FORT HAMILTON HOSPITAL DELINEATION OF CLINICAL PRIVILEGES & QUALIFICATIONS ADVANCED PRACTICE NURSE CERTIFIED NURSE-MIDWIFE (CNM)

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1 Name FORT HAMILTON HOSPITAL DELINEATION OF CLINICAL PRIVILEGES & QUALIFICATIONS ELIGIBILITY REQUIREMENTS ADVANCED PRACTICE NURSE CERTIFIED NURSE-MIDWIFE (CNM) Required Qualifications: Demonstration of satisfactory training, experience, and current competence Certification by American College of Midwives Current BCLS certification required, current ACLS certification preferred. Current Licensure by the Ohio Board of Nursing as a CNM. Current Ohio Prescriptive Authority License if requesting prescription privileges. Current Ohio Certificate of Authority by the Ohio Board of Nursing. Submission of a completed Commitment to Provide Nurse Midwifery Direction and Supervision form which signifies the agreement of a physician member of Fort Hamilton Hospital medical staff with clinical privileges in obstetrics at this hospital, to direct and supervise the nurse midwife s professional activities as well as provide coverage in clinical situations requiring judgement and intervention beyond the nurse midwife s scope of practice. Such document shall serve as the Standard Care Agreement and include requirements that the supervising physician(s) must: o Assume responsibility for supervision and direction of the nurse midwife s practice conducted inside the hospital. o Be continuously available to provide consultation when requested and to intervene when necessary. o Assume total responsibility for the care of any obstetrical patient when requested by the nurse midwife or as required by this protocol or in the interest of the patient. o Adhere to the protocols developed by the Department of Obstetrics and Gynecology that govern nurse midwifery care provided within this hospital. o Abide by all standards of the Ohio Revised Code pertaining to nurse midwifery and Fort Hamilton Hospital Medical Staff Bylaws, Rules & Regulations. o Abide by the American College of Nurse Midwives functions, standards, and qualifications. DELINEATION OF PRIVILEGES Please place a checkmark before each privilege you are requesting. Some privilege may require documentation of special training or experience before privileges are granted. Perform history and physical examination and arrange for laboratory testing of pregnant patients. H&Ps performed by the nurse midwife shall be limited to his/her area of training, i.e. the pregnancy only. Examination of the patient s other systems shall be performed by and signed by the sponsoring physician.

2 Delineation of Privileges (continued) Page 2 of 5 Perform routine prenatal care including appropriate instruction for Rh-negative mothers. Examine and co-admit patients in labor. The sponsoring physician shall be responsible for co-admitting the patient. Write orders and notify consultant of patient s status and plan or change of plan. Perform artificial rupture of membranes. Apply: External scalp monitor Fetal scalp electrode Intrauterine pressure catheter as indicated Order for administration of installation of newborn Erythromycin Ophthalmic Order for administration of Vitamin K 1 mg (0.5ml) IM before 1 hour of age Order and monitor oxytocin for augmentation or induction after consultation. Physician is to be readily available in case of emergency Perform normal spontaneous vaginal delivery with or without episiotomy. Repair 1 st and 2 nd degree perineal/vaginal lacerations. Provide routine postpartum care, orders, and discharge. Perform sonography to determine fetal presentation if presentation is in question. Write or dictate discharge summaries. Independently conduct rounds for routine postpartum/postoperative care. Administer prostaglandin gel for cervical ripening. Repair of 3 rd degree lacerations with documentation of competence from sponsoring physician. PRESCRIPTIVE AUHORITY: Non-narcotic medications Additional documentation required: Current Certificate to Prescribe by the Ohio Board of Nursing. Only medications listed in the Standard Care Agreement and the Ohio Committee on Prescriptive Authority Governance (CPG ) formulary may be prescribed. PRESCRIPTIVE AUHORITY: Narcotic medications Additional documentation required: Current Certificate to Prescribe by the Ohio Board of Nursing and Federal DEA license. Only medications listed in the Standard Care Agreement and the Ohio Committee on Prescriptive Authority Governance (CPG) formulary, and within the narcotic classes on the individual s DEA license may be prescribed.

3 Delineation of Privileges (continued) Page 3 of 5 NOTES 1. All orders for diagnostic and/or therapeutic intervention for a patient written by an appropriately credentialed and privileged CNM shall be counter-signed by the supervising physician within the time frame specified by applicable hospital and medical staff bylaws, rules and regulation, and policies, procedures and protocols. 2. Law Regulating the Practice of Nursing, Chapter 4723, Ohio Revised Code, effective June 14, 1988, No certificate to practice nurse midwifery shall authorize its holder to perform version, treat breech or face presentation, do any obstetric operation requiring instruments, or treat any other abnormal conditions, except in emergencies. 3. CNMs do have co-admitting privileges. Printed Name of Applicant Printed Name of Collaborating Physician Signature, Applicant Signature, Collaborating Physician

4 Delineation of Privileges (continued) Page 4 of 5 DEFINITION AND SCOPE OF PRACTICE OF SPECIALIZED NURSING SERVICES Certified nurse-midwife means a registered nurse who holds a valid certificate of authority issued that authorizes the practice of nursing as a certified nurse-midwife in accordance with section of the Revised Code and rules adopted by the Board of Nursing. A nurse authorized to practice as a certified nurse-midwife, in collaboration with one or more physicians, may provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically, consistent with the nurse s education and certification, and in accordance with rules adopted by the Board.

5 Delineation of Privileges (continued) Page 5 of 5 FORT HAMILTON HOSPITAL OB/GYN DEPARTMENT COMMITMENT TO PROVIDE NURSE MIDWIFERY DIRECTION & SUPERVISION I hereby agree to provide direction and supervision to, A certified nurse midwife, requesting clinical privileges at Fort Hamilton Hospital in nurse midwifery. Such direction and supervision, as well as, necessary coverage in clinical situations outside of the nurse midwife s scope of practice, will be provided in accordance with Section of the Revised Code, once the requested clinical privileges are granted and will continue until rescinded in writing by myself or the nurse midwife or until such clinical privileges are no longer in effect. The supervising physician(s) must: o Assume responsibility for supervision and direction of the nurse midwife s practice conducted inside the hospital. o Be continuously available to provide consultation when requested and to intervene when necessary. o Assume total responsibility for the care of any obstetrical patient when requested by the nurse midwife or as required by this protocol or in the interest of the patient. o Adhere to the protocols developed by the Department of Obstetrics and Gynecology that govern nurse midwifery care provided within this hospital. o Abide by all standards of the Ohio Revised Code pertaining to nurse midwifery and Fort Hamilton Hospital Medical Staff Bylaws, Rules & Regulations. o Abide by the American College of Nurse Midwives functions, standards, and qualifications. Printed Name Signature of Collaborating Physician Revised & approved 3/16/06 Revised & approved 9/20/07 Board of Trustees

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