R156.  Commerce, Occupational and Professional Licensing.
R156-77.  Direct-Entry Midwife Act Rule.
R156-77-101.  Title.
	This rule is known as the "Direct-Entry Midwife Act Rule."

R156-77-102.  Definitions.
	In addition to the definitions in Title 58, Chapters 1 and 77, as used in Title 58, Chapter 77 or this rule:
	(1)  "Accredited school", as used in this rule, includes any midwifery school that has been granted pre-accredited status by MEAC.
	(2)  "Apgar score", as used in Section R156-77-601, means an index used to evaluate the condition of a newborn based on a rating of 0, 1, or 2 for each of the five characteristics of color, heart rate, response to stimulation of the sole of the foot, muscle tone, and respiration with 10 being a perfect score.
	(3)  "Appropriate provider", as used in Sections R156-77-601 and 602, means a licensed provider who is an appropriate contact person based on the provider's level of education and scope of practice.
	(4)  "Approved continuing education", as used in Subsection R156-77-303(3)(c), means:
	(a)  continuing education that has been approved by a nationally recognized professional organization that approves health related continuing education;
	(b)  a course offered by a post-secondary education institution that is accredited by an accrediting board recognized by the U.S. Department of Education, an MEAC approved midwifery program or accredited midwifery school, or an MEAC approved program or course; or
	(c)  continuing education that is sponsored or presented by MANA or any subgroup thereof, a government agency, a recognized direct-entry midwifery or health care association.
	(5)  "Collaborate", as used in Section R156-77-601, means the process by which an LDEM and another licensed health care provider jointly manage a specific condition of a client according to a mutually agreed-upon plan of care.  The LDEM continues midwifery management of the client and may follow through with the medical management as agreed upon with the provider.
	(6)  "Consultation", as used in Section R156-77-601, means the process by which the LDEM discusses client status with an appropriate licensed health care provider by phone, written note, or in person.  The provider may give a recommendation for management, but does not assume the management of the client.
	(7)  "CPR", as used in this rule, means cardiopulmonary resuscitation.
	(8)  "C-section", as used in this rule, means a cesarean section.
	(9)  "LDEM", as used in this rule, means a licensed direct entry midwife licensed under Title 58, Chapter 77.
	(10)  "LDEM Outcome Database", as used in Section R156-77-604, means a web based application created by the Division to collect data regarding the outcome of pregnancies and deliveries managed by an LDEM.
	(11)  "MANA", as used in this rule, means the Midwives Alliance of North America.
	(12)  "MEAC", as used in this rule, means the Midwifery Education Accreditation Council.
	(13)  "Midwifery Care", as used in this rule, has the same meaning as the practice of direct-entry midwifery as defined in Subsection 58-77-102(8).
	(14)  "NARM", as used in this rule, means the North American Registry of Midwives.
	(15)  "Refer", as used in Section R156-77-601, means the process by which an LDEM directs the client to an appropriate licensed health care provider for management of a specific condition.  The LDEM continues midwifery management of the client.
	(16)  "TOLAC", as used in Section R156-77-602, means a trial of labor after cesarean section.
	(17)  "Transfer", as used in Section R156-77-601, means the process by which an LDEM relinquishes management of a client to an appropriate licensed health care provider.  The LDEM may provide on-going support services as appropriate.
	(18)  "Unprofessional conduct," as defined in Title 58 Chapters 1 and 77, is further defined, in accordance with Subsection 58-1-203(1)(e), in Section R156-77-502.
	(19)  "VBAC", as used in this rule, means a vaginal birth after cesarean section.
	(20)  "Weeks gestation", as used in this rule, means the age of a pregnancy calculated using accepted pregnancy dating criteria such as menstrual or ultrasound dating, to determine an estimated date of delivery which equals 40 weeks 0 days gestation and is noted as 40.0.

R156-77-103.  Authority - Purpose.
	This rule is adopted by the Division under the authority of Subsection 58-1-106(1)(a) to enable the Division to administer Title 58, Chapter 77.

R156-77-104.  Organization - Relationship to Rule R156-1.
	The organization of this rule and its relationship to Rule R156-1 is as described in Section R156-1-107.

R156-77-302a.  Qualifications for licensure - Application Requirements.
	In accordance with Subsections 58-1-203(1), 58-1-301(3), and 58-77-302(5), the application requirements for licensure in Section 58-77-302 are defined herein.
	(1)  An applicant for licensure as an LDEM must submit documentation of current CPR certification for health care providers, for both adults and infants, from one of the following organizations:
	(a)  American Heart Association;
	(b)  American Red Cross or its affiliates; or
	(c)  American Safety and Health Institute.
	(2)  An applicant for licensure as an LDEM must submit documentation of current newborn or neonatal resuscitation certification from one of the following organizations:
	(a)  American Academy of Pediatrics;
	(b)  American Heart Association; or
	(c)  a MEAC approved program or accredited school.

R156-77-302b.  Qualifications for licensure - Education Requirements.
	In accordance with Subsections 58-1-203(1)(b), 58-1-301(3), and 58-77-302(6), the pharmacology course requirement for licensure in Subsection 58-77-302(6) is defined herein.  The course must be:
	(1)  offered by a post-secondary educational institution that is accredited by an accrediting board recognized by the Council for Higher Education Accreditation of the American Council on Education, a MEAC approved midwifery program or accredited midwifery school, or be a MEAC approved program or course; and
	(2)  at least eight clock hours in length and include basic pharmacotherapeutic principles and administration of medications including the drugs listed in Subsections 58-77-102(8)(f)(i) through (ix); or
	(3)  a general pharmacology course of at least 20 clock hours in length from a health-related course of study.

R156-77-303.  Renewal Cycle - Procedures.
	(1)  In accordance with Subsection 58-1-308(1), the renewal date for the two-year renewal cycle applicable to licensees under Title 58, Chapter 77 is established by rule in Subsection R156-1-308a(1).
	(2)  Renewal procedures shall be in accordance with Section R156-1-308c.
	(3)  Each applicant for renewal shall comply with the following:
	(a)  submit documentation of holding a current Certified Professional Midwife certificate in good standing with NARM;
	(b)  submit documentation of current certifications in adult and infant CPR, and newborn resuscitation that meets the criteria established in R156-77-302a; and
	(c)  complete at least two clock hours of approved continuing education in intrapartum fetal monitoring during each preceding two year licensure cycle which may be part of the hours required in Subsection (a) to maintain certification provided the hours meet the requirements established by NARM.
	(4)  A licensee must be able to document completion of the continuing education hours upon the request of the Division.  Such documentation shall be retained until the next licensure renewal cycle.

R156-77-502.  Unprofessional Conduct.
	"Unprofessional conduct" includes:
	(1)  failure to practice in accordance with the knowledge, clinical skills, and judgments described in the MANA Core Competencies for Basic Midwifery Practice (1994), which is hereby adopted and incorporated by reference; and
	(2)  failing as a midwife to follow the MANA Standards and Qualifications for the Art and Practice of Midwifery (2005), which is hereby adopted and incorporated by reference.

R156-77-601.  Standards of Practice.
	Except as provided in Subsection 58-77-601(3)(b), and in accordance with Subsection 58-77-601(2), the standards and circumstances that require an LDEM to recommend and facilitate consultation, collaboration, referral, transfer, or mandatory transfer of client care are established herein.  These standards are at a minimum level and are hierarchical in nature.  If the standard requires at least consultation for a condition, an LDEM may choose to collaborate, refer, or transfer the care of the client.
	(1)  Consultation:
	(a)  antepartum:
	(i)  suspected intrauterine growth restriction;
	(ii)  severe vomiting unresponsive to LDEM treatment;
	(iii)  pain unrelated to common discomforts of pregnancy;
	(iv)  presence of condylomata that may obstruct delivery;
	(v)  anemia unresponsive to LDEM treatment;
	(vi)  history of genital herpes;
	(vii)  suspected or confirmed fetal demise after 14.0 weeks gestation;
	(viii)  suspected multiple gestation;
	(ix)  confirmed chromosomal or genetic aberrations;
	(x)  hepatitis C;
	(xi)  prior c-section without a second trimester ultrasound to determine the location of placental implantation; and
	(xii)  any other condition in the judgment of the LDEM requires consultation.
	(2)  Mandatory Consultation:
	(a)  incomplete miscarriage after 14.0 weeks gestation;
	(b)  failure to deliver by 42.0 weeks gestation;
	(c)  a fetus in the breech position after 36.0 weeks gestation;
	(d)  any sign or symptom of:
	(i)  placenta previa;
	(ii)  deep vein thrombosis or pulmonary embolus; or
	(iii)  vaginal bleeding after 20.0 weeks gestation, in a woman with a history of a c-section who has not had an ultrasound performed;
	(e)  Rh isoimmunization or other red blood cell isoimmunization known to cause erythroblastasis fetalis; or
	(f)  any other condition or symptom in the judgment of the LDEM that may place the health of the pregnant woman or unborn child at unreasonable risk.
	(3)  Collaborate:
	(a)  antepartum:
	(i)  infection not responsive to LDEM treatment;
	(ii)  seizure disorder affecting the pregnancy;
	(iii)  history of cervical incompetence with surgical therapy;
	(iv)  increase in blood pressure with a systolic pressure greater than 140 mm or a diastolic pressure greater than 90 mm in two readings at least six hours apart, no more than trace proteinurea or other evidence of preeclampsia; and
	(vi)  any other condition in the judgment of the LDEM requires collaboration;
	(b)  postpartum:
	(i)  infection not responsive to LDEM treatment; and
	(ii)  any other condition in the judgment of the LDEM requires collaboration.
	(4)  Refer:
	(a)  antepartum:
	(i)  thyroid disease;
	(ii)  changes in the breasts not related to pregnancy or lactation;
	(iii)  severe psychiatric illness responsive to treatment;
	(iv)  heart disease that has been determined by a cardiologist to have potential to affect or to be affected by pregnancy, labor, or delivery; and
	(v)  any other condition in the judgment of the LDEM requires referral;
	(b)  postpartum:
	(i)  bladder dysfunction;
	(ii)  severe depression; and
	(iii) any other condition in the judgment of the LDEM requires referral;
	(c)  newborn:
	(i)  birth injury requiring on-going care;
	(ii)  minor congenital anomaly;
	(iii)  jaundice beyond physiologic levels;
	(iv)  loss of 15% of birth weight;
	(v)  inability to suck or feed; and
	(vi)  any other condition in the judgment of the LDEM requires referral.
	(5)  Transfer, however may be waived in accordance with Subsection 58-77-601(3)(b):
	(a)  antepartum:
	(i)  current drug or alcohol abuse;
	(ii)  current diagnosis of cancer;
	(iii)  persistent oligohydramnios not responsive to LDEM treatment;
	(iv)  confirmed intrauterine growth restriction;
	(v)  prior c-section with unknown uterine incision type provided a reasonable effort has been made to determine the uterine scar type and the client has signed an informed consent that meets the standards established in Section R156-77-602;
	(vi)  history of preterm delivery less than 34.0 weeks gestation;
	(vii)  history of severe postpartum bleeding;
	(viii)  primary genital herpes outbreak;
	(ix)  increase in blood pressure with a systolic pressure greater than 140 mm or a diastolic pressure greater than 90 mm in two readings at least six hours apart, and 1+ to 2+ proteinurea confirmed by a 24 hour urine collection of greater than 300 mg of protein; and
	(x)  any other condition in the judgment of the LDEM may require transfer;
	(b)  intrapartum:
	(i)  visible genital lesions suspicious of herpes virus infection;
	(ii)  severe hypertension defined as a sustained diastolic blood pressure of greater than 110 mm or a systolic pressure of greater than 160 mm;
	(iii)  excessive vomiting, dehydration, acidosis, or exhaustion unresponsive to LDEM treatment; and
	(iv)  any other condition in the judgment of the LDEM may require transfer;
	(c)  postpartum:
	(i)  retained placenta; and
	(ii)  any other condition in the judgment of the LDEM may require transfer;
	(d)  newborn:
	(i)  gestational age assessment less than 36 weeks gestation;
	(ii)  major congenital anomaly not diagnosed prenatally;
	(iii)  persistent hyperthermia or hypothermia unresponsive to LDEM treatment; and
	(iv)  any other condition in the judgment of the LDEM may require transfer.
	(6)  Mandatory transfer:
	(a)  antepartum:
	(i)  severe preeclampsia or severe pregnancy-induced hypertension as evidenced by:
	(A)  a systolic pressure greater than 160 mm or a diastolic pressure greater than 110 mm in two readings at least six hours apart, or 3+ to 4+ proteinurea, or greater than 5 gms of protein in a 24 hour urine collection; or
	(B)  a systolic pressure greater than 140 mm or a diastolic pressure greater than 90 mm in two readings at least six hours apart, at least 1+ proteinurea, and one or more of the following:
	(1)  epigastric pain;
	(2)  headache;
	(3)  visual disturbances; or
	(4)  decreased fetal movement;
	(ii)  eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP);
	(iii)  documented platelet count less than 75,000 platelets per mm3 of blood;
	(iv)  placenta previa after 27.0 weeks gestation;
	(v)  confirmed ectopic pregnancy;
	(vi)  severe psychiatric illness non-responsive to treatment;
	(vii)  human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS);
	(viii)  diagnosed deep vein thrombosis or pulmonary embolism;
	(ix)  multiple gestation;
	(x)  no onset of labor by 43.0 weeks gestation;
	(xi)  more than two prior c-sections;
	(xii)  prior c-section with a known uterine classical, inverted T or J incision, or an extension of an incision into the upper uterine segment;
	(xiii)  prior c-section without an ultrasound that rules out placental implantation over the uterine scar obtained no later than 35.0 weeks gestation or prior to commencement of care if the care is sought after 35.0 weeks gestation;
	(xiv)  prior c-section without a signed informed consent document meeting the standards established in Section R156-77-602;
	(xv)  prior c-section with a gestation greater than 42.0 weeks gestation;
	(xvi)  Rh isoimmunization or other red blood cell isoimmunization known to cause erythroblastasis fetalis, with an antibody titre of greater than 1:8;
	(xvii)  insulin-dependent diabetes;
	(xviii)  significant vaginal bleeding after 20.0 weeks gestation not consistent with normal pregnancy and posing a continuing risk to mother or baby; and
	(xiv)  any other condition in the judgment of the LDEM that could place the life or long-term health of the pregnant woman or unborn child at risk;
	(b)  intrapartum:
	(i)  signs of uterine rupture;
	(ii)  presentation(s) not compatible with spontaneous vaginal delivery;
	(iii)  fetus in breech presentation during labor unless delivery is imminent;
	(iv)  progressive labor prior to 37.0 weeks gestation except miscarriages, confirmed fetal death, or congenital anomalies incompatible with life;
	(v)  prolapsed umbilical cord unless birth is imminent;
	(vi)  clinically significant abdominal pain inconsistent with normal labor;
	(vii)  seizure;
	(viii)  undiagnosed multiple gestation, unless delivery if imminent;
	(ix)  suspected chorioamnionitis;
	(x)  prior c-section with cervical dilation progress in the current labor of less than one centimeter in three hours once labor is active;
	(xi)  non-reassuring fetal heart pattern indicative of fetal distress that does not immediately respond to treatment by the LDEM, unless delivery is imminent;
	(xii)  moderate thick, or particulate meconium in the amniotic fluid unless delivery is imminent;
	(xiii)  failure to deliver after three hours of pushing unless delivery is imminent; or
	(xiv)  any other condition in the judgment of the LDEM that would place the life or long-term health of the pregnant woman or unborn child at significant risk if not acted upon immediately;
	(c)  postpartum:
	(i)  uncontrolled hemorrhage;
	(ii)  maternal shock that is unresponsive to LDEM treatment;
	(iii)  severe psychiatric illness non-responsive to treatment;
	(iv)  signs of deep vein thrombosis or pulmonary embolism; and
	(v)  any other condition in the judgment of the LDEM that could place the life or long-term health of the mother or infant at significant risk if not acted upon immediately;
	(d)  newborn:
	(i)  non-transient respiratory distress;
	(ii)  non-transient pallor or central cyanosis;
	(iii)  Apgar score at ten minutes of less than six;
	(iv)  low heart rate of less than 60 beats per minute after one complete neonatal resuscitation cycle;
	(v)  absent heart rate except with confirmed fetal death or congenital anomalies incompatible with life, or shoulder dystocia resulting in death;
	(vi)  hemorrhage;
	(vii)  seizure;
	(viii)  persistent hypertonia, lethargy, flaccidity or irritability, or jitteriness;
	(ix)  inability to urinate or pass meconium within the first 48 hours of life; and
	(x)  any other condition in the judgment of the LDEM must be transferred.

R156-77-602.  Informed Consent.
	In addition to the standards for informed consent established in Subsection 58-77-601(1)(b), an informed consent for a client with a previous c-section, must include the following information about a VBAC:
	(1)  TOLAC is associated with the risk of uterine rupture.  Uterine rupture can cause brain damage or death of the baby and result in serious hemorrhage or hysterectomy in the mother.
	(2) VBAC poses more medical risks to the baby than a scheduled repeat c-section.
	(3)  Repeat c-section poses more medical risks to the mother than VBAC.
	(4)  C-section after a failed TOLAC is associated with more risks than a c-section done before labor has begun.
	(5)  If a complication occurs from a TOLAC outside of a hospital setting, the risk to mother and baby may be higher due to the inherent delay in obtaining access to hospital care.
	(6)  Multiple c-sections are associated with, but not limited to, increased risks due to abnormal placental implantation, hemorrhage requiring hysterectomy, and other surgical and postoperative complications.
	(7)  The risks associated with TOLAC after two c-sections are greater than those after one c-section.
	(8)  Risks associated with TOLAC when the type of uterine scar is unknown are greater than when the uterine scar is known to be low transverse.
	(9)  The 2004 National Birth Center study revealed women who attempt TOLAC in a birth center setting have an overall transfer rate of 24%, and a vaginal delivery rate of 87%.
	(10)  A woman with no previous vaginal birth and two previous c-sections for documented failure to progress, has a very low vaginal delivery success rate.

R156-77-603.  Procedures for the Termination of Midwifery Care.
	(1)  The procedure to terminate midwifery care for a client who has been informed that she has or may have a condition indicating the need for medical consultation, collaboration, referral, or transfer is established herein:
	(a)  provide no fewer than three business days written notice, unless an emergency, during which the LDEM shall continue to provide midwifery care, to enable the client to select another licensed health care provider;
	(b)  provide a referral; and
	(c)  document the termination of care in the client's records.
	(2)  The procedure to terminate midwifery care to a client who has been informed that she has or may have a condition indicating the need for mandatory transfer is established herein:
	(a)  have the client sign a release of care indicating the LDEM has terminated providing midwifery care as of a specific date and time; or
	(b)  verbally instruct the client of the termination of midwifery care and document said instruction in the client record;
	(c)  make a reasonable effort to convey significant information regarding the client's condition to the receiving provider; and
	(d)  if possible, when transferring the client by ambulance or private vehicle, the LDEM accompanies the client.

KEY:  licensing, midwife, direct-entry midwife
Date of Enactment or Last Substantive Amendment:  May 22, 2014
Notice of Continuation:  April 26, 2016
Authorizing, and Implemented or Interpreted Law:  58-1-106(1)(a); 58-1-202(1)(a); 58-77-202(4); 58-77-601(2)