COLLEGE OF NURSING

NAME: _________________________________________________ DATE: _______________________

BLOCK: ________________________________________________ SCORE: ______________________
CLINICAL INSTRUCTOR: __________________________________________________________________

EARLY INTRAPARTUM NEWBORN CARE (EINC)

PROCEDURE CHECKLIST

I. Objective/s
- To provide essential care for newborns to avoid possible complications at birth.
- To prevent hemorrhage on mothers after birth.
- To promote bond between mother and child.
II. Materials/equipment
- Two (2) pair of sterile gloves
- One (1) pair of clean gloves
- 2 warmed blankets
- Bonnet
- 1 cord care set (plastic sterile clamp, umbilical clamp, surgical scissors)
- Oxytocin “10u”
- Two (2) 1ml. syringe
- Vitamin K
- Hepatitis B vaccine
- Erythromycin ointment
- Cotton balls soaked in antiseptic like Povidone Iodine
III. Procedure Steps. Check Done or Not done. The student is expected DONE NOT REMARKS
to perform the following DONE
1 0

1. Assemble all necessary equipment

2. Introduce self and verify client’s identity
3. If patient is delivering the newborn with other mothers in the
delivery room, use a room divider. Provide privacy.
4. Ensuring a draft-free and warm environment.
A. Assessment
5. Observe for the coherence of patient in the second stage of labor.
6. Assess the appearance of fatigue and apprehension.
7. Check client’s vital signs.
8. Monitor uterine contractions and fetal heart tone.
9. Examine the appearance of ruptured amniotic fluid.
B. Planning
10. At the end of the procedure,
A. Maintain and establish respirations in newborn.
B. Prevent hemorrhage and uterine atony on mother after birth.
C. Provide essential newborn care.
D. Check newborn for specialized care.
C. Implementation
11. Washing hands with clean water and soap.
Rationale: Handwashing is the single most important method of
preventing nosocomial infections during delivery.
12. Putting on double gloves just before delivery.
Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
Ms. Bernice U. Caliwagan, RN MAN Page - 1 -
Maternal and Child 2nd Semester August 2022 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 4
Health SY 2020-2021 Faculty Dean
 COLLEGE OF NURSING

Rationale: One set of gloves is for delivery of the baby,

and the other set is for cord clamping and cutting.
C.1. Within the first 30 seconds after birth:
13. Use a clean, dry cloth to thoroughly dry the baby, wiping from the
eyes, to the face, head, front and back, arms and legs in a
cephalocaudal (head-to-toe) direction.
Rationale: Prevents heat loss by evaporation.
14. Remove the wet cloth.
Rationale: To avoid heat loss by conduction and evaporation.
15. Do a quick check of newborn’s breathing while drying. Obtain the
APGAR score for the first minute of life. Rationale: Normal
breathing is quiet, nasal, abdominal, synchronized, shallow, and
rapid with the rate of 30 to 60 bpm. APGAR score would help
determine if NB have breathing and circulation concerns.
C.2. After 30 seconds of thorough drying with the newborn
breathing or crying:
16. Place newborn prone on the mother’s abdomen or chest, with
skin-to-skin contact.
Rationale: The prone position helps draining of secretions and
clearing of air passages. SSC provide warm to newborn thru
conduction from the body of the mother.
17. Cover the back of the newborn with a blanket and the head with a
bonnet or a cap.
Rationale: To avoid hypothermia and continuously provide
warmth to newborn.
18. Place the identification band around the ankle.
Rationale: To provide identification on newborn most especially if
baby needs to taken from the mother for a while.
C.3. Within 1 to 3 minutes after delivery or while on SSC,
the essential newborn care focuses on cord care:
19. Remove the first set of gloves immediately prior to cord clamping.
Rationale: To avoid transmission of microorganisms from the soiled
first gloves to the umbilical cord.
20. Clamp and cut the cord after cord pulsations have stopped
(typically at 1-3 minutes).
Rationale: To allow blood from the placenta to continue being
transferred to the newborn.
21. Put ties around the cord at 2 cm (plastic cord clamp) and 5 cm
(umbilical metal clamp) from the newborn’s abdomen.
Rationale: To facilitate the drying and dropping off time of the
cord stump.
22. Cut between ties with sterile instrument. (surgical scissors)
Rationale: To prevent tetanus neonatorum.
23. Check for the 2 arteries and 1 vein (AVA), and observe for oozing
of blood from the cord. If with blood, wipe it with cotton soaked
with antiseptic.
Rationale: To avoid omphalanghia.
24. Inject 10 U oxytocin intramuscularly (IM) to the mother’s deltoid.
Rationale: To prevent hemorrhage and uterine atony.
C.4. Within 5 minutes after delivery is for the third stage of
labor (delivery of the placenta)
25. Leave the newborn on the mother’s chest for a skin-to-skin
contact.
Rationale: To continuously keep the newborn warm.
Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
Ms. Bernice U. Caliwagan, RN MAN Page - 2 -
Maternal and Child 2nd Semester August 2022 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 4
Health SY 2020-2021 Faculty Dean
 COLLEGE OF NURSING

26. Perform Brandt Andrews maneuver. Pressure is applied with the

fingers of the other hand to elevate the uterus into the abdomen
and at the same time express the placenta into the vagina. Gently
apply cord traction with the other hand to guide the placenta into
the birth canal.
Rationale: To facilitate the swift delivery of the placenta.
27. Note for signs of placental separation such as globular shaped
uterus (Calkin’s sign), lengthening of the cord, and sudden gush of
blood.
Rationale: These signs of placental separation determine the
effectiveness of Brandt Andrews Maneuver.
28. After placenta is delivered, note for the time of placental
separation.
Rationale: For documentation purposes.
29. Place placenta on the basin against the perineum. Take note of the
fetal side and maternal side.
Rationale: To determine the completeness of the placenta.
30. Note the amount of blood loss and completeness of cotyledons.
Rationale: To check if there is/are missing part/s of cotyledons that
might lead to infection, and also to check if mother is suspected for
possible hemorrhage.
31. Remove soiled gloves.
Rationale: Soiled gloves can be a source of transmission of
microorganisms.
32. Take the blood pressure of the mother.
Rationale: To ensure mother’s condition and to check if mother is
suspected for hypovolemic shock.
33. Check again the APGAR score of the NB after birth.
Rationale: Five (5) minutes after birth, it is mandatory to check
again the APGAR score of the NB to ensure breathing and to
check if NB needs further resuscitation or medical assistance.
C.5. Essential newborn care within 90 minutes focuses on
breastfeeding and eye care:
34. Leave the newborn on the mother’s chest in SSC.
Rationale: To continuously keep the newborn warm.
35. Observe the newborn for the feeding cues.
Rationale: Suggest the mother to encourage the baby to move
towards the breast.
36. Counsel the mother on positioning and attachment and when the
baby is ready.
Rationale: For a successful breastfeeding.
37. Wear a pair of clean gloves for eye care: Administer ophthalmic
ointment, Erythromycin or tetracycline ointment: apply 1 cm from
inner to outer canthus of each eye.
Rationale: To prevent opthalmia neonatorum.
38. Do not wash away the eye antimicrobial agent.
Rationale: Eyes can utilize the medication.
C.6. Essential newborn care from 90 minutes to 6 hours:
39. Give vitamin K prophylaxis: 1 mg/.1 cc for full term NB and
0.05cc for preterm NB IM.
Rationale: For blood coagulation.
40. Inject Hepatitis B (IM-Vastus Lateralis) and BCG vaccinations
(ID-Upper Left Arm)
Rationale: Mandatory vaccinations: Hepa B vaccine protection
Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
Ms. Bernice U. Caliwagan, RN MAN Page - 3 -
Maternal and Child 2nd Semester August 2022 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 4
Health SY 2020-2021 Faculty Dean
 COLLEGE OF NURSING

against hepatitis B and BCG to prevent severe infection of TB.

41. Examine the newborn for birth injuries, malformations and defects.
Rationale: To address the concerns immediately.
42. Record all the intervention done, specifically the Vitamin K, BCG
and Hepa B.
Rationale: For documentation purposes.
D. Evaluation
43. At the end of the procedure,
A. Maintain and establish respirations in newborn.
B. Prevent hemorrhage and uterine atony on mother after birth.
C. Provide essential newborn care.
D. Check newborn for specialized care.
E. Documentation
44. Validate data gathered for accuracy, reliability and completeness.
Document and record findings accurately. Record interventions
done specifically Vitamin K, BCG and Hepa B.
45. Refer newborn to pediatrician if,
- With difficulty in breathing, alterations on findings, birth
injuries, malformations and defects.
Evaluator’s name and signature: Score:
_____________
/45

REFERENCE:

Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, Adele Pillitteri ,7th Edition, Volume 1
“UnangYakap”; Essential Procedures in the Care of Normal Newborn (DOH A.O. 25, 2009; WHO, 2009)

Remark/s:

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Evaluated by: Student conforme:

___________________________________ _______________________________________________
Clinical Instructor Name and Signature Student’s Name and Signature

Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
Ms. Bernice U. Caliwagan, RN MAN Page - 4 -
Maternal and Child 2nd Semester August 2022 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 4
Health SY 2020-2021 Faculty Dean