Rule 111-8-40-.34 - Maternal and Newborn Services(1) No later than 90 days after the effective date of these rules, if the hospital offers an organized service for the provision of care for expectant mothers and newborns, it shall clearly define the level of services provided according to the levels described in these rules (basic, intermediate, or intensive) and comply with the rules set forth in this section. (a) The hospital shall establish and utilize admission criteria for the maternal and newborn services that reflect the level of services offered by the hospital.(b) The hospital shall have established mechanisms, through written agreement and other arrangement, for transfers to or consultations with facilities providing services at the higher levels of care for those maternal and newborn patients who require such care. The agreements or arrangements shall ensure that there is collaboration between the sending and receiving hospital concerning the transfer of such patients prior to the actual need for transfer and shall include mechanisms for the communication of information regarding the outcome of each transfer and for periodic review of the agreements or arrangements.(c) All hospitals offering obstetrical care shall have facilities, staff, and equipment necessary for delivery, management, and stabilization of expectant women who present at the hospital in active labor and for whom delivery is imminent, regardless of the level of care anticipated for the newborn. The hospital shall have in place a system for communication and consultation with a board certified obstetrician or maternal-fetal medicine specialist and a board certified neonatologist for situations where transport of high-risk patients prior to delivery is not feasible.(d) The hospital shall establish a system for receipt of prenatal records for admissions to the maternal and newborn service other than emergency admissions to include the results of any routine laboratory tests as required by the hospital.(e) The hospital shall have written plans and procedures for transfer of expectant mothers or newborns presenting at the hospital who exceed the criteria for admission, which shall include mechanisms for accessing transportation appropriate to the needs of the patient(s).(f) The hospital shall include in the internal quality management program a systematic review of the admissions and transfers for maternal and newborn services, with comparison to the established admission criteria, which shall prompt corrective action when indicated.(g) With the exception of hospitals permitted as specialized children's hospitals, hospitals shall offer a level of services for maternal care comparable to the level of services offered for neonatal care.(2) The hospital shall have sufficient staff, space, facilities, equipment, and supplies to support the range of maternal and infant services offered, according to generally accepted standards of practice.(3)Basic Maternal and Newborn Services. All hospitals offering maternal and newborn services shall offer at least a basic level of those services. The basic level of maternal and newborn services shall provide comprehensive care for women with low-risk pregnancies, anticipated uncomplicated deliveries, and apparently normal developing fetuses with estimated gestation of thirty-six (36) weeks or greater and for newborns with anticipated birth weights of 2500 grams or greater. The maternal and newborn services of these hospitals shall meet the following minimum requirements:(a)Organization of Basic Maternal and Newborn Services.1. The director of obstetrical services shall be a board eligible or board certified obstetrician, or a board eligible or board certified family practitioner with obstetrical privileges, or shall be a credentialed member of the medical staff with obstetrical privileges with access to such board eligible or board certified specialists by consultation.2. The director of newborn services shall be a member of the medical staff who is a board eligible or board certified pediatrician, or a board eligible or board certified family practitioner, or shall be a credentialed member of the medical staff with access to such specialists by consultation. The director of newborn services shall be responsible for ensuring that medical care is provided for all newborns.3. The perinatal nurse manager shall be a licensed registered nurse with education and demonstrated knowledge and experience in perinatal nursing;(b)Delivery of Basic Maternal and Newborn Services.1.Staffing Plan. The hospital shall follow a staffing plan that ensures the availability of appropriate numbers of qualified staff for the perinatal services offered, according to generally accepted standards of practice and state licensing regulations.(i)Staffing for the Labor and Delivery Area. For the delivery of newborns, the hospital shall provide for at least the following: (I) A birth attendant, who may be an obstetrician, a physician with obstetrical privileges, or a certified nurse midwife who has been granted clinical privileges in accordance with these rules, present at the hospital or immediately available by telephone and able to be on-site within thirty (30) minutes;(II) A registered nurse present to assist with each delivery;(III) An individual credentialed in neonatal resuscitation to be present in the delivery room for each delivery for the purpose of receiving the newborn;(IV) For Cesarean deliveries, an additional physician or certified nurse midwife, a registered nurse, or a surgical assistant or technician, able and qualified to assist with a Cesarean section, on-site or able to arrive in sufficient time to accommodate the time limit for emergency Cesarean section of thirty (30) minutes from the physician's decision to operate to the initial incision; and(V) Professional staff qualified to administer anesthesia, on-site or able to arrive in sufficient time to accommodate the time limit for emergency Cesarean section of thirty (30) minutes from the physician's decision to operate to initial incision.(ii)Staffing for the Newborn Nursery. The hospital shall provide for at least: (I) A qualified registered nurse with experience or training in the care of newborns to supervise and be responsible for the quality of nursing care given to newborns, for nursing in-service programs in nursery issues, for assisting the director of the newborn nursery in carrying out his or her duties, and for the maintenance of the nursery records;(II) A licensed nurse on duty in the nursery at all times in hospitals with a daily newborn nursery census greater than ten (10) newborns; and(III) A staff member trained in newborn service provision present in the newborn nursery when it is occupied by any newborn.2. The directors of obstetrical and newborn services shall develop and implement written policies, procedures, and guidelines for the services that reflect current standards of practice and address at least: (i) Admission criteria for the services based on the level of service provided;(ii) Guidelines and mechanisms for specialty consultations and transfer for high-risk patients whose needs exceed the range of services offered at the hospital;(iii) The orientation program for maternal and newborn services staff;(iv) Patient care requirements for mothers and newborns, including but not limited to nursing assessments, gestational age assessment, newborn assessments including Apgar scoring immediately after delivery, assessment and management of nutritional needs including feedings for the newborn whether normal or gavage, umbilical and circumcision care, assessment of thermoregulation by the newborn, prevention of blindness, hypoglycemia, and hemorrhagic disease for the newborn, use of appropriate prophylaxes, patient monitoring needs, and assessment of educational needs of the mother;(v) Procedures for a family-centered environment (rooming-in) as an option for each patient unless contraindicated by the medical condition of the mother or infant or unless the hospital does not have sufficient facilities to accommodate all such requests;(vi) Room assignments and procedures for traffic control and security, including such security measures as are necessary to limit access to newborns by unauthorized persons and to prevent kidnapping of newborns;(vii) Guidelines for the use of anesthetic agents for pain management and the requirements for the qualifications and responsibilities of persons who administer the agents and the required patient monitoring;(viii) Guidelines for induction and augmentation of labor and for designation of qualified personnel who must be in attendance during these procedures;(ix) Indicators and procedures for vaginal birth after Cesarean section (VBAC);(x) Indicators and procedures for operative vaginal deliveries;(xi) Staffing and procedural guidelines for management of obstetrical and newborn emergencies, including the availability of staff components to manage such emergencies twenty-four (24) hours per day;(xii) Guidelines for the monitoring of newborns during the first twelve (12) hours after birth and until discharge;(xiii) Procedures for infection control, including isolation procedures, visiting privileges, individualized infant hygiene care, and specific policies regarding the prevention and management of infectious diseases, including but not limited to Hepatitis B, Hepatitis C, Group B Streptococcal infections, tuberculosis, human immunodeficiency virus (HIV), and sexually transmitted diseases;(xiv) Requirements for newborn screening tests for metabolic disorders and hemoglobinopathies and other screenings, as required by law.(xv) Procedures for continuous and unquestionable identification of newborns;(xvi) Procedures for completing birth and death certificates in accordance with Georgia's official vital records registration system; and(xvii) Guidelines for discharge of mothers and newborns, including early discharge, and for assessment of education and other discharge needs.(c)Physical Environment for Maternal and Newborn Services.1. Obstetrical and newborn service areas shall be located, arranged, and utilized so as to provide for every reasonable protection from infection and from cross-infection. The physical arrangements shall separate the obstetric patients from other patients with the exception of non-infectious gynecological patients.2. Rooms used for patients in labor shall be located with convenient access to the delivery room(s). If labor rooms also serve as birthing rooms, the rooms shall be equipped to handle obstetric and neonatal emergencies.3. Delivery suites shall be used for no purpose other than for the care of obstetrical patients. Each room shall have the necessary equipment and facilities for infection control and for the management of obstetric and neonatal emergencies. Delivery suites shall be designed to include an anesthesia supply and equipment storage room and a communication system to ensure that emergency backup personnel can be summoned when needed.4. A newborn stabilization area shall be located within each delivery room or birthing room and shall be equipped with oxygen and suction outlets.5. The newborn nursery shall have an air temperature maintained at 75-80 degrees Fahrenheit, with a relative humidity of thirty percent to sixty percent (30% - 60%).6. Air from other areas of the hospital shall not be recirculated into the newborn nursery. Ventilation of the nursery suite(s) shall provide the equivalent admixture of a minimum of six (6) total air changes per hour.7. Life-sustaining nursery equipment and lighting for the nursery areas shall be connected to outlets with an automatic transfer capability to emergency power.8. Each labor room, delivery room, birthing room, and nursery station shall be equipped with sufficient power outlets to handle the equipment required for the provision of patient care without the use of extension cords,"cheater" plugs, or multiple outlet adapters, which are prohibited.(d)Clinical Laboratory, X-Ray, and Ultrasound Services. Diagnostic support services such as laboratory, x-ray, and ultrasound, shall be available on an on-call basis, with the capability to perform studies as needed for maternal and newborn care; and(e)Records Requirements. 1. The medical record for each maternity patient shall be maintained in accordance with Section 111-8-40-.18 of these rules, with the following additions: (i) The medical record for each maternity patient shall contain a copy of the patient's prenatal records, submitted at or before the time of admission;(ii) The admission data shall include the date and time of notification of the birth attendant, the condition on admission of the mother and fetus, labor and membrane status, presence of bleeding, if any, fetal activity level, and time and content of the most recent meal ingested; and(iii) Labor and postpartum care notes shall be included.2. The medical record for each newborn shall be cross-referenced with the mother's medical record and shall contain the following additional record information: (i) Physical assessment of the newborn, including Apgar scores, presence or absence of three cord vessels, and vital signs;(ii) Accommodation to extra uterine life including the ability to feed and description of maternal-newborn interaction;(iii) Treatments and care provided to the newborn to include the specimens collected, newborn screening tests performed, and appropriate prophylaxes;(iv) The infant's footprint and mother's fingerprint, or comparable positive newborn identification information; and(v) Report of the physical examination of the newborn prior to discharge, performed by an appropriately credentialed physician, physician's assistant, nurse practitioner, or nurse midwife.3. The hospital shall maintain a register of births, in which is recorded the name of each patient admitted for delivery, the date of admission, date and time of birth, type of delivery, names of physicians or other birth attendants, assisting staff and anesthetists, the sex, weight, and gestational age of the infant, the location of the delivery, and the fetal outcome of the delivery.4. The hospital shall maintain annual statistics regarding the number of births and number of infant deaths. Death statistics for infants shall include birth weights, gestational ages, race, sex, age at death, and cause of death.(4)Intermediate Maternal and Newborn Services. The hospital offering intermediate maternal and newborn services shall offer comprehensive care for women with the potential or likelihood for only certain pre-defined high-risk complications and with anticipated delivery of a newborn at greater than thirty-two (32) weeks' gestation and birth weight greater than 1500 grams who are anticipated to have only such medical conditions which can be expected to resolve rapidly. The maternal and newborn service shall meet all of the requirements for provision of the basic services as described above in these rules, with the following additions or exceptions:(a)Organization of Intermediate Maternal and Newborn Services.1. The director of obstetric services shall be a member of the medical staff who is a board eligible or board certified obstetrician or board eligible or board certified maternal-fetal medicine specialist; provided, however, within five (5) years from the effective date of these rules, the director of obstetric services shall be a board certified obstetrician or board certified maternal-fetal medicine specialist.2. The director of newborn services shall be a member of the medical staff who is board eligible or board certified pediatrician or board eligible or board certified neonatologist; provided, however, within five (5) years from the effective date of these rules, the director of newborn services shall be a board certified pediatrician or board certified neonatologist.3. A board eligible or board certified neonatologist shall be available to participate in care for the neonates.4. The perinatal nurse manager shall be a licensed registered nurse with the training and demonstrated knowledge and experience in care of high-risk maternal care and moderately ill newborns.5. When a neonate is on mechanical ventilation or when a high risk maternity patient is being managed, a respiratory therapist, certified lab technician/blood gas technician, and an x-ray technologist shall be on-site and available to the maternal and newborn services area on a twenty-four (24) hour basis.6. If the facility offers care for newborns requiring parenteral support, a licensed dietitian and a licensed pharmacist with parenteral experience shall be on staff.(b)Delivery of Intermediate Maternal and Newborn Services. Service delivery shall meet the requirements of the basic maternal and newborn services, with the following additions or exceptions:1. The hospital shall provide care for expectant mothers and newborns requiring the basic level of maternal and newborn services, as well as for those requiring an intermediate level of care;2. Portable x-ray and ultrasound equipment and services shall be available on a twenty-four (24) hour basis;3. The intermediate level nursery shall provide care to neonates expected to require no more than short-term mechanical ventilation or parenteral support. Such support, if needed for more than forty-eight (48) hours, shall be authorized daily by the consulting neonatologist, or the neonate shall be transferred to a facility with a higher (intensive) level of care; and4. Written policies, procedures, protocols, and guidelines shall reflect the pre-defined level of care provided. Criteria for admission to and discharge from the intermediate level nursery shall be defined in the written policies and procedures.(c)Physical Environment for Intermediate Maternal and Newborn Services. The physical environment shall meet the requirements of the basic maternal and newborn services, with the following additional requirements:1. There shall be provided in the intermediate level nursery sufficient space between each patient station to allow for easy access for staff and visitors on three (3) sides of the patient bed and to allow for easy access with portable diagnostic and support equipment as may be required;2. Each patient station in the intermediate level nursery shall have at least two (2) oxygen outlets, two (2) compressed air outlets, and two (2) suction outlets;3. There shall be adequate lighting provided for patient care while avoiding extra illumination of adjacent neonates; and4. The patient bed areas shall be designed to minimize the impact of noise on the infants.(5)Intensive Maternal and Newborn Services. The hospital offering an intensive level of maternal and newborn services shall provide services for normal and high-risk maternal, fetal, and newborn conditions. The hospital providing the intensive level of services shall meet all requirements for basic and intermediate maternal and newborn services, with the following additions and/or exceptions:(a) The director of intensive obstetric services shall be a member of the medical staff who is a board certified obstetrician or board certified maternal-fetal medicine specialist;(b) The director of intensive newborn services shall be a member of the medical staff who is a board certified pediatrician or board certified neonatologist;(c) The hospital shall have on call, on a twenty-four (24) hour basis, a board certified obstetrician or maternal-fetal medicine specialist to provide on-site supervision and management of maternal patients;(d) The hospital shall have available for consultation a maternal-fetal medicine specialist;(e)The hospital shall have on call, on a twenty-four (24) hour basis, a board certified neonatologist to provide on-site supervision and management of neonates;(f) The hospital shall provide pediatric subspecialties on staff or have a mechanism to provide consultation and care for pediatric subspecialties in a timely manner;(g) The nursery manager of the intensive care nursery shall have demonstrated knowledge, training, and experience in neonatal intensive care nursing and shall have a dedicated assignment to the intensive care nursery;(h) The hospital shall have on staff pharmacology personnel competent in perinatal pharmacology. Total parenteral nutrition shall be available; and(i) The hospital shall have on staff a licensed physical therapist or occupational therapist and a licensed dietitian with training and experience in neonatal care.Ga. Comp. R. & Regs. R. 111-8-40-.34
O.C.G.A. § 31-7-2.1.
Original Rule entitled "Maternal and Newborn Services" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.