MARY DANIELLE O. SALUDARIO, RN

1. What are the necessary instruments and materials to prepare in the delivery tray in the delivery room?

There are different instruments or materials that are needed in preparing in the delivery room such as bandage scissors, mosquito and Kelly forceps, kidney basin, sponge forceps and sterile towel are needed.

2. What does BOW mean in labor and delivery?

BOW means bag of water. The amniotic fluid acts as a shock absorber to the baby. Allows the baby to move freely. Helps the baby keep his temperature up. Keeps the membranes from sticking to the baby's skin.

3. What are the types of rupture of amniotic sac/membranes?

• Spontaneous Rupture of Membranes (SROM): This occurs naturally, often as a sign of the onset of labor. The amniotic sac breaks, releasing the amniotic fluid.
• Premature Rupture of Membranes (PROM): When the amniotic sac ruptures before the onset of labor, typically more than an hour before contractions start. This can increase the risk of infection and complications and may require medical intervention.
• Preterm Premature Rupture of Membranes (PPROM): Similar to PROM, but occurring before 37 weeks of pregnancy. It carries a higher risk of complications due to the baby's prematurity.
• Artificial Rupture of Membranes (AROM): This is done intentionally by a healthcare provider to induce or accelerate labor. It's usually performed using a tool called an amnihook or amnicot.
• Rupture of the amniotic sac is a significant event during pregnancy and labor, as it often indicates the start of the birthing process. However, it's essential to manage it appropriately, especially if it occurs before term or without the onset of labor, to prevent potential complications

4. What are the types of maneuvers during delivery? Briefly describe each of the FETAL and MATERNAL maneuvers.

Fetal Maneuvers:

1. Internal Rotation: Sometimes, the baby may need to rotate within the birth canal for a smoother delivery. This can involve manual assistance or maternal positioning to encourage the baby's rotation.
2. Shoulder Dystocia Maneuvers: If the baby's shoulders get stuck after the head is delivered, maneuvers like the McRoberts maneuver (hyperflexion of the mother's legs) or the Gaskin maneuver (changing the mother's position to all-fours) can be used to help release the shoulders.
3. External Cephalic Version (ECV): This is done before labor to manually turn a breech baby into the head-down position, reducing the risk of complications during delivery.
4. Leopolds Maneuver: A systematic method of observation and palpation to determine fetal presentation and position.

Maternal Maneuvers:

1. Brandt-andrews: placing fingers of one hand at lower uterine segment and uterus is pushed upwards in to the abdomen at the same time maintaining gentle traction on clamped umbilical cord
2. Modified crede’s- gentle pressure is applied on the fundus of the contracted uterus, separated placenta is pushed downward to the vagina. Uterine fundus is grasped with 4 fingers at the back and the thumb anteriorly
3. The Ritgen maneuver- also known as the Ritgen's maneuver or perineal support, is a technique used during the delivery of the baby's head to protect the perineum (the area between the vaginal opening and the anus) and prevent excessive tearing or trauma.

5. What are the stages of labor? Describe and identify the specific signs for each stage.

STAGES OF LABOR

6. What are the cardinal movements of mechanisms of labor?

Cardinal movements of labor: De-F-IR-E-R-ER-E

• ENGAGEMENT
• Descent- fetal head enters the maternal inlet in the occiput transverse or oblique position
• Occurs because of 4 forces: (1) pressure of the amniotic fluid, (2) direct pressure of the uterine fundus on the breech, (3) contraction of the abdominal muscles, (4) extensions and straightening of the fetal body
• Flexion- fetal chin flexes downward onto the chest
• Allows smallest fetal diameter (suboccipitobregmatic diameter) to enter the maternal pelvis
• Internal rotation- fetal head must rotate to fit the diameter of the pelvic cavity
• Occiput usually rotated from left to right and the sagittal suture aligns in the anteroposterior pelvic diameter
• Extension- head is born in extension as the occiput slides under the symphysis pubis
• Face is directed towards the rectum
• With this positional change, the occiput, then brow and face, emerge from the vagina
• EXTENSION COMPLETE
• External rotation;Restitution- once the head is born and free from pelvic resistance, the neck untwists, turning the head to one side and aligns with the position of the back of the birth canal
• External rotation;shoulder rotation- head rotates (from anteroposterior position it assumed to enter the outlet) back to the diagonal or transverse position. This brings the shoulders into an anteroposterior position
• Expulsion- Anterior and posterior shoulders are born, quickly followed by the rest of the body

7. Signs of imminent vaginal fetal delivery?

• Once the fetus reaches +5 fetal station, which is crowning, the delivery of the fetus is imminent.
• Crowning.
• Contractions < 2 minutes.
• Rectal Fullness (c/o needing to have a bowel movement)
• Bulging in the perineum
•  Strong, reflexive maternal urge to push or defecate

8. What are some activities to stimulate uterine contractions?

• Fundal Massage Purpose: To stimulate uterine contraction, promote uterine tone and consistency, and minimize the risk of hemorrhage.
• Nipple stimulation
• Administration of oxytocin (synthetic form of naturally occurring pituitary hormone) initiates contractions in a uterus at pregnancy term.
• Prostaglandin Administration. Prostaglandins promote strong, sustained uterine contractions. Intramuscular injection of prostaglandin F22 is another way to initiate uterine contractions. Observe for nausea, diarrhea, tachycardia, and hypertension, all of which are possible adverse effects of prostaglandin administration.
• Exercise

9. Signs of placental separation - in proper order of events?

Signs of Placental Separation

• Uterus becomes firm and globular

• Uterine fundus rises in the abdomen

• Sudden gush of blood from the vagina

• Lengthening of the umbilical cord

• Appearance of the placenta at the vaginal opening

10. What is the maneuver used for placental delivery?

• Brandt-andrews: placing fingers of one hand at lower uterine segment and uterus is pushed upwards in to the abdomen at the same time maintaining gentle traction on clamped umbilical cord •Modified crede’s- gentle pressure is applied on the fundus of the contracted uterus, separated placenta is pushed downward to the vagina. Uterine fundus is grasped with 4 fingers at the back and the thumb anteriorly

11. What is "Unang Yakap"?

Unang yakap is a campaign launched by the Department of Health (DOH) with support from the World Health Organization. Many initiatives, globally and locally, help save lives of pregnant women and children.  Essential Newborn Care (ENC) is one.  

ENC is a simple cost-effective newborn care intervention that can improve neonatal as well as maternal care.  It is an evidence-based intervention that

• emphasizes a core sequence of actions, performed methodically (step -by-step);
• is organized so that essential time bound interventions are not interrupted; and
• fills a gap for a package of bundled interventions in a guideline format.

12. What is the normal/expected VS for the mother immediately postpartum and the newborn?

MOTHER

• • Blood pressure: 120/80
  • Heart Rate: 60-100 bpm
  • Respiratory rate: 12-20 bpm
  • Temp: 36.5 – 37.2
  • Oxygen: 95- 100%

NEWBORN

• • Blood pressure: 60/80- NOT DONE ROUTINELY
  • Heart Rate: 110-160 bpm
  • Respiratory rate: 30-60 bpm
  • Temp: 36.5 – 37.5
  • Oxygen: 95- 100%

13. What is lanugo? What is vernix caseosa?

Lanugo refers to the fine, downy hair that covers the body of a developing fetus. It typically begins to appear on the fetus around the 5th month of pregnancy and is most noticeable on the shoulders, back, and forehead. Lanugo serves various purposes, including regulating the body temperature of the fetus and aiding in the development of the skin and hair follicles.

Vernix caseosa is a waxy, white substance that covers the skin of a newborn baby. It's formed from secretions of the fetal sebaceous glands and dead skin cells. This substance serves as a protective barrier in the womb, shielding the baby's skin from the amniotic fluid. Additionally, vernix has antimicrobial properties that can help protect the baby's delicate skin from infections and maintain moisture levels after birth. Typically, it's wiped off or absorbed into the skin during the first hours or days after birth.

14. What is Crede maneuver for the placenta?

The Crede maneuver is a technique used to assist in the expulsion of the placenta after childbirth. It involves applying gentle pressure to the mother's abdomen, specifically over the uterus, to encourage the delivery of the placenta.

15. What is oxytocin? What are the uses of oxytocin?

Oxytocin is a hormone that is used to induce labor or strengthen uterine contractions, or to control bleeding after childbirth. Oxytocin is also used to stimulate uterine contractions in a woman with an incomplete or threatened miscarriage. Oxytocin may also be used for purposes not listed in this medication guide.

16. When is oxytocin given during labor and delivery?

• Induction of labor
• Augmentation of labor
• Facilitates sealing of rupture capillaries which then stops the bleeding and hemorrhage after delivery.
• To accelerate normal parturition
• Postpartum evacuation of uterine debris
• Postoperative contraction of the uterus following Cesarean section and control of uterine hemorrhage.

17. How is oxytocin given?

• Oxytocin (Pitocin) 10-20 u may be added to an IV infusion or 10 u intramusculary.
• 10 unit intramuscularly (IM) after delivery of the placenta
• Add 10-40 units; not to exceed 40 units; to 1000 mL of non-hydrating intravenous (IV) solution and infuse at the necessary rate to control uterine atony
• Labor Induction
• 0.5-1 mUnit/min IV, titrate 1-2 mUnit/min q15-60min until contraction pattern reached that is similar to normal labor (usually 6 mUnits/min); may decrease dose after the desired frequency of contraction reached and labor has progressed to 5-6 cm dilation
• Incomplete or Inevitable Abortion
• 10-20 mUnit/min; not to exceed 30 units/12 hours

18. What are the precautions for oxytocin administration?

• If uterine hyperactivity occurs, discontinue immediately
• Intravenous preparations should be administered by trained personnel
• Risk of severe water intoxication on prolonged administration due to its antidiuretic effect
• Restricting fluid intake may be warranted
• Uterine hypertonicity, spasm, rupture of the uterus, and tetanic contractions may occur from high doses
• Intramuscular (IM) not recommended for labor induction/augmentation

19. When is oxytocin NOT administered?

• Not indicated for elective labor induction
• Hypersensitivity
• Fetal distress, polyhydramnios, partial placenta previa, prematurity, borderline cephalopelvic disproportion, previous major surgery of cervix or uterus (including C-section), over-distension of the uterus, grand multiparity, invasive cervical carcinoma, history of uterine sepsis, or traumatic delivery
• Hyperstimulation of the uterus, with strong (hypertonic) and/or prolonged (tetanic) contractions, or a resting uterine tone of 15-20 mm H2O between contractions may occur, possibly resulting in uterine rupture, cervical and vaginal lacerations, postpartum hemorrhage, abruptio placentae, impaired uterine blood flow, amniotic fluid embolism, & fetal trauma including intracranial hemorrhage
• Significant cephalopelvic disproportion
• Unfavorable fetal positions or presentations, e.g., transverse lies, which are undeliverable without conversion before delivery
• Obstetric emergencies that favor surgery
• Fetal distress where delivery is not imminent
• Where adequate uterine activity fails to achieve satisfactory progress
• Hyperactive or hypertonic uterus
• Contraindicated vaginal delivery, e.g., invasive cervical carcinoma, active herpes genitalis, total placenta previa, vasa previa, and cord presentation or prolapse of cord

20. What are the anthropometric measurements to take in a newborn?

Anthropometric Measurement

• Head: 33cm - 35cm
• Chest: 30.5cm - 33cm (measure at the level of the nipple) *less than 30 is a sign of prematurity
• Abdomen: 30.5cm - 33cm
• Length: 45cm – 55cm (head to heel, follow contours

21. What vaccines are given in a newborn or before the NB is discharged from the hospital. Enumerate the vaccines, dosage , site, and the type of injection for each.

• BCG, Right Deltoid muscle- 0.1ml
• Vitamin K, Left Vastus Lateralis- 0.5
• Hepa B, Right vastus lateralis- 0.5 or 0.05

22. What is vacuum extraction assisted delivery?

• A fetus, if positioned far enough down the birth canal, may be born by vacuum extraction (Incerpi, 2007). With the fetal head at the perineum, a disk-shaped cup is pressed against the fetal scalp, over the posterior fontanelle. When vacuum pressure is applied, air beneath the cup is suctioned out and the cup then adheres so tightly to the fetal scalp that traction on the cord leading to the cup extracts the fetus (Fig. 23.14). Vacuum extraction has advantages over forceps birth in that little anesthesia is necessary (leaving the fetus with less respiratory depression at birth) and fewer lacerations of the birth canal occur (Johanson & Menon, 2009). Its major disadvantage is that it causes a marked caput on the newborn head that may be noticeable as long as 7 days after birth. Tentorial tears from extreme pressure also have occurred. A woman may need reassurance that the caput swelling is harmless to her infant and will decrease rapidly. Vacuum extraction should not be used as a method of birth if fetal scalp blood sampling was used, because the suction pressure can cause severe bleeding at the sampling site. Moreover, vacuum extraction is not advantageous for preterm infants because of the softness of the preterm skull.
• Vacuum extraction is one kind of assisted delivery procedure that can help get your baby through the birth canal when labor is stalled in the second stage. The vacuum extractor applies suction and traction to the baby’s head to help pull it out while you push. Vacuum extraction is only recommended under certain conditions.

23. What is the most common type of fetal presentation during delivery and the least common?

• Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.
• Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries.

24. What are the steps of female urinary catheter insertion?

1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy
4. Place the client in the appropriate position and drape all areas except the perineum. • Female: supine with knees flexed, feet about 2 feet apart, and hips slightly externally rotated, if possible
5. Establish adequate lighting. Stand on the client’s right if you are right-handed, on the client’s left if you are left-handed. 6. If using a collecting bag and it is not contained within the catheterization kit, open the drainage package and place the end of the tubing within reach.

base on the book.

26. What is the significance of the mother having an empty bladder during delivery?

• Women should be encouraged to void regularly during pregnancy and during labour, the volume passed should be recorded on the partogram (NICE, 2017) and fluid balance chart during labour. Incomplete bladder emptying can delay the descent of the baby, reduce the efficiency of the contractions and increase pain so it is vital that bladder function and health is considered throughout labour. The need for assessment of urinary symptoms and of bladder emptying and urinary residual is critical to ensure accurate diagnosis and care. During labour there is an increased risk of bacteria entering the urinary tract. Urethral catheterisation, whether indwelling or in and out, also increases the risk of a UTI. The role of catheter fixation devices and good catheter care in preventing this, should be part of usual care. Women naturally open their bowels during labour because the muscles used to push during labour are the same as those used for defaecation. It is important that dignity is maintained throughout when women pass a stool without having control of it.

27. Types of episiotomy

• An episiotomy is a surgical incision of the perineum that is made both to prevent tearing of the perineum and to release pressure on the fetal head with birth
• Episiotomy is classified into the following types: Midline, Mediolateral, Lateral, the modified-median, J-shaped, anterior, and radical (Schuchardt incision).

Severity of Episiotomies

Episiotomies are classified by degrees that are based on the severity or extent of the tear:

• First Degree: A first-degree episiotomy consists of a small tear that only extends through the lining of the vagina. It doesn’t involve the underlying tissues.
• Second Degree: This is the most common type of episiotomy. It extends through the vaginal lining as well as the vaginal tissue. However, it doesn’t involve the rectal lining or anal sphincter.
• Third Degree: A third-degree tear involves the vaginal lining, the vaginal tissues, and part of the anal sphincter.
• Fourth Degree: The most severe type of episiotomy includes the vaginal lining, vaginal tissues, anal sphincter, and rectal lining.

28. When is an episiotomy done?

• The baby does not have enough oxygen (fetal distress) Complicated birth, such as when the baby is positioned bottom or feet first (breech) or when the baby's shoulders are trapped (shoulder dystocia) Long pushing stage of labor.
• The pressure of the fetal presenting part against the perineum is so intense that the nerve endings in the perineum are momentarily deadened. This lack of sensation allows an episiotomy to be done without anesthesia. For some women, a pudendal block may be done beforehand to ensure that there is no pain.

29. What are the advantages and disadvantages of an episiotomy?

• The advantage of an episiotomy is that it substitutes a clean cut for a ragged tear, minimizes pressure on the fetal head, and may shorten the last portion of the second stage of labor.
• Mediolateral episiotomies have the advantage over midline cuts in that, if tearing occurs beyond the incision, it will be away from the rectum, creating less danger of complication from rectal mucosal tears (de Leeuw et al., 2008). Anal sphincter tears can lead to fecal incontinence later in life (Mous, Muller, & de Leeuw, 2008). Midline episiotomies, however, heal more easily, cause less blood loss, and result in less postpartal discomfort.
• Disadvantages of mediolateral incisions include difficulty to repair, greater blood loss and more discomfort during recovery.
• Higher risk for infection, prolonged healing time
• Develop complications
• increased blood loss
• more severe pain
• difficult repair

30. In proper order, what are the steps for doing perineal care for a female patient?

• Clean the labia majora. Then spread the labia to wash the folds between the labia majora and the labia minora. ❷ Rationale: Secretions that tend to collect around the labia minora facilitate bacterial growth.
• Use separate quarters of the washcloth for each stroke, and wipe from the pubis to the rectum. For menstruating women and clients with indwelling catheters, use clean wipes. Use a clean wipe for each stroke. Rationale: Using separate quarters of the washcloth or new wipes prevents the transmission of microorganisms from one area to the other. Wipe from the area of least contamination (the pubis) to that of greatest (the rectum).
• Rinse the area well. You may place the client on a bedpan and use a Peri-Wash or solution bottle to pour warm water over the area. Dry the perineum thoroughly, paying particular attention to the folds between the labia. Rationale: Moisture supports the growth of many microorganisms.