TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 265 BIRTH CENTER DEMONSTRATION PROGRAM CODE
SECTION 265.1550 ADMISSION PROTOCOLS FOR ACCEPTANCE FOR BIRTH CENTER CLIENTS
Section 265.1550 Admission Protocols for Acceptance for Birth Center Clients
a) An admission protocol specifying the criteria for admitting a client to the birth center shall be included in the application as provided in Section 265.1300.
b) Only clients whose births are planned to occur following a normal, uncomplicated, and low-risk pregnancy shall be allowed to receive services at the birth center. The medical director and the Director of Nursing and Midwifery Services shall jointly develop and approve policies defining the criteria to determine which pregnancies are accepted as normal, uncomplicated and low-risk, and the anesthesia services and other services available at the birth center. (Section 35(6) of the Act)
c) No general anesthesia, which includes spinal/epidural, or regional, may be administered at the birth center. (Section 35(6) of the Act)
d) Any pregnant walk-in person who is beyond 32 weeks of gestation or is ready to deliver her baby, and who has not previously been approved for admission, shall be immediately transferred to a hospital.
e) An obstetrician, family practitioner/physician, or certified nurse midwife shall attend each woman in labor from the time of admission through birth and throughout the immediate postpartum period. (Section 35(6) of the Act)
f) Criteria for acceptance for admission shall be in writing.
g) No pharmacologic agents are permitted to induce or enhance labor.
h) The birth center shall have a contractual relationship/transfer agreement with a hospital capable of performing obstetric deliveries.
i) The birth center shall have a letter of agreement with a hospital designated under the Perinatal System. (Section 35(6) of the Act)
j) The birth center's governing body shall approve the acceptance for admission protocol and any subsequent revisions.
k) Each birth center shall establish written policies and procedures stating the medical and social risk factors that exclude women from the low-risk intrapartum group.
l) Each birth center shall establish a written risk assessment that shall be completed for each client and included in the client's clinical record. The assessment shall include a detailed medical history, a physical examination, family circumstances and other social and psychological factors.
m) Women who fail to register for acceptance with the birth center before 32 weeks gestation and who have not received prenatal care shall be excluded from admission unless a written, signed exception is made by the medical director on an individual basis. The woman shall otherwise meet the criteria for the risk assessment that are set forth in this Section, the birth center shall have documentation of prenatal care, and the birth center shall comply with the letter of agreement between the birth center and the hospital in the Perinatal System, pursuant to the requirement of subsection (i).
n) Criteria for antepartum acceptance and transfer to a hospital, and intrapartum and postpartum transfer to a hospital, and the certified nurse midwife-physician collaborative agreement shall be described in the birth center's established written protocols in accordance with the American Association of Birth Centers, Standards for Birth Centers. The criteria for acceptance and transfer to a hospital at any stage shall also comply with the letter of agreement between the birth center and the hospital in the Perinatal System, pursuant to the requirements of subsection (i).
o) A physician or a certified nurse midwife shall determine the general health and complete a risk assessment of the client, using the following criteria for exclusion as a birth center client. These criteria shall be applied to all clients prior to acceptance for birth center services and throughout the pregnancy for continuation of services. The medical director and Director of Nursing and Midwifery Services shall make the final determination of each client's risk.
1) Body mass index of less than 18 or greater than 40 (client will not be accepted).
2) Medical problems, including, but not limited to:
A) Heart disease, pulmonary embolus, or chronic hypertension not controlled by medication;
B) Congenital heart defects assessed as pathological by a cardiologist, placing mother and/or fetus at risk;
C) Severe renal disease;
D) Current drug or alcohol addiction;
E) Diabetes mellitus or gestational diabetes not controlled by diet;
F) Thyroid disease that is not maintained in a euthyroid state;
G) Bleeding disorder or hemolytic disease;
H) Adrenal disease;
I) Systemic collagen, connective tissue and autoimmune diseases (e.g., systemic lupus erythematosis, anti-phospholipid syndrome, progressive system sclerosis, and periarteritis nodosa);
J) Acute or chronic liver disease;
K) Neurological disorder or seizure disorder requiring use of anticonvulsant drugs;
L) Active HIV positive or confirmed active genital herpes at term;
M) Active subarachnoid hemorrhage, aneurysm;
N) Active hernia of the nucleus pulposus;
O) Active lung function disorder/COPD;
P) Active moderate to severe asthma;
Q) Tuberculosis, active; or
R) Active inflammatory bowel disease, including ulcerative colitis and Crohn's disease.
3) Previous history of obstetrical complications, including, but not limited to:
A) Previous gynecologic uterine wall surgery where uterine cavity was entered;
B) Two previous caesarean sections;
C) Previous caesarean section with documented conditions: vertical scar, placenta anterior and low lying;
D) Cervical insufficiency (and/or Shirodkar-procedure);
E) Placental abruption;
F) Postpartum hemorrhage as a result of cervical tear;
G) Postpartum hemorrhage, other causes;
H) Manual removal of a placenta.
4) Risk factors in prenatal course of current pregnancy, including, but not limited to:
A) Anemia (less than 9 gm hemoglobin concentration and not responding to therapy);
B) Complete placenta previa in third trimester;
C) Nonvertex presentation in labor;
E) Known multiple gestation;
F) Hypertension – resting blood pressure 140/90 or an increase of 30 systolic or 15 diastolic over the client's baseline pressure;
G) Premature labor at less than 37 weeks; the client may return to the birth center if undelivered at 37 weeks;
H) Premature rupture of membrane at less than 37 weeks;
I) Prolonged rupture of membranes requiring Pitocin induction/augmentation:
J) Prolonged pregnancy (at 42 completed weeks or more);
K) Significant isoimmunization against Rh or other antigen that may affect the fetus with rising titres;
P) Parvovirus infection;
Q) Tuberculosis, active;
S) Ectopic pregnancy;
T) Deep venous thrombosis;
U) Placental abruption; or
V) Dead fetus.
p) The acceptance and admission policies of the birth center shall not discriminate against clients based on disability, race, religion, source of payment, sexual preference/orientation or any other basis recognized by applicable State and federal laws.
q) Before acceptance and admission to services, a client shall be informed of:
1) The qualifications of the birth center clinical staff;
2) The risks related to out-of-hospital childbirth;
3) The benefits of out-of-hospital childbirth; and
4) The possibility of referral or transfer if complications arise during pregnancy or labor, with additional costs for services rendered.
r) The birth center shall obtain the client's written consent for birth center services, and a copy of the signed consent shall be included in the client's individual clinical record.
s) The number of women in active labor who have been admitted to the birth center at any given point in time shall be no greater than the number of birth rooms in the birth center.