DAILY CHECKLIST OF REQUIREMENTS ON EQUIPMENT, INSTRUMENTS/SUPPLIES AND

BASIC MEDICINES FOR BIRTHING HOME.

GENERAL ADMINISTRATIVE SERVICE AREA

EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
1.BENCH 1
2.CABINET 1
3.CALCULATOR 1
4.CHAIR 1/ STAFF
5.DESK 1/ STAFF
6. ELECTRICFAN 1
7.FIRE EXTINGUISHER 1
8.OPEN SHELF 1
9.STANDBY 1
GENERATOR
10.TRANSPORT 1
VEHICLE OR MOA
WITH A SERVICE
PROVIDER
11.COMPUTER/LAPTOP 1
12. REFRIGIRATOR 1
(FOR BREASTMILK,
MEDS AND VACCINES
SUCH AS HEP B AND
BCG)
DAILY CHECKLIST OF REQUIREMENTS ON EQUIPMENT,
INSTRUMENTS/SUPPLIES AND BASIC MEDICINES FOR BIRTHING
HOME.

STERILIZATION AREA

EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN

INSTRUMENTS REQT.
1.AUTOCLAVE/STEAM 1
STERILIZER
DAILY CHECKLIST OF REQUIREMENTS ON EQUIPMENT,
INSTRUMENTS/SUPPLIES AND BASIC MEDICINES FOR BIRTHING
HOME.

TREATMENT ROOM (SAME AS OUTPATIENT AREA)

EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
1.CLINICAL 1
WEIGHING
SCALE
2.EXAMINING 1
TABLE
3.FOOT STOOL 1
4.GOOSENECK/ 1
EXAMINING
LIGHT
5.STETHOSCOPE 1
6.TAPE 1
MEASURE
7.VAGINAL 2
SEPECULUM
DAILY CHECKLIST OF REQUIREMENTS ON EQUIPMENT,
INSTRUMENTS/SUPPLIES AND BASIC MEDICINES FOR BIRTHING
HOME.

WARD (LABOR ROOM AND RECOVERY ROOM)

EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
1.LUBRICANT 1
2.SPHYGMO 1
3.STERILE 2
GLOVES
4.STETHOSCOPE 1
5.THERMOMETER 1
6.WALL CLOCK 1
7.BED WITH 1
GUARD RAIL
8.BED SHEETS DEPENDS
ON THE
NUMBER
OF BEDS
DAILY CHECKLIST OF REQUIREMENTS ON EQUIPMENT,
INSTRUMENTS/SUPPLIES AND BASIC MEDICINES FOR BIRTHING
HOME.

BIRTHING ROOM
EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
1.DELIVERY SET 1 PER 2
BEDS
a. Hemostatic/ 2
Kelly, curve or
straight
b. Kidney basin 1
c. Neddle holder, 1
8 inches
d. Surgical 1
scissors
(straight mayo)
e. Bandage 1
Scissors
f. Thumb 1
Forceps
g. Tissue Forceps 1
(with Teeth)

h. Umbilical 1
Cord Clamp
i. Umbilical 1
Cord Scissors
 BIRTHING ROOM
EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
2.DELIVERY 1
TABLE
3.EMERGENCY 1
LIGHT/FLASH
LIGHT
4.FOOT STOOL 1
5.GOOSE NECK/ 1
EXAMINING
LAMP
6.INSTRUMENT 1
TABLE
7.INSTRUMENT 1
CABINET
8.IV STAND 1
9.KELLY PAD 1
(OPTIONAL)
10.OXYGEN 1
UNIT
11. PAIL 1
12. STOOL 1
13.SUCTION 1
APPARATUS
14. PAIR OF 2 PAIRS
SLIPERS
15.ROOM 1
THERMOMETER
(MAINTAIN
ROOM TEMP
WITHIN 25-28
DEGREES
CELSIUS)
16.GOWNS OR FOR
PATIENT’S BIRTHING
GOWN ROOM USE
17.LINEN FOR 1 PER BED
DRYING
NEWBORNS
18. STERILE 1 PER BED
DRAPES
19. SCRUB SUITS 1 PER
STAFF
DAILY CHECKLIST OF REQUIREMENTS ON EQUIPMENT,
INSTRUMENTS/SUPPLIES AND BASIC MEDICINES FOR BIRTHING
HOME.

NEWBORN RESUSCITATION AREA

EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
2.EMERGENCY 1
KIT OR CART/
PORTABLE KIT
OR TROLLEY
 DAILY CHECKLIST OF REQUIREMENTS ON EQUIPMENT,
INSTRUMENTS/SUPPLIES AND BASIC MEDICINES FOR BIRTHING
HOME.

BASIC MEDICINES
EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
A.ATROPINE 1
1MG/ML AMPULE
B. BCG VACCINES 1
(STORED INSIDE
REF AT TEMP
BETWEEN 2-8
CELSIUS)
C.BETAMETHASONE 1
DEXAMETHASONE
D.CALCIUM 1
GLUCONATE
10MG/AMPULE
E.DIPHEN 1
50MG/AMP
F. EPINEPHRINE 1
G.ERYTHROMYCINE 1
H.HEP B 1
(STORED INSIDE REF
AT TEMP BETWEEN 2-
8 CELSIUS)
I. I. IV FLUIDS
II. D5LR 3 BOTTLES
III. PLR 3 BOTTLES
IV. PNSS 2 BOTTLES
V. J.LIDOCAINE 1
VI. K.MAGNESIUM 1
SULFATE AMP
VII. L.OXYTOCIN 2
VIII. M.TETANUS TOXOID 2
IX. N. TRANEXAMIC 1
ACID AMP
X. O. VITAMIN K AMP 2
XI.
 BASIC EQUIPMENT
EQUIPMENT/ MINIMUM MON TUES WED THURS FRI SAT SUN
INSTRUMENTS REQT.
A.BAG VALVE MASK

ADULT 1
NEWBORN 1

B.STETHOSCOPE

ADULT 1
PEDIA 1
C.SPHYGMO 1

D.THERMOMETER 1
E.WEIGING SCALE 1
FOR NEWBORN
 BASIC SUPPLIES
EQUIPMENT/ MINIMU MON TUES WED THURS FRI SAT SUN
INSTRUMENTS M
REQT.
A. A. IV CATHETER

ADULT 1
NEWBORN 1
B. 70% ISOP. 1
ALCOHOL BOTTLE
C.SYRINGEES

1CC 1
3CC 1
5CC 1
10CC 1

D. IV TUBINGS

MACRO SET 1
MICRO SET 1

E.NASAL CANNULA 1
OR FACE MASKS
F. PLASTER 1
G.BETADINE 1
BOTTLE
H.STERILE 1
ABSORBABLE
SUTURES

XII. I. STERILE COTTON 1 PACK

BALLS
XIII.
XIV. J.STERILE COTTON 1 PACK
PLEDGETS
XV. K.STERILE GAUZES 1 PACK
XVI. L.STERILE GLOVES 1 BOX
XVII. M.SURGICAL CAPS 1 BOX
XVIII. N. SURGICAL 1 BOX
MASKS
XIX. O. SHARP 1
CONTAINER
XX. P.SUCTION
CATHETER
ADULT 1/ BED
NEW BORN 1/BED
 DAILY ROOM TEMP MONITORING CHART

DATE TEMP A.M. SIGNATURE TEMP P.M. SIGNATURE