Section SPS 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. 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. SPS 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 post-partum 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.s. Labor prior to the 37th week of gestation.t. History of prior uterine incision.u. Lie other than vertex at term.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.za. Evidence of intrauterine growth restriction.zb. Significant abnormal ultrasound findings.zc. 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.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.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.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.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 uterineatony.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.(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.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.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.Wis. Admin. Code Department of Safety and Professional Services SPS 182.03
CR 06-096: cr. Register December 2006 No. 612, eff. 5-1-07; renumbers to (4) (b) 1. za., zb. and zc. made under s. 13.93(2m) (b) 1, Stats., Register November 2007 No. 623.