va dept of health protocols for midwives

7/30/2019 VA Dept of Health Protocols for Midwives

1/29

Certified Professional Midwives

Caring for Mothers and Babies in Virginia

CommonwealthMidwives Alliance


2/29

Certified Professional Midwives in VA

z Licensed by the BOM since J anuary 2006

z 5 member Midwifery Advisory Board under the BOM(Obstetrician, 3 CPMs, Citizen member)

Board Members

http://www.dhp.state.va.us/medicine/advisory/mw/Default.asp

Regulations

http://www.townhall.virginia.gov/chapter/ViewChapter.cfm?Vac=127&Chapter=130

z Currently 30 licensed midwives located around the state


3/29

CPM Scope of Practice

CPMs in VA are licensed to:

z provide primary maternity care to women and their

newborns throughout the childbearing cycle.z identify and refer women or their newborns who

require medical care to an appropriate

practitioner.http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+54.1-2957.7


4/29

Midwives Model of Care

z The Midwives Model of Care is based on the fact that pregnancy and birth are normal lifeprocesses.

The Midwives Model of Care includes:

z Monitoring the physical, psychological, and social well-being of the mother throughout thechildbearing cycle

z Providing the mother with individualized education, counseling, and prenatal care,continuous hands-on assistance during labor and delivery, and postpartum support

z Minimizing technological interventionsz Identifying and referring women who require obstetrical attentionz The application of this woman-centered model of care has been proven to reduce the

incidence of birth injury, trauma, and cesarean section.

Copyright (c) 1996-2005, Midwifery Task Force, Inc., All Rights Reserved.


5/29


6/29


z Monitoring the physical, psychological, andsocial well-being of the mother throughoutthe childbearing cycle Standard lab tests

Involve mother in self-care

Continuity of care

30-60 minute average prenatal visit Balance evidenced-based care with traditional

practices. (herbs, homeopathy, yoga)


7/29


8/29


z Providing the mother with individualizededucation, counseling, and prenatal care,continuous hands-on assistance during labor and

delivery, and postpartum support Start to finish labor support

Informed choice includes both the risks and benefits ofaccepting or avoiding a test, procedure, or drug

Respect for mothers culture and preferences

Effective breastfeeding support


9/29


10/29


z Minimizing technological interventions

"... giving birth at home bears similar risks of intrapartum and neonatal mortalityas low-risk birth in hospital, but planned home births are associated with lowerrates of medical interventions.

... The study participants experienced substantially lower rates of epidurals,episiotomies, forceps deliveries, vacuum extractions, and cesarean sectionsthan women with low risk pregnancies who gave birth in hospital."

J ohnsson and Daviss, Outcomes of p lanned home bi rths with certified professional

midwives: large prospective study in North Americahttp://www.bmj.com/cgi/content/full/330/7505/1416


11/29


12/29


z Identifying and referring women whorequire obstetrical attention Midwives are trained to recognize signs of

complications before they become emergencies. Optimal outcomes for mothers and babies are

achieved when there is trust and respect amongproviders

Autonomous practice removes liability basedobstacles to midwife-physician relationships


13/29

Statutory Immunity

54.1-2957.12. Immunity.No person other than the licensed midwife who provided care to the patient shall beliable for the midwife's negligent, grossly negligent or willful and wanton acts oromissions.

Except as otherwise provided by law, no other licensed midwife, doctor of medicine orosteopathy, nurse, prehospital emergency medical personnel, or hospital as defined in32.1-123, or agents thereof, shall be exempt from liability (i) for their own subsequent andindependent negligent, grossly negligent or willful and wanton acts or omissions or (ii) ifsuch person has a business relationship with the licensed midwife who provided care to thepatient.

A doctor of medic ine or osteopathy, nurse, prehospital emergency medical person,or hospital as defined in 32.1-123, or agents thereof, shall not be deemed to haveestablished a business relationship or relationship of agency, employment,partnership, or jo int venture with the licensed midwife solely by providingconsultation to or accepting referral from the midwife.

(2005, cc. 719, 917.)


14/29

Excerpted from a presentationgiven at the American Public

Health Association ConferenceBoston, MA November 2006 by

Saraswathi Vedam, CNM & DerenBader, CPM, DrPH

Systematic Review of Recent Out-of-Hospital Birth Studies

Included Studies

z Northern Region Perinatal Mortality Survey

z National Birthday Trust Study

z Ackerman-Liebrich et al.,1996z Wiegers, Keirse, et al., 1996

z Meta-analyses, Olsen, 1997, 2000

z J ohnsson and Daviss, 2005z Murphy and Fullerton, 1998

z J anssen, 2002, 2003


15/29

Systematic Review of Out of Hospital BirthStudies; Summary

z Perinatal mortality comparable home birth populations - 0.6-2.5/1000

U.S. Birth Centers - 1.3/1000

Uncomplicated hospital births - 1-2.9/1000

z Maternal and fetal outcomes fewer medical interventions (induction,augmentation,

episiotomy, operative vaginal birth, and cesarean)

better Apgar scores, less severe lacerations

findings supported by clinical trials of elements of care


16/29

Systematic Review of Out-of-Hospital BirthSummary: Referrals from home to hospital

z 7-18% antepartum referrals for obstetricreasons (IUGR, previa, PIH, preterm)

z 8-12% intrapartum (IP) referrals

z 1-2% postpartum maternal referrals

z 1-2% neonatal referrals

z

urgent transfer 1/1000


17/29

Reasons for IntrapartumTransfer to Hospital Facility

z 5-15% of all planned home births

z failure to progress (65-75%)

z prolonged rupture of membranes

z meconium staining

z nonvertex presentation

z fetal distress

z desire for pharmaceutical pain relief

z bleeding

z hypertension


18/29

Reasons for Postpartum Transfer

z Maternal Retained placenta

postpartum hemorrhage

laceration repair

z Neonatal inability to establish normal respiration

congenital anomaly low birth weight

low Apgar

birth trauma

sepsis


19/29

Intrapartum Transfer of Care Plan

z Upon initiation of care, the midwife

develops an individualized IntrapartumTransfer of Care plan with each client. Includes nearest hospital with maternity services, distance from

hospital, EMS estimated response time (rarely used)

This is in accordance with the Virginia State Law for LicensedMidwives. 54.1-2957.7 through 54.1-2957.13


20/29

Components of a Transport Protocol

z Identify the need for transfer of care.z Midwife will call the nearest tertiary care center with maternity

services (per the clients transport plan).

z The midwife will speak with the attending physician, reportingon all relevant details and confirming the plan for transport.z The midwife will provide access to all client records to the

receiving physician.z As per Virginia state law, the midwife will accompany the client

to the hospital, providing care until transfer of care has beenmade to the attending physician.


21/29

CPM-EMS Call Report

1 home birth transport out of every 1000 will involve EMS

When the midwife makes the call, she provides the following

information:

z

maternal/infant conditionz what actions have been taken by the midwife to assess and

stabilize the patient/s

z what emergency equipment the midwife has and does not

have at her disposal in the homez how the midwife would like to collaborate with EMS

providers during the transport


22/29

CPM-EMS Collaborative Care

Upon arrival at patients home, EMS willreceive report from the midwife including:

z

Vital signsz Brief description of reason for call

z Brief description of current patient condition

z Brief description of all actions taken tostabilize patient


23/29

CPM Skills- Newborn Resuscitation

z Adult and Infant CPR certification (required)

z Most CPMs are advanced NRP providers

Includes- Overview and Principles of Resuscitation

Initial Steps in Resuscitation

Use of Resuscitation Bag and Mask Chest Compressions


24/29

CPM Skills-3rd Stage Management

z Assessment of hypovolemia/shock

z Manual removal of placenta

z Bi-manual compression/uterine massagez Administration of oxygen and anti-

hemorrhagic medications*

*currently restricted by VA Statute


25/29

CPM- Emergency Medications

z All CPMs are trained and certified to deliveremergency anti-hemorrhagic medicationssuch as IM pitocin, IM methergine, and POmethergine.

z Currently, VA law does not allow for thecarrying or administering of any controlledsubstance by CPMs


26/29

CPMs: Our potential in Virginia

z Integration of Licensed Midwives into existinghealthcare systems

z

Coordination of efforts to support compliancewith state health programs for women andinfants

z

Identifying and removing obstacles to optimalcare for women and babies birthing out ofhospital in Virginia


27/29

Additional Information

CPM Professional Certification:

Commonwealth Midwives Alliance (CMA) www.commonwealthmidwives.orgz State professional organization

North American Registry of Midwives (NARM) www.narm.orgz J ob Analysisz Test Specificationsz Credentialing Processz Continuing Education/Recertification

National Association of Certified Professional Midwives (NACPM)www.nacpm.net

z CPM Guidance Documents- Practice Guidelines referenced in VA statute


28/29

Additional Resources

z EMS/Homebirth Resource Packet- available at Symposium orcontact [email protected]:

Directory of licensed CPMs in each EMS Region

Sample transport guidelines- Washington statez http://www.washingtonmidwives.org/assets/MAWS_PLANNED_OOH_BIRTH_TRANSPORT_

GUIDELINE.4.24.pdf

Sample planned homebirth transport forms- Washington state.z Maternal: http://washingtonmidwives.org/assets/matern_transpt_form.pdf

z Newborn: http://washingtonmidwives.org/assets/newbn_transpt_form.pdf

Overview of CPM emergency training

Overview of conditions likely to initiate a call to EMS


29/29