INDICATIONS FOR CONSULTATION IN AN OUT-OF-HOSPITAL MIDWIFERY PRACTICE

Revised and approved August 2, 2002 by the Midwives' Association of Washington State.

• Introduction
• Pre-existing Conditions
• Antepartum Conditions
• Intrapartum Conditions
• Postpartum Conditions
• Neonatal Conditions

11/17/07 Proposed Draft Revision to MAWS Indications for Discussion, Consultation and Transfer of Care in an Out-of-Hospital Midwifery Practice - pdf 

Licensed Midwifery is an autonomous profession. Licensed Midwives work interdependently with one another and with other health care providers to promote the optimal health and well-being of mothers and babies during the normal childbearing cycle. When there are significant deviations from normal during pregnancy, labor, or postpartum, Licensed Midwives are required by law in Washington State (RCW 18.50.010) to consult with a physician regarding the client's care.

Midwives engage in an on-going assessment process that begins during the initial prenatal consultation and continues through the completion of care in the postpartum period. In providing care, midwives take into account the client's own informed choice, the state laws and regulations, the standards for practice and core competencies for basic midwifery care provided by their professional organization, the midwifery and medical literature, the settings in which they practice, the collaborative relationships they have with other healthcare providers and area hospitals, and their clinical judgement, expertise and philosophy of care.

During pregnancy, labor, or postpartum, risk factors or complications may develop. This document provides a representative but not exhaustive list of the conditions that a midwife might encounter in practice for which consultation is indicated.

When there are significant deviations from normal, Consultation involves soliciting the advice or opinion of a physician while maintaining primary responsibility for the client's care. In some instances, a midwife may consult with another appropriate health care provider for less significant deviations from normal. The midwife has the duty to communicate accurately that advice to the client. Consultation may or may not result in:

• Recommendations by the consulting provider via telephone, written or electronic mail;
• Collaboration between providers, which occurs when the midwife and the consulting provider jointly manage the client's care or some aspect of care;
• Referral of the client to the consulting provider for examination and/or treatment of a specific problem or condition; or
• Complete Transfer of Care from the midwife to the consulting provider.

This screening tool was developed for use in conjunction with clinical judgment and expertise. Its purpose is to enhance midwives' accountability to their clients, to one another, to other healthcare professionals, and to the general public. The Midwives' Association of Washington State reviews and revises this document regularly in order to reflect the most current evidence available and to see that the parameters identified promote safety for the mother and infant, without unduly restricting safe midwifery practice. In addition, new clinical procedures may be undertaken in accordance with the Midwives' Association of Washington State's Guidelines for Introducing Expanded Clinical Procedures into Midwifery Practice.

I. Pre-existing Conditions
The following maternal conditions existing prior to the current pregnancy necessitate physician consultation and may require physician collaboration and/or referral:

1. Current or any history of significant cardiovascular disease
2. Pre-existing hypertension
3. Pulmonary disease/active tuberculosis/asthma if severe or uncontrolled by medication
4. Current or significant history of renal disease
5. Current or significant history of hepatic disorders
6. Current or significant history of endocrine disorders except controlled mild thyroid disorders
7. Significant hematological disorders
8. Collagen-vascular diseases
9. Current or significant history of neurological disorders
10. Current or significant history of cancer
11. Current alcoholism or abuse, current drug addiction or abuse (excluding tobacco use)
12. Current severe psychiatric illness
13. Isoimmunization with an antibody known to cause hemolytic disease of the newborn
14. Two or more prior uterine incisions, classical uterine incision, or uterine incision less than 18 months prior to anticipated birth; history of myomectomy
15. Other significant deviations from normal as assessed by the midwife

II. Antepartum Conditions
The following conditions arising during pregnancy necessitate consultation and may require physician collaboration and/or referral:

1. Labor before the completion of 37 weeks gestation
2. Premature pre-labor rupture of membranes (PPROM)
3. Presentation other than cephalic at term
4. Multiple gestation
5. Significant vaginal bleeding
6. Gestational diabetes mellitus
7. Severe anemia unresponsive to treatment
8. Evidence of hypertension or pre-eclampsia
9. Ectopic pregnancy
10. Molar pregnancy
11. Significant size/dates discrepancies
12. Polyhydramnios or oligohydramnios
13. Documented or suspected intrauterine growth restriction
14. Thrombophlebitis
15. Known fetal anomaly or condition affected by site of birth, with an infant compatible with life
16. Fetal demise after 12 completed weeks gestation
17. Non-reassuring fetal heart rate
18. Significant abnormal ultrasound finding
19. Documented placental abnormalities or placenta previa
20. Postdates pregnancy > 42 completed weeks
21. Positive HIV antibody test
22. Primary herpes past the first trimester
23. Significant infections, the treatment of which is beyond the midwife's scope of practice
24. Parent(s) ill-prepared for out-of-hospital birth at 37 weeks
25. Inability of client and midwife to come to an agreement regarding plan of care
26. Development of any of the conditions listed previously
27. Other significant deviations from normal as assessed by the midwife

III. Intrapartum Conditions
The following conditions arising during labor warrant consultation and may require physician and/or hospital referral. It should be noted that in some intrapartum situations, because of time urgency, it may not be prudent to pause care long enough to seek physician consultation prior to action being taken.

1. Non-cephalic fetal presentation
2. Sustained maternal fever (greater or equal to 100.4 F or 38 C) or evidence of maternal infection
3. Hypertension, with or without additional signs or symptoms of pre-eclampsia
4. Moderate or thick meconium-stained amniotic fluid with delivery not imminent
5. Persistent non-reassuring fetal heart rate pattern
6. Maternal exhaustion unresponsive to rest and hydration
7. Abnormal bleeding
8. Maternal seizure
9. ROM > 72 hours
10. ROM > 18 hours with GBS + status and no prophylactic antibiotics
11. Prolapsed cord or cord presentation
12. Significant allergic response
13. Active genital herpes in labor or after ROM
14. Adhered placenta or retained with or without bleeding
15. Client's clear desire for pain medication, consultation, or referral
16. Other significant deviations from normal as assessed by the midwife

IV. Postpartum Conditions
The following maternal conditions arising during postpartum necessitate consultation and may require physician collaboration and/or referral.

1. Seizure
2. Anaphylaxis
3. Significant hemorrhage not responsive to treatment
4. Sustained maternal vital sign instability or shock
5. Significant uterine prolapse or inversion
6. Significant uterine subinvolution
7. Signs of uterine infection or maternal sepsis
8. Lacerations, repair of which is beyond the midwife's level of expertise
9. Development of any of the conditions listed previously
10. Other significant deviations from normal as assessed by the midwife

V. Neonatal Conditions
The following conditions arising in the neonate necessitate pediatric provider consultation and may require physician collaboration and/or referral.

1. Seizure
2. Abnormal tone, posture or behavior
3. Persistent respiratory distress
4. Persistent cardiac irregularities
5. Persistent central cyanosis or pallor
6. Persistent temperature instability
7. Persistent hypoglycemia
8. Apgar score less than 7 at five minutes of age and not improving
9. Pattern of progressive worsening of symptoms
10. Birth weight $lt; 2500 grams (5.5 pounds)
11. Significant clinical evidence of prematurity
12. Significant jaundice or jaundice in the first 24 hours after birth
13. Loss of greater than 10% of birth weight and/or failure to thrive
14. Major apparent congenital anomalies
15. Birth injury requiring medical attention
16. Other significant deviations from normal as assessed by the midwife