Amended  IN  Senate  June 18, 2020
Amended  IN  Senate  May 19, 2020
Amended  IN  Senate  May 13, 2020

CALIFORNIA LEGISLATURE— 2019–2020 REGULAR SESSION

Senate Bill
No. 1237

Introduced by Senator Dodd
(Coauthor: Senator Mitchell)
(Principal coauthor: Assembly Member Burke)

February 20, 2020

An act to amend Sections 650.01, 2746.2, 2746.5, 2746.51, and 2746.52 of, and to add Section Sections 2746.54 and 2746.55 to, the Business and Professions Code, relating to healing arts.


LEGISLATIVE COUNSEL'S DIGEST


SB 1237, as amended, Dodd. Nurse-midwives: scope of practice.
(1) Existing law, the Nursing Practice Act, establishes the Board of Registered Nursing within the Department of Consumer Affairs for the licensure and regulation of the practice of nursing. A violation of the act is a crime. Existing law requires the board to issue a certificate to practice nurse-midwifery to a person who, among other qualifications, meets educational standards established by the board or the equivalent of those educational standards. Existing law authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. Existing law defines the practice of nurse-midwifery as the furthering or undertaking by a certified person, under the supervision of licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. Existing law requires all complications to be referred to a physician immediately. Existing law excludes the assisting of childbirth by any artificial, forcible, or mechanical means, and the performance of any version from the definition of the practice of nurse-midwifery.

The bill

This bill would delete the above-described provisions defining the practice of nurse-midwifery, would delete the condition that a certified nurse-midwife practice under the supervision of a physician and surgeon surgeon, and would instead authorize a certified nurse-midwife to attend cases of normal pregnancy low-risk pregnancy, as defined, and childbirth and to provide prenatal, intrapartum, and postpartum care, including gynecologic and family-planning services, interconception care, and immediate care of the newborn, consistent with standards adopted by a specified professional organization, or its successor, as approved by the board. The bill would delete the above-described provisions defining the practice of nurse-midwifery, and instead would provide that the practice of nurse-midwifery includes consultation, comanagement, or referral, as those terms are defined by the bill, as indicated by the health status of the patient and the resources and medical personnel available in the setting of care, subject to specified conditions, including that a patient is required to be transferred from the primary management responsibility of the nurse-midwife to that of a physician and surgeon for the management of a problem or aspect of the patient’s care that is outside the scope of the certified nurse-midwife’s education, training, and experience. The bill would authorize a certified nurse-midwife to practice with a physician and surgeon under mutually agreed-upon policies and protocols that delineate the parameters for consultation, collaboration, referral, and transfer of a patient’s care, signed by both the certified nurse-midwife and a physician and surgeon to provide a patient with specified services. The bill would require the patient to be transferred to the care of a physician and surgeon to provide those services if the nurse-midwife does not have those mutually agreed-upon policies and protocols in place, and would authorize the return of that patient to the care of the nurse-midwife after the physician and surgeon has determined that the condition or circumstance that required, or would require, the transfer is resolved. The bill would authorize a certified nurse-midwife to continue to attend the birth of the newborn and participate in physical care, counseling, guidance, teaching, and support, if a physician and surgeon assumes care of the patient, as indicated by the mutually agreed-upon policies and protocols. The bill would authorize a certified nurse-midwife, after referring a patient to a physician and surgeon, to continue care of a patient the patient during a reasonable interval between the referral and the initial appointment with the physician and surgeon. The bill would authorize a certified nurse-midwife to attend pregnancy and childbirth in an out-of-hospital setting if specified conditions are met, including that the gestational age of the fetus is within a specified range. consistent with the above-described provisions. Under the bill, a certified nurse-midwife would not be authorized to assist childbirth by vacuum or forceps extraction, or to perform any external cephalic version. The bill would require a certified nurse-midwife to maintain clinical practice guidelines that delineate the parameters for consultation, comanagement, referral, and transfer of a patient’s care, and to document all consultations, referrals, and transfers in the patient record. The bill would require a certified nurse-midwife to refer all emergencies to a physician and surgeon immediately, and would authorize a certified nurse-midwife to provide emergency care until the assistance of a physician and surgeon is obtained.
This bill would require a certified nurse-midwife who is not under the supervision of a physician and surgeon to provide oral and written disclosure to a patient and obtain a patient’s written consent, as specified. By expanding the scope of a crime, the bill would impose a state-mandated local program.
(2)  Existing law authorizes the board to appoint a committee of qualified physicians and nurses, including, but not limited to, obstetricians and nurse-midwives, to develop the necessary standards relating to educational requirements, ratios of nurse-midwives to supervising physicians, and associated matters. Existing law, additionally, authorizes the committee to include family physicians.
This bill would specify the name of the committee as the Nurse-Midwifery Advisory Committee. The bill would delete the provision including ratios of nurse-midwives to supervising physicians and associated matters in the standards developed by the committee, and would instead require the committee to make recommendations to the board on all matters related to midwifery practice, education, appropriate standard of care, and other matters as specified by the board. The bill would authorize the committee to make recommendations on disciplinary actions at the request of the board. The bill would require a majority of the members of the committee to be nurse-midwives and at least 40% of the members of the committee to be physicians and surgeons. The bill would require the committee to continue to make the recommendations described above if the board, despite good faith efforts, is unable to solicit and appoint committee members pursuant to these provisions.
(3) Existing law authorizes a certified nurse-midwife to furnish drugs or devices, including controlled substances, in specified circumstances, including if drugs or devices are furnished or ordered incidentally to the provision of care in specified settings, including certain licensed health care facilities, birth centers, and maternity hospitals provided that the furnishing or ordering of drugs or devices occur under physician and surgeon supervision. Existing law requires the drugs or devices to be furnished in accordance with standardized procedures or protocols, and defines standardized procedure to mean a document, including protocols, developed and approved by specified persons, including a facility administrator. Existing law requires Schedule II or III controlled substances furnished or ordered by a certified nurse-midwife to be furnished or ordered in accordance with a patient-specific protocol approved by the treating or supervising physician and surgeon. Existing law requires a certified nurse-midwife who is authorized to furnish or issue a drug order for a controlled substance to register with the United States Drug Enforcement Administration.
This bill would delete the condition that the furnishing or ordering of drugs or devices occur under physician and surgeon supervision, and would authorize a certified nurse-midwife to furnish drugs or devices incidentally to the provision of care and services allowed by a certificate to practice nurse-midwifery as provided by the bill and when care is rendered in an out-of-hospital setting, as specified. The bill would limit the requirement that the furnishing or ordering of drugs or devices by a certified nurse-midwife be in accordance with the standardized procedures or protocols to the furnishing or ordering of drugs or devices for services that do not fall within the scope of services specified by the bill, and the furnishing of Schedule IV or V controlled substances by a nurse-midwife for any condition. The bill would require Schedule II or III controlled substances furnished or ordered by a certified nurse-midwife for any condition to be furnished or ordered in accordance with a patient-specific protocol approved by a physician and surgeon. The bill would remove the requirement that the standardized procedures be revise the definition of standardized procedure to mean a document, including protocols, developed in collaboration with, and approved by a facility administrator. by, a physician and surgeon and the certified nurse-midwife. The bill would require a certified nurse-midwife who is authorized to furnish or issue a drug order for a controlled substance to additionally register with the Controlled Substance Utilization Review and Enforcement System (CURES). The bill would authorize a certified nurse-midwife to procure supplies and devices, obtain and administer diagnostic tests, obtain and administer nonscheduled drugs consistent with the provision of services that fall within the scope of services specified by the bill, order laboratory and diagnostic testing, and receive reports, as specified. The bill would make it a misdemeanor for a certified nurse-midwife to refer a person for specified laboratory and diagnostic testing, home infusion therapy, and imaging goods or services if the certified nurse-midwife or their immediate family member has a financial interest with the person receiving a referral. By expanding the scope of a crime, the bill would impose a state-mandated local program.
(4) Existing law authorizes a certified nurse-midwife to perform and repair episiotomies and repair lacerations of the perineum in specified health care facilities only if specified conditions are met, including that the protocols and procedures ensure that all complications are referred to a physician and surgeon immediately, and that immediate care of patients who are in need of care beyond the scope of practice of the certified nurse midwife, nurse-midwife, or emergency care for times when the supervising physician and surgeon is not on the premises.
This bill would delete those conditions, and instead would require a certified nurse-midwife performing and repairing lacerations of the perineum to ensure that all complications are referred to a physician and surgeon immediately, and that immediate care of patients who are in need of care beyond the scope of practice of the certified nurse midwife, nurse-midwife, or emergency care when a physician and surgeon is not on the premises.
(5) Existing law, the Health Data and Advisory Council Consolidation Act, requires certain health facilities to make and file with the Office of Statewide Health Planning and Development specified reports containing various financial and patient data. Existing law requires a licensed midwife who assists, or supervises a student midwife in assisting, in childbirth that occurs in an out-of-hospital setting to annually report specified information to the Office of Statewide Health Planning and Development.
This bill would require a certified nurse-midwife to report the outcome of a birth in an out-of-hospital setting to ensure consistent reporting of birth outcomes in all settings, consistent with the information currently reported by hospitals to the Office of Statewide Health Planning and Development.

(5)

(6) The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 The Legislature hereby finds and declares the following:
(a) There is a maternity care workforce crisis in California. At least nine counties have no obstetrician at all, and many more counties fall below the national average for obstetricians. This will worsen to the point of critical shortage if the state refuses to take steps to innovatively address this issue. Nurse-midwives and physicians and surgeons can work together to innovatively address this issue and fill gaps in care, before California reaches the point of a critical provider shortage.
(b) While California has made great strides in reducing maternal mortality overall, there still mortality. Nonetheless, there remains a large disparity for Black and indigenous birthing people, and other birthing people of color. The maternal mortality rate for black Black women in California is still three to four times higher than white White women. Within an integrated model of care, physicians and surgeons and nurse-midwives can work together with patients and community leaders to eradicate this disparity. This measure will set the foundation for that work.
(c) Structural, systemic, and interpersonal racism, and the resulting economic and social inequities and racial disparities in health care are complex problems requiring multiple, innovative strategies in order to turn the tide. Midwifery care collaboration between certified nurse midwives and physicians has the potential to serve as Expansion of care teams, working together in a patient-centered approach, is one of these innovative strategies.
(d) State studies show that wherever midwifery is scaled up and integrated successfully into the overall health system, regardless of the region’s income level, the well-being of birthing people and babies is increased, including reductions in racial disparities, maternal mortality and morbidity, and neonatal mortality and prematurity. successful physician-midwifery integration enhances well-being and maternal and neonatal outcomes.

(e)A study supported by the California Health Care Foundation shows that increasing the percentage of pregnancies with midwife-led care from the current level of about 9 percent to 20 percent over the next 10 years could result in $4 billion in cost savings and 30,000 fewer preterm births.

(f)

(e) Nurse-midwives attend 50,000 births a year in California and are currently underutilized and prevented from expanding. Reducing unnecessary cesarean section alone could save $80 million to $440 million annually in California. underutilized.
(f) Supporting vaginal birth could improve health outcomes and save millions in annual health care costs in California.
(g) California is the only western state that still requires nurse-midwives to be supervised by a physician and surgeon and one of only four states in the nation that still requires this. Forty-six other states have removed the requirement for physician and surgeon supervision.
(h) Bodily autonomy including the choice of health care provider and the personalized, shared involvement in health care decisions is key fundamental to reproductive rights. Racial and other disparities in health care cannot be reduced without adherence to this concept.
(i) Every person is entitled to access dignified, person-centered childbirth and health care, regardless of race, gender, age, class, sexual orientation, gender identity, ability, language proficiency, nationality, immigration status, gender expression, religion, insurance status, or geographic location.
(j) The core philosophy of nurse-midwifery is to provide patient-centered, culturally sensitive, holistic care, care in collaboration with physicians and surgeons and other health care providers, all of which are key to reducing disparities in maternal health care.

SEC. 2.

 Section 650.01 of the Business and Professions Code is amended to read:

650.01.
 (a) Notwithstanding Section 650, or any other provision of law, it is unlawful for a licensee to refer a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the licensee or their immediate family has a financial interest with the person or in the entity that receives the referral.
(b) For purposes of this section and Section 650.02, the following shall apply:
(1) “Diagnostic imaging” includes, but is not limited to, all X-ray, computed axial tomography, magnetic resonance imaging nuclear medicine, positron emission tomography, mammography, and ultrasound goods and services.
(2) A “financial interest” includes, but is not limited to, any type of ownership interest, debt, loan, lease, compensation, remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, between a licensee and a person or entity to whom the licensee refers a person for a good or service specified in subdivision (a). A financial interest also exists if there is an indirect financial relationship between a licensee and the referral recipient including, but not limited to, an arrangement whereby a licensee has an ownership interest in an entity that leases property to the referral recipient. Any financial interest transferred by a licensee to any person or entity or otherwise established in any person or entity for the purpose of avoiding the prohibition of this section shall be deemed a financial interest of the licensee. For purposes of this paragraph, “direct or indirect payment” shall not include a royalty or consulting fee received by a physician and surgeon who has completed a recognized residency training program in orthopedics from a manufacturer or distributor as a result of their research and development of medical devices and techniques for that manufacturer or distributor. For purposes of this paragraph, “consulting fees” means those fees paid by the manufacturer or distributor to a physician and surgeon who has completed a recognized residency training program in orthopedics only for their ongoing services in making refinements to their medical devices or techniques marketed or distributed by the manufacturer or distributor, if the manufacturer or distributor does not own or control the facility to which the physician is referring the patient. A “financial interest” shall not include the receipt of capitation payments or other fixed amounts that are prepaid in exchange for a promise of a licensee to provide specified health care services to specified beneficiaries. A “financial interest” shall not include the receipt of remuneration by a medical director of a hospice, as defined in Section 1746 of the Health and Safety Code, for specified services if the arrangement is set out in writing, and specifies all services to be provided by the medical director, the term of the arrangement is for at least one year, and the compensation to be paid over the term of the arrangement is set in advance, does not exceed fair market value, and is not determined in a manner that takes into account the volume or value of any referrals or other business generated between parties.
(3) For the purposes of this section, “immediate family” includes the spouse and children of the licensee, the parents of the licensee, and the spouses of the children of the licensee.
(4) “Licensee” means a physician as defined in Section 3209.3 of the Labor Code or a certified nurse-midwife as described in Article 2.5 (commencing with Section 2746) of Chapter 6, acting within their scope of practice.
(5) “Licensee’s office” means either of the following:
(A) An office of a licensee in solo practice.
(B) An office in which services or goods are personally provided by the licensee or by employees in that office, or personally by independent contractors in that office, in accordance with other provisions of law. Employees and independent contractors shall be licensed or certified when licensure or certification is required by law.
(6) “Office of a group practice” means an office or offices in which two or more licensees are legally organized as a partnership, professional corporation, or not-for-profit corporation, licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code, for which all of the following apply:
(A) Each licensee who is a member of the group provides substantially the full range of services that the licensee routinely provides, including medical care, consultation, diagnosis, or treatment through the joint use of shared office space, facilities, equipment, and personnel.
(B) Substantially all of the services of the licensees who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group, except in the case of a multispecialty clinic, as defined in subdivision (l) of Section 1206 of the Health and Safety Code, physician services are billed in the name of the multispecialty clinic and amounts so received are treated as receipts of the multispecialty clinic.
(C) The overhead expenses of, and the income from, the practice are distributed in accordance with methods previously determined by members of the group.
(c) It is unlawful for a licensee to enter into an arrangement or scheme, such as a cross-referral arrangement, that the licensee knows, or should know, has a principal purpose of ensuring referrals by the licensee to a particular entity that, if the licensee directly made referrals to that entity, would be in violation of this section.
(d) No claim for payment shall be presented by an entity to any individual, third party payer, or other entity for a good or service furnished pursuant to a referral prohibited under this section.
(e) No insurer, self-insurer, or other payer shall pay a charge or lien for any good or service resulting from a referral in violation of this section.
(f) A licensee who refers a person to, or seeks consultation from, an organization in which the licensee has a financial interest, other than as prohibited by subdivision (a), shall disclose the financial interest to the patient, or the parent or legal guardian of the patient, in writing, at the time of the referral or request for consultation.
(1) If a referral, billing, or other solicitation is between one or more licensees who contract with a multispecialty clinic pursuant to subdivision (l) of Section 1206 of the Health and Safety Code or who conduct their practice as members of the same professional corporation or partnership, and the services are rendered on the same physical premises, or under the same professional corporation or partnership name, the requirements of this subdivision may be met by posting a conspicuous disclosure statement at the registration area or by providing a patient with a written disclosure statement.
(2) If a licensee is under contract with the Department of Corrections or the California Youth Authority, and the patient is an inmate or parolee of either respective department, the requirements of this subdivision shall be satisfied by disclosing financial interests to either the Department of Corrections or the California Youth Authority.
(g) A violation of subdivision (a) shall be a misdemeanor. In the case of a licensee who is a physician and surgeon, the Medical Board of California shall review the facts and circumstances of any conviction pursuant to subdivision (a) and take appropriate disciplinary action if the licensee has committed unprofessional conduct. In the case of a licensee who is a certified nurse-midwife, the Board of Registered Nursing shall review the facts and circumstances of any conviction pursuant to subdivision (a) and take appropriate disciplinary action if the licensee has committed unprofessional conduct. Violations of this section may also be subject to civil penalties of up to five thousand dollars ($5,000) for each offense, which may be enforced by the Insurance Commissioner, Attorney General, or a district attorney. A violation of subdivision (c), (d), or (e) is a public offense and is punishable upon conviction by a fine not exceeding fifteen thousand dollars ($15,000) for each violation and appropriate disciplinary action, including revocation of professional licensure, by the Medical Board of California, the Board of Registered Nursing, or other appropriate governmental agency.
(h) This section shall not apply to referrals for services that are described in and covered by Sections 139.3 and 139.31 of the Labor Code.
(i) This section shall become operative on January 1, 1995.

SEC. 3.

 Section 2746.2 of the Business and Professions Code is amended to read:

2746.2.
 (a) An applicant shall show by evidence satisfactory to the board that they have met the educational standards established by the board or have at least the equivalent thereof.
(b) (1) The board may appoint a committee of qualified physicians and surgeons and nurses called the Nurse-Midwifery Advisory Committee.
(2) The committee shall make recommendations to the board on all matters related to midwifery practice, education, appropriate standard of care, and other matters as specified by the board. At the request of the board, the committee may make recommendations on disciplinary actions.
(3) (A) The committee shall include, but not be limited to, qualified nurses and qualified physicians and surgeons, including, but not limited to, obstetricians or family physicians.
(B) A majority of the members of the committee shall be nurse-midwives.
(C) At least 40 percent of the members of the committee shall be physicians and surgeons.
(4) If the board is unable, despite good faith efforts, to solicit and appoint committee members pursuant to the specifications in subparagraph (B) or (C) of paragraph (3), the committee shall continue to make recommendations pursuant to paragraph (2).

SEC. 4.

 Section 2746.5 of the Business and Professions Code is amended to read:

(a)For purposes of this section, the following definitions apply:

(1)“Consultation” means a request for the professional advice or opinion of a physician or another member of a health care team regarding a patient’s care while maintaining primary management responsibility for the patient’s care.

(2)“Comanagement” means the joint management by a certified nurse-midwife and a physician and surgeon, of the care of a patient who has become more medically, gynecologically, or obstetrically complicated.

(3)“Referral” means the direction of a patient to a physician and surgeon or healing arts licensee for management of a particular problem or aspect of the patient’s care.

(4)“Transfer” means the transfer of primary management responsibility of a patient’s care from a certified nurse-midwife to another healing arts licensee or facility.

(b)

2746.5.
 (a) The certificate to practice nurse-midwifery authorizes the holder to attend cases of normal low-risk pregnancy and childbirth and to provide prenatal, intrapartum, and postpartum care, including gynecologic and family-planning services, interconception care, and immediate care for the newborn, consistent with the Core Competencies for Basic Midwifery Practice adopted by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the board. For purposes of this subdivision, “low-risk pregnancy” means a pregnancy in which all of the following conditions are met:
(1) There is a single fetus.
(2) There is a cephalic presentation at onset of labor.
(3) The gestational age of the fetus is greater than or equal to 37 weeks and zero days and less than or equal to 42 weeks and zero days at the time of delivery.
(4) Labor is spontaneous or induced.
(5) The patient has no preexisting disease or condition, whether arising out of the pregnancy or otherwise, that adversely affects the pregnancy and that the certified nurse-midwife is not qualified to independently address pursuant to this section.

(c)A certified nurse-midwife shall, in the practice of nurse-midwifery, emphasize informed consent, preventive care, and early detection and referral of complications to physicians and surgeons.

(d)As used in this chapter, the practice of nurse-midwifery includes consultation, comanagement, or referral as indicated by the health status of the patient and the resources and medical personnel available in the setting of care, subject to the following:

(1)(A)The certificate to practice nurse-midwifery authorizes the holder to work collaboratively with a physician and surgeon to comanage care for a patient with more complex health needs.

(B)The scope of comanagement may encompass the physical care of the patient, including birth, by the certified nurse-midwife, according to a mutually agreed upon plan of care with the physician and surgeon.

(C)If the physician and surgeon must assume a lead role in the care of the patient due to an increased risk status, the certified nurse-midwife may continue to participate in physical care, counseling, guidance, teaching, and support, according to a mutually agreed upon plan.

(2)After a certified nurse-midwife refers a patient to a physician and surgeon, the certified nurse-midwife may continue care of the patient during a reasonable interval between the referral and the initial appointment with the physician and surgeon.

(3)(A)A patient shall be transferred from the primary management responsibility of the nurse-midwife to that of a physician and surgeon for the management of a problem or aspect of the patient’s care that is outside the scope of the certified nurse-midwife’s education, training, and experience.

(B)A patient that has been transferred from the primary management responsibility of a certified nurse-midwife may return to the care of the certified nurse-midwife after resolution of any problem that required the transfer or that would require transfer from the primary management responsibility of a nurse-midwife.

(e)The certificate to practice nurse-midwifery authorizes the holder to attend pregnancy and childbirth in an out-of-hospital setting if all of the following conditions apply:

(1)Neither of the following are present:

(A)A preexisting maternal disease or condition creating risks higher than that of a low-risk pregnancy or birth, based on current evidence and accepted practice.

(B)Disease arising from or during the pregnancy creating risks higher than that of a low-risk pregnancy or birth, based on current evidence and accepted practice.

(2)There is a singleton fetus.

(3)There is cephalic presentation at the onset of labor.

(4)The gestational age of the fetus is at least 37 completed weeks of pregnancy and less than 42 completed weeks of pregnancy at the onset of labor.

(5)Labor is spontaneous or induced in an outpatient setting.

(b) (1) The certificate to practice nurse-midwifery authorizes the holder to practice with a physician and surgeon under mutually agreed-upon policies and protocols that delineate the parameters for consultation, collaboration, referral, and transfer of a patient’s care, signed by both the certified nurse-midwife and a physician and surgeon to do either of the following:
(A) Provide a patient with care that falls outside the scope of services specified in subdivision (a).
(B) Provide intrapartum care to a patient who has had a prior cesarean section or surgery that interrupts the myometrium.
(2) If a physician and surgeon assumes care of the patient, the certified nurse-midwife may continue to attend the birth of the newborn and participate in physical care, counseling, guidance, teaching, and support, as indicated by the mutually agreed-upon policies and protocols signed by both the certified nurse-midwife and a physician and surgeon.
(3) After a certified nurse-midwife refers a patient to a physician and surgeon, the certified nurse-midwife may continue care of the patient during a reasonable interval between the referral and the initial appointment with the physician and surgeon.
(c) (1) If a nurse-midwife does not have in place mutually agreed-upon policies and protocols that delineate the parameters for consultation, collaboration, referral, and transfer of a patient’s care, signed by both the certified nurse-midwife and a physician and surgeon pursuant to paragraph (1) of subdivision (b), the patient shall be transferred to the care of a physician and surgeon to do either of the following:
(A) Provide a patient with care that falls outside the scope of services specified in subdivision (a).
(B) Provide intrapartum care to a patient who has had a prior cesarean section or surgery that interrupts the myometrium.
(2) A patient who has been transferred from the care of a certified nurse-midwife to that of a physician and surgeon may return to the care of the certified nurse-midwife after the physician and surgeon has determined that the condition or circumstance that required, or would require, the transfer from the care of the nurse-midwife pursuant to paragraph (1) is resolved.
(d) The certificate to practice nurse-midwifery authorizes the holder to attend pregnancy and childbirth in an out-of-hospital setting if consistent with subdivisions (a), (b), and (c).
(e) This section shall not be interpreted to deny a patient’s right to self-determination or informed decisionmaking with regard to choice of provider or birth setting.
(f) The certificate to practice nurse-midwifery does not authorize the holder of the certificate to assist childbirth by vacuum or forceps extraction, or to perform any external cephalic version.

(g)A certified nurse-midwife shall maintain clinical practice guidelines that delineate the parameters for consultation, comanagement, referral, and transfer of a patient’s care.

(h)

(g) A certified nurse-midwife shall document all consultations, referrals, and transfers in the patient record.

(i)

(h) (1) A certified nurse-midwife shall refer all emergencies to a physician and surgeon immediately.
(2) A certified nurse-midwife may provide emergency care until the assistance of a physician and surgeon is obtained.
(i) This chapter does not authorize a nurse-midwife to practice medicine or surgery.
(j) This section shall not be construed to require a physician and surgeon to sign protocols and procedures for a nurse-midwife or to permit any action that violates Section 2052 or 2400.

SEC. 5.

 Section 2746.51 of the Business and Professions Code is amended to read:

2746.51.
 (a) Neither this chapter nor any other law shall be construed to prohibit a certified nurse-midwife from furnishing or ordering drugs or devices, including controlled substances classified in Schedule II, III, IV, or V under the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code), when all of the following apply:
(1) The drugs or devices are furnished or ordered incidentally to the provision of any of the following:

(A)Family planning services, as defined in Section 14503 of the Welfare and Institutions Code.

(B)

(A) The care and services described in Section 2746.5.

(C)

(B) Care rendered, consistent with the certified nurse-midwife’s educational preparation or for which clinical competency has been established and maintained, to persons within a facility specified in subdivision (a), (b), (c), (d), (i), or (j) of Section 1206 of the Health and Safety Code, a clinic as specified in Section 1204 of the Health and Safety Code, a general acute care hospital as defined in subdivision (a) of Section 1250 of the Health and Safety Code, a licensed birth center as defined in Section 1204.3 of the Health and Safety Code, or a special hospital specified as a maternity hospital in subdivision (f) of Section 1250 of the Health and Safety Code.

(D)

(C) Care rendered in an out-of-hospital setting pursuant to subdivision (e) (d) of Section 2746.5.
(2) The furnishing or ordering of drugs or devices by a certified nurse-midwife for services that do not fall within the scope of services specified in subdivision (a) of Section 2746.5, and the furnishing of Schedule IV or V controlled substances by a nurse-midwife for any condition, including, but not limited to, the furnishing of Schedule IV or V controlled substances for services that fall within the scope of services specified in subdivision (a) of Section 2746.5, are in accordance with the standardized procedures or protocols. For purposes of this section, standardized procedure means a document, including protocols, developed in collaboration with, and approved by, a physician and surgeon and the certified nurse-midwife. The standardized procedure covering the furnishing or ordering of drugs or devices shall specify all of the following:
(A) Which certified nurse-midwife may furnish or order drugs or devices.
(B) Which drugs or devices may be furnished or ordered and under what circumstances.
(C) The method of periodic review of the certified nurse-midwife’s competence, including peer review, and review of the provisions of the standardized procedure.
(3) If Schedule II or III controlled substances, as defined in Sections 11055 and 11056 of the Health and Safety Code, are furnished or ordered by a certified nurse-midwife, nurse-midwife for any condition, including, but not limited to, the furnishing of Schedule II or III controlled substances for services that fall within the scope of services specified in subdivision (a) of Section 2746.5, the controlled substances shall be furnished or ordered in accordance with a patient-specific protocol approved by a physician and surgeon. For Schedule II controlled substance protocols, the provision for furnishing the Schedule II controlled substance shall address the diagnosis of the illness, injury, or condition for which the Schedule II controlled substance is to be furnished.
(b) (1) The furnishing or ordering of drugs or devices by a certified nurse-midwife is conditional on the issuance by the board of a number to the applicant who has successfully completed the requirements of paragraph (2). The number shall be included on all transmittals of orders for drugs or devices by the certified nurse-midwife. The board shall maintain a list of the certified nurse-midwives that it has certified pursuant to this paragraph and the number it has issued to each one. The board shall make the list available to the California State Board of Pharmacy upon its request. Every certified nurse-midwife who is authorized pursuant to this section to furnish or issue a drug order for a controlled substance shall register with the United States Drug Enforcement Administration. Administration and the Controlled Substance Utilization Review and Enforcement System (CURES) pursuant to Section 11165.1 of the Health and Safety Code.
(2) The board has certified in accordance with paragraph (1) that the certified nurse-midwife has satisfactorily completed a course in pharmacology covering the drugs or devices to be furnished or ordered under this section, including the risks of addiction and neonatal abstinence syndrome associated with the use of opioids. The board shall establish the requirements for satisfactory completion of this paragraph.
(3) A copy of the standardized procedure or protocol relating to the furnishing or ordering of controlled substances by a certified nurse-midwife shall be provided upon request to any licensed pharmacist who is uncertain of the authority of the certified nurse-midwife to perform these functions.
(4) Certified nurse-midwives who are certified by the board and hold an active furnishing number, who are currently authorized through standardized procedures or protocols to furnish Schedule II controlled substances, and who are registered with the United States Drug Enforcement Administration shall provide documentation of continuing education specific to the use of Schedule II controlled substances in settings other than a hospital based on standards developed by the board.
(c) Drugs or devices furnished or ordered by a certified nurse-midwife may include Schedule II controlled substances under the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code) under the following conditions:
(1) The drugs and devices are furnished or ordered in accordance with requirements referenced in paragraphs (2) and (3) of subdivision subdivisions (a) and in paragraphs (1) and (2) of subdivision (b).
(2) When Schedule II controlled substances, as defined in Section 11055 of the Health and Safety Code, are furnished or ordered by a certified nurse-midwife, the controlled substances shall be furnished or ordered in accordance with a patient-specific protocol approved by a physician and surgeon.
(d) Furnishing of drugs or devices by a certified nurse-midwife means the act of making a pharmaceutical agent or agents available to the patient in strict accordance with a standardized procedure or protocol. patient. Use of the term “furnishing” in this section shall include the following:
(1) The ordering of a nonscheduled drug or device in accordance with the standardized procedure or protocol. for services that fall within the scope of services specified in subdivision (a) of Section 2746.5.
(2) The ordering of a nonscheduled drug or device for services that fall outside the scope of services specified in subdivision (a) of Section 2746.5 in accordance with standardized procedures or protocols pursuant to paragraph (2) of subdivision (a).
(3) The ordering of a Schedule IV or V drug for any condition, including, but not limited to, the furnishing of Schedule IV or V controlled substances for services that fall within the scope of services specified in subdivision (a) of Section 2746.5, in accordance with standardized procedures or protocols pursuant to paragraph (2) of subdivision (a).
(4) The ordering of a Schedule II or III drug in accordance with a patient-specific protocol approved by a physician and surgeon pursuant to paragraph (3) of subdivision (a).

(2)

(5) Transmitting an order of a supervising physician and surgeon.
(e) “Drug order” or “order” for purposes of this section means an order for medication or for a drug or device that is dispensed to or for an ultimate user, issued by a certified nurse-midwife as an individual practitioner, within the meaning of Section 1306.03 of Title 21 of the Code of Federal Regulations. Notwithstanding any other provision of law, (1) a drug order issued pursuant to this section shall be treated in the same manner as a prescription of the supervising physician; (2) all references to “prescription” in this code and the Health and Safety Code shall include drug orders issued by certified nurse-midwives; and (3) the signature of a certified nurse-midwife on a drug order issued in accordance with this section shall be deemed to be the signature of a prescriber for purposes of this code and the Health and Safety Code.
(f) Notwithstanding any other law, a certified nurse-midwife may directly procure supplies and devices, obtain and administer diagnostic tests, directly obtain and administer nonscheduled drugs consistent with the provision of services that fall within the scope of services specified in subdivision (a) of Section 2746.5, order laboratory and diagnostic testing, and receive reports that are necessary to their practice as a certified nurse-midwife within their scope of practice.

SEC. 6.

 Section 2746.52 of the Business and Professions Code is amended to read:

2746.52.
 (a) Notwithstanding Section 2746.5, the certificate to practice nurse-midwifery authorizes the holder to perform and repair episiotomies, and to repair first-degree and second-degree lacerations of the perineum.
(b) A certified nurse-midwife performing and repairing first-degree and second-degree lacerations of the perineum shall do both of the following:
(1) Ensure that all complications are referred to a physician and surgeon immediately.
(2) Ensure immediate care of patients who are in need of care beyond the scope of practice of the certified nurse midwife, nurse-midwife, or emergency care for times when a physician and surgeon is not on the premises.

SEC. 7.

 Section 2746.54 is added to the Business and Professions Code, to read:

2746.54.
 (a) A certified nurse-midwife shall disclose in oral and written form to a prospective patient as part of a patient care plan, and obtain informed consent for, all of the following:
(1) The patient is retaining a certified nurse-midwife and the certified nurse-midwife is not supervised by a physician and surgeon.
(2) The certified nurse-midwife’s current licensure status and license number.
(3) The practice settings in which the certified nurse-midwife practices.
(4) If the certified nurse-midwife does not have liability coverage for the practice of midwifery, the certified nurse-midwife shall disclose that fact.
(5) There are conditions that are outside of the scope of practice of a certified nurse midwife nurse-midwife that will result in a referral for a consultation from, or transfer of care to, a physician and surgeon.
(6) The specific arrangements for the referral of complications to a physician and surgeon for consultation. The certified nurse-midwife shall not be required to identify a specific physician and surgeon.
(7) The specific arrangements for the transfer of care during the prenatal period, hospital transfer during the intrapartum and postpartum periods, and access to appropriate emergency medical services for mother and baby if necessary, and recommendations for preregistration at a hospital that has obstetric emergency services and is most likely to receive the transfer.
(8) If, during the course of care, the patient is informed that the patient has or may have a condition indicating the need for a mandatory transfer, the certified nurse-midwife shall initiate the transfer.
(9) The availability of the text of laws regulating certified nurse-midwifery practices and the procedure for reporting complaints to the Board of Registered Nursing, which may be found on the Board of Registered Nursing’s internet website.
(10) Consultation with a physician and surgeon does not alone create a physician-patient relationship or any other relationship with the physician and surgeon. The certified nurse-midwife shall inform the patient that certified nurse-midwife is independently licensed and practicing midwifery and in that regard is solely responsible for the services the certified nurse-midwife provides.
(b) The disclosure and consent shall be signed by both the certified nurse-midwife and the patient and a copy of the disclosure and consent shall be placed in the patient’s medical record.
(c) The Nurse-Midwifery Advisory Committee, in consultation with the board, may recommend to the board the form for the written disclosure and informed consent statement required to be used by a certified nurse-midwife under this section.
(d) This section shall not apply when the intended site of birth is the hospital setting.

SEC. 8.

 Section 2746.55 is added to the Business and Professions Code, to read:

2746.55.
 To ensure consistent reporting of birth outcomes in all settings, consistent with the information currently reported by hospitals to the Office of Statewide Health Planning and Development, a certified nurse-midwife shall report the outcome of a birth in an out-of-hospital setting.

SEC. 8.SEC. 9.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.