RN Competency Form: Obstetrics
Competence Verification & Learning Guide: Facility
Name (learner)
Date Initiated
Unit
☐RN  ☐LPN  ☐Recent Graduate  ☐Experienced Nurse  ☐New to Specialty  ☐Traveling Nurse 
Note: for LPN practice guidelines, see state nursing statutes & regulations
The preceptor will initial each competency when he/she, as preceptor and colleague, feels safe in allowing the learner to deliver this aspect of
care without direct supervision.
Self-Assessment: 1 – Identified Limitation (little or no experience); 2 – Capable (familiar but may need assistance); 3 – Independent - can
perform these tasks safely; 4 – Proficient - extensive experience *For further information, see instruction sheet at end of this form.
IA. The learner will incorporate relevant assessment & intervention (A&I) skills in antepartum care
Perform antepartum assessment accurately:
check DTR’s / clonus
perform non-stress test and
perform contraction stress test
perform sterile speculum exam
auscultate FHR
assess uterine activity
integrate knowledge of purpose for/expected norms
of prenatal labs
Perform fetal monitoring per AWHONN standards
Complete Intermediate Fetal Monitoring Course
IB The learner will incorporate relevant A & I Skills in intrapartum care:
Assess labor patient on admit (LPN non-complicated
only)
identify risk factors (maternal history)
collect lab samples
performs vaginal exam
Learning Guide #
Preceptor initials
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Learner initials
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Date all met
Self-assessment
Learning Guide follows competency pages and contains items for each competency that need to be reviewed based on learner’s experience and unit
need, they include reminders of important teaching points that may otherwise be missed.
Required Competencies
Verification method
References
Main categories followed by associated competencies
& facility specific requirements
IA 1
IA 2
IB 1
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 1
References
Learning Guide #
Preceptor initials
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Learner initials
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Verification method
& facility specific requirements
Date all met
Self-assessment
RN Competency Form: Obstetrics
Required Competencies
Assist patient during labor
offer comfort measures and coaching during each
stage
evaluate during each stage
ensure emergency equipment standby
monitor mom & baby
manage changes in fetal well-being
assist with placenta delivery
monitor patient after placenta delivery
Correlate clinical condition with drug indications, desired
effects, dosage and contraindications for commonly
given medications (IVP RN only)
IB 2
Monitor patient and baby receiving anesthesia (local,
pudendal, intrathecal, spinal, general) per policy
IB 4
Assist with induction/ augmentation of labor per nursing
role expectations (RN only)
IB 5
Explain role and use of tocolytic meds in pre-term labor
patients
IB 6
IC. The learner will incorporate relevant A & I skills in OB interventions & complications:
Perform amnioinfusion per policy (RN only)
IB 3
IC 1
Perform role in assisting with OB procedures per policy
IC 2
Provide perioperative care for cesarean section patient
prep patient per policy
perform L&D role in OR
IC 3
Manage care of client with pregnancy complication per
protocol
IC 4
Provide emergency measures to mom and fetus as
needed
IC 5
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 2
ID The learner will incorporate relevant A & I skills in postpartum care:
Provide care for post-partum patient
identify abnormal findings during complete
postpartum assessment
respond correctly to abnormal findings in
fundus/lochia/ perineal checks
teach caregivers per guidelines
administer RhoGam, immunizations
complete legal documentation
Facilitate breast feeding
identify community and facility support services
identify any maternal problems with breastfeeding
identify any infant problems with breastfeeding
References
Learning Guide #
Preceptor initials
D—Demonstrated; T—Test;
M—Module/class;
V—Verbalized
Learner initials
Main categories followed by associated competencies
and critical elements.
(Preceptor needs to verify learner capability for these items.)
Verification method
& facility specific requirements
Date all met
Self-assessment
RN Competency Form: Obstetrics
Required Competencies
ID 1
ID 2
Provide support to non-breast feeding mothers
ID 3
Comments/alternative learning plans:
All preceptors are to sign & initial below. Ideally new graduates should have only one to two preceptors for the entire orientation.
Preceptor Signature
Initials
Preceptor Signature
Initials
Signatures at completion of preceptorship/orientation:
Preceptee/orientee
Date
Primary Preceptor
Date
Manager
Date
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 3
RN Competency Form: Obstetrics
LEARNER GUIDE: Reference content in the right-hand column that needs review.
IA. The learner will incorporate relevant assessment & intervention (A&I) skills in antepartum care
IA 1
. Perform antepartum assessment accurately:
Review policies and procedures, required notifications and charting, standing
- check DTR’s / clonus
orders
- perform non-stress test and
Review the following: GBS, Rh rubella status, HSV, etc.
- perform contraction stress test
Review maternal history risk factors
- perform sterile speculum exam
- auscultate FHR
- assess uterine activity
- integrate knowledge of purpose for/expected norms of
prenatal labs
IA 2
Perform fetal monitoring per AWHONN standards
Practice with ultrasound and EFM equipment, review manuals/policy
- Complete Intermediate Fetal Monitoring Course
Review s/s of fetal distress
IB. The learner will incorporate relevant A & I Skills in intrapartum care:
IB 1
Assess labor patient on admit (LPN non-complicated
Review policy, procedure and admission forms
only)
Review vaginal culture process
- identify risk factors (maternal history)
- collect lab samples
- performs vaginal exam
IB 2
Assist patient during labor
Review guidelines for laboring patient
- offer comfort measures and coaching during each stage Review high risk labor factors and specific interventions to anticipate:
- evaluate during each stage
hemorrhage, shoulder dystocia, breech delivery, use of vacuum/forceps, etc.
- ensure emergency equipment standby
- monitor mom & baby
- manage changes in fetal well-being
- assist with placenta delivery
- monitor patient after placenta delivery
IB 3
Correlate clinical condition with drug indications, desired
Review the following commonly used medications: oxytocin, magnesium
effects, dosage and contraindications for commonly
sulfate, terbutaline, hemabate, methergine, betamethasone, rhogam,
given medications (IVP RN only)
ephedrine, procardia, misoprostil, prostin gel and others as applicable
IB 4
Monitor patient and baby receiving anesthesia (local,
Review procedure, equipment, troubleshooting, anesthesiology role
pudendal, intrathecal, spinal, general) per policy
Review nurses role for telemetry monitoring of infant
IB 5
Assist with induction/ augmentation of labor per nursing
Review special precautions with pitocin (set up, safety issues, etc.) and other
role expectations (RN only)
High risk medications
IB 6
Explain role and use of tocolytic meds in pre-term labor
Review commonly used tocolytics, policies, expected response
patients
IC. The learner will incorporate relevant A & I skills in OB interventions & complications:
IC 1
Perform amnioinfusion per policy (RN only)
Review procedure and patient teaching
IC 2
Perform role in assisting with OB procedures per policy
Review policy and role of nurse with the following: placement of IUPC, AORM,
use of vacuum and forceps, episiotomy, amniocentesis, fetal scalp electrode
placement
IC 3
Provide perioperative care for cesarean section patient
Review pre-op prep procedures and patient/family teaching
- prep patient per policy
Scrub in to OR with C Section patient or simulate
- perform L&D role in OR
IC 4
Manage care of client with pregnancy complication per
Review the following complications and local policies for caring for patients with
protocol
them: hyperemesis gravidarum, bleeding, fetal demise, multiple gestation,
pre-eclampsia, eclampsia, HELLP syndrome, preterm labor, diabetes,
placenta previa/ abruption/ accrete, trauma, malpresentation, substance
abuse, PROM, prolapsed cord.
IC 5
Provide emergency measures to mom and fetus as
Review policies on precipitous childbirth, hemorrhage, fetal distress, etc.
needed
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 4
RN Competency Form: Obstetrics
LEARNER GUIDE: Reference content in the right-hand column that needs review.
ID. The learner will incorporate relevant A & I skills in postpartum care::
ID 1
Provide care for post-partum patient
Review all policies and procedures related to postpartum care.
- identify abnormal findings during complete postpartum
Review postpartum assessment normal findings including physical,
assessment
psychological, emotional and spiritual aspects
- respond correctly to abnormal findings in fundus/lochia/ Review teaching needed: breast & bottle feeding, lactation program, care of
perineal checks
mom, care of baby
- teach caregivers per guidelines
Review legal requirements: birth certificate, footprint sheet, ID bands, photo,
- administer RhoGam, immunizations
etc.
- complete legal documentation
ID 2
Facilitate breast feeding
Review physiology of lactation
- identify community and facility support services
Review breastfeeding resources.
- identify any maternal problems with breastfeeding
Review maternal complications: feelings/concerns, mastitis, yeast infections,
- identify any infant problems with breastfeeding
engorgement, nipple pain, plugged ducts, adequate nutrition/hydration,
relaxation.
Review s/s letdown
Review infant assessment for effective latch, suck/swallow, hunger and satiety
cues, bilirubin, positioning, detaching.
ID 3
16. Provide support to non-breast feeding mothers
Review comfort measures: wrap, ice, NSAIDS, decreasing breast stimulation,
pumping breast for support, etc.
Other facility specific items to cover:
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 5
RN Competency Form: Obstetrics
REQUIREMENTS: All nurses will complete these competencies upon hire. Some competencies may be reviewed annually. This form
follows the Competency Outcomes and Performance Assessment (COPA) model.
PRECEPTEE/LEARNER INSTRUCTIONS:
Complete self-assessment: Rate your skill in each area to identify the areas where you need additional experience, access to
teaching resources, and/or lab practice. Discuss your results with your preceptor to help establish a plan and goals for your learning
experience and to aid in choosing patient assignments. Scoring per instructions at the top of page 1.
PRECEPTOR INSTRUCTIONS:
A. Review self-assessment with preceptee/learner to establish plan.
B. Required Competencies: The specialty area competency forms are required for independent practice on this unit. This column
represents the Alaska Statewide required competencies per ACE-HC and should not be altered. The preceptor will sign each one off
when he/she, as preceptor and colleague, feels safe in allowing the preceptee/learner to deliver this aspect of care without
direct supervision.
C. Verification Method & Agency Specific. Document comments/check marks for the competency and any agency specific
requirements. Verification methods include:
1. Demonstration – Preceptor watches learner perform task/procedure in safe, capable manner in a simulated lab or computer
setting or as part of direct care performance. The expectation for new graduates is that they demonstrate as many of the
competencies as possible.
2. Test – Learner passes a test provided by the facility to measure competence for this skill. (Minimum passing grade indicated.
Initial only after test passed.)
3. Module –Learner has completed a training tool (computerized or written module, class, video, etc.) provided by the facility to
measure competence for this skill.
4. Verbalization - Learner explains to the preceptor the process and/or planning that evidences safe, reliable knowledge base.
This may include case scenarios, discussion, and/or description of plan.
NOTE: some competencies may have the verification method specified per facility guidelines (e.g. “test only”)
Record N/A and initials only for items that never apply to this learner’s role or performance.
D. Sign-off: Sign and date when all elements of the competency are met. If unable to sign off an area due to patient population issues
or learner needs more time, document a plan in the comments section at the end of the form. Discuss alternative ways of meeting
the requirement(s) as well as any additional time needed with the nurse manager and/or nurse educator. All preceptors assisting in
orientation of a new staff member/intern must sign and initial in the signature chart at the end of this document.
E. References: Competencies should be met in accordance with these. Add your facility approved references here.
F. Learning Guide: These are memory ticklers. The amount of time spent on each of them depends on the learner’s experience. New
graduates will likely need time on almost all of the areas listed.
REFERENCES COLUMN: List foundational documents to support the learning experience and to use as the official measure by which
the competencies are assessed. The ACE-HC group recognizes the following as sources for evidence based practice that can be
included in the reference list along with local policies, procedures and forms: Perry & Potter, Elsevier/Mosby, Lippincott, Kozier & Erb,
ANA, nationally recognized hospital related regulatory organizations (CLIA, CDC, CMS, JC, etc.), and specialty nursing organizations’
scope, standards and core curricula. This column’s content may be changed to be facility specific.
NOTE: ACE-HC competency forms are intended to be used between facilities within Alaska.
Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model.
Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved.
Page 6