Professional Documents
Culture Documents
L&D Nurse Managers and Instructors (May 21, 2004) April 1, 1999 May 27, 2005
Women’s and Infant Health Managers (May 10, 2005)
PURPOSE
1. To provide evidence based guidelines for safe care including standards for frequency of bio-
psycho-social assessments, nursing interventions and documentation.
APPLICABILITY
This policy applies to Calgary Health Region nursing staff caring for postpartum women and their families.
POLICY
1. Transfer of Care
1.1 Nursing staff, from the receiving unit, are to receive a patient report given by a nursing
staff member from the sending unit.
1.2 Nurse-to-nurse report is to include all relevant information related to antepartum and
intrapartum events, as well as a review of outstanding intrapartum and postpartum
orders.
1.3 All relevant documentation is to be completed prior to transfer of care (including the
discontinuation or completion of all physician/midwifery orders that are no longer relevant
to care, according to patient care information system {PCIS} protocols).
2.2 Documentation on health records is to accurately reflect all aspects of this care.
2.2 Maternal assessments are to be made and documented on the patient health record
accordingly:
At admission, and
At least once during the following six (6) hours, then
Q12h and PRN, as determined by nursing judgment, until discharge.
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WOMEN’S AND INFANT HEALTH
POLICY AND PROCEDURE
SUBJECT/TITLE: DATE DATE REVISED: NUMBER: PAGE:
ESTABLISHED:
3. Infant Nutrition
3.1 Nursing staff are to support the mother’s choice of infant feeding (breast milk or formula).
3.2 Parents are to be provided with relevant, unbiased information about infant nutrition in
order to make informed decisions.
POINTS OF EMPHASIS
1. Mother-Infant Separation
1.1 Every effort must be made to limit separation of mother and infant.
1.2 Encourage skin-to-skin contact.
2. Breastfeeding
Breastfeeding is the recommended method of feeding for newborn infants; new parents require
information (through the use of appropriate current resources, including From Here Through
Maternity), support and encouragement in order to learn and understand:
• Benefits of breastfeeding
• Recognition of feeding cues
• Identification of proper latching and how to correct an improper latch
• Assessment of effective milk transfer by infant:
- Sucking
- Swallowing
- Output (urine and stool)
- Behaviour
• Breast care
3. Formula Feeding
3.1 Parents choosing to formula feed their infants require information and support in order
to learn the principles of effective, safe formula feeding; provide teaching and
encourage the use of appropriate current resources, including From Here Through
Maternity.
3.2 Women choosing to formula feed their infants require information on breast care.
PROCEDURE
2. Greet transferred family, assist mother into bed as necessary and orientate family to room/call
bells.
3. Verify and document mother and infant ID bands; refer to policy 4-I-1 Identification of the
Newborn.
4. Ensure mother understands importance of calling for assistance when getting out of bed for
the first time.
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WOMEN’S AND INFANT HEALTH
POLICY AND PROCEDURE
SUBJECT/TITLE: DATE DATE REVISED: NUMBER: PAGE:
ESTABLISHED:
9. Address family learning needs based on the maternal bio-psycho-social assessment findings,
past experience with infant care, educational level and available family and community
support.
10. If necessary, initiate Social Work or other referrals, preferably with maternal consent; refer to
policy 4-S-1 Social Work Referral.
12. Document all assessments and interventions/responses and plans for subsequent care using
appropriate health record forms and/or the PCIS, e.g., multidisciplinary progress record, flow
sheets, graphic sheets and discharge teaching record; refer to Calgary Health Region policy
1611: Clinical Responsibility for Documentation of Health Information.
REFERENCES
1. American Academy of (2005) Position Paper on Breastfeeding and the Use of Human Milk.
2. AWHONN (1996). Compendium of Postpartum Care.
3. AWHONN (2002). AWHONN Standards For Perinatal Nursing Practice.
4. Green, CJ, & Wilkinson, JM. (2003). Maternal Newborn Nursing Care Plans, Mosby.
5. Lowdermilk, DL. Perry, SE. (2003). Maternity Nursing 6th Edition. Mosby.
6. Pillitteri. A. (2002). Maternal & child health nursing 4th Edition. Lippincott.
7. Simpson, K. R., & Creehan, P. A. (Eds.). (1996). AWHONN Perinatal Nursing. Philadelphia PA: Lippincott.
CROSS REFERENCES