Material highlighted in lite beige connotes text quoted directly in the CCM S&G, those excerpted in part, modified or universally used by all sources is
Material highlighted in green represents ideas incorporated in a general language but not quoted
Material of interest highlighted in light yellow in documents from other states that indicates that it wasn't incorporated do to its overly specific nature or dubious utility.
Editorial notes, commentary and other editorial functions are highlighted in lite blue
The best way to review this material is to simply start reading at the top, and scroll down.
Use the hyperlinks above to return to where you left off (the whole file takes 2-3 hours to read.
What follows are the original documents that I worked from, with all the original sources and each area of text highlighted that was "cut and pasted" into the final CCM S&G. I also color-coded background ideas and language that we clearly did not/do not want.
As you read, pay special attention to the many versions of similar language that were NOT chosen. Some state statutes were many times more specific than any of us would be happy with or that would permit compliance with evidence-based parameters.
I know many think I am too wordy and overly specific, but in fact, the "words" used in the CCM document belong to other midwives. CCM S&G are 95% compilation from more than a dozen state, national & international mfry sources. Only about 5% is authored by me and most of that is either explanatory text or addresses legal problem specific to California. I consistently choose the least "wordy" (i.e. specific) version that was consistent with the scientific or legal facts and met the political needs relative to the Medical Board and Senator Figueroa.
After reading the source material, click on the link immediately below and re-read the PDF of Sections 1& 2 (same content as published on MBC web site).
CCM Standards & Guidelines ~ Sections 1 & 2 only in PDF, as referenced
in proposed MBC regulations and posted on MBC web site~
Bottom line, it isn't perfect.
But, if adopted, it can be perfected over time. It acknowledges the autonomy of healthy childbearing women to make informed choices & have the final say so, even if such choices are medically unpopular. It gives LMs legal protection in many important areas that we did not have before, for example, acknowledging maternal autonomy and the legal basis (under the OAL decision in Alison Osborn's case) for LMs to provide care in "moderate risk" circumstances.
We will never have a better chance than right now. The tide is high, we have a lot of reason to hope that we will prevail. We surely don't want to go back to the 'bad old days', in which the MBC // ACOG had carte blanch to select the most limiting, most prohibitive, most prescriptive language from these source documents (they have access to the Internet too!) and impress them on us as a 'midwifery' standards that is neither midwife or mother-friendly or scientifically valid.
Alaska Statutes and Regulations // Excerpts relative to mfry practice
Note: Alaska has a direct-entry midwifery board with LMs, OBs and CNMs as seated members. The Alaska DE mfry law does NOT require physician supervision but OBs, nurse-midwives and lay members out-number the LMs on the board.
The Original proposal by Dr Fantozzi (chair of mfry task force) was to adopt some version of the Alaska statutes and regulations for California LMs
Many LMs found the proposed Alaska rules to be problematic for both political & practical reasons. Those items highlighted below in yellow were thought to be out-dated, overly specific, not evidence-based, of dubious utility. Sometimes the objection was wording, rather than the actual criteria. Except for 'Ethics' and the drug list, the Alaska statues made a nominal contribution to the CCM S&G.
Sec. 08.65.140. REQUIRED PRACTICES. (a) Except as provided in (d) of this section, a certified direct-entry midwife may not assume the care or delivery of a client unless the certified direct-entry midwife has recommended that the client undergo a physical examination performed by a physician, physician assistant, advanced nurse practitioner, or certified nurse midwife, who is licensed in this state.
(b) A certified direct-entry midwife shall inform a woman seeking home birth of the possible risks of home birth and shall obtain a signed informed consent, including the recommendation for a physical examination required under (a) of this section, from the woman before the onset of labor. The consent shall be maintained by the certified direct-entry midwives as part of the woman’s record. A certified direct-entry midwife shall accept full legal responsibility for the direct-entry midwife’s acts or omissions.
(c) A certified direct-entry midwife shall comply with the requirements of AS 18.15.150 concerning taking of blood samples, AS 18.15.200 concerning screening of phenylketonuria (PKU), AS 18.50.160 concerning birth registration, AS 18.50.230 concerning registration of deaths, AS 18.50.240 concerning fetal death registration, and regulations adopted by the Department of Health and Social Services concerning prophylactic treatment of the eyes of newborn infants.
(d) A certified direct-entry midwife may not knowingly deliver a woman who
(1) has a history of thrombophlebitis or pulmonary embolism;
(2) has gestational diabetes, diabetes, hypertension, Rh disease with positive titer, active tuberculosis, active syphilis, active gonorrhea, epilepsy, heart disease, or kidney disease;
(3) contracts genital herpes simplex in the first trimester of pregnancy or has active genital herpes in the last two weeks of pregnancy;
(4) has severe psychiatric illness;
(5) inappropriately uses controlled substances, including those obtained by prescription;
(6) has multiple gestation;
(7) has a fetus of less than 37 weeks gestation at the onset of labor;
(8) has a gestation of more than 42 weeks by dates and examination;
(9) has a fetus in any presentation other than vertex at the onset of labor;
(10) is a primigravida with an unengaged fetal head in active labor, or any woman who has rupture of membranes with unengaged fetal head, with or without labor;
(11) has a fetus with suspected or diagnosed congenital anomalies that may require immediate medical intervention;
(12) has pre-eclampsia or eclampsia;
(13) has bleeding with evidence of placenta previa;
(14) any condition determined by the board to be of high risk to the pregnant woman and newborn;
(15) has had a previous caesarian delivery or other uterine surgery;
(16) experienced the rupture of membranes at least 24 hours before the onset of labor; or
(17) is less than 16 years of age at the time of delivery.
(e) Notwithstanding (d) of this section, a certified direct-entry midwife may deliver a woman with any of the complications or conditions listed in (d)(1) — (17) of this section if
(1) the delivery is a verifiable emergency; and
(2) a physician or certified nurse midwife is not available in the geographic vicinity.
(f) A certified direct-entry midwife may not attempt to correct fetal presentation by external or internal inversion unless
(1) there is a verifiable emergency; and
(2) a physician or certified nurse midwife is not available in the geographic vicinity.
Sec. 08.65.180. RESPONSIBILITY FOR CARE. If a certified direct-entry midwife seeks to consult with or refer a patient to a licensed physician, the responsibility of the physician for the patient does not begin until the patient is physically within the physician’s care. On our Wish List // i.e., a legislative remedy to vicarious liability !
Duties and Responsibilities.
500. Prenatal care
510. Intrapartum care
520. Postpartum care
530. Infant care
550. Medical back-up arrangements
560. Permitted practices
580. Withdrawal from service
12 AAC 14.500. PRENATAL CARE. (a) The board recommends that a certified direct-entry midwife make prenatal visits to a client every four weeks until the 28th week of gestation, every two weeks from the 29th through the 35th week of gestation, and weekly from the 36th week of gestation until birth.
(b) At the initial prenatal visit, the certified direct-entry midwife shall recommend that the client undergo a physical examination as required in AS 08.65.140 to screen for health problems that could complicate the pregnancy or delivery and that includes a review of the laboratory studies required in (c) of this section. The certified direct-entry midwife shall obtain a signed written consent from the client reflecting the client’s informed choice regarding the recommended physical examination and retain the consent in the client’s record.
(c) At the initial prenatal visit, the certified direct-entry midwife shall
(1) order the following laboratory tests:
(A) a serological test for syphilis, either rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL);
(B) blood group;
(C) Rh factor and screen;
(D) rubella titer;
(E) complete blood count;
(F) gonorrhea screen;
(H) urine culture;
(I) chlamydia screen;
(J) cervical cytology; and
(2) recommend the following laboratory tests:
(A) test for tuberculosis; and
(B) test for hepatitis and human immune deficiency virus (HIV).
(d) At 15 to 20 weeks of gestation, the certified direct-entry midwife shall discuss with the client the availability of maternal serum alphafetoprotein screening.
(e) At 24 to 28 weeks of gestation, the certified direct-entry midwife shall recommend a 50 gm glucose tolerance test for gestational diabetes.
(f) The certified direct-entry midwife shall order
(1) at 28 and 36 weeks of gestation
(A) a hemoglobin or hematocrit test; and
(B) for a woman with Rh negative type blood, an antibody screen; and
(2) a culture for Group B Streptococci at 35 – 37 weeks of gestation.
(g) At each prenatal visit, the certified direct-entry midwife shall order the analysis of a clean catch urine sample for glucose and protein.
(h) The certified direct-entry midwife shall comply with AS 08.65.140(b) in obtaining a signed informed consent for home delivery.
(i) During the third trimester, the certified direct-entry midwife shall consult with the client concerning selection of a pediatrician, family physician, or other health care provider who will assume responsibility for the infant. The certified direct-entry midwife shall record the client’s choice in the client’s record. If the client cannot or will not select a provider for the infant, the certified direct-entry midwife shall document this information in the client’s record.
(j) The certified direct-entry midwife shall consult with a physician if, during the prenatal period, the client
(1) develops 2+ or greater pitting edema on the face and hands;
(2) develops consistent glucosuria or proteinuria of 1+ or greater;
(3) has marked or severe polyhydramnios or oligohydramnios;
(4) prior to 37 weeks gestation, has six or greater contractions per hour not resolved with hydration or rest, or has effacement or dilation of the cervix;
(5) has severe protruding varicose veins of the extremities or vulva;
(6) develops blood pressure of 140/90 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic over the usual blood pressure;
(7) develops severe, persistent headaches, epigastric pain, or visual disturbances;
(8) has symptoms of urinary tract infection such as a rise in temperature, kidney or flank pain, urinary frequency, or dysuria;
(9) has rupture of membranes before 37 weeks gestation;
(10) has marked decrease or cessation of fetal movement;
(11) has fetal heart tones of less than 100 or more than 170 per minute;
(12) has inappropriate gestational size;
(13) has fever of 100.4° F. or 38° C. for 24 hours or more;
(14) has severe or ongoing medical complications;
(15) has demonstrated anemia by blood test (hematocrit 27 percent or hemoglobin 9 grams);
(16) is found to have a positive antibody screen;
(17) has vaginal bleeding other than show before the onset of labor;
(18) fails a three-hour oral glucose tolerance test; or
(19) has a positive purified protein derivative (PPD) test, hepatitis screen, or human immune deficiency virus (HIV) test.
(k) If, following the consultation set out in (j) of this section, the physician recommends referral for immediate medical care the certified direct-entry midwife shall refer the client for immediate medical care. A referral for immediate medical care does not preclude the possibility of a home delivery if, following the referral, the client does not have any of the conditions set out in AS 08.65.140(d).
(l) During the third trimester, the certified direct-entry midwife shall ensure that the client is adequately prepared for a home birth by discussing issues such as sanitation, facilities, adequate heat, availability of telephone and transportation, plans for emergency evacuation to a hospital, and the skills and equipment that the midwife will bring to the birth.
(m) A certified direct-entry midwife shall make a home visit three to five weeks before the estimated date of confinement to assess the physical environment, to determine whether the client has the necessary supplies, to prepare the family for the birth, and to instruct the family in correction of problems or deficiencies.
12 AAC 14.510. INTRAPARTUM CARE. (a) Intrapartum care includes the management of low risk women whose labor, delivery, postpartum course, and infant are not reasonably expected to require consultation with a physician or referral for medical care.
(b) A certified direct-entry midwife may not perform a vaginal examination on a client with ruptured membranes and no onset of labor unless
(1) less than 24 hours have elapsed since the rupture of the membranes; and
(2) there is a reasonable and strong suspicion of a prolapsed cord.
(c) A certified direct-entry midwife shall obtain medical consultation or refer for medical care any client who during the intrapartum period
(1) develops a blood pressure of 160/100 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic over the baseline blood pressure;
(2) develops a fever of 100.4° F. or 38° C.;
(3) has bleeding other than show before delivery;
(4) develops severe headaches, epigastric pain, or visual disturbance;
(5) develops respiratory distress;
(6) has persistent or recurrent fetal heart tones below 100 or above 170 beats per minute at any time, or a fetal heart rate that is irregular or showing late or variable decelerations; WORDING ISSUE
(7) has meconium stained amniotic fluid other than very light;
(8) desires medical consultation or transfer; or
(9) develops symptoms or signs of an allergic reaction.
(d) A consultation or referral as required in (c) of this section does not preclude the possibility of a home delivery if, following the consultation with a physician or referral for medical care, the client does not have any of the conditions set out in AS 08.65.140(d).
(e) A certified direct-entry midwife shall ensure that a client on whom cardiopulmonary resuscitation is administered or treatment for anaphylactic shock is administered is immediately transported to a hospital.
(f) A certified direct-entry midwife shall accompany to the hospital any client requiring hospitalization and provide copies of all pertinent client data and make a verbal report to the physician assuming care. If reasonably possible, the certified direct-entry midwife shall remain with the client to receive information regarding the results of the client’s hospitalization.
(g) A certified direct-entry midwife may start antibiotic intravenous therapy treatment on a woman who tests positive for Group B Streptococci and chooses antibiotic treatment.
12 AAC 14.520. POSTPARTUM CARE.
(a) Postpartum care is management of the client through the six week postpartum period.
(b) After normal delivery, a certified direct-entry midwife shall remain with the client and infant for at least three hours postpartum or until both the client’s and infant’s conditions are stable. If the client or infant is not stable within five hours, the certified direct-entry midwife shall transfer the client to an appropriate medical facility.
(c) Maternal stability is evidenced by normal blood pressure, pulse, and respiration; firmness of fundus; normal lochia; and the ability to empty the bladder.
(d) Neonatal stability is evidenced by established respirations, normal temperature, normal heart rate, and strong sucking of the infant.
(e) A certified direct-entry midwife shall maintain close contact with the client during the first 72 hours postpartum, A certified direct-entry midwife shall determine whether the mother is bleeding excessively, has a firm fundus, has a normal temperature, and is establishing successful breast-feeding or bottle-feeding.
(f) In the case of a mother with Rh negative type blood, a certified direct-entry midwife shall
(1) obtain a sample of cord blood from the placenta and arrange for testing; and
(2) administer or arrange for and be certain that the mother receives Rh immune globulin as indicated within 72 hours of delivery.
(g) A certified direct-entry midwife shall obtain medical consultation or refer for medical care any client who, during the postpartum period,
(1) does not void within six hours after birth;
(2) has a third or fourth degree perineal or cervical laceration;
(3) develops a fever greater than 100.4° F. or 38° C. on any two of the first 10 postpartum days;
(4) develops foul smelling lochia;
(5) develops hematoma;
(6) does not deliver the placenta within one hour of delivery of the infant;
(7) bleeds more than 1,000 cc (four cups) immediately after the delivery of the placenta and the bleeding is not readily controlled;
(8) has a partially separated placenta with
(A) heavy bleeding;
(B) a blood pressure below 90 systolic;
(C) a pulse rate of 110 beats per minute or more; or
(D) weakness and dizziness; or
(9) has retained placental fragments or membranes.
12 AAC 14.530. INFANT CARE. (a) A certified direct-entry midwife shall consult with a physician concerning an infant who
(1) has an Apgar score of seven or less at five minutes;
(2) has a congenital defect;
(3) has tachycardia of 170 or above, bradycardia of 100 or below, or cardiac irregularities;
(4) develops jaundice within 24 hours of birth or significant scleral icterus within one week of birth;
(5) has an abnormal cry;
(6) shows signs of prematurity, dysmaturity, or postmaturity;
(7) had meconium stained fluid before birth other than very light;
(8) is lethargic or does not feed well;
(9) has edema;
(10) develops grunting respirations, retractions, central cyanosis, or apnea;
(11) has a pale, generalized cyanotic or grey color;
(12) weighs less than five and one half pounds or 2,500 grams, or more than 10 pounds or 4,500 grams;
(13) does not urinate or pass meconium within 24 hours of birth;
(14) requires resuscitation by bag and mask or cardiopulmonary resuscitation; or
(15) appears weak, flaccid, or abnormal in any other respect.
(b) Within two hours of birth, a certified direct-entry midwife shall administer appropriate eye prophylaxis to the newborn infant in accordance with 7 AAC 27.111.
(c) A certified direct-entry midwife shall offer, to one or both of the parents, to administer intramuscular vitamin K to the infant for the prevention of acute and late onset hemorrhagic disease. If a parent consents to the within two hours of birth. A certified direct-entry midwife shall note in the client’s records a parent’s acceptance or refusal of intramuscular vitamin K.
(d) A certified direct-entry midwife shall ensure that the newborn receives metabolic blood disorder screening in accordance with 7 AAC 27.510 - 7 AAC 27.580. The certified direct-entry midwife shall use a metabolic blood disorder screening kit obtained from the Department of Health and Social Services.
(e) A certified direct-entry midwife shall recommend to the client an evaluation of the infant by a physician within one week of birth or sooner if it becomes apparent that the infant needs medical attention.
(f) A certified direct-entry midwife shall complete and file a birth certificate within seven days after the birth in accordance with AS 18.50.160.
12 AAC 14.540. RECORDS. (a) A certified direct-entry midwife shall maintain records of each client on standard obstetric forms prescribed by the board.
(b) A certified direct-entry midwife shall maintain records of the recommended medical visit, all prenatal visits, charting of labor and delivery, summary of birth, and charting of the newborn examination and postpartum visits.
(c) A certified direct-entry midwife shall maintain birth records of an infant until at least two years after the infant has reached the age of 19 years. Prenatal and infant records must be maintained for at least seven years from the date of birth.
(d) A certified direct-entry midwife shall provide copies of pertinent records to medical personnel when the client or infant is referred for medical care or transported for emergency care.
(e) All records maintained by the certified direct-entry midwife are subject to review by the board.
12 AAC 14.550. MEDICAL BACK-UP ARRANGEMENTS. (a) A certified direct-entry midwife shall have written back-up arrangements that must include procedures concerning
(1) alternate midwife assistance for clients in the certified direct-entry midwife’s absence;
(2) abnormal conditions and medically indicated maternal or infant consultations; and
(3) conducting laboratory tests.
(b) A certified direct-entry midwife shall present the written back-up arrangements to the board upon request.
12 AAC 14.560. PERMITTED PRACTICES. (a) The following practices may be performed by a certified direct-entry midwife who provides documentation acceptable to the board of having acquired the training and skills necessary to safely perform them:
(1) catheterization of the urinary bladder;
(2) administration of medications as specified in 12 AAC 14.570 and 12 AAC 14.600;
(3) clamping and cutting the umbilical cord;
(4) artificial rupture of the amniotic membranes if the fetal head is at zero station or lower and the client is past five centimeters dilation;
(6) capillary blood sampling;
(8) emergency measures as specified in 12 AAC 14.600; and
(9) intravenous therapy.
(b) The board will notify the certified direct-entry midwife that documentation submitted under this section is acceptable to the board of competence in these practices. A certified direct-entry midwife may not perform the practices set out in (a) of this section until notification of acceptance has been provided by the board.
12 AAC 14.570. MEDICATIONS. A certified direct-entry midwife may not administer restricted drugs or medications except for the following, and only if the certified direct-entry midwife has documented the training and skills demonstrating competence to administer them as required in 12 AAC 14.560:
(1) Xylocaine hydrochloride, one or two percent, administered by infiltration, for the postpartum repair of tears, lacerations, and episiotomy;
(2) Cetacaine, applied topically, for the postpartum repair of tears, lacerations, and episiotomy;
(3) vitamin K, administered by intramuscular injection, for the prevention of acute and late onset hemorrhagic disease of the infant;
(4) Rhogam, administered by intramuscular injection, for an unsensitized client with Rh negative type blood to prevent Rh disease;
(5) eye prophylaxis as required by 7 AAC 27.111;
(6) Pitocin, administered by intramuscular injection or intravenous drip, in an emergency situation for the control of postpartum hemorrhage;postpartum hemorrhage that was not controlled by the administration of pitocin;
(8) lactated ringers, plain or with dextrose five percent, or normal saline administered intravenously to a postpartum client, in an emergency situation to prevent or treat shock and stabilize her condition while arranging transport to a hospital;
(9) antibiotic intravenous therapy treatment for Group B Streptococci in accordance with the United States Department of Health and Human Services, Centers for Disease Control and Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC, revised as of August 16, 2002 and adopted by reference, except that vancomycin may not be administered;
(10) epinephrine for allergic reaction or anaphylactic shock;
(11) diphenhydramine administered by intramuscular injection or intravenously for allergic reaction or anaphylactic shock.
12 AAC 14.580. WITHDRAWAL FROM SERVICE. (a) A certified direct-entry midwife may withdraw from responsibility for a client during the prenatal period if, for any reason, the midwife does not feel comfortable continuing as the client’s midwife. The decision to withdraw may take into account
(1) the client’s failure to consult a physician when recommended to do so by the certified direct-entry midwife;
(2) the client’s failure or refusal to follow recommendations;
(3) personality incompatibilities; or
(4) any other factor that the certified direct-entry midwife believes may create an unwarranted risk to the client, fetus, or infant, or may interfere with the certified direct-entry midwife’s ability to care responsibly for the client, fetus, or infant.
(b) If the certified direct-entry midwife withdraws, the midwife shall immediately notify the client in writing and shall cooperate with the client in finding alternative care.
(c) After the onset of labor, a certified direct-entry midwife may withdraw only if the midwife believes that the midwife is unable to competently care for the client, fetus, or infant. The certified direct-entry midwife shall arrange for transfer of the client to medical care. If the client refuses to accept transfer to medical care, the certified direct-entry midwife shall document the relevant events and shall stay with the client until attended by hospital or emergency medical personnel
Article 6. Emergency Measures
600. Emergency practices
610. Emergency transport plan
620. Emergency defined
12 AAC 14.600. EMERGENCY PRACTICES. In addition to the practices permitted in AS 08.65.140(e) and (f) and 12 AAC 14.560, in an emergency a certified direct-entry midwife who has documented training and skills demonstrating competence as set out in 12 AAC 14.560 may
(1) perform an episiotomy; and
(2) administer pitocin, methergine, epinephrine, and diphenhydramine as described in 12 AAC 14.570(6), (7), (10).
12 AAC 14.610. EMERGENCY TRANSPORT PLAN. (a) A certified direct-entry midwife shall present a copy of the midwife’s emergency transport plan to each client before the onset of labor.
(b) The emergency transport plan must be signed by the client and include
(1) written permission to release the client’s records to a physician in an emergency; and
(2) a statement that costs will be incurred for emergency transportation and an agreement as to who is responsible for the costs.
(c) The certified direct-entry midwife shall include the signed emergency transport plan in the client’s records.
12 AAC 14.620. EMERGENCY DEFINED. In this chapter and in AS 08.65, “emergency” means a situation that presents an immediate hazard to the health and safety of the client.
12 AAC 14.900. PEER REVIEW. (a) The board will designate, as a peer review committee, a qualified organization with experience in certified direct-entry midwifery to provide peer review to the board concerning the quality of care provided by a certified direct-entry midwife.
(b) In the agreement for peer review services, the board will require the organization providing peer review to
(1) maintain confidentiality of medical records as required by law;
(2) randomly review summaries of births submitted by a certified direct-entry midwife under (c)(1) of this section;
(3) review those summaries of births or other records submitted under (c)(2) and (3) of this section;
(4) review at the request of the board any case or summary of birth relating to care by a certified direct-entry midwife;
(5) maintain records of the organization related to the review;
(6) provide records to the board and division investigative staff, as requested by the board or division investigative staff; and
(7) report to the board or division investigative staff on activities and results of the peer review conducted under this section, including any recommendations for disciplinary action.
(c) A certified direct-entry midwife shall submit to the board or, if an organization has been designated under
(a) of this section, to that organization the following information:
(1) a copy of the summary of birth for each labor and delivery for which the certified direct-entry midwife had primary responsibility during the 12-month period that began on April 1 of the preceding year; the copy must be submitted on or before May 1 of each year;
(2) all records required under 12 AAC 14.540 as requested by the board through the organization providing peer review for cases selected under (b)(2) of this section; and
(3) within 10 days after the delivery or transfer of care all records required under 12 AAC 14.540 for any case in which a client for whom the certified direct-entry midwife had primary responsibility
(B) required emergency hospital transport;
(C) required intensive care; or
(D) had any of the complications or conditions listed in AS 08.65.140(d)(1) - (17).
(d) Failure to comply with the requirements of this section is grounds for disciplinary sanction under AS 08.65.110(6).
12 AAC 14.990. DEFINITIONS. In this chapter
(1) “board” means the Board of Certified Direct-Entry Midwives;
(2) “client” means a pregnant woman, postpartum woman up to six weeks, fetus, or newborn, as appropriate;
(5) “supervision” means the direct observation and evaluation by the preceptor of the clinical experiences and technical skills of the apprentice direct-entry midwife or other supervised person while present with the supervised person in the same room.
APPENDIX B ~ ETHICS
On April 26, 1994 the Board of Certified Direct-Entry Midwives adopted the following code of ethics:
1. The principle objective of the midwifery profession is to render service to humanity with full respect for the dignity of the human race. Midwives should merit the confidence of patients entrusted to their care, rendering to each a full measure of services and devotion.
2. Midwives should strive continually to improve medical knowledge and skill, and should make available to their clients and colleagues the benefits of their professional attainments.
3. A midwife should practice a method of maternal care utilizing accreditable research as a criteria for care, and promote such research.
4. The midwifery profession should safeguard the public and itself against midwives deficient in moral character or professional competence. Midwives should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed disciplines. They should expose, without hesitation, illegal or unethical conduct of fellow members of the profession.
5. A midwife may choose whom she will serve. In a life-threatening emergency, however, she should render service to the best of her ability. Having undertaken the care of a client, she may not neglect her; and, unless she has been discharged, she may discontinue services only after giving adequate notice.
6. A midwife should not dispense her services under terms or conditions which tend to interfere with or impair her midwifery judgment and skill or tend to cause a deterioration of the quality of midwifery care.
7. A midwife should seek consultation and/or referral upon request; in doubtful or difficult cases; or whenever it appears that the quality of health care would be enhanced thereby.
8 A midwife may not reveal the confidences entrusted to her in the course of midwifery attendance, or the deficiencies she may observe in the character of patients, unless she is required to do so by law or unless it becomes necessary in order to protect the welfare of the individual or of the community.
9. The honored ideals of the midwifery profession imply that the responsibilities of the midwife extend not only to the individual, but also to society where these responsibilities deserve her interest and participation in activities which have the purpose of improving both the health and the well-being of the individual and the community.
Arizona Licensed Midwives effective June 18, 2002 (Supp. 02-2)
Responsibilities of the Licensed Midwife
A. A midwife shall provide care only to clients determined to be low risk.
B. A midwife shall maintain all instruments used for delivery in an aseptic manner and other birthing equipment and supplies in clean and good condition.
C. A midwife shall both initially and periodically thereafter assess a client's physical condition in order to establish the client's continuing eligibility to receive midwifery services.
D. A midwife shall inform clients, both orally and in writing, of the midwife's scope of practice; the risks and benefits of home birth; the required tests and potential risks to a newborn if refused, and the need for written documentation of client's refusal; the use of a physician or medical facility for the provision of emergency consultation or services; midwife facilitation of the transfer of care to the physician or medical facility; and the midwife's termination of care should certain medical conditions arise or the client refuses intervention. A written informed consent shall be signed by the client upon acceptance for midwifery care.
E. Initial care and care during the prenatal period shall be provided as follows:
1. The following tests shall be scheduled or ordered during the 1st visit:
a. Blood type, including ABO and Rh, with antibody screen;
c. Hematocrit, hemoglobin, or complete blood count, initially and rechecked at 28 to 36 weeks of the pregnancy;
d. Syphilis, gonorrhea, and chlamydia testing, unless a written refusal for gonorrhea or chlamydia testing is obtained from the client;
e. Rubella titer; and
f. One-hour blood glucose screening test for diabetes, between 24 to 28 weeks of the pregnancy.
2. Prenatal visits shall be conducted at least every 4 weeks until 28 weeks gestation, every 2 weeks from 28 weeks until 36 weeks gestation, and weekly thereafter, and each shall include;
a. The taking of weight, urinalysis for protein, nitrites, glucose and ketones, blood pressure, and assessment of the lower extremities for swelling;
b. Measurement of the fundal height and listening for fetal heart tones and, later in the pregnancy, feeling the abdomen to determine the position of the fetus;
c. Referral of a client as appropriate for ultrasound or other studies recommended based upon examination or history;
d. Recommendation of administration of the drug RhoGam to unsensitized Rh negative mothers after 28 weeks, or any time bleeding or invasive uterine procedures are done, or midwife administration of RhoGam under physician's written orders; and
e. Fetal movement counts by client beginning at 28 weeks gestation.
3. Fetal heart tones with fetoscope and documentation of 1st quickening shall begin between 18 and 20 weeks gestation and weekly visits shall be conducted until these signs have occurred. If these signs do not occur by 22 weeks gestation, medical consultation shall be initiated. NOT used
4. A visit shall be made to the client's home prior to 35 weeks gestation to ensure that the birthing environment is appropriate for birth and that a working telephone or citizen's band radio is available.
F. Care during the intrapartum period shall be provided as follows:
1. The midwife shall initially determine if the client is in labor and the appropriate course of action to be taken by:
a. Assessing the interval, duration, intensity, location, and pattern of the contractions;
b. Determining the condition of the membranes, whether intact, ruptured, and the amount and color of fluid;
c. Evaluating the presence of bloody show;
d. Reviewing with the client the need for an adequate fluid intake, relaxation, activity, and emergency management; and
e. Deciding whether to go to client's home, remain in telephone contact, or arrange for transfer of care or consultation.
2. During labor, the condition of the mother and fetus shall be assessed upon initial contact, every half hour in active labor until completely dilated, and every 15 to 20 minutes during pushing, after the bag of water has ruptured or until the newborn is delivered. Care shall include the following:
a. Checking of vital signs every 2 to 4 hours and an initial physical assessment of the mother;
b. Assessment of fetal heart tones every 30 minutes in active 1st stage labor, and every 15 minutes during 2nd stage, following rupture of the amniotic bag or with any significant change in labor patterns;
c. Periodic assessment of contractions, fetal presentation, dilation, effacement, and position by vaginal examination;
d. Determination of the progress of active labor for primiparas by determining if dilation occurs at an average of 1 cm/hr until completely dilated, and a 2nd stage not to exceed 2 hours;
e. Determination of a normal progress of active labor for multigravidas by determining if dilation occurs at an average of 1.5 to 2 cm/hr until completely dilated, and a 2nd stage not to exceed 1 hour;
f. Maintenance of proper fluid balance for the mother throughout labor as determined by urinary output and monitoring urine for presence of ketones, at least every 2 hours; and
g. Assisting in support and comfort measures to the mother and family.
3. After delivery of the newborn, care shall include the following:
a. Assessment of the newborn at 1 minute and 5 minutes to determine the Apgar scores;
b. Physical assessment of the newborn for any abnormalities;
c. Inspection of the mother's perineum for lacerations; and
d. Delivery of the placenta within 40 minutes during which time the midwife shall assess for signs of separation, frank or occult bleeding, examine for intactness, and determine the number of umbilical cord vessels.
4. The responsibility of the midwife shall include recognition of and response to any situation requiring immediate intervention.
G. A midwife shall provide the following care during the postpartum period:
1. During the immediate postpartum period of 2 hours after delivery of the placenta, care of the mother shall include:
a. Taking of vital signs of the mother with external massage of the uterus and evaluation of bleeding every 15 to 20 minutes for the 1st hour and every half hour for the 2nd hour;
b. Assisting the mother to urinate within 2 hours following the birth;
c. Evaluating the perineum for tears, bleeding, or blood clots;
d. Assisting with maternal and infant bonding;
e. Assisting with initial breast feeding, instructing the mother in the care of the breast, and reviewing potential danger signs, if appropriate;
f. Providing instruction and support to the family to ensure adequate fluid and nutritional intake, rest, and type of exercise allowed, normal and abnormal bleeding, bladder and bowel function, appropriate baby care, and any danger signals with appropriate emergency phone numbers;
g. Recommending the drug RhoGam or administering it, under written physician's orders, to an unsensitized Rh-negative mother who delivers an Rh-positive newborn. Administration shall occur not later than 72 hours after birth.
2. During the immediate postpartum period of 2 hours after delivery of the placenta, care of the newborn shall include:
a. Perform a newborn physical exam to determine the newborn's gestational age and any abnormalities;
b. Apply erythromycin optic ointment or other preparation specifically approved by the Director to each of the newborn's eyes in accordance with A.A.C. R9-6-718; and
c. Recommend or administer Vitamin K under physician's written orders to the newborn. Administration shall occur not later than 72 hours after birth.
3. Any abnormal or emergency situation shall be evaluated and consultation or intervention sought in accordance with these rules.
4. The condition of the mother and newborn shall be re-evaluated between 24 and 72 hours of delivery to determine whether the recovery is following a normal course and shall include:
a. Assessment of baseline indicators such as the mother's vital signs, bowel and bladder function, bleeding, breasts, feeding of the newborn, sleep/rest cycle, activity with any recommendations for change;
b. Assessment of baseline indicators of well-being in the newborn such as vital signs, weight, cry, suck and feeding, fontanel, sleeping, bowel and bladder function with documentation of meconium, and any recommendations for changes made to the family;
c. Submission of blood obtained from a heel stick to the newborn to the Regional Genetic Screening Laboratory, P.O. Box 17123, Denver, Colorado 80217, for metabolic screening for common genetic disorders, within 72 hours of the birth, unless a written refusal is obtained from the client and documented in the newborn's record.
d. Recommendation to the mother to secure medical follow-up for her newborn; and
e. Advice on the necessity of family planning interventions for the couple.
H. The midwife shall file a birth certificate with the local registrar within 7 days after the birth of the newborn.
Adopted effective March 14, 1994 (Supp. 94-1).
Recordkeeping and Report Requirements
A. Each midwife shall establish and maintain a record of the care provided and data gathered for each client.
B. Information in the client's record shall be released by the midwife only with the written consent of the client, legal guardian, or as otherwise provided by law.
C. If a client is a minor, informed consent shall be signed by the parent or legal guardian except as provided in A.R.S. § 44-132 and shall be filed in the client's record.
D. A midwife shall make records available to other health care providers engaged in the care and treatment of the client and upon request by the Department for periodic quality review.
E. A midwife shall maintain evidence of medical evaluation and physician visits in the client's record. Such evidence shall consist of either a report signed by the physician, a copy of the medical and physician notes, or other documentation received from the physician or medical provider.
F. A midwife shall enter a date for each entry in the prenatal record and the postpartum record. A date and time shall be recorded for each entry in the labor record. Each entry shall be initialed or signed by the midwife. If initials are used, the midwife shall sign on the same page.
G. Each licensed midwife shall submit a client summary report for each client to the Department. Such reports shall be submitted within 15 days after the close of each quarter on the form set forth as Exhibit E.
H. Each client's record shall contain the following information, as applicable:
1. Client identification sheet, including name, address, date of birth, sex, next of kin, spouse or other designated person, directions to the client's home, telephone number, and marital status;
2. Health history sheet including pre-existing conditions or surgeries, previous pregnancies, physical examination, nutritional status, and a written assessment of risk factors with an intervention plan when risk factors that require termination of the agreement are present;
3. Progress notes of all encounters with the midwife and other health care consultants, in chronological order, documenting any actions, guidance, and consultations, with copies if appropriate;
4. Laboratory and diagnostic reports;
5. Written informed consent which is signed by the client.
Colorado Midwifery Practice
RULE 4 - PRACTICE RESTRICTIONS ~ The purpose of this rule is to define the practice restrictions applicable to a registered direct-entry midwife.
The registered direct-entry midwife shall not provide care to any woman whose medical history exhibits the following signs or symptoms:
1. Insulin-dependent diabetes mellitus or Insulin-dependent gestational diabetes;
2. hypertensive disease ( blood pressure greater than 140/90 at rest);
3. pulmonary disease or cardiac disease which interferes with activities of daily living;
4. a history of thrombophlebitis or pulmonary embolism;
5. blood dyscrasia, for example sickle cell anemia;
6. seizures controlled by medication if the mother has seized within the last year;
7. Hepatitis B, HIV positive, or AIDS;
8. current use of psychotropic medications if woman is not under the care and monitoring of a physician during the pregnancy;
9. current substance abuse of drugs or alcohol;
10. Rh sensitization (positive antibody titre), an incompetent cervix, or previous uncontrollable postpartum hemorrhage;
11. The midwife shall not provide care to any woman who has had a previous cesarean section whose emergency plan does not include the ability to transport consistent with Rule 10 to a facility able to perform a cesarean section, and
12. infants who were premature, stillborn, or neonatal deaths associated with maternal health or genetic anomaly, unless there is a normal amniocentesis ruling out said anomaly, without an intervening normal pregnancy.
B. The registered direct-entry midwife shall not:
1. perform any operative or surgical procedures;
2. utilize any instruments or mechanical means of delivery, other than hemostats to clamp the cord; perform versions; or e. administer any medications except for eye prophylaxis of the newborn.
RULE 5 – MINIMUM PRACTICE REQUIREMENTS REGARDING ANTEPARTUM CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding antepartum care.
The registered direct-entry midwife shall schedule patient visits at least once a month beginning in the first trimester through 28 weeks; every 2 weeks from 28 weeks through 35 weeks; and weekly from 36 weeks to delivery.
B. At the time of the initial visit for care, the registered direct-entry midwife shall, at a minimum:
1. obtain a medical, obstetrical, family and nutritional history;
2. determine the EDC and perform a baseline physical examination;
3. arrange to or obtain laboratory testing to include: blood group and Rh type, if unknown; Coombs test for all Rh negative mothers; CBC with differential; rubella titre; serology for syphilis; hepatitis B screen, urine for protein and glucose, culture if indicated; Gonococcal Culture screen and Chlamydia culture if needed based on social history, offer HIV testing;
4. discuss home birth, options to home birth, risk assessment, and referral procedures;
5. provide the client with the “Mandatory Disclosure” form and obtain informed consent on forms approved or provided by the Director; and
6. complete the emergency plan.
RULE 6 - MINIMUM PRACTICE REQUIREMENTS REGARDING INTRAPARTUM CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding intrapartum care.
A. The direct-entry midwife is responsible for making arrangements to be with the patient by the time active labor has been established as determined by contractions occurring every 5 minutes and lasting for 60 seconds or cervical dilation of 5 cm or more, once labor has been so established, the registered direct-entry midwife shall remain with the mother.
B. When membranes rupture, the registered direct-entry midwife shall perform a sterile vaginal exam for prolapsed cord if the presenting part is not engaged and record fetal heart tones. In the case of premature rupture of the membranes , no further vaginal checks shall be made.
C. Aseptic technique and universal precautions will be used while rendering care.
D. The registered direct-entry midwife is responsible for monitoring the status of the mother and baby during labor and delivery including:
1.maternal vital signs and physical well being such as: (a) maternal temperature, pulse and respirations shall be measured at least every 4 hours, (b) maternal blood pressure shall be measured at least every four hours in early labor and hourly during the active phase of labor, and(c) check for bladder distention, signs of maternal fatigue, and hydration status;
2. fetal vital signs and well being such as: (a) fetal heart tones in response to contractions as well as when the uterus is at rest. These shall be assessed, at a minimum, every hour during early labor, every half hour during active labor and every 5-10 minutes during the second stage of labor, and (b) normality of fetal lie, presentation, attitude and position;
3. progress of labor including cervical effacement and dilation, station, presenting part and position;
4. coaching the birthing family;
5. obtaining a cord blood specimen, if feasible, which shall accompany the infant in case of transport;
6. checking the placenta and blood vessels and estimating blood loss;
7. checking the perineum and vaginal vault for tears; and
8. checking the cervix for tears and, if present, making appropriate referral.
E. The registered direct-entry midwife shall arrange for immediate consultation and transport according to the emergency plan if the following conditions exist:
1. bleeding other than capillary bleeding ("show") prior to delivery;
2. signs of placental abruption including continuous lower abdominal pain and tenderness;
3. prolapse of the cord;
4. any meconium staining without reassuring fetal heart tones, moderate or greater meconium staining regardless of status of fetal heart tones;
5. significant change in maternal vital signs such as; (a) temperature greater than 101oF, (b) pulse over 100 with decrease in blood pressure, or (c) increase in blood pressure greater than 140/90 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic;
6. failure to progress in labor such as:
(a) lack of steady progress in dilation and descent after 24 hours in the primipara or 18 hours in the multipara,
(b) second stage of labor without steady progress of descent through the mid-pelvis and/or pelvic outlet longer than two hours in the primipara or one hour in the multipara, or
(c) third stage of labor longer than one hour;
7. fetal heart rate below 120 or above 160 between contractions;
8. protein or glucose in the urine;
10. atonic uterus;
11. retained placental fragments;
12. vaginal or cervical lacerations requiring repair; or
13. client requests transport.
RULE 7 - MINIMUM PRACTICE REQUIREMENTS REGARDING POSTPARTUM CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding postpartum care.
A. The direct-entry midwife shall remain with the mother and infant for a minimum of two hours after the birth or until the mother and infant are stable, whichever is longer.
B. The direct-entry midwife shall make a follow up visit within 72 hours to assess the progress of the mother and infant. Such visit shall include an assessment of, at a minimum, fundus, lochia, perineum, breasts, nutrition, hydration, elimination, emotional adjustment and bonding.
C. The direct-entry midwife shall instruct the mother and family in self care until the follow up visit is done.
D. The direct-entry midwife shall refer all Rh negative mothers for Rhogam within 72 hours of the birth.
E. The direct-entry midwife shall arrange for consultation and/or transport when:
1. There is maternal blood loss of more than 500 cc;
2. The mother has a fever of greater than 101oF on any of the second through 10th days postpartum;
3. The mother cannot void within 6 hours after birth;
4. The lochia is excessive, foul smelling, or otherwise abnormal; or
5. There are signs of clinically significant depression (not the "baby blues").
RULE 8 - MINIMUM PRACTICE REQUIREMENTS REGARDING NEWBORN CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding newborn care.
A. The direct-entry midwife will perform the following care for the newborn:
1. Apgar scores at one minute and five minutes after birth and at 10 minutes if the 5 minute score is below 7;
2. a physical assessment including assessing presence of femoral pulses.
3. eye prophylaxis within 1 hour after birth as provided by 25-4-303, C.R.S.;
4. weigh the infant, measure height and head circumference, and check for normal reflexes;
5. perform a gestational age assessment; and
6. arrange to or obtain laboratory testing on the infant of an Rh negative mother to include blood type and Coombs test.
B. The direct-entry midwife shall arrange for or obtain the required newborn screenings required by § 25-4-1004, C.R.S.
C. The direct-entry midwife shall recommend that the mother arrange for the administration of Vitamin K by a licensed health care provider birth within 72 hours.
D. The direct-entry midwife shall arrange for immediate transport for the infant who exhibits the following signs:
- Apgar of 7 or less at ten minutes;
- respiratory distress exhibited by respirations greater than 60 per minute, grunting, retractions, nasal flaring at one hour of age that is not showing consistent improvement;
- inability to maintain body temperature;
- medically significant anomaly;
- fontanel full and bulging;
- suspected birth injuries;
- cardiac irregularities;
- pale, cyanotic, gray newborn; or
- lethargy or poor muscle tone.
E. The direct-entry midwife will arrange for consultation and transport for an infant who exhibits the following:
- signs of hypoglycemia including jitteriness;
passes no urine in 12 hours or meconium in 24 hours;
inability to suck;
pulse greater than 180 or less than 80 at rest;
jaundice within 24 hours of birth; or
positive Coombs test.
F. Follow-up visits shall include assessment of the infant to include umbilical cord, temperature, pulse, respirations, weight, skin color and hydration status, feeding and elimination, sleep/wake patterns, and bonding.
RULE 9 - MINIMUM PRACTICE REQUIREMENTS REGARDING RECORD KEEPING ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding record keeping.
The direct-entry midwife shall keep appropriate records on all patients. All records shall, at a minimum:
1. be accurate, current, and comprehensive, giving information concerning the condition and care of the client and associated observations;
2. provide a record of any problems that arise and the actions taken in response to them;
3. provide evidence of care required, interventions by professional practitioners and patient responses;
4. include a record of any factors (physical, psychological or social) that appear to affect the patient;
5. record the chronology of events and the reasons behind decisions made;
6. provide baseline data against which improvement or deterioration may be judged;
7. have a signature and date for each entry; and
8. all records shall be made available to the receiving health care provider in the event of transfer of care or the transport of mother or newborn.
B. The patient records shall include, at a minimum:
1. risk assessment;
2. mandatory disclosure form;
3. informed consent form and emergency plan;
4. assessments, interventions and recommendations for each prenatal visit;
5. progress of labor and maternal assessments during labor;
6. fetal assessments during labor;
7. Apgar scores and newborn examination;
8. administration of eye prophylaxis;
9. refusal of care by the mother;
10. filing the birth certificate
11. follow-up postpartum visits;
12. statement of verification that one copy of the record was provided to the mother or the health care provider of her choice; and
13. baseline blood pressure determined prior to the end of the second trimester or upon the initial visit if such visit occurs subsequent to the second trimester.
RULE 10 -EMERGENCY PLAN ~ The purpose of this rule is to establish the following emergency plan parameters pursuant to § 12-37-105(6), C.R.S.:
The time required for transportation to the nearest facility capable of providing appropriate treatment shall not exceed 30 minutes unless the emergency plan prepared by the direct-entry midwife and the client, on the form prescribed by the Director, includes an estimate of time for transportation for appropriate treatment for the conditions listed above in Rules 5G, 6E, 7E, 8D, and 8E, and such plan is consented to by both the patient and the direct-entry midwife. A copy of such plan shall be give to
British Columbia (Canada) College of Midwives
Standards of Practice Policy
This document provides a detailed interpretation of the Standards of Practice for the purpose of defining the practice of midwifery in British Columbia. This interpretation provides direction to members regarding the parameters of the Standards of Practice.
The College of Midwives of British Columbia requires its members to review all College policies and updates, to act responsibly and with integrity and to maintain appropriate levels of competence.
The midwife shall be the primary care provider within the midwives' scope of practice.
The midwife: is an autonomous health care professional governed by the College of Midwives of British Columbia; practises within her scope without supervision, and takes full responsibility for the care provided; practises within her community as a primary care provider for clients during pregnancy, birth and the postpartum period
The midwife shall collaborate with other health professionals and, when the client's conditions or needs exceed the midwives' scope of practice, shall consult with and refer to a physician.
The midwife: shares records and information with the woman's physician and other health care professionals with informed consent of the client; initiates physician consultation and transfer of primary care where appropriate and in accordance with the College of Midwives' policies; makes use of professional, technical and administrative resources that serve the interests of the client, makes use of community resources and groups that serve the interests of the client
If the pregnancy becomes high-risk and primary care is transferred to a physician, the midwife may continue to counsel, support and advise the client at her request.
The midwife: n a supportive care role, is not responsible for the provision of clinical care, but shall work cooperatively within her scope of practice with the primary care team; documents clearly in the client's records when a transfer of care has taken place and then is no longer responsible for documentation; provides, at the mother's request, supportive and/or primary care to either the mother and/or newborn after the birth
The midwife shall work in partnership with the client recognising individual and shared responsibilities.
The midwife: develops a plan for midwifery care together with the client; facilitates open and interactive communication with the client; shares all relevant information with the client; supports the client's role as the primary decision maker in her care, involves the client's family according to her wishes; respects the client's value system; practises in a manner which respects cultural differences.
The midwife shall uphold the client's right to informed choice and to provide consent throughout the childbearing experience.
The midwife: shares relevant information with clients in a non-authoritarian, cooperative manner; encourages clients to actively participate in care and to make choices about the services they receive and the manner in which care is provided; discusses the scope, standards of practice and limitations of midwifery care with the client; acts as an advocate for the client and her newborn; respects the client's right to decline treatments or procedures; advises the client of her professional judgement with respect to safe care.
The midwife shall provide continuity of care to the client according to the Model of Practice throughout the childbearing experience.
The midwife: provides comprehensive midwifery care during all trimesters of pregnancy, and throughout labour, birth, and postpartum; provides, within her practice, 24 hour on-call availability to her clients, keeping them informed of the practice's call schedule; identifies the principle midwife who is responsible for coordinating the client's midwifery care within the practice group; establishes and maintains a consistent and coordinated approach to clinical practise, when sharing primary care with another midwife; ensures that no more than four midwives within a practice shall provide care to an individual client.
The midwife shall respect the client's right to make informed choices about the setting for birth and shall provide care in all appropriate settings. In each case, the midwife shall assess safety considerations and the risks to the client and inform her of same.
The midwife: provides the client with the required information, including that related to safety, to make an informed choice about appropriate settings in which to give birth; provides care in a variety of settings including hospitals, homes and birth centres; promotes a safe environment for the birth experience; notifies the appropriate agencies when any safety concerns arise
The midwife shall make every effort to ensure that a second midwife or qualified birth attendant who is currently certified in neonatal resuscitation and cardiopulmonary resuscitation assists at every birth.
The midwife: is responsible for primary care throughout the full course of care; ensures that a second midwife, or a qualified second attendant approved by the College, is available and in attendance at all births regardless of setting; shall inform the client of the arrangements for a second midwife or qualified birth attendant and ensures the client's consent to those arrangements.
The midwife shall ensure that no action or omission places the client at unnecessary risk.
The midwife: uses current knowledge and established policies and protocols within her practice to plan and implement midwifery care provides on-going assessment and modifies planned care as required; responds promptly and appropriately to emergency situations; maintains access to appropriate equipment and supplies; does not abandon care of a client during the course of labour; refers to another appropriate practitioner when her ability to practise safely is mentally or physically impaired.
The midwife shall maintain complete and accurate health care records.
The midwife: uses records that facilitate accurate communication of information to and from consultants and institutions; reviews and updates records at each professional contact with the client; ensures prompt entry of screening and diagnostic test results, treatments and consultations into health care records; ensures that records are legible, signed and dated; documents decisions and professional actions; documents informed choice discussions; documents errors, incidents and complaints, reports to the appropriate authorities and initiates restorative actions; makes every effort to document events contemporaneously; refers to part 7 of the college Bylaws for additional requirements regarding client records
The midwife shall ensure confidentiality of information except with the client's consent, or as required to be disclosed by law, or in extraordinary circumstances where the failure to disclose will result in immediate and grave harm to the client.
The midwife: establishes procedures, including systems for storing and disposing of records, which protect the confidentiality of information within the midwifery practice.
The midwife shall be accountable to the client, the midwifery profession and the public for safe, competent and ethical care.
The midwife: informs the client as to complaint and review procedures established under the Act and the Bylaws; participates in mortality and morbidity reporting and review processes as required by institutional policies and the College of Midwives of British Columbia; participates in quality management programs as established by the College of Midwives of British Columbia.
The midwife shall participate in the continuing education and evaluation of self, colleagues, and the community.
The midwife: involves the client in evaluating midwifery practice and integrates the results of the evaluation into the practice; participates in peer review; adjusts clinical practise after review of current literature and appropriate education or training; shares knowledge with colleagues and students and assists in developing mechanisms to promote this sharing; maintains current knowledge of academic and professional research based on developments that are directly related to midwifery practise.
The midwife shall critically assess reseach findings for use in practice and shall support research activities.
The midwife: complies with bylaw 84 when engaged in any research activities; identifies areas for research, shares research findings and incorporates these appropriately into practice; ensures that the research in which midwives participate meets acceptable standards of research methodology and design, and is consistent with the College's Code of Ethics.
The midwife shall only order, prescribe or administer those drugs and substances listed in Schedule 1 and these must be ordered, prescribed or administered in accordance with the direction provided in Schedule 1.
The midwife shall only order, perform, collect samples for or interpret those screening and diagnostic tests for a woman or a newborn listed in Schedule 2 and these shall be ordered, performed or interpreted in accordance with Schedule 2.
Standards of Practice Policy 14 April 1997
In this and all CMBC documents, gender references use the generic feminine which also includes the masculine
Florida State Statutes for THE PRACTICE OF MIDWIFERY 467.015 Responsibilities of the midwife.--
(1) A midwife shall accept and provide care for only those mothers who are expected to have a normal pregnancy, labor, and delivery and shall ensure that the following conditions are met:
(a) The patient has signed an informed consent form approved by the department pursuant to s. 467.016.
(b) If the patient is delivering at home, the home is safe and hygienic and meets standards set forth by the department.
(2) A midwife may provide collaborative prenatal and postpartal care to pregnant women not at low risk in their pregnancy, labor, and delivery, within a written protocol of a physician currently licensed under chapter 458 or chapter 459, which physician shall maintain supervision for directing the specific course of medical treatment. The department shall by rule develop guidelines for the identification of high-risk pregnancies.
(3) A midwife licensed under this chapter may administer prophylactic ophthalmic medication, oxygen, postpartum oxytocin, vitamin K, rho immune globulin (human), and local anesthetic pursuant to a prescription issued by a practitioner licensed under chapter 458 or chapter 459, and may administer such other medicinal drugs as prescribed by such practitioner.
Any such prescription for medicinal drugs shall be in a form that complies with chapter 499 and shall be dispensed in a pharmacy permitted under chapter 465 by a pharmacist licensed under chapter 465.
(4) The care of mothers and infants throughout the prenatal, intrapartal, and postpartal periods shall be in conformity with rules adopted by the department pursuant to this chapter and the public health laws of this state.
(5) The midwife shall:
(a) Prepare a written plan of action with the family to ensure continuity of medical care throughout labor and delivery and to provide for immediate medical care if an emergency arises. The family should have specific plans for medical care throughout the prenatal, intrapartal, and postpartal periods.
(b) Instruct the patient and family regarding the preparation of the environment and ensure availability of equipment and supplies needed for delivery and infant care, if a home birth is planned.
(c) Instruct the patient in the hygiene of pregnancy and nutrition as it relates to prenatal care.
(d) Maintain equipment and supplies in conformity with the rules adopted pursuant to this chapter.
(6) The midwife shall determine the progress of labor and, when birth is imminent, shall be immediately available until delivery is accomplished. During labor and delivery, the midwife shall comply with rules adopted by the department pursuant to this chapter, which shall include rules that govern:
(a) Maintaining a safe and hygienic environment;
(b) Monitoring the progress of labor and the status of the fetus;
(c) Recognizing early signs of distress or complications; and
(d) Enacting the written emergency plan when indicated.
(7)(a) The midwife shall remain with the postpartal mother until the conditions of the mother and the neonate are stabilized.
(b) The midwife shall instill into each eye of the newborn infant a prophylactic in accordance with s. 383.04.
History.--ss. 1, 3, ch. 82-99; s. 89, ch. 83-218; s. 8, ch. 84-268; ss. 4, 5, ch. 91-429; ss. 11, 19, ch. 92-179; s. 79, ch. 2001-62.
467.016 Informed consent.--The department shall develop a uniform client informed-consent form to be used by the midwife to inform the client of the qualifications of a licensed midwife and the nature and risk of the procedures to be used by a midwife and to obtain the client's consent for the provision of midwifery services.
History.--ss. 1, 3, ch. 82-99; s. 8, ch. 84-268; ss. 4, 5, ch. 91-429; s. 19, ch. 92-179; s. 79, ch. 2001-62.
467.017 Emergency care plan; immunity.--
(1) Every licensed midwife shall develop a written plan for the appropriate delivery of emergency care. A copy of the plan shall accompany any application for license issuance or renewal. The plan shall address the following:
(a) Consultation with other health care providers.
(b) Emergency transfer.
(c) Access to neonatal intensive care units and obstetrical units or other patient care areas.
(2) Any physician licensed under chapter 458 or chapter 459, or any certified nurse midwife, or any hospital licensed under chapter 395, or any osteopathic hospital, providing medical care or treatment to a woman or infant due to an emergency arising during delivery or birth as a consequence of the care received by a midwife licensed under chapter 467 shall not be held liable for any civil damages as a result of such medical care or treatment unless such damages result from providing, or failing to provide, medical care or treatment under circumstances demonstrating a reckless disregard for the consequences so as to affect the life or health of another. Another example of our Wish List!
History.--ss. 1, 3, ch. 82-99; s. 8, ch. 84-268; ss. 4, 5, ch. 91-429; ss. 12, 19, ch. 92-179; s. 79, ch. 2001-62.
467.019 Records and reports.--
(1) The midwife shall mail or submit a completed birth certificate for each birth, in accordance with the requirements of chapter 382, to the local registrar of vital statistics within 5 days following birth.
(2) The midwife shall instruct the parents regarding the requirement for an infant screening blood test for metabolic diseases as required by s. 383.14 and rules promulgated pursuant thereto, and shall notify the county health department in the county where the birth occurs, within 48 hours following delivery, unless other arrangements for the test have been made by the parents.
(3) Each maternal death, newborn death, and stillbirth shall be reported immediately to the medical examiner.
(4) The department shall adopt rules requiring that a midwife keep a record of each patient served. Such record must document, but need not be limited to, each consultation, referral, transport, transfer of care, and emergency care rendered by the midwife and must include all subsequent updates and copy of the birth certificate. These records shall be kept on file for a minimum of 5 years following the date of the last entry in the records.
(5) Within 90 days after the death of a midwife, the estate or agent shall place all patient records of the deceased midwife in the care of another midwife licensed in this state who shall ensure that each patient of the deceased midwife is notified in writing. A midwife who terminates or relocates to private practice outside the local telephone directory service area of the midwife's current practice shall provide notice to all patients as prescribed by department rule.
(6) The department shall adopt rules to provide for maintaining patient records of a deceased midwife or a midwife who terminates or relocates a private practice.
(7) A licensed midwife who is or has been employed by a practice or facility, such as a birth center, which maintains patient records as records belonging to the facility may review patient records on the premises of the practice or facility as necessary for statistical purposes.
History.--ss. 1, 3, ch. 82-99; s. 8, ch. 84-268; ss. 4, 5, ch. 91-429; s. 19, ch. 92-179; s. 144, ch. 97-101; s. 8, ch. 98-130.
MANA Standards & Qualification for the Art and Practice of Midwifery
Revised & Approved October 1997
The midwife recognizes that childbearing is a woman's experience and encourages the active involvement of family members in her care.
1. Skills: Necessary skills of a practicing midwife include the ability to:
Provide continuity of care to the woman and her family during the maternity cycle, continuing interconceptually throughout the childbearing years; Provide continuity of care to the woman and her family during the maternity cycle, Assess and provide care for normal antepartal, intrapartal, postpartal and neonatal periods; Identify and assess deviations from normal; Maintain proficiency in life-saving measures by regular review and practice; and Deal with emergency situations appropriately.
In addition, a midwife may choose to provide well-woman care.
It is affirmed that judgment and intuition play a role in competent assessment and response.
2. Appropriate equipment: Midwives are equipped to assess maternal, fetal, and newborn well-being; to maintain a clean and/or aseptic technique; to treat maternal hemorrhage; and to resuscitate mother or infant.
3. Records: Midwives keep accurate records of care provided for each woman such as are acceptable in current midwifery practice. Records shall be held confidential and provided to the woman on request.
4. Data Collection: Midwives collect data for their practice on a regular basis. It is highly recommended that this be done prospectively, following the guidelines and using the data form developed by the MANA Statistics and Research Committee.
5. Compliance: Midwives will inform and assist parents regarding the Public Health requirements of the jurisdiction in which the midwifery practice will occur.
6. Medical Consultation and Referral: All midwives recognize that there are certain conditions when medical consultations are advisable. The midwife shall make a reasonable attempt to assure that her client has access to consultation and/or referral to a medical care system when indicated.
7. Screening: Midwives respect the woman’s right to self-determination within boundaries of responsible care. Midwives continually assess each woman regarding her health and well-being relevant to the appropriateness of midwifery services. Women will be informed of this assessment. It is the right and responsibility of the midwife to refuse or discontinue services in certain circumstances. Appropriate referrals are made in the interest of the mother or baby’s well-being or when the required or requested care is outside the midwife’s legal or personal scope of practice as described in her protocols.
8. Informed Choice: Each midwife will present accurate information about herself and her services, including but not limited to:
her education in midwifery
her experience level in midwifery
her protocols and standards
her financial charges for services
the services she does and does not provide
the responsibilities of the pregnant woman and her family
9. Continuing Education: Midwives will update their knowledge and skills on a regular basis.
10. Peer Review: Midwifery practice includes an on-going process of case review with peers
11. Protocols: Each midwife will develop protocols for her services that are in agreement with the basis philosophy of MANA and in keeping with her level of understanding. Each midwife is encouraged to put her protocols in writing.
The following sources were utilized for reference: American College of Nurse-Midwives documents; ICM membership and joint study on maternity; FIGO, WHO, etc. revised 1972; New Mexico regulations for the practice of lay midwifery, revised 1982; North West Coalition of Midwives Standards for Safety and Competency in Midwifery; Varney, Helen, Nurse-Midwifery, Blackwell Scientific Pub., Boston, MA 1980.
New Hampshire Pink Highlighting = text used in sections three (not part of MBC regulation)
(a) Each New Hampshire Certified Midwife shall document client-related data on a form provided by the Midwifery Council and shall submit this biennially on a state fiscal year basis.
Client data shall not be name identified.
(b) This information shall include
(1) Name of the New Hampshire Certified Midwife;
(2) Midwifery certification number;
(3) Fiscal year reporting on;
(4) The total number of clients cared for;
(5) The number of live births attended;
(6) The number of stillbirths attended;
(7) The number of spontaneous abortions;
(8) The number of transfers or transports and the reasons for transfer or transport;
(9) Gestational ages of infants delivered;
(10) Birth weights of infants delivered;
(11) A description of any complications resulting in mortality or significant morbidity for mother and/or infant; and
(12) The number of cases not accepted for care.
NOTE ~ this text is similar to a requirement in the Alaska statutes but currently not part of MBC regulation. However, the MBC has plans to seekout new legislation that would require something similar in the future
Notification of Transfers
(a) New Hampshire Certified Midwives shall notify the Midwifery Council in writing, on a form provided by the Midwifery Council of all transfers that result in significant morbidity or mortality of the woman or infant within 72 hours of the occurrence. If initial notice is a phone report, this shall be followed-up in writing within 10 days.
(b) This information shall include
(1) Name of New Hampshire Certified Midwife;
(2) Midwifery certification number;
(3) Name of client;
(4) Date and time of call for transport;
(5) Reason for transfer;
(6) Time of transfer; 11
(7) Means of transfer;
(8) Destination of transfer;
(9) Date and time of destination arrival;
(10) Maternal and/or newborn outcome.
(c) Significant morbidity or mortality may be subjected to peer review.
NOTE ~ this text is similar to a requirement in the Alaska statutes but currently not part of MBC regulation. However, the MBC has plans to seekout new legislation that would require something similar in the future
PROCEDURES IN THE PRACTICE OF MIDWIFERY
Role of the New Hampshire Certified Midwife
(a) The task of a New Hampshire Certified Midwife shall be to provide prenatal care, birth attendance, and postpartum care for normal and uncomplicated pregnancy and delivery.
(b) The New Hampshire Certified Midwife shall be able to
(1) Provide antinatal education and preparation for parenthood;
(2) Provide the necessary supervision, care and advice to women during pregnancy, labor and the postpartum period;
(3) Conduct deliveries on her own responsibility;
(4) Assess the newborn.
(c) A New Hampshire Certified Midwife's care shall include
(1) Preventative measures;
(2) Prenatal education and preparation for childbirth and parenting;
(3) The detection of abnormal conditions in mother and newborn;
(4) The procurement of medical assistance;
(5) The execution of emergency measures in the absence of medical help;
(6) Counseling and education in the postpartum period.
(g) All clients with genital herpes shall be advised by the New Hampshire Certified Midwife of the current ACOG herpes protocol.
(1) Signed informed consent which shall include the following information
a. The name and address of the client and her partner;
b. The risks associated with home birth and/or birth in a freestanding birth center;
c. The benefits of home birth and/or birth in a freestanding birth center;
d. A statement that says that all the client's questions regarding theirchoice of out of hospital birth have been satisfactorily answered;
(4) Records of consultations with physicians or other health care providers;
(5) Records of waivers signed, including those for vaginal birth after cesarean section;
(a) A New Hampshire Certified Midwife shall not assume primary responsibility for prenatal care and/or birth attendance for women with the following medical conditions
(1) Insulin dependent diabetes mellitus;
(2) Previous Cesarean section (see section He-P 3110.01, Vaginal birth after cesarean birth);
(3) Maintenance on antiepileptic medications with convulsive activity within the last year;
(4) Blood dyscrasias;
(5) Current hepatitis B or hepatitis C positivity, HIV positivity, or AIDS;
(6) Current alcoholism;
(7) Current drug addiction, including use of hallucinogens;
(8) Chronic pulmonary disease that interferes with oxygen saturation;
(9) Rh sensitivity with positive antibody titre;
(10) Chronic hypertension;
(11) History of significant heart disease;
(12) Maintenance on psychotropic medication which, as a result of a consultation with the client's physician, has been determined to have a sedating effect on the newborn; and
(13) Documented mental disease which might interfere with the responsibility necessary for home birth.
(b) If the following client conditions are present, or become apparent during prenatal care, a New Hampshire Certified Midwife shall consult with a physician with obstetrical knowledge or a Certified Nurse Midwife to evaluate whether the client is an appropriate candidate for home birth
(1) Primipara younger than age 16 or older than age 40;
(2) Maintenance on antiepileptic medications without a history of convulsions in the previous year;
(3) High blood pressure defined as 140/90 or elevation of 30 systolic and/or 15 diastolic on at least 2 occasions, 6 hours apart;
(4) History of genetic problems or previous intrauterine death greater than 20 weeks or stillbirth;
(5) Possibility of multiple fetuses, malpresentation or fetus small or large for gestational age;
(6) History of significant hemorrhaging during delivery;
(7) Abnormal Pap smear, HGSIL or greater;
(8) Indications that the fetus has died in utero;
(9) Suspected postmaturity greater than 42 weeks gestation;
(10) Heart murmur or arrhythmia other than functional;
(11) Prior obstetrical problems, including, but not limited to
b. Uterine abnormalities;
c. Placental abruption; and
d. Incompetent cervix;
(12) Development of other conditions potentially detrimental to the pregnancy, such as recurrent urinary tract or kidney infection or active gonorrhea;
(13) Polyhydramnios or oligohydramnios;
(14) Suspected intrauterine growth retardation;
(15) Condyloma acuminata, significant or intravaginal;
(16) Suspected premature labor at less than 37 weeks;
(17) Positive cervical herpes cultures;
(18) Prepregnancy weight in excess of 250 pounds;
(19) Gestational diabetes or abnormal glucose challenge test; or
(20) Grand Multiparity.
(c) If the following conditions occur or become apparent during prenatal care, a New Hampshire Certified Midwife shall not continue primary responsibility for prenatal care and/or attendance at the birth, and shall transfer the client to the care of a physician or Certified Nurse Midwife
(1) Anemia defined as a hemoglobin of less than 10g, unresolved at term;
(2) Multiple fetuses;
(3) Malpresentation, including breech position, that is not resolved before onset of labor;
(4) Confirmation that fetus is small for gestational age;
(5) Placenta previa or abruptio placenta;
(6) Onset of labor prior to 37 weeks;
(7) Active herpes at term; and/or
(8) Insulin dependent diabetes.
Withdrawal from Service
(a) A New Hampshire Certified Midwife shall withdraw from responsibility for a client during the prenatal period if any factor exists that the New Hampshire Certified Midwife believes might create an unwarranted risk to mother or child or might interfere with the New Hampshire Certified Midwife's ability to care responsibly for the client and/or newborn.
(b) The New Hampshire Certified Midwife's decision shall take into account, but not be limited to, the following factors
(1) The client's refusal to consult with a physician when the New Hampshire Certified Midwife believes consultation is warranted;
(2) The client's failure or refusal to follow recommendations; and
(3) Personality incompatibilities.
(c) In the event that the New Hampshire Certified Midwife withdraws from responsibility, she/he shall immediately notify the client and assist the client in finding alternate care.
(d) After the onset of labor, the New Hampshire Certified Midwife shall withdraw only if she/he believes she/he is unable to care responsibly for the client and/or newborn and the client refuses to transfer. The New Hampshire Certified Midwife shall document the relevant events, and make attempts to ensure that the client is not left unattended, such as by contacting the rescue squad, a physician, or other appropriate emergency personnel.
b) If the following conditions should occur intrapartum, the New Hampshire Certified Midwife shall consult immediately with a physician or Certified Nurse Midwife as to whether the client or newborn should be transferred to a hospital setting
(1) Unforeseen malpresentation;
(2) Unforeseen multiple fetuses;
(3) Fetal distress as indicated by heart rate monitoring and/or gross meconium staining;
(4) Failure to progress in spite of active labor, such that
(a) In the first stage of labor, there is lack of steady progress in dilation and descent after 24 hours in a primagravida or 18 hours in a multigravida;
(b) In the second stage, there are more than 2 hours without progress in descent or more than 3 hours with slow descent; or
(c) In the third stage there is more than one hour without delivery of the placenta.
(5) More than 24 hours elapsed following the rupture of membranes without onset of labor;
(6) Maternal distress;
(7) Excessive maternal bleeding greater than 500 cc either intrapartum or postpartum not controlled or when stability of client is in question;
(8) Significant cervical, vaginal, or rectal lacerations;
(9) Low apgars of less than 7 in 5 minutes (editor's note: as a stand alone criteria, 5 minute Apgar is a poor predictor of the need for neonatal hospitalization –for example, if Apgar is normal at 10 minute, transporting is unnecessary while Apgar may be fine at 5 mins. and the baby develop problems in the early hours after birth (mec aspiration, infection, etc).
(10) Jaundice in newborn before 24 hours;
(11) Obvious congenital anomalies
(12) Infant who is less than 5 1/2 pounds or over 10 1/2 pounds and any large for gestational age (LGA) baby with or without any maternal history of diabetes; (Why, what is physician going to do?, what medical “treatment” does a healthy LGA baby need?)
(13) Infant with persistent central cyanosis or pallor;
(14) Infant with persistent grunting and retractions without signs of improvement in one hour;
(15) Infant with persistent pulse rate greater than 160;
(16) Infant with respirations greater than 80 and/or inability to stabilize infant's temperature; and/or
(17) Other conditions which the New Hampshire Certified Midwife questions a being outside normal limits.
(b) The New Hampshire Certified Midwife shall recommend that the parents contact the pediatrician or family primary care provider who will be assuming care for the infant to arrange for a neonatal examination.
(d) The New Hampshire Certified Midwife shall remain with the client and newborn for a minimum of 2 hours after birth or until the client and the newborn are stable. In an emergency situation, wherein the New Hampshire Certified Midwife is called away, she/he shall designate an associate to remain.
(e) The New Hampshire Certified Midwife shall maintain close contact with the client during the first 72 hours postpartum.
(f) The New Hampshire Certified Midwife shall make a home visit if feasible or, if not, arrange an office encounter to be held during the first 72 hours. If a home visit is not made, the New Hampshire Certified Midwife shall contact the client by telephone.
g) The New Hampshire Certified Midwife shall ascertain that the infant
(1) Is alert;
(2) Has good color;
(3) Is breathing normally;
(4) Is establishing a healthy pattern of waking, feeding, and sleeping;
(h) The New Hampshire Certified Midwife shall ascertain that the mother
(1) Is not experiencing excessive bleeding;
(2) Has a firm fundus;
(3) Does not have a fever or other signs of infection;
(4) Is voiding properly; and
(5) Is establishing successful breastfeeding.
(i) In the event that any complications arise, the New Hampshire Certified Midwife shall consult with a physician or other health care provider or shall ensure that the client contacts her own physician or primary care provider.
(a) The Midwifery Council shall conduct a review on any birth resulting in mortality. This review shall take place upon receipt of the records and/or report of the mortality/morbidity.
(b) Mortality/Morbidity review shall include the following
(1) The Midwifery Council shall meet within 40 days of the date the home birth mortality or significant morbidity is reported, and shall review the following information
a. The New Hampshire Certified Midwife's account of the facts surrounding the incident; and
b. The autopsy report and/or any other pertinent medical records.
(2) The midwifery Council shall, within 90 days, prepare a written consensus report summarizing the review conducted.
Vaginal Birth After Cesarean Birth
(a) A waiver of He-P 3108.03 (a) (2) shall be granted if the requirements of He-P 3110.01 (b)-(d) have been met.
(b) To obtain a waiver of He-P 3108.03 (a) (2) the New Hampshire Certified Midwife shall
(1) Obtain an informed consent as in He-P 3108.02 (2) (h) (5).
(2) Obtain records from client's previous birth(s) including, but not limited to documentation of reason for Cesarean Section, the type of uterine incision performed, and any resultant complications.
(3) Documentation of explanation of risks and benefits associated with vaginal birth after cesarean section in the home or freestanding birth center setting. Such documentation will be included in the client's chart and will include
a. The name and address of the client;
b. The name of the New Hampshire Certified Midwife;
c. Date the documentation was presented;
d. The authorization of the New Hampshire Certified Midwife to attend the client;
e. Signature(s) of the client and her partner, if applicable;
f. The signature of the New Hampshire Certified Midwife;
g. The signature of a witness; and
h. The date and time of signing.
MEDICAL BOARD OF CALIFORNIA
DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA
In the Matter of the Accusation Against: Case No. 1M-98-83794
ALISON OSBORN, L.M. OAH No. N-1999040052
P.O. Box 453; Grass Valley, CA 95945
Licensed Midwife No. LM- 16,
This matter came on regularly for hearing before Jaime Rene' Roman, Administrative Law Judge, Medical Quality Hearing Panel, Office of Administrative Hearings, in Sacramento, California, on August 16 - 20, 1999.Pertinent Excerpts (entire text elsewhere on College of Midwives.org web site
8. On February 6, 1998, having obtained some of M.G.'s medical records, which included clinical confirmation of the breech presentation, Respondent agreed to undertake M.G.'s delivery for a vaginal breech home birth. M.G. was provided an Informed Consent and Waiver of Medical Referral for Vaginal Breech Delivery which stated, in pertinent part:' informed consent form.' my experience level and the signing of an informed consent form
A. 'The medical 'standard of care' for breech babies is to do a cesarean section in most cases. First time mothers are considered to have an ,unproven pelvis' which means that it is not certain that a baby can fit through it. Even women who have had a baby are encouraged or made to have a cesarean due to the increased risks to the baby during delivery.
B. "My practice guidelines include the right of the client to choose to continue care with me after a complete discussion of the risks involved,
C. "Risks may include increased fetal morbidity and mortality (injury and death).."6
M.G. executed the waiver which further provided, "After careful evaluation of the above information I am exercising my right to choose to birth my breech baby at home and waive referral to another provider. This decision is made of my own free will and I absolve and hold harmless my attending midwife, Alison Osborn." By separate document, Respondent provided M.G. with a Disclosure Statement which set forth, in pertinent part,
"It is also a requirement of my license to have a 'specific OB informed of your pregnancy who is prepared to take your case if transport becomes necessary.' - Despite all reasonable efforts to have a relationship thus described, no obstetrician cares to have that kind of relationship with a homebirth midwife;however, many are happy to continue as we have been working for the past I I years--they will receive cases if/when a transport becomes necessary or when a referral needs to happen."
17. Respondent claims, in contrast, that she, subject to a midwifery model, has engaged in neither unprofessional conduct nor violation of the Act. Within the ambit of that model and her professional licensure, Respondent acknowledges that she is subject to the following standards of practice:
A. Providing continuity of care for women and their families during the perinatal cycle.
B. Fostering the delivery of safe and satisfying care.
C. Recognizing that childbearing is a family experience.
D. Upholding the right of the woman/family to informed consent and self determination, within the boundaries of safe care.
E. Focusing on patient health and maturation during the reproductive years.
F. Working as an independent midwife towards an interdependent relationship within a healthcare system capable of providing consultation and referral.
G. Participating in continuing education that enhances professional growth and development and complete continuing education units required by licensure.
H. Performing duties within professional competence.
18. Respondent further submits that midwifery duties and responsibilities include, but are not limited, to:
A. Following initial and ongoing client risk assessment, the assumption of responsibility for the management and care of the essentially healthy woman and newborn during the childbearing process.
B. Properly documenting and maintaining the confidentiality of client records, including physician visits and referrals.
C. Providing a disclosure statement to each client and family at the initial interview that includes
(1) Educational background,
(2) Level of experience,
(3) Types of services rendered,
(4) Licenses, certifications, and professional affiliations,
(5) Midwifery expectations of clients, and
(6) Financial charges.
D. Eliciting informed consent to declined services, home birth, and risks involved to both patient and infant.
E. Requiring laboratory tests.
F. Employing team practice which includes, but is not limited to, the presence of a trained assistant or midwife.
G. Using and maintaining aseptically clean equipment.
H. Employing advance preparation which includes, prior to labor, arrangements for client and/or infant transport to hospital and client agreement to such transport.
1. Employing newborn screening within three days of delivery.
J. Referring and/or consulting with healthcare professionals as required by each client presentation. Within this obligation to refer or consult, the standard of practice compels obstetrical referral or consult for a client who exhibits:or greater PAP.
Active syphilis, gonorrhea, or chlamydia.
(2) Unresolved signs of PIH.
(3) Chronic and unresolved vaginitis, UTI, and/or anemia.
(4) Persistent glucosuria.
(5) Diabetic symptoms.
(6) Third trimester vaginal bleeding.
(7) ROM prior to 37 weeks minus 2 days.
(8) Familial history of congenital abnormalities.
(9) Prior obstetrical difficulties (e.g., uterine abnormalities, placental acretia or abruptia, or incompetent cervix).
(10) Polyhydramnios or oligohydramnlos.
(11) A Class III
(12) Size incompatible with date.
(13) Suspected malpresentation.
(14) Suspected twins or breech.
(15) Indications that fetus has died in utero or marked decrease in fetal movement.
(16) Rh negative mother with positive titers.
(17) Signs of preterm. labor (before 37 weeks minus 2 days).
(18) Gestation past 43 weeks.
(19) Fever of 100.4 for longer than 24 hours.
(20) Herpes: initial primary outbreak anytime during pregnancy.
(21) Abnormal FHTs.
19. Respondent acknowledges that within the scope of midwifery practice, planned home birth may be contraindicated and is specifically precluded in the following instances:
A. Diabetes, essential hypertension, active TB, epilepsy, heart lung, liver or kidney disease, cancer, bleeding disorders, or any other major medical problem or congenital abnormality that affects childbearing.
B. History of thrombophlebitis and/or pulmonary embolism
C. Use of psychotropic medication or evidence of significant mental illness.
D. Addiction to or use of narcotics or other drugs (except marijuana
E. Excessive use of alcohol.
F. Smoking more than one-half pack of cigarettes with no likelihood of cessation.
G. Unresolved anemia.
J. Placental previa or abruption.
K. Active herpes when commencing labor.
L. Fetus with congenital anomalies that may require immediate medical attention.
20. Respondent further acknowledges that the midwifery model includes, during labor and delivery,
that a licensed midwife:
A. Monitor the mother and baby.
B. Coach the mother.
C. Assist in the delivery.
D. Examine and assess the newborn.
E. Manage any third stage bleeding.
F. Inspect the placenta, membranes, and cord vessels.
G. Inspect the perineum vagina, and, if necessary, the cervix.
H. Repair lacerations, as necessary.
I. Provide no less than two hours postpartum care for the mother and infant and, in any event, until stable.
J. Transport or referral upon any of the following:
(1) Signs of preeclampsia.
(2) Fever over 100.4 degrees
(3) PROM accompanied by diminished maternal or fetal well-being.
(4) Evidence of fetal distress as indicated by fetal heart rate unless birth is imminent.
(5) Abnormal bleeding or blood loss.
(6) Significant meconium with birth not imminent.
(7) Prolonged labor accompanied by potential or actual diminished maternal or fetal well-being.
(8) Signs of maternal shock.
(9) Retained placenta or placental parts.
(10) Unexplained pain.
(11) Two hours of second stage with no progress.
(12) maternal desire.
21. Respondent, while acknowledging an obligation to refer or consult for a breech presentation and possessing a current neonatal cardiopulmonary resuscitation certificate, submits that vaginal breech home births are within the standard of practice for midwives, possessed of appropriate experience, knowledge and training, provided further particular criteria are satisfied; namely:
A. Frank breech presentation: sacrurn in the anterior aspect at onset of labor.
B. Flexed head.
C. Adequate pelvis for estimated fetal weight (by palpation and pelvimetry).
D. Sonogram to rule out anomalies.
E. Proximity to hospital.
F. Gestation is greater that 37 weeks and less than 41 1/2 weeks
G. Psychosocial aspects of client, client's partner, and midwife.
22. Respondent, possessing experience in vaginal breech births and examined by Respondent on February 19, 1998, presented with a frank breech, flexed head, adequate pelvic space for the fetus, appropriate psychosocial factors, and within the appropriate gestation period. Her location for delivery of the baby in Nevada City was approximately 20 - 25 minutes from the hospital in Grass Valley by vehicle. The sonogram. provided Respondent was taken at 22 weeks and one day; however, a (external) version under sonogram attempted only weeks earlier clinically ruled out hydrocephaly,
23. Factors concerning the credibility of evidence are contained, in part, in Evidence Code sections 412, 780, 786, 790 and 791. When applied to the evidence herein, this tribunal concludes, on balance, that:
A. Midwives employ a midwifery model of practice distinct from the medical model of practice. The testimony of Complainant's witnesses as to the medical model's applicability to midwifery is inapposite and summarily dismissed.
B. Respondent, residing and laboring in an area where the medical community of obstetricians is hostile to licensed midwives, has been unable to gain supervision by a physician and surgeon. As a consequence of such hostility, unsupervised by any physician except as set forth in Finding 14, she lacks a specific physician to whom she might regularly brief regarding clients undergoing midwifery care and treatment, or who might provide care for complications in a hospital.
The evidence presented this tribunal further establishes that, with the exception of one licensed midwife who is also a licensed physician assistant, no California licensed midwife, despite efforts for supervision, possesses a supervising physician except as referenced in Finding 14. Nevertheless, the evidence further established that Respondent uses at least one physician for collaborative consult, collaborative assistance, and emergent issues. Respondent, consistent with the extant midwifery standard of care (Findings 17 - 21), transfer patients to physicians or hospitals as necessary.
C. Respondent, within the context of the midwifery model, possesses the appropriate knowledge, training, and experience to conduct planned and emergent vaginal home deliveries, including vaginal breech deliveries.
D. The labor and delivery of M.G. did not necessitate her transport for C-section. Complainant's reliance on two hours as a benchmark is a guideline necessitating particular attention by the healthcare provider but not, absent other circumstances lacking herein, hospital transport.
E. Breech presentation is a variant of normal birth presentation. It occurs in approximately 3 - 4% of pregnancies and possesses particular risks for both mother and baby during the labor and delivery process"-9. Such risks, however, no longer necessarily compel C-section.8 Within particular criteria, a vaginal breech birth effected by a properly trained, experienced, and knowledgeable healthcare provider is, with the informed consent of the mother, not contraindicated. M.G.'s presentation, combined with a review by Respondent of her Great Beginnings' healthcare records, was neither abnormal nor, upon the inception of labor, lacking in normal progress and, concomitantly lacking in complications, did not compel immediate or emergent physician referral during the labor and delivery.
F. Respondent, having competently reviewed M.G.'s Great Beginnings' healthcare records, properly discharged her obligation to consult with M.G.'s former healthcare provider.
TENNESSEE MIDWIVES’ ASSOCIATION (TMA) PRACTICE GUIDELINES © Adopted 01/22/2001
Midwifery care is the autonomous practice of giving care to women during pregnancy, labor, birth, and the postpartum period, as well as care to the newborn infant. Midwifery care is provided in accordance with established standards, which promote safe and competent care. The Midwife implements these standards through adherence to the Tennessee Midwives’ Association (TMA) Practice Guidelines and MANA’s Core Competencies.
Evaluation of the childbearing woman is an on-going process, including risk screening to assess and identify conditions, which may indicate a deviation from normalcy. The identification of those conditions may require physician involvement. In making this assessment, a Midwife relies on her/his training, skill, and clinical judgment.
This document is representative and not an exhaustive list of the conditions that a Midwife may encounter.
This document is not meant to replace the clinical judgment or experience of the Midwife. There may be variations based on agreements between individual midwives and their consulting physicians. Editor's Note: Really regret that this gem got missed!
I. MIDWIFE AND CLIENT RESPONSIBILITIES AND RIGHTS _
The Informed Choice and Disclosure (ICD) Agreement
The Midwife is required to have on file, a signed statement that each client has read and understood the Midwife’s Informed Choice and Disclosure (ICD) agreement. The ICD should be written or translated in language understandable to the client. There must be a place on the form for the client to attest that she understands the content, by signing her full name. The ICD discloses, to a prospective client, information regarding the Midwife’s practice. The ICD includes information regarding the Midwife’s responsibilities and rights as well as the client’s responsibilities and rights. Each Midwife may broaden the agreement to include additional information reflecting details of the Midwife’s practice.
The ICD shares information regarding the responsibilities and rights of the Midwife. It includes information including, but not limited to:
1. philosophy of practice and care;
2. benefits and risks of out-of-hospital birth;
3. training and education;
4. years of experience;
5. participation in Peer Review;
6. information regarding the Midwife’s emergency care plan and collaborating or consulting physician (s);
7. care/equipment provided;
8. information regarding a client’s right to giving informed consent prior to any procedure and/or administration of any prescribed medication to mother or newborn, risks, benefits, options, and alternatives;
9. acceptance/refusal of Midwife’s recommended care. The client’s decision to refuse/decline recommended care will be made in writing, signed by the client, and kept in client’s records;
10. information regarding client conditions/concerns for which a Midwife may need to consult with a physician, refer client to a physician, and/or transfer client out of Midwife’s care to a physician’s care;
11. Midwife’s expectations of the clients' responsibilities and the Midwife’s right to discontinue care;
12. legal requirements, i.e. TN mandated newborn screening for inborn errors of metabolism (PKU), eye prophylaxis, reporting of communicable diseases, and registration of birth and death certificates;
13. financial information;
14. Midwife’s current legal status;
15. grievance process(es) for client complaints regarding care;
16. Process to access copies of the client’s Midwifery records.
The Midwife will give a copy of the ICD to the client and keep a copy of the ICD Agreement Statement in the client’s records.
II. MIDWIFERY RECORD KEEPING _
A. documents completely and accurately the client’s history, physical exam, laboratory test results, prenatal visits, consultation reports, referrals, labor and birth care, postpartum care/visits, and neonatal evaluations at the time Midwifery services are delivered and when reports are received;
B. facilitates clients’ access to their own records;
C. maintains the confidentiality of client records
D. retains records for a minimum of five years;
E. completes/files all state required reports/certificates in a timely manner
III. PRACTICE PROTOCOLS _
Practice protocols based on TMA Practice Guidelines will be available for each potential client to review.
IV. SAFE ENVIRONMENT FOR BIRTH _
A. assesses the birth setting for freedom from environmental hazards.
B. brings own equipment to birth setting.
C. promptly responds to client’s needs.
D. practices universal precautions established by OSHA (Occupational Safety and Health Administration) guidelines regarding equipment, examinations, and procedures.
V. PRENATAL CARE _
During prenatal care, the client shall be seen by the Midwife or other appropriate health care provider at least once every four weeks until 30 weeks gestation, once every two weeks from 30 until 36 weeks gestation, and weekly after 36 weeks gestation, or as appropriate.
A. Initial Prenatal Visit
1. History/assessment of general health.
2. History/assessment of obstetric status.
3. History/assessment of psychosocial status.
4. Physical Exam to include, but not limited to:
c. blood pressure;
e. breasts, to include teaching on self exam (may be deferred);
f. abdomen, to include fundal height, fetal heart tones, fetal lie, and presentation.
g. estimation of gestational age by physical findings; and
h. assessment of varicosities, edema and reflexes.
5. Laboratory Tests. The client will be offered the following laboratory tests to include but not limited to:
a. hemoglobin and/or hematocrit or CBC;
b. gross urinalysis for protein and glucose;
c. syphilis serology;
d. blood group, Rh type, and antibody screen;
e. hepatitis B surface antigen;
f. rubella screen;
g. genetic screening tests;
h. gonorrhea test, if at risk;
i. chlamydia test, if at risk;
j. HIV test, if at risk.
B. On-going Prenatal Care
1. Assessment of general health.
2. Assessment of psychosocial health.
3. Nutritional counseling.
4. Physical Exam to include, but not limited to:
a. blood pressure;
b. pulse, optional;
d. abdomen, to include fundal height, fetal heart tones, fetal lie, and presentation;
e. estimation of gestational age by physical findings; and
f. assessment of varicosities, edema and reflexes.
5. Laboratory Tests. The client will be offered the following laboratory tests to include by not limited to:
a. hemoglobin, hematocrit, or CBC by 28 and/or after 32 weeks;
b. gross urinalysis for protein and glucose at each visit;
c. Glucose Tolerance Test (GTT), if indicated;
d. Group Beta Strep (GBS) culture(s), according to CDC Guidelines;
e. Herpes (HSV 1 and/or HSV 2) cultures(s), if indicated;
6. Prophylactic Rhogam information for Rh negative clients, as indicated.
VI. INTRAPARTUM CARE _
During labor, the Midwife shall monitor and support the natural process of labor and birth, assessing mother and baby throughout the birthing process:
1. Assess & monitor fetal well-being. While in attendance, assess FHT:
a. 1st Stage of labor: at least once every hour, or as indicated;
b. 2nd Stage of labor: at least every 10 minutes, or as indicated;
2. Assess & monitor maternal well-being. While in attendance, assess vital signs at least every 4 hours, or as indicated;
3. Monitor the progress of labor;
4. Monitor membrane status for rupture, relative fluid volume, odor, and color of amniotic fluid;
5. Assist in birth of baby;
6. Inspection of placenta and membranes;
7. Manage any problems in accordance with the guidelines cited elsewhere in this document;
8. Whenever vaginal examinations are performed to assess the progress of labor, they will be kept to a
minimum to reduce the risk of infection. Attention will be directed toward aseptic technique. Assess
cervical dilatation, effacement, station, and position during each exam and document in client’s chart.
VII. POSTPARTAL CARE _
After the birth of the baby, the Midwife shall assess, monitor, and support the mother during the immediate postpartum period until the mother is in stable condition and during the on-going postpartum period.
A. Immediate Postpartal Care
1. Overall maternal well-being;
3. Vital signs;
4. Abdomen, including fundal height and firmness;
5. Bowel/bladder function;
6. Perineal exam and assessment;
7. Suture 1st or 2nd degree laceration(s)/episiotomy, as indicated;
8. Facilitation of maternal-infant bonding and family adjustment;
9. Concerns of the mother.
B. On-going Postpartal Care
1. Overall maternal well-being;
3. Abdomen, including fundal height and firmness;
4. Bowel/bladder function;
5. Perineal exam and assessment, as indicated;
6. Facilitation of maternal-infant bonding and family adjustment
7. Concerns of the mother.
VIII. NEWBORN CARE _
After the birth of the baby, the Midwife shall assess, monitor, and support the baby during the immediate postpartum period until the baby is in stable condition, and during the on-going postpartum period.
A. Immediate Newborn Care
1. Overall newborn well-being;
2. Vital signs;
5. APGAR scores at 1 and 5 minutes, and at 10 minutes when indicated;
8. Bowel/bladder function;
9. Clamping/cutting of umbilical cord;
10. Newborn physical exam, including weight and measurements;
11. Eye prophylaxis;
12. Administration of Vitamin K, orally or intramuscularly;
13. Concerns of the family.
B. Ongoing Newborn Care
1. Vital signs, including color and temperature;
4. Bowel/bladder function;
5. Weight gain;
6. Newborn screening (PKU);
7. Concerns of family.
IX. PHYSICIAN CONSULTATION AND REFERRAL _
The Midwife shall consult with a physician whenever there are significant deviations (including abnormal laboratory results, during a client’s pregnancy and birth, and/or with the newborn. If a referral to a physician is needed, the Midwife will remain in consultation with the physician until resolution of the concern. It is appropriate for the Midwife to maintain care of her client to the greatest degree possible, in accordance with the client’s wishes, remaining present through the birth, if possible.
The following conditions require physician consultation and may require physician referral and/or transfer of care.
1. Pre-existing Conditions _ include but are not limited to:
a. cardiac disease;
b. active tuberculosis;
c. asthma, if severe or uncontrolled by medication;
d. renal disease;
e. hepatic disorders;
f. endocrine disorders;
g. significant hematological disorders;
h. neurological disorders;
i. essential hypertension;
j. active cancer;
k. diabetes mellitus;
l. history of newborn with positive Group Beta Strep (GBS);
m. previous Cesarean section with classical incision;
n. three or more previous Cesarean sections;
o. previous Cesarean section within one year of current EDD;
p. current alcoholism or abuse;
q. current drug addiction or abuse;
r. current severe psychiatric illness;
t. positive for HIV antibody.
2. Prenatal Conditions include but are not limited to:
a. labor before the completion of the 36th week (i.e. 37 weeks) of gestation;
b. lie other than vertex at term;
c. multiple gestations;
d. significant vaginal bleeding;
e. gestational Diabetes Mellitus, uncontrolled by diet;
f. severe anemia, not responsive to treatment;
g. evidence of pre-eclampsia;
h. consistent size/dates discrepancy;
i. deep vein thrombosis (DVT);
j. known fetal anomalies or conditions affected by site of birth, with an infant compatible with life;
k. threatened or spontaneous abortion after 12 weeks;
l. abnormal ultrasound findings;
n. documented placental anomaly or previa;
o. documented low lying placenta in woman with history of Cesarean section;
p. post-maturity pregnancy (>42 completed weeks);
q. positive HIV antibody test.
3. Intrapartal Conditions _ It should be noted that because of time urgency during certain intrapartal situations, it may be necessary to institute emergency interventions while waiting for physician consultation. These conditions include but are not limited to:
a. persistent and/or severe fetal distress;
b. abnormal bleeding;
c. thick meconium-stained fluid with birth not imminent;
d. significant rise in blood pressure above woman’s baseline with or without proteinuria;
e. maternal fever > 100.4 degrees Fahrenheit, unresponsive to treatment;
f. transverse lie;
g. primary genital herpes outbreak;
h. prolapsed cord;
i. client’s desire for pain medication.
4. Postpartum Conditions _ It should be noted that because of time urgency during certain postpartal situations, it may be necessary to institute emergency interventions while waiting for physician consultation. These conditions include but are not limited to:
b. significant hemorrhage, not responsive to treatment;
c. adherent or retained placenta;
d. sustained maternal vital sign instability;
e. uterine prolapse;
f. uterine inversion;
g. repair of laceration(s)/episiotomy, which is beyond Midwife’s level of expertise;
5. Neonatal Conditions _ It should be noted that because of time urgency during certain postpartal situations, it may be necessary to institute emergency interventions while waiting for physical consultation. These conditions include but are not limited to:
a. Apgar score less than 7 at five minutes of age, without significant improvement at 10 minutes;
b. persistent respiratory distress;
c. persistent cardiac irregularities;
d. central cyanosis or pallor;
e. prolonged temperature instability or fever >100.4 degrees Fahrenheit, unresponsive to treatment;
f. significant clinical evidence of glycemic instability;
g. evidence of seizure;
h. birth weight <2300 grams;
i. significant clinical evidence of prematurity;
j. significant jaundice or jaundice prior to 24 hours;
k. loss of >10% of birth weight/failure to thrive;
l. major apparent congenital anomalies;
m. significant birth injury.
X. ADMINISTRATION OF PRESCRIBED MEDICATIONS _
Upon the administration of any prescribed medication(s), the Midwife shall document in the client’s chart the type of prescribed medication(s) administered, name of prescribed medication, expiration date, lot number, dosage, method of administration, site, date, time, and the prescribed medication’s effect.
Administration of Physician Prescribed Medications by a Midwife*:
1. Rh Immune Globulin;
3. Pitocin and Methergine, orally or intramuscularly, postpartally (as described under section XI.
Emergency Care, below);
4. Local anesthetic for perineal repair;
5. Prophylactic ophthalmic medication for newborn;
6. Vitamin K, orally or intramuscularly, for newborn;
7. Other medications, as prescribed by a physician.
XI. EMERGENCY CARE _
The following procedures may be performed by the Midwife, only in an emergency situation in which the health and safety of the mother or newborn are determined to be at risk.
Medications listed will be prescribed by a physician*:
1. Cardiopulmonary resuscitation of the mother or newborn with a bag and mask
2. Administration of oxygen;
4. Administration of Pitocin or Methergine to control postpartum bleeding;
5. Manual exploration of the uterus for placenta to control severe bleeding.
XII. PROHIBITIONS IN THE PRACTICE OF MIDWIFERY _
The Midwife shall not administer any prescribed medications or injections of any kind, except as indicated
in section X.
Administration of Prescribed Medications.
1. The use of synthetic prostaglandin compounds (Cervidil, Prepidil, or Cytotec) is not sanctioned for out-of-hospital use, even when prescribed by a physician.
2. Intrapartum use of oxytocics, such as Pitocin and Methergine, is prohibited through all routes of administration.
B. Surgical Procedures
The Midwife shall not perform any operative procedures or surgical repairs other than:
1. artificial rupture of membranes (AROM);
2. perform and repair episiotomy;
3. perineal/vaginal repair;
4. clamping and cutting of the newborn’s umbilical cord.
C. Instrumental Delivery
The Midwife shall not use forceps and/or vacuum extraction to assist the birth of the baby.
Standards for the Practice of Midwifery in Texas
(a) Purpose. To establish standards for safe midwifery care.
(b) Midwifery is the practice by a midwife of giving the necessary supervision, care, and advice to a woman during normal pregnancy, labor and the postpartum period; conducting a normal delivery of a child; and providing normal newborn care.
(c) Midwifery practice is based upon education in the sciences and upon necessary clinical skills as defined in §831.11 of this title (relating to Annual Documentation) and §831.31 of this title (relating to Education). The education shall be obtained through apprenticeship or an approved basic midwifery education course.
(d) Midwifery care is provided by qualified practitioners. The midwife:
(1) is regulated by the Midwifery Board of the Texas Department of Health; and
(2) is in compliance with the legal requirements of the State of Texas while practicing in the state.
(e) Midwifery care supports individual rights and self-determination within the boundaries of safety.
The midwife shall:
(1) provide clients with a description of the scope of midwifery services and information regarding the client's rights and responsibilities in accordance with §203.351 of the Texas Midwifery Act;
(2) provide clients with information about other providers and services when requested or when the care required is not within the scope of practice of midwifery, or as further limited by the protocols of the individual midwife; and
(3) practice in accordance with the knowledge, clinical skills, and judgments described in the Midwives Alliance of North America (MANA) Core Competencies for Basic Midwifery Practice, adopted October 3, 1994 within the bounds of the midwifery scope of practice as defined by the Texas Midwifery Act; the Texas Midwifery Board Standards for the Practice of Midwifery in Texas and; the protocols of the individual midwifery service/practice.
(f) The midwife shall provide care in a safe and clean environment.
The midwife shall:
(1) carry, and use, when needed, resuscitation equipment; and
(2) use universal precautions for infection control.
(g) Midwifery care is documented in legible, complete health records. The midwife shall:
(1) maintain records that completely and accurately document the client's history, physical exam, laboratory test results, antepartum visits, consultation reports, referrals, labor, delivery, postpartum visits, and neonatal evaluations at the time midwifery services are delivered and when reports are received;
(2) grant clients access to their records within 30 days of the date the request is received;
(3) provide a mechanism for sending a copy of the health record upon referral or transfer to other levels of care;
(4) maintain the confidentiality of client records; and
(5) maintain records:
(A) for the mother, for a minimum of five years; and
(B) for the infant, until the age of majority.
(h) Midwifery care includes documentation of a periodic process of evaluation and quality assurance of midwifery practice. The midwife shall:
(1) collect client care data systematically and be involved in analysis of that data for the evaluation of the process and outcome of care;
(2) review problems identified by the midwife or by other professionals or consumers in the community; and
(3) act to resolve problems that are identified
Informed Choice and Disclosure Statement
As required by the Act, §203.351 (relating to Informed Choice and Disclosure Requirements), each midwife shall disclose in oral and written form to a prospective client the limitations on the skills and practices of the midwife. The written informed choice and disclosure statement which has been approved by the Midwifery Board shall include:
(1) an informed choice statement containing:
(A) statistics of the midwife's experience as a midwife;
(B) the date of expiration of the midwife's documentation;
(C) the date of expiration of the midwife's adult and infant cardiopulmonary resuscitation and neonatal resuscitation certification;
(D) the midwife's compliance with continuing education requirements; and
(E) medical backup arrangements; and
(2) a disclosure statement, which includes the legal requirements of the midwife and prohibited acts as stated in the Act. The disclosure statement may not exceed 500 words and must be in Spanish and English
Termination of the Midwife-Client Relationship
A midwife shall terminate care of a client only in accordance with this section unless a transfer of care results
from an emergency situation.
(1) Once a midwife has accepted a client, the relationship is ongoing and the midwife cannot refuse to continue to provide midwifery care to the client unless:
(A) the client has no need of further care;
(B) the client terminates the relationship; or
(C) the midwife formally terminates the relationship.
(2) The midwife may terminate care by:
(A) providing a minimum of 30 days written notice, during which the midwife shall continue to provide midwifery care, to enable the client to select another health care provider;
(B) making an attempt to tell the client in person and in the presence of a witness of the midwife's wish to terminate care;
(C) providing referrals; and
(D) documenting the termination of care in midwifery records.
The following definitions regarding inter-professional care of women within a midwifery model of care apply to this chapter.
(1) Consultation is the process by which a midwife, who maintains primary management responsibility for the woman's care, seeks the advice of another health care professional or member of the health care team.
(2) Collaboration is the process in which a midwife and a health care practitioner of a different profession jointly manage the care of a woman or newborn who needs joint care, such as one who has become medically complicated. The scope of collaboration may encompass the physical care of the client, including delivery, by the midwife, according to a mutually agreed-upon plan of care. If a physician must assume a dominant role in the care of the client due to increased risk status, the midwife may continue to participate in physical care, counseling, guidance, teaching, and support. Effective communication between the midwife and the health care professional is essential to ongoing collaborative management.
(3) Referral is the process by which a midwife directs the client to a health care professional who has current obstetric or pediatric knowledge and is either a physician licensed in the United States; or working in association with a licensed physician. The client and the physician (or associate) shall determine whether subsequent care shall be provided by the physician or associate, the midwife, or through collaboration between the physician or associate and midwife. The client may elect not to accept a referral or a physician or associate's advice, and if such is documented in writing, the midwife may continue to care for the client according to his/her own policies and protocols.
(4) Transfer is the process by which a midwife relinquishes care of the client for pregnancy, labor, delivery, or postpartum care or care of the newborn to another health care professional who has current obstetric or pediatric knowledge and is either a physician licensed in the United States; or working in association with a licensed physician. If a client elects not to accept a transfer, the midwife shall terminate the midwife-client relationship according to §831.57 of this title (relating to Termination of the Midwife-Client Relationship). If the transfer recommendation occurs during labor, delivery, or the immediate postpartum period, and the client refuses transfer; the midwife shall call 911 and provide further care as indicated by the situation. If the midwife is unable to transfer to a health care professional, the client will be transferred to the nearest appropriate health care facility. The midwife shall attempt to contact the facility and continue to provide care as indicated by the situation.
Policies and Protocols
(a) The midwife shall establish, review, update, and adhere to individualized policies and protocols in the practice of midwifery. These protocols shall be consistent with standard midwifery management as described in a standard midwifery textbook or a combination of standard textbooks and references. Any textbook or reference which is also an approved text or reference for a midwifery educational program or school which has been approved by the Texas Midwifery Board shall be considered an acceptable textbook or reference for use in developing a midwife's personal protocols.
(b) The midwife shall:
(1) establish policies or protocols for each practice area, which include but are not limited to:
(i) parameters and methods for initial assessment of the current pregnancy, including history, physical exam/assessment, and laboratory tests;
(ii) parameters and methods for assessing the progress of pregnancy, including history, physical exam/assessment, and laboratory tests;
(iii) parameters and methods for assessing fetal well-being, including history, physical exam/assessment, and laboratory tests;
(iv) indicators of risk in pregnancy and appropriate intervention in accordance with §831.60 of this title (relating to Prenatal Care); and
(v) medications and natural remedies used during pregnancy;
(i) parameters and methods for assessment of labor and birth, including history, physical exam/assessment, and laboratory tests;
(ii) medications and natural remedies used during labor and birth;
(iii) methods to facilitate the newborn's adaptation to extrauterine life; and
(iv) significant deviations from normal and appropriate interventions in accordance with §831.65 of this title (relating to Labor and Delivery);
(C) postpartum and newborn;
(i) parameters and methods for assessing the postpartum status of the mother, including history, physical exam/assessment, and laboratory tests;
(ii) parameters and methods for assessing the well-being of the newborn, including history, physical exam/assessment, and laboratory tests;
(iii) medications and natural remedies used in the postpartum and newborn period; and
(iv) significant deviations from normal and appropriate interventions in accordance with §831.70 of this title (relating to Postpartum Care) and §831.75 of this title (relating to Newborn and Infant Care);
(2) develop and implement a plan of care based on the policies and protocols;
(3) evaluate and modify the plan of care as necessary;
(4) provide health education and counseling based on the policies and protocols;
(5) review and document review of all policies and protocols at least annually; and
(6) modify policies and protocols as needed, and document any changes
Labor and Delivery
(a) The midwife shall evaluate the client when the midwife arrives for the labor and delivery, by obtaining a history, performing a physical exam, and collecting laboratory specimens.
(b) The midwife shall monitor the client after the midwife's arrival for the labor and delivery by monitoring vital signs, contractions, fetal heart tones, cervical dilation, effacement, station, presentation, membrane status, input/output and subjective status.
(c) The midwife shall assist in normal, spontaneous vaginal deliveries.
(d) The midwife shall not engage in the following:
(1) application of fundal pressure on abdomen or uterus during first or second stage of labor;
(2) administration of oxytocin, ergot, or prostaglandins prior to or during first or second stage of labor; or
(3) any other prohibited practice as delineated by the Act, §203.401 (relating to Prohibited Practices).
(e) If on initial or subsequent assessment during labor or delivery, one of the following conditions exists, the midwife shall initiate immediate emergency transfer in accordance with §831.58 of this title (relating to Transfer of Care in an Emergency Situation) and document that action in the midwifery record:
(1) prolapsed cord;
(3) uncontrolled hemorrhage;
(4) gestational hypertension/preeclampsia/eclampsia;
(5) severe abdominal pain inconsistent with normal labor;
(6) a non-reassuring fetal heart rate pattern;
(8) thick meconium unless the birth is imminent;
(9) visible genital lesions suspicious of herpes virus infection;
(10) evidence of maternal shock;
(11) preterm labor (less than 36 weeks);
(12) presentation(s) not compatible with spontaneous vaginal delivery;
(13) laceration(s) requiring repair beyond the parameters set forth and documented in the protocols of the midwife;
(14) failure to progress in labor;
(15) retained placenta; or
(16) any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a midwife exercising ordinary skill and knowledge
Transfer of Care in An Emergency Situation
In an emergency situation, the midwife shall initiate emergency care as indicated by the situation and initiate immediate transfer of care in accordance with the protocols of his or her practice by making a reasonable effort to contact the health care professional or institution to whom the client will be transferred and to follow the health care professional's instructions; and continue emergency care as needed while:
(1) transporting the client by private vehicle; or (2) calling 911 and reporting the need for immediate transfer.
Title 26: Professions and Occupations Chapter 85: MIDWIVES
§ 4181. Definitions
The definitions contained in this section shall apply throughout this chapter unless the context clearly requires otherwise:
(3) "Midwifery" means the provision of care, support and education to healthy women during the childbearing cycle, including normal pregnancy, labor, childbirth and the postpartum period. Such care occurs in collaboration and consultation with other health care providers, and can appropriately occur at home, in birthing centers or in medical facilities. Such care, support and education may relate to:
(A) appropriate measures that promote and maintain the health of the mother and baby;
(B) the availability of birthing alternatives;
(C) the prevention or reduction of risk to the mother and baby;
(D) the detection of abnormal conditions;
(E) the procurement of appropriate medical assistance;
(F) the execution of emergency measures;
(G) the provision of newborn care and appropriate screening; and
(H) the provision of well woman health care.
(4) "Midwifery educational process" means a course of study that includes a combination of apprenticeship, self teaching, experience, formal instruction, correspondence work or at-distance learning, and practice in non medical settings, usually the home, but sometimes freestanding birth centers, approved or accredited, or both, by the Midwifery Education Accreditation Council.
(5) "NARM" means the North American Registry of Midwives.
(6) "VMA" means the Vermont midwives alliance. (Added 1999, No. 133 (Adj. Sess.), § 44, eff. Jan. 1, 2001.)
§ 4182. Exemptions
In recognition that, in Vermont, a variety of practitioners provides care to women during pregnancy and birth, this chapter does not apply to the following:
(1) Certified nurse midwives authorized under the board of nursing to practice in Vermont, unless they have chosen to become licensed midwives. Notwithstanding this subsection, certified nurse-midwives who choose to become licensed midwives remain subject to the jurisdiction of the board of nursing as well as to the provisions of this chapter.
(2) Licensed physicians or other licensed health care providers authorized to provide midwifery care.
(3) Student midwives in training with licensed midwives.
§ 4183. Eligibility
A person shall be eligible to be licensed as a midwife, if the person has:
(1) certification as a certified professional midwife (CPM) by the North American Registry of Midwives;
(2) earned a high school degree or its equivalent as a basis for entry into the study of midwifery; and
(3) agreed to practice according to the scope and standards of practice as required by rules adopted pursuant to section 4185 of this title.
§ 4188. Unprofessional conduct
(a) A licensed midwife or applicant for licensing, renewal or reinstatement shall not engage in unprofessional conduct.
(b) Unprofessional conduct shall include the conduct prohibited by section 129a of Title 3 and by this section, whether or not taken by a license holder:
(1) failing to provide for informed consent, or exercising undue influence on or taking improper advantage of a person using midwifery services;
(2) willfully making or filing false reports or records in the practice of midwifery, obstructing that filing, or willfully failing to file required reports or records, including birth certificates;
(3) engaging in abusive behavior of any kind with clients.
(c) After a hearing, and upon a finding of unprofessional conduct, an administrative law officer may take disciplinary action against a licensed midwife or applicant.
§ 4189. Prohibition; offenses
(a) No person shall use in connection with the person's name any letters, words or insignia indicating or implying that the person is a licensed midwife, unless the person is licensed in accordance with this chapter. However, a person may use any designation issued by a state or nationally-recognized organization, as long as the name of that organization is clearly used with the designation.
(b) No person shall practice midwifery in this state without a valid license issued in accordance with this chapter except as provided in section 4182 of this title.
(c) A person who violates this section shall be fined not more than $1,000.00.
§ 4190. Written plan for consultation, emergency transfer and transport
Every licensed midwife shall develop a written plan for consultation with physicians licensed under chapter 23 of this title and other health care providers for emergency transfer, for transport of an infant to a newborn nursery or neonatal intensive care nursery, and for transport of a woman to an appropriate obstetrical department or patient care area. The written plan shall be submitted to the director on an approved form with the application required by section 4184 of this title and biennially thereafter with the renewal form required by section 4187 of this title.
§ 4191. Informed consent
A licensed midwife shall provide each client with and maintain a record of a signed informed consent form that describes the midwife's education and credentials, whether the midwife has professional liability insurance coverage, procedures and risks of home birth, a copy of the emergency plan required by section 4190 of this title, and the address and phone number of the office of professional regulation where complaints may be filed.
STANDARDS FOR THE PRACTICE OF MIDWIFERY
Revised and approved December 6, 2002 by the Midwives' Association of Washington State.
Practice within the parameters of Washington State law
Maintain currency of practice through continuing education.
Demonstrate knowledge, clinical skills and judgment as described in the Midwives' Alliance of North America (MANA) Core Competencies for Basic Midwifery Practice or the American College of Nurse Midwives (ACNM) Core Competencies for Basic Midwifery Practice.
Foster the delivery of safe, satisfying and accessible maternity services and may provide gynecology, family planning, and well baby care, according to individual licensure.
Participate in state protected quality assurance/improvement activities for the evaluation of individual midwifery practice, as available.
Engage in an ongoing process of risk assessment that begins during the initial consultation and continues through the completion of care.
Seek physician consultation for conditions that present a significant deviation from normal.
Use the MAWS or ACNM practice mechanism for introducing expanded clinical procedures into midwifery practice.
2. ENVIRONMENT- Midwives:
Practice in a variety of settings.
Arrange for 24-hour clinical coverage
Foster a safe environment by having the appropriate equipment available including that needed to assess and promote maternal, fetal and newborn well-being.
3. DOCUMENTATION- Midwives:
Maintain comprehensive, accurate, legible, up-to-date and confidential records of the clinical care provided by the midwife for each client. These shall be made available to appropriate health care personnel upon consultation or transfer of care. Maintain written guidelines that are congruent with state regulations for the midwifery profession. Guidelines shall contain a clear, written plan for physician consultation, collaboration, referral, hospital access and transfer of care.
4. CLIENT RELATIONS - Midwives:
Provide thorough informed choice in accordance with RCW 7.70, which includes risk/benefit analysis of options for care, and uphold the client's right to information and resources.
Incorporate client education in clinical care.
Provide accurate information regarding the scope of midwifery practice, fees, medical consultation arrangements and the rights and responsibilities of the client.
Emphasize client's responsibility for active participation in her own care, and encourage the participation of family members in care as appropriate.
Elicit client feedback to evaluate and modify services, and provide an avenue for resolving client grievances.
Affirm the client's right to self-determination while acknowledging that the midwife has a duty to use her professional judgment and skills to provide safe and competent care that is within her scope of practice and written guidelines.
The midwife may decline to provide care but shall make appropriate arrangements for referral and/or the timely transfer of care.
5. COMMUNITY RELATIONS - Midwifery:
Is an autonomous profession. Midwives work interdependently with each other and other health care providers to promote the optimal health and well-being of women and babies
Thrives within a community context in which collaboration with other professionals fosters clients' physical, psycho-social, spiritual, economic, cultural and family well-being.