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CARE DOCUMENTATION
All aspects of care will be documented on client forms and kept in her file.
MoonDragon's Client Forms Index
All homebirth clients will arrange for obstetrical, maternity and pediatric back-up care and such information will be documented on the client's chart by the attending midwife.
Prenatal care includes:
1. Complete history (medical, obstetrical, psychosocial).
2. Complete physical exam.
3. Complete pelvic exam and assessment.
4. Nutritional assessment and counseling.
5. Lab work; standard prenatal screen is recommended:
LAB WORK RECOMMENDATIONS
Complete blood count (CBC) with differential.
ABO type & Rh factor.
Rubella.
Rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL).
Hepatitis B surface antigen.
Antibody screen.
Urinalysis (UA) culture & sensitivity.
Other "as needed" possible lab work & prenatal screening may include:
- Glucose testing.
- Alpha fetal protein.
- Amniocentesis.
- Ultrasound.
- Sickle cell screening.
- HIV screening.
- Gonorrhea.
- Chlamydia.
- Toxoplasmosis.
- Group B Strep (GBS) culture.
- Platelet & differential.
- Pap test.
- And any other diagnostic tests used for assessing the well being of mother and fetus.
RETURN PRENATAL VISITS
1. Frequency:
- Every 4 weeks, up to 28 weeks LMP.
- Every 2 weeks, from 28 weeks to 36 weeks.
- Weekly from 36 weeks until the birth.
2. Visits more frequent as needed.
3. Assessment of client's general well-being:
- Weight gain assessment.
- Fetal heart tones.
- Fetal growth.
- Urinalysis for protein/glucose.
- Blood pressure.
- Nutritional review and counseling.
- Educational review and discussion.
- Psychosocial review and counseling.
4. 30 minute minimum visit (most visits may last about 45 minutes to an hour, sometimes longer, depending upon maternal issues needing discussion, educational birth preparation instruction and other factors).
5. Lab update as needed:
- 28 - 36 weeks CBC with diff.
- Rh Antibody screen.
- Urine culture.
- Group B Strep.
- Any other diagnostic test that may need to be repeated.
36 WEEK VISIT
1. Home visit when possible.
2. Check emergency transport phone number list.
3. Check birth supplies.
4. Instructions for early labor, including when to call and how to reach midwife.
The midwife will refer the mother for consultation and/or care with the mother's health care provider if any client exhibits signs and/or symptoms of abnormal conditions as outlined in the Risk Factor Guidelines.
Initial exam during labor includes checking Fetal Heart Rate (FHR), maternal blood pressure, pulse, temperature, fetal position by palpation, and noting status of membranes. When indicated, a vaginal exam to assess dilation, effacement and station may be done.
LABOR
1. Fetal Heart Rate Screening includes:
A. Frequency.
- Minimum of every 15-30 minutes during early active labor.
- Every 5-15 minutes during late active labor.
- Every contraction to every other contraction during second stage, not to exceed 5 minute intervals.
B. In addition, it is beneficial to evaluate FHT's.
- Immediately after contractions.
- Intermittently through contractions.
- Upon rupture of membranes.
- With increasing frequency if any signs of risk factors develop.
2. Temperature, pulse, blood pressure repeated every 4 hours or as indicated.
3. Monitor progress of labor through observation and/or examination.
4. Anticipate transport if risk factors develop.
5. The midwife or qualified assistant must be present in home from beginning of active phase onward.
6. Maintain maternal hydration / nutrition / elimination.
7. Maintain sterile technique as procedure dictates.
BIRTH
1. Prepare for birth: check/set up supplies, set appropriate room temperature.
2. Assist client with birth according to her wishes and present circumstances.
3. Use midwifery techniques to preserve perineal integrity.
THIRD STAGE: NEWBORN
1. Assess neonatal status, record 1 and 5 minute Apgar.
2. Suction or resuscitate, as needed.
3. Maintain newborn temperature through immediate maternal contact and appropriate room temperature.
4. Use sterile instruments for cord cutting.
THIRD STAGE: MOTHER
1. Expectant management unless otherwise indicated.
2. Assess uterine height, tone, and estimate blood loss.
3. Facilitate birth of placenta.
4. Take cord blood if necessary.
5. Examine placenta and cord.
6. Examine perineum for lacerations.
7. Suture if necessary using sterile technique and local anesthetic as needed.
FOURTH STAGE - IMMEDIATE POSTPARTUM
Minimum 2 hour postpartum maternal and newborn monitoring including:
- Facilitating breastfeeding.
- Perform newborn examination.
- Offer eye prophylaxis.
- Offer vitamin K.
- Give postpartum instructions for first 24 hours.
- Encourage appropriate home environment.
- Ensure stable condition of mother and baby.
- The midwife should consult or refer the mother to her health care provider according toTransfer Criteria and Risk Factor Guidelines.
POSTPARTUM CARE UP TO 6 WEEKS AFTER BIRTH
Post Partum care with a minimum 2 visits. 1. First visit within 24-36 hours.
2. Second visit within 5 days.
3. Perform or refer to pediatrician for Newborn Screening Program.
4. Observe and monitor parameters of maternal and newborn well-being including involution, lochia, breastfeeding, jaundice, and cord condition.
Midwife recommends clients make arrangements for pediatric exam with their health care provider according to the provider's preferred time frame.
6-WEEK OFFICE VISIT
1. Complete pelvic exam. (bimanual and speculum).
2. Pap test if not done during pregnancy.
3. Breast exam and instructions on self exam as needed.
4. Abdominal exam.
5. Assessment of family adjustment and parenting.
6. Birth control counseling and information.
7. Follow up on pediatric care.
BIRTH CERTIFICATE
Assist parents with filing Birth Certificate within the required time frame. In Massachusetts and New Hampshire, birth certificates are filed with the city hall in the town where the infant was born at home. The midwife should accompany the mother to the city hall to help fill in any statistical data gathered by the state regarding prenatal care and birth outcomes. If the birth ended up in a medical facility, the hospital will file the birth certificate.
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