1. (a) The Licensed Midwife shall make an immediate Referral for any woman who during the antepartum period:

   1. (1) Develops edema of the face and hands, severe, persistent headaches, epigastric pain, or visual disturbances concerning for preeclampsia;
   2. (2) Develops eclampsia;
   3. (3) Develops a systolic blood pressure of 140 or greater or diastolic blood pressure of 90 or greater on two separate occasions 4 hours apart, or develops a systolic blood pressure over 150 or greater or a diastolic blood pressure of 100 or greater on a single reading;
   4. (4) Has persistent, frank vaginal bleeding before onset of labor;
   5. (5) Has rupture of membranes prior to 37 weeks gestation;
   6. (6) Has marked decrease in or cessation of fetal movement;
   7. (7) Has polyhydramnios or oligohydramnios;
   8. (8) Develops gestational diabetes by history or testing, unresponsive to dietary and exercise changes per American Diabetes Association (ADA) guidelines within two (2) weeks of implementing dietary and lifestyle changes;
   9. (9) Has sexually transmitted infection including but not limited to, HIV, Syphilis, and HSV-1 or HSV-2 with an active infection or prodromal symptoms in the last trimester or at time of delivery; or
   10. (10) Identifies twins other than di/di.

2. (b) The Licensed Midwife shall obtain Medical Consultation for a woman who during the antepartum period:

   1. (1) Develops marked glucosuria or proteinuria on two consecutive separate visits;
   2. (2) Has abnormal vaginal discharge with no signs of improvement with medication;
   3. (3) Has symptoms of urinary tract infection that does not improve with treatment;
   4. (4) Has inappropriate gestational size, through physical evaluation or diagnostic examination;
   5. (5) Has demonstrated anemia by blood test (hematocrit less than 30 percent, hemoglobin under 10) that does not improve with treatment;
   6. (6) Has demonstrated Thrombocytopenia by blood test (platelets under 150) that does not improve with treatment;
   7. (7) Has an unexplained fever of equal or greater than 101⁰ F or 38⁰ C;
   8. (8) Has hyperemesis;
   9. (9) Has severe, protruding varicose veins of extremities or vulva with no signs of improvement after treatment;
   10. (10) Has known structural abnormalities of the reproductive tract which are incompatible with vaginal birth;
   11. (11) Has an abnormal Pap smear;
   12. (12) Has sexually transmitted infection including but not limited to, Chlamydia, Gonorrhea, Trichomoniasis, Bacterial Vaginosis, HSV-1, HSV-2, HPV, Condylomata Acuminata;
   13. (13) Reaches a gestation of 41 weeks, 3 days by dates and examination;
   14. (14) Hepatitis C; and
   15. (15) Any other infection requiring treatment or monitoring.

3. (c) The Licensed Midwife shall make an immediate Referral for any woman who during the intrapartum period:

   1. (1) Goes into labor prior to 37 weeks 0/7 days gestation;
   2. (2) Develops a systolic blood pressure of 140 or greater or diastolic blood pressure of 90 or greater on two separate occasions 4 hours apart, or develops a systolic blood pressure over 150 or greater or a diastolic blood pressure of 100 or greater on a single reading;
   3. (3) Develops severe headache, epigastric pain, or visual disturbance concerning for eclampsia;
   4. (4) Develops a fever over 100.4 ⁰F or 38 ⁰C;
   5. (5) Develops respiratory distress;
   6. (6) Has persistent baseline or recurrent fetal heart tones below 110 or above 160 beats per minute, or a fetal heart rate that is abnormal and does not improve with attempts to correct;
   7. (7) Has ruptured membranes and birth has not reached active labor after 18 hours;
   8. (8) Has unresolving, frank bleeding prior to delivery (other than bloody show);
   9. (9) Has thick meconium or blood-stained amniotic fluid with non-reassuring fetal heart tones;
   10. (10) Has a malpresentation incompatible with vaginal delivery;
   11. (11) Does not progress in effacement, dilation, or station after 4 hours of adequate uterine activity in active labor;
   12. (12) Does not show continued progress to deliver in second stage labor after adequate pushing effort for 4 hours;
   13. (13) Does not deliver the placenta within one hour if there is no bleeding and the fundus is firm;
   14. (14) Has a partially separated placenta during the third stage of labor with bleeding;
   15. (15) Exhibits signs or symptoms of hypovolemia (low blood volume) and has a blood pressure below 100 systolic if the sustained pulse rate exceeds 100 beats per minute or who is symptomatic;
   16. (16) Estimated blood loss greater than 500 ml with or after the delivery of the placenta and the mother is symptomatic;
   17. (17) Has placental fragment or membranes (pieces of the placenta or amniotic sac) retained in the uterus; or
   18. (18) Desires transfer.

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