Additional material from the California Association of Midwives certification process and state-wide guideline for practice, the W.H.O. "Care in Normal Birth: A Practical Guide" and the Kloosterman List (Netherlands) Combined with practice guidelines from many California midwives as well as other sources and personal conversations with midwives world-wide.

Criteria for Initial Selection of Clients (see background information)
Indications for Discussion, Consultation and Transferal of Care during
Initial Interview, antepartum,  intrapartum, postpartum and postnatal periods:

Most Recent Edit Date -- Jan 23, 2004 (no substantive changes since October 22, 2002) 

1) Criteria for Initial Selection of Clients for Independent Midwifery Care:

• Healthy mother without serious pre-existing medical or mental conditions affecting major body organs or biological systems

• History, physical assessment and laboratory results should be within limits commonly accepted as normal with no evidence of the following:

• Tuberculosis or other serious chronic or acute pulmonary problem
• Rh negative with positive titer not related to RhoGam or Anti-E factor 
• Severe Anemia (Hgb of 9 or less) or Sickle Cell Anemia
• Heart Disease
• Renal Disease
• Severe Psychiatric Disorders
• Insulin-deficient Diabetes
• Serious Congenital Abnormalities affecting childbirth
• Morbid Obesity
• Alcoholism or Substance Abuse (not use but abuse)
• Significant Pelvic/Uterine Abnormalities (tumors, malformations, etc.,)
• Other significant abnormality affecting pregnancy, parturition and/or
  ability to safely care for a newborn.

Obstetrical consultation recommended for:

• Grand multipara (5 or more previous births) and/or less than 12 months from last delivery to present due date

• History of repeated spontaneous abortions and/or more than one late miscarriage, pre-term birth or low-birth weight baby or unexplained stillbirth or neonatal mortality

• Family history of genetic disorders, hereditary disease or significant congenital anomalies

• History of fibroids or previous unexplained antepartum / postpartum hemorrhage requiring transfusion

• Any current medical condition of significance for which ongoing treatment is required or Rx medication is routinely being taken

2). Informed Consent for Domiciliary Birth Services -- In the US home-based maternity care is of itself other than "standard" as defined by the dominate medical model. Client families should be fully informed of risks and benefits of domiciliary birth services. It is strongly recommended (but not mandatory) that families read and sign a formal consent for OOH labor and/or birth. see sample Consent for Home-based Midwifery Care

Informed Consent/ Decline of Standardized Medical or Midwifery Care --  This form is to document the informed decision to decline standardized medical/midwifery care when the mother/family is convinced that the proposed procedure would violate a core value or strongly- held religious belief or that it entails risks of iatrogenic complications that outweigh the proposed benefit. Examples include declining medical evaluation or proprophylactic risk managment via medicalization of pregnancy, labor or birth.  see sample Special Circumstances Informed Decline of Consent

Indications for Discussion,
Consultation, Referral and Transfer of Care 
Relative to Home-based Maternity Services

As a primary caregiver, the midwife is fully responsible for decision-making, together with the client. The midwife is responsible for writing orders and carrying them out or delegating them in accordance with the standards of the College of Midwives.

The midwife discusses care of a client, consults, refers and/or transfers primary care responsibility according to the Indications For Discussion, Consultation, Referral And Transfer Of Care in conjunction with the informed consent of the parents. The responsibility to consult with or refer the mother to a family physician/general practitioner, obstetrician, specialist physician or other healthcare professional initially lies with the midwife; the responsibility to follow-up on a referral lies with the parents. It is also the midwife's responsibility to initiate a consultation or recommend referral within an appropriate time period after detecting an indication. The severity of the condition and the availability of an appropriate physician consultant will influence these decisions.

The College of Midwives expects members to use their professional judgment in making decisions to consult, refer or transfer care. The following list is not exhaustive. Other circumstances may arise where the midwife believes consultation, referral or transfer of care is necessary.

The informed choice agreement between the midwife and client should outline the extent of midwifery care, so that the client is aware of the scope and limitations of midwifery care. The midwife should review the Indications For Discussion, Consultation And Transfer of Care  with the client.

The principle of professional care includes providing full information and regularly obtaining fully-informed maternal consent. While the standard of care requires the licensed midwife to seek out or recommend a specified relationship with the medical model whenever indicated, individual mothers may decline the midwife's advise after being provided with full information. 

A decline of consultation or referral must be duly noted in the client's chart. Except for truly rare and extremely exceptional circumstances ("clear and present danger of death or permanent disability"), the final disposition must include the informed consent of the parents.

DEFINITIONS

Discussion with Another Midwife or a Physician

When increased concern for the well being of mother and baby arises from an identified risk or complication (either actual or potential) it is the midwife's responsibility to initiate a discussion with, or provide information to, another experienced midwife or a physician in order to plan care appropriately.

Many situations listed under the category of midwife discussion lend themselves to group decisions made a priori by the professional midwives who regularly attend a geographical peer review (or other experienced midwives and/or physicians who regularly confer with one another, either by phone or in person). These specific recommendations should be memorialized in writing in the peer review attendance log, a journal or other form of documentation. Whenever peer group or experienced midwife recommendations apply to a specific circumstance, the primary care midwife need not discuss the situation unless there are additional factors.   All such decisions (via discussion with another midwife or by implementing a peer group policy) should be documented by the midwife in the client's  record.

Consultation with a Physician*
or other Appropriate Health Care Professional

It is the midwife's responsibility to initiate a consultation and to communicate clearly to the consultant that she is seeking a consultation(*a). A consultation refers to a situation in which a midwife, using her professional knowledge of the client and in accordance with the standards of the College of Midwives, requests the opinion of a physician competent to give advice in the relevant field. A midwife may also seek a consultation when another opinion is requested by the client. Consultation should be documented by the midwife in her records.

The midwife should expect that the consultant will address the problem that led to the referral, conduct an in-person assessments) of the client when appropriate, and promptly communicate findings and recommendations to the client and to the referring midwife. Discussion may then occur between the midwife and the consultant regarding the future care of the client.

(*a) When consultative relationships between physicians and community midwives are not available due to political hostility from the obstetrical community, the midwife may instead refer the mother to medical practitioners independently from her care. Under circumstances of "Medical Referral" it is the responsibility of the client to arrange for a medical evaluation of the condition identified by the midwife. In this situation it would not be expected that the physician would communicate with or provide advise to the midwife. Under the theory of parental autonomy, the mother/parents may, with fully informed consent (and appropriately documented in the chart -- see Informed decline of consent form), decline medical evaluation except under "rare and exceptional circumstances" that represent in a clear and present danger of death or disability to mother and/or unborn/newborn baby. 

Where urgency, distance or climatic conditions do not allow an in-person consultation with a physician, the midwife should seek advice from the physician by phone or other similar means. The midwife should document this request for advice in her records, in accordance with the standards of the College of Midwives, and discuss the advice received with the client.

A consultation can involve the physician providing advice and information, and/or providing therapy to the woman/newborn, or prescribing therapy to the midwife for the woman/newborn.

After consultation with a physician, primary care of the client and responsibility for decision-making, with the informed consent of the client, either:

[a) continues with the midwife, or [b) is transferred to physician.

Once a consultation has taken place and the consultant's findings, opinions and recommendations have been communicated to the client and the midwife, the midwife must discuss the consultant's recommendations with the client and ensure that the client understands which health professional will have responsibility for primary care.

The consultant may be involved in, and responsible for, a discrete area of the client's care, with the midwife maintaining overall responsibility within her scope of practice. Areas of involvement in client care must be clearly agreed upon and documented by the midwife and the consultant.

Only one health professional has overall responsibility for a client at any one time, and the client's care should be coordinated by that person. The identity of the primary caregiver should be clearly known to all of those involved and documented in the records of the referring health professional and the consultant. Responsibility could be transferred temporarily to another health professional, or be shared between health professionals, according to the client's best interests and optimal care; however, transfer or sharing of care should occur only after discussion and agreement among the client, the referring health professional, and the consultant[s).

Transfer to a physician for primary care:

When primary care is transferred permanently or temporarily from the midwife to a physician, the physician assumes full responsibility for subsequent decision-making, together with the client. When primary care is transferred to a physician, the midwife may at the mother's invitation provide supportive care within her scope of practice, in collaboration with the physician and the client.

Midwives are strongly encouraged to file an incident report about situations  each time they occur in which appropriate medical interface is unavailable or has been denied. (see chapter 4, page # 1 for information on CCM incident reports)

Transfer:

* any serious medical condition, for example: cardiac or renal disease with failure, or insulin-dependent diabetes mellitus

Antepartal Care 

INDICATIONS for: 

Discussion:

* no prenatal care before 28 weeks gestation
* presentation other than cephalic at 36 weeks
* unusual circumstances - social, physical, economic or mental health, etc.

Consultation/Medical Referral:

* medical conditions arising during prenatal care, for example: signs/symptoms of endocrine
  disorders, renal disease, significant infection, sexually transmitted disease  
* serious psychological problems, incl. eating disorders [1]
* significant anemia unresponsive to therapy 
* hyperemesis or suspected malnutrition
* pregnancy-induced hypertension
* red cell isoimmunization, hemoglobinopathies, blood dyscrasia
* repeated vaginal bleeding other than transient spotting 
* unexplained persistent or severe pain
* polyhydramnios or oligohydramnios
* suspected or diagnosed fetal anomaly that may require physician
  management during or immediately after delivery
* significantly inappropriate uterine growth or signs of fetal distress 
* multiple gestation [3)
* presentation other than cephalic at 37 weeks
* documented post-term pregnancy (42 completed weeks**) with
  accompanying tests for fetal well-being which demonstrate
  non-reassuring FHT patterns
* other abnormalities that could result in significant loss of well being

Transfer:

* insulin-dependent diabetes
* onset of cardiac, renal or other serious medical disease
* proteinuric pre-eclampsia or eclampsia  
* symptomatic placental abruption
* placenta previa with or without bleeding
* abnormal presentations or lies incompatible with spontaneous
  vaginal delivery

During Labor and Delivery

INDICATIONS:

Discussion:

* no prenatal care
* primipara in early active labor with fetal head not in pelvis
* poor or unsupportive social circumstances

Consultation/Medical Referral:

* unexplained persistent or severe pain not relative to normal labor
* pre-term labor [after first day of 36th completed week of pregnancy **]
* detection of frank or complete breech presentation  
* prolonged rupture of membranes
* prolonged active phase
* prolonged second stage
* abnormal bleeding
* retained placenta

Transfer:

* severe hypertension
* detection of footling breech
* unsatisfactory progress in labor
* active genital herpes at time of labor
* proteinuric pre-eclampsia or eclampsia
* premature labor [less than 36 completed weeks**)
* temperature > 38°C/100.4 F on two or more occasions,
  other signs of  infection
* abnormal presentation or lie incompatible with spontaneous vaginal birth
* multiple pregnancy (2)
* prolapsed cord
* thick meconium or moderate particulate meconium in early active labor
* abnormal fetal heart rate patterns unresponsive to standard interventions
* placenta abruption and/or previa
* uterine rupture
* uterine inversion
* hemorrhage unresponsive to standard interventions
* symptoms of obstetric shock
* laceration of genital tract beyond the ability of practitioner to repair
* serious/significant deviation from normal requiring medical intervention
*  desire of the client for medical or hospital care

Postpartum (Maternal)

INDICATIONS:

Consultation/Medical Referral:

* Excessive bleeding or trickle bleed unresponsive to therapy
* breast infection unresponsive to therapy
* wound infection
* uterine infection
* signs of urinary tract infection
* temperature over 38°C / 100.4 F on two or more occasions ( > 6hrs apart)
* persistent hypertension
* serious psychological problems [4]

Transfer:

* hemorrhage unresponsive to therapy
* postpartum eclampsia
* thrombophlebitis or thromboembolism
* uterine prolapse
* serious physical or mental health problem
* desire by family for medical care

Postnatal (Infant ~ immediate and extended care) 
Also see "Guideline for Postnatal Management " following mild to moderate difficulties
during birth at home

INDICATIONS:

Discussion:

* feeding problems [5]
* excessive molding or cephalohaematoma
* minor respiratory irregularities /Transient Tachypnea of the Newborn (TTN)
* significant risk of neonatal infection

Consultation/Medical Referral:

* infant less than 2,400 g
* suspicion of neonatal infection
* less than 3 vessels in umbilical cord
* abnormal findings on physical exam
* birth injury requiring investigation
* excessive bruising, abrasions, unusual pigmentation and/or lesions
* congenital abnormalities, for example: cleft lip or palate, congenital
  dislocation of hip, ambiguous genitalia
* abnormal heart rate or pattern
* persistent poor suck, hypotonia or abnormal cry
* persistent abnormal respiratory rate and/or pattern
* persistent central cyanosis, pallor or jitteriness
* jaundice in first 24 hours
* failure to pass urine or meconium within 30 hours of birth
* suspected pathological jaundice after 24 hours
* temperature less than 36°C unresponsive to midwifery-based interventions
* temperature more than 37.9°C unresponsive to midwifery-based interventions
* persistent/serious vomiting or diarrhea
* infection of umbilical stump site
* significant weight loss (more than 10% of body weight)
* failure to regain birth weight in 3 weeks
* failure to thrive

Transfer:
* apgar score below 7 at 10 minutes
* respiratory difficulties which are either sever or protracted
* seizure activity
* significant congenital anomaly requiring immediate medical intervention
  for example: omphalocele, myelomeningocele
* temperature instability unresponsive to usual corrective measures
* Other problems determined to require hospital care

** Note on dating pregnancy and the custom of "weeks" of pregnancy in regard to management decisions:

The estimated date of delivery (EDD) is always an approximation unless the mother conceived by IVF. Even the best ultrasound technology in very early pregnancy (5-8 weeks) can only date a pregnancy within 72 hrs or 3 day plus or minus.

When the LMP due date and the ultrasound EDD are in conflict the customary practice is to use the LMP date unless ultrasound measurements indicate the LMP date to be off by more than a one week (for first trimester ultrasound); more than 2 weeks (second trimester ultrasound) or more than 3 weeks (third trimester ultrasound). Ultrasound "correction" of the EDD should only be done ONCE, preferably in early pregnancy. It is not considered appropriate to continually slide the date back and forth as a result of subsequent ultrasounds or fundal height discrepancies. Always the EDD should be correlated with date of quickening, sequential fundal height measurements and growth (girth), familial history (LGA babies) and ethnicity (Asian and Hispanic babies often measure SGA). 

Informed consent discussions with parents relative to EDD-sensitive topics should take into account the variable nature of due dates. All management decisions should factor in the likelihood of at least 72hrs greater or lesser gestation than the EDD. On the early end -- 37 weeks gestation or less -- the baby could easily be up to 3 days less mature than expected. At 42+ weeks the baby could be as little as 41.4 wks OR as much as 42.3 wks.  

This requires vigilance as greater pre- or post-maturity could be present than expected. It also speaks for permitting (with fully informed consent of the parents) a  little grace in the system. In particular, it is not appropriate to think that the mother or baby have magically improved or suddenly devolved in status with the stroke of the clock at midnight.  Seventy-two hours plus or minus seems prudent, along with continuing vigilance.

Background: The above recommendations are consistent with the Licensed Midwifery Practice Act of 1993 for the State of California and with the guidelines from the College of Midwives, BC.  These criteria include by reference the two previous sections of Clinical Competencies (1a and 1b) and incorporate the foundational principles of informed consent and the right of parents to make medically unpopular decisions or even decline prophylactic medical evaluation or medical management of risk factors.

2. While most of these clients will require transfer of care, complete or frank breech presentation and twins @ term in a longitudinal lie are listed as indications for consultation to allow discretion in deciding if a midwife should manage such a delivery, where a spontaneous birth is reasonably anticipated and the midwife is trained and experienced in their management. In a remote area, the availability of an experienced midwife may prevent a woman from having to leave her family and community for care elsewhere or being subjected to an unwanted and unnecessary cesarean delivery (for example, circumstances where no physicians are experienced in vaginal breech or twin delivery). Midwives may also gain important hands-on experience under obstetrical supervision where available.

3. see #2 above        4. see #1 above   5. Not withstanding the requirement for discussion with a physician or midwife, discussion may be with another appropriate health care professional

Adapted from the College of Midwives, British Columbia 14 April 1997 Refer Standard 2, CMBC Standards of Practice -- Indications for Discussion, Consultation and Transfer of Care

Additional material from the California Association of Midwives certification process and state-wide guideline for practice, the W.H.O. "Care in Normal Birth: A Practical Guide" and the Kloosterman List (Netherlands) and elements of practice guidelines from many California midwives