IX. Physician Collaboration, Consultation, and Referral

 

A collaborative care plan is an agreement between the Midwife and a physician. Midwives collaborate with other care professionals to ensure their clients receive the best possible care when the needs of the client exceed the scope of practice of the midwife. Collaborative care involves the cooperation of various professionals in the provision of care. If care is transferred to a physician, the midwife is expected to continue providing supportive care after care transfer and will resume primary care if appropriate. Collaboration with other health care providers occurs with informed client choice.

Low risk refers to a pregnancy that is anticipated to be problem free. This assessment is based on a woman’s past medical history, past gynecological/obstetrical history, and any other relevant issues as the pregnancy continues.

The Midwife shall consult with a physician whenever there are significant deviations from normal during a client’s pregnancy and birth, and/or with the newborn. If a referral to a physician is needed, the Midwife will remain in consultation with the physician until resolution of the concern. It is appropriate for the Midwife to maintain care of her client to the greatest degree possible, in accordance with the client’s wishes, remaining present through the birth, if possible. The following conditions require physician consultation and may require physician referral and/or transfer of care.

A.     Pre-existing Conditions  include but are not limited to:

1.     cardiac disease;

2.     active tuberculosis;

3.     asthma, if severe or uncontrolled by medication;

4.     renal disease;

5.     hepatic disorders;

6.     endocrine disorders;

7.     significant hematological disorders;

8.     neurologic disorders;

9.     essential hypertension;

10.   active cancer;

11.   diabetes mellitus;

12.   history of newborn with group B strep disease;

13.   previous Cesarean section with classical incision;

14.   three or more previous Cesarean sections;

15.   previous Cesarean section within one year of current EDD;

16.   current alcoholism or abuse;

17.   current drug addiction or abuse;

18.   current severe psychiatric illness;

19.   isoimmunization;

20.   positive for HIV antibody.

 

B.     Prenatal Conditions  include but are not limited to:

1.     labor before the 37th week of gestation;

2.     lie other than vertex at term;

3.     multiple gestations;

4.     significant vaginal bleeding;

5.     gestational hypertension;

6.     gestational diabetes mellitus, uncontrolled by diet;

7.     severe anemia, not responsive to treatment;

8.     evidence of pre-eclampsia;

9.     consistent size/dates discrepancy;

10.   deep vein thrombosis (DVT);

11.   known fetal anomalies or conditions affected by site of birth, with an infant compatible with life;

12.   threatened or spontaneous abortion after 12 weeks;

13.   abnormal ultrasound findings;

14.   isoimmunization;

15.   documented placental anomaly or previa;

16.   documented low-lying placenta in woman with history of Cesarean section;

17.   postdates pregnancy (>42 weeks);

18.   positive HIV antibody test.

 

C.     Intrapartal Conditions  It should be noted that because of time urgency during certain intrapartal situations, it may be necessary to institute emergency interventions while waiting for physician consultation. These conditions include but are not limited to:

1.     persistent and/or severe fetal distress;

2.     abnormal bleeding;

3.     thick meconium-stained fluid with birth not imminent;

4.     significant rise in blood pressure above woman’s baseline with or without proteinuria;

6.     maternal fever >100.4 degrees Fahrenheit, unresponsive to treatment;

7.     transverse lie;

8.     primary genital herpes outbreak;

9.     prolapsed cord;

10.   client’s desire for pain medication.

 

A.     Postpartum Conditions  It should be noted that because of time urgency during certain postpartal situations, it may be necessary to institute emergency interventions while waiting for physician consultation. These conditions include but are not limited to:

1.     seizure;

2.     significant hemorrhage, not responsive to treatment;

3.     adherent or retained placenta;

4.     sustained maternal vital sign instability;

5.     uterine prolapse;

6.     uterine inversion;

7.     repair of laceration(s)/episiotomy, which is beyond Midwife’s level of expertise;

8.     anaphylaxis.

 

B.     Neonatal Conditions  It should be noted that because of time urgency during certain postpartal situations, it may be necessary to institute emergency interventions while waiting for physician                 consultation. These conditions include but are not limited to:

1.     Apgar score less than 7 at five minutes of age, without significant improvement at 10 minutes;

2.     persistent respiratory distress;

3.     persistent cardiac irregularities;

4.     central cyanosis or pallor;

5.     prolonged temperature instability or fever >100.4 degrees Fahrenheit, unresponsive to treatment;

6.     significant clinical evidence of glycemic instability;

7.     evidence of seizure;

8.     birth weight <2300 grams (5 pounds, 2 ounces);

9.     significant clinical evidence of prematurity;

10.   significant jaundice or jaundice prior to 24 hours;

11.   loss of >10% of birth weight/failure to thrive;

12.   major apparent congenital anomalies;

13.   significant birth injury.