Standards of Practice, Protocols, Guidelines,
 & Minimum Practice Requirements

For California Licensed Midwives Ì

Characteristics of Clinical Competency
associated with science-based maternity care as
 provided by professionally-licensed Community Midwives

Reviewed by Clinical and Academic Advisors
and Experienced Midwives

 

 

Includes:

 

Standards of Practice

 

Administrative Obligations

 

Protocols & Policies

 

Criteria for Client Eligibility

 

Physician Consultation, Referral, & Transfer

 

Minimum Practices Requirements

 

 

 

California College of Midwives

State Chapter of the American College of Community Midwives
(ACCM)

Ì

October 2004 Edition

 

 

Ì Characteristics of Clinical Competency
Associated with Science-based Maternity Care

 

 

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NOTE: this html web page format does NOT print well, ie, will not paginate properly.
 PDF is best if you want a hard copy.

 

 

Table of Contents

eSection I: Standards of Practice                                                                                 

Page

I A     Definition of Physiological Management of Normal Labor & Birth............................................    3

I B     Standards of Practice...............................................................................................................    4

I C     Midwife & Client Responsibilities   ...........................................................................................    8

I D     Medical Interface, Emergency Plan & Other Requirements of LMPA......................................    11

I E     Record Keeping for Licensed ..................................................................................................    13

I F     Termination of Midwife- Client Relationship & Withdrawal of Service.....................................    14

I G     Prohibitions in the Practice of Midwifery  .................................................................................    15

I H     Professional Relationships between Physicians & Licensed..................................................    16

I I       Practice Protocols and Policies ...........................................................................................    18

I J      Protocols & Criteria for Moderate Risk Labor & Birth...............................................................    20

e Section II: Consultation, Referral, Transfer of Care & Minimum Practice Requirements

II A   Criteria for Client Selections ~ Eligibility for Domiciliary Birth Services....................................    26

II B   Safe Environment for Planned Home Birth...............................................................................    28

II C   Equipment & Administration of Medication ...............................................................................    29

II D   Emergency Care & Emergency Transfer ................................................................................    30

II E   Minimum Practice Requirements ~ Antepartum Care..............................................................    31

II F   Physician Consult and Transfer of Care ~ Antepartum Referral..............................................    33

II G   Minimum Practice Requirements ~ Intrapartum Care .............................................................    35

II H   Physician Consult and Transfer of Care ~ Intrapartum Referral .............................................    38

II I    Minimum Practice Requirements ~ Postpartum Care .............................................................    40

II J   Physician Consult and Transfer of Care ~ Postpartum Referral...............................................    42

II K   Minimum Practice Requirements ~ Neonatal Care..................................................................    43

II L   Physician Consult and Transfer of Care ~ Neonatal Referral ..................................................    45

II M  Guidelines for Assessing the Neonate ......................................................................................    47

II N   Instructions for Parents on Newborn Care  ..............................................................................    50

 

 

 __________________________________________________________________________________________________

California College of Midwives
State Chapter ~ American College of Community Midwives

Section I - A

 

Physiological Management  of Normal Labor & Birth Defined

 

Science-based principles of maternity care for spontaneous labor and normal birth care include the following physiologically sound practices: 

1.      Continuity of care 
2.      Patience with nature
3.      Social and emotional support 
4.      Full-time presence of the primary caregiver during active labor
5.      Mother-controlled environment (place) for labor and birth 
6.      Provision for appropriate psychological privacy (persons present) 
7.      Mother-directed activities, positions, and postures for labor and birth  
8.      Opportunity for an upright and mobile mother during active labor  
9.      Recognition of the non-erotic but nonetheless sexual nature of spontaneous labor and             normal birth
10.    Non-pharmaceutical pain management such as walking, one-to-one care, touch           relaxation, showers  and  deep water tubs, other traditional midwifery strategies 
11.    Judicious use of drugs and anesthesia when needed
12.    Absence of arbitrary time limits as long as some progress, mother and baby OK
13.    Vertical postures, pelvic mobility and the right use of gravity for pushing
14.    Birth position by maternal choice unless medical or other factors require otherwise
15.    Mother-directed pushing --NO prolonged breath-holding (Valsalva maneuver)
16.    Physiological clamping/cutting of umbilical cord-- after circulation between baby and   placenta has stopped (approximately 3-5 minutes)
17.    Immediate possession and control of newborn by mother and father
18.    On-going and  unified care and support of the mother-baby during the    postpartum/postnatal period. 

Physiological management is the science-based model of normal maternity care and is the foremost standard of care for all healthy women with normal pregnancies, regardless of the category of maternity care provider and regardless of the setting for labor and birth (hospital, home or birth center).

___________________________________________________________________________________________________

California College of Midwives

State Chapter ~ American College of Community Midwives

Section I - B

STANDARDS OF PRACTICE

e Professionally licensed midwives offer primary care to healthy women and their normal unborn and newborn babies throughout normal pregnancy, labor, birth, postpartum, neonatal, and intra-conceptional periods. Standards of practice, protocols, minimum practice requirements, and detailed guidelines for appropriate physician consultation, referral, transfer of care, and emergency care are contained within the Standards and Guidelines of the California College of Midwives / American College of Community Midwives (ACCM).
 

I. Purpose, Definitions & General Provisions:

 

A.     Standards of practice provide a framework to evaluate the licensed midwife's practice to ensure that it is safe, ethical, and consistent with the professional practice of midwifery in California. The professionally licensed midwife who conforms to these standards and their associated practice requirements is judged to be competent. Sources and documentation for practice requirements include, but are not limited to, the following:

 

1.   The International Definition of a Midwife (International Confederation of Midwives) and international scope of practice

2.   Customary definitions of the midwifery model of care by state and national midwifery organizations, including the 2000 LMPA amendment  (See language from SB 1479 at end of this section.)  

3.   Standards of practice for community midwives published by state and national midwifery organizations

4.   Philosophy of Care, Code of Ethics, and Informed Consent Policy published by state and national midwifery organizations

5.   Educational competencies published by state and national midwifery organizations

 

B.     The California licensed midwife is a competent health care practitioner who maintains all requirements of state certification, keeps current with safe and ethical midwifery practice and who practices in accordance with:

 

1.      The body of knowledge, clinical skills, and clinical judgments described in the Midwives Alliance of North America (MANA) Core Competencies for Basic Midwifery Practice

2.      The statutory requirements as set forth in the Licensed Midwifery Practice Act of 1993, all amendments to LMPA and the Health and Safety Code on Birth Registration

3.      The standards and guidelines for community-based midwifery practice

4.      The protocols of the individual midwifery service/practice

 

C. The California licensed midwife provides care in clinics, physician offices, client homes, hospitals & birth centers. The licensed midwife provides well-woman services pre- and inter-conceptionally and maternity care to essentially healthy women who are experiencing a normal pregnancy. An essentially healthy woman is without serious pre-existing medical or mental conditions affecting major body organs, biological systems, or competent mental function. An essentially normal pregnancy is without serious medical conditions or complications affecting either mother or fetus.

 

D.     The California licensed midwife must be able to give the necessary supervision, care and advice to women prior to and during pregnancy, labor and the postpartum period, to conduct deliveries, and to care for the newborn infant. This care includes preventative measures, policies and protocols for variations/ deviations from norm, detection of complications in the mother and child, the procurement of medical assistance when necessary, and the execution of emergency measures in the absence of medical help.

 

E.     The California licensed midwife's fundamental accountability is to the women in her care. This includes a responsibility to uphold professional standards and avoid compromise based on personal or institutional expediency.

 

F.    The California licensed midwife is also accountable to peers, the regulatory body, and to the public for safe, competent, ethical practice. It is the responsibility of the licensed midwife to incorporate evaluation of her practice that includes ongoing community input and participation in mortality and morbidity reporting and review processes. The results of these individual evaluations can be distributed to influence professional policy development, education, and practice. 

 

G.     The California licensed midwife is accountable to the client, the community, and the midwifery profession for evidence-based practice. This includes but is not limited to continuing education and on-going evaluation of the scientific literature. It may also include developing and sharing midwifery knowledge and participating in research regarding midwifery outcomes.

 

 

II.   A brief overview of the licensed midwife’s duties and responsibilities to childbearing women and their unborn and newborn babies

 

A.     The California licensed midwife engages in an ongoing process of risk assessment that begins during the initial consultation and continues through the completion of care. Within the midwifery model of care, the licensed midwife’s duties to mother and baby shall include the following individualized forms of care:

 

1.      Antepartum care and education, preparation for childbirth, breastfeeding and parenthood

2.      Risk assessment, risk prevention, and risk reduction Identifying and assessing variations and deviations from normal and detection of abnormal conditions

3.      Maintaining an individual plan for consultation, referral, transfer of care, and emergencies

4.      Evidence-based physiological management to facilitate spontaneous progress in labor and normal vaginal birth while minimizing the need for medical interventions

5.      Procurement of medical assistance when indicated

6.      Execution of appropriate emergency measures in the absence of medical help

7.      Postpartum care to mother and baby, including counseling and education

8.      Maintaining up-to-date knowledge in evidence-based practice and proficiency in life-saving measures by regular review and practice

9.      Maintaining all necessary equipment and supplies, preparation of documents including educational handouts, charts, informed consent waivers, birth registration, newborn screening, practice protocols, morbidity reports, annual statistics, and other required documentation.

 

 

III. Standards of Practice for Community-Based Midwifery

 

STANDARD ONE ~ The licensed midwife shall be accountable to the client, the midwifery profession and the public for safe, competent, and ethical care.

 

STANDARD TWO ~ The licensed midwife shall ensure that no act or omission places the client at unnecessary risk.

 

STANDARD THREE ~ Within realistic limits the licensed midwife shall provide continuity of care to the client throughout the childbearing experience according to the midwifery model of practice.

 

STANDARD FOUR ~ The licensed midwife shall respect the autonomy of the mentally competent adult woman and work in partnership with her, recognizing individual and shared responsibilities.  The licensed midwife recognizes the healthy woman as the primary decision maker throughout the childbearing experience.

STANDARD FIVE ~ The licensed midwife shall uphold the client's right to make informed choices about the manner and circumstance of normal pregnancy and childbirth and shall facilitate this process by providing complete, relevant, objective information in a non-authoritarian and supportive manner, while continually assessing safety considerations and the risks to the client and informing her of same.

 

STANDARD SIX ~ The licensed midwife shall collaborate with other healthcare professionals and, when the client's condition or needs exceed the midwife’s scope of practice, shall consult with and refer to a physician or other appropriate healthcare provider.

 

STANDARD SEVEN ~ Should the pregnancy become high-risk and require that primary care be transferred to a physician, the licensed midwife may continue to counsel, support, and advise the client at her request.

 

STANDARD EIGHT ~ The licensed midwife shall maintain complete and accurate health care records.
 

STANDARD NINE ~ The licensed midwife shall ensure confidentiality of information except with the client's consent, or as required to be disclosed by law, or in extraordinary circumstances where the failure to disclose will result in immediate and grave harm to the client, baby, or other immediate family members.
 

STANDARD TEN ~ The licensed midwife shall make every effort to ensure that a second midwife or a qualified birth attendant who is currently certified in neonatal resuscitation and cardiopulmonary resuscitation assists at every birth.

 

STANDARD ELEVEN ~ The licensed midwife shall order, prescribe or administer only those prescription drugs and procedures as authorized in the Licensed Midwifery Practice Act, Section 2514 and shall do so in accordance with the client's informed consent.

 

STANDARD TWELVE ~ The licensed midwife shall order, perform, collect samples for, or interpret those screening and diagnostic tests for, a woman or newborn as identified in the Licensed Midwifery Practice Act, Section 2514 and in accordance with the client's informed consent.

 

STANDARD THIRTEEN ~ The licensed midwife shall participate in the continuing education and evaluation of self, colleagues, and the maternity care system.
 

STANDARD FOURTEEN~ The licensed midwife shall critically assess evidence-based research findings for use in practice and shall support research activities.
 

SB 1479 ~ Amendment to the Licensed Midwifery Practice Act of 1993

 

Section 4 ~ THE LEGISLATURE FINDS AND DECLARES THAT:

 

(a) Childbirth is a normal process of the human body and not a disease.

 

(b) Every woman has a right to choose her birth setting from the full range of safe options available in her community.

 

(c) The midwifery model of care emphasizes a commitment to informed choice, continuity of individualized care, and sensitivity to the emotional and spiritual aspects of childbearing, and includes monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle; providing the mother with individualized education, counseling, prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support; minimizing technological interventions; and identifying and referring women who require obstetrical attention.

 

(d) Numerous studies have associated professional midwifery care with safety, good outcomes, and cost-effectiveness in the United States and in other countries. California studies suggest that low-risk women who choose a natural childbirth approach in an out-of-hospital setting will experience as low a perinatal mortality as low-risk women who choose a hospital birth under management of an obstetrician, including unfavorable results for transfer from the home to the hospital.

 

(e) The midwifery model of care is an important option within comprehensive health care for women and their families and should be a choice made available to all women who are appropriate for and interested in home birth.

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Section I-C

 

MIDWIFE & CLIENT RESPONSIBILITIES AND RIGHTS

 

e The licensed midwife provides accurate information regarding the standards and scope of midwifery practice, fees, medical consultation arrangements, and the rights and responsibilities of the client.

CLIENT RIGHTS & RESPONSIBILITIES SPECIFIED

 

A. The client shall receive complete, relevant, objective and, where appropriate, evidence-based information regarding community-based midwifery, including but not limited to:

 

1. The risks and benefits associated with midwifery services provided in the client’s home or freestanding birth center
2. The right of the client to change her mind and seek out obstetrical services or hospitalization
3. A description of the responsibilities for the client and her family, relative to choosing community-based maternity care
4. The client’s right to receive full information, including risks, benefits, options, and alternatives, and to provide permission or informed consent prior to the performance of routine procedures of midwifery care or other treatments, procedures, or administration of any drug to mother or newborn
5. The client’s right to decline standard or recommended midwifery care. The client’s decision to decline recommended care will be made in writing and signed or initialed by the client and kept in the client’s chart;
6. Birth-related legal requirements for California residents which include newborn screening for inborn errors of metabolism (PKU/newborn genetic screening), eye prophylaxis, registration of birth and death certificates, and reporting requirements for emergency transports involving mortality or serious complications
7. Information regarding the client’s medical conditions and other concerns for which a licensed midwife may need to consult with a physician, refer client to a physician, and/or transfer the client to a physician’s care
8. Information and referral of the client to other providers and services whenever requested  or if the care required by the client is outside the scope of practice for midwifery or the protocols of the individual licensed midwife
9. The grievance process for client complaints to the Medical Board of California regarding unsatisfactory or unethical care; (Medical Interface form per SB 1479 - see Section I-D)
10. The client’s right to have pertinent records in her chart forwarded to other professionals when requested, to obtain copies of her midwifery records and those of her baby
11. The licensed midwife’s expectations of the client and the licensed midwife’s right to discontinue care

 

 

MIDWIFE RESPONSIBILITIES

 

e The principal objective of the midwifery profession is to render service to healthy women and their infants with full respect for human dignity. Licensed midwives should merit the confidence of women entrusted to their care, rendering to each a full measure of service and devotion. Each licensed midwife should uphold the dignity and honor of the profession and accept its self-imposed disciplines. Such disciplines include a responsibility to uphold professional standards, to avoid compromise based on personal or institutional expediency, and to adhere to professional rather than commercial standards in making known the availability of their services.

 

Client Disclosure and Informed Consent for Community-based Midwifery Services

 

B. The licensed midwife shall provide a professional disclosure to each client that includes a brief description, either orally or in writing, of the following:

 

1. The licensed midwife’s practice standards, guidelines, protocols and policies
2. The licensed midwife’s training and years of experience
3. The licensed midwife’s compliance with adult and infant cardiopulmonary resuscitation and neonatal resuscitation certification, continuing and/or special education
4. The licensed midwife's practice statistics, noting the number of clients served annually and the percentage of NSVD at home, of hospital transfers and subsequent operative or instrumental deliveries, and the perinatal mortality rate for her practice
5. Any limitations on the skill, practice, or other special requirements specific to the licensed midwife
6. Care and equipment available and supplies provided
7. How to contact the licensed midwife for routine communication
8. How to reach the licensed midwife in an emergency, including phone numbers for a second-call midwife or backup arrangements if the licensed midwife cannot be reached 

 

C. There shall be a place on the form for the client to attest, by signing her full name, that she has received complete, relevant, objective information on Client Rights and Responsibilities and Midwife Responsibilities as listed above. 

 

D. The Disclosure and Consent form shall include the date, name and signature of the client and, if appropriate, her partner, and become an official part of the client’s records.

 

 

E.  Medical Interface Community-Based Maternity Services & Plans for Emergency Services ~ disclosure statement as required by LMPA / SB 1479

 

Each licensed midwife shall disclose to a client, in oral and written form:

 

1. The legal scope of practice for licensed midwives under the LMPA
2. The specific arrangements for the client to access medical services including consultation and transfer of care during the prenatal period, hospital transfer during labor, birth and the immediate postpartum
3. How to obtain appropriate emergency medical services for mother and baby when necessary
4. The professional liability insurance status of the licensed midwife
5. How to inquire about the midwife’s licensure status from the Medical Board of California
6. Methods to report unsatisfactory or unethical care to the Medical Board of California

 

The Medical Interface “Plan for Emergency Care” form shall include the date, name and signature of the client and, if appropriate, her partner and become an official part of the client’s records.

 

The Medical Interface Form, as developed by the California College of Midwives, is accepted by the MBC as satisfying the requirements of the 2000 amendment to the LMPA.

 

However, any licensed midwife may develop her own version as long as it includes the same six areas of required information.

 

 

F. Midwife Responsibilities & Client Informed Consent Documents ~ Sample forms

 

1. Sample forms as developed by California midwives are available on line ~ at www.collegeofmidwives.org or in Section 4 of this midwives may use or develop their own version for each form as long as each one includes the necessary information.

 

1. Professional Disclosure and Informed Consent for routine care
2. Medical Interface and Plans for Emergency Care per SB 1479
3. Information on Group B Strep and Consent/Decline of prenatal GBS cultures
4. Information and Consent /Decline ~ Routine Newborn Ophthalmic Prophylaxis
5. Information and Consent /Decline ~ Routine Administration of Vitamin K

f.        Consent for Out Of Hospital Intrapartum Care

g.      Special Circumstances-Moderate Risk Wavier // Informed Decline of Standardized Care

___________________________________________________________________________________

 

Section I-D -

CLIENT DISCLOSURE FORM ~Required by the LMPA
Midwifery Scope of Practice, Medical Interface, Emergency Arrangements, Malpractice Insurance Disclosure, Reporting Unsatisfactory Care to MBC

Informed Consent for Community-Based Midwifery Care

e The Licensed Midwifery Practice Act (LMPA) requires that each licensed midwife provide information on the scope of licensed midwifery practice in California to clients seeking community-based midwifery care.

The LMPA also requires that licensed midwives identify appropriate arrangements for medical consultation and transfer of care during the prenatal period, for hospital transfer during labor, birth and immediate postpartum, and for how to obtain appropriate emergency medical services for mother and baby when necessary.

Medical arrangements must be specific to each client's circumstance, discussed with her, documented in writing and retained in her chart.

In addition, licensed midwives are legally responsible for registering the births of all babies born under their care.  

 

Midwifery Scope of Practice as defined by the LMPA, Sec 2507: 

(a) The license to practice midwifery authorizes the holder, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn.

(b) As used in this article, the practice of midwifery constitutes the furthering or undertaking by any licensed midwife, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. All complications shall be referred to a physician immediately. The practice of midwifery does not include the assisting of childbirth by any artificial, forcible, or mechanical means, nor the performance of any version.

(c) As used in this article, "supervision" shall not be construed to require the physical presence of the supervising physician.

(d) The ratio of licensed midwives to supervising physicians shall not be greater than four individual licensed midwives to one individual supervising physician.

(e) A midwife is not authorized to practice medicine and surgery by this article.

 

Note regarding physician supervision as referenced above ~ Currently the malpractice carriers who provide professional liability insurance to California obstetricians will not permit physicians to have a supervisory relationship with licensed midwives who provide community-based birth services. 
 

Specific Arrangements for Medical Care are as follows:

Licensed Midwife _____________________________________  License #_____

Client Name   ___________________________________________ Date _______

(1) Medical/Obstetrical Consultation and Transfer of Care during your pregnancy: __________________________________________________________________

(2) Hospital-based physician care during your labor, birth and the immediate postpartum: __________________________________________________________________

(3) Emergency Care for you or your newborn baby during or after the birth:  __________________________________________________________________

 

As a consumer of healthcare services you have the right to check on the licensure status of any health care practitioner licensed in California. Physicians, Licensed Midwives and 18 allied health professions are licensed and regulated by the Medical Board of California (MBC). For information on Medical Board licentiates call 1- 916 / 263-2382 or visit their web site at www.caldocinfo.ca.gov/. You also have the right to report any complaints about care received to the MBC by calling 1- 800 / 633-2322. Instructions and a complaint form are available on-line by visiting the MBC Internet site @ www.caldocinfo.ca.gov/.

If the above named licensed midwife does not carry professional liability (i.e. malpractice) insurance, I have been so informed of that fact.  Initials ______

 

Client Signature _____________________________________     Date _______

Partner’s Signature __________________________________      Date _______

Witness Signature ___________________________________      Date_______

________________________________________________________________________________________________

 

Section I-E

 

To establish minimum standards in regard to RECORD KEEPING

e The licensed midwife shall keep appropriate records on all clients.

All records shall, at a minimum:

1.      Be accurate, current and comprehensive, giving information concerning the condition and care of the client and associated observations

2.      Provide a record of any problems that arise and actions taken in response to them

3.      Provide evidence of care required, interventions provided by professional practitioners and patient responses

4.