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Doi:10.1016/j.jmwh.2007.02.013

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
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