Best Practices Guidelines

OMC BEST PRACTICE GUIDELINES

The Oregon Midwifery Council Best Practice Guidelines are meant to be used as one of many tools to guide and improve home and birth center midwifery care. These Guidelines should not be construed as rules or requirements in the practice of midwifery in Oregon. Each client and each pregnancy, birth, and postpartum must be considered individually and no guideline will ever be appropriate to all situations. These guidelines are offered to support midwives and student midwives in the practice of midwifery centered in informed choice and respect for the autonomy of birthing people.

These Guidelines progress chronologically through pregnancy, birth, and postpartum and then address some more complex situations individually.

Primary Risk Assessment

Things to assess and consider before you accept a client into your care and during the first appointments.  This list is meant to help you evaluate potential clients and decide what risks you are or are not willing to take on. With each potential client, we are responsible to assess the risks and determine whether we are a good care option for this person and, if so, can we intervene to mitigate some of the risk.  If you have any concerns about taking a potential client, discuss with a peer (either at peer review or in private consultation).

Historical Perspectives and Experiences, evaluate for:
Hostility toward previous healthcare provider by mother or partner
Someone who has sued another healthcare provider in the past
Extreme aversion to transfer
Social relationship: family members opposed to homebirth who are involved with client, obvious violence, partner always speaking for her, etc.
2.  Psychosocial
Affect/communication/ability to understand what’s being communicated.
Level of responsibility they are willing to take: financially, nutritionally, personal health, communication (answers questions, returns phone calls, shows up to appointments)
Language barrier
Literacy
Ability to access resources
Prior involvement of protective services, child removed from the home.
3.  Health History
Health/Medical/Surgical history
Ob/Gyn history including STIs
Family health history
Prior drug abuse
OARs Risk Assessment Criteria: Absolutes and Non-absolutes
Late to care
Access to current or previous records
4.  Midwife’s Self-Assessment
Appropriate boundaries
impression
intuition
appropriate skill level and/or experience

Consult with another midwife if you are noticing a significant layering of risk factors.
The more risks factors present, the more consideration should be given to planning your care or not initiating care.

Ongoing Prenatal Risk Assessment

Midwives engage in an ongoing process of risk assessment that begins during the initial consultation and continues through the completion of care which will include the following:
At every prenatal or on-going:
Evaluate maternal nutrition
Maternal: BP, pulse, offer a weight check, to establish baselines and assess maternal well-being
Fetal: evaluate fundal height, abdominal palpation, FHT; to assess for fetal growth, position, and well-being
Psychosocial issues assessment, including but not limited to physical safety, socioeconomic status, obstacles to accessing care, mental health and emotional status
Provide education when appropriate on the following topics: pregnancy, labor and birth, breastfeeding, postpartum and newborn care
Offer labs/external services with informed choice/shared decision making including but not limited to: OB Panel,  genetic screening, STI screen, GD screen, GBS screen
Assess and address maternal discomforts
Offer breast exam evaluation for breastfeeding
Evaluate client responsibility and follow-through (ex: keeping appointments, upholding financial agreement, upholding care agreements)
Offer vaginal exam in late pregnancy
Offer ultrasound to evaluate dating, fetal development, and position as needed
At 4+3 weeks begin following postdates guideline

The assessment and plans for on-going risks will be charted at each visit and the midwife will consult or transfer care when appropriate, including for possible cumulative risks that are neither non-absolute or absolute (per OARs).

35 Week Risk Assessment

As the client approaches term the midwife will review and assess risk factors including:
Labs and ultrasounds
Health History
Ob/Gyn History
Baseline and/or changes in Maternal Vitals
Baseline and/or changes in Fetal Heart Tones
Fetal growth and position
Any ongoing issues resolved or appropriate follow-up (for example anemia or recurrent UTIs)
Bleeding in pregnancy
Presence of any absolute or non-absolute risks (OARs)
Social-emotional health
Moms preparedness/expectations for birth, postpartum and breastfeeding
Appropriateness for midwifery care and OOH birth

Midwife will chart risk assessment and plan at 35-36 weeks and review at term.
Consult with another midwife if you are noticing a significant layering of risk factors.
The more risks factors present, the more consideration should be given to planning your care or transferring care.
Ask yourself, at what point is the client risked out?

Labor Guidelines

Initial Contact Assessment
When a client calls to report signs of labor, midwife will:
Assess if there is an immediate need for the birth team’s presence,
If the midwife’s immediate presence is not required, additional assessment may include:
Review prenatal course and relevant risk factors
Emotional well-being, labor coping
Rest and hydration
Contraction pattern: strength, duration and frequency as reported
Evaluation of amniotic fluid, if ROM has occurred
Fetal movement
Evaluation of birth environment and support system
ROM (see below)
The assessment and plan should be charted including the midwives’ interpretation of the assessed data, actions necessary to address the assessments, and define the time frame for next steps.
Give the client any information appropriate for labor coping, nutrition, hydration, rest
In addition, provide information regarding reducing the risk of infection with ROM

Initial Labor Assessment will include:
Ideally, a midwife will be present for the initial labor assessment. If another birth team member arrives first she will consult directly with a midwife about the initial assessment unless needs of direct care prevent this (i.e. precipitous birth)
Review prenatal course and identified risks
Maternal vital signs
Emotional well-being, labor coping
Hydration and voiding
Contraction pattern: strength, duration and frequency
Fetal heart tones before, during and after contraction, minimum two minutes to establish baseline
Evaluation of amniotic fluid, if ROM has occurred
Position of baby
Fetal movement
Evaluation of birth environment and support system
The assessment and plan should be charted including the midwives’ interpretation of the assessed data, actions necessary to address the assessments, and define the time frame for next steps.

Equipment Setup
Check and prepare equipment for resuscitation
Lay out supplies for birth and hemorrhage

Ongoing 1st Stage Assessment:
Throughout labor, midwife will regularly evaluate the following:
Maternal vital signs (minimum every four hours)
Change in emotional well-being, labor coping
Hydration and voiding
Contraction pattern: strength, duration and frequency
Fetal heart tones (see below)
Evaluation of amniotic fluid, if ROM has occurred
Position of baby, if applicable
Fetal movement
Change in birth environment and support system
Progress during labor and causes of slow progress
Reevaluate assessment and plan every four hours and as risk factors arise, paying attention to the cumulative risks
Consider vaginal exam to assess progress, fetal position, presenting part
All of the assessment and plan should be regularly charted including the midwives’ interpretation of the assessed data, actions necessary to address the assessments, and define the time frame for next steps.

Ongoing 2nd Stage Assessment
Throughout second stage, midwife will regularly evaluate the following:
FHTs (every 10 minutes and listening during and after contraction regularly, more frequently if any concerns present)
Vitals every 4 hours, more often if indicated
Progress during pushing and causes of slow progress
Evaluate hydration, bladder, energy level, exhaustion
Reevaluate assessment and plan every hour and as risk factors arise, paying attention to the cumulative risks
Consider vaginal exam to assess progress, fetal position, presenting part
Consult and/or transport should be considered if progress not seen with active pushing or if there is concern about exhaustion
All of the assessment and plan should be regularly charted including the midwives’ interpretation of the assessed data, actions necessary to address the assessments, and define the time frame for next steps.

Ongoing 3rd Stage Assessment
Placenta
If placenta not delivered by 1 hour, assess cause, address at home if possible, consult if needed, and transport if indicated
Transport if placenta not delivered by 2 hours
With no abnormal bleeding or vitals,
assess vitals
assess placental detachment
at 30 min try non-allopathic methods, herbs, voiding, position changes, talk with mother
evaluated for the need for catheterization
consider pitocin injection (if within scope of practice)
consider initiating transport prior to 2 hours
With bleeding or non-reassuring vitals (low bp or elevated pulse)
Consider pitocin, misoprostol, or methergine as appropriate (if within scope of practice)
assess vital signs frequently
consider starting an IV or using an enema
oxygen
shock treatment
consider catheterization
consider manual removal if applicable, evaluate whether manual removal is possible/advisable
consider transport
Reevaluate assessment and plan every 1/2 hour and as risk factors arise, paying attention to the cumulative risks
Assessment and plan should be regularly charted including the midwives’ interpretation of the assessed data, actions necessary to address the assessments, and define the time frame for next steps.

Fetal Heart Tone Monitoring:
Once the midwife has arrived at the birth, she will regularly evaluate and chart fetal heart tones.
Every hour in early labor
Every 20-30 minutes in active labor
At least every 10 minutes or after every other push, as indicated, during second stage
More frequently if concerns or abnormalities arise
Midwife will use her discretion to alter the frequency of FHT assessment according to the clinical picture and maternal needs/requests

Rupture of Membranes
Upon report of ROM, midwife should rule out what can falsely appear to be ROM
When ROM occurs the midwife will assess in person, or by phone if the midwife has not arrived at the birth, the following: fetal movement, fluid color, contraction pattern, concerns of the mother, any prior concerns specific to particular mother and baby, FHT (if midwife is present)
If the color of the fluid changes there will be further assessment of the plan

Community Standards: Immediate Postpartum Care
Midwife should stay and assess for minimum of 2 hours postpartum

Maternal
Immediately after placenta check fundus, bleeding, pulse
Vitals (pulse, BP) checked within 30 minutes of placenta then once an hour until leaving
Assess temperature once before discharge and more if indicated
Assess bleeding and fundus regularly.
Encourage urination. If unable to urinate, assess bladder.
Assess perineum, vagina, and anal sphincter within first two hours
Ensure mother’s questions about breastfeeding are addressed and encourage skin to skin contact
Evaluate need for repair
If repair needed, is repair within practitioner’s scope of practice and skill level
Provide informed choice regarding repair
Newborn
Assess APGAR at 1 and 5 minutes, and 10 minutes if less than 7
Assess color, tone and respiration regularly.
Assess newborn temperature
Perform a thorough and complete newborn exam including all vitals (heart rate, temp, resp rate)
Administer, or provide access to (if not in scope), vitamin K and eye prophylaxis if parents have consented to these.

If Rh negative mom, give informed choice re: collect cord blood and send/bring to lab

Before Departing
Perform full set of vitals on mother and baby within one hour of leaving
Provide oral and written maternal and newborn postpartum instructions

Community Standards: Postpartum Care in the First Week

At least two home visits, in absence of risk factors
First visit within 36 hours
Second visit at 2-4 days
Third visit at 7-10 days
Postnatal care given by midwife (not by an unsupervised student/apprentice)

BABY
vital signs, including but not limited to temperature, heart rate and sounds, respiratory rate and sounds, color
file birth certificate
newborn screens (with informed consent)
breastfeeding evaluation
cord
input/output, stool evaluation
monitor weight gain/loss, monitor for 7-10% loss
behavior and sleep  patterns, neuro-muscular evaluation, behavioral milestones
recommend hearing screening, provide referral information
consider follow-up, including labs as indicated, for jaundice, birth injury

MOTHER
vital signs, including but not limited to BP, heart rate, color, temperature
evaluate fundus, perineum, lochia, breasts
input/output
support system evaluation
sleep
emotional state, mood disorder evaluation
evaluation for infection
appropriate intervention,, consult, labs or referral as needed
provide opportunity for emotional evaluation of birth
consider follow-up, including labs as appropriate, for hemorrhage, pre-eclampsia or concerning s/sx prenatally, incision/suturing
Rho-gam if indicated
Between visit phone contact as necessary, on-call status continues
Follow-up with postpartum instructions, clarification of concerning signs to monitor
Community Standards: Postpartum Care Weeks 2-8
Visits Schedule
Minimum of 2 from 2-8 weeks or more as indicated by individual client needs.
Baby
adequate weight gain
if breastfeeding issues are unresolved by 2 weeks, consider new strategies or referrals
2nd NB screen at or before 2 weeks
if oral mephyton was chosen, recommend follow-up doses weekly for 12 weeks and provide at least 3 doses in your care
auscultation of heart and lungs for rate and clarity of lungs
assessment of skin including umbilical healing
assessment of jaundice
assessment of output
assessment of normal physical development and developmental milestones
assessment of normal maternal-child attachment
assessment of birth trauma resolving (hematoma, bruising, birth injury)
follow-up on any abnormal findings from newborn exams, or issues that arose in the first two weeks
give information on family doctors/pediatricians, or specific referral if needed for specific reason
follow-up on recommendation for hearing screen
monitor healing if circumcised
discuss care of the normal newborn penis if left intact
provide vaccination information resources and referral as needed
assessing healing of frenectomy as needed
Mom
if breastfeeding issues are unresolved, consider new strategies or referrals (i.e. IBCLC)
assess BP, pulse, bleeding, and appropriate involution of the uterus
follow-up on perineal recovery plan, including offering to visually assess healing as appropriate
assess for adequate nutrition and hydration
assess for pelvic floor health and any lingering incontinence, constipation, or hemorrhoids
discuss plan for family planning
educate regarding resumption of sexual activity, ask about pain with sex
Follow-up on any past issues and run appropriate labs (anemia, thyroid, glucose testing, etc.)
Assess for PAP being due per ACOG guidelines, or revisit assessment done during pregnancy.  Do or refer for PAP if indicated, or notify when next due.
Assess postpartum mental health, including both disorders and normal processing of birth/motherhood, refer if appropriate.
Assess for diastasis.
Discuss plan for return to normal activity level.

Community Standards: Postpartum Care after Transport

First 48 hours
Check in – either phone or in-person
In person visit in hospital
Stay with client until on PP unit (or otherwise settled for their postpartum stay)
Provide support around breastfeeding initiation
Communicate with other providers about client choice re: oral vitamin K administration and ensure that we provide it within proper time frames
Communication with hospital about midwife’s availability and plan for PP care
Provide education around rebuilding flora for mom and baby if antibiotics were used
Find out about what information they received regarding  breastfeeding and then assess what additional and constructive info could support them
Assess plans for placenta and help facilitate client choice
Revisit plans for newborn procedures and reassess recommendations
Work to facilitate bonding and attachment
Ensure clarity around your availability by phone (we’re still on-call for you)

When clients come home from hospital
Home visit within 48 hours of hospital discharge
Emotionally support the transition from hospital to home

Within first two weeks
Normal PP care
Follow up on newborn procedures (who is doing the second newborn screen, etc.)
Screen for attachment disorder and bonding issues
Screen for PPD
Assess weight gain/loss and possible need for lactation support

Within first 6 weeks
Provide opportunities for review of sequence of events leading up to transfer with the client
Review recommendations for subsequent pregnancies (if impacted)
Provide opportunity for client to share her experience of the story
Provide opportunities to debrief with others at the birth (co-parent, grandparent, siblings)
Request records from hospital
Discussion about body healing (might be different depending on complications) and give resources
Discussion about emotional healing (might be different depending on complications)
Assess for newborn neurological development (possibly impacted by birth trauma)

On-Going
General screen for PPD
Appropriate outreach to clients and respect for client choice around PP care
General screen for attachment disorder and bonding issues
Provide resources as needed (i.e. Lactation, Baby Blues Connection, cranial-sacral therapy)

We agree there would be extra care if there is a situation that merits it, such as a baby in the NICU.  With a baby in the NICU support maternal access to baby, help her get a breast pump

If a client discontinues care
Formal contact to check in sometime in the first 6 weeks
(i.e. We’re calling to check in.  Your 2 week appointment would be on Friday, we’re just checking in to find out what your hopes are for care.)
Offer multiple opportunities for listening to client and family about their experience.

Post cesarean care
Visually evaluate incision at PP visits
Provide resources (ICAN, Homebirth Cesarean International)

Prolonged Rupture of Membranes

When a client calls with possible ROM the midwife will assess in person or by phone if the midwife has not arrived at the birth, the following:
fetal movement
amount of fluid and pattern of leaking
fluid color
contraction pattern
concerns of the mother
any prior concerns specific to particular mother and baby
FHT (if midwife is present)

Once rupture of membranes has been confirmed by the midwife, she will see the mother within the first 24 hours and provide her with information about
the risk of infection
ways to reduce the risk of infection
the option of hospital transport for induction of labor

If labor has not begun within 12-24 hours, consider:
Drawing a baseline CBC.
Encouraging labor with acupuncture, herbs, nipple stimulation or other methods appropriate to the situation and OOH midwifery care.

Prolonged Labor
Midwives perform and chart a general labor assessment every four to six hours. In a longer labor, especially after 24 hours of attendance in active labor, consider consulting with another midwife or physician. During pushing, consider consulting if mom has ROM and has been actively pushing without notable progress for three hours. Special attention should be paid to normal labor progress with VBAC, breech or postdates births (42+ weeks).
Postdates

Careful evaluation of dates, ultrasound, and menstrual cycle length will be done at the start of care to optimize the accuracy of pregnancy dating. Between 41and 42 weeks the midwife will re-assess the risk factors of this mother and pregnancy and then discuss risks and care options for postdates pregnancy. Fetal surveillance tests are offered every 3-4 days starting at 41+3. Reassessment of risk factors becomes more frequent after 41+3 and midwife will discuss risks and care options including transfer to hospital care for induction by 42 weeks. If pregnancy continues past 42 weeks, evaluation of mother and baby and discussion of risks and care options happens at least every 3 days. Out-of-hospital birth past 43 weeks is outside of our community standard of care.

Vaginal Birth After Cesarean

Midwives will offer thorough informed choice including the clear information about the risk of uterine rupture to clients considering OOH birth after a previous cesarean section. Care will be taken to evaluate whether each particular VBAC mom is a good candidate for OOH birth. Surgical report records will be acquired as part of accepting a client into care. Client education on optimal fetal positioning can be a useful tool. Midwife will offer ultrasound to evaluate position of placenta before labor. More frequent auscultation and vital sign assessment is appropriate. FHT are checked every 15-20 minutes in active labor and vitals will be re-evaluated between regular assessments if any concerns arise. Consider transport for prolonged labor or irregular progress in active labor.

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