H Written Protocol for Consultation/Transfer/Transport

Section 640 Section 640.APPENDIX H  Written Protocol for Consultation/Transfer/Transport Section 640.EXHIBIT A  Level I:  Patients for consultation with ________________ (Level III hospital or Administrative Perinatal Center) 1)         Maternal Conditions A)        Previous Pregnancy Problems: i)          Premature infant ii)         Perinatal death or mental retardation iii)        Isoimmunization iv)        Difficult deliveries v)         Congenital malformations vi)        Mid-trimester loss B)        Current Pregnancy Problems: i)          Any medical disorder (e.g., diabetes mellitus, hemoglobinopathy, chronic hypertension, heart disease, renal disease) ii)         Drug addiction iii)        Multiple gestation iv)        Intrauterine growth retardation v)         Preterm labor less than or equal to 36 weeks vi)        Postdate greater than or equal to 42 weeks vii)       Third trimester bleeding viii)      Abnormal genetic evaluation ix)        Pregnancy induced hypertension 2)         Neonatal Conditions A)        Gestation less than or equal to 36 weeks, weight less than or equal to 2500 grams B)        Small-for-gestational age (less than 10 th percentile) C)        Sepsis D)        Seizures E)        Congenital heart disease F)         Multiple congenital anomalies G)        Apnea H)        Respiratory distress I)         Neonatal asphyxia J)         Handicapping conditions or developmental disabilities that threaten life or subsequent development K)        Severe anemia L)        Hyperbilirubinemia, not due to physiologic cause M)       Polycythemia 3)         Consultation and transfer to a Level III or Administrative Perinatal Center shall occur for the following conditions: A)        Premature labor or premature birth less than 34 weeks gestation. B)        Birth weight less than or equal to 2000 grams.