1. (1) When necessary, patients shall be transferred from the birthing center to a hospital with which a written Transfer Agreement is in effect. A complete copy of the health record of both the mother and newborn, maintained up to and including the time of transfer, shall be provided to the referred provider or facility upon transfer.

   If the mother is unable to ride in an upright position, or the mother's condition is such that she needs observation or treatment by EMS personnel, or the mother requires transportation on a stretcher, gurney, or cot, the birthing center shall arrange or request transportation services only from providers who are ambulance service operators licensed by the Alabama State Board of Health and with whom the birthing center has a written agreement for the transport of a patient to the hospital named in the Transfer Agreement. For the purposes of this rule, an upright position means no more than 20° from vertical.

2. (2) The birthing center shall have a written protocol for emergency situations, which shall include:

   1. (a) The name, address, telephone numbers, and contact persons of the licensed ambulance service; identify the hospital under written agreement with the birthing center to provide emergency obstetrical and neonatal services; and list other hospitals in the vicinity.
   2. (b) The conditions specified in the arrangements between the birthing center, the ambulance service, and the hospital, including financial responsibility for services rendered.

   3. (c) The criteria requiring medical consultation with a qualified physician who is (1) certified by the American Board of Obstetrics and Gynecology or the American Board of Osteopathic Obstetricians and Gynecologists or (2) qualified as a family practice physician with an obstetrical emphasis or fellowship, or transfer to the hospital under written agreement with the birthing center, including, but not limited to:

      1. 1. Premature labor, meaning labor occurring at less than 37 weeks gestation.
      2. 2. Estimated fetal weight less than 2,500 grams. Newborns weighing more than 4,000 grams may require referral in the clinical judgment of the staff physician or consultant physician.
      3. 3. Hypertension.
      4. 4. Preeclampsia.
      5. 5. Failure to progress in labor.
      6. 6. Evidence of an infectious process.
      7. 7. Premature rupture of the membranes, meaning rupture occurring more than 24 hours before onset of active labor, provided there is no evidence of infection.
      8. 8. Suspected placenta previa or abruption.
      9. 9. Non-vertex presentation.
      10. 10. Hemorrhage of greater than 500 cc of blood.
      11. 11. Anemia, consisting of less than 10 grams of hemoglobin per 100 milliliters of blooc or 30 percent hematocrit.
      12. 12. Persistent fetal tachycardia (heart rate more than 160 beats per minute), repetitive fetal bradycardia (heartbeat less than 110 beats per minute for more than 10 minutes), or undiagnosed abnormalities of the fetal heart tones.
      13. 13. Persistent hypothermia in the newborn.

   4. (d) Criteria to determine risk status which requires immediate emergency transfer include, but are not limited to:

      1. 1. Prolapsed cord.
      2. 2. Uncontrolled hemorrhage.
      3. 3. Placental abruption.
      4. 4. Convulsions.
      5. 5. Major anomaly of the newborn.
      6. 6. Apgar score of 7 or less at 5 minutes.
      7. 7. Fetal heart rate of 90 or less beats each minute for 3 minutes.
      8. 8. Thick meconium staining at the time of membrane rupture.
      9. 9. Respiratory distress in the newborn.
      10. 10. Weight less than 2,500 grams.
   5. (e) The criteria and protocols for transfer shall be readily accessible to medical staff members at all times.
3. (3) The name and telephone numbers of the licensed ambulance services providing transport for the birthing center, the Children's Hospital Critical Care Transport Team, and the hospital accepting transfer shall be clearly posted at each telephone in the birthing center.

4. (4) A written report of the transfer shall be provided and retained for quality assurance review and Departmental inspection. The report shall include:

   1. (a) The Patient's name.
   2. (b) The date of the event.
   3. (c) The reason for transfer.
   4. (d) The provider and mode of transportation to the hospital.
   5. (e) The exact time of the initial call and of any subsequent calls.
   6. (f) Time of arrival of the emergency personnel.
   7. (g) Time of the patient's departure from the birthing center.
   8. (h) Time of arrival at the hospital.
   9. (i) Name of the receiving hospital.
   10. (j) Details concerning the initiation of EMS.
   11. (k) The condition of the patient at the time of transfer.
   12. (l) Any information regarding the medical care of the patient and outcome.
5. (5) The medical staff, consultants, and governing authority shall review and evaluate the criteria, protocols, and emergency transfer reports on a monthly basis. The results of the evaluation shall be documented.

Author: Dana Billingsley, Diane Milledge

Statutory Authority: Code of Ala. 1975, §22-2-2(6), et seq.; §22-21-20, et seq.

History: Filed November 19, 1987. Repealed: Filed April 16, 2010; effective May 21, 2010. New Rule: Published August 31, 2023; effective October 15, 2023.