314.410 Board of Nursing to promulgate administrative regulations based upon recommendations of the council -- Recommendations to include regulatory framework to support consultation and collaboration between licensed certified professional midwives and other appropriate licensed health care providers -- Specifications to be included in regulatory framework -- Management of clients whose conditions may preclude them from being considered at low risk -- Board to enforce specified safety precautions before administrative regulations are in place

314.410 Board of Nursing to promulgate administrative regulations based upon

recommendations of the council -- Recommendations to include regulatory

framework to support consultation and collaboration between licensed

certified professional midwives and other appropriate licensed health care

providers -- Specifications to be included in regulatory framework --

Management of clients whose conditions may preclude them from being

considered at low risk -- Board to enforce specified safety precautions before

administrative regulations are in place.

(1) Within one (1) year of June 27, 2019, the council shall make recommendations to

the board for the promulgation of administrative regulations by the board regarding

requirements for the management of clients who may have a condition that

precludes the clients from being considered at low risk of an adverse outcome for

the mother, her fetus, or her newborn. These recommendations shall include:

(a) A regulatory framework to support consultation and collaboration between

licensed certified professional midwives and other appropriate licensed health

care providers with expertise in obstetrical and neonatal care, in order to

optimize obstetrical and neonatal outcomes in whatever setting a client

chooses for birth. The regulatory framework shall specify:

1. Processes and infrastructure to facilitate collaboration and consultation

with other licensed healthcare providers who possess the appropriate

medical expertise;

2. Processes and infrastructure to facilitate co-management with, or

transfer of primary management responsibility to, other licensed

healthcare providers who possess the appropriate medical expertise;

3. Processes and infrastructure for transfer of clients to facilities with a

higher level of care, as developed by the Transfer Guidelines Work

Group established in KRS 314.414, and as updated by the council;

4. Processes for the provision of required or routinely recommended

screening and disease prevention measures, if not provided directly by

the licensed certified professional midwife; and

5. Other collaborative processes deemed necessary by the council or the

board to optimize obstetrical and neonatal outcomes;

(b) A list of conditions or symptoms associated with a risk of death or serious

permanent harm affecting a mother, fetus, or newborn, as assessed by a

licensed certified professional midwife exercising reasonable skill and

knowledge, and:

1. Requirements for collaborative management with, or referral of primary

management responsibility to, a physician or other appropriate licensed

healthcare provider, of a client with conditions or symptoms specified

under this paragraph, to protect the health and safety of a mother, fetus

or newborn. Separate regulatory requirements shall be developed for

each or any condition on the list, if clinically appropriate; and

2. Requirements for management of a client with conditions or symptoms

specified under this paragraph who refuses to consent to

recommendations intended to prevent death or serious permanent harm,

including requirements for informed refusal by the client. The

requirements for informed refusal shall be tailored to the specific

condition or symptom, and shall reflect maximal effort to protect the life

and health of the mother, her fetus, and her newborn; and

toms

specified under this paragraph who refuses to consent to

recommendations intended to prevent death or serious permanent harm,

including requirements for informed refusal by the client. The

requirements for informed refusal shall be tailored to the specific

condition or symptom, and shall reflect maximal effort to protect the life

and health of the mother, her fetus, and her newborn; and

(c) A list of conditions or symptoms associated with a more than minimal risk of

adversely affecting a mother, fetus, or newborn, but not a significant risk of

death or serious permanent harm, as assessed by a licensed certified

professional midwife exercising reasonable skill and knowledge, and:

1. Requirements for consultation, collaborative management, or referral of

primary management responsibility of a client with conditions or

symptoms specified under this paragraph, for each condition or

symptom on the list, to ensure the health and safety of a mother, fetus, or

newborn; and

2. Requirements for documentation of an informed refusal by a client with

conditions or symptoms specified under this paragraph of recommended

consultation, referral of care, or other management, including the

information to be provided to a client that is necessary to enable

informed refusal of recommended care.

(2) The council's recommendations shall be considered by the board to form the basis

for any requirements or restrictions imposed by the board on the provision of

certified professional midwifery services to a client whose condition is not

classified as low-risk. The recommendations shall be based on evolving medical

evidence published in peer-reviewed medical literature and with consideration to

the likelihood of serious harm or death to the mother or newborn.

(3) Until such time as the council has conveyed superseding recommendations to the

board and the board has promulgated superseding administrative regulations, the

following shall be enforced by the board:

(a) If on initial or subsequent assessment, one (1) of the following conditions

exists, the licensed certified professional midwife shall arrange for

consultation and either collaboration or referral in accordance with KRS

314.400 to 314.414, and document that recommendation in the licensed

certified professional midwife's record:

1. Complete placenta previa, or partial placenta previa persisting after

twenty eight (28) weeks;

2. HIV infection;

3. Cardiovascular disease, including hypertension;

4. Severe psychiatric illness that may result in self-harm or harm to others;

5. History of cervical incompetence;

6. Pre-eclampsia or eclampsia;

7. Intrauterine growth restriction, oligohydramnios or polyhydramnios in

the current pregnancy;

8. Known potentially serious anatomic fetal abnormalities;

9. Any type of diabetes requiring insulin or other medication for

management;

10. Gestational age greater than forty-three (43) weeks; or

11. Any other condition or symptom which could threaten the life of the

mother or fetus, as assessed by a licensed certified professional midwife

exercising reasonable skill and knowledge;

gnancy;

8. Known potentially serious anatomic fetal abnormalities;

9. Any type of diabetes requiring insulin or other medication for

management;

10. Gestational age greater than forty-three (43) weeks; or

11. Any other condition or symptom which could threaten the life of the

mother or fetus, as assessed by a licensed certified professional midwife

exercising reasonable skill and knowledge;

(b) The licensed certified professional midwife may continue to participate in the

care of a client requiring transfer, in a collaborative fashion and as mutually

agreed upon with the accepting physician, to the extent permitted by hospital

regulations and if it is beneficial to the client. If a client with a condition listed

in paragraph (a) of this subsection declines to accept a medically indicated

consultation or referral, the licensed certified professional midwife shall

document such refusal in writing and shall endeavor to transition the client to

an appropriate higher level of care. If the condition mandating transfer occurs

during labor or delivery, or the client is otherwise acutely in jeopardy but

refuses transfer, then the midwife shall call 911 and provide care at least until

relieved by another appropriate licensed health care provider; and

(c) If on initial or subsequent assessment, one (1) of the following conditions

exists, the midwife shall arrange for consultation and either collaboration or

referral in accordance with KRS 314.400 to 314.414, and document that

recommendation in the midwifery record:

1. Prior cesarean section or other surgery resulting in a uterine scar;

2. Multifetal gestation;

3. Non-cephalic presentation after thirty-six (36) weeks gestation; and

4. History of severe shoulder dystocia as documented by objective

findings.

(4) The board shall, at the earliest opportunity, promulgate administrative regulations

specific to the conditions listed in subsection (3)(c) of this section, including the

minimum requirements for informed refusal by the client of otherwise mandatory

consultation and either collaboration or referral.

(5) If the client has complied with administrative regulations promulgated by the board

for informed refusal, then the licensed certified professional midwife may pursuant

to subsection (4) of this section, continue to assume primary management

responsibility for the client unless and until the client subsequently consents to

collaborative care or referral.