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.
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.