California College of Midwives
Mar 1999 Principles of Mother-Friendly Childbearing Services

Characteristics of Clinical Competency associated with
Science-Based Maternity Care Systems

Recommendations on Scope of Practice &
Risk Reduction Strategies

Community Midwives Professional
Insurance Consortium
and other California Licensed Midwives

The dynamics of a group policy or combined "pool" are such that it provides us with something we couldn’t afford as individuals but it also has its own down-side and limitations. For instance, if we all do well (no litigation) the premiums will remain low. However if any midwife is sued, it will effect the premiums we all pay the next year.  If several midwives get sued the cost of premiums will sky-rocket and coverage will become unaffordable. So we all have a shared interest in reducing the risk of litigation in regard to both economics and the reputation of midwifery.

The best way to achieve this is for all the members of the master policy to practice in a safe and competent manner consistent with the history and tradition of midwifery in the US and the midwifery model of care as practiced world-wide. In addition, we must establish practice parameters and standards for our individual jurisdictions (state and local). That is one of the reasons for the expanded questionnaire mailed out to all the members as this information helps establish the common scope of practice and characteristics of competency of domiciliary midwives as a class. Should we be required to defend midwives in court, this information would be crucial to establish the community standard for community-based midwives.

As administrator and holder of the master policy I will publish a series of documents that explore that history and tradition of skillful midwifery and particularly the topic of risk-reduction. Currently the members of the Consortium are mostly direct-entry midwives licensed in California. In an effort to help California midwives remain in compliance with our state midwifery statute, I will also provide information on the Licensed Midwifery Practice Act of 1993 and guidance on the statutory scope of practice and characteristics of competent practice. However, I believe that most of these guidelines would be useful to midwives in general.

Reference materials used in this exploration:

Official publication by the College of Midwives of British Columbia defining the Model of Midwifery Practice, Philosophy of Midwifery Care, Code of Ethics, Competencies of Registered Midwives, Indication for Planned Place of Birth, Statement on Home Birth, Indication for domicilairy Midwives to Discuss, Consult and transfer Care (September 1997 version)

World Health Organization "Safe Motherhood" publication "Care in Normal Birth- A Practical Guide" (1996)

California Licensed Midwifery Practice Act, 1993 -- as passed in October and SB 350 April version before being amended by the CMA

The Netherlands Board of Medical Insurance Funds, Obstetric Indication List; Final Report of the Study Group Revision Kloosterman List (February 1987)

California Nurse-Midwifery Practice Act - 1974

Handbook -- Central Midwives Board, Midwives Act, 1951, Untied Kingdom, 25th edition, 1962

Original Midwifery Statute for California - Section 2505, 1917

City of Rochester (New York) Midwifery statute - 1896 

Recommendations on Scope of Practice
and Characteristics of Competency
for California Midwives

Normal Birth as defined by the California
Licensed Midwifery Practice Act of 1993

Normal Birth is not specifically defined by the Licensed Midwives Practice Act of 1993. However, it is defined in the inverse -- abnormal birth is functionally identified as parturition (i.e. intrapartum period) in which there is a need to use "artificial, forcible or mechanical means", which is specifically prohibited to the midwife by the statute. In addition, the use of "artificial, forcible and mechanical means" is defined by other sections of Chapter five of the Business and Profession Code as the unauthorized practice of medicine.

This definition is one of the oldest and most traditional in the history of midwifery regulation, having been chosen by the framers of one of the first midwifery laws ever written in the US -- a statue for the city of Rochester, NY passed in 1896. It was then adopted word for word in the original Section 2505 (1917) California midwifery statue in an amendment to the 1913 Medical Practice Act. The 1974 nurse-midwifery statue regulating the practice of nurse midwives reiterated the same text. These same principles using the same language were chosen as the definition of the scope of practice of direct-entry midwives in the Licensed Midwives Practice Act of 1993.

To better understand the intent of our contemporary statute which focuses on abnormal (or medicalized) birth, it is useful to recount the history of obstetrical interventions as used in the late 19th and early 20th century as this wording was first adopted to legally define the difference between the scope of practice for midwives and that of physicians (i.e., the practice of medicine). Medical methods of the period used to artificially stimulate labor were usually mechanical means or devices including intrauterine injections of hot and cold water, glycerin, milk, ergot, electricity and x-rays. The most popular method at the turn of the century was a series of "bougies" -- inflatable balloons on the end of a long rubber catheter. These devices were forced through the undialated cervix and then filled with increasing amounts of water or air to mechanically pry the cervix open. Debilitating and even fatal infections were a frequent side effect of these invasive maneuvers which was one reason their use was restricted to medically- licensed practitioners.

Physical means employed to force the delivery of the baby included binding of the mother’s abdomen tightly to jam the baby down into the pelvis, fundal pressure applied during delivery to extend the baby’s head (or deliver the shoulders) and the obstetrical maneuver known as "podalic version and extraction", in which a practitioner inserts a gloved hand high up into the uterus by first pushing the baby’s head up out of the pelvis and then grasping the baby’s feet and working the baby around until the it can be pulled out by the ankles as a footling breech. The use of artifical, forcible and mechanical means such as these frequently resulted in maternal and infant death from birth trauma. It was not until the discovery of safe oxytocic drugs, which is very recent -- 1953 -- that the use of such dangerous and even lethal force was replaced by the relative safety of oxytocic drugs, which are now only given intravenously to hospitalized patients who are being electronically monitored.

In contemporary times, the term 'artificial means' as used in the 1993 statute would prohibits the use of formulary drugs, such as Pitocin, that stimulate uterine activity, ‘forcible means' would prohibit the routine use of fundal pressure. The prohibition on the use of 'mechanical' would prevent midwives from performing forceps deliveries or using vacuum extraction. The statutory definition does not focus on the defining normalcy by specific characteristics of pregnancy, maternal health, pelvic dimensions, estimated fetal weight or position. One reason for this is that the medical definition of "normal" birth is commonly applied only in retrospect -- that is, after the birth when one is reflecting on whether or not it was necessary to employ "artificial, forcible or mechanical means" or the labor and delivery was characterized by serious medical complication for either mother or baby.

Historically, midwives have been trained to attend all spontaneous labors in healthy mothers in which vaginal birth was expected to be successful -- including babies in a vertex position, breeches and twins (reference -- 1917 version of 2505, 1962 edition of the English Midwife’s Code and the 1997 protocols for the College of Midwives, British Columbia). The last 2 decades has seen an experimental medical protocol imposed on breech and twin pregnancies in an attempt to improve perenatal outcomes by performing routine Cesarean surgery in these cases. 

Statutory modifier to the scope of practice established by the LMPA

Emergency Exemption Clause -- one well-recognized legal modifier to the statutory scope of practice in California is the emergency provision of the MPA (Section 2063). Under emergency conditions when the care of a physician is unavailable, any citizen, including a licensed midwife, is authorized to do that which is necessary and within the ability of the individual to save a life, prevent serious injury or permanent damage. This does not generally extend to the performance of major surgery such as Cesarean section or the use of forceps. The emergency clause does not in any way affect the normal scope of practice of midwives as applied to routine or normal care.

Religious Exemptions Clause (Section 2063) -- another recognized modifier of the scope of practice is the religious exemptions clause. This prohibits the Medical Practices Act from being used in any way that interferes with the practice of religion. Families requesting care under the Rel Ex Clause lawfully may decline and caregiver may lawfully accede to their declinations for all routine procedures relevant to pregnancy and birth care.

The linguistic problem inherent in the word "Birth"

The word ‘birth’, as used in the Rochester statute and all subsequent California statutes is a non-technical stand-in for the combined stages of gestation (antepartum) and parturition (1st, 2nd, and 4th stage of labor or the intrapartum), the immediate postpartum and postnatal period as it applies to the newborn baby. This can be documented by referring to the original (1917) version of section 2505 which delineates each of these stages (pregnancy, labor & delivery, postpartum and postnatal).

The logical problems inherent in the word "normal"

Normal must be defined within a context and it also must be acknowledged that the idea of "normal has more than one valid context. For example, the most familiar context of "normal" is what is normally done by practitioners. However, that which is normally done may not actually be the safest or most desirable or most up to date. For instance, if practitioners routinely (i.e., normally) fail to wash their hands after each patient encounter or still employ a practice that has been proven ineffectual or even harmful or has been supplanted by a better, safer method, it could be said that is what they "normally" do. Since the fundamental purpose of the midwifery statutes is to protect the citizens of California from incompetent or negligent practices, we clearly would not want to elevate this familiar definition of "normal" into the equivalent of a standard for practice. There must be other factors to balance familiar interpretation.

There is another pitfall with defining "normal" by what practitioners normally do.  The circumstances that call for the definition of "normal" are themselves frequently atypical -- they represent a unique combination of factors that do not have a precedent in the experience of most midwives. This often cuts both ways. It may be a series of things that individually would be considered normal but the aggregate results in a significantly increased risk that is clearly reducible by obstetrical care and hospitalization. Or it may be a series of things that are themselves not normal/typical but together result in a situation which is already at the lowest level of irreducible risk and could not be improved by medicalization.

A similar concern in defining normal is the experience, specialized training and level of expertise by the practitioner. A new graduate who is functioning at the entry-level should routinely define normal very narrowly, restricting herself to very low risk mothers (pregnancy and parturition is, of itself, a risk-factor). On the other hand, midwives who have been practicing for 10-20 years and have been trained in managing intrapartum situations that require advanced skills will reasonably define normal as including situations of moderate risk (i.e. "moderate risk" is the aggregate of the inherent risks of normal birth plus a "minor" medical problem or an identified (or potential) obstetrical or perinatal risk), assuming (as always) that full disclosure of all identified risks has been employed and adequate informed consent given by the parents (or the parents requested care under the Rel Exemption Clause).

Statistical analysis of more than 800,000 California birth certificates and discharge abstracts identifies that the midwifery model of care, that is permitting labor and birth to unfold normally ie., physiolgically and spontaneously, is the safest course for healthy mothers with normal pregnancies (approx. 71% of pregnancies) , as measured by perinatal mortality, rate of medical and surgical intervetions and maternal and neonatal morbidity. What this means to the vast majority of  childbearing familes is that the danger of overtreatment is greater than the danger of undertreatment. [Safety of  Alternative Approaches to Childbirth; Peter Schlenka, 1999]

Guidelines for "Normal Birth" as applied to the California LMPA

In light of the problems and inherent limitation in the above definition of normal as "what other practitioner are doing", the following definition of "normal birth" as used by various jurisdictions could properly function as guidelines for the practice of midwives licensed in the state of California. These principles are not inconsistent with the legislative intent and language of the LMPA of 1993 which as noted earlier does not actually mandate any specific definition:

Guidelines defining the term "normal birth" for licensed midwives practicing in domicilairy settings (locations other than a licensed medical facility) would have three characteristics.

First it would utilize the technical definition of "birth" that is consistent with other aspects of the current Midwifery Act and the historical version of section 2505 which is to say extending to all stages of "parturition" -- the intrapartum, postpartum and the immediate postnatal period including lactation.

Secondly, it would define/recognize that normal equates with natural (i.e., not artificially stimulated) spontaneous physiological processes which are characteristic of healthy reproductive biology of childbearing women and can reasonably be expected to lead to normal conclusions -- pregnancy naturally advancing to term with a live, growth-appropriate fetus, spontaneous labor leading to spontaneous live birth of a viable neonate and conservation of the health of the mother and wellbeing of the baby.

Third, it would define "normal" in relation to pregnancy, parturition, postpartum/postnatal and lactation as that level of risk which is naturally inherent and irreducible in the physiology (including psychological aspects which affect biological function) of each of these phases, stages and discrete events of normal/natural childbearing.

This functional definition would take into account the informed consent decisions made by the childbearing family. For instance, when the parents have chosen to forego or will not permit the use of medical or surgical interventions or treatments which might theoretically tip the scales toward medicalized care, then the inherent risks remain irreducible (i.e., would not be substantially changed or eliminated by physician and hospital care or such medical care has been refused by the parents) -- such as declining the use of antibiotics in the presence of prolonged rupture of membranes or when the estimated weight of the baby is above average. In these circumstances, the care of the midwife would normally preserve the well-being of mother and baby at the highest level achievable and thus would fall within the realm of "normal" as defined through a risk-related standard.

General Guidelines for Midwife-managed Pregnancy & Parturition

It is also possible to offer general guidelines that historically have prevailed and which are also in accordance with contemporary definitions of "normal" as provided by the College of Midwives of British Columbia, Canada (which specifically addresses the practice of direct-entry midwives providing care in domiciliary settings), the World Health Organization’s Safe Motherhood publication entitled "Care in Normal Birth: A practical Guide" and the Dutch "Koosterman List".

The most simple and most generally accepted definition of low-risk "normal birth" (i.e., pregnancy and parturition) by midwives around the world has been applied to a healthy mother who is pregnant with a single fetus in a longitudinal lie (either vertex or breech) with spontaneous onset of labor between 36 1/2 weeks to 42 1/2 weeks, progressing in a timely manner through out the various phases associated with physiological parturition while the mother and baby are able to remain adequately hydrated and free of distress.

This definition usually stays away from specifying times or other criteria (fetal position, estimated weight of baby, length of labor, how long she pushes, etc.) for each of these stages and phases of physiological labor and birth. It assumes that midwives will voluntary match their experience and skill level to the needs of the childbearing mother and her unborn baby. Further more it assumes that the midwife will seek out more experienced midwives when indicated and/or consult with medical practitioners and transfer to medical care when indicated.

Fetal Position and Normal Birth

As anyone familiar with the medical literature knows, routine cesarean surgery for breech does not improve perinatal outcomes in term pregnancies, in spite of the increased maternal mortality subsequent to cesarean surgery. For babies of average weight, vaginal birth is equal or superior to operative delivery in regard to the baby and several times safer for the mother. Now days most practicing physicians no longer have the experience or skill to deliver breeches vaginally, making it desirable for those who have these valuable skills to utilize then in situations that reduce the risk to the mother from unneccessary surgical delivery while maintaining the same level of irreducible risk to the baby.

Regardless of whether or not physicians maintain vaginal breech delivery skills, it is necessary for all midwives to understand the theory and mechanisms of normal breech birth as well as those of emergency breech extraction skills (in case of dystocia). Due to the propensity for emergency births to include undetected breeches midwives must maintain vaginal breech skills permitting them to adequately manage emergent situations. This is an excellent topic for CEUs.

For those practitioners who have had ample experience working in circumstances where breeches are routinely delivered by midwives (such as other countries or religious communities), low-risk vaginal breeches (a category that excludes premature, postmature, and macrosomic babies and those in a footling or incomplete breech position) it would be "normal" (as defined by the criteria of irreducible risk) to manage the labor of a mother who is between 37 and 41 weeks of pregnancy, has had a previous successful vaginal birth, has given "special circumstances" informed consent/declination (i.e.. specifically declining hospital and physician care) and is carrying an average sized baby in a frank or complete breech well-engaged in the pelvis with briskly progressive labor and no indication of fetal distress. 

9. Special Circumstances Informed Consent -- parents who decline routine medical interventions:

Many states, including California, have no state law which defines childbirth to be a medical or pathological condition or requires a mother to seek out medical or midwifery care during the pregnancy or to be attended a licensed doctor or midwife during labor and birth. In California neither residency nor status as a bona fide citizen obligates the state to provide care or pay for care rendered to pregnant women. Any voluntary arrangements made by the mother for antepartum, intrapartum, postpartal or postnatal care are above that required by law.

As a risk-reduction strategy for both mothers and the unborn babies, a midwife attended-birth (even in the presence of identified risk factors) is far safer (most especially for the baby),  than a unattended labor  or an unnecessary and unwanted cesarean section forced on the mother because physicians are mandated to perform surgical deliveries by either malpractice carriers or HMO protocols. According to a highly respected obstetrical textbook (Gabbe's Obstetrics: Normal and Problem Pregnancies, 3rd edition 1995) the risk of maternal mortality associated with Cesarean surgery is 16 times greater than vaginal delivery* while CS for breech babies at term is no safer  for babies than vaginal birth.  [*maternal mortality for vaginal birth 1:16,666 as cited by Lilford, et al vs. maternal mortality for CS is 1:1000]

Sample Text for Special Circumstances Informed Consent/Informed Decline of Standard Medical Care and/or Medical Interventions due to moderate (or potential) risks of pregnancy or parturition:

After receiving extensive information regarding risks and current medical criteria for managing ___________ (specify circumstance), the parents have declined prophylactic hospitalization & obstetrician care for labor and delivery.

(List specifics of risks and benefits as well as all other pertinent information)

See  Samples of Special Circumstance Informed Consent for Macrosomia, VBAC, Twins and GBS consent in other documents on our web site.

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