1. (a) A certified direct-entry midwife shall consult with a licensed physician or advanced practice registered nurse providing obstetrical care whenever there are significant deviations, including significant abnormal laboratory results, relative to a client's pregnancy or to a neonate. If a referral is needed, the certified direct-entry midwife shall refer the client and, if possible, remain in consultation with the physician or advanced practice registered nurse until resolution of the cause of the deviation.

2. (b) A certified direct-entry midwife shall consult with a licensed physician or advanced practice registered nurse about any mother who presents with or develops risk factors that in the judgment of the certified direct-entry midwife warrant consultation or presents with or develops the following risk factors:

   1. (1) antepartum

      1. (A) pregnancy induced hypertension, as evidenced by a blood pressure of 140/90 on at least two occasions greater than six hours apart;
      2. (B) persistent, severe headaches, epigastric pain, or visual disturbances;
      3. (C) persistent symptoms of urinary tract infection;
      4. (D) significant vaginal bleeding before the onset of labor not associated with uncomplicated spontaneous abortion;
      5. (E) rupture of membranes before the 37th week of gestation;
      6. (F) noted abnormal decrease in or cessation of fetal movement;
      7. (G) anemia resistant to supplemental therapy;
      8. (H) fever of 102 degrees Fahrenheit or 39 degrees Celsius or greater for more than 24 hours;
      9. (I) unresolved hyperemesis or significant dehydration;
      10. (J) isoimmunization, Rh-negative sensitized, positive titers, or any other positive antibody titer that may have a detrimental effect on the mother or fetus;
      11. (K) elevated blood glucose levels unresponsive to dietary management;
      12. (L) positive HIV antibody test;
      13. (M) primary genital herpes infection in pregnancy;
      14. (N) symptoms of malnutrition or anorexia, protracted weight loss, or failure to gain weight;
      15. (O) suspected deep vein thrombosis;
      16. (P) documented placental previa;
      17. (Q) documented low lying placenta or placenta accreta in woman with history of previous cesarean delivery;
      18. (R) labor before the 37th week of gestation;
      19. (S) known fetal anomalies that may be affected by the site of birth;
      20. (T) marked abnormal fetal heart tones;
      21. (U) abnormal non-stress test or abnormal biophysical profile;
      22. (V) marked or severe poly or oligodydramnios;
      23. (W) evidence of intrauterine growth restriction; or
      24. (X) significant abnormal ultrasound findings;

   2. (2) intrapartum

      1. (A) rise in blood pressure above baseline, more than 30/15 points or greater than 160/100;
      2. (B) persistent, severe headaches, epigastric pain, or visual disturbances;
      3. (C) significant proteinuria or ketonuria;
      4. (D) fever over 100.6 degrees Fahrenheit or 38 degrees Celsius in absence of environmental factors;
      5. (E) ruptured membranes without onset of established labor after 24 hours;
      6. (F) significant bleeding before delivery or any abnormal bleeding, with or without abdominal pain; or evidence of placental abruption;
      7. (G) lie not compatible with spontaneous vaginal delivery or unstable fetal lie;
      8. (H) signs or symptoms of maternal infection;
      9. (I) active genital herpes at onset of labor;
      10. (J) fetal heart tones with non-reassuring patterns;
      11. (K) signs or symptoms of fetal distress;
      12. (L) thick meconium or frank bleeding with birth not imminent; or
      13. (M) physician consultation or transfer desired by the client or certified direct-entry midwife;

   3. (3) postpartum

      1. (A) failure to void within 12 hours of birth;
      2. (B) signs or symptoms of maternal shock;
      3. (C) febrile symptoms or fever 102 degrees Fahrenheit or 39 degrees Celsius;
      4. (D) abnormal lochia or signs or symptoms of uterine sepsis;
      5. (E) suspected deep vein thrombosis; or
      6. (F) signs of clinically significant depression.

3. (c) A certified direct-entry midwife shall consult with a licensed physician or advanced practice registered nurse with regard to any neonate who is born with or develops

   1. (1) an Apgar score of six or less at five minutes without significant improvement by 10 minutes;
   2. (2) persistent grunting respirations or retractions;
   3. (3) persistent cardiac irregularities;
   4. (4) persistent central cyanosis or pallor;
   5. (5) persistent lethargy or poor muscle tone;
   6. (6) abnormal cry;
   7. (7) birth weight less than 2,300 grams;
   8. (8) jitteriness or seizures;
   9. (9) jaundice occurring before 24 hours or outside of normal range;
   10. (10) failure to urinate within 24 hours of birth;
   11. (11) failure to pass meconium within 48 hours of birth;
   12. (12) edema;
   13. (13) prolonged temperature instability;
   14. (14) significant signs or symptoms of infection;
   15. (15) significant clinical evidence of glycemic instability;
   16. (16) abnormal, bulging, or depressed fontanel;
   17. (17) significant clinical evidence of prematurity;
   18. (18) medically significant congenital anomalies;
   19. (19) significant or suspected birth injury;
   20. (20) persistent inability to suck;
   21. (21) diminished consciousness;
   22. (22) clinically significant abnormalities in vital signs, muscle tone, or behavior;
   23. (23) clinically significant color abnormality, cyanotic, or pale or abnormal perfusion;
   24. (24) abdominal distension or projectile vomiting; or
   25. (25) signs of clinically significant dehydration or failure to thrive.

(Eff. 5/11/94, Register 130; am 5/2/2004, Register 170; am 10/18/2007, Register 184; am 3/2/2011, Register 197; am 9/9/2016, Register 219; am 2/22/2023, Register 245)