PERFORMANCE EVALUATION CHECKLIST

ANTENATAL CARE INITIAL VISIT

Name of Student: Date:
Year/Clinical Semester Term:
Group:

INSTRUCTIONS:
1. Accomplish the appropriate checklist based on your observation of the performance of the
mentee of each of the tasks, as follows:
a. Put a check () under the column labelled “2” if the student has performed the
task completely.
b. Put a check () under the column labelled “1”if the student has performed the
task partially.
c. Put a check () under the column labelled “0” if the student did not perform the task
or the task was not observed.

Rating
Items
2 1 0 NA Remarks
Prenatal Care
1. Greet the woman and make her
comfortable.

2. Register the woman and issue a

Mother and Child book.
3. Interview the woman and get the
baseline/Personal information.

4. Determines the age of gestation

based on the last menstrual period

5. Informs the woman of the age of

gestation and the expected date of
delivery

6. Discusses with the woman the need

to have at least 4 prenatal visits
during pregnancy

7. Takes the woman’s complete

history which includes:
• Personal history
• Medical history (past and family)

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 Rating
Items
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• Present pregnancy
• Social history (e.g., daily habits,
lifestyle, relationships)
• FP history/plans
8. Asks about previous pregnancies:
• No. of previous pregnancies
• Outcomes of previous
pregnancies (abortion, pre-term,
full term)
• Mode of delivery (normal,
assisted as in forceps delivery or
breech extraction, caesarean
section)
• Abnormalities/ complications
such as:
- Heavy bleeding during or
after delivery
- Hypertension
- Convulsions
- Stillbirth
- Prolonged labor
- Malpresentation
Obstetrical(Physical) Examination
1. Takes and records vital signs

2. Takes and records the weight

3. Explains to the woman the next

steps of the physical examination

4. Obtain woman’s consent

5. Tells the woman to urinate and

wash her genitals

6. Helps the woman unto the

examining table or bed

7. Assists the woman in assuming a

comfortable supine position with
knees bent

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 Rating
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8. Washes hands with soap and water
and air dry or dry with a clean towel
before and after performing
examinations
9. Exposes the abdomen of the woman
while covering the lower part of the
body with a sheet or blanket
10. Inspects and palpates the breast

11. Performs abdominal examination

and checks for post-caesarean scar

12. Determines the size of the uterus

and assess compatibility of uterine
size to age of gestation
13. Requests for laboratory
examinations like:
 CBC, blood typing
 Urinalysis
 VDRL or RPR
 Hepa B
 Fecalysis
 Pap Smear
14. Provides information about any
health problems you discover and
discusses about referral, if
appropriate
15. Refer to back-up obstetrician for any
abnormal results of the physical or
laboratory examination.
16. Explains to the woman the need to
deliver in a facility like the birthing
home
17. Discusses with the client the need to
develop a birth plan that includes
complication readiness, such as
early detection of warning signs,
emergency transportation,
designated decision maker, and
blood donor if necessary
18. Assists the client make a “birth plan”
using the recommended form

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 Rating
Items
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19. Describes the “danger signs” for
which she will need immediate
consultation and referral such as:
- swelling of the legs, hands,
and/or face
- severe headache
- dizziness
- blurring of vision
- convulsions
- vaginal bleeding
- vaginal discharge
- watery vaginal discharge
- fever and chills
- vomiting
- fast or difficult breathing
- severe abdominal pain
- painful urination
- absence or reduced fetal
movements
20. Determines tetanus toxoid status
and provides the vaccine as
appropriate
21. Dispenses/provides iron, folic acid
tablets, and vitamin A in appropriate
doses
22. Provides information on:
 Proper nutrition (eat foods rich in
protein, iron and calcium)
 Daily exercises
 Fluid intake
 Proper sleeping habits
 Oral and personal hygiene
23. If with risk for STI, discusses with
client how to avoid exposure to STI
and HIV by being faithful and asking
her partner to wear a condom
FP Counseling
1. Discusses with the woman the need
to think about her reproductive
intentions
2. Assess the client’s reproductive
needs (short, long term, permanent
term)

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 Rating
Items
2 1 0 NA Remarks
3. Assess what client knows about FP
methods

4. Asks if client has previously used an

FP method and reason for
discontinuing

5. Corrects rumors and misconceptions,

if any

6. Tells woman about available methods

based on her knowledge and
reproductive needs?
 What is the method
 Mode of action
 Advantages and disadvantages
 STI and HIV prevention
 Possible side effects
7. Helps the woman make a decision by
asking her if she can tolerate possible
side effects of the method chosen

8. Instructs the woman on how she can

have the method after she delivers

9. Instructs and writes on the woman’s

card the schedule of her next visit

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 PERFORMANCE EVALUATION CHECKLIST
ANTENATAL CARE (subsequent visits)

Name of Student: Date:

Year/Clinical Group: Semester Term:

INSTRUCTIONS:
2. Accomplish the appropriate checklist based on your observation of the performance of the
mentee of each of the tasks, as follows:
a. Put a check () under the column labelled “2” if the student has performed the
task completely.
b. Put a check () under the column labelled “1”if the student has performed the
task partially.
c. Put a check () under the column labelled “0” if the student did not perform the task
or the task was not observed.

Rating
Items
2 1 0 NA Remarks
Prenatal care - Succeeding visit
1. Greet the woman and make
her comfortable.

2. Ensure and respect her

privacy.

3. Informs the client of her age of

gestation.

4. Asks whether any of the

“warning or danger signs” has
occurred since the last visit.
a. swelling of the legs,
hands, and/or face
b. severe headache
c. dizziness
d. blurring of vision
e. convulsions
f. vaginal bleeding
g. vaginal discharge

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 Rating
Items
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- watery vaginal discharge
- fever and chills
- vomiting
- fast or difficult breathing
- severe abdominal pain
- painful urination
- absence or reduced fetal
movements
5. Explains about the importance
of personal hygiene.
a. bathing during
pregnancy,
b. washing breast daily
with soft cloth,
c. wearing support bra,
d. cleaning external
genitalia daily, wiping
6. Providesfrom front toadvice,
nutritional back. e.g.,
eat a variety of nutritious foods,
take folic acid and iron
supplement, drink plenty of
liquids, no alcohol, gain an
adequate amount of weight (1
kilo/month).
7. Explains the importance of
newborn screening and when
this is performed.
8. Describes the signs and
symptoms of labor and what
to do when these occur:
a. bloody, sticky
vaginal
discharge,
b. painful contractions
every 20 mins. with
decreasing intervals
and increasing
9. intensity,
. Discusses how to safely
c. water
dispose of thefrom the vagina
placenta if she
decides to bring it home.

10. Reviews with the woman the

Birth and Delivery Plan
developed during the 1st visit.

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 Rating
Items
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Obstetrical (Physical) Exam
1. Records and notes changes in:
- blood pressure
- weight
- uterine size/fundal height

2. Listens to fetal heart tones

when the woman is 18 weeks or
more gestation or if the uterus
is palpable near the umbilicus.

3. Perform Leopold’s maneuver,

as follows, if the woman is in
her 28-32 weeks of gestation:
- Faces the woman and
palpates the fundus to
identify which part of the
fetus occupies the fundus.
- Moves the hands
downward to the sides of
the uterus to locate the
fetal back
- Grasps the lower part of the
abdomen just above the
symphysis pubis with
thumb and fingers to
determine which part of
the fetus is presenting
- Faces the feet of the
woman and with the three
middle fingers of both
hands palpates deeply in
the symphysis pubis to
determine whether the
fetal head (if presenting) is
still ballotable or engaged.

4. Records findings.

5. Refers to back-up obstetrician

if, by the 36th week, the
presenting part is not the head.

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 Rating
Items
2 1 0 NA Remarks
6. Checks for warning/danger
signs such as:
- vaginal bleeding
- severe headache, visual
changes or epigastric pain
- swelling of the face or
hands
- leaking amniotic fluid
- severe nausea or vomiting
- fever (T>38C)
- severe abdominal pain
- absence of fetal movement
7. Refers client to higher level of
care (i.e., obstetrician or
hospital) if any of the warning
signs occurs.

Exclusive Breastfeeding Counseling

1. Discusses with the woman the
importance and advantages of
exclusive breastfeeding.
2. Discusses the importance of
breastfeeding within 1 hour after
birth and problems the client
may have for doing this.
3. Asks the woman if there are any
problems that will hinder her
being able to breastfeed her
baby exclusively.
4. Recommends practices that will
enable her to breastfeed
exclusively for 6 months.
5. Tells the woman that exclusive
breastfeeding can be used as a
FP method.
6. Tells the woman about
colostrum.

7. Tells the woman when to start

and up to when she should
breastfeed.
8. Provides information on how to
care for the nipple.

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 Rating
Items
2 1 0 NA Remarks
9. Explains about correct positions
on breastfeeding.

10. Tells the woman the 4 key

points of attachment.

11. Discusses on demand

breastfeeding.

12. Explains the advantages of

breastfeeding on demand.

13. Tells the woman she can

continue breastfeeding upon
return to work.
14. Explains how to express breast
milk by hand.

15. Explains how to correctly store

express breast milk.

16. Asks if she has any questions or

worries.

FP Counseling
1. Re-enforces the messages that:
- It is recommended that, for
health reasons, births must
be spaced at 3 years
intervals.
- If she does not practice FP
after delivery, her fertility
returns in 4 weeks.
2. Asks the woman if her
reproductive plans have
changed since the last visit.
3. If woman still plans to practice
FP, informs her on how and
where she can avail of services.

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 PERFORMANCE EVALUATION CHECKLIST
ESSENTIAL INTRAPARTUM AND NEWBORN CARE

Name of Student: Date:

Year/Clinical Group: Semester Term:

INSTRUCTIONS:
3. Accomplish the appropriate checklist based on your observation of the performance of the
mentee of each of the tasks, as follows:
a. Put a check () under the column labelled “2” if the student has performed the
task completely.
b. Put a check () under the column labelled “1”if the student has performed the
task partially.
c. Put a check () under the column labelled “0” if the student did not perform the task
or the task was not observed.

Rating
Items Remarks
2 1 0 NA
DURING LABOR
1. Greet the woman and
make her comfortable
2. Ensure and respect her
privacy.
3. Check Mother and
childbook.
4. Get the vital signs and
does a quick check at
different times to ensure
that the woman is normal
- appears calm and
relaxed between
contractions
- has an oral
temperature of 36 ºC
to 37ºC
- has a pulse rate of 80
to 100 beats/min.
- has BP of 100/60
mmHg or above but
less than 140/90

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 Rating
Items 2 1 0 NA Remarks
5. Perform vaginal
examination and
determine the stage of
labor.
6. Uses a partograph to
chart progress of labor
and do labor
monitoring.
7. Encourages the woman to
have support person of
her choice present with
her
8. Encourages the woman to
continue taking liquids
and eating light foods as
she desires
9. Encourages the woman to
void whenever she feels like
10. Urgently refers the
woman to the backup
obstetrician or hospital at
any time the following
danger signs are
observed:
- vaginal bleeding of more
than 100 ml. since the
start of labor
- high blood pressure (>
140/90 mmHg)
- temperature > 38ºC
- low blood pressure with
a systolic BP<
90mmHg
- severe pallor
- epigastric or abdominal
pain
- severe headache
- blurred vision
- convulsions or
unconscious
- breathing difficulty
- fetal heart rate <100
beats/min. or
>180 beats/min
- partograph plotting
goes to the right of
the “alert line”
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 Rating
Items Remarks
2 1 0 NA
11. Communicates with the
woman - informing her of
the progress of labor,
providing reassurance
and encouragement
DURING DELIVERY
Preparing for Delivery
1. Checks temperature in
the DR area to be 25-28⁰C
and eliminates air draft

2. Ensures a safe delivery by

having:
- a clean surface for
delivery that is semi-
upright
- all delivery equipment
including newborn
resuscitation
equipment available
and functional
- high level disinfected
(HLD) instruments to
cut cord
3. Arranges materials/
supplies in a linear
sequence as follows:
 Gloves (2 pairs)
 Dry cloth
 Bonnet
 Oxytoxin injection
 Plastic clamp
 Instrument clamp
(Kelly forceps)
 Scissors
 Kidney basins (2)
4. Arranges in sequence
another set of materials
and supplies for after the
first breastfeed:
 Eye ointment
 Stethoscope
 Vitamin K
 Vaccines (Hepatitis B
and BCG) and supplies

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 Rating
Items Remarks
2 1 0 NA
for injection (e.g.
isopropyl alcohol,
cottonballs,
tuberculin syringes
with needles)
5. Prepares a clean newborn
resuscitation area on a
firm and flat surface
6. Ensures privacy

7. Helps the woman unto

the delivery table and
ensures that she is
comfortable in the semi-
upright position.
8. Cleans the perineum with
antiseptic solution

9. Washes hands and puts

on 2 pairs of sterile gloves
(if same worker handles
the perineum and the
cord)
10. Drapes the woman’s
abdomen with clean cloth
which will be used to dry
the baby.
During Delivery
11. Allows the woman to
push as she wishes with
contractions. Does not
urge her to push.
12. Waits until the head is
visible and the perineum
is distending
13. Ensure controlled
delivery of the fetal head
by instructing the woman
not to bear down
- Keeps one hand
gently on the head as
it advances

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 Rating
Items 2 1 0 NA Remarks
- Supports the
perineum with the
other hand with
pad/cloth covering
the perineum and
anus
- Asks the woman to
breathe steadily and
not to push during
delivery of the head
- Encourages rapid
breathing with mouth
open.
- Feels gently around
baby's neck for the
cord.
- If with cord around
the neck, either slips
the cord over the
head or cuts the cord
between clamps.
14. Wipes baby's face to
remove mucus and
membranes, if any.
15. Awaits spontaneous
rotation of shoulders and
delivery (within 1-2
minutes).
16. Applies gentle downward
traction to deliver the top
shoulder
17. Lifts the baby up, towards
the mother's abdomen to
deliver the lower
shoulder.
18. Supports the baby by
having one hand
supporting the head and
the other hand sliding
through its back and
supporting the buttocks
as it is delivered.
19. Calls out time of birth and
sex of the baby

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 Rating
Items Remarks
2 1 0 NA
First 30 seconds
20. Places the baby prone on
woman’s abdomen and
dries thoroughly by
wiping the eyes, face,
head, front and back,
arms, and legs with dry
cloth while doing a quick
check (BMTG-breathing,
not meconium stained,
good tone and term
gestation)
1-3 minutes
21. Discards the wet cloth to
start skin-to-skin contact
and wraps the baby with
another clean, dry cloth
and blanket. Puts the
bonnet on the baby’s
head
22. Does resuscitation, if
needed.
23. Remove the first set of
gloves
24. Clamps and cuts the cord
as follows:
- if pulsations have
stopped clamps cord
with sterile plastic
clamp at 2 cm and
places the instrument
clamp 5cm from the
base of the umbilical
cord
- Wraps the cord with
sterile gauze between
the clamps
- Cuts the cord between
clamps close to the
first clamp near the
baby’s abdomen.
Delivering the placenta
1. Palpates the abdomen to
rule out another baby
(multiple pregnancy)

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 Rating
Items Remarks
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2. Injects 10 IU of oxytoxin
intramuscularly
3. Performs controlled cord
traction by:
- Supporting the uterus
above the symphysis
pubis and applying
gentle traction on the
cord when the uterus
contracts
- Relaxing traction on
the cord when the
uterus relaxes
- Repeating cord
traction with upward
counter-traction on
the uterus when
contractions occur and
until the placenta is
delivered.
4. Catches the placenta with
both hands as the
placenta comes out
5. Rotates the placenta to
gently twist the
membranes into a rope to
deliver the membranes
6. Immediately massages
the uterus to keep it
contracted
7. Inspects the lower vagina
and perineum for
lacerations/tears. Repairs
as needed.
8. Checks the membranes
and placenta to ensure
that the membranes and
cotyledons are complete
9. Re-check baby’s
breathing, warmth and
color and that the
mother’s uterus is
contracted.

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 Rating
Items Remarks
2 1 0 NA
10. Advises mother to
maintain skin-to-skin
contact with the baby
prone on her chest
between the breasts with
head turned to one side
11. Cleans the vagina,
perineum, and the inner
thighs with betadine.
12. Checks that the uterus is
contracted and massages
it through the abdomen
when relaxed.
15-90 minutes
1. Keeps mother and baby
together and covers them
with blanket for warmth
2. Encourages the woman to
breastfeed when the baby
shows cues that it is ready
to feed
3. Assists the woman if
difficulties in latching are
observed
4. After a full breastfeed,
administers eye
prophylaxis (i.e.
Erythromycin ophthalmic
ointment) and vitamin K,
hepatitis B and BCG
injections to infant
5. Advises mother to:
• breastfeed on
demand
• delay bathing the
baby
6. Decontaminates used
instruments before
cleaning
7. Decontaminate gloves
and placenta before
disposing in a leak-proof
container

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 Rating
Items Remarks
2 1 0 NA
8. Records details of birth,
including:
• Date and time of
delivery and sex of
the baby
• Baby’s length and
birth weight
• Condition of the
perineum and if any
suturing was done
• Estimated blood loss
• Any changes from
normal and referral
9. Performs a complete
examination of the baby
within the first two hours
of life and informs the
mother of results
10. Refers newborn for
further care if necessary
based on examination of
the baby
11. Checks mother and baby
every 30 minutes for at
least 2 hours or until
stable
12. Encourages woman to
continue taking liquids
and eating light foods as
she desires
13. Completes all records

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 PERFORMANCE EVALUATION CHECKLIST

POSTPARTUM CARE
Before discharge or within the first week postpartum

Name of Student: Date:

Year/Clinical Group: Semester Term:

INSTRUCTIONS:
4. Accomplish the appropriate checklist based on your observation of the performance of the
mentee of each of the tasks, as follows:
a. Put a check () under the column labelled “2” if the student has performed the
task completely.
b. Put a check () under the column labelled “1”if the student has performed the
task partially.
c. Put a check () under the column labelled “0” if the student did not perform the task
or the task was not observed.

Rating
Items
Remarks
2 1 0 NA
1. Explain to the mother the
importance of Newborn
Screening and Hearing
Screening
2. Perform Newborn
Screening after 24 hours
after delivery
3. Refer newborn to a
health facility performing
newborn hearing
screening

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 Rating
Items
Remarks
2 1 0 NA
4. Checks maternal and
neonatal vital signs

5. Conducts physical exam

of mother and baby and
records any abnormal
changes
6. Records findings and
informs mother of her
condition and that of her
baby
7. Teaches how to care for
the umbilicus

8. Assesses mother’s
knowledge of and ability
to breastfeed

9. Discusses the following

with the mother
• Personal Hygiene
• Nutrition & infant
feeding
• Care of the baby
• Care of the perineum
and breast
• Family support
• Family planning and
how to avoid
pregnancy
• Benefit of exclusive
breastfeeding for six
months
• Infant immunization
• Preventing infant
diarrhea and
dehydration
10. Gives mother a schedule
of immunization for her
baby and where to get
these

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 Rating
Items
Remarks
2 1 0 NA
11. Teaches the mother
about the following signs
of potential serious
problems with the infant
and instruct her to
contact you for referral if
the infant:
• Does not feed well
• Has watery blood-
tinged stool
• Vomits or spits out a
lot
• Has stiffness or
convulsions
• Has yellow skin and
eyes
• Has redness or foul
discharge from the
umbilicus or discharge
from the eyes
12. Teaches the mother
about postpartum danger
signs and instruct her to
contact you for referral if
she has the following:
• Excessive vaginal
bleeding (one sanitary
napkin fully soaked per
hour) anytime after
delivery or bleeding for
more than two weeks
• Vaginal discharge with
a foul or fishy odor
• Severe abdominal pain
• Worsening perineal
pain from repaired
laceration
• Temperature ≥ 38⁰C
• Redness, warmth, or
pain in the breast
• Pain on urination,
difficulty in voiding, or
defecating or

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 Rating
Items
Remarks
2 1 0 NA
incontinence of urine
or stool
Exclusive Breastfeeding
Counseling
1. Discusses with the
woman the importance
and advantages of
exclusive breastfeeding?
2. Asks the woman if there
are any problems that will
hinder her being able to
breastfeed her baby
exclusively?
3. Recommends practices
that will enable the
woman to breastfeed
exclusively for 6 months?
4. Tells the woman that
exclusive breastfeeding
can be used as FP
method?
5. Tells the woman about
colostrum?

6. Provides information on
how to care for the
nipple?
7. Explains about correct
positions on
breastfeeding?
8. Tells the woman the 4 key
points of attachment?

9. Discusses on demand
breastfeeding.

10. Explains the advantages

of breastfeeding on
demand?

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 Rating
Items
Remarks
2 1 0 NA
11. Tells the woman she can
continue breastfeeding
upon return to work?

12. Explains how to express

breast milk by hand?

13. Explains how to correctly

store express breast milk?

14. Asks if she has any

questions or worries?

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