Varney’s midwifery fourth edition doc

Breastfeeding and Human Lactation, Second Edition, Riordan/AuerbachClinical Lactation: A Visual Guide, Auerbach Coach’s Notebook: Games and Strategies for Lactation Education, Smith Comp

varney’s midwifery

Breastfeeding and Human Lactation, Second Edition, Riordan/Auerbach

Clinical Lactation: A Visual Guide, Auerbach

Coach’s Notebook: Games and Strategies for Lactation Education, Smith

Comprehensive Lactation Consultant Exam Review, Smith

Core Curriculum for Lactation Consultant Practice, Walker

Counseling the Nursing Mother: A Lactation Consultant’s Guide, Third Edition,

Lauwers/Shinskie

Family-Centered Maternity Care, Phillips

Health and Welfare for Families in the 21st Century, Second Edition, Wallace/Green/Jaros

Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum,

Kroeger/Smith

Integrated Women’s Health: Holistic Approaches for Comprehensive Care, Olshansky

The Lactation Consultant in Private Practice: The ABCs of Getting Started, Smith

Maternal and Infant Assessment for Breastfeeding and Human Lactation: A Guide for the

Practitioner, Cadwell/Turner-Maffei/O’Connor/Blair

New Dimensions in Women’s Health, Second Edition, Alexander

Pocket Guide for Counseling the Nursing Mother, Shinskie/Lauwers

Pocket Guide to Breastfeeding and Human Lactation, Second Edition, Riordan/Auerbach Reclaiming Breastfeeding for the United States: Protection, Promotion, and Support, Cadwell Resource Guide to Accompany Breastfeeding and Human Lactation, Riordan/Auerbach

Study Guide for Breastfeeding and Human Lactation, Second Edition, Riordan/Auerbach

Ten Steps to Successful Breastfeeding: An 18 Hour Interdisciplinary Breastfeeding Management

Course for the United States, Cadwell/Turner-Maffei

Varney’s Midwifery Study Question Book, Fahey

Varney’s Pocket Midwife, Varney/Kriebs/Gegor

Varney’s midwifery

fourth edition

Professor, Nurse-Midwifery SpecialtyYale University School of Nursing

Jan M KrIebs, cnm, msn, facnm

Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of Maryland School of Medicine

carolyn l gegor, cnm, msn, facnm

FORMERLY Assistant Professor, Department of Obstetrics,

gynecology, and reproductive sciencesUniversity of Maryland School of Medicine

Copyright © 2004 by Jones and Bartlett Publishers, Inc.

All rights reserved No part of the material protected by this copyright may be reproduced or

utilized in any form, electronic or mechanical, including photocopying, recording, or by any

in-formation storage and retrieval system, without written permission from the copyright owner

Library of Congress Cataloging-in-Publication Data

1 Midwifery 2 Gynecologic nursing 3 Maternity nursing I Title: Midwifery II

Kriebs, Jan M III Gegor, Carolyn L IV Title

[DNLM: 1 Nurse Midwives 2 Midwifery 3 Obstetrical Nursing 4 Women’s Health

WY 157 V318v 2003]

RG950 V37 2003

618.2—dc21

2003047512

Chief Executive Officer: Clayton Jones

Chief Operating Officer: Don W Jones, Jr

Executive V.P and Publisher: Robert W Holland, Jr

V.P., Design and Production: Anne Spencer

V.P., Manufacturing and Inventory Control: Therese Bräuer

Director of Sales and Marketing: William Kane

Acquisitions Editor: Penny M Glynn

Production Manager: Amy Rose

Associate Production Editor: Karen C Ferreira

Associate Production Editor: Renee Sekerak

Associate Editor: Karen Zuck

Production Assistant: Jenny L McIsaac

Senior Marketing Manager: Alisha Weisman

Associate Marketing Manager: Joy Stark-Vancs

Manufacturing Buyer: Amy Bacus

Cover Design: Anne Spencer

Interior Design: Anne Spencer

Composition: Jacqueline Davies

Printing and Binding: Courier Westford

Cover Printing: Courier Westford

Printed in the United States of America

Barb House, Barb MewsLondon W6 7PAUK

profession of midwifery; and to the women, mothers, babies, and families who receive health care from all those who study this book.

Helen Varney

For the mentors, midwives, and mothers who have shared with me their knowledge of midwifery and birth; and for David, my partner in everything I do.

Jan M Kriebs

To Lisa L Paine, CNM, DrPH, my midwifery mentor and friend, and to all those whose wisdom and vision inspires us to go further and to give more than we ever knew was possible to care for mothers and babies; and

to Andy, my husband and soul mate, with whom so many dreams have come true.

Carolyn L Gegor

Dedication to the Third Edition

In honor and memory of my beloved parents, Helene Hahn Varney and Theodore Roosevelt Varney.

Dedication to the Second Edition

In tribute to Therese Dondero and all other Certified Midwives whose masterly contributions to our profession were tragically curtailed because of untimely death.

Nurse-Dedication to the First Edition

For my students, peers, and colleagues; the profession of midwifery; and the women, mothers, babies, and families who receive health care from those who study this book.

nurse-In my backyard there are nuns who live in a shaded brick buildingnext to the St Stanislaus church and elementary school.

Together we rise before the sun is in the sky

Behind the kitchen curtain, in the damp haze of morning,

I watch them walk in shades of blue robe

They glide in white sneakers across the parking lot

They are cool, calm, brisk

Some day, I’ll go see them

I’ll ask for some lesson on prayer

Because the thing is I pray now

Not Dear God Almighty!

Just slow, easy, quiet thoughts

I pray when my patience is worn

When my shoulders ache

When my own voice becomes tiring to my ears

I pray when my heart sits heavy with stories and faces of women

A prayer for the 32 week babe

A prayer for the lady with the skinny, squawking twins

A prayer for the woman without a mother, or a lover, or a friend

I pray when my cold hands run across a pregnant belly

and I feel a kick from the inside

I pray for all my babies, Be good to your mama.

I pray for all my mothers, Be strong, be good to this baby.

I pray secretly and I pray slowly

I pray for us, the midwives and almost-midwives

I pray that we make the right decisions

And I pray for those of us who make bad decisions

Decisions we regret with outcomes we can’t change

I pray that we learn from our mistakes

That with age comes wisdom

I pray deeply and I pray completely

For all of the hands and all of the bellies

I pray for holy births and howling babies

Dana Quealy, CNM, MSN

Brief Contents

Part I Midwifery

Part II Primary Care of Women

Jo-Anna L Rorie

Margaret A Marshall Joyce E Thompson

Jenifer O Fahey

Ann Cowlin

Mary C Brucker Mary Ann Faucher

Laura Zeidenstein

Nancy Jo Reedy Mary C Brucker

Mary Ellen Rousseau

Part III Reproductive Health Care

William F McCool Dawn Durain

Chapter 17 Natural Methods of Family Planning 471

Carmela Cavero

Part IV Antepartal Care

the Embryo and the Fetus, and the Placenta 543

Carol L Wood

Part V Intrapartal Care

Chapter 29 Screening for and Collaborative Management of Selected Complications During the

First and Second Stages of Labor 853

Alice J Bailes Marsha E Jackson

Chapter 36 Physiological Transition to Extrauterine Life 961

Mary Kathleen McHugh

Mary Kathleen McHugh

Mary Kathleen McHugh

Mary Kathleen McHugh

Mary Kathleen McHugh

Chapter 41 Recognition and Immediate Care of Sick Newborns 1029

Mary Kathleen McHugh

Part VII Postpartal Care

Karin Cadwell Cynthia Turner-Maffei Sarah Coulter Danner

Part VIII Skills

Chapter 61 Anatomy of the Pelvis, Pelvic Types, Evaluation of the Bony Pelvis, and Clinical

Pelvimetry 1205

Chapter 63 Injection of Intradermal Sterile Water Papules for Relief of Low

Back Pain in Labor 1219

Saraswathi Vedam

Chapter 64 Inserting an Intrauterine Pressure Catheter; Amnioinfusion 1223

Position 1241

Chapter 71 Hand Maneuvers for Birth with the Mother in Dorsal Position 1249

Saraswathi Vedam

Chapter 73 Hand Maneuvers for Birth with the Mother in the Squatting or Supported Squat

Position 1257

Saraswathi Vedam

Chapter 75 Postbirth Inspection of the Cervix and Upper Vaginal Vault 1267

Vivian H Lowenstein

Wendy Grube William F McCool

Contributor List for the Fourth Edition xxvii

Preface to the Fourth Edition xxix

Acknowledgments xxx

Preface to the Third Edition xxxii

Preface to the Second Edition xxxv

Preface to the First Edition xxxviii

Part I Midwifery

Definitions and Practice 3Beliefs Characterizing Midwifery 4Early History 5

Factors Leading to Disrepute 5The Early Twentieth Century 7The First Nurse-Midwifery Education Programs 10The 1940s and 1950s 12

The 1960s 13The 1970s 14The 1980s 17The 1990s and Early 2000s 18The American College of Nurse-Midwives 19References 23

Bibliography 24

Primary Care and Scope of Practice 29Independent and Collaborative Management of Care 30The Management Process 31

Screening for Abnormality and Differential Diagnosis 33Physical Assessment for a Database 35

References 45Additional References 46

Part II Primary Care of Women

Jo-Anna L Rorie

The Demographic Shift 50

xi

Women of Color Population Overview 51Culturally Competent Care 52

Application of the Cultural Competence Continuum 53Conclusion 56

References 56Additional References 57

Margaret A Marshall Joyce E Thompson

Introduction 59The Situation Worldwide 60

Health and Risk Assessment 87Counseling Specific to Preconception Care 88Medical Risk Factors 89

Environmental and Workplace Issues 93Preconception Issues for Men 95Other Considerations 96

Intervention 96References 97

Jenifer O Fahey

Principles of Nutrition 99Weight and Body Fat Measurements and Overweight and Obesity 112Cardiovascular Disease 115

Cancer 116Diabetes 117Nutrition, the Menstrual Cycle, and Fertility 118Adolescence 118

Nutrition During Menopause and Beyond 119Eating Disorders 120

Nutrition and Vegetarianism 122Nutrition and the Female Athlete 122Alcohol and Nutrition 123

Nutritional Guidelines 123Conclusion 129

References 129Additional References 133

Primary Care 135Hematologic Conditions 138The Cardiovascular System 141Respiratory Diseases 143Gastrointestinal Disorders and Abdominal Pain 147Assessing Abdominal Pain 150

Genitourinary Problems 151Diabetes 152

Thyroid Disease 154Carpal Tunnel Syndrome 156Headache 156

Depression 158Conclusion 160References 160Additional References 164

Tuberculosis 175Hepatitis 177

(Coauthored with Mary Curran)

References 183

Ann Cowlin

The Value of Exercise to Women’s Health 187

A New Exercise Model for Adolescent Girls 188Appropriate Exercise during Pregnancy 193Exercise for Postpartum Recovery 214Essential Exercise for Menopause 220Exercise in the Senior Years 231

References 233Additional References 247

Mary C Brucker Mary Ann Faucher

Introduction 249The Lexicon of Pharmacology 249

Drugs in Modern Society 251Practicalities and Issues Involving Drugs 252Adverse Drug Reactions/Adverse Drug Events 255Drug Resistance 255

Drug-to-Drug Reactions 256Drug Costs 256

Drugs and Herbs 257Pregnancy and Drug Use 257Metabolism 259

Elimination/Clearance 259Teratology and Drugs During Pregnancy 260Commonly Used Pharmaceuticals 264Drugs for the Treatment of Various Medical Conditions 266Pharmaceuticals and Breastfeeding 268

Selected Drugs and the Breastfeeding Woman 269Conclusion 272

References 272Additional References 276Appendix A: Top 200 Drugs by Rank, by Generic Name, and by Brand Name 277Appendix B: Teratology Information Systems by Location 289

Appendix C: The Transfer of Drugs and Other Chemicals into Human Milk 292

Laura Zeidenstein

Background 299Data Collection 301Management of Health Care Issues 302Childbearing and Parenting 304Special Health Concerns 307

References 308Appendix: Resources 310

Nancy Jo Reedy Mary C Brucker

Introduction 313Women and Substance Abuse 313Attraction of Substance Abuse 315Assessment of Drug Use 316General Treatment Issues 317General Management of Substance Abuse During Pregnancy 317Substance Abuse and Lactation 318

Neonatal Implications 318Common Substances of Abuse 320

Appendix A: Health Education Fact Sheet from the American Lung Association onNicotine Replacement Therapy (NRT) 330

References 332Additional References 334

Mary Ellen Rousseau

Definitions 335Age at Menopause 336Adult Development, Society, and Menopause 336Medicalization of Menopause 336

Endocrinology 339Changes of Perimenopause and Aging 340Breast Cancer 347

Cardiovascular Disease 350Osteoporosis 352

The Perimenopausal Visit 357Postmenopausal and Older Woman Visit 358Menopausal Therapeutic Interventions, Preventive Measures, and Health Promotion 361

The Menopause as Opportunity 366References 367

Part III Reproductive Health Care

William F McCool Dawn Durain

Issues Concerning the Menstrual Cycle 379Abdominal and Pelvic Pain 396

Pelvic Masses 404Congenital Uterine Anomalies 407Pelvic Floor 408

Urinary Incontinence 409Effects of DES Use 410Special Considerations in Gynecologic Care 411Cancer Screening/Diagnoses 413

Conclusion 428References 429

Vulvovaginal/Cervical Infections and Sexually Transmitted Diseases 439Pelvic Inflammatory Disease 457

Anaphylactic Shock 458References 458

Chapter 16 Family Planning and Contraception 461

History and Concepts of Family Planning 461Selection of a Contraceptive Method 462Effectiveness of a Contraceptive Method 465Folklore Methods 466

Sterilization 467Future Methods of Contraception 468References 468

The Basal Body Temperature Method 474The Sympto-Thermal Method 475Lactation Amenorrhea Method 478 Client/Couple Instruction 478Technology and Natural Family Planning 478References 478

Bibliography 478Resources 479

Spermicidal Preparations 481

Diaphragms 487Cervical Caps 493Other Vaginal Contraceptive Barrier Methods 496References 496

Additional References 497

Description, Effectiveness, User Response, and Noncontraceptive Benefits 499Contraindications and Side Effects 500

Management Plan for the IUD 501References 510

Combination Pills 513Progestin-Only Contraceptive Pills (Minipills) 527Emergency Postcoital Contraception 528

Injectable Hormonal Contraception 531Subdermal Implants 534

Contraceptive Vaginal Ring (NuvaRing) 536

Transdermal Contraceptive Patch (OrthroEvra) 537References 539

Additional References 540

Part IV Antepartal Care

the Embryo and the Fetus, and the Placenta 543

Maternal Anatomical and Physiological Changes 543Maternal Physiological Changes 549

Maternal Psychological Adjustment and Processes 553Fetal Growth and Development 556

Placental Development, Circulation, and Functions 564References 568

Additional References 569

Philosophy and Scope 571Diagnosis and Early Management of Care During Pregnancy 573Assessment and Evaluation of the Well-Being of the Woman 577Case Study 587

Common Discomforts of Pregnancy and Their Relief Measures 591Nutritional Intervention in Pregnancy 598

Instruction and Anticipatory Guidance 608References 612

Bibliography 614Appendix A: Immunization During Pregnancy 619

First Trimester Assessment of Pregnancy Well-Being 623Second Trimester Screening 627

Invasive Fetal Assessment Throughout Gestation 630Third Trimester Fetal Assessment 632

References 652Additional References 658

First Trimester Bleeding 662Ectopic Pregnancy 666Hydatidiform Mole 667Hyperemesis Gravidarum 668Incompetent Internal Cervical Os 669Infections 670

Tuberculosis 670Hepatitis 674

Rubella 674Cytomegalovirus 676Toxoplasmosis 677Varicella 678Parvovirus B19 (Fifth Disease, Erythema Infectiosum) 680Urinary Tract Infections 681

Anemias and Hemoglobinopathies 683Heart Disease 688

Thyroid Disorders 689

Multiple Pregnancy 691Polyhydramnios (Hydramnios) 694Oligohydramnios 694

Diabetes Mellitus 695Rh(D) Isoimmunization 699Placenta Previa 702

Abruptio Placentae 703Management of Hemorrhage Due to Placenta Previa or Abruptio Placentae 705Hypertensive Disorders of Pregnancy 705

Anatomy and Physiology of the Cervix 722Management Approach for the Postdate Pregnancy: Anticipatory Versus Active 723

References 730

Part V Intrapartal Care

Signs and Symptoms of Impending Labor 737Database for the First Stage of Labor 739Management of Care During the First Stage of Labor 754References 790

Introduction and History 793Physiology and Scope of Problem 794Midwifery Management of Nonreassuring Fetal Heart Rate Patterns 811 Methods to Evaluate Fetal Acid-Base Balance Directly 813

Fetal Oxygen Saturation Monitoring 815

Admission to L&D and Establishing Initial Well-Being 816

References 818

Database for the Second Stage of Labor 821Management Plan for the Second Stage of Labor 829References 845

Bibliography (Chapters 26 and 28) 846

Chapter 29 Screening for and Collaborative Management of Selected Complications During the

First and Second Stages of Labor 853

Previous Cesarean Section 853Preterm Labor/Birth 856Premature Rupture of the Membranes 863Amnionitis and Chorioamnionitis 867Group B Streptococcus 868

Umbilical Cord Prolapse 870Cephalopelvic Disproportion 872Deep Transverse Arrest 873Uterine Dysfunction 874Maternal Exhaustion (Maternal Distress; Ketoacidosis) 876Uterine Rupture 876

Blood Transfusion Reaction 877References 878

Additional References 881

Management of Shoulder Dystocia 883Delivery of an Infant with a Face Presentation 890Delivery of an Infant with a Breech Presentation 892Delivery of a Woman with Multiple Gestation 899References 901

Bibliography 902

Database for the Third Stage of Labor 905Management Plan for the Third Stage of Labor 907References 911

Retained Placenta 913Third Stage Hemorrhage 914Placenta Accreta 914

Uterine Inversion 915References 916

Chapter 33 The Normal Fourth Stage of Labor 917

Database for the Fourth Stage of Labor 917Management Plan for the Fourth Stage of Labor 919Initiation of Family Relationships with the Newborn 921References 923

Causes of Immediate Postpartum Hemorrhage 925Predisposing Factors 926

Preparatory Measures 926Action, Effect, Dosage, and Route of Oxytocic Drugs 926Management Steps 927

References 928

Alice J Bailes Marsha E Jackson

Introduction 929History 930

(Authored by Helen Varney Burst)

Characteristics of Birth Center and Home Birth 933Birth Center and Home Birth Practice Models 936Midwife/Client Relationship 938

Initial Visit 939Return Visits 943The Family’s Preparation for Birth and Postpartum 943The Experience of Birth at Home or in the Birth Center 945The Early Postpartum Period and Follow-up 947

Maintaining Safety 947How to Accomplish an Effective Hospital Transfer 954Business Issues 955

Special Home and Birth Center Resources 956References 957

Chapter 36 Physiological Transition to Extrauterine Life 961

Mary Kathleen McHugh

Immediate Extrauterine Transition 961Ongoing Extrauterine Transition 967References 972

Mary Kathleen McHugh

Assessment Prior to Birth 973

Assessment at the Moment of Birth 973Care During the First Hours After Birth 974Plan of Care for the First Few Days of Life 977Planning Discharge 979

References 982

Mary Kathleen McHugh

Infrastructure for Safe Resuscitation of the Newborn 983Pathophysiology of Asphyxia 984

Care of the Newborn Following Resuscitation 986The Process of Resuscitation 987

Special Situations in Neonatal Resuscitation 995Quality Assurance and Risk Management 996References 997

Mary Kathleen McHugh

Structuring the Newborn Examination 999Gestational Age Assessment 1002

Physical Examination of the Newborn 1004References 1009

Mary Kathleen McHugh

The Midwife’s Role in Neonatal Well-Child Care 1011Newborn Behavior 1014

Developmental Milestones in the First Six Weeks 1016Psychological Tasks of Early Infancy 1016

Physical Care of the Newborn 1018The Circumcision Decision 1019Nonnutritive Sucking 1020Feeding 1020

Common Variations in the First Six Weeks 1023Eating Patterns and Weight Gain 1025

Physiological Jaundice 1026References 1027

Mary Kathleen McHugh

The Midwife’s Roles and Responsibilities 1029The Sick Newborn 1030

Signs of Possible Infection 1033Signs of Birth Injuries 1034Signs of Neurological Disease 1035Signs of Surgical Emergencies 1036

Signs of Drug Exposure in the Newborn 1036Infants of Diabetic Mothers 1039

Signs of Intrauterine Growth Restriction 1039References 1040

Part VII Postpartal Care

Database for the Puerperium 1041Management Plan for the Puerperium 1052References 1064

Additional References 1065

Karin Cadwell Cynthia Turner-Maffei Sarah Coulter Danner

Breastfeeding-Optimal Infant Nourishment 1067The Baby-Friendly Hospital Initiative 1069The International Code of Marketing of Breast-milk Substitutes 1070Anatomy and Physiology of Lactation 1070

Antepartum Preparation for Breastfeeding 1072The Effect of Birth Practices on Breastfeeding 1074Successful Breastfeeding 1074

Problem Prevention and Management 1078Breast Discomfort 1079

Milk Supply 1081When Breast Is Not Best 1085Conclusion 1087

References 1087Professional Resources and Equipment and Supply Resources 1091

Puerperal Morbidity 1093Puerperal Infection 1094Other Puerperal Complications 1095Postpartum Depression 1098

Attachment Failure and the Potential for Child Abuse or Neglect 1101 References 1102

Additional References 1103

Part VIII Skills

References 1108

Chapter 46 Finger Puncture 1109

References 1133

Relevant History 1135Physical Examination 1136Variations in Breast Examination and Findings for the Pregnant Woman 1142Variations in Breast Examination for the Postpartal Woman 1143

Teaching Breast Self-Examination 1144References 1144

Additional References 1145

Antepartal/Intrapartal Abdominal Examination 1147Postpartal Abdominal Examination 1156

References 1159Additional References 1159

Significance and Charting 1161Procedure and Rationale for Examination 1161

Deep Tendon Reflexes 1163Clonus 1167

Bibliography 1167

Procedures, Observations or Findings, and Significance 1169Bibliography 1193

Reference 1197

Chapter 58 Obtaining a Specimen for Gonococcal (GC) and Chlamydia Diagnostic Testing 1199

Chapter 61 Anatomy of the Pelvis, Pelvic Types, Evaluation of the Bony Pelvis, and Clinical

Pelvimetry 1205

Types of Pelves 1209Procedure, Rationale, and Description of Findings 1211Evaluation of Findings 1215

Bibliography 1215

Procedure for Breast Massage 1217Procedure for Manual Expression 1218Procedure for Nipple Rolling 1218Reference 1218

Breath Control 1233Body Position 1233Arm Position and Action 1234Pubic Pressure 1234

Vaginal Stimulation 1234

Local Infiltration Before Birth 1239Local Infiltration for Repair After Birth 1240

Chapter 70 Hand Maneuvers for Birth with the Mother in Lithotomy or Modified Lithotomy

Position 1241

Reference 1248

Chapter 75 Postbirth Inspection of the Cervix and Upper Vaginal Vault 1267

Procedure for Cervical Inspection 1267Procedure for Inspection of the Upper Vaginal Vault 1268

Relevant Anatomy 1275Cutting an Episiotomy 1279Aids to Wound Healing 1280Manipulation of Equipment 1281Knots and Suture Stitches 1282Principles of and Thoughts About Episiotomy and Laceration Repair 1284Repair of a Midline Episiotomy 1287

Repair of First and Second Degree Lacerations and Sulcus Tears 1290Repair of Third Degree Lacerations 1290

Repair of Fourth Degree Lacerations 1291 Repair of Periurethral and Clitoral Lacerations 1291Repair of Cervical Lacerations 1292

Defibulation and Repair 1292References 1293

Chapter 81 Circumcision 1313

Vivian H Lowenstein

Relevant Male Genital Anatomy 1314Circumcision Instruments 1314Pain Relief 1315

Postcircumcision Care and Parental Instruction 1323References 1324

Additional References 1325

Wendy Grube William F McCool

Indications for Endometrial Biopsy 1327Contraindications and Precautions 1327Potential Side Effects/Complications and Preventive Measures 1328Procedure and Rationale 1328

Results and Management 1331References 1332

Additional References 1332

Alice J Bailes, CNM, MSN

Co-Director, BirthCare & Women’s Health, Ltd.

Alexandria, Virginia

Mary C Brucker, CNM, DNSc, FACNM

Director, Parkland School of Nurse-Midwifery

Dallas, Texas

Karin Cadwell, RN, PhD, IBCLC

Faculty, Healthy Children Project, Inc.

East Sandwich, Massachusetts

Carmela Cavero, CNM, MS, FACNM

Certified Natural Family Planning Instructor

Consultant with the Natural Family Planning Program

of the Diocese of San Diego, California

Ann F Cowlin, MA, CSM, CCE

Dance and Movement Specialist,

Yale University Athletic Department

Assistant Clinical Professor,

Yale University School of Nursing

Founder/Director, Dancing Thru Pregnancy ® ,Inc.

Expert Consultant, U.S Army Pregnancy Fitness

Physical Training Program

Mary E Curran, CNM, MPH

Nurse-Midwife

Dartmouth Hitchcock Nashua

Nashua, New Hampshire

Sarah Coulter Danner, CNM, CPNP, MSN, IBCLC

Chairperson, Department of Nursing,

Oglala Lakota College

Pine Ridge, South Dakota

Dawn Durain, CNM, MPH

Faculty, Midwifery Graduate Program

University of Pennsylvania School of Nursing

Jenifer O Fahey, CNM, MSN, MSPH

Nurse-Midwife and Clinical Instructor

Department of Obstetrics, Gynecology,

and Reproductive Sciences

University of Maryland School of Medicine

Mary Ann Faucher, CNM, PhD

Faculty, Parkland School of Nurse-Midwifery

Dallas, Texas

Contributor List for the

Fourth Edition

Wendy Grube, RN, CRNP, MSN Lecturer/Clinical Specialist Women’s Health Care Studies University of Pennsylvania School of Nursing Marsha E Jackson, CNM, MSN, FACNM Co-Director, BirthCare & Women’s Health, Ltd Alexandria, Virginia

Vivian H Lowenstein, CNM, CRNP, MSN, Certified Mohelet

Nurse Midwife, GCSF OB/GYN Assoc.

Abington, Pennsylvania Margaret Ann Marshall, CNM, MPH, EdD, FACNM Technical Advisor for AIDS and Child Survival Latin America and the Caribbean

United States Agency for International Development William F McCool, CNM, PhD, FACNM

Associate Professor Director, Midwifery Graduate Program University of Pennsylvania School of Nursing Mary Kathleen McHugh, CNM, MSN Lecturer/Clinical Specialist

University of Pennsylvania School of Nursing Dana Quealy, CNM, MSN

Nurse Midwife, Alivio Medical Center Chicago, Illinois

Nancy Jo Reedy, CNM, MPH Director of Nurse-Midwifery Services Texas Health Care, PLLC

Fort Worth, Texas Jo-Anna L Rorie, CNM, MSN, MPH, FACNM Assistant Professor, Maternal and Child Health Associate Director, Nurse-Midwifery Education Program Boston University School of Public Health

Mary Ellen Rousseau, CNM, MS, FACNM Associate Professor, Nurse-Midwifery Specialty Yale University School of Nursing

Joyce Beebe Thompson, CNM, DrPH, FAAN, FACNM Lacey Professor of Community Health Nursing Western Michigan University

Bronson School of Nursing Director, Board of Management International Confederation of Midwives

xxvii

Cynthia Turner-Maffei, MA, IBCLC

Faculty, Healthy Children Project, Inc.

East Sandwich, Massachusetts

Saraswathi Vedam, CNM, MSN

Assistant Professor, Nurse-Midwifery Specialty

Yale University School of Nursing

Carol L Wood, CNM, EdD Associate Professor and Graduate Program Coordinator University of Maine School of Nursing

Laura Zeidenstein, CNM, MSN Assistant Professor of Clinical Nursing Program Director, Graduate Nurse Midwifery Program Columbia University School of Nursing

This is a textbook written for all midwives.

Midwives worldwide have a primary focus

on pregnancy and birth in all types of

set-tings International concern for safe motherhood

and the health and well-being of women builds on

this core of midwifery In the United States, the

practice of midwifery encompasses the health care

of women from puberty through senescence and

from normal to high-risk, and the collaborative

care of the medically or obstetrically complicated

To be with and provide care to women in all

set-tings requires an extensive and in-depth knowledge

base and skill competency This book was written

to provide both the student and the practitioner

with the underlying theory, procedural know-how,

and elaboration on the Hallmarks of Midwifery

that enables the midwife to function with

knowl-edge, safety, and caring in all settings The book

thus reflects a balance of art and science, a blend of

spirituality and evidence-based care, and a

commit-ment to being “with woman”

The book once again expanded with the fourth

edition to provide more comprehensive coverage of

the scope of practice of midwifery as the primary

health care of women from puberty through

senes-cence Clinical content expansion is reflected in new

chapters on Cultural Competence in Midwifery

Practice, Primary Care and Midwifery, Nutrition in

Women’s Health, Common Diagnoses in Women’s

Gynecological Health, and Pharmacology and

Midwifery Other new chapters reflect increased

comprehensiveness of material previously found in

chapters such as Chronic Infectious Diseases,

Complications of Gestational Age Assessment and

the Postdate Pregnancy, Fetal Assessment in Labor,

and Infant Feeding A new chapter on International

Midwifery and Safe Motherhood bespeaks

acknowl-edgment of the role midwives have internationally in

xxix

promoting and safeguarding the health and being of women Two previous chapters were com-pletely rewritten and retitled by new authors asHealth Issues of Lesbian and Bisexual Women andBirth in the Home or Birth Center Four new skillschapters were essential additions supplementing ourclinical practice: Endometrial Biopsy, Sterile WaterPapules, Hands and Knees Birth Position HandManeuvers, and Squatting or Supported Squat BirthPosition Hand Maneuvers Although Norplant hasbeen removed from the market, the removal proce-dure was retained as there are still women who havethe implants All chapters, references, and bibliogra-phies were meticulously scrutinized and comprehen-sively updated to reflect both expansion andevidence-based changes in our practice

well-The book has more than doubled in size (acombination of page size and number of pages)since first published in 1980 The number of chap-ters has increased from 57 to 82 The preface andacknowledgments to each of the previous editionsare included for historical purposes

As with earlier editions, the comments and gestions of readers are encouraged

sug-Finally, the fourth edition is the last edition ofthis book that I will author The continuity and fu-ture of this book has been ensured by the two co-authors with whom I worked on this edition andwho henceforth will be the authors of the book.They not only meet but exceed my requirements ofhaving compatible clinical and educational philoso-phy with that upon which this book is structured,imposing expertise in clinical practice, exquisitewriting and editorial talent, and absolute integrity

The fourth edition has been a time of

transi-tion from a book with a single author to a

book with three co-authors and preparing

for two co-authors in the future This enabled

Helen Varney (HV) to take Jan Kriebs (JK) and

Carolyn Gegor (CG) through the endless details

and decisions of the entire process of book

publish-ing from contract through writpublish-ing, workpublish-ing with

contributing authors, editing, copyediting, page

proofs, front matter, permissions, art work,

mar-keting, and relations with all the helpful people at

Jones and Bartlett Publishers

We want to thank all the contributing authors,

some of whom comprehensively updated their

chapters and others who authored new chapters

which assured expansion of the book to cover all

facets of the scope of our practice All wrote

mag-nificently and we are so proud and pleased to have

them sharing their knowledge and expertise in this

book that represents our profession Five

contribut-ing authors responded with commitment and grace

to personal requests for help in meeting formidable

deadlines relatively late in the process and to them

we are especially grateful: Mary Brucker, Karin

Cadwell and Cindy Turner-Maffei, Bill McCool,

and Carol Wood

Each of us had the support of family, friends,

and colleagues, without whom the book would

never have been completed HV expresses heartfelt

gratitude to Margaret-Ann Corbett, CNM, MS, JD

who has supported, encouraged, and enabled me to

write the book through all four editions In the end,

it was Margaret-Ann who convinced me that I had

to write the book one last time in order to facilitate

an effective and fair transition She then provided

me with knowledgeable and wise counsel

through-out, and the time, space, and sanity that I needed to

do the work Margaret-Ann’s contributions to the

book through the years defy an adequate thank

you I am also grateful to my brother and

sister-in-law, T William Varney, BS, CPA and Laura E

Varney, PhD for providing back-up dog walking

and meals in Maine, and who gave of themselves

and respected my need for time; to Catherine L

Gilliss, RN, DNSc, FAAN, Dean of the YaleUniversity School of Nursing, for supportive under-standing; and to my friends, family, and colleagueswho sacrificed time together over and over again inorder for me to work on the book

JK expresses gratitude to my current and mer partners at the University of Maryland:Carolyn L Gegor, CNM, MS, FACNM, Mary E.Curran, CNM, MPH, Lisa McCullum, CNM,MSN, MPH, Jenifer Fahey, CNM, MSN, MPH,Rachel K Payne, CNM, MS, IBCLC, JenniferKaye, CNM, MSN, and to Linda Sparks, our ad-ministrative secretary, all of whom made space inour practice for this book to grow I am also grate-ful to Carol Snapp, CNM, MSN, who willingly re-viewed and commented on material for me, and toTekoa King, CNM, MPH and Lisa Summers,CNM, DrPH for their continual support this lastyear Finally, I owe a great debt to my family:David, Rob, and Juniper, each of whom con-tributed time out of our lives so I could learn how

for-to write a book, and then do it Many thanks for-toeach of these and all the other midwives andfriends who believed I could do this

Although my name (CG) appears as co-author,

it is truly the work and love and support of so manypeople that has made this possible I have to startwith my husband, Andy, and daughters, Stacey andBrittany, whose love and support have sustained meand continue to make my life glow I am grateful to

my parents, Gordon and Sylvia Pearson who havealways believed in me The path that led me to thisbook began at Johns Hopkins under the mentoring

of Lisa L Paine, CNM, DrPH, FACNM andTimothy R B Johnson, MD who showed me thevalue of teaching, writing and mentoring as ameans of improving the care for many women andbabies, far beyond those I could actually care formyself The midwives with whom I practiced: LisaSummers, CNM, DrPH, Aileen MacLaren, CNM,DrPH, Jan Kriebs, CNM, MSN, FACNM, EmilyDeFerrari, CNM, Mary Curran, CNM, MPH, LisaMcCullum, CNM, MSN, MPH, Jenifer Fahey,CNM, MSN, MPH and Rachel Payne, CNM, MS,

Acknowledgments

xxx

IBCLC have all taught me so much and were

sup-portive of creating opportunities to care for women

as well as to teach midwives, nurses, medical

stu-dents, and residents the ways of midwifery Linda

Sparks has always provided invaluable

administra-tive support Thank you to each one

We wish to express special thanks to the

in-credible team at Jones and Bartlett Publishers First

and foremost, we thank Penny Glynn, RN, ANP,

PhD our editor who simultaneously cajoled and

cared for us while unfailingly facilitating our efforts

to get this book done; Karen Zuck, associate editor,

who was always helpful but particularly invaluable

with the permissions; Amy Rose, production editor,

who was always open to author ideas and helpfully

clear about what could and could not be done,

Jenny McIsaac, production assistant, who carefully

reviewed all the work and had endless essential

questions and exhortations; Stephanie Magean,

copyeditor, whose willingness to be simpatico with

the author makes working with a copyeditor a

pleasant experience; Joy Stark-Vancs, associate

marketing manager, who sees involvement of

au-thors as critical in the marketing process; and

al-though not as directly involved in this edition, it

was good to know that we had the continuing

in-terest and support of Clayton Jones, CEO

Underlying their efforts is the philosophy of Jones

and Bartlett to involve authors in all stages of

pro-duction This results in a real working relationship

and partnership

A number of people helped with specific

as-pects of the book There were those who were

help-ful in offering suggestions, acting as a sounding

board, and contributing information at just theright times: Mary Curran, CNM, MPH, KathrynKravetz, SNM, MSN, Lisa McCullum, CNM,MSN, MPH, Lisa Paine, CNM, DrPH, FACNMand Johanna K Rizzardini, CNM, MSN As witheach edition of the book, Phyllis Long, CNM, MPHwrote helpfully, this time with commentary fromstudents at the Institute of Midwifery, Women, andHealth that raised our consciousness in the use ofwords Proofreading was done by the co-authorsand by Margaret-Ann Corbett, CNM, MS, JD, whodid the majority of this work, Donna Diers, RN,PhD, FAAN, who saved the day at one criticalpoint, Teresa Marsico, CNM, MEd, FACNM, and

T William Varney, BS, CPA Grateful thanks toeach Margaret-Ann and Donna have the distinc-tion of having done proofreading for all four edi-tions of the book

Carolyn Gegor and Jan Kriebs are indebted toHelen Varney Burst for giving us the honor, oppor-tunity, and mentoring to participate in this book.Thank you for entrusting us with the profound re-sponsibility to further the art and science of mid-wifery through this book

Finally, we wish to thank all of the midwiferystudents with whom we have worked during ourprofessional lives It is from our students that wehave learned, been stimulated, and renewed ourcommitment to midwifery and to the constantsearch for knowledge

HVBJKCG

The third edition of this book marks a time of

change and expansion in the profession This

change and expansion is reflected in the title

and in the size of the book The change in the title

from Nurse-Midwifery to Midwifery reflects the

re-cent actions of the American College of

Nurse-Midwives and the ACNM Certification Council,

which assumed responsibility for setting the

stan-dard for the practice of midwifery in the United

States through the credentialing mechanisms of

ac-creditation and national certification of both

nurse-midwives and non-nurse-nurse-midwives

The practice of midwifery in the United States

has expanded and now entails the provision of

pri-mary care to women from puberty through

senes-cence, including the maternity cycle and primary care

of the well newborn Thus, this edition of the book

involved extensive rewriting, with significant

changes in wording, the expansion of existing

chap-ters, and the addition of several new chapters of

con-tent as well as the updating that largely comprises a

revision All chapters and bibliographies have been

critically scrutinized and updated Content has been

expanded, added, or deleted as indicated

What was Part IV on Management of the

Interconceptional Period in the first and second

edi-tions has been renamed Health Care of Women and

appears as Part II in the third edition Many of the

new chapters are in this section This section also

contains a chapter on primary care, which includes

new and expanded material on the definition of

pri-mary health care of women; basic gynecologic care

with an emphasis on the diagnosis and treatment of

vaginitis/cervicitis and sexually transmitted

dis-eases; pelvic inflammatory disease; Pap smears;

di-ethylstilbestrol (DES) exposure; toxic shock

syndrome; and premenstrual syndrome The family

planning methods in this section have been updated

and expanded to include more natural methods of

family planning, a chapter on long-term hormonal

contraception, and information on emergency

post-coital contraception

The second edition added a chapter on

out-of-hospital birth settings; the third edition takes the

ad-ditional step of integrating all practice settings

throughout the book The second edition was inpress just before the HIV/AIDS epidemic was gener-ally recognized The topics of HIV/AIDS and uni-versal precautions are integrated throughout thethird edition, in addition to being covered in depth

in new chapters on the health care of women withHIV/AIDS and on universal precautions Other newchapters address the full scope of practice of themidwife: preconception care, women and exercise,gynecologic and obstetric care of lesbian and bisex-ual women, substance abuse, midlife health, fetal as-sessment, Norplant insertion and removal, inserting

an intrauterine pressure catheter, attaching a fetalscalp electrode, and circumcision Kate McHugh hastotally rewritten all the chapters in Part V onNewborn Care and added a new chapter on the pri-mary care of the newborn in the first six weeks.All told, the book has almost doubled in size (acombination of page size and number of pages)since the first edition was published 16 years ago.The preface and acknowledgments to the first andsecond editions are included in the third edition Ikept them in not only for historical purposes butalso because in them I articulated why this bookwas originally written and the educational princi-ples and beliefs on which this book is based As al-ways I welcome the comments of readers, includingsuggestions that will enable me to better meet theneeds of our students, our colleagues, ourselves,and our profession in this book

Acknowledgments

The third edition is the product of many helpinghands I am going to run the risk of naming thembecause I believe that contributions should be ac-knowledged publicly and because the third edition

is truly the effort of a large number of people whobelieve in the book and its contribution to our pro-fession I hope not to offend anyone by unintendedoversight The contribution of each was invaluable.The third edition would not have been writtenwere it not for my friend Margaret-Ann Corbett,CNM, MS, JD It was Margaret-Ann who saw methrough the death of both of my parents, five majorsurgeries, and almost two years of daily occupa-

xxxii

Preface to the Third Edition

tional therapy for my right elbow and hand since

the last edition of this book Just as I began to feel

my energy returning, Margaret-Ann spoke with me

quite seriously about her concerns that the book

was now out of date and what this could mean to

the profession that I love so much Throughout the

subsequent year and a half it has taken to write the

third edition, Margaret-Ann has provided

continu-ous support, encouragement, wise counsel, and a

sane balance in my life as well as help with

obtain-ing permissions and proofreadobtain-ing I am deeply

grateful for all

The Guardian Angels of Varney’s Midwifery,

Third Edition was what I named a group of Air

Force nurse-midwives at Andrews Air Force Base In

addition to Captain Nancy Lachapelle, CNM, MS,

the Squadron Leader of the Guardian Angels, the

core group consisted of Lieutenant Colonel Debra

Erickson-Owens, CNM, MS, Lieutenant Colonel

Colleen Gutierrez, CNM, MS, Lieutenant Colonel

Dorothea Morris, CNM, MS, and Major David

Padd, CNM, MS Major Marsha Atkins, CNM, ND

was an early member of the group prior to being

transferred to another Air Force base, and Major

David Kutzler, CNM, MS joined the group in time

for proofreading Nancy wrote me a letter on behalf

of the group, none of whom I knew, to volunteer

their services in whatever way would be helpful to

get out the third edition The timing of her letter was

shortly after Margaret-Ann’s motivating talk, and

after ascertaining the group’s expectations and

al-truistic motivations, I took them up on their offer

The Guardian Angels, under Nancy’s tutelage,

divvied up and did the painstaking work of reading

the entire second edition word for word and

mark-ing it for additions, deletions, changes, and

updat-ing They then did the leg work of library research

With each chapter they sent copies of the latest

arti-cles and book references pertinent to the topics they

believed needed to be changed, updated, or added I

wrote a large part of the third edition last summer in

my home far down east on the coast of Maine a long

way from any university libraries for health care

professionals The writing would not have been

pos-sible without the work of the Guardian Angels Two

of them, Nancy Lachapelle and Colleen Gutierrez,

also drafted new chapters that I had requested and

became coauthors on them with me The Guardian

Angels were unfailingly willing, cheerful, and

on-time productive All I had to do was ask and they

would respond on a moment’s notice to horrendous

deadlines; the last time was for proofreading How

does one say thank you to guardian angels? But

thank them I do, not only for the work they did for

the book but for the fun I’ve had in getting to knowthem

There are several authors to thank for newchapters in the third edition In previous editions theonly chapters totally written by someone other than

me were the chapters on the newborn If I thoughtsomething needed to be added to the book that Ididn’t know how to do, I learned it so I could writeabout it from experience, as I did with out-of-hospi-tal birth, uterine exploration, and manual removal

of the placenta for the second edition This was notpossible for the third edition It was clear to me that

I could not claim to be an expert in all the facets ofnurse-midwifery practice that needed to be included

in the third edition I sought out the experts, andeach responded with alacrity to my call for helpwithout even asking about contracts or payment;their only interest was to contribute to the profes-sion through writing for the third edition I thankeach of them—Sue Andrews, CNM, MAT, MSN;Ann Cowlin, MA, CSM; Vivian Lowenstein, CNM,CRNP, MSN; Nancy Jo Reedy, CNM, MPH; MaryEllen Rousseau, CNM, MS; Carolyn Gegor, CNM,

MS, RDMS, and Jan Kriebs, CNM, MSN; andChristina Krutsky, CNM, MSN, Jennifer Foster,CNM, MPH, Nina Kleinberg, CNM, MSN, AnneMorris, MD, and Kathleen Singleton, RN, MPH notonly for their magnificent contributions but also fortheir support, unhesitating willingness, and thepleasure of working with them on their chapters

A special thank you goes to Nancy Reedy, whocame to Maine to coauthor Chapter 21 on antepar-tal complications with me Nancy also wrote a newchapter on substance abuse, reviewed the old chap-ter on intrapartal complications to suggest revisionsand put me in touch with Linda Bertucci, andthrough it all kept saying, “Helen, just tell me whatyou want me to do and I will do it for you.”Working with Nancy was a happy time of relivingold memories, making new ones, being productive,and knowing that the new tables in Chapter 21would be the type midwives would copy to put intheir pocket clinical notebooks

Linda Bertucci more than lived up to Nancy’srecommendation and I am grateful for Linda’s revi-sion of the section in Chapter 25 on abnormal fetalheart rates and patterns I am also grateful to PatPaluzzi, CNM, MPH for sharing materials and forher help in integrating content on domestic violence

My other visitor to Maine for the purpose ofwriting was Kate McHugh, CNM, MSN, author ofall the chapters on the newborn Kate told me thatrewriting the neonatal chapters (in contrast to revis-ing the previously written neonatal chapters for the

second edition) gave her the wonderful feeling of

writing in her own voice And a wonderful voice it is

Thank you, Kate, for elegant writing; shared purpose,

values, and experiences; and friendship throughout

In addition to my collection of books and the

work of the Guardian Angels, two other people

made my writing life in Maine possible without

im-mediate access to a library Thanks go to Mary

Brucker, CNM, DNSc, who generously shared the

results of her life-long habit of clipping and filing

articles by sending me her most recent article files

and the references for the educational modules in

the Parkland School of Nurse-Midwifery The other

thank you goes to Mary Angelotti, MLS, MS,

li-brarian in the Yale University School of Nursing

Wiedenbach Reference Room, whose helpfulness

was as close as my telephone and fax machine

It was a special treat to work with an old friend

separated by distance, Carmela Cavero, CNM, MS,

FACNM, as coauthor of the chapter on natural

methods of family planning I had asked Carmela to

review the old chapter and tell me honestly what

she thought She did and became coauthor of the

chapter, for which I am grateful

I am deeply grateful to Barbara Decker, CNM,

EdD, FACNM, Director of the Yale University

School of Nursing Nurse-Midwifery Program, for

her caring, unfailing support, understanding, and

positive reinforcement, and to Judy Krauss, RN,

MSN, FAAN, Dean of the Yale University School of

Nursing, for her continuing support, thoughtfulness,

good humor, and generosity of time Special thanks

are due to Yale University School of Nursing faculty

member Carrie Klima, CNM, MSN, who was the

of-ficial photographer and spent hours taking and

re-taking pictures to satisfy not only her own but my

and the production editor’s demanding eyes Yale

University School of Nursing faculty Heather

Reynolds, CNM, MSN, Mary Ellen Rousseau,

CNM, MS, and Leslie Robinson, CNM, MSN and

their patients posed for Carrie’s camera lens, as did

Yale University School of Nursing students Candice

Becker, RN, SNM, MPH, Julianne Seymour, RN,

BA, MSN, and Michelle Sullivan, RN, SNM, BSN

Thanks to all

Several other CNMs also contributed to the

ef-fort to obtain pictures and figures in the book: Mary

Bradish, CNM; Connie Breece, CNM, MSN; Mary

Ellen Galante, CNM, MSN; Susan Thomforde,

CNM, MSN; Susan Ulrich, CNM, DrPH; and

Deanne Williams, CNM, MS Henrietta Clews,

CNM, MSN, Pat Cross, and Lucille Madri, AS,

con-tributed in circumscribed but significant ways

Grateful thanks to each

Toward the end, when every day meant a delay

in when the book would be available, I traveledwith page proofs to Palm Desert, Washington,D.C., and Maine seeking help from members of theACNM Division of Accreditation Governing Boardand Board of Review as well as from the GuardianAngels, Yale University School of Nursing facultyand students, family, and friends Proofreading wasdone by Mary Brucker, CNM, DNSc; Nancy Clark,CNM, PhD; Margaret-Ann Corbett, CNM, MS,JD; Barbara Decker, CNM, EdD, FACNM; Jeanne

F DeJoseph, CNM, PhD, FAAN; Donna Diers, RN,MSN, FAAN; Theresa Gesse, CNM, PhD;Lieutenant Colonel Colleen Gutierrez, CNM, MS;Betty Hilliard, CNM, PhD, FAAN, FACNM; CarrieKlima, CNM, MSN; Major David Kutzler, CNM,MS; Captain Nancy Lachapelle, CNM, MS; TeresaMarsico, CNM, MEd, FACNM; LieutenantColonel Dorothea Morris, CNM, MS; KristinMurray, RN, SNM, BA; Major David Padd, CNM,MS; Nancy Jo Reedy, CNM, MPH; Kelly Riordan,

RN, SNM, BA; Betty Schlatter, CNM, PhD;Elizabeth S Sharp, CNM, DrPH, FAAN, FACNM;Lara Slattery, BA; Gwen Spears, CNM, MSN,FACNM; and John Varney, BS, MBA A heartfeltthank you to each

One of the joys of the third edition has been

my association with Jones and Bartlett Publishers,the new publishing company for the book Theirwelcoming inclusion and philosophy of involve-ment of the author in all stages of production;eager willingness to listen and understand the com-plexities of our profession; and overall class acthave been deeply appreciated I thank all withwhom I have been involved at Jones and Bartlettbut wish especially to thank Clayton Jones, MarySanger, and Jan Wall Jones and Bartlett’s philoso-phy was shared by Lifland et al., Bookmakers, towhom Jones and Bartlett contracted the copyedit-ing Special thanks to Quica Ostrander who re-versed my residual horror from the second editionwith her very fine comprehensive copyediting andcontinuing communication throughout

Finally, I thank all those who spoke to me withcomments or suggestions to improve the book Twowrote thoughtful and specifically detailed letters:thanks to Phyllis Long, CNM, MPH and to PaulaStephens-Bibeau and the 100th graduating classfrom the Frontier Nursing School of Midwifery.Truly this has been a book from the profession

to the profession

Helen Varney BurstNew Haven, Connecticut

The First Edition of this book reflected the

basic practice of nurse-midwifery in the

United States The Second Edition addresses

the full scope of nurse-midwifery practice in the

United States, thereby adding the two ends of a

con-tinuum that extends from home birth to

collabora-tive management of high-risk patients with

physicians in tertiary medical centers

The process of addressing the full scope of

nurse-midwifery practice entailed a rethinking of

the philosophy and definition of nurse-midwifery A

commonly held viewpoint is that nurse-midwifery is

the management of the health care of only normal,

or essentially normal, women A review of our

his-tory is instructive because it is quickly obvious that

nurse-midwifery was never limited to “normal” or

“low-risk” childbearing women The women in the

remote areas of the Kentucky mountains in 1925,

or in the Madera County, California project, or in

Mississippi, or in the city hospitals of New York

City, or any of the number of other underserved

areas where nurse-midwives have reduced perinatal

and infant mortality and prematurity rates and

in-creased birth weights, were high-risk, or at-risk,

and rarely low-risk The education of

nurse-mid-wives has always emphasized screening for the

ear-liest possible signs and symptoms of an existing or

developing complication The profession has

un-shakably believed that nurse-midwives must work

in a health care system that provides for physician

consultation, collaboration, and referral Such

em-phasis on screening and relationships with

physi-cians clearly reflects concerns emanating from

working with at-risk or high-risk populations from

the beginning of our profession in the United States

In the days when nurse-midwives worked only

with underserved, and therefore at-risk or high-risk,

populations, it was assumed that the nurse-midwife

managed the care of the woman as long as she was

essentially normal, consulted when there was any

evidence of complications, and continued to care

for the woman in a collaborative relationship with

the physician It was always entirely possible that if

a woman remained essentially healthy that she

would never see a physician This did not deny,however, the role of the nurse-midwife in contribut-ing to the collaborative management of at-risk orhigh-risk patients if they developed complicationsnor the focus of the nurse-midwife upon those as-pects of childbearing which are normal in anywoman, regardless of how complex her obstetriccare becomes

It was not until nurse-midwifery included theprivate patient sector in the early 1970s that nurse-midwives began taking care of women from an es-sentially healthy, largely normal or low-riskpopulation Many of these women were seekinghealth care that involved them and their families inknowledgeable participatory decision making andwhich supported natural, normal processes Theyfound this in the care given by nurse-midwives.Some of them were disenchanted with technologyand displeased with routine hospital maternity care.Nurse-midwives responded by being advocates forthe women (both normal and complicated) who re-mained within the hospital health care system and

by providing care to carefully screened, normalchildbearing women in out-of-hospital settings.Being able to work with a variety of popula-tions has meant that some nurse-midwives focus onone or another of these populations and thus applythe basic practice of nurse-midwifery to either end

of the continuum Those who work solely with amiddle/upper class, educated, healthy population in

an out-of-hospital setting have a different worldview of the practice of nurse-midwifery than thosenurse-midwives who work solely with a lower so-cioeconomic, complicated population in a tertiarymedical center This has led at times to a sense of di-chotomy or of nurse-midwives on either end of thecontinuum being out of harmony with either ac-cepted practice or with our basic definition Nottrue Our history encompasses the care of women inall settings Our focus on normal does not define orlimit our patient populations; it simply defines ourarea of expertise regardless of the population

This edition of Nurse-Midwifery thus adds the

two ends of the continuum Chapter 20 is a new

xxxv

Preface to the Second Edition

chapter which focuses on out-of-hospital birth and

the responsibilities of both the consumer and the

nurse-midwife in that setting At the other end of

the continuum Chapters 9 and 14 on antepartal and

intrapartal complications have been completely

rewritten and expanded to reflect the contribution

the nurse-midwife makes to the collaborative

management of complicated patients These two

chapters also add topics not included in the First

Edition such as size/dates discrepancy,

small-for-dates, large-for-small-for-dates, postsmall-for-dates, oligohydramnios,

preterm labor, etc Chapters 57 and 58 on manual

removal of the placenta and intrauterine

explo-ration were added because of recognition that these

are essential skills for a nurse-midwife to know in

any setting in the event of an emergency This led to

changes in Chapters 17 and 19 on the management

of third and fourth stage hemorrhage

All chapters and bibliographies have been

criti-cally scrutinized, updated, and content expanded,

added or deleted as indicated I made a deliberate

last-minute decision to retain the chapter on

in-trauterine contraceptive devices (Chapter 31) after

they were removed from the market because (1)

some women we care for still have them, (2) some

Certified Nurse-Midwives practice in other

coun-tries where they are still available, and (3) I believe

they someday once again will be available in the

United States and we need to have that knowledge

The removal of Nisentil from the market did not

happen until too late to make changes in Chapter

12 The dedication, preface, and acknowledgments

to the First Edition were retained for historical

pur-poses and because the purpose of this book and the

educational principles used in its writing have not

changed and are articulated in the preface to the

First Edition

Once again I welcome comments from readers

including suggestions “which will enable me to ever

better meet the needs of our students, our

col-leagues, and ourselves in this book.”

Acknowledgments to the Second Edition

Writing a new edition is quite different from

writ-ing the original text The original text was based on

what I knew, had practiced and taught for a

num-ber of years I wanted, however, in the Second

Edition to include some aspects of practice with

which I was not as well versed Since I refuse to

write what I do not know and have not done

my-self, writing the Second Edition required some

preparation and expansion of my own scope of

practice

I owe a debt of gratitude to four very specialCNM friends who generously gave of themselvesand allowed me to practice with them in their set-tings With three of them I had the greatest joy andfulfillment a teacher can have: that of working withformer students who now were teaching me

My odyssey for the Second Edition began withJudy Edwards, CNM, MS, with whom I began thetransition away from 20 years experience in deliv-ery rooms in tertiary medical centers The patients

in the obstetrical practice Judy is in deliver in aLevel I New Hampshire community hospital whichhas a nursing staff supportive of all possible alter-natives and delivery positions Judy’s experienced,laid-back and honest approach provided a safe set-ting for me to accept the welcome challenge oflearning what for me were new methods of delivery

My education in this vein culminated with JudyKier, CNM, MSN in her combination birth centerand home birth practice, Women’s Health CareAssociates in Houston, Texas Under Judy’sthoughtful, analytical, and articulate tutelage I ex-panded my mind in the realm of alternative modal-ities I also learned the basics of out-of-hospitalpractice This learning is reflected in Chapter 20 Aspecial thank you goes to Cheryl, Tom, and AshleyMarie Linn who shared their life and home birthwith me and to Susan Melnikow, CNM, who com-pletely integrated me into the experience

Susan Wente, CNM, MPH, Director ofMidwifery at Baylor Medical College/JeffersonDavis Hospital in Houston, Texas, spent precioustime with me as I learned the procedures of manualremoval of the placenta and intrauterine explo-ration (Chapters 57 and 58) What Susan has ac-complished in a health care and hospital systemthat has the largest number of deliveries in thecountry is a pre-eminent model which served to re-mind me of the immense impact public health ori-ented nurse-midwifery can have

Therese Dondero, CNM, BSN, Director ofMidwifery, North Central Bronx Hospital, NewYork, not only shared her unique setting with mebut challenged me to remember my own earlyteachings and to rethink, again, the philosophy, def-inition, and scope of practice of nurse-midwifery.She entered this soul-searching thought processwith me and then joined with me in the outcome ofthis process by coauthoring the total rewrite andexpansion of Chapters 9 and 14 She also was in-fluential in the review and discussion of parts ofChapters 3, 15, 17, 19, 20, 57, and 58 A year and

a half of driving down and up the Merritt Parkway

to accomplish this not only reinforced my

enjoy-ment of that drive but also built a fund of shared

time and thoughts with Therese which I treasure

Kate McHugh, CNM, MSN, accepted the job

of reviewing, updating, and rewriting the section on

the Neonate (Chapters 21, 22, and 23) Kate is a

former neonatal intensive care nurse specialist and

a former Yale nurse-midwifery faculty member who

taught the Neonatal Module It was good to once

again work and enjoy lively and purposeful

discus-sion with her

I said in the preface to the first edition that I

would welcome comments and suggestions A few

wrote thoughtful and specifically detailed letters:

Doris Abbott, CNM, MPH, Patricia Deibel, CNM,

BSN, Helen Gabel, CNM, MSN, Mary Alice

Johnson, CNM, MSN, and Phyllis Long, CNM,

MSN Into this category must also go the helpful

book review written by Mary Widhalm, CNM, MS

Many other CNMs wrote or spoke to me with

use-ful tidbits which ranged from clinical observations

to missing categories in the index Elisabeth Genley,

CNM, MSN felt so strongly about the deficits of

the index while a student that she became the

in-dexer for this edition In addition, Rochelle Kanell,

CNM, MS undertook the initial critical review of

Section VI (Chapter 26, 27, 28, 29, 30, and 31) to

identify content that needed to be updated and

added

Samuel G Oberlander, MD, FACOG, Assistant

Clinical Professor, Department of

Obstetrics-Gynecology, Albert Einstein College of Medicine,

Bronx, New York, graciously reviewed the new andupdated material in Chapters 9, 14, 17, 19, 57, and

58 for obstetric theoretical accuracy EllenHarrison, MD, Associate Director of Medicine,Montefiore-North Central Bronx HospitalAffiliation and Assistant Clinical Professor,Department of Medicine, Albert Einstein College ofMedicine, Bronx, New York was critically helpful

in her review of the segments on hepatitis and berculosis I retain, however, full responsibility forany inaccuracies and the determination of clinicaljudgment presented in this book

tu-Friends and family again played a critical role inthe writing of the book Margaret-Ann Corbett,CNM, JD, Anne Malley-Corrinet, CNM, MS, andJerrilyn Meyer, CNM, MS took primary care of me

as a person My parents, Theodore R and HeleneHahn Varney, sacrificed precious time for us to be to-gether and were unfailingly interested and encourag-ing

Finally, I wish to acknowledge the editorial help

of Richard Zorab, Editor in Chief, and of ElizabethMcGuire, Production Manager, at BlackwellScientific Publications; and of Patricia Sheehan.Richard was especially supportive and facilitativewhen contracted copyediting proved problematicand delayed the publication of this edition by sev-eral months

A heartfelt thank you to all

Helen Varney BurstNew Haven, Connecticut

This book was written because it needed to be

written As a nurse-midwifery educator I

quickly became aware of my students’

frus-tration in trying to piece together what the practice

of nurse-midwifery is from a conglomeration of

American nursing and medical literature and

English midwifery texts The former was either too

superficial or too much in depth with too little

de-tail, while the latter were not always applicable to

the practice of nurse-midwifery in the United States

This affected, in part, the content of this book For

example, the section on skills (Part VII) was written

because the medical texts are woefully inadequate

in explaining to non-physicians how to perform

tra-ditionally medical procedures Consequently

fac-ulty in the different nurse-midwifery programs have

written their own procedures or borrowed from

other programs Nurse-midwifery educators are

characterized by their willingness to help each other

and to share their materials with their peers This

has resulted in a sizable body of unpublished

litera-ture What a student in any given program might

actually get, however, varies considerably from

pro-gram to propro-gram The rest has been taught in the

oral tradition from teacher to student, from

demon-stration to demondemon-stration, from generation to

gen-eration All have learned, and learned well, but at

the price of frustration for the student and endless

repetition for the teacher

Several educational principles have guided the

writing of this book A primary one has been that

learning takes place best when used For this reason

the anatomical, physiological, and psychological

bases for what is being observed and the rationale

for action are given together rather than in separate

and discrete chapters This has been reinforced by

my belief that the nurse-midwifery management

process is the core of any nurse-midwifery

curricu-lum I first articulated the rudiments of this process

in Mississippi based in part on my observations and

analyses of my own and others’ thought processes

when managing the care of patients Others have

since added their own interpretations The one

pre-sented in this book is a composite drawn from

many minds Learning the nurse-midwifery agement process is facilitated by basic educationalprinciples of application and reinforcement In turn,the design of the process is such as to foster the uti-lization of these basic educational principles inteaching

man-This book has a definite hospital orientation, inpart because this is what I know, and in part be-cause this is where the basic education of studentsusually takes place This orientation is not meant toimply any questioning of the value of out-of-hospi-tal birth settings nor to reflect any personal reser-vations on my part in relation to them Future

editions of Nurse-Midwifery will include expanded

coverage of nurse-midwifery practice in pital birth settings, additional aspects of care duringthe interconceptional period, and comprehensivecare of the pregnant adolescent as a specialty area.Finally, I have designed this book so that it will

out-of-hos-be of value as a permanent reference not only tonurse-midwifery students but to all those who areinvolved in the care of women and of the child-bearing family I welcome comments from readers,including suggestions which will enable me to everbetter meet the needs of our students, our col-leagues, and ourselves in this book

Acknowledgments to the First Edition

This book would not exist were it not for a number

of helping and helpful people, some whose butions have been highly visible and others whohave been supportive in various indirect ways.There have been the many who posed for pictures,took pictures, sent pictures, sent professional litera-ture and materials, typed, photocopied and, most ofall, patiently waited And there have been the manywho have touched and shaped my life and beliefs innurse-midwifery: from Ernestine Wiedenbach,CNM, MA, my teacher and mentor from the be-ginning; through nurse-midwifery faculty and staff

contri-in the contri-institutions where I have studied; to thenurse-midwifery faculty, staff, and students at theUniversity of Mississippi Medical Center(1969–1974); the faculty, staff, and students at the

xxxviii

Preface to the First Edition

Medical University of South Carolina (1974–1979);

the faculty in the nurse-midwifery education

pro-grams I have served as a consultant; the Certified

Nurse-Midwives who have shared so much with me

during my terms of office as President of the

American College of Nurse-Midwives; and now the

faculty and students at Yale University

There has been one person who has lived the

book with me To my friend, Margaret-Ann

Corbett, CNM, MS, goes the most special

ac-knowledgment and thank you for her never-failing

encouragement, wise counsel, performance of

innu-merable detailed tasks, and provision of a sane

counterbalance to the demands of the book

A special acknowledgment and thank you also

goes to Sally Ann Yeomans, CNM, MSN, who has

given much personally and professionally out of her

conviction that the book should be written This

in-cluded her assuming the Chairpersonship of the

Division of Examiners of the American College of

Nurse-Midwives which I held, so I would have the

time to write

A very special thank you must be said to Joy M

Brands, CNM, MPH, who rescued me and the

book at one low point by volunteering to write the

Neonatal section She enlisted the aid of Mary J

Banigan, RN, PhD in that project and the results

are Chapters 20, 21, and 22 They were assisted in

their endeavors by Sally Ann Yeomans

A number of professionals reviewed parts of

the book Foremost among these is Henry A

Thiede, MD, FACOG, Professor and Chairman,

Department of Obstetrics-Gynecology, The

University of Rochester School of Medicine and

Dentistry and Strong Memorial Hospital He

re-viewed the entire book for medical accuracy always

with ready willingness and a prompt response

Alfred W Brann, Jr., MD, FAAP and Linda Book,

MD, FAAP, reviewed the section on the

Management of the Newborn Agnes Higgins, CM,

BSc, PDT, FRSH, LLD, Executive Director of the

Montreal Diet Dispensary, reviewed Chapter 8

Helen E Browne, CNM, ScD (Hon.), CBE, Aileen

Hogan, CNM, MA, Ruth Lubic, CNM, PhD,

Agnes Reinders, CNM, MS in NEd., and Ernestine

Wiedenbach, CNM, MA, reviewed parts of the

first two chapters Margaret-Ann Corbett, CNM,

MS, and Linda Wheeler, CNM, EdD reviewed other

chapters throughout the book All reviewers took this work at my request as personal favors and

under-I whole-heartedly thank them all, while assumingfull responsibility for any inaccuracies which mayexist

I learned a great deal about the arts from BettyGoodwin, Chief, Section of Illustration and Design,Division of Audiovisual Production, MedicalUniversity of South Carolina, who drew the originalillustrations in this book, and from John WattsClark, ARPS, Supervisor of Photograph Department,Medical University of South Carolina, the photogra-pher who took most of the original photographs inthis book Their helpfulness and pleasant ways made

my learning what is entailed in their respective fields

a most enjoyable experience

I have known several editors throughout theprocess of writing this book A special thank yougoes to Christopher Campbell and Martha WhiteTenney of Blackwell Scientific Publications, Inc.,and to Eleanor Mora Without Chris and Martyurging and helping me through the last stages ofproduction, the book would have stopped at thepoint of an edited manuscript Special thanks must

be given to Donna Diers, RN, MSN, FAAN, Deanand Professor of Yale University School of Nursing,for instigating and encouraging the contacts be-tween Christopher Campbell and myself that led tothe finalization and realization of the book

In the end it was my local friends who enabledthe book to be finished The bulk of the six hundredpages of galleys was divided up and proofread byJoy Ruth Cohen, CNM, MSN, Margaret-AnnCorbett, CNM, MS, Anne Malley-Corrinet, CNM,

MS, Donna Diers, RN, MSN, FAAN, Charlotte(Pixie) Elsberry, CNM, MSN, Elizabeth Grob,CNM, BSN, and Elizabeth Cole Rogers, CNM,MN

Finally, not least but most, I acknowledge andthank my parents, Theodore R and Helene HahnVarney, who have provided both personal encour-agement and financial support through the years ithas taken to write this book, and in whose honor Ihave decided to publish this book under my maidenname

Helen Varney BurstNew Haven, Connecticut