New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 19 - OBSTETRICS › Section 8:43G-19.2 - Obstetrics policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(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.