INTRAPARTUM : DELIVERY ROOM TECHNIQUE

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

Materials/ Instruments Needed:

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

IF WITH EPISIOTOMY OR LACERATION:

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

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

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

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

Outcome Identification and Planning:

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

Desired outcome includes the following:

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

IMPLEMENTATION
Nursing Action Rationale
1. Assist patient into a lithotomy position  Provides the best position for
(or other alternative birth position per performing an episiotomy and for
agency policy) viewing the perineum to detect
laceration or other problems at
birth.
2. Checks bladder for fullness and  A full bladder or bowel can
encourage voiding or catheterize as impede fetal descent.
needed.
3. Cleans the perineum using correct  Perineal care helps to remove
technique. any possible drainage or
secretions from the birth canal
that may pose a risk for infection.
4. Don/wear gloves.  To prevent exposure to client’s
body secretion.
5. Drapes the client properly.  To create a sterile field and provide
patient’s privacy.
6. Instruct to bear down properly (push  Promotes effective second-stage
with contractions), coaches to take deep pushing.
breaths as soon as contraction begins.
7. Encourages to keep both legs flexed  To promote comfort; avoid ligament
and firm on the stirrup. strain, backache or injury
8. Performs Ritgen’s maneuver  To control the rate at which the
properly/ safely while fetal head is being head is born and prevent laceration
delivered. of the perineum.
9. Checks for nuchal cord, loosen and  Umbilical loop could tear and
slip over the head if possible; if cord interfere fetal oxygen supply.
cannot be slipped over the head, it is
clamped using two clamps and cut
between the clamps.
10. Notes and records time the baby  For proper identification
was delivered and the gender.
11.Thoroughly dries baby for at least 30  To prevent hypothermia, stimulate
seconds starting from the face and breathing and determine the ability
head, going to the trunk and extremities to adjust in the extrauterine life.
while performing a quick check for
breathing; evaluate the APGAR score 1
min. and 5 min. after birth
12. Places neonate on the maternal  To initiate parent-child bonding.
abdomen.
13. Clamps cord using 2 Kelly 
hemostats, support and cut in between
them using mayo scissor. (Follow
agency policy on cord length.)
14. Delivers the placenta when signs of 
placental separation is observed and
note the time.
15. Checks placenta for presentation 
(Schultz or Duncan). Assess amount of
blood loss.
16. Palpates and massages the
hypogastric area (fundus of the uterus)
17. Inspects perineum for presence and
degree of laceration. Assists in repair of
laceration.
18. Cleans the perineum and buttocks
area.
19. Do after care of the instruments
used and unit of responsibility.
Clamping the cord is part of the
stimulus that initiate a first breath.
The infant’s most important
transition to the outside world
establishing of independent
respiration is made.
Delivery of the placenta should not
take more than 30 min.
Duncan placental presentation
carries a slightly increased risk of
retained placental fragments due to
incomplete separation. To check if
placenta is complete or intact.
 To ensure uterus is firm and
contracted and prevent bleeding.
 To prevent bleeding.
 To minimize risk of infection and
promote comfort.
 To restore cleanliness and
orderliness of the unit.

INTRAPARTUM: PERFORMING NORMAL SPONTANEOUS VAGINAL

DELIVERY TECHNIQUE

IMPLEMENTATION
Nursing Action Rationale
1. Places client’s hand on handgrip and  Tug of war pushing technique uses
explains its purpose (elbow out the natural bearing down effort of
technique) the abdominal muscles. This
method also causes minimal
change in the maternal blood
pressure and relaxes the perineum.
To get force during bearing down
effort.
2. Checks client’s necessary articles  To maintain adequacy of supplies
needed for delivery. as delivery progresses; manage
resources, equipments and
environment.
3. Monitors fetal heart tone.  To identify non-reassuring or
unfavorable fetal heart rate
characteristics that may indicate a
fetus at risk for asphyxia.
4.Instructs to bear down properly,  Promotes effective second-stage
coaches to take deep breaths as soon pushing; the birth process expense
as contraction begins(Proper pushing a great deal of energy.
and breathing techniques). Encouraging proper pushing and
breathing techniques conserves
maternal energy.
5. Wipe mucous from face, mouth and  To remove secretion from the
nose, establishes initial airway neonate’s mouth and nose.
clearance using bulb suction.
6. Using a sterile blanket, hold newborn  To avoid slipping of the baby;
firmly and close to the introitus with prevent tension to the cord and to
head in a slightly dependent position. allow secretion to drain from the
mouth and the nose.
7. Safely lay the infant on the radiant  To facilitate thermoregulation.
heat warmer.
8. Provide immediate newborn care:  Gentle suctioning removes
A. Maintains airway by suctioning secretions that may collect in these
mouth first then the nose. areas. Suctioning mouth before the
nose prevents possible aspiration
of oral secretion.
B. Maintains body temperature  Newborns have difficulty
 Dries the neonate immediately after conserving body heat. Exposure to
delivery cold increases the metabolic rate,
 Cover neonates head with towel or increasing the need for oxygen and
cap further the respiratory rate.
 Wrap neonate snugly with warm
towel
C. Place Identical identification  To prevent risk of switching babies
bracelets on the mother and the and kidnapping.
neonate ( follow agency policy)
9. Performs immediate cord care and  To minimize bacterial colonization
notes the cord vessels. and identify congenital anomalies.
10. Places ice pack over the uterine  To promote uterine contraction and
fundus prevent bleeding.
11. Monitors maternal vital signs every  To evaluate maternal post partum
15 min. for 1 hour until stable. condition and prevents
complications.
12. Places adult diaper and change  To promote comfort.
soiled gown.
13. Assists in the after care of the unit.  To restore cleanliness and
orderliness of the unit.
14. Safely transfers mother to the  To prepare transport to post partum
stretcher per doctor’s order. unit.

birth of the head with

application of
modified Ritgen
maneuver
 Third Stage of labor- Placenta

Evaluation:

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

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

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

Instruction to the mother on cord care:

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

THE APGAR SCORING SYSTEM

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

DOCUMENTATION:

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

1. Clients Post partum condition:

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

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

delivered.

Signs 0 1 2

Respiratory Rate Absent Slow ,weak Good cry

cry

Reflex irritability No Grimace Cry

response

Pulse , heart rate Absent Slow >100

(<100)

Skin Color Blue Body pink Completely

pale extremities pink
blue
Muscle Tone Flaccid Some Well flexed
flexion of
extremities

Reference:

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the Childbearing and Childrearing Family 8th Ed.
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