279 DEPARTMENT OF REGULATION AND LICENSING RL 182.03
Unofficial Text (See Printed Volume). Current through date and Register shown on Title Page.
Register, December, 2006, No. 612
Chapter RL 182
STANDARDS OF PRACTICE
RL 182.01 Standards.
RL 182.02 Informed consent.
RL 182.03 Practice.
RL 182.01 Standards. Licensed midwives shall comply
with the standards of practice of midwifery established by the
National Association of Certified Professional Midwives.
Note: The standards of the National Association of Certified Professional Midwives
are set forth in Appendix I. The National Association of Certified Professional
Midwives may be contacted at 234 Banning Road, Putney, VT 05346, (866)
704−9844.
History: CR 06−096: cr. Register December 2006 No. 612, eff. 5−1−07.
RL 182.02 Informed consent. (1) DISCLOSURE OF
INFORMATION TO CLIENT. A licensed midwife shall, at an initial
consultation with a client, provide a copy of the rules promulgated
by the department under subch. XII of ch. 440, Stats., and disclose
to the client orally and in writing on a form provided by the department
all of the following:
(a) The licensed midwife’s experience and training.
(b) Whether the licensed midwife has malpractice liability
insurance coverage and the policy limits of the coverage.
(c) A protocol for medical emergencies, including transportation
to a hospital, particular to each client.
(d) A protocol for and disclosure of risks associated with vaginal
birth after a cesarean section.
(e) The number of babies delivered and the number of clients
transferred to a hospital since the time the licensed midwife commenced
his or her practice of midwifery.
(f) A statement that the licensed midwife does not have the
equipment, drugs or personnel available to perform neonatal
resuscitations that would normally be available in a hospital setting.
Note: Forms are available from the Department of Regulation and Licensing,
Division of Professional Credential Processing, 1400 East Washington Avenue, P.O.
Box 8935, Madison, Wisconsin 53708, or from the department’s website at:
http://drl.wi.gov.
(1m) DISCLOSURE OF INFORMATION BY TEMPORARY PERMIT
HOLDER. A temporary permit holder shall inform a client orally
and in writing that the temporary permit holder may not engage
in the practice of midwifery unless he or she practices under the
direct supervision of a licensed midwife.
(2) ACKNOWLEDGEMENT BY CLIENT. A licensed midwife shall,
at an initial consultation with a client, provide a copy of the written
disclosures required under sub. (1), to the client and obtain the client’s
signature acknowledging that she has been informed, orally
and in writing, of the disclosures required under sub. (1).
History: CR 06−096: cr. Register December 2006 No. 612, eff. 5−1−07.
RL 182.03 Practice. (1) TESTING, CARE AND SCREENING.
A licensed midwife shall:
(a) Offer each client routine prenatal care and testing in accordance
with current American College of Obstetricians and Gynecologists
guidelines.
(b) Provide all clients with a plan for 24 hour on−call availability
by a licensed midwife, certified nurse−midwife or licensed
physician throughout pregnancy, intrapartum, and 6 weeks postpartum.
(c) Provide clients with labor support, fetal monitoring and
routine assessment of vital signs once active labor is established.
(d) Supervise delivery of infant and placenta, assess newborn
and maternal well being in immediate postpartum, and perform
Apgar scores.
(e) Perform routine cord management and inspect for appropriate
number of vessels.
(f) Inspect the placenta and membranes for completeness.
(g) Inspect the perineum and vagina postpartum for lacerations
and stabilize.
(h) Observe mother and newborn postpartum until stable condition
is achieved, but in no event for less than 2 hours.
(i) Instruct the mother, father and other support persons, both
verbally and in writing, of the special care and precautions for
both mother and newborn in the immediate postpartum period.
(j) Reevaluate maternal and newborn well being within 36
hours of delivery.
(k) Use universal precautions with all biohazard materials.
(L) Ensure that a birth certificate is accurately completed and
filed in accordance with state law.
(m) Offer to obtain and submit a blood sample in accordance
with the recommendations for metabolic screening of the newborn.
(n) Offer an injection of vitamin K for the newborn in accordance
with the indication, dose and administration route set forth
in sub. (3).
(o) Within one week of delivery, offer a newborn hearing
screening to every newborn or refer the parents to a facility with
a newborn hearing screening program.
(p) Within 2 hours of the birth offer the administration of antibiotic
ointment into the eyes of the newborn, in accordance with
state law on the prevention of infant blindness.
(q) Maintain adequate antenatal and perinatal records of each
client and provide records to consulting licensed physicians and
licensed certified nurse−midwives, in accordance with HIPAA
regulations.
(2) PRESCRIPTION DRUGS, DEVICES AND PROCEDURES. A
licensed midwife may administer the following during the practice
of midwifery:
(a) Oxygen for the treatment of fetal distress.
(b) Eye prophylactics – 0.5% erythromycin ophthalmic ointment
or 1% tetracycline ophthalmic ointment for the prevention
of neonatal ophthalmia.
(c) Oxytocin, or pitocin, as a postpartum antihemorrhagic
agent.
(d) Methyl−ergonovine, or methergine, for the treatment of
postpartum hemorrhage.
(e) Vitamin K for the prophylaxis of hemorrhagic disease of
the newborn.
(f) RHo (D) immune globulin for the prevention of RHo (D)
sensitization in RHo (D) negative women.
(g) Intravenous fluids for maternal stabilization – 5% dextrose
in lactated Ringer’s solution (D5LR), unless unavailable or
impractical in which case 0.9% sodium chloride may be administered.
(h) In addition to the drugs, devices and procedures that are
identified in pars. (a) to (g), a licensed midwife may administer
any other prescription drug, use any other device or perform any
other procedure as an authorized agent of a licensed practitioner
with prescriptive authority.
280 RL 182.03 WISCONSIN ADMINISTRATIVE CODE
Unofficial Text (See Printed Volume). Current through date and Register shown on Title Page.
Register, December, 2006, No. 612
Note: Licensed midwives do not possess prescriptive authority. A licensed midwife
may legally administer prescription drugs or devices only as an authorized agent
of a practitioner with prescriptive authority. For physicians and advanced practice
nurses, an agent may administer prescription drugs or devices pursuant to written
standing orders and protocols.
Note: Medical oxygen, 0.5% erythromycin ophthalmic ointment, tetracycline
ophthalmic ointment, oxytocin (pitocin), methyl−ergonovine (methergine), injectable
vitamin K and RHo (D) immune globulin are prescription drugs. See s. RL
180.02 (1).
(3) INDICATIONS, DOSE, ADMINISTRATION AND DURATION OF
TREATMENT. The indications, dose, route of administration and
duration of treatment relating to the administration of drugs and
procedures identified under sub. (2) are as follows:
Medication Indication Dose Route of Administration Duration of Treatment
Oxygen Fetal distress Maternal:
6−8 L/minute
Infant: 10−12 L/minute
2−4 L/minute
Mask
Bag and mask
Mask
Until delivery or transfer to a
hospital is complete
20 minutes or until transfer to
a hospital is complete
0.5% Erythromycin Ophthalmic
Ointment
Or
1% Tetracycline Ophthalmic
Ointment
Prophylaxis of Neonatal Ophthalmia
1 cm ribbon in each eye from
unit dose package
1 cm ribbon in each eye from
unit dose package
Topical
Topical
1 dose
Oxytocin (Pitocin)
10 units/ml
Postpartum hemorrhage only 10−20 units, 1−2 ml Intramuscularly only 1−2 doses
Methyl−ergonovine (Methergine)
0.2 mg/ml or 0.2 mg tabs
Postpartum hemorrhage only 0.2 mg Intramuscularly
Orally
Single dose
Every 6 hours, may repeat 3
times
Contraindicated in hypertension
and Raynaud’s Disease
Vitamin K
1.0 mg/0.5 ml
Prophylaxis of Hemorrhagic
Disease of the Newborn
0.5−1.0 mg, 0.25−0.5 ml Intramuscularly Single dose
RHo (D) Immune Globulin Prevention of RHo (D) sensitization
in RHo (D) negative
women
Unit dose Intramuscularly only Single dose at any gestation
for
RHo (D) negative, antibody
negative women within 72
hours of spontaneous bleeding.
Single dose at 26−28 weeks
gestation for
RHo (D) negative, antibody
negative women
And
Single dose for RHo (D) negative,
antibody negative women
within 72 hours of delivery of
RHo (D) positive infant, or
infant with unknown blood
type
5% dextrose in lactated Ringer’s
solution (D5LR), unless
unavailable or impractical in
which case 0.9% sodium chloride
may be administered
To achieve maternal stabilization
during uncontrolled postpartum
hemorrhage or anytime
blood loss is accompanied by
tachycardia, hypotension,
decreased level of consciousness,
pallor or diaphoresis
First liter run in at a wide−
open rate, the second liter
titrated to client’s condition
IV catheter 18 gauge or
greater (2 if hemorrhage is
severe)
Until maternal stabilization is
achieved or transfer to a hospital
is complete
(4) CONSULTATION AND REFERRAL. (a) A licensed midwife
shall consult with a licensed physician or a licensed certified
nurse−midwife providing obstetrical care, whenever there are significant
deviations, including abnormal laboratory results, relative
to a client’s pregnancy or to a neonate. If a referral to a physician
is needed, the licensed midwife shall refer the client to a
physician and, if possible, remain in consultation with the physician
until resolution of the concern.
Note: Consultation does not preclude the possibility of an out−of−hospital birth.
It is appropriate for the licensed midwife to maintain care of the client to the greatest
degree possible, in accordance with the client’s wishes, during the pregnancy and, if
possible, during labor, birth and the postpartum period.
(b) A licensed midwife shall consult with a licensed physician
or certified nurse−midwife with regard to any mother who presents
with or develops the following risk factors or presents with
or develops other risk factors that in the judgment of the licensed
midwife warrant consultation:
1. Antepartum.
a. Pregnancy induced hypertension, as evidenced by a blood
pressure of 140/90 on 2 occasions greater than 6 hours apart.
b. Persistent, severe headaches, epigastric pain or visual disturbances.
c. Persistent symptoms of urinary tract infection.
d. Significant vaginal bleeding before the onset of labor not
associated with uncomplicated spontaneous abortion.
e. Rupture of membranes prior to the 37th week gestation.
f. Noted abnormal decrease in or cessation of fetal movement.
g. Anemia resistant to supplemental therapy.
h. Fever of 102° F or 39° C or greater for more than 24 hours.
i. Non−vertex presentation after 38 weeks gestation.
j. Hyperemisis or significant dehydration.
k. Isoimmunization, Rh−negative sensitized, positive titers,
or any other positive antibody titer, which may have a detrimental
effect on mother or fetus.
L. Elevated blood glucose levels unresponsive to dietary
management.
m. Positive HIV antibody test.
n. Primary genital herpes infection in pregnancy.
o. Symptoms of malnutrition or anorexia or protracted weight
loss or failure to gain weight.
p. Suspected deep vein thrombosis.
q. Documented placental anomaly or previa.
r. Documented low lying placenta in woman with history of
previous cesarean delivery.
281 DEPARTMENT OF REGULATION AND LICENSING RL 182.03
Unofficial Text (See Printed Volume). Current through date and Register shown on Title Page.
Register, December, 2006, No. 612
s. Labor prior to the 37th week of gestation.
t. History of prior uterine incision.
u. Lie other than vertex at term.
v. Multiple gestation.
w. Known fetal anomalies that may be affected by the site of
birth.
x. Marked abnormal fetal heart tones.
y. Abnormal non−stress test or abnormal biophysical profile.
z. Marked or severe poly− or oligo−dydramnios.
aa. Evidence of intrauterine growth restriction.
bb. Significant abnormal ultrasound findings.
cc. Gestation beyond 42 weeks by reliable confirmed dates.
2. Intrapartum.
a. Rise in blood pressure above baseline, more than 30/15
points or greater than 140/90.
b. Persistent, severe headaches, epigastric pain or visual disturbances.
c. Significant proteinuria or ketonuria.
d. Fever over 100.6° F or 38° C in absence of environmental
factors.
e. Ruptured membranes without onset of established labor
after 18 hours.
f. Significant bleeding prior to delivery or any abnormal
bleeding, with or without abdominal pain; or evidence of placental
abruption.
g. Lie not compatible with spontaneous vaginal delivery or
unstable fetal lie.
h. Failure to progress after 5 hours of active labor or following
2 hours of active second stage labor.
i. Signs or symptoms of maternal infection.
j. Active genital herpes at onset of labor.
k. Fetal heart tones with non−reassuring patterns.
L. Signs or symptoms of fetal distress.
m. Thick meconium or frank bleeding with birth not imminent.
n. Client or licensed midwife desires physician consultation
or transfer.
3. Postpartum.
a. Failure to void within 6 hours of birth.
b. Signs or symptoms of maternal shock.
c. Febrile: 102° F or 39° C and unresponsive to therapy for
12 hours.
d. Abnormal lochia or signs or symptoms of uterine sepsis.
e. Suspected deep vein thrombosis.
f. Signs of clinically significant depression.
(c) A licensed midwife shall consult with a licensed physician
or licensed certified nurse−midwife with regard to any neonate
who is born with or develops the following risk factors:
1. Apgar score of 6 or less at 5 minutes without significant
improvement by 10 minutes.
2. Persistent grunting respirations or retractions.
3. Persistent cardiac irregularities.
4. Persistent central cyanosis or pallor.
5. Persistent lethargy or poor muscle tone.
6. Abnormal cry.
7. Birth weight less than 2300 grams.
8. Jitteriness or seizures.
9. Jaundice occurring before 24 hours or outside of normal
range.
10. Failure to urinate within 24 hours of birth.
11. Failure to pass meconium within 48 hours of birth.
12. Edema.
13. Prolonged temperature instability.
14. Significant signs or symptoms of infection.
15. Significant clinical evidence of glycemic instability.
16. Abnormal, bulging, or depressed fontanel.
17. Significant clinical evidence of prematurity.
18. Medically significant congenital anomalies.
19. Significant or suspected birth injury.
20. Persistent inability to suck.
21. Diminished consciousness.
22. Clinically significant abnormalities in vital signs, muscle
tone or behavior.
23. Clinically significant color abnormality, cyanotic, or pale
or abnormal perfusion.
24. Abdominal distension or projectile vomiting.
25. Signs of clinically significant dehydration or failure to
thrive.
(5) TRANSFER. (a) Transport via private vehicle is an acceptable
method of transport if it is the most expedient and safest
method for accessing medical services. The licensed midwife
shall initiate immediate transport according to the licensed midwife’s
emergency plan; provide emergency stabilization until
emergency medical services arrive or transfer is completed;
accompany the client or follow the client to a hospital in a timely
fashion; provide pertinent information to the receiving facility
and complete an emergency transport record. The following conditions
shall require immediate physician notification and emergency
transfer to a hospital:
1. Seizures or unconsciousness.
2. Respiratory distress or arrest.
3. Evidence of shock.
4. Psychosis.
5. Symptomatic chest pain or cardiac arrhythmias.
6. Prolapsed umbilical cord.
7. Shoulder dystocia not resolved by Advanced Life Support
in Obstetrics (ALSO) protocol.
8. Symptoms of uterine rupture.
9. Preeclampsia or eclampsia.
10. Severe abdominal pain inconsistent with normal labor.
11. Chorioamnionitis.
12. Clinically significant fetal heart rate patterns or other
manifestation of fetal distress.
13. Presentation not compatible with spontaneous vaginal
delivery.
14. Laceration greater than second degree perineal or any cervical.
15. Hemorrhage non−responsive to therapy.
16. Uterine prolapse or inversion.
17. Persistent uterine atony.
18. Anaphylaxis.
19. Failure to deliver placenta after one hour if there is no
bleeding and fundus is firm.
20. Sustained instability or persistent abnormal vital signs.
21. Other conditions or symptoms that could threaten the life
of the mother, fetus or neonate.
(b) A licensed midwife may deliver a client with any of the
complications or conditions set forth in par. (a), if no physician or
other equivalent medical services are available and the situation
presents immediate harm to the health and safety of the client; if
the complication or condition entails extraordinary and unnecessary
human suffering; or if delivery occurs during transport.
(6) PROHIBITED PRACTICES. A licensed midwife may not do
any of the following:
(a) Administer prescription pharmacological agents intended
to induce or augment labor.
282 RL 182.03 WISCONSIN ADMINISTRATIVE CODE
Unofficial Text (See Printed Volume). Current through date and Register shown on Title Page.
Register, December, 2006, No. 612
(b) Administer prescription pharmacological agents to provide
pain management.
(c) Use vacuum extractors or forceps.
(d) Prescribe medications.
(e) Provide out−of−hospital care to a woman who has had a
vertical incision cesarean section.
(f) Perform surgical procedures including, but not limited to,
cesarean sections and circumcisions.
(g) Knowingly accept responsibility for prenatal or intrapartum
care of a client with any of the following risk factors:
1. Chronic significant maternal cardiac, pulmonary, renal or
hepatic disease.
2. Malignant disease in an active phase.
3. Significant hematological disorders or coagulopathies, or
pulmonary embolism.
4. Insulin requiring diabetes mellitus.
5. Known maternal congenital abnormalities affecting childbirth.
6. Confirmed isoimmunization, Rh disease with positive titer.
7. Active tuberculosis.
8. Active syphilis or gonorrhea.
9. Active genital herpes infection 2 weeks prior to labor or in
labor.
10. Pelvic or uterine abnormalities affecting normal vaginal
births, including tumors and malformations.
11. Alcoholism or abuse.
12. Drug addiction or abuse.
13. Confirmed AIDS status.
14. Uncontrolled current serious psychiatric illness.
15. Social or familial conditions unsatisfactory for out−of−
hospital maternity care services.
16. Fetus with suspected or diagnosed congenital abnormalities
that may require immediate medical intervention.
History: CR 06−096: cr. Register December 2006 No. 612, eff. 5−1−07.