PART Mid 101 PURPOSE

Mid 101.01 Purpose. These rules implement the statutory responsibilities of the New Hampshire Midwifery Council created by RSA 326-D:3.

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PART Mid 102 DEFINITIONS

Mid 102.01 Definitions.

(a) "Council" means "council" as defined in RSA 326-D:2, II, namely, "the midwifery council established in RSA 326-D:3".

(b) "Midwifery" means "midwifery" as defined in RSA 326-D:2, V, namely, "the practice, by persons other than physicians or surgeons licensed under RSA 329, nurses registered under RSA 326-B, or physician's assistants licensed under RSA 328-D, of:

(1) Providing the necessary supervision, care and advice to women during pregnancy, labor and the postpartum period;

(2) Conducting vaginal deliveries on the midwife's own responsibility, and caring for the newborn and the infant; such care to mother and child to include preventive measures, the detection of abnormal conditions, the procurement of medical assistance, and the execution of emergency measures in the absence of medical help; and

(3) Consulting with a physician whenever there are significant deviations from normal or whenever there is a medical emergency in either the mother or the infant."

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PART Mid 103 DESCRIPTION OF THE COUNCIL AND COUNCIL MEETINGS

Mid 103.01 Composition of the Council. The council consists of 6 members appointed pursuant to, and meeting the eligibility requirements of, RSA 326-D:3, I.

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Mid 103.02 Responsibilities of the Council. The council's responsibilities include, but are not limited to:

(a) Establishing qualifications for certification to practice midwifery, renewal of certification and recertification after lapse of certification;

(b) Issuing certificates to practice midwifery;

(c) Establishing fees for the examination of applicants and for certification and renewal of certification;

(d) Defining the scope of practice and procedures for the practice of midwifery in accordance with RSA 326-D:5, I(c);

(e) Regulating the practice of midwifery through necessary investigations, disciplinary proceedings and disciplinary action; and

(f) Reporting to the commissioner of health and human services concerning the practice of midwifery.

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Mid 103.03 Council Meetings and Quorum.

(a) Pursuant to RSA 326-D:3, IV the council shall meet no fewer than 4 times a year and at such additional times as the council chair or a majority of the council members shall designate.

(b) Pursuant to RSA 326-D:3, IV the quorum required for council meetings is 4 members.

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Mid 103.04 Ineligibility of Council Members to Vote On Certain Matters and Participate in Certain Deliberations.

(a) A council member shall not be eligible to vote on, or participate in the council's deliberations about, matters pertaining to:

(1) The member's own application for initial or renewal certification or recertification; and

(2) Any matter in which the member has a personal, professional, or financial interest including, but not limited to, any matter involving:

a. The member;

b. The member's spouse, parent, child or business partner; or

c. A business investment of the member.

(b) Under the circumstances described in paragraph (a) the council member shall:

(1) Promptly disclose to the council his or her interest; and

(2) Recuse himself or herself from voting on, and participating in council deliberations about, the matter.

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Mid 103.05 Attendance at Meetings By Members of the Public. Pursuant to RSA 91-A:2, II, members of the public may attend and record council meetings, except for those parts of the meetings which are nonpublic sessions as defined in RSA 91-A:3.

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Mid 103.06 Notice of Meetings.

(a) Notice of the time and place of council meetings, excluding emergency meetings, shall be given in accordance with RSA 91-A:2, II.

(b) Information about the time and place of council meetings shall also be available by telephone at the number stated in Mid 104.01 (b).

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Mid 103.07 Minutes of Council Meetings.

(a) Minutes shall be kept of council meetings and of official actions taken by the council.

(b) Such minutes shall:

(1) Record the members participating in each vote; and

(2) Separately record the position of members who dissent, abstain or concur.

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PART Mid 104 PUBLIC REQUESTS FOR INFORMATION

Mid 104.01 Office Location and Mailing Address, Telephone Number, and Number for TTY Users.

(a) The council's office location and mailing address is:

NH Midwifery Council

Longmeadow Farm

585 Hopkinton Road

Hopkinton, New Hampshire 03229

(b) The council's telephone number is (603) 224-0049.

(c) Access for TTY users is through Relay New Hampshire by calling 711.

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Mid 104.02 Communication with the Council.

(a) Persons wishing to make submissions to, or requests of, the council may mail a letter to the address stated in Mid 104.01(a), call the number stated in Mid 104.01 (b) or communicate by TTY using the number stated in Mid 104.01(c).

(b) Persons seeking information from the council may do so by mail, telephone or TTY as described in paragraph (a).

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Mid 104.03 Public Access to Records.

(a) Pursuant to RSA 91-A:4 members of the public may inspect and copy those records of the council, including meeting minutes, which are public records and not exempt from disclosure under RSA 91-A:5 or other applicable law.

(b) Public records shall be inspected and copied at the office of the council at the location stated in Mid 104.01(a) during regular business hours.

(c) Persons desiring copies of public records shall reasonably describe the information being sought and pay the actual cost of the copies.

(d) If records are requested which contain both public and confidential information, the council shall delete the confidential information and provide the remaining information.

CHAPTER Mid 200 - RESERVED

CHAPTER Mid 300 CERTIFICATION REQUIREMENTS

PART Mid 301 DEFINITIONS

Mid 301.01 Definitions.

(a) "ACNM" means The American College of Nurse-Midwives.

(b) "Abnormal conditions" means conditions of pregnancy, birth, or postpartum outside normal parameters, with the potential for compromising the well-being of the client, the fetus or the newborn.

(c) "APGAR assessment" means an evaluation of the newborn based on an assessment of the heart rate, respiration, reflexes, color and muscle tone, performed at intervals of one minute and five minutes after birth.

(d) "CPR" means cardiopulmonary resuscitation.

(e) "Certified midwife (CM)" means an individual who has a background in any health field other than nursing, has graduated from a midwifery education program accredited by the ACNM Division of Accreditation and has passed a national examination to become professionally designated as a CM by the ACNM Certification Council.

(f) "Certified nurse-midwife (CNM)" means a registered nurse who has graduated from a nurse-midwifery education program accredited by the ACNM Division of Accreditation and has passed a national examination to become professionally designated as a CNM by the ACNM Certification Council.

(g) "Certified professional midwife (CPM)" means an individual who has met the standards for certification in the practice of midwifery set by NARM and who holds such certification.

(h) "Doula" means a person trained to give women information, comfort, and emotional support before, during and after birth.

(i) "GED certificate" means a certificate showing that the individual to whom it was issued has passed the general educational development test of the American Council on Education.

(j) "Leopold's maneuver" means the use of 4 specific steps in palpating the uterus externally in order to determine the position of the fetus.

(k) "Neonatal resuscitation program (NRP)" means a course of study in the prevention and treatment of neonatal respiratory depression which is cosponsored by the American Academy of Pediatrics and The American Heart Association.

(l) "North American Registry of Midwives (NARM)" means a non-profit agency established to certify practitioners of midwifery on the basis of experience and examination.

(m) "Practicing midwives" means residents of the state who held themselves out as midwives prior to July 1, 1999 and are authorized by RSA 326-D:14, II to practice midwifery without certification until June 30, 2001.

(n) "Prenatal" means during the period of time between conception and the onset of labor.

(o) "Postpartum" means occurring after childbirth.

(p) "Rh(D) immune globulin" means a preparation used to prevent the development of Rh antibodies in Rh negative mothers.

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PART Mid 302 APPLICATION PROCEDURE

Mid 302.01 Application Process for Initial Certification.

(a) Persons who wish to be issued a first certificate to practice midwifery shall submit:

(1) The application form provided by the council and described in Mid 302.03; and

(2) Supporting documentation as follows:

(2) Had the responsibility to provide the applicant with individualized instruction, close supervision and ongoing evaluation during the applicant's participation in the experiences set forth in Mid 303.03(a) and during the applicant's learning of the skills set forth in Mid 303.04.

(b) Each applicant, except a practicing midwife, shall have obtained, from the applicant's preceptor(s), a report which:

(1) Bears the name and original signature of the preceptor;

(2) States the licenses and certifications held by the preceptor during the period of the preceptor's instruction, supervision and evaluation of the applicant in accordance with (a)(2);

(3) States the address of the preceptor's practice during the period of the preceptor's instruction, supervision and evaluation of the applicant in accordance with (a)(2);

(4) States which of the experiential requirements set forth in Mid 303.03(a) were achieved by the applicant during the period of the preceptor's instruction, supervision and evaluation of the applicant in accordance with (a)(2); and

(5) States which of the technical skills set forth in Mid 303.04 were mastered by the applicant during the period of the preceptor's instruction, supervision and evaluation of the applicant in accordance with (a)(2).

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PART Mid 304 EXAMINATIONS AND EXAMINATION FEES

Mid 304.01 Examination Requirements.

(a) As a condition of certification, the applicant shall pass the following examinations in the order in which they are described in this section:

(1) The NARM written examination for certification as a CPM;

(2) A written examination which shall:

a. Test the applicant's knowledge of RSA 326-D and these rules;

b. Be composed of multiple choice questions; and

c. Be administered by the midwifery council; and

(3) An oral examination as set forth in (b).

(b) As a condition of certification an applicant shall pass an oral examination which:

(1) Assesses the applicant's:

a. Clinical midwifery skills;

b. Knowledge about and ability to manage abnormal conditions in a midwifery client;

c. Knowledge about and ability to manage medical emergencies relevant to the practice of midwifery; and

d. Knowledge of pharmaceuticals permitted to be used in the practice of midwifery;

(2) Utilizes questions standardized to avoid bias and variations in difficulty among different administrations of the examination; and

(3) Is administered by a panel of at least 3 council members including the obstetrician member and at least one midwife certified in the state, but not the consumer member.

(c) The standard for passing the examinations described in (a)(2) and (b) shall be a score of 80% correct answers.

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Mid 304.02 Examination Fees. Before taking or retaking the written examination described in Mid 304.01(a)(2) or the oral examination described in Mid 304.01(b), the applicant shall pay the applicable non-refundable examination fee set forth in Mid 306.03.

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Mid 304.03 Election to Retake Examinations. An applicant who has failed the examination described in Mid 304.01(a)(2), the examination described in Mid 304.01(b) or both, shall have the opportunity to retake each failed examination:

(a) No more than twice ever; and

(b) No sooner than 6 months after the applicant last failed the examination being retaken.

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Mid 304.04 Notification of Examination Results. The council shall notify the applicant of examination results on the following schedule:

(a) For the NARM written examination, within 15 days of the notification to the council of the examination results by NARM;

(b) For the written examination administered by the council, within 15 days of the date of administration; and

(c) For the oral examination administered by the council, within 7 days of the date of administration.

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PART Mid 305 CERTIFICATION BASED ON RECIPROCITY

Mid 305.01 Qualifications for Certification Based on Reciprocity. A person currently licensed, certified, permitted or otherwise approved to practice midwifery in another state shall be certified on the basis of reciprocity if he or she:

(a) Is a certified professional midwife;

(b) Meets the qualifications set forth in Mid 303.01(a)-(h);

(c) Has met the experiential requirements of Mid 303.03(a);

(d) Has passed with a score of at least 80% correct answers the examination described in Mid 304.01(a)(2); and

(e) Has paid the examination and certification fees set forth in Table 3-1 of Mid 306.03.

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Mid 305.02 Meeting Requirements for Certification Based on Reciprocity. If a person seeking certification on the basis of reciprocity has not at the time of application met the experiential requirements of Mid 303.03(a), he or she shall:

(a) Not be eligible to take the examination described in Mid 304.01(a)(2) until he or she has met the experiential requirements; and

(b) Acquire the experiences in which he or she is deficient under the direction of one or more preceptors who shall:

(1) Meet the qualifications for a preceptor set forth in Mid 303.05(a)(1);

(2) Carry out the responsibilities of a preceptor set forth in Mid 303.05(a)(2); and

(3) Provide the report described in Mid 303.05(b).

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Mid 305.03 Application Process for Certification Based on Reciprocity. A person applying to be certified pursuant to Mid 305.01 shall:

(a) Complete the application form described in Mid 302.03:

(1) By printing legibly in ink or by use of a typewriter; and

(2) Completing every section or designating the section as not applicable;

(b) Submit the following documentation:

(1) A copy of a high school diploma or a GED certificate;

(2) Proof of having passed one college-level anatomy and physiology course, or proof of receipt through examination of college-level credit in anatomy and physiology;

(3) A photocopy of the front and back of the applicant's current certificate in adult and infant and child CPR issued by either the American Heart Association or the American Red Cross;

(4) A photocopy of the front and back of the applicant's current NRP provider card;

(5) If applicable, a notarized affidavit disclosing criminal convictions;

(6) At least 4 written references, including at least 2 from certified or licensed health care professionals familiar with the applicant's midwifery experience, and not more than one from a client, affirming the applicant's competence and high standards in providing midwifery care;

(7) If required to acquire experiences pursuant to Mid 305.02, submit one or more preceptor reports as described in Mid 303.05(b); and

(8) If not required to acquire experiences pursuant to Mid 305.02, submit a statement that the applicant has met the experiential requirements of Mid 303.03(a);

(c) Arrange for the submission by the state issuing the current license, certificate, permit or other approval copies of the following documents:

(1) The current license, certificate or permit or other document of approval; and

(2) All application materials, including any preceptor's report, submitted at the time of application for such license, certificate, permit or other approval; and

(d) Submit a copy of the midwifery statute and regulations of the state issuing such license, certificate, permit or approval.

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Mid 305.04 Review of Application Based on Reciprocity and Notification Procedure.

(a) Within 60 days of the receipt of the application, the council shall:

(1) Review the application form and documentation for legibility and completeness;

(2) Determine whether additional information or documentation is required to clarify the application or to determine whether the applicant meets the qualifications for certification; and

(3) Notify the applicant in writing of any deficiencies in the application and of any additional information or documentation required under (a)(2).

(b) An application shall be deemed completed on the date when the council has received:

(1) The application form required by Mid 305.03(a) which has been legibly completed and signed;

(2) The supporting documentation required by Mid 305.03(b); and

(3) Any additional information and documentation required under (a)(3).

(c) Within 120 days from the completion of the application, the council shall notify the applicant in writing that:

(1) The applicant meets the certification qualifications of Mid 305.01 and will be certified upon payment of the certification fee specified in Mid 306.03; or

(2) The applicant does not meet the certification qualifications of Mid 305.01.

(d) An application for which the council is waiting for additional information or documentation shall be held open for one year from the date of its receipt by the council, after which time it shall be closed and the application denied.

(e) All applications for certification based on reciprocity shall be kept as part of the permanent records of the council.

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PART Mid 306 DURATION OF CERTIFICATIONS AND FEES

Mid 306.01 Duration of Certifications. The duration of certifications shall be as set forth in Table 3-1.

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Mid 306.02 Certification Fee. No applicant for initial certification or certification based on reciprocity shall be certified before the applicant has paid the certification fee specified in Mid 306.03.

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Mid 306.03 Fee Schedule. Fees shall be as set forth in Table 3-1.

(a) "The American College of Obstetricians and Gynecologists (ACOG)" means a fellowship of physicians with special interest in obstetrics and gynecology and the promotion of women's reproductive health care.

(b) "Apgar assessment" means an evaluation of the newborn based on an assessment of the heart rate, respiration, reflexes, color and muscle tone, performed at intervals of one minute and 5 minutes after birth.

(c) "Apgar score" means a numerical expression of the results of an Apgar assessment.

(d) "Central cyanosis" means a bluish discoloration of the skin and mucous membranes involving the whole body and resulting from a lack of oxygen in the blood.

(e) "Certified nurse-midwife (CNM)" means a registered nurse who has graduated from a nurse-midwifery education program accredited by the Division of Accreditation of the American College of Nurse-Midwives and has successfully taken the national examination required for designation as a CNM by the Certification Council of the American College of Nurse-Midwives.

(f) "Extended postpartum period" means the period from the birth of the newborn to 3 months after the birth.

(g) Fetal heart auscultation" means listening to the fetal heartbeat through the abdominal and uterine walls of the mother.

(h) "Freestanding birth center" means an out-patient maternity care facility.

(i) "Grand multiparity" means the condition of having borne 7 or more children.

(j) "High grade squamous intraepithelial lesions (HGSIL)" means squamous cells that are highly suggestive of being pre-cancerous or pre-invasive cancerous.

(k) "Holistic care" means care which attends to the needs of the client in all areas, including physical, emotional, social, spiritual and economic.

(l) "Home birth" means a planned home delivery attended by a midwife taking primary responsibility for the care of the mother and the newborn.

(m) "Immediate postpartum period" means the period from birth until the midwife determines that mother and newborn are in stable condition.

(n) "Incompetent cervix" means the premature painless dilatation of the cervix typically at 24 to 26 weeks gestation, which, without medical intervention, is often associated with repeated second trimester spontaneous abortion.

(o) "Intrapartum" means the period from the onset of labor to its termination with the delivery of the placenta.

(p) "Intrauterine growth retardation (IUGR)" means a decreased rate of growth of the fetus.

(q) "Large for gestational age (LGA)" means a newborn weighing over 9 pounds, 8 ounces.

(r) "Multigravida" means a woman who has been pregnant 2 or more times.

(s) "Oligohydramnios" means an abnormally small amount of amniotic fluid during pregnancy.

(t) "Out-of-hospital birth" means a home birth or a birth in a freestanding birth center.

(u) "Pap smear" means a procedure by which cells are obtained from the cervix and prepared on a slide to be tested in a laboratory for cancer and other abnormal conditions.

(w) "Placenta previa" means the condition whereby the placenta is implanted in the lower portion of the uterus, covering the cervix marginally, partially, or completely.

(x) "Placental abruption" means premature separation of the placenta from the uterine wall.

(y) "Polyhydramnios" means an excess of amniotic fluid during pregnancy.

(z) "Preeclampsia" means a combination in the mother of hypertension, fluid retention, protein in the urine and brisk reflexes.

(aa) "Primigravida" means a woman who is pregnant for the first time.

(ab) "Prenatal" means during the period of time between conception and the onset of labor.

(ac) "Postpartum" means occurring after childbirth.

(ad) "Rh immune globulin" means a preparation used to prevent the development of Rh antibodies in Rh negative mothers.

(ae) "Rh sensitivity with positive antibody titre" means the development by a pregnant Rh negative woman of antibodies which might cross the placenta and destroy the cells of an Rh positive fetus.

(af) "Small for gestational age (SGA)" means a newborn weighing less than 5 pounds, 8 ounces.

(ag) "Squamous cells" means flat, scaly cells forming the outer surface of the body and lining the body cavities and the principal tubes and passageways leading to the exterior of the body.

(ah) "Vaginal birth after cesarean (VBAC)" means a vaginal birth after any previous delivery by cesarean section.

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PART Mid 502 SCOPE OF PRACTICE

Mid 502.01 Midwifery Care. Acting autonomously, a midwife shall provide the following supervision, care and advice, as appropriate, to her client and the newborn:

(a) Counseling and education about:

(1) Conception;

(2) Health and nutrition;

(3) Pregnancy;

(4) Lactation;

(5) Family planning; and

(6) The postpartum period;

(b) Holistic care;

(c) Early recognition and prevention of potential health problems;

(d) Detection of any abnormal conditions in the mother, fetus, and newborn;

(e) Procurement of medical assistance, if necessary;

(f) Execution of emergency measures in the absence of medical help, if necessary; and

(g) Lactation assistance.

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Mid 502.02 Midwifery Procedures. The procedures of midwifery shall include, as appropriate, the following:

(a) Basic physical examination;

(b) Breast examination;

(c) Pelvic examination;

(d) Venipuncture;

(e) Hematocrit and hemoglobin specimen collection;

(f) Capillary blood collection;

(g) The taking of a Pap smear;

(h) Cervical culture collection;

(i) Urinalysis;

(j) Wet mount specimen collection;

(k) Administration of oxygen to mother and newborn;

(l) Urinary bladder catherization;

(m) Episiotomy;

(n) Neonatal resuscitation;

(o) Repair of tears, lacerations or episiotomy, infiltration of lidocaine hydrochloride and use of suture material;

(p) Intramuscular injection of the following medications:

(1) Oxytocins such as pitocin, ergotrate and methergine, only for postpartum control of maternal hemorrhage;

(2) Rh immune globulin, if indicated;

(3) Vitamin K for control and prevention of acute and late-onset hemorrhagic disease of the newborn; and

(4) Other medications as prescribed by a physician, consistent with the scope of midwifery practice as defined in this chapter;

(q) Oral administration of the following medications:

(1) Methergine, only for postpartum control of maternal hemorrhage;

(2) Vitamin K, for control and prevention of acute and late-onset hemorrhagic disease of the newborn; and

(3) Other medications as prescribed by a physician, consistent with the scope of midwifery practice as defined in this chapter;

(r) Intravenous administration of the following fluids:

(1) Ringer's Lactate, with or without D5W;

(2) Normosol-R, with or without D5W; and

(3) Other medications as prescribed by a physician, consistent with the scope of midwifery practice as defined in this chapter;

(s) Clamping and cutting of the umbilical cord;

(t) Administration of newborn eye prophylaxis in accordance with RSA 132:6, I;

(u) Metabolic screening of the newborn in accordance with RSA 132:10-a and RSA 132:10-c; and

(v) Contraception counseling and family planning methods.

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Mid 502.03 Requirements for Prenatal Care.

(a) A midwife shall provide prenatal care to a client at least:

(1) Once a month through the twenty-eighth week of pregnancy;

(2) Once every 2 weeks from the twenty-eighth through the thirty-sixth week of pregnancy; and

(3) Once a week from the thirty-sixth week of pregnancy until the onset of labor.

(b) A midwife shall schedule the initial prenatal visit with a client in the first or second trimester of pregnancy.

(c) If a woman requesting midwifery services does not contact the midwife before the third trimester of her pregnancy, the midwife shall accept her as a client only if she:

(1) Has had adequate prenatal care;

(2) Has had adequate nutritional intake;

(3) Displays adequate fetal growth, fetal heart rate and fetal movement; and

(4) Is herself in apparent good health.

(d) During the initial prenatal visit the midwife shall:

(1) Obtain a maternal health, obstetrical and gynecological history;

(2) Perform a nutritional assessment and provide nutritional counseling;

(3) Discuss the availability of options for testing for fetal defects;

(4) Obtain blood pressure;

(5) Perform a pelvic exam, including:

a. Uterine sizing to estimate gestational age;

b. Pelvic size assessment;

c. A chlamydia and gonorrhea screening test; and

d. A Pap smear, if none was done in the previous one year period;

(6) Either perform or arrange for blood analysis, including:

a. Blood group and Rh factor;

b. Antibody screen;

c. A complete blood count;

d. Rubella titre;

e. Syphilis serology;

f. Hepatitis B surface antigen;

g. Hepatitis C surface antigen, if indicated; and

h. HIV testing, if accepted by the client;

(7) Recommend that the client receive a general physical exam by a qualified health care provider to screen for general health problems that have the potential to complicate the pregnancy or delivery; and

(8) Obtain informed consent for midwifery care and out-of-hospital birth, to include the information described in Mid 405.02 as well as the following information:

a. A description of the midwife's background and credentials;

b. Whether the midwife has professional liability coverage; and

c. The address and telephone number of the council, where complaints against the midwife may be filed.

(e) During subsequent prenatal visits the midwife shall:

(1) Assess maternal nutrition and weight gain;

(2) Obtain blood pressure;

(3) Test urine for protein and glucose;

(4) Assess general well-being;

(5) Check for signs and symptoms of edema, bleeding, headache, visual disturbances or unusual vaginal discharge;

(6) Obtain fundal height measurement;

(7) Arrange for periodic hematocrit or hemoglobin testing;

(8) Assess fetal heart rate and fetal activity;

(9) Assess position and presentation of the fetus;

(10) Perform or arrange for the following as necessary:

a. Rh antibody screening;

b. Urinalysis;

c. Microscopic analysis of vaginal discharges;

d. Obstetric ultrasound;

e. Prophylactic Rh immune globulin injection;

f. Blood sugar screening; and

g. Vaginal culture, rectal culture or both;

(11) Observe aseptic technique and universal health precautions; and

(12) Discuss:

a. Any recent illnesses, symptoms, social or emotional problems;

b. Diet;

c. Supplements;

d. Reading suggestions;

e. Exercise;

f. Rest and sleep requirements;

g. Sexuality;

h. Partner's role;

i. Birth preparation;

j. Newborn care;

k. Parenting; and

l. Transportation arrangements.

(f) A midwife shall advise any client with genital herpes of the ACOG herpes protocol current at the time of the midwife's conversation with the client.

(g) A midwife shall discuss with clients the options for testing for and treating group B streptococcus.

(h) A midwife shall encourage any client expecting a first child to attend childbirth education classes.

(i) A midwife shall discuss with the client, during the prenatal period, the selection of a pediatrician, family physician, or other health care provider who will assume care of the newborn.

(j) A midwife shall alert the client to:

(1) Signs of complications that necessitate immediate contact with the midwife; and

(2) Signs of labor and of when it is time to call the midwife.

(k) A midwife shall be on call or make specific arrangements for on call coverage with another midwife or licensed health care provider whose scope of practice includes birth.

(l) In the third trimester, a midwife shall ensure that a client is adequately preparing for birth in an out-of-hospital location by discussing:

(1) The place of the birth and the facilities available there;

(2) The availability of adequate heat and water;

(3) The supplies the client must procure;

(4) The availability of a telephone;

(5) Arrangements for help after the birth;

(6) With a client preparing for birth in a private home, the importance of keeping readily available the following written information:

a. The name, location and phone number of the nearest ambulance service;

b. The name, location and phone number of the nearest hospital;

c. The name and phone number of the newborn's health care provider; and

d. The street address of the location of the birth and directions to that location from the nearest ambulance service; and

(7) The transfer of care to a hospital setting in an emergency.

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Mid 502.04 Requirements for Care throughout Labor, Birth and The Immediate Postpartum Period.

(a) During the appropriate period of labor, birth, and the immediate postpartum period a midwife shall:

(1) Monitor the condition of the mother and fetus or newborn;

(2) Support and encourage the laboring woman;

(3) Assist with the birth;

(4) Assist client with breastfeeding;

(5) Inspect the perineum and lower vagina;

(6) Inspect as necessary the cervix and upper vaginal vault;

(7) Make necessary laceration repairs;

(8) Examine and assess the health of the newborn;

(9) Inspect the placenta, membranes and vessels of the umbilical cord;

(10) Manage any third-stage bleeding;

(11) Administer medications listed in RSA 326-D:12 as needed;

(12) Administer eye prophylaxis to the newborn in accordance with RSA 132:6, I;

(13) Administer vitamin K to the newborn;

(14) Remain with the client and newborn:

a. At least 2 hours after the birth; and

b. If the conditions of the mother and the newborn are not stable after 2 hours, until the conditions of the mother and the newborn have become stable;

(15) Provide the client with information concerning routine postpartum care of the mother and infant, including information on breastfeeding and perinatal care, and indications that warrant contacting the midwife or physician;

(16) Recommend to the client that she contact the newborn's health care provider to arrange for an examination within 24 to 48 hours after birth; and

(17) Observe aseptic technique and use universal health precautions.

(b) The midwife shall not end the immediate postpartum period by determining that the mother and newborn are in stable condition for at least 2 hours after the birth.

(c) In the event the client is transferred to a hospital setting, a midwife shall make every effort to remain with her to provide labor support.

(d) In the event of an emergency transfer, the midwife shall notify the obstetrician on call at the accepting hospital of the nature of the emergency and the estimated time of arrival of the client.

Source. #7759, eff 9-7-02

Mid 502.05 Consultation With Physician to Determine Setting for Care During the Intrapartum Period. A midwife shall consult immediately with a physician with experience in the active practice of obstetrics or a CNM about whether the care of the client should be transferred to the hospital setting if any of the following conditions should occur intrapartum:

(a) Unforeseen malpresentations;

(b) Unforeseen multiple fetuses;

(c) Fetal distress as indicated by heart rate monitoring;

(d) The presence of particulate meconium;

(e) Failure to progress such that:

(1) In the first stage of labor, there is a lack of progress in dilation and descent for a period of up to 24 hours in the case of a primigravida or 18 hours in the case of a multigravida;

(2) In the second stage, there are more than 2 hours without progress in descent or more than 3 hours with slow descent; or

(3) In the third stage, there is more than one hour without delivery of the placenta;

(f) More than 18 hours elapse following the rupture of the membranes without the onset of labor;

(g) Maternal distress including:

(1) Extreme physical or mental exhaustion; and

(2) Abnormal vital signs; and

(h) Uncontrolled maternal bleeding.

Source. #7759, eff 9-7-02

Mid 502.06 Consultation to Determine Setting for Care During the Immediate Postpartum Period. A midwife shall consult immediately with a physician with experience in the active practice of obstetrics or with a CNM about whether the care of the client or the newborn should be transferred to the hospital setting if any of the following conditions should occur immediately postpartum:

(a) Significant bleeding cervical lacerations;

(b) Third or fourth degree perineal lacerations;

(c) Uncontrolled maternal bleeding when the condition of the woman is becoming unstable;

(d) An Apgar score of 6 or less at 5 minutes after birth, or an Apgar score that is dropping;

(e) Jaundice in the newborn appearing before 24 hours after birth;

(f) Obvious congenital anomalies;

(g) A newborn who is SGA;

(h) A newborn who shows signs of hypoglycemia, such as jitteriness, lethargy or hypothermia;

(i) A newborn with persistent central cyanosis or pallor;

(j) A newborn with persistent signs of respiratory difficulty without signs of improvement within one hour after birth;

(k) A newborn with a pulse rate greater than 160 at rest;

(l) A newborn with respirations greater than 80 at rest;

(m) A newborn with temperature outside the parameters of 97.7-99.4 degrees fahrenheit or 36.5 to 37.5 degrees celsius; or

(n) Other conditions which the midwife assesses as outside normal limits.

Source. #7759, eff 9-7-02

Mid 502.07 Requirements for Care During the Extended Postpartum Period. During the extended postpartum period, a midwife shall:

(a) Maintain close contact with the client through phone calls and at least one home or office visit within the first 72 hours after the birth;

(b) Ascertain during the visit described in (a) above that:

(1) The newborn is alert;

(2) The newborn has good color;

(3) The newborn is breathing normally;

(4) The newborn is establishing a healthy pattern of waking, sleeping, feeding, voiding and stooling;

(5) The mother is not bleeding excessively;

(6) The mother has a firm fundus;

(7) The mother does not have a fever or other sign of infection;

(8) The mother is voiding properly; and

(9) The mother, if intending and able to do so, is establishing successful breastfeeding;

(c) Consult with a physician if any of the circumstances in paragraph (b) are not present;

(d) Be available to consult with the newborn's health care provider about the newborn's condition;

(e) Recommend that the client arrange for newborn hearing screening;

(f) Test the newborn for metabolic disorders as required by RSA 132:10-a at 24 to 72 hours after birth; and

(g) By 6 weeks postpartum provide the following:

(1) A pelvic exam and Pap smear if one was not done at the initial visit of the client with the midwife;

(2) Hemoglobin or hematocrit testing;

(3) Contraceptive counseling and family planning methods; and

(4) Referral for rubella vaccination if the client showed no immunity to rubella when tested at the time of her initial visit with the midwife.

Source. #7759, eff 9-7-02

Mid 502.08 Ineligibility for Midwifery Care. A midwife shall not accept as a client a woman who appears to have or reports any of the following:

(a) Insulin- or drug-dependent diabetes;

(b) Maintenance on anti-epileptic medication;

(c) Convulsive activity within the past year;

(d) Blood diseases that could complicate pregnancy;

(e) Current hepatitis B and C positive antigen;

(f) Current HIV positivity or AIDS;

(g) Current chemical dependency or substance abuse;

(h) Chronic pulmonary disease that interferes with oxygen saturation;

(i) Rh sensitivity with positive antibody titre;

(j) Chronic hypertension;

(k) History of significant heart disease;

(l) Renal disease;

(m) Maintenance on a psychotropic medication which the client's physician has determined has the potential to sedate the newborn;

(n) Documented mental illness or disease which has the potential to interfere with the client's ability to effectively participate in her care or in out-of-hospital birth;

(o) Diseases and disorders such as:

(1) Addison's disease;

(2) Cushing's disease;

(3) Systemic lupus erythematosus;

(4) Anti-phospholipid syndrome;

(5) Scleroderma;

(6) Rheumatoid arthritis;

(7) Periarteritis nodosa;

(8) Marfan's syndrome; and

(9) Other systemic and rare diseases and disorders;

(p) Acute toxoplasmosis infection, where the client is currently symptomatic;

(q) Acute rubella infections, where the client is currently symptomatic;

(r) Acute cytomegalovirus infection, where the client is currently symptomatic;

(s) Acute parvovirus infection, where the client is currently symptomatic;

(t) Thrombosis; or

(u) Inflammatory bowel disease that is not in remission.

Source. #7759, eff 9-7-02

Mid 502.09 Obstetrical Consultation Required To Determine Eligibility for Midwifery Care. A midwife shall consult with an obstetrician to evaluate whether a woman is an appropriate candidate for out-of-hospital birth when she or her fetus, as applicable, appears to have or develops any of the following conditions:

(a) A first pregnancy at an age younger than 16 or older than 40;

(b) Maintenance on anti-epileptic medications without a history of convulsions in the previous year;

(c) Hypertension measured at 140/90 or at an elevation over previously established baseline of 30 systolic, 15 diastolic, or both, on at least 2 occasions 6 hours apart;

(d) An arrhythmia or a heart murmur other than a benign, functional murmur;

(e) A history of hereditary problems with the potential to affect the fetus or newborn;

(f) A history of significant postpartum hemorrhage;

(g) A history of previous intrauterine death of a fetus of more than 20 weeks' gestation;

(h) A history of stillbirth;

(i) A history of prior obstetrical problems including:

(1) Prematurity;

(2) Uterine abnormalities;

(3) Placental abruption; and

(4) Incompetent cervix;

(j) The possibility of a cancerous or pre-cancerous condition of the cervix as indicated by an abnormal Pap smear;

(k) Recurrent urinary tract or kidney infection;

(l) Active gonorrhea;

(m) Active chlamydia;

(n) A positive cervical herpes culture;

(o) The possibility of gestational diabetes;

(p) Second or third-trimester bleeding;

(q) Grand multiparity;

(r) The possibility of multiple fetuses;

(s) The possibility of malpresentation;

(t) The possibility of the fetus' being small for gestational age or developing IUGR;

(u) The possibility of fetus' being large for gestational age;

(v) Polyhydramnios;

(w) Oligohydramnios;

(x) Ultrasound evidence of a fetal or placental abnormality; or

(y) Suspected postmaturity greater than 42 weeks' gestation.

Source. #7759, eff 9-7-02

Mid 502.10 Conditions Requiring Transfer From Midwifery Care.

(a) A midwife shall transfer to the care of a physician with experience in the active practice of obstetrics or a CNM any client who appears to have or develops any of the following conditions during the prenatal period:

(1) Anemia measured by hemoglobin of less than 10g or a hematocrit of less than 30% unresolved by 37 weeks' gestation;

(2) Multiple fetuses;

(3) Malpresentation of the fetus, including presentation in breech position, that is not resolved before the onset of labor;

(4) Confirmation by obstetric ultrasound that the fetus is small for gestational age;

(5) Indications that the fetus of more than 12 weeks' gestation has died in utero;

(6) Rh sensitization with positive antibody titre;

(7) Preeclampsia;

(8) Placenta previa;

(9) Placental abruption;

(10) Onset of labor prior to 37 weeks; or

(11) Herpes on the cervix or vulva or in the vaginal mucosa that is active at the onset of labor and cannot be isolated by covering it.

(b) Upon transfer of the client's care pursuant to paragraph (a) the midwife shall give the health care provider to whose care the client is transferred a copy of the client's chart.

Source. #7759, eff 9-7-02

Mid 502.11 Termination of Services by the Midwife.

(a) During the prenatal period a midwife shall terminate services if:

(1) The client refuses the transfer of her care as required by Mid 502.10;

(2) The client consistently fails or refuses to follow the recommendations of the midwife; or

(3) The environment for home birth becomes unsafe or unsanitary.

(b) A midwife terminating services during the prenatal period shall immediately notify the client in person or by phone, and follow-up with written notification of the termination.

(c) A midwife terminating services during the prenatal period shall assist the client in finding another health care provider.

(d) After the onset of labor a midwife shall terminate her services only if:

(1) The client refuses a transfer of care determined necessary on the basis of the consultation required by Mid 502.05; or

(2) The midwife believes she is unable to care adequately for the client or the newborn.

(e) A midwife terminating services after the onset of labor shall:

(1) Document the events causing the termination; and

(2) Attempt to ensure that the client is not left unattended by:

a. Contacting a local rescue service, a hospital emergency room or other appropriate emergency resource;

b. Dialing 911; or

c. Calling a physician who is on call at the nearest hospital and has experience in the active practice of obstetrics to inform the physician of the situation.

Source. #7759, eff 9-7-02