ESSENTIAL INTRAPARTUM AND NEWBORN CARE

I. CARE FOR THE LOW RISK MOTHER

Intrapartum care covers Stage 1 to Stage 4 of labor. The practices which are beneficial and
recommended, those deemed harmful or those which are neither beneficial nor harmful,
and therefore, not recommended, are also discussed. The practices which are
recommended and not recommended are consistent with the Essential Intrapartum and
Newborn Care Protocol .

Terminal Competency

Ater completion of the module, the participant will be able to apply the principles in
intrapartum care which is the period covering labor and delivery.

A. THE FIRST STAGE OF LABOR

Definition: The first stage of labor is the period from the onset of regular contractions up to
full cervical dilatation.

The criteria for the diagnosis of labor include:

 Uterine contraction of at least 4 in 20 minutes

 Progressive changes in cervical dilatation and effacement
 Cervical effacement or loss of the canal of the cervix of greater than 75%
 Cervical dilatation of at least 4 cm. The most important evidence that labor is in the
active phase is cervical dilatation of at least 4 cm in a pregnant woman who has been
experiencing regular uterine contractions that have become stronger, more frequent
and more painful.

1. First stage latent phase not yet in active labor

 Characterized by cervix dilated 0-3 cm., contractions are weak, <2 in 10 minutes
 Check for emergency signs, frequency, intensity & duration of contractions,
FHR, mood and behavior. every hour
 Check vital signs and cervical dilatation every 4 hours
 Record findings in Labor record
 Assess progress of labor:
 If the woman is in early or latent phase of labor and <37 weeks, facilitate
urgent referral/transfer

 If contractions are stronger and more frequent for 8 hours but with no
progress in cervical dilatation, refer the woman urgently to doctor or
 hospital. If no increase in contractions, and membranes are not ruptured,
and no progress in cervical dilatation, Discharge the woman and advise
her to return if the pain and discomfort increases, there is vaginal bleeding
and the membranes rupture

 If cervical dilatation progresses to 4 cm or greater, begin plotting the

partograph and manage the woman as in active labor

2. First stage in active labor

 Characterized as cervix dilated at 4 cm or more, frequency of contractions 3-5/
10 minutes lasting >40 seconds
 Check for emergency signs, frequency and duration of contractions, FHR, mood
and behavior every 30 minutes. If the woman is in active labor and 37 weeks or
more, proceed with basic care for normal labor and birth
 Check temperature (presence of fever), blood pressure (BP), pulse rate (PR),
cervical dilatation every 4 hours.
 Record time of rupture of membranes and color of the amniotic fluid
 Record findings in the WHO partograph

3. Allow mobility and position of choice.. Encourage the woman to walk around freely
with her companion of choice(if BOW has not ruptured) during the first stage of
labor. Support the woman’s choice of position (left lateral, squatting, kneeling,
standing supported by the companion) for each stage of labor and delivery. Figure 1
shows the different positions that a woman can assume throughout labor:

Figure 1.Positions during labor

4. Encourage to urinate on her own. Remind her to empty her bladder every 2 hours.
(A full bladder may prolong the labor).
5. Allow the the woman to eat and drink as she wishes throughout labor. Nutritious
liquid drinks are important, even in late labor. If the woman has visible severe
wasting or tires during labor, make sure she eats and drinks. Withholding food and
drink during labor is an outdated practice that has been shown to negatively affect
birth outcomes.
6. Do not give routine intravenous fluids (IVF)
 Interferes with the natural birthing process as it restricts woman’s freedom to
move
 A mother who is eating and drinking during labor will not require intravenous
fluid. IVF is not as effective as allowing food and fluids in labor to treat/prevent
dehydration, ketosis or electrolyte imbalance
 Having an IV in place, even prophylactic placement of IVF, does not improve
delivery outcome. No evidence exists that suggest that the placement of an IV in
the low-risk intrapartum client prevents poor outcome. The only advantage is to
have ready access for emergency medications and to maintain maternal
hydration.
7. Relief of pain and discomfort
 Suggest change of position
 Encourage mobility as comfortable for her
 Encourage proper breathing: breath more slowly, make a sighing noise, make 2
short breaths followed by a long breath out.
 Massage her lower back if she finds it helpful
8. Do NOT do routine enema
 No longer recommended as it is uncomfortable
 Can damage the bowel
 Increases the cost of delivery
 Does not shorten labor or decrease newborn and perineal wound infection
9. Do NOT shave the perineal area
 Routine pubic or perineal shaving (either full or mini) of women in labor at the
time of admission does not have sufficient evidence on side effects of advantage
or benefit.
 Shaving can lead to side effects like irritation, redness, multiple superficial
scratches, burning and itching of the vulva
 If there is a need to remove the hair on the perineum, clipping it is a better
alternative to shaving.
10. Precautions
 DO NOT do IE more frequently than every 4 hours
  DO NOT allow the woman to push unless delivery is imminent. Pushing at this
stage does not speed up labor, It will just make the cervix swell and the mother
tired.
 DO NOT give medications to speed up labor. It is dangerous as it may cause
trauma to the mother and baby.
 DO NOT do fundal pressure as it may cause uterine rupture or fetal death

Table 1 shown below summarizes the practices that are recommended and not
recommended during the first stage of labor.

Table 1. Recommended and Not recommended Practices During the First Stage of
Labor

Recommended Practice Not Recommended Practice

 Admission to labor when in the Routine perineal shaving on

active phase. admission

 Companion of choice to provide Routine enema

continuous maternal support
Routine NPO
 Mobility and upright position
Routine IVF
 Allow food and drink
Routine vaginal douching.
 Use of WHO partograph to
Routine amniotomy
monitor progress of labor
Routine oxytocin augmentation
 Limit IE to 5 or less.

B. THE SECOND STAGE OF LABOR

Definition of the Second Stage of Labor: period from full cervical dilatation (10cm) to the
birth of the baby

The criteria for diagnosing a woman to be in the second stage of labor:

 Fully dilated cervix (10 cm.) on internal examination

 Woman wants to bear down
 Strong uterine contractions every 2-3 minutes
  Bulging thin perineum with the fetal head visible during contractions.
 BOW will rupture if it has not ruptured earlier

1. Monitoring and Management of the Second Stage of Labor

a. Preparation of the mother for delivery
1) Continue close monitoring
 Check uterine contractions, fetal heart rate, mood and behaviour
 Continue recording in the partograph
2) Implement the 3 CLEANS
 Clean hands. Wear double gloves
 Clean delivery surface
 Clean cutting and care of the cord
3) Ensure all delivery equipment and supplies, including newborn resuscitation
equipment are available and place of delivery is warm (25°C)
4) Ensure bladder is empty. Encourage the woman to urinate. If unable to pass
urine, empty bladder with catheter.
b. Stay with the woman and encourage her. Offer her emotional and physical support. If
the woman is distressed, encourage pain discomfort
c. Assist the woman into a comfortable position of her choice, as upright as possible. DO
NOT let her lie flat (horizontally) on her back.
d. Allow her to push as she wishes with contractions. Do not urge her to push .If, after
30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin out
and stretch with contractions, do a vaginal examination to confirm full dilatation of
cervix. If cervix is not fully dilated, await second stage. Place the woman on her left
side and discourage pushing. Encourage breathing technique.
e. Wait until head is visible and perineum distending. DO NOT massage or stretch the
perineum as these have not been shown to be beneficial and may even be harmful .
f. Wash hands with clean water and soap using the 1-2-3-4-5 method.
g. Put on double gloves just before delivery if you are the sole birth attendant. Follow
universal precautions during labor and delivery.
h. If second stage lasts for 2 hours or more without visible steady descent of the head,
refer urgently to hospital
i. If obvious obstruction to progress (warts, scarring/ keloid tissue/ previous third
degree tear), refer to doctor to do a generous episiotomy. Do not perform episiotomy
routinely.
j. If breech or other presentation, manage appropriately based on situation.
k. Encourage the mother to bear down when the baby’s head is coming down.
l. When the birth opening is stretching, support the perineum and anus with a clean
pad to prevent lacerations.
m. DO NOT apply fundal pressure to help deliver the baby as this may harm both the
mother and the baby.
n. Ensure controlled delivery of the head. Keep one hand on the head as it advances
during contraction. Keep the head from coming out too quickly. Support the
perineum with other hand.
o. Discard pad and replace when soiled to prevent infection. During delivery of the
head, encourage woman to stop pushing and breathe rapidly with mouth open

Figure 2. Perineal support

p. Gently feel if the cord is around the neck. If it is loosely around the neck, slip it over
the shoulders or head. If it is tight, place a finger under the cord, clamp and cut the
cord, and unwind it from around the neck.
q. Wait for external rotation (within 1-2 min), head will turn sideways bringing one
shoulder just below the symphysis pubis and other facing the perineum
r. Apply gentle downward pressure to deliver top shoulder then lift baby up to deliver
lower shoulder. Gently deliver the rest of the baby.
s. Call out the sex and time of delivery of the baby.

Table 2 summarizes the practices that are recommended and not recommended during
the second stage of labor.

Table 2 Recommended and Not recommended Practices During the Second Stage of
Labor
Recommended Practice Not Recommended Practice

 Upright position during delivery Coaching the mother to push

 Perineal support and controlled Perineal massage in the 2nd

delivery of the head stage of labor

 Use of prophylactic oxytocin for Fundal pressure during the

 mgt of 3rd stage of labor second stage of labor

 Properly-timed cord clamping

 Controlled cord traction with

countertraction to deliver the
placenta

 Uterine massage

C. THE THIRD AND FOURTH STAGES OF LABOR

Definition of the Third and Fourth Stage of Labor
 Third Stage of Labor covers the period from the delivery of the baby to the delivery
of the placenta
 Fourth Stage of Labor is the hour immediately after the delivery of the placenta.
Some do not recognize this extra stage

A. Monitoring and Management of the Third Stage of Labor

1. Call out the sex and the time of birth of the baby. This marks the end of the second
stage and the start of the third stage.
2. Place the baby prone on the mother’s abdomen.
3. Thoroughly and systematically dry the baby, assess the baby’s breathing and
perform resuscitation if needed. Discard the wet towel.
4. Place the baby in skin-to-skin contact with the mother. Cover with a fresh dry linen
and put a bonnet on the baby’s head.
5. Exclude 2nd baby by palpating mother’s abdomen. Administer 10 IU of oxytocin IM
within one minute of the baby’s birth.
6. If you are the sole birth attendant, remove the first set of gloves. Check for the cord
pulsation.
7. Clamp and cut the umbilical cord 1-3 minutes after the delivery of the baby or when
cord pulsations have stopped.

a. 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.

b. Observe the stump for blood oozing. Do not bandage or bind the stump. Leave
it open.
 Figure 3. Cutting the umbilical cord.

8. Place the palm of the other hand on the LOWER abdomen to feel for the strong
uterine contraction.
9. Perform controlled cord traction (CCT) with counter-traction on the uterus
10. Support the placenta with both hands.
11. Gently move membranes up and down until delivered
12. Massage the uterus
13. Examine the placenta and the membranes for completeness
14. Keep the baby warm. Maintain skin-to-skin contact between mother and baby but
both wrapped with linen.

ACTIVE MANAGEMENT OF THE THIRD STAGE

(by trained skilled midwife)
 Give 10 units oxytocin IM to the
mother. (Active management of the 3rd
stage of labor).
 When the uterus is contracted, deliver
the placenta by controlled cord
traction (with counter traction on the
uterus above the symphysis pubis).
 Massage the uterus over the fundus.
Figure 4. Controlled cord traction and counter traction
B. Monitoring and Management of the Fourth Stage of Labor
1. Monitor both the mother and newborn (maternal-newborn dyad) immediately after
the delivery of the placenta, within 1 hour after delivery (Immediate postpartum
period).
 Examine the lower vagina and the perineum. Check for tears and bleeding.
 Clean the woman and make her comfortable.
  Check BP, PR, emergency signs & uterine contraction every 15 minutes.
 Keep the mother and baby together in skin-to-skin contact. Wait for baby to have
breastfeeding cues to show that baby is ready to breastfeed.
 Initiate breastfeeding within 1-hour when the baby is ready.
2. Allow baby to have a full breastfeed before doing routine newborn care like eye
prophylaxis and vaccinations. DO NOT interrupt breastfeeding for these reasons.

Table 4. Summary of Recommended and Not recommended Practices During the 3rd
and 4th Stages of Labor
Recommended Practice Not Recommended Practice

 Routinely inspect the birth canal Manual exploration of the uterus

for lacerations
Routine use of icepacks over the
 Inspect the placenta & membranes hypogastrium.
for completeness
Routine oral methylergometrine
 Early resumption of feeding (<6
hours after delivery)

 Massage the uterus –ensure

uterus is well contracted

 Prophylactic antibiotics for

women with a 3rd or 4th degree
perineal tear

 Early postpartum discharge

References

Basic Maternal and Newborn Care: A Guide for Skilled Providers. Barbara Kinzie, Patricia
Gomez,2004.

BEMONC Modules for Midwives: Second Women’s Health and Safe Motherhood Project.
Department of Health.September 20-27, 2010

Clinical Practice Guidelines on Normal Labor and Delivery. Philippine Obstetrical and
Gynecological Society, Inc.. 2009
Community-Managed Maternal and Newborn Care: A Guide for Primary Health Care
Professionals. Department of Health. 2006

Continuous support for women during childbirth.Hodnett ED, Gates S, Hofmeyr GJ,
SakalaC.Cochrane Database of Systematic Reviews 2007, Issue 3.

Integrated Management of Pregnancy and Childbirth. Pregnancy, Childbirth, Postpartum

and Newborn Care (PCPNC): A Guide for Essential Practice in the Philippines 2006. World
Health Organization and Department of Helath- Philippines.

Intrapartum Care. Care of healthy women and their babies during childbirth, National
Collaborating Centre for Women’s and Children’s Health, Sptember 2007.

Lifesaving Skills (LSS) Training Course . Philippine Obstetrical and Gynecological Society
Foundation, Inc. 2007

Managing Complications in Pregnancy and Childbirth: A Gjuide for Midwives and

Doctors.World Health Organization. 2000.

Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice.
World Health Organization 2006

II. IMMEDIATE NEWBORN CARE

Introduction to the Module

The Department of Health (DOH) in partnership with the WHO and the United Nations
Children’s Fund (UNICEF) initiated the development of an Essential Newborn Care
protocol. This protocol is contained in the Clinical Practice Pocket Guide which has
been approved and has since been integrated with the existing Emergency Obstetric
and Neonatal Care documents. It is now known as the Essential Intrapartum and
Newborn Care (EINC) protocol.

The protocol draws its content from the Pregnancy, Child Birth, Postpartum and
Newborn Care (PCPNC) and enhances the PCPNC with updates from current medical
literature. It tackles the time-bound sequence of actions that you should take in care of
the newborn in the immediate period after birth. The rationale for each of the “Four (4)
Core Steps” in Immediate Newborn Care is presented and the detailed procedure for
each of these steps is described. In addition, unnecessary and/or potentially harmful
practices that should be avoided are likewise discussed.
A. PREPARING FOR DELIVERY

1. Preparations in the workplace

a. Make sure all necessary equipment and supplies are available
b. Staffing and schedules are in order
c. Proper documentation
2. Maintaining the ideal room temperature at 25-28˚C to prevent cold stress and
hypothermia in the baby.
a. Check room temperature using a room thermometer
b. Close windows, draw curtains, turn off electric fans to eliminate air drafts
c. Turn off the air-conditioning unit at the time of delivery.
d. If air-conditioning is centralized, adjust the thermostat setting prior to the
delivery
3. Prepare necessary equipment
a. Delivery Instruments
i. Handwashing implements
ii. Sterile gloves – 2 sets if solitary health care worker
iii. Warm towels or linen
iv. A bonnet
v. Sterile plastic cord clamp or cord tie
vi. Sterile instrument clamp
vii. Sterile pair of scissors (separate from that used for episiotomy, if
done)
viii. Oxytocin 10 IU and sterile syringe for IM injection
ix. Receptacle for placenta, container with 0.5% chlorine for used gloves
and instruments
b. Newborn Care Interventions/Supplies (after the first breastfeed,
approximate 1-2 hours after birth)
i. Eye prophylaxis – erythromycin or tetracycline ointment
ii. Vitamin K ampule; cotton balls; sterile syringe for IM injection
iii. Anti-hepatitis B vaccine; cotton balls; sterile syringe for IM injection
iv. BCG vaccine; cotton balls; sterile syringe for ID injection
4. Check resuscitation equipment
Resuscitation equipment should be clean and functional, and within reach at every
delivery.
5. Perform hand hygiene
Hand hygiene practices consisting of hand washing and alcohol hand rub are important
for health workers as these protect them and their patients from the risk of infection.
6. Wearing sterile gloves
Sterile gloves are worn routinely for each delivery to protect the mother, her baby and
health workers from exposure to diseases spread by blood and other body fluids.
B. IMMEDIATE NEWBORN CARE OF THE EINC PROTOCOL
What happens to a mother and her baby during labor, delivery and in the first hours after
birth has a major influence on their survival, future health and wellbeing. Health workers
have an important role at this time. The care they give is critical in helping to prevent
complications and maintaining normality. By following the practices laid out in the PCPNC
Guidelines and the EINC protocol, health workers are giving care which is based on many
years of research evidence, and which is known to save the lives of mothers and their
newborn babies. This session will give emphasis on essential newborn care for the first 90
minutes.

FOUR CORE STEPS OF IMMEDIATE NEWBORN CARE OF THE EINC PROTOCOL

1. Immediate and thorough drying with the 1st 30 seconds (First Core Step)
a. Drying is the first core step in the essential newborn care protocol. It stimulates the
baby’s breathing and provides warmth to the newborn to prevent hypothermia.
Hypothermia can result in infection, coagulation defects, acidosis, delayed fetal-to-
newborn circulatory adjustment, hyaline membrane disease, and brain
hemorrhage. The following is the procedure after delivery of the baby:
b. Call out the time of birth.
c. Place the baby on the mother’s abdomen. Baby should be in prone position with the
head turned to the side or in a side-lying position. Baby should be placed vertically
on the mother’s abdomen with the head close to the mother’s chest. If this is not
possible, put the newborn on a clean, warm, safe place close to the mother.
d. Use a clean, dry cloth to thoroughly dry the newborn by wiping the eyes, face, head,
scalp, front and back, arms and legs. Wipe away any blood or meconium.
Remember to discard the wet cloth afterwards.
e. Assess the newborn’s breathing while drying the baby.
f. If after 30 seconds newborn is breathing or crying normally, do skin-to-skin contact.
g. However, if after 30 seconds the newborn is not breathing or is gasping, clamp and
cut the umbilical cord, call for help, and start basic resuscitation (see newborn
resuscitation algorithm)
h. Reminders:
 Do not routinely suction the mouth and nose of the vigorous newborn unless the
mouth/nose is blocked by secretions. Routine suctioning has no proven benefit if
amniotic fluid is clear and especially with newborns who cry and breathe
immediately after birth. Unnecessary suctioning in a baby who is crying and
breathing normally can cause apnea, vagal-induced bradycardia, slower rise in
 oxygen saturations, and mucosal trauma with possibly an increased risk for
infection if inexpertly performed.
 Do not ventilate within the first 30 seconds, unless the baby is both floppy/limp
and not breathing. Only a small number of all babies born in facilities need some
form of resuscitation. In mildly depressed newborns, drying provides sufficient
stimulation.
 Do not slap, shake or rub the baby.
 Do not hang the baby upside down.
 Do not squeeze the baby’s chest.
 Do not wipe off the white greasy substance covering the newborn’s body
(vernix). This helps to protect the newborn’s skin and get reabsorbed very
quickly.

2. Skin-to-skin contact (Second Core Step)

a. Skin-to-skin contact facilitates bonding between the mother and her newborn. It
also provides warmth which prevents hypothermia and its complications. It
provides protection from infection by exposing the baby to the good bacteria of the
mother , and it increases the blood sugar of the baby. More importantly, it aids in
the initiation of breastfeeding with colostrum, and facilitates successful
breastfeeding.

b. Remove the mother’s gown then place the newborn prone on the mother’s chest,
skin-to-skin, with the head turned to one side to facilitate drainage of any secretions
from the mouth and nose.
c. Cover the newborn’s back with a dry blanket and head with a bonnet.
d. Place the identification band on the ankle.
e. Make sure that the room temperature is properly maintained at 25 - 28°C and the
baby’s temperature is between 36.5 - 37.5°C.
f. Reminders:
 Do not separate the newborn from the mother if the newborn does not exhibit
severe chest in-drawing, gasping or apnea; and the mother does not need urgent
medical or surgical management (e.g. emergency hysterectomy).
 Do not put the newborn on a cold or wet surface.
 Do not do footprinting. It is an inadequate technique for newborn identification
purposes. DNA genotyping and human leukocyte antigen tests are better
methods of identification.
g. Check for multiple births as soon as the newborn is securely positioned on the
mother. Palpate the mother’s abdomen to check for a second baby or for multiple
 births. If there is another baby (or more), call for help. Deliver the second baby and
manage like the first baby.
h. The first skin-to-skin contact should last uninterrupted for at least one hour after
birth or until after the first breastfeed.
i. Skin-to skin contact can re-start at any time if the mother and the newborn have to
be parted for any treatment or care procedures. If they are separated, wrap baby in
warm covers and place in a cot in a warm room. A radiant warmer may be used if
the room is not warm or if the newborn is small.

3. Properly-timed cord clamping within 1-3 minutes (Third Core Step)

a. The placenta transfuses blood to the newborn after delivery, providing oxygen,
nutrients, and additional blood volume through the pulsating cord. Once this
transfusion is completed, cord pulsations will stop and the cord will flatten.
Placental transfusion can provide the infant with an more blood volume and
additional red blood cells, resulting in less anemia in both term and preterm babies.
In preterms, it reduces the need for blood transfusion in the first 4 - 6 weeks of life,
and the occurrence of intraventricular hemorrhage and late-onset sepsis.
b. Remove the first set of gloves immediately prior to cord clamping.
c. Palpate the umbilical cord and wait for cord pulsations to stop (typically at 1-3
minutes).
d. After cord pulsations have stopped and the cord has flattened, clamp and cut the
cord as follows:
 Place the first plastic clamp/tie at 2 cm from the umbilical cord base and the
second instrument clamp/tie at 5 cm from the base.
 Cut the cord near the plastic clamp/first tie.
 Observe for oozing of blood. If there is, place a second tie near the plastic clamp.
e. Reminders:
 Do not milk the cord towards the newborn.
 Do not clamp the cord earlier than 1 minute after birth in both term and preterm
babies who do not require positive pressure ventilation
 Do not use binder/“bigkis” or bandage the stump. When the binder gets soiled
and is unchanged, it may harbor germs that will cause infection. It also prevents
aeration which will facilitate the drying process. The binder may also rub against
the fresh cord and cause irritation.
 Do not apply any substance on to the cord. Use of antiseptics delay the falling off
of the stump. Dry cord care is recommended.
f. After cord clamping, give 10 IU oxytocin intramuscularly to the mother.
g. Wait until the mother feels strong uterine contractions before delivering the
placenta by controlled cord traction, with counter-traction on the uterus. There is
 no need to separate the mother and baby during delivery of the placenta. Skin-to-
skin contact can and should continue unless there are complications.

4. Non-separation of the newborn from the mother for early initiation of

breastfeeding within the first 1 – 2 hours after birth (Fourth Core Step)
a. Keeping the newborn and mother together facilitates the newborn’s early initiation
to breastfeeding and the transfer of colostrums. Early initiation of breastfeeding
reduces the number of newborn deaths by decreasing the ingestion of infectious
organisms. Breast milk also provides many anti-infective substances like
immunoglobulins and lymphocytes that may stimulate and enhance the baby’s
immune system. Studies have shown that breastfeeding reduces deaths due mainly
to diarrhea and lower respiratory tract infections.
b. Leave the newborn on the mother’s chest in continuous skin-to-skin contact.
c. Do not leave the mother and baby alone during the first hour after delivery. Monitor
the mother and baby every 15 minutes in the first hour, every 30 minutes in the
second hour, and regularly thereafter to prevent accidents such as falls and
accidental suffocation from occurring.
d. Monitor the baby’s breathing and take note of the presence of grunting, chest
indrawing or fast breathing. Check to see if the baby’s feet are cold to the touch.
e. Observe the newborn. The baby may want to rest for 20-30 minutes and even up to
120 minutes before showing signs of readiness to feed
f. Advise the mother to start feeding the newborn once the baby shows feeding cues
(e.g. opening of mouth, tonguing, licking, rooting). Make verbal suggestions to the
mother to encourage her newborn to move toward the breast (e.g. nudging).
g. When the newborn is ready, advise the mother to position and attach her newborn.
Counsel on positioning and attachment, if needed. (Details on breastfeeding will be
discussed in the Breastfeeding Module)
h. Look for signs of good attachment and suckling. I the attachment or suckling is not
good or is not successful, try again then reassess.
i. A small amount of breastmilk may be expressed before starting breastfeeding to
soften the nipple area so that it is easier for the newborn to attach.

5. Newborn procedures can be done at bedside after the initial breastfeed

a. Administer erythromycin or tetracycline eye ointment, or 2.5% povidone iodine
drops to the newborn’s eyes within one hour after birth. Do not wash away the eye
antimicrobial. Eye care is given to protect the baby’s eyes from infections such as
gonorrhea which can be passed on to the baby during the birthing process and can
eventually result in blindness.
b. Proceed to the physical examination and weighing of the newborn.
 c. This should be followed by injections with Vitamin K (IM), Hepatitis B vaccine (IM),
and BCG (ID).
d. Maternal procedures can be done with the newborn in skin-to-skin contact with the
mother unless the treatment requires sedation.
6. Reminders:
a. Do not touch the newborn unless there is a medical indication.
b. Do not throw away colostrum. It is equivalent to the baby’s first immunization.
c. Do not give sugar water, formula or other pre-lacteals. These will delay the initiation
of breastfeeding which increases the risk of the newborn dying from serious
infection.
d. Do not give bottles or pacifiers. If these are introduced, the newborn may develop a
learned preference for the bottle leading to nipple confusion (especially if these are
used before the newborn is offered the mother’s breast). This contributes to a
vicious cycle of poor attachment, sore nipples and milk insufficiency, which will
undermine the chances of successful breastfeeding.
e. Let the baby feed for as long as he/she wants on both breasts.
f. Postpone washing until after 6 hours. Early bathing removes the vernix which is a
protective barrier to E.coli and Group B Strep. It also hinders the crawling reflex and
leads to hypothermia.

Table 5. EINC Delivery Checklist

Step/Task
PRIOR TO WOMAN’S TRANSFER TO THE DR
Communicated with mother: asked about position of choice, desire to eat or drink, update on
progress of labor.
PREPARING FOR DELIVERY
Checked temperature in DR area to be 25-28 °Celsius; eliminated air draft.
Removed all jewelry then washed hands thoroughly observing the WHO 1-2-3-4-5 procedure.
Prepared newborn resuscitation area and checked that resuscitation equipment are clean and
functional
Prepared materials for routine newborn procedures: eye ointment, stethoscope, vit K, hepatitis B
and BCG vaccines
Performed handwashing again and put on two pairs of sterile gloves.
Prepared sterile materials/supplies in a linear sequence: dry linen, bonnet, oxytocin injection, plastic
clamp, instrument clamp, scissors, 2 kidney basins
Cleaned the perineum with antiseptic solution.
AT THE TIME OF DELIVERY
Encouraged woman to push as desired.
Draped the clean, dry linen over the mother’s abdomen or arms in preparation for drying the baby.
Applied perineal support and did controlled delivery of the head.
Called out time of birth and sex of baby and informed mother of outcome. [Assessor to start timing]
FIRST 30 SECONDS
Immediately started thorough drying and continued for 30 seconds, starting from the face and
head, going down to the trunk and extremities while performing a quick check for breathing.
1 - 3 MINUTES
Removed the wet cloth.
Placed baby in skin-to-skin contact on the mother’s abdomen or chest.
Covered baby with the dry cloth and the baby’s head with a bonnet.
Checked for 2nd baby by palpating the abdomen in preparation for giving oxytocin.
Wiped the soiled gloves with the wet cloth and gave IM oxytocin within one minute of baby’s birth,
then disposed of wet cloth afterwards.
Positioned baby for cord clamping then removed 1st set of gloves. Decontaminated the
gloves properly (in 0.5% chlorine solution for at least 10 mins).
Palpated umbilical cord to check for pulsations.
Checked pulsations then clamped cord using the plastic clamp or cord tie 2 cm from the base,
instrument clamp 5 cm from the base, and cut cord near the plastic clamp.
Waited for strong uterine contractions then applied controlled cord traction and counter traction
on the uterus, continuing until placenta was delivered.
Massaged the uterus and checked that it is firm.
Inspected the lower vagina and perineum for lacerations/tears and repaired lacerations/tears, as
necessary.
Examined the placenta for completeness and abnormalities and disposed of the placenta in a leak-
proof container or plastic bag.
Cleaned the mother: flushed perineum and applied perineal pad/napkin/cloth.
Checked baby’s color and breathing; checked that mother was comfortable, uterus contracted.
Decontaminated (soaked in 0.5% chlorine solution) instruments before cleaning; decontaminated 2nd
pair of gloves before disposal.
15 - 90 MINUTES
Advised mother to observe for feeding cues and cited examples of feeding cues, instructed
her on positioning and attachment.
After a complete breastfeed, administered eye ointment (first), did thorough physical
examination, then gave Vit. K, Hepatitis B and BCG injections (simultaneously explained
purpose of each intervention).
Monitored mother and baby every 15 minutes in the 1st hour (checked baby’s breathing and
color; and checked mother’s vital signs and massaged uterus) and every 30 minutes in the 2nd
hour.
Completed all RECORDS.

CONTENT SUMMARY

This module discussed the preparation for delivery and the performance of the Four Core
Steps of the Essential Intrapartum and Newborn Care Protocol. For the vast majority of
newborns who are stable at birth, they will require only the routine or simple immediate
care of the newborn as described here. The module presents in detail how immediate and
thorough drying, skin-to-skin contact, properly timed cord clamping and non-separation
are performed in the proper sequence to benefit the newborn. For cases wherein the
mother is HIV-positive, is unable to breastfeed, or encounters problems in breastfeeding,
additional recommendations are given to ensure breastmilk is properly given to the baby.

Recommended Individual Study Activities

1. Department of Health and World Health Organization (2011). The EINC Advocacy
Partners Handbook.
 2. Administrative Order No. 2008-0029. “Implementing Health Health Reforms for the
Rapid Reduction of Maternal and Neonatal Mortality “
3. Administrative Order No. 2009-0025.”Adopting New Policies and Protocol on
Essential Newborn Care”
4. World Health Organization computerized interactive Self-Instructional Module
(SIM) on EINC

REFERENCES

World Health Organization. (2009). Newborn Care Until the First Week of Life: Clinical
Practice Pocket Guide. Manila.
World Health Organization. (2006). Integrated Management of Pregnancy and
Childbirth. Pregnancy, Childbirth, Postpartum and Newborn Care : A Guide for Essential
Practice.

III. HAND HYGIENE

Hand hygiene may be composed of hand washing with soap and water or doing an
alcohol hand rub.

A. When to do hand hygiene

1. Before and after touching the patient
2. Before handling an invasive device for patient care
3. After contact with body fluids or excretions, mucous membranes, non-intact skin
or dressings
4. If moving from a contaminated body site to another body site during care of the
patient
5. After removing sterile or non-sterile gloves

B. Handwashing
Wash hands with soap and water when these are visibly dirty or visibly soiled with
blood or other body fluids, or after using the toilet. Prepare a basin or pail of water,
soap and towel. Steps are as follows:
1. Remove all jewelry, rings and watches, then wet hands with clean running water.
If running water is not available, ask another person to pour the clean water for
handwashing, or use alcohol handrub/sanitizer.
i. Apply soap to your hands, and work into a lather. Proceed to cover all surfaces of
the hands using 5 strokes each as follows:(Procedure should take 40-60 seconds)
a. Rub palms against each other
 b. Rub dorsum of 1 hand with the palm of the other hand with interlaced
fingers. Do the same with the other hand.
c. Rub palms together with fingers interlaced.
d. Flex fingers of both hands and interlock with each other and rub in a to-and-fro
motion.
e. Wrap the thumb with the other hand and rub in semi-circular motion. Do
the same with the thumb of the other hand.
f. With fingertips together rub into the palm of the other hand in a circular
motion. Do the same with the other hand.
g. Wrap the wrist with the other hand and rub in semi-circular motion. Do
the same with the wrist of the other hand.
ii.Rinse with a stream of running or poured water and dry hands thoroughly with
single use towels if possible.

Figure Steps in Handwashing

 C. Use of Alcohol Hand Rub
1. Pour 3-5 ml (1 teaspoon) of the alcohol handrub into the palm of your hand.
2. Rub hands together, including between fingers and under nails, until dry.

IV. THE STEPS IN THE EINC (ESSENTIAL AND INTRAPARTUM AND NEWBORN CARE)
PROTOCOL

After completion of the module, the participant will be able to adequately prepare for a
delivery by assembling the necessary equipment, supplies and personnel in an ideal
environment. After performing proper hand hygiene, the participant should then be able
to describe and carry out the evidence-based care of a newborn baby at the time of birth.

1. The EINC protocol is a package of evidence-based practices which is a series of time

bound, chronologically-ordered, standard procedures that birthing mothers and their
newborns receive during labor and delivery and at birth, respectively. It is mandated
by Administrative Order 2009-0025 (Adopting Policies and Guidelines on Essential
Newborn Care (ENC) and is a basic component of the Department of Health’s Maternal,
Newborn and Child Health and Nutrition (MNCHN) strategy covered by Administrative
Order 2008-0029 Implementing Health Reforms for Rapid Reduction of Maternal and
Newborn Mortality (MNCHN Strategy). It is a commitment towards achieving UN
Millennium Development Goals (MDG) 4 and 5 by the year 2015
 Recommended as the standard of care in all births by skilled health professionals
in all government and private settings by: Department of Health (DOH),
Philippine Health Insurance Corp.(PhilHealth), World Health Organization (WHO)
 The goal is for health professionals and health facilities to stop practicing
unnecessary medicalized practices and use the DOH/WHO protocol for low-risk,
evidence-based intrapartum & newborn care that protects and saves lives
2. The recommended obstetric practices are:
 Antenatal steroids for mothers in preterm labor and mothers at risk for
preterm birth such as those with antenatal bleeding (placenta previa),
hypertension, preterm prelabor rupture of membranes
 Allowing a companion of choice
 Mobility and position of choice during labor
 Use of partograph to monitor the course of labor
 Non-routine practice of perineal shaving, enema, NPO, IV fluid administration,
episiotomy
  Active Management of the 3rd Stage of Labor
3. The harmful or unnecessary obstetric practices are:
 Doing early amniotomy to hasten labor
 Routine administration of oxytocin to augment labor
 Routine administration of analgesia and/or anesthesia
 Supine lithotomy position during delivery
 Fundal pressure to hasten the 2nd stage of labor
 Perineal massage during the 2nd stage of labor or plantsa
 Routine manual exploration of the uterine cavity to evacuate blood clots even if
the placenta was examined after delivery and found to be complete
 Routine methergin use with or without the use of oxytocin even without undue
vaginal bleeding
 Ice pack on the abdomen in an attempt to control postpartum hemorrhage
4. The recommended maternal care practices that improve neonatal outcome most
especially for preterm births (to be further discussed in other modules) are:
 Antenatal steroids given to the mother at risk for preterm labor or preterm
delivery
 Maintain thermoregulation (room temp. at 25-28°C)
 Performance of the 4 Core steps of the EINC Protocol which are:
o Immediate and thorough drying at delivery
o Skin-to-skin contact of mother and baby
o Properly-timed cord clamping within 1-3 minutes of birth or when
cord pulsations stop. No additional “cord care” with trimming and
application of alcohol or povidone iodine is needed,
o Non-separation of mother and baby to encourage early
breastfeeding initiation.
 Dry cord care without any further trimming or application of alcohol, povidone
iodine or other substances
 Early breastfeeding with no use of prelacteals such as glucose water or milk
formula
5. The unnecessary and/ or harmful newborn practices are:
 Unnecessary suctioning of the newborn’s mouth and nares
 Immediate cord clamping
 Footprinting
 Cord care with antiseptics
 Use of bigkis
 Early bathing with removal of vernix
 Artificial breastmilk substitutes
 Figure 5 shows the step-by-step choreography in the care of the mother and the baby
emphasizing the chronology and proper timing of the procedures

Figure 5A. Step-by-Step EINC Protocol from Antenatal to the Time of Perineal Bulging
Figure 5B. Step-by-Step EINC Protocol from Delivery to the Time Six (6) Hours Postpartum

SUMMARY OF EINC MODULE

The EINC Module discussed intrapartum care of the mother from the first stage of labor
which starts with regular uterine contractions up to the fourth stage of labor which refers
to the first twenty-four (24) hours after delivery. Each of the stages are discussed
separately with emphasis on the practices that are recommended and not recommended
during each stage. In the last unit, the Essential Intrapartum and Newborn Care Protocol, is
presented stressing on these same practices arranged in a choreography of time-bound,
evidenced-based steps for mother and newborn survival.