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Sub-Chapter
6
Licensing and Scope
of Practice - Direct-Entry Midwifery
24.111.601
MINIMUM DIRECT-ENTRY MIDWIFE EDUCATION STANDARDS
(1) The board may approve a direct-entry midwife
program or course of study which shall include instruction in a
core program which requires each student to demonstrate
competence in each of the following substantive content areas:
(a)
antepartum care, including:
(i)
preconceptional factors likely to influence pregnancy outcome;
(ii)
basic genetics, embryology and fetal development;
(iii)
anatomy and assessment of the soft and bony structure of the
pelvis;
(iv)
identification and assessment of the normal changes of
pregnancy, fetal growth and position;
(v)
nutritional requirements for pregnant women and methods of
nutritional assessment and counseling;
(vi)
environmental and occupational hazards for pregnant women;
(vii)
education and counseling to promote health throughout the
childbearing cycle;
(viii)
methods of diagnosing pregnancy;
(ix)
the etiology, treatment and referral, when indicated, of the
common discomforts of pregnancy;
(x)
assessment of physical and emotional status, including relevant
historical and psycho-social data;
(xi)
counseling for individual birth experiences, parenthood and
changes in the family;
(xii)
indications for, risks and benefits of screening/diagnostic
tests used during pregnancy;
(xiii)
etiology, assessment of, treatment for and appropriate referral
for abnormalities of pregnancy;
(xiv)
identification of, implications of and appropriate treatment for
various STD/vaginal infections during pregnancy;
(xv)
special needs of the Rh negative woman; and
(xvi)
identification and care of women who are HIV positive, have
hepatitis or other communicable and non-communicable diseases.
(b)
intrapartum care, including:
(i)
normal labor and birth processes;
(ii)
anatomy of the fetal skull and its critical landmarks;
(iii)
parameters and methods for assessing maternal and fetal status,
including relevant historical data;
(iv)
emotional changes and support during labor and delivery;
(v)
comfort and support measures during labor, birth, and
immediately postpartum;
(vi)
techniques to facilitate the spontaneous vaginal delivery of the
baby and placenta;
(vii)
etiology, assessment of, appropriate referral or transport of
and/or emergency measures (when indicated) for the mother or
newborn for abnormalities of the four stages of labor;
(viii)
anatomy, physiology, and supporting normal adaptation of the
newborn to extrauterine life;
(ix)
familiarity with medical interventions and technologies used
during labor and birth; and
(x)
assessment and care of the perineum and surrounding tissues,
including suturing necessary for perineal repair.
(c)
postpartum care, including:
(i)
anatomy and physiology of the postpartum period;
(ii)
anatomy and physiology and support of lactation, and appropriate
breast care and assessment;
(iii)
parameters and methods for assessing and promoting postpartum
recovery;
(iv)
etiology and methods for managing the discomforts of the
postpartum period;
(v)
emotional, psycho-social and sexual changes which may occur
postpartum;
(vi)
nutritional requirement for women during the postpartum period;
(vii)
etiology, assessment of, treatment for and appropriate referral
for abnormalities of the postpartum period;
(viii)
methods to assess the success of the breastfeeding relationship
and identify lactation problems, and mechanisms for making
appropriate referrals;
(ix)
suturing necessary for episiotomy repair;
(x)
dispensing and administering pitocin (intramuscular) postpartum;
and
(xi)
dispensing and administering xylocaine (subcutaneous).
(d)
neonatal care, including:
(i)
anatomy and physiology of the newborn's adaptation and
stabilization in the first hours and days of life;
(ii)
parameters and methods for assessing newborn status, including
relevant historical data at gestational age;
(iii)
nutritional needs of the newborn;
(iv)
ARM and MCA standards for an administration of prophylactic
treatments commonly used during the neonatal period;
(v)
ARM and MCA standards for indications, risks and benefits of,
and method of performing common screening tests for the newborn;
and
(vi)
etiology, assessment of (including screening and diagnostic
tests), emergency measures and appropriate transport/referral or
treatments for neonatal abnormalities.
(e)
health and social sciences, including:
(i)
communication, counseling and teaching techniques, including the
areas of client education and interprofessional collaboration;
(ii)
human anatomy and physiology relevant to human reproduction;
(iii)
ARM and MCA standards of care, including midwifery and medical
standards for women during the childbearing cycle;
(iv)
inter-professional communication and collaboration with
community health and social resources for women and children;
(v)
significance of and methods for thorough documentation of client
care through the childbearing cycle;
(vi)
informed decision making;
(vii)
health education, health promotion, and self care;
(viii)
the principles of clean and aseptic techniques, and universal
precautions;
(ix)
psychosocial, emotional and physical components of human
sexuality, including indications of common problems and method
of counseling;
(x)
ethical considerations relevant to reproductive health;
(xi)
epidemiologic concepts and terms relevant to perinatal and
women's health;
(xii)
the principles of how to access and evaluate current research
relevant to midwifery practice;
(xiii)
family centered care, including maternal, infant and family
bonding;
(xiv)
identification of an appropriate referral of disease in women
and their families; and,
(xv)
the importance of accessibility, quality health care for all
women that includes continuity of care, and special requirements
for home births.
(2)
The applicant shall submit certificates of completion or
certified transcripts sent directly from the institution, as
verification the education is equivalent to or exceeds the
minimum direct-entry midwife educational standards required by
the board's laws and rules.
(3)
The applicant shall submit course and program descriptions, from
the time of applicant's graduation or completion, found in
pertinent institution catalogs and brochures, to verify the
training received fulfills minimum direct-entry midwife
educational standards.
(4)
The board reserves the right to evaluate individual applications
as to their compliance with equivalent direct-entry midwife
educational standards, on a case-by-case basis, in the sole
discretion of the board. (History: 37-27-105, MCA; IMP,
37-27-201, MCA; NEW, 1992 MAR p. 2722, Eff. 12/25/92; TRANS,
from Commerce, 2001 MAR p. 1642.)
24.111.602
DIRECT-ENTRY MIDWIFE APPRENTICESHIP REQUIREMENTS
(1) The direct-entry midwife apprenticeship license
program shall be that instructional period composed of practical
experience time obtained under the personal supervision of a
supervisor approved by the board. A direct- entry midwife
apprentice shall not work alone, except at the discretion of the
licensed supervisor under level III as defined below.
(2)
Applicants for a direct-entry midwife apprenticeship license
shall submit a completed application with the proper fee, a
current CPR card indicating certification to perform adult and
infant cardiopulmonary resuscitation, a supervision agreement
and a curriculum outline or method of academic learning that
meets the board's educational rule requirements for licensure.
A supervision agreement shall include:
(a)
name of supervisor who shall be a licensed direct- entry
midwife, a certified nurse midwife, a licensed naturopathic
physician who is certified for the specialty practice of
childbirth attendance or a physician licensed under Title 37,
chapter 3, MCA;
(b)
agreement of parties that supervisor will provide personal
supervision of the direct-entry midwife apprentice during levels
I and II, and may, at the supervisor's discretion, allow the
direct-entry midwife apprentice to work under indirect
supervision during level III only;
(c)
agreement of supervisor to supervise no more than four
direct-entry midwife apprentices at the same time.
(3)
A level I direct-entry midwife apprenticeship is served under
the personal supervision of the licensed supervisor, with a
focus on prenatal care. To complete level I, the
direct-entry midwife apprentice shall:
(a)
observe 40 births;
(b)
provide 20 prenatal examinations;
(c)
complete level I skills checklist;
(d)
submit evaluation of skills and educational progress form, with
written verification by supervisor of completion of level I.
(4)
A level II direct-entry midwife apprenticeship is served under
the personal supervision of the licensed supervisor, with a
focus on birth, postpartum and newborn care. To complete level
II, the direct-entry midwife apprentice shall:
(a)
attend 10 births as primary birth attendant, which births are
verified by signed birth certificates, or affidavit from
supervisor;
(b)
provide 40 prenatal examinations;
(c)
submit prenatal protocols;
(d)
complete level II skills checklist;
(e)
submit evaluation of skills and educational progress form, with
written verification by supervisor of completion of level II.
(5)
A level III direct-entry midwife apprenticeship is served as
either level III-A, as defined below, under the personal
supervision of the licensed supervisor or as level III-B, as
defined below, under indirect supervision. The focus of
level III shall be continuous prenatal, perinatal and postnatal
care. To complete level III, the direct-entry midwife
apprentice shall:
(a)
complete 15 continuous care births as the primary attendant,
which are verified by signed birth certificates, or affidavit
from supervisor;
(i)
documentation of 15 continuous care births must show at least
five prenatal visits beginning on or before the 28th week of
gestation, as determined by last menstrual period or sonogram,
and include one post-natal visit. Ten of the 15 continuous
care births must have occurred under the personal supervision of
a qualified supervisor.
(b)
provide 40 prenatal examinations;
(c)
submit protocols for birth, postpartum and newborn care;
(d)
complete level III skills checklist;
(e)
submit evaluation of skills and educational progress form, with
written verification by supervisor of completion of level III.
(6)
Level III direct-entry midwife apprentices are separated as
follows:
(a)
A level III-A direct-entry midwife apprentice shall require
personal supervision in the form of the physical presence of the
licensed supervisor;
(b)
A level III-B direct-entry midwife apprentice shall require
indirect supervision in that the physical presence of the
licensed supervisor is not always required. Level III-B
may only be implemented upon prior board approval after the
following requirements have been met:
(i)
verification of completion of 10 personally supervised
continuous care births, as required by ARM 24.111.604;
(ii)
verification of completion of at least 75% of
educational/academic requirements for full licensure;
(iii)
a formal outline of the method of indirect supervision
communication shall be submitted in writing to the board for
approval, which shall include supervisor chart review and may
include telephone contact supervision.
(7)
Direct-entry midwife apprenticeship applicants who have, at the
time of application, through an apprenticeship or other
supervisory setting, participated as the primary birth attendant
at 25 births, 15 of which included continuous care, may enter
directly into direct-entry midwife apprenticeship license level
III-B. The 25 births and 15 continuous care births shall
be evidenced by the signed birth certificate as primary birth
attendant, an affidavit from the birth mother or documented
records from the applicant, as shown on the birth experience
form prescribed by the board.
(a)
Documentation of 15 continuous care births must show at least
five prenatal visits beginning on or before the 28th week of
gestation, as determined by last menstrual period or sonogram,
and include one post-natal visit. Ten of the 15 continuous
care births must have occurred under the personal supervision of
a qualified supervisor.
(8)
To be approved by the board as a supervisor of a direct-entry
midwife apprentice, each supervisor shall:
(a)
be currently licensed in good standing as a direct- entry
midwife, a certified nurse midwife, a licensed naturopathic
physician who is certified for the specialty practice of
naturopathic childbirth attendance or a physician licensed under
Title 37, chapter 3, MCA. A licensed direct-entry midwife
supervisor shall have been licensed for one year and have 20
continuous care births as primary attendant, before becoming a
supervisor for level II and III apprentices, except for those
licensees who have successfully passed the first licensing exam
administered by the board. A licensed direct-entry midwife
who has not been licensed for one year and/or completed 20
continuous care births may only supervise level I apprentices;
(b)
review and sign all documents required by the board under the
direct-entry midwife apprenticeship program;
(c)
supervise no more than four direct-entry midwife apprentices at
the same time;
(d)
notify the board in writing of any change in the supervisory
relationship, including advancement from personal to indirect
supervision, termination of the supervisory relationship or any
other relevant changes;
(e)
be directly responsible for all activities undertaken by the
apprentice(s) under their supervision agreement. Violation
of the board statutes or rules may result in license discipline
action against the direct-entry midwife apprentice, or
supervisor, or both. (History: 37-27-105, MCA; IMP,
37-27-201, 37-27-205, 37-27-210, 37-27-321, MCA; NEW,
1992 MAR p. 2498, Eff. 11/26/92; AMD, 1993 MAR p. 1639,
Eff. 7/30/93; AMD, 1996 MAR p. 2576, Eff. 10/4/96; AMD,
2000 MAR p. 456, Eff. 2/11/00; TRANS, from Commerce, 2001
MAR p. 1642.)
24.111.603
DIRECT-ENTRY MIDWIFE PROTOCOL STANDARD LIST REQUIRED FOR
APPLICATION (1) The antepartum
protocol standards include, but are not limited to, the
following:
(a)
abruptio placenta (suspected);
(b)
anemia;
(c)
bleeding, first, second and third trimesters;
(d)
breech presentation;
(e)
candidiasis;
(f)
care schedule;
(g)
date/size discrepancy;
(h)
ectopic pregnancy;
(i)
fetal demise first, second, third trimester;
(j)
genetic counsel;
(k)
glycosuria/glucose screen;
(l)
group beta strep;
(m)
hepatitis B;
(n)
HIV;
(o)
human papilloma virus (HPV);
(p)
hyperemesis gravidarum;
(q)
internal pelvic examination;
(r)
intrauterine growth retardation;
(s)
minor pregnancy discomfort (heartburn, constipation, insomnia,
etc.);
(t)
placenta previa (suspected);
(u)
polyhydramnios;
(v)
post dates pregnancy;
(w)
pregnancy induced hypertension (mild, severe);
(x)
proteinuria;
(y)
Rh negative;
(z)
sexually transmitted diseases (chlamydia, herpes, bacterial
vaginosis, gonorrhea, trichomosis, etc.);
(aa)
transfer of care/termination of midwife-parent relationship;
(ab)
twins (diagnosis of);
(ac)
ultrasound (indications for);
(ad)
urinary tract infection;
(ae)
vaginal birth after cesarean.
(2)
The intrapartum protocol standards include, but are not limited
to, the following:
(a)
amnionitis/chorioamnionitis;
(b)
bleeding in labor;
(c)
care schedule;
(d)
edematous cervical lip;
(e)
emergency breech delivery;
(f)
emergency twin delivery;
(g)
face presentation;
(h)
fetal distress;
(i)
fetal heart rate evaluation;
(j)
indications for transfer of care;
(k)
meconium staining;
(l)
nuchal cord;
(m)
oxygen in labor;
(n)
perineal support;
(o)
placenta abruptio;
(p)
posterior fetal presentation;
(q)
premature labor;
(r)
prolonged rupture of membranes;
(s)
prolapsed cord;
(t)
shoulder dystocia;
(u)
stillbirth;
(v)
vaginal birth after cesarean.
(3)
The postpartum protocol standards include, but are not limited
to, the following:
(a)
assessment of placenta;
(b)
breast care;
(c)
care schedule;
(d)
delivery of placenta;
(e)
depression;
(f)
hematoma;
(g)
hemorrhage;
(h)
hemorrhoids;
(i)
perineal second degree laceration or episiotomy repair (suture);
(j)
preparation of mother for transport;
(k)
retained placenta (manual removal);
(l)
Rh negative mom;
(m)
shock;
(n)
subinvolution;
(o)
uterine infection;
(p)
uterine inversion.
(4)
The newborn protocol standards include, but are not limited to,
the following:
(a)
care schedule (postpartum visits);
(b)
eye prophylaxis;
(c)
hypoglycemia (suspected);
(d)
hypothermia;
(e)
infection (suspected sepsis)
(f)
evaluation of jaundice;
(g)
neonatal resuscitation;
(h)
newborn examination to include gestational age determination and
assessment of minor anomalies;
(i)
newborn metabolic screening;
(j)
normal newborn transition to include maintenance of body
temperature, cardiopulmonary function;
(k)
normal infant feeding patterns;
(l)
polycythemia (suspected);
(m)
preparation of infant for transport;
(n)
problems of large- and small-for-gestational-age infants;
(o)
respiratory distress;
(p)
umbilical cord care;
(q)
vitamin K administration. (History: 37-1-131,
37-27-105, MCA; IMP, 37-27-201, MCA; NEW, 1999 MAR
p. 2038, Eff. 9/24/99; TRANS, from Commerce, 2001 MAR p.
1642; AMD, 2001 MAR p. 1644, Eff. 8/24/01.)
24.111.604
LICENSING BY EXAMINATION (1)
Applicants for direct-entry midwifery licensure by examination
shall submit a completed application with the proper fees and
supporting documents, at least 90 days prior to the examination
date, to the board office. Applications for licensure by
examination shall expire one year from the date of receipt of
the application. An applicant who, for any reason, fails
or neglects to take the examination within the year shall be
required to file another application and submit another
application fee. Supporting documents shall include:
(a)
written documentation of good moral character consisting of
three letters of reference, at least one of which must be from a
licensed direct-entry midwife;
(b)
a copy of a certified transcript sent directly from a high
school, showing evidence the applicant has graduated from the
school;
(c)
a GED or other high school equivalency program certificate of
completion; or
(d)
any other documents, affidavits and certificates required by
37-27-201 or 37-27-203, MCA, whichever is applicable, and board
rules;
(i)
documentation of 15 continuous care births must show at least
five prenatal visits beginning on or before the 28th week of
gestation, as determined by last menstrual period or sonogram,
and include one postnatal visit. Ten of the 15 continuous
care births must have occurred under the personal supervision of
a qualified supervisor.
(2)
All applicants shall take the North American registry of
midwives (NARM) examination as endorsed by the board, or any
other examination to be prescribed or endorsed by the board, and
have their scores reported to the board office by the proper
NARM interstate reporting service, or its equivalent. All
applicants for NARM examination shall:
(a)
sit for the NARM examination only when administered by the
board, at its designated Montana site, or when administered by
proper NARM officials in conjunction with the annual midwives
alliance of North America (MANA) national meeting;
(b)
achieve a scaled score of 75%.
(3)
All applicants shall comply with the adult and infant
cardiopulmonary resuscitation certification requirement set
forth in 37-27-201, MCA, and provide a photocopy of a current
CPR card, which must remain valid throughout the license period.
(4)
Applicants who fail the licensing examination twice shall in
addition to being retested, file in advance with the board a
plan regarding arrangements for securing further professional
training and experience. (History: 37-27-105, MCA; IMP,
37-27-201, 37-27-202, 37-27-203, MCA; NEW, 1992 MAR p.
2048, Eff. 9/11/92; AMD, 1993 MAR p. 1639, Eff. 7/30/93; AMD,
1998 MAR p. 529, Eff. 2/27/98; AMD, 1999 MAR p. 2038, Eff.
9/24/99; TRANS, from Commerce, 2001 MAR p. 1642.)
24.111.605
LICENSURE OF OUT-OF-STATE APPLICANTS (1)
A license to practice as a direct-entry midwife in the state of
Montana may be issued at the discretion of the board provided
the applicant completes and files with the board an application
for licensure and the required application fee.
Applications for licensure from out-of-state applicants shall
expire one year from the date of receipt of the application.
The candidate must meet the following requirements:
(a)
The candidate holds a current, valid and unrestricted license to
practice as a direct-entry midwife in another state or
jurisdiction, which was issued under standards equivalent to or
greater than current standards in this state. Official
written verification of such licensure status must be received
by the board directly from the other state(s) or jurisdiction(s);
(b)
The candidate shall supply a copy of a high school diploma or
its equivalent, plus verification in the form of certified
transcripts sent directly from an institute of higher education,
or certificates of completion from other courses of study,
indicating the candidate has successfully completed educational
requirements in pregnancy and natural childbirth, approved by
the board as per ARM 24.111.601;
(c)
The candidate shall supply proof of successful completion of all
parts of the North American registry of midwives (NARM)
examination with a scaled score of 75 or higher. Candidate
scores on the examination must be forwarded by the exam agency
directly to the board;
(d)
Candidates who were licensed without sitting for the NARM
examination shall supply proof of successful completion of a
qualifications examination (acceptable to the board)
administered by the licensing authority of the state or
jurisdiction granting the license.
(e)
The candidate shall supply written documentation of good moral
character consisting of three letters of reference, at least one
of which must be from a licensed direct-entry midwife;
(f)
The candidate shall supply a copy of the laws and rules from the
state of licensure, which were in effect at the time the license
was granted in the other state. (History: 37-27-105,
MCA; IMP, 37-1-304, 37-27-202, MCA; NEW, 1996 MAR
p. 2576, Eff. 10/4/96; AMD, 1998 MAR p. 921, Eff.
4/17/98; AMD, 1999 MAR p. 2038, Eff. 9/24/99; TRANS,
from Commerce, 2001 MAR p. 1642; AMD, 2001 MAR p. 1644,
Eff. 8/24/01.)
Rules
24.111.606 through 24.111.609 reserved
24.111.610
HIGH RISK PREGNANCY: CONDITIONS REQUIRING PRIMARY CARE BY
A PHYSICIAN (1) If the following
conditions are present, the licensed direct-entry midwife shall
not accept the woman as a client:
(a)
Chronic medical problems:
(i)
cardiac disease (Class II or greater);
(ii)
diabetes mellitus (Class II or greater);
(iii)
essential hypertension (greater than 140/90 Hg, not controlled
by medication);
(iv)
hemoglobinopathies:
(v)
renal disease (chronic, diagnosed, not urinary tract infection);
(vi)
thrombophlebitis or pulmonary embolism;
(vii)
epilepsy currently on medication;
(viii)
current severe psychiatric condition requiring medication within
a six month period prior to pregnancy;
(ix)
active: tuberculosis, syphilis, gonorrhea, strep B,
hepatitis, AIDS, genital herpes at onset of labor;
(x)
current drug or alcohol abuse/dependency;
(xi)
current malignant disease;
(xii)
chronic obstructive pulmonary disease, except for controlled
asthma.
(b)
Current pregnancy related conditions:
(i)
pregnancy induced hypertension (pre-eclamptic or eclamptic
symptoms);
(ii)
premature labor (before 36 1/2 weeks gestation verified
estimated date of delivery by dates and physical exam);
(iii)
placental abruption;
(iv)
placenta previa at onset of labor;
(v)
has a fetus in any presentation other than vertex at onset of
labor;
(vi)
multiple gestation;
(vii)
contracts primary genital herpes in the first trimester;
(viii)
Rh sensitization.
(c)
Previous obstetrical history:
(i)
previous Rh sensitization;
(ii)
history of inverted uterus. (History: 37-27-105,
MCA; IMP, 37-27-105, MCA; NEW, 1993 MAR p. 1639,
Eff. 7/30/93; AMD, 1995 MAR p. 2684, Eff. 12/8/95; TRANS,
from Commerce, 2001 MAR p. 1642.)
24.111.611
CONDITIONS WHICH REQUIRE PHYSICIAN CONSULTATION OR TRANSFER OF
CARE (1) If the following
conditions are present in a client, the direct-entry midwife
shall attempt to consult a physician and/or transfer care to a
physician. A certified nurse midwife or licensed
direct-entry midwife shall also be consulted if appropriate
attempts to consult a physician have been unsuccessful.
Documentation of the condition, recommendation (including
continuation of care by the licensed direct-entry midwife, if
appropriate) and treatment must be maintained in the client
records. Conditions include, but are not limited to the
following:
(a)
Prenatal factors:
(i)
severe hyperemesis;
(ii)
rubella contracted in the first or second trimester;
(iii)
maternal anemia (hemoglobin less than 10, hematocrit less than
30) unresponsive within one month of treatment;
(iv)
oligohydramnios (suspected);
(v)
polyhydramnios (suspected);
(vi)
premature rupture of membranes at less than 36 1/2 weeks;
(vii)
post term at 42 weeks by dates and physical exam;
(viii)
large for gestational age (LGA) or small for gestational age (SGA)
(suspected);
(ix)
Rh sensitization in present pregnancy (not resulting from recent
Rhogam);
(x)
history of severe postpartum hemorrhage requiring transfusion;
(xi)
known serious maternal viral/bacterial infection at term;
(xii)
blood pressure greater than 140/90 or increase of 30 mm Hg
systolic or 15 mm Hg diastolic over baseline, that is unresolved
within seven days;
(xiii)
develops signs and symptoms of pre-eclampsia;
(xiv)
develops signs and symptoms of gestational diabetes;
(xv)
has unresolved vaginitis that requires antibiotic treatment;
(xvi)
has unresolved urinary tract infection;
(xvii)
continued vaginal bleeding before onset of labor;
(xviii)
signs of fetal distress including prolonged fetal tachycardia
(more than 170) or prolonged fetal bradycardia (less than 100),
or fetal demise;
(xix)
persistent fever;
(xx)
history of pre-term delivery (less than 36 1/2 weeks);
(xxi)
positive maternal diagnosis of HIV;
(xxii)
abnormal Pap smear (showing atypia or CIN);
(xxiii)
all condylomas;
(xxiv)
grand multiparity;
(xxv)
maternal age less than 16 or greater than 40;
(xxvi)
history of previous stillbirth;
(xxvii)
history of incompetent cervix;
(xxviii)
history of previous birth with Erb's Palsy or fractured clavicle
or humerus;
(xxix)
history of neonatal anomaly; or
(xxx)
history of previous cesarean birth.
(b)
Labor, birth risks, and postpartum factors:
(i)
significant fetal distress including prolonged fetal tachycardia
(more than 170) or prolonged fetal bradycardia (less than 100);
(ii)
unengaged vertex above -3 station in primipara in active labor;
(iii)
fever of 102 degrees Fahrenheit or greater;
(iv)
prolonged rupture of membranes (greater than 24 hours with no
progress of labor);
(v)
thick meconium stained fluid with delivery not imminent;
(vi)
severe bleeding prior to or during delivery;
(vii)
maternal respiratory distress;
(viii)
mother desires consult or transfer;
(ix)
maternal hemorrhage uncontrolled by IM pitocin;
(x)
third or fourth degree perineal laceration;
(xi)
signs of infection;
(xii)
evidence of thrombophlebitis.
(c)
Newborn risk factors:
(i)
less than three vessels in umbilical cord;
(ii)
Apgar score less than 7 at five minutes;
(iii)
fails to urinate or move bowels within 24 hours;
(iv)
obvious anomaly;
(v)
respiratory distress;
(vi)
cardiac irregularities;
(vii)
pale cyanotic or gray color;
(viii)
abnormal cry;
(ix)
jaundice within 24 hours of birth;
(x)
signs of prematurity, dysmaturity, or post-maturity;
(xi)
lethargic;
(xii)
has edema;
(xiii)
signs of hypoglycemia;
(xiv)
abnormal facial expression;
(xv)
abnormal body temperature (outside the 97-100ºF range, not
resolved within one hour;
(xvi)
abnormal neurological signs, including jitteriness, decreased
tones, seizures or poor sucking reflex; or
(xvii)
inability to nurse after 12 hours. (History:
37-27-105, MCA; IMP, 37-27-105, MCA; NEW, 1993 MAR
p. 1639, Eff. 7/30/93; AMD, 1994 MAR p. 386, Eff.
2/25/94; AMD, 1995 MAR p. 2684, Eff. 12/8/95; TRANS,
from Commerce, 2001 MAR p. 1642.)
24.111.612
VAGINAL BIRTH AFTER CESAREAN (VBAC) DELIVERIES (1)
A licensed direct-entry midwife shall not assume primary
responsibility for prenatal care and/or birth attendance for
women who have had a previous cesarean section, unless all of
the following conditions are met:
(a)
An informed consent statement, on a form prescribed by the
board, shall be signed by all prospective VBAC parents and the
licensee, and retained in the licensee's records. The form
shall include:
(i)
VBAC educational information, including history of VBAC and
client's own personal information;
(ii)
associated risks and benefits of VBAC at home;
(iii)
a workable hospital transport plan;
(iv)
alternatives to VBAC at home;
(v)
other information as required by the board.
(b)
A workable hospital transport plan must be established for home
VBAC. The plan shall include:
(i)
provision for physician/hospital back-up, e.g., through the
physician/hospital policy on back-up;
(ii)
place of birth within 30 minutes of transport to the nearest
hospital able to perform an emergency cesarean;
(iii)
readily available phone numbers for physician back-up and
nearest hospital, in writing, in client's records;
(iv)
phone contact with nearest hospital at onset of labor and prior
to any transport to notify that transport is in progress; and at
conclusion of home birth if no transport is necessary.
(c)
Licensee shall obtain prior doctor/hospital cesarean records, in
writing, prior to acceptance of the woman as a client, and shall
analyze the indication for the previous cesarean, and retain the
records and a written assessment of the physical and emotional
considerations in licensee's files. Records which show a
previous classical uterine/vertical incision are a
contraindication to VBAC at home, and shall require immediate
transfer of care of the client. If a licensee is unable to
obtain written records, the licensee shall not retain the woman
as a client.
(d)
VBAC deliveries shall be performed by a fully licensed midwife
(not an apprentice licensee), skilled with VBAC support, able to
assess true complications and emergencies, to be present from
the onset of active labor, throughout the immediate postpartum
period.
(2)
The board shall conduct a "sunset" review, including
the necessity for and safety of the VBAC rule, on or about May,
2001, or five years from the effective date of this rule.
(History: 37-27-105, MCA; IMP, 37-27-105, MCA; NEW,
1996 MAR p. 1829, Eff. 7/4/96; TRANS, from Commerce, 2001
MAR p. 1642.)
24.111.613
REQUIRED REPORTS (1) A licensed
direct-entry midwife shall submit semiannual summary reports on
each client, covering the six-month period of January 1 through
July 1, or July 1 through January 1 as appropriate, as required
by 37-27-320, MCA. The reports are due on or before
January 15 and July 15 of each year.
(2)
A licensed direct-entry midwife who is supervising a licensed
midwife apprentice shall be responsible for filing the
statutorily required 72 hour mortality/morbidity report and the
semiannual summary report on clients seen by a level I, II or
III apprentice who is not approved for indirect supervision.
(a)
A level III apprentice direct-entry midwife, approved by the
board for indirect supervision, shall be responsible for filing
the statutorily required 72 hour mortality/morbidity report and
the semiannual summary report.
(b)
Certified nurse midwife, physician or naturopathic supervisors
of an apprentice direct-entry midwife shall be responsible to
ensure the level I, II or III (not approved for indirect
supervision) apprentice files the statutorily required 72 hour
mortality/morbidity report and the semiannual summary reports.
(History: 37-27-105, MCA; IMP, 37-27-320, MCA; NEW,
1993 MAR p. 1639, Eff. 7/30/93; AMD, 1996 MAR p. 2576,
Eff. 10/4/96; TRANS, from Commerce, 2001 MAR p. 1642.)
Sub-Chapters
7 through 20 reserved
Sub-Chapter
21
Renewals and Continuing Education
24.111.2101
RENEWAL (1) All naturopathic
physician licenses, naturopathic specialty certificates and
direct-entry midwife licenses will expire each year, on the date
set by ARM 8.2.208, unless otherwise provided by statute.
A renewal notice will be sent by the board to each
license/certificate holder to the last address in the board's
files. Failure to receive such notice shall not relieve
the license/certificate holder of his/her obligation to pay
renewal fees in such a manner that they are received by the
department on or before the renewal date. All licensees
must submit the proper renewal fee, proper documentation of
completion of appropriate continuing education hours as required
by statute or rule and any other forms or documents required by
the board.
(2)
A renewed license shall be valid for one year following the
expiration date of the previously held license/certificate.
(3)
The fee for any licensee who fails to renew or submit a renewal
fee prior to the expiration date shall be increased by 50% of
his renewal fee. Renewals may not be processed until all
fees are paid.
(4)
Any person failing to renew a license within six months of the
expiration date will be considered to have forfeited the
license. The licensee shall reapply to the board in order
to be relicensed to practice naturopathic medicine or
direct-entry midwifery in this state. (History: 37-26-201,
37-27-105, MCA; IMP, 37-26-201, 37-27-105, MCA; NEW,
1992 MAR p. 555, Eff. 3/27/92; AMD, 1996 MAR p. 2576, Eff.
10/4/96; TRANS, from Commerce, 2001 MAR p. 1642.)
24.111.2102
NATUROPATHIC PHYSICIAN CONTINUING EDUCATION REQUIREMENTS
(1) In accordance with 37-26-201(9), MCA, the
Montana board of alternative health care hereby establishes
requirements for the continuing education of licensed
naturopaths as a condition of license renewal. Training
for entry into the field is not considered adequate assurance of
continued competence throughout a naturopath's career.
Fulfillment of continuing education requirements is viewed as
one necessary vehicle for maintaining standards of professional
practice and for assuring the public of a high standard of
naturopathic services.
(2)
The board/staff will not preapprove continuing education
programs or sponsors. Qualifying criteria for continuing
education are specified in these rules. It is the
responsibility of the licensees to select quality programs that
contribute to their knowledge and competence which also meet
these qualifications.
(a)
The continuing education program must meet the following
criteria:
(i)
The activity must have significant intellectual or practical
content. The activity must deal primarily with substantive
naturopathic issues as contained in the scope of practice of
naturopathy in Montana. In addition, the board may accept
continuing education activities from other professional groups
or academic disciplines if the licensee demonstrates that the
activity is substantially related to his or her role as a
naturopath. A continuing education program is defined as a
class, institute, lecture, conference, workshop, cassette or
video tape.
(ii)
The activity itself must be conducted by an individual or group
qualified by practical or academic experience.
(iii)
All acceptable continuing education courses must issue a program
or certificate of completion containing the following
information: full name and qualifications of the presentor;
title of the presentation attended; number of hours and date of
each presentation attended; name of sponsor; and description of
the presentation format.
(iv)
Preparation for and presentment of a program shall be allowed at
the rate of one continuing education credit for each hour of
preparation or presentment, limited to one presentation of the
program. No more than three credits of continuing
education presentations will be allowed.
(v)
Excluded are programs that promote a company, individual or
product (hosted programs are not approved), and programs whose
subject is practice economics except those programs specifically
dealing with workers' compensation or public health.
(b)
Implementation for continuing education shall be as follows:
(i)
One continuing education credit shall be granted for each hour
of participation in the continuing education activity excluding
breaks and meals. A licensed naturopath must earn at least
15 continuing education credits within the 12 months prior to
renewal on April 30 of each year. (Five must be in
naturopathic pharmacy, five additional in obstetrics if licensee
has childbirth specialty certificate.) A maximum of two
credits by cassette or videotape will be allowed. A
certificate of completion or an outline of course content must
be submitted by the licensee for each cassette or videotape for
the maximum two continuing education credits to be granted.
The total number of continuing education credits obtained via
the internet and/or correspondence courses will be limited to
three credits.
(ii)
No continuing education is required for naturopaths renewing
their license for the first time.
(iii)
All licensed naturopaths must submit to the board, on the
appropriate year's license renewal, a report summarizing their
obtained continuing education credits. The board will
review these reports prior to October 30 of that same year and
notify the licensee regarding his/her noncompliance.
Licensees found to be in noncompliance with the requirement will
be asked to submit to the board for approval a plan to complete
the continuing education requirements for licensure. Prior
to the next consecutive year's license renewal deadline, those
licensees who were found to be in noncompliance will be formally
reviewed to determine their eligibility for license renewal.
Licensees, who at this time have not complied with continuing
education requirements, will not be granted license renewal
until they have fulfilled the board-approved plan to complete
the requirements. Those not receiving notice from the
board regarding their continuing education should assume
satisfactory compliance. Notices will be considered
properly mailed when addressed to the last known address on file
in the board office. No continuing education used to
complete delinquent continuing education plan requirements for
licensure may be used to meet the continuing education
requirements for the next continuing |