California College of Midwives
State chapter ~ American College of Community Midwives


Section 3 L

Minimum Practice Requirements – Neonatal Referral


~ to define and clarify minimum practice requirements for the safe care of women and infants in regard to PHYSICIAN CONSULTATION, REFERRAL, TRANSFER OF CARE & EMERGENCY TRASPORT for the NEONATE


h The Midwife shall consult with a physician and/or another professional midwife whenever there are significant deviations relative to the newborn. If a referral to a physician is needed, the Midwife will, if possible, remain in consultation with the physician until resolution of the concern. It is appropriate for the Midwife to continue caring for her client to the greatest degree possible, in accordance with the client’s wishes, during the postpartum/postnatal period.


A. The following conditions require physician consultation or client referral and may require transfer of care. 


1. Neonatal Conditions: The Midwife shall arrange for immediate consultation and transport according to the emergency plan if the following conditions exist. Due to time urgency during certain situations, it may be necessary to institute emergency interventions while waiting for physical consultation or emergency transport.


These conditions include but are not limited to:

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

b.      persistent respiratory distress exhibited by respirations greater than 70 per minute, grunting, retractions, or nasal flaring at one hour of age that is not showing consistent improvement and/or pulse oximetry readings below normal at one hour

c.       persistent cardiac irregularities

d.      central cyanosis or pallor, gray newborn

e.       lethargy or poor muscle tone

f.        prolonged temperature instability

g.       fever >100.6 degrees Fahrenheit, unresponsive to treatment

h.       significant clinical evidence of glycemic instability

i.         evidence of seizures 

j.        bulging or depressed fontanel

k.      birth weight <2300 grams

l.         significant clinical evidence of prematurity

m.     clinically significant jaundice at birth

n.       major or medically significant congenital anomalies

o.      significant or suspected birth injury

p.      other serious medical conditions

q.      parental request


2. Postnatal Care: The physiologic competencies that are generally recognized as defining the normal healthy neonate are the ability to maintain a normal body temperature fully clothed in an open bed with normal ambient temperature, the ability to coordinate suckle feeding, swallowing, breathing while ingesting an adequate volume of feeding, the ability to grow at an acceptable rate and normal elimination of urine and stool. Inability or dysfunction in any of the above named areas is cause for concern and on-going evaluation. Unless the problem is able to be correct in a timely fashion, consultation, referral or transfer of care will become necessary.


The midwife will arrange for consultation, referral or transport for an infant who exhibits the following:


a.       abnormal cry

b.      diminished consciousness

c.       inability to suck

d.      passes no urine in 30 hours or meconium in 48 hours

e.       fever >100.6 degrees Fahrenheit, unresponsive to treatment

f.        baseline pulse rate greater than 156 or less than 90

g.       baseline respiratory rate greater than 70 or less than 30

h.       clinically significant color abnormality - cyanotic, pale, grey

i.         abdominal distension, projectile vomiting

j.        jaundice within 30 hours of birth

k.      signs of a significant infection or skin or umbilical stump

l.         strongly positive Coombs test

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

n.       other concerns of family or midwife