Part 1

Labor and Delivery Nurses, Nursing Administration, and Certified Nurse-Midwives

From the time that nurse-midwives first set foot on the labor units of American hospitals, there has been an ongoing tendency toward conflict and miscommunication between nurses and midwives, existing together in the action-packed setting of childbirth. Turf/territorial issues were created when former labor and delivery nurses decided that they wanted more. They went back to school and earned advanced academic degrees and certifications in a specialty known as Maternal-Child Health, also referred to as Certified Nurse-Midwifery.

Switching their professional identities from RN to CNM created varying amounts of confusion and stress on the birthing units of hospitals nationwide. Who, exactly, were these former nurses who now called themselves Midwives? These misguided nurses dared to believe that they could elevate their practice above being an RN?

Nurse in Nurse-Midwife

Part of the problem, then and now, is the hyphenated title, Nurse-Midwife. Registered Nurses have always functioned competently within the traditional doctor-nurse hierarchy. Nursing skills and expectations are well established and understood. “Where, exactly, were these Nurse-What-Evers going to fit in?” "How is this even safe?” “Were the Labor and Delivery nurses, heaven forbid, going to have to take orders from these midwives?” “ Or actually work with them?” “We are not going to be involved in a delivery that does not include the presence of a physician!” “Are they going to independently manage a patient’s labor and delivery from start to finish?”

Nursing’s Answer: “Over our dead bodies”. . . . Yes, it was that bad. But nobody died.

Midwives and Nurses: Working Together Against All Odds

And so began the uneasy and, frequently, passive-aggressive association between L&D nurses and midwives, forced together in the delivery of maternal-child healthcare. Over decades, relationships did become better. . .and worse. Expectations became clearer but members of the traditional healthcare team (docs and nurses, only) could not quite comprehend, nor accept, that anyone would discard their primary identity as “nurse” for “midwife”.

While we what-evers tried to maintain a fairly low professional profile, birthing babies and refraining from wearing Birkenstocks with our scrub dresses(!), we applied deodorant and even shaved our legs. Despite our efforts, acceptance from within L&D establishments did not come easy (or ever) in some institutions. (There are hospitals today with maternity units that will not allow nurse-midwives on their staff.)

Despite uneasy alliances and a few mutually respectful friendships, most RNs held to the opinion that midwives were just “wimpy” nurses who had abandoned their skills (i.e., fulfilling doctors’ orders, starting IVs, drawing blood, and providing actual nursing care).

Most nurse-midwives have set some of these nursing skills aside (except when trying to help out on a busy labor deck) in favor of new and different competencies; an elevated scope of practice which encompasses independent thinking, delivery management, pre- and post-natal delivery oversight, diagnoses, treatment, prescriptive authority, anticipatory planning, and providing a higher level of care.

From the outset, none of this went down very well, and, sadly, RN-CNM grievances persist to the present time. Traditionally, directors of labor and delivery/postpartum units (Directors of Women’s Services) were RNs with hospital-schools-of-nursing training and favoritism for the needs of their staff RNs. Nurse-midwives, forced to function under RN directives, often felt aggrieved and insulted.

If a Lead-Midwife was appointed, her authority was watered down, and any attempts at control were curtailed. Except for one brilliant CNM (and former classmate), the few CNM Leads I have known consistently lacked any meaningful power or strength to advocate for or defend the CNMs in hospital group practice. They were entirely controlled by nursing/hospital administration. Nursing director qualifications may have elevated over time, but negative attitudes toward midwives persist. I regret to say that I have observed these unfortunate dynamics in several hospital systems across multiple states.

Welcome the New Nurse-Midwife on the Unit
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Nursing Admin Running CNM Practice

Certified Nurse-Midwives forced to exist in an RN administrative world may experience stress and frustration. Hospital Administrations have usually been the worst to deal with. Obstetrical department administrators have yet to comprehend that a nurse-midwife is an independent provider, and not just an alien incarnation of a labor nurse. Unfortunately, nurse-midwifery practices may continue to be inappropriately administered and overseen by RN administrators.

Consistently, hospital administrative entities insist that the practice of midwifery belongs within the sphere of labor and delivery RN’s. To appoint a midwife supervisor or “lead midwife”, with any influence, would require understanding that CNMs function independently from physicians and RN’s. Currently, there remains little acknowledgment or recognition that CNMs are independent providers of maternity care. It has been much easier for hospital administrations to corral certified nurse-midwives into the same pen with registered nurses, failing to recognize that the two specialties have significantly different skills, models of care, competencies, and scopes of practice. Recognition that midwives are independent, or distinguishable from labor and delivery nurses, would require thinking “outside of the box”, which would be inconsistent with normal administrative behavior.

Nursing Continuing Education Units Required For Midwifery Practice?

After decades of midwifery practice on their maternity units, hospital corporate administrations continue to burden CNMs with RN-related tasks, directives, continuing education, and other hospital-campus issues that may be appropriate for nursing but should not be essential for CNM practice. Instead of obstetric/midwifery/childbirth-related educational modules consistent with what midwives actually do at the hospital, CNMs are expected to complete registered nursing Continuing-Education Modules addressing items such as patient restraints for the elderly, hospital plant HVAC issues, and disposition of hospital hazardous waste, to mention a few dynamic educational requirements.

This is not about CNMs “playing doctor” or seeking unrealistic levels of regard. It is about acknowledgment that nurse-midwifery’s unique model of care is separate from nursing; academically founded, hard-earned, and legitimate. Unfortunately, the specialty of nurse-midwifery remains unfamiliar and is often misunderstood by medicine, nursing, and society.

Catching Babies: The Skill Behind the Practice?

In addition to their diverse responsibilities on labor and delivery, nurses frequently enjoy the pleasure of “catching babies”, when a physician or midwife does not arrive at a patient’s bedside in time. Labor and Delivery nurses are amazingly proficient in a wide variety of clinical skills. Preventing a baby from taking flight into the birthing room linen hamper is an essential skill for all providers of maternity care. Regarding what nurses may think of midwives, I have been aware that many RNs cannot resist thinking, “How special can this midwife thing be?” “I can deliver a baby.” “Most midwives couldn’t insert an IV catheter if life on earth depended on it.”

Aside from the spectra of obstetrical, midwifery, and nursing scopes of practice, the truth is: For the instances when a baby descends the birth canal at Mach 2, the required skills of doctors, nurses, and midwives are nearly identical. Basic requirements for a safe supersonic delivery are: showing up in time, hand-eye coordination, a calm demeanor, and perhaps... an NHL goalie’s glove. *

* One thing we all understand in this business: When a woman laboring with her 5th child tells you that she has a history of rapid deliveries, take her word for it

http://www.midwivesontrial.com

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The Obstetrical Malpractice Trial - Part 1

Frivolous Lawsuits