Chapter He-P 3100
New Hampshire Certified Midwife
Links to Key Words; Technical skills essential to the practice of midwifery Peer Review
Role / Scope of Practice of Midwife Plan for Medical Backup Prenatal Care
Client Chart Requirements Contraindications Withdrawal of Service Intrapartum Care
Postpartum Care Duty to Register Births Authorized Medications Reporting Requirement
Complaints & Investigations Notification of Hosp transfer Definition of Significant Morbidity
Midwifery Council M&M review
Statutory Authority RSA 326-D 3 // Part He-P 3101 DEFINITIONS
He-P 3101.01 "Advanced Registered Nurse Practitioner (ARNP)" means a registered nurse licensed in New Hampshire who has met the requirements of Nur 300.
He-P 3101.02 "Apprentice" means any person desiring to become a midwife whom is engaged in a clinical education and experience under the supervision of a preceptor such as a physician, New Hampshire Certified Midwife, or Certified Nurse Midwife.
He-P 3101.03 "Certified Nurse Midwife" means an advanced registered nurse practitioner licensed to practice in this state who has been certified by the American College of Nurse Midwives and has met the requirements of Nur 300.
He-P 3101.04 "Client" means a woman whom a midwife has agreed to care for and attend.
He-P 3101.05 "Commissioner" means the Commissioner of the New Hampshire Department of Health and Human Services.
He-P 3101.06 "Midwife" means a person who has successfully completed the prescribed course of studies in midwifery pursuant to He-P 3102.01 and has acquired the requisite qualifications to be certified in the practice of midwifery.
He-P 3101.07 "Midwifery" means the practice of providing the necessary supervision, care and advice to women during pregnancy, labor and the postpartum period, including care for the newborn, by a person who is not a medical professional otherwise licensed by an agency of the State.
He-P 3101.08 "Midwifery Council" means a council appointed by the governor for the practice of midwifery pursuant to HB 720.
He-P 3101.09 "Mortality" means the death of a fetus, neonate, or woman.
He-P 3101.10 "New Hampshire Certified Midwife" means a midwife certified in New Hampshire according to He-P 3103.
He-P 3101.11 "Out of hospital birth" means births attended at home or in a freestanding birth center.
He-P 3101.12 "Peer Review" means the ongoing process and documentation of discussions of the care and outcome of cases with colleagues.
He-P 3101.13 "Physician" means a person licensed to practice medicine and engaged in the active practice of medicine in New Hampshire or a bordering state.
He-P 3101.14 "Preceptor" means a person who instructs, supervises, and assesses the clinical skills and knowledge of an apprentice midwife throughout the process of meeting the specific knowledge, skills and experience goals required to fulfill standards for certification. Preceptor-based education offers the apprentice midwife one-on-one instruction, close supervision of clinical experience, and on-the-spot evaluation.
He-P 3101.15 "Reader" means and individual designated by the Midwifery Council to review and grade written exams.
He-P 3101.16 "Significant Morbidity" means any event that requires hospitalization for more than 24 hours for purposes other than observation.
Part He-P 3102 QUALIFICATIONS FOR THE PRACTICE OF MIDWIFERY
He-P 3102.01 Certification Criteria
(a) To obtain certification as a midwife in New Hampshire, a person shall
(1) Be a high school graduate or the equivalent;
(2) Complete one college-level course in human anatomy and physiology, or pass a college-level equivalency program and/or obtain credit by exam;
(3) Express an intent to engage in the practice of midwifery in New Hampshire;
(4) Disclose any criminal convictions;
(5) Present evidence to the Midwifery Council that within 3 years prior to the time of application the applicant has met the following requirements for practical experience
a. Performed at least 100 prenatal visits on at least 15 different women, including at least 5 prenatal visits and postpartum follow-up on each of 10 clients;
b. Attended at least 25 live out-of-hospital births as an observer or assistant attendant;
c. Attended at least 25 live out-of-hospital births at which the applicant was the primary birth attendant and was accompanied by a
2. Certified Nurse Midwife
3. New Hampshire Certified Midwife
4. North American Registry of Midwives (NARM) Certified Professional Midwife (CPM); or
5. American College of Nurse Midwives Certification Council (ACC) Certified Midwife (CM);
d. Performed at least 25 newborn examinations;
e. Performed at least 5 repairs of lacerations;
f. Performed at least 20 postpartum home or office visits; and
g. Made at least 5 observations of in-hospital births, which may include transfers of the midwife's clients;
(6) Present evidence to the Midwifery Council pursuant to He-P 3103.01 that the applicant possesses technical skills essential to the practice of midwifery including, but not limited to, the following
a. Hand washing;
b. Gloving and ungloving;
c. Sterile technique;
d. Sterilization of instruments;
e. Maternal vital signs assessment;
f. Oxygen set up and administration to mother and newborn;
g. Treatment of shock;
h. Universal precautions;
i. Prenatal history;
j. Anemia screening;
k. Obtaining clean catch urine and performing dipstick urinalysis;
l. Breast exam and assessment for breast feeding;
m. Deep tendon reflexes of the knee;
n. Basic physical exam;
o. Pelvic and speculum exam including pap smears and obtaining cervical
specimens for sexually transmitted disease testing;
p. Uterine size, fundal height and fetal age assessment;
q. Pelvic measurements;
r. Leopold's maneuvers;
s. Fetal activity testing;
t. Intrapartum pelvic exam and assessment of progression of labor;
u. Assessment of contractions and fetal heart rate pattern;
v. Delivery maneuvers;
w. Management of nucal cord, hand, or arm;
x. Newborn suction and resuscitation;
y. Postpartum maternal assessment;
z. Delivery and assessment of the placenta;
aa. Estimation of blood loss;
bb. Postpartum hemorrhage management;
cc. Assessment and repair of lacerations;
dd. Postpartum exams of the mother;
ee. Immediate care of the newborn;
ff. Clamping and cutting of the cord;
gg. Newborn vital signs;
hh. Newborn assessment;
ii. APGAR assessment;
jj. Newborn eye prophylaxis;
kk. Newborn metabolic screening;
ll. Assessment of jaundice in the newborn;
mm. Urinary catheterization;
nn. Intramuscular injection;
pp. Administration of IV fluids;
qq. Episiotomy and repair; and
rr. Wet mount slide and use of the microscope;
(7) Present evidence of a passing grade on the NARM certification examination;
(8) Pass a written examination assessing familiarity with statutes and rules governing midwifery in New Hampshire; and
(9) Pass the New Hampshire oral exam administered by the Midwifery Council pursuant to He-P 3103.02 (f).
(b) Certification as a midwife in New Hampshire shall not require residency in New Hampshire nor prohibit a practice that crosses state lines.
He-P 3102.02 Experience Requirements
All experience and skill requirements as set forth in He-P 3102.01 (a) (5) and (6) shall be met in the presence of a New Hampshire Certified Midwife, NARM Certified Professional Midwife (CPM), ACC Certified Midwife (CM), and/or either a Certified Nurse Midwife (CNM) or licensed physician practicing primary care obstetrics.
Part He-P 3103 PROCEDURES FOR APPLICATION, CERTIFICATION, RECERTIFICATION AND REVOCATION
He-P 3103.01 Application Process
(a) Each person wishing to become certified under this chapter shall submit an application to the Midwifery Council pursuant to He-P 3102.01.
(b) An applicant shall supply the following
(1) Name of applicant and legal address;
(2) Date of application;
(3) Home and business phone number, if different;
(4) Copies of current certification in adult and child cardio-pulmonary resuscitation and neonatal resuscitation;
(5) The certification above in (4) shall include the name and address of the certifying agency; and the dates of certification and expiration;
(6) Name and address of high school attended and date of graduation, or copy of General Equivalency Degree (GED) certificate;
(7) Four written professional references, including one from a health care provider;
(8) If applicable, information regarding post-secondary education, including
a. Name and address of college or vocational training school;
b. Dates attended;
c. Total credit hours;
d. Certificate or diploma granted and date;
e. List of courses taken; and
f. Official college transcripts;
(9) Disclosure of any criminal convictions;
(10) A signed statement by the applicant certifying that everything in the application is true to the best of the applicant's knowledge;
(11) Any professional licenses held; and
(12) Current midwifery certifications including but not limited to North American Registry of Midwives, American College of Nurse Midwives Certification Council, etc.
(c) Each applicant shall submit a written plan setting forth the applicant's arrangements, both formal and informal, for medical back-up.
(d) Medical back-up arrangements shall include
(1) Coverage for clients in the event of the applicant's absence or illness;
(2) Plans for consultation with individual or group practices of obstetricians, family practitioners, pediatricians, or other physicians concerning abnormal conditions or medically indicated transfers;
(3) Description of hospital services to be used for emergency transfers;
(4) Arrangements for conducting prenatal laboratory tests;
(5) Arrangements for ensuring that newborn metabolic screening tests and Rhogam are administered; and
(6) Description of any ongoing relationships such as hospital privileges or association with a physician.
(e) If the Midwifery Council determines that an applicant's back-up arrangements are not in accordance with He-P 3103.01 (c) and (d), the Midwifery Council shall require an applicant to provide additional information or to make additional arrangements for back-up in order to obtain or keep certification.
(f) Each applicant shall present a written description of her/his training and experience in midwifery, including related experience such as obstetrical nursing, and including experience outside the State of New Hampshire.
(g) Each applicant shall submit an affidavit, approved by the preceptor, attesting to the requisite number of clients attended and skills attained pursuant to He-P 3102.01 (a) (5) and (6).
(h) Each applicant shall submit evidence of a passing grade on the NARM Certification Exam.
He-P 3103.02 Certification Process
(a) The Midwifery Council shall check the application for completeness.
The Midwifery Council shall notify the applicant regarding receipt of the application and its completeness within 2 weeks of receipt of the application.
(b) The Midwifery Council shall review complete applications. Within 30 days, the Midwifery Council will make recommendations to the applicant of acceptance or rejection.
(c) After reviewing the submitted application, the Midwifery Council shall
(1) Determine whether the applicant meets the criteria as set forth in He-P 3102.01; and
(2) Notify the applicant in writing within one week of the Midwifery Council's decision to accept or reject the application.
(3) If application is accepted, notify applicant of dates for qualifying exams (NARM, NH Rules, Oral).
(d) Administration of the written examinations shall be in accordance with the following
(1) In addition to a passing grade on the NARM Certification Exam, the applicant must receive a score of 80% or better on a written exam assessing familiarity with RSA 326 and He-P 3100;
(2) The New Hampshire Rules Examination shall be scored and evaluated by a representative of the Midwifery Council.
(3) The NARM and the New Hampshire Rules Examinations shall be available at least twice a year.
(e) The Midwifery Council shall make arrangements for the administration of an oral examination. The oral exam shall further test midwifery skills and knowledge. A passing score of 80% or greater shall be required.
(f) Applicants shall be notified of their test results within 4 weeks of the test date or within 4 weeks from the receipt of the test score from NARM.
(g) When an applicant demonstrates satisfactory completion of all of the requirements for certification, the Midwifery Council shall issue within 2 weeks a written certificate to that person indicating that she/he is a New Hampshire Certified Midwife. The effective date of certification shall be the date the Midwifery Council approves the certification. The expiration date of the certification shall be 2 years after the effective date.
(h) In the event a midwife certification candidate fails to pass one or
both of the written exams or the oral exam, the following retest procedure shall apply
(1) The applicant shall apply to the Midwifery Council to re-take the exams after at least 4 weeks have passed;
(2) The applicant shall provide the following information on the application
b. Date of last exam;
c. Applicant name;
d. Home address;
e. Home phone and;
f. Business phone (if different).
(3) Candidates may apply for retest no more than 3 times;
(4) Procedures for scoring the exam and notification of the applicant of the results shall be as set forth in He-P 3103.02 (d), (e), and (f).
(i) The Midwifery Council shall maintain a list, to be updated annually, of all persons who have been certified as midwives in the State, together with their addresses and region in which they practice. This list shall be available to the public as wall as to other agencies. The Midwifery Council shall disseminate the list, on request.
He-P 3103.03 Reciprocity
(a) If an applicant has been duly certified or licensed in another state or country and the credentialing requirements are deemed by the Midwifery Council equivalent to or higher than these rules, the applicant shall be considered for certification.
(b) A midwife with current recognition by the North American Registry of Midwives as a Certified Professional Midwife (CPM) shall be eligible for New Hampshire Certification by reciprocity. American College of Nurse Midwives Certification Council Certified Midwives (CM) shall be eligible for New Hampshire Certification by reciprocity if their requirements for certification are deemed equal to or better than the New Hampshire State requirements as determined by the Midwifery Council.
(c) Certification by reciprocity shall be issued to any applicant who
(1) Plans to engage in active practice in New Hampshire;
(2) Submits a complete application pursuant to He-P 3103.01;
(3) Includes with the application
a. An official copy of
1. The certification or licensure;
2. The midwifery law from that state or country; and
3. The rules and regulations which support the practice of midwifery in the state or country; or
b. The NARM CPM Certificate or ACC Certified Midwife Certificate; and
(4) Submits references required in He-P 3103.01 (b) (7), which may be from a previous practice location.
(d) The applicant shall be provided with a copy of RSA 326-D and these rules and shall be required to demonstrate knowledge of them by obtaining an 80% or higher score on the examination covering the New Hampshire Midwifery Rules and Law.
(e) The applicant must pass and oral exam of practical experience unless waived by the Midwifery Council.
(f) If the certification/licensure requirements of the other state or country are not deemed equivalent to or higher than RSA 326-D and these rules by the Midwifery Council, a subcommittee shall prepare a list of requirements which are lacking and make appropriate recommendations.
(g) The Midwifery Council shall notify the applicant in writing, pursuant to He-P 3103.07 (b) of
(1) The specific deficiencies identified by the subcommittee;
(2) Suggestions for ways the applicant can fulfill the requirements; and
(3) Resources that would assist the applicant in fulfilling the requirements.
He-P 3103.04 Recertification
(a) In order to renew certification as a midwife in New Hampshire, a midwife shall once every two years request continued certification and provide evidence of the following
(1) If engaged in active practice, submit current back-up arrangements as set forth in He-P 3103.01 and He-P 3103.02;
(2) Documentation of attendance of at least 20 hours of continuing education programs during the preceding 2 years pursuant to He-P 3106.01;
(3) Participation in peer reviews pursuant to He-P 3107 in conjunction with other midwives and/or health professionals concerned with obstetrics and/or newborn care; and
(4) If applicable, names of any assistants, associates or apprentices with whom the midwife regularly works, with an indication of whether each person is certified under this chapter.
(b) Applicants for recertification who meet the requirements listed in (a) shall be issued a New Hampshire Midwifery Certificate effective for 2 years from date of recertification.
(c) If the application is not received prior to the expiration date of the certification, the certification shall be considered lapsed. A midwife whose certificate has lapsed can no longer legally practice midwifery in New Hampshire. The penalty for a lapsed certificate will result in a fine of an additional $50 for reinstating certification within 30 days. Past 30 days of the recertification date, the applicant must re-apply for full certification.
He-P 3103.05 Complaints and Investigations
(a) In the event that it comes to the attention of the Midwifery Council, either through the midwife's reports or a signed, written complaint from a consumer, physician, or other source, that a New Hampshire Certified Midwife is not practicing in accordance with these rules, or is in other ways endangering the life or health of mothers and infants under her/his care, the Midwifery Council shall investigate the complaint.
(b) All complaints shall contain the following information
(1) Name and address of the individual or group filing the complaint;
(2) Date of the complaint and signature(s) of complainant(s);
(3) Date, time, place and summary of the suspected violations(s); and
(4) Other data pertinent to the complaint.
(c) The Midwifery Council shall notify in writing the New Hampshire Certified Midwife against whom the complaint is registered and that an investigation will be conducted. If, upon completion of the investigation, the Midwifery Council believes that further action is warranted, pursuant to He-P 3103.07, to protect the public's health and safety, the Midwifery Council shall conduct a show cause hearing in accordance with He-C 200.
Any members of the Midwifery Council that have had any involvement with the case shall not be included in this conference.
He-P 3103.06 Revocation, Denial or Refusal to Renew Certification
(a) Certification of a midwife shall be revoked, denied, or not renewed when it has been determined by the Midwifery Council that
(1) A midwife has endangered the life and health of a mother and/or infant under her/his care;
(2) A midwife violates the provisions of these rules; and/or
(3) A midwife fails the meet the requirements for recertification.
(b) If the Midwifery Council revokes, refuses to issue, or refuses to renew a midwife's certification, notice in writing describing the grounds for any of these decisions shall be sent to the midwife by certified mail with return receipt requested, together with a statement of the midwife's right for an adjudicative proceeding.
(c) A request for an adjudicative proceeding shall be made in writing by the New Hampshire Certified Midwife and be filed within 10 working days following the date of receipt of the certified letter.
(d) Adjudicative hearings shall be conducted in accordance with He-C 200.
(e) Appeal hearings shall be conducted in accordance with the procedures set forth in He-C 200.
He-P 3104.01 Leave of Absence of Less Than 3 years
(a) The Midwifery Council will grant a leave of absence to a New Hampshire
Certified Midwife for up to 3 years after receiving a written letter of intent prior to the date of recertification.
(b) To become recertified, an NHCM may re-apply under He-P 3104.01 as follows
(1) Submit written documentation of attendance at 10 hours of continuing education programs and 3 peer review sessions in the year previous to the application date; and
(2) Submit documentation of current CPR and Neonatal Resuscitation
Part He-P 3104 LEAVE OF ABSENCE
He-P 3104.02 Leave of Absence of More Than 3 years
(a) If a midwife lets her/his certification lapse and more than 3 years have passed, she or he shall apply for full certification.
(b) Pursuant to He-P 3104.02 (a), all applicants for full certification shall
(1) Meet the criteria set forth in He-P 3102.01 and 3102.02;
(2) Submit a signed letter from one of the following attesting to completion of a refresher course consisting of care and delivery of at least 10 pregnant women
a. A NH Certified Midwife;
b. A NARM Certified Professional Midwife;
c. A Certified Nurse Midwife;
d. A licensed physician practicing obstetrics;
(3) Provide documentation of the skills set forth in He-P 3102.01; and
(4) Re-take the exam on New Hampshire rules and statutes
(c) An applicant who has been actively practicing midwifery outside the State of NH within the previous 3 years of application for recertification and who can submit documentation of such, shall have He-P 3104.02 (b) (2) waived.
Part He-p 3105 REPORTING REQUIREMENTS
He-P 3105.01 Client Information
(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.
He-P 3105.02 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.
Part He-P 3106 CONTINUING EDUCATION
He-P 3106.01 Continuing Education Requirements
(a) Each New Hampshire Certified Midwife shall attend at least 20 hours of continuing education programs during the preceding 2 years which shall be in the subject areas of prenatal, intrapartum and postpartum care of the mother and newborn.
(b) Home study continuing education programs approved by the American Medical Association (AMA), the American College of Obstetrics and Gynecology (ACOG), and the American College of Nurse Midwives (ACNM) or any accredited institution offering midwifery as a degree, shall also be accepted providing they do not total more than 10 of the total 20 hours required.
Part He-P 3107 PEER REVIEW
He-P 3107.01 Peer Review Requirements
(a) Each Certified New Hampshire Midwife shall participate in at least 6 peer review case conferences every 2 years, which include discussion of the care and outcome of cases for educational purposes.
(b) The list of dates of all peer review case conferences and evidence of attendance and content shall be submitted upon application for re-certification.
Part He-P 3108 PROCEDURES IN THE PRACTICE OF MIDWIFERY
He-P 3108.01 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.
He-P 3108.02 Prenatal Care
(a) If the client initially contacts the New Hampshire Certified Midwife during the first or second trimester of pregnancy, the New Hampshire Certified Midwife shall
(1) Complete a maternal health history;
(2) Complete a pelvic exam;
(3) Obtain blood pressure;
(4) Complete routine blood work including but not limited to
a. Blood type and Rh antibody screen;
c. Rubella titre;
d. Syphilis serology;
e. Hepatitis B surface antigen; and
f. HIV testing, if elected by the client.
(5) Complete and initial nutritional assessment and counseling;
(6) Obtain a pap smear if none has been done in the previous 6 months;
(7) Obtain chlamydia and gonorrhea screening tests;
(8) Establish gestational age; and
(9) Advise of available prenatal testing.
(b) A health care provider other than the New Hampshire Certified Midwife may do the laboratory tests listed in paragraph (a), with the results forwarded to the New Hampshire Certified Midwife.
(c) During the first trimester, the New Hampshire Certified Midwife shall recommend the client receive a general physical exam by a qualified health care provider to screen for general health problems that might complicate the pregnancy and/or delivery.
(d) If the client first contacts the New Hampshire Certified Midwife during the third trimester of pregnancy, the New Hampshire Certified Midwife shall assess the adequacy of any previous prenatal care and/or self care, including nutrition, and shall assume responsibility for the client only if she/he is satisfied that the prior care has been adequate.
(e) Following the initial visit, the New Hampshire Certified Midwife shall see the client
(1) Once a month through the twenty-eighth week of pregnancy;
(2) Once every 2 weeks from the twenty-eighth through the thirty-sixth week; and
(3) Once a week from the thirty-sixth week until the onset of labor,
assuming pregnancy is normal.
(f) At each prenatal visit, the New Hampshire Certified Midwife shall
(1) Check the client's
b. Blood pressure;
c. Urine dip for protein and glucose; and
d. General health, including checking for
5. Dizziness; and
6. Other symptoms of preeclampsia.
(2) Conduct or arrange for additional laboratory tests or procedures as indicated, including but not limited to
a. Rh antibody screening;
b. Prophylactic Rhogam injection;
c. Blood sugar screening; and
d. Periodic hemoglobin testing.
(3) Monitor uterine measurements, fetal heart rate, and fetal activity.
(g) All clients with genital herpes shall be advised by the New Hampshire
Certified Midwife of the current ACOG herpes protocol.
(h) The New Hampshire Certified Midwife shall maintain an individual client chart for each woman under her/his care, which includes
(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 their
choice of out of hospital birth have been satisfactorily answered;
e. The name of the New Hampshire Certified Midwife;
f. Authorization for the New Hampshire Certified Midwife to attend the client;
g. The signature of the client and her partner, if applicable;
h. The date of the signing.
(2) Results of laboratory tests and observations from each prenatal visit;
(3) Prenatal visit records pursuant to He-P 3108.02
(4) Records of consultations with physicians or other health care providers;
(5) Records of waivers signed, including those for vaginal birth after cesarean section;
(6) A postpartum report concerning labor, delivery, and condition of the
(i) The individual client chart shall be made available to the client upon request, and, with the client's consent, to any physician or health care provider who is called in as a consultant or back-up. The labor and delivery summary shall be routinely provided to the pediatrician who will be following the child. The chart maintained by a New Hampshire Certified Midwife and the communications between a New Hampshire Certified Midwife and her client shall be considered confidential information pursuant to RSA 91-A.
(j) During the third trimester, the New Hampshire Certified Midwife shall ensure that the client is adequately preparing for a home birth or birth in a freestanding birth center by discussing such issues as
(2) Adequate heat and water;
(3) Availability of telephone and transportation;
(4) Equipment needed; and
(5) Emergency back-up plan
(k) During the third trimester, the New Hampshire Certified Midwife shall consult with the client concerning the selection of a pediatrician, family physician, or other health care provider who will be assuming responsibility for the infant and shall note the parent's choice on the chart.
(l) The Certified New Hampshire Midwife shall encourage the client to take a prepared childbirth class oriented toward birth at home or in a freestanding birth center. If the client has previously taken a class, a refresher course shall be encouraged.
He-P 3108.03 Contraindications
(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; 16
(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.
He-P 3108.04 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.
He-P 3108.05 Intrapartum Care
(a) During labor and delivery, the attending New Hampshire Certified Midwife shall
(1) Monitor the condition of mother and fetus;
(2) Coach labor;
(3) Assist with the delivery;
(4) Repair lacerations as necessary;
(5) Examine and assess the newborn;
(6) Inspect the placenta, membranes, and cord vessels;
(7) Inspect the perineum and lower vagina and the cervix and upper vaginal vault, if indicated; and
(8) Manage any third-stage maternal bleeding.
(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;
(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;
(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.
(c) In the event that the client is transferred to a hospital, the New Hampshire Certified Midwife shall make every effort to remain with her as a labor coach and prepare a report for the client's chart concerning the reasons for transfer and the outcome.
(d) The attending New Hampshire Certified Midwife shall prepare a summary of labor and delivery and an assessment of the newborn. One copy of each summary shall be retained with the client's chart, and one copy transmitted to the pediatrician or family doctor entrusted with the infant's care.
(e) The New Hampshire Certified Midwife shall administer an appropriate eye prophylaxis to the newborn infant in accordance with New Hampshire RSA
1326 and He-P 3108.05 (g). If parents refuse, the New Hampshire Certified Midwife shall document that she/he has informed parents of the purpose and risks and shall obtain a signed statement of refusal.
(f) The attending New Hampshire Certified Midwife shall make a report of the birth to the Bureau of Vital Records and Health Statistics.
(g) A New Hampshire Certified Midwife shall administer the following medications, as outlined in RSA 326-D12 II under the conditions indicated
(1) Rh immune globulin (Rhogam), if indicated;
(2) Eye prophylaxis in accordance with RSA 1326;
(3) Oxygen for fetal distress and infant resuscitation;
(4) Lidocaine hydrochloride by infiltration, for the purpose of postpartum repair of tears, lacerations, or episiotomy;
(5) Vitamin K by injection, or oral Vitamin K for control and prevention of acute and late onset hemorrhagic disease in the newborn;
(6) Oxytocins such as pitocin, ergotrate, or methergine, by injection or orally, for postpartum control of maternal hemorrhage; and
(7) Intravenous fluids such as Ringer's Lactate with or without D5W, or Normosol-R with or without D5W with additional medications only if specifically ordered by a physician.
He-P 3108.06 Postpartum Care
(a) The New Hampshire Certified Midwife shall provide the client with information concerning routine postpartum care of the mother and infant, including information on breastfeeding, and perinatal care.
(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.
(c) The New Hampshire Certified Midwife shall provide the primary care provider with her/his written summary of labor and delivery and an assessment of the newborn, and be available to consult with the doctor concerning the infant's condition.
(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.
(j) The New Hampshire Certified Midwife shall obtain a blood sample for Newborn metabolic screening as required by RSA 13210-a at 4-7 days of age, or shall recommend that the test is done by the family physician or other health care provider. If the parents refuse the testing procedure, the New Hampshire Certified Midwife shall document that they have been informed of the purpose and risks and obtain a signed statement of refusal.
(k) The New Hampshire Certified Midwife shall conduct a postpartum office visit at 4-6 weeks postpartum to include
(1) A Pap smear, if indicated;
(2) Recommendation for rubella vaccine, if indicated;
(3) Counseling concerning contraception; and
(4) The answering of any questions that may have arisen.
(l) Alternately, the client shall be referred back to her primary care physician or other health care provider for postpartum care.
Part He-P 3109 MIDWIFERY COUNCIL REVIEW
He-P 3109.01 Mortality/Morbidity Review
(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.
(c) If the Midwifery Council's report determines that the care provided by the New Hampshire Certified Midwife was not in accordance with the rules as set forth in He-P 3108, they shall
(1) Review the related records and reports and take appropriate action in accordance with He-P 3103.07; and
(2) Refer to the Attorney General if there is suspicion of violation of State law.
Part He-P 3110 WAIVERS
He-P 3110.01 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
(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.