Hill Country Memorial Health System

Fredericksburg, Texas

Originating Department: Obstetrics





APPROVED:  V. Keyser

EFFECTED DATE:  January  1993  

REVISED DATE:  February 2001


The Obstetrics Unit serves antepartum, labor and delivery, postpartum, and newborn patients.  The Obstetrics Unit is a Level 1 care unit. When needs arise and/or conditions warrant, clean gynecological surgical patients are admitted to the Obstetrical Unit. The unit strives to provide appropriate, comprehensive, individualized and consistent nursing care in a safe environment.


The unit includes two labor rooms, one birthing room, one delivery room, and three postpartum beds, operated on a twenty-four hour basis on the second floor of Hill Country Memorial Hospital. The most frequent diagnosis for obstetrical patients are: vaginal delivery, cesarean delivery, threatened premature labor, pregnancy induced hypertension, gestational or insulin dependent diabetes. The most frequent gynecological surgical patients are hysterectomy, D & C, and mastectomy. Family practice and OB-GYN physicians represent the specialty areas providing services to the obstetric and gynecological patients.


Patient services provided on this unit includes, but are not limited to:


  1. pregnancy induced hypertension   

  2. diabetes

  3. bleeding

  4. premature rupture of membranes

  5. multiple gestation

  6. preterm labor

  7. post-term pregnancy



Individualized plan of care and teaching are provided and include the family members when applicable. The plan of care and discharge plan are activated on admission and updated as needed.


The nursery unit has a capacity for five bassinets, one isolette and two overhead warmers. The nursery operates on a twenty-four hour basis on the second floor of Hill Country Memorial Hospital. Family practice physicians and pediatricians represent the specialty areas providing services to the newborn patient.                                                                        




Because the staff in this area are required to manage the care of laboring mother, the postpartum mother, the infant, and infrequently, surgical gynecological patients, the following requirements exist:










Team nursing is used as the method to deliver care in this unit.  Staffing is highly variable as reflected in census and types of patients.  There is a Nurse manager who works as a Charge Nurse on the 7-3 shift, and has 24-hour responsibility of the department.  On weekends and nights there is a charge nurse on each shift who is a RN.  This provides coverage of 8.6 hours of nursing care per patient day.


Staffing is performed using staffing guidelines established from actual staffing for 2000-current, and within the standards of AWHONN.  One to one staffing is provided for this type of patient:  2nd stage labor and delivery and the immediate recovery phase of the cesarean patient.  One to one staffing is also provided for this type of patient:  VBAC, terbutaline, magnesium sulfate drips, and Prostin/Cervidil/ cervical ripening during the stabilization phase.  The Pitocin and monitored high risk OB patient are one to one, however this type of patient can be managed 1:2 if located in the LR 1 & 2.  A RN circulator is present for each delivery and for assessment of the newly admitted patient including the newborn.


Minimum staffing in the OB Unit is 1 Licensed Nurse per shift.  At any time the census exceeds 1 mother and 1 newborn, the staff will be supplemented with Licensed Staff or nurse aide staff as required by types of patients and acuity.  


There is a designated OB trained Licensed Nurse designated on each shift to supplement OB staff when needed.


HPPD = 1.6




Patients are assigned to a nurse upon presentation to the Labor/Delivery area.  The RN charge nurse who is designated makes the assignment for that shift.  Assignments will reflect the degree of supervision needed by the individual, the patient and family's needs, the technology used and geography of the unit.  Assignments are to follow practices outlined in Staffing Guidelines.  The charge nurse responsible for making these assignments will be familiar with these policies and procedures and will review them as necessary to keep his/her information current.  Rooming In will be permitted and encouraged for healthy newborns.




Staffing include RNs, LVNs, and NA.


In the event of a severe emergency, the minimum amount of staff would be 1 RN.  Consideration would also have to be made to the number of patients and stage of labor they were experiencing at the time.




Staffing will be dictated by the acuity and logistics of all patients in the OB department, Nursery, L&D, and Postpartum within the standards of AWHONN (Association of Women's Health, Obstetric and Neonatal Nurses).


There will always be a staff member or parent with infant's during the hospital stay.  Also, note there is a security policy located in the policy and procedure manual.


1. Nursery will be staffed according to the acuity of the infant(s).

  1. Nursery skilled aides or licensed staff may care for well infant(s).

  2. Infant(s) requiring more than normal newborn care will be cared for by skilled Licensed personnel.

  3. Infants who have an IV may be cared for by a nursery skilled NA as long as the infant is in stable condition.


2. Infants may be taken with staff member to other areas of department for staff member to complete other tasks, i.e. stocking, making up delivery room/patient room, cleaning.


3. Rooming-in is encouraged according to the needs and desires of the mother.


4. Listed below are the AWHONN standard guidelines:


Nurse/patient Ratio

Care Provided


Newborns requiring only routine care


Normal mother-newborn couplet care


Newborns requiring continuing care


Newborns requiring intermediate care


Newborns requiring intensive care


Newborns requiring multi-system support


Unstable newborns requiring complex critical care


*This ratio reflects traditional newborn nursery care.  If couplet care or rooming-in is used, a professional nurse who is responsible for the mother should coordinate and administer neonatal care.  If direct assignment of the nurse is also made tot he nursery to cover the newborn's care, there may be double assigning (one nurse for the mother-neonate couplet and one for just the neonate if returned to the nursery).  A nurse should be available at all time, but only one may be necessary, as most neonates will not be  physically present in the nursery.  Direct care of neonates in the nursery may be provided by ancillary personnel under the nurse's direct supervision.  Adequate staff is needed to respond to acute and emergency situations.


Recommended Nurse/Patient Ratios for Perinatal Care Services:


Nurse/Patient Ratio

Care Provided




Patients in Labor


Patients in second stage of labor


Patients with medical or obstetric complications


Oxytocin induction or augmentation of labor (If the patients are located in LR 1 & 2)


Coverage for initiating epidural anesthesia


Circulation for cesarean or vaginal delivery




Antepartum/postpartum patients without complications


Patients in postoperative recovery


antepartum/postpartum patients with complications

but in stable condition


recently born infants and those requiring close







The  OB nurse manager is responsible for maintaining adequately trained staff.


1. Ascertains that all personnel are trained in procedures before being assigned to duty, plans and participates in orientation and ongoing education

2. Maintain personnel records, does routine evaluations of staff work performance

3. Promotes professional development of staff consults with staff development to provide education

4. Maintain personnel records

5. Holds periodic meetings with staff to improve efficiency of care and solve problems.