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(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:

(a) prenatal factors:

(i) severe hyperemesis;

(ii) rubella contracted in the first or second trimester;

(iii) maternal anemia (hemoglobin less than ten, hematocrit less than 30) unresponsive within one month of treatment;

(iv) oligohydramnios (suspected);

(v) polyhydramnios (suspected);

(vi) premature rupture of membranes at less than 36 1/2 weeks;

(vii) post term at 42 weeks by dates and physical exam;

(viii) large for gestational age (LGA) or small for gestational age (SGA) (suspected);

(ix) Rh sensitization in present pregnancy (not resulting from recent Rhogam);

(x) history of severe postpartum hemorrhage requiring transfusion;

(xi) known serious maternal viral/bacterial infection at term;

(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;

(xiii) develops signs and symptoms of preeclampsia;

(xiv) develops signs and symptoms of gestational diabetes;

(xv) has unresolved vaginitis that requires antibiotic treatment;

(xvi) has unresolved urinary tract infection;

(xvii) continued vaginal bleeding before onset of labor;

(xviii) signs of fetal distress including prolonged fetal tachycardia (more than 170) or prolonged fetal bradycardia (less than 100), or fetal demise;

(xix) persistent fever;

(xx) history of preterm delivery (less than 36 1/2 weeks);

(xxi) positive maternal diagnosis of HIV;

(xxii) abnormal Pap smear (showing atypia or CIN);

(xxiii) all condylomas;

(xxiv) grand multiparity;

(xxv) maternal age less than 16 or greater than 40;

(xxvi) history of previous stillbirth;

(xxvii) history of incompetent cervix;

(xxviii) history of previous birth with Erb's Palsy or fractured clavicle or humerus;

(xxix) history of neonatal anomaly; or

(xxx) history of previous cesarean birth.

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

(i) significant fetal distress including prolonged fetal tachycardia (more than 170) or prolonged fetal bradycardia (less than 100);

(ii) unengaged vertex above -3 station in primipara in active labor;

(iii) fever of 102 degrees Fahrenheit or greater;

(iv) prolonged rupture of membranes (greater than 24 hours with no progress of labor);

(v) meconium stained fluid with delivery not imminent;

(vi) severe bleeding prior to or during delivery;

(vii) maternal respiratory distress;

(viii) mother desires consult or transfer;

(ix) maternal hemorrhage uncontrolled by IM pitocin;

(x) third or fourth degree perineal laceration;

(xi) signs of infection;

(xii) evidence of thrombophlebitis.

(c) newborn risk factors:

(i) less than three vessels in umbilical cord;

(ii) Apgar score less than seven at five minutes;

(iii) fails to urinate or move bowels within 24 hours;

(iv) obvious anomaly;

(v) respiratory distress;

(vi) cardiac irregularities;

(vii) pale cyanotic or gray color;

(viii) abnormal cry;

(ix) jaundice within 24 hours of birth;

(x) signs of prematurity, dysmaturity, or postmaturity;

(xi) lethargic;

(xii) has edema;

(xiii) signs of hypoglycemia;

(xiv) abnormal facial expression;

(xv) abnormal body temperature (outside the 97-100 degrees Fahrenheit range, not resolved within one hour);

(xvi) abnormal neurological signs, including jitteriness, decreased tones, seizures or poor sucking reflex; or

(xvii) inability to nurse after 12 hours.


History: 37-27-105, MCA; IMP, 37-27-105, MCA; 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.

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