Closing the Theory–Practice Gap: Intrapartum Midwifery Management of Planned Homebirths Saraswathi Vedam, CNM, MSN, Meredith Goff, CNM, MS,and Vicki Nolan Marnin, CNM, MSN
In the United States, access to qualified homebirth providers varies by state, city, and community, and consistent, evidence-based guidelines for intrapartum management at home are not available. This article examines the similarities and differences in midwifery management of the intrapartum, postpartum, and neonatal course between planned homebirths and planned hospital births. Characteristics of qualified attendants, essential medical supplies and equipment, methods for maternal and fetal surveillance, and common intrapartum indications for transfer are discussed. Unique features of management of the healthy woman and baby in the home are described, as well as the process of consultation and/or referral for collaborative or medical management. Current evidence for the management of fetal intolerance of labor, meconium stained amniotic fluid, prolonged labor, postpartum hemorrhage, and the unstable newborn is discussed in the context of homebirth practice. Aspects of homebirth care that require cultural competency and affect the informed consent process are included. Homebirth practice may provide opportunities to increase the congruence between espoused midwifery philosophy and actual practice. J Midwifery Womens Health 2007;52:291–300 2007 by the American College of Nurse-Midwives. keywords: collaborative care, core competencies, cultural competency, evidence-based care, home child- birth, intrapartum management, low risk obstetrics, midwifery, perinatal management, planned homebirth, risk assessment, screening criteria, transfer criteria, transfer protocols INTRODUCTION
reduced access to qualified homebirth attendants. Atten-dant choice of intrapartum practice site and style of
The phrase “planned homebirth” describes births that
management may be influenced by a lack of exposure to
occur when “the woman intends to deliver at home; she
effective care in out-of-hospital settings. This article
meets defined medical and environmental criteria for an
discusses effective intrapartum care across birth settings.
optimal perinatal course; and she has qualified birthattendants who work within a health care system that
The Theory–Practice Gap in Contemporary Midwifery Care
provides access to equipment, specialized personnel,and/or hospitalization when In the last
Recently, Lange and described a theory–
decade, controlled trials and observational studies have
practice gap between espoused midwifery philosophy
described excellent perinatal outcomes for planned
and professional behavior as reported by 245 newly
CNMs. When asked to reflect on their final clinical
the environment and process of care when delivering at
rotation as students (87% hospital placements), study
participants described a “lack of congruity between ideal
according to birth setting. In developed nations, out-
and actual midwifery practices that support normal birth”
of-hospital births have been associated with the appro-
in the practice(s) of the CNM preceptors they worked
priate use of technology and reductions in health care
with just before graduation. This work suggests that there
are unique competencies in perinatal management that
sory panels have supported informed choice for place of
characterize, promote, and preserve the midwifery model
birth and increased access to appropriate out-of-hospital
of care. While respondents noted very little theory–
practice gap in the behavior of preceptors in the “dimen-
In the United States, less than 4% of members of the
sion of caring,” they observed large differences between
American College of Nurse-Midwives (ACNM) attend
ideal and actual midwifery practice in “using low tech-
nology approaches when possible” and “intervening only
do not provide home care, and 95% of certified nurse-
if necessary and appropriate.” Maintenance of a support-
midwives (CNMs) or certified midwives (CMs) provide
ive presence in labor was found to be less congruent
intrapartum care only in the The low rates of
between professed theory and actual practice. Students in
homebirth in the United States may be a result of
birth center settings (10%) observed the greatest congru-ence for “respecting the normal processes of birth” (P Ͻ.01). Respondents also reported a gap between theirperception of ideal practice and actual practice in “vigi-
Address correspondence to Saraswathi Vedam, CNM, MSN, Division of
lance and attention to details” in homebirth practices.
Midwifery, University of British Columbia, B54-2194 Health Sciences
Authors concluded that this perception may be a function
of an incongruence between “how watchfulness is done
Journal of Midwifery & Women’s Health • www.jmwh.org
2007 by the American College of Nurse-Midwives
1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.02.013
in a hospital setting compared with how a midwife
Table 1. Antepartum Assessment Criteria for Birth Site Selection
conducts that same activity at home,” further confoundedby the students’ very limited exposure to homebirth
General Criteria
midwifery practice (2.9% of student placements).
● Woman physically and mentally healthy and well-nourished
Educational programs for CNMs and CMs in the
● Adequate social supports before and during birth● Primary participants mature and able to accept responsibility for self-
United States rarely offer out-of-hospital clinical experi-
ences as a core part of the curriculum. Hence, while
● Commitment to maintaining a positive emotional environment for
to any practice setting, the translation of these compe-
● Arrangements made for emergency transport
tencies to an out-of-hospital setting may not be obvious.
● Childbirth, homebirth, and breastfeeding education secured (books/
In addition, there are some screening concepts, manage-
● Preparation of persons planning to be present at the birth
ment priorities, and therapeutic measures that assume
● Complete records from previous provider for current and/or past
greater significance or are different according to birth
site. Increasing confidence among CNMs/CMs in the
● Pediatric care arranged before 36 weeks of pregnancy
application of these concepts and methods may reduce
● Obstetric consultant identified by 36 weeks● Help available in home 24 hours a day for at least 1 week after the
the theory–practice gap in the promotion of normal birth.
If they become familiar with the realities of care at home,
● Commitment to birth without pharmacologic analgesia or anesthesia
they may consider homebirth practice, and therefore
● Understanding of and agreement to the screening criteria
increase access to out-of-hospital maternity services.
● Open and clear communication with the midwife
These low technology core competencies become even
Recommended Indications for Consultation, Collaboration, and/or Referral of Care
more critical in an era when management of health care
access and delivery outside the hospital during pandem-
● Chronic hypertension and/or pre-eclampsia requiring management with
ics, natural disasters, or national crises is a palpable
● Current mental illness that the midwife deems would have a harmful
Antepartum factors that affect birth site selection have
● Thromboembolic disease (event) requiring heparin
been described in detail This article provides
a review of the aspects of intrapartum, postpartum, and
neonatal midwifery management that can be provided
● Rh isoimmunization or positive antibody screen during current
similarly across birth sites, as well as those assessment,
management, and therapeutic measures that need to be
● Active preterm labor that cannot be stopped● Evidence of chorioamnionitis
● Multiple gestation diagnosed before labor● Substance abuse
CORE COMPETENCIES ACROSS BIRTH SITES
● Non-reassuring fetal surveillance results
Most women will have two providers present for a
Adapted with permission from Jackson et al., eds.,
planned homebirth, primarily because after the birth,both mother and baby will require attention and surveil-
the homebirth midwife may need to manage the compli-
lance. Midwives may collaborate with other midwives,
cation independently. Hence, preparation for skills, pro-
nurses, or trained birth assistants. Qualified homebirth
cedures, and management during common urgent care
attendants have the ability to monitor maternal and fetal
condition and assess and treat common obstetric condi-
In reality, the competencies required for managing
tions with low technology methods. The identification of
complications during the perinatal period are common to
complications that would be best addressed by equip-
many midwifery practice settings. The management of
ment or personnel available in the hospital and the ability
immediate postpartum hemorrhage (PPH) or unexpected
to initiate a referral are essential components of profes-
breech delivery, and neonatal resuscitation of the term
sional homebirth care. When delivery is imminent or the
infant are topics within core curriculum in midwifery
stage or nature of the condition prohibits safe transfer,
educational programs, and prerequisite knowledge forbasic certification and practice in any setting. In additionto screening for potential complications and impediments
Saraswathi Vedam, CNM, MSN, is the Director of the Division of
to normal birth, homebirth midwives avoid interventions
Midwifery at University of British Columbia and serves as chair of theACNM Division of Standards and Practice Homebirth Section.
that may adversely affect maternal or fetal status and
Meredith Goff, CNM, MS, is on the midwifery faculty at Yale School of
precipitate a need for transfer. For example, medications
Nursing and provides intrapartum midwifery care in the Yale Midwifery
for pain management can affect neonatal respiratory
status, thermoregulation, glucose metabolism, and be-
Vicki Nolan Marnin, CNM, MSN, is clinical preceptor for Yale School of
Nursing and practices in a homebirth midwifery private practice as well asa tertiary care intrapartum setting.
hospital setting, the availability of naloxone (Narcan;
Volume 52, No. 3, May/June 2007
Endo Pharmaceuticals, Chadds Ford, PA) and immediate
Table 2. Basic Equipment for Homebirth Bag
access to neonatal providers can mitigate the adverseeffects of maternal administration of medications during
Sterile Supplies
labor. Even common procedures, such as amniotomy and
vaginal exams, have potential adverse consequences if
compression, chorioamnionitis, or a reduced dilution of
meconium may increase the necessity of therapy only
Conversely, homebirth midwives and families employ
a variety of intrapartum and postpartum measures to
prevent complications and promote maternal and fetal
well-being in an effort to avoid a change in the setting for
Equipment for Maternal and Fetal Assessment
care. The best available evidence supports continuous
labor support, active hydration and nutrition, and meth-
ods to conserve energy and rest in the latent phase.
Optimal maternal and fetal positioning, the use of upright
Pharmaceuticals
positions, heat, and nonpharmacologic methods of pain
management are effective, safe, and satisfying supportive
and preventative measures that can be employed at
Resuscitation Equipment Essential Birth Supplies and Equipment
The “sterile tray” is nearly identical for planned home-
Nonsterile Supplies
birth and planned, term hospital birth The
equipment and supplies are best organized in a limited
number of carrying cases, which can be easily trans-
ported in the midwife’s vehicle and carried quickly from
the curb into the home. Materials that are sensitive to
heat (medications) can be carried in a Thermos or
package with cold packs. Hard or padded cases for
oxygen tanks will protect them from damage and inad-
vertent release in the midwife’s vehicle.
The physical environment of the home may be unfa-
miliar to the midwife and may not provide the conve-
nience of ergonomic examination and treatment features(adjustable beds, lighting, wall suction, neonatal warm-
GBS ϭ Group B streptococcus; PROM ϭ premature rupture of membranes.
ing exam tables, etc.). With a little imagination and
The DeLee mucus trap is manufactured by Sherwood Medical (Saint Louis, MO). The
ingenuity, all of these items can be created simply.
RescueVac is manufactured by Rescue Vac Systems, Inc. (Naperville, IL). Uristix aremanufactured by Bayer Diagnostics (Chicago, IL). AquaMEPHYTON is manufactured
Pillows, chair backs, stools, and human supports can be
by Merck & Co., Inc. (Whitehouse Station, NJ).
used to position both mother and midwife comfortably.
Adapted with permission from Jackson et al., eds.27
Flashlights and adjustable desk lamps can be propped upwith rolled washcloths to direct a beam of light. A cityphone book wrapped in a folded towel and underpad
nearest hospital. Organization of and access to the birth
makes a firm but comfortable surface to stabilize and
supplies, clear passageways, and clear, firm surfaces will
visualize the perineum during repairs. A baking sheet or
facilitate efficient care and prompt transfer when neces-
cutting board layered with soft flannel receiving blankets
and an electric heating pad serves as a firm, flat, warm,portable surface for neonatal exam or resuscitation. Modifications Related to Cultural Competence
The family supplies sources of heat, light, and water,
nourishing fluids and foods for labor, and a transport
Homebirth midwives often are witness to cultural and
vehicle for non-urgent transfer. The plan for emergency
religious traditions, specific to labor and birth, that may
transfer is assisted with a posted written listing of
not be practical or permissible in a hospital
emergency numbers, including transport, obstetric, and
As invited guests in the home, it is incumbent upon
pediatric personnel, and directions to and from the
midwives to be both respectful and knowledgeable about
Journal of Midwifery & Women’s Health • www.jmwh.org
the details of these practices. The inclusion of song,
Postpartum Follow-up At Home
prayer, or specific support persons are components that
Follow-up postpartum care in the home involves the
can be easily integrated into usual practice. The desire for
standard maternal postpartum evaluation of involution,
specific environmental modifications (altar, candles,
bleeding, vital signs, breasts, perineum, and emotional
lighting, birthing room location, etc.) sometimes has to
status during each of the scheduled postpartum visits.
be balanced with the practicalities of access to birthing
Homebirth midwives commonly provide in-home assess-
equipment, visualization, and ease of transport. Prohibi-
ments two to four times in the first week, and offer office
tions on the use of motor vehicles (Orthodox Jewish or
visits subsequently. Homebirth families frequently re-
Amish families) may require special arrangements or
quire reminders of normal postpartum recovery needs for
exceptions when transport is necessary. Specific food and
rest because they do not benefit from limited “visiting
food preparation requirements (Kosher or Brahmin rules)
hours” and 24-hour access to nutritional and physical
may have an impact on the midwife’s ability to prepare
support in the hospital. At home, the expectations for
or serve food and fluids to the woman. Generally, the
return to normal roles and self-care activities may pre-
midwife can engage the client in an anticipatory discus-
cede physical and emotional readiness. Many homebirth
sion about how to best serve her within the context of
midwives encourage the mother to arrange for 24-hour
how she interprets the aspects of her culture that interact
in-home help during the first week. The importance of
adequate postpartum rest and psychosocial support toprevent postpartum depression has been well docu-
Anticipatory Guidance, Support, and Maternal Surveillance
Once labor is established, the initial and ongoing assess-
directive role by providing written instructions and mes-
ment and management priorities are common to all
sages to the extended family, adherence may improve.
midwifery practice regardless of anticipated birth site. Whether in home or hospital, the midwife performs a
Care of the Normal Neonate in the Home
physical exam and checks the signs and symptoms of
Unlike the hospital-based midwife, the homebirth mid-
labor progress and coping abilities at regular intervals.
wife is the sole provider responsible for initial examina-
Evidence-based measures to provide comfort and pro-
tion and care of the newborn at birth and at the early
mote progress include continuous loving support, hydro-
postpartum visits. In the immediate postpartum period,
therapy, acupressure, sterile water papules, massage,
the midwife examines the newborn for signs of normal
cardiac and respiratory transition. The newborn’s vital
The impact of emotional and environmental factors on
signs, output, gross anatomy, alertness, responsiveness,
the progress of labor is well documented in the litera-
and feeding/attachment behaviors inform ongoing care.
Maternal anxiety engendered by the planned
Like many hospital-based midwives, the homebirth mid-
place of birth (either at home or in the hospital) may
wife also makes it her priority to assist with initial
emerge as a reason to transfer or to initiate preventative
lactation. However, because there is usually no other
strategies earlier. The client’s psychological prepared-
experienced nurse or lactation consultant on site after the
ness is a critical variable that may affect the ability to
midwife leaves the home, many homebirth midwives will
deliver in the home setting without analgesia or labor
not leave until latch and adequate suck/swallow is
augmentation. Management of the environment at a
established. Some homebirth midwives require clients to
planned homebirth has some unique challenges. The
breastfeed in the initial postpartum period, as the ability
midwife’s status as a guest may increase the need to
to breastfeed is a marker of neonatal health, and breast-
balance advocacy for her patient with negotiating family
feeding improves maternal immunity, reduces stress and
dynamics and cultural expectations. For example, when
the primary decision-makers are the elders in the family,
ate newborn care may include the administration of
they may feel more empowered to assert or insert their
prophylactic therapies and medications (vitamin K or eye
presence, opinions, and fears in the home than in the
To ensure that the family has ample opportunity to
recuperate and to concentrate on establishing good par-
Fetal Surveillance
enting and breastfeeding habits, homebirth midwives
In all intrapartum settings, midwifery evaluation of fetal
often provide in-home newborn care and assessment
well-being is indirectly monitored via periodic assess-
until the child is 2 weeks of age. In addition to the
ment of fetal heart rate pattern. In the home, intermittent
physical examination, midwives can evaluate feeding
auscultation is the method of fetal heart rate evaluation.
behaviors, monitor family adjustment, and collect state-
Guidelines have been established outlining the frequency
and interpretation of intermittent auscultation for low-
Ideally, the family will establish a relationship with a
pediatric provider who is willing to be available for
Volume 52, No. 3, May/June 2007
The most common reason for transfer from home to
Table 3. Reasons for Transfer From Planned Homebirth to Hospital
hospital once labor has started is failure to progress.
Johnson and evaluated the outcomes of 5418
women who planned homebirths with certified profes-
sional midwives in North America. Twelve percent (n ϭ
655) were transferred to a hospital in the intrapartum or
postpartum period. Of those women transferred during
labor, 51.2% (n ϭ 323) were transferred for failure to
progress in the first or second stage of labor. Murphy and
conducted a prospective observational study
describing outcomes of intended homebirths (N ϭ 1221)
attended by CNMs. Of those beginning labor at home,
102 (8.3%) were transferred to the hospital in labor, more
membranes. Ten women (0.8%) were transferred post-
Inability to establish normal respirations
partum and 14 (1.1%) infants were transferred. Intrapar-
tum problems were positively associated with transfer to
hospital-based care, and overall outcomes were consis-
tent with expected outcomes for low-risk birth.
When possible, the homebirth midwife encourages a
birth site that is within 30 minutes of a hospital that
Data taken from Ackermann-Liebrich et Wiegers et Davies et Janssenet Murphy and and Johnson and
provides obstetric and neonatal services. Once thewoman enters the intrapartum period at home, the mid-wife may recommend a change in planned site of birth
consultation and referral before the birth. Some pediatric
regardless of need for consultation or referral. The
providers are unaware that midwifery core competencies
midwife must consider time required for and method of
include newborn examination skills and may expect the
transfer, in light of whether safe and effective manage-
family to bring the baby to their office in the first 24
ment would be adversely affected if maternal/fetal status
hours. The midwife may inform the pediatric providers
changes while en route. The continuing role of the
of their intention to provide care in the immediate
midwife will vary according to her status as a creden-
newborn period with a letter of introduction detailing
tialed provider or a referring provider. If the woman is
rationale for providing in-home care, and the reassurance
transferred for pain management or augmentation of
that the midwife will provide them with copies of the
labor, the midwife who is also on staff at the admitting
records of the birth, newborn exams, postpartum course,
hospital may remain as primary provider. If the same
and newborn screening results. In any situation that
woman subsequently requires surgical intervention, the
deviates from the normal newborn course, the midwife
midwife will then consult and transfer care. She might
will contact the pediatric provider directly as well as
provide solely supportive care or assist in the surgery
referring the family to him/her. Frequently, care and
recovery care. Ideally, the physician consultants are
follow-up in such cases results in collaborative
available to provide offsite consultation and assumecollaborative or primary care role as necessary while stillbeing willing to preserve as much of the birth plan as
TRANSFER FROM HOME TO HOSPITAL
possible in the hospital setting. Joint reviews of transfers
Several prospective analyses of the outcomes of planned
from home to hospital can inform ongoing collaboration
homebirths have described reasons for transfers from
and promote mutual respect. Families requiring an emer-
home to hospital before and after onset of labor at
gency transfer or prompt care for maternal or pediatric
In these studies, the rate of antepartum refer-
concerns will need extra support in the immediate post-
rals for obstetric reasons (e.g., fetal growth restriction,
partum period. Assistance with transport, physical sup-
previa, pregnancy-induced hypertension, twins, or pre-
port (rest, hydration, and food), emotional support, and
term) for women who intended a planned homebirth
guidance regarding unexpected hospital tests, routines,
ranges from 10% to 20%. Of those women who reached
and treatments is invaluable. The perceived losses of
term without medical complications, 5% to 10% required
normalcy and control and the loss of a low intervention
intrapartum referrals, 1% postpartum maternal referrals,
birth experience can contribute to dissatisfaction and
and 1% neonatal referrals. The large majority of these
depression, especially if women are not allowed to
transfers occurred for nonemergent conditions
Journal of Midwifery & Women’s Health • www.jmwh.org
possible neonatal resuscitation and encouraging delivery
Table 4. Common Intrapartum Indications for CNM/MD Consultation,
may be a better use of time and resources. An efficient
Collaboration, and/or Referral During A Planned Homebirth in
resuscitation is best accomplished in a stable setting, not
in a moving vehicle. The equipment and skill set that a
Intrapartum and Immediate Postpartum Factors
homebirth midwife can provide for a term infant with a
● Evidence of fetal intolerance of labor
terminal bradycardia is identical to those available in
● Thick or particulate meconium-stained amniotic fluid with non-
● Breech or transverse fetus during labor● Pharmaceutical induction or augmentation of labor
Meconium
Evidence-based management of the woman with meco-
● Prolonged labor with no evidence of progress and/or evidence of
nium-stained amniotic fluid has evolved in the last
decade. Level 1 evidence from prospective multicenter
● Maternal desire for pharmaceutical pain management
trials addressing the incidence of meconium aspiration
● Elevated maternal temperature with ruptured membranes
syndrome in infants born through meconium-stained
● Severe or persistent postpartum hemorrhage
amniotic fluid suggests no benefit from amnioinfusion,
● Retained placenta● Congenital anomalies
endotracheal intubation, or intratracheal suctioning, es-
harm associated with suctioning includes apnea, in-
Intrapartum guidelines assume adequate time to initiate consultation. Emergent
creased hypoxia, delay in resuscitation, damage of the
situations are stabilized and, if necessary, hospital transport is arranged. Exceptions
upper airway, and cardiac arrhythmias. Community stan-
to this list may be made taking religious exemptions into consideration.
dards for care, however, may not yet acknowledge a
Adapted with permission from Jackson et al.,
change in recommendations. Application of the bestavailable evidence (avoidance of suctioning) is possibleand may be advisable in the home setting, but if transfer
MANAGEMENT OF INTRAPARTUM AND POSTPARTUM
is subsequently affected, differing protocols in the re-
COMPLICATIONS
ceiving institution may lead to conflict.
Common intrapartum factors that require specialized
The development of meconium aspiration syndrome
midwifery management or consultation, collaborative
appears to be associated with intrauterine fetal hypoxia.
care, or transfer are described in While the
In the context of thick or particulate meconium-stained
reasons for most are self-explanatory, management rec-
amniotic fluid with nonreassuring fetal heart tones and/or
ommendations for some conditions are affected by the
lack of progress, the homebirth midwife initiates transfer
evolving state of the evidence and the chosen birth place.
unless birth is imminent. If delivery is imminent, thehomebirth midwife prepares for potential resuscitation
Evidence of Fetal Intolerance of Labor
and ongoing vigilance for signs and symptoms of meco-nium aspiration syndrome. Typically, the infant with
Midwives in the home and in the hospital address
meconium aspiration syndrome will display symptoms of
significant fetal heart rate decelerations, tachycardia, and
respiratory distress (e.g., nasal flaring, retractions, poor
unexpected persistent bradycardias identically. If a non-
color, and an unwillingness to breastfeed), though in an
reassuring fetal heart rate characteristic is heard, increas-
otherwise vigorous term baby, these symptoms may
ing the frequency and duration of auscultation is contin-
develop over several Initiation of surfactant
ued for several contractions to confirm if it is transitory
and/or nitrous oxide therapy within 12 hours of delivery
or persistent. Simultaneously, interventions to improve
may reduce hospital This information can guide
uterine blood flow and fetal oxygenation are instituted,
the timing of transfer decisions when symptoms of
such as maternal position changes and hydration. Fetal
meconium aspiration syndrome develop.
scalp or acoustic stimulation may be performed to elicita reassuring acceleration of the fetal Abdominal
Prolonged Labor
and/or vaginal exams may be indicated to diagnosisabruption, cord prolapse, precipitous descent, or malpre-
Management of a long labor is another example of the
sentation. If the fetal heart remains nonreassuring, the
gap between evidence and practice. Practice and hospital
feasibility of timely transfer to a facility with continuous
protocols frequently expect adherence to an expected
electronic fetal monitoring is evaluated.
partogram. The need to progress 1 cm/hour or deliver in
Consideration of stage of labor and imminence of
8 hours via active management of labor, or to deliver
delivery will influence the chosen course. If a persistent
when staffing is available, has made time an outcome
variant fetal heart rate pattern is identified in first-stage
measure in itself. In the last 50 years, Friedman’s
labor, transfer to hospital-based care may be the prudent
definitions for normal length of labor have been widely
plan. However, if delivery is imminent, preparing for
adopted. However, Friedman’s methodology has recently
Volume 52, No. 3, May/June 2007
come under scrutiny. His conclusions were based on
to therapy before their arrival. In this case, the midwife
plotting 500 individual labor curves and synthesizing
and family will determine advisability of transport de-
them into one Zhang et applied a statistical
pendent on the current maternal status and prognosis. If
analysis to compare dilatation at various points during
the uterus is well contracted, the sources of bleeding have
labor (repeated measures analysis) in nulliparous partu-
been addressed, the infant is nursing well, the vital signs
rients who started labor spontaneously at term with
are stable, and the mother is able to engage in self-care
singleton fetuses in a vertex presentation (N ϭ 1992).
without syncope, she may remain on bed rest at home. To
assure stability, the midwife usually remains in the home
Labor patterns for the study subjects differed markedly
for several hours more than usual. Prophylactic infusion
from the Friedman curve, both in increased length and
of one or two liters of intravenous fluid and/or a
lack of manifestation of a deceleration phase.
prescription for a postpartum oral oxytocic agent may be
Several other investigators have reported that the
provided, especially in the context of homebirth and the
normal lengths for each stage of labor are likely to be
longer than Friedman described, without evidence ofmaternal or fetal also noted that
Unstable Newborn
because the increased maternal morbidity in patients who
Assessment of respiratory and cardiac status of the
have a prolonged second stage is partially a result of
newborn begins immediately after the birth in all set-
operative interventions, providers should not base active
tings. Both hospital and homebirth providers evaluate
and treat infants with poor or absent respiratory effort
The evidence on maternal preference for active versus
according to American Academy of Pediatrics/Neonatal
Resuscitation Program standards. Recent evidence indi-
that patient involvement in decision making is associated
cates initiation of bag and mask ventilation with room air
riencing a prolonged labor at home may wish to try all of
gardless, the oxygen tank can be attached to the tubing
the nonpharmacologic methods of augmentation before
and tested for flow before the birth. The reservoir bag can
considering transfer to the hospital. Emerging evidence
be detached and placed next to the tank with the
suggests that hydration and rest, followed by nipple
stethoscope, so that should the addition of oxygen or
stimulation, maternal position changes, acupuncture,
cardiac assessment be necessary, they are easily acces-
sible. Warmth can be provided continuously with the use
reviewed the conflicting data on the effects of
of space heaters, the tray prepared with heating pad and
ambulation and cited problems in methodology and
receiving blankets, or with foil transport bunting. Emer-
confounders in many studies (e.g., randomized women
gency services are called for any infant who does not
switching groups, definition of ambulation, rules for
rapidly respond to resuscitation efforts.
bedrest, style of electronic fetal monitoring, and am-
Signs of the inability to maintain respiratory health,
niotomy). As prolonged labor is a nonurgent indication
thermoregulation, hypoglycemia, birth injury, or inability
for transfer, some variation in choice can be supported.
to suckle are all indicators for additional vigilance,supportive therapy, and pediatric consultation if unre-
Immediate Postpartum Hemorrhage
solved. Some conditions will resolve spontaneously inthe first 24 hours with supportive therapy. For example,
With advanced planning, immediate PPH is a complica-
transient tachypnea of the newborn is usually self-
tion that can usually be well managed in the home.
limiting, but may require the presence of and monitoring
Factors such as prolonged labor, grand multiparity, or
by the midwife for an extended period of time. In these
rapid labor with a large infant may increase the risk of
cases, the choice of the site of care is made collabora-
PPH. The homebirth midwife will have heightened
tively between the family, the midwife, and the pediatric
sensitivity to such factors, may consider prophylactic
transfer, and will have pharmaceuticals, syringes, intra-venous supplies, and a urinary catheter immediately
Congenital Anomalies
available. Evaluation and management of bleeding in thehome is identical to hospital practice (e.g., digital com-
Some clients seeking homebirth services decline prenatal
pression and/or repair of lacerations, vaginal exploration,
testing, such as ultrasound, first trimester screening,
and assessment and treatment of atony). If there is
and/or amniocentesis. This requires the midwife to be
inadequate response to therapy, emergency medical ser-
prepared for a wide range of uncommon anomalies,
vice is contacted for transport for hospital care.
which may not be immediately life-threatening but re-
Transport in the case of moderate PPH is not always
quire prompt transport and evaluation. For an infant who
required. Sometimes, the midwife will summon emer-
has established adequate oxygenation and perfusion,
gency personnel but the hemorrhage will have responded
there is usually a brief visual assessment as the infant
Journal of Midwifery & Women’s Health • www.jmwh.org
begins to nurse. Infants with cardiac problems often have
alternatives have been explained, a woman has the right
difficulty simultaneously nursing and breathing. These
to exercise full autonomy in making an informed deci-
infants need immediate hospital care. The goal for
sion, which includes informed An individual’s
managing newborns with anatomical anomalies, includ-
assessment of risk is based on both fact and emotion.
ing gastroschisis, omphalocele, exstrophy of the bladder,
Risk is most effectively communicated when the infor-
or open spinal cord defects is to keep exposed areas moist
mant is perceived as being both competent and caring,
with sterile saline and gauze, and covered with plastic
supportive, and empathetic, all of which engenders
wrap to maintain moisture, heat, and decrease contami-
For the homebirth midwife, the development of
nation. The infant should be positioned to support the
mutual trust and a collaborative relationship with the
defect (e.g., prone for Pierre–Robins syndrome) while
family is an essential goal, developed over the course of
pregnancy through prenatal visits that allow ample time
Any infant presenting significant findings outside the
for discussion of medical, psychosocial, and family
normal range requires a consult with the pediatric care-
issues. The joint plan for the intrapartum care of the
giver. Stable infants presenting with orthopedic anoma-
woman and baby at home acknowledges the family and
lies or chromosomal disorders (e.g., a cleft lip/palate,
the midwife as the core health care team, and accounts
Down’s syndrome, or a club foot) may not need imme-
for individual and cultural differences in priorities for
diate pediatric evaluation but may need extra midwifery
management. Antepartum discussions about variations
support and care during the first 24 hours. The infant’s
from normal, transfer protocols, and birth site selection
condition, the physical exam, and type of indicated
can minimize the possibility of conflict when essential
therapy will help determine the timing, setting, and
decisions need to be made during the intrapartum period.
appropriate caregiver for care and/or consultation. LESSONS IN PROMOTING NORMAL BIRTH ACROSS SETTINGS INFORMED CHOICE
When midwives assume the primary management role,
Informed decision-making is an essential characteristic
they are required to utilize the full scope of the ACNM
of midwifery care. CNMs/CMs who practice in the home
setting need to have a clear understanding of the legal
independently responsible for assessment, diagnosis, and
and ethical basis of informed decision making. The goal
initiation of therapy, even as they arrange for staff
is to provide the laboring woman with the information
assistance, physician consultation, or collaborative care.
necessary for her to make an informed choice.
Their competencies and judgment are deemed adequate
The core elements of informed consent include a
to promote optimal outcomes. However, variations
discussion of the indications for the intervention, a
among hospitals in CNM/CM credentialing for specific
description of the probable benefits and probable risks
procedures (e.g., repair of lacerations, manual removal of
associated with the recommended intervention, a discus-
the placenta) may restrict a CNM’s/CM’s ability to
sion of alternative interventions, and a description of the
independently manage these patients, even though such
consequences of declining the recommended interven-
management is within her scope of practice. Within
tion. In the context of homebirth, the consequences may
hospital settings, the ability to receive instant technologic
include conflict with community providers who prefer
assistance is the “safety net” that provides reassurance to
adherence to an established protocol.
the provider. The presence of pediatric staff at birth,
Truly informed choice also requires that a patient be
required by some hospitals, may decrease the midwife’s
informed when there is little or no evidence to support a
role in newborn care, resulting in a lack of confidence in
particular intervention, or when there is a gap between
applying neonatal skills. Although trained in resuscita-
evidence and standard community practice. This may
tion, without practice, a midwife may experience appre-
become particularly relevant when discussing when and
hension when required to use the skill. Regardless,
if to transfer to the hospital, and what can be
instant access to technology and specialized staff has not
Many homebirth clients will have had both the time and
eliminated perinatal mortality and morbidity, even for the
inclination to research all options for care, and will be
lowest-risk women managed in the hospital. Skilled
aware of community standards that do not follow the best
providers must use technology correctly and judiciously
to improve obstetric outcomes in any setting.
The courts have repeatedly upheld a patient’s right to
Familiarity with changes in midwifery practice, based
refuse treatment, even if not treating may result in serious
upon emerging evidence that supports the reduced use of
morbidity or mortality, based on the belief that only the
an intervention, may be difficult to acquire within an
patient can understand her own priorities. Acknowledg-
institution that has not updated its protocols. Midwives
ing this, the American College of Obstetricians and
practicing in homes and midwife-managed birth centers
Gynecologists issued a committee opinion in 2004 on
can implement evidence-based management and new
informed refusal, stating that once risks, benefits, and
procedures more rapidly. The philosophic tenets of the
Volume 52, No. 3, May/June 2007
hallmarks of include the advocacy of non-
15. American College of Nurse Midwives. Criteria for provision
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Volume 52, No. 3, May/June 2007
Conservation of Wetlands- A pilot study on the effect of pollution of the river Kuroor Thodu, Kothamangalam, Kerala Dr. Selven S., Assistant Professor, Department of Zoology Mar Athanasius College, Kothamangalam, Kerala The present study investigated the extent of pollution in terms of bacteriological and physicochemical parameters in a fresh water stream, at Kothamangalam municip
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