PAMA Standards of Care and Practice Protocols
The Pennsylvania Midwives Alliance supports evidence-based clinical practice, grounded in current medical research presented by the midwife to the client, combined with the midwife's experience and clinical expertise. This, alongside the client's cultural beliefs, convictions, and desires, is used to develop personalized care that honors the time-tested midwifery model of care. The goal is to ensure the safest and healthiest possible pregnancy, birth, and postpartum for low-risk women.
PAMA Standards of Care and Practice Protocols are designed to guide midwives in delivering care that meets the highest possible standards in community birth settings without interfering with their clinical judgment or practice.
PAMA Standards and Protocols:
● Standards: Accepted as a model or example by general consent.
● Protocols: Represent a course of treatment or a code of correct conduct.
Table of Contents
● In General
● Prenatal Care
● Birth Preparation
● Labor
● Birth
● Postpartum Care
● Appendix A: Medical and Obstetrical History
● Appendix B: Prenatal Exams
● Appendix C: Postpartum Care
● Appendix D: Newborn Care
● Appendix E: Regarding Stillborn Babies and Fetal Death In Utero
In General:
PAMA midwives:
● Participate in peer review meetings.
● Maintain thorough records for antepartum (prenatal), intrapartum (birth), and postpartum (immediate and up to six weeks) care.
● Complete a minimum of 30 hours of continuing education through workshops, local organization meetings, classes, and self-instruction each three years.
Prenatal Care:
Before beginning prenatal care, each family will be given the midwife's Informed Disclosure of Midwifery Practice in writing. This disclosure will include:
● The midwife's experience, training, emergency backup, financial arrangements, privacy practices, and the legal status of midwives in their state.
● A discussion on contraindications to home birth, associated risks of home and hospital birth, and expectations of both the midwife and the family.
The midwife will:
● Obtain the medical and obstetrical history (See Appendix A).
● Encourage regular prenatal visits and provide prenatal exams at least every four weeks until the 36th week of pregnancy, and weekly after that until birth.
● Recommend appropriate lab tests, as outlined in Appendix B.
● Continually assess the pregnancy for risks, considering lab results, complications, PAMA Risk Factor Guidelines, and the mother's overall physical and emotional health. The client will be informed of these risks and options for care or referral.
● Support healthy lifestyle choices, such as regular exercise, proper nutrition, and attending childbirth education classes.
● Educate on breastfeeding, its importance, and provide assistance or referrals to ensure successful breastfeeding.
Birth Preparation:
The midwife will:
● Inform the family about labor signs, how to contact the midwife, and establish a due window in birth at home is safe. Specific arrangements will be made for backup care if necessary.
● Ensure the family has all necessary supplies ready at least four weeks before the due date and that emergency contact information (e.g., hospital, EMS) is available.
● Discuss and help the family develop a birth plan for both home and hospital births.
● Make at least one visit to the intended birth location before labor to ensure it is adequately prepared.
Labor:
The midwife will:
● Monitor the mother's vital signs, labor progress, and fetal well-being throughout labor. This includes tracking fetal heart tones, contractions, and signs of potential complications.
● Maintain cleanliness and use sterile techniques when necessary, particularly after the rupture of membranes.
● Use the least intrusive methods for monitoring progress and minimize vaginal exams to reduce the risk of infection.
Birth:
The midwife will:
● Ensure the safety of both the mother and baby throughout the birth process, using necessary equipment, skills, and intuition. Consultation with other midwives or healthcare professionals as needed.
● Document all birth-related events, including labor progress, fetal heart tones, maternal vital signs, and any complications. Medical charts will be consistent and available to the client at the end of care or PAMA for case review.
Postpartum Care:
The midwife:
● Assess both the mother and baby post-birth, using checklists outlined in Appendices C and D. The midwife will stay with the family for at least two hours after birth, ensuring both mother and baby are stable.
● Provide information about the normal postpartum period and any warning signs of complications. The midwife will remain in contact with the family for at least one week postpartum and provide ongoing breastfeeding support.
● Conduct postpartum visits for at least two weeks and encourage a follow-up exam with the midwife or another healthcare provider 4-8 weeks after birth.
● Address any abnormalities or concerns and provide referrals as needed.
Appendices:
Appendix A: Medical and Obstetrical History
● Includes detailed family history, medical history, obstetric history, and social history, covering conditions like hereditary diseases, past surgeries, substance use, or any relevant social factors.
Appendix B: Prenatal Exams
● Includes suggested blood work, physical assessments, and regular monitoring of maternal and fetal health during prenatal visits.
Appendix C: Postpartum Care
● Covers immediate postpartum assessments of the mother and baby, including monitoring bleeding, lactation, perineal health, and infant well-being.
Appendix D: Newborn Care
● Describes the newborn's physical exam, including checking vital signs, reflexes, and developmental milestones.
Appendix E: Regarding Stillborn Babies and Fetal Death In Utero
● Provides protocols for handling stillbirths, including documentation, family support, funeral arrangements, and follow-up care.
Appendix A: Medical and Obstetrical History
The midwife will gather the following information to establish a comprehensive understanding of the client’s health:
1. Family History:
○ Major diseases in first-degree relatives (parents, siblings, children) such as cancer, diabetes, heart disease, and mental health conditions.
○ Hereditary conditions like Huntington’s chorea, sickle cell anemia, Tay-Sachs disease, multiple sclerosis, hemophilia, neural tube defects, Down's Syndrome, and any other genetic disorders.
○ Obstetric history of previous pregnancies, including complications or conditions such as gestational diabetes, pre-eclampsia, fetal anomalies, and labor complications.
2. Medical History:
○ Cardiovascular, endocrine, gastrointestinal, respiratory, gynecological health, including any surgeries or past injuries.
○ Past issues like high blood pressure, bleeding, blood transfusions, hospitalizations, and other pertinent health concerns.
○ The last Pap smear, and any issues related to sexual and reproductive health, including previous miscarriages, abortions, or stillbirths.
3. Obstetrical History:
○ Information on previous pregnancies, including the number of births, the type of birth (vaginal or cesarean), complications, and outcomes.
○ Fetal position during previous labors, length of labor stages, any use of interventions (forceps, vacuum, etc.), and perineal lacerations.
○ Birth weight, sex, and any birth complications such as shoulder dystocia or neonatal jaundice.
4. Social History:
○ Information regarding potential impacts on home birth, such as domestic violence, substance abuse, or social stress.
○ The client’s knowledge of community resources (e.g., WIC, Medicaid, legal services) and support structures such as family or partner involvement.
○ Any relevant personal history such as prior abuse, current family dynamics, or lifestyle factors affecting pregnancy.
Appendix B: Prenatal Exams
The midwife will conduct the following during each prenatal visit to ensure the health and well-being of both the mother and baby:
1. Initial Assessment:
○ Blood work: Basic OB panel including CBC, ABO/Rh type, Rh antibody titers, and other screenings (hepatitis, gonorrhea, chlamydia, HIV, syphilis, and glucose metabolism tests).
○ Comprehensive physical exam: Including assessment of reflexes, weight gain, and any other concerns the mother may have.
2. Routine Monitoring:
○ Weight: Compare the client’s weight gain to her pre-pregnancy weight.
○ Blood pressure: Regular monitoring to detect signs of preeclampsia or other issues.
○ Fetal heart tones and fetal position: To ensure fetal health and growth.
○ Fundal height: To ensure the baby’s growth is consistent with gestational age.
○ Urinalysis: Checking for protein, glucose, and ketones in the urine.
3. Additional Testing:
○ At the appropriate times during the pregnancy, tests like the Glucose Tolerance Test (GTT) for gestational diabetes or other lab tests may be conducted based on the midwife’s assessment and the mother’s health history.
4. Nutritional Counseling:
○ Offer dietary advice, and monitor for any nutritional deficiencies. 5
○ Provide additional resources for managing common discomforts during pregnancy, such as nausea or swelling.
Appendix C: Postpartum Care
The midwife will provide comprehensive care for the mother and baby immediately after birth and through the postpartum period:
1. Immediate Postpartum Care:
Mother: Assess vital signs, bleeding, uterine tone (fundus), and perineal health. Monitor the amount of lochia and any possible signs of infection or complications.
Baby: Check for jaundice, ability to nurse, and overall newborn activity level. The midwife will also assess the newborn’s temperature, heart rate, and general condition.
The midwife will stay for at least two hours post-birth to ensure stability.
2. Breastfeeding and Bonding:
○ Provide support for successful breastfeeding, focusing on latch, milk production, and mother-infant bonding.
○ Address any issues with breastfeeding, including pain, latch issues, or concerns with milk supply.
3. Follow-Up Care:
○ Postpartum visits: The midwife will conduct visits within the first two weeks after birth to monitor the mother’s recovery, and the baby’s health.
○ Encourage the mother to schedule a follow-up appointment with either the midwife or another healthcare provider 4-8 weeks postpartum for a comprehensive check-up.
Appendix D: Newborn Care
The midwife will perform a thorough newborn examination, assessing the following:
1. General Physical Exam:
○ Vital Signs: Record the newborn’s weight, temperature, and heart rate.
○ Head: Symmetry, fontanelles, and sutures.
○ Eyes: Check for clarity and absence of discharge or cataracts.
○ Mouth: Inspect for intact palate, well-formed chin, jawline, and the ability to suck.
○ Skin: Inspect for birthmarks, dimples along the spine, or any abnormalities.
2. Developmental Assessments:
○ Check for symmetrical muscle development in the arms and legs.
○ Palpate the abdomen to assess liver, kidneys, and overall abdominal tone.
○ Ensure the hips and feet are well-formed and symmetrical.
3. Reflexes:
○ Observe and test primary newborn reflexes such as rooting, sucking, grasping, Moro, Babinski, and others.
4. Additional Observations:
○ Genitals: Inspect genital openings, testicular descent, and the anus for patency.
○ Check for any signs of abnormality or developmental concerns that may require further investigation.
Appendix E: Regarding Stillborn Babies and Fetal Death In Utero
In the event of a stillbirth or fetal death in utero, the midwife will follow the protocols outlined below:
1. Handling the Death:
○ If the family chooses to go to the hospital, the midwife will advocate for them and assist with transportation if needed.
○ If the family prefers not to go to the hospital, the midwife will arrange for the medical examiner to come to the home.
2. Family Support and Options:
○ The midwife will inform the family of their options for photographs, birth certificates, footprints, naming the baby, and funeral arrangements.
○ Provide guidance on autopsy options, and support the family’s decisions throughout the grieving process.
3. Postnatal Care and Follow-Up:
○ The midwife will provide ongoing emotional support, regular follow-up visits, and referrals to support groups or counseling agencies to help the family process the loss.
○ Ensure the family is aware of local resources for bereavement support.