Advisory Committee Arizona Department of Health Services January - - PowerPoint PPT Presentation

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Advisory Committee Arizona Department of Health Services January - - PowerPoint PPT Presentation

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Midwifery Scope of Practice Advisory Committee Arizona Department of Health Services January 14, 2013 6:00-8:00pm azdhs.gov Health and Wellness for all Arizonans Agenda Call to Order- Welcome and Introductions Review/Approve Dec. 17,

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Health and Wellness for all Arizonans

azdhs.gov

Midwifery Scope of Practice Advisory Committee

Arizona Department of Health Services January 14, 2013 6:00-8:00pm

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Health and Wellness for all Arizonans

azdhs.gov

Agenda

  • Call to Order- Welcome and Introductions
  • Review/Approve Dec. 17, 2012 Minutes
  • Presentation on Smooth Transitions
  • Presentation on Consumers
  • Discussion of ADHS Data
  • Discussion of Rules for Midwifery Scope of

Practice

  • Call to Public
  • Future Agenda Items and Closing Remarks
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Health and Wellness for all Arizonans

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CALL TO ORDER: WELCOME & INTRODUCTIONS

Will Humble 6:00-6:05 pm

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Health and Wellness for all Arizonans

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Advisory Committee Members

Name Position Will Humble Director, Co-Chair Cara Christ Co-Chair Wendi Cleckner Licensed Midwife Mary Langlois Licensed Midwife Allyson Fernstrom Member of the Public Julie R. Gunnigle Member of the Public Karen Holder Certified Nurse Midwife Maria Manriquez M.D., OB/Gyn Susan Hadley M.D., Family Practice Jeffrey Northup D.O., OB/Gyn

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Health and Wellness for all Arizonans

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REVIEW AND APPROVE MINUTES DECEMBER 17, 2012 MEETING

Will Humble 6:05-6:10 pm

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Health and Wellness for all Arizonans

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SMOOTH TRANSITIONS PRESENTATION

Maria Manriquez, MD and Wendi Cleckner 6:10-6:30 pm

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Health and Wellness for all Arizonans

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CONSUMERS PRESENTATION

Mary Langlois 6:30-6:35 pm

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ADHS MIDWIFERY DATA

Cara Christ, MD 6:35-6:40 pm

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Health and Wellness for all Arizonans

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Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118)

  • 3118 reported patients
  • Limitations of the data

– Incomplete reports – Missing data fields – No consensus for filling out form – 1st analysis of the database – Matching with birth certificates – Working with various time frames- cannot be compared

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Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118)

367 520 576 570 620 465 100 200 300 400 500 600 700 2007 2008 2009 2010 2011 2012

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Health and Wellness for all Arizonans

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Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118) Maternal Outcomes (n=3118)

  • Normal: 506
  • Abnormal: 1
  • Expired: 0
  • Missing: 2611

Maternal Transport (n=3118)

  • Transferred to hospital: 421

– Admitted: 390 – Released after evaluation: 13

  • Physicians office: 13
  • Missing: 2684
  • 13.9% of reported patients

required transport

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Health and Wellness for all Arizonans

azdhs.gov

Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118)

Physician Consultation (n=460)

  • On call: 1
  • DO: 10
  • Dr: 1
  • MD: 424
  • ND: 24

Limitations/Complications/ Consults/Transferred (n=3118)

  • No limitations: 2255
  • Yes: 759
  • Missing: 104
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Health and Wellness for all Arizonans

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Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118)

Termination of Services (n=211)

  • Most common:

– Prolonged 1st stage: 27 – Prolonged ROM: 15 – Failure to progress: 10 – Preterm labor: 8 – Elevated BP: 5 – Not vertex: 5 – Prolonged 2nd stage: 4 – Fetal demise: 3 – Retained placenta: 3

Client Conditions/Complications (n=673)

  • Initial workup: 88
  • Antepartum: 147
  • Fetal: 67
  • Intrapartum: 266
  • Infant: 83
  • Postpartum: 22
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Health and Wellness for all Arizonans

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Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118) Complications Fetus (n=67)

  • FHT < 100: 15
  • FHT > 160: 2
  • Irregular FHT: 9
  • Cord Prolapse: 2
  • Meconium Staining: 11

Complications Intrapartum (n=266)

  • Not vertex: 11
  • Prolonged ROM: 34
  • Shoulder dystocia: 3
  • 3rd stage hemorrhage: 25
  • Retained placenta: 12
  • Shock: 2
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Health and Wellness for all Arizonans

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Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118) Infant Outcomes (n=3118)

  • Normal: 462
  • Abnormal: 6
  • Expired: 14
  • Missing: 2636

Infant Outcomes (n=3118)

  • SGA: 46
  • AGA: 2416
  • LGA: 260
  • Missing: 396
  • 7 required transport for

preterm delivery

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Health and Wellness for all Arizonans

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Midwife Quarterly Reports

1/1/2007-12/31/2012 (n=3118)

APGAR score at 1 min (n=3118)

  • 0-3: 30
  • 4-6: 141
  • 7+: 2610
  • Missing: 337

APGAR score at 5 min (n=3118)

  • 0-3: 3
  • 4-6: 15
  • 7+: 2760
  • Missing: 340
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Birth Certificate Data

2006-2010 (n=2290)

100 200 300 400 500 600 2006 2007 2008 2009 2010

Number of births County of Home Birth

APACHE COCHISE COCONINO GILA GRAHAM LA PAZ MARICOPA MOHAVE NAVAJO PIMA PINAL SANTA CRUZ YAVAPAI YUMA

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Health and Wellness for all Arizonans

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Birth Certificate Data

2006-2010 (n=2290)

  • Multiple births: 2
  • Low Birth Weight (<2500 g): 21 (1%)
  • Preterm births (<37 weeks): 24 (1%)
  • Small for gestational age: 139 (6%)
  • Large for gestational age: 297 (13%)
  • Transfer:

– Maternal: 1 (0.04%) – Infant: 29: (1%)

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Health and Wellness for all Arizonans

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Birth Certificate Data

2006-2010 (n=2290)

  • Amniocentesis: 10 (0.44%)
  • Induction of Labor: 5 (0.22%)
  • Stimulation of Labor: 11

(0.48%)

  • Tocolysis: 5 (0.22%)
  • Febrile: 1 (0.04%)
  • Meconium: 19 (0.83%)
  • Premature rupture of

membranes: 14 (0.61%)

  • Abruptio Placenta: 2 (0.09%)
  • Excessive bleeding: 14 (0.61%)
  • Prolonged labor: 18 (0.79%)
  • Dysfunctional labor: 1 (0.04%)
  • Breech: 7 (0.31%)
  • Cephalopelvic disproportion: 1

(0.04%)

  • Cord Prolapse: 1 (0.04%)
  • VBAC: 3 (0.13%)
  • Vacuum: 2 (0.09%)
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Health and Wellness for all Arizonans

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DISCUSSION OF RULES FOR MIDWIFERY SCOPE OF PRACTICE

Thomas Salow, J.D., Acting Deputy Assistant Director, Division of Licensing and Manager, Office of Administrative Counsel and Rules 6:40-7:40PM

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Scope of Practice by State

Normal Pregnancies VBAC Multiples Breech Only 1 out of 3

VBAC/ Twins

2 out of 3

VBAC/ Breech Twins/ Breech

VBAC, Multiples, and Breech Unregulated Maine Missouri Alaska Arizona (currently) Colorado Idaho Montana New Hampshire Wyoming Texas Utah Vermont South Carolina California Delaware New Jersey New Mexico Oregon Wisconsin Washington Tennessee Arizona (Proposed)

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Summary of Changes to 9 A.A.C. 16, Licensing

  • f Midwifery Made by the Exempt Rulemaking,

Laws 2012, Chapter 93

Laws 2012, Chapter 93 (HB 2247) requires the Department to consider adopting rules regarding midwifery to reduce the regulatory burden on midwives, streamline the regulatory process, revise the midwifery scope of practice, and, if available, adopt national licensure testing standards.

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Scope of Practice Sections

  • To be discussed:

– R9-16-10-106. R9-16-108. Responsibilities of the Licensed Midwife; Scope of Practice – R9-16-108. R9-16-109. Prohibited Practice; Transfer of Care – R9-16-109. R9-16-110. Required Consultation – R9-16-110. R9-16-111. Emergency Measures

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Health and Wellness for all Arizonans

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Proposed Changes

  • Requirements for:

– Emergency Action Plan – Physician Consult

  • Physician
  • Consumer

– Sending the prenatal records to the maternity ward of the hospital identified in the Emergency Action plan – Notifying the maternity ward:

  • The patient begins to labor
  • When the patient has delivered or the patient requires

transfer

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Health and Wellness for all Arizonans

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Emergency Action Plan

  • Identifies the nearest hospital from birthing

location

– The midwife must attest that the birthing hospital is located within 25 miles of the birthing location

  • Send a copy of the client records to the hospital

at 32 weeks of gestation

  • Call the hospital when the client begins labor and

when labor ends, or if the patient requires transfer

  • Coordination with Emergency Medical Services.
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Health and Wellness for all Arizonans

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Physician Consult

  • Physician Consult

– Requires attestation from an OB-Gyn

  • Discussed with client, reviewed medical records
  • Explains risks of at home delivery
  • Acknowledges that the physician is not responsible for

the client’s medical care or outcome

– Requires attestation from the client

  • Patient received the consultation
  • Acknowledges that the physician is not responsible for

the client’s medical care or outcome

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Health and Wellness for all Arizonans

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Scope of Practice

  • Vaginal Birth After Cesarean Section (VBAC)

– Places restrictions on:

  • Number of previous c-sections
  • Type of previous c-section
  • Reason for previous c-section
  • Time elapsed since previous c-section
  • Previous complications
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Scope of Practice

  • Multiple gestations

– Places restrictions on:

  • Number of fetuses
  • Gestational age
  • Fetal presentation
  • Complications during current pregnancy
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Health and Wellness for all Arizonans

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Scope of Practice

  • Vaginal breech deliveries

– Places restrictions on:

  • Number of fetuses
  • Fetal weight
  • Fetal presentation
  • Complications during current pregnancy
  • Complications during previous pregnancies
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Health and Wellness for all Arizonans

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CALL TO PUBLIC

Will Humble 7:40-7:75 pm

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FUTURE AGENDA ITEMS AND CLOSING REMARKS

Will Humble 7:55-8:00 pm