OB Guideline 35: Institutional Responsibilities

When obstetrical services are provided in a CRICO-insured institution, the following support services, staff training, and arrangements are the responsibility of the institution.

For Emergency Support

1. Blood products should be available at all times.
2. Personnel capable of performing an emergent surgical airway must always be immediately available.
3. Obstetrical (birthing person) resuscitation guidelines should be readily available by each institution and include:
   • a designated response team for birthing person emergencies in Labor and Delivery that includes members familiar with the physiologic changes of pregnancy and the procedures for notification of the response team; and
   • a designated response team for obstetrical patients who experience emergencies anywhere in the hospital other than Labor and Delivery.
4. Consultants from other services should be readily available as needed.

For Infant Identification and Protection

1. Each institution should affirm the identity of the newborn prior to any procedure, testing, and prior to being released to the birthing person and/or their designee(s) while in the hospital.
2. Each institution should establish clear protocols to prevent infant abduction.

For General Support

These responsibilities are imbedded in specific guidelines. They are repeated here for clarity. CRICO-insured institutions are responsible for:

1. Adequate resources for record processing and adhering to record keeping standards including compliance with federal regulations (e.g., HIPAA) and its mandate for a designated institutional compliance officer (Guideline 1).
2. Accommodations for preserving all electronic fetal monitoring tracings (Guideline 1).
3. Support for quality improvement activities (Guideline 1).
4. A formal process to resolve disagreements between professional staff about medical management, conduct of labor, or interpretation of tests of fetal status (Guideline 5).
5. A standard policy and procedure for establishing gestational age (Guideline 7).
6. Guidelines for second trimester pregnancy termination (Guideline 9).
7. Ensuring that, whenever there is an actively laboring patient on the labor floor, a physician credentialed to perform an emergency operative delivery is readily available (Guideline 13).
8. A system by which alternative clinician coverage (as needed) is clearly communicated and available to all members of the labor and delivery staff (Guideline 13).
9. Providing and maintaining appropriate fetal monitoring apparatus to meet the needs of its patients (Guideline 15).
10. Convening at least daily multidisciplinary meetings held on the Labor and Delivery unit to discuss all patients’ relevant clinical issues and have appropriate clinical and administrative plans agreed upon by the team caring for the patients (Guideline 15).
11. A standard policy and procedure for scheduling induction of labor (Guideline 16).
12. A standard policy and procedure for establishing the indication and method for induction of labor, including the preparation and use of oxytocin and use of cervical ripening agents (Guideline 16).
13. Guidelines for the use of oxytocin (Guideline 17).
14. Ensuring that enough controlled infusion devices for administration of oxytocin are maintained and available to meet the needs of the patient population (Guideline 17).
15. Guidelines for communication prior to, during, and immediately after obstetrical surgery (Guideline 27).
16. Ensuring that a physician with appropriate privileges to administer obstetrical anesthesia (or a designee) will be available in the medical facility from the initiation of an anesthetic until the patient’s post-anesthesia condition is satisfactory and stable (Guideline 28).
17. A policy for the management of patients in the PACU that describes who is responsible for the care of patients in the PACU, how they will be monitored, and the process for discharge (Guideline 28).
18. An early warning system and provide necessary resources for implementation, including staffing, education, a quality improvement process, and leadership from senior medical and nursing personnel (Guideline 30).
19. A process or program to instruct each patient regarding normal postpartum events. These instructions should include care of the breasts, perineum, bladder, the incision (if appropriate), and signs of complications (Guideline 31).
20. A process or program to instruct each patient regarding infant care, infant feeding (including the benefits of breastfeeding), and subsequent birthing person and newborn medical examinations (Guideline 31).
21. Adopting a standardized neonatal encephalopathy assessment tool—mutually agreeable to both referring and accepting neonatal units— that meets the needs of the providers and patient population served. (Guideline 32).
22. Each institution will develop guidelines for circumcision (Guideline 33).
23. Tracking short-term complications of circumcision, including the type of complication, the method of circumcision, and the performing clinician (Guideline 33).
24. Identifying and reporting serious reportable events (SREs) to the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health (Guideline 34).
25. Policies and procedures for disclosure to patients of adverse events and outcomes involving their care (Guideline 34).

For Staff Communication, Education, and Training

1. A program to evaluate and document staff competence.
2. Continuing education for all obstetrical personnel including:
   FHR monitoring, emergency measures for the treatment of shoulder dystocia and eclampsia, and forceps or vacuum application.
3. Developing a plan for obstetrical safety drills to prepare staff in the event of high acuity, low frequency emergent events such as shoulder dystocia.
4. All existing and future CRICO-insured institutions and/ or Departments of Obstetrics/Gynecology will endorse individualized institutional guidelines that define the roles and responsibilities and collaborative relationship of Certified Nurse Midwives and Obstetrician/Gynecologists.