PRAKASH INSTITUTE

Of Physiotherapy, Rehabilitation & Allied Medical Sciences

(RUN BY GAUTAM BUDDHA HEALTH CARE FOUNDATION)

Plot no-9A, Pocket – P2, Omega – 1, Builders Area, Greater Noida

Ph: 0120-427 9362, 98105 32534, FAX: 0120-427 9260

PIPRAMS E-Mail: Prakashinstitute@gmail.com, Website: www.piprams.com.

CHECKLIST OF

MIDWIFERY AND OBSTETRICAL NURSING

NAME-
BATCH-
 INDEX

S. TOPIC PAGE
NO. NO.
1. CHECKLIST FOR ANTENATAL ASSESSMENT (HISTORY 1-2
TAKING)

2. PHYSICAL EXAMINATION OF ANTENATAL MOTHER 3-4

3. ABDOMINAL PALPATION OF ANTENATAL MOTHER 5-6

4. CHECKLIST FOR URINE TEST FOR ALBUMIN 7-8

5. CHECKLIST FOR URINE TEST FOR GLUCOSE 9

6. CHECKLIST FOR BLOOD TEST FOR HEMOGLOBIN 10-11

7. CHECKLIST FOR HEALTH EDUCATION ON ANTENATAL 12-13

EXERCISES
8. CHECKLIST FOR NORMAL VAGINAL DELIVERY 14-16

9. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR 17

10. CHECKLIST FOR PERFORMING AND SUTURING AN 18-19

EPISIOTOMY

11. CHECKLIST FOR VAGINAL EXAMINATION DURING LABOUR 20-21

12. CHECKLIST FOR PERINEAL CARE 22-23

13. CHECKLIST FOR POSTNATAL ASSESMENT AND CARE OF THE 24-25

MOTHER

14. CHECKLIST FOR ASSISTING IN BREASTFEEDING 26

15. CHECKLIST FOR HEALTH TEACHING ON POSTNATAL 27-28

EXERCISES

16. CHECKLIST FOR WEIGHING OF BABY 29

17. CHECKLIST FOR ESSENTIAL NEWBORN CARE 30

18. CHECKLIST FOR NEWBORN RESUSCITATION 31
19. CHECKLIST FOR CARE OF NEWBORN IN INCUBATOR 32

20. CHECKLIST FOR CARE OF NEWBORN IN PHOTOTHERAPY 33

21. CHECKLIST FOR PHYSICAL EXAMINATION OF NEWBORN 34-35

22. STEPS FOR ADMINISTRATION OF INJ. MGSO4 FOR INITIAL 36

MANAGEMENT OF ECLAMPSIA
23. STEPS FOR ADMINISTERING INJ.MG SO4, INTRAVENOUSLY 37-38
AND INTRAMUSCULARLY

24. CHECKLIST FOR INITIAL MANAGEMENT OF SHOCK 39

25. CHECKLIST FOR MANAGEMENT OF PPH DUE TO PERSISTENT 40

ATONIC UTERUS

26. CHECKLIST FOR IUCD INSERTION (COPPER T 380A or 375) 41-42

27. CHECKLIST FOR IUCD REMOVAL 43

28. CHECKLIST FOR PPIUCD INSERTION 44-45

(POSTPLACENTAL AND WITHIN 48 HOURS OF DELIVERY- CU
380A AND CU 375)

29. CHECKLIST FOR COUNSELING FOR FAMILY PLANNING 46-47

 SUBJECT- MIDWIFERY AND OBSTETRICAL NURSING
3RD & 4TH YEAR B.SC NURSING

CLINICAL OBJECTIVES

ANTENATAL CLINIC/OPD

1. Assess and provide care to the antenatal woman

*History taking
*General examination
* Vital signs
* Abdominal examination
2. Perform antenatal Counseling and interventions-Administer Inj.TT & supply IFA
tablets
3. Demonstrate counseling techniques
4. Assess and care a woman with PIH
5. Provide initial management to woman with convulsions in Eclampsia
6. Follow the infection prevention practices
7.Perform pregnancy detection test using "Pregnancy detection Kit", Hb test using
Hemoglobin meter", Urine sugar and protein using "Dipstick or Boiling method”
8. Follow the infection prevention practices

LABOR ROOM/ OT
1. Assess the woman in labor
2. Perform vaginal examination in labor
3. Manage the first stage of labor using partograph
4. Conduct normal vaginal delivery with AMTSL
5. Provide care during fourth stage of labor.
6. Provide Essential Newborn care
7. Resuscitate the newborn when need arises
8. Perform initial management of shock and vaginal bleeding in early pregnancy
9. Perform initial management of shock and postpartum hemorrhage
10. Perform episiotomy and repair
11. Maintenance of labour and birth records
12. Arrange for and assist with Caesarean section and care for woman and baby
during Caesarean.
13. Arrange for and assist with MTP and other surgical procedures.
POSTNATAL WARD
1. Conduct postnatal assessment of mother
2. Conduct new born assessment
3. Perform perineal care
4. Assist in breast feeding
5. Provide care to postnatal mother and baby
6. Provide health education to mother about general hygiene, diet, follow-up,
newborn care and immunization.

FAMILY PLANNING OPD

1. Provide family planning counseling
2. Insertion and removal of IUCD

NICU
1. Describe the physical setup of the clinical area.
2. Perform newborn assessment.
3. Admission procedure of neonates.
4. Feeding of high risk neonates.
5. Maintain thermo regulation of neonates –kangaroo mother care, care of baby
in incubator.
6. Administer medication to neonates
7. Provide care of baby in phototherapy.
8. Assisting in diagnostic procedures.
9. Maintenance of record and report of neonates

INSTRUCTIONS FOR USE OF CHECKLIST

1. Place a tick (√) in box against steps/task if it is performed satisfactorily, and

cross (X) if it is performed unsatisfactorily.
  Satisfactory: performs the step or task according to the standard procedure
or guidelines
 Unsatisfactory: Not performed or unable to perform the step or task
according to the standard procedure or guidelines

2. There are five columns of observations which has to be used as following:

 1 column should be filled when the teacher demonstrates the skill in
respective labs to students.
 2 column should be filled when the students practice it in respective
labs.
 3 column should be filled when the students demonstrates it infront of
supervisor at clinical site and evaluation is done.
 4th and 5th column could be filled in cases of redemonstration for
attaining competency in particular skill.

3. Procedures after demonstration should be recorded in the cumulative record

on the same day itself.
 CHECKLIST FOR ANTENATAL ASSESSMENT (HISTORY TAKING)

S. No STEPS /TASK OBSERVATIONS

1 2 3 4 5
GETTING READY
1 Prepare the necessary equipment.
- ANC Card
- Pen
- ANC register
2 Greet the woman respectfully and with kindness.
3 Tell the woman (and her support person) what is going
to be done, listen to her attentively and respond to her
questions and concerns
PERSONAL INFORMATION
4 Ask the women her name, age, occupation, husband’s
name, address and duration of marriage.
5 Find out the date of the first day of last menstruation
period (LMP).
6 Ask the women if she has any of the following
symptoms which have to be attended to
immediately( first and return visits)
 Fever
 Vomiting
 Vaginal bleeding
 Severe headache / blurring of vision
 Difficulty in breathing, palpitations
 Severe pain in abdomen
 Decrease or absent fetal movement
 Generalized swelling of the body, puffiness of
the face
 Reduced urine output or burning micturations.

7 History of drug intake, allergies, intake of habit forming

or harmful substance, blood transfusion.
OBSTETRIC HISTORY
8 History of previous pregnancies
Inquire about the number of previous pregnancies,
mode, place and outcome of previous delivery, number
of living children, menstrual history, contraceptive
 history, birth weight and age of the last child and history
of all abortions if any.
MEDICAL HISTORY
9 History of systemic illness
 High BP
 Diabetes
 Breathlessness on exertion, palpitation
 Tuberculosis
 Renal diseases
 Convulsion
 Jaundice, malaria
 RTI/STI/HIV
FAMILY HISTORY
10 Family history of systemic illness
 High BP
 Diabetes
 Tuberculosis
11 History of thalassaemia or history of repeated blood
transfusion
12 Record all relevant information on the women’s MCP
card.

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT -
 PHYSICAL EXAMINATION OF ANTENATAL MOTHER

S.NO STEPS/TASK OBSERVATIONS

.
1 2 3 4 5
1. Keep the following necessary items for antenatal
physical examination
 B P apparatus
 Stethoscope
 Thermometer
 Weighing scale
 Watch with second hand
2 Greet the woman respectfully and with kindness.
3. Tell the woman (and her support person) what is going
to be done, listen to her attentively and respond to her
questions and concerns
ASSESSMENT OF GENERAL WELL-BEING (EVERY VISIT)
4. Look for pallor by observing conjunctiva and examining
tongue and nails.
5. Look for yellowish discoloration of the skin and
conjunctiva for Jaundice.
6. Count pulse for one minute by placing the finger tips of
3 fingers on her wrist, below her thumb.
7. Count the respiratory rate by observing the rise and fall
of the chest for 1 minute.
8. Measure blood pressure while the woman is seated and
relaxed.
9. Check for oedema by pressing your thumb against the
bone for 5 seconds.
10. Record weight (ensure that the women is wearing light
clothing and is barefoot.)
BREAST EXAMINATION ( take verbal consent)
11. Help the women on to the examination table, place a
pillow under her head and upper shoulders, and help her
to relax.
12. Examine the breasts. Examine each breast up to the
axilla separately with the pad of your finger for any
lumps or tenderness. If either lumps or tenderness is
present, refer the women.
13. Observe the size of nipples. Looks for inverted or flat
nipples and crusted or sore nipples.
14. Record and inform the findings to mother.
SIGNATURE OF EVALUATORS AND DATE

COMMENTS/ REMARKS-
 ABDOMINAL PALPATION OF ANTENATAL MOTHER

S.NO STEPS/TASK OBSERVATIONS

.
1 Keep the following necessary items for antenatal 1 2 3 4 5
abdominal palpation
 Inch tap
 Feto scope/ Doppler/ stethoscope
 Watch with second hand
2. Explain to the woman what will be done and how she
may cooperate.
3. Instruct the woman to empty her bladder.
4. Help her onto the examination table. Maintain privacy
and obtain the women’s verbal consent.
INSPECTION:
5. Position the woman for examination. Have her arms by
her sides. Expose her abdomen from below the breasts to
the symphysis pubis.
6. Inspect the abdomen for the following:
Scars, linea nigra, Striae gravidarum, Contour of the
abdomen, state of umblicus, skin condition.
FUNDAL HEIGHT
7. Ask the women to keep her legs straight.
8. Measure fundal height from symphysis pubis to fundas.
FETAL LIE AND PRESENTATION
9. Now ask the women to flex her knees.
10. Carry out fundal palpation:
 Make sure hands are clean and warm.
 Stand at the woman’s side, facing her head.
 1st maneuver (Fundal Palpation) - Apply gentle
but firm pressure to assess consistency and mobility
of the fetal part.
 Round, hard, readily movable part, ballotable
between the fingers of both hands is indicative of
head.
 Irregular, bulky, less firm and well defined/movable
part is indicative of breech. Neither of the above is
indicative of transverse diameter.
11. Carry out lateral palpation/ grip
 Place your hands on either side of the uterus at the
level of the umbilicus and apply gentle pressure.
The foetal back feels like a continuous hard,
 The foetal back feels like a continuous hard, flat
 surface on one side of the midline, while the limbs
feel like irregular small knobs on the other side.
 In a transverse lie, the baby’s back is felt across the
abdomen and the pelvic grip is empty.
12. Carry out superficial pelvic ( Pawlik’s Grip)
 Spread your right hand widely over the symphysis
pubis, with the ulner border of the hand touching the
symphysis pubis.
 Try to approximate the fingers and thumb, by
putting gentle but deep pressure over the lower part
of the uterus. The presenting part can be felt
between the thumb and four fingers. Determine
whether it is head or breech.
 If neither the head, nor the buttocks are felt on the
superficial pelvic grip, the baby is lying transverse.
13. Carry out deep pelvic grip (Pelvic Palpation) only on
3rd trimester
 Turn and face the woman’s feet. Ensure that knees
are bent.
 Place your hands on the sides of the uterus, with the
palm of your hands just below the level of umbilicus
and your fingers directed towards the symphysis
pubis.
 Press deeply with your fingertips into the lower
abdomen and move them towards the pelvic inlet.
 The ends converge around the presenting part when
head is not engaged.
 The hands will diverge away from the presenting
part when head is engaged.
FETAL HEART
14. Listen to the fetal heart rate- Place fetoscope on
abdomen at right angles to it (on the same side that you
palpated the fetal back)
15. Record and inform the findings to mother.
SIGNATURE OF EVALUATORS AND DATE

COMMENTS/ REMARKS-
 CHECKLIST FOR URINE TEST FOR ALBUMIN

S. STEPS/TASK OBSERVATIONS
No
GETTING READY 1 2 3 4 5
1 Prepare the necessary equipment. A tray containing:
 Test tube
 Test tube holder
 Spirit lamp
 Match box
 Kidney tray,
 Duster or rag piece
 Acetic acid, Red and blue litmus paper
 A small bottle brush and Container for collecting urine
2 Explain to the woman how to collect a clean-catch
specimen of urine.
DIPSTICK PROCEDURE
3 Remove one strip from the bottle of dipsticks and replace
cap.
4 Completely immerse reagent areas of strip in urine and
remove immediately to avoid dissolving reagents. When
removing the strip, run the edge against the rim of the
urine container to remove excess urine.
5 Hold the strip horizontally and compare reagent areas to
corresponding color chart on bottle label, at the time
specified (usually 60 seconds):
6 Interpretation:
Yellow: Albumin absent
Yellowish green: Traces of albumin
Light green: Albumin +
Green: Albumin ++
Greenish blue: Albumin +++
Blue: Albumin ++++
7 Place strip in plastic bag or leak proof covered container.
HOT TEST FOR DECTING PROTEIN IN URINE
8 Fill three fourths of the test tube with urine and heat the
upper third of the urine over the spirit lamp and allow it
to boil. Keep the mouth of the test tube away from the
face to prevent scalding.
9 Turbidity of the sample indicates the presence of either
phosphate or albumin. Add 2-3 drops of 2% - 3% acetic
acid drop by drop into the test- tube.
10 If the sample remains turbid, it indicates the presence of
proteins. If the turbidity clears, it indicates the absence of
 proteins.
POST-PROCEDURE TASKS
11 Dispose of urine in toilet or latrine.
12 Decontaminate urine container and test tube in 0.5%
chlorine solution
13 Wash hands thoroughly with soap and water and dry with
a clean, dry cloth or allow to air dry.

SIGNATURE OF EVALUATORS AND DATE

COMMENT/ REMARKS -
 .

CHECKLIST FOR URINE TEST FOR GLUCOSE

S. STEPS/TASK OBSERVATIONS
NO
GETTING READY 1 2 3 4 5
1 Prepare the articles needed for the test-
 Test tube in a test tube rack
 Test tube holder
 Spirit lamp
 Match box
 Kidney tray
 Duster or rag pieces to wipe test tube before heating
 Benedict’s solution
 Pipette/filler
 Syringe
 Small bottle brush
2 Explain the procedure to the patient, the purpose of the test, what
specimen to collect, when to collect, how to collect and the amount to be
collected.
3 Provide appropriate container and demonstrate how to use it. Instruct
patient not to contaminate the outside of the bottle
4 Ask patient to wash external genitalia with soap and water before
collecting the urine specimen
PROCEDURE
5 Wash hands
6 Take 5 ml of benedicts solution in a testtube. Boil it over the spirit lamp
holding it away from your face.
7 If the color of the solution does not change on heating it is pure.
8 Add 8 drops of urine in the testube using a dropper. Shake it well and
boil.
9 Allow it to cool and observe the color.
10 Read the result as follows-
- No precipitate: No Sugar
- green precipitate: +
- green liquid with yellow deposits: ++
- Colorless liquid orange deposit: +++
- Brick red: ++++
AFTER CARE-
11 Discard the urine in toilet and clean the test tube using brush, replace
12 Record and inform patient about result
SIGNATURE OF EVALUATORS AND DATE

Comments/Remark-
 CHECKLIST FOR BLOOD TEST FOR HEMOGLOBIN

S. No STEPS/TASK OBSERVATIONS

GETTING READY 1 2 3 4 5
1 Prepare the necessary equipment -
 A pair of gloves
 Spirit swabs
 Lancet
 N/10 HCL
 Distilled water
 Dropper
 Haemoglobinometer with a comparator on both sides
 Pipette and stirrer
 Hemoglobin tube (Sahli-Adams Tube) It is graduated
on one side in g% from 2 to 24g% and on the other side
in percentage from 20% to 40%
2 Explain the purpose of the hemoglobin test to the woman and
encourage her to ask questions.
3 Wash hands thoroughly with soap and water and dry with
clean dry cloth or allow to air dry.
4 Put new examination or high-level disinfected gloves on both
hands.
5 Fill the Hb tube with N/10 HCl Upto 20% or 2g% with the
dropper
HEMOGLOBIN TEST (Using Haemoglobinometer)
6 Clean the tip of the woman’s index finger with an alcohol
swab.
7 Prick finger using lancet and discard first drop of blood.

8 Allow a large drop of blood to form on the fingertip. Dip the

tip of the Hb pipette into the blood drop and suck blood up to
the 20 cmm mark on the pipette. Do not squeeze finger tip to
collect blood. While sucking the blood, care should be taken
to prevent entry of air.
9 Wipe the tip of the pipette with cotton. Immediately transfer
the 20 cmm (0.02ml) of blood from the pipette into the Hb
tube containing N/10 HCL
10 Rinse the pipette two to three times by drawing up and
blowing out the acid solution
11 Leave the solution in the tube for about 10 minutes (for
conversion of Hb into hematin)
12 After 10 minutes, dilute the acid by adding distilled water
drop by drop. Mix it with stirrer.
13 Note down the reading (lower meniscus) when the colour of
the solution exactly matches that of the comparator on both
sides of the hemoglobinometer. This expresses the Hb
 content as g%.
POST-TEST TASKS
14 Dispose of pipette or capillary tube and lancet in puncture
proof container
15 Immerse both gloved hands in 0.5% chlorine solution:
 Remove gloves by turning them inside out
 If disposing of gloves, place in leak proof container
or plastic bag.
16 Rinse the pipette and Hb tube, two or three times by drawing
up and blowing out the acid solution.
17 Discuss the results of the test with the woman:
 If hemoglobin is less than 7 g/dL, refer the woman
for treatment
If hemoglobin is 7-11 g/dL prescribe iron/folate one tablet
daily and provide nutrition counseling
18 Record test results on the woman’s record
SIGNATURE OF EVALUATORS AND DATE

COMMENT/REMARKS-
 CHECKLIST FOR HEALTH EDUCATION ON ANTENATAL EXERCISES

S. No STEPS/TASK OBSERVATIONS
ABDOMINAL BREATHING 1 2 3 4 5
1 Sit comfortably or kneel on all fours (hands and legs)
2 Breath in and out normally.
3 Pull on the lower part of the lower abdomen below the
umbilicus while continuing to breath normally.
4 Hold the muscles in the drawn in position for 10 seconds
5 Repeat up to 10 times.
PELVIC FLOOR EXERCISES
6. Sit, stand or half lie with leg slightly apart.
7 Close and draw up around the anal passage as though
preventing a bowel action.
8 Then draw up around the vagina and urethra as if to stop
the flow of urine in mid stream.
9 Hold for as long as possible for 10 seconds. Breathing
normally then relax.
10 Repeat up to 10 times.
FOOT AND LEG EXERCISES
11. Sit or half lie with leg supported.
12 Bend and stretch the ankles at least 12 times
13 Circle both feet at the ankles at least 20 times in each
direction.
14 Hold tight both knees for a count of four and then relax
15 Repeat 12 times
PELVIC TILTING EXERCISE-
16 Place your hands on the abdomen
17 Gently tighten your tummy muscles and buttocks and
allow the back of your waist to slump backwards. Your
pubic bone rocks up towards you. Breathe normally and
hold the tilt for 5-10 secs.
18 Relax and Repeat a few times

ABDOMINAL BREATHING
19 Instruct the woman to assume supine position with knees
bent.
20 Instruct her to inhale through the nose. Keep the rib cage as
stationery as possible and allow the abdomen to expand
and then contract the abdominal muscles as she exhales
slowly through the mouth.
21 Instruct her to place one hand on the chest and one on the
abdomen when inhaling. The hand on the abdomen should
rise and the hand on the chest should remain stationery.
22 Repeat the exercise 5 times.
SIGNATURE OF EVALUATORS AND DATE

COMMENTS/REMARKS-
 CHECKLIST FOR NORMAL VAGINAL DELIVERY

S. No STEPS/TASK OBSERVATIONS

GETTING READY 1 2 3 4 5
1 Prepare the necessary equipment.
 Plastic apron, mask, covered shoes, goggles, cap
 HLD/ sterile gloves
 Swab/ pieces of gauze
 Antiseptic solution
 Pre warm towel -2
 Artery forcep-2
 Scissors- 1
 Cord ligature
 Mucus extractor
 Kidney tray
 Pad for mother
 Disposable needle/ syringe
 Oxytocin injection(10 unit)/ Misoprostol tablet( 200
mcg,3 tablet)
 I.V. fluid( NS/RL), I.V. stand, I.V. set
 One leak proof container to dispose of solid linen.
 One punture proof container
 One plastic container for disposing placenta
 One plastic container with 0.5% chlorine solution
for decontamination
 Watch/clock
 Partograph
2 Encourage the woman to adopt the position of choice and
continue spontaneous bearing-down efforts
3 Tell the woman and support person what is going to be
done, and encourage them to ask questions.
4 Provide continual emotional support and reassurance, as
feasible.
5 Put on personal protective barriers.
ASSISTING THE BIRTH
6 Wash hands thoroughly with soap and water and dry with a
clean, dry cloth or air dry.
7 Put high-level disinfected or sterile surgical gloves on both
hands.
8 Clean the woman’s perineum with a cloth or compress, wet
with antiseptic solution or soap and water, wiping from
 front to back.
9 Place one sterile drape from delivery pack under the
woman’s buttocks and two warm towels over abdomen to
dry the baby.
BIRTH OF THE HEAD
10 Ask the woman to give only small pushes with contractions
as the baby’s head is born. (Put blanket or towel on
woman’s abdomen.)
11 Keep one hand gently on the head as it advances with the
contractions to maintain flexion.
12 Support the perineum with the other hand, using a clean
pad. Give good perineal support to prevent perineal tears.
13 Once the head is out, gently wipe the mucus from the
baby’s mouth and nose with a clean gauze.
14 Feel around the baby’s neck to ensure the umbilical cord is
not around the neck:
• If the cord is around the neck but is loose, slip it over the
baby’s head
• If the cord is tight around the neck, clamp the cord with
two artery forceps, placed 3 cm apart, and cut the cord
between the two clamps.
COMPLETING THE BIRTH
15 Wait for spontaneous rotation and delivery of the
shoulders. This happens in about 1-2 minutes.
16 Apply gentle pressure downwards to deliver the anterior
shoulder.
17 Then lift the baby up, towards the mother’s abdomen, to
deliver the posterior shoulder. The rest of the baby’s body
follows smoothly.
18 Note time of birth
19 Place the baby on the mother’s abdomen and out
identification tag on the newborn.
20 Thoroughly dry the baby and cover with a clean, dry cloth:
• Assess breathing while drying the baby and if does not
breathe immediately, begin resuscitative measures.
21 Clamp and cut the umbilical cord after pulsations have
ceased or approximately 1–3 minutes after the birth,
whichever comes first: • Tie the cord at about 3 cm and 5
cm from the umbilicus; • Cut the cord between the ties.
22. Leave the baby between the mother’s breasts to start skin to
skin care and let the baby suckle.
23 Cover the baby’s head with a cloth. Cover the mother and
the baby with a warm cloth.
SIGNATURE OF EVALUATORS AND DATE

SUMMARY/REMARKS-
 .

ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR

S. NO. STEPS /TASK OBSERVATION

1 2 3 4 5
1. Preliminary step--Rule out the presence of another baby
by abdominal examination
2. Administer Uterotonic Drug—10 IU oxytocin IM OR
Misoprost 3 tablets (600ug) orally
3. Controlled Cord Traction-
 Place the other hand just above the pubic bone and
gently apply counter traction during a strong
uterine contraction
 When the uterus becomes rounded or the cord
lengthens, very gently pull downward on the cord
to deliver the placenta.
 Continue to apply counter traction with the other
hand
4. Uterine massage
5. Examination of the lower vagina and perineum, Apply a
clean pad to the vulva and give comfortable position to
mother.
6. Examination of placenta, membranes and umbilical cord
a. Maternal surface of placenta
b. Foetal surface
c. Membranes
d. Umbilical cord
7 Place instruments in 0.5% chlorine solution for 10
minutes for decontamination
8. Decontaminate or dispose the syringe and needle
9 Immerse both your gloved hands in 0.5% chlorine
solution
10. Wash hands and air dry.
SIGNATURE OF EVALUATORS AND DATE

COMMENTS/REMARKS –
 CHECKLIST FOR PERFORMING AND SUTURING AN EPISIOTOMY

S. No STEPS/TASK OBSERVATIONS
GETTING READY 1 2 3 4 5
1 Prepare the necessary equipments like:
0.2% lignocaine loaded in 10 cc syringe
Episiotomy scissor
Needle holder
Thumb forceps
Suture cutting Scissor
Suture material 2-0 chromic catgut
Gauze pieces
Sterile pad
Sterile gloves
Antiseptic solution
PERFORMING THE EPISIOTOMY
2 Tell the woman what is going to be done and encourage her
to ask questions.
3 Place the patient in delivery table in dorsal recumbent
positionwhen the fetal head is distending the perineum.
4 Cleanse perineum with antiseptic solution.
5 Infiltrate the perineum using 10 ml of local anaesthetic.
6 Place the index and middle finger in the vagina with palmer
side down and facing you
7 Insert open blade of scissors between perineum and two
fingers and cut medio laterally the perineum and posterior
vagina.
8 Control birth of head and shoulders to avoid extension of the
episiotomy
9 After completion of delivery, repair episiotomy incision
REPAIRING THE EPISIOTOMY
10 Apply antiseptic solution to area around episiotomy
11 Focus light on the perineal area.
12 Visualize the apex of the mucosa. Start suturing little above
the apex. Perform continous suture over the mucosa.
13 Repair the perineal muscles by interrupted sutures.
14 Perineal skin is repaired by mattress sutures.
15 Clean the perineal area with antiseptic and place a sterile
sanitary pad over the vulva and perineum.
POST-PROCEDURE TASKS
16 Dispose of waste materials (e.g. blood-contaminated swabs)
in a leak-proof container or plastic bag.
17 Decontaminate instruments by placing in a plastic container
filled with 0.5% chlorine solution for 10 minutes
18 Decontaminate or dispose of syringe and needle.
19 Immerse both gloved hands in 0.5% chlorine solution and
remove gloves by turning them inside out.
20 Wash hands thoroughly with soap and water and dry with
clean, dry cloth or air dry.
SIGNATURE OF EVALUATORS AND DATE

COMMENT/ REMARKS-
 CHECKLIST FOR VAGINAL EXAMINATION DURING LABOUR

S. STEP/TASK OBSERVATIONS
NO
1 2 3 4 5
1 Keep the equipments ready:-
Sterile gloves
plastic apron
boiled and cooled sterile swabs in antiseptic solution
0.5% chlorine solution.
2 Tell the woman and her support person what is going to be done and
encourage them to ask questions.
3 Ask the woman to pass urine and lie down with her knees flexed and legs
apart. Uncover her genital area and cover to maintain privacy.
4 Put on clean plastic apron.
5 Wash your hands thoroughly with soap and water and wear sterile gloves
on both hands.
6 Check the vulva for the presence of:
 Mucous discharge
 Excessive watery discharge
 Foul smelling discharge
8 Clean the vulva from above downwards with one gloved hand (not the
examining hand)
9 Gently insert the index and middle fingers of the examining hand into the
vagina.
10 Feel the cervix: it should be soft and elastic, and closely applied to the
presenting part.
11 Measure the dilatation of the cervical os by inserting middle and index
fingers into the open cervix and gently opening the fingers to reach the
cervical rim.
- 0cm indicates a closed external cervical os.
- 10cm indicates full dilatation
12 Feel the membranes:
 Intact membranes can be felt as a bulging balloon during a
contraction through the dilating os.
 Feel for the umbilical cord.
 If the membranes have ruptured, check whether the amniotic fluid
is clear or meconium stained.
13 Identify the presenting part.
14 Assessing the pelvis.
 Try to reach the sacral promontory if the head is not engaged. If
the sacral promontory is felt, the pelvis is contracted.
 If the sacral promontory is not felt, trace downwards and feel for
the sacral hollow. A well curved sacrum is favourable.
 Spread your two fingers to feel for the ischial spines. If both
ischial spines can be felt at the same time, the pelvic cavity is
contracted.
15 Gently remove your fingers from the vagina and immerse your gloved
hand in 0.5% chlorine solution.
16 Rinse the gloves in 0.5% chlorine solution and remove them by turning
them inside out.
17 Wash the hands thoroughly with soap and water, dry with a clean dry
cloth or air dry.
18 Inform the findings to the woman and record them.
SIGNATURE OF EVALUATORS AND DATE

REMARKS/ COMMENTS:
 CHECKLIST FOR PERINEAL CARE

S.no. STEPS/TASK OBSERVATIONS

1 2 3 4 5
1. Prepare needed articles-
1. sterile perineal care pack containing-
- cotton balls
- gauze pieces
-Artery forceps
-Thumb forceps
2. Other articles-
-Anti septic solution
- Kidney tray
- Cheatle forceps
-Extra cotton balls
-Sanitary pads
-Hip tie
-Sterile gloves
2. Explain the procedure to patient and provide privacy
3. Assist the patient to assume dorsal recumbent position
with knees bent and drape the area.
4. Open sterile tray. Arrange articles with cheatle forcep
and pour antiseptic solution in sterile bowl in tray.
5. Scrub hand and dry.
6. Put on sterile gloves.
7. Take the cotton swab with artery forceps dipped in
antiseptic solution.
8. Clean the mons pubis in zigzag manner
9. clean labia minora and labia majora using one cotton
ball for each stroke
10. Using cotton ball, separate labia majora with non
dominant index finger and thumb
11. Clean with cotton ball and antiseptic solution from
clitoris down. Use fresh cotton ball for each stroke
12. If catheter is present, clean urethra around catheter using
fresh cotton ball. Clean catheter to a length of 2 inches
away from urethra using fresh cotton ball
13. Clean perineal suture line if present
14. Finally clean from forchette to anus
15. Fix pad from front to back
16. Position patient comfortably

17. Dispose of waste materials (e.g. blood-contaminated

swabs) in a leak-proof container or plastic bag.
18. Decontaminate instruments by placing in a plastic
container filled with 0.5% chlorine solution for 10
 minutes
19. Immerse both gloved hands in 0.5% chlorine solution
and remove gloves by turning them inside out
20. Wash hands thoroughly with soap and water and dry
with clean, dry cloth or air dry.
21. Record the procedure- date, time, type of lochia, color
consistency, odour and condition of the suture line if
present.
22. Report any foul smelling discharge and gaping of
wound to the concerned doctor

SIGNATURE OF EVALUATORS AND DATE

REMARKS/ COMMENTS-
 CHECKLIST FOR POSTNATAL ASSESMENT AND CARE OF THE MOTHER

S. STEP/TASK OBSERVATIONS
No
GETTING READY 1 2 3 4 5
1 Prepare the necessary equipment.
2 Greet the woman respectfully and with kindness.
3 Tell the woman (and her support person) what is going to be done,
listen to her attentively and respond to her questions and concerns.
4 Provide continual emotional support and reassurance, as possible.
HISTORY TAKING
5 How are you feeling? Did you take adequate rest and sleep?
6 How is your diet? Did you pass urine and stools, any perineal pain?
7 Are you breastfeeding? Where did the delivery take place?
8 Was there heavy bleeding? What is the number of pads or pieces of
cloth getting soaked with blood?
9 Did you have convulsion or loss of consciousness?
10 Did you have abdominal pain, fever and pain in legs?
11 Do you have any dribbling/burning sensation on micturation
12. Do you have tenderness of the breast?
EXAMINATION
13. Ask the mother to sit/lie comfortably.
 Check her vitals signs.
 Look for pallor.
14. Conduct an abdominal examination. Check if the uterus is well
contracted. i.e. hard and round.
15. Examine the vulva and perineum for the presence of any tear, swelling
or pus discharge.
16. Examine the pad for bleeding and assess if the bleeding is heavy. Also
see if the lochia is healthy.
17. Examine the breast for lumps or tenderness and check the condition of
the condition of the nipples.
18. Observe breastfeeding technique and enquire if milk is adequate.
MANAGEMENT AND COUNSELING – Give the mother following advices.
19. Postpartum care and hygiene
 She should wash perineum daily after passing the stools.
 The perineal pad should be changed every 4-6 hourly, or
 according to bleeding.
 She should take bath daily and get enough sleep and rest.
 Sexual intercourse should be avoided until the perineal wounds
have healed.
 She should wash her hand before and after handling the baby.
 Rooming in.
20. Nutrition
 She should increase her intake of food and fluids.
 She should not follow taboos on nutritionally healthy foods.
21. Contraception- Advice the couple on birth spacing or limiting the
family planning.
22. Counsel about breast feeding technique, registration of birth, IFA
supplementation and danger signs.

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT-
 CHECKLIST FOR ASSISTING IN BREASTFEEDING

S. No STEP/TASK OBSERVATIONS
1 2 3 4 5
1 Explain the mother about the advantages of exclusive breast
feeding
2 After birth, let the baby rest comfortably on the mother’s chest in
skin-to-skin contact.
3 Check that position and attachment are correct at the first feed.
Offer to help the mother at any time
4 Let the baby release the breast by her/himself; then offer the second
breast
5 If the baby does not feed in 1 hour, examine the baby. If healthy,
leave the baby with the mother to try later. Assess in 3 hours, or
earlier if the baby is small
6 If the mother is ill and unable to breastfeed, help her to express
breast milk and feed the baby by cup. On day 1 express in a spoon
and feed by spoon.
TEACH CORRECT POSITIONING AND ATTACHMENT FOR BREASTFEEDING
7 Show the mother how to hold her baby. She should:
 make sure the baby’s head and body are in a straight line
 make sure the baby is facing the breast, the baby’s nose is
opposite her nipple
 hold the baby’s body close to her body
 support the baby’s whole body, not just the neck and shoulders
8 Look for signs of good attachment:
 more of areola visible above the baby's mouth
 mouth wide open
 lower lip turned outwards
 baby's chin touching breast
9 Look for signs of effective suckling (that is, slow, deep sucks,
sometimes pausing

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT –
 CHECKLIST FOR HEALTH TEACHING ON POSTNATAL EXERCISES

S. No STEP/TASK OBSERVATIONS
Pelvic floor exercises-(start exercise as soon after birth as possible. 1 2 3 4 5
But if urinary catheter is in place, wait until it is removed)
1 Sit, stand or half lie with leg slightly apart.
2 Close and draw up around the anal passage as though preventing a
bowel action.
3 Then draw up around the vagina and urethra as if to stop the flow
of urine in mid stream.
4 Hold for as long as possible for 10 seconds. Breathing normally
then relax.
5 Repeat up to 10 times.
PELVIC TILTING AND ROCKING EXERCISE
6 Lie flat on the floor with knees bend and feet flat, inhale and while
exhaling, flatten the back hard against the floor, so that there is no
space between the back and the floor.
7 Inhale normally. Hold breath for upto 10 seconds and then relax.
8 Repeat up to 10 times
KNEE BEND AND LEG ROLLING
9 Lie flat on back with knee bent and feet flat on the floor or bed.
10 Keep the shoulders and feet stationery and roll the knees to side to
touch first one side of the bed then the other.
11 Maintain a smooth motion as the exercise is repeated five times.
HIP HITCHING
12 Lie on her back with one knee bent and other knee straight.
13 Slide the heel of the straight leg downwards thus lengthening the
legs
14 Shorten the same leg by drawing the hip up towards the ribs on the
same side.
15 Repeat upto 10 times keeping the abdomen pulled in.
16 Change to the opposite side and repeat.
FOOT AND LEG EXERCISES
17 Sit or half lie with leg supported.
18 Bend and stretch the ankles at least 12 times
19 Circle both feet at the ankles at least 20 times in each direction.
20 Hold tight both knees for a count of four and then relax
21 Repeat 12 times
ABDOMINAL BREATHING
22 Instruct the woman to assume supine position with knees bent.
23 Instruct her to inhale through the nose. Keep the rib cage as
stationery as possible and allow the abdomen to expand and then
contract the abdominal muscles as she exhales slowly through the
mouth.
24 Instruct her to place one hand on the chest and one on the
abdomen when inhaling. The hand on the abdomen should rise and
the hand on the chest should remain stationery.
25 Repeat the exercise 5 times.

SIGNATURES OF EVALUATORS AND DATE

REMARKS/COMMENT-

.
 CHECKLIST FOR IMMUNIZATION- OPV, BCG, DPT, MEASLES

S. No STEP/TASK OBSERVATIONS
GETTING READY 1 2 3 4 5
1 Prepare the necessary equipment
2 Tell the mother what is going to be done, listen to her attentively
and respond to her questions and concerns.
3 Wash hands thoroughly with soap and water and dry with a clean,
dry cloth or air dry.
POLIO IMMUNIZATION
4 Check the label on the vaccine container for:
Vaccine name and expiration date
5 Check the symbol to ensure patency of the vaccine
6 Remove rubber top from vaccine container:
Place the pipette on the container (if this is required).
7 Place 2 drops of vaccine on the baby’s tongue.
8 Make sure that the baby swallows the vaccine:
Ask mother not to breastfeed the baby until it is obvious that the
vaccine has been swallowed.
BCG IMMUNIZATION
9 Select the site for injection: Deltoid muscle area for immunization
10 Clean the skin with an alcohol swab or cotton-wool ball soaked in
antiseptic and allow drying.
11 Check the expiry date on the vial of vaccine.
12 Draw vaccine into a TB (1 cc) syringe
13 Check that vaccine and dose are correct.
14 Hold the syringe and needle almost parallel with skin, with the
bevel of needle facing up.
15 Pull the skin taut with one hand, insert the tip of needle barely
under the skin and advance the needle slowly until bevel of
needle has fully entered the skin:
16 Gently point the needle upward, without repiercing skin, and
inject the vaccine with steady pressure for three to five seconds
and look for blanching of skin.
17 Withdraw the needle in a single smooth motion after completing
the injection and apply gentle pressure with a dry cotton-wool
ball.
DPT IMMUNISATION
18 Check the vaccine name and expiry date
19 Draw vaccine into a 2 cc syringe.
20 Select the site for injection; Antero lateral aspect of the middle
one third of the thigh.
21 Restraint the thigh with the help of an assistant to avoid injury
due to movement
22 Clean the site with spirit swab in circular motion and allow it to
 dry
23 Insert the needle at 90 degree angle intramuscularly.
24 Slowly administer the vaccine
25 Withdraw the needle in a single smooth motion after completing
the injection and apply gentle pressure with a dry cotton-wool
ball. Do not massage
MEASLES IMMUNISATION
26 Check the vaccine name and expiry date
27 Draw vaccine into a 2 cc syringe
28 Select the site for injection; Dorsal aspect of upper arm just below
the deltoid.
29 Clean the site with spirit swab in circular motion and allow it to
dry
30 Hold the sub Cutaneous tissue with thumb and index finger and
Insert the needle at 45 degree angle into the subcutaneous tissue.
31 Slowly administer the vaccine
32 Withdraw the needle in a single smooth motion after completing
the injection and apply gentle pressure with a dry cotton-wool
ball. Do not massage
33 POST-PROCEDURE TASKS (Note: the following steps apply,
where appropriate, to each of the procedures above.)
34 Place any blood-contaminated items (cotton-wool balls) in a
plastic bag or leak proof, covered waste container.
35 Decontaminate needles and syringes:
If disposing of needle and syringe, hold the needle under the
surface of a 0.5% chlorine solution, fill the syringe and push out
(flush) three times; then place in a puncture-resistant sharps
container.

SIGNATURE OF EVALUATORS AND DATE

REMARKS/ COMMENT –
 CHECKLIST FOR WEIGHING OF BABY
S. STEP/TASK OBSERVATIONS
NO.
1 2 3 4 5
1 Places the weighing scale on a flat and stable surface.
2 Checks whether pan is centrally placed
3 Checks whether the pan is free to move
4 Places towel/clean paper on the pan
5 Adjusts the setting to “0”
6 Undresses the baby and places the undressed baby on the
weighing machine
7 Places baby centrally on the pan, Pacifies the baby if it is
vigorous.
8 Informs the mother about baby’s weight
9 Removes the baby from the pan and dresses the baby
quickly.
10 Gives the baby to the mother
11 Records the reading in the register.
12 Removes the used towel/ clean paper. Cleans the pan if it
is soiled

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENTS-

CH
ECKLIST FOR ESSENTIAL NEWBORN CARE
S.NO STEPS/ TASK OBSERVATION
1 2 3 4 5
1. Call out the time of birth
 Deliver the baby on a warm clean towel on the
2.
mothers abdomen or chest

Immediately dry the baby with a warm clean

3.
towel

Remove the wet towel and wrap the baby in a

4.
warm dry towel.

Wipe both the eyes separately with sterile gauze

5.
from medial to lateral side.

6. Clamp and cut the umbilical cord in 1-3 minutes

7. Place an identity label on the baby.

Leave the baby in between the mothers breast to

8.
initiate skin to skin care

Cover the baby’s head with a cap and cover the

9.
mother and baby with a warm cloth

10. Encourage initiation of breast feeding

SIGNATURE OF EVALUATORS

COMMENT/ REMARKS-

CHECKLIST FOR NEWBORN RESUSCITATION

S.NO STEPS/ TASK OBSERVATIONS
1 2 3 4 5
1. Getting ready with :
 Bag and mask
 Suction equipment
 Radiant warmer or other heat source
 2 warm towels
 Clock with seconds hand
  Oxygen source
 Gloves
 Shoulder roll
 Cord tie
 Scissor
2. Look for Meconium and suck mouth and nose at the mother’s
abdomen
3. Dry the baby, remove wet towel and wrap in warm dry towel

4. Assess breathing
5. Cut the cord immediately

6. Place the baby on a warm, firm flat surface

7. Position the baby in slight neck extension using a shoulder roll

Suction of mouth and nose
Stimulate the baby
Reposition and reassess breathing
8. If not breathing provide bag and mask ventilation for 30 seconds,
make sure that the chest rises.
9. Reassess the baby after 30 seconds of ventilation.
10. If still not breathing continue bag and mask ventilation, start
oxygen and assess the heart rate.
11. If the baby is still not breathing, continue bag and mask ventilation
and refer to higher center
12. At any point if baby starts breathing , provide observational care
SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENTS -

CHECKLIST FOR PHYSICAL EXAMINATION OF NEWBORN

S.No STEP/TASK OBSERVATIONS
1 GETTING READY
Maintain the temperature of the room above 25
degree centigrade. Close doors and windows
Collect articles needed for examination-
Gloves, inch tape, weighing machine, Infantometer,
thermometer, stethoscope.
2 Vital signs-
 Check temperature, heart rate and respiration, BP if
instrument available
3 Anthropometry-
Check weight, length, Head circumference, chest
circumference
4 Skin- assess appearance, color, note presence of
vernix caseosa, milia, Mongolian spots, erythema
toxicum
5 Head- Assess fontanelles, caput succedaneum,
cephalhematoma.
Ears- Look for symmetry, firmness of the pinna
6 Hearing- Check for alertness in the presence of
conversation or noise
7 Nose- Should be symmetrical and patent
8 Mouth and chin- Open at equal angles bilaterally
Presence of cleft lip and palate
9 Chest- Shape and circumference
10 Abdomen- Soft
11 Umbilicus- Should be positioned midway between the
xyphoid and the pubis. Cord should contain two
arteries and one vein
12 Genitalia and anus-
Male- Glans is completely covered by the foreskin at
birth, Testes is descended, scrotum is highly
pigmented, anus and rectum is patent.
Female- labia majora covers labia minora, vaginal
orifice is pink, glistening and patent.
13 Musculo skeletal system-
Spine is of normal curvature
Extremities are symmetrical in position and presence
of normal active and passive movements
Posture- resting posture is with hips abducted and
partially flexed, and knees flexed.
14 Central nervous system-
Reflexes- Check for the following reflexes: Rooting,
sucking, extrusion, blinking, doll’s eye, palmer grasp,
moro’s, tonic neck reflex.

SIGNATURE OF EVALUATORS AND DATE

 REMARKS/COMMENTS -

CHECKLIST FOR CARE OF NEWBORN IN INCUBATOR

SI NO Step/Task 1 2 3 4 5
1 Explain the need for incubator to parents
2 Check for doctor’s order
3 Make sure incubator is clean before placing the baby. Apply liquid soap
and clean it with dry duster.
4 Switch on incubator for 15-20 minutes to prewarm and then place the
baby.
5 Adjust incubator and keep it according to the temperature chart available
in the nursery.
6 Check temperature of the baby and the incubator every hour and repeat
every hour until the temperature of baby is stabilized.
7 Maintain flow chart to record temperature, HR, respiration and oxygen
 saturation.
8 Give care for baby by introducing hands through arm ports.
9 Report to doctor if baby is not maintaining normal temperature for two
consecutive readings.
10 Document
 Time and temperature of the baby
 Set temperature of the incubator

SIGNATURE OF EVALUATOR AND DATE

REMARKS/COMMENTS -

CHECKLIST FOR CARE OF NEWBORN IN PHOTOTHERAPY

SI NO Step/Task 1 2 3 4 5
1 Keep all the equipment ready
 Photo therapy machine
 Measuring tape
 Eye shield
 Baby blanket
 Napkin to cover the genitalia
2 Explain to the parents need of phototherapy
3 Check machine for electrical safety and proper insulation of wires
4 Check whether all the bulbs in the machine are in working condition.
5 Transfer the baby in to isolette overwhich phototherapy lights are placed
6 Adjust the height between the baby and the lamp to 45 cm maximum.
7 Place baby under light without dress.
8 Cover baby’s eye with eye shield. Cover the genitalia with the napkin
9 Switch on machine.
10 Check the
 temperature
 respiratory rate
 color of the skin
 color of the urine
 color of the stool
11 Change position of the baby every 2 hrly.
12 Give two hourly feeds, if baby is not taking adequate feeds, inform
doctor.

13 Watch for signs of

 Dehydration
 Decreased urine output
 Temperature instability
 Diarrhea
 rashes
14 Document procedure

SIGNATURE OF EVALUATOR AND DATE

REMARKS/COMMENTS –

STEPS FOR ADMINISTRATION OF INJ. MGSO4 FOR INITIAL MANAGEMENT OF

ECLAMPSIA

S.
STEPS/TASK OBSERVATIONS
NO
1 2 3 4 5

Wash hands thoroughly with soap and water and dry

1.
before and after the procedure
Keep ready 10 ampoules (20 ml=10 gms) of 50% Mg
2.
SO4 so give 5amp.= 10ml.=5gms.in each buttock
Prepares 2 syringes(10ml syringe and 22 gauze
3.
needle) with 5 g of 50% magnesium sulfate solution
Carefully cleans the injection site with an alcohol
4.
wipe.
 5. Gives 5 g by DEEP IM injection in one buttock.
Disposes of used needle and syringe in a puncture
6.
proof box
Carefully cleans the injection site in the alternate
7.
buttock with an alcohol wipe.
Gives 5 g by DEEP IM injection into the other
8.
buttock.
Disposes of used needle and syringe in puncture
9.
proof box
10. Records drug administered

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT-

STEPS FOR ADMINISTERING INJ.MG SO4, INTRAVENOUSLY AND

INTRAMUSCULARLY

S. NO. STEPS OBSERVATIONS

Administering Loading Dose (IV+ IM ) of Magnesium 1 2 3 4 5
Sulfate
Washes hands thoroughly with soap and water and air
1.
dry. Puts clean exam gloves on both hands.
Prepares magnesium sulfate 20% solution, 4 g .
(Take one 20ml sterile syringe, draw 4 ampoules of Mg
2.
So4 (8ml=4g) into the syringe, add 12 ml of distilled
water /normal saline for injection to make it 20%)
3. Carefully cleans the injection site with an alcohol wipe.
Gives magnesium sulfate 20% solution, 4 g by IV
4.
injection SLOWLY over 5 minutes
Disposes of used needle and syringe in a sharps disposal
5.
box
Administering IM loading Dose of Magnesium Sulfate
Prepares 2 syringes(10ml syringe with 22 gauze needle)
6.
with 5 g of 50% magnesium sulfate solution
7. Carefully cleans the injection site with an alcohol wipe.
8. Gives 5 g by DEEP IM injection in one buttock.
 Disposes of used needle and syringe in a sharps disposal
9.
box
Carefully cleans the injection site in the other buttock
10.
with an alcohol wipe.
11. Gives 5 g by DEEP IM injection into the other buttock.
Disposes of used needle and syringe in a sharps disposal
12.
box
13. Disposes of gloves in a 0.5% decontamination solution
Washes hands thoroughly with soap and water then air
14.
dry.
Records drug administration and findings on the
15.
woman’s record.
Administering IV Dose of Magnesium Sulfate for recurrent fits / convulsions
Washes hands thoroughly with soap and water and air
16.
dry. Puts clean exam gloves on both hands.
Prepares syringe with 2 g magnesium sulfate (50%
solution)
17. Take one 10ml sterile syringe, draw 2 ampoules of Mg
So4 50%(4ml=2g) into the syringe add 6 ml of distilled
water /normal saline
18. Carefully cleans the injection site with an alcohol wipe.
Gives magnesium sulfate 20% solution, 2 g by IV
19.
injection SLOWLY over 5 minutes
Disposes of used needle and syringe in a sharps disposal
20.
box
21. Disposes of gloves in a 0.5% decontamination solution
Washes hands thoroughly with soap and water and dries
22.
with a clean, dry cloth or air dry.
Maintenance dose of MgSo4
Washes hands thoroughly with soap and water and air
23
dry. Puts clean exam gloves on both hands.
Prepares 1 syringe (10ml syringe with 22 gauze needle)
24
with 5 g of 50% magnesium sulfate
25 Carefully cleans the injection site with an alcohol wipe.
Gives 5 g by DEEP IM injection every 4 hourly in
26
alternate buttock.
Maintenance dose of MgSO4 to be continued till 24
27 hours after delivery or the last convulsion whichever is
later
Disposes of used needle and syringe in a sharps disposal
28
box
29 Disposes of gloves in a 0.5% decontamination solution
Washes hands thoroughly with soap and water and dries
30
with a clean, dry cloth or air dry.
Records drug administration and findings on the
31
woman’s record

SIGNATURE OF EVALUATORS AND DATE

REMARKS/ COMMENT -
 CHE
CKLIST FOR INITIAL MANAGEMENT OF SHOCK

SI NO STEP/TASK 1 2 3 4 5
1 Keep the woman’s leg elevated
2 Prepare the necessary equipment for starting IV line. Check the IV
solution
3 Wash hands thoroughly and dry
4 Connect IV solution and tubing; flush tubing
5 Put on new examination gloves
6 Select IV site and cleanse with alcohol or antiseptic solution
7 Start IV using large bore needle or cannula
8 Attach infusion set and ensure infusion is running well
9 Infuse IV fluid 2L in 60 drops/min rate
10 dispose of waste materials
11 Remove gloves
12 Wash hands thoroughly
13 Assess the vital signs in every 15 minutes

SIGNATURE OF EVALUATORS AND DATE

 REMARKS/ COMMENTS

CHECKLIST FOR MANAGEMENT OF PPH DUE TO PERSISTENT ATONIC UTERUS

S. STEP/TASK OBSERVATIONS
NO
1 2 3 4 5
1 Massages the uterus
2 Checks the woman’s bleeding
3 Inspects the placenta for any missing pieces
4 Re-checks the uterus and bleeding
5 Gives a second dose of medication telling what dose, route and
why (IV drip with Injection oxytocin 20 units in 500 ml of
Ringer Lactate at 40-60 drops per minute)
6 Re-checks bleeding and tone
7 Puts on long gloves
Empty the bladder
8 Explains to patient that he/she will be providing bi-manual
compression
9 Clean vulva and perineum with antiseptic solution
10 Insert hand in cone shaped and make a fist when it reaches the
anterior vaginal fornix and apply pressure against the anterior
wall of the uterus
11 Place other hand on abdomen behind uterus, press the hand
deeply into the abdomen and apply pressure against the posterior
wall of the uterus
12 Maintain compression until bleeding is controlled and the uterus
contracts
13 Remove gloves and discard them in leak proof container or
plastic bag if disposing of or decontaminate them in 0.5%
chlorine solution if reusing
 14 Wash hands thoroughly
15 Monitor vaginal bleeding, take the woman’s vital signs and
makes sure that the uterus is firmly contracted
16 Makes the decision to transfer
17 Explains to the patient that they will need to be transported for
advanced care
18 Answers patient’s question, "Why can’t I stay here, my bleeding
is better” correctly. (Because she is at risk for complications that
cannot be treated at this local facility, or is “too high risk”, or
“might bleed again”, or “we don’t have blood here”)
SIGNATURE OF EVALUATORS AND DATE

REMARK / COMMENTS-

CHECKLIST FOR IUCD INSERTION (COPPER T 380A or 375)

SI STEP/TASK 1 2 3 4 5
NO
1 Review the client’s medical and reproductive history.
2 Arrange the articles:
- Copper T (380 A or 375)
- Sponge holding forceps
- Sim’s or Cusco’s vaginal speculum
- Vulsellum
- Antiseptic solution with swabs for cleaning
- Sterile gloves
- Scissor
- Sterile pad
3 Make the client empty her bladder and wash her perineal area.
4 Tell the mother what is going to be done, listen to her attentively and respond
to her questions and concerns.
5 Wash hands thoroughly with soap and water and dry with a clean, dry cloth or
air dry.
6 Put sterile gloves on both hands
7 Inspect the external genitalia
8 Perform a bimanual examination to note the position of uterus
9 Perform a speculum examination by gently inserting speculum to visualize the
cervix and cleanses the cervical os and vaginal wall with antiseptic.
10 Gently grasp the cervix with a sterile vulsellum and apply gentle traction
11 Insert the sterile uterine sound using the “no touch” technique.
With Cu IUCD 380 A With Cu IUCD 375
12 Load the IUCD in its sterile package Grasp the insertion tube and the IUCD
string together at the lower end of the
tube
13 Set the blue depth gauze to the Move the cervical guard to the
measurement of the uterus. measurement of the uterus
14 Carefully insert the loaded IUCD and Gently advances the loaded IUCD into
release it into the uterus using the the uterine cavity until the cervical
withdrawal technique guard touches cervix or a slight
resistance is felt
15 Gently pushes the insertion tube Partially remove the insertion tube
upwards again until, care provider from the cervical canal
feels a slight resistance.
16 Withdraw the rod and partially
withdraw the insertion tube until the
IUCD strings can be seen.
17 Use sterile scissor to cut the IUCD strings to three to four centimeter length
18 Gently remove the vulsellum and speculum
19 Examine the cervix for bleeding. Ask how the client is feeling
20 Place in 0.5% chlorine solution for 10 minutes for decontamination
21 Rinse gloved hands in 0.5% chlorine solution. Remove them inside out. Wash
hands thoroughly and dry them.
22 Provide post insertion instructions:
- Basic facts about her IUCD – type, how long effective, when to replace
or remove.
- No protection against STI’s, need for condom if at risk
- Possible side effect
- Warning signs (PAINS)
- Checking for possible IUCD expulsion
- When to return to clinic
23 Maintain records and fill IUCD card
SIGNATURE OF EVALUATORS AND DATE

REMARKS /COMMENTS
 CHECKLIST FOR IUCD REMOVAL

SI STEP/TASK 1 2 3 4 5
NO
1 Ask the woman her reason for IUCD removal.
Determine whether she have another IUCD insertion immediately, start a
different method, or neither
2 Arrange the articles:
- Sponge holding forceps
- Sim’s or Cusco’s vaginal speculum
- Antiseptic solution with swabs for cleaning
- Sterile gloves
- Sterile pad
3 Check to be sure client has emptied her bladder and washed and rinsed her
genital area.
4 Tell the client what is going to be done and encourage her to ask questions.
5 Help client onto examination table.
6 Wash hands thoroughly with soap and water and dry with clean, dry cloth or air
dry.
7 Put new examination or high-level disinfected surgical gloves on both hands.
8 Insert vaginal speculum to see cervix and IUCD strings.
9 Clean the cervix with antiseptic solution.
10 Grasp the strings of the IUCD with a sterile straight artery forceps.
11 Gently pull the string by applying steady but gentle traction with the artery
forceps.
12 Show IUCD to client.
13 If the woman is having a new IUCD insertion, insert it now if appropriate.
14 Gently remove speculum and place all instruments in 0.5% chlorine solution
for 10 minutes for decontamination.
15 Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by
turning inside out.
16 Wash hands thoroughly with soap and water and dry with clean, dry cloth or air
dry.
17 Counsel client regarding new contraceptive method if desired and provide
18 Record IUCD removal in client record.
SIGNATURE OF EVALUATORS AND DATE

REMARKS/ COMMENTS

CHECKLIST FOR PPIUCD INSERTION

(POSTPLACENTAL AND WITHIN 48 HOURS OF DELIVERY- CU 380A AND CU 375)

SI STEP/TASK 1 2 3 4 5
NO
1 Pre insertion screening and medical assessment done prior to conducting vaginal
delivery
For post placental For insertion within 48 hours of
delivery
2 Perform pre insertion screening of Perform pre insertion screening of
client. Confirm that there are no client. Confirm that there are no
delivery related conditions which delivery related conditions which
prevents insertion of IUCD now: prevents insertion of IUCD now:
 Rupture of membrane for greater  Rupture of membrane for
than 18 hours greater than 18 hours
 Chorioamnionitis  Chorioamnionitis
 Unresolved PPH  Puerperal sepsis
 Continuous excessive post
partum bleeding
 Extensive genital trauma.
3. If any of these conditions exist inform the woman. Explain that this is not a safe
time for insertion of IUCD.plan re evaluation for an IUCD at 6 weeks post
partum
4 Arrange articles:
- PPIUCD forceps
- Sponge holding forceps
- Speculum
- Vulsellum
- Cu T 380A or 375
- Antiseptic solution with swabs for cleaning
- Sterile gloves
- Sterile pad
For post placental For insertion within 48 hours of
 delivery
5 If insertion is done by the same provider Perform hand hygiene then, put on
that assisted delivery, put on new pair of new pair of sterile gloves.
sterile gloves.
If insertion is done by different
provider, who has not assisted delivery,
then perform hand hygiene then, put on
new pair of sterile gloves.
6 Ensure that AMTSL has been performed
7 Inspects perineum, labia and vaginal Inspect the external genitalia.
wall for lacerations. If lacerations are
not bleeding heavily, insert the IUCD
and repair the laceration if needed.
8 Perform a speculum examination by gently inserting speculum to visualize the
cervix and cleanses the cervical os and vaginal wall with antiseptic two times two
swabs and wait for two minutes.
9 Gently grasp the anterior lip of cervix with a sterile vulsellum
10 Open the sterile packet of IUCD from bottom by pulling back plastic covers
approximately 1/3rd upwards. Remove plunger rod, inserter rod from the packet.
11 Grasps IUCD with PPIUCD forceps in a sterile packet using non touch technique
12 Gently lift anterior lip of cervix using vulsellum
13 Insert PPIUCD forcep into lower uterine cavity upto the point of feeling slight
resistance against back wall of the uterus. Gently remove the vulsellum.
14 Moves hand to the lower part of abdomen (base of hand on lower part of uterus
and fingers towards fundus) and gently push uterus upwards in the abdomen to
reduce the angle and curvature between the uterus and vagina
15 Gently move the PPIUCD forceps holding the IUCD upwards towards the uterine
fundus. Lower right hand down, to enable forceps to easily pass vaginal- uterine
angle and follow the curve of the uterine cavity. Keep placental forceps closed
while moving up, so IUCD does not become displaced. Take care not to perforate
the uterus
16 Confirm that the end of the forceps has reached the fundus.
17 Opens the forceps, tilt it slightly towards mid line, and releases IUCD at the
fundus.
18 Continues to stabilize the uterus with the hand on the abdomen.
19 Sweeps placental forceps to side wall of the uterus
20 Slowly removes forceps from uterine cavity.
21 Stabilizes the uterus until the forceps are completely out the uterus.
22 Examine the cervix to see if any portions of IUCD or string are visible protruding
from the cervix. If IUCD or strings are seen protruding from cervix remove
IUCD, reload in sterile package and reinsert. Ensure that there is no bleeding
from cervix.
23 Remove all instrument used and placed in 0.5% chlorine solution in open position
and ensure that they are totally sub merged.
24. Allow the women to rest for few minutes support the initiation of routine
postpartum care, including immediate breastfeeding.
25. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning
inside out.
26. Wash hands thoroughly with soap and water and dry with clean, dry cloth or air
dry.
27. Post insertion instruction to the client-
 - Reviews IUCD side effects and normal postpartum symptoms.
- Tells the client when to return for IUCD/PNC/ newborn checkup.
- Inform about the warning signs for IUCD.
28. Record information in the client chart or record.

SIGNATURE OF EVALUATORS AND DATE

REMARKS/ COMMENTS

CHE
CKLIST FOR COUNSELING FOR FAMILY PLANNING

SI STEP/TASK 1 2 3 4 5
NO
1 Greets the woman with respect and kindness. Introduces self.
2 Asks the woman if she is breastfeeding and offer help to get her started.
 Discuss benefits for the baby once baby is attached to the breast
 Discuss that exclusive breastfeeding also offers 98% protection
against pregnancy
3 Discuss the 3 criteria: Exclusive breastfeeding, no menses, and the baby
is less than 6 months
4 Asks the woman if she and her husband plan to have more children
5 Asks the woman when she and her husband would like to have more
children (if applicable) Tell the woman the benefit of healthy spacing of
pregnancy (if applicable)
6 Tell the woman the risk of another pregnancy before the return of her
menses if she is not fully breastfeeding her baby
7 Tell her that there are methods of contraception that are available that
will not affect the quantity or quality of her breast milk such as
progestin-only pills, INJECTABLES, the IUCD or condoms.
8 Remind the client that withdrawal is not very effective; 25 women in 100
will become pregnant!
9 Ask her if she would like any information about these methods
10 Leave the client information sheet and invite her to participate on the
postpartum education session.
11 Thank the woman and encourage her to see her obstetrician at 6 weeks to
discuss contraception or earlier if she is not breastfeeding
12 Gives the client advice on how to maintain exclusive breastfeeding:
 Breastfeed as often as your baby wants, day and night
 Continue to breastfeed even when you or your baby is sick
 Do not give your baby any foods, water or other liquids before 6
 months of age
 Breast milk gives your baby everything she/he needs to be healthy
 Do not use bottles, pacifiers or other artificial nipples. These
discourage your baby from breastfeeding as frequently
13 Discusses the importance of transitioning to another method immediately
if any of the three criteria is not met
14 Discusses the method of family planning she would like to use when no
longer using LAM
15 Discusses the importance of continuing to breastfeed after LAM criteria
are not met and she is using another method of contraception. Include
discussion of appropriate methods for the breastfeeding mother.
16 Advises the woman to return to the clinic for a family planning method
when LAM is no longer met. Give client education material.
SIGNATURE OF EVALUATORS AND DATE

REMARKS/ COMMENTS
 CHECKLIST FOR HAND WASHING

S. OBSERVATIONS
NO STEP/TASK 1 2 3 4 5
1. Remove rings, bracelets, and watch.

2. Wet hands in clean running water. Apply soap.

Vigorously rub hands together in following manner
3.
 Palms, fingers and web spaces
4.  Back of hands
5.  Fingers and knuckles
6.  Thumbs
7.  Fingertips and creases
8.  Wrist and forearm up to the elbow
9. Thoroughly rinse hands in clean running water.
Dry hands using clean personal towel, paper towel, or
10.
allows to air dry.

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT -
 CHECKLIST FOR PUTTING ON STERLE GLOVES

S. OBSERVATIONS
NO STEP/TASK 1 2 3 4 5
1. Open the outer package of gloves in a clean, dry area and
wash your hands
2. Open the inner wrapper, exposing the cuffed gloves with
the palms facing upwards.
3. Pick up the first gloves by the cuff, touching only the
inside portion of the cuff.
4. Pick up the first glove by the cuff, touching only the
inside portion of the cuff.
While holding the cuff in one hand, slip your other hand
5.
into the glove. Be careful not to touch anything and hold
the gloves above the level of your waist.
6. Pick up the second glove by sliding the fingers of the
gloved hand under the cuff of the second glove.
7. Put the second glove on the ungloved hand by maintaining
a steady pull through the cuff.
8. Adjust the glove finger and cuff until the gloves fit
comfortably.
SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT -
 CHECKLIST FOR PREPARATION OF 0.5% CHLORINE SOLUTION

S. OBSERVATIONS
NO STEP/TASK 1 2 3 4 5
Articles needed-
 Bleaching powder
 Teaspoon
 One litter measuring mug
1.
 Plastic bucket
 Utility gloves
 Plastic apron
 1 litter water
 Wooden stick.
2. Wear utility gloves and plastic apron while making
chlorine solution.
3. Measure 1 litter of tap water and put it in to a plastic
bucket.
4. Take 3 level teaspoon of bleaching powder in a plastic mug
and make a thick paste, using little water.
5. Mix this paste to the 1 litter of water to make 0.5%
chlorine solution
Note- change the chlorine solution after 24 hours and make
6.
fresh solution every day. Always prepare in plastic
container.

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT -
 CHECKLIST FOR PROCESSING OF EQUIPMENT

S. OBSERVATIONS
NO STEP/TASK 1 2 3 4 5
DECONTAMINATION
Immediate after using instrument and other items,
1 decontaminate them by placing them in a plastic container
of 0.5% chlorine solution.
2 Let them sock for 10 minutes.

After 10 minutes, remove the items from the chlorine

3. solution and rinse them with water or clean immediately by
putting utility gloves.
CLEANING
Wear utility gloves and use a soft brush or old tooth brush,
4.
detergent and water.
Scrub the instruments and other items vigorously to
5. completely remove all blood, other body fluids, tissue and
other foreign matter.
Hold the items under the surface of the water while
6.
scrubbing and cleaning to avoid splashing.
Disassemble instruments and other items that have
multiple parts. Make sure you brush in the grooves, teeth
7.
and joints of items, as these are areas where organic
material can get collected and stick.
Rinse the items thoroughly with water to remove all
8.
detergent.
 Allow the items to air dry or dry them with a clean cloth,
9.
and send them for autoclave.
STERILIZATION

10. Fill the bottom of the autoclave with water till the ridge.

Place the items in autoclave drum loosely and put it on the

11.
stove or electrically connected system.
Note the timing when the steam emits from the pressure
valve. Keeps the wrapped items for 30 min and unwrapped
12.
for 20 min at 15 pound per square inch at 212 degree
centigrade.
Open the pressure valve to release the steam and allows
13.
autoclave to cool for 15-30 min before opening.
Dip instruments like laparoscope or bag & mask ect. In
14.
glutaraldehyde 2% solution
STORAGE

15. Store the instruments at a clean dry place.

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT -
 CHECKLIST FOR ASSISTING WITH VENTOUSE EXTRACTION

S. OBSERVATIONS
NO STEP/TASK 1 2 3 4 5
Articles required-
 Suction cups of varying sizes (30,40,50 and 60 mm)
 A vacuum generator
 Traction tubing and handle
 NBR equipment.
 Delivery pack containing-
- Artery forceps
- Dissecting forceps
- Cord clamp
- Suture needle and suture material
- Pad
- Mucous sucker

SIGNATURE OF EVALUATORS AND DATE

REMARKS/COMMENT -