1. (a) The Licensed Midwife will make an immediate Referral to a physician of an infant with:

   1. (1) Apgar score of less than seven (7) at five (5) minutes or less than seven (7) at ten (10) minutes;
   2. (2) Abnormal cry;
   3. (3) Medically significant anomaly;
   4. (4) Respiratory distress;
   5. (5) Cardiac irregularities;
   6. (6) Cardio Pulmonary Resuscitation efforts initiated;
   7. (7) Signs of hypoglycemia such as but not limited to tremors, apnea, lethargy, poor feeding, poor muscle tone, weak or high-pitched cry, hypothermia, cyanosis, seizures;
   8. (8) Persistent Newborn temperature below 97 or above 100.4 degrees;
   9. (9) Heart rate > 160 bpm or <100 bpm;

   10. (10) Birth weight less than 2500 grams and with any of the following;

       1. (A) Lethargy;
       2. (B) Low temperature;
       3. (C) Poor suck; or
       4. (D) Jitteriness.
   11. (11) SpO2 (pulse oxygenation) outside of NRP (Neonatal Resuscitation Program) guidelines or failed CCHD (critical congenital heart disease) pulse oximetry screening; or
   12. (12) Cyanosis, pallor or abnormal color that does not resolve within the expected time frame.

2. (b) The Licensed Midwife will initiate a Medical Consultation for treatment of infants exhibiting signs and/or symptoms of any of the following:

   1. (1) Jaundice within twenty-four (24) hours of birth or jaundice above physiological jaundice in the Postpartum Period;
   2. (2) Birth weight greater than nine (9) pounds with a maternal history of diabetes;
   3. (3) Prematurity, dysmaturity, or post maturity as determined by the Newborn exam;
   4. (4) Failure to urinate within twenty-four (24) hours or pass meconium within forty-eight (48) hours;
   5. (5) Poor feeding, poor or no suck reflex, lethargy;
   6. (6) Inability to maintain Normal body temperature;
   7. (7) Suspected or confirmed injuries or abnormalities; or
   8. (8) Otherwise healthy infant with a birth weight below 2500 grams.
3. (c) If possible, the Licensed Midwife may accompany the mother or infant to the hospital if hospitalization is necessary. If possible, the Licensed Midwife may remain with the mother or infant until a care plan is established to provide continuity of care. Licensed Midwives should not be considered as a visitor in the healthcare setting and should be allowed into the hospital consistent with hospital policy even when there may be visitor restrictions, such as those imposed due to COVID-19.
4. (d) The Licensed Midwife shall inform parents of recommended guidelines for Newborn eye prophylaxis and Vitamin K prophylaxis.
5. (e) The Licensed Midwife shall inform parents of recommended guidelines for GBS prophylaxis. If the prophylaxis is not administered, the Licensed Midwife shall recommend physician evaluation within 24 hours of birth.
6. (f) Licensed Midwives are required to arrange administration of Hep B immunoglobin to infants born to mothers with Hep B within 12 hours of birth.

Added at 38 Ok Reg 2005, eff 9-11-21