D.20 SOP for Maternity Care at Salem VAMC.pdf

D.20 SOP for Maternity Care at Salem VAMC 36C24621R0068

Salem VA Medical Center Salem, VA 24153

Signatory Authority:

MATERNITY CARE

SOP 658-11-003

Service Line(s):

Primary Care

Effective Date:

Special Program Assistant to the Chief of Staff

Responsible Owner:

Women Veterans Program Manager

1. PURPOSE AND AUTHORITY:

December 4, 2020

Recertification Date:

December 4, 2025

To establish processes, roles and responsibilities for coordinating the maternity care of eligible, enrolled women Veterans at the Salem VA Medical Center.

2. PROCEDURES

a. To establish requirements to apply standardized communication and care coordination for Pregnant Veterans at the Salem VAMC and all Community Based Outpatient Clinics (CBOCs). This includes the evaluation and authorization process for maternity care in the community and education regarding maternity benefits.

b. Establish the role of the Maternity Care coordinator and transitions of care between Salem VA Primary care Providers (PCP), Gynecologists and community providers including inpatient and emergency services.

3. ASSIGNMENT OF RESPONSIBILITIES

a. The primary care provider confirms pregnancy (clinically or with urine/serum testing) (Quantitative HCG is recommended). (Complete history needs to be taken to evaluate for high risk—see Appendix A ) Point of Care testing is available at all CBOCs.

b. Immediately after confirmation of pregnancy, PCP places Community Care (CC) Obstetrics (OB) consult. If patient deemed high risk, provider should make notation of clinical condition and factors that increase risk in the consult. Direct communication with community care service is required to expedite referral process.

c. The CitC OB SEOC includes (but is not limited to) comprehensive assessment, standard and special laboratory tests, maternity prenatal screening for genetic disorders, gestational dating ultrasounds, new specialty consultations, comorbid conditions, postpartum contraception, newborn care (first 7 days of newborn’s life), pharmacy prescriptions during pregnancy and postpartum, beneficiary travel to VA appointments when eligible, pregnancy related education (childbirth preparation

December 4, 2020 SOP 658-11-003 classes, parenting classes, nutrition counseling and breastfeeding support and lactation classes for community partners that are vendorized with VA), and miscarriage.

d. Maternity care that is not covered includes: home deliveries, services by Doulas, deliveries by direct-entry midwives, experimental procedures, elective abortions.

e. The PCP (consulting with Pharmacy as needed) will counsel women Veterans on the risks and benefits of high-risk teratogenic medications (e.g., FDA class D or X) if those drugs are being considered for use. Any use of hazardous drugs will have appropriate consents in place.

f. The PCP will ensure that all pregnant Veterans are screened for depression, intimate partner violence/domestic violence (IPV/DV), military sexual trauma (MST), post- traumatic stress disorder (PTSD), anxiety, substance use, and postpartum depression and that referrals and authorizations for care of any confirmed conditions are made, as appropriate.

g. The Salem VA staff Gynecologist will be available for consultation with the Primary Care Provider to provide ongoing care for acute issues or problems for pregnant Veterans who present to the Salem VA before the initial community OB appointment can be made. Once an initial OB appointment has been completed in the community, the routine care of the pregnant Veteran will be directed by the Community attending provider. (If a pregnant Veteran comes to the Emergency Department but does not have a VA PCP, the ED staff will make a referral to establish a Primary Care initial appointment.)

h. If a Veteran presents to the Salem VA with a suspected spontaneous abortion, the Gynecologist may deem it medically necessary to provide care in the form of a procedure (i.e., dilation and curettage) or medical management consistent with standard of care. Such medically necessary procedures for the management of spontaneous abortion are covered medical benefits. All specimens of miscarriage shall be sent to lab for examination.

i. The Women Veterans Program Manager (WVPM) activates the pregnancy/lactation flag in CPRS after receiving the CitC obstetrics consult alert and ensure the Veteran’s electronic health record reflects Veteran’s pregnancy and lactation status.

j. The MCC calls all new pregnant female Veterans (within 3 business days of the CC Obstetric consult being placed) to review emergency policies as listed below.

(1) The Veteran must be provided information in advance about seeking emergency care at the closest Emergency Department or at the hospital the Veteran will be using for delivery.

(2) The Veteran will be advised the use of 911 services and the closest community Emergency Room is the most appropriate action in emergency situations that occur off-site. Salem VA clinics and emergency department are unlikely to be equipped for all obstetrical scenarios.

(3) In the event The Veteran has an emergency situation while on-site, they will be triaged in the Salem VAMC ED then transferred to a medically appropriate facility, once stabilized.

k. The MCC will review maternity care benefits with the pregnant Veteran including regular care coordination telephone triage. The MCC will make at least 7 phone calls using national templated notes, throughout the patient’s pregnancy to address VA coverage of services, locating a community obstetrician, childbirth preparation, breastfeeding and newborn care classes, pharmacy questions, postpartum and breast pump issues, tubal ligation and IUD information, family planning and contraception, health problems, smoking and alcohol cessation, local and community resources, suicide and IPV assessment, miscarriage or fetal demise assessment, and post-partum follow-up. Depression screens are performed during the first call and any positive results will be sent to PCMHI for follow-up. Pregnant patients are educated on how to fill prescriptions from outside OB providers.

l. The MCC will ensure the effective coordination of care between the VA and maternity care providers in the community and community specialist providers.

m. The MCC will retrieve statistical data on maternity care and utilization including Veteran demographics, number of Veterans being managed for maternity care, pregnancy outcomes, lactation status. All relevant data will be reported to the Women’s Health Committee.

n. The MCC will ensure women have post-partum visits with their community provider and records are available in the EMR for their first follow-up visit with VA PCP.

The patient should follow-up with her VA PCP 6 weeks post-partum.

o. Women Veterans may continue to receive care through the VA health care system during their pregnancies, either for management of coexisting medical or mental health conditions or for acquiring laboratory tests or medications during their pregnancy.

p. VA pharmacies are authorized to fill prescriptions that are written by Authorized community Providers in accordance with VHA Handbook 1108.05(2), Outpatient Pharmacy Services.

q. Inpatient hospitalizations of pregnant Veterans are triaged by the hospitalist in consultation with the Gynecologist on call. As standard protocol, pregnant women greater than 20 weeks will be referred for inpatient care through Community Care.

Pregnant Veterans less than 20 weeks will be triaged on a case by case basis with the Chief of Staff, Deputy Chief of Staff and Gynecologist.

r. The WH Medical Director will immediately refer all pregnant women who are transferring from other facilities to a community care OB.

-05'00'

s. The WH Nurse Manager will audit all pregnant patients charts per month to ensure compliance with this SOP.

4. DEFINITIONS

None.

5. REFERENCES

VHA Handbook 1330.03: Maternity Health Care and Coordination, November 3, 2020.

6. REVIEW

Review of this SOP will be, at minimum at recertification, and including when there are changes to the governing document.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day 5 years from effective date. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Tammy S. Snyder

181419

Digitally signed by Tammy S.

Snyder 181419

Date: 2020.12.07 09:32:04 -05'00'

Tammy Snyder, LCSW Special Program Assistant to the Chief of Staff

SOHEIR S Digitally signed by SOHEIR S

BOSHRA 1440776

BOSHRA 1440776 Date: 2020.12.07 08:20:07 -05'00'

Soheir Boshra, MD Women’s Health Medical Director

Eleanor E.

Digitally signed by Eleanor E. Wright 181394

Wright 181394 Date: 2020.12.07 07:57:09

Eleanor Elizabeth Holt Wright, LCSW Women Veterans Program Manager

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs are available at:

https://dvagov.sharepoint.com/sites/salem/Salem%20SOPs/Forms/AllItems.aspx https://dvagov.sharepoint.com/sites/salem/Salem%20SOPs/Forms/AllItems.aspx

Appendix A

HIGH RISK PREGNANCY

Maternal Factors:

A. Age (younger than age 15, older than age 35)

B. Weight (pre-pregnancy weight under 100 lb. or obesity)

C. Height (under five feet)

D. History of complications during previous pregnancies (including stillbirth, fetal loss, preterm labor and/or delivery, small-for-gestational age baby, large baby, pre-eclampsia or eclampsia)

E. More than five previous pregnancies

F. Bleeding during the third trimester; abnormalities of the reproductive tract

G. Uterine fibroids; hypertension

H. Rh incompatibility

I. Gestational diabetes

J. Infections of the vagina and/or cervix

K. Kidney infection

L. Acute surgical emergency (appendicitis, gallbladder disease, bowel obstruction)

M. Post-term pregnancy

N. Pre-existing chronic illness (such as asthma, autoimmune disease, cancer, sickle cell anemia, tuberculosis, herpes, AIDS, heart disease, kidney disease, Crohn's disease, ulcerative colitis, diabetes).

Fetal factors

A. Exposure to infection (especially herpes simplex, viral hepatitis, mumps, rubella, varicella, syphilis, toxoplasmosis, and infections caused by coxsackievirus)

B. Exposure to damaging medications (especially phenytoin, folic acid antagonists, lithium, streptomycin, tetracycline, thalidomide, and warfarin)

C. Exposure to addictive substances (cigarette smoking, alcohol intake, and illicit or abused drugs).

D. Prenatal tests indicate that the baby has a serious health problem (for example, a heart defect).

E. Certain maternal or fetal problems may prompt a physician to deliver a baby early, or to choose a surgical delivery (cesarean section) rather than a vaginal delivery.