Nursing Management

During Child Birth UNIT 6 SETTING UP OF A DELIVERY

Process
TROLLEY AND ARTICLES FOR
IMMEDIATE CARE OF NEWBORN
Structure
6.0 Objectives
6.1 Introduction
6.2 Review of Aseptic Techniques and Practices
6.3 Conducting Delivery — Articles Required
6.3.1 Normal Delivery
6.3.2 Normal Delivery with Espisiotomy
6.3.3 Instrumental Deliveries
6.4 Analgesia and Anesthesia
6.5 Immediate Care of Newborn
6.5.1 Articles Required for Receiving the Newborn
6.5.2 Articles Required for Immediate Care of Newborn
6.5.3 Essential Supplies and Equipments for Resuscitation of Newborn
6.6 Emergency Equipment as Precautionary Measures in Labour Room (Birthing Room)
6.7 Let Us Sum Up
6.8 Activity

6.0 OBJECTIVES
After completion of this unit, you will be able to :

· review the principles of medical and surgical asepsis and critically analyze the aseptic;
practices carried out in a labour room of a maternity hospital/block of a hospital;
· assemble the necessary articles and drugs for conducting a normal delivery;
· appreciate the system of setting up of a Delivery trolley for conducting a normal
delivery;
· differentiate between the articles required for a normal delivery and operative procedures
in a labour room;
· develop skills in setting up of conducting normal delivery with episiotomy,
forceps delivery and vacuum extraction; and
· identify the essential articles required for immediate care of the newborn soon
after delivery.

6.1 INTRODUCTION
In the theory Block, you have reviewed your knowledge on physiology and
management of different stages of labour and delivery for which you are required to
strengthen your skills to participate actively in keeping the labour room or birthing
room ready for receiving the mothers in labour and also to take part actively in seeing
that they deliver normally, safely giving birth to a normal, alive and active child
without entering into any kind of complications. Labour and delivery are always
considered to be as emergency conditions and the midwife is expected to be careful
and alert in almost all the activities which help the mothers to have a normal and safe
child birth process.

In your other courses, while practicing basic nursing techniques you might have had
the opportunities to handle various types of equipment and supplies. The procedures
while rendering care might have been involved with assembling articles in a systematic
way and setting up of trays or trolleys especially in surgical wards and operation
theaters. In medical wards you might have observed trolleys, being used for
emergency resuscitative procedures like defibrillation, cardiac monitoring or cardio
16 pulmonary resuscitation with different types of articles and equipment.
The basic principles of microbiology in setting up of trolleys or trays might have been Setting up of a Delivery
studied and practised in fundamentals of nursing. Trolley and Articles for
Immediate Care of
The technique of packing and handling of sterile supplies have to be revised throughout Newborn
the nursing practice as it is a part and parcel of those measures which have to be kept
in mind for prevention of infection, in other words we call them as aseptic practices.

Before setting up a trolley or a tray for conducting delivery in a labour room, a

midwife is expected to review the details of aseptic and antiseptic procedures.

A single article missing in the trolley or tray may complicate the delivery process or
may cause danger to the life of the baby. A thorough knowledge of all the
requirements necessary for conducting a normal and safe delivery is a vital component
of the management of a normal delivery.

After studying this unit, you will be able to set up trolley for conducting normal
delivery.

6.2 REVIEW OF ASEPTIC TECHNIQUES AND

PRACTICES
To become a midwife, the basic requirement is to have knowledge and skills of basic
nursing and a certain amount of knowledge about medical surgical conditions and
pediatric nursing. You are expected to know the microbiology aspects of wound and
its healing. In this connection you have learnt about surgical dressing, suturing
techniques, antiseptics used for dressing and about different suturing material.

The knowledge will be able to help the midwife to perform procedures in a labour
room without causing harm to any one especially in terms of causing and spreading
infection. This is all the more true in HIV patients have the practical of universal
precautions must be enforced for all the deliveries.

The medical asepsis is concerned with keeping everything or anything clean but a
surgical asepsis does need sterile area, sterile articles and precautions or techniques to
see that the sterile condition is maintained as ‘sterile’ without contamination.

The equipment and supplies which come in contact with the mother in labour
especially near the vaginal outlet during the process of child birth, the articles and
supplies handled by midwife for child birth need to be free from contamination, in
other words they are to be perfectly ‘sterile’.

Similarly the articles which are used for receiving and caring the newborn are to be
sterile.

It is really a challenging experience for a midwife to see that there is no chance for
any contamination to the articles used by midwife/obstetrician for conducting delivery
and for the immediate care of newborn.

It is not only the delivery trolley, which needs to be taken a special care but all the
articles necessary for emergency such as Boyle’s apparatus, Oxygen Cylinders, Suction
apparatus and their accessories, sterilizers and other articles used for instrumental
deliveries such as obstetric forceps, Vacuum extractor (Ventouse) etc. need extra
attention for keeping them clean and sterile.

The bed pan which is offered repeatedly needs extra care to keep it clean.

The above details are a reminder to a midwife to be extremely sensitive and careful
regarding prevention of infection.

The labour room where mothers and babies are received and cared for and where there
are cupboards, trays, containers, stainless steel drums etc. needs to be kept clean and
the walls and floors need concurrent and terminal disinfection. A busy labour room
where there are continuous deliveries taking place, cannot be kept as clean as it is
17
Nursing Management expected to be. The quick turn over due to mothers entering for and leaving after
During Child Birth delivery, constantly moving health care personnel and other workers in the labour room
Process make the labour room a favorable medium for contamination and infection.

The mother and the newborn are vulnerable to infection in a labour room.

Women’s chances of getting infection when she is in labour are increased because of
show (bloody discharge) and early rupture of membranes. There is a possibility of
contamination of vaginal outlet with faeces etc.

The delivery process which needs articles are supplied; care during and after
conducting the delivery need to observe strict aseptic precautions.

The articles and supplies used for delivery are to be sterile and utmost care has to be
taken that they are handled with sterile articles, e.g., sterile gloved hands, sterile lifting
forceps etc. The solutions used to clean the perineum and vulva of mother need to be
sterile and fresh. The linen that comes in contact with mother, near and surrounding
the birth passage need to be sterile.

Baby’s resuscitating unit has to fulfill the same requirement. The articles used for
oropharyngeal suction; cleaning the eyes and cord; cord ligatures, are to be sterile and
thermometer should be properly disinfected. The linen should be warm and perfectly
clean. If possible, the first sheet/towel used to receive the baby immediately after birth
should be sterile. The labour room as it is described above does have varieties of
articles and supplies. Some are always used, for e.g., delivery trays/trolleys, antiseptic
solutions, gloves, gowns, masks etc.; and some may be used sometimes for e.g.,
obstetric forceps etc. Some articles are used rarely such as instruments used for
destructive operations, Boyle’s appratus etc. Whatever the usage it could be, they are
always to be kept sterile for any kind of emergency.

There are articles which are commonly used and some are used whenever the need arises
(e.g. vacuum, forceps etc.) and a few are rarely used such as Boyle’s apparatus etc.

The physical set up labour room plays an important role in setting up of trolley and
other articles. This is also an important part of labour room administration

Labour room as any other operation theatre should have easily washable walls and
floors and the bathrooms and toilets should be non-slippery. Labour rooms should
have fly proof window shutters and a good lighting system and ventilation and the
space in between beds/tables should permit free movements and placement of trolleys.
There should be enough place for the assistant to stand to assist the midwife while the
midwife is conducting the delivery. There are other articles required apart from
Delivery trolley.

The following are a sort of review of those articles:

The labour room should have:

· Gowns — (as per the hospital policies, the colour is selected)

· Masks — Adequate to protect from infection

· Head covers — caps (turbans) as per the policies

· Slippers for using in labour room only (washable type)

· Furniture — Sufficiently placed for health care personnel to sit and do their
work and to relax in between the relative/attendants should have facilities to
relax with comfortable furniture
· Telephone and paging system for appropriate communication

· Refrigerators for storing drugs and specimens

· Portable extra spot lights

18 · Adequate water supply

· Drinking water facilities Setting up of a Delivery
Trolley and Articles for
· Resting rooms for doctors, midwives and other workers within the reach of the Immediate Care of
labour room Newborn

· Recovery room and a first stage room for mothers and their attendants
· Cupboards sufficiently available for stationery, linen, drugs and equipment.
· Emergency drug cupboard/try
· All the necessary records and reports in relation to labour and new born.

The description of the labour room in relation to its location, rooms, etc. (floor plan) is
not elaborated here as this may be studied in details as a part of special department or
nursing administration.

6.3 CONDUCTING DELIVERY — ARTICLES REQUIRED

You will learn in this subsection about labour room and its requirements to provide a
base to understand the method/technique of setting up a tray or trolley for conducting
normal as well as instrumental deliveries.

The following paragraphs elaborate the requirements for setting up of a trolley for
different kinds of deliveries commonly seen in labour rooms. The labour may be
conducted on a table or bed in different positions (discussed in the next unit). The
labour room practices may differ in using a tray or trolley for conducting the delivery.
Similarly methods of receiving the baby soon after delivery may also differ. In some
labour rooms, the baby is received in a tray lined with sterile warm linen after cutting
the cord.

6.3.1 Normal Delivery

The below mentioned articles are sterile in a hospital situation but for a home delivery
sterile linen may be replaced with clean ones in emergencies. A hospital usually has a
central sterile supply department which looks after supplying sterile packs of
instruments, linen, glassware and rubber goods required for labour room.

Sterile Articles

i) Delivery pack with:

· Cap – (usage depends on hospital policies and it may be clean or sterile)
· Mask (same as for cap) but ideal pack should have one
· Gown with full sleeves (as in Operation theatre)
· Gloves – 1 pair
ii) Linen Pack with:
· Abdominal sheet – 80 to 90 cms × 90 cms
· Perineal sheet – Same as above sheet with a hole sufficient to deliver the baby
and placenta
· Leggings – 1 Pair to cover till the level of mid thigh
· Sheet – for receiving the baby 90 cms × 90 cms
· Sheet – to spread on the edge of the table – same measurements
iii) Equipment
a) Bowls — 2
· One with cotton swabs – 20
· Another for antiseptic solution used for cleaning (e.g. Dettol 1:60 or clorhexidine
1 : 2000) 19
Nursing Management b) Sponge holding forceps – 2
During Child Birth
Process · For cleaning the birth passage
c) Towel clips – 4 to 6
· To keep the linen in position after draping
d) Kidney tray – Big size to receive the placenta and membranes (a tray 15 cms x 15
cms is also used)
e) Artery forceps – straight – 2
· For clamping the cord
f) Dissecting forceps (non toothed)
To use as a liftings forceps to pick up sterile cotton etc.
g) Syringe – 5 ml
· Needle – G.21 to 22
· For administering ergometrine/to mothers
h) Scissors – to cut the cord
i) Perineal pads – 2
Proportionately bigger and thicker in size.
· One is used for protecting the perineum during head delivery.

· Another one is used after cleaning the perineum after delivery (in 4th stage)
Other articles are optional in the delivery set. They are:
a) A soft rubber catheter and a jug
— To receive urine if catheterization is necessary
b) An aminiotomy forceps to rupture the membranes
i) Kochers forceps – 1 (Kochers forceps is used in Indian hospitals as an usual
practice.)
ii) Goodwins Amniotomy forceps – 1

6.3.2 Normal Delivery with Episiotomy

The delivery trolley for conducting normal delivery is set ready. In addition to this, an
extra tray or a pack is used for performing episiotomy and suturing.

The trolley set for normal or instrumental deliveries should have enough place to keep
on the top shelf:
· Delivery pack
· Linen pack
· Delivery set
· Episiotomy and suturing tray
The bottom shelf should have clean articles and supplies such as:

· A bucket to receive body fluids and liquid waste during the process of child
birth.

· Rubber sheet or ideally a doube layered ‘trough’ (similar to Kelly pad used for
hair wash) to protect the labour table and to drain the fluids directly into the
bucket. On this, perineal sheet is draped. After each delivery, the rubber article
used should be cleaned throughly under running water and cleaned with
disinfectant (1 : 60 Dettol or chlorhexidine – 1 to 2%).

· Clean cotton and bandages (if place is there on top, they can be placed in a
corner in a clean try)
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In some labour rooms because of limited space, instead of trolley a big tray is used Setting up of a Delivery
only with required articles for delivery. The delivery pack and other linen are kept in Trolley and Articles for
a separate tray. Immediate Care of
Newborn
The labour room to manage the deliveries normally also need the following facilities :

1) Handwashing facilities:
· An elbow operating tap
· Wide wash basin
· Nail brush
· Soap/bottle of antiseptic solution
· Clean towel on a towel stand/electric hand dryer
2) Masks and caps in a covered container for those who enter the delivery room.
3) Slippers, (assorted sizes) in a rack at the entrance to be used by them who enter the
delivery room.
4) Weighing scale (for mothers)
5) Temperature tray (with oral thermometers; cotton swabs; disinfectant solution in a
container and kidney tray).
6) Foetoscope
7) B.P. apparatus (Spyghmomanometer)
8) Stethoscope
9) Articles for urine testing – for sugar, albumin and ketone bodies
10) Sterile articles in different sterile drums:
· Gowns
· Gloves
· Cotton swabs
· Gauze pieces
· Perineal pads

11) Sterile Trays with

Sterile sharp instruments such as :
· Surgical blades
· Scissors and
Instruments like obstetric forceps, cups and tubings of vaccum extractor, foetal
scalp electrodes, metal catheters, amniotomy forceps
· Rubber catheters and tubings
· Catgut and other suturing material
· Scissors (assorted sizes)
· Needles (1/M, I/V, pudendal block)
12) Sterilizer in a separate room to boil the articles if needed (if there is no
provision for adequate suply or in emergencies)

13) Antiseptics and disinfectants – Dettol, Savlon, Chlorhexidene, Cidex etc.

14) Sterile complete set of enema can with connections – tubings, catheters, clamps

15) Stools – Revolving type for adjusting the height to be used by midwife/
obstetrician helping herself/himself to make comfortable for suturing after
episiotomy or for waiting in between during delivery to watch the progressive
signs.

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Nursing Management 6.3.3 Instrumental Deliveries
During Child Birth
Process
Till now you have learnt about the setting up of trolley for conducting normal delivery.
Now you will learn about articles required for forceps delivery.

Articles Required for Forceps Delivery :

The trolley on the upper shelf should have :

· Delivery pack
· Linen pack
· Episiotomy and perineal suturing tray
· Articles necessary for cleaning and for conducting delivery
· If necessary a 15 cm needle for pudendal block is added into the episiotomy tray
with the help of lifting forceps.
· Obstetric forceps
— midcavity forceps with Axistraction devices
— outlet forceps – Wrigley’s forceps
· The baby’s unit with necessary resuscitation equipment

Articles for Vacuum Extraction

The articles of :

· Normal delivery
· Episiotomy and suturing
· Vacuum extractor is used which need sterile cups of different sizes and tubing
to fix/attach with the apparatus
solution apparatus
· Obstetric forceps should also be kept for emergency
Rest of the articles for conducting delivery and baby are same.

The obstetrician needs extra spot lights to have proper observations and a stool of the
desired height to sit for applying forceps or ventouse.

Woman in labour require drugs and sometimes they are in need of getting anesthesia
and analgesia. In this practical you are provided with details in brief about analgesia
and anesthesia.

6.4 ANALGESIA AND ANESTHESIA

In this section you will learn about analgesia and anesthesia. As you know analgesia
and anesthesia is very important drug during delivery. The delivery room should also
be equipped with necessary drugs for providing relief from pain and sedation and the
necessary equipment to administer these drugs are to be kept inside the labour room in
working condition.

In order to show the significance of these drugs and equipment, this section has
included a few details as a part of management of normal delivery.

The below mentioned list is a kind of review to help the midwife to keep necessary
drugs etc. along with delivery trolley.

Natural child birth tries to avoid administration of drugs till delivery except
syntometrine or ergometrine which is given to control bleeding soon after delivery.
The antenatal care and relaxation exercises aim to avoid the interference with drugs
and permits natural process of child birth.
22
Necessary Drugs and Articles Setting up of a Delivery
Trolley and Articles for
The drugs used for pain relief are: Immediate Care of
Newborn
1) Sedatives and tranquilizers e.g. Nitrazepam, Chlorpromazine, Promazine etc.
2) Hypnotics – Barbiturates etc.
3) Narcotics – Pethedine, morphine etc.

The antagonists to sedative analgesics and hypnotic drugs are:

1) Nalorphine
2) Amiphenzole
3) Levallorphan etc.

Nalorphine and Amiphenazole are administered through umbilical vein of the newborn
immediately after birth if mother has received sedative analgesics and hypnotic within
3 to 4 hours before delivery or according to the condition of the newborn soon after
birth.

Inhalation analgesias such as:

· Trichlorethylene (Trilene)
· Methoxy flurane (penthrane)
· Nitrous oxide with air

To administer these agents commonly used equipment are:

· Emotril and tecota inhalers
· Cyprane inhaler
Some other agents such as:
· Nitrous oxide and oxygen
· Ether
· Chloroform
· Thiopentone Sodium (Pentothal Sodium) are made available for emergencies.

You are requested to study the details of using these drugs, and other methods of
regional analgesia in obstetrics.

The midwife is responsible to check the expiry dates of all the agents and functioning
condition of all the equipments in labour room.

Till now you have studied about articles required for conducting normal as well as
instrumental deliveries in the labour room.

Care of the newborn as it is a vital aspect of Obstetric management, you are expected
to keep the necessary articles before delivery for sending immediate care to newborns.

This practical prepares you with the skills to keep the unit ready with necessary articles
for immediate resuscitation of newborn babies.

6.5 IMMEDIATE CARE OF NEWBORN

In this section you will learn about immediate care of newborn and articles required
soon after delivery.

6.5.1 Articles Required for Receiving the Newborn

Following articles are needed to receive the nowborn.

· A sterile warm sheet 90 cms × 90 cms (36" × 36")
23
Nursing Management · Artery forceps – 2, to clamp the cord
During Child Birth
Process · Cord scissors

At present the practical is to immediately show the newborn to the mother and taken
to the baby’s unit to keep the baby clean and warm and to clear the air passages.

Baby is cleaned and kept warm and taken care of with the help of following articles. The
articles listed below are for:
· Identification
· Cord ligation
· Assessment for abnormalities
· Prevention of immediate complications
· Resuscitation

6.5.2 Articles Required for Immediate Care of Newborn

· For identification – Wrist name tapes

· To obtain foot prints necessary stamped and ink

· Cord ligation – ligatures or clamps in a sterile covered containers. Rubber

bands are used in many labour rooms as it remains tight and firm to
accommodate with the shrinking of the umbilical cord. Clamps are used
horizontal to the abdomen and the edges are kept in such a way to avoid injury
to the abdominal wall.
· For oropharygeal suction:
— Mucus extractors in a covered sterile tray
— Rubber suction catheters — No. 12 F with a lumen of 2 to 3 mm.
— Gauze pieces in a sterile covered container to wipe the mucus
· Cotton swabs – for cleaning the eyes, cord and for checking the temperature
For assessing the temperature:
— Oral Thermometer
— Bottle or containers with disinfectant to disinfect the thermometer after use
(e.g. 5% Dettol)
· Infantometer to measure the length
· Measuring tape – to assess the head, chest and abdominal circumference
· Weighing scale – to check weight
· Linen – Sheets to cover the baby and to line the cradle
· Cradle – Well padded with baby mattress and linen which is kept warm and clean
For keeping the baby clean and dry

6.5.3 Essential Supplies and Equipments for Resuscitation of Newborn

· Radiant warmer or room heater or any heat source (200 watt bulb)

· Light source or spot light

· Dry warm linen, baby clothing, towel, shoulder roll, and blanket

· Suction equipment — Electric suction machine, slow sucker machine, Mucous

Sucker (Delee type), Bulb sucker, sterile suction catheter (10F or 12F),
feeding tube (6F)
· Neonatal resuscitation bag and face mask (of different sizes) for baby.

· Oxygen source or cylinder with flowmeter, tubings manometer and humidifier

24
· Intubation equipments — Neonatal laryngoscape with blades of different sizes Setting up of a Delivery
(No. 0 and 1), extra bulb and batteries for laryngoscope. Endotracheal tube Trolley and Articles for
Immediate Care of
(size 2.5, 3.0, 3.5, 4.0 mm), stylet, Scissors, oral airway.
Newborn
· Medications — Epinephrine, Naloxone. Normal saline, Sodium-bi-Carbonate,
Dopamine, Ringer lactate, Albumin 5%, sterile water for injection
· Miscellaneous — Low reading thermometer, Stethoscope, B.P. instrument, Neonatal
ventilators I/V infusion set, slow infusion pumps, syringes (1 cc, 2cc, 5 cc, 10 cc, 20
cc, 50 cc) Needles (of different sizes), scalp vein set, umbilical artery catheters (3.5F,
5F) Three way connection, Gloves, sterile gauze pieces. Adhesive tape etc.
· Some hospitals use disposable diapers or diapers made out of cotton and gauze.

6.6 EMERGENCY EQUIPMENT AS PRECAUTIONARY

MEASURES IN LABOUR ROOM (BIRTHING ROOM)
In this section you will be learning about emergency equipment which are used in labour
room.

i) For assessing the progress of labour:

· Tocodynamometer for guarding the uterine activity

· Cardio tocography machine (CTG) to assess the uterine contractions and

foetal well being.
· Ultrasonic Doppler with Transducer to monitor the foetal heart sounds

· Scalp electrodes to record the foetal heart rate and it is applied to foetal
scalp when the cervical dilatation is one centimeter. The heart rate is
displayed on the panel meter of CTG. This electrode is applied by a
screwing instrument with the help of a special introducer and this device
is not to be applied on the suture or fontanneles of foetal skulls.
ii) Other equipment such as:
· Central Venous pressure monitoring device

· Intravenous infusion pumps, I/V. stand; I/V sets

· Blood transfusion sets

iii) Instruments for destructive operations
iv) Sterile specimen bottles for investigations e.g. mother’s blood investigations; cord
blood for some tests.
v) Articles for administering general anesthesia (if O.T. is far from labour room).
vi) Other important articles to be kept ready in the neonatal unit of the labour room are
· Overhead radiant warmer to maintain stable body temperature

· Hot water bottles

· Suction source — wall and mucus extractors

· Oxygen source — Central supply or through cylinders; tubings, flow meter,

oxygen face mask of different sizes, hood; catheters
· Infant resuscitation ambu bag

· Endotracheal tubes

· Laryngoscope with cells

· Umbilical catheters
vii) Drugs including emergency drugs; e.g. antidotes for narcotics; coagulants,
antibiotics, antipyretics, respiratory and cardiac stimulants, sedatives, narcotics,
oxytocic drugs. etc. 25
Nursing Management Normal child birth process requires minimum articles and minimum drugs. But every
During Child Birth delivery room in a hospital should be well equipped with all the necessary equipment
Process and supplies at each stage of labour till it is completed safely, cannot be predicted as
normal. An ideal labour room is one in which the midwife works with adequate and
necessary supplies without compromising the scientific and nursing principles

6.7 LET US SUM UP

In this unit you have learnt about Nurses responsibility for setting up of a delivery
trolley for normal delivery and normal delivery with episiotomy and instrumental
deliveries. You have also learnt how to give analgesia and anestnesia during labour.
You have also learnt articles required for receiving the newborn and equipment for
resuscitation.

6.8 ACTIVITY
Visit a labour room and write an observation report

1) Name of the hospital .....................................................................................................

2) Location of the labour room ........................................................................................

3) Physical setup:

· No. of rooms for delivery

· No. of rooms for relaxation (first stage room)

· No. of tables/cots for delivery

· Baby units

· Other facilities (toilets, drinking water, facilities for relatives etc.)

4) Articles required for conducting normal delivery ..............................................................

........................................................................................................................................

5) a) Procedure followed by midwives in labour room to maintain asepsis

.............................................................................................................................

b) Comments and suggestions for improvement in relation to aseptic practices:

.............................................................................................................................

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