Target Health Blog

Midwifery

July 22, 2019

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Quiz
Source:

The 112 countries (light brown) containing member associations of the International Confederation of Midwives (ICM) in 2017
Graphic credit: by Rodguerrer - Own work, CC BY-SA 4.0,
https://commons.wikimedia.org/w/index.php?curid=41142309

Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period (including care of the newborn), in addition to the sexual and reproductive health of 1) ___ throughout their lives. In many countries, midwifery is a medical profession (special for its independent and direct specialized education; should not be confused with the medical specialty, which depends on a previous general training). A professional in midwifery is known as a midwife.

Educational Requirements for Midwives

Certified Nurse Midwife (CNM)

A certified nurse midwife (CNM) has obtained advanced educational credentials in both midwifery and nursing. In addition, midwives have successfully completed the certification program required by the American Midwifery Certification Board (AMCB). Each state sets its specific requirements to which a midwife must adhere to become certified, including the training that qualifies as an acceptable post-secondary degree. A certified nurse midwife is a registered nurse (RN) who has completed coursework approved by the Accreditation Commission for Midwifery Education (ACME). Before working as a certified nurse midwife, RNs must pass a national board exam administered by the ACMB, which also requires licensed midwives to complete and pass a recertification exam once every five years.

Certified Midwife (CM)

The “certified midwife“ credential indicates that the individual graduated from college with a non-nursing degree. However, he or she must meet the requirements established by the AMCB in addition to state-of-residency requirements. The certified midwife also must complete a degree program accredited by the ACME and pass the nationwide AMCB board exam. Typically, a certified midwife holds a bachelor's degree in a health-related field, but he or she is not a registered nurse. Individuals with either the certified midwife or certified nurse midwife title have the same basic responsibilities, although some patients may prefer to work with a certified nurse midwife because of the RN credential.

Midwifery Licensure Requirements

A benefit of earning the certified nurse midwife credential is that these professionals not only can offer a wider range of services, but they are also capable of performing more complex treatments. Additionally, they may be more qualified from a legal standpoint. Since it's in the patient's best interest to work with a highly educated and certified nurse midwife, many states now require midwives to have a graduate degree in nursing to become eligible for licensure. In 2012, the ACME required every program it certifies to offer either a Master of Science in a general health care field, a Master of Science in Nursing, or a Doctor of Nursing Practice degree. A certified nurse midwife can practice in all 50 states as well as in the District of Columbia. The role of a nurse midwife is legally recognized in Delaware, Missouri, New Jersey, and New York. Missouri is one of the few states that does not require licensure for certified midwives. Since state laws and guidelines vary greatly, students must understand and fulfill their state requirements when obtaining licensure and establishing a practice.

A 2013 Cochrane review (English speaking countries) concluded that “most women should be offered midwifery-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.“ Midwifery is best used by 2) ___ women giving birth. The review found that midwifery-led care was associated with a reduction in the use of epidurals, with fewer episiotomies or instrumental births, and a decreased risk of losing the baby before 24 weeks' gestation. However, midwifery-led care was also associated with a longer mean length of labor as measured in hours.

First trimester

Trimester means “three months.“ A normal pregnancy lasts about nine months and has 3) ___ trimesters. First trimester screening varies by country. Women are typically offered a Pap smear and urine analysis (UA), and blood tests including a complete blood count (CBC), blood typing (including Rh screen), syphilis, hepatitis, HIV, and rubella testing. Additionally, women may have chlamydia testing via a urine sample, and women considered at high risk are screened for Sickle Cell disease and Thalassemia. Women must consent to all tests before they are carried out. The woman's blood pressure, height and weight are measured. Her past pregnancies and family, social, and medical history are discussed. Women may have an ultrasound scan during the first trimester which may be used to help find the estimated due date. Some women may have genetic testing, such as screening for Down 4) ___. Diet, exercise, and discomforts such as morning sickness are discussed.

Second trimester

The mother visits the midwife monthly or more often during the second trimester. The mother's partner and/or the labor coach may accompany her. The midwife will discuss pregnancy issues such as fatigue, heartburn, varicose veins, and other common problems such as back pain. Blood pressure and weight are monitored and the midwife measures the mother's abdomen to see if the baby is growing as expected. Lab tests such as a UA, CBC, and glucose tolerance test are done if the midwife feels they are necessary.

Third trimester

In the third trimester the midwife will see the mother every two weeks until week 36 and every week after that. Weight, blood pressure, and abdominal measurements will continue to be done. Lab tests such as a CDC and UA may be done with additional testing done for at-risk pregnancies. The midwife palpates the woman's abdomen to establish the presentation and position of the 5) ___ and later, the engagement. A pelvic exam may be done to see if the mother's cervix is dilating. The midwife and the mother discuss birthing options and write a birth care plan. Midwives are qualified to assist with a normal vaginal delivery while more complicated deliveries are handled by a health care provider who has had further training. Childbirth is divided into four stages.

First stage of labor: The first stage of labor involves the opening of the cervix. In the early parts of this stage the cervix will become soft and thin thus preparing for the delivery of the baby. The first stage of labor is complete when the 6) ___ has dilated the full 10cm. During the first stage of labor the mother begins to feel strong and regular contractions that come every 5 to 20 minutes and last 30 to 60 seconds. Contractions gradually become stronger, more frequent, and longer lasting.

Second stage of labor: During the second stage the baby begins to move down the birth canal. As the baby moves to the opening of the vagina it “crowns“, meaning the top of the head can be seen at the vaginal entrance. At one time an “episiotomy“, (an incision in the tissue at the opening of the vagina) was done routinely because it was believed that it prevented excessive tearing and healed more readily than a natural tear.  However, more recent research shows that a surgical incision may be more extensive than a natural tear, and is more likely to contribute to later incontinence and pain during sex than a natural tear would have. The midwife assists the baby as needed and when fully emerged, cuts the umbilical cord. If desired, the baby's father may cut the cord. In the past the cord was cut shortly after birth, but there is growing evidence that delayed 7) ___-cutting may benefit the infant.

Third stage of labor: The third stage of labor is where the mother must deliver the placenta. In order for the mother to do this, she may need to push. Just like the contractions in the first stage of labor, there may be one or two of these. The midwife may assist the mother in delivering the placenta by gently pulling on the umbilical cord.

Fourth stage of labor: The fourth stage of labor is the period beginning immediately after the birth and extending for about six weeks. The World Health Organization describes this period as the most critical and yet the most neglected phase in the lives of mothers and babies. Until recently babies were routinely removed from their mothers following birth, however beginning around 2000, some authorities began to suggest that early skin-to-skin contact (placing the naked baby on the mother's chest) is of benefit to both mother and infant. As of 2014, early skin-to-skin contact is endorsed by all major organizations that are responsible for the well-being of 8) ___. Thus, to help establish bonding and successful breastfeeding, the midwife carries out immediate mother and infant assessments as the infant lies on the mother's chest. Then she removes the infant for further observations only after the first breastfeed.

Following the birth: if the mother had an episiotomy or a tearing of the perineum, it is stitched. The midwife does regular assessments for uterine contraction, fundal height, and vaginal bleeding. Throughout labor and delivery the mother's vital signs (temperature, blood pressure, and pulse) are closely monitored and her fluid intake and output are measured. The midwife also monitors the baby's pulse rate, palpates the mother's abdomen to monitor the baby's position, and does vaginal checks as needed. If the birth deviates from the norm at any stage, the midwife requests assist from a more highly trained health care provider.

Birthing positions

Until the last century most women have used both the upright position and alternative positions to give birth. The lithotomy position was not used until the advent of forceps in the seventeenth century and since then childbirth has progressively moved from a woman supported experience in the home to a medical intervention within the hospital. There are significant advantages to assuming an upright position in labor and birth, such as stronger and more efficient uterine contractions aiding cervical dilatation, increased pelvic inlet and outlet diameters and improved uterine contractility. Upright positions in the second stage include sitting, squatting, kneeling, and being on hands and knees.

Postpartum period

For women who have a hospital birth, the minimum hospital stay is six hours. Women who leave before this do so against medical advice. Women may choose when to leave the hospital. Full postnatal assessments are conducted daily in the hospital or more frequently if needed. A postnatal assessment may include: the midwife's observations, general well-being, breasts (either a discussion and assistance with breastfeeding or a discussion about lactation suppression), abdominal palpation (if she has not had a caesarean section) to check for involution of the uterus, or a check of her caesarean wound (the dressing doesn't need to be removed for this), a check of her perineum, particularly if she tore or had stitches, reviewing her lochia, ensuring she has passed urine and had her bowels open and checking for signs and symptoms of a DVT. The baby is also checked for jaundice, signs of adequate feeding, or other concerns. The baby has a nursery exam between six and seventy two hours of birth to check for conditions such as heart defects, hip problems, or eye problems. In the community, the community midwife sees the woman at least until day ten. This does not mean she sees the woman and baby daily, but she cannot discharge them from her care until day ten at the earliest. Postnatal checks include neonatal screening test (NST, or heel prick test) around day five. The baby is weighed and the midwife plans visits according to the health and needs of mother and baby. They are discharged to the care of the health visitor.

At birth, the baby receives an Apgar score at, at the least, one minute and five minutes of age. This is a score out of 10 that assesses the baby on five different areas - each worth between 0 and 2 points. These areas are: color, respiratory effort, tone, heart rate, and response to stimuli. The midwife checks the baby for any obvious problems, weighs the baby, and measure head circumference. The midwife ensures the cord has been clamped securely and the baby has the appropriate name tags on (if in hospital). Babies lengths are not routinely measured. The midwife performs these checks as close to the mother as possible and returns the baby to the mother quickly. 9) ___-to-skin is encouraged, as this regulates the baby's heart rate, breathing, oxygen saturation, and temperature?and promotes bonding and breastfeeding. In some countries, such as Chile, the midwife is the professional who can direct neonatal intensive care units. This is an advantage for these professionals, because they can use the knowledge in perinatology to bring a high quality care of the newborn, with medical or surgical conditions. Midwifery-led continuity of care is where one or more midwives have the primary responsibility for the continuity of care for childbearing women, with a multidisciplinary network of consultation and referral with other health care providers. This is different from “medical-led care“ where an obstetrician or family physician is primarily responsible. In “shared-care“ models, responsibility may be shared between a midwife, an obstetrician and/or a family physician. The midwife is part of very intimate situations with the mother. For this reason, many women as well as physicians, say that the most important thing to look for in a midwife is a level of comfort and trust, since the woman and even her husband, will go to them with personal questions and/or problems.

Licensed midwifery-led care has effects including the following:

  • a reduction in the use of epidurals, with fewer episiotomies or instrumental births.
  • a longer mean length of labor as measured in hours
  • increased chances of being cared for in labor by a midwife known by the childbearing woman
  • increased chances of having a spontaneous vaginal birth
  • decreased risk of preterm birth
  • decreased risk of losing the baby before 24 weeks' gestation, although there appears to be no differences in the risk of losing the baby after 24 weeks or overall
  • no difference in the number of Caesarean sections.

At Mount Sinai Hospital in New York City's upper east side, (Manhattan), certified nurse-midwives and certified midwives provide expectant mothers with sensitive care before, during, and after the birthing process. They are typically by your side from the moment you enter the 10) ___ and provide prenatal care, manage labor and delivery, and offer a wide range of well-woman gynecologic services, including routine physical exams and all methods of family planning. Midwives work with consulting physicians to offer integrated care that meets all of the patient's medical needs. After birth, midwives offer physical assessment and advice and provide support on breastfeeding, baby care, contraception, and other issues. In addition, midwives will continue to see new mothers throughout a six-week postpartum period. Mount Sinai Health System has a number of midwives on faculty at Mount Sinai West and has connections to several excellent, well-established groups of independent midwives. Most of these highly trained, certified midwives work in collaboration with a physician. Source: Wikipedia

ANSWERS: 1) women; 2) healthy; 3) three; 4) syndrome; 5) fetus; 6) cervix; 7) cord; 8) infants; 9) Skin; 10) hospital

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