Bullet Point List of What You Cannot Refuse, By Request

There has been a request for a simple bullet point list of what your midwife is supposed to make you do under current AZ midwifery rules, so here you go. This list in no way reflects my views as a midwife about what should or shouldn’t be considered safe for home birth; it is simply a summary straight from rule of what AZ says is required for home birth midwives. Arizona Department of Health (AzDHS) will say that you of course have the right to refuse, which is technically true. You just do not have the right to refuse and keep your midwife. In order for your midwife to be in compliance, you must consent to the following:

During pregnancy
A syphilis blood test before 28 weeks gestation
Prenatal visits on schedule (every 4 weeks until 28 weeks, every two weeks from 28 weeks to 36 weeks, weekly from 36 weeks until birth)
A home visit before 35 weeks gestation
Weight at every prenatal visit
Urinalysis at every visit (apparently there is room to waive this in writing, although the form offered by AzDHS to do so only states before 28 weeks, what happens after that?)
Blood pressure at every visit
Assessment of your legs for swelling at every visit
Measuring your fundal height at every visit
Listening for fetal heart tones at very visit
Feeling for baby’s position at every visit
If you are having a VBAC or breech baby, be within 25 miles of a hospital
Not return to your midwife’s care if you transfer to a physician

Transfer to a physician if any of the following occur:
Uterine surgery in history other than allowed VBACs
More than one prior cesarean
Prior cesarean with unknown incision, classical incision or vertical incision
Prior cesarean with any complications including infection
Prior cesarean with 18 months of current due date
Twins, triplets or more
History of Postpartum Hemmorhage of unknown cause that required a transfusion
Insulin dependent diabetes
Placenta previa
placenta accreta
Deep vein thrombosis
Pulmonary embolism
Uncontrolled gestational diabetes
Hypertension
Rh disease with positive titers
Active Tuberculosis
Active Syphilis
Active Hepatitis until treated and recovered
Active Gonorrhea until treated and recovered
Preeclampsia or eclampsia persisting after the second trimester
A blood pressure of 140/90 or an increase of 30/15 above your lowest BP twice in a row;
Anemia in the third trimester
A pelvis that will not safely allow a baby to pass through during labor
Serious mental illness
Evidence of substance abuse, including six months prior to pregnancy, to alcohol, narcotics, or other drugs
Gestational age greater than 34 weeks with no prior prenatal care;
A gestation beyond 42 weeks;
Prior cesarean due to “failure to progress as a result of cephalopelvic insufficiency”
Complications during a previous vaginal delivery after a Cesarean section
If your baby has any anomalies confirmed by ultrasound
If you are a VBAC and your baby is breech

During labor
Transfer to the closest OB hospital in case of an emergency
Your midwife phoning that hospital to tell them you are in labor and when your baby has arrived, if that hospital wants a call from the midwife
An initial physical assessment
Checking your vital signs (blood pressure, pulse, respirations, temperature) every 2-4 hours
Checking fetal heart tones every 30 minutes in labor, every15-20 minutes when pushing, after your bag of waters opens, and with any change of labor pattern
Periodic vaginal examinations (not just for VBAC and breech. this is how AzDHS says we are to assess “contractions, fetal presentation, dilation, effacement, and fetal position”  for all clients.)
Monitoring urine output
Urinalysis for ketones every two hours
Not return to your midwife’s care if you transfer to the hospital

Go to the hospital if any of the following occur:
Active  Genital herpes at the onset of labor
Any baby position other than flexed cephalic, frank breech, or complete breech positions
Labor beginning before the beginning of 36 weeks gestation;
Progress at at rate of less than 1-2cm per hour (VBAC or breech)
Push for more than 2 hours if this is your first baby (VBAC or breech)
Push for more than 1 hour if this is your second or greater baby (VBAC or breech)
A blood pressure of 140/90 or an increase of 30/15 above your lowest BP twice in a row;
Presence of ruptured membranes without onset of labor within 24 hours;
Abnormal fetal heart rate consistently less than 120 beats per minute or more than 160 beats per minute;
Presence of thick meconium, blood-stained amniotic fluid, or abnormal fetal heart tones;

During Postpartum
1 minute and 5 minute Apgar scores on baby
Physical exam of baby for “abnormalities”
Inspection of your perineum, vagina and cervix (requires a speculum) for tears
Taking your vital signs (blood pressure, pulse, respirations, temperature) every 15-20 minutes for the first hour
Taking your vital signs every 30 minutes for the second.
Breastfeed with your midwife’s help
A complete newborn physical
Erythromycin eye ointment for your baby (can be waived)
Vitamin k shot for baby before 72 hours of age (can be recommended rather than given)
A postpartum visit between 24 and 72 hours after birth
Vital signs for you (blood pressure, pulse, respirations, temperature) at every postpartum visit
Vital signs for baby (pulse, respirations temperature, fontanels, weight) at every postpartum visit
Your midwife must submit a birth certificate within 7 days
Your midwife must file a report to AzDHS about your care
Complete all postpartum care within 6 weeks (now the Department is saying before 6 weeks, so 5 weeks 6 days is your limit with your midwife)
Not return to you midwife’s care if you transfer to the hospital

Go to the hospital if any of the following occur:
A blood pressure of 140/90 or an increase of 30/15 above your lowest BP twice in a row
A postpartum hemorrhage of greater than 500 milliliters in the current pregnancy
A non-bleeding placenta retained for more than 60 minutes
Your midwife uses medications to control your bleeding
Your midwife sutures a tear or episiotomy
Your midwife uses oxygen for you or your baby for any reason
If your baby is less that 2000 grams (4# 6.4oz) at birth
If your baby is pale, blue, or grey in color after 10 minutes
If your baby has excessive edema
If your baby has respiratory distress
If your baby has major congenital anomalies

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Required consultations: In addition to the things you must agree to DO, the following is a list of things you are required to allow your midwife to discuss with a physician or nurse midwife if they come up in your care. I separated them out for ease of reading the above, as there are so many.

During Pregnancy
No fetal movement felt before 22 weeks
A positive culture for Group B Streptococcus
History of seizure disorder
History of stillbirth
History of premature labor
Have has more than 5 babies
You are younger than 16
You are having your first baby over the age of 40
Your midwife cannot hear baby’s heart before 22 weeks
Failure to gain 12 pounds by the beginning of 30 weeks gestation
Gaining more than 8 pounds in any two-week period during pregnancy
Greater than 1+ sugar, ketones, or protein in the urine on two consecutive visits
Excessive vomiting or continued vomiting after the end of 20 weeks gestation
Symptoms of decreased fetal movement
A fever of 100.4° F or 38° C or greater measured twice at 24 hours apart
Tender uterine fundus
Effacement or dilation of the cervix, greater than a fingertip, accompanied by contractions, prior to the beginning of 36 weeks gestation
Measurements for fetal growth that are not within 2 centimeters of the gestational age
Persistent shortness of breath requiring more than 24 breaths per minute, or breathing which is difficult or painful
Gonorrhea
Chlamydia
Syphilis
Heart disease
Kidney disease
Blood disease
Positive test result for HIV
Positive test result for Hepatitis B
Positive test result for Hepatitis C

During Labor and Birth
An abnormal progression of labor
An unengaged head at 7 centimeters dilation in active labor

Postpartum
Second degree or greater lacerations of the birth canal
Failure of the uterus to return to normal size in the current postpartum period
You baby weighs less than 2500 grams (5#8oz)
Your baby has congenital anomalies
Your baby has an Apgar score less than 7 at 5 minutes
Your baby has persistent fast breathing
Your baby has an irregular heartbeat
Your baby has persistent poor muscle tone
Your baby is younger than 36 weeks or older than 42 weeks age by exam
your baby has jaundice within 48 hours
Your baby has abnormal crying
Your baby has meconium staining of the skin;
Your baby is lethargic
Your baby is irritable
Your baby has poor feeding
Your baby is excessively pink
Your baby does not urinate or pass meconium (Poop) in the first 24 hours
Your baby has a hip click or incorrect angle
Your baby has an uncommon skin rash
Your baby’s temperature stays below 97.6° F or above 99.0° F

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