DELIVERY ROOM STUDENT

NURSE RESPONSIBILITIES
@SNURSES_NOTES
 VITAL SIGNS CHART (ADULTS)
NORMAL ABNORMAL
TEMPERATURE AXILLARY - 36.4 <36.4 HYPOTHERMIA

60-100 BEATS PER < 60 BPM = BRADYCARDIA

PULSE RATE MINUTE (BPM) > 100 BPM = TACHYCARDIA

12-20 BEATS PER < 12 = BRADYPNEA

RESPIRATORY RATE MINUTE (BPM) > 20 = TACHYPNEA

< 90/60 = HYPOTENSION

BLOOD PRESSURE 120/80 mmHg
>130/90 = HYPERTENSIVE

OXYGEN SATURATION 95-100 % <95 % = HYPOXEMIA

 SIGNS OF PREGNANCY
1. PRESUMPTIVE
LARGELY SUBJECTIVE IN NATURE IN NATURE THAT SUGGEST BUT DO NOT
CONFIRM A PREGNANCY IS PRESENT

2. PROBABLE
LARGELY OBJECTIVE IN NATURE THAT SUGGEST BUT DO NOT CONFIRM A
PREGNANCY IS PRESENT.

3. POSITIVE
FINDINGS THAT DEFINITELY INDICATE A PREGNANCY IS PRESENT
 PRESUMPTIVE SIGNS
Amenorrhea
Breast changes
Nausea , Vomiting
Frequent urination
Fatigue
Linea nigra
Melasma
Striae gravidarum
Quickening
 PROBABLE SIGNS
Laboratory Tests: Serum , Urine
Chadwick's Sign: Color change of the vagina from pink to
violet
Goodell's Sign: Softening of the cervix
Ballottement: When lower uterine segment is tapped on
bimanual examination , the fetus can be felt to rise against
abdominal wall.
Hegar's Sign: Softening of the lower uterine segment
Braxton Hicks Contraction: Periodic Uterine Tightening occurs
Evidence of gestational sac on ultrasound
Palpation of fetal outline
 POSITIVE SIGNS
Fetal outline on ultrasound
Audible Heart Sound
Fetal movement felt by examiner
 TERMS RELATED TO PREGNANCY STATUS
Gravida/ Gravidity - Number of times a woman is or has been pregnant
Para/Parity - Number of births where pregnancies hav pregnancies have
reached age of viability (including live births & still births)
Primigravida - Woman who is pregnant for the first time
Multigravida - Woman who has been pregnant more than once
Nulligravida - Woman who has never been and is not currently
pregnant
Primipara - Woman who has given birth to one child past age of viability
Multipara - Woman who has given birth to more than one child past the
age of viability
 OBSTETRIC SCORING
GTPAL
Gravida = Present pregnancy
Term = Number of full term infants born (infants born at 37
weeks or after)
Preterm = Number of preterm infants born ( Infants born before
37 weeks)
Abortion = Number of spontaneous miscarriages or therapeutic
abortion
Living = Number of living children
 NAEGELE'S RULE
EDD (ESTIMATED DATE OF DELIVERY)
LMP minus 3 months , +7 days , + 1 year

Example:
LMP: 09/01/2022
-3 +7 +1
EDD: 6/8/ 2023

ALWAYS REMEMBER!
use + 9 + 7 ( JANUARY-MARCH)
use -3 +7 +1 (APRIL - DECEMBER)
 CALCULATING AGE OF GESTATION BY LMP
LMP :May 25,2022
Current Date: October 6 , 2022

Take the remaining days of May (31 days - 25) = 6

May 6
June 30
July 31
August 31
September 30
October 6 (current date)
137 ÷ 7 (constant = 19 1/7 weeks AOG
 STAGES OF LABOR
First Stage: begins with the initiation of true labor contractions
and ends when the cervix is fully dilated.
Second Stage: extending from the time of full dilatation until the
infant is born
Third or placental stage: lasting from the time the infant is
born until after the delivery of the placenta

The first 1 to 4 hours after birth of the placenta is sometimes termed

the “fourth stage” to emphasize the importance of close maternal
observation needed at this time
 LABOR ROOM RESPONSIBILITIES
LABOR MONITORING
Monitor Uterine Contractions
✔Duration - Start to end of the contraction
✔Frequency - Start of the contraction to the next contraction
✔Interval - End of the contraction to the beginning of the next contraction
✔Intensity - MILD , MODERATE , STRONG

Secure patient's safety while on CTG (Cardiotocography)

Asses progress of labor (rupture of BOW , cervical dilatation ,
effacement & degree of descent of the fetal head)
Obtain Patient's Data/Information
✔ Vital signs ( T, P, R , BP)
✔Obtain Fetal Heart Beat
 LABOR ROOM RESPONSIBILITIES
Obtain Patient's Data/Information
Patient's Identity
Determine OB HISTORY ( GTPAL , LMP AOG)
(GRAVIDA , PARA)
G = GRAVIDA
LMP = LAST MENSTRUAL PERIOD
T = TERM
AOG = AGE OF GESTATION
P = PRE TERM
A = ABORTION
L = LIVING
 LABOR ROOM RESPONSIBILITIES
Perform Leopold's Maneuver
Locate Fetal Heart Beat
Presentation
Position
Degree of Descent
 LABOR ROOM RESPONSIBILITIES
Secure articles needed by the patient (MOTHER)
✔ Adult diaper
✔ Maternity napkin
✔ Underwear
Secure articles needed by the patient (NEWBORN)
✔ Baby cloth ("lampin)
✔ Baby clothing/layette
✔Newborn diaper
✔Cord clip
✔Bonnet
 LABOR ROOM RESPONSIBILITIES
Assist in internal examination (IE) as necessary.
Perform straight catheterization as necessary.
Change patient diaper as necessary.
Secure patient's comfort and hygiene.
Study patient's case (Complications , special
procedures , medication given)
 RESPONSIBILITIES IN THE DELIVERY ROOM
HANDLE
Assist patient to be transported to the DR
Position patient in lithotomy on the DR table
Perform hand hygiene
Perform perineal flushing/preparation
Don gloves
Prepare/arrange instruments/DR pack
Perform Straight catheterization
Drape patient aseptically
 RESPONSIBILITIES IN THE DELIVERY ROOM
HANDLE
Instruct patient proper breathing technique (baring down or
correct pushing technique)
Perform/assist in Ritgen's maneuver during crowning
Assist in episiotomy as necessary
Deliver the newborn's head , shoulders and the rest of the
the body safely
Place the newborn on mother's abdomen , initiate skin to
skin contact & breast feeding ( latching on)
Assist in the cutting of the cord
 RESPONSIBILITIES IN THE DELIVERY ROOM
HANDLE
Wait for the sign of placental expulsion
Identify the signs of placental separation
✔ Lengthening of the cord
✔Sudden gush of vaginal blood
✔ Change in shape of the uterus
✔Firm contraction of the uterus
✔ Appearance of the placenta at the vaginal opening
Deliver the placenta; examine completeness of cotyledons
 RESPONSIBILITIES IN THE DELIVERY ROOM
HANDLE
Identify mechanism of placental separation (2)
✔Schultz - "Shiny" , clean & fetal membrane comes out first ,
separates from the center
✔ Duncan - "Dirty" , red , irregular
÷
with ridges of cotyledons and
maternal side comes out first ; separates from the sides.
Assess the amount of blood loss ( NORMAL BLOOD LOSS
= 300- 500 ML )
Assist in the evacuation of blood clots , massage uterus
over the fundus
 RESPONSIBILITIES IN THE DELIVERY ROOM
HANDLE
Identify mechanism of placental separation (2)
✔Schultz - "Shiny" , clean & fetal membrane comes out first ,
separates from the center
✔ Duncan - "Dirty" , red , irregular
÷
with ridges of cotyledons and
maternal side comes out first ; separates from the sides.
Assess the amount of blood loss ( NORMAL BLOOD LOSS
= 300- 500 ML )
Assist in the evacuation of blood clots , massage uterus
over the fundus
 RESPONSIBILITIES IN THE DELIVERY ROOM
HANDLE
Assist physician in episiorraphy or suturing of perineal
laceration as needed
✔ Prepare suturing equipment
✔Attached suture to the needle holder
✔Prepare Lidocaine 2% (Anesthesia)
AFTERCARE RESPONSIBILITIES
Clean the perineum thoroughly and apply betadine to
episiorrhaphy
Dispose sharps and placenta to respective receptacle
Wash used instruments at the aftercare area
 RESPONSIBILITIES IN THE DELIVERY ROOM
ASSIST
Assist patient to be transported to the DR
Position patient in lithotomy on the DR table
Take note of the time of mounting on the DR table
Assist in perineal flushing/preparation
Assist in catheterization
Coach patient on proper beathing and pushing
technique (health teaching)
Stimulate uterine contraction ( massage fundus
gently ; nipple stimulation)
 RESPONSIBILITIES IN THE DELIVERY ROOM
ASSIST
Take note of the time of the rupture of the
membrane (Bag of Water)
Identify and assist in the mechanism of labor
(Cardinal signs of labor) to deliver the newborn:
Descent
Flexion
Internal Rotation
Extension
External rotation
Expulsion
 RESPONSIBILITIES IN THE DELIVERY ROOM
ASSIST
Take note of the time of the expulsion of newborn
Announce the newborn's delivery , the gender and
the time " Baby out , baby girl , 10:23 am"
Record the time of delivery , and gender of the baby
Prepare the oxytocin injection
Wait for the sign of placental expulsion
 RESPONSIBILITIES IN THE DELIVERY ROOM
ASSIST
Identify the signs of placental separation
✔ Lengthening of the cord
✔Sudden gush of vaginal blood
✔ Change in shape of the uterus
✔Firm contraction of the uterus
✔ Appearance of the placenta at the vaginal opening
Take note of the time of the expulsion of placenta (record
mechanism)
Take and record the blood pressure of the patient (may
announce)
 RESPONSIBILITIES IN THE DELIVERY ROOM
ASSIS T
Inject oxytocin IM or incorporate to the patient's IVF (if with
IVF more than 500 cc)
Label IVF properly if incorporation of oxytocin is done
Record the NEWBORN'S DATA/ANTHROPOMETRIC
DATA:
✔ Weight
✔Head Circumference
✔Chest Circumference
✔Abdominal Circumference
✔Length/Height
Prepare the newborn's identification band/anklet
 RESPONSIBILITIES IN THE DELIVERY ROOM
ASSI
Prepare suturing equipment
ST
✔5 cc syringe with needle
✔Lidocaine 2% (Anesthesia)
✔Suture (Chromic 2/0)
✔Needle holder
✔Tissue forceps with teeth (optional)
Serve the Lidocaine to the handling student nurse
Prepare/apply maternity napkin
Health teaching
Proper hygiene
Post partum checkup
 RESPONSIBILITIES IN THE DELIVERY ROOM
CORD CARE
Bring all baby's equipment/articles along with the mother
inside the delivery room.
Prepare all the needed articles at the newborn care
area/table.
ARTICLES TO PREPARE:
✔ Baby's cloth (Lampin)
✔ Baby's diaper & clothes )
✔ Baby's bonner , mittens , socks
✔ Tape measure
✔ Gauze (Operative Sponge)
✔ Vitamin K Injection (tuberculin syringe)
 RESPONSIBILITIES IN THE DELIVERY ROOM
ARTICLES TO PREPARE:
CORD CARE
✔ Hepatitis B Vaccine (tuberculin syringe)
✔Erythromycin Ophthalmic Ointment (Crede's Prophylaxis)
✔Cotton balls with alcohol , dry cotton balls , cotton balls with
sterile water
✔Baby's identification band/anklet
✔Rectal thermometer & /or NGT tubings
Perform hand hygiene
Don gloves (Double gloving)
Dry the newborn thoroughly (remove secretions from the
mouth)
Keep the newborn on side lying position on mother's abdomen
 RESPONSIBILITIES IN THE DELIVERY ROOM
CORD CARE
Observe the newborn carefully while performing the
procedure
Perform a thorough assessment
APGAR SCORING -assessment of the newborns well
being/health status
✔ 1st minute of life
✔After 5 minutes
✔After 10 minutes
Observe for any signs of congenital abnormalitiy/deformity
 APGAR SCORING
SCORE 0 POINTS 1 POINT 2 POINTS
APPERANCE cyanotic /pale all Peripheral cyanosis Pink
(SKIN COLOR over only

PULSE 0 <100 100-140

(HEART RATE)
GRIMACE
No response to Grimace or weak cry
(REFLEX Cry when stimulated
stimulation when stimulated
IRRITABILITY

Floppy Some flexion Well flexed &

ACTIVITY (TONE)
resisting extension
Slow, irregular
RESPIRATION Apneic Strong cry
breathing
 RESPONSIBILITIES IN THE DELIVERY ROOM
CORD CARE
Initiate skin to skin contact ( 30 minutes)
INITIATE
Keep the newborn warm by covering with
KEEP the dry sterile towel

FEEL Feel the pulsation of the umbilical cord

Clamp and cut the cord only when the

CLAMP & CUT pulsation on the umbilical cord stops
 RESPONSIBILITIES IN THE DELIVERY ROOM
CORD CARE
WEIGH Weigh the newborn

Measure the head, chest , abdominal circumference and length

MEASURE
PUT ON Put on baby's bonnet and clothes

APPLY Apply crede's prophylaxis from inner to the outher canthus of

the newborn's eyes
CHECK Check temperature per rectum/check patency of the anus

APPLY Apply baby's diaper

INJECT Inject Vitamin K and Hepa B vaccine to separate thighs