NURSING STANDARDS FOR LABOUR ROOM

Target Group : Patients admitted in labour room

Standard prepared by : Miss. Ashwini.Shindhe

Standard statement : Comprehensive nursing care is given to all patients admitted in labour
room.

Structure Process Outcome

S1 RN able to perform P1 RN receives the patients with case O1 Nurse understands
nursing assessment records, investigations and handing over nursing assessment
from the transferring station
P2 RN check patients name, age , diagnosis
and other identification
P3 RN connect the patient to CTG
RN check and carry out the physician’s
P4 order
RN see for uterine contraction and
P5 active bleeding

RN perform continuous electronic fetal

S2 RN is able to P6 monitoring and charting O2 Nurse aware of
monitor and record RN perform intermittent manual monitor and
patient condition P7 monitoring of FHS. recording the
RN monitors uterine contractions for patient condition
P8 10min.
RN assess condition of patient.
RN compares 24 hrs total intake and
P9 total output
P10 RN records medications, iv fluids,
uterine contractions and FHS.
P11 RN monitors for premature rupture of
membrane, cervical dilaation and
P12 effacement.

S3 RN is able to P13 RN follows strict aseptic precautions, O3 Nurse administered

perform routine hand hygiene and preventive care. medication timely
patient care P14 RN is aware of timely administration of according to the
medications doctors order
P15 RN is able to perform critical care in
case of emergency such as cardiac/ or
respiratory arrest
P16 RN carryout patient feeding based on
his/ her requirements
P17 RN meet the hygienic needs of the
patient
P18 RN assist in delivery and newborn care
P19 RN make use of comfort devices as per
 patient requirements
P20 RN do episiotomy suturing
P21 RN administer inj oxytocin or
Methergin after delivery as per doctors
order

S4 RN is aware about P22 RN clean episiotomy site O4 RN understand the

infection control RN change IV cannula( 48 hrs-96 need for
P23 hrs),Folys catheter( 14 days), ETT maintaining aseptic
(5days), & bed sheets, pads, pillow techniques
cover(12hrs or SOS)
RN supervised the bed and floor
cleaning
RN send microbiological cultures and
fumigate the labour room once in a
P24 month
RN sterilize the equipment by
P25 autoclaving/ ETO
RN perform the proper disposal of
P26 waste
RN check the instrument and its
P27 calibration periodically
RN follow labour room dress code
P28 RN restricts admission to authorised
staff only.
P29 RN allows the visitors twice a day with
P30 dress code, protective mask, caps and
aprons
P31 RN maintain visitors register

S5 RN is aware of P32 RN properly record in chart O5

documentation RN follow the principles of record Record is
writing maintained
P33 RN sign and date at the end of the
record
NURSING PROTOCOL FOR: NON-STRESS TEST
POLICY: 1. Non-stress tests will be conducted for a minimum of 20 minutes.
2. Antepartum outpatients may not be discharged until the NST has been
reviewed and signed by the antepartum testing nurse or attending physician.
3. All NSTs will be reviewed and signed by the attending physician at
the end of the day.
CLINICAL ASSESSMENT AND CARE:
1. Place the patient in a semi-fowler’s position with slight uterine displacement (i.e., towel or
blanket roll under one hip).
2. Take BP and pulse at the start of the testing period and as per physician’s order for all
outpatients.
3. Patient’s temperature is not necessary unless:
a. Amniocentesis will be performed following NST
b. Fetal tachycardia is present
c. The patient complains of malaise
d. Ordered by the physician
e. Patient has ruptured membranes
4. Place patient on the monitor per protocol.
5. Instruct patient to press the monitor event marker every time she perceives a fetal
movement.
6. If the NST is reactive within 20 minutes, the physician will be notified to review and sign
EFM tracing.
7. If the NST continues for 40 minutes and remains non-reactive, a biophysical profile (BPP)
will be performed. Maintain FHR monitoring until BPP is initiated or tracing becomes
reactive. If fetus has yet to demonstrate a reactive NST but tracing is consistent with previous
monitor tracings, it is not necessary to maintain monitoring until BPP is completed.
8. If a non-reassuring fetal heart tracing occurs, immediately bring it to the attention of the
fellow or attending physician.
9. Regular uterine contractions during testing period should also be brought to the attention of
the physician.
10. For outpatients, send signed, labeled tracings with associated documentation to Medical
Records.
11. For inpatients, signed tracing will be kept with the patient’s chart.
DOCUMENTATION: 1. Enter NST in Observer program.
2. Document NST on charge sheet