This chapter presents the available evidence related to postpartum mood and anxiety disorders. It addresses the three postpartum mood disorders-postpartum psychosis, bipolar II disorder, and postpartum depression. Postpartum psychosis is a psychiatric emergency that requires immediate intervention and hospitalization. This dangerous mood disorder presents rapidly after birth. Symptoms can include rapid mood fluctuations, delusions, hallucinations, marked confusion, extreme agitation and disorganized speech. Postpartum depression not only negatively affects mothers’ quality of life but it extends to negative consequences for their children. Midwives have clearly identifiable predictors that allow clinicians to screen and monitor these high-risk women for early intervention and help to prevent the development of postpartum depression. There are three postpartum anxiety disorders that women can experience. These disorders include postpartum onset panic disorder, postpartum obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) following traumatic childbirth. Middle range theory of traumatic childbirth is valuable source for evidence-based practice.

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.

This chapter addresses components essential to the establishment and sustainability of collaborative physician and advanced practice registered nurse (APRN) partnerships in health care. The need for a strong and affordable health care infrastructure has been the primary impetus for health care reform. Workforce issues in women’s health are a significant concern. Policy makers and health care leaders are looking for innovative strategies that can help develop policy, programs, and practice models to increase the efficiency of potential shortages in the health care workforce. Collaborative practice strengthens and improves health outcomes. The foundations of collaborative practice are built on a process of education, skill-building, and continuous evaluation. Leadership for interprofessional practices involves emphasis on disease-preventive services, health-promotion counseling, and coordination of team activities. Effective use of information technology (IT) in health care practices (health IT) can help providers improve their ability to deliver high-quality care.

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.