Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 1 – Complete Care Model

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3.1.16 Patient Care During Pregnancy and Childbirth

  • Policy

    • California Correctional Health Care Services (CCHCS) staff shall provide health care for the pregnant patient population. CCHCS provides comprehensive and coordinated health care services to female patients commensurate with each patient’s risk level and complexity, based on the Complete Care Model.

    • Every institution housing women shall provide obstetrical services, to include care for women with high-risk pregnancies. The California Institution for Women (CIW) is the designated institution for management of pregnancy and childbirth.  All newly identified pregnant patients shall be referred for transfer to CIW.

  • Purpose

    • To ensure health care concerns are met for the pregnant patient population both pre- and post-partum and for the birth of children at local hospitals.

  • Responsibility

    • Statewide

      • CCHCS and California Department of Corrections and Rehabilitation (CDCR) departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place; and appropriate tools, training, technical assistance, and levels of resources are available so that care teams can successfully implement this procedure at all institutions housing female patients.

    • Regional

      • Regional Health Care Executives shall implement this procedure at the subset of institutions within an assigned region.

    • Institutional

      • The Chief Executive Officer (CEO), or designee, is responsible for the implementation, monitoring, and evaluation of this policy.

      • The CEO shall implement and manage a system to administer this procedure.  The CEO shall delegate decision making authority to designated institutional health care executives for daily operations of the health care delivery system and ensure adequate resources are deployed to support the required elements of care including, but not limited to:

        • Provision of obstetrical services 24 hours per day.

        • Emergency treatment and management of preterm and/or precipitous delivery 24 hours per day.

        • Provision of hospital, surgical, and neonatal services.

        • Provision of social and educational services pertaining to pregnancy, childbirth, and health promotion.

      • The CEO and all members of the institution leadership team shall ensure all necessary resources are in place to support the successful implementation of this procedure at all levels; including, but not limited to:

        • Institution level

        • Patient panel level

        • Patient level

      • The CEO and all members of the institution leadership team shall ensure access to and utilization of equipment, supplies, health information systems, patient registries and summaries, and evidence-based guidelines, to ensure coordinated and integrated management of pregnancy and childbirth.

  • Local Operating Procedure

    • Each CDCR institution shall maintain a Local Operating Procedure to implement the statewide procedure.

  • Procedure

    • General Requirements

      • CCHCS staff shall conduct a health screening, including a pregnancy screening, for all female patients upon reception into CDCR per the Health Care Department Operations Manual (HCDOM), Section 3.1.8, Reception Center.

      • The Primary Care Provider (PCP) shall evaluate patients within seven calendar days of self-reporting a suspected pregnancy or when pregnancy is suggested by the patient’s physical appearance, and/or signs and symptoms of pregnancy are present.

      • CCHCS staff shall obtain diagnostic studies within three business days of evaluation by the PCP.

      • Upon confirmation of pregnancy, the Primary Care Team (PCT) shall provide and/or coordinate obstetrical and health care services to include a written plan of care.

        • A patient may request to receive medical services from the PCP of her choice who is credentialed and trained in obstetrics.

        • Any expenses incurred by the services of a non-CCHCS/CDCR PCP of the patient’s choice shall be the responsibility of the patient.

      • Patients with health care conditions that increase the risk of, or cause a high-risk pregnancy shall be identified, monitored, and referred to the appropriate level of care as indicated by health care needs of the patient.

      • PCPs at institutions housing female patients other than CIW shall refer newly identified pregnant patients to CIW by referral to the Classification and Parole Representative (C&PR) and the completion of a Medical Classification Chrono.

      • The PCT shall ensure communication with the receiving institution and other health care providers, regarding the patient’s status and treatment plans to ensure continuity and coordination of services.

      • Transfer shall occur in accordance with the procedure outlined in the HCDOM, Section 3.1.9, Health Care Transfer.  Special consideration shall be given to ensure that the appropriate mode of transportation is selected and communicated.

    • Care of Pregnant Patients

      • Pregnant patients shall be provided the following:

        • An initial Obstetrician visit scheduled to occur within seven days of pregnancy diagnosis.

        • Diagnostic studies; ordered as medically necessary.

        • A determination of the gestational age of the pregnancy and the estimated due date.

        • The option to be tested for human immunodeficiency virus (HIV) and other communicable diseases that may be transmitted to the infant.

        • Education by the PCP or Obstetrician regarding the patient’s choice of pregnancy options such as:

          • Continuing pregnancy and childcare plans.

          • Prenatal health care.

          • Adoption services.

          • Termination services.

          • Emergency contraceptives.

          • Obtaining pregnancy information pamphlets or other pertinent educational material.

        • CCHCS staff shall document the provision of this education in the health record.

      • Pregnant patients shall be prescribed or issued:

        • Prenatal vitamins (which contain iron and folic acid).

        • Dietary supplementation to include:

          • Two extra cartons of milk,

          • Two extra servings of fresh fruit, and

          • Two extra servings of fresh vegetables daily.

          • Additional nutrients or supplements and/or referral to a Dietitian as necessary.

        • A CDCR 7410, Comprehensive Accommodation Chrono, for lower bunk and lower tier housing if housed in a multi-tier housing unit and any other necessary medical clearances or restrictions in their third trimester or earlier, if medically indicated.

        • A referral to the dentist on a priority basis, as early in the second trimester of gestation as possible, for a comprehensive dental examination and treatment of periodontal disease.

      • The PCP shall prepare a CDCR 7252, Request for Authorization of Temporary Removal for Medical Treatment, for all pregnant patients within 30 calendar days prior to the estimated delivery date.  This form shall be taken to the Watch Commander’s office in advance to enable custody staff to prepare the patient for transportation to an outside facility in a timely manner.

      • Unless otherwise indicated by the Obstetrician, pregnant patients shall be scheduled for their obstetrical visits as follows:

        • Every four weeks in the first trimester and up to 24-28 weeks gestation.

        • Every two weeks thereafter up to 36 weeks gestation.

        • Weekly after 36 weeks gestation up to delivery.

      • Pregnant patients shall be provided additional health care services as medically indicated.

      • Every pregnant patient electing to continue her pregnancy shall be referred to a Medical Social Worker for case management to discuss placement of her child and options available for placement and care of the child after delivery.

        • The Medical Social Worker shall discuss the options available for feeding, placement, and care of the child after birth, including the benefits of lactation, and provide the pregnant patient with access to the written application for community-based programs serving pregnant, birthing, or lactating patients.

        • A Medical Social Worker shall assist the pregnant patient to contact relatives regarding newborn placement, even while still in process of reception.

        • The Medical Social Worker shall initiate and oversee the management of all newborn placements.

      • A pregnant patient electing to terminate her pregnancy shall be offered all due medical care and accommodations until she is no longer pregnant. Refusal of medical care shall be documented in the health record and signed by the patient.

      • If clinically appropriate, patients shall be provided opioid maintenance therapy during pregnancy.

    • Outside Consultation or Non-Emergent Labor and Delivery

      • Transportation shall occur in accordance with the procedure outlined in the HCDOM, Section 3.1.9, Health Care Transfer.  Special consideration shall be given to ensure that the appropriate mode of transportation is selected and communicated. 

      • Copies of all prenatal forms and the completed CDC 7243, Health Care Services Physician Request for Services, shall accompany the pregnant patient when sent for medical treatment or consultation to an outside facility, and when the patient is transported for labor and delivery.

      • When a patient returns, the Registered Nurse (RN) on duty in the Triage and Treatment Area (TTA), Outpatient Housing Unit (OHU), or Correctional Treatment Center (CTC) shall receive the patient’s paperwork from the outside facility.  The receiving nurse shall notify the PCP and Obstetrician of the patient’s return, medical status, recommendations from the outside consultant, and ensure the documents are filed in the health record.

    • Emergency Onsite Delivery

      • In emergent circumstances where the patient cannot be transported offsite prior to delivery of a baby, the patient shall be given the maximum level of privacy possible during the labor and delivery process. If custody personnel must be present, they shall be stationed outside the room absent extraordinary circumstances.

      • Infants delivered onsite shall be provided all appropriate care until transported to an offsite facility.

    • Emergency Transport

      • A pregnant patient in labor shall be treated as an emergency and be transported immediately via ambulance.  In the event of an emergency transport for the delivery of a baby, the Obstetrician and PCP shall be immediately notified and provide appropriate assistance and orders.

      • Application of restraint gear and physical restraints shall be in accordance with California Penal Code, Sections 3407 and 3423, and the Department Operations Manual, Sections 54045.1 and 54045.11.  If handcuffs are applied, the patient’s arms shall be brought to the front of the body for application.

    • Postpartum Care

      • Postpartum patients who deliver a child via cesarean section shall be admitted to the OHU or CTC via the TTA upon return to the institution.

      • All postpartum patients who deliver a child vaginally shall be assessed by the TTA RN who shall review discharge orders and initiate postpartum care following communication and receipt of orders with the PCP or Physician-on-call and determine appropriate housing.

      • If postpartum mental health concerns present, the patient shall be referred to Mental Health Services for proper assessment and treatment.

      • CCHCS staff shall schedule follow-up appointments, articulate treatment plans, and determine the need for continued limited duty, for all postpartum patients including the following:

        • A postpartum examination within one week from childbirth and as needed for up to 12 weeks postpartum.

        • At least 12 weeks of recovery after any childbirth before being required to resume normal activity.

      • Patients shall be afforded family planning services if their release and/or parole date falls within 12 to 16 weeks after delivery.

    • Local Oversight – Designated Standing Improvement Committee

      • Institution leadership shall designate an existing standing committee that reports to the local Quality Management Committee for oversight of the systems and processes dedicated to the health care management of pregnant patients.

      • Tracking and monitoring activities shall be performed to identify trends and opportunities for improvement.

  • References

    • Code of Federal Regulations, Title 42, Chapter 1, Subchapter A, Part 8, Subpart B, Section 8.12(f)(3), Federal Opioid Treatment Standards

    • California Penal Code, Part 3, Title 2, Chapter 3, Sections 3406-3409

    • California Penal Code, Part 3, Title 2, Chapter 4, Section 3423

    • California Code of Regulations, Title 9, Division 4, Chapter 4, Subsection 5, Article 3, Section 10360, Additional Requirements for Pregnant Patients

    • California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 2, Article 7, Section 3170-3182, Visiting

    • California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 4, Article 7, Section 3337, Classification Hearing of Administrative Segregation Placements

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.1, Complete Care Model

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.8, Reception Center

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.9, Health Care Transfer

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.10, Specialized Health Care Housing

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.12, Outpatient Dietary Intervention

    • Health Care Department Operations Manual, Chapter 3, Article 2, Section 3.5.1, Pharmacy and Medication Services

    • California Department of Corrections and Rehabilitation, Department Operations Manual, Article 45, Sections 54045.1 and 54045.11

  • Revision History

    • Effective: 01/2006
      Revised: 09/2021