H Written Protocol for Consultation/Transfer/Transport

Section 640 Section 640.APPENDIX H   Written Protocol for Consultation/Transfer/Transport Section 640.EXHIBIT B   Level II:  Patients for consultation with or transfer to ____________________ (Level III hospital or Administrative Perinatal Center) 1)         Maternal Conditions (Consultation) A)        Essential hypertension on medication. B)        Chronic Renal disease. C)        Chronic medical problems with known increase in perinatal mortality or morbidity. D)        Prior birth of neonate with serious complication resulting in a handicapping condition. E)        Abnormalities of the reproductive tract known to be associated with an increase in preterm delivery. F)         Previous delivery of preterm infant 34 weeks gestation. G)        Insulin-dependent diabetes Class B or greater. 2)         Maternal Conditions (Transfer) A)        Patients from the above consultation list, for whom transfer is deemed advisable by mutual collaboration between the maternal-fetal medicine physician at the Level III hospital and the obstetrician at the referring office of the hospital. B)        Isoimmunization with possible need for intrauterine transfusion. C)        Suspected congenital anomaly compatible with life. D)        Insulin-dependent diabetes mellitus. E)        Cardiopulmonary disease with functional impairment. F)         Multiple gestation, with exception of twins. G)        Premature labor prior to 32 weeks. H)        Premature rupture of membranes prior to 32 weeks. I)         Medical and obstetrical complication of pregnancy, possibly requiring induction of labor or cesarean section for maternal or fetal conditions prior to 32 weeks gestation. J)         Severe pre-eclampsia or eclampsia. 3)         Neonatal Conditions (Consultation or transfer):  Specify whether consultation or transfer will occur for each of the following: A)        Gestation less than 32 weeks or less than 1800 grams. B)        Sepsis unresponsive to therapy. C)        Uncontrolled seizures. D)        Significant congenital heart disease. E)        Major congenital malformations requiring surgery. F)         Assisted ventilation required after initial stabilization (greater than 6 hours). G)        Oxygen requirements in excess of 50% (greater than 6 hours). H)        10-minute Apgar scores of 5 or less. I)         Major surgery. J)         Exchange transfusion. K)        Persistent metabolic derangement (e.g., hypocalcemia, hypoglycemia, metabolic acidosis). L)        Handicapping conditions or developmental disabilities that threaten life or subsequent development. 4)         Consultation and transfer to a Level III hospital 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. C)        Assisted ventilation beyond the initial stabilization period (6 hours).