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

~~~~ Outline of Principles of Mother-Friendly Maternity Care~~~~

     I. Mother as primary caregiver to her unborn / newborn baby

A. Parental Autonomy

1. Mother as a self-directed individual - she is not a "patient" in the sense of being infirm or incompetent

2. Recognition that the integrity of the mother-child relationship begins in   pregnancy and is compromised by treatment of mother and baby as if they  were separate units with conflicting needs

a. Statutory and case law supports the autonomy of adults, including childbearing women, to make healthcare decisions except in "extremely rare and truly exceptional circumstances"
b. Autonomy extends to circumstances in which the mother (or parents) make medically unpopular decision which may be considered by others to be an irrational choice

(1) it is not necessary to convince a third party of the reasonableness of an adult’s health-related choice;
(2) irrationality per se is not synonymous with parental incompetence 

c. Limits to Autonomy

(1) Medical Diagnosis of serious illness sufficient to produce mental incompetence
(2) Uncontrolled use of alcohol and/or street drugs such as cocaine, crack, amphetamines, narcotics or similar substances that result in incompetence
(3) Extreme youth/immaturity as demonstrated by lack of capacity to understand the danger of situations or inability to be self-controlled (such as acting out adolescents) demonstrating incompetence
(4) Rapidly-developing, life and limb-threatening emergencies in which HCPs take on a function of proxy decision making as ceded to him/her by parents prior to the emergent condition or if  the mother is unconscious or otherwise unable to make an appropriately timely decision ("better to ask forgiveness than permission")

d. These principles are consistent with ACOG guidelines which respects the autonomy of childbearing women [Gabbe], Mother-friendly Childbirth Initiative by CIMS, Safe Motherhood Initiative as initiated by the ACNM, and Maternity Center Association "Statement of Right of Childbearing Women", Dona Position Paper "The Doula’s Contribution   to Modern Maternity Care

3. Acknowledgement of the non-erotic but none-the-less sexual nature of   childbearing which involves the same biological structures and psychologically includes many of the same principles necessary for physiological function in both sexual and excretory biology 

a. Mother’s right to and physiological need for privacy
b. Right to voluntariness in participation of persons and procedures that transgress the boundaries of her body or sexual psyche
c. Freedom from performance pressure and arbitrary time constraint
d. Mother’s right to that quality of care from her companions and her caregivers that does not disturb or interfere with normal physiology of spontaneous progress in labor & birth (for example the "fetal ejection  reflex"), the functionality of which is heavily influenced by psychological factors (both mental & emotional states) which are an extension of  normal reproductive sexuality

4. Mother’s right to special considerations relative to history of physical or sexual abuse or other unique psychological factors, including her right to choose pain medications, anesthesia and/or elective surgical delivery even though these medical and surgical procedures carry with them additional risks to her and her fetus / neonate

5. Recognition of special circumstances and considerations based on ethnic, cultural, gender-identity circumstances

6. Recognition of religious exemptions (incomplete) 

        B. Permission, Paternalism and Proxy decision-making [Ethics and Midwifery, textbook from the UK]

1. Permission or voluntary consent is the least standard which is legally   acceptable and must be obtained in all but "extremely rare and truly exceptional circumstances"; ("Informed Choice" is a higher standard than  mere consent)

a. Consent has four components

(1) Voluntariness -- opposite of coercion, either direct or indirect (example of indirectly coercion is to make care desired by family dependent on acquiescing - coerced consent - to unwanted  treatments
(2) Information -- Being adequately informed is one aspect of voluntary consent (quality and quantity of information offered by  HCPs should not be used to manipulate parents into decisions they otherwise would not make)
(3) competence -- the foundation for autonomy
(4) decision -- decision-making is a conscience process, where as to acquiesce is to agree without reflection; consent and actually contracting to do something is far different than expressing a mere preference  --- a conscience decision is the last step in consent and also the final point in the process of refusing consent

b. Consent is an expression of autonomy and inextricably linked to responsibility -- where autonomous choice is exercised, responsibility   follows

c. Freedom and ability to exercise autonomy is necessary condition for individuals to be considered a moral agent

d. Consent is a safeguard for the mother’s best interests and a protection from paternalism, personal preference, prejudice, ignorance or hidden agendas of personal gain by healthcare professionals

e. A valid refusal of consent should be as binding as a valid consent and is equally linked to responsibility of the parents for outcomes of their decision to decline treatment or standardized care

2. Paternalism

a. Paternalism - when someone’s capacity to make their own decision is ignored
b. Takes the form of overriding an actual decision, not bothering to get a decision in the first place, or deliberately manipulating a decision by misleading the parents through information given or withheld.
c. Employing these techniques invalidates consent and renders the procedure concerned involuntary (i.e.. shift responsibility to caregiver,  with its associated increase in vulnerability to litigation)
d. Paternalism arises out of an honest but misguided opinion that the HCP knows better than the subject as to where the subject’s best  interest lies
e. Paternalism correctly describes actions or omissions based on a benevolent but arguably misguided motive-- is of a different nature than usurping parental autonomy for reasons growing out of a hidden  agenda concerned with caregiver gain (convenience, added profit, prejudice against racial, ethnic group or religious affiliation, etc)

3. Proxy decisions -- those decisions made for the mother (or parents) due to their inability to give timely consent; mother should identify someone ahead of time to act as a proxy decision maker if she is unable or unavailable, most often identified proxy is husband or other family member; parental - caregiver contract also contains a measure of assumption that HCPs will take on proxy decision making role in presence of evident need

a. Emergent conditions requiring rapid response and specialized knowledge

b. Temporary maternal incompetence due to illness, medications,  anesthesia or loss of consciences

c. Moment-by-moment proxy decision-making by family members and caregivers is qualitatively different that those rare circumstances of a valid judicial process usurping parental rights via a determination parens patria

d. Proxy decision making by caregivers increases their vulnerability to litigation if there is client dissatisfaction or unsatisfactory outcome as the mother did not give consent or make an informed choice, thereby diminishing her responsibility for outcome and increasing the caregiver’s  

C. The Midwifery Practitioner is responsible for providing (or designating an   appropriate person to provide) client education and is directly responsible  for obtaining consent before undertaking any form of care or performing any procedures upon mother or baby

1. Practitioner is directly responsible for providing information necessary for fully-informed consent or declination of standardized care and for documenting such informed consent or informed decline of standard care and/or recommended interventions

a. Signed consent/decline by mother (also father where appropriate)
b. Memorialized in progress notes each informed consent conversation and the mother’s decision
c. Notation of other witnesses present during verbal conversations

2. Mother’s informed choice consent or informed decline of standard midwifery/ medical interventions be honored in all but those emergent circumstances in which there is a clear and present danger of death or permanent disability to either mother or baby (HCP as proxy decision-maker) and for which medical, obstetrical or neonatal care offers a dependable treatment of acceptable risk to the individuals treated and to society [3]

3. Informed decline of standard midwifery advise by parents in non-emergent but controversial circumstances during pregnancy parturition or neonatal period that is other than low risk (such as post-dates, twins, breech, PROM, etc)

a). No California statutes or case law requires childbearing women to seek medical care or follow medical advise, regardless of  circumstances of pregnancy

b). In case of a bad outcome such as admission of baby to NICU, permanent disability or death, it is possible that parents who declined midwifery/medical advise in the presence of an evident risk factor could to be prosecuted for felony child endangerment

c). Informed consent for parents who decline standardized must include information on the possible legal consequences of their decision; the informative conversation should be memorialized in writing, preferably by having parents sign consent or initialing the narrative on the chart.

d). Failure by practitioner to follow the protocols of fully informed declination and adequate documentation of this process could result in the caregiver being acquised of unprofessional conduct.

4. Professional duties in regard to midwifery care in situations where the mother 's pregnancy is currently normal, normal labor and birth are anticipated but the circumstances are associated a with statistically greater possibility of complications

a). Professional responsibilities are to:

1.) Safeguard the physical health and psychological  well-being  of the mother
2). Safeguard the physical health and psychological well-being  of the baby
3). Safeguard the personal and professional well-being of the midwife
4). Safeguard the reputation of Midwifery

b). Practitioner  responsible for listening carefully, explaining fully and assessing the various options and offering to work with the parents to find appropriate medical consultation and specialty referral if indicated
c). Practitioner cannot force compliance but none the less, the  above professional duties are most usually fulfilled by strong  encouragement of parents to seek appropriate medical consultation and transfer of care if/when appropriate
d). Duty of  practitioner to continue to provide support services during hospitalization, either personally or by arranging for a  labor companion and  patient advocacy

5. Involuntary termination of caregiver-client relationship -- situations may  arise in which the practitioner feels ethically or educationally unable to provide any further care or a personality conflict occurs

a). Discuss this fully with the client and offer to help her find a suitable replacement 
b). Memorialize conversation in chart with reasons for termination and arrangement for suitable transfer of care
You must remain available for 30 days or until the client  makes suitable arrangements. You must consult with any medical care provider if requested & provided midwifery records 

6. Intrapartum circumstances of concern -- situations that are currently normal stable and/or improving but associated with greater risk of  complications (such as undetected breech, PROM, slow progress in labor, light to moderate mec at end of normal first stage, etc)

a). Professional responsibilities are to:
1.) Safeguard the physical health and psychological  well-being
2). Safeguard the physical health and psychological well-being
of the baby
3). Safeguard the personal and professional well-being of the midwife
4). Safeguard the reputation of Midwifery
b). Situations can develop during the intrapartum which may create high anxiety for the practitioner. All reasonable efforts should be made to get consent from the parents for medical consultation and/or hospital transfer in this case.
c). If parents refuse medical consultation, it is prudent for the caregiver herself to consult with another practitioner (either midwife or physician) about her management of the labor and the problematic aspects of parental autonomy.  Document all such  conversations (with parents and any other persons/professionals)

7. Potential abandonment of childbearing women by a midwifery  practitioner --  Abandonment is never justified and is illegal /unprofessional conduct unless care has been turned over to a suitable medical or para-medical care provider.

a).   Reasons for this would be a situation that was unstable or  devolving and/or fear on the part of the practitioner that a complication was developing that she would not be able to  meet, either do to the inherent limitations of a domiciliary (non-medical) environment, such as seriously-elevated BP of  mother or birth of a premie at home or lack of training by   caregiver, such as skill in breech delivery.
b). Abandonment is a very last resort -- should be rare and reserved for "extremely rare and truly exceptional circumstances" in which para-medics are called and the midwife does not leave the parental premises until she reports to the supervisor of the EMTs

D. Practitioner Role includes assisting parents-to-be to prepare for and to take on the role of responsible parenting

1. Practitioner duties extend to promoting autonomous behavior and assisting the client to exercise autonomy as an aspect of accepting the independent role of parental responsibilities
2. Example abound in the daily life in which parents face life/death decisions that lasts for a life time -fire safety, water such as bathtubs , pools, potential falls, cars, babies who choke on a button or  swallow a marble, decision about how ill the child is, when medical care is necessary, possible injury from a jealous sibling, choice of a baby sitter, etc. Parents benefit from being exposed to these realities and given tools to help them respond to the risks of daily life.

II. Midwifery Model of Care -- scientifically-based standard of care for healthy women experiencing normal pregnancies, may be provided in hospital, birth centers and home-based birth services as provided by physicians and professional midwives -- both nurse and direct-entry

Domiciliary midwifery care is a privilege of health and therefore restricted to healthy mothers with normal pregnancies who do not desire or require induction of labor, or anticipate the need or desire for narcotic pain medications or anesthesia during labor and birth  

A. Mother and baby are distinct yet interdependent during pregnancy, birth and infancy. Their interconnectedness is vital and must be respected

B. Pregnancy, birth and the postpartum period are milestone events in the    continuum of life. These experiences profoundly affect women, babies, fathers, and families and have important and long-lasting effects on society

  C. Duty of medical care providers to inform all healthy women seeking normal maternity services that midwifery management of pregnancy, childbirth and the postpartum/neonatal period provides the safest and most efficacious form of professional care

1. Duty of healthcare professionals to provide care to healthy mothers based on midwifery philosophy and principles -- may be provided by  physicians** and professional midwives of all backgrounds who are  qualified by education & clinical training to provide midwifery services (**medical students should be trained in midwifery before being exposed to an obstetrical residency or, as graduate physicians, seek midwifery-specific education, training and certification from national  midwifery organizations)

2. MANA & ACMN definitions of midwifery view birth as a normal,  positive, growth-producing experience for the family and identify that it  is not normally a medical or pathological event

(a) Use of technology, drugs and interventions in childbearing is based on quality research and fully informed consent, and is individualized to the health needs of each woman

3. Safe Motherhood Initiatives, USA; ACNM, ACOG, MANA, March of Dimes National Black Women’s Health Project

(a) Safe Motherhood in the US is a women-centered effort within the community that requires the support of many people and in  which midwifery care is an central component

4. Mother-Friendly Childbirth Initiative - CIMS

(a) The Midwifery Model of Care, which supports and protects the normal birth process, is the most appropriate form of care for   the majority of women during pregnancy and birth

5. Statement of the Rights of Childbearing Women -- Maternity Center Association

6. Guide to Safe and Effective Care during Labor and Birth - Maternity Center Association, based on Cochran Data Base and EGPC/Enkin  

(a) "..some of the procedures, drugs, tests and treatments used in the care of low-risk women are not necessary or effective. Some practices have not been adequately evaluated, and some may do more harm than good. At the same time, some practices that are known to be beneficial to either the woman or baby are not   available in many hospitals in the US. There are significant gaps between the care that current scientific evidence shows to be safe and effective and the care actually provided to many women in the USA during pregnancy and childbirth"

D. Duty of all providers of normal maternity services to follow midwifery  standard of care in accordance with the following quality indicators

1. 80% of maternity care to be provided by the primary caregiver, to include initial assessment and intake interview, with social,   familial and psychological history as well as general medical and ob-gyn history

a. Antepartum care (incomplete - see text "Ambulatory Obstetrics" for specifics)

2. Non-interventist, non-invasive intrapartum care as standard [Safety of
  Alternative Approaches to Childbirth; Peter Schlenka, 1999]

a. Social, emotional support, including companions of choice
b. Presence of midwife, midwifery student throughout active labor   with continuity of care strongly encouraged

(1) If no midwife or midwifery student present, a trained labor support companion who can be constantly present and who is not an employee or otherwise under control of the   hospital

3. Active First Stage -- 4+cms dilatation, UC q 60+ sec, 5 min or less interval, for one hour or more for primipara or 3 or more UC in 10 minutes for multip -- ideal is spontaneous progress without pharmaceutical, medical or surgical intervention

a. Acknowledgement of psycho-social/sexual nature of childbearing  and related needs for privacy, no performance pressures, etc
b. Oral hydration and light eating [EGPC]
c.  Encouragement of maternal mobility, variety of activity and location [GEPC}
d. Use of non-Rx comfort and pain-relief techniques such as shower and/or deep water, breathing with mom, touch relaxation, etc (hot link to list of Penny Simkin's labor tips)
e. FHT accessed with mother’s permission q 30 minutes during   active labor, more often if concern over fetal well-being
f. Auscultation of fetal heart tones in 5 second units for 60 seconds   following uterine contraction to determine baseline fetal heart  rate, presence or absence of long-term variability and  accelerations and other periodic changes, record on special graph
g. preserve intact membranes [GEPC}
h. limited Vag exams -- only with mother’s consent and only when necessary for objective data leading to management decision or mother’s request
i. Flexible Time frame [GEPC}

  4. Second-stage (zero through 4+ station) -- ideal is physiological decent  of fetus

a. Mother-directed initiation of  pushing based on spontaneous urge (even if cx already fully dilated) [GEPC}
b. Flexible Time frame as long as there is progress and mother/fetus are in good condition [GEPC}
c. Maternal mobility, vertical postures, squatting to facilitate decent of fetal head [GEPC}
d. Full-time presence of primary caregiver trained in application of midwifery principles and techniques [GEPC}
e. Non-directive pushing (no routine breath-holding) [GEPC}
g. FHTs by auscultation with mother’s permission after every 3rd push, less often if briskly advancing labor and very interventive to mother, more often if any additional concern about fetal well-being [GEPC} 

5. Perineal phase (+5 station through delivery) , Ideal is physiological (non-surgical) birth while maintaining well-being of mother/baby

a. Recognition of role of "fetal ejection reflex" in non-traumatic birth     -- mother’s emotional comfort necessary for success of the fetal ejection reflex which facilitates the preservation of the maternal perineum without distressing unborn baby
b. no episiotomy unless

(1) mother’s request/permission for maternal fatigue
(2) fetal distress unresponsive to intrauterine resuscitation
(3) Consensus due to non-progression (‘iron" perineum)

c. Evidence-based management of perineium - HOOP study

(1) perineal massage only at mother’s informed request
(2) Encourage maternal participation to maintain flexion of the fetal head
(3) Maternal position of choice, encourage side-lying for multips to reduce perineal lacerations and shoulder dystocia
(4) Pelvic torquing changes of posture such as Gaskin maneuver (hand and knees) for shoulder dystocia

6. Spontaneously born baby- role of primary caregiver is to deliver to deliverability -- OK if mother or father actually catch baby

a. Caregiver is present as "insurance" policy and helper
b. Physical position and activity of laboring women is to:

(1) Empower the mother
(2) Improve advancement of fetal decent
(3) reduce fetal distress, shoulder dystocia, perineal trauma
(4) maternal-infant bonding and establishment of   breastfeeding

c. expectant management includes slight pressure on fetal head to maintain flexion, waiting for baby to restitute, perineal guarding during expulsion of shoulders when feasible (side-lying) and permitting posterior shoulder to emerge first, which is the natural inclination of spontaneous birth process
d. Use of "somersault" maneuver for nucal cord / cut only if unsuccessful
d. Appropriately timed intervention if fetal distress present or obvious signs of shoulder dystocia is evident (turtle sign, purple head, etc)

7. Third Stage - physiological delivery of placenta. Expectant   management with careful observation for excessive bleeding

b. Baby to breast to stimulate endogenous oxytocins, push maternal fluids to maintain blood volume
c. Delivery -- maternal position of choice, including squatting
d. Flexible time frame in absence of hemorrhage
e. Use of IM / IV oxytocin or for excessive bleeding uncontrollable  by other means such as nipple stimulation, etc
f. Methergine p.o.  1/320 gr q2-3 hrs for uterine atony with trickle  bleeding unresponsive to breastfeeding, etc

III. Postpartum, neonatal and postnatal period  (INCOMPLETE SECTION)

A. Immediate pp care includes "forth stage" - first hour or two after birth

B. Extended postpartum/postnatal care

IV. On-going - (incomplete)

Next Section -- Risk Reduction Strategies

Copyright ACDM / California College of Midwives 1999