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Rule R156-77. Direct-Entry Midwife Act Rules.

As in effect on August 1, 2009

Table of Contents

• R156-77-101. Title.
• R156-77-102. Definitions.
• R156-77-103. Authority - Purpose.
• R156-77-104. Organization - Relationship to Rule R156-1.
• R156-77-302a. Qualifications for licensure - Application Requirements.
• R156-77-302b. Qualifications for licensure - Education Requirements.
• R156-77-303. Renewal Cycle - Procedures.
• R156-77-502. Unprofessional Conduct.
• R156-77-601. Standards of Practice.
• R156-77-602. Procedures for the Termination of Midwifery Care.
• R156-77-603. Submission of Outcome Data.
• KEY
• Date of Enactment or Last Substantive Amendment
• Authorizing, Implemented, or Interpreted Law

R156-77-101. Title.

These rules are known as the "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.

(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.

(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.

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

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

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

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

(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).

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

(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.

(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.

(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.

R156-77-103. Authority - Purpose.

These rules are adopted by the division under the authority of Subsection 58-1-106(1)(a) to enable the division to administer Title 58, Chapter 77.

R156-77-104. Organization - Relationship to Rule R156-1.

The organization of this rule and its relationship to Rule R156-1 is as described in Section R156-1- 107.

R156-77-302a. Qualifications for licensure - Application Requirements.

In accordance with Subsections 58-1-203(1), 58-1-301(3), and 58-77-302(5), the application requirements for licensure in Section 58-77-302 are defined herein.

(1) An applicant for licensure as an LDEM must submit documentation of current CPR certification for health care providers, for both adults and infants, from one of the following organizations:

(a) American Heart Association;

(b) American Red Cross or its affiliates; or

(c) American Safety and Health Institute.

(2) An applicant for licensure as an LDEM must submit documentation of current newborn or neonatal resuscitation certification from one of the following organizations:

(a) American Academy of Pediatrics;

(b) American Heart Association; or

(c) a MEAC approved program or accredited school.

R156-77-302b. Qualifications for licensure - Education Requirements.

In accordance with Subsections 58-1-203(1), 58-1-301(3), and 58-77-302(6), the pharmacology course requirement for licensure in Subsection 58-77-302(6) is defined herein. The course must be:

(1) offered by a post-secondary educational institution that is accredited by an accrediting board recognized by the Council for Higher Education Accreditation of the American Council on Education, a MEAC approved midwifery program or accredited midwifery school, or be a MEAC approved program or course; and

(2) at least eight clock hours in length and include basic pharmacotherapeutic principles and administration of medications including the drugs listed in Subsections 58-77-102(7)(f)(i) through (ix); or

(3) a general pharmacology course of at least 20 clock hours in length from a health-related course of study.

R156-77-303. Renewal Cycle - Procedures.

(1) In accordance with Subsection 58-1-308(1), the renewal date for the two-year renewal cycle applicable to licensees under Title 58, Chapter 77 is established by rule in Subsection R156-1-308a(1).

(2) Renewal procedures shall be in accordance with Section R156-1-308c.

(3) Each applicant for renewal shall comply with the following:

(a) submit documentation of holding a current Certified Professional Midwife certificate in good standing with NARM; and

(b) submit documentation of current certifications in adult and infant CPR, and newborn resuscitation that meets the criteria established in R156-77-302a.

R156-77-502. Unprofessional Conduct.

"Unprofessional conduct" includes:

(1) failure to practice in accordance with the knowledge, clinical skills, and judgments described in the MANA Core Competencies for Basic Midwifery Practice (1994), which is hereby adopted and incorporated by reference; and

(2) failing as a midwife to follow the MANA Standards and Qualifications for the Art and Practice of Midwifery (1997), which is hereby adopted and incorporated by reference.

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 restriction;

(ii) severe vomiting unresponsive to LDEM treatment;

(iii) pain unrelated to common discomforts of pregnancy;

(iv) presence of condylomata that may obstruct delivery;

(v) anemia unresponsive to LDEM treatment;

(vi) history of genital herpes;

(vii) suspected fetal demise;

(viii) suspected multiple gestation;

(ix) confirmed chromosomal or genetic aberrations;

(x) hepatitis C; and

(xi) 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) mild hypertension defined as a sustained diastolic blood pressure of between 90 mm and 100 mm in two readings at least six hours apart; and

(vi) 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) changes in the breasts not related to pregnancy or lactation;

(iii) severe psychiatric illness responsive to treatment;

(iv) 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) 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) 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 with Subsection 58-77-601(3)(b):

(a) antepartum:

(i) current drug or alcohol abuse;

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

(iii) current diagnosis of cancer;

(iv) persistent oligohydramnios not responsive to LDEM treatment;

(v) confirmed intrauterine growth restriction;

(vi) confirmed breech presentation;

(vii) twins;

(viii) two previous c-sections;

(ix) history of preterm delivery less than 34 weeks;

(x) history of severe postpartum bleeding;

(xi) primary genital herpes outbreak;

(xii) 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;

(xiii) gestation greater than 43 weeks; and

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

(b) intrapartum:

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

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

(iii) moderate hypertension defined as a sustained diastolic blood pressure of greater than 110 mm in two readings at least six hours apart;

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

(v) 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 severe 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) 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;

(x) three or more previous c-sections;

(xi) higher order (greater than two) multiple gestations;

(xii) RH isoimmunization in a mother carrying Rh positive baby or a baby of unknown Rh type;

(xiii) insulin-dependent diabetes;

(xiv) significant vaginal bleeding after 20 weeks not consistent with normal pregnancy and posing a continuing risk to mother or baby; and

(xv) 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;

(viii) suspected chorioamnionitis;

(ix) 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) 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) 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;

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

(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.

R156-77-603. Submission of Outcome Data.

In accordance with Subsection 58-77-601(5), an individual licensed as an LDEM must submit outcome data electronically to the MANA's Division of Research on the form prescribed by MANA, and in accordance to the policies and procedures established by MANA.

KEY

licensing, midwife, direct-entry midwife

Date of Enactment or Last Substantive Amendment

September 14, 2006

Authorizing, Implemented, or Interpreted Law

58-1-106(1)(a); 58-1-202(1)(a); 58-77-202(4); 58-77-601(2)