DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

DIRECTOR’S OFFICE

BOARD OF MIDWIFERY

Filed with the secretary of state on

These rules take effect immediately upon filing with the secretary of state unless

adopted under section 33, 44, or 45a(6)(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, and 16205, 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, and 333.16205, and sections 17105, 17107, 17111, 17112, and 17117 of 2016 PA 417, MCL 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 338.17115, R 338.17121, R 338.17123, R 338.17125, R 338.17134, R 338.17137, and R 338.17141 of the Michigan Administrative Code are amended and

R 338.17127 of the Michigan Administrative Code is rescinded as follows:

PART 1. GENERAL PROVISIONS

R 338.17101 Definitions.

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

    (a) “Appropriate health professional” means any individual licensed, registered, or otherwise authorized to engage in a health profession under article 15 of the public health 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.

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

    (d) “CPM” means a certified professional midwife who has met 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) “Department” means the Michigan department of licensing and regulatory affairs.

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

  (2) Unless otherwise defined in these rules, the termsTerms defined in the code have the same meanings 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 section 16148 of the code, MCL 333.16148, an individual seeking licensure or registration who is licensed or registered shall complete a training in identifying victims of human trafficking that meets all the following standards:

    (a) Training content shall 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 health care settings.

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

      (iv) Resources 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 review journal, health care 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 individuals and request documentation of proof of completion of training. If audited by the department, an individual shall provide an acceptable proof of completion of training, including either of the following:

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

    (b) A self-certification statement by an individual. The certification statement shall must include the individual’s name and either 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 review journal, health care journal, or professional or scientific journal, and 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 shall apply for license or registration renewals beginning with the first renewal cycle after the promulgation of this rule August 1, 2019, and for initial licenses or registrations issued 5 or more years after the promulgation of this rule after August 1, 2024.

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 standards and evaluative criteria are equivalent to the credential of a certified professional midwife (CPM) from the North American registry of midwives(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 National Commission for Certifying Agencies (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 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 liceFDnsure 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 MEAC, or its successor entity, or by another accrediting organization approved by the board under R 333.17113.

      (ii) If prior to January 1, 2020, the applicant holds a current credential of CPM from NARM, or 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 he or she the applicant holds a midwifery bridge certificate awarded by NARM, or 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, or its successor entity, or another accrediting organization approved by the board only if the standards and evaluative criteria of the accrediting organization are determined to be equivalent to the standards of NCCA, or its successor entity.

     (b) Submit proof to the department of holding a current credential of CPM from 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 NARM or another exam approved by the board under subrule (3) of this rule.

(d) Submit proof to the department of meeting the English language requirement under R 338.17127, if applicable.

  (2) The board approves and adopts the examination developed and scored by 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(1).

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

R 338.17123  Licensure by endorsement from another state.

  Rule 123. (1) An applicant who currently holds a an active midwifery license in good standing in another state as a midwife in another state but 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 he or she 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 submits complies with all of the following:

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

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

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

    (d) Proof there are no pending disciplinary proceedings against the applicant before a licensing agency in this state, any other state, or country, or any sanctions currently imposed against the applicant by a licensing agency in this state, any other state, or country which are based on grounds similar to those under article 15 of the code.  Discloses each license, registration, or certification in a health profession or specialty issued by any other 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, 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.   

(e) Proof to the department of meeting the English language requirement under R 338.17127, if applicable.

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

  (2) If an 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, may apply to the department may for a determine determination that the applicant has met the requirements of subrule (2)(1)(a) of this rule if he or she 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 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 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 NCCA or its successor entity.

R 338.17125  Relicensure requirements.

  Rule 125. (1) An applicant for relicensure whose Michigan licensed midwifery license has lapsed, under the provisions of section 16201(3) or (4) of the code, MCL 333.16201(3) or (4), as applicable, may be relicensed by complying with the following requirements as noted by (√):

(1) (a) For a midwife who has let his or her Michigan license from this state lapse 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
(a) (i) Application and fee: submit Submit a completed application on a form provided by the department, together with the requisite fee.	√	√	√
(b) (ii) Good moral character: establish Establish that he or she the applicant is of good moral character as defined under sections 1 to 7 of 1974 PA 381, MCL 338.41 to 338.47.	√	√	√
(c) (iii) Fingerprints: submit Submit fingerprints as required under section 16174(3) of the code, MCL 333.16174(3).		√	√
(d) (iv) Continuing education: submit Submit proof of having completed 30 hours of continuing education in courses and programs and at least 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 which that was earned within the 3-year period immediately preceding before the application for relicensure. However, if the continuing education hours submitted with the application are deficient, the applicant shall have has 2 years from the date of the application to complete the deficient hours. The application will must be held, and the license will may not be issued until the continuing education requirements have been 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.	√	√	√
(e) (vii) Examination: within Within the 3-year period immediately preceding before the application for relicensure, retake and pass the examination approved by the board pursuant to R 338.17121.			√
(f) (viii) Proof of license from another state verification by the licensing agency of all other states of the United States in which the application ever held a license as a midwife must be sent directly to the department from the licensing agency and include the record of any disciplinary action taken or pending against the applicant. An applicant who is or has ever been licensed, registered, or certified in a health profession or specialty by any other 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 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.	√	√	√
(g) (ix) Credential: submit 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 credential of CPM from NARM, or equivalent credential approved by the board, during the license cycle.	√	√	√

(2)(b) For a midwife who has let his or her Michigan license from this state lapse, but who holds a current and valid licensed midwife license in good standing in another state:	Michigan license lapsed Less than 3 years	Michigan license lapsed more than 3 years, but less than 7 years	Michigan license lapsed 7 or more years
(a) (i) Application and fee: submit Submit a completed application on a form provided by the department, together with the requisite fee.	√	√	√
(b) (ii) Good moral character: establish Establish that he or she the applicant is of good moral character as defined under sections 1 to 7 of 1974 PA 381, MCL 338.41 to 338.47.	√	√	√
(c)(iii) Fingerprints: submit Submit fingerprints as required under section 16174(3) of the code, MCL 333.16174(3).		√	√
(d) (iv) Continuing education: submit Submit proof of having completed 30 hours of continuing education in courses and programs and at least 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 which that was earned within the 3-year period immediately preceding before the application for relicensure. However, if the continuing education hours submitted with the application are deficient, the applicant shall have has 2 years from the date of the application to complete the deficient hours. The application will must be held, and the license will may not be issued until the continuing education requirements have been 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.	√	√	√
(e) (vii) Proof of license verification from another state where licensed: an applicant’s license must be verified by the licensing agency of all other states of the United States in which the applicant holds a current license or ever held a license as a midwife. Verification must be sent directly to the department from the licensing agency and include the record of any disciplinary action taken or pending against the applicant. An applicant who is or has ever been licensed, registered, or certified in a health profession or specialty by any other 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 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) (viii) Credential: submit 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 credential of CPM from 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.

R 338.17127  English language requirement. Rescinded.

Rule 127. An applicant who attended a nonaccredited program pursuant to R 338.17121, or a program outside of the United States, shall demonstrate a working knowledge of the English language. An applicant shall demonstrate a working knowledge of the English language by satisfying either of the following requirements: 

(a) Submit proof that he or she has obtained a total score of not less than 80 on the test of English as a foreign language internet-based test (TOEFL-iBT) administered by the educational testing service (ETS).

  (b) Submit proof that he or she completed a midwifery educational program or pathway conducted in the English language.

PART 4. PRACTICE, CONDUCT, AND CLASSIFICATION OF CONDITIONS

R 338.17134  Consultation and referral.

  Rule 134. (1) A licensed midwife shall consult with or refer a patient to a physician, physician’s assistant, or advanced practice registered nurse licensed under article 15 of the code, MCL 333.16101 to 333.18838, document the consultation or referral, and follow up with the patient regarding the consultation or referral, if the patient presents with any of the following conditions:

    (a) Antepartum:

      (i) Hypertension in pregnancy as defined as systolic blood pressure greater than 140 mm Hg and diastolic blood pressure greater than 90 mm Hg measured on two 2 separate occasions more than four 4 hours apart.

      (ii) Persistent, severe headaches, epigastric pain, or visual disturbances.

      (iii) Persistent symptoms of urinary tract infection.

      (iv) Significant vaginal bleeding before the onset of labor not associated with uncomplicated spontaneous abortion.

      (v) Rupture of membranes prior to the 36.6 weeks of gestation without active labor.

      (vi) Noted abnormal decrease in or cessation of fetal movement.

      (vii) Hemoglobin level less than 9 and resistant to supplemental therapy.

      (viii) A temperature of 100.4 degrees Fahrenheit or 38.0 degrees Celsius or greater for more than 24 hours.

      (ix) Isoimmunization, Rh-negative sensitization, or any other positive antibody titer, which would have a detrimental effect on the mother or fetus.

      (x) Abnormally elevated blood glucose levels unresponsive to dietary management.

      (xi) Positive HIV antibody test.

      (xii) TORCH (Toxoplasmosis, other, rubella, cytomegalovirus, and herpes simplex infections.)

      (xiii) Symptoms of severe malnutrition, severe persistent dehydration, or protracted weight loss.

      (xiv) Symptoms of deep vein thrombosis.

      (xv) Documented placenta previa.

      (xvi) Documented placenta overlying the site of a previous uterine scar.

      (xvii) Active labor prior to 36.0 weeks of gestation.

      (xviii) Fetus with diagnosed congenital abnormalities that will require immediate medical intervention at birth.

      (xix) History of myomectomy.

      (xx) Prior history of early preterm birth, 32 weeks or less.

      (xxi) Pelvic or uterine abnormalities affecting normal vaginal births, including tumors and malformations.

      (xxii) Marked abnormal fetal heart tones.

      (xxiii) Abnormal non-stress test or abnormal biophysical profile.

      (xxiv) Marked or severe hydramnios or oligohydramnios.

      (xxv) Suspected intrauterine growth restriction.

      (xxvi) Gestation beyond 42.0 weeks.

      (xxvii) Suspected perinatal mood disorder or uncontrolled current serious psychiatric illness.

      (xxviii) Suspected active alcohol use disorder.

      (xxix) Suspected active substance use disorder.

      (xxx) Receiving opioid replacement therapy.

      (xxxi) Sexually transmitted infection.

      (xxxii) Symptoms of ectopic pregnancy

      (xxxiii) Second or third trimester fetal demise.

      (xxxiv) Symptoms or evidence of hydatidiform mole.

      (xxxv) Thrombocytopenia with a count less than 100,000 platelets per microliter.

      (xxxvi) Vaginal infection unresponsive to treatment.

      (xxxvii) Symptoms or clinical evidence of hepatitis.

      (xxxviii) Abnormal liver or metabolic panel.

      (xxxix) Significant proteinuria.

      (xl) Abnormal PAP test results.

      (xli) Significant hematological disorders or coagulopathies, or pulmonary embolism.

      (xlii) Hyperreflexia.

      (xliii) Clonus.

      (xliv) Rheumatoid arthritis.

      (xlv) Chronic pulmonary disease.

      (xlvi) Uncontrolled gestational diabetes.

      (xlvii) Hyperthyroidism treated with medication.

      (xlviii) Suspected coagulation disorder.

      (xlix) Inflammatory bowel disease.

      (l) Addison’s disease.

      (li) Scleroderma.

      (lii) Any other condition or symptom that could threaten the health of the mother or fetus, as assessed by a licensed midwife exercising reasonable skill and judgment.

    (b) Intrapartum:

      (i) Persistent, severe headaches, epigastric pain or visual disturbances.

      (ii) Temperature over 100.4 degrees Fahrenheit or 38.0 degrees Celsius in absence of environmental factors.

      (iii) Signs or symptoms of maternal infection.

      (iv) Confirmed ruptured membranes without onset of labor after 24 hours.

      (v) Excessive vomiting, dehydration, acidosis, or exhaustion unresponsive to treatment.

      (vi) Uncontrolled current serious psychiatric illness.

      (vii) Fetal heart rate abnormalities of severe bradycardia, fetal tachycardia, or sustained deceleration of fetal heart rate.

      (viii) Any other condition or symptom that could threaten the health of the mother or fetus, as assessed by a licensed midwife exercising reasonable skill and judgment.

    (c) Postpartum:

      (i) Failure to void bladder within 6 hours of birth or catheterization.

      (ii) Temperature of 101.0 degrees Fahrenheit or 39 degrees Celsius for more than 12 hours.

      (iii) Signs or symptoms of uterine sepsis.

      (iv) Symptoms of deep vein thrombosis.

      (v) Suspected perinatal mood disorder or uncontrolled current serious psychiatric illness.

      (vi) Suspected active alcohol use disorder.

      (vii) Suspected active substance use disorder.

      (viii) Lacerations requiring repair beyond the scope of practice of the licensed midwife.

      (ix) Systolic blood pressure greater than 140 mm Hg and diastolic blood pressure greater than 90 mm Hg measured on two (2) separate occasions more than four (4) hours apart after delivery of the baby.

      (x) Any other condition or symptom that could threaten the health of the mother, as assessed by a licensed midwife exercising reasonable skill and judgment.

  (2) A licensed midwife shall consult with or refer a patient to a physician, physician’s assistant, or advanced practice registered nurse licensed under article 15 of the code, MCL 333.16101 to 333.18838, document the consultation or referral, and follow up with the patient regarding the consultation or referral, if the infant presents with any of the following conditions:

    (a) Abnormal metabolic blood spot infant screening.

    (b) Failed hearing screening.

(c) Failed critical congenital heart defect screening (CCHD).

(c) (d) Jaundice occurring outside of normal range.

(d) (e) Failure to urinate within 36 hours of birth.

(e) (f) Failure to pass meconium within 48 hours of birth.

(f) (g) Medically significant nonlethal congenital anomalies.

(g) (h) Suspected birth injury.

(h) (i) Signs of clinically significant dehydration.

(i) (j) Signs and symptoms of neonatal abstinence syndrome.

(j) (k) Weight less than 2500 grams or 5 pounds, 8 ounces, singleton.

(k) (l) Any other abnormal infant behavior or appearance that could adversely affect the health of the infant, as assessed by a licensed midwife exercising reasonable skill and judgment.

  (3) When a referral to a physician, physician’s assistant, or advanced practice registered nurse licensed under article 15 of the code, MCL 333.16101 to 333.18838, is made, after referral the licensed midwife may, if possible, remain in communication with the physician, physician’s assistant, or advanced practice registered nurse until resolution of the concern.

  (4) If the patient elects not to accept a referral or the physician, physician’s assistant, or advanced practice registered nurse’s advice, the licensed midwife shall do the following:

    (a) Obtain full informed consent from the patient and document the refusal in writing.

    (b) Discuss with the patient what the continuing role of the licensed midwife will be and whether the licensed midwife will continue or discontinue care of the patient.

  (5) Neither consultation nor referral preclude the possibility of continued care by a licensed midwife or the possibility of an out-of-hospital birth. The licensed midwife may maintain care of the patient to the greatest degree possible.

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 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 preventionCenters 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 complybe in accordance 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
Maternal
Oxygen		Maternal: distress or fetal distress, maternal shock, stroke-like symptoms.	Maternal: 10-12 L/minute.	Maternal: free-Free-flow, nasal cannula, mask.	Maternal: until Until stabilized 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.
Pitocin 10 units/ml		Prevention and treatment of postpartum hemorrhage.	10 units/ml.	Intramuscular.	1-2 doses, PRN.
Pitocin 10 units/ml		Prevention and treatment of postpartum hemorrhage.	20 units in 1000 ml IV fluids, Initial initial bolus rate 1000 ml/hour bolus for 30 minutes (equals 10 units) followed by a maintenance rate 125 ml/hour over 3.5 hours (equals remaining 10 units).	Intravenous.	4 hours.
Methyl-ergonovine (Methergine) 0.2 mg/ml		Prevention and treatment of postpartum hemorrhage.	0.2 mg/ml.	Intramuscular.	0.2 mg IM q2-4hr 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 mg			0.2 mg tab.	Oral.	0.2-0.4 mg PO q6-8hr 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 mcg oral or 800 mcg buccal or rectal.	Oral, buccal, rectal.	Single1 dose.
Hemabate (Carboprost)		Treatment of postpartum hemorrhage.	0.25mg IM.		Every 15-90 minutes; not to exceed 8 doses.	Asthma.		Relative counterindications: hypertension.
Tranexamic Acid (TXA or Lystdea)		Treatment of postpartum hemorrhage.	1g in 10 ml IV at 1 ml/min, administered  over 10 minutes.	Intravenous.	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 over 10 minutes 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 mcg 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 IVP 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 g IV. Subsequent doses: 1 g IV every 4 hours.	Administer via IVP with prepared minibag.	Until delivery.	Allergy to penicillin.		No saline limitation when administering antibiotics.
Administration of Prescription Drugs and Medications
Medication Maternal	Indication		Dose	Route of Administration	Duration of Treatment		Contraindications	Comments
Cefazolin	Group Beta Strep prophylaxis in labor.		Initial loading dose: 2g IV. Subsequent doses: 1g IV every 8 hours.	Administer via IVP 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 mg IV every 8 hours until delivery.	Administer via IVP 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. Clindamycin and Vancomycin are the drugs of choice for GBS prophylaxis for patients who have a history of anaphylactic reactions to penicillin. No saline limitation when administering antibiotics.
Vancomycin	Group Beta Strep prophylaxis in labor.		1 g IV every 12 hours.	Administer via IVP 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. Clindamycin and Vancomycin are the drugs of choice for GBS prophylaxis for patients who have a history of anaphylactic reactions to penicillin. No saline limitation when administering antibiotics.
Epinephrine	Severe allergic reaction.		Single dose of 0.3 mg, USP, 1:1000 (0.3 mLml) 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 Solutionsolution	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.
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 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 ml 2%, up to 30 ml 1%, or up to 60 ml 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/kg infiltration.
Lidocaine	Postpartum repair of vulvo-vaginal lacerations.			Topical cream, spray, or gel.			Known allergy or signs or symptoms of allergic  reaction.
Antiemetic ranitidine zantac	To reduce vomiting during labor.		150 mg every 6 hours.	Oral.	Treat until symptoms subside.
Diphenhydramine (Benadryl)	To reduce vomiting during labor.		25 to 50 mg every 4 to 6 hours / 10-50 mg every 4- 6 hours.	Oral; intravenous.
Ondansetron (Zofran)	To reduce vomiting during labor.		4-8 mg IVP / 4 mg (up to twice PRN).	Oral; intravenous.				May produce headache as side effect.

Table 2

Neonatal - Administration of Prescription Drugs and Medications

Medication Neonatal	Indication	Dose	Route of Administration	Duration of Treatment	Contraindications	Comments
Oxygen	Neonatal: neonatal resuscitation, if indicated; abnormal pulse oximetry readings.	Neonatal: 10L/minute, or as indicated.	Neonatal: bag Bag and mask, free-flow.	Neonatal: until 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.	0.5-1.0 mg.	Intramuscular.	Single 1 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 mLml/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 mLml 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.

Editor's Note: An obvious error in R 338.17137 was corrected at the request of the promulgating agency, pursuant to Section 56 of 1969 PA 306, as amended by 2000 PA 262, MCL 24.256.  The rule containing the error was published in Annual Administrative Code Supplement, 2019.  The memorandum requesting the correction was published in Michigan Register, 2020 MR 3.

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, prior to renewal, shall hold the credential of CPM from 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 period immediately prior to renewal shall accumulate all of the following, during the prior 2 years by the end of the license cycle: 

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

    (b) One hour of continuing education in pain and symptom management pursuant to section 16204(2) of the code, MCL 333.16204(2). Acceptable methods of continuing education in pain and symptom management includes online and in person presentations, courses or programs and may include, but is not limited to, the following subject areas: behavior management, psychology of pain, behavior modification, stress management, and clinical applications as they relate to professional practice.

    (c) Two hours of continuing education on cultural awareness that include examination of disparate maternal infant mortality and morbidity experienced by the African American and indigenous 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 review journal, health care journal, or professional or scientific journal.

    (d) Two 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.

(d)(e) One hour of continuing education 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) Submission of an application for renewal constitutes the applicant’s certification of compliance with the requirements of this rule.

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

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

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

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

  (9) A request for a waiver under section 16205 of the code, MCL 333.16205, must be received by the department prior to the expiration date of the license. A CPM credential from 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.