g) A physician, certified nurse midwife, or a licensed certified professional midwife shall determine the general health and complete a risk assessment of the client per requirements in subsection (f), using the following criteria for exclusion as a birth center client. These criteria shall be considered for all clients prior to acceptance for birth center services and throughout the pregnancy for continuation of services. The clinical director shall use professional judgment consistent with recommendations in the Guidelines for Perinatal Care, Standards for Birth Centers, and Indicators of Compliance with Standards for Birth Centers to make determinations of the criteria for exclusion for delivery at the birth center.

1. 1) Pre-pregnancy body mass index of less than 18 or greater than 40.

2. 2) Medical risk factors, including, but not limited to:

   1. A) Chronic hypertension not controlled by medication;
   2. B) Elevated blood glucose levels unresponsive to dietary management;
   3. C) Positive HIV antibody test; or
   4. D) Current drug or alcohol substance use disorder.

3. 3) Obstetrical risk factors, including but not limited to:

   1. A) Two or more prior cesarean sections (a client with a single prior cesarean may be admitted subject to conditions in subsection (h));
   2. B) History of gynecologic uterine wall surgery in which the uterine cavity was entered; or
   3. C) History of manual removal of a placenta.

4. 4) Prenatal/delivery risk factors, including but not limited to:

   1. A) Documented low-lying placenta in an individual with a history of previous cesarean delivery;
   2. B) Anemia resistant to supplemental therapy;
   3. C) Documented placental anomaly;
   4. D) Lie other than vertex at term;
   5. E) Pre-eclampsia/gestational hypertension (as defined by current ACOG standards);
   6. F) Multiple gestation;
   7. G) Premature labor at less than 36 weeks (client may return to the birth center if not delivered at 37 weeks);
   8. H) Rupture of membranes prior to the 37^th week gestation;
   9. I) Gestation beyond 42 weeks by reliable confirmed dates;
   10. J) Isoimmunization, Rh-negative sensitized, positive titers, or any other positive antibody titer, which may have a detrimental effect on the childbearing individual or fetus;
   11. K) Suspected deep vein thrombosis;
   12. L) Placental abruption or previa;
   13. M) Dead fetus;
   14. N) Known fetal anomalies that may be affected by the site of birth; or
   15. O) Primary genital herpes infection in pregnancy.

h) Trial of labor after cesarean/vaginal birth after cesarean (TOLAC/VBAC)

1. 1) A birth center may admit a client with a previous cesarean section for a TOLAC/VBAC if the client meets the following criteria:

   1. A) The client has an operative report documenting one prior low transverse cesarean section, or if the surgical details of the previous cesarean incision are not known, the client gives informed consent based on information provided under subsection (h)(3)(C);
   2. B) The client's BMI prior to the current pregnancy was less than 40;
   3. C) A documented ultrasound of the client's placental location, performed by a radiologist or maternal-fetal medicine physician, shows no abnormalities (previa, low-lying/suspected accreta, percreta, increta, etc.); and
   4. D) The Department additionally recommends that the interval since the client's previous birth be at least 19 months and that the estimated weight of the fetus at delivery be less than 4000 grams (8.8 pounds).

2. 2) A birth center that accepts clients for TOLAC/VBAC shall have a transfer agreement with a Level 1 or higher perinatal center that agrees to receive TOLAC patients from birth centers, within a ground travel time distance that allows for an emergency cesarean section to be started within 30 minutes after the decision that a cesarean section is necessary.

   1. A) The transfer agreement must address communication between the receiving hospital and birth center when a TOLAC client is admitted to the birth center and during the progression of the client's labor. The agreement must also address the hospital's and birth center's response in situations where progression of labor is delayed.
   2. B) The birth center shall notify the receiving hospital immediately if an emergency transfer becomes necessary.

3. 3) The birth center shall obtain informed consent from a prospective client for a TOLAC/VBAC.

   1. A) The consent forms must include up to date information, from peer reviewed publications or expert consensus such as that of the American College of Obstetricians and Gynecologists (ACOG) or the American Academy of Pediatrics (AAP), concerning the incidence of uterine rupture during TOLAC/VBAC and the incidence of neonatal ICU admissions and neonatal deaths when uterine rupture occurs.
   2. B) The consent form shall use language that is easily understood from a health literacy perspective and is translated into the language of the birthing person.
   3. C) In a case where the surgical details of the previous cesarean incision are not known, the birth center shall notify the client that the quoted risk of rupture is based on their history only, and may be higher than the risk for a client with a documented low transverse cesarean section.
4. 4) A birth center that accepts TOLAC/VBAC clients shall have a letter of agreement with an Administrative Perinatal Center and share the renewal data submitted to DPH OCHR with the APC on an annual basis, including the addition of TOLAC/VBAC patient numbers. The birth center shall also participate in the APC's morbidity and mortality reviews.

k) Before acceptance and admission to services, a client shall be informed of:

1. 1) The qualifications of the birth center clinical staff;
2. 2) The risks related to out-of-hospital childbirth;
3. 3) The benefits of out-of-hospital childbirth; and
4. 4) The possibility of referral or transfer if complications arise during pregnancy or labor, with additional costs for services rendered.