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August 1999
Volume 63 |
Number 8
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| Certified Nurse
Midwives, Obstetric Anesthesia and You |
Joy L. Hawkins, M.D.
Committee on Obstetric Anesthesia
More women are choosing to have a certified nurse midwife (CNM)
provide their obstetric care, and anesthesiologists are being
asked more frequently to provide regional anesthesia during that
care. What are the clinical and legal implications of our involvement?
In 1995, 6 percent of births in the United States were
attended by a CNM.1 Often, this
choice is based on the perception that fewer interventions will
be performed by a nurse midwife than a physician. Midwives are
less likely to induce or augment labor, continuously monitor their
patients electronically, use epidural anesthesia or perform episiotomies.1
Many women enter into labor with the hope they will require minimal
intervention, but labor is an unpredictable and dynamic event.
A nulliparous patient may find that labor pain is not at all what
she was led to expect in her childbirth education class and that
nonpharmacologic methods are inadequate. A parturient may require
induction or augmentation with oxytocin, resulting in an increase
in the pain and duration of labor. These women are more likely
to request epidural analgesia.
Patients of midwives have a lower cesarean section rate
than obstetricians or family practitioners and are less likely
to have instrumented vaginal deliveries.1
A recent study from the National Center for Health Statistics
examined infant mortality rates for midwife-attended deliveries
and physician-attended births. After controlling for social and
medical risk factors, they found the risk of infant death was
19 percent lower, the risk of neonatal mortality was 33 percent
lower, and the risk of delivering a low birth weight infant was
31 percent lower in midwife-attended births.2
With no evidence of an adverse effect on outcomes and because
their approach to obstetrics may result in fewer interventions,
lower costs and fewer days of hospital stay, midwives are increasingly
popular providers in hospitals and managed care organizations.
Certified nurse midwives may be self-employed or employed
by obstetricians or managed care organizations. They are often
given admitting privileges by a hospital to provide uncomplicated
obstetric care in the antepartum, intrapartum and postpartum period.
Most hospitals and obstetric groups will have protocols outlining
when a physician must be consulted, and all certified nurse midwives
are required by the state Nurse Practice Act to have a physician
with privileges in obstetrics available for consultation and collaboration.
Consultation in this case is defined as the process whereby a
CNM maintains primary management responsibility but seeks the
advice of a physician. Collaboration is defined as the process
whereby a CNM and physician jointly manage the care of a woman
who has become medically or obstetrically complicated. If a cesarean
section is required, the collaborative physician would perform
the surgical procedure. Depending on the hospital size and location,
that physician might be an obstetrician, family practitioner or
general surgeon.
A joint statement between the American College of Obstetricians
and Gynecologists (ACOG) and the American College of Nurse-Midwives
(ACNM) states that "...the appropriate practice of the certified
nurse-midwife includes the participation and involvement of the
obstetrician/gynecologist as mutually agreed upon in written medical
guidelines/protocols... This does not necessarily imply the physical
presence of the physician when care is being given by the certified
nurse-midwife." Financial arrangements for this relationship may
be complicated; reimbursement for obstetric services often is
a global fee paid to the provider who performs the delivery. If
the collaborative physician performs the delivery, that person
may receive the entire global fee regardless of who had provided
the preceding months of antepartum care and/or hours of intrapartum
care.
It is quite likely that an increasing number of anesthesiologists
will be asked to provide epidural analgesia to patients who are
attended by a nurse midwife. Is it necessary for an obstetrician
to become involved in her care once we become involved? The ASA
"Guidelines for Regional Anesthesia in Obstetrics" state: "Regional
anesthesia should not be administered until: 1) the patient has
been examined by a qualified individual; and 2) the maternal and
fetal status and progress of labor have been evaluated by a physician
with privileges in obstetrics who is readily available to supervise
the labor and manage any obstetric complications that may arise."
Some ASA members have interpreted this statement to mean they
cannot place an epidural for labor analgesia unless the patient
has been seen and examined by an obstetrician or family practitioner.
Yet, if a low-risk patient's care has been provided by a nurse
midwife to that point, the collaborative physician likely has
not met or examined the patient and may not be able to provide
additional obstetric information. The collaborative physician's
expectation is to be available only for emergencies and/or cesarean
delivery. Certainly, if the anesthesiologist has any concerns
about the maternal or fetal condition or the progress of labor,
he or she can contact the collaborative physician to discuss the
case and state that a spinal or epidural has been requested for
labor analgesia.
Some anesthesiologists have suggested that a woman becomes
"high risk" when she chooses to have regional analgesia for pain
relief during her labor, and therefore, an obstetrician should
be involved. Obstetric anesthesiologists have fought for years
to make patients and obstetric providers realize that regional
analgesia for labor is the most effective form of pain relief
with minimal and manageable side effects. Review of hospital quality
assurance data shows that emergency cesarean delivery is rarely
required after placement of regional analgesia.3
Virtually all recent studies have "debunked" the myth that epidural
analgesia leads to an increase in the cesarean delivery rate.4,5
Regional analgesia for labor should not automatically move a parturient
into a higher risk category.
Another concern is that medicolegal liability will be
increased if the anesthesiologist is the only physician directly
involved in the patient's care and there is a bad outcome. Michael
Scott, ASA Director of Governmental and Legal Affairs, has expressed
the view that as long as the anesthesiologist is not involved
in the obstetrical management and decision-making, he or she should
bear little or no risk. Liability should not be attached merely
because the anesthesiologist is the only physician in the room
any more than the surgeon is automatically liable for a nurse
anesthetist's decision. Unless a hospital rule or state law says
the anesthesiologist is "supervising" the nurse midwife (a highly
unlikely situation), liability should not attach. Other than anecdotal
comments without supporting data, I know of no case where an anesthesiologist
has been held liable for the negligent omissions or commissions
of a certified nurse midwife. This issue should be discussed with
your liability insurer.
ÒAlthough midwifery patients are less likely to require
anesthesia servicesÉ, these parturients should not be denied
our care simply because their obstetric provider is a nurse
midwife.Ó
In summary, anesthesiologists are going to be increasingly
involved with parturients whose care is provided by certified
nurse midwives. An open discussion with the midwives and their
consulting, collaborating or supervising obstetricians should
occur early in the relationship. Although midwifery patients are
less likely to require anesthesia services for labor analgesia
or cesarean delivery, these parturients should not be denied our
care simply because their obstetric provider is a nurse midwife.
The anesthesia group should be aware of the protocols used to
determine when an obstetrician will be consulted and have input
as it relates to their services. My interpretation of the ASA
"Guidelines for Regional Anesthesia in Obstetrics" is that an
anesthesiologist may administer regional analgesia to a patient
whose attendant is a midwife, provided that an obstetrician is
readily available to perform an emergency cesarean delivery or
manage other obstetric complications. Anesthesiologists and obstetricians
must define "readily available" at the local level.
References:
- Rosenblatt RA, Dobie SA, Hart LG, et al.
Interspecialty differences in the obstetric care of low-risk
women. Am J Public Health. 1997; 87:344-351.
- MacDorman MF, Singh GK. Midwifery care,
social and medical risk factors, and birth outcomes in the USA.
J Epidemiol Community Health. 1998; 52:310-317.
- Albright GA, Forster RM. Does combined
spinal-epidural analgesia with subarachnoid sufentanil increase
the incidence of emergency cesarean delivery? Reg Anesth.
1997; 22:400-405.
- Sharma SK, Sidawi JE, Ramin SM, et al.
Cesarean delivery: A randomized trial of epidural versus patient-controlled
meperidine analgesia during labor. Anesthesiology. 1997;
87:487-494.
- Halpern SH, Leighton BL, Ohlsson A, et
al. Effect of epidural versus parenteral opioid analgesia on
the progress of labor. JAMA. 1998; 280:2105-2110.
Joy L. Hawkins, M.D., is Professor of
Anesthesiology and Director of Obstetric Anesthesia, University
of Colorado School of Medicine, Denver, Colorado.
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