R156-77-601. Standards of Practice

Except as provided in Subsection 58-77-601(3)(b), and in accordance with Subsection 58-77-601(2), the standards and circumstances that require an LDEM to recommend and facilitate consultation, collaboration, referral, transfer, or mandatory transfer of client care are established herein. These standards are at a minimum level and are hierarchical in nature. If the standard requires at least consultation for a condition, an LDEM may choose to collaborate, refer, or transfer the care of the client.

(1) Consultation:

(a) antepartum:

(i) suspected intrauterine growth restriction;

(ii) severe vomiting unresponsive to LDEM treatment;

(iii) pain unrelated to common discomforts of pregnancy;

(iv) presence of condylomata that may obstruct delivery;

(v) anemia unresponsive to LDEM treatment;

(vi) history of genital herpes;

(vii) suspected or confirmed fetal demise after 14.0 weeks gestation;

(viii) suspected multiple gestation;

(ix) confirmed chromosomal or genetic aberrations;

(x) hepatitis C;

(xi) prior c-section without a second trimester ultrasound to determine the location of placental implantation; and

(xii) any other condition in the judgment of the LDEM requires consultation.

(2) Mandatory Consultation:

(a) incomplete miscarriage after 14.0 weeks gestation;

(b) failure to deliver by 42.0 weeks gestation;

(c) a fetus in the breech position after 36.0 weeks gestation;

(d) any sign or symptom of:

(i) placenta previa;

(ii) deep vein thrombosis or pulmonary embolus; or

(iii) vaginal bleeding after 20.0 weeks gestation, in a woman with a history of a c-section who has not had an ultrasound performed;

(e) Rh isoimmunization or other red blood cell isoimmunization known to cause erythroblastasis fetalis; or

(f) any other condition or symptom in the judgment of the LDEM that may place the health of the pregnant woman or unborn child at unreasonable risk.

(3) Collaborate:

(a) antepartum:

(i) infection not responsive to LDEM treatment;

(ii) seizure disorder affecting the pregnancy;

(iii) history of cervical incompetence with surgical therapy;

(iv) increase in blood pressure with a systolic pressure greater than 140 mm or a diastolic pressure greater than 90 mm in two readings at least six hours apart, no more than trace proteinurea or other evidence of preeclampsia; and

(vi) any other condition in the judgment of the LDEM requires collaboration;

(b) postpartum:

(i) infection not responsive to LDEM treatment; and

(ii) any other condition in the judgment of the LDEM requires collaboration.

(4) Refer:

(a) antepartum:

(i) thyroid disease;

(ii) changes in the breasts not related to pregnancy or lactation;

(iii) severe psychiatric illness responsive to treatment;

(iv) heart disease that has been determined by a cardiologist to have potential to affect or to be affected by pregnancy, labor, or delivery; and

(v) any other condition in the judgment of the LDEM requires referral;

(b) postpartum:

(i) bladder dysfunction;

(ii) severe depression; and

(iii) any other condition in the judgment of the LDEM requires referral;

(c) newborn:

(i) birth injury requiring on-going care;

(ii) minor congenital anomaly;

(iii) jaundice beyond physiologic levels;

(iv) loss of 15% of birth weight;

(v) inability to suck or feed; and

(vi) any other condition in the judgment of the LDEM requires referral.

(5) Transfer, however may be waived in accordance with Subsection 58-77-601(3)(b):

(a) antepartum:

(i) current drug or alcohol abuse;

(ii) current diagnosis of cancer;

(iii) persistent oligohydramnios not responsive to LDEM treatment;

(iv) confirmed intrauterine growth restriction;

(v) prior c-section with unknown uterine incision type provided a reasonable effort has been made to determine the uterine scar type and the client has signed an informed consent that meets the standards established in Section R156-77-602;

(vi) history of preterm delivery less than 34.0 weeks gestation;

(vii) history of severe postpartum bleeding;

(viii) primary genital herpes outbreak;

(ix) increase in blood pressure with a systolic pressure greater than 140 mm or a diastolic pressure greater than 90 mm in two readings at least six hours apart, and 1+ to 2+ proteinurea confirmed by a 24 hour urine collection of greater than 300 mg of protein; and

(x) any other condition in the judgment of the LDEM may require transfer;

(b) intrapartum:

(i) visible genital lesions suspicious of herpes virus infection;

(ii) severe hypertension defined as a sustained diastolic blood pressure of greater than 110 mm or a systolic pressure of greater than 160 mm;

(iii) excessive vomiting, dehydration, acidosis, or exhaustion unresponsive to LDEM treatment; and

(iv) any other condition in the judgment of the LDEM may require transfer;

(c) postpartum:

(i) retained placenta; and

(ii) any other condition in the judgment of the LDEM may require transfer;

(d) newborn:

(i) gestational age assessment less than 36 weeks gestation;

(ii) major congenital anomaly not diagnosed prenatally;

(iii) persistent hyperthermia or hypothermia unresponsive to LDEM treatment; and

(iv) any other condition in the judgment of the LDEM may require transfer.

(6) Mandatory transfer:

(a) antepartum:

(i) severe preeclampsia or severe pregnancy-induced hypertension as evidenced by:

(A) a systolic pressure greater than 160 mm or a diastolic pressure greater than 110 mm in two readings at least six hours apart, or 3+ to 4+ proteinurea, or greater than 5 gms of protein in a 24 hour urine collection; or

(B) a systolic pressure greater than 140 mm or a diastolic pressure greater than 90 mm in two readings at least six hours apart, at least 1+ proteinurea, and one or more of the following:

(1) epigastric pain;

(2) headache;

(3) visual disturbances; or

(4) decreased fetal movement;

(ii) eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP);

(iii) documented platelet count less than 75,000 platelets per mm³ of blood;

(iv) placenta previa after 27.0 weeks gestation;

(v) confirmed ectopic pregnancy;

(vi) severe psychiatric illness non-responsive to treatment;

(vii) human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS);

(viii) diagnosed deep vein thrombosis or pulmonary embolism;

(ix) multiple gestation;

(x) no onset of labor by 43.0 weeks gestation;

(xi) more than two prior c-sections;

(xii) prior c-section with a known uterine classical, inverted T or J incision, or an extension of an incision into the upper uterine segment;

(xiii) prior c-section without an ultrasound that rules out placental implantation over the uterine scar obtained no later than 35.0 weeks gestation or prior to commencement of care if the care is sought after 35.0 weeks gestation;

(xiv) prior c-section without a signed informed consent document meeting the standards established in Section R156-77-602;

(xv) prior c-section with a gestation greater than 42.0 weeks gestation;

(xvi) Rh isoimmunization or other red blood cell isoimmunization known to cause erythroblastasis fetalis, with an antibody titre of greater than 1:8;

(xvii) insulin-dependent diabetes;

(xviii) significant vaginal bleeding after 20.0 weeks gestation not consistent with normal pregnancy and posing a continuing risk to mother or baby; and

(xiv) any other condition in the judgment of the LDEM that could place the life or long-term health of the pregnant woman or unborn child at risk;

(b) intrapartum:

(i) signs of uterine rupture;

(ii) presentation(s) not compatible with spontaneous vaginal delivery;

(iii) fetus in breech presentation during labor unless delivery is imminent;

(iv) progressive labor prior to 37.0 weeks gestation except miscarriages, confirmed fetal death, or congenital anomalies incompatible with life;

(v) prolapsed umbilical cord unless birth is imminent;

(vi) clinically significant abdominal pain inconsistent with normal labor;

(vii) seizure;

(viii) undiagnosed multiple gestation, unless delivery if imminent;

(ix) suspected chorioamnionitis;

(x) prior c-section with cervical dilation progress in the current labor of less than one centimeter in three hours once labor is active;

(xi) non-reassuring fetal heart pattern indicative of fetal distress that does not immediately respond to treatment by the LDEM, unless delivery is imminent;

(xii) moderate thick, or particulate meconium in the amniotic fluid unless delivery is imminent;

(xiii) failure to deliver after three hours of pushing unless delivery is imminent; or

(xiv) any other condition in the judgment of the LDEM that would place the life or long-term health of the pregnant woman or unborn child at significant risk if not acted upon immediately;

(c) postpartum:

(i) uncontrolled hemorrhage;

(ii) maternal shock that is unresponsive to LDEM treatment;

(iii) severe psychiatric illness non-responsive to treatment;

(iv) signs of deep vein thrombosis or pulmonary embolism; and

(v) any other condition in the judgment of the LDEM that could place the life or long-term health of the mother or infant at significant risk if not acted upon immediately;

(d) newborn:

(i) non-transient respiratory distress;

(ii) non-transient pallor or central cyanosis;

(iii) Apgar score at ten minutes of less than six;

(iv) low heart rate of less than 60 beats per minute after one complete neonatal resuscitation cycle;

(v) absent heart rate except with confirmed fetal death or congenital anomalies incompatible with life, or shoulder dystocia resulting in death;

(vi) hemorrhage;

(vii) seizure;

(viii) persistent hypertonia, lethargy, flaccidity or irritability, or jitteriness;

(ix) inability to urinate or pass meconium within the first 48 hours of life; and

(x) any other condition in the judgment of the LDEM must be transferred.