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Out of Hospital Birth: Washington State
Standards for Midwifery Practice in WA State
Expanded Clinical Practice
Indications for Practice and Consultation
Forms for Transfer and Consultation
MAWS PRACTICE GUIDELINES for RISK SCREENING
WA STATE W.A.C. REGULATIONS
WA STATE BIRTH CENTER CRITERIA
MAWS PRACTICE GUIDELINES RISK SCREENING
PRACTICE GUIDELINES FOR RISK SCREENING AND INDICATIONS FOR CONSULTATION AND REFERRAL FOR OUT-OF-HOSPITAL BIRTH
I.  Pre-existing Conditions
The following maternal conditions existing prior to the current pregnancy require that a physician be consulted and may require physician referral
1. Cardiovascular Disease/Hypertension
2. Pulmonary Disease/Active tuberculosis/asthma if severe or uncontrolled by medication
3. Renal Disease
4. Hepatic Disorders
5. Endocrine Disorders
6. Significant Hematological Disorders
7. Collagen-Vascular Diseases
8. Neurologic Disorders
9. Cancer
10. Infectious Diseases; the treatment of which is beyond the birth attendant's scope of practice.
11. Current alcoholism or abuse.
12. Current drug addiction or abuse.
13. Current severe psychiatric illnesses
14. Isoimmunization
15. Previous C-section with classical incision
16. Significant deviations from normal as assessed by the birth attendant
II.  AntePartum Conditions
The following conditions arising during the current pregnancy require that a physician be consulted and may require physician referral:
1. Labor before the completion of 37 weeks gestation. 
2. Presentation other than vertex at term.
3.  Multiple gestation.
4.  Significant bleeding.
5.  Gestational Diabetes Mellitus uncontrolled by diet.
6.  Severe anemia
7.  Evidence of PIH or pre-eclampsia.
8.  Documented IUGR
9.  Thrombophlebitis.
10.  Known fetal anomalies with an infant computable with life.
11. Fetal demise after 12 weeks completed weeks gestation.
12.  Abnormal fetal NST.
13.  Abnormal ultrasound findings.
14.  Isoimmunization.
15.  Documented placental abnormalities or previa.
16. Post-dates pregnancy (>42 completed weeks)
17. Positive HIV antibody test.
18. Parent (s) ill prepared for out-of-hospital birth.
19. Inability of client and birth attendant to come to an agreement regarding plan of care.
20. Development of any of the conditions listed previously.
21. Other significant deviations from normal as assessed by the birth attendant.
III Intrapartum Conditions
The decision to transport at any time during labor or the postpartum period will be based on any serious deviation from the normal course of events. The following conditions arising during labor require that a physician be consulted and may require a physician and/or hospital referral. It should be noted that in some intrapartum situations, because of time urgency, it may not be prudent to pause management long enough to seek physician consultation before management is given.
1.  Abnormal fetal presentation
2.  Maternal fever.
3.  Hypertension with or without additional signs and symptoms of pre-eclampsia
4.  Thick meconium stained fluid with delivery not imminent. 
5.  Persistent and/or severe fetal distress
6.  Significant abnormal labor pattern in active labor
7.  Abnormal bleeding
8.  Maternal seizure
9.  ROM > 24 hours with unknown or GBS+ status
10. Prolapsed cord
11. Anaphylaxis
12. Active genital herpes in labor
13.  Adhered placenta or retained without bleeding
14.  Client's desire for pain medication, consultation or referral
15.  Development of any of the conditions listed previously
16.  Other significant deviations from normal as assessed by the midwifery staff.
IV Postpartum Conditions
The following maternal conditions arising during the postpartum period require that a physician be consulted and may require physician referral
1.  Seizure
2. Significant hemorrhage not responsive to treatment
3. Sustained maternal vital sign instability
4. Uterine prolapse
5.  Lacerations, repair of which is beyond the birth attendant's level of experience.
6.  Development of any of the conditions listed previously
7.  Other significant deviations from normal as assessed by the birth attendant staff
V.  Neonatal Conditions
The following conditions arising in a neonate require that a pediatric physician be consulted and may require referral
1. Persistent respiratory distress
2. Persistent cardiac irregularities
3. Central cyanosis or pallor
4. Prolonged temperature instability
5. Prolonged glycemic instability
6. Seizure
7. Apgar score less than 7 at five minutes of age
8. Birth weight <2000 grams
9. Significant clinical evidence of prematurely
10. Significant jaundice or jaundice prior to 24 hours.
11. Loss > 10 % of birth weight/failure to thrive
12.  Major apparent congenital anomalies
13.  Birth injury requiring medical attention
14. Other significant deviations from normal as assessed by mirth center staff

MAWS RISK SCREENING DOCUMENT: 4-96