ESSENTIAL INTRAPARTUM NEWBORN CARE (Assisting and Handling Delivery)

Definition:

Purpose:

Materials:

Direction: Score the following steps according to the rating scale:

3 – Excellent
2 – Satisfactory
1 – Needs Practice
0 – Not Performed
PROCEDURE RATIONALE RATING REMARKS
Done by the Assistant Nurse
1. Ensures that mother is on her
position of choice when in labor.
2. Asks mother if she wishes to
eat/drink.
3. Communicates with the mother –
informs her of progress of labor,
gives reassurance and
encouragement.
Patient Already in the Delivery Room Preparing for Delivery
Done by the Handle Nurse
4. Checks temperature in DR area,
checks for air draft.
5. Asks the patient if she is
comfortable in semi-upright position,
which is the default position.
6. Washes hands.
7. Puts on 2 pairs of sterile gloves
aseptically (if same worker handles
perineum and cord)
8. Arranges things in a linear fashion
(gloves, dry linen, bonnet, oxytocin
injection, plastic clamp, scissors and
2 kidney basins).
Done by the Assistant Nurse
9. Cleanse the perineum with
antiseptic solution.
At the Time of Delivery
Done by the Handle Nurse
10. Encourages woman to push as
desired.
11. Applies perineal support and does
controlled delivery of the head.
12. Calls out time of birth and sex of
baby.
13. Informs the mother of outcome.
First 30 Seconds (Immediate and Thorough Drying)
 Done by the Newborn Care Nurse
14. Places the baby on a clean dry
cloth
15. Thoroughly dries baby for at least
30 seconds starting from the face,
head, back going down top the trunk
and extremities (simultaneously
assessing the Apgar’s score and refer
to APGAR score).
Skin to Skin Contact (Up to 3 Minutes)
Done by the Newborn Care Nurse
16. Removes the wet cloth.
17. Places the baby on skin-to-skin
contact on the mother’s abdomen.
18. Covers the baby with a clean dry
cloth/towel.
19. Covers the baby’s head with a
bonnet.
20. Excludes a 2nd baby by palpating
the abdomen.
21. Uses the wet cloth to wipe the
soiled gloves.
22. Disposes the wet cloth properly.
23. Removes the first set of gloves.
Properly Timed Cord Clamping (1-3mins)
Done by the Handle Nurse
24. Palpates umbilical cord to check
for pulsations.
25. Places the plastic clamp 2cm from
the base of the umbilicus.
26. Apply 2nd clamp 5cm from the
base of the umbilicus then cut 1cm
from the plastic clamp.
Done by the Assistant Nurse
27. Gives IM oxytocin within 1
minute of baby’s birth.
Done by the Handle Nurse

28. Performs the remaining steps of

the active management of Third stage
of Labor:
● Waits for strong uterine
contraction then applies
controlled cord traction and
counter traction on the
uterus continuing until the
placenta is delivered.
● Massages the uterus until it
is firmed
29. Deliver the placenta.
Done by the Assistant Nurse
30. Check the BP and list down the
time the placenta was delivered.
Done by the Handle Nurse
31. Examines the placenta for
completeness and abnormalities.
Disposes the placenta in a leak-proof
container or plastic bag.
32. Inspects the lower vagina and
perineum for lacerations or tears and
repairs lacerations/tears if necessary.
Done by the Assistant Nurse
33. Cleanse the mother; flushes the
perineum and applies perineal pad,
napkin or cloth.
Done by the Handle Nurse
34. Checks the baby’s color and
breathing; checks that mother is
comfortable, uterus is contracted.
35. Decontaminates instruments in
0.5% chlorine solution before
cleaning; decontaminates 2nd pair of
gloves before disposal.
Done by the Handle Nurse
36. Advises mother to maintain skin-
to-skin contact. Baby should be in
prone position on mother’s chest/in-
between the breast with head turned
to one side.
Within 90 Minutes
(Done by the Newborn care Nurse)
37. Advises mother to observe for
feeding cues.
38. Supports mother, instructs her on
positioning and attachment.
39. Waits until full breastfeeding is
completed.
40. Administers eye ointment first,
does thorough physical examination,
gives vitamin K, Hepa B, and BCG
simultaneously explains the purpose
of each intervention.
41. Room in. Advises breastfeeding
per demand and about danger signs
for early referral.
42. In the first hour, checks baby’s
breathing and color; and checks
mother vital signs and massage uterus
every 15 minutes.
43. In the second hours, checks
mother-baby-dyad every 30 minutes
to one hour.
44. Document all nursing
interventions implemented.
TOTAL SCORE
132
EINC Team. June 2012. MNCHN EINC Advocacy Partners Handbook for Safe and Quality Care of
Birthing Mothers and Newborns.

Pilliteri, A. (2014). Maternal & Child Health Nursing: Care of the Childbearing &Childrearing
Family (7th Ed.). Philadelphia, PA: Wolters Kluwer.

WHO. Department of Making Pregnancy Safer. Essential Newborn Care Course. Integrated Management
of Pregnancy and Childbirth. Regional Trainors’ Training Course, Manila, Philippines. January
2009.

INSTRUCTOR: __________________________ AVERAGE: _______________________

DATE : __________________________