UNIVERSITY OF THE PHILIPPINES MANILA SCHOOL OF HEALTH SCIENCES EXTENSION CAMPUS IN SOUTH COTABATO Koronadal City CHW DEPARTMENT

RLE PERFORMANCE EVALUATION TOOL Name of Student: ______________________________ Year Level/Clinical Group: _______________________ Clinical Area: ______________________________ Academic Year: __________ Quarter: __________ Rating: __________

Direction: Rate if the following behaviour/skill was demonstrated. Indicate remarks as needed. Done at Seldom Done RATING/ DR COMPETENCY ( HANDLE/ASSIST) all done/ frequently REMARKS times Never done I. SAFE AND QUALITY NURSING CARE (5%) 1. Obtains obstetrical data including parity, gravida score, LMP/EDC, AOG, BOW, onset of true labor 2. Checks vital signs 3. Conducts physical examination 4. Performs Leopolds maneuver 5. Checks fetal heart rate and fundic height 6. Monitor progress of labor/uterine contractions as to: Frequency Duration Intensity Interval 7. Observes for the timely rupture of membrane 8. Coaches mother on process of labor II. FUNCTIONS DURING ACTUAL LABOR (30%) 1. Prepares room, supplies, equipments needed 2. Maintains adequacy of supplies as the delivery progresses 3. Maintains orderliness of the sterile table 4. Observes precautionary measures related to use of electrical equipment 5. Uses supplies diligently 6. Transports clients safely while providing privacy 7. Places mother in lithotomy position 8. Performs perineal care using sterile technique correctly 9. Performs proper hand scrub 10. Wears gown and gloves according to hospital policy 11. Coaches mother on breathing and pushing techniques 12. Performs Ritgens maneuver safely 13. Delivers baby and placenta Clamps and cuts the cord correctly Identify signs of placental separation Checks the characteristics and completeness of the placenta 14. Assess amount of blood loss (normal: less than 500 cc) 15. Employs interventions to achieve and maintain a well contracted uterus to prevent/control haemorrhage Uterine massage, Cold compress, Correct administration of Methergine 16. Assesses presence and degree of laceration 17. Assists in episiorrhaphy

18. Checks size, consistency and location of uterus 19. Performs perineal care and applies pad correctly 20. Provides emotional support to the mother throughout labor 21. Evaluates patients condition and records data accordingly 22. Performs after care of the materials and equipment used 23. Ensures proper disposal of hospital waste including blood and other fluids III. IMMEDIATE NEWBORN CARE (15%) 1.Suctions newborn from mouth to nose 2. Performs oil bath/water bath according to hospital policy 3. Weighs newborn accurately 4. Cord care done observing proper aseptic technique at all times 5. Anthropometric measurements done accurately 6. Gets newborns V/S efficiently 7. Credes prophylaxis and Vit. K injection given accurately 8. Performs practical measures to keep the baby warm Dries newborn immediately Wraps newborn properly Initiates skin-to-skin contact of mother and newborn 9. Latching-on/ breast crawl initiated IV. HEALTH EDUCATION (10%) 1. Demonstrates proper latch-on/ breast feeding technique 2. Gives instructions to parents regarding infant care before discharge 3. Provides discharge instructions as to feeding, bathing, administration of ordered medications, appointment dates for post natal and well-baby check-up 4. Responds to questions of clients and relatives V. LEGAL RESPONSIBILITY (10%) 1. Reports accurately and honestly the gender, time of delivery of the baby and placenta 2. Ensures proper identification of the mother and the newborn 3. Document all pertinent data correctly and completely. VI. ETHICO-MORAL RESPONSIBILITY (5%) 1. Respects the religious, cultural and ethnic practices of the client and family of the woman in labor and delivery 2. Promotes emotional security by supporting needs 3. Ensures privacy and confidentiality VII. PROFESSIONAL DEVELOPMENT (20%) 1. Reports every hospital duty schedule 2. Reports on time at the hospital 3. Assumes responsibility assigned by C.I. and other hospital staff 4. Performs functions even without immediate C.I.s supervision 5. Projects a professional image of a delivery room midwife 6. Accepts criticisms and recommendations 7. Performs functions according to standards VIII. COLLABORATION AND TEAM WORK (5%) 1. Functions effectively as a team player in the delivery room/lying-in 2. Communicates the progress of clients condition

to the health team 3. Establishes collaborative relationship with members of the health team and family members. TOTAL SCORE:

Evaluated by:

_________________________________ Name and Signature of Clinical Instructor Date: ___________________________

Examination Period: _______________ Overall Remarks: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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