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Seventh Substitute S.B. 93

Representative Jackie Biskupski proposes the following substitute bill:


             1     
LICENSED DIRECT ENTRY MIDWIFE

             2     
AMENDMENTS

             3     
2008 GENERAL SESSION

             4     
STATE OF UTAH

             5     
Chief Sponsor: Margaret Dayton

             6     
House Sponsor: Bradley G. Last

             7     
             8      LONG TITLE
             9      General Description:
             10          This bill amends the Direct-entry Midwife Act.
             11      Highlighted Provisions:
             12          This bill:
             13          .    defines low risk birth;
             14          .    amends the definition of the practice of Direct-entry midwifery;
             15          .    requires administrative rulemaking for standards of practice related to mandatory
             16      transfers of clients;
             17          .    creates an advisory committee for the administrative rules related to licensed
             18      Direct-entry midwives; and
             19          .    repeals the advisory committee in two years.
             20      Monies Appropriated in this Bill:
             21          None
             22      Other Special Clauses:
             23          None
             24      Utah Code Sections Affected:
             25      AMENDS:


             26          58-77-102, as enacted by Laws of Utah 2005, Chapter 299
             27          58-77-201, as enacted by Laws of Utah 2005, Chapter 299
             28          58-77-601, as enacted by Laws of Utah 2005, Chapter 299
             29          63-55b-158, as last amended by Laws of Utah 2006, Chapters 46 and 291
             30      ENACTS:
             31          58-77-204, Utah Code Annotated 1953
             32     
             33      Be it enacted by the Legislature of the state of Utah:
             34          Section 1. Section 58-77-102 is amended to read:
             35           58-77-102. Definitions.
             36          In addition to the definitions in Section 58-1-102 , as used in this chapter:
             37          (1) "Board" means the Licensed Direct-entry Midwife Board created in Section
             38      58-77-201 .
             39          (2) "Certified nurse-midwife" means a person licensed under Title 58, Chapter 44a,
             40      Nurse Midwife Practice Act.
             41          (3) "Client" means a woman under the care of a Direct-entry midwife and her fetus or
             42      newborn.
             43          (4) ["Direct-entry] "Direct-entry midwife" means an individual who is engaging in the
             44      practice of Direct-entry midwifery.
             45          (5) "Licensed Direct-entry midwife" means a person licensed under this chapter.
             46          (6) "Low risk" means a labor and delivery and postpartum, newborn and
             47      interconceptual care that does not include a condition that requires a mandatory transfer under
             48      administrative rules adopted by the division.
             49          [(6)] (7) "Physician" means an individual licensed as a physician and surgeon,
             50      osteopathic physician, or naturopathic physician.
             51          [(7)] (8) "Practice of Direct-entry midwifery" means practice of providing the
             52      necessary supervision, care, and advice to a client during essentially normal pregnancy, labor,
             53      delivery, postpartum, and newborn periods that is consistent with national professional
             54      midwifery standards and that is based upon the acquisition of clinical skills necessary for the
             55      care of pregnant women and newborns, including antepartum, intrapartum, postpartum,
             56      newborn, and limited interconceptual care and includes:


             57          (a) obtaining an informed consent to provide services;
             58          (b) obtaining a health history, including a physical examination;
             59          (c) developing a plan of care for a client;
             60          (d) evaluating the results of client care;
             61          (e) consulting and collaborating with and referring and transferring care to licensed
             62      health care professionals, as is appropriate, regarding the care of a client;
             63          (f) obtaining medications, as specified in this Subsection [(7)] (8)(f) , to administer to
             64      clients, including:
             65          (i) prescription vitamins;
             66          (ii) Rho D immunoglobulin;
             67          (iii) sterile water;
             68          (iv) one dose of intramuscular oxytocin after the delivery of the placenta to minimize
             69      blood loss;
             70          [(v) one dose of intramuscular oxytocin if a hemorrhage occurs, in which case the
             71      licensed Direct-entry midwife must either consult immediately with a physician licensed under
             72      Title 58, Chapter 67, Utah Medical Practice Act, or Title 58, Chapter 68, Utah Osteopathic
             73      Medical Practice Act, and initiate transfer, if requested , or if the client's condition does not
             74      immediately improve, initiate transfer and notify the local hospital;]
             75          (v) an additional single dose of oxytocin if a hemorrhage occurs, in which case the
             76      licensed Direct-entry midwife must initiate transfer if the client's condition does not
             77      immediately improve;
             78          (vi) oxygen;
             79          (vii) local anesthetics without epinephrine used in accordance with Subsection [(7)]
             80      (8)(l);
             81          (viii) vitamin K to prevent hemorrhagic disease of the newborn;
             82          (ix) eye prophylaxis to prevent opthalmia neonatorum as required by law; and
             83          (x) any other medication approved by a licensed health care provider with authority to
             84      prescribe that medication;
             85          (g) obtaining food, food extracts, dietary supplements, as defined by the Federal Food,
             86      Drug, and Cosmetic Act, homeopathic remedies, plant substances that are not designated as
             87      prescription drugs or controlled substances, and over-the-counter medications to administer to


             88      clients;
             89          (h) obtaining and using appropriate equipment and devices such as Doppler, blood
             90      pressure cuff, phlebotomy supplies, instruments, and sutures;
             91          (i) obtaining appropriate screening and testing, including laboratory tests, urinalysis,
             92      and ultrasound;
             93          (j) managing the antepartum period;
             94          (k) managing the intrapartum period including:
             95          (i) monitoring and evaluating the condition of mother and fetus;
             96          (ii) performing emergency episiotomy; and
             97          (iii) delivering in any out-of-hospital setting;
             98          (l) managing the postpartum period including suturing of episiotomy or first and
             99      second degree natural perineal and labial lacerations, including the administration of a local
             100      anesthetic;
             101          (m) managing the newborn period including:
             102          (i) providing care for the newborn, including performing a normal newborn
             103      examination; and
             104          (ii) resuscitating a newborn;
             105          (n) providing limited interconceptual services in order to provide continuity of care
             106      including:
             107          (i) breastfeeding support and counseling;
             108          (ii) family planning, limited to natural family planning, cervical caps, and diaphragms;
             109      and
             110          (iii) pap smears, where all clients with abnormal results are to be referred to an
             111      appropriate licensed health care provider; and
             112          (o) executing the orders of a licensed health care professional, only within the
             113      education, knowledge, and skill of the Direct-entry midwife.
             114          [(8)] (9) "Unlawful conduct" is as defined in Sections 58-1-501 and 58-77-501 .
             115          [(9)] (10) "Unprofessional conduct" is as defined in Sections 58-1-501 and 58-77-502
             116      and as may be further defined by rule.
             117          Section 2. Section 58-77-201 is amended to read:
             118           58-77-201. Board.


             119          (1) There is created the Licensed Direct-entry Midwife Board consisting of:
             120          (a) four licensed Direct-entry midwives; and
             121          (b) one member of the general public.
             122          (2) The board shall be appointed and serve in accordance with Section 58-1-201 .
             123          (3) (a) The duties and responsibilities of the board shall be in accordance with Sections
             124      58-1-202 and 58-1-203 .
             125          (b) The board shall designate one of its members on a permanent or rotating basis to:
             126          (i) assist the division in reviewing complaints concerning the unlawful or
             127      unprofessional conduct of a licensed Direct-entry midwife; and
             128          (ii) advise the division in its investigation of these complaints.
             129          (c) (i) For the years 2006 through 2011, the board shall present an annual report to the
             130      Legislature's Health and Human Services Interim Committee describing the outcome data of
             131      licensed Direct-entry midwives practicing in Utah.
             132          (ii) The board shall base its report on data provided in large part from the Midwives'
             133      Alliance of North America.
             134          (4) A board member who has, under Subsection (3), reviewed a complaint or advised
             135      in its investigation may be disqualified from participating with the board when the board serves
             136      as a presiding officer in an adjudicative proceeding concerning the complaint.
             137          (5) Qualified faculty, board members, and other staff of Direct-entry midwifery
             138      learning institutions may serve as one or more of the licensed Directed-entry midwives on the
             139      board.
             140          Section 3. Section 58-77-204 is enacted to read:
             141          58-77-204. Administrative rules advisory committee.
             142          (1) The division shall:
             143          (a) convene an advisory committee to assist the division with developing
             144      administrative rules under Section 58-77-601 ; and
             145          (b) provide notice of any meetings convened under Subsection (1)(a) to the members of
             146      the advisory committee at least one week prior to the meeting, if possible.
             147          (2) The advisory committee shall include:
             148          (a) two physicians:
             149          (i) licensed under Chapter 67, Utah Medical Practices Act;


             150          (ii) recommended by the Utah Medical Association; and
             151          (iii) who have experience working with Direct-entry midwives; and
             152          (b) one licensed certified nurse midwife recommended by the Utah Chapter of the
             153      American College of Nurse Midwives; and
             154          (c) three licensed direct entry midwives, selected by the board.
             155          (3) The division shall adopt administrative rules regarding conditions that require
             156      mandatory transfer which shall include:
             157          (a) failure to deliver the infant after three hours of pushing unless birth is imminent;
             158          (b) gestation beyond 42 weeks without consultation with a licensed health care
             159      provider or with non-reassuring surveillance;
             160          (c) gestation beyond 43 weeks;
             161          (d) moderate, thick, or particulate meconium in the amniotic fluid unless birth is
             162      imminent;
             163          (e) non-reassuring fetal heart rate pattern indicative of fetal distress that does not
             164      immediately respond to the licensed Direct-entry midwife's treatment, unless birth is imminent;
             165          (f) a fetus in the breech presentation during labor unless birth is imminent;
             166          (g) multiple gestation unless birth is imminent;
             167          (h) more than two prior c-sections;
             168          (i) prior c-section with a known classical or inverted-T or J incision;
             169          (j) prior c-section without an ultrasound that rules out placental implantation over the
             170      uterine scar;
             171          (k) prior c-section without a signed informed consent document detailing the risks of
             172      vaginal birth after caesarean;
             173          (l) prior c-section with cervical dilation progress in the current labor of less than 1 cm
             174      in three hours once labor is active;
             175          (m) prior c-section with a gestation greater than 42 weeks; and
             176          (n) Rh isoimmunization with an antibody titre of greater than 1:8 in a mother carrying
             177      an Rh positive baby or a baby of unknown Rh type.
             178          (4) Members appointed to the advisory committee created in this section may also
             179      serve on the Licensed Direct-entry Midwife Board established under this chapter.
             180          (5) The director shall make appointments to the committee by July 1, 2008.


             181          (6) The director of the division shall appoint one of the three licensed Direct-entry
             182      midwives to serve as chair of the committee.
             183          (7) A committee member shall serve without compensation and may not receive travel
             184      costs or per diem for the member's service on the committee.
             185          (8) (a) The committee shall recommend rules under Subsection (1) based on
             186      convincing evidence presented to the committee, and shall strive to maintain medical
             187      self-determination.
             188          (b) A majority of members present at a meeting constitute a quorum.
             189          (9) This section is repealed on July 1, 2011.
             190          Section 4. Section 58-77-601 is amended to read:
             191           58-77-601. Standards of practice.
             192          (1) (a) Prior to providing any services, a licensed Direct-entry midwife must obtain an
             193      informed consent from a client.
             194          (b) The consent must include:
             195          (i) the name and license number of the Direct-entry midwife;
             196          (ii) the client's name, address, telephone number, and primary care provider, if the
             197      client has one;
             198          (iii) the fact, if true, that the licensed Direct-entry midwife is not a certified nurse
             199      midwife or a physician;
             200          [(iv) all sections required by the North American Registry of Midwives in its informed
             201      consent guidelines, including:]
             202          [(A)] (iv) a description of the licensed Direct-entry midwife's education, training,
             203      continuing education, and experience in midwifery;
             204          [(B)] (v) a description of the licensed Direct-entry midwife's peer review process;
             205          [(C)] (vi) the licensed Direct-entry midwife's philosophy of practice;
             206          [(D)] (vii) a promise to provide the client, upon request, separate documents describing
             207      the rules governing licensed Direct-entry midwifery practice, including a list of conditions
             208      indicating the need for consultation, collaboration, referral, transfer or mandatory transfer, and
             209      the licensed Direct-entry midwife's personal written practice guidelines;
             210          [(E)] (viii) a medical back-up or transfer plan;
             211          [(F)] (ix) a description of the services provided to the client by the licensed


             212      Direct-entry midwife;
             213          [(G)] (x) the licensed Direct-entry midwife's current legal status;
             214          [(H)] (xi) the availability of a grievance process; [and]
             215          [(I)] (xii) client and licensed Direct-entry midwife signatures and the date of signing;
             216      and
             217          [(v)] (xiii) whether the licensed Direct-entry midwife is covered by a professional
             218      liability insurance policy.
             219          (2) A licensed Direct-entry midwife shall:
             220          (a) limit the licensed Direct-entry midwife's practice to a normal pregnancy, labor,
             221      postpartum, newborn and interconceptual care, which for purposes of this section means a
             222      normal labor:
             223          (i) that is not pharmacologically induced;
             224          (ii) that is low risk at the start of labor;
             225          (iii) that remains low risk through out the course of labor and delivery; and
             226          (iv) in which the infant is born spontaneously in the vertex position between 37 and 43
             227      completed weeks of pregnancy; and
             228          (b) appropriately recommend and facilitate consultation with, collaboration with,
             229      referral to, or transfer or mandatory transfer of care to a licensed health care professional when
             230      the circumstances require that action in accordance with this section and standards established
             231      by division rule.
             232          (3) If after a client has been informed that she has or may have a condition indicating
             233      the need for medical consultation, collaboration, referral, or transfer and the client chooses to
             234      decline, then the licensed Direct-entry midwife shall:
             235          (a) terminate care in accordance with procedures established by division rule; or
             236          (b) continue to provide care for the client if the client signs a waiver of medical
             237      consultation, collaboration, referral, or transfer.
             238          (4) If after a client has been informed that she has or may have a condition indicating
             239      the need for mandatory transfer, the licensed Direct-entry midwife shall, in accordance with
             240      procedures established by division rule, terminate the care or initiate transfer by:
             241          (a) calling 911 and reporting the need for immediate transfer;
             242          (b) immediately transporting the client by private vehicle to the receiving provider; or


             243          (c) contacting the physician to whom the client will be transferred and following that
             244      physician's orders.
             245          (5) The standards for consultation and transfer under Subsection (3) are the minimum
             246      standards that a licensed Direct-entry midwife must follow. A licensed Direct-entry midwife
             247      shall initiate consultation, collaboration, referral, or transfer of a patient sooner than required
             248      by Subsection (3) or administrative rule if in the opinion and experience of the licensed
             249      Direct-entry midwife, the condition of the client or infant warrant a consultation, collaboration,
             250      referral, or transfer.
             251          [(5)] (6) For the period from 2006 through 2011, a licensed Direct-entry midwife must
             252      submit outcome data to the Midwives' Alliance of North America's Division of Research on the
             253      form and in the manner prescribed by rule.
             254          [(6)] (7) This chapter does not mandate health insurance coverage for midwifery
             255      services.
             256          Section 5. Section 63-55b-158 is amended to read:
             257           63-55b-158. Repeal dates -- Title 58.
             258          (1) Section 58-31b-301.6 , Medication Aide Certified Pilot Program, is repealed May
             259      15, 2010.
             260          (2) Section 58-77-204 is repealed July 1, 2011.


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