MATERNAL AND CHILD NURSING Prepared by: Ma. Reina Rose D. Gulmatico, RN, MSN I. FEMALE REPRODUCTIVE ANATOMY ANATOMY AND A. External Reproductive Organs
PHYSIOLOGY
Mons Pubis (Mons Veneris) – (Mount of Venus) is a pad of fat lying over the symphysis pubis; covered with pubic hair from the time of puberty Labia Majora (Greater lips) – are two folds of fat and areolar tissue, covered with with skin and pubic hair on the outer surface; arise in the mons veneris and merge into the perineum behind. Labia Minora (Lesser lips) - two folds of the skin between the labia majora; anteriorly, they divide to enclose the clitoris; posteriorly they fuse, forming the fourchette Clitoris - rudimentary organ corresponding to the male penis; extremely sensitive and highly vascular and plays a part in the orgasm of sexual intercourse Vestibule - area enclosed by the labia minora in which encloses the openings of the urethra and the vagina Vaginal orifice- also known as the introitus of the vagina and occupies the posterior two-thirds of the vestibule; partially closed by the hymen, a thin membrane that tears during sexual intercourse or during birth of the first child Skene’s Glands- either side of the meatus which are often involved in infections of external genitalia
Bartholins Glands - are two small glands which open on either side of the vaginal orifice and lie on the posterior part of the labia majora. They secrete mucus which lubricates the vaginal opening. B. Internal Reproductive Organs THE VAGINA Structure: vaginal walls are pink in appearance and thrown into small folds called the rugae that stretches during intercourse and delivery. Functions: a passage that allows the escape of the menstrual flow receives the penis and the ejected sperm during sexual intercourse and provides an exit for the fetus during delivery
THE UTERUS Structure hollow, muscular, pear-shaped organ situated in the true pelvis the cervix forms the lower third of the uterus Functions to shelter the fetus during pregnancy contents
and following pregnancy it expels the
uterine
Parts of the Uterus Body or corpus – makes up the upper two-thirds of the uterus and is the greater part Fundus – domed upper wall between
the insertions of the uterine tubes
Cornua – are the upper outer angles
of the uterus where the uterine
Cavity – potential space between the
anterior and posterior walls
tubes join
Isthmus – narrow area between the cavity and the cervix that enlarges during pregnancy to form the lower uterine segment Cervix or Neck – protrudes into the vagina; supravaginal (upper half)- above the infravaginal portion (lower half)
vagina
Layers of the Uterus Endometrium - forms a lining of ciliated ephitelium (mucus membrane) on a base of connective tissue (stroma) Myometrium (muscle coat)- thick in the upper part of the uterus and is more sparse in the isthmus an cervix. Perimetrium D. UTERINE TUBES Functions •
The The uter uterin ine e tube tubes s prop propel els s the the ovum ovum towa toward rds s the the uter uterus us,, rece receiv ives es the the sperma spermatozo tozoa a as they travel travel upwards upwards and provides provides a site for fertiliza fertilization tion.. It supplies the fertilized ovum with the nutrition during its continued journey to the uterus.
Structure •
Each tube is 10 cm long. long. The lumen of the tube tube provides an open open pathway from the outside to the peritoneal cavity. cavity. The uterine tube has four portions:
a) The interstitial interstitial portion – is 1.25 1.25 cm long and and lies within the wall wall of the the uterus. uterus. It’s lumen lumen is 1 mm wide. b) The isthmus isthmus – is another another narrow part part which extends extends from 2.5 2.5 cm from the the uterus. c) The ampulla ampulla – is the wider portion portion where where fertilization fertilization usually occurs. occurs. d) The The infun infundib dibulu ulum m – is the funne funnell shap shaped ed fringed fringed end which which is comp compos osed ed of many many processes processes known as fimbriae. fimbriae. One fimbriae fimbriae is elongated to form the ovarian ovarian fimbria which is attached to the ovary. E. THE OVARIES Functions •
The ovaries produce ova and the hormones estrogen and progesterone.
Structure •
The The ovary ovary is comp compose osed d of the the medu medulla lla and and cortex cortex,, cover covered ed with with germ germina inall epithelium.
F. THE FEMALE PELVIS Functions •
•
•
The primary function of the pelvic girdle is to allow movement of the body especially walking and running. It permits the body to sit and kneel. The woman’s pelvis is adapted to child-bearing, and because of its increased width and rounded brim, women are less speedy than men. The female pelvis, because of its characteristics, gives rise to no difficulties during in childbirth, provided that the fetus is of normal size.
Pelvic Bones •
There are four pelvic bones: 1. two two inno innomi mina nate te (nam (namel eles ess) s) or hip hip bone bones s – each each inno innomi mina nate te bone bone is composed of three bones: The ilium The ischium The pubic bone 2. one sacru crum 3. one coccy ccyx
False Pelvis superior half half formed by the ilia; offers landmarks landmarks for pelvic pelvic measurements; measurements; supports supports the growing uterus during pregnancy; directs the fetus into the true pelvis near the end of gestation
True True Pelvis- is the bony canal through through which the fetus must pass during during birth. It has a brim, a cavity and an outlet. inferior half formed by the pubes in sacrum and coccyx behind
front, the ilia and the ischia on the sides and the
1. Inlet entranceway to the true pelvis; transverse diameter is wider than its anteroposterior (AP) diameter * *
Transve sverse diameter – 13.5 cm. Ante Antero ropo post ster erio iorr (AP (AP) diame iamete terr – 11 cm.
2. Outlet inferior portion/ lower border of the true pelvis of the pelvis anteroposterior diameter is wider than its transverse diameter 3. Cavity space between the inlet and the outlet contains the bladder and the rectum, with the uterus between them in an ANTEFLEXED position towards the bladder
Variation/Types of Pelvis 1. Gynecoid – “normal” female pel pelvis tha that is mos most ide ideal for chi childbirth bec because it is wel well rounded forward and back 2. Anth Anthro ropo poid id – tran transv sver erse se diam diamet eter er is narr narrow ow,, AP diam diamet eter er is larg larger er than than norm normal al 3. Platypelloid – in inlet is is ov oval, AP diameter is is sh shallow 4. Andr Androi oid d – “ma “male le”” pel pelvi vis; s; inle inlett has has a nar narro row w sha shall llow ow post poster erio iorr por porti tion on and and poi point nted ed ante anteri rior or portion.
MENSTRUAL CYCLE A. KEY CONCEPTS 1. Hormones •Estrogen •Progesterone •Follicle Stimulating Hormone (FSH) •Luteinizing Hormone (LH) 2. Associated Terms • Amenorrhea • Menorrhagia • Metrorrhagia • Polymenorrhea • Oligomenorrhea
STAGES OF FETAL DEVELOPMENT I. FERTILIZATION FERTILIZATION Site: fallopian tube mature ovum + sperm = (zygote) Gamete: sex cell contains 23 chromosomes Sperm: contains X and Y chromosomes (XY) Ovum: contains X chromosomes (XX)
II. Implantation occurs 7 days post fertilization Fertilized zygote
migrates 3-4 days (uterus)
morulla
mitosis multiplication and floating in the uterine cavity (3 - 4 days)
+ mass of large cells (fluid space)
Blastocysts a. Trophoblast b. Erythroblast Post implantation: uterine endothelium
Apposition A. Adhesion (endometrium) B. Invasion
DECIDUA
Blastocysts a. Trophoblast (outer)- PLACENTA PLACENTA b. Erythroblast (inner)- EMBRYO TROPHOBLAST decidua (endometrium) chorionic villi “falling off” remov emoved ed afte afterr deli delive very ry Cyto Cytottroph rophob obla lasst Synncyt Sy cytiotr iotrop opho hobl blas astt a. Basali Basaliss (mater (maternal nal circul circulati ation) on) (inner (inner)) (outer (outer)) b. Encapsularis (trophobast) c. Vera Vera (remaining portion) Langhan’s
Syncytial
protection for fetal membranes infection *present until 20th – 24th week
SYNCYTIAL
+
Decidua basalis
fetal membranes Amnion Umbilical cord
Chorion
Amniotic fluid
Placenta Fetal Development
A. Amniotic fluid 1. Protective function Shields the fetus against blows or pressures on the mother’s mother ’s abdomen Protects the fetus against sudden changes in temperature Protects the fetus from infection “Injury, Temperature, Temperature, Infection”
2. Diagnostic function Amniocentesis (chromosomal abnormalities) Meconium-strained amniotic (fetal distress) 3. Aids in tthe he descent descent of the the fetus fetus during during active labor B. Placenta 1. Provides oxygen to the fetus 2. Provisions of nutrients (diffusion (diffusion through the placental tissues) 3. Feto-placental circulation (osmosis) 4. Excretion of waste products 5. Production of hormones HCG HPL Estrogen Progesterone 6. Protective – inhibits the passage of bacteria and large molecules to the fetus
Stages of human prenatal development: First 12-14 days – zygote From 15th day up to the 8th week – embryo From the 8th week up to the time of birth – fetus I. First Lunar month a. Germ layers: differentiate by the 2nd week 1. Endoderm – develops into the lining of the GIT, GIT, respiratory tract, tonsils, thyroids, parathyroid, thymus gland, bladder and urethra
system,
2. Mesoderm – forms into the supporting structures of the body (connective tissues, cartilage, bones, muscles and tendons); heart, circulatory system, reproductive kidneys and ureters 3. Ectoderm – responsible for the formation of the nervous system; the skin, hair and nails; and the mucous mucous membrane of the mouth and anus
b. Fetal membranes (amnion and chorion): 2nd week c. Nervous system: 3rd week d. Fetal heart begins to form at 16th day of life II. Second lunar month a. All vital organs are formed: 8th week. b. Placenta develops c. Sex organs (ovaries/testes) are formed: 8th week Sex determination: conception Sex formation: 2nd lunar month d. Meconium formation: 5th-8th week. III. Third lunar month a. Urine formation: 12th week of pregnancy b. Fetus swallows amniotic fluid c. Feto-placental Feto-placental circulation circulation begins through osmosis: osmosis: no direct exchange between fetal and maternal blood IV. Fourth lunar month a. Lanugo appears b. Heart beats maybe audible with fetoscope
V. Fifth lunar month a. Vernix Vernix caseosa (cheesy covering on entire body to prevent drying of fetal skin) appears b. Lanugo covers entire body c. Quickening (fetal movements) is felt d. Fetal heart beats very audible VI. Sixth lunar month a. Skin markedly wrinkled b. Attains proportions of full term baby VII. Seventh lunar month a. Alveoli begin to form b. Production of surfactant VIII. Eight lunar month a. Fetus is viable b. Lanugo begins to disappear IX. Ninth lunar month a. Lanugo and vernix disappear b. Amniotic fluid volume somewhat
decreases
X. Tenth lunar month – has all characteristics of a normal newborn. FETAL CIRCULATION
NURSING CARE DURING LABOR AND DELIVERY Theories of labor
Uterine Stretch theory – any hollow body organ when stretched to capacity contract and empty Oxytocin theory – production of oxytocin from posterior pituitary gland uterine contraction Progesterone Deprivation theory – progesterone inhibits uterine motility Decrease progesterone uterine contraction Prostaglandin theory: increase prostaglandin synthesis
uterine contraction
Theory of Aging Placenta: Placenta: decrease in blood supply supply to the placenta placenta uterine contraction Premonitory/ Preliminary Signs of Labor
1. Lightening - the settling of the fetal head into the pelvic brim *Engagement occurs when the presenting part has descended into the pelvic inlet (station 0) 2. Loss of weight – about 2-3 lbs. 1 to 2 days before labor onset due to decrease progesterone resulting to decrease fluid retention 3. Increased activity level – due to increase in epinephrine level 4. Braxton Hicks Hicks contractions- irregular painless, “practice” “practice” contractions contractions 5. Ripening of the cervix – Goodell’s sign 6. Rupture of the membranes Important Nursing Considerations: A. Ruptured BOW *Initial Nursing Action: Put her on the bed immediately, immediately, then take the FHT Instruct the client not to ambulate: FETAL CORD COMPRESSION
B. Cord Prolapse *Initial Nursing Action: Put her on Trendelenburg position to reduce pressure on the cord. (REMEMBER: Only 5 minutes of umbilical cord compression can already lead to CNS damage even death.) Apply a warm saline-saturated OS on the cord to prevent drying of the cord. 7. Show Sudden gush of blood (pinkish vaginal discharge) *Nursing Implication: Assess for the the color of vaginal discharge GREENISH- meconium stained BRIGHT RED- vaginal bleeding SIGNS OF TRUE LABOR
1. Uterine contractions 2. Effacement/ Dilatation In primis, effacement occurs before dilatation (ED) In multis, dilatation proceeds effacement (DE) False vs True Labor
Parameters for comparison: 1. Regularity 2. Location 3. Changes in contractions (FID) 4. Absence/ Presence of contractions during activity] 5. Cervical changes
FALSE LABOR PAINS
TRUE LABOR PAINS
Remain irregular
May be slightly irregular at first but predictable within regular and predictable within a matter of hours
Generally confined to the abdomen
First felt in the lower back and sweep around to the abdomen in a girdle-like fashion
No increases in duration, frequency and intensity
Increase in frequency, frequency, duration and intensity
Often disappears if the woman ambulates
Continue no matter what the woman’s level of activity is
Absent cervical changes
Accompanied by cervical effacement and dilatation (the most important difference)
Length of Normal labor: Primis- 14 hours Multis- 8 hours 5 P’s of Labor 1. Passenger (Fetus) 2. Passageway (Pelvis) Shape and measurement of maternal pelvis and distensibility of birth canal Engagement: fetal presenting part enters true pelvis (inlet) Primi: two weeks before labor Multi: beginning of labor Soft tissue (cervix, vagina): stretches and dilates under the force f orce of contractions to accommodate the passage of the fetus
3. Power A. Uterine Contractions (involuntary): fingers should be spread lightly over the fundus 1. Frequency: from the BEGINNING of one contraction to the beginning of the next contraction (A-C) 2. Interval: from the END of one contraction to the BEGINNING of the next contraction (B-C) 3. Duration: from the BEGINNING of one contraction to the END of the same contraction (A-B) 4. Intensity: strength of a contraction should be measured during the acme of contraction a. mild b. moderate c. strong A
B
C
B. Voluntary Bearing Down Efforts: use of ABDOMINAL MUSCLES to help expel fetus thru CONTRACTION OF LEVATOR ANI MUSCLES 4. Placenta 5. Psychological response “A positive attitude during labor yields a positive outcome.”
A woman who is: relax, aware and participating in the birth process : shorter, less intense labor A woman who is: fearful has high levels of adrenaline which slows uterine contractions
STAGES ST AGES OF LABOR LAB OR
1st - Stage St age of o f Dilatat Dil atation ion 1st - Stage of dilatation: from onset of labor until full dilatation of cervix Phases: Latent phase: 3-4 cm Active phase: 4-8 cm Transition phase: 8-10 cm 1. Latent Phase
Duration: 6 hours Cervical dilatation: 3-4 cm Uterine contractions: every 15-30 minutes; short duration; mild intensity Women’s Attitude: excited with some degree of apprehension Support Measures 1. Establish rapport 2. Breathing exercise 3. Encourage ambulation 4. Offer ice chips or fluids 5. Encourage voiding of the client 2. Active/Accelerated Active/Accelerated
Cervical dilation: 4-8 cm Uterine Contractions: every 3-5 minutes; 30-60 seconds duration; moderate intensity Women’s omen’s Attitude: afraid of losing control of herself Support Measures 1. Encourage breathing exercise 2. Provide a quiet environment 3. Provide reassurance, encouragement and support 4. Provide Provide comfort (back massage, assisting positioning, support with pillows 5. Provide ice chips for dry mouth
Nursing management/ Health Teaching During Stage 1
1. Ambulation (+) Ambulation – during the LATENT PHASE *to shorten the first stage of labor BUT (-) Ambulation- RUPTURED BOW 2. Diet “No food or fluid please!”
On NPO Solid or liquid foods are to be avoided because: Digestion is delayed during labor A full stomach interferes with proper bearing down May vomit resulting to ASPIRATION 3. Enema administration NOT a routine procedure Purposes: A full bowel hinders the progress of labor Expulsion of feces during second stage of labor- INFECTION of the mother and baby Full bowel predisposes to postpartum discomfort Procedure: Enema solution: soapsuds or Fleet enema Optimal temperature of the solution: 105°F to 115°F (40.5 °C-46.1°C) Patient on side-lying position NURSING IMPLICATION DURING ENEMA: (+) RESISTANCE RESISTANCE during insertion of rectal catheter: withdraw the tube slightly while letting a small amount of solution enter (+) CONTRACTION: clamp rectal tubing
IMPORTANT IMPORTANT NURSING NURS ING ACTION: Check FHR AFTER enema administration to determine any FETAL FETAL DISTRESS Contraindications: Vaginal bleeding Premature labor Abnormal fetal presentation or position Ruptured membranes Crowning 4. Voiding “Please empty my bladder”
Should void every 2-3 hours Offer the bedpan if BOW has ruptured because: A full bladder retards fetal descent Urinary stasis can lead to urinary tract infection A full bladder can be traumatized during delivery 5. Breathing Technique DO NOT PUSH OR BEAR DOWN DURING CONTRACTIONS because it leads to: unnecessary exhaustion AND cervical edema (due to repeated strong pounding of the fetus against the pelvic floor); thus interfering with dilatation and prolonging the length of labor ABDOMINAL BREATHING should be encourage to reduce tension and prevent hyperventilation “No to pushing, Yes to breathing!”
6. Position “I need to lie on my side!”
Sim’s position SINCE: It favors anterior rotation of the fetal f etal head It promotes relaxation between contractions It prevents Supine Hypotensive Syndrome/Vena Syndrome/Vena Cava Syndrome
7. Monitoring Contractions Vital Signs (Temperature/ BP) A. Temperature: Temperature: sign of infection due to early RUPTURE OF MEMBRANE B. Blood pressure (q 30 minutes) Should be taken midway/between contractions BECAUSE BP INCREASES during contraction (-) blood going to the uterus (+) blood in the periphery Danger Signals Signs of Fetal distress Signs of Maternal Distress FHT/ FHT Variabilit Variabilityy NORMAL Fetal heart rate: 120/160 BPM Should be taken midway/between contractions BECAUSE FHT DECREASES during contraction (AS A RESULT vagal stimulation due to fetal head compression by the contracting uterus) Should not be mistaken for UTERINE SOUFFLÉ which synchronizes maternal heart/pulse rate Should be taken: every hour - latent phase every half hour - active phase every 15 minutes – transition INITIAL NURSING ACTION FOR ABNORMAL FHT: Change the mother’ mother ’s position
apparent abrupt INCREASE in Acceleration: visually apparent
FHR; increase of 15 beats per minute or greater and lasts 15 seconds or more; with return to baseline less than 2 minutes a. Periodic: usually encountered with BREECH PRESENTATION
Remember: Pressure Pressure of the contraction applied to A. Fetal buttock- ACCELERATION ACCELERATION B. Fetal head- DECELERATION b. Episodic: increase FHR during fetal movement
NORMAL FINDING Deceleration: dominance of PARASYMPATHETIC response
described in relation to the ONSET and end of a CONTRACTION and by their SHAPE COMPRESSION a. Early- HEAD COMPRESSION
visually apparent decrease in an return to baseline FHT normal and benign finding Characteristic: Characteristic: uniform shape
early onset due to RISE in INTRAAMNIOTIC PRESSURE as the uterus contracts occurs during the first stage when cervix is dilated to 4 to 7 cm
COMPARISON COMPARISON BETWEEN ACELERA ACELE RATION TION AN DECELERATION DE CELERATION PARAMETERS ACCELERATION DECELERATION DESCRIPTION
transitory increase of fhr transitory decrease of fhr above above baseline baseline
SHAPE
resembles shape of uterine uniform, MIRROR IMAGE OF contraction UTERINE CONTRACTION
early in contraction phase bfore ONSET onset to peak : 30 seconds peak orocurs during contraction end of uterine contraction RECOVERY less than 2 minutes HEAD COMRESSION COMMON CAUSE SPONTANEOUS FETAL MOVEMENT b. Late- UTEROPLACENTAL INSUFFICIENCY
occurs after the start of contraction lowest point of of decelertion: after peak does not return to baseline until after the contraction is over CAUSE: maternal supine hypotensive syndrome Effect: fetal hypoxia c. Variable: UMBILICAL CORD COMPRESSION
decrease is > 15 bpm; lasts at least 15 seconds; returns to baseline in less than 2 minutes from the time of onset SHAPE: U, V , W COMPARISON COMPARISON BETWEEN LATE LATE AN VARIABLE VARIABLE DECELERATION
PARAMETERS
LATE DECELERATION GRADUAL decrease
VARIABLE DECELERATION ABRUPT decrease
SHAPE
uniForm, MIRROR IMAGE OF UTERINE CONTRACTION
U, V, W
ONSET
Late in contraction; after Beginning of the depth < peak of contraction 30 sec; duration of ≥ 15 sec; decrease in FHR is ≥ 1 BPM
RECOVERY
After end of contraction < 2 minutes from onset less than 2 minutes
DESCRIPTION
COMMON CAUSE Uteroplacental Insufficiency
Umbilical Cord Compression
8. Administration of Analgesics (Demerol) Drug of choice: DEMEROL Indication: analgesic, sedative and antispasmodic (CNS DEPRESSION) IMPLICATION TO NURSING CARE: Do not give A. early in labor:
Retards progress of uterine contractions B. if delivery is only an hour away : Respiratory depression in the newborn occurs Give if cervical dilatation is already 6-8 cm
9. Administration of Anesthetics Anesthetic of choice: choice: Xylocaine
NURSING CONSIDERATION: On NPO with IV to prevent prevent aspiration and dehydration Types of anesthesia: A. Paracervical – transvaginal injection into either side of the cervix B. Pudendal - through the sacrospineous ligament into the posterior areolar tissues Side effect: (+) ecchymosis to the right of the perineum Ice bag application to the area on the first day to reduce swelling or bleeding C. Low spinal 1. Epidural (caudal) - local anesthetic injected at the lumbar lu mbar level 2. Saddle block - injection into the 5th lumbar space (+) Anesthesia: perineum, upper thighs and lower pelvis Position: sitting or side-lying position with back aligned NURSING IMPLICATIONS: TYPE of delivery: Forceps delivery (due to loss of coordination in second stage pushing) Adverse effect: effect: POSTSPINAL POSTSPINAL HEADACHES (due to the leakage of anesthetic into the CSF or injection of air at the time ti me of needle insertion) Management: Increase fluid intake FLAT ON BED without pillows for the first 12 hrs after delivery Common side effects of regional anesthesia 1. Hypotension - due to vasodilator vasodilator effects of xylocaine Management: Turn to side; prompt elevation of legs; legs; administration of vasopressors as ordered and oxygen
2. Fetal bradycardia 3. Decreased maternal respiration 3. TRANSITION PHASE
A. Cervical Dilatation: 8-10 cm B. Characteristics: 1. changes in the mood and intensity of contraction 2. rupture of membrane if (-) ROM: AMNIOTOMY AMNIOTOMY to prevent aspiration of fetus from amniotic amniotic fluid CONSIDERATION: “(-) AMNIOTOMY for STATION (-)” to prevent cord compression 3. Prominent SHOW 4. Uncontrollable urge urge to push during contraction Nursing management:
1. Breathing technique Controlled chest (costal) breathing during contractions 2. Avoidance of Bearing Down 3. Emotional Support 4. Comfort measures (Sacral pressure)
2nd - Stage Stag e of Expuls Exp ulsion ion
begins with complete dilatation of the cervix and ends with the delivery of the baby Mechanisms of Labor /Fetal Labor /Fetal Position Changes (D FIRE ERE) Descent Flexion Internal Rotation Extension External Rotation Expulsion Nursing management 1. Positioning LITHOTOMY When positioning legs onto the stirrups, put them up at the same time in order to prevent injury to the uterine ligaments 2. Bearing Down technique/ technique / Mc Robert’s maneuver Head crowning: instruct instr uct mother NOT TO PUSH, BUT TO TO PANT PANT (rapid and shallow breathing), so as to prevent rapid expulsion of the baby. baby. Mc Robert’s Maneuver: To prevent shoulder dystocia (+) delivery of the head BUT (-) delivery of the anterior shoulder in the pubic arch Position: woman’s woman’s legs are flexed apart with her her knees on her abdomen Mc Robert’s Maneuver SACRUM straightens SYMPHYSIS PUBIS rotates PELVIC INCLINATION decreased
freeing the shoulder
3. Breathing Technique 4. Episiotomy Indications: MAIN- TO PREVENT LACERATIONS Prevent prolonged and severe stretching of muscles supporting the bladder and rectum Reduce duration of second stage of labor Enlarge outlet in breech presentations or forceps delivery Types of episiotomy A. Median – from middle portion of the lower vaginal border directed towards the anus B. Mediolateral – begun in the midline but directed laterally away from the anus 5. Modified Ritgen’s Maneuver Apply PRESSURE AGAINST THE THE RECTUM using sterile towel; drawing it DOWNWARD to aid in flexing the head as the back of the neck catches under the symphysis pubis Apply UPWARD UPWARD pressure from the coccygeal region to extend the head during the actual birth (to protect the musculature of the perineum) 6. Handling of Newborn Immediately after delivery A. Infant Position: 1. head lower than the rest of the body to allow drainage of secretions 2. NEWBORN is held below the level of the mother’s vulva for a few seconds to allow placental blood to enter enter the infant’s body through gravity flow
B. Provide warmth by 1. Wrapping Wrapping the baby in a sterile diaper to keep him warm. C. Place the baby on the mother’s mother ’s abdomen. The weight of the baby will help contract the uterus. 7. Cutting of Cord Cutting of the cord- until until the pulsations have stopped stopped because 50-100 ml. ml. of blood is still flowing from the placenta to the baby at this time Then, clamp twice, an inch apart and cut between. 8. Initial Contact After newborn care, Show the baby to the mother, inform her of the sex and time of delivery Encourage the mother to start breastfeeding of the child. 3rd - Placen Placental tal Stag Stagee 4th - First 2 hours after delivery
