TITLE examining-boards

Part XXX. Texas State Board of Examiners of Professional Counselors

Chapter 681. Professional Counselors

The Texas State Board of Examiners of Professional Counselors (board) adopts the repeal of §681.84; amendments to §§681.2, 681.3, 681.16-681.18, 681.32, 681.33, 681.40, 681.43, 681.52, 681.63, 681.81-681.83, 681.92, 681.94, 681.96, 681.111, 681.112, 681.121-681.124, 681.126, 681.128, 681.172-681.178, 681.192 and 681.196; and new §§681.251-681.256 concerning the licensing and regulation of licensed professional counselors. Sections 681.2, 681.32, 681.81, and 681.92 are adopted with changes to the proposed text as published in the April 9, 1999, issue of the Texas Register (24 TexReg 2829). Sections 681.3, 681.16-681.18, 681.33, 681.40, 681.43, 681.52, 681.63, 681.82, 681.83, 681.94, 681.96, 681.111, 681.112, 681.121-681.124, 681.126, 681.128, 681.172-681.178, 681.192, 681.196, and 681.251-681.256 are adopted without changes and therefore will not be republished.

The General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, requires that each state agency review and consider for readoption each rule adopted by that board pursuant to the Government Code, Chapter 2001 (Administrative Procedures Act). Sections 681.1-681.19, 681.26, 681.32-681.43, 681.51, 681.52, 681.61-681.64, 681.81-681.84, 681.91-681.96, 681.111-681.114, 681.121-681.128, 681.161-681.163, 681.171-681.179, 681.191-681.200, 681.211, and 681.220 have been reviewed and the board determined that reasons for adopting the sections continue to exist. No comments were received from the public during the 30 days following publication of the notice and intent to review these rules which was published in the July 17, 1998, issue of the Texas Register (23 TexReg 7396). All rule changes and new rules are the result of the review by the board and staff.

Specifically, §681.2 concerning definitions, is amended to ensure that all definitions are listed with numbers to comply with the Texas Register format required by 1 Texas Administrative Code, §91.1, effective February 17, 1998.

Section 681.2(14) is amended to clarify the definition of recognized religious practitioner.

Section 681.2(14)(A) is amended to accurately reflect federal regulation citations.

Section 681.3(c) is amended to remove language " Texas Civil Statutes".

Section 681.16(c) is amended to remove the word "copies" in reference to making rosters available to licensees and other agencies as this information is now available through electronic means.

Section 681.17(a)(5) is amended to provide additional clarification of late renewal fees.

Section 681.17(a)(6) is amended to provide additional clarification concerning when renewal penalty fees must be submitted to the board.

Section 681.18(a)(1) is amended to clarify procedures for written notifications related to applications.

Section 681.18(a)(1)(A) is amended to remove the reference to letters of acceptance of applications and replace with language to indicate that the time frame is in reference to the issuance of a temporary license.

Section 681.32(e) is amended to require licensees to inform in writing individuals entering into a counseling relationship of fees, counseling purposes, goals and techniques, any restrictions placed on the license by the board, limits of confidentiality, and intent to use another individual to provide counseling or supervision of the licensee by another licensed mental health care professional.

Section 681.32(g) is amended to define telepractice and to remove the prohibition of the provision of counseling services by electronic means. It is further amended to require counselors engaging in telepractice to adhere to each provision of this chapter.

Section 681.32(k) is amended to require the licensee to set and maintain professional boundaries and to clarify the meaning of dual relationship and boundary violations within a counseling relationship.

Section 681.32(q) is amended to require a written agreement between licensee and client for any modification in services rendered by the licensee.

Section 681.32(q)(1) is amended to require the licensee to indicate any relationship between the licensee and any other person used by the licensee to provide services to a client on billing documents.

Section 681.32(q)(2) is amended to provide clarification concerning persons who are entitled to client records and the type of information that must be provided by the licensee.

Section 681.32(u) is amended to remove reference to the Crime Victims Compensation Act and replace it with the Code of Criminal Procedure, Chapter 56, to provide accurate information concerning applicable laws.

Section 681.32(w) is amended to provide clarification of the intent of the rule by replacing "subversion" with the term "falsification".

Section 681.33(f) is amended to more accurately state the purpose of the rule by replacing " person" with the word "client".

Section 681.33(g)(8) is amended to indicate that any form of kissing or fondling of a client by a licensee may constitute sexual exploitation.

Section 681.33(i)(1) is amended to clarify the duty to report suspected client sexual exploitation, sexual misconduct, or therapeutic deception by a mental health service provider.

Section 681.40(f) is amended to remove the word " intervention" from the reference to counseling treatment services.

Section 681.40(g) is added to this section to require counselors holding a temporary license to indicate intern status on all advertisements, billing and announcements of counseling treatment by use of the term LPC-Intern.

Section 681.43(1) is amended to accurately reflect the applicable chapter of the Family Code by replacing Chapter "34" with Chapter "261".

Section 681.52(a)(7) is amended to remove the requirement that an imprint of a notary seal must appear on the edge of the photograph of applicants for licensure.

Section 681.52(d) is amended to include a requirement that supervisor agreements be dated by both supervisor and applicant before a notary public.

Section 681.63(d) is amended to modify wording to the past tense.

Section 681.81(a) is amended to clarify when a temporary license may be issued to an applicant.

Section 681.81(a)(4) is amended to add language to clarify time restrictions for reapplication when the applicant has failed the board examination two successive times.

Section 681.81(a)(5) is amended to further clarify requirements for reapplication for a second temporary licensure for a person having failed the board examination two successive times.

Section 681.81(b) is amended to remove paragraphs (1), (2), and (3) concerning the provisions for acceptance of supervised experience hours and to provide a statement of improved clarification concerning time periods for acceptable supervisory experience for persons not holding a temporary license.

Section 681.82 is amended by the addition of subsections (l)-(o) containing rules moved from §681.84 in order that they may be located in the rule section more appropriate for experience requirements for interns.

Section 681.83(a)(2) is amended to provide clarification of persons eligible to supervise counseling services provided by interns.

Section 681.83(b)(2)(B) is amended to provide clarification of persons eligible to supervise counseling services provided by interns.

Section 681.83(c) is amended to clarify that supervisors of interns must be board approved.

Section 681.83(d)(1)-(5) is amended to add these paragraphs containing rules moved from §681.84 in order that they may be located in the rule section more appropriate to requirements concerning supervisors of interns.

Section 681.84 is repealed to move specific rules related to interns receiving supervision to §681.82 and move specific rules related to the supervision of interns to §681.83.

Section 681.92(a) is amended to allow interns to take the Licensed Professional Counselor Examination at any time during the effective dates of their temporary license. Paragraphs (1)-(4) have been added to this section to clarify when a regular license may be issued after successful completion of the examination, when an application or temporary licensed may be voided if the examination is failed twice and reapplication requirements after failing the examination twice.

Section 681.92(b) is amended to further clarify application requirements for applicants seeking a regular license and not holding a temporary license at the time of application.

Section 681.94(d) is amended to clarify the need for and requirements concerning licensure reapplication for persons failing the examination twice.

Section 681.96 is amended to correct punctuation, and delete the word "or".

Section 681.111(a) is amended to clarify procedures concerning the payment of fees associated with the issuance of a license.

Section 681.111(b) is amended to remove reference to fee requirements associated with the submission of an examination score report.

Section 681.112(a)(1) is amended to remove reference to a provisional license fee and replace with a statement indicating only a license fee in keeping with §681.17(a)(1) concerning fees.

Section 681.112(a)(3) is amended to clarify the types of examinations that are acceptable to the board for licensure by endorsement.

Section 681.121(c) is amended to indicate the requirement that all licenses issued by the board are to be renewed annually.

Section 681.122 is amended to clarify and revise the the effective dates of an initial license issued by the board.

Section 681.123(a) is amended to reduce and clarify the type of information to be included in a notice of license renewal issued to the licensee by the board.

Section 681.124(d) is amended to clarify procedures for making late license renewal payments to the board.

Section 681.126(a) is amended to remove references to date stamps on retired licenses. The retired license will now be returned to the retiring licensee after it is marked as a retired license, but without processing date.

Section 681.128(c) is amended to reflect only the Family Code, Chapter 232 and remove all other references to legislative citations.

Section 681.172 is amended to allow the completion of at least three hours of continuing education directly related to counselor ethics issues in any two successive twelve month periods instead of one twelve month period.

Section 681.173 is amended to remove the requirement that a licensee must complete at least three clock-hours directly related to counselor ethics as a part of the required twelve clock-hours of continuing education in each twelve month period.

Section 681.174 is amended to clarify the types of continuing education activity that will be acceptable to the board.

Section 681.175 is amended to require that individuals and organizations initiate requests for board approval of specific programs for continuing education credit before these programs occur.

Section 681.176(a)(2)(A) is amended to remove the requirement that pre-approved providers maintain resumes of all presenters.

Section 681.177(5) is amended to allow for all of the twelve clock-hours of continuing education to be obtained through independent study instead of restricting independent study to three hours.

Section 681.178(1) is amended to clarify that continuing education completed by the licensee shall be reported on a form provided by the board.

Section 681.178(7) is amended to indicate that a failure to meet the continuing education requirement is a violation of board rules.

Section 681.192(e) is amended to indicate correspondence content, format and mailing procedures for service of notices of hearings to licensees, including information concerning default procedures associated with the licensees failure to appear for hearing.

Section 681.196(d)(7) is amended to clarify types of felony and misdemeanor offenses under various titles of the Texas Penal Code by adding reference to Title 8 offenses against public administration.

New Subchapter N. Schedule of Sanctions, §§681.251- 681.256 is added to comply with the Licensed Professional Counselor Act, Chapter 681, Sec. 16(d) which requires the board to adopt by rule a schedule of sanctions for violations under this Act. The schedule will be used by the State Office of Administrative Hearings (SOAH) when imposing any sanction as a result of an administrative hearing. Specifically, this subsection covers the purpose, relevant factors, severity levels and sanction guide, other disciplinary actions, SOAH and probation considerations.

The following comment was received concerning the proposed sections. Following this comment is the board's response and any resulting change(s).

COMMENT: Concerning proposed §681.32(k)(l)-(6), renumbered as §681.32(k)(1)-(3), a comment was received from the Texas Counseling Association which states that the proposed changes to the board rules concerning dual relationships are so delineating as to virtually preclude practice in small towns, schools, and other settings and are overly definitive and requests the rules be rewritten so as to be less restrictive and less prohibitive of reasonable practice.

RESPONSE: The board agrees that the proposed rules concerning dual relationships are overly definitive and has revised the rule to reduce restrictive language that could effect professional counselors practicing in small communities.

The board is making the following changes to further clarify the rules.

CHANGE: Concerning §681.2, all definitions are listed with numbers to comply with Texas Register format.

CHANGE: Concerning §681.81(a)(4), additional clarifying language has been added to further clarify the requirements for obtaining a temporary license by those applicants that have never held a temporary license, but have failed the counselor examination two successive times.

CHANGE: Concerning §681.81(a)(5), additional clarifying language has been added to better define the requirements for obtaining a second temporary license by those applicants who have held a temporary license, but have had their temporary licenses voided after failing the counselor examination two successive times.

CHANGE: Concerning §681.92(a)(3), additional language has been added to better clarify the application requirements and assist the applicant by providing a rule reference to required application materials necessary for reapplication for licensure.

Subchapter A. The Board

22 TAC §§681.2, 681.3, 681.16-681.18

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

§681.2.Definitions.

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1)

Accredited universities--Universities as reported by the American Association of Collegiate Registrars and Admission Officers.

(2)

Act--The Licensed Professional Counselor Act, Texas Civil Statutes, Article 4512g, as amended.

(3)

APA--The Administrative Procedure Act, Government Code, Chapter 2001.

(4)

Art therapy--The practice of professional counseling through services that use art media to promote perceptive, intuitive, affective, and expressive experiences that alleviate distress and emotional, behavioral, or social impairment.

(5)

Art therapy intern--An LPC or an LPC intern holding a temporary license with an art therapy specialty designation.

(6)

Authorized representative--An individual authorized to act on behalf of a licensee as evidenced by a written power of attorney or the licensee's spouse.

(7)

Board--The Texas State Board of Examiners of Professional Counselors.

(8)

Client--A person who seeks or receives services from a licensee or from a person who is practicing counseling without a license, either because no license is required under the Act at the time of counseling or because the person has not obtained the license required by the Act.

(9)

Department--The Texas Department of Health.

(10)

Health care professional--A licensee or any other person licensed, certified, or registered by the State in a health related profession.

(11)

License--A regular, regular with art therapy specialty designation, provisional, or temporary license issued by the board unless the content of the rule indicates otherwise.

(12)

Licensee--A person who holds a regular, regular with art therapy specialty designation, provisional, or temporary license.

(13)

LPC intern--A person who holds a temporary license to practice counseling.

(14)

Recognized religious practitioner--A rabbi, member of the clergy, or person of similar status who is a member in good standing of and accountable to a legally recognized denomination, church, sect or religious organization legally recognized under the Internal Revenue Code, §501(c)(3), and other individuals participating with them in pastoral counseling if:

(A)

the counseling activities are within the scope of the performance of their regular or specialized ministerial duties and are performed under the auspices of sponsorship of the legally recognized denomination, church, sect, religious organization or an integrated auxiliary of a church as defined in Federal Tax Regulations, 26 Code of Federal Regulations;

(B)

the individual providing the service remains accountable to the established authority of that denomination, church, sect, religious organization or integrated auxiliary; and

(C)

the person does not use the title of or hold himself or herself out as a professional counselor.

(15)

Supervisor--A person approved by the board as meeting the requirements set out in §681.83 of this title (relating to Supervisor Requirements), to supervise an LPC intern.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904161

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners for Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter C. Codes of Ethics

22 TAC §§681.32, 681.33, 681.40, 681.43

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

§681.32.General Ethical Requirements.

(a)-(d)

(No change.)

(e)

A licensee shall inform an individual in writing before or at the time of the individual's initial professional counseling session with the licensee of the following:

(1)-(6)

(No change.)

(f)

(No change.)

(g)

A licensee shall provide counseling treatment intervention only in the context of a professional relationship. Telepractice (interactive long distance counseling delivery, where the client resides in one location and the counselor in another) may be used as a part of the therapeutic counseling process. Counselors engaging in Telepracticing must adhere to each provision of this chapter.

(h)-(j)

(No change.)

(k)

The licensee shall set and maintain professional boundaries. Dual relationships, with clients are prohibited. A dual relationship is considered any non-counseling activity initiated by either the licensee or client for the purpose of establishing a non-therapeutic relationship.

(1)

The licensee shall not provide counseling services to previous or current:

(A)

family members;

(B)

personal friends;

(C)

educational associates; or

(D)

business associates.

(2)

The licensee shall not give or accept a gift from a client or a relative of a client valued at more than fifty dollars, enter into barter for services, or borrow or lend money or items of value to clients or relatives of clients.

(3)

The licensee shall not enter into a non-professional relationship with a client's family member or any person having a personal or professional relationship with a client.

(l)-(p)

(No change.)

(q)

A licensee shall bill clients or third parties for only those services actually rendered or as agreed to by mutual understanding at the beginning of services or as later modified by mutual written agreement.

(1)

Relationships between a licensee and any other person used by the licensee to provide services to a client shall be so reflected on billing documents.

(2)

On the written request of a client, a client's guardian, or a client's parent (sole managing, joint managing or possessory conservator) if the client is a minor, a licensee shall provide, in plain language, a written explanation of the types of treatment and charges for counseling treatment intervention previously made on a bill or statement for the client. This requirement applies even if the charges are to be paid by a third party.

(3)-(4)

(No change.)

(r)-(t)

(No change.)

(u)

A licensee shall be subject to disciplinary action if the licensee is issued a public letter of reprimand, is assessed a civil penalty by a court, or has an administrative penalty imposed by the attorney general's office under the Code of Criminal Procedure, Chapter 56.

(v)

(No change.)

(w)

An applicant for licensure shall not participate in anyway in the falsification of licensing materials.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904165

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter D. Application Procedures

22 TAC §681.52

The amendment is adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, §6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904166

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter E. Academic Requirements for Examination and Licensure

22 TAC §681.63

The amendment is adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, §6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904167

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter F. Experience Requirements for Examination and Licensure

22 TAC §§681.81-681.83

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

§681.81.Temporary License.

(a)

The Texas State Board of Examiners of Professional Counselors (board) may issue a temporary license to an applicant who:

(1)

has filed all required application forms and license fee;

(2)

has met all academic requirements for licensure;

(3)

(No change.)

(4)

has never held a temporary license from the board and has not failed any two successive board examinations within two years prior to application or;

(5)

if applying for a second temporary license, (not a 30 month extension referenced in subsection (f) of this section), has failed the board examination two successive times, has not completed the required supervised experience and has waited two years since the date of the last failed counselor examination or has completed nine graduate level semester hours in the subject areas in which the applicant scored lowest on the previous counselor examination. Documentation of completion of all graduate course work must be submitted on an official school transcript.

(b)

In Texas, a person must obtain a temporary license before the person begins an internship or continues an internship. Hours obtained by an unlicensed person in any setting shall not count toward the supervised experience requirements. Supervised experience hours gained prior to June 1, 1994, may count toward licensure if all academic requirements have been met at the time of application. Hours gained after June 1, 1994 cannot count without a temporary license.

(c)-(g)

(No change.)

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904168

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


22 TAC §681.84

The repeal is adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904169

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter G. Licensure Examinations

22 TAC §§681.92, 681.94, 681.96

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

§681.92.Requirements for Licensure Examination.

(a)

An applicant who is an LPC intern may sit for the Licensed Professional Counselor Examination at any time during the effective dates of their temporary license.

(1)

A regular license will be issued to an applicant only after completion of required supervised experience and successful completion of the licensed professional examination.

(2)

The application of a person who fails any two successive examinations shall be voided.

(3)

The temporary license of a person who fails any two successive examinations shall be voided. Reapplication for a temporary license must be in accordance with §681.52 of this title (relating to Required Application Materials) and §681.81(a)(5) of this title (relating to Temporary License).

(4)

Reapplication for a regular license must be in accordance with §681.52 of this title.

(b)

Applicants for a regular license that do not hold a temporary license must apply for licensure in accordance with §681.51 of this title (relating to General), §681.52 of this title and §681.82 of this title (relating to Experience Requirements (Internship)).

(c)

(No change.)

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904170

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter H. Licensing

22 TAC §681.111, §681.112

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904171

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter I. Regular License Renewal and Inactive and Retirement Status

22 TAC §§681.121-681.124, 681.126, 681.128

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904172

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter K. Continuing Education Requirements

22 TAC §§681.172-681.178

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, §6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904162

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter L. Complaints and Violations

22 TAC §681.192, §681.196

The amendments are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, §6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904163

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Subchapter N. Schedule of Sanctions

22 TAC §§681.251-681.256

The new sections are adopted under the Licensed Professional Counselor Act, Texas Civil Statutes Article 4512g, Section 6(e)(2) which provide the Texas State Board of Examiners of Professional Counselors with the authority to adopt and revise rules that are necessary to administer the Licensed Professional Counselor Act and the General Appropriations Act, House Bill 1, Article IX, Rider 167, passed by the 75th Legislature, is implemented by this adoption.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904164

Anthony P. Picchioni

Chairperson

Texas State Board of Examiners of Professional Counselors

Effective date: August 1, 1999

Proposal publication date: April 9, 1999

For further information, please call: (512) 458-7236


Part XXXVIII. Texas Midwifery Board

Chapter 831. Midwifery

The Texas Midwifery Board (board) adopts new §§831.1-831.3, 831.7, 831.51, 831.111, 831.121, 831.131, and 831.141 concerning the regulation of midwives. Sections 831.2, 831.51, and 831.121 are adopted with changes to the proposed text as published in the March 5, 1999 issue of the Texas Register (24 TexReg 1539). Sections 831.1, 831.3, 831.7, 831.111, 831.131, and 831.141 are adopted without changes, and therefore the sections will not be republished.

The sections cover introduction; definitions; the Midwifery Board; petition for the adoption of a rule; midwifery practice standards and principles; eye prophylaxis; newborn screening; informed choice and disclosure statement; and the provision of support services. The board is authorized by the Texas Midwifery Act (the Act), Texas Civil Statutes, Article 4512i, §8A(b), to adopt rules concerning documentation of midwives; standards for approval of midwifery education courses, instructors, and facilities; standards for midwifery practice; basic and continuing midwifery education requirements; reporting and processing complaints; disciplinary procedures; procedures for reciprocity for initial documentation; and any additional rules necessary to implement any duty imposed on the board by the Act, subject to the approval of the Texas Board of Health. The new sections are necessary for the limited purpose of locating all rules governing the documentation and regulation of midwives in 22 TAC Chapter 831, based on the Midwifery Board's increased rulemaking and enforcement authority. The rules were located in 25 Texas Administrative Code (TAC), and the Texas Board of Health adopted the repeal of 25 TAC §§37.171-37.174, 37.176-37.177, 37.179, 37.181-37.185 in order that the new sections may be adopted by the Texas Midwifery Board, which will be listed as an independent board under 22 TAC. The repeal of 25 TAC §§37.171-37.174, 37.176-37.177, 37.179, 37.181-37.185 can be found in this same issue of the Texas Register in the adopted rules section.

Changes made to the proposed text result from comments received during the comment period. The following changes were due to staff comments.

Change: Concerning §§831.2 and 831.51, minor editorial changes such as grammar and punctuation were made for clarification purposes.

Change: Concerning §831.121(a), the cite for §§37.51 - 37.69 was corrected from 22 Texas Administrative Code (TAC) to 25 TAC.

The following comments were received concerning the proposed sections. Following each comment is the board's response and any resulting change(s).

Comment: Concerning §831.2(5), one commenter stated that the definition of "certified nurse-midwife" should be amended as follows: "A registered nurse licensed in Texas, recognized by the Board of Nurse Examiners as an advanced practice nurse, and certified by the American College of Nurse-Midwives or the ACNM Certification Council."

Response: The board disagrees. The definition of "certified nurse-midwife" proposed for final adoption and the definition in the Act, §1(c)(5), are identical. No change was made as a result of this comment.

Comment: Concerning §831.2(14), one commenter stated that the definition of "midwifery" should be amended as follows: "The practice by a midwife or certified nurse-midwife of giving the necessary supervision, care, and advise to a woman during normal pregnancy, labor and the postpartum period; conducting a normal delivery of a child; and providing newborn care."

Response: The board disagrees. The definition of "midwifery" proposed for final adoption is the same as that in the Act, §1(c)(2). In addition, §2 of the Act states that its provisions do not apply to certified nurse-midwives. No change was made as a result of this comment.

Comment: Concerning §831.51(b), one commenter stated that midwives should be allowed to refer clients to "a licensed health care provider with current obstetric/pediatric knowledge" rather than only to "a licensed physician or licensed health care provider working under the supervision of a physician". The commenter's stated intent is to include certified nurse-midwives working within their scope of practice; i.e., in collaboration with but not under the supervision of a physician, as appropriate health care providers for consultation or referral.

Response: Section 831.51 is being adopted by the board at this time without change from the original 25 TAC §37.185 for the limited purpose of locating all rules governing the documentation and regulation of midwives in 22 TAC Chapter 831. Chapter 831 will contain the rules adopted by the board with approval of the Board of Health as allowed by the Midwifery Act, Texas Civil Statutes, Article 4512i, (Act). 25 TAC Chapter 37 will no longer contain any rules adopted under the Act. Those Board of Health rules are being repealed in this same issue of the Texas Register in the Adopted Rules section. The board anticipates substantive review and possible revision of §831.51 in the future, and this comment will be retained for consideration at that time. No change was made as a result of this comment.

The comments on the proposed rules were submitted by the Consortium of Texas Certified Nurse-Midwives. The comments were neither for nor against the rules in their entirety; however, they raised questions, offered comments for clarification purposes, and suggested clarifying language concerning specific provisions in the rules.

Subchapter A. The Board

22 TAC §§831.1-831.3, 831.7

The new sections are adopted under Texas Civil Statutes, Article 4512i, §8A(b), which authorizes the board to adopt rules, subject to the approval of the Texas Board of Health, necessary for the documentation and regulation of Texas midwives.

§831.2.Definitions.

The following words and terms when used in these sections shall have the following meaning unless the context clearly indicates otherwise:

(1)

Act - The Texas Midwifery Act, Texas Civil Statutes, Article 4512i.

(2)

Appropriate health care facility - The Department of Health, a local health department, a public health district, a local health unit or a physician's office where specified tests can be administered and read, and where other medical/clinical procedures normally take place.

(3)

Approved midwifery education courses - The basic midwifery education courses approved by the Midwifery Board.

(4)

Board - The Texas Board of Health.

(5)

Certified nurse-midwife - A registered nurse licensed in Texas, recognized by the Board of Nurse Examiners as an advanced nurse practitioner, and certified by the American College of Nurse-Midwives.

(6)

Code - Texas Health and Safety Code.

(7)

Commissioner - The Commissioner of Health.

(8)

Department - The Texas Department of Health.

(9)

Documentation - The annual process of documenting midwives under the Texas Midwifery Act.

(10)

Health authority - A physician who administers state and local laws regulating public health under the Health and Safety Code, Chapter 121, Subchapter B.

(11)

Local health department - A department of health created by the governing body of a municipality or county under the Health and Safety Code, Chapter 121, Subchapter D.

(12)

Local health unit - A division of a municipality or county government that provides limited public health services as provided by the Health and Safety Code, §121.004.

(13)

Midwife - A person who practices midwifery under the Texas Midwifery Act and has met the requirements and standards of the Midwifery Board in these sections.

(14)

Midwifery - The practice by a midwife of giving the necessary supervision, care, and advise to a woman during normal pregnancy, labor and the postpartum period; conducting a normal delivery of a child; and providing newborn care.

(15)

Midwifery Board - The Midwifery Board appointed by the Texas Board of Health.

(16)

Newborn care - The care of a child for the first six weeks of the child's life.

(17)

Normal childbirth - The labor and delivery at or close to term (37 up to 42 weeks) of a pregnant woman whose assessment reveals no abnormality or signs or symptoms of complications.

(18)

Physician - A physician licensed to practice medicine in Texas by the Board of Medical Examiners.

(19)

Postpartum care - The care of a woman for the first six weeks after the woman has given birth.

(20)

Program - The department's midwifery program.

(21)

Public health district - A district created under the Health and Safety Code, Chapter 121, Subchapter E.

(22)

Standing delegation orders - Written instructions, orders, rules, regulations or procedures prepared by a physician and designated for a patient population, and delineating under what set of conditions and circumstances actions should be instituted, as described in the rules of the Texas Board of Medical Examiners in Chapter 193 (relating to standing delegation orders).

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904185

Edna Dougherty

Chair

Texas Midwifery Board

Effective date: August 1, 1999

Proposal publication date: March 5, 1999

For further information, please call: (512) 458-7236


Subchapter D. Practice of Midwifery

22 TAC §§831.51, 831.111, 831.121, 831.131, 831.141

The new sections are adopted under Texas Civil Statutes, Article 4512i, §8A(b), which authorizes the board to adopt rules, subject to the approval of the Texas Board of Health, necessary for the documentation and regulation of Texas midwives.

§831.51. Midwifery Practice Standards and Principles.

(a)

Standards for the Practice of Midwifery in Texas.

(1)

Midwifery care is provided by qualified midwives as defined by the Texas Midwifery Act, Texas Civil Statutes, Article 4512i.

(2)

Midwifery care supports individual rights and self-determination within the boundaries of safety.

(3)

Midwifery care is based upon the knowledge, skill, and judgment that foster the delivery of safe and competent care to mother and newborn, giving the newborn the opportunity for a good beginning.

(4)

Midwifery care is provided in accordance with established minimal standards which promote safe and competent care. The midwife implements these standards through adherence to the principles for the practice of midwifery in Texas as detailed in subsection (b) of this section.

(5)

Midwifery care is provided in a safe environment.

(6)

Midwifery care utilizes the community health care and social system to meet medical, psychosocial, economic and cultural or family needs.

(7)

Midwifery care is documented in complete, legible health records.

(8)

Midwifery care includes an ongoing process of evaluation and quality assurance.

(b)

Principles. Midwifery practice is based upon the acquisition of clinical skills necessary for the care of essentially normal pregnant women and newborns. These skills may be obtained through apprenticeship or within an institution. Care as defined by the Midwifery Board of the Texas Department of Health (department) includes antepartum, intrapartum, postpartum, and newborn services. The midwife is committed to maintain a high standard of professional care, to participate in continuing education, and to promote the concepts of high quality and safe practice among all Texas midwives.

(1)

Qualifications for midwives in Texas. The midwife:

(A)

is documented through the Texas Department of Health, Midwifery Program;

(B)

has attended an approved mandatory basic midwifery education course or has been exempted from this requirement prior to January 1, 1994;

(C)

shows evidence of continuing competency through an ongoing process of continuing education; and

(D)

is in compliance with the legal requirements of Texas while practicing in the state.

(2)

Clients rights. The midwife:

(A)

provides clients with a description of the scope of midwifery practice, both in written and oral form, which includes but is not limited to her/his:

(i)

midwifery experience;

(ii)

limitations of practice;

(iii)

date of expiration of documentation;

(iv)

date of expiration of cardiopulmonary resuscitation certification;

(v)

compliance with continuing education;

(vi)

compliance with the standards of practice of midwifery in Texas as adopted in rule by the Texas Department of Health;

(vii)

compliance with the client's individual rights relative to this paragraph;

(viii)

medical consultation arrangements;

(ix)

procedures regarding newborn blood screening;

(x)

practice for ophthalmia neonatorum prevention; and

(xi)

a delineation of the prohibited acts as detailed by the Midwifery Act of 1993.

(B)

provides information regarding the client's rights as follows. The client has the right:

(i)

prior to the administration of any drug or natural remedy to herself or her infant, to be informed by the midwife caring for her of the reason for such administration, all potential direct or indirect effects, and all risks or hazards to herself or her unborn or newborn infant which may result from the use of the drug or remedy;

(ii)

to be accompanied during the stress of labor and birth by someone she cares for, and to whom she looks for emotional comfort and encouragement;

(iii)

to be informed of any known or suspected condition which may cause her or her baby difficulty or problems. She has the right to care by a physician or other licensed health care professional operating under physician supervision for conditions or problems which are outside the scope of practice of the midwife. The client has the right to timely referral in such situations;

(iv)

to be informed of the name and qualifications of all individuals participating in her care;

(v)

to have access to and receive copies upon request of her and her baby's midwifery records which will be complete, accurate and legible; and

(vi)

of self-determination to decline or continue care upon the midwife's recommendation. The client's decision to exercise this right will be made in writing. The midwife will retain a copy of this document to demonstrate compliance with this section.

(3)

Criteria for safe and competent care. The midwife:

(A)

provides care only to clients determined to be at low or normal risk, as defined in the following subparagraphs, of developing complications during pregnancy, childbirth, and the postpartum and neonatal periods;

(B)

provides clients with information on other providers and services when requested or when care required is not within the scope of midwifery practice;

(C)

practices in accordance with this section; and

(D)

will not knowingly accept nor thereafter maintain responsibility for the prenatal, intrapartum, or postpartum care of a woman or neonatal care of an infant who has or develops a high risk condition or complication, except as detailed in clauses (i), (iv), (v), and (vi) of this subparagraph.

(i)

If on the initial assessment or subsequent assessments, the midwife determines or suspects that the client has any of the conditions or symptoms listed in clauses (ii) and (iii) of this subparagraph, a consult by a physician who has current obstetric knowledge or another licensed health care provider with current obstetric knowledge operating under such a physician's supervision will be obtained in a timely manner. "Consultation" refers to a particular client, not generalized advice affecting more than one woman. The consultant is to evaluate the client and then advise the midwife whether to refer the client, co-manage the client with specified medical supervision, or continue midwifery care. The midwife will document the consultation in writing. If reasonable and documented attempts have been made to consult with a licensed physician or other licensed health care provider operating under physician supervision and the physician or other provider refuses to see the client, then the midwife may continue to provide care to the client after obtaining written informed consent that the client agrees to such care and is aware that she has or may have a high-risk condition which should be evaluated by a physician. If after the client has been made aware that she has or may have a high-risk condition; and she chooses to decline medical consultation, co-management, or referral, then the midwife may continue to provide care for the client if she signs a waiver of medical referral.

(ii)

The midwife will recommend consultation if the client's history concerning prior pregnancies or medical history includes any of the following:

(I)

preterm (less than 36 weeks) labor during two or more previous pregnancies;

(II)

preterm (less than 36 weeks) rupture of membranes;

(III)

delivery of an infant weighing less than 5 1/2 pounds or 2500 grams at term;

(IV)

delivery of a large infant weighing greater than or equal to 10 pounds or 4500 grams that resulted in trauma to the infant;

(V)

neonatal (first month of life) death;

(VI)

severe postpartum hemorrhage (non-traumatic) requiring transfusion;

(VII)

three or more consecutive spontaneous abortions;

(VIII)

suspicion for an incompetent cervix;

(IX)

mother or current conception's father having had a previous infant or fetus with a known or suspected genetic or familial disorder. (Refer to subsection 9 of this section for sample prenatal genetic screening questions which are from the American College of Obstetricians and Gynecologists (ACOG) Technical Bulletin #108.);

(X)

mother or current conception's father having had a previous infant or fetus with a significant congenital anomaly;

(XI)

pregnancy induced hypertension requiring medication, medical supervision or hospitalization; pre-eclampsia; or eclampsia;

(XII)

gestational diabetes (diet controlled);

(XIII)

intrauterine fetal demise;

(XIV)

shoulder dystocia that resulted in trauma to the infant;

(XV)

placenta previa at time of labor;

(XVI)

placental abruption;

(XVII)

Rh or other blood group isoimmunization;

(XVIII)

inverted uterus;

(XIX)

pelvic or genital tract anomaly;

(XX)

cardiac disease;

(XXI)

rheumatic fever;

(XXII)

renal disease, pyelonephritis, recurrent urinary tract infection, urinary calculi, or urinary tract anomaly;

(XXIII)

cancer;

(XXIV)

vascular disease;

(XXV)

any non A-Hepatitis;

(XXVI)

hepatic insufficiency;

(XXVII)

thyroid disease;

(XXVIII)

syphilis;

(XXIX)

thrombophlebitis or thromboembolism;

(XXX)

HIV positivity; or

(XXXI)

any other history which poses a risk to the mother or fetus as assessed by a midwife exercising ordinary skill and education.

(iii)

The midwife will recommend a consultation if the client's history or examination concerning her current pregnancy includes any of the following:

(I)

age 15 or under;

(II)

exposure to a teratogen during current pregnancy or six weeks prior to conception;

(III)

drug, tobacco and/or alcohol abuse;

(IV)

significant psychological dysfunction;

(V)

vaginal bleeding after twelve weeks;

(VI)

significant abdominal pain;

(VII)

significantly decreased fetal movement;

(VIII)

urinary tract infection or signs or symptoms of urinary tract infection unresponsive to natural remedies or in association with temperature equal to or greater than 100.4 degrees Fahrenheit;

(IX)

elevated temperature equal to or greater than 100.4 degrees Fahrenheit for more than 48 hours;

(X)

chest pain and/or difficulty breathing;

(XI)

signs or symptoms of thrombophlebitis or thromboembolism;

(XII)

persistent, severe headaches;

(XIII)

visual disturbances;

(XIV)

seizure disorder requiring treatment;

(XV)

asthma requiring treatment;

(XVI)

pulmonary disease;

(XVII)

gastrointestinal or colon disease requiring treatment;

(XVIII)

contracted pelvis;

(XIX)

hypertension, a diastolic blood pressure of at least 90 mm Hg or systolic pressure of at least 140 mm Hg or a rise in the former of at least 15 mm Hg or in the latter of 30 mm Hg. The blood pressures cited should be manifested on at least two occasions six hours or more apart;

(XX)

severe edema of hands, face, or lower extremities;

(XXI)

severe varicosities of vulva or lower extremities;

(XXII)

intrauterine fetal demise;

(XXIII)

non-vertex presentation after 36 weeks;

(XXIV)

anemia (hemoglobin equal to or less than 10 g/dl or hematocrit equal to or less than 30%) not corrected by iron therapy;

(XXV)

active genital herpes at the time of delivery;

(XXVI)

gonorrhea, chlamydia, HPV, or pelvic inflammatory disease;

(XXVII)

syphilis;

(XXVIII)

HIV positivity;

(XXIX)

proteinuria, equal to or greater than +1 on two consecutive visits or equal to or greater than +2 on one visit;

(XXX)

glycosuria, equal to or greater than +1 on two visits (if unable to perform blood glucose screening for this finding);

(XXXI)

abnormal pap smear;

(XXXII)

abnormal fetal growth pattern or uterine discrepancy greater than four weeks on two visits unless assessment by palpation finds fetal growth appropriate for dates;

(XXXIII)

intrauterine growth retardation;

(XXXIV)

post-term pregnancy, equal to or greater than 42 and 0/7 weeks;

(XXXV)

possible preterm (less than 36 weeks) labor;

(XXXVI)

significant maternal trauma;

(XXXVII)

hyperemesis gravidarum;

(XXXVIII)

polyhydramnios or ogliohydramnios;

(XXXIX)

vaginitis other than simple, non-recurrent monilia;

(XL)

hepatitis, chronic hepatic dysfunction, or positive Hepatitis B surface antigen; or

(XLI)

any other medical or obstetric condition or symptom which could adversely affect the mother or fetus, as assessed by a midwife exercising ordinary skill and education.

(iv)

If on any assessment, the midwife determines that the client has one or more of the following conditions, she will consult, in a timely manner, with a licensed physician with current obstetric knowledge or another licensed health care provider with current obstetric knowledge operating under such a physician's supervision and, upon his/her documented recommendation, transfer care of the client or otherwise follow his/her recommendation. If the midwife is unable to obtain a consult, in a timely manner, the care of the client must be transferred to a licensed physician with current obstetric knowledge or another licensed health care provider with current obstetric knowledge operating under such a physician's supervision:

(I)

history of incompetent cervix;

(II)

history of gestational diabetes in a prior pregnancy requiring insulin therapy;

(III)

history of autoimmune disease; e.g., systemic lupus erythematosus;

(IV)

diabetes mellitus or gestational diabetes during current pregnancy;

(V)

history of prior C-section or uterine surgery;

(-a-)

The department agrees with the current obstetric practice of encouraging vaginal birth after C-section (VBAC). Further, it agrees with the most recent (1994) ACOG guidelines concerning VBAC which state that:

(-1-)

The concept of routine repeat cesarean birth should be replaced by a specific decision process between the client and the physician for a subsequent mode of delivery;

(-2-)

In the absence of a contraindication, a woman with one previous cesarean delivery with a lower uterine segment incision should be counseled and encouraged to undergo a trial of labor in her current pregnancy;

(-3-)

A woman who has had two or more previous cesarean deliveries with lower uterine segment incisions and who wishes to attempt vaginal birth should not be discouraged from doing so in the absence of contraindications;

(-4-)

A trial of labor and delivery should occur in a hospital setting that has professional resources to respond to obstetric emergencies;

(-b-)

If however, a client chooses not to accept the department's position that VBACs should be conducted in a hospital setting, then she may continue care with the midwife if the client signs a waiver of medical transfer and the client has not had a classical C-section.

(-c-)

A waiver document shall be developed by the Midwifery Board and department for use in this situation and the midwife will have each client, for whom she conducts a VBAC, sign this form. The form will be retained in the client's midwifery record.

(VI)

chronic hypertension;

(VII)

hemoglobinopathy;

(VIII)

preterm labor (less than 36 weeks);

(IX)

preterm rupture of membranes (less than 36 weeks);

(X)

multiple gestation;

(XI)

Rh or other blood group isoimmunization;

(XII)

seizure activity;

(XIII)

pyelonephritis;

(XIV)

AIDS or HIV positivity with immune compromise;

(XV)

cancer; or

(XVI)

any other medical or obstetric condition or symptom which poses a significant risk to the mother or fetus, as assessed by a midwife exercising ordinary skill and education.

(v)

If any of the following conditions or symptoms are noted during labor, delivery, or immediately postpartum (the first 24 hours), the midwife will immediately consult with a licensed physician who has current obstetric knowledge and, unless the physician recommends otherwise, transfer care. If a physician is not available for immediate consultation, the midwife will transfer care to a licensed physician. If delivery is imminent after recognition of one of these conditions or symptoms and transfer is not feasible, then delivery should be carried out by the midwife. Consultation and/or transfer should then occur immediately postpartum except for those conditions in subclauses (I) and (III)-(VI) of this clause:

(I)

multiple gestation;

(II)

preterm (less than 36 weeks) labor;

(III)

estimated fetal weight less than 51/2 pounds or 2500 grams;

(IV)

active phase dilatation less than 1 cm/3-4 hours;

(V)

second stage greater than 1-2 hours in a multiparous woman or greater than 2-3 hours in a primiparous woman and delivery;

(VI)

rupture of membranes for greater than 24 hours and not anticipated to deliver within 4 hours or delivery not imminent after an additional 4 hours;

(VII)

premature rupture of membranes longer than 24 hours and not in the active phase of labor;

(VIII)

foul smelling amniotic fluid;

(IX)

hypertension, a diastolic blood pressure greater than 90 mm Hg or systolic pressure greater than 140 mm Hg or a rise in the former of at least 15 mm Hg or in the latter of 30 mm Hg;

(X)

severe abdominal pain inconsistent with normal labor or involution;

(XI)

significant decrease in urine output;

(XII)

persistent vomiting or diarrhea;

(XIII)

foul smell to the placenta or infant;

(XIV)

retained placenta or fragment, i.e., lack of spontaneous placental expulsion within one hour with no excessive bleeding or evidence of shock, or evidence of incomplete placenta on post expulsion exam;

(XV)

inappropriate uterine involution;

(XVI)

inability to void within six hours of delivery with adequate hydration; or

(XVII)

any other medical or obstetric condition which poses a risk to the mother or fetus, as assessed by a midwife exercising ordinary skill and education.

(vi)

If any of the following conditions or symptoms are noted during labor, deliver, or immediately postpartum (the first 24 hours), the midwife will transfer the client immediately to a physician. If delivery is imminent after recognition of one of these conditions or symptoms and transfer is not feasible, then delivery should be carried out by the midwife. Consultation and/or transfer should then occur immediately postpartum except for those conditions in subclauses (I) and (IV)-(VI) of this clause:

(I)

non-vertex presentation; e.g., breech or transverse lie or face with position other than mentum anterior;

(II)

vaginal bleeding more than bloody show (prior to delivery);

(III)

herpetic lesions;

(IV)

moderate to severe thick meconium staining of amniotic fluid;

(V)

non-reassuring fetal heart rate - persistent baseline rate less than 120 beats per minute or greater than 160 beats per minute; persistent decelerations (greater than 10 minutes without variability or greater than 30 minutes with good variability) or recurring decelerations from baseline. A shorter observation interval prior to transfer may be indicated in the presence of large decreases in rate;

(VI)

umbilical cord or extremity prolapse;

(VII)

persistent fall in blood pressure to equal to or less than 80/50;

(VIII)

pulse persistently greater than 120 or less than 50;

(IX)

respiratory rate persistently greater than 30 or less than 10;

(X)

elevated temperature, equal to or greater than 100.4 degrees Fahrenheit;

(XI)

faintness, pallor, or other signs/symptoms consistent with shock;

(XII)

loss of consciousness;

(XIII)

persistent severe headache;

(XIV)

visual disturbance;

(XV)

seizure;

(XVI)

chest pain and/or difficulty breathing;

(XVII)

uterine inversion;

(XVIII)

uterine atony with significant bleeding;

(XIX)

significant postpartum bleeding, i.e., greater than 1,000 cc during the first two hours following delivery of the infant;

(XX)

third- or fourth-degree perineal laceration, or significant vulvar, vaginal, or cervical laceration; or

(XXI)

any other medical or obstetric condition which poses a significant risk to the mother or fetus, as assessed by a midwife exercising ordinary skill and education.

(vii)

If any of the following conditions or symptoms are noted during the postpartum period, the midwife will refer the client in a timely manner to a licensed physician who has current obstetric knowledge or another licensed health care provider with current obstetric knowledge operating under such a physician's supervision:

(I)

significant vaginal bleeding;

(II)

persistent severe headache;

(III)

visual disturbance;

(IV)

seizure;

(V)

significant abdominal pain inconsistent with involution;

(VI)

chest pain and/or difficulty breathing;

(VII)

signs or symptoms of thrombophlebitis;

(VIII)

urinary problems, e.g., difficulty with initiation or emptying, pain, blood, or frequency;

(IX)

blood pressure equal to or greater than 140 mm Hg systolic or 90 mm Hg diastolic;

(X)

temperature equal to or greater than 100.4 degrees Fahrenheit;

(XI)

improper healing or infection of delivery site lacerations;

(XII)

inappropriate uterine involution;

(XIII)

foul smelling lochia;

(XIV)

significant edema of hands, legs, or face;

(XV)

signs or symptoms of mastitis unresponsive to natural remedies within 24 hours;

(XVI)

hemoglobin less than or equal to 10 g/dl and/or hematocrit less than or equal to 30%; or

(XVII)

any other medical or obstetric condition or symptom which poses a risk to the mother, as assessed by a midwife exercising ordinary skill and education.

(viii)

If any of the following conditions or symptoms are noted in the neonate at birth or during the immediate postpartum period (the first 24 hours), the infant will be immediately transferred to a physician:

(I)

vital signs that indicate the following:

(-a-)

APGAR score less than seven at five minutes and/or less than eight at 20 minutes;

(-b-)

pulse rate at rest persistently less than 120 beats per minute or greater than 160 beats per minute during the first hour of life and then less than 100 beats per minute or greater than 160 beats per minute;

(-c-)

respiratory rate persistently less than 30 breaths per minute or greater than 60 breaths per minute and/or difficulty breathing and/or grunting and/or nasal flaring and/or sternal retraction;

(-d-)

persistent temperature equal to or greater than 100.4 degrees Fahrenheit or less than 97.7 degrees Fahrenheit rectally; or

(-e-)

requires full cardiopulmonary resuscitation;

(II)

physical exam (done within one to two hours of birth) that indicate the following:

(-a-)

foul smelling infant;

(-b-)

birth injury;

(-c-)

flaccidity and/or lethargy and/or irritability;

(-d-)

asymmetrical movements of extremities:

(-1-)

spasticity;

(-2-)

seizure and/or twitching and/or tremor;

(-3-)

abnormal tone; or

(-4-)

persistent jitteriness;

(-e-)

shrill or abnormal cry;

(-f-)

vomiting or choking;

(-g-)

persistent poor suck or swallow;

(-h-)

central cyanosis;

(-i-)

pale;

(-j-)

persistent "beefy" red skin in conjunction with other signs and symptoms;

(-k-)

mottling of skin with normal temperature;

(-l-)

jaundice;

(-m-)

presence of abnormal rash or vesicles;

(-n-)

loss of consciousness;

(-o-)

delivered with meconium staining and symptoms of respiratory distress; or

(III)

any other condition or symptom which poses a significant risk to the infant, as assessed by a midwife exercising ordinary skill and education.

(ix)

If any of the following conditions or symptoms are noted in the neonate within the first 24 to 36 hours after birth, then a consult by a licensed physician who has current pediatric knowledge or another licensed health care provider with current pediatric knowledge operating under such a physician's supervision will be obtained within 24 hours or the time specified:

(I)

birth weight less than 5 1/2 pounds with respiratory distress or greater than 10 pounds with signs of hypoglycemia;

(II)

congenital anomaly, e.g.:

(-a-)

cleft lip and/or palate;

(-b-)

possible Down's Syndrome;

(-c-)

umbilical abnormalities, e.g., umbilical cord with more or less than three vessels;

(-d-)

abnormal abdominal wall; or

(-e-)

spinal dimple.

(III)

any non-vertex delivery;

(IV)

absence of urination within 12-24 hours;

(V)

absence of meconium passage within 24-36 hours;

(VI)

head/length ratio discrepancy; or

(VII)

any other condition or symptom which poses a risk to the infant, as assessed by a midwife exercising ordinary skill and education.

(x)

If any of the following conditions or symptoms are noted in the infant during the first four to six weeks of life, the neonate will be referred in a timely manner to a licensed physician who has current pediatric knowledge or another licensed health care provider with current pediatric knowledge operating under such a physician's supervision:

(I)

vital signs that indicate the following:

(-a-)

pulse rate persistently less than 110 beats per minute or greater than 160 beats per minute;

(-b-)

respiratory rate persistently less than 30 breaths per minute or greater than 60 breaths per minute and/or difficulty breathing and/or grunting and/or nasal flaring and/or sternal retraction; or

(-c-)

temperature persistently above 99.6 degrees Fahrenheit or less than 96.5 degrees Fahrenheit axillary;

(II)

physical exam that indicates the following:

(-a-)

flaccidity and/or lethargy and/or irritability;

(-b-)

asymmetrical movements of extremities:

(-1-)

spasticity;

(-2-)

seizure and/or twitching and/or tremor;

(-3-)

abnormal tone; or

(-4-)

persistent jitteriness.

(-c-)

vomiting and/or choking;

(-d-)

persistent poor suck and/or poor swallow;

(-e-)

central cyanosis;

(-f-)

pale;

(-g-)

persistent "beefy" red skin in conjunction with other signs and symptoms;

(-h-)

mottling of skin with normal temperature;

(-i-)

jaundice;

(-j-)

presence of abnormal rash or vesicles;

(-k-)

loss of consciousness;

(-l-)

failure to appropriately wet eight to ten diapers per day;

(-m-)

failure to pass stool in a normal manner;

(-n-)

bloody stool or abdominal distention;

(-o-)

poor feeding, less than eight feedings daily; or

(-p-)

failure to gain weight.

(III)

abnormal lab:

(-a-)

newborn screening; or

(-b-)

positive syphilis serology; or

(IV)

any other condition or symptom which poses a risk to the infant, as assessed by a midwife exercising ordinary skill and education.

(4)

Guidelines for safe and competent care.

(A)

The midwife will collect and assess maternal care data through a detailed obstetric, gynecologic, medical, social, and family history and a complete prenatal physical exam and appropriate laboratory testing; develop and implement a plan of care; thereafter evaluate the client's condition on an ongoing basis; and modify the plan of care as necessary:

(i)

Antepartum evaluation. The following components will be included in the antepartum evaluation:

(I)

History. The history will include an inquiry regarding all of the following categories:

(-a-)

client identification;

(-b-)

age;

(-c-)

race, ethnicity;

(-d-)

psychosocial/economic;

(-e-)

drug/alcohol/tobacco;

(-f-)

medications;

(-g-)

allergies;

(-h-)

gynecologic;

(-i-)

menstrual;

(-j-)

contraceptive;

(-k-)

sexual;

(-l-)

HIV risk;

(-m-)

obstetric;

(-n-)

current pregnancy;

(-o-)

perinatal risk;

(-p-)

current problems;

(-q-)

medical;

(-r-)

surgical;

(-s-)

anesthesia problems;

(-t-)

hospitalizations;

(-u-)

transfusions;

(-v-)

family/genetic;

(-w-)

immunization status (Td, rubella, etc.);

(-x-)

nutrition; and

(-y-)

abuse/trauma.

(II)

Physical exam/assessment. The physical exam/assessment will include at least the following:

(-a-)

weight and height;

(-b-)

blood pressure;

(-c-)

pulse;

(-d-)

breasts, to include teaching on self exam (may be referred);

(-e-)

abdomen, to include fundal height, estimated fetal weight, and fetal heart tones;

(-f-)

pelvic, to include external genitalia, vagina, cervix, uterus, adnexa, and pelvimetry (unless contraindicated);

(-g-)

fetal lie and presentation, if equal to or greater than 36 weeks;

(-h-)

estimation of gestational age by physical findings; and

(-i-)

assessment of varicosities, edema, and reflexes.

(III)

Laboratory. The client will be encouraged to have the following laboratory tests performed:

(-a-)

hemoglobin and/or hematocrit or CBC;

(-b-)

urine dipstick for protein, glucose, and nitrites;

(-c-)

syphilis serology;

(-d-)

blood group, Rh type, and antibody screen;

(-e-)

hepatitis B surface antigen;

(-f-)

rubella screen;

(-g-)

pap smear;

(-h-)

gonorrhea test, if at risk;

(-i-)

chlamydia test, if at risk;

(-j-)

HIV test, if at risk; and

(-k-)

hemoglobin electrophoresis, if Black or of Italian, Greek, Mediterranean, Philippine or Oriental ancestry and not previously tested.

(IV)

Assessment. At the conclusion of the initial evaluation the antepartum client's overall health and risk status will be assessed. The assessment will include a consideration of at least the following:

(-a-)

gestational age;

(-b-)

maternal status;

(-c-)

fetal status;

(-d-)

nutritional/Women, Infants, and Children (WIC) status;

(-e-)

psychosocial status; and

(-f-)

educational needs.

(V)

Plan. A plan of care will be developed based upon the assessment of the antepartum client. The plan of care will include a referral plan for diagnosis and treatment if necessary.

(VI)

Education and counseling. Health education/counseling will be provided and will include consideration of at least the following (depending upon gestational age, certain of these items may be covered during subsequent visits as appropriate):

(-a-)

midwife services/routine;

(-b-)

reproductive physiology/anatomy;

(-c-)

roles of various members of the health care team;

(-d-)

caution concerning medications, recreational drugs, alcohol, tobacco, x-ray and chemical exposure, and sexual transmitted disease (STD) exposure;

(-e-)

HIV infection;

(-f-)

toxoplasmosis risk;

(-g-)

environmental/work hazards;

(-h-)

nutritional needs of pregnancy, weight gain, referral to WIC;

(-i-)

danger signs of pregnancy appropriate to gestational age;

(-j-)

when to seek medical care and where to obtain care in the case of an emergency;

(-k-)

delivery arrangements;

(-l-)

signs and symptoms of preterm labor;

(-m-)

labor;

(-n-)

rupture of membranes;

(-o-)

fetal movement;

(-p-)

minor discomforts/symptoms of pregnancy;

(-q-)

comfort measures;

(-r-)

physical changes of pregnancy, fetal growth;

(-s-)

sexual activity;

(-t-)

self breast exam;

(-u-)

physical activity/exercise/posture;

(-v-)

preparation for labor and delivery, childbirth classes;

(-w-)

preparation for parenthood and arrangement for infant health care;

(-x-)

infant feeding choices, breast-feeding should be promoted; and

(-y-)

family planning/ postpartum care.

(ii)

Subsequent antepartum evaluations. The following components will be included in each subsequent antepartum evaluation:

(I)

History. Each follow-up history will include an inquiry regarding at least the following historical categories:

(-a-)

current problems;

(-b-)

progress of pregnancy to include an evaluation of fetal movement after 20 weeks;

(-c-)

perinatal risks; and

(-d-)

follow-up of problems identified in previous visits.

(II)

Physical assessment. Each follow-up assessment will include at least the following:

(-a-)

weight;

(-b-)

blood pressure;

(-c-)

abdomen, to include fundal height, estimated fetal weight, and fetal heart tones;

(-d-)

fetal lie and presentation, if equal to or greater than 36 weeks;

(-e-)

estimation of gestational age by physical findings; and

(-f-)

assessment of varicosities and edema.

(III)

Laboratory. Each follow-up assessment will include at least the following:

(-a-)

urine dipstick for protein, glucose, and nitrites; and

(-b-)

each client will be encouraged to have the following laboratory tests performed at the times indicated:

(-1-)

hemoglobin and/or hematocrit at 28 and 36 weeks;

(-2-)

blood glucose screening one hour post oral 50 gram glucose load at 24 to 28 weeks;

(-3-)

if Rh negative, and initial antibody screen negative, repeat antibody screen at 28 weeks as precursor to Rh immune globulin administration. If the screen is still negative, the midwife will recommend that the client receive Rh immune globulin. If antibody screen is positive, refer to physician; and

(-4-)

Maternal Serum Alpha-Fetoprotein (MSAFP) or triple screen, ideally at 16 to 18 weeks, may be done from 15 to 20 weeks.

(IV)

Assessment. Each follow-up evaluation will conclude with an assessment which includes a consideration of at least the following:

(-a-)

gestational age;

(-b-)

maternal status;

(-c-)

fetal status;

(-d-)

nutritional/WIC status;

(-e-)

psychosocial status; and

(-f-)

educational needs.

(V)

Plan. The current plan of care will be continued or modified based upon the assessment of the client. The plan will include a referral plan for diagnosis and treatment if necessary.

(VI)

Education and counseling. The following health education and counseling components will be discussed or reviewed at subsequent evaluations as appropriate to the client's gestational age and needs:

(-a-)

danger signs of pregnancy appropriate to gestational age;

(-b-)

signs and symptoms of preterm labor, 24-36 weeks;

(-c-)

true/false labor, if equal to or greater than 36 weeks;

(-d-)

rupture of membranes;

(-e-)

fetal movement;

(-f-)

comfort measures;

(-g-)

weight gain;

(-h-)

physical activity/exercise/posture;

(-i-)

physical changes of pregnancy/fetal growth;

(-j-)

delivery arrangements;

(-k-)

preparation for labor and delivery, childbirth classes;

(-l-)

preparation for parenthood and arrangement for infant health care;

(-m-)

infant feeding choices, breast-feeding should be promoted; and

(-n-)

family planning/postpartum care.

(iii)

Routine antepartum visits. Routine antepartum visits will be scheduled according to the following intervals:

(I)

every four weeks for the first 28 weeks;

(II)

every two to three weeks from 28 to 36 weeks;

(III)

every week after 36 weeks; or

(IV)

more frequently, if indicated.

(iv)

Recommended vitamins. The midwife should recommend to all clients that they take one, over-the-counter, prenatal, multi-vitamin supplement with folic acid/iron each day (unless allergic or contraindicated).

(B)

The midwife will appropriately evaluate the client when the midwife arrives for the labor and delivery, by obtaining a history, performing a physical exam, and performing a laboratory evaluation. The following components will be included in the evaluation of the client:

(i)

History. The history will include an inquiry regarding all of the following:

(I)

contractions - onset, frequency, duration;

(II)

other abdominal or pelvic pain;

(III)

status of membranes - if ruptured, when, amount, clear versus meconium stained;

(IV)

vaginal bleeding;

(V)

fetal movement; and

(VI)

other problems or concerns.

(ii)

Physical assessment. The physical will include at least the following:

(I)

blood pressure;

(II)

pulse;

(III)

temperature;

(IV)

abdomen, to include estimated fetal weight, fetal lie and presentation, and fetal heart tones;

(V)

assessment of varicosities and edema; and

(VI)

pelvic exam (unless contraindicated) which will include the following:

(-a-)

external genitalia;

(-b-)

cervix for dilatation, effacement, station, presentation, and position; and

(-c-)

a sterile speculum exam, if necessary, prior to or in lieu of the cervical exam to evaluate for possible rupture of membranes.

(iii)

Laboratory. The laboratory assessment will include a urine dipstick for protein, glucose, and nitrites.

(C)

The midwife will appropriately monitor the client after the midwife's arrival for the labor and delivery. This monitoring will be done unobtrusively in order not to disturb the physiological process of labor. The following components will be included in the evaluation:

(i)

Vital signs. The following vital signs will be obtained:

(I)

blood pressure - to be measured at least every two hours, or more frequently if indicated;

(II)

pulse - to be taken at least every four hours;

(III)

respirations - to be evaluated at least every four hours; and

(IV)

temperature - to be measured at least every four hours unless equal to or greater than 99 degrees Fahrenheit, then measured at least every one to two hours.

(ii)

Contractions. Contractions will be monitored as follows:

(I)

frequency, duration, and intensity at least every two hours in the latent phase of the first stage;

(II)

frequency, duration, and intensity at least every 30 minutes to one hour in the active phase of the first stage or as indicated by heart rate patterns; and

(III)

frequency, duration, and intensity at least every 15 minutes in the second stage.

(iii)

Fetal heart tones. Fetal heart tones will be auscultated as follows:

(I)

for routine monitoring, first establish a baseline by listening for several minutes before, during, and after a contraction; then listen during and for at least 30 seconds following a contraction according to the following schedule:

(-a-)

at least every two hours in the latent phase of the first stage;

(-b-)

at least every 30 minutes in the active phase of the first stage;

(-c-)

at least every 15 minutes in the second stage; and

(-d-)

for at least 30 seconds immediately after rupture of the membranes, and during and for at least 30 seconds following the next contraction.

(II)

For VBAC monitoring, first establish a baseline as in subclause (I) of this clause, then listen during and for at least 30 seconds following a contraction according to the following schedule:

(-a-)

at least every two hours in the latent phase of the first stage;

(-b-)

at least every 15 minutes in the active phase of the first stage;

(-c-)

at least every five minutes in the second stage; and

(-d-)

for at least 30 seconds immediately after rupture of the membranes, and during and for at least 30 seconds following the next contraction.

(III)

As indicated for bleeding or other signs of a possible problem.

(iv)

Cervical and vertex status. Vaginal examinations are performed to assess the progress of labor. Although necessary, they will be kept to a minimum to reduce the risk of infection. Attention will be directed toward aseptic technique. Cervical dilatation and effacement and vertex station and position will be evaluated during each exam.

(v)

Membrane status. Membrane status will be monitored for rupture, relative fluid volume, foul odor, and the presence of meconium once ruptured:

(I)

temperature monitored every four hours;

(II)

pulse monitored every four hours; and

(III)

minimal sterile vaginal exams.

(vi)

Intake/output status. The intake/output of the client will be monitored as follows:

(I)

intake - all oral or other intake will be monitored on an ongoing basis; and

(II)

urinary output - the client will be encouraged to void at least every two to three hours. Frequency and relative volume of voiding will be monitored on an ongoing basis.

(vii)

Subjective status. The client will be monitored for complaints and concerns.

(viii)

The following will not occur:

(I)

application of pressure on abdomen or uterus at any stage in labor; and

(II)

administration by any method (buccal, vaginal, IM, IV, intranasal, etc.) of oxytocin (Pitocin, Syntocinon, Uteracon), ergot, or prostaglandins prior to or during labor. Oxytocin or ergot may be administered after delivery of the placenta only under delegated authority of a licensed physician with current obstetric knowledge.

(D)

The midwife will appropriately assist in normal, spontaneous vaginal deliveries.

(i)

When delivery is imminent, the patient will not be left unattended, nor should any attempt be made to delay the birth of the infant by physical restraint; and

(ii)

Forceps or vacuum extraction will not be utilized.

(E)

The midwife will appropriately monitor and advise the mother during the immediate postpartum period for at least two hours and until her condition is stable. The following components will be evaluated or covered during this time period:

(i)

Vital signs. The following vital signs will be obtained:

(I)

blood pressure - to be measured at least every 15-30 minutes during the first hour and then every hour if stable;

(II)

pulse - to be taken at least every 15-30 minutes during the first hour and then every hour if stable;

(III)

respirations - to be taken at least every 15-30 minutes during the first hour and then every hour if stable; and

(IV)

temperature - to be taken at least every four hours.

(ii)

Intake/output status. Intake and output will be monitored.

(iii)

Physical assessment. The client will be assessed frequently to assure that:

(I)

the uterine fundus is well contracted; and

(II)

bleeding is not excessive.

(iv)

Subjective status. The client will be monitored for complaints and concerns.

(v)

Laboratory and isoimmunization prophylaxis. If unsensitized and Rh negative, the client will be referred to a licensed physician with current obstetric knowledge or another licensed health care provider with current obstetric knowledge operating under such a physician's supervision within 72 hours of delivery for laboratory work-up and administration of Rh immune globulin or the midwife will obtain the necessary laboratory specimen and administer Rh immune globulin under standing delegation order from a licensed physician with current obstetric knowledge within 72 hours of delivery.

(vi)

Education and counseling. Health education and counseling will be provided and will include consideration of at least the following (reinforcement will occur during subsequent postpartum visits):

(I)

diet/nutrition;

(II)

bowel/bladder function;

(III)

postpartum bleeding;

(IV)

perineal care;

(V)

breast-feeding;

(VI)

warning signs;

(VII)

pain relief;

(VIII)

physical activity/exercise;

(IX)

sexual activity;

(X)

contraception; and

(XI)

infant care - located in subparagraph (F)(iii) and subparagraph (J)(vi) this paragraph.

(F)

The midwife will appropriately evaluate the newborn by monitoring the vital signs, performing a physical exam, and obtaining the laboratory tests necessary for the infant during the immediate postpartum period; provide necessary infant care; and provide pertinent education and counseling to the mother:

(i)

Evaluation and monitoring. The following components will be included in the evaluation and monitoring of the infant.

(I)

Vital signs. APGAR scores will be obtained at one minute and five minutes. If the five minute score is less than seven, obtain additional scores every five minutes until twenty minutes has passed or two successive scores are equal to or greater than 7. The following vital signs will be taken at 30 minute intervals for at least two hours or until the infant's temperature has stabilized, whichever is longer:

(-a-)

pulse;

(-b-)

respirations (rate and effort); and

(-c-)

temperature.

(II)

Physical exam. The physical exam will include at least the following:

(-a-)

skin;

(-b-)

head and neck;

(-c-)

eyes, ears, nose, and throat;

(-d-)

fontanel;

(-e-)

heart/lungs;

(-f-)

abdomen;

(-g-)

umbilical cord;

(-h-)

external genitalia;

(-i-)

back;

(-j-)

extremities (check for hip dislocation);

(-k-)

neurological exam; and

(-l-)

weight, length, head circumference.

(III)

Laboratory.

(-a-)

Cord blood will be taken and submitted to a state-approved lab for testing for syphilis. In the event that cord blood is not obtained, the midwife will arrange for collection of a specimen of blood from the mother within 24 hours after delivery and submit such sample to an approved laboratory; and

(-b-)

The blood specimen for the first newborn screening will be obtained after 36 hours of age. It should be obtained after the baby has been breast-feeding or on protein (milk) feeding for at least 24 hours. The second screen will be done between one and two weeks of age.

(IV)

Monitoring. The newborn will be observed for a minimum of two hours if stable with no signs of distress.

(ii)

Care of the infant. The following components will be included in the care of the infant.

(I)

Prophylaxis. Eye treatment will be provided within two hours after birth using one of the CDC approved ophthalmic preparations, i.e., silver nitrate, erythromycin, or tetracycline; and

(II)

Feeding. Feeding can begin in the immediate newborn period if the infant is stable with no signs of distress.

(iii)

Education and counseling. The following components will be included in education and counseling of the mother:

(I)

Signs and symptoms. The significance of the following if observed in the newborn will be discussed:

(-a-)

poor suck;

(-b-)

abnormal cry;

(-c-)

irritability, lethargy; or

(-d-)

elimination:

(-1-)

abnormalities with urine; or

(-2-)

abnormalities with stool.

(II)

Health care and immunization. Information regarding health care and immunization will be provided as follows:

(-a-)

Routine pediatric care by a licensed physician with current pediatric knowledge or another licensed health care provider with current pediatric knowledge operating under such a physician's supervision will be recommended to begin at birth. Arrangements with an appropriate physician or other health care provider should be made during the antepartum period;

(-b-)

The administration of the first hepatitis B vaccine at 12 hours of age will be discussed; the client will also be educated during the antepartum period about hepatitis B and the newborn hepatitis B vaccine; and

(-c-)

The client should be referred to a licensed physician or other health care provider for vaccine information.

(G)

The midwife will appropriately evaluate the mother at one to two days postpartum, including the following components.

(i)

History. The history will include consideration of at least the following:

(I)

current problems;

(II)

abdominal/uterine/perineal pain;

(III)

bleeding;

(IV)

intake/output; and

(V)

breast-feeding.

(ii)

Physical assessment. The physical assessment will include at least the following:

(I)

blood pressure;

(II)

pulse;

(III)

respirations;

(IV)

temperature;

(V)

breasts;

(VI)

abdomen/fundus;

(VII)

perineum; and

(VIII)

assessment of varicosities and edema.

(iii)

Laboratory. Hemoglobin and/or hematocrit or CBC will be strongly encouraged.

(iv)

Assessment. The assessment will include at least the following:

(I)

physical status;

(II)

nutritional/WIC status; and

(III)

psychosocial status.

(v)

Plan. A plan of care will be developed based upon the assessment of the client. The plan of care will include a referral plan for diagnosis and treatment if necessary. The client will be counseled regarding family planning, contraception, and routine health care provided by a licensed physician or another licensed health care provider supervised by a licensed physician. The client's prenatal, multi-vitamin supplement with folic acid/iron should be continued during the postpartum period unless contraindicated.

(H)

The midwife will appropriately evaluate the mother at two to three weeks postpartum, including the following components:

(i)

History. The history will include consideration of at least the following:

(I)

drugs/alcohol/tobacco;

(II)

medications;

(III)

current problems;

(IV)

nutrition;

(V)

bowel/bladder function;

(VI)

abdominal/uterine/perineal pain;

(VII)

bleeding; and

(VIII)

breast-feeding.

(ii)

Physical assessment. The physical assessment will include at least the following:

(I)

blood pressure;

(II)

pulse;

(III)

weight;

(IV)

abdomen/fundus;

(V)

perineum; and

(VI)

assessment of varicosities and edema.

(iii)

Assessment. The assessment will include at least the following:

(I)

physical status;

(II)

nutritional/WIC status; and

(III)

psychosocial status.

(iv)

Plan. The current plan of care will be continued or modified based upon the assessment of the client. Family planning, contraception, and the client's medical postpartum follow up will be discussed.

(I)

The midwife will appropriately evaluate the mother at four to six weeks postpartum, including the following components.

(i)

History. The history will include consideration of at least the following categories:

(I)

drugs/alcohol/tobacco;

(II)

medications;

(III)

allergies;

(IV)

current problems;

(V)

abdominal/uterine/perineal pain;

(VI)

nutrition;

(VII)

bowel/bladder function;

(VIII)

bleeding;

(IX)

menstruation;

(X)

gynecologic;

(XI)

sexual activity;

(XII)

contraception; and

(XIII)

abuse/trauma.

(ii)

Physical exam/assessment. The physical exam/assessment will include at least the following:

(I)

blood pressure;

(II)

pulse;

(III)

weight;

(IV)

abdomen;

(V)

pelvic exam to include external genitalia, vagina, cervix, uterus, and adnexa; and

(VI)

assessment of varicosities and edema.

(iii)

Laboratory. Hemoglobin and/or hematocrit or CBC will be encouraged.

(iv)

Assessment. The assessment will include at least the following:

(I)

physical status;

(II)

nutritional/WIC status; and

(III)

psychosocial status.

(v)

Plan of care. A plan of care will be developed based upon the assessment of the client. The plan of care will include a referral plan for diagnosis and treatment if necessary. Family planning, contraception, and routine health care follow up provided by a licensed physician or other licensed health care provider operating under the supervision of a licensed physician should be reiterated.

(J)

The midwife appropriately encourages follow-up care of the infant in concert with the mother for the first four to six weeks postpartum. The following components will be included in each evaluation of the newborn.

(i)

History. The history will include consideration of at least the following categories:

(I)

feeding;

(II)

bowel and bladder function;

(III)

concerns of mother;

(IV)

problems;

(V)

illnesses;

(VI)

allergies; and

(VII)

evaluations by other health care providers.

(ii)

Vital signs. The following vital signs will be taken:

(I)

pulse;

(II)

respiratory rate; and

(III)

temperature.

(iii)

Physical assessment. The physical assessment will include at least the following:

(I)

general health;

(II)

muscle tone;

(III)

feeding pattern;

(IV)

color;

(V)

skin condition;

(VI)

elimination; and

(VII)

cumulative weight gain.

(iv)

Assessment. The infant's overall health and risk status will be assessed. The assessment will include at least the following:

(I)

physical status; and

(II)

feeding and weight gain status.

(v)

Plan of care. A plan of care will be developed based upon the assessment of the infant. The plan of care will include a referral plan for diagnosis and treatment if necessary. The midwife will encourage the mother to take the infant to a licensed physician with current pediatric knowledge or another licensed health care provider with current pediatric knowledge operating under such a physician's supervision for a complete six week assessment.

(vi)

Education and counseling. Health education and counseling will be provided to the mother and reviewed as appropriate to the infant's age and needs. It will include consideration of at least the following:

(I)

diet, nutrition;

(II)

bowel and bladder function;

(III)

growth, weight gain;

(IV)

bathing;

(V)

clothing;

(VI)

injury/poison prevention;

(VII)

danger signs, illness;

(VIII)

medical care and follow up; and

(IX)

immunizations.

(5)

Safe environment. The midwife:

(A)

assesses the birth setting for reasonable freedom from environmental hazards;

(B)

arranges, with the cooperation of the woman and family, the intended birth place;

(C)

brings her/his own equipment;

(D)

will not make arrangements for a home delivery if there is no phone available at the home or nearby or an adequate emergency transport system;

(E)

promotes involvement of family and support persons in the birth setting;

(F)

does not leave the client unattended during established active labor;

(G)

is available and responds promptly to her client's needs;

(H)

follows accepted infection control procedures regarding equipment, examinations, and procedures; and

(I)

is familiar with and practices universal precautions established by Occupational Safety and Health Administration (OSHA) guidelines.

(6)

Community systems. The midwife:

(A)

collaborates and consults with and refers to the available medical and health care community;

(B)

utilizes ancillary health and social community services; and

(C)

demonstrates knowledge of psychosocial, economic, cultural, and family factors that may affect care, appropriate collaboration, and referral.

(7)

Midwifery care records. The midwife:

(A)

completely and accurately documents the client's history, physical exam, laboratory test results, antepartum visits, consultation reports, referrals, labor, delivery, postpartum visits, and neonatal evaluations at the time midwifery services are delivered and when reports are received;

(B)

utilizes a record format that facilitates communication of information to consultants or other appropriate providers of care;

(C)

facilitates clients' access to their own records;

(D)

maintains the confidentiality of client records; and

(E)

retains records for a minimum of five years.

(8)

Evaluation and quality assurance. The midwife:

(A)

collects client care data systematically and is involved in analysis of that data for evaluation of the process and outcome of care;

(B)

seeks consultation to review problems identified by the midwife or by other professionals or consumers in the community; and

(C)

acts to resolve problems that are identified.

(9)

Sample Prenatal Genetic Screen. The following questions on this sample prenatal genetic screening form should be answered to determine possible risks.

Figure: 22 TAC §831.51(b)(9)

§831.121.Newborn Screening.

(a)

Each midwife who assists at the birth of a child is responsible for seeing that newborn screening tests are performed according to the Health and Safety Code, Chapters 33 and 34, and 25 Texas Administrative Code §§37.51-37.69 (relating to Newborn Screening Program). The midwife may perform the tests or refer for them. If she or he does them, then she or he must have been appropriately trained. Each midwife must have one of the following documents on file with the midwifery program in order to be documented.

(1)

Midwife Training Certification Form for Newborn Screening Specimen Collection. Should the midwife choose to do the newborn screening she or he will obtain training to perform this test from an appropriate health care facility. Instruction will be based upon the procedure for newborn screening developed by the department's Newborn Screening Program under authority of the Health and Safety Code, Chapter 33. The midwife who requests the training must show the training facility a copy of her or his documentation form to prove that she or he is in compliance with the Midwifery Act. At the completion of the instruction for newborn screening blood collection, the midwife will request that the form Midwife Training Certification Form for Newborn Screening Specimen Collection be signed by the designated representative of the health care facility, attesting to the fact that the midwife has complied with this requirement. This training, as part of the documentation requirements, is only necessary once unless there is a change in screening procedures.

(2)

Newborn Screening Agreement for Newborn Babies of Midwife Clients. The midwife could also choose to refer the family to have the infant's screening done at an appropriate health care facility. In this case, the midwife must use the form Newborn Screening Agreement for Newborn Babies of Midwife Clients to attest to her responsibility for seeing that the screening is done and to designate a facility for such screening. The form must include a section where the facility representative signs, agreeing that the facility will do the screening.

(b)

As long as the midwife has been approved to perform the newborn screening test, the act of collecting this specimen will not constitute "practicing medicine" as defined by the Medical Practice Act, Texas Civil Statutes, Article 4495b, §1.03(a)(12).

(c)

As long as one is available, a physician or an appropriately trained professional acting under standing delegation order from a physician at an appropriate health care facility shall instruct midwives in the proper procedure (newborn screening collection procedure of the department's Newborn Screening Program) for newborn screening blood specimen collection and submission. The physician, registered nurse, or any other person who instructs a midwife in the approved techniques for newborn screening on the orders of a physician is immune from liability arising out of the failure or refusal of a midwife to:

(1)

collect and submit the blood specimen in an approved manner; or

(2)

send the samples to the designated department laboratories in a timely manner.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 12, 1999.

TRD-9904186

Edna Dougherty

Chair

Texas Midwifery Board

Effective date: August 1, 1999

Proposal publication date: March 5, 1999

For further information, please call: (512) 458-7236