Adopt Mid 500 to read as follows:

CHAPTER Mid 500 SCOPE OF MIDWIFERY PRACTICE

PART Mid 501 DEFINITIONS

Mid 501.01 Definitions.

(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.

(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) “Cervical insufficiency” means the premature painless dilatation of the cervix after the first trimester and typically before 24 weeks gestation, which, without medical intervention, is often associated with repeated second trimester spontaneous abortion.

(f) “Community birth” means a home birth or a birth in a freestanding birth center.

(g) “Chronic hypertension” means elevated blood pressures diagnosed or present before pregnancy or before 20 weeks gestation. Elevated blood pressures are defined at systolic blood pressure (sBP) 140 mm Hg or more, or diastolic blood pressure (dBP) 90 mm Hg or more on 2 occasions at least 4 hours apart.

(h) “Extended postpartum period” means the period from the birth of the newborn to 6 weeks after the birth.

(i) “Fetal heart auscultation” means listening to the fetal heartbeat through the abdominal and uterine walls of the client.

(j) “Freestanding birth center” means an out-patient maternity care facility.

(k) “Grand multiparity” means the condition of having borne 5 or more children.

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

(m) “Holistic care” means care which attends to the needs of the client in all areas, including physical, emotional, and social.

(n) “Home birth” means a planned home delivery attended by a New Hampshire (NH) certified midwife or a licensed health care provider whose scope of practice includes birth, taking primary responsibility for the care of the client and the newborn.

(o) “Immediate postpartum period” means the period from birth until the midwife determines that client and newborn are in stable condition.

(p) “Intrauterine growth restriction (IUGR)” means ultrasound estimated fetal weight less than the 10^th percentile for gestational age.

(q) “Large for gestational age (LGA)” means a newborn weighing more than the 90^th percentile for gestational age.

(r) “Macrosomia” means an infant whose birth weight is 4500 grams or 9 pounds 15 ounces or higher.

(s) “Multipara” means a person who has carried a pregnancy 20 weeks or longer at least once prior to the current pregnancy.

(t) “Oligohydramnios” means an abnormally small amount of amniotic fluid during pregnancy.

(u) “Pap test” means a procedure by which cervical cells are collected and tested in a laboratory for pre-cancer and other abnormal conditions.

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

(w) “Placental abruption” means premature separation of the placenta from the uterine wall.

(x) “Polyhydramnios” means an excess of amniotic fluid during pregnancy.

(y) “Preeclampsia” means a maternal condition of pregnancy occurring at or after 20 weeks 0 days of gestation or postpartum in which the person has a systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mm Hg or more on 2 occasions 4 hours apart plus proteinuria of 300 mg or more on the 24-hours collection or protein, creatinine ratio of 0.3, or more or urine dipstick of 2+ protein or more.

(z) “Primigravida” means a person who is pregnant for the first time.

(aa) “Primipara” means a person is carrying a pregnancy beyond 20 weeks for the first time.

(ab) “Postpartum” means occurring after the delivery of the placenta until 6 weeks after childbirth.

(ac) “Rh immune globulin” means a medication used to prevent the development of Rh antibodies in Rh negative pregnant person.

(ad) “Rh sensitivity with positive antibody titre” means the development of Rh antibodies in a pregnant person which might cross the placenta and destroy the red blood cells of an Rh-positive fetus.

(ae) “Severe preeclampsia” means a maternal condition of pregnancy beyond 20 weeks 0 days of pregnancy with new-onset hypertension, even in the absence of proteinuria, with any of the following features:

(1) Systolic blood pressure of 160 mm Hg or more;

(2) Diastolic blood pressure of 110 mm Hg or more;

(3) Thrombocytopenia of less than 100,000;

(4) Renal insufficiency of creatinine of 1.1 mg/dl or higher;

(5) Impaired liver function with liver transaminases (ALT and AST) twice normal or higher, pulmonary edema, or visual disturbances; or

(6) New-onset headache unresponsive to medication.

(af) “Significant postpartum hemorrhage” means blood loss of greater than 1,000 milliliters.

(ag) “Small for gestational age (SGA)” means a newborn weighing less than 5 pounds, 8 ounces, 10^th percentile for gestational age.

(ah) “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.

(ai) “Vaginal birth after cesarean (VBAC)” means a vaginal birth after any previous delivery by cesarean section.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

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 the client and the newborn:

(a) Counseling and education about:

(1) Conception;

(2) Health and nutrition;

(3) Pregnancy;

(4) Labor and delivery;

(5) Lactation;

(6) Family planning; and

(7) The postpartum period;

(b) Holistic care;

(d) Detection of any abnormal conditions in the client, 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.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

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

(a) Basic physical examination;

(b) Breast examination;

(d) Venipuncture;

(e) Hematocrit and hemoglobin specimen collection;

(f) Capillary blood collection;

(g) Pap smear collection and Human Papillomavirus (HPV) testing, as indicated;

(h) Culture collection;

(i) Urinalysis;

(j) Wet mount specimen collection;

(k) Administration of oxygen to client and newborn;

(l) Urinary bladder catheterization;

(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, and methergine, only for postpartum control of maternal hemorrhage;

(2) Rh immune globulin, if indicated;

(3) Vitamin K for prevention of vitamin K deficiency bleeding (VKDB) and 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, buccal, or rectal administration of the following medications:

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

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

(3) Oral tranexamic acid for severe postpartum control of maternal hemorrhage; and

(4) 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:

(1) Lactated ringer’s solutions, with or without D5;

(2) Normal saline (0.9%), with or without D5;

(3) Tranexamic acid only for postpartum control of maternal hemorrhage; and

(4) 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;

(v) Newborn hearing screening;

(w) Newborn pulse oximetry screening, as required by RSA 132:10-aa; and

(x) Contraception counseling and family planning methods.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

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 client requesting midwifery care does not contact the midwife before the third trimester of pregnancy, the midwife shall accept the client only if:

(1) A reliable due date can be established by:

a. Determining that one or more of the following conditions are present:

1. Certainty of the last menstrual period;

2. Knowledge of the date of conception or ovulation;

3. Fundal height consistent with menstrual dates; or

4. Documentation of a first- or second-trimester ultrasound; or

b. Meeting the current guidelines set by:

1. The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, committee opinion on “Methods of Estimating Due Date” Number 700 dated May 2017 and available as indicated in Appendix B; or

2. The World Health Organization “WHO recommendations on antenatal care for positive pregnancy experience” 2016 publication, available as indicated in Appendix B;

(2) The client has had adequate prenatal care, or has met the criterion for a low risk birth as required by the midwifery scope of practice pursuant to Mid 502.08 and Mid 502.09; and

(3) The client displays adequate fetal growth, fetal heart rate, and fetal movement.

(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) Screen for tobacco, alcohol, marijuana, prescription drugs, or illicit drugs;

(4) Offer to perform or provide referral to a prenatal provider trained to counsel for antenatal screening for chromosomal and other genetic disorders;

(5) Obtain height, weight, and baseline blood pressure;

(6) Perform a pelvic exam, if indicated, including:

a. Uterine sizing to estimate gestational age;

b. Pelvimetry;

c. A chlamydia and gonorrhea screening test; and

d. A Pap test;

(7) Offer or recommend the following blood or urine tests:

a. Antibody screening;

b. Blood type and Rh factor;

c. Complete blood count or hemogram;

d. Gestational diabetics screening;

e. Gonorrhea and chlamydia urine screening

f. Hepatitis B surface antigen;

g. Hepatitis C antibody;

h. HIV testing;

i. Rubella titre;

j. Syphilis screening either by treponemal antibody or rapid plasma reagin (RPR);

k. Thyroid stimulating hormone (TSH);

l. Varicella titer;

m. Vitamin D; and

n. Urine culture;

(8) Document client education and counseling about prenatal tests as well as the client’s acceptance or refusal of specific prenatal tests;

(9) 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

(10) For those parents planning a VBAC, obtain an informed consent by completing an informed consent document with the clients by performing the following:

a. The midwife to place the name of the client and their name at the top of the form;

b. The client to place their initials before each of the following statements:

“I have read my midwife’s informed consent for out of hospital VBAC, discussed the topic in depth, and have had all my questions and concerns addressed”;

“I am aware of the risks associated with planned vaginal birth after cesarean, including the risk of uterine rupture. I understand that if my uterus were to rupture in labor this could result in serious damage to myself and my baby, and there is an increased risk that my baby could die”;

“I understand that being a greater distance from emergency services could increase the risk to myself and my baby. I have discussed the distance between the hospital and my intended place of birth with my midwife”;

“I understand that I have the option to attempt a VBAC at a hospital or to plan a repeat cesarean at a hospital”;

“I agree that if my NH certified midwife recommends a transfer I will comply with their recommendation”;

“I have had only one previous cesarean, and the scar is in the lower part of my uterus”;

“My single previous cesarean occurred 18 months or more before the due date of my current pregnancy”;

“I will give permission for the release of the operative records of my previous cesarean birth to my midwife”;

“I agree to having at least one prenatal ultrasound in the second or third trimester of this pregnancy to determine the location of my placenta”; and

“I agree to having lab work done in this pregnancy that determines my blood group and type”;

c. The midwife to provide the following:

1. The certified midwife’s NH certification number;

2. The certified midwife’s business address; and

3. The name of the freestanding birth center;

d. The NH certified midwife to place their full name printed legibly, signature, and date of signing;

e. The client to place their full name printed legibly, signature, and date of signing under the following affirmation:

“I understand that these measures are required to improve the safety of my care. Given the increased risks associated with planning an out of hospital VBAC, I agree that if my midwife recommends a transfer of care or emergency transport in labor I will promptly comply with this recommendation. Having received adequate information and resources, and having had my questions addressed, I express my understanding of the risks and my desire to initiate care with "insert the midwife’s name"."; and

f. An individual who is 18 years or older to witness the client and midwife by signing and dating the form and attesting to that fact by placing their full name printed legibly, signature, and date of signing on the bottom of the form.

(e) The midwife shall screen for domestic violence and history of sexual trauma or abuse.

(f) During subsequent prenatal visits, the midwife shall:

(1) Assess maternal nutrition and weight gain;

(2) Obtain blood pressure;

(3) Assess general well-being;

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

(5) Obtain fundal height measurement;

(6) Arrange for periodic hematocrit or hemoglobin testing;

(7) Assess fetal heart rate and fetal activity;

(8) Assess position and presentation of the fetus;

(9) Provide education of, perform, or order the following:

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 Tetanus, Diphtheria, Acellular Pertussis (Tdap) booster;

g. Thyroid screening, if indicated;

h. Gestational diabetes screening;

i. Group B strep screening; and

j. Herpes Simplex Virus (HSV) in pregnancy and labor, if applicable;

(10) Observe aseptic technique and standard precautions; and

(11) Discuss:

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

b. Diet;

c. Medications and supplements;

d. Educational resources;

e. Social determinants of health;

f. Exercise;

g. Rest and sleep requirements;

h. Sexuality;

i. Partner's role;

j. Birth preparation;

k. Newborn care;

l. Parenting; and

m. Transportation arrangements.

(g) 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.

(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 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 community 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 needs to 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, as appropriate:

a. The name, location, and phone number of the nearest ambulance service for non emergency transport;

b. The name, location, and phone number of the nearest hospital and the hospital with obstetric and neonatal services;

c. Availability of 911 services at the proposed birth location;

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

e. Directions to the location of the birth.

(m) The midwife shall transfer care of the client to a hospital setting as needed, when appropriate.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 502.04 Requirements for Care during Labor, Birth, and the Immediate Postpartum Period.

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

(1) Assess maternal vital signs at regular intervals;

(2) Assess fetal heart tones at regular intervals;

(3) Support and encourage the laboring client;

(4) Assist with the birth;

(5) Assist the client with breastfeeding;

(6) Inspect the perineum and lower vagina;

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

(8) Perform necessary laceration repairs or transfer the client to the hospital for third or fourth degree lacerations;

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

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

(11) Manage any third-stage bleeding;

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

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

(14) Administer vitamin K to the newborn;

(15) Remain with the client and newborn:

a. At least 2 hours after the birth; and

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

(16) Provide the client with information concerning routine postpartum care of both the client and newborn, and indications that warrant contacting the midwife or physician;

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

(18) Follow aseptic technique and use standard precautions.

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

(c) In the event of a hospital transfer, the midwife shall notify the hospital staff in accordance with the hospital transfer protocols and provide a complete set of prenatal, intrapartum, and newborn records.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 502.05 Consultation With Physician or Certified Nurse Midwife 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 with a certified nurse midwife (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;

(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 with an active contraction pattern for more than 20 hours in the case of a primipara or 14 hours in the case of a multipara;

(2) In the second stage, there is no descent after more than 3 hours for a primipara and more than 2 hours for a multipara; or

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

(f) More than 24 hours elapse following the rupture of the membranes without the onset of labor; and

(g) Maternal distress including:

(1) Extreme physical or mental exhaustion;

(2) Abnormal vital signs; or

(3) Abnormal vaginal bleeding equal to or more than a typical menstrual period.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 502.06 Consultation to Determine Setting for Care During the Immediate Postpartum Period. A midwife shall consult immediately with a physician practicing hospital obstetrics or pediatrics or a CNM with hospital privileges 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) Significantly bleeding cervical lacerations;

(b) Third or fourth degree perineal lacerations;

(d) Maternal fever or unstable vital signs;

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

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

(g) Obvious congenital anomalies;

(h) A newborn who is SGA;

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

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

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

(l) A newborn with a pulse rate greater than 160 at rest persisting for longer than 2 hours;

(m) A newborn with respirations greater than 80 at rest persisting for longer than 2 hours;

(n) A newborn with temperature outside the parameters of 97.7-99.4 degrees Fahrenheit or 36.5 to 37.5 degrees Celsius persisting for longer than 2 hours; or

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

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

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 client is not bleeding excessively;

(6) The client has a firm fundus;

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

(8) The client is voiding properly; and

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

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

(e) Recommend or perform newborn hearing screening;

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

(g) Perform newborn pulse oximetry screening for congenital cardiac defects pursuant to RSA 132:10-aa;

(h) By 6 weeks postpartum provide the following:

(1) A pelvic exam including a Pap test, if indicated;

(2) Hemoglobin or hematocrit testing, if indicated;

(3) Screening for postpartum mental health disorders;

(4) Contraceptive counseling and family planning methods; and

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

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

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

(a) Diabetes requiring medication to control glucose;

(b) Seizure disorder with convulsive activity during pregnancy or within the 12 months prior to pregnancy;

(d) Current hepatitis B positive antigen;

(e) Current HIV positivity or AIDS;

(f) Chemical dependency or substance abuse that is current or the patient is on medication assisted treatment (MAT);

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

(h) Rh sensitivity with positive antibody titre;

(i) Chronic hypertension;

(j) History of significant heart disease;

(k) Renal disease requiring dialysis;

(l) Mental illness or condition which has the potential to interfere with the client's ability to effectively participate in their own care;

(m) Diseases and disorders such as:

(1) Addison’s disease;

(2) Cushing’s disease;

(3) Systemic lupus erythematosus;

(4) Anti-phospholipid syndrome;

(5) Scleroderma;

(6) Periarteritis nodosa;

(7) Marfan’s syndrome; and

(8) Other systemic and rare diseases and disorders;

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

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

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

(q) Deep vein thrombosis or pulmonary embolism.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 502.09 Obstetrical Consultation Required to Determine Eligibility for Midwifery Care. A midwife shall consult with a physician practicing hospital obstetrics or a CNM with hospital privileges to evaluate whether a client is an appropriate candidate for a community birth when the client or 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) Maintenance on psychotropic medication, including but not limited to, SSRI’s, benzodiazepines, antipsychotics, and lithium;

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

(e) Gestational hypertension with a systolic blood pressure of 140 mm Hg or more or a diastolic blood pressure of 90 mm Hg or more on 2 occasions 4 hours apart;

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

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

(h) A history of significant postpartum hemorrhage;

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

(j) A history of stillbirth;

(k) A history of prior obstetrical problems including:

(1) Prematurity;

(2) Uterine abnormalities;

(3) Placental abruption; and

(4) Insufficient cervix;

(l) Cancerous or pre-cancerous condition of the cervix as indicated by an abnormal Pap test;

(m) Renal disease not requiring dialysis, such as recurrent urinary tract or kidney infection;

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

(o) Inflammatory bowel disease that is not in remission;

(p) Rheumatoid arthritis;

(q) Hepatitis C antibody positive;

(r) Active gonorrhea;

(s) Active chlamydia;

(t) Primary herpes before 37 weeks if recurrent or during pregnancy at or after 28 weeks;

(u) Gestational diabetes with blood sugars not normalized with diet and exercise alone;

(v) Significant second or third-trimester vaginal bleeding, more than spotting;

(w) Grand multiparity;

(x) Multiple fetuses;

(y) Malpresentation after 36 weeks;

(z) Suspected SGA to rule out developing intrauterine growth restriction (IUGR);

(aa) Suspected large for gestational age;

(ab) Polyhydramnios;

(ac) Oligohydramnios;

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

(ae) Post term gestation at 42 weeks 0 days or beyond;

(af) Thyroid diseases;

(ag) Obesity with a pre-pregnancy body mass index (BMI) of 50 or greater;

(ah) History of deep vein thrombosis or pulmonary embolism;

(ai) Toxoplasmosis infection during pregnancy;

(aj) Rubella infection during pregnancy;

(ak) Anemia measured by hemoglobin of less than 10g or a hematocrit of less than 30% unresolved by 36 weeks’ gestation;

(al) Fetus is SGA by obstetric ultrasound;

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

(an) Rh sensitization with positive antibody titre;

(ao) Cytomegalovirus infection during pregnancy; or

(ap) Parvovirus infection during pregnancy.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

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) Multiple fetuses;

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

(3) Preeclampsia;

(4) Placenta previa;

(5) Placental abruption;

(6) Onset of labor prior to 37 weeks;

(7) Primary herpes outbreak at or after 37 weeks;

(8) History of uterine surgery involving myometrial surgery; or

(9) Any criteria met pursuant to Mid 502.08.

(b) Upon transfer of the client's care pursuant to paragraph (a) above, 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, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

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 their 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 is 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 offer to assist the client in finding another health care provider.

(d) After the onset of labor, a midwife shall terminate 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 they are 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. Calling the on-call obstetrician or family physician practicing obstetrics at the nearest hospital to inform the physician of the situation;

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

c. Dialing 911.

Source. #7759, eff 9-7-02, EXPIRED: 9-7-10

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

PART Mid 503 MIDWIFERY CARE WHEN PREVIOUS BIRTH WAS BY CESAREAN SECTION

Mid 503.01 Definitions. In this part the following terms shall have the following meanings:

(a) “Active labor” means the period of labor beginning when the cervix is at least 6 centimeters dilated and the client is experiencing regular uterine contractions until the cervix is fully dilated;

(b) “Second stage of labor” means the period of labor from the time the cervix is fully dilated and the client begins expulsive efforts until the birth of the baby; and

Source. #7931, eff 8-6-03, EXPIRED: 8-6-11

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 503.02 Eligibility for Midwifery Care. A midwife shall accept a person as a client if the person has had a previous birth by cesarean section only if:

(a) The potential client has had only one previous cesarean section;

(b) The midwife can confirm through a review of the records of the previous delivery by cesarean section that the section was performed through a low transverse uterine segment incision and shall analyze the indication for the previous cesarean;

(c) The potential client has had no other uterine incisions based on review of the operative notes from any other uterine incisions;

(d) At least 18 months’ time separates the date of the potential client’s previous cesarean section and the due date of the current pregnancy;

(e) An obstetric ultrasound in the second trimester documents that the placenta is not in a low-lying anterior position nor is there any indication of any placenta accreta spectrum disorder;

(f) The midwife:

(1) Documents the client’s blood group and type in the current pregnancy;

(2) Reviews the diagnostic obstetric ultrasound in the second trimester and refers the client to a maternal-fetal medicine specialist if:

a. The placenta is low-lying and anterior; or

b. There is any indication of any placenta accreta spectrum disorder;

(3) Recommends, encourages, and offers to arrange for a consultation between the client and a practicing obstetrician to discuss the risk and benefits of VBAC and document refusal if the client declines;

(g) The midwife provides the potential client with the information required by Mid 503.04; and

(h) The midwife obtains the potential client's signature and date of signing on the informed consent form specified in Mid 503.05.

Source. #7931, eff 8-6-03, EXPIRED: 8-6-11

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 503.03 Duties of the Midwife. A midwife attending a client who has had a previous birth by cesarean section shall:

(a) Provide all services required by this chapter;

(b) Monitor the fetal heart rate at least every 15 minutes during active labor;

(d) Monitor for signs of uterine rupture, including but not limited to:

(1) Abnormal fetal heart rate pattern;

(2) Loss of engagement of fetal station;

(3) Unstable vital signs;

(4) Inability to asculate fetal heart tones;

(5) Inability to palpate the uterine fundus;

(6) Changes in maternal mental status, including but not limited to:

a. Confusion;

b. Abnormal speech patterns;

c. Abnormal thinking patterns; and

d. Disorientation;

(7) Unexplained changes in clinical status;

(8) Excessive vaginal bleeding; and

(9) Abnormal abdominal pain;

(e) Monitor the client during labor for excessive vaginal bleeding;

(f) Monitor the client during labor for abnormal abdominal pain;

(g) Monitor the labor for failure to progress as indicated by the following:

(1) The passage of at least 4 hours without cervical change during active labor;

(2) The passage of at least one hour without progress in descent of the head or the passage of at least 2 hours with slow progress in descent of the head during the second stage of labor; or

(3) The passage of at least one hour without delivery of the placenta during the third stage of labor;

(h) Consult immediately with an obstetrician if any of the circumstances listed in (d) above occur;

(i) Transfer the client to the hospital closet to the planned location of the birth when any of the following occur:

(1) Repeated fetal heart rate decelerations less than 110 bpm in the first stage of labor;

(2) Persistent fetal heart tachycardia more than 160 BPM; and

(3) Any of the symptoms of uterine rupture listed in (d) above; and

(j) In the event of an emergency transfer to a hospital, immediately notify the hospital to which the client is to be transferred of the nature of the emergency and the estimated time of arrival of the client.

Source. #7931, eff 8-6-03, EXPIRED: 8-6-11

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 503.04 Midwife's Duty to Provide Client with Information. A midwife shall:

(a) Provide the client with current resources for data comparing VBAC safety versus planned cesarean section;

(b) Provide the client with a copy of Mid 503;

(1) That community VBAC involves labor and delivery at home or in a freestanding birth center with a certified midwife in attendance at either location;

(2) As part of a review of Mid 503:

a. The midwife's obligation to comply with Mid 503;

b. The client's eligibility for community VBAC pursuant to Mid 503.02; and

c. How the midwife would carry out the duties set forth in Mid 503.03 if the client were to choose community VBAC;

(3) The normal risks of labor and of VBAC in any setting, including the risk of uterine rupture during labor and abnormally adherent placenta after the birth resulting in severe hemorrhage;

(4) That the distance of the birth location to a hospital with obstetrical and anesthesia services, whether in-house or on-call, impacts the risk of catastrophic outcome for the client, the baby, or both. These risks include, but are not limited to:

a. Permanent brain damage for the baby;

b. Death of the baby;

c. Emergency hysterectomy;

d. Intensive care;

e. Multiple transfusions; or

f. Death of the client;

(5) The precautions that the midwife would take if the client were to choose community birth, including but not limited to:

a. Use of obstetric ultrasound for the location of the placenta, and if the placenta is low and anterior, that the client will be ineligible for midwifery care; and

b. Closer monitoring of client and baby during active labor;

(6) The possible benefits of community VBAC over in-hospital VBAC including but not limited to:

a. No surgical intervention;

b. Greater freedom of movement and of positioning at time of birth; and

c. Birth in familiar and private surroundings with the support of the client's midwife;

(7) The possible benefits of in-hospital VBAC over community VBAC, including the availability in hospitals of resources not available in community setting, including but not limited to, immediate access to surgical intervention and intensive care facilities and services; and

(8) The possibility that the client might need to be transferred to a hospital; and

(d) Ensure the client's questions are answered.

Source. #7931, eff 8-6-03, EXPIRED: 8-6-11

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 503.05 Informed Consent Documentation for Community VBAC.

(a) A midwife shall review with the VBAC client an informed consent document and shall obtain the information listed in (b) below.

(b) The informed consent document shall be signed by the client in the presence of the midwife and the client and midwife shall provide the following:

(1) The client’s full legal name;

(2) The certified midwife’s name as it appears on their New Hampshire certification;

(3) The certified midwife’s NH certification number;

(4) The certified midwife’s business address;

(5) The name of the freestanding birth center, if applicable;

(6) The client’s acknowledgement that they:

a. Have read the midwife’s informed consent form for out of hospital VBAC, discussed the topic in depth, and have had all of their questions and concerns addressed;

b. Have read and understand Mid 503.04 and acknowledge that the midwife is required to adhere to the laws and rules governing their profession;

c. Are aware of the risks associated with planned VBAC , including the risk of uterine rupture. The client understands that if their uterus were to rupture in labor it could result in serious damage to themselves or their baby, and if a uterine rupture were to occur that there is an increased risk that the baby could die;

d. Have discussed with the midwife and understand that the greater the distance from a hospital with obstetrical and anesthesia services on call 24 hours a day that there is an increased risk to themselves or the baby; and

e. Understand that they have the option to attempt a VBAC at a hospital or to plan a repeat cesarean at a hospital; and

(7) An acknowledgement by the client that the following statements about their previous medical history provided to the midwife is accurate:

a. They have had only one previous cesarean and the scar is transverse in the lower part of their uterus; and

b. The cesarean indicated in (7)a. above occurred 18 months or more before the due date of the current pregnancy;

(8) An agreement to:

a. Give permission for the release of the operative records of the previous cesarean birth to the midwife; and

b. Having at least one prenatal ultrasound in the second or third trimester of their pregnancy to determine the location of their placenta.

(1) Print their legal names on the document;

(2) Provide their signatures on the bottom of the document; and

(3) Date the document when they have signed it.

Source. #7931, eff 8-6-03, EXPIRED: 8-6-11

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Mid 503.06 Effect of Client's Signature on the Informed Consent Document. By signing the document described in Mid 503.05, the client acknowledges that:

(a) They understand the information described in Mid 503.04(c);

(b) They have read the documents described in Mid 503.04(a) and (b) and understand the significance of the facts in both documents;

(d) The midwife has answered all questions to the satisfaction of the client; and

(e) They consent to midwifery services community VBAC .

Source. #7931, eff 8-6-03, EXPIRED: 8-6-11

New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16

New. #12040, eff 11-10-16; ss by #14594, eff 7-20-26, EXPIRES: 7-20-36

Appendix A

Rule	Specific State Statute which the Rule Implements
Mid 501	RSA 326-D:5, I (c)
Mid 502.01	RSA 326-D:5, I (c) & (f); RSA 326-D:2, V
Mid 502.02	RSA 326-D:2, V(a) and (b); RSA 326-D:12, I(a)-(h)
Mid 502.03 – Mid 502.11	RSA 326-D:5, I(c)
Mid 503.01 – Mid 503.06	RSA 326-D:5, I(c)

Appendix B

Rule

Title

Obtain at:

Mid 502.03(c)(1)d.i.

The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, committee opinion on “Methods of Estimating Due Date” dated 5/2017

Obtain for no cost online at:

https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2017/05/methods-for-estimating-the-due-date.pdf

Mid 502.03(c)(1)d.ii.

The World Health Organization “WHO recommendations on antenatal care for a positive pregnancy experience” 2016 publication

Obtain for no cost online at:

https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf