To define and clarify CCM concepts &Vocabulary
 for community-based midwifery care

NOTE for CAM reviewers:
Glossary of Terms relative to interpretation of legal and practice requirements

Language used in documents of this type is specific and/or technical. It is helpful, when considering the proposed CCM standards and Guidelines, to have the key to those concepts and  its technical vocabulary.

1. Individual Vocabulary                   2.Concepts                      3. Planned Home Birth Defined

                    4. Clarifying Commentary on Intrapartum Transport          5. The How and the Why of it all......

6. Master List ~ Marked Copies of the 12 major Background Resources used to compile S & G


Individual Words

Shall = must do, should be done, required unless there are "extenuating circumstances" or the parents refuse their voluntary permission. Unless a phrase includes the word "shall", it falls into the category below. 

Can, may, recommended, suggested = useful information offering options or providing instruction or establishing a certain action as the statistically most frequent or ideal response but the decision as to whether or not to act on the 'recommendation' is a function of the professional judgment of the LM and is made in the specific situation as 'appropriate'.

Clinically significant deviations = means "serious", obvious, visible, evident or has a long history of, with important clinical implications for serious complications at the time or during labor, birth or for the newborn. 

Note: When the language "clinically significant"  or "significant deviations" is used in the first or primary paragraph of a topic (i.e. "Client Selection", "Antepartum Referral", "Newborn Transport", etc,) it applies to ALL the items listed in that document. It has not been added separately to each item listed because it applies overall.

Abnormal = clinically significant deviation or pathology with serious consequences (see above)

As indicated = performance of, or the schedule of performance (for example, how frequently to take FHTs and whether or not certain "assessments" are done at all) is to be determined by the clinical judgment of the midwife, that is, do more often if the situation call for it or is done less frequency or not done at all if the treatment, procedure or routine surveillance is simply not warranted, not helpful, disruptive (for example, waking a sleeping mother-to-be to take FHTs). Synonym for this term would be "as appropriate".

Even without the "as indicated" preface, some assessments only come into play because there is an identified problem -- for example, the assessment of varicosities is only done IF the mother HAS varicosities. If there is nothing to comment on, no comment is entered into the chart relative to that topic.


General Concepts that have confused some readers:

Community-based midwifery practice = client home and independent birth centers, that is, maternity care by midwives that is not provided in an institution or hospital based setting. Synonyms for "community-based midwifery practice" are the words "domiciliary" or "home-based."

Community standard = as used by the Medical Board and in CCM documents on standards of care, the community standard is the "customary" method used by members of the same profession (i.e. standard for obstetricians different than that of midwives, etc). Sometimes community standard is even more specific to the geographical area in which those professionals practice (i.e. the community standard of Sacramento midwives may differ from those of  LA midwives)

The issue of mortality and morbidity reporting = the MBC requires doctors and ALL its other licentiates to report mortality. In the near future,  they are introducing legislation that will require LMs to report both mortality and morbidity, including emergency transports. This legislation will also require midwives to provide statistics when renewing their license on the number and outcome of all birth attended since last renewal.

Consultation = seeking the advice of another health care professional or member of the health care team. in person, by electronic communication or by telephone and may include other professional midwives as well as physicians and specialists in other healthcare disciplines.

An example of this is included from the Antepartum Referral in Section 2:

"The licensed midwife shall consult with a physician and/or another professional midwife whenever there are significant deviations, including abnormal laboratory results, during a client’s pregnancy."

Note: this means that initial or primary consultation may be with another professional midwife. In conversation with the 2nd midwife, the conclusion arrived at may be that physician consultation or referral is not warranted or helpful or (depending on the obstetrical politics of your region) not feasible.

Informal peer review with another licensed midwife = consultation between two midwives -- see above

 Formal peer review = setting of policies or protocols by a geographical peer review group so that individual "consultation' on frequently occurring questions/issues (such as light mec, lack of progress due to posterior position, etc) is addressed preemptively by the whole group of midwives in that region.

"policies and guidelines shall be consistent with standard midwifery management as described in a standard midwifery textbook or a combination of standard textbooks and references, including research published in peer-reviewed journals. Any textbook or reference which is also an approved textbook or reference for a midwifery educational program or school shall be considered an acceptable textbook or reference for use in developing a licensed midwife's individual policies and practice guidelines. "

This provision allows midwives to make changes in their practices policies and protocols as the scientific evidence changes and support those decisions via published mfry textbooks and other published sources.

 It does not preclude the use of “traditional” mfry methods which currently have not been the subject of published research but are widely used and reflect the wise use intuitive approaches, unless that specific method is in direct contradiction to broadly based scientific research – for example, doing frequent vag exam on mothers with ROM is documented to increase infection rate, thus would not be “justifiable” within evidence-based parameters.  

 (sorry, for the poor example but we couldn't think of anything midwives traditionally do that is known to be harmful) 

*** The licensed midwife shall establish policies and/or guidelines for each practice area..........The customary method for establishing and implementing clinical guidelines for routine care is through the adoption of, or development of, appropriate chart forms, informed consent documents and other appropriate documents used routinely during each of these periods of care.

Bottom line here is simple -- chart forms, instructional or consent forms is HOW we establish and implement "policies and/or guidelines" for clinical practice. The chart form manifests what we routinely do for that office visit or during that phase of the intrapartum or relative to informed consent for care or for procedures. It is the forms that we revise or change when we change our protocols.

***  The midwife shall review policies and guidelines annually or as indicated, modify as needed, and document any changes

This only refers to updating any published forms and charts and noting the date of the update on the bottom of the form or chart or other changed document)

*** The licensed midwife shall identify the phase of active labor (typically at 4-5 cms dilatation) or other point in time that it is appropriate to make a decision about planned place of birth. The question to be addressed is whether the mother and fetus are  healthy and can reasonably be expected to progress and give birth normally at home OR, due to the absence of effective labor or the presence of complications, a timely elective transfer to medical services is called for. Official determination of planned place of labor and  birth should be made in conjunction with the mother/parents. Unless this results in referral or transfer of care at that time, the licensed midwife shall enter a note in the chart confirming the intention of a “planned home birth in an essentially healthy mother with a normal fetus.”

Yes, this is new. However, shame on us for not doing this 25 years ago. By not having the status of a planned homebirth be determined by the parents and the midwife (the people directly involved and present!) it left us (midwives and those interested in home-based maternity care) vulnerable to the dubious and at time unethical practice of obstetrical researchers, such as the Pang study and other so-called scientific research on "planned home birth" that arbitrarily categorized births as "planned at home" when in fact the mother transferred to a doctor at 8 months due to her high blood pressure or other similar disqualifiers. Click here to read the clarification of PHB