HomeMy WebLinkAboutSrvcs Agrmt - Obstetrical Services - Health Depte
E
Deschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of June 30, 2008
Please see directions for completing this document on the next page.
DATE: June 17, 2008
FROM: Dan Peddycord Health Department 322-7426
TITLE OF AGENDA ITEM:
Consideration of Board signature of document # 2008-354 — Personal Services Contract between
Deschutes County and Bend Obstetrics and Gynecology for the obstetrical services to support the
Healthy Start Prenatal program for the fiscal year 2009.
PUBLIC HEARING ON THIS DATE? No.
BACKGROUND AND POLICY IMPLICATIONS:
This contract provides obstetrical services through the Healthy Start Prenatal program for the purpose
of a safety -net service for pregnant, low-income women. Bend Obstetrics and Gynecology (Bend
OB/Gyn) will deliver the babies, provide consultation and provide a doctor to work in the prenatal
clinic for a minimum of 10 hours per week. The contract amount represents the actual fee paid by
Oregon Health Plan (OHP) for deliveries and wages for the doctor in the clinic as well as some
reimbursement for in-hospital care for uninsured patients.
FISCAL IMPLICATIONS:
Healthy Start Prenatal program will pay the contractor for 120 deliveries and clinicial services at a
monthly rate of $12,035.00 for a total of $144,430.00 for the fiscal year 2009. Deliveries over 120 will
be reimbursed at a rate of $918.00 per delivery up to 180 deliveries for a maximum consideration of
$171,970.00. This contract represents a reduction in amount due to reduced patient enrollment in the
Healthy Start Prenatal program. The contract amount was included in fiscal year 2009 budget.
RECOMMENDATION & ACTION REQUESTED:
Approval and signature of Document # 2008-354 - Personal Services Contract between Deschutes
County and Bend Obstetrics and Gynecology for the obstetrical services to support the Healthy Start
Prenatal program for the fiscal year 2009 is requested.
ATTENDANCE: Dan Peddycord, Deschutes County Health Department
DISTRIBUTION OF DOCUMENTS:
Cindy Romine, Bend Obstetrics and Gynecology, 2381 NE Conners Ave., Bend, Oregon 97701, 541-
385-8050; and Jill Fox, Health Department, 2577 NE Courtney Drive, Bend, Oregon 97701, 322-71.78.
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Date:
Please complete all sections above the Official Review line.
June 18, 2008
Contact Person:
Dan Peddycord
Contractor/Supplier/Consultant Name:
Department:
Health Department
Phone #:
322-7426
Cindy Romine, Bend Obstetrics and
Gynecology, 2381 NE Conners Ave., Bend, Oregon 97701, 541-385-8050
Goods and/or Services:
Consideration of Board signature of document # 2008-354 — Personal Services Contract
between Deschutes County and Bend Obstetrics and Gynecology for the obstetrical
services to support the Healthy Start Prenatal program for the fiscal year 2009.
Background & History:
This contract provides obstetrical services through the Healthy Start Prenatal program
for the purpose of a safety -net service for pregnant, low-income women. Bend
Obstetrics and Gynecology (Bend OB/Gyn) will deliver the babies, provide consultation
and provide a doctor to work in the prenatal clinic for a minimum of 10 hours per week.
The contract amount represents the actual fee paid by Oregon Health Plan (OHP) for
deliveries and wages for the doctor in the clinic as well as some reimbursement for in-
hospital care for uninsured patients.
Agreement Starting Date:
2009
July 1, 2008
Annual Value or Total Payment:
Ending Date:
June 30,
Healthy Start Prenatal program will pay the
contractor for 120 deliveries and clinicial services at a monthly rate of $12,035.00 for a
total of $144,430.00 for the fiscal year 2009. Deliveries over 120 will be reimbursed at a
rate of $918.00 per delivery up to 180 deliveries for a maximum consideration of
$171,970.00. This contract represents a reduction in amount due to reduced patient
enrollment in the Healthy Start Prenatal program. The contract amount was included in
fiscal year 2009 budget.
LI Insurance Certificate Received (check box)
Insurance Expiration Date: N/Ak
Check all that apply:
RFP, Solicitation or Bid Process
❑ Informal quotes (<$150K)
❑ Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
Funding Source: (Included in current budget? ® Yes ❑ No
if No, has budget amendment been submitted? ❑ Yes D No
6/18/2008
Kate Moore,
Departmental Contact:
Title:
Manager, Maternal Child Health
Department Director Approval: f'L
Phone #:
Signate
322-7422
Date
Distribution of Document: Include complete information if document is to be mailed.
Official Review:
County Signature Required (check one): ❑ BOCC ❑ Department Director (if <$25K)
❑ Administrator (if >$25K but <$150K; if >$150K, BOCC Order No.
Legal Review Date
Document Number
6/18/2008
PERSONAL SERVICES CONTRACT
Medical/Obstetrical Services to the
HealthyStart Prenatal Program
This agreement is made and entered into by and between Deschutes County, a political
subdivision of the State of Oregon, and Bend Obstetrics and Gynecology, LLC, an Oregon
Limited Liability Company, Federal Tax Identification Number io8b yg%s , hereinafter referred
to as "Contractor,"
WITNESSETH:
IT IS HEREBY AGREED by and between the parties mentioned above, for and in consideration of the
mutual promises hereinafter stated as follows:
1. Effective Date. This agreement is effective: July 1, 2008.
2. Duration. This agreement terminates at 11:59 p.m. on June 30, 2009. This agreement
will automatically renew each year on July 1 for two successive terms of one year each
unless prior to the anniversary date either party gives at least 60 days written notice to the
other party of intent not to renew the agreement.
3. Contractor's Services. Contractor agrees to provide services described as follows and
agrees to employ a certified nurse midwife or physician to assist with these provisions:
a. Provide prenatal medical services in -clinic a minimum of 8 hours per week,
specifically, 8 hours either Tuesday or Friday, throughout the entire fiscal year (July 1 —
June 30), according to the scope of services described in Attachment A. Additional
clinic hours will be paid at the rate of $58 per hour after invoicing from contractor.
These services are to be performed at the Deschutes County Health Department, in
Bend, Oregon, by an MD or certified nurse midwife, trained and competent to render
such services to obstetrical clients in accordance with a schedule approved by the
County. Matters and calls related to the Contractor's private medical practice shall be
undertaken in a mariner, which minimizes the impact on the HealthyStart Clinic. Private
clinic patients may not be seen in the HealthyStart clinic or at the Deschutes County
Health Department. During in -clinic hours, the Contractor's certified nurse midwife or
physician shall not leave the HealthyStart Clinic for non-HealthyStart business without
the first discussing the matter, and seeking approval from the Healthy Start program
supervisor.
b. Provide physician level clinical consultation and in -office direct medical services for
HealthyStart clients who are too high risk for mid-level provider care at the high-risk
HealthyStart Clinic. The Contractor's certified nurse midwife, or physician shall act as
primary clinician for review of high risk pregnancies in consultation with the
HealthyStart Staff.
1 - PERSONAL. SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
c. Provide in-hospital clinical services, to all HealthyStart prenatal clients, according to
the scope of services described in Attachment A to this Agreement. These services
will be performed at St. Charles Medical Center in Bend, Oregon, by a certified nurse
midwife, or OB physician, trained and competent to render such services.
Provide delivery, perinatal, postpartum and other related obstetrical care services to
HealthyStart clients (approximately 120-170 deliveries per year). These services are
hereafter referred to as "non -clinic" hours. These services will be performed at St.
Charles Medical Center, Bend, Oregon, by a certified nurse midwife or OB physician,
trained and competent to perform such service in accordance with the Doctors' and
Certified Nurse Midwife's privileges and standards of care generally accepted in the
community. The assigned staff is subject to the approval of Health Department director
and Program Manager of the Healthy Start Clinic.
e. Provide in hospital emergency obstetrical care, 24/7, as medically necessary to
HealthyStart clients, as coordinated with hospital's medical emergency response plan
for Obstetrical clients. Provider must be able to respond with 30 minutes in person to
the hospital, for in-patient medical emergencies.
f. Provide 24 hour, 7 day per week physician telephone consultation to HealthyStart staff
for emergency consultation to HealthyStart clients. Provide 1 week per month
HealthyStart cell phone standby coverage to triage HealthyStart patient calls.
g. Provide OB physician services for procedures not in the scope of practice of mid-level
providers, including but not limited to: versions, amniocentesis and D&Cs.
h. Participate with Deschutes County Health Department Health Officer in annual review
of Guidelines for Prenatal Care. The guidelines will be approved by the Deschutes
County Health Officer assigned to the HealthyStart program., and guide the practice of
all clinicians in the Healthy Start Clinic.
i Assure compliance with Deschutes County Policies for patient confidentiality and
privacy and Federal regulations associated with the Health Insurance Portability and
Accountability act.
J•
A physician member of Contractor will act as primary contact for all matters related to
the execution of this contract. The Contractor shall oversee delivery of services
provided in this agreement in accordance with the Doctor's and Certified Nurse
Midwife's privileges and standards of care generally accepted in the community.
k. Receive payments under this contract as complete compensation for services provided
and described in this agreement. Clinic services provided outside this agreement are
between the client and the Contractor.
2 - PERSONAL SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
1. Contractor shall be entitled to reasonable absence from HealthyStart in -clinic hours,
described in item # 3.a above, for illness, personal leave, and continuing education, not
to exceed eight (8) clinic days off per fiscal year. The Contractor shall provide not less
than 3 weeks advance notice of request to take leave to the HealthyStart program
supervisor. The HealthyStart clinic will be closed on scheduled County Holidays.
m. Contractor's certified nurse midwife or physician shall maintain certifications and/or
licenses and comply with applicable legal requirements of the particular health care
services they provide under this agreement.
4. Confidentiality. Contractor shall maintain confidentiality of information obtained
pursuant to this Agreement as follows:
a. Contractor shall not use, release or disclose any information concerning any
employee, client, applicant or person doing business with the County for any purpose
not directly connected with the administration of County's or the Contractor's
responsibilities under this Agreement except upon written consent of the County, and
if applicable, the employee, client, applicant or person. The Contractor shall ensure
that its agents, employees, officers, and subcontractors with access to County and
Contractor records understand and comply with this confidentiality provision.
b. Contractor shall treat all information as to personal facts and circumstances obtained
on Medicaid eligible individuals as privileged communication, shall hold such
information confidential, and shall not disclose such information without the written
consent of the individual, his or her attorney, the responsible parent of a minor child,
or the child's guardian, except as required by other terms of this Agreement. Nothing
prohibits the disclosure of information in summaries, statistical information, or other
form that does not identify particular individuals.
c. Personally identifiable health information about applicants and Medicaid recipients
will be subject to the transaction, security and privacy provisions of the Health
Insurance Portability and Accountability Act (HIPAA). Contractor shall incorporate
County policies and procedures for the use and disclosure of Protected Health
Information to maintain the privacy and security of records and for processing
transactions pursuant to HIPAA requirements. This Agreement may be amended in
writing in the future to incorporate additional requirements related to compliance with
HIPAA. If Contractor receives or transmits protected health information, Contractor
shall enter into a Business Associate Agreement with County.
5. Consideration: From the period July 1, 2008 to June 30, 2009, the County shall pay
Contractor on a flat fee basis at a rate of $12,035.83 per month. Such rate includes up to
120 deliveries during the period July 1 to June 30. In the event the annual deliveries
3 - PERSONAL SERVECES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
exceed 120, County shall pay Contractor an additional $918.00 per delivery, which
payment shall be due at the end of the year (June 30). The monthly flat fee can be
adjusted in the event of a substantial increase in expected deliveries by agreement of the
county and contractor. Said rates to be the complete compensation to Contractor for
services performed. The maximum consideration authorized under this agreement for the
aforementioned time period is $171,970 if there were 180 deliveries. Consideration for
each renewal period will be negotiated prior to July 1 of each year and attached as an
addendum to this contract. If the parties fail to agree on new consideration for a renewal
term, Contractor may continue services at the previous year's fee or give written notice of
termination sixty days prior to the date services under this Agreement are to be
terminated.
6. Termination. This agreement may be terminated by County or Contractor upon 60 days
written notice to the other party, however, clients currently under the care of HealthyStart
shall be transitioned through the program through the point of delivery. The intent is that
no client shall be severed from pre -natal care once qualified and initiated into the
program. During the 60 day transition period, the Contractor shall be compensated in
accordance with the provisions of Section 5. If any party gives 60 days notice, no further
clients shall be initiated into the program without prior approval from the full
HealthyStart Steering Committee. Termination, which affects current clients, shall be
addressed in a termination transition plan proposed by the party initiating termination.
There will be no automatic transition of Healthy Start patients to Bend OB/Gyn practice.
7. Independent Contractor. Contractor is engaged hereby as an independent contractor and
will be so deemed for purposes of the following:
a. Contractor will be solely responsible for payment of any federal or state taxes
required as a result of this agreement.
b. This agreement is not intended to entitle Contractor to any benefits generally granted
to County employees. Without limitation, but by way of illustration, the benefits
which are not intended to be extended by this agreement to Contractor are vacation,
holiday and sick leave, other leaves with pay (excluding any time listed in Section
3.m.), tenure, medical and dental coverage, life and disability insurance, overtime,
Social Security, Workers' Compensation, unemployment compensation, or retirement
benefits (except insofar as benefits are otherwise required by law if Contractor is
presently a member of the Public Employees Retirement System).
c. Contractor is an independent contractor for purposes of the Oregon Workers'
Compensation law (ORS Chapter 656) and is solely liable for any Workers'
Compensation coverage under this agreement. If Contractor has the assistance of
other persons in the performance of this agreement, Contractor shall qualify and
remain qualified for the term of this agreement as a direct responsibility employer
under ORS 656.507, and furnish County with evidence of said insurance. If
Contractor performs this agreement without the assistance of any other person,
4 - PERSONAL SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
Contractor shall execute a Joint Declaration with County's Workers' Compensation
carrier absolving County of any and all liability from Workers' Compensation
provided in ORS 656.029(2).
8. Delegation and Reports. Contractor shall not delegate the responsibility for providing
services hereunder to any other individual or agency, other than an employed certified
nurse midwife or physician of Contractor, and shall provide County with periodic reports
at the frequency and with the information reasonably requested by County. .
9. Constraints. Pursuant to the requirements of ORS 279B.220 through 279B.235 and
Article XI, Section 10, of the Oregon Constitution, the following terms and conditions are
made a part of this agreement.
a. Contractor shall:
1) make payments promptly, as due, to all persons supplying to such party labor
or materials for the performance of the work provided for in this agreement;
2) pay all contributions or amounts due the Industrial Accident Fund from such
party incurred in the performance of this agreement;
3) not permit any lien or claim to be filed or prosecuted against County on
account of any labor or material furnished; and
4) pay to the Department of Revenue all sums withheld from employees pursuant
to ORS 316.167.
b. If Contractor fails, neglects or refuses to make prompt payment of any claim for labor
or services furnished to Contractor by any person in connection with this agreement
as such claim becomes due, the proper offices representing County may pay such
claim to the person furnishing the labor or services and charge the amount of the
payment against funds due or to become due the Contractor by reason of this
agreement.
c. Contractor shall pay their employees for overtime work performed under the public
contract in accordance with ORS 653.010 to 653.261 and Fair Labor Standards Act of
1938 (29 U.S.C. 201 et seq.). Except for excluded employees, no person will be
employed with Contractor for more than ten (10) hours in any one day, or forty (40)
hours in any one week, except in cases related to medical/obstetrical care and delivery
as necessity, emergency, or where the public and/or HealthyStart policy requires it.
1) Contractor must give notice to employees who perform work under this
agreement in writing, either at the time of hire or before commencement of
work on the agreement, or by posting a notice in a location frequented by
employees, of the number of hours per day and days per week that employees
may be required to work.
5 - PERSONAL. SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
d. Contractor must promptly, as due, make payment to any person or partnership,
association or corporation furnishing medical, surgical and hospital care or other
needed care and attention incident to sickness and/or injury to the employees of
Contractor, of all sums which the Contractor agrees to pay for such services, and al
monies and sums which Contractor collected or deducted from the wages of
Contractor's employees pursuant to any law, contract or agreement for the purpose of
providing or paying for such services.
e. The agreement is expressly subject to the debt limitation of Oregon counties set forth
in Article XI, Section 10, of the Oregon Constitution, and is contingent upon funds
being appropriated therefore. Any provisions herein, which would conflict with law,
are deemed inoperative to that extent.
f. All subject employers working under the Agreement are either employers that will
comply with ORS 656.017 or employers that are exempt under ORS 656.126.
10. Hold Harmless. Contractor shall indemnify, save harmless and defend the County from
and against any and all claims, lawsuits, or actions for damages, costs, losses and
expenses, arising from Contractor's torts, as the term "tort" is defined in ORS 30.260(8).
11. Contractor Not an Agent of County. It is agreed by and between the parties that
Contractor is not carrying out a function on behalf of County, and County does not have
the right of direction or control of the manner in which Contractor delivers services under
this agreement or exercise any control over the activities of Contractor.
12. Partnership. County is not, by virtue of this agreement, a partner or joint venturer with
Contractor in connection with activities carried out under this agreement, and shall have
no obligation with respect to Contractor's debts or any other liabilities of each and every
nature.
13. Insurance. In conjunction with all services performed under this agreement:
a. Contractor shall maintain Commercial General Liability insurance with minimum
limits of $1,000,000 per occurrence/ $3,000,000 aggregate. Contractor shall also
furnish County with an endorsement naming the County, its officers, agents and
employees as an additional named insured.
b. The Contractor or their employee's shall maintain automobile liability insurance o
not less than the limits set forth below.
1) $500,000, combined single limit, or
2) Split limits of $250,000 per person, $500,000 per occurrence and $100,00()
property damage.
6 - PERSONAL. SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
c. All insurance policies shall be written on an occurrence basis and be in effect for the
term of this agreement. Should insurance change to "claims made" the contractor
shall be responsible for additional coverage and will notify Deschutes County, in
advance, of any substantive changes made.
d. Prior to execution of this agreement, Contractor shall provide County with
Certificates of Insurance, or copies of insurance policies and declarations as evidence
of insurance requirements under this paragraph. Additionally Contractor shall
provide proof of Workers' Compensation from the contractor and all sub -contractors
required prior to the commencement of labor.
e. Contractor shall immediately notify County if any insurance coverage required by this
agreement will be canceled, not renewed, or substantially modified in any way.
Thirty -day cancellation notice required on all policies.
f. County reserves the right to require complete, certified copies of all required
insurance policies.
g.
Contractor shall maintain Professional Malpractice Liability Insurance with minimum
limits of $2,000,000 per occurrence / $4,000,000 aggregate. The insurance policy
shall name the Contractor's business and any of the Contractor's employees providing
professional services under this agreement. If the policy is written on a "Claims;
Made" basis, the contractor shall be responsible for any additional coverage and shall
maintain Professional Liability insurance coverage three years following expiration or
termination of the policy.
14. Non -Discrimination. Contractor agrees that no person shall, on the grounds of race,
color, creed, national origin, sex, marital status, or age, suffer discrimination in the
performance of this agreement when employed by Contractor. Contractor agrees to
comply with Title VI of the Civil Rights Act of 1964, with Section V of the
Rehabilitation Act of 1973, and with all applicable requirements of federal and state civil
rights and rehabilitation statutes, rules and regulations. Additionally, each party shall
comply with the Americans with Disabilities Act of 1990 (Pub. L. No. 101-336), OR;
659.425, and all regulations and administrative rules established pursuant to those laws.
15. Non -Appropriation. In the event sufficient funds shall not be appropriated for the
payment of consideration required to be paid under this agreement, and if County has no
funds legally available for consideration from other sources, then County may terminate
this agreement in accordance with Paragraph 5 of this agreement.
16. Attorney Fees. In the event an action, lawsuit or proceeding, including appeal therefrom
is brought for failure to observe any of the terms of this agreement, each party shall Ix
7 - PERSONAL, SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
responsible for their own attorney fees, expenses, costs and disbursements for said action,
lawsuit, proceeding or appeal.
SIGNATURES:
COUNTY:
ATTEST:
Recording Secretary
CONTRACTOR:
DATED this Day of 2008.
BOARD OF COUNTY COMMISSIONERS
OF DESCHUTES COUNTY, OREGON
DENNIS R. LUKE, Chair
TAMMY MELTON, Commissioner
MICHAEL M. DALY, Commissioner
ATTEST:
Recording Secretary
Dated this I% day of 3 -One , 2008.
CONTRACTOR NAME:.
CONTRACTOR NAME: BEN BSTETRICS &
GYNECOLOGY, LLC
Pyr E Poi4X b inn fJ u_ c mem, L,,
8 - PERSONAL SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM.
1
By: John A. Ml
Date 6,,?-Gieg
hy, M.D., LLC Me ser
By: Peter E. Palacio, M.D., LLC Member
Date:
9 - PERSONAL, SERVICES CONTRACT: CONTRACTOR NAME: HEALTHYSTART PROGRAM
Exhibit A
HEALTHYSTART PRENATAL SERVICES
GUIDELINES FOR PRENATAL CARE
TABLE OF CONTENTS
HPS Table of Contents.doc 1
Page
I. CONSULTATION GUIDELINES
When To Consult With SCMC Clinicians
1
High Risk Management
2
Colposcopy Clinic Referral
3
Socioeconomic Aspects
4
I, E
Initial Exam
1
Return Prenatal Visits
2
Vitamin/Iron/Mineral Supplementation
3
Pharmacy Guidelines
4-5
Dispensing STD Medications
6
III'MAN AGEIVNT PROTOCOL BASED ON HISTORICAL DATA
Advanced Maternal Age
1
Allergies
2
Previous Cesarean Section / Cesarean Section
3
X -Ray Exposure
4
Blood Group, Rh and Antibody Screen
5
Common Discomforts of Pregnancy
6-7
Rubella
8-9
Gonorrhea
10
Chlamydia
11
Genital Herpes
12
Syphilis
13
Diabetes Screening
14-15
Urinary Tract Infections
16-17
Iron Deficiency Anemia
18
Vaginal Infections
19
Condylomata Acuminata
20-21
Hepatitis B
22
Human Immunodeficiency Virus
23-24
Tuberculosis
25
IV. MANAGEMENT PROTOCOL,— PHYSICAL EXAM DATA
Breech Position
1
Lice
2
Scabies
3
Dental Care
4
Intrauterine Growth Retardation
5-6
Post Term Pregnancy
7
Size/Dates Discrepancy
8
Pregnancy Induced Hypertension
9
Childbirth at HealthyStart Prenatal Service
10-11
HPS Table of Contents.doc 1
VII. MANAGEMENT PROTOCOL - LAB DATA
Ultrasound
1
Non -Stress Testing and Contraction Stress Testing
2-3
Fetal Echocardiography Lab Testing
4
Alpha Fetoprotein Prenatal Testing of Maternal Serum
5
VIII. GUIDELINES FOR NURSE MIDWIFERY
Intrapartum Care
1-2
Postpartum Care
3
Conditions Which Require Intrapartum Consultation and Collaboration
4-5
Intrauterine Device (IUD)
6-9
HPS Table of Contents.doc 2
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: CONSULTATION
GUIDELINES
PAGE# 1
GUIDELINE TITLE: CONSULTATIONS
PURPOSE: Identification of diagnosis needing consultation by physician partners
INSTRUCTIONS: The following categories require a physician's consultation:
1. Persistent or recurrent urinary tract infection during pregnancy - prn
2. Rubella - infection
3. Alcohol abuse - prn
4. Pre-eclampsia
5. Hepatitis exposure
6. Pernicious vomiting with ketonuria - prn
7. Rh sensitization (asap)
8. Diabetes (asap)
9. Chronic hypertension
10. History of herpes in present pregnancy - prn
11. Condylomata acuminata requiring therapy - prn
12. Abnormal 3 hour GTT
13. Significant chronic illness
14. Hemoglobinopathies
15. Intestinal parasites
16. Jaundice
17. Multiple gestation (transfer to physician)
18. History of or question history of incompetent cervix (asap)
19. Syphilis
20. Tuberculosis
21. Intrauterine growth retardation
22. HCT under 30 - prn
23. History of fetal or neonatal loss - prn
24. History of previous premature labor - prn
25. Chronic renal disease
26. Unexplained severe pruritus
27. Any previous uterine surgery - prn
28. Use of thyroid medication - prn
29. Size -dates discrepancy - prn
30. Incompetent cervix in DES exposed patients
31. Abnormal AFP test results with normal follow-up amniocentesis results after consult
with SCMC/OHSU clinicians.
32. Postdates pregnancy (41 weeks gestation)
33. Current seizure disorder
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HPS Table of Contents.doc
3
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: CONSULTATION
GUIDELINES
PAGE# 2
GUIDELINE TITLE: HIGH RISK MANAGEMENT
PURPOSE: Identification of diagnosis requiring possible direct admit to Family Birthing
Center
INSTRUCTIONS: The following diagnoses require a physician's consultation and may require direct
admission to the Family Birthing Center:
1. Vaginal bleeding after 20 weeks.
2. Pyelonephritis
3. Premature cervical dilation
4. Possible premature labor
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-11-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: CONSULTATION
GUIDELINES
PAGE# 3
GUIDELINE TITLE: COLPOSCOPY REFERRAL
PURPOSE: Identification of diagnosis needing referral for colposcopy.
INSTRUCTIONS: The following patients will be referred for colposcopy:
1. Patients who have had an abnormal Pap read as dysplasia, CIS, adenocarcinoma, or
condyloma.
2. Patients with atypical cells present on Pap after having been treated.
3. Refer to OB/GYN for procedure.
REVISED BY: Mari Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HPS Table of Contents.doc
4
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: CONSULTATION
GUIDELINES
PAGE# 4
GUIDELINE TITLE: SOCIOECONOMIC ASPECTS
PURPOSE: Identification of women/families at increased risk due to social/economic
situation.
INSTRUCTIONS: For those women/families that you consider to be at significant risk due to their
social/economic situation, please consider a chart review with the consultant. These cases will be
examined on an individual basis.
REVISED BY: Maj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-11-00
HPS Table of Contents.doc
5
HEALTHYSTART PRENATAL SERVICES
GUIDELINES FOR PRENATAL CARE
TABLE OF CONTENTS
Page
II. PRENATAL CA
Initial Exam
Return Prenatal Visits
Vitamin/Iron/Mineral Supplementation
1
2
3
Pharmacy Guidelines
4-5
Dispensing STD Medications
6
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: PRENATAL
CARE
PAGE# 1
GUIDELINE TITLE: INITIAL EXAM
PURPOSE: Identification of required elements of initial exam.
INSTRUCTIONS: The initial prenatal exam will include the following:
History, physical exam, and labs
1. Medical -surgical history
2. Family medical history
3. Social history
4. Complete physical examination including bimanual or fundal height assessment of
gestational age
5. Urine checked with dipstick for glucose, protein, and nitrites
6. Weight
7. Appropriate counseling
8. Gestational age assessment
9. Compiling of a problem list with initial management plans
10. Assessment whether woman is appropriate for your clinic or needs referral for
consultation
11. Lab work
12. Initial lab work should include:
a. Blood type, Rh, and antibody screen
b. CBC
c. VDRL and Hepatitis screen
d. Endocervical gonococcal culture prn
e. PAP smear
f. Sickle cell screen — Blacks/Mediterraneans
g. Chlamydia screen
h. HIV test offered
HPS Table of Contents.doc 6
i. Varicella status prn
j. PPD with TB risk
k. Gram stain
13. Give patient tentative EDC
B. Risk Score (see page B of prenatal form)
This is a tool to help you determine which women need further evaluation and/or more
careful attention during their pregnancy. You may increase the risk score of any individual
factor as indicated, however, a given risk score may not be reduced.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: PRENATAL CARE
PAGE# 2
GUIDELINE TITLE: RETURN PRENATAL VISITS
PURPOSE: Identification of necessary elements of return prenatal visits, scheduling of
routine laboratory tests, and scheduling of prenatal visits.
INSTRUCTIONS:
A. At a minimum, the exam and record should include:
1. Blood pressure
2. Urine dipstick for protein, glucose and nitrites
3. Weight
4. Measurement of fundal height in cm.
5. Position of fetus after 30 weeks
6. Fetal heart rate with Doppler
B. Scheduling of routine laboratory tests:
1. AFP 15-20 weeks (recommended)
2. Repeat hct and hgb at 28-38 weeks
3. At 28-30 weeks:
a. Antibody screen (if Rh negative, particularly with history of blood transfusion)
b. Rhogam 300 mg IM at 28-32 weeks following a negative AB screen
c. 1 hour diabetes screen
4. If Rh negative and no prenatal Rhogam given, obtain antibody screen and repeat
monthly until delivery
5. Hepatitis screen prn
6. Beta strep screening at 36 weeks
C. Scheduling of prenatal visits:
1. Schedule as necessary and appropriate with the following guidelines in mind:
a. Every 4 weeks up to 28 weeks
b. Every 2-3 weeks 28-36 weeks
c. Every week 36-41 weeks (weekly V.E. prn)
d. Have patient seen in clinic at 41 weeks from LMP for postdates management plan
D. 37 week risk score (see sample form)
HPS Table of Contents.doc 7
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: PRENATAL
CARE
PAGE# 3
GUIDELINE TITLE: VITAMIN / IRON / MINERAL SUPPLEMENTATION
PURPOSE: Identification of recommended nutritional supplementation.
INSTRUCTIONS:
Vitamins
1. All prenatal patients are to be supplemented with multivitamins containing iron (30-60
mg elemental iron) and folic acid (400-1,000 mg folacin), except for those with sickle
cell anemia.
B. Iron
1. Criteria for supplementation additional to vitamins:
a. HCT is below 34
2. High risk for anemia:
a. Adolescents
b. Women who conceive within one year of prior pregnancy
c. Women with previous history of anemia or post partum hemorrhage
d. Women who have breastfed within one year of pregnancy
3. Preparations — equal amounts of elemental iron have equal incidence of side effects.
a. Ferrous Sulfate 300-325 mg BID, po (TID if hct 30-32%) (cheapest)
b. Ferrous Gluconate 300 mg BID, po (TID if hct 30-32%)
c. Fer-in-sol Syrup, 2 tsp BID po with meals
4. Patient directions:
a. Take with orange juice or on an empty stomach
b. Avoid taking with milk products
C. Calcium
1. If patient has a calcium deficient diet (under 4 servings of milk products per day),
consider:
a. Calcium Lactate 600 mg/day po OR
b. OSCAL 250 mg TID, po
c. Tums (calcium carbonate) 200 mg in each tablet: 1 tab TID, po (also recommend
skim or 1% milk)
D. Folic Acid
1. If patient is anemic secondary to folic acid deficiency, or if patient's prenatal vitamins
do not include folic ace, give folic acid 1 mg qd, po. Sickle cell patients should receive
5 mg qd, po. Patients with prior infant with NTD, supplement with 4 mg qd.
HPS Table ofContents.doc 8
E. Fluoride
1. Based on the lack of controlled, scientific data to support the use of fluoride in
pregnancy, we cannot recommend the practice of prenatal fluoride administration. It is
known, however, that this administration is not harmful to the mother or the fetus. We
can recommend the supplementation for newborns, infants and children.
REVISED BY: Marj Gold, RN
APPROVED BY: Mari Gold, Leader Manager FBC
DATE: 6-29-99
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: PRENATAL
CARE
PAGE# 4-5
GUIDELINE TITLE: PHARMACY GUIDELINES
PURPOSE: Identification of protocol for dispensing of drugs by HeathyStart
staff.
INSTRUCTIONS:
A. Drugs will be dispensed by RN's, Nurse Practitioners, or the Health Officer.
B. Drugs will be dispensed in childproof containers; oral contraceptives may dispensed in "zip
lock" bags with a label. A Drug Info. sheet will be included.
C. Registered Nurses may only dispense drugs listed in the Drug Formulary.
D. All drugs will be labeled by the Nurse or Health Officer. The label will include the
following:
1. Patient name
2. Name of prescriber
3. Clinic name, address, and phone number
4. Dispensing date
5. Drug name and strength (if generic drug, include manufacturer name) and expiration
date
6. Directions for use and any cautionary statements
7. Initials of dispensing person
E. A Drug Information Fact Sheet shall accompany all drugs.
F. Repackaged Drugs shall include: Brand name (if generic include manufacturer), strength,
lot number, and expiration date. Repackaging is done by RN's only.
G. All drugs are stored in a locked cabinet in the clinic supply room. Cabinets may be
unlocked only if RN's are present in the clinic. No patients are permitted in the supply
room. Cabinet is locked outside of clinc hours.
H. Upon arrival to the Health Department, drugs are to be checked in by RN and entered on
the appropriate Medication Logs.
HPS Table of Contents.doc 9
I. Each drug is logged onto a Medication Dispensing Sheet by lot number and expiration
date.
J. When a drug is dispensed, the RN writes in the patient's name, chart number, amount
dispensed, and forward balance of that particular medication.
K. The Medication Dispensing Sheet is kept locked in the supply room and then transferred to
a "Medications Dispensed" file at the Program Manager's desk. The file is kept for a
minimum of three years, then shredded.
L. The Dispensing Sheet is only transferred to the "Medications Dispensed" file after that
particular drug and lot numbers supply has been exhausted.
M. Drug Ordering:
1. All Family Planning drugs are ordered by the Family Planning Coordinator (RN).
2. All STD drugs are ordered by the STD Coordinator (RN).
3. All TB drugs are ordered by the TB Coordinator (RN).
4. All Child Health drugs are ordered by the MCH Program Manager or her designee
(RN).
5. All Prenatal drugs are ordered by the Prenatal Program Manager or her designee.
N. Drug Inventory: Once per month, all drugs are inventoried. All overages and shortages are
reported to the appropriate Program Manager. The Program Manager is responsible for
implementing steps to rectify any problems in the drug dispensing procedure.
O. Drug inventories are done by the Family Planning, STD, and TB Program Coordinators as
well as the Maternal Child Health and Prenatal Program staff.
P. Prescription medications for patients can also be ordered through SCMC pharmacy when
needed.
REVISED BY: Marj Gold, RN
APPROVED BY: Mari Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: PRENATAL CARE
PAGE# 6
GUIDELINE TITLE: DISPENSING STD MEDICATIONS
PURPOSE: Identification of protocol for dispensing STD medications.
INSTRUCTIONS:
A. STD's that are diagnosed in HPS patients will require treatment to promote well being in
patient, fetus, and sexual partner. Medications can be accessed through:
1. DCHD STD supply, if available
2. Prescription, written or telephoned to a pharmacy for OHP clients or personal pay.
HPS Table of Contents,doc 10
3. Bend Aid to assist with payment for a written prescription (Associated with American
Red Cross).
4. St. Charles Medical Center Pharmacy.
Documentation of such services will be required of HPS staff to ensure consistent and
complete records.
13. Charting forms needed:
1. CVR
2. Master Index Card for Client contact/partner
3. HPS Charge Sheet
4. DCHD Medication Dispensing Record.
C. Dispensing procedure:
1. When an STD has been diagnoses by the nurse practitioner, the patient and family will
be given written and verbal information regarding the type of infection, mode of
transmission, and treatment plan. Once patient education is completed, the method of
obtaining medication will be discussed and agreed upon.
2. Complete education of patient and partner on effects of medication, restrictions on
ETOH use, and sexual precautions. Documented:
a. CVR by the Nurse Practitioner
b. Medication Log Book: record medication that is dispensed from DCHD for both
patient and partner.
c. Prenatal Record: page II and III needed. Document date, dx, Rx, and follow up
plan.
d. HPS Billing Sheet: charge medications dispensed.
3. If needed, after completion of medication, a test of cure follow up exam will be
performed on HPS patient.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 1 1 -6-00
HPS Table of Contents.doc 11
HEALTHYSTART PRENATAL SERVICES
GUIDELINES FOR PRENATAL CARE
TABLE OF CONTENTS
HPS Table of Contents.doc 12
Page
III. MANAGEMENT PROTOCOL BASED ON HISTORICAL DATA
Advanced Maternal Age
1
Allergies
2
Previous Cesarean Section / Cesarean Section
3
X -Ray Exposure
4
Blood Group, Rh and Antibody Screen
5
Common Discomforts of Pregnancy
6-7
Rubella
8-9
Gonorrhea
10
Chlamydia
11
Genital Herpes
12
Syphilis
13
Diabetes Screening
14-15
Urinary Tract Infections
16-17
Iron Deficiency Anemia
18
Vaginal Infections
19
Condylomata Acuminata
20-21
Hepatitis B
22
Human Immunodeficiency Virus
23-24
Tuberculosis
25
HPS Table of Contents.doc 12
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 1
GUIDELINE TITLE: ADVANCED MATERNAL AGE
PURPOSE: Identification of management protocol when patient is age 34 or older at
EDC.
INSTRUCTIONS:
A. Contact consulting clinician for patient counseling asap.
B. Guidelines:
1. Incidence of Down's:
a. Age 35 1/200
b. Age 37 1/100
c. Age 40 1/50
d. Age 44 1/20
2. With amniocentesis, family may also request to know sex of child, if they desire.
3. It may take 2-6 weeks for results
4. See also Genetic Counseling Guideline
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 2
GUIDELINE TITLE: ALLERGIES
PURPOSE: Identification of management protocol when patient has allergies.
INSTRUCTIONS:
Obtain history
B. If taking allergy shots, discontinue (inform MD). If bothersome symptoms continue,
consider conservative use of:
1. Tylenol
2. Sudafed
3. Ornex (contraindicated in hypertensive patients)
4. Benadryl
HPS Table of Contents.doc
13
C. Consult or refer to MD if significant symptoms persist or if continuous use of medication is
required.
REVISED 13Y: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL SERVICE
DESCHLTTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 3
GUIDELINE TITLE: PREVIOUS CESAREAN SECTION / CESAREAN SECTION
PURPOSE: Identification of management protocol when patient has had previous
Cesarean Section or may require Cesarean Section with this delivery.
INSTRUCTIONS:
Management of woman with history of previous Cesarean Section:
1. Obtain good dating parameters, including ultrasound
2. Record indication for previous cesarean section(s)
3. Obtain previous operative records from cesarean section(s). These records should be
part of the prenatal records given to the patient and sent to the hospital with other
satellite records. If operative records unavailable, consult with MD for possible trial of
labor.
4. Record the type of uterine incision in the OB chart (classical, low transverse, low
vertical).
5. If the patient is interested in a vaginal birth after a previous cesarean section:
a. The operative note from every prior cesarean section should be obtained.
b. More than one previous cesarean section is not a contraindication to a vaginal birth
after cesarean.
c. Confirm low transverse uterine incision.
d. The patient may continue to have her prenatal care with HPS.
e. She should be instructed to present at SCMC early in labor.
f. She should be advised that a trial of labor includes: placement of heparin lock for
obtaining a blood sample for a type and screen, Hct and Hbg, continuous electronic
monitoring of the fetus, and close observation. However, a vaginal birth after
cesarean section does not exclude her from use of epidural anesthetic or possible
augmentation of labor with pitocin when indicated.
Cesarean Section
1. Anesthesia: In general, regional anesthesia is recommended for a cesarean birth. This
may be an epidural or a spinal anesthetic. It is most common to require a general
anesthetic only for an emergent situation. A regional anesthetic is medically safer than
a general anesthetic.
2. A support person during cesarean section is permissible. This is generally the partner of
the patient, though if he is not available or interested in being present at a cesarean
HPS Table of Contents. doc 14
section, then another friend or relative may be present as support person during a
cesarean section:
a. The surgeon must approve
b. A regional anesthetic must be used
c. The woman desires the presence of a support person
d. Support person understands and follows basic OR rules.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 4
GUIDELINE TITLE: X-RAY EXPOSURE
PURPOSE: Identification of management protocol related to x-ray exposure in pregnancy.
INSTRUCTIONS:
A. Avoid x-ray exposure if possible, especially in first trimester.
B. If films are needed, use minimal number. Consult with physician before getting x-ray
during pregnancy.
C. Patient is to be fully shielded abdominally during x-ray exposure.
D. If x-ray exposure occurred on patient who was unknowingly pregnant, consult physician.
E. All elective films should be delayed until after delivery.
REVISED BY: Marj Gold, RN
APPROVED BY: Mari Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 5
GUIDELINE TITLE: BLOOD GROUP, RH AND ANTIBODY SCREEN
PURPOSE: Identification of management protocol of blood group, RH and antibody
screen.
HPS Table of Contents.doc
15
INSTRUCTIONS:
A. All patients: Blood group, type, and antibody screen at first visit (may get antibody screen
only if you have accurate record of group and type).
B. Rh positive patients: Repeat antibody screen during third trimester of pregnancy for
irregular antibodies.
C. Rh negative unsensitized:
1. Get history regarding previous pregnancies, Rhogam, and infant Rh type.
2. Rhogam 300 ug, IM at 28-30 weeks following negative antibody screen as
recommended by ACOG.
Microgram 50 ug, or full dose Rhogam,. IM post abortions and ectopic pregnancies
Rhogam 300 ug, IM during postpartum hospitalization if mother unsensitized and baby
Rh positive.
F. Rh negative sensitized, i.e., positive for c, C, d, D, or E:
1. Immediately call physician to arrange for immediate evaluation.
G. Other antigens:
1. No follow up necessary (not hemolytic):
a. Ba
b. BP
c. Duffy Fy(3
d. H
e. I
f. Lewis
g. N
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HPS Table of Contents.doc 16
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 6-7
GUIDELINE TITLE: COMMON DISCOMFORTS OF PREGNANCY
PURPOSE: Identification of management protocols for common discomforts of
pregnancy.
INSTRUCTIONS:
Nausea and vomiting
1. Consider other etiologies: gastritis, pancreatitis, hyperemesis gravidarum, hydatidiform
mole, UTI, appendicitis, obstruction, hepatitis.
2. Historical data: previous history, weight loss, dehydration, decreased urine output, less
than 12 weeks gestation.
3. Physical exam: poor skin turgor, sunken orbits.
4. Laboratory data: increased urine gravity, ketonuria, increased hematocrit, weight loss.
5. Management:
a. Small frequent meals; liquid between meals; avoid spicy foods; avoid fatty foods;
light snack of CHO and protein before bedtime; snack between meals; reassurance
that it will end during 4th month.
b. Pharmacologic Rx: if above measures fail — Vitamin B6 50 mg 3-4 times per day.
c. Phenergan suppository 25 mg prn.
d. Compazine 5-10 mg.
e. Antacids
f. Unisom — %2 tablet po at bedtime.
6. CONSULT: persistent ketonuria or persistent weigh loss.
B. Hemorrhoids
1. Consider other etiologies: e.g. tumor.
2. Historical data: previous history, bleeding, discomfort/pain with bowel movements.
3. Physical exam data: presence of dilated, tortuous veins at anal opening.
4. Management: gentle manual replacement; sitz baths; adequate fluid intake; avoidance
of constipation; witch hazel compresses; ice packs; bedrest with hips and lower
extremities elevated; Kegel exercises; stool softener (i.e. Metamucil or Colace as
directed).
5. Anusol HC
C. Braxton -Hicks contractions:
1. Consider other etiologies: round ligament pain; fetal movements; bowel peristalsis/gas
pains; labor; UTI.
2. Historical data: duration, intensity, location, character of pain; presence of associated
symptoms suggestive of abnormality; similar symptoms in previous pregnancy.
3. Physical exam data: examine abdomen for uterine contractions, rigidity, guarding,
distension.
4. Lab data: urinalysis
5. Management: reassure woman; inform re: S/S of labor; warm tub; relaxing massage a
home; walking vs. lying down.
HPS Table of Contents.doc 17
D. Round ligament pain
1. Consider other etiologies: appendicitis; labor (true vs. false); UTI; hernia; ovarian cyst;
chronic constipation; gastritis; peptic ulcer.
2. Historical data: c/o pain extending from lateral aspects of uterus down into inguinal
area. Stretching/pressure type sensations. Ask questions re: symptoms suggestive of
abnormality.
3. Physical exam data: examine abdomen for uterine contractions; CVAT; distention.
4. Management: warm baths, heating pad to the area (only if sure is round ligament pain);
support of the uterus with a pillow between knees when lying on side; inform as to
cause; may suggest maternity girdle if pendulous abdomen.
E. Varicosities
1. Contribute to the development of thrombophlebitis, dependent edema
2. Historical data: family history, constrictive clothing, periods of prolonged standing,
obesity.
3. Management/relief measures: support hose; avoid constrictive clothing; avoid long
periods of standing; rest periods with legs elevated; avoid crossing legs when sitting;
good posture; good body mechanics; exercise to facilitate increased circulation; right-
angle position several times daily; physical support of vulvar varicosities with foam pad
held in place with a sanitary belt.
F. Low back pain
1. Consider UTI, musculo -skeletal disorder, chronic constipation, labor, engaged fetal
head.
2. Historical data: increased parity; character, location, duration of pain; relationship of
pain to time, position, activity; symptoms associated with renal disease; meds taken;
other methods of therapy used; excessive bending, walking without rest periods and
lifting.
3. Physical exam data: CVAT, check temperature, palpate area for tenderness, inspect.
Abdominal exam re: fetal position.
4. Lab data: check urinalysis
5. Management: good posture, proper body mechanics for lifting; avoiding excessive
bending, lifting, or walking without rest periods; pelvic rock exercise; supportive, low-
heeled shoes; hard mattress for sleeping.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL
SERVICE
DESCHUTES COUNTY HEALTH
DEPT.
TRAINING DOCUMENT -
PROTOCOLS
SECTION: MANAGEMENT PROTOCOL
BASED ON HISTORICAL DATA
PAGE# 8-9
GUIDELINE TITLE: RUBELLA
PURPOSE: Identification of management protocol regarding rubella exposure and
immune status.
HPS Table of Contents.doc
18
INSTRUCTIONS:
A, Routine prenatal screen:
1. Draw rubella titer on all new prenatal patients. It cam be omitted if there is
documentation of a previous titer of over 1:8.
2. If titer is under 1:8, inform patient:
a. Of necessity to avoid contact with people exposed to or diseased with rubella;
b. That postpartum vaccine is recommended;
c. To immediately report any possible contact with rubella cases.
B. Exposure to rubella during pregnancy — Clinical course:
1. Incubation period is 2-3 weeks
2. Lymphadenopathy (postauricular, postcervical & suboccipital nodes)
3. Low grade fever
4. Joint manifestations
5. Maculopapular rash
a. Face is always involved
b. Starts on face and spreads downward
c. For about 3 days
6. Most contagious 1-2 days before symptoms
7. Not all infections are apparent DAYS AFTER EXPOSURE
Mangement
1. Contact consultant
2. If titer unknown, get sample drawn immediately
3. If initial prenatal titer is above 1:8, no follow up is necessary. It is probably OK if
patient cares for family members with active Rubella.
4. If initial prenatal titer is 1:8 or less:
a. Inquire about the nature of exposure (intimate, prolonged, casual, brief)
b. If laboratory did not keep the blood used for the initial prenatal titer, obtain blood as
soon as possible after the exposure and preserve it by:
1) Separating blood from serum by either centrifuging an unclotted blood
specimen, then drawing off .5-1.0 cc serum, or
2) Refrigerate a tube of blood for 25 hours, then draw off .5-1.0 cc serum,
3) Then freeze serum.
5. Three weeks after exposure, repeat Rubella titer. Send frozen specimen to lab at same
time. Have the lab test both specimens at the same time.
a. If patient had no signs or symptoms, and if second titer remains 1:8 or less, no
follow up is necessary.
b. If second titer greater than initial one, immediately consult with consultant.
D. Postpartum Rubella vaccine
1. If titer is under 1:8, a vaccine is recommended during early postpartum period.
2. Patient must use good birth control for at least three months after vaccine.
3. Consult if patient becomes pregnant within three months of vaccine.
4. Counsel patient that vaccine may not be 100% effective.
5. Counsel on side effects of vaccine.
6. If Rhogam given after delivery, wait to give MMR at 6 weeks postpartum.
E. Breastfeeding is not a contraindication to the vaccine.
HPS Table of Contents.doc 19
Sources:
1. Burrow and Ferris, Medical Complications During Pregnancy
2. ACOG Newsletter, January 1971
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 10
GUIDELINE TITLE: GONORRHEA
PURPOSE: Identification of management protocol for gonorrhea screening.
INSTRUCTIONS: (CDC Recommendation)
A. Most women should have an endocervical culture obtained at the first prenatal visit. The
criteria for PRN GC testing of HPS patients is as follows:
1. Multiple sexual partners
2. Other STD infections diagnosed during exam
3. History of previous STD's
4. History of street drug use
5. Teenage pregnancy
B. Women at risk of gonorrhea should have a repeat culture in the last month of pregnancy.
C. Treatment of uncomplicated infections:
1. Ceftriaxone 125 m to 250 m IM x 1. PLUS erythromycin base or stearate 500 mg by
mouth QID for 7 days.
2. If allergic to penicillin, cephalosporins or probenecid, treat with spectinomycin 2.0 IM
followed by erythromycin as give above.
Special Considerations
1. Pharyngeal infection is difficult to treat; high failure rates have been reported with
ampicillin and spectomycin.
2. Men and women exposed to gonorrhea should be examined, cultured, and treated at
once.
3. Chlamydia is coexistent infection in up to 45% of all patients with positive gonorrhea
cultures.
Follow up
1. Follow up cultures should be obtained from the infected site(s) three to seven days after
completion of treatment. Cultures should be obtained from the anal canal of all women
who have been treated for gonorrhea.
2. Post treatment culture isolates should be tested for penicillinase production.
HPS Table of Contents.doc 20
F. Treatment failure
1. Most recurrent infections after treatment with recommended schedules are due to
reinfection, and indicate a need for improved contact tracing and patient education.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 11
GUIDELINE TITLE: CHLAMYDIA
PURPOSE: Identification of management protocol for chlamydia.
INSTRUCTIONS:
A. This is the most common sexually transmitted disease in the Western world. Leading cause
of infectious blindness in the world. May also cause newborn pneumonitis.
B. High risk group:
1. Poor
2. Non-white
3. Unmarried
4. 18-24 years of age
5. Gonorrhea (seen in conjunction in up to 45% of cases)
C. Signs: 3-5% of unselected pregnant women will have positive cultures, while 30-60% of
those with non-gonococcal mucopurulent cervicitis will be positive.
D. Diagnosis: any clinic whose population has a high proportion of high risk women should
do routine chlamydia screening (Fastrak immunofluorescence test) while screening for GC.
All mucopurulent cervicitis should be checked as well.
E. Treatment:
1. Azithromycin 1 gram PO x 1. Sexual partner treatment the same.
2. Amoxicillin — 500 mg PO TID x 7 days.
3. Do not use erythromycin estolate.
4. Do follow up test for cure as with GC.
HPS Table of Contents.doc 21
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 12
GUIDELINE TITLE: GENITAL HERPES
PURPOSE: Identification of management protocol for genital herpes.
INSTRUCTIONS:
A. Predisposing factors:
1. Multiple sexual partners
2. History of other venereal disease
3. Exposure
B. Historical and physical exam data suggestive of herpes:
1. Vesical surrounded by erythematous zone.
2. Lesions begin as a closely aggregated group of painful papules, progressing rapidly to
vesicles, shallow ulcers, pustules and crusts.
3. Healing takes several days to several weeks without scar formation and in absence of
secondary infection.
4. Can be associated with tender, regional lymphadenopathy and constitutional symptoms:
chills, fever, malaise, headache, myalgia and occasionally generalized
lymphadenopathy, splenomegaly and atypical lymphocytosis.
C. Diagnostic tests: viral culture of cervix/lesion/vagina.
D. Clinical management:
1. Cultures, when active lesions are seen, if no previous positive cultures for herpes at any
time in the past.
2. Cesarean section will be done if there is an active lesion, or prodromal symptoms atthe
time of rupture of membranes and/or onset of labor. Patient should be cautioned to
present rapidly for evaluation if membranes rupture or labor starts when she feels that
she has a prodromal symptom.
3. Weekly cultures are no longer performed.
4. Information re: prognosis, plans.
5. General relief measures:
a. Sitz baths
b. Open wet dressings
c. Keep lesions dry
d. Handwashing
e. Reduced contact with lesion
HPS Table of Contents.doc 22
E. CONSULT: When active herpes lesion from 36 weeks onward.
1. In patient with recurrent herpes outbreaks during pregnancy or after 36 weeks
gestation, start Acyclovir 400 mg BID until delivery.
Sources:
1. Arvin, A., Hensleigh, P., Prober, C., et al, New England Journal of Medicine. Volume 315:13 p.
796-800 September 25, 1986
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: : MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 13
GUIDELINE TITLE: SYPHILIS
PURPOSE: Identification of management protocol for syphilis.
INSTRUCTIONS:
A. State law requires all pregnant women to receive a serologic test for syphilis within 10 days
of presenting for prenatal care. Due to the resurgence of the disease, however, patients in
selected high risk groups are now in need of a screening test in the third trimester. The
current policy at SCMC is to screen all women who present for care with little or now
prenatal care. Individual clinics may wish to institute routine third trimester screening as
well. High risk patient groups include, but are not limited to, the following:
1. Those with current or recent history of other STD's.
2. Those engaged in prostitution.
3. Those with sex partner(s) from an itinerant group.
4. Those with multiple sex partners.
5. Those known to abuse street drugs.
6. Those who are not married.
B. Treatment:
1. Evaluate all positive RPR or VDRL tests with FTA testing of direct examination
(darkfield) of a lesion.
2. Treatment should be as per the attached Oregon Health Division guidelines.
3. Patients with penicillin allergy and those who fail to respond to conventional therapy
should be managed with consultation.
Sources:
1. CDC -Summary Oregon State Division; 37:6, March 15, 1988
2. CDC -Summary Oregon State Division; 37:7, March 29, 1988
3. CDC-MMWR 37: S-1, January 15, 1988
HPS Table of Contents.doc 23
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: : MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 14-15
GUIDELINE TITLE: DIABETES SCREENING
PURPOSE: Identification of protocol for diabetes screening.
INSTRUCTIONS:
In early pregnancy for any one of the following:
1. Immediate family history of diabetes (i.e., sibling on insulin)
2. Obesity (>200 lbs.)
3. Polyhydramnios
4. Glycosuria (persistent)
5. History of infant:
a. Over 4000 gm
b. Term sized with RDS
c. With unexplained congenital anomalies
d. Unexplained stillborn
One hour diabetes screen at 24-28 weeks for all pregnancies:
1. Procedure:
a. Woman drinks 50 grams of glucose (e.g. Glucola). The relationship to meals is
unimportant. The test can be done at any time of the day.
b. Exactly one hour later, blood is drawn for glucose level.
2. Abnormal values in pregnancy:
a. Plasma: over 140
b. If BG >200, no need for 3°. Diagnosis is gestational diabetic.
Three hour glucose tolerance test (3° GTT)
1. Procedure:
a. Woman eats well three days prior to test (this may be better insured by having
woman drink 1 quart of juice/day or eat 4 slices bread/day).
b. NPO, except water, eight hours prior to test (this includes no gum, lifesavers, etc.).
c. A fasting blood or plasma glucose level is drawn.
d. Woman drinks 100 grams of glucose (e.g. Glucola).
e. Blood is drawn at exactly one, two, and three hours after drinking the 100 grams of
glucose.
f. Urine does not have to be tested for sugar during the test.
g. No smoking during test period.
HPS Table of Contents.doc 24
2. Two values must be elevated in order for 3° GTT to be abnormal:
Time Plasma or serum glucose oxidase by Auto. Analyzer
Fasting 105
1 hour 190
2 hour 165
3 hour 145
3. Comments:
If 3° GTT is abnormal, call consultant immediately for management plan. You may
expect a plan that includes diet counseling and blood glucose testing with fasting blood
sugar (FBS) and 2 hour post prandial (2° PP). The following is for your information:
Fasting Blood Sugar (FBS) and 2 hour Post Prandial Testing (2° PP).
1. How done:
a. Woman is NPO, except water, for 8 hours prior to A.M. test.
b. FBS check (at home or by lab, depending on management plan).
c. Meal is eaten
d. Re -check blood glucose 2° after meal.
2. Values to aim for (whole blood):
a. FBS: <100
b. 2° PPL: <120
E. Screen process:
1. Screen women with several factors that place them at particular risk for diabetes, by
performing a one hour screen early in pregnancy.
a. If normal, no follow up
b. If abnormal, perform 3 hour GTT
2. At 28-30 weeks: Screen all women for diabetes using the 1 hour screen.
a. If normal, no follow up
b. If abnormal, get 3 hour GTT asap
3. If 3 hour GTT is abnormal, call SCMC consultant immediately for management plan.
REVISED BY: Mari Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 16-17
GUIDELINE TITLE: URINARY TRACT INFECTIONS
PURPOSE: Identification of protocol for treating urinary tract infections.
INSTRUCTIONS:
A. Women at risk for developing UTI's in pregnancy:
1. Previous history of UTI
2. Women with sickle cell disease
HPS Table of Contents.doc
25
3. Women with asymptomatic bacteriuria
4. Women with Diabetes Mellitus
B. History and physical exam suggestive of UTI:
1. Burning on urination; frequency; urgency
2. Suprapubic pain
3. Urethral inflammation
4. Fever; chills
5. Hematuria
6. Low back pain
7. Loss of appetite, nausea & vomiting
8. CVA tenderness
C. Lab data to diagnose UTI:
1. Routine microscopic urinalysis
2. Culture and sensitivity
D. Clinical management:
1. Rest — increase rest periods
2. Diet — well balanced with increase in protein intake
3. Hygiene — perineal hygiene
a. Cotton underwear with daily changes
b. Avoid tight underwear and pants, and avoid wearing underwear while sleeping
c. Empty bladder frequently (q 3 hr)
d. Avoid hose unless a problem exists with varicosities
E. If symptomatic, or if lab data indicate UTI:
1. Initiate treatment right away. Macrobid bid x 7 days, or Ampicillin 500 mg qid x 7
days.
2. Obtain C&S and change treatment as necessary.
3. May order Monistat p.v. concurrent with antibiotic treatment to avoid vaginitis.
4. Obtain follow up urine C&S after therapy is completed as test for cure.
5. Repeat UA in last trimester PRN.
F. Consult:
1. For greater than 2 UTI's in the pregnancy
2. Suspected pyelonephritis
Sources:
1. Williams, 1980 pp 701-77, 209-11
2. Varney, Nurse Midwifery, pp 130-42
3. Burrow & Ferris, Medical Complications in Pregnancy, pp 34-44, 382-94
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HPS Table of Contents. doc 26
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON
HISTORICAL DATA
PAGE# 18
GUIDELINE TITLE: IRON DEFICIENCY ANEMIA
PURPOSE: Identification of protocol for treatment of iron deficiency anemia.
INSTRUCTIONS:
A. Historical and physical exam data suggestive of anemia:
1. Fatigue, malaise, drowsiness, depression
2. Dizziness, weakness
3. Headaches
4. Sore tongue, skin pallor, pale mucous membranes and fingernail beds
5. History of heavy menses
6. History of closely spaced pregnancies
7. History of anemia/post partum hemorrhage in previous pregnancy
8. Multiple gestation
9. Adolescent
10. History of sickle cell disease
11. History of OC use (folic acid antagonist)
12. History/presence ova & parasites
B. Clinical management:
1. Hgb 10-12 gms (Hct 30-32%)
a. Supplement with Fe tid (unless patient has sickle cell anemia), folic acid and
vitamins
b. Counsel re: high iron foods
c. Recheck H/H after 2 weeks of Fe treatment.
2. Hgb 9-10 gms (Hct < 30%)
a. Recheck H/H (r/o lab error)
b. Obtain CBC including indices and peripheral smear.
c. Obtain consult from SCMC clinician when results received.
C. Consult:
1. If less than 30%/10 gms and greater than 36 weeks gestation
2. If less than 9 gms consult immediately regardless of gestation
3. Obtain lab results if less than 36 weeks and greater than 9 gms prior to consult
D. General measures:
1. Conservation of energy (increased rest)
2. Well balanced diet with increased protein, iron and vitamins
3. Protection from infection and trauma
4. Iron supplements with source of vitamin C
5. Good hygiene including mouth care
6. Educate/counsel/inform
HPS Table of Contents.doc 27
REVISED BY: Marj Gold, RN
APPROVED BY: Marl Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 19
GUIDELINE TITLE: VAGINAL INFECTIONS
PURPOSE: Identification of protocol for treatment of vaginal infections.
INSTRUCTIONS:
Gardnerella vaginalis vaginitis
1. Etiology: A complex vaginal infection currently thought to be caused by a combination
of Gardnerella Vaginalis and anaerobic bacteria.
2. Symptoms: Patients may complain of a malodorous, watery discharge.
3. Clinical diagnosis: A discharge, which is often gray then watery, with a pH of 4.5;
bubbles may be present; fishy odor may be noticed with the addition of 10% KOH; clue
cells are seen on microscopic exam.
4. Treatment:
a. Metronidazole 500 mg bid x 7 days after 20 weeks.
b. Metrogel vaginal treatment x 7 days at bedtime.
B. Monilia/Yeast/Candida albicans
1. Historical data: CIO pruritus; profuse, mucopurulent, white, curdy discharge
2. Physical exam: Vaginal mucosa red with white patches; cheesy, curd -like detachable
fragments
3. Lab: use KOH on wet smear — spores/hypae observable on micro exam
4. Management: Monistat vaginal suppositories as directed OR Monistat vaginal cream 1
appl. Full qhs x 7 days. Full course is important. Gyne -Lotrimin vaginal cream prn.
Partner advised to use condom during treatment. Re -check wet smear after course of
treatment complete as test for cure.
C. Trichomonas vaginalis
1. Historical data: C/O profuse, frothy, green -white, watery discharge with fishy odor.
2. Physical exam: Vaginal mucosa red with occasional strawberry pocking.
3. Lab: wet prep, use normal saline. Microscopic exam shows one celled oval shaped,
motile flagellate.
4. Management: Treat patient and partner with Metronidazole 1 gm po bid x 1 day; no
alcoholic beverages; use condoms x 7 days. Metronidazole should not be administered
during the first trimester of pregnancy or to women who are breastfeeding. Re -check
wet smear after course of treatment complete.
HPS Table of Contents.doc 28
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 10-24-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 20-21
GUIDELINE TITLE: CONDYLOMATA ACUMINATA (VENERAL WARTS)
PURPOSE: Identification of protocol for treatment of venereal warts.
INSTRUCTIONS:
A. Etiology: Nearly always sexually transmitted (small DNA virus). Infants may develop
laryngeal papillomas due to infection from maternal genital warts at birth.
B. Symptoms: Often asymptomatic and painless. May be solitary but usually multiple lesions.
Begin as small papules the size of a match head which may reproduce to from soft
cauliflower -like growths covering large area. Commonest sight of infection is in the
introitus and vulva, but may infect the vagina and cervix. Other sites include the perineum,
anus and rectum. Must rule out syphilitic condylomata, skin papillomata.
C. Diagnosis: Based on clinical appearance and/or pap smear.
D. Management for small lesions:
1. Treat associated vaginal discharges
2. Obtain Pap Smear
a. Condylomata on Pap: Refer to physician clinic
b. No Condylomata on Pap:
1) Follow up and treat partner(s) as necessary.
2) Recommend use of condoms to prevent spread during treatment.
3) Counsel regarding hygiene, usual resolution after birth.
4) Follow growth and development, refer to below if extensive growth.
5) PODOPHYLLIN is not used during pregnancy.
6) Histofreeze or tri-chloreacetic acid weekly to external lesions.
E. Management for large/extensive lesions:
1. Treat associated vaginal discharges
2. Obtain Pap Smear
a. Condylomata on Pap: Refer to physician clinic
b. No Condylomata on Pap:
1) Follow up and treat partner(s) as necessary.
2) Recommend use of condoms to aid in prevention
3) Counsel regarding hygiene
4) PODOPHYLLIN is not used during pregnancy
c. Treatment:
1) Cryotherapy (freezing with liquid nitrogen)
2) Laser therapy
HPS Table of Contents.doc 29
F. Follow up: Any person with an abnormal Pap smear associated with condyloma should
have a repeat Pap smear every three months until no evidence of condyloma are present,
and an annual Pap smear thereafter.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 9-11-01
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 22
GUIDELINE TITLE: HEPATITIS B
PURPOSE: Identification of management protocol for Hepatitis B.
INSTRUCTIONS:
A. Oregon Health Division recommends screening all women during pregnancy.
B. High risk individuals should be tested prenatally, to allow for early counseling if positive.
1. Southeast Asian or Haitian women.
2. IV drug abuser or living in household with IV drug abuser.
3. Acute/chronic liver disease.
4. Spouse of individual with chronic or acute Hepatitis B.
5. Repeated blood transfusion.
6. Healthcare workers with occupational exposure to blood or blood products.
7. Jaundice.
8. Resident or staff in an institution for mentally retarded.
Lab tests
1. Screen with Hepatitis B Surface Antigen (HbsAg).
2. If HbsAg is positive, obtain e antigen (HbeAg) and antibody.
3. If HbeAg is positive, risk of perinatal infection si 80-90%. If HbeAb is present,
however, this risk drops back to 10%.
4. Regardless of results in 3., all infants whose mothers have HbsAg present should
receive Hepatitis B Immune Globulin (HBIG) within 12 hours of birth, and Heptavax
(Hepatitis B vaccine) within 7 days of age and again at one and six months of age.
References:
Morbidity and Mortality Weekly Report, June 10, 1988 37:22 (Contains 23 references).
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents.doc 30
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 23-24
GUIDELINE TITLE: HUMAN IMMUNODEFICIENCY VIRUS
PURPOSE: Identification of management protocol for Human Immunodeficiency virus.
INSTRUCTIONS:
All pregnant clients will be offered HIV Counseling and testing. The following risk groups will
be strongly encouraged to test:
1. IV drug users
2. Partners of IV drug users
3. Former IV drug users since 1997/partners of former IV drug users
4. Partners of gay or bisexual males
5. Recipients of blood transfusions or blood products (since 1977)
6. Partners of an HICV seropositive person
7. Patients of recent African origin
8. Patients with multiple sexual partners
9. Hemophiliacs
10. Prostitutes and former prostitutes (since 1977)
11. Other risk groups that may develop over time
HIV Counseling and Testing
1. Before testing, patients must be counseled comprehensively regarding the testing
procedures, the significance of positive or negative results, and follow up testing.
Literature regarding the HIV test and AIDS should be offered.
2. Consent to testing must be documented in the patient chart.
3. All patients at risk, whether tested or not, should be given information regarding
preventive measures. Patients should be advised to avoid:
a. Mucosal exposure to blood, semen, vaginal/cervical secretions as applicable.
b. Any sexual practices which involve trauma and bleeding (e.g. rectal intercourse).
c. Needle sharing of any kind.
d. Sharing of sharp objects, including toothbrushes, tattoo instruments, razors, ear
piercing devices, etc.
e. Work situations which risk bleeding wounds.
4. Patients should be encouraged to use:
a. Condoms
b. Bleach as needed for sterilization of needles and/or other surfaces which come in
contact with body fluids.
c. Sexual practices not involving body fluid exchange, such as mutual masturbation.
5. 90% of the HIV infected population are asymptomatic and unaware of their infection.
Further, even those tested and found to be negative remain at risk for up to six months
after their last contact, as the test may not become positive for that long a period.
Therefore, all blood and vaginal/cervical specimens should be handled as potentially
infectious:
HPS Table of Contents.doc 31
a. Avoid resheathing needles
b. Glove up
c. Dispose of sharps immediately, etc.
C. Perinatal Infections
1. Patients with HIV+ test results should be informed by the clinician (or other
responsible party) of their test results. If at all possible, this should be done in person
with adequate support assured.
a. Patients should be told with complete privacy and confidentiality.
b. Partners should be informed at the patient's request, and counseling and testing
should be offered.
c. The patient should be given a list of HIV/AIDS resources and literature at the time
she is informed of her test results.
d. Both medical follow up and social services should be arranged before the patient
leaves the satellite clinic.
REVISED BY: Mari Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL BASED ON HISTORICAL
DATA
PAGE# 25
GUIDELINE TITLE: TUBERCULOSIS
PURPOSE: Identification of management protocol for Tuberculosis.
INSTRUCTIONS:
A. Historical or Physical Exam Data:
1. Exposure to person with active tuberculosis (groups at high risk of exposure are
immigrants from Asia, Africa and Latin America).
2. Previous case of active TB that was not adequately treated.
3. Medical conditions that increase the risk of TB.
4. Signs/symptoms of active TB (fever, fatigue, weight loss, cough, chest pain, anorexia).
B. Clinical Management:
1. Lab work: Mantoux test
2. Chest x-ray if positive Mantoux (obtain in second trimester and shield the abdomen).
3. Consult with SCMC if patient has Mantoux positive results and a high risk pregnancy,
is immune compromised, or had contact with recently infected individuals. Consult if
chest x-ray is abnormal.
4. Other general recommendations are:
a. If x-ray is normal, do not treat prophylactically unless immune compromised, but
do continue to monitor patient for signs and symptoms of active disease.
Prophylaxis in the otherwise healthy patient consists of Isoniazid (INH) 300 mg po
qid for 12 months.
HPS Table of Contents,doc
32
b. If x-ray is abnormal, bacteriologic testing should include three sputum specimens
for smear and culture. One positive culture specimen should be tested for drug
susceptibility.
c. Report active TB cases to the patient's county health department within one week
after identification.
d. Active disease is currently treated in the healthy pregnant patient with Isoniazid
(INH) 300 mg po qd, Rifampin 600 mg po qd and Pyridoxine 25 mg po qd for nine
months. Consultation should be obtained.
e. Monitor patients taking other medications, particularly phenytoin, for peripheral
neuropathy,
GI disturbances, skin eruptions. Women over 35 should receive baseline liver
function tests.
f. Repeat sputum smear and culture should be done monthly until a negative culture is
obtained. In addition, two sputum cultures should be done to confirm the negative
findings. If the patient remains culture positive after three months of therapy,
consult with SCMC.
g. Insure that mothers and infants at risk for TB or with active TB receive appropriate
follow up and monitoring of health status and drug therapy.
Sources: Communicable Disease Summary, Oregon State Health Division, 1987, Vol. 36, No. 1, 2 and
14.
"Tuberculosis: A Persistent Health Care Problem", Summer, L.,
Journal of Nurse Midwifery, 1987, Vol. 32, No. 2, March/April
"Tuberculin Skin Testing: When and How to Use It", Gantz, N.M.
Hospital Practice, 1986, Vol. 21, No. 9, 29-33.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents.doc
33
HEALTHYSTART PRENATAL SERVICES
GUIDELINES FOR PRENATAL CARE
TABLE OF CONTENTS
HPS Table of Contents.doc 34
Page
IV: MANAGEMENT PROTOCOL - PHYSICAL EXAM DATA
Breech Position
1
Lice
2
Scabies
3
Dental Care
4
Intrauterine Growth Retardation
5-6
Post Term Pregnancy
7
Size/Dates Discrepancy
8
Pregnancy Induced Hypertension
9
Childbirth at HealthyStart Prenatal Service
10-11
HPS Table of Contents.doc 34
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT PROTOCOL
— PHYSICAL EXAM DATA
PAGE 1
GUIDELINE TITLE: BREECH POSITION
PURPOSE: Identification of management protocol for breech position.
INSTRUCTIONS:
A. If breech, anytime after 33 weeks:
1. The consulting physician should be informed of patient status.
2. Woman should be referred for possible external version.
a. Relative contraindications to external version:
1) Hypertension
2) Anterior placenta
3) Dilated cervix
4) Previous uterine surgery
5) Oligohydramnios
b. Counsel about the possibility of cesarean section
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT PROTOCOL
— PHYSICAL EXAM DATA
PAGE 2
GUIDELINE TITLE: LICE
PURPOSE: Identification of management protocol for lice.
INSTRUCTIONS:
A. Symptoms: Range from none to intolerable pruritus and/or swelling of the eyelids.
B. Diagnosing:
1. Observe for small, bluish hemorrhages into the skin (Maculae Caerulas).
2. Observe for tiny, crab -like extroparasites, 1-2 mm, usually seen grasping hair.
3. Remove hair, place under microscope and look for lice, nits, or both.
C. Management:
1 No need to shave hair.
2. Apply Eurax cream or lotion to infested area and to the surrounding areas, making a
thin layer (if patient has many open lesions, consult consultant first).
a. Leave on for 12-24 hours,
b. Then wash off thoroughly and put on freshly laundered or dry-cleaned clothing.
c. Repeat in 4 days if necessary.
HPS Table of Contents.doc 35
d. DO NOT EXCEED RECOMMENDED DOSAGE.
3. Use freshly laundered underwear and bedding daily for 1 week.
4. Wash (in hot water) all contaminated clothing and other personal articles, such as hats,
towels, etc. Combs and brushes should be washed in Eurax.
5. Others in household should be treated, if infested.
6. Use Kwell only in recalcitory cases.
a. Apply a thin layer of Kwell cream or lotion to affected areas and the surrounding
skin surface,
b. Leave on for 8-12 hours,
c. Then wash Kwell off thoroughly.
d. If necessary, may repeat Kwell treatment in one week.
e. DO NOT EXCEED RECOMMENDED DOSAGE.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL — PHYSICAL EXAM DATA
PAGE# 3
GUIDELINE TITLE: SCABIES (SARCOPTES SCABIEI)
PURPOSE: Identification of management protocol for scabies.
INSTRUCTIONS:
A. Symptoms: Pruritus, rash, others in household with similar symptoms.
B. Look for: Pruitic skin eruptions (where eggs are buried) marked by a vesicle or pustule.
C. Sites commonly infected: between fingers, backs of arms and legs, in areas where clothes
may be tight (wrists, axillae, waist, crotch).
D. Diagnosing: Use strong hand lens, if available, to look for skin eruptions. Scrape vesicles
and place material in normal saline, then look under microscope.
E. Treatment:
1. If woman has many open sores, consult with consultant before treatment.
2. Have woman take shower or bath using liberal amounts of soap.
3. Have patient dry skin.
4. Eurax:
a. Thoroughly massage into skin of the whole body from chin down.
b. Apply second application in 24 hours.
c. 48 hours later, woman takes a cleansing bath.
5. Have other affected people in household treated (close contacts and pets).
F. Affected people to wear freshly laundered clothing.
G. Encourage good personal hygiene.
H. Watch for secondary skin infection.
HPS Table of Contents.doc 36
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 1 1 -6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL — PHYSICAL EXAM
DATA
PAGE# 4
GUIDELINE TITLE: DENTAL CARE
PURPOSE: Identification of management protocol for dental care.
INSTRUCTIONS:
A. Avoid x-rays, especially during first 12 weeks of pregnancy.
B. Dental work recommended best during second trimester.
C. If history of rheumatic fever, give 2 gm procaine penicillin G po 12 hours before
procedure, then 500 mg q 6 hours x 6 doses po.
D. No adrenaline use.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL — PHYSICAL EXAM DATA
PAGE# 5-6
GUIDELINE TITLE: INTRAUTERINE GROWTH RETARDATION (IUGR)
PURPOSE: Identification of management protocol for IUGR.
INSTRUCTIONS:
A. Possible causes of IUGR:
1. Inaccurate dates
2. Constitutionally small
3. Poor maternal nutrition
4. Placental insufficiency
a. Chronic hypertension
b. PIH
c. Vascular disease
d. Multiple gestation
e. Long-term diabetes
HPS Table of Contents.doc
37
f. Chronic abruptio placentae
g. Etc.
5. Chromosomal anomalies
6. Drug exposure
7. Ethanol
8. Smoking
9. Fetal infection
10. Maternal anemia
B. What to look for:
1. The presence of any of the above predisposing factors.
2. A difference of 3 cm or more between fundal height and weeks gestation after 20
weeks.
a. Fundal height should grow at least lcm/2 weeks and at least 3 cm/4 weeks.
b. Rapid growth is more than 2 cm/week or 3 cm/2 weeks.
3. In extremely obese women, consider sonogram at least every 6 weeks to follow fetal
growth after 16 weeks.
C. Diagnosis of IUGR:
1. Establish dates!
a. Review menstrual history, early exams, pregnancy tests.
2. Sonogram
D. Clinical Management:
1. Symmetric IUGR
a. High risk consultation regarding possible congenital infection, chromosome
anomaly, etc.
b. Review exposure to drugs, cigarettes, ethanol.
c. Check family history — small parents?
d. Test fetal well being: NST, CST, and/or Biophysical Profile per consulting
physician recommendation.
e. Same care provider to follow fundal height growth.
f. Consult with consultant for plan of care.
2. Asymmetric IUGR:
a. Test fetal well being: NST bi-weekly, CST and/or Biophysical Profile every week
per consulting physician recommendation.
b. Same care provider to follow fundal height growth.
c. Review maternal nutritional status/WIC referral.
d. Decrease/eliminate smoking, drugs and ethanol.
e. Bedrest.
f. Identify and alleviate maternal condition leading to IUGR if possible.
g. Repeat fetal testing as needed once or twice a week. Once normal growth is re-
established, my discontinue testing.
h. Home fetal movement count (10 fetal movements in 1 hour, then stop counting).
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents.doc 38
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL — PHYSICAL EXAM DATA
PAGE# 7
GUIDELINE TITLE: POST TERM PREGNANCY
PURPOSE: Identification of management protocol for post term pregnancy.
INSTRUCTIONS:
A. Historical and physical exam findings indicative of post term:
1. EGA greater than or equal to 42 weeks gestation with correct LMP and EDC (increased
incidence in primigravidas, increase parity, previous history of post term pregnancy).
2. Maternal weight loss in last weeks of pregnancy.
3. Oligohydramnios or reduced amount of amniotic fluid.
4. Reduced rate of uterine and fetal growth.
5. Large for gestational age fetus.
B. Clinical Management:
1. Review dating parameters.
2. Vaginal exam for cervical status re: consistency, dilatation and effacement, and
relationship of fetal head to cervix (well applied or not).
3. It is recommended that antepartum fetal testing begin at the 41st week of pregnancy.
4. Provide anticipatory guidance to patient and family re: induction, NST, OCT,
biophysical profile.
5. Consultation with OB physician.
REVISED BY: Marj Gold, RN
APPROVED BY: Mari Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT PROTOCOL
— PHYSICAL EXAM DATA
PAGE# 8
GUIDELINE TITLE: SIZE/DATES DISCREPANCY
PURPOSE: Identification of protocol for size/dates discrepancy.
INSTRUCTIONS:
A. Size greater than dates:
1. Historical findings: Large mother or father; history of LGA infant(s); uncertain or
incorrect dates; irregular menstrual history.
2. Physical exam findings: R/O multiple gestation; hydatidiform mole; polyhydramnios;
"Fibroids"; large uterus for dates.
3. Lab findings: Ultrasound most accurate at SCMC between 18-24 weeks for dating.
HPS Table of Contents.doc
39
B. Size less than dates:
1. Historical findings: Smoker; high blood pressure; high altitude; ETOH consumption;
malnutrition; renal disease; irregular menstrual history; spotting; uncertain or incorrect
dates.
2. Physical exam findings: Oligohydramnios; fetal demise; IUGR; transverse lie; fetus
engaged.
C. CONSULT: When discrepancy between size and dates presents beyond the normal patterns
as stated below, particularly when associated with any of the above stated findings.
D. NORMAL FUNDAL GROWTH PATTERNS: At least lcm/2 weeks or 3cm/4 weeks. No
greater than 2cm/1 week or 3cm/2 weeks.
Sources:
1. Williams, 1980 pp 949-52
2. Oxorn & Foote, 4th Ed. Pp 602-606
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL — PHYSICAL EXAM
DATA
PAGE# 9
GUIDELINE TITLE: PREGNANCY INDUCED HYPERTENSION
PURPOSE: Identification of management protocol for Pregnancy Induced Hypertension.
INSTRUCTIONS:
A. Predisposing factors: Primigravida, adolescent, family history.
B. Historical and physical exam data suggestive of PIH:
1. Blood pressure: Greater than or equal to 140/90, or an increase of 30 torr systolic
and/or 15 torr diastolic in basal blood pressure.
2. Classic triad: Hypertension as above, edema, proteinuria. This triad represents end
stage of disease process.
3. Other S/S: Headaches, dizziness, other visual disturbances, drowsiness, weight gain
greater than 2.5 lb/week or greater than 7 lb. in 4 weeks. Greater than 2 DTRs, any
presence of clonus.
C. Laboratory Data:
1. 24 hour protein: Normal less than 300 mg/24 hour period.
2. Creatine clearance: Less than or equal to 85 mi/min is abnormal (usual normal range is
120-180 ml/min).
3. Uric acid: Upper limit is less than or equal to 4.5 mg/dl.
4. Serum creatinine: Normal less than or equal to 0.7 mg/dl.
HPS Table of Contents.doc
40
5. BUN: Normal less than or equal to 10 mg/dl.
6. Platelet count: for baseline.
D. Management:
1. CONSULT if patient presents with blood pressure greater than or equal to above
parameters OR presents with the above triad symptoms.
2. Mild PIH:
a. Elevated (upper range normal / lower range abnormal) blood pressure with no
edema
b. No proteinuria
c. No hyperreflexia
3. General measures:
a. Bedrest — on left side with legs elevated
b. 100 gm protein/day diet; no added salt
c. Ensure adequate fluid intake — 10 glasses liquid/day
d. Counsel regarding danger signs: Severe headaches, dizziness, blurred vision, severe
abdominal pain, significant edema.
3. Check DRTs and clonus; chart
4. RTC more frequently for BP checks, etc.
5. If decline noted in patient status, contact MD consultant immediately for plan. Provide
patient/family with anticipatory guidance re: Ultrasound, NST, OCT, coagulation
studies, possible/probable hospitalization.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOL — PHYSICAL EXAM
DATA
PAGE# 10-11
GUIDELINE TITLE: CHILDBIRTH AT HEALTHYSTART PRENATAL SERVICE
PURPOSE: Identification of management protocol for childbirth at HealthyStart Prenatal
Service.
INSTRUCTIONS: Although it is the policy and intention of HealthyStart Prenatal Service to
have all patients deliver at St. Charles Medical Center with HPS physicians in attendance, it is
necessary to prepare for an unexpected childbirth at the HPS location.
A. HPS will have emergency delivery equipment available at all times:
1. OB Delivery Pack (1)
2. OB Delivery Instrument Kits (2)
3. Sterile Gloves
4. Goggles (1)
5. Sterile Water — 1500 cc (1)
6. Delee Suction Catheter (1)
7. Mucous Tram Suction Catheter (1)
HPS Table of Contents,doc 41
8. Oxygen Masks: Neonatal (1), Adult (1)
9. Oxygen Tank
10. Resuscitation Bags: Neonatal (1), Adult (1)
11. Emergency Drug Kit:
a. Pitocin — 4 vials
b. Methergin — 2 amps
c. Syringes, filters, needles, alcohol wipes
B. A thorough assessment will be made of the HPS patient in labor. If it is determined by HPS
staff that there is time, the patient will be transported to SCMC 's Family Birthing Center
by Bend Ambulance for delivery there.
C. The FBC nursing staff and on-call HPS staff will be notified of patient's condition and
estimated time of arrival.
D. If the delivery is imminent, HPS staff will prepare for delivery at HPS.
E. Delivery at HPS will be attended by qualified HPS staff as available.
F. After delivery, the attending staff will note:
1. Time of birth
2. APGAR scores
3. Infant's condition
4. Mother's condition
5. Complications, if any
6. Time of delivery of placenta
G. Bend Ambulance (call 911) will be notified of patient's condition to transport to SCMC
after delivery. Mother, infant and placenta will be transported to SCMC. Attending HPS
staff should accompany patient to SCMC.
H. If placenta does not deliver spontaneously within 30 minutes, transfer of patient to SCMC
will be initiated.
I. The on-call HPS doctor will be given report about the birth and any complicatins by HPS
attending staff.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 1-1-01
HPS Table of Contents.doc 42
HEALTHYSTART PRENATAL SERVICES
GUIDELINES FOR PRENATAL CARE
TABLE OF CONTENTS
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOLS — LAB DATA
PAGE# 1
GUIDELINE TITLE: ULTRASOUND
PURPOSE: Identification of protocol for use of ultrasound.
INSTRUCTIONS:
A. Purpose:
1. To determine gestational age
2. To estimate fetal size
3. To rule out the presence of multiple fetuses
4. To determine fetal presentation, i.e., cephalic, breech, etc.
5. To evaluate presence of intrauterine growth retardation (by serial ultrasound)
6. To determine placental location and size
7. To rule out fetal demise
8. To evaluate bleeding and rule out placenta previa or abruption
9. To determine quantities of amniotic fluid
10. Not used to determine sex
11. Ultrasound for dating required for any gestation >20 weeks at first prenatal visit
12. Post dates pregnancy may require Biophysical Profile and/or amniotic fluid volume
evaluation
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents.doc 43
Page
VII. MANAGEMENT PROTOCOL — LAB DATA
Ultrasound
1
Non -Stress Testing and Contraction Stress Testing
2-3
Fetal Echocardiography Lab Testing
4
Alpha Fetoprotein Prenatal Testing of Maternal Serum
5
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOLS — LAB DATA
PAGE# 1
GUIDELINE TITLE: ULTRASOUND
PURPOSE: Identification of protocol for use of ultrasound.
INSTRUCTIONS:
A. Purpose:
1. To determine gestational age
2. To estimate fetal size
3. To rule out the presence of multiple fetuses
4. To determine fetal presentation, i.e., cephalic, breech, etc.
5. To evaluate presence of intrauterine growth retardation (by serial ultrasound)
6. To determine placental location and size
7. To rule out fetal demise
8. To evaluate bleeding and rule out placenta previa or abruption
9. To determine quantities of amniotic fluid
10. Not used to determine sex
11. Ultrasound for dating required for any gestation >20 weeks at first prenatal visit
12. Post dates pregnancy may require Biophysical Profile and/or amniotic fluid volume
evaluation
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents.doc 43
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOLS — LAB DATA
PAGE# 2-3
GUIDELINE TITLE: NON-STRESS TESTING AND/OR CONTRACTION STRESS TESTING
PURPOSE: Identification of protocol for use of NST and/or CST.
INSTRUCTIONS:
Indications — Non -Stress Test
1. History of previous stillborn. Consult with MD.
2. Drug abuse and/or chronic alcoholism
3. Systemic lupus erythematosus
4. Hemoglobinopathy
5. Chronic renal disease
6. Hyperthyroidism
7. FHR abnormalities, heard on auscultation
8. Decreased fetal movement
9. Hypertensive disorders in pregnancy
10. Suspected IUGR
11. Placenta previa
12. Abruption
13. Postdates greater than or equal to 41 weeks from LMP documented by one of the
following:
a. Clinical assessment
1) Pelvic examination prior to 12 weeks which agrees with dates
2) Auscultation of unamplified fetal heart tones for at least 22 weeks
b. Reliable menstrual history: Exact date of LMP was known, duration and flow had
been normal for that patient, and oral contraceptives had not been used within 3
months of that period. At least one of the clinical assessments must agree with
menstrual history.
c. Ultrasound prior to 25 weeks gestation
d. Meconium in the amniotic fluid as seen by amnioscope or amniocentesis.
B. Indications — Contraction Stress Test (Breast Stimulation Stress Test)
1. Non-reactive NST
2. Documented IUGR (by serial ultrasounds)
3. Class A Diabetes Mellitus at 40 weeks. Class B -R Diabetes Mellitus greater than or
equal to 30 weeks.
4. Hypertensive on medication.
C. Contraindications for CST:
1. Previous cesarean section (relative). Classical c/s (absolute).
2. Placenta previa
3. Premature rupture of membranes
4. Premature labor
5. Bishop score of greater than or equal to 6.
HPS Table of Contents.doc 44
D. Biophysical Profile may be done on patients with equivocal CST or non-reactive NST. This
is NOT a fetal structure survey.
E. Amniotic fluid testing may be ordered for the postdates patient. Amniotic fluid testing is
NOT a fetal structural survey.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT
PROTOCOLS — LAB DATA
PAGE# 4
GUIDELINE TITLE: FETAL ECHOCARDIOGRAPHY LAB TESTING
PURPOSE: Identification of protocol for Fetal Echocardiography Lab Testing.
INSTRUCTIONS:
A. Management: It is recommended that an ultrasound be done at 16-18 weeks for the
following indications. If abnormalities are noted on ultrasound, then echocardiography
should be done at 24-28 weeks gestation.
B. Indications:
1. Fetal arrhythmias (refer anytime in pregnancy)
2. Women with previous history of babe with cardiac anomalies
3. History of cardiac disease in mother or father of babe.
4. Any fetus at risk for congenital heart disease (mother exposed to lithium, rubella, some
diabetic mothers)
5. Fetal hydrops of unknown cause
C. Cost:
1. $300
2. May be submitted for one-time test
D. Location:
1. University Hospital South — 9th floor
2. Lab phone number: (503) 225-8754
E. Duration:
1. Approximately 30 to 60 minutes
F. Special requests:
1. No meal before exam, please
HPS Table of Contents.doc 45
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: MANAGEMENT PROTOCOLS
— LAB DATA
PAGE# 5
GUIDELINE TITLE: ALPHA-FETOPROTEIN PRENATAL TESTING OF MATERNAL
SERUM
PURPOSE: Identification of protocol for Alpha-fetoprotein testing.
INSTRUCTIONS:
A. Indications:
1. Family history of neural tube defect (NTD) — sibling, nieces/nephews
2. Women with previous history of child born with a NTD should be advised to have an
amniocentesis to check for AFP levels.
3. Test is being offered to all pregnant women, regardless of age or history of previous
pregnancies.
B. Counseling:
1. Careful counseling needs to be offered regarding possible results and the various
subsequent plans.
2. Refer to Abbot Laboratory information for further detail.
C. Timing:
1. Optimal timing is during week 16, 17 or 18 of pregnancy.
D. Cost:
1. Including postage paid mailer is $99.
E. Sampling procedure: See SAMPLE sheet that follows.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents.doc 46
HEALTHYSTART PRENATAL SERVICES
GUIDELINES FOR PRENATAL CARE
TABLE OF CONTENTS
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: GUIDELINES FOR NURSE -
MIDWIFERY CARE
PAGE# 1-2
GUIDELINE TITLE: INTRAPARTUM CARE
PURPOSE: Identification of guidelines for intrapartum care by nurse -midwife.
INSTRUCTIONS:
Provide comprehensive intrapartum care to low-risk HealthyStart clients, in collaboration with
hospital obstetric, pediatric, anesthesia and nursing staff.
A. Admit women in labor.
B. Diagnose labor and its progress.
C. Order appropriate laboratory tests.
D. Diagnose rupture of the membranes.
E. Perform periodic pelvic examinations and assess the status of the woman and fetus during.
labor.
1. Intermittent auscultation with Doptone or fetoscope
2. External fetal monitor
3. Fetal scalp electrode
4. Fetal blood pH, after consultation with the back-up physician
F. Perform amniotomy if/when indicated.
G. Order and administer analgesia (per established SCMC Standing Orders). Consult with or -
call obstetrician when epidural or other anesthesia is indicated; CNM will evaluate and
obtain consult with anesthesiologist.
H. Order or initiate intravenous therapy when indicated.
HPS Table of Contents.doc 47
Page
VIII. GUIDELINES FOR NURSE MIDWIFERY
Intrapartum Care
1-2
Postpartum Care
3
Conditions Which Require Intrapartum Consultation and Collaboration
4-5
Intrauterine Device (IUD)
6-9
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: GUIDELINES FOR NURSE -
MIDWIFERY CARE
PAGE# 1-2
GUIDELINE TITLE: INTRAPARTUM CARE
PURPOSE: Identification of guidelines for intrapartum care by nurse -midwife.
INSTRUCTIONS:
Provide comprehensive intrapartum care to low-risk HealthyStart clients, in collaboration with
hospital obstetric, pediatric, anesthesia and nursing staff.
A. Admit women in labor.
B. Diagnose labor and its progress.
C. Order appropriate laboratory tests.
D. Diagnose rupture of the membranes.
E. Perform periodic pelvic examinations and assess the status of the woman and fetus during.
labor.
1. Intermittent auscultation with Doptone or fetoscope
2. External fetal monitor
3. Fetal scalp electrode
4. Fetal blood pH, after consultation with the back-up physician
F. Perform amniotomy if/when indicated.
G. Order and administer analgesia (per established SCMC Standing Orders). Consult with or -
call obstetrician when epidural or other anesthesia is indicated; CNM will evaluate and
obtain consult with anesthesiologist.
H. Order or initiate intravenous therapy when indicated.
HPS Table of Contents.doc 47
I. Deliver the infant and the placenta (SVD or Mityvac prn).
J. Perform and repair episiotomy, repair lacerations as needed.
K. Identify abnormal conditions and consult with or refer to physician.
L. Assist with cesarean delivery, after an orientation period to be specified by the Medical
Director of HealthyStart.
M. Utilize medications and procedures to prevent/limit postpartum hemorrhage.
N. Facilitate family participation and bonding.
0. Perform immediate newborn assessment.
P. Prescribe routine postpartum orders for SCMC.
Q.
Manage obstetric emergencies until the physician arrives (e.g., cord prolapse, hemorrhage,
seizures, shoulder dystocia, retained placenta, resuscitation).
R. Manage induction of labor with pitocin and/or prostaglandins, after physician consultation.
S. Manage augmentation of labor with pitocin in uncomplicated labor.
T. Maintain clear and accurate medical records for all clients, including an initial history and
physical exam, and ongoing progress at appropriate intervals, especially in the case of
parturients whose condition deviates from the normal. All consultations and referrals for
such deviations from the norm should be noted in the chart, including the name,
professional status, and affiliation of the person consulted, and the date and time of the
consultation.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 1 1 -6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: GUIDELINES FOR
NURSE -MIDWIFERY CARE
PAGE# 3
GUIDELINE TITLE: POSTPARTUM CARE
PURPOSE: Identification of guidelines for postpartum care by nurse -midwife.
INSTRUCTIONS:
Provide comprehensive postpartum care to HealthyStart clients.
A. Perform postpartum examination before discharge from hospital and at follow-up visits.
HPS Table of Contents.doc
48
B. Provide appropriate teaching and counseling (e.g., regarding infant feeding, family
planning, etc.).
C. Manage lactation and its common problems.
D. Assure ongoing care for client and infant by referring appropriately before discharge from
service.
E. Maintain appropriate medical records.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 1 1 -6-00
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: GUIDELINES FOR NURSE -
MIDWIFERY CARE
PAGE# 4-5
GUIDELINE TITLE: INTRAPARTUM CONSULTATION AND COLLABORATION
PURPOSE: Identification of intrapartum cases requiring physician consultation and
collaboration.
INSTRUCTIONS:
The nurse -midwife must consult with the physician (obstetrician or pediatrician as appropriate) in the
following cases. A plan for collaborative care, referral, or follow-up consultation must be included on
the chart at the time of diagnosis.
A. Pregnancy induced hypertension.
B. Abnormal vaginal bleeding.
C. Preterm labor.
D. Preterm rupture of the fetal membranes.
E. Fetal demise.
F. Rupture of the fetal membranes for greater than 6-8 hours, at term.
G. Moderate to heavy meconium staining of the amniotic fluid.
H. Moderate to severe variable decelerations of the fetal heart rate.
I. Repetitive late decelerations of the fetal heart rate.
HPS Table of Contents.doc
49
J. Protraction or arrest of labor greater than 2 hours.
K. Second stage of greater than 60 minutes without progress.
L. Prolapsed umbilical cord.
M. Postpartum hemorrhage unresponsive to immediate measures.
N. Laceration of the rectum.
0. Cervical lacerations.
P. Third stage greater than 30 minutes without significant bleeding.
Q. Postpartal pyrexia after the first 24 hours, (temperature greater than 100.4).
R. Postpartal wound infection.
S. Postpartal hematoma.
T. Dysmaturity of the neonate (prematurity, postmaturity, SGA/LGA).
U. Major congenital anomalies of the neonate.
V. Abnormal vital signs in the neonate, including hypothermia.
W. Meconium aspiration.
X. Apgar of less than 7 at 5 minutes.
Y. Birth trauma.
Z. Respiratory distress.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents.doc 50
HEALTHYSTART PRENATAL SERVICE
DESCHUTES COUNTY HEALTH DEPT.
TRAINING DOCUMENT - PROTOCOLS
SECTION: GUIDELINES FOR
NURSE -MIDWIFERY CARE
PAGE# 6-9
GUIDELINE TITLE: INTRAUTERINE DEVICE (IUD)
PURPOSE: Identification of protocol for use of Intrauterine Device.
INSTRUCTIONS:
A. CONTRAINDICATIONS:
1. Pregnancy or suspected pregnancy. A copper IUD is an acceptable method of postcoital
contraception.
2. History of infected abortion, pelvic inflammatory disease, or postpartum endometritis
with the previous three months.
3. Cancer of the uterus; untreated cancer of ovary or cervix; trophoblastic cancer.
4. Cervicitis or positive GC or CT culture until treated and test of cure reported.
5. Wilson's Disease (copper -bearing IUD only).
6. Allergy to copper (copper -bearing IUD only).
7. Between 48 hours and 4 weeks postpartum.
B. Precautions:
The following conditions may preclude the use of an IUD by the client unless she and the
clinician agree that the risk of pregnancy with alternative methods of contraception
outweighs any risks or discomforts that may be a consequence of IUD insertion/usage.
Consultation with a physician may be indicated in some cases.
1. Pelvic inflammatory disease in the past without subsequent pregnancy, especially in a
woman desiring more children.
2. Previous pelvic infection or physical findings of previous infection, such as
enlargement or scar tissue in adnexa.
3. Previous tubal pregnancy. Patient may have copper -containing IUD inserted but should
be counseled that IUD does not decrease rate of ectopic pregnancy like methods
preventing ovulation.
4. Multiple partners, or partner with multiple partners because of STD risk.
5. Menorrhagia, metrorrhagia, or severe dysmenorrhea. Progestin -containing IUD may
improve dysmenorrhea and bleeding pattern.
6. Undiagnosed uterine bleeding until evaluated.
7. Anemia — hematocrit below 32 or hemoglobin below 10. Sickle cell disease and
thalassemia.
8. Impaired clotting response; anticoagulant therapy; thrombocytopenia purpura.
9. Distortion of uterine cavity due to myomata or congenital malformation, such as septate
uterus, double uterus, DES exposure with cervical anomalies. Severe cervical stenosi.i.
10. Endometriosis.
11. Inability to sound the uterus to a depth of at least 6 cm from external os.
12. Women with valvular heart disease need prophylactic antibiotics. Use amoxicillin 3
grams one hour before the procedure and 1.5 grams six hours after the procedure. If
client is allergic to penicillins, use erythromycin 1 gram one hour before the procedure
and 0.5 gram six hours after the procedure.
13. Less than 6 weeks postpartum, or 4 weeks post abortion.
HPS Table of Contents.doc 51
14. Trophoblastic disease during previous year.
15. Impaired inflammatory response: immunosuppressive or cortisone treatment,
immunodeficiency disease, cancer chemotherapy. Recent studies indicate copper -
bearing IUD are save in diabetic women.
16. Nulliparity. Intrauterine contraception is generally not the method of choice for the
woman who has never been pregnant. Reasons include risk of infection, infertility, and
severe pain or syncope on insertion.
17. Inability to palpate the string. The partner may assist, or client may need to make more
frequent visits to the clinic for evaluation.
18. Known or suspected cervical neoplasia or abnormal Pap not yet treated. Colposcopy
and appropriate treatment should be completed before insertion of an IUD since
sometimes temporary removal is necessary before treatment.
19. Actinomyces on present or previous Pap smears.
20. Bacterial vaginosis may predispose to pelvic infection after insertion of the IUD. If
infection is present, treat before insertion, even if the infection is asymptomatic. Once
infection has been treated, the IUD may be inserted.
C. SIDE EFFECTS AND COMPLICATIONS:
1. Bleeding starting soon after insertion — Rule out anemia, infection or pregnancy.
Provide iron as appropriate (page ). Ibuprofen 400 to 800 mg three times daily may
help (not aspirin). Reassure client that bleeding usually decreases after a few months.
2. Bleeding starting many months after insertion — Evaluate for infection including
actinomyces, pregnancy including ectopic, uterine pathology, or dysfunctional uterine
bleeding. Manage with iron and ibuprofen as appropriate. Consider removal of the IUD
if client requests.
3. Cramping or pain — Pain associated with insertion or dysmenorrhea may be relieved by
ibuprofen or other medication (page ). Check for possible perforation or partial
expulsion. If the IUD is partially expelled, remove the IUD and replace with a new IUD
as appropriate. Rule out infection or other causes of late onset of pain.
4. Missing IUD strings may be due to expulsion, pregnancy, perforation of the uterus or
retraction into the nonpregnant uterus. Use an alternative method of contraception until
the next period. Examine for the string and seek with a string retriever under aseptic
techniques if the strings are not visible. If the IUD cannot be located, refer the client for
an ultrasound to confirm the location of the IUD. If her period is late, she should come
in for a pregnancy check. If the IUD is in the uterus, a string retriever may bring down
the strings, or a hook may be used to remove the IUD if desired. Some women may
choose to retain the IUD with the strings not palpable once ultrasound has confirmed
intrauterine placement. If the IUD has perforated the uterus, refer for surgical removal.
If the IUD was expelled, a new IUD may be inserted. Expulsion occurs in about 4 to
8% of women with an IUD.
5. Pregnancy with a device in the uterus — Remove the IUD as early in pregnancy as
possible if the strings are visible. If the IUD strings are not visible when the pregnancy
is detected, recommend and ultrasound examination. If the IUD is in the uterus, stress
to the woman to report any symptoms of infection. Consider the possibility of an
ectopic pregnancy, especially with the Progestasert.
6. Uterine infection — Beyond the first few months after insertion, PID is not increased
with IUD use but the IUD acts as a foreign body and may complicate treatment.
Manage as for PID (see page ). Usually the IUD should be removed 24 to 48 hours after
starting the antibiotics. If the infection is not cleared within two weeks, the IUD must
be removed.
HPS Table of Contents.doc 52
7. Actinomyces on Pap in woman with IUD in uterus — In most cases the actinomyces is
confined to the vagina and coats the IUD string. In nulliparous women consider
removal of the IUD. During removal, do a Pap from the surface of the IUD, avoiding
the string. If the Pap smear shows actinomyces had reached the uterus, treat with
amoxicillin 500 mg three times daily for 10 days.
a. In symptomatic women (pain, abnormal bleeding), or women with an abnormal
pelvic examination (tenderness, mass, etc.), remove the IUD and treat for pelvic
inflammatory disease (see page ).
b. Counsel the multiparous woman with no symptoms and a normal pelvic
examination about possible problems. She should return for examination and
treatment if any symptoms develop. The IUD may be removed if she desires, but it
is not necessary unless signs or symptoms develop.
D. PRESCRIBING OF IUD:
1. A GC culture, wet mount and chlamydia test should be done about one to 12 weeks
before insertion of an IUD and results recorded on chart. If bacterial vaginosis is
diagnosed, treat before insertion, even if it is asymptomatic.
2. The clinic copy of the informed consent is signed before insertion and kept in the
client's chart. A copy of the consent is given to the client. Prophylactic antibiotics may
be prescribed according to clinician preference.
3. The advantages of insertion soon after the menstrual period include: an early pregnancy
is not overlooked, the device is easier to insert, and bleeding due to the device is not as
readily apparent. Insertion near midcycle is easier due to dilation of the os at this time,
expulsion tends to be lower than other times during the cycle, and the IUD can work for
emergency contraception. The IUD may be inserted from day 1 to day 7 of the cycle. If
client is on hormonal contraceptives, has an IUD in place, or pregnancy is ruled out, the
insertion may be at any time of the cycle.
4. Advise the client to eat within three hours before time of insertion, to decrease
incidence of vasovagal reactions. Ibuprofen 600 to 800 mg about one hour before the
procedure will decrease discomfort.
5. The type of IUD will depend on the clinician, the client, and availability. Generally, a
copper T380A or Progestasert will be used. The Copper T380A is replaced every ten
years and the Progestasert is replaced every year.
INSERTION OF IUD
1. Use sterile instruments and gloves.
2. Thoroughly (at least three times) swab the cervix with a povidone-iodine solution or
other approved antiseptic. Topical anesthetic (Hurricane gel) on the tenaculum site and
inside the cervical canal will decrease discomfort.
3. Use a tenaculum through the anterior lip of the cervix to straighten the uterus and
facilitate sounding and insertion.
4. Carefully sound the uterus before insertion to ascertain the depth and direction of the
uterine cavity and to reduce the risk of perforation. If necessary, use slow, steady
pressure of the sound to effect dilation of the cervical os. Set the movable flange on t
insertion tube to the depth of the uterus, or measure the depth with the insertion tube.
5. Insert the IUD as directed on the package insert. Orient the IUD so the arms will opel
horizontally in the uterus. Use the withdrawal insertion technique. Aim to place the
IUD high in the uterus, at the fundus.
6. Cut the IUD string to leave a minimum length of 1.5" protruding into the vagina.
7. Check the pulse of the client after insertion.
HPS Table of Contents.doc 53
8. Instruct the client in feeling for the ILTD strings.
9. For cramping, give an analgesic such as ibuprofen.
10. If severe syncope occurs (BP under 70 systolic or pulse under 50): administer 0.5 to 2.0
mg atropine intravenously (subcutaneous if cannot get into a vein) and remove the IUD
if persists.
11. Record client identification information and lot number of IUD in IUD log.
REVISED BY: Marj Gold, RN
APPROVED BY: Marj Gold, Leader Manager FBC
DATE: 11-6-00
HPS Table of Contents. doc 54
NAMED
INSURED
AN D
MAILING
ADDRESS
AMERICAN ECONOMY INSURANCE COMPANY
SEATTLE, WASHINGTON
ULTRA SELECT POLICY
BEND OBSTETRICS AND
GYNECOLOGY, LLC
2450 NE MARY ROSE PL STE 220
BEND, OR 97701
SEE NAMED INSURED EXTENSION
POLICY PERIOD FROM 04-23-08 TO 04-23-09 12:01 AM
STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE.
FORM OF
BUSINESS:
LIMITED LIABILITY COMPANY
PAGE 1
AMENDED DECLARATIONS
EFFECTIVE: 04-23-08
POLICY NUMBER 02 -BO -946504-7
RENEWAL OF 02 -BO -946504-6 04-02
AGENT
NAM E
AND
ADDRESS
THE PARTNERS GROUP
11740 SW 68TH PKWY STE 200
PORTLAND, OR 97223
36-43841 (503) 241-9550
THE CHANGE IN YOUR POLICY RESULTS IN AN ADDITIONAL PREMIUM OF $156.00.
YOU WILL BE BILLED THROUGH YOUR CUSTOMER ACCOUNT #210-7650-447-01.
Location one has been amended to 2450 NE Mary Rose P1, Bend, Or 977C1.
Business personal property has been increased to $350,000.
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU
TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
ADDL INSD-BLDG MGR/LESSOR
D & D PROPERTY OF TULSA
PREMISES001 C/O COLDWATER BANKER PROPERTY
PO BOX 190
BEND, OR 97709
THE FOLLOWING FORMS CURRENTLY APPLY TO THIS POLICY:
BP0003(0106) BUSINESSOWNERS SPECIAL COVERAG
BP7080(0606) ORDINANCE OR LAW COVERAGE
BP8094(0606) NON -OWNED AUTO LIAB. AMEND. EN
BP7057(0702) ADDT'L INSD-DESIG.PERSON OR OR
BP7059(0105) COMMERCIAL FINE ARTS COV FORM
BP0523(1102) CAP ON LOSSES CERTIFIED ACTS 0
BP8206(0606) ID RECOVERY COV FOR DEFINE
BP8068(0702) EXCLUSION -ASBESTOS
BP0455(0106) BUSINESS LIAB COV - TENANT
BP0417(0702) EMPLOYMENT RELATED PRACT. EXCL
BP8128(0502) EMPLOYMENT PRACTICES LIABILITY
(DATE)
9-BP(11-88)
BY
LOSS PAYEE
BANK OF THE CASCADES
PREMISES 001 THIRD & REVERE BRANCH
1700 NE THIRD ST / P(1 BOX 5879
BEND, OR 97708
LOAN #10069072 & 010(187046
BP7076(0606)
BP0402(0106)
BP1203(0106)
BP7058(1003)
BP8136(0702)
BP0430 (0106)
IL7201(0392)
BP8029 (0702)
BP0441 (0106)
BP0178(0108)
ULTRA PLUS
ADDTIONAL INSURED -MANAGERS/1
LOSS PAYABLE PROVISIONS
HIRED AUTO PHYSICAL DAMAGE B(
EQUIPMENT BREAKDOWN ENDORSEMI
PROTECTIVE SAFEGUARDS
COMPANY COMMON POL CONDITION:
AMENDMENT -AGGREGATE LIMITS 01
BUSINESS INCOME CHANGES -
OREGON CHANGES
(AUTHORIZED REPRESENTATIVE)
COMPANY USE ONLY
NORTHWEST GO (LISMES) INSURED COPY
Safeco and the Safeco logo are iradernar s of Safeco Corporatio
PREPARED 05-14-08
(DALMAI) CB
POLICY DECLARATIONS EXTENSION
NAMED INSURED: BEND OBSTETRICS AND POLICY NUMBER: 02 -BO -946504-7
THE FOLLOWING FORMS CURRENTLY APPLY TO THIS POLICY (CONTINUED FROM PREVIOUS PAGE):
PAG E
Rr
NAMED INSURED EXTENSION
AMERICAN ECONOMY INSURANCE COMPANY
SEATTLE, WASHINGTON
The following is a complete list of the named insureds:
BEND OBSTETRICS AND
GYNECOLOGY, LLC
9 -BP (1188)
POLICY NUMBER: 02—BO-946504-7
PAGE 2
COMPANY USE ONLY
ADDLNAMINS089461
Safeco and the Safeco logo are registered trademarks of Safeco Co poration
NORTHWEST 60 (LISMES) PREPARED 05-14-08 (DALMAI)
POLICY DECLARATIONS EXTENSION
NAMED INSURED: BEND OBSTETRICS AND
POLICY NUMBER: 02 -BO -946504-7
PAGE
PREMISES 1
BUILDING 1
2450 NE MARY ROSE PL STE 220
BEND, OR 97701
CONSTRUCTION: FRAME
OCCUPANCY: OFFICE - PHYSICIANS
APPLICABLE TO THESE PREMISES
LIMITS OF INSURANCE
EXCEPT WHERE NOTED BELOW, A DEDUCTIBLE OF
$ 250
APPLIES
BUSINESS PERSONAL PROPERTY
$ 350,000
BUSINESS INCOME (NOT EXCEEDING 12 CONSECUTIVE MONTHS)
ACTUAL LOSS SUSTA[NED
DEDUCTIBLE: NONE
DAMAGE TO PREMISES RENTED TO YOU
$ 2,000,000
DEDUCTIBLE: NONE
EQUIPMENT BREAKDOWN
INCLUDED
OUTDOOR SIGNS (DEDUCTIBLE: $ 250)
$ 7,500
MONEY AND SECURITIES (DEDUCTIBLE: $ 250):
INSIDE THE PREMISES
$ 10,000
OUTSIDE THE PREMISES
$ 5,000
ACCOUNTS RECEIVABLE
$ 25,000
COMMERCIAL FINE ARTS
$ 10,000
VALUABLE PAPERS AND RECORDS
$ 25,000
MINI COMPUTER EQUIPMENT COVERAGE
INCLUDED
SEWER OR DRAIN BACK-UP
$ 5,000
ORDINANCE OR LAW - COVERAGES B AND C - COMBINED LIMIT
FOR DEMOLITION COST COVERAGE AND INCREASED COST OF
$ 150,000
CONSTRUCTION COVERAGE
BUSINESS INCOME CAUSED BY DEPENDENT PROPERTIES
$ 5,000
ELECTRONIC DATA
$ 25,000
POLICY DECLARATIONS EXTENSION
NAMED INSURED: BEND OBSTETRICS AND
POLICY NUMBER: 02 -BO -946504-7
PAGE
APPLICABLE TO ALL PREMISES YOU OWN, RENT OR OCCUPY
LIMITS OF INSURANCE
BUSINESS LIABILITY:
LIABILITY (INCLUDING PRODUCTS AND COMPLETED
OPERATIONS) AND MEDICAL EXPENSES
MEDICAL EXPENSES (ANY ONE PERSON)
AGGREGATE LIMITS
HIRED AUTO AND NON -OWNED AUTO LIABILITY
HIRED AUTO PHYSICAL DAMAGE
DEDUCTIBLE: $100 COMPREHENSIVE $250 COLLISION
EMPLOYEE DISHONESTY (DEDUCTIBLE: NONE)
FORGERY OR ALTERATION (DEDUCTIBLE NONE)
EMPLOYMENT PRACTICES (DEDUCTIBLE: NONE):
EACH INCIDENT LIMIT
AGGREGATE LIMIT
RETROACTIVE DATE OF 04/23/03
IDENTITY RECOVERY COVERAGE EXPENSE REIMBURSEMENT
$ 2,000,000
$ 10,000
$ 4,000,000
SEE BUSINESS LIABILITY
$ 50,000
$ 15,000
$ 25,000
$ 10,000
$ 10,000
$ 25,000
PREMIUM FOR CERTIFIED ACTS OF TERRORISM $ 3.00
TERM PREMIUM $ 653.00
TOTAL TERM PREMIUM $ 656.00
Liberty
Northwest
Mcmbcr of Uberry Mutual Group
December 28, 2007
BEND OBSTETRICS GYNECOLOGY LLC
2381 NE CONNERS AVE
BEND OR 97701-6068
11111111111111111111111111111111111111111h1111111111111111111
RE: Policy Renewal and Reinstatement of Guaranty Contracts
Policy No. WC4-3NC-507169-018 RO6
WCD No. 1096528
Dear Policyholder:
Liberty Centre
650 NE Holladay Street
P.O. BOK 4555
Portland, OR 9720+3-4555
Tel: (503) 239-5800
www.Iibertynorthwe st.com
The above captioned workers' compensation policy has been renewed, without lapse in coverage, for the
period of 3/01/08 to 3/0 1 / 09 . The Guaranty Contract is reinstated effective 3/0 1 / 08 .
Thank you for renewing with Liberty Northwest. Please contact the Customer Contact Center at 866-456-
1715, if you have any questions regarding your workers' compensation coverage.
Sincerely,
Liberty Northwest Insurance Corporation
cc: National Council on Compensation Insurance
Department of Consumer and Business Services
WR REED & CO
4380 SW MACADAM AVE STE 300
PORTLAND OR 97239-6427
1li1111111l11l1l11ll11111111l111l11l1111111111l111l11111111111
12/28/07 EFSsa
ARRRGC