Rural hospitals: standby perinatal services.

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Digest key metadata added showing Vote: MAJORITY, Appropriation: NO, Fiscal Committee: YES, Local Program: YES

Version history listing added (09/16/25 Enrolled through 02/20/25 Introduced) and publication date (10/13/2025)

Printed document formatting removed, including page numbers (92, -2-, -3-, etc.), 'STATE OF CALIFORNIA AUTHENTICATED ELECTRONIC LEGAL MATERIAL' header, and chapter layout artifacts

Pilot project duration extended from 5 years to 10 years.

The first two selected hospitals must be nonprofit and located in the County of Humboldt and the County of Plumas. Up to three additional hospitals may be added if they include a signed agreement from exclusive employee representatives that the pilot would not adversely impact the workforce, or an attestation that no such representative exists.

Code placement changed from adding Article 3.5 (Sections 123530-123535) to Chapter 2 of Part 2 of Division 106, to adding Sections 1256.05 and 1256.06 immediately following Section 1256.01.

State-mandated local program designation changed from 'no' to 'yes,' meaning the bill now imposes costs on local agencies that may trigger state reimbursement obligations (though the bill states no reimbursement is required for a specified reason).

Eligible hospitals narrowed from 'critical access and individual and small system rural hospitals' to critical access hospitals only, with a cap of up to five participating sites.

Hospital eligibility criteria were restructured. The old requirements (60-minute distance, no closure after Jan 1 2025, Level I agreement) were replaced with a department determination process requiring: ability to meet Section 1256.06 standards, provision of surgery and anesthesia as basic services, capability for blood gas/pH/microbiologic analyses, ability to maintain premixed infusions, maintenance of an emergency medical service, and designation of specific room(s) for the service.

The department must establish the pilot project by July 1, 2026.

The definition of 'standby perinatal services' was broadened from 'emergency obstetric medical care' to 'obstetric and neonatal medical care to patients who are transferred from an alternative birth center, or who present to the hospital's emergency department with an urgent or emergent obstetric issue.'

New defined term: 'standardized order sets' means predefined groups of orders supporting clinical decisions developed using evidence-based guidelines.

Legislative findings were revised: removed the finding about minimum staffing standards being designed for moderate/high volume hospitals; changed all references from 'maternity units' to 'perinatal services'; changed the stated intent from testing in 'hospitals that have not operated a maternity unit in the past three years' to 'critical access hospitals in rural areas with limited access to comprehensive perinatal services.'

New provision allows the department to suspend or revoke a hospital's participation in the pilot project if it fails to meet requirements or fails to ensure patient health and safety.

The department is authorized to implement, interpret, or make specific the new sections via All Facilities Letters (AFL) without formal regulatory rulemaking.

New program flexibility provision allows hospitals to request modifications to statutory requirements, following existing procedures under Section 1276(b).

Equipment requirements were reorganized: instead of listing every item in the statute, the new version references existing regulations (Section 70551 of Title 22) for base equipment and adds specific perinatal items on top (fetal heart rate monitor with internal monitoring capability, postpartum hemorrhage kit with uterine tamponade device, neonatal resuscitation supplies with umbilical access, maternal steroid medications, refrigerated medication storage, suction device).

New nursing training requirement: biennial week-long rotations at a Level II, III, or IV maternal or neonatal care facility.

Hospitals must initiate and sustain an education program and develop a quality improvement program to maximize patient safety, in collaboration with facility partners providing higher levels of care.

Data reporting frequency specified: hospitals must report required data quarterly in the manner and method required by the department.

Header changed from Senate/Assembly passage language to 'STATE OF CALIFORNIA AUTHENTICATED ELECTRONIC LEGAL MATERIAL' with chapter number 603 and governor approval date of October 11, 2025.

Page numbering and running headers changed from page 93 with 'SB 669' to page 92 with 'Ch. 603', reflecting the standard chaptered law pagination format.

Removed the requirement that hospital written policies be 'not in conflict with the standards and recommendations of the Guidelines for Perinatal Care Level I developed by the American Academy of Pediatrics.' Policies now only need to be consistent with basic Level I perinatal care as defined by the American College of Obstetricians and Gynecologists, dropping the AAP alignment requirement.

Broadened the credentialing provision from requiring that providers in the emergency room, standby perinatal unit, or inpatient setting have privileges and be credentialed by the medical staff, to requiring that any provider furnishing services pursuant to the article in the hospital meet requirements set forth in both the medical staff bylaws and the facility's rules, regulations, and policies.

Added a requirement for hospitals to have either a fetal stethoscope or a fetal doppler in addition to the regular and fetal stethoscope already required in the standby perinatal unit equipment list.

Changed the postpartum hemorrhage kit requirement from specifying 'Bakri balloon or large Foley catheter for uterine tamponade' to the generic term 'a uterine tamponade device,' removing product-specific language.

Removed the 'glass trap' specification from the neonatal suction device requirement, now simply requiring a 'suction device appropriate for neonatal resuscitation.'

Corrected numerous typos and duplicate words throughout the bill (e.g., 'developed counties countries,' 'birthing persons persons,'' 'S.T.A.B.L.E S.T.A.B.L.E.,' 'non-reassuring nonreassuring'), fixed letter numbering errors in Section 123533(b)(8), and cleaned up amendment markup references changing 'this chapter article' to 'this article' throughout.

Assembly Member Bonta was added as a coauthor of the bill.

The requirement that a hospital not have closed a full maternity or labor and delivery department within the past three years now only counts closures on or after January 1, 2025, effectively exempting hospitals that closed before that date.

A new third eligibility option allows hospitals to qualify by agreeing to provide basic Level I maternal and neonatal services pursuant to ACOG Levels of Maternal Care, in addition to the existing options of partnering with a freestanding birth center or providing routine labor and delivery services.

A new provision allows a participating hospital to serve as the designated emergency-capacity hospital for an alternative birth center under Section 1204.3, expanding the pilot's role in the broader birth center regulatory framework.

The standard for written policies changed from 'consistent with' to 'not in conflict with' the Guidelines for Perinatal Care (8th Edition, 2017), a materially lower compliance threshold. The reference now also specifies Level I of those guidelines.

Detailed nursing certification requirements were added, mandating current BLS, ACLS, electronic fetal monitoring, S.T.A.B.L.E neonatal education, neonatal resuscitation program, and neonatal airway management certifications for all perinatal nursing staff.

A new section requires annual documentation of nursing competencies in maternal care, fetal and newborn care, post-delivery care, and emergency situations, including participation in simulation-based training for obstetric emergencies such as postpartum hemorrhage, eclampsia, shoulder dystocia, and neonatal resuscitation.

New equipment requirements include a postpartum hemorrhage kit with Bakri balloon or large Foley catheter, neonatal resuscitation supplies with umbilical access capability, maternal steroid medications for preterm labor, and a refrigerated medication storage unit in the standby unit.

A new capabilities section requires hospitals to maintain ability to begin emergency cesarean delivery within an appropriate time frame, provide limited obstetric ultrasonography with interpretation available at all times, implement patient safety bundles for venous thromboembolism/obstetric hemorrhage/severe hypertension, initiate massive transfusion protocol, and have pharmacy capability for premixed infusions.

A new section requires hospitals to maintain stabilization and transport capabilities, including risk identification procedures, a transfer mechanism to higher-level hospitals at all times, and a reliable communication system between participating hospitals, personnel, and transport teams.

The physician with overall program responsibility may now be certified by the American Board of Family Medicine in addition to Obstetrics and Gynecology or Pediatrics, broadening the pool of eligible physicians for rural settings.

The responsible physician must now develop order sets for pregnant patients presenting to the emergency department and perinatal standby unit, covering admission, chorioamnionitis/sepsis, labor augmentation, cesarean section, pregnancy-induced hypertension, premature rupture of membranes, preterm labor stabilization, post-anesthesia recovery, postpartum care, neonatal care, and discharge.

The 24-hour on-call coverage requirement was expanded from physician coverage only to 'physician and nursing staff coverage,' explicitly requiring both to be available within 30 minutes.

The medical staff membership requirement was broadened from applying only to physicians and certified nurse midwives to all providers serving in the emergency room, standby perinatal unit, or inpatient setting, who must have privileges and be credentialed by the medical staff.

New policy requirements were added including perinatal unit activation protocols, condition-specific management protocols, emergency codes (code pink, code blue, code c), equipment monitoring and check-off procedures, documentation standards for all phases of care, and anesthesia services readily available at all times.

The fetal heart rate monitor requirement was expanded to require capability for monitoring multiple gestation pregnancies using internal monitors (fetal scalp electrodes and intrauterine pressure catheters) and integration of maternal pulse to distinguish it from fetal pulse.

Stakeholder consultation requirements were expanded to explicitly include the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American Academy of Pediatrics, and health care professionals who provide pediatric and pregnancy-related services. The term 'certified midwives' was changed to 'certified licensed midwives.'

The laboratory requirement was changed from requiring the hospital to have its own laboratory capable of performing blood gas analyses, pH, and microbiologic analyses, to only requiring 'access to a laboratory' with those capabilities, and added the qualifier 'timely' for blood gas analyses. This significantly lowers the infrastructure burden on small rural hospitals.

Added 'Administration of antihypertensives' as a new required emergency service in the standby perinatal medical services unit, with renumbering of subsequent items in the list.

Policies and procedures for standby perinatal services must now be approved by both the medical staff AND the governing body, whereas previously only the governing body approval was required.

Nursing competencies for maternal care were expanded to include identification of 'gestational hypertension' signs (added alongside preeclampsia, placental abruption, preterm labor, and hemorrhage), and 'pain assessment' was broadened to 'pain and labor coping assessment.'

The quality improvement obligation was split: hospitals must now both 'maintain the ability to initiate and sustain education' AND separately 'develop a quality improvement program,' making the QI program an explicit standalone requirement rather than part of a combined education and QI obligation.

The physician with overall responsibility for the pilot program (Section 123534) must now also be 'a member of the medical staff of the facility,' adding a new eligibility requirement beyond board certification or eligibility.

The standard for written policies changed from being 'not in conflict with' ACOG guidelines broadly to being 'consistent with basic Level I perinatal care, as defined by' ACOG, narrowing the scope of the applicable standard.

The credentialing and privileges requirement was expanded to specify that providers must meet requirements of both medical staff bylaws AND facility rules, regulations, and policies, with a clarifying clause stating the article does not require changes to existing credentialing or privilege policies.

Added the American College of Nurse-Midwives to the list of stakeholders the department must consult when developing the pilot program monitoring plan and reporting template.

The resuscitation equipment requirement was changed from specifically requiring a 'glass trap suction device with catheter' to the broader 'suction device appropriate for neonatal resuscitation,' giving hospitals more flexibility in equipment choice.

The postpartum hemorrhage kit requirement was changed from specifying 'Bakri balloon or large Foley catheter for uterine tamponade' to the general term 'a uterine tamponade device,' removing product-specific references.

Multiple instances of 'chapter' were corrected to 'article' throughout the bill, reflecting that the new provisions are codified as Article 3.5 rather than a chapter.

Hospital eligibility was restructured from a two-part test (distance + no recent closure AND one of three service options) to a single three-part requirement. Hospitals must now agree to provide basic Level I maternal and neonatal services per ACOG Levels of Maternal Care. The previous options to simply agree to routine labor and delivery services or have an agreement with a freestanding birth center were eliminated.

A new subdivision (e) in Section 123533 requires that standby perinatal medical services comply with the same licensed nurse-to-patient ratios as a combined labor, delivery, and postpartum area of perinatal services. This is a significant staffing mandate that ensures adequate nursing coverage.

The physician oversight requirement was simplified. The previous version allowed a non-board-certified physician with relevant training and experience to have overall responsibility if no board-certified physician was available, provided they received consultation from a qualified physician. This fallback is now removed; only a physician certified or eligible for certification by the American Board of Obstetrics and Gynecology, Pediatrics, or Family Medicine may have overall responsibility.

The standard for hospital written policies was relaxed from being 'consistent with' the Guidelines for Perinatal Care Level I to being 'not in conflict with' those guidelines. The specific edition reference (8th Edition, 2017) was also removed, allowing for future updates without amendment.

The requirement for sterile 1 percent silver nitrate and irrigating solutions for prophylactic Crede treatment of the eyes was removed, aligning the bill with current medical practice that has moved away from this specific method of neonatal eye prophylaxis.

The newborn screening policy requirement was broadened from specifically requiring Phenylketonuria (PKU) screening to requiring compliance with 'current state newborn screening requirements,' making it more comprehensive and easier to maintain as the state panel evolves.

The designated perinatal medical services space no longer must be 'used for no other purpose,' giving hospitals more flexibility in how they designate and use their space, particularly relevant for small rural hospitals.

Senator Dahle was added as a coauthor of the bill.