varney’s
midwifery
Other Titles Available from Jones and Bartlett Publishers
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,
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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
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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

helen varney, cnm, msn, dhl, (hon.) FACNM
Professor, Nurse-Midwifery Specialty
Yale University School of Nursing
Jan M. KrIebs, cnm, msn, facnm
Assistant Professor, Department of Obstetrics,
Gynecology, and Reproductive Sciences
University of Maryland School of Medicine
carolyn l. gegor, cnm, msn, facnm
FORMERLY Assistant Professor, Department of Obstetrics,
gynecology, and reproductive sciences
University 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
Varney, Helen.
Varney’s midwifery / Helen Varney Burst, Jan M. Kriebs, Carolyn L. Gegor. – 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7637-1856-4
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

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A rededication to the students, practitioners, and
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 Nurse-

Midwives whose masterly contributions to our profession were
tragically curtailed because of untimely death.
Dedication to the First Edition
For my students, peers, and colleagues; the profession of nurse-
midwifery; and the women, mothers, babies, and families who
receive health care from those who study this book.
Holy Births and Howling Babies
In my backyard there are nuns who live in a shaded brick building
next 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
vii
Brief Contents
Part I Midwifery
Chapter 1 The Profession and History of Midwifery in the United States 3
Chapter 2 Basics of Management of Care 29
Part II Primary Care of Women
Chapter 3 Cultural Competence in Midwifery Practice 49
Jo-Anna L. Rorie
Chapter 4 International Midwifery and Safe Motherhood 59
Margaret A. Marshall
Joyce E. Thompson
Chapter 5 Preconception Care 85
Chapter 6 Nutrition in Women’s Health 99
Jenifer O. Fahey
Chapter 7 Primary Care and Midwifery 135
Chapter 8 Chronic Infectious Diseases 165
Chapter 9 Women and Exercise 187
Ann Cowlin
Chapter 10 Pharmacology and Midwifery 249

Mary C. Brucker
Mary Ann Faucher
Chapter 11 Health Issues of Lesbian and Bisexual Women 299
Laura Zeidenstein
Chapter 12 Substance Abuse 313
Nancy Jo Reedy
Mary C. Brucker
Chapter 13 Health Care of Midlife and Aging Women 335
Mary Ellen Rousseau
Part III Reproductive Health Care
Chapter 14 Common Diagnoses in Women’s Gynecological Health 379
William F. McCool
Dawn Durain
Chapter 15 Infections of the Genital Tract 439
Chapter 16 Family Planning and Contraception 461
Chapter 17 Natural Methods of Family Planning 471
Carmela Cavero
Chapter 18 Nonhormonal Contraceptive Methods 481
Chapter 19 Intrauterine Contraceptive Devices 499
Chapter 20 Hormonal Contraception 513
Part IV Antepartal Care
Chapter 21 Normal Pregnancy Database: Adaptations of the Mother, Development and Growth of
the Embryo and the Fetus, and the Placenta 543
Chapter 22 Management Plan for Normal Pregnancy 571
Chapter 23 Fetal Assessment 623
Chapter 24 Screening for and Collaborative Management of Antepartal Complications 661
Chapter 25 Complications of Gestational Age Assessment and the Postdate Pregnancy 715
Carol L. Wood
Part V Intrapartal Care
Chapter 26 The Normal First Stage of Labor 737

Chapter 27 Fetal Assessment During Labor 793
Chapter 28 The Normal Second Stage of Labor 821
Chapter 29 Screening for and Collaborative Management of Selected Complications During the
First and Second Stages of Labor 853
Chapter 30 Management of Selected Obstetric Complications and Deviations from Normal 883
Chapter 31 The Normal Third Stage of Labor 905
Chapter 32 Third Stage Complications and Management 913
Chapter 33 The Normal Fourth Stage of Labor 917
Chapter 34 Management of Immediate Postpartum Hemorrhage 925
Chapter 35 Birth in the Home and in the Birth Center 929
Alice J. Bailes
Marsha E. Jackson
Part VI Newborn Care
Chapter 36 Physiological Transition to Extrauterine Life 961
Mary Kathleen McHugh
Chapter 37 Immediate Care and Assessment of the Healthy Newborn 973
Mary Kathleen McHugh
Chapter 38 Resuscitation at Birth 983
Mary Kathleen McHugh
Chapter 39 Examination of the Newborn 999
Mary Kathleen McHugh
Chapter 40 Primary Care of the Newborn: The First Six Weeks 1011
Mary Kathleen McHugh
viii Brief Contents
Chapter 41 Recognition and Immediate Care of Sick Newborns 1029
Mary Kathleen McHugh
Part VII Postpartal Care
Chapter 42 The Normal Puerperium 1041
Chapter 43 Infant Feeding 1067
Karin Cadwell

Cynthia Turner-Maffei
Sarah Coulter Danner
Chapter 44 Screening for and Midwifery Management of Puerperal Abnormality 1093
Part VIII Skills
Chapter 45 Universal Precautions 1107
Chapter 46 Finger Puncture 1109
Chapter 47 Venipuncture 1113
Chapter 48 Inserting an Intravenous Catheter 1121
Chapter 49 Giving Intravenous Medications 1125
Chapter 50 Spin-Down Hematocrit 1127
Chapter 51 Removal of Norplant 1131
Chapter 52 Breast Examination 1135
Chapter 53 Obstetric Abdominal Examination 1147
Chapter 54 Checking for Costovertebral Angle Tenderness 1161
Chapter 55 Checking for Deep Tendon Reflexes and Clonus 1163
Chapter 56 Pelvic Examination 1169
Chapter 57 Obtaining a Specimen for Papanicolaou (Pap) Diagnostic Evaluation 1195
Chapter 58 Obtaining a Specimen for Gonococcal (GC) and Chlamydia Diagnostic Testing 1199
Chapter 59 Making a Wet Smear Slide of Vaginal Secretions 1201
Chapter 60 Using a Microscope 1203
Chapter 61 Anatomy of the Pelvis, Pelvic Types, Evaluation of the Bony Pelvis, and Clinical
Pelvimetry 1205
Chapter 62 Breast Massage, Manual Expression, and Nipple Rolling 1217
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
Chapter 65 Attaching a Fetal Scalp Electrode 1227
Chapter 66 Perineal Prep (Cleaning) 1231
Chapter 67 Second Stage Pushing 1233

Chapter 68 Pudendal Block 1235
Chapter 69 Local Infiltration 1239
Chapter 70 Hand Maneuvers for Birth with the Mother in Lithotomy or Modified Lithotomy
Position 1241
Brief Contents ix
Chapter 71 Hand Maneuvers for Birth with the Mother in Dorsal Position 1249
Chapter 72 Hand Maneuvers for Birth with the Mother in the Hands and Knees Position 1253
Saraswathi Vedam
Chapter 73 Hand Maneuvers for Birth with the Mother in the Squatting or Supported Squat
Position 1257
Saraswathi Vedam
Chapter 74 Inspection of the Placenta, Membranes, and Cord 1261
Chapter 75 Postbirth Inspection of the Cervix and Upper Vaginal Vault 1267
Chapter 76 Manual Removal of the Placenta 1269
Chapter 77 Fourth Stage Intrauterine Exploration 1271
Chapter 78 Bimanual Compression 1273
Chapter 79 Cutting an Episiotomy and Repairing Episiotomies and Lacerations 1275
Chapter 80 Physical Examination of the Newborn 1295
Chapter 81 Circumcision 1313
Vivian H. Lowenstein
Chapter 82 Endometrial Biopsy 1327
Wendy Grube
William F. McCool
x Brief Contents
Contents
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
Chapter 1 The Profession and History of Midwifery in the United States 3
Definitions and Practice 3
Beliefs Characterizing Midwifery 4
Early History 5
Factors Leading to Disrepute 5
The Early Twentieth Century 7
The First Nurse-Midwifery Education Programs 10
The 1940s and 1950s 12
The 1960s 13
The 1970s 14
The 1980s 17
The 1990s and Early 2000s 18
The American College of Nurse-Midwives 19
References 23
Bibliography 24
Chapter 2 Basics of Management of Care 29
Primary Care and Scope of Practice 29
Independent and Collaborative Management of Care 30
The Management Process 31
Screening for Abnormality and Differential Diagnosis 33
Physical Assessment for a Database 35
References 45
Additional References 46
Part II Primary Care of Women
Chapter 3 Cultural Competence in Midwifery Practice 49
Jo-Anna L. Rorie
The Demographic Shift 50
xi

Women of Color Population Overview 51
Culturally Competent Care 52
Application of the Cultural Competence Continuum 53
Conclusion 56
References 56
Additional References 57
Chapter 4 International Midwifery and Safe Motherhood 59
Margaret A. Marshall
Joyce E. Thompson
Introduction 59
The Situation Worldwide 60
The Newborn 64
Global Partners Promoting the Health of Women and Childbearing Families 66
Frequently Asked Questions About International Midwifery 76
Future Trends and Challenges in International Midwifery 79
References 80
Bibliography 81
Appendix A: Sources for International Health Low Cost Books 83
Appendix B: Helpful Websites and Videos 83
Chapter 5 Preconception Care 85
Health and Risk Assessment 87
Counseling Specific to Preconception Care 88
Medical Risk Factors 89
Environmental and Workplace Issues 93
Preconception Issues for Men 95
Other Considerations 96
Intervention 96
References 97
Chapter 6 Nutrition in Women’s Health 99
Jenifer O. Fahey

Principles of Nutrition 99
Weight and Body Fat Measurements and Overweight and Obesity 112
Cardiovascular Disease 115
Cancer 116
Diabetes 117
Nutrition, the Menstrual Cycle, and Fertility 118
Adolescence 118
Nutrition During Menopause and Beyond 119
Eating Disorders 120
Nutrition and Vegetarianism 122
Nutrition and the Female Athlete 122
Alcohol and Nutrition 123
xii Contents
Nutritional Guidelines 123
Conclusion 129
References 129
Additional References 133
Chapter 7 Primary Care and Midwifery 135
Primary Care 135
Hematologic Conditions 138
The Cardiovascular System 141
Respiratory Diseases 143
Gastrointestinal Disorders and Abdominal Pain 147
Assessing Abdominal Pain 150
Genitourinary Problems 151
Diabetes 152
Thyroid Disease 154
Carpal Tunnel Syndrome 156
Headache 156
Depression 158

Conclusion 160
References 160
Additional References 164
Chapter 8 Chronic Infectious Diseases 165
HIV/AIDS 165
Tuberculosis 175
Hepatitis 177
(Coauthored with Mary Curran)
References 183
Chapter 9 Women and Exercise 187
Ann Cowlin
The Value of Exercise to Women’s Health 187
A New Exercise Model for Adolescent Girls 188
Appropriate Exercise during Pregnancy 193
Exercise for Postpartum Recovery 214
Essential Exercise for Menopause 220
Exercise in the Senior Years 231
Summary 233
References 233
Additional References 247
Chapter 10 Pharmacology and Midwifery 249
Mary C. Brucker
Mary Ann Faucher
Introduction 249
The Lexicon of Pharmacology 249
Contents xiii
Drugs in Modern Society 251
Practicalities and Issues Involving Drugs 252
Adverse Drug Reactions/Adverse Drug Events 255
Drug Resistance 255

Drug-to-Drug Reactions 256
Drug Costs 256
Drugs and Herbs 257
Pregnancy and Drug Use 257
Metabolism 259
Elimination/Clearance 259
Teratology and Drugs During Pregnancy 260
Commonly Used Pharmaceuticals 264
Drugs for the Treatment of Various Medical Conditions 266
Pharmaceuticals and Breastfeeding 268
Selected Drugs and the Breastfeeding Woman 269
Conclusion 272
References 272
Additional References 276
Appendix A: Top 200 Drugs by Rank, by Generic Name, and by Brand Name 277
Appendix B: Teratology Information Systems by Location 289
Appendix C: The Transfer of Drugs and Other Chemicals into Human Milk 292
Chapter 11 Health Issues of Lesbian and Bisexual Women 299
Laura Zeidenstein
Background 299
Data Collection 301
Management of Health Care Issues 302
Childbearing and Parenting 304
Special Health Concerns 307
Summary 308
References 308
Appendix: Resources 310
Chapter 12 Substance Abuse 313
Nancy Jo Reedy
Mary C. Brucker

Introduction 313
Women and Substance Abuse 313
Attraction of Substance Abuse 315
Assessment of Drug Use 316
General Treatment Issues 317
General Management of Substance Abuse During Pregnancy 317
Substance Abuse and Lactation 318
Neonatal Implications 318
Common Substances of Abuse 320
xiv Contents
Appendix A: Health Education Fact Sheet from the American Lung Association on
Nicotine Replacement Therapy (NRT) 330
References 332
Additional References 334
Chapter 13 Health Care of Midlife and Aging Women 335
Mary Ellen Rousseau
Definitions 335
Age at Menopause 336
Adult Development, Society, and Menopause 336
Medicalization of Menopause 336
Endocrinology 339
Changes of Perimenopause and Aging 340
Breast Cancer 347
Cardiovascular Disease 350
Osteoporosis 352
The Perimenopausal Visit 357
Postmenopausal and Older Woman Visit 358
Menopausal Therapeutic Interventions, Preventive Measures, and Health
Promotion 361
The Menopause as Opportunity 366

References 367
Part III Reproductive Health Care
Chapter 14 Common Diagnoses in Women’s Gynecological Health 379
William F. McCool
Dawn Durain
Issues Concerning the Menstrual Cycle 379
Abdominal and Pelvic Pain 396
Pelvic Masses 404
Congenital Uterine Anomalies 407
Pelvic Floor 408
Urinary Incontinence 409
Effects of DES Use 410
Special Considerations in Gynecologic Care 411
Cancer Screening/Diagnoses 413
Conclusion 428
References 429
Chapter 15 Infections of the Genital Tract 439
Vulvovaginal/Cervical Infections and Sexually Transmitted Diseases 439
Pelvic Inflammatory Disease 457
Anaphylactic Shock 458
References 458
Contents xv
Chapter 16 Family Planning and Contraception 461
History and Concepts of Family Planning 461
Selection of a Contraceptive Method 462
Effectiveness of a Contraceptive Method 465
Folklore Methods 466
Sterilization 467
Future Methods of Contraception 468
References 468

Bibliography 469
Chapter 17 Natural Methods of Family Planning 471
Carmela Cavero
The Calendar Method (Rhythm Method) 472
The Ovulation Method (Cervical Mucus Method; Billings Method; Creighton
Model) 472
The Basal Body Temperature Method 474
The Sympto-Thermal Method 475
Lactation Amenorrhea Method 478
Client/Couple Instruction 478
Technology and Natural Family Planning 478
References 478
Bibliography 478
Resources 479
Chapter 18 Nonhormonal Contraceptive Methods 481
Spermicidal Preparations 481
Condoms 484
Diaphragms 487
Cervical Caps 493
Other Vaginal Contraceptive Barrier Methods 496
References 496
Additional References 497
Chapter 19 Intrauterine Contraceptive Devices 499
Description, Effectiveness, User Response, and Noncontraceptive Benefits 499
Contraindications and Side Effects 500
Management Plan for the IUD 501
References 510
Chapter 20 Hormonal Contraception 513
Combination Pills 513
Progestin-Only Contraceptive Pills (Minipills) 527

Emergency Postcoital Contraception 528
Injectable Hormonal Contraception 531
Subdermal Implants 534
Contraceptive Vaginal Ring (NuvaRing) 536
xvi Contents
Transdermal Contraceptive Patch (OrthroEvra) 537
References 539
Additional References 540
Part IV Antepartal Care
Chapter 21 Normal Pregnancy Database: Adaptations of the Mother, Development and Growth of
the Embryo and the Fetus, and the Placenta 543
Maternal Anatomical and Physiological Changes 543
Maternal Physiological Changes 549
Maternal Psychological Adjustment and Processes 553
Fetal Growth and Development 556
Placental Development, Circulation, and Functions 564
References 568
Additional References 569
Chapter 22 Management Plan for Normal Pregnancy 571
Philosophy and Scope 571
Diagnosis and Early Management of Care During Pregnancy 573
Assessment and Evaluation of the Well-Being of the Woman 577
Case Study 587
Common Discomforts of Pregnancy and Their Relief Measures 591
Nutritional Intervention in Pregnancy 598
Instruction and Anticipatory Guidance 608
References 612
Bibliography 614
Appendix A: Immunization During Pregnancy 619
Chapter 23 Fetal Assessment 623

First Trimester Assessment of Pregnancy Well-Being 623
Second Trimester Screening 627
Invasive Fetal Assessment Throughout Gestation 630
Third Trimester Fetal Assessment 632
References 652
Additional References 658
Chapter 24 Screening for and Collaborative Management of Antepartal Complications 661
First Trimester Bleeding 662
Ectopic Pregnancy 666
Hydatidiform Mole 667
Hyperemesis Gravidarum 668
Incompetent Internal Cervical Os 669
Infections 670
Tuberculosis 670
Hepatitis 674
Contents xvii
Rubella 674
Cytomegalovirus 676
Toxoplasmosis 677
Varicella 678
Parvovirus B19 (Fifth Disease, Erythema Infectiosum) 680
Urinary Tract Infections 681
Anemias and Hemoglobinopathies 683
Heart Disease 688
Thyroid Disorders 689
Asthma 690
Multiple Pregnancy 691
Polyhydramnios (Hydramnios) 694
Oligohydramnios 694
Diabetes Mellitus 695

Rh(D) Isoimmunization 699
Placenta Previa 702
Abruptio Placentae 703
Management of Hemorrhage Due to Placenta Previa or Abruptio Placentae 705
Hypertensive Disorders of Pregnancy 705
References 712
Chapter 25 Complications of Gestational Age Assessment and the Postdate Pregnancy 715
Carol L. Wood
Fetal Age Determination 715
The Size/Date Discrepancy: Identifying the Problem 718
Postdate Pregnancy: The Clinical Problem 721
Anatomy and Physiology of the Cervix 722
Management Approach for the Postdate Pregnancy: Anticipatory Versus Active 723
Summary 729
References 730
Part V Intrapartal Care
Chapter 26 The Normal First Stage of Labor 737
Signs and Symptoms of Impending Labor 737
Database for the First Stage of Labor 739
Management of Care During the First Stage of Labor 754
References 790
Chapter 27 Fetal Assessment During Labor 793
Introduction and History 793
Physiology and Scope of Problem 794
Midwifery Management of Nonreassuring Fetal Heart Rate Patterns 811
Methods to Evaluate Fetal Acid-Base Balance Directly 813
Fetal Oxygen Saturation Monitoring 815
xviii Contents
Admission to L&D and Establishing Initial Well-Being 816
Summary 817

References 818
Chapter 28 The Normal Second Stage of Labor 821
Database for the Second Stage of Labor 821
Management Plan for the Second Stage of Labor 829
References 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 853
Preterm Labor/Birth 856
Premature Rupture of the Membranes 863
Amnionitis and Chorioamnionitis 867
Group B Streptococcus 868
Umbilical Cord Prolapse 870
Cephalopelvic Disproportion 872
Deep Transverse Arrest 873
Uterine Dysfunction 874
Maternal Exhaustion (Maternal Distress; Ketoacidosis) 876
Uterine Rupture 876
Blood Transfusion Reaction 877
References 878
Additional References 881
Chapter 30 Management of Selected Obstetric Complications and Deviations from Normal 883
Management of Shoulder Dystocia 883
Delivery of an Infant with a Face Presentation 890
Delivery of an Infant with a Breech Presentation 892
Delivery of a Woman with Multiple Gestation 899
References 901
Bibliography 902
Chapter 31 The Normal Third Stage of Labor 905

Database for the Third Stage of Labor 905
Management Plan for the Third Stage of Labor 907
References 911
Chapter 32 Third Stage Complications and Management 913
Retained Placenta 913
Third Stage Hemorrhage 914
Placenta Accreta 914
Uterine Inversion 915
References 916
Contents xix
Chapter 33 The Normal Fourth Stage of Labor 917
Database for the Fourth Stage of Labor 917
Management Plan for the Fourth Stage of Labor 919
Initiation of Family Relationships with the Newborn 921
References 923
Chapter 34 Management of Immediate Postpartum Hemorrhage 925
Causes of Immediate Postpartum Hemorrhage 925
Predisposing Factors 926
Preparatory Measures 926
Action, Effect, Dosage, and Route of Oxytocic Drugs 926
Management Steps 927
References 928
Chapter 35 Birth in the Home and in the Birth Center 929
Alice J. Bailes
Marsha E. Jackson
Introduction 929
History 930
(Authored by Helen Varney Burst)
Characteristics of Birth Center and Home Birth 933
Birth Center and Home Birth Practice Models 936

Midwife/Client Relationship 938
Initial Visit 939
Return Visits 943
The Family’s Preparation for Birth and Postpartum 943
The Experience of Birth at Home or in the Birth Center 945
The Early Postpartum Period and Follow-up 947
Maintaining Safety 947
How to Accomplish an Effective Hospital Transfer 954
Business Issues 955
Special Home and Birth Center Resources 956
References 957
Part VI Newborn Care
Chapter 36 Physiological Transition to Extrauterine Life 961
Mary Kathleen McHugh
Immediate Extrauterine Transition 961
Ongoing Extrauterine Transition 967
References 972
Chapter 37 Immediate Care and Assessment of the Healthy Newborn 973
Mary Kathleen McHugh
Assessment Prior to Birth 973
xx Contents
Assessment at the Moment of Birth 973
Care During the First Hours After Birth 974
Plan of Care for the First Few Days of Life 977
Planning Discharge 979
References 982
Chapter 38 Resuscitation at Birth 983
Mary Kathleen McHugh
Infrastructure for Safe Resuscitation of the Newborn 983
Pathophysiology of Asphyxia 984

Care of the Newborn Following Resuscitation 986
The Process of Resuscitation 987
Special Situations in Neonatal Resuscitation 995
Quality Assurance and Risk Management 996
References 997
Chapter 39 Examination of the Newborn 999
Mary Kathleen McHugh
Structuring the Newborn Examination 999
Gestational Age Assessment 1002
Physical Examination of the Newborn 1004
References 1009
Chapter 40 Primary Care of the Newborn: The First Six Weeks 1011
Mary Kathleen McHugh
The Midwife’s Role in Neonatal Well-Child Care 1011
Newborn Behavior 1014
Developmental Milestones in the First Six Weeks 1016
Psychological Tasks of Early Infancy 1016
Physical Care of the Newborn 1018
The Circumcision Decision 1019
Nonnutritive Sucking 1020
Feeding 1020
Common Variations in the First Six Weeks 1023
Eating Patterns and Weight Gain 1025
Physiological Jaundice 1026
References 1027
Chapter 41 Recognition and Immediate Care of Sick Newborns 1029
Mary Kathleen McHugh
The Midwife’s Roles and Responsibilities 1029
The Sick Newborn 1030
Signs of Possible Infection 1033

Signs of Birth Injuries 1034
Signs of Neurological Disease 1035
Signs of Surgical Emergencies 1036
Contents xxi
Signs of Drug Exposure in the Newborn 1036
Infants of Diabetic Mothers 1039
Signs of Intrauterine Growth Restriction 1039
References 1040
Part VII Postpartal Care
Chapter 42 The Normal Puerperium 1041
Database for the Puerperium 1041
Management Plan for the Puerperium 1052
References 1064
Additional References 1065
Chapter 43 Infant Feeding 1067
Karin Cadwell
Cynthia Turner-Maffei
Sarah Coulter Danner
Breastfeeding-Optimal Infant Nourishment 1067
The Baby-Friendly Hospital Initiative 1069
The International Code of Marketing of Breast-milk Substitutes 1070
Anatomy and Physiology of Lactation 1070
Antepartum Preparation for Breastfeeding 1072
The Effect of Birth Practices on Breastfeeding 1074
Successful Breastfeeding 1074
Problem Prevention and Management 1078
Breast Discomfort 1079
Milk Supply 1081
When Breast Is Not Best 1085
Conclusion 1087

References 1087
Professional Resources and Equipment and Supply Resources 1091
Chapter 44 Screening for and Midwifery Management of Puerperal Abnormality 1093
Puerperal Morbidity 1093
Puerperal Infection 1094
Other Puerperal Complications 1095
Postpartum Depression 1098
Attachment Failure and the Potential for Child Abuse or Neglect 1101
References 1102
Additional References 1103
Part VIII Skills
Chapter 45 Universal Precautions 1107
References 1108
xxii Contents
Chapter 46 Finger Puncture 1109
Bibliography 1111
Chapter 47 Venipuncture 1113
Bibliography 1120
Chapter 48 Inserting an Intravenous Catheter 1121
Bibliography 1124
Chapter 49 Giving Intravenous Medications 1125
Chapter 50 Spin-Down Hematocrit 1127
Chapter 51 Removal of Norplant 1131
References 1133
Chapter 52 Breast Examination 1135
Relevant History 1135
Physical Examination 1136
Variations in Breast Examination and Findings for the Pregnant Woman 1142
Variations in Breast Examination for the Postpartal Woman 1143
Teaching Breast Self-Examination 1144

References 1144
Additional References 1145
Chapter 53 Obstetric Abdominal Examination 1147
Antepartal/Intrapartal Abdominal Examination 1147
Postpartal Abdominal Examination 1156
References 1159
Additional References 1159
Chapter 54 Checking for Costovertebral Angle Tenderness 1161
Anatomy 1161
Significance and Charting 1161
Procedure and Rationale for Examination 1161
Chapter 55 Checking for Deep Tendon Reflexes and Clonus 1163
Deep Tendon Reflexes 1163
Clonus 1167
Bibliography 1167
Chapter 56 Pelvic Examination 1169
Procedures, Observations or Findings, and Significance 1169
Bibliography 1193
Chapter 57 Obtaining a Specimen for Papanicolaou (Pap) Diagnostic Evaluation 1195
Reference 1197
Contents xxiii
Chapter 58 Obtaining a Specimen for Gonococcal (GC) and Chlamydia Diagnostic Testing 1199
Chapter 59 Making a Wet Smear Slide of Vaginal Secretions 1201
Chapter 60 Using a Microscope 1203
Chapter 61 Anatomy of the Pelvis, Pelvic Types, Evaluation of the Bony Pelvis, and Clinical
Pelvimetry 1205
Anatomy 1205
Types of Pelves 1209
Procedure, Rationale, and Description of Findings 1211
Evaluation of Findings 1215

Bibliography 1215
Chapter 62 Breast Massage, Manual Expression, and Nipple Rolling 1217
Procedure for Breast Massage 1217
Procedure for Manual Expression 1218
Procedure for Nipple Rolling 1218
Reference 1218
Additional Reference 1218
Chapter 63 Injection of Intradermal Sterile Water Papules for Relief of Low Back Pain in
Labor 1219
Saraswathi Vedam
References 1221
Chapter 64 Inserting an Intrauterine Pressure Catheter; Amnioinfusion 1223
References 1225
Chapter 65 Attaching a Fetal Scalp Electrode 1227
References 1229
Chapter 66 Perineal Prep (Cleaning) 1231
Chapter 67 Second Stage Pushing 1233
Breath Control 1233
Body Position 1233
Arm Position and Action 1234
Pubic Pressure 1234
Vaginal Stimulation 1234
Chapter 68 Pudendal Block 1235
Chapter 69 Local Infiltration 1239
Local Infiltration Before Birth 1239
Local Infiltration for Repair After Birth 1240
xxiv Contents