Midwifery Rules & Regulations

State Of Wyoming

Board Of Midwifery
PROPOSED RULES AND REGULATIONS
(Promulgated by authority under the Wyoming Midwives Licensing Act, W.S. 33-46-101 through W.S. 33-46-108.)

October 2010

CHAPTER 1 GENERAL PROVISIONS Section 1. Rules of the Board of Midwifery hereinafter referred to as the Board. Section 2. Statutory Authority. The Board of Midwifery was created by W.S. 33-46-101 through 33-46-108, herein after referred to as the Act. Section 3. Severability. If any provisions of these regulations or the application thereof to any person or circumstance is invalid, such invalidity shall not affect other provisions or application of these regulations which can be given effect without the invalid provision or application, and to this end the provisions of these regulations are declared to be severable. Section 4. Purpose of These Rules. The purpose of these rules shall be to develop procedures and establish requirements for: (a) Developing uniform and reasonable scope of practice standards for midwifery consistent with W.S. 33-46-102(a)(ii) and (iii); (b) Developing a protocol for written informed consent to treatment;

(c) Defining a protocol for the use of those drugs approved by the board for administration to mothers and babies; (d) (e) Defining a protocol for management of newborns; Defining a protocol for medical waste disposal;

(f) Requiring midwives to report outcomes of all clients for which the midwife provided services at any point during labor or delivery to the board after each birth; (g) Establishment of Board organization, and codification of rules and procedures for Board meetings and subcommittee meetings; (h) Developing standards and qualifications requisite in the issuance of licenses to practice midwifery; (i) Evaluating the qualifications of individuals applying for licensure;

(j) Issuance and renewal of licenses to persons qualified to practice midwifery in the state of Wyoming; (k) Setting fees necessary for the administration of this act;

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(l)

Establishing criteria for actions against licensees, including but not limited to: (i) Investigation and conduct of hearings on complaints of violations of this

act; (ii) act; (iii) (m) Revocation, suspension, or condition of a license. Proceedings to enjoin, restrain or bring suit against persons violating this

Codification of a canon of ethics.

Section 5. Terms Defined by Statute. Terms defined in W.S. 33-46-101 through 33-46108 shall have the same meanings when used in these regulations unless the context or subject matter clearly requires a different interpretation. Section 6. Terms Defined Herein. As used in these regulations, the following terms shall have the following meanings unless the context or subject matter clearly requires a different interpretation. (a) (b) (c) (d) (e) (f) childbirth. “Antepartum” means occurring or existing during pregnancy. “Intrapartum” means occurring during labor and delivery. “MEAC” means the Midwifery Education Accreditation Council. “NACPM” means the National Association of Certified Professional Midwives. “NARM” means the North American Registry of Midwives. “Postpartum” means occurring in approximately the six (6) week period after

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CHAPTER 2 ORGANIZATION AND PROCEDURES OF THE BOARD Section 1. Structure of the Board. The board shall consist of seven (7) members appointed by the governor including four (4) certified professional midwives, one (1) certified nurse midwife, one (1) physician licensed under the Medical Practice Act who is board certified in either obstetrics and gynecology or family medicine and who has experience in primary maternity care and one (1) consumer of midwifery care. The governor shall have the authority to appoint to the board qualified midwives licensed or certified in another state provided any person appointed becomes licensed in Wyoming within one (1) year of appointment. Section 2. Establishment of Licensure Standards. The professional organizations representing midwifery may recommend to the Board the specific requirements, rules, and procedures appropriate for licensing persons in that field and suggest changes to the rules and regulations. Section 3. Officers. Officers of the Board shall be elected annually, by a majority vote of the Board, and be comprised of a chair, and a vice chair. Section 4. Meetings of the Board. (a) The Board shall meet at least three (3) times each year at a date, place and time established by the Chair with special meetings held as requested by the Chair or by a majority of the members. (b) Meetings shall be open to the public and held in accordance with the Wyoming Administrative Procedures Act. The Board has the right to call executive sessions pursuant to W.S. 16-4-405. (c) The Chair may conduct meetings and Board business by telephone as a means of conserving funds and expediting appropriate business. (d) A quorum shall consist of at least four (4) members, and a majority of the quorum is required to approve Board actions. Section 5. Establishment of Committees. The Board may, by a majority vote of the membership, establish and empower committees to approve or preliminarily deny applications for license, applications for renewal, special request, and other issues that the Board deems proper to delegate. Committees may also be established and empowered to conduct complaint investigations, and make recommendations on complaints. These committees shall be comprised of current members of the Board and/or administrative staff.

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CHAPTER 3 LICENSE REQUIREMENTS Section 1. General Requirements for Licensure. It is the sole responsibility of the applicant to ensure that the Board receives all documentation necessary to prove to the Board’s satisfaction that the applicant meets all the requirements for licensure herein. The applicant shall provide satisfactory evidence to the Board that they: (a) Are legal inhabitants of the United States, and

(b) Have not been convicted of a crime which in the judgment of the board renders the person unfit to practice midwifery; and (c) (d) Have not provided materially false or misleading information to the board; and Satisfy the requirements established in these rules.

Section 2. Certification. The applicant must provide proof of current certification as a certified professional midwife by the NARM. Section 3. Education. The applicant must have graduated from a midwifery education program accredited by the MEAC or a similar successor organization. (a) If the applicant has not graduated from a midwifery education program accredited by the MEAC or a similar successor organization, the applicant shall have five (5) years experience practicing as a licensed or certified midwife in another state, and (b) The applicant shall provide the board with evidence of successful completion of board approved courses in the treatment of respiratory distress in newborns, pharmacology, the treatment of shock, intravenous therapy, and suturing specific to midwives as follows: (i) Treatment of respiratory distress in newborns- current certification in neonatal resuscitation obtained through completion of American Heart Association approved cardiopulmonary resuscitation courses and American Academy of Pediatrics approved neonatal resuscitation courses. (ii) Pharmacology specific to midwives- training obtained through completion of MEAC approved courses, or other courses sponsored by or approved by the Board which cover all drugs listed in the formulary. (iii) Treatment of shock- training obtained through completion of MEAC approved courses or other courses approved by the Board. (iv) Intravenous therapy- training obtained through completion of MEAC

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approved courses or other courses approved by the Board. (v) Suturing specific to midwives- training obtained through completion of MEAC approved courses or other courses approved by the Board. Section 4. Practical Experience. During the course of their educational process, all applicants are expected to acquire the full range of entry-level midwifery skills as defined in the NARM Candidate Information Bulletin (CIB) and on the NARM Skills, Knowledge and Abilities Essential for Competent Practice Verification Form 201. The applicant shall complete a practicum or course of practical experience in midwifery. The applicant shall: (a) Attend a minimum of twenty (20) births;

(b) While functioning in the role of primary midwife under supervision, attend a minimum of an additional twenty (20) births; (i) A minimum of ten (10) of the twenty (20) births attended as primary midwife under supervision must be in homes or other out-of-hospital settings. (ii) A minimum of three (3) of the twenty (20) births attended as primary midwife under supervision must be with women for whom you have provided primary care during at least four (4) prenatal visits, birth, newborn exam and one (1) postpartum exam. (iii) At least ten (10) of the twenty (20) primary births must have occurred within three (3) years of application submission. (c) While functioning in the role of primary midwife under supervision, the licensee must document having completed: (i) (ii) (iii) Seventy-five (75) prenatal exams, including twenty (20) initial exams; Twenty (20) newborn exams; and Forty (40) postpartum exams.

Section 5. Background Check. Every applicant shall provide the board fingerprints and other information necessary for a criminal history record background check. Section 6. Personal Interview. The applicant may be required to appear for a personal interview with the board if the Application Review Committee deems an interview appropriate in general, or in a specific case; Section 7. License by Reciprocity. An individual holding a license in good standing to engage in the practice of midwifery under the laws of another state may, upon approval of the board, be issued a license in this state, provided:

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(a) The applicant is currently licensed or certified by any state with requirements at least as stringent as this state; (b) the NARM; (c) The applicant holds current certification as a certified professional midwife by

The applicant meets the criteria established in this chapter, and

(d) The applicant has not been sanctioned in another state without resolution satisfactory to the Board. Section 8. Provisional License. The board may issue a provisional license to: (a) Any person eligible for licensure, to allow the applicant to practice under the supervision of another midwife, a person licensed under the Medical Practice Act or a certified nurse midwife until the board has the opportunity to act on the person's application for licensure. However, this paragraph shall not apply to any person whose license or certificate is under revocation, suspension or disciplinary restriction in another state; (i) A provisional license issued under this paragraph is valid until action is taken on the application. (b) Any person (i.e. a student midwife), undertaking the practicum required under this act to practice under the supervision of another midwife, a certified nurse midwife or a person licensed under the Medical Practice Act; (i) year. (c) Any person licensed or certified in another state with requirements at least as stringent as this state to practice for thirty (30) days to provide education and instruction in midwifery or to act as a locum tenens for a midwife licensed under this act. (i) A provisional license is not required in order to provide classroom instruction or continuing education that does not involve participation at a birth. A provisional license issued under this paragraph is valid for one (1)

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CHAPTER 4 APPLICATION PROCEDURE Section 1. General Application Procedures. The Board shall not review an individual’s credentials prior to receiving a complete application. All applicants must submit: (a) A complete official application form accompanied by the application fee and appropriate proof of legal presence in the U.S.; and (b) Official verification of current CPM credential sent to the Board directly from the NARM; and (c) Two (2) complete finger print cards provided by the Board.

(d) Completion of all requirements for licensure shall be documented within one (1) year of the date the application was received by the Board, otherwise the application will be deemed incomplete and closed without further notice. (e) specified. The Board shall not accept faxed or photocopied documents unless otherwise

Section 2. Application for Licensure by Reciprocity. In addition to the documents required in Section 1 of this chapter, the applicant shall request official verification of licensure in good standing from a jurisdiction where the applicant holds or has held a license as a midwife. Section 3. Notification of Applicants and Right of Appeal. If the applicant's initial application is denied, the reasons for this rejection shall be communicated in writing. The applicant shall have the right to request reconsideration of the application materials, and may further request a hearing before the Board in accordance with the Wyoming Administrative Procedures Act. Section 4. Issuance of License. Initial licenses shall expire on the second (2nd) anniversary of the issue date. Thereafter, upon renewal, the license shall be valid for two (2) years. The Board shall issue a wall certificate and pocket identification card to the successful applicant bearing the full name of the holder, license number, date of issuance, expiration date, and appropriate seal. Section 5. Change of Name, Address or Telephone Number. (a) Licensees shall register with the Board any change in their legal name by submitting documentation demonstrating the change of name, along with the appropriate fee. A new wall certificate shall be issued by the Board. (b) Each applicant and licensee shall file with the Board their current home and

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professional mailing addresses and telephone numbers and shall report to the Board in writing any change of addresses or telephone numbers, giving both old and new addresses and telephone numbers. Section 6. Release of Confidential Records. Release of Board records shall be governed by W.S. 16-4-201 et seq., The Public Records Act. Section 7. Correction and Amendment. Any applicant or licensee may clarify erroneous, inaccurate or misleading information in their file by submitting a written statement to the Board which will be placed in their file.

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CHAPTER 5 FEES Section 1. Fees. This fee schedule is adopted by the Board pursuant to W.S. 33-1-201. Actual fees charged shall be adopted in the minutes of the Board and shall be readily available to the public. Fees shall not exceed: (a) (b) Application Fee: Provisional License Fee: (i) (ii) (iii) (c) (d) (e) (f) (g) (h) (i) Pending Application Processing Undertaking Practicum $200 maximum $400 maximum per year $1200 maximum

Education/Instruction/Locum Tenens $200 maximum per provisional $1200 maximum every 2 years $50.00 per delivery in accordance with W.S. 1-1-115 $30.00 maximum $.50 per page maximum $20.00 maximum $10.00 maximum

Renewal Fee: Per Delivery Fee: Non-sufficient Funds Fee: Verification Fee: Copy Fee: Duplicate Wall Certificate Fee: Duplicate Pocket Card (2):

Section 2. Refunds. All fees collected by the Board are non-refundable. Section 3. Applications Unaccompanied by Fees. Applications shall not be considered by the Board unless accompanied by the application fee. Section 4. Duplicate or Replacement Certificate and Pocket Card. Duplicate or replacement wall certificates and pocket cards may be issued by the Board. All requests for duplicate or replacement certificates and/or pocket cards shall be in writing and shall be accompanied by the fee for each duplicate or replacement. Section 5. Requests for Roster of Licensees. The roster of current licensees shall be updated at least annually and made available electronically at no charge.

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CHAPTER 6 RENEWAL Section 1. Biennial Renewal. Licenses may be renewed every two (2) years by providing the Board with the following: (a) (b) Complete application for renewal; and Payment of the renewal fee; and

(c) Verification of having maintained CPM certification from NARM, or verification of compliance with the continuing education requirements established below. (d) Approximately sixty (60) days prior to the renewal date the Board may send a renewal notice to the licensee’s last address of record. (e) Renewal applications shall not be accepted more than one hundred twenty (120) days prior to the expiration date. (f) Renewal applications received by the Board which are postmarked after the expiration date, or after the next business day in cases when the expiration date falls on a weekend or holiday, will not be accepted by the Board, and the license will become null and void for failure to timely and sufficiently secure renewal. (g) Failure to receive a notice for renewal from the Board does not excuse a licensee from the requirement for renewal under the Act and these rules. Section 2. Continuing Education. (a) Each licensee shall earn a minimum of twenty (20) contact hours of continuing education during each two (2) year renewal period. Continuing Education Units (CEUs) in excess of the amount required cannot be carried over for credit in subsequent reporting periods. CEUs cannot be earned prior to certification. A license may not be renewed if the holder fails to complete the required number of continuing education credits. (b) CEUs shall be the actual number of hours during which instruction was received. A CEU shall consist of not less than fifty (50) minutes of actual instruction or presentation. For academic courses, one (1) semester credit equals fifteen (15) CEUs. One (1) quarter credit equals ten (10) CEUs. (c) Only those CEUs acquired during the two (2) years immediately preceding the expiration date will be considered. (d) Licensees shall maintain copies of any certificates of attendance, letters

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certifying attendance, transcripts, or any official documents which serve as proof of participation or attendance for at least two (2) years from the date submitted for renewal. (e) Proof of attendance shall contain the activity title, dates, contact hours attended, sponsor, presenter, qualifications of the presenter, the name of the licensee, and shall be signed by the sponsor or the presenter. (f) Licensees are responsible for maintaining their own continuing education documentation. Section 3. Acceptable Activities and Subject Matter. (a) CEUs must relate to midwifery or women’s health including both allopathic and non-allopathic areas of study. (b) The Board may accept a course of study for continuing education credit that does not include the actual physical attendance of the licensed midwife in a face-to-face setting with the course instructor. Distance learning or independent study courses will be eligible for continuing education credits if approved by NARM or upon approval of the Board.

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CHAPTER 7 PROFESSIONAL RESPONSIBILITY Section 1. The Practice of a Licensed Midwife. The practice of a licensed midwife consists of providing primary maternity care that is consistent with a midwife’s training, education and experience to women and their newborn children throughout the childbearing cycle, and includes identifying and referring women or their newborn children who require medical care to an appropriate health professional; Section 2. Scope and Practice Standards. A licensed midwife must adhere to the following scope and practice standards when providing antepartum, intrapartum, postpartum, and newborn care. (a) NACPM Scope and Practice Standards. The Board adopts the Essential Documents of the National Association of Certified Professional Midwives as scope and practice standards for licensed midwives. All licensed midwives must adhere to these scope and practice standards during the practice of midwifery to the extent such scope and practice standards are consistent with the Board’s enabling law. (b) Conditions for Which a Licensed Midwife May Not Provide Care. A licensed midwife may not provide care for a client with: (i) A current history of any of the following disorders, diagnoses, conditions, or symptoms: (A) (B) Placental abnormality; Multiple gestations;

(C) Noncephalic presentation at the onset of labor or rupture of membranes, whichever occurs first, unless birth is imminent; (D) weeks gestational age; (E) (F) (ii) or symptoms: (A) More than one (1) prior cesarean section with no history of a vaginal birth, a cesarean section within eighteen (18) months of the current delivery, or any cesarean section that was surgically closed with a classical or vertical uterine incision; Pre-eclampsia; Cervical insufficiency; or Birth under thirty-seven (37) weeks or after forty-two (42)

A past history of any of the following disorders, diagnoses, conditions,

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(B) Rh or other blood group or platelet sensitization, hematological or coagulation disorders; (C) Cervical insufficiency.

(c) Conditions for Which a Licensed Midwife May Not Provide Care Without Physician Involvement. A licensed midwife may not provide care for a client with a current history of the disorders, diagnoses, conditions, or symptoms listed herein unless such disorders, diagnoses, conditions or symptoms are being treated, monitored or managed by a licensed physician. Before providing care to such a client, the licensed midwife must notify the client in writing that the client must obtain the described physician care as a condition to the client’s eligibility to obtain maternity care from the licensed midwife. The licensed midwife must, additionally, obtain the client’s signed acknowledgement that the client has received the written notice. The disorders, diagnoses, conditions, and symptoms are: (i) (ii) (iii) (iv) (v) (vi) (vii) Diabetes; Thyroid disease; Epilepsy; Hypertension; Cardiac disease; Pulmonary disease; Renal disease;

(viii) Previous major surgery of the pulmonary system, cardiovascular system, urinary tract or gastrointestinal tract; (ix) Hepatitis.

(d) Conditions for Which a Licensed Midwife Must Recommend Physician Involvement. Before providing care for a client with a history of any of the disorders, diagnoses, conditions or symptoms listed, a licensed midwife must provide written notice to the client that the client is advised to see a licensed physician during the client’s pregnancy. Additionally, the licensed midwife must obtain the client’s signed acknowledgement that the client has received the written notice. The disorders, diagnoses, conditions, and symptoms are: (i) (ii) Previous complicated pregnancy; Previous cesarean section;

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(iii) (iv) (v) (vi) (vii) (viii) herpes simplex virus; (ix) (x) conception; (xi) (xii)

Previous pregnancy loss in second or third trimester; Previous spontaneous premature labor; Previous preterm rupture of membranes; Previous preeclampsia; Previous hypertensive disease of pregnancy; Prior infection with parvo virus, toxoplasmosis, cytomegalovirus or

Previous newborn group B streptococcus infection; A body mass index of thirty-five (35.0) or greater at the time of

Underlying family genetic disorders with potential for transmission; or Psychiatric illness.

(e) Conditions for Which a Licensed Midwife Must Facilitate Hospital Transfer. A licensed midwife must facilitate the immediate transfer of a client to a hospital for emergency care if the client has any of the following disorders, diagnoses, conditions or symptoms: (i) Maternal fever in labor of more than 100.4 degrees Fahrenheit, in the absence of environmental factors; (ii) Suggestion of fetal jeopardy, such as any abnormal bleeding (with or without abdominal pain), evidence of placental abruption, thick meconium, or abnormal fetal heart tones with non-reassuring patterns where birth is not imminent; (iii) Noncephalic presentation at the onset of labor or rupture of membranes, whichever occurs first, unless birth is imminent; (iv) adequate progress; (v) (vi) Second stage labor after two (2) hours of initiation of pushing without

Current spontaneous premature labor; Current preterm premature rupture of membranes;

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(vii) (viii) (ix)

Current preeclampsia; Current hypertensive disease of pregnancy; Continuous uncontrolled bleeding;

(x) Bleeding that necessitates the administration of more than two (2) doses of oxytocin or other antihemorrhagic agent; (xi) (xii) (xiii) (xiv) (xv) (xvi) Delivery injuries to the bladder or bowel; Seizures; Uncontrolled vomiting; Coughing or vomiting of blood; Severe chest pain; or Sudden onset of shortness of breath and associated labored breathing.

(f) Plan for Emergency Transfer and Transport. When facilitating a transfer, the licensed midwife must notify the hospital when the transfer is initiated, accompany the client to the hospital if feasible, or communicate by telephone with the hospital if the licensed midwife is unable to be present. The licensed midwife must also ensure that the transfer of care is accompanied by the client’s medical record, which must include: (i) (ii) (iii) (iv) The client’s name, address, and next of kin contact information; A list of diagnosed medical conditions; A list of prescription or over the counter medications regularly taken; A history of previous allergic reactions to medications; and

(v) If feasible, the licensed midwife’s assessment of the client’s current medical condition and description of the care provided by the licensed midwife before transfer. Section 3. Record Keeping. Each client record must be retained for a minimum of ten (10) years after the birth. Section 4. Written Informed Consent. The licensee shall provide to the client written informed consent documents in accordance with W.S. 33-46-103(j)(ii). (a) The written informed consent to treatment shall include all of the following:

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(i) (ii) pursuant to this act;

The licensed midwife's experience and training; Instructions for obtaining a copy of rules adopted by the board

(iii) Instructions for obtaining a copy of documents adopted by the National Association of Certified Professional Midwives that identify the nature of and standards of practice for responsible midwifery practice; (iv) Instructions for filing complaints with the board;

(v) Notice of the type and liability limits of professional or personal liability insurance maintained by the midwife or notice that the midwife does not carry liability insurance; (vi) A written protocol for emergencies that is specific for each individual client, including the following provisions: (A) Transport to a hospital in an emergency;

(B) Notification of the hospital to which a client will be transferred upon initiation of the transfer; (C) Accompaniment of the client to the hospital by the midwife, if feasible, or telephone notice to the hospital if the midwife is unable to be present personally; (D) Transmission of the client's record to the hospital, including the client's name, address, list of known medical conditions, list of prescription or over the counter medications regularly taken, history of previous allergic reactions to medications, the client's current medical condition and description of the care provided by the midwife; (E) Next of kin contact information.

(vii) A description of the procedures, benefits and risks of home birth, primarily those conditions that may arise during delivery; (viii) A recommendation to the client that two (2) providers trained in neonatal resuscitation program be present at delivery. Section 5. Medication Formulary. During the practice of midwifery a licensed midwife may obtain and administer the following drugs described in the midwifery formula, according to the protocol outlined in Appendix A, describing the indication for use, dosage, route of administration and duration of treatment:

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(a) (b) (c) (d)

Oxygen; Oxytocin as a postpartum antihemorrhagic agent; Misoprostol as a postpartum antihemorrhagic agent; Methylergonovine (Methergine) as a postpartum antihemorrhagic agent;

(e) Injectable local anesthetic for the repair of lacerations which are no more extensive than second degree; (f) Antibiotics for group B streptococcus prophylaxis consistent with the guidelines set forth in Prevention of Perinatal Group B Streptococcal Disease, published by the Centers for Disease Control and Prevention; (g) (h) (i) (j) (k) (l) Epinephrine administered via a metered dose auto-injector; Intravenous fluids for stabilization of the woman; Rho(D) immune globulin; Phylloquinone (Vitamin K1); Eye prophylactics for the baby; Sterile H2O Papules.

Section 6. Obtaining, Storing, and Disposing of Formulary Drugs. A licensed midwife must adhere to the following protocol for obtaining, storing, and disposing of formulary drugs during the practice of midwifery. (a) Obtaining Formulary Drugs. A licensed midwife may obtain formulary drugs as allowed by law, including, without limitation, from: (i) A person or entity that is licensed as a Wholesale Distributor by the Wyoming State Board of Pharmacy; and (ii) A retail pharmacy, in minimal quantities for office use.

(b) Storing Formulary Drugs. A licensed midwife must store all formulary drugs in secure areas suitable for preventing unauthorized access and for ensuring a proper environment for the preservation of the drugs. However, licensed midwives may carry formulary drugs to the home setting while providing care within the course and scope of the practice of midwifery. The licensed midwife must promptly return the formulary drugs to the secure area when the licensed midwife has finished using them for patient care.

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(c) Disposing of Formulary Drugs. A licensed midwife must dispose of formulary drugs using means that are reasonably calculated to guard against unauthorized access and harmful excretion of the drugs into the environment. The means that may be used include, without limitation: (i) Transferring the drugs to a reverse distributor who is registered to destroy drugs with the U.S. Drug Enforcement Agency; (ii) Removing the drugs from their original containers, mixing them with an undesirable substance such as coffee grounds or kitty litter, putting them in impermeable, nondescript containers such as empty cans or sealable bags, and throwing the containers in the trash; or (iii) Flushing the drugs down the toilet if the accompanying patient information instructs that it is safe to do so. Section 7. Newborn Care. (a) newborn. The licensee shall carry the equipment necessary for resuscitation of the

(b) Midwives shall transfer (immediately if indicated) any newborn showing the following signs to the nearest hospital or pediatric care provider: (i) (ii) Ten (10) minute Apgar score of less than seven (7); Signs of a medically significant anomaly;

(iii) Signs of respiratory distress including respiratory rate over eighty (80) per minute, poor color, grunting, nasal flaring and/or retractions that are not showing consistent improvement; (iv) Need for oxygen for more than twenty (20) minutes, or after one (1) hour following the birth; (v) (vi) (vii) Seizures; Fontanel full and bulging; Significant or suspected birth injury;

(viii) Cardiac irregularities including a heart rate that is consistently below eighty (80) beats per minute or greater than one hundred sixty (160) beats per minute; poor capillary refilling (greater than three (3) seconds);

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(ix) (x) (xi)

Pale, cyanotic, gray color; Lethargy or poor muscle tone; Temperature instability

(c) All licensees shall comply with the Wyoming Department of Health’s Newborn Screening requirements stated in W.S. 35-4-801. (i) Informed consent of parents shall be obtained and if any parent or guardian of a child objects to a mandatory examination, the child is exempt from subsection (c). (d) All licensees shall register births, still births and deaths with the local registrar of the district in which the occurrence took place within ten (10) days after the birth pursuant to W.S. 35-1-401 through 431; Section 8. Medical Waste. Medical waste (items removed from a private residence) must be disposed of according to the following protocol: (a) Containers for Non-Sharp, Medical Waste. Medical waste, except for sharps, must be placed in disposable containers/bags which are impervious to moisture and strong enough to preclude ripping, tearing or bursting under normal conditions of use. The bags must be securely tied so as to prevent leakage or expulsion of solid or liquid waste during storage, handling or transport. The containment system must have a tight-fitting cover and be kept clean and in good repair. All bags used for containment of medical waste must be clearly identified by label or color, or both. (b) Containers for Sharps. Sharps must be placed in impervious, rigid, punctureresistant containers immediately after use. Needles must not be bent, clipped or broken by hand. Rigid containers of discarded sharps must either be labeled or colored like the disposable bags used for other medical waste, or placed in such labeled or colored bags. (c) Storage Duration. Medical waste may not be stored for more than seven (7) days, unless the storage temperature is below thirty-two (32) degrees Fahrenheit. Medical waste must never be stored for more than ninety (90) days. Section 9. Ethical Standards. The protection of the public health, safety and welfare and the best interest of the public shall be the primary guide in determining the appropriate professional conduct of all persons whose activities are regulated by the Board. (a) Ethical standards are incorporate and are based on the Standards of Practice of the NACPM. The published Standards of Practice of the NACPM are adopted by reference herein as Appendix B and shall be used by the licensee and the Board to provide additional guidelines to ethical standards. All references to an NACPM member shall mean the same as a

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licensed midwife. Where the Standards of Practice of the NACPM conflict with the Act and/or these rules and regulations, the Act and rules and regulations shall control. (b) Persons licensed by the Board shall:

(i) Use the term “Licensed Midwife” and/or the initials LM only after the applicant is granted licensure by the Board. (ii) Practice in a manner that is in the best interest of the public and does not endanger the public health, safety or welfare. (iii) Be able to justify all services rendered to clients as necessary for diagnostic or therapeutic purposes. (iv) Practice only within the competency areas for which they are trained and experienced. The licensee must be able to demonstrate to the Board competency, training, and/or expertise. (v) Report to the board outcomes of all clients for which they have provided services at any point during labor or delivery within thirty (30) days after each birth. (vi) Report to the Board known or suspected violations of the laws and regulations governing the practice of licensed professionals. (vii) Maintain accurate documentation of all professional services rendered to a client in confidential files for each client and ensure that client records are kept in a secure, safe, retrievable and legible condition. (A) The licensee shall make provisions for the retention and/or release of client records if the licensee is unable to do so. Such provision shall include the naming of a qualified person who will retain the client records and properly release the client records upon request. (viii) Clearly state the person’s licensure status by the use of a title or initials such as “licensed midwife” (LM) or a statement such as “licensed by the Wyoming Board of Midwifery” in any advertising, public directory or solicitation, including telephone directory listings. (ix) from the Board. (x) Not permit, condone or facilitate unlicensed practice or any activity which is a violation of the Act or these rules and regulations. (xi) Not use vacuum extraction or forceps as an aid in the delivery of a Respond to all requests for information and all other correspondence

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newborn. (xii) Not perform abortions.

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CHAPTER 8 ADVERSE ACTION Section 1. Board Authorization. The Board is authorized to censure, suspend, revoke, refuse to renew, impose probationary conditions, or otherwise restrict the license of any person violating provisions of the Act pursuant to W.S. 33-46-101 et seq. Section 2. Grounds. In addition to the grounds outlined in W.S. 33-46-103, the Board may take action for unprofessional conduct. (a) Unprofessional conduct shall include, but is not limited to:

(i) Suspension, revocation, denial, or other disciplinary action imposed upon a license held in another jurisdiction. A certified copy of the disciplinary order shall be conclusive evidence. (ii) Board. (iii) conclusive evidence. Conviction of a felony. A certified copy of the conviction shall be Engaging in the practice of midwifery without a license issued by this

(iv) Conviction of a misdemeanor involving moral turpitude. A certified copy of the conviction shall be conclusive evidence. (v) (vi) (vii) (viii) (ix) controlled substance. Renting or lending the license issued pursuant to this act to any person; Gross incompetence or malpractice. Mental incompetency. Knowingly submitting false information to the Board. Addiction or habitual intemperate use of alcohol, drugs and/or a

(x) Violation and conviction of a charge under W.S. 35-7-1001 et seq., the Wyoming Controlled Substance Act. (xi) Sexual exploitation of a client, defined as: (A) gratification; or Offering professional services for some form of sexual

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(B) (xii)

Sexual contact with a client.

Willful violation of any provisions of this Act, W.S. 33-45-101, et seq.

(b) Unethical conduct shall be a violation of any provision of the adopted Standards of Practice as set forth in these Rules.

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CHAPTER 9 COMPLAINTS: PRACTICE AND PROCEDURE Section 1. Complaints. All complaints shall be filed with the Board in writing and shall contain: (a) (b) (c) (d) (e) Name and address of licensee; Name, address and telephone number of complainant; Nature of alleged violations; A short and concise statement of facts relating to the alleged violations; and Signature of complainant.

Section 2. Investigation. (a) The Board shall assign an investigation committee comprised of Board member(s) or other individuals with assistance from a representative of the Attorney General's Office. (b) As part of the complaint investigation the licensee may be required to provide fingerprints to the Board. (c) Upon completion of the investigation, the committee may:

(i) Prepare and file a formal complaint and notice of hearing with the Board, setting the matter for a contested case hearing; (ii) (d) Recommend to the Board that the complaint be dismissed.

The Board may resolve a complaint at any time by: (i) (ii) (iii) (iv) Sending a written letter of reprimand/warning to the licensee; Accepting a voluntary surrender of a license or certification; Accepting conditional terms for settlement; Dismissal.

Section 3. Service of Notice and Formal Complaint. Notice and Complaint shall be served by mail at least twenty (20) days prior to the date set for hearing. It shall be sent by

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certified or registered mail with return receipt thereof to the licensee’s last known address. Section 4. Docket. A contested case shall be assigned a number when a complaint is filed with the Board. A separate file shall be established for each docketed case, in which shall be systematically placed all papers, pleadings, documents, transcripts, evidence and exhibits. Section 5. Answer or Appearance. The licensee shall file an Answer or Notice of Appearance, which shall be received by the Board at least three (3) working days prior to the date set for hearing in the matter. Section 6. Default in Licensee Answering or Appearing. In the event of the failure of a licensee to answer or otherwise appear within the time allowed, a default may be entered and the allegations as set forth in the Notice and Complaint shall be taken as true and an Order of the Board entered accordingly. Section 7. Discovery. In all contested cases coming before the Board, the taking of depositions and discovery shall be available to the parties. Section 8. Subpoenas. Subpoenas for appearance and to produce testimony, books, papers, documents, or exhibits may be issued by the Board or hearing officer on behalf of any party to the contested case. Section 9. Contested Case Hearing. All issues and matters set forth in the Notice and Complaint shall be presented to the Board. A licensee may be represented by an attorney, licensed to practice law in this State or otherwise associated at the hearing with an attorney licensed to practice law in this State. Section 10. Hearing Officer. The Board may employ and secure a hearing officer to assist and advise the Board in the conduct of a hearing and the preparation of recommended findings of fact, conclusions of law and order. Section 11. Order of Procedure. As nearly as may be, hearings shall be conducted in accordance with the following order of procedure: (a) The Board or hearing officer shall announce that the hearing is convened upon the call of the docket number and title of the matter and case to be heard, and thereupon the Board or hearing officer shall incorporate all pleadings into the record and shall note for the record all subpoenas issued and all appearances of record; (b) All persons testifying at the hearing shall be administered the standard oath;

(c) The attorney or representative of the State shall thereupon proceed to present the State's evidence. Witnesses may be cross-examined by the licensee or attorney if represented. Redirect examination may be permitted;

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(d) The licensee shall be heard in the same manner as the State's evidence. The State shall have the opportunity of cross-examination and redirect examination may be permitted; (e) Opening statements may be made;

(f) Closing statements, at the conclusion of the presentation of evidence, may be made by parties or attorneys. A rebuttal statement may be made by the State. The time for oral argument may be limited by the Board or hearing officer; (g) After all proceedings have been concluded, the Board or hearing officer shall dismiss and excuse all witnesses and declare the hearing closed. Any party who may wish or desire to tender written briefs of law unto the Board may do so. The Board may take the case under advisement and shall declare unto each of the parties that the decision of the Board shall be announced within due and proper time following consideration of all the matters presented at the hearing; and (h) The Board and hearing officer shall retain the right and opportunity to examine any witness upon the conclusion of all testimony offered by a particular witness. Section 12. Rules of Civil Procedure to Apply. The rules of practice and procedure contained in the Wyoming Rules of Civil Procedure insofar as they are applicable and not inconsistent with the matters before the Board and applicable to the rules and orders promulgated by the Board shall apply. Section 13. Attorneys. The filing of an answer or other appearance by an attorney constitutes an appearance for the party for whom the pleading is filed. The Board and all parties shall be notified in writing of any withdrawal. Any person appearing before the Board at a hearing in a representative capacity shall be precluded from examining or cross-examining any witness unless the person is an attorney licensed to practice law in this State, or associated with an attorney licensed to practice law in this State. This rule shall not be construed to prohibit any licensee from representing themselves in any hearing before the Board, but any licensee appearing in their own behalf shall not be relieved of abiding by all rules established for the hearing proceedings. Section 14. Attorney General to be Present. In all hearings held upon formal action brought before the Board, a representative of the Office of the Attorney General of Wyoming shall appear on behalf of the State, and shall present all evidence, testimony and legal authority in support of the Notice and Complaint to be considered by the Board. Section 15. Record of Proceedings. When the denial, revocation or suspension of any license or certification is the subject for hearing, it shall be regarded as a contested case and the proceedings, including all testimony, shall be reported verbatim by a court reporter or other adequate recording device.

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Section 16. Decision, Findings of Fact and Conclusions of Law and Order. (a) The Board shall, with the assistance of the hearing officer if requested, following the full and complete hearing, make and enter a written decision and order containing findings of fact and conclusions of law. The decision and order shall be filed with the Board and shall, without further action, become the decision and order as a result of the hearing. (b) No member, staff or agent of the Board who participated or advised in the investigation or presentation of evidence at the hearing shall participate or advise in the decision. (c) Upon entry and filing, the Board shall mail copies of the decision to each licensee and attorneys of record. Section 17. Appeals to District Court. Appeals from Board decisions shall be taken to the district court having jurisdiction and proper venue in accordance with applicable statutes and the Wyoming Rules of Appellate Procedure. Section 18. Transcript in Case of Appeal. In the case of an appeal to the district court, the appellant shall pay and arrange for the transcript of the testimony. The transcript shall be verified by the oath of the reporter who took the testimony as a true and correct transcript of the testimony and other evidence in the case.

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Drug 10-12 L/min 10 L/min Mask or Bag and mask Until maternal/fetal stabilization is achieved or transfer to hospital is complete. Until stabilization is achieved or transfer to a hospital is complete. 1-2 doses. Transport to hospital required if more than two (2) doses are administered 1-2 doses. Transport to hospital required if more than 2 doses are administered. Not to exceed 800 micrograms.

Indication

Dose

Route of Administration

\Duration of Treatment

Oxygen

Maternal/Fetal Distress

Neonatal Resuscitation 10-12 L/min 10 L/min 10 Units/ml Intramuscularly only Mask or Bag and mask

Oxytocin (Pitocin) 200 microgram tabs, as Rectal or 800 micrograms per dose sublingual, or may (4 tabs). be used as ½ rectally and ½ sublingually

Postpartum hemorrhage only

Misoprostol

Postpartum hemorrhage only

APPENDIX A

DRUG FORMULARY

A licensed midwife may use the drugs described in the midwifery formula according to the following protocol describing the indication for use, dosage, route of administration and duration of treatment:

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0.2 mg Percutaneous infiltration only

(Note that this is off label use of this drug, but an appropriate use.) Intramuscularly or Single dose. Every six hours, may orally repeat 3 times. Contraindicated in hypertension and Raynaud’s Disease. Completion of repair

Methylergonovine (Methergine)

Postpartum hemorrhage only

Lidocaine HCl 1% Or 2%

Local anesthetic for Maximum 50 ml (1%) use during postpartum repair of lacerations Maximum 15 ml (2%) or episiotomy

Penicillin G Group B Strep (Recommended) Prophylaxis

5 million units initial dose, IV in > 100 ml LR, Birth of baby then 2.5 million units every NS or D5LR 4 hours until birth 2 grams initial dose, then 1 IV in > 100 ml NS Birth of baby gram every 4 hours until birth

Ampicillin Sodium (Alternative)

Group B Strep Prophylaxis

Drug

Indication

Dose

Route of Administration Duration of Treatment

Cefazolin Sodium Group B Strep Prophylaxis

2 grams initial dose, then IV in > 100 ml LR, Birth of baby 1 gram every 8 hours NS or D5LR

(Drug of choice for penicillin allergy with low risk for anaphylaxis) Group B Strep Prophylaxis 900 mg every 8 hours IV in > 100 ml NS or Birth of baby LR

Clindamycin Phosphate

(Drug of choice for penicillin allergy with high risk for anaphylaxis)

Epinephrine HCl 1:1000 Treatment or post0.3 ml pre-metered dose As directed exposure prevention of severe allergic reactions

(EpiPen)

Every 20 minutes or until emergency medical services arrive. Administer first dose then immediately request emergency services

A-2 Reconstitution of antibiotic powder As directed As directed

Lactated Ringer’s To achieve maternal (LR) stabilization

1 - 2 liter bags - First liter Intravenous catheter Until maternal stabilization is run in at a wide-open achieved or transfer to a hospital is rate, the second liter complete. titrated to client’s condition

5% Dextrose in To achieve maternal Lactated Ringer’s stabilization solution (D5LR)

500 ml may run in wide Intravenous catheter Until maternal stabilization is open then hydrate to achieved or transfer to a hospital is client’s condition complete. Birth of Baby

0.9% Sodium Chloride (NS)

Drug

Indication

Dose

Route of Administration Duration of Treatment

Sterile H2O Papules

Relief of back labor

0.1-0.5 cc at the 4 corners Subdermally, using 1 to 2 times during labor. Duration of the sacrum, Should be TB syringe and of pain relief is 2 to 4 hours. administered rapidly, one needle. after another, over a 30 to 90 second total period Intramuscularly

Rh(D) Immune Globulin

Prevention of Rh(D) 300 mcg sensitization in Rh(D) negative women

A-3 Prophylaxis for 1 mg Vitamin K Deficiency Bleeding Intramuscularly Prophylaxis of 1 cm ribbon in each eye Topical Neonatal Ophthalmia

Single dose at any gestation for Rh(D) negative, antibody negative women within 72 hours of spontaneous bleeding or abdominal trauma. Single dose at 26-28 weeks gestation for Rh(D) negative, antibody negative women. Single dose for Rh(D) negative, antibody negative women within 72 hours of delivery of Rh(D) positive infant, or infant with unknown blood type. 1 dose

Phylloquinone (Vitamin K1)

0.5% Erythromycin Ophthalmic Ointment

1 dose

APPENDIX B NATIONAL ASSOCIATION OF CERTIFIED PROFESSIONAL MIDWIVES STANDARDS OF PRACTICE 2004 Standard One: The NACPM member works in partnership with each woman she serves. The NACPM member: • Offers her experience, care, respect, counsel and support to each woman she serves

• Freely shares her midwifery philosophy, professional standards, personal scope of practice and expertise, as well as any limitations imposed upon her practice by local regulatory agencies and state law • Recognizes that each woman she cares for is responsible for her own health and wellbeing • Accepts the right of each woman to make decisions about her general health care and her pregnancy and birthing experience • Negotiates her role as caregiver with the woman and clearly identifies mutual and individual responsibilities, as well as fees for her services • Communicates openly and interactively with each woman she serves

• Provides for the social, psychological, physical, emotional, spiritual and cultural needs of each woman • • • Does not impose her value system on the woman Solicits and respects the woman’s input regarding her own state of health Respects the importance of others in the woman’s life.

Standard Two: Midwifery actions are prioritized to optimize well-being and minimize risk, with attention to the individual needs of each woman and baby. The NACPM member: • • Supports the natural process of pregnancy and childbirth Provides continuous care, when possible, to protect the integrity of the woman’s

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experience and the birth and to bring a broad range of skills and services into each woman’s care • Bases her choices of interventions on empirical and/or research evidence, verifying that the probable benefits outweigh the risks • Strives to minimize technological interventions

• Demonstrates competency in emergencies and gives priority to potentially life-threatening situations • Refers the woman or baby to appropriate professionals when either needs care outside her scope of practice or expertise • Works collaboratively with other health professionals

• Continues to provide supportive care when care is transferred to another provider, if possible, unless the mother declines • Maintains her own health and well-being to optimize her ability to provide care.

Standard Three: The midwife supports each woman's right to plan her care according to her needs and desires. The NACPM member: • Shares all relevant information in language that is understandable to the woman

• Supports the woman in seeking information from a variety of sources to facilitate informed decision-making • Reviews options with the woman and addresses her questions and concerns

• Respects the woman’s right to decline treatments or procedures and properly documents her choices • Develops and documents a plan for midwifery care together with the woman

• Clearly states and documents when her professional judgment is in conflict with the decision or plans of the woman • Clearly states and documents when a woman’s choices fall outside the NACPM member’s legal scope of practice or expertise • Helps the woman access the type of care she has chosen

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• May refuse to provide or continue care and refers the woman to other professionals if she deems the situation or the care requested to be unsafe or unacceptable • Has the right and responsibility to transfer care in critical situations that she deems to be unsafe. She refers the woman to other professionals and remains with the woman until the transfer is complete. Standard Four: The midwife concludes the caregiving partnership with each woman responsibly. The NACPM member: • Continues her partnership with the woman until that partnership is ended at the final postnatal visit or until she or the woman ends the partnership and the midwife documents same • Ensures that the woman is educated to care for herself and her baby prior to discharge from midwifery care • Ensures that the woman has had an opportunity to reflect on and discuss her childbirth experience • Informs the woman and her family of available community support networks and refers appropriately. Standard Five: The NACPM member collects and records the woman’s and baby's health data, problems, decisions and plans comprehensively throughout the caregiving partnership. The NACPM member: • Keeps legible records for each woman, beginning at the first formal contact and continuing throughout the caregiving relationship • Does not share the woman’s medical and midwifery records without her permission, except as legally required • Reviews and updates records at each professional contact with the woman

• Includes the individual nature of each woman’s pregnancy in her assessments and documentation • • Uses her assessments as the basis for on-going midwifery care Clearly documents her objective findings, decisions and professional actions

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• Documents the woman’s decisions regarding choices for care, including informed consent or refusal of care • Makes records and other relevant information accessible and available at all times to the woman and other appropriate persons with the woman's knowledge and consent • Files legal documents appropriately.

Standard Six: The midwife continuously evaluates and improves her knowledge, skills and practice in her endeavor to provide the best possible care. The NACPM member: • Continuously involves the women for whom she provides care in the evaluation of her practice • • Uses feedback from the women she serves to improve her practice Collects her practice statistics and uses the data to improve her practice

• Informs each woman she serves of mechanisms for complaints and review, including the NARM peer review and grievance process • • • • Participates in continuing midwifery education and peer review May identify areas for research and may conduct and/or collaborate in research Shares research findings and incorporates these into midwifery practice as appropriate Knows and understands the history of midwifery in the United States

• Acknowledges that social policies can influence the health of mothers, babies and families; therefore, she acts to influence such policies, as appropriate. Copyright © 2004 National Association of Certified Professional Midwives, All Rights Reserved. Reprinted with permission.

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