DE LA SALLE LIPA

COLLEGE OF NURSING

Nursing Care Management 107

Procedural Checklist in PRE, POST and INTRA

Name: Year/Sec: Rating:

General Objective:
Given an actual or simulated situations/conditions, the students will be able to perform and discuss
the management of labor and delivery in all stages.

Specific Objectives:
1. Explain the concepts of labor and delivery.
2. Identify interventions to reduce the risks of infections
3. Correctly implement aseptic practices while rationalizing each step in the procedure.

CRITERIA:
Item Weight Descriptors Verbal Interpretation
2 Excellent Performed the procedure with great ease and confidence, observing work ethics
(prudent, accepts criticisms and suggestions), able to rationalize scientifically and
shows diligence in documenting observations at all times.
1 Satisfactory Performed the procedure with less confidence and requires close supervision
observing work ethics (prudent, accepts criticisms and suggestions), able to
rationalize scientifically and shows minimal diligence in documenting observations.

0.5 Needs Failed to perform the procedure, unable to function well and needs repeated
Improvement specific/ detailed guidance or direction.
I. Values Based 2 1 0.5 Remarks

1. Perform history taking and physical assessment.

1.1 History Taking: (present pregnancy, LMP, PMP, EDC, AOG,
Immunizations, and other illness.)
1.2 Physical Examination: (Vital Signs: Height, Weight, BP, HR, RR,
Temp and pain scale.)
1.3 Abdomen: FH, FHT, LM1, LM2, LM3, LM4
1.4 Internal examination: Cervical Dilatation, Cervical Effacement,
Status of Membranes, Presentation, and Station
2. Check for the following:
2.1 Diagnostic Examination: CBC, Blood Typing and Rh, HBsAg,
Pelvic/TVS Ultrasound report.
2.2 Diet: NPO when cervix is >4cm, +/- BOW, sedated, and Clear
Liquids to soft diet when cervix is <4cm, + BOW
2.3 Medications as ordered before delivery: Insert IV, and other
medications as ordered.
2.4 Physician: inform OB and pediatrician
2.5 Status of the patient: Send and endorsed patient to Delivery
Room, and Send to Wards to wait for schedule and monitoring of
progress of labor.

FIRST STAGE of LABOR:

3. Monitor and record the following:
3.1 VS
3.2 Uterine contractions: Frequency, Duration and Intensity
3.3 Fetal heart tones: intermittent auscultation examination every 30
minutes and records.
3.4 Cervical Dilation & deceleration : Cervix dilates 1.2 cm / 1.5 cm
per hour, and deceleration phase (8 cm dilated) Descent of the fetal head
(Station 0).
4. Carry out doctor’s orders: augmentation of labor with oxytocin
incorporation to IVF, dose and rate of infusion, based on the
character of uterine contractions, and progress of labor: Vital signs
and fetal heart tones are within normal parameters, Patient’s
cervical dilatation has reached 10 cm. and fetal head at station 0

SECOND STAGE of LABOR

5. Perform the following:
5.1 Placed patient on Delivery Room table in dorsolithotomy
position.
5.2 Provide oxygen support at 3-4 lpm via nasal cannula.
5.3 Monitor and record the following: VS, labor (frequency,
duration and intensity of uterine contractions), fetal heart tones:
intermittent (auscultate after every contraction.
6. Advised the patient to perform Bearing down techniques:
Sustained breath holding – Valsalva maneuver and Spontaneous
exhalatory method and assess descent to monitor progress of labor.

7. Cleanse the vulvar and perineal cleansing with povidone in

preparation for delivery and assist the physician in performing
episiotomy until delivery of the baby aseptically.
 THIRD STAGE of LABOR
8. Perform the following:
8.1 Monitor the uterus for contraction.
8.2 Provide prophylactic medications as ordered (Oxytocin thru IV and
Methylgometrine maleate thru IM).
8.3 Perform controlled cord traction of the umbilical cord (Brandt-
Andrew’s Maneuver),
8.4 Massage the uterus: wait for signs of placental separation and
allow placenta to deliver spontaneously or aided by gravity or nipple
stimulation.
8.5 Assist the physician:
- for inspection of placenta and umbilicus for completeness, vagina
and cervix for lacerations
- Performs correct anatomi restoration (Episiorrhaphy) for all cases
of episiorrhapy) for all cases of episiotomy and record the type of
suturing ( Continuous subcuticular stitching and Interrupted
transcutaneous suturing).

FOURTH STAGE of LABOR

9. Monitor and assess the for postpartum monitoring in RR: vital signs every 15
minutes, ascertain sustained uterine contractility, for character of vaginal
bleeding and urinary bladder for fullness, then transfer patient after 2 hours of
vital signs stable with no excessive hemorrhage for not >500 ml.

10. Instruct and provide the following:

10.1 Diet
10.2 Medications as ordered: antibiotics, and analgesics

DISCHARGE TEACHING
11. Instruct the patient:
11.1 Early ambulation
11.2 Breastfeeding
11.3 Perineal washing / hygiene.
11.4 Home medications and follow up.
ATTITUDE
12. Reports with proper grooming and displays correct decorum and manifest
great confidence in his/her work, shows diligence in documenting
observations.

Comments / Strengths & Weaknesses:

Conforme: Evaluated by:

Student’s Signature Clinical Instructor’s Signature

Date: Date: