Md. Code, Health Occupations § 8-6C-04

(a) A licensed direct–entry midwife shall consult with a health care practitioner, and document the consultation, the recommendations of the consultation, and the discussion of the consultation with the client, if any of the following conditions are present during the course of care:

(1) Significant mental disease, including depression, bipolar disorder, schizophrenia, and other conditions that impair the ability of the patient to participate effectively in the patient’s care or that require the use of psychotropic drugs to control the condition;

(2) Second or third trimester bleeding;

(3) Intermittent use of alcohol into the second trimester;

(4) Asthma;

(5) Diet–controlled gestational diabetes;

(6) History of genetic problems, intrauterine death after 20 weeks’ gestation, or stillbirth;

(7) Abnormal pap smear;

(8) Possible ectopic pregnancy;

(9) Tuberculosis;

(10) Controlled hypothyroidism, being treated with thyroid replacement and euthyroid, and with thyroid test numbers in the normal range;

(11) Rh sensitization with positive antibody titer;

(12) Breech presentation between 35 and 38 weeks;

(13) Transverse lie or other abnormal presentation between 35 and 38 weeks;

(14) Premature rupture of membranes at 37 weeks or less;

(15) Small for gestational age or large for gestational age fetus;

(16) Polyhydramnios or oligohydramnios;

(17) Previous LEEP procedure or cone biopsy;

(18) Previous obstetrical problems, including uterine abnormalities, placental abruption, placenta accreta, obstetric hemorrhage, incompetent cervix, or preterm delivery for any reason;

(19) Postterm maturity (41 0/7 to 6/7 weeks gestational age);

(20) Inflammatory bowel disease, in remission;

(21) Active genital herpes lesions during pregnancy except as required by § 8–6C–03(29) of this subtitle;

(22) Prepregnancy body mass index (BMI) of less than 18.5 or 35 or more; or

(23) Significant fetal congenital anomaly.

(b) Subject to subsection (c) of this section, a licensed direct–entry midwife shall arrange immediate emergency transfer to a hospital if:

(1) The patient requests transfer; or

(2) The patient or newborn is determined to have any of the following conditions during labor, delivery, or the immediate postpartum period:

(i) Unforeseen noncephalic presentation;

(ii) Unforeseen multiple gestation;

(iii) Nonreassuring fetal heart rate or pattern, including tachycardia, bradycardia, significant change in baseline, and persistent late or severe variable decelerations;

(iv) Prolapsed cord;

(v) Unresolved maternal hemorrhage;

(vi) Retained placenta;

(vii) Signs of fetal or maternal infection;

(viii) Patient with a third– or fourth–degree laceration or a laceration beyond the licensed direct–entry midwife’s ability to repair;

(ix) Apgar of less than seven at 5 minutes;

(x) Significant congenital anomalies that directly affect delivery or immediate postpartum care or require immediate emergency care, as determined by the Board in regulations;

(xi) Need for chest compressions during neonatal resuscitation;

(xii) Newborn with persistent central cyanosis;

(xiii) Newborn with persistent grunting and retractions;

(xiv) Newborn with abnormal vital signs;

(xv) Gross or thick meconium staining, when discovered; or

(xvi) Newborn with excessive dehydration due to inability to feed.

(c) If transfer is not possible because of imminent delivery, the licensed direct–entry midwife shall consult with a health care provider for guidance on further management of the patient and to determine when transfer may be safely arranged, if required.

(d) (1) A licensed direct–entry midwife shall immediately transfer the care of a patient to a health care provider for the treatment of any significant postpartum morbidity, including:

(i) Uncontrolled postpartum hemorrhage;

(ii) Preeclampsia;

(iii) Thrombo–embolism;

(iv) An infection; or
on further management of the patient and to determine when transfer may be safely arranged, if required.

(d) (1) A licensed direct–entry midwife shall immediately transfer the care of a patient to a health care provider for the treatment of any significant postpartum morbidity, including:

(i) Uncontrolled postpartum hemorrhage;

(ii) Preeclampsia;

(iii) Thrombo–embolism;

(iv) An infection; or

(v) A postpartum mental health disorder.

(2) A licensed direct–entry midwife who is required to transfer care of a patient under paragraph (1) of this subsection may continue other aspects of postpartum care in consultation with the treating health care practitioner.