Labor & Delivery Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWork SettingsL and D 1 2 3 4 LDRP 1 2 3 4 Antepartum 1 2 3 4 Mother Baby 1 2 3 4 AntepartumDiabetes 1 2 3 4 Fetal Demise 1 2 3 4 HELLP Syndrome 1 2 3 4 Hyperemesis 1 2 3 4 Immunologic Disorder 1 2 3 4 Infectious Disease 1 2 3 4 Multiple Gestation 1 2 3 4 Placenta Previa/Abruptio 1 2 3 4 Pre-Term Labor 1 2 3 4 Premature Rupture of Membranes 1 2 3 4 Special ProceduresConduct Stress Test 1 2 3 4 Conduct Non-Stress Test 1 2 3 4 Assist with External Version 1 2 3 4 Assist with Umbilical Blood Sampling 1 2 3 4 Use of Nitrazine/Fern Test 1 2 3 4 Pain ManagementEpidural Anesthesia 1 2 3 4 General Anesthesia 1 2 3 4 Spinal Anesthesia 1 2 3 4 Response to Pain Management 1 2 3 4 Fetal MonitoringExternal 1 2 3 4 IUPC Placement/Monitoring 1 2 3 4 Spiral Electrode Placement 1 2 3 4 Identify, Document & Treat Abnormal FHR Patterns 1 2 3 4 Labor ManagementAuscultate Fetal Heart Tones 1 2 3 4 Determine Fetal Position 1 2 3 4 Assess Contraction Characteristics 1 2 3 4 Assess Status of Membranes 1 2 3 4 Assess Station/Dilation/Effacement 1 2 3 4 Positioning 1 2 3 4 Leopold's Maneuver 1 2 3 4 Assess for Reflexes/Clonus 1 2 3 4 Bladder Catheterization 1 2 3 4 Amnioinfusion (Assist or Perform) 1 2 3 4 Recognize Complications of AROM 1 2 3 4 Delivery ManagementDelivery Table Set Up 1 2 3 4 Circulate Vaginal Delivery 1 2 3 4 Circulate C - Section 1 2 3 4 Scrub C - Section 1 2 3 4 Neonatal ManagementRadiant Warmer 1 2 3 4 APGAR Scores 1 2 3 4 Neonatal Vital Signs 1 2 3 4 Neonatal Resuscitation 1 2 3 4 Naso/Oropharyngeal Suctioning 1 2 3 4 Bulb Syringe Suction 1 2 3 4 ComplicationsPlacenta Previa/Abruptio 1 2 3 4 Asthma 1 2 3 4 Cardiac Disease 1 2 3 4 Chorioamnionitis 1 2 3 4 Diabetes 1 2 3 4 Pregnancy Induced Hypertension 1 2 3 4 HELLP 1 2 3 4 Hemolytic Anemia 1 2 3 4 Hemorrhage 1 2 3 4 HIV Positive 1 2 3 4 HBV Disease 1 2 3 4 Malpresentations 1 2 3 4 Multiple Gestation 1 2 3 4 Pre-Term Labo 1 2 3 4 Fetal Demise 1 2 3 4 Rh Disease 1 2 3 4 Post Partum CareVaginal Delivery 1 2 3 4 Cesarean Section 1 2 3 4 Anesthesia - General 1 2 3 4 Anesthesia - Spinal 1 2 3 4 Bladder Distention 1 2 3 4 Breast Milk Collection and Storage 1 2 3 4 Breast Pump 1 2 3 4 Breastfeeding - Latch Score 1 2 3 4 Breastfeeding - Supplemental Feeding 1 2 3 4 Breastfeeding Support 1 2 3 4 Contraceptive Education 1 2 3 4 Epidural/PCA 1 2 3 4 Homan's Sign 1 2 3 4 Multiple Births 1 2 3 4 Parent/Infant Interaction/Attachment 1 2 3 4 Post Partum Hemorrhage 1 2 3 4 Pregnancy Induced Hypertension 1 2 3 4 MedicationsAntibiotics/Antivirals 1 2 3 4 Antihypertensives 1 2 3 4 Antiseizure 1 2 3 4 Betamethasone 1 2 3 4 Insulin 1 2 3 4 Magnesium Sulfate 1 2 3 4 Methergine 1 2 3 4 Opioids and Reversal Agents 1 2 3 4 Pitocin 1 2 3 4 Terbutaline 1 2 3 4 IV TherapyStart IVs 1 2 3 4 IV Management 1 2 3 4 Blood Product Administration 1 2 3 4 Newborn CareNewborn Assessment 1 2 3 4 Infant Vital Signs 1 2 3 4 Ballard Scale/Dubowitz 1 2 3 4 Car Seat Education 1 2 3 4 Circumcision Care/Teach to Parents 1 2 3 4 Cord Care/Teach to Parents 1 2 3 4 Immunizations - Infant 1 2 3 4 Infant Caretaking Skills 1 2 3 4 Infant Identification and Security 1 2 3 4 Metabolic Screen 1 2 3 4 Jaundice/Bilirubin 1 2 3 4 Phototherapy 1 2 3 4 Thermoregulation 1 2 3 4 Professional Knowledge & SkillsNational Patient Safety Goals/Core Measures 1 2 3 4 Experience in a "Baby Friendly" Facility 1 2 3 4 Fall Risk Assessment/Prevention 1 2 3 4 Restraints/Use of Least Restrictive Device 1 2 3 4 Parent/Family Teaching 1 2 3 4 Age Specific/Population-Based Care 1 2 3 4 Isolation Precautions 1 2 3 4 Infection Prevention 1 2 3 4 Charge Experience 1 2 3 4 Interpretation and Communication of Lab Values 1 2 3 4 EMREpic 1 2 3 4 Cerner 1 2 3 4 Eclipsys 1 2 3 4 McKesson 1 2 3 4 Meditech 1 2 3 4 Other Computerized System 1 2 3 4 Computerized Physician Order Entry 1 2 3 4 Bar Coding for Medication Administration 1 2 3 4 EMR Conversion Yes No Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 CertificationsBLS Yes BLS Expiration Date Month Day Year NRP Yes NRP Expiration Date Month Day Year S.T.A.B.L.E. Yes S.T.A.B.L.E. Expiration Date Month Day Year ACLS Yes ACLS Expiration Date Month Day Year AWHONN FHM Intermediate Yes AWHONN FHM Intermediate Expiration Date Month Day Year AWHONN FHM Advanced Yes AWHONN FHM Advanced Expiration Date Month Day Year NCC - EFM Yes NCC - EFM Expiration Date Month Day Year Other: Specify Other Expiration Date Month Day Year AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Labor & Delivery Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
