Nursing Care During Labor

Mindanao State University – Iligan Institute of Technology College of Nursing

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

NURSING CARE DURING LABOR

Definition:Labor is the series of events by which uterine contractions and abdominal pressure expel a fetus and placenta from the uterus. It
represents time of change as it is both an ending and a beginning for the woman, her fetus, and her family.(Pilliteri,2014)
Providing a safe and therapeutic environment for mother experiencing labor and delivery.

Purpose:
1. To determine cervical readiness for labor
2. Determine fetal position and presentation as well as degree of descent
3. Determine extent of cervical effacement and dilatation
4. To assess for abnormal vaginal bleeding
5. To assess amniotic fluid status

Indication: Pregnant woman to monitor for signs of labor and delivery

Contraindication: Contraindicated to patients with placenta previa.

Client Education:

1. Update the patient with the findings of the examination
2. Explain to the patient the importance of the procedure and that in monitoring progress of labor, IE may be done several times.
3. Educate the patient about frequency, duration and intensity of pain in each stage of labor.

NCM 101.1 NURSING CARE MANAGEMENT Page 1


Special Consideration: Since this procedure involves exposing the private parts of the client, some patient feel embarrass while this procedure is
performed. Make sure to drape properly.

Equipment: Sterile examination gloves Sterile lubricating solution Aseptic solution

Vaginal Examination

Description: Determine cervical readiness for labor and fetal position and presentation (Pillitteri, 2014). The introduction of gloved hand intravaginally
in an aseptic manner to estimate progress of labor.

Purposes:
1. To determine cervical readiness for labor.
2. Determine fetal position and presentation as well as degree of descent.
3. Determine extent of cervical effacement and dilatation.
4. To assess for abnormal vaginal bleeding.
5. To assess amniotic fluid status.

Indication: Pregnant woman to monitor for signs of labor and delivery

Contraindication: Contraindicated to patients with placenta previa.

Client Education:
1. Update the patient with the findings of the examination
2. Explain to the patient the importance of the procedure and that in monitoring progress of labor, IE may be done several times.
3. Educate the patient about frequency, duration and intensity of pain in each stage of labor.

Special Consideration: Since this procedure involves exposing the private parts of the client, some patient feel embarrass while this procedure is
performed. Make sure to drape properly.

Equipment:
● Sterile examination gloves


● Sterile lubricating solution
● Aseptic solution

Leopold’s Maneuver

Description: Systematic method of observation and palpation to determine fetal presentation and position and are done as part of physical
examination.(Pillitteri,2014)

Purpose: To determine fetal presentation and position and the expected location of the point of maximal intensity (PMI) of fetal heart rate (FHR) in
the woman’s abdomen.

Indication: For pregnant woman with palpable fetus usually performed starting from the middle of pregnancy.

Contraindication: A full bladder (may obscure the findings)

Special Considerations:
1. Obese clients have thick belly fat which can also obscure the findings.
2. Patients who are polyhydramnios may give the examiner a little difficulty; however reassessment and rechecking of another nurse
and intravaginal examination (IE) can help to confirm the finding

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ADMISSION
1.Obtain vital signs (BP, HR, RR) including To obtain baseline data and determine for
temperature, height and weight. any problems. Blood pressure is taken
between contractions because BP rises
515 mm hg during a contraction. An
increase in BP may indicate the
development eclampsia. A decrease in BP
may indicate hemorrhage.
2. Obtain relevant data related to the pregnant This data helps establish the viability of
woman such as LMP, AOG, and EDC. fetus
3. Place client on a supine position with knees To relax the abdomen. Performing
flexed and measure the fundic height and Leopold’s
perform Leopolds maneuver. maneuver will determine the fetal
position

**Obtain Fundic height: the tape can be During the second trimester, the uterus
placed in the middle of a woman’s abdomen, becomes an abdominal organ. The fundal
and the measurement made from the upper height, measurement of the height of the
border of the symphysis pubis to the upper uterus above the symphysis pubis, is
border of the fundus with the tape measure used as one indicator of fetal growth. The
held in contact with skin for the entire length measurement also provides a gross
of the uterus. estimate of the duration of pregnancy.
Perform Leopold’s Maneuver:

A. PREPARE THE PATIENT Explanation reduces anxiety and
1. Explain the procedure to the client. enhances cooperation.
2. Instruct the client to empty her bladder An empty bladder promotes comfort and
allows for more productive palpation
because fetal contour will not be obscured
by a distended bladder.


3. Wash your hands using warm water. Hand washing prevents the spread of
possible infection. Using warm water aids
in client comfort and prevents in
tightening of abdominal muscles during
palpation.

4. Position the woman supine with knees Flexing the knees relaxes the abdominal
slightly flexed. Place a small pillow or rolled muscles. Using a pillow or towel tilts the
towel under one side uterus off the vena cava, preventing
supine hypotension syndrome.
5. Observe the woman's abdomen for longest The longest diameter (axis) is the length
diameter and where fetal movement is of the fetus. The location of activity most
apparent likely reflects the position of the feet.
B. PERFORM THE FIRST MANEUVER
Stand at the foot of the client, facing her, and This maneuver determines whether the
place both hands flat on the abdomen. Palpate fetal head or breech is in the fundus. A
the superior surface of the fundus. Determine head feels more firm than a breech, is
the consistency, shape, and mobility. round and hard, and moves
independently of the body; the breech
feels softer and moves only in
conjunction with the body
C. PERFORM THE SECOND MANEUVER
Face the client and place the palms of your This maneuver locates the back of the
hands on both sides of the abdomen. Palpate fetus. The fetal back feels like smooth,
the sides of the uterus. Hold the left hand hard, and resistant surface; the knees
stationary on the left side of the uterus while and elbows of the fetus on the opposite
the right hand palpates the opposite side of


the uterus from top to bottom. side feel more like a number of angular
bumps or nodules.
D. PERFORM THE FOURTH MANEUVER
Place fingers on both sides of the uterus This maneuver is only done if the fetus is
approximately 2 inches above the inguinal in a cephalic presentation because it
ligaments, pressing downward and inward to determines fetal attitude and degree of
the direction of the birth canal. Allow fingers to fetal extension into the pelvis. The fingers
be carried downward. of one hand will slide along the uterine
contour and meet no obstruction,
indicating the back of the fetal neck. The
other hand will meet an obstruction an
inch or so above the ligament this is the
fetal brow. The position of the fetal brow
should correspond to the side of the
uterus that contained the elbows and
knees of the fetus. If the fetus isin a poor
attitude, the examining fingers will meet
an obstructiion on the same side as the
fetal back; that is, the fingers will touch
the hyperextended head. If the brow is
very easily palpated (as if it lies just
under the skin), the fetus is probably in
posterior position (the occiput is pointing
toward the woman’s back).
4. Prepare the client for vaginal to assess cervical readiness
examination.
Vaginal Examination
1. Wash hands. Deters spread of infection


2. Explain the procedure to the client. Ensures cooperation and compliance
3. Provide privacy. Enhances self esteem and avoid
embarrassment

4. Assess client status and plan to meet To individualize the care for the patient
individual client need.
5. Prepare all needed equipment. To save time and improve efficiency
6. Ask the woman to turn unto back with For good visualization of the perineum
knees flexed (dorsal recumbent position).
7. Repeat handwashing and put on sterile Prevents contamination
examination gloves.
Prepping and Draping Remove secretions and feces from the
a. Pour antiseptic solution over vulva perineal area.
using the nondominant hand.
b. Take a fresh sponge to begin each new
area, and do not return to a clean with a
used sponge. Six sponges are needed. Prevents from cross contamination or
The proper order and motion are as recontamination of an area that is already
follows. clean.
1. Use a zigzag motion from clitoris
to lower abdomen just above the
pubic hairline.
2. Use a zigzag motion on the inner
thigh from the labia majora to
about halfway between the hip
and the knee. Repeat for the
other inner thigh.


3. Apply a single stroke on one side
from the clitoris over labia,
perineum and anus. Repeat for
the other side.
4. Use a single stroke in the middle
from the clitoris over the vulva
and the perineum.

8. Discard one drop of clean lubricating Ensures that the quantity used will not be
solution and drop an ample supply on tips of contaminated
gloved fingers.

9. Place non dominant hand on the outer Positioning hands in this way allows good
edges of the woman's vulva and spread her visualization of the perineum. Presence of
labia while inspecting the external genitalia for any
lesions. Look for red, irritated mucous lesion may indicate infection and possible
membranes, open, ulcerated sores, clustered preclude vaginal birth
and pinpoint vesicles.

10. Look for escaping fluid or presence of Amniotic fluid implies membranes have
umbilical cord or bleeding. ruptured and umbilical cord may have
prolapsed. Bleeding may be a sign of
placenta
previa.

11. If there is no bleeding or cord visible, Posterior vaginal wall is less sensitive
introduce your pointer and middle fingers of than


dominant hand gently into the vagina, anterior wall. Stabilize the uterus by
directing them toward the posterior vaginal placing
wall. your nondominant hand on the woman
abdomen

12. Touch the cervix with your gloved
examining fingers.
a. palpate for cervical consistency and rate if a. The cervix feels like a circular rim of
firm or soft tissue
around a center depression. Firm is
similar to
the tip of a nose; soft as pliable as an
earlobe. The anterior rim is usually the
b. measure the extent of dilatation; palpate for last
an anterior rim or lip of cervix. portion to thin.

b. The width of the fingertip helps to
estimate
the degree of dilatation. An index finger
average about 1 cm; a middle finger
about 1 ½ cm. If they can both enter the
cervix, the
cervix is 2 ½ to 3 cm. If there would be
room
for double the width of your examining
fingers
in the cervix, the dilatation is about 5 to 6
cm. when the space is four times the
width of


your fingertips, dilatation is complete 10
cm.

13. Estimate the degree of effacement. Effacement is estimated by percentage
depending on the thickness. A cervix
before labor is 2 to 2 ½ cm thick. If it is
only 1 cm
thick, it is 50 % effaced. If it is tissue
paper
thin, it is 100 % effaced. With a 100%
effaced
cervix, dilatation is difficult to feel
because the edges of the membranes are
so thin.

14. Estimate whether membranes are intact. The membranes are shape of a watch
crystal. With a contraction they bulge
forward and become prominent and can
be felt much more readily.

15. Locate the ischial spines. Rate the station Ischial spine is palpated at the 4 and 8
of the presenting part and identify the o’clock position at the pelvic cutlet.
presenting part. Identifying the presenting part confirms
the findings of the Leopold’s maneuver
and will determine potential problems
with the delivery of the fetus.
Differentiating a vertex from a breech
may be difficult than would first appear A


vertex has a hard, smooth surface. Fetal
hair may be palpable but massed
together and wet; it may be difficult to
appreciate through gloves. Palpating the
two fontanelles, one diamond shaped and
one triangular helps the identification.
Buttocks feels softer and give the under
fingertip pressure. Identifying the anus
may be possible because the sphincter
action will trap the index fingers.

16. Establish the fetal positioning. The fontanelle palpated is invariably the
posterior one because the fetus maintains
a flexed position, presenting the posterior
not the anterior fontanelle. In ROA
position, the triangular fontanelle will
point toward the right anterior pelvic
quadrant. In LOA position, the posterior
fontanelle will point toward the left
anterior pelvis. In a breech presentation,
the anus can serve as a marker for
position. When the anus is pointing
toward the left anterior quadrant of the
woman’s pelvis, the position is LSA

17. Withdraw your hand slowly and wipe the Using a gentle technique in withdrawal
perineum front to back to remove secretions will provide patient comfort. Wiping from
or examining solution. front to back prevents contamination



18. Leave client comfortable. Left lateral position is most recommended
to prevent supine hypotension syndrome
in labor
19. Document procedure and assessment Provide a means of communication and
findings and how client tolerated procedure. evaluation of care and client outcomes

20. Monitor for frequency, interval and To assess progress of labor and monitor
duration of the uterine contractions,and record fetal well being
in the monitoring sheet (Refer to Partograph
Checklist)

21. Encourage the client to urinate and A full bladder may impede descent of the
defecate. presenting part; over distention may
cause injury as well as postpartum
voiding difficulty.

22. Encourage her to walk and rest This will reduce muscle tension, relieves
alternately, unless contraindicated. pressure and promotes fetal descent

23. Assist in administering IV fluids as ordered Maintains hydration and provides venous
by the Attending Physician. access for medication.

STUDENT’S LEARNING FEEDBACK AND INSTRUCTOR’S COMMENT:

FACULTY SIGNATURE: __________________________
Reference(s):


Pillitteri, A. (2014). Maternal and Child Health Nursing: Care of the Childbearing & Childrearing Family 7th edition . Walnut St. Philadelphia: Lippincot
Williams and Wilkins.
Williams and Wilkins .
Lowdermilk, D. and Perry, S. (2006). Maternity Nursing 7th edition. St Louis, Missouri: Mosby Elsevier

PARTOGRAPH USE

Definition: A partograph is a graphical record of a woman in labor and of fetal and maternal condition during labour on a labor record (partogram) on
which Vital signs, fetal heart rate, cervical dilatation,descent of the fetal head, urine tests , and any drug administration can be
recorded.(Pillitteri,2014)

Purposes:
1. To detect abnormal progress of labor as early as possible
2. To prevent prolonged labor
3. To recognize CPD long before obstructed labor
4. To assist in early decision on transfer, augmentation or termination of labor
5. To increase the quality and regularity of all observations of mother and fetus
6. To recognize maternal or fetal problems as early as possible
Considerations:
1. A partograph should be started when a woman is in active labor (cervix dilated at 4cm or more).
2. If there are any complications that require immediate attention, take appropriate actions before starting the partograph.
3. All the recordings on the partograph should be done in relation to the timeline.
4. Each rectangle of the time line represents one hour.
5. Record the number of hours passed since the partograph was started in the upper row.
6. Record the actual time in the lower row.


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1. Assess the woman in labor for any possible
complications that require immediate nursing
action.
2. Perform careful vaginal examination to The vaginal examination reveals whether the woman
determine cervical dilatation and stage of labor. is in true labor and enables the examiner to
Succeeding vaginal examinations should then be determine whether the membranes have ruptured.
done every 4 hours. Because this examination is often stressful and
uncomfortable for the woman, it should be
performed only when indicated by the status of the
woman and her fetus.
Also, the only certain objective sign that the second
stage of labor has begun is the inability to feel the
cervix during vaginal examination, indicating that the
cervix is fully dilated and effaced.


I. Assessing the Fetal Condition
3. Assessing the fetal condition involves assessing Because labor is a period of physiologic stress for the
the Fetal Heart Rate (FHR), Amniotic Fluid, and fetus, frequent monitoring of fetal status is part of
Degree of Moulding. the nursing care during labor.

4. The first graph represents the FHR. Each vertical Fetal wellbeing during labor can be measured by the
side of the rectangle represents the beats per response of the fetal heart heart (FHR) to uterine
minute in 10 increments, while each horizontal contractions (UCs).
side represents the time by 30 minutes.

5. Monitor the heart rate for beats of less than 100 A baseline FHR is 110 to 160 and must be checked.
or beats of more than 180 beats per minute. If the baseline rate begins to slow or if deceleration
This requires immediate attention. patterns develop, prompt treatment must be
initiated.

6. The next set of graph pertains to the status of Labor is initiated at term by SROM in approximately
amniotic fluid and membranes. If the 25% of pregnant women. Membranes (the BOW)
membranes have not yet ruptured, write I on also can rupture spontaneously any time during
the box. labor, but most commonly in the transition phase of
the first stage of labor.

7. If the membranes have ruptured, record the Amniotic fluid should be clear as water.
characteristics of the amniotic fluid. Write C if Yellowstained fluid suggests a blood incompatibility
Clear, write B if bloody or red, write M if the between the mother and fetus (the amniotic fluid is
fluid is green or meconium stained, and write A


if amniotic fluid is absent even
after bilirubin stained from the breakdown of red blood
membranes ruptured. cells). Green fluid suggests meconium staining.

8. If the amniotic fluid is absent after rupture of Because this may cause fetal distress. Assess FHR
membranes, increase frequency of assessing immediately to be certain the umbilical cord hasn’t
the fetal heart rate. prolapsed and is now being compressed against the
cervix by the fetal head.
9. The last portion of fetal assessment is the
moulding. Moulding is an important indicator of
how well the pelvis can accommodate the fetal
head.
10. Note and record moulding at each vaginal
examination. To monitor progress of labor.
11. Normally, in the early stage of labor, the fetal
sutures are separate and bones do not touch
each other. This is recorded on the moulding
graph as (zero) 0.
12. On the later stage of labor, moulding will If the presenting part is below the ischial spines, the
become prominent as the head fits on the distance is stated as plus stations (+1 to +4 cm). At
pelvic inlet. If the fetal bones are touching each a +3 or +4 station, the presenting part is at the
other, record +, if they are overlapping perineum and can be seen if the vulva is separated.
moderately, record ++, and if the bones are
overlapping severely, record +++.
13. Watch out for severely overlapping skull bones
which are nonreducible while the head is still

above the ischial spines. It is an ominous sign
of labor.
II. Assessing the Progress of Labor


14. This portion of the partograph assesses the Dilatation occurs first because uterine contractions
degree of cervical dilatation against time. gradually increase the diameter of the cervical canal
Cervical dilatation is measured in cm. Time lumen by pulling the cervix up over the presenting
refers to the hours starting from the time the part of the fetus.
mother has entered the active stage of labor
(4cm) and has started using the partograph.
This is recorded as x on the graph.
15. The progress of labor graph features the Alert The form shows an “alert line”, which marks when 4
Line and the Action Line. The goal of monitoring hours has passed. Four hours beyond that, an “action
is to keep the progress line on the left side of line” advises a primary care provider that cervical
the lines and prevent or manage if the labor dilation is taking longer than usual and that an
progress crosses the alert or action line. intervention may be necessary to make the labor
safe and effective.

16. The alert line represents cervical dilatation rate
of 1 cm per hour which is considered to the
slowest rate of cervical dilatation in normal
conditions both for nullipara and multipara.
17. The normal progress of labor should be along Maintaining an ongoing record and alerting the care
the Alert Line or to the left of the alert line. If provider that the alert line or action line is
the rate of dilatation crosses the alert line (but approaching are important nursing responsibilities.
before the action line) decisions to speed up
the dilation such as amniotomy can be
considered.



18. If the rate of dilatation reaches or crosses the
Action Line, it indicates dangerously slow
progress of labor. Decision and action must be
done to transfer the mother to a hospital with
equipment and facilities that deal with obstetric
emergencies.
19. Cervical dilatation should be accompanied with
fetal head descent. Head descent is plotted on
the same graph representing the cervical
dilation on the spaces from 05cm along the
vertical line.
20. The assessment of head descent is done
abdominally and is represented by the
examiners fingerbreadth with each finger
approximating 1cm.
21. Head descent is plotted as O on the partograph
and must be assessed and plotted the same
time as the cervical dilatation.

22. It is important to remember that the direction
of the dilatation and the fetal head descent must
be in opposite direction to represent a normal
progress of labor. As the dilatation goes up, the
fetal head simultaneously goes down in normal
labor progress.

23. The third portion of labor progress monitoring is Between contractions, the uterus relaxes. As labor
the labor contraction. Normally as the labor progresses, the relaxation intervals decrease from 10
minutes early in labor to only 2 to 3 minutes.


progresses, the uterine contractions become
more frequent and last longer.
24. Uterine contraction should be assessed every 30 The duration of contractions also changes, increasing
minutes, and is taken on a 10minute period. from 20 to 30 seconds at the beginning to a range of
The technique is counting how many contraction 60 to 70 seconds by the end of the first stage.
within 10 minutes and recording the duration of
each contraction in seconds.
25. If contraction last for 20 seconds or less fill
square with dots. If between 2040 seconds by
diagonal line and >40 seconds fill the square
completely by shading.

III. Assessment of Maternal Condition
26. Assess maternal condition regularly by
monitoring. Drugs, IV fluids, Pulse are
monitored every 30 minutes; Temperature and
BP every 4 hours; and urine volume, analysis for
protein and acetones every 2 to 4 hours.
27. When poor progress of labor is due to When labor contractions are ineffective, several
inadequate uterine activity, the use of interventions, such as induction and augmentation of
amniotomy followed by oxytocin infusion after labor with oxytocin or amniotomy (artificial rupture
may be considered. of the membranes), may be initiated to strengthen
them.

28. When oxytocin is used, record every 30 minutes Oxytocin is an effective uterine stimulant, but there
the concentration per liter and the number of is a thin line between adequate stimulation and
drops infused to the patient. Always check the hyperstimulation, so careful observation during the


membranes are ruptured before oxytocin is entire infusion time is an important nursing
used. responsibility.

28. Always observe that oxytocin infusion must
result to increased frequency and duration of
uterine contractions.

29. Drugs on IV infusions given during labor must
be recorded on the portion of the partograph
just below the oxytocin infusion area. Record
the name, dosage, and route of administration.
Make sure that it is parallel on the exact time of
the labor progress.

30. Record the mother’s pulse every 30 minutes A side effect of oxytocin is that it causes peripheral
and reflect as a dot connected with solid lines on vessel dilatation, and peripheral dilation can lead to
each subsequent recordings. BP and extreme hypotension. To ensure safe induction,
temperature are recorded every 4 hours or more therefore, take the woman’s pulse and blood
frequently if indicated. pressure.
31. If ordered, obtain urine sample every 2 to 4 A second side effect of oxytocin is that it can result in
hours and check for protein, volume, and decreased urine flow, possibly leading to water
acetone. intoxication.
32. Finally, do a written documentation of the
outcome of labor based on the observation
obtained on the previous monitoring.



STUDENT LEARNER’S FEEDBACK/INSTRUCTOR’S COMMENT:

Reference(s):

Maternal and Child Health Nursing(2014) Adele Pillitteri
MaternalNeonatal Nursing (2008). Lippincott Williams & Wilkins
Maternal and Child Nursing (2007), Elsevier Inc.



Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)
Essential Intrapartum and Newborn Care represents the highest standard for safe and quality care for birthing mothers and healthy newborns in the
48 hours of the intrapartum period and up to a week of life of the newborn. Its adoption helps reduce maternal and newborn morbidity and
deaths.(WPRO,2016)

The recommended EINC practices during the intrapartum period include:
1. Continuous maternal support by having a companion of choice during labor and delivery
2. Freedom of movement during labor
3. Monitoring progress of labor using the partograph
4. Nondrug pain relief before offering labor anesthesia
5. Position of choice during labor and deliver
6. Spontaneous pushing in a semiupright position
7. Nonroutine episiotomy; and
8. Active management of the third stage of labor (AMTSL).

4 core steps in the essential newborn care:
1. immediate and thorough drying
2. early skintoskin contact
3. properly timed cord clamping
4. non separation of the newborn and mother for early initiation of breastfeeding

MATERIALS NEEDED:
2 sterile gloves dry linens bandage/ surgical scissor 0.5% chlorine solution 2 kidney basins
plastic cord clamp bonnet
instrument clamp cherry balls soaked in an antiseptic solution


APGAR SCORING
Named after Virginia Apgar (19091974), an American obstetrical anesthesiologist who was interested in the side effects of anesthesia given to
a mother during labor on her newborn baby. In 1952, the Apgar Score at 1 minute was first planned as a guide to the need for resuscitation.

Nowadays, APGAR is a standard test for a quick newborn assessment. It helps identify babies that have difficulty breathing or have a problem
that need further care. It's a great method for evaluating the newborn's transition to life outside the womb.

5 simple criteria are used to evaluate your newborn baby's health. Each criteria is scored on a scale of 0 to 2 (2 being the best score) for a
maximum of 10. Each letter of the name Apgar became a way to retain information more easily:
● A for APPEARANCE. What is the skin coloration or complexion? The entire body is pink (score of 2). The body is pink and
the extremities are blue (score of 1). The skin color is pale blue (score of 0).
● P for PULSE. What is the heart rate? Greater than 100 beats per minute (score of 2). Less than 100 beats per minute
(score of 1). Absent (score of 0).
● G for GRIMACE. What is the reflex irritability? What is the response to stimulation such as a mild pinch? Grimacing
and/or a vigorous cry when stimulated (score of 2). Grimace or weak cry when stimulated (score of 1). No response
(score of 0).
● A for ACTIVITY. What is the muscle tone? Active motion, flexed arms and legs that resist extension (score of 2). Some
muscle tone (score of 1). Muscle loose and no tonus (score of 0).
● R for RESPIRATION. What is the breathing rate and effort? A good cry (score of 2). Respirations slow or irregular, weak,
gasping (score of 1). No breathing (score of 0).



VITAMIN K INJECTION
Description: Vitamin K plays a key role in helping the blood clot, preventing excessive bleeding.

Equipment:
● Vitamin K (Phytonadione); Aquamephyton, Konakion, Mephyton 10 mg ampule
● Tuberculin syringe
● G25 needle
● Alcohol swab
● Dry cotton ball
● Plaster
● Medication card

HEPATITIS B VACCINATION
Description: Hepatitis B (Hep B) vaccine is given to protect the infant against Hepatitis B viral infection.
Normal Course:
● Hepatitis B vaccine is very safe.
● Most common side effects include redness, swelling, and pain where the injection has been given. These side effects usually
start within a day after the vaccine has been given and last for one to three days.
● Fever may occur for a short time after the vaccine has been given.

Equipment:
● Hepatitis B Vaccine (dose: 0.5 ml)
● Tuberculin syringe with needle; 0.5 ml Autodisable (AD) injection device
● G22/G23 needle
● Dry cotton ball
● Plaster


● Medication card

BCG VACCINATION
Description: Bacillus CalmetteGuerin (BCG) is a vaccine against Tuberculosis (TB). This is given to a newly delivered infant to protect
him/her from pulmonary TB in children called Primary Complex.

Normal Course:
● The wheal raised by the injection disappears in about half an hour.
● After two weeks, a small, red, tender swelling about 10mm across appears the injection site.
● After 23 weeks, the swelling may become a small abscess which then ulcerates and heals by itself.
● After about 12 weeks from vaccination, a raised scar is formed at the site of injection and which is used as proof of prior
immunization.

Equipment:
● BCG Vaccine (dose: 0.05 ml)
● Tuberculin syringe
● G25 needle
● Alcohol swab
● Dry cotton ball
● Plaster
● Medication card

CREDE’S PROPHYLAXIS
Description: Crede’s Prophylaxis is a method of applying eye drops on a newly delivered infant’s eyes to protect him or her against
ophthalmia neonatorum.
Purpose: To prevent bacterial infection of the newborn’s eyes
Recipient of Care: Mandatory; given to all.
Time of Administration: Immediately after initial bonding between the mother and the infant.
Equipment:
● Medication: Opthalmic ointment (Tetracyline 1%, Erythromycin 0.5%) or Opthalmic drops (Povidoneiodine 2.5%,
Silver Nitrate 1%)


● Sterile water
● Syringe
● PPE, if indicated

DIAPERING
Description: To put or change a diaper and fastening it around the waist in an aseptic manner after cleaning the perineum

Purposes: 1. To retain urine and stool adequately
1. Prevent soiling of linens
2. Provide comfort for the infant to wear
3. To assess the newborn’s stool and urine for any abnormalities

Contraindication: Contraindicated when there is presence of diaper rash

Special Considerations:
Types of diapers
1. Disposable diapers come in a variety of sizes such as newborn, infant or toddler and may cause irritation to infants who develop
sensitivity to paper and plastic products. May cause environmental concern because of disposal problems
2. Cloth diapers can be softer and less irritating for most infants. They are usually prefolded and are available in different sizes.
Cleansing at diaper changes
1. Wash with a mild soap and water, then rinse thoroughly. Keep a washcloth and towel at the side of the crib for this purpose
2. Use commercial disposable wipes that contain a nonallergenic agent baby oil or lotion for cleansing. Rinsing is not needed
because no irritating substance is present, although some babies may be sensitive to components of any cleaning solution.
Fastening diapers
1. Disposable diapers come with attached tapes for fastening
2. Safety pins are also used but must be used with caution since open safety pins are always a hazard.
3. Close pins as soon as they are removed and place them out of reached.
4. Place the pin horizontally with the point toward the infant’s side.
5. Place your hand between the infant and diaper you are pinning to prevent injury to the infant.
Skin Problems
1. Diaper rash is a skin reaction that appears as a macular to solid redness in perineal area. It maybe caused by prolonged contact
with urine or feces and irritation from residual detergents or cleansing agents in a diaper.
2. Scald occurs rapidly and appears as a totally reddened area much like a burn.


Ways to prevent diaper rash
1. Change diaper frequently and clean the skin with each change to remove residual urine or feces.
2. Allow the infant to go without wearing a diaper for several hours each day.
3. If the infant is wearing disposable diapers, a change to cloth diaper or inserting holes in the disposable ones may help control
diaper rash.
Equipment needed:
● Diaper
● Wet cotton sponge
● Clean gloves

NEWBORN BATHING
Description: Washing an infant using warm water and mild cleanser in a systematic manner
Purposes: 1. For removal of debris accumulated during the birthing process
2. For providing comfort of an infant
3. For performing of daily routine of cleaning and assessment if infant
Contraindication: Contraindicated to hypothermic patients (temperature below 36.3°C)
Special considerations:
Safety: Everything must be within reach before beginning; one hand must remain in contact with the infant at all times to prevent
falls. Care must be taken so that the environment is free from draft and warm enough.
Holding the infant: Any method of holding an infant must provide support for the head and neck and keep the infant close to your
body to lessen chance or injury or dropping. A football holding does all of these things.
Shampooing: This is usually done each time an infant is bathed to prevent a scale accumulation called cradle cap. Hold the infant
footballstyle with head over the basin so that the scalp can be gently scrubbed and thoroughly rinsed with strokes going away
from the infant’s face.
Eye care: Without soap, clean each eye from inner to outer canthus, using a clean area of the washcloth for each eye so that the
microorganisms are not transferred form one eye to the other.
Folds: Infants may have creases and folds. Wash and dry carefully in all of them. Moisture left in the creases causes skin breakdown.
Perineal Care: For the female infant, be sure to clean between the labia and in all folds from front to back. For the uncircumcised
male infant, gently retract the foreskin only as far as it will go easily, and return it to its normal position after cleansing the
exposed surfaces. Secretions left under the foreskin may cause irritation and infection, with resulting adhesions.
Cord Care: When the newborn has the cord stump in place, you must perform cord care. This includes carefully inspecting the base of
the cord for signs of infection (such as redness, drainage, or odor) and cleaning it with alcohol. The area is also kept dry, and
the infant is not bathed in a basin or sink until the cord detaches (in 14 weeks).


Client Education: Advise parents that the infant’s ability to regulate body temperature has not fully developed and their body loses
heat readily.
Equipment:
● Basin with Lukewarm water
● Soft comb or brush
● Mild soap
● Sterile cotton balls
● Clean towel
● wrapper and baby’s clothes
BREASTFEEDING
Description: Breastfeeding is considered the safest, simplest, and least expensive way to provide complete infant nourishment. The
American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for the first 4 to
6 months of the infant’s life and then in combination with infant foods until age 1.
Purpose: Helping the patient to latch the neonate properly.
Principles: After the immediate care of the normal newborn delivered spontaneously, bring the baby to the mother for the first feeding.
In the hospital, roomingin policies support breastfeeding. (R.A. 7600: The RoomingIn and Breastfeeding Act of 1992).
Guidelines/ Special Considerations: Breastfeeding is contraindicated if the mother:
● Has herpes lesions on her nipples
● Is receiving certain medication, such as methotrexate or lithium, that pass into the breast milk and may harm the neonate.
● Is on restricted diet that interferes with adequate nutrient intake and subsequently affects the quality of milk produced
● Has breast cancer
Equipment:
● Breastfeeding handouts/resources
● Bed pillows or breastfeeding pillows
● Cloth diaper



N
O
E
T
X
P
C
E UNS VE
SATI E
R ATIS GO RY
SFAC L
PROCEDURE RATIONALE F FACT OD GO
TORY L
O ORY OD
E
R
N
M
T
E
D
0 1 2 3 4 5 6 7 8 9
Prior to Patient’s Transfer to the Delivery

Room
The best position for a woman in labor is
1. Ensure that the mother is on her position whatever she finds most comfortable and which

of choice when in labor. gives her the most control of her labor.

To provide nourishment. A woman placed on a prolonged
2. Ask the mother if she wishes to eat or
NPO can become dehydrated.
drink.

3. Communicate with the mother. Inform her
of the progress of labor, give reassurance To minimize anxiety and promote cooperation.
and encouragement.
Patient Already in the Delivery Room
A. Preparing for Delivery


1. Check temperature in the Delivery Room
area. Appropriate room temp is 2025
degree Celsius Check for air draft.
2. Ask the patient if she is comfortable in the The upright position has a favorable effect on uterine
semiupright position which is the default contractility and reduces pain and perineal trauma.
position.
3. Remove all jewelry. Prevents harbor of microorganisms
4. Wash hands thoroughly observing the Deters spread of infection
proper procedure.
5. Arrange these things in a linear fashion: Organization facilitates ease in the performance of the
gloves, dry linen, bonnet, oxytocin task and facilitates a systematic progression of the
injection, plastic clamp, instrument clamp, procedure.
scissors, 2 kidney basins.
6. Clean the perineum with antiseptic To reduce the number of microorganisms in the skin.
solution. Use sterile gloves or working
forceps to clean the perineal area. Use
cherry balls soaked with antiseptic solution
or 7% betadine solution.
a. Start prep with cleansing the pubis,
progressing downward over the vulva and

perineum and last over the anus.
b. The inner aspect of the thighs is cleansed
from the labia majora to the inner aspect
of the upper third of the thighs. Each
sponge in contact with the anus is
discarded.
7. Prepped the vagina last.
8. Wash hands. Deters spread of infection


9. Put on 2 pairs of sterile gloves aseptically. To prevent spread of infection and protect the nurse from
(If same worker handles perineum and the body fluids of the patient.
cord).
B. At the Time of Delivery
The natural urge to push is coupled with positioning,
1. Encourage the mother to push as desired. breathing, and relaxation techniques to make effective
use of the woman’s expulsive efforts.
2. Apply perineal support and do controlled Supporting the perineum will prevent laceration.
delivery of the head.
The time of delivery serves as the time of birth. It is the
3. Call out the time of birth and sex of baby. responsibility of the nurse to check and record accurate
data especially the gender and time of birth.

4. Inform the mother of outcome.

C. First 30 Seconds
Maintains appropriate room temperature
(2025 degrees Celsius)
1. Does immediate and thorough drying Newborns are wet, so they lose a great deal of heat as
within the first 30 seconds: the amniotic fluid on their skin evaporates.
a. Puts on double gloves
b. Places 2 sterile towels/linens on
mother’s abdomen
c. Dries the newborn thoroughly by
patting, making sure that the vernix
caseosa is not removed
d. Does a quick check on the APGAR of
the newborn while drying. (Refer to
illustration for APGAR Scoring)


e. Removes the top most wet
towel/linen
Note: Avoid bathing earlier than 6
hours of life.
D. 13 Minutes
1. Early skintoskin contact:

● Maintains prone position of the
Facilitate bonding between the mother and her
newborn on the mother’s abdomen
newborn through skintoskin contact to reduce
● Covers the back of the newborn with
likelihood of infection and hypoglycemia.
the second towel/linen and head

with bonnet

● Observes initial crawling reflex

● Places ID band on ankle (indicate

gender and family name)

● Does not separate from mother

unless newborn is having severe

chest indrawing, gasping or apneic.
2. Exclude a second baby by palpating the
abdomen. Use the wet cloth to wipe the
soiled gloves.
3. Give IM oxytocin within 1 minute of baby’s
birth (after confirmation of no succeeding
baby). Dispose the wet cloth properly.
4. Remove the first set of gloves.
(Decontaminate these properly by soaking

in 0.5% chlorine solution for at least 10
minutes.)
Reduce the incidence of anemia in term newborns
5. Properly timed cord clamping:
and intraventricular hemorrhage in preterm


a. Palpate umbilical cord to check for newborns by delaying or nonimmediate cord
pulsations. clamping.
b. After pulsations has stopped (13
minutes), put plastic clamp or tie
tightly around cord at 2cm and the
forceps 5cm from newborn’s
abdomen
c. Cut near the plastic clamp (not
midway).
d. Observe for oozing of blood; if blood
oozes, place a second clamp
between the skin and first clamp.
Perform the following steps of the active

management in the third stage of labor.
6. Wait for strong uterine contractions then Signs of placental separation are lengthening of the cord,
apply controlled cord traction and counter a sudden gush of blood and changing of the size of the
traction on the uterus, continuing until
placenta is delivered. lower abdomen
Keeping the uterus firm after placental delivery promotes
7. Massage the uterus until it is firm.
uterine contraction thereby prevents postpartum bleeding.
8. Inspect the lower vagina and perineum for Perineal lacerations, if not properly repaired, can result in

lacerations/tears and repair if necessary. maternal health problems.
To ascertain that placenta is intact and normal in
9. Examine the placenta for completeness appearance and weight. Normally, a placenta is onesixth
and abnormalities.
of the weight of the infant.


10.Clean the mother by flushing the perineum This will remove blood stains and promote comfort.
with sterile water and apply perineal

pad/napkin/cloth.
11.Check the baby’s color and breathing.
Ensure that the mother is comfortable and
uterus is contracting.
12.Dispose the placenta in a leakproof

container or plastic bag.
Bloody instruments must be properly cleaned to eliminate
13.Decontaminate instruments before
cleaning (soaked in 0.5% chlorine microorganism. After care will ensure a clean
nd
solution). Dispose 2 gloves appropriately. environment for labor and childbirth.
14.Advise mother to maintain skintoskin This position allows secretions to drain from the nose and
contact. Baby should be prone on mother’s mouth.

chest or in between the breasts with head
turned to one side.
E. 1590 Minutes

1. Nonseparation for early breastfeeding
Facilitate the newborn’s early initiation to
a) Leave the newborn on the mother’s
breastfeeding and transfer of colostrum through
chest in skintoskin contact.
support and initiation of breastfeeding.
b) Advise mother to observe for

feeding cues (e.g., opening of

mouth, tonguing, licking, and

rooting).

c) Support the mother; give instruction

on proper positioning and

attachment.



d) Observes for signs of good
attachment (e.g., chin touching the
breast, mouth wide open, lower lip
turned outward, more areola seen
above than below the mouth)
2. Eye Care (must be done within 1 hour
after birth)
a. Position newborn on supine.
b. Wipes both eyes with sterile OS
(inner to outer canthus) starting
with the farther eye.
c. Using the forefinger of the
nondominant hand placed over
cheekbone, gently pull the lower
lid down. Never apply drop or
ointment directly on the eyeball.
d. Using the dominant hand and

holding the dropper/tube,
instill/apply:
● Ophthalmic drop into the
center of the lower
conjunctival sac.
● Ophthalmic ointment from
the inner to the outer
canthus of the lower eye
lid.
e. Observe care not to touch the
eye with the dropper or tip of
ointment.


f. If there is an order to give two
preparations (ointment and
drops) give drops first. Wait for 3
minutes before applying the
ointment.
g. Close the eyelids.
h. Wipe excess medication in one
sweep from the inner to the
outer canthus Do not wash away
the antimicrobial.
3. Administer Vitamin K prophylaxis
(IMRight thigh;0.1ml for fullterm
babies; 0.05ml for preterm babies)
a. Locate the site. Best site: Vastus
Lateralis (middle third,
anterolateral or outer aspect of
the thigh); Alternate site: Rectus
femoris (mid anteromedial
aspect of the thigh)
b. Cleanse the site thoroughly by

applying friction with an alcohol
swab in an inner to outer,
circular motion. Let the site dry.
c. Establish anatomic landmark.
d. Grasp the vastus lateralis and
quickly insert the needle at a
90degree angle to the thigh.
e. As soon as the needle is in place,
use the thumb and forefinger of
your nondominant hand to hold


the lower end of the syringe.
Slide down your dominant hand
to the end of the plunger and
carefully inject the drug.
f. Swiftly remove the needle
smoothly and steadily at the
same angle at which it was
inserted. Apply gentle pressure
at the site with an alcohol swab.
g. Press dry cotton ball into the
injection site and fix it with
plaster.
h. Do not recap used needle.
Dispose it properly according to
agency policy.
4. Administer Hepatitis B Vaccine (IMLeft
thigh; 0.5ml, except for preterm
babies)
a. Locate the site. Best site: Vastus
lateralis or anterolateral aspect
of the thigh.


swab in an inner to outer,
circular motion. Let the site dry.
c. Establish the anatomic landmark
chosen.
d. Grasp the vastus lateralis and
quickly insert the needle at a
90degree angle to the thigh.


e. As soon as the needle is in place,
use the thumb and forefinger of
your nondominant hand to hold
the lower end of the syringe.
Slide down your dominant hand
to the end of the plunger and
carefully inject the drug.
f. Swiftly remove the needle
smoothly and steadily at the
same angle at which it was
inserted. Apply gentle pressure
at the site with an alcohol swab.
g. Press dry cotton ball into the
injection site and fix it with
plaster.
h. Do not recap used needle.
Dispose it properly according to
agency protocol.
5. Administer BCG Vaccine ID BCG is the only vaccine with this route of
(Intradermal) at the right deltoid or administration. Intradermal injection of BCG
upper arm. Intradermal vaccine is vaccine reduces the risk of neurovascular
injected into the top layers of the skin injury.(WHO,2016)
a. Locate the site. Best site:Right

Deltoid or right upper arm.
swab in an inner to outer, circular
motion. Let the site dry.


c. Aspirate the equivalent of 0.05 ml of
BCG vaccine from the ampule. injecting the vaccine in the same place (upper
right arm) for each child is to make it easy to find
d. Locate the site. BCG vaccine is
the BCG scar subsequently. This enables you to
given at the right deltoid of the arm
check that the immunization has been effective.
of a newborn intradermally.

e. Establish the anatomic landmark

chosen.

f. Hold the newborn’s arm with your
To prevent unnecessary movement.
nondominant hand so that your

hand is under the arm, your thumb
and fingers come around the
stretched skin.
g. Hold the syringe using your
dominant hand with the bevel and
scale pointing upward.
h. Insert the tip of the needle – just
the bevel and a little bit more – into
the skin, keeping the needle flat
with the bevel facing upward.
i. Place your nondominant thumb
over the needle end of the syringe
to hold it in position Hold the
plunger end of the syringe between
the index and middle fingers of your
dominant hand and press the
plunger in with your thumb.
j. Slowly inject the agent while
watching for a small wheal or blister
to appear


k. Withdraw the needle gently. Gently
blot the site with a dry cotton. Do
not massage or rub the site.
l. Expose the arm completely, from the top
of the shoulder to the elbow; roll up the
sleeve or remove the shirt if needed.
m. Record accurately
n. Provide client education on what to
expect days after the injection.
5. Obtain anthropometric measurements:
● Weight (Put protective liner
cloth or paper in place and
adjust scale to 0
grams/kilograms/lbs/ounces)
● Height (measure height from
top of head to heel)
● Head (measure head at greatest
diameter: occipitofrontal
circumference)
● Chest (measure at nipple line)
● Abdomen (measure above
umbilicus)
● Midarm (measure the diameter
of the midarm)
5. 1. Obtain Vital signs
● Obtain respiratory rate and effort; observe
respirations when infant is at rest; count
respirations for full minute
● Obtain heart rate and count for full minute


● Obtain body temperature

6. Assess the newborn for birth injuries,

malformation or defects.
7. Diaper the baby.
a. Place the infant in supine To make sure the infant is safe from falling. The
position. infant must never be left alone with side rails
b. Lift the infant’s buttocks by down or out of the crib.
grasping both ankles with one
hand, and place a clean diaper To prevent contamination of the urinary meatus
under the infant. For male infant, with bacteria from the rectal area.
place a clean diaper over the
penis to protect against sudden So that it fits snugly around the abdomen.
voiding.

c. Pull the front of the diaper up To prevent contamination.
between the infant’s legs. Tape
the adhesives. *** For soiled
diaper Remove the soiled
diaper, using the clean portion of
the diaper, wipe away the stool.
Clean from anterior region to
posterior region using the
equipment for cleaning.
d. Dress the baby.
8 Advise optional/delayed bathing of the
It helps to reduce risk of infection and stabilized
baby and explain the rationale. Bathing
infant blood sugar. Also, Vernix does more than
must be done 6 hours after delivery.
act as a protective barrier from liquids while in
a. Fill the basin with water and
the uterus. It acts as an antioxidant, skin
check the temperature by using
cleanser, moisturizer, temperature regulator, and
your elbow. Use water 100 º to


105 ºF ( 37.740.5ºC). Place it a natural, safe antimicrobial for the new baby
on a firm surface. post delivery.
b. With cotton balls, wash the
infant’s eyes from inner to outer
canthus. Wash and dry infant’s Moving from the inner to outer aspect of the eye
face. Soap is not needed. prevents carrying debris to the nasolacrimal
c. Hold the infant securely in a ducts.
football hold with head over the
basin.
d. Shampoo the scalp. Use your
fingertips and massage firmly. If For safety purposes
any loose skin are present,
remove them from the hair with To prevent the formation of cradle cap
a fine, toothed comb. Do not
hesitate to wash over the
fontanelles.
e. Rub the head with a towel.
f. Undress the infant.
g. Hold the infant securely as you Drying prevents chilling
place him in the water. Use a
towel in the basin to decrease For safety
slipping.
h. Keep one hand securely on the To prevent injury
infant while bathing.
i. Wash and rinse the shoulders, To clean the infant from less contaminated to the
arms and chest and move down most contaminated
the body. To prevent unnecessary exposure
j. Lift the infant out of water, and
lay him or her on the towel. Prevents chilling
k. Wrap the infant while you dry.


l. Diaper and redress the infant.
9 Advise breastfeeding per demand and

about the danger signs for early referral.

a. Illustrate to the mother how to

clean the nipple. (With the wet

cotton balls, clean the breast,

starting from the nipple, in a

circular motion towards the

areola.)

b. Assist the mother find a

comfortable position. Popular
The cradle position is most commonly used after
feeding positions:
the first few weeks of breastfeeding. The
● Cradle Position – the
crosscradle position gives you more control.
mother cradles the neonate’s

head in the crook of her arm.

Instruct her to place a pillow

on her lap for the neonate to

lie on. Offer to place a pillow

behind her back; this
Many mothers find lying down to nurse a
provides comfort and may
comfortable position, especially at night. Both
also assist with correct
mother and baby lie on their sides facing each
positioning.
other. You can use pillows behind your back and
● SideLying Position –
behind or between your knees to help get
instruct the mother to lie in
comfortable.
her side with her stomach

facing the neonate’s. As the

neonate’s mouth opens, she

should pull him toward the

nipple. Inform her to place

pillow or rolled blanket behind


the neonate’s back to prevent This is a good position for a mother who has had
him from moving or rolling a Cesarean birth, as it keeps the baby away from
away from the best. the incision. Most newborns are very comfortable
● Football Position – Sitting in this position. It also helps when a mother has a
with a pillow in front of her, forceful milk ejection reflex (let down) because
the mother places her hand the baby can handle the flow more easily.
under the neonate’s head. As
the neonate’s mouth opens,
she pulls the neonates head
near her breast. This position
may be more comfortable for
the woman who has had a
caesarean birth.
c. Have the mother expose one
breast and rest the nape of the
neonate’s neck in the crook of
her arm, supporting his back
with her forearm.
d. Guiding the mother’s free hand,
have her place her thumb on top
of the exposed breast’s areola
and her first two fingers beneath
it, forming a “C”. Have her turn
the neonate so that his entire
body faces the breast.
e. Inform the mother to fondle the
neonate’s cheek with her finger
or the neonate’s mouth with her
nipple.



f. When the neonate opens his
mouth and roots for the nipple,
coach the mother to move him
onto the breast so that he gets
as much of the areola as possible The length of time on the second side is related to
into his mouth. the quality of the infant’s suckling. At the next
g. Illustrate the mother how to feeding, your infant starts to feed on the breast
check for occlusion of the used to finish the preceding feeding.
neonate’s nostrils by the breast.
(If this happens, she should
reposition the neonate to give
him room to breathe.)
h. Advise that the mother Infants should be burped after each breast and at
breastfeed for 15 minutes on the end of the feeding.
each breast for the first 24 hours
after birth. When gas bubbles get stuck in your baby's
i. To switch to the other breast, stomach, they can cause a feeling of fullness and
instruct the mother to slip a discomfort, which often causes babies to squirm
finger into the side of the or cry. Babies use crying as a signal to announce
neonate’s mouth to break the almost every feeling, whether they are tired,
seal, and then move him to the hungry, wet, or bored, so it can be hard to know
other breast. if crying is due to gas discomfort.
j. At the end of each feeding,
encourage the mother to burp
the neonate after emptying the
first breast. Remind the mother
to place a protective cover.
Possible Positions:
● Place the neonate over one
shoulder and gently pat or


rub his back to help expel
ingested air.
● Sitting up – Hold the neonate
in a sitting position on your
lap. Lean the neonate forward
against one hand and support
his head and neck with the
index finger and thumb of
that same hand.
● Placing the neonate prone
across the mother’s lap.
10 In the first hour: check baby’s breathing
and color, mother’s vital signs, and
massage uterus every 15 minutes.
11 In the second hour: check motherbaby

dyad every 30 minutes to 1 hour.
Documentation serves as a means of
communication and basis of care and evaluation
12 Document the interventions and findings.
of patient outcomes.

STUDENT’S LEARNING FEEDBACK/ INSTRUCTOR’S COMMENT:



References:
Williams and Wilkins .
Salustiano, R. (2011). Essential Procedures for Safe Maternity Care 3rd edition. Quezon City: C & E Publishing, Inc.
WHO(2016). Vaccine Safety Basics eLearning Course,Module 2.
https://www.scribd.com/document/50591331/AO20090025EssentialNewbornCare




Nursing Care During Labor

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Mindanao State University – Iligan Institute of Technology College of Nursing

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