Ariz. Admin. Code § R9-16-108 - Responsibilities of a Midwife; Scope of Practice

A. A midwife shall provide midwifery services only to a woman:

1. Who does not have any of the conditions specified in R9-16-111(B) through (E) or another condition that may increase the risk of harm to the woman or the woman's fetus or newborn during pregnancy or labor, as determined through a physical assessment and review of the woman's medical history and past pregnancies; and

2. Whose expected outcome of pregnancy is most likely to be the delivery of a newborn, with none of the conditions requiring transfer of care as specified in R9-16-111(J)(1), 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 vaginal delivery:

1. After prior Cesarean section, or

2. Of a fetus in a complete breech or frank breech presentation.

C. Before providing services to a pregnant woman, a midwife shall:

1. Inform the pregnant woman, both orally and in writing, of:

a. The midwife's scope of practice, educational background, and credentials, as specified in R9-16-102(A)(4) and (6) as applicable;

b. If applicable to the pregnant woman's condition, the midwife's experience with:

i. Vaginal birth after prior Cesarean section delivery, 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 alternatives associated with an at-home delivery specific to the pregnant woman's condition, including the conditions described in subsection (C)(1)(b);

d. The requirement for tests specified in subsections (I) and (K)(3)(c), and the potential risks for declining a test, and, if a test is declined, the need for a written assertion of a pregnant woman'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 condition specified in R9-16-111 ; and

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

D. A midwife shall:

1. Establish an emergency care plan for a client that includes:

a. The name of the client;

b. The name of the midwife;

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

a. i. The hospital closest to the birthing location that provides obstetrical services, and

b. ii. An emergency medical services provider that provides service between the birthing location and the hospital identified in subsection (D)(1)(c)(i);

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

e. The signature of the midwife and the date signed; and

2. For a delivery identified in subsection (B), ensure that the hospital identified in subsection (D)(1)(c)(i) is within 25 miles of the birthing location.

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 emergency care plan required in subsection (D).

F. A midwife shall implement the emergency care plan by immediately calling the emergency medical services provider identified in subsection (D)(1)(c)(ii) for any condition that threatens the life of the client or the client's fetus or newborn.

G. A midwife shall maintain all instruments used for delivery in a germ-free 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 midwifery services.

I. During the prenatal period, the midwife shall:

1. Except as provided in R9-16-110, ensure that the following tests are completed by 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. Except as provided in R9-16-110, ensure that the following tests are completed by the client:

a. A blood glucose screening test for diabetes completed 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 Streptococcus 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 subsection (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. 3. Conduct a prenatal visit at least once every four weeks until the beginning of 28 weeks of gestation, once every two 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. Documentation 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. Either:

i. Recommendation of administration of Rh immunoglobulin to an unsensitized Rh negative client after 28 weeks, or any time bleeding or invasive uterine procedures are done; or

ii. Midwife administration of Rh immunoglobulin under a physician's written orders;

6. 4. Monitor fetal heart tones with a fetoscope;

5. Document the client's report of first quickening;

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

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

9. 8. 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 communication is available to the hospital and emergency medical services provider identified in subsection (D)(1)(c)(i) and (ii); and

9. Review with the client the circumstances when a transfer of care is required, as specified in R9-16-111.

J. During the intrapartum period from the onset of labor until after the delivery of the placenta, 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, including whether the membranes are intact or ruptured, and the amount and color of fluid;

c. Reviewing with the client the need for fluid intake related to subsection (J)(3)(d), relaxation, and activity; and

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

2. Contact the hospital identified in subsection (D)(1)(c)(i) 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:

a. Assess the condition of the client and fetus:

i. Upon initial contact;

ii. Every half hour during active labor until completely dilated; and

iii. Every 15 to 20 minutes during pushing, following rupture of the amniotic bag, or until the newborn is delivered;

a. b. Include in the assessments required in subsection (J)(3)(a):

i. A physical assessment and checking of the client's vital signs every two to four hours; and

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

c. Periodically Assess contractions, fetal presentation, dilation, effacement, and fetal position by vaginal examination;

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

e. Assist In support and comfort measures to the client and family;

4. For deliveries described in subsection (B), during labor determine the progression of active labor:

a. For a pregnant woman giving birth to her first newborn, by monitoring whether dilation occurs at an average of one centimeter per hour until completely dilated, and a second stage does not exceed two hours;

b. For a pregnant woman who has previously given birth to one or more newborns, by monitoring whether dilation occurs at an average of 1.5 to two centimeters per hour until completely dilated, and a second stage does not exceed one hour; or

c. According to the Management Guidelines recommended by the American Congress of Obstetricians and Gynecologists;

5. After delivery of the newborn:

a. Assess the newborn at one minute and five 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 client for signs of placental separation from the inner wall of the uterus, resulting in vaginal or internal 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 immediate intervention, including measures to be taken during an emergency, as specified in R9-16-113.

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;

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

d. Assist with maternal-newborn bonding to develop a relationship between the client and newborn;

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

f. Provide instruction to the family about:

i. Fluid and nutritional intake requirements to meet the needs of the mother and newborn;

ii. Rest and the types of exercise allowed;

iii. Normal and abnormal bleeding, bladder and bowel function;

iv. How to care for the newborn;

v. Signs and symptoms of postpartum depression; and

v. Any symptoms that may pose a threat to the health or life of the client or the client's newborn and appropriate emergency phone numbers;

g. Recommend, or administer under physician's written orders, Rh immunoglobulin to an unsensitized Rh-negative client who delivers an Rh-positive newborn so that administration occurs within 72 hours after birth; and

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

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

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

b. Comply with the requirements in A.A.C. R9-6-338 ;

c. Recommend, or administer under physician's written orders, Vitamin K to the newbornso that administration occurs within 72 hours after birth; and

d. Document the physical assessment and 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 emergency 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, and 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 providing 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 according 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 newborn's record; and

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

L. A midwife shall request the registration of the birth of a newborn according to A.A.C. R9-19-203 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.

Notes

Ariz. Admin. Code § R9-16-108

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). Amended by final expedited rulemaking at 28 A.A.R. 1119, effective 5/4/2022.