Skip to content. | Skip to navigation

Personal tools

Home > Medical Center > Department Resources > Women's Services, Protocols & Guidelines

Table of Contents

UVAHS Women's Services:
Policies, Protocols, Guidelines, & CVRs

Inpatient Women's Services

Ambulatory Women's Services

     Children's Hospital and Women's Service Line Model Cell

        

 

Quick Links to Other Clinical References:

-------------------------

  

 

 

Inpatient Women’s Services

---------------------------------------------------------------------------------------

Competency Verification Record (CVR)

Obstetrics Department Specific Competency: (9/2018)

  1.01  Physical, Psychological, Social, and Cultural Dimensions of Care (Adult & Newborn)

  2.01  Nursing Care

  2.02  Technical Skills

  3.01  Patient Emergencies & Patient Safety/Security

  3.02  OB Emergency

  4.01  Utilization of Equipment: Unit & Patient Care Resources

  5.01  Newborn Care

  6.01  Post-Partum Care

  7.01  Antepartum Care

  8.01  Intrapartum Care

  9.01  Intraoperative Care

10.01  Progressive Care

11.01  Patient & Family Education

 

 Safety/Security

- Newborn Safety and Security: Labor and Delivery and Mother-Baby Units (TWP 2.03) (1/2015)
- Newborn-Mother-Care Partner Identification: from Admission through Discharge (posted in Lippincott)
(2/2015)
-
Mother-Baby Patient Identification Time Out (6/2013)
- Newborn Admission Photo Policy (TWP 3.06) (1/2015)
- Newborn Foot Printing Policy  (TWP 2.06) (1/2015)
- Guideline: Cord Blood Specimen for Security Purposes (TWP 2.07) (1/2015)
- Child ID Program in The Women's Place (posted in Lippincott) (10/2012)
- Med Ctr Policy 0030, The Use of Cameras and other Electronic Devices and Media (L&D local
policy 1.02 "Photography During Labor and Delivery”) (6/24/2016)
Standard Work: Zebra Band Printing (4/2018) 

 

Infection Control

- Infection Control Guideline of the Women’s Place (Inpatient) (TWP 2.02) (2/2015)
- Management of Infant Care in Regards to Maternal HIV Status (TWP local 3.10) (9/2018)
-
Zika Guidelines (3/2016)

 

Medication Guidelines

- Med Ctr Policy 0299 Controlled Drugs including drug wastage(1/1/2017)
- Insulin Infusion Protocol - Labor & Delivery (6/2016)
- Methotrexate Guideline Used to Treat Ectopic Pregnancy (TWP 1.13) (1/2015)
- Antenatal Corticosteroid Administration (TWP 1.26) (8/2017)
- Management of the Obstetrical Patient Receiving Magnesium Sulfate Therapy (TWP 1.07) (02/2018)
- Guidelines for Labor Epidural (TWP 1.12) (1/2015); related nursing procedures:
    Epidural anesthesia, care during labor (posted in Lippincott) (1/2015)
    Epidural analgesic administration and patient care (posted in Lippincott) (1/2015) 
    Epidural Placement Checklist (4/2017)
- Protocol: Newborn Admission Medications (3/2015)
- Nitrous Oxide for Intrapartum and Immediate Postpartum Period (11/2017)
-
Standard Work : Management of Acute Severe Hypertension in Pregnant and Post-Partum Patients (1/2018)

 

Laboratory Guidelines

- Handling Lab Specimens Standard Work (v1.0, 1/30/17) 
- Placing Pathology Orders in Epic  Standard Work (v1.0, 1/30/17)  
- Sending Specimens to Pathology  Standard Work (v1.0, 1/28/17)

 

OB: Triage and Antepartum Care

- Standard Work: Amniocentesis  (12/11/2017)
- Pregnancy Testing Guidelines (#2.185 in the Clinical Practice Guidelines Manual) (12/2015)
Procedure for the Initial Assessment and Triage of Obstetric Patient  (2/2018)
- Screening and Stabilization of the Obstetrical Patient Guideline (also Emergency Dept Manual S8) (12/2017)
- Diabetes in Pregnancy (09/2017)
- EFM Certification Requirements for Women's Place Staff and Providers (10/2017)
- Antepartum Fetal Testing (12/2014)
- Antenatal Testing Guidelines (12/2016)
- External Cephalic Version Guideline (TWP 1.18) (10/2017)
-
Algorithm: Assignment of the Attending of Record at Delivery (11/28/15)
- UVA Cholestasis of Pregnancy Clinical Practice Guidelines (10/2016)
- VTE Prophylaxis Guideline, Pregnancy & Postpartum (2/2017)
- Care of Pregnant Women in the Ambulatory Clinics and Inpatient Obstetrics Units of the University of Virginia Health System (6/2017)
-
Screening for Maternal Substance Abuse (11/2017)
Standard Work: Point of Care Microscopy (3/2018) 
- Standard Work: Caesarian Scheduling and Pre-op Preparation: ERAS-OB (6/2018)
- ERAS OB Post Call Script (6/2018)

 

OB: Intrapartum Care

- Amnioinfusion  (2/2018)
Care of Pregnant Women in the Ambulatory Clinics and Inpatient Obstetrics Units of the University of Virginia Health System (6/2017)
- Perineal Wash (8/2012)
- Non-Medically Indicated Elective Delivery (TWP 1.25a) (08/2017)
Elective Induction of Labor (TWP 1.25b) (08/2017)
- Labor & Delivery, Nursing Care (12/2014)
- Standard Work: Birthing Stool Use During Labor   (2/2014)
- Guideline: Hydrotherapy Tub for Labor (5/2015)
- Operative Vaginal Delivery - Forceps and Vacuum (TWP 1.22) (2/2018)
- Guidelines for Fetal Heart Rate Monitoring (1/2015)
-
Policy & Procedure: Intrapartum Fetal Surveillance with Intermittent Auscultation and Uterine Assessment with Palpation (1/2016)
- Telemetry Guideline in TWP (TWP 1.28) (2/2015) and
    Cardiac Monitoring, Including Telemetry Monitoring (posted in Lippincott) (10/2014)
- Procedure: Invasive  Vascular Catheter (TWP 1.27) (11/2015) and
    IV Therapy: Central Venous Catheters (Adult) (posted in Lippincott) (8/2016)
- 62: Arterial Catheter Insertion (Assist), Care & Removal (posted in Critical Care Procedures)
- 61: Arterial Catheter Insertion (Perform) (posted in Critical Care Procedures)
- 64: Blood Sampling from Arterial Catheter (posted in Critical Care Procedures)
- 63: Arterial Pressure-Based Cardiac Output Monitoring (posted in Critical Care Procedures)
- Obstetrical Hemorrhage, Prevention and Management  (4/2018)
- Placenta Handling Guideline (10/2017) and Drawing Neonatal Blood from Placenta After Delivery
-
VTE Prophylaxis Guideline, Pregnancy & Postpartum (2/2017)
-
Vaginal Delivery Checklist (4/2017)
- Epidural Placement Checklist (4/2017)
- Standard Work for Cleaning/Disinfecting Labor Tub with Jets (5/2017)
- Cervical Ripening and Induction of Labor (7/2018)
- Screening for Maternal Substance Abuse (11/2017)
- Standard Work: Vaginal Prep Before Caesarian Section (1/2018)
-
Standard Work: Active Management of the Third Stage of Labor (AMTSL) (4/2018)

 

OB: Surgical Care

- Surgical/Procedural Attire (Dress Code) [from Infection Prevention and Control Manual] (9/2017)
- Pre-Op Anesthesia Guidelines for Obstetrical Surgery (TWP 1.14) (2/2015)
- Emergency Cesarean Birth: Team Roles (2/2018)
- Guideline: Patient Support Person in the Operating Room During Birth (TWP 1.04) (12/2017)
- See also Main OR Policies & Main OR Procedure Manual
-
Nitrous Oxide for Intrapartum and Immediate Postpartum Period Policy (11/2017)

 

OB: Post Partum Care

- PostPartum Nursing Care Guidelines (TWP 1.23) (1/2015)
- Protocol: PostPartum Care Routines (TWP 1.24) (2/2017)
- Obstetrical Hemorrhage, Prevention and Management  (2/2018)
- Maternal Hospitalization Policy - Baby Staying with Mother (TWP 4.03) (2/2018)
-
VTE Prophylaxis Guideline, Pregnancy & Postpartum (2/2017)
- Standard Work: Patient Discharge (11/2017)
- Standard Work: Prevention of Post-Anesthesia Falls (1/2018)
- Standard Work: Transvaginal Use of Bakri Balloon for Uterine Tamponade (8/2016)
- Standard Work: Women's and Newborn Patient Progression Board (1/2018)
-
Standard Work: Active Management of the Third Stage of Labor (AMTSL) (1/2018)

 Neonatal Care (L&D and Newborn Nursery)

- Algorithm: Assignment of the Attending of Record at Delivery (11/28/15)
- Admission Process for Periviable Birth, Standard Work (11/16/15)
- Guidelines for Admission and Care of a Newborn (10/2016) and Flow Diagram (7/2015)
- Protocol: Newborn Admission Medications (3/2015)
- Newborn Delivery and Clinical Status Change Response Plan (10/2015)
- Reference: How to Get Help for Newborns (6/2015)
- Protocol: Neonatal Emergency Response System (1.111) (1/2018)
-
Newborn Temperature Check Algorithm (5/2017)
- Maternal Hospitalization Policy - Baby Staying with Mother (TWP 4.03) (2/2018) and
  
Rooming-In for Newborn Nursery Neonates (posted in Lippincott) (10/2017)
- Drug withdrawal care, neonates/pediatric patients weaning from narcotics (opioids/benzodiazepines) 
          (posted in Lippincott) (2/2015)
- Promoting Psychosocial Adaptation in Neonates (posted in Lippincott) (8/2015)
- Guidelines for Prevention, Detection and Treatment of Newborn Hypoglycemia (4/2017) and Flow Diagram (08/2017)
- Management of Jaundice in the Newborn Nursery (10/2017)
Newborn Nursery CCHD Screening Protocol (10/2017)
- Neonatal Male Circumcision Guideline (TWP 3.04) (2/2018)
- Guidelines for Carseat Trials (posted in Lippincott) (1/2015)
-
Policy: Hepatitis B Vaccine for Newborn Infants (9/5/2015) | Related Nursing Procedure (posted in Lippincott) (5/2012)
-
Immunization administration, neonatal (posted in Lippincott) (1/2018)
-
Neonatal Screening (posted in Lippincott) (6/2015) and Standard Work for Drying and Transit of Newborn Screening(6/2015)
- Blood Specimen Collection By Heel Stick (8/2016) (related procedures; both posted in Lippincott)
- Policy: Infant Positioning and Safe Sleep Practices for Infants Less Than One Year of Age (10/2015, posted in Children's Manual)
-
Protocol: Management and Evaluation of Infants with Possible Congenital Zika Virus Infection (09/2016)
- Maternal Substance and Medication Use and Abuse and the Care of Exposed Newborns (8/2017)
   *
Maternal Substance and Medication Use and Abuse and the Provision of Breastmilk to Exposed Newborns | Flowchart (9/2017)
-
Standard Work: Umbilical Cord Drug Screening Panel (UCDSP) (10/2017)
- Management of Newborn Care at Delivery (1/2018)
- Standard Work: Women's and Newborn Patient Progression Board (1/2018)

 

Breastfeeding Support

- Feeding Young Children: Newborns, Infants and Toddlers (MC POLICY 0317) | 4/2017)
-
Infant Feeding Policy (8/2017)
- Maternity Care Infant Nutrition Algorithm (5/4/2017)
- Maternal Substance and Medication Use and Abuse, and the Provision of Breastmilk to Exposed Newborns | Flowchart (9/2017)
-
Breastmilk Storage, Handling, and Administration Guideline  (3/2018)
-
Standard Work: Freezing Breastmilk (5/2018)
- Standard Work: Procurement of a Breast Pump through ABC Healthcare (4/2018)
- Standard Work: Obtaining a DME Breast Pump with a Voucher Payment (4/2018)

- (08/28/2017)

 

Family Centered Care
- Standard Work for Obtaining and Maintaining a Comfort Cart for Visitors of Patients at the End of Life (12/2017)

 

Perinatal Bereavement Resources

- Med Ctr Policy 0014: Death Certificates, Fetal Death Reports and Consultation/Disposition (3/2015)

 

TWP Family/Visitor Guidelines

- Guideline: Patient Support Person in the Operating Room During Birth (TWP 1.04) (12/2014)
- Med Ctr Policy 0030, The Use of Cameras and other Electronic Devices and Media (L&D local policy 1.02 "Photography During Labor and Delivery”) (9/2014)

 

Social Services

- Post-Partum Discharge Planning for Substance Abusers (12/2014)
- Paternity Establishment Project (PEP) (12/2014)
- Policy and Procedure: Coordination of Care for Incarcerated Pregnant Women and their Infants (12/2014)
and Checklist: Inmate in Labor and Delivery (12/2014)

 

GYN and GYN-Onc Care

- Active Fill Voiding Trials (Lippincott, per Drs. Hullfish & Trowbridge OPSC 2017)

 

Patient Education

Newborn Patient Education
-
Formula Preparation
   -
Spanish--Safe Preparation and Feeding of Formula
   - English Safe Preparation and Feeding of Formula

 

Departmental Operational Guidelines

- TWP Scheduling Guidelines and Staffing Requirements (3/2012)
-
Attendance Policy Addendum, Children's Hospital and Women's Services (3/2016)
-
Certified Nurse Midwives (CNM) Practice Agreement (5/2018)
- Escalation of Care for 1st PDA Cycle (5/2017)
- Standard Work: TWP Lead RNs (10/2017)

 

Research Studies
-
R-E-S-P-E-C-T ... Tell Me What It means (9/2017)

 

 

Ambulatory Women’s Services
---------------------------------------------------------------------------------------

Ambulatory Ordering Protocol for Obstetrics Patients (OB) (2018)

Amniocentesis, Diagnostic, Standard Work (OB)

Amniotic Fluid Index (OB)

Antenatal Corticosteroid Administration

Biophysical Profile (OB)

Birth Occurring in Clinic, Management of, Standard Work (OB) (2018)

Caesarian Scheduling and Pre-op Preparation: ERAS-OB, Standard Work (OB)(6/12/2018)

Care of Pregnant Women in the Ambulatory Clinics and Inpatient Obstetrics Units of the University of Virginia Health System (OB)

Certified Nurse Midwives (CNM) Practice Agreement (5/2018)

Cervical/Vaginal Biopsy (GYN)

Chaperone Policy (OB and GYN)

Cholestasis of Pregnancy Clinical Practice Guidelines (OB)

Chorionic Villus Sampling, Standard Work (OB)

Colposcopy (GYN)

Condyloma Treatment (OB and GYN)

Depo Lupron, Administration (GYN)

Depo Provera, Administration (GYN)

Diabetes in Pregnancy 

Diaphragm Fitting (GYN)

EFM Certification Requirements for Women's Place Staff and Providers

Endocervical Curretage (GYN)

Endocervical Polypectomy (GYN)

Endometrial Biopsy (GYN)

ERAS OB Post Call Script (OB)

Fetal Blood Sampling, Standard Work (OB)

Hepatitis A Vaccine, Administration (GYN) (1/2018)

Human Papillomavirus Vaccine (HPV), Administration (GYN) (2/2018)

Hysteroscopy (GYN)

I&D of Vulvar Abscess or Bartholin’s Gland Cyst (OB and GYN)

Influenza Vaccination, Administration | CPG (OB and GYN)

IUD, Insertion (GYN)

LEEP (GYN)

Management of Early Pregnancy Loss, (GYN)

Methotrexate Use for Ectopic Pregnancy (OB and GYN)

Microscopy, Point of Care, Standard Work (OB and GYN) (2016)

Nexplanon Insertion, Standard Work (GYN)

Nexplanon Removal (GYN)

Non-Stress Test (OB)

Nurse Call Line (OB and GYN)

PAP Test Collection Procedure (OB and GYN)

Perinatal Genetic Counselors, Laboratory Test Ordering Protocol (OB) (3/2018)

Pessary Fitting (GYN)

Pneumoccocal Vaccine | CPG (OB and GYN)

Patient Notification of Women’s and Children’s Hospital (WCH) Ambulatory Service Schedule Changes Related to an Emergency Event (2018)

Sonohysterogram (GYN)

Sterilization Surgery (GYN)

Supervision of Residents and Fellows by Attending Physician (2016)

Tdap Vaccination of Pregnant Women (OB)

Ultrasound, Endovaginal (OB and GYN)

Ultrasound, First Trimester (OB)

Ultrasound, Second Trimester (OB)

Ultrasound, Third Trimester (OB)

Urodynamics Evaluation (GYN) 

VTE Prophylaxis Guideline, Pregnancy & Postpartum (2/2017)

Vulvar Biopsy/Excision (OB and GYN)

Zika Guidelines