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
2
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. _______________________________
3
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: _______________________
4
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
5
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: ____________________________________________________
6
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 _____ , ______
7
XVI. LABORATORY RESULTS (CBC, Urinalysis, etc.)
Date and Examination Results Normal Values Interpretation
Reference: Reference:
Hepatitis B Screening Result
______________________________________________________________
8
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: ________________________________________________________________
10
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: ________________________________________________________________
11
CARE OF A WOMAN DURING LABOR AND DELIVERY
First Stage:
Second Stage:
Third Stage:
Fourth Stage:
Reference: ________________________________________________________________
12
