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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


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Part 3 - Professional Services

Chapter 13 - Maternal And Child Health


Title Section
Introduction 3-13.1
    Purpose 3-13.1A
    Policy 3-13.1B
    Objectives 3-13.1C
    Procedures 3-13.1D
    Responsibilities 3-13.1E
        Headquarters 3-13.1E1
        Area/Program Director 3-13.1E2
        Area/Program MCH Chief 3-13.1E3
        Service Unit MCH Coordinator 3-13.1E4
Maternal and Neonatal Health Services 3-13.2
    Purpose 3-13.2A
    Policy 3-13.2B
    Objectives 3-13.2C
    Procedures 3-13.2D
    Responsibilities 3-13.2E
    Service Standards and Guidelines 3-13.2F
        General 3-13.2F1
        Maternal Services 3-13.2F2
        Newborn Services 3-13.2F3
        Safe Hospital Environment 3-13.2F4
Obstetric Anesthesia Care 3-13.3
    Purpose 3-13.3A
    Policy 3-13.3B
    Objectives 3-13.3C
    Procedures 3-13.3D
    Responsibilities 3-13.3E
Nurse-Midwifery 3-13.4
    Purpose 3-13.4A
    Policies 3-13.4B
    Objectives 3-13.4C
    Procedures 3-13.4D
    Responsibilities 3-13.4E
        Headquarters 3-13.4E1
        Area 3-13.4E2
        Service Unit 3-13.4E3
    Standards and Guidelines 3-13.4F
Perinatal and Infant Mortality Reviews 3-13.5
    Purpose 3-13.5A
    Policy 3-13.5B
    Objective 3-13.5C
    Procedures 3-13.5D
    Responsibility 3-13.5E
    Audit and Reporting Procedures 3-13.5F
Care of the Infant and Child 3-13.6
    Purpose 3-13.6A
    Policy 3-13.6B
    Objective 3-13.6C
    Procedures 3-13.6D
    Responsibilities 3-13.6E
    Program Guidelines 3-13.6F
Child Abuse and Neglect 3-13.7
Purpose 3-13.7A
    Policies 3-13.7B
    Objectives 3-13.7C
    Procedures 3-13.7D
    Responsibilities 3-13.7E
    Program Guidelines 3-13.7F
        Identification and Reporting 3-13.7F1
        Admission Policy 3-13.7F2
        Medical Services 3-13.7F3
        Problem Identification & Corrective Actions 3-13.7F4
        Area Monitoring 3-13.7F5
        Legal Proceedings for Removal of Child From Home 3-13.7F6
        The Child Protection Team 3-13.7F7
        Central Registers 3-13.7F8
        Prevention 3-13.7F9
        Training 3-13.7F10
Sexual Abuse 3-13.8
    Purpose 3-13.8A
    Policy 3-13.8B
    Objectives 3-13.8C
    Procedures 3-13.8D
    Responsibilities 3-13.8E
    Program Guidelines 3-13.8F
        Counseling Services 3-13.8F1
        Clinical Services 3-13.8F2
        Legal Responsibilities 3-13.8F3
School Health 3-13.9
    Purpose 3-13.9A
    Policy 3-13.9B
    Objectives 3-13.9C
    Procedures 3-13.9D
    Responsibilities 3-13.9E
    School Health Program Guidelines 3-13.9F
        School Health Services 3-13.9F1
        School Health Education 3-13.9F2
        School Nutrition Program 3-13.9F3
        Healthful School Environment 3-13.9F4
        School Health Staffing 3-13.9F5
        School Health Facilities 3-13.9F6
Care of Adolescent 3-13.10
    Purpose 3-13.10A
    Policy 3-13.10B
    Objectives 3-13.10C
    Procedures 3-13.10D
    Responsibilities 3-13.10E
    Program Guidelines 3-13.10F
        Definition 3-13.10F1
        Consent Regulations 3-13.10F2
        Disclosure of Information 3-13.10F3
        Education and Counseling 3-13.10F4
        Alternative Clinic Site 3-13.10F5
Preventive Health Services 3-13.11
    Purpose 3-13.11A
    Policy 3-13.11B
    Objectives 3-13.11C
    Procedures 3-13.11D
    Responsibilities 3-13.11E
    Guidelines 3-13.11F
        Yearly Encounters 3-13.11F1
        Follow-up Activities 3-13.11F2
Family Planning Services 3-13.12
    Purpose 3-13.12A
    Policy 3-13.12B
    Objectives 3-13.12C
    Procedures 3-13.12D
    Responsibilities 3-13.12E
    Service Guidelines and Policies 3-13.12F
        Adoption Services 3-13.12F1
        Contraceptive Services 3-13.12F2
        Education Services 3-13.12F3
        Infertility Services 3-13.12F4
        Sterilization Services 3-13.12F5
            Rules and Regulations 3-13.12F5.a
            Consent Procedures 3-13.12F5.b
            Monitoring Procedures 3-13.12F5.c
            Audit Procedures 3-13.12F5.d
            Corrective Action 3-13.12F5.e
Hysterectomies Resulting in Sterilization 3-13.13
    Purpose 3-13.13A
    Policies 3-13.13B
    Objectives 3-13.13C
    Procedures 3-13.13D
    Responsibilities 3-13.13E
Abortion Services 3-13.14
    Purpose 3-13.14A
    Policies 3-13.14B
    Objectives 3-13.14C
    Procedures 3-13.14D
    Responsibilities 3-13.14E

Exhibit/Appendix Description
Exhibit I Drugs for Newborn Resuscitation
Exhibit II Recommendations for Preventive Health Care
Exhibit III Office of Indian Education Program (OIEP) Indian Health Service (IHS) procedures for preparation and transmittal of Health Records of American Indian and Alaska Native Students in OIEP Boarding Schools (Signed March 7, 1983)
Appendix 3-13-A Obstetrical Services

3-13.1  INTRODUCTION

  1. Purpose:

    This chapter establishes the policies objectives, procedures, responsibilities and guidelines relating to specific health care activities provided for children, youth and the family by the Indian Health Service (IHS).

  2. Policy:

    Comprehensive health services will be provided to children, youth and the family addressing preventive, therapeutic and rehabilitative aspects.

  3. Objectives:

    1. To promote health services of such quality and availability to children, youth and the family that American Indian and Alaska Native children and adults will have full opportunity to attain and maintain optimal physical and mental health.

    2. To provide guidelines and standards as a basis of measurement, evaluation and improvement of services for children, youth and the family.

  4. Procedures:

    1. This chapter is divided into program areas defining specific aspects of care.

    2. This chapter will be periodically reviewed and updated to reflect changes or improvements in standards of care.

  5. Responsibilities:

    1. Headquarters - Maternal and Child Health (MCH) Program Coordinator, Senior Clinicians of Obstetrics/Gynecology (OB/GYN) and Pediatrics, Chief, Nurse-Midwifery Branch and Deputy Chief, Nursing Services Branch.

      1. Will work with Area/Program MCH Chiefs in formulating, developing and evaluating programs and recommendations for the improvement of health and medical care services to children, youth and the family.

      2. Will provide liaison with and consultation to other IHS Headquarters staff, tribal officials, and other Federal and non-Federal agencies regarding MCH programs and activities.

      3. Will represent the interests of The Area/Program MCH Chiefs at the headquarters and at national levels.

      4. Will maintain familiarity with IHS MCH program and budget and assist in the preparation of the MCH portion of the IHS budget in concert with appropriate IHS headquarters and field personnel.

    2. Area/Program Director:

      1. Is responsible for the implementation of this policy by delegating authority to his/her appropriate staff.

    3. Area/Program MCH Chief:

      1. Is responsible to the IHS Area/Program Chief Medical Officer for developing programs and recommendations necessary to implement this policy.

      2. Is responsible for monitoring compliance with this policy within the Area/Program.

      3. Is responsible for developing an Area/Program MCH team which includes nutrition, dietetics, social Service, health education, public health, ambulatory care and hospital nursing staffs, pharmacy, dentistry, laboratory, and environmental health to develop programs and recommendations within the Area/Program.

    4. Service Unit MCH Coordinator:

      1. Is to be appointed by the Service Unit Director (SUD) and is responsible to the service unit and clinical directors while working closely with the Area/Program MCH Chief for developing and carrying out the service unit programs and policies as defined in this Manual, utilizing a inter-disciplinary team approach in order to achieve maximum effectiveness.  The Service Unit MCH Coordinator may be from any of the professional disciplines emphasizing MCH - e.g., Physician, Public Health Nurse, Registered Nurse (R.N.), or Social Worker.

      2. Should have major responsibility for monitoring compliance with this policy.

3-13.2  MATERNAL AND NEONATAL HEALTH SERVICES

  1. Purpose:

    This section sets forth the IHS policy, objectives, procedures, responsibilities, standards and guidelines governing the delivery of health services to pregnant women, mothers and newborns.

  2. Policy:

    The IHS will provide quality comprehensive health services for women eligible for IHS services and their newborns during the prenatal, perinatal and postpartum/neonatal periods of their lives.

  3. Objectives:

    1. To provide national and IHS guidelines and standards for use by Area/Program and service unit staff that will enable them to develop plans for the provision of comprehensive maternal and neonatal health services.

    2. To outline the responsibilities of IHS staff in providing these services.

    3. To assure that proper standards of care are being followed in the delivery of maternal and newborn care.

  4. Procedures:

    1. Each service unit will have written plans and protocols identifying standards for delivering the following services either directly, by referral or through contract care systems to include what is done, who is responsible for implementing the activity, when should it be done:

      1. Prenatal services.

      2. Care during labor.

      3. Care during delivery.

      4. Postpartum services.

        1. Inpatient

        2. Outpatient

      5. Prenatal and perinatal referral systems.

      6. Newborn services.

      7. Safe hospital environment.

      8. Infection control (including HIV control measures).

      9. Genetic counseling.

      10. Quality assurance and risk management.

    2. The guidelines and standards in Section 3-13.2F in conjunction with the recommendations of the Committee on Perinatal Health (AAFP, AAP, ACOG, and AMA) as found in the AAP and ACOG Guidelines for Perinatal Care (1988) will be Used by the service units when developing their plans and protocols.

      American Academy of Pediatrics, 141 Northwest Point Road, P.O. Box 927, Elk Grove Village, Illinois 60204.

      American College of Obstetricians and Gynecologists, 409 12th Street, S.W., Washington, D.C. 20024.

    3. Each service unit will be designated as to the technical level of maternity and newborn services that it will deliver.  All IHS maternity services will meet at least Level I standards except for the cesarean section and anesthesia standards which could not be met by units unable to support an operative Obstetric/surgical unit.  These units are designated as low-risk maternity units in contrast to the full-service obstetric departments of the larger IHS hospitals.  However, even the low risk maternity units will meet all other requirements of Level I programs in order to assure the highest possible level of care.

    4. Each service unit will have on file verified documentation of the obstetrical and pediatric credentials and privileges for each primary care provider delivering services to maternal and newborn patients, in accordance with specifications outlined in the Service Unit Medical Staff Bylaws and Rules and Regulations.

    5. Tribal, referral and contract care providers and facilities shall meet at least Level I standards and provide at least the same quality of care as outlined for the IHS.

    6. A free-standing low risk maternity unit (Birthing Center) may be an acceptable site for labor and delivery depending on the wishes of the patient and the availability of a unit which (1) meets the obstetric and newborn care standards of this manual and (2) meets the Guidelines for Licensing and Regulating Birth Centers as adopted by the American Public Health Association 17 November 1982.  The Area/Program MCH Chief, with consultation from the OB/GYN and pediatric senior clinicians, is responsible for assuring that any unit utilized meets these standards.

      Cooperative Birth Centers Network News Vol.1, No.4, Summer, 83. Box 1 RD 1, Perkiomenville, PA 18074.

  5. Responsibilities:

    1. The IHS Obstetric and pediatric senior clinicians, in consultation with appropriate staff are responsible for developing and periodically updating the standards to be used by service units in developing their plans and protocols.  In addition, these senior clinicians in consultation with the Area/Program MCH Chief and Chief Medical Officer (CMO) will formally designate the level of care provided at each service unit and review the designation annually.

    2. The Area/Program MCH Chief is responsible through periodic Visits, to review and evaluate all service units' programs to assure that they are in compliance with these policies.

    3. The Area/Program MCH Chief in conjunction with Contract Health Services, and a tribal representative should periodically evaluate tribal, referral and contract providers and facilities to assure that they continue to meet the intent of this policy.

  6. Service Standards and Guidelines:

    1. General:

      1. At those service units where maternal and newborn care, in part or totally, is to be provided by referral or contract care providers and facilities, there should be on file formal written agreements defining the standards of care and specific services to be provided.

      2. The service unit Health Education staff should be responsible for developing an education program informing the community of services offered and targeted towards pregnant women encouraging them to utilize these Services early in pregnancy.  This program should reach mothers, fathers and extended family members.  (See IHS Manual, Part 3, Chapter 12, Health Education.)

    2. Maternal Services:

      1. Antepartum Period:  Health Supervision

        1. Initial Encounter:

          1. Medical History - should be careful and complete.  Documentation of the menstrual history, use of oral contraceptives past obstetrical history, dates of earliest positive pregnancy test and the onset of quickening are required in the critical assessment of gestational age.

            AIDS Risk Assessment As part of the initial history all prenatals should be interviewed for high risk sexual behaviors.  If risk factors are present, the patient should be offered HIV testing with precounseling and post counseling by an AIDS counselor certified by either the Centers for Disease Control (CDC), State or IHS.

          2. Physical Examination - should be a complete general examination including a thorough breast exam.  The pelvic examination should include an estimation of the uterine size as well as pelvic adequacy.  The fundal height should be measured in centimeters by tape measure and the fetal heart rate recorded, specifying whether obtained by fetoscope or doppler.  Form HRSA 800-1 (Prenatal and Pregnancy) shall be used.  An equivalent form which also emphasizes gestational age dating and formalized risk assessment may be utilized, subject to review by the IHS OB/GYN Senior Clinician and/or MCH Program Coordinator.

          3. Laboratory Assessment - should include:

            General - CBC including platelet count, blood type, Rh and prenatal antibody screen; serologic test for syphilis; rubella titer (if not previously positive); Urinalysis and possibly Urine Culture; cervical cytologic examination (PAP smear) and gonorrhea culture (GC).  Chlamydia, hepatitis and HIV testing should be done in accordance with risk factors.

            Diabetes Screening - Women who are at increased risk for diabetes (e.g, family history of diabetes, previous gestational diabetes, or history of large babies, stillbirths, and previous premature births) should be screened for diabetes at the time of the initial prenatal assessment (by fasting and/or 2-hour blood sugar tests).

          4. Ultrasound - An initial ultrasound examination should be scheduled early in the second trimester (14-18 weeks) where there is a discrepancy between the dates and the uterine size, or the dates are uncertain.

            Other diagnostic ultrasound - examinations should be performed when clinically indicated.

            X-ray- Should be avoided unless medically indicated.

          5. Nutritional Assessment and Counseling - should include evaluation of present basic diet, meal patterns, cultural food practices, exercise regimen and special dietary problems such as allergies, nausea, vomiting, under or overweight, etc.

            Prenatal nutrition counseling should be initiated at this time with high risk patients targeted for follow-up.  Documentation of assessment must be in medical record.  Emphasis should be placed upon nutrient needs during pregnancy and dietary practices to meet these needs.  Refer, as necessary, to food assistance programs.

          6. Chemical Abuse Assessment and Counseling - Screening for alcohol or substance abuse will be completed at the initial visit.  Counseling and education should be provided to all patients as to the effect these substances have upon the women's health and the development of the fetus.  A management plan should be developed by a multidiscipline team for all identified abusers.

          7. Immunizations - Immunizing agents shall be used only under specific orders from the physician.  Measles and rubella immunizations are contraindicated during pregnancy.  All patients should have current dT immunization.

            Tuberculin and coccidioidin skin testing may be indicated, depending on the risk of the population served.

          8. Medications During Pregnancy - should be limited to those that are medically indicated.  Most pregnant women should receive a daily iron, vitamin and mineral supplement which contains 800-1000 mcg of folic acid.

          9. High Risk Obstetrical Patient - After consultation with an obstetrician a management plan should be developed for each high risk patient as defined by historical risk factors, early pregnancy and late pregnancy problems, and should be recorded on the health record so as to be readily visible at each encounter.

          10. Genetic Counseling - Patients found to be at increased risk for birth defects due to heritable factors or maternal risk conditions (advanced age, exposure to tetratogens, etc.) should be offered counseling for possible diagnostic studies at a center which is experienced in such techniques.

        2. Follow-up Visits:

          1. Standards for the normal patient are monthly clinic visits until the 32nd week, visits every two weeks from the 32nd through the 36th week, and weekly visits from then until delivery.  The frequency of visits should be increased as clinically indicated.

          2. Each prenatal visit should include determination of blood pressure and weight, palpation of the abdomen for position and size of the fetus, measurement of fundal height by tape measure, recording of fetal heart tone (note whether by fetoscope or doppler), urinalysis and careful evaluation of any unusual symptoms.  Instructions for general care and diet should be given.

        3. Additional Screening at 24-28 weeks

          1. Hemoglobin or hematocrit determination should be repeated at 24-28 weeks.

          2. At 28 weeks gestation, all women who have not been previously identified as having glucose intolerance should be tested for diabetes:  e.g., blood glucose 1 hour following an oral glucose load of SO G. (glucola, others), or other acceptable screening test for gestational diabetes.  A positive screening test requires further diagnostic evaluation (e.g. oral glucose tolerance test).

          3. A repeat RPR or VDRL should be done in the 3rd trimester or immediate postpartum.

          4. Repeat AIDS screening if indicated at 27-28 weeks.

          5. Rh-negative, unsensitized women should have antibody titers repeated at 27-28 weeks.  Administration of Rh-immune globulin is indicated at 28 weeks if the mother is unsensitized.  Another full dose of Rh-immune globulin must be given after delivery, preferably within 72 hours, if the baby is Rh(D) positive or Du positive.  (The passive antibody given to the mother can affect the interpretation of the laboratory tests to identify and monitor the candidate for Rh-immune globulin.  If in doubt, Rh-immune globulin should be given).  Babies born of women given Rh-immune globulin antepartum may have a weakly positive direct Coombs test at birth.  Women with positive titers (1:8) should be managed in consultation with an obstetrician.

        4. Fetal Monitoring:

          Each service unit should have fetal monitoring available for non-stress testing when indicated.  Patients should be counseled on how to count fetal movements.  Capability for contraction testing and bio-physical profiles should be available either directly or by referral.  Contraction stress testing should not be done unless surgery capability is immediately available.

        5. Patient Referrals/Consultation

          A referral system is necessary to provide for the exchange of written information between health care providers and facilities serving the patient.  A summary of the antepartum findings and care should be available to the obstetric team at the time of labor and delivery.

        6. Nutrition Services - Nutritional counseling services should be provided to all patients, with patients at nutritional risk receiving first priority.  (See IHS Manual, Part 3, Chapter 5, Nutrition-Dietetics.)

        7. Prenatal Health Instruction - A prenatal instruction program shall be provided by every maternity service.  Form HHS 443 - Patient Teaching Flow Record - AP, PP, FP will be used to document teaching.  Nutritional counseling and instruction in the benefits of breast-feeding will be included in the curriculum.  The program should encourage the participation of fathers.  A tour of the obstetric unit should be offered.

        8. Dental Care - All expectant women should have an examination of their teeth by the clinical provider in the early stage of pregnancy and be referred to a dentist if further evaluation and/or treatment is needed.  The primary provider should evaluate the patient's periodontal condition and discuss pregnancy gingivitis.

        9. Medical Social Services - Medical social services should be available at each facility serving maternity patients to assess; family support system and counseling needs.  (See IHS Manual, Part 3, Chapter 8, Medical Social Services.)

        10. Public Health Nurse - At risk patients should have at least one home visit by the Public Health Nurse staff to provide education and support as well as to evaluate the home environment and family situation.  Selected high risk patients should be visited more frequently, as indicated.  Written reports of such visits should be incorporated promptly into the patients' medical record.  (See PHN Criteria of Care for Frequency of Visits and Content of Visits, Nursing Services Branch (NSB) 12187 or latest edition).

        11. Community education activities should be directed toward informing the general population of the specific value of early prenatal care and where it can be obtained.  A sound health instruction program in the school system with a component of family life education should be provided.  (See IHS Manual, Part 3, Chapter 12, Health Education.)

        12. Boarding Accommodations - Boarding or rooming accommodations in or near the hospital should be available for certain high risk patients who require close medical supervision but who cannot get to the hospital promptly or conveniently.

      2. Labor Delivery and Recovery Period Following Delivery:

        1. In order to further reduce morbidity and mortality and enhance outcomes for both the mother and neonate, it is IHS policy that intrapartum services will be provided in a health care facility that meets approved IHS standards.  Any exception to this policy must have prior approval from the Area/Program Director and the Director of IHS.

          The father and/or other supporting person(s) may be with the mother as much as desired within the constraints of acceptable standards of care and hospital policy.  This includes the labor, delivery (including cesarean delivery), recovery, and postpartum periods.  Local policies should be developed and adhered to consistently.  Recent trends toward flexibility and liberalization of policies for fathers is encouraged within the context of family-centered care.

          Sibling visits may be desirable in the early labor and postpartum periods.  Children under 6 years of age frequently experience anxiety when separated from their mother.  Contact with the mother and newborn while they are in the hospital helps prepare siblings for a new family member.

        2. Admission - Women in labor or presenting with an acute obstetric condition such as hemorrhage shall be evaluated without delay.

          The history and appropriate physical examination will be performed as early as possible after the patient is admitted.  Forms HRSA 800-11 and 800-12 may be used.

          It is required that a 20-30 minute fetal heart rate (FHR) monitoring recording be obtained on each patient as part of the initial evaluation for possible labor.  Those patients who have a normal FHR pattern should be offered the opportunity for continuous monitoring during labor.  Consultation with an obstetrician should be obtained if the patient fails to demonstrate a normal FHR pattern.  All appropriate maternity records shall be completed.  Forms HRSA 800-2 (Labor and Delivery) and 800-3 (Labor Continuation) shall be used.

          Equivalent forms which provide for graphic presentation of labor data (i.e. Friedman Curve) may be utilized subject to review by the IHS OB/GYN Senior Clinician and/or IHS MCH Program Coordinator.

        3. Use Of Drugs - Drugs shall be given during labor and delivery only on the order of a physician or under the standing orders written specifically for that facility which are reviewed annually and signed by appropriate clinical and administrative staff.

        4. Conduct of Labor and Delivery - Artificial induction or oxytocin augmentation of labor using an infusion controller/regulator shall be done under the supervision of a physician or certified nurse-midwife only after consultation with an obstetrician.  Trained R.N.(s) can monitor patients under the supervision of the primary clinical provider who must be immediately available within the facility.

          Where oxytocin or oxytocic agents are permitted to be used for induction or augmentation, there shall be written protocol(s) for its/their use.

          Inductions and augmentation should be coordinated through nursing supervisors to assure that qualified nurses are in attendance.  Inductions should not be done when emergency surgical capabilities are not available.  A written policy addressing when, where and how augmentations/inductions of labor can be done will be in place at each service unit that provides obstetric services.

          A log will be maintained in the delivery area in accordance with the Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards.

          Electronic fetal monitoring shall be available for use, as indicated, for laboring patients as well as for antepartum assessment at each facility.  It is essential that there be a sufficient number of monitors available to provide these services.  Trained professional nursing staff must be available to care for monitored patients.

        5. Anesthesia - See IHS Manual, Part 3, Chapter 13, Section 3, Obstetric Anesthesia Care.

        6. Consultation-Referral - Each facility offering maternity care must have a well defined, efficient system of communication, consultation, referral and transportation with/to a facility that can provide specialized care for high risk and complicated maternity and newborn patients.

          Each facility offering maternity care that does not have an obstetrician on staff or surgical capabilities must have an active, formalized relationship with a regional (IHS or contract) center for the support of in-service education, monthly on-site patient and service consultation and evaluation, and general support of the perinatal services.  These visits should be documented for quality assurance purposes.

          Consultation should be obtained for the following:

          • Development of guidelines for OB/GYN referrals and consultations,

          • all major obstetric complications,

          • all artificial inductions and augmentations of labor.

          Documentation of patient consultation must be recorded in the health record.

        7. Recovery Period Following Delivery - Every patient is to be kept under the constant observation of an experienced nurse or primary care provider during at least the first hour postpartum.  Blood pressure, pulse, condition of the uterus, and degree of bleeding shall be recorded at least every 15 minutes during the first hour postpartum.  Placement of mother and infant together for observation is encouraged.

        8. Nutrition Counseling - (See IHS Manual, Part 3, Chapter 5, Nutrition-Dietetics.)

          Breast feeding should be encouraged and positively supported.  Early, frequent, on demand feedings are to be encouraged.  Timed feeding routines are unphysiologic and inhibit adequate lactation.

          Supplemental feedings are to be avoided.  Instructions should be provided by a knowledgeable person.  Refer mother to community resources that support breast feeding, La Leche League, county health department, etc.

          Before discharge, each mother will receive family-centered nutrition counseling, with emphasis placed on her nutritional needs and those of the infant.

        9. Family Planning Instruction and/or Services - Before discharge the mother will be offered an opportunity for counseling, guidance and/or services for family planning.

      3. Postpartum Services:

        1. Clinic Visit - Every postpartum patient should be given an appointment for a follow-up visit within 6 weeks of delivery.

          Family planning counseling and/or services should be available to any woman who desires such services.

        2. Public Nurse Home Visit - Each postpartum patient should have one home visit by a member of the Public Health Nursing staff to reinforce educational objectives and to support the patient.  Written reports of such visits should be incorporated promptly into the medical records of the mother and her baby.  (See PHN Criteria for Care for Frequency of Visits and Content of Visits, NSB 12/87 or latest edition).

      4. Personnel and Facility Standards:

        1. Personnel:

          Ambulatory Staff - Minimum standards for each maternity clinic require the attendance of a primary care provider, a registered nurse and a clerk-helper.  Appropriate support personnel must be available:  i.e., laboratory, pharmacy, social service, etc.

          Inpatient Services:

          Nursing Personnel - Supervision of the maternity unit shall be by a professional nurse who has had advanced clinical preparation and/or experience in obstetric nursing.  The professional nurses and auxiliary nursing personnel shall be under the supervision of the nursing service.  Professional nursing personnel shall be available in the maternity unit on all shifts such that at a minimum there is a nurse with the patient in active labor or with acute problems, during delivery, and during the early recovery period.  (See IHS Manual, Part 3, Chapter 4, Nursing.)

          Professional nursing staff shall serve a probationary period of sufficient length to ensure their competence before they are granted privileges to be the sole nursing charge nurse.  A supervised probationary period covering at least 10 patients, including labor and delivery management should be required of intrapartum nursing staff.

          Nurse-midwives - Certified nurse-midwives may provide all phases of approved maternity care under the supervision of IHS physicians.  The certified nurse-midwife must have direct consultation access to the designated OB/GYN consultant as well.  (See IHS Manual, Part 3, Chapter 13, Section 4, Nurse-Midwifery.)

          Clinical privileges - Shall be granted only to those physicians and certified nurse-midwives who have demonstrated competence in maternity care and newborn stabilization.  Each practitioner should have experienced at least 30 supervised deliveries during training or on-the-job experience in order to have independent obstetric privileges.

        2. Facilities:

          Clinics:

          Minimum guidelines for clinic facilities are:

          Waiting room accommodations,

          A room with privacy where providers can interview patients,

          Dressing and examination room,

          Hand-washing and toilet facilities,

          Space for records, supplies, and simple laboratory tests such as urinalysis, smears and hematocrit.

          Inpatient - Maternity patients should be segregated from other patients in the hospital.  A private room within the maternity unit, which could be used for isolation, must be available.  "Clean" non-obstetric patients can be admitted to the maternity unit only with the permission of the chief of the maternity service or his/her designee.

          Labor Rooms - Labor rooms shall be located near the delivery room, and shall be so arranged and constructed as to permit effective observation by the nursing staff.  Patients in labor shall be isolated from other patients.  The labor rooms should be equipped with the following:  an emergency alarm, an inter-communication system with the nursing station, oxygen and suction, preferably piped in, a labor bed with adjustable side rails, foot stool, fetal heart rate monitor, adjustable lighting, sphygmomanometer, hand-washing facilities, toilet facilities, comfortable chair, and at least one IV infusion controller/regulator.  When appropriate equipment and supplies are available delivery of patient in a labor room is acceptable.

          Delivery Rooms - Shall be used solely for deliveries or clean gynecological surgery as determined by the clinical director.  Each delivery room shall be maintained as a self-sufficient unit containing necessary and adequate equipment and supplies for oxygen administration, newborn suctioning and resuscitation and maintenance of body temperature.  An emergency alarm must be available.

          Patient Area - The number of beds and type of rooms will vary with the special needs of the population served by the hospital.  Wards shall not contain more than four beds.

          The patient area shall be adequate to house mother and infant in a rooming-in plan for those parents who so desire.

          A conference or teaching room where parents can meet with staff members for discussion periods should be available.  Attention must be given to providing space and facilities for individual demonstration of mother and infant care.  (See the Guidelines for Perinatal Care, AAP-ACOG, 1988, for specific criteria).

          A family visiting area to promote family involvement and bonding should be identified.  (Guidelines for Perinatal Care, AAP-ACOG, 1988.)

          Laboratory and Blood Transfusion Facilities - Facilities or resources must be available at all hours for examination of urine, blood counts, typing and cross-matching blood, and Rh-factor determination.  The establishment and maintenance of a blood bank or an organized blood donor program is necessary to provide blood for transfusion in obstetrical emergencies.

    3. Newborn Services:

      1. Procedures:

        1. Delivery Room - A preliminary newborn examination should be done to identify any life threatening conditions and to enable stabilization of the newborn, Apgar scoring should be done at 1 and 5 minutes and recorded.  Capabilities for fetal cord blood acid/base studies are encouraged.

          Mother-infant bonding should be encouraged by permitting the mother to see, hold, touch and breast-feed in the delivery room if she so desires once the infant's skin is dry, the airway is clear and the infant is breathing satisfactorily.

          Cord blood should be collected at birth to be refrigerated and stored for blood type, Coombs; serologic test for syphilis or other tests that may become necessary.

          Newborn Identification - The Service Unit Director and attending health professionals are responsible for insuring that all newborns are immediately identified at the time of birth in accordance with procedures set forth below.  Written orders covering the routines and procedures for newborn identification shall be available in the nursing station serving the newborn nursery.

          Delivery Room Nurse Responsibility - Three identical identification bands showing mother's name and admission number, sex of infant and date and time of birth shall be prepared individually for each infant by the nurse in the delivery room.

          Two identification bands shall be secured to a wrist and an ankle of the newborn infant immediately following delivery.  The third band is placed on the mother's wrist.

          Checking the Identification - Before mother and infant leave the delivery area, all identification items must be checked by the nurse to insure that the name of the mother, her admission number, date and time of delivery, and sex of the infant are correctly recorded on all bands and written on the newborn record.

        2. Nursery:

          Nursery Nurse Responsibility - The nursery nurse shall check to insure that information on both newborn identification bands are identical.  A card shall be filled out and affixed to the bassinet with the infant's identification, and checked each time the infant is removed and returned to the bassinet.

          The eyes of all newborns are to be treated with an approved prophylactic agent to protect against gonococcal ophthalmia neonatorum.  Instillation can be delayed up to 1 hour following birth.  Washing out the prophylactic agent is inappropriate since it will lower the efficacy of treatment.

          Each newborn shall (unless contraindicated) receive parenteral vitamin K [O.5 mgm Vit. Kl (Phytonadione); or 0.1 mgm -0.2 mgm Menadione Sodium Bisulfide] within 1 hour after birth to prevent hemorrhagic disease of the newborn.  Pediatric consult should be obtained on all infants < 2500 Gms.

          The newborn's temperature should be recorded on admission to the nursery.  The weight, length, and head circumference should be obtained and recorded when the infant's temperature and vital signs have stabilized.  Admission and discharge weight temperature and daily weight on all low birth weight infants should be recorded until discharge.

          At the time of admission to the nursery an estimation of gestational age based on morphologic criteria should be made by the nurse.

          Capillary (i.e. Dextrostix or chemstrip BG) blood sugar determinations should be done on all newborns at risk of hypoglycemia (i.e., diabetic mother, birth weight below 2500 GM or over 4000 GM, distress or asphyxia) within 30 minutes of birth.

          Bathing of the infant should be deferred until temperature and vital signs are stable.  Hexachlorophene bathing should not be done unless a nursery epidemic due to staphylococci is documented and the hexachlorophene is prescribed by a clinician for each infant.

          Feeding - Under normal circumstances, newborns may nurse as soon as possible after delivery and on demand.  Breast feeding is preferred and should be supported by all health personnel.  Supplements should not be given.  However, if the neonate is to be fed formula, sterile water is given in the initial reactive period, which is 30 minutes to 2 hours following delivery.  All neonates should be given some fluid and nutritional support by at least 6 hours of age.  Prematures require a pediatric consult for a care plan.

          A newborn procedure manual shall contain guidelines for the initial management - including notification of the responsible physicians of infants which meet the following risk factors:

          • Mother with fever or other evidence of intrapartum infection

          • Mother diabetic or pre-eclamptic

          • Less than 38 or greater than 41 weeks gestation

          • Born by cesarean section

          • Birth injury

          • Possible aspiration of meconium

          • Birth weight less than 2500 GMS. or greater than 4000 GMS.

          • Small or large for gestational age

          • Fever

          • Persistent cyanosis

          • Heart rate under 120 or over 160

          • Apneic episodes

          • Respiratory rate over 60

          • Persistent nasal flaring

          • Retractions

          • Grunting

          • Capillary blood glucose less than 45 mg/dl

          • Capillary hematocrit greater than 70%

          This procedure will be reviewed annually and sign by the Director of Nursing (DON), Chief of Staff Clinical Director.

          Presentation of the Infant to the Mother - On the first presentation of the infant to the mother, after the delivery room encounter, the procedure of checking and identifying the infant shall be explained to the mother, who will be instructed to check the infant's identification each time she receives the infant.  The mother shall be shown the sex of the infant at the time of the first presentation, preferably at time of delivery.  Infants will be taken to mothers, one infant at a time.

          Clinician's Responsibility - A complete examination, including the independent estimation of gestational age, shall be done and recorded within 24 hours of birth.

        3. Neonatal Period (Hospital) - Periodic evaluation by a health professional should be done and recorded on the newborn's chart daily.

          Continuing education of the mother should be carried out by each staff member emphasizing the proper care of the infant including the technique and benefits of breast-feeding.

          Treatment of jaundiced neonates with fluorescent lights must be based on accurate laboratory studies and clear clinical indications.

          Newborn metabolic screening test including that for hypothyroidism is to be done 72 hours after birth or on discharge, whichever occurs first.  Follow local and State law for specific tests which will be done.  If the metabolic screening for thyroid is done less than 24 hours of age, it should be repeated during the second week of life.

        4. Discharge - A complete examination of the newborn will be done within 12 hours prior to discharge.

          Prior to discharge each mother should be instructed on the condition of her infant, proper care, diet, car seat usage and appropriate medications.  She should be given an appointment to a well-child clinic within 6 weeks.

          Results of the mother's 3rd trimester serologic test for syphilis must be recorded on the infant's record prior to discharge.

          At Discharge - At the time of discharge, all identification items on the infant shall be checked with the bassinet card and the newborn record in the nursery by a professional nurse.

          Acknowledging Acceptance of the Infant - The infant shall be taken to the mother or to the person taking custody of the baby.  With the assistance of the nurse, the mother or other person taking custody of the infant shall be asked to check the infant's identification and to record her/his signature acknowledging acceptance of the infant.  One identification band shall then be removed and attached to the infant's record.  If the infant is to be taken from the hospital by a person other than parents, a signed release from the parents, Form 214, shall be made part of the record.

      2. Facilities:

        1. Delivery Room - (See IHS Manual, Part 3, Chapter 13 Section 2F2, Maternal Services.)

          Infant Resuscitation and Care Supplies - The following basic items of equipment should be present in each facility where newborns are delivered and delivery room staff should be skilled in their use:

          Equipment for Resuscitation of the Newborn

          Basic equipment ready for immediate use

          • Table with overhead radiant warmer to effectively maintain body temperature of 97O skin (axillary) minimum.

          • Oxygen Piped-in, or two cylinders (one full and one partially used).

          • Resuscitation Bag with pressure relief valve or gauge and oxygen reservoirs.

          • Face Masks for bags, to fit premature and term infants.

          • Suction piped in or mechanical.

          • DeLee suction catheters (disposable type) with large reservoir, sizes 6 & 8 French.

          • Laryngoscope with infant and premature blades, sizes 0 and 11 (with good batteries and bulb).  Spare batteries and bulbs for laryngoscope.

          • Straight Blades Miller No. 0 (Premature) Miller No. 1 (Infant)

          • Endotracheal Tubes (disposable) at least 3 each of 2.5mm, 3mm, 3.5mm, 4.Omm sizes

          • Plastic oro-pharyngeal airways (multiple sizes).

          • Stylets (disposable) for use with endotracheal tubes.

          • Suction Catheters (disposable) with proximal hole for occlusion by operator's finger tip, sizes 5, 8, 10 French.

          • Airway Berman plastic - infant size.

          • Various appropriate syringes & needles, tape, scissors, oxygen tubing, etc.

          • Umbilical vessel catheter insertion equipment (sterile tray with appropriate equipment) and IV sets.  Duplicate tray needed in nursery.

          • Equipment and supplies should be checked and completeness periodically documented.

          • Emergency drugs for resuscitation (See Exhibit I).

        2. Nursery - The nursery should be adjacent to the maternal care area 60 that both can be managed as a single unit.  Hand-washing facilities must be provided at the entrance to each nursery.  Oxygen (preferably piped in) should be available.  Oxygen-mixing equipment calibrated for accuracy at intervals (at least annually) and oxygen monitors checked for accuracy at each usage, must be available.  Suction equipment (preferably piped in) should be available.  An emergency alarm should be available.

        3. Laboratory - Each hospital caring for newborns should have a laboratory capable of analyzing blood samples by micro techniques.

      3. Personnel:

        1. An RN must be on duty on all shifts whenever a newborn is in the nursery.

        2. For all anticipated high risk births additional health professionals should be in attendance, including an RN skilled and trained in the care the newborn, and a physician to care for the infant.  Another RN should be present to assist the physician in providing care to the mother.

        3. Screening of all employees to determine their immunization status, especially for rubella and measles, should be done.

      4. Birth and Fetal Death Certificates:

        1. Time Limit - The primary provider in attendance at the delivery will report live births and fetal deaths to the State by completing and signing of appropriate certificates.  This should be done within 24 hours and the limit must not exceed seven days after birth.  Evidence of the reporting should be available in the hospital.

        2. Legal Requirements - In many States a Register of Births and a Register of Deaths is required by 1aw to be kept in the hospital.  The medical officer in charge and the hospital director should be familiar with the legal requirements of the State and see the person delegated the responsibility for reporting follows the necessary procedures.

        3. Each Area Office should obtain copies of matched birth and death certificates from the State Health Department's Vital Statistics Office to assist with the investigation of infant deaths.

      5. Use of Oxygen:

        1. When an infant of less than 36 weeks gestation requires supplemental oxygen, the concentration of inspired oxygen should be regulated by measuring arterial oxygen tension.  If the place of birth h no facilities for measuring arterial oxygen tension the prematurely born infant with cyanosis should be given oxygen in a concentration just high enough to abolish the cyanosis, in general not exceeding 40 percent concentration.  Pediatric/neonatal consultation must be obtained and the newborn should then be moved to a hospital which can measure arterial blood oxygen tensions.

        2. When the measurement of oxygen tension in arterial blood is not available for an infant of greater than 36 weeks gestation with generalized cyanosis, he/she should be given oxygen in a concentration just high enough to abolish the cyanosis.  If a concentration in excess of 40% must be given for more than a few hours, the infant should be moved to a hospital in which arterial blood oxygen tension can be measured.

        3. When supplemental oxygen is given to the premature neonate, an attempt should be made to maintain the Pa02 at a level not greater than 100 mm Hg, preferably between 50-90 mm Hg.

        4. When any infant is in an oxygen-enriched environment, the concentration of oxygen in the environment should be measured with an oxygen analyzer and recorded, or the setting on a reliable oxygen-air mixer should be noted and recorded at least every hour.  The performance of the oxygen-air mixer should be calibrated and recorded at each usage with both room air and 100% oxygen.

        5. A person experienced in neonatal ophthalmology and indirect ophthalmoscopy should dilate the pupils and examine the retina of all prematurely born infants treated with oxygen at the time, supplemental oxygen is discontinued and at discharge from the hospital.  If questionable or abnormal at discharge, re-examine in 6-8 weeks.

      6. Family Participation in the Infant's Care:

        1. Rooming-In - Mothers should have access to their newborns 24 hours a day and should be encouraged to participate in the care of their newborns.  Immediate and continuous postpartum contact with the baby promotes bonding by facilitating sensitive maternal responsiveness to infant signals, thus facilitating maternal behavior which helps the infant become securely attached.

          During the prenatal period, families should be a full explanation of the aims and techniques rooming-in.  If possible, they should have visited the hospital before delivery.  The father or a person of the mother's choosing has, within limits of the needs of other mothers in the room, unlimited visiting privileges as a part of rooming-in.  In multiple bed rooms visiting should be limited to one visitor per patient when newborns are in the room.  Proper handwashing techniques should be demonstrated and instructions for proper hand washing techniques are to be posted over all lavatories used by rooming-in mothers.

        2. Sibling Visitation - Sibling visitation with the mother during the intrapartum period and with the mother and infant during the postpartum period may be encouraged.  Sibling visitation should take place in the mother's private room or in a specially designated area.

          Only siblings free of illness should be permitted to visit.  Parents should share the responsibility of keeping their newborn from being exposed to a sibling with a contagious disease.  Proper handwashing of each sibling, and others, is mandatory upon entering the labor and/or postpartum units.

          Each hospital should develop its own policy regarding sibling visits.  Exposure of the newborn to children other than siblings should be avoided.  (Guidelines for Perinatal Care, AAP-ACOG, 1988).

      7. Regionalization of Newborn Care:

        1. Each facility will have written plans in reference to consultation routes, stabilization routines, transport plans, and risk assessment.

        2. The names and phone numbers of referral and consultation sources will be posted in the clinic, emergency room and obstetric unit.

    4. Safe Hospital Environment

      1. The Service Unit Office of Environmental Health will by periodic review assure that each facility is in compliance with national and IHS standards defining a safe and healthy environment for mothers, newborns and staff (See IHS Manual, Part 3, Chapter 11, Environmental Health).

      2. Infection Control:

        1. There shall be written infection control policies and procedures for the maternity unit, including labor, delivery, postpartum, and nursery areas.  The policy will reflect universal precautions as defined by CDC and total body substances isolation technique.

        2. Each infant's bassinet unit and supplies should be kept isolated from other infants to prevent the spread of infection.  The only common piece of equipment should be the scales and care should be taken in weighing so that the infant's skin does not come in contact with the scales.

        3. Routine nursery procedures should include thorough handwashing before and after handling each infant.

        4. The need for gowns has not been documented.

        5. Written procedures should be posted and followed for prevention and control of infection in the nursery and in the postpartum rooms where rooming-in is practiced.

        6. Specific policies regarding HIV protection are required.

3-13.3  OBSTETRIC ANESTHESIA CARE

  1. Purpose:

    This section sets forth the IHS policy, objectives and procedures and the responsibilities of IHS staff in regards to the provision of obstetric anesthesia care.

  2. Policy:

    IHS facilities which have inpatient maternity services will provide anesthesia care that meets IHS and national quality standards.

  3. Objectives:

    1. To define IHS staff responsibilities for implementation of this policy.

    2. To assure that all obstetric anesthesia care meets these quality standards.

  4. Procedures

    1. IHS obstetric services which have major obstetric surgical programs shall have:

      1. An organized anesthesia program under the direction of physician member of the medical staff.

      2. Anesthesia care provided by anesthesiologists or other qualified persons such as certified registered nurse anesthetists and physicians with sufficient training and experience to be granted specific anesthesia privilege such as for subdural and/or epidural techniques.

      3. Regulations relative to anesthetic safety.

      4. Written policies related to the delivery of obstetric anesthesia care.

      5. Post-anesthesia recovery should be performed by either a Certified Registered Nurse Anesthetist (CRNA) or RN.

    2. IHS low risk maternity units without major obstetric surgical and anesthesia capabilities shall:

      1. Provide only analgesia and/or local anesthesia for the conduct of labor and delivery utilizing those techniques and drugs and approved by the medical staff.

      2. Have a physician member of the medical staff as director of the maternity analgesia and/or local anesthesia care program.

      3. Grant privileges for local anesthesia only to those physicians and certified nurse midwives who have demonstrated ability, training and experience.

      4. Have written policies related to the delivery of maternity analgesia and/or local anesthesia care.

    3. In the absence of a staff or Area anesthesiologist, a practicing consultant anesthesiologist shall provide specific guidelines based on a site assessment of the IHS program.  The anesthesiologist shall review the policies and procedures, provide a continuing education session, and review the quality of anesthesia care on at least an annual basis.

  5. Responsibilities:

    1. The Area/Program Chief Medical Officer is responsible for assuring that each service unit is aware of this policy and has implemented it.

    2. The Area/Program MCH Chief is responsible for periodically reviewing each service unit to assure that it is conforming to this policy.

    3. The Service Unit Clinical Director is responsible for the local implementation of the procedures stated in this section.

3-13.4  NURSE-MIDWIFERY

  1. Purpose:

    This section sets forth the policies, objectives, procedures, responsibilities, standards and guidelines relating to nurse-midwifery services within the IHS.

  2. Policies:

    1. Nurse-midwifery services may be provided as part of the comprehensive MCH services offered by the IHS.

    2. Certified nurse-midwives (CNM) will adhere to IHS policies and standards which relate to their area of practice.

  3. Objectives:

    1. To provide guidelines and standards for use by Area/Program and service unit staff that will enable them to plan for the best utilization of certified nurse-midwives.

    2. To outline the responsibilities of the IHS staff when providing nurse-midwifery services.

    3. To provide for a mechanism of review and monitoring of services provided by certified nurse-midwives.

  4. Procedures:

    1. Each service unit providing nurse-midwifery services must have a procedural manual governing the delivery of those services.

    2. At the service unit, the nurse-midwifery services must be under the direction of a physician whose responsibility includes the service unit OB/GYN or MCH program.

    3. Every certified nurse-midwife must be able to obtain direct -consultation with a qualified obstetrician-gynecologist even if such consultation is not deemed appropriate by the local physician supervisor.

  5. Responsibilities:

    1. Headquarters - Chief, Nurse-Midwifery Branch.

      1. In collaboration with other, IHS MCH program consultants, identifies standards and policies governing nurse-midwifery services for IHS.

      2. Leads and coordinates nurse-midwifery staff recruitment when requested by Area/Program or service unit management.

      3. Provides technical consultation and guidance to Headquarters, Area/Program Office and service unit staff in relation to nurse-midwifery services in IHS.

      4. Provides liaison with and consultation to other Federal and non-Federal organizations regarding nurse-midwifery services.

      5. Reviews and monitors nurse-midwifery activities provided by all levels of IHS.

    2. Area

      1. The Area/Program MCH Chief is responsible for periodically reviewing and evaluating all service unit programs to assure that they are in compliance with this policy.

      2. The Area/Program MCH Chief provides professional and technical guidance, consultation and assistance on nurse-midwifery matters to the Area/Program Directors, Service Unit Directors, nurse-midwifery staff, physicians and allied health professionals.

    3. Service Unit

      1. The Clinical Director is responsible for assigning a specific physician to serve as the professional and technical supervisor to the nurse-midwifery staff.

      2. Certified nurse-midwives are responsible for:

        1. Providing primary health services to essentially well women and infants.

        2. Obtaining medical consultation, participating in collaborative management and/or referring of patients with complications.

        3. Participating in educational programs for patients, communities, students and staff.

      3. The supervising physician, in collaboration with CNM staff is responsible for annually reviewing and updating the service unit's procedural manual governing nurse-midwifery services.

  6. Standards and Guidelines:

    1. The service unit's procedural manual should meet the standards as defined by IHS Manual, Part 3, Chapter 13, Maternal and Child Health, and should address the following:

      1. Specific objectives for nurse-midwifery services.

      2. Specific responsibilities of the nurse-midwives in relation to medical and nursing staffs with regard to obstetrical and gynecological patients, newborns and well babies.

      3. Standing orders for:

        1. Care of uncomplicated maternity, newborn, well baby, gynecologic, and family planning patients.

        2. Management of maternity and newborn emergencies, pending the arrival of a physician.

        3. OPD management of maternity, gynecologic and family planning patients with selected complications.

        4. Approved treatments and medications.

    2. Standing orders must be reviewed and signed by the physician supervisor and nurse-midwifery staff at least annually and signed by both when either position is newly filled.

    3. The obstetrical consultant should provide the following services during the monthly on-site visit:  (See IHS Manual, Part 3, Chapter 13, Section 2, Maternal and Neonatal Health Services.)

      1. Clinical evaluation of nurse-midwives' skills through direct observation and chart review.

      2. In-service continuing education through didactic lectures and/or hands-on example.

3-13.5  PERINATAL AND INFANT MORTALITY REVIEWS

  1. Purpose:

    This section sets forth the IHS policy, objective, procedures and responsibilities for reviewing all maternal, fetal and infant deaths within the service area.

  2. Policy:

    Each maternal, fetal (weight over 500 grams or pregnancy greater than 29 weeks gestation) and infant (under 1 year of age) death must be reviewed according to the following procedures.

  3. Objective:

    To provide a mechanism whereby maternal, fetal and infant deaths are reviewed in order to provide recommendations regarding the multiple factors involved in each case.

  4. Procedures:

    1. Each service unit and Area/Program Office will establish a perinatal and infant mortality review committee.

    2. Each service unit and Area/Program review committee will develop a written plan to implement this policy and conform to the Audit and Reporting requirements.

  5. Responsibility:

    The Area/Program Director is responsible for compliance by the service units and Area/Program review committees with the audit and reporting policy.

  6. Audit and Reporting Procedures:

    1. As part of the quality assurance process each service unit review committee will meet and submit its findings, conclusions and recommendations to the Area MCH Chief within 30 days after becoming aware of the death of a mother, fetus or infant.

    2. Each Area/Program Office review committee will meet and submit its findings, conclusions and recommendations to the Headquarters MCH Program Coordinator, with copies to the OB/GYN & Pediatric Senior Clinicians, quarterly after receipt of the service unit committee report.

    3. A report documenting the corrections of any identified deficiencies will be submitted by the chairperson of the Area/Program review committee to the Headquarters MCH Program Coordinator with copies to the OB/GYN and Pediatric Senior Clinicians, within 90 days of the original Area/Program review committee report.

3-13.6  CARE OF THE INFANT AND CHILD

  1. Purpose:

    This section sets forth the IHS policies, objectives, procedures, responsibilities, and guidelines for meeting specific health needs of infants and children.

  2. Policies:

    1. As a component of the health care system of the IHS, health services to infants and children will be made available.

    2. These services should address the preventive, therapeutic and rehabilitative needs of infants and children.

    3. All facilities without a pediatrician on staff should have pediatric consultant site visits quarterly with the content of these visits documented for quality assurance purposes.

    4. Acute and urgent problems requiring pediatric consultation should be identified in the service unit's policy manual.

  3. Objectives:

    1. To define required Area/Program and service unit responsibilities in order to provide this care.

    2. To provide for a system that will permit monitoring of compliance with this policy and evaluation of program performance.

  4. Procedures:

    Each service unit must have a well defined written plan and protocol that addresses the following areas of service:

    1. The Well Child.

    2. The Sick Child.

    3. The Handicapped Child (including the chronically ill).

  5. Responsibilities

    1. The Service Unit MCH Program Coordinator will periodically review the program performance and update or change existing plans and protocols.

    2. The Area MCH Chief will periodically evaluate the service unit programs and evaluate each service unit's conformity to the above policies.

  6. Program Guidelines:

    Service unit plans and protocols should be developed using these guidelines, in conjunction with standards and guidelines established by the American Academy of Pediatrics and the State's Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT).

    1. The Well Child - The following services should be offered:

      1. Recommendations for Preventive Health Care - Use AAP schedule (See Exhibit II).

      2. If resources are not available to meet all of the recommendations, priority must be given to infancy and early childhood.

      3. Nutrition Emphasis:

        Infants:

        • Breast feeding

        • iron-fortified formula if bottle fed

        • introduction of solids

        • weaning from bottle or breast

        • avoidance of fluids containing sucrose by bottle

        • evaluation for nutritional problems

        • iprophylactic medication as indicated i.e., vitamins, iron, fluoride

        Children and Adolescents - Evaluate for nutritional problems, i.e., under/overweight, allergies, carbohydrate intolerance, anemia, etc.

        (See IHS Manual, Part 3, Chapter 2, Dental; Part 3, Chapter 5, Nutrition and Dietetics.)

        Nutrition counseling and education for parent or primary caretaker with emphasis on nutrient requirements for specific age (Health Maintenance Schedule).

        Follow-up referral, if necessary, to food assistance program.

        References

        Nutrition Services in Perinatal Care, Committee on Nutrition of the Mother and Pre-School Child, FNB 1981.

        Recommended Dietary allowances, National Research Council, 1981, or latest edition,

        Available "National Academy of Sciences, 2101 Constitution Avenue, N.W., Washington, D.C. 20418".

        Pediatric Nutrition Handbook, American Academy of Pediatric, 1985, or latest edition.

        American Academy of Pediatrics, 141 Northwest Point Road, P.O. Box 927; Elk Grove Village, Illinois 60204.

      4. Safety and Injury Control - Accident and injury prevention should be emphasized, i.e. infant car seat programs, automobile safety, poison prevention, home safety, drowning and other areas of the environment which may be life threatening to the child.

    2. The Sick Child:

      1. Inpatient Care:

        Facilities - Pediatric units and rooms should be designed to meet the special physical and emotional needs of children.  Pediatric rooms should be located for continuous observation by the nursing staff.

        Specific concerns are:

        Rooming-in or convenient boarding arrangements for parents,

        Play area with toys and dining areas for children not confined to bed,

        Provision of an educational program for children hospitalized for 2 weeks or longer.

        Appropriate medical equipment, i.e. pediatric emergency equipment, B/P cuffs, etc.

        Personnel - The skill, experience and motivation of personnel assigned to the pediatric care area is the most significant factor in creating an appropriate setting for the hospitalized child.  Young patients require more nursing care and supervision than older patients; therefore, staff-patient ratios will be higher.  (See IHS Manual, Part 3, Chapter 4 -Nursing.)

        Infectious and/or Contagious Disease - These are frequent causes of admission or complications of children's hospitalization, therefore; specific policies and procedures must be identified to address these issues:

        basic isolation techniques

        cohorting of admissions

        referral of patients to another facility when appropriate isolation cannot be provided

        body substance isolation/universal precautions

        environmental control

        (See IHS Manual, Part 3, Chapter 11, Environmental Health.)

        Discharge Planning - Specific protocols should be written to address:

        Discharge plans

        referral patterns

        follow-up requirements

      2. Ambulatory Care:

        Facilities - Every effort should be made to provide a separate area within the outpatient unit for the care of sick children.  Specific concerns are:

        Separate waiting area

        room design

        isolation capabilities

        Personnel - Staff with special skills, experience and motivation are needed in order to provide an atmosphere conducive to the best care of sick children.  (See IHS Manual, Part 3, Chapter 4 -Nursing).

        Protocols - Specific protocols should be designed to address the care of sick children by non-pediatric staff.

        Specific issues are:

        Referral and consultation standards

        admitting privileges

        after hour coverage

    3. The Handicapped and Chronically Ill Child - services must be provided that will emphasize the importance of preventing handicapping conditions or preventing extension of existing conditions.  Specific issues to be addressed:

      1. Early identification of defects:  Since early recognition of children with abnormal development is essential to minimize handicaps and identify children not receiving adequate amounts of stimulation in the home, it is essential that every child be developmentally screened at least once by age one with some form of standardized screening instrument, such as the Denver Prescreening Developmental Questionnaire (PDQ) or the Denver Developmental Screening Test.  This should then be repeated per EPSDT or AAP Guidelines (see Exhibit II).

        Children with an abnormal test on routine well child screening should receive a comprehensive evaluation and individual education plan from qualified professionals.

      2. Management:  To insure adequate long-team treatment and coordination of services for children with handicaps, each service unit is to designate one person to serve as Handicapped Child Coordinator.  This person will be expected to carry out the following activities:

        1. Maintain an up-to-date register of all children and young adults up to age 21 who have a chronic, handicapping or potentially handicapping condition.

          The registers are to assure continuity of care and communication between the various health care providers.

          Four types of conditions are to be addressed:

          1. Children needing frequent medical visits (endocrine problems, seizures, etc.).

          2. Children with established disabilities (mental retardation, example - Fetal Alcohol Syndrome/Fetal Alcohol Effect).

          3. Children with conditions awaiting future surgery, (example - cleft palate).

          4. Children at risk for problems (prematures, post meningitis, post head injury).

        2. Review the progress of each child at least yearly and serve as or appoint a case manager for those children requiring frequent and continuing medical supervision.

        3. Maintain or have access to a regionalized directory of available services for handicapped children and their families.

          Coordinate referral and follow-up, including linkages to other agencies such as State crippled children's programs, Indian children's program, special education.

        4. Orient the medical staff annually to the existence of the program and the services available.

          In addition, it is recommended that the coordinator participate in or organize a community coordinating body consisting at least of a representative from Head Start, the local school special education program, parents of handicapped children, and a representative from the regional developmental disability and special education programs.  This group would help facilitate transitions from preschool to school and identify gaps and bottlenecks in existing services.

      3. Prevention:  Early prenatal care, nutrition counseling, genetic counseling, and injury control are discussed in other sections of the manual.

      4. A referral to mental health providers requesting assistance in identification of developmental deviations and handicapping conditions from a psychological perspective should be made as appropriate.

3-13.7  CHILD ABUSE AND NEGLECT

  1. Purpose:

    This section sets forth the IHS policies, objectives, procedures and responsibilities that relate to the detection, management and prevention of child abuse and neglect (CA/N).

  2. Policies:

    1. The IHS will provide prompt comprehensive health services to the abused and neglected child and his family, assure a safe environment for the welfare of the child, and work toward the ultimate rehabilitation of the child and his family.

    2. The IHS in cooperation with the Bureau of Indian Affairs (BIA), tribal programs, and State/county services will participate in multidisciplinary child protection teams on the Area Office and local levels.

    3. The IHS will coordinate its activities with other community agencies toward the prevention of abuse and neglect.

  3. Objectives:

    1. To assure that Area/Program and service unit staff understand their responsibilities towards the victims or suspected victims of CA/N.

    2. To define the legal requirements governing the comprehensive care of abused and neglected children.

  4. Procedures:

    1. Each service unit must have a current procedural manual outlining its management of CA/N issues.

    2. Each service unit plan should address the following issues:

      Identification and Mandatory Reporting of Cases

      Medical, Social Work and Mental Health Services

      Admission Policy

      Legal Proceedings.

    3. Each service unit shall develop a cooperative relationship with BIA, tribal and county/State agencies to develop the following:

      Multidisciplinary Child Protection Team (CPTs)

      Central Registries

      Monitoring and Data Collection

      Primary, Secondary and Tertiary Prevention of Child Abuse

      Training of Professional Staff and Community Member

  5. Responsibilities:

    1. Each Area/Program MCH Chief is responsible to assure that each service unit is in conformity with this policy.

    2. An IHS employee, when authorized in accordance with pertinent IHS regulations, and subpoenaed to do so, may testify and may disclose information from any IHS record in any court duly constituted under law and having authority to issue and enforce a judgment regarding parental rights, criminal prosecution and other issues related to CA/N.  This allows an IHS employee to testify and disclose information from IHS records to tribal courts as qualified above.  For guidance regarding submission of medical information to courts or testifying before such courts, advice should be solicited from the Area Director and the appropriate Regional Attorney.

    3. An employee sued because of actions or statements made during the performance of these or any other duties within the scope of his/her employment should immediately notify his/her supervisor and the Office of DHHS Regional Attorney serving his/her Area/Program.  Promptness is particularly important when the suit is against only the individual or has been filed in a State or tribal court rather than in Federal court.

  6. Program Guidelines:

    1. Identification and Reported - Any IHS employee or tribal contract employee through direct P.L. 93-638 contracting with IHS suspecting or having knowledge of CA/N is legally obligated to report his suspicions promptly and directly to the designated law enforcement/social service staff in their respective communities.  Each Service Unit Director is to provide for the staff the name and location of the appropriate authority to receive reports of CA/N.  The service unit may choose to coordinate reporting through the CPT but this should not hinder prompt reporting to responsible agencies.

      There is to be no requirement that such reports must be cleared through service unit administrative channels.  However, the CPT should and the Service Unit Director can be informed about the action.  There is to be no administrative or other adverse action taken against any IHS employee who without malice reports suspected CA/N.

    2. Admission Policy - Hospital admission may be necessary to guarantee a safe environment for the child.  This is to be considered an emergency admission, if other protective placement is not available, from the viewpoint of utilization of hospital beds or contract health service funds.  The medical condition, i.e., extent of injury is not relevant to this requirement.

      At times, it may be necessary to obtain from a court of competent jurisdiction an order placing the child under emergency protective custody of the court so that the child may be hospitalized over the objections of the parents.  Each service unit manual should state the procedure for emergency hospitalization and for obtaining authorization for protective custody admissions.

    3. Medical Services:

      1. Responsibility - In most localities, it is IHS's responsibility to provide medical and mental health services for the abused or neglected child and family either directly or through contract health services.

      2. Diagnosis. - The diagnostic procedures must be conducted in a manner which, if necessary, will provide thorough documentation for legal actions.

        Diagnostic procedures generally considered necessary include the following:

        1. A detailed history of the injury or neglect from all those caring for the child and the child himself plus documentation from previous visits for health services.

        2. A complete physical examination documenting evidence of injury or neglect.

        3. Appropriate laboratory and radiological tests such as trauma X-ray survey, bleeding disorder screen, cultures or serology for sexually transmitted disease.

        4. Color photographs or anatomic drawings.

        5. Behavioral and developmental assessment.

        6. Observations and documentation of parent-child interactions.

        7. Accurate documentation of spontaneous disclosures by the victim in his/her own words.

        Psycho-social data from parents and other significant persons are to be obtained by the medical social worker or mental health worker if not obtained by child protective services.

        In cases of physical abuse and neglect the siblings or other children in the home should be examined as soon as feasible.

      3. If BIA Social Services staff are not available, IHS Social Services staff may be asked to investigate or assist with the investigation of a CA/N referral with the concurrence of the IHS Service Unit Director.

      4. Treatment- The treatment of the abused or neglected child has two major components.  The first component, that of immediate care of the injury produced by the abuse or neglect, is in most localities the primary responsibilities of IHS and is conducted in the usual manner.  It is wise to determine in advance the availability of pediatric consultation in the care of abused or neglected children.  The responsibility for the second component of treatment, the rehabilitation of the child and his family, is much more diffuse.  It is essential that IHS participate in planning the long-term treatment and rehabilitation.  The locally available IHS social or mental health services are to be utilized to the fullest extent possible.

    4. Problem Identification and Corrective Actions - Problems which hinder the provision of protective services and/or medical, social and mental health services for abused children and their families shall be brought to the attention of the Service-Unit Director.  Every effort should be made to initiate corrective actions to remedy the identified problems at the local level.  Some circumstances, however, may require referral to the Area or Central Office for follow-up.

    5. Area Monitoring - In order to monitor this effort, all IHS and BIA Area Directors shall coordinate a report to be submitted to BIA Central Office Social Services staff on a monthly basis.  By Agency/service unit it shall identify the 1) Number of child abuse/neglect referrals, including those involving alcohol and/or drugs; 2) types of referrals - child abuse, child neglect or sexual abuse; 3) results of investigations, substantiated, unsubstantiated and under investigation: and, 4) actions taken - referral to court, referral to social services or other agency, no follow-up action.  The reports are submitted by each Area monthly to the Division of Social Services, Central Office.

    6. Legal Proceedings for Removal of Child From Home - It is the function and responsibility of the agency charged with child protective services together with that agency's legal counsel to determine whether to seek temporary or permanent termination of parental rights.  The function and responsibility of IHS are to make recommendations to the child protective service worker and furnish medical information to the court if requested.

    7. The Child Protective Team:

      Membership on Area CPT

      Each Area Director is to arrange for the appropriate IHS employees to serve on the Area CPT and for them to have sufficient time available to carry out their responsibilities to the team.  The Area’s protocol is to specify who will serve on the Area CPT.  Other IHS employees may be called upon from time to time to provide services to the Area CPT.

      Area CPTs

      Each Area CPT should be composed of, but not limited to, members from the following agencies:

      BIA IHS
      Director of Social Services
      Law Enforcement
      Judicial Services
      Education

      Direcctor of Social Services
      Maternal and Child Health Care Con.
      Mental Health Consultant
      Public Health Nurse

      Tribal Other
      Tribal Social Services or
      Health Program(s)

      State Social Services

      1. Functions of the Child Protective Teams - All communities will have need for a permanently organized team of persons from different professions and agencies to plan and coordinate services to families in which abuse and neglect occur.  In this document the term Child Protective Team, (CPT) is used to denote this organization though other titles may be used.  Only the child protective service agency has the authority to intervene in a family without the family's invitation.  In most States the legal authority for the CPT is based on the child protective service agency's mandate to receive and investigate reports of suspected abuse and neglect and make recommendations to the court.  Therefore, members of the CPT serve at the request of the child protective service agency.  CPTs are technical and advisory in nature.  In no way are they intended to undermine the authorities and responsibilities of individual agencies.  They are designed to promote cooperation, communication, and consistency among agencies.  It is appropriate for CPTs to debate what actions would best promote the well-being of a child and provide relevant information and advice to decision-making agencies.  CPTs should facilitate (not hinder) the decision-making process.  The team may have several functions but the essential functions are assessment of family dynamics, treatment planning, and monitoring of the care.  Without such a CPT no one agency, including IHS, can carry out its individual responsibilities to the family in the best manner.

        Area CPTs duties shall include:

        1. Providing General Oversight

          • At a minimum, hold quarterly meetings to review the activities and assess the needs of local CPTs.

          • In accordance with sections IV A 8 and IV B 5 of the memorandum of agreement between BIA and IHS (May 7, 1987), review local CPT plans in the Area for their adequacy.  Suggest improvements to local CPTs.

          • Monitor local CPT activities to determine whether they are appropriate, timely efficient, and effective.

          • Collect local CPT data for the Area and submit to the national policy group.

          • Develop and submit annual reports to the national policy group, including a comprehensive summary and assessment of the status of CPT activities.  Identify the strengths and weaknesses of the CPTs in the Area and discuss their effectiveness.  Provide recommendations.

        2. Facilitating Local CPT Activities

          • Based on identified needs and weaknesses, recommend appropriate corrective actions to local CPTs.

          • To the extent possible, assist local CPTs in obtaining adequate resources for their operations.

          • Coordinate local CPT activities with national and regional resources, programs, and professional organizations.

          • Communicate changes in national policy to local CPTs.

        3. Providing Technical Assistance

          • Develop Area policies for local CPTs.

          • Identify effective CPT models developed in other areas.  Assist local CPTs in adapting these models.

          • Identify local CPT training needs and provide available training resources.

          • Provide appropriate expertise and skills to local CPTs.

          Local CPTs

          Each local CPT should be composed of, but not limited to, members from the following agencies:

          BIA IHS
          Social Services
          Law Enforcement
          Judicial Services
          Education

          Social Services
          Maternal and Child Health Rep. and/or Physician
          Public Health Nurse

          Tribal Other
          Tribal Judicial Services
          Tribal Education
          Tribal Police
          Tribal Social Services Programs

          State/County Social Services

          However, in order to assure effective group interaction, it is suggested that membership should be limited to eight or less.  Other agency representatives may serve as resources for the CPT.  Confidentiality is a vitally important issue to address at the onset of the CPT's development.  Confidentiality shall be maintained and the tribal code or relevant Federal law will be the basis for any legal action required in response to a CA/N referral.  Confidentiality statements shall be signed by anyone who attends a CPT staffing.

      2. Membership on Local CPT - Each Service Unit Director is to arrange for the appropriate IHS employees to serve on the local CPT and for them to have sufficient time available to carry out their responsibilities to the team.  The service unit's protocol is to specify who will serve on the local CPT.  Other IHS employees may be called upon from time to time to provide services to the local CPT.

        The duties of the local CPT shall include the development and implementation of procedures for:

        1. Providing Oversight

          • Monitor child abuse and neglect activities to ensure that adequate preventive, protective, and corrective services are provided.

          • Review and track all child abuse and neglect cases which have been referred.

          • Investigate cases to determine whether the best interests of the children are being met.

          • Review case plans for their adequacy.

          • Maintain confidentiality of information.

          • Send local CPT data to Area CPT.

        2. Facilitating Provision of Services

          • Receive child abuse and neglect referrals and assign case managers to track cases.

          • Identify available community resources, programs, and services.

          • Provide recommendations to various pertinent agencies.

          • Promote cooperation, communication, and consistency among agencies.

          • Provide a forum for debating what actions would best promote the well-being of Indian children.

          • Respond to inquiries from the community, Area CPT, and other individuals and groups.

        3. Providing Technical Assistance

          • Develop procedures to provide effective and efficient preventive, protective, and corrective child abuse and neglect services.

          • Develop standards to determine which cases are to be investigated.

          • Provide information and technical recommendations to decision-making agencies.

          • Educate communities about child abuse and neglect problems and solutions.

          • Identify danger signs which prompt intervention and/or preventive actions.

          • Assist in the development and implementation of plans to promote the long-term well-being of children and their families.

          • Assist in the development and implementation of strategies by communities to create environments which provide opportunities for community members to lead meaningful, productive, self-fulfilling, and rewarding lives.  These environments should promote the dignity, self-worth, self-respect, and self-sufficiency of community members.

          Each local CPT shall develop and implement a plan of operation that shall relate to the critical elements identified below and specify the involvement of all members of the CPT:

          ________
          > Report >
          ________
          > Intake >
          > __________
          > -------------------->Referral >
          _______________ >
          > Investigation >
          ________________ ___________________ >
          > Study Assessment >--->Review by full CPT >
          _________ >
          > Diagnosis >
          _________ >
          > Case Plan >
          _________ >
          > Treatment >
          __________ >
          > Evaluation >
          ___________ >
          > Termination >
          > Case Closure >
          _____________

      3. Use of IHS Records - The CPTs can not function unless all participants are free to share whatever information they may have about the child and his family  Information contained in IHS medical, public health nursing, mental health, social service records as well as any other IHS records may be shared in interagency interdisciplinary conferences for the purposes of establishing a diagnosis, formulating a treatment plan, and monitoring the plan whenever those conferences are not open to the general public and participants in the conference are required to keep conference proceedings confidential.  They may also be shared with local social service and law enforcement personnel responsible for the investigation.  The information in the records may be shared in these circumstances but they are not copied and turned over to these agencies without a subpoena.  Each time a child is reviewed by the CPT a notation that such a review occurred must be documented in the progress notes of the child's health record.

    8. Central Registries - Central registries provide prevalence data and a means of tracking families between various clinics and service units in which abuse and neglect are occurring.  It is desirable that IHS participate in State operated central registries.  In some locations, a State operated central registry may not be practical; in such circumstances the Area Office may want to establish a registry system or, as a minimum, a system for collecting data on the prevalence of CA/N.  Each Area Office is to establish a policy for participation in a central registry or data collection system,

      Note:  Any Area or Program Office wishing to establish a registry system should coordinate the activities with the Area/Program Office Health Records Branch Chiefs and Privacy Act Coordinators to insure compliance with Privacy Act regulations.

    9. Prevention - The prevention of CA/N could be viewed as a community responsibility since CA/N may be a manifestation of faulty parent-child relationships.  However, IHS has a unique opportunity during the course of providing maternity care and preventive health services to children to participate in primary prevention by teaching and supporting parents and in secondary prevention by early detection and treatment.

      The service unit's manual is to specify a plan of action for prevention and for early detection and treatment of CA/N.  The most elementary plan would provide for screening for behavioral and discipline problems during provision of preventive health services for children and screening of maternity patients for those at high risk for CA/N.  Some plan is indicated for providing services for those families found to be at high risk.  In communities where there is no promotion of positive child rearing skills it would be appropriate for IHS to take a lead in developing resources within the community.

    10. Training - Each Service Unit Director will ensure that each physician, physician extender, nurse, public health nurse, social service and mental health worker has sufficient training to detect CA/N and to carry out his/her appropriate functions related to CA/N.  Such training will include identification of abuse/neglect; medical evaluation, and appropriate elements regarding medical record entries and testimony relevant to the medicolegal aspects of CA/N.

3-13.8  SEXUAL ABUSE

  1. Purpose:

    This section sets forth the IHS policy, objectives, procedures, responsibilities and guidelines related to services involving sexual abuse cases.

  2. Policy:

    The IHS will provide appropriate health care to any American Indian and Alaska Native identified as or suspected of being a victim of sexual abuse.

  3. Objectives:

    1. To assure that service units understand their responsibility in providing care to victims of sexual abuse and their family members.

    2. To assure that services are delivered in a sensitive manner.

    3. To define the legal requirements involving sexual abuse cases.

    4. To assure that such service meet all clinical, legal and reporting standards.

  4. Procedures:

    1. Each service unit must have written plans and protocols relating to the delivery of care to sexually abused clients.

    2. Each plan and protocol should address the following:

      Medical Evaluation and Treatment
      Counseling Services
      Legal Responsibilities
      Confidentiality
  5. Responsibilities:

    1. The Area/Program MCH Chief is responsible for assuring that each service unit is in conformity with this policy.

    2. If a health provider suspects that the sexual abuse is a component of child abuse and neglect, the policies as contained in IHS Manual, Part 3, Chapter 13, Section 3-13.7, Child Abuse and Neglect, should be followed.

  6. Program Guidelines:

    1. Counseling Services - The Social Work Services/Mental Health Branches should have primary responsibility for developing and coordination of this portion of the program.  (See IHS Manual, Part 3, Chapter 8, Medical Social Work Services; and Part 3, Chapter 14, Mental Health.)

      1. Pre-Examination - Culturally sensitive counseling of the victim and/or the family prior to medical care is of utmost importance and can aid in the ultimately satisfactory emotional resolution of the problem.

      2. Post-Examination - Supportive contact may need to be provided to the victim for months after the event.  Appropriate referral to trained counselors may be indicated.

    2. Clinical Services - There must be a designated clinician with primary responsibility for developing the following aspects of the program.  There are available numerous guidelines published outlining this aspect.  The IHS senior clinician of OB/GYN is available for consultation.

      References

      ACOG Technical Bulletin, 101, February 1987 Sexual Assault Abuse.

      American College of Obstetrician and Gynecologists
      409 12th Street, S.W.
      Washington, D.C.  20024

      Specific issues to address:

      Examination
      Laboratory Specimens
      Clothing
      Photographs or anatomic Drawings
      Health Record Recording
      Prevention of Disease
      Prevention of Pregnancy

    3. Legal Responsibilities:

      1. Consent Regulations:

        1. Except in emergency situations it is advisable to obtain the informed consent of the patient or other responsible person before a physician may treat a patient.

          Initial treatment for victims of sexual injury can be reasonably considered an emergency situation akin to traumatic injury.

          Therefore, it is not necessary to obtain a signed consent form as a prerequisite to providing medical assistance if to do so would endanger the patient's life or health.  This means that to the extent necessary an immediate diagnostic exam and first aid may be given to the victim of sexual assault.

        2. The emergency treatment exception to the requirement of consent is valid only as long as the extenuating circumstances exist.

          Therefore, in all cases requiring treatment beyond emergency first aid, or where it is possible to obtain consent before treatment without endangering the patient, a consent of the patient, according to the requirements of State laws, should be obtained.

          If the patient is a competent adult, this is a routine matter.

          In the case of a minor, however, State laws regarding consent to treatment vary greatly and it is IHS policy that consent to examination for treatment and evidence of sexual assault is governed by the law of the State where the IHS facility is located.

          If the minor is competent under State law to sign a consent to treatment for him/herself but refuses treatment, a demand by a parent cannot supersede the competent minor's refusal.

          Rape is a crime, and medical examination cannot conclusively establish the presence or absence of the commission of a crime.  It is IHS policy to perform only medically related care and treatment.

          Therefore, a parental demand that a physician determine whether a minor has been raped can always be refused if there is no apparent medical reason for the requested "rape" exam.

      2. Disclosure of Information:

        Reporting alleged or known child sexual abuse to law enforcement officials is mandatory and is permissible under the Privacy Act when such disclosure is required by State, local, or Federal law.

        It is IHS policy to disclose medical findings verbally when requested to social services and law enforcement officials who are responsible for the civil and criminal investigations of sexual abuse.  A written record is not released without a subpoena of a court of competent jurisdiction.

        Voluntary release of clinical information is governed by the Department's Privacy Act regulations at 45 CFR Part 56.

3-13.9  SCHOOL HEALTH

  1. Purpose:

    This chapter establishes the policy, objectives, procedures, responsibilities and guidelines related to school health activities of the IHS.

  2. Policy:

    The IHS will, in cooperation with local school administrators, assist in the provision of a comprehensive school health program.

  3. Objectives:

    1. To make available to each American Indian and Alaska Native student a school health program that is integrated with his/her entire educational experience.

    2. To provide a school health program that will help all students reach their full educational potential.

    3. To encourage that each school health program be developed and implemented according to IHS policies and standards.

  4. Procedures:

    1. Educational services are now provided to American Indian and Alaskan Native children through a variety of community, county and State systems as well as the traditional BIA program.

      In the case of the Federal BIA Programs, the IHS has certain direct responsibilities as agreed upon, from time to time, by the directors of both programs.  The non-Federal schools usually operate under State health codes and programs.  The IHS Service Unit and Area staff should be aware of these programs and work cooperatively to assure that good health services are being provided for IHS beneficiaries.  In BIA programs, a more direct provider role will be required.

    2. Each service unit will have written school health plans and supporting protocols, based on standards found in this manual and "School Health:  A Guide for Health Professionals" American Academy of Pediatrics, (1981) and appropriate to the role of direct provider (BIA) see Exhibit III, OIEP-IHS) or consultant (State and local).

    3. Serious outbreaks of disease or a death should be immediately reported to the Area Communicable Disease Officer. MCH Consultant and CMO.

    4. Each school health program should address the following areas:
      School Health Services,
      School Health Education,
      Healthful School Environment.

    5. All forms used and statistical data maintained must conform to IHS standards and policies.  (See IHS Manual, Part 3, Chapter 3, Medical Records; Part 3, Chapter 4, Nursing; Part 4, Chapter 3, Program Analysis Reports and Statistics.)

  5. Responsibilities:

    1. The MCH Area Chief is responsible for assuring that the policies in this issuance are being met.

    2. Through periodic assessments the MCH Area Chief will review the effectiveness of the service unit school health programs and make appropriate recommendations for needed changes.

  6. School Health Program Guidelines:

    1. School Health Services - includes all school activities directed at improving the total health status of the student.  This includes such activities as health appraisals, prevention and control of diseases, including alcoholism, first aid and emergency care, correction of remedial health defects, health counseling, mental health, etc.

      Plans will address when written consent will be necessary and how to obtain it to provide the services listed below.

      1. Physical Examinations:

        1. Initial - a complete physical should be given to students entering school for the first time, preferably before the opening of school.  By using form HSA 197 (3-74) in its entirety a complete history, examination and recommendation for each student can be noted.  Each student should bring this with him to admission/enrollment.

        2. Repeat Exams/Assessments:

          Annual Exams - all students who are planning to participate in bodily contact sports or as required by State law.

          Periodic Exams - all students K-1st, 6th and 12th grades.

      2. Health Appraisals:

        1. Annually, the individual student's health record will be reviewed by professional health staff to appraise completeness of the health plan for that student and to assure that all the necessary remedial services are initiated, followed through or completed.

        2. More frequent appraisals may be necessary for specific individuals, e.g., handicapped, recurrent clinic or center visitors, pregnant teenagers etc.

        3. Information from the appraisals should be used in planned staff-teacher, staff-parent, or staff-student conferences.

      3. Screening Procedures:

        1. Vision - screening should be done annually or according to State guidelines.  Screening should be done soon after school starts.

        2. Hearing - screening should be done on all students as soon as possible after they start school and annually throughout elementary grades l-3; 6th grade, and 7th through 9th grade and 10th through 12th grade or per State guidelines.

          All Students found upon otologic examination to have significant middle ear abnormalities should be tested semi-annually and be closely followed by a physician.

          All students referred by a nurse, teacher, or guidance staff, etc., because of suspected hearing impairment should be tested as soon as possible.

          Students with speech or hearing defects or other significant defects should be tested until the consultant states further evaluation is not necessary.

      4. Immunization:

        Immunizations should be provided based upon the most current guidelines from CDC, and the American Academy of Pediatrics and in accordance with State laws.

      5. Medical Care and Treatment:

        1. Emergency Care - The IHS school health facilities should be equipped to handle emergency illnesses or accidents until referral, if indicated, can be accomplished.

          The IHS school health staff should act as a consultant to the School administrators regarding plans and procedures for handling emergency care after the IHS school health facilities are closed.

          Formal written emergency plans should be available outlining referral resources and transportation systems.

        2. Acute Care - Specific plans and protocols should be written defining how acute care services including the dispensing of medications will be provided by both IHS health staff and School staff.  These plans should address such things as:
          referral mechanisms,

          notification of parents or guardians,

          holding facilities,

          schedules, etc.,

          epidemics.

        3. Chronic Care:

          The IHS staff should act as a coordinator of services to assure that students are referred and are receiving adequate remedial health care.

          The IHS staff should insofar as possible arrange for the student's health care to continue, if necessary, during periods of absence from the school (including holidays and vacations).

      6. Health Counseling - The IHS staff should be available to counsel students and their parents about health issues and questions.  This service should be provided in a way that respects the Student's right to privacy.

      7. Mental Health/Social Service - Encompasses services to any student with social, emotional, behavioral or learning problems which interfere with his learning experience.  In consultation with school administrators, mental health/social services should be made available to each student either directly or through well defined referral systems.

      8. Dental Health - A comprehensive dental program encompasses both preventive and curative activities.  (See IHS Manual, Part 3, Chapter 2, Dental.)

        1. Prevention - Oral health education activities should occur in the school curriculum, at dental chair-side, and in the home with/by parents.

          Adequate fluoridation exposure should occur.

        2. Curative - Emergency dental care for treatment and relief of pain, infection, trauma, etc.

          Dental examination once in a school year to assess state of oral health.

          Necessary routine dental care to maintain oral health status.

    2. School Health Education - encompasses all phases of planned as well as incidental school health instructions, including the motivational efforts essential to stimulate the child to help him/herself in developing and practicing proper health habits and attitudes in order to maintain a high level of personal health and community health.  It also involves the anticipatory guidance with parents in becoming more responsible for the health of their children.

      1. Curriculum planning - IHS staff should be available as a consultation resource to School staff in regards to teaching health related subjects.

      2. Primary teaching - Health education and preventive health is an integral part of IHS staff functioning, IHS staff should be available for an occasional course or subject presentation but are not to consider this as their primary role.  Actual provision of medical health care should remain the priority.

      3. Family life education - IHS staff should encourage the school staff to provide basic family life education/human sexuality courses within the curriculum and should assure that health services promoted by the course are available.

      4. Incidental teaching - IHS staff should take every opportunity when in contact with a student to instruct the student regarding her/his responsibility for his/her own health.

    3. School Nutrition Program - Nutrition education should be a definitive and planned part of the total health program from kindergarten through high school both for the students and school personnel, including food service employees.

      1. Curriculum - IHS staff should be available, as a resource, to school personnel in planning nutrition-related subjects including teaching aids, curriculum plans and field trips.

      2. Class Presentations - IHS staff should be available for instructing students with regard to the nutritional value of foods and the relationship between food and health.

      3. Workshops - IHS staff should plan with school personnel nutrition workshops for teachers based upon needs assessments.  Parental involvement should be encouraged.

      4. Food-Service Consultation - IHS staff should provide planned in-service education to food-service personnel in the principles and practices of food-service management and be available for consultation.

      5. Referrals - Upon referral, IHS staff should counsel teachers and food-service personnel on diet-related problems.  Students requiring individual counseling for a nutrition-related health condition (obesity, underweight, diabetes, allergies, etc.) should be referred to nutrition/dietetic staff.

    4. Healthful School Environment - Includes all activities which promote, correct, or improve environmental factors, both physical and mental, that may affect the health and safety of the school student and school personnel.

      1. Accident prevention - IHS staff should take an active role in promoting accident prevention by the school administration.

      2. Athletic Competition - IHS staff can act as consultants to coaching staffs in proper training programs and handling of injuries.  IHS health providers frequently provide direct medical support to teams during games or contests.

      3. Environmental inspection - IHS environmental health staff has specific responsibilities toward, BIA schools.  They may act as consultants to schools of other agencies if requested.  (See IHS Manual Issuance Part 3, Chapter 11, Environmental Health).

      4. Disease control - Environmental health staff and public health nursing (PHN) should be consulted any time there is any question of possible environmental spread of disease.

    5. School Health Staffing - Due to the variety of types of schools within each service unit (i.e., boarding vs. day schools; BIA vs. State or private schools) specific requirements can not be written.  It is the responsibility of each service unit to identify the proper staff needed to implement this policy.  As a rule, the IHS does not provide direct services in county, private or community schools in which there are organized school nurse activities.

    6. School Health Facilities - Due to the variations in size and type of schools within each service unit specific recommendations can not be made.  The service units, using the resources referenced in this policy, are responsible for determining the type of facility needed to implement a comprehensive school health program.

3-13.10  CARE OF THE ADOLESCENT

  1. Purpose:

    This section establishes the policy, objectives, procedure, responsibilities and guidelines related to health care provided to adolescents by the IHS.

  2. Policy:

    Health services will be provided to adolescents in a manner that will allow the young people to fully participate in their own health care.

  3. Objectives:

    1. To assure that health services are provided in a manner that is sensitive to the developmental tasks of the adolescent period.

    2. To assure that the adolescent's right to privacy will be respected.

    3. To assure that the adolescent is provided with education and counseling in order that he/she may make informed, intelligent decisions about health care and make life choices that will affect health positively.

  4. Procedure:

    Each service unit must have a written plan or protocol which addresses the specific issues listed below in accordance with local resources, State laws, Federal regulations and IHS policy.

    consent regulations

    disclosure of information

    education and counseling - e.g. substance abuse, smoking, sexuality, etc.

  5. Responsibilities:

    1. The Area/Program MCH Chief through periodic review will assure that each service unit's plan is in conformity with this policy.

    2. The Area/Program MCH Chief will periodically review the effectiveness of this policy in addressing the needs of the adolescent.

  6. Program Guidelines:

    1. Definition - The term adolescent refers to those individuals between puberty and legal age of maturity.  They are usually capable of actively participating in their own health care but, solely because of age, are not competent under State law to give signed consent for treatment.

    2. Consent Regulations - In accordance with applicable State laws, counseling and services regarding pregnancy, sexually transmitted diseases and family planning may be provided without the parents knowledge and consent.  In general the IHS policy is to encourage adolescents to involve their parents in their health care.  It is the adolescent's responsibility to inform his/her parents.  The health care provider should encourage, counsel and support adolescents in the process of involving their parents.

    1. As consistent with local laws, adolescents may request and receive examination for diagnosis and/or treatment of sexually transmitted disease or pregnancy without the knowledge and consent of parents.  These medical examinations or other procedures can be done only with the adolescent's consent with the exception that if the person is unable to consent because of a physical/emotional condition then customary procedures for treating patients in those conditions will be used.

    2. Contraceptives may be prescribed and dispensed without the knowledge and consent of parents.

  7. Disclosure of Information - The service unit must protect the privacy of the adolescent by applying the same safeguards to the adolescent's health records and other documents as are applied to those of adults.  Parents and guardians may be provided information only with the adolescent's consent.

  8. Education and Counseling - Each service unit should attempt to assure that health care providers serving adolescents are trained in adolescent development and adolescent health issues as appropriate for the providers role.

    1. The IHS should provide education and counseling to adolescents about major health problems of the adolescent age including accidents, drugs, alcohol, emotional stress, nutrition, sexually transmitted diseases, pregnancy, family planning, and maturational disorders such as acne.

    2. The IHS should encourage other agencies and resources within the community to participate or even take the lead in providing education and counseling in these areas.

  9. Alternative Clinic Site - Separate adolescent clinics are encouraged.  These may simply be at a separate time in the general clinic or provided at a alternative physical location.  Adolescents respond best if they can be assured of confidentiality and recognition of their emerging independence.  They respond poorly to the classic clinic setting.

3-13.11  PREVENTIVE HEALTH SERVICES FOR WOMEN

  1. Purpose:

    This section outlines the policy, objectives, procedure, responsibilities and guidelines relating to health promotion and disease prevention for women.

  2. Policy:

    Periodic disease prevention and health promotion services should be provided to eligible women.

  3. Objectives:

    1. To define services needed to meet this policy.

    2. To provide guidelines that should be followed in providing services to women.

  4. Procedure:

    Each service unit should have a procedural manual which addresses the following:

    Services to be provided.
    Protocols for follow-up of identified abnormalities.

  5. Responsibilities:

    1. The Area/Program MCH Chief through periodic review will evaluate compliance with this policy.

    2. The Area/Program MCH Chief will periodically evaluate the effectiveness of the service unit program.

    3. The Service Unit MCH Program Coordinator will be responsible for the implementation of this policy.

  6. Guidelines:

    1. Yearly encounters - Every woman should be encouraged to have an annual examination which should include the following:

      1. Interval history, including review of the menstrual cycle, and contraceptive use or need.

      2. Physical assessment including a breast, pelvic, heart, lung and abdomen examination, blood pressure and weight.

      3. Laboratory tests:

        1. Hemoglobin or hematocrit

        2. Urinalysis - protein and glucose

        3. Pap smear - annually after age 18 or after becoming sexually active.

        4. Screening of sexually active women for STD annually or as indicated.

        5. Random blood sugar if at risk.

      4. Immunization - Complete review of her immunization status should be done stressing the importance of TD boosters and rubella immunization if non-immune.

      5. Information regarding disease prevention should be provided, especially emphasizing breast self-examination.

        Resources for screening mammography should be identified for patients at increased risk for breast cancer as based upon age as well as other personal and familial risk factors.

      6. A health promotion program should be available for all women in accordance with the Objectives for the Nation, including:

        • Smoking and health
        • Misuse of alcohol and drugs
        • Nutrition
        • Physical fitness and exercise
        • Control of stress and violent behavior
        • Prevention of AIDS and other STDs

      7. The terminology develop by NCI for reporting pap smear results should be integrated into the Area/service units laboratory contracts (1988).

    2. Follow-up Activities - Procedures and policies for the treatment and/or referral of women with abnormal laboratory tests or physical findings must be documented.

3-13.12  FAMILY PLANNING SERVICES

  1. Purpose:

    This section sets forth the policies, objectives, procedures and responsibilities related to the family planning services of the IHS.

  2. Policies:

    1. The IHS will provide comprehensive family planning services to all eligible American Indian and Alaska Native men and women regardless of age requesting such services.  It is understood that these services are an integral part of the total comprehensive services offered to American Indian and Alaska Natives.

    2. IHS will neither promote nor discourage sterility or fertility of the population it serves.  Its overall policy is geared to the enhancement of life through assuring the availability of legally, ethically and medically acceptable information and services that afford families and individuals the opportunity to assure that each child is a wanted one.

    3. Rejection or acceptance of this service will not affect the families' or individual's eligibility for other services offered by the IHS.

    4. IHS personnel will not be forced to personally provide family planning services against their will but it will be their responsibility to refer the client requesting such services to the proper available resource.

  3. Objectives:

    1. To outline the responsibilities of the IHS staff in providing comprehensive family planning services.

    2. To assure that procedures meet all clinical, legal regulatory and reporting standards and requirements.

    3. To assure that programs developed will be sensitive to cultural beliefs and practices of American Indian and Alaska Natives.

    4. Provide guidelines for family planning services.

  4. Procedure:

    Each IHS service unit will have written plans and protocols for delivering the following services either directly, by referral or through contract care systems.

    1. Adoption Services.

    2. Contraceptive Services.

    3. Family Planning Education Services including Family Life and Human Sexuality Education

    4. Infertility Services.

    5. Sterilization Services.

  5. Responsibilities:

    1. The Area/Program MCH Chief is responsible for periodically reviewing all service units' plans and protocols to confirm that they meet the standards set forth in Sub-Section F of Section 3-13.12.

    2. It will be the responsibility of the Area/Program MCH Chief to confirm that all service unit plans and protocols regarding sterilization meet the regulatory policy and legal requirements for informed consent and performance of sterilization procedures (Federal Register 42 CFR, Parts 50 and 441, Sterilization and Abortions, November 8, 1978).

    3. The Chief Medical Officer of each Area/Program is responsible for assuring that each individual involved with the delivery of sterilization services is provided information about departmental policies, has read the material and is conforming to those policies.

    4. Area/Program Directors and Service Unit Directors are responsible for assuring that all staff responsible for providing sterilization services and staff responsible for authorizing Federal funds for sterilization services are aware of and in compliance with Department of Health and Human Services rules and regulations governing delivery of these services.

    5. It is the responsibility of the Area/Program Directors to assure that all required monitoring data and statistics are correct and are transmitted to Headquarters correctly and on time.

    6. The Office of Program Operations is responsible for tabulating all reported data and initiating any corrective action needed as a result of apparent violations of policy.

  6. Service Guidelines and Policies:

    1. Adoption Services - The Social Service Branch has the primary responsibility for developing and monitoring this aspect of the program.  (See IHS Manual, Part 3, Chapter 8, Medical Social Services).

      Although the IHS has no responsibility for finalizing placement of a child, IHS staff should provide the following components:

      1. Counseling - Psychosocial support should be offered to those women or couples requesting help in making decisions regarding adoption.

      2. Referral - Only those agencies that are aware of the cultural sensitivities of the client and that meet the regulations of the Indian Child Welfare Act will be utilized as referral sources.

    2. Contraceptive Services - All available Food and Drug Administration (FDA) approved types of contraceptive (mechanical, chemical and natural) methods should be available to those clients requesting such services.  The choice of method will be that of the patient based on a careful explanation of each method in accordance with the medical judgment of the provider. Adequate follow-up should be available to respond promptly to complications or side effects of the various methods as well as to assure proper and effective use of the selected method.

      1. Insertion and removal of IUDs and the fitting of diaphragms will be performed only by those health providers granted the appropriate clinical privileges by the medical staff of the local health facility.  A signed informed consent should be obtained prior to insertion of IUD.

      2. Specific protocols must be written for all physician extenders involved in the delivery of contraceptive services.  These protocols must provide for periodic physician supervision and review.  (See IHS Circular #76-4, Dated 6-3-76, Physician Extenders).

      3. When the primary provider or counselor is not an employee of the IHS a written agreement should be executed between the individual's employing agency and the IHS facility to include such factors as clinical supervision, workload, schedule, compliance with IHS standards, etc.

      4. Documentation that appropriate counseling was provided should be recorded in the patient's health record.

      5. All patients receiving Depo Provera will be placed on a register collected and maintain by the service unit pharmacy.  Consultation with a OB/GYN specialist is required prior to prescribing this drug for therapeutic or prophylactic purposes.  Date therapy was initiated/discontinued and purpose for therapy is to be maintained in the register.  An informed consent must be obtained from the patient, parent or guardian.

    3. Education Services - Health Education staff have the primary responsibility for developing and monitoring this aspect of the program.  (See IHS Manual, Part 3, Chapter 12, Health Education).

      Specific plans should be developed to address the following:

      1. Specific individual and group education needs regarding various family planning methods and the benefits, complications, and side effects of each method.

      2. Community education about services available.

      3. Family Life and Human Sexuality courses Educational programs should be appropriate for school, church, youth groups and other settings.

    4. Infertility Services - The basic elements should be provided to women and men when requested and indicated, including history and exam, basal temperature charting, semen analysis and post coital testing, and serum progesterone assay.  Endometrial biopsy, hysterosaipingography and diagnostic laparoscopy should be made available in those facilities with Ob/Gyn specialists on-site.  Specific clinical protocols can be developed by consultation with gynecological consultants within each Area/Program.

    5. Sterilization Service - Are offered as a method of family planning to any client requesting such service, but only within the constraints and mandates of the Department of Health and Human Services rules and regulations.  The decision to be sterilized must be that of the individual, it must be made only after thorough information regarding the risks, benefits and permanence of the procedure have been explained and alternative methods of family planning have been offered.

      1. Rules and Regulations:  (Reference Federal Register - Sterilization and Abortions, November 8, 1978.)

        1. The only procedures which may be performed for the primary purpose of sterilization are tubal ligation and vasectomy.

        2. The use of or arranging for an hysterectomy solely for the purpose of sterilization is prohibited.  If there is more than one purpose for the procedure, the hysterectomy would not be performed for the sole purpose of rendering the individual permanently incapable of reproduction.

        3. The performance of, arranging for, or authorization of expenditures of Federal funds for any sterilization procedure in IHS or non-IHS facilities is prohibited when the following conditions exist:

          The intent of the surgical procedure is to render the individual incapable of fathering or conceiving children, and

          The individual is:

          Under 21 years of age, or,

          Incapable of giving informed consent as a result of having been legally determined to be mentally incompetent, or,

          Institutionalized in a correctional, mental or other facility (See Section 42 CFR 50. 205 (b) Federal Register).

          * Reference

          Federal Register - Sterilization and Abortions, November 8, 1978.

        4. All IHS employees directly or indirectly responsible for sterilization procedures, both in performing such procedures or authorizing funds for such procedures, will be provided the information contained in this part of Section 3-13.12 explaining all sterilization rules and regulations including auditing and reporting requirements.

      2. Consent Procedures:*  (Reference Federal Register - Sterilization and Abortions, November 8, 1978.)

        1. No sterilization procedure may be performed until informed consent is obtained from the patient and documented.  Department of Health and Human Services rules and regulations require that the information and consent forms as found in the booklets - "Information for Women" DHHS Publication DHEW #(OS) 79-50061 and "Information for Men" DHEW #(OS) 79-50062 must be used in order to meet consent requirements.

        2. Consent forms must be signed at least 30 days prior to the sterilization procedure except in instances of premature delivery or emergency abdominal surgery, in which cases consent must have been signed at least 72 hours prior to the procedure.

        3. The consent can not be obtained while the individual to be sterilized is in labor or childbirth; seeking to obtain or obtaining an abortion; or under the influence of alcohol or other substances that affect the individual's state of awareness.

        4. The consent is effective for 180 days from the date the consent form was signed.

      3. Monitoring Procedures - Sterilization and Hysterectomy Surveillance.

        1. Reporting Procedures - Within 30 days after the end of each calendar quarter the Sterilization Record, PHS Form 6044 (Rev. l-791, is required to be submitted to the Area Office from any IHS facility, tribal program or project that performs or arranges for sterilization or hysterectomy either through direct services or indirectly through contracts, agreements or arrangements with other providers.  Explanation of what constitutes performing or arranging for sterilization or hysterectomy is included in the instructions for completing PHS Form 6044.

          Any IHS facility, tribal program or project which does not perform or arrange for sterilization or hysterectomy must file a letter with the Area/Program.  Office stating that the facility, program or project does not perform or arrange for sterilization or hysterectomy either through services provided directly or services provided indirectly through contracts, agreements or arrangements with other providers.  This letter must be updated at least annually.

          The IHS Area/Program Office should compile and maintain lists of IHS facilities, tribal programs and projects which are required to report quarterly.

          The Area/Program Office has 45 days to summarize the reports by State and properly fill out a summary REPORT TO THE SECRETARY ON STERILIZATION (Form PHS 6045, Rev. 1-79) for each State.  This form is to be submitted by the Area/Program Office to the Office of Program Operations (OPO), IHS Headquarters within 45 days after the end of the quarter.

          The OPO will combine State totals where necessary and Send the completed State reports to the Deputy Assistant Secretary for Population Affairs (DASPA) within 60 days after the end of the quarter.

          The REPORT TO THE SECRETARY ON STERILIZATION due from the Area/Program Office to the OPO, IHS Headquarters, for the fourth quarter of the calendar year, will be accompanied by a brief narrative summary of sterilization and hysterectomy activities within the Area/Program for the preceding year.  This annual narrative will contain, at a minimum, the following information:

          1. Summary of follow-up on violations including:

            Number and type of violations

            Corrective action taken

          2. Summary of audit investigations including:

            Number completed

            Results

          The OPO, IHS Headquarters, will forward a summary from each State to DASPA within 60 days after the end. of the calendar year.

        2. Reporting of Apparent Violations - For each apparent violation reported in quarterly reports, the following information must be submitted to the IHS-MCH Coordinator through the Area/Program Office:

          1. Area, State, and quarter.

          2. Whether the circumstances of the case were normal (less than 30 days), or exceptional (less than 72 hours).

          3. An explanation if it was not a violation.

          4. If it was a violation, the following must be included:

            1. Identify the provider site(s), name of facility, program, or project involved.

            2. Provide an explanation of the circumstances.

            3. Indicate whether there have been similar violations in previous quarters from this provider.

            4. Indicate what has been done regarding the violations (follow-up action).

            5. Indicate what action has been (or will be) taken to recover Federal funds.

            6. Indicate when inappropriately expended Federal funds will be reimbursed.

            7. Describe what disciplinary action was (or will be) taken or planned for cases involving IHS employees.

            8. Describe the steps taken (or to be taken) to prevent a recurrence.

        3. Audit Procedures - sterilization and hysterectomy systematic audits, to ensure that all rules and regulations as contained in IHS Manual, Part 3, Chapter 13, Section 12 and 13 have been met, must be performed by Area/Program Office personnel annually according to the following guidelines:

          1. Those IHS facilities, tribal programs and projects or individual providers reporting a rate equal to or greater than 100 sterilization procedures per year should be audited annually.

          2. Any IHS facilities, tribal programs, projects or providers consistently having apparent violations should be audited more frequently.

          3. All audits should review compliance with:
            Rules and regulations, consent procedures, monitoring procedures including the validity of the quarterly Sterilization Record Reports. (Form PHS 6044).

          4. All audits will cover the activities performed in the two latest reported quarters.

          5. All IHS facilities, tribal programs and projects or individual providers to be audited should be provided advance notice so they can gather the necessary data together.

        4. Corrective Action - Proven violations require recovery of Contract care funds, termination of contract and/or disciplinary action.

3-13.13  HYSTERECTOMIES RESULTING IN STERILIZATION

  1. Purpose:

    This section outlines the policies, objective, procedures and responsibilities concerned with the provision of hysterectomies by the IHS.

  2. Policies:

    1. Hysterectomies may be performed on American Indian and Alaska Native women when medically indicated.

    2. The use of or arranging for hysterectomy for the primary purpose of sterilization is prohibited.

  3. Objective:

    To assure that all hysterectomies performed, as part of the comprehensive health care system of the IHS, are medically indicated and meet legal, consent and reporting requirements.

  4. Procedures:

    1. Any woman requiring a hysterectomy must be informed prior to surgery, that she will be permanently sterile.

    2. Every woman, prior to having a hysterectomy, must sign a statement in the chart, signifying she understands she will be permanently sterile.

    3. The physician who will perform the procedure must record in the chart that the patient has been informed that she will be permanently sterile.

    4. The procedures of paragraphs 1, 2 and 3 of this section do not apply if either of the following circumstances exists:

      1. The individual is already sterile at the time of the hysterectomy.

      2. The individual requires a hysterectomy because of a life threatening emergency in which the physician determines that prior acknowledgement is not possible.

    5. If the procedures of paragraphs 1, 2 and 3 of this section are not followed because one or more of the circumstances of paragraph 4 exists the physician who performs the hysterectomy must certify in the chart.

      1. That the woman was already sterile, stating the cause of that sterility, or;

      2. That the hysterectomy was performed under a life-threatening emergency situation in which he or she determined prior acknowledgement was not possible.  He or she must also include a description of the nature of the emergency.

  5. Responsibilities:

    1. The Area/Program Chief Medical Officer is responsible for the implementation of this policy.

    2. The MCH Area Consultant is responsible, through periodic chart review, for assuring that the above requirement of informed consent is documented.

    3. The Area/Program Director is responsible for implementing the audit and reporting procedures as outlined in IHS Manual, Part 3, Chapter 13, Section 12F.5., Sterilization Services.

    Reference - Federal Register 42 CFR, Parts 50 and 441, Sterilization and Abortions, November 8, 1978, Requirements Applicable to Sterilizations (Hysterectomies) August 4, 1982 (47-FR-33695).

3-13.14  ABORTION SERVICES

  1. Purpose:

    This section sets forth the IHS policies, objectives and procedures, and the responsibilities of IHS staff in regards to abortion services for American Indian and Alaska Native women.

  2. Policies:

    1. Federal funds may not be used to pay for or otherwise provide for elective induced abortions unless:  *

      A physician has found and certified in writing to the appropriate tribal or other contracting organization, and to the service unit or Area program director that "on the basis of my professional judgment the life of the mother would be endangered if the fetus were carried to term".  The certification must contain the name and address of the patient.

      *  The Federal Register, 42 CFR, Part 36 defines or otherwise provides for as follows:

      "...Federal funds may not be used to provide abortion services either directly or indirectly.  For example, IHS funds cannot be used to pay the salary of an individual who performs non-conforming abortions on salaried time, or for the costs incurred at an IHS facility where an abortion is performed.  Nor can IHS contract care funds be used to reimburse a physician or a facility performing an abortion, for this would constitute indirect support."

    2. Federal funds are available for drugs or devices to prevent implantation of the fertilized ovum, and for medical procedures necessary for the termination of an ectopic pregnancy.

    3. Health care services associated with spontaneous abortions threatened, inevitable, missed, incomplete or habitual may continue to be provided.

    4. Documentation of the certification statement must be maintained in the Office of the Service Unit Director for three years pursuant to the retention and custodial requirements for records at 45CFR 74.20 et seq.

    5. Information which is acquired in connection with these requirements may not be disclosed in a form which permits the identification of an individual without the individual's consent, except as may be necessary for the Secretary of the Department of Health and Human Services to monitor IHS program activities.  In any event, any disclosure shall be subject to appropriate safeguards which will minimize the likelihood of disclosures of personal information in identifiable form.

  3. Objectives:

    To define IHS staff responsibilities for implementing the policies.

  4. Procedures:

    1. Documentation to the Service Unit Director from contract care providers should consist of the signed certification statement, as defined in (B) above, and the signature of the Contract Care Office indicating that the procedure was approved and funded.

    2. Documentation to the Service Unit Director from providers within IHS facilities should consist of the date of the procedure and the patient's health record number.  The certification statement, as defined in (B) above, will be written on the operative consent form and be maintained as a part of the health record.

  5. Responsibilities:

    1. The Area/Program Chief Medical Officer is responsible for assuring that each service unit is aware of these policies and is implementing them.

    2. The Area/Program MCH Consultant is responsible for periodically reviewing each service unit's experience to assure that it is conforming to these policies.

    3. The Area/Program Chief Medical Officer in consultation with Area/Program gynecologists is responsible for the development of specific clinical standards for medically indicated abortion services.

    Reference -  Federal Register, 42 CFR, Part 36.


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