# COMAR Title 10 — Maryland Department of Health

## Subtitle 64 — Board of Nursing — Licensed Direct-Entry Midwives

### Chapter 01 — Practice of Licensed Direct-Entry Midwives

#### Regulation .03 Scope of Practice — Prohibitions.

*COMAR 10.64.01.03*

A. The practice of direct-entry midwifery does not include:

  (1) Pharmacological induction or augmentation of labor or artificial rupture of membranes before the onset of labor;

  (2) Surgical delivery or any surgery except an emergency episiotomy;

  (3) Use of forceps or vacuum extractor;

  (4) Except for the administration of a local anesthetic, administration of an anesthetic;

  (5) Administration of any kind of narcotic analgesic; or

  (6) Administration of any prescription medication not authorized in accordance with Regulation .07 of this chapter.

B. A licensed direct-entry midwife may not assume care or continue to take responsibility for a patient’s pregnancy and birth care if a finding of any of the disorders or situations listed under §C of this regulation is found to be present:

  (1) At the initial interview;

  (2) During an examination of the patient;

  (3) While obtaining a patient history or at subsequent prenatal visits;

  (4) As a result of a laboratory or other test; or

  (5) After consultation with another health care practitioner.

C. If any of the following disorders or situations exist, the licensed direct-entry midwife shall arrange for the orderly transfer of care to a health care practitioner:

  (1) Diabetes mellitus, including uncontrolled gestational diabetes;

  (2) Hyperthyroidism treated with medication;

  (3) Uncontrolled hypothyroidism;

  (4) Epilepsy with seizures or antiepileptic drug use during the previous 12 months;

  (5) Coagulation disorders;

  (6) Chronic pulmonary disease;

  (7) Heart disease in which there are arrhythmias or murmurs except when, after evaluation, it is the opinion of a physician licensed under Health Occupations Article, Title 14, Annotated Code of Maryland, or a licensed nurse certified as a nurse-midwife or a nurse practitioner under Health Occupations Article, Title 8, Annotated Code of Maryland, that midwifery care may proceed;

  (8) Hypertension, including pregnancy-induced hypertension (PIH);

  (9) Renal disease;

  (10) Except as otherwise provided in Health Occupations Article, §8-6C-04(a)(11), Annotated Code of Maryland, Rh sensitization with positive antibody titer;

  (11) Previous uterine surgery, including a cesarean section or myomectomy;

  (12) Indications that the fetus has died in utero;

  (13) Premature labor (gestation less than 37 weeks);

  (14) Multiple gestation;

  (15) Noncephalic presentation at or after 38 weeks;

  (16) Placenta previa or abruption;

  (17) Preeclampsia;

  (18) Severe anemia, defined as hemoglobin less than 10 g/dL;

  (19) Uncommon diseases and disorders, including:

    (a) Addison’s disease;

    (b) Cushing’s disease;

    (c) Systemic lupus erythematosus;

    (d) Antiphospholipid syndrome;

    (e) Scleroderma;

    (f) Rheumatoid arthritis;

    (g) Periarteritis nodosa;

    (h) Marfan’s syndrome; and

    (i) Other systemic and rare diseases and disorders, as determined by the Department;

  (20) AIDS/HIV;

  (21) Hepatitis A through G and non-A through G;

  (22) Acute toxoplasmosis infection, if the patient is symptomatic;

  (23) Acute Rubella infection during pregnancy;

  (24) Acute cytomegalovirus infection, if the patient is symptomatic;

  (25) Acute Parvovirus infection, if the patient is symptomatic;

  (26) Alcohol abuse, substance abuse, or prescription abuse during pregnancy;

  (27) Continued daily tobacco use into the second trimester;

  (28) Thrombosis;

  (29) Inflammatory bowel disease that is not in remission;

  (30) Primary herpes simplex virus, genital infection during pregnancy, or any active genital lesions at the time of delivery;

  (31) Significant fetal congenital anomaly;

  (32) Ectopic pregnancy;

  (33) Prepregnancy body mass index (BMI) of less than 18.5 or 35 or more; or

  (34) Post term maturity (gestational age 42 0/7 weeks and beyond).