RT LIM FAMILY HOSPITAL CO Page No.

Nursing Service Department Issue No.

Standard Operating Procedure Issue date
Labor and Delivery Room
Document Code:

1.0 Purpose

To establish infection control guidelines for healthcare workers (HCWs) in the Labor and
Delivery area.

2.0 Scope

All healthcare workers, including staff nurses, midwives, and nursing attendants; volunteers,
and students in the Labor and Delivery area; this also includes physicians and anesthesiologists

3.0 Duties and Responsibilities

3.1 Head Nurse 

 Plans and supervises nursing related activities of the staff in the unit. 
 Manages patient care and other nursing activities (e.g. bedside care, soliciting feedback
from patients, administering medications and reporting unusual symptoms). 
 Monitors and evaluates the performance of staff nurses and midwives in providing
patient care. 
 Prepares and submits work schedule/ward assignment of staff. 
 Acts as liaison in order to coordinate functions between nurses, patients and others
members of the health team for endorsement of patient care.
 Ensures that there is adequate medical supplies and equipment in the different clinical
areas of the unit.
 Participates in the development of plans, policies, procedures and standards related to
the delivery of nursing service. 
 Monitor patient’s profile and charts for billing reports.
 Performs other related functions as maybe assigned by the Chief Nurse and Chief of the
Hospital
3.2 Staff Nurse/Midwife

 Performs direct nursing care procedures, which include bedside nursing, hygiene, pre
and post -operative nursing care.
 Performs admission and discharge duties and responsibilities.
 Observes, records and reports patients' symptoms, conditions, and progress of
treatment and therapy. 
 Prepares patients for, and assists physicians with diagnostic and therapeutic procedures
for both normal and specialized treatment cases. 
 Administers and records prescribed medications and documents any adverse drug
reactions. 
 Prepares treatment trays and instruments. 
 Maintains accuracy in the documentation of patient condition, medication and
treatment. 
 Performs other related functions as maybe assigned.

3.3 Nursing Attendant 

 Assists with admission, transfer and discharge of patients.

 Prepares patient for emergency or scheduled surgery and diagnostic procedures. 
 Takes and records patients' vital signs, intake and output.
 Maintains cleanliness of equipment and orderliness of the work station. 
 Ensures that patients are provided with clean linens and gowns.
 Provides comfort measures. 
 Performs post mortem care. 
 Performs other related functions as may be assigned. 

4.0 Policy 

4.1 Unit Policy 

 Door shall be close at all times. Movement and conversation during cases shall be
minimized.
 Strictly no watcher shall be allowed inside the unit, unless emergency cases. If the case
arises watcher shall use gown and change slippers in entering the unit 
  A cap that covers all hair including beard and side burns, mask and eye protective
shields, sterile gloves and sterile gowns shall be worn by all personnel involved in
deliveries that take place in the restricted area.
 Sharps shall be disposed of in puncture-resistant leakproof containers. The containers
shall be closed and replaced when ¾ full.
 Standard Precautions shall be followed for all patients
 All personnel shall wear prescribed uniform / attire. No watches and jewelries shall be
allowed.
 Dirty and contagious cases shall be attended at the Delivery Isolation Room, use of PPE
shall be employed. 
 Employees shall eat and drink only in designated areas

4.2 Receiving of Patients 

4.2.1 Criteria for patient received in the labor room: 

 Cervical opening of 5 cm and above 

 Active labor 
 With doctor's order 

4.2.2 Patient will be endorsed by the obstetric examining nurse to labor room with the
following: 

 Patient's Record 
 Medicine 
 No jewelries 

4.2.3 Inform the delivery room nurse for the minor procedures to be endorsed and prepare the
instrument to be used. 

4.2.4 If the baby is well, implement breastfeeding and the mother will be brought back to the
ward.

4.2.5 Transport of stable patient for diagnostics or to other units shall be accompanied by the
staff nurse, and physician

4.2.6 Transport of the unstable patient within the hospital premises shall be accompanied by
the staff nurse and physician, with the following:

 Emergency kit containing Laryngoscope, ET tube, bag-valve 

mask, epinephrine. 

 Stethoscope. 
 Portable oxygen tank, portable pulse oximeter. 

4.3 Housekeeping

4.3.1 Termination of Case

 Thorough cleaning and misting must be done after every use of Delivery Isolation Room 
 Routine terminal cleaning of the room(s) shall be performed after the room has been
vacated.
 Weekly general cleaning of the unit and daily cleaning must be religiously done 
 Linens:
- The linen shall be bagged and taken to the soiled linen area.

4.3.2 Equipment
 All reusable items shall be sterilized or properly disinfected prior to reuse.
 All disposable items shall be discarded after use.
 Floors shall be wet mopped after each case.
 All instrument and tables shall be thoroughly cleaned after each case.
 All blood spills or spills of bloody body fluids shall be cleaned up with an EPA-registered
tuberculocidal (hospital-grade) disinfectant.

4.3.3 Daily Cleaning

 Floors shall be thoroughly cleaned.
 Wheels and castors shall be cleaned and inspected carefully for debris.
 Sinks and faucets shall be cleaned with a suitable abrasive.
 Cleaning equipment shall be taken apart, cleaned with a detergent germicide, and
allowed to dry.
 Routine cleaning schedules shall be established for the autoclave, warmers,
refrigerators, cabinets, storage areas, and other permanent equipment. Cleaning of
these items/areas shall be documented.
 All blood shall be handled as if it were infectious. Bulk blood and bloody body fluids shall
be carefully poured into the sewage system for disposal.
 Equipment shall be cleaned with an EPA-registered tuberculocidal (hospital-grade)
disinfectant. Disposable items that are saturated with blood or bloody body fluids shall
 be placed in a red biohazard bag and discarded.

4.3.4 Disinfection and Sterilization

 Disinfection and sterilization shall be carried out according to the hospital guidelines.

 Items to be sterilized are sent to Sterile Processing.

 All sterilized items shall be labeled with the name of the item. The policy for event-related
sterility shall be followed.

4.3.4 Storage of Clean and Sterile Supplies

 All clean/sterile supplies shall be stored on shelves and be dust free.

 All sterile supplies inside each sterile pack shall be checked routinely for expiration dates
 RT LIM FAMILY HOSPITAL CO Page No.
Nursing Service Department Issue No.
Standard Operating Procedure Issue date
Operating Room
Document Code:

1.0 Purpose

2.0 Scope

All healthcare workers, including staff nurses, OR tech; volunteers, and students in the
Operating room area; this also includes physicians and anesthesiologists

3.0 Duties and Responsibilities

3.1 OR Head Nurse 

 Assists in the development and revision of policies, procedures and standards in the unit
for the smooth flow of activities in the operating room 
 Determine amounts and kinds of equipment and supplies 
 Supervises the total implementation of peri-operative nursing care
 Checks patient schedule for operation and assigns staff to assist on each operating
room. 
 Supervise staff to assure proper technique and practice in the preparation / processing
of instruments and supplies 
 Supervise in the issuance of sterile equipment, instruments and supplies to different
Operating Room 
 Keep an inventory for all equipment, instruments and supplies issued under her/his
responsibility.
 Coordinates support services involved in the care, maintenance  of the operating room 
 Assures and maintains an environment of asepsis
 Performs other related functions as maybe assigned by the Chief nurse and Chief of
Hospital
3.2 Staff Nurse 

 Performs direct nursing care services and assist physician in surgical, diagnostic and
therapeutic procedures in order to provide proper patient care 
 Observe aseptic techniques in preparing for and assisting surgical procedures and
provides necessary instruments, supplies and equipments for operations according to
hospital policy and preference of surgeons. 
 Administer prescribed medication 
 Ensures availability of supplies and instruments 
 Performs head to toe assessment and proper documentation
 Receives and endorse patient 

3.3 Scrub Nurse 

 Responsible for the safety of the patient while in the operating room 

 Cleans the room and disinfect equipments, instruments inside the operating room. 
 See to it that all equipments needed for operation are functional 
 Get needed packs from the central supply room  
 Set up the operating rooms with all necessary equipments, instruments and supplies 
 Arranges instruments at the mayo table 
 Does the initial sponges, sharps and instruments count together with the circulating
nurse
 Serves gowns and gloves to the surgeon and assistant surgeon 
 Assists and anticipate the surgeon's needs throughout the operation 
 Maintains sterility of instruments and supplies used directly in the sterile field 
 Coordinate with the circulating nurse during the entire operation for additional supplies,
equipments and instruments needed and when operation is about to end. 
 Does final counting of sponges, sharps and instruments together with the circulating
nurse 
 Inform the surgeon for the completeness of sponges, sharps and instruments count 
 Assist in the dressing of operative site 
 Strip off all soiled linens used in the operation 
 Does after care of instruments and equipments
 Dispose Operating Room waste to hamper accordingly 
 Set up the operating room with all the necessary equipments and instruments for the
next case 
3.4 Circulating Nurse 

 Check for the availability of room, equipment and packs for the assigned room. 
 Check and help in the preparation of instruments, packs for each procedure 
 Informs the ward nurse to endorse patient to the operating room
 Supervise safe transfer of patient from OR trolley to OR bed 
 Oversee the smooth flow of the surgery 
 Assist the scrub nurse in positioning the Mayo table
 Does the surgical sign in using the surgical safety checklist 
 Assist the anesthesiologist when necessary 
 Coordinate with the surgeon to the proper positioning of the patient according to the
type of surgery 
 Does the surgical time out using the surgical safety checklist 
 Coordinate with the scrub nurse during operation and anticipates for the needs of the
surgical team 
 Attends to sponge count, sharps and instruments count 
 Attends to the immediate post-operative needs of the patient until after the patient is
properly transported to the recovery room.
 Endorses post operative orders and patient condition to nurse assigned in recovery
room 
 Supervise safe transfer of patient from OR bed to trolley 
 Attends to records and ensure complete documentation 
 Attends to care of specimens 
 Does after care of instruments and equipments 
 Return unused supplies to central supply room
 Does charging of surgical procedure performed, equipment used and oxygen consumed 
 Set up the operating room with all the necessary equipments and instruments for the
next case 

3.5 Nursing Attendant 

 Transport patient from operating room holding area to operating room, from operating
room to recovery room, from recovery room to ward 
 Cleans, sanitize and disinfect OR equipments 
 Prepares OR room for incoming operations 
 Position patient for spinal / general anesthesia 
  Get packed linen from the laundry staff and endorsed to CSR staff for sterilization 
 Endorse packed instruments to CSR staff for sterilization 
 Sends specimen to laboratory
 Get blood / blood products from blood bank personnel
 Performs other tasks assigned to him by the OR Nurses 

4.0 Policies 

4.1 Schedule of Operation 

 Three (3) copies Operating Room slip properly filled up shall be submitted to the
operating room staff a day before surgery by the ward nurse, (1) one copy of the
Operating Room (OR) slip is given to the anesthesiologist on duty, one (1) copy is given
to CSR and Pharmacy Satellite Staff, one (1) copy is filed by the Operating Room (OR)
nurse
 All schedule of operation must be submitted to the operating room on or before 4pm a
day before surgery 
 On the day of surgery, the ward nurse endorse the patient, patient's record with signed
consent to the operating room nurse 
 After operation, the OR nurse shall document the procedure in patient's record and OR
logbook and endorse the patient's record to billing section

4.2 Cutting Time for Elective Cases 

 OR cutting time start at 7:00AM 

 Patient's must be brought to Operating Room 30 minutes before scheduled cutting time 
 Ward nurse is responsible in transporting patient from the ward to the holding area of
the operating room 

4.3 Delay in Operations 

 All delay in operation must be reported to the Operating Room Manager 

 Reasons for delay should be recorded for audit purposes 
4.4 Postponement of Cases 

 The anesthesiologist may suggest postponement when patient after proper evaluation is
found to be high risk. 

4.5 General Protocol of Operating Room 

 Minor cases under sedation are allowed to stay in recovery area for a maximum of two
(2) hours.
 All schedule of operation must be on time, the time of operation is the time marked by
the actual first incision 
 During the actual surgery, additional procedures when necessary 
 are allowed provided client's family members are informed and signed consent is
obtained. 
 Smoking is strictly prohibited in any area of the operating room (hospital is a smoke free
zone) 
 No eating a meal policy. All personnel are obliged to eat their meals at the dietary hall.
Eating in the working area is strictly prohibited. 
 All personnel shall observe proper dress code during their tour of duty in the hospital. 
 Personal belongings of surgeons, anesthesiologist and others are their responsibilities.
Bringing of valuables in the Operating Room are not allowed. Bag could be deposited in
every dressing area for safekeeping 
 Surgeries shall be done according to the scheduled time 
 Surgeon/anesthesiologist must be present during induction, intubation and extubation
of the patient 
 Cases to follow must be indicated properly and brought to OR of assignment if the room
cleaned ready for the coming operation. 

4.6 Dress Code in the Operating Room 

 Wearing street clothes underneath the scrub suit is not allowed 

 Jewelries are not allowed to be worn inside the operating room 
 Operating Room attire soiled during the performance of the procedure shall be
discarded and change with the new set 

4.7 Specimen 

 Specimen taken from medico-legal cases are the responsibility of the laboratory
department staff who will provide storage for these specimen 
  Label of the specimen shall include the following: 
-Name of patient 
-Age, Sex 
-Date of Operation
-Type of specimen 
-Area / Site from which it has been removed 
-Name and signature of the surgeon 
-Name and signature of the nurse 
 The OR nurse shall endorses the specimen to the medico-legal surgeon who will be
responsible in endorsing the specimen to the laboratory staff 

4.8 Transport of Patient 

 Elective and Emergency Cases transported from the ward are transferred to the
operating room trolley at the holding area prior to the transport of patient inside the
sterile room 
 Direct to OR, critically ill and intubated patients from wards and ER, emergency
cases must be brought directly to sterile operating room without delay. No need to
transfer patient from ward trolley to OR trolley. OR staff nurses should take into
consideration that patient condition is of utmost priority and immediate surgical
intervention is life saving 

4.9 General Protocol at the Recovery room

 The nursing care given to the patient in the recovery room is under the direct
supervision of the OR head nurse. 
 The duration of service to be offered by the recovery room will be 24 hours based on
the OR room schedules 
 Patient’s conditions and vital signs shall be closely monitored, documented and prompt
referral shall be done to the assigned anesthesiologist 
 Visitors are restricted in the recovery room 
 The anesthesiologist will decide when the patient's condition warrants his/her transfer
to ward or to his/her room. 
 Infectious disease cases shall not be admitted in the recovery room

4.10 Shaving of patient for operation 

 Once shaving is needed, surgeon in-charge must make an order in the patient's record
as to the specific site to be shaved. 
 Shaving must be done in the respective ward immediately prior to operation 
 Once patient is in the holding area the surgeon should check the operative site if shaving
is correct. In case a surgeon will order for additional shaving of the operative site it shall
be done in the holding area. 

RT LIM FAMILY HOSPITAL CO Page No.

Nursing Service Department Issue No.
Standard Operating Procedure Issue date
Admission to Ward
Document Code:
1.0 Purpose

To ensure that patients for admission to the ward are registered and their needs are identified
prior to receiving clinical treatment and care.

2.0 Scope

This defines the actions and responsibilities of the doctor, nurses, and other healthcare workers
during the admission process of patient to the ward.

3.0 Duties and Responsibilities

3.1 Head Nurse

 Participates in the development of plans, policies, procedures and standards related

to the delivery of nursing service.
 Coordinates nursing services with the services of other health care disciplines
 Monitors and evaluates the performance of staff nurses and other healthcare
personnel in providing patient care.
 Performs other related functions as maybe assigned.

3.2 Staff Nurse

 Performs direct nursing care procedures, which include bedside nursing, medication
preparation, pre and post-operative nursing care.
 Performs admission and discharge duties and responsibilities.
 Prepares patients for, and assist physicians with diagnostic and therapeutic procedures
for both normal and specialized treatment cases
 Observes, records and reports patients' symptoms, conditions, and progress of
treatment and therapy.
 Performs other related functions as maybe assigned.

3.3 Nursing attendant

 Assists with admission / transfer / discharge 

 Serves and removes bedpans, urinals, emesis basin as needed
  Maintains patients immediate environment clean and orderly
 Assists in the preparation of patients for treatment, examination and surgery
 Collets specimen (urine, stool, sputum); labels specimen in bottles
 Assists physician with minor procedures and physical examination of patients

4.0 Policy

4.1 Health and Safety

 Attend to patient immediately if he/she seeks help

 Exercise caution at all times when transporting patient to avoid injury
 Observe proper lifting technique when handling, turning and carrying patients
 Wear appropriate personal protective equipment when handling patients suffering from
infectious disease.
 Ensure that all waste containers are correctly labelled describing the contents

4.2 Environmental

 Handle hazardous substances with utmost care

 Inform the housekeeping personnel to dispose the contaminated items after spill clean-
up.
 Cap all bottles of hazardous substances to prevent evaporation
 Dispose the wastes generated in the appropriate containers and at designated locations.
Observe relevant wastes handling procedure at all times.