Section R9-16-108. Responsibilities of a Midwife; Scope of Practice

A.      A midwife shall provide midwifery services only to a healthy woman, determined through a physical assessment and review of the woman’s obstetrical history, whose expected outcome of pregnancy is most likely to be the delivery of a healthy new- born and an intact placenta.

B.       Except as provided in R9-16-111(C) or (D), a midwife who is certified by the North American Registry of Midwives as a Certified Professional Midwife may accept a client for a vagi- nal delivery:

1.        After prior Cesarean section, or

2.        Of a fetus in a complete breech or frank breech presenta- tion.

C.      Before providing services to a client, a midwife shall:

1.        Inform a client, both orally and in writing, of:

a.         The midwife's scope of practice, educational back- ground, and credentials;

b.        If applicable to the client’s condition, the midwife’s experience with:

i.         Vaginal birth after prior Cesarean section deliv- ery, or

ii.        Delivery of a fetus in a complete breech or frank breech presentation;

c.         The potential risks; adverse outcomes; neonatal or maternal complications, including death; and alter- natives associated with an at-home delivery specific

and (K)(4)(c), and the potential risks for declining a test, and, if a test is declined, the need for a written assertion of a client’s decision to decline testing;

e.         The requirement for consultation for a condition specified in R9-16-112; and

f.         The requirement for the transfer of care for a condi- tion specified in R9-16-111; and

2.        Obtain a written informed consent for midwifery services according to R9-16-109.

D.      A midwife shall establish an emergency care plan for the client that includes:

1.        The name, address, and phone number of:

a.         The hospital closest to the birthing location that pro- vides obstetrical services, and

b.        An emergency medical services provider that pro- vides service between the birthing location and the hospital identified in subsection (D)(1)(a);

2.        The hospital identified in subsection (D)(1)(a) is within 25 miles of the birthing location for a delivery identified in subsection (B);

3.        The signature of the client and the date signed; and

4.        The signature of the midwife and the date signed.

E.       A midwife shall ensure the client receives a copy of the emer- gency care plan required in subsection (D).

F.       A midwife shall implement the emergency care plan by imme- diately calling the emergency medical services provider identi- fied in subsection (D)(1)(b) for any condition that threatens the life of the client or the client’s child.

G.      A midwife shall maintain all instruments used for delivery in an aseptic manner and other birthing equipment and supplies in clean and good condition.

H.      A midwife shall assess a client's physical condition in order to establish the client's continuing eligibility to receive mid- wifery services.

I.        During the prenatal period, the midwife shall:

1.        Until October 1, 2013, schedule or arrange for the follow- ing tests for the client within 28 weeks gestation:

a.         Blood type, including ABO and Rh, with antibody screen;

b.        Urinalysis;

c.         HIV;

d.        Hepatitis B;

e.         Hepatitis C;

f.         Syphilis as required in A.R.S. § 36-693;

g.        Rubella titer;

h.        Chlamydia; and

i.         Gonorrhea;

2.        Until October 1, 2013, schedule or arrange for the follow- ing tests for the client:

a.         A blood glucose screening test for diabetes com- pleted between 24 and 28 weeks of gestation;

b.        A hematocrit and hemoglobin or complete blood count test completed between 28 and 36 weeks of gestation;

c.         A vaginal-rectal swab for Group B Strep Streptococ- cus culture completed between 35 and 37 weeks of gestation;

d.        At least one ultrasound and recommended follow-up testing to determine placental location and risk for placenta previa and placenta accrete; and

e.         An ultrasound at 36-37 weeks gestation to confirm fetal presentation and estimated fetal weight for a breech pregnancy;

3.        As of October 1, 2013, except as provided in R9-16-110, ensure that the tests in section (I)(1) are completed by the client within 28 weeks gestation;

4.        As of October 1, 2013, except as provided in R9-16-110, ensure that the tests in subsection (I)(2) are completed by the client;

5.        Conduct a prenatal visit at least once every 4 weeks until the beginning of 28 weeks of gestation, once every 2 weeks from the beginning of 28 weeks until the end of 36 weeks of gestation, and once a week after 36 weeks of gestation that includes:

a.         Taking the client’s weight, urinalysis for protein, nitrites, glucose and ketones; blood pressure; and assessment of the lower extremities for swelling;

b.        Measurement of the fundal height and listening for fetal heart tones and, later in the pregnancy, feeling the abdomen to determine the position of the fetus;

c.         Documentation of fetal movement beginning at 28 weeks of gestation;

d.        Document of:

i.         The occurrence of bleeding or invasive uterine procedures, and

ii.        Any medications taken during the pregnancy that are specific to the needs of an Rh negative client;

e.         Referral of a client for lab tests or other assessments, if applicable, based upon examination or history; and

f.         Recommendation of administration of the drug RhoGam to unsensitized Rh negative mothers after 28 weeks, or any time bleeding or invasive uterine procedures are done, or midwife administration of RhoGam under a physician's written orders;

6.        Monitor fetal heart tones with fetoscope and document the client’s report of first quickening, between 18 and 20 weeks of gestation;

7.        Conduct weekly visits until signs of first quickening have occurred if first quickening has not been reported by 20 weeks of gestation;

8.        Initiate a consultation if first quickening has not occurred by the end of 22 weeks of gestation; and

9.        Conduct a prenatal visit of the birthing location before the end of 35 weeks of gestation to ensure that the birthing environment is appropriate for birth and that communica- tion is available to the hospital and emergency medical services provider identified in subsection(D)(1).

J.        During the intrapartum period, a midwife shall:

1.        Determine if the client is in labor and the appropriate course of action to be taken by:

a.         Assessing the interval, duration, intensity, location, and pattern of the contractions;

b.        Determining the condition of the membranes, whether intact or ruptured, and the amount and color of fluid;

c.         Reviewing with the client the need for an adequate fluid intake, relaxation, activity, and emergency management; and

d.        Deciding whether to go to client's home, remain in telephone contact, or arrange for transfer of care or consultation;

2.        Contact the hospital identified in subsection (D)(1)(a) according to the policies and procedures established by the hospital regarding communication with midwives when the client begins labor and ends labor;

3.        During labor, assess the condition of the client and fetus upon initial contact, every half hour in active labor until completely dilated, and every 15 to 20 minutes during pushing, following rupture of the amniotic bag, or until the newborn is delivered, including:

a.         Initial physical assessment and checking of vital signs every 2 to 4 hours of the client;

b.        Assessing fetal heart tones every 30 minutes in active first stage labor, and every 15 minutes during second stage, following rupture of the amniotic bag, or with any significant change in labor patterns;

c.         Periodically assessing contractions, fetal presenta- tion, dilation, effacement, and fetal position by vagi- nal examination;

d.        Maintaining proper fluid balance for the client throughout labor as determined by urinary output and monitoring urine for presence of ketones; and

e.         Assisting in support and comfort measures to the cli- ent and family;

4.        For deliveries described in subsection (B), during labor determine:

a.         For primiparas, the progress of active labor by mon- itoring whether dilation occurs at an average of 1 centimeter per hour until completely dilated, and a second stage does not exceed 2 hours, if applicable;

b.        Normal progress of active labor for multigravidas by monitoring whether dilation occurs at an average of

1.5 to 2 centimeters per hour until completely dilated, and a second stage does not exceed 1 hour, if applicable; or

c.         The progress of active labor according to the Man- agement Guidelines recommended by the American Congress of Obstetricians and Gynecologists;

5.        After delivery of the newborn:

a.         Assess the newborn at 1 minute and 5 minutes to determine the Apgar scores;

b.        Physically assess the newborn for any abnormalities;

c.         Inspect the client's perineum, vagina, and cervix for lacerations;

d.        Deliver the placenta within 1 hour and assess the cli- ent for signs of separation, frank or occult bleeding; and

e.         Examine the placenta for intactness and to determine the number of umbilical cord vessels; and

6.        Recognize and respond to any situation requiring imme- diate intervention.

K.      During the postpartum period, the midwife shall:

1.        During the 2 hours after delivery of the placenta, provide the following care to the client:

a.         Every 15 to 20 minutes for the first hour and every 30 minutes for the second hour:

i.         Take vital signs of the client,

ii.        Perform external massage of the uterus, and

iii.      Evaluate bleeding;

b.        Assist the client to urinate within 2 hours following the birth, if applicable;

c.         Evaluate the perineum, vagina, and cervix for tears, bleeding, or blood clots;

d.        Assist with maternal newborn and infant bonding;

e.         Assist with initial breast feeding, instructing the cli- ent in the care of the breast, and reviewing potential danger signs, if appropriate;

f.         Provide instruction to the family about adequate fluid and nutritional intake, rest, and the types of exercise allowed, normal and abnormal bleeding, bladder and bowel function, appropriate baby care, signs and symptoms of postpartum depression, and any symptoms that may pose a threat to the health or life of the client or the client’s newborn and appro- priate emergency phone numbers;

g.        Recommend or administer under physician’s written orders, the drug RhoGam to an unsensitized Rh-neg- ative mother who delivers an Rh-positive newborn. Administration shall occur not later than 72 hours after birth; and

h.        Document any medications taken by the client in the client’s record to an unsensitized Rh-negative client who delivers an Rh-positive newborn;

2.        During the 2 hours after delivery of the placenta, provide the following care to the newborn:

a.         Perform a newborn physical exam to determine the newborn's gestational age and any abnormalities;

b.        Comply with the requirements in A.A.C. R9-6-332;

c.         Recommend or administer Vitamin K under physi- cian's written orders to the newborn. Administration shall occur not later than 72 hours after birth; and

d.        Document the administration of any medications or vitamins to the newborn in the newborn’s record according to the physician’s written orders;

3.        Evaluate the client or newborn for any abnormal or emer- gency situation and seek consultation or intervention, if applicable, according to these rules; and

4.        Re-evaluate the condition of the client and newborn between 24 and 72 hours after delivery to determine whether the recovery is following a normal course, including:

a.         Assessing baseline indicators such as the  client's vital signs, bowel and bladder function, bleeding, breasts, feeding of the newborn, sleep/rest cycle, activity with any recommendations for change;

b.        Assessing baseline indicators of well-being in the newborn such as vital signs, weight, cry, suck and feeding, fontanel, sleeping, and bowel and bladder function with documentation of meconium, and pro- viding any recommendations for changes made to the family;

c.         Submitting blood obtained from a heel stick to the newborn to the state laboratory for screening accord- ing to A.R.S. § 36-694(B) and 9 A.A.C. 13, Article 2, unless a written refusal is obtained from the client and documented in the client’s record and the new- born's record; and

d.        Recommending to the client that the client secure medical follow-up for her newborn.

L.       A midwife shall file a birth certificate with the local registrar within seven calendar days after the birth of the newborn.

M.     Subsections (B), (C)(1)(b), (C)(1)(d) and (J)(2) and (4) are effective July 1, 2014.

Historical Note

Adopted effective March 14, 1994 (Supp. 94-1). R9-16- 108 renumbered to R9-16-111; new Section R9-16-108 renumbered from R9-16-106 and amended by exempt rulemaking at 19 A.A.R. 1805, effective July 1, 2013

(Supp. 13-2).