Labor and Delivery Skills Checklist Form

Items in red are REQUIRED fields.

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Directions for completing Skills Checklist:

The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar. Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience.
B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.



A. ADMISSION:  A     B     C     D
Admission Data Collection Procedures:
   1. Review of maternal record for care plan:         
   2. Maternal vital signs:         
   3. Fetal heart rate:  
      (a) Fetascope         
      (b) Doppler         
      (c) Electronic fetal monitor/ external and internal         
   4. Leopold's maneuvers:  
      (a) Presentation         
      (b) Position         
      (c) Size         
   5. Assessment/palpitation of contractions:  
      (a) Frequency         
      (b) Intensity         
      (c) Duration         
   6. Assessment of membrane status:  
      (a) Nitrazine test (amnicator)         
      (b) Pooling of amniotic fluid         
      (c) Fern test         
   7. Assessment of show:         
   8. Assessment of edema/ reflexes:         
   9. Urine dipstick:         
   10. Admission vaginal exam:  
      (a) Station         
      (b) Effacement/dilation         
      (c) Presenting part         
   11. Assitance with sterile speculum exam         
   12. Initiation of IV access:         
   13. Patient/family orientation to facility, procedures:         
   14. Admission nursing documentation:  
      (a) Nursing history         
      (b) Labor record         


B. FIRST STAGE OF LABOR:  A     B     C     D
Latent Phase:
   1. Assessment:  
      (a) Maternal vital signs         
      (b) Fetal heart rate         
      (c) Contraction pattern         
      (d) Rate of effacement/dilation         
      (e) Rate of descent         
      (f) Behavior/sources of discomfort         
   2. Nursing interventions:  
      (a) Diet/hydration         
      (b) Activity         
      (c) Elimination         
      (d) Hygiene         
      (e) Comfort/support         
      (f) Family involvement         
   3. Outpatient:  
      (a) Nursing documentation         
      (b) Assessment of true vs false labor         
      (c) Physician notification         
      (d) Common tocolytic medications         
      (e) Discharge instructions/ nursing documentation for undelivered patient         
      (f) Critical thinking         
Active Phase:
   1. Assessment:  
      (a) (following) SROM         
      (b) Hydration         
      (c) Activity         
      (d) Elimination         
      (e) Hygiene         
      (f) Comfort/support         
      (g) Family involvement         
   2. Patient Education:         
   3. Nursing documentation:  
      (a) Maternal vital signs         
      (b) Fetal Heart Rate  
         (I) Electronic fetal monitor/ external and internal         
         (II) IUPC, assist with         
      (c) Contraction pattern         
      (d) Rate of dilation/ descent         
      (e) Vaginal exam         
      (f) Fluid/ hydration status         
      (g) Behavior and sources of pain/ discomfort         
   4. Nursing interventions:  
      (a) (following) SROM         
      (b) Hydration         
      (c) Activity         
      (d) Elimination         
      (e) Comfort/Support  
         (I) Whirlpool         
         (II) Psychoprophylactic         
         (III) Family support/ involvement         
   5. Analgesia/anesthesia:  
      (a) IM/IV analgesics         
      (b) Epidural anasthesia, assistance with         
   6. Patient Education:         
   7. Nursing documentation:         
   8. Critical thinking:         


C. SECOND STAGE OF LABOR:  A     B     C     D
   1. Assessment of second stage:  
      (a) Maternal vital signs         
      (b) Fetal heart rate         
      (c) Contraction pattern         
      (d) Rate of descent         
      (e) Behavior/sources of pain         
   2. Nursing interventions:  
      (a) Breathing/pushing techniques         
      (b) Suprapubic/fundal pressure (shoulder dystocia)         
      (c) Pain relief/support         
      (d) Maternal positioning  
         (I) Birthing bed         
      (e) Family support/ involvement         
   3. Preparation for/Assistance with delivery:  
      (a) Routine setup of equipment/ supplies/ delivery cart         
      (b) Spontaneous delivery         
      (c) Forceps-assisted delivery         
      (d) Vacuum-assisted delivery         
   4. Patient Education:         
   5. Nursing documentation:         



D. THIRD STAGE OF LABOR DELIVERY OF PLACENTA:  A     B     C     D
   1. Post-delivery assessment of newborn:  
      (a) APGAR score         
      (b) Initial newborn vital signs         
      (c) Initial newborn screening assessment         
   2. Nursing interventions for newborn stabilization:  
      (a) Comfort/Support  
         (I) Drying/wrapping techniques         
         (II) Skin to skin contact         
         (III) Radiant warmer         
      (b) Maintenance of airway/ suctioning  
         (I) Bulb         
         (II) De Lee         
         (III) Wall         
      (c) Identification  
         (I) Bands         
         (II) Footprint sheets         
   3. One touch:         
   4. Vitamin K:         
   5. Erythromyacin ointment:         
   6. Cord blood:         
   7. Parental/newborn bonding:         
   8. Maternal assessment:  
      (a) Placental separation         
   9. Maternal nursing interventions:  
      (a) Fundal pressure         
      (b) Pitocin         
      (c) Examination of placenta/ membrane/ cord         
      (d) Disposal of placenta         
   10. Assistance with perineal repair:         
   11. Patient education:         
   12. Nursing documentation:         


E. THIRD STAGE OF LABOR RECOVERY OF MOTHER:  A     B     C     D
   1. Maternal assessment:  
      (a) Maternal vital signs         
      (b) Fundus  
      ;   (I) Fundal massage         
      (c) Lochia         
      (d) Perineum         
      (e) Fluid/hydration status         
      (f) Bladder/voiding status         
      (g) Anal/hemmorhoid assessment         
   2. Maternal nursing interventions:  
      (a) Diet/hydration         
      (b) Ambulation         
      (c) Elimination         
      (d) Diet/hydration  
         (I) Perineal cleansing         
         (II) Application of pad         
      (e) Comfort/ Pain relief  
         (I) Perineal ice pack         
      (f) Maternal/ newborn bonding  
         (I) Breastfeeding         
         (II) Bottle feeding         
         (III) Cord care         
         (IV) Bathing the newborn         
         (IV) Bulb syringe         


F. SPECIAL SITUATION/COMPLICATIONS:  A     B     C     D
   1. Emergency transfer to L&D:         
   2. Emergency transfer to Surgery:         
   3. Transfer to another facility:         
   4. Vaginal birth after Cesarean (VBAC):         
   5. Assessment of VBAC patient:         
   6. Management/nursing interventions:         
   7. Patient education:         
   8. Nursing documentation:         

Induction/Augmentation of labor/ artificial rupture of membranes
   1. Assessment of need for Picotin induction/ augmentation:         
   2. Management/ nursing interventions:         
   3. Patient education:         
   4. Nursing documentation:         
   5. Assistance with AROM:  
      (a) Assessment of fluid color, odor:         
   6. Softening agents:         

Meconium-stained amniotic fluid
   1. Assessment of meconium in labor:         
   2. Management/ nursing interventions:         
   3. Amnioinfusion:         
   4. DeLee suctioning on the perenium:         
   5. Nursing documentation:         
   6. Patient education:         

Prolapsed cord
   1. Assessment/identification of prolapsed cord:         
   2. Management/ nursing interventions:         
   3. Patient education:         
   4. Nursing documentation:         

Group B Strep
   1. Assessment/identification of prolapsed cord:         
   2. Risk factors:         
   3. Management/ nursing interventions:         
   4. Cultures:         

Postpartum hemorrhage
   1. Assessment/identification:         
   2. Management/nursing interventions:  
      (a) Fundal massage:         
      (b) Picotin:         
      (c) Methergine:         
      (d) Hemabate:         
   3. Patient education:         
   4. Nursing documentation:         

Cesarean sections
   1. Consents:         
   2. Teaching:         
   3. Preparation of patient:  
      (a) Bicitra:         
      (b) Foley:         
      (c) Shave prep:         
   4. Labs:         
   5. Notify surgery, nursery, pediatrician:         
   6. Crash cart:         
   7. Warmer:         
   8. Suction and oxygen setup in OR:         

Medications
   1. Administration responsibilities/ five rights:         
   2. Patient education:         
   3. Nursing documentation:         

Common Medications for Labor and Delivery
   1. Demerol:         
   2. Morphine:         
   3. Nubain:         
   4. Phenergan:         
   5. Pitocin:         
   6. Methergine:         
   7. Hemabate:         
   8. Prostin E:         
   9. Terbutaline:         
   10. MgS04:         
   11. Stadol:         
   12. Cytotec:         
   13. Vistaril:         

Antepartum
   1. Antepartum testing:  
      (a) NST:         
      (b) CST:         
      (c) OCT:         
   2. Amniocentesis:         
   3. Hemorrhage:         
   4. External version:         
   5. Preterm labor management:         
   6. Trauma:         

Special Circumstances
   1. Still born-nonviable fetus:  
      (a) Definitions:  
         (I) Miscarriage:         
         (II) Stillborn:         
         (III) Live Birth:         
   2. Social services:         
   3. Disposal of:         
   4. Patient teaching:         
   5. Nursing documentation:         

High Risk
   1. PIH Assessment:  
      (a) Risk factors:         
      (b) Definition:         
      (c) Classifications:         
      (d) Treatment management:         
      (e) Nursing documentation:         
   2. Diabetes:  
      (a) Definition:         
      (b) Assessment:         
      (c) Risk factors:         
      (d) Classifications:         
      (e) Treatment/management:         
      (f) Nursing documentation:         
   3. HIV/Hepatitis B:  
      (a) Assessment:         
      (b) Risk factors:         
      (c) Classifications:         
      (d) Treatment/management:         
      (e) Nursing precautions:         
      (f) Confidentiality:         
      (g) Documentation:         
   4. Drug Abuse:  
      (a) Assessment:         
      (b) Risk factors:         
      (c) Classifications:         
      (d) Treatment/management:         
      (e) Nursing precautions:         
      (f) Confidentiality:         
      (g) Documentation:         
   5. Placenta Previa/Abruption:  
      (a) Assessment:         
      (b) Risk factors:         
      (c) Definition:         
      (d) Treatment/management:         
      (e) Nursing precautions:         
      (f) Documentation:         

The information I have given is true and accurate to the best of my knowledge. I hereby authorize Professional Nursing Service to release my Labor and Delivery Skills Checklist to Client facilities of PNS in relation to consideration of employment as a Traveler with those facilities.

Yes, I agree and consent to the statement above         Date: