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Name ________________________________
FORT HAMILTON HOSPITAL
DELINEATION OF CLINICAL PRIVILEGES & QUALIFICATIONS
ADVANCED PRACTICE NURSE
CERTIFIED NURSE-MIDWIFE (CNM)
ELIGIBILITY REQUIREMENTS
Required Qualifications:
Demonstration of satisfactory training, experience, and current competence
Certification by American College of Midwives
Current BCLS certification required, current ACLS certification preferred.
Current Licensure by the Ohio Board of Nursing as a CNM.
Current Ohio Prescriptive Authority License if requesting prescription privileges.
Current Ohio Certificate of Authority by the Ohio Board of Nursing.
Submission of a completed Commitment to Provide Nurse Midwifery Direction and Supervision
form which signifies the agreement of a physician member of Fort Hamilton Hospital medical
staff with clinical privileges in obstetrics at this hospital, to direct and supervise the nurse
midwife’s professional activities as well as provide coverage in clinical situations requiring
judgement and intervention beyond the nurse midwife’s scope of practice. Such document shall
serve as the Standard Care Agreement and include requirements that the supervising physician(s)
must:
o Assume responsibility for supervision and direction of the nurse midwife’s practice
conducted inside the hospital.
o Be continuously available to provide consultation when requested and to intervene
when necessary.
o Assume total responsibility for the care of any obstetrical patient when requested by
the nurse midwife or as required by this protocol or in the interest of the patient.
o Adhere to the protocols developed by the Department of Obstetrics and Gynecology
that govern nurse midwifery care provided within this hospital.
o Abide by all standards of the Ohio Revised Code pertaining to nurse midwifery and
Fort Hamilton Hospital Medical Staff Bylaws, Rules & Regulations.
o Abide by the American College of Nurse Midwives functions, standards, and
qualifications.
DELINEATION OF PRIVILEGES
Please place a checkmark before each privilege you are requesting. Some privilege may require
documentation of special training or experience before privileges are granted.
____ Perform history and physical examination and arrange for laboratory testing of pregnant
patients. H&Ps performed by the nurse midwife shall be limited to his/her area of training,
i.e. the pregnancy only. Examination of the patient’s other systems shall be performed by
and signed by the sponsoring physician.
Delineation of Privileges (continued)
Certified Nurse Midwife
Page 2 of 5
____ Perform routine prenatal care including appropriate instruction for Rh-negative mothers.
____ Examine and co-admit patients in labor. The sponsoring physician shall be responsible for
co-admitting the patient. Write orders and notify consultant of patient’s status and plan or
change of plan.
____ Perform artificial rupture of membranes.
____ Apply:
____ External scalp monitor
____ Fetal scalp electrode
____ Intrauterine pressure catheter as indicated
____ Order for administration of installation of newborn Erythromycin Ophthalmic
____ Order for administration of Vitamin K 1 mg (0.5ml) IM before 1 hour of age
____ Order and monitor oxytocin for augmentation or induction after consultation. Physician is
to be readily available in case of emergency
____ Perform normal spontaneous vaginal delivery with or without episiotomy.
____ Repair 1st – and 2nd – degree perineal/vaginal lacerations.
____ Provide routine postpartum care, orders, and discharge.
____ Perform sonography to determine fetal presentation if presentation is in question.
____ Write or dictate discharge summaries.
____ Independently conduct rounds for routine postpartum/postoperative care.
____ Administer prostaglandin gel for cervical ripening.
____ Repair of 3rd – degree lacerations with documentation of competence from sponsoring
physician.
_____ PRESCRIPTIVE AUHORITY: Non-narcotic medications
Additional documentation required: Current Certificate to Prescribe by the Ohio Board of Nursing.
Only medications listed in the Standard Care Agreement and the Ohio Committee on Prescriptive
Authority Governance (CPG ) formulary may be prescribed.
_____ PRESCRIPTIVE AUHORITY: Narcotic medications
Additional documentation required: Current Certificate to Prescribe by the Ohio Board of Nursing
and Federal DEA license. Only medications listed in the Standard Care Agreement and the Ohio
Committee on Prescriptive Authority Governance (CPG) formulary, and within the narcotic
classes on the individual’s DEA license may be prescribed.
Delineation of Privileges (continued)
Certified Nurse Midwife
Page 3 of 5
NOTES
1.
2.
3.
All orders for diagnostic and/or therapeutic intervention for a patient written by an
appropriately credentialed and privileged CNM shall be counter-signed by the supervising
physician within the time frame specified by applicable hospital and medical staff bylaws, rules
and regulation, and policies, procedures and protocols.
Law Regulating the Practice of Nursing, Chapter 4723, Ohio Revised Code, effective June 14,
1988, “No certificate to practice nurse midwifery shall authorize its holder to perform version,
treat breech or face presentation, do any obstetric operation requiring instruments, or treat any
other abnormal conditions, except in emergencies.”
CNMs do have co-admitting privileges.
_________________________
Printed Name of Applicant
_______________________________
Printed Name of Collaborating Physician
_____________________________
Signature, Applicant
________________________________
Signature, Collaborating Physician
_____________________________
Date
________________________________
Date
Delineation of Privileges (continued)
Certified Nurse Midwife
Page 4 of 5
DEFINITION AND SCOPE OF PRACTICE OF SPECIALIZED NURSING SERVICES
“Certified nurse-midwife” means a registered nurse who holds a valid certificate of authority issued that
authorizes the practice of nursing as a certified nurse-midwife in accordance with section 4723.43 of the
Revised Code and rules adopted by the Board of Nursing.
A nurse authorized to practice as a certified nurse-midwife, in collaboration with one or more physicians,
may provide the management of preventive services and those primary care services necessary to provide
health care to women antepartally, intrapartally, postpartally, and gynecologically, consistent with the
nurse’s education and certification, and in accordance with rules adopted by the Board.
Delineation of Privileges (continued)
Certified Nurse Midwife
Page 5 of 5
FORT HAMILTON HOSPITAL OB/GYN DEPARTMENT
COMMITMENT TO PROVIDE NURSE MIDWIFERY
DIRECTION & SUPERVISION
I hereby agree to provide direction and supervision to _________________________________,
A certified nurse midwife, requesting clinical privileges at Fort Hamilton Hospital in nurse
midwifery. Such direction and supervision, as well as, necessary coverage in clinical situations
outside of the nurse midwife’s scope of practice, will be provided in accordance with Section
4723.43 of the Revised Code, once the requested clinical privileges are granted and will continue
until rescinded in writing by myself or the nurse midwife or until such clinical privileges are no
longer in effect.
The supervising physician(s) must:
o Assume responsibility for supervision and direction of the nurse midwife’s practice
conducted inside the hospital.
o Be continuously available to provide consultation when requested and to intervene
when necessary.
o Assume total responsibility for the care of any obstetrical patient when requested by
the nurse midwife or as required by this protocol or in the interest of the patient.
o Adhere to the protocols developed by the Department of Obstetrics and Gynecology
that govern nurse midwifery care provided within this hospital.
o Abide by all standards of the Ohio Revised Code pertaining to nurse midwifery and
Fort Hamilton Hospital Medical Staff Bylaws, Rules & Regulations.
o Abide by the American College of Nurse Midwives functions, standards, and
qualifications.
__________________________________
Printed Name
_____________________________
Signature of Collaborating Physician
_____________________________
Date
Revised & approved 3/16/06
Revised & approved 9/20/07
Board of Trustees