Barbara W. Graves

Maternal Body Mass Index, Delivery Route, and Induction of Labor in a Midwifery Caseload

The purpose of this study was to identify the association between prepregnancy body mass index (BMI), weight gain in pregnancy, and newborn birth weight on route of delivery and induction of labor in patients receiving nurse-midwifery care. This retrospective cohort study examined the outcomes of 1500 consecutively delivered women who were cared for by two midwifery practices and delivered between January 1, 1998, and December 31, 2000. Cesarean delivery was significantly associated with the obese BMI (P < .001), nulliparity (P < .02), and newborn birth weight (P =.006). Prenatal weight gain did not have a significant correlation with cesarean birth (P = .24). In multivariable modeling, obese BMI, high newborn birth weight, nulliparity, and induction of labor increased the risk of cesarean birth. There was also a significant association between higher BMI and risk of induction of labor (P < .001). In a secondary analysis, obese BMI was associated with increased risk of induction in cases with ruptured membranes (OR 2.2; 95% CI 1.4-3.4) and postdates pregnancy (OR 2.0; 95% CI 1.1-3.4).

Making it work: Successful collaborative practice

There are three major examples of collaborative programs between certified nurse-midwives (CNMs) and obstetrician-gynecologists at Baystate Medical Center in Springfield, Massachusetts, within the Department of Obstetrics and Gynecology. One program is a midwifery practice that serves a diverse population in a hospital-based office, four neighborhood health centers, and a correctional facility. Another program provides a triage function for patients who present to the hospital with obstetric or gynecologic problems. The third program introduces a team approach to the education of residents with a CNM having primary responsibility for teaching normal obstetrics to first-year residents and medical students in collaboration with attending physicians. Keys to success include an understanding of the principles of collaborative practice, the use of a detailed practice agreement between midwives and attending physicians, keeping open lines of communication, understanding and accepting differing philosophies of practice, and, most importantly, maintaining trust across all levels of providers.

The Obesity Epidemic: Scope of the Problem and Management Strategies

As the obesity epidemic increases, primary care clinicians are encountering obesity and health problems associated with obesity more frequently than ever before. In 2007, 41% of women were classified as obese, with a body mass index (BMI) of 30 or higher. Non-Hispanic blacks and Hispanics are more likely to be obese than white, non-Hispanics. A wide spectrum of health problems has been associated with obesity, including cardiovascular disease, diabetes, metabolic syndrome, osteoarthritis, and polycystic ovary syndrome. Obesity has been shown to be a low-grade inflammatory state, which may be responsible for many of the comorbidities. The general consensus recommends screening for obesity and counseling to promote weight loss. In some cases, pharmacotherapy and or bariatric surgery may be recommended.

Midwifery triage of first trimester bleeding.

Approximately one of five pregnant women will experience bleeding during the first trimester of pregnancy. Of these women, about half will go on to have a spontaneous abortion. Comfort with triaging this common problem assists the midwife in providing quality, cost-effective care without eliminating continuity. This article reviews the causes of early pregnancy bleeding, offers strategies to differentiate between these causes, and identifies emergent from nonemergent presentations. Triage and management strategies for women with an impending or threatened spontaneous abortion are reviewed, exploring the alternative of expectant management.

The Past, Present, and Future of Assessing Continuing Competency for Midwives

BACKGROUNDConsumers deserve to know th at health care professionalsnot only are competent as they b egin their careers, but alsothat they are exerting every effort to ensure that they remaincompetent throughout their careers. The fundamental basisfor any health profession’s interaction with the public mustbe demonstrable competence. Health care occurs withina health care system that is continually seeing new advancesin technology and science, as well as changes in health caremanagement and consumer expectations. The critical task ofmaintaining and proving competence at regular intervals willremain a challenge for health care providers for the foresee-able future. According to the Institute of Medicine, theknowledge explosion in medicine is one of the factors thatcan reduce the quality of care to consumers.

Newborn resuscitation revisited

The techniques for assessing and resuscitating newborns at birth have become well established over the last 10 years. Standardization of this procedure lagged far behind the standardization of adult and child resuscitation. In 1987, the American Heart Association and the American Academy of Pediatrics published the combined recommendations of the Working Group on Pediatric Resuscitation and the National Task Force on Neonatal Resuscitation of the Section on Perinatal Pediatrics of the American Academy of Pediatrics. This article summarizes those recommendations and suggests means for nurse-midwives to become certified in neonatal resuscitation.

CHALLENGES OF NEONATAL RESUSCITATION FOR NURSE-MIDWIVES

Competency in neonatal resuscitation should be developed and maintained by every practicing nurse-midwife, although it is difficult to obtain the necessary experience. Individual competency should not, however, substitute for a formal institutional plan for responding to depressed neonates. This article reviews the knowledge base necessary to assess the neonate and to intervene appropriately. The management of the infant with meconium stained amniotic fluid is discussed. Ways for the nurse-midwife to gain adequate clinical practice are explored.

DIFFERENTIAL DIAGNOSIS OF RESPIRATORY DISTRESS

Although nurse-midwives care for essentially normal women, even healthy pregnant women at term may deliver babies with respiratory distress. Nurse-midwives need the knowledge to decide whether an infant with respiratory distress needs immediate evaluation by a pediatrician or neonatal specialist or can be safely observed for a while to see if the respiratory distress resolves. This paper reviews the developmental anatomy and physiology of the respiratory system and the pathophysiology of the most common causes of immediate respiratory distress in the newborn. This information will aid nurse-midwives in making appropriate differential diagnoses and management plans for the newborns in their care.