24 Del. Admin. Code § 1795-4.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1795-4.0 - Home Birth

4.1 A midwife offering home birth services shall only accept and provide care to those women who are classified as being low risk pregnancy, labor, and delivery. Low risk pregnancy, labor, and delivery means:

4.1.1 There is no preexisting maternal disease or condition likely to affect the pregnancy, including but not limited to:

4.1.1.1 Prior cesarean procedures;

4.1.1.2 Significant cardiac disease;

4.1.1.3 Active tuberculosis;

4.1.1.4 Asthma, if severe or uncontrolled by medication, or other chronic pulmonary disease;

4.1.1.5 Preexisting renal disease;

4.1.1.6 Hepatic disorders;

4.1.1.7 Untreated or uncontrolled endocrine disorders;

4.1.1.8 Significant hematological disorders;

4.1.1.9 Preexisting/uncontrolled neurologic disorders;

4.1.1.10 Essential hypertension;

4.1.1.11 Active cancer;

4.1.1.12 Pre-gestational diabetes mellitus;

4.1.1.13 History of newborn with group B strep disease;

4.1.1.14 Current substance addiction or abuse;

4.1.1.15 Current severe psychiatric illness;

4.1.1.16 History of Rh red cell isoimmunization;

4.1.1.17 Positive for HIV antibody or hepatitis B;

4.1.1.18 Primary or uncontrolled infections;

4.1.1.19 History of uterine surgery involving breach of the uterine wall;

4.1.1.20 Prior neonatal death related to an intrapartum event;

4.1.1.21 Primary post-partum hemorrhage requiring surgery.

4.1.2 There is no significant disease or condition arising from the pregnancy, including:

4.1.2.1 Onset of labor before the 37th week of gestation with a positive GBS or GBS status unknown;

4.1.2.2 Lie other than vertex at term;

4.1.2.3 Multiple gestations;

4.1.2.4 Significant vaginal bleeding;

4.1.2.5 Significant gestational hypertension;

4.1.2.6 Gestational diabetes mellitus, uncontrolled by diet;

4.1.2.7 Hemoglobin less than 10 mg/dl, not responsive to treatment;

4.1.2.8 Evidence of pre-eclampsia;

4.1.2.9 Consistent size/date discrepancy;

4.1.2.10 Deep vein thrombosis or other significant hematologic syndrome;

4.1.2.11 Known fetal anomalies or conditions that would render a home birth unsafe;

4.1.2.12 Threatened or spontaneous abortion in the second trimester or later;

4.1.2.13 Abnormal ultrasound findings requiring a higher level of care;

4.1.2.14 Red cell isoimmunization with rising titer;

4.1.2.15 Documented placental anomaly or late term previa;

4.1.2.16 Rare diseases or disorders outside of the midwife's scope of care;

4.1.2.17 Postdates pregnancy;

4.1.2.18 HIV infection;

4.1.2.19 Primary or uncontrolled infections;

4.1.2.20 Significant decreased fetal responsiveness or evidence of non-reassuring fetal status.

4.1.3 There is a singleton fetus.

4.1.4 There appears to be a cephalic presentation prior to delivery.

4.1.5 The onset of labor occurs when the fetus has a gestational age greater than 37 and 0/7 weeks and less than 42 completed weeks, unless GBS positive or GBS status unknown.

4.1.6 Labor is most likely to be spontaneous.

4.2 The following equipment must be present at every home birth and the midwife must be properly trained on the use of each piece of equipment:

4.2.1 Equipment for assessing maternal well-being:

4.2.1.1 Blood pressure cuff;

4.2.1.2 Stethoscope;

4.2.1.3 Thermometer;

4.2.1.4 Time keeping device with the ability to track seconds.

4.2.2 Equipment for assessing fetal well-being:

4.2.2.1 Doppler and Fetoscope.

4.2.3 Equipment for assessing newborn well-being:

4.2.3.1 Stethoscope;

4.2.3.2 Thermometer;

4.2.3.3 Blood glucose monitor;

4.2.3.4 Pulse oximeter;

4.2.3.5 Time keeping device with the ability to track seconds.

4.2.4 Supplies to maintain asepsis:

4.2.4.1 Sterile gloves;

4.2.4.2 Antiseptic hand cleanser;

4.2.4.3 Paper towels;

4.2.4.4 Protective gowns;

4.2.4.5 Eye shields;

4.2.4.6 Surgical face masks;

4.2.4.7 Protective fluid-resistant barrier;

4.2.4.8 Sterile cord occlusive device;

4.2.4.9 General purpose antiseptic;

4.2.4.10 Sterile gauze;

4.2.4.11 Speculum;

4.2.4.12 Scissors;

4.2.4.13 Hemostats;

4.2.4.14 Ring forceps;

4.2.4.15 Sterile barrier;

4.2.4.16 Needle holder;

4.2.4.17 Sutures.

4.2.5 Maternal emergency resuscitation equipment:

4.2.5.1 Ammonia inhalants;

4.2.5.2 Suction catheter;

4.2.5.3 Cuffless oral/nasal tube;

4.2.5.4 Benadryl;

4.2.5.5 Pepcid;

4.2.5.6 Epinephrine;

4.2.5.7 Dextrose;

4.2.5.8 0.9% Sodium Chloride;

4.2.5.9 Needles;

4.2.5.10 Angiocath;

4.2.5.11 10 cc syringe;

4.2.5.12 1 cc syringe;

4.2.5.13 Alcohol swabs;

4.2.5.14 Gauze;

4.2.5.15 Nasal cannula or mask;

4.2.5.16 Lactated ringers.

4.2.6 Newborn emergency resuscitation equipment;

4.2.6.1 Suction device;

4.2.6.2 Neo-natal resuscitation bag, mask, and board;

4.2.6.3 Feeding tube;

4.2.6.4 Endotracheal tube laryngoscope;

4.2.6.5 Meconium aspirator;

4.2.6.6 Epinephrine;

4.2.6.7 Needles;

4.2.6.8 1 cc syringe;

4.2.6.9 Alcohol swabs;

4.2.6.10 Gauze;

4.2.6.11 Oxygen.

4.3 A midwife must ensure that every location where a homebirth will occur is equipped with all of the following:

4.3.1 Running water;

4.3.2 A room with heat.

4.4 Administration of Prescribed Medications and Authorized Tests:

4.4.1 Upon the administration of any prescribed medication, the Midwife shall document in the client's chart the type of prescribed medication administered, name of prescribed medication, expiration date, lot number, dosage, method of administration, site of administration, date, time, and the prescribed medication's effect.

4.4.2 Administration of Approved Prescribed Medications by a Midwife includes:

4.4.2.1 Rh-immune globulin to Rh negative, antibody negative mothers, for the prevention of isoimmunization in Rh (D) negative women. One 300 microgram dose (or as recommended by the manufacturer) at 26-28 weeks gestation via intramuscular injection. In addition, one 300 microgram dose (or as recommended by the manufacturer) administered via intramuscular injection to the mother within 72 hours of delivery of an Rh positive infant (or an infant with unknown blood type) to an Rh negative, antibody negative mother. If mother does not deliver by 12 weeks after the dose is administered, mother must be administered another dose of Rh-immune globulin.

4.4.2.2 Oxytocin (Pitocin) for postpartum hemorrhage or, following delivery of the newborn to prevent postpartum hemorrhage. One or two doses of 10 units/ml may be administered via intramuscular injection. If a second dose is administered, for any reason, transport must be initiated in accordance with the emergency plan.

4.4.2.3 Methylergonovine (Methergine) for postpartum hemorrhage only; one 0.2 mg per 1 ml dose ampule administered via intramuscular injection. Every six hours, may repeat 3 times. Contraindicated in hypertension and Raynaud's Disease. If Methylergonovine (Methergine) is administered more than 3 times, transport must be initiated in accordance with the emergency plan.

4.4.2.4 Misoprostol (Cytotec) for postpartum hemorrhage only. Rectal or sublingual, or may be used as 1/2 rectally and 1/2 sublingually. 800 mcg dose (four 200 mcg tabs) administered rectally or a 400-600 mcg dose (two or three 200 mcg tabs) administered sublingually. 1-2 doses; not to exceed 800 mcg total. Transport to hospital required if more than 2 doses are administered.

4.4.2.5 Oxygen 10-12 L/min. for maternal /fetal distress; bag or bag and mask until stabilization is achieved or transfer to a hospital is complete.

4.4.2.6 Erythromycin Ophthalmic Ointment to a newborn, for prophylaxis of neonatal ophthalmia, as provided by Delaware law. A single topical dose of Erythromycin Ophthalmic, Ointment USP (0.5%) is to be administered within two (2) hours after birth via topical application of a ribbon of ointment approximately 1 cm in length into each eye.

4.4.2.7 Vitamin K1 (phylloquinone, phytonadione) to a newborn, as prophylaxis for vitamin K deficiency bleeding. One 1 mg dose of 2 mg / ml concentration vitamin K1 via intramuscular injection.

4.4.2.8 Lidocaine HCl 1% or 2% Local anesthetic for use during postpartum repair of lacerations Maximum 50 ml (1%), Maximum 15 ml (2%) percutaneous infiltration only.

4.4.2.9 Epinephrine HCl 1:1000 (Epi-Pen Twin Jet® auto injector adult [GREATER THEN OR EQUAL TO] 66 lbs.) Treatment or post exposure prevention of severe allergic reactions. 0.3 ml-1.5 mg pre-metered dose as directed. Administer first dose then immediately request emergency services. Thereafter, administer every 20 minutes or until emergency medical services arrive.

4.4.2.10 If IV therapy is initiated for blood loss, transport must be initiated in accordance with the emergency plan. The preferred drug list of IV fluids necessary to restore fluid volume lost due to postpartum hemorrhage consists of:

4.4.2.10.1 Lactated Ringers (LR); 1 - 2 liter bags - first liter run in at a wide open rate, via intravenous catheter, the second liter titrated to client's condition.

4.4.2.10.2 Lactated Ringers solution (D5LR); 500 ml - may run in at a wide open rate, via intravenous catheter, and then titrated to client's condition.

4.4.2.11 Clients found to have a culture indicated Group B Streptococcal Infection should be treated with appropriate antibiotics during labor according to CDC guidelines.

4.4.2.11.1 0.9% sodium chloride in sterile water (NS) for reconstitution of the antibiotic.

4.4.2.11.2 Penicillin G: 5 million units initial dose then 2.5 million units every four hours until birth IV in >100 ml LR or NS; or Ampicillin sodium: 2 grams initial dose, then 1 gram every four hours until birth IV in > 100 mg LR, NS or D5LR.

4.4.2.11.3 For clients found to have Group B Streptococcal infection with a history of penicillin allergy, antibiotics to which the strain of Group B Streptococcus carried by the client is sensitive must be determined prior to labor and the client must be treated with those antibiotics during labor as outlined by the CDC guidelines.

4.5 Emergency Care: The following procedures may be performed by the Midwife, only in an emergency situation in which the health and safety of the mother or newborn are determined to be at risk.

4.5.1 Administration of oxygen

4.5.2 Episiotomy

4.5.3 Administration of Pitocin, Methergine or Cytotec to control postpartum bleeding

4.5.4 If any of the following conditions arise during intrapartum or postpartum care, the midwife must immediately engage emergency medical services, and may continue to assist in the emergency:

4.5.4.1 Persistent abnormal bleeding;

4.5.4.2 Signs or symptoms of maternal or fetal infection;

4.5.4.3 Transverse lie or any other unresolvable malpresentation;

4.5.4.4 Visualization of active genital herpetic lesion;

4.5.4.5 Development of pre-eclampsia or gestational hypertension;

4.5.4.6 Abnormal findings on rupture of membranes;

4.5.4.7 Seizure;

4.5.4.8 Significant hemorrhage, greater than 1,000 cc with symptoms, not responsive to treatment;

4.5.4.9 Adherent or retained placenta;

4.5.4.10 Sustained maternal vital sign instability;

4.5.4.11 Suspected uterine prolapse;

4.5.4.12 Repair of laceration or episiotomy beyond the midwife's level of expertise;

4.5.4.13 Anaphylaxis;

4.5.4.14 Need for cardiopulmonary resuscitation of the mother or newborn with a bag and mask;

4.5.4.15 Need for manual exploration of the uterus for placental extraction to control severe bleeding.

4.5.5 A second attendant, certified in neonatal resuscitation, must be present at every home birth.

24 Del. Admin. Code § 1795-4.0

20 DE Reg. 62 (7/1/2016) (Final)