L&D Newsletter

February 2016


As you all know, both our unit and our service line are going through numerous changes this year. I want to thank you all for "rolling with the punches" and being so accepting of everything that is going on!!

Here are some important dates;

  • Feb 15 - small changes to breastfeeding documentation and hypoglycemia protocol
  • March 29th - anticipated Go-Live date for OB ED
  • March and April - March of Dimes fundraising activities
  • April 24 - March of Dimes walk-a-thon


Effective on Jan 1, 2016, there were changes to the Texas law that allow patients to bring their placentas home if they desire. However, we must follow a short set of specific rules to do this.

1. Patients must receive educational material from the State. We have ordered these forms, and they have arrived. We will find a home for them in the file cabinet.

2. Placentas must be placed in a specific biohazard container and bag. Likewise, we have ordered these and are finding a home for them.

3. Placentas must go straight from L&D to HOME! Patients can't take them to their Family Place room with them.

We are NOT advertising this, or promoting it directly for our patients, but if they ask, they do have the right to take them home.


1. Correcting an error: A member from Memorial Hermann legal council spoke at the Women's Council meeting this month. Several things came out of this meeting. NO ONE can correct documentation except for the original person documenting. So this means that if the birth weight is incorrect, for example, a good-meaning nurse cannot go in and mark this as an error and correct it. It must be corrected by the ORIGINAL person entering the documentation.

2. Missing documentation: As with correcting data above, there has been a trend of some vital information being missing from our documentation, especially delivery record information (delivery time, sex of baby, type of delivery and apgars). There is an easy way to help you check to make sure that your documentation is complete. To know that your documentation is complete, look for the "green check mark" on the tracking shell. This will replace the EGA on the tracking shell. If all information is completed after delivery, the EGA number goes away and is replaced by a green check mark. If we all do this before we transfer our patients to FP, we can ensure that the documentation is complete.

3. Baby weights: There has been some discrepancies noted between the weight that we document in L&D and the weight that is taken in the FP. We have done some investigation, and found that the root cause of the discrepancies is the conversion of the weight from pounds/ounces to grams or grams to pounds/ounces. To correct this, we will only document the infant's weight in grams from now on. The family place will also adopt this practice. You can tell the patient and family the weight in pounds/ounces, but please do not document this in the record.

4. Breastfeeding documentation changes: We will no longer document BOTH as a feeding option for our patients. The breastfeeding committee has come up with some scripting for us to say to those patients that state they want to both breast and bottle feed. In addition, we have a breastfeeding commitment form that we will go over with patients on admission. It will be with the consents. This same form will be discussed with the patients again once they reach the Family Place, and throughout their stay. Kathy Miller has all of the information prepared and will in-service all of the staff starting on Monday. We will implement this change on Feb 15th. I know that this is a controversial topic, but much thought has gone into it, and as our breastfeeding rates are the lowest in the system, we felt that we had to make a big change. All changes are evidence-based and have been proven to work at other facilities. The information that Kathy has goes into much more detail. If you have questions, please let me know.

Occupational Health Hours changes and PPD readers

In an effort to make it easier for all of you to get your annual TB tests and visit occupational health, the office hours have been changed. Several emails have been sent out with the new hours. In addition, your clinical coordinators, Sara and Laura have all attended PPD reader classes, so if you just need a test read, see one of us!

L&D Shared Governance updates

We have started having our unit council/committee meetings. There are many exciting things happening!! Once I start receiving monthly reports of committee projects and activities, I will include them in this section of the newsletter. Here are a few updates:

  • Safety/Pharmacy/Falls: they will make a safety poster for National Safety week. Ours will focus on our drills. Pharmacy wants to be notified of any problems programming medications into the alaris pump. Falls risk committee wants us to remember to make sure that we are giving a fall risk assessment in patient handoff. Also, good safety catches should be reported to Charlotte/Sara so that we can send to Administration. They report out on these each month, and we should get credit for everything that we find. See Charlotte for more info.
  • Evidence based practice committee: The EBP council will sponsor nursing grand rounds quarterly. The first will be on 2/22. They will discuss the EBP research process.
  • Magnet Council: Kathy Miller has LOTS of information. She will include this in the breastfeeding/hypoglycemia inservice this week.

Nurse Residents EBP project

Melissa and Katie have asked me to pass on to you that you will soon get a SurveyMonkey survey from them. They are using the results for their project, so please support them and complete the survey.

Mock Joint Commission Survey

We will have a company here Feb 8-12 doing a mock Joint Commission survey. They will be focusing on tracer rounds, and have asked that we send them our induction and surgery schedule each day. This leads me to believe that we will be part of the tracers. The surveyor will come by the unit and choose a patient. They will want to look through the record with the primary nurse, and will ask questions just like the real Joint Commission surveyors. In addition, they will be observing the unit. Please take a careful look around the department to make sure that we are in compliance (especially with NO food and drink at the desk, hallways clear, and nothing under any sinks). You will all do wonderfully!!!

Please email Sara to receive staff meeting credit for reading this newsletter!