Prelabor rupture of the membranes (PROM) is a well-established risk factor for maternal and neonatal infection. Interventions to hasten birth are often employed when PROM occurs in an effort to lessen the risk of infection. One of the primary management decisions to be made with term PROM is choosing between expectant management and induction of labor. Limitations of TERMPROM Study include potential overdiagnosis of chorioamnionitis, vaginal exams as an independent risk factor for infection, and the vaginal presence of group B streptococcus (GBS). Accurate diagnosis of chorioamnionitis can be difficult because there are no definitive diagnostic criteria. The signs and symptoms, such as fever, foul-smelling fluid, and abdominal tenderness, are either nonspecific or subjective. In the TERMPROM study, women in the expectant management groups had significantly more vaginal exams than women in the induction groups.

This chapter provides historical background on why and how the shift to hospitalization for all childbearing women occurred in the United States. It describes why and how the Maternity Center Association (MCA) decided to launch and evaluates their demonstration of freestanding birth centers as a safe place for the practice of midwifery. MCA’s mission was to respond to educated women activists who were seeking more control over their childbirth experience and rejecting the routine policies and medical practices interfering with birth in busy hospital maternity services. The Cooperative Birth Center Network (CBCN) was established to develop the national infrastructure to ensure quality care, conduct research, and lay a foundation to support future replication. The Childbearing Center (CbC) demonstration set the bar for quality assurance by including the National League for Nursing (NLN)/American Public Health Association (APHA) program for accreditation of home health agencies and community nursing services.

This chapter focuses on principles in establishing a birth center. The birth center model has been a practice site primarily for midwifery rather than medicine. Although the image of the birth center is a place for labor and birth, the setting also provides prenatal and well-woman office visits, programs for education and support, and newborn care. Evaluating the local community and assessing the need for additional clinical services will impact the direction the entrepreneurs will take in creating the birth center. A key preliminary step in creating a birth center is performing an in-depth community assessment. The category of “birth attendant” is important to consider, as a number of clinicians use the midwifery model of care: nurse-midwives; direct-entry midwives, including certified professional midwives (CPM) who could be licensed mid-wives (LM); family physicians; and naturopathic physicians. The birth center has long been a model of successful interagency and interdisciplinary health care.

This chapter focuses on the contemporary evidence for supporting health and preventing complications in women during the third stage of labor. The current expectation for the length of the third stage of labor is based primarily on a study of more than 12,000 vaginal births that found the median length of the third stage was 6-minutes, with only 3.3” lasting more than 30-minutes. In addition to prolonged third-stage-length, other factors contributing to an increased risk of postpartum hemorrhage (PPH) include hypertensive disorders, oxytocin induction and large-for-gestational-age neonates. Midwives need to be aware of the increased risk of PPH when the third stage is longer than 30-minutes. Active management of the third stage of labor (AMTSL) is a bundle of interventions implemented during the third stage of labor to decrease the incidence of PPH. Current international recommendations for AMTSL include administration of an uterotonic, controlled cord traction, and uterine massage.

The increasing rates of overweight and obesity in women of childbearing age, combined with the risks of poor outcomes for the mother-child dyad, make it imperative for midwives to be aware of the evidence. This chapter describes the evidence-based best practices for the preconception, antepartum, intrapartum, and postpartum care of the obese woman. In addition, in providing care to the normal-weight pregnant woman with a history of gastric surgery for weight loss, the midwife needs to be cognizant of unique clinical considerations that deviate from routine care. During preconception/well-woman visits, the midwife needs to obtain accurate height and weight measurements, determine body mass index (BMI), and tactfully discuss BMI outside the defined limits as a risk in pregnancy. Obese women are at greater risk of giving birth to an infant with congenital anomaly. The midwife needs to counsel the obese pregnant woman about options available for screening for congenital anomalies.

The emotional processes that start during pregnancy and continue during the childbearing event have a major impact on the evolving mother child relationship. A woman-centered approach to childbirth services acknowledges and attends to the psychological and social components of childbearing. Lehrman developed a theoretical framework to describe relationships among midwifery care, psychosocial outcomes, and maternal psychosocial variables. Lehrman’s research demonstrated that positive therapeutic presence by midwives increases a woman’s self-esteem and satisfaction with the labor experience. The specific behaviors of labor support can be categorized into three areas that encompass the elements of therapeutic presence: emotional support, physical care and comfort, and advocacy for the laboring woman. Midwives are ideal leaders in educating nurses, obstetrical teams, and childbearing women on the benefits and implementation of continuous labor support for all women as a routine intervention in all birth settings.

Midwives need to understand how the move toward value-based purchasing, with less emphasis on payment for procedures and more emphasis on primary and preventive care, provides opportunities for describing midwifery care and empowering midwives as primary care providers. Strong Start is a Center for Medicare and Medicaid Innovation (CMMI) initiative that is raising awareness of the value of two midwife-led innovations: centering and birth centers. Midwives must understand the potential for policy decisions to influence the growth of midwifery and the midwifery model. Midwifery has grown both nationally and internationally, and birth is becoming safer in large part as a result of effective advocacy. Membership in professional associations provides midwives the ability to combine individual advocacy with organizational capacity, and each member contributes to the strength of the collective voice. Midwives must understand the potential for policy decisions to influence the growth of midwifery and the midwifery model.

High-technology use in physiologic birth requires tethering women to cables and hoses, restricting freedom of movement. This tethering increases the likelihood for a cascade of medical interventions disrupting physiologic birth and affecting the woman’s ability for decision making. According to the American College of Nurse-Midwives (ACNM), nutritional deprivation is one factor that can disrupt the normal physiologic processes that occur during childbirth. Continuous electronic fetal monitoring (EFM) is one of the most routine and tethering practices used in the United States with women at low risk for complications. Much of the tethering observed in typical hospital labor management arises from the use of pharmacological intervention. In view of the numerous challenges to maternal mobility in labor with the use pharmacological pain management and the ensuing cascade of interventions, a strong case can be made for nonpharmacological management as the best practice to support physiologic birth.

This chapter explores the scientific evidence for vaginal birth after cesarean (VBAC) practice in the United States and discusses best practices for midwives caring for women planning a VBAC. Women may choose to have a VBAC at home because of a strong preference for home birth, for circumstantial reasons like VBAC bans. The midwife can have an influence on the option for a VBAC and the management pathways used during labor. In US, maternal mortality represents a growing concern. Uterine rupture is the significant adverse event associated with VBAC and drives much of the debate on the issue. Essential components of midwifery care for a woman who has chosen VBAC includes decision support, emotional support, and midwifery clinical care. Consumers have considerable impact on health care policy decisions. For instance, the International Cesarean Awareness Network (ICAN) has a volunteer workforce and a public website with extensive resources on VBAC.