Certified Nurse Midwife - Kaleida Health

Name ________________________________________ Date ____________________
CERTIFIED NURSE MIDWIFE - DELINEATION OF PRIVILEGES
PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or
line to make selections. We will return applications that ignore this directive.
All privileges listed are for Adult and/or Pediatric patients.
PART I:
TITLE
In the State of New York, the Title Nurse Midwife refers to and includes the profession of midwifery
and a licensed midwife. Only those persons registered as a midwife may use this title.
PART II:
DEFINITION (Excerpt from Article 130, Section 6951, NYS Education Law)
The practice of the profession of midwifery is defined as the management of normal pregnancies,
child birth and postpartum care, as well as primary preventive reproductive health care of essentially
healthy women and shall include newborn evaluation, resuscitation and referral for infants.
PART III
PRACTICE RELATIONSHIPS (Excerpt from The Midwifery Modernization Act)
A Certified Nurse Midwife shall have collaborative relationships with (i) a licensed physician who is
Board Certified as an Obstetrician/Gynecologist by a national certifying body or (ii) a licensed
physician who practices obstetrics and has obstetric privileges or (iii) a hospital that provides
obstetrics through a licensed physician having obstetrical privileges at such institution. The
collaborative relationship shall provide for consultation, collaborative management, and referral to
address the health status and risks of his or her patients and that include plans for emergency medical
gynecological and/or obstetrical coverage. A midwife shall maintain documentation of such
collaborative relationships and shall make information about such collaborative relations available to
his or her patients. Failure to comply with the requirements found in the NYS Education Law shall
be subject to professional misconduct provisions as sent forth in the subdivision of Article.

CERTIFIED NURSE MIDWIFE Page 2
Name ______________________________
PART IV:
DELINEATION OF PRIVILEGES
LEVEL I (CORE) CERTIFIED NURSE MIDWIFE PRIVILEGES
Applicants for Level I privileges have successfully graduated form a NYS approved program that includes classroom
training and clinical experience. Studies include courses in maternity and pediatric care, pharmacology, well-woman
care, neonatal care and family planning and gynecological care.
History and physical examinations
Comprehensive maternity care including prenatal, labor, delivery, postpartum and newborn care
Amniotomy
Augmentation of labor
Induction of labor with consultation
NST/OCT
Placement of Internal Fetal scalp electrode and Intrauterine pressure catheter
Spontaneous vaginal vertex birth
Episiotomy and repair
Repair of 1 st and 2 nd degree lacerations of vagina, perineum and labia
Administration of local anesthesia
Hospital admission, rounds and discharge
Referral to specialists
Collaborative management of minor pregnancy complications with consultation
LEVEL I (CORE)
CERTIFIED NURSE MIDWIFE
PRIVILEGES
CNM
REQUEST
Granted
Not
Granted*
With Following
Requirements**
(Provide Details)
LEVEL II
CERTIFIED NURSE MIDWIFE
PRIVILEGES (require documentation
of training beyond basic education)
Anesthesia, paracervical
Anesthesia, pudendal
Newborn circumcision
First assist at Cesarean Section
Basic Ultrasound exam
CNM
REQUEST
Granted
Not
Granted*
With Following
Requirements**
(Provide Details)
KEY
*NOT GRANTED DUE TO:
Provide Details Below
**WITH FOLLOWING REQUIREMENTS
Provide Details Below
1) Lack of Documentation 1) With Consultation
2) Lack of Required Training/Experience 2) With Assistance
3) Lack of Current Competence (Databank Reportable) 3) With Proctoring
4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define)
DETAILS:_______________________________________________________________________________________
___________________________________________________________________________________________________________

CERTIFIED NURSE MIDWIFE Page 3
National Practitioner Databank Disclaimer Statement
Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted
for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act
of 1986 (42 U.S.C. 11101 et seq.)
________________________________________
Practitioner’s Signature
_____________
Date
_____________________________________
Chief of Service
____________
Date
_____________________________________
Allied Health Professional Representative
____________
Date
Should you need to request any of the privileges on this form mid-cycle, please put your request in writing, along with all required
documentation and send it to the Medical Staff Office. If you plan on being supervised/proctored for any privileges you must first
request this in writing and send it to the Medical Staff Office with documentation of a completed training course. Your requests will
be submitted to the Chief of Service for approval and then the Credentials Committee. You will receive notification of approval or
denial. You can contact the Medical Staff Office at 716-859-5502 if you have any questions.
APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION
FOR YOUR RECORDS
CNM – 01/2011