TITLE 22.EXAMINING BOARDS

Part 9. TEXAS STATE BOARD OF MEDICAL EXAMINERS

Chapter 163. LICENSURE

22 TAC §163.1, §163.10

The Texas State Board of Medical Examiners adopts amendments to §163.1 and §163.10, concerning Licensure, without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1784) and will not be republished.

The amendments are made to definitions and relicensure requirements.

No comments were received regarding adoption of the rules.

The amendments are adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

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 April 7, 2003.

TRD-200302269

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Chapter 167. REINSTATEMENT AND REISSUANCE

22 TAC §§167.1, 167.2, 167.4 - 167.6

The Texas State Board of Medical Examiners adopts amendments to §§167.1, 167.2, 167.4-167.6, concerning procedures for reinstatement and reissuance of a license, without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1787) and will not be republished.

Elsewhere in this issue of the Texas Register , the Texas State Board of Medical Examiners adopts the rule review for Chapter 167.

No comments were received regarding adoption of the rules.

The amendments are adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

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 April 7, 2003.

TRD-200302270

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Chapter 169. AUTHORITY OF PHYSICIANS TO SUPPLY DRUGS

22 TAC §§169.1 - 169.5, 169.7

The Texas State Board of Medical Examiners adopts amendments to §§169.1-169.5, 169.7, concerning authority of physicians to supply drugs. Sections 169.1-169.4 and §169.7 are adopted without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1789) and will not be republished. Section 169.5 is adopted with non substantive changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1789). The text of the rule will be republished.

The amendments are necessary for general clean up of the chapter.

Elsewhere in this issue of the Texas Register , the Texas State Board of Medical Examiners adopts the rule review for Chapter 169.

The Texas State Board of Pharmacy commented that deletion of the phrase "in which there is no pharmacy" from §169.5(1) might mislead physicians with respect to the statutory requirement in §563.053 of the Texas Pharmacy Act.

The Board agreed to make a nonsubstantive change in the proposed rule to alleviate the concerns of the State Board of Pharmacy.

The amendments are adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

§169.5.Exceptions.

Under the following circumstances, a physician may dispense or distribute drugs in quantities greater than those necessary to meet a patient's immediate needs.

(1) A licensed physician who practices medicine in a rural area, as defined in Section 169.2(10) of this chapter, may maintain a supply of dangerous drugs in his or her office to be dispensed in treating his or her patients and may be reimbursed for the cost of supplying those drugs without violating the Texas Pharmacy Act, Title 3 Subtitle J Tex. Occ. Code Ann. A physician desiring to dispense dangerous drugs in compliance with this subsection and §§158.001-.003 of the Act, shall notify the board and the Texas State Board of Pharmacy that he or she practices in a rural area.

(2) If a physician believes that a patient's prescribed treatment regimen should include certain drugs, the physician may supply them to the patient by means of pharmaceutical samples. No charge may be made by a physician for such samples. A patient's immediate needs as defined in this chapter shall not affect or limit the quantity of pharmaceutical samples a physician may provide to the patient.

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 April 7, 2003.

TRD-200302271

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Chapter 171. POSTGRADUATE TRAINING PERMITS

22 TAC §171.1

The Texas State Board of Medical Examiners adopts an amendment to §171.1, concerning reporting requirements relating to postgraduate training permits, without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1791) and will not be republished.

The amendment is necessary to update the reporting requirements.

No comments were received regarding adoption of the rule.

The amendment is adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

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 April 7, 2003.

TRD-200302272

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Chapter 174. TELEMEDICINE

22 TAC §§174.1 - 174.6, 174.10, 174.12 - 174.14, 174.17

The Texas State Board of Medical Examiners adopts amendments to §§174.1-174.6, 174.10, 174.12-174.14 and new §174.17, concerning Telemedicine without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1792) and will not be republished.

The amendments are necessary to clarify definitions and informed consent and for general cleanup of the chapter.

New §174.17 concerns the use of the Internet in medical practice.

No comments were received regarding adoption of the rules.

The amendment and new rule are adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

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 April 7, 2003.

TRD-200302273

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Chapter 184. SURGICAL ASSISTANTS

22 TAC §184.25

The Texas State Board of Medical Examiners adopts new §184.25, concerning surgical assistants, without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1795) and will not be republished.

The amendments concern continuing education for surgical assistants.

No comments were received regarding adoption of the rule.

The new rule is adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

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 April 7, 2003.

TRD-200302274

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Chapter 187. PROCEDURAL RULES

Subchapter B. INFORMAL BOARD PROCEEDINGS

22 TAC §§187.10, 187.12, 187.13

The Texas State Board of Medical Examiners adopts amendments to §§187.10, 187.12 and 187.13, concerning Procedural Rules, without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1797) and will not be republished.

The amendments are necessary to formalize the procedure whereby the Executive Director has the authority to offer restricted licenses and permits.

No comments were received regarding adoption of the rules.

The amendments are adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

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 April 7, 2003.

TRD-200302275

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Chapter 196. VOLUNTARY SURRENDER OF A MEDICAL LICENSE

22 TAC §§196.1 - 196.5

The Texas State Board of Medical Examiners adopts amendments to §§196.1-196.5, concerning Voluntary Surrender of a Medical License, without changes to the proposed text as published in the February 28, 2003, issue of the Texas Register (28 TexReg 1798) and will not be republished.

The amendments are necessary for general clean up of the chapter.

Elsewhere in this issue of the Texas Register , the Texas State Board of Medical Examiners adopts the rule review for Chapter 196.

No comments were received regarding adoption of the rules.

The amendments are adopted under the authority of the Occupations Code Annotated, §153.001, which provides the Texas State Board of Medical Examiners to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; and enforce this subtitle.

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 April 7, 2003.

TRD-200302276

Donald W. Patrick, MD, JD

Executive Director

Texas State Board of Medical Examiners

Effective date: April 27, 2003

Proposal publication date: February 28, 2003

For further information, please call: (512) 305-7016


Part 38. TEXAS MIDWIFERY BOARD

Chapter 831. MIDWIFERY

The Texas Midwifery Board (board), with the approval of the Texas Board of Health, adopts amendments to §§831.1, 831.2, 831.3, 831.7, 831.11, 831.31, 831.101, 831.111, 831.121, §831.131, 831.141, and 831.161, the repeal of §831.51, and new §§831.51, 831.52, 831.54, 831.57, 831.58, 831.60, 831.65, 831.70, and 831.75 concerning the documentation and regulation of midwives. Sections 831.1, 831.51, 831.58, and 831.75 are adopted with changes to the proposed text as published in the December 6, 2002 issue of the Texas Register (27 TexReg 11372) as a result of comments received during the 60-day comment period. Sections §§831.2, 831.3, 831.7, 831.11, 831.31, 831.101, 831.111, 831.121, §831.131, 831.141, and 831.161, the repeal of §831.51, and new §§831.52, 831.54, 831.57, 831.60, 831.65, and 831.70 are adopted without changes, and therefore the sections will not be republished.

Government Code, §2001.039, requires that each state agency conduct a review of its rules every four years and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act). Sections 831.1-831.3, 831.7, 831.11, 831.31, 831.101, 831.111, 831.121, 831.131, 831.141 and 831.161 have been reviewed and the board has determined that the reasons for adopting the sections continue to exist. The board has also determined that §831.51 should be repealed and replaced with new sections as described in this preamble.

The amendments correct internal references to §831.51 being repealed and replace them with new §§831.51, 831.52, 831.54, 831.57, 831.58, 831.60, 831.65, 831.70, and 831.75; update references to the Act as codified in Texas Occupations Code, Chapter 203; and replace language which refers to the department's Fair Hearing Procedures with language referring to the State of Office of Administrative Hearings. The amendments to §831.11, Annual Documentation, increase the documentation requirements for persons who graduate from a basic midwifery education program and do not apply for initial documentation within four years, and recognize graduation from a Midwifery Education and Accreditation (MEAC) accredited basic midwifery school as acceptable basic midwifery education. The amendments to §831.161 delete language referencing complaint categories, and replace it with language referencing board policy in order to enable the board to participate in the development of standardized complaint categories currently underway in the Professional Licensing and Certification Division. Minor amendments to wording in several sections for which no substantive change is indicated were also adopted to allow the sections as proposed to be published in their entirety.

All comments received concerned the proposed repeal of §831.51 and the new sections. One hundred and thirty-eight comments were received from individuals and twelve comments were received from organizations, Austin Area Midwives Association, Metroplex Area Midwifery Association, Association of Texas Midwives, Rio Grande Valley Midwifery Association, West Texans for Natural Childbirth, San Antonio Birth Doulas, Texans for Midwifery, North Texas Midwives Association, Texas Medical Association, Texas Nurses Association, Consortium of Texas Certified Nurse Midwives, and Student Midwives of Maternidad la Luz. Most of the comments (150) received were in support of the proposed rules as written. Only one commenter, the Texas Medical Association, opposed the rules as proposed in their entirety.

Comment: One hundred and forty-four commenters supported the adoption of the rules as proposed.

Response: The board considered the comments. No change was made as a result of the comments.

Comment: One commenter requested that the proposed repeal and new sections be withdrawn, and that the existing repeal of §831.51 be retained.

Response: The board disagrees. The proposed repeal and new standards organize and update the rules, are written to function as regulatory rather than proscriptive rules, and appropriately implement the Act. No change was made as a result of the comment.

Comment: One commenter stated that both the old and the new rules inappropriately assign responsibility to the midwife, although the ultimate responsibility rests with the mother in a home birth setting.

Response: The board disagrees. The Act and rules establish requirements related to the practice of midwifery by documented midwives. Legislative change would be required to shift all responsibility to the mother. No change was made as a result of the comment.

Comment: One commenter stated that the language at §831.51(d) and (e) appears to promote midwifery and should be modified to be more in keeping with the regulatory function of the rules.

Response: The board disagrees. This language, retained from the existing rules, accurately describes the board's standards for midwifery practice. No change was made as a result of the comment.

Comment: One commenter requested that §831.51(g)(2) be modified to require that a midwife grant the client access to her records within 30 days.

Response: The board agrees and has amended the section accordingly.

Comment: One commenter requested that §831.51(g)(5)(B) be amended from "age of majority" to "age of maturity".

Response: The board disagrees. The language reflects the definition of "age of majority" in state law at Civil Practice and Remedies Code, Chapter 129. No definition exists in state law for age of maturity. No change was made as a result of the comment.

Comment: One commenter suggested that the existing language found in the repeal of §§831.51(b)(3)(D)(i) through §831.51(b)(3)(D)(x) be retained unchanged in its entirety. The commenter stated that the proposed rules are silent as to a definition of low, normal or high-risk pregnancies as required by the Act, and silent as to whether a midwife should accept a mother who has or develops a high-risk condition.

Response: The board disagrees. The new sections appropriately delineate findings that would preclude a woman or newborn from being classified as normal. The Act specifically defines normal: "Normal" means, as applied to pregnancy, labor, delivery, the postpartum period, and the newborn period, and as defined by midwifery board rule, circumstances under which a midwife has determined that a client is at a low risk of developing complications." The categories proposed by the commenter, "low, normal and high-risk pregnancies", do not track the language of the Act. Inclusion of the existing language in the new sections as proposed would be confusing, contradictory, and duplicative. No change was made as a result of the comment.

Comment: Concerning §831.11, one commenter objected to the requirement that midwives practice in accordance with the Midwives Alliance of North America (MANA) Core Competencies, and specifically objected to the use of the word "intuition", stating that this replaces the acquisition of clinical skills and clearly alludes to the establishment of a medical diagnosis and treatment process.

Response: The board disagrees. The MANA Core Competencies are nationally-recognized direct entry midwifery competencies, and have been required subject matter for every midwifery student, as well as for all midwives redocumenting after a lapse, since 1999. The board specifically disagrees that the word "intuition" refers to medical diagnosis and treatment, and asserts to the contrary that it appropriately reflects one aspect of the unique client-centered care provided by midwives, without precluding the clinical skills and judgment required for the independent practice of both midwifery and medicine. No change was made as a result of the comment.

Comment: One commenter provided a specific comment of support for §831.52 (relating to Inter-Professional Care) for appropriately including language which authorizes a midwife to refer or transfer to a certified nurse-midwife, thereby enhancing consumer access to care and facilitating interprofessional communication and collaboration.

Response: The board considered the comment. No change was made as a result of the comment.

Comment: One commenter stated that the language at §831.52(3) concerning the referral process is inconsistent and has the potential for abuse, and should be replaced with a requirement for collaboration with a physician.

Response: The board disagrees. The language is specifically designed to permit a client to receive collaborative care in lieu of referral, but also to permit the client to refuse referral and continue to receive midwifery care unless her pregnancy requires transfer to the care of a physician as specified by rule. No change was made as a result of the comment.

Comment: One commenter requested that the language in the repeal of §831.51(b)(3)(D)(i) relating to informing the client that she has or may have a high-risk condition be retained.

Response: The board disagrees. The proposed requirement for referral is sufficient to inform the client, in conjunction with the proposed requirements included in §831.51(e)(1)-(2). No change was made as a result of the comment.

Comment: One commenter stated that the rules remove an existing requirement that midwives consult with a physician regarding the condition of the mother and the newborn. The commenter stated that if midwives are no longer required to speak to a physician, the scope of practice of midwives will be expanded and the safety levels of practice will be lowered.

Response: The board disagrees. The language regarding consultation does not in fact require a midwife to consult with a physician, the language in the repeal of §831.51(b)(3)(D)(ii)-(iii) requires that a consultation be recommended, the language in the repeal of §831.51(b)(3)(D)(iv)-(vi) provides that the midwife may transfer the client in lieu of consultation. No change was made as a result of the comment.

Comment: One commenter stated that the proposed rules remove or radically redefine many of the medical findings currently used to delineate a "normal" pregnancy.

Response: The board disagrees. The Act requires the board to delineate standards for findings that preclude a pregnancy from being considered normal. These standards are specifically listed in the new sections. No change was made as a result of the comment.

Comment: One commenter stated that the requirement in §831.54 (relating to Policies and Protocols) be based on standard textbooks and references used by basic midwifery education courses approved by the board constitutes inappropriate delegation of authority to a private entity. The commenter requests that any reference list be approved by the board before final rules are adopted and be published by the board for public comment.

Response: The board disagrees. The requirement for written protocols is an increased requirement placed on midwives to enable the board to regulate midwifery practice based not only on the required rules delineating what is not normal, but also on the individual midwife's adherence to her own specific practice protocols. The reference lists for midwifery education courses approved by the board reflect the board's standards both for the way midwifery is taught and the way it should be practiced in Texas. No change was made as a result of the comment.

Comment: One commenter objected to §831.54 (relating to Policies and Protocols) on the grounds that it would not impose significant restrictions on the midwife's practice, and that the section is too general for the quality of the policies to be enforceable. The commenter requested that the phrase "to the extent not inconsistent with the midwifery act or these rules" be added to the section.

Response: The board disagrees. The section imposes additional requirements on the midwife for written protocols not previously set out in rule. The requirement that a midwife comply with the Act and rules is clear and need not be restated in this section. No change was made as a result of the comment.

Comment: One commenter requested that §831.58 (relating to Transfer of Care in An Emergency Situation) be removed as untenable, unsafe and unfair to both the mother and the physician, and that additional rules clarifying protocols and requiring collaboration with a physician be added.

Response: The board disagrees. The proposed rules impose additional requirements on a midwife beyond those imposed by the existing rules (which do not define what constitutes "transfer") to make reasonable attempts to contact the health care provider to whom the client will be transferred and follow his/her instructions. An "emergency transfer of care", like any medical emergency, may require that the affected individual be seen by the physician currently on duty in an emergency room. No change was made as a result of this comment.

Comment: One commenter requested that additional language be added to §831.58 requiring the midwife to provide emergency care as needed until transfer of care has been accomplished.

Response: The board agrees and has amended the section accordingly.

Comment: One commenter requested that midwives be required to provide a copy of the rules at §831.60 to their clients.

Response: The board agrees that the client has the right to understand the law and rules which govern midwifery practice in Texas, and believes that §831.51(e) appropriately requires the midwife to provide this information to the client. No change was made as result of the comment.

Comment: One commenter requested that the terms "infant" and "newborn" be clarified in §831.75 (relating to Newborn and Infant Care) to make clear that a midwife may not provide care to the infant beyond six weeks postpartum.

Response: The board agrees and has inserted new language and clarified the terms.

The board made minor editorial changes due to staff comments to clarify the rules in the amendment to §831.1 and new §831.51.

Subchapter A. THE BOARD

22 TAC §§831.1 - 831.3, 831.7

The amendments are adopted under the Government Code, §2001.03, which requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act); the Occupations Code, §203.151, which provides the board with the authority to adopt rules prescribing the standards for the practice of midwifery, subject to the approval of the Texas Board of Health; and the Health and Safety Code, §12.001, which provides the Board of Health with authority to adopt rules for the performance of every duty imposed by law on the Board of Health, the department, and the commissioner of health.

§831.1.Introduction.

(a) Purpose. This chapter implements the applicable provisions of the Texas Midwifery Act, Texas Occupations Code, Chapter 203; relating to the practice and regulation of direct entry midwifery in Texas.

(b) Construction. These sections cover definitions; the Midwifery Board; the petition for the adoption of a rule; annual documentation; education; standards for the practice of midwifery in Texas; definitions; protocols; termination of the midwife-client relationship; transfer of care in an emergency situation; prenatal care; labor and delivery; postpartum care; newborn and infant care; the administration of oxygen; eye prophylaxis; newborn screening; the informed choice and disclosure statement; the provision of support services; and complaint review.

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 April 4, 2003.

TRD-200302253

Debra Evans

Chair

Texas Midwifery Board

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Subchapter B. DOCUMENTATION

22 TAC §831.11

The amendment is adopted under the Government Code, §2001.03, which requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act); the Occupations Code, §203.151, which provides the board with the authority to adopt rules prescribing the standards for the practice of midwifery, subject to the approval of the Texas Board of Health; and the Health and Safety Code, §12.001, which provides the Board of Health with authority to adopt rules for the performance of every duty imposed by law on the Board of Health, the department, and the commissioner of health.

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 April 4, 2003.

TRD-200302254

Debra Evans

Chair

Texas Midwifery Board

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Subchapter C. EDUCATION

22 TAC §831.31

The amendment is adopted under the Government Code, §2001.03, which requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act); the Occupations Code, §203.151, which provides the board with the authority to adopt rules prescribing the standards for the practice of midwifery, subject to the approval of the Texas Board of Health; and the Health and Safety Code, §12.001, which provides the Board of Health with authority to adopt rules for the performance of every duty imposed by law on the Board of Health, the department, and the commissioner of health.

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 April 4, 2003.

TRD-200302255

Debra Evans

Chair

Texas Midwifery Board

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Subchapter D. PRACTICE OF MIDWIFERY

22 TAC §831.51

The repeal is adopted under the Government Code, §2001.03, which requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act); the Occupations Code, §203.151, which provides the board with the authority to adopt rules prescribing the standards for the practice of midwifery, subject to the approval of the Texas Board of Health; and the Health and Safety Code, §12.001, which provides the Board of Health with authority to adopt rules for the performance of every duty imposed by law on the Board of Health, the department, and the commissioner of health.

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 April 4, 2003.

TRD-200302256

Debra Evans

Chair

Texas Midwifery Board

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


22 TAC §§831.51, 831.52, 831.54, 831.57, 831.58, 831.60, 831.65, 831.70, 831.75, 831.101, 831.111, 831.121, 831.131, 831.141

The amendments and new sections are adopted under the Government Code, §2001.03, which requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act); the Occupations Code, §203.151, which provides the board with the authority to adopt rules prescribing the standards for the practice of midwifery, subject to the approval of the Texas Board of Health; and the Health and Safety Code, §12.001, which provides the Board of Health with authority to adopt rules for the performance of every duty imposed by law on the Board of Health, the department, and the commissioner of health.

§831.51.Standards for the Practice of Midwifery in Texas.

(a) Purpose. To establish standards for safe midwifery care.

(b) Midwifery is the practice by a midwife of giving the necessary supervision, care, and advice to a woman during normal pregnancy, labor and the postpartum period; conducting a normal delivery of a child; and providing normal newborn care.

(c) Midwifery practice is based upon education in the sciences and upon necessary clinical skills as defined in §831.11 of this title (relating to Annual Documentation) and §831.31 of this title (relating to Education). The education shall be obtained through apprenticeship or an approved basic midwifery education course.

(d) Midwifery care is provided by qualified practitioners. The midwife:

(1) is regulated by the Midwifery Board of the Texas Department of Health; and

(2) is in compliance with the legal requirements of the State of Texas while practicing in the state.

(e) Midwifery care supports individual rights and self-determination within the boundaries of safety. The midwife shall:

(1) provide clients with a description of the scope of midwifery services and information regarding the client's rights and responsibilities in accordance with §203.351 of the Texas Midwifery Act;

(2) provide clients with information about other providers and services when requested or when the care required is not within the scope of practice of midwifery, or as further limited by the protocols of the individual midwife; and

(3) practice in accordance with the knowledge, clinical skills, and judgments described in the Midwives Alliance of North America (MANA) Core Competencies for Basic Midwifery Practice, adopted October 3, 1994 within the bounds of the midwifery scope of practice as defined by the Texas Midwifery Act; the Texas Midwifery Board Standards for the Practice of Midwifery in Texas and; the protocols of the individual midwifery service/practice.

(f) The midwife shall provide care in a safe and clean environment. The midwife shall:

(1) carry, and use, when needed, resuscitation equipment; and

(2) use universal precautions for infection control.

(g) Midwifery care is documented in legible, complete health records. The midwife shall:

(1) maintain records that completely and accurately document 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;

(2) grant clients access to their records within 30 days of the date the request is received;

(3) provide a mechanism for sending a copy of the health record upon referral or transfer to other levels of care;

(4) maintain the confidentiality of client records; and

(5) maintain records:

(A) for the mother, for a minimum of five years; and

(B) for the infant, until the age of majority.

(h) Midwifery care includes documentation of a periodic process of evaluation and quality assurance of midwifery practice. The midwife shall:

(1) collect client care data systematically and be involved in analysis of that data for the evaluation of the process and outcome of care;

(2) review problems identified by the midwife or by other professionals or consumers in the community; and

(3) act to resolve problems that are identified.

§831.58.Transfer of Care in An Emergency Situation.

In an emergency situation, the midwife shall initiate emergency care as indicated by the situation and initiate immediate transfer of care in accordance with the protocols of his or her practice by making a reasonable effort to contact the health care professional or institution to whom the client will be transferred and to follow the health care professional's instructions; and continue emergency care as needed while:

(1) transporting the client by private vehicle; or

(2) calling 911 and reporting the need for immediate transfer.

§831.75.Newborn Care During the First Six Weeks After Birth.

(a) Prior to delivery, the midwife shall establish a plan with the client for continuing care of the newborn. This plan shall:

(1) include referral or transfer to a health care professional who has current pediatric knowledge; and

(2) be documented in the midwifery record.

(b) The midwife shall:

(1) evaluate the newborn by monitoring the vital signs, performing a physical exam, and obtaining the laboratory tests necessary for the infant during the postpartum period;

(2) provide appropriate education and counseling to the mother; and

(3) observe the newborn for a minimum of two hours after he or she is stable with no signs of distress.

(c) If on any newborn assessment in the immediate postpartum period (first six hours of life), one of the following conditions exists, the midwife shall recommend referral in accordance with §831.52 of this title (relating to Inter-Professional Care) and document that recommendation in the midwifery record:

(1) birth injury;

(2) gestational age assessment less than 36 weeks;

(3) small for gestational age;

(4) large for gestational age; or

(5) any other abnormal newborn behavior or appearance which could adversely affect the newborn, as assessed by a midwife exercising ordinary skill and knowledge.

(d) If on any newborn assessment in the immediate postpartum period (first six hours of life), one of the following conditions exists, the midwife shall initiate immediate transfer to an appropriate health care professional in accordance with §831.58 of this title (relating to Transfer of Care in an Emergency Situation), initiate emergency care as indicated by the situation, continue care as needed, and document that action in the midwifery record:

(1) non-transient respiratory distress;

(2) non-transient pallor or central cyanosis;

(3) jaundice;

(4) apgar at 5 minutes less than or equal to 6;

(5) prolonged apnea;

(6) hemorrhage;

(7) signs of infection;

(8) seizure;

(9) major congenital anomaly not diagnosed prenatally;

(10) unstable vital signs;

(11) prolonged:

(A) lethargy;

(B) flaccidity; or

(C) irritability;

(12) inability to suck;

(13) persistent jitteriness;

(14) hyperthermia;

(15) hypothermia; or

(16) other abnormal newborn behavior or appearance which could threaten the life of the newborn, as assessed by a midwife exercising ordinary skill and knowledge.

(e) If on any newborn assessment after the immediate postpartum period, one of the following conditions exists, the midwife shall recommend referral to an appropriate health care professional in accordance with §831.52 of this title and document that recommendation in the midwifery record:

(1) abnormal laboratory test results;

(2) minor congenital anomaly;

(3) failure to thrive; or

(4) any other abnormal newborn behavior or appearance which could adversely affect the infant, as assessed by a midwife exercising ordinary skill and knowledge.

(f) If on any newborn assessment after the immediate postpartum period, one of the following conditions exists, the midwife shall initiate immediate transfer to an appropriate health care professional in accordance with §831.58 of this title and document that action in the midwifery record:

(1) respiratory distress;

(2) pallor or central cyanosis;

(3) pathological jaundice;

(4) hemorrhage;

(5) seizure;

(6) inability to urinate or pass meconium within 24 hours of birth;

(7) unstable vital signs;

(8) lethargy;

(9) flaccidity;

(10) irritability;

(11) inability to feed;

(12) persistent jitteriness; or

(13) any other abnormal newborn behavior or appearance which could threaten the life of the newborn, as assessed by a midwife exercising ordinary skill and knowledge.

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 April 4, 2003.

TRD-200302257

Debra Evans

Chair

Texas Midwifery Board

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Subchapter E. COMPLAINT REVIEW

22 TAC §831.161

The amendment is adopted under the Government Code, §2001.03, which requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act); the Occupations Code, §203.151, which provides the board with the authority to adopt rules prescribing the standards for the practice of midwifery, subject to the approval of the Texas Board of Health; and the Health and Safety Code, §12.001, which provides the Board of Health with authority to adopt rules for the performance of every duty imposed by law on the Board of Health, the department, and the commissioner of health.

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 April 4, 2003.

TRD-200302258

Debra Evans

Chair

Texas Midwifery Board

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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