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 |
|
|
|
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) |