ACDM

California College of Midwives

Mar 1999 Principles of Mother-Friendly Childbearing Services

Indications for Discussion,
Consultation and Transfer of Care

Relative to Home-based services

As a primary caregiver, the midwife is fully responsible for decision-making, together with the client. The midwife is responsible for writing orders and carrying them out or delegating them in accordance with the standards of the College of Midwives.

The midwife discusses care of a client, consults, and/or transfers primary care responsibility according to the Indications For Discussion, Consultation And Transfer Of Care. The responsibility to consult with a family physician/general practitioner, obstetrician and/or specialist physician lies with the midwife. It is also the midwife's responsibility to initiate a consultation within an appropriate time period after detecting an indication for consultation. The severity of the condition and the availability of a physician will influence these decisions.

The College of Midwives expects members to use their professional judgement in making decisions to consult or transfer care. The following list is not exhaustive. Other circumstances may arise where the midwife believes consultation or transfer of care is necessary.

The informed choice agreement between the midwife and client should outline the extent of midwifery care, so that the client is aware of the scope and limitations of midwifery care. The midwife should review the Indications For Discussion, Consultation And Transfer Of Care  with the client.

DEFINITIONS

Discussion with Another Midwife or a Physician

It is the midwife's responsibility to initiate a discussion with, or provide information to, another midwife or a physician in order to plan care appropriately. It is also expected that the midwife will conduct regularly scheduled reviews of client charts to assist in planning care. Discussion should be documented by the midwife in her records.

Consultation with a Physician

It is the midwife's responsibility to initiate a consultation and to communicate clearly to the consultant that she is seeking a consultation. A consultation refers to the situation where a midwife, using her professional knowledge of the client and in accordance with the standards of the College of Midwives, requests the opinion of a physician competent to give advice in the relevant field. A midwife may also seek a consultation when another opinion is requested by the client. Consultation must be documented by the midwife in her records in accordance with the standards of the College of Midwives.

The midwife should expect that the consultant will address the problem that led to the referral, conduct an in-person assessment(s) of the client, and promptly communicate findings and recommendations to the client and to the referring midwife. Discussion may then occur between the midwife and the consultant regarding the future care of the client.

Where urgency, distance or climatic conditions do not allow an in-person consultation with a physician, the midwife should seek advice from the physician by phone or other similar means. The midwife should document this request for advice in her records, in accordance with the standards of the College of Midwives, and discuss the advice received with the client.

A consultation can involve the physician providing advice and information, and/or providing therapy to the woman/newborn, or prescribing therapy to the midwife for the woman/newborn.

After consultation with a physician, primary care of the client and responsibility for decision-making, with the informed consent of the client, either:

[a) continues with the midwife, or [b) is transferred to physician.

Once a consultation has taken place and the consultant's findings, opinions and recommendations have been communicated to the client and the midwife, the midwife must discuss the consultant's recommendations with the client and ensure that the client understands which health professional will have responsibility for primary care.

The consultant may be involved in, and responsible for, a discrete area of the client's care, with the midwife maintaining overall responsibility within her scope of practice. Areas of involvement in client care must be clearly agreed upon and documented by the midwife and the consultant.

Only one health professional has overall responsibility for a client at any one time, and the client's care should be co-ordinated by that person. The identity of the primary caregiver should be clearly known to all of those involved and documented in the records of the referring health professional and the consultant. Responsibility could be transferred temporarily to another health professional, or be shared between health professionals, according to the client's best interests and optimal care; however, transfer or sharing of care should occur only after discussion and agreement among the client, the referring health professional, and the consultant(s).

Transfer to a physician for primary care:

When primary care is transferred permanently or temporarily from the midwife to a physician, the physician assumes full responsibility for subsequent decision-making, together with the client. When primary care is transferred to a physician, the midwife may provide supportive care within her scope of practice, in collaboration with the physician and the client.


Initial History and Physical Examination

INDICATIONS:

Discussion:

* adverse socio-economic conditions
* age less than 17 years or over 40 years
* cigarette smoking
* grand multipara (5 or more previous births)
* history of infant over 4,500 g
* history of one late miscarriage (after 14 weeks) or pre-term birth
* history of one low-birth-weight infant
* history of serious psychological problems
* less than 12 months from last delivery to present due date
* obesity
* poor nutrition
* previous antepartum haemorrhage
* previous postpartum haemorrhage
* one documented previous low-segment caesarean section
* history of essential or pregnancy-induced hypertension
* known uterine malformations or fibroids

Consultation:

* current medical conditions, for example: cardiovascular disease, pulmonary disease, endocrine disorders, hepatic disease, neurologic disorders, severe gastrointestinal disease
* family history of genetic disorders, hereditary disease or significant congenital anomalies
* history of cervical cerclage or incompetent cervix
* history of repeated spontaneous abortions
* history of more than one late miscarriage or pre-term birth
* history of more than one low-birth-weight infant
* history of eclampsia
* history of significant medical illness
* previous myomectomy, hysterotomy or caesarean section other than one     documented previous low-segment caesarean section
* previous neonatal mortality or stillbirth
* rubella during first trimester of pregnancy
* significant use of drugs, alcohol or other toxic substances
* age less than 14 years
* history of postpartum haemorrhage requiring transfusion

Transfer:

* any serious medical condition, for example: cardiac or renal disease with failure,   or insulin-dependent diabetes mellitus


Prenatal Care
INDICATIONS: 

Discussion:

* presentation other than cephalic at 4 weeks prior to due date
* no prenatal care before 28 weeks gestation
* uncertain expected date of delivery

Consultation:

* anaemia (unresponsive to therapy)
*documented post-term pregnancy (42 completed weeks)
* suspected or diagnosed foetal anomaly that may require physician management during or immediately after delivery
* inappropriate uterine growth
* medical conditions arising during prenatal care, for example: endocrine disorders, hypertension, renal disease, suspected significant infection, hyperemesis
* placenta previa without bleeding
* polyhydramnios or oligohydramnios
* pregnancy-induced hypertension
* isoimmunization, haemoglobinopathies, blood dyscrasia
* serious psychological problems
[1]
* sexually transmitted disease
* twins
* repeated vaginal bleeding other than transient spotting
* presentation other than cephalic at 37 weeks

Transfer:

* cardiac or renal disease with failure
* insulin-dependent diabetes
* multiple pregnancy (other than twins)
* proteinuric pre-eclampsia or eclampsia
*symptomatic placental abruption

During Labour and Delivery

INDICATIONS:

Discussion:


*no prenatal care
*thin meconium

Consultation:

* breech presentation
[2]
* pre-term labour (34-37 completed weeks)
* prolonged active phase
* prolonged rupture of membranes
* prolonged second stage
* suspected placenta abruption and/or previa
* retained placenta
* third or fourth degree tear
* twins
[3]
* unengaged head in active labour in primipara

Transfer:

* temperature over 38C on more than one occasion
* active genital herpes at time of labour
* pre-term labour (less than 34 weeks)
* abnormal presentation (other than breech)
* multiple pregnancy (other than twins)
* proteinuric pre-eclampsia or eclampsia
* prolapsed cord
* placenta abruption and/or previa
* severe hypertension
* thick meconium
* abnormal foetal heart rate patterns unresponsive to therapy
* uterine rupture
* uterine inversion
* haemorrhage unresponsive to therapy
* obstetric shock

Postpartum (Maternal)

INDICATIONS:

Consultation:

* breast infection unresponsive to therapy
* wound infection
* uterine infection
* signs of urinary tract infection
* temperature over 38C on more than one occasion
* persistent hypertension
* serious psychological problems
[4]

Transfer:

* haemorrhage unresponsive to therapy
* postpartum eclampsia
* thrombophlebitis or thromboembolism
* uterine prolapse

Postnatal (Infant)
INDICATIONS:

Discussion:

* feeding problems
[5]

Consultation:

*suspicion of or significant risk of neonatal infection
* 34 to 37 weeks gestational age
* infant less than 2,500 g
* ess than 3 vessels in umbilical cord
* excessive moulding and cephalohaematoma
* abnormal findings on physical exam
* excessive bruising, abrasions, unusual pigmentation and/or lesions
* birth injury requiring investigation
* congenital abnormalities, for example: cleft lip or palate, congenital
  dislocation of hip, ambiguous genitalia
* abnormal heart rate or pattern
* persistent poor suck, hypotonia or abnormal cry
* persistent abnormal respiratory rate and/or pattern
* persistent cyanosis, pallor or jitteriness
* jaundice in first 24 hours
* failure to pass urine or meconium within 24 hours of birth
* suspected pathological jaundice after 24 hours
* temperature less than 36C unresponsive to therapy
* temperature more than 37.9C unresponsive to therapy
* vomiting or diarrhoea
* infection of umbilical stump site
* significant weight loss (more than 10% of body weight)
* failure to regain birth weight in 3 weeks
* failure to thrive

Transfer:
* Apgar score lower than 7 at 10 minutes
* suspected seizure activity
* significant congenital anomaly requiring immediate medical intervention, for example: omphalocele, myelomeningocele
*temperature instability
* where another midwife is not available


1. Notwithstanding the requirement for consultation with a physician, consultation may be with another appropriate health care professional; for example, a clinical psychologist or mental health worker.
2. While many of these deliveries may become transfers of care, breech presentation and twins are listed as indications for consultation to allow an obstetrical consultant discretion in deciding if a midwife may manage such a delivery, where a spontaneous birth is reasonably anticipated. In a remote area, the availability of an experienced midwife may prevent a woman from having to leave her family and community. Midwives may also gain important hands-on experience under obstetrical supervision.
3. see #2 above
4. see #1 above
5. Notwithstanding the requirement for discussion with a physician or midwife, discussion may be with another appropriate health care professional; for example, a lactation consultant.


Adapted from the College of Midwives, British Columbia 14 April 1997
Refer Standard 2
CMBC Standards of Practice
Indications for Discussion, Consultation and Transfer of Care