self-assessment form

Use these questions to assess your performance, reflect on what you did well and what you can improve in the future

Guidelines to help you assess your performance

• Facilitates Relationship
  • takes responsibility for negotiating an effective partnership
  • maintains comfortable rapport with the woman
  • establishes trust
  • is responsive to the needs expressed by the woman
  • maintains professional manner and presentation

• Assesses
  • assesses woman’s own knowledge and experience
  • identifies woman’s needs and responds
  • recognises woman’s social, cultural and health context

• Shares Information
  • displays an accurate knowledge base
  • provides quality evidence based information
  • appropriate options offered
  • communicates clearly and effectively
  • establishes woman’s understanding

• Conclusion
  • brief summary of information provided
  • establishes availability for ongoing discussion/advice
  • documents discussions, assessments and actions
    

Specific guidelines to help you assess your actions

• Assesses woman’s condition
  • general condition and how she is coping
  • history of contractions since the last check-up: how often they are, how long they last, how strong they are, can she talk through them?
  • has she had a show, what does it look like?
  • has she ruptured her membranes? what colour is the liquor?
  • is she managing to eat and drink?
  • is she passing urine and had normal bowel movements
  • how the baby has been moving
  • physical assessment including blood pressure, respiration, temperature, pulse
  • abdominal palpation to include assessment of contraction length, strength and frequency.
  • abdominal palpation to assess lie, presentation, position and decent of baby
  • assessment of baby's health to include monitoring baby's heart rate
  • vaginal assessment to include cervical dilatation, effacement, position, consistency and application. **Presentation part, position, station and attitude. Presence of moulding, caput, liquor and cord.
  • what support and comfort measures does she need?
  • appropriate equipment ready, including emergency resuscitation equipment and medication
  • confirm second stage of labour
  • support of mother during second stage of labour including position, comfort measures, ongoing monitoring of mother and baby's health, when and how to push, progress
  • monitoring of progress
  • assessment of baby's condition when born including apgar score
  • assessment of mother's condition once baby is born including blood loss
  • reviews history and background from woman’s notes, exclude risk factors
  • reviews careplan

• Sharing information
  • possible need for vaginal examination
  • findings of all assessments
  • ongoing monitoring of health of mother and baby, as well as progress of labour
  • need for food and drink
  • how to stay comfortable and mobile
  • what to expect in the second stage of labour including how to birth her baby - position, how to push, comfort measures,progress
  • things that will necessitate further assessment eg delayed progress

• Plan for ongoing care
  • confirm second stage of labour
  • mother to push as body dictates
  • mother to birth in comfortable position that encourages descent of fetal head
  • mother to mobilize at will
  • monitor baby's heart rate every 5 minutes
  • monitor color of liquor
  • assess mother's progress and health as required
  • ensure skin-to-skin once baby is born
  • provide ongoing support, comfort measures and reassurance as required

• Concludes discussion appropriately
  • briefly summarize advice and plan of action
  • ensure woman’s understanding
  • emphasize her choice about plan of action
  • make sure she knows you will be providing ongoing support

• Documents discussion including advice and plan for ongoing care
  • date, time, signature
  • information woman shared with you
  • advice you gave woman
  • plan of action