midwives practice question

[mothercat]

Let me start out by saying I am a CNM with a OOH practice.
So, here's the back story:

Got the prenatal record of a client who transferred from a hospital based practice. As she and I are going through the notes, the previous midwife wrote a long note about counseling the client about the danger of OOH birth and quite specifically noted " that the midwife at this particular practice (that would be me) does not have a consulting physician."

It got me thinking about why that should influence a woman's decision about where to birth. Is it because as a CNM (who used to be an L&D nurse), she doesn't think she can practice safely w/o the consulting doc in the office to provide support?

In states where CNM's could have their own independent practices, is this the reason most choose not to?

How pervasive is this attitude?

Linda

[nashvillemidwife]

Linda, do you have a relationship with a physician? Do you have a doc you can consult with if needed?

I'm sorry I don't really have an answer to your question. As a CPM, I feel it's important for me to have a relationship with a doctor that I can consult with and refer clients to if necessary. I have one main backup doctor and a few others for clients who live in specific areas, but I am not bound to any in a supervisory relationship. I feel this makes client care better and safer - I am never afraid or reluctant to ask for help and the clients have a smooth transition if we have to transport. But things are different for everyone; I'm a CPM who lives in an area that I and my clients might not be treated well if I didn't practice this way.

[mothercat]

That was the thing that kind of peeved me about the midwife's note. She just assumed that because I don't work in an OB's practice, that I don't have any physicians that I consult with when needed.
In truth, I am currently co-managing a client with a MFM and he knows I do birth OOH. He manages a few aspects of her care (meds), but I am providing all the prenatal care. He sees her maybe 3-4 times during the pregnancy. I can call him if needed, but he has kept me well informed of the care he is providing. I am considered the referring provider and he is the consultant.
This is not the first time I have used him, and he has always been gracious in the way he treats me as a colleague.

My question was about midwives who work with physicians. Where did we get the attitude that w/o a physician to supervise and advise that we can't provide safe care?

[MommyMidwife]

I am in Virginia

And the CNMs must have physician supervision but the CPMs do not. I am a CPM.
We wrote our law and got it passed in 2005 and the CNMs are working on changing theirs.
I have lots of docs I can call and consult wiht too.
I would be hurt if i found that in a chart. That is just a mean ratty thing to do.
jeni

[mothercat]

The thing that I don't think the CNM understood was that it is precisely that midwife's relationship with the physician that caused this woman to switch to the birth center.

I get that question frequently, along the lines of "how involved is your consultant?". I think that women who have had an unnecessary C/sec., or other traumatic birth, are very aware that the midwife may have wanted to do one thing but had to answer to the doc who wanted to handle things differently.

In my state (Michigan), CNM's are independent practitioners other than prescriptive privileges which are a delegated medical act. I have a DO who delegates that ability to me, but most of the time it is just for giving Pit, occ. antibiotics for mastitis, etc.

Personally, I like being independent because I know that how I handle any given situation is based on what I know, not someone else's time constraints or other needs.

It was just eye opening and it's not the first time I've seen a note like this.

I almost want to label it as fear on her part that she doesn't place enough trust in her own ability to manage normal birth. But then she worked L&D for a lot of years before becoming a CNM and maybe she really does believe that birth OOH is dangerous.

[mwherbs]

so in Az CNMs can have independent practice including Rx, scope of practice is defined to your training including the Rx-- and the majority choose to be employed, instead of having independent practices employment means the local hospitals "require" signed protocols and back up physician in order for the CNM to attend births (even thought this is not what the law requires) there is one OOH CNM who practices in the state, has her protocols and has a plan. She doesn't have a back up physician- she has back-up plans and she will consult with who ever is appropriate - most women who have insurance have a list of providers that are insurance approved, after a while you get to know the different providers and have a general idea of what insurance cover them so if there is someone you feel has better judgment or is a human being to talk to you can recommend those docs as the consults - at the hospital you end up with the staff on call physician. we are all in the same boat as far as that goes LMs and CNMs alike.
About all you can do is educate the other providers- sometimes it takes complaining and sometimes it takes being friendly-with an explaination - I really don't know- maybe the practice agreements are mistaken for laws- or maybe the gals that practice closely with docs have no idea how to go without a close relationship .
Personally I don't even know how to have a close consulting physician relationship- and why would I want to have one- seems like alot of work, most OBs are in group practice and if you can get along with one the others don't hold up so they are not always on call for you or the client... also the docs we like the most have tons of trouble with the other medical staff as well- nurses and nurse managers who undermine orders the doc gives, hospital administration that dictates policy, chief of staff ...
for most things that may take co-management the gals are going to end up out of our scope of practice- exceptions would be something like ovarian cyst - gal followed by oncology specialist who ordered all the follow-up labs and tests saw client several times- got reports and spend a bit of time on the phone more recently the clotting/ heparin treatment...