Nurse-Midwifery Management of Obstetric Complications


The Journal of Nurse-Midwifery Editorial Board is pleased to present its 1994 Home Study Program, which features Obstetric Complications. The content that is presented herein consists of a select group of complications and is not intended to be representative of the full spectrum of complicated pregnancies; in fact, the companion issue to this supplement (JNM 39:2) includes additional articles that address obstetric complications.

The prevention and identification of complicated pregnancies have always been a part of nurse-midwifery's repertoire. In addition, collaborative management of such obstetric complications as gestational diabetes, iron-deficiency anemia, pregnancy-induced hypertension, premature rupture of membranes, preterm labor, postdate pregnancy, and intrauterine growth retardation is increasingly being adopted by CNM/MD teams.

Basic CNM education programs have traditionally included the recognition of deviations from the expected norm, as well as the initial management and follow-up of problems within their curricula. However, their primary goals are to provide basic skills necessary for midwifery practice; thus, CNMs who are adept in advanced practice have had to acquire on-the-job training and/or informal apprenticeship at their site of practice. Furthermore, there is usually no documentation of supervised clinical practice that attests to the acquisition of knowledge and skills in the management of obstetric complications.

The role of the CNM in the management of complications is generally viewed differently by individual clinicians and educators. One influential variable is geographic location of the practice site. CNMs who practice in remote rural areas often play primary roles in the management of specific complications because of the dearth of health care practitioners. On the other hand, CNMs who practice in large urban teaching institutions may be forced to transfer their patients to the physician as soon as an initial identification of a problem is made. Might the need for clinical learning by medical students, residents, family practice physicians, and physician assistants be the factor that supersedes the CNM's role as primary care provider?

The current reorganization of the U.S. health care delivery system under the guidance of Hillary Rodham Clinton promotes total CNM involvement in the primary care of their patients. Primary care is advanced practice and expands the definition of full-scope nurse-midwifery care to encompass the independent and collaborative management of a broad range of health problems. How much responsibility do CNMs want then, for providing family-centered care?

The International Confederation of Midwives, the International Federation of Gynaecology and Obstetrics, and the World Health Organization include in their joint definition of midwifery practice the following statement: “… This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help” (1). The ACNM's Core Competencies further delineate the CNM's responsibilities in relation to primary management, collaboration, and referral (2). Although they do not address specific complications, neither are they prohibitive in terms of midwifery practice and the management of obstetric complications. Indeed, the scope of nurse-midwifery practice must not be limited by prohibitive language or attitudes. Within the boundaries of safe practice, CNM knowledge and skill base should be encouraged to stretch its limits; however, this expansion of practice shifts the responsibility for maintaining clinical competence directly to the individual practitioner.

By nature, pregnancy, birth, and the postpartal period are generally healthy processes. Complications that arise are statistically infrequent, although specific populations do experience increased incidences of certain complications. Native Americans have an increased incidence of diabetes; African-Americans are at risk for sickle-cell anemia and hypertension; people of Asian, Mediterranean, and African descent have an increased incidence of the thalassemia anemias; Anglo-Saxons have an increased incidence of cystic fibrosis; and Ashkenazl Jews have an increased incidence of Tay-Sachs and Gaucher's diseases. Still, the infrequency of occurrence in clinical practice makes up-to-date knowledge and skills of a wide range of potential problems even more vital to safe CNM practice. The need for immediate action in the management of select complications such as shoulder dystocia and postpartum hemorrhage are added incentives for continuously updating current knowledge, skills, and management options. Complications such as preterm labor, premature rupture of membranes, intrauterine growth retardation, and postdates pregnancy can often be successfully managed with vigilant nurse-midwifery assessment and individualized plans.

The legal implications of nurse-midwives taking a more primary role in the collaborative management of complications are many. As stated earlier, there are no guidelines for the documentation of acquired advanced practice skills. Legally, nurse-midwives might have to provide evidence that they are competent in a particular skill if it was not covered in a basic education program prior to collaborative management of a patient. For the last three decades, the ACNM has had guidelines for the incorporation of new procedures; this document is broad enough to incorporate all aspects of advanced primary care (3). The art and science of nurse-midwifery must work interdependently. CNM clinicians and educators are in a position to integrate holistic midwifery assessment and management skills with collaborative management of obstetric complications. The identification of influential variables that may increase the likelihood of the complications commonly associated with pregnancy such as overwork, unemployment, poverty, poor nutrition, and abusive relationships, as well as the identification of relevant nurse-midwifery interventions, would provide needed data for the investigation of the effects of nurse-midwifery care. Obstetric complications will, unfortunately, always be a reality. The JNM Editorial Board encourages you to participate in this Home Study Program and to keep your knowledge base current while you earn ACNM CEUs!