MATERNAL AND CHILD NURSING

Prepared by:
Ma. Reina Rose D. Gulmatico, RN, MSN

I. FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY

A. External Reproductive Organs

Mons Pubis (Mons Veneris) – (Mount of Venus) is a pad of fat lying over the symphysis pubis;
covered with pubic hair from the time of puberty

Labia Majora (Greater lips) – are two folds of fat and areolar tissue, covered with skin and pubic hair
on the outer surface; arise in the mons veneris and merge into the perineum behind.

Labia Minora (Lesser lips) - two folds of the skin between the labia majora; anteriorly, they divide to
enclose the clitoris; posteriorly they fuse, forming the fourchette

Clitoris - rudimentary organ corresponding to the male penis; extremely sensitive and highly vascular
and plays a part in the orgasm of sexual intercourse

Vestibule - area enclosed by the labia minora in which encloses the openings of the urethra and the
vagina

Vaginal orifice- also known as the introitus of the vagina and occupies the posterior two-thirds of the
vestibule; partially closed by the hymen, a thin membrane that tears during sexual intercourse or
during birth of the first child

Skene’s Glands- either side of the meatus which are often involved in infections of external genitalia

Bartholins Glands - are two small glands which open on either side of the vaginal orifice and lie on the
posterior part of the labia majora. They secrete mucus which lubricates the vaginal opening.

B. Internal Reproductive Organs

THE VAGINA
Structure:
vaginal walls are pink in appearance and thrown into small folds called the rugae that stretches during
intercourse and delivery.

Functions:
a passage that allows the escape of the menstrual flow
receives the penis and the ejected sperm during sexual intercourse and provides an exit for the fetus
during delivery
THE UTERUS
Structure
hollow, muscular, pear-shaped organ situated in the true pelvis

the cervix forms the lower third of the uterus

Functions
to shelter the fetus during pregnancy and following pregnancy it expels the uterine
contents

Parts of the Uterus

Body or corpus – makes up the upper two-thirds of the uterus and is the greater part

Fundus – domed upper wall between the insertions of the uterine tubes

Cornua – are the upper outer angles of the uterus where the uterine tubes join

Cavity – potential space between the anterior and posterior walls

Isthmus – narrow area between the cavity and the cervix that enlarges during pregnancy to form the
lower uterine segment

Cervix or Neck – protrudes into the vagina; supravaginal (upper half)- above the vagina
infravaginal portion (lower half)

Layers of the Uterus

Endometrium - forms a lining of ciliated ephitelium (mucus membrane) on a base of connective
tissue (stroma)

Myometrium (muscle coat)- thick in the upper part of the uterus and is more sparse in the isthmus
an cervix.

Perimetrium

D. UTERINE TUBES

Functions
• The uterine tubes propels the ovum towards the uterus, receives the
spermatozoa as they travel upwards and provides a site for fertilization. It
supplies the fertilized ovum with the nutrition during its continued journey to the
uterus.

Structure
• Each tube is 10 cm long. The lumen of the tube provides an open pathway from
the outside to the peritoneal cavity. The uterine tube has four portions:
 a) The interstitial portion – is 1.25 cm long and lies within the wall of the uterus. It’s lumen
is 1 mm wide.
b) The isthmus – is another narrow part which extends from 2.5 cm from the uterus.
c) The ampulla – is the wider portion where fertilization usually occurs.
d) The infundibulum – is the funnel shaped fringed end which is composed of many
processes known as fimbriae. One fimbriae is elongated to form the ovarian fimbria
which is attached to the ovary.

E. THE OVARIES

Functions
• The ovaries produce ova and the hormones estrogen and progesterone.

Structure
• The ovary is composed of the medulla and cortex, covered with germinal
epithelium.

F. THE FEMALE PELVIS

Functions
• The primary function of the pelvic girdle is to allow movement of the body
especially walking and running. It permits the body to sit and kneel.
• The woman’s pelvis is adapted to child-bearing, and because of its increased
width and rounded brim, women are less speedy than men.
• The female pelvis, because of its characteristics, gives rise to no difficulties
during in childbirth, provided that the fetus is of normal size.

Pelvic Bones
•There are four pelvic bones:
1. two innominate (nameless) or hip bones – each innominate bone is
composed of three bones:
 The ilium
 The ischium
 The pubic bone

2. one sacrum

3. one coccyx
 False Pelvis
superior half formed by the ilia; offers landmarks for pelvic measurements; supports the
growing uterus during pregnancy; directs the fetus into the true pelvis near the end of gestation

True Pelvis- is the bony canal through which the fetus must pass during birth. It has a brim, a
cavity and an outlet.

inferior half formed by the pubes in front, the ilia and the ischia on the sides and the
sacrum and coccyx behind

1. Inlet
entranceway to the true pelvis; transverse diameter is wider than its anteroposterior (AP)
diameter

* Transverse diameter – 13.5 cm.

* Anteroposterior (AP) diameter – 11 cm.

2. Outlet
inferior portion/ lower border of the true pelvis of the pelvis

anteroposterior diameter is wider than its transverse diameter

3. Cavity
space between the inlet and the outlet

contains the bladder and the rectum, with the uterus between them in an ANTEFLEXED
position towards the bladder

Variation/Types of Pelvis
1. Gynecoid – “normal” female pelvis that is most ideal for childbirth because it is well
rounded forward and back
2. Anthropoid – transverse diameter is narrow, AP diameter is larger than normal
3. Platypelloid – inlet is oval, AP diameter is shallow
4. Android – “male” pelvis; inlet has a narrow shallow posterior portion and pointed anterior
portion.
 MENSTRUAL CYCLE

A. KEY CONCEPTS
1. Hormones
•Estrogen
•Progesterone
•Follicle Stimulating Hormone (FSH)
•Luteinizing Hormone (LH)

2. Associated Terms
• Amenorrhea
• Menorrhagia
• Metrorrhagia
• Polymenorrhea
• Oligomenorrhea
 STAGES OF FETAL DEVELOPMENT

I. FERTILIZATION
Site: fallopian tube
mature ovum + sperm = (zygote)
Gamete: sex cell
contains 23 chromosomes
Sperm: contains X and Y chromosomes (XY)
Ovum: contains X chromosomes (XX)
II. Implantation
occurs 7 days post fertilization

Fertilized zygote migrates 3-4 days

(uterus)

morulla mitosis

multiplication and floating in the

uterine cavity (3 - 4 days)
+

mass of
large cells
(fluid space)

Blastocysts Apposition
a. Trophoblast A. Adhesion
b. Erythroblast (endometrium)
B. Invasion

Post implantation:
uterine endothelium DECIDUA

Blastocysts
a. Trophoblast (outer)- PLACENTA
b. Erythroblast (inner)- EMBRYO

TROPHOBLAST

decidua (endometrium) chorionic villi

“falling off”
removed after delivery Cytotrophoblast Syncytiotrophoblast
a. Basalis (maternal circulation) (inner) (outer)
b. Encapsularis (trophobast)
c. Vera (remaining portion)

Langhan’s Syncytial

protection for fetal membranes

infection
*present until 20th – 24th week
 SYNCYTIAL + Decidua
basalis

fetal membranes

Amnion Chorion

Umbilical cord Amniotic fluid Placenta

Fetal Development

A. Amniotic fluid
1. Protective function
Shields the fetus against blows or pressures on the mother’s abdomen
Protects the fetus against sudden changes in temperature
Protects the fetus from infection

“Injury, Temperature, Infection”

2. Diagnostic function
Amniocentesis (chromosomal abnormalities)

Meconium-strained amniotic (fetal distress)

3. Aids in the descent of the fetus during active labor

B. Placenta
1. Provides oxygen to the fetus
2. Provisions of nutrients (diffusion through the placental tissues)
3. Feto-placental circulation (osmosis)
4. Excretion of waste products
5. Production of hormones
HCG
HPL
Estrogen
Progesterone
6. Protective – inhibits the passage of bacteria and large molecules to the fetus
 Stages of human prenatal development:
First 12-14 days – zygote

From 15th day up to the 8th week – embryo

From the 8th week up to the time of birth – fetus

I. First Lunar month

a. Germ layers: differentiate by the 2nd week

1. Endoderm – develops into the lining of the GIT, respiratory tract, tonsils, thyroids,
parathyroid, thymus gland, bladder and urethra

2. Mesoderm – forms into the supporting structures of the body (connective tissues,
cartilage, bones, muscles and tendons); heart, circulatory system, reproductive
system, kidneys and ureters

3. Ectoderm – responsible for the formation of the nervous system; the skin, hair and nails;
and the mucous membrane of the mouth and anus

b. Fetal membranes (amnion and chorion): 2nd week

c. Nervous system: 3rd week

d. Fetal heart begins to form at 16th day of life

II. Second lunar month

a. All vital organs are formed: 8th week.
b. Placenta develops
c. Sex organs (ovaries/testes) are formed: 8th week
Sex determination: conception
Sex formation: 2nd lunar month
d. Meconium formation: 5th-8th week.

III. Third lunar month

a. Urine formation: 12th week of pregnancy
b. Fetus swallows amniotic fluid
c. Feto-placental circulation begins through osmosis: no direct exchange between fetal and maternal
blood

IV. Fourth lunar month

a. Lanugo appears
b. Heart beats maybe audible with fetoscope
V. Fifth lunar month
a. Vernix caseosa (cheesy covering on entire body to prevent drying of fetal skin) appears
b. Lanugo covers entire body
c. Quickening (fetal movements) is felt
d. Fetal heart beats very audible

VI. Sixth lunar month

a. Skin markedly wrinkled
b. Attains proportions of full term baby

VII. Seventh lunar month

a. Alveoli begin to form
b. Production of surfactant

VIII. Eight lunar month

a. Fetus is viable
b. Lanugo begins to disappear

IX. Ninth lunar month

a. Lanugo and vernix disappear
b. Amniotic fluid volume somewhat decreases

X. Tenth lunar month – has all characteristics of a normal newborn.

FETAL CIRCULATION
 NURSING CARE DURING LABOR AND DELIVERY

Theories of labor
Uterine Stretch theory – any hollow body organ when stretched to capacity
contract and empty

Oxytocin theory – production of oxytocin from posterior pituitary gland

uterine contraction

Progesterone Deprivation theory – progesterone inhibits uterine motility

Decrease progesterone uterine contraction

Prostaglandin theory: increase prostaglandin synthesis uterine contraction

Theory of Aging Placenta: decrease in blood supply to the placenta

uterine contraction

Premonitory/ Preliminary Signs of Labor

1. Lightening - the settling of the fetal head into the pelvic brim
*Engagement occurs when the presenting part has descended into the pelvic
inlet (station 0)

2. Loss of weight – about 2-3 lbs. 1 to 2 days before labor onset due to decrease progesterone
resulting to decrease fluid retention

3. Increased activity level – due to increase in epinephrine level

4. Braxton Hicks contractions- irregular painless, “practice” contractions

5. Ripening of the cervix – Goodell’s sign

6. Rupture of the membranes

Important Nursing Considerations:
A. Ruptured BOW
*Initial Nursing Action:
Put her on the bed immediately, then take the FHT
Instruct the client not to ambulate: FETAL CORD COMPRESSION
B. Cord Prolapse
*Initial Nursing Action:
Put her on Trendelenburg position to reduce pressure on the cord.

(REMEMBER: Only 5 minutes of umbilical cord compression can already lead to CNS
damage even death.)

Apply a warm saline-saturated OS on the cord to prevent drying of the

cord.

7. Show
Sudden gush of blood (pinkish vaginal discharge)

*Nursing Implication:
Assess for the color of vaginal discharge
GREENISH- meconium stained
BRIGHT RED- vaginal bleeding

SIGNS OF TRUE LABOR

1. Uterine contractions
2. Effacement/ Dilatation
In primis, effacement occurs before dilatation (ED)
In multis, dilatation proceeds effacement (DE)

False vs True Labor

Parameters for comparison:
1. Regularity
2. Location
3. Changes in contractions (FID)
4. Absence/ Presence of contractions during activity]
5. Cervical changes
FALSE LABOR PAINS TRUE LABOR PAINS
Remain irregular May be slightly irregular at first but
predictable within regular and predictable
within a matter of hours

Generally confined to the abdomen First felt in the lower back and sweep around
to the abdomen in a girdle-like fashion

No increases in duration, frequency and Increase in frequency, duration and intensity

intensity

Often disappears if the woman ambulates Continue no matter what the woman’s level of
activity is

Absent cervical changes Accompanied by cervical effacement and

dilatation (the most important difference)

Length of Normal labor:

Primis- 14 hours
Multis- 8 hours

5 P’s of Labor
1. Passenger (Fetus)

2. Passageway (Pelvis)

Shape and measurement of maternal pelvis and distensibility of birth canal

Engagement: fetal presenting part enters true pelvis (inlet)

Primi: two weeks before labor
Multi: beginning of labor

Soft tissue (cervix, vagina): stretches and dilates under the force of contractions to
accommodate the passage of the fetus
3. Power

A. Uterine Contractions (involuntary): fingers should be spread lightly over the fundus
1. Frequency: from the BEGINNING of one contraction to the beginning of the
next contraction (A-C)
2. Interval: from the END of one contraction to the BEGINNING of the next
contraction (B-C)
3. Duration: from the BEGINNING of one contraction to the END of the
same contraction (A-B)

4. Intensity: strength of a contraction should be measured during the acme of

contraction
a. mild
b. moderate
c. strong

A B C

B. Voluntary Bearing Down Efforts: use of ABDOMINAL MUSCLES to help expel fetus
thru CONTRACTION OF LEVATOR ANI MUSCLES

4. Placenta

5. Psychological response
“A positive attitude during labor yields a positive outcome.”

A woman who is: relax, aware and participating in the birth process: shorter, less
intense labor
A woman who is: fearful has high levels of adrenaline which slows uterine contractions
 STAGES OF LABOR

1st - Stage of Dilatation

1st - Stage of dilatation: from onset of labor until full dilatation of cervix

Phases:
Latent phase: 3-4 cm
Active phase: 4-8 cm
Transition phase: 8-10 cm

1. Latent Phase
Duration: 6 hours
Cervical dilatation: 3-4 cm
Uterine contractions: every 15-30 minutes; short duration; mild intensity
Women’s Attitude: excited with some degree of apprehension

Support Measures
1. Establish rapport
2. Breathing exercise
3. Encourage ambulation
4. Offer ice chips or fluids
5. Encourage voiding of the client

2. Active/Accelerated
Cervical dilation: 4-8 cm
Uterine Contractions: every 3-5 minutes; 30-60 seconds
duration; moderate intensity
Women’s Attitude: afraid of losing control of herself

Support Measures
1. Encourage breathing exercise
2. Provide a quiet environment
3. Provide reassurance, encouragement and support
4. Provide comfort (back massage, assisting positioning,
support with pillows
5. Provide ice chips for dry mouth
Nursing management/ Health Teaching During Stage 1
1. Ambulation
(+) Ambulation – during the LATENT PHASE

*to shorten the first

stage of labor

BUT

(-) Ambulation- RUPTURED BOW

2. Diet

“No food or fluid please!”

On NPO
Solid or liquid foods are to be avoided because:
Digestion is delayed during labor
A full stomach interferes with proper bearing down
May vomit resulting to ASPIRATION

3. Enema administration
NOT a routine procedure

Purposes:
A full bowel hinders the progress of labor
Expulsion of feces during second stage of labor- INFECTION of the
mother and baby
Full bowel predisposes to postpartum discomfort
Procedure:
Enema solution: soapsuds or Fleet enema
Optimal temperature of the solution: 105°F to 115°F (40.5 °C-46.1°C)
Patient on side-lying position

NURSING IMPLICATION DURING ENEMA:

(+) RESISTANCE during insertion of rectal catheter: withdraw the
tube slightly while letting a small amount of solution enter

(+) CONTRACTION: clamp rectal tubing

IMPORTANT NURSING ACTION:
Check FHR AFTER enema administration to determine any FETAL
DISTRESS

Contraindications:
Vaginal bleeding
Premature labor
Abnormal fetal presentation or position
Ruptured membranes
Crowning

4. Voiding
“Please empty my bladder”

Should void every 2-3 hours

Offer the bedpan if BOW has ruptured because:

A full bladder retards fetal descent
Urinary stasis can lead to urinary tract infection
A full bladder can be traumatized during delivery

5. Breathing Technique
DO NOT PUSH OR BEAR DOWN DURING CONTRACTIONS because it leads
to: unnecessary exhaustion AND cervical edema (due to repeated strong pounding
of the fetus against the pelvic floor); thus interfering with dilatation and prolonging
the length of labor

ABDOMINAL BREATHING should be encourage to reduce tension and prevent

hyperventilation

“No to pushing, Yes to breathing!”

6. Position
“I need to lie on my side!”

Sim’s position
SINCE:
It favors anterior rotation of the fetal head
It promotes relaxation between contractions
It prevents Supine Hypotensive Syndrome/Vena Cava Syndrome
7. Monitoring
Contractions
Vital Signs (Temperature/ BP)
A. Temperature: sign of infection due to early RUPTURE OF
MEMBRANE

B. Blood pressure (q 30 minutes)

Should be taken midway/between contractions

BECAUSE

BP INCREASES during contraction

(-) blood going to the uterus

(+) blood in the periphery

Danger Signals
Signs of Fetal distress
Signs of Maternal Distress

FHT/ FHT Variability

NORMAL Fetal heart rate: 120/160 BPM

Should be taken midway/between contractions BECAUSE FHT

DECREASES during contraction (AS A RESULT vagal stimulation
due to fetal head compression by the contracting uterus)

Should not be mistaken for UTERINE SOUFFLÉ which

synchronizes maternal heart/pulse rate

Should be taken:
every hour - latent phase
every half hour - active phase
every 15 minutes – transition

INITIAL NURSING ACTION FOR ABNORMAL FHT:

Change the mother’s position
Acceleration: visually apparent abrupt INCREASE in FHR; increase
of 15 beats per minute or greater and lasts 15 seconds
or more; with return to baseline less than 2 minutes
a. Periodic: usually encountered with BREECH
PRESENTATION

Remember:
Pressure of the contraction applied to
A. Fetal buttock- ACCELERATION
B. Fetal head- DECELERATION

b. Episodic: increase FHR during fetal movement

NORMAL FINDING

Deceleration: dominance of PARASYMPATHETIC response

described in relation to the ONSET and end of a
CONTRACTION and by their SHAPE

a. Early- HEAD COMPRESSION

visually apparent decrease in an return to baseline FHT

normal and benign finding

Characteristic: uniform shape

early onset due to RISE in INTRAAMNIOTIC

PRESSURE as the uterus contracts

occurs during the first stage when cervix is dilated to 4 to

7 cm
 COMPARISON BETWEEN ACELERATION AN DECELERATION
PARAMETERS ACCELERATION DECELERATION
DESCRIPTION transitory increase of fhr transitory decrease of fhr above
above baseline baseline

SHAPE resembles shape of uterine uniform, MIRROR IMAGE OF

contraction UTERINE CONTRACTION

early in contraction phase bfore

ONSET onset to peak : 30 seconds peak
orocurs during
contraction
end of uterine contraction
RECOVERY less than 2 minutes
HEAD COMRESSION
COMMON CAUSE SPONTANEOUS FETAL
MOVEMENT

b. Late- UTEROPLACENTAL INSUFFICIENCY

occurs after the start of contraction

lowest point of decelertion: after peak does not return to

baseline

until after the contraction is over

CAUSE: maternal supine hypotensive

syndrome

Effect: fetal hypoxia

c. Variable: UMBILICAL CORD COMPRESSION

decrease is > 15 bpm; lasts at least 15 seconds;

returns to baseline in less than 2 minutes from the
time of onset

SHAPE: U, V , W
COMPARISON BETWEEN LATE AN VARIABLE DECELERATION
 PARAMETERS LATE VARIABLE
DECELERATION DECELERATION
DESCRIPTION GRADUAL decrease ABRUPT decrease

SHAPE uniForm, MIRROR U, V, W

IMAGE OF UTERINE
CONTRACTION

ONSET Late in contraction; after Beginning of the depth <

peak of contraction 30 sec; duration of ≥ 15
sec; decrease in FHR is ≥
1 BPM

RECOVERY After end of contraction < 2 minutes from onset

less than 2 minutes

COMMON CAUSE Uteroplacental Umbilical Cord

Insufficiency Compression

8. Administration of Analgesics (Demerol)

Drug of choice: DEMEROL
Indication: analgesic, sedative and antispasmodic (CNS DEPRESSION)

IMPLICATION TO NURSING CARE:

Do not give
A. early in labor:
Retards progress of uterine contractions

B. if delivery is only an hour away : Respiratory depression in the

newborn occurs

Give if cervical dilatation is already 6-8 cm

9. Administration of Anesthetics
Anesthetic of choice: Xylocaine
 NURSING CONSIDERATION:
On NPO with IV to prevent aspiration and dehydration

Types of anesthesia:
A. Paracervical – transvaginal injection into either side of the cervix

B. Pudendal - through the sacrospineous ligament into the posterior areolar

tissues
Side effect:
(+) ecchymosis to the right of the perineum

Ice bag application to the area on the first day to reduce

swelling or bleeding

C. Low spinal
1. Epidural (caudal) - local anesthetic injected at the lumbar
level
2. Saddle block - injection into the 5th lumbar space
(+) Anesthesia: perineum, upper thighs and lower pelvis
Position: sitting or side-lying position with back aligned

NURSING IMPLICATIONS:
TYPE of delivery: Forceps delivery (due to loss of coordination in
second stage pushing)

Adverse effect: POSTSPINAL HEADACHES (due to the leakage of

anesthetic into the CSF or injection of air at the time of needle
insertion)

Management:
Increase fluid intake
FLAT ON BED without pillows for the first 12 hrs after
delivery

Common side effects of regional anesthesia

1. Hypotension - due to vasodilator effects of xylocaine
Management: Turn to side; prompt elevation of legs;
administration of vasopressors as ordered and
oxygen
 2. Fetal bradycardia
3. Decreased maternal respiration

3. TRANSITION PHASE

A. Cervical Dilatation: 8-10 cm

B. Characteristics:
1. changes in the mood and intensity of contraction
2. rupture of membrane
if (-) ROM: AMNIOTOMY
to prevent aspiration of fetus from amniotic fluid

CONSIDERATION:
“(-) AMNIOTOMY for STATION (-)”
to prevent cord compression

3. Prominent SHOW

4. Uncontrollable urge to push during contraction

Nursing management:
1. Breathing technique
Controlled chest (costal) breathing during contractions

2. Avoidance of Bearing Down

3. Emotional Support

4. Comfort measures (Sacral pressure)

2nd - Stage of Expulsion

begins with complete dilatation of the cervix and ends with the
delivery of the baby

Mechanisms of Labor /Fetal Position Changes

(D FIRE ERE)
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion

Nursing management
1. Positioning
LITHOTOMY
When positioning legs onto the stirrups, put them up at the same time
in order to prevent injury to the uterine ligaments

2. Bearing Down technique/ Mc Robert’s maneuver

Head crowning: instruct mother NOT TO PUSH, BUT TO PANT (rapid and
shallow breathing), so as to prevent rapid expulsion of the baby.

Mc Robert’s Maneuver: To prevent shoulder dystocia

(+) delivery of the head BUT (-) delivery of the anterior
shoulder in the pubic arch

Position: woman’s legs are flexed apart with her knees on her
abdomen

Mc Robert’s Maneuver

SACRUM straightens
SYMPHYSIS PUBIS rotates
PELVIC INCLINATION decreased

freeing the shoulder

3. Breathing Technique
4. Episiotomy
Indications:
MAIN- TO PREVENT LACERATIONS

Prevent prolonged and severe stretching of muscles

supporting the bladder and rectum

Reduce duration of second stage of labor

Enlarge outlet in breech presentations or forceps delivery

Types of episiotomy
A. Median – from middle portion of the lower vaginal border
directed towards the anus

B. Mediolateral – begun in the midline but directed laterally

away from the anus

5. Modified Ritgen’s Maneuver

Apply PRESSURE AGAINST THE RECTUM using sterile towel;
drawing it DOWNWARD to aid in flexing the head as the back of the
neck catches under the symphysis pubis

Apply UPWARD pressure from the coccygeal region to extend the

head during the actual birth (to protect the musculature of the
perineum)

6. Handling of Newborn
Immediately after delivery

A. Infant Position:
1. head lower than the rest of the body to allow drainage of
secretions

2. NEWBORN is held below the level of the mother’s vulva for

a few seconds to allow placental blood to enter the infant’s
body through gravity flow
 B. Provide warmth by
1. Wrapping the baby in a sterile diaper to keep him warm.

C. Place the baby on the mother’s abdomen.

The weight of the baby will help contract the uterus.

7. Cutting of Cord
Cutting of the cord- until the pulsations have stopped because 50-100 ml. of
blood is still flowing from the placenta to the baby at this time

Then, clamp twice, an inch apart and cut between.

8. Initial Contact
After newborn care,

Show the baby to the mother, inform her of the sex and time of delivery

Encourage the mother to start breastfeeding of the child.

3rd - Placental Stage

4th - First 2 hours after delivery