California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 7 - Primary Care Clinics › Article 9 - Birth Services › Section 75075 - Birth Services-General Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Primary care clinics providing a birth
				  service shall provide:
(1) Care for patients
				  during pregnancy, labor, delivery and the immediate postpartum period, and
				  refer patients in need for specialized or tertiary care at any stage of
				  pregnancy.
(2) A continuing
				  assessment of all factors which would indicate whether labor and delivery may
				  post high-risk or life threatening problems to a maternal patient or infant.
(A) Upon a determination that high-risk,
				  abnormal or life threatening factors exist or are likely to occur, a birth
				  service shall not proceed with plans to provide childbirth services during
				  labor and delivery beyond the extent necessary to provide emergency care and
				  stabilization.
(3)
				  Emergency care for mothers who have delivered in the clinic and infants born in
				  the clinic who require immediate life support measures to sustain life pending
				  transfer to a general acute care hospital.
(4) Written policies and procedures for
				  medical backup, consultation and emergency transfer and transportation of an
				  infant to a newborn nursery or an intensive care nursery or of the mother and
				  infant to a general acute care hospital with the capacity for management of
				  obstetrical and neonatal emergencies. Written policies shall address the
				  assignment of duties and responsibilities of all parties in resuscitation and
				  stabilization in an emergency transfer.
(5) An educational program designed for
				  patients and their families to include but not limited to benefits and risks
				  involved, information about genetic counseling, health behavior screening
				  services available, proper prenatal care, nutrition, preparation for labor and
				  delivery and routine care for the newborn.
(6) A maternal health record including:
(A) Past medical, social and psychological
				  history of significant risk factors for pregnancy which shall include but not
				  be limited to:
1. Cardiovascular, pulmonary,
				  renal, endocrine, metabolic and hematologic disease.
2. Venereal and infectious disease.
3. Substance abuse.
4. Infertility.
(B) Past obstetrical history which shall
				  include but not be limited to:
1. Pregnancy
				  history.
2. Maternal and newborn
				  complications of previous deliveries, if any.
3. Iso-immunization.
(C) Prenatal physical examination which
				  includes but is not limited to:
1. Last
				  menstrual period.
2. Estimated date
				  of confinement.
3. Hemoglobin and
				  hematocrit tests.
(D)
				  Prenatal monitoring record which shall include but not be limited to:
1. Blood pressure.
2. Weight.
3. Urine protein and glucose tests.
4. Edema.
5. Estimated weeks of gestation.
6. Fundal height.
(E) Onset of labor record which includes but
				  is not limited to:
1. Physical
				  examination.
2. Fetal
				  evaluation.
(F) Labor
				  progress record which includes but is not limited to:
1. Time of onset of labor.
2. Time of rupture of membranes.
3. Length of each stage of
				  labor.
(G) Delivery
				  record including complications, if any.
(H) Postpartum observations which shall
				  include but not be limited to:
1. Vital
				  signs.
2. Examination of
				  fundus.
3. Ability of mother to
				  ambulate, void and care for her infant.
(I) Medication and anesthesia administration
				  records.
(J) Discharge note which
				  includes but is not limited to:
1. Summary of
				  intrapartum and postpartum course.
2. Activity limitations.
3. Instructions for follow-up
				  care.
(7)
				  Infant health record including:
(A) Physical
				  examination.
(B) Weight.
(C) APGAR scores.
(D) Results of newborn heritable disease
				  screening.
(E) Prophylaxis for
				  ophthalmia neonatorum.
(F) Evidence
				  of vital statistics registration.
(G) Discharge
				  note.