1. A. The practice of direct-entry midwifery does not include:

   1. (1) Pharmacological induction or augmentation of labor or artificial rupture of membranes before the onset of labor;
   2. (2) Surgical delivery or any surgery except an emergency episiotomy;
   3. (3) Use of forceps or vacuum extractor;
   4. (4) Except for the administration of a local anesthetic, administration of an anesthetic;
   5. (5) Administration of any kind of narcotic analgesic; or
   6. (6) Administration of any prescription medication not authorized in accordance with Regulation .07 of this chapter.

2. B. A licensed direct-entry midwife may not assume care or continue to take responsibility for a patient’s pregnancy and birth care if a finding of any of the disorders or situations listed under §C of this regulation is found to be present:

   1. (1) At the initial interview;
   2. (2) During an examination of the patient;
   3. (3) While obtaining a patient history or at subsequent prenatal visits;
   4. (4) As a result of a laboratory or other test; or
   5. (5) After consultation with another health care practitioner.

3. C. If any of the following disorders or situations exist, the licensed direct-entry midwife shall arrange for the orderly transfer of care to a health care practitioner:

   1. (1) Diabetes mellitus, including uncontrolled gestational diabetes;
   2. (2) Hyperthyroidism treated with medication;
   3. (3) Uncontrolled hypothyroidism;
   4. (4) Epilepsy with seizures or antiepileptic drug use during the previous 12 months;
   5. (5) Coagulation disorders;
   6. (6) Chronic pulmonary disease;
   7. (7) Heart disease in which there are arrhythmias or murmurs except when, after evaluation, it is the opinion of a physician licensed under Health Occupations Article, Title 14, Annotated Code of Maryland, or a licensed nurse certified as a nurse-midwife or a nurse practitioner under Health Occupations Article, Title 8, Annotated Code of Maryland, that midwifery care may proceed;
   8. (8) Hypertension, including pregnancy-induced hypertension (PIH);
   9. (9) Renal disease;
   10. (10) Except as otherwise provided in Health Occupations Article, §8-6C-04(a)(11), Annotated Code of Maryland, Rh sensitization with positive antibody titer;
   11. (11) Previous uterine surgery, including a cesarean section or myomectomy;
   12. (12) Indications that the fetus has died in utero;
   13. (13) Premature labor (gestation less than 37 weeks);
   14. (14) Multiple gestation;
   15. (15) Noncephalic presentation at or after 38 weeks;
   16. (16) Placenta previa or abruption;
   17. (17) Preeclampsia;
   18. (18) Severe anemia, defined as hemoglobin less than 10 g/dL;

   19. (19) Uncommon diseases and disorders, including:

       1. (a) Addison’s disease;
       2. (b) Cushing’s disease;
       3. (c) Systemic lupus erythematosus;
       4. (d) Antiphospholipid syndrome;
       5. (e) Scleroderma;
       6. (f) Rheumatoid arthritis;
       7. (g) Periarteritis nodosa;
       8. (h) Marfan’s syndrome; and
       9. (i) Other systemic and rare diseases and disorders, as determined by the Department;
   20. (20) AIDS/HIV;
   21. (21) Hepatitis A through G and non-A through G;
   22. (22) Acute toxoplasmosis infection, if the patient is symptomatic;
   23. (23) Acute Rubella infection during pregnancy;
   24. (24) Acute cytomegalovirus infection, if the patient is symptomatic;
   25. (25) Acute Parvovirus infection, if the patient is symptomatic;
   26. (26) Alcohol abuse, substance abuse, or prescription abuse during pregnancy;
   27. (27) Continued daily tobacco use into the second trimester;
   28. (28) Thrombosis;
   29. (29) Inflammatory bowel disease that is not in remission;
   30. (30) Primary herpes simplex virus, genital infection during pregnancy, or any active genital lesions at the time of delivery;
   31. (31) Significant fetal congenital anomaly;
   32. (32) Ectopic pregnancy;
   33. (33) Prepregnancy body mass index (BMI) of less than 18.5 or 35 or more; or
   34. (34) Post term maturity (gestational age 42 0/7 weeks and beyond).

Authority: Health-General Article, §§8-205 and Title 8, Subtitle 6C, Annotated Code of Maryland;
Ch. 383, Acts of 2015

Effective date: December 19, 2016 (43:25 Md. R. 1385)

Regulation .15B amended as an emergency provision effective July 11, 2023 (50:15 Md. R. 680); adopted permanently effective October 16, 2023 (50:20 Md. R. 887)