CODE

STANDARDS

1

2

3

N/A

Explanation

L&D 1

Labouranddelivery sectionaredesigned and equipped to facilitatethesafe andeffective careofpatients.

 

 

 

 

 

L&D 2

Each L&D is organized physically and functionally as a distinct entity within the hospital.

 

 

 

 

 

L&D 3

Sufficientfloorspaceis allocatedtoeachbedtoaccommodatethe equipmentandpersonnelnecessarytomeetthepatientísneeds andanyemergencysituation.

 

 

 

 

 

L&D 4

Each labour & deliverywardprovide appropriatespace for the provision of services and the following:

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 4.1 Single occupancy roomsandeach room shall provide space for the mother, newborn and support person

 

 

 

 

 

 

L&D 4.2 A private toilet in each room

 

 

 

 

 

 

L&D 4.3 An appropriately designedandequippeddistinctareawithin the room for newborn resuscitation and stabilization

 

 

 

 

 

 

L&D 4.4 L&D wardis appropriatelyventilated area†† basedonMOHspecification

 

 

 

 

 

 

L&D 4.5 Accessible examination lights

 

 

 

 

 

L&D 5

Thepostpartumareaprovidessemi privatespace for provisionofservice

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 5.1 Thepostpartumarea†† isproperlyequipped

 

 

 

 

 

 

L&D 5.2 Thepostpartumarea†† isundertheassignment†† ofappropriately qualifiedandexperienced staff

 

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

 

L&D 5.3 The postpartumarea is equipped with a private bathroom

 

 

 

 

 

L&D 6

In the L&D ward, there†† is a properly equipped area to perform emergency surgicalinterventions and space for newborn resuscitation.

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 6.1L&D should have the following:

(1) Heat source equipment;

(2) Oxygen, suction, and air outlets;

(3) Resuscitation equipment;

(4) Equipment necessary for physiologic monitoring;

(5) Transport conveyer system

 

 

 

 

 

L&D 7

For patientsrequiringisolation,an effectivemeanofisolation isprovidedfor those patients sufferingfromcommunicableorinfectiousdisease, until placement elsewherebecomespossible

 

 

 

 

 

L&D 8

Director indirect†† observationby L&Dstaffofallpatientsispossible

 

 

 

 

 

L&D 9

A directintercommunicationalarmsystem isprovidedbetweenthenursesstationandthepatientísbedwith connectionstotreatment, work loungeorotherareasfromwhichadditionalpersonnel maybe summoned

 

 

 

 

 

L&D 10

Theunitisequippedwiththenecessaryequipmentandsupplies suitableforthe typeand†† sizeofthepatientísloadbeing handledbytheunit.

 

 

 

 

 

L&D 11

An emergencycartwithin†† theunit containsappropriate drugsandequipment asdeterminedbythemedicalstaff

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

L&D 12

Theemergencycart is checked at the beginning ofeachshiftandaftereachusebytheproperpersonnel for,quantityandquality

 

 

 

 

 

L&D 13

Emergency medications are available, monitored and safely stored.

 

 

 

 

 

L&D 14

AllequipmentswithintheL&Daremaintained , testedand inspected ,periodicallyanddysfunctionsarereported

 

 

 

 

 

L&D 15

Appropriate safety measures are implemented in the L&D.

 

 

 

 

 

L&D 16

Equipmentsthatmonitorthe patientísvitalfunctionsinthe L&Darea††† areoperativeatalltimes,hasanalarmsystem and hasbatterybackupsystemtooperateincaseofelectricalfailure

 

 

 

 

 

L&D 17

Eachstaffmemberresponsibilities inL&Daredefinedinacurrentjobdescription

 

 

 

 

 

L&D 18

L&Dwardisproperlydirectedandstaffedaccording tothenatureofspecialpatientcareneedsanticipatedand thescopeofserviceoffered

 

 

 

 

 

L&D 19

Theobstetricalservicehas anappropriately qualified Ob/Gynphysiciandirector

 

 

 

 

 

L&D 20

Thosepermittedtowritepatientísorderswritetheorderinthepatientísrecordinauniformlocation.

 

 

 

 

 

L&D 21

Allphysicians inL&Dwardarecertified and welltrainedasappropriate toprovidethecarerequired

 

 

 

 

 

L&D 22

A sufficientnumberofpermanentlyassignedqualifiedstaffareondutywithinL&D ward†† atalltimes.

 

 

 

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

L&D 23

Clinicalprivileges formidwivesshallbethosestandards/usualandcustomaryproceduresappropriatetothediagnosisandmanagementofuncomplicatedobstetricalpatients.They†† include thefollowing:

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 23.1 applyandremovefetalscalpelectrode

 

 

 

 

 

 

 

L&D 23.2 assessandevaluateuncomplicatedobstetrical patients for position

 

 

 

 

 

 

 

L&D 23.3 performvaginalexamination

 

 

 

 

 

L&D 24

NursingactivitiesaremanagedbyRegisterednurseswhohaveexperienceintheparticularareaofpractice.

 

 

 

 

 

L&D 25

Allstaffareappropriatelytrainedondealingwithall†† equipmentsintheunitduringtheprovisionofcare

 

 

 

 

 

L&D 26

AcopyoftheoperatingmanualofeachmachineisavailablewithinL&D ward

 

 

 

 

 

L&D 27

Themaininstructions foroperatingeachmachineintheunitis posted nearby the machine.

 

 

 

 

 

L&D 28

Allmidwives havetheproper†† qualificationandexperience

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 28.1Midwivesmusthavea††† midwifecertificatefromtheircountryoforigininIn additiontoanapprovedRNeducationacceptabletoministryofhealth

 

 

 

 

 

 

L&D 28.3Thereisa formaldocumentedclinicalprivilegeinplaceformidwives whichrequirerenewalevery2year

 

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

 

L&D 28.4OnlyRN midwiveswithcurrentclinicalprivilegepracticeindependently

 

 

 

 

 

L&D 29

Non-midwivesobstetric RNhavedocumentedcompetence†† in:

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 29.1 antenatalabdominalassessment / palpation

 

 

 

 

 

 

 

L&D 29.2 recognizingsignsandsymptomsofantenatalcomplicationwith subsequentintervention (e,g. pre-eclampsia, hemorrhages, fetal distress)

 

 

 

 

 

 

 

L&D 29.3 performingnon-stress test forantenatalpatients

 

 

 

 

 

 

 

L&D 29.4 assessingfetalheart

 

 

 

 

 

 

 

L&D 29.5 recognizingsigns andsymptomsforlabour

 

 

 

 

 

 

 

L&D 29.6assistingatdeliveries

 

 

 

 

 

L&D 30

Healthcaretolabouringand delivery patientisprovidedindependentlyonly byprivilegedRN midwifes orphysician.

 

 

 

 

 

L&D 31

Thescopeof†† practiceformidwivesisclearlydelineated

 

 

 

 

 

L&D 32

There is 24-hour physician coverage for the unit.

 

 

 

 

 

L&D 33

An obstetrician and a pediatricianmustalwaysbereadilyavailabletoattend intheobstetriccare

 

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

L&D 34

RN and/or RN midwifesandOb/GYNdirectorcollaboratively providedirectionofcareinin theobstetricarea. Evidenceofthis

collaborationisdocumented

 

 

 

 

 

L&D 35

Patientísprivacy††† isensuredbyindividualroomsorproperpartitions

 

 

 

 

 

L&D 36

Thestaff of the obstetrics area adheres follow specific and hospital-wide infection control measures.

 

 

 

 

 

L&D 37

SterilizationofallobstetricsequipmentsandinstrumentstakesplaceintheCSSD

 

 

 

 

 

L&D 38

Obstetrics suites are organized to preventmovement ofnon-related

traffic.

 

 

 

 

 

L&D 39

Allstaffareappropriatelytrainedondealingwithall†† equipmentsintheunitduringtheprovisionofcare

 

 

 

 

 

L&D40

Nursingstaffisfamiliarwiththeadmissionanddischargecriteria

 

 

 

 

 

L&D41

Additionalnursingpersonnel trainedandexperiencedinspecialcareunitsareavailableandassignedasneeded

 

 

 

 

 

L&D 42

Therearewrittenguidelineswhichguidestaffastowhentocallapediatriciantobepresentfordelivery ( e.g. fetal distress , instrumentaldelivery , multiple births or premature )

 

 

 

 

 

L&D 43

Thereisevidenceofcontinuoustrainingandeducation for thenursingstaff†† related††† tothecareprovided

 

 

 

 

 

L&D 44

Thereisamechanismtosummonhelpwithoutleavingthepatientísbed side

 

 

 

 

 

L&D 45

Religiousandculturalissuesduring††† provision ofcare†† arerespectedandsupported

 

 

 

 

 

L&D 46

Thepatientísrighttotreatmentorserviceisrespectedandsupported

 

 

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

L&D 47

Properpatientíscovering, anddrapingtoensurepatientsprivacy

 

 

 

 

 

L&D 48

Obstetricalcare†† area(labour anddelivery ,postpartum, andnursery )haveunit specificspecialtymanualswithwrittenpoliciesandproceduresthat 1.definerolesandresponsibilities, 2. guidesupport , 3. assistallstaffintheprovisionofnursing and midwiferypractice

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D48.1 Strictpolicyandproceduresare written and enforced forthe proper identification of babies

 

 

 

 

 

 

L&D48.2 Written policiesandproceduresguidetheprovisionofcareinL&D ward

 

 

 

 

 

 

L&D 48.3 Policies and Procedures are written by the medical and nursing staff.

 

 

 

 

 

 

L&D48.4 Prescribing, orderingandadministeringmedicationsareguidedbypoliciesandprocedures

 

 

 

 

 

 

L&D48.5 Written policiesandproceduresguidethecareofemergencypatients

 

 

 

 

 

 

L&D48.6 Written policiesandproceduresguidetheuseofresuscitationservices

 

 

 

 

 

 

L&D48.7 Written policiesandproceduresguide the handling, useandadministrationof bloodandbloodproduct

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

 

L&D48.8 Written policiesandproceduresguidecodeblueteams

 

 

 

 

 

 

L&D48.9 Written policiesandproceduresguide thecareofpatients onlifesupportorwhoarecomatose

 

 

 

 

 

 

L&D 48.10 Writtenpoliciesandproceduresarereviewed periodicallyasrequiredbythemedicalstaffandupdatedatleasteverytwoyears.

 

 

 

 

 

 

L&D 48.11 Writtenpoliciesandproceduresare communicated and implemented effectively

 

 

 

 

 

L&D 49

Writtenguidelines/algorithmsforthe care of highriskpatientsinthelabourroom†† include:

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 49.1 Pregnancyinducedhypertension

 

 

 

 

 

 

L&D 49.2 Diabetes mellitus

 

 

 

 

 

 

L&D 49.3 Cardiac disease

 

 

 

 

 

 

L&D 49.4 premature labour

 

 

 

 

 

 

L&D 49.5 abnormalpresentation

 

 

 

 

 

 

L&D 49.6 multiplebirths

 

 

 

 

 

 

L&D 49.7 fetal distress

 

 

 

 

 

 

L&D 49.8 chorioamnionitis

 

 

 

 

 

L&D 50

Appropriatedocumentationofallprocesses inthepatientíschart

 

 

 

 

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

 

Measurable Elements:

 

 

 

 

 

 

L&D.5.1 Appropriatedocumentationofallinterventions

 

 

 

 

 

L&D 51

Each unit is directed and staffed according to the specific patient care needs and the scope of services provided.

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 51.1 Units are managed by RNs and/or RN midwives who have experience in the particular area of practice

 

 

 

 

 

 

L&D 51.2 The obstetrical service has an ob/gyn physician director with recognized specialization in the care of obstetric patients.

 

 

 

 

 

 

L&D 51.3 RNís and/or RN midwives and ob/gyn physician director collaboratively provide direction for care delivered in the obstetric areas.Evidence of this collaboration is documented.

 

 

 

 

 

L&D 52

A multidisciplinary committee, including the nurse manager and obstetrical director for the unit, oversee and guide the ongoing administrative and clinical functions of the area.

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 52.1 The committee meets at least four times a year.

 

 

 

 

 

 

L&D 52.2 The committee assists in developing, reviewing, and revising policies and procedures for the provision of healthcare to obstetric patients and newborn infants.

 

 

 

 

 

 

L&D 52.3 The committee ensures enforcement of these policies.

 

 

 

 

 

 

L&D 52.4 The committee chairperson or obstetrical/gyn director of this committee signs off, in addition to nursing, on any policies and/or procedures that have any direct or indirect involvement on the physician role.

 

 

 

 

 

 

 

 

 

 

CODE

STANDARDS

1

2

3

N/A

Explanation

L&D 53

Physician standing orders are available for:

 

 

 

 

 

 

Measurable Elements:

 

 

 

 

 

 

L&D 53.1 Tocolytic administration (e.g. ritodrine, terbutaline and magnesium sulphate).

 

 

 

 

 

 

L&D 53.2 Pictocin stress test.

 

 

 

 

 

 

L&D 53.3 Routine orders for pitocin administration.

 

 

 

 

 

 

L&D 53.4 Routine labor patient orders.

 

 

 

 

 

 

L&D 53.5 Magnesium sulphate for pre-eclamptic toxemia (PET).

 

 

 

 

 

 

L&D 53.6 Routine delivery and recovery room orders.

 

 

 

 

 

 

L&D 53.7 Admission orders for all newborns.

 

 

 

 

 

 

L&D 53.8 Routine post partum orders.