First Substitute S.B. 243

Senator Margaret Dayton proposes the following substitute bill:

1 DIRECT-ENTRY MIDWIFE AMENDMENTS
2 2007 GENERAL SESSION
3 STATE OF UTAH
4 Chief Sponsor: Margaret Dayton
5 House Sponsor: ____________
6
7 LONG TITLE
8 General Description:
9 This bill amends the Direct-entry Midwife Act.
10 Highlighted Provisions:
11 This bill:
12 . defines a normal birth for purposes of the practice of direct-entry midwifery; and
13 . amends the standards of practice to clarify when consultation or transfer is required.
14 Monies Appropriated in this Bill:
15 None
16 Other Special Clauses:
17 None
18 Utah Code Sections Affected:
19 AMENDS:
20 58-77-102, as enacted by Chapter 299, Laws of Utah 2005
21 58-77-601, as enacted by Chapter 299, Laws of Utah 2005
22
23 Be it enacted by the Legislature of the state of Utah:
24 Section 1. Section 58-77-102 is amended to read:
25 58-77-102. Definitions.

26 In addition to the definitions in Section 58-1-102 , as used in this chapter:
27 (1) "Board" means the Licensed Direct-entry Midwife Board created in Section
28 58-77-201 .
29 (2) "Certified nurse-midwife" means a person licensed under Title 58, Chapter 44a,
30 Nurse Midwife Practice Act.
31 (3) "Client" means a woman under the care of a Direct-entry midwife and her fetus or
32 newborn.
33 (4) "Direct-entry Midwife" means an individual who is engaging in the practice of
34 Direct-entry midwifery.
35 (5) "Licensed Direct-entry midwife" means a person licensed under this chapter.
36 (6) "Physician" means an individual licensed as a physician and surgeon, osteopathic
37 physician, or naturopathic physician.
38 (7) (a) "Practice of Direct-entry midwifery" means practice of providing the necessary
39 supervision, care, and advice to a client during essentially normal pregnancy, labor, delivery,
40 postpartum, and newborn periods that is [consistent with national professional midwifery
41 standards and that is] based upon the acquisition of clinical skills necessary for the care of
42 pregnant women and newborns, including antepartum, intrapartum, postpartum, newborn, and
43 limited interconceptual care and includes:
44 [(a)] (i) obtaining an informed consent to provide services;
45 [(b)] (ii) obtaining a health history, including a physical examination;
46 [(c)] (iii) developing a plan of care for a client;
47 [(d)] (iv) evaluating the results of client care;
48 [(e)] (v) consulting and collaborating with and referring and transferring care to
49 licensed health care professionals, as is appropriate, regarding the care of a client;
50 [(f)] (vi) obtaining medications, as specified in this Subsection (7)(f), to administer to
51 clients, including:
52 [(i)] (A) prescription vitamins;
53 [(ii)] (B) Rho D immunoglobulin;
54 [(iii)] (C) sterile water;
55 [(iv)] (D) one dose of intramuscular oxytocin after the delivery of the placenta to
56 minimize blood loss;

57 [(v)] (E) one dose of intramuscular oxytocin if a hemorrhage occurs, in which case the
58 licensed Direct-entry midwife must either consult immediately with a physician licensed under
59 Title 58, Chapter 67, Utah Medical Practice Act, or Title 58, Chapter 68, Utah Osteopathic
60 Medical Practice Act, and initiate transfer, if requested, or if the client's condition does not
61 immediately improve, initiate transfer and notify the local hospital;
62 [(vi)] (F) oxygen;
63 [(vii)] (G) local anesthetics without epinephrine used in accordance with Subsection
64 (7)[(l)](a)(xii);
65 [(viii)] (H) vitamin K to prevent hemorrhagic disease of the newborn;
66 [(ix)] (I) eye prophylaxis to prevent opthalmia neonatorum as required by law; and
67 [(x)] (J) any other medication approved by a licensed health care provider with
68 authority to prescribe that medication;
69 [(g)] (vii) obtaining food, food extracts, dietary supplements, as defined by the Federal
70 Food, Drug, and Cosmetic Act, homeopathic remedies, plant substances that are not designated
71 as prescription drugs or controlled substances, and over-the-counter medications to administer
72 to clients;
73 [(h)] (viii) obtaining and using appropriate equipment and devices such as Doppler,
74 blood pressure cuff, phlebotomy supplies, instruments, and sutures;
75 [(i)] (ix) obtaining appropriate screening and testing, including laboratory tests,
76 urinalysis, and ultrasound;
77 [(j)] (x) managing the antepartum period;
78 [(k)] (xi) managing the intrapartum period including:
79 [(i)] (A) monitoring and evaluating the condition of mother and fetus;
80 [(ii)] (B) performing emergency episiotomy; and
81 [(iii)] (C) delivering in any out-of-hospital setting;
82 [(l)] (xii) managing the postpartum period including suturing of episiotomy or first and
83 second degree natural perineal and labial lacerations, including the administration of a local
84 anesthetic;
85 [(m)] (xiii) managing the newborn period including:
86 [(i)] (A) providing care for the newborn, including performing a normal newborn
87 examination; and

88 [(ii)] (B) resuscitating a newborn;
89 [(n)] (xiv) providing limited interconceptual services in order to provide continuity of
90 care including:
91 [(i)] (A) breastfeeding support and counseling;
92 [(ii)] (B) family planning, limited to natural family planning, cervical caps, and
93 diaphragms; and
94 [(iii)] (C) pap smears, where all clients with abnormal results are to be referred to an
95 appropriate licensed health care provider; and
96 [(o)] (xv) executing the orders of a licensed health care professional, only within the
97 education, knowledge, and skill of the Direct-entry midwife.
98 (b) "Practice of Direct-entry midwifery" does not include a pregnancy that involves:
99 (i) pulmonary disease, renal disease, chronic or active hepatic disease, endocrine
100 disease, neurological disease, a significant autoimmune disease, GBS disease, or
101 isoimmunization;
102 (ii) deep vein thrombosis or pulmonary embolus;
103 (iii) a significant hematological disorder or coagulopathy;
104 (iv) hypertension;
105 (v) diabetes mellitus;
106 (vi) a family history of a serious genetic disorder that may affect the current pregnancy;
107 (vii) a history of neonatal infection, cerclage or incompetent cervix, an infant below
108 2,500 grams or above 4,000 grams, a preterm birth of 36 weeks or less, postpartum hemorrhage
109 requiring transfusion, three or more consecutive miscarriages, a miscarriage after 14 weeks, or
110 a stillborn;
111 (viii) a prior myomectomy, hysterotomy, or c-section;
112 (ix) current drug addition or abuse;
113 (x) positive HIV antibody or AIDS;
114 (xi) any condition, disease, or illness that would disqualify a certified nurse midwife,
115 licensed under Chapter 44a, Nurse Midwife Practice Act, from delivering a child without
116 assistance under the protocols of two or more general acute hospitals in Utah; or
117 (xii) any other condition that may present an unreasonable risk of harm to a pregnant
118 woman or unborn child as determined by the division by administrative rule.

119 (8) "Unlawful conduct" is as defined in Sections 58-1-501 and 58-77-501 .
120 (9) "Unprofessional conduct" is as defined in Sections 58-1-501 and 58-77-502 and as
121 may be further defined by rule.
122 Section 2. Section 58-77-601 is amended to read:
123 58-77-601. Standards of practice.
124 (1) (a) Prior to providing any services, a licensed Direct-entry midwife must obtain an
125 informed consent from a client.
126 (b) The consent must include:
127 (i) the name and license number of the Direct-entry midwife;
128 (ii) the client's name, address, telephone number, and primary care provider, if the
129 client has one;
130 (iii) the fact, if true, that the licensed Direct-entry midwife is not a certified nurse
131 midwife or a physician;
132 (iv) all sections required by the North American Registry of Midwives in its informed
133 consent guidelines, including:
134 (A) a description of the licensed Direct-entry midwife's education, training, continuing
135 education, and experience in midwifery;
136 (B) a description of the licensed Direct-entry midwife's peer review process;
137 (C) the licensed Direct-entry midwife's philosophy of practice;
138 (D) a promise to provide the client, upon request, separate documents describing the
139 rules governing licensed Direct-entry midwifery practice, including a list of conditions
140 indicating the need for consultation, collaboration, referral, transfer or mandatory transfer, and
141 the licensed Direct-entry midwife's personal written practice guidelines;
142 (E) a medical back-up or transfer plan;
143 (F) a description of the services provided to the client by the licensed Direct-entry
144 midwife;
145 (G) the licensed Direct-entry midwife's current legal status;
146 (H) the availability of a grievance process; and
147 (I) client and licensed Direct-entry midwife signatures and the date of signing; and
148 (v) whether the licensed Direct-entry midwife is covered by a professional liability
149 insurance policy.

150 (2) (a) A licensed Direct-entry midwife shall appropriately recommend and facilitate
151 consultation with, collaboration with, referral to, or transfer or mandatory transfer of care to a
152 licensed health care professional when the circumstances require that action in accordance with
153 this section and standards established by division rule.
154 (b) Mandatory consultation with a licensed health care provider is required upon:
155 (i) a threatened miscarriage or miscarriage after 14 weeks;
156 (ii) vaginal bleeding after 13 weeks of gestation;
157 (iii) symptoms of malnutrition or anorexia;
158 (iv) discovery of maternal age as of the estimated day of conception of less than 16
159 years or more than 35 years;
160 (v) history of genital herpes or a current sexually transmitted disease;
161 (vi) infection requiring antibiotics;
162 (vii) hepatitis;
163 (viii) abnormal pap smear during current pregnancy;
164 (ix) significant decrease in fetal movement after 24 weeks;
165 (x) no prenatal care prior to 28 weeks;
166 (xi) thin, nonparticulate meconium; or
167 (xii) any other condition or symptom that may place the health of the pregnant woman
168 or unborn child at unreasonable risk as determined by the division by rule.
169 (c) Mandatory transfer of patient care before the onset of labor to a physician licensed
170 under Chapter 67, Utah Medical Practice Act, or Chapter 68, Utah Osteopathic Medical
171 Practice Act is required, upon evidence of:
172 (i) preeclampsia or other hypertensive disorder;
173 (ii) diabetes mellitus;
174 (iii) deep vein thrombosis or pulmonary embolus;
175 (iv) placental anomaly;
176 (v) placenta previa after 20 weeks;
177 (vi) onset of labor or membrane rupture before the completion of 37 weeks;
178 (vii) abnormal fetal heart rate, biophysical profile, or nonreactive stress test;
179 (viii) multiple gestations;
180 (ix) known or suspected group B strep;

181 (x) intrauterine growth restriction, which includes a fundal height that measures more
182 than three centimeters less than the weeks of gestation;
183 (xi) any other condition that could place the life or long-term health of the pregnant
184 woman or unborn child at risk as determined by the division by rule; or
185 (xii) suspected macrosomia, which includes a fundal height measuring more than three
186 centimeters greater than the weeks of gestation.
187 (d) Mandatory transfer of care during labor and an immediate transfer in the manner
188 specifically set forth in Subsection (4)(a), (b), or (c) is required upon evidence of:
189 (i) any condition listed in Subsection (2)(c);
190 (ii) a prolapsed cord;
191 (iii) chorioamnionitis;
192 (iv) a membrane rupture of more than 18 hours;
193 (v) maternal seizure, loss of consciousness, or shock;
194 (vi) breech or other inappropriate fetal presence;
195 (vii) an erratic fetal heart rate or other form of fetal distress;
196 (viii) any other condition that could place the life or long-term health of the pregnant
197 woman or unborn child at significant risk if not acted upon immediately as determined by the
198 division by rule; or
199 (ix) failure to deliver after three hours of pushing.
200 (e) Mandatory transfer of care after delivery and immediate transfer of the mother in
201 the manner specifically set forth in Subsection (4)(a), (b), or (c) is required upon evidence of:
202 (i) no immediate cessation of hemorrhage after a single dose of IM pitocin;
203 (ii) retained placenta or placental fragments;
204 (iii) a cervical laceration, sulcus laceration, or laceration of the third or fourth degree;
205 (iv) uterine prolapse, inversion, or rupture;
206 (v) maternal seizure, loss of consciousness, or shock;
207 (vi) postpartum preeclampsia;
208 (vii) a temperature of more than 38.5 degrees Celsius or other abnormal vital sign;
209 (viii) anaphylaxis; or
210 (ix) any other condition that could place the life or long-term health of the mother at
211 significant risk if not acted upon immediately as determined by the division by rule.

212 (f) Mandatory transfer of care after delivery and an immediate transfer of a newborn
213 child in the manner specifically set forth in Subsection (4)(a), (b), or (c) is required upon
214 evidence of:
215 (i) an Apgar of less than six at five minutes;
216 (ii) a heart rate of less than 100 beats per minute or other unstable vital sign;
217 (iii) respiratory distress;
218 (iv) prolonged apnea of more than 20 seconds;
219 (v) persistent cardiac irregularities, central cyanosis or pallor, or lethargy;
220 (vi) a temperature below 36 degrees Celsius, above 37.9 degrees Celsius, or
221 persistently unstable;
222 (vii) neonatal infection;
223 (viii) serum glucose at less than 40 mg/dl;
224 (ix) jaundice within 30 hours of birth;
225 (x) abnormal bulging, depressed fontanel, or other significant birth injury or congenital
226 abnormality;
227 (xi) seizure;
228 (xii) birth weight less than 2,500 grams;
229 (xiii) inability to suck, evidence of dehydration, or other indicator of a failure to thrive;
230 (xiv) failure to pass urine within 24 hours of birth or meconium within 48 hours of
231 birth; or
232 (xv) any other condition that could place a newborn's health at risk as determined by
233 the division by rule.
234 (3) If after a client has been informed that she has or may have a condition indicating
235 the need for medical consultation, collaboration, referral, or transfer and the client chooses to
236 decline, then the licensed Direct-entry midwife shall:
237 (a) terminate care in accordance with procedures established by division rule; or
238 (b) except when transfer of care is mandatory under Subsections (2)(c) through (f),
239 continue to provide care for the client if the client signs a waiver of medical consultation,
240 collaboration, referral, or transfer.
241 (4) If after a client has been informed that she has or may have a condition indicating
242 the need for mandatory transfer, the licensed Direct-entry midwife shall, in accordance with

243 procedures established by division rule, terminate the care or initiate transfer by:
244 (a) calling 911 and reporting the need for immediate transfer;
245 (b) immediately transporting the client by private vehicle to the receiving provider; or
246 (c) contacting the physician to whom the client will be transferred and following that
247 physician's orders.
248 (5) For the period from 2006 through 2011, a licensed Direct-entry midwife must
249 submit outcome data to the Midwives' Alliance of North America's Division of Research on the
250 form and in the manner prescribed by rule.
251 (6) This chapter does not mandate health insurance coverage for midwifery services.
252 (7) (a) If the division determines that assistance is required in establishing rules in
253 accordance with this section and Section 58-77-102 , the division shall create an advisory group
254 consisting of:
255 (i) two direct-entry midwives;
256 (ii) two physicians recommended by the Utah Medical Association; and
257 (iii) two certified nurse midwives.
258 (b) Members of the advisory board shall serve without compensation.