Labor and Delivery Policy and Procedure Manual
Labor and Delivery Policy and Procedure Manual
About this Manual
Labor and Delivery Policy and Procedure Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.Want access to all our manuals? Click here
SECTION 01 - EMERGENCY MANAGEMENT
SECTION 02 - ENVIRONMENT OF CARE
2001 - Safety2002 - Visitation on Labor and Delivery Unit2003 - Body Mechanics Training2004 - Identification of Infants2005 - Infant Security Plan2006 - Infant/Child Abduction Response Plan2007 - Hazardous Materials and Waste - Nursing Services2008 - How to Read Safety Data Sheets (SDS)2009 - Fire Safety - Labor and Delivery2010 - Electrical Safety2011 - Use of Electrical Equipment in Oxygen Enriched Environment
SECTION 03 - HUMAN RESOURCES
3001 - Position Description/Performance Evaluation - Maternal Child Health Nurse Manager3002 - Performance Evaluation - Population-Specific/Age-Related Competency - Maternal Child Health Nurse Manager3003 - Annual Competency Clinical Skills Assessment - Maternal Child Health Nurse Manager3004 - Position Description/Performance Evaluation - Labor and Delivery RN3005 - Performance Evaluation - Population-Specific/Age-Related Competency - Labor and Delivery RN3006 - Annual Competency Clinical Skills Assessment - Labor and Delivery RN3007 - Position Description/Performance Evaluation - Labor and Delivery LPN/LVN3008 - Performance Evaluation - Population-Specific/Age-Related Competency - Labor and Delivery LPN/LVN3009 - Annual Competency Clinical Skills Assessment - Labor and Delivery LPN/LVN3010 - Position Description/Performance Evaluation - Maternal Child Health Unit Secretary3011 - Performance Evaluation - Population-Specific/Age-Related Competency - Maternal Child Health Unit Secretary3012 - Annual Competency Skills Assessment - Maternal Child Health Unit Secretary3013 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol3014 - Staff Qualifications and Competency3015 - New Employee Orientation3016 - Orientation/Skills Checklist - Labor and Delivery RN/LPN/LVN3017 - Orientation/Skills Checklist - Maternal Child Health Unit Secretary3018 - Competencies for Drug Administration3019 - Insertion of Intrauterine Pressure Catheter Performance Evaluation Form - Sample3020 - Peer Review Feedback Form3021 - Employee Preparation for Performance Review Form
SECTION 04 - INFECTION PREVENTION AND CONTROL
4001 - Infection Prevention and Control - General Procedures4002 - Infection Prevention and Control - Labor and Delivery4003 - Infection Prevention and Control - Nursery4004 - Standard Precautions4005 - Transmission-Based Precautions (Isolation Precautions)4006 - Hand Hygiene - CDC Guidelines4007 - Surgical Hand Scrub4008 - Closed Gowning and Gloving Technique4009 - HBsAg and Prophylaxis to the Neonate4010 - Hospital Report Form - Perinatal Hepatitis B4011 - Hepatitis B Vaccine - What You Need to Know4012 - Instruments - Cleaning and Processing4013 - Sharps Injury Protection Plan4014 - Sharps Injury Log Form4015 - Handling of Biohazardous Waste
SECTION 05 - INFORMATION MANAGEMENT/RECORD OF CARE, TREATMENT AND SERVICES
5001 - Prenatal Record - Antepartum5002 - Documentation of Intrapartum Procedures and Care5003 - Fetal Monitor Strip - Documentation5004 - Labor and Delivery Log5005 - Reporting of Critical Results of Tests and Diagnostic Procedures5006 - Panic Values5007 - Legibility of Medical Record Documentation5008 - Documentation and the Use of Abbreviations, Acronyms and Symbols5009 - Unacceptable Abbreviation and Symbol List
SECTION 06 - LEADERSHIP
6001 - Organizational Description6002 - Accountability and Responsibility6003 - Standards of Care - Admission6004 - Standards of Care - Comfort6005 - Standards of Care - Education6006 - Standard of Care - PACU Services6007 - Staffing6008 - Nurse Recognition Program - Introduction6009 - Staff Rights and Ethical Dilemmas in Patient Care6010 - Resolution of Conflicts with Staff Member's Cultural/Ethical/Religious Belief System6011 - Request for Revised/Excused Duty Form6012 - Sentinel Event
SECTION 07 - MEDICATION MANAGEMENT
7001 - High Alert Medication Management7002 - Insert List of High-Risk/High Alert Medications for Your Facility7003 - Patient Medication Information/Reconciliation7004 - Patient Medication Information/Reconciliation Form7005 - Controlled Drug Management on Patient Care Units7006 - Narcotics7007 - Emergency Crash Carts7008 - Emergency Crash Cart Security and Accountability7009 - Emergency Medications7010 - Sample Crash Cart and Defibrillator Checklist Signature Form7011 - Resuscitation of Neonate - Supply and Equipment Checklist7012 - Prescribing/Ordering - General Practices7013 - Verbal and Written Orders - General7014 - Telephone, Verbal and Written Orders for Medications7015 - Medication Ordered STAT and at Specified Time Intervals7016 - Standing Orders7017 - Titrating Medications7018 - Range Orders for Medications7019 - Medication Administration7020 - Safe Medication Practices7021 - Medication and Solution Administration - Invasive Procedures7022 - Apresoline (Hydralazine Hydrochloride) Administration7023 - Betamethasone (Celestone) Administration7024 - Cervidil Administration for Pre-Induction Cervical Ripening and Labor Induction7025 - Eye Treatment of Newborn7026 - Magnesium Sulfate Administration7027 - Oxytocin Induction/Augmentation - Care of the Patient7028 - Rubella Vaccination7029 - Rubella Virus Vaccine Post Delivery - Consent to Administer Form - Sample7030 - Measles, Mumps and Rubella (MMR) Vaccines - What You Need to Know7031 - Terbutaline Tocolysis7032 - Decreasing Medication Errors7033 - Medication Errors7034 - Medication Inadvertent Incident Report Form7035 - Medication Error Analysis Tool
SECTION 08 - PERFORMANCE IMPROVEMENT
8001 - Performance Improvement Plan8002 - Labor and Delivery Nursing - PI Monitoring and Evaluation Plan8003 - Labor and Delivery Nursing - PI Trending Sheet8004 - Labor and Delivery Nursing - PI Outcome Evaluation8005 - Maternal Child Health Nursing - PI Volume Measures/Statistics8006 - Cesarean Section Response Log - Sample8007 - Occurrence Report Form (Incident Report)
SECTION 09 - PROVISION OF CARE, TREATMENT AND SERVICES
Admission and Assessment
9001 - Admission to Labor and Delivery9002 - Obstetrical Triage9003 - Labor, Delivery, Recovery, Postpartum (LDRP) Criteria9004 - Admission History and Physical9005 - Admission Clinical Laboratory Tests9006 - Group B Streptococcus9007 - Assessment by a Registered Nurse to Determine Labor Status9008 - Assessment - Preterm Labor9009 - Assessment - Early/False Labor9010 - Assessment - Progress of Labor9011 - Assessment - Uterine Contractions9012 - Contraction Stress Test (CST) and Oxytocin Challenge Test (OCT) - Antepartum Testing9013 - Fetal Heart Rate (FHR) Assessment During Labor9014 - Continuous Electronic Fetal Heart Rate Monitoring (EFM)9015 - Fetal Monitor - External9016 - Fetal Monitor - Internal9017 - Pain Assessment, Reassessment and Management9018 - Pain Scale, Admission Pain History9019 - Pain Scale Examples9020 - Care of the Latex Sensitive Patient9021 - Latex and Non-Latex Alternatives
Patient Care
9101 - Patient Identification for Clinical Care and Treatment9102 - "Hand-Off" Communication - Labor and Delivery9103 - Amnioinfusion9104 - Amniotomy9105 - Amniocentesis - Care of the Patient9106 - Antepartum Hemorrhage9107 - Apgar Scores9108 - Birth Out of Asepsis (BOA Delivery)9109 - Blood Alcohol9109A - Breastfeeding - Baby-Friendly Hospital Initiative9110 - Breast/Nipple Stimulation - Antepartum Testing9111 - Carboprost (Hemabate) - Management of Patient9112 - Care and Observation of the Patient in Labor9113 - Care of the Dying Patient9114 - Care Planning9115 - Catheterizing the Bladder During Labor9116 - Indwelling Urinary Catheter Insertion and Maintenance - Female Patient9117 - Cesarean Section - Preparation of the Patient9118 - Cesarean Deliveries in Labor and Delivery9119 - Cord Blood Banking for Donation or Private Banking9120 - Epidural Anesthesia - Care of the Patient9121 - Estimation of Blood Loss9122 - Fetal Fibronectin Testing9123 - Fetal Heart Rate (FHR) Abnormalities9124 - Fetal/Neonatal Demise9125 - Forceps Application for Assisted Vaginal Delivery - Care of the Patient9126 - Gestational Age Evaluation9127 - Induction of Labor9128 - Infusion Pumps - Equipment Inspection, Care and Maintenance9129 - Insulin Infusion During Labor and Delivery9130 - Invasive Procedure Site Identification (Outside of the OR)9131 - Invasive/Surgical Procedure Verification/Time Out Checklist9132 - Lithotomy Position9133 - Management of Patient with Malignant Hyperthermia (MH)9134 - Malignant Hyperthermia (MH) Cart9135 - Multiple Gestation Labor and Delivery9136 - Nonstress Test (NST) - Antepartum Testing9137 - Oxygen, Free-Flow, in Emergency Situations9138 - Placement of a Fetal Scalp Electrode by a Registered Nurse9139 - Placenta Examination9140 - Positions During Labor9141 - Postpartum Hemorrhage9142 - Precipitous Birth9143 - Pre-eclampsia (Pregnancy-Induced Hypertension)9144 - Rapid Response Team9145 - Neonatal Resuscitation Team9146 - Resolving Conflicting Interpretations of Fetal and/or Maternal Data9147 - Rh Sensitization9148 - Ruptured Membranes - Care of the Patient9149 - Sedation9150 - Sedation Monitoring Form9151 - Sterile Speculum Examination by a Registered Nurse9152 - Umbilical Cord Blood Gas9153 - Umbilical Cord Prolapse9154 - Use of Clinical Alarms on Medical Equipment9155 - Vacuum Extraction for Assisted Vaginal Delivery - Care of the Patient9156 - Vaginal Birth After Cesarean (VBAC)9157 - Vaginal Delivery9158 - Version - External Cephalic9159 - Vital Signs9160 - Waived Testing9161 - Urine Dipstick Testing9162 - Scheduling Elective Labor Inductions and Cesarean Sections9163 - Cesarean Section Scheduling Classification
Patient and Family Education
Discharge or Transfer
9301 - Discharge Planning9302 - Maternal Transfer for Level II Care9303 - Transfer Summary and Certification9304 - Transfer Summary and Certification Form - Sample9305 - Transfer Request/Refusal/Consent to Transfer Form - Sample9306 - Nursing Transfer Summary Form9307 - Maternal Consultation - Receiving Transfer Record Form9308 - Transport Log Form9309 - Referral to Outside Agency - Infant
SECTION 10 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
10001 - Patient Rights and Responsibilities10002 - Informed Consent10003 - Photography and Videotaping on the Labor and Delivery Unit10004 - Advance Directives10005 - Confidentiality of Information - General Issues10006 - Patient Complaint and Grievance Process10007 - Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation10008 - Toxicology Screening for Suspected Maternal Substance Abuse10009 - Drug and Alcohol Exposure - Reporting Protocol10010 - Substance Use (Maternal) and Neonatal Drug Withdrawal10011 - Father and/or Support Person in Labor and Delivery Room10012 - Cesarean Section - Criteria for Admission of Support Person to OR