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Re: Midwifery Care and Birth Outcomes in USAFrom: Betsy Hyde (elishyde@connix.com)Thu Aug 13 21:51:58 1998
>At the two hospitals in which I practice, there are guidelines of which >type of patients the midwives can't handle alone, meaning they must have >some level of MD consultation, be it on site evaluation, telephone >contact, or presence for the actual delivery. I bet that there are *no* >guidelines for office practice, except those created by the practice >itself. I would guess that you are in an unusual situation, being in an >academic center, in that you see many complicated patients that normally >would not be seen by private practice CNMs (ie Class B diabetes, twins, >etc.). > >Color me silly, but if I'm your MD (collaborating or whatever name), I >would at least like for us to talk about some of those patients who are >nonroutine, since I share in the care and in the responsibility. > >Garry > >-- >Garry E. Siegel, M.D., FACOG >Private Practice >Roswell, Ga. Garry- You are not silly at all, nor are your concerns silly....just that my response to some prior post did not adequately describe how we work. I will try to briefly describe how mds/cnms collaborate in my practice. Although I have an academic appointment at Yale, I am a midwife in a *private* md/cnm collaborative practice (6 obs, 5 cnms). Our practice is high volume (~700 births/year) and sees many high risk women, ie twins, Class B-FR diabetics, chronic hypertensives, lupus etc. We frequently (and gratefully) collaborate with the perinatologists at Yale, and with other physicians in the area (endocrinologists, hematologists etc). In the case of the woman with low platelets, the midwives referred her to a hematologist who did APA, bone marrow bx etc. Insulin management is w/ endocrinologist. Rheumatologists manage the women w/ lupus. But the midwives are often the providers who are over-seeing the pregnancy, and coordinating her care. Despite the fact that there may be incredibly high risk medical problems, the pregnancy, labor and birth may be perfectly normal. I feel that it is the midwife's job to elicit and support that which is normal, even if there is much that requires medical management. This is the nature of collaborative practice. Each Tuesday morning all the mds and cnms meet over breakfast to discuss our high risk list. This list is maintained by the nurse manager of one of our offices. Each clinician calls/faxes updates on the high risk patients, and the list is updated. Charts are brought to the Tuesday am meetings. High risk patients are discussed, and a plan of care is agreed upon. We have found that it is necessary (with 11 clinicians) to have everyone agree upon the plan....otherwise the patients go crazy, as do the providers. So, we do talk. Boy, do we talk!! In addition, on the first Thursday of each month, the mds and cnms meet for dinner. The purpose of this meeting is to discuss the generic issues like clinical practice guidelines etc. This is when we hash out the nitty-gritty of GBS protocols, management of PROM, best way to manage postdates, PIH etc. The midwives are *not* just spinning aimlessly in space....we are working under guidelines which have been discussed, and agreed upon, by us all. ACNM requires that CNMs have mutually-agreed upon protocols signed by the midwives and their consultant MDs. The scope of the protocols is totally dependent upon the nature of that particular practice. Our protocols discuss which patients the midwives may manage totally independently (supervision is *not* required by ACNM, although different states may have their own rules and regs....), and also when we consult. They discuss office practice, as well as labor practice. We have frequent "curb side consults"....ie I see someone who has problems outside of my scope of practice. I review the case with one of the obs, we mutually agree upon a plan of care, and I make sure that it is instituted. For much of our high risk care, it is within the practice guidelines mutually established by all of us. Diabetics have guidelines, twins have guidelines, women w/ lupus have guidelines, PIH and chronic hypertensives have guidelines. We have all agreed that particular high risk situations require x,y,z for care. The midwives are well capable of checking sugars, interpreting BPPs, reviewing PIH labs. And, our physicians *trust* us to provide good care...and we do. Despite the many medical risk factors which may complicate pregnancy, there is always *something* which is normal...and this is the midwife's job to seek out and promote. I have attended totally non-interventive births of women who were medically at risk. For instance, there is no reason why a class FR diabetic cannot have a spontaneous, non-interventive vaginal birth. The midwives in our practice attend *all* the labors and births, regardless of risk, gestational age etc. We are, of course, in close consultation with the obs if there are obstetrical or medical risks. There are many checks and balances in our practice. It works well. Our outcomes are good. Someone asked about who would be sued.....I am an employee of a private corporation. If I had acted negligently, I would be named, my name would be submitted to the National Practitioner Data Bank, and my practice would be named as well. This has never happened. I am well aware that I practice in a setting which is probably unusual for many midwives, because we have so much high risk care. However, it happens collaboratively, in a setting with mutual respect and bidirectional communication.
-- Betsy Hyde CNM Branford,CT Midwife in private practice Assistant clinical professor/Yale University
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