LABOR AND DELIVERYSKILLS CHECKLIST
DATE: ______
Applicant’s Name: ______
FIRSTMIDDLE INITIALLAST
To IITR Professionals:
The purpose of the following checklist is to assist in matching your skills and interests withavailable assignments, thus meeting your needs and the needs of our clients as much as possible. Your employment is not dependant upon responses given in this checklist.
**Please make sure this Skills checklist is signed and dated.
The information I have given is true and accurate to the best of my knowledge
Signature______Date ______
To IITR:
IITR has developed unique skills checklist for each nursing specialty. This checklist is not necessarily a valid indicator of clinical skills and should not be utilized as the sole measure of the ability of an individual to perform the duties of a registered nurse or therapist in your facility. It is intended to be used only as a guide in your screening procedures and in orientation to procedure within your institution.
PLEASE MARK YOUR LEVEL OF EXPERIENCE X
Self-Assessed Experience Rating Scale
Limited Experience1234Very Experienced
Mark One Mark One
A. / Medication Administration / 1 / 2 / 3 / 4 / 1 / 2 / 3 / 41. / Administer From a Stock Medication System / 3. / Regulate IVs
2 / Use a Unit Dose System / 4. / Mix IV Infusion Uing Additives
3. / Administer IM, SC Medications (i.e., Narcotics) / 5. / Discontinue Peripheral IVs
4. / Use of Patient controlled Analgesia Pump / 6. / Use IV Infusion Pumps
5. / Monitor IV Drips / 7. / Use Heparin Locks
a. Oxytocin Inductin /Augmentation Prostaglandin Induction / 8. / Institute & Monitor Blood/Blood Products
b. Cervical Ripening Agents: / 9. / Measure CVP Readings
1. Prostaglandin / 10. / Patient Controlled Analgesia
2. Cervidil
3. Cytotec / C. / Aseptic Technique Relative to L&D
c. MgSo4 for Pre-eclampsia / 1. / Set-up Delivery Table
d. Labor Suppressants: / 2. / Set-up a Caesarean table
1. MgSo4 / 3 / Circulate for a Caesarean Section
2. Terbutalene / 4. / Scrub for a Cesarean Section
3. Ritodrine / 5. / Circulate, Scrub, for a Postpartum Tubal Ligation
e. Insulin / 6. / Assist with AROM (Artificial Rupture of Membranes) Procedure
B. / Phlebotomy/IV Therapy / 7. / Assist with Placement of fetal Scalp Electrodes for internal Monitoring
1. / Draw Blood / 8. / Assist with Placement of an Intrauterine Pressure Catheter of internal Monitoring
a. Arterial tick
b. Venous Stick
c. Central Line
2. / Start IV Lines
Labor and Delivery Skills Checklist
Applicants Name______
Self Assessed Experience Rating Scale
Limited Experience 1234Very Experienced
Mark One Mark One
1 / 2 / 3 / 4 / 1 / 2 / 3 / 49. / Assist with the Fetal Scalp Blood Sampling Procedure / 4. / Ultrasound for Fetal Position
10. / Insert a Straight or Foley Catheter / 5. / Triage of OB Patients
11 / Perform a Vaginal Exam and Assess Effacement, Dilatation, Station, Presentation / 6. / Leopold Maneuvers
12. / Amnioinfusion / G / Assessment During Labor
D. / Antepartum Care of Women With: / 1. / Assess and document progression of labor:
1. Preterm Labor / a. Contraction Characteristics
2. Premature Rupture of Membranes / b. Changes in Woman’s Behavior, Appearance
3. Pyleonephritis / c. Status of membranes
4. Heyperemesis Gravidorum / 2. / Assess and Documents Fetal Status
E / Intrapartum Care of Woman With / a. Determine Fetal Position
1. / Pregnancy-Induced Hypertension / b. Ausucltate FHR (Fetal heart Rate) Using:
2. / Preeclampsia / 1. Fetoscope
3. / Eclampsia (seizures) / 2. Doptone (Doppler ultrasound)
4. / Placenta Previa / 3. / Use of Fetal Monitor
5. / Abruptio Placenta / a. External monitor
6. / Multiple Gestation / 1. Tocotransducer, Ultrasound
7. / . Malpresentations / 2. Phono or Abdominal, ECG Transducer
8. / Premature Labor / b. Internal Monitor (Including Connection the Leads and calibrating Machine)
9. / Diabetes Mellitus / c. Pattern Recognition/Interventions:
10. / Cardiac Disease / 1. Basic FHR
11. / Asthma / 2. Bradycardea
12. / Infectious Disease: / 3. Tachycardia
a. Group Beta Strep / 4. Sinusoidal (True/False)
b. HIV / d. Periodic Changes:
c. Hepatitis B / 1. Accelerations
d. Hepatitis C / 2. Decelerations
e. Herpes / e. Dysrythmias
Patient with History of Substance Abuse / 4. / Assess & Documents Maternal Status:
14. Sickle Cell Crisis / a. Vital Signs
F / Obstetric Techniques and Procedures / b. Deviations From The Norm(Edems; Deep Tendon reflexes, Clonus)
1. / Conduct a Stress test (Oxytocin Challenge test) / c. Intake and Output including testing Urine
2. / Conduct a Non-Stress Test (NST) / d. Asses for Bladder Retention
3. / Perform Cardiopulmonary Resuscitation / 5. / Assist with Ultrasound Scan
a. Adult
b. Child
Labor and Delivery Skills Checklist
Applicants Name______
Self Assessed Experience Rating Scale
Limited Experience 1234Very Experienced
Mark One Mark One
1 / 2 / 3 / 4 / 1 / 2 / 3 / 4H / Interventions During Labor / K / Postpartum Assessment
1. / Provide Physical Comfort Measures / 1. / Fundus Consistency
2. / Provide Emotional Support / 2. / Lochia
3. / Coach in Psychoprophylatic Breathing and Relaxation Techniques / 3. / Bladder Distention
4. / Support, Guide labor Coach, PRN / 4. / Episiotomy
5. / Administer Analgesics / 5. / Incicion (for Caesarean Delivery)
6. / Change Woman’s Position, PRN / 6. / Physical Assessment
7. / Do a Perineal Prep
8. / Provide Care and Monitor After Rupture of Membranes (Spontaneous or Artificial) / L / Postpartum Intervention
9. / Monitor Fluid Status / 1. / Fundal Massage
2. / Assist with initial Attempts with Breastfeeding at/after Delivery
I / Assist With Interventions During Delivery / 3. / Provide Perineal Care
1. / Spontaneous Vaginal Delivery / 4. / Assess/Foster Parent-Infant Bonding
2. / Forceps Vaginal Delivery/vacuum Extraction Deliver / 5. / Post-Anesthesia Recovery care
3. / Caesarean Section / a. Spinal
4. / Delivery in a Birthing Rom Setting / b. Epidural
5. / Labor Room Delivery / c. General
6. / Assist/monitor Those Requiring Special Surveillance: / 6. / Implement Measures to initiate Voiding if Distention Occurs
a. General Anesthesia / 7. / Interventions for Post C-Section
b. Regional Anesthesia
1. Epidural / M / Age of Patients Cared For
2. Spinal / 1. / Infants and Toddlers (ages 0-3)
3. Local Infiltration / 2. / Young Children (ages 4-6)
J / Immediate Care of Infant Post-Birth / 3. / Older Children (ages 7-12)
1. / Assess Infant & Assign Apgar / 4. / Adolescents (ages 13-29)
2. / Suction infant / 5. / Young Adults (ages 21-39)
3. / Weight Infant / 6. / Middle Adults (ages 40-64)
4. / Identify Infant using Bracelet, Footprint and Mothers Bands / 7. / Older Adults (ages 65-79)
5. / Administer Vitamin K IM and Eye Prophylaxis / 8. / Adults (ages 80 and over))
6. / Collect Cord Blood Samples
7. / Perform Emergency Baptism
8. / Transfer to Newborn Nursery
9. / Care of Infant with Maternal History of Substance abuse