RLE WORKSHEET

LABOR ROOM and DELIVERY ROOM

Student Name:___________________________________

Dates of Rotation: _________

Clinical Instructor: ________________________________

Grade : ____________________ Signature: _____________

 ASSESSMENT DURING LABOR AND DELIVERY
Name: _________________________________ Age: ____ Status: ____ Religion: ______
Address: __________________________________________________________________
Date and Time of Admission: __________________________________________________

I. OBSTETRIC ADMITTING RECORD

_ Ambulatory _ Wheelchair _ Direct Admit _ Stretcher _ Transfer from ________

G ___ P ___ T ___ P ___ A ___ L ___ M ___

LMP: _____________________ Computation:

EDD: _____________________
AOG: _____________________

Contractions: Frequency _______ Duration ________ Intensity __________

Began on _________________ Time _______________

II. Reasons for Admission

_ Labor pains
_ Induction of Labor
_ Spontaneous Abortion
_ Cesarean Section
_ Primary Reason for Primary ______________________
_ Repeat
_ VBAC
_ Vaginal Bleeding
_ PROM
_ Preterm Labor

III. OBSTETRIC HISTORY

Children:

Year Type of Delivery Gender Weight

1
2
3
4
5

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IV. CURRENT HEALTH STATUS

Amniotic Membrane : _____ Intact _____ Ruptured, Date______ Time: ____

Amniotic Fluid : __ Clear __ Bloody __ Foul smelling

__ Meconium stained __ No foul odor

Cervical Dilatation : _____ cm Time: ________

Vaginal Bleeding : __ None __ Normal Show

__ Bleeding

Stage of Labor : __________

Fetal Heart Rate : __________

Vital Signs : Blood Pressure : _______________

Body Temperature : _______________
Heart Rate : _______________
Respiratory Rate : _______________

Intravenous Fluid : _________________________________________________

Medications : a. _________________________________________
b. _________________________________________
c. _________________________________________

Ultrasound Result : ____________________________________________

____________________________________________
____________________________________________
____________________________________________
____________________________________________
Laboratory Tests
a. _______________________________
b. _______________________________
c. _______________________________

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 Labor Watch

Uterine Characteristic Cervical Fetal

Contractions Duration Interval Frequency of Contraction Dilatation Heart
Rate
Time Time
Started Ended
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

V. GYNECOLOGIC HISTORY
Age of Menarche : ________________
Menstrual Period
Cycle : ________________
Duration : ________________
Amount of Flow : ________________
Discomforts : ________________
Contraceptive Method Used : ___________________________________________
Past Surgeries on Reproductive Organs: ___________________________________
Sexual Partner/s (optional) : ________________
Breast Self-examination : ______ Yes ______ No

VI. PAST ILLNESS

Disease/s on : ______ kidney ______ heart

Conditions like : ______ hypertension ______ diabetes

______ asthma ______ hepatitis B
______ tuberculosis ______ STD (HIV)
______ thyroid disease: specify: _______________________

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 Childhood Disease/s : ______ chicken pox ______ measles
______ mumps ______ poliomyelitis

Immunizations: ______________________________________________________
_______________________________________________________
_______________________________________________________
Allergies : _______________________________________________________
HPV Vaccine : ______ Yes ______ No

VII. HISTORY OF FAMILY ILLNESS

_____ renal disease _____ asthma _____ blood disorders

_____ hypertension _____ cancer _____ cognitive impairment
_____ diabetes _____ seizures _____ genetic disorder/
congenital anomalies
VIII. PSYCHOSOCIAL HISTORY

_____ smoking _____ use of herbal supplements

_____ alcohol intake _____ use of recreational drugs
_____ medications taken

IX. PHYSICAL ASSESSMENT

Pallor : _____ Yes _____ No

Dental Problems : _____ Yes _____ No
Pallor : _____ Yes _____ No

Edema : _____ Yes Location: __________________________

_____ No
Open Lesions : _____ Yes Location: __________________________
_____ No
Varicose Veins : _____ Yes Location: __________________________
_____ No
Enlarge Lymph Nodes: _____ Yes Location: __________________________
_____ No

Color of the mucous membrane of the mouth: ______________________________

Color of the conjunctiva of the eyes: ______________________________________
Lung Auscultation : _________________________________________________

Breasts: Lesions: ______ Yes _____ No

Discharges: ______ Yes _____ No
Lump/mass: ______ Yes _____ No

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 Abdomen: Fundal Height: __________ cm
Abdominal Scars: ______ Yes ______ No
Linea Nigra: ______ Yes ______ No

Striae Gravidarum: ______ Yes ______ No

Distended Bladder: ______ Yes ______ No

X. EPISIOTOMY _____ Yes Type: __________________________

_____ No

Laceration: _____ Yes ___ 1st ___ 2nd ___ 3rd ___ 4th
_____ No

Anesthesia Used: _________________________

XI. TIME OF DELIVERY: __________________________

XII. TIME OF PLACENTAL DELIVERY: ________ Mechanism: ____________

Blood Pressure: ________
Medication/s: _________________________________

XIII. ESTIMATED BLOOD LOSS: _________ mL

XIV. IMMEDIATE POST-PARTUM CARE

Vital Signs: every 15 minutes for 1 hour

Time Blood Pressure Body Pulse Rate Respiratory

Temperature rate

Uterus
Location: ___________________ Consistency: _________________
Lochia
Amount: ___________________

Distended Bladder: _____ Yes _____ No

Fever: _____ Yes _____ No
Chills: _____ Yes _____ No

Intravenous Fluid: ____________________________________________________

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 Maternal Problem Identified after delivery: _________________________________
_________________________________
________________________________
Fetal Problem Identified: _____________________________________________
_____________________________________________
_____________________________________________
XV. NEWBORN DATA

Gender : __________________________
Time of Delivery : __________________________
Type of Delivery : __________________________
Fetal Presentation : __________________________
APGAR Score : __________________________
Ballard Score : __________________________
Weight : __________________________

Anthropometric Measurements:

Head circumference : ______ cm Mid-arm circumference : _______ cm

Chest circumference : ______ cm Length/Height : _______ cm
Abdominal girth : ______ cm

No. of umbilical blood vessels: ___________________________________________

Eye Prophylaxis : _________________________________________________
Vitamin K : _________________________________________________
Hepatitis B Vaccine : _________________________________________________

Vital Signs: Heart Rate : _______________

Respiratory Rate : _______________
Body Temperature : _______________

APGAR SCORING
Score Score
Indicator 0 1 2 at 1 at 5
minute minute
s
A Appearance Blue/Pale Pink Body Pink all over the
(Cyanosis) Blue extremities body
(Acrocyanosis)
P Pulse Absent <100 bpm >100 bpm
G Grimace Floppy Grimace Cough/Sneeze
(Reflex Irritability
A Activity Flaccid Some flexion of Well-flexed/
(Muscle Tone) extremities Active
R Respiration Absent Slow, irregular, Good, strong cry/
weak cry Vigorous cry
Total _____ , ______

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XVI. LABORATORY RESULTS (CBC, Urinalysis, etc.)

Date and Examination Results Normal Values Interpretation

Reference: Reference:

Hepatitis B Screening Result

______________________________________________________________

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 ANATOMY
Instruction:
1. Draw and label its parts the anatomy of the involved organ during pregnancy.
2. Illustrate the Mother and Fetal Circulation.

Reference: ________________________________________________________________

9
 PHYSIOLOGY
Instruction:
1. Make a schematic diagram of the normal physiology of pregnancy.
2. Describe the milestones of fetal growth and development according to the number of
Weeks of intrauterine life.

Reference: ________________________________________________________________

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 Stages of Labor Description
Stages of labor Contractions Duration of Cervical Duration
Contractions Dilatation

1st Stage:

_____________

Latent

Active

Transition

2nd Stage

_____________

Description:
3rd Stage

_____________

Description:
4th Stage

_____________

Reference: ________________________________________________________________

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CARE OF A WOMAN DURING LABOR AND DELIVERY
First Stage:

Second Stage:

Third Stage:

Fourth Stage:

Reference: ________________________________________________________________
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