Iloilo Doctors’ College

College of Nursing
West Avenue, Molo, Iloilo City

PERINEAL PREP BEFORE VAGINAL DELIVERY

PERFORMANCE CHECKLIST

Student’s Name: ______________________________Score/ Equivalent: ________________

Year & Sec: __________________________________Date Performed: _________________

PERFORMANCE RATING
4– Consistently demonstrates high level performance
3 – Satisfactorily achieves performance based on standard
2 – Performs task with difficulty
1 – Unable to perform tasks as required

Procedure 4 3 2 1
1. Gathered all materials to be used.
2. Explained the procedure to patient.
3. Placed the patient in lithotomy position.
4. Placed a waterproof pad under the patient’s buttocks
5. Provided privacy.
6. Secured a bucket below the delivery table for sponges to be discarded.
7. Opened pack of sterile basin containing sponges using aseptic technique.
8. Filled the sterile basin with selected solution (according to hospital protocol).
9. Washed hands aseptically and donned sterile gloves.
10. Held basin in one hand and used the other hand for cleansing.
11. With the sponge, started to scrub back and forth across the mons pubis.
12. Cleansed across (going downwards) the vulva and perineum. Discarded the first
sponge.
13. Using a new sponge, scrubbed the labia vertically going outwards to the thigh.
14. Repeated the same process on the other side. Discarded the sponge.
15. Spread the labia minora and cleansed midline from clitoris to perineal area.
Discarded the sponge.
16. Cleansed anal area last and discarded sponge.
17. Patted the area dry with sterile pad after perineum was rinsed (by assistant) with
sterile solution.
18. Secured the patient appropriately and comfortably in lithotomy position.
19. Discarded used materials properly.
20. Documented the procedure.
Total

Student’s Signature: __________________ Instructor’s Signature: ___________________