QF SON 042 Summary Performance Evaluation Achieving Intra Partal Care Competency
QF SON 042 Summary Performance Evaluation Achieving Intra Partal Care Competency
QF SON 042 Summary Performance Evaluation Achieving Intra Partal Care Competency
I. SAFE AND QUALITY NURSING CARE (SQC) Weight Self Score Remarks
Evaluation
Intra-Partal Care Competencies
1. Obtains obstetrical history including parity, gravida score, LMP, EDC, 4
AOG, BOW onset of true labor.
2. Checks vital signs. 1
3. Conducts physical examination. 2
4. Performs Leopold’s maneuver. 2
5. Checks Fetal Heart Rate and Fundic height. 2
6. Monitor progress of labor/uterine contractions using partograph. 4
7. Ensure that the mother is in her position of choice during labor 2
8. Ask the mother if she wishes to eat/ drink or void. 2
9. Communicates with the mother-informs her progress of labor, gives 2
reassurance and encouragement.
10. Checks temperature in the DR area to be 25-28C;eliminates air draft 4
Performs functions during actual labor
1. Transports clients safely while providing privacy. 1
2. Ensures that the mother is comfortable in the semi-upright position 2
3. Removes all the jewelry and washes hands thoroughly observing the 4
WHO 1-2-3-4-5 procedure
4. Performs perineal care using sterile technique correctly 2
5. Washes hands 1
6. Wears gown and gloves according to hospital policy. 1
7. Encourages mother to push as desired 2
8. Drapes the clean, dry linen over the mother’s abdomen or arms in 2
preparation for drying the baby
9. Performs Ritgen’s maneuver safely and controlled delivery the baby’s 2
head
10. Calls-out time of birth and sex of the baby 2
11. Informs the mother of the outcome 1
12. Excludes a 2nd baby by palpating the abdomen in preparation for giving 2
the oxytocin.
13. Gives 10 units of oxytocin intramuscularly within 1 minute after baby’s 4
birth.
14. Performs the remaining steps of the AMSTL:
Checks for strong uterine contraction then applies controlled 1
cord traction and counter traction on the uterus, continuing
until placenta is delivered.
Massage the uterus until it is firm 1
Checks the characteristics/completeness of the placenta 1
15. Inspect the lower vagina and perineum for lacerations/tears and assist in 2
the repair (episiorraphy) as necessary.
16. Cleans the mother, flushes the perineum and applies perineal 2
pad/napkin/cloth
17. Dispose the placenta in leak-proof container or plastic bag 1
18. Decontaminates instruments for 10 minutes before cleaning 1
19. Advise the mother to maintain skin to skin contact with the baby. Baby 4
should be prone on the mother’s chest or between the breast with the
head turned to one side.
20. Advise mother to observes for feeding cues 2
21. Supports mother, instruct her on positioning and attachment 2
22. Waits for full breastfeeding to be completed 1
23. Advise the mother about the optional/delayed bathing of the baby 1
24. Advise the mother to do breastfeeding per demand 1
25. In the first hour: checks mother’s vital signs and massage the uterus 4
every 15 minutes
26. In the second hour: checks mother-baby dyad every 30 minutes to 1 hr. 2
27. Evaluates patient’s condition and records pertinent data accordingly. 4
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QF-SON-042
28. Prepares patient for transfer to recovery room/ward. 1
Newborn Competencies
1. Thoroughly dries the baby at leaser 30 seconds while performing a quick 4
check for breathing.
2. Removes the wet cloth
3. Places baby in skin to skin contact on the mother’s abdomen or chest 4
4. Cover the baby with the dry cloth and the baby’s head with the bonnet 2
5. Performs properly-timed cord clamping
Palpates umbilical cord to check pulsation 1
After pulsations stop, clamp the cord using plastic clamp or cord tie 1
2 cm from the base
Places the instrument clamp 5cm from the base or 3cm from the 1
plastic clamp.
Cut the cord near the plastic clamp 1
6. Checks baby’s color and breathing. May perform and interpret APGAR 2
scoring.
7. Maintains the baby in a skin to skin contact. Baby should be prone on the 4
mother’s chest or between breasts with the head turned to one side
8. Observes for breastfeeding cues 2
9. Waits for full breastfeeding to be completed 1
10. Administer eye ointment. (CREDE’s Prophylaxis) 1
11. Do thorough physical examination and anthropometric measurement 4
12 Administer injections:
Vitamin K (1 mg/IM) into the lateral anterior thigh or vastus 1
lateralis,left leg.
Hepatitis B on the right leg. 1
BCG intradermal on either arm 1
13.In the first hour: checks baby’s breathing and color every 15 minutes 2
14. In the 2nd hour: checks the mother-baby dyad every 30 minutes to 1 hour 1
15. Records pertinent observations and nursing care done. 1
16. Reports any signs of deviation/abnormality to the pediatrician. 1
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)
Intra-Partal Care Competencies
1. Prepares room, instruments and equipment needed.
Sterile drape
Clear, clean newborn resuscitation area. Check the equipments if 1
clean, functional and within easy reach 1
Arrange materials/supplies in a linear sequence: gloves, dry linen,
cloth/napkin( for Ritgens maneuver), bonnet, oxytocin injection, 2
plastic clamp, instrument clamp,scissors,2 kidney basins
2. Performs sterilization procedure. 1
3. Maintains adequacy of supplies as the delivery progresses. 1
4. Maintains orderliness of the sterile table. 1
5. Observes precautionary measures related to use of electrical equipment. 1
6. Ensures a quiet and draft free environment. 1
7. Uses supplies diligently. 1
8. Performs after care of the materials and equipments used. 1
9. Ensures proper disposal of hospital waste including blood and other fluids. 1
Newborn Competencies
10. Prepares room, instruments and equipment needed.
Clear, clean Newborn resuscitation area. Check the equipments if
clean, functional and within easy reach
(Checks materials/supplies in a linear sequence) 1
In a separate sequence to be used after the 1st full breast feeding:
prepares eye ointment, stethoscope, tape measure and others to be
used in anthropometric measurement ,injections (Vit.K, Hepatitis B 2
& BCG vaccines),cotton balls, forceps, etc.
11.Ensures use of sterile equipment during immediate care of the newborn 1
12.Maintain adequacy of supplies as newborn care is rendered 1
13Maintain adequacy of supplies as newborn care is rendered 1
14. Observes precautionary measures related to use of electrical equipment. 1
15. Ensures a warm and quiet environment. Maintains temperature at 25-28C 2
16. Uses supplies diligently. 1
17.Ensures proper disposal of hospital waste 1
III. HEALTH EDUCATION (HE)
1. Teaches client on basic preparation during labor and deliver 1
(can be done in the labor room).
2. Coaches client on breathing /bearing down technique. 2
3. Demonstrates proper “latch-on” breast feeding technique 1
(done post-partum period).
4. Gives instructions to parents regarding infant care before discharge 1
(done post-partum period).
5. Provides discharge instructions as to feeding, bathing, administration of 1
ordered medications, appointment dates for post natal and well baby
check up (done post-partum period).
Newborn Competencies
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6. Provides instructions to the mother on daily cord care and prevention of 1
cord infection
7. Provides discharge instructions to the mother on when to expect cord to 1
fall off or to report signs of cord infection.
8. Provides information regarding newborn screening, immunization, 2
feeding, etc
9. Responds to questions of clients and relatives regarding expectations. 1
IV.LEGAL RESPONSIBILITIES (LR)
1. Secures informed consent in all procedures related to labor and delivery. 1
2. Reports accurately any deviations/abnormal findings and nursing 1
intervention rendered.
3. Reports accurately and honestly the gender, time of delivery of the baby 2
and placenta.
4. Ensures proper identification of the mother and newborn. 2
5. Identifies newborn by comparing ID band with data in the chart 2
6. Performs foot printing according to hospital policy 1
7. Ensures that birth certificate and other civil registration forms are 2
accomplished/filled out according to institutional policy.
8. Documents all pertinent data correctly and completely. 1
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the religious, cultural and ethnic practices of the family of the 1
woman in labor and delivery.
2. Promotes emotional security by supporting needs. 1
3. Ensures privacy and confidentiality. 1
VI.PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Updates oneself with the latest trends and development in labor and 1
delivery
2. Projects a professional image of a delivery room nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
VII. QUALITY IMPROVEMENT (QI) (preferably done during post conferences)
1. Identifies deviation of practice from the standards. 1
2. Participates in audit practices in the delivery room/lying in. 1
3. Recommends corrective and preventive measures for the identified 1
deviations.
VIII. RESEARCH (R)
1. Identifies researchable problems related to labor and delivery/immediate 2
care of the newborn
2. Utilize findings of research studies in intra-partal care/ immediate care of 2
the newborn
IX RECORDS MANAGEMENT (RM)
1. Documents accurately relevant data about client. 1
2. Maintains an organized system of filing and keeping records of the 1
client.
X. COMMUNICATION (Comm)
1. Utilizes appropriately all forms of communication; verbal, non-verbal, 1
electronic.
2. Inform client’s significant others of the progress of labor and delivery. 1
3. Listens attentively to clients and families queries and requests. 1
XI. COLLABORATION AND TEAMWORK (CTW)
1. Functions effectively as a team player in the delivery room/lying in. 1
2. Communicates the progress of labor/delivery to significant others. 1
3. Establishes collaborative relationship with members of the health team 1
and family members.
TOTAL SCORE: 188
Grading System
TARDINESS ABSENCES
DATE NUMBER OF MINUTES DATE REMARKS
Remarks/Comment:
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EVALUATED BY:
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Clinical Instructor’s Signature Student’s Signature