The Vermont Statutes Online

Material highlighted in lite beige connotes text quoted directly in the CCM S&G, those excerpted in part, modified or universally used by all sources is

Material highlighted in green represents ideas incorporated in a general language but not quoted

Material of interest highlighted in light yellow in documents from other states that indicates that it wasn't incorporated do to its overly specific nature or dubious utility.

Editorial notes, commentary and other editorial functions are highlighted in lite blue

The best way to review this material is to simply start reading at the top, and scroll down.

Use the hyperlinks above to return to where you left off (the whole file takes 2-3 hours to read.

What follows are the original documents that I worked from, with all the original sources and each area of text highlighted that was "cut and pasted" into the final CCM S&G. I also color-coded background ideas and language that we clearly did not/do not want.

As you read, pay special attention to the many versions of similar language that were NOT chosen. Some state statutes were many times more specific than any of us would be happy with or that would permit compliance with evidence-based parameters.

I know many think I am too wordy and overly specific, but in fact, the "words" used in the CCM document belong to other midwives. CCM S&G are 95% compilation from more than a dozen state, national & international mfry sources. Only about 5% is authored by me and most of that is either explanatory text or addresses legal problem specific to California. I consistently choose the least "wordy" (i.e. specific) version that was consistent with the scientific or legal facts and met the political needs relative to the Medical Board and Senator Figueroa.

After reading the source material, click on the link immediately below and re-read the PDF of Sections 1& 2 (same content as published on MBC web site).

CCM Standards & Guidelines ~ Sections 1 & 2 only in PDF, as referenced
in proposed MBC regulations and posted on MBC web site~

But, if adopted, it can be perfected over time. It acknowledges the autonomy of healthy childbearing women to make informed choices & have the final say so, even if such choices are medically unpopular. It gives LMs legal protection in many important areas that we did not have before, for example, acknowledging maternal autonomy and the legal basis (under the OAL decision in Alison Osborn's case) for LMs to provide care in "moderate risk" circumstances.

We will never have a better chance than right now. The tide is high, we have a lot of reason to hope that we will prevail. We surely don't want to go back to the 'bad old days', in which the MBC // ACOG had carte blanch to select the most limiting, most prohibitive, most prescriptive language from these source documents (they have access to the Internet too!) and impress them on us as a 'midwifery' standards that is neither midwife or mother-friendly or scientifically valid.

Alaska Statutes and Regulations // Excerpts relative to mfry practice

Note: Alaska has a direct-entry midwifery board with LMs, OBs and CNMs as seated members. The Alaska DE mfry law does NOT require physician supervision but OBs, nurse-midwives and lay members out-number the LMs on the board.

The Original proposal by Dr Fantozzi (chair of mfry task force) was to adopt some version of the Alaska statutes and regulations for California LMs

Many LMs found the proposed Alaska rules to be problematic for both political & practical reasons. Those items highlighted below in yellow were thought to be out-dated, overly specific, not evidence-based, of dubious utility. Sometimes the objection was wording, rather than the actual criteria. Except for 'Ethics' and the drug list, the Alaska statues made a nominal contribution to the CCM S&G.

Sec. 08.65.140. REQUIRED PRACTICES. (a) Except as provided in (d) of this section, a certified direct-entry midwife may not assume the care or delivery of a client unless the certified direct-entry midwife has recommended that the client undergo a physical examination performed by a physician, physician assistant, advanced nurse practitioner, or certified nurse midwife, who is licensed in this state.

(b) A certified direct-entry midwife shall inform a woman seeking home birth of the possible risks of home birth and shall obtain a signed informed consent, including the recommendation for a physical examination required under (a) of this section, from the woman before the onset of labor. The consent shall be maintained by the certified direct-entry midwives as part of the woman’s record. A certified direct-entry midwife shall accept full legal responsibility for the direct-entry midwife’s acts or omissions.

(c) A certified direct-entry midwife shall comply with the requirements of AS 18.15.150 concerning taking of blood samples, AS 18.15.200 concerning screening of phenylketonuria (PKU), AS 18.50.160 concerning birth registration, AS 18.50.230 concerning registration of deaths, AS 18.50.240 concerning fetal death registration, and regulations adopted by the Department of Health and Social Services concerning prophylactic treatment of the eyes of newborn infants.

(d) A certified direct-entry midwife may not knowingly deliver a woman who

(1) has a history of thrombophlebitis or pulmonary embolism;
(2) has gestational diabetes, diabetes, hypertension, Rh disease with positive titer, active tuberculosis, active syphilis, active gonorrhea, epilepsy, heart disease, or kidney disease;
(3) contracts genital herpes simplex in the first trimester of pregnancy or has active genital herpes in the last two weeks of pregnancy;
(4) has severe psychiatric illness;
(5) inappropriately uses controlled substances, including those obtained by prescription;
(6) has multiple gestation;
(7) has a fetus of less than 37 weeks gestation at the onset of labor;
(8) has a gestation of more than 42 weeks by dates and examination;
(9) has a fetus in any presentation other than vertex at the onset of labor;
(10) is a primigravida with an unengaged fetal head in active labor, or any woman who has rupture of membranes with unengaged fetal head, with or without labor;
(11) has a fetus with suspected or diagnosed congenital anomalies that may require immediate medical intervention;
(12) has pre-eclampsia or eclampsia;
(13) has bleeding with evidence of placenta previa;
(14) any condition determined by the board to be of high risk to the pregnant woman and newborn;
(15) has had a previous caesarian delivery or other uterine surgery;
(16) experienced the rupture of membranes at least 24 hours before the onset of labor; or
(17) is less than 16 years of age at the time of delivery.

(e) Notwithstanding (d) of this section, a certified direct-entry midwife may deliver a woman with any of the complications or conditions listed in (d)(1) — (17) of this section if

(1) the delivery is a verifiable emergency; and
(2) a physician or certified nurse midwife is not available in the geographic vicinity.
(f) A certified direct-entry midwife may not attempt to correct fetal presentation by external or internal inversion unless
(1) there is a verifiable emergency; and
(2) a physician or certified nurse midwife is not available in the geographic vicinity.

Sec. 08.65.180. RESPONSIBILITY FOR CARE. If a certified direct-entry midwife seeks to consult with or refer a patient to a licensed physician, the responsibility of the physician for the patient does not begin until the patient is physically within the physician’s care. On our Wish List // i.e., a legislative remedy to vicarious liability !

Duties and Responsibilities.

500. Prenatal care
510. Intrapartum care
520. Postpartum care
530. Infant care
540. Records
550. Medical back-up arrangements
560. Permitted practices
570. Medications
580. Withdrawal from service

12 AAC 14.500. PRENATAL CARE. (a) The board recommends that a certified direct-entry midwife make prenatal visits to a client every four weeks until the 28th week of gestation, every two weeks from the 29th through the 35th week of gestation, and weekly from the 36th week of gestation until birth.

(b) At the initial prenatal visit, the certified direct-entry midwife shall recommend that the client undergo a physical examination as required in AS 08.65.140 to screen for health problems that could complicate the pregnancy or delivery and that includes a review of the laboratory studies required in (c) of this section. The certified direct-entry midwife shall obtain a signed written consent from the client reflecting the client’s informed choice regarding the recommended physical examination and retain the consent in the client’s record.

(c) At the initial prenatal visit, the certified direct-entry midwife shall

(1) order the following laboratory tests:

(A) a serological test for syphilis, either rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL);
(B) blood group;
(C) Rh factor and screen;
(D) rubella titer;
(E) complete blood count;
(F) gonorrhea screen;
(G) urinalysis;
(H) urine culture;
(I) chlamydia screen;
(J) cervical cytology; and

(2) recommend the following laboratory tests:

(A) test for tuberculosis; and
(B) test for hepatitis and human immune deficiency virus (HIV).
(d) At 15 to 20 weeks of gestation, the certified direct-entry midwife shall discuss with the client the availability of maternal serum alphafetoprotein screening.

(e) At 24 to 28 weeks of gestation, the certified direct-entry midwife shall recommend a 50 gm glucose tolerance test for gestational diabetes.
(f) The certified direct-entry midwife shall order

(1) at 28 and 36 weeks of gestation
(A) a hemoglobin or hematocrit test; and
(B) for a woman with Rh negative type blood, an antibody screen; and
(2) a culture for Group B Streptococci at 35 – 37 weeks of gestation.

(g) At each prenatal visit, the certified direct-entry midwife shall order the analysis of a clean catch urine sample for glucose and protein.

(h) The certified direct-entry midwife shall comply with AS 08.65.140(b) in obtaining a signed informed consent for home delivery.

(i) During the third trimester, the certified direct-entry midwife shall consult with the client concerning selection of a pediatrician, family physician, or other health care provider who will assume responsibility for the infant. The certified direct-entry midwife shall record the client’s choice in the client’s record. If the client cannot or will not select a provider for the infant, the certified direct-entry midwife shall document this information in the client’s record.

(j) The certified direct-entry midwife shall consult with a physician if, during the prenatal period, the client

(1) develops 2+ or greater pitting edema on the face and hands;
(2) develops consistent glucosuria or proteinuria of 1+ or greater;
(3) has marked or severe polyhydramnios or oligohydramnios;
(4) prior to 37 weeks gestation, has six or greater contractions per hour not resolved with hydration or rest, or has effacement or dilation of the cervix;
(5) has severe protruding varicose veins of the extremities or vulva;
(6) develops blood pressure of 140/90 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic over the usual blood pressure;
(7) develops severe, persistent headaches, epigastric pain, or visual disturbances;
(8) has symptoms of urinary tract infection such as a rise in temperature, kidney or flank pain, urinary frequency, or dysuria;
(9) has rupture of membranes before 37 weeks gestation;
(10) has marked decrease or cessation of fetal movement;
(11) has fetal heart tones of less than 100 or more than 170 per minute;
(12) has inappropriate gestational size;
(13) has fever of 100.4° F. or 38° C. for 24 hours or more;
(14) has severe or ongoing medical complications;
(15) has demonstrated anemia by blood test (hematocrit 27 percent or hemoglobin 9 grams);
(16) is found to have a positive antibody screen;
(17) has vaginal bleeding other than show before the onset of labor;
(18) fails a three-hour oral glucose tolerance test; or
(19) has a positive purified protein derivative (PPD) test, hepatitis screen, or human immune deficiency virus (HIV) test.

(k) If, following the consultation set out in (j) of this section, the physician recommends referral for immediate medical care the certified direct-entry midwife shall refer the client for immediate medical care. A referral for immediate medical care does not preclude the possibility of a home delivery if, following the referral, the client does not have any of the conditions set out in AS 08.65.140(d).

(l) During the third trimester, the certified direct-entry midwife shall ensure that the client is adequately prepared for a home birth by discussing issues such as sanitation, facilities, adequate heat, availability of telephone and transportation, plans for emergency evacuation to a hospital, and the skills and equipment that the midwife will bring to the birth.

(m) A certified direct-entry midwife shall make a home visit three to five weeks before the estimated date of confinement to assess the physical environment, to determine whether the client has the necessary supplies, to prepare the family for the birth, and to instruct the family in correction of problems or deficiencies.

12 AAC 14.510. INTRAPARTUM CARE. (a) Intrapartum care includes the management of low risk women whose labor, delivery, postpartum course, and infant are not reasonably expected to require consultation with a physician or referral for medical care.

(b) A certified direct-entry midwife may not perform a vaginal examination on a client with ruptured membranes and no onset of labor unless

(1) less than 24 hours have elapsed since the rupture of the membranes; and
(2) there is a reasonable and strong suspicion of a prolapsed cord.

(c) A certified direct-entry midwife shall obtain medical consultation or refer for medical care any client who during the intrapartum period

(1) develops a blood pressure of 160/100 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic over the baseline blood pressure;
(2) develops a fever of 100.4° F. or 38° C.;
(3) has bleeding other than show before delivery;
(4) develops severe headaches, epigastric pain, or visual disturbance;
(5) develops respiratory distress;
(6) has persistent or recurrent fetal heart tones below 100 or above 170 beats per minute at any time, or a fetal heart rate that is irregular or showing late or variable decelerations; WORDING ISSUE
(7) has meconium stained amniotic fluid other than very light;
(8) desires medical consultation or transfer; or
(9) develops symptoms or signs of an allergic reaction.

(d) A consultation or referral as required in (c) of this section does not preclude the possibility of a home delivery if, following the consultation with a physician or referral for medical care, the client does not have any of the conditions set out in AS 08.65.140(d).
(e) A certified direct-entry midwife shall ensure that a client on whom cardiopulmonary resuscitation is administered or treatment for anaphylactic shock is administered is immediately transported to a hospital.
(f) A certified direct-entry midwife shall accompany to the hospital any client requiring hospitalization and provide copies of all pertinent client data and make a verbal report to the physician assuming care. If reasonably possible, the certified direct-entry midwife shall remain with the client to receive information regarding the results of the client’s hospitalization.
(g) A certified direct-entry midwife may start antibiotic intravenous therapy treatment on a woman who tests positive for Group B Streptococci and chooses antibiotic treatment.

12 AAC 14.520. POSTPARTUM CARE.

(a) Postpartum care is management of the client through the six week postpartum period.
(b) After normal delivery, a certified direct-entry midwife shall remain with the client and infant for at least three hours postpartum or until both the client’s and infant’s conditions are stable. If the client or infant is not stable within five hours, the certified direct-entry midwife shall transfer the client to an appropriate medical facility.
(c) Maternal stability is evidenced by normal blood pressure, pulse, and respiration; firmness of fundus; normal lochia; and the ability to empty the bladder.
(d) Neonatal stability is evidenced by established respirations, normal temperature, normal heart rate, and strong sucking of the infant.
(e) A certified direct-entry midwife shall maintain close contact with the client during the first 72 hours postpartum, A certified direct-entry midwife shall determine whether the mother is bleeding excessively, has a firm fundus, has a normal temperature, and is establishing successful breast-feeding or bottle-feeding.
(f) In the case of a mother with Rh negative type blood, a certified direct-entry midwife shall
(1) obtain a sample of cord blood from the placenta and arrange for testing; and
(2) administer or arrange for and be certain that the mother receives Rh immune globulin as indicated within 72 hours of delivery.
(g) A certified direct-entry midwife shall obtain medical consultation or refer for medical care any client who, during the postpartum period,

(1) does not void within six hours after birth;
(2) has a third or fourth degree perineal or cervical laceration;
(3) develops a fever greater than 100.4° F. or 38° C. on any two of the first 10 postpartum days;
(4) develops foul smelling lochia;
(5) develops hematoma;
(6) does not deliver the placenta within one hour of delivery of the infant;
(7) bleeds more than 1,000 cc (four cups) immediately after the delivery of the placenta and the bleeding is not readily controlled;
(8) has a partially separated placenta with

(A) heavy bleeding;
(B) a blood pressure below 90 systolic;
(C) a pulse rate of 110 beats per minute or more; or
(D) weakness and dizziness; or
(9) has retained placental fragments or membranes.

12 AAC 14.530. INFANT CARE. (a) A certified direct-entry midwife shall consult with a physician concerning an infant who

(1) has an Apgar score of seven or less at five minutes;
(2) has a congenital defect;
(3) has tachycardia of 170 or above, bradycardia of 100 or below, or cardiac irregularities;
(4) develops jaundice within 24 hours of birth or significant scleral icterus within one week of birth;
(5) has an abnormal cry;
(6) shows signs of prematurity, dysmaturity, or postmaturity;
(7) had meconium stained fluid before birth other than very light;
(8) is lethargic or does not feed well;
(9) has edema;
(10) develops grunting respirations, retractions, central cyanosis, or apnea;
(11) has a pale, generalized cyanotic or grey color;
(12) weighs less than five and one half pounds or 2,500 grams, or more than 10 pounds or 4,500 grams;
(13) does not urinate or pass meconium within 24 hours of birth;
(14) requires resuscitation by bag and mask or cardiopulmonary resuscitation; or
(15) appears weak, flaccid, or abnormal in any other respect.

(b) Within two hours of birth, a certified direct-entry midwife shall administer appropriate eye prophylaxis to the newborn infant in accordance with 7 AAC 27.111.

(c) A certified direct-entry midwife shall offer, to one or both of the parents, to administer intramuscular vitamin K to the infant for the prevention of acute and late onset hemorrhagic disease. If a parent consents to the within two hours of birth. A certified direct-entry midwife shall note in the client’s records a parent’s acceptance or refusal of intramuscular vitamin K.

(d) A certified direct-entry midwife shall ensure that the newborn receives metabolic blood disorder screening in accordance with 7 AAC 27.510 - 7 AAC 27.580. The certified direct-entry midwife shall use a metabolic blood disorder screening kit obtained from the Department of Health and Social Services.

(e) A certified direct-entry midwife shall recommend to the client an evaluation of the infant by a physician within one week of birth or sooner if it becomes apparent that the infant needs medical attention.

(f) A certified direct-entry midwife shall complete and file a birth certificate within seven days after the birth in accordance with AS 18.50.160.

12 AAC 14.540. RECORDS. (a) A certified direct-entry midwife shall maintain records of each client on standard obstetric forms prescribed by the board.

(b) A certified direct-entry midwife shall maintain records of the recommended medical visit, all prenatal visits, charting of labor and delivery, summary of birth, and charting of the newborn examination and postpartum visits.
(c) A certified direct-entry midwife shall maintain birth records of an infant until at least two years after the infant has reached the age of 19 years. Prenatal and infant records must be maintained for at least seven years from the date of birth.
(d) A certified direct-entry midwife shall provide copies of pertinent records to medical personnel when the client or infant is referred for medical care or transported for emergency care.
(e) All records maintained by the certified direct-entry midwife are subject to review by the board.

12 AAC 14.550. MEDICAL BACK-UP ARRANGEMENTS. (a) A certified direct-entry midwife shall have written back-up arrangements that must include procedures concerning

(1) alternate midwife assistance for clients in the certified direct-entry midwife’s absence;
(2) abnormal conditions and medically indicated maternal or infant consultations; and
(3) conducting laboratory tests.
(b) A certified direct-entry midwife shall present the written back-up arrangements to the board upon request.

12 AAC 14.560. PERMITTED PRACTICES. (a) The following practices may be performed by a certified direct-entry midwife who provides documentation acceptable to the board of having acquired the training and skills necessary to safely perform them:

(1) catheterization of the urinary bladder;
(2) administration of medications as specified in 12 AAC 14.570 and 12 AAC 14.600;
(3) clamping and cutting the umbilical cord;
(4) artificial rupture of the amniotic membranes if the fetal head is at zero station or lower and the client is past five centimeters dilation;
(5) venipuncture;
(6) capillary blood sampling;
(7) suturing;
(8) emergency measures as specified in 12 AAC 14.600; and
(9) intravenous therapy.
(b) The board will notify the certified direct-entry midwife that documentation submitted under this section is acceptable to the board of competence in these practices. A certified direct-entry midwife may not perform the practices set out in (a) of this section until notification of acceptance has been provided by the board.

12 AAC 14.570. MEDICATIONS. A certified direct-entry midwife may not administer restricted drugs or medications except for the following, and only if the certified direct-entry midwife has documented the training and skills demonstrating competence to administer them as required in 12 AAC 14.560:

(1) Xylocaine hydrochloride, one or two percent, administered by infiltration, for the postpartum repair of tears, lacerations, and episiotomy;
(2) Cetacaine, applied topically, for the postpartum repair of tears, lacerations, and episiotomy;
(3) vitamin K, administered by intramuscular injection, for the prevention of acute and late onset hemorrhagic disease of the infant;
(4) Rhogam, administered by intramuscular injection, for an unsensitized client with Rh negative type blood to prevent Rh disease;
(5) eye prophylaxis as required by 7 AAC 27.111;
(6) Pitocin, administered by intramuscular injection or intravenous drip, in an emergency situation for the control of postpartum hemorrhage;postpartum hemorrhage that was not controlled by the administration of pitocin;
(8) lactated ringers, plain or with dextrose five percent, or normal saline administered intravenously to a postpartum client, in an emergency situation to prevent or treat shock and stabilize her condition while arranging transport to a hospital;
(9) antibiotic intravenous therapy treatment for Group B Streptococci in accordance with the United States Department of Health and Human Services, Centers for Disease Control and Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC, revised as of August 16, 2002 and adopted by reference, except that vancomycin may not be administered;
(10) epinephrine for allergic reaction or anaphylactic shock;
(11) diphenhydramine administered by intramuscular injection or intravenously for allergic reaction or anaphylactic shock.

12 AAC 14.580. WITHDRAWAL FROM SERVICE. (a) A certified direct-entry midwife may withdraw from responsibility for a client during the prenatal period if, for any reason, the midwife does not feel comfortable continuing as the client’s midwife. The decision to withdraw may take into account

(1) the client’s failure to consult a physician when recommended to do so by the certified direct-entry midwife;
(2) the client’s failure or refusal to follow recommendations;
(3) personality incompatibilities; or
(4) any other factor that the certified direct-entry midwife believes may create an unwarranted risk to the client, fetus, or infant, or may interfere with the certified direct-entry midwife’s ability to care responsibly for the client, fetus, or infant.
(b) If the certified direct-entry midwife withdraws, the midwife shall immediately notify the client in writing and shall cooperate with the client in finding alternative care.
(c) After the onset of labor, a certified direct-entry midwife may withdraw only if the midwife believes that the midwife is unable to competently care for the client, fetus, or infant. The certified direct-entry midwife shall arrange for transfer of the client to medical care. If the client refuses to accept transfer to medical care, the certified direct-entry midwife shall document the relevant events and shall stay with the client until attended by hospital or emergency medical personnel

Article 6. Emergency Measures

600. Emergency practices
610. Emergency transport plan
620. Emergency defined

12 AAC 14.600. EMERGENCY PRACTICES. In addition to the practices permitted in AS 08.65.140(e) and (f) and 12 AAC 14.560, in an emergency a certified direct-entry midwife who has documented training and skills demonstrating competence as set out in 12 AAC 14.560 may

(1) perform an episiotomy; and
(2) administer pitocin, methergine, epinephrine, and diphenhydramine as described in 12 AAC 14.570(6), (7), (10).

12 AAC 14.610. EMERGENCY TRANSPORT PLAN. (a) A certified direct-entry midwife shall present a copy of the midwife’s emergency transport plan to each client before the onset of labor.

(b) The emergency transport plan must be signed by the client and include
(1) written permission to release the client’s records to a physician in an emergency; and
(2) a statement that costs will be incurred for emergency transportation and an agreement as to who is responsible for the costs.
(c) The certified direct-entry midwife shall include the signed emergency transport plan in the client’s records.

12 AAC 14.620. EMERGENCY DEFINED. In this chapter and in AS 08.65, “emergency” means a situation that presents an immediate hazard to the health and safety of the client.

12 AAC 14.900. PEER REVIEW. (a) The board will designate, as a peer review committee, a qualified organization with experience in certified direct-entry midwifery to provide peer review to the board concerning the quality of care provided by a certified direct-entry midwife.

(b) In the agreement for peer review services, the board will require the organization providing peer review to
(1) maintain confidentiality of medical records as required by law;
(2) randomly review summaries of births submitted by a certified direct-entry midwife under (c)(1) of this section;
(3) review those summaries of births or other records submitted under (c)(2) and (3) of this section;
(4) review at the request of the board any case or summary of birth relating to care by a certified direct-entry midwife;
(5) maintain records of the organization related to the review;
(6) provide records to the board and division investigative staff, as requested by the board or division investigative staff; and
(7) report to the board or division investigative staff on activities and results of the peer review conducted under this section, including any recommendations for disciplinary action.
(c) A certified direct-entry midwife shall submit to the board or, if an organization has been designated under
(a) of this section, to that organization the following information:
(1) a copy of the summary of birth for each labor and delivery for which the certified direct-entry midwife had primary responsibility during the 12-month period that began on April 1 of the preceding year; the copy must be submitted on or before May 1 of each year;
(2) all records required under 12 AAC 14.540 as requested by the board through the organization providing peer review for cases selected under (b)(2) of this section; and
(3) within 10 days after the delivery or transfer of care all records required under 12 AAC 14.540 for any case in which a client for whom the certified direct-entry midwife had primary responsibility

(A) died;
(B) required emergency hospital transport;
(C) required intensive care; or
(D) had any of the complications or conditions listed in AS 08.65.140(d)(1) - (17).
(d) Failure to comply with the requirements of this section is grounds for disciplinary sanction under AS 08.65.110(6).

12 AAC 14.990. DEFINITIONS. In this chapter

(1) “board” means the Board of Certified Direct-Entry Midwives;
(2) “client” means a pregnant woman, postpartum woman up to six weeks, fetus, or newborn, as appropriate;
(5) “supervision” means the direct observation and evaluation by the preceptor of the clinical experiences and technical skills of the apprentice direct-entry midwife or other supervised person while present with the supervised person in the same room.

APPENDIX B ~ ETHICS

On April 26, 1994 the Board of Certified Direct-Entry Midwives adopted the following code of ethics:

1. The principle objective of the midwifery profession is to render service to humanity with full respect for the dignity of the human race. Midwives should merit the confidence of patients entrusted to their care, rendering to each a full measure of services and devotion.
2. Midwives should strive continually to improve medical knowledge and skill, and should make available to their clients and colleagues the benefits of their professional attainments.
3. A midwife should practice a method of maternal care utilizing accreditable research as a criteria for care, and promote such research.
4. The midwifery profession should safeguard the public and itself against midwives deficient in moral character or professional competence. Midwives should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed disciplines. They should expose, without hesitation, illegal or unethical conduct of fellow members of the profession.

5. A midwife may choose whom she will serve. In a life-threatening emergency, however, she should render service to the best of her ability. Having undertaken the care of a client, she may not neglect her; and, unless she has been discharged, she may discontinue services only after giving adequate notice.

6. A midwife should not dispense her services under terms or conditions which tend to interfere with or impair her midwifery judgment and skill or tend to cause a deterioration of the quality of midwifery care.

7. A midwife should seek consultation and/or referral upon request; in doubtful or difficult cases; or whenever it appears that the quality of health care would be enhanced thereby.

8 A midwife may not reveal the confidences entrusted to her in the course of midwifery attendance, or the deficiencies she may observe in the character of patients, unless she is required to do so by law or unless it becomes necessary in order to protect the welfare of the individual or of the community.

9. The honored ideals of the midwifery profession imply that the responsibilities of the midwife extend not only to the individual, but also to society where these responsibilities deserve her interest and participation in activities which have the purpose of improving both the health and the well-being of the individual and the community.

Arizona Licensed Midwives effective June 18, 2002 (Supp. 02-2)

Responsibilities of the Licensed Midwife

A. A midwife shall provide care only to clients determined to be low risk.

B. A midwife shall maintain all instruments used for delivery in an aseptic manner and other birthing equipment and supplies in clean and good condition.

C. A midwife shall both initially and periodically thereafter assess a client's physical condition in order to establish the client's continuing eligibility to receive midwifery services.

D. A midwife shall inform clients, both orally and in writing, of the midwife's scope of practice; the risks and benefits of home birth; the required tests and potential risks to a newborn if refused, and the need for written documentation of client's refusal; the use of a physician or medical facility for the provision of emergency consultation or services; midwife facilitation of the transfer of care to the physician or medical facility; and the midwife's termination of care should certain medical conditions arise or the client refuses intervention. A written informed consent shall be signed by the client upon acceptance for midwifery care.

E. Initial care and care during the prenatal period shall be provided as follows:

1. The following tests shall be scheduled or ordered during the 1st visit:

a. Blood type, including ABO and Rh, with antibody screen;

b. Urinalysis;

c. Hematocrit, hemoglobin, or complete blood count, initially and rechecked at 28 to 36 weeks of the pregnancy;

d. Syphilis, gonorrhea, and chlamydia testing, unless a written refusal for gonorrhea or chlamydia testing is obtained from the client;

e. Rubella titer; and

f. One-hour blood glucose screening test for diabetes, between 24 to 28 weeks of the pregnancy.

2. Prenatal visits shall be conducted at least every 4 weeks until 28 weeks gestation, every 2 weeks from 28 weeks until 36 weeks gestation, and weekly thereafter, and each shall include;

a. The taking of weight, urinalysis for protein, nitrites, glucose and ketones, blood pressure, and assessment of the lower extremities for swelling;

b. Measurement of the fundal height and listening for fetal heart tones and, later in the pregnancy, feeling the abdomen to determine the position of the fetus;

c. Referral of a client as appropriate for ultrasound or other studies recommended based upon examination or history;

d. Recommendation of administration of the drug RhoGam to unsensitized Rh negative mothers after 28 weeks, or any time bleeding or invasive uterine procedures are done, or midwife administration of RhoGam under physician's written orders; and

e. Fetal movement counts by client beginning at 28 weeks gestation.

3. Fetal heart tones with fetoscope and documentation of 1st quickening shall begin between 18 and 20 weeks gestation and weekly visits shall be conducted until these signs have occurred. If these signs do not occur by 22 weeks gestation, medical consultation shall be initiated. NOT used

4. A visit shall be made to the client's home prior to 35 weeks gestation to ensure that the birthing environment is appropriate for birth and that a working telephone or citizen's band radio is available.

F. Care during the intrapartum period shall be provided as follows:

1. The midwife shall initially determine if the client is in labor and the appropriate course of action to be taken by:

a. Assessing the interval, duration, intensity, location, and pattern of the contractions;

b. Determining the condition of the membranes, whether intact, ruptured, and the amount and color of fluid;

c. Evaluating the presence of bloody show;

d. Reviewing with the client the need for an adequate fluid intake, relaxation, activity, and emergency management; and

e. Deciding whether to go to client's home, remain in telephone contact, or arrange for transfer of care or consultation.

2. During labor, the condition of the mother and fetus shall be assessed upon initial contact, every half hour in active labor until completely dilated, and every 15 to 20 minutes during pushing, after the bag of water has ruptured or until the newborn is delivered. Care shall include the following:

a. Checking of vital signs every 2 to 4 hours and an initial physical assessment of the mother;

b. Assessment of fetal heart tones every 30 minutes in active 1st stage labor, and every 15 minutes during 2nd stage, following rupture of the amniotic bag or with any significant change in labor patterns;

c. Periodic assessment of contractions, fetal presentation, dilation, effacement, and position by vaginal examination;

d. Determination of the progress of active labor for primiparas by determining if dilation occurs at an average of 1 cm/hr until completely dilated, and a 2nd stage not to exceed 2 hours;

e. Determination of a normal progress of active labor for multigravidas by determining if dilation occurs at an average of 1.5 to 2 cm/hr until completely dilated, and a 2nd stage not to exceed 1 hour;

f. Maintenance of proper fluid balance for the mother throughout labor as determined by urinary output and monitoring urine for presence of ketones, at least every 2 hours; and

g. Assisting in support and comfort measures to the mother and family.

3. After delivery of the newborn, care shall include the following:

a. Assessment of the newborn at 1 minute and 5 minutes to determine the Apgar scores;

b. Physical assessment of the newborn for any abnormalities;

c. Inspection of the mother's perineum for lacerations; and

d. Delivery of the placenta within 40 minutes during which time the midwife shall assess for signs of separation, frank or occult bleeding, examine for intactness, and determine the number of umbilical cord vessels.

4. The responsibility of the midwife shall include recognition of and response to any situation requiring immediate intervention.

G. A midwife shall provide the following care during the postpartum period:

1. During the immediate postpartum period of 2 hours after delivery of the placenta, care of the mother shall include:

a. Taking of vital signs of the mother with external massage of the uterus and evaluation of bleeding every 15 to 20 minutes for the 1st hour and every half hour for the 2nd hour;

b. Assisting the mother to urinate within 2 hours following the birth;

c. Evaluating the perineum for tears, bleeding, or blood clots;

d. Assisting with maternal and infant bonding;

e. Assisting with initial breast feeding, instructing the mother in the care of the breast, and reviewing potential danger signs, if appropriate;

f. Providing instruction and support to the family to ensure adequate fluid and nutritional intake, rest, and type of exercise allowed, normal and abnormal bleeding, bladder and bowel function, appropriate baby care, and any danger signals with appropriate emergency phone numbers;

g. Recommending the drug RhoGam or administering it, under written physician's orders, to an unsensitized Rh-negative mother who delivers an Rh-positive newborn. Administration shall occur not later than 72 hours after birth.

2. During the immediate postpartum period of 2 hours after delivery of the placenta, care of the newborn shall include:

a. Perform a newborn physical exam to determine the newborn's gestational age and any abnormalities;

b. Apply erythromycin optic ointment or other preparation specifically approved by the Director to each of the newborn's eyes in accordance with A.A.C. R9-6-718; and

c. Recommend or administer Vitamin K under physician's written orders to the newborn. Administration shall occur not later than 72 hours after birth.

3. Any abnormal or emergency situation shall be evaluated and consultation or intervention sought in accordance with these rules.

4. The condition of the mother and newborn shall be re-evaluated between 24 and 72 hours of delivery to determine whether the recovery is following a normal course and shall include:

a. Assessment of baseline indicators such as the mother's vital signs, bowel and bladder function, bleeding, breasts, feeding of the newborn, sleep/rest cycle, activity with any recommendations for change;
b. Assessment of baseline indicators of well-being in the newborn such as vital signs, weight, cry, suck and feeding, fontanel, sleeping, bowel and bladder function with documentation of meconium, and any recommendations for changes made to the family;
c. Submission of blood obtained from a heel stick to the newborn to the Regional Genetic Screening Laboratory, P.O. Box 17123, Denver, Colorado 80217, for metabolic screening for common genetic disorders, within 72 hours of the birth, unless a written refusal is obtained from the client and documented in the newborn's record.
d. Recommendation to the mother to secure medical follow-up for her newborn; and
e. Advice on the necessity of family planning interventions for the couple.

H. The midwife shall file a birth certificate with the local registrar within 7 days after the birth of the newborn.

Historical Note

Adopted effective March 14, 1994 (Supp. 94-1).

Recordkeeping and Report Requirements

A. Each midwife shall establish and maintain a record of the care provided and data gathered for each client.

B. Information in the client's record shall be released by the midwife only with the written consent of the client, legal guardian, or as otherwise provided by law.

C. If a client is a minor, informed consent shall be signed by the parent or legal guardian except as provided in A.R.S. § 44-132 and shall be filed in the client's record.

D. A midwife shall make records available to other health care providers engaged in the care and treatment of the client and upon request by the Department for periodic quality review.

E. A midwife shall maintain evidence of medical evaluation and physician visits in the client's record. Such evidence shall consist of either a report signed by the physician, a copy of the medical and physician notes, or other documentation received from the physician or medical provider.

F. A midwife shall enter a date for each entry in the prenatal record and the postpartum record. A date and time shall be recorded for each entry in the labor record. Each entry shall be initialed or signed by the midwife. If initials are used, the midwife shall sign on the same page.

G. Each licensed midwife shall submit a client summary report for each client to the Department. Such reports shall be submitted within 15 days after the close of each quarter on the form set forth as Exhibit E.

H. Each client's record shall contain the following information, as applicable:

1. Client identification sheet, including name, address, date of birth, sex, next of kin, spouse or other designated person, directions to the client's home, telephone number, and marital status;

2. Health history sheet including pre-existing conditions or surgeries, previous pregnancies, physical examination, nutritional status, and a written assessment of risk factors with an intervention plan when risk factors that require termination of the agreement are present;

3. Progress notes of all encounters with the midwife and other health care consultants, in chronological order, documenting any actions, guidance, and consultations, with copies if appropriate;

4. Laboratory and diagnostic reports;

5. Written informed consent which is signed by the client.

Historical Note

Colorado Midwifery Practice

RULE 5 – MINIMUM PRACTICE REQUIREMENTS REGARDING ANTEPARTUM CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding antepartum care.

RULE 6 - MINIMUM PRACTICE REQUIREMENTS REGARDING INTRAPARTUM CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding intrapartum care.

RULE 7 - MINIMUM PRACTICE REQUIREMENTS REGARDING POSTPARTUM CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding postpartum care.

RULE 8 - MINIMUM PRACTICE REQUIREMENTS REGARDING NEWBORN CARE ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding newborn care.

RULE 9 - MINIMUM PRACTICE REQUIREMENTS REGARDING RECORD KEEPING ~ The purpose of this rule is to define and clarify generally accepted standards of safe care for women and infants regarding record keeping.