Prepared for the Midwifery Committee,
Medical Board of California

Authorization via Progenitor Nursing Legislation for Nurse Midwifery

by faith gibson, LM,
community midwife

The basic scope of practice prerogatives by nurse-midwives derives from section 2725 which identifies three modalities of professional practice based on whether or not the specific treatment modalities being employed at any given time by the midwife is or is not physician centric (i.e., medicalization outside of the legislatively-authored scope of independent practice, thus requiring physician supervision).

These categories are:

1) Independent practice which authorizes the independent performance of the statutorily-mandated scope of practice and commonly-accepted patient care functions and requiring NO physician supervision. Independent practice prerogatives under 2725 are divided into four distinct areas which are:

a) direct and indirect patient care services that insure the safety, comfort, personal hygiene and protection of patients from injury, disease prevention and restorative measures;

b) direct and indirect patient care services, including but not limited to the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or a rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist;

c) the performance of skin tests, immunization and withdrawal of human blood from veins and arteries;

d) the observation of signs and symptoms of illness, reactions to treatment, general behavior, or general condition and (1) the determination of whether such signs, symptoms, reactions, behavior or general appearance exhibit abnormal characteristics; and (2) implementation, based on observed abnormalities, of appropriate reporting, or referral, or (universally) standardized procedures or changes in treatment regime in accordance with (universally) standardized procedures or the initiation of emergency procedures.

2) Overlapping or collaborative practice define as an "interdependent" realm. Interdependent functions are predicated on collaboration with a physician in the development of standardized procedures and continuing consultation between the two. They address those areas of professional practice not delineated in the statutes NOR as yet having common acceptance as an independent area of professional practice. Examples of INTERdependent practice are medical treatments and diagnostic procedures authorized via "standardized procedures" to be implemented in abnormal medical situations such as management of cardiac arrests in ICU & ER, defibrillation and administration of potent cardiac drugs and intravenous fluids. Life-saving and clearly "medical treatments" are now routinely performed by ICU nurses under standardized procedures.

3) "dependent" practice in which an action by the practitioner directly depends on a specific, real-time physician's order, such as the administration of antibiotics to a mother with prolonged rupture of membranes (administration of antibiotics are not specified in either statutes or regulations) or the non-emergency manual removal of a placenta (specifically forbidden under the independent scope of midwifery practice but one which could, in a specific circumstance, be authorized by verbal order via telephone consultation with a physician).

SCOPE OF PRACTICE

The statutorily-mandated scope of practice for certified nurse-midwives is to attend of cases of normal childbirth and to provide prenatal, intrapartum an postpartum care, including family planning care for the mother and immediate care for the newborn. BRN regulations (16 CCR 1463) further clarify this by specifying that nurse-midwives may provide supervision, care and advise to women during interconceptual periods, conduct deliveries on his/her own responsibility, and care for the newborn and infant, including preventative measures for detection of abnormal conditions in the mother and child, obtaining physician assistance and consultation when indicted, or providing emergency care until physician assistance can be obtained and performing other practices and procedures deemed appropriate pursuant to standardized procedures.

SUPERVISION of CMNs / BRN Regs

Supervision, as identified in for CNMs is not applied to this realm of the independent scope of practice but rather to those areas which would otherwise be considered medical practice. Areas of inter-dependence defined in written standardized procedures such as the setting parameters between the individual physician and midwife for defining abnormal situations such as prolonged labors, PROM, elevated vital signs, premature or postdates pregnancies and other agreed-upon guidelines for the interface between the MEDICAL and MIDWIFERY scope of practice such as the ordering of and interpretation of lab work, ordering or performing diagnostic tests such as ultrasound or NSTs. The "dependent" function by statute is that which falls outside the identified interdependent function as documented in standardized procedures and refers to actions which, if taken by the midwife without a physician's order, would be considered an unauthorized practice of medicine such as administration of medications (examples are antibiotics for a mother with PROM, manual removal of placenta, etc.).