Nursing Info

The Mechanical Factors

The uterus reduces in size 2.5cm below the umbilicus, or 15cm above the symphysis pubis after the expulsion of the fetus. The contraction and retraction of the uterine muscles continues. The placental site is reduced to half. Since the placenta is inelastic, it does not contract, so it detaches from the shrinking uterine wall. The placenta is pushed further to the lower.

This is accumulated blood from the separated placenta. With the next contraction the placenta is pushed into the vagina and expelled.

You will know that the placenta has separated and has been expelled from the upper uterine segment into the lower segment or into the vagina when you have noted:

Elongation of the cord which does not recede on pressing at the symphysis pubis

A gush of blood.

The uterus contracts like a cricket ball.

The placenta is expelled either with maternal side exposed, known as the Mathew-Duncan method or the foetal side exposed known as the Shultz Method.

Control of Bleeding After Delivery

Steps should be taken to ensure the control of bleeding:

• The uterine muscle’s contraction and retraction causes the placental site to reduce into half. Criss-cross fibres control bleeding by compressing the blood vessels. These fibresare also known as ‘living ligatures’
• Clotting of blood takes place in the sinuses sealing the bleeding points a few hours later when uterine contractions are less vigorous.
• The time interval between the delivery of the baby and delivery of the placenta is a dangerous period, in which one of the greatest complications of pregnancy and labour can occur.
• This complication is excessive bleeding or postpartum haemorrhage (PPH). You should never leave the mother alone even for a short while during this stage.
• The third stage of labour can be managed either passively or actively.

The Passive or Natural Method of Managing the Third Stage of Labour

The passive or natural method occurs naturally, that is without any interference. For example, in a normal delivery, if oxytoxic drugs are not used, the uterus generally remains inactive for a few minutes after the delivery of the baby, after which regular contractions then begin again.

Physiology of the third stage takes place, the placenta is expelled and bleeding is controlled.

Giving Oxytocic Drugs

Oxytocin, ergometrine or syntometrine stimulate uterine contraction.

Ergometrine 0.5mg given IM causes a uterine contraction to occur five to seven minutes after the injection. Given intravenously it acts within 45 seconds.

Syntometrine is a mixture of oxytocin and ergometrine 0.5ml given IM acts within two to three minutes.

Usually sytrometrine is given with the delivery of the anterior shoulder while ergometrine is given at the crowning of the head.

Controlled Cord Traction

The uterus must be firmly contracted before this method can be used. It is not necessary to wait for signs of placenta separation.

Place the left hand above the symphyis pubis, push the uterus upwards and backwards with the right hand and pull the cord downwards and outwards.

Apply traction steadily without jerking When the placenta is visible at the vulva, direct the cord upwards.

The placenta will follow the curve of the birth canal. Receive it with both hands and rotate the placenta. This will twist the membranes. You can then deliver the membranes with up side movements, which enable them to be drawn out without breaking.

Maternal Effort

This method is not commonly used. When the placenta has separated and descended, the palm is placed downwards on the mother’s abdomen to provide a backup that the mother can push against.

During a contraction, the mother should be asked to push down. The placenta will be pushed out of the vagina. This method is useful in the event of a macerated birth.

Do not apply downward fundal pressure while doing cord traction as this can lead to inversion of the uterus.

The other method that can be used to deliver the placenta is the fundal pressure method.

Fundal Pressure

This method should be used in case of a macerated or pre-term baby as the strength of the cord is reduced. You should wait for the following signs of placental separation:

The fundus feels hard like a cricket ball.

There is a gush of blood due to placenta separation.

The cord lengthens and doesn’t recede with pressure on the symphysis pubis.

Procedure

• Make sure the bladder is empty.
• Instruct the mother to breathe through an open mouth slowly and quietly.
• When there is a contraction, grasp the uterus with your left hand fingers behind the uterus.
• Thumb in the anterior surface. Apply pressure to the pelvic inlet in downward and backward direction.
• Receive the placenta with both hands. 
• If the membranes do not slip out, turn the placenta around and deliver the membranes slowly with an upward movement.
• Rub the uterus and expel the clots. Once the placenta is out, you will need to examine the birth canal.
• Explain to the mother that you need to check if she has any tears, warn her it will be a bit painful but the worst part has passed, you will be very gentle and quick and that she needs to cooperate
• Change the gloves, roll gauze over pointing and middle fingers of the right hand
• Insert middle fingers of left hand facing upwards pushing the upper vaginal wall
• With the right hand press down the lower vaginal wall exposing the cervix.
• Check for any tears with the two fingers of your right hand, mop both sides of the vaginal wall, finish with the fourchette
• Reassure the mother in case there is any tear for suturing
• Cover the perineum with the folded pad into a half
• Wipe the buttocks from the fourchette towards the rectum cover the perineum completely.
• Collect any blood loss from the bed
• Change the bed linen with the help of an assistant
• In case of episiotomy or a tear, scrub your hands while your assistant is setting a sterile suturing pack and repair the tear.
• Ask the mother to lie on her back with her legs crossed on each other
• Ask the assistant to hand over the baby to the mother.
• Leave the mother to rest while you go to examine the placenta.

The Fourth Stage of Labour

The fourth stage starts after the delivery of the placenta and lasts for one hour. The nurse or midwife should observe the mother for blood loss, monitor vital signs, reassure her and let the mother hold the baby.

The nurse should also record notes in the patients file, fill in the baby notification form and after the hour is over escort the mother to the maternity unit.

Examination of the Baby

A thorough physical examination is done one hour after birth with the aim of assessing maturity and excluding obvious congenital abnormalities and injuries at birth.

In order to carry out this examination, you need to have with you the following equipment in a tray:

• Tape measure
• Second hand watch
• Gloves
• Weighing scale
• Clinical thermometer
• Lubricant
• Swabs
• Stethoscope

Vital signs – heart rate (120-160/min), respiration (20-60 average 44/min), and temperature (36-37 degrees centigrade).

Head – Check the shape to see if there is excessive moulding, caput succedaneum or depressed fractures to exclude head injury, microcephalus or hydrocephalus. Take head circumference (Approximately 33-37 cm).

Ears – Check position. If they are low set, this may indicate Down’s syndrome or Mongolism. Check for any missing lobes or cartilage.

Eyes – Check for presence of eyeball injuries, discharge or jaundice.

Mouth – Check for harelip, cleft palate, tongue-tie or false teeth, septic spots, thrush, cysts.

Nostrils – Check for patency with no polyps or flaring.

Neck – Check for congenital goitre or enlarged glands.

Upper limbs – Check for equality, free movement, fractures, webbed fingers, extra digits and any bony tissues. Extra digits can be ligated with silk and will fall off (with the parents permission). Check for Erb’s palsy.

Chest – Check for continuity of sternum and the shape of rib-cage, respiratory rate, enlarged breast or absence of breast tissue.

Abdomen – Should be intact and firm, check for umbilical hernia and exomphalus(protrusion of abdominal organs through a defect in the anterior wall). Abdominal distension is present in hydrops foetalis. Check for blood oozing from the cord and clamp again if necessary (cord shrivels within 24 hours, falls off 6-10 days).

External genitalia – Confirm the sex of the baby to rule out pseudohaemophrodism or intersexes. In males check for undescendedtestes, hypo/hyperspadias and phimosis. In females, check for bleeding from urethral and vaginal orifice. Vaginal bleeding may be due to excessive hormones from the mother.

Neurological Assessment

This entails the checking of reflexes, which deal with the function of the baby’s nervous system as well as physical and behavioral assessments. At the beginning of the examination, observe the baby’s movements.

These movements involve all extremities and should be random and symmetrical but never stereotyped. Sometimes jitteriness or tremors will be noted. The first time you notice these movements they may look like fits. To determine the difference between the two, hold the affected limb. If it is the former the tremors should stop.

Moro Reflex

Support the baby’s head and body in supine position about a centimeter from the cot. Allow the head to drop back. Look at the baby’s response. The baby throws out his arms extending the elbows and fingers with embracing movements of the arms. What is the significance of the Moro reflex?

The Moro reflex is symmetrical in a normal baby at birth and disappears after three months.

It is incomplete in the pre-term baby and absent in the baby with inter cranial drainage. If brain damage is not severe it returns after three to four days. If it disappears some hours after birth, you should then suspect increasing cerebral oedema or slow intra cranial haemorrhage.

Tonic Neck Reflex

A fencing position is assumed, that is, the baby lies on the back, head rotated to one side with one arm and leg partially or completely extended. The opposite arm and leg are flexed. This is a manifestation of the immaturity of the newborn’s nervous system.

Rooting Reflex

To test for the rooting reflex, gently touch the corner of the baby’s mouth with clean fingers.

The baby will open his mouth turning towards the stimulus in anticipation of the mother’s nipple. To check for sucking reflex place a clean finger in the baby’s mouth noting the sucking strength. The sucking reflex is poor in pre-term babies.

Stepping Reflex

The stepping or dancing reflex is present at birth but disappears soon after. Once this reflex diminishes, the infant does not attempt a stepping motion until he/she starts to walk. Hold the infant up, with the feet touching a surface. The infant will attempt to make some steps or pressing movements.

Grasp Reflex

It is amusing to learn that a newborn baby can grasp. At birth, the grasping reflex of both hands and feet is present. The infant will grasp any object you place in their hand, and then let it go.

They are able to hold on to a finger so securely, that you can lift them to a standing position. Stroking the soles of the feet causes the toes to turn downwards trying to grasp. By applying traction to the baby’s wrists raise them to a sitting position. A full term infant will offer a pre-term does not resist the pull.

Protective Reflex

Other reflexes include protective reflexes such

as:

• The blinking reflex, which protects the eyes from bright light.
• Sneezing and coughing reflexes used to infant’s throat.
• The yawn reflex, which draws additional oxygen.
• Cry reflex, which helps to withdraw from painful stimuli.
• Once this examination is completed, the baby can be placed on the cot for transfer to the nursery or given to the mother.
• After completing the delivery of the baby, you should transfer the mother to the postnatal ward where she will rest.

Changes that take place in a woman who has just delivered during puerperium

The puerperium period covers six to eight weeks following delivery or abortion and is characterized by:

• General organs return to their pregravida state
• Initiation of lactation..
• Recuperation.

The Psychology of the Mother During Puerperium

During the puerperium the mother is subjected to emotional turmoil and you must be supportive and observant.

She should be allowed to cuddle her baby and express her love as she wishes. This maternal instinct is at times delayed.

The midwife should be kind, patient, and compassionate towards the mother and give her the necessary education concerning her and the baby.

Each mother should be taken as an individual based on her maternal experience, educational background, maturity and parity.

Mothers should be given all the information necessary to ensure they know how to care for their babies.

Rooming is the term given when a hospital plans for the mother to stay with the baby for most of the 24 hours in a day.

It is highly recommended because it has been seen to have great psychological advantages for both mother and baby.

Bonding commences immediately and demand breast-feeding can be successfully practiced.

Most baby-friendly hospitals in this country encourage rooming in.

Postpartum Tears or Fourth Day Blues

This condition is characterized by mild depression and mood swings due to a Temporary endocrine hormonal imbalance following childbirth.

It occurs in fifty percent of post-natal mothers on around the fourth day.

A midwife should try to prevent the ‘blues’ by educating the mother during the pre-natal period on how to take care of herself and the baby to build up her confidence.

How to Manage the First Stage of Labour

When managing the first stage of labour, you should keep to the following procedure, making sure you record your findings in a partogram:

• Admit the patient to the waiting room, reassure her, and introduce her to other patients.
• Reassure her and explain what is being done at every stage.
• Give her an enema only if she is in early labour(this will reduce the risk of faecal soiling and infection at delivery).
• The patient may have a warm bath and change into a hospital gown.
• Encourage her to walk about and empty her bladder frequently.
• Give her plenty of fluids with sugar or glucose as she has to work hard and needs the energy.
• Do not allow any solid foods as the stomach takes a long time to empty in labour.
• Should she need an operation and anaesthesia, the emptying of the stomach will be difficult and she might vomit and inhale the vomit.
• If she is in much pain and the delivery is still far off, give her a sedative.

Check the following regularly:

• Check the foetal heart rate half hourly or more often if you suspect distress
• Check uterine contractions (strength, type, frequency and duration) as well as maternal pulse, BP and temperature.
• Check the urine output and check for albumin and acetone if indicated every two hours.
• Every four hours check the level of the presenting part and the degree of dilatation of the cervix.
• Constantly check the woman’s reaction to labour and be aware of her needs, especially for pain relief. You can repeat pethidine 50 mg IM if cervical dilatation is still 5 cm or less. Do not give more pethidine if delivery is imminent as it depresses the baby’s respiration
• Towards the end of the first stage, she can rest on her side, or in any position she finds comfortable, for example, squatting.
• Discourage pushing or bearing down before the cervix is fully dilated 
• Early pushing only exhausts the woman and will cause oedema of the cervix and interfere with normal dilatation
• If the bladder is full and she cannot empty it on her own, catheterize her using aseptic technique.
• When the membranes rupture, usually at the end of the first stage, check the colour of the liquor for meconium staining, the foetal heart rate and do a vaginal examination to exclude prolapse of the cord.

Observations to record in the partogram

➢Vital signs

➢Blood pressure

➢ Details of vaginal examination

➢ Contraction strength and number of contractions in ten minutes

➢Fluid balance

➢ Urinalysis

➢Drugs administered

When observing the contractions, you should note the following:

• Uterine contraction duration, strength and frequency.
• In early labour the contractions are mild, lasting 20 to 30 seconds and are infrequent.
• As labour progresses, the contractions become stronger, lasting 40 to 50 seconds and are about three contractions per ten minutes.
• The uterus should always relax between contractions.
• The cervix dilates progressively from 4cm at a rate of approximately 1cm and 1.5cm hourly in primigravida and multigravida respectively.
• The descent of the presenting part can be noted by abdominal palpation or vaginal examination.
• Avoid unnecessary vaginal examination.
• Remember to allay the mother’s fears and reassure her throughout your examination and indeed throughout labour. A mother in labour needs to feel loved, cared for and to be treated with dignity.

Prevention of Infection

To prepare for clean delivery you should:

• Give an enema or suppositories
• Avoid shaving the pubic hair, given current HIV/AIDS prevalence rates.
• Allow the mother to have bath whenever she wishes as it is soothing during labour.
• Practice aseptic techniques through labour.
• Ensure a clean environment within and around the ward.

After conducting a thorough examination of the mother and recording your observations in the partogram, there are a number of things you can do to make her feel comfortable during her labour i.e. allow her to change position and move around, use back massage, have a chosen companion with her during labour, allow her to take fluids as required and return the placenta to parents if so desired and directed by the culture. However, do not forget to check on the fetus especially if you suspect.

What Happens in the Second Stage of Labour

As mentioned earlier, the second stage of labour begins with full dilatation of the cervix. It is the stage of descent and expulsion of the baby.

It normally lasts from one to two hours on average in primigravida, and half an hour in multipara.

If this stage goes beyond two hours it is considered abnormal.

The contractions become stronger, lasting 40 to 60 seconds, with a one-minute recovery.

The retracted and contracting uterus pushes the foetus down into the pelvis.

During the relaxation phase the pelvic floor pushes the presenting part up again but the retracted uterus does not allow all the progress achieved to be lost.

Progressively the presenting part moves down until it reaches the pelvic floor.

The presence of a foreign body in the vagina makes the woman want to bear down even against her will. 

The voluntary muscles of her abdomen and diaphragm help the uterus in the pushing.

As a contraction comes the mother should be instructed to take in a deep breath, hold it and then bear down.

These expulsive efforts are partially voluntary. The vagina widens to accommodate the baby. It is now a continuous cavity with the uterus. The presenting part may push out feces from the rectum as it goes through the vagina.

When the presenting part reaches the pelvic floor it starts stretching the vulva, causing much pain, especially in the primigravida.

For some time it keeps popping out during a contraction and receding back.

After some time it can no longer slip back. This is known as ‘crowning’. The head will have passed through the bony outlet of the pelvis. The perineum becomes stretched and paper-thin and it is at this stage that an episiotomy should be performed if necessary. The next contraction normally expels the presenting part.

What Happens in the Mechanism of the Second Stage of Labour

The mechanism of labor refers to a series of movements the fetus has to make to pass through the birth canal.

Lie

Lie means the relation of the fetus to the long axis of the uterus. It may be longitudinal, oblique or transverse.

Presentation

The presenting part of the foetus is that part which is in or over the pelvic brim. Its position is examined in relation to the cervix. It could be vertex, face, or a breech. However, 95% of all presentations are cephalic, and the presenting part is usually the vertex.

Attitude

The pelvis is a curved passage with different diameters at the inlet, mid-cavity and outlet.

The foetus, therefore, has to adapt itself to the shape, size, and curve of the pelvis at different levels as it descends.

To be able to manage labour skilfully, you need to understand the natural movements made by the baby so that, when assisting in delivery, you can follow the movements rather than oppose them. The factors, that influence the mechanism of labor, are known as the three ‘Ps’: power, passage, and passenger.

Power

The stronger the contraction in a well prepared mother, the better the outcome of labour.

Passage

The size, shape and resistance of the birth canal including the bony pelvis, cervix, vagina and pelvic floor may speed up or slow down the process of delivery. A gynaecoid pelvis and a fully dilated cervix speed up the process.

Passenger

This refers to the size, lie and presentation of the foetus, as well as the placenta and membranes.

For the foetus, a vertex presentation makes labour shorter as the presenting part fits well on the cervical Os and stimulates the cervix to dilate faster.

It is important to remember that descent occurs throughout and as mentioned earlier, ninety five per cent of all presentations are cephalic, and the presenting part is usually the vertex. 

This areas boundaries include the bregma or the anterior fontanel, the perietal eminences and the posterior fontanel.

The presenting diameter is, therefore, the smallest – 9.5cm. In order to present with the smallest diameter, the head must be well flexed on the neck with the chin touching the chest. 

As the leading part meets the resistance of the pelvic floor it rotates 1/8th forwards until it comes under the symphysis pubis.

The mechanism of labour in a cephalic vertex presentation includes the following steps:

➢Engagement and descent

➢Internal rotation

➢Birth by extension of the head

➢Restitution and external rotation

What Engagement and Descent Mean During Labour

Engagement is the descent of the presenting diameter through the pelvic brim.

The head usually engages late in pregnancy in the primigravida while in the multipara it does not engage till labour starts.

The head enters the pelvic brim in oblique diameter with sub occipital frontal diameter (10.5cm). With good uterine contraction, there is more flexion of the head. The head engages with suboccipital bregmatic (9.5 cms) oblique diameter of the pelvis brim.

Internal Rotation

The head rotates 1/8th of a circle. Such a rotation is achieved by the action of the uterine muscle pushing downwards. The pointed vertex presents on the broad levator ani muscle. When the vertex reaches the perineum, the occiput turns from the posterior to the anterior position.

Anteriorly there is more room for further descent. When the occiput is below the symphysispubis, crowning takes place.

Birth By Extension of the Head

Once the occiput has escaped from under the symphysis pubis, the head extends forward. The nape of the neck is pressed firmly against the pubic arch. This extension of the head causes the anterior part to stretch the perineum gradually.

Further extension allows the sinciput, face and chin to escape the perineum and the head is born by extension. Extension is the result of action from two forces. The abdominal and thoracic muscles exert downward pressure. The pelvic floor and perineum resist this pressure and push the head forward and upward through the weak area, which is the vagina.

What Restitution Means During Labour

The head turns 1/8 of the circle to the left, back to where it was before. This rotation takes place to undo the twist, which occurred during the previous internal rotation.

This ‘undoing of the twist’ is known as restitution.

What Internal Rotation of the shoulder mean during Labour

When the head is passing through the level of the ischial spines and the outlet in anterior posterior position, the shoulders enter in the oblique diameter of the pelvis and rotate forward 1/8 of a circle. The shoulders are now in the anterior posterior diameter of the outlet. The anterior shoulder escapes the symphysis pubis while the posterior shoulder sweeps the perineum.

What External Rotation of the Head Means During Labour

As the internal rotation of the shoulders takes place, the head, which has already been born, rotates 1/8 of a circle as in restitution. The head now lies in the lateral position.

Meaning Of Lateral Flexion During Labour/Birth

Following these movements the body bends sideways to follow the curve of the birth canal.

The anterior shoulder escapes under the symphysis pubis and the posterior shoulder sweeps the perineum. The body of the baby is born by lateral flexion.

To recap, the cardinal movements of labour in a vertex presentation are:

1. Engagement

2. Descent

3. Flexion

4. Internal rotation

5. Extension

6. External restitution of the head

7. Expulsion

An easy way to remember these movements is by use of the mnemonic device -‘ Every descent Family In Europe Eats Eggs’

Management of the Second Stage of Normal Labour

The signs of the second stage of labour

• Expulsive uterine contraction. This may happen in occipital posterior or when the head is deeply engaged with fully loaded rectum (in a case where the mother is not in second stage)
• A trickle of blood
• There may be no bleeding while the cervix is fully dilated
• Pouting and gaping of the anus
• Gaping of the vulva in primigravida. The vulva of multiparous will gape even in premature pushing
• Tenseness between the anus and coccyx
• Bulging of the perineum usually means delivery is imminent

Equipment required
in second stage of labour

You will need a trolley with a top and bottom shelf.

On the top shelf make sure you have:

• Sterile delivery pack
• Small bucket with 0.5% jik for decontaminating instruments
• Bucket with 0.5% jik for decontaminating linen
• A bucket with plastic bag for used swabs and gloves

On the bottom shelf you should have the following:

• Suturing pack
• Antiseptic solution
• Draw sheet and mackintosh
• Syntocinon drawn, in a receiver
• Lignocaine
• 5% dextrose solution 500mls
• Needles
• Branulars

Steps for the management of the second stage of labour:

• Explain the procedure to the mother and reassure her
• Ask your assistant to open and arrange the delivery pack while you scrub up.
• Gown and glove yourself methodically.
• Instruct your assistant to put the patient in the dorsal position.
• Swab the mother methodically.
• Lubricate your two fingers and perform vaginal examination to confirm second stage.
• You should also instruct your assistant to check the foetal heart beat after every contraction, the mother’s pulse after every ten minutes and to administer syntometrin after the delivery of the anterior shoulder
• Tell the patient to wait for a contraction. When it comes, she should take in a full breath, close her mouth and bear down as strongly as she can, then quickly take in another breath and bear down again.
• She should be able to make at least two efforts during each contraction and relax between contractions. Encourage her all the time and explain the progress being made towards the birth of her baby.
• Place the baby towel on the bed, with the scissors and two forceps for clamping the cord. Prepare two pieces of cotton wool for wiping the newborn’s eyes, some gauze for cleaning the airway and for a covering when cutting the cord.
• At this stage the head might start distending the perineum. The anus starts dilating and the head is seen at the vulva. It keeps receding between contractions.
• When the head distends the perineum check if the perineum is stretching well.
• Place the left hand on the advancing head with fingers spread equally over the vertex towards the bregma to stop any sudden explosive effort during and after crowning of the head. With the right hand guard the perineum, holding it with the pad.
• Check if the perineum is stretching. If not, give an episiotomy at the height of a contraction if there is any indication that the head is about to crown.

Crowning of the Head

Next is the crowning of the head.

The parietal eminences pass through the bony outlet. At this stage the head no longer recedes between contractions.

Tell the mother to stop pushing as this might lead to a rapid delivery of the head and consequent brain damage. Ask her to pant. Research has shown that a series of short pushes are more effective than a long pus.

It is really hard work! So keep encouraging the mother with kind words and warmth.

Extension of the head

Assist the extension by grasping the parietal eminences with your left hand. Let the head come out slowly and naturally. Feel for the cord around the baby’s neck. If it is there, slip it from the baby’s neck over the head. If it is too tight, place two artery forceps on the cord and cut it between them. When the nose and mouth come out, wipe away the mucus with a sterile swab.

By this point the whole head should be out. The head will have restituted and rotated spontaneously to face the mother’s left or right thigh. 

This shows you that the shoulders have descended and rotated to the anterior posterior diameter.

Delivering the Shoulders by Lateral Flexion of the Body

Place one hand above and one below the fontal head. Depress the head gently toward the anus/neck, making sure it is neither twisted nor bent sideways till the anterior shoulder is free.

The delivering of anterior shoulder

Remind your assistant to give syntometrine intramuscularly (in a single dose). Guide the head upwards in the direction of the mother’s abdomen.

The delivering of posterior shoulder

The posterior shoulder will escape smoothly over the perineum. The rest of the body will be born by lateral flexion. Ask your assistant for the time and note the time of birth. Place the baby at a slight slant to drain the mucous. Put the baby on the baby towel, clamp and cut the cord. Give the APGAR score to the baby. Show the baby to the mother to identify the sex of the baby.

Ask your assistant to continue with the immediate care of the baby. Continue with the delivery of the placenta by using control cord traction. Check the placenta for completeness and/or malformation. Measure blood loss.

Do the first examination of the baby. Weigh the baby. Do a post natal examination and record all the findings. Give the mother a hot drink and transfer her to the postnatal ward.

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