WSR 24-05-052

PROPOSED RULES

DEPARTMENT OF HEALTH

[Filed February 16, 2024, 2:52 p.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 22-15-083.

Title of Rule and Other Identifying Information: Midwives limited prescriptive license extension and health equity continuing education (CE). The department of health (department) is proposing amendments to chapter 246-834 WAC to implement SSB 5765 (chapter 289, Laws of 2022), which created two levels of limited prescriptive license extension for midwives to prescribe, obtain, and administer medications and therapies for the prevention and treatment of common prenatal and postpartum conditions, family planning methods, medical devices, and implants. This bill also gave the secretary the authority to establish education requirements in the chapter. The department is also proposing amendments to implement ESSB 5229 (chapter 276, Laws of 2021) regarding health equity CE requirements.

Hearing Location(s): On April 4, 2024, at 9:00 a.m., at the Washington State Department of Health (DOH), 111 Israel Road S.E., Town Center 2, Room 166/167, Tumwater, WA 98501; or via Zoom. Register in advance for this webinar https://us02web.zoom.us/webinar/register/WN_1CXy_0KyTYWCRbR8iKJiTA. After registering, you will receive a confirmation email containing information about joining the webinar. You may attend virtually or in person. You may also submit comments in writing.

Date of Intended Adoption: April 11, 2024.

Submit Written Comments to: Kathy Weed, DOH, P.O. Box 47852, Olympia, WA 98504-7852, email https://fortress.wa.gov/doh/policyreview, fax 360-236-2901, kathy.weed@doh.wa.gov, by April 4, 2024.

Assistance for Persons with Disabilities: Contact Kathy Weed, phone 360-236-4883, fax 360-236-2901, TTY 360-833-6388 or 711, email kathy.weed@doh.wa.gov, by March 25, 2024.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rules implement SSB 5765, which created two levels of limited prescriptive license extension for midwives to prescribe, obtain, and administer medications and therapies for the prevention and treatment of common prenatal and postpartum conditions, family planning methods, medical devices, and implants. The department is proposing rules that establish the new education and training requirements for the license extensions as well as amending the expired and inactive requirements to reactive [reactivate] a license extension.

The proposed rules update the legend drug and devices regulations to include the types of medications and therapies that midwives can prescribe, obtain, and administer under the newly created license extensions.

The proposed rules include making the chapter more inclusive by replacing gendered language with gender-neutral terms.

Finally, the proposed rules also require credential holders to complete CE to renew the credential. CE requirements include completion of two hours of health equity CE every four years that comply with the department's model rules established under ESSB 5229.

Reasons Supporting Proposal: The department proposes these amendments to align with the legislative intent of SSB 5765 and ESSB 5229. Rules are needed to establish the regulatory framework for the midwifery scope expansion and CE requirements. The drafting of these rules included collaborating with the midwifery advisory committee, Washington medical commission, and pharmacy quality assurance commission.

Statutory Authority for Adoption: RCW 18.50.115, 18.50.135, and 43.70.613.

Statute Being Implemented: SSB 5765 (chapter 289, Laws of 2022) and ESSB 5229 (chapter 276, Laws of 2021).

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: DOH, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Kathy Weed, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-4883.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Kathy Weed, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-4883, fax 360-236-2901, TTY 711, email kathy.weed@doh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules are adopting or incorporating by reference without material change federal statutes or regulations, Washington state statutes, rules of other Washington state agencies, shoreline master programs other than those programs governing shorelines of statewide significance, or, as referenced by Washington state law, national consensus codes that generally establish industry standards, if the material adopted or incorporated regulates the same subject matter and conduct as the adopting or incorporating rule; and rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect.

Is exempt under RCW 19.85.025(4).

Explanation of exemptions: The following proposed rules or portions of the proposed rules are exempt under RCW 34.05.310 (4)(c): WAC 246-835-030 and 246-835-065. The following proposed rules or portions of the proposed rules are exempt under RCW 34.05.310 (4)(d): WAC 246-835-010, 246-835-020, 246-835-030, 246-835-055, 246-835-062, 246-835-065, 246-835-066, 246-835-067, 246-835-160, 246-835-255, 246-835-345, 246-835-360, and 246-835-370. The entire proposed rule is exempt under RCW 19.85.025(4).

Scope of exemption for rule proposal:

Is fully exempt.

February 16, 2024

Kristin Peterson, JD

Chief of Policy

for Umair A. Shah, MD, MPH

Secretary

OTS-4944.6

AMENDATORY SECTION(Amending WSR 17-15-024, filed 7/7/17, effective 8/7/17)

WAC 246-834-010Definitions.

The following definitions apply throughout this chapter unless the context clearly indicates otherwise:

(1) "Active practice" means ((twenty))20 hours per month in prenatal and postpartum clinical care, or minimum of six births annually as the primary midwife;

(2) "Administer" means to dispense, apply, and manage drugs, medical devices, and implants;

(3) "Department" means the Washington state department of health;

(((3)))(4) "Directly assisted" means the act where a student midwife is learning the skills of a midwife through hands-on clinical experience in gradually increasing degrees of responsibility while under supervision of a licensed midwife or other obstetric provider;

(((4)))(5) "Lactation care and services" means evaluation, problem identification, treatment, education, and consultation regarding lactation and ((breastfeeding))chest feeding to ((mothers))gestational parents and neonates;

(((5)))(6) "Nursing education" means completion of courses for credit in a school that is approved to train persons for licensure as registered nurses or licensed practical nurses, or courses in other formal training programs which include instruction in basic nursing skills, excluding nursing assistant training;

(((6)))(7) "Postpartum" means the 12-month period beginning on the last day of the pregnancy.

(8) "Practical midwifery experience" means performance of tasks within the midwifery scope of practice, that is verified by affidavit, testimony or other sworn written documentation that verifies that the experience and its documentation is equivalent to that required of students enrolled in an accepted midwifery education program;

(((7)))(9) "Preceptor" means a licensed midwife or other obstetric practitioner licensed by their state or jurisdiction to provide maternity care who assumes responsibility for supervising the practical (clinical obstetric) experience of a student midwife;

(((8)))(10) "Primary attendant" means a student midwife who acts as primary midwife making intrapartum clinical decisions while under supervision of a licensed midwife or other obstetric provider;

(((9)))(11) "Secretary" means the secretary of the Washington state department of health;

(((10)))(12) "Supervision" means the observation and evaluation of a student midwife's practical performance. A supervisor must be physically present on-site and available to intervene when a student midwife performs any clinical care task at births and prenatal and postpartum care exams.

AMENDATORY SECTION(Amending WSR 17-15-024, filed 7/7/17, effective 8/7/17)

WAC 246-834-062Initial or reinstating application for individuals who have not been in the active practice of midwifery.

This section applies to applicants for an initial license as a licensed midwife, or reinstatement of a midwifery license, who have not been in the active practice of midwifery prior to initial or reinstatement license application.

(1) Any applicant who has not been engaged in the active practice of midwifery for more than three years but less than five years prior to the date of application shall, in addition to the requirements for licensure as specified in WAC 246-834-030 and 246-834-060 ((and 246-834-140)):

(a) Provide documentation of a minimum of ((ten))10 births while acting as a birth assistant under the supervision of a preceptor within the last ((twelve))12 months; and

(b) Provide documentation of completion of continuing education for the three years prior to application that meets the requirements of WAC 246-834-355.

(2) Any initial or reinstating applicant who has not been engaged in the active practice of midwifery for five or more years prior to the date of application shall, in addition to the requirements for licensure as specified in WAC 246-834-030 and 246-834-060 ((and 246-834-140)):

(a) Provide documentation of a minimum of ((fifteen))15 births while acting as a birth assistant under the supervision of a preceptor within the last ((twelve))12 months;

(b) Provide documentation of completion of continuing education for the three years prior that meets the requirements of WAC 246-834-355; and

(3) This section does not apply to any applicant who has been enrolled in a recognized educational program under WAC ((246-834-135))246-834-020 or 246-834-065.

AMENDATORY SECTION(Amending WSR 17-15-024, filed 7/7/17, effective 8/7/17)

WAC 246-834-065Application for examination—Foreign trained.

An applicant for a midwife license who graduated from a foreign educational institution on midwifery outside of any U.S. jurisdiction may sit for the licensing examination provided the applicant completes all requirements in this section:

(1) Complete application requirements for licensure in WAC 246-834-060;

(2) Provide proof of a certificate or diploma from a foreign institution on midwifery of equal requirements conferring the full right to practice midwifery in the country in which it was issued. The diploma must bear the seal of the institution from which the applicant graduated. If applicable, the candidates must, at ((her or his))the individual's own expense, present with the application a certified translation of the foreign certificate or diploma ((made by and under the seal of the consulate of the country in which the certificate or diploma was issued));

(3) Submit proof of completing at least three years of midwifery training including the study of basic nursing that meets the requirements under WAC ((246-834-140))246-834-030(1);

(4) Submit proof of meeting minimum educational requirements under WAC ((246-834-140))246-834-030 (2)(a) and (b);

(5) Submit to the department documentation of attendance at ((one hundred))100 births that meets the requirements of WAC ((246-834-140))246-834-030 (3)(a);

(6) Submit to the department documentation of prenatal care examinations of ((fifty women))50 individuals and early postpartum care examinations of ((fifty women))50 individuals that meets the requirements of WAC ((246-834-140))246-834-030 (3)(b); and

(7) Demonstrate competency in the use and administration of legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250. The applicant shall submit documentation of competency to the department on a department supplied form. A licensed health care professional who, within ((his or her))the individual's scope of practice, is qualified in the use and administration of legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250 must sign the form.

AMENDATORY SECTION(Amending WSR 15-20-049, filed 9/30/15, effective 10/31/15)

WAC 246-834-066Certified professional midwife (CPM) licensure requirements.

An applicant who holds a current North American Registry of Midwives (NARM) certified professional midwife (CPM) certification may apply for a Washington state midwife license by completing all requirements in this section.

(1) To be eligible for a midwife license an applicant holding a CPM shall:

(a) Complete all application requirements for licensure in WAC 246-834-060.

(b) Ensure that proof of the CPM certification is sent to the department directly from NARM.

(i) At least ((thirty))30 births where the applicant was the primary attendant under supervision of a qualified attendant;

(ii) At least ((twenty))20 births where the applicant directly assisted;

(iii) At least ((fifty))50 births that the applicant observed in addition to births counted in (c)(i) and (ii) of this subsection; and

(iv) Documentation for (c)(i) through (iii) of this subsection must include at least the date, client identifier, the applicant's role at each birth, and the signature or initials of the qualified attendant at the birth of either: A licensed midwife, a CPM preceptor, a certified nurse midwife, or a practitioner licensed by their state or jurisdiction to provide maternity care. The applicant shall submit to the department the name and contact information of each signatory, if available. The department may approve exceptions to the required documentation in this subsection.

(d) Submit to the department documentation of prenatal care examinations of ((fifty women))50 individuals and early postpartum care examinations of ((fifty women))50 individuals. The same ((women))individuals need not be seen for both examinations. Documentation must include at least the date, client identifier, and the signature or initials of the qualified attendant at the care examination of either: A licensed midwife, a CPM preceptor, a certified nurse midwife, or a practitioner licensed by their state or jurisdiction to provide maternity care. The applicant must submit to the department the name and contact information of each signatory, if available. The department may approve exceptions to the required documentation in this subsection.

(e) Demonstrate competency in the use and administration of legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250. The applicant shall submit documentation of competency to the department on a department supplied form. A licensed health care professional who, within ((his or her))the individual's scope of practice, is qualified to use and administer legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250 must sign the form.

(f) Successfully complete courses on epidemiology and obstetric pharmacology from:

(i) An institution that is accredited by an agency recognized by the Council for Higher Education Accreditation (CHEA) and included in their database of institutions on programs accredited by recognized United States accrediting organizations;

(ii) An institution that is accredited by an agency recognized by the United States Department of Education (USDOE) and included in their database of accredited postsecondary institutions and programs; or

(iii) A curriculum or program approved by the department.

(2) Applicants applying under this section who have a current CPM but do not meet all of the requirements listed in subsection (1)(c) through (f) of this section may apply to the department for a trainee permit under WAC 246-834-068. The trainee permit authorizes the applicant to complete subsection (1)(c) through (e) of this section, under the supervision of a preceptor as described in WAC 246-834-067.

AMENDATORY SECTION(Amending WSR 15-20-049, filed 9/30/15, effective 10/31/15)

WAC 246-834-067Preceptor for certified professional midwife (CPM) licensure program.

This section defines the role of a preceptor as used in WAC 246-834-066. A certified professional midwife (CPM) applicant for licensure as a midwife may use more than one preceptor to meet the requirements for licensure under WAC 246-834-066.

(1) A preceptor for clinical requirements including observed, managed, and assisted births, and prenatal and postpartum examinations must:

(a) Have a current Washington state license as a midwife under chapter 18.50 RCW, physician under chapter 18.71 RCW, osteopathic physician under chapter 18.57 RCW, or certified nurse midwife under chapter 18.79 RCW; and

(b) Have actively practiced obstetrics for at least three consecutive years or attended at least ((one hundred fifty))150 births.

(2) A preceptor for legend drugs and devices must have a current Washington state credential and be, within ((his or her))the individual's scope of practice, qualified to use and administer legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250.

AMENDATORY SECTION(Amending WSR 17-15-024, filed 7/7/17, effective 8/7/17)

WAC 246-834-080Examination failures.

(1) An applicant who has failed the NARM examination or the Washington state licensing examination, or both, shall retake and pass the examination(s) which he or she failed.

(2) The applicant who fails the Washington state licensing examination may sit for the reexamination if ((he or she))the individual:

(a) Applies to the department at least ((fourteen))14 days prior to the next scheduled examination; and

(b) Pays the required fee as specified in WAC 246-834-990.

(3) An applicant who fails the NARM or Washington licensing examination three consecutive times shall submit evidence to the secretary of completion of an individualized program of study approved by the department prior to retaking the examination.

AMENDATORY SECTION(Amending WSR 17-15-024, filed 7/7/17, effective 8/7/17)

WAC 246-834-140Eligibility for state licensing examination.

Candidates for the state licensing examination shall meet the following conditions, unless applying under WAC 246-834-066 Certified professional midwife (CPM) licensure requirements:

(1) Midwifery training shall be at least three academic years, and shall consist of both didactic and clinical instruction sufficient to meet the educational standards of the school and this section. However, the length of required training may be shortened, but not to less than two academic years, after consideration of the student's documented education and experience in the required subjects, if the applicant is a registered nurse or practical nurse licensed under chapter 18.79 RCW, or has had previous nursing education or practical midwifery experience.

(2) The applicant must receive instruction in the following educational areas:

(a) Midwifery, basic sciences (including biology, physiology, microbiology, anatomy with emphasis on female reproductive anatomy, genetics and embryology), normal and abnormal obstetrics and gynecology, family planning techniques, childbirth education, nutrition both during pregnancy and lactation, ((breast))chest feeding, neonatology, epidemiology, community care, and medicolegal aspects of midwifery; and

(b) Basic nursing skills and clinical skills including, but not limited to, vital signs, perineal prep, catheterization, aseptic techniques, administration of medications both orally and by injection, local infiltration for anesthesia, venipuncture, administration of intravenous fluids, infant and adult resuscitation, and charting.

(3) The applicant must undertake the care of not less than ((one hundred women))100 individuals in the intrapartum period. No less than ((fifteen))15 of the ((one hundred women))100 individuals must be cared for in the intrapartum period while the applicant was enrolled in the school from which the student graduates.

(a) The applicant shall submit to the department documentation of attendance at ((one hundred))100 births of which:

(i) At least ((thirty))30 births where the applicant was the primary attendant under supervision of a qualified attendant;

(ii) At least ((twenty))20 births where the applicant directly assisted;

(iii) At least ((fifty))50 births that the applicant observed in addition to births counted in (d)(i) and (ii) of this subsection; and

(iv) Documentation for (a)(i) through (iii) of this subsection must include at least the date, client identifier, the applicants role at each birth, and the signature or initials of the qualified attendant at the birth of either: A licensed midwife, a CPM preceptor, a certified nurse midwife, or a practitioner licensed by their state or jurisdiction to provide maternity care. The applicant shall submit to the department the name and contact information of each signatory, if available. The department may approve exceptions to the required documentation in this subsection.

(b) The applicant shall submit to the department documentation of prenatal care examinations of ((fifty women))50 individuals and early postpartum care examinations of ((fifty women))50 individuals. The same ((women))individuals need not be seen for both examinations.

(i) No less than ((fifteen women))15 individuals must be cared for in the prenatal and postpartum periods while enrolled in the school from which the student graduates.

(ii) Documentation must include at least the date, client identifier, and the signature or initials of the qualified attendant at the care examination of either: A licensed midwife, a CPM preceptor, a certified nurse midwife, or a practitioner licensed by their state or jurisdiction to provide maternity care. The applicant must submit to the department the name and contact information of each signatory, if available. The department may approve exceptions to the required documentation in this subsection.

(4) The applicant shall demonstrate competency in the use and administration of legend drugs and devices described in WAC 246-834-250. The applicant shall submit documentation of competency to the department on a department supplied form. A licensed health care professional who, within his or her scope of practice, is qualified in the use and administration of legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250 must sign the form.

AMENDATORY SECTION(Amending WSR 22-13-079, filed 6/10/22, effective 7/11/22)

WAC 246-834-160Student midwife permit.

(1) A student midwife permit may be issued to any individual who has:

(a) Successfully completed an accredited midwifery program as specified in WAC ((246-834-135))246-834-020, or is foreign trained as specified in WAC 246-834-065(1);

(b) Obtained a minimum period of midwifery training of at least three academic years as required by WAC ((246-834-140))246-834-030;

(d) Documentation of undertaking the care of not less than 50 ((women))individuals in each of the prenatal, intrapartum and early postpartum periods as required by RCW 18.50.040 (2)(c);

(e) Satisfactorily completed the NARM examination required by WAC 246-834-050; and

(f) Filed a completed application for student midwife permit under WAC 246-834-060 and accompanied by a nonrefundable fee as specified in WAC 246-834-990.

(2) The student midwife permit authorizes the ((individuals))student to practice and observe ((women))individuals in the intrapartum period under the supervision of a licensed midwife under 18.50 RCW, an allopathic physician under chapter 18.71 RCW, an osteopathic physician under chapter 18.57 RCW or certified nurse midwife under chapter 18.79 RCW.

(3) Once all application requirements including clinical components are completed the applicant may be eligible to sit for the Washington state licensure examination as required in WAC 246-834-050.

NEW SECTION

WAC 246-834-165Application requirements for a licensed midwife seeking a limited prescriptive license extension, a license extension for medical devices, or a license extension for implants.

(1) A licensed midwife seeking a limited prescriptive license extension shall:

(a) Submit evidence of completion of 15 additional obstetrical pharmacology didactic training hours. The additional hours must include the prescription classifications listed in WAC 246-834-250(4) and provide skills and knowledge beyond entry-level skills or knowledge in antibiotics and contraceptives; and

(b) Submit evidence of completion of additional training on family planning and treating common, low risk prenatal and postpartum conditions. Such training must be either:

(i) A clinical experience of at least 20 cases reviewed in consultation with a licensed health care professional who, within their scope of practice, is qualified to use and administer legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250. The licensed health care professional must attest to the applicant's knowledge and skills by signing a form provided by the department; or

(ii) A clinical training course or courses approved by the department.

(2) A licensed midwife seeking the license extension for medical devices or the license extension for implants shall:

(a) Submit completion of the requirements in subsection (1) of this section;

(b) Submit evidence of completion of training as required by the medical device manufacturers, or an equivalent. The training must include at least three simulated medical device insertions under direct supervision;

(c) Submit evidence of completion of training as required by the implant device manufacturers, or an equivalent. The training must include at least three simulated removals under direct supervision; and

(d) Submit evidence of completion of additional training on medical devices or implants, or both that includes:

(i) A clinical experience of four inserted medical devices and one medical device removal under direct supervision;

(ii) A clinical experience of one inserted implant and three implant removals under direct supervision;

(e) The clinical experience in (d) of this subsection must be supervised by a licensed health care professional who, within their scope of practice, is qualified to administer medical devices and implants and has at least two years of experience. The health care professional must attest to the applicant's knowledge and skills by signing a form provided by the department.

(f) A licensed midwife may pursue all three license extensions. The training on prescriptive, medical devices, and implants in subsections (1) and (2) must be completed within five years from the date of application.

(3) The license extensions referenced in this section do not apply to newborn care.

AMENDATORY SECTION(Amending WSR 22-13-079, filed 6/10/22, effective 7/11/22)

WAC 246-834-250Legend drugs and devices.

A licensed midwife shall have a procedure, policy or guideline for the use of each legend drug and device. A midwife may not administer or prescribe a legend drug or use a legend device for which they are not qualified by education, training, and experience.

(1) A licensed midwife may purchase and use legend drugs and devices as follows:

(a) Dopplers, syringes, needles, phlebotomy equipment, sutures, urinary catheters, intravenous equipment, amnihooks, airway suction devices, electronic fetal monitors, jada system, tocodynamometer monitors, oxygen and associated equipment, glucose monitoring systems and testing strips, neonatal pulse oximetry equipment, hearing screening equipment, centrifuges, and nasopharyngeal or nasal swabs for appropriate testing;

(b) Nitrous oxide as an analgesic, self-administered inhalant in a 50 percent blend with oxygen, and associated equipment, including a scavenging system;

(c) Ultrasound machine used in the real time ultrasound of pregnant uterus for the confirmation of viability, first trimester dating, third trimester presentation, placental location, and amniotic fluid assessment; and

(d) Neonatal and adult resuscitation equipment and medication, including airway devices and epinephrine for neonates.

(2) Pharmacies may issue ((breast))the following as ordered by a licensed midwife: Lactation pumps, compression stockings and belts, maternity belts, diaphragms and cervical caps, glucometers and testing strips, iron supplements, prenatal vitamins, and recommended vaccines as specified in subsection (3)(e) through (j) of this section ((ordered by licensed midwives)).

(3) In addition to prophylactic ophthalmic medication, postpartum oxytocic, vitamin K, Rho (D) immune globulin, and local anesthetic medications as listed in RCW 18.50.115, licensed midwives may obtain and administer the following medications:

(a) Intravenous fluids limited to Lactated Ringers, ((5%))five percent Dextrose with Lactated Ringers, and 0.9% sodium chloride;

(b) Sterile water for intradermal injections for pain relief;

(d) Epinephrine for use in ((maternal))peripartum anaphylaxis and resuscitation and neonatal resuscitation, pending transport;

(e) Measles, Mumps, and Rubella (MMR) vaccine to nonimmune postpartum ((women))individuals;

(f) Tetanus, diphtheria, acellular pertussis (Tdap) vaccine for use in pregnancy;

(g) Hepatitis B (HBV) birth dose for any newborn administration;

(h) HBIG and HBV for any neonates born to a hepatitis ((B+ mothers))B positive gestational parent;

(i) Influenza vaccine ((for use in pregnancy));

(j) Any vaccines recommended by the Centers for Disease Control and Prevention (CDC) advisory committee on immunization practices for ((pregnant or postpartum people or)) infants in the first two weeks after birth((, as it existed on the effective date of this section))or pregnant or postpartum people;

(k) Terbutaline to temporarily decrease contractions pending emergent ((intrapartal))intrapartum transport;

(l) Antibiotics for intrapartum prophylaxis of Group B ((beta hemolytic)) Streptococcus (GBS) per current CDC guidelines; ((and))

(m) Antihemorrhagic drugs to ((control))treat postpartum hemorrhage including, but not limited to, intravenous tranexamic acid, oxytocins, misoprostol, methylergonovine maleate (oral or intramuscular), and prostaglandin F2 alpha; and

(n) Nifedipine for indication of preterm labor pending transport.

(4) A licensed midwife with a limited prescriptive license extension may prescribe, obtain, and administer the items in subsections (1) through (3) of this section, and the following medications and therapies for the prevention and treatment of outpatient conditions that do not constitute a significant deviation from normal per RCW 18.50.010 during pregnancy or postpartum based on current evidence and practice:

(a) Antibiotics;

(b) Antiemetics;

(d) Antifungals;

(e) Low-potency topical steroids;

(f) Antipruritic medications and therapies;

(g) Other medications and therapies including, but not limited to:

(i) Galactagogues;

(ii) Topical analgesia for anal, vulvar, and perineal pain;

(iii) Preterm labor preventatives;

(iv) Stool softeners;

(v) Vitamins and minerals for preventing and treating deficiencies;

(vi) Over-the-counter medications as needed;

(vii) Nonopioid medication for therapeutic rest;

(viii) Medications for miscarriage prevention and completion;

(ix) Smoking cessation;

(x) Prescription referrals for IV iron infusions; and

(h) Hormonal and nonhormonal family planning methods.

(5) Pursuant to RCW 18.50.010, a licensed midwife with a license extension that includes medical devices or implants, or both may prescribe, obtain, and administer hormonal and nonhormonal family planning method devices including, but not limited to, copper or other nonhormonal intrauterine devices (IUD), IUDs with levonorgestrel or other progestin, implants or as consistent with current evidence and practice so long as they have a license extension to perform the task.

(6) The client's records must contain documentation of all medications and devices prescribed, ordered, and administered.

AMENDATORY SECTION(Amending WSR 17-15-024, filed 7/7/17, effective 8/7/17)

WAC 246-834-255Elements of care for the newborn.

The customary scope of care of a newborn up to two weeks of age by a licensed midwife includes, but is not limited to, clinical assessment, treatment, education, support and referral as described in this section. Newborn care shall not go beyond the scope of the midwife's education, training and experience.

(1) Immediate newborn care includes, but is not limited to:

(a) Appearance, pulse, grimace, activity and respiration (APGAR) assessment;

(b) Stabilization and monitoring of the newborn for a minimum of two hours postpartum;

(d) Complete physical examination;

(e) Education for parents regarding care and monitoring of the normal newborn; and

(f) Physician consultation, referral and/or transfer of care in the event of significant deviations from normal.

(2) Other support may include:

(a) Neonatal resuscitation; and

(b) Legend drugs and devices allowed in RCW 18.50.115 and WAC 246-834-250.

(3) Subsequent care may include, but is not limited to:

(a) Evaluating the newborn for well-being such as jaundice, weight loss, and adequate feeding and elimination patterns;

(b) Newborn metabolic screening per RCW 70.83.020;

(d) Lactation care and services; and

(e) Consultation ((and/or))and possible referral to pediatric care for any significant deviation from normal.

AMENDATORY SECTION(Amending WSR 15-24-092, filed 11/30/15, effective 12/31/15)

WAC 246-834-345License renewal.

A licensed midwife must renew their license every year on ((his or her))the individual's birthday. To renew a license, a licensed midwife shall comply with the requirements in:

(1) RCW 18.50.102 License renewal;

(2) RCW 18.50.108 Written plan for consultation, emergency transfer, and transport;

(3) WAC 246-12-030 How to renew a credential;

(4) WAC 246-834-355 Continuing education;

(5) WAC 246-834-360 Quality improvement program;

(6) WAC 246-834-370 Data submission; and

(7) WAC 246-834-990 Midwifery fees and renewal cycle.

AMENDATORY SECTION(Amending WSR 15-24-092, filed 11/30/15, effective 12/31/15)

WAC 246-834-355Continuing education.

(1) A licensed midwife shall complete ((thirty))30 hours of continuing education (CE) every three years and must comply with ((chapter 246-12 WAC, Part 7))WAC 246-12-170 through 246-12-240. CE course work must contribute to the professional knowledge and development of the licensed midwife.

(a) A minimum of ((twenty-five))25 hours must be directly related to the clinical practice of midwifery. A licensed midwife who has a license extension shall complete a minimum of three hours of CE relevant to the license extension or extensions they hold as part of the 25-hour requirement.

(b) In addition to the 25 hours of clinical practice CE in (a) of this subsection, a licensed midwife shall complete two hours of health equity CE every four years per chapter 43.70 RCW and in compliance with WAC 246-12-800 through 246-12-830.

(2) A licensed midwife shall obtain CE hours through one or more of the categories listed below. Documentation for all activities must include licensee's name, date of activity, and number of hours. Additional specific documentation is defined below:

(a) Acceptable CE course work. A minimum of ((ten))10 hours is required per reporting period in acceptable CE course work. For the purposes of this section, acceptable CE course work means courses offered or authorized by industry recognized local, state, private, national and international organizations, agencies or institutions of higher learning. The department will not authorize or approve specific CE courses. The required documentation for this category is a certificate or documentation of attendance.

(b) Course work or classes offered by an accredited college or university. The course work must provide skills and knowledge beyond entry-level skills. The required documentation for this category is a transcript or documentation of attendance. A maximum of ((ten))10 hours is allowed per reporting period for this category.

(c) Research, writing, or teaching. The required documentation for this category is a two-page synopsis for each activity written by the licensee. A maximum of ((fifteen))15 hours is allowed per reporting period for this category.

(d) Documented self-study or life experience. The required documentation for this category is a two-page synopsis of each activity written by the licensee. A maximum of five hours is allowed per reporting period for this category.

(e) Serving on a professional board, committee, disciplinary panel, or association. The required documentation for this category is a letter or other documentation from the organization. A maximum of five hours is allowed per reporting period for this category.

(f) Professional manuscript review. The required documentation for this category is a letter from the publishing organization verifying review of the manuscript. A maximum of ((ten))10 hours is allowed per reporting period for this category.

(g) Professional conference or workshop. The required documentation for this category is a certificate or documentation of attendance. A maximum of ((ten))10 hours is allowed per reporting period for this category.

(3) Continuing education credit will not be given for the following:

(a) A cardiopulmonary resuscitation course;

(b) A neonatal resuscitation course; or

(4) ((Verification of))The department may verify completion of continuing competency hours ((will begin on January 1, 2019)).

AMENDATORY SECTION(Amending WSR 15-24-092, filed 11/30/15, effective 12/31/15)

WAC 246-834-360Quality improvement program.

(1) As a condition of renewing a license, a licensed midwife shall:

(a) Participate in a Washington state coordinated quality improvement program peer review process that complies with the requirements in RCW 43.70.510.

(b) Attest every two years that the midwife has completed peer review for a minimum of five of the midwife's clinical cases over the course of those two years.

(2) A midwife may be excused from or granted an extension of participation in a peer review process due to illness or other extenuating circumstances. The department, upon request, will determine if the requirements may be waived or if an extension may be granted.

(3) For auditing purposes, written confirmation of participation in a peer review process from the approved coordinated quality improvement program shall suffice. The midwife must keep ((her/his))their participation records; records must not be sent to the department.

(4) Verification of completion of participation in a peer review process will begin on January 1, 2018.

AMENDATORY SECTION(Amending WSR 22-13-079, filed 6/10/22, effective 7/11/22)

WAC 246-834-370Data submission.

(1) As a condition of renewing a license, a licensed midwife shall report data on all courses of care for every ((mother))gestational parent and newborn under the midwife's care to a national or state research organization approved by the department. If the ((mother))gestational parent declines to participate in the collection of data, the midwife shall follow the protocol of the approved national or state research organization.

(2) The licensed midwife shall verify compliance by submitting an attestation to the department annually with the license renewal. For good cause, the secretary may waive reporting requirements.

(3) For auditing purposes, written confirmation of full participation in data collection from the approved state or national research organization shall suffice.

(4) The midwife must keep ((her/his))their data and participation records; data and participation records will not be submitted directly to the department.

AMENDATORY SECTION(Amending WSR 19-15-005, filed 7/5/19, effective 8/5/19)

WAC 246-834-400Expired license.

A midwife licensed under this chapter may reinstate an expired license or license extension.

(1) If a midwife's license ((under this chapter)) has been expired for less than three years, ((to reinstate the license)) the practitioner shall meet the requirements of ((chapter 246-12 WAC, Part 2))WAC 246-12-040.

(2) If a midwife's license ((under this chapter)) has expired and the practitioner has been engaged in the active practice of midwifery in another United States jurisdiction or territory, or other location approved by the department, ((to reinstate the license)) the practitioner shall:

(a) Submit verification of active practice; and

(b) Meet the requirements of ((chapter 246-12 WAC, Part 2))WAC 246-12-040.

(3) If a midwife's license ((under this chapter)) has been expired for three years or more but less than five years at time of application, and the practitioner has not been actively engaged in midwifery, the practitioner shall:

(a) Work as a birth assistant under the supervision of a department-approved preceptor for a minimum of ((ten))10 births; and

(b) Meet the requirements of ((chapter 246-12 WAC, Part 2))WAC 246-12-040.

(4) If a midwife's license ((under this chapter)) has been expired for more than five years at time of application, and the practitioner has not been actively engaged in midwifery, the practitioner shall:

(a) Work as a birth assistant under the supervision of a department-approved preceptor for a minimum of ((fifteen))15 births;

(b) Retake and successfully pass the Washington state licensing examination; and

(5) A proposed preceptor shall:

(a) Hold an active license without restriction, current discipline, or conditions as a midwife under chapter 18.50 RCW, a certified nurse midwife under chapter 18.79 RCW, an allopathic physician under chapter 18.71 RCW, or an osteopathic physician under chapter 18.57 RCW;

(b) Have actively practiced at least three consecutive years or attended at least ((one hundred fifty))150 births; and

(6) If a midwife's license extension has expired and the practitioner has been engaged in the active practice of midwifery prescriptive or medical devices and implant practice in another United States jurisdiction or territory, or other location approved by the department, the practitioner shall:

(a) Submit verification of active practice of prescriptive, devices, or implant practices; and

(b) Meet the requirements of WAC 246-12-040.

(7) If a licensed midwife at the time of reactivation has had an expired license extension for less than five years and has not been engaged in the active practice of midwifery prescriptive or medical devices and implant practice, the practitioner may submit their records for their initial training as required in WAC 246-834-165 and meet the requirements in WAC 246-12-040.

(8) If a licensed midwife at the time of reactivation has had an expired license extension for five years or more and has not been engaged in the active practice of midwifery prescriptive or medical devices and implant practice, the practitioner shall retake the required training in WAC 246-834-165.

AMENDATORY SECTION(Amending WSR 19-15-005, filed 7/5/19, effective 8/5/19)

WAC 246-834-450Inactive license.

(1) A licensed midwife may obtain an inactive license by meeting the requirements of ((chapter 246-12 WAC, Part 4))WAC 246-12-090.

(2) An inactive license must be renewed every year on the midwife's birthday according to WAC 246-12-100 and by paying the fee required under WAC 246-834-990.

(3) A midwife with an inactive license may return to active status.

(a) A midwife with an inactive license for three years or less who wishes to return to active status must meet the requirements of ((chapter 246-12 WAC, Part 4))WAC 246-12-110.

(b) A midwife with an inactive license for more than three years, who has been in active practice in another United States jurisdiction or territory or other location approved by the department and wishes to return to active status ((must))shall:

(i) Submit verification of active practice; and

(ii) Meet the requirements of ((chapter 246-12 WAC, Part 4))WAC 246-12-110.

(c) A midwife with an inactive license for more than three years but less than five, who has not been in active practice and wishes to return to active status must:

(i) Work as a birth assistant under the supervision of a department-approved preceptor for a minimum of ((ten))10 births; and

(ii) Meet the requirements of ((chapter 246-12 WAC, Part 4))WAC 246-12-110.

(d) A midwife with an inactive license for more than five years who has not been in active practice and wishes to return to active status ((must))shall:

(i) Work as a birth assistant under the supervision of a department-approved preceptor for a minimum of ((fifteen))15 births;

(ii) Retake and successfully pass the Washington state licensing examination; and

(iii) Meet the requirements of ((chapter 246-12 WAC, Part 4))WAC 246-12-110.

(4) A proposed preceptor shall:

(b) Have actively practiced at least three consecutive years or attended at least ((one hundred fifty))150 births; and

(5) A licensed midwife with an inactive license extension who has been engaged in the active practice of midwifery prescriptive or medical devices and implant practice in another United States jurisdiction or territory, or other location approved by the department, and wishes to return to active practice shall:

(a) Submit verification of active practice of prescriptive, devices, or implant practices; and

(b) Meet the requirements of WAC 246-12-110.

(6) A licensed midwife with an inactive license extension for less than five years at the time of reactivation, and has not been actively practicing in midwifery prescriptive, medical devices, and implants practice, the individual may submit their records for their initial training as required in WAC 246-834-165 and meet the requirements in WAC 246-12-040.

(7) A licensed midwife with an inactive license extension for five years or more at the time of reactivation, and who has not been actively engaged in midwifery prescriptive or medical devices and implant practice, shall retake the required training in WAC 246-834-165.

NEW SECTION

The following sections of the Washington Administrative Code are decodified and recodified as follows:

Old WAC Number	New WAC Number
246-834-080	246-834-055
246-834-135	246-834-020
246-834-140	246-834-030