Obstetrics & Gynecology:
Obstetrician and Nurse–Midwife Collaboration: Successful Public Health and Private Practice Partnership
Shaw-Battista, Jenna CNM, PhD; Fineberg, Annette MD; Boehler, Barbara CNM; Skubic, Blanche CNM; Woolley, Deborah CNM, PhD; Tilton, Zoe MD
From Sutter West Medical Group, Davis, California.
See related editorial on page 503 and related articles on pages 673, 678, and 683.
The authors appreciate the contributions of clinicians at the site of the quality assessment project who provided data, guidance, and editing of this manuscript, including Beth Johnson, MD (Sutter West Medical Group), and Leon Schimmel, MD (CommuniCare Health Centers, Inc.).
Presented at the 2011 annual meeting of the American College of Nurse–Midwives, May 24–28, 2011, San Antonio, Texas.
Corresponding author: Annette Fineberg, MD, Sutter West Medical Group, 2020 Sutter Place, Davis, CA 95616; e-mail: FinebeA@sutterhealth.org.
Financial Disclosure The authors did not report any potential conflicts of interest.
OBJECTIVE: To evaluate maternal and neonatal outcomes of collaborative maternity care for a socioeconomically diverse patient population in a California community hospital.
METHODS: Collaborative practice structure and clinical guidelines were analyzed, as were de-identified electronic medical records for all primiparous women who delivered term singletons between 2000 and 2010 (N=4,426). Demographics, care processes, and perinatal outcomes were compared among women seen prenatally in a private collaborative practice compared with a Federally Qualified Health Center prenatal clinic run by nurse–midwives.
RESULTS: Evidence-based practices were used to achieve excellent perinatal outcomes. Three quarters of women received intrapartum nurse–midwifery care (74.4%). Few differences were seen in management or outcomes among women from different prenatal clinics despite significant variation in demographic and clinical characteristics. Private practice patients were older, less likely to be obese, and more likely to speak English compared with counterparts from public health clinics. They were also more likely to use hydrotherapy or epidural analgesia, or experience severe perineal laceration and repair. Overall, pharmacologic pain relief methods were limited: less than a quarter of primiparous women used narcotics (21.2%), epidural analgesia (23.7%), or warm water immersion (23.2%). Labor induction and augmentation, and cesarean delivery rates (12.5%), were similar among groups and low overall.
CONCLUSION: A collaborative practice of low-tech, high-touch care results in high-quality maternity services. The care model holds promise for replication to address health disparities by limiting obstetric interventions and warrants further investigation with regard to associated costs and resultant outcomes.
LEVEL OF EVIDENCE: III
A collaborative practice of obstetricians and certified nurse–midwives in Yolo County, California, was founded in 1979 in response to women's requests for natural childbirth and increased participation in their health care. The practice was strengthened by a shared commitment to provide obstetric services to women without means and has evolved into a successful model that provides high-quality, family-centered maternity care. The collaborative practice serves diverse communities through a physician-owned suburban private practice, and a federally qualified health center with primary and prenatal clinics throughout the county. The patient population, collaborative practice, and selected perinatal outcomes have been described previously.1–4 Women seen prenatally by members of the collaborative practice give birth at Sutter Davis Hospital, a 45-bed community facility with a level I nursery located in a college town situated between two major metropolitan areas and expansive agricultural areas.
The collaborative practice philosophy includes extensive prenatal education, shared decision-making, and judicious use of obstetric interventions in accordance with evidence-based clinical guidelines that are developed collaboratively. Interprofessional clinicians believe that high-touch, low-tech care practices resulted in the limited use of pharmacologic pain relief methods and obstetric interventions, and optimal perinatal outcomes observed previously at the site.1–4 Further, postpartum patient satisfaction has ranked in the 91st through 95th percentiles over the past decade according to Press-Ganey national surveys. The objective of this quality assessment study was to re-evaluate the model of care and maternity services provided by the collaborative practice, and assess both adherence to stated philosophy and the quality of resultant maternal-neonatal outcomes in the socially and economically diverse child bearing population.
MATERIALS AND METHODS
Members of the collaborative practice undertook a review of organizational structure, clinical policies, and quality improvement data in response to the joint call for manuscripts about collaborative maternity care issued by the American Congress of Obstetricians and Gynecologists and the American College of Nurse–Midwives in 2010. Practice members actively participated in efforts to identify key administrative factors and clinical guidelines that have contributed to the longevity and success of the collaboration.1–4 This quality assessment project had three additional goals: 1) articulate a shared philosophy of collaborative maternity care developed through an iterative process undertaken by interprofessional group members, 2) re-evaluate the evidence base for intrapartum management as part of ongoing clinical guidelines review, and 3) analyze de-identified electronic medical record data from 2000 to 2010 to assess whether maternity care practices or perinatal outcomes differed among first-time mothers who were seen prenatally by a nurse–midwife in a federally qualified health center compared with those seen by a nurse–midwife or obstetrician or both in the collaborative private practice.
Intrapartum care practices and outcomes data were analyzed for the 5,283 vertex singleton term births (more than 37 weeks of gestation) to primiparous women at the site during the study period. Deliveries by family practice physicians and other providers outside of the collaborative practice were excluded from analyses, leaving a sample of 4,426 primiparous women. Details about the collaborative practice structure, organization, and clinical guidelines are available in Table 1 and the Appendix. Clinical variables were selected for study a priori based on national quality measures and previous research demonstrating health disparities between patients in public and private maternity care settings.5,6
Medical record data were extracted from the First Pregnancy and Delivery database, a regional quality initiative of Sutter Health that uses a standardized primiparous patient population to facilitate comparisons between hospitals within and outside of the Sutter Health system.7–9 The use of de-identified First Pregnancy and Delivery data for this quality assessment project did not require approval from the Sutter Health Central Area Institutional Review Committee. Clinicians and administrative staff prospectively enter First Pregnancy and Delivery data during routine clinical charting, billing, and interface with county and state birth certificate and newborn screening programs. The validity of these data has been established in previous perinatal outcomes assessments, and related quality improvement measures have helped to minimize missing data and increase the number of parameters tracked at the site over time.7,8
After First Pregnancy and Delivery data were obtained, SPSS was used to generate crosstabs, perform hierarchical multiple logistic regression and χ2 testing, and compare means using independent samples t tests. Bivariate analyses were performed because regression analyses failed to reveal significant interactions between demographic factors, pre-existing clinical conditions, care processes, and perinatal outcomes. Analyses included the complete number of cases for each variable by list wise deletion; differences in sample sizes are primarily related to the timing of First Pregnancy and Delivery database modifications and inclusion of additional parameters. Given the large sample size, stringent criteria were selected to reduce type I error; findings were considered significant with a P<.01. Nonetheless, the study may have insufficient power to detect differences among groups for rare perinatal outcomes (eg, fetal demise) because of an insufficient number of cases (type II error).
Clinical and demographic characteristics and risk factors are summarized in Table 2 with reference to site of prenatal care. Most women who gave birth at the hospital spoke at least some English (71.5%), whereas 29.1% were Spanish-speaking and smaller proportions spoke languages from Asia (4%), Europe (1.7%), or elsewhere (0.9%). The sample was more diverse than these data indicate; 11.1% of women were Asian or Southeast Asian, and 2.5% were African American or African immigrants.
There were significant demographic differences among women attended prenatally in the private practice compared with federally qualified health center sites with regard to maternal age, obesity, educational attainment, race or ethnicity, and the ability to speak English. Hispanic, African, and African American women were significantly more likely to attend federally qualified health center prenatal clinics, whereas Asian women were more likely to receive care from the private practice (P<.001). There were no significant differences in adequacy of prenatal care among groups, although women initiated care at federally qualified health centers 1 month later than counterparts in the private practice; the mean gestational age at first prenatal visit was 3.95 months (±1.91 months) and 3.07 months (±1.45 months), respectively (P<.001).
Intrapartum care process and perinatal outcomes are summarized in Tables 3 and 4. Three quarters of women received nurse–midwifery care during labor (74.4%). Average dilation at admission was similar among groups (4.2±1.8 cm; P=.824), as was mean gestational age at delivery (40.14±1.28 weeks; P=.424), induction and augmentation of labor, and method of delivery. Overall, 14.7% of women experienced induction of labor, 21.6% received oxytocin augmentation, and 63.7% had spontaneous labors. Similarly, operative delivery rates were low and equivalent among groups; 12.5% of primiparous women delivered by cesarean, 4.1% of births were vacuum-assisted, and 0.3% required forceps extraction.
Less than one quarter of primigravid women used narcotics, epidural analgesia, and warm water immersion for labor pain relief, and a small percentage of neonates were born underwater (7.9%). Pain relief methods employed by women during labor varied by site of prenatal care; primiparous women from the private practice were significantly less likely to receive narcotics and more likely to utilize hydrotherapy, epidural analgesia, or both than women who were seen in a federally qualified health center prenatally (P<.001 for all comparisons).
Intrapartum and postpartum complications were rare in this primiparous sample. Outcomes selected a priori for analysis included intrapartum fever, defined as temperature 38.0°C and higher and used as a proxy for chorioamnionitis, and postpartum hemorrhage, defined as more than 500 mL blood loss after vaginal birth or more than 1,000 mL after cesarean delivery. Neither fever nor excessive blood loss differed by site of prenatal care (P=.698 and .971, respectively). Overall, 13.1% of women in the sample were febrile in labor and one tenth (9.9%) experienced hemorrhage. The blood transfusion rate was found to be 0.5% in a prior study of births at the site between 1997 and 2008, but was not examined in this quality assessment project.4
Obstetric laceration was one of few outcomes that significantly differed among women attended in the public compared with private prenatal clinics. Overall, 27.5% of primiparous delivery records lacked documentation of genital laceration (with or without suturing), with an intact perineum significantly more likely among women from federally qualified health center prenatal care sites (P<.001). The finding that women who received care in the private collaborative practice were significantly more likely to experience severe perineal laceration may be related to an apparent trends toward more episiotomies in this group.
Neonatal parameters examined included birth weight and nursery admission rates, neither of which differed among neonates born to women seen in the private practice compared with those born in federally qualified health centers. Mean birth weight was 3,471.7 g (±448.5 g), and 3.1% of neonates were admitted to the nursery rather than regular care (rooming in). Among neonates admitted to the nursery, 81.8% had Apgar scores of at least 7 at 5 minutes compared with 1.4% of neonates overall.
There were no intrapartum fetal deaths in the sample. Seven fetal demises occurred before hospital admission (0.16%). Diagnoses after stillbirths included tight nuchal cord (n=4), true knot in cord (n=1), chorioamnionitis (n=3), poorly controlled gestational diabetes (n=1), sexually transmitted infection other than HIV (n=3), or a combination. Gestational age at diagnosis of pre-labor fetal demise in this term nulliparous sample ranged from 37 0/7 to 40 4/7 weeks of gestation.
In addition to review of outcomes for primiparous women over the past decade, this study aimed to identify factors perceived to contribute to the longevity and success of the collaborative practice. Results of the interprofessional evaluation process include a mutually defined philosophy of collaborative maternity care, and list of organizational and administrative supports and hindrances to collaborative practice. Group members used consensus to identify five key factors they believe are involved in the collaborative model's sustainability and success: 1) a philosophy that optimal labor begins spontaneously and is permitted to progress without intervention; 2) extensive prenatal education to help women prepare for childbirth and understand what pain relief methods are available, including nonpharmacologic methods to increase coping with the challenges of labor; 3) ample hands-on support during labor from nurses, nurse–midwives, and volunteer or private doulas; 4) uniform adherence to mutually developed evidence-based clinical guidelines; and 5) obstetricians who firmly believe in the collaborative practice model and are experienced with facilitating normal birth that is independently attended by nurse–midwives.
Members of the collaborative also described challenges to the model of care both within the practice and occasionally with members of the larger medical community. Challenges were primarily related to cultural conflict with regard to the shared practice philosophy of childbirth as a physiologic process requiring supportive care rather than management unless illness or pathology is present. Although members reported intentionally cultivating a cohesive model of care that is presented to parturients in a consistent manner, they described inherent philosophical differences among individual clinicians and some notable differences between obstetrician and nurse–midwife care practices. The group attempts to lessen these differences through continual discussion, and members unequivocally feel that benefits of collaboration are worth the extra time and effort required for ongoing debate and review of research literature.
The iterative process used to identify practice members' fundamental beliefs about their collaboration and philosophy of care has already served as a springboard for additional quality assessment and improvement projects to enhance maternity services and test the hypotheses identified by practice members in this study. Detailed information about study findings related to collaborative practice structure, philosophy of care, ongoing quality improvement projects, and implications for model replication is provided in the Appendix and following discussion.
A survey of objectives for safe and effective perinatal health care identified by national agencies such as the Joint Commission, National Quality Forum, and U.S. Department of Health and Human Services (Healthy People 2010) reveals a consensus regarding the need to decrease the primary cesarean birth rate and prevalence of elective delivery before 39 weeks of gestation, among other perinatal benchmarks. Data suggest that women with the most access to care have the highest risk of cesarean delivery10 and a recent study found that nearly half (43.8%) of primigravid women in 19 U.S. hospitals were induced,11 which could double the risk for operative delivery.12 As demonstrated in this project and previous studies at the hospital, outcomes of the collaborative practice in Davis, California, meet or exceed measures of excellence, despite an economically and socially diverse population with significant risk factors for operative delivery, poor perinatal outcomes, and health disparities.1–6
The primary objective of this study was to assess whether maternity care practices and perinatal outcomes differed among women attended prenatally in federally qualified health centers compared with the collaborative private practice. Prenatal care site was examined as a proxy for socioeconomic and insurance status considering that the majority of women in the private practice have employee-sponsored or personal health insurance policies (more than 85%), whereas the federally qualified health center serves exclusively uninsured and low-income women enrolled in government health insurance programs. Despite statistically significant and clinically meaningful differences in demographic and clinical risk factors, few care processes or outcomes varied significantly by site of prenatal care. This was surprising given the body of literature that supports relationships between socioeconomic status and both maternity care processes and perinatal outcomes, including cesarean delivery.13
Overall, obstetric interventions were limited in this term primiparous sample; rates of labor induction and augmentation, analgesia and anesthesia, and operative delivery were low in comparison to comparable populations at the regional or national level.14,15 The descriptive study design does not establish causality and it is unclear whether the collaborative care model would result in fewer obstetric interventions or operative deliveries if applied to higher-risk populations. Nonetheless, the alarming health disparities experienced by minority women and underserved communities in California and nationally should compel further research on the collaborative care model as a potentially safe and cost-effective means to increase access to high-quality maternity services and improve perinatal health at the local and national levels.5,6,16
The collaborative model of care and restricted use of obstetric interventions were not associated with adverse maternal or neonatal outcomes. The observed rate of intrapartum fever (13.1%) does not suggest that the group's policy of expectant management of premature rupture of membranes (PROM) contributes to an excessive risk of uterine infection. Nationally, incidence of intrapartum maternal pyrexia ranges from 4% to 46%. This wide variation reflects the relationships between infection and premature labor, and epidural and intrapartum fever, which complicate comparisons among populations.4,17–19 Neonatal outcomes of the collaborative practice were similarly reassuring after analysis of birth weight, nursery admissions, and Apgar scores. The rate of 5-minute Apgar scores less than 7 (1.4%) is comparable to findings from national samples.20 Postnatal transfers to neonatal intensive care facilities were beyond the scope of this study, but a prior analysis of births at the site from 1997 to 2008 found a transfer rate of 2.1%.4
In addition to evidence-based clinical policies and reassuring perinatal outcomes, this quality assessment project revealed opportunities for further study and quality improvement, namely management of the third stage of labor. The observed postpartum hemorrhage rate (9.9%) is not the highest reported by facilities within the Sutter Health system, but ranks within the uppermost quartile. Further, recent National Hospital Discharge Survey data indicate a 2.6% incidence of hemorrhage and a range from 1.4% to 4.9% has been observed in California hospitals.21,22 Interpretations of study findings are complicated by a previous analysis of deliveries at the site during the same study period in which a 0.5% incidence of severe hemorrhage requiring blood transfusion was observed; this transfusion rate is equivalent to national data that report a range from 0.3% to 0.5%.4,21,23,24
Outstanding questions about postpartum hemorrhage and transfusion rates have generated ongoing collaborative practice discussion and hospital review. Because of the significant discrepancies in hemorrhage but not transfusion rates observed at the site compared with regional and national samples, quarterly drills have been instituted, postpartum blood transfusions are being tracked more closely, and related policies are under hospital review. Given the critical nature of this opportunity for quality improvement, active management of the third stage of labor is also being evaluated for increased utilization. Although compelling data suggest a significant reduction in blood loss is possible with routine implementation, there are outstanding questions about the generalizability of previous findings to women in spontaneous labor, as well as acceptance of active management by the local patient population.25 Other considerations include the possibility of increased blood loss after delivery in upright positions and decreased blood loss observed among women with epidural analgesia.26,27 Further, it is possible that blood loss was underestimated in comparative samples because measures of hemorrhage are frequently subjective. In contrast, members of the collaborative practice use objective measurements when excessive bleeding occurs; this may result in more accurate documentation of blood loss rather than reflecting an increased rate of hemorrhage among primiparous women at the site compared with other patient populations.
The collaborative approach to clinical decision-making regarding postpartum hemorrhage and active management of the third stage of labor are examples of the collective endeavors frequently undertaken by maternity care providers at the site. Within the model of interprofessional practice, all members are engaged stakeholders in quality improvement activities and evidence-based policy revisions. This likely fosters consensus and group adherence to clinical guidelines, improves patient education and outcomes, promotes normal birth, and reduces medical liability.28,29
Despite the longevity of the practice and favorable clinical outcomes, this study identified ongoing challenges to the model of care and barriers to its replication elsewhere. Communities may not be able to afford the time-intensive activities required to reach interprofessional consensus on differing philosophies of care and clinical guidelines, while still respecting and empowering all participants. Efficient use of time is critical for cost-effectiveness, which should be a future area of evaluation and improvement. With the ever-changing health care environment, determining the fiscal viability of the collaborative care model may prove challenging.
Other limitations on collaborative practice may arise from the belief systems and preferences of patients and members of the larger community. Members of the collaborative practice credit ongoing review of research literature with changes in the collaborative practice style, which is perceived to have become more conservative over the past decade to more closely adhere to community standards and policies about best practices in maternity care. Although clinical guidelines have evolved for specific conditions, the overarching practice model has remained patient-centered and respects women's choices to accept or decline interventions after informed consent discussions. This fundamental aspect of the model informs all management decisions and is intrinsically tied to the satisfaction with care experienced by our patients. When women choose to decline recommended care, they are asked to sign refusal forms that specify the risks, benefits, and alternatives discussed. These encounters need not be antagonistic if women are respected as partners in shared medical decision-making and clinicians are well versed in available data and able to effectively facilitate therapeutic relationships and informed consent.30 Despite the lament of one obstetrician in the practice, conflicts in treatment decisions are infrequent.31 Further, data from the practice suggest that optimal maternity care is fostered within the collaborative model and cannot be exclusively attributed to the demographics or clinical characteristics of the patient population.1–4,32,33 Therefore, patients' belief systems may not be a barrier to collaborative practice elsewhere, using the model of care described.
In summary, data from this quality assessment project and previous studies at the site demonstrate that collaborative maternity care contributes to excellent maternal and neonatal outcomes among diverse child bearing women in a California community hospital.1–4 The study identified a variety of organizational and cultural factors that practice members believe support or hinder collaborative maternity care. Collectively, the administrative processes and philosophical framework for collaborative practice result in a strong shared mission to provide safe, effective, satisfying, and cost-effective care to improve public health and benefit the community. Although the model of care is not typical, it holds great promise for replication because of the diversity of patients served and tremendous satisfaction for patients and providers alike. Practice members invite you to read more about their collaboration in the Appendix, and challenge you to identify a better method to achieve optimal perinatal results.
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17. Agakidis C, Agakidou E, Philip Thomas S, Murthy P, John Lloyd D. Labor epidural analgesia is independent risk factor for neonatal pyrexia. J Matern Fetal Neonatal Med. 2011 [epub ahead of print 19 Jan].
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20. Marowitz A, Jordan R. Midwifery management of prelabor rupture of membranes at term. J Midwifery Womens Health 2007;52:199–206.
21. Berg CJ, Mackay AP, Qin C, Callaghan WM. Overview of maternal morbidity during hospitalization for labor and delivery in the United States: 1993–1997 and 2001–2005. Obstet Gynecol 2009;113:1075–81.
22. Lu MC, Fridman M, Korst LM, Gregory KD, Reyes C, Hobel CJ, et al.. Variations in the incidence of postpartum hemorrhage across hospitals in California. Matern Child Health J 2005;9:297–306.
23. Weeks AD. The retained placenta. Best Pract Res Clin Obstet Gynaecol 2008;22:1103–17.
24. Callaghan W, MacKay A, Berg C. Identification of severe morbidity during delivery hospitalizations, United States, 1991–2003. Am J Obstet Gynecol 2008;199:133.e1–8.
25. Leduc D, Senikas V, Lalonde AB, Ballerman C, Biringer A, Delaney M, et al.; Clinical Practice Obstetrics Committee; Society of Obstetricians and Gynaecologists of Canada. Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can 2009;31:980–93.
26. Gupta JK, Hofmeyr GJ. Position for women during second stage of labour. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub2.
27. Driessen M, Bouvier-Colle MH, Dupont C, Khoshnood B, Rudigoz RC, Deneux-Tharaux C; Pithagore6 Group. Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol 2011;117:21–31.
28. Kennedy HP, Grant R, Walton C, Shaw-Battista J, Sandall J. Normalizing birth in England: a qualitative study. J Midwifery Womens Health 2010;55:262–9.
29. Kirkpatrick DH, Burkman RT. Does standardization of care through clinical guidelines improve outcomes and reduce medical liability? Obstet Gynecol 2010;116:1022–26.
30. Goldberg H. Informed decision making in maternity care. J Perinat Educ 2009;18:32–40.
31. Fineberg AE. An obstetrician's lament. Obstet Gynecol 2011;117:1188–90.
32. Kennedy HP. A concept analysis of optimality in perinatal health. J Obstet Gynecol Neonatal Nurs 2006;35:763–9.
33. Low LK, Seng JS, Miller JM. Use of the Optimality Index-United States in perinatal clinical research: a validation study. J Midwifery Womens Health 2008;53:302–9.
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35. Premature rupture of membranes: clinical management guidelines for obstetrician-gynecologists. ACOG Practice Bulletin No. 80. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1007–19.
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37. Seaward PG, Hannah ME, Myhr TL, Farine D, Ohlsson A, Wang EE, et al.. International Multicentre Term Prelabor Rupture of Membranes Study: evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. Am J Obstet Gynecol 1997;177:1024–9.
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Appendix: Collaborative Practice Structure, Model of Care, and Clinical Policies
Although the model of collaborative maternity care has remained cohesive over 30 years, specific care practices have evolved in response to research, a significant growth in the demand for nurse–midwifery and family-centered maternity services, and successive changes in the staffing, practice ownership, and business affiliations. Details will be provided regarding the collaborative practice structure, philosophy of care, and clinical guidelines to facilitate evaluation of the model and inform replication elsewhere.
Three quarters of births to women in the collaborative practice are attended by nurse–midwives, and obstetricians primarily manage care for women with significant disease or need for operative delivery. Nurse–midwives from the private practice and federally qualified health centers provide shared 24-hour coverage in the hospital's birthing center, which allows for a sustainable provider lifestyle. The on-call private practice obstetrician provides consultation, comanagement, and referral for all women regardless of prenatal care setting. This is possible because of a fiscal arrangement negotiated jointly with the federally qualified health center and physician-owned private practice, which has allowed both organizations to be financially viable. Obstetric revenue is shared by physician shareholders in the private multispecialty medical group. Practice members are not paid per delivery so there is no financial incentive to hasten its course. This is aligned with the philosophy shared by the obstetricians, nurse–midwives, and hospital nurses who are committed to promoting spontaneous physiologic birth with the judicious use of obstetric intervention and the practice of evidence-based maternity care.
The groups' values are reinforced with administrative, educational, and clinical processes. Interprofessional activities contribute to cultural cohesion and mutual respect, including continuing education activities, clinical training for student nurse–midwives, team-based emergency simulations, and shared administration of quality-improvement activities. Quarterly consensus meetings are designed to facilitate on-going discussion of values and foster consistency of care and guideline adherence among practice members, as well as permit timely review of emerging research to inform clinical management.
Nurse–midwifery care at the study site is primarily provided to healthy childbearing women, but significant psychosocial risk factors and moderate biophysical risk factors are not uncommon. This study did not attempt to examine the full range of risk factors present in the primiparous sample. However, an earlier examination at the hospital from 1997 to 2008 indicated that 17.7% of women attended by collaborative practice members had at least one significant medical condition before pregnancy, including chronic pulmonary disease or asthma (6.0%); psychiatric diagnoses requiring medication, inpatient treatment, or both (5.1%); endocrine disorders (3.0%); and hypertension (0.8%).4 Additional risk factors for poor perinatal outcomes present in the earlier sample included substance use (5.1%), sexually transmitted infection (4.5%), severe anemia (1.9%), multiple gestation (1.1%), intrauterine growth restriction (0.9%), and other antepartum fetal diagnoses (3.4%).4 Among women attended by nurse–midwives, 18.0% reported one or more of these pre-existing medical conditions or risk factors.4
During pregnancy, women who receive nurse–midwifery care at federally qualified health center prenatal sites and report or develop significant health conditions, illnesses, or other risk factors for poor perinatal outcomes are discussed in weekly collaborative practice meetings where interprofessional members jointly develop management plans and parameters for consultation and referral as indicated in Table 1. The private practice providers meet for the same purpose twice a month to discuss their at-risk patients. Further, the on-call obstetrician is always available to answer urgent nurse–midwifery management questions. Additionally, there are monthly hospital Performance Improvement Committee and Birth Center Issues meetings, which include all delivering providers as well as other stakeholders.
Advanced-practice nursing and nurse–midwifery care for women with significant medical or obstetric complications may require a standardized procedure approved by a supervising physician. At the study site, standardized procedures are reviewed by a quality-improvement committee and the hospital board of directors. Current standardized procedures include a nurse–midwife formulary, and guidelines for limited obstetric ultrasound scans and the nurse–midwife role as first assistant for cesarean deliveries. Standardized procedures and clinical guidelines are evidence-based and consistent with the Sutter Health System's First Pregnancy and Delivery initiative that outlines best practices for labor management in primigravid women.7
Obstetricians and nurse–midwives at Sutter Davis Hospital uniformly endorse the same basic labor management principles. First, low-risk women are encouraged to spend early labor at home, and inpatient admission generally occurs after cervical change has been observed and active labor has commenced. Therapeutic rest with morphine sulfate and sedatives is provided for prolonged latent labor on an inpatient or outpatient basis. Elective inductions before 42 weeks of gestation are avoided and elective primary cesarean deliveries are not performed.
The labor induction and cesarean delivery rates are also limited by a policy of expectant management for PROM at term. Afebrile women with clear amniotic fluid, reassuring nonstress testing, and negative group B streptococcus status are offered expectant management at home for up to 72 hours with informed consent. CNM-obstetrician consultation is required for abnormal findings, PROM more than 48 hours, and induction of labor. Speculum examinations are used for confirmation of rupture and to visually inspect cervical dilation. Digital cervical examinations are prohibited until active labor is evident. A daily nonstress test is performed and vertex lie is confirmed with ultrasonography on diagnosis of rupture. Women self-monitor temperature, color of the amniotic fluid, and fetal movements. Spontaneous labor ensues in 95% of women by 72 hours, thus induction is strongly recommended at this time.34 The practice of expectant management is based on data that indicate a strong correlation between chorioamnionitis and digital examinations, meconium staining, and group B streptococcus status, variables that have not been consistently well controlled in studies of PROM.20,35–38 Further, early induction of labor after PROM may be associated with higher operative delivery rates and prolonged labor lengths despite probable decreased intervals between PROM and delivery.39,40
Labor pain management is innovative at Sutter Davis Hospital. Nurses use a coping rather than pain scale, and analgesics are not routinely offered without maternal request and informed consent.41 Registered nurses organized and oversee a volunteer doula service to provide continuous labor support free of charge for women who request the service, whereas other women employ a private doula or decline support beyond that offered by their labor nurse and delivering provider. Comfort during labor is facilitated in a variety of additional ways. Laboring women may eat and drink unless they receive epidural analgesia, at which time clear fluids are recommended.42 Heat packs, sterile water papules, exercise balls, and hydrotherapy (showers and tubs for labor and birth) are encouraged. Water birth is permitted for healthy women with normal labors and reassuring intermittent or continuous fetal monitoring by means of waterproof Doppler or telemetry. The extensive use of nonpharmacologic pain relief methods is reflected in an epidural rate far below what was recently observed in California (65%) or nationally (76%); from 1999 to 2009 the annual rate of epidural analgesia at the hospital ranged from 13.3% to 23.9%.14,43
Additional unusual intrapartum care practices include intermittent fetal monitoring, which was used in 49% of deliveries in an earlier study at the site, in accordance with Association of Women's Health, Obstetric and Neonatal Nursing standards.4,44 Ambulation during labor is encouraged with either intermittent fetal monitoring or continuous use of a telemetry unit as indicated by clinical conditions. Movement is also facilitated by restricting intravenous fluid administration in the absence of indications for hydration by means other than oral intake.
Management practices in the second and third stages of labor at Sutter Davis Hospital facilitate optimal physiology and increase the spontaneous vaginal birth rate. Passive descent or “laboring down” is encouraged at the onset of second stage, especially for women with epidural anesthesia.45 Providers describe supporting rather than managing the second stage of labor by encouraging spontaneous pushing after an involuntary urge occurs with advanced fetal descent. Operative vaginal delivery and cesarean deliveries are not routinely recommended after prolonged pushing (more than 2–3 hours) if progressive descent is occurring in the absence of nonreassuring fetal status, maternal exhaustion, or both.46 Active management of the third stage of labor is not practiced routinely and is reserved for women with significant risk factors for postpartum hemorrhage at the discretion of individual providers. Delayed cord clamping (more than 1–3 minutes) is the norm, in the absence of indications for neonatal resuscitation.47
The collaborative practice described is an unusual provider of high-quality maternity services. As such, the model offers potential solutions to the challenges faced by maternity care providers who seek to offer evidence-based care practices in the context of dwindling private and public health resources and changes in maternal preferences and demographics. Practice members look forward to ongoing publication and discussion about optimal maternity care practices and additional examples of successful interprofessional collaboration. Practice guidelines, standardized procedures, and administrative policies are available from Sutter Davis Hospital upon request.
© 2011 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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