Name: ___________________________________________________________________ Date: ______________

Evaluator/Signature: ________________________________________________________ Grade: _____________

NURSING CARE DURING LABOR

Description:

Purposes:

1.
2.
3.
4.
5.

Indication:

Contraindication:

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 1

Client Education:

1.
2.
3.
Special Consideration:

Equipment:

• Sterile examination gloves

• Sterile lubricating solution
• Aseptic solution

Vaginal Examination

Description:

Purposes:

1.
2.
3.
4.
5.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 2

Indication:

Contraindication:

Client Education:

1.
2.
3.
Special Consideration:

Equipment:

● Sterile examination gloves

● Sterile lubricating solution
● Aseptic solution

Leopold’s Maneuver

Description:

Purpose:

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 3

Indication:

Contraindication:

Special Considerations:

1.
2.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
ADMISSION
1. Obtain vital signs (BP, HR, RR) including
temperature, height and weight.
2. Obtain relevant data related to the pregnant
woman such as LMP, AOG, and EDC.

3. Place client on a supine position with knees

flexed and measure the fundic height and
perform Leopold’s maneuver.
**Obtain Fundic height: the tape can be placed
in the middle of a woman’s abdomen, and
the measurement made from the upper
border of the symphysis pubis to the upper
border of the fundus with the tape measure

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 4

 held in contact with skin for the entire
length of the uterus.
PERFORMED
ACTION RATIONALE REMARKS
YES NO
Perform Leopold’s Maneuver:
A. Preparing the Patient
1. Explain the procedure to the client.

2. Instruct the client to empty her bladder.

3. Wash your hands using warm water.

4. Position the woman supine with knees

slightly flexed. Place a small pillow or
rolled towel under one side.
5. Observe the woman's abdomen for longest
diameter and where fetal movement is
apparent.

B. Perform first maneuver

Stand at the foot of the client, facing her, and
place both hands flat on the abdomen. Palpate
the superior surface of the fundus. Determine
the consistency, shape, and mobility.
C. Perform second maneuver
Face the client and place the palms of your
hands on both sides of the abdomen. Palpate
the sides of the uterus. Hold the left hand
stationary on the left side of the uterus while

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 5

 the right hand palpates the opposite side of the
uterus from top to bottom.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
D. Perform third maneuver
Gently grasp the lower portion of the abdomen
just above the symphysis pubis, between the
thumb and index finger and try to press the
thumb and your index finger together.
Determine any movement and whether the
part is firm or soft.
E. Perform fourth maneuver
Place fingers on both sides of the uterus
approximately 2 inches above the inguinal
ligaments, pressing downward and inward to
the direction of the birth canal. Allow fingers
to be carried downward.
4. Prepare the client for vaginal examination.

Perform Vaginal Examination

1. Wash hands.

2. Explain the procedure to the client.

3. Provide privacy.

4. Assess client status and plan to meet

individual client need.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 6

 5. Prepare all needed equipment.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
6. Ask the woman to turn unto back with knees
flexed (dorsal recumbent position).
7. Repeat handwashing and put on sterile
examination gloves.

Prepping and Draping

a. Pour antiseptic solution over vulva using the
non-dominant hand.

b. Take a fresh sponge to begin each new area,

and do not return to a clean with a used
sponge. Six sponges are needed. The proper
order and motion are as follows.

1. Use a zig-zag motion from clitoris to

lower abdomen just above the pubic
hairline.
2. Use a zig-zag motion on the inner
thigh from the labia majora to about
half-way between the hip and the
knee. Repeat for the other inner
thigh.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 7

 3. Apply a single stroke on one side
from the clitoris over labia, perineum
and anus. Repeat for the other side.
4. Use a single stroke in the middle
from the clitoris over the vulva and
the perineum.
PERFORMED
ACTION RATIONALE REMARKS
YES NO
8. Discard one drop of clean lubricating
solution and drop an ample supply on tips of
gloved fingers.

9. Place non dominant hand on the outer edges

of the woman's vulva and spread her labia
while inspecting the external genitalia for
lesions. Look for red, irritated mucous
membranes, open, ulcerated sores, clustered
and pinpoint vesicles.

10. Look for escaping fluid or presence of

umbilical cord or bleeding.

11. If there is no bleeding or cord visible,

introduce your pointer and middle fingers of
dominant hand gently into the vagina,
directing them toward the posterior vaginal
wall.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 8

12. Touch the cervix with your gloved examining
fingers.
a. palpate for cervical consistency and rate
if firm or soft

b. measure the extent of dilatation; palpate

for an anterior rim or lip of cervix.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
13. Estimate the degree of effacement.

14. Estimate whether membranes are intact.

15. Locate the ischial spines. Rate the station of

the presenting part and identify the
presenting part.

16. Establish the fetal positioning.

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 9

 17. Withdraw your hand slowly and wipe the
perineum front to back to remove secretions
or examining solution.

18. Leave client comfortable.

19. Document procedure and assessment findings

and how client tolerated procedure.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
20. Monitor for frequency, interval and duration of
the uterine contractions,and record in the
monitoring sheet (Refer to Partograph
Checklist).
21. Encourage the client to urinate and defecate.

22. Encourage her to walk and rest alternately,

unless contraindicated.

23. Assist in administering IV fluids as ordered by

the Attending Physician.

Learner’s Reflection: (What did you learn most of the activity? What is its impact to Instructor’s Comments:
you?)

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 10

Reference(s):
Pillitteri, A. (2014). Maternal and Child Health Nursing: Care of the Childbearing & Childrearing Family 7th edition . Walnut St. Philadelphia: Lippincot Williams and
Wilkins.
Pillitteri, A. (2010). Maternal and Child Health Nursing: Care of the Childbearing & Childrearing Family 6th edition . Walnut St. Philadelphia: Lippincot Williams and
Wilkins.
Lowdermilk, D. and Perry, S. (2006). Maternity Nursing 7th edition. St Louis, Missouri: Mosby Elsevier

MATERNAL AND CHILD HEALTH NURSING COMPETENCY WORKBOOK 11