ArizonaArticle 7 - Licensing and Regulation of Midwifery
36-751. Definitions
36-752. Licensure; exceptions
36-753. Application for license as midwife
36-754. Licensing of midwives; renewal of license
36-755. Powers and duties of the director (L90, ch 241, sec 5.)
36-756. Grounds for denial of license and disciplinary action; hearing; appeal; civil penalties; injunctions
36-756.01. Investigations; right to examine evidence; subpoenas; confidentiality
36-757. Violations; classification
36-758. Fees
36-759. Use of title; prohibitions
36-760. Persons and acts not affected by this article
36-770. Tobacco products tax fund (Caution: 1998 Prop. 105 applies)
TITLE 9. HEALTH SERVICESCHAPTER 16. DEPARTMENT OF HEALTH SERVICES Supp. 02-2 ARTICLE 1. LICENSING OF MIDWIFERY Article 1, consisting of Sections R9-16-101 through R9-16-112 and Exhibits A through E, adopted effective as noted in Section Historical Notes (Supp. 94-1). Section R9-16-101. Definitions ARTICLE 1. LICENSING OF MIDWIFERY R9-16-101. Definitions
Historical NoteSection repealed, new Section adopted effective March 14, 1994 (Supp. 94-1). R9-16-102. Qualifications for Licensure
Historical NoteSection repealed, new Section adopted effective March 14, 1994 (Supp. 94-1). Amended by final rulemaking at 8 A.A.R. 2896, effective June 18, 2002 (Supp. 02-2). Exhibit A. Repealed Historical NoteSection repealed, new Section adopted effective March 14, 1994 (Supp. 94-1). Exhibit A repealed by final rulemaking at 8 A.A.R. 2896, effective June 18, 2002 (Supp. 02-2). R9-16-103. Application for Licensure
Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). EXHIBIT B. MIDWIFE LICENSE APPLICATION FORM Office Use Only
I. Core Subjects: Grade: Study Completed at: Anatomy & Physiology _________ __________________________________________ Embryology/Genetics _________ __________________________________________ Pharmacology _________ __________________________________________ Psychology _________ __________________________________________ Nutrition _________ __________________________________________
II. Practical Experience Grade: General Experience Grade: Prenatal visits (60) _________ Overall Care _________ Observe birth (10) _________ Recognition & Intervention _________ L & D Management (25) _________ of norm., abnormal & emerg. Newborn Exams (25) _________ Universal Precautions _________ Postpartum Exam (25) _________ Technique of obtaining spec. _________ Childbirth Prep class _________ Techniques of record manage. _________ Physical Assessment Adult & NB _________
(Refer to attached detail)
III. American Heart Association CPR Certification Exp. Date CPR Adult & Infant (Certified copy of card enclosed) _________
IV. Letters of Recommendation Three letters of recommendation must be mailed directly to the Program Manager from the following individuals: your preceptor, a physician or certified nurse midwife, and a client.
Have you ever been convicted of a felony? Yes No Have you ever been convicted of a misdemeanor? Yes No Explanation:_____________________________________________________________________________________ _______________________________________________________________________________________________
By signing this application, I certify under penalty of law that the information provided anywhere in this application is true, correct, and complete to the best of my knowledge and belief. I also acknowledge that, should investigation at any time disclose any misrepresentation or falsification, my license will be revoked, denied, or suspended. I also authorize the Department to make all necessary and appropriate investigations allowable by law to verify the information provided: ________________________________________________________________________________________________ Social Security # ____________________________
DIVISION OF FAMILY HEALTH SERVICES APPLICATION PART II VALIDATION OF MIDWIFERY APPRENTICESHIP
Office Use Only
Preceptor Name & Title:____________________________________________________________________________ Address:______________________________________________________ Home Phone:_______________________________________ Work Address:_________________________________________________ Work Phone:_______________________________________
(Enclose a copy of your current license and circle the expiration date.)
By signing this application, I certify under penalty of law that the information provided anywhere in this application is true, correct, and complete to the best of my knowledge and belief. I also acknowledge that, should investigation at any time disclose any misrepresentation or falsification, my license will be revoked, denied, or suspended. I also authorize the Department to make all necessary and appropriate investigations allowable by law to verify the information provided: ______________________________________________________________________________
_______________________________________________________________________________ Historical NoteAdopted effective March 14, 1994 (Supp. 94-1).
EXHIBIT C. PRECEPTOR RATING GUIDE The following assessment form is provided to act as a guide for the preceptor and student. This guide will act as a standard to measure student strengths and opportunities for improvement. 1. Excellent: Demonstrates consistently high level of performance using sound scientific principles for practice, able to motivate patient and family in practice, uses consultation, requires minimal supervision. 2. Above Average: Generally performs with competence but requires periodic supervision, uses consultation appropriately, applies sound scientific principles to practice, protects patient's safety and dignity. 3. Average: Performs procedures adequately but needs supervision, can answer questions relative to underlying scientific principles, practice more self-centered than client-centered. 4. Below Average: Needs considerable supervision, can perform skills if has them demonstrated or reinforced; knows most of the principles underlying procedures but needs help in making application in the situation. 5. Unacceptable: Cannot perform skill with even minimal competence, does not know or understand principles underlying the procedures to be performed, practices inappropriately so as to threaten patient's safety, dignity, or comfort. Unable to judge. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-104. Qualifying Examination A. An applicant for midwifery licensure shall take a three-part examination administered sequentially and biannually by the Department and consisting of the following: 1. A written examination designed to test the applicant's knowledge of the theory of pregnancy, childbirth, and the core subjects; 2. An oral examination designed to test clinical judgment in the practice of licensed midwifery; and 3. A practical examination designed to demonstrate the applicant's mastery of skills necessary for the practice of midwifery. B. All applicants registered for the examination shall provide proof of identity by a photographic identification upon request of the proctor administering the test. The proctor shall take all necessary and appropriate actions to secure the integrity of the examination process and may change an applicant's seating location or, for good cause, exclude an applicant from the examination. C. An applicant shall score 80% or more correct in an examination part before being permitted to take the next part of the examination. D. An applicant shall score 80% correct on all parts of the examination to be eligible for licensure. E. An applicant who fails the examination shall not be required to retake those parts of the examination for which the applicant scored 80% or more correct if the applicant retests within two years of taking the examination. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-105. Initial License Fee; Renewal; Continuing Education A. An applicant who qualifies for initial licensure shall submit a $25 licensing fee. B. For purposes of renewal of license, each licensee shall, in accordance with A.R.S. ｧ 36-754(C), file the following with the Department: 1. An application for renewal on the form set forth in Exhibit D. 2. A $25 renewal fee. 3. A signed affidavit as evidence of completion of the continuing education requirement, pursuant to subsection (C), for courses which have been approved by either the American Nurses Association, the American College of Obstetrics and Gynecologists, Midwives Alliance of North America, Arizona Medical Association, or the American College of Nurse Midwives. 4. Evidence of current certification by the American Heart Association in cardiopulmonary resuscitation for the adult and by the American Academy of Pediatrics in newborn resuscitation. C. During the term of a license, a licensed midwife shall obtain 10 continuing education units which are related to maintaining the skills and judgment necessary to: 1. Assess a client for acceptance and monitor the client's ongoing condition; 2. Plan and manage care during the normal prenatal, intrapartum, and postpartum periods; 3. Intervene when the client's condition deviates from normal. 4. Provide emergency assistance, as permitted by these rules, until medical care can be obtained; 5. Offer anticipatory guidance and support on an ongoing basis for the client and family including nutritional counseling, substance abuse cessation, encouragement for early and continuous care for mother and infant, and motivate the client to establish a relationship with a primary care provider; and 6. Provide referral services to medical and community services as appropriate for the client's needs. D. A midwife shall submit a written request and a fee of $10.00 to receive a duplicate license. Historical NoteAdopted effective March 14, 1994, except for subsections (B)(3) and (C) which are effective September 15, 1994 (Supp. 94-1).
EXHIBIT D. RENEWAL APPLICATION FORM
1.NAME:_______________________________________________ (Last First Middle) 2. MIDWIFE LICENSE NUMBER:_________________________ 3. SOCIAL SECURITY NUMBER:___________________________ 4. DATE OF BIRTH:____________________________________ (day/month/year) 5. HOME ADDRESS: ___________________________________________
(_____)___________________ _____________________________________________________________________ _____________________________________________________________________
6. BUSINESS ADDRESS: __________________________________________________________________ Business Title ________________________________________
(_____)_____________________ _____________________________________________________________________ _____________________________________________________________________
7. CONSUMER LISTING: A listing of the licensed midwives is maintained for ADHS use. Consumers and various groups request copies of the listing of licensed midwives. Do you wish to have your name on this list? Yes _____ No ______ If yes, which name, address, and phone number would you like to have on that list?
_______________________________________________________________________________ __________________________________________________(_____)________________________ _________________________________________________________________________________
8. ATTENDING DELIVERIES: 1) If you do not plan to attend any births during the next licensure period (July 1 to June 30), please complete the following statement. I do not plan to attend any deliveries as a licensed midwife from July 1, ____ to June 30, ____.
Signature:_________________________________________________________________
2) If you do attend births after signing this statement, you must submit quarterly reports.
9. MIDWIFERY PRACTICE:
1) Have you had any maternal deaths during the past licensure period? Yes ____ No ____. If yes, give client name and number. ________________________________________________________________________________________________
2) Have you delivered any stillborn infants during the past licensure period? Yes ____ No ____. If yes, give client name and number. _______________________________________________________________________________________________
3) Have any of the infants you delivered died within the first 28 days of life? Yes____ No ____. If yes, give client name and number. ________________________________________________________________________________________________ 10. Do you have any communicable diseases (i.e., tuberculosis, rubella, hepatitis, etc.)? Yes ____ No ____. If yes, please explain on a separate sheet of paper.
11. Besides your midwifery license, do you hold any other licenses in Arizona as a health care provider (i.e., R.N., E.M.T., N.D., etc.)? Yes ____ No ____. If yes, what other licenses do you hold?______________________________________________
12. Have you been convicted of a felony or a misdemeanor (besides a traffic ticket) during the past licensure period? Yes ____ No ____. If yes, please explain on a separate sheet of paper.
13. What are the backup facilities you expect to use? Name Address 1) Hospitals:___________________________________________________________________________________ ______________________________________________________________________________________________
2) Physicians:__________________________________________________________________________________ ______________________________________________________________________________________________
3) Other:_______________________________________________________________________________________ _______________________________________________________________________________________________
I certify that the above information is true, complete, and correct. Signature: ________________________________________ Date of Application _____________________________________
Attach affidavit of continuing education.
*************************************************************************************************************** DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY Date Renewal Notice Sent ______________________________ Date Renewal Form Returned _____________________________
Application returned on __________________________________ for ______________________________________
Date completed application received ______________________ License Renewal Granted: Yes ______ No _______ Other _______
Effective Date of License ______________________________ Application Reviewed by _________________________________
OASpgh:PPMWLIC.w93 7/20 10/89 MIDWIFE LICENSING PROGRAM
A.A.C. R9-16-105(C) requires a licensed midwife to obtain 10 continuing education units (CEUs) during the term of a license. A CEU is defined by the approving agency.
Units are acceptable for continuing education when approved by 1 of the following: American Nurses Association American College of Obstetrics and Gynecologists American Medical Association Midwives Alliance of North America American College of Nurse Midwives
COMPLETE THE FOLLOWING: NAME: ADDRESS: CITY/STATE/ZIP _______________________________________________________________________________ TITLE SPONSOR/AGENCY DATE CITY/STATE CEUs/HOURS ________________________________________________________________________________________________
I hereby swear or affirm that the information given on this form is accurate and complete, and that I have maintained records as evidence of compliance. ________________________________________________________________________________________________
Subscribed and sworn to before me this ________ day of ______________, 20___. ___________________________________________________________________ My commission expires: _______________________________________________
Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-105.01. Time-frames A. The overall time-frame described in A.R.S. ｧ 41-1072(2) for each type of approval granted by the Department is specified in Table 1. The applicant and the Department may agree in writing to extend the substantive review time-frame and the overall time-frame. The substantive review time-frame and the overall time-frame may not be extended by more than 25 percent of the overall time-frame. B. The administrative completeness review time-frame described in A.R.S. ｧ 41-1072(1) for each type of approval granted by the Department is specified in Table 1. 1. The administrative completeness review time-frame begins: a. For an applicant submitting the application in R9-16-103, when the Department receives the application packet required in R9-16-103; b. For an applicant who is requesting approval to take the oral part of the midwifery examination, when the applicant completes taking the written part of the midwifery examination; c. For an applicant for licensure, when the applicant completes taking the practical part of the midwifery examination; and d. For a licensed midwife applying to renew a midwifery license, when the Department receives the application required in R9-16-105. 2. If an application submitted under R9-16-103 is: a. Incomplete, the Department shall provide a deficiency notice to the applicant describing the missing documentation or incomplete information. The administrative completeness review time-frame and the overall time-frame are suspended from the date of the notice until the date the Department receives the documentation or information listed in the deficiency notice. An applicant shall submit to the Department the documentation or information listed in the deficiency notice within the time specified in Table 1 for responding to a deficiency notice. i. If the applicant submits the documentation or information listed in the deficiency notice within the time specified in Table 1, the Department shall provide a written notice of administrative completeness to the applicant. ii. If the applicant does not submit the documentation or information listed in the deficiency notice within the time specified in Table 1, the Department considers the application withdrawn and shall return the application packet to the applicant; or b. Complete, the Department shall provide a notice of administrative completeness to the applicant. 3. If an applicant takes and submits a part of the midwifery examination in R9-16-104 and the examination part is: a. Incomplete, the Department shall provide a deficiency notice to the applicant stating that the applicant's examination part is incomplete and identifying the date of the next scheduled examination. The administrative completeness review time-frame and the overall time-frame are suspended from the date of the notice until the Department receives a completed part of the midwifery examination; or b. Complete, the Department shall provide a written notice of administrative completeness to the applicant. C. The substantive review time-frame described in A.R.S. ｧ 41-1072(3) is specified in Table 1 and begins to run on the date of the notice of administrative completeness. 1. If an application submitted under R9-16-103 or R9-16-105: a. Does not comply with the requirements in this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall provide a written request for additional information to the applicant. i. If the applicant does not submit the additional information within the time specified in Table 1 or the additional information submitted by the applicant does not demonstrate compliance with this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall provide the applicant a written notice of denial that complies with A.R.S. ｧ 41-1092.03(A); or ii. If the applicant submits the additional information within the time specified in Table 1 and the additional information submitted by the applicant demonstrates compliance with this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall provide a written notice of approval to take the examination to the applicant; or b. Complies with the requirements in this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall provide a written notice of approval to take the examination to the applicant. 2. If the Department determines that an applicant: a. Failed to take any part of the midwifery examination within the time specified in subsection (F), the Department shall provide a written notice to the applicant requiring the applicant to submit a new application in R9-16-403; b. Failed any part of the midwifery examination, the Department shall provide a written notice of appealable agency action that complies with A.R.S. Title 41, Chapter 6, Article 10 to the applicant; or c. Passed all parts of the midwifery examination, the Department shall issue a midwifery license to the applicant. 3. If an application for renewal of a midwifery license in R9-16-105: a. Does not comply with the requirements in this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall provide a comprehensive request for additional information to the applicant; i. If the applicant does not submit the additional information within the time specified in Table 1 or the additional information submitted does not demonstrate compliance with the requirements in this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall provide a written notice of appealable agency action that complies with A.R.S. Title 41, Chapter 6, Article 10 to the applicant; or ii. If the applicant submits the additional information within the time specified in Table 1 and the additional information demonstrates compliance with the requirements in this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall issue a midwifery renewal license to the applicant; or b. Complies with the requirements in this Article and A.R.S. Title 36, Chapter 6, Article 7, the Department shall issue a midwifery renewal license to the applicant. D. If an applicant receives a written notice of appealable agency action under subsection (C)(2)(b) or (C)(3)(a)(i), the applicant may file a notice of appeal with the Department within 30 days after receiving the notice of appealable agency action. The appeal shall be conducted according to A.R.S. Title 41, Chapter 6, Article 10. E. If the Department grants approval of an application or approval to take a part of the midwifery examination or renews a midwifery license during the administrative completeness review time-frame, the Department shall not issue a separate written notice of administrative completeness. F. If an applicant does not take a part of the midwifery examination within 12 months of the Department's approval to take the midwifery examination, the applicant shall, before taking any part of the midwifery examination: 1. Submit a new application for Department approval and the application fee required in R9-16-103; 2. Receive Department approval to take the midwifery examination; and 3. Submit the nonrefundable examination fee required in R9-16-104. G. If a time-frame's last day falls on a Saturday, Sunday, or a legal holiday, the Department considers the next business day as the time-frame's last day. Table 1. Time-frames
Historical NoteNew Section made by final rulemaking at 8 A.A.R. 2896, effective June 18, 2002 (Supp. 02-2).
R9-16-106. Responsibilities of the Licensed Midwife A. A midwife shall provide care only to clients determined to be low risk. B. A midwife shall maintain all instruments used for delivery in an aseptic manner and other birthing equipment and supplies in clean and good condition. C. A midwife shall both initially and periodically thereafter assess a client's physical condition in order to establish the client's continuing eligibility to receive midwifery services. D. A midwife shall inform clients, both orally and in writing, of the midwife's scope of practice; the risks and benefits of home birth; the required tests and potential risks to a newborn if refused, and the need for written documentation of client's refusal; the use of a physician or medical facility for the provision of emergency consultation or services; midwife facilitation of the transfer of care to the physician or medical facility; and the midwife's termination of care should certain medical conditions arise or the client refuses intervention. A written informed consent shall be signed by the client upon acceptance for midwifery care. E. Initial care and care during the prenatal period shall be provided as follows: 1. The following tests shall be scheduled or ordered during the 1st visit: a. Blood type, including ABO and Rh, with antibody screen; b. Urinalysis; c. Hematocrit, hemoglobin, or complete blood count, initially and rechecked at 28 to 36 weeks of the pregnancy; d. Syphilis, gonorrhea, and chlamydia testing, unless a written refusal for gonorrhea or chlamydia testing is obtained from the client; e. Rubella titer; and f. One-hour blood glucose screening test for diabetes, between 24 to 28 weeks of the pregnancy. 2. Prenatal visits shall be conducted at least every 4 weeks until 28 weeks gestation, every 2 weeks from 28 weeks until 36 weeks gestation, and weekly thereafter, and each shall include; a. The taking of 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. Referral of a client as appropriate for ultrasound or other studies recommended based upon examination or history; d. 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 physician's written orders; and e. Fetal movement counts by client beginning at 28 weeks gestation. 3. Fetal heart tones with fetoscope and documentation of 1st quickening shall begin between 18 and 20 weeks gestation and weekly visits shall be conducted until these signs have occurred. If these signs do not occur by 22 weeks gestation, medical consultation shall be initiated. 4. A visit shall be made to the client's home prior to 35 weeks gestation to ensure that the birthing environment is appropriate for birth and that a working telephone or citizen's band radio is available. F. Care during the intrapartum period shall be provided as follows: 1. The midwife shall initially 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, ruptured, and the amount and color of fluid; c. Evaluating the presence of bloody show; d. Reviewing with the client the need for an adequate fluid intake, relaxation, activity, and emergency management; and e. Deciding whether to go to client's home, remain in telephone contact, or arrange for transfer of care or consultation. 2. During labor, the condition of the mother and fetus shall be assessed upon initial contact, every half hour in active labor until completely dilated, and every 15 to 20 minutes during pushing, after the bag of water has ruptured or until the newborn is delivered. Care shall include the following: a. Checking of vital signs every 2 to 4 hours and an initial physical assessment of the mother; b. Assessment of fetal heart tones every 30 minutes in active 1st stage labor, and every 15 minutes during 2nd stage, following rupture of the amniotic bag or with any significant change in labor patterns; c. Periodic assessment of contractions, fetal presentation, dilation, effacement, and position by vaginal examination; d. Determination of the progress of active labor for primiparas by determining if dilation occurs at an average of 1 cm/hr until completely dilated, and a 2nd stage not to exceed 2 hours; e. Determination of a normal progress of active labor for multigravidas by determining if dilation occurs at an average of 1.5 to 2 cm/hr until completely dilated, and a 2nd stage not to exceed 1 hour; f. Maintenance of proper fluid balance for the mother throughout labor as determined by urinary output and monitoring urine for presence of ketones, at least every 2 hours; and g. Assisting in support and comfort measures to the mother and family. 3. After delivery of the newborn, care shall include the following: a. Assessment of the newborn at 1 minute and 5 minutes to determine the Apgar scores; b. Physical assessment of the newborn for any abnormalities; c. Inspection of the mother's perineum for lacerations; and d. Delivery of the placenta within 40 minutes during which time the midwife shall assess for signs of separation, frank or occult bleeding, examine for intactness, and determine the number of umbilical cord vessels. 4. The responsibility of the midwife shall include recognition of and response to any situation requiring immediate intervention. G. A midwife shall provide the following care during the postpartum period: 1. During the immediate postpartum period of 2 hours after delivery of the placenta, care of the mother shall include: a. Taking of vital signs of the mother with external massage of the uterus and evaluation of bleeding every 15 to 20 minutes for the 1st hour and every half hour for the 2nd hour; b. Assisting the mother to urinate within 2 hours following the birth; c. Evaluating the perineum for tears, bleeding, or blood clots; d. Assisting with maternal and infant bonding; e. Assisting with initial breast feeding, instructing the mother in the care of the breast, and reviewing potential danger signs, if appropriate; f. Providing instruction and support to the family to ensure adequate fluid and nutritional intake, rest, and type of exercise allowed, normal and abnormal bleeding, bladder and bowel function, appropriate baby care, and any danger signals with appropriate emergency phone numbers; g. Recommending the drug RhoGam or administering it, under written physician's orders, to an unsensitized Rh-negative mother who delivers an Rh-positive newborn. Administration shall occur not later than 72 hours after birth. 2. During the immediate postpartum period of 2 hours after delivery of the placenta, care of the newborn shall include: a. Perform a newborn physical exam to determine the newborn's gestational age and any abnormalities; b. Apply erythromycin optic ointment or other preparation specifically approved by the Director to each of the newborn's eyes in accordance with A.A.C. R9-6-718; and c. Recommend or administer Vitamin K under physician's written orders to the newborn. Administration shall occur not later than 72 hours after birth. 3. Any abnormal or emergency situation shall be evaluated and consultation or intervention sought in accordance with these rules. 4. The condition of the mother and newborn shall be re-evaluated between 24 and 72 hours of delivery to determine whether the recovery is following a normal course and shall include: a. Assessment of baseline indicators such as the mother's vital signs, bowel and bladder function, bleeding, breasts, feeding of the newborn, sleep/rest cycle, activity with any recommendations for change; b. Assessment of baseline indicators of well-being in the newborn such as vital signs, weight, cry, suck and feeding, fontanel, sleeping, bowel and bladder function with documentation of meconium, and any recommendations for changes made to the family; c. Submission of blood obtained from a heel stick to the newborn to the Regional Genetic Screening Laboratory, P.O. Box 17123, Denver, Colorado 80217, for metabolic screening for common genetic disorders, within 72 hours of the birth, unless a written refusal is obtained from the client and documented in the newborn's record. d. Recommendation to the mother to secure medical follow-up for her newborn; and e. Advice on the necessity of family planning interventions for the couple. H. The midwife shall file a birth certificate with the local registrar within 7 days after the birth of the newborn. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-107. Recordkeeping and Report Requirements A. Each midwife shall establish and maintain a record of the care provided and data gathered for each client. B. Information in the client's record shall be released by the midwife only with the written consent of the client, legal guardian, or as otherwise provided by law. C. If a client is a minor, informed consent shall be signed by the parent or legal guardian except as provided in A.R.S. ｧ 44-132 and shall be filed in the client's record. D. A midwife shall make records available to other health care providers engaged in the care and treatment of the client and upon request by the Department for periodic quality review. E. A midwife shall maintain evidence of medical evaluation and physician visits in the client's record. Such evidence shall consist of either a report signed by the physician, a copy of the medical and physician notes, or other documentation received from the physician or medical provider. F. A midwife shall enter a date for each entry in the prenatal record and the postpartum record. A date and time shall be recorded for each entry in the labor record. Each entry shall be initialed or signed by the midwife. If initials are used, the midwife shall sign on the same page. G. Each licensed midwife shall submit a client summary report for each client to the Department. Such reports shall be submitted within 15 days after the close of each quarter on the form set forth as Exhibit E. H. Each client's record shall contain the following information, as applicable: 1. Client identification sheet, including name, address, date of birth, sex, next of kin, spouse or other designated person, directions to the client's home, telephone number, and marital status; 2. Health history sheet including pre-existing conditions or surgeries, previous pregnancies, physical examination, nutritional status, and a written assessment of risk factors with an intervention plan when risk factors that require termination of the agreement are present; 3. Progress notes of all encounters with the midwife and other health care consultants, in chronological order, documenting any actions, guidance, and consultations, with copies if appropriate; 4. Laboratory and diagnostic reports; 5. Written informed consent which is signed by the client. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1).
EXHIBIT E. INDIVIDUAL QUARTERLY REPORT
_________________________________________
1. |__|__|__|__| 2. |__| |__|__|
_________________________________________
3.
PATIENT:______________________________________________
4. D.O.B. |__|__| |__|__| |__|__| 5. |__|__| 6.
|__|__|__|
7. REGISTERED: 8. E.D.C. 9. DELIVERED: 10. GRAVIDA: |__|__| 11. PARA. TERM: |__|__| PREMATURE: |__|__| ABORTIONS: |__|__| LIVING |__|__| *12. PREV. HOME BIRTH: YES/NO *13. REASON FOR CHOOSING H.B.:_______________________________________________
ANTEPARTUM: 14. NO. MIDWIFE VISITS:____________________ 15. NO. MEDICAL VISITS:_________________________ 16. MEDICAL VISITS BY:__________________________________ MD/DO/OTHER:___________________________________________ 17. DATES OF FIRST AND LAST MEDICAL VISITS:_________________________________________________________________ 18. TOTAL WEIGHT GAIN: |__|__| LBS.
FORMAL ARRANGEMENT FOR MEDICAL BACK-UP: 19. PHYSICIAN:_____________________________________, MD/DO 20. HOSPITAL:___________________________________
21. MIDWIFE CARE TERMINATED AT |__|__| WKS. GEST. 22.
REASON:_____________________________________ LABORATORY DATA: (MOST RECENT)
LABOR/DELIVERY: LOCATION OF: 53. LABOR___________________________ 54. DELIVERY_________________________ 55. FIRST STAGE |__|__| |__|__| 56. SECOND STAGE |__|__| |__|__| 57. THIRD STAGE |__|__| |__|__| HRS. MINS. HRS. MINS. HRS. MINS. 58. ROM TO DEL: |__|__| |__|__| 59. E.B.L. |__|__|__|__| ml. HRS. MINS.
NEWBORN: 60. SEX: MALE/FEMALE 61. WT. |__|__|__|__| gm. 62. LENGTH |__|__| cm. 63. H.C. |__|__| cm. 64. EST. GEST. AGE |__|__| WKS. 65. SGA / AGA / LGA APGAR SCORE: 66. 1 MIN.________ 67. 5 MINS.________ 68. NO. CORD VESSELS |__| 69. EYE PROPHYLAXIS: NO/YES:_______ 70. DATE OF METABOLIC SCREENING |__|__| |__|__| |__|__| (AGENT) MO. DAY YR. FOLLOWUP: 71. RhoGam: YES/NO 72. FIRST MIDWIFE VISIT AT: 24 HRS./24-48 HRS./48-72 HRS./Other:__________________________________ 73. TOTAL NO. VISITS:____________________ 74. VISITS BY__________________________________L.M./S.M./OTHER ROUTINE PHYSICIAN EVALUATION 75. MOTHER: YES/NO 76. BABY: YES/NO LIMITATIONS/COMPLICATIONS/CONSULTATIONS/TRANSFER: (FROM INITIAL WORK-UP THROUGH FOLLOW-UP) 77. _____NONE ______YES: (Detail on back)
*OPTIONAL ORIGINAL TO ADHS Check any of the following conditions/limitations/complications encountered. Complete a CONSULTATION/TRANSPORT SUMMARY if client or newborn required transport and/or transfer to physician care, or if you have additional information/comments to provide.
EXHIBIT E. INDIVIDUAL QUARTERLY REPORT
(continued) __________________________________________
1. /__/__/__/__/ 2. /__/ /__/__/
___________________________ 3. /__/__/__/
NARRATIVE SUMMARY: ______________________________________________________________________________________ ________________________________________________________________________________________________
DETAILS ON TRANSFER/TRANSPORT AND OUTCOME: 4. REFERENCE NO.______________________________________ PROBLEM_______________________________________
CALL FOR TRANSPORT: 5. DATE /__/__/ /__/__/ /__/__/ 6. TIME /__/__/__/__/ MO. DAY YEAR (MILITARY TIME)
8. AMBULANCE 7. PARAMEDICS
TRANSFER: 9. TIME /__/__/__/__/
AMBULANCE PRIVATE AUTO 10. VEHICLE: OTHER:________________________________________
PHYSICIAN'S OFFICE 11. DESTINATION: OTHER:_________________________________HOSPITAL
12. NAME OF HOSPITAL IF APPLICABLE:_______________________________________________________________
ARRIVAL DISPOSITION: 13. DATE /__/__/ /__/__/ /__/__/ 14. /__/__/__/__/ MO. DAY YEAR (MILITARY TIME)
EVAL/Rx AT PHYS. OFFICE 15. MOTHER: ADMITTED HOSPITAL EVAL/Rx AS OUTPATIENT AT HOSPITAL AND RELEASED
16. NEWBORN: EVAL/Rx AT PHYS. OFFICE ADMITTED TO HOSPITAL EVAL/Rx AS OUTPATIENT AT HOSPITAL AND RELEASED TRANSFERRED TO NICU AT______________________________________________________________________
NORMAL 17. MATERNAL OUTCOME: EXPIREDABNORMAL
NORMAL 18. NEWBORN OUTCOME: EXPIREDABNORMAL Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). Amended to correct printing errors (Supp. 99-4). R9-16-108. Prohibited Practice; Transfer of Care A. A licensed midwife shall not accept for care and shall not during pregnancy, labor and delivery, and postpartum knowingly continue to provide care to, and shall immediately transfer care of, any women who has or develops any of the following conditions or circumstances: 1. A previous Cesarean section or other known uterine surgery; 2. A history of severe postpartum bleeding, of unknown cause, which required transfusion; 3. Deep vein thrombophlebitis or pulmonary embolism; 4. Insulin-dependent diabetes, hypertension, heart disease, kidney disease, blood disease, Rh disease with positive titers, active tuberculosis, or active syphilis; 5. Active hepatitis or active gonorrhea until treated and recovered, following which midwife care may resume; 6. An unsafe location for delivery; 7. A blood pressure of 140/90 or an increase of 30mm Hg systolic or 15mm Hg diastolic over client's lowest baseline blood pressure for 2 consecutive readings taken at least 6 hours apart; 8. A persistent hemoglobin level blow 10g or a hematocrit below 30 during the 3rd trimester; 9. Primary genital herpes simplex infection in the 1st trimester or has active genital herpes at the onset of labor; 10. A pelvis that will not safety allow a baby to pass through during labor; 11. A severe psychiatric illness evident during assessment of client's preparation for birth, or a history of severe psychiatric illness in the 6-month period prior to pregnancy; 12. An addiction to alcohol, narcotics, or other drugs; 13. Prematurity or labor beginning before 36 weeks gestation; 14. Multiple gestation in the current pregnancy; 15. Gestational age greater than 34 weeks with no prior prenatal care; 16. A gestation beyond 42 weeks; 17. Presence of ruptured membranes without onset of labor within 24 hours; 18. Abnormal fetal heart rate of below 120 beats per minute or above 160 beats per minute; 19. Presence of thick meconium, blood-stained amniotic fluid, or abnormal fetal heart tones; 20. A postpartum hemorrhage of greater than 500cc in the current pregnancy; 21. A nonbleeding placenta retained more than 40 minutes; and 22. Expressed wishes of the client or family. B. A midwife shall not perform any operative procedures except as provided in R9-16-110. C. A midwife shall not use any artificial, forcible, or mechanical means to assist birth, nor shall the midwife attempt to correct fetal presentations by external or internal movement of the fetus. D. A midwife shall not administer drugs or medications except as provided in R9-16-110 and R9-16-106(E)(2)(d), (G)(1)(g), and (G)(2)(c). E. A midwife shall not knowingly continue and shall transfer care of any newborn in whom any of the following conditions are present: 1. Birth weight less than 2000 grams; 2. Pale, blue, or gray color after 10 minutes; 3. Excessive edema; 4. Major congenital anomalies; or 5. Respiratory distress. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-109. Required Consultation A. The midwife shall obtain medical consultation to obtain a recommendation for treatment, referral, or transfer of care at the time any client is determined to have any of the following circumstances or conditions during the current pregnancy: 1. Testing positive for HIV; 2. History of seizure disorder; 3. History of stillbirth, premature labor, or parity greater than 5; 4. Is younger than 16 years of age or a primigravida older than 40 years of age; 5. Failure to auscultate fetal heart tones by 22 weeks gestational age; 6. Refusal of Rh blood work or treatment; 7. Failure to gain 12 pounds by 30 weeks gestation or gaining more than 8 pounds in any 2-week period during pregnancy; 8. Severe, persistent headaches, with visual disturbances, stomach pains, or swelling of the face and hands; 9. Greater than 1+ sugar, ketones, or protein in the urine on 2 consecutive visits; 10. Excessive vomiting or continued vomiting after 20 weeks gestation; 11. Symptoms of decreased fetal movement; 12. A fever of 100.45 Fahrenheit or 385 Centigrade twice at 24 hours apart; 13. Effacement or dilation of the cervix, greater than a fingertip, accompanied by contractions, prior to 36 weeks gestation; 14. Measurements for fetal growth are not within 2cm of the gestational age; 15. Second degree or greater lacerations of the birth canal; 16. An abnormal progression of labor; 17. An unengaged head at 7 centimeters dilation in active labor; 18. An abnormal presentation after 36 weeks; 19. Failure of the uterus to return to normal size in the current postpartum period; or 20. Persistent shortness of breath requiring more than 24 breaths per minute, or breathing which is difficult or painful. B. A midwife shall obtain medical consultation to obtain a recommendation for treatment, referral, or transfer of care at the time any newborn demonstrates any of the following conditions: 1. Weight less than 2500 grams or 5 lbs., 8 oz.; 2. Congenital anomalies; 3. An Apgar score less than 7 at 5 minutes; 4. Persistent breathing at a rate of more than 60 breaths per minute; 5. An irregular heartbeat; 6. Persistent poor muscle tone; 7. Less than 36 weeks gestation or greater than 42 weeks gestation by gestational exam; 8. Yellowish-colored skin within 48 hours; 9. Abnormal crying; 10. Meconium staining of the skin; 11. Lethargy, irritability, or poor feeding; 12. Excessively pink coloring over entire body; 13. Failure to urinate or pass meconium in the 1st 24 hours of life; 14. A hip examination which results in a clicking or incorrect angle; 15. Skin rashes not commonly seen in the newborn; or 16. Temperature persistently above 99.05 or below 97.65 F. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-110. Emergency Measures A. A licensed midwife shall, before the arrival of emergency medical personnel, perform the following procedures only in an emergency situation in which the health and safety of the mother or newborn are determined to be at sufficient risk: 1. Cardiopulmonary resuscitation of the mother or newborn with a bag and mask; 2. Administration of oxygen at no more than 8 liters per minute via mask for the mother and 5 liters per minute for the newborn via neonatal mask; 3. Midline episiotomy to expedite the delivery during fetal distress; 4. Suturing of episiotomy or tearing of the perineum, to stop active bleeding, following administration of local anesthetic, contingent upon physician consultation or standing orders of physician; 5. Release of shoulder dystocia by rotating the shoulders into 1 of the oblique diameters of the pelvis; and 6. Manual exploration of the uterus for control of severe bleeding. B. A licensed midwife may administer a maximum does of 20 units of pitocin intramuscularly, in 10-unit dosages each, 30 minutes apart, to a client for the control of postpartum hemorrhage, contingent upon physician consultation or standing orders by a physician, and arrangements for immediate transport of the client to a hospital. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-111. Denial, Suspension, or Revocation of License; Civil Penalties; Procedures A. In addition to those grounds set forth in A.R.S. ｧｧ 36-756 and 13-904(E), the Department may deny, suspend, or revoke a license permanently or for a definite period of time and may assess a civil penalty of $50 for the 1st offense and $100 for each subsequent offense, for any of the following causes: 1. Failure to maintain the standards of practice and clinical judgment; 2. Practicing under a false name or alias which will interfere with or obstruct the investigative or regulatory process; 3. Practicing under the influence of drugs or alcohol; 4. Falsification of records; 5. Obtaining any fee for midwifery services by fraud or misrepresentation; 6. Permitting another to use the midwife's license; and 7. Failure to submit quarterly reports within 15 days after the close of the quarter. B. All administrative proceedings shall be conducted in accordance with the Department's rules of practice and procedure, 9 A.A.C. 1, Article 1. Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). R9-16-112. Expired Historical NoteAdopted effective March 14, 1994 (Supp. 94-1). Section expired under A.R.S. ｧ 41-1056(E) at 7 A.A.R. 5029, effective September 30, 2001 (Supp. 01-4). 覧覧覧覧覧 Updated 8-28-2003
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