Legalization without regulation - midwifery in Missouri

Recently we became aware of the tragic death of a baby at planned home birth in Missouri. A Missouri CPM took on the care of a woman expecting twins, and one of the twins died due to a cord prolapse during the birth. You can read this story here:
http://dreahlouis.blogspot.com/2013/10/the-midwife-from-hell.html

Midwives practiced underground for many years in Missouri, the practice of midwifery was explicitly illegal, and any midwife openly practicing was arrested and investigated for breaking the law. Read this story about how not only midwives, but clients used to conceal the identities of their midwives when planning home births.

In 2007, Missouri legalized the practice of midwifery. But as of today, midwives practicing home birth in Missouri do not have licenses - the state has virtually no oversight or regulations over the practice of midwives.

The law stipulates that if one holds the NARM credential, one may legally practice midwifery.

This is very, very little oversight or regulation of a 'profession' that holds the lives of women and their children in their hands.

Presumably, the legalization of midwifery in Missouri allows midwives to attend any and all births that they deem appropriate for OOH care. Like a twin birth.

And when a birth ends tragically with the death of a baby in a state with no licensing, what is the recourse for the midwife? 

Is her license reprimanded? No, she has no license.
Does a professional board evaluate the midwife's practice? No, there is no professional board.
Do her malpractice insurance premiums increase? No, she is not required to carry malpractice insurance.
Does she lose her credential from NARM? Possibly, though NARM appears to be more interested in promoting midwifery than disciplining dangerous midwives.
Or does she keep on practicing like nothing ever happened, because the state allows this, because there is no oversight?

We've heard the nonsensical argument from some Michigan midwifery advocates that legalization of midwifery should be pushed for, not licensing.  We believe Michigan women and their families deserve better than a state-sanctioned free-for-all in the realm of midwifery where any form of risk-factor (breech, twins, VBAC, post-dates) can be "supported" in the out-of-hospital setting, and legally attended by midwives who can wash their hands of the responsibility when there is a bad outcome.

Certified Professional Midwife Credential

Some may read our blog and draw the conclusion that we do not "like" or support Certified Professional Midwives."  Please know that is not the intention.  We do not aim to be inflammatory or derogatory toward CPMs.

For Safer Midwifery for Michigan, the bottom line is a clear, an appropriate standard for education and training is absolutely critical.  Research from around the world points to a high level of education as one of the key factors in positive birth outcomes outside the hospital.  You can visit recent posts about the Education of Midwives Around the World, Part I, and Part II to further understand this research, and how it highlights glaring disparities between educational standards for midwives in other countries as compared to the US.  Notice in these links that other first world countries have much higher standards, most requiring a university level education for the women delivering their babies.  What about the USA?   The minimum standard for a CPM's education is only recently (2012), a high school diploma.

The problem with the CPM credential lies in credibility and severe inconsistencies among providers who carry the credential.  While there may be some CPMs who are highly educated, there are far, far too many who are not, and they are all thrown in the pot together.  Scope of practice is undefined at best, purposefully leaving it up to the midwife herself to determine along the way.  For example, check out NARM's "Shared Decision Making Statement".  The end result is a variable pool of midwives, some who are highly educated, and those that are not with a smattering of skills in between.  Some are even rushing through the training with a careless preceptor so they can be "grandfathered in" when licensing legislation does pass.  For a little history lesson about the CPM credential, and the importance of educational standards, visit our recent guest post by Judith Rooks, CNM.

The American College of Nurse Midwives said it well in a letter sent to members of Congress in 2009: 

     "Until the CPM community has developed a uniform process to ensure that all 
      CPMs have graduated from an accredited program, Congress should not recognize 
      this class of provider in its entirety."

 
We sincerely understand the desire and need for a credential that offers reliable care for the out-of hospital client, but in what world is an apprenticeship process acceptable for delivering babies?  Especially when there are other routes to professional midwifery credentials that require a graduate level of education, like the CM credential, or the CNM.  Or what about states that provide provisions and appropriate licensing for all three credentials like the state of New York? 

Education Requirements for Licensure in NYS:

All midwives, regardless of credential or educational background must meet certain criteria to be eligible for licensure in NYS:

-- Bachelor's degree (doesn't matter what subject) -- which you already have.
-- Midwifery education at a NYS approved midwifery school*
-- Can demonstrate competency in particular areas relating to well-woman care and pharmacology (see http://www.op.nysed.gov/midwif.htm check under education)

All midwives must take and pass the AMCB certification exam which is designed for CNMs or CMs, but which all midwives in NYS must take (the NARM exam is not accepted here).

** Several MEAC schools have been deemed acceptable by NYS. CPMs using the PEP process can become licensed, but they must then go to a midwifery school and have a bachelor’s degree. Several CPMs have become licensed in NYS by attending the distance learning program at the National College of Midwifery and obtaining a BS in midwifery.

(These guidelines and standards for education are in line with ACOG and AAP's recent statements on planned home birth.)

Some are uncomfortable with any kind of comparison among credentials, CPM, CM, and CNM.  I would ask them, how is a healthy conversation about the safety of midwifery, and educational standards possible without discussing the difference among them?  Somehow that is misconstrued as breaking the sisterhood, or damaging the image of midwifery.  I have to say, nothing is more damaging to midwifery than continued unsafe practices, preventable deaths, and injuries that are ignored, and the multitude of issues that continue to go unaddressed ~ even outright ignored.  

Our advocacy group believes that women and families deserve transparency.  They deserve to know, discuss, and understand the differences between these credentials, and how it impacts their care.  Lines between these credentials have been purposefully blurred to the public, allowing dangerous midwives to practice under the same hat as those who practice responsibly.  Need an example?  MANA's "What is a Midwife?" leaves out all the important details about educational standards and the differences in scope of practice among various types of midwives.  They make it seem as if their training is on par with the rest of the world, even citing an International definition of "midwife"...all while the minimum standards for CPMs don't even meet International educational standards. It's misleading, confusing, and leaves women feeling scammed when the unthinkable happens.  

It's time for frank discussions about what our standards should be for education and practice of all midwives in this country and state, and the public deserves to have a say.  It's not about leaving anyone out, insulting any one body of midwives, or being divisive.  It's about establishing a minimum bar for education and standards for practice that are appropriate, with safety and outcomes at the forefront.  It's about supporting midwives in reaching that bar if they aim to provide excellent care for mothers and babies in any environment, home or hospital.  It's about taking the time to get a sound education and offer women choices they can rely upon.  We've said all along, the state of midwifery cannot improve if it cannot accept and address its shortcomings.  

Instead of getting offended, lets get the difficult conversations started, and move toward real progress. 

"Certified Midwives" Examining the CM Credential

What is a Certified Midwife?

A Certified Midwife (CM) is a health care professional who holds a credential in midwifery from the American Midwifery Certification Board. Certified nurse-midwives (CNMs) are the most prevalent type of midwife in the US and are certified by this same board.

The standards for education for CMs and CNMs are identical. Both must be educated in a graduate degree program, are trained in the same competencies, and must pass the same certification examination.

By credential, certified midwives are qualified to independently manage low-risk pregnancies and deliveries, provide routine well-woman care and screenings, diagnose and treat health conditions, and prescribe medications. 

How is a certified midwife CM different than the CPM or CNM?

Educationally, the only difference between CMs and CNMs is that CMs do not have degrees in nursing. It is an equivalent credential to the CNM.

The differences between CPMs and CMs are that CMs must be trained at a graduate level, CMs are integrated healthcare providers working alongside physicians, nurses and other healthcare providers, CMs are qualified to attend births in any setting, CMs are trained in pharmacology and prescribing medications.

The differences are so important, we felt a graph would be helpful:

	CM	CPM
Graduate degree required	YES
Training in medical pharmacology required	YES
Skilled in providing care in all birth settings	YES
Providers of gynecology and well-woman care	YES
Qualified to prescribe birth control and other medications	YES
Trained with in the health care system among physicians, nurses, and other healthcare professionals	YES
Self-purported “experts” in out-of-hospital birth		YES

 
How are CMs and CPMs similar?

• Neither CPMs or CMs are required to have a degree in nursing.
• CMs and CPMs are not licensed in every state. The state of Michigan does not currently recognize either the CPM or the CM through licensing. 

But the differences between CPMs and CMs are vast and striking. Why are so many states 'pushing' for licensure of such poorly-trained midwives as CPMs, when there already is a high-quality, non-nurse credential? Why, when every state already recognizes and licenses CNMs, is it so difficult to enact licensing for the CM - an equivalent credential? Why, when it comes to midwifery licensing, should we reinvent the wheel - and an inferior wheel, at that -and license midwives with minimal training, minimal oversight, and minimal (or non-existent) standards of practice?

What we'd like to see in Michigan:

We would like to see Michigan take the lead on this very important issue, and license only the most qualified and highly-skilled midwives for women and their families, CNMs and CMs. We would like to see Michigan's nurse-midwifery programs, the University of Michigan and Wayne State, create pathways for training midwives who would become CMs in our state, and we would like to see not only the Michigan Affiliate of the ACNM but also the Michigan Midwives Association openly support improving the educational standards of midwives in our state by endorsing and promoting the CM credential.

Considering Home Birth?

Our country affords many freedoms, among them the right to birth where and with whom we choose.  In a state like Michigan where there are currently no regulations or laws surrounding midwifery, that freedom is widely interpreted.  But what about the rights of consumers to be "fully informed", and what exactly does that mean?  It seems that many home birth advocates tell mothers to "educate themselves", and defend their cause when things go awry with reprimands about the mother's responsibility to make an educated choice.  

In a state with no defined scope of practice or licensing measures for out-of-hospital midwives, it's extremely difficult for consumers to access information that would allow them to fully educate or inform themselves before making the choice to have a home birth or birth center birth.  Being fully informed means families are told about the good, the bad, and the ugly as they pertain to home birth.  It means a woman is told by her care provider directly & honestly the benefits of home birth, and the inherent risks that come along with it. 

All too often I meet mothers, usually those whose birth stories don't have happy endings, who were only told about the benefits of home birth.  They feel duped, embarrassed, like they somehow were fooled by an illusion of promises that turned out to be anything but empowering.   These mothers have not been informed, they have been misled. 

There will also forever and always be those mothers who choose home birth despite the risks that come with it, and fully knowing what they are risking.  And there are mothers who do not fully understand the choices, and more importantly the consequences that can be associated with making the home birth choice.  I fully accept a woman's right to choose home birth, but the one caveat is that she deserves to know a few key facts.  Then, if knowing these facts, she still makes the choice for home birth, then the choice and responsibility can truly be her own.  The problem comes when mothers choose home birth with their heads full of misguided information and misleading propaganda...blinded by the woo as some might say.  

And so with these mothers in mind, those who weren't fully informed about the important factors to consider before choosing home birth, here is a list of things to consider...

Facts You Should Know When Considering Home Birth

1. "Planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth." ~ ACOG Statement on Planned Homebirth
   
2. Requirements for licensing vary widely by state.  This includes minimum standards for education, scope of practice, collaborative agreements, and insurance requirements.  Some states have NO regulations, others some, and still others more thorough guidelines.  Know your state laws well, and consider heavily the impact they have on safety in practice.  (MI is a state that has no regulation what so ever.) 
3. Credentials and educational training vary greatly too.  Look for a midwife who is certified by the American Midwifery Certification Board.  The only type of midwives who are AMCB certified are Certified Nurse Midwives and Certified Midwives.  CPMs, DEMs, or lay midwives do not typically meet the educational standards for this important certification. There are exceptions for CPMs in states like NY where state law has required CPMs to further their education and pass the AMCB exam to earn a license to practice.  In other states CPMs are licensed without the added educational requirements.  Certification by AMCB demonstrates a high degree of competency, and is a more reliable hallmark of educational training than licensing alone. 
4. Outcomes for home birth are greatly impacted by several factors.  Among the most critical are a high degree of education and training (In the US that means an AMCB certified midwife), working within a fully integrated health system, and practices regarding consultation, referral, and transfer of care.
5. Not all women are good candidates for home birth.  Risk factors matter a great deal when considering where to have your baby, and they matter even more if you're considering an out-of-hospital birth. Research has shown time and time again that home birth is intended for LOW RISK pregnancies...yet somehow story after story of baby deaths and injuries are surfacing, revealing they were high risk to begin with according to modern medical standards. 
6. Assessments matter in order to ensure your pregnancy is and stays low-risk.  If your midwife disregards important assessments, she is "trusting birth" more than she is assessing and monitoring your risk factors.  A good midwife will value assessments so she can be informed, and she can keep you informed about whether or not your pregnancy becomes high risk at any point.  She should have very clear guidelines for what defines high risk, and what situations "risk out".
7. Not all "birth centers" are safe.  Looking for a birth center?  Look for one that is affiliated with a hospital with licensed, insured midwives providing the care.  At the very least, choose a birth center that is accredited by AABC. 
   
8. Most midwives practicing outside of a hospital DO NOT carry malpractice insurance.  Midwives like to claim that they can't afford it.  Insurance protects both the consumer and the midwife.  The former by providing specific safety guidelines for practice, and protecting those who are victims of negligence.  The latter from lawsuits that could be life altering. 
9. Just because a midwife is covered by Medicaid, does not mean she is a safe care provider. 
10. Just because a midwife tells you home birth is safe, and that she has never been responsible for a baby or mother's death, doesn't mean it is true.  When there is no oversight and no public track record, there is no way to actually know the truth.  You have to decide whether or not to take your chances. 

What Factors Contribute to the Best Outcomes for Out-of-Hospital Birth?

1. An educated, licensed midwife 
2. A low-risk pregnancy and health status of mother and baby 
3. A professional, collaborative relationship between the midwife and local physicians and medical providers 
4. Routine prenatal care and testing in accordance with professional medical guidelines 
5. Informed consent leading to a clear knowledge that certain conditions are more dangerous in out-of-hospital settings - and not indoctrination into 'trusting birth' at all costs. A provider should be honest and open about what cannot be handled in an out-of-hospital setting. If the client is led to believe that all complications are handled better at home with a midwife, or if those 'scary' complications only happen in hospitals, then they are being misled.
   

Other Important Thoughts

1. Cesareans are not the worst outcome.  A baby who is injured or does not survive birth is the absolute worst outcome, especially when that death or injury was fully preventable. 
2. Collaborative Care Models are on the rise.  Want a natural childbirth?  You have options, many of them.  Look for a collaborative care model where midwives work as part of the fully integrated health care system.   This means the midwife delivers in a hospital or in a hospital-affiliated birth center.  (Not to be confused with a freestanding birth center.)  Many collaborative care midwife groups have their own practices.  You'll have the most highly educated midwives in the country, with emergency care seconds away should you need it.  You'll have licensed, insured care providers working within a defined scope of practice.   

Any mother planning a home birth who goes around touting that it is safe or as safe as a hospital birth does not have, or fails to acknowledge the facts.  A mother who claims her unlicensed midwife is safe, cannot really know without the data on her outcomes to back it up.  A  mother who tells you she is educating herself and choosing not to do any of the prenatal assessments because they are unnecessary or harmful has fallen hard for the fallacy of trusting birth.  Whatever your choices may be surrounding birth, take time to understand the benefits, the risks, and their subsequent consequences before making the decision to have your baby at home. 

Freedom to Choose

Since this week marks our Nation's birthday and celebration of the many freedoms we enjoy, I thought it was the perfect time to approach the topic of freedom to choose when and with whom we give birth.  Is it a basic human right?  Is it about the safety of the baby?  No matter where your opinion falls on this highly debated topic, one thing is certain, that no matter what choices we make they should undoubtedly be genuinely informed of all risks and benefits. 

I find this subject tends to be addressed like a one way street.  The moment the word "regulation" comes up in discussion surrounding midwifery, home birth advocates start screaming, "don't take away my choice to birth where and how I please."  The tone of those same voices shifts though with the slightest mention of elective cesarean.  Judgment fills the room, sucking all the oxygen out.  The discussion then becomes less about choices and more about quoting the cesarean rate as being too high.  

But is there a time when an elective cesarean has its place?  Is it not the right of the woman and her care provider to make those choices?  Take the woman who was sexually abused for example, or the mom whose natural birth left her so injured that it took years to heal.  Do these women not have a say in how they give birth during subsequent pregnancies?  Where do we draw the line and how shall we write the rules?

What about the former loss mom who already endured NCB and intervention-free birth in all its tragedy?  That was my story.  An elective cesarean saved my emotional sanity.  It also re-established my trust in care providers taking good care of me.  After the worst imaginable tragedy resulting from natural, out-of-hospital childbirth and incompetent care, an elective cesarean gave me peace of mind and a way forward.  It was my choice to make with my doctor and for that I am immensely grateful. 

If a woman truly has the freedom to choose where and how she gives birth, then every home birth advocate should also support a woman's right to elect a cesarean.  They should support and appreciate the life saving measures a cesarean can offer period, whether elected or emergency. 

"Take Responsibility for Your Pregnancy and Birth!"

We welcome a guest post today from an anonymous midwife, who takes research and serving mothers safely very seriously. 


“Pregnant women need to educate themselves and take responsibility for their births.”
 
Women receive this advice, and admonition, from many quarters, but it does not usually mean what you would think it does.  It does not usually mean to educate themselves about their risks in pregnancy and childbirth, or how to know when intervention may be necessary.  What it usually means is to trust your midwife, and not to trust the doctors, nurses, hospitals, or medical advice.  

If your pregnancy and birth are completely normal and you don’t have any risk factors, that advice may work fine. But, what if your midwife tells you how to handle a condition or situation that seems contrary to your instincts and intuition, contrary to evidence based practices, or without safety at the forefront?  If women are told to take responsibility for their births then they should know when it is time to trust themselves that they may know more about about their pregnancy, labor, birth, and newborn than their midwife or doctor does.
 
Midwives attending women planning a home or birth center birth frequently quote the World Health Organization (WHO) which recommends that the cesarean section rate should not be higher than 10% to 15%. However, WHO also has many excellent midwifery educational publications that midwives may not be using, including

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice (http://www.who.int/maternal_child_adolescent/documents/924159084x/en/)
 
The overview for this publication describes the contents:
    
     “This guide provides evidence-based recommendations to guide health-care   
      professionals in the management of women during pregnancy, childbirth and 
     postpartum period, post abortion, and newborns during their first weeks
     of life.  It is a guide for clinical decision-making.  It facilitates the collection,
     analysis, classification and use of relevant information by suggesting key
     questions, essential observations and/or examinations, and by recommending
     appropriate research-based interventions. It supports the early detection of
     complications and the initiation of early and appropriate treatment, including
     timely referral, if necessary.

In other words, where ever midwives are providing evidence based care, this is what they should be doing.  The Institute for Clinical Systems Improvement (ICSI) also publishes two interactive healthcare guidelines. The first is for  Routine Prenatal Care, and the second is Management of Labor.  

Routine Prenatal Care pertains to the care of all women who are pregnant or are considering pregnancy, and the labor management guide is for all women who present in labor, including preterm labor.  

Management of Labor provides algorithms (charts) for decision making during labor, birth, and the newborn period.

The Hesperian Foundation publishes a number of books and guides for developing or low literacy countries, including Where There is No Doctor.  An excellent guide for pregnant women, simply written is A Book for Midwives.  You could purchase the entire book as a download, but the Hesperian Foundation has made the chapters available here, for free. The medical advice used in the book has been recently updated to reflect WHO guidelines for safe, evidence based care during pregnancy. This is the care your midwife should be providing using the best evidence available. 

If labor is progressing normally, watchful waiting and careful attentive monitoring are required. If your labor varies, or something feels wrong to you, your midwife should assist in assessing the situation and transfer you to the hospital.  A Cesarean is not automatic when you transfer to the hospital, but more careful monitoring may necessary to be sure you and
baby are safe and healthy.  Cesareans are also not the worst possible outcome should the need arise.  A safe and healthy mother and baby in end is what most mothers care most about.  At times we become so entranced with the "experience" of birth, we lose sight of what matters most. 


Links for each of these guidelines is included above, but they are summarized in the two tables below.

Safer Midwifery for Michigan has already discussed what should be included in Routine Prenatal Care at each visit.  The remainder of this post will describe the conditions that mean you should trust yourself that the pregnancy is no longer completely normal.  Unfortunately this list of signs and symptoms have been taken from the birth stories of loss moms.  Women whose babies died or were permanently injured because the midwives caring for these moms either didn’t know that these were signs of complications or did not believe the mothers.  If these things occur, please find answers.
 
Sometimes there are other explanations, but minimizing your symptoms and hoping they will go away is not the same as knowing these things are not problems.  Trying to manipulate the symptoms does not mean they didn’t occur. Using a different thermometer to get a lower temperature doesn’t mean you didn’t have a fever.  Resting on your left side for 10 minutes before having your blood pressure retaken, and getting a lower number the second time, doesn’t mean you don’t have high blood pressure.  It only means your midwife has found a way to get a lower number so she doesn’t need to make the diagnosis of hypertension or possible pre-eclampsia. Or, that she doesn’t need to transfer you to the hospital.
 
Although some midwives may say this chart is medical management and such precautions are not necessary with a normal pregnancy, if these things are happening with your pregnancy you need to know that they may be signs of complications or impending complications.  The midwife may tell you that she has seen this before, and everyone was fine, meaning it’s no reason to go to the hospital.  Dismissing or minimizing your concerns does not make the problem or the risks go away, and it may put you or your baby in danger if ignored.  A skilled, knowledgeable, and competent midwife will take your concerns seriously and will help you find answers. 

Remember how often your midwife told you that she was an “expert in normal birth”?  That she was also excellent at catching complications before things got serious, and would transfer you to the hospital if complications occurred?  The situations in these charts are some of the red flags they were talking about.  Is she living up to the expectations you had for the care you thought you would receive?

Care During Pregnancy

Sign or symptom	What it could mean	What may happen next
Bleeding, 15-42 weeks	Placenta previa or abruption.	May be a minor problem and could resolve on its own. However, you should have an ultrasound so you have better information for making decisions. The bleeding may occur on and off but may recur during labor. The bleeding you are seeing is almost never all the bleeding occurring, as the baby’s head may act as a cork at the cervix.
Severe pain in abdomen or uterus	• Any belly pain with fever can be a sign of womb infection. • Constant belly pain in late pregnancy may mean the placenta is coming off the womb wall. • Strong, constant belly or side pain in the first 3 months may mean that this is a tubal pregnancy.	The severe pain may be caused by an infection or problem not related to pregnancy. You may have a kidney stone, appendicitis, or a problem with your gall bladder. Any of these things may cause problems for you and for the baby including the baby coming much earlier than it should.
Severe nausea	You should be concerned if you can’t keep water, or any other fluid or food down.	If the mother is unable to keep fluids down and stops urinating, get medical help immediately. She may already have severe dehydration, which is very dangerous.
Large amount of uterine (baby) growth	May be twins. May be that your pregnancy is farther along than you think. Could be a very large baby or an excessive amount of amniotic fluid.	If you decided not to have the glucose test at 24-28 weeks, you may have a missed diagnosis of gestational diabetes or diabetes that was present before pregnancy. A very large baby may make it difficult for the baby to get in the best position for birth and lead to shoulder dystocia. An excessive amount of amniotic fluid makes it easier for baby to float in the uterus which increases the risk for a cord prolapse or a baby that is breech, sideways, or otherwise in a poor position for birth.
Less  uterine (baby) growth than expected	Pregnancy may not be as far along as you or your midwife think, but baby may also be smaller than expected because the placenta is not working correctly.	Babies who are not receiving enough nutrients because the placenta isn’t working well will usually have problems with low blood sugars when they are born, which can lead to trouble breathing and maintaining their temperature. Low blood sugars can lead to brain damage that becomes permanent.
Fever	Can have a number of causes from an infection you have to an infection the baby has.	You should try to find the reason for any fever. If your midwife can’t help, seeing your family doctor might. It may be a kidney infection, but could also be an infection of the amniotic fluid, or  of the uterus. These infections require antibiotics. Untreated infections may lead to  the baby’s death from sepsis (severe blood infection).
High blood pressure, headache, dizziness, or blurred vision , especially with generalized swelling	Usually associated with preeclampsia.	The Brewer diet does not prevent or treat preeclampsia. Urine dip sticks are not an accurate way of finding protein in the urine. Preeclampsia labs need to be done and a 24 hour urine performed. Anytime the headache doesn’t go away with your usual remedies, you should have it investigated further at the hospital. When a woman has high blood pressure during pregnancy, it is harder for her blood to bring food to the baby. The baby then grows too slowly. Very high blood pressure can also cause the mother to have kidney problems, bleeding in the womb before birth, or bleeding in the brain. High blood pressure can also be a sign of pre-eclampsia. Pre-eclampsia can cause premature birth, bleeding, convulsions, or even death for the mother.
Blood pressure elevated	Usually associated with hypertension, and pregnancy may make the high blood pressure more obvious. Can also be associated preeclampsia.	(See headache with swelling above) Women with pre hypertension or chronic hypertension are at greater risk for developing preeclampsia, but this may also indicate a need for lifestyle changes to prevent the development of chronic hypertension within a few months or years.
Labor doesn’t start by 42 weeks	Baby is in a bad position, the head is in a bad position and can’t apply the appropriate pressure to the cervix to assist the start of labor. It can also be related to chronic medical problems like under functioning thyroid (hypothyroid). If labor doesn’t start on its own, then the family should ask themselves how long they are willing to wait, and whether waiting  will make the birth more likely to occur.	As long as baby if moving the same number of times each day it is fine to wait for the baby past your due date. However, at approx. 41 weeks a biophysical profile (ultrasound) should be done to check the amount of amniotic fluid and how well baby is doing with waiting. If the amniotic fluid is very low, there is a greater risk that baby will inhale meconium when it occurs because there is less fluid to dilute the meconium. A low volume of amniotic fluid also increases the risk that the cord will be “pinched” during labor, or that baby may not have gotten enough nutrients to tolerate labor well.

Care During Labor and Birth

Sign or symptom	What it could mean	What may happen next
Bright red bleeding	May be an undiagnosed placenta previa or a placental abruption.	The amount you are seeing is not all there is, and baby has a lot less blood to lose than you do.
Very long labor   Or Close  or strong contractions with little progress (Usually a sign of obstruction either because of the shape of the pelvis or the position of the baby’s head)	Once you reach 4 cms  (6 cms if you have had 5 or more births) you should be making steady, continuous progress in labor. Active labor should not last longer than 24 hours for a first time mother, and no longer than 12 hours for a mother having another baby.	If you had a previous Cesarean for CPD, this may be an indication that the problem has recurred. A very long labor may mean the labor is obstructed. Signs of obstruction include:  Continuous contractions.  Constant pain between contractions.  Sudden and severe abdominal pain.  Horizontal ridge across lower abdomen.  Labour >24 hours. Can lead to exhaustion for the mom, or permanent, serious damage to the baby. Worst case scenario is a catastrophic uterine rupture which puts mom and baby at risk for dying.
Water is broken for a long time	A long time is 12 hours without signs of labor beginning	Consider going to the hospital, but at all times you should be watching for signs of infection. Go to the hospital immediately if you notice  Fever >38˚C  (100 degrees F)  Foul-smelling vaginal discharge
Fever	A sign of dehydration or infection. All infections in labor are dangerous for the mom and the baby.	The uterus doesn’t contract well if you are dehydrated. So you have an increased risk of prolonged labor and a large hemorrhage after baby is born. If you have an infection, baby probably has an infection too. These can be life threatening especially for the baby.
Pushing without progress for longer than 2 hours in first birth, longer than an hour in subsequent births.	The mother’s genitals should be bulging within 30 minutes of when her cervix is completely open and she begins pushing.	If the birth is taking too long, go to a medical center. This is one of the most important things a midwife can do for the mother and baby to prevent serious problems or even death in women or their babies. If you have tried different methods for bringing the baby down — better pushing, different positions, emptying the bladder, rehydration drink, acupressure, and any other methods you know — and you still see no progress after 1 hour of good pushing, you should go to a medical center. It is not safe to wait until more warning signs appear.
Severe abdominal or uterine pain	• Any belly pain with fever can be a sign of womb infection. • Constant belly pain in late pregnancy may mean the placenta is coming off the womb wall.	Severe pain in the abdomen or uterus during labor is usually a sign of the placenta becoming detached (abruption), the uterus tearing (uterine rupture) or an infection in the uterus. All are emergencies and you need to go to the hospital right away. Don’t wait to see if the pain goes away or becomes worse.
Dehydration		Dehydration can also make a woman feel exhausted. Signs of dehydration: • dry lips • sunken eyes • loss of stretchiness of the skin • mild fever (up to 38°C or 100.4°F) • fast, deep breathing (more than 20 breaths a minute) • fast, weak pulse (more than 100 beats a minute) • baby’s heartbeat is faster than 160 beats a minute
Baby has a slow heart beat when the midwife listens	The midwife should listen to the baby’s heart beat at least every hour in early labor, every 30 minutes in active (hard) labor, and with every contraction while you are pushing.	These things can cause the baby’s heartbeat to drop below 100 beats a minute: • Cord is very short or is being pinched. • The baby is not healthy. • There is not enough amniotic water. •  Placenta does not work well, usually because the mother has high blood pressure or the baby is late. •  • Placenta is separating from the womb. • Contractions are too strong. (This is rare for a normal labor. But too-strong contractions can easily happen to a woman who is given medicines or herbs to strengthen labor.) If the baby’s heartbeat is slower than 100 beats a minute and stays slow until the next contraction or almost to the next contraction, the baby is in danger. This is especially true if there are other warning signs, like green waters or a long labor. The baby could be very weak at birth or have brain damage. You must go to the hospital so baby can be watched more closely.
Baby has a fast heart beat-faster than 160 beat per minute.	The midwife should listen to the baby’s heart beat at least every hour in early labor, every 30 minutes in active (hard) labor, and with every contraction during pushing.	These things can make the baby’s heartbeat speed up to more than 180 beats a minute: • The mother is dehydrated • The mother or baby has an infection • The mother is bleeding. • The mother has been in labor for too long. • The mother’s womb is tearing (uterine rupture). If the baby’s heartbeat stays fast for 20 minutes (or 5 contractions), get medical help.

 
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