N.J. Admin. Code § 8:43G-19.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43G-19.2 - Obstetrics policies and procedures

(a) The hospital shall develop and implement written policies and procedures, review them every three years and make revisions at any time as necessary, make current copies available to obstetrics staff in all areas of the obstetrics service, and address:

1. Criteria for the identification of high-risk obstetric and newborn patients;

2. Guidelines for when to call a physician during labor;

3. Qualifications for nurses who provide maternal and infant care appropriate to the level of care provided;

4. The use of fetal monitors;

5. A protocol for the use of oxytoxics for induction and stimulation of labor, including physician assessment of the patient before the drug's use, monitoring of the patient and fetus during its use, indications for discontinuance of the drug, educating staff in the use of oxytocin and a policy which addresses the availability of a physician to manage any complications that may arise during infusion;

6. A system for identifying hospital personnel while they are working in the unit;

7. The attire required to be worn in the labor and delivery areas;

8. A visitors policy that includes permitted visitors to the obstetrics unit, visitation hours, security procedures, and infection control measures;

9. Core competencies for the initiation and maintenance of infant feeding that are developed using evidence-based reference materials including, but not limited to, Implementing the Joint Commission Perinatal Care Core Measure on Exclusive Breastmilk Feeding.

i. The hospital shall ensure that all staff demonstrate proficiency in core competencies prior to providing related patient care;

10. Distribution of printed materials about infant feeding to the prenatal patient, at the pre-admission contact and on admission. These materials shall be developed:

i. Using evidenced-based source materials free of commercial interests that address maternal choice for infant feeding including, but not limited to, maternal and child health outcomes related to breastfeeding and formula feeding; successful breastfeeding management, and potential contraindications to breastfeeding, including maternal medications and infections; and

ii. In all languages spoken exclusively by at least 10 percent of the hospital community;

11. A program that ensures the cultural competence of obstetrics staff regarding childbirth, lactation, and the provision of patient care services that is delivered in a language the mother understands.

i. When necessary, obstetrics staff shall make use of a language line or interpreter and maintain the quality, privacy, and confidentiality of any interpreted conversations;

12. Professional resources regarding lactation, including those addressing medications that may impact breastfeeding, which are current and accessible to all staff in the obstetrics service;

13. Formula supplementation for a breastfed newborn when medically indicated or when requested by the mother;

14. Rooming-in, taking into account the mother's preference, available space, and any medical or other contraindication;

15. The use of pacifiers during the neonatal period, including the benefits of delaying pacifier use in healthy, full-term breastfed infants until breastfeeding is well established;

16. The option to exclusively breastfeed and breastfeeding assistance consistent with the lactation education requirements set forth at 8:43G-19.3(d), including, but not limited to, instruction in the hand expression of breast milk and in recognizing infant feeding cues.

i. The labeling and storage of breast milk, in accordance with 8:43G-19.31(n), to include the infant's name and date and time of storage;

17. The option to formula feed and formula-feeding assistance for mothers who use formula or a combination of breast milk and formula.

i. The labeling and storage of infant formula to include the infant's name and date and time of storage; and

18. A hospital discharge policy that addresses:

i. The distribution of gifts and promotional materials and the impact of such distribution on exclusive breastfeeding and formula feeding;

ii. A plan for patients who will be discharged less than 48 hours after delivery, including the need for home health services; and

iii. Maternal education about infant feeding consistent with exclusive breast feeding, formula feeding, or a combination, as applicable, and the availability of the appropriate community-based resources.

(b) A current list of physicians and nurse-midwives, their specific obstetric service privileges, and an on-call schedule shall be available in the department to professional staff.

(c) On obstetric units where Cesarean sections are performed, all requirements of surgical standards shall apply.

(d) The hospital shall require submission of a copy of the prenatal record for all patients registered to deliver at the hospital once the patient reaches 34 weeks gestation. These prenatal records shall be accessible to the obstetrical unit at all times.

(e) Restrictions shall be established and posted governing entry into the delivery/cesarean suite.

(f) Entry into the surgical area shall be restricted to staff and support persons. Scrub attire shall be required.

(g) All pregnant women admitted to the hospital with unknown or undocumented hepatitis-B surface antigen (HBsAg) assay results shall be immediately screened for the hepatitis-B virus using the HBsAg test or other standardized hepatitis-B tests. Test results should be available within 24 hours but no later than 48 hours. All positive HBsAg test results shall be reported in compliance with N.J.A.C. 8:57.

N.J. Admin. Code § 8:43G-19.2

Amended by 50 N.J.R. 552(b), effective 1/16/2018