STATEMENT ON PATIENTS RIGHTS

1. The patient has the right to consider and respectful care. information concerning his diagnosis, treatment and progress in terms the patient can be reasonably expected to understand. 3. The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure and /or treatment. Where medically significant alternatives for care treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information and to know the name of the person responsible for the procedures and/or treatment. 4. The patient has the right to refuse treatment to the extent permitted by law, and to be informed of the medical consequences of his action. 5. The patient has the right to every consideration of his privacy concerning his own medical care program. 6. The patient has the right to expect that all communication and records pertaining to his care should be treated confidential. 7. The patient has the right to expect that within its capacity a lying in must make reasonable response to the request of a patient for services. 8. The patient has the right to obtain information as to any relationship of his lying in to other health care and educational institutions in so far as his care is concerned and any professional relationship among individuals, by name, who are treating them. 9. The patient has the right to expect continuity of care. 10. The patient has the right to examine and receive an explanation of his bill regardless of source of payment. 11. The patient has right to know what lying-in rules and regulations apply to his/her contract as patient.

2. The patient has the right to obtain from his physician complete current

DELIVERY AND LABOR ROOM POLICY

1. All patients should be handled by the Midwife/Referring OB. 2. Primigravidas and other gravides requiring episiotomy should be done by the OB, but in case of emergency, skilled Midwife may handle. 3. Always secure consent, maternal history and complete right name of patient for correct documentation and tagging. 4. Upon admission, patients are examined in the labor room. Always take her vital signs, do proper assessment including the FHT and if uncomplicated to do an IE to determine cervix dilatation, presentation and status of BOW. 5. Maintain courtesy and politeness at all times. 6. Always assist mother in labor. NEVER LEAVE THE MOTHER ALONE in the labor and delivery room. 7. Always use the partograph sheet in each patient to determine proper and timely referrals. 8. Make constant round to patients in labor, check for vaginal bleeding, any unusual signs and symptoms and REFER! 9. Mother with 4cms cervical dilation and those requiring close monitoring are admitted in labor room. 10. Infection control policies of DR must be followed at ALL TIMES! 11. Relatives and companions of patients are not allowed to enter Labor and Delivery Room. 12. EiNC or the Essential Intrapartum Newborn Care should always be practiced. 13. Breast Feeding should always be encouraged to all mothers. 14. The skilled Midwife on duty can repair first and second degree perennial lacerations to control bleeding and should be examined by Referring OB. 15. The woman who also undergone epissiorraphy should be checked by the OB prior to transferring her to postpartum unit.

DUTIES AND RESPONSIBILITIES OF DR STAFF MIDWIVES

1. Gives direct nursing care for all pregnant patients. 2. Identifies nursing needs of patient in labor. 3. Plans, gives and evaluates nursing care. 4. Admits patients and if not complicated may do IE to determine cervical dilatation status of BOW, and fetal presentation. 5. Performs such nursing activities such as bathing and oral hygiene, Leopolds maneuver and fundic height measurement. 6. Assist patient in moving, monitoring proper alignment of patients body especially during labor and utilizing good body mechanics. 7. Takes and records vital signs, FHT and the partograph. 8. Observes medical asepsis. 9. Observes signs and symptoms of labor, institutes remedial action when appropriate and record these in chart. 10. Reports observation to the Physician. 11. Observes and records patients emotional and spiritual needs. 12. Acts as liaison between patients and lying in personnel. 13. Interprets to the patient and her family their roles in promoting successful delivery. 14. Prepares patients, and assists physicians with diagnostic and therapeutic procedure 15. Carries out Doctors order 16. Assist physician when examining patients. 17. Performs irrigation, catheterization, gives enemas and IV fluid insertion. 18. Administers and chart medication and patients reactions to medications. 19. Instructs patients and families. 20. Sees to it that equipment receive with proper care and maintenance. 21. Transfer and endorse patients to postpartum unit. 22. Performs postmortem care. 23. Teaches and direct nonprofessional nursing personnel. 24. Acts as a senior nurse when so delegated.

25. Receives and endorses ward equipment and supplies. 26. Interprets hospital, DR policies and procedures. 27. Gives health teaching. 28. Maintains good relationships with other hospital personnel. 29. Charts medications and treatments given accurately. 30. Attends meetings and conferences. 31. Checks and receives articles from outgoing midwife. 32. Attends rounds. 33. Assists in giving baths to pregnant woman. 34. Serves drinking water and nourishment to woman not in active labor. 35. Performs simple procedure as perineal care shaving and SS Enema. 36. Measure fluid intakes and outputs. 37. Takes and Charts vital signs when delegated. 38. Answers patients calls and deliver messages. 39. Maintains cleanliness and orderliness of the Delivery and Labor Room. 40. Tidy Beds and bedside tables, counters, cabinets. 41. Removes all used or discontinued equipment from the labor and Delivery Room. 42. Attend delivery of normal pregnant patients.

DUTIES AND RESPONSIBILITIES OF DR STAFF NURSES AND MIDWIVES

Philippine Midwifery practice is guided by the Midwifery Act of 1992 (R.A 7392). Aside from providing care to woman during normal pregnancy and childbirth, the law has provided added skills that the midwife must learn to do her task completely. These include: 1. Repair of first and second degree perineal lacerations to control bleeding 2. Internal examination except when the woman has antepartum bleeding 3. Intravenous Fluid infusion during obstetric emergencies 4. Giving oxytocic drugs after delivery of placenta 5. Giving vitamin K to the newborn The Midwife must adhere to her scope of work and training to protect the safety of those who seek her care. As a health professional, she is duty bound to improve and continuously update and enhance her knowledge, skills and practice by attending and participating in continuing professional Education (midwifery) activities.

LABOR AND DELIVERY ROOM INFECTION CONTROL GUIDELINES

1. All delivery room personnel are required to wear gown, cap, mask, and slippers. Always change scrub suit before entering and leaving DR. 2. Proper hand washing and septic technique in attending/handling deliveries always should be observed. 3. Do aseptic techniques in doing procedures, handling delivery and instrument and preparation of the patient. 4. Always lead the patient to the labor room upon admission and change her slippers use gown before entering. 5. Kelly pads, pails and DR tables should be scrubbed well every after using and cleanse with Lysol Solutions, soap and water. 6. Delivery packs and instruments are properly cleaned, and should dry, packed, autoclaved and should always be ready for use. 7. Needles and sharps are kept in a separate plastic container with cover for proper disposal. 8. Placentas are collected properly in a plastic container kept in freezer for proper disposal. 9. Do daily mopping, weekly cleaning and walling of unit. 10. Change curtains every 15 days. 11. 5s should always be implemented: a. Sort or SURIIN b. Set Up or SINUPIN c. Sweep or SIMUTIN d. Sanitize or SIGURADUHIN ANG KALINISAN e. Self-Discipline or SARILING DISIPLINA 12. Proper waste disposal and segregation should be followed AT ALL TIMES. 13. Use bleach for cleaning bowls and buckets, and for blood and body fluid spills 14. Collect clothing or sheets stained with blood or body fluids and keep them separately from other laundry, wearing gloves or use a plastic bag. DO NOT TOUCH THEM DIRECTLY

15. Wear gloves, cover crests, abrasions or broken skin with a waterproof bandage; take care when handling any sharp instruments (use good light); and practice safe sharp disposal 16. Wear a long apron made from plastic or other fluid resistant materials, and shoes 17. If possible protect your eyes from splashes of blood. Normal spectacles are adequate eye protection 18. Wear sterile or highly disinfectant gloves when performing vaginal examination, delivery, cord cutting, repair of episiotomy or tear, blood drawing. 19. Wear long sterile or highly disinfectant gloves for manual removal of placenta. 20. Wear clean gloves when: a. Handling and cleaning instruments b. Handling contaminated waste c. Cleaning blood and body spills 21. Proper waste disposal and segregation should be followed AT ALL TIMES COLOR CODING OF VARIOUS WASTE CATEGORIES a. BLACK BAG- for collection of non-infective dry waste b. GREEN BAG- the collection of non-infective wet waste c. YELLOW BAG- for collection of infective and pathological wet wastes d. SHARPS- like needles, scalpel, and other disposable sharp shall be collected using a proof containers and must be properly labeled to avoid accident and health hazard EFFECTIVE HAND WASHING 1. When coming on duty 2. Before and after patient contact 3. Between dirty and clean procedure on the same patient 4. Before preparing medications 5. Before performing an invasive procedure 6. Before and after handling patient equipment 7. After blowing or wiping nose 8. Before and after eating 9. Before and after wearing gloves 10. After use toilet

GUIDELINES IN ESSENTIAL INTRAPARTUM NEWBORN CARE

REFERENCES: POGS MDG COUNTDOWN CAPACITY ENHANCEMENT PROGRAM FOR MIDWIVES 2010 OBJECTIVES To describe and carry out the evidence based routine care of a newborn baby at the time of birth and prevent complications

DO PROPER HANDWAHING STEPS: 1. 2. 3. 4. 5. Call out time of birth Deliver the baby prone on the mothers abdomen Dry the newborn thoroughly for a full 30 seconds. Remove wet cloth Check breathing while drying Position newborn prone on the mothers abdomen in skin to skin contact. Cover the back with the dry blanket, if this is not possible, place newborn in a warmer, safer place close to the mother. 6. Exclude second baby 7. Wait for cord pulsation to stop (approx. 1-3min) 8. Remove first pair of gloves 9. Clamp cord 2cm away from newborn skin using sterile plastic cord and apply sterile forceps 5cm from the skin then cut the cord. 10. Monitor skin to skin contact; do not separate baby from the mother until a full breastfeed; watch for feeding cues. 11. Place identification band in ankle 12. Give eye prophylaxis within the first hour. Delay vitamin K and immunization until after 90 min. of uninterrupted skin to skin contact.

BASIC NEEDS OF A BABY AT BIRTH 1. 2. 3. 4. To breath normally To be warm To be protected To be feed

POLICY ON BREASTFEEDING 1. All mothers will practice exclusive breastfeeding 2. Rooming-in practice for all patients except problematic mother or baby 3. Information dissemination daily through lecture/audiovisual/ demonstration in the OPD and in the rooming-in wards by the lying-in clinic personnel in charge. 4. Formation of lactation management team for: a. Lactation management training program by 2 weeks every 6 months b. Management of problematic cases in the clinic 5. Early mother child bonding in the delivery 6. Assignment of lactation management program. 7. Formation of lactation brigade-those volunteers who wants to help in the promotion of breast feeding and give assistance to mother during their stay in ward. 8. Incorporation of BF related knowledge, attitudes and skills in the residency training program, in service physicians, nurses or midwives from and other lying-in clinic on the job training of the staff. 9. Monitoring of all breast feeding promotion strategies in the lying-in clinic 10. No lying-in clinic purchase of milk and confiscation of milk formula from the patient if relative made it available for them. 11. Posters and instructional materials are being posted in the different strategic place to enhance the knowledge of the patient, relative and lying-in clinic personnel

GUIDELINES OF PARTOGRAPH REFERENCES: POGS MDG COUNTDOWN The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity is not needlessly increased, to interfere in a timely manner to avoid maternal and neonatal morbidity and ensure close monitoring of the woman in labor.

USE OF PARTIGRAPH 1. Assessment of progress of labor a. Cervical dilation b. Contractions c. Alert and action lines 2. Assessment of maternal well being a. Pulse, temperature, blood pressure b. Urine voided 3. Assessment of fetal well being a. Fetal heart rate pattern b. Color of amniotic fluid

Note: Start the partograph only when the woman is in ACTIVE labor (4cm or more) and is contracting enough (3-4 contraction in 10 mins). Label patient identifying information.

WHAT TO PLOT? 1. Plot the cervical Dilation - This is plotted or recording using X - Perform IE every 4 hours. Or more frequently if necessary 2. Note and monitor BP, temperature, PR and cervical dilations 3. Note and monitor every hour the FHT, frequency, intensity and duration of contractions, womans mood and behavior.

OTHER FINDINGS TO RECORDS 1. VAGINAL BLEEDING (0,++.+++) 2. Time membrane ruptured - I if membrane are intact 3. Color of amniotic fluid C membranes are ruptured and amniotic fluid is clear M amniotic fluid is stained with meconium A amniotic fluid is absent B amniotic fluid is bloody 4. Urine voided (yes or no)

The use of PARTOGRAPH is NOT RECOMMENDED to the following risk factors: 1. Very short stature 2. Antepartum hemorrhage 3. Severe pre-eclampsia and eclampsia 4. Fetal distress 5. Previous Cesarian section 6. Severe anemia 7. Multiple pregnancy 8. Malpresentation 9. Very premature labor 10. Obvious obstructed labor

POLICY ON INTERNAL EXAMINATION (IE) WHENT TO DO AN INTERNAL EXAMINATION 1. Only during labor 2. When the bow ruptures ( to rule out cord prolapse) 3. If malpresentation, is suspected on abdominal examination 4. Before transferring a woman to mother facility to ensure she is not likely to deliver in journey 5. In the third stage, if there is postpartum hemorrhage caused by retained placenta or suspected laceration 6. If woman has had vaginal bleeding after 5th month of pregnancy. DO NOT PROCEED 7. Never do an IE unless you have a good indication for doing so. Every IE may bring INFECTION to that woman and her baby

PROCEDURE FOR IE 1. Explain to the woman what you are going to do 2. Take the full aseptic precautions 3. Rinse vulva with clean water 4. Wear clean gloves 5. INSPECT THE VULVA 5.1 5.2 Is there amniotic fluid? Is it clear or meconium stained? Is there any abnormal discharge, blood or pus?

6. Feel inside the vagina with the middle and index fingers. WHAT TO NOTE DURING INTERNAL EXAMINATION 1. Cervical dilatation 2. Bag of water 3. Presenting part 4. Pelvis (architecture, adequacy of diameters)

WHAT IS CERVICAL DILATION Gradual opening of the cervix Measured in centimeters Feel with your 2 fingers The fully dilated cervix is 10 cm

CARE OF PREGNANT WOMAN DURING LABOR STEPS TO FOLLOW IN INTRAPARTAL CARE 1. Examine the woman for emergency signs Unconscious, convulsing Vomiting Severe headache with blurring of vision Vaginal bleeding Severe abdominal pain Looks very ill Fever Severe breathing difficulty Do not make a very sick woman wait, attend to her quickly. Ask for informed consent before examination or any procedure Respect her privacy Inform her of results of examination Reassure 3. Assess the woman in labor Take the history of labor and record on the labor form Review Homed Base Maternal Record (HBMR) Mother and Child Book which includes: When is delivery expected? Preterm or Term, Prior Pregnancies and Birth Plan Assess uterine contractions: intensity, duration and frequency Observe the womans response to contractions. Perform abdominal exam: Leopolds maneuver, FHT between contractions 4. Determine the stage of labor Explain to the woman that you will perform a vaginal examination and ask for her consent Respect her privacy Observe standard precautions (wash hands, wear gloves) 2. Greet the woman and make her comfortable

 Observe the vulva for: Bulging perineum Any visible fetal parts Vaginal bleeding

Leaking amniotic fluid; if yes it is meconium stained, foul smelling? Warts, keloid tissue or scar that may interfere with delivery Perform gentle vaginal examination (do not start during contraction) Explain findings to the woman. Reassures her. Records findings in labor record or partograph 5. Decide if the woman can safely deliver. If there is indication for referral.. In early labor. Refer urgently in ACTIVE LABOR 6. Give supportive care throughout the nabor Explain procedures, seek permission and discuss findings with the woman and her family Always maintain privacy when examining the mothers NEVER LEAVE a woman in labor alone Encourage the woman to: wash from her waist down or to take a bath on the onset of labor empty her bladder and bowel. Remind her to empty her bladder every 2 hours (a full bladder may prolong the labor) move freely ( if BOW is not ruptured. Respect and support her choice of a birthing position) drink as she wishes. Drinking will give her energy for contraction and the sugar will give her energy for her labor. Do not give solid food this may take her vomit. FIRST STAGE OF LABOR- period from regular uterine contraction to cervical dilation first stage: not yet in active labor, cervix is dilated 0-3cm, contraction are week ,2 in 10 minutes. Every hour: check for emergency signs, frequency. Intensity and duration of contraction. FHR mood and behavior. Every 4 hours: check V/S and cervical dilation

 Record findings in labor record. Assess progress of labor: after 8 hours, of contractions are stronger and more frequent but no progress in cervical dilation. REFER First stage: in active labor, cervix is dilated at 4cm or more. Check every 30 minutes for emergency signs frequency and duration of contractions, FHR mood and behavior. RELIEF PF PAIN DISCOMFORT 1. Suggest change of position 2. Encourage mobility as comfortable for her 3. Encourage proper breathing: breathe more slowly make sighing noise and make 2 short breathe follow by a long breathe out. 4. Massage her lower back if she finds it helpful. CAUTIONS: 1. Do not do IE more frequent for every 4 hours. 2. Do not allow the woman to push unless delivery imminent- pushing does not speed up labor. Mother will become tired, cervix as well. 3. Do not give medication to speed up labor. DANGEROUS: may cause trauma to the mother and baby. Do not fundal pressure or push- may cause uterine rupture and fetal death. REFERENCES: POGS MDG COUNTDOWN: Capacity Enhancement Program for Midwives 2010 SECOND STAGE OF LABOR: the period fully dilation 10cm of the cervix until birth of baby. The woman is on 2nd stage of labor if: 1. On IE, cervix is fully dilated 2. Woman wants to bear down 3. Strong uterine contractions every 2-3 minutes 4. Bulging thin perenium fetal head visible during contractions

5. BOW will rupture MONITORING THE SECOND STAGE 1. Check uterine contractions, feel heart rate, mood and behavior 2. Continue recording in the partograph REMINDERS: Massaging or stretching the perineum have not been down to be beneficial DO NOT apply fundal pressure to help deliver the baby- may harm mother and baby 1. Implement the 3 CLEANS: 1.1 1.2 1.3 clean hands. Wear double gloves clean delivery surface clean cutting and care of the cord

2. stay with the woman and encourage her comfortable 3. encourage the mother to bear down when babys head is coming down 4. when the birth opening is stretching support the perineum and anus with clean swab to prevent laceration 5. ensure controlled delivery of the head 5.1 5.2 5.3 5.4 keeps one hands on the head as it advances during contraction, keep the head coming out too quickly. Support the perineum with other hand Discard pad and replace when soiled to prevent infections During delivery of the head, encourage woman to stop pushing and breathe rapidly with mouth open gently feel if the cord is round the neck 6. Gently feel if the cord is round the neck: 6.1 6.2 if it loosely around the neck slip it over the shoulder or head. If it is tight place the finger under the cord clamp and cut the cord unwind the neck 7. Gently wipe the babys nose and mouth with a clean gauze or cloth 8. Wait for external rotation( within 1-2 minutes) head will turn sideways bringing one shoulder just below the symphysis pubis and other facing perineum

9. Apply gentle downward pressures to deliver the shoulder then lift baby up to delivered. 10. Put baby on mothers abdomen in prone position cover with dry towel 11. Thorough dry the baby immediately. Wipe eyes 12. Discard wet cloth 13. Put baby prone on mothers abdomen in skin to skin contact. Keep the baby warm 14. Exclude 2nd baby by palpating mothers abdomen. 15. Give 10 units oxytocin IM to the mother. Maybe done by skilled midwife with supervision of doctor. 16. Watch for vaginal bleeding 17. Remove first set of gloves 18. Clamp and cut the cord Feel the cord. When no more cord pulsation is felt on the cord (usually within 3 mins) clamp the cord 2cm from base using sterile plastic cord clamp. Sweep the cord and apply Kelly forceps 5cm from the base then cut in between. Observestump for blood oozing. Do not bandage or bind the stamp. Leave it open

CHOICE OF NEEDLES 1. Round. Soft tissue like mucosa and muscles 2. Cutting tougher like fascia and skin STEPS IN PERINEAL REPAIR 1. Provide emotional support and encouragement 2. Ask assistant to massage the uterus and provide fundal pressure 3. Carefully examine the vagina perineum and cervix 4. If the tear is long and deep through the perineum inspect to be sure there is no third or fourth degree tear a. Place a gloved finger in the uterus b. Gently lift the finger and identify the sphincter

c. Feel the tone and tightness of the sphincter d. Change to clean high level disinfected gloves e. If the sphincter is injured- REFER f. If the sphincter is not injured proceed with repair 5. Clean area with anti-septic solutions 6. Apply firm pressures on bleeding areas. Clamp and ligate bleeders 7. Infiltrate site with local anesthetic Make sure there are no known allergies to Never inject lidocaine if blood is aspirated-the woman can suffer convulsion and death if IV injection of lidocaine occurs. 8. Close the vaginal mucosa using continuous inter-locking or simple interrupted 2-0 suture 9. Close the perineal muscle using interrupted 2-0 suture 10. Close the skin using interrupted (subcuticular) 2-0 sutures starting at the vaginal opening. If the tears is deep perform a rectal examination. Make sure no stitches are in the rectum TECHNIQUES AND TIPS IN PERINEAL REPAIR 1. Repair lacerations in layer 2. Close the deeper perineal tissue with interrupted suture 3. Use small caliber suture (chromic 2-0) 4. Avoid tying the suture tight 5. Check the rectal lumen after repair. A rectal exam should be performed to check is any of those stitches have been accidentally put through into the rectum. If so, they must be removed. Removal will help prevent infections as well as formations of an open sinus tract from perineum to rectum 6. remove the gauze when finished 7. clean the area before and after repair NOTE: skilled midwives or nurses who undergo training are only allowed to repair 1st and 2nd degree laceration and should be checked by OB

PERINEAL TEARS OR LACERATION- are injuries or tears with vaginal canal and the outlet that occurs during delivery of the baby. The areas affected by perineal tears are the perineum lateral vaginal walls and areas adjacent to clitoris lateral sulcus tears and others. Basc Principles in Repairing Lacerations 1. adequate homeostasis 2. abdominal restoration 3. use minimum suture materials 4. adequate anesthesia classification of laceration 1st degree- involving the fourchette perineal skin and vaginal mucus membrane 2nd degree- fourchette, perineal skin, and vaginal mucus membrane PLUS the facia and muscles of the perineal body. 3rd degree- fourchette, perineal skin vaginal mucus membrane, the fascia and muscles of the perineal body plus the anal sphincter 4th degree- extends through the rectal mucosa exposing the lumen of the rectum Different Technique of Suturing 1. Continuous suture technique- to repair subcutaneous fascia 2. Interrupted suture- to repair fascia and muscle 3. Lock suture- to repair vaginal wall Choice of suture materials: Must be absorbable: chromic 2-0 polyglocolic derivative (vicryl, dexon) Preferably with needle- attached to I (atrauma c)

THIRD STAGE OF LABOR- between birth of the baby and delivery of the placenta

1. deliver the placenta by controlled cord traction ( with countertraction in the uterus above symphysis pubis 2. massage the uterus over the fundus 3. inject oxytocin 10 units IM if not yet given 4. encourage initiation of breastfeeding . keep the baby on mother;s abdomen for 60-90 minutes 5. check if the placenta and membrabes are COMPLETE. Put the placenta into container for disposal IMMEDIATE POST-PARTUM CARE 1. check for vaginal bleeding 2. clean the woman and make her comfortable 3. check BP PR emergency signs of uterine contractions every 15 minutes 4. initiate BF within 1 hour when the mothers ready 5. make sure the uterus is well contracted with stable V/S before transferring to the postpartum unit. NORMAL POST PARTUM WOMAN: note the following 1. mother feels well 2. no pallor 3. no breast problem 4. no fever pain 5. no problem with urination 6. normal V/S 7. uterus well contracted and hard 8. no perineal swelling GUIDELINES ON INTRAVEMOUS FLIUD 1. PREPARE MATERIALS TO BE USED a. Bottle or bag of IV fluid: D5LR or NSS b. IV needle/cannula/catheter: gauze 18 or 20 c. IV taking or administration set

d. Tourniquet e. Tape or microsoft f. Disposable 2. PREPARE FOR IV INSERTION a. Check the pt. identification b. Explain in simple terms the procedure to the patient and make her comfortable c. Organize correct and adequate lighting d. Wash hand to prevent infectious or cross-examination e. Wear protective gloves f. Place yourself in comfortable positions sitting if possible 3. PREPARE IV ADMINISTRATION SET a. Check the type clarify. And expiration of fluid b. Remove the plug of protective covering from the bottom of the bag/bottle. Close the flow regulator remove protective covering from the spike of tubing set and insertion of the spike into the port of fliud bag or bottle. c. Place the fluid bag/bottle higher squeeze the deep drip chamber to fill 1/3 of it opens the flow regulator to flush the air & bubbles from the rest of the tubing and close the flow regulator. d. Hang the bag on an IV pole. Care should be taken out to avoid contaminate the end of the tubing 4. CHOOSE THE SITE OF INFECTION a. PREFERRED: hand viens b. AVOID -areas of joint flexion -veins close to anterior and deep lying vessels -small visible but impalpable superficials viens -veins irritated by previous use c. USE DISTAL VIENS FIRST d. USE VIENS ON OPPOSITE SIDE TO THE SIDE OF INTENDED PROCEDURE 5. PERFORMED THE VENIPUNCTURE

a. Apply a tourniquet above the choosen site to create an adequate venous filling b. Ask the patient to make a fist to maximize vein engorgement c. Palpate the vein or top help it dilate d. Clean the entry side with alcohol and allow it to dry e. Do not repalpatate f. Insert the IV Catheter into the 30-45 angles with the bevel up and the directions of the veins g. Advance the catheter to enter the vein until blood is visible in the flush chamber of the catheter h. Advance the plastic catheter on into the vein while leaving the needle stationary i. j. Apply gentle pressure over the vein just proximal to the entry site to prevent blood flow and remove the needle from the plastic catheter Connect the plastic catheter to the previous prepared IV tubing set and open the flow regulator k. Tape the catheter in place and adjust the flow rate 6. COMPLICATION OF IV THERAPY a. Hematoma b. Infiltration( pain swelling pallor of site,IV flow rate decrease or stops observe of back flow or blood into the tubing c. Thromboembolism d. Air embolism e. Phlepitis and septicemia f. Fluid overload

INTERVENTIONS DURING DELIVERY THAT ARE RECOMMENDED 1. In pregnant woman having vaginal birth restrictive episiotomy(over routine episiotomy) is recommended 2. Delayed cord clamping 3. Management of third stage labor (MTSL): among parturients in the 3rd stage of labor use of oxytocin

4. MTSL: controlled cord traction 5. MTSL: uterine massage after placental delivery 6. Routine use of ice packs over the hypogastrium in the immediate post-partum period is not recommended