EINC

Xavier University
COLLEGE OF NURSING
Ateneo de Cagayan
NCM 107 RLE - Care of Mother, Child, Adolescent (Well Clients)
PERFORMANCE RATING SCALE

Essential Intrapartum & Newborn Care Procedure
(Prepared by TEAM EINC for the Association of Deans of Philippine Colleges of Nursing Incorporated in a 3-day live-in Training of Trainers on EINC)
SCALE DESCRIPTION INDICATORS

4 Very Good Student performs behaviors/tasks reflecting the highest level of performance: consistent, independent,
effective
3 Good Student performs behaviors/tasks reflecting mastery of performance with minimal supervision
2 Fair Student performs behaviors/tasks reflecting development and movement towards mastery of performance
with help or direct supervision in some aspect
1 Needs Improvement Student performs behaviors/tasks reflecting beginning level of performance; tasks not done properly majority
of the time but demonstrate understanding of concepts involved with tasks
PROCEDURE 4 3 2 1 REMARKS
1. In advance, prepare decontamination solution by mixing 1 part 5% chlorine bleach to 8 parts
of water to make 0.5% chlorine solution. Change chlorine solution at the beginning of each
day or whenever solution is very contaminated or cloudy.
PRIOR TO WOMAN’s TRANSFER TO THE DR
2. Ensure that mother is in her position of choice while in labor.
3. Ask mother if she wishes to eat/drink or void.
4. Communicate with the mother – inform her of progress of labor, give reassurance and
encouragement
WOMAN ALREADY IN THE DR
PREPARING FOR DELIVERY
5. Check temperature in DR area to be 25-28 °C, eliminate air draft
6. Ask woman if she is comfortable in the semi-upright position (the default position of delivery
table)
7. Prepare a clear, clean newborn resuscitation area. Check the equipment if clean, functional
and within easy reach.
8. Ensure the woman’s privacy.
9. Remove all jewelry then wash hands thoroughly observing the WHO 1-2-3-4-5 procedure.
10. Arrange material/supplies in a linear sequence:
Gloves, dry linen, bonnet, oxytocin injection, plastic clamp, instrument clamp, scissors, 2
kidney basins
In a separate sequence, for after the 1st breastfeed:
Eye ointment, stethoscope (to symbolize PE), Vitamin K, Hepatitis B and BCG vaccines (plus
cotton balls, etc.)
11. Clean the perineum with antiseptic solution.
12. Wash hands and put on 2 pairs of sterile gloves aseptically (if same worker handles perineum
and cord)
AT THE TIME OF DELIVERY
13. Encourage woman to push as desired.
14. Drape the clean, dry linen over the mother’s abdomen or arms in preparation for drying the
baby
15. Apply perineal support and do controlled delivery of the head
16. Call out time of birth and sex of baby
17. Inform the mother of outcome
FIRST 30 SECONDS
18. Thoroughly dry baby for at least 30 seconds, starting from the face and head, going down to
the trunk and extremities while performing a quick check for breathing
1 – 3 MINUTES
19. Remove the wet cloth
20. Place baby in skin-to-skin contact on the mother’s abdomen or chest
21. Cover baby with the dry cloth and the baby’s head with a bonnet
22. Exclude a 2nd baby by palpating the abdomen in preparation for giving oxytocin
23. Use wet cloth to wipe the soiled gloves. Give IM oxytocin within one minute of baby’s birth.
Dispose of wet cloth properly.
24. Remove 1st set of gloves and decontaminate them properly (in 0.5% chlorine solution for at
least 10 minutes)
25. Palpate umbilical cord to check for pulsations
26. After pulsations stopped, clamp cord using the plastic clamp 2 cm from the base
27. Place the instrument clamp 5 cm from the base
28. Cut near plastic clamp (not midway)
29. Perform the remaining steps of the AMTSL:
Wait for strong uterine contractions then apply controlled cord traction and counter traction on
the uterus, continuing until placenta is delivered
30. Massage the uterus until firm
31. Inspect the lower vagina and perineum for lacerations/tears and repair lacerations/repair, as
necessary
32. Examine the placenta for completeness and abnormalities
33. Clean the mother, flush perineum and apply perineal pad/napkin/cloth
34. Check baby’s color and breathing, check that mother is comfortable, uterus contracted
35. Dispose of the placenta in a leak-proof container or plastic bag
36. Decontaminate (soaked in 0.5% chlorine solution) instruments before cleaning;
decontaminate 2nd pair of gloves before disposal, stating that decontamination lasts for at
least 10 minutes
37. Advise mother to maintain skin-to-skin contact. Baby should be prone on mother’s chest/in
between the breasts with head turn to one side
15 – 90 MINUTES
38. Advise mother to observe for feeding cues and cite examples of feeding cues
39. Support mother, instruct her on positioning and attachment
40. Wait for FULL BREASTFEED to be completed
41. After a complete breastfeed, administer eye ointment (first), do thorough physical
examination, then do Vitamin K, Hepatitis B and BCG injections (simultaneously explained
purpose of each intervention)
42. Advise OPTIONAL/DELAYED bathing of baby and explain the rationale
43. Advise breastfeeding per demand and about DANGER SIGNS for early referral
44. In the first hour: check baby’s breathing and color; and check mother’s vital signs and
massage uterus every 15 minutes
45. In the second hour: check mother-baby dyad every 30 minutes to 1 hour
46. Complete all RECORDS
TOTAL / 184
Score/184 x 100
A (92 – 100)
A- (84 – 91.99)
B (76 – 83.99)
B- (68 – 75.99)
C (60 – 67.99)
F (< 60)
Student’s Signature : ________________________

Clinical Instructor’s Signature : ________________________

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PERFORMANCE RATING SCALE

SCALE DESCRIPTION INDICATORS

Student’s Signature : ________________________

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