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Re: Abnormal hemoglobin/long responseFrom: Betsy Hyde (elishyde@connix.com)Tue Jan 21 23:10:52 1997
On 1/20 I posted about a primip with hemoglobinopathy unable to be diagnosed by clinical lab, and unable (yet) to be interpreted by referral to local tertiary care center perinatologists. We are all perplexed, and I wondered what should be done. Thought this list might be a good global referral source. Unfortunately, the responses have not dealt with my post, but have focused on my practice.
> I don't know who clemdmon is, because s/he did not sign her/his post as most of the rest of us do...general courtesy etc There were then sarcastic/humerous posts re: I must charge $10 and that's what my services were worth. These were posted with a notation that they were sarcastic, and I'm sure they were. Of note, no one responded to my original question. Have I stumped y'all? I work in a collaborative md/cnm practice (as my signature makes clear). In our practice, the cnms have clinical practice guidelines signed by all cnms and mds.These guidelines were written by me so that the midwives in our practice would be in compliance with ACNM requirements for written clinical practice agreements, and so that safe care would be provided to our patients. These guidelines describe what the cnms may do independently, and what they may do collaboratively.In addition, our *practice* has clinical guidelines (for *mds* and cnms) for care of multiple gestations, hypertensives, PTL,postdates etc. We have weekly high risk meetings so that there is a consistent plan of care for all high risk patients. The cnms in our practice are responsible for labor management and delivery of *all* women in our practice, with appropriate consultation during labor, and physician attendance for high risk births.(We have approx 520 births/year and a primary c/s rate of 11%). Care of twin gestation is included as appropriate for collaborative cnm/md care, and midwives attend all twin births with mds in attendance.Usually the midwife delivers twin A, and oftentimes delivers twin B. The physician is always present. In addition, I care for diabetics (class B, C and occasionally F), hypertensives (chronic and PIH), women with lupus, incompetent cervix, oligo and polyhydramnios, PTL, anemia, isoimmunizations. You name it, we include it in our practice.Just because someone has an incompetent cervix or diabetes does not mean that she does not have the same dreams and wishes for her pregnancy. The midwives try, as much as possible, to support whatever normal exists in our high risk clients. Our practice backup is the High Risk OB service at Yale. We have frequent, and collegial consultations with the fellows and attendings at Yale, and welcome their input into our management. There are times when total management is referred to the perinatologists, because that is what is best for our patients. I feel that a collaborative md/cnm practice is a model which offers the best of both worlds for high risk women. Often these women are in need of the extra TLC which a midwife can provide. High risk women are often in need of someone who can make them feel in some way normal. (This does not mean ignoring their medical problems). In addition, these women can frequently have perfectly normal, noninterventive births....despite their medical problems. I feel that I am able to pick out, and support, the normal in pregnancy, labor and birthing despite a host of medical problems which are certainly in need of medical consultation and support. An example would be a diabetic in labor. It would be the physician responsibility to manage insulin and glucose drips. It would be my responsibility to assess and manage the course of labor. Another example would be PIH. It is the physician's responsibility to assess and manage Mag etc, and my responsibility to assess and manage the course of labor. For those of you who do not have a collaborative practice, this may all sound crazy. For those of you who have a collaborative md/cnm practice it probably sounds like old hat. I almost didn't post this....I do not want midwifery issues to dominate this list. I utilize this list as a resource for my *obstetrical* questions. I do feel, however, that there is a lack of understanding of the potentials of collaborative md/cnm care. I would hope that respondants to my questions would have the courtesy to identify themselves, and to address my questions....not my practice. Should the list not wish to respond to questions from midwives, please let me know. I felt my original question was appropriate.
-- Betsy Hyde CNM Midwife in collaborative md/cnm practice Assistant clinical professor/Yale University
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