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Nurse–Midwifery Care in an Academic Health Center
Nurse-Midwifery Care in an Academic Health Center KATHLEEN CARRICAN KELEHER, CNM, MPH, A N D LEON I. MANN, M D A study of 1,966 women who registered in a certified nursemidwife (CNM) program for pregnancy and delivery at an academic health center is reported. Eleven percent either were medically disqualified or voluntarily transferred out of the program. Of the 1,852 women who entered labor, 46.5% required MD consultation most often for dysfunctional labor patterns. The primary cesarean section rate was 10.4%. The corrected perinatal mortality rate was 3.80/1,000 births. CNM care is a safe, cost-effective, and soughtafter alternative to MD-only care for low-risk women within a tertiary care setting.
The University of Vermont Department of Obstetrics and Gynecology first recruited a British-trained midwife to its practice in 1968. This expansion of the obstetric team was a direct result of the growing realization by the medical staff that as obstetric care shifted from general practice to obstetric practice, medical staff were becoming increasingly involved in normal routine obstetric care that did not require that level of specialized skills.' To serve the needs of most normal, low-risk pregnant women, and to ensure that the women at higher risk for obstetric problems received adequate attention, the Department of Obstetrics and Gynecology staff decided that certified nurse midwives (CNMs) could help provide the full range Of comprehensive, efficient,and cost-effective services to all obstetric patients. The added skills of the CNM in childbirth education, counseling, and labor support were recognized as assets for comprehensive obstetric care. Between 1968 and 1979, the nurse-midwifery staff at the Medical Center Hospital of Vermont (MCHV) evolved from one that provided only prenatal care and limited labor and delivery care to one in which four, full-time CNMs with medical backup by the ob/ Accepted: September 1984. Updated: May 1986.
September/October 1986 JOGNN
gyn faculty followed a specific group of women throughout the reproductive cycle. The CNM service, a Division of the Department of Obstetrics and Gynecology, has its own director. The four CNMs are employed by the Department of Obstetrics and Gynecology's private, not-for-profit group practice and all have appointments as clinical instructors at The University of Vermont College of Medicine. The CNMs have admitting privileges at the 500-bed MCHV. MCHV is the only Level-3 teaching and transfer institution for the state of Vermont and northeastern New York. The hospital has approximately 2,400 births a year, and the CNMs attend approximately 16% of these. Protocols that define CNM care were written and are reviewed annually. CNM practice is specifically legislated in Vermont by the Administrative Rules of the Vermont Nurse Practice Act. After a thorough examination of risk factors by an obstetrician and CNM, all low-risk women who come to the practice are offered three options for obstetric care. The women may be seen exclusively by an obstetrician (MD), they may alternate visits between one physician and one CNM (MD-CNM), or they may choose to be cared for primarily both antepartum and intrapartum by the four CNMs with a backup physician from the practice (CNM). Women who choose the third option see the obstetrician once each trimester. 369
The CNM patients are encouraged to meet prenatally with each of the nurse midwives at least once. This system ensures that the woman’s labor and delivery will be attended by a CNM who is familiar with the woman. The CNMs follow a full-time call system for the woman registered in the CNM option. To help ensure continuity of care, the decision to be followed by the CNM must be made by the 30th week of pregnancy unless the woman is new to the practice. If problems arise prenatally, the CNM consults with the specific backup physician. If need for consultation occurs during labor or delivery, the attending and resident staff are consulted. The communication and working relationship between the medical-nursing staff and the CNM staff are positive, supportive, and complementary. Quality assurance is facilitated by weekly meetings between the CNMs and the medical director, by monthly chart review, and by funding for continuing education conferences. Insurance status is not a factor in deciding on any of the possible options, and no differences exist in the fees charged. Cost-effectiveness of the program is difficult to measure and in this setting would best be determined in assessing the increased availability of physician time for other procedures. Patient satisfaction, although also difficult to measure objectively, also seems to be affected favorably if measured by the increased interest and response to the service over the years. From 1980 to 1985, inclusively, nearly a twofold increase (21 1 to 401) occurred in the number of women who chose the CNM option. SIX-YEAR ANALYSIS Data collected for a six-year period from the birth log kept by the nurse midwives on each birth for the CNM service was retrospectively analyzed. This includes all women who were followed prenatally by the nurse midwives regardless of complications after admission to the labor and delivery unit. Women who required joint management by the CNM and physician during labor and delivery are, therefore, included. Statistical analysis, when appropriate, was performed by student’s f-test comparison of means. From January 1, 1980, to December 31, 1985, 2,126 women registered for the CNM service. Of these 2,126 patients, 238 (1 1.2%) either were transferred out of the CNM option for medical or obstetric complications (135,6.3%) or voluntarily transferred out (82, 3.9%). Voluntary transfer included 37 of the 82 who switched to the MD-CNM service, 41 who moved from the area, and 9 who planned a home birth. Prenatal complications that required 135 patients to be transferred
370
involved spontaneous abortion in 42, medical complications in 21, and obstetric complications in 72. Whenever possible, the CNM continued to participate in the care of patients who were transferred out of the CNM option. Eighteen hundred fifty-two women were followed throughout the antepartum and intraparturn periods. Their mean age (29.7), ethnicity (Caucasian, 99.6%), and parity (primiparous, 53.2%) generally reflect the total obstetric population at MCHV. On admission to labor and delivery, each of the 1,852women was electronically monitored for 20 minutes for detection of abnormalities in baseline fetal heart rate, variability, and uterine contraction patterns. If no abnormality was noted, intermittent fetal auscultation was conducted by established obstetric protocol, and continuous electronic monitoring reinstituted only when indicated. Of the 1,852 women, 47.2% required continuous electronic monitoring at some point during labor. Of these, 62.3%were monitored by the internal system. Intrapartum complications necessitating MD (obstetric and/or pediatric) involvement occurred in 861 or 46.5% of cases. Dysfunctional labor patterns accounted for the largest number of consultations (256, 29.7%),while meconium staining (199,23.1%) and fetal stress (164, 19.0%) represented other significant problems requiring MD involvement. Spontaneous vagina1 delivery occurred in 1,561 (84.0%) of the patients. Sixty percent of the patients delivered vaginally in the labor/birthing rooms. Sixtyseven percent of the patients did not require analgesia during labor, and 72.1%required no anesthesia or only local anesthesia for episiotomy incision and repair. Shoulder dystocia occurred in 11 cases, postpartum hemorrhage in 27, and retained placenta in 13. The rate for primary cesarean section was 10.4% (193 patients) and for forceps delivery 5.6% (103 patients), with a total operative delivery rate of 16.0%.All deliveries requiring intervention were performed in t h e delivery/cesarean section room in the labor and delivery suite. Perinatal morbidity and mortality are shown in Table 1. An Apgar score of less than 7 at five minutes was recorded in 16 newborns or 0.9%of all deliveries. Of the 8 newborns with Apgar scores 0 to 3 at five minutes, 6 were fetal deaths before labor, 1 was associated with a prolapsed cord and emergency cesarean section, and 1 was due to a diaphragmatic hernia. No intrapartum deaths occurred. The four neonatal deaths occurred as a result of 1 newborn with trisomy 18, 1 with a diaphragmatic hernia, 1 with a severe cardiac defect, and 1 with neonatal sepsis. T h e corrected perinatal death rate was 3.8/1,000 total births.
September/October 1986 JOCNN
Table 1. Perinatal Morbidity and Mortality
1,852
Total births Apgar score 1 min
27 <7 27
5 min
(91.7%) (8.3%) (99.1Yo) (0.9YO)
1,699 153 1,836 16
<7
6
Fetal deaths Preterm Term lntrapartum Rate Neonatal deaths Rate Perinatal death rate Corrected
0 6
0 3.24/1,000 4
2.17/1,000 5.43/1,00 3.80/1,000
DISCUSSION Over the past decade, obstetric care has undergone extensive alteration in organization of providers and settings. Pregnant patients have been recognized as a heterogeneous group, with some at high risk for problems requiring intensive care and others at low risk requiring minimal intervention. Training programs for subspecialists in perinatal care, perinatal tertiary centers, and regional perinatal programs have been developed to serve the needs of the high-risk obstetric patient and her newborn. Nurse-midwifery training and certification, childbirth educational courses, birthing rooms, and alternative birthing centers (ABCs) represent major changes in providers and settings that are directed at improving care for the
low-risk patient. The success of these programs must be measured not only by consumer acceptance or satisfaction but by careful evaluation of outcome parameters that relate to quality of care. The issue of cost-effectiveness, whether expenditure for the highrisk pregnancy or containment for the low-risk pregnancy, must be related to the measures of quality of care. As an academic health center, The University of Vermont College of Medicine, The Medical Center Hospital of Vermont, and University Health Center has a defined mandate for excellence in teaching, research, and clinical care. For the Department of Obstetrics and Gynecology, clinical care involves not only development of referral and tertiary-level programs but also, as the only obstetric service for the area, responsive programming for the low-risk patient. In 1979, the traditional setting of separate labor and delivery rooms was modified to allow delivery in each of the labor rooms (birthing rooms). The provider options for obstetric care include the CNM-MD team. The results presented here represent the analysis of the experience of the CNM-MD team working with low-risk patients in a hospital setting of birthing rooms as well as the conventional delivery rooms. The percent of patients who were transferred out of the CNM option (6.4%) during the antepartal period was surprisingly low but probably represents the strong self-selection involved in seeking CNM care. The proximity of certified nurse midwives and medical doctors in a large practice and a philosophy that encourages continued CNM involvement after risk determination might also have affected this low transfer rate. Comparison with other CNM reports is outlined
Table 2. Comparison of Nurse-Midwifery Services Labor and Delivery Consult Stewart‘ Americus, GA 1982 Hewitt’ Minneapolis I 981 Schreiera
Tucson1983
50.0
Manns San Francisco 1981 ScupholmeS Jacksonville 1982 Keleher’O Burlington. VT 1986
57.0
46.5
5-min
Spontaneous ABC/Labor Room
60.0
Forceps
Perinatal Death Rate
Episiotomy
No Analgesia
9.4
5.0
9.34
27.0
97.0
89.3
6.4
4.8
10.08
27
72.0
86.0
5.0
5.0
3.6*
31 .O
80.3
9.0
8.5
9.0
62.3
71.9
95.9
2.1
2.0
58.2
49.7
.35
83.4
10.4
5.6
59.3
67.0
.9
Vaginal Delivery
Cesarean Section
85.6
3.8
Apgar 5’ 5 6
1. I
7.8
All figures are percentages except perinatal deaths. ‘Neonatal death rate. I
September/October 1986 JOCNN
37 1
in Table 2. However, exact comparisons are difficult because of differences in setting such as out-of-hospita1 birthing center? clinic versus private practice patient p r ~ f i l e ,academic ~.~ health center5versus rural community hospital: and others. The 46.5% rate for consultation or management by the MD during the intrapartum period is comparable with the 50% consultation rate reported by Schreier.8The reasons for MD involvement are quite similar to those reported by Mann' and Hewitt' and relate primarily to dysfunctional labor patterns and concern for fetal distress. The primary cesarean section rate of 10% for this group was somewhat less than the rate of 15% for the Medical Center Hospital of Vermont obstetric service. Primary cesarean section was performed most often for cephalopelvic disproportion or fetal distress. In addition to a screening period of electronic fetal heart rate monitoring for 20 minutes in all patients, 47% of patients had the monitor replaced during labor to evaluate further the fetus during Pitocin@induction, epidural anesthesia, or auscultatory evidence of fetal stress. The frequency of MD involvement, electronic monitoring, and cesarean section for this group of patients indicated that in this setting the placement of birthing rooms or an ABC close to in-hospital facilities seemed most appropriate for the needs of both mothers and infants. The perinatal mortality rate of 5.43/1,000 (corrected 3.80/1,000) and 0.9% Apgar scores of less than 7 at five minutes compare favorably with published reports of other^^^^^"^*" and the Medical Center Hospital of Vermont total rate of 8.2/1,000 during this six-year period. No intrapartum deaths occurred among this group of 1,852 patients. SUMMARY The data presented demonstrate a CNM service that has been successfully incorporated into the Department of Obstetrics and Gynecology of a tertiary academic health center. The philosophy of minimal intervention, patient advocacy, and emotional support for each childbearing family is equally balanced by provision of immediate medical and technical expertise and consultation whenever necessary. The team CNM-MD practice is a well-accepted and positive component of the obstetric care. The exposure of medical students, nurse-midwifery students, and residents to this collaborative approach is a valuable ex-
372
perience in demonstrating the delivery of safe, comprehensive, and cost-effective patient care. This example demonstrates that alternatives in obstetric care can be routinely offered at a tertiary center without sacrificing the safety of the newborn o r mother. ACKNOWLEDGMENT Supported in part by a grant from the Lintilhac Foundation Nurse Midwifery Care Academic Health Center.
REFERENCES
2
1. Maeck JVS. Obstetrician-midwife artnership in obstetric care. Obstet Gynecol 1971;3 :315. 2. Lubic RW, Ernst EKM. The childbearing center: an alternative to conventional care. Nurs Outlook 1978;26: 754. 3. Gatewood TS, Stewart RB. Obstetricians and nursemidwives: The team approach in private practice. Am J Obstet Gynecol 1975;123:35. 4. Stewart RB, Clark L. Nurse-midwifery practice in an inhospital birthing center: 2050 births. J Nurse Midwifery 1982;27:21. 5. Laube DW. Experience with an alternative birth center in a university hospital. J Reprod Med 1983;28:391. 6. Mann RJ. San Francisco General Hospital nurse-midwifery practice: the first thousand births. Am J Obstet Gynecol 1981;140:676. 7. Hewitt MA, Hangslehen KL. Nurse-midwives in a hospital birth center. J Nurse Midwifery 1981;26:21. 8. Schreier AC. The Tucson Nurse-Midwifery Service: t h e first four years. J Nurs Midwifery 1983;28(6):24-9. 9. Scupholme A. Nurse-midwives and physicians: a team approach to obstetrical care in a perinatal center. J Nurs Midwifery 1982;27(1):21-7. 10. Keleher KC, Mann LI. Nurse-midwifery care in an academic health center. JOGNN 1986;15:369-72. 11. Platt LD, Angelini DJ, et al. Nurse-midwifery in a large teaching hospital. Obstet Gynecol 1985;66:816.
Address for correspondence: K.C. Keleher, CNM, Dept. of Ob/Gyn, Medical Center of Vermont, Mary Fletcher Unit, Burlington, VT 05401.
Kathleen C. Keleher is the nurse-midwifery director and clinical instructor at The University of Vermont College of Medicine and Medical Center Hospital of Vermont in Burlington, Vermont. Leon I. Mann is professor and chairman of the Department of Obstetrics and Gynecology at Case Western Reserve School of Medicine and Cleveland Metropolitan Hospital in Cleveland, Ohio.
September/October 1986 JOG"
The University of Vermont Department of Obstetrics and Gynecology first recruited a British-trained midwife to its practice in 1968. This expansion of the obstetric team was a direct result of the growing realization by the medical staff that as obstetric care shifted from general practice to obstetric practice, medical staff were becoming increasingly involved in normal routine obstetric care that did not require that level of specialized skills.' To serve the needs of most normal, low-risk pregnant women, and to ensure that the women at higher risk for obstetric problems received adequate attention, the Department of Obstetrics and Gynecology staff decided that certified nurse midwives (CNMs) could help provide the full range Of comprehensive, efficient,and cost-effective services to all obstetric patients. The added skills of the CNM in childbirth education, counseling, and labor support were recognized as assets for comprehensive obstetric care. Between 1968 and 1979, the nurse-midwifery staff at the Medical Center Hospital of Vermont (MCHV) evolved from one that provided only prenatal care and limited labor and delivery care to one in which four, full-time CNMs with medical backup by the ob/ Accepted: September 1984. Updated: May 1986.
September/October 1986 JOGNN
gyn faculty followed a specific group of women throughout the reproductive cycle. The CNM service, a Division of the Department of Obstetrics and Gynecology, has its own director. The four CNMs are employed by the Department of Obstetrics and Gynecology's private, not-for-profit group practice and all have appointments as clinical instructors at The University of Vermont College of Medicine. The CNMs have admitting privileges at the 500-bed MCHV. MCHV is the only Level-3 teaching and transfer institution for the state of Vermont and northeastern New York. The hospital has approximately 2,400 births a year, and the CNMs attend approximately 16% of these. Protocols that define CNM care were written and are reviewed annually. CNM practice is specifically legislated in Vermont by the Administrative Rules of the Vermont Nurse Practice Act. After a thorough examination of risk factors by an obstetrician and CNM, all low-risk women who come to the practice are offered three options for obstetric care. The women may be seen exclusively by an obstetrician (MD), they may alternate visits between one physician and one CNM (MD-CNM), or they may choose to be cared for primarily both antepartum and intrapartum by the four CNMs with a backup physician from the practice (CNM). Women who choose the third option see the obstetrician once each trimester. 369
The CNM patients are encouraged to meet prenatally with each of the nurse midwives at least once. This system ensures that the woman’s labor and delivery will be attended by a CNM who is familiar with the woman. The CNMs follow a full-time call system for the woman registered in the CNM option. To help ensure continuity of care, the decision to be followed by the CNM must be made by the 30th week of pregnancy unless the woman is new to the practice. If problems arise prenatally, the CNM consults with the specific backup physician. If need for consultation occurs during labor or delivery, the attending and resident staff are consulted. The communication and working relationship between the medical-nursing staff and the CNM staff are positive, supportive, and complementary. Quality assurance is facilitated by weekly meetings between the CNMs and the medical director, by monthly chart review, and by funding for continuing education conferences. Insurance status is not a factor in deciding on any of the possible options, and no differences exist in the fees charged. Cost-effectiveness of the program is difficult to measure and in this setting would best be determined in assessing the increased availability of physician time for other procedures. Patient satisfaction, although also difficult to measure objectively, also seems to be affected favorably if measured by the increased interest and response to the service over the years. From 1980 to 1985, inclusively, nearly a twofold increase (21 1 to 401) occurred in the number of women who chose the CNM option. SIX-YEAR ANALYSIS Data collected for a six-year period from the birth log kept by the nurse midwives on each birth for the CNM service was retrospectively analyzed. This includes all women who were followed prenatally by the nurse midwives regardless of complications after admission to the labor and delivery unit. Women who required joint management by the CNM and physician during labor and delivery are, therefore, included. Statistical analysis, when appropriate, was performed by student’s f-test comparison of means. From January 1, 1980, to December 31, 1985, 2,126 women registered for the CNM service. Of these 2,126 patients, 238 (1 1.2%) either were transferred out of the CNM option for medical or obstetric complications (135,6.3%) or voluntarily transferred out (82, 3.9%). Voluntary transfer included 37 of the 82 who switched to the MD-CNM service, 41 who moved from the area, and 9 who planned a home birth. Prenatal complications that required 135 patients to be transferred
370
involved spontaneous abortion in 42, medical complications in 21, and obstetric complications in 72. Whenever possible, the CNM continued to participate in the care of patients who were transferred out of the CNM option. Eighteen hundred fifty-two women were followed throughout the antepartum and intraparturn periods. Their mean age (29.7), ethnicity (Caucasian, 99.6%), and parity (primiparous, 53.2%) generally reflect the total obstetric population at MCHV. On admission to labor and delivery, each of the 1,852women was electronically monitored for 20 minutes for detection of abnormalities in baseline fetal heart rate, variability, and uterine contraction patterns. If no abnormality was noted, intermittent fetal auscultation was conducted by established obstetric protocol, and continuous electronic monitoring reinstituted only when indicated. Of the 1,852 women, 47.2% required continuous electronic monitoring at some point during labor. Of these, 62.3%were monitored by the internal system. Intrapartum complications necessitating MD (obstetric and/or pediatric) involvement occurred in 861 or 46.5% of cases. Dysfunctional labor patterns accounted for the largest number of consultations (256, 29.7%),while meconium staining (199,23.1%) and fetal stress (164, 19.0%) represented other significant problems requiring MD involvement. Spontaneous vagina1 delivery occurred in 1,561 (84.0%) of the patients. Sixty percent of the patients delivered vaginally in the labor/birthing rooms. Sixtyseven percent of the patients did not require analgesia during labor, and 72.1%required no anesthesia or only local anesthesia for episiotomy incision and repair. Shoulder dystocia occurred in 11 cases, postpartum hemorrhage in 27, and retained placenta in 13. The rate for primary cesarean section was 10.4% (193 patients) and for forceps delivery 5.6% (103 patients), with a total operative delivery rate of 16.0%.All deliveries requiring intervention were performed in t h e delivery/cesarean section room in the labor and delivery suite. Perinatal morbidity and mortality are shown in Table 1. An Apgar score of less than 7 at five minutes was recorded in 16 newborns or 0.9%of all deliveries. Of the 8 newborns with Apgar scores 0 to 3 at five minutes, 6 were fetal deaths before labor, 1 was associated with a prolapsed cord and emergency cesarean section, and 1 was due to a diaphragmatic hernia. No intrapartum deaths occurred. The four neonatal deaths occurred as a result of 1 newborn with trisomy 18, 1 with a diaphragmatic hernia, 1 with a severe cardiac defect, and 1 with neonatal sepsis. T h e corrected perinatal death rate was 3.8/1,000 total births.
September/October 1986 JOCNN
Table 1. Perinatal Morbidity and Mortality
1,852
Total births Apgar score 1 min
27 <7 27
5 min
(91.7%) (8.3%) (99.1Yo) (0.9YO)
1,699 153 1,836 16
<7
6
Fetal deaths Preterm Term lntrapartum Rate Neonatal deaths Rate Perinatal death rate Corrected
0 6
0 3.24/1,000 4
2.17/1,000 5.43/1,00 3.80/1,000
DISCUSSION Over the past decade, obstetric care has undergone extensive alteration in organization of providers and settings. Pregnant patients have been recognized as a heterogeneous group, with some at high risk for problems requiring intensive care and others at low risk requiring minimal intervention. Training programs for subspecialists in perinatal care, perinatal tertiary centers, and regional perinatal programs have been developed to serve the needs of the high-risk obstetric patient and her newborn. Nurse-midwifery training and certification, childbirth educational courses, birthing rooms, and alternative birthing centers (ABCs) represent major changes in providers and settings that are directed at improving care for the
low-risk patient. The success of these programs must be measured not only by consumer acceptance or satisfaction but by careful evaluation of outcome parameters that relate to quality of care. The issue of cost-effectiveness, whether expenditure for the highrisk pregnancy or containment for the low-risk pregnancy, must be related to the measures of quality of care. As an academic health center, The University of Vermont College of Medicine, The Medical Center Hospital of Vermont, and University Health Center has a defined mandate for excellence in teaching, research, and clinical care. For the Department of Obstetrics and Gynecology, clinical care involves not only development of referral and tertiary-level programs but also, as the only obstetric service for the area, responsive programming for the low-risk patient. In 1979, the traditional setting of separate labor and delivery rooms was modified to allow delivery in each of the labor rooms (birthing rooms). The provider options for obstetric care include the CNM-MD team. The results presented here represent the analysis of the experience of the CNM-MD team working with low-risk patients in a hospital setting of birthing rooms as well as the conventional delivery rooms. The percent of patients who were transferred out of the CNM option (6.4%) during the antepartal period was surprisingly low but probably represents the strong self-selection involved in seeking CNM care. The proximity of certified nurse midwives and medical doctors in a large practice and a philosophy that encourages continued CNM involvement after risk determination might also have affected this low transfer rate. Comparison with other CNM reports is outlined
Table 2. Comparison of Nurse-Midwifery Services Labor and Delivery Consult Stewart‘ Americus, GA 1982 Hewitt’ Minneapolis I 981 Schreiera
Tucson1983
50.0
Manns San Francisco 1981 ScupholmeS Jacksonville 1982 Keleher’O Burlington. VT 1986
57.0
46.5
5-min
Spontaneous ABC/Labor Room
60.0
Forceps
Perinatal Death Rate
Episiotomy
No Analgesia
9.4
5.0
9.34
27.0
97.0
89.3
6.4
4.8
10.08
27
72.0
86.0
5.0
5.0
3.6*
31 .O
80.3
9.0
8.5
9.0
62.3
71.9
95.9
2.1
2.0
58.2
49.7
.35
83.4
10.4
5.6
59.3
67.0
.9
Vaginal Delivery
Cesarean Section
85.6
3.8
Apgar 5’ 5 6
1. I
7.8
All figures are percentages except perinatal deaths. ‘Neonatal death rate. I
September/October 1986 JOCNN
37 1
in Table 2. However, exact comparisons are difficult because of differences in setting such as out-of-hospita1 birthing center? clinic versus private practice patient p r ~ f i l e ,academic ~.~ health center5versus rural community hospital: and others. The 46.5% rate for consultation or management by the MD during the intrapartum period is comparable with the 50% consultation rate reported by Schreier.8The reasons for MD involvement are quite similar to those reported by Mann' and Hewitt' and relate primarily to dysfunctional labor patterns and concern for fetal distress. The primary cesarean section rate of 10% for this group was somewhat less than the rate of 15% for the Medical Center Hospital of Vermont obstetric service. Primary cesarean section was performed most often for cephalopelvic disproportion or fetal distress. In addition to a screening period of electronic fetal heart rate monitoring for 20 minutes in all patients, 47% of patients had the monitor replaced during labor to evaluate further the fetus during Pitocin@induction, epidural anesthesia, or auscultatory evidence of fetal stress. The frequency of MD involvement, electronic monitoring, and cesarean section for this group of patients indicated that in this setting the placement of birthing rooms or an ABC close to in-hospital facilities seemed most appropriate for the needs of both mothers and infants. The perinatal mortality rate of 5.43/1,000 (corrected 3.80/1,000) and 0.9% Apgar scores of less than 7 at five minutes compare favorably with published reports of other^^^^^"^*" and the Medical Center Hospital of Vermont total rate of 8.2/1,000 during this six-year period. No intrapartum deaths occurred among this group of 1,852 patients. SUMMARY The data presented demonstrate a CNM service that has been successfully incorporated into the Department of Obstetrics and Gynecology of a tertiary academic health center. The philosophy of minimal intervention, patient advocacy, and emotional support for each childbearing family is equally balanced by provision of immediate medical and technical expertise and consultation whenever necessary. The team CNM-MD practice is a well-accepted and positive component of the obstetric care. The exposure of medical students, nurse-midwifery students, and residents to this collaborative approach is a valuable ex-
372
perience in demonstrating the delivery of safe, comprehensive, and cost-effective patient care. This example demonstrates that alternatives in obstetric care can be routinely offered at a tertiary center without sacrificing the safety of the newborn o r mother. ACKNOWLEDGMENT Supported in part by a grant from the Lintilhac Foundation Nurse Midwifery Care Academic Health Center.
REFERENCES
2
1. Maeck JVS. Obstetrician-midwife artnership in obstetric care. Obstet Gynecol 1971;3 :315. 2. Lubic RW, Ernst EKM. The childbearing center: an alternative to conventional care. Nurs Outlook 1978;26: 754. 3. Gatewood TS, Stewart RB. Obstetricians and nursemidwives: The team approach in private practice. Am J Obstet Gynecol 1975;123:35. 4. Stewart RB, Clark L. Nurse-midwifery practice in an inhospital birthing center: 2050 births. J Nurse Midwifery 1982;27:21. 5. Laube DW. Experience with an alternative birth center in a university hospital. J Reprod Med 1983;28:391. 6. Mann RJ. San Francisco General Hospital nurse-midwifery practice: the first thousand births. Am J Obstet Gynecol 1981;140:676. 7. Hewitt MA, Hangslehen KL. Nurse-midwives in a hospital birth center. J Nurse Midwifery 1981;26:21. 8. Schreier AC. The Tucson Nurse-Midwifery Service: t h e first four years. J Nurs Midwifery 1983;28(6):24-9. 9. Scupholme A. Nurse-midwives and physicians: a team approach to obstetrical care in a perinatal center. J Nurs Midwifery 1982;27(1):21-7. 10. Keleher KC, Mann LI. Nurse-midwifery care in an academic health center. JOGNN 1986;15:369-72. 11. Platt LD, Angelini DJ, et al. Nurse-midwifery in a large teaching hospital. Obstet Gynecol 1985;66:816.
Address for correspondence: K.C. Keleher, CNM, Dept. of Ob/Gyn, Medical Center of Vermont, Mary Fletcher Unit, Burlington, VT 05401.
Kathleen C. Keleher is the nurse-midwifery director and clinical instructor at The University of Vermont College of Medicine and Medical Center Hospital of Vermont in Burlington, Vermont. Leon I. Mann is professor and chairman of the Department of Obstetrics and Gynecology at Case Western Reserve School of Medicine and Cleveland Metropolitan Hospital in Cleveland, Ohio.
September/October 1986 JOG"