What is the role of a midwife in prenatal, delivery, and postpartum care?

Role of Midwives in Perinatal Care

Midwives serve as primary maternity care providers for low-risk pregnancies across the prenatal, intrapartum, and postpartum continuum, delivering care that reduces unnecessary interventions while maintaining or improving maternal and neonatal outcomes compared to physician-led care. 1, 2

Prenatal Care Responsibilities

Midwives provide comprehensive antepartum care for women with uncomplicated singleton term pregnancies, including:

• Routine prenatal visits following established schedules, with mental health screening at every consultation and connection to relevant resources 3, 4
• Risk assessment and prevention strategies, including prescribing low-dose aspirin (81 mg daily) for women at high risk of preeclampsia, ideally started before 16 weeks gestation 4
• Coordination of diagnostic testing such as second-trimester detailed fetal anatomy ultrasound and fetal growth surveillance for women with risk factors 4
• Education on essential topics including nutrition, exercise, weight gain, preparation for labor and delivery, family planning, and breastfeeding 3
• Psychosocial screening and management for tobacco use, alcohol use, substance use, intimate partner violence, mental health disorders, housing insecurity, and nutritional needs 3
• Venous thromboembolism risk assessment for all pregnant women 4

Intrapartum Care Delivery

Midwives attend births in multiple settings including birth centers, Level I (basic care) facilities, and higher-level hospitals, always maintaining capability to detect, stabilize, and transfer when complications arise. 3

Birth Center Practice

• Every birth must be attended by at least two professionals, with the primary provider being a certified nurse-midwife (CNM), certified professional midwife (CPM), or licensed midwife legally recognized in that jurisdiction 3
• Care is limited to low-risk women with uncomplicated singleton term pregnancies with vertex presentation 3
• Cesarean delivery and operative vaginal delivery are not offered; established transfer agreements with receiving hospitals must be in place 3

Hospital-Based Practice

• Midwives provide one-to-one care in labor, which maternity services should support as the standard model 3
• Active management of third stage of labor is performed for all women to reduce postpartum hemorrhage risk 5
• Delayed cord clamping for at least 1 minute at term (30 seconds for preterm) is implemented 5

Evidence-Based Outcomes

Midwife-led care demonstrates:

• Approximately 30% lower cesarean delivery risk in nulliparous women (aRR 0.68) and 40% lower risk in multiparous women (aRR 0.57) 2
• Reduced rates of labor interventions including induction, artificial rupture of membranes, epidural analgesia, oxytocin augmentation, and episiotomy 1, 2
• Lower operative vaginal delivery rates in both nulliparous (aRR 0.73) and multiparous patients (aRR 0.30) 2
• Shorter hospital stays and lower risks of maternal infection, manual placenta removal, blood transfusion, and ICU admission 1
• Improved neonatal outcomes including lower risks of acidosis, asphyxia, and neonatal ICU admission 1

Important caveat: Multiparous women receiving midwifery care show increased shoulder dystocia risk (aRR 1.42), requiring vigilance for this complication 2

Postpartum Care Functions

Midwives provide comprehensive postpartum management including:

• Immediate newborn care with maintenance of body temperature between 36.5°C and 37.5°C, avoiding routine airway suctioning unless secretions obstruct the airway 5
• Early breastfeeding initiation with additional support as needed, particularly for women with obesity 5
• Continued monitoring for complications, particularly hypertension which may worsen between postpartum days 3-6 5
• Lifestyle counseling and modification of risk factors, especially for women with pregnancy complications 5
• Behavioral interventions including diet and exercise recommendations for postpartum weight reduction 5

Scope and Limitations

Midwives function optimally within health systems that allow smooth transfer when complications arise, as their scope is limited to low-risk pregnancies 1. Transfer to physician care is indicated when:

• High-risk conditions develop requiring subspecialty maternal-fetal medicine consultation 3
• Cesarean delivery or operative vaginal delivery becomes necessary 3
• Maternal or fetal complications exceed the capability of the current care level 3

Critical practice point: The success of midwifery care depends on established protocols for timely transfer and interprofessional collaboration with obstetricians 3, 6. Systems must support midwives' full scope of practice while ensuring access to higher-level care when needed 6.