1. (a) Immediate transport. The following intrapartum conditions preclude midwifery care, and when identified, the client must be transported to the planned hospital by the most expedient method of transportation available to obtain treatment/evaluation:

   1. (1) Position other than vertex;
   2. (2) Active genital herpes lesions;
   3. (3) Labor prior to thirty-seven (37) weeks, zero out of seven (0/7) days gestation;
   4. (4) Bleeding in labor that exceeds scant amount with each cervical examination;
   5. (5) Thick meconium if birth is not imminent;
   6. (6) Prolapsed cord;

   7. (7)

      1. (A) Non-reassuring fetal heart rate (FHR) patterns (Category II or Category III) that are repetitive and do not promptly respond to maternal position changes, unless birth is imminent.
      2. (B) Category I FHR patterns are reassuring and are not an indication to transport.
      3. (C) Characteristics of Categories II and III include:

2. (i) Variable decelerations. Abrupt decreases in the FHR by fifteen beats per minute (15 bpm) or more lasting fifteen (15) seconds or more;

   1. (ii) Late decelerations. Gradual decreases in the FHR occurring in the latter portion of the contraction, returning to baseline after the end of the contraction;

      1. (iii) Prolonged decelerations. A decrease in the FHR baseline by fifteen beats per minute (15 bpm) or more lasting between two (2) minutes and ten (10) minutes;

         1. (iv) Tachycardia. FHR baseline greater than one hundred sixty beats per minute (>160 bpm); and
         2. (v) Bradycardia. FHR baseline fewer than one hundred ten beats per minute (<110 bpm);

   2. (8) Signs of maternal infection include any of the following:

      1. (A) Temperature of greater than or equal to one hundred and four tenths of one degrees (≥100.4°);
      2. (B) Fetal tachycardia (baseline heart rate greater than one hundred sixty beats per minute (>160 bpm)); and
      3. (C) Maternal tachycardia (heart rate greater than one hundred ten beats per minute (>110 bpm));
   3. (9) Signs of fetal infection. Baseline FHR greater than one hundred sixty (>160) or a baseline FHR that is continually increasing;
   4. (10) Suspected or confirmed fetal death;
   5. (11) Two (2) high blood pressure readings, meaning a systolic of greater than or equal to one hundred forty (≥140) or a diastolic of greater than or equal to ninety (≥90), two (2) hours apart unless birth is imminent; or

   6. (12)

      1. (A) Unknown GBS status prior to sixteen (16) hours of ruptured membranes, when delivery is not imminent.
      2. (B) Prophylactic antibiotics are indicated by eighteen (18) hours of ruptured membranes.

3. (b) Physician consultation.

   1. (1)

      1. (A) The following intrapartum conditions require consultation with a physician or CNM who has obstetric privileges in a hospital within fifty (50) miles of the delivery site.

      2. (B)

         1. (i) A plan of care must be established and execution documented.
         2. (ii) Midwives caring for these clients will submit additional required incident reports (found in Appendix A or available on the Department of Health website).
         3. (iii) If consultation is not available the client must be transported to the hospital per the emergency plan.
         4. (iv) If the client’s condition is not stable she should be transported to the nearest hospital.

   2. (2) The intrapartum conditions are:

      1. (A) Prolonged labor in a primagravida defined as more than:

         1. (i) Twenty (20) hours from onset of contractions to five centimeters (5 cm);
         2. (ii) Seventeen (17) hours from five centimeters (5 cm) to complete dilation;
         3. (iii) Two and a half (2.5) hours pushing; or
         4. (iv) One (1) hour from delivery of the infant to delivery of the placenta; and

      2. (B) Prolonged labor in the multigravida defined as more than:

         1. (i) Fourteen (14) hours from onset of contractions to five centimeters (5 cm);
         2. (ii) Sixteen (16) hours from five centimeters (5 cm) to complete dilation;
         3. (iii) One (1) hour pushing; or
         4. (iv) One (1) hour from delivery of the infant to delivery of the placenta.

Codification Notes: "CNM" means certified nurse midwife. "GBS" means group B streptococcus.