1. (a) Each client is to have a risk assessment (see 17 CAR § 47-303(a)) documented by a physician, CNM, or Department of Health clinician at or near the initiation of care and again around the thirty-sixth week.

2. (b)

   1. (1) The following sections detail the actions to be followed by the LLM if the client exhibits or develops one (1) of the specified conditions.
   2. (2) The LLM will refer women for medical evaluation as soon as possible after the condition is identified.
3. (c) The LLM is expected to use their judgment regarding the need for consultation, referral, or transfer when problems arise that are not specified in this part.
4. (d) In addition to the birth log, such care will be documented on an incident report and submitted to the department.

5. (e) Conditions precluding midwifery care.

   1. (1)

      1. (A) The following conditions preclude midwifery care and the client must be transferred to a physician, CNM, or department clinician upon diagnosis.
      2. (B) There may be additional high-risk conditions judged by either a physician, CNM, department clinician, or LLM that could also preclude midwifery care.

   2. (2) The conditions are:

      1. (A) Previous cesarean delivery;
      2. (B) Multiple gestation;
      3. (C) Documented placenta previa in the third trimester;
      4. (D) Insulin-dependent diabetes; and
      5. (E)

6. (i) Pregnancy that extends beyond forty-two (42) weeks, zero out of seven (0/7) days gestational age unless there is a third risk assessment and a documented plan of care submitted to the department.

   1. (ii) If the clinician advises against home delivery, the client must be transferred.

7. (f) Pre-existing conditions requiring antepartum consultation, referral, or transfer of care.

   1. (1) If any of the following pre-existing conditions are identified, the client must be examined by a:

      1. (A) Physician;
      2. (B) CNM; or
      3. (C) Department clinician.

   2. (2)

      1. (A) A plan of care for the condition must be established, including a plan for transfer of care if indicated, and execution of the plan of care must be documented.
      2. (B) Midwives caring for these clients will be required to submit additional incident reports to the department.
      3. (C) If a referral is not made or if the clinician advises against home birth, the care must be transferred to a physician or CNM.

   3. (3) The pre-existing conditions are:

      1. (A) Heart disease;
      2. (B) Epilepsy;
      3. (C) Diabetes;
      4. (D) Neurological disease;
      5. (E) Sickle cell or other hemoglobinopathies;
      6. (F) Cancer;
      7. (G) Psychiatric disorders;
      8. (H) Active tuberculosis;
      9. (I) Chronic pulmonary disease;
      10. (J) Thrombophlebitis;
      11. (K) Endocrinopathy;
      12. (L) Collagen vascular diseases or other severe collagen disease;
      13. (M) Renal disease;
      14. (N) Hypertension;
      15. (O) Drug or alcohol use during current pregnancy;
      16. (P) Significant congenital or chromosomal anomalies;
      17. (Q) History of postpartum hemorrhage not caused by placenta previa or abruption;
      18. (R) Rh negative isoimmunization (positive Coombs);
      19. (S) Structural abnormalities of the reproductive tract including fibroids;
      20. (T) HIV positive or AIDS;
      21. (U) Previous infant with GBS disease;
      22. (V) History of unexplained perinatal death;
      23. (W) History of seven (7) or more deliveries;
      24. (X) Maternal age greater than or equal to forty (40) at estimated date of delivery;
      25. (Y) Previous infant weighing less than five (5) pounds or more than ten (10) pounds;
      26. (Z) Previous surgery involving the uterus or cervix; and
      27. (AA) Pregnancy termination or loss more than or equal to three (≥3).

8. (g) Antepartum conditions requiring consultation, referral, or transfer of care.

   1. (1) If any of the following antepartum conditions are identified:

      1. (A) A physician/CNM consultation, referral, or transfer is required; and
      2. (B) The client must be examined by a physician or CNM currently practicing obstetrics.

   2. (2)

      1. (A) Department clinicians may accept referrals per department protocol.
      2. (B) A plan of care for the condition must be established and execution of the plan must be documented.
      3. (C) Midwives caring for these clients shall submit additional required incident reports to the department.
      4. (D) If a referral is not made or if the clinician advises against home delivery the client must be transferred immediately to a physician or CNM.

   3. (3) The antepartum conditions are:

      1. (A) A sudden decrease in fetal movement or kick count of fewer than ten (10) per hour after twenty-seven (27) weeks, six out of seven (6/7) days;

      2. (B) Group B strep prophylaxis indication.

         1. (i)
9. (a) (a) Centers for Disease Control and Prevention-approved group B strep intrapartum prophylaxis (per department-approved guidelines) must be obtained for the clients listed below (subdivision (g)(3)(B)(ii) of this section).

10. (b) (b) Clients who refuse antibiotics will be transferred from midwifery care to a physician for hospital care unless a physician agrees to supervise the LLM care of the client.

    1. (c) (c) The plan of care agreed to by the physician and the LLM must be documented and submitted as an incident report to the department.

       1. (ii) The clients are:

11. (a)

    1. (1) (a)(1) Clients who test positive for group B strep in the urinary tract at any time in the current pregnancy (regardless of repeated testing that is negative for group B strep).
    2. (2) (2) Vaginal/rectal testing for group B strep is not indicated when the urine testing is positive for group B strep in the current pregnancy;

12. (b) (b) Clients who test positive for group B strep in the vagina or rectum at any time in the current pregnancy (regardless of repeated testing that is negative for group B strep);

    1. (c) (c) Clients with positive history of birth of an infant with early-onset group B strep disease; and

       1. (d) (d) Clients with antepartum group B strep culture status that is unknown at the time of labor onset and:
    2. (1) (1) Temperature in labor (greater than or equal to one hundred and four tenths of one degrees Fahrenheit (> 100.4° F));

    3. (2)

       1. (A) (2)(A) Rupture of membranes more than sixteen (>16) hours (17 CAR § 47-306(12)).
       2. (B) (B) Prophylactic antibiotics are indicated by eighteen (18) hours of ruptured membranes; or

    4. (3) (3) Preterm labor (less than thirty seven (<37) weeks, zero out of seven (0/7) days of gestation);

       1. (C) Cervical effacement or dilatation prior to thirty-seven (37) weeks, zero out of seven (0/7) days;

       2. (D)

          1. (i) Late term pregnancy greater than forty-one (>41) weeks, zero out of seven (0/7) days.
          2. (ii) The third risk assessment is required between forty-one (41) weeks, zero out of seven (0/7) days and forty-two (42) weeks, zero out of seven (0/7) days, and transfer of care may be required depending on results (17 CAR § 47-303(a)(5)(C));
       3. (E) Genital herpetic lesions;
       4. (F) Clients with a previous preterm delivery must be co-managed until thirty-seven (37) weeks, zero out of seven (0/7) days;
       5. (G) Suspected or confirmed fetal death;
       6. (H) Vaginal bleeding heavier than a normal period;
       7. (I) Persistent or significant weight loss after the first trimester;
       8. (J) Abnormal weight gain;
       9. (K) Symptoms of vaginitis refractory to treatment;
       10. (L) Symptoms of UTI refractory to treatment;
       11. (M) Hematocrit of less than thirty (<30) or hemoglobin of less than ten (<10), or platelets less than one hundred thousand (<100,000);
       12. (N) Hyperemesis with weight loss;
       13. (O) Two (2) blood pressure readings at least one (1) hour apart of systolic greater than or equal to one hundred forty (≥140) or diastolic greater than or equal to ninety (≥90);
       14. (P) Size/date discrepancy of three (3) or more weeks on two (2) successive exams;
       15. (Q) Positive antibody screen;
       16. (R) Abnormal pap test;
       17. (S) Sexually transmitted infection;

       18. (T)

           1. (i) Ruptured membranes without onset of labor within twenty-four (24) hours and group B strep testing is negative.
           2. (ii) Refer to 17 CAR § 47-304(g)(3)(B) for mothers who are GBS positive or have unknown GBS status;
       19. (U) Signs and symptoms of preeclampsia;
       20. (V) Fetal heart rate below one hundred ten beats per minute (110 bpm) or above one hundred sixty beats per minute (160 bpm);
       21. (W) Spontaneous rupture of membranes prior to thirty-seven (37) weeks, zero out of seven (0/7) days;
       22. (X) Gestational diabetes, as defined by department-approved guidelines;
       23. (Y) Rh negative mothers with abdominal trauma, with or without antepartum bleeding; or
       24. (Z) Position other than vertex any time after thirty-five (35) weeks, six out of seven (6/7) days.

Codification Notes: "AIDS" means acquired immunodeficiency syndrome. "APRN" means advanced practice registered nurse. "CBC" means complete blood count. "CLIA" means Clinical Laboratory Improvement Amendments. "CNM" means certified nurse midwife. "GBS" means group B streptococcus. "HIV" means human immunodeficiency virus. "HPV" means human papillomavirus. "LLM" means licensed lay midwife. "UTI" means urinary tract infection.