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Oregon Bulletin

May 1, 2011

Oregon Health Licensing Agency,
Board of Direct Entry Midwifery
Chapter 332

  • Rule Caption: Amend requirements related to third degree lacerations, peer review, certain breech births, and post-date protocols.
  • Adm. Order No.: DEM 1-2011(Temp)
  • Filed with Sec. of State: 4-4-2011
  • Certified to be Effective: 4-4-11 thru 9-27-11
  • Notice Publication Date:
  • Rules Amended: 332-015-0070, 332-025-0020, 332-025-0021, 332-025-0022, 332-025-0040
  • Subject: Revise administrative rules related to a licensed direct entry midwife (LDM) repairing third degree lacerations. Currently the practice of repairing third degree lacerations is not universally taught during initial education and training for an LDM. Limiting LDMs to only performing first and second degree laceration repairs protects the public because LDMs are consistently trained in those types of repairs.
  •       Amend general practice standards to address those LDMs who do not attend any births from the requirement of peer review.
  •       Amend intrapartum absolute risk criteria to clarify the type of breech that is restricted and requires the transport and transfer of the client.
  •       Amend mother and baby practice standards to provide clearer fetal surveillance requirements related to post-date protocol. (pregnancy lasting longer than 43 weeks gestation).
  •       Amend approved legend drugs for maternal use to add more forms of procaine HCI, including Novocaine and benzocaine.
  • Rules Coordinator: Samantha Patnode—(503) 373-1917
  •  
  • 332-015-0070
  • Approved Legend Drugs and Devices Prescribed Education
  • (1) To be granted a license, an applicant must successfully complete the Initial Legend Drugs and Devices Program consisting of 40 clock hours of instruction in the approved curriculum. Each component of the initial program must be completed within the two years or 24 months immediately preceding the date of application. The initial program must be taught by a MEAC accredited or pre-accredited school, the Oregon Midwifery Council, or by an organization authorized by the Board. The program is composed of theory, hands-on practice, and skills testing for competency.
  • (2) The initial program consists of:
  • (a) Eight clock hours in Pharmacology covering drugs listed in OAR 332-025-0040 and 332-025-0050;
  • (A) Mechanism of Pharmacological Action;
  • (B) Indications;
  • (C) Therapeutic Effects;
  • (D) Side Effects/Adverse Reactions;
  • (E) Contraindications;
  • (F) Incompatibilities/Drug Interactions; and
  • (G) Drug administration including:
  • (i) Dosage;
  • (ii) Dosage Form and Packaging;
  • (iii) Routes of Administration;
  • (iv) Onset of Action;
  • (v) Peak Effect; and
  • (vi) Duration of Action.
  • (b) Four clock hours of administration of medications through injection, which includes:
  • (A) Universal precautions including the use and disposal of sharps;
  • (B) Equipment including:
  • (i) Needles;
  • (ii) Filter Needles (for use with glass ampules);
  • (iii) Syringes;
  • (iv) Skin surface disinfectants; and
  • (v) Medication containers (ampules, multi- and single-use vials).
  • (C) Appropriate injection sites;
  • (D) Procedures for drawing up and administering drugs;
  • (E) Special case: Administration of Medications Intravenously; and
  • (F) Care of equipment.
  • (c) Four clock hours in advanced treatment of shock, which includes:
  • (A) Theory of shock; and
  • (B) Treatment of shock.
  • (d) Ten clock hours in intravenous therapy, which includes:
  • (A) Intravenous fluid therapy;
  • (B) Purpose of IV fluid therapy;
  • (C) Equipment;
  • (D) Appropriate sites;
  • (E) Procedure;
  • (F) Rate of administration; and
  • (G) Care of equipment.
  • (e) Four clock hours in neonatal resuscitation, which includes:
  • (A) Basic life support techniques;
  • (B) Cardio-Pulmonary Resuscitation (CPR);
  • (C) Use of oxygen; and
  • (D) Positive pressure ventilation (bag, valve, mask).
  • (f) 10 clock hours in suturing which includes:
  • (A) Explanation of the pelvic floor and genital anatomy;
  • (B) Assessing the degree of damage for repair;
  • (C) Use of local anesthetic;
  • (D) Equipment including:
  • (i) Sutures;
  • (ii) Needles; and
  • (iii) Instruments.
  • (E) Use of needle holder and working with curved needle;
  • (F) Knot tying (instrument knot);
  • (G) Basic stitching techniques including:
  • (i) Interrupted;
  • (ii) Basting;
  • (iii) Lock Blanket; and
  • (iv) Running mattress.
  • (H) Repairing a simple first-degree tear; and
  • (I) Repairing a second-degree tear;
  • (3) A copy of Board-approved curriculum objectives will be retained on file at the agency and made available upon receipt of a written request and payment of an administrative fee for acquiring public records. Refer to OAR 331-010-0030.
  • Stat. Auth.: ORS 676.615, ORS 687.485 & 687.493
  • Stats. Implemented: ORS 676.615, ORS 687.485 & 687.493
  • Hist.: DEM 1-2001(Temp), f. & cert. ef. 10-1-01 thru 3-29-02; DEM 1-2002, f. 2-25-02 cert. ef. 3-1-02; DEM 1-2004, f. 6-29-04, cert. ef. 7-1-04; DEM 2-2008(Temp), f. 9-15-08 cert ef. 10-1-08 thru 3-30-09; DEM 1-2009, f. 3-31-09, cert. ef. 4-1-09; DEM 4-2010, f. 12-30-10, cert. ef. 1-1-11; DEM 1-2011(Temp), f. & cert. ef. 4-4-11 thru 9-27-11
  •  
  • 332-025-0020
  • General Practice Standards
  • Pursuant to ORS 687.480, licensees must comply with the following practice standards when, advising the mother and in rendering antepartum, intrapartum and postpartum care.
  • (1) A licensee must include the designation LDM after the licensee’s name when completing birth certificates; and
  • (2) As a condition of license renewal, licensees must participate in peer review meetings in their regions or in conjunction with professional organization meeting(s), which must include, but are not limited to, the discussion of cases and obtaining feedback and suggestions regarding care. Documentation must be made on forms approved by the board. Licensees must participate in peer review according to the following schedule:
  • (a) Once per year if the licensee served as the primary birth attendant at 40 or fewer births during the license year; or
  • (b) Twice per year if the licensee served as the primary birth attendant at more than 40 births during the license year.
  • (c) For the purpose of reporting peer review, if there is more than one birth attendant present at the same birth, the birth attendants must designate which birth attendant is primary.
  • (d) If a licensee has not attended any births participation in peer review is not required. Licensee must attest to not having attended any births on a form prescribed by the agency.
  • (3) In accordance with ORS 687.480 and 687.493 a licensee must maintain equipment necessary to: assess maternal, fetal and newborn well being; maintain aseptic technique; respond to emergencies requiring immediate attention; and to resuscitate mother and newborn when attending an out-of-hospital birth.
  • (4) A licensee must dispose of pathological waste resulting from the birth process in accordance with the Department of Human Services Public Health Division under OAR 333 Division 056. Provisions include:
  • (a) Incineration, provided the waste is properly containerized at the point of generation and transported without compaction to the site of incineration; or
  • (b) Burial on private property if burial of human remains on such property is not prohibited or regulated by a local government unit at the designated site.
  • (5) Licensees must dispose of biological waste materials that come into contact with blood and/or body fluids in a sealable plastic bag (separate from sealable trash or garbage liners) or in a manner that protects the licensee, mother, baby, and others who may come into contact with the material during disposal. Biological wastes may also be incinerated or autoclaved in equipment dedicated to treatment of infectious wastes.
  • (6) Licensees must dispose of sharps that come into contact with blood or bodily fluids in a sealable, (puncture proof) container that is strong enough to protect the licensee, mother, baby and others from accidental cuts or puncture wounds during the disposal process.
  • (7) Sharps must be placed into appropriate containers at the point of generation and may be transported without compaction to a landfill having an area designed for sharps burial or transported to an appropriate health care facility equipped to handle sharps disposal, provided the lid of the container is tightly closed or taped to prevent the loss of content and the container is appropriately labeled.
  • (8) Licensees must maintain a “patient disclosure form” providing current and accurate information to prospective clients. Licensees must provide the mother with this information. This statement must include, but is not limited to:
  • (a) Philosophy of care;
  • (b) Midwifery training and education;
  • (c) Clinical experience;
  • (d) Services provided to mother and baby;
  • (e) Types of emergency medications and equipment used;
  • (f) Responsibilities of the mother and her family;
  • (g) Fees for services including financial arrangements;
  • (h) Malpractice coverage;
  • (i) Risk assessment criteria as listed in OAR 332-025-0021; and
  • (j) Signature of mother and date of signature documenting discussion and receipt of patient disclosure form.
  • (9) A licensee must maintain a plan for emergency transport and must discuss the plan with the mother. The plan must include, but is not limited to:
  • (a) Place of transport;
  • (b) Mode of transport;
  • (c) Provisions for hospital and physician support including location and telephone numbers; and
  • (d) Availability of private vehicle or ambulance including emergency delivery equipment carried in the vehicle.
  • (10) Signature of mother and date of signature documenting discussion of emergency transport plan must be placed in the mother’s record.
  • (11) A licensee must maintain complete and accurate written records documenting the course of midwifery care as listed under OAR 332-025-0070.
  • (12) A licensee must maintain current certification in cardiopulmonary resuscitation for adults and infants and current certification in neonatal resuscitation.
  • (13) All births must be registered with the Department of Human Services Vital Records Section, as provided in ORS chapter 432.
  • Stat. Auth.: ORS 676.605, 676.615, 687.480 & 687.485
  • Stats. Implemented: ORS 676.605, 676.615, 687.480 & 687.485
  • Hist.: DEM 1-1993(Temp), f. & cert. ef. 12-22-93; DEM 1-1994, f. & cert. ef. 6-15-94; DEM 2-1998, f. 4-14-98, cert. ef. 4-15-98; DEM 1-1999(Temp), f. 9-1-99, cert. ef. 9-9-99 thru 2-29-00; DEM 2-1999, f. 12-17-99, cert. ef. 12-20-99; DEM 2-2000(Temp), f. 8-22-00, cert. ef. 8-22-00 thru 2-17-00; DEM 2-2000(Temp), f. 8-22-00, cert. ef. 8-22-00 thru 2-17-01; DEM 3-2000, f. 9-29-00, cert. ef. 10-1-00; DEM 1-2001(Temp), f. & cert. ef. 10-1-01 thru 3-29-02; Administrative correction 11-7-01; DEM 1-2002, f. 2-25-02 cert. ef. 3-1-02; DEM 1-2004, f. 6-29-04, cert. ef. 7-1-04; DEM 6-2010, f. 12-30-10, cert. ef. 1-1-11; DEM 1-2011(Temp), f. & cert. ef. 4-4-11 thru 9-27-11
  •  
  • 332-025-0021
  • Risk Assessment Practice Standards
  • Licensees must assess the appropriateness of an out-of-hospital birth taking into account the health and condition of the mother and baby according to the following absolute and non-absolute risk criteria:
  • (1) “Absolute risk” as used in this rule means conditions or clinical situations of obstetrical or neonatal risk that cannot be resolved and that preclude out-of-hospital birth. If the mother or baby presents with any absolute risk factors, the LDM must:
  • (a) During the antepartum period, plan for transfer of care and an in-hospital birth;
  • (b) During the intrapartum period, arrange transportation to the hospital and transfer of care unless the birth is imminent;
  • (c) When the birth is imminent, take the health and condition of the mother and baby and conditions for transport into consideration in determining whether to proceed with out-of-hospital birth or to arrange for transportation to a hospital and transfer of care;
  • (d) During the postpartum period, arrange for transportation of mother or baby to a hospital and transfer of care;
  • (2) The following constitute absolute risk factors:
  • (a) ANTEPARTUM ABSOLUTE RISK CRITERIA:
  • (A) Active cancer;
  • (B) Cardiac condition with hemodynamic consequences;
  • (C) Severe renal disease — active or chronic;
  • (D) Severe liver disease — active or chronic;
  • (E) Uncontrolled hyperthyroidism;
  • (F) Chronic obstructive pulmonary disease;
  • (G) Essential chronic hypertension over 140/90;
  • (H) Pre-eclampsia/eclampsia;
  • (I) Current venous thromboembolic disease;
  • (J) Current substance abuse known to cause adverse effects for the mother or baby;
  • (K) Incomplete spontaneous abortion;
  • (L) Hemoglobin under nine at term;
  • (M) Placental abruption;
  • (N) Placenta less than 2.0 centimeters from internal os at onset of labor;
  • (O) Persistently or severely abnormal quantity of amniotic fluid;
  • (P) Signs and symptoms of chorioamnionitis;
  • (Q) Ectopic pregnancy;
  • (R) Pregnancy lasting longer than 43 weeks gestation (21 days past the due date);
  • (S) Any pregnancy with abnormal fetal surveillance tests;
  • (T) Active acquired immune deficiency syndrome (AIDS);
  • (U) Higher order multiples (three or more);
  • (V) Monochorionic, monoamniotic twins;
  • (W) Twin-to-twin transfusion;
  • (X) Presenting twin transverse;
  • (Y) Three cesarean sections unless previous successful vaginal birth;
  • (Z) Placenta accreta, percreta or increta;
  • (AA) Non-cephalic presentation except as noted in non-absolute risk criteria;
  • (BB) Previous classical uterine incision, T-incision, prior uterine rupture or extensive transfundal surgery;
  • (CC) Four or more cesarean sections; and
  • (DD) Pre-existing diabetes requiring oral medication or insulin.
  • (b) INTRAPARTUM ABSOLUTE RISK CRITERIA:
  • (A) Documented intrauterine growth restriction at term;
  • (B) Suspected uterine rupture;
  • (C) Prolapsed cord or cord presentation;
  • (D) Suspected complete or partial placental abruption;
  • (E) Suspected placenta previa;
  • (F) Signs and symptoms of chorioamnionitis;
  • (G) Pre-eclampsia/eclampsia;
  • (H) Thick meconium-stained amniotic fluid without reassuring fetal heart tones and birth is not imminent;
  • (I) Evidence of fetal distress or abnormal fetal heart rate pattern unresponsive to treatment or inability to auscultate fetal heart tones;
  • (J) Excessive vomiting, dehydration, acidosis or exhaustion unresponsive to treatment;
  • (K) Blood pressure greater than or equal to 150/100 which persists or rises, and birth is not imminent;
  • (L) Labor or premature rupture of membrane less than 35 weeks according to estimated due date;
  • (M) Current substance abuse known to cause adverse effects for the mother or baby;
  • (N) Retained placenta with suspected placenta accreta;
  • (O) Active herpes lesion in an unprotectable area;
  • (P) Primary herpes outbreak in labor; and
  • (Q) Footling or kneeling breech as determined by vaginal examination.
  • (c) MATERNAL POSTPARTUM ABSOLUTE RISK CRITERIA:
  • (A) Retained placenta with suspected placenta accreta;
  • (B) Retained placenta with abnormal or significant bleeding;
  • (C) Laceration requiring hospital repair including but not limited to third and fourth-degree lacerations;
  • (D) Uncontrolled postpartum bleeding;
  • (E) Increasingly painful or enlarging hematoma;
  • (F) Development of pre-eclampsia; and
  • (G) Signs or symptoms of shock unresponsive to treatment.
  • (d) INFANT ABSOLUTE RISK CRITERIA:
  • (A) Apgar less than 7 at 10 minutes of age;
  • (B) Respiration rate greater than 100 within the first two hours postpartum, and greater than 80 thereafter, lasting more than one hour without improvement;
  • (C) Persistent nasal flaring, grunting, or retraction after one hour of life without improvement;
  • (D) Seizures;
  • (E) Apnea;
  • (F) Central cyanosis;
  • (G) Large or distended abdomen;
  • (H) Any condition requiring more than 12 hours of observation postbirth;
  • (I) Persistent poor suck, hypotonia or a weak or high-pitched cry;
  • (J) Persistent inability to maintain temperature between 97-100 degrees Fahrenheit;
  • (K) Persistent projectile vomiting or emesis of fresh blood; and
  • (L) Signs and symptoms of infection in the infant.
  • (3) “Non-absolute” means a condition or clinical situation that places a mother or baby at increased obstetric or neonatal risk, but does not automatically exclude a mother and baby from an out-of-hospital birth.
  • (4) When a mother or baby presents with one or more non-absolute risk factors, the LDM must:
  • (a) Arrange for the transfer of care of the mother or baby; or
  • (b) Comply with all of the following:
  • (A) Consult with at least one Oregon licensed health care provider regarding the non-absolute risk factors present.
  • (B) Discuss the non-absolute risk(s) with the mother, including:
  • (i) Possible adverse outcomes;
  • (ii) Whether an out-of-hospital birth is a reasonably safe option based upon the risk(s) present;
  • (iii) The anticipated risk(s) and the likelihood of reducing or eliminating said risks;
  • (iv) The midwife’s experience with said risk(s);
  • (v) The ease and time involved in accomplishing transport or transfer of care;
  • (vi) Recommendation(s) given by the consulting Oregon licensed health care provider(s); and
  • (vii) Recommendation(s) given by the LDM to the mother.
  • (C) Document discussion of information listed in subsection (B).
  • (D) To the extent the LDM acts contrary to the recommendations given by the consulting Oregon licensed health care provider, the LDM must document the justification.
  • (E) Informed consent must be obtained and documented in records.
  • (5) The following are non-absolute risk factors:
  • (a) MATERNAL ANTEPARTUM NON-ABSOLUTE RISK CRITERIA:
  • (A) Conditions that could negatively affect maternal or fetal status that require ongoing medical supervision or ongoing use of medications;
  • (B) Inappropriate fetal size for gestation;
  • (C) Significant second or third trimester bleeding;
  • (D) Abnormal fetal cardiac rate or rhythm;
  • (E) Decreased fetal movement;
  • (F) Uterine anomaly;
  • (G) Anemia (hematocrit less than 30 or hemoglobin less than 10 at term);
  • (H) Seizure disorder requiring prescriptive medication;
  • (I) Platelet count of less than 75,000;
  • (J) Isoimmunization to blood factors;
  • (K) Psychiatric disorders;
  • (L) History of thrombophlebitis and hemoglobinopathies;
  • (M) Dichorionic, diamniotic twins;
  • (N) Monochorionic, diamniotic twins;
  • (O) Known fetal anomalies that require medical attention at birth;
  • (P) Two cesarean sections without previous successful vaginal birth;
  • (Q) Three cesarean sections with a previous successful vaginal birth;
  • (R) Blood coagulation defect;
  • (S) Significant glucose intolerance unresponsive to dietary and exercise intervention;
  • (T) Gestational diabetes well controlled with diet or oral glycemic medications; and
  • (U) Primary herpes outbreak.
  • (b) INTRAPARTUM NON-ABSOLUTE RISK CRITERIA:
  • (A) No prenatal care or unavailable records;
  • (B) History of substance abuse during this pregnancy;
  • (C) Signs and symptoms of infection including but not limited to a temperature 100.4 degrees Fahrenheit or higher with adequate hydration in the mother;
  • (D) Labor or premature rupture of membrane from 35 to 36 weeks gestation;
  • (E) Frank and complete breech presentation, as determined by vaginal examination;
  • (F) Lack of adequate progress in second stage:
  • (i) Lack of adequate progress in vertex presentation is when there is no progress after a maximum of three hours in cases with full dilation, ruptured membranes, strong contractions and sufficient maternal effort; and
  • (ii) Lack of adequate progress in breech presentation is when there is no progress in descent after a maximum of one hour in cases with full dilation, ruptured membranes, strong contractions and sufficient maternal effort.
  • (c) MATERNAL POSTPARTUM NON-ABSOLUTE RISK CRITERIA:
  • (A) Signs and symptoms of infection;
  • (B) Any condition requiring more than 12 hours of postpartum observation;
  • (C) Retained placenta greater than two hours with no unusual bleeding;
  • (D) Evidence of urinary retention that cannot be resolved in an out-of- hospital setting; and
  • (d) INFANT NON-ABSOLUTE RISK CRITERIA:
  • (A) Apgar less than 7 at five minutes without improvement;
  • (B) Weight less than 2,270 grams (five lbs.);
  • (C) Failure to void within 24 hours or stool within 48 hours from birth;
  • (D) Excessive pallor, ruddiness, or jaundice at birth;
  • (E) Any generalized rash at birth;
  • (F) Birth injury such as facial or brachial palsy, suspected fracture or severe bruising;
  • (G) Baby with signs and symptoms of hypoglycemia unresolved in the out-of-hospital setting;
  • (H) Weight decrease in excess of 10 percent of birth weight that does not respond to treatment;
  • (I) Maternal-infant interaction problems;
  • (J) Direct Coomb’s positive cord blood;
  • (K) Infant born to HIV positive mother;
  • (L) Suspected or evident major congenital anomaly;
  • (M) Estimated gestational age of less than 35 weeks;
  • (N) Maternal substance abuse identified postpartum; and
  • (O) Cardiac irregularities, heart rate less than 80 or greater than 160 (at rest) without improvement, or any other abnormal or questionable cardiac findings.
  • (6) For the purpose of this rule “transfer of care” means the process whereby any LDM who has been providing care relinquishes this responsibility to a hospital or to licensees under ORS chapter 682.
  • (a) The LDM must provide the following at the time of transfer, to the hospital or licensees under ORS chapter 682: medical history, prenatal flow sheet, diagnostic studies, laboratory findings, and maternal and baby care notes through time of transfer;
  • (b) In cases of emergency, at the time of transfer, the LDM must provide the records required in subsection (a) to the hospital or licensees under ORS chapter 682, including notes for care provided during the emergency, if available. If notes are not available, an oral summary of care during the emergency must be made available to the hospital or licensees under ORS chapter 682; and
  • (c) Under no circumstances shall the midwife leave the mother or baby until such a time that transport is arranged and another Oregon licensed health care provider or a licensee under ORS chapter 682 assumes care.
  • (7) For the purpose of this rule “consultation” means a dialogue for the purpose of obtaining information or advice from an Oregon licensed health care provider who has direct experience handling complications of the risk(s) present, as well as the ability to confirm the non-absolute risk, which may include, but is not limited to confirmation of a diagnosis and recommendation regarding management of medical, obstetric, or fetal problems or conditions. Consultation may be by phone, in person or in writing.
  • (8) For the purpose of this rule “Oregon licensed health care provider” means a physician or physician assistant licensed under ORS 677, a certified nurse midwife or nurse practitioner licensed under ORS 678, a naturopath licensed under ORS 685, or a licensee under ORS 687.
  • Stat. Auth.: ORS 676.605, 676.615, 687.480 & 687.485
  • Stats. Implemented: ORS 676.605, 676.615, 687.480 & 687.485
  • Hist.: DEM 1-1993(Temp), f. & cert. ef. 12-22-93; DEM 1-1994, f. & cert. ef. 6-15-94; DEM 2-1998, f. 4-14-98, cert. ef. 4-15-98; DEM 1-1999(Temp), f. 9-1-99, cert. ef. 9-9-99 thru 2-29-00; DEM 2-1999, f. 12-17-99, cert. ef. 12-20-99; DEM 2-2000(Temp), f. 8-22-00, cert. ef. 8-22-00 thru 2-17-00; DEM 2-2000(Temp), f. 8-22-00, cert. ef. 8-22-00 thru 2-17-01; DEM 3-2000, f. 9-29-00, cert. ef. 10-1-00; DEM 1-2001(Temp), f. & cert. ef. 10-1-01 thru 3-29-02; Administrative correction 11-7-01; DEM 1-2002, f. 2-25-02 cert. ef. 3-1-02; DEM 1-2004, f. 6-29-04, cert. ef. 7-1-04; DEM 6-2010, f. 12-30-10, cert. ef. 1-1-11; DEM 1-2011(Temp), f. & cert. ef. 4-4-11 thru 9-27-11
  •  
  • 332-025-0022
  • Mother and Baby Care Practice Standards
  • (1) An LDM may:
  • (a) Order and receive laboratory and ultrasound results;
  • (b) Order and receive fetal surveillance testing and results.
  • (c) Fit barrier methods of contraception, if qualified to fit barrier methods of contraception.
  • (2) For mother and baby care practice standards the agency and board adopt by reference the MANA core competencies, current version as approved by MANA. Reference http://mana.org/manacore.html for current version.
  • (3) In addition to and not in lieu of the MANA core competencies, an LDM must adhere to the following mother and baby care practice standards:
  • (a) Care During Pregnancy (Antepartum) - The LDM must:
  • (A) Provide health care, support and information to the mother throughout pregnancy;
  • (B) Determine the need for consultation or referral as appropriate;
  • (C) Provide a mechanism that ensures 24 hour coverage for the practice;
  • (D) Assess, identify, evaluate and support maternal and fetal well-being throughout the process of pregnancy;
  • (E) Thoroughly educate and counsel mother regarding the childbearing cycle;
  • (F) Identify preexisting conditions in a woman’s health history that are likely to influence her well-being when she becomes pregnant;
  • (G) Educate mother regarding nutritional requirements of pregnant mother and provide methods of nutritional assessment and counseling;
  • (H) Educate mother regarding changes in emotional, psychosocial and sexual variations that may occur during pregnancy;
  • (I) Identify and educate mother regarding environmental and occupational hazards for pregnant mother.
  • (J) Educate mother regarding genetic factors that may indicate the need for counseling, testing or referral;
  • (K) Educate mother regarding the growth and development of the unborn baby;
  • (L) Identify and educate mother regarding indications for, risks and benefits of bio-technical screening methods and diagnostic tests used during pregnancy;
  • (M) Educate mother regarding anatomy, physiology and evaluation of the soft and bony structures of the pelvis;
  • (N) Exercise palpation skills for evaluation of the fetus and uterus;
  • (O) Assess and educate mother regarding causes and treatment of the common discomforts of pregnancy;
  • (P) Identify implications of and appropriate treatment for various infections, disease conditions and other problems that may affect pregnancy;
  • (Q) Identify and educate of special needs of the Rh(D)-negative woman;
  • (R) Obtain fetal surveillance testing no later than 41 weeks and three days by arranging one or more of the following:
  • (i) Biophysical profile weekly and non-stress test bi-weekly; or
  • (ii) Amniotic fluid index and non-stress test bi-weekly;
  • (S) When risk factors that could impair fetal/placental circulation are present, obtain fetal surveillance testing as indicated anytime during the pregnancy.
  • (T) If the LDM is denied access to fetal surveillance testing listed under Subsection R of this section, the LDM must document the place, date, time, and name of individual who denied access in the mother’s records. If access to fetal surveillance testing is denied, then the LDM must perform an accelerated auscultation test twice weekly until delivery.
  • (b) Care During Labor, Birth and Immediately Thereafter (Intrapartum) — the LDM must:
  • (A) Provide health care, support and information to the mother throughout labor, birth and the hours immediately thereafter;
  • (B) Determine the need for consultation or referral as appropriate;
  • (C) Make appropriate and ongoing risk assessment and document maternal and fetal status and response throughout labor;
  • (D) Evaluate maternal and fetal well-being during labor, birth and immediately thereafter, including relevant historical data;
  • (E) For mothers and babies without signs of risk factors, during the active phase of the first stage of labor, evaluate the fetal heart rate at least every 30 to 60 minutes, listening toward the end of a contraction and for at least 30 seconds after;
  • (F) For mothers and babies with risk factors, auscultate fetal heart tones more frequently than every 30 to 60 minutes and listen through contractions as indicated in the active stage of labor;
  • (G) Auscultate fetal heart tones approximately every 5 to 10 minutes or after every contraction, as indicated, with active pushing;
  • (H) Assess birthing environment, assuring that it is clean, safe and supportive, and that appropriate equipment and supplies are on hand;
  • (I) Assess emotional responses and their impact during labor, birth and immediately thereafter;
  • (J) Provide comfort and support measures during labor, birth and immediately thereafter;
  • (K) Evaluate fetal and maternal anatomy and their interactions as relevant to assessing fetal position and the progress of labor;
  • (L) Utilize techniques to assist and support the spontaneous vaginal birth of the baby and placenta;
  • (M) Assess and meet fluid and nutritional requirements during labor, birth and immediately thereafter;
  • (N) Assess and support maternal rest and sleep as appropriate during the process of labor, birth and immediately thereafter;
  • (O) Assess causes of, evaluate and treat variations that occur during the course of labor, birth and immediately thereafter;
  • (P) Provide appropriate support for the newborn’s transition during the first minutes and hours following birth;
  • (Q) Evaluate and care for perineum and surrounding tissues; and
  • (R) Before the LDM leaves or the family is discharged, the placenta must be delivered and the mother’s general condition, blood pressure, pulse, temperature, fundus, lochia, and ability to ambulate and urinate must be assessed. Mother’s and baby’s condition must be found to be within normal limits.
  • (c) Care After Delivery (Postpartum Care) — The LDM must:
  • (A) Provide health care, support and information to the mother throughout the postpartum period;
  • (B) Determine the need for consultation or referral as appropriate;
  • (C) Assess anatomy and physiology of the mother during the postpartum period;
  • (D) Educate mother regarding lactation support and appropriate breast care including evaluation of, identification of and treatments for problems with nursing;
  • (E) Evaluate and promote maternal well-being;
  • (F) Assess causes of, evaluate and treat maternal discomfort;
  • (G) Evaluate and educate emotional, psychosocial and sexual variations;
  • (H) Monitor and educate mother regarding maternal nutritional requirements during including methods of nutritional evaluation and counseling;
  • (I) Assess causes of, evaluate and treat problems arising during the postpartum period, consulting as necessary;
  • (J) Provide family with written and verbal postpartum instructions; and
  • (K) Provide support, information and referral for family planning methods, as the individual woman desires.
  • (d) Newborn Care — The LDM must:
  • (A) Provide health care to the newborn;
  • (B) Provide support and information to parents regarding newborn care;
  • (C) Determine the need for consultation or referral as appropriate;
  • (D) Evaluate anatomy and physiology of newborn and support of the newborn’s adjustment during the first days and weeks of life;
  • (E) Evaluate newborn wellness including relevant historical data and gestational age;
  • (F) Assess and educate the mother regarding nutritional needs of the newborn;
  • (G) Educate mother regarding state laws concerning indications for, administration of, and the risks and benefits of prophylactic bio-technical treatments and screening tests commonly used during the neonatal period;
  • (H) Educate mother regarding causes of, assessment of, appropriate treatment and emergency measures for newborn problems and abnormalities;
  • (I) Adhere to state guidelines for the administration of vitamin K and ophthalmic prophylaxis pursuant to ORS 433.306 and OAR 333-021-0800; and
  • (J) Ensure infant metabolic screening is performed and documented according to the Department of Human Services recommendations unless the mother declines, as provided ORS Chapter 432 and OAR 333-024-0205 through 0235.
  • (4) Declined Procedure: In the event the mother refuses any testing or procedures required by administrative rule or recommended by the LDM, the LDM must document discussion with the mother of why the test or procedure is required or recommended, and document the mother’s refusal of the test or procedures, including the mother’s signature in the chart. In addition, the LDM must follow the requirements of ORS Chapter 432, 433.306, OAR 333-021-0800 and 333-024-0205 through 0235 when the mother declines administration of vitamin K or infant metabolic screening.
  • Stat. Auth.: 676.605, 676.615, 687.480 & 687.485
  • Stats. Implemented: 676.605, 676.615, 687.480 & 687.485
  • Hist.: DEM 1-1993(Temp), f. & cert. ef. 12-22-93; DEM 1-1994, f. & cert. ef. 6-15-94; DEM 2-1998, f. 4-14-98, cert. ef. 4-15-98; DEM 1-1999(Temp), f. 9-1-99, cert. ef. 9-9-99 thru 2-29-00; DEM 2-1999, f. 12-17-99, cert. ef. 12-20-99; DEM 2-2000(Temp), f. 8-22-00, cert. ef. 8-22-00 thru 2-17-00; DEM 2-2000(Temp), f. 8-22-00, cert. ef. 8-22-00 thru 2-17-01; DEM 3-2000, f. 9-29-00, cert. ef. 10-1-00; DEM 1-2001(Temp), f. & cert. ef. 10-1-01 thru 3-29-02; Administrative correction 11-7-01; DEM 1-2002, f. 2-25-02 cert. ef. 3-1-02; DEM 1-2004, f. 6-29-04, cert. ef. 7-1-04; DEM 6-2010, f. 12-30-10, cert. ef. 1-1-11; DEM 1-2011(Temp), f. & cert. ef. 4-4-11 thru 9-27-11
  •  
  • 332-025-0040
  • Approved Legend Drugs For Maternal Use
  • Licensees may administer the following legend drugs as approved by the board for maternal use:
  • (1) Anti-Hemorrhagics for use by intramuscular injection includes:
  • (a) Synthetic Oxytocin (Pitocin, Syntocin and generic);
  • (b) Methylergonovine (Methergine);
  • (c) Ergonovine (Ergotrate); or
  • (2) Anti-Hemorrhagics by intravenous infusion is limited to Synthetic Oxytocin (Pitocin, Syntocin, and generic).
  • (3) Anti-Hemorrhagics for oral administration is limited to:
  • (a) Methylergonovine (Methergine);
  • (b) Misoprostol (Cytotec).
  • (4) Anti-Hemorrhagics for rectal administration is limited to Misoprostol (Cytotec).
  • (5) Resuscitation is limited to medical oxygen and intravenous fluid replacement.
  • (6) Intravenous fluid replacement includes:
  • (a) Lactated Ringers Solution;
  • (b) 0.9% Saline Solution;
  • (c) D5LR (5% Dextrose in Lactated Ringers); or
  • (d) D5W (5% Dextrose in water).
  • (7) Anaphylactic treatment by subcutaneous injection is limited to Epinephrine.
  • (8) Local anesthetic includes:
  • (a) Lidocaine HCl (1% and 2%) (Xylocaine and generic);
  • (b) Topical anesthetic;
  • (c) Procaine HCl (Novocain, benzocaine, cetacane and generic); and
  • (d) Sterile water papules.
  • (9) Rhesus Sensitivity Prophylaxis is limited to Rho(d) Immune Globulin (RhoGAM, Gamulin Rh, Bay Rho-D and others).
  • (10) Tissue adhesive (Dermabond or generic).
  • Stat. Auth.: ORS 676.605, 676.615, 687.485 & 687.493
  • Stats. Implemented: ORS 676.605, 676.615, 687.485 & 687.493
  • Hist.: DEM 1-2001(Temp), f. & cert. ef. 10-1-01 thru 3-29-02; DEM 1-2002, f. 2-25-02 cert. ef. 3-1-02; DEM 1-2004, f. 6-29-04, cert. ef. 7-1-04; DEM 6-2010, f. 12-30-10, cert. ef. 1-1-11; DEM 1-2011(Temp), f. & cert. ef. 4-4-11 thru 9-27-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

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