-separation of the newborn and mother for early initiation of breastfeeding

1.a. Time Band: Within 1st 30 secs (Immediate Drying)

 Call out the time of birth

 Dry the newborn thoroughly for at least 30 seconds

– Wipe the eyes, face, head, front and back, arms and legs

 Remove the wet cloth

 Do a quick check of breathing while drying
Notes:

 During the 1st secs:

– Do not ventilate unless the baby is floppy/limp and not breathing

– Do not suction unless the mouth/nose are blocked with secretions or other material

1.b Time Band: Within 10-3 mins (Thorough Drying)

Notes:

 Do not wipe off vernix

 Do not bathe the newborn
 Do not do foot printing
 No slapping
 No hanging upside – down
 No squeezing of chest

2. Time Band: After 30 secs of Drying (Early Skin-Skin Contact)

If newborn is breathing or crying:

 Position the newborn prone on the mother’s abdomen or chest

 Cover the newborn’s back with a dry blanket
 Cover the newborn’s head with a bonnet

Notes:

 Avoid any manipulation, e.g., routine suctioning that may cause trauma or infection
 Place identification band on ankle (not wrist)
 Skin to skin contact is doable even for cesarean section newborns

3. Time Band: 1-3 mins (Properly timed-cord clamping)

 Remove the first set of gloves

 After the umbilical pulsations have stopped, clamp the cord using a sterile plastic clamp or tie
at 2 cm from the umbilical base
 Clamp again at 5 cm from the base
 Cut the cord close to the plastic clamp

Notes:

 Do not milk the cord towards the baby

 After the 1st clamp, you may “strip” the cord of blood before applying the 2nd clamp
 Cut the cord close to the plastic clamp so that there is no need for a 2nd “trim”
 Do not apply any substance onto the cord

4. Time Band: Within 90 mins (non-separation of newborn from mother to early breastfeeding)

 Leave the newborn in skin-to-skin contact

 Observe for feeding cues, including tonguing, licking, rooting
 Point these out to the mother and encourage her to nudge the newborn towards the breast
 Counsel on positioning
 – Newborn’s neck is not flexed nor twisted
– Newborn is facing the breast
– Newborn’s body is close to mother’s body
– Newborn’s whole body is supported

 Counsel on attachment and suckling

– Mouth wide open

– Lower lip turned outwards
– Baby’s chin touching breast
– Suckling is slow, deep with some pauses

Notes:

 Minimize handling by health workers

 Do not give sugar water, formula or other prelacteals
 Do not give bottles or pacifiers
 Do not throw away colostrum

Actual Birth, IENC and Immediate Post-partum Care

Instruction: Check under Correctly Done if identified skill is correctly performed; Incorrectly Done if skill is
not performed correctly; and Not Done if the student failed to perform the skill.
Correctly Incorrectly Not Done
Procedure Done Done
2 1 0
Prior to woman’s transfer to the DR
1. Ensure that the mother is in her position of choice while in labor.
2. Ask the mother if she wishes to eat/drink or void.
3. Communicate with the mother- inform her of the progress of labor;
give reassurance and encouragement.
Woman already in the DR
A. Preparing for delivery
4. Check temperature of the DR area to be 25-28 degree Celsius;
eliminate air draft.
5. Ask the woman if she is comfortable in the semi-upright position (the
default position of delivery table)
6. Ensure the woman’s privacy
7. Remove all jewelry then wash hands thoroughly observing the WHO
1-2-3-4-5 procedure
8. Prepare a clear, clean newborn resuscitation area on a firm and flat
surface. Check the equipment if clean, functional and within easy reach
9. Arrange materials/supplies in a linear sequence:
gloves, dry linen, bonnet, oxytocin injection, plastic clamp, instrument
clamp, scissors, 2 kidney basins
10. Clean the perineum:
a. Wash the perineal area with clean water
b. Clean the perineal area using cotton balls soaked in cleanser
following the 7 strokes
c. Wash the perineal are with clean water until cleanser is removed
d. Clean the perineal area using cotton balls soaked in antiseptic
solution following the 7 strokes.
7 strokes:
1st symphysis pubis upward
2nd & 3rd inner thigh, left & right (inner to outer stroke)
4th & 5th left & right labia majora (downward stroke)
6th clitoris to vaginal orifice (downward stroke)
7th vaginal orifice to anus (downward stroke)
11. Wash hands and put on 2 pairs of sterile gloves aseptically. (If same
worker handles perineum and cord)
B. At the Time of Delivery
12. Encourage woman to push as desired
13. Drape the clean, dry linen over the mother’s abdomen or arms in
preparation for drying the baby
14. Apply perineal support and do control delivery of the head
15. Call out time of birth and sex of baby
16. Inform the mother of outcome
After Delivery
C. First 30 seconds
17. Thoroughly dry baby for at least 30 seconds, starting from the face
and head, going down to the trunk and extremities while performing a
quick check for breathing
18. Remove the wet cloth
D. After 30 seconds
19. Place baby in skin-to-skin contact on the mother’s abdomen or
chest
20. Cover baby with a dry cloth and the baby’s head with a bonnet
21. Exclude a 2nd baby by palpating the abdomen in preparation for
giving oxytocin to the mother.
22. Give IM oxytocin within one minute of baby’s birth.
E. 1-3 minutes
23. Remove first set of gloves after positioning the baby for cord
clamping.
24. Palpate umbilical cord to check for pulsations
25. After pulsations stop, clamp cord using the plastic clamp or cord tie
2cm from the base
26. Place the instrument clamp 5 cm from the base
27. Cut near plastic clamp (not midway)
28. Perform the remaining steps of the AMTSL:
 Wait for strong uterine contractions then apply control cord
traction and counter traction on the uterus, continuing until
placenta is delivered
 Massage uterus until it is firm
F. Immediate Postpartum Care
29. Inspect the lower vagina and perineum for lacerations/tears and
repair lacerations/tears if necessary.
30. Examine the placenta for completeness and abnormalities
31. Clean the mother: flush perineum and apply perineal
pad/napkin/cloth
32. Check baby’s color and breathing: check that the mother is
comfortable, uterus is contracted
33. Dispose the placenta in a leak-proof container or plastic bag
34. Decontaminate (soak in 0.55 chlorine solution) instruments before
cleaning: decontaminate second pair of gloves before disposal
(decontamination lasts for atleast 10mins)
35. Advise mother to maintain skin to skin contact. Baby should be
positioned prone on mother’s chest/in between the breasts with head
turned to one side
G. 15-90 minutes
36. Advise mother to observe for baby’s feeding cues and cite examples
of feeding cues
37. Support mother, instruct mother on positioning and attachment
38. Wait for full breastfeed to be completed

***After a complete breastfeed, may administer eye ointment (first),

do thorough physical examination, then administer Vitamin K, Hepatitis
B, BCG injections
39. Advise breastfeeding per demand
40. In the first hour: check baby’s breathing and color; check mother’s
vital signs and massage uterus every 15 minutes
41. In the second hour: Check mother-baby dyad every 30 minutes to 1
hour.
42. Complete all records.

IMMEDIATE POSTPARTUM CARE (ONLINE)

A. Repair of Lacerations
Classification of Perineal Lacerations
 First degree – involves the vaginal mucous membranes and perineal skin
 Second degree – involves not only the muscles, vaginal mucous membranes, and skin, but also the
muscles.
 Third degree – involves not only the vaginal mucous membranes and skin, but also the external
sphincter of the rectum
 Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous
membranes, and skin, but also the m mucous membranes of the rectum.

1. Assist the doctor in doing episiorrhapy repair of episiotomy or lacerations). In vaginal

episiorrhapy, packing is done to maintain pressure on the suture line, thus prevent further
bleeding. Note: Vaginal packs have to be removed after 24 – 48 hours
2. After repair of lacerations & episiotomy, perineum is cleansed, the legs are lowered from
stirrups at the same time.
3. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to
prevent its moving forward from the anus to the vaginal opening. Soiled napkins should be
removed from front to back.
4. Position the newly – delivered mother flat on bed without pillows to prevent dizziness due to
decrease in intraabdominal pressure.
5. Check V/S of the mother every 15 mins for the first hour & every 30 mins for the next 2 hours
until stable.
6. Check uterus & bladder q 15 mins. A full bladder is evidenced by a fundus which is to the right
of the midline and dark – red bleeding with some clots. Will prevent adequate uterine
contraction.
7. Fundus – should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4
hours. Fundus should be firm, in the midline, and during the first 12 hours postpartum, is a
little above the umbilicus. First nursing action for a non- contracted uterus: massage.
8. Perineum – is normally tender, discolored and edematous. It should be clean, with intact
sutures.
9. Blood pressure and pulse rate may be slightly increased from excitement and effort of delivery,
but normalize within one hour.

B. Apgar Scoring

Special Considerations:

 1st 1 min – determine general condition of baby

 Next 5 min- determine baby’s capabilities to adjust extra uterinely (most important)
 Next 15 min – (optional) dependent on the 5 min

A- appearance- color – slightly cyanotic after 1 st crybaby becomes pink.

P- pulse rate – apical pulse – left lower nipple

G- grimace – reflex irritability- (1) tangential foot slap, (2) catheter insertion
 A – activity – degree of flexion or muscle tone

R – respiration - assessment of lungs

 Baby cries – within 30 secs

 Failure to cry after 30 secs – asphyxia neonatorum

DANGER ASSESSMENT: Respiratory depression – due to Demerol (given to the mother).

– administer Naloxone

Table 4.4. APGAR Scoring Chart

0 1 2
HR (most important) Absent <100 >100
Respiratory Effort Absent Slow, irregular, weak Good strong cry
Muscle Tone Flaccid extremities Some flexion Well flexed
Reflex Irritability No Response Grimace Cough, sneeze
Acrocyanosis Pinkish
Color Blue/pale (Body- pink
extremities-blue)

APGAR Result:

0 – 3 = severely depressed, need CPR, admission NICU

4 – 6 = moderately depressed, needs additional suctioning & O2 administration

7 - 10 =good/ healthy

ANTHROPOMETRIC MEASUREMENTS
 refers to comparative measurements of the human body.
 The anthropometric measurements commonly used as indices of growth and development for
infants include length, weight, and head circumference.
 Growth is evaluated by comparing individual measurements to reference standards,
represented by percentile curves on a growth chart.
 For anthropometric measurements to be valid indices of growth status, they must be highly
accurate, requiring precision in measuring technique.

*Normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm

*Head circumference 33- 35 cm or 13 – 14 “

*Hydrocephalus - >14”

*Chest 31 – 33 cm or 12 – 13” (Average 32 cm)

*Abdomen 31 – 33 cm or 12 – 13”
Length Measurement

 Newborn average head to heel length is 45 to 55 cm (18-22 inches)

 Average is 50 cm
 Females generally are ½ inch shorter than male infants. The average length of boys is 20 inches
or 50 cm and girls, 19.6 or 49 cm
 The height and length of the newborn increases by 2.5 cm or 1 in a month from 1-5 months
and 1.25 cm from 6 months to 1 year
 Total average increase in length during the first year of life is 25 cm distributed as follows:
o from birth to 3 months: 9 cm
o From 3 to 6 months: 8 cm
o From 6 to 9 months: 5 cm
o From 9 to 12 months: 3 cm
 Formula for expected height:
o Height in cm = age in years X 5 + 80
o Height in inches = age in years X 2 + 32 or,
o Height in inches = age in years X 2 ½ + 30

Equipment:
 Use a length-measuring device with a fixed headboard and a moveable footboard that are
perpendicular to the surface on which the child is lying. A fixed measuring tape, marked in
millimeters or in 1/16 in. segments, should be attached to the surface with the zero end at the
edge of the headboard. Several commercial versions of length boards are available.
Weight Measurement

 Birth weight of full-term newborn infants range from 6 to 8.5 lbs. or 2700 to 4000 g. Average is
3500 g.
 Birth weight should be recorded immediately after birth because weight loss occurs rapidly in
newborns.
 The average female infant birth weight is around 7 lbs. while that of male infant is around 7.5
lbs. Boys is usually heavier than girls by 100 g or 3 ounces. The average birth weight of Filipino
infants is 3000 grams.
 Physiologic weight loss: Newborns loss about 10% (6 to 10 oz) of their birth weight during the
first 3-4 days of life due:
o Excretion of fluids through the lungs, urinary bladder, and bowels
o Passage of meconium
o Withholding of calories and fluids immediately after birth
o Minimal food intake because sucking is not yet established and colostrum
contains less calories than mature milk
 Weight Gain:
o Breastfeed infants regain their birthweight within 10 days and formula fed infants
within 7 days
o BW doubles at 5-6 months and expected to triple at one year
o Weight by 2 years is 4 times the BW
o Infants generally gain approximately 20 – 25 grams per day or 150-210 g weekly
during the first five months of life
o 5-6 months --- 2X birth weight
o 1 year --- 3X birth weight
o 2 years --- 4X birth weight
o 3 years --- 5X birth weight
o 5 years --- 6X birth weight
o 7 years --- 7X birth weight
o 10 years --- 10X birth weight

EQUIPMENT:

 Use a beam scale with non-detachable weights or an equally accurate electronic scale. For
infants and young children who are weighed lying down use a pan-type pediatric scale that is
accurate to within 10 grams or 1/2 oz.
 Do not use spring-type bathroom scales; with repeated use, they may not maintain the
necessary degree of accuracy.
 Frequently check and adjust the zero weight on the beam scale by placing the main and
fractional sliding weights at their respective zeros and moving the zeroing weight until the
beam is in balance at zero.
 If a pad or diaper is used to make the pan more comfortable, place it in the pan when the zero
adjustment is made; otherwise, the weight of the pad or the diaper must be subtracted from
the weight of the child each time a measurement is made. Whichever method is used to
account for the weight of the diaper or pad, note it on the growth chart. At least two or three
times per year, have the accuracy of the scale checked with a set of standard weights by a local
dealer or inspector of weights and measures.
Head Circumference Measurement

 The measurement of head circumference is an important screening procedure for detecting

abnormalities of head growth.
 Although usually caused by non-nutritional factors, slow head growth can be a result of severe
under nutrition.
 Children with poor head growth frequently have poor linear growth as well. Thus, knowledge
of head size is very important in assessing possible nutritional factors contributing to short
length or stature. Head circumference should be measured routinely.
 Normal measurement: 33 to 35 cm (13 to 14 inches). In vaginal delivery, molding may reduce
head circumference (HC) immediately after birth but it will return to normal size after two to
three days. The HC is actually the occipitofrontal circumference (OFC).
 It is approximately equal to crown-rump length or sitting height which is about 31 to 35 cm in
term infants. The relationship of HC to CRL is more reliable in identifying in high-risk infants
than that of the head and chest.
 The HC is usually greater than chest circumference (CC) by 2 cm.
 The head is one fourth of the total body length; this is because the head of the newborn is
proportionately larger than the head of the adult
 During the first four months, HC increases by half an inch a month and in the next 8 months,
by one fourth inch a month
 Measure HC at the level of eyebrows to the most prominent portion of the infant’s head with
the use of a tape measure. Measure it after birth, then after 48 hours because molding and
caput succedaneum may misshape the head making the first measurement inaccurate
 Take note of the following changes in the head circumference:
o At birth HC may be equal or greater than CC due to molding.
o After 2 to 3 days, HC is greater than CC by 2 to 3 cm.
o After six months, HC is equal to CC.
o After 1 year, HC is less than CC.
 Abnormal findings:
o HC less than 32 cm is indicative of microcephaly in term infants
o HC that is 4 cm and greater than CC or more than 37 cm is indicative of
neurologic involvement such as hydrocephalus
Equipment:

 Use a flexible, non-stretchable measuring tape.

Chest Circumference Measurement

 Normal CC range from 30.5 to 33 (12 to 13 inches), usually 2 cm less than HC.
 The CC is measured at the level of the nipple using a tape measure.
 A CC less than 30 cm indicates prematurity. An enlarged heart may make the left side of the
chest larger.

Abdominal Circumference Measurement

 Abdominal circumference (AC) is approximately the same as chest circumference.

 It is measured just above the level of the umbilicus. It is no longer recommended to measure
AC below the level of the umbilicus because a full bladder may interfere with accurate
measurement.

AC is not routinely measured unless there is obstruction in the gastrointestinal tract. The neonate’s
abdomen usually enlarges after a feeding due to lax abdominal

Anthropometric Measurement
Instruction: Check under Correctly Done if identified skill is correctly performed; Incorrectly Done if skill is
not performed correctly; and Not Done if the student failed to perform the skill.
Correctly Incorrectly Not Done

Procedure Done Done

2 1 0
1. Verify doctor’s order and identify the patient.
2. Introduce yourself and explain the procedure to the mother
3. Gather all equipment and perform hand washing
4. Measure the infant’s weight
Ü Remove infant’s clothing or be sure the diaper is clean and dry
ü Center the infant on the scale tray
ü Weigh infant to nearest 0.01 kg, 10 gm, or 1/2 oz
ü Write the weight on the infant’s chart
ü Reposition and repeat weighing the infant
ü Compare weights. Weight should agree within 0.01 kg, 10 gm or ½ oz
5. Measure infant length
ü Measure infant without shoes and wearing light underclothing or
diaper
ü the assistant measurer holds the infant’s head so the infant is looking
upward and the crown of the head is against the headpiece. This is the
Frankfort Plane.
ü the measurer aligns the infant’s trunk and legs, extends both legs, and
brings the footboard firmly against the feet
ü Measure the infant’s length to the nearest 0.1 cm or 1/8 in. write length
measurement on chart
6. Head Circumference
ü Position the tape just above the eyebrows, above the ears, and around
the biggest part of the head
ü Pull tape snuggly to compress the hair
ü Read the measurement to the nearest 0.1 cm or 1/8 in. Write the
measurement on the chart
7. Chest Circumference
ü Feel for the xiphisternum where the ribs meet the sternum and mark
the base of the xiphisternum
ü Pass the tape around the lower chest so that the mark is at the upper
border of the tape
ü Record three measurements of the chest circumference
ü Record the mean measurement by adding the values together and
dividing by three
8. Abdomen Circumference
ü Pass the tape around the baby’s bare skin at the level of the umbilicus
ü Ensure the nappy is not obstructing or constricting the area. If so, it
will be necessary to adjust or remove the nappy.
ü If the umbilicus protrudes too much and it is not possible to measure at
this level, then the reading should be taken immediately above the
umbilicus
ü Pass the tape around the abdomen at the position described above.
Take the reading at the end of expiration
9. Dress the infant and perform hand washing
10. Document the finding and refer if necessary