POLICIES AND PROCEDURES

Transcription

1 Purpose: To establish guidelines for the clinical practice of Nurse Midwives. Policy: The Central California Alliance for Health (the Alliance) requires all Nurse Midwives to meet the Alliance s guidelines with respect to scope of practice and supervision. Definitions: Certified Nurse Midwife: A Certified Nurse Midwife (CNM) is a registered nurse who is a graduate of a Board-approved nurse midwifery program and who possesses evidence of certification issued by the California Board of Registered Nursing. A certified nurse midwife may be known as an Advanced Practice Registered Nurse in Accordance with Business and professions Code Section Standardized Procedures: CNMs practice in collaboration and consultation with physicians. All complications must be referred to physicians immediately (BP Code ) and the CNM is to provide emergency care until physician assistance can be obtained. Standardized procedures, developed with the supervising physician are the legal mechanism for registered nurses, including Nurse Midwives, to perform functions that would otherwise be considered the practice of medicine. The CNM will develop Standardized Procedures in collaboration with physicians and administrators in the organized health system which is to be used. Practices and procedures that overlap the practice of nurse-midwifery into medicine require a standardized procedure (e.g. episiotomy and repair of first or second degree lacerations). CNMs may not assist childbirth by any artificial, forcible, or mechanical means and may not perform version (BP Code (b)). Procedures: 1. Alliance General Guidelines a. Credentialing: The credentialing of CNMs will be processed in adherence to Policy Professional Provider Credentialing Guidelines. b. Ratios: The ratio of physicians available for supervision to CNMs will not exceed the standards outlined in Policy Verification of Physician Supervision to Non-Physician Medical Practitioners Supervision Ratios. 2. Scope of Practice: Page 1 of 5

2 a. A nurse midwife that is currently certified may perform independent comprehensive management of women s health care focusing on pregnancy, childbirth, the postpartum period, care of the newborn as well as family planning and gynecologic needs of women throughout the life cycle. Nurse midwifery care requires the supervision of a licensed physician and surgeon but does not require the physical presence of a physician. b. The CNM is able to assume responsibility for the management of normal pregnant women whose medical, surgical and post-obstetrical history and present health status reveal no conditions that would adversely influence the patient's course of pregnancy or be unfavorably affected by it. Such management includes: i. Observation, assessment and treatment of patients according to approved standardized procedures; ii. Implementation of selected standardized procedures to establish a diagnosis; and iii. Management of selected deviations from normal when the diagnosis is clear with a predictable outcome. c. During the course of care, the CNM will consult with the physician when deviations from normal arise and a course of action is not already specified in the standardized procedure. If a condition requires frequent and / or continuing management by a physician, but certain aspects of care remain within the scope of nurse midwifery management, a situation of collaborative management exists. Under collaborative management, all patients will be followed by both the physician and the CNM. The CNM may institute those standardized nurse midwifery procedures that do not conflict with the aspect of care under the physician's management. Thus, collaborative management requires careful communication between the CNM and the physician, who assumes responsibility for overall provision of that care. d. When a patient develops a condition that requires management by a physician, they are transferred to physician management for antepartum, intrapartum, and / or postpartum care. Orders should then be communicated directly between the physician and the nurse in charge. The CNM should continue to provide supportive care. The conditions that may warrant medical management include, but are not limited to: i. Hypertension, severe pre-eclampsia; ii. Malpresentation (breech, brow, face, abnormal lie, etc.); iii. Dysfunctional labor; iv. Third stage hemorrhage or retained placenta; v. Multiple gestation; Page 2 of 5

3 vi. Preterm labor; vii. Fetal demise; viii. Prolapsed cord; ix. Fetal distress; x. Rh Sensitization; xi. Cardiac disease; xii. Chronic renal disease; xiii. Thrombophlebitis; xiv. Diabetes mellitus, class A2 or greater; xv. Late prenatal care; xvi. Lacerations: 3rd or 4th degree must be inspected and repaired or supervised by the physician but may remain under midwife care; xvii. Need for maintenance psychoactive drugs; xviii. Acute bronchospasm; and xix. Conditions agreed upon by physician and Nurse Midwife to be beyond the scope of midwifery practice. 3. Physician Supervision a. A physician will provide oversight and consultation for the CNM as required by the Nurse Practice Act and will provide consultation when needed or requested by the CNM; b. The physician will assume intrapartum management or co-management of those women whose conditions are beyond the scope of midwifery practice; c. The physician will provide coverage when the CNM is unavailable; and d. A physician must be available at all times, either by physical presence or electronic communication. 4. Prescribing Authority a. A CNM may furnish drugs or devices in accordance with standardized procedures and incidentally to the provision of any family planning services, routine health care or perinatal care, or care rendered consistent with the CNM s education, training, and competency. The CNM is required to have a furnishing number by the Board of Registered Nursing. b. CNMs may prescribe Schedule II or III controlled substances under the following circumstances: i. The CNM must complete an approved course that includes Schedule II Controlled Substances content; Page 3 of 5

4 ii. The CNM must register with the United States Drug Enforcement Administration; and iii. The CNM must furnish controlled substances only in accordance with patientspecific protocols approved by the treating/supervising physician. References: Alliance Policies: Professional Provider Credentialing Guidelines Verification of Physician Supervision to Non-Physician Medical Practitioners Supervision Ratios Regulatory: CCR 16 Section 1474 CCR 22 Section Business and Professions Code Sections , , (a) Nurse Midwife Practice. Board of Registered Nursing, Nov Contractual: Medi-Cal Contract Exhibit A, Attachment 9 Legislative: MMCD Policy Letter: Supersedes: Other: Lines of Business This Policy Applies To: Medi-Cal Healthy Families Healthy Kids Santa Cruz Alliance Care IHSS Access for Infants and Mothers Individual Conversion Plan Santa Cruz County LIHP Program Monterey County LIHP Program Revision History: Review Date Revised Date Changes Made By Approved By 12/01/ /01/1998 Barbara Flynn, RN Barbara Flynn, RN 07/01/ /01/2000 Barbara Flynn, RN Barbara Flynn, RN 07/01/ /01/2002 Barbara Flynn, RN Barbara Flynn, RN 07/01/ /01/2006 Barbara Flynn, RN Barbara Flynn, RN 10/01/ /01/2008 Barbara Flynn, RN Barbara Flynn, RN 03/01/ /01/2010 Barbara Flynn, RN Barbara Flynn, RN Page 4 of 5

5 12/16/ /16/2011 David Altman, MD David Altman, MD 11/01/ /01/2012 David Altman, MD David Altman, MD 09/28/ /28/2013 Dale Bishop, MD, CMO CQIW Page 5 of 5