1. (a) Immediate transport. The following postpartum conditions preclude midwifery care and when identified, the client must be transported to the hospital indicated in the emergency plan by the fastest method of transportation available to obtain treatment/evaluation:

   1. (1) Hemorrhage. Estimated blood loss of five hundred milliliters (500 mL) or more;

   2. (2) Exhibiting signs of shock:

      1. (A) Systolic BP less than ninety (<90);
      2. (B) Diastolic BP less than sixty (<60);
      3. (C) Heart rate fewer than fifty beats per minute (<50) or greater than one hundred twenty beats per minute (>120);
      4. (D) Respiratory rate fewer than ten (<10) or greater than thirty (>30); or
      5. (E) Maternal agitation, confusion, or unresponsiveness;

   3. (3) Elevated BP:

      1. (A) Systolic greater than or equal to one hundred sixty (≥160); or
      2. (B) Diastolic greater than or equal to one hundred (≥100);
   4. (4) Third and fourth degree lacerations;
   5. (5) Maternal temperature greater than one hundred and four tenths of one degrees (>100.4°) on two (2) occasions one (1) hour or more apart; and
   6. (6) Inability to urinate by six (6) hours after delivery.

2. (b) Consultation or referral.

   1. (1)

      1. (A) The following postpartum conditions require consultation with a physician or a CNM.
      2. (B) A plan of care must be established and execution documented.
      3. (C) Midwives caring for these clients will submit additional required incident reports to the Department of Health (found in Appendix A or available on the department website).

   2. (2) The postpartum conditions are:

      1. (A) Signs and symptoms of postpartum infection:

3. (i) Endometritis;

   1. (ii) Mastitis; and

      1. (iii) Urinary tract infection;
      2. (B) Signs and symptoms of sub-involution;
      3. (C) Signs and symptoms of postpartum preeclampsia; and
      4. (D) Signs and symptoms of postpartum depression.

Codification Notes: "BP" means blood pressure. "CNM" means certified nurse midwife.