Responsibilities of

Student Nurses in
Handling, Assisting
and in Cord Care in
the Delivery Room
S K I L L S L A B O R ATO R Y
- Assess progress of labor (rupture of BOW, cervical dilatation, effacement & degree of descent of the fetal head)

Labor Room Responsibilities:

❖ Labor monitoring
- Monitor uterine contractions
✓ Duration
✓ Frequency
✓ Interval
✓ Intensity
 Labor Room Responsibilities:
• Secure patient’s safety
while on CTG
(Cardiotocography)
- Assess progress of labor (rupture of BOW, cervical dilatation, effacement & degree of descent of the fetal head)

Labor Room Responsibilities:

❖ Labor monitoring
- Assess progress of labor (rupture of
BOW, cervical dilatation, effacement &
degree of descent of the fetal head)
 Labor Room Responsibilities:

Obtain Patient’s Data/ Information

✓ Patient’s identity
✓ Determine OB History (GTPAL, LMP, AOG)
(Gravida, Para)
G = Gavidity
P= Parity
(Term, Pre-term, Abortion, Living)
Labor Room Responsibilities:

Obtain Patient’s Data/ Information

✓

Vital signs (T, P, R, BP)

✓

Obtain FHB
 Labor Room
Responsibilities

✓
Perform Leupold’s maneuver
- Locate FHB
- Presentation
- Position
- Degree of descent
Labor Room Responsibilities:

Secure articles needed by the patient

(Mother):
Adult diaper
➢

➢
Maternity napkin
➢
Underwear
 Maternity Pad

Maternity underwear
 Labor Room Responsibilities:

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
HANDLING:
Assisting:
✓Assist patient to be ✓ Assist patient to be
transported to the DR transported to the DR
✓Position patient in lithotomy ✓ Position patient in lithotomy
on the DR table on the DR table
✓Perform hand hygiene ✓ Take note of the time of
mounting on the DR table
✓Perform perineal flushing/ ✓ Assist in perineal flushing/
preparation preparation
 Responsibilities in the Delivery Room
HANDLING:
Assisting:
• Don gloves
• Assist in catheterization
• Prepare/ arrange
instruments/ DR pack • Coach patient on proper
• Perform straight breathing and pushing
technique (health teaching)
catheterization
• Drape patient aseptically
 Responsibilities in the Delivery Room
HANDLING:
• Instruct patient proper
breathing technique
(baring down or correct
pushing technique)
• Perform/ assist in Ritgen’s
maneuver during crowning
Assisting:
• Stimulate uterine
contraction (massage
fundus gently; nipple
stimulation)
• Take note of the time of the
rupture of the membrane
(Bag of water)
 Responsibilities in the Delivery Room
Handling & Assisting
• 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
HANDLING:
• Assist in episiotomy as Assisting:
necessary
• Deliver the newborn’s head, • Take note of the time of the
shoulders and the rest of the expulsion of newborn
body safely (“Baby Out”)
• Record the time of delivery
• Announce the newborn’s
and the, gender of the baby.
delivery, the gender & the time
“Baby out, baby girl, 10:23
am!”
 Responsibilities in the Delivery Room
HANDLING:
• Place the newborn on mother’s Assisting:
abdomen; initiate skin to skin • Prepare the oxytocin
injection
contact & breast feeding
(latching on) • Wait for the sign of
(Cord Care Assistance ) placental expulsion
• Assist in the cutting of the
cord
• Wait for the sign of placental
expulsion
 Responsibilities in the Delivery Room
Handling & Assisting
• 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
 Responsibilities in the Delivery Room
HANDLING:
• Deliver the placenta; examine
completeness of cotyledons
• Identify mechanism of
placental Separation (2)
• Schultze – “shiny”, clean & fetal
membrane comes out first; separates
from the center
• Duncan – “dirty”, red, irregular with
ridges of cotyledons and the maternal
side comes out first; separates from the
sides.
Assisting:
• Take note of the time of the
expulsion of placenta (record
mechanism)
• Take and record the blood pressure
of the patient (may announce)
• 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
 Responsibilities in the Delivery Room
Handling & Assisting
• Assess the amount of blood
loss (normal blood loss = 300
- 500 ml)
• Assist in the evacuation of
blood clots, massage uterus
over the fundus
(assist: anticipate need of
additional instruments or
supplies)
Assisting:
• 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
HANDLING: Assisting:
• Assist physician in • Prepare suturing equipment
episiorrhaphy or suturing of • 5 cc syringe with needle
perineal laceration as needed • Lidocaine 2% (Anesthesia)
• Prepare suturing equipment • Suture (Chromic 2/0)
• Needle holder
• Attached suture to the • Tissue forceps with teeth
needle holder (optional)
• Serve the Lidocaine to the
• Prepare Lidocaine 2%
handling student nurse
(Anesthesia)
 Responsibilities in the Delivery Room
HANDLING:
• 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
Assisting:
• Prepare/ apply maternity
napkin
• Health teaching
• Care of the newborn: exposure to
sunlight, bathing, care of the
cord, breastfeeding, burping, well
baby check up, completion of
immunization, newborn
screening
• Proper hygiene
• Post partum check up
 Responsibilities in the Delivery Room
• Clean and organize the area as necessary; refill
supplies as necessary
• Health teaching (Responsible parenthood, hygiene,
application of ice pack over hypogastrium, massage of
uterus for contraction, report profuse vaginal
bleeding)
• Documentation
Responsibilities
of the Student
Nurse in-charge
of Cord Care
Cord Bring all baby’s
equipment/ articles
Care along with the
mother inside the
delivery room.

Prepare all the

needed articles at
the newborn care
area/ table.
 Cord Care
Articles to prepare:
• Baby’s cloth (“Lampin”)
• Baby’s diaper & clothes
• Baby’s bonnet, mittens, socks
• Tape measure
• Gauze (operative sponge)
• Vitamin K injection (tuberculin syringe)
• 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 tubbings
Cord Perform hand hygiene
Care
Done gloves (double gloving)

Dry the newborn thoroughly

(remove secretions from the mouth)

Keep the newborn on side lying

position on mother’s abdomen
Cord Care
• Observe the newborn carefully while performing the
procedure
• Perform a thorough assessment
• APGAR SCORING – assessment of the newborns well
being/ health status
• 1’st minute of life
• after 5 minutes
• after 10 minutes

• Observe for any signs of congenital abnormality/ deformity

Cord Care Initiate skin to skin contact (30
Initiate minutes)

Keep the newborn warm by covering

Keep with the dry sterile towel

Feel Feel the pulsation of the umbilical cord

Clamp Clamp and cut the cord only when the

and cut pulsation on the umbilical cord stops
 Weigh Weigh the newborn

Measure the head, chest abdominal circumference and the

Measure
Cord Care length

Put on Put on baby’s bonnet and clothes

Apply crede’s prophylaxis from inner to the outer canthus of the

Apply 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

 Cord Care

• Attach the newborn’s identification

band

• Mummy wrap the newborn and keep

warm by placing under the drop light
or warmer
Cord Care

Take the
newborn’s
cardiac rate and
respiratory rate
 • Bring the newborn to the
mother to start breastfeeding.

Cord Care
• Conduct health education to the
mother on proper breastfeeding
techniques.
 • After care
• discard all sharps to
appropriate receptacle
• Clean the area with used
Cord Care
articles
• Refill supplies as necessary
 QUIZ #1

Take a rest and be a

blessing to your family ☺