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Thursday
May022013

AAP's New Home Birth Guidelines

The American Academy of Pediatrics came out with some guidelines for a safe home birth after first stating the safest place to deliver was in the hospital and in a birth center.

The guidelines, in bold italics, state; (my comments in afterwards):

- There should be no preexisting medical conditions.

This would rule out thyroid, heart, renal disease and more. Most home birth midwives wouldn’t have a problem with someone with thyroid disease, but would risk out for more serious diseases and conditions.

- There should be no diseases during pregnancy.

This would include not having women with diabetes in their practice. CPMs generally accept and keep women with diabetes as long as they aren’t on insulin. For the rest of the diseases of pregnancy, Preeclampsia, Pregnancy Induced Hypertension, HELLP Syndrome, etc., most midwives would risk out. There might be some midwives who wouldn’t recognize the lower levels of these issues and a few might not appreciate the gravity of the diseases, but most would.

- No one with twins, triplets or higher should deliver at home.  

We know this is one that is ignored too much.

- The baby needs to be vertex (no breech).

This one is also ignored too often, many/most midwives believing that breech is a variation of normal. It is not. The number one reason a midwife ends up arrested is because of a breech death. (This is my informal observation over the years.)

- The pregnancy should be at least 37 weeks, but no more than 41 weeks.

The 37-week limit is a common demarcation point although some midwives would deliver a woman under 37 weeks with specific clients, believing it’s okay to step out of the rule for special circumstances. This is one of the issues I have with CPMs; they don’t have hard lines, but find so much ambiguous. It’s part of what women want in a midwife, being seen as an individual, not a number, but there does come a time when hard lines should be drawn in the name of safety.

- The AAP says that labor needs to be spontaneous or induced as an outpatient.

Induced?! What were they thinking?

- Pediatricians should advise parents who are planning a home birth that AAP and ACOG recommend only midwives who are certified by the American Midwifery Certification Board.

This means they recommend only Certified Nurse Midwives, not CPMs.

- There should be at least one person present at the delivery whose primary responsibility is the care of the newborn infant and who has the appropriate training, skills and equipment to perform a full resuscitation of the infant.

This would include intubation, something the majority of home birth midwives do not do. However, even if one learns intubation, we don’t get a chance to practice it and it is a skill that requires constant practice in order not to injure the baby. It is a nuanced skill that nurses practice a lot and/or use more frequently than a home birth midwife would ever have the chance to do, mainly because most of the babies we see are from (or are supposed to be from) low-risk women. So the likelihood of ever being able to do this regularly is remote… something we might just have to scratch off the list of being able to do… keeping us from being 100% accepted by the AAP.

- A newborn infant who requires any resuscitation should be monitored frequently during the immediate postnatal period, and infants who receive extensive resuscitation (e.g., positive pressure ventilation for more than 30–60 seconds) should be transferred to a medical facility for close monitoring and evaluation.

30 – 60 seconds is too ambiguous and ambiguity is the hallmark of CPMs. I wish they had said 30 seconds and left it at that.

- Home birth mothers and caregivers also should take any infant with respiratory distress, continued cyanosis, or other signs of illness to a medical facility.

I’ve seen, many times, a baby with central cyanosis receive blow-by oxygen for extended periods of time. “The baby just needs to nurse!” is what so many midwives believe. Annoying. That the baby does transition eventually reinforces their actions, but what of the babies that do have problems that need to be watched by an NICU staff? What happens to them? They are delayed and delayed going in.

- All medical equipment, and the telephone, should be tested before the delivery, and the weather should be monitored.

This is always done in my experience.

- A previous arrangement needs to be made with a medical facility to ensure a safe and timely transport in the event of an emergency.

Something that cannot be done for many midwives whether because of legalities or hostilities in the community.

- AAP guidelines include warming, a detailed physical exam, monitoring of temperature, heart and respiratory rates, eye prophylaxis, vitamin K administration, hepatitis B immunization, feeding assessment, hyperbilirubinemia screening and other newborn screening tests.

While many home birth families refuse Vitamin K and Erythromycin eye ointment, midwives who can, do carry it for those that want it. When a midwife can’t do something, like the Hep B vaccine, she would send the baby to the pediatrician to have it done. Same with the bili checks; blood work is done via the pediatrician, so it isn’t ignored, just that we don’t typically do that lab test. There are home bili tests, but they aren’t as accurate as blood tests. In my experience, even with the home tests, if there is a question, the midwife would send the baby in to be checked by the pediatrician.

- The baby needs to be monitored every 30 minutes for the first two hours and consider transitional care to be 4-8 hours postpartum.

Midwives at home monitor more frequently in my experience. Not a complete newborn exam every 30 minutes but absolutely doing vitals. Most midwives stay at least 3-4 hours postpartum. Now maybe we should stay a minimum of 4 hours?

- If warranted, infants may also require monitoring for group B streptococcal disease and glucose screening.

This would be something I would hope all midwives do, but I know too many don’t even test for GBS in the pregnancy, much less treat with antibiotics in labor. This must change. I worry how may babies have to die of GBS before home birth midwives get the connection between testing and a live baby. Then there’s the LGA babies that need to be tested for glucose levels, but midwives often merely go by symptoms and even then don’t test. I would like to see glucose monitoring of newborns become more common.

- Comprehensive documentation and follow-up with the child’s primary health care provider is essential. They want to have the baby see  a pediatrician within 24 hours after the birth and again 48 hours after that first visit.

A variation of this is done by most midwives. Some will say the baby needs to be seen within the first three days and others within the first two weeks. I err on the side of caution and liked my clients to see the Pediatrician within the first three days. AAP takes a much more conservative take and wants the babies seen much sooner and more often,

As I’ve read through the articles about the new guidelines, there have been some comments from CPMs saying they are glad for the guidelines because all CPMs do them already. As you read above, that isn’t true at all. There are specific items on the list, namely risking out for diabetes, intubation and vaccinations, that most (if not the great majority of) CPMs do not do. These need to be known and if we want to win the hearts of the AAP (and the public), we might consider adding stringent limits with diseases and intubation into our repertoire. And many midwives are wont to limit their clients to normal, vertex, singleton mothers and babies, instead being led by clients and their needs, not adhering to what is proven safe for those wanting a home birth. It’s frustrating when midwives take these high/er risk women and things go wrong. It makes all midwives look careless and ignorant of risk. If we were able to adhere to strict standards, perhaps CPMs might finally be included in the professionals’ recommendations. I don’t see that happening any time soon.

When we get standards from others such as this and we’re able to compare the requests with the realities, it is perfect for giving the CPM areas where she needs to increase her education and skills training. I’m often asked what exactly do I think midwives need to learn and this post is perfect for that. Tops is learning to adhere to the Standards of Care of not step out of the boundaries just because the midwife feels sorry for the mother. There is nothing mentioned in this piece about malpractice insurance and that should be a requirement, too. I can see, with increased education and skills training and standardized education (not the haphazard methods there are now to become a CPM) and malpractice insurance, CPMs finding a more accepted place in states. But there are still too many challenges that don’t fit the exacting standards of ACOG or AAP. I hope we midwives strive for what their looking for, not minimize their requests. It is in our self-care that we will be able to garner more and more respect. With respect, we get laws on our sides, Medicaid payments, all states with CPM laws and a great reputation. It’s time we had a great reputation.

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