02-502 C.M.R. ch. 6, § A-5 - Requirement for consultation, collaboration, referral, or transfer of care

1. When the following conditions or circumstances occur, the certified professional midwife is required to initiate the associated actions of consultation, collaboration, referral, or transfer of care. Such action may be initiated at any time when in the professional judgment of the certified professional midwife such action is warranted.

A. Antepartum. During the antepartum period the following actions are required in the presence of the listed conditions or circumstances:

1) Consultation

a) Suspected intrauterine growth restriction;

b) Severe vomiting unresponsive to certified professional midwife treatment;

c) Pain unrelated to common discomforts of pregnancy;

d) Presence of condylomata that may obstruct delivery;

e) Anemia unresponsive to certified professional midwife treatment, with a hemoglobin less than 10.0 g/dL;

f) Suspected or confirmed fetal demise after 14.0 weeks gestation;

g) Suspected multiple gestation;

h) Confirmed chromosomal or genetic abnormalities;

i) Hepatitis C;

j) Suspected fetal mal presentation after 36.0 weeks;

k) Ultrasound diagnosis of complete placenta previa from 28.0 - 34.0 weeks gestation; and

l) Any other condition that in the judgment of the certified professional midwife requires consultation.

2) Collaboration

a) Infection unresponsive to certified professional midwife treatment;

b) Incomplete miscarriage;

c) Significant vaginal bleeding;

d) Signs or symptoms of deep vein thrombosis or pulmonary embolus;

e) Stable thyroid disease;

f) Stable seizure disorder;

g) Chronic hypertension requires collaboration with an obstetrical physician;

h) History of cervical incompetence treated with surgical therapy, requires collaboration with an obstetrical physician;

i) Severe depression, exacerbations of mood disorder, or psychiatric illness responsive to treatment;

j) Confirmed fetal malpresentation at or after 37.0 weeks; and

k) Any other condition that in the judgment of the certified professional midwife requires collaboration.

3) Referral

a) Signs or symptoms of untreated thyroid disease;

b) Gestational diabetes requiring pharmacologic therapy;

c) Changes in the breast(s) suspicious for malignancy and unrelated to pregnancy or lactation;

d) Documented platelet count less than 80,000 platelets per mm³ of blood in the absence of signs or symptoms of pre-eclampsia or HELLP syndrome. HELLP means findings of hemolysis, elevated liver enzymes, and low platelets;

e) Confirmed or developing deep vein thrombosis or pulmonary embolism;

f) Rh isoimmunization or other red blood cell isoimmunization known to cause erythroblastasis fetalis;

g) Primary genital herpes outbreak;

h) Preeclampsia;

i) Oligohydramnios hydramnious or poly hydramnios;

j) Pregnancy beyond 41.6 weeks gestation; with NON-reassuring fetal assessment; and

k) Any other condition that in the judgment of the certified professional midwife requires referral.

4) Transfer of Care

a) Current substance use disorder;

b) Current diagnosis of cancer;

c) Confirmed intrauterine growth restriction;

d) No onset of labor by 43.0 weeks gestation;

e) Heart disease that has been determined by a cardiologist to have potential to affect or to be affected by pregnancy, labor, or delivery;

f) Ultrasound diagnosis of complete or partial placenta previa after 34.0 weeks gestation;

g) Preeclampsia with severe features; including any of the following:

i. A systolic pressure greater than 160 mm or a diastolic pressure greater than 110 mm in two readings at least four hours apart after a period of bedrest;

ii. Documented platelet count of less than 100,000 platelets per mm3 of blood, or presence of other coagulation disorder;

iii. Impaired liver function;

iv. Progressive renal insufficiency;

v. Pulmonary edema; or

vi. New onset cerebral of visual disturbances;

h) Eclampsia;

i) Signs of suspected placental abruption, or fetal compromise;

j) Confirmed or suspected ectopic pregnancy;

k) Severe psychiatric illness non-responsive to treatment;

l) Insulin-dependent diabetes;

m) Significant vaginal bleeding after 20.0 weeks gestation inconsistent with normal pregnancy and posing a continuing risk to client or baby;

n) Any other condition that in the judgment of the midwife could place the life or long-term health of the pregnant person or unborn child at risk; and

o) Human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS).

B. Intrapartum. During the intrapartum period the following actions are required in the presence of the listed conditions or circumstances:

1) Consultation

a) Any condition that in the judgment of the certified professional midwife requires consultation.

2) Collaboration

a) Any condition that in the judgment of the certified professional midwife requires collaboration.

3) Referral

a) Any condition that in the judgment of the certified professional midwife requires referral.

4) Transfer of Care

a) Visible genital lesions suspicious of herpes virus infection in a location unable to be isolated from the neonate during the birth process;

b) Signs or symptoms of preeclampsia;

c) Excessive vomiting, dehydration, acidosis, or exhaustion unresponsive to certified professional midwife treatment;

d) Excessive bleeding, inconsistent with normal bloody show;

e) Progressive labor prior to 37.0 weeks gestation except in the presence of known miscarriage, confirmed fetal death, or known congenital anomalies incompatible with life;

f) Signs or symptoms of uterine rupture;

g) Prolapsed umbilical cord, unless birth is imminent;

h) Clinically significant abdominal pain inconsistent with normal labor;

i) Maternal seizure;

j) Suspected chorioamnionitis;

k) Fetal heart rate indicative of fetal labor intolerance that does not immediately respond to treatment by the midwife, unless birth is imminent;

l) Meconium in the amniotic fluid accompanied by abnormal fetal heart rate, or other identified risk factors for neonatal resuscitation, unless birth is imminent;

m) Lack of descent after three hours of effective second stage efforts;

n) Signs of impending maternal shock unresponsive to certified professional midwife treatment;

o) Retained placenta or retained placental parts not resolved by clinical management;

p) Postpartum hemorrhage not resolved by clinical management;

q) Breech or other malpresentation diagnosed in labor, unless birth is imminent

r) Multi fetal presentation diagnosed in labor, unless birth is imminent; or

s) Any other condition that in the judgment of the certified professional midwife would place the life or long-term health of the pregnant person or unborn child at significant risk if not acted upon immediately.

C. Postpartum. During the postpartum period the following actions are required in the presence of the listed conditions or circumstances:

1) Consultation

a) Bladder dysfunction;

b) Persistent abnormal uterine bleeding; or c) Any other condition that in the judgment of the certified professional midwife requires consultation.

2) Collaboration

a) Signs or symptoms of infection unresponsive to certified professional midwife treatment;

b) Symptoms of breast disorders unresponsive to certified professional midwife treatment c) Postpartum depression or exacerbation of mood disorder; or d) Any other condition that in the judgment of the certified professional midwife requires collaboration.

3) Referral

a) Any birth-related lacerations or trauma beyond the ability of the midwife to repair, to include:

* 3^rd or 4^th degree perineal lacerations;

* Severe vaginal, periurethral, or clitoral lacerations

* Cervical lacerations; or

* Signs or symptoms of developing significant hematoma;

b) Early signs or symptoms of deep vein thrombosis or pulmonary embolus;

c) Severe depression;

d) Evolving hypertension or the presence of any signs or symptoms of preeclampsia; or e) Any other condition that in the judgment of the certified professional midwife requires referral.

4) Transfer of Care

a) Severe psychiatric illness non-responsive to treatment; or b) Any other condition that in the judgment of the certified professional midwife could place the life or long-term health of the postpartum person at significant risk if not acted upon immediately.

D. Neonatal. During the neonatal period of the life of the newborn, the following actions are required in the presence of the listed conditions or circumstances:

1) Consultation

a) Poor feeding and/or poor weight gain; or

b) Any other condition that in the judgment of the certified professional midwife requires consultation.

2) Collaboration

a) Hospital-based newborn hearing screening;

b) Minor congenital anomaly; or

c) Any condition that in the judgment of the certified professional midwife requires collaboration.

3) Referral

a) Apparent birth injury;

b) Loss of 15% or more of birth weight;

c) Unusual bruising or bleeding, petechiae, or lesions;

d) Abnormal screening or testing results;

e) Dysmorphic features suggesting a genetic diagnosis;

f) Blood in stools or emesis (not from cracked nipples);

g) Early onset or excessive jaundice;

h) No passage of stools or urine within 24 hours of birth;

i) Abdominal distention or vomiting;

j) Gestational age assessment less than 37.0 weeks gestation;

k) Insufficient suck or feed, not responsive to certified professional midwife treatment; or l) Any other condition that in the judgment of the certified professional midwife requires referral.

4) Transfer of Care

a) Congenital anomalies requiring timely intervention;

b) Persistent abnormalities of vital signs (temp, respiratory rate, heart rate, pulse oximetry readings);

c) Upper airway obstruction;

d) Persistent respiratory distress;

e) Persistent pallor or central cyanosis;

f) Apgar score at ten minutes of less than seven;

g) Post-resuscitative care after Neonatal Resuscitation Program (NRP) chest compressions;

h) Signs of newborn hemorrhage;

i) Seizure, or seizure-like activity;

j) Hypotonia, hypertonia or tremors; or

k) Any other condition that in the judgment of the certified professional midwife could place the life or long-term health of the infant at significant risk if not acted upon immediately.

Notes

02-502 C.M.R. ch. 6, § A-5