Updated 12/4/19

Individual Midwifery Practice Guideline

Katlyn Carter, LM (expected 2020)

Philosophy of Practice

As a licensed midwife, I provide care for women and families in low-risk pregnancies, birth, and
the postpartum period. I strive to give professional guidance and support when appropriate. I
respect the rights of women, their body, and their baby. I believe pregnancy and birth are normal,
physiological processes and should be treated as such with appropriate respect and vigilance.

As a midwife I adhere to The Midwives Model of Care™ which is:

• Monitoring the physical, psychological, and social well-being of the mother throughout
the childbearing cycle
• Providing the mother with individualized education, counseling, and prenatal care,
continuous hands-on assistance during labor and delivery, and postpartum support
• Minimizing technological interventions
• Identifying and referring women who require obstetrical attention

Copyright (c) 1996-2008, Midwifery Task Force, Inc., All Rights Reserved.

All women should have physical, emotional, and social support during their pregnancy, birth,
and postpartum. Pregnancy, birth, and breastfeeding are normal, healthy events that have the
potential to be strengthening and empowering to all women.

Within the bounds of safety, all women have the right to birth how, where, and with whom they
choose. I believe in the importance of prenatal education, planning, and shared decision-making
with clients. I strive to build relationships with clients built on trust, respect, and understanding.
Legal Parameters of Midwifery Care
In the State of Washington, a midwife must be licensed within the parameters of the licensing
process, after having completed a 3-year accredited program. A midwife is any person practicing
midwifery who offers medical aid for compensation to a woman during the prenatal, intrapartum,
and postpartum stages and to her newborn up to two weeks of age. It is also the midwife’s duty
to consult with a physician whenever there are significant deviations from normal in either the
mother or the newborn (RDW 18.50.010).

Routine Schedule of Care & General Services Provided

 Personal, individualized care including an initial visit, prenatal care, labor, birth, and
postpartum care
 24/7 availability for urgent needs
 A complete medical and obstetrical history, physical and pelvic examination including
lab work
 Nutritional assessment and counseling
 Prenatal visits once monthly from onset of care until 28 weeks, every two weeks until 36
weeks, and then weekly until birth
 A prenatal home visit at approximately 36-37 weeks
 On-call availability for client from 37-43 weeks (can be reached by phone 24 hours a day
and will not travel more than 1 hour from home)
 Attendance at client’s home during active labor, birth, and immediate postpartum
 An initial newborn examination that takes place shortly after birth
 Care of newborn up to two weeks of age
 Visits after birth including two home visits in the first 5 days, then office or phone visits
at 10-14 days and 3-4 weeks, and a final office visit at 6 weeks postpartum
 Availability for lactation support or referral, if needed

Assessment for Candidacy for Midwifery Care

Upon inquiry for midwifery care and consultation, a consult form is given to every potential
client to evaluate eligibility for midwifery and out of hospital care.
This form includes:
 Client’s basic information (Name, contact information, date of birth, pre-pregnancy
weight, height, etc.)
 Last menstrual period used to date pregnancy
  Basic health history to screen for conditions that may risk client out of care. (Birth
defects, genetic disorders in family, twins, uterine rupture, pre-eclampsia, insufficient
cervix, abnormal pap smear, high blood pressure, seizures, sleep apnea, platelet
sensitization, cancer, prior radiation treatment, diabetes, blood disorders, kidney
disease, thyroid disease, lung or respiratory disease, cardiac disease, gastrointestinal
disorders, bariatric surgery, other major surgeries, alcohol or drug use, tobacco use,
sexually transmitted disease, HIV positive, and hepatitis)
Some conditions may indicate that a potential client may not be eligible for out of hospital
midwifery care. That may be conveyed over the phone or during an initial consultation. Further
risk factors may be assessed during the initial prenatal visit. Any concerns will be discussed with
the client and a physician consultation may indicated.

ELEMENTS OF INITIAL PRENATAL VISIT & ROUTINE PRENATAL VISITS

 Accurate and complete documentation of all visits, communications, examinations and

findings, laboratory tests and results, medications administered, procedures, and referrals
 Initial prenatal visit of approximately 2 hours
o medical, obstetric, social, and family history
o physical exam may include but is not limited to:
 height, weight, and BMI calculation
 blood pressure, pulse, respirations
 auscultation of heart and lungs
 HEENT
 abdominal exam including FHT if audible
 assessment of uterine size
o laboratory tests
 prenatal panel (CBC, blood type/Rh, Rubella, etc.)
 urine dipstick for glucose and protein
 genetic screening tests offered
 additional tests offered as indicated by risk may include but are not limited
to glucose, vitamin D, TSH, tuberculosis, Pap, other STI (gonorrhea,
chlamydia, syphilis, herpes cultures, etc.)
 Regular prenatal visits of approximately 1 hour
o conform to the following schedule, which may be adjusted upon agreement with
the midwife and according to the specific needs of the client:
 once per month up to 28 weeks; once every 2 weeks from 28 to 36 weeks;
once a week from 36 weeks until the birth unless, otherwise indicated
o regular prenatal visits consist of:
 general assessment of well-being
 blood pressure, pulse
 weight
 nutrition
 sleep and exercise habits
 emotional well-being
 fetal heart rate (with Doppler or fetoscope)
  fetal growth, movement, and position
 discomforts and concerns
 evaluation, counseling, education, and recommendations as appropriate
o laboratory tests offered:
 urine dipstick for glucose and protein
 GDM screening at 28 weeks
 GBS testing at 36 weeks
 genetic screening as requested
 ultrasound anatomy scan at 18-20 weeks
 additional tests offered as appropriate including anti-D antibody titer
 Home visit with birth team at 36 weeks lasting approximately 1.5 hours
o all members of the birth team present at the home or alternative birth site (may
include client, partner, other friends or family members, doula, midwife,
midwife’s assistant)
 confirm that the birth site is adequately prepared and appropriate for
homebirth (running water, power, etc.)
 confirm all members of the birth team are familiar with the site
 address any questions or concerns of the birth team in advance of the birth.
 On-call availability from 37 weeks until birth with back-up coverage
(Davis, 2012)

ELEMENTS OF INTRAPARTUM/IMMEDIATE POSTPARTUM CARE

 Accurate and complete documentation of all visits, communications, examinations and

findings, laboratory tests and results, medications administered, procedures, and referrals
 Continuous care and attendance of midwife and skilled assistant at client’s labor and birth
once active labor is established and for a minimum of 2 hours after the birth to ensure
both client and baby are stable and well
 Provision of the following safety equipment at the birth site:
o oxygen
o adult oxygen mask
o neonatal bag and mask
o suction equipment (DeLee)
o IV fluids
o oxytoxic medications
(Pitocin, Methergine,
Cytotec)
  Ongoing assessment of well-being of both client and baby includes regular monitoring of:
o client vital signs at least every 4 hours, or as indicated
o fetal heart tones by intermittent auscultation using a Doppler
 latent 1st stage of labor: at least once every hour, or as indicated
 active 1st stage of labor: at least once every 30 minutes, or as indicated
 2nd stage of labor: at least once every 5-10 minutes, or as indicated
o progress of labor
o client’s emotional and physical state
o eating, drinking, and voiding adequately
o status of membranes: intact/ruptured (volume, color, odor of fluid)
 Sterile vaginal exams as indicated or desired by client to assess dilation, effacement,
station, position
 Artificial rupture of membranes (AROM) as indicated or desired
 Physical and emotional labor support and comfort measures
 Assist in birth of baby
 Minimal interference in the moments after birth
 Assessment of newborn transition
 Assisting the baby with breathing/resuscitation, if indicated
 Cord clamped and cut after it stops pulsing, unless indicated to cut earlier
(Davis, 2012)

ELEMENTS OF POSTPARTUM VISITS

 Accurate and complete documentation of all visits, communications, examinations and

findings, laboratory tests and results, medications administered, procedures, and referrals
 Immediate postpartum care:
o monitor client’s bleeding
o monitor client’s vital signs
o assess fundal height and firmness of uterus
o facilitate skin-to-skin contact and bonding of client with newborn infant
o perineal exam and assessment
o perform repairs of 1st or 2nd degree lacerations
o ensure that the client has been able to void, has had something to eat and drink,
and that breastfeeding has been initiated
o address any concerns of the client
 Ongoing postpartum care:
o Visits after birth including two home visits in the first 5 days, then office or phone
visits at 10-14 days and 3-4 weeks, and a final office visit at 6 weeks postpartum
to monitor and assess:
 overall client well-being
 bleeding
 uterine involution via fundal height and firmness
 healthy bowel/bladder function

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  perineal exam/assessment as indicated
 adequate client rest/sleep
 emotional adjustment
 perinatal mood disorders screening
 family adjustment
 General:
o unlimited telephone consultation
o family planning counseling
(Davis, 2012)

ELEMENTS OF NEWBORN CARE

“The customary scope of care of a newborn up to two weeks of age by a licensed midwife
includes, but is not limited to, clinical assessment, treatment, education, support and referral as
described in this section. Newborn care shall not go beyond the scope of the midwife's education,
training and experience.” In addition, it is the midwife’s duty to file a birth certificate within 10
days of birth. (RCW 70.58.080)

 Accurate and complete documentation of all visits, communications, examinations and

findings, laboratory tests and results, medications administered, procedures, and referrals
 Immediate newborn care:
o minimum interference in the moments after birth
o immediate assessment of newborn transition
o drying baby, keeping warm, and placing skin-to-skin
o assisting the baby with breathing/resuscitation should the need arise
o APGAR assessment – 1 and 5 minutes
o vital signs
o initiation of breastfeeding
o clamping and cutting of umbilical cord
 Neonatal resuscitation, if indicated, (NRP, CPR)
 Newborn exam
o performed at the client’s side
o includes assessment which may include the following but is not limited to, paying
attention to any abnormal findings and appropriate referral to pediatric care when
indicated:
 external anatomy including genitalia and assessing anus for patency
 palpate abdomen for masses
 skin: color, presence of birthmarks, skin tags, lesions
 check for cleft lip/palate
 check for tongue/lip tie
 assess reflexes (rooting, sucking, moro, palmar, plantar, Babinski)
 vital signs
 auscultate lungs for clarity, heart for murmurs, irregularities
 measurements: weight, length, head and chest circumference
o administer vitamin K if desired by client

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  IM or give instructions on oral administration
o administer erythromycin eye ointment if desired by client
o give instruction to the parent before departure including warning signs

 24-hour visit
o critical congenital heart defect (CCHD) screening
o newborn metabolic screening
o vitals
o weight
o evaluation of jaundice
 Ongoing newborn care 1-2 weeks
o monitor condition of cord stump
o second newborn metabolic screening
o overall newborn well-being:
 vital signs
 feeding
 sleeping
 bowel and bladder function
 weight
 any concerns
(Davis, 2012)

REASONS FOR DISCUSSION, CONSULTATION, OR TRANSFER OF CARE

PRE-EXISTING CONDITIONS & INITIAL VISIT

Discussion:

 Family history of significant disorders, hereditary disease, or congenital

anomalies
 History of preterm birth (<36 weeks)
 History of IUGR
 History of severe postpartum hemorrhage
 History of severe pre-eclampsia or HELLP
 History of gestational diabetes requiring or hypoglycemic or insulin
 No prenatal care prior to third trimester
 History of lap band, gastroplasty, or other bariatric (weight loss) surgery
 Previous unexplained neonatal mortality or stillbirth

Consultation:

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  Absent prenatal care at term
 History of seizure disorder in adulthood
 History of HELLP
 History of uterine surgery, including myomectomy
 Two or more prior cesarean births with low transverse incision
 Significant history of or current cardiovascular, renal, hepatic, neurological or
severe gastrointestinal disorder or disease
 Significant history of or current endocrine disorder (excluding controlled mild
hypothyroidism)
 Pulmonary disease/active tuberculosis/severe asthma
 Collagen vascular diseases
 Significant hematological disorders
 Current or recent diagnosis of cancer requiring chemotherapy
 History of cervical cerclage
 History of 3 consecutive spontaneous abortions (excluding clients who present
to care with viable pregnancy at gestation >14wks and beyond previous
miscarriage)
 Significant uterine anomalies
 Essential hypertension
 History of eclampsia
 History of postpartum hemorrhage requiring transfusion
 Current severe psychiatric illness
 Current seizure disorder
Transfer:

 Any serious medical condition associated with increased risk status for client
or fetus, for example: cardiac disease, renal disease with failure, insulin
dependent diabetes mellitus, uncontrolled asthma, or HIV infection
 Isoimmunization with an antibody known to cause hemolytic disease of the
newborn
 Prior cesarean with incision other than low transverse (e.g. classical)
Source: (modified) Midwives' Association of Washington State: Indications for Discussion, Consultation, and
Transfer of Care in a Home or Birth Center Midwifery Practice

PRENATAL CONSIDERATIONS

Discussion:
 Urinary tract infection unresponsive to treatment
 Significant abnormal ultrasound finding

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  Significant abnormal laboratory finding
 Unresolved size/dates discrepancies
 42 completed weeks with reassuring fetal surveillance including AFI and BPP
with NST
Consultation:

 Reportable sexually transmitted infection

 Significant abnormal Pap
 Significant abnormal breast lump
 Pyelonephritis
 Thrombosis
 Fetal demise after 14 weeks gestation
 Anemia unresponsive to treatment
 Primary herpes infection
 Significant vaginal bleeding
 Hemoglobinopathies
 Platelets <105,000/μL
 Persistent abnormal fetal heart rate or rhythm
 Non-reassuring fetal surveillance
 Significant placental abnormalities
 Significant or unresolved polyhydramnios or oligohydramnios
 Presentation other than cephalic at 37 weeks (refer for chiropractic and other
body work)
 Multiple gestation if co-managing prenatal care
 Significant infection the treatment of which is beyond the midwife's scope of
practice
Transfer:

 Ectopic pregnancy
 Molar pregnancy
 Premature pre-labor rupture of membranes (PPROM)
 Documented persistent/unresolved intrauterine growth restriction (IUGR)
 Multiple gestation if not co-managing prenatal care
 Eclampsia, HELLP, pre-eclampsia, or persistent hypertension
 Placenta previa at term
 Isoimmunization with an antibody known to cause hemolytic disease of the
newborn
 Clinically significant placental abruption
 Deep vein thrombosis

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  Cardiac or renal disease with failure
 Gestational diabetes requiring management with medication; consultation in
lieu of transfer if co-managing metformin with physician
 Known fetal anomaly or condition that requires physician management during
or immediately after delivery
 43 weeks completed gestation

Source: (modified) Midwives' Association of Washington State: Indications for Discussion, Consultation, and
Transfer of Care in a Home or Birth Center Midwifery Practice

INTRAPARTUM
In certain intrapartum situations, self-transport is appropriate. In other situations,
there may need to be immediate action taken in which the midwife will use clinical
judgment and expertise accessing 9-1-1 and emergency services as appropriate, and
transport as able.
Discussion:

 >8 hours of active labor pattern without significant change in cervix and/or
station and/or position
 >3 hours of active pushing without significant change
 Prolonged rupture of membranes (>48 hours)
Transfer:

 Active labor before 37 completed weeks

 Undiagnosed multiple gestation
 Fever (>100.4 F) that persists >1 hour
 Findings indicative of chorioamnionitis including, but not limited to
tachycardia, fetal tachycardia, temperature >100.4 F, uterine tenderness, purulent
or malodorous amniotic fluid.
 Thick or particulate meconium
 Persistent non-reassuring fetal heart rate pattern
 Exhaustion unresponsive to rest/hydration
 Abnormal bleeding during labor
 Suspected placental abruption
 Suspected uterine rupture
 Hypertension (>140 systolic or 90 diastolic twice 4 hours apart)
 Suspected pre-eclampsia (hypertension and proteinuria)

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  Seizure
 ROM > 72 hours
 ROM > 18 hours with GBS status unknown and no prophylactic antibiotics, or
GBS+ and no prophylactic antibiotics
 Prolapsed cord or cord presentation
 Significant allergic response
 Active genital herpes in vaginal, perineal or vulvar area in labor or after ROM
 Client's stated desire for transfer to hospital-based care

Source: (modified) Midwives' Association of Washington State: Indications for Discussion, Consultation, and
Transfer of Care in a Home or Birth Center Midwifery Practice

POSTPARTUM CONDITIONS

Consultation:
 Urinary tract infection unresponsive to treatment
 Mastitis (including breast abscess) unresponsive to treatment
 Reportable sexually transmitted infections
 Retained products/unresolved subinvolution/prolonged or excessive lochia
 Hypertension presenting beyond 72 hours postpartum
 Significant abnormal Pap
 Significant postpartum depression
Transfer:

 Significant postpartum hemorrhage unresponsive to treatment, with or without

sustained vital sign instability or shock
 Retained placenta (>1 hour or active bleeding and manual removal
unsuccessful)
 Lacerations beyond midwife's ability to repair
 Unusual or unexplained significant pain or dyspnea
 Significant, enlarging hematoma
 Endometritis
 Seizure
 Anaphylaxis
 Persistent uterine prolapse or inversion
 Fever (>100.4 F) that persists > 1 hour within the first 72 hours postpartum

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  Persistent hypertension in the first 72 hours postpartum (>140 systolic or 90
diastolic twice 4 hours apart)
 Postpartum psychosis
Source: (modified) Midwives' Association of Washington State: Indications for Discussion, Consultation, and
Transfer of Care in a Home or Birth Center Midwifery Practice

NEWBORN CONDITIONS

It is recommended that parents establish a relationship with a pediatric provider before

the baby is born. It is strongly recommended that all parents be advised to establish care
with a pediatric provider by 2 weeks of age. The following conditions warrant contact
sooner.

Consultation:
 Low birth weight newborn (< 2500 gm = 5 lbs 8 oz)
 Loss of greater than 10% of birth weight
 Prolonged asymptomatic jaundice
 Persistent cardiac arrhythmias or murmurs
 Significant clinical evidence of prematurity
 Failure to thrive • Hypoglycemia
 Significant or symptomatic jaundice beyond the first 24 hours
 Positive critical congenital heart disease screening (CCHD)

Transfer:
 Seizure
 Jaundice in the first 24 hours
 Persistent respiratory distress
 Persistent central cyanosis or pallor
 Persistent temperature instability
 Persistent hypoglycemia
 Significant bruising, petechiae or purpura
 Apgar score 6 or less at ten minutes of age
 Major congenital anomalies affecting well-being
 Birth injury requiring medical attention

Source: (modified) Midwives' Association of Washington State: Indications for Discussion, Consultation,
and Transfer of Care in a Home or Birth Center Midwifery Practice

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Communication with Clients
All clients and/or potential clients will be given the following documents to inform them of the
midwife’s role and scope of practice. These documents include information about limitations and
complications that necessitate referral or transfer of care to a physician and/or hospital for a
higher level of care.
 Informed Disclosure of Midwifery Care
 Informed Consent/Refusal to Midwifery Care
 Informed Choice for Midwifery Care

Interface with Medical Community

When referral is indicated or necessary, the client and midwife will make the decision and the
referring physician/hospital will be notified. Referral can be made by preference of the client, the
midwife’s back-up physician, or the on-call hospitalist at the closest facility. The client’s chart
will be sent, with permission. The midwife will collaborate and provide continuity of care, if
desired by the client.

References
Davis, E. (2012). Heart and hands: a midwife's guide to pregnancy and birth. Random House.

Midwives' Association of Washington State (2016). Indications for discussion, consultation,

and transfer of care in a home or birth center midwifery practice. Retrieved from:
http://www.washingtonmidwives.org/documents/MAWS-indications-2016.pdf

Revised Code of Washington (2018). RCW 70.58.080 Birth certificates. Retrieved from:
http://app.leg.wa.gov/RCW/default.aspx?cite=70.58.080

Washington Administrative Code (2018). WAC 246-834-255 Elements of care for the newborn.
Retrieved from: http://app.leg.wa.gov/wac/default.aspx?cite=246-834-25

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