1. A. Except for §B of this regulation, a licensed direct-entry midwife shall arrange immediate emergency transfer to a hospital if:

   1. (1) The patient requests transfer; or

   2. (2) The patient or newborn is determined to have any of the following conditions during labor, delivery, or the immediate postpartum period:

      1. (a) Unforeseen noncephalic presentation;
      2. (b) Unforeseen multiple gestation;

      3. (c) Nonreassuring fetal heart rate or pattern, including:

         1. (i) Tachycardia
         2. (ii) Bradycardia;
         3. (iii) Significant change in baseline; or
         4. (iv) Persistent late or severe variable decelerations;
      4. (d) Prolapsed cord;
      5. (e) Unresolved maternal hemorrhage;
      6. (f) Retained placenta;
      7. (g) Signs of fetal or maternal infection;
      8. (h) Patient with a third or fourth degree laceration or a laceration beyond the licensed direct-entry midwife’s ability to repair;
      9. (i) Apgar of less than seven at 5 minutes;
      10. (j) Obvious congenital anomalies;
      11. (k) Need for chest compressions during neonatal resuscitation;
      12. (l) Newborn with persistent central cyanosis;
      13. (m) Newborn with persistent grunting and retractions;
      14. (n) Newborn with abnormal vital signs;
      15. (o) Gross or thick meconium staining, when discovered; or
      16. (p) Newborn with excessive dehydration due to inability to feed.
2. B. If transfer is not possible because of imminent delivery, the licensed direct-entry midwife shall consult with a health care provider for guidance on further management of the patient and to determine when transfer may be safely arranged, if required.

3. C. A licensed direct-entry midwife shall immediately transfer the care of a patient to a health care provider for the treatment of any significant postpartum morbidity, including:

   1. (1) Uncontrolled postpartum hemorrhage;
   2. (2) Preeclampsia;
   3. (3) Thrombo-embolism;
   4. (4) An infection; or
   5. (5) A postpartum mental health disorder.
4. D. A licensed direct-entry midwife who is required to transfer care of a patient under this regulation may continue other aspects of postpartum care in consultation with the treating health care practitioner.

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)