Category:OB & Newborn

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Unit Description (Facility)

The OB Unit consists of 6 LDRP (Labor-Delivery-Recovery-Postpartum) rooms with a bed total of 16 (8 mother and 8 newborn), one C-Section Delivery room, two OB Triage rooms, an infant treatment area, and a potential infant isolation area. Additionally, Room #1 can function as a negative air flow isolation room.

An average of 400 deliveries occur annually with the number increasing each year. The unit provides care to outpatient and inpatient obstetrical patients with a gestation of > 20 weeks gestation as well as newborns born in the unit. There is no nursery and babies room-in with the mothers unless they are being observed for a short while or are being stabilized for medevac.

Overview

The OB/NEWBORN scope of service includes routine vaginal births, external cephalic version, ante-partum testing, elective and emergency primary and repeat cesarean sections, pre-induction cervical ripening, labor induction/augmentation, low-risk VBAC (vaginal birth after C-section), stabilization of a sick neonate for transport and stabilization of the preterm or term patient for transport.

Family medicine hospitalists do all deliveries and take care of all mother baby pairs unless HROB (high risk OB) consultant assumes care of the mother (especially post-op) or pediatrics assumes care of an ill newborn. The average healthy mom/babe pair stays for 48 hours. This is because most of the patents will be returning to a remote village where access to care and travel back to Bethel may be difficult. Some exceptions are be made for Bethel patients who may leave as early as 36 hours. For billing purposes if a mother or baby is staying longer than 48 hours (or 2 hospital days) a justification for the increased length of stay must be given. If a patient delivers later in the evening, yet before midnight, consider discharging the mom and baby to pre-maternal home in the evening for travel home the next day.

There is on call pediatrician available for all newborn consulta¬tions. Pediatricians also attend all C-Sections and any deliveries on infants who are less than 36 weeks gestation or as requested. Note: We try to get moms to Anchorage if they are less than 36 weeks gestation. Some babies that are delivered close to 37 weeks, but many will have problems with feeding and maintaining temps. These babies will be need to be transferred to Anchorage when they are stable. Moms may travel with them if it is more than eight hours after delivery and they are stable post partum. Pediatricians also attend meconium deliveries and any other deliveries where there is evidence of significant fetal distress. Pediatricians are available to come to any delivery that a FM physician has concerns about the fetal/newborn status.

All sick newborns should be seen by the pedia¬trician to arrange or assist in arranging a transport via LifeMED with or without a NICU NP.

Because there is no nursery and limited nursing staff, all babies that need more than mother’s care must be transferred to Anchorage. Each delivery room is set up for meconium deliveries and any initial resus¬citation. If a baby requires ongoing resuscitation or intubation, they are moved into the procedure room. There are two neonatal crash carts, one in the procedure room and one on the unit across from the nurse’s station. The carts have all the needed resuscitation supplies and meds. On top of each cart are neonatal resuscitation worksheets with equipment sizes, medication doses, and fluids based on weight or estimated gestation age to guide resuscitation.

The goal of OB nursing and provider staff at YKHC is to ensure the safest delivery and the best care possible for our newborns as well as promoting good maternal-newborn bonding and avoiding separating moms and babies whenever possible.

Occasionally infants will be delivered that will need further evalu¬ation, observation, interventions and/or transport to a higher level of care. Because we do not have a nursery or the staffing level to care for sick infants we need to decide which baby’s will need to be transported out. We can do some limited observation and supportive care, but for all sick infants that require a higher level of care, providers will stabilize and transport the patient as quickly as possible.

If a newborn has a possibly transient condition (examples: TTN, low glucose, minor depression from precipitous delivery etc.) a baby may be evaluated and watched in the nursery for a limited length of time. If the newborn is not showing signs of improvement and it does not appear that they can be cared for as a rooming in patient with mom by 4-8 hours of life (depending on staffing and nursing comfort level), arrangements will be made to medevac the infant.

If a newborn is stable and shows no signs of illness or instability (i.e. can room in with mom), but needs labs and observation for 48 hours (ex: GBS exposure without appropriate maternal prophylax¬is or jaundice and phototherapy) the baby may stay with mom in OB with or without a heplock in place. Heplocks will be monitored per hospital policy.

At this time, if a newborn is well, but has borderline or questionable screening labs that require 48 hours of antibiotics and observation, the infant will need to be transferred to NW or to ANMC.

OB Triage Patients

OB Admissions

OB patients are generally admitted only for when they are in active labor unless an OB Triage patient requires more than 24 hours of observation. Other OB admissions might be for a C-section post-op problem or a pregnant woman (>20 weeks gestation) but with a different primary diagnosis requiring admission…Although these technically would go to NW for admission they might be admitted to OB with permission from OB nursing staff.

  • Complete a general admission H&P and include pregnancy problem list and prenatal labs.
  • Complete the Medication Reconciliation
  • Complete an E&M charge
  • Update Diagnoses and Problem List

OB Progress Labor Notes

A note/update must be completed every four hours for any patient in active labor.

OB Deliveries

OB Special Circumstances

OB Rounding

This occurs daily while admitted and every 2 hours for active labor or induction patients. If you deliver someone at night, you are expected to see that patient the following days, if you are continuing on Night Float shift. Otherwise, sign out to the ward docs.

OB Discharges/Follow Up

The recommended NSVD postpartum discharge time for the mother and newborn is 36-48 hours except for the late preterm newborn which is 72 hours. The mother and newborn can actually be discharge any time they are stable as long as a screening fractionated bilirubin level can be assessed for the newborn during the 36-48 hour time period. For the village newborn, this usually means no sooner than 36 hours unless they want to stay with a Bethel family.

OB Medevacs

In consultation with HROB and the ANMC OB on-call physician, OB patients with a serious but stable medical condition may need transport to a higher level of care (ANMC or other). Once an accepting physician is identified, LifeMED should be activated and the patient should discharged pending medevac team arrival. Essential documentation should include a transfer summary and three papers from the “Transport Pack” completed by hand: PTO Signed consent form Diagnostic imaging request form for studies to be loaded on a CD Discharge summary, which you should do before LifeMed team arrives.

OB Procedures

Nexplanon:

This is one of the most popular birth control methods postpartum on the OB Unit. It is an insertable 3-year capsule and can only be inserted by a specially trained (and certified) provider. This can usually be arranged for the patient within a 24 hour (or sooner) period.

Induction:

See the new Induction Policy in the NWing Doc’s Office in the “Induction Book.” The YKHC Clinical Guidelines (2011) concerning this are not current.

Episiotomy:

See the same topic above under “Deliveries”

Vacuum assist/extraction:

See the same topic above under “Deliveries”

Repair of Vaginal Delivery Lacerations:

1st and some 2nd degree lacerations may not need repair if hemostasis evident and anatomy is intact (e.g. peri-urethral, vaginal wall).

3rd and 4th degree lacerations repairs usually require HROB presence.

Newborns

Links to page with the following contents:
Newborn Admissions
Scenarios/Special Situations
Newborn Rounding
Newborn Discharge Process

Consults

Transfers/Medevacs (Transfer/medevac section LINK)

As soon as it is obvious that a mom or baby needs to be transferred (in some cases this is before the baby delivers i.e. when there is a known maternal or infant problem that necessitates a NICU or higher level of care for mother and/or infant during labor and/or delivery).

  • Call ANMC and get an accepting physi¬cian for mom if she has not delivered or for baby if baby has delivered…if a patient is non-native the accepting physician should be from Providence NICU.
  • Complete the Patient Transport Order (PTO) and other paper work in the transport packet
  • Continue to monitor and stabilize the infant
  • Complete the Newborn Discharge/Transfer Summary and add updates as needed. You can create your own transfer template or you can use McClure’s shared template and modify it for your own use.
  • Update Diagnoses and Problem List
  • Complete and E&M charge
  • Complete the Medication Reconciliation

Case Management

Hospitalist Documentation (RAVEN)

Guidelines

( make a list of commonly used OB inpatient and OB outpatient guidelines here and put a link to guidelines section)

Formularies

Pages in category "OB & Newborn"

The following 3 pages are in this category, out of 3 total.