Title: Nurse Midwife as First Assist at Surgical Procedures

(Formally Advisory Ruling Nurse Midwives as First Assistants at Cesarean Sections)

Advisory Ruling Number: 9902

Authority: The Massachusetts Board of Registration in Nursing (Board) issues this Advisory Ruling on Nursing practice pursuant to Massachusetts General Laws ("G.L."), chapter 30A, section 8 and chapter 112, section 80B.

Date of Issue: Aug 12, 1998

Revised: September 9, 1998, September 8, 2010

Scope of Practice: Advance Practice Registered Nurse (APRN) authorized by the Board as a Nurse Midwife (RN/NM)

Purpose: To guide the practice of the RN/NM who incorporates the role of first assist in obstetric and gynecologic surgery, including, but not limited to cesarean sections and tubal ligations into his/her practice. First assist at obstetric and gynecologic surgery may be an enhanced component of nurse midwifery practice and may include: handling tissue; providing exposure to the operative site; using instruments; suturing; and providing hemostasis.

Such practice must be in compliance "G.L." c. 112, s. 80B, 80C and 80G, 244 CMR 4.12(3): Prohibition of Practice without Authorization and Rules Governing Advertising and Personal Identification; 244 CMR 4.21: Responsibility; 244 CMR 4.22: Development, Approval, and Review of Guidelines for Nurse Midwives, Nurse Practitioners and Nurse Anesthetists; 244 CMR 4.24: Specific Requirements Applicable to Guidelines for Categories of Nurses Practicing in an Expanded Role; 244 CMR 4.25: Scope of Practice for Categories of Nurses Practicing in an Expanded Role; 244 CMR 3.02: Responsibility and Functions - Registered Nurse; 244 CMR 9.03 (2): Practice as Advanced Practice Nurse; 4.24244 CMR 9.03 (5): Adherence to Standards of Nursing Practice; 244 CMR 9.03 (8): Identification Badge; 244 CMR 9.03 (9): Responsibility and Accountability; 244 CMR 9.03 (10): Acts within Scope of Practice; 244 CMR 9.03 (11): Performance of Techniques and Procedures; 244 CMR 9.03 (12): Competency; 244 CMR 9.03 (14): Asepsis and Infection Control; 244 CMR 9.03 (44): Documentation; 244 CMR 9.04: Standards of Conduct for Advanced Practice Nurses.

Advisory: The licensed RN with authorization from the Board to practice as a RN/NM will assume only those duties and responsibilities within his or her scope of practice and for which he or she has acquired and maintained necessary knowledge, skills and abilities to serve as first assist in obstetric and gynecologic surgery under established employer policies and procedures by:

  • providing adequate exposure to the operative site;
  • applying the principles of safe tissue handling;
  • preventing unnecessary blood loss and ensuring hemostasis; and
  • assisting with closure by "following" the suture or suturing,

The RN/NM who functions as a first assist must engage in practice consistent with accepted standards and only after appropriate education and demonstrated clinical competence. The RN/NM who functions as a first assist may not concurrently function as scrub nurse.

In addition to the core educational requirements, the RN/NM who functions as a first assist must successfully complete formal study, supervised practice, and comprehensive evaluation, as required in the American College of Nurse Midwives' Guidelines for the Incorporation of New Procedures into Midwifery Practice, including, but not limited to demonstrated:

  • ability to apply principles of asepsis and infection control;
  • knowledge of surgical anatomy, physiology, pathophysiology and operative technique related to cesarean sections, tubal ligations and other gynecologic surgery;
  • ability to perform cardiopulmonary resuscitation;
  • ability to perform effectively in stressful and emergency situations;
  • ability to recognize safety hazards and initiate appropriate preventive and corrective action; and
  • ability to perform effectively and harmoniously as a member of the operative team.

The employing organization must document education, training, and experience, validating qualifications for credentialing purposes to demonstrate competence. Additionally, the employing organization must maintain current policies and procedures related to RN/NM who practice in the expanded role of first assist.

The RN/NM will adhere to standard precautions and to principles of asepsis and infection control and will not place self, patient or others at risk for infectious disease transmission.

The RNNM will ensure documentation is complete, accurate and legible in all records required by federal and state law.

The RN/NM will identify self and disclose to patients, verbally, and in consent forms, as a person practicing as a RN/NM through the posting of appropriate signs, the wearing of an appropriate name tag, the use of appropriate stationery, and other methods of communication.


This information is provided by the Division of Health Professions Licensure within the Department of Public Health.