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ASIAN DEVELOPMENT FOUNDATION COLLEGE

Tacloban City

COLLEGE OF NURSING & SCHOOL MIDWIFERY


PERFORMANCE RATING SCALE: ASSISTING DELIVERY
NAME: _______________________________________ COURSE/YR: ________________ DATE: ________

Skills:
1. Puts on mask and gown.
2. Washes hands thoroughly.
3. Follows aseptic technique:
a. Grabs strings of DR gown
b. Moves around sterile area.
4. Skillfully performs periwash:
a. Washes hands thoroughly
b. Informs client what he/she is about to do
c. Pours water on thighs and mons pubis
d. Disinfects with one stroke from:
d.1 Upper to lower thighs in an S movement
d.2 Mons pubis to symphysis pubis
d.3 Labia majora to minora
d.4 Clitoris
d.5 Urethral orifice
d.6 Vagina
d.7 Anus
e. Informs client before pouring water when rinsing.
5. Aseptically performs catheterization:
a. Identifies size of catheter to be used (F 16)
b. Informs client what he/she is about to do
c. Disinfects the urinary meatus
d. Lubricates tip of catheter (1-2 inches)
e. Informs client before inserting catheter
f. Instruct client to breathe through mouth
g. Inserts catheter gently
h. Observes urine flow until it stops
i. Removes catheter slowly
6. Records time membranes ruptured.
7. Records time delivered and gender of newborn.
8. Records time placenta delivered accurately.
9. Administers accurately oxytocin/methergine after
obtaining BP reading of mother.
10. Assists in episiorraphy:
a. Disinfects bottle of lidocane
b. Positions correctly lidocane bottle for extraction
c. Anticipates need of Nurse and Obstetrician:
c.1 Provides additional cherries/cottonballs for
disinfecting incision site
c.2 Provides additional suture needle and other
materials as needed
c.3 Wipes perspiration of Nurse and Obstetrician
11. Takes and records vital signs:
a. Temperature
b. Pulse rate
c. Respiratory rate
d. Blood Pressure
12. Adjusts accurately IV flow as ordered.

Remarks

CLINICAL INSTRUCTORS COMMENTS:


____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____

____________________
C.I.s Signature

RATING SCALE

FREQUENCY
OUTSTANDING

_______________

_______________

VERY SATISFACOTRY

_______________

_______________

SATISFACTORY

_______________

_______________

NEEDS IMPROVEMENT

_______________

_______________

NO OPPURTUNITY

_______________

_______________

DIVISOR __________

DIVIDEND __________ =

QUOTIENT __________

Quotient with the Corresponding Grade in Percent


4.0
3.90
3.75
3.60
3.50
3.40
3.25
3.10
3.0
2.90
2.75
2.60
2.50
2.40
2.25
2.10
2.0
1.90
1.75
1.60
1.50
1.40
1.25
1.10
1.0
.90
.75
.60

95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%

=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=

1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.7

.50
.40
.25

67% = 3.8
66% = 3.9
65% = 4.0

ASIAN DEVELOPMENT FOUNDATION COLLEGE


Tacloban City

COLLEGE OF NURSING & SCHOOL MIDWIFERY


PERFORMANCE RATING SCALE: HANDLING DELIVERY
NAME: _____________________________________ COURSE/YR: __________________ DATE:__________

Skills:
1. Puts on mask and cap properly.
2. Checks for functionality of:
a. Lights
b. Delivery table
c. Oxygen apparatus
d. Emergency cart
3. Washes hands aseptically.
4. Gathers equipments and supplies needed.
5. Observes aseptic technique when using pick-up
forceps.
6. Observes aseptic technique when moving around sterile
field.
7. Opens sterile pack aseptically.
8. Drapes mayo table aseptically.
9. Arranges equipments and supplies according to use.
10. Covers table with sterile sheet.
11. Performs surgical handwashing.
12. Put on sterile gown correctly.
13. Dons sterile gloves.
14. Shows independence, confidence and
conscientiousness in providing nursing care:
a. Establishes rapport with client and significant other(s)
b. Maintains client comfort and privacy
15. Observes aseptic technique when draping the:
a. Mothers abdomen
b. Legs
c. Buttocks
16. Notes precisely time membranes ruptured.
17. Applies gentle pressure over perineum during
crowning.
18. Instructs mother to correctly bear down:
a. During contractions
b. Pushes with mouth closed
19. Instructs mother to do proper deep breathing.
20. Checks accurately for cord coil once head of neonate
is out.
21. Performs suctioning correctly:
a. Deflates suction bulb first
b. Suctions mouth then nose
22. Delivers anterior shoulder and gently pulls downward.
23. Releases gently posterior shoulder by pulling upward.
24. Supports back of neonate by sliding one hand under it.
25. Grasps firmly both feet of neonate.
26. Places neonate on mothers abdomen and wraps in
sterile sheet.
27. Clamps and cuts cord properly.
28. Observes for signs of placental separation (Sudden

Remarks

gush of blood, uterine contraction, globular shape of abdomen,


lengthening of cord & appearance of cord in the vaginal
opening)

29. Observes for:


a. Mechanism of placental separation
b. Time of placental separation
c. Completeness of placenta
30. Discards properly the placenta.
31. Assists in episiorraphy.
32. Performs skillfully perineal washing.
33. Changes mothers clothing.
34. Applies maternity pad.
35. Transfers mother safely:
a. Supports neck, truck and legs
b. Lifts side rails
c. Endorses properly to OB Nurse
36. Mops DR.
37. Discards contents of bucket.
38. Washes and packs instruments and equipments used.
39. Sterilizes instruments properly.
40. Replaces supplies used for next delivery.

CLINICAL INSTRUCTORS COMMENTS:


____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____

____________________
C.I.s Signature

RATING SCALE

FREQUENCY
OUTSTANDING

_______________

_______________

VERY SATISFACOTRY

_______________

_______________

SATISFACTORY

_______________

_______________

NEEDS IMPROVEMENT

_______________

_______________

NO OPPURTUNITY

_______________

_______________

DIVISOR __________

DIVIDEND __________ =

QUOTIENT __________

Quotient with the Corresponding Grade in Percent


4.0
3.90
3.75
3.60
3.50
3.40
3.25
3.10
3.0
2.90
2.75
2.60
2.50
2.40
2.25
2.10
2.0
1.90
1.75
1.60
1.50
1.40
1.25

95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%

=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=

1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
3.0
3.1
3.2

1.10
1.0
.90
.75
.60
.50
.40
.25

72%
71%
70%
69%
68%
67%
66%
65%

=
=
=
=
=
=
=
=

3.3
3.4
3.5
3.6
3.7
3.8
3.9
4.0

ASIAN DEVELOPMENT FOUNDATION COLLEGE


Tacloban City

COLLEGE OF NURSING & SCHOOL MIDWIFERY

NAME: _____________________________________ COURSE/YR: __________________ DATE:__________

Immediate Competencies: At the end of the DR exposure, the students are expected to apply their
knowledge, skills and attitude in providing proper intrapartal care to the mother and child.
Student Competencies

Activities

1. Prepare the birthing/delivery room for


necessary equipments, materials and
procedures according to agency policy for
infection protection and control.

a. Gathers organizes equipments and materials for


delivery according to use.
b. Sets-up sterile table aseptically.
c. Prepares client for actual delivery.

2. Deliver the baby safely.

a. Assists in safely delivering the baby and placenta.

3. Perform immediate post-partum care to


mother:
a. Checks Vital Signs after delivery of a. Checks uterine contraction after delivery of placenta.
placenta
b. Administer medication accurately after b. Monitors for mothers wellbeing after delivery.
delivery of placenta.
4. Performs after care in the DR.

a. Cleans DR after delivery.


b. Replaces all used equipments and materials aseptically.