Assisting Nurse Flow
1. Wash hands. Wear gloves.
2. Introduce/Position/Assess. Introduce self. Position the mother in Lithotomy Position.
Assess for the ff:
a. Dilation
b. Pain
c. Contractions
d. Leopold’s Maneuver
e. FHR
3. Perineal Flushing
a. Materials - Working gloves, Working forceps, Dry and Wet Cotton Balls, Water for
flushing. Povidone Iodine (Antiseptic).
4. Initial 1)VS - BP, SpO2, PR, Temp, RR.
5. Instruct BT (Proper Breathing Techniques), Dropping of sterile gloves in a sterile field.
6. Reassess pain, contraction, and FHR.
7. Inform the mother about Skin to skin contact AFTER birth.
8. Assist in Placing leggings to the mother. Holding ONLY an unsterile area.
9. DELIVER
10.Encourage Mother to Push
11.Congratulate Mother for a successful delivery
12.Administer 10 units of Oxytocin to mother. (IM, Deltoid, Right). Ask permission for
injection.
13.Reassess BP of mother
a. Stable BP - Methergine 1mL, Left Deltoid.
b. High BP - Carboprost 1mL, Left Deltoid.
14.Reassess VS of mother
15.Prepare Medications for anesthesia
a. Drop sterile syringe on sterile field
b. Give medication to handle. Handle RN aspirates.
16.Help in cleaning mother.
17.Help in cleaning unsterile field.
Newborn Care Nurse Flow
1. Wash hands. Wear clean gloves.
2. Introduce/Position. Introduce self. Position the mother in Lithotomy Position.
3. Prepare the ff:
a. Baby’s Crib - Tilt the bed, cover, bonnet, Mittens, Diaper, Inserted Linen, Name
Tag, Warm light.
b. Medications - 0.1mL Vit. K (L, Leg, Tuberculin), 0.5mL (R, Leg, Tuberculin), 0.1
(R, Arm, Tuberculin).
c. Sterile items - Gloves, Cord clip, 3 OS, Cutting scissors.
d. Wear clean gloves first. Sterile gloves when the baby is almost out.
e. Make sure that DR temp. Is not too cold (AC: 25-58c)
4. DELIVER
5. Initial Drying of Baby.Stimulate the baby for breathing. Initial APGAR
6. Skin to skin contact. Place the baby on the mother's chest.
a. 2nd sterile towel to cover baby on top.
b. Baby bonnet
c. Name tag
7. Crede’s prophylaxis. Erythromycin ointment. Put on baby eyelids (inner to outer
canthus)
8. Administer the ff:
a. Vitamin K 0.1mL L.LEG IM
b. Hepa B 0.5mL R. LEG IM
c. BCG 0.1mL R. ARM ID
9. Weight the baby. Get the baby from the mother.
10.Place the baby back to the mother. Do Anthropometric measurements.
a. Head circumference
b. Chest circumference
c. Abdominal circumference
d. Length
11.Baby Vital Signs
a. Temperature
b. HR
c. RR
12.After care
13.Make sure baby is on mother’s chest
14.Baby on crib
Handle Nurse Flow
1. Wash hands. Wear clean gloves.
2. Introduce/Position. Introduce self. Position the mother in Lithotomy Position.
3. Prepare the following:
a. OB package set - 3 towels, 2 leggings, Gowns
b. Instruments - Forceps, Medical Scissors, Needle holder, Kidney basin, Cord clip,
OS, Suture needle (For Primi mothers)
4. Wear Sterile Gloves
5. Apply Leggings to the mother. Hold only the inner part of the sterile area.
6. Drape the patient with the first towel on abdomen
7. DELIVER
8. Apply Modified Ritgen’s Maneuver - Put OS on end of perineal area near anus to
prevent laceration of perineum.
9. Report if mother already needs to push.
10.Report: Baby out!
a. Baby out!
b. Baby (Sex + Last name)
c. Time
d. Initial APGAR score
11.Baby on sterile towel. Place the baby on the mother's abdomen.
12.Feel pulsations. Feel the umbilical cord pulsations.
13.Clamp. Clamp the umbilical cord clip 2 cm or ½ inch from baseline.Apply forceps 5cm
apart.
14.Cut the umbilical cord near the cord clip.
15.3rd towel. Place on the mother’s abdomen in preparation for placental delivery
16.Massage. Uterus until firm.
17.Hold the forceps attached to the end of placenta, wait till the placental separation
takes place
18.Shorten the length of the umbilicus by applying control cord traction and
countertraction
19.Declare placenta out:
a. Placenta out, time
b. Presentation (schultz/Duncan presentation)
c. Complete/incomplete cotyledon
d. Put placenta in kidney basin
20.Assess for hemorrhage or tears. Declare if there are any lacerations. What degree?
21.After care.
22.Clean Mother Private area
