MCN RLE | LABOR & DELIVERY PROCESS

I. LABOR
• Refers to series of process by which the products of
conception are expelled by the mother
• It implies physical exertion applied to attaining a specific
goal
• It is also called childbirth, parturition, accouchement and
confinement
• It represents a time of change as it is both an ending and
a beginning for the woman, her fetus and her family
• A series of events by which abdominal pressure and
uterine contraction expels the fetus and placenta
outside the woman's body.
• The process of fetal expulsion along with the products of
conception secondary to the regular, progressive, and
frequently occurring uterine contraction. • Even in an adequately sized pelvic outlet, there may be
difficulties in delivery if the passenger, the fetus, is too
4 COMPONENTS OF LABOR large or in a difficult position.
1. Passage (a woman's pelvis) is of adequate size and • There are various means of assessing the fetal head, fetal
contour lie, fetal attitude, fetal presentation, and fetal position.
2. Passenger (the fetus) is of appropriate size and in an
advantageous position and presentation • Also called as upper flaring part is much less
FALSE
3. Powers/Forces of Labor (uterine factors) concerned with the problem of labor than
PELVIS
• Involuntary uterine contraction the true pelvis
• Voluntary uterine contraction • Support the uterus during late pregnancy
4. A woman’s psychological outlook is preserved so and directs the fetus into the true pelvis at
afterward labor can be viewed as a positive the proper time
TRUE
experience • Forms bony canal through which the fetus
PELVIS
must pass during parturition
PASSAGEWAY • It is divided into 3 parts inlet or brim, a cavity
• Slight irregularities in the structure of the pelvis may and an outlet
delay the progress of labor and any marked deformity
may render delivery through natural passages B. PASSENGER
impossible • The body part that has a widest diameter is the head, so
• Regarded as a whole the pelvis may be described as a this is the part least likely to pass through the pelvic ring
two-story bony basin that is divided into 2 parts by a
natural line of division, the inlet or brim
• The upper part is the false pelvis and the lower part is
the true pelvis
A. PASSAGE
• Refers to route a fetus must travel from the uterus
through the cervix and vagina to the external perineum
• The 2 pelvic measurement that are important to
determine: the adequacy of the pelvis are diagonal
conjugate (anteroposterior diameter of the inlet) and
transverse diameter of the outlet.

Cephalic Presentation
 1. Vertex: head is sharply flexed making the parietal B. Voluntary bearing down efforts.
bones or space between fontanels the presenting • After full dilatation of the cervix, the mother can use her
part. It is the most common presentation abdominal muscle to help expel the fetus.
2. Brow: Head is moderately flexed the brow or sinciput • These efforts are similar to those for defecation, but the
becomes presenting part mother is pushing out the fetus from the birth canal.
3. Face: Head is extended to the face to make it the • Contraction of levator ani muscles (broad, thin muscle
presenting part. Extreme edema and distortion can group).
occur
4. Mentum: The fetus completely hyperextended the II. PRELIMINARY SIGNS OF LABOR
head that vaginal birth may not be possible • Lightening or descent of fetal head into pelvis
• Sciatic nerve pressure
• Increase vaginal discharge
• Greater frequency of urination
• Increase level of activity
• Braxton Hicks Contraction
• Ripening of the cervix
• Bloody show
• Rupture of membrane
• Uterine contraction

• No change in cervix
• Discomfort usually in low abdomen & groin
FALSE
• Contractions occur at irregular interval
LABOR
• No increase in frequency & intensity of
contractions
• Progressive cervical dilatation
Breech Presentation • Discomfort in back and abdomen
TRUE
1. Complete breech: Thighs tightly flex in the abdomen • Contractions occur at regular intervals
LABOR
both the buttocks and the tightly flexed feet present • Progressive increase in frequency and
to the cervix intensity of contractions
2. Frank: Attitude is moderate because the hips are
flexed but the knees are extended to the rest of the III. MECHANISMS OF LABOR
chest. Buttocks alone present the cervix
The head is fixed in
3. Footling: Neither thigh nor lower legs are flexed. It
can be single footling breech or double-footling the pelvis.
breech Downward
movement of the
fetal head.

The head bends

forward into the
chest.

Fetal skull rotates,

head passes the
C. POWERS
mid pelvis.
• The body part that has a widest diameter is the head, so
this is the part least likely to pass through the pelvic ring
Uterine Factors
A. Uterine contraction (involuntary)
• Frequency - timed from the beginning of one
As the occiput is
contraction to the beginning of the next.
born, the back of
• Regularity - discernable pattern, better established as
the neck stops
pregnancy progresses.
beneath the pubic
• Intensity - strength of contraction, a relative arch.
assessment without a use of monitor
• Duration - length of contraction. Contraction lasting
more than 90 seconds without subsequent period of
uterine relaxation may have severe implication for the
fetus and should be reported.

The head rotates
along with back
and shoulders for
shoulder delivery
Once the shoulder
is born the rest of
the body follows.
A. ENGAGEMENT
• Engagement takes place when the biparietal diameter of
the fetal head has passed through the pelvic inlet.
• In primigravida, it usually occurs 12hours. In multi it will
occur within 6hrs.
• Mechanism by which the biparietal diameter-the
greatest transverse diameter in an occiput presentation
passes through the pelvic inlet (station 0)
• the fetal head may engage during the last few weeks of
pregnancy or not until after labor commencement.
• if the fetal head is freely movable above the pelvic inlet,
the head is sometimes referred to as "floating."
(unengaged)
• A normal-sized head usually does not engage with its
sagittal suture directed anteroposteriorly. Instead. the
fetal head usually enters the pelvic inlet either
transversely or obliquely
B. DESCENT
• It is a continuous movement throughout the process of
delivery. Descent result in number of forces including
contractions, and maternal pushing effort with
contraction of her abdominal muscles.
• this movement is the first requisite for birth of the
newborn.
• In nulliparas, engagement may take place before the
onset of labor, and further descent may not follow until
the onset of the second stage.
• In multiparas, descent usually begins with engagement
Descent is brought about by one or more of four
forces:
a. pressure of the amnionic fluid
b. direct pressure of the fundus upon the breech with
contractions
c. bearing-down efforts of maternal abdominal muscles
d. extension and straightening of the fetal body.
C. FLEXION
• As the head descends, it meets resistance from the
pelvic walls and floor and this leads to increased flexion
of the head.
• As the head flexed it brings the shortest longitudinal
diameter of the head ( suboccipitobregmatic 9.5cm ) to
pass through the birth canal.
• As soon as the descending head meets resistance,
whether from the cervix, pelvic walls, or pelvic floor, it
normally flexes.
• With this movement, the chin is brought into more
intimate contact with the fetal thorax, and the
appreciably shorter suboccipitobregmatic diameter is
substituted for the longer occipitofrontal diameter.
D. INTERNAL ROTATION
• This movement consists of turning of the head in such a
manner that the occiput gradually moves toward the
symphysis pubis anteriorly from its original position or,
less commonly, posteriorly toward the hollow of the
sacrum
• Internal rotation is essential for completion of labor,
except when the fetus is unusually small.
E. EXTENSION
• After internal rotation, the sharply flexed head reaches
the vulva and undergoes extension.
• When the head presses on the pelvic floor, 2 forces
come into play:
1. First force is exerted by the uterus and acts more
posteriorly
2. Second force is supplied by the resistant pelvic floor and
the symphysis, and acts more anteriorly.
• The resultant vector force is in the direction of the vulvar
opening, thereby causing head extension.
• This brings the base of the occiput into direct contact
with the inferior margin of the symphysis pubis
• Immediately after its delivery, the head drops downward
so that the chin lies over the maternal anus.
F. EXTERNAL ROTATION
• If the occiput was originally directed toward the left, it
rotates toward the left ischial tuberosity. If it was
originally directed toward the right, the occiput rotates
to the right.
• Restitution of the head to the obliquis position is
followed by external rotation completion to the
transverse position.
• This movement corresponds to rotation of the fetal body
to bring its bisacromial diameter into relation with the
anteroposterior diameter of the pelvic outlet.
• Thus, one shoulder is anterior behind the symphysis and
the other is posterior.
Restitution
Head rotates to natural position relative to the
shoulders.
G. EXPULSION
• Almost immediately after external rotation, the anterior
shoulder appears under the symphysis pubis, and the
perineum soon becomes distended by the posterior
shoulder.
• After delivery of the shoulders, the rest of the body
quickly passes.
IV. STAGES OF LABOR
1. Dilatation stage 2. Expulsion stage
3. Placental stage 4. Recovery stage
A. FIRST STAGE OF LABOR
• First stage starts from the onset of labor until full dilation
of the cervix.
• Guide summary recall LAT (Latent, Active, Transition)
• Effacement - shortening and thinning of the cervix. In
primipara, effacement usually well advance before
dilation begins; in a multipara, effacement and dilation
progress together.
• Dilation - enlargement or widening of the cervical os and
canal. Full dilation is considered 10 cm.
LATENT PHASE
• 0-3 cm (4.5 hours in multipara, 6 hours
in primipara)
• Contractions:
Description ▪ Frequency: every 20 minutes
decreasing to 5 minutes.
▪ Intensity: Mild to moderate
▪ Duration: 20 - 40 seconds.
• Bloody show present
Assessment • Cervical change
• BOW - intact or ruptured
• Anxiety
Nursing • Ineffective breathing pattern
Diagnosis • Pain
• Knowledge deficit
• Perineal prep/enema if ordered
• Assess v/s, FHR, BP, contraction,
cervical changes
Nursing • Maintain bedrest
Intervention • Reinforce teach breathing technique
• Have client attempt to void
• Apply external fetal monitoring if
indicated
ACTIVE PHASE
• 4-7 cm (2 hours in multipara; 3 6
hours in primipara)
• Contractions:
Description
▪ Frequency: 3-5 minutes apart
▪ Intensity: Moderate to firm
▪ Duration: 40 -60 seconds
• Effacement of cervix completed
• Membranes may be ruptured
Assessment • Progress of descent
• Maternal /fetal vital signs
• Affect: more anxious and helpless
• Ineffective individual coping
• Alteration in oral mucous membranes
Nursing • Knowledge deficit
Diagnosis • Pain
• Altered tissue perfusion
• High risk for injury
• Continue to monitor progress of labor
• Teach breathing technique as needed
Nursing • Position client for maximum comfort
Intervention • Administer analgesia if ordered
• Keep client/couple informed as labor
progresses
TRANSITION PHASE
• 8-10 cm
• Contractions:
Description ▪ Frequency: every 2-3 minutes.
▪ Intensity: Firm
▪ Duration: 60-90 seconds
• Membrane ruptured, bloody show
increases, cervical dilation
completed.
• Maternal mood change - Irritable or
aggressive and loss of control,
Assessment
• Trembling, crying & irritable.
• Maternal/fetal vital signs
• Breathing pattern - hyperventilating
• Feeling to urge
• Loss of control is common
• Ineffective breathing pattern
Nursing
• Powerlessness
Diagnosis
• Ineffective individual coping
• Continue observation of labor
progress, maternal/fetal vital signs.
• Give mother positive support if tired
or discouraged
• Accept behavioral changes of mother.
Nursing • If hyperventilation present, have
Intervention mother rebreathe carbon dioxide to
reverse respiratory alkalosis.
• Discourage pushing effort until cervix
until is completely dilated, then assist
with pushing.
• Observe for signs of delivery
B. SECOND STAGE OF LABOR
• Expulsion stage – from full dilation of the cervix to birth
of baby.
• Signs of imminent delivery
• Progress descent
• Maternal and fetal vital signs
• Maternal pushing effort
Assessment
• Vaginal distention
• Bulging of perineum
• Crowning
• Birth of baby
• High risk of injury
Nursing • Non-compliance related to
Diagnosis exhaustion
• Knowledge deficit
• Transfer mother carefully to DR table,
support both legs equally to prevent
strain or ligament tear.
• Use handles or legs to pull on as she
Nursing
bears down with contraction.
• Clean vulva and perineum to prepare
Intervention
for delivery.
• Encourage mother to sustained 5 7
seconds pushes with contraction
• Catheterized mother's bladder
• Note time of delivery
C. THIRD STAGE OF LABOR
• Placental stage – from birth of baby to expulsion of
placenta.
Types of Placental Delivery
1. Shultz – Placenta separates from the center of the edge
(clean, shiny).
2. Duncan – Placenta separates from the edge to the
center (dirty).
Nursing Intervention
▪ Trap and rotate the cord slowly so that no fragments of
placenta is left in the uterus.
▪ Palpate the uterus. If boggy, Immediately massage the
uterus
▪ Put ice
▪ Vital signs q hour
▪ Assist in episiorrhapy.

• Signs of placental separation:

• Calkin's sign - earliest sign
Assessment
• Sudden gush of blood
• Lengthening of umbilical cord
Nursing • Pain
Diagnosis • Potential fluid volume deficit
• Palpate fundus immediately after
delivery of placenta; massage gently if
not firm.
• Palpate fundus at least q 15 min for 1-
Nursing
2 hours.
Intervention
• Inspect perineum
• Offer fluid as indicated
• Promote mother baby's relationship.
• Administer medication as ordered.

D. FOURTH STAGE OF LABOR

• Recovery stage – time after birth of immediate recovery;
critical period of 1-2 hours.

• Fundal firmness, position

• Lochia; color, amount
• Perineum
• Vital signs
Assessment
• IV if running
• Infant's heart rate, airways, color,
muscle tone, reflexes, activity
• Bonding/ family integration
• Pain
Nursing
• High risk for fluid volume deficit
Diagnosis
• High risk for altered family process
• Palpate fundus after q 15 minutes for
the first 1-2 hours, massage gently if
not firm.
• v/s q 15 minutes
Nursing • Check lochia
Intervention • Inspect the perineum
• Apply ice if swollen or episiotomy
• Encouraged mother to void
• Use handles or legs to pull on as she
bears down with contraction.
 MCN RLE | ESSENTIAL INTRAPARTUM NEWBORN CARE
I. UNANG YAKAP PROTOCOL
• Unang Yakap: A simple and evidence-based intervention
that may help in ensuring the survival of all newborns
and young infant.
• This encompasses interventions such as:
a. Ensuring warmth
b. Breastfeeding
c. Love and safety
d. Infection control
• This protocol is being practiced in:
a. Birthing centers
b. Hospitals
II. DEVELOPMENT OF ENC PROTOCOL
• The ENC was developed by the Newborn Care Technical
Working Group that conducted a systematic search and
critical appraisal of foreign and local medical and allied
health literature on practices in the immediate newborn
care.
• An evidence-based draft was developed and reviewed by
the DOH, United Children’s Fund, UNICEF, United
Nations Population Fund, Philippine Obstetrical
Gynecological Society, Philippine Society of Newborn
Medicine, a sub-specialty of Pediatric Society, and other
professional organizations and associations.
III. ESSENTIAL INTRAPARTUM NEWBORN CARE
A. EINC PRACTICES DURING THE INTRAPARTUM PERIOD
• Continuous maternal support, by a companion of her
choice, during labor and delivery
• Mobility during labor – the mother is still mobile, within
reason, during this stage
• Position of choice during labor and delivery
• Non-drug pain relief, before offering labor anesthesia
• Spontaneous pushing in a semi-upright position
• Episiotomy will not be done unless necessary
• Active management of third stage of labor (AMTSL)
• Monitoring the progress of labor with the use of
partograph
Recommended Practices for Newborn
• Time-bound interventions at the time of birth:
1. Immediate and thorough drying of the newborn
2. Early skin-to-skin contact between the mother and
her newborn
3. Properly-timed cord clamping and cutting
4. Unang yakap (first embrace) of the mother and her
newborn for early breastfeeding initiation
Unnecessary Interventions Eliminated
• The unnecessary interventions during L&D, which do not
improve the health of mother and child, are eliminated.
1. Enemas and shavings
2. Fluid and food intake restriction
3. Routine insertion of intravenous fluids
4. Fundal pressure to facilitate 2nd stage of labor is no
longer practice because it resulted to maternal and
newborn injuries and death.
• Likewise, the unnecessary interventions in newborn care
which include:
1. Routine suctioning
2. Early bathing
3. Routine separation from the mother
4. Foot printing
5. Application of various substances to the cord
6. Giving pre-lacteals or artificial infant milk formula, or
other breast-milk substitutes.
Four Time-bound Interventions Involved in ENC
• At the heart of the protocol are four time-bound
interventions:
1. Immediate and thorough drying,
2. Early skin-to-skin contact followed by,
3. Properly-timed clamping and cutting of the cord
after 1-3 minutes, and
4. Non-separation of the newborn from the mother for
early breastfeeding initiation and rooming in.
What do these 4 time-bound interventions do to the
newborn?
• Immediate and thorough drying of the newborn
prevents hypothermia which is extremely important
to newborn survival
• Keeping the mother and baby in uninterrupted skin-
to-skin contact prevents hypothermia, hypoglycemia
and sepsis, increases colonization with protective
bacterial flora and improved breastfeeding initiation
and exclusivity
• Properly timed cord clamping and cutting until the
umbilical cord pulsation stops decreases anemia in
one out of every seven term babies and one out of
every three preterm babies. It also prevents brain
(intraventricular) hemorrhage in one of two preterm
babies.
• Breastfeeding initiation within the first hour of life
prevents an estimated 19.1% of all neonatal deaths.
B. GOVERNMENT EFFORTS TO ENSURE
IMPLEMENTATION OF ENC PROTOCOL
• The signing of the Administrative Order 2009-0025 last
Dec. 1, 2009 institutionalizes policies and guidelines for
government and private health facilities to adopt the
essential newborn care protocol.
• Advocacy and dissemination for a have been done since
its launch.
• Scale up implementation in all health facilities and social
marketing are both in the pipeline to ensure that the
policy is implemented all over the country.
C. RELATIONSHIP OF ENC TO MCN HEALTH NUTRITION
STRATEGY
• The Maternal, Newborn, Child Health and Nutrition
(MNCHN) Strategy is in line with the DOH Administrative
Order 2008-0029 that seeks to rapidly reduce maternal
and newborn morbidity and mortality.
• Foremost to this is the provision of Basic and
Comprehensive Emergency Obstetric and Newborn Care
(BEmONC and CEMONC) capability of health facilities to
meet the UN MDGs 4 and 5.
• Newborn care has been incorporated in the provision of
these service capabilities. The Administrative Order
2009-0025 formalized the adoption of policies and
guidelines on essential newborn care.
 D. PEOPLE INVOLVED IN ENC PROTOCOL
• Healthcare professionals, either in government or in
private facilities, involved in maternal and newborn care
not limited to:
a. obstetrician-gynecologists,
b. pediatricians/neonatologists,
c. nurses,
d. midwives,
but also the:
e. hospital administration officials,
f. anesthesiologists,
g. hospital infection control officers,
h. hospital PhilHealth/Quality officers,
i. clinical nutritionists,
j. clinical pharmacists,
k. nursing attendants,
l. health promotion and information officers.
 MCN RLE | NEWBORN CARE
I. IMMEDIATE CARE OF NEWBORN
A. THE 1ST 24 HOURS OF LIFE
• The first 24 hours of life is a very significant time due to
critical transition from intrauterine to extra uterine life.
B. PURPOSES OF IMMEDIATE CARE OF NEWBORN
• Establish and maintain respiratory function.
• Provide warmth and prevent hypothermia.
• Ensure safety from injury and infection.
• Identify actual and potential problems that might
require immediate action.
C. ASSESS THE NEWBORN'S CONDITION
a. One minute APGAR Score; reassess at 5 minutes.
b. Neurological examination by checking common reflexes
of the newborn.
c. Vital signs pulse, respiration & temperature.
d. Growth measurements include length, weight, head &
chest circumferences.
e. Assess for any gross abnormality, congenital defects in
head, eyes, ears, chest, spine, face, nose, abdomen,
anus, external genitalia, & extremities.
f. Assess for any signs of eye infection.
D. IMMEDIATE NEWBORN CARE
1. Establishment and maintenance of respiration
• The infant's respiration must be established and
maintained; the baby should cry lustily periodically to
create full expansion of the lungs that provides oxygen
for the blood which until birth was supplied through the
placental circulation
• If the newborn does not breathe within 30 seconds
after birth, suctioning or resuscitation is needed
• If baby is asphyxiated endotracheal suctioning is
needed
• A method of scoring the amount of retraction,
respiratory rate and absence or presence of cyanosis
present indicates the degree respiratory difficulty in the
new born; resuscitation with an ambu bag is essential.
• Failure of the baby to cry suggests obstruction of the air
passage with mucus; mucus drainage with the help of a
bulb syringe is necessary.
2. Gentleness and prevention of infection
• Sterility must be maintained using aseptic techniques
during and after delivery to prevent cross infection
from either the mother or the delivery room.
• Using gentle pressure during and after delivery,
prevents the likelihood of injuries or wounds that can
ease the entry of pathogenic micro-organism
3. Regulation and maintaining body temperature
A. Stabilization of the baby's temperature
• Since the delivery room temperature is lower than that
of utero, drying and wrapping the baby in a dry, warm,
sterile flannel blanket immediately after birth is helpful
in preventing the drop in baby's temperature.
B. To provide warmth and prevent hypothermia
• Drying the baby with warm towels or cloths, while being
placed on the mother's abdomen or in her arms. This
mother-child skin-to skin contact is important to
maintain the baby's temperature to ensure no
metabolic problems associated with exposure to the
cold arise
C. Poor thermoregulation of the newborn
• Maintaining a neutral thermal environment is one of
the key physiologic challenges that a newborn must
face after delivery.
• Accurate temperature monitoring of neonates is vital
due to the significant morbidities and mortality
associated with neonatal hypothermia.
The following characteristics put newborns at a greater
risk of heat loss:
• A large surface area-to-body mass ratio
• Decreased subcutaneous fat
• Greater body water content
• Immature skin leading to increased evaporative water
and heat losses
• Poorly developed metabolic mechanism for
responding to thermal stress (e.g., no shivering)
• Altered skin blood-flow (e.g., peripheral cyanosis )
E. CORD CARE
• Cord has 2 arteries + 1 vein (AVA)
• Done with strict aseptic technique practice
• Apply cord clamp to prevent bleeding
• Application of antiseptic solution
a. Povidone iodine
b. 70% alcohol
• Application of sterile cord clamp to prevent bleeding
within the first 24 hours
• The cord will fall off after 7-10 days
F. CARE OF THE EYES
• As the baby's head is born eyes are swabbed using sterile
swab; one swab per wipe, inwards to outwards and
discarded to prevent transmission of infections like
gonorrhoea (ophthalmia neonotorum).
• In additional, application of tetracycline eye ointment is
helpful in preventing and treating the suspected eye
infection on the new born.
F. INJECTION
1. Vitamin K Injection
• Administer 1mg. Vitamin K by I.M injection.
• Route: IM into the lateral anterior thigh (Vastus
lateralis).
• Vitamin K is also administered to prevent
hemorrhagic disease of the newborn because the
newborn has a sterile intestine at birth, hence, the
newborn does not possess the intestinal bacteria that
manufactures vitamin K which is necessary for the
formation of clotting factors.
2. Hepatitis B Vaccine
• It is recommended that newborns receive their first
dose of the hepatitis B vaccine within the first 24
hours of their life.
• One reason for this is that it is possible for the birth
mother to pass the infection onto the baby, which is
known as a perinatal infection.
• One reason for this is that it is possible
for the birth mother to pass the
PURPOSE
infection onto the baby, which is
known as a perinatal infection.
 • If a newborn contracts hepatitis B,
there is a significant chance that this
infection will be chronic, meaning that
it will persist for a long time.
• Without treatment, it is possible that
the infant will die from complications
of the infection.
• The main benefit of the vaccine is its
effectiveness. The AAP note that if
doctors give the first dose of the
hepatitis B vaccine within 24 hours of
the baby's delivery, it is 75 to 95
percent effective in preventing the
passage of hepatitis B from the birth
mother to the baby.
BENEFITS • If the newborn also receives the
medication hepatitis B immune
globulin (HBIG) at the correct time and
a series of follow-up vaccines, the AAP
estimate that the infection rate drops
to between 0.7 and 1.1 percent.
• For the best possible protection, the
baby will need to complete the full
series of vaccines.
3. BCG Vaccine
• Bacillus Calmette-Guérin vaccine is a vaccine
primarily used against tuberculosis. It is named after
its inventors Albert Calmette and Camille Guérin. In
countries where tuberculosis or leprosy is common,
one dose is recommended in healthy babies as soon
after birth as possible.
II. NEWBORN ASSESSMENT
• Assessment of newborn can be divided into 4 phases:
1. Initial assessment
2. Transitional assessment
3. Gestational age assessment
4. Systematic physical examination.
Anthropometric Measurement
• HEAD CIRCUMFERENCE: 33-35cm
• CHEST and ABDOMEN: 31-33cm
• LENGTH: 47-54cm
• WEIGHT: 2500-4000 grams
VITAL SIGNS
TEMPERATURE
• indicate whether oral or axillary(is usually 1degree
lower than rectal)
• Rectal -is usually 1 degree higher than oral
• The axillary method is the safest.
• Normal axillary temperature is 36-36.5 °C
RESPIRATION
• Normal: 40-60breath/min
• RR varies from 30-60 b/m when the infant is not
crying.
BLOOD PRESSURE
• Correlates directly with gestational age, postnatal age
of infant, and birth weight.
• Not routinely assessed in healthy term infants.
• The range of normal blood pressure in term infants is
60-90 mmHg for systolic pressure and 40-50 mmHg
for diastolic pressure.
PULSE RATE
• Ranges 120-160 but in normal healthy babies the
heart rate increases with stimulation.
• HR is counted for 60 seconds at the apex of the heart
(Range from 100- 160 b/m immediately after birth).
A. NEWBORN INITIAL ASSESSMENT
1. APGAR SCORING
• Apgar is a quick test performed on a baby at 1 and 5
minutes after birth.
• The 1-minute score determines how well the baby
tolerated the birthing process.
• The 5-minute score tells the health care provider how
well the baby is doing outside the mother's womb.
A Appearance
P Pulse
G Grimace
A Activity
R Respiration
▪ The Apgar rating is based on a total score of 1 to 10.
▪ The higher the score the better the baby is doing after
birth.
▪ A score of 7,8,9 is normal and is assign that the newborn
is in good health
▪ A score of 10 is unusual, since almost all newborns lose
1 point for blue hands and feet, which is normal for
after birth.
B. GESTATIONAL AGE ASSESSMENT
• The first 24 hours of life is a very significant time due to
critical transition from intrauterine to extra uterine life.
• A method to determine the gestational age is New
Ballard Scale(NBS).
• It was proposed by Dr. Jenne L Ballard in 1991.
• NBS assesses 6 external physical and 6 neuromuscular
signs of maturity.
• Assessment of gestational age from 20 to 44 weeks
• Scores range from -10 to +50
• Optimal time for assessment if from birth to 90 hours

NEUROMUSCULAR MATURITY
1. Posture
• Observe in the supine position at rest
• Score is assigned based on the degree of flexion of arms,
knees and hips
• Increased flexion and hip adduction with increased
gestational age.
2. Square Window
• Infant’s hand is flexed on the forearm between the
thumb and index finger of the examiner
• Apply enough pressure to get full flexion without
rotating the wrist
• Angle between the forearm and the palm is measured.
3. Arm Recoil
• This maneuver focuses on passive flexor tone of the
biceps muscle by measuring the angle of recoil following
very brief extension of the upper extremity.
• Flex the neonate’s arms for 5 seconds while in the supine
position
• Fully extend the arms by pulling on the hands and
release
• The degree of arm flexion and strength of recoil are
measured. Full term can flex hand completely up to face.
4. Popliteal Angle
• Place infant in supine position with the pelvis on the
mattress
• Using the thumb and index finger of one hand, examiner
holds the knee adjacent to the chest and abdomen
• Gently extend the leg with the index finger
• Look at the angle between the lower leg, thigh and
posterior knee.
5. Scarf Sign
• Place infant in supine position with head in mid-line
position.
• Grasp the infant’s hand and pull the arm across the chest
and around the neck.
• Look at the relationship of elbow to mid-line of body
when arm pulls across the chest

6. Heel – to – ear
• Place the infant supine with pelvis flat on table.
• Grasp one foot with thumb and index finger and draw
foot as near to head as possible.
• Note the distance between the foot and head as well as
degree of knee extension
PHYSICAL MATURITY
1. Skin
• Less transparent and tougher with increasing gestational
age
• 36-37 weeks loses transparency and underlying vessels
are no longer visible
• Increasing gestational age the veins become less viable
and increasing subcutaneous tissue.
2. Lanugo
• Fine downy hair covering fetus from 20-28 weeks
• Disappears around face and anterior trunk -28 weeks
• Term infants may have a few patches over shoulders.
3. Plantar Surface
• 28-30 weeks appear and cover the anterior portion of
the plantar surface of the foot
• Extend toward the heel as increases gestational age
• After 12 hours sole creases are not valid indicator of
gestational age due to drying of the skin.
4. Breast
• Areola is raised by 34 weeks
• A 1-2 mm nodule of breast tissue is palpable by 36 weeks
• By 40 weeks the nodule is 10mm.
5. Eye/Ear
• Lids are open and complete eyelashes develops at term
• Incurving of the upper pinna begins by 34 weeks
gestation and extend entire lobe by 40 weeks
• Before 34 weeks, pinna has very little cartilage (Stays
folded on itself)
• At 36 weeks, there is some cartilage and will spring back.
6. Genitalia
MALE
• Testes begin to descend from abdomen around 28
weeks
• At 37 weeks, testes can be palpated high in scrotum
• At 40 weeks, testes are completely descended and
covered with rugae
• As gestation progresses, scrotum becomes more
pendulous
FEMALE
• Early gestation, clitoris prominent and widely separated
labia
• By 40 weeks, fat deposits have increased in size in labia
majora so labia minora are completely covered