Massachusetts Midwives Alliance (MMA)

A midwife is a person who is qualified to practice midwifery. She is trained to give the necessary care and advice to women during labor, pregnancy and the postnatal period, to conduct normal deliveries on her own responsibility and to care for the newly born infant as well as having training in gynecology and child care. At all times she must be able to recognize the warning signs of abnormal or potentially abnormal conditions which necessitate referral to a doctor, and to carry out emergency measures in the absence of medical help. She may practice in hospitals, health units, or domiciliary services. In any of these situations she has an important task in health education within the family and community.

-World Health Organization

Massachusetts Midwives’ Alliance (MMA)

6/2005 Page 2

How to Use This Book

In keeping with its purpose of upholding high standards of care, while both unifying and increasing communication among midwives, the Massachusetts Midwives’ Alliance has created the MMA Practice Guidelines as a living document. The removable pages and one-guideline-per-page format are designed to allow easy changes and updates, and all members are encouraged to participate in the revision process. For this purpose, Appendix 6 provides a form for suggestions and revisions. Send Completed forms to the MMA business address on the front cover and meetings will be scheduled to discuss revisions.

The MMA encourages members to supply copies of the Practice Guidelines to medical colleagues who provide back-up and support. Appendix 7 provides the request form to facilitate this process. Please be sure the Practice Guidelines have not already been provided before requesting Guidelines for medical colleagues. This service is included with the one-time purchase of the Practice Guidelines Book.

The Massachusetts Midwives’ Alliance Practice Guidelines is available to all members. You will automatically be placed on the practice Guidelines Registry. You will then receive update pages each time a guideline is revised. Annual membership is required to remain on the registry.

4/1998 Page 4

Professional Guidelines

I. Certification & Continuing Education

A. Keep current with all certifications and continuing education units required for safe practice. These include:

1. CPM (which also includes the following):

a. CPR

b. NNR

c. Case Review

d. Continuing Education

2. OSHA Guidelines/Universal Precautions

II. Equipment

A. Stock, carry and maintain all equipment necessary for safe practice.

III. Consultation

A. Refer for consultation according to Risk Factor Guidelines (Appendix 1).

B. Request Case Review in the event of unusual circumstances.

IV. Educational and Training Guidelines

A. MMA recognizes the NARM route of certification or equivalent for entry-level midwives.

B. MMA recommends completing the “Practical Skills Guide for Midwifery” (Weaver & Evans, 2nd ed. 1997) as a foundation for the practical aspects of apprenticeship

C. MMA recommends that only experienced midwives (by NARM’s definition) take on apprentices.

D. MMA recognizes apprenticeship as an individualized, yet structured educational relationship with definitive endpoint goals.

V. Transfer of Care

A. In the event that a client chooses to transfer care from one midwife to another during her pregnancy, MMA recommends communication between midwives. If communications involve medical history, written permission from the client is necessary.

B. MMA encourages midwives to establish a working relationship with an OB practice. In addition, we encourage midwives to have a referral file to augment midwifery care (including chiropractors, mental health professionals, health care providers, and community resources such as La Leche League, WIC, Childbirth Educators, etc.).

VI. Transfer Criteria

A. It is inevitable that a certain percentage of clients will require care beyond the scope of midwifery. Transfer to the OB practice and/or hospital may occur if any of the transfer criteria are met (see Appendix 2).

B. When a primary care provider decides that a woman and/or baby must be transferred, the family will participate in the decision-making process and will be given a full explanation of the immediate problem and reason for the decision.

VII. Informed Consent (see Appendix 3)

Revised 4/2003 Page 5

Massachusetts Midwives’ Alliance

Practice Guidelines for Normal Pregnancy & Birth

I. All aspects of care will be documented.

II. Back-up

A. All homebirth clients will arrange for obstetrical, maternity and pediatric back-up care and such information will be documented on her chart.

B. MMA practice guidelines are available to back-up care providers.

III. Normal Pregnancy

A. Prenatal Care includes:

1. Complete history (medical, obstetrical, psychosocial)

2. Complete physical exam

3. Complete pelvic exam and assessment

4. Nutritional assessment and counseling

5. Lab work – standard prenatal screen including CBC with Diff, ABO Type & Factor, Rubella, RPR, Hep.B surface antigen, Antibody screen, UA culture & sensitivity.

6. Other lab work when appropriate: glucose testing, alpha fetal protein, amniocentesis, ultrasound, sickle cell, HIV, gonorrhea, Chlamydia, toxoplasmosis, GBS culture, platelet & diff, Pap test, etc.

B. Return Visits

1. Frequency: every 4 weeks, up to 28 weeks LMP; every 2 weeks from 28 to 36 weeks; weekly from 36 weeks until the birth.

2. Visits more frequent as needed.

3. Assessment of client’s general well being, including weight, fetal heart tones, fetal growth, urinalysis for protein/glucose, blood pressure, ongoing review of nutritional, educational and psychosocial needs and concerns of women and family.

4. 30-minute minimum visit.

5. Lab update as needed, such as 28 – 36 wks CBC with Diff., antibody screen, urine culture, Group B strep, etc.

C. 36 Week Visit

3. Home visit when possible

1. Check emergency transport phone # list

2. Check birth supplies

3. Instructions for early labor, including when to call and how to reach midwife.

D. The midwife will refer for consultation and/or care if any client exhibits signs and/or symptoms of abnormal conditions as outlined in the MMA Risk Factor Guidelines (see Appendix 1).

Page 6

IV. Labor and Birth

A. Initial exam during labor includes checking FHR, Maternal blood pressure, pulse, temperature, fetal position by palpation, and noting status of membranes. When indicated, a vaginal exam to assess dilatation, effacement and station may be done.

B. Labor

1. Fetal Heart Rate Screening includes:

a. Frequency:

Minimum of every 15-30 minutes during early active labor;
Every 5-15 minutes during late active labor;
Every contraction to every other contraction during second stage, not to exceed 5-minute intervals.

b. In addition, it is beneficial to evaluate FHT’s

1. Immediately after contractions

2. Intermittently through contractions

3. Upon rupture of membranes

4. With increasing frequency if any signs of risk factors develop

2. Temp., pulse, blood pressure repeated every 4 hours or as indicated

3. Monitor progress of labor through observation and/or examination

4. Anticipate transport if risk factors develop

5. Midwife or qualified assistant must be present in home from beginning of active phase onward

6. Maintain maternal hydration/nutrition/elimination

a. Maintain sterile technique as procedure dictates

C. Birth

1. Prepare for birth; check/set up supplies, set appropriate room temperature

2. Assist client with birth according to her wishes and present circumstances

3. Use midwifery techniques to preserve perineal integrity

D. Third Stage: Newborn

1. Assess Neonatal status, record 1 and 5 minute Apgar

2. Suction or resuscitate as needed

3. Maintain newborn temperature through immediate maternal contact and appropriate room temperature

4. Use sterile instruments for cord cutting

E. Third Stage: Mother

1. Expectant management unless otherwise indicated

4. Assess uterine height, tone, and estimate blood loss

5. Facilitate birth of the placenta

6. Take cord blood, if necessary

7. Examine placenta and cord

8. Examine perineum for lacerations

9. Suture, if necessary, using sterile technique and local anesthetic as needed

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F. Fourth Stage

1. Minimum 2 hour postpartum maternal monitoring including:

a. Facilitating breastfeeding

b. Give postpartum instructions for first 24 hours

c. Encourage appropriate home environment

2. Minimum 2 hour postpartum newborn monitoring including:

a. Perform newborn examination (see Appendix 5)

b. Offer eye prophylaxis

c. Offer Vitamin K

3. Ensure stable condition of mother and baby

4. Consult or refer according to Transfer Criteria (Appendix 2) and Risk Factor Guidelines (Appendix 1)

V. Post Partum

A. Minimum 2 visits

1. First visit within 24-36 hours

2. Second visit within 5 days

3. Perform or refer to pediatrician for Newborn Screening Program

4. Observe and monitor parameters of maternal and newborn well-being including involution, lochia, breastfeeding, jaundice, and cord condition

5. Pediatric exam – midwife recommends clients make arrangement exam with their health care provider according to the provider’s preferred time frame

B. 6 week office visit

1. Complete pelvic exam (bimanual and speculum)

2. Pap test if not done during pregnancy

3. Breast exam and instruction on self exam as needed

4. Abdominal exam

5. Assessment of family adjustment and parenting

6. Birth control counseling and information

7. Follow up on pediatric care

C. Birth Certificate: Assist parents with filing for a Birth Certificate within the required time frame.

4/1998 Page 8

Mass Midwives’ Alliance

Practice Guidelines for Variations in Pregnancy & Birth

I. Pregnancy

A. Vaginal Bleeding

1. Spotting before 12 weeks, not associated with lower quadrant pain

Advise client to rest and abstain from sexual intercourse for at least seven days after spotting has ceased
Schedule prenatal visit within 7-14 days to assess uterine growth, rule out missed abortion or ectopic pregnancy, check FHT’s, discuss serial beta sub/quant
If not resolved after 2 consecutive visits, consult and/or refer to back-up

2. Vaginal bleeding before 12 weeks

Advise client to rest and abstain from sexual intercourse for at least seven days after bleeding has ceased
Schedule prenatal visit
If bleeding persists for 5 days, cramping persists for 1-2 days, or uterine or fetal growth stop, refer client to back-up
If bleeding is heavy, (more than 3 full-size pads/hour or 8 pads in 12 hours? Consult back-up. When possible, save any tissue passed
Administer Rh immune globulin to all unsensitized RH- women within 42 hours of spontaneous abortion
If spontaneous abortion is inevitable, refer to miscarriage guidelines (page 9)

3. Vaginal bleeding after 12 weeks

Evaluate client as soon as possible for possible placenta previa or abruption
Rule out precipitating factors such as vaginal exam or intercourse
If bleeding is heavy and/or painful, direct client to a medical facility immediately

4. Spotty or minimal bleeding after 12 weeks

Take history noting time of onset, amount, duration, activity at time of onset
Assess maternal and fetal vital signs
Assess fetal position by abdominal exam
Careful digital and/or speculum exam
Obtain ultrasound scan; if abnormal, consult back-up
If spotting persists despite normal U/S scan, consult back-up
If spontaneous abortion is inevitable, refer to miscarriage guidelines (page 10)

Page 9

5. Miscarriage Guidelines

Defined as cramping and bleeding that lead to pregnancy loss
Stay in close telephone contact with client
Be sure she and her partner have a clear understanding of what is normal and what is not. Have them write everything down and save any clots or tissue passed
Expect cramping to be quite severe and suggest complementary and support measures
Determine if you will attend her when the process is intensifying
Refer her if and when the following situations present:
She desires to be in the hospital
Bleeding exceeds one pad every two hours, not counting the 2-3 hours of actually “passing” the baby and placenta
Administer RhoGAM if needed
Schedule a two week follow-up appointment

B. History of a previous Cesarean Section

1. Review complete health and obstetrical history

2. Obtain and review all hospital labor and delivery records, including documentation of uterine incision

3. Discuss benefits and risks of home VBAC early in pregnancy

4. Be aware of possible increased emotional needs and be prepared to make appropriate referrals

5. MMA considers it likely that the risks of home VBAC are minimal but present. MMA stands behind risk assessment oh home VBAC as stated in Risk Factor Guidelines (Appendix1)

C. Genital Herpes

1. Culture all suspicious lesions in pregnancy and refer for consultation if primary outbreak

2. If diagnosed, discuss with client risks of herpes in pregnancy and preventative measures for eliminating and/or reducing genital herpes outbreaks in pregnancy

3. Any area that is likely to come in contact with the baby during birth must be free of active herpes lesions

4. Refer client to hospital for birth if contact with active lesion cannot be prevented

D. Anemia

1. Marginal Anemia – defined as Hct/Hgb less than 35/12

Thoroughly review medical history
Check symptoms
Review diet and supplements and provide counseling as needed
Repeat blood work in 1 – 2 months

Page 10

2. Anemia – defined as Hct/Hgb less than 32/11

Proceed as above
Repeat blood work in 1 month

3. Severe Anemia – defined as Hct/Hgb less than 30/10

Proceed as above
Perform further screening tests to determine/rule out other forms of anemia
Consult with back-up for further evaluation to rule out other conditions

E. Glycosuria

1. Defined as dipstick reading + to ++++