A. Licensed midwife practitioners may provide care only to low risk clients determined by physician evaluation and examination to be prospectively normal for pregnancy and childbirth, and at low risk for the development of medical complications. Licensed midwife practitioners shall provide such care with the supervision of a physician who is actively engaged in the practice of obstetrics.

AUTHORITY NOTE: Promulgated in accordance with R.S.37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. All licensed midwife practitioners shall have available, for their immediate use, appropriate birthing equipment, including equipment to assess maternal, fetal, and newborn well-being, maintenance asceptic technique, perform emergency maternal or infant resuscitation, and accomplish all permitted emergency procedures. All equipment used in the practice of midwifery shall be maintained in an asceptically clean manner, and be in good working order.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. All midwives will use risk factor assessments of their clients in order to establish their initial and continuing eligibility for midwifery services. Clients will be informed of their risk status. All midwives have the right and responsibility to refuse and discontinue services to clients based on these risk factors and to make appropriate referrals when indicated for the protection of the mother and baby. All final decisions on risk factors will be made by the midwife and the client's backup physician. 

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner must require that the client have a physical examination by a physician and be found to be essentially normal or at low risk before her care can be assumed. The initial physician examination shall include the physical assessment procedures which meet current standards of care set forth by the American College of Obstetricians and Gynecologists (ACOG).

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. Initial physician examination shall include clinical pelvimetry, and the following laboratory tests: GC screen, blood group and Rh, hematocrit or hemoglobin, rubella titer, and urinalysis. Hematocrit or hemoglobin must be rechecked at 28 and 36 weeks gestation. The midwife must ensure that all women she plans to deliver receive the required tests. Additionally, if no objection is made to the taking of a VDRL test, the physician shall include such test in his examination. The midwife must ensure that the VDRL test was offered to the client.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of M edical Examiners, LR 17:779 (August 1991).

A. Prior to the acceptance of a client for care, a licensed midwife practitioner shall inform the client orally and in writing that:

1. certain risks and benefits exist for home birth and certain risks and benefits exist for other childbirth alternatives, (including hospital, physician-assisted birth). The midwife is responsible for informing the client of the risks and benefits of all childbirth options to ensure informed consent;

2. regular antepartum care is required if the midwife is to attend the birth;

3. certain medical conditions and/or client noncompliance with midwife or physician recommendations may preclude midwife attendance at birth or continued midwife care during any phase of the pregnancy;

4. the client must make arrangements for the services of a backup physician located within a 50 mile radius of the client's home and the planned delivery site;

5. the midwife will develop and implement a plan for obtaining consultation from and/or referral to the client's backup physician, and will consult with the client's backup physician or transfer the client when necessary;

6. emergency transport may be required in certain situations; when situations warrant emergency transport and the hazards involved;

7. a specific written consent for out-of-hospital birth with the licensed midwife practitioner must be obtained prior to the onset of labor;

8. the client will be provided with a copy of the labor, birth, and newborn record by the midwife;

9. the midwife's agreement can be terminated at any time that the midwife deems it necessary for maintenance of the client's mental and physical safety. When termination occurs, the reasons for termination will be given in writing and an alternative source of care indicated; and

10. the client may terminate the agreement at any time.

B. Prior to accepting care for a client, the midwife shall consult with a physician who performed the medical evaluation to ensure that the client is at low or normal risk for pregnancy.

C. After accepting care, the midwife shall obtain a detailed obstetric and medical history of the client; including the results of all tests conducted during the medical evaluation.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. Prenatal visits should be every four weeks until 28 weeks gestation, every two weeks from 28 until 35 weeks gestation, and weekly from 36 weeks until delivery.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. Each client must be evaluated by the supervising physician at or near the thirty-sixth week. The purpose of this visit is to ensure that the client has no potentially serious medical conditions and has no medical contraindications for delivery by a licensed midwife practitioner or for home birth.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:518 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner, prior to the onset of labor, must make arrangements for the transport of mother and infant to a hospital and know the client's arrangements for a backup physician and hospitalization should these needs arise.

A. The licensed midwife practitioner shall accompany to the hospital any mother or infant requiring hospitalization, giving any pertinent written records and verbal report to the physician assuming care. If possible, she should remain with the mother and/or infant to ascertain outcome. In those instances where it is necessary to continue providing necessary care to the party remaining in the home, the midwife may turn over the care of the transport of mother or child to qualified emergency or hospital personnel. All necessary written records shall be forwarded with such personnel and a verbal report must be given.

B. For home birth, the licensed midwife practitioner will make a home visit three to five weeks prior to the Estimated Date of Confinement (EDC) to assess the physical environment, including the availability of telephone and transportation, to ascertain whether the woman has all the necessary supplies, to prepare the family for the birth, and to instruct the family to correct problems and/or deficiencies.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner shall remain with the mother and infant for at least two hours postpartum, or until the mother's condition is stable and the infant's condition is stable, whichever is longer. Maternal stability is evidenced by normal blood pressure, normal pulse, normal respirations, firm fundus, and normal lochia. Infant stability is evidenced by established respirations, normal  temperature, and strong sucking.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR  12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner will not perform any vaginal examinations on a woman with ruptured membranes and no labor, other than an initial examination to be certain that there is no prolapsed cord. Once active labor is assured in progress, exams may be made as necessary.

A. The licensed midwife practitioner will not perform, routinely, an operative procedure other than artificial rupture of membranes when the head is well engaged or at zero station, clamping and cutting the umbilical cord, repair of first or second degree perinial lacerations, or repair of episiotomy, if done.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. A midwife licensed under this Chapter shall administer an eye prophylaxis to prevent infant blindness which is authorized by the department and may administer the following medications under the conditions indicated: 

1. oxygen for fetal distress, infant resuscitation;

2. local anesthetic, by infiltration, only for the purpose of postpartum repair of tears, lacerations, or episiotomy (no controlled substances);

3. vitamin K, by injection, for control of bleeding in the newborn;

4. oxytocin (pitocin or methergine) by injection or orally, only for postpartum control of maternal hemorrhage;

5. intravenous fluids (Ringer's Lactate with or without D5W, normosol-R with or without D5W) with additional medications as provided by a physician's order or protocol to control maternal hemorrhage.

A. The licensed midwife practitioner will not attempt to correct fetal presentations by external or internal version nor will the midwife use any artificial, forcible, or mechanical means to assist the birth.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The following measures are permissible in an emergency situation:

1. cardiopulmonary-resuscitation;

2. episiotomy;

3. intramuscular administration of pitocin for the control of postpartum hemorrhage in accord with the prescription or standing order of a physician;

4. intravenous (IV) fluids and medications in accordance with the prescription or standing order of a physician.

B. When any of the above measures is utilized, it will be charted on the birth record with detail describing the emergency situation, the measure taken, and the outcome.

C. The back-up physician of any client upon whom an emergency measure is taken must be contacted by the midwife immediately upon control of the emergency situation, and the midwife shall then transfer care of the client to such physician as he may direct or request.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. Without one hour of birth, the licensed midwife practitioner shall administer two drops of 1.0 percent solution of silver nitrate or other agent of equal effectiveness and harmlessness into the eyes of the infant in accordance with applicable state laws and regulations governing the prevention of infant blindness.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. All licensed midwife practitioners shall request copies of printed instructions relating to completion of birth certificates from the Louisiana State Registrar of Vital Records. The licensed midwife practitioner must complete a birth certificate in accordance with these instructions and file it with the registrar within five days of the birth. 

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner must recommend that any infant delivered by the midwife be evaluated by a physician within three days of age or sooner if it becomes apparent that the newborn needs medical attention for problems of, but not limited to, congenital anomalies.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner shall make a postpartum visit to evaluate the condition of mother and infant within 36 hours of birth, with further visits as necessary.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:519 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. All midwives shall keep accurate and complete records of all care provided and data gathered for each client. Licensed midwife practitioners shall semi -annually submit a summary report in a form prescribed by the board of the statistics of each birth attended. This report must be submitted within the months of January and July of each year. Midwives shall provide all other reports as required and mandated by the board. A copy of all submissions will be provided to members of the Louisiana Advisory Committee on Midwifery.

B. The midwife shall maintain an individual client chart for each woman under her care. The chart shall include results of laboratory tests, observations from each prenatal visit, records of consultations with physicians or other health care providers, and a postpartum report concerning labor, delivery, and condition of the newborn child. The chart shall be made available to the client upon request, and with the client's consent, to any physician or health care provider who is called in as a consultant or backup. This chart shall be kept on standard obstetric forms, or other forms approved by the board. Inactive records shall be maintained no less than 10 years. All records are subject to review by the board.

C. Evidence of the required medical evaluation and physician visits shall be maintained in the client's records.

D. The attending midwife shall prepare a summary of labor, delivery, and assessment of the newborn, using the Hollister form, or an alternate form containing substantially similar information. One copy of each summary shall be retained with the client's chart and one copy transmitted to the pediatrician or family doctor.

E. Copies of the disclosure and consent forms required by §5315 and of the report required by §5337 shall be maintained in the records.

F. The attending midwife shall make a timely report of the birth incidents to the registrar.

A. The board shall review all reports from licensed midwife practitioners, complete annual midwifery statistics, and make them available to all interested groups or persons.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:520 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. At the visit when physical care of the client is initiated, the licensed midwife practitioner shall review the results of the medical evaluation to ensure that the client has received a general physical examination which included the taking of a comprehensive medical, obstetrical, and nutritional history sufficient to identify potentially dangerous conditions that might preclude midwife care. The midwife must ensure that the following examinations have been completed for each client: a pelvic examination to size the uterus, a speculum examination, blood pressure, routine bloodwork (CBC with differential, rubella titer, VDRL, hematocrit or hemoglobin, Rh, and antibody screening), Pap smear, height, weight, and urine testing for glucose and protein. After conducting these examinations or reviewing their results, the midwife shall make an initial nutritional assessment, counsel the clients as to the nutritional needs of mother and fetus during pregnancy and develop a comprehensive plan of care for the client which identifies all problems and need for consultation and establishes realistic health care goals.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:520 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. At each prenatal visit, the midwife will check the client's weight, blood pressure, fundal height, urinalysis (protein and glucose), and general health, including checking for pain, bleeding, headaches, edema, dizziness, and other symptoms of preeclampsia. The midwife shall monitor uterine measurements, fetal heart tones, and fetal activity and shall obtain a medical and nutritional history since the last visit. The midwife shall conduct or arrange for additional laboratory tests as indicated, including Rh antibody screening, blood sugar screening, gonorrhea culture, and periodic hematocrit or hemoglobin screening.

B. A record of fetal heart rate and rhythm shall be made at least every 30 minutes during first stage, after each contraction in second stage and after rupture of membranes. The duration, interval, and intensity of uterine contraction and material blood pressure shall be recorded at least ever hour and immediately after delivery.

C. During labor and delivery, the attending midwife is responsible for monitoring the condition of mother and fetus; assisting with the delivery; coaching labor; repairing minor tears as necessary; examining and assessing the newborn; inspecting the placenta, membranes, and cord vessels; inspecting the cervix and upper vaginal vault, if indicated; and managing any third-stage material bleeding.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:520 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner shall remain in attendance for at least two hours after the delivery. 

B. Immediately following delivery of the placenta, the midwife must determine that the uterus is firmly contracted without excessive bleeding. The uterus should be massaged firmly to stimulate contraction if relaxation is noted.

C. In case of an unsensitized Rh negative mother, the midwife shall obtain a sample of cord blood from the placenta and arrange for testing within 24 hours of the birth and ensure referral to back-up physician so that the mother receives Rh immunoglobin as indicated within 72 hours of delivery.

D. The midwife shall provide the client with information concerning routine postpartum care of the mother and infant, including information on breast-feeding, care of navel, and perinatal care.

E. The midwife shall recommend that the parents immediately contact the pediatrician or family doctor who will be assuming care for the infant to arrange for a neonatal examination. The midwife shall provide the doctor with her written summary of labor, delivery, and assessment of the newborn and shall be available to consult with the doctor concerning the infant's condition.

F. The midwife shall make a postpartum contact within 36 hours of birth, with further visits as necessary. The purpose of these contacts is to ascertain that the infant is alert, has good color, is breathing well, and is establishing a healthy pattern of waking, feeding, and sleeping and that the mother is not bleeding excessively, has a firm fundus, does not have a fever or other signs of infection, is voiding properly, and is establishing successful breastfeeding. In the event that any complications arise, the midwife shall consult with a physician or other appropriate health care provider or shall ensure that the client contacts her own physician.

G. The midwife may conduct a postpartum office visit not later than six weeks postpartum, to include a recommendation for rubella vaccine if indicated, counseling concerning contraception and answering any other questions that have arisen. Alternatively, the client may be referred back to her primary care physician or other health care provider for this care.

H. The midwife shall encourage the mother to have a postpartum evaluation conducted by a physician within two to six weeks after delivery. 

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:520 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner shall be responsible for care immediately following the delivery only.  Subsequent infant care should be managed by a physician or a physician/registered nurse team. This does not preclude the midwife from providing counseling regarding routine newborn care and breastfeeding and arranging for the neonatal tests required by state law. If any abnormality is suspected, the newborn must be sent for medical evaluation as soon as possible.

B. Immediately following delivery the midwife shall:

1. wipe face, then suction (with bulb syringe) mouth and nose if necessary;

2. prevent heat loss by the neonate;

3. determine Apgar scores at one and five minutes after delivery;

4. observe and record: skin color and tone, heart rate and rhythm, respiration rate and character, estimated gestational age (premature, term, or post-mature), weight, length, and head circumference.

C. The midwife shall ensure that a medically acceptable drug for eye prophylaxis is available at the time of delivery and take appropriate measures designed to prevent infant blindness.

D. The midwife is responsible for ensuring and documenting that a PKU test and all other neonatal tests required by state law are performed on the infant between 24 hours and no later than 14 days after birth. If any of the tests are positive, the midwife shall notify the department. If the parents object to such tests being performed on the infant, the midwife shall document this objection.

E. The midwife shall leave clear instructions for followup care including signs and symptoms of conditions that require medical evaluation.

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:520 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).

A. The licensed midwife practitioner shall provide care only to clients determined to be at low or normal risk of developing complications during pregnancy and child birth by a supervising physician.

B. The midwife shall not knowingly accept or thereafter maintain responsibility for the prenatal or intraparturn care of a woman who:

1. has had a previous Cesarean section or other known uterine surgery such as hysterectomy or myornectomy, except upon the express approval of the board which may be granted upon individual application of the client or midwife where the client has previously been evaluated by a physician who determines that vaginal delivery represents no untoward medical/obstetrical risk for the client and is not contraindicated;

2. has a history of difficult to control hemorrhage with previous deliveries;

3. has a history of thrombophlebitis or pulmonary embolism;

4. has diabetes, hypertension, Rh disease with positive titer, active tuberculosis, active syphilis, active gonorrhea, epilepsy, hepatitis, heart disease, kidney disease, or blood dyscrasia;

5. contracts genital herpes simplex in the first trimester or has active genital herpes in the last four weeks of pregnancy;

6. has a contracted pelvis;

7. has severe psychiatric illness or a history of severe psychiatric illness in the six month period prior to pregnancy;

8. is addicted to narcotics or other drugs; 

9. ingests more than two ounces of alcohol or 24 ounces of beer a day on a regular day or participates in binge drinking;

10. smokes 20 cigarettes or more per day, and is not likely to cease in pregnancy;

11. has a multiple gestation;

12. has a fetus of less than 37 weeks gestation at the onset of labor;

13. has a gestation beyond 42 weeks by dates and examination;

14. has a fetus in any presentation other than vertex at the onset of labor;

15. is a primigravida with an unengaged fetal head in active labor, or any woman who has rupture of membranes with unengaged fetal head, with or without labor; 

16. has a fetus with suspected or diagnosed congenital anomalies that may require immediate medical intervention;

17. has preeclampsia;

18. has a parity greater than five with poor obstetrical history; or

19. is younger than 16 or a primipara older than 40.

A. The midwife shall obtain medical consultation or refer for medical care any woman who during the anteparturn period:

1. develops edema of the face and hands;

2. develops severe, persistent headaches, epigastric pain, or visual disturbances;

3. develops a blood pressure of 140/90 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic over her normal blood pressure;

4. does not gain 14 pounds by 30 weeks gestation or at least four pounds a month in the last trimester or gains more than six pounds in two weeks in any trimester;

5. develops glucosuria or proteinuria;

6. has symptoms of vaginitis;

7. has symptoms of urinary tract infection;

8. has vaginal bleeding before onset of labor;

9. has rupture of membranes prior to 37 weeks gestation;

10. has marked decrease in or cessation of fetal movement;

11. has inappropriate gestational size;

12. has demonstrated anemia by blood test (hematocrit less than 30 percent);

14. has effacement and/or dilation of the cervix prior to 36 weeks gestation;

15. has polyhydramnios or oligohydramnios;

16. has excessive vomiting or continued vomiting after 24 weeks gestation;

17. is found to be Rh negative;

18. has severe, protruding varicose veins of extremities or vulva;

19. has known structural abnormalities of the reproductive tract;

20. has a history of two or more stillbirths from any cause or of stillbirth where cause was unpreventable;

21. has an abnormal Pap smear;

22. reaches a gestation of 41 weeks by dates and examination.

B. The midwife shall obtain medical consultation or refer for medical care any woman who during the intraparturn period:

1. develops a blood pressure of 140/90 or an increase of 30 mm Hg systolic or 15 mrn Hg diastolic over her normal blood pressure;

2. develops severe headache, epigastric pain, or visual disturbance;

3. develops proteinuria;

5. develops respiratory distress;

6. has persistent or recurrent fetal heart tones below 100 or above 160 beats per minute between or during contractions, or a fetal heart rate that is irregular;

7. has ruptured membranes without onset of labor after 12 hours;

8. has bleeding prior to delivery (other than bloody show);

9. has meconium or blood stained amniotic fluid with abnormal fetal heart tones;

10. has a presenting part other than a vertex;

11. does not progress in effacement, dilation, or station after two hours in active labor (or one hour if distance to hospital is greater than one hour);

12. does not show continued progress to deliver after two hours of second stage labor (or one hour if distance to hospital is greater than one hour);

13. does not deliver the placenta within one hour if there is no bleeding and the fundus is firm (or 30 minutes, if distance to hospital is greater than one hour);

14. has a partially separated placenta during the third stage of labor with bleeding or with a blood pressure below 100 systolic if the pulse rate exceeds 100 beats per minute or who is weak and dizzy;

15. bleeds more than 500 cc with or after the delivery of the placenta;

16. has retained placental fragment or membranes;

17. desires medical consultation or transfer.

C. The midwife shall obtain medical consultation or refer for medical care any woman who, during the postpartum period:

1. has a third or fourth degree laceration;

2. has uterine atony;

3. bleeds in an amount greater than normal lochial flow;

4. does not void within 6 hours of birth;

6. develops foul smelling lochia;

7. develops blood pressure below 100/50 if pulse exceeds 100, pallor, cold clammy skin, and/or weak pulse.

D. The midwife shall obtain medical consultation or refer for medical care any infant who:

1. has an Apgar score of 7 or less at 5 minutes;

2. has any obvious anomaly;

3. develops grunting respirations, retractions, or cyanosis;

4. has cardiac irregularities;

5. has a pale, cyanotic, or grey color;

6. develops jaundice within 48 hours of birth;

7. has an abnormal cry;

8. weighs less than five pounds or 2,500 grams or weighs more than nine pounds or 4,100 grams;

9. shows signs of prematurity, dysmaturity, or postmaturity;

10. has meconium staining of the placenta, cord, and/or infant with signs or symptoms of aspiration pneumonia;

11. does not urinate or pass meconium in the first 12 hours after birth;

12. is lethargic or does not feed well;

13. has edema;

14. appears weak or flaccid, has abnormal feces, or appears not to be normal in any other respect;

16. has jitteriness not resolved after feeding.

AUTHORITY NOTE: Promulgated in accordance with R.S 37:1270 and R.S. 37:3241-3257. HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:521 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991).