NCM 107: RLE
PRINCIPLES OF STERILITY
STERILE
• free from bacteria or other living
microorganisms totally clean
ASEPSIS
• means absence of microorganisms that
cause disease
STERILE TECHNIQUE
• Are methods employed inside the delivery
room or operating room to prevent
contamination of organisms throughout the
procedure.
When are sterile techniques used or applied?
1. Preparation for an invasive procedure.
→ An invasive procedure is one in which the
body is "invaded", or entered by a
needle, tube, device, or scope.
2. In preparation of the sterile team to handle
sterile supplies and contact to the site
(gowning, gloving and scrubbing).
3. Skin preparation and draping of the
patient.
4. Sterility maintenance throughout the
procedure in the DR.
PRINCIPLES OF STERILITY
1. Only sterile items are used within the sterile
field.
 drapes, basins, instruments used in the DR
are obtained from sterile packages
Special consideration:
IF YOU ARE IN DOUBT ABOUT THE STERILITY
OF A CERTAIN OBJECT, CONSIDER IT
UNSTERILE.
2. Sterile persons are gowned and gloved.
 Sterile area:
 front of gown 2” below the neck
 sleeves above the elbow
Note: Below the waist considered unsterile
3. Tables are only sterile at table level.
 Edges and below the table is considered
unsterile
4. Sterile persons touch ONLY sterile while
unsterile personnel touch ONLY unsterile
items.
5. Unsterile persons avoid reaching over
sterile field and sterile persons avoid
touching or leaning over unsterile area.
❖ In cases where a solution has to be
poured into a sterile basin, the solution
should be held 6 inches away from the
sterile field.
❖ In dropping sterile item in a sterile area,
drop the item at the center.
6. Sterile field is set-up just before a
procedure.
 The longer a sterile item is exposed to air
and environment, the higher the possibility
of contamination
ASSISTING A DELIVERY: PERINEAL CARE
1. Put on a bonnet and a mask
 To prevent transfer of microorganism
thus preventing cross contamination
2. Assist a patient to a delivery table and
place in a lithotomy position.
 To provide minimum exposure (lessening
embarrassment)
2.1. The patient buttocks are placed to the
edge of the table.
2.2. The knees are flexed and feet are
supported with stirrups.
2.3. The kelly pad (instead of a bed pan)
may be placed under the buttocks.
 Prevents the bed from becoming soiled
3. Check equipment needed. Prepare ahead
of time.
→ Cherry balls
→ Kelly pad
→ Clean gloves
→ warm water (43-46℃ or 110-115℉)
→ Waste Receptacle
→ Pitcher or container with a prescribed
solution
ASSISTING A DELIVERY: FEMALE PERINEAL
CARE
FEMALE PERINEAL CARE
• It is the cleaning of the vulva and perineum
Purposes
1. To promote normal perineal secretions
and odors.
2. To promote client’s comfort.
3. To prevent infection.
4. Do perineal care
4.1.
Pour water over the vulva. Pitcher
should be 6 inches above the
vulva.
 Prevents the transmission of
microorganism from one area to the
other
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4.2. Use a new sponge for each numbered
area: clean the rectal area last.
4.3. Using a cherry ball moistened with
soap solution or disinfectant solution, clean
the vulva in the following manner:
4.3.1 mons pubis
4.3.2 thighs, start with the nearer thigh
from the vulva going to the farther
thigh
4.3.3. farther side of the labia majora
then to the nearer side
 wash from the area of the least
contamination to that of the
greatest contamination
 you can spread the labia to wash
the folds between the labia
majora and labia minora
 secretions that tend to collect
around the labia minora can also
facilitate bacterial growth
4.3.4. clitoris to vaginal orifice.
4.3.5. anus
PERINEAL CARE STROKES
•
•
•
“S stroke”
This is to wash from the least contaminated
area to the most contaminated area
Use one cherry ball per stroke
Discard after using
•
A cherry bowl is a rolled gauze - that is
used to facilitate better absorption when
cleaning the perineal area
4.4 Flush the vulva and dry with a sterile dry
cotton balls or cherry balls in the same
sequence.
 A basin is used where you could drop
your cotton balls (1 cotton ball per
stroke to avoid contamination)
 Ensure that your hand should not go
below your waist level
 Wash it with a water so that you could
facilitate now the drying of the
perineal area
OPENING/CLOSING OF D.R PACKS
GUIDELINES FOR WORKING IN STERILE
FIELD/STERILE ATTIRE
1. Everything below the waist or table height
is considered nonsterile. Keep your hands
above your waist. Keep sterile equipment
on top of the tables.
→ When you are waiting, it is often
convenient to clasp your gloved hand
together in front of you
2. Your back is considered potentially
contaminated because you cannot see what
happens to it.
→ Do not turn your back on any sterile
area
→ Always pass the sterile area facing it
3. When passing another person in sterile
attire, pass either face to face or back-toback. If you must stand behind someone,
fasten a sterile towel over that person’s
back
4. Sterility is a matter of certainty, not
conjecture (educated guess).
→ If a part of your attire is
contaminated, notify the appropriate
person (circulating nurse – give
assistance in changing)
5. Moisture allows microorganisms to wick
quickly & easily from one area to another.
6. Contamination often occurs accidentally.
PREPARING A STERILE FIELD
1. Explain the procedure to the patient &
perform hand hygiene.
• An explanation encourages patient
cooperation & reduces apprehension.
Hand hygiene deters the spread of
microorganisms.
2. Select a work area that is waist level or
higher. Choose a flat, hard, & dry surface.
• Work area is within sight. Bacteria tend
to settle, so there is less contamination
above the waist.
3. Put a sterile drape. Sterile drape should be
waterproof on one side w/ that side
placed down on the work surface.
2
•
To establish a sterile field or to extend
the sterile area & to avoid moisture to
wick into the sterile field.


OPENING D.R. (STERILE) PACK OR SET
Remember: D.R. pack should be opened before
putting on the gloves.
1. Check that sterile wrapped drape or
package is dry & unopened. Also note
expiration date, making sure that the date
is still valid.
• Moisture contaminates a sterile package.
Expiration date indicates period that
package remains sterile.



topmost flap of wrapper away from you.
Open Right & left flap before grasping the
nearest flap & opening toward you.
• Proper placement prevents contamination
by reaching across sterile field. Touching
outer side of wrapper/drape maintains
sterile field
There are also commercially prepared
package
Do not cross your hand or arm over sterile area
Touch wrapper outside only
Do not allow anything nonsterile to touch
contents of the pack.
D. Opening bottom corner toward the body.
A. Opening top most flap of sterile package.
CONTENTS OF THE D.R PACK
2. Open sterile wrapped drape, open outer
covering. Remove sterile drape, lifting it
carefully by its corners. Gently shake open,
hold away from your body, & lay drape on
selected work area.
• Outer 1 inch (2.5cm) of drape is
considered contaminated. Any item
touching this area is also considered
contaminated.
3. Place agency-wrapped package in the
center of work area. Touching outer surface
only, carefully reach around item & fold
B. Opening left side (use left hand)
C. Opening right side. (use right hand)
Normal Delivery Instrument Set
• 2 Mayo/Surgical Scissors
• 2 Kelly Forceps
• 1 Needle Holder
• 1 Tissue/Thumb Forceps
• 2 Kidney Basin
✓ Usually added to the Set
• 1 10cc Syringe
• Operative Sponge (OS) /Gauze
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•
•
•
Chromic 2/0
Cherry Balls w/ Betadine antiseptic
1 Plastic Cord Clamp
ADDING A STERILE ITEM TO A STERILE FIELD
1. Hold agency-wrapped item in one hand
w/ top flap opening away from you. With
other hand unfold top flap & both sides.
Keeping a secure hold on item, grasp the
corners of the wrapper & pull back toward
wrist, covering hand & wrist.
• Only sterile surface & items are
exposed before dropping onto sterile
field.
✓ If commercially packaged item has an
unsealed corner, hold package in one hand
& pull back on top cover w/ other hand. If
edge is partially sealed, use both hands to
carefully peel apart.
• Contents remain uncontaminated by hands.
2. Drop sterile item onto sterile field from a
6” (15cm) ht. or add item to field from the
side. Be careful to avoid dropping onto the
1” border.
• Wrapper does not contaminate sterile
field. Any items landing on 1” border are
considered contaminated.
• ARMS should be placed at the side of the
table not above the sterile field
•
3. Discard wrapper.
• A neat work area promotes proper
technique.
POURING A STERILE SOLUTION TO A
STERILE FIELD
1. Obtain appropriate solution & check
expiration date.
• Once opened, a bottle should be labeled
w/ date & time. Solution remains sterile for
24 H once opened.
2. Open solution container according to
directions & place cap on table w/ edge
up.
• Sterility of inside cap is maintained.
3. If bottle has previously been opened, “lip”
it by pouring a small amount of solution into
waste container.
• This cleanses the lip of the bottle.
4. Hold bottle outside the edge of the sterile
field w/ the label side facing the palm of
your hand & prepare to pour from a height
of 4” to 6” (10 to 15cm). The tip of the
bottle should never touch a sterile container
or dressing.
Label remains dry, & solution may be
poured without reaching across sterile field.
Minimal splashing occurs from that height.
Accidentally touching the tip of the bottle
to a container or dressing contaminates
them both.
5. Pour required amount of solution steadily
into sterile container positioned at side of
sterile field. Avoid splashing any liquid.
• Moisture contaminates sterile field.
6. Touch only the outside of the lid when
recapping.
• Solution remains uncontaminated.
CLOSING D.R PACKS
 Used for instruments, OS, gowns for
autoclave or sterilization.
1. Place two wrappers on flat surface with
one point toward you. Place item to be
wrapped in center of wrapper with its
length parallel to you.
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•
•
6. Repeat step 2
2. Fold corner nearest you over item until it is
completely covered. Fold corner back
toward you 2 to 3 inches.
•
•
•
7. Repeat step 3
•
•
3. Fold left side of wrapper over and parallel
to item. Fold end of corner back 2 to 3
inches.
8. Repeat step 4
4. Repeat with right side. Lap center folds
atleast ½ inch
9. Bring point of wrapper completely around
package and seal with appropriate tape
5. Tuck in side edges of remaining corner to
eliminate any direct opening to item. Bring
top corner down to bottom edges and tuck
in, leaving point for opening.
SUMMARY/SALIENT POINTS
• Below the waist or table height is
considered nonsterile.
• Do not turn your back on any sterile area.
Sterile field that becomes wet is considered
contaminated.
Outer 1 inch (2.5cm) of drape/covering is
considered contaminated.
Do not cross your hand or arm over sterile
area. Drop sterile item onto sterile field
from a 6” (15cm) ht.
Solution remains sterile for 24H once
opened.
Pour solution to sterile field from a height
of 4” to 6” (10 to 15cm).
When closing packs, fold corner back
toward you 2-3”; parallel to the item 2-3”;
lap center folds at least 1/2 inch.
When adding sterile item, arms should be
kept to the side of the table, not above the
sterile field.
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•
•
LEGGINGS & DRAPINGS
These are procedures of covering a patient
and surrounding areas with a sterile barrier
to create and maintain a sterile field
during a procedure.
Draping materials may be disposable or
non-disposable.
The importance of draping is to maintain
patient’s dignity.
PRINCIPLES OF DRAPING “HIGHLIGHTS”
• Be clear with patients about how you will
touch them, why you need to touch them,
and which body parts need to be exposed.
Get permission (consent) each and every
time. Balance the patient’s need for privacy
with your need to expose certain areas.
• Give the patient options when possible.
• Keep the time that body areas are
exposed to a minimum.
• Be sure the blanket or sheet will not slip or
move. Give the patient control by asking
them to hold the drape or position it in a
way that makes them most comfortable.
• Avoid unnecessary physical contact and use
strategic barriers like pillows or draping
between yourself and the patient’s body.
• Position the patient comfortably and ensure
they are warm. Check in regularly to see
how they are feeling.
• Consider cultural differences but don't
assume everyone from a particular culture
has the same values or sensitivities. That
goes for age and gender too.
LEGGINGS & DRAPINGS
1. Place under buttocks drape with hands
(left & right) underneath the buttock. Use
Lithotomy “T” Drape for patients who are
about to give birth
5. Position drape on the lower abdomen and
unfold laterally.
2. With an Under Buttocks Drape in place,
proceed to apply leggings. Grasp the
legging where the word "Toe" is marked
with your right hand while placing your
left hand within marked pocket
(underneath the folds).
→ While the toe part is grabbed by your
right hand, slip right hand to the
folded cuff and create an opening
6. Continue to unfold downward, between
the patient's legs, exposing the perineal
fenestration. Unfold the top of the drape
laterally and then towards the patient's
head.
3. Holding onto toe of legging, slip drape
over stirrup. Repeat for the other leg.
7. Adjust perineal fenestration as needed to
complete the draping.
4. Locate and orient the body stamp on the
drape with patient. Remove the adhesive
strip liner.
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INSTRUMENTATION
THUMB FORCEPS
• Thumb forceps, smooth
•
•
•
•
forceps or pickups are
spring forceps used by
compression between your
thumb and forefinger and
are used for grasping,
holding or manipulating body tissue.
Tissues should be grasped and held in
position so the Obstetrician or surgeon can
perform the desired maneuver such as
dissecting, or suturing without injuring
surrounding tissues
For example, you could use thumb forceps
to hold or move tissue during surgery or to
move dressings.
Thumb forceps should be held between the
thumb and index finger with a pencil grip
when in use, and in the palmed position
when not in use.
Thumb forceps are tapered with serrations
or groove at the tip, they will injure
delicate structures
TISSUE FORCEPS
• Tissue
forceps
provide firm
hold on tough tissues, including skin.
•
•
→ It is used to cut thick tissues such as those
found in the uterus, muscles, breast, and
foot.
→ Mayo scissors are used for dissection and
are placed on tissue with the tips closed
→ The scissors are then opened so that the
tips open and spread out the tissue the
dissection process
The tips may be flat, serrated, cupped,
ringed, grooved, diamond dusted or have
teeth.
They have single tooth on one side that fits
between two teeth on the opposing side.
MAYO SCISSORS
•
• Mayo scissors is a type of surgical scissors,
often used in the cutting of FASCIA
• Mayo scissors may be made from stainless
steel or titanium.
• There are Straight-and Curved-blade
•
varieties of Mayo scissors.
•
•
Mayo scissors have semi-blunt end that
distinguishes them from any other surgical •
scissor
STRAIGHT-BLADED MAYO SCISSORS
→ Are designed for cutting body tissues
near the surface of a wound.
→ It is used for cutting sutures. "suture
scissors".
CURVED-BLADED MAYO SCISSORS
→ allow deeper penetration into the wound
than the type with straight blades.
METZENBAUM
Metzenbaum scissors
are surgical scissors
designed for cutting
delicate tissue and
blunt dissection.
They are constructed of stainless
steel and may have tungsten
carbide cutting surface inserts.
The blades can be curved or
straight and the most common
type of scissors used in organ-related operations.
Its handle is longer and its needle section is slightly
narrower
PEAN FORCEP
• A HEMOSTAT.
• It is also called a hemostatic
clamp or arterial forceps.
Pean after Jules-Émile Péan
• It is a surgical tool used
in many surgical
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•
procedures to CONTROL BLEEDING
It is a surgical tool used in many surgical
procedures to control bleeding
For this reason it's common in the initial
phases of surgery for initial incision to be
lined with hemostats which close blood
vessels awaiting ligation.
Forceps are used for clamping larger tissue
and vessels for hemostasis.
The full horizontal serrations and 12”
lengths make these forceps a versatile
instrument used in multiple procedures.
This product is Curved with full horizontally
serrated jaws, and a length of 12 inches.
ALLIS FORCEP
• The all is clamp is a
surgical instrument with
sharp teeth, used to hold
or grasp heavy tissue.
• It is also used to grasp fascia
and soft tissues such as
breast or bowel tissue.
• Allis clamps can cause damage, so they are
often used in tissue about to be removed.
• When used to grasp the cervix to stabilize
the uterus, such as when an intrauterine
device is being inserted, an Allis clamp has
the advantage of causing less bleeding
than the more commonly used tenaculum.
NEEDLE HOLDER
• A needle holder is a surgical
instrument, similar to a
•
hemostat, used by doctors and surgeons to
hold a suturing needle for closing wounds.
Most needle holders also have a clamp
mechanism, allowing the user to maneuver
the needle through various tissues
OVUM FORCEP
• Ovum forceps are
commonly used to
properly remove
pieces of placenta or products of
conception from the uterus
to prevent infection.
• The flat blades are
serrated and hollow to
firmly grasp the tissue to be removed
• It is also used as a hemostat or a clamping
instrument and used as gynecological
instruments (used in abortion).
UTERINE SOUND
• Uterine sounds are
gynecological instruments
which are used to
examine the vaginal cavity
and to measure the depth
of the uterus.
• It is commonly used for
probing and dilating the
uterus through the cervix.
• Primary used to measure
the length of cervical canal and uterus
• Uterine sounds are inserted into the
women’s uterus from the cervix so that the
length of the uterus can be determined and
can be find out what direction the uterus
•
and the cervical canal take so that it can
determined the amount of dilation which
has already taken place and to determine
the dilation to the amount which is required
Uterine sounds are commonly used for
insertion and removal of IUDs.
OBSTETRICAL FORCEP
• Obstetrical forceps are an instrument that
can be used to assist in the delivery of a
baby as an alternative to vacuum
extraction method.
• It should only be undertaken to help
promote the health of the mother or the
baby
• Obstetrical Forceps are instruments
designed to aid in the delivery of the fetus
by applying traction to the fetal head.
ADVANTAGES OF FORCEPS
• Use include avoidance of Cesarian Section
• Reduction of delivery time
• General applicability with cephalic
presentation
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ESSENTIAL INTRAPARTUM & NEWBORN
CARE From Evidence to Practice
STATISTICS
• Postpartum hemorrhage (PPH) is
responsible for around 25% of Maternal
Mortality Worldwide (WHO,2007)
• PPH can be a long term cause of severe
morbidity. Approximately 12% of PPH
survivors will have severe anemia Abou
Zahr , 2003; WHO, 2006)
DATA FROM THE DOH, 2006
• As of 2006, 162 mothers/100,000 live
births have died due to complications from
pregnancy and childbirth.
• Maternal deaths comprise as much as
14%of all death to women of reproductive
age.
• Majority of maternal deaths occurred
during labor, delivery and the immediate
postpartum period.
 The Philippines is concerned that it may
not meet the millennium development
goal 5/MDG 5, to reduce maternal
death unless rapid action is taken (MDG
4) in the rate of newborn death
especially in the first 48 hours of life is
not arrested
 Maternal deaths are estimated to be
162/100,000 live births or close to
5,000 mothers dying annually
 The MDG 5 target is 52 maternal
deaths per 100,000
 Postpartum hemorrhage continues to a
major cause of maternal mortality which
accounts 41%
 Around 40,000 newborns die in the
country each year, from causes that is
most preventable which is complications
of prematurity (41%), birth asphyxia
(15%) or severe infection (16%). Most
death occur in the first 2 days of life
and conditions surrounding labor,
delivery, and immediate post-partum
period has been pinpointed as
contributory factors
 In 2009, the DOH began hospital based
initiative to change practices for the
safe and quality care of mothers and
newborns, supported by the WHO and
the joint program of maternal and
neonatal health, the program is being
piloted in 11 hospitals
ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC) – UNANG YAKAP
• Evidence Based standards
UNNECESSARY INTERVENTIONS IN THE
INTRAPARTUM PERIOD:
 Routine performance of enemas and
shaving
 Restriction of fluid and food intake during
labor and routine insertion of intravenous
fluid continue with no evidence of food
outcomes for the mother/newborn
 Routine early anatomy and oxytocin
augmentation
 Fundal Pressure to facilitate 2nd stage of
labor has been found to cause maternal
and newborn injuries
EINC PRACTICES
 Continuous maternal support by having a
companion of choice during labor and
delivery
 Freedom of movement during labor
 Monitoring progress of labor ursing
partograph
 Non drug pain relief before offering
labor anesthesia
 Position of choice during labor and
delivery
 Spontaneous pushing in a semi-upright
position
 Non routine episiotomy
 Active management of the 3rd stage of
labor
UNNECESSARY PRACTICES FOR NEWBORN
 Routine suctioning
 Early bathing
 Routine separation from the mother
 Foot printing
 Application of various substances to the
cord
 Giving pre-nap pills or artificial milk
formula or other breastmilk substitute
NECESSARY PRACTICES FOR NEWBORN
 Immediate and Thorough drying of the
newborn
 Early Skin-to-skin contact between the
mother and newborn
 Properly timed cord clamping and cutting
 Nonseparation of newborn and mother
for early breastfeeding initiation
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ANTEPARTUM CARE
ANTENATAL CARE
• At least 4 antenatal visits with a skilled
health provider
• To detect diseases which may complicate
pregnancy
• To educate women on danger and
emergency signs & symptoms
• To prepare the woman and her family for
childbirth
TO DETECT DISEASES WHICH MAY
COMPLICATE PREGNANCY
SCREEN
→ Anemia
→ Pre-eclampsia
→ Diabetes Mellitus
→ Syphilis
DETECT
→ Pre Mature Rupture of Membrane
(PROM)
→ Preterm labor
PREVENT
→ Ferrous and folic acid supplementation
→ Tetanus toxoid immunization
→ Corticosteroids for preterm labor
TREAT
→ Ferrous sulfate for anemia
→ Antihypertensive meds and Magnesium
sulfate for SEVERE pre-eclampsia
→ REFER
ANTENATAL CORTICOSTEROIDS
• Administer ANTENATAL STEROIDS to all
patients who are at risk for preterm
delivery
→ with preterm labor between 24 –34
weeks Age of Gestation
→ or with any of the following prior to term:
• Antepartal hemorrhage/bleeding
• Hypertension
• (Preterm) Pre-labor rupture of membranes
ANTENATAL STEROIDS
BETAMETHASONE
• 12 mg IM q 24 hrs x 2 doses
DEXAMETHASONE
• 6 mg IM q 12 x 4 doses
 Overall reduction in neonatal death
→ Reduction in Respiratory Disease
Syndrome (RDS)
❖ RDS is a serious complication among
premature babies and the primary
cause of early neonatal morbidity,
death, and disability
→ Reduction in cerebroventricular
hemorrhage
→ Reduction in sepsis in the first 48 hours of
life
•
Even a single dose of 6 mg IM before
delivery is beneficial
• Emergency drug should be available at the
OPD and ER
 Studies show that treatment with
antenatal corticosteroid does not includes
risk of the mother’s death
 Chorioamnionitis or chorio sepsis
 Treatment with antenatal corticosteroids
is associated with the overall reduction in
neonatal death, cerebroventricular
hemorrhage, necrotizing enterocolitis,
respiratory support, neonatal intensive
care unit, and systemic infection in the
first 48 hours of life
 Antenatal corticosteroid use is also
effective in women, with premature
rupture of membrane or PROM, and
pregnancy related hypertension
syndrome
 Continued use of a single course of
antenatal corticosteroids to accelerate
fetal lung maturation in women at risk of
preterm birth
 A single course of antenatal
corticosteroid should be considered
routine for preterm delivery with few
exceptions
DEXA AREA & TRAY IN THE ER, DR, WARD
DEXAMETHASONE PHOSPHATE
• 2ml ampules: 4mg/ml
• 6 mg –1.5 ml injected intramuscularly
10
DANGER SIGNS and SYMPTOMS
• Vaginal bleeding
• Headache
• Blurring of vision
• Abdominal Pain
• Severe difficulty breathing
• Dangerous fever (T°>38, weak)
• Burning on urination
INTRAPARTUM CARE
RECOMMENDED PRACTICES DURING LABOR
1. Admission to labor when the parturient is
already in the active phase.
→ Active phase labor:
→ 2-3 contractions in 10 minutes
→ cervix is 4 cm dilated
• Admit when the parturient is already in
ACTIVE LABOR
 No difference in Apgarscore
 ↓ Need for Cesarean Section by 82%
 No difference in need for labor
augmentation
2. Continuous maternal support.
→ ↓ Need for pain relief by 10%
→ Duration of labor SHORTER by half an
hour
→ ↑ Spontaneous vaginal delivery by 8%
→ ↑ Instrumental vaginal delivery by 10%
 Forceps delivery and vacuum
extraction delivery
→ 5-minute Apgar < 7  by 30%
• Having a LABOR COMPANION can
result in:
 Less use of pain relief drugs →
increased alertness of baby
 Baby less stressed, uses less energy
▪ Reduced risk of infant hypothermia
▪ Reduced risk of hypoglycemia
 Early and frequent breastfeeding
 Easier bonding with the baby
→ Women who receive continuous
support are more likely to have a
spontaneous vaginal birth
→ Their labors are shorter and less
likely to have a Cesarian or
Instrumental vaginal birth, regional
anesthesia, or a baby with a low
five-minute Apgar score
3. Upright position during first stage of
labor.
→ First stage of labor shorter by about 1
hour
→ Need for epidural analgesia ↓ by 17%
→ No difference in rates SVD, CS, and
Apgar score < 7 at 5 minutes
• Freedom of movement
→ Distract mothers from the discomfort of
labor, release muscle tension, and give
a mother the sense of control over her
labor (Storton, 2007).
•
Restricting practices
→ limit a mother’s freedom to move
and/or her position of choice.
a. IV lines
b. Fetal monitoring
c. Labor stimulating medications that
require monitoring of uterine activity
d. Small labor rooms
e. Epidural placement
f. Absence of support persons to “be
with” the intrapartum client
→ Use of upright position can reduce the
length of labor
→ EINC offer nondrug methods of pain
relief before pain medications
➢ Continuous maternal support during
labor
➢ Walking and moving around
➢ Massage
➢ Verbal and physical reassurance
➢ Quite environment
➢ IF anesthesia is required, if the
mother asked for it, epidural
anesthesia is widely used
4. Routine use of WHO partograph to
monitor progress of labor.
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•
A partograph is a tool to be used to assess
the progress of labor
• To identify when interventions are
necessary
• Reduce of partograph can reducing
complications from prolonged labor like
post partum hemorrhage, sepsis, uterine
rupture, and for the newborn – asphyxia,
infection, and death
5. Limit total number of IE to 5 or less.
→ No difference in endometritis
→ UTI lower by 34%
→ ↓ Chorioamnionitis by 72%
→ ↓ Neonatal sepsis by 16%
PRACTICES NOT RECOMMENDED DURING
LABOR
1. Routine perineal shaving on admission
for labor and delivery.
→ No difference in rates of maternal fever,
perineal wound infection, and perineal
wound dehiscence
→ No neonatal infection was observed
2. Routine enema during the first stage of
labor.
→ Fecal soiling during delivery reduced by
64%
→ No difference in maternal puerperal
infection, episiotomy dehiscence, neonatal
infection, and neonatal pneumonia
→ Studies does not support the routine use
of enemas during first stage of labor
→ Enemas should not be done routinely
unless the patient specifically request for
one.
3. Routine vaginal douching.
→ No difference in chorioamnionitis,
postpartum endometritis, perinatal
mortality, neonatal sepsis
→ No side effects reported
4. Routine amniotomy to shorten
spontaneous labor.
→ ↓ Risk of dysfunctional labor by 25%
→ No difference in duration of labor, CS
rate, cord prolapse, maternal infection
and Apgar score < 7 at 5 minutes
→ Amniotomy and Oxytocin augmentation
are require other inteventions which may
restrict maternal movement, the increased
risk for intrauterine infection after
amniotomy create a sense of urgency to
deliver the fetus within a specified
timeframe, usually 24 hours post
amniotomy
OXYTOCIN AUGMENTATION
• Should only be used to augment labor in
facilities where there is immediate access to
cesarean section should the need arise.
• Use of any IM oxytocin before the birth of
the infant is generally regarded as
dangerous because the dosage cannot be
adapted to the level of uterine activity.
ROUTINE IVF
• No study found showing that having an IV
in place improves outcome.
• Even the prophylactic insertion of an IV line
should be considered unnecessary
intervention.
• Used to hydrate women, but reduces
freedom of movement
•
•
•
•
Adverse Effect: Infusion of glucose solutions
to the mother will interfere with glucose
and insulin levels in both the mother and
baby
The use of IV glucose and fluids to prevent
or combat ketosis and dehydration of the
mother may have serious unwanted effects
on the baby
IV Therapy predisposes women to
immobilization, stress, increased risk of fluid
overload, and does not insure a nutrient
and fluid balance for the demands of
labor
Normal: low risk birth in any setting, no
need for restriction of food
ADVANTAGE
 To have ready access for emergency
medications
 To maintain maternal hydration
DISADVANTAGE
 Interferes with the natural birthing process
 Restricts woman’s freedom to move
 IVF not as effective as allowing food and
fluids in labor to treat/prevent
dehydration, ketosis or electrolyte
imbalance
ROUTINE NPO DURING LABOR
• Possible risk of aspirating gastric contents
with the administration of anesthesia.
• One study evaluated the probable risk of
maternal aspiration mortality, which is
approximately 7 in 10 million births.
• No evidence of improved outcomes for
mother or newborn.
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•
•
•
•
•
Use of epidural anesthesia for intrapartum
For the normal, low risk birth, there is no
need for restriction of food except where
intervention is anticipated.
A diet of easy to digest foods and fluids
during labor is recommended.
Isotonic caloric drinks consumed during
labor reduce the incidence of maternal
ketosis without increasing gastric volumes.
anesthesia in an otherwise normal labor
should not preclude oral intake.
Oral intake is prohibited during active
labor because of the possible risk of
aspirating gastric contents with the
administration of anesthesia
PRACTICES RECOMMENDED DURING
DELIVERY
WASH YOUR HANDS
• Prevent nosocomial infection and
antimicrobial resistance in clinical setting
TRADITIONAL
→ Defined by a “fully dilated cervix”
→ Coached to push though out of phase with
her own sensation
NON-TRADITIONAL
→ Redefined as “complete cervical
dilatation” + “spontaneous expulsive
efforts”
→ Pelvic phase of passive descent
→ Perineal phase of active pushing
INTERVENTIONS THAT ARE RECOMMENDED
DURING DELIVERY
1. Upright position during delivery.
→ More efficient uterine contractions
→ Improved fetal alignment
→ Larger anterior-posterior and transverse
diameters of pelvic outlet enhances fetal
movement through the maternal pelvis in
descent for birth
→ Faster delivery
→ Leads to less interventions: less
episiotomies
→ Continuous bearing down prevents
perineal trauma and oxygen sparing for
the fetus
→ Directed bearing down once the cervix is
fully dilated is ineffective, result in
maternal exhaustion and a greater need
for operative intervention
→ Upright position or pushing during the
second stage of labor enhance descent of
the fetal head because of the additional
effect of gravity
2. Selective (non-routine) episiotomy.
→ ↑ Anterior perineal trauma by 84%
→ ↓ Posterior perineal trauma by 12%
→ ↓ 2nd-4th degree tears by 33%
→ ↓ Need for suturing by 29%
→ No difference in infection rate
→ It is used to protect the perineum
• Perineal Support and Controlled Delivery
of the Head
 Keep one hand on the head as it
advances during contractions
while the other hand supports
the perineum.
 During the delivery of the head,
encourage woman to stop
pushing and breathe rapidly
with mouth open.
3. Use of prophylactic oxytocin for
management of third stage of labor.
→ Within one minute of birth, palpate the
abdomen to rule out a second baby
→ Give Oxytocin 10 IU IM (international
unit)
RECOMMENDATIONS IN THE USE OF
UTEROTONICS IN ACTIVE MANAGEMENT
ON THE THIRD STAGE OF LABOR:
• WHO recommends OXYTOCIN as the drug
of choice for AMTSL
• If Oxytocin is not available, offer
ERGOMETRINE/METHYLERGOMETRINEor
a fixed drug combination to women without
hypertension or heart disease
• If the woman has hypertension or heart
disease, offer MISOPROSTOL orally
• Postpartum blood loss ≥ 500 ml reduced
by 39%
• Need for additional uterotonic reduced by
47%
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•
No difference in need for maternal blood
transfusion, need for manual removal of
placenta, and duration of third stage
INTERVENTIONS THAT ARE RECOMMENDED
DURING DELIVERY CONTINUATION…
4. Delayed cord clamping.
→ Early clamping: < 1 minute after birth
→ Delayed (properly timed): 1-3 minutes
after birth or when pulsations stop
• Lower infant hemoglobin at birth and
at 24 hours after birth
• Fewer infants requiring phototherapy
for jaundice
• No difference in rates of polycythemia,
need for neonatal resuscitation, and
NICU admission
5. Controlled cord traction with counter
traction on the uterus to deliver the
placenta.
→ Await strong uterine contractions (2-3
minutes)
→ Push the uterine fundus upwards with one
hand while applying continuous, steady
traction on the umbilical cord with the
other hand, to deliver the placenta
→ If the placenta does not descend, STOP
traction and AWAIT next contraction
→ ↓ Postpartum blood loss ≥ 500 ml by 7%
→ ↓ Postpartum blood loss ≥ 100 ml by
24%
→ No difference in rates of maternal
mortality or serious morbidity and need
for additional uterotonics
6. Uterine massage after placental delivery.
→ Massage the uterus immediately after the
placenta delivers until it is firm
 Lower mean blood loss
 Less need for uterotonics
ACTIVE MANAGEMENT OF THE THIRD STAGE
OF LABOR (AMTSL)
1. Administration of uterotonic within one
minute of delivery of the baby. (Oxytocin
10 IU IM)
2. Controlled cord traction with counter
traction (CCT with CT) on the uterus.
3. Uterine massage.
APPROACHES IN THE MANAGEMENT OF THE
3RD STAGE OF LABOR
UTEROTONIC
• Physiologic (Expectant)
 NOT GIVEN before placenta is delivered
• Active (AMTSL)
 GIVEN within 1 minute of baby’s birth
SIGNS OF PLACENTAL SEPARATION
• Physiologic (Expectant)
 WAIT
• Active (AMTSL)
 DON’T WAIT
DELIVERY OF THE PLACENTA
• Physiologic (Expectant)
 By gravity with maternal effort
•
Active (AMTSL)
 CCT with counter traction on the uterus
UTERINE MASSAGE
• Physiologic (Expectant)
 After placenta is delivered
• Active (AMTSL)
 After placenta is delivered
PRACTICES NOT RECOMMENDED DURING
DELIVERY
1. Perineal massage in the 2nd stage of
labor.
→ Based on review, there is clear benefit
(↓3rd-4th degree tears) and no clear
harm ( no difference in 1st and 2nd
degree tears, vaginal pain, blood loss)
→ Commonly noted complications in practice
perineal edema, perineal wound
infection, and perineal wound dehiscence)
were not evaluated
→ Further studies are needed
2. Fundal pressure during the second stage
of labor.
→ 2ndstage longer by 29 minutes
→ Increased 3rdand 4thdegree perineal
tears
→ No difference in rates of postpartum
hemorrhage, instrumental vaginal
delivery, Apgarscore < 7 at 5 minutes,
and NICU admission
→ Uterine rupture was not evaluated
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POSTPARTUM CARE
RECOMMENDED
• Routinely inspect the birth canal for
lacerations
• Inspect the placenta and membranes for
completeness
• Early resumption of feeding (< 6 hours
after delivery)
• Massage the uterus ensure uterus is well
contracted
• Prophylactic antibiotics for women with a
3rd or 4th degree perineal tear
• Early postpartum discharge
NOT RECOMMENDED
• Manual exploration of the uterus
• Routine use of icepacks over the
hypogastrium
• Routine oral methylergometrine
ESSENTIAL NEWBORN CARE
UNNECESSARY INTERVENTIONS
a. Routine Suctioning
→ In the presence of clear amniotic fluids,
routine suctioning has been associated
with bradycardia, apnea, and delays in
achieving normal oxygen saturations
→ Cause trauma
b. Foot printing
→ Increased risk of cross contamination
among babies
→ It was used for identification purposes
→ DNA Genotyping and human leukocyte
antigen test are better methods of
identification
c. Early Bathing and Washing
→ Predeveloping hypothermia (increase risk
of infection, coagulation, acidosis,
delayed fetal circulatory adjustment,
hyaline membrane disease, and
intracranial disease
→ Washes away the vernix caseosa
(antimicrobial properties)
→ Can cause baby to be disorganized
→ Bathing be delayed at least 6 hours
after birth
d. Routine Separation
→ Babies are placed to their mothers after
birth transition more easily to
extrauterine life
→ They stay warm, cry less, and more likely
to breastfeed
→ Separation and restriction on
breastfeeding seriously compromise
colonization of the newborn with
maternus skin flora immunoprotection,
milk production, and eventual exclusive
breastfeeding
e. Giving Glucose Water or Artificial Milk
Substitutes
→ Pre lacteals
→ This delays the mother’s breastmilk let
downs and the ease of feeding from the
bottle decreases the newborn urge to
suckle
→ The newborn can get different infection
agents and challenges an already weak
or premature GI system
RECOMMENDED PRACTICES
1. Immediate and thorough drying of the
newborn
→ Stimulates breathing
2. Early skin-to-skin contact between mother
and newborn
→ Provision of warmth and bonding
→ Skin-to-skin contact reduces crying,
improves mother-baby interaction, keeps
the baby warmer, aids in stabilizing the
baby, and helps women breastfeed
successfully, cardiorespiratory stability,
body temp, blood sugar levels
3. Properly-timed cord clamping and cutting
→ Increases the baby’s blood volume and
iron reserves
→ Preterm infant: reduces the need for blood
transfusions and decreases the incidence
of life threatening intracranial
hemorrhages
4. Non-separation of the newborn from the
mother for early breastfeeding initiation
and rooming-in
→ 1 hour after birth
→ Reduce neonatal mortality by decreasing
ingestion of infection pathogens
→ Implementation of the mother-baby
friendly hospital initiative
15
→ 10 steps to successful breastfeeding
→ Avoidance of the use of intramuscular
narcotic analgesia
→ Nonseparation mother and baby after
birth
→ Placing the newborn on the mother’s
chest, abdomen and skin-to skin-contact
SUMMARY –Key Points
• Maternal and neonatal mortality in the
Philippines is still unacceptably high
• Prevention of postpartum hemorrhage
through interventions like the use AMTSL
will address the #1 cause of maternal
mortality
• The evidence based practices in the EINC
Protocol are lifesaving for both mother and
baby
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