DAR File No. 28294

Commerce, Occupational and Professional Licensing

R156-77

Direct-Entry Midwife Act Rules

NOTICE OF CHANGE IN PROPOSED RULE

DAR File No.: 28294
Filed: 03/09/2006, 11:36
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

Following a public hearing and further review by the Division, Licensed Direct-Entry Midwife Board and Licensed Direct-Entry Midwife Temporary Rules Committee, amendments are being proposed to the rule.

Summary of the rule or change:

In Section R156-77-102, added a definition for an "appropriate provider" which is based on level of education and scope of practice. Remaining subsections have been renumbered. In Section R156-77-601, amendments are made to the practice standards by including more symptoms/problems or moving a symptom/problem to a different category of a practice standard. For example, several problems were moved from transfer (which is waiveable by the client to mandatory transfer such as a client with HIV or AIDS). In Section R156-77-602, additions were made in Subsection R156-77-602(2) to further clarify the responsibility of the licensed direct-entry midwife (LDEM) who is transferring the care of a client to another provider. The LDEM should travel with the client if possible and should make a reasonable effort to convey client information to the accepting provider. (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed new rule that was published in the November 15, 2005, issue of the Utah State Bulletin, on page 14. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike-out indicates text that has been deleted. You must view the change in proposed rule and the proposed new rule together to understand all of the changes that will be enforceable should the agency make this rule effective.)

State statutory or constitutional authorization for this rule:

Subsections 58-1-106(1)(a), 58-1-202(1)(a), 58-77-202(4), and 58-77-601(2)

Anticipated cost or savings to:

the state budget:

No additional costs are anticipated as a result of these proposed amendments beyond those previously identified in the original rule filing.

local governments:

No fiscal impact on local governments is anticipated because local governments would not need to seek direct-entry midwife licensure or the services of a licensed direct-entry midwife.

other persons:

No additional costs or savings are anticipated as a result of these proposed amendments beyond those previously identified in the original rule filing for persons applying for licensure as a direct-entry midwife. The proposed amendments do however increase the number and type of problems with respect to a client that must be transferred to another appropriate provider. The cost to the client would increase in this situation because a home birth would no longer be an option. The Division is not able to determine an exact increase in costs to a client as the costs would depend on numerous variable factors.

Compliance costs for affected persons:

No additional costs or savings are anticipated as a result of these proposed amendments beyond those previously identified in the original rule filing for persons applying for licensure as a direct-entry midwife. The proposed amendments do however increase the number and type of problems with respect to a client that must be transferred to another appropriate provider. The cost to the client would increase in this situation because a home birth would no longer be an option. The Division is not able to determine an exact increase in costs to a client as the costs would depend on numerous variable factors.

Comments by the department head on the fiscal impact the rule may have on businesses:

The original rule filing adopted standards to administer the Direct-Entry Midwife Act, which was adopted by H.B. 25 in the 2005 Legislative Session. The costs associated with the rules were indicated in the rule summary and were part of the fiscal impact statement to H.B. 25. This rule filling, a change in proposed rule, takes into consideration various comments from the industry. No additional fiscal impact to businesses is anticipated as a result of this filing. Francine A. Giani, Executive Director (DAR NOTE: H.B. 25 is found at Chapter 299, Laws of Utah 2005, and was effective 05/02/2005.)

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Laura Poe at the above address, by phone at 801-530-6789, by FAX at 801-530-6511, or by Internet E-mail at lpoe@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

05/01/2006

This rule may become effective on:

05/02/2006

Authorized by:

J. Craig Jackson, Director

RULE TEXT

R156. Commerce, Occupational and Professional Licensing.

R156-77. Direct-Entry Midwife Act Rules.

R156-77-102. Definitions.

In addition to the definitions in Title 58, Chapters 1 and 77, as used in Title 58, Chapter 77 or these rules:

(1) "Accredited school", as used in these rules, includes any midwifery school that has been granted pre-accredited status by MEAC.

(2) "Apgar score", as used in Section R156-77-601, means an index used to evaluate the condition of a newborn based on a rating of 0, 1, or 2 for each of the five characteristics of color, heart rate, response to stimulation of the sole of the foot, muscle tone, and respiration with 10 being a perfect score.

(3) "Appropriate provider", as used in Sections R156-77-601 and 602, means a licensed provider who is an appropriate contact person based on the provider's level of education and scope of practice.

([3]4) "Collaborate", as used in Section R156-77-601, means the process by which an LDEM and another licensed health care provider jointly manage a specific condition of a client according to a mutually agreed-upon plan of care. The LDEM continues midwifery management of the client and may follow through with the medical management as agreed upon with the provider.

([4]5) "Consultation", as used in Section R156-77-601, means the process by which the LDEM discusses client status with an appropriate licensed health care provider by phone, written note, or in person. The provider may give a recommendation for management, but does not assume the management of the client.

([5]6) "CPR", as used in these rules, means cardiopulmonary resuscitation.

([6]7) "LDEM", as used in these rules, means a licensed direct entry midwife licensed under Title 58, Chapter 77.

([7]8) "MANA", as used in these rules, means the Midwives Alliance of North America.

([8]9) "MEAC", as used in these rules, means the Midwifery Education Accreditation Council.

([9]10) "Midwifery Care", as used in these rules, has the same meaning as the practice of direct-entry midwifery as defined in Subsection 58-77-102(7).

([10]11) "NARM", as used in these rules, means the North American Registry of Midwives.

([11]12) "Refer", as used in Section R156-77-601, means the process by which an LDEM directs the client to an appropriate licensed health care provider for management of a specific condition. The LDEM continues midwifery management of the client.

([12]13) "Transfer", as used in Section R156-77-601, means the process by which an LDEM relinquishes management of a client to an appropriate licensed health care provider. The LDEM may provide on-going support services as appropriate.

([13]14) "Unprofessional conduct," as defined in Title 58 Chapters 1 and 77, is further defined, in accordance with Subsection 58-1-203(5), in Section R156-77-502.

R156-77-601. Standards of Practice.

Except as provided in Subsection 58-77-601(3)(b), and in accordance with Subsection 58-77-601(2), the standards and circumstances that require an LDEM to recommend and facilitate consultation, collaboration, referral, transfer, or mandatory transfer of client care are established herein. These standards are at a minimum level and are hierarchical in nature. If the standard requires at least consultation for a condition, an LDEM may choose to collaborate, refer, or transfer the care of the client.

(1) Consultation:

(a) antepartum:

(i) suspected intrauterine growth [retardation]restriction;

(ii) [changes in the breasts not related to pregnancy]mild preeclampsia defined as a sustained diastolic blood pressure of 90 mm or greater in two readings at least six hours apart and 1+ to 2+ proteinurea;

(iii) significant vaginal bleeding inconsistent with normal pregnancy or miscarriage;

(iv) hyperemesis unresponsive to LDEM treatment;

(v) pain unrelated to common discomforts of pregnancy;

(vi) presence of condylomata that may obstruct delivery;

(vii) anemia unresponsive to LDEM treatment;

(viii) history of genital herpes;

(ix) suspected fetal demise;

(x) suspected multiple gestation;

(xi) confirmed chromosomal or genetic aberrations;

(xii) hepatitis C; and

(xiii) any other condition in the judgment of the LDEM requires consultation.

(2) Collaborate:

(a) antepartum:

(i) infection not responsive to LDEM treatment;

(ii) seizure disorder affecting the pregnancy;

(iii) history of cervical incompetence with surgical therapy;

(iv) third trimester genital herpes outbreak;

(v) moderate [preeclampsia or ]pregnancy induced hypertension defined as a sustained diastolic blood pressure of between 100 mm and 110 mm in two readings at least six hours apart;[ and]

(vi) persistent oligohydramnios or polyhydramnios; and

(vii) any other condition in the judgment of the LDEM requires collaboration;

(b) postpartum:

(i) infection not responsive to LDEM treatment; and

(ii) any other condition in the judgment of the LDEM requires collaboration.

(3) Refer:

(a) antepartum:

(i) thyroid disease;

(ii) [human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS)]changes in the breasts not related to pregnancy or lactation;

(iii) severe psychiatric illness responsive to treatment;

(iv) [persistent oligohydramnios or polyhydramnios;

(v) ]heart disease that has been determined by a cardiologist to have potential to affect or to be affected by pregnancy, labor, or delivery; and

(v[i]) any other condition in the judgment of the LDEM requires referral;

(b) postpartum:

(i) bladder dysfunction;

(ii) severe depression; and

(iii) any other condition in the judgment of the LDEM requires referral;

(c) newborn:

(i) birth injury requiring on-going care;

(ii) minor congenital anomaly;

(iii) jaundice beyond physiologic levels;

(iv) [failure to thrive]loss of 15% of birth weight;

(v) inability to suck or feed; and

(vi) any other condition in the judgment of the LDEM requires referral.

(4) Transfer, however may be waived in accordance to Subsection 58-77-601(3)(b):

(a) antepartum:

(i) current drug or alcohol abuse;

(ii) [mono-amniotic multiple gestation;

(iii) twin-to-twin transfusion syndrome;

(iv) ]greater than a one and one-half pound estimated weight discrepancy between fetuses in a multiple gestation;

([v]iii) current diagnosis of cancer;

([vi]iv) Rh isoimmunization;

(v[ii]) confirmed intrauterine growth [retardation]restriction;

(vi[ii]) insulin-dependent diabetes;[ and]

(vii) gestation greater than 43 weeks; and

([ix]viii) any other condition in the judgment of the LDEM may require transfer;

(b) intrapartum:

(i) suspected chorioamnionitis;

(ii) non-reassuring fetal heart rate pattern indicative of fetal distress that does not respond to LDEM treatment;

(iii) visible genital lesions suspicious of herpes virus infection;

(iv) moderate hypertension;[ and]

(v) excessive vomiting, dehydration, acidosis, or exhaustion unresponsive to LDEM treatment; and

(vi) any other condition in the judgment of the LDEM may require transfer;

(c) postpartum:

(i) retained placenta; and

(ii) any other condition in the judgment of the LDEM may require transfer;

(d) newborn:

(i) gestational age assessment less than thirty-six (36) weeks;

(ii) major congenital anomaly not diagnosed prenatally;

(iii) persistent hyperthermia or hypothermia unresponsive to LDEM treatment; and

(iv) any other condition in the judgment of the LDEM may require transfer.

(5) Mandatory transfer:

(a) antepartum:

(i) severe preeclampsia or pregnancy induced hypertension;

(ii) eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP);

(iii) documented platelet count less than 75,000 platelets per mm³ of blood;

(iv) [complete placenta previa at week 36 or greater; and]diagnosed partial placenta previa at week 36, or complete placenta previa at 32 weeks;

(v) confirmed ectopic pregnancy;

(vi) severe psychiatric illness non-responsive to treatment;

(vii) human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS);

(viii) mono-amniotic multiple gestation;

(ix) twin-to-twin transfusion syndrome; and

([v]x) any other condition in the judgment of the LDEM must be transferred;

(b) intrapartum:

(i) signs of uterine rupture;

(ii) presentation(s) not compatible with spontaneous vaginal delivery;

(iii) progressive labor prior to 36 weeks gestation except miscarriages, confirmed fetal death, or congenital anomalies incompatible with life;

(iv) prolapsed umbilical cord unless birth is imminent;

(v) clinically significant abdominal pain inconsistent with normal labor;

(vi) seizure;

(vii) complete placenta previa; and

(viii) any other condition in the judgment of the LDEM must be transferred;

(c) postpartum:

(i) uncontrolled hemorrhage;

(ii) maternal shock that is unresponsive to LDEM treatment;

(iii) [postpartum psychosis]severe psychiatric illness non-responsive to treatment;

(iv) signs of deep vein thrombosis or pulmonary embolism; and

(v) any other condition in the judgment of the LDEM must be transferred;

(d) newborn:

(i) non-transient respiratory distress;

(ii) non-transient pallor or central cyanosis;

(iii) Apgar score at ten minutes of less than six;

(iv) [full CPR for greater than two minutes]low heart rate of less than 60 beats per minute after one complete neonatal resuscitation cycle;

(v) absent heart rate except with confirmed fetal death or congenital anomalies incompatible with life, or shoulder dystocia resulting in death;

(vi) hemorrhage;

(vii) seizure;

(viii) persistent hypertonia, lethargy, flaccidity or irritability, or jitteriness;

([viii]ix) inability to urinate or pass meconium within the first 48 hours of life; and

([i]x) any other condition in the judgment of the LDEM must be transferred.

R156-77-602. Procedures for the Termination of Midwifery Care.

(1) The procedure to terminate midwifery care for a client who has been informed that she has or may have a condition indicating the need for medical consultation, collaboration, referral, or transfer is established herein:

(a) provide no fewer than three business days written notice, unless an emergency, during which the LDEM shall continue to provide midwifery care, to enable the client to select another licensed health care provider;

(b) provide a referral; and

(c) document the termination of care in the client's records.

(2) The procedure to terminate midwifery care to a client who has been informed that she has or may have a condition indicating the need for mandatory transfer is established herein[.]:

(a) have the client sign a release of care indicating the LDEM has terminated providing midwifery care as of a specific date and time; or

(b) verbally instruct the client of the termination of midwifery care and document said instruction in the client record;

(c) make a reasonable effort to convey significant information regarding the client's condition to the receiving provider; and

(d) if possible, when transferring the client by ambulance or private vehicle, the LDEM accompanies the client.

KEY: licensing, midwife, direct-entry midwife

Date of Enactment or Last Substantive Amendment: [2005]2006

Authorizing, and Implemented or Interpreted Law: 58-1-106(1)(a); 58-1-202(1)(a); 58-77-202(4); 58-77-601(2)

ADDITIONAL INFORMATION

PLEASE NOTE:

• Text to be deleted is struck through and surrounded by brackets (e.g., [example]). Text to be added is underlined (e.g., example). Some browsers may not depict some or any of these attributes on the screen or when the document is printed.
• Please see the DISCLAIMER regarding information available from state web pages.

For questions regarding the content or application of this rule, please contact Laura Poe at the above address, by phone at 801-530-6789, by FAX at 801-530-6511, or by Internet E-mail at lpoe@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.