Prenatal Check-up

Proc 54 3 2 1
edur
e

Preparatory
Phase

1
1 Introduce self and verify the client's identity
and assess the client’s health history.
- Introducing self will build rapport to the client.
verifying the patient ensures the right patient
receives the intervention and helps prevent errors.
Ask about the ff: allergies, medications, undergone
operations, any signs that you think are not normal
during pregnancy.

2 Assess the client’s knowledge on the guidelines

for healthy pregnant and antenatal care.
 -To evaluate the client’s knowledge on
childbearing.

3 Performs hand washing and donned gloves (if

deemed necessary).

-To avoid the spread of harmful microorganisms

and donning gloves will give extra protection to
the healthcare provider.

4 Wash hands and prepare the equipment needed.

-To avoid the spread of microorganisms. Preparing

the equipment needed minimizes actions and
avoid errors.

5 Identify and explain the procedure.

- To encourage cooperation throughout the
procedure.

A.
Performance
Phase

6 Monitor vital signs.

 -It allows medical professionals to assess your
wellbeing.

7 Measure the height on initial visit and monitor

weight on succeeding visit.
- it is often used to calculate the appropriate
medication dose.

8 Measure fundal height.

- to determine if a baby is small for its gestational
age and it helps to show how large your baby is
(fetal growth).

9 Perform Leopold’s maneuver.

a systematic method of observation and palpation
to determine fetal presentation and position.
A. Since I am right-handed, I am going to stand at
woman's right, facing the patient.
Proper positioning of hands ensures accurate
findings.

FIRST MANEUVER
B. Face the patient and palpate the uterine fundus
(it is the top portion) to determine what part of the
fetus lies in the upper part of the uterus.
Determines whether fetal head or breech is in the
fundus.
When palpating, a head feels firmer than a breech.
A head is round and hard; the breech is less well
defined.
SECOND MANEUVER
C. Palpate in a downward direction on the sides of
the abdomen applying gently but deep pressure to
determine the position of the fetal extremities, the
fetal back and the anterior shoulder.
Determines on which side of the uterus is the
back and on which side are the fetal arms and
legs.
THIRD MANEUVER
D. Put one hand over the symphisis pubis (base of
the uterus) and grasp the lower uterine segment
between the thumb and fingers to feel the
presenting part.
Confirms the presentation determined in the first
maneuver. Determines whether the presenting
part is engaged in the maternal pelvis.
FOURTH MANEUVER
E. Face the women's feet to confirm the findings
of the third maneuver and determine the flexion of
the vertex. Place fingers on both sides of the
uterus approximately 2 inches above the inguinal
ligaments. Allow fingers to be carried downward.
This maneuver determines fetal attitude and
degree of fetal extension into the pelvis.
F. Locate again for the back of the fetus and
places the stethoscope over it and listens for the
fetal heart tone for one full minute.
Listening for fetal heart tone for 1 full minute
ensures accuracy.
E. Note the location, rate and character of the FHT.
This serves as data for documentation.
12 Administer iron folate supplement until second
month postpartum.
During pregnancy, pregnant woman need double
the amount of iron to make more blood to supply
oxygen to the baby.

And administer malaria prophylaxis (Chloroquine

250mg) every week as ordered by the doctor.
-it is recommended for preventing the
consequences of malaria during pregnancy.

13 Advise client to observe good nutrition and

encourage personal hygiene.
- it helps promote a healthy body and prevent
getting infectious disease

14 Reassure the client’s expectation about

pregnancy.
-to assess client’s knowledge about childbearing

15 Give some health guidelines pertaining to the

danger signs of pregnancy, delivery and labor.
- Knowledge of possible danger signs allows for
 early detection and prompt intervention should it
be necessary.
Some of the Danger signs for women to report
during pregnancy are vaginal bleeding, persistent
vomiting, chills and fever.
Danger Signs of Labor: abnormal maternal pulse
or blood pressure, inadequate or prolonged
contractions

16 Provide information on breastfeeding.

Is a method of feeding a baby with milk from the
breast.

Termination
Phase

17 Arrange for the

next prenatal
check-up.

-To avoid conflict

of schedules
between the client
and healthcare
 provider.
-Explain to the
client the
importance of pre-
natal check-ups
even when she
feels fine.

18 Evaluate the information gathered and reassess

the health status of the mother and the baby.
-to make sure that the health status of the mother
and baby is normal.

19 Evaluate the expected outcome toward

understanding goals of care for pregnancy.
-this will encourage the client to participate and
help achieve the goal of having a healthy
pregnancy.

20 Record and
chart all
pertinent data.
-To keep track
on the patient’s
 status and to
have a baseline
data for future
check ups.

21 Make referrals/ recommendations if there is any

abnormal finding.
-. Documentation provides ongoing data
collection and coordination of care

-----END-----
 Prenatal Exercise

Procedure 5 4 3 2 1

Pre-Exercise Phase

1 Assess client's ability to perform the

activity.
To obtain information about the client’s
health status and potential health problems
or needs.

2 Determine the scope of assessment

needed. Prepare necessary equipment.
To deliver specific nursing interventions.
Preparing the necessary supplies will
ensure convenience and efficiency

3 Perform hand washing and donned gloves

(if deemed necessary).
To prevent the spread of microorganism.

4 Introduce self and verify the client's

identity.
To develop trust and cooperation between
 the client and health provider. Verifying
client’s identity ensures right patient and
the right intervention.

5 Explain the procedure to the client.

Explanation relieves anxiety and promote
cooperation.

6 Position patient comfortably and provides

privacy.
To ensure safety and protect client’s
dignity.

7 Before exercise, instruct client to do warm

up:
Warming up aids the body in preparing the
muscles and lessen the client’s rick of
injury.

8 Inform client to stand with equal eight in

both legs.
To prevent injury and probability of fall.

9 Ensure client to maintain good posture

 during exercise at all times.
To ensure safety and reduce the risk of
injury

Exercise Phase

Pelvic tilting or pelvic rocking

10 Standing - buttocks are tucked and

flattened out the bottom of the lower back.
Hold 3 seconds. Then, relax allowing hips
to move to former position
To relieve back pain and improve
flexibility. It can also get you ready for
labor. Using this technique while laboring
and during delivery can distract from
painful contractions, help baby move down
the birth canal, and relieve minor back
pain.

11 While down on hands and knees, arch back

and drop abdominal wall forward

12 Lie supine without pillow on head, arch

lower back upward so that abdomen rises,
 then relax & repeat.

Knee-chest twist

13 Lying on back, knees are pulled to the

chest and arms stretched straight to the
side. Knees are rolled to one side while the
head is turned to the opposite side, hips
are rotated and twisted.

Leg Raising

14 Alternate raising of the legs while lying on

the floor without bending the knees.
This will ensure that the blood and fluid
return to your heart—relieving the swelling
in your lower extremities.

Tailoring Sitting

15 Sitting on the floor with one foot in front of

the other, tucked inward towards the
perineum and press kness with hands
 downward toward the floor
Tailor sitting encourages good posture that
helps move the uterus forward, improve
circulation along the midline of the body,
and ease back pain.

Rib Cage Lifting

16 Tailor sitting to help muscles of the thigh,

hips, and lower back.
Tailor sitting encourages good posture that
helps move the uterus forward, improve
circulation along the midline of the body,
and ease back pain.

17 Inhale while extending the right arm with

elbows slightly flexed above the head with
arms extended.
Lifts the diaphragm and rib cage up off the
uterus which promotes relief from the rib
pain.

18 Exhale again and return to starting

 position.
Repeating the steps ensures longer pain
relief for the client.

Shoulder Circling

19 Either standing or sitting, keep back, head

and neck straight throughout the exercise
and allow arms to hand loosely in the side.
Make sure to always maintain good
posture and stay relax as you start the
exercise.

20 Slowly rotate the shoulder up and back in

circular motion.
Rotating the shoulders help retain range of
motion.

21 Inhale as shoulder is rotated and exhale as

the circle is completed.
Patterned breathing relaxes the mother
and improves her response to pain.
 Knee bending

22 Deep knee-bend using a chair for

stabilization.
Deep squats open the hips and pelvis,
helps locate and relax pelvic floor muscles,
lower back pain, and creates a feeling of
being grounded. Ensure a chair for support
and safety in case of imbalances while
performing.

23 With feet slightly apart, inhale when

bending, exhale when standing.
Patterned breathing relaxes the mother
and improves her response to pain.

Calf Stretching

24 Stand with feet slightly apart. Hands

should be at the back of the chair for
support.
Ensure wide base support on the feet and a
chair support in front to ensure safety.

25 Inhale and slide foot or right leg sideward

 as far as possible without letting the heel
leave the floor.
Stretching the calf help prevent and
provide relief from leg cramps during
pregnancy.

26 Bend knee of the other leg and return to

first position. Exhale and relax.
Perform it on the other side to stretch both
calves, repeat it as desired. Patterned
breathing relaxes the mother and improves
her response to pain.

Post-exercise Phase

27 Perform cool down exercise

28 Do after care. Fix the equipment used and

arrange it properly.
Proper disposal of equipment ensures
safety.

29 Perform hand washing.

 To deter the spread of microorganisms.

30 Evaluate client’s response to the

procedure.
Evaluation will aid assessing patient’s
understanding and clarification on the
procedure.

31 Document the findings in the client’s

record.
For documentation and future referrals.

-----END-----

Breast Feeding Initiation

Breastfeeding Initiation and Positioning

Preparatory Phase
1 Assess client's ability to
perform the activity
 To identify a client’s health
status & actual or potential
health problems or needs.
2 Determine the scope of
assessment needed.
Prepare necessary
equipment.
To deliver specific nursing
interventions to meet those
needs.
3 Perform hand washing and
donned gloves (if deemed
necessary).
To deter the spread of
microorganism
4 Introduce self and verify the
client's identity.
To develop trust and
rapport between the client
and nurse.
5 Explain the procedure to
the client.
To encourage cooperation
throughout the procedure.
6 Position patient
comfortably and provides
privacy.
To ensure safety and to
 guarantee the patient's
dignity.
7 Instruct mother to do
handwashing before
nursing
To deter the spread of
microorganisms.
8 Clean breast with water
only using clean white cloth
or cotton balls
Using soap can cause dry,
cracked, and irritated skin.
It can also remove the
natural oils produced by the
Montgomery glands located
on the dark area
surrounding your nipples
Assessment Phase
9 Position mother in a This position is comfortable for
comfortable chair and mother’s who’ve had a
support baby on a pillow on cesarean section.
mother's lap.
1 Instruct mother to support U-hold provides better support
0 and narrow breast with one under the breast since the hand
hand using "U hold." is cupping the breast from
Thumb will be on the outer underneath with the thumb
side of breast and fingers going up one side of the breast
will be on the inner side. and the fingers going up the

1 Introduce also the use of "C
1 hold," with all your fingers
below the nipple and thumb
above it.
1 Instruct and assist mother
2 to position by putting her
other arm behind baby's
back, with hand supporting
the base of the baby's head.
1 Point mother's fingers and
3 thumb toward baby's ears.
1 Instruct mother to touch
4 baby's lower lip with her
nipple to get baby's mouth
to open. Wait until the baby
opens up really wide, like a
big yawn. Then bring the
baby quickly to breast-not
the breast to the baby.
1 Let the mother guide her
5 breast into the baby's
mouth.
1 Observe for signs of good
6 attachment between the
other side.
‘C hold’ allows you to aim your
nipple into the proper position
so that the baby latches on
correctly.
This is to support your baby's
head, neck, and shoulder by
placing your hand at the base
of your baby's head.
To support the baby’s head.
Tickling your baby’s lip will
encourage him to open his
mouth wide (like he is
yawning).
This will help the mother to
have a good latch that
promotes high milk flow and
minimizes nipple discomfort for
the mother.
These signs can be used to
decide if a mother and baby
 breast and the baby: (1) need help.
more areola is visible above
the baby's top lip than
below the lower lip; (2)
baby's mouth is wide open;
(3) baby's lower lip is curled
outwards; (4) baby's chin is
touching or almost
touching the breast.
Breaking The Latch
1 Teach mother to break This action will break the
7 baby's latch by putting one suction between your child's
finger in the corner of mouth and your breast.
baby's mouth
1 Let the mother push finger Simply pulling the nipple out of
8 between baby's gums to the infant’s mouth while
gently break the latch. latched can cause nipple
damage and is best to avoid.
Different Breastfeeding Position
1 Perform Laid back position HOW: Lie back in a reclined
9 position (you can use pillows
to support your back, neck, and
arms. Place the baby on your
stomach with their belly
touching yours and their head
up at the level of your breasts.
They will then begin to smell
and feel their way to your

2 Perform Cradle hold
0 postion
2 Perform Cross-cradle hold
1 position
nipple. Once they find it, they
will move their head back and
forth, open their mouth wide,
latch on and begin to nurse.
Laid-back breastfeeding is
about using positions that tap
into your baby's natural
reflexes.
HOW: Hold your baby across
your lap; he should be lying on
his side, resting on his
shoulder and hip with his
mouth level with your nipple.
Support your breast with either
the “U” hold” or “C” hold. Your
baby’s head will be on your
forearm and his back will be
along your inner arm and palm.
The cradle position is most
commonly used after the first
few weeks. The cross-cradle
position (see below) gives you
more control.
HOW: Your baby is supported
on a pillow across your lap to
help raise him to your nipple
level. If you are preparing to

2 Perform Football position.
2 your side, facing you, with the
breastfeed on the left breast,
your left hand supports that
breast in a “U” hold. If you are
breastfeeding on the opposite
breast, reverse hand use.
Support your baby with the
fingers of the right hand; by
gently placing your hand
behind your baby’s ears and
neck with your thumb and
index finger behind each ear.
Your baby’s neck rests in the
web between the thumb, index
finger and palm of your hand,
forming a “second neck” for
the baby. The palm of your
hand is placed between his
shoulder blades.
During the early weeks, many
mothers find a variation of the
cradle position, called the
cross-cradle position to be
useful.
HOW: Position your baby at
baby's legs tucked under your
arm on the same side as the
breast you're nursing from.
Support your baby’s head with

2 Perform Double football
3 hold
2 Perform Sidelying Position
4 on their sides facing each
the same hand, and use your
other hand to cup your breast.
The football hold allows babies
to take milk more easily —
which is also good for mothers
with a forceful milk ejection
reflex (or let down).
HOW: Rest your babies’ bodies
on pillows along your sides
and under your arms. Your
hands will cradle their heads
with their bodies held right up
next to your hips.
This hold is often an easy
transition into tandem feedings
for both mom and babies.
HOW: Both mother and baby lie
other. You can use pillows
behind your back and behind
or between your knees to help
get comfortable. A pillow or
rolled blanket behind the
baby’s back will keep him from
rolling away from you. The
 baby can be cradled in your
arm with his back along your
forearm. Having his hips flexed
and his ear, shoulder and hip in
one line helps your baby get
milk more easily.

For some mothers, this

position works best after the
early days of breastfeeding.
2 Perform Upright or Koala HOW: In the upright or koala
5 Position hold, your baby sits straddling
your thigh, or on your hip, with
his spine and head upright as
he feeds.

The upright or koala hold is

often the most comfortable
breastfeeding position for
babies who suffer from reflux
or ear infections (who often
prefer to be upright), and it can
also work well with babies who
have a tongue-tie or low
muscle tone.
2 Perform a Dangle Feeding HOW: This breastfeeding
6 Postion position involves your baby
lying on his back, while you
crouch over him on all fours

Termination Phase
2 Do after care. Fix the
7 equipment used and
arrange it properly
2 Perform hand washing.
8 microorganism
2 Evaluate client’s response
9 to the procedure.
and dangle your nipple in his
mouth.
Some mums say doing this for
short periods helps if they have
conditions like mastitis and
don’t want their breasts to be
squashed or touched
After care ensures proper
nursing care. Proper disposal
of equipment used ensures
safety of the client and
prepares these equipment for
future use.
To deter the spread of
Evaluation is important to
assess whether the client can
do these procedures on her
own or if she still needs further
teaching and clarification for
some steps.
3 Document the findings in For future referral and use.
0 the client’s record.

-----END-----
 Essential Intrapartum Newborn Care

Done by the Handle Nurse

3 Palpates umbilical cord to check for

3 pulsations.

3 Places the plastic clamp 2cm from

4 the base of the umbilicus.

3 Apply 2nd clamp 5cm from the base

5 of the umbilicus then cut 1cm from
the plastic clamp.

Done by the Assistant Nurse

3 Gives IM oxytocin within 1 minute of

7 baby’s birth.

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

Deliver the placenta.

Done by the Assistant Nurse

Check the BP and list down the time

the placenta was delivered.

Done by the Handle Nurse

Examines the placenta for

completeness and abnormalities.
Disposes the placenta in a leak-
proof container or plastic bag.

Inspects the lower vagina and

perineum for lacerations or tears
and repairs lacerations/tears if
necessary.

Done by the Assistant Nurse

Cleanse the mother; flushes the
perineum and applies perineal pad,
napkin or cloth.

Done by the Handle Nurse

Checks the baby’s color and

breathing; checks that mother is
comfortable, uterus is contracted.

Decontaminates instruments in 0.5%

chlorine solution before cleaning;
decontaminates 2nd pair of gloves
before disposal.

Done by the Handle Nurse

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)
Advises mother to observe for
feeding cues

Supports mother, instructs her on

positioning and attachment.

Waits until full breastfeeding is

completed.

Administers eye ointment first, does

thorough physical examination,
gives vitamin K, Hepa B, and BCG
simultaneously explains the
purpose of each intervention.

Room in. Advises breastfeeding per

demand and about danger signs for
early referral.

In the first hour, checks baby’s

breathing and color; and checks
mother vital signs and massage
uterus every 15 minutes.

In the second hours, checks mother-

baby-dyad every 30 minutes to one
 hour.

Document all nursing interventions

implemented.

Termination Phase

4 Do after care. Fix the equipment

6 used and arrange it properly.

4 Perform hand washing.

7

4 Document the findings in the

8 client’s record.

-----END-----
 Immediate Newborn Care

Procedure 5 4 3 2 1

Preparatory Phase

1 Reassess client's previous medical

records if available.
To establish a database reference

2 Determines the scope of assessment

needed. Prepares necessary
equipment.
To have an organized approach to
the procedure.

3 Performs hand washing and donned

gloves (if deemed necessary).
To prevent the spread of
microorganisms.

4 Introduces self and verify the client's

identity.
To build rapport and to ensure that
 the right patient receives the
intervention.

5 Explains the procedure to the client.

To minimize anxiety and to promote
patient cooperation.

6 Positions the patient on side lying or

sitting and provide privacy.
To protect the patient’s dignity and
ensure safety.

A. Performance Phase

7 Call out the time of birth. E.g.

“8:30am, Baby Boy/Girl OUT”
This is done until the entire baby
from head to feet has completely
exited the mother’s body. Nurses call
out the time of birth, usually to the
nearest minute.

8 Lay the newborn on the mother’s

abdomen on top of the sterile linen.*
 Mother-child skin-to-skin contact is
important to maintain the baby's
temperature, encourage bonding.

Use the dry cloth to thoroughly dry

the baby by wiping the eyes, face,
head, front and back, arms and legs.
Drying the baby’s body with a dry
warm towel stimulates breathing.
Drying often provides sufficient
stimulation for breathing to start in
mildly depressed newborn babies.

9 Do a quick check of newborn's

breathing while drying.
This checks if the baby is breathing
normally or if the baby is having
trouble breathing. If a baby is
breathing normally, both sides of the
chest will rise and fall equally at
around 30–60 times per minute.

Remove the first set of gloves

immediately prior to cord clamping.
 To prevent the contamination of the
umbilical cord with the soiled gloves

1 Clamp and cut the cord after cord

0 pulsations have stopped (typically at
1 to 3 minutes)
Delaying clamping lets blood
continue to flow from the placenta to
the newborn baby after delivery.

Put the cord clamp tightly around the

cord at 2 cm and 5 cm from the base
of the umbilical cord.
The clamp helps stop bleeding from
the blood vessels in the umbilical
cord.

1 An inch from the cord clamp, use a

1 straight forceps to clamp the cord
Forceps are used as a clamp to helps
stop bleeding from the blood vessels
in the umbilical cord

Cut the cord in between the cord

clamp and the straight forceps. *
 Cutting the cord detaches the baby
to the placenta. When the umbilical
cord is not clamped and cut right
after the baby is born, the baby gets
more of their own blood back into
their body which will result to low
iron levels at 4 to 6 months of life.

1 Place the newborn on mother’s chest

2 in skin-to-skin contact. Use clean
and dry sheets wiping the newborn.
Never remove the vernix caseosa.*
Placing the newborn on mother’s
chest in skin-to-skin contact creates
mother and child bonding. Skin-to-
skin contact also helps the baby's
body self-regulate, which stabilizes
the heartbeat and breathing patterns.
Using clean and dry sheets to wipe
the newborn prevents hypothermia.
Leaving the vernix on the baby’s
skin provides extra protection to the
baby.
Cover the head with bonnet. Provide
extra blankets to keep the baby
warm.*
This ensures the baby gets enough
warmth and prevent the occurence
of hypothermia.

Assess the APGAR score, auscultate

for the heart rate, observe for the
rhythm. Note for the respiration.*
Assessing APGAR score is essential
to know the condition of the newborn
infant immediately after birth

Observe the newborn. Only when the

newborn shows feeding cues (e.g.
opening of mouth, tonguing, licking,
and rooting).
These cues are essential to know if
the baby is ready for breastfeeding.

Make verbal suggestions to the

mother to encourage her newborn to
move toward the breast e.g. nudging.
Suggesting the mother to encourage
her newborn to move towards the
breast initiates breastfeeding.

Counsel on positioning and

attachment. When the baby is ready,
advise the mother to:

a. Make sure the newborn’s neck is

not flexed nor twisted.
To prevent twisted neck and other
injuries from happening. This is done
since the baby’s neck muscles are
not yet strong.

b. Make sure the newborn is facing

the breast, with the newborn’s nose
opposite her nipple and chin
touching the breast.
To prevent aspiration and to ensure
that the baby's mouth is latched on
properly to the mother’s breast.

c. Hold the newborn’s body close to

her body.
This is done to provide warmth and
promote mother-child bonding.

d. Support the newborn’s whole

body, not just the neck and
shoulders.
Supporting the whole body of the
newborn ensures proper positioning
and it will prevent injury and fall.

e. Wait until her newborn’s mouth is

opened wide.
Because this feeding cue signifies
that the baby is ready to breastfeed.

f. Move her newborn onto her breast,

aiming the infant’s lower lip well
below the nipple
The mother should encourage her
newborn to move toward the breast
to promote the attachment of the
newborn when breastfeeding.

Look for signs of good attachment

and suckling:

a. Mouth wide open

In order to suckle effectively, the
baby must open his/her mouth wide
in order to take enough of the breast
into his/her mouth

b. Lower lip turned outwards

This indicates that the baby is is
putting enough pressure on the milk
ducts for it to secrete the milk

c. Baby’s chin touching breast

This indicates that the baby is well
attached and can easily get the milk.

d. Suckling is slow, deep with some

pauses.
This method of suckling allows more
milk to flow into the lactiferous
sinuses/milk ducts.

. Continue the skin-to-skin contact

while on breastfeeding.
Engaging in skin-to-skin contact
while breastfeeding makes the baby
more calm and contributes to
strengthening the bond of the
mother and baby.

After a Complete Breastfeed

Weigh the baby and return the baby

on the mother’s abdomen to
continue the skin-to-skin contact
The baby should only be separated
from the mother if deemed
necessary and must return to skin-
to-skin contact with the mother
whenever possible.

Crede’s prophylaxis. Do eye care.

Administer gentamicin eye drops/
erythromycin or tetracycline
ointment. (Medication varies among
different institutions) or 2.5%
povidone-iodine drops to both eyes
after newborn has located breast.
To protect the newborn against
neonatal conjunctivitis caused by
Neisseria gonorrhoeae.

Give 0.1 mL (1 mg) Vitamin K

prophylaxis IM to right vastus
lateralis.
Newborns are at risk for vitamin K
deficiency bleeding (VKDB) caused
by inadequate prenatal storage and
deficiency of vitamin K in breast
milk. Injection of vitamin K at birth
effectively prevents VKDB.

Inject 0.5 mL Hepatitis B Vaccine IM

to left vastus lateralis.
This vaccine prevents the birth
mother from passing an infection
onto the neonate, which is known as
a perinatal infection.

Take Vital signs and measurements

and record:

a. Weight in kilograms
Weighing is considered to be
important in the assessment of
newborn's growth and hydration
status

b. Take temperature per rectum.

This method is accurate and gives a
quick reading of the newborn's
internal temperature.

c. Measure head circumference in

centimeters.
Head circumference accurately
reflects brain size and growth during
gestation, therefore, it may indicate a
potential problem if the values
deviate from the standard values.

d. Measure chest circumference in

centimeters.
To determine whether or not the
chest circumference of the neonate
is within the normal range, if
otherwise, then it may indicate a
problem.

e. Measure length in centimeters.

From sole/heel to calf to back to
neck to head.
This method of measurement
ensures the collection of accurate
data regarding the length of the
neonate. Also, measuring the length
of the neonate provides useful
information regarding the general
condition and has predictive value
for the final adult height.

Perform a quick, head to toe

assessment.
This is to detect potentially fatal or
disabling conditions in newborns as
early as possible.

Put on diapers; fold the top of the

diaper below stump. Keep cord
stump loosely covered with clean
clothes.
It is important that you keep the
umbilical cord stump so that it can
gradually dry and shrivel until it falls
off, 1 to 2 weeks after birth. Letting it
dry also helps prevent infection

Put identification tag on the ankle or

wrist.
To prevent misidentification errors
which may lead to: providing 2
vaccines to the same infant, wrong
infant being circumcised, and giving
the baby to the wrong mother.

Assist the mother in doing Kangaroo

Mother Care/ Skin-to-Skin Contact.
This form of care provides numerous
benefits, including regulating
heartbeat and temperature for the
baby and promoting feelings of calm
and wellbeing in both mother and
baby

a. Place the baby in upright position

between the mother’s breasts, chest
to chest
Holding your baby closely to your
chest is a special experience that
can help build the bond between you
and your baby.

b. Position the baby’s hips in a ‘frog-

leg’ position with the arms also
flexed.
A “frog” leg position is when a
baby’s hips are flexed and open out
to the side so that their inner leg is
resting on the mother’s chest.

c. Secure the baby in this position

with the support binder.
To keep the baby secured and to
ensure safety.

d. Turn the baby’s head to one side,

slightly extended
To keep the airway open and allow
eye contact with the mother
 e. Tie the cloth firmly
To help secure the baby’s position

Do health teaching breastfeeding,

include health teachings and stress
its importance.
Breastfeeding promotes
development of the infant's immune
system and meets the nutritional
needs of a full term infant until
approximately six months of age,
when complementary foods and
fluids are usually added to the diet

Termination Phase

4 Do after care of the equipment used.

1
To prepare the equipments for their
next use

4 Dispose soiled materials.

2
To prevent the contamination of
other materials
 Performed hand hygiene.
To prevent the spread of
microorganisms

4 Document date, time of delivery, sex

6 of the baby, condition at birth,
procedure done and reaction of the
baby.
To ensure accurate and timely
record of data.

4
7

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 LAMAZE Method

Reassess client's previous medical records if

available. This helps to identify the client’s health
status & actual or potential health problems or
needs

Determine the scope of assessment needed.

Prepares necessary equipment. To deliver specific
nursing interventions to meet those needs.

Perform hand washing and donned gloves (if

deemed necessary). To deter the spread of
microorganism

Introduce self and verify the client's identity. To

foster trust and develop rapport

Explain the procedure to the client. To encourage

cooperation throughout the procedure.

Position the patient on side lying or sitting and

provide privacy. To ensure safety and to restore
the patient's dignity.
First Stage of Labor: Place patient to side lying or
sitting position. allows the mother to assume a
comfortable position during labor

Cleansing Breathing:

Inform the patient that she should take a cleansing

breath at the beginning and end of each
contraction. Help the patient organize her
breathing pattern, and also provide focus during
contraction.

Demonstrate and allow the patient to follow by:

Taking in a long breath through her nose and

exhaling through her mouth. Concentrating on
breathing patterns or imagery or focusing can
block incoming pain sensations. This will also give
the baby an extra boost of oxygen.

Making the inhalation as long as exhalation. This

limits the possibility of hyperventilation (blowing
off too much carbon dioxide) or hypoventilation
(not exhaling enough carbon dioxide), both of
which could happen with rapid breathing patterns
and can interfere with an adequate fetal oxygen
supply.

Slow-paced Breathing: to take an organizing

breath to prepare the client for the contraction.

Inform the patient that she should perform this

during early labor when contractions are mild.
However, the patient should use this method for
as long as possible, even during the active and
transition phases of labor, or until it’s no longer
effective.. The cleansing breath also signals to the
woman’s partner a contraction is about to begin or
has ended.

Demonstrate and allow the patient to follow by:

Taking a cleansing breath when the contraction

begins. It limits the possibility of either
hyperventilation or hypoventilation.

Continuing to breathe very slowly and deeply

during the contraction, directing breaths into the
uterus by guided imagery, with a pace that’s one-
half as fast as a normal breathing pattern. It helps
the patient stay centered and process everything
that's happening.

Taking another cleansing breath when the

contraction ends. To prevent hyperventilation or
hypoventilation

Visualizing something relaxing during this

process. Promotes comfort to the patient and
helps reduce pain during labor as it can block
incoming pain sensations.

Modified-paced breathing:

Inform the patient that she should perform this

when slow-paced breathing is no longer effective
and the patient can’t stay “on top of” of
contractions. This is shorter, lighter breath that to
reduce the stress chemicals your brain produces
and facilitate a relaxation response

Demonstrate and allow the patient of follow by:

Taking a cleansing breath Prevents possibility of

hyperventilation or hypoventilation by breathing in
and exhaling deeply.
Breathing with the contraction’s intensity by
starting out using slow-paced breathing; as the
intensity peaks, transition into modified-paced
breathing that is twice as fast as the patient’s
normal breathing, similar to the breathing pattern
used when running a race. This helps the patient
relax and reduce pain from the contractions

Focusing breathing on expanding the lungs. Helps

to further relax the patient

Taking another cleansing breath when the

contraction ends. To prevent possibility of
hypertension or hypotension after contractions

Pattern-paced breathing:

Inform the patient that she should perform this to

prevent hyperventilation and to decrease the sick
of the patient inadvertently pushing before her
cervix is ready. It provides distraction as well as
prevents the diaphragm from descending fully and
putting pressure on the expanding uterus.

Demonstrate and allow the patient of follow by:

Taking a cleansing breath at the start of the
contraction. Prevents possibility of hypotension or
hypertension

Breathing according to this pattern; inhale, exhale,

inhale, blow forcefully from pursed lips. It is used
when the patient is transitioning to the second
stage of labor if the patient is feeling overwhelmed
or exhausted.

Repeating the sequence until the contraction

ends. For the patient to have sufficient breathing

Taking a cleansing breath and relax until the next

contraction begins. It avoids the possibility of
hypotension or hypertension

Repeating the blowing using short puffs of air if

the patient feels the urge to push at the height of
the contraction, which essentially causes her to
pant, and then restart the original pattern of
inhaling, exhaling, inhaling, and blowing forcefully
when the pushing urge has subsided.

Second Stage of Labor:

Breathing techniques for pushing and delivery of
the fetus:

Inform the patient that she should perform while

the patient is pushing. If the patient is sleeping,
you’ll need to awaken her at the start of the
contraction and encourage and assist her into the
pushing position. You may need to be firm or
insistent to ensure that the patient is in a position
for pushing before the contraction becomes too
intense.

Demonstrate and allow patient to follow by taking

the following steps:

Assisting the patient into a position for pushing.

Examples of the position are squatting,sitting
upright, leaning on a partner, but should always be
cautioned not to actually bear down and push.

Instructing the patient to take a cleansing breath.

Help the patient organize her breathing pattern,
and also provide focus during contraction.
 When the patient experiences the urge to push,
encourage her to bear down for as long as she
can, using open-glottis pushing (exhaling as she
pushes). This is to prolonged exhalation
contracting the abdominal muscles (pulling the
stomach in) to help move the fetus down the birth
canal

Discourage the patient from holding her breath for

more than 8 seconds and for more than four
pushes per contraction. Encourage the patient to
determine what feels natural for her. This is to
make the patient feel comfortable during labour.
And holding the breath is discouraged for a
prolonged time because it impairs blood return
from the vena cava.

Inform the patient of the contraction’s increment,

acme, and decrement. These contractions cause
the upper part of the uterus (fundus) to tighten and
thicken while the cervix and lower portion of the
uterus stretch and relax, helping the baby pass
from inside the uterus and into the birth canal for
delivery.

When the contraction ends, instruct the patient to

take a cleansing breath.This will help the patient to
stay centered and process everything that's
happening.

Offer to place a cool cloth on the patient’s

forehead or neck between contractions. Then, put
the cloth into a basin of ice water to cool for the
next rest period between contractions. A cool
cloth to wipe perspiration from the forehead, neck,
and chest can keep a woman from feeling
overheated.

Encourage the patient to relax and rest between

contractions (which may be only a 1-minute
interval). Consciously relaxing between
contractions makes the breaks more restful.

When the next contraction begins, repeat the

previous steps, continuing until delivery (usually
occurring within 60 minutes). Provide a patient
with sufficient breathing as she starts pushing the
baby out.

Provide encouragement during labor, and refrain

the patient on the use of breathing techniques
during labor as needed. Encouragement helps a
patient to be strong. Holding the breath is
discouraged for a prolonged time because it
impairs blood return from the vena cava.

Perform hand hygiene. Hand hygiene prevents the

risk of possible spread of microorganisms.

Document the procedure. Documentation ensures

ongoing data collection and coordination of care.

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