NURSE-MIDWIFERY SERVICE IN A RURAL SETTING

This article describes the structure and development of a successful, rural nurse-midwifery service consisting of nine certified nurse-midwives and four obstetricians. The model has shown that the addition of a nurse-midwifery service and the adoption of a collaborative care model can improve obstetric outcomes. The outcomes of this model include an increase in the number of women served each year, a decrease in the cesarean section rate, an increase in the number of twin gestations delivered vaginally, an increase in the number of breech presentations delivered vaginally, an increase in the success rate of vaginal birth after cesarean section, and decreased numbers of episiotomies, with a resulting decrease in the number of third- and fourth-degree lacerations.     

NURSE-MIDWIFERY SERVICE MODEL IN AN ACADEMIC ENVIRONMENT

This article discusses the development and unique features of a nurse-midwifery division within a university school of medicine department of obstetrics and gynecology and its expanded scope of activities in nurse-midwifery education and research.     

VBAC PROGRAM IN A NURSE-MIDWIFERY SERVICE Five Years of Experience

Vaginal birth after cesarean (VBAC) is well documented by research studies to be safe and, in many cases, better for women with a previous cesarean birth than a repeat cesarean. The article describes one nurse-midwifery service's policies and procedures for helping women to prepare for and have a trial of labor. During the intrapartal period women with a uterine scar are managed similar to those without a scar except for closer monitoring, lab studies, and intravenous heparin lock. An obstetrician is always in the hospital and available for consultation. Of 53 women attempting VBAC, 83% had a vaginal birth. Those with a previous cesarean for failure to progress had the lowest vaginal birth after cesarean rate of 65%. Maternal and newborn morbidity was low. The authors conclude that nurse-midwifery management of vaginal birth after cesarean candidates is safe and very successful when appropriate physician consultation and hospital services are readily available.     

PERINEAL OUTCOMES AND NURSE-MIDWIFERY MANAGEMENT

This article describes the association among perineal outcomes, selected risk factors, and alternative intrapartum approaches used by nurse-midwives. This nonrandomized concurrent (cohort) study analyzed all spontaneous vaginal births (N = 1211) attended by nurse-midwives at a university hospital over a 2-year period. Univariate analysis was used to calculate relative risks for the associations between two perineal outcomes and selected variables. Study results indicated that parity, ethnicity, birth weight, and use of two techniques (hot compresses and lubrication) were associated with lacerations. The same factors that increase the risk of perineal lacerations also made the performance of an episiotomy more likely; however, for episiotomy, an inverse relationship with perineal hot compresses was noted, and perineal lubrication had no effect. Lack of perineal support was associated with a 66% rise in the risk of episiotomy. Use of birthing positions other than lithotomy significantly reduced the likelihood of episiotomy. The authors concluded that selected care measures to protect the perineum may reduce maternal morbidity and simplify intrapartum care. The risks and benefits of alternative strategies commonly used by nurse-midwives while caring for diverse populations during birth should be further evaluated in large multiethnic populations.     

DEVELOPMENT AND OUTCOMES OF THE MULTIPLE-CHOICE FORMAT NATIONAL CERTIFICATION EXAMINATION IN NURSE-MIDWIFERY AND MIDWIFERY

The national certification examination in nurse-midwifery and midwifery now is offered exclusively in the multiple-choice format. The strategies used to develop equivalent examination forms are described. The manner of criterion-referenced standard setting is explained. Outcomes of the first five multiple-choice examination forms include an aggregate first-time failure rate of 8.3%. Multiple- and logistic-regression analyses indicate that examination scores of African-American and Hispanic ethnic candidates, and older candidates, are lower with regard to statistical significance; however, these differences are too modest to be of practical significance. No substantive relationship was observed between any demographic or academic variable and the probability of passing the examination. The experience gained by the ACNM Certification Council during development, administration, and evaluation of these first five multiple-choice examination forms has provided strong support for the transition to multiple-choice testing for the assessment of entry into practice of this competency-based profession.     

CLOSING OF THE NURSE-MIDWIFERY SERVICE AT BOSTON CITY HOSPITAL

This article describes the experiences of 11 staff cnm s practicing in an inner-city hospital serving low-income women. A history of the conflicts between the ob/gyn Department and the Midwifery Service at Boston City Hospital is presented, as well as an overview of events in 1987-88 that resulted in the unanimous resignation of the staff cnm s and the closing of the service. Discussion of the issues is presented, as well as implications for midwifery practice.     

PORTRAIT OF NURSE-MIDWIFERY PATIENTS IN A PRIVATE PRACTICE

Demographic and obstetric characteristics of patients seen by a nurse-midwife in a private obstetric practice over a 3 year period are reviewed. 212 patients had extensive contact with the nurse-midwife. Ethnic background, age, and marital status of the patients are discussed, as well as the educational and occupational status of the patient and her husband. Where appropriate, the figures are compared to the general population of delivered mothers in Milwaukee. 40 patients who had asked for the nurse-midwife were delivered by physicians because of complications or other circumstances. Thirteen patients were delivered by cesarean section and 13 deliveries had forcep deliveries. The majority of the patients who sought the services of the nurse-midwife were Caucasian and married. 71% of the patients were between the ages of 20 and 29.     

DEVELOPMENT OF AN ACADEMIC NURSE-MIDWIFERY SERVICE PROGRAM: A Partnership Model Between Medicine and Midwifery

Academic nurse-midwifery services have shown themselves to be strong collaborators with medical education. The development and functioning of an academic nurse-midwifery service program built on a partnership model between medicine and midwifery are highlighted. Organizational relationships, philosophical approach, and practice dimensions including responsibilities for clinical practice, medical student, and obstetrical resident education are explored. As the obstetrical patient pool diminishes in academic service settings, this model may prove useful.     

CHLAMYDIA INFECTION IN A NURSE-MIDWIFERY CASELOAD

The purpose of this study was to determine whether antepartum treatment of chlamydia infection resulted in a change in incidence of maternal infection in the intrapartum and postpartum periods as indicated by the incidence of maternal febrile morbidity or antibiotic therapy. In June of 1986, an inner-city tertiary-care center nurse-midwifery service began including diagnosis and treatment of chlamydia infection in routine antepartum care. In this retrospective chart review, the incidence of intrapartum and postpartum infection among women who delivered in this caseload between May 1985 and May 1986 (the last year prior to the routine chlamydia diagnosis and treatment) was compared with that of women who delivered between July 1986 and July 1987 (the first year after initiation of the testing). No significant differences were found. Implications for the development of research projects within nurse-midwifery clinical services are discussed, along with methodologic problems that may ensue when attempting to study changes in outcome in ones' own service.     

THE USE OF AMNIOINFUSION IN NURSE-MIDWIFERY PRACTICE

Intrapartum amnioinfusion is being used in a variety of clinical settings and for multiple therapeutic modalities to prevent fetal distress and improve outcomes. The procedure has demonstrated efficacy in cases of variable decelerations and thick, meconium-stained amniotic fluid. Amnioinfusion has been shown to improve maternal and neonatal outcomes by decreasing cesarean sections for fetal distress, improving cord pH, and decreasing the amount of meconium present below the cords at delivery. This article describes the pathophysiology of amniotic fluid volume disorders that indicate the use of amnioinfusion, reviews the literature regarding the indications and therapeutic effects, and describes techniques for the use of amnioinfusion. In addition, there is a discussion of the contraindications associated with the use of amnioinfusion and its use in and out of hospital settings. The technique for amnioinfusion is simple, easy, and inexpensive to initiate. It can be performed in a variety of settings, provided there is adequate equipment, personnel, and emergency services available. Certified nurse-midwives should become familiar and comfortable with the procedure in order to provide complete care for the families they serve.     

HISTORY OF NURSE-MIDWIFERY IN REPRODUCTIVE HEALTH CARE

From the maternity cycle to the primary health care of women, this article traces the expansion of the role of midwives in reproductive health care over the past 3 decades. Included are the recollections of Shirley Okrent about the early development of this role expansion and a few of the author's personal memories.     

INCORPORATION OF A NURSE-MIDWIFERY PRACTICE*

Should a nurse-midwifery practice be incorporated or should the practice remain unincorporated? Many nurse-midwives are considering practice in the corporate form—there are advantages and disadvantages to practicing that way. This discussion is designed to given an overview of the subject so that a CNM may decide whether or not professional incorporation is appropriate under his/her circumstances.     

FUTURE PROSPECTS OF NURSE-MIDWIFERY IN THE UNITED STATES*

The future prospects of the nurse-midwifery profession are evaluated by considering both the factors which support and also those which may impede continued growth. Nurse-midwifery's contribution to health policy goals, in particular, increased access to services and cost containment; consumer preference for this provider; and the uniqueness of the content of care given in nurse-midwifery practice all portend favorably for the future of the profession. Factors which might jeopardize continued growth include an oversupply of obstetricians and legal and reimbursement constraints. Reckoning with the possible effects of a physician oversupply may be the most important task facing the profession.     

HEMATOCRIT VALUES DURING PREGNANCY IN A NURSE-MIDWIFERY CASELOAD

This article reviews the normal hematologic changes in pregnancy and the kinetics of iron metabolism. The differences between iron depletion and anemia are described. The hematocrit levels of a nurse-midwifery caseload in a tertiary-care setting are described and compared with recently published population norms. Hematocrits of the sample compared favorably to the population hematocrits until 24 weeks' gestation, when the sample hematocrit mean became statistically lower and remained that way throughout pregnancy. Further analysis was done on the sample hematocrits, comparing differences in parity, age, pregnancy spacing, and AS versus AA hemoglobin. Parous women with a pregnancy interval >12 months had a higher mean hematocrit then nulliparous women. Mean hematocrits of age groups varied significantly only at the 29–32-week interval, with women younger than 18 having lower mean hematocrits than those ≥18. A trend of women with AS hemoglobin having higher hematocrits than women with AA hemoglobin was identified, reaching statistical significance at the 29–32-week interval.