(a) Each hospital providing perinatal care services shall provide patient care based on the individual needs of the patient and in accordance with the following criteria.

1. (1) A Level I perinatal care service hospital shall evaluate and stabilize all women and neonates.

   1. (i) For patients needing a higher level of care, it shall consult with a higher level hospital and arrange for timely transfer to a Level III perinatal care service hospital or an RPC that provides the appropriate level of perinatal care.
   2. (ii) For healthy women with an anticipated delivery at 36 weeks gestation or later and for healthy newborns with a birthweight of 2,500 grams or more, it shall provide continuing care until their discharge.
   3. (iii) Except in unusual circumstances, smaller and more premature infants shall be delivered at higher level hospitals; if such an infant is born at a Level I perinatal care hospital, he/she shall be transferred promptly after birth.
   4. (iv) Women and neonates who have relatively minor problems that do not require advanced laboratory, radiologic, or consultation services may remain in the Level I perinatal care hospital.
   5. (v) When it is known that the newborn may require immediate complex care, it shall be delivered at a Level III perinatal care hospital or an RPC whenever possible.
   6. (vi) Level I perinatal care hospitals shall also provide care for convalescing babies who have been transferred from Level II, Level III and RPC perinatal care hospitals.

2. (2) A Level II perinatal care services hospital shall:

   1. (i) provide the Level I perinatal care services described in paragraph (1) of this subdivision and be capable of providing care for moderately high-risk women, fetuses and newborns and moderately ill women and newborns who have problems that do not require highly specialized care;
   2. (ii) stabilize ill women and newborns and women whose fetuses are expected to need complex care, consult with a higher level hospital and arrange for timely transfer to a hospital that provides the appropriate level of perinatal care;
   3. (iii) Level II perinatal care hospitals are qualified to deliver infants with an anticipated delivery at 30 weeks gestation or later and with an anticipated birthweight of 1,250 grams or more; and
   4. (iv) except in unusual circumstances, infants smaller and more premature than is described at subparagraph (iii) of this paragraph shall be delivered at Level III hospitals or RPCs. If an infant who is smaller or a lower gestational age than described in subparagraph (iii) of this paragraph is born at the Level II hospital, he/she shall be transferred promptly after birth.

3. (3) A Level III perinatal care services hospital shall:

   1. (i) provide Level I and Level II perinatal care services described in paragraphs (1) and (2) of this subdivision and shall care for women, fetuses, and newborns who may require complex care;
   2. (ii) stabilize ill women and newborns prior to transfer, including women whose newborns are expected to need the most complex care, consult with its designated RPC, and transfer if appropriate; and
   3. (iii) women in unstable medical and/or obstetric situations shall be cared for at a Level III hospital or an RPC.
4. (4) Regional perinatal care centers (RPC) shall provide Level I, Level II and Level III perinatal care services described in paragraphs (1), (2), and (3) of this subdivision and shall also care for women, fetuses, and newborns who require highly specialized services not available at the Level III care hospital, such as sophisticated ventilation techniques (e.g., high-frequency ventilation and extracorporeal membrane oxygenation), cardiac surgery or neurosurgery.

5. (5) The transfer and consultation criterion included in the affiliation and transfer agreements can be customized to reflect the RPC's knowledge and the capabilities of each affiliate hospital. Any variation in transfer of patients to a higher level perinatal care service hospital as specified in this section must be in accordance with generally accepted standards of professional practice and criteria established in the affiliation agreement with each hospital's respective RPC.

   (b) Ventilation for distressed newborns.

   Resuscitation and ventilation of neonates who require cardiorespiratory assistance shall be performed at each level of perinatal care and in the following ways:

6. (1) at a Level I perinatal care services hospital the ventilation of distressed newborns shall be immediate resuscitation after birth as appropriate, stabilization, and assisted ventilation of newborns until timely transfer to a hospital that provides a higher level of perinatal care;
7. (2) at a Level II perinatal care hospital the ventilation of a distressed newborn shall be as described in paragraph (1) of this subdivision and, in addition, standard short-term mechanical ventilation. A Level II perinatal care hospital may care for infants requiring mechanical ventilation and/or 50 percent or more oxygen for no more than four days. By the fourth day of a newborn's receipt of assisted ventilation or oxygen at 50 percent or more, the Level II hospital shall consult with its designated RPC regarding the status of the newborn and determine whether to transfer the newborn to a higher level hospital. If after such consultation the neonate stays at the Level II hospital, that hospital may retain the neonate for no more than a total of seven days on assisted ventilation or oxygen at 50 percent and must then transfer the neonate to a Level III hospital or to an RPC unless the hospital's RPC is consulted and agrees that the neonate's care is appropriate and in accordance with current standards of professional practice and remaining at the Level II hospital is in the best interests of the neonate; and

8. (3) at Level III perinatal care services hospitals and RPCs the ventilation of a distressed newborn shall be as described in paragraphs (1) and (2) of this subdivision and, in addition, may also include long-term standard mechanical ventilation and complex ventilation techniques, such as high-frequency ventilation and extracorporeal membrane oxygenation (ECMO).

   (c) Transfers.

9. (1) All patient care and transfers shall be in accordance with generally accepted professional standards and be consistent with section 405.21(g) and this Title. Requirements for consultation and for transfer to a higher level of perinatal care and transfer back to the referring hospital or other hospital providing a lower level of care, shall be described in any transfer agreement negotiated between Level I, II and III perinatal care hospitals, and in transfer provisions in the perinatal affiliation agreements between Level I, II and III perinatal care hospitals and their RPCs.
10. (2) When a newborn and/or mother requires transfer, care shall be provided at a hospital providing the appropriate level of perinatal care which is, whenever feasible, accessible and convenient to the mother's place of residence. When mothers and their infants need different levels of care, efforts shall be made to keep the mother-newborn dyad together. Level III hospitals and RPCs shall return a newborn to the sending hospital when the condition has been stabilized and return is medically appropriate.