Midwifery, Board of

Midwifery, Board of

Chapter 7: Professional Responsibility

Effective Date: 10/31/2011 to 12/10/2015

Rule Type: Superceded Rules & Regulations

Reference Number: 036.0001.7.10312011

CHAPTER 7

PROFESSIONAL RESPONSIBILITY

Section 1. The Practice of a Licensed Midwife. The practice of a licensed midwife consists of providing primary maternity care that is consistent with a midwife's training, education and experience to women and their newborn children throughout the childbearing cycle, and includes identifying and referring women or their newborn children who require medical care to an appropriate health professional;

Section 2. Scope and Practice Standards. A licensed midwife must adhere to the following scope and practice standards when providing antepartum, intrapartum, postpartum, and newborn care.

(a) NACPM Scope and Practice Standards. The Board adopts the Essential Documents of the National Association of Certified Professional Midwives as scope and practice standards for licensed midwives. All licensed midwives must adhere to these scope and practice standards during the practice of midwifery to the extent such scope and practice standards are consistent with the Board's enabling law.

(b) Conditions for Which a Licensed Midwife May Not Provide Care. A licensed midwife may not provide care for a client with:

(i) A current history of any of the following disorders, diagnoses, conditions, or symptoms:

(A) Placental abnormality;

(B) Multiple gestations;

(C) Noncephalic presentation at the onset of labor or rupture of membranes, whichever occurs first, unless birth is imminent;

(D) Birth under thirty-seven (37) weeks or after forty-two (42) weeks gestational age;

(E) Pre-eclampsia;

(F) Cervical insufficiency; or

(ii) A past history of any of the following disorders, diagnoses, conditions, or symptoms:

(A) More than one (1) prior cesarean section with no history of a vaginal birth, a cesarean section within eighteen (18) months of the current delivery, or any cesarean section that was surgically closed with a classical or vertical uterine incision;

(B) Rh or other blood group or platelet sensitization, hematological or coagulation disorders;

(C) Cervical insufficiency.

(c) Conditions for Which a Licensed Midwife May Not Provide Care Without Physician Involvement. A licensed midwife may not provide care for a client with a current history of the disorders, diagnoses, conditions, or symptoms listed herein unless such disorders, diagnoses, conditions or symptoms are being treated, monitored or managed by a licensed physician. Before providing care to such a client, the licensed midwife must notify the client in writing that the client must obtain the described physician care as a condition to the client's eligibility to obtain maternity care from the licensed midwife. The licensed midwife must, additionally, obtain the client's signed acknowledgement that the client has received the written notice. The disorders, diagnoses, conditions, and symptoms are:

(i) Diabetes;

(ii) Thyroid disease;

(iii) Epilepsy;

(iv) Hypertension;

(v) Cardiac disease;

(vi) Pulmonary disease;

(vii) Renal disease;

(viii) Previous major surgery of the pulmonary system, cardiovascular system, urinary tract or gastrointestinal tract;

(ix) Hepatitis;

(x) HIV positive;

(xi) Anemic with documented hemoglobin at less than nine (9) at thirty-seven (37) weeks.

(d) Conditions for Which a Licensed Midwife Must Recommend Physician Involvement. Before providing care for a client with a history of any of the disorders, diagnoses, conditions or symptoms listed, a licensed midwife must provide written notice to the client that the client is advised to see a licensed physician during the client's pregnancy. Additionally, the licensed midwife must obtain the client's signed acknowledgement that the client has received the written notice. The disorders, diagnoses, conditions, and symptoms are:

(i) Previous complicated pregnancy; (ii) Previous cesarean section; (iii) Previous pregnancy loss in second or third trimester; (iv) Previous spontaneous premature labor; (v) Previous preterm rupture of membranes; (vi) Previous preeclampsia; (vii) Previous hypertensive disease of pregnancy; (viii) Prior infection with parvo virus, toxoplasmosis, cytomegalovirus or herpes simplex virus; (ix) Previous newborn group B streptococcus infection; (x) A body mass index of thirty-five (35.0) or greater at the time of conception; (xi) Underlying family genetic disorders with potential for transmission; or (xii) Psychiatric illness.

(e) Conditions for Which a Licensed Midwife Must Facilitate Hospital Transfer. A licensed midwife must facilitate the immediate transfer of a client to a hospital for emergency care if the client has any of the following disorders, diagnoses, conditions or symptoms:

(i) Maternal fever in labor of more than 100.4 degrees Fahrenheit, in the absence of environmental factors; (ii) Suggestion of fetal jeopardy, such as any abnormal bleeding (with or without abdominal pain), evidence of placental abruption, thick meconium, or abnormal fetal heart tones with non-reassuring patterns where birth is not imminent; (iii) Noncephalic presentation at the onset of labor or rupture of membranes, whichever occurs first, unless birth is imminent;

(iv) Second stage labor after two (2) hours of initiation of pushing without adequate progress;

(v) Current spontaneous premature labor;

(vi) Current preterm premature rupture of membranes;

(vii) Current preeclampsia;

(viii) Current hypertensive disease of pregnancy;

(ix) Continuous uncontrolled bleeding;

(x) Bleeding that necessitates the administration of more than two (2) doses of oxytocin or other antihemorrhagic agent;

(xi) Delivery injuries to the bladder or bowel;

(xii) Seizures;

(xiii) Uncontrolled vomiting;

(xiv) Coughing or vomiting of blood;

(xv) Severe chest pain;

(xvi) Sudden onset of shortness of breath and associated labored breathing; or

(xvii) Rupture of membranes greater than twenty-four (24) hours unless delivery is imminent.

(f) Plan for Emergency Transfer and Transport. When facilitating a transfer, the licensed midwife must notify the hospital when the transfer is initiated, accompany the client to the hospital if feasible, or communicate by telephone with the hospital if the licensed midwife is unable to be present. The licensed midwife must also ensure that the transfer of care is accompanied by the client’s medical record, which must include:

(i) The client’s name, address, and next of kin contact information;

(ii) A list of diagnosed medical conditions;

(iii) A list of prescription or over the counter medications regularly taken;

(iv) A history of previous allergic reactions to medications; and

(v) If feasible, the licensed midwife's assessment of the client's current medical condition and description of the care provided by the licensed midwife before transfer.

Section 3. Record Keeping. Each client record must be retained for a minimum of ten (10) years after the birth during which time reasonable efforts are to be made to advise clients of closure of practice or change in record location.

Section 4. Written Informed Consent. The licensee shall provide to the client written informed consent documents in accordance with W.S. 33-46-103(j)(ii).

(a) The written informed consent to treatment shall include all of the following:

(i) The licensed midwife's experience and training;

(ii) Instructions for obtaining a copy of rules adopted by the board pursuant to this act;

(iii) Instructions for obtaining a copy of documents adopted by the National Association of Certified Professional Midwives that identify the nature of and standards of practice for responsible midwifery practice;

(iv) Instructions for filing complaints with the board;

(v) Notice of the type and liability limits of professional or personal liability insurance maintained by the midwife or notice that the midwife does not carry liability insurance;

(vi) A written protocol for emergencies that is specific for each individual client, including the following provisions:

(A) Transport to a hospital in an emergency;

(B) Notification of the hospital to which a client will be transferred upon initiation of the transfer;

(C) Accompaniment of the client to the hospital by the midwife, if feasible, or telephone notice to the hospital if the midwife is unable to be present personally;

(D) Transmission of the client's record to the hospital, including the client's name, address, list of known medical conditions, list of prescription or over the counter medications regularly taken, history of previous allergic reactions to medications, the client's current medical condition and description of the care provided by the midwife;

(E) Next of kin contact information.

(vii) A description of the procedures, benefits and risks of home birth, primarily those conditions that may arise during delivery;

(viii) A recommendation to the client that two (2) providers trained in neonatal resuscitation program be present at delivery.

Section 5. Medication Formulary. During the practice of midwifery a licensed midwife may obtain and administer the following drugs described in the midwifery formula, according to the protocol outlined in Appendix A, describing the indication for use, dosage, route of administration and duration of treatment:

(a) Oxygen;

(b) Oxytocin as a postpartum antihemorrhagic agent;

(c) Misoprostol as a postpartum antihemorrhagic agent;

(d) Methylergonovine (Methergine) as a postpartum antihemorrhagic agent;

(e) Injectable local anesthetic for the repair of lacerations which are no more extensive than second degree;

(f) Antibiotics for group B streptococcus prophylaxis consistent with the guidelines set forth in Prevention of Perinatal Group B Streptococcal Disease, published by the Centers for Disease Control and Prevention;

(g) Epinephrine administered via a metered dose auto-injector;

(h) Intravenous fluids for stabilization of the woman;

(i) Rho(D) immune globulin;

(j) Phylloquinone (Vitamin K₁);

(k) Eye prophylactics for the baby;

(l) Sterile H₂O Papules.

Section 6. Obtaining, Storing, and Disposing of Formulary Drugs. A licensed midwife must adhere to the following protocol for obtaining, storing, and disposing of formulary drugs during the practice of midwifery.

(a) Obtaining Formulary Drugs. A licensed midwife may obtain formulary drugs as allowed by law, including, without limitation, from:

(i) A person or entity that is licensed as a Wholesale Distributor by the Wyoming State Board of Pharmacy; and

(ii) A retail pharmacy, in minimal quantities for office use.

(b) Storing Formulary Drugs. A licensed midwife must store all formulary drugs in secure areas suitable for preventing unauthorized access and for ensuring a proper environment for the preservation of the drugs. However, licensed midwives may carry formulary drugs to the home setting while providing care within the course and scope of the practice of midwifery. The licensed midwife must promptly return the formulary drugs to the secure area when the licensed midwife has finished using them for patient care.

(c) Disposing of Formulary Drugs. A licensed midwife must dispose of formulary drugs using means that are reasonably calculated to guard against unauthorized access and harmful excretion of the drugs into the environment. The means that may be used include, without limitation:

(i) Transferring the drugs to a reverse distributor who is registered to destroy drugs with the U.S. Drug Enforcement Agency;

(ii) Removing the drugs from their original containers, mixing them with an undesirable substance such as coffee grounds or kitty litter, putting them in impermeable, non-descript containers such as empty cans or sealable bags, and throwing the containers in the trash; or

(iii) Flushing the drugs down the toilet if the accompanying patient information instructs that it is safe to do so.

Section 7. Newborn Care.

(a) The licensee shall carry the equipment necessary for resuscitation of the newborn.

(b) Midwives shall transfer (immediately if indicated) any newborn showing the following signs to the nearest hospital or pediatric care provider:

(i) Ten (10) minute Apgar score of less than seven (7);

(ii) Signs of a medically significant anomaly;

(iii) Signs of respiratory distress including respiratory rate over eighty (80) per minute, poor color, grunting, nasal flaring and/or retractions that are not showing consistent improvement;

(iv) Need for oxygen for more than twenty (20) minutes, or after one (1) hour following the birth;

(v) Seizures;

(vi) Fontanel full and bulging;

(vii) Significant or suspected birth injury;

(viii) Cardiac irregularities including a heart rate that is consistently below eighty (80) beats per minute or greater than one hundred sixty (160) beats per minute; poor capillary refilling (greater than three (3) seconds);

(ix) Pale, cyanotic, gray color;

(x) Lethargy or poor muscle tone;

(xi) Temperature instability;

(xii) Jaundice at less than twenty-four (24) hours;

(xiii) Loss of greater than ten (10) percent birth weight.

(c) All licensees shall comply with the Wyoming Department of Health’s Newborn Screening requirements stated in W.S. 35-4-801.

(i) Informed consent of parents shall be obtained and if any parent or guardian of a child objects to a mandatory examination, the child is exempt from subsection (c).

(d) All licensees shall register births, still births and deaths with the local registrar of the district in which the occurrence took place within ten (10) days after the birth pursuant to W.S. 35-1-401 through 431;

Section 8. Medical Waste. Medical waste (items removed from a private residence) must be disposed of according to the following protocol:

(a) Containers for Non-Sharp, Medical Waste. Medical waste, except for sharps, must be placed in disposable containers/bags which are impervious to moisture and strong enough to preclude ripping, tearing or bursting under normal conditions of use. The bags must be securely tied so as to prevent leakage or expulsion of solid or liquid waste during storage, handling or transport. The containment system must have a tight-fitting cover and be kept clean and in good repair. All bags used for containment of medical waste must be clearly identified by label or color, or both.

(b) Containers for Sharps. Sharps must be placed in impervious, rigid, puncture-resistant containers immediately after use. Needles must not be bent, clipped or broken by hand. Rigid containers of discarded sharps must either be labeled or colored like the disposable bags used for other medical waste, or placed in such labeled or colored bags.

(c) Storage Duration. Medical waste may not be stored for more than seven (7) days, unless the storage temperature is below thirty-two (32) degrees Fahrenheit. Medical waste must never be stored for more than ninety (90) days.

Section 9. Ethical Standards. The protection of the public health, safety and welfare and the best interest of the public shall be the primary guide in determining the appropriate professional conduct of all persons whose activities are regulated by the Board.

(a) Ethical standards are incorporate and are based on the Standards of Practice of the NACPM. The published Standards of Practice of the NACPM are adopted by reference herein as Appendix B and shall be used by the licensee and the Board to provide additional guidelines to ethical standards. All references to an NACPM member shall mean the same as a licensed midwife. Where the Standards of Practice of the NACPM conflict with the Act and/or these rules and regulations, the Act and rules and regulations shall control.

(b) Persons licensed by the Board shall:

(i) Use the term “Licensed Midwife” and/or the initials LM only after the applicant is granted licensure by the Board.

(ii) Practice in a manner that is in the best interest of the public and does not endanger the public health, safety or welfare.

(iii) Be able to justify all services rendered to clients as necessary for diagnostic or therapeutic purposes.

(iv) Practice only within the competency areas for which they are trained and experienced. The licensee must be able to demonstrate to the Board competency, training, and/or expertise.

(v) Report to the board outcomes of all clients for which they have provided services at any point during labor or delivery within thirty (30) days after each birth.

(vi) Report to the Board known or suspected violations of the laws and regulations governing the practice of licensed professionals.

(vii) Maintain accurate documentation of all professional services rendered to a client in confidential files for each client and ensure that client records are kept in a secure, safe, retrievable and legible condition.

(A) The licensee shall make provisions for the retention and/or release of client records if the licensee is unable to do so. Such provision shall include the naming of a qualified person who will retain the client records and properly release the client records upon request.

(viii) Clearly state the person’s licensure status by the use of a title or initials such as “licensed midwife” (LM) or a statement such as “licensed by the Wyoming Board of Midwifery” in any advertising, public directory or solicitation, including telephone directory listings.

(ix) Respond to all requests for information and all other correspondence from the Board.

(x) Not permit, condone or facilitate unlicensed practice or any activity which is a violation of the Act or these rules and regulations.

(xi) Not use vacuum extraction or forceps as an aid in the delivery of a newborn.

(xii) Not perform abortions.