Definition
Conducting or managing a normal vaginal delivery involves the hand maneuvers used to assist the baby’s birth, immediate care of the newborn, and the delivery of the placenta.
Purposes
- To have the childbirth event take place in a prepared and safe environment.
- To conduct delivery with least trauma to mother and baby.
- To assist mother, go through the process without undue stress, injury or complication.
- To promote smooth and safe transition of newborn to the extra uterine life.
- To avoid complications.
Articles
For Mother
A sterile delivery pack containing:
- Articles for cutting and suturing an episiotomy:
- Episiotomy scissors
- Artery clamps-3
- Tissue forceps-1
- Needle holder-1
- Syringe and needle for infiltration-10 mL.
- Scissors for cutting the cord
- Bowl for cleaning solution
- Basin to receive placenta
- Cotton balls
- 4×4 gauze pieces
- Towel/gauze pad to cover the hand supporting the perineum
- Sterile gown
- Leggings for the mother
- Aprons, gloves, and masks for staff.
For Newborn
- Baby blanket or flannel cloth-2; one to receive and dry the baby of excess secretions and another to wrap the baby.
- Neonatal resuscitation equipment checked and ready for use.
- Oxygen source with tubing.
- Suction apparatus and mucus extractor.
- Cord clamp.
- Bulb syringe for nasal and oropharyngeal suctioning of the baby.
Other Articles
- Antiseptic lotions-savlon or dettol.
- Suture material.
- Perineal pads for the mother.
- Oxytocic drugs.
- Sterile gloves.
- Methergine.
- Lignocaine 2%.
Points to remember
- Follow strict aseptic technique.
- Never ask the mother to bear down before full dilatation.
- Always give episiotomy at the peak of a uterine contraction.
- Check that the resuscitation set, suction apparatus, and other equipment are in good working condition.
- Record any alteration in uterine contraction or fetal heart rate (FHR). Record the time of rupture of membranes and color of amniotic fluid.
- Note FHR when the uterine contractions are not present.
Preparation
- Provide local preparation as per agency policy.
- Administer enema.
Procedure
| Nursing actions | Rationale | |
| 1. | Before procedure Transfer mother to the delivery room. | Provides for safe delivery. |
| 2. | Change her clothing into hospital gown. | Maintains hygiene. |
| 3. | Monitor uterine contraction and PV findings. | Helps in assessing progress of labor. |
| 4. | Assess the presentation, lie, position, attitude, station, cervical dilatation, effacement, etc. | Helps in assessing progress of labor. |
| 5. | Maintain labor progress chart (partograph). | Helps in determining abnormalities. |
| 6. | Note the color of the liquor if the membranes rupture. | Meconium-stained liquor indicates fetal distress. |
| 7. | Note the FHR every 10-15 minutes, if not on continuous fetal monitoring. | Detects fetal distress at an early stage. |
| 8. | Avoid giving solid foods. | During labor, emptying time of the stomach is delayed and may cause regurgitation. |
| 9. | Give her fluids in the form of lemon juice or fruit juice (if an operative delivery is anticipated keep mother on NPO). | Maintains hydration. |
| 10. | Instruct her to follow breathing techniques. | Ensures more oxygen supply to the fetus and promotes relaxation. |
| 11. | Instruct mother to lie down in left lateral position. | Enhances more blood supply to the fetus as well as prevents supine hypotensive syndrome. |
| 12. | Give adequate explanation regarding breathing, relaxation, and pushing (bearing down) to mother. | Obtains her cooperation and participation during the process. |
| 13. | Once the onset of second stage has been confirmed, place the woman in dorsal position with knees bent at lower end of the delivery bed. Ensure that bladder is empty. | Gives view to the perineum and to assess the progress clearly. |
| 14. | During procedure Open the delivery pack, arrange the articles, and pour cleansing solution in the bow. | For convenience and timely use. |
| 15. | Perform a surgical hand scrub and put on sterile gown and gloves. | Reduces transfer of microorganisms. |
| 16. | Drape the mother’s perineum and delivery area. | Obtains a sterile field for delivery. |
| 17. | Clean the perineum in the following manner using one cotton ball separately for each stroke: Mons pubis in zigzag manner from level of clitoris upward. Clitoris to fourchette one downward stroke. Farther labia minora and then near side. Labia majora farther side first and then near side. Thighs in long strokes away from the perineum. Anus in one circular stroke. | Proper cleansing makes the perineum free from microorganisms. |
| 18. | Delivery of the head: As the head becomes visible at the introitus, place the pads of your fingertips on the portion of the vertex at vaginal introitus. | |
| 19. | As more of the head is visible, spread your fingers over the vertex of the baby’s head, with fingertips pointing toward the unseen face of the fetus and the elbow pointing upward toward the mother. | Gives pressure against the fetal head to keep it well- flexed. |
| 20. | Cover the hand not used on baby’s head with a towel and place the thumb in the crease of the groin midway on one side of the perineum. Place the middle finger in the same way on the other side of perineum. | Prevents contamination from the anus. |
| 21. | As the head advances, allow it to gradually extend beneath your hand by exerting control but not prohibitive pressure. | Control of the head in this manner will prevent explosive crowning and pressure on the perineum. |
| 22. | With the hand over the perineum, apply pressure downward and inward toward each other across the perineal body at the same time. | This support will prevent rapid birth of head causing intracranial damage to baby and laceration to perineum. |
| 23. | Observe the perineum in the space between the thumb and middle finger while offering head control and perineal support. | Detects signs of impending tear, such as stretch marks beneath the perineal skin. |
| 24. | Give an episiotomy if required when there is bulging, thinned perineum during the peak of a contraction or just prior to crowning. | Avoids injury to the anal sphincter and spontaneous laceration of the perineum. |
| 25. | As soon as the head is born, during the resting phase, before the next contraction, place the fingertips of one hand on the occiput and slide them down to the level of shoulders. | Feel for cord around the baby’s neck. |
| 26. | Sweep the fingers in both directions to feel for the umbilical cord. | Detects the presence of nuchal cord which can prevent the descend of the fetus and the delivery of the body. |
| 27. | If the cord is felt and if it is loose, slip it over the baby’s head. If the cord is tight, apply clamps about 3 cm, apart and cut the cord at the middle of the neck (mother must be instructed to pant while clamping, cutting, and unwinding the cord). | Prevents the cord from becoming tightened around the neck. |
| 28. | Wipe the baby’s face and wipe off fluid from nose and mouth. | Facilitates breathing. |
| 29. | Suction the oral and nasal passage with a bulb syringe. | Prevents aspiration of the fluid. |
| 30. | Delivery of shoulders: Wait for a contraction and watch for restitution and external rotation of head. | Allows time for shoulders to rotate to the anteroposterior diameter of the outlet. |
| 31. | When the shoulders reach the anteroposterior diameter of the pelvic outlet, proceed to deliver one shoulder at a time in the following manner: Place a hand on each side of the head over the ears and apply downward traction to deliver the anterior shoulder. When the axillary crease is seen, guide the head and trunk in an upward curve to allow the posterior shoulder to escape over the posterior vaginal wall. | Avoids overstretching of the perineum. |
| 32. | Grasp the baby around the chest and lift the baby toward the mother’s abdomen. | This allows the mother to immediately see her baby and have close physical contact. |
| 33. | Note the time of birth. | To document the moment of birth and birth notification. |
| 34. | Place two clamps on the cord about 8-10 cm from the umbilicus and cut it between the two clamps while covering it with a gauze. | Covering with a gauze while cutting prevents spraying the delivery field with blood. |
| 35. | Give the baby to the nursery nurse who will place him in the designated area, dry him, and carry out the assessment and care. | Provides for continuity of care. |
| 36. | Place the placenta receiver against the perineum. | For receiving the placenta and membranes. |
| 37. | Place one hand over the fundus to feel the contraction of the uterus. | To assess the status of uterus after expulsion of fetus. |
| 38. | Watch for signs of placental separation: Lengthening of cord, gush of blood, fundus becoming round, and placenta descending into the vagina. | Contraction and placental separation may occur in 5 minutes. |
| 39. | When placental descend is confirmed, ask the patient to bear down as the uterus contracts, as she did during the second stage of labor (controlled cord traction can be used to deliver placenta). | Bearing down simultaneously with a contraction aids expulsion of the placenta. |
| 40. | As soon as the placenta passes through the introitus, grasp it in cupped hands. | Avoids chances of breaking of membranes. |
| 41. | Twist the placenta round and round with gentle traction so that the membranes are stripped off intact. If the length of the membranes make the movements difficult, catch the membranes with an artery forceps and give gentle traction till they are stripped off and expelled intact. | Helps in complete expulsion of membranes. |
| 42. | If spontaneous expulsion fails to occur in 20-30 minutes, perform controlled cord traction or Brandt-Andrews maneuvers. | Gets the membrane stripped off and expelled completely. |
| 43. | Examine the patient’s vulva, vagina, and perineum for any laceration. | |
| 44. | Massage the uterus to make it contract. | For expulsion of any retained products of conception. |
| 45. | Suture episiotomy layer by layer if one was made. | For adequate healing. |
| 46. | Clean the vulva and surrounding area with antiseptic solution and place perineal pad. | Promotes comfort. |
| 47. | Straighten mother’s legs, cross them and make her comfortable. | Reduces bleeding. |
| 48. | Clean and replace articles. | |
| 49. | Remove gloves and wash hands. | Prevents spread of microorganisms. |
| 50. | Record the details of delivery and condition of the mother and baby in the patient’s chart. | Promotes communication among staff. |
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Annamma Jacob, Manual of Midwifery and Gynaecological Nursing, 4th Edition, 2023, Jaypee Publishers, ISBN: 978-9356961593
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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