When reporting an incident of maternal or neonatal significant morbidity or mortality, a midwife shall provide the following information on the “Significant Morbidity and Mortality Report Form” provided by the midwifery council and available on the boards web site, https://www.oplc.nh.gov/midwifery-council-forms-and-documents:

1. (a) The name of the midwife;
2. (b) The Midwife’s address;
3. (c) The Midwife’s phone number;
4. (d) The midwife’s certification number;
5. (e) The name of the client;
6. (f) The client’s address and phone number;
7. (g) The client’s date of birth;
8. (h) The newborn’s name and date of birth, if applicable;
9. (i) The location of the incident of significant morbidity or mortality;

10. (j) If the client or newborn was transferred to a hospital:

    1. (1) A detailed description of the reason for the transfer of the care of the client or newborn to the hospital;
    2. (2) The name and location of the hospital to which the care of the client or newborn was transferred and the phone number of the hospital’s medical records department;
    3. (3) The date and time of the call for transportation to the hospital;
    4. (4) The date and time the client or newborn arrived at the hospital; and
    5. (5) The means of transportation to the hospital;
11. (k) A detailed description of the maternal illness, injury, or morbidity, and outcome;
12. (l) A detailed description of the newborn’s illness, injury, or morbidity, and outcome;
13. (m) A detailed description of any additional significant concerns or information; and
14. (n) The midwife’s signature and date of signing.

Source. #8840, eff 3-13-07, EXPIRED: 3-13-15 New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16 New. #12040, eff 11-10-16; ss by #13611, eff 6-13-23