Midwifery Chain of Command

CNM/CM Emergency Action

Chain of command (COC) is a familiar concept to many, such as individuals with backgrounds in the military, law enforcement, firefighting, and those who have been employed in healthcare settings.  A chain of command is a power hierarchy consisting of individuals that are contacted when emergencies or difficult situations arise. For nurses working in a hospital, the COC might begin with a staff RN, ascending to a charge nurse, and then upward through various nursing managers, directors of nursing, and finally to a chief nursing officer.  Hospital chains of command are individualized within different departments and specialties.  Any member of medical or nursing staff in a hospital corporation must be clear on COC reporting in the context of their specialties.

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RN Chain of Command Not Appropriate For CNMs/CMs

Unfortunately, CNMs/CMs working as employees or members of a hospital medical staff may be expected to follow an RN/staff nursing hierarchy when seeking assistance or when a patient emergency presents.  However, this may be a totally inappropriate path for an obstetrical/midwifery emergency which demands that the appropriate assistance be summoned in a timely manner.  For nurse-midwives delivering their patients in hospitals, it is crucial that a clear and expedient path to appropriate individuals is established within the policies of hospital units where they practice.  Depending on the role of the nurse-midwife, and the nature of the need to engage a chain of command, a variety of individuals may be involved.  

CNM Chain of Command in Teaching Hospitals

A nurse-midwife who is employed by a teaching hospital is usually associated with obstetrical interns and residents.  For emergency situations in these settings, an appropriate starting point for a nurse-midwife requiring consultation or assistance might be the Obstetrical Chief Resident, followed by the faculty attending physician on the labor deck.  Although many OB residency programs might place a second-year resident (R2) in a position of crucial decision-making, it is not appropriate for a CNM, facing an acute patient emergency, to consult at this level.  Essentially, an R2 would be of little value to the CNM in an emergency.  In rare circumstances where the OB chief and attending physician are unavailable, the chain of command can expand laterally to any attending obstetricians that might be present in the hospital.  For administrative or other non-emergent matters, individuals in the higher tiers of decision-making might include the director of OB or even further to the chief medical officer of the hospital.

Chain of Command For CNMs/CMs Not Employed By the Hospital

CNMs on the hospital staff, but not hospital employees, may need to utilize any OB attending that might be available for unanticipated, acute emergencies.  An available chief resident or attending physician could be called on to help while the CNM’s consultant is en-route. Fortunately, many hospitals, with OB departments, are employing hospitalist and laborist groups that are available in-house 24/7 to address acute emergencies on the labor and delivery unit.

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Emergency Planning for Birth Center and Homebirth Settings

CNMs practicing in a patient’s home, or in out-of-hospital birth centers, should have pre-existing emergency plans in place for physician/hospital or CNM consultation and for necessary transport of mothers and babies.  CNM practice structures vary, but to avoid unnecessary delay in emergencies, it is important that a cooperative, written plan is in place and that it can be readily located by the midwife delivering at home, and for birth center and hospital CNMs to access. Plans should include call schedules and contact information for assisting physicians who have agreed to take transfers, in addition to patient information for individuals at designated receiving hospitals who will accept emergency patients from out-of-hospital nurse-midwives, CPMs, or lay midwives.

CNM/CM Contingency Planning and Standard of Practice

Having to access, and actually utilize a chain of command in emergencies, is fairly infrequent. From a medical-legal standpoint, a coherent and organized written plan will provide evidence that CNMs, in all settings, have prepared for obstetrical contingencies consistent with the ACNM standards of practice.  In addition to the existence of an appropriate and effective chain of command, it should also make practical sense.  For CNMs, following an RN/nursing chain of command is neither an appropriate nor timely path to assistance in an acute midwifery emergency.  I suggest that CNMs, regardless of clinical setting, ensure that an updated, written COC exists for their individual practice settings.  It may be important evidence in the event of legal inquiries.

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