# 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 .05 Required Transfer of Care.

*COMAR 10.64.01.05*

A. Except for §B of this regulation, a licensed direct-entry midwife shall arrange immediate emergency transfer to a hospital if:

  (1) The patient requests transfer; or

  (2) The patient or newborn is determined to have any of the following conditions during labor, delivery, or the immediate postpartum period:

    (a) Unforeseen noncephalic presentation;

    (b) Unforeseen multiple gestation;

    (c) Nonreassuring fetal heart rate or pattern, including:

      (i) Tachycardia

      (ii) Bradycardia;

      (iii) Significant change in baseline; or

      (iv) Persistent late or severe variable decelerations;

    (d) Prolapsed cord;

    (e) Unresolved maternal hemorrhage;

    (f) Retained placenta;

    (g) Signs of fetal or maternal infection;

    (h) Patient with a third or fourth degree laceration or a laceration beyond the licensed direct-entry midwife’s ability to repair;

    (i) Apgar of less than seven at 5 minutes;

    (j) Obvious congenital anomalies;

    (k) Need for chest compressions during neonatal resuscitation;

    (l) Newborn with persistent central cyanosis;

    (m) Newborn with persistent grunting and retractions;

    (n) Newborn with abnormal vital signs;

    (o) Gross or thick meconium staining, when discovered; or

    (p) Newborn with excessive dehydration due to inability to feed.

B. If transfer is not possible because of imminent delivery, the licensed direct-entry midwife shall consult with a health care provider for guidance on further management of the patient and to determine when transfer may be safely arranged, if required.

C. A licensed direct-entry midwife shall immediately transfer the care of a patient to a health care provider for the treatment of any significant postpartum morbidity, including:

  (1) Uncontrolled postpartum hemorrhage;

  (2) Preeclampsia;

  (3) Thrombo-embolism;

  (4) An infection; or

  (5) A postpartum mental health disorder.

D. A licensed direct-entry midwife who is required to transfer care of a patient under this regulation may continue other aspects of postpartum care in consultation with the treating health care practitioner.