STANDARDS OF PRACTICE FOR COMMUNITY MIDWIVES

1- Strive to provide continuity of care for women & newborns during the perinatal period.

2- Foster the delivery of safe and satisfying care.

3- Recognize that childbearing is a family experience.

4- Uphold the right of the woman/family to informed consent and self-determination, within the boundaries of safe care.

5- Focus on health and personal growth during the reproductive years.

6- Work as an independent midwife, and work towards an interdependent relationship within a health care system capable of providing consultation & referral.

7- Involve myself with opportunities for continuing education that will enhance professional growth & development and complete the CEUs required by my license.

8- Perform duties with professional competence.

9- Participate in on-going peer evaluation.

10- Keep all aspects of license current.

DUTIES AND RESPONSIBILITIES

1- Job Description ~ The midwife assumes responsibility for the management and care of the essentially healthy woman and newborn throughout the childbearing period.

2- Client Records ~ Confidential client records are maintained documenting all care provided to the client including referrals to other healthcare providers.

3- Disclosure Statement ~  shall be given to each client and family at the interview appointment. This includes the midwife's educational background, experience level, licenses, professional affiliations, services, expectations of clients, and financial charges.

4- Informed Consent ~ If a client chooses to decline any offered service an informed consent will be signed by the client. If a client chooses to continue plans for a home birth after full discussion of any risks involved, this too will be documented. Any time this occurs it will be discussed in peer review.

5- Lab Tests All women in my care shall receive required tests, unless their religious beliefs prohibit them (ie Christian Scientists).

6- Team Practice ~ each birth is attended with another trained assistant or midwife, and includes 24 hour on-call service always.

7- Asepsis ~ All equipment used will be maintained in an aseptic manner and kept in good working order.

8- Advance preparation ~ Prior to the onset of labor, arrangements are discussed regarding the transport of the mother and/or infant to a hospital and all clients must be in agreement to transport if the midwife it has become necessary.

9- Newborn Screening ~ provide newborn screening at the 3-day postpartum visit.

10- Birth Registration ~ provide the parents with all information regarding registration of their babies.

11- Risk Status ~ An initial risk assessment is done and ongoing risk status is revised as necessary. Referrals and/or consultation will occur as appropriate.

GUIDELINES OF PRACTICE

Part 1- Normal prenatal care

A. The midwife's duties include a maternal, family, previous pregnancy/obstetric history; determination of dates; PAP and other cultures as indicated; Multidip and UA if indicated; ordering of blood work (type & factor, antibody screen, rubella, CBC with differential, VDRL and HbsAg); and state-mandated offering of testing (HIV & MSAFP). A diet history will be taken and nutritional recommendations made.

B. Following the initial visit, the client is rescheduled at 4-week intervals until 28 weeks, then every 2 weeks until 36 weeks, then weekly until she delivers.

C. Routine prenatals include weight, BP, urine dip for protein, glucose, leukocytes, blood and ketones (if indicated), fundal height and baby's growth, fhts, baby's presentation and position, activity, and maternal nutritional, exercise, and psychosocial well-being. Any additional labs are to be ordered, including hgb, Rh antibody screening, glucose tests if indicated, etc.

D. A chart is maintained for each woman and includes observations, lab results, records of consultations and referrals, records of L&D and postpartum care and all other pertinent medical and psycho-social data. This chart is to be made available upon request and with the client's written or verbal consent to any physician or other health care provider who is called upon for consultation, referral or in the event of a hospital transport.

E. A home visit is made at 36 weeks and the following are assessed:

facilities, adequate heat, availability of a phone and transportation readiness. Between a class at 34 weeks and this home visit, the other issues relevant to a home birth are discussed, including signs of labor, when and how to contact the midwfe, father's participation, sibling preparation and plans for them, meeting others who are invited to be present at the birth, nursing preparation and emergency transport. Also noted is discussion of the parent's choice of newborn health care provider.

Part 2- Contraindications for Home Birth

The midwife does not assume primary care of clients with the following conditions:

A. Diabetes, essential hypertension, active TB, epilepsy, heart, lung, liver or kidney disease, cancer, bleeding disorders, or any other major medical problem or congenital abnormality that affects childbearing

B. History of thrombophlebitis or pulmonary embolism

C. Use of psychotropic medication or evidence of significant mental illness.

D. Substance Abuse

E. Smoking more than ½ pack of cigarettes with no likelihood of quitting or changing

F. Preeclampsia.

Part 3- Prenatal Conditions Requiring Consultation and or referral (At this time, most Obs refuse to see clients who are planning homebirths. However, every effort has been and is being made to make this interaction available to mfryclients.)

A. Active syphilis, gonorrhea, or chlamydia.

B. Unresolved signs of PIH.

C. Vaginitis which doesn t respond to alternative or OTC meds

D. UTI which doesn t respond to alternative or OTC meds.

E Anemia which doesn t respond to alternative or OTC meds.

F. Persistent glucosuria or other signs & symptoms of diabetes.

G. Third trimester vaginal bleeding

H. ROM prior to 37 weeks minus 2 days.

I. History of genetic abnormalities.

J. Prior obstetrical problems, e.g. uterine abnormalities, placental acretia or abruptia, incompetent cervix.

K. Poly- or oligohydramnios.

L. Abnormal PAP (Class III or greater).

M. (Significant) Size/dates discrepancy.  (?? by how much??)

N. Suspected malpresentation.

O. Suspected twins or breech.

P. Indications that the baby has died in utero or unexplained decrease in fetal movement.

Q. Rh neg mother with positive titers.

R. Signs of preterm labor (before 37 weeks -2 days).

S. Gestation past 43 weeks.

T. Fever of 100.4 degrees for longer than 24 hours.

U. Herpes Initial primary outbreak any time during pregnancy.

V. Abnormal FHTs.

IUGR.

Signs of placental previa or abruption.

Active herpes when beginning labor.

Fetus with congenital anomalies that may require immediate medical attention.

Midwives recognize the medical factors of risk involved with some situations including breech birth and twin pregnancies. It is my policy to counsel any client with these situations regarding the increased risk factors for both herself and her baby. I encourage the parents to make a responsible decision in conjunction with their physician, while upholding the right of the consumer to informed consent and self-determination. The intrinsic right of the parents to choose their place of birth is recognized, and within the bounds of my training and my comfort level I shall not be prohibited from aiding the clients with their choice. If unusual conditions exist an informed consent will be signed. Midwives reserve the right to withdraw care if situations arise that are unreconcilable or are outside her training and comfort level.

"REFER" is defined by Webster as "To send or direct for aid, information, etc." Women have the right to decline referral. Again, if referral is declined, informed consent will be documented.

Part 4 Normal Intrapartum Care

A. During labor & delivery, the following is done

Monitoring of the wellbeing of the mother & baby. Vitals q. 6 hrs if nl, more often as indicated if out of normal; Periodic auscultation of FHTs- q hr once labor has been established, more often as labor intensifies, after q cont. once pushing has begun; Vag exams when I arrive and as often as necessary after that, unless ROM has occurred with no labor.

2- Coaching the mom.

3- Assisting the delivery.

4- Examining and assessing the newborn.

5- Managing any third stage bleeding.

6- Inspecting the placenta, membranes and cord vessels.

7- Inspecting the perineum, vagina, and if necessary the cervix.

8- Assuring that lacerations are repaired as necessary.

B. Provide care for the mother and infant for at least 2 hours postpartum, or until the mother s and infant's condition are stable, whichever is longest.

C. carry and use the following medications:

1- Rhogam for the Rh- mom who birthed an Rh+ baby, given by 72 hours.

2- Antibiotic ointment for newborn s eyes, given within 2 hours of birth.

3- Oxygen

4- Lidocaine for repair of lacerations or episiotomy.

5- Vitamin K (mephyton 5 mg), 1/2 to be given to the baby PO within 2 hours of birth and ½ again at 1 week to 10 days.

6- Pitocin and methergine for the control of postpartum hemorrhage.

7- IV fluids

Part 5 Intrapartum Conditions Requiring Consultation and/or Transport, and Responsibilities During Transport

A. During labor or postpartum the following conditions will require hospital transport.

1- Signs of preeclampsia

2- Fever over 100.4 degrees

3- PROM accompanied by diminished maternal or fetal well-being

4- Evidence of fetal distress as indicated by fetal heart rate unless birth is imminent

5- Abnormal amount of bleeding before delivery.

6- Significant meconium-stained fluid with birth not imminent.

7- Prolonged labor accompanied by potential or actual diminished maternal or fetal well- being.

8- Signs of maternal shock.

9- Severe maternal hemorrhage.

10- Retained placenta or parts.

11- Unexplained pain.

12- 2 hour 2nd stage with no progress.

13- Maternal desire.

B. In the event that the client is transferred to a hospital, the midwiwfe will make every effort to remain with her. When possible the midwife will make a telephone report advising the hospital that of the impending transport. After arrival, the midwife will make a report to the RN on duty, and when appropreate, to the doctor.

Part 6 Normal Postpartum Care

A. Clients seem at 1, 3 and 7-10 days postpartum. Midwife is responsible for ascertaining that the mother s lochia is normal, fundus firm, no signs & symptoms of infection, is voiding, is successfully breastfeeding, and that she is getting adequate rest and support; and that the baby is stable, alert, breathing normally, that the heart sounds normal and that the heart rate is normal, that the cord is healing properly and that the weight loss/gain is normal, and that there are no signs of infection.

B. Recommend that the mom have a pediatrician, family practice doctor or another provider chosen for newborn care.

C. For the Rh- woman, obtain cord blood at birth and get a type, Rh factor and direct Coombs. If indicated, administer Rhogam within 72 hours.

D. Perform a NBS (Newborn Screening Test) at the 3-day postpartum visit.

E. Availabity by telephone and pager through 6-weeks postpartum. If out of town, arrangements will be made for someone else to be available.

F. It is available see midwife at 3 weeks postpartum for a "casual visit" to weigh the baby and discuss questions.

G. A 6 week postpartum visit which includes

1- Weight of mom and baby.

2- Discussion of birth control and referral when indicated.   

3- Inspection of tears and/or repairs and assess healing.

4- Pap smear, and bimanual exam to assess involution.

5- Hgb.

6- Answer questions which have arisen.

7- Provide referrals as indicated.

Part 7 Postpartum Conditions Requiring Consultation, referral or Transport as indicated.

A. Newborn problems

1- Apgar score of less than 7 at 10 minutes.

2- Baby with obvious anomaly.

3- Respirations with grunting, retractions, nasal flaring and tachypnea.

4- Cardiac irregularities.

5- Persistent (how long is "persistent"?) pale, cyanotic or gray color.

6- Jaundice within 24 hours of birth.

7- Abnormal cry

8- Signs of prematurity or postmaturity.

9- Absence of passage of meconium or urination during first 24 hours.

10- Lethargy or poor feeding.

11- Any other conditions which the parents or midwife has questions about.

B. Maternal Problems

1- A laceration beyond the ability of the midwife to repair.

2- Persistent uterine atony.

3- Excessive bleeding

4- Inability to void within 12 hours of birth.

5- Fever greater than 100.4.

6- Foul smelling lochia.

7- Failure of episiotomy or tear to heal properly

8- Pelvic, leg or chest pain.

9- Signs of postpartum shock.

10- Insufficient involution.