1. (1) If the following conditions are present in a client, the direct-entry midwife shall attempt to consult a physician and/or transfer care to a physician. A certified nurse midwife or licensed direct-entry midwife shall also be consulted if appropriate attempts to consult a physician have been unsuccessful. Documentation of the condition, recommendation (including continuation of care by the licensed direct-entry midwife, if appropriate) and treatment must be maintained in the client records. Conditions include, but are not limited to the following:

   1. (a) prenatal factors:

      1. (i) severe hyperemesis;
      2. (ii) rubella contracted in the first or second trimester;
      3. (iii) maternal anemia (hemoglobin less than ten, hematocrit less than 30) unresponsive within one month of treatment;
      4. (iv) oligohydramnios (suspected);
      5. (v) polyhydramnios (suspected);
      6. (vi) premature rupture of membranes at less than 36 1/2 weeks;
      7. (vii) post term at 42 weeks by dates and physical exam;
      8. (viii) large for gestational age (LGA) or small for gestational age (SGA) (suspected);
      9. (ix) Rh sensitization in present pregnancy (not resulting from recent Rhogam);
      10. (x) history of severe postpartum hemorrhage requiring transfusion;
      11. (xi) known serious maternal viral/bacterial infection at term;
      12. (xii) blood pressure greater than 140/90 or increase of 30 mm Hg systolic or 15 mm Hg diastolic over baseline, that is unresolved within seven days;
      13. (xiii) develops signs and symptoms of preeclampsia;
      14. (xiv) develops signs and symptoms of gestational diabetes;
      15. (xv) has unresolved vaginitis that requires antibiotic treatment;
      16. (xvi) has unresolved urinary tract infection;
      17. (xvii) continued vaginal bleeding before onset of labor;
      18. (xviii) signs of fetal distress including prolonged fetal tachycardia (more than 170) or prolonged fetal bradycardia (less than 100), or fetal demise;
      19. (xix) persistent fever;
      20. (xx) history of preterm delivery (less than 36 1/2 weeks);
      21. (xxi) positive maternal diagnosis of HIV;
      22. (xxii) abnormal Pap smear (showing atypia or CIN);
      23. (xxiii) all condylomas;
      24. (xxiv) grand multiparity;
      25. (xxv) maternal age less than 16 or greater than 40;
      26. (xxvi) history of previous stillbirth;
      27. (xxvii) history of incompetent cervix;
      28. (xxviii) history of previous birth with Erb's Palsy or fractured clavicle or humerus;
      29. (xxix) history of neonatal anomaly; or
      30. (xxx) history of previous cesarean birth.

   2. (b) labor, birth risks, and postpartum factors:

      1. (i) significant fetal distress including prolonged fetal tachycardia (more than 170) or prolonged fetal bradycardia (less than 100);
      2. (ii) unengaged vertex above -3 station in primipara in active labor;
      3. (iii) fever of 102 degrees Fahrenheit or greater;
      4. (iv) prolonged rupture of membranes (greater than 24 hours with no progress of labor);
      5. (v) meconium stained fluid with delivery not imminent;
      6. (vi) severe bleeding prior to or during delivery;
      7. (vii) maternal respiratory distress;
      8. (viii) mother desires consult or transfer;
      9. (ix) uncontrolled maternal hemorrhage;
      10. (x) third or fourth degree perineal laceration;
      11. (xi) signs of infection;
      12. (xii) evidence of thrombophlebitis.

   3. (c) newborn risk factors:

      1. (i) less than three vessels in umbilical cord;
      2. (ii) Apgar score less than seven at five minutes;
      3. (iii) fails to urinate or move bowels within 24 hours;
      4. (iv) obvious anomaly;
      5. (v) respiratory distress;
      6. (vi) cardiac irregularities;
      7. (vii) pale cyanotic or gray color;
      8. (viii) abnormal cry;
      9. (ix) jaundice within 24 hours of birth;
      10. (x) signs of prematurity, dysmaturity, or postmaturity;
      11. (xi) lethargic;
      12. (xii) has edema;
      13. (xiii) signs of hypoglycemia;
      14. (xiv) abnormal facial expression;
      15. (xv) abnormal body temperature (outside the 97-100 degrees Fahrenheit range, not resolved within one hour);
      16. (xvi) abnormal neurological signs, including jitteriness, decreased tones, seizures or poor sucking reflex; or
      17. (xvii) inability to nurse after 12 hours.

Authorizing statute(s): 37-27-105, MCA

Implementing statute(s): 37-27-105, MCA

History: NEW, 1993 MAR p. 1639, Eff. 7/30/93; AMD, 1994 MAR p. 386, Eff. 2/25/94; AMD, 1995 MAR p. 2684, Eff. 12/8/95; TRANS, from Commerce, 2001 MAR p. 1642; AMD, 2018 MAR p. 976, Eff. 5/12/18; AMD, 2023 MAR p. 886, Eff. 8/26/23.