Justification for Adoption of Administrative Rules

16 TAC Chapter 115, amendments §§115.1, 115.70, 115.100, 115.112 - 115.115, 115.117 - 115.119; repeal §115.90 and §115.111, and new §115.111.

The Texas Commission of Licensing and Regulation (Commission) adopts amendments to existing rules at 16 Texas Administrative Code (TAC), Chapter 115, §§115.1, 115.70, 115.100, 115.112 - 115.115, 115.117 - 115.119; adopts the repeal of existing rules §115.90 and §115.111; and adopts new §115.111, regarding the Midwives program.

The amendments to §§115.1, 115.70, 115.100, 115.112 - 115.115 and 115.117, and new §115.111, are adopted with changes to the proposed text as published in the September 28, 2018, issue of the Texas Register (43 TexReg 6426). The rules will be republished.  The repeal of existing rule §115.90 and §115.111 and amendments to §115.118 and §115.119 are adopted without changes to the proposed text as published in the September 28, 2018, issue of the Texas Register (43 TexReg 6426).  The rules will not be republished.

JUSTIFICATION AND EXPLANATION OF THE RULES

The adopted rules implement House Bill (H.B.) 2886 and House Bill (H.B.)  4007, 85th Legislature, Regular Session (2017).  Collectively these bills:

- remove criminal, civil, and administrative liability for licensed midwives who are unable to administer prophylaxis to a newborn’s eyes because of an objection from a parent, managing conservator, or guardian;
- mandate that midwives document objections from the parent, managing conservator, or guardian in the child’s medical record; and
- require the Department to post a list of licensed midwives on its internet site but remove the requirement to provide the list to counties.

The adopted rules also implement recommendations of the Midwives Advisory Board to update the standard of practice requirements by:

- requiring midwives to either terminate the midwife-client relationship or collaborate care with a physician, or a qualified delegate of a physician, when a client refuses a non-emergency transfer to a physician or a qualified delegate of a physician;
- specifying that an emergency exists when a client refuses a transfer deemed necessary by the midwife during labor, delivery, or six hours after delivery, and requiring the midwife to call 911 and provide further care until the arrival of EMS, at which point the midwife may only provide further care if requested by EMS;
- clarifying and expanding the list of prenatal conditions which require the midwife to recommend transfer of a client to a physician or a qualified delegate of a physician; and
- requiring midwives, when a client reaches 42.0 weeks gestation and is not yet in labor, to either: (1) transfer the client to a physician or a qualified delegate of a physician; or (2) collaborate care with a physician and obtain appropriate antenatal testing.

SECTION-BY-SECTION SUMMARY

The adopted amendments to §115.1 add new definitions and renumber the section accordingly.

The adopted amendments to §115.70 update standards of conduct to reflect industry best practices by adding requirements to:

- use generally accepted standards of midwifery care;
- exercise ordinary diligence in the provision of midwifery care;
- act competently in the provision of midwifery care; and
- refrain from knowingly making material misrepresentations to the Department or a client.

The adopted repeal of §115.90 removes the requirement for the Department to provide a copy of the midwife roster to counties.

The adopted amendments to §115.100 update the standards for the practice of midwifery to reflect best practices by adding a requirement to document assessments of clients for factors which might preclude a client from receiving midwifery care.

The adopted repeal of existing §115.111 eliminates current rules for inter-professional care, which are being replaced with a new §115.111.

The adopted new §115.111 establishes the role of the midwife in coordinating care with other health care providers.

The adopted amendments to §115.112 determine when and how a midwife may terminate a client relationship.

The adopted amendments to §115.113 clarify when a midwife must call 911 and transfer care in an emergency situation.

The adopted amendments to §115.114 clarify prenatal care requirements by:

- clarifying the list of conditions that require a midwife to recommend referral;
- clarifying and expanding the list of conditions that require a midwife to recommend transfer; and
- requiring a midwife, when a client reaches 42.0 weeks gestation and is not yet in labor, to either: (1) transfer the client to a physician or a qualified delegate of a physician; or (2) collaborate care with a physician and obtain appropriate antenatal testing.

The adopted amendments to §115.115 clarify requirements during labor and delivery.

The adopted amendments to §115.117 clarify newborn care during the first six weeks after birth by updating the list of conditions that require a midwife to recommend referral.

The adopted amendments to §115.118 clarify standards for administration of oxygen by a midwife to a mother or newborn.

The adopted amendments to §115.119 remove criminal, civil, and administrative liability for licensed midwives who are unable to administer prophylaxis to a newborn’s eyes because of an objection from a parent, conservator, or guardian.

PUBLIC COMMENTS

The Department drafted and distributed the proposed rules to persons internal and external to the agency. The proposed rules were published in the September 28, 2018, issue of the Texas Register (43 TexReg 6426).  The deadline for public comment was October 29, 2018.  The Department received 26 comments during the 30-day public comment period, including five late comments.  One joint comment was submitted by the Texas Medical Association, the Texas Association of Obstetricians and Gynecologists, and the Texas District of the American College of Obstetricians and Gynecologists (hereinafter referred to collectively as “the Physician Associations”).  One comment was submitted by the Association of Texas Midwives.  The public comments received with the Department’s responses are summarized below.

§115.1. Definitions.

Comment: The Physician Associations recommend changing the definition of “collaboration” in proposed §115.1(6) to expressly mention physicians as a profession with whom midwives may collaborate and to provide more consistency in terminology by choosing between “health care practitioner” used in this definition and “health care professional” used in other definitions.

Department Response: The Department agrees with the comment and has amended proposed §115.1(6) to read: “Collaboration--The process in which a midwife and a physician or another licensed health care professional of a different profession jointly manage the care of a woman or newborn according to a mutually agreed-upon plan of care.”

Comment: The Physician Associations recommend changing the definition of “consultation” in proposed §115.1(8) to expressly mention physicians as a profession with whom midwives may consult and to require that a consultation be done with a licensed health care professional of a different profession, rather than with just another “lay midwife.”

Department Response: The Department does not use the term “lay midwife” because Texas-licensed midwives are licensed health care professionals. However, the Department otherwise agrees with the comment and has amended proposed §115.1(8) to read: “Consultation--The process by which a midwife, who maintains responsibility for the woman's care, seeks the advice of a physician or another licensed health care professional or member of the health care team of a different profession.”

Comment: The Physician Associations recommend changing the definition of “referral” in proposed §115.1(19) by specifying that referral to a physician must be to a Texas-licensed physician and removing the phrase “working in association with a licensed physician” and replacing it with the phrase “working under supervision and delegation of a physician.”

Department Response: The Department agrees with the comment and has amended proposed §115.1(19) to read: “Referral--The process by which a midwife directs the client to a physician or another licensed health care professional who has current obstetric or pediatric knowledge and who is working under supervision and delegation of a physician.” Section 115.1(13) defines “physician” as “[a] physician licensed to practice medicine in Texas by the Texas Medical Board.”

Comment: The Physician Associations recommend changing the definition of “transfer” in proposed §115.1(22) by: expressly mentioning physicians as a profession to whom midwives may transfer patients’ care; specifying that transfer to a physician must be to a Texas-licensed physician; and removing the phrase “working in association with a licensed physician” and replacing it with the phrase “working under supervision and delegation of a physician.”

Department Response: The Department agrees with the comment and has amended proposed §115.1(22) to read: “Transfer--The process by which a midwife relinquishes care of the client for pregnancy, labor, delivery, or postpartum care or care of the newborn to a physician or another licensed health care professional who has current obstetric or pediatric knowledge and who is working under the supervision and delegation of a physician.” Section 115.1(13) defines “physician” as “[a] physician licensed to practice medicine in Texas by the Texas Medical Board.”

§115.70. Standards of Conduct.

Comment: One commenter expressed disapproval of the removal of the word “demonstrated” from §115.70(1)(M) because the commenter believes it is more conclusive to leave it.

Department Response: The Department disagrees with the comment. The Department has determined that the term “demonstrated” is redundant and unnecessary because any enforcement action based on “a lack of personal or professional character in the practice of midwifery” would necessarily require evidence of the midwife’s practice that demonstrates such deficiency in character. The Department did not make any changes to the proposed rules in response to this comment.

Comment: With regard to proposed §115.70(1)(N), one commenter stated that the phrase “generally accepted standards of midwifery care” could refer to North American Registry of Midwives (NARM) requirements or be clarified by the Midwifery Model of Care, avoiding the typical medical model of care.

Department Response: The Department has determined that it is preferable to use the proposed language because its breadth can accommodate changes to the standards of midwifery care without reference to any particular organization or model. The Department did not make any changes to the proposed rules in response to this comment.

Comment: With regard to proposed §115.70(1)(P), one commenter asked how the phrase “failure to act competently” will be judged.

Department Response: The issue of whether a midwife has acted competently is a determination that will be made by considering all of the legal provisions and standards applicable to licensed Texas midwives and may, in some circumstances, require expert witness advice and testimony from other midwives with appropriate qualifications. The Department did not make any changes to the proposed rules in response to this comment.

§115.100. Standards for the Practice of Midwifery in Texas.

Comment: The Physician Associations recommend changing proposed §115.100(a)(4) to require midwives to adhere to the Global Standards for Midwifery Education adopted by the International Confederation of Midwives (ICM).

Department Response: The Department disagrees with the comment. The standards adopted by ICM include many issues that fall outside of the scope of midwifery as defined by the Texas Midwifery Act. The ICM standards that do fit the scope of midwifery in Texas are included in the standards adopted by the Midwives Alliance of North America (MANA), which are already referenced in §115.100(a)(4). The Department did not make any changes to the proposed rules in response to this comment.

Comment: The Physician Associations recommend changing §115.100(c)(3) to require midwives to transfer records by adding the phrase “and promptly use” after the word “provide.”

Department Response: The comment does not address any current proposed rule change. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to proposed §115.100(d), the Physician Associations support the directive to engage in periodic evaluation and quality assurance but find that it is unclear how the data will be collected, analyzed, and used to improve quality of care. They recommend that TDLR develop a standardized set of guidelines and documentation requirements for the collected data to further quality assurance and improvement.

Department Response: The comment addresses issues that are beyond the scope of the Department’s proposed changes to the rule. The Department did not make any changes to the proposed rules in response to this comment.

New §115.111. Coordinating Care with Other Health Care Providers.

Comment: The Physician Associations oppose the authorization under proposed §115.111(b)(1) for a midwife to continue care of a patient (without any additional assistance or consultation with another health professional) after the midwife has already identified some condition that increases the risk of complication and requires a higher level of care. They point out that this is outside the scope of midwifery as defined in the Texas Midwifery Act.

Department Response: The Department agrees with the comment and has amended proposed §115.111(b) by adding the phrase “who is at a low risk of developing complications” to clarify that the rule does not apply to conditions that require a higher level of care. Proposed §115.111(b) has been amended to read: “If a client who is at a low risk of developing complications elects not to accept a referral or a physician or associate's advice, the midwife shall: (1) continue to care for the client after discussing and documenting the risks in the midwifery record, which shall include informing the client that her condition may worsen and require transfer; (2) seek a consultation; (3) manage the client in collaboration with an appropriate health care professional; or (4) terminate care.”

Comment: The Physician Associations recommend changing the language in proposed §115.111(c) to better match the language in Occupations Code §203.401(2)(A) relating to the administration of prescription drugs and by removing the passive voice and ambiguity in the phrase “must be obtained.”

Department Response: The Department agrees with the comment and has amended proposed §115.111(c) to read: “If a midwife administers any prescription medication to a client or her newborn other than oxygen and eye prophylaxis, the midwife must do so in accordance with standing delegation orders from and under the supervision of a physician licensed in Texas. The midwife shall ensure that the orders are current (renewed annually) and comply with state law and the rules of the Texas Medical Board.”

Comment:  With regard to proposed §115.111(c), one commenter stated that requiring standing delegation orders from a physician creates a barrier to care and an undue burden on the healthcare delivery system and that TDLR should develop a training and certification program that allows midwives full access to routine, life-saving medications.

Department Response: The Department does not have the statutory authority to make the change requested by the comment. The Texas Legislature determines who has the authority to prescribe and administer prescription medications in Texas, so making the change suggested by this comment would require legislative action. The Department did not make any changes to the proposed rules in response to this comment.

§115.112. Termination of the Midwife-Client Relationship.

Comment:  With regard to proposed §115.112(2)(A), the Physician Associations express concern that the reduction in days of required notice could increase the risk that the patient will experience a lapse in care and will increase the burden on the patient to identify a new health care provider willing to accept responsibility for her care. They suggest adding a requirement to complete a transition of care plan with the patient.

Department Response: The Department disagrees with the comment. Occupations Code §203.351(b)(5) already requires the informed choice and disclosure statement to include a description of medical backup arrangements, so there should not be an increased risk of the client experiencing a lapse in care due to the decrease in the number of days of required notice of the midwife’s termination of care. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to proposed §115.112(2)(A), one commenter supported the change from 30 days to 14 days written notice because it is more reasonable.

Department Response: The Department appreciates this comment. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to proposed §115.112(3)(B), the Physician Associations state that there is no statutory authority for a midwife to jointly manage the care of a patient because the Texas Midwifery Act does not contain the word “collaboration.”

Department Response: The Department disagrees with the comment. Occupations Code §203.151(a-1)(1) provides that “[t]he commission shall adopt rules prescribing the standards for the practice of midwifery in this state…” The Department has determined that this language is intentionally broad to provide the Commission flexibility to adopt concepts not specifically articulated in the statutory language, as long as they do not exceed the scope of the statutory language. The Department did not make any changes to the proposed rules in response to this comment.

Comment: With regard to proposed §115.112(3)(B), the Physician Associations express concern that if the midwife already recognizes that a transfer may be in the patient’s best interest, there is nothing to gain from the midwife’s joint management of the patient with another health care professional because the conditions for which a transfer recommendation is required are serious conditions that cannot be treated properly by a person who does not have advanced medical training.

Department Response: The Department disagrees with the comment. Proposed §115.112(3) is meant to address situations where the client refuses a transfer. The Department has determined that when the client refuses transfer, it is better for the midwife to have the option to continue care in collaboration with a health care professional than it is for the midwife to be forced to terminate the midwife-client relationship and increase the likelihood of an unassisted birth. The Department did not make any changes to the proposed rules in response to this comment.

Comment: The Physician Associations recommend changing proposed §115.112(3)(B) to read: “manage the client in collaboration with a physician or another licensed health care professional who has current obstetric or pediatric knowledge and who is working under supervision and delegation of a physician.”

Department Response: The Department agrees with the comment and has amended proposed §115.112(3)(B) to read: “manage the client in collaboration with a physician or another licensed health care professional who has current obstetric or pediatric knowledge and who is working under the supervision and delegation of a physician.”

§115.113. Transfer of Care in an Emergency Situation.

Comment: With regard to proposed §115.113(b), the Association of Texas Midwives suggested removing the phrase “unless requested by first responders” because a midwife might find herself in a situation where she would be drawn back into the primary care provider position or, if she refused to continue care, may find herself compromised.

Department Response: The Department agrees with the comment and has amended proposed §115.113(b) to read: “It is an emergency if, during labor, delivery, or six hours immediately following placental delivery, the midwife determines that transfer is necessary and the client refuses transfer. The midwife shall call 911 and provide further care as indicated by the situation. The midwife shall not provide any further care after the arrival of emergency medical service (EMS) personnel but may do so if requested by EMS personnel.”

Comment: With regard to proposed §115.113(b), four commenters had concerns, that first responders, such as police officers and firefighters, may not have sufficient medical training and knowledge to take over care and may not request help from the midwife.

Department Response: The Department agrees with the comment and has amended proposed §115.113(b) to read: “It is an emergency if, during labor, delivery, or six hours immediately following placental delivery, the midwife determines that transfer is necessary and the client refuses transfer. The midwife shall call 911 and provide further care as indicated by the situation. The midwife shall not provide any further care after the arrival of emergency medical service (EMS) personnel but may do so if requested by EMS personnel.”

Comment: With regard to proposed §115.113(b), one commenter stated that midwives often report negative experiences and outcomes due to factors related to emergency medical service (EMS) care. The commenter stated that while the midwife may be the more experienced obstetric provider, EMS has its own policies and procedures to follow. The commenter stated that TDLR should investigate which actions a midwife can take when EMS appears to put a mother or baby at risk.

Department Response: The Department understands that EMS personnel may not have the obstetric knowledge and skills that midwives possess. However, when an emergency situation exists, EMS is necessary to transport the client to a facility where a higher level of care can be provided. It would be outside the scope of midwifery to continue providing sole care of the client in an emergency situation. The midwife may contact the health care professional or institution to whom the client is being transferred to communicate concerns about EMS actions that appear to put the mother or baby at risk. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to proposed §115.113(b), one commenter asked what happens if the client refuses care from the first responders.

Department Response: The midwife would not be authorized to continue sole care of the client in this situation because the client’s condition does not qualify as a “normal” labor, delivery, or postpartum period and therefore falls outside of the scope of the Texas Midwifery Act. The Department did not make any changes to the proposed rules in response to this comment.

§115.114. Prenatal Care.

Comment: The Physician Associations expressed concern that the rules do not require planning for emergency transfers and suggested adding the following language to §115.114(a): “The plan of care must include a plan developed with the patient for transfers in emergency situations that accounts for the situations in which a transfer is required and consideration of the licensed health care professionals or institutions that the patient will be transferred to in the event of an emergency.”

Department Response: This comment does not address any current proposed rule change. However, it should be noted that Occupations Code §203.351(b)(5) already requires the informed choice and disclosure statement to include a description of medical backup arrangements. The Department did not make any changes to the proposed rules in response to this comment.

Comment: With regard to proposed §115.114(c)(8), ten commenters were concerned that “uterine surgery” is too broad of a term that includes procedures, such as dilation and curettage, which should not preclude an out-of-hospital birth.

Department Response: The Department agrees with the comments and has amended proposed §115.114(c)(8) to read: “previous uterine surgery involving incision into the uterine myometrium, other than a low transverse cesarean section.”

Comment:  With regard to proposed §115.114(c)(8), the Physician Associations expressed concern that a midwife would be allowed to continue caring for a patient who has had a low transverse cesarean section because vaginal birth after cesarean section has risks and may result in the need for an emergency cesarean section. They suggest changing the language to remove the phrase “other than a low transverse cesarean section.”

Department Response: The Department disagrees with the comment. The Department, in consultation with the Midwives Advisory Board, has determined that although vaginal birth after cesarean section involves risks that would require the midwife to recommend referral, it does not constitute a high-risk condition that would require the midwife to recommend transfer. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to proposed §115.114(c)(8), one commenter stated that the old language is better because it is specific to the uterine fundus.

Department Response: The Department agrees that the published language was too broad, so the Department has amended proposed §115.114(c)(8) to read: “previous uterine surgery involving incision into the uterine myometrium, other than a low transverse cesarean section.”

Comment: With regard to §115.114(d), the Association of Texas Midwives suggests changing the proposed language to read “collaborate with a health care professional” instead of “a physician,” to better reflect the new proposed definition of “collaboration” as “the process in which a midwife and a health care practitioner of a different profession jointly manage the care of a woman or newborn according to a mutually agreed-upon plan of care.”

Department Response: The Department disagrees with the comment because the Department has determined that the risks associated with continued gestation at 42.0 weeks require the advice and assistance of a physician. The Department did not make any changes to the proposed rules in response to this comment.

Comment: With regard to §115.114(d), 14 commenters expressed concern that many midwives, especially in rural areas, have limited or no access to physicians willing and able to participate in collaboration or transfer at 42.0 weeks.

Department Response: The Department acknowledges that many midwives, especially in rural areas, have limited access to physicians; however, the Department has determined that the risks associated with continued gestation at 42.0 weeks require the advice and assistance of a physician. The commenters seem to misunderstand the intent and effect of the proposed rule. Section 115.1(12) already defines “normal childbirth” as “the labor and vaginal delivery at or close to term (37 up to 42 weeks) of a pregnant woman whose assessment reveals no abnormality or signs or symptoms of complications.” This definition already created the requirement of transfer at 42 weeks, but it left some ambiguity about what is meant by “42 weeks.” The proposed rule more clearly draws the line at “42.0 weeks” while also adding the option of continuing midwifery care through collaboration with a physician and appropriate antenatal testing. Therefore, rather than limiting the options for midwifery care, the proposed rule is actually expanding the options for midwifery care. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to §115.114(d), 11 commenters stated that it is a standard of care for midwives to order appropriate antenatal testing without a collaborating physician.

Department Response: The Department disagrees with the comment because antenatal testing is necessarily done by a physician. The Department has determined that the risks associated with continued gestation at 42.0 weeks require the advice and assistance of a physician. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to §115.114(d), seven commenters stated that being 42 weeks gestation does not threaten the lives of most mothers or fetuses, as long as proper monitoring shows no problems.

Department Response: The Department disagrees with the comment because the Department, through consultation with the Midwives Advisory Board, has determined that the risks associated with continued gestation at 42.0 weeks require the advice and assistance of a physician. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to §115.114(d), seven commenters submitted suggestions for alternatives to collaboration with a physician that allow the midwife to continue sole care of the client.

Department Response: The Department disagrees with the suggested alternatives because the Department, through consultation with the Midwives Advisory Board, has determined that the risks associated with continued gestation at 42.0 weeks require the advice and assistance of a physician. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to §115.114(d), five commenters stated that the proposed change unfairly restricts the mother’s right to choose the conditions of her birth.

Department Response: The Department disagrees with the comment because the Department, through consultation with the Midwives Advisory Board, has determined that the risks associated with continued gestation at 42.0 weeks require the advice and assistance of a physician. The commenters seem to misunderstand the intent and effect of the proposed rule. Section 115.1(12) already defines “normal childbirth” as “the labor and vaginal delivery at or close to term (37 up to 42 weeks) of a pregnant woman whose assessment reveals no abnormality or signs or symptoms of complications.” This definition already created the requirement of transfer at 42 weeks, but it left some ambiguity about what is meant by “42 weeks.” The proposed rule more clearly draws the line at “42.0 weeks” while also adding the option of continuing midwifery care through collaboration with a physician and appropriate antenatal testing. Therefore, rather than limiting the options for midwifery care, the proposed rule is actually expanding the options for midwifery care. The Department did not make any changes to the proposed rules in response to this comment.

Comment:  With regard to §115.114(d), one commenter asked what the midwife is supposed to do when the client refuses collaboration and transfer at 42.0 weeks and the midwife terminates care but is still responsible for care for 14 days.

Department Response: The midwife should not wait until 42.0 weeks to determine whether the client will agree to collaboration or transfer. This determination should be made in advance so that if the client will not agree, the midwife can begin the termination process with sufficient time for the care to be terminated on the date the client reaches 42.0 weeks. The Department did not make any changes to the proposed rules in response to this comment.

§115.115. Labor and Delivery.

Comment:  With regard to §115.115(e)(6), 26 commenters opposed the proposed language because it includes conditions which cannot be detected by intermittent auscultation and would require continuous electronic fetal monitoring. Many of these commenters included suggestions for changes that list conditions which can be detected by intermittent auscultation.

Department Response: In response to the comments received on this rule, the Midwives Advisory Board recommended amending proposed §115.115(e)(6) to read: “abnormal fetal or uterine monitoring, which includes but is not limited to bradycardia, tachycardia, abnormal rhythm, persistent decelerations after position changes, and uterine tachysystole.” However, after considering the concerns raised in public comments and discussing the issue, the Commission believes that further study of this issue is warranted and therefore declines to adopt the proposed amendment to §115.115(e)(6) at this time, leaving the current language in effect. The Commission has directed that this rule be returned to the Board for further consideration. The Department will work with the Board on development of a proposed rule amendment to bring to the Commission at a later date.

Comment:  With regard to §115.115(e)(6), one commenter supported the proposed language and believed that the listed conditions can be detected without continuous electronic fetal monitoring.

Department Response: In response to the comments received on this rule, the Midwives Advisory Board recommended amending proposed §115.115(e)(6) to read: “abnormal fetal or uterine monitoring, which includes but is not limited to bradycardia, tachycardia, abnormal rhythm, persistent decelerations after position changes, and uterine tachysystole.” However, after considering the concerns raised in public comments and discussing the issue, the Commission believes that further study of this issue is warranted and therefore declines to adopt the proposed amendment to §115.115(e)(6) at this time, leaving the current language in effect. The Commission has directed that this rule be returned to the Board for further consideration. The Department will work with the Board on development of a proposed rule amendment to bring to the Commission at a later date.

Comment:  With regard to §115.115(e)(6), one commenter stated that all obstetric attendants have abandoned the term “non-reassuring” because it is vague, with over 30 definitions, and has been replaced by a 3-tiered system since 2010.

Department Response: In response to the comments received on this rule, the Midwives Advisory Board recommended amending proposed §115.115(e)(6) to read: “abnormal fetal or uterine monitoring, which includes but is not limited to bradycardia, tachycardia, abnormal rhythm, persistent decelerations after position changes, and uterine tachysystole.” However, after considering the concerns raised in public comments and discussing the issue, the Commission believes that further study of this issue is warranted and therefore declines to adopt the proposed amendment to §115.115(e)(6) at this time, leaving the current language in effect. The Commission has directed that this rule be returned to the Board for further consideration. The Department will work with the Board on development of a proposed rule amendment to bring to the Commission at a later date.

Comment:  With regard to §115.115(e)(6), one commenter stated that the listed patterns include conditions which are present in over 80% of labors and are non-emergent, which would make it nearly impossible for midwives to attend out-of-hospital births.

Department Response: In response to the comments received on this rule, the Midwives Advisory Board recommended amending proposed §115.115(e)(6) to read: “abnormal fetal or uterine monitoring, which includes but is not limited to bradycardia, tachycardia, abnormal rhythm, persistent decelerations after position changes, and uterine tachysystole.” However, after considering the concerns raised in public comments and discussing the issue, the Commission believes that further study of this issue is warranted and therefore declines to adopt the proposed amendment to §115.115(e)(6) at this time, leaving the current language in effect. The Commission has directed that this rule be returned to the Board for further consideration. The Department will work with the Board on development of a proposed rule amendment to bring to the Commission at a later date.

Comment:  With regard to §115.115(e)(6), one commenter stated that the specificity of the proposed language is problematic because the standards and terminology could change and require further amendments to the rule.

Department Response: In response to the comments received on this rule, the Midwives Advisory Board recommended amending proposed §115.115(e)(6) to read: “abnormal fetal or uterine monitoring, which includes but is not limited to bradycardia, tachycardia, abnormal rhythm, persistent decelerations after position changes, and uterine tachysystole.” However, after considering the concerns raised in public comments and discussing the issue, the Commission believes that further study of this issue is warranted and therefore declines to adopt the proposed amendment to §115.115(e)(6) at this time, leaving the current language in effect. The Commission has directed that this rule be returned to the Board for further consideration. The Department will work with the Board on development of a proposed rule amendment to bring to the Commission at a later date.

Comment:  With regard to §115.115(e)(6), the Association of Texas Midwives opposes the proposed language because the section has received the greatest number of criticisms.

Department Response: In response to the comments received on this rule, the Midwives Advisory Board recommended amending proposed §115.115(e)(6) to read: “abnormal fetal or uterine monitoring, which includes but is not limited to bradycardia, tachycardia, abnormal rhythm, persistent decelerations after position changes, and uterine tachysystole.” However, after considering the concerns raised in public comments and discussing the issue, the Commission believes that further study of this issue is warranted and therefore declines to adopt the proposed amendment to §115.115(e)(6) at this time, leaving the current language in effect. The Commission has directed that this rule be returned to the Board for further consideration. The Department will work with the Board on development of a proposed rule amendment to bring to the Commission at a later date.

§115.117. Newborn Care During the First Six Weeks After Birth.

Comment:  With regard to §115.117(c)(4), one commenter stated that it is better to leave the language as it is because it is accepted terminology.

Department Response: The Department disagrees with the comment. The Department has determined that the new language reflects the proper medical standard and is preferable because it provides more specificity. The Department did not make any changes to the proposed rules in response to this comment.

§115.118. Administration of Oxygen.

Comment:  With regard to §115.118(a), the Physician Associations express concern that the proposed language could be interpreted to mean that there is no requirement for a midwife to provide oxygen when the client or the newborn require it. The Physician Associations believe that Occupations Code §203.151 requires a midwife to provide oxygen when a client or newborn require it.

Department Response: The Department disagrees with the comment. The relevant statutory language in Occupations Code §203.151(a-1) provides: “The commission shall…(1) adopt rules prescribing the standards for the practice of midwifery in this state, including standards for…(B) administration of oxygen by a midwife to a mother or newborn[.]” The Department does not interpret this language as a requirement for midwives to administer oxygen; rather, the Department interprets the language as a requirement to adopt standards for administration of oxygen to be applied when a midwife chooses to administer oxygen. The Department did not make any changes to the proposed rules in response to this comment.

ADVISORY BOARD RECOMMENDATIONS AND COMMISSION ACTION

The Midwives Advisory Board (Board) met on January 8, 2019, to discuss the proposed rules and the comments received. The Board recommended adopting the proposed rules with changes to §115.1 and §115.100, proposed new §115.111, and §§115.112 - 115.115.

At its meeting on March 22, 2019, the Commission adopted the rules with changes as recommended by the Board, with the exception of the proposed amendments to §115.115(e)(6), which the Commission did not adopt.  The Commission has directed that this rule be returned to the Board for further consideration.

STATUTORY AUTHORITY

The amendments and new rules are adopted under Texas Occupations Code, Chapters 51 and 203, which authorize the Commission, the Department’s governing body, to adopt rules as necessary to implement these chapters and any other law establishing a program regulated by the Department.

The statutory provisions affected by the adoption are those set forth in Texas Occupations Code, Chapters 51 and 203. No other statutes, articles, or codes are affected by the adoption.

§115.1. Definitions.

The following words and terms when used in this chapter shall have the following meaning unless the context clearly indicates otherwise.

(1) Act--The Texas Midwifery Act, Texas Occupations Code, Chapter 203.

(2) Advisory Board--The Midwives Advisory Board appointed by the presiding officer of the Commission with the approval of the Commission.

(3) Appropriate health care facility--The Department of State Health Services, a local health department, a public health district, a local health unit or a physician's office where specified tests can be administered and read, and where other medical/clinical procedures normally take place.

(4) Approved midwifery education courses--The basic midwifery education courses approved by the department.

(5) Code--Texas Health and Safety Code.

(6) Collaboration--The process in which a midwife and a physician or another licensed health care professional of a different profession jointly manage the care of a woman or newborn according to a mutually agreed-upon plan of care.

(7) Commission--The Texas Commission of Licensing and Regulation.

(8) Consultation--The process by which a midwife, who maintains responsibility for the woman's care, seeks the advice of a physician or another licensed health care professional or member of the health care team of a different profession.

(9) Department--The Texas Department of Licensing and Regulation.

(10) Executive director--The executive director of the department.

(11) Health authority--A physician who administers state and local laws regulating public health under the Health and Safety Code, Chapter 121, Subchapter B.

(12) Local health unit--A division of a municipality or county government that provides limited public health services as provided by the Health and Safety Code, §121.004.

(13) Newborn care--The care of a child for the first six weeks of the child's life.

(14) Normal childbirth--The labor and vaginal delivery at or close to term (37 up to 42 weeks) of a pregnant woman whose assessment reveals no abnormality or signs or symptoms of complications.

(15) Physician--A physician licensed to practice medicine in Texas by the Texas Medical Board.

(16) Postpartum care--The care of a woman for the first six weeks after the woman has given birth.

(17) Program--The department's midwifery program.

(18) Public health district--A district created under the Health and Safety Code, Chapter 121, Subchapter E.

(19) Referral--The process by which a midwife directs the client to a physician or another licensed health care professional who has current obstetric or pediatric knowledge and who is working under supervision and delegation of a physician.

(20) Retired midwife--A midwife licensed in Texas who is over the age of 55 and not currently employed in a health care field.

(21) Standing delegation orders--Written instructions, orders, rules, regulations or procedures prepared by a physician and designated for a patient population, and delineating under what set of conditions and circumstances actions should be instituted, as described in the rules of the Texas Medical Board in Chapter 193 (relating to Standing Delegation Orders) and §115.111 of this title (relating to Coordinating Care with Other Health Care Providers).

(22) Transfer--The process by which a midwife relinquishes care of the client for pregnancy, labor, delivery, or postpartum care or care of the newborn to a physician or another licensed health care professional who has current obstetric or pediatric knowledge and who is working under the supervision and delegation of a physician.

(23) Voluntary charity care--Midwifery care provided without compensation and with no expectation of compensation.

§115.70. Standards of Conduct.

The following are grounds for denial of application for licensure or license renewal and for disciplinary action.

(1) The commission or executive director may deny an application for initial licensure or license renewal and may take disciplinary action against any person based upon proof of the following:

(A) violation of the Act or rules adopted under the Act;

(B) submission of false or misleading information to the department;

(C) conviction of a felony or a misdemeanor involving moral turpitude;

(D) intemperate use of alcohol or drugs while engaged in the practice of midwifery;

(E) unprofessional or dishonorable conduct that may reasonably be determined to deceive or defraud the public;

(F) inability to practice midwifery with reasonable skill and safety because of illness, disability, or psychological impairment;

(G) judgment by a court of competent jurisdiction that the individual is mentally impaired;

(H) disciplinary action taken by another jurisdiction affecting the applicant's legal authority to practice midwifery;

(I) submission of a birth or death certificate known by the individual to be false or fraudulent, or other noncompliance with Health and Safety Code, Chapter 191, or 25 Texas Administrative Code (TAC), Chapter 181 (relating to Vital Statistics);

(J) noncompliance with Health and Safety Code, Chapter 244, or 25 TAC, Chapter 137 (relating to Birthing Centers);

(K) failure to practice midwifery in a manner consistent with the public health and safety;

(L) failure to submit midwifery records in connection with the investigation of a complaint;

(M) a lack of personal or professional character in the practice of midwifery;

(N) failure to use generally accepted standards of midwifery care;

(O) failure to exercise ordinary diligence in the provision of midwifery care;

(P) failure to act competently in the provision of midwifery care; or

(Q) a material misrepresentation knowingly made to the department on any matter or to a client during the provision of midwifery care.

(2) The department may refuse to renew the license of a person who fails to pay an administrative penalty imposed under the Act, unless enforcement of the penalty is stayed or a court has ordered that the administrative penalty is not owed.

(3) The commission or executive director may revoke course approval if:

(A) the course no longer meets one or more of the standards established by this subsection;

(B) the course supervisor, instructor(s), or preceptor(s) do not have the qualifications required by this subsection;

(C) course approval was obtained by fraud or deceit;

(D) the course supervisor falsified course registration, attendance, completion and/or other records; or

(E) continued approval of the course is not in the public interest.

§115.100. Standards for the Practice of Midwifery in Texas.

(a) Using reasonable skill and knowledge, the midwife shall:

(1) provide clients with a description of the scope of midwifery services and information regarding the client's rights and responsibilities in accordance with the Act;

(2) assess the client on an ongoing basis for any factors which might preclude a client from admission into or continuing in midwifery care and document that assessment in the midwifery record;

(3) provide clients with information about other providers and services when requested or when the care required is not within the scope of practice of midwifery; and

(4) practice in accordance with the knowledge, clinical skills, and judgments described in the most recently adopted version of the Midwives Alliance of North America (MANA) Core Competencies for Basic Midwifery Practice, within the bounds of the midwifery scope of practice as defined by the Act and Rules;

(b) The midwife shall provide care in a safe and clean environment. The midwife shall:

(1) carry and use when needed, resuscitation equipment; and

(2) use universal precautions for infection control.

(c) The midwife shall document midwifery care in legible, complete health records. The midwife shall:

(1) maintain records that completely and accurately document the client's history, physical exam, laboratory test results, antepartum visits, consultations, referrals, labor, delivery, postpartum visits, and neonatal evaluations at the time midwifery services are delivered and when reports are received;

(2) review problems identified by the midwife or by other professionals or consumers in the community; and

(3) act to resolve problems that are identified.

(4) maintain the confidentiality of midwifery records; and

(5) maintain records:

(A) for the mother, for a minimum of five years; and

(B) for the infant, until the age of majority.

(d) The midwife shall engage in a periodic process of evaluation and quality assurance. The midwife shall:

(1) collect client care data systematically and be involved in analysis of that data for the evaluation of the process and outcome of care;

(2) review problems identified by the midwife or by other professionals or consumers in the community; and

(3) act to resolve problems that are identified.

§115.111. Coordinating Care with Other Health Care Providers.

(a) A midwife shall consult with, refer to, collaborate with, or transfer to an appropriate healthcare provider or facility in accordance with the Act and this chapter.

(b) If a client who is at a low risk of developing complications elects not to accept a referral or a physician or associate's advice, the midwife shall:

(1) continue to care for the client after discussing and documenting the risks in the midwifery record, which shall include informing the client that her condition may worsen and require transfer;

(2) seek a consultation;

(3) manage the client in collaboration with an appropriate health care professional; or

(4) terminate care.

(c) If a midwife administers any prescription medication to a client or her newborn other than oxygen and eye prophylaxis, the midwife must do so in accordance with standing delegation orders from and under the supervision of a physician. The midwife shall ensure that the orders are current (renewed annually) and comply with state law and the rules of the Texas Medical Board.

§115.112. Termination of the Midwife-Client Relationship.

A midwife shall terminate care of a client only in accordance with this section unless a transfer of care results from an emergency situation.

(1) Once the midwife has accepted a client, the relationship is ongoing and the midwife cannot refuse to continue to provide midwifery care to the client unless:

(A) the client has no need of further care;

(B) the client terminates the relationship; or

(C) the midwife formally terminates the relationship.

(2) The midwife may terminate care for any reason by:

(A) providing a minimum of 14 days written notice, during which the midwife shall continue to provide midwifery care;

(B) making an attempt to tell the client in person and in the presence of a witness of the midwife's wish to terminate care and the date that care will be terminated;

(C) providing a list of alternate health care providers; and

(D) documenting the termination of care in midwifery records.

(3) If a client elects not to accept a non-emergency transfer, the midwife shall:

(A) terminate the midwife-client relationship; or

(B) manage the client in collaboration with a physician or another licensed health care professional who has current obstetric or pediatric knowledge and who is working under the supervision and delegation of a physician.

§115.113. Transfer of Care in an Emergency Situation.

(a) In an emergency situation, the midwife shall initiate emergency care as indicated by the situation and immediate transfer of care by making a reasonable effort to contact the health care professional or institution to whom the client will be transferred and to follow the health care professional's instructions; and continue emergency care as needed while:

(1) transporting the client by private vehicle; or

(2) calling 911 and reporting the need for immediate transfer.

(b) It is an emergency if, during labor, delivery, or six hours immediately following placental delivery, the midwife determines that transfer is necessary and the client refuses transfer. The midwife shall call 911 and provide further care as indicated by the situation. The midwife shall not provide any further care after the arrival of emergency medical service (EMS) personnel but may do so if requested by EMS personnel.

§115.114. Prenatal Care.

(a) Using reasonable skill and knowledge, the midwife shall collect, assess, and document maternal care data through a detailed obstetric, gynecologic, medical, social, and family history and a complete prenatal physical exam and appropriate laboratory testing, including antenatal testing if necessary; develop and implement a plan of care; thereafter evaluate the client's condition on an ongoing basis; and modify the plan of care as necessary. Health education/counseling shall be provided by the midwife as appropriate.

(b) If on initial or subsequent assessment, one of the following conditions exists, the midwife shall recommend referral and document that recommendation in the midwifery record:

(1) infection requiring antimicrobial therapy;

(2) Hepatitis;

(3) non-insulin dependent diabetes;

(4) thyroid disease;

(5) current drug or alcohol abuse;

(6) asthma;

(7) abnormal pap smear (consistent with malignancy or pre-malignancy) during the current pregnancy;

(8) seizure disorder;

(9) prior cesarean section (except for prior classical or vertical incision, which will require transfer in accordance with subsection (c)(8));

(10) twin gestation;

(11) history of prior antepartum or neonatal death;

(12) history of prior infant with a genetic disorder;  

(13) abnormal vaginal bleeding;

(14) maternal age less than 15 at estimated date of delivery;

(15) history of cancer (except for ovarian, breast, uterine, or cervical cancer which will require transfer in accordance with subsection (c)(16));

(16) psychiatric illness; or

(17) any other condition or symptom which could adversely affect the mother or fetus, as assessed by a midwife exercising reasonable skill and knowledge.

(c) If on initial or subsequent assessment, one of the following conditions exists, the midwife shall recommend transfer in accordance and document that recommendation in the midwifery record:

(1) placenta previa in the third trimester;

(2) Human Immunodeficiency Virus (HIV) positive or Acquired Immunodeficiency Syndrome (AIDS);

(3) cardio vascular disease, including hypertension, with the exception of varicosities;

(4) severe psychiatric illness;

(5) history of cervical incompetence with surgical therapy;

(6) pre-term labor (less than 37 weeks);

(7) Rh or other blood group isoimmunization;

(8) previous uterine surgery involving incision into the uterine myometrium, other than a low transverse cesarean section;

(9) preeclampsia/eclampsia;

(10) documented oligo-hydramnios or poly-hydramnios;

(11) any known fetal malformation requiring immediate post-natal hospital care;

(12) Preterm Premature Rupture of Membranes (PPROM);

(13) intrauterine growth restriction;

(14) insulin dependent diabetes;

(15) triplet or higher order multiple gestation;

(16) active cancer or history of ovarian, breast, uterine, or cervical cancer;

(17) undiagnosed vaginal bleeding lasting longer than two weeks; or

(18) any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a midwife exercising reasonable skill and knowledge.

(d) If a client has reached 42.0 weeks gestation and is not yet in labor, the midwife shall immediately either:

(1) collaborate with a physician and obtain appropriate antenatal testing, in order to continue midwifery care; or

(2) initiate transfer and document that action in the midwifery record.

§115.115. Labor and Delivery.

(a) Using reasonable skill and knowledge, the midwife shall evaluate the client when the midwife arrives for labor and delivery, by obtaining a history, performing a physical exam, and collecting laboratory specimens.

(b) The midwife shall monitor the client's progress in labor by monitoring vital signs, contractions, fetal heart tones, cervical dilation, effacement, station, presentation, membrane status, input/output and subjective status as indicated.

(c) The midwife shall assist only in normal, spontaneous vaginal deliveries as allowed by the Act or this chapter.

(d) The midwife shall not engage in the following:

(1) application of fundal pressure on abdomen or uterus during first or second stage of labor;

(2) administration of oxytocin, ergot, or prostaglandins prior to or during first or second stage of labor; or

(3) any other prohibited practice as delineated by the Act, §203.401 (relating to Prohibited Practices).

(e) If on initial or subsequent assessment during labor or delivery, one of the following conditions exists, the midwife shall initiate immediate emergency transfer in accordance with §115.113 and document that action in the midwifery record:

(1) prolapsed cord;

(2) chorio-amnionitis;

(3) uncontrolled hemorrhage;

(4) gestational hypertension/preeclampsia/eclampsia;

(5) severe abdominal pain inconsistent with normal labor;

(6) a non-reassuring fetal heart rate pattern;

(7) seizure;

(8) thick meconium unless the birth is imminent;

(9) visible genital lesions suspicious of herpes virus infection;

(10) evidence of maternal shock;

(11) preterm labor (less than 37 weeks);

(12) presentation(s) not compatible with spontaneous vaginal delivery;

(13) laceration(s) requiring repair beyond the scope of practice of the midwife;

(14) failure to progress in labor;

(15) retained placenta; or

(16) any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a midwife exercising reasonable skill and knowledge.

§115.117. Newborn Care During the First Six Weeks After Birth.

(a) Prior to delivery, the midwife shall establish a plan with the client for continuing care of the newborn. This plan shall:

(1) include referral or transfer to a health care professional who has current pediatric knowledge;

(2) include a recommendation that the client pre-arrange the timing of the first newborn visit with the health care professional; and

(3) be documented in the midwifery record.

(b) Using reasonable skill and knowledge, the midwife shall:

(1) collect, assess and document newborn care data by monitoring the vital signs, performing a physical exam, and obtaining the laboratory tests necessary for the infant during the postpartum period;

(2) provide appropriate education and counseling to the mother; and

(3) observe the newborn for a minimum of two hours after he or she is stable with no signs of distress.  

(c) If on any newborn assessment in the immediate postpartum period (first six hours of life), one of the following conditions exists, the midwife shall recommend referral and document that recommendation in the midwifery record:

(1) birth injury;

(2) gestational age assessment less than 36 weeks;

(3) small for gestational age;

(4) larger than 97th percentile for gestational age; or

(5) any other abnormal newborn behavior or appearance which could adversely affect the newborn, as assessed by a midwife exercising reasonable skill and knowledge.

(d) If on any newborn assessment in the immediate postpartum period (first six hours of life), one of the following conditions exists, the midwife shall initiate immediate transfer to an appropriate health care professional, initiate emergency care as indicated by the situation, continue care as needed, and document that action in the midwifery record:

(1) non-transient respiratory distress;

(2) non-transient pallor or central cyanosis;

(3) jaundice;

(4) apgar at 5 minutes less than or equal to 6;

(5) prolonged apnea;

(6) hemorrhage;

(7) signs of infection;

(8) seizure;

(9) major congenital anomaly not diagnosed prenatally;

(10) unstable vital signs;

(11) prolonged:

(A) lethargy;

(B) flaccidity; or

(C) irritability;

(12) inability to suck;

(13) persistent jitteriness;

(14) hyperthermia;

(15) hypothermia; or

(16) other abnormal newborn behavior or appearance which could threaten the life of the newborn, as assessed by a midwife exercising reasonable skill and knowledge.

(e) If on any newborn assessment after the immediate postpartum period, one of the following conditions exists, the midwife shall recommend referral to an appropriate health care professional and document that recommendation in the midwifery record:

(1) abnormal laboratory test results;

(2) minor congenital anomaly;

(3) failure to thrive; or

(4) any other abnormal newborn behavior or appearance which could adversely affect the infant, as assessed by a midwife exercising reasonable skill and knowledge.

(f) If on any newborn assessment after the immediate postpartum period, one of the following conditions exists, the midwife shall initiate immediate transfer to an appropriate health care professional and document that action in the midwifery record:

(1) respiratory distress;

(2) pallor or central cyanosis;

(3) pathological jaundice;

(4) hemorrhage;

(5) seizure;

(6) inability to urinate or pass meconium within 24 hours of birth;

(7) unstable vital signs;

(8) lethargy;

(9) flaccidity;

(10) irritability;

(11) inability to feed;

(12) persistent jitteriness; or

(13) any other abnormal newborn behavior or appearance which could threaten the life of the newborn, as assessed by a midwife exercising reasonable skill and knowledge.

§115.118. Administration of Oxygen.

(a) A midwife is not required to use oxygen but remains responsible for assessing the client and newborn, recommending referral, and recommending transfer or transport of the mother and newborn.

(b) This section establishes that:

(1) intrapartum oxygen may be administered to the mother for the following:

(A) fetal heart rate irregularities while assessing for consultation and/or possible transfer;

(B) cord prolapse prior to transport;

(C) signs or symptoms of maternal shock or hemorrhage prior to transport;

(D) as indicated by American Heart Association Cardiopulmonary Resuscitation Guidelines; or

(E) other situations not listed above and deemed necessary according to generally accepted standards of midwifery practice to protect the health and well-being of the mother or fetus;

(2) postpartum oxygen may be administered while monitoring according to the Midwifery Practice Standards and Principles:

(A) to the newborn during the initial neonatal period at a rate concurrent with American Academy of Pediatrics Neonatal Resuscitation guidelines; or

(B) to the mother and/or newborn in other situations not listed above and deemed necessary according to generally accepted standards of midwifery practice to protect the health and well-being of the mother and/or newborn;

(3) indications for administration of oxygen shall be clearly documented in the midwifery record.

(c) Midwives are authorized to purchase equipment and supplies listed in the American Heart Association Cardiopulmonary Resuscitation Guidelines and the American Academy of Pediatrics Neonatal Resuscitation Guidelines for the administration of oxygen.

§115.119. Eye Prophylaxis.

(a) Each midwife is responsible for administering or causing to be administered to every infant which she or he delivers the necessary eye prophylaxis to prevent ophthalmia neonatorum in accordance with the medications specified in Health and Safety Code, §81.091.

(b)  A midwife in attendance at childbirth who is unable to apply prophylaxis as required by Section 81.091, Health and Safety Code, due to the objection of the parent, managing conservator, or guardian of the newborn child does not commit an offense under that section and is not subject to any criminal, civil, or administrative liability or any professional disciplinary action for failure to administer the prophylaxis. The midwife in attendance at childbirth shall ensure that the administration of eye prophylaxis, or the objection of the parent, managing conservator, or guardian, is entered into the medical record of the child.

(c) The administration and possession of prophylaxis by a midwife is not a violation of the provisions of the Health and Safety Code, Chapter 483, concerning dangerous drugs.

The repeal is adopted under the Texas Occupations Code, Chapters 51 and 203, which authorize the Commission, the Department’s governing body, to adopt rules as necessary to implement these chapters and any other law establishing a program regulated by the Department.

The statutory provisions affected by the adoption are those set forth in Texas Occupations Code, Chapters 51 and 203. No other statutes, articles, or codes are affected by the adoption.

[§115.90. State Roster of Licensed Midwives.]
[§115.111. Inter-professional Care.]

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency’s legal authority.

Filed with the Office of the Secretary of State, on March 28, 2019.

Brad Bowman
General Counsel
Texas Department of Licensing and Regulation