DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

DIRECTOR’S OFFICE

BOARD OF LICENSED MIDWIFERY

Filed with the secretary of state on

These rules become effective immediately after filing with the secretary of state unless adopted under section 33, 44, or 45a(9) of the administrative procedures act of 1969, 1969 PA 306, MCL 24.233, 24.244, or 24.245a.  Rules adopted under these sections become effective 7 days after filing with the secretary of state.

(By authority conferred on the director of the department of licensing and regulatory affairs by sections 16145, 16148, 16174, 16186, 16201, 16204, 16205, 16287, 17105, 17107, 17111, 17112, and 17117 of the public health code, 1978 PA 368, MCL 333.16145, 333.16148, 333.16174, 333.16186, 333.16201, 333.16204, 333.16205, 333.16287, 333.17105, 333.17107, 333.17111, 333.17112, and 333.17117, and Executive Reorganization Order Nos. 1991-9, 1996-2, 2003-1, and 2011-4, MCL 338.3501, 445.2001, 445.2011, and 445.2030)

R 338.17101, R 338.17111, R 338.17113, R 338.17115, R 338.17121, R 338.17122, R 338.17123, R 338.17125, R 338.17131, R 338.17132, R 338.17137, R 338.17138, and R 338.17141 of the Michigan Administrative Code are amended, and R 338.17114 and R 338.17139 are added, as follows:

PART 1. GENERAL PROVISIONS

R 338.17101 Definitions.

  Rule 101. (1) As used in these rules:

   (a) “Appropriate health professional” means any an individual licensed, registered, or otherwise authorized to engage in a health profession under article 15 of the code, MCL 333.16101 to 333.18838, who is referred to, consulted with, or collaborates with a licensed midwife.

   (b) "Board" means the Michigan board of licensed midwifery created in section 17113 of the code, MCL 333.17113.

   (c) “Code” means the public health code, 1978 PA 368, MCL 333.1101 to 333.25211.

   (d) "Continuing education hour" means the cumulative number of program minutes divided by 60. If the fractional part of an hour is 55 minutes or more, it counts as 1 hour. Any portion of an hour between 30 and 54 minutes counts as half of an hour. Any part of an hour less than 30 minutes will not be counted. Breaks are not counted.

(d)(e) “CPM” means a certified professional midwife who has met meets the standards for certification set by the North American Registry of Midwives. (NARM).  The CPM credential is accredited by the National Commission for Certifying Agencies (NCCA).  The CPM credential with NARM requires a midwife to:

    (i) Validate education.

    (ii) Pass an examination.

    (iii) Complete a workshop, module, or course on cultural awareness.

    (iv) Meet general education requirements.

    (v) Maintain current adult CPR and current neonatal resuscitation program certification (NRP) with a hands-on component.

    (vi) Complete obstetric emergency skills training.

(e)(f) “Department” means the department of licensing and regulatory affairs.

(g) “MEAC” means the Midwifery Education Accreditation Council.

(h) “NARM” means the North American Registry of Midwives.

   (i) “NCCA” means the National Commission for Certifying Agencies.

(f)(j) “PeerPeer-review” means the process utilized by midwives to confidentially discuss patient cases in a professional forum, which includes including support, feedback, follow-up, and learning objectives.

  (2) Unless otherwise defined in these rules, the terms defined in the code have the same meaning when used in these rules.

PART 2. PRELICENSURE LICENSED MIDWIFERY EDUCATION

R 338.17111  Training standards for identifying victims of human trafficking: requirements.

  Rule 111. (1) Pursuant to Under section 16148 of the code, MCL 333.16148, an individual seeking licensure or who is licensed shall complete a training in identifying victims of human trafficking that meets all the following standards:

   (a) Training content shall must cover all of the following:

    (i) Understanding the types and venues of human trafficking in the United States.

    (ii) Identifying victims of human trafficking in healthcare health care settings.

    (iii) Identifying the warning signs of human trafficking in health care healthcare settings for adults and minors.

    (iv) Identifying Rresources for reporting suspected victims of human trafficking.

   (b) Acceptable providers or methods of training include any of the following:

    (i) Training offered by a nationally-recognized or state-recognized health-related organization.

    (ii) Training offered by, or in conjunction with, a state or federal agency.

    (iii) Training obtained in an educational program that has been approved by the board for initial license or registration, or by a college or university.

    (iv) Reading an article related to the identification of victims of human trafficking that meets the requirements of subdivision (a) of this subrule and is published in a peer peer-reviewed journal, health care healthcare journal, or professional or scientific journal.

   (c) Acceptable modalities of training may include any of the following:

    (i) Teleconference or webinar.

    (ii) Online presentation.

    (iii) Live presentation.

    (iv) Printed or electronic media.

  (2) The department may select and audit a sample of an individuals and request documentation of proof of completion of training. If audited by the department, an the individual shall provide acceptable proof of completion of training, including either 1 of the following:

   (a) Proof of completion certificate issued by the training provider including that includes the date, provider name, name of training, and individual’s name.

   (b) A self-certification statement by an the individual. The certification self-certification statement must include the individual’s name and either 1 of the following:

    (i) For training completed pursuant to subrule (1)(b)(i) to (iii) of this rule, the date, training provider name, and name of training.

    (ii) For training completed pursuant to subrule (1)(b)(iv) of this rule, the title of the article, author, publication name of peer the peer-reviewed journal, health care healthcare journal, or professional or scientific journal, and the date, volume, and issue of publication, as applicable.

  (3) Pursuant to section 16148 of the code, MCL 333.16148, the requirements specified in subrule (1) of this rule apply for license renewals beginning with the first renewal cycle after August 1, 2019, and for initial licenses issued after August 1, 2024.

R 338.17113  Licensed midwifery accrediting organizations.

Rule 113. (1) The board approves the Midwifery Education Accreditation Council (MEAC)MEAC, or its successor entity, as an accrediting organization for an educational program or pathway.

  (2) A petition may be filed with the board for approval of a midwifery accrediting organization for an educational program or pathway, which will be is evaluated to determine the organization’s equivalence to the standards of other board approved accrediting organizations. The board may approve a petition only if the standards and evaluative criteria of the organization are determined to be equivalent to the standards of the MEAC, or its successor entity.

R 338.17114  CPM credential.

Rule 114. The CPM credential is accredited by the NCCA.  The CPM credential with the NARM requires a midwife to do all of the following:

  (a) Validate education.

  (b) Pass an examination.

  (c) Complete a workshop, module, or course on cultural awareness.

  (d) Meet general education requirements.

  (e) Maintain current adult cardiopulmonary resuscitation (CPR) certification and current neonatal resuscitation program certification with a hands-on component.

R 338.17115  Licensed midwifery credentialing program.

  Rule 115. The board may approve a licensed midwifery credentialing program only if the program meets all of the following:

  (a) The It satisfies the standards and evaluative criteria are equivalent to the credential of a CPM from the NARM, or its successor entity.

  (b) It satisfies the criteria of section 16148 of the code, MCL 333.16148.

  (c) It is accredited by the National Commission for Certifying Agencies (NCCA)NCCA, or its successor entity, or another accrediting organization approved by the board if the standards and evaluative criteria of the accrediting organization are determined to be equivalent to the standards of the NCCA, or its successor entity.

PART 3. LICENSURE

R 338.17121 Licensure.

  Rule 121. (1) In addition to meeting the requirements of sections 16174 of the code, MCL 333.16174, and R 338.7001 to R 338.7005, an applicant for licensure shall submit a completed application on a form provided by the department, together with the requisite fee, and meet all of the following requirements:

   (a) Meet 1 of the following:

    (i) Submit proof to the department of completion of an educational program or pathway accredited by the MEAC, or its successor entity, or by another accrediting organization approved by the board under R 333.17113.

    (ii) If before January 1, 2020, the applicant holds a current credential of CPM from the NARM, its successor entity, or an equivalent credential from another midwifery credentialing program that is approved by the board under R 383.17115, and satisfies both of the following:

     (A) Submits proof to the department that the applicant holds a midwifery bridge certificate awarded by the NARM, its successor entity, or an equivalent credential from another midwifery credentialing program that meets the criteria of section 16148 of the code, MCL 333.16148.

     (B) The midwifery credentialing program is accredited by the NCCA, its successor entity, or another accrediting organization approved by the board if the standards and evaluative criteria of the accrediting organization are determined to be equivalent to the standards of the NCCA, or its successor entity.

    (b) Submit proof to the department of holding a current credential of CPM from the NARM, or its successor entity, or an equivalent credential from another midwifery credentialing program, that is approved by the board under R 383.17115.

    (c) Submit proof to the department of successfully passing the examination developed and scored by the NARM or another exam approved by the board under subrule (3) of this rule.

   (d) Submit proof to the department of completing the human trafficking training required in R 338.17111.

  (2) The board approves and adopts the examination developed and scored by the NARM.

  (3) An applicant for licensure may petition the board to evaluate whether another examination meets the requirements of section 16178(1) of the code, MCL 333.16178.

  (4) A licensed midwife shall have obtained his or her the recredential or maintain his or her the CPM credential from the NARM, or equivalent credential approved by the board, pursuant to R 338.17115, during the license cycle.

R 338.17122  Nonrenewable temporary license.

  Rule 122. (1) If an applicant holds a current CPM credential from a midwifery education program that is not MEAC accredited by the MEAC or accredited by an accrediting organization approved by the board under R 338.17113, he or she the applicant may apply for a nonrenewable temporary license if he or she the applicant satisfies both of the following:

   (a) Meets the requirements of sections 16174 of the code, MCL 333.16174.

   (b) Submits to the department a completed application, on a form provided by the department, together with the requisite fee. 

  (2) An individual who holds a temporary license must shall hold a midwifery bridge certificate from the NARM or an equivalent credential approved by the board pursuant to R 338.17115, to qualify for a license when his or her the individual’s temporary license expires, pursuant to section 17116 of the code, MCL 333.17116.

  (3) The term of a temporary license is 24 months and is not renewable.

R 338.17123  Licensure by endorsement from another state.

  Rule 123. (1) An applicant who currently holds an active midwifery license in good standing in another state and who has never been licensed as a midwife in this state may apply for a license by endorsement and is presumed to meet the requirements of section 16186 of the code, MCL 333.16186, if the applicant meets the requirements of section 16174 of the code, MCL 333.16174, and R 338.7001 to R 338.7005; submits a completed application, on a form provided by the department, together with the requisite fee; and complies with all of the following:

   (a) Submits proof to the department of completion of an educational program or pathway accredited by the MEAC, or its successor entity, or by another accrediting organization approved by the board under R 333.17113.

   (b) Submits proof to the department of holding a current credential of CPM from the NARM or another midwifery credentialing program approved by the board under R 333.17115.

   (c) Submits proof of successfully passing the examination developed and scored by the NARM or another exam approved by the board under R 338.17121(3).

   (d) Discloses each license, registration, or certification in a health profession or specialty issued by another state, the United States military, the federal government, or another country on the application form. 

   (e) Satisfies the requirements of section 16174(2) of the code, MCL 333.16174, including which includes verification from the issuing entity showing that disciplinary proceedings are not pending against the applicant and sanctions are not in force at the time of application.   

   (f) Submits proof to the department of meeting the human trafficking training required in R 338.17111.

  (2) An applicant who is licensed as a midwife in a state that does not require completion of an educational program or pathway that is MEAC approved by the MEAC, may apply to the department for a determination that the applicant has met the requirements of subrule (1)(a) of this rule if the applicant satisfies both of the following:

   (a) The applicant meets all the other requirements for licensure.

   (b) The applicant holds a midwifery bridge certificate awarded by the NARM or an equivalent credential from another midwifery credentialing program that meets the criteria of section 16148 of the code, MCL 333.16148, and is accredited by the NCCA, or another accrediting organization approved by the board, if the standards and evaluative criteria of the accrediting organization are determined to be equivalent to the standards of the NCCA or its successor entity.

R 338.17125  Relicensure requirements.

  Rule 125. (1) An applicant for relicensure who has let his or her whose license from this state lapse has lapsed, under the provisions of section 16201(3) or (4) of the code, MCL 333.16201, as applicable, may be relicensed by complying with the following requirements as noted by (√):

(a) For a midwife who has let his or her whose license from this state lapse has lapsed and who does not hold a license in another state:	Lapsed less than 3 years	Lapsed more than 3 years, but less than 7 years	Lapsed 7 or more years
(i) Submit a completed application on a form provided by the department, together with the requisite fee.	√	√	√
(ii) Establish that the applicant is of good moral character as defined in, and determined under, 1974 PA 381, MCL 338.41 to 338.47.	√	√	√
(iii) Submit fingerprints as required under section 16174(3) of the code, MCL 333.16174.		√	√
(iv) Submit proof of having completed 30 hours of continuing education hours in courses and programs and not less than 1 hour in pain and symptom management, 2 hours of cultural awareness, and 1 hour of pharmacology related to the practice of midwifery, as required under R 338.17141, and that the continuing education hours were was earned within the 3-year period immediately before the application for relicensure. However, if the continuing education hours submitted with the application are deficient, the applicant has 2 years from after the date of the application to complete the deficient hours. The application must be held, and the license may not be issued until the continuing education requirements are met.	√	√	√
(v) Complete a 1-time training in identifying victims of human trafficking that meets the standards in R 338.17111.	√	√	√
(vi) Meet the English language requirement under R 338.7002b and the implicit bias training required in R 338.7004.	√	√	√
(vii) Within the 3-year period immediately before the application for relicensure, retake and pass the examination approved by the board pursuant to R 338.17121.			√
(viii) An applicant who is or has been licensed, registered, or certified in a health profession or specialty by another state, the United States military, the federal government, or another country, shall do both of the following: (A) Disclose each license, registration, or certification on the application form. (B) Satisfy the requirements of section 16174(2) of the code, MCL 333.16174, which include including verification from the issuing entity showing that disciplinary proceedings are not pending against the applicant and sanctions are not in force at the time of application.	√	√	√
(ix) Submit proof of an active credential of CPM from the NARM or an equivalent credential from another midwifery credentialing program that is approved by the board and accredited by the NCCA or another accrediting organization approved by the board. A licensed midwife shall maintain his or her the credential of CPM from the NARM, or equivalent credential approved by the board, during the license cycle.	√	√	√

(b) For a midwife who has let his or her whose license from this state lapse has lapsed, but who holds a current midwife license in good standing in another state:	Michigan license lapsed Less  less than 3 years	Michigan license lapsed more than 3 years, but less than 7 years	Michigan license lapsed 7 or more years
(i) Submit a completed application on a form provided by the department, together with the requisite fee.	√	√	√
(ii) Establish that the applicant is of good moral character as defined in, and determined under, 1974 PA 381, MCL 338.41 to 338.47.	√	√	√
(iii) Submit fingerprints as required under section 16174(3) of the code, MCL 333.16174.		√	√
(iv) Submit proof of having completed 30 hours of continuing education hours in courses and programs and not less than 1 hour in pain and symptom management, 2 hours of cultural awareness, and 1 hour of pharmacology related to the practice of midwifery, as required under R 338.17141, and the continuing education hours were that was earned within the 3-year period immediately before the application for relicensure. However, if the continuing education hours submitted with the application are deficient, the applicant has 2 years from after the date of the application to complete the deficient hours. The application must be held, and the license must not be issued until the continuing education requirements are met.		√	√
(v) Complete a 1-time training in identifying victims of human trafficking that meets the standards in R 338.17111.	√	√	√
(vi) Meet the English language requirement under R 338.7002b and the implicit bias training required in R 338.7004.	√	√	√
(vii) An applicant who is or has been licensed, registered, or certified in a health profession or specialty by another state, the United States military, the federal government, or another country, shall do both of the following: (A) Disclose each license, registration, or certification on the application form. (B) Satisfy the requirements of section 16174(2) of the code, MCL 333.16174, which include including verification from the issuing entity showing that disciplinary proceedings are not pending against the applicant and sanctions are not in force at the time of application.	√	√	√
(viii) Submit proof of an active credential of CPM from the NARM or an equivalent credential from another midwifery credentialing program that is approved by the board and accredited by the NCCA, or another accrediting organization approved by the board. A licensed midwife shall maintain his or her the credential of CPM from the NARM, or equivalent credential approved by the board, during the license cycle.	√	√	√

  (2) If relicensure is granted and it is determined that a sanction has been imposed by another state, the United States military, the federal government, or another country, the disciplinary subcommittee of the board may impose appropriate sanctions under section 16174(5) of the code, MCL 333.16174.

PART 4. PRACTICE, CONDUCT, AND CLASSIFICATION OF CONDITIONS

R 338.17131 Definitions.

  Rule 131. As used in this part:

  (a) “Appropriate pharmacology training” means 8 hours of training related to pharmacology applicable to midwifery practice, approved by the MEAC or the board.

  (b) “Consultation” means the process by which a licensed midwife, who maintains primary management responsibility for the patient’s care, seeks the advice of another appropriate health professional or member of the health care healthcare team.

  (c) “DOR” means the Division of Research for the Midwives Alliance of North America.

(c)(d) “Emergency medical services personnel” means a medical first responder, emergency medical technician, emergency medical technician specialist, or paramedic.

(d)(e) “Futility” means care offered that would not mitigate a patient’s lethal diagnosis or prognosis of imminent death.

(f) “HIPAA” means the health insurance portability and accountability act of 1996, Public Law 104-191.

(g) “MANA” means the Midwives Alliance of North America.

 (e)(h) “Refer” means to suggest a patient seek discussion, information, aid, or treatment from a particular appropriate health professional.

(f)(i) “Transfer” means to convey the responsibility for the care of a patient to a hospital, emergency medical services personnel, or another appropriate health professional.  Transfer may occur at any point during care, during the prenatal, intrapartum, postpartum, or neonatal period, and may be either of an emergent or non-emergent nature.

(g)(j) “Transport” means the physical movement of a patient from 1 location to another.

R 338.17132  Informed disclosure and consent.

  Rule 132. (1) At the inception of care for a patient, a licensed midwife shall provide an informed disclosure in writing to the patient that includes all the following: 

   (a) A description of the licensed midwife’s training, philosophy of practice, information regarding the care team, transfer of care plan, credentials and legal status, services to be provided, availability of a complaint process both with the NARM and the this state, and relevant Health Insurance Portability and Accountability Act (HIPAA) HIPAA disclosures.

   (b) Access to the midwife’s practice guidelines.

   (c) Whether the licensed midwife is permitted allowed to administer drugs and medications pursuant to R 338.17137, which medications the licensed midwife carries for potential use, if a medication is required by law, and if certain standard medications are not available from the midwife, how and where the medications can be obtained.

(d) Access to the board of licensed midwifery rules.

   (e) Whether the licensed midwife has malpractice liability insurance coverage, and if so, the policy limitations of the coverage. The patient must shall be informed of the coverage and policy limitations both verbally and in writing.

  (2) If during care and shared decision making, a patient chooses to deviate from a licensed midwife’s recommendation, the licensed midwife shall provide the patient with an informed consent process that includes which must include all the following:

   (a) Explanation of the available treatments and procedures.

   (b) Explanation of both the risks and expected benefits of the available treatments and procedures.

   (c) Discussion of alternative procedures, including delaying or declining of testing or treatment, and the risks and benefits associated with each choice.

   (d) Documentation of any initial refusal by the patient of any action, procedure, test, or screening that is recommended by the licensed midwife.

  (3) A licensed midwife shall obtain the patient’s signature acknowledging that the patient has been informed, verbally and in writing, of the disclosures.

  (4) A licensed midwife shall provide an abbreviated informed consent appropriate to the emergent situation with documentation to follow once the situation has stabilized.

R 338.17137  Administration of prescription drugs or medications.

  Rule 137. (1) Pursuant to section 17111 of the code, MCL 333.17111, a licensed midwife who has appropriate pharmacology training and holds a standing prescription from an appropriate health professional with prescriptive authority, is permitted allowed to administer the following prescription drugs and medications:

   (a) Prophylactic vitamin K to an infant, either orally or through intramuscular injection.

   (b) Antihemorrhagic agents to a postpartum mother after the birth of the infant.

   (c) Local anesthetic for the repair of lacerations to a mother.

   (d) Oxygen to a mother or infant.

   (e) Prophylactic eye agent to an infant.

   (f) Prophylactic Rho(D) immunoglobulin to a mother.

   (g) Agents for group B streptococcus prophylaxis, recommended by the federal Centers for Disease Control and Prevention, to a mother.

   (h) Intravenous fluids, excluding blood products, to a mother.

   (i) Antiemetics to the mother.

   (j) Epinephrine.

  (2) Administration of any of the drugs included in subrule (1) of this rule must comply with this rule. The indications, dose, route of administration, duration of treatment, and contraindications relating to the administration of drugs or medications identified under subrule (1) of this rule are shown in Table 1 and Table 2:

Table 1
Maternal - Administration of Prescription Drugs and Medications
Medication		Indication	Dose	Route of Administration	Duration of Treatment	Contraindications		Comments
Oxygen		Maternal distress or fetal distress.	10-12 L/liters per minute.	Free-flow, nasal cannula, mask.	Until stabilized or transfer of care.	None, with indications present.
Pitocin 10 units/ml per milliliter		Prevention and treatment of postpartum hemorrhage.	10 units/ml per milliliter.	Intramuscular.	1-2 doses, PRN.
Pitocin 10 units/ml per milliliter		Prevention and treatment of postpartum hemorrhage.	20 units in 1000 mlmilliliters IV fluids, initial bolus rate 1000 ml/milliliters per hour bolus for 30 minutes (equals 10 units) followed by a maintenance rate 125 ml/milliliters per hour over 3.5 hours (equals remaining 10 units).	Intravenous.	4 hours.
Methyl-ergonovine (Methergine) 0.2 mg/ml milligram per milliliter		Prevention and treatment of postpartum hemorrhage.	0.2 mg/mlmilligram per milliliter.	Intramuscular.	0.2 milligram IM q2-4hr hours PRN; not to exceed 5 doses.	Contraindicated for patient with hypertension or Reynaud's disease. Can be used in conjunction with Pitocin after delivery of the placenta.		IM preferred for acute postpartum use. Oral methergine can help to lessen continued bleeding after hemorrhage.
Methyl-ergonovine (Methergine) 0.2 mgmilligram			0.2 mgmilligram tab.	Oral.	0.2-0.4 mgmilligram PO q6-8hr hours PRN for 2-7 days.	Contraindicated for patient with hypertension or Reynaud's disease.		IM preferred for acute postpartum use. Oral methergine can help to lessen continued bleeding after hemorrhage.
Medication		Indication	Dose	Route of Administration	Duration of Treatment	Contraindications		Comments
Misoprostol (Cytotec)		Treatment of postpartum hemorrhage.	600 mcgmicrograms oral or 800 mcgmicrograms buccal or rectal.	Oral, buccal, rectal.	1 dose.
Hemabate (Carboprost)		Treatment of postpartum hemorrhage.	0.25mg milligram IM.		Every 15-90 minutes; not to exceed 8 doses.	Asthma.		Relative counterindications: hypertension.
Tranexamic Acid (TXA or Lystdea Lysteda)		Treatment of postpartum hemorrhage.	1g in 10 ml IV at 1 ml/min, administered  over 10 minutes. 1000 milligrams in 50 milliliters 0.9 normal saline administered over 15 minutes.	Intravenous piggy back (IVPB) or intravenous push (IV push).	Use within 3 hours and as early as possible after onset of postpartum hemorrhage.	Contraindicated for patient with deep vein thrombosis, history of coagulopathy, or active hypersensitivity to TXA.		TXA should be administered slowly as an IV injection IVPB or  IV push over 10 15 minutes or longer because bolus injection carries a potential risk of hypotension. Should not be mixed with blood or solutions containing penicillin or mannitol.
RHo (D) Immune Globulin (Rhogam)		Prophylactic dose: RH- patient at 28-30 weeks gestation; RH- patient after a miscarriage; postpartum RH- patient with an RH+ baby. A prenatal dose can also be given after an injury under advisement of a physician.	300 mcgmicrograms pre-filled syringe.	Intramuscular.	Administer within 72 hours of birth or antenatal event.	RH positive; IgA deficiency.
Penicillin G		Group Beta Strep (GBS) prophylaxis in labor.	Initial loading dose: 5 million units IV. Subsequent doses: 2.5–3.0 million units IV every 4 hours.	Administer via IV with prepared minibag.	Until delivery.	Allergy to penicillin.		No saline limitation when administering antibiotics.
Ampicillin		Group Beta Strep prophylaxis in labor.	Initial loading dose: 2 grams IV. Subsequent doses: 1 gram IV every 4 hours.	Administer via IV with prepared minibag.	Until delivery.	Allergy to penicillin.		No saline limitation when administering antibiotics.
Medication	Indication		Dose	Route of Administration	Duration of Treatment		Contraindications	Comments
Cefazolin	Group Beta Strep prophylaxis in labor.		Initial loading dose: 2g grams IV. Subsequent doses: 1gram IV every 8 hours.	Administer via IV with prepared minibag.	Until delivery.		Allergy to cefazolin.	Cefazolin is the first choice for patients who have a history of allergy to penicillin but no history of anaphylactic reaction to penicillin. Use clindamycin or vancomycin for patients who have a history of anaphylactic penicillin allergy. No saline limitation when administering antibiotics.
Clindamycin	Group Beta Strep prophylaxis in labor.		900 mgmilligrams IV every 8 hours until delivery.	Administer via IV with prepared minibag.	Until delivery.		Allergy to clindamycin.	Use only with patient with history of anaphylactic reaction to penicillin and the GBS isolate is laboratory proven to be susceptible to Clindamycin. No saline limitation when administering antibiotics.
Vancomycin	Group Beta Strep prophylaxis in labor.		1 gram IV every 12 hours.	Administer via IV with prepared minibag.	Until delivery.		Allergy to vancomycin.	Use only with patient with history of anaphylactic reaction to penicillin and the GBS isolate is laboratory proven to be resistant to Clindamycin. No saline limitation when administering antibiotics.
Epinephrine	Severe allergic reaction.		Single dose of 0.3 mgmilligram, USP, 1:1000 (0.3 mlmilliliters) in a sterile solution.		5-15 minutes. Transport to hospital should be initiated.			Discontinue medication that is causing reaction; place patient supine and elevate lower extremities. Protect the airway. Transport to hospital should follow.
Lactated Ringers solution	Dehydration during labor.		Up to 2L liters.	Intravenous.	Over the course of 3-5 hours.			Most patients respond to intravenous hydration and a short period of gut rest, followed by reintroduction of oral intake. Preferred over normal saline.
Medication	Indication		Dose	Route of Administration	Duration of Treatment		Contraindications	Comments
0.9% Normal Saline solution	Dehydration during labor, when LR not available. Postpartum hemorrhage. Allergic reactions.		1L- 2L liters bolus.	Intravenous.	During course of infusion.			Intrapartum: the addition of 5% Dextrose to solution can increase success rate with nausea or vomiting.
Lidocaine	Postpartum repair of vulvo-vaginal lacerations.		Injectable: up to 20 mlmilliliters 2%, up to 30 mlmilliliters 1%, or up to 60 mlmilliliters 0.5%.	Injection.	2 hours.		Known allergy or signs or symptoms of allergic  reaction.	Do not use lidocaine with epinephrine, max dose 4.5 mg/kgmilligrams per kilogram infiltration.
Lidocaine	Postpartum repair of vulvo-vaginal lacerations.			Topical cream, spray, or gel.			Known allergy or signs or symptoms of allergic  reaction.
Diphenhydramine (Benadryl)	To reduce vomiting during labor.		25 to 50 mgmilligrams every 4 to 6 hours / 10-50 mgmilligrams every 4- 6 hours.	Oral; intravenous.
Ondansetron (Zofran)	To reduce vomiting during labor.		4-8 mgmilligrams IVP / 4 mgmilligrams (up to twice PRN).	Oral; intravenous.				May produce headache as side effect.
Ibuprofen	To reduce post-partum discomfort.		200 milligrams up to 4 tablets every 6-8 hours.	Oral.	Until postpartum pain resolves.		History of gastritis; history of gastrointestinal bleed.

Table 2

Neonatal – Administration of Prescription Drugs and Medications

Medication	Indication	Dose	Route of Administration	Duration of Treatment	Contraindications	Comments
Oxygen	Neonatal resuscitation, if indicated; abnormal pulse oximetry readings.	10L/ liters per minute, or as indicated.	Bag and mask, free-flow.	Until pulse- oximetry readings are within target range of infant age, or transfer of care.	None, with indications present.	Administration of oxygen to a neonate should be in accordance with NRP standards. When an oxygen blender is not accessible, free-flow oxygen may be used combined with pulse oximetry.  Current research cautions that inappropriate use of oxygen can cause free radical and oxidative stress damage in the neonate.
0.5% Erythromycin Ophthalmic ointment	Prophylaxis of neonatal ophthalmia neonatorum due to N. gonorrhoeae or chlamydia trachomatis.	1 cmcentimeter ribbon of 0.5% ointment in each eye within 24 hours of birth.	Ocular, in lower eyelid.	1 dose.	Hypersensitivity to drug class or component.	May cause ocular irritation or blurred vision.
Vitamin K 1.0 mg/milligram per 0.5 mlmilliliter	Prophylaxis and therapy of hemorrhagic disease of the newborn.	0.5-1.0 mg. 1.0 milligram for a newborn above 1500 grams.	Intramuscular.	1 dose.	Family history of hypoprothrombinemia; hypersensitivity to drug class or component.	Vitamin K 1.0 mg/milligram per 0.5 mlmilliliter.
Epinephrine	Neonatal resuscitation.	0.1 - 0.30.2 ml/kgmilliliter per kilogram (0.01 – 0.030.02 mg/kgmilliliter per kilogram) of body weight in a 1:10,000 concentration.	Administered in the umbilical venous catheter or interosseous route followed by 1 – 3 3 mlmilliliter flush of sterile normal saline.	Repeat every 3-5 minutes if HR <60 bpmbeats per minute with chest compressions.		EMS services should be en route.
Epinephrine	Neonatal resuscitation.	1 ml/kgmilliliter per kilogram 1:10,000 concentration.	Endotracheal.	Repeat every 3-5 min if HR <60 bpm with chest compressions. If heart rate remains less than 60 beats per minute, move on to Epinephrine administered by IV or interosseous route.		Max 3 ml/dosemilliliters per dose, EMS services should be en route.

Administration of Prescription Drugs and Medications

Maternal
Cefazolin	Group Beta Strep prophylaxis in labor.	Initial loading dose: 2g IV. Subsequent doses: 1g IV every 8 hours.	Administer via IVPB with prepared minibag.	Until delivery.	Allergy to cefazolin.	Cefazolin is the first choice for patients who have a history of allergy to penicillin but no history of anaphylactic reaction to penicillin. Use clindamycin or vancomycin for patients who have a history of anaphylactic penicillin allergy.
Clindamycin	Group Beta Strep prophylaxis in labor.	900 mg IV every 8 hours until delivery.	Administer via IVPB with prepared minibag.	Until delivery.	Allergy to clindamycin.	Use only with history of anaphylactic reaction to penicillin. Clindamycin and Vancomycin are the drugs of choice for GBS prophylaxis for patients who have a history of anaphylactic reactions to penicillin.
Vancomycin	Group Beta Strep prophylaxis in labor.	1 g IV every 12 hours.	Administer via IVPB with prepared minibag.	Until delivery.	Allergy to vancomycin.	Use only with history of anaphylactic reaction to penicillin. Clindamycin and Vancomycin are the drugs of choice for GBS prophylaxis for patients who have a history of anaphylactic reactions to penicillin.
Epinephrine	Severe allergic reaction.	Single dose of 0.3 mg, USP, 1:1000 (0.3 mL) in a sterile solution.		5-15 minutes. Transport to hospital should be initiated.		Discontinue medication that is causing reaction; place patient supine and elevate lower extremities. Protect the airway. Transport to hospital should follow.
Lactated Ringers Solution	Dehydration during labor.	Up to 2L.	Intravenous.	Over the course of 3-5 hours.		Most patients respond to intravenous hydration and a short period of gut rest, followed by reintroduction of oral intake. Preferred over normal saline.
0.9% Normal Saline solution	Dehydration during labor, when LR not available. Postpartum hemorrhage. Allergic reactions.	1L- 2L bolus.	Intravenous.	During course of infusion.		Intrapartum: the addition of 5% Dextrose to solution can increase success rate with nausea or vomiting.
Lidocaine	Postpartum repair of vulvo-vaginal lacerations.	Injectable: up to 5 ml 2%, 10 ml 1%, or 20 ml 0.5%. Topical cream, spray, or gel.	Injection.	2 hours.	Known allergy or signs or symptoms of allergic reaction.	Do not use lidocaine with, epinephrine, max dose 3 mg/kg.
Antiemetic ranitidine zantac	To reduce vomiting during labor.	150 mg every 6 hours.	Oral.	Treat until symptoms subside.
Diphenhydramine	To reduce vomiting during labor.	25 to 50 mg every 4 to 6 hours / 10-50 mg every 4- 6 hours.	Oral; intravenous.
Ondansetron	To reduce vomiting during labor.	4-8 mg IVP / 4 mg (up to twice PRN).	Oral; intravenous.			May produce headache as side effect.

Neonatal
Oxygen	Neonatal: neonatal resuscitation, if indicated; abnormal pulse oximetry readings.	Neonatal: 10L/minute, or as indicated.	Neonatal: bag and mask, free-flow.	Neonatal: until pulse- oximetry readings are within target range of infant age, or transfer of care.	None, with indications present.	Administration of oxygen to a neonate should be in accordance with NRP standards. When an oxygen blender is not accessible, free-flow oxygen may be used combined with pulse oximetry.  Current research cautions that inappropriate use of oxygen can cause free radical and oxidative stress damage in the neonate.
0.5% Erythromycin Ophthalmic ointment	Prophylaxis of neonatal ophthalmia neonatorum due to N. gonorrhoeae or chlamydia trachomatis.	1 cm ribbon of 0.5% ointment in each eye within 24 hours of birth.	Ocular, in lower eyelid.	1 dose.	Hypersensitivity to drug class or component.	May cause ocular irritation or blurred vision.
Vitamin K 1.0 mg/0.5 ml	Prophylaxis and therapy of hemorrhagic disease of the newborn.	0.3 to 05 mg per kg of bodyweight.	Intramuscular.	Single dose.	Family history of hypoprothrombinemia; hypersensitivity to drug class or component.	Vitamin K 1.0 mg/0.5 ml
Epinephrine	Neonatal resuscitation.	0.1 - 0.3 mL/kg (0.01 - 0.03 mg/kg) of body weight in a 1:10,000 concentration.	Administered in the umbilical venous catheter followed by 1 - 3 mL flush of sterile normal saline.	Repeat every 3-5 min if HR <60 bpm with chest compressions.		EMS services should be en route.
Epinephrine	Neonatal resuscitation.	1 ml/kg 1:10,000 concentration.	Endotracheal.	Repeat every 3-5 min if HR <60 bpm with chest compressions.		Max 3 ml/dose, EMS services should be en route.

R 338.17138  Report patient’s data.

  Rule 138. (1) Unless the patient refuses, aA licensed midwife shall report patient data to the statistics registry maintained by midwives alliance of North America’s (MANA) the MANA’s DOR division of research (DOR), or its successor organization, pursuant to the MANA’s policies and procedures, or a similar registry maintained by a successor organization approved by the board, unless the patient refuses.

  (2) A licensee licensed midwife shall register with the MANA’s DOR.

  (3) Annually, by the date determined by the MANA, a A licensee licensed midwife shall submit patient data on all completed courses of care in the licensee’s licensed midwife’s practice during the previous 12 months by the date determined by the MANA, annually.

  (4) During the first year of licensure, aA licensee licensed midwife shall submit data from the date of licensure to the date determined by the MANA, during the first year of licensure.

R 338.17139  Telehealth.

  Rule 139.  (1)  A licensed midwife shall obtain consent for treatment before providing a telehealth service under section 16284 of the code, MCL 333.16284.

  (2) A licensed midwife shall keep proof of consent for telehealth treatment in the patient’s up-to-date medical record and satisfy section 16213 of the code, MCL 333.16213.

  (3) A licensed midwife providing telehealth services shall do both of the following:
   (a) Act within the scope of the licensed midwife’s practice.
   (b) Exercise the same standard of care applicable to a traditional, in-person health
care service.

PART 5. LICENSE RENEWAL AND CONTINUING EDUCATION

R 338.17141  License renewals; requirements; applicability.

  Rule 141. (1) In addition to meeting the requirements of section 16201 of the code, MCL 333.16201, an applicant for renewal shall submit a completed application on a form provided by the department, together with the requisite fee and, before renewal, shall hold the credential of CPM from the NARM, or equivalent credential approved by the board.

  (2) Pursuant to section 16201 of the code, MCL 333.16201, an applicant for license renewal who has been licensed for the 2-year 3-year period immediately before the expiration date on the license, renewal shall accumulate not less than 30 continuing education hours. The continuing education hours must include all of the following, during the prior 2 3 years by the end of the license cycle: 

   (a) Not less than 30 hours of continuing education that is met by obtaining Obtain or maintainingmaintain, the credential of CPM from the NARM, or an equivalent credential approved by the board.

   (b) One hour of continuing education hour in pain and symptom management pursuant to section 16204(2) of the code, MCL 333.16204. Acceptable methods of continuing education in pain and symptom management includes include online and in-person presentations, courses, or programs and may include, but is are not limited to, the following subject areas:

    (i) Behavior management.

    (ii) Psychology of pain.

    (iii) Behavior modification.

    (iv) Stress management.

    (v) Clinical applications as they relate to professional practice.

   (c) Two hours of continuing education hours on cultural awareness that include examination of disparate maternal infant mortality and morbidity experienced by the African American, and indigenous Indigenous populations, the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, and other vulnerable and marginalized populations. Acceptable methods of continuing education in cultural awareness include online and in-person presentations, courses, programs, or reading an article that is published in a peer-reviewed journal, health care healthcare journal, or professional or scientific journal.

   (d) Two Three hours of implicit bias training required in R 338.7004. The implicit bias training required in R 338.7004 may also be used for credit for the cultural awareness training in subdivision (c) of this subrule if the training meets all of the requirements in subdivision (c) of this subrule.

   (e) One hour of continuing education hour in pharmacology applicable to the practice of midwifery.

   (f) Submit proof to the department of meeting the human trafficking training required in R 338.17111.

  (3) "Continuing education hour" as used in these rules means the cumulative number of program minutes divided by 60. When the fractional part of an hour is 55 minutes or more, it counts as 1 hour. Any portion of an hour between 30 and 54 minutes counts as half of an hour. Any part of an hour less than 30 minutes will be discarded. Breaks are not counted.

(4)(3) Submission of an application for renewal constitutes the applicant’s certification of compliance with the requirements of this rule.

(5)(4) A licensee licensed midwife shall retain documentation of meeting the requirements of this rule for a period of  4   6 years from after the date of applying for license renewal.

(6)(5) The board may require an applicant or licensee licensed midwife to submit evidence to demonstrate compliance with this rule.

(7)(6) A self-certification statement by an the individual that includes the title of the article, author, publication name, and the date, volume, and issue of publication, as applicable, is acceptable evidence of reading an article that is published in a peer-reviewed journal, health care healthcare journal, or professional or scientific journal.

(8)(7) Failure to comply with this rule is a violation of section 16221(h) of the code, MCL 333.16221.

(9)(8) A request for a waiver under section 16205 of the code, MCL 333.16205, must be received by the department before the expiration date of the license. A CPM credential from the NARM, or equivalent credential approved by the board, may not be waived.

  (10) The requirements of this part do not apply to an applicant during an initial 1-year licensure cycle.