Form 0917-0009-5 0917-0009-5, OB-GYN Privileges Form

Circular Appendix 95–16–C.2 (04/10)
Page 4 of 4

MEDICAL PRIVILEGES REQUEST FORM

(CATEGORICAL METHOD FOR OB-GYN PRIVILEGES)

I. OBSTETRICS

A. Category I	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Diagnosis and therapy, with minimal threat to life

Qualifications

Physicians with minimal formal training in the specialty, but with training and experience in the care of the specific conditions, and certified nurse midwives. In either case, clinician has had at least 30 supervised deliveries.

Examples	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Normal prenatal and postpartum care
2. Uncomplicated labor and vaginal delivery
3. Maternal fetal monitoring (clinical and electronic)
4. Local and pudendal anesthesia
5. Amniotomy
6. Episiotomy and repair of second degree laceration
7. Use of oxytocic drugs after completion of third stage
8. Management of uncomplicated postpartum infection
9. Repair of minor vaginal/cervical laceration
10. Management of mild preeclampsia after consultation with an OB-GYN specialist
11. Other (Specify):

B. Category II	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Major diagnosis and therapy, but with no significant threat to life

Qualifications

Physicians with significant training in the specialty related to diagnosis and therapy, i.e., full 3–6 months of training and experience within an approved obstetric training program, as in an OB-GYN or family practice residency, and experience in the care of the specific conditions.

Fully trained and certified nurse midwives must be able to demonstrate competence through training and experience to be granted privileges for manual removal of the placenta and for postpartum uterine exploration. An individual certified nurse midwife who has had advanced training and experience may be granted privileges for low-vacuum extraction delivery and/or Level I ultrasound.

Examples	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Category I
2. Low forceps or vacuum extractor delivery
3. Manual removal of placenta and postpartum uterine exploration
4. Repair of third/fourth degree perineal laceration
5. Level I Ultrasound
6. Other (Specify):

C. Category III

Major diagnosis and therapy with possible serious threat to life

Qualifications

Physicians with completed residency training in the specialty or with extensive experience in the care of specific conditions.

Examples	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Categories I and II
2. All vaginal deliveries, including breech delivery and mid forceps delivery
3. All cesarean deliveries
4. Amniocentesis
5. All high risk pregnancies, including major medical diseases complicating pregnancy except intrauterine transfusion
6. Other (Specify):

II. GYNECOLOGY

A. Minor

Physician with minimal formal training in the discipline but with training and experience in the care of the specific conditions.

Examples	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. I & D of vulvar or perineal abscess
2. Biopsy of vulva, vagina or cervix
3. Endometrial biopsy
4. Culdocentesis
5. Polypectomy
6. Curettage for incomplete abortion
7. Other (Specify):

B. Major

Physician with completed residency training in the specialty or with extensive training or experience in the care of the specific conditions. Radical or exenterative procedures are generally excluded in the IHS clinical setting.

Examples	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Minor gynecologic surgery
2. All gynecologic illnesses and complications
3. Examination under anesthesia
4. Tubal sterilization
5. Abdominal hysterectomy
6. Salpingoophorectomy
7. Incidental appendectomy
8. Vaginal hysterectomy
9. Anterior and posterior repair
10. Urethropexy (abdominal and/or vaginal)
11. Laparoscopy
12. Other (Specify):

Note: All clinicians granted obstetrics privileges must also be qualified for and granted privileges in newborn resuscitation.

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