NURSING SKILLS MODULE: ESSENTIAL INTRAPARTAL & NEWBORN CARE (EINC)

AND PARTOGRAPH

COURSE CODE: NCM 107 (RLE SKILLS LABORATORY)

COURSE NAME/TITLE: CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
RELATED LEARNING EXPERIENCE (RLE)

CLINICAL INSTRUCTOR: Bianca Camille M. Mercado, RN, MSN

COURSE DESCRIPTION: This course deals with concepts, principles, theories and
techniques in the nursing care of individuals and families during
childbearing and childbearing years toward health promotion,
disease prevention, restoration and maintenance and
rehabilitation. The learners are expected to provide appropriate
and holistic nursing care to clients utilizing the nursing process.

INSTRUCTION TO THE USERS:

This module provides concepts, principles, theories, techniques and skills in
the nursing care of mother and newborn during the intrapartal and postpartal
period. Please accomplish the assigned activities like actual video
demonstration, plotting partograph and others.

LEARNING OBJECTIVES:
At the end of the rotation, the student will be expected to:
1. Adhere and apply the new policies and protocols on essential intrapartal and
newborn care.
2. Provide safe and quality maternal and newborn care services.
3. Perform efficiently and effectively the intrapartal and newborn care practices that
save lives.
4. Plot correctly in the partograph thru a given scenarios.
5. Appreciate the use of partograph in monitoring the progress of labor.

TOPIC OUTLINE:
I. Introduction
a. MDG 4 & 5
b. Two main strategies in the implementation of MDG 4 & 5
1. MNCHN
2. EINC Campaign
II. Essential Intrapartal Care
1. Recommended
2. Not Recommended Practices during labor and delivery and postpartum
III. Essential Newborn Care
1. 4 Core Steps of EINC
2. Breastfeeding
a. Feeding cues
b. Positioning & Attachment
3. Physical Assessment
a. Vital signs/APGAR
b. Anthropometric Measurement
4. Prophylaxis and vaccines
IV. Partograph
a. Definition of a partoraph and parts of a partograph
 b. Monitoring the progress of labor using the partograph
c. When to start to use the WHO partograph?
d. How to use and graph the progress of labor in the partograph?
e. How to interpret the partograph?
f. What are the immediate nursing actions in reference to the result of
graphing the progress of labor?
LEARNING CONTENT
Introduction
Millennium Development Goals 4 and 5

Goal 4: Reduce child mortality

Target 4 A: Reduce by two-thirds, between 1990 and 2015, the under-five
mortality rate
 Indicator 4.1 Under-five mortality rate
 Indicator 4.2 Infant mortality rate
 Indicator 4.3 Proportion of 1year-old children immunized against measles

Goal 5: Improve maternal health by 2015

Target 5 A: Reduce by three-quarters, between 1990 and 2015, the maternal
mortality ratio
 Indicator 5.1 Maternal mortality ratio
 Indicator 5.2 Proportion of births attended by skilled health personnel
 Indicator 5.3 Contraceptive prevalence rate
 Indicator 5.4 Adolescent birth rate
 Indicator 5.5 Antenatal care coverage (at least one visit and
at least four visits)
 Indicator 5.6 Unmet need for family planning
Maternal, Newborn Child Health and Nutrition Strategy (MNCHN)
Policy Objective
1. Administrative Order 2008-0029
– Implementing Health Reforms for Rapid Reduction of Maternal and Newborn
Mortality (MNCHN Strategy)
2. Administrative Order 2009-0025
– Adopting Policies and Guidelines on Essential Newborn Care (ENC)
To reduce maternal and neonatal mortality rates faster from 2007 to 2015 to meet
MDG targets
However, we need to understand features and characteristics of maternal and
newborn deaths to focus our interventions.
MNCHN Strategy

Every pregnancy is wanted, planned and Every pregnancy is adequately managed

supported
Every pregnancy is wanted, planned and Every pregnancy is adequately managed
supported
Intermediate
Goals
Every delivery is facility-based and Every pregnancy
mother is adequately
and managed
newborn pair secure
managed by skilled health professional proper postpartum and postnatal care
with smooth transitions to the women’s
Every delivery is facility-based and managed health care package for the mother and
by skilled health professional child survival package for the newborn.
very pregnancy is adequately managed
 Pre-pregnancy services Ante-natal care

Financing Health Facilities and Service

Packages Human Resource, Health
information**
Health Products and Pharmaceuticals
Other Support Systems
Postpartum and
Care during delivery
postnatal care

MNCHN Service Delivery Network

A. Third Tier: CEmONC Capable Health

Facilities

B. Second Tier: BEmONC Capable

Health Facilities
C. First Tier: Community Level Service
Providers with Community Health
Teams

Community Health Teams (CHTs)

With the support of barangay leaders
CHTs known before as “women’s health
team”
Led by the public health midwife (CHT
Team leaders
Members:
Barangay nutrition scholars
Barangay health workers
Barangay service point officers
Women’s groupsTBAs as ‘trackers’ in some CHTs
Things to consider in Curriculum Integration
LIFE EVENTS MNCHN-related program
re-
Pre-union Birth and Under 5 P re- union
Under 5
Premarital Conception Deliveryry Premarital
Conception Birth and
cy
Pregnancy years cy ry yea rs
ng
counseling Delive counseli ng

MBFHY
MBFHI
MBFHI

EINC
BEmONC with POGS MDG

EINC NBS, EPI, IMCI, IYCF

NBS, EPI, IMCI, IYCF

Family Planning, Adolescent Health

5/6/2013 Healthy Lifestyle 12 17

Micronutrient supplementation
 Essential intrapartum and newborn care
The EINC Campaign
Rooming-in and breastfeeding
Breastfeeding and infant and young child feeding
Hospital Network of
Breastfeeding during emergencies and disaster Reform Centers of
Agenda Excellence
Newborn screening and newborn hearing screening
Postpartum care and postnatal care Curriculum Social
Birth spacing, family planning Changes Marketing
Campaig
Health lifestyle
Oral health

ESSENTIAL INTRAPARTUM CARE From Evidence to Practice

Causes of Maternal Mortality
Four Major causes:
1. Hemorrhage
2. Infection (Sepsis)
3. Hypertension
4. Unsafe abortion
5. Others like embolism
Too many mothers and newborns are dying every year…

ANTENATAL CARE
 At least 4 antenatal visits with a skilled health provider
1. To detect diseases which may complicate pregnancy
2. To educate women on danger and emergency signs & symptoms
3. To prepare the woman and her family for childbirth
4. To detect diseases which may complicate pregnancy

 Detection of diseases which may complicate pregnancy

Screening
 Anemia
 Pre-eclampsia
 Diabetes Mellitus
 Syphilis

Detection
  PROM
 Preterm labor
Prevention
– Ferrous and folic acid supplementation
– Tetanus toxoid immunization
– Corticosteroids for preterm labor
Treatment
– Ferrous sulfate for anemia
– Antihypertensive meds and Magnesium sulfate for SEVERE pre-eclampsia
– REFER

Antenatal Corticosteroids
 ANTENATAL STEROIDS to all patients who are at risk for preterm delivery
– with preterm labor between 24-34 weeks AOG
– 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 OR DEXAMETHASONE 6 mg IM q 12 x 4 doses
• Overall reduction in neonatal death
• Reduction in RDS
• Reduction in cerebroventricular hemorrhage

DEXAMETHASONE PHOSPHATE 2ml ampules: 4mg/ml 6 mg – 1.5 ml injected

intramuscularly Even a single dose of 6 mg IM before delivery is beneficial
emergency drug should be available at the OPD and ER
A single course of corticosteroids is recommended for
pregnant women between 24 0/7 weeks and 33 6/7 weeks of
gestation, and may be considered for pregnant women starting
at 23 0/7 weeks of gestation who are at risk of preterm delivery
within 7 days 1 11 13.

Educate women on danger and emergency signs & symptoms

DANGER SIGNS and SYMPTOMS
 Vaginal bleeding
 Headache
 Blurring of vision
 Abdominal Pain
 Severe difficulty breathing
 Dangerous fever (T°>38, weak)
 Burning on urination

Prepare the woman and her family for childbirth

Counsel on
o Proper nutrition and self-care during pregnancy
o Breastfeeding and family planning • BIRTH PLAN
o Where she will deliver; transportation
o Who will assist her delivery
o What to expect during labor and delivery
o What to prepare, estimated cost of delivery
o Possible blood donors; where will she be referred in case of emergency

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 Apgar score
 ↓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 10%
 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

3. Upright position during first stage of labor

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)
 First stage of labor shorter by about 1 hour
 Need for epidural analgesia ↓ by 17%
 No difference in rates of SVD , CS, and Apgar score < 7 at 5 minutes

Restricting practices limit a mother’s freedom to move and/or her position of choice.
 1. IV lines*
2. fetal monitoring
3. labor stimulating medications that require monitoring of uterine activity,
4. small labor rooms,
5. epidural placement
6. absence of support persons to “be with” the intrapartum client

4. Routine use of WHO partograph to monitor progress of labor

5. Limit total number of IE to 5 or less.
 No difference in endometritis
 UTI lower by 34% An observational study on 161,077 women (with or w/o
PPROM) who had < 5 exams (Ayzac, L., et.al., 2008)
 ↓ Chorioamnionitis by 72%
 ↓ Neonatal sepsis by 61% 1 RCT on 5,018 women with PROM comparing < 3
Exams.

PRACTICES NOT RECOMMENDED DURING LABOR

Interventions that are 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
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

Oxytocin Augmentation
 Should only be used to augment labor in facilities where there is immediate
access to caesarean 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 (Intravenous Fluid)

Advantages
  to have ready access for emergency medications
 to maintain maternal hydration
Disadvantages
 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
 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.

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.
 Use of epidural anesthesia for intrapartum anesthesia in an otherwise normal
labor should not preclude oral intake.
 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 calorific drinks consumed during labor reduce the incidence of
maternal ketosis without increasing gastric volumes.

CARE DURING LABOR

RECOMMENDED NOT RECOMMENDED

 Admission to labor when in the active  Routine perineal shaving on admission
phase.  Routine enema
 Companion of choice to provide  Routine NPO
continuous maternal support  Routine IVF
 Mobility and upright position  Routine vaginal douching.
 Allow food and drink  Routine amniotomy
 Use of WHO partograph to monitor  Routine oxytocin augmentation
progress of labor
 Limit IE to 5 or less.
PRACTICES RECOMMENDED DURING DELIVERY

1. Upright position during delivery

o More efficient uterine contractions
o Improved fetal alignment
o Larger anterior-posterior and
transverse diameters of pelvic outlet
o enhances fetal movement through the
maternal pelvis in descent for birth
o Faster delivery
o Leads to less interventions : less
episiotomies.

2. Selective (non-routine) episiotomy.

Non-Routine Episiotomy
o ↑Anterior perineal trauma by 84%
o ↓ Posterior perineal trauma by 12%
o ↓ 2nd-4th degree tears by 33%
o ↓ Need for suturing by 29%
o No difference in infection rate

3. Perineal Support and Controlled Delivery of the Head

o Keep one hand on the head as it advances during contractions while the other
hand supports the perineum during delivery of the head,
o encourage woman to stop pushing and breathe rapidly with mouth open

4. Use of prophylactic oxytocin for management of third stage of labor

o OXYTOCIN 10 U intramuscular
Palpate abdomen to rule out a second baby

Prophylactic OXYTOCIN for the 3rd stage of labor

 Postpartum blood loss ≥ 500 ml reduced by 39%
 Need for additional uterotonic reduced by 47%
 No difference in need for maternal blood transfusion, need for manual
removal of placenta, and duration of third stage

5. Delayed cord clamping

Early clamping : <1 min after birth
Delayed (properly timed) :1-3 minutes after birth or when pulsations stop
 Lower infant hemoglobin at birth and at 24 hrs after birth prevented
 Fewer infants requiring phototherapy for jaundice
 No difference in rates of polycythemia, need for neonatal resuscitation, and
NICU admission
 6. Controlled cord traction with countertraction
to deliver the placenta
Controlled Cord Traction
 ↓Postpartum blood loss >500ml by 7%
 ↓Postpartum blood loss >100ml by 24%
 No difference in rates of maternal
mortality or serious morbidity and need
for additional uterotonics.

7. Uterine massage after placental delivery

Active Management of the Third Stage

(AMTSL)
o Administration of uterotonic within one
minute of delivery of the baby.
o Controlled cord traction with counter
traction on the uterus
o Uterine massage

Approaches in the Management of the 3rd Stage of Labor

Physiologic (Expectant) Active (AMTSL)

Uterotonic (Oxytocin) NOT GIVEN before GIVEN within 1 min. of
placenta is delivered baby’s birth
Signs of place WAIT DON’T WAIT
ntal separation
Delivery of the placenta By gravity with maternal Controlled cord traction with
effort counter traction on the
uterus
Uterine massage After placenta is delivered After placenta is delivered

PRACTICES NOT RECOMMENDED DURING DELIVERY

Interventions that are NOT recommended during delivery
1. Perineal massage in the 2nd stage of labor
o Based on review, there is clear benefit (↓3rd-4th degree tears) and no clear
harm (no difference in 1sr and 2nd degree tears, vaginal pain, blood loss)
o Commonly noted complications in practice (perineal edema, perineal wound
infection, and perineal wound dehiscence) were not evaluated
o Further studies are needed
2. Fundal pressure during the second stage of labor

Fundal Pressure during 2nd stage

o 2nd stage longer by 29 minutes
o Increased 3rd and 4th degree perineal tears
 o No difference in rates of postpartum hemorrhage, instrumental vaginal delivery,
Apgar score < 7 at 5 minutes, and NICU admission
o Uterine rupture was not evaluated

CARE DURING DELIVERY

RECOMMENDED NOT RECOMMENDED

 Upright position during delivery  Coaching the mother to push
 Selective episiotomy  Perineal massage in the 2nd stage of
 Use of prophylactic oxytocin for management labor
of 3rd stage of labor  Fundal pressure during the second
 Delayed cord clamping stage of labor
 Controlled cord traction with countertraction to
deliver the placenta
 Uterine massage

POSTPARTUM CARE
RECOMMENDED
 Routinely inspect the birth canal for lacerations
 Inspect the placenta & 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

Republic of the Philippines

TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph
 PERFORMANCE EVALUATION CHECKLIST
ESSENTIAL INTRAPARTUM AND NEWBORN CARE PRACTICE (EINC)

Name of Student: ___________________________

Year and Clinical Group: ______________________
School year: ________Term: __1st Sem ___2nd Sem _____Summer
Inclusive dates of Clinical Rotation: ________________
Instructor: _________________

Description:
The EINC (Essential Intrapartum And Newborn Care) practices are evidenced-based
standards for safe and quality care of birthing mothers and their newborns, within the 48
hours of Intrapartum period (labor and delivery) and a week of life for the newborn.

Purposes:
1. To provide safe and quality nursing care to birthing mothers and their newborns.
2. To practice the recommended practices during the antepartum, intrapartum and
immediate postpartum period.
3. To follow the recommended practices in newborn care.

Equipment/Materials:
Decontamination Solution Umbilical cord clamp
Kellies/forceps Baby towels (2-3)
Mayo scissor Baby’s blanket
Sterile gauze Baby dress/layette
Cotton balls Adult and baby Diaper
Sterile gloves Under pad
Syringes Vitamin K
Weighing scale Eye ointment
Dummies Hepatitis B vaccine
Tape measure BCG vaccine
Pale Plaster
kelly pad

SCORE Remarks
PROCEDURES
2 1 0
In advance, prepare decontamination solution by mixing 1 part 5%
chlorine bleach to 9 parts water to make 0.5% chlorine solution.
1 Change chlorine solution at the beginning of each day or whatever
solution is very contaminated or cloudy.
PRIOR TO WOMAN’S TRANSFER TO THE DR
2 Ensure that the mother is in her position of choice while in labor.
3 Ask mother if she wishes to eat/drink or void.
Communicate with the mother –informed her of progress of labor,
4 give reassurance and encouragement.
WOMAN ALREADY IN THE DR
PREPARING FOR DELIVERY
5 Check temperature in DR area to be 25-28 Celsius; eliminate air
draft.
6 Ask woman if she is comfortable in the semi-upright position (the
default position of delivery table).
7 Ensure the woman’s privacy.
8 Remove all jewelry then wash hands thoroughly observing the
WHO 1-2-3-4-5 procedure.
 9 Prepare a clear, clean newborn resuscitations area. Check the
equipment if clean, functional and within easy reach.
10 Arrange materials/supplies in a linear sequence.
11 Gloves, dry linen, bonnet, oxytocin injection, plastic clamp,
instrument clamp, scissors, 2 kidney basins.
(In a separate sequence for after the 1st breastfeed.)
12 Eye ointment, (stethoscope to symbolize PE), Vitamin k, hepatitis B
and BCG vaccines (plus cotton balls, etc).
13 Clean the perineum with antiseptic solution.
14 Wash hands and put it on 2 pairs of sterile gloves aseptically. (if
same worker handles perineum and cord)
AT THE TIME OF DELIVERY
15 Encourage woman to push as desired.
16 Drape clean, dry linen over the mother’s abdomen or arms in
preparation for drying the baby.
17 Apply perineal support and did controlled delivery of the head.
18 Call out time of birth and sex of baby.
19 Inform the mother of outcome.
FIRST 30 SECONDS
20 Thoroughly dry the baby at least 30 seconds, starting from the face
and the head, going down to the trunk and extremities while
performing a quick check for breathing.
1-3 MINUTES
21 Remove the wet cloth.
22 Place the baby in skin-to-skin contact on the mother’s abdomen or
chest.
23 Cover baby with the dry cloth and the baby’s head with a bonnet.
24 Exclude a 2nd baby by palpating the abdomen in preparation for
giving oxytocin.
25 Use wet cloth to wipe the soiled gloves. Give IM oxytocin within one
minute of baby’s birth. Dispose wet cloth properly.
26 Remove 1st set of gloves and decontaminate them properly (in 0.5%
chlorine solution for at least 10 minutes).
27 Palpate umbilical cord to check for pulsations.
28 After pulsations stopped, clamp cord using the plastic clamp /cord
tie 2 cm from the base.
29 Place instrument clamp 5 cm from the base.
30 Cut near plastic clamp (not midway).
31 Perform the remaining steps of AMTSL (Active Management of the
Third Stage of the Labor)
32 Wait for the strong uterine contractions then controlled cord traction
and counter traction on the uterus, continuing until placenta is
delivered.
33 Massage the uterus until its firm.
34 Inspect the lower vagina and perineum for lacerations/tears and
repair lacerations/tears, as necessary.
35 Examine the placenta for completeness and abnormalities.
36 Dispose the placenta in leak-proof container or plastic bag.
37 Clean the mother: flush perineum and apply perineal
pad/napkin/cloth.
38 Check the baby’s color and breathing; check that mother is
comfortable, uterus contracted.
39 Decontaminate (soak in 0.5% chlorine solution) instruments before
 cleaning; decontaminate 2nd pair of gloves before disposal, stating
that decontamination lasts for at least 10 minutes.
15-90 MINUTES
40 Advise mother to observe for feeding cues and cite examples of
feeding cues.
41 Support mother, instruct her on positioning and attachment.
42 Wait for FULL BREASTFEED to be completed.
43 After a completed breastfeed, administer eye ointment (first).
44 Do thorough physical examination.
45 and then do Vitamin K, Hepatitis B and BCG injections
(simultaneously explain purpose of each intervention)
46 Advise OPTIONAL/DELAYED bathing of baby (and able to explain
the rationale).
47 Advise breastfeeding per demand.
48 In the first hour: check baby’s breathing and color, and check
mother’s vital signs and massage uterus every 15 minutes.
49 In the second hour: check mother-baby dyad every 30 minutes to 1
hour.
50 Complete all RECORDS.
TOTAL SCORE
TRANSMUTED GRADE

Descriptive Interpretation for Actual Score:

2- Very Good
1- Good
0- Not Performed

Shown to me:
________________________________
Signature over Printed Name
Student

Shown to me by:
___BIANCA CAMILLE M. MERCADO___
Signature over Printed Name
Clinical Instructor