ANMC Certified-Nurse Midwife Practice Guideline

Approved by the ANMC MCH CCBG April 2013 Reviewed Nov. 16, 2015 1. Intent of Certified Nurse-Midwife Practice Guideline 1.1. The intent of this practice guideline is to provide guidance for midwifery practice at the Alaska Native Medical Center (ANMC). The standards in this document have come from established organizations such as the American College of Nurse-Midwives (ACNM), the American College of Obstetricians and Gynecologists (ACOG), and the Guidelines for Perinatal Care (American Academy of Pediatrics and ACOG). The Certified Nurse-Midwife practice guideline is not intended to restrict good clinical judgment, but does recognize that obstetric care providers have a different range of skills. Certain situations will arise in which decision for clinical care will differ from these guidelines. In these situations, it is necessary to clearly document the justification for clinical judgment and ongoing provision of care in the customer s medical record. 2. Definition of Certified Nurse-Midwife (CNM) and midwifery practice 2.1. CNMs are educated in two disciplines: midwifery and nursing. They earn graduate degrees, complete a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME), and pass a national certification examination administered by the American Midwifery Certification Board (AMCB) to receive the professional designation of CNM. CNMs at ANMC receive privileges through the ANMC Medical Staff Bylaws, Rules and Regulations as associate staff of the Obstetrics & Gynecology service center, and as such the Obstetrics & Gynecology Medical Director provides oversight of clinically related activities and professional performance. 2.2. Credentials. In the State of Alaska, the Advanced Nurse Practitioner (ANP) is a registered nurse authorized to practice in the state who, because of specialized education and experience, is certified to perform acts of medical diagnosis and the prescription and dispensing of medical, therapeutic, or corrective measures under regulations adopted by the Board of Nursing (12 AAC 44.990 (3)). The ANP role includes authorization to practice as a nurse midwife. Credentials of a CNM at ANMC include meeting the State of Alaska Nursing Statutes & Regulations (12 AAC 44.400), which include: 2.2.1. Current license to practice as a registered nurse 2.2.2. Current authorization to practice as an advanced nurse practitioner 2.2.3. Successful completion of a formal, accredited education program and documentation of 30 hours of continuing education every 2 years 2.2.4. Current certification by the American Midwifery Certification Board 2.3. Practice of Certified Nurse-Midwives 2.3.1. Midwifery practice is the independent management of women's health care, focusing on pregnancy, childbirth, the post-partum period, care of the newborn, and the family planning and gynecologic needs of women. The Page 1

3.1. Outpatient practice ANMC Certified-Nurse Midwife Practice Guideline ANMC health care system provides for consultation, collaborative management, or referral, as indicated by the health status of the customer. In the health care of women, there are situations in which deviations from normal will occur in which the CNM can consult, collaborate, or refer. In situations where collaborative care is appropriate, the CNM may manage by approved ANMC guidelines or consult with a physician for management 2.3.1.1. Consultation- the process whereby a CNM who maintains primary management responsibility for the woman s care seeks the advice or opinion of a physician or another member of the health care team. After consultation, a mutual decision for the customer to remain under CNM management, be collaboratively managed, or become medically managed by a physician will be agreed upon, and documented in the customer s medical record. When the physician must assume a dominant role in the care of the client due to the increased risk status of the mother or baby, the CNM may continue to participate in physical, mental, and emotional care, counseling, guidance, teaching and support of the mother 2.3.1.2. Collaboration (co-management)- is the process whereby a CNM and physician jointly manage the care of a woman or newborn who has become medically, gynecologically or obstetrically complicated. The scope of collaboration may encompass the physical, mental, and emotional care of the customer, including delivery by the CNM, according to a mutually agreed-upon plan of care. When the physician must assume a dominant role in the care of the customer due to increased risk status of the mother or baby, the CNM may continue to participate in physical, mental, emotional care, counseling, guidance, teaching and support. Effective communication between the CNM and physician is essential for ongoing collaborative management 2.3.1.3. Referral- is the process by which the CNM directs the client to a physician or another health care professional for management of a particular problem or aspect of the client s care 3.2.ACNM defines the midwife s role in primary health care based on the Institute of Medicine s report and the ACNM philosophy. Primary health care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing the majority of health care needs, developing a sustained partnership with customers, and practicing within the context of family and community. This section outlines the guidelines for the care of Page 2

women by CNMs in the outpatient settings, such as the primary care clinic, obstetrics & gynecology clinic, the Valley Native Primary Care Center, and rural clinics 3.3.At ANMC a physician is always available for CNM consultation. To address immediate or urgent concerns, the obstetrician on-call for Labor and Delivery will generally serve as the consultant 3.4.Midwifery as practiced by CNMs encompasses a full range of primary care service for women from adolescence to beyond menopause. These services include primary care, gynecological and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment for sexually transmitted infections including treatment of partners, and incorporates elements of care, such as: 3.4.1. Provide intrapartum and postpartum care to essentially healthy women at ANMC. Per mutual consent by the customer, midwife, and physician involved, a CNM may co-manage care when identified risks are made (see CNM roles and responsibilities) 3.4.2. Inform the woman of the scope of practice of a CNM and her rights and responsibilities as a customer. As a system we standardly offer CNM care, with physician consultation or referral as warranted (see CNM roles and responsibilities) 3.4.3. Provide health care through observation, assessment, and management according to approved ANMC clinical guidelines and medical staff privileges 3.4.4. Order and interpret diagnostic and laboratory tests for screening or diagnostic purposes 3.4.5. Prescribe therapeutic agents, devices and therapies according to accepted guidelines and Alaska state law 3.4.6. Manage customers with selected diagnoses when the diagnosis is clear with an expected normal and predictable outcome, consult ANMC OB/GYN clinical guidelines, or request physician consultation or collaboration (see CNM roles and responsibilities) 3.4.7. Physician consultation results in a mutual decision for continued primary CNM management of the customer s care. Consultation and collaboration with the physician will be documented in the customer s medical record and include the assessment, plan of care Page 3

and recommendations for continued physician involvement. The goal of collaborative management is to establish a plan of care for the Customer-Owner while ensuring her that continued relationship with her primary CNM will be maintained 3.4.8. The plan for collaborative care is dependent upon the specific Customer-Owner and the situation. Examples include the following: 3.4.8.1.Management by the CNM with frequent verbal consultations with the physician 3.4.8.2. Plan of care with both CNM and physician visits 3.4.9. Documentation of discussions and management of care will be placed by each provider in the Customer-Owner s medical record 3.3.9.1.It is the CNM s responsibility to document all phone and verbal consultations in the medical record 3.3.9.2.It is the physician s responsibility to document all direct customer-owner interactions and conversations, assessments, and procedures 3.3.9.3.Clear communication is essential for collaborative management 3.5.Referral of Customer-Owners 3.5.1. When the CNM refers a customer, clear documentation of the plan of care, the customer s current status, and the referral will be made in the customer s medical record 3.5.2. The CNM maintains primary responsibility for care until they are evaluated by the physician and the physician assumes care. Up to that point and until the physician assumes care, the CNM is responsible for follow-up of the customer 3.5.3. The physician accepting the customer for care will document their acceptance, status of the customer, and plan of care in the customer s medical record 3.5.4. The customer may be referred back into the CNM s care at any time that the condition resolves or becomes appropriate for collaborative management 3.5.5. Customers with high risk pregnancies or pregnancy complications can always benefit from psycho/social support and other routine midwifery care provided by CNMs Page 4

Nov 2015 4.1. Inpatient practice 4.2.In addition to outpatient responsibilities, this section outlines additional responsibilities of CNM care in the inpatient setting by providing guidelines for the care of women who present to the obstetric triage area, or who are admitted to the obstetrical service for labor care 4.3.During intrapartum care the CNM manages the labor per CNM inpatient care roles and responsibilities, in accordance with evidence-based practice and within the scope of ANMC s CNM clinical privileges. The CNM respects the woman s plan for labor and birth, while integrating her chosen support person into the process and maximizing mother and newborn interaction 4.4.The CNM continuously informs the woman of her condition, progress, and when there has been consultation to other health providers 4.5.The documentation of physician consultation will include the assessment, plan of care and recommendations for continued physician involvement and will be documented in the medical record by both the physician and the CNM 4.6.When collaborative management is deemed appropriate, the physician will be readily available for the duration of the intrapartal period. When exclusive medical management by a physician is appropriate, the customer may be supported in labor by the CNM, and the CNM may assist the physician as mutually agreed upon 4.7.Women in Latent phase (including pharmacologic and/or mechanical induction of labor), should be evaluated as clinically warranted 4.8.In obstetric triage the CNMs can provide an appropriate medical screening exam to determine within reasonable clinical confidence whether the customer has an emergency medical condition. If the CNM recognizes a customer does have an emergency medical condition, they can admit, provide necessary stabilizing treatment, and/or an initiate an appropriate consult or referral. If an emergency medical condition is not recognized, or false labor is determined, the customer will be offered additional care, referral, or discharge as appropriate 4.9.A Medical Screening Examination is not an isolated event, but an ongoing process of continued monitoring according to the pregnant woman s needs 4.10. The CNM communicates changes in status to the labor & delivery obstetrician, or designee (see CNM roles and responsibilities) Page 5

4.11. The CNM communicates the admission of a customer to Labor & Delivery to the labor & delivery obstetrician and staff 4.12. When a CNM is managing three or more customer s in active labor, another CNM or obstetrician will be readily available 4.13. Emergency measures may be ordered or instituted at any time prior to the arrival of a physician. While the following list of examples is not intended to be all inclusive, emergency measures should be ordered or instituted while awaiting the arrival of a physician in scenarios, such as: 4.13.1. Manual removal of placenta 4.13.2. Fetal bradycardia 4.13.3. Resuscitative care of the newborn 4.13.4. Fetal expulsion disorder 4.14. Post-partum care 4.14.1. The CNM will evaluate, manage, round on, and treat women during the postpartum period to include evaluating maternal physical, emotional, mental, and psychosocial status, maternalnewborn relationship, and to provide appropriate education including breastfeeding support 4.14.2. The CNM will initiate routine postpartum orders seeking physician input or evaluation when necessary 4.14.3. The CNM communicates deviations from normal to the labor and delivery obstetrician, or their designee (see CNM roles and responsibilities). The CNM evaluates the customer and orders the hospital discharge. The CNM is responsible for entering the discharge summary for customers not referred for physician management in their medical record 5.1.Education and Quality Management 5.2.Continuing Education, Training, and Learning Opportunities 5.2.1. Participate in ongoing learning and demonstrate completion of the continuing competency as set forth by the American Midwifery Certification Board. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, developed by the APRN Consensus Work Group and the National Council of State Boards of Nursing currently recommends that certificate maintenance activities be required for all APRNs and that recertification occur at a minimum of every five years. The CNM provides proof of enrollment or completion Page 6

5.2.2. Participate in departmental continuing education offerings, including journal clubs, morbidity and mortality review, grand rounds, simulation, mock code training, as well as other continuing education offerings 5.2.3. Support the education of fellow staff, students, residents, and practitioners including those in other nursing, medicine, and allied health fields. This may include: 5.2.3.1.Clinical precepting and supervision 5.1.3.2.Lectures or multidisciplinary education 5.1.3.3.Simulation training 5.3.Quality Management (QM) 5.3.1. Midwifery care is based upon knowledge, skills, and judgments which are reflected in written practice guidelines and are used to guide the scope of midwifery care and services provided to customers. At ANMC, CNMs participate in QM processes that guide the evaluation of practice, identify and resolve problems, and establish care standards that optimize the outcomes for women, newborns, midwives, physicians, and other healthcare professionals involved with women s health care. In accordance with ACNM recommendations, all CNMs will be involved and incorporate key components of QM into their practice to include: 5.2.1.1.Ability to delineate and demonstrate appropriate scope of practice, use of practice guidelines, and parameters of independent, consultative, collaborative and referral of care 5.2.1.2.Participate in MCH emergency simulations, TeamStepps TM training, and OPPE activities 5.2.1.3.Participation in Quality Assurance reviews to include but not limited to documentation methods, monitoring systems, and procedural and outcome indicators as they relate to established benchmarks and standards of care 5.2.1.4.Practice review through peer review and the assessment and evaluation of midwifery practice by other midwives 5.2.1.5.Participate in clinical practice review such as the evaluation of employee and customer satisfaction, use of medical technology and interventions, application of ANMC clinical care guidelines, and recommended evidence-based practice standards Page 7

References: American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Guidelines for Perinatal Care, 7th edition, (2012). ACNM Core Competencies for Basic Midwifery Practice (2012). Retrieved 4-10-13 at http://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000 050/Core%20Comptencies%20Dec%202012.pdf ACNM Position Statement: Clinical Practice Guidelines (2010). Retrieved 4-10-13 at http://www.midwife.org/sitefiles/education/clinical_practice_guidelines_02_2010.pdf ACNM Position Statement: Joint Statement of Practice Relations between Obstetrician- Gynecologists and Certified Nurse-Midwives/Certified Midwives (2011). Retrieved 4-18-13 at http://www.midwife.org/acnm/files/cclibraryfiles/filename/000000000751/collegeacnmpolicy% 20StatementFeb2011_2.pdf ACNM Standards for the Practice of Midwifery (2011). Retrieved on-line 4-09-13 at http://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000 051/Standards_for_Practice_of_Midwifery_Sept_2011.pdf Standardization of practice to improve outcomes. Committee Opinion No. 526. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:1081-2 State of Alaska Nursing Statutes and Regulations. (Dec 2012). Retrieved 4-10-13 at http://www.dced.state.ak.us/occ/pub/nursingstatutes.pdf - Approved: April 2013 - Reviewed Page 8

Midwifery care Routine prenatal care Absent or limited prenatal care Current psychiatric condition or mental impairment, stable History of GDM History of PEC History PPH A1GDM Hx of severe postpartum hemorrhage Obesity BMI <40 Asthma mild intermittent Routine postpartum care Contraception management including IUD and implantable devices Mastitis Lactation support Routine discomforts of pregnancy Uncomplicated UTI, STIs, vaginitis Well woman care Colposcopy (if granted per ANMC privileges) ANMC Certified-Nurse Midwife Practice Guideline CNM ROLE & RESPONSIBILITIES - OUTPATIENT PRACTICE Consultation (consult physician or refer to ANMC OB/GYN Clinical Guidelines) *ANMC clinical guideline available Previous uterine scar/surgery Previous Cesarean Delivery Previous unexplained stillbirth Abnormal Pap* Asthma, other than mild intermittent* Hx of one or more preterm birth (<35 weeks) CHTN, mild PEC* H/O severe PEC* Cholestasis* Hyperemesis* Obesity > 40* Anemia* Postdates* Active Hepatitis B or C Hepatitis B carrier* Seizure disorder Family H/O significant hereditary disease or congenital anomaly Active TB History of incompetent cervix H/O IUGR Autoimmune disorder Known uterine anomalies Severe psychiatric disorder Chemical dependent, uncontrolled Collaboration (routine prenatal care provided by CNM with ongoing medical management provided by physician) A2GDM Current preterm contractions Planned Cesarean Delivery Hypertension requiring medication Placenta previa, accreta, or other placental abnormality >32 weeks Preexisting DM Significant fetal anomaly IUGR Isoimmunization Incompetent cervix, currently pregnant Preterm delivery risk (short cervix + FFN) <34 weeks Active or significant hepatic, renal, cardiac, neurologic, thromboembolic, pulmonary or vascular disease (consult or collaboration) Hemoglobinopathies or other blood dyscrasia HIV+ Referral Malpresentation after 37 weeks Severe PEC, HELLP, acute fatty liver Placenta abruption Placenta accreta Vasa previa Ectopic pregnancy Molar pregnancy Page 9

CNM ROLE & RESPONSIBILITIES- OB TRIAGE Midwifery Care Eval of labor or ruptured membranes >34 weeks or ruptured membranes Routine discomforts of pregnancy at any gestation Decreased fetal movement Rule out preeclampsia Uncomplicated UTI Uncomplicated vaginitis, STI, or other common infection related diseases Gastrointestinal distress Trauma without significant maternal injury, contractions or bleeding Spotting, 2 nd or 3 rd trimester Management of reassuring fetal heart tracing OB/GYN physician PPROM, PTL <34 weeks Transports Significant 2nd or 3rd trimester bleeding Severe preeclampsia, eclampsia Significant GU, GI, neurologic, or infectious disorders Trauma with maternal injury or evidence of contractions or bleeding Multiple gestation Malpresentation Cerclage removal Non-reassuring fetal heart tracing, category III tracing Fetal demise Pyelonephritis Chest pain/shortness of breath/fever Medical problems associated with pregnancy Poorly controlled medical conditions such as diabetes, asthma Page 10

*ANMC clinical guideline available Manage >34 weeks labor and vaginal delivery PPH, hemodynamically stable Meconium First assist for cesarean delivery Augmentation of labor Postpartum care Induction of labor* Cervical ripening with medication or balloon* Post-dates 41+ weeks* Post-placental IUD placement Placement of implantable contraception Lactation support Management of reassuring fetal heart tracing PROM at >34 weeks Placement and management of internal fetal monitors A1GDM* ANMC Certified-Nurse Midwife Practice Guideline CNM ROLE & RESPONSIBILITIES- LABOR & DELIVERY, INPATIENT and/or POSTPARTUM CARE Midwifery Care Collaborate (when collaborative care is deemed appropriate, the physician will be readily available for the duration of the intrapartal period) *ANMC clinical guideline available 32-34 weeks preterm labor Fetal demise IUGR* Isoimmunization PPH >1000 ml or hemodynamically unstable Amnioinfusion Multi-fetal gestation* Breech/Malpresentation* TOLAC* Chorioamnionitis Manual removal of placenta Fetal expulsion disorder* Fetal bradycardia Non-reassuring fetal heart tracing Chemical dependency Hypertensive disorders in pregnancy* A2GDM* Moderate or Severe persistent asthma* Placenta abruption Fetal-maternal hemorrhage HIV* Oligohydramnios*, polyhydramnios Seizure disorder Active or significant liver, renal, cardiac, thromboembolic, neurologic, pulmonary or vascular disease Hemoglobinopathies or other blood dyscrasia Fetal malformation, chromosomal abnormality, or suspected fetal injury Post-partum hematoma Refer/transfer care (the CNM may provide labor support and assist the physician) Vacuum assisted vaginal delivery Forceps assisted vaginal delivery Cesarean delivery Antepartum obstetric admission or observation Endometritis, wound complications Active HSV Arrest of dilatation or arrest of descent Placenta previa 3 rd or 4 th degree laceration Cervical laceration Page 11