332-025-0021 Risk Assessment Practice Standards (1) Recognizing the importance of collaborative maternal health care, when determining the appropriateness of community birth, an LDM must assess risks, including ongoing and cumulative risks, by using clinical skills and expertise, relevant state rules and laws, principles of informed choice, midwifery core competencies, the setting of practice and access to higher levels of care, and careful consideration of selection criteria. (2) When an indication to transfer presents the LDM must transfer care as defined in OAR 332-015-0000(13). If the birthing person or newborn present with any of the following indications the LDM must: (a) During the antepartum period, plan for transfer of care and an in-hospital birth; (b) During the intrapartum period, arrange transportation to the hospital and transfer of care unless the birth is imminent; (c) When the birth is imminent, take the health and condition of the birthing person and baby and conditions for transport into consideration in determining whether to proceed with out-of-hospital birth or to arrange for transportation to a hospital and transfer of care; (d) During the postpartum period arrange for transfer of care. (3) The timing for when arranging transportation and transfer of care in subsection (2) of this rule must occur is tied to the degree of risk of the indication to transfer. (4) If a client refuses transfer of care, the midwife must terminate midwifery care. The timing for when termination of care must occur is tied to the degree of risk of the indication to transfer. The LDM may immediately terminate midwifery care orally and then provide written notice to the client or relinquish care to a licensee under ORS 682. (5) After transferring care, an LDM may continue to provide supportive care to the client including, but not limited to, nutritional advice, education, emotional, and psychosocial support. (6) Upon documented resolution of an indication to transfer, an LDM may resume primary care and responsibility for the client or newborn, or both, and proceed with midwifery care. (7) When transferring care, the LDM must provide the following at the time of transfer, to the hospital or licensees under ORS Chapter 682: medical history, prenatal flow sheet, diagnostic studies, laboratory findings, and maternal and baby care notes through time of transfer. (8) In cases of emergency, at the time of transfer, the LDM must provide the records required in subsection (7) of this rule to the hospital or licensees under ORS Chapter 682, including notes for care provided during the emergency, if available. If notes are not available, an oral summary of care during the emergency must be made available to the hospital or licensees under ORS Chapter 682. (9) Indication to transfer - Pre-existing and historical conditions: (a) Chronic renal disease. (b) Acquired immune deficiency syndrome (AIDS). (c) Diabetes currently requiring oral medication or insulin. (d) Previous classical uterine incision, T-incision, extensive transfundal surgery or prior uterine rupture. (e) Three (3) cesarean sections without previous successful vaginal birth. (f) Four (4) or more cesarean sections. (10) Indication to transfer - Antepartum: (a) Active cancer. (b) Acquired Immune Deficiency Syndrome (AIDS). (c) Ectopic pregnancy. (d) Active substance abuse. (e) Deep venous or any treated thromboembolic disease. (f) Higher order multiples (three or more). (g) Monochorionic, monoamniotic twins. (h) Twin-to-twin transfusion. (i) Presenting twin transverse. (j) Hypertension at or above 140 systolic or at or above 90 diastolic on two (2) separate occasions that are more than four (4) hours apart, or hypertension at or above 160 systolic or at or above 110 diastolic on one (1) occasion. (k) Pre-eclampsia or eclampsia. (l) Placenta less than 2.0 centimeters from internal os not resolved by onset of labor and as determined by ultrasound evidence. (m) Evident or suspected placenta accreta. (n) Hemoglobin under nine (9) unresponsive to treatment at term. (o) Abnormal fetal surveillance testing including, but not limited to, biophysical profile, non-stress test , and auscultated acceleration testing. (p) Pregnancy lasting longer than 43 weeks 0 days gestation (21 days past the due date). (q) Gestational diabetes requiring oral medication or insulin. (r) Chronic renal disease. (11) Indication to transfer - Intrapartum: (a) Labor or premature rupture of membrane less than 36 and 0 weeks gestation. (b) Evident or suspected footling or kneeling breech and birth is not imminent. (c) Transverse or oblique lie at onset of labor. (d) Prolapsed cord or cord presentation. (e) Active genital herpes in the vaginal, perineal, or vulva areas in labor or with ruptured membranes. (f) Two (2) temperatures at 100.4 degrees Fahrenheit or 38 degrees Celsius or greater within one (1) hour or one (1) temperature at 102.2 degrees Fahrenheit or 39 degrees Celsius or greater. (g) Signs or symptoms of chorioamnionitis or suspected chorioamnionitis. (h) Excessive vomiting, dehydration, acidosis or exhaustion unresponsive to treatment. (i) Hypertension at or above 140 systolic or at or above 90 diastolic on two (2) separate occasions that are more than four (4) hours apart or hypertension at or above 160 systolic at or above 110 diastolic on one (1) occasion. (j) Pre-eclampsia or eclampsia. (k) Signs or symptoms of complete or partial placental abruption. (l) Signs or symptoms of placenta previa or suspected placenta previa. (m) Signs or symptoms of uterine rupture. (n) Persistent inability to auscultate fetal heart tones. (o) Persistent non-reassuring fetal status. (p) Thick meconium-stained amniotic fluid and birth is not imminent. (q) Lack of adequate progress in second stage in breech presentation, which means no progress in descent after a maximum of one (1) hour of active pushing in cases with complete dilation and ruptured membranes. (r) Lack of adequate progress in second stage with cephalic presentation, which means no descent after a maximum of three (3) hours of active pushing in cases with complete dilation and ruptured membranes. (s) Significant hemorrhage unresponsive to treatment with or without sustained vital sign instability or shock. (t) Signs or symptoms of shock. (u) Vital sign instability or altered level of consciousness unresponsive to treatment. (v) Retained placenta. (12) Indication to transfer - Postpartum: (a) Significant hemorrhage unresponsive to treatment with or without sustained vital sign instability or shock. (b) Laceration requiring transfer of care for repair including but not limited, to 3rd and 4th degree lacerations. (c) Increasingly painful or enlarging hematoma. (d) Pre-eclampsia or eclampsia. (e) Signs or symptoms of uterine infection. (f) Postpartum depression or mood disorder with suspicion of possible endangerment of self or others. Notwithstanding the definition of transfer of care the LDM may continue clinical postpartum care for the birthing person unless another licensed health care provider assumes clinical postpartum care. (13) Indication to transfer - Newborn Care: (a) Apgar less than seven (7) at 10 minutes of age. (b) Apnea. (c) Persistent nasal flaring, grunting or retraction after one (1) hour of life without improvement. (d) Persistent inability to maintain temperature between 97 to 100 degrees Fahrenheit or 36 to 37 degrees Celsius. (e) Seizures. (f) Central cyanosis. (g) Weight less than 2,270 grams (five pounds.) (h) Significantly distended abdomen. (i) Unresolved pallor at birth. (j) Jaundice at birth or in the first 24 hours. (k) Persistent projectile or bilious vomiting or emesis of fresh blood. (l) Evident or suspected infection. (14) "Indication for Consult" means a condition or clinical situation that places a birthing person or newborn at increased obstetric or neonatal risk but does not automatically exclude a birthing person or newborn from a community birth or midwifery care. (15) When a birthing person or newborn present with one (1) or more indications for consult the LDM must: (a) Arrange for transfer of care; or (b) Comply with all the following: (A) Consult with an Oregon licensed health care provider, as defined in OAR 332-025-0021(20) and (21) of this rule, who is experienced and knowledgeable about the indication for consult unless a different Oregon licensed health care provider is otherwise stated specifically within this rule; (B) Communicate to the birthing person the recommendations given by the consulting Oregon licensed health care provider if the birthing person was not present at the consultation; (C) Obtain informed consent in accordance with OAR 332-025-0120; (D) Make a plan with the birthing person about the indication; and (E) Document the recommendations, consultation, discussion, informed consent and plan. (16) Indication for Consult - Preexisting or historical medical conditions: (a) Three (3) cesarean sections with a previous successful vaginal birth. Consult must be with a physician who provides cesarean delivery. (b) One (1) or two (2) cesarean sections without previous successful vaginal birth. (c) Current treatment with prescription medication for any ongoing or chronic medical conditions. (d) Human Immunodeficiency Virus (HIV) positive. (e) Syphilis. (f) Cardiac condition. (g) Active or chronic liver disease. (h) Hyperthyroidism. (i) Pulmonary disease being currently treated or is symptomatic. (j) Hypertension at or above 140 systolic or at or above 90 diastolic outside of pregnancy. (k) Deep venous thrombosis or any treated thromboembolic event. (l) Thrombophlebitis. (m) Family history of thrombophilia. (n) Hemoglobinopathies. (o) Bleeding disorder. (p) Psychiatric disorders with concern for maternal and fetal safety. (q) Isoimmunization to blood factors. (r) Previous myomectomy. (s) Placental abruption with adverse outcomes. (t) Preterm pre-eclampsia. (u) Preterm delivery less than 34 weeks. (v) Obstetric hemorrhage requiring transfusion. (w) Fetal demise. (17) Indication for consult - Antepartum: (a) Dichorionic, diamniotic twins . Consult must be with a physician who provides cesarean delivery. (b) Monochorionic, diamniotic twins. Consult must be with a physician who provides cesarean delivery. (c) Substance use disorder. (d) Incomplete spontaneous abortion. (e) Primary genital herpes. (f) Known fetal anomalies that may require medical attention. (g) Second or third trimester bleeding. (h) Gestational diabetes or blood glucose dysregulation well-controlled with diet and exercise. (i) Uterine anomaly. (j) Platelet count of less than 115,000. (k) Isoimmunization to blood factors. (l) Psychiatric disorders with concern for maternal and fetal safety. (m) Syphilis. (n) Human Immunodeficiency Virus (HIV) positive. (o) Suspected thromboembolic event. (p) Hemoglobinopathies. (q) Thrombophilia. (r) Confirmed or suspected cholestasis. (s) Breech presentation after 36 weeks. Consult for breech presentation after 36 weeks must be with a physician who provides cesarean delivery. (t) Hemoglobin under 10 unresponsive to treatment. (u) Oligohydramnios or polyhydramnios. (v) Abnormal fetal cardiac rate or rhythm. (w) Abnormally decreased fetal movement. (x) Abnormal hepatic or renal function test. (y) Active renal disease. (z) Fetal growth restriction. Consult must be with a physician who practices maternal fetal medicine or obstetrics and gynecology. (18) Indication for consult - Intrapartum: (a) Hypertension at or above 140 systolic or at or above 90 diastolic. (b) Frank or complete breech identified in labor and without previous consult unless birth is i mminent. (19) Indication for consult - Postpartum: (a) Hypertension at or above 150 systolic or at or above 100 diastolic on two (2) separate occasions which are more than four (4) hours apart or hypertension at or above 160 systolic or at or above 110 diastolic on one (1) occasion. (b) Ongoing or unresolved urinary retention. (c) Evident or suspected infection unresponsive to treatment. (20) Indication for consult - Newborn: (a) Gestational age assessment of less than 36 weeks and 0 days. (b) Excessive ruddiness at birth. (c) Any generalized rash at birth. (d) Persistent hypotonia. (e) Heart rate less than 80 or greater than 160 (at rest) without improvement. (f) Birth injury such as facial or brachial palsy, suspected fracture or severe bruising. (g) Evident or suspected major congenital anomaly. (h) Direct Coomb's positive. Consultation for Direct Coomb’s positive newborns must be with a pediatric care provider. (i) Evident or suspected neonatal opioid withdrawal syndrome. (j) Failure to urinate within 24 hours after birth or pass stool within 48 hours after birth. (k) Pulse oximeter reading of less than 90 percent on right hand at greater than 24 hours. (l) Persistent cardiac murmur. (m) Persistent poor feeding. (n) Weight loss greater than 10 percent of birth weight that is unresponsive to treatment. (o) Newborn with Human Immunodeficiency Virus (HIV)-positive mother. Consultation must be with a pediatric care provider. (p) Respiration rate greater than 100 within the first two (2) hours postpartum, and greater than 80 thereafter, lasting more than one (1) hour without improvement. (q) Evident or suspected abnormally elevated bilirubin. (21) For the purpose of this rule “consultation” means a dialogue for the purpose of obtaining information or advice, with an Oregon licensed health care provider who has direct experience handling complications of the risk(s) present, as well as the ability to confirm the indication for consult, which may include, but is not limited to confirmation of a diagnosis and recommendation(s) regarding management of medical, obstetric, or fetal problems or conditions. Consultation may be by phone, in person, or in writing. (22) For the purpose of this rule “Oregon licensed health care provider” means a physician or physician assistant licensed under ORS 677, a nurse practitioner who is licensed as a nurse midwife under ORS 678 or nurse practitioner licensed under ORS 678, a naturopath licensed under ORS 685, or a licensed direct entry midwife licensed under ORS 687. Statutory/Other Authority: ORS 676.615(1), ORS 687.480(1), ORS 687.405, ORS 676.615(2) & ORS 687.480(2) Statutes/Other Implemented: ORS 676.615(1), ORS 687.480(1), ORS 687.405, ORS 676.615(2) & ORS 687.480(2) History: DEM 3-2023, amend filed 06/29/2023, effective 06/29/2023 DEM 2-2023, amend filed 06/28/2023, effective 06/28/2023 DEM 3-2020, amend filed 10/15/2020, effective 10/20/2020 DEM 5-2011, f. & cert. ef. 9-26-11 DEM 1-2019, amend filed 12/19/2019, effective 01/01/2020 DEM 1-2011(Temp), f. & cert. ef. 4-4-11 thru 9-27-11 DEM 6-2010, f. 12-30-10, cert. ef. 1-1-11 DEM 1-2004, f. 6-29-04, cert. ef. 7-1-04 DEM 1-2002, f. 2-25-02 cert. ef. 3-1-02 DEM 1-2001(Temp), f. & cert. ef. 10-1-01 thru 3-29-02 DEM 3-2000, f. 9-29-00, cert. ef. 10-1-00 DEM 2-2000(Temp), f. 8-22-00, cert. ef. 8-22-00 thru 2-17-01 DEM 2-1999, f. 12-17-99, cert. ef. 12-20-99 DEM 1-1999(Temp), f. 9-1-99, cert. ef. 9-9-99 thru 2-29-00 DEM 2-1998, f. 4-14-98, cert. ef. 4-15-98 DEM 1-1994, f. & cert. ef. 6-15-94 DEM 1-1993(Temp), f. & cert. ef. 12-22-93