CHAPTER Mid 500  SCOPE OF MIDWIFERY PRACTICE

 

PART Mid 501  DEFINITIONS

 

          Mid 501.01  Definitions.

 

          (a)  “The American College of Obstetricians and Gynecologists (ACOG)” means a fellowship of physicians with special interest in obstetrics and gynecology and the promotion of women’s reproductive health care.

 

          (b)  “Apgar assessment” means an evaluation of the newborn based on an assessment of the heart rate, respiration, reflexes, color, and muscle tone, performed at intervals of one minute and 5 minutes after birth.

 

          (c)  “Apgar score” means a numerical expression of the results of an Apgar assessment.

 

          (d)  “Central cyanosis” means a bluish discoloration of the skin and mucous membranes involving the whole body and resulting from a lack of oxygen in the blood.

 

          (e)  “Certified nurse-midwife (CNM)” means a registered nurse who has graduated from a nurse-midwifery education program accredited by the Division of Accreditation of the American College of Nurse-Midwives and has successfully taken the national examination required for designation as a CNM by the Certification Council of the American College of Nurse-Midwives.

 

          (f)  “Consultation” means the process whereby a NHCM who maintains primary management responsibility for the client seeks the advice or opinion of another appropriate healthcare practitioner.

 

          (g)  “Extended postpartum period” means the period from the birth of the newborn to 6 weeks after the birth.

 

          (h)  “Fetal heart auscultation” means listening to the fetal heartbeat through the abdominal and uterine walls of the mother.

 

          (i)  “Freestanding birth center” means an out-patient maternity care facility.

 

          (j)  “Grand multiparity” means the condition of having borne 7 or more children.

 

          (k)  “High grade squamous intraepithelial lesions (HGSIL)” means squamous cells that are highly suggestive of being pre-cancerous or pre-invasive cancerous.

 

          (l)  “Holistic care” means care which attends to the needs of the client in all areas, including physical, emotional, and social.

 

          (m)  “Home birth” means a planned home delivery attended by a midwife taking primary responsibility for the care of the mother and the newborn.

 

          (n)  “Immediate postpartum period” means the period from birth until the midwife determines that mother and newborn are in stable condition.

 

          (o)  “Cervical insufficiency” means the premature painless dilatation of the cervix typically at 24 to 26 weeks gestation, which, without medical intervention, is often associated with repeated second trimester spontaneous abortion.

 

          (p)  Intrapartum” means the period from the onset of labor to its completion with the delivery of the placenta.

 

          (q)  “Intrauterine growth restriction (IUGR)” means a decreased rate of growth of the fetus.

 

          (r)  “Large for gestational age (LGA)” means a newborn weighing over 9 pounds, 8 ounces.

 

          (s)  “Multigravida” means a woman who has been pregnant 2 or more times.

 

          (t)  Oligohydramnios” means an abnormally small amount of amniotic fluid during pregnancy.

 

          (u)  “Out-of-hospital birth” means a home birth or a birth in a freestanding birth center.

 

          (v)  “Pap test” means a procedure by which cells are collected and tested in a laboratory for pre-cancer and other abnormal conditions.

 

          (w)  “Placenta previa” means the condition whereby the placenta is implanted in the lower portion of the uterus, covering the cervix marginally, partially, or completely.

 

          (x)  “Placental abruption” means premature separation of the placenta from the uterine wall.

 

          (y)  Polyhydramnios” means an excess of amniotic fluid during pregnancy.

 

          (z)  “Preeclampsia” means a combination in the mother of hypertension, fluid retention, protein in the urine, and brisk reflexes.

 

          (aa)  Primigravida” means a woman who is pregnant for the first time.

 

          (ab)  “Prenatal” means during the period of time between conception and the onset of labor.

 

          (ac)  “Postpartum” means occurring after childbirth.

 

          (ad)  “Rh immune globulin” means a preparation used to prevent the development of Rh antibodies in Rh negative mothers.

 

          (ae)  “Rh sensitivity with positive antibody titre” means the development by a pregnant Rh negative woman of antibodies which might cross the placenta and destroy the cells of an Rh positive fetus.

 

          (af)  “Significant PP hemorrhage” means blood loss of greater than 1,000 cubic centimeters.

 

          (ag)  “Small for gestational age (SGA)” means a newborn weighing less than 5 pounds, 8 ounces.

 

          (ah)  “Squamous cells” means flat, scaly cells forming the outer surface of the body and lining the body cavities and the principal tubes and passageways leading to the exterior of the body.

 

          (ai)  “Vaginal birth after cesarean (VBAC)” means a vaginal birth after any previous delivery by cesarean section.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

PART Mid 502  SCOPE OF PRACTICE

 

          Mid 502.01 Midwifery Care.  Acting autonomously, a midwife shall provide the following supervision, care, and advice, as appropriate, to her client and the newborn:

 

          (a)  Counseling and education about:

 

(1)  Conception;

 

(2)  Health and nutrition;

 

(3)  Pregnancy;

 

(4)  Labor and delivery;

 

(5)  Lactation;

 

(6)  Family planning; and

 

(7)  The postpartum period;

 

          (b)  Holistic care;

 

          (c)  Early recognition and prevention of potential health problems;

 

          (d)  Detection of any abnormal conditions in the mother, fetus, and newborn;

 

          (e)  Procurement of medical assistance, if necessary;

 

          (f)  Execution of emergency measures in the absence of medical help, if necessary; and Lactation assistance.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.02  Midwifery Procedures.  The procedures of midwifery shall include, as appropriate, the following:

 

          (a)  Basic physical examination;

 

          (b)  Breast examination;

 

          (c)  Pelvic examination;

 

          (d)  Venipuncture;

 

          (e)  Hematocrit and hemoglobin specimen collection;

 

          (f)  Capillary blood collection;

 

          (g)  Pap testing;

 

          (h)  Culture collection;

 

          (i)  Urinalysis;

 

          (j)  Wet mount specimen collection;

 

          (k)  Administration of oxygen to mother and newborn;

 

          (l)  Urinary bladder catheterization;

 

          (m)  Episiotomy;

 

          (n)  Neonatal resuscitation;

 

          (o)  Repair of tears, lacerations or episiotomy, infiltration of lidocaine hydrochloride, and use of suture material;

 

          (p)  Intramuscular injection of the following medications:

 

(1)  Oxytocins such as pitocin, and methergine, only for postpartum control of maternal hemorrhage;

 

(2)  Rh immune globulin, if indicated;

 

(3)  Vitamin K for control and prevention of vitamin K deficiency bleeding; and

 

(4)  Other medications as prescribed by a physician, consistent with the scope of midwifery practice as defined in this chapter;

 

          (q)  Oral, buccal, or rectal administration of the following medications:

 

(1)  Methergine, and misoprostol, only for postpartum control of maternal hemorrhage;

 

(2)  Vitamin K, for control and prevention of acute and late-onset hemorrhagic disease of the newborn; and

 

(3)  Other medications as prescribed by a physician, consistent with the scope of midwifery practice as defined in this chapter;

 

          (r)  Intravenous administration of the following fluids:

 

(1)  Ringer’s Lactate, with or without D5W;

 

(2)  Normosol-R, with or without D5W; and

 

(3)  Other medications as prescribed by a physician, consistent with the scope of midwifery practice as defined in this chapter;

 

          (s)  Clamping and cutting of the umbilical cord;

 

          (t)  Administration of newborn eye prophylaxis in accordance with RSA 132:6, I;

 

          (u)  Metabolic screening of the newborn in accordance with RSA 132:10-a and RSA 132:10-c;

 

          (v)  Newborn hearing screening;

 

          (w)  Newborn pulse oximetry screening, as required by RSA 132:10-aa; and

 

          (x)  Contraception counseling and family planning methods.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.03  Requirements for Prenatal Care.

 

          (a)  A midwife shall provide prenatal care to a client at least:

 

(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 of pregnancy; and

 

(3)  Once a week from the thirty-sixth week of pregnancy until the onset of labor.

 

          (b)  A midwife shall schedule the initial prenatal visit with a client in the first or second trimester of pregnancy.

 

          (c)  If a woman requesting midwifery services does not contact the midwife before the third trimester of her pregnancy, the midwife shall accept her as a client only if she:

 

(1)  Has had adequate prenatal care, or has met the criterion for a low risk birth as defined by an NHCM’s scope of practice; and

 

(2)  Displays adequate fetal growth, fetal heart rate and fetal movement.

 

          (d)  During the initial prenatal visit the midwife shall:

 

(1)  Obtain a maternal health, obstetrical, and gynecological history;

 

(2)  Perform a nutritional assessment and provide nutritional counseling;

 

(3)  Discuss the availability of options for screening and testing for fetal abnormalities;

 

(4)  Obtain blood pressure;

 

(5)  Perform a pelvic exam, if indicated, including:

 

a.  Uterine sizing to estimate gestational age;

 

b.  Pelvimetry;

 

c.  A chlamydia and gonorrhea screening test; and

 

d.  A Pap test;

 

(6)  Either perform or order blood analysis, including, but not limited to:

 

a.  Blood group and Rh factor;

 

b.  Antibody screen;

 

c.  A complete blood count;

 

d.  Rubella titre;

 

e.  Syphilis serology;

 

f.  Hepatitis B surface antigen;

 

g.  Hepatitis C surface antigen, if indicated; and

 

h.  HIV testing, if accepted by the client;

 

(7)  Recommend that the client receive a general physical exam by a qualified health care provider to screen for general health problems that have the potential to complicate the pregnancy or delivery; and

 

(8)  Obtain informed consent for midwifery care and out-of-hospital birth, to include the following information:

 

a.  A description of the midwife’s background and credentials;

 

b.  Whether the midwife has professional liability coverage; and

 

c.  The address and telephone number of the council, where complaints against the midwife may be filed.

 

          (e)  During subsequent prenatal visits the midwife shall:

 

(1)  Assess maternal nutrition and weight gain;

 

(2)  Obtain blood pressure;

 

(3)  Test urine for protein and glucose;

 

(4)  Assess general well-being;

 

(5)  Check for signs and symptoms of edema, bleeding, headache, visual disturbances, or unusual vaginal discharge;

 

(6)  Obtain fundal height measurement;

 

(7)  Arrange for periodic hematocrit or hemoglobin testing;

 

(8)  Assess fetal heart rate and fetal activity;

 

(9)  Assess position and presentation of the fetus;

 

(10)  Perform or order the following as necessary:

 

a.  Rh antibody screening;

 

b.  Urinalysis;

 

c.  Microscopic analysis of vaginal discharges;

 

d.  Obstetric ultrasound;

 

e.  Prophylactic Rh immune globulin injection;

 

f.  Blood sugar screening;

 

g.  Cultures; and

 

h.  Thyroid screening, if indicated;

 

(11)  Observe aseptic technique and standard precautions; and

 

(12)  Discuss:

 

a.  Any recent illnesses, symptoms, social or emotional problems;

 

b.  Diet;

 

c.  Medications and supplements;

 

d.  Reading suggestions;

 

e.  Exercise;

 

f.  Rest and sleep requirements;

 

g.  Sexuality;

 

h.  Partner's role;

 

i.  Birth preparation;

 

j.  Newborn care;

 

k.  Parenting; and

 

l.  Transportation arrangements.

 

          (f)  A midwife shall advise any client with genital herpes of the ACOG herpes protocol current at the time of the midwife's conversation with the client.

 

          (g)  A midwife shall discuss with clients the standards of care and recommendations for testing for and treating of group B streptococcus.

 

          (h)  A midwife shall encourage any client expecting a first child to attend childbirth education classes.

 

          (i)  A midwife shall discuss with the client, during the prenatal period, the selection of a pediatrician, family physician, or other health care provider who will assume care of the newborn.

 

          (i)  A midwife shall alert the client to:

 

(1)  Signs of complications that necessitate immediate contact with the midwife; and

 

(2)  Signs of labor and when it is time to call the midwife.

 

          (j)  A midwife shall be on call or make specific arrangements for on call coverage with another midwife or licensed health care provider whose scope of practice includes birth.

 

          (k)  In the third trimester, a midwife shall ensure that a client is adequately preparing for birth in an out-of-hospital location by discussing:

 

(1)  The place of the birth and the facilities available there;

 

(2)  The availability of adequate heat and water;

 

(3)  The supplies the client must procure;

 

(4)  The availability of a telephone;

 

(5)  Arrangements for help after the birth;

 

(6)  With a client preparing for birth in a private home, the importance of keeping readily available the following written information, as appropriate:

 

a.  The name, location, and phone number of the nearest ambulance service;

 

b.  The name, location, and phone number of the nearest hospital;

 

c.  The name and phone number of the newborn's health care provider; and

 

d.  The street address of the location of the birth and directions to that location from the nearest ambulance service; and

 

          (l)  The transfer of care to a hospital setting in an emergency.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.04  Requirements for Care throughout Labor, Birth and the Immediate Postpartum Period.

 

          (a)  During the appropriate period of labor, birth, and the immediate postpartum period a midwife shall:

 

(1)  Monitor the condition of the mother and fetus or newborn;

 

(2)  Support and encourage the laboring woman;

 

(3)  Assist with the birth;

 

(4)  Assist client with breastfeeding;

 

(5)  Inspect the perineum and lower vagina;

 

(6)  Inspect as necessary the cervix and upper vaginal vault;

 

(7)  Perform necessary laceration repairs;

 

(8)  Examine and assess the health of the newborn;

 

(9)  Inspect the placenta, membranes, and vessels of the umbilical cord;

 

(10)  Manage any third-stage bleeding;

 

(11)  Administer medications listed in RSA 326-D:12 as needed;

 

(12)  Administer eye prophylaxis to the newborn in accordance with RSA 132:6, I;

 

(13)  Administer vitamin K to the newborn;

 

(14)  Remain with the client and newborn:

 

a.  At least 2 hours after the birth; and

 

b.  If the conditions of the mother and the newborn are not stable after 2 hours, until the conditions of the mother and the newborn have become stable;

 

(15)  Provide the client with information concerning routine postpartum care of herself and her newborn, and indications that warrant contacting the midwife or physician;

 

(16)  Recommend to the client that she contact the newborn’s health care provider within 24 to 48 hours after birth to arrange for an examination; and

 

(17)  Observe aseptic technique and use standard precautions.

 

          (b)  In the event the client is transferred to a hospital setting, a midwife shall make every effort to remain with her to provide labor support.

 

          (c)  In the event of an emergency transfer, the midwife shall notify the obstetrician on call at the accepting hospital of the nature of the emergency and the estimated time of arrival of the client.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.05  Consultation With Physician or CNM to Determine Setting for Care During the Intrapartum Period.  A midwife shall consult immediately with a physician with experience in the active practice of obstetrics or with a CNM about whether the care of the client should be transferred to the hospital setting if any of the following conditions should occur intrapartum:

 

          (a)  Unforeseen malpresentations;

 

          (b)  Unforeseen multiple fetuses;

 

          (c)  Fetal distress as indicated by heart rate monitoring;

 

          (d)  The presence of particulate meconium;

 

          (e)  Failure to progress such that:

 

(1)  In the first stage of labor, there is a lack of progress in dilation and descent for a period of up to 24 hours in the case of a primigravida or 18 hours in the case of a multigravida;

 

(2)  In the second stage, there are more than 2 hours without progress in descent or more than 3 hours with slow descent; or

 

(3)  In the third stage, there is more than one hour without delivery of the placenta;

 

          (f)  More than 18 hours elapse following the rupture of the membranes without the onset of labor;

 

          (g)  Maternal distress including:

 

(1)  Extreme physical or mental exhaustion;

 

(2)  Abnormal vital signs; and

 

(3)  Uncontrolled maternal bleeding.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.06  Consultation to Determine Setting for Care During the Immediate Postpartum Period.  A midwife shall consult immediately with a physician with experience in the active practice of obstetrics or with a CNM about whether the care of the client or the newborn should be transferred to the hospital setting if any of the following conditions should occur immediately postpartum:

 

          (a)  Significantly bleeding cervical lacerations;

 

          (b)  Third or fourth degree perineal lacerations;

 

          (c)  Uncontrolled maternal bleeding when the condition of the woman is becoming unstable;

 

          (d)  Maternal fever or unstable vital signs;

 

          (e)  An Apgar score of 6 or less at 5 minutes after birth, or an Apgar score that is dropping;

 

          (f)  Jaundice in the newborn appearing before 24 hours after birth;

 

          (g)  Obvious congenital anomalies;

 

          (h)  A newborn who is SGA;

 

          (i)  A newborn who shows signs of hypoglycemia, such as jitteriness, lethargy, or hypothermia;

 

          (j)  A newborn with persistent central cyanosis or pallor;

 

          (k)  A newborn with persistent signs of respiratory difficulty without signs of improvement within one hour after birth;

 

          (l)  A newborn with a pulse rate greater than 160 at rest persisting for longer than 2 hours;

 

          (m)  A newborn with respirations greater than 80 at rest persisting for longer than 2 hours;

 

          (n)  A newborn with temperature outside the parameters of 97.7-99.4 degrees Fahrenheit or 36.5 to 37.5 degrees Celsius persisting for longer than 2 hours; or

 

          (o)  Other conditions which the midwife assesses as outside normal limits.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.07  Requirements for Care During the Extended Postpartum Period.  During the extended postpartum period, a midwife shall:

 

          (a)  Maintain close contact with the client through phone calls and at least one home or office visit within the first 72 hours after the birth;

 

          (b)  Ascertain during the visit described in (a) above that:

 

(1)  The newborn is alert;

 

(2)  The newborn has good color;

 

(3)  The newborn is breathing normally;

 

(4)  The newborn is establishing a healthy pattern of waking, sleeping, feeding, voiding, and stooling;

 

(5)  The mother is not bleeding excessively;

 

(6)  The mother has a firm fundus;

 

(7)  The mother does not have a fever or other sign of infection;

 

(8)  The mother is voiding properly; and

 

(9)  The mother, if intending and able to do so, is establishing successful breastfeeding;

 

          (c)  Consult with a physician if any of the circumstances in paragraph (b) are abnormal;

 

          (d)  Be available to consult with the newborn’s health care provider about the newborn’s condition;

 

          (e)  Recommend or perform newborn hearing screening;

 

          (f)  Test the newborn for metabolic disorders as required by RSA 132:10-a at 24 to 72 hours after birth;

 

          (g)  Perform pulse oximetry screening pursuant to RSA 132:10-aa;

 

       (h)  By 6 weeks postpartum provide the following:

 

(1)  A pelvic exam including a Pap test if indicated;

 

(2)  Hemoglobin or hematocrit testing, if indicated;

 

(3)  Contraceptive counseling and family planning methods; and

 

(4)  Referral for rubella vaccination if the client showed no immunity to rubella when tested at the time of her initial visit with the midwife.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.08  Ineligibility for Midwifery Care.  A midwife shall not accept as a client a woman who appears to have or reports any of the following:

 

          (a)  Insulin- or drug-dependent diabetes;

 

          (b)  Maintenance on anti-epileptic medication;

 

          (c)  Convulsive activity within the past year;

 

          (d)  Blood diseases that could complicate pregnancy;

 

          (e)  Current hepatitis B and C positive antigen;

 

          (f)  Current HIV positivity or AIDS;

 

          (g)  Current chemical dependency or substance abuse;

 

          (h)  Chronic pulmonary disease that interferes with oxygen saturation;

 

          (i)  Rh sensitivity with positive antibody titre;

 

          (j)  Chronic hypertension;

 

          (k)  History of significant heart disease;

 

          (l)  Renal disease requiring dialysis;

 

          (m)  Maintenance on a psychotropic medication which the client's physician has determined has the potential to sedate the newborn;

 

          (n)  Documented mental illness or disease which has the potential to interfere with the client's ability to effectively participate in her care or in out-of-hospital birth;

 

          (o)  Diseases and disorders such as:

 

(1)  Addison’s disease;

 

(2)  Cushing’s disease;

 

(3)  Systemic lupus erythematosus;

 

(4)  Anti-phospholipid syndrome;

 

(5)  Scleroderma;

 

(6)  Rheumatoid arthritis;

 

(7)  Periarteritis nodosa;

 

(8)  Marfan’s syndrome; and

 

(9)  Other systemic and rare diseases and disorders;

 

          (p)  Acute toxoplasmosis infection, where the client is currently symptomatic;

 

          (q)  Acute rubella infections, where the client is currently symptomatic;

 

          (r)  Acute cytomegalovirus infection, where the client is currently symptomatic;

 

          (s)  Acute parvovirus infection, where the client is currently symptomatic;

 

          (t)  Thrombosis; or

 

          (u)  Inflammatory bowel disease that is not in remission.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.09  Obstetrical Consultation Required To Determine Eligibility for Midwifery Care.  A midwife shall consult with an obstetrician or CNM to evaluate whether a woman is an appropriate candidate for out-of-hospital birth when she or her fetus, as applicable, appears to have or develops any of the following conditions:

 

          (a)  A first pregnancy at an age younger than 16 or older than 40;

 

          (b)  Maintenance on anti-epileptic medications without a history of convulsions in the previous year;

 

          (c)  Gestational hypertension measured at 140/90 after 20 weeks on at least 2 occasions 6 hours apart;

 

          (d)  An arrhythmia or a heart murmur other than a benign, functional murmur;

 

          (e)  A history of hereditary problems with the potential to affect the fetus or newborn;

 

          (f)  A history of significant postpartum hemorrhage;

 

          (g)  A history of previous intrauterine death of a fetus of more than 20 weeks' gestation;

 

          (h)  A history of stillbirth;

 

          (i)  A history of prior obstetrical problems including:

 

(1)  Prematurity;

 

(2)  Uterine abnormalities;

 

(3)  Placental abruption; and

 

(4)  Insufficient cervix;

 

          (j)  Cancerous or pre-cancerous condition of the cervix as indicated by an abnormal Pap test;

 

          (k)  Renal disease not requiring dialysis, such as recurrent urinary tract or kidney infection;

 

          (l)  Active gonorrhea;

 

          (m)  Active chlamydia;

 

          (n)  Gestational diabetes;

 

          (o)  Significant second or third-trimester bleeding;

 

          (p)  Grand multiparity;

 

          (q)  Multiple fetuses;

 

          (r)  Malpresentation after 36 weeks;

 

          (s)  Suspected small for gestational age to rule out developing IUGR;

 

          (t)  Suspected large for gestational age;

 

          (u)  Polyhydramnios;

 

          (v)  Oligohydramnios;

 

          (w)  Ultrasound evidence of a fetal or placental abnormality; or

 

          (x)  Suspected postmaturity greater than 42 weeks' gestation.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.10  Conditions Requiring Transfer From Midwifery Care.

 

       (a)  A midwife shall transfer to the care of a physician with experience in the active practice of obstetrics or a CNM any client who appears to have or develops any of the following conditions during the prenatal period:

 

(1)  Anemia measured by hemoglobin of less than 10g or a hematocrit of less than 30% unresolved by 37 weeks' gestation;

 

(2)  Multiple fetuses;

 

(3)  Malpresentation of the fetus, including presentation in breech position, that is not resolved before the onset of labor;

 

(4)  Confirmation by obstetric ultrasound that the fetus is small for gestational age;

 

(5)  Indications that the fetus of more than 12 weeks' gestation has died in utero;

 

(6)  Rh sensitization with positive antibody titre;

 

(7)  Preeclampsia;

 

(8)  Placenta previa;

 

(9)  Placental abruption;

 

(10)  Onset of labor prior to 37 weeks; or

 

(11)  Herpes on the cervix or vulva or in the vaginal mucosa that is active at the onset of labor and cannot be isolated by covering it.

 

       (b)  Upon transfer of the client's care pursuant to paragraph (a)  the midwife shall give the health care provider to whose care the client is transferred a copy of the client's chart.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 502.11  Termination of Services by the Midwife.

 

          (a)  During the prenatal period a midwife shall terminate services if:

 

(1)  The client refuses the transfer of her care as required by Mid 502.10;

 

(2)  The client consistently fails or refuses to follow the recommendations of the midwife; or

 

(3)  The environment for home birth becomes unsafe or unsanitary.

 

          (b)  A midwife terminating services during the prenatal period shall immediately notify the client in person or by phone, and follow-up with written notification of the termination.

 

          (c)  A midwife terminating services during the prenatal period shall assist the client in finding another health care provider.

 

          (d)  After the onset of labor a midwife shall terminate her services only if:

 

(1)  The client refuses a transfer of care determined necessary on the basis of the consultation required by Mid 502.05; or

 

(2)  The midwife believes she is unable to care adequately for the client or the newborn.

 

          (e)  A midwife terminating services after the onset of labor shall:

 

(1)  Document the events causing the termination; and

 

(2)  Attempt to ensure that the client is not left unattended by:

 

a.  Contacting a local rescue service, a hospital emergency room, or other appropriate emergency resource;

 

b.  Dialing 911; or

 

c.  Calling a physician who is on call at the nearest hospital and has experience in the active practice of obstetrics to inform the physician of the situation.

 

Source.  #7759, eff 9-7-02, EXPIRED: 9-7-10

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

PART Mid 503  MIDWIFERY CARE WHEN PREVIOUS BIRTH WAS BY CESAREAN SECTION

 

          Mid 503.01  Definitions.  In this part the following terms shall have the following meanings:

 

          (a)  “Active labor” means the period of labor beginning when the cervix is at least 4 cm dilated and the client is experiencing regular uterine contractions until the cervix is fully dilated;

 

          (b)  “Northern New England Perinatal Quality Improvement Network (NNEPQIN)” means a consortium of medical and administrative representatives from hospitals across New Hampshire and Vermont having the goal of improving perinatal health throughout Northern New England;

 

          (c)  “Second stage of labor” means the period of labor from the time the cervix is fully dilated and the client begins expulsive efforts until the birth of the baby; and

 

          (d)  “Third stage of labor” means the period of labor from the birth of the baby until the delivery of the placenta.

 

Source.  #7931, eff 8-6-03, EXPIRED: 8-6-11

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 503.02  Eligibility for Midwifery Care.  A midwife shall accept as a client a woman who has had a previous birth by cesarean section only if:

 

          (a)  The potential client has had only one previous cesarean section;

 

          (b)  The midwife can confirm through a review of the records of the previous delivery by cesarean section that the section was performed through a low transverse uterine segment incision;

 

          (c)  The potential client has had no other uterine surgeries;

 

          (d)  At least 18 months’ time separates the date of the potential client’s previous cesarean section and the due date of the current pregnancy;

 

          (e)  An obstetric ultrasound documents that the placenta is not in a low-lying anterior position;

 

          (f)  The potential client plans to give birth in a location no more than 20 minutes’ drive from a hospital with obstetrical and anesthesia services on call 24 hours a day;

 

          (g)  The midwife:

 

(1)  Arranges a consultation between the client and an obstetrician affiliated with the hospital closest to the planned location of the birth to discuss the following topics:

 

a.  The information in NNEPQIN's patient education brochure entitled “Birth Choices After Cesarean Section”; and

 

b.  The hospital’s abilities to respond if an emergency transfer from the care of the midwife to the hospital should become necessary; or

 

(2)  Having been refused a consultation for the potential client by every obstetrician affiliated with the hospital closest to the planned location of the birth, records that fact in the potential client's record;

 

          (h)  The midwife provides the potential client with the information required by Mid 503.04; and

 

          (i)  The midwife obtains the potential client's signature and date of signing on the informed consent form specified in Mid 503.05.

 

Source.  #7931, eff 8-6-03, EXPIRED: 8-6-11

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 503.03  Duties of the Midwife.  A midwife attending a woman who has had a previous birth by cesarean section shall:

 

          (a)  Provide all services required by this chapter;

 

          (b)  Monitor the fetal heart rate at least every 15 minutes during active labor;

 

          (c)  Monitor the fetal heart rate at least every 5 minutes during the second stage of labor;

 

          (d)  Monitor the client during labor for excessive vaginal bleeding;

 

          (e)  Monitor the client during labor for abnormal abdominal pain;

 

          (f)  Monitor the labor for failure to progress as indicated by the following:

 

(1)  During active labor, the passage of at least 2 hours without cervical change;

 

(2)  In the second stage of labor, the passage of at least one hour without progress in descent of the head or the passage of at least 2 hours with slow progress in descent of the head; or

 

(3)  In the third stage, the passage of at least one hour without delivery of the placenta;

 

          (g)  Consult immediately with an obstetrician if any of the circumstances listed in (f) above occur;

 

          (h)  Transfer the client to the hospital identified pursuant to Mid 503.02(f) when any of the following occur:

 

(1)  Repeated fetal heart rate abnormalities;

 

(2)  Unstable vital signs;

 

(3)  Significant bleeding; or

 

(4)  Abdominal pain experienced by the client which is inconsistent with the normal pain of labor; and

 

          (i)  In the event of an emergency transfer to a hospital, immediately notify the hospital to which the client is to be transferred of the nature of the emergency and the estimated time of arrival of the client.

 

Source.  #7931, eff 8-6-03, EXPIRED: 8-6-11

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 503.04  Midwife's Duty to Provide Potential Client with Information.  Before obtaining a potential VBAC client's signature and the date of the signature on the informed consent form described in Mid 503.05 a midwife shall:

 

          (a)  Provide her with NNEPQIN's patient education brochure describing in-hospital VBAC and entitled “Birth Choices After Cesarean Section”;

 

          (b)  Provide her with NNEPQIN's informed consent form, excluding the signature page, related to in-hospital VBAC and entitled “Consent for Birth After Cesarean Section”;

 

          (c)  Provide her with a copy of Mid 503;

 

          (d)  Discuss with the potential client the following:

 

(1)  That out-of-hospital VBAC involves labor and delivery at home or in a freestanding birth center with a midwife certified in this state in attendance in either case;

 

(2)  As part of a review of Mid 503:

 

a.  The midwife's obligation to comply with Mid 503;

 

b.  The potential client's eligibility for out-of-hospital VBAC pursuant to Mid 503.02; and

 

c.  How the midwife would carry out the duties set forth in Mid 503.03 if the potential client were to choose out-of-hospital VBAC;

 

(3)  The normal risks of labor and of VBAC in any setting, including the risk of uterine rupture during labor;

 

(4)  The risks associated with out-of-hospital VBAC which are additional to those associated with in-hospital VBAC;

 

(5)  The precautions that the midwife would take if the potential client were to choose out-of-hospital VBAC, including but not limited to:

 

a.  Use of obstetric ultrasound;

 

b.  Close monitoring of mother and baby during active labor; and

 

c.  Choosing a birth location no more than 20 minutes’ drive from a hospital with obstetrical and anesthesia services on call 24 hours a day;

 

(6)  The possible benefits of out-of-hospital VBAC over in-hospital VBAC whenever there is no need for transfer to a hospital,  including:

 

a.  No surgical intervention;

 

b.  Greater freedom of movement and of positioning at time of birth; and

 

c.  Birth in familiar and private surroundings with the support of the potential client's midwife;

 

(7)  The possible benefits of in-hospital VBAC over out-of-hospital VBAC, including the availability in hospitals of resources not available in an out-of-hospital setting, including immediate access to surgical intervention and intensive care facilities and services; and

 

(8)  The possibility that the potential client might need to be transferred to a hospital; and 

 

          (d)  Answer the potential client's questions.

 

Source.  #7931, eff 8-6-03, EXPIRED: 8-6-11

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 503.05  Informed Consent Form.

 

          (a)  A midwife shall review with the potential VBAC client the informed consent form entitled "New Hampshire Midwifery Council Informed Consent for an Out-of-Hospital Vaginal Birth After Cesarean Section (VBAC)".

 

          (b)  Before obtaining the potential client's signature and date of signing of the form, the midwife shall insert in the spaces provided on the form:

 

(1)  The name of the midwife;

 

(2)  If the birth is to take place in a freestanding birth center, the name of the birth center;

 

(3)  The signature of the midwife and the date of her signing;

 

(4)  The New Hampshire certification number of the midwife; and

 

(5)  The business address of the midwife.

 

          (c)  The midwife shall arrange for a person of at least 18 years of age to:

 

(1)  Witness the client's signing and dating of the form; and

 

(2)  Place his or her printed name, signature and date of signing in the spaces provided on the form.

 

Source.  #7931, eff 8-6-03, EXPIRED: 8-6-11

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

          Mid 503.06  Effect of Client's Signature on Informed Consent Form.  By signing the form entitled "New Hampshire Midwifery Council Informed Consent for an Out-of-Hospital Vaginal Birth After Cesarean Section (VBAC)" the client:

 

          (a)  Shall acknowledge that:

 

(1)  She understands the information described in Mid 503.04(d);

 

(2)  She has read the documents described in Mid 503.04(a) and (b) and understands the significance of the facts and figures in both documents;

 

(3)  She has received and read Mid 503 and understands that the midwife practices according to its requirements; and

 

(4)  The midwife has answered her questions to her satisfaction; and

 

          (b)  Shall consent to midwifery services by the midwife signing the form for an out-of-hospital vaginal birth after a cesarean section.

 

Source.  #7931, eff 8-6-03, EXPIRED: 8-6-11

 

New.  #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

 

New.  #12040, eff 11-10-16

 

Appendix

 

Rule

Specific State Statute which the Rule Implements

 

 

Mid 501

RSA 541-A:7

Mid 502.01

RSA 326-D:5, I (c); RSA 326-D:2, V

Mid 502.02 (a) through (j) and (l) thru (n)

RSA 326-D:2, V (a) and (b)

Mid 502.02 (k)

RSA 326-D:12, I (c)

Mid 502.02 (o)

RSA 326-D:12, I (d)

Mid 502.02 (p) (1) and (2)

RSA 326-D:12, I (f)

Mid 502.02 (p) (3)

RSA 326-D:12, I (a)

Mid 502.02 (p) (4)

RSA 326-D:12, I (e)

Mid 502.02 (p) (5)

RSA 326-D:12, I (h)

Mid 502.02 (q) (1)

RSA 326-D:12, I (f)

Mid 502.02 (q) (2)

RSA 326-D:12, I (e)

Mid 502.02 (q) (3)

RSA 326-D:12, I (h)

Mid 502.02 (r) (1) and (2)

RSA 326-D:12, I (g)

Mid 502.02 (r) (3)

RSA 326-D:12, I (h)

Mid 502.02 (s)

RSA 326-D:2, V (a) and (b)

Mid 502.02 (t)

RSA 326-D:12, I (b)

Mid 502.02 (u) and (v)

RSA 326-D:2, V (a) and (b)

Mid 502.03 and 502.04

RSA 326-D:2, V (a) and (b)

Mid 502.05 and 502.06

RSA 326-D:2, V (c)

Mid 502.07 and 502.08

RSA 326-D:2, V (a) and (b)

Mid 502.09 and 502.10

RSA 326-D:2, V (c)

Mid 502.11

RSA 326-D:2, V (a) and (b)

Mid  503.01

RSA 541-A:7

Mid 503.02-Mid 503.06

RSA 326-D:5, I(c)