POLICIES
§ 137.21. Policies and procedures.
(a) Written policies and procedures for obstetrical services shall be maintained and made available to medical and nursing staff members. They shall be reviewed by the medical staff, revised as necessary, and dated to indicate the time of last review.
(b) Obstetrical services policies and procedures shall include:
(1) A current roster of physicians with a delineation of their obstetrical privileges which shall be properly maintained and made available to nursing personnel.
(2) An on-call schedule established to ensure that a physician with obstetrical privileges is readily available at all hours.
(3) Provisions to ensure that spontaneous deliveries of patients in the final stages of labor shall not be delayed.
(4) Policies for intervention where patients demonstrate evidence of maternal, fetal, or neonatal distress.
(5) Criteria established by the medical staff to govern the administration of oxytocic agents, when used for induction or stimulation of labor. These criteria shall include a requirement for the immediate presence of a physician.
(6) A program to prevent isoimmunization of RH-negative mothers.
(7) A program for immediate blood transfusion services, as necessary.
(8) Procedures in accordance with Chapters 27 and 29 (relating to communicable and noncommunicable diseases; and miscellaneous health provisions) governing the reporting of metabolic diseases in the newborn and screening for phenylketonuria. All hospitals with obstetrical services must comply with the act of September 9, 1965 (P. L. 497, No. 251) (35 P. S. § 621) which provides for the testing of all newborns for phenylketonuria.
(9) Clean gynecology patients may be housed on maternity units at the discretion of the chief of service. A maternity patient shall not be denied a bed because of the presence of gynecological patients.
(10) Policies for visitors.
(11) Policies and procedures governing the presence of fathers or other supportive persons in the delivery room, if the hospital allows this practice.
(12) Policies and procedures for the care and treatments of drug-dependent newborns.
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