Midwifery Profile and EMTALA - Part 4
Radek Skrzypczak unsplash image
Patient Presentation and Variable Research
Variations are appreciated and expected when encountering competing research findings. Women will always labor outside of research expectations, despite best practices and the predictions of labor models. CNMs/CMs will recognize the contracting multigravida at 1 cm, presenting to triage with her hair on fire, who delivers within minutes. Also familiar is the nullipara, discharged with a closed cervix, who returns within an hour, having delivered her baby in the car on the way back to the hospital.
Clinician performance may fall outside of professional expectations, as well. Too often, research recommendations can be misunderstood or misapplied, favoring the agenda of the provider, rather than the unique needs of the laboring woman. Delay in addressing these needs, or awaiting an arbitrary milestone of dilatation, might be unintentionally abusive. Nurse-midwifery practice must first consider the needs of a vulnerable human woman, over any specific performance model. Friedman and Zhang have both represented that dilatation curves are never sufficient for ultimate decision-making.1-3 Research studies and analytical conclusions inform and enhance midwifery management when applied within the broader context of experience, empathy, well-established science, and committed surveillance. CNMs and CMs should seek to avoid stubborn adherence to one isolated feature (e.g. 6 cm dilatation) in any set of research guidelines.
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Maintaining Midwifery Knowledge Base in Practice
Due to the rather poor professional profile of midwifery, maintaining a current professional knowledge base is protective. This is particularly true in litigation-prone environments. In legal proceedings and everyday practice, the importance of displaying professionalism and scientific acumen cannot be overstated. What any individual midwife has memorized regarding EMTALA, or embraced in specific research, must include an ability to understand, apply, and even testify-to the important legislative considerations and scientific evidence which informed the basis for triage care that may come into question.
Physician/Attorney Presentations on “Midwifery Challenges”
Prominant individuals in the medical-legal environment are lecturing on what they represent as "midwifery challenges" in litigation. These published physicians and lawyers have presented their idea of midwifery incompetence, citing "lack of knowledge in the basic sciences, physiology, obstetrical literature reports, and ACOG policies".4 Naturally, midwives were not invited to comment or affirm these faulty allegations.
The conference materials, offered to those litigating midwifery negligence cases, may negatively influence a panel of jurors in a midwifery negligence case. Nurse-midwives must be willing to defend their care in several ways, beginning with documentation in the medical record. A willingness to demonstrate the practical and scientific foundations for midwifery management is important. This will raise the professional profile of midwives and provide evidence to medical malpractice professionals that CNMs and CMs possess the knowledge and competence to provide reasonable and scientifically-based plans of care for their patients.
Ethan Robertson
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1. Cohen WR, Friedman EA, Perils of the new labor management guidelines. Am J Obstet Gynecol. April 2015: 420-427.
2. Zhang J, Troendle JF, Yancy, MK. Reassessing the labor curve in nulliparourous women: TRANSACTIONS OF THE TWENTY-SECOND ANNUAL MEETING OF THE SOCIETY FOR MATERNAL-FETAL MEDICINE. Am J Obstet Gynecol. 2002; 187(4): 824-828.
3. Lauphon SK, Branch DW, Beaver J, et al. Changes in labor patterns over 50 years. Am J Obstet Gynecol. 2012:206:419:e1-e9.
4. American Conference Institute, 19th Annual Advanced Forum on Obstetric Malpractice Claims: Analyzing Claims against L&D Nurses and Midwives in OB Cases. Novemeber 9, 2020. Benjamin A. Post, Esq., Daryl L. Zaslow, Esq., Michael G. Ross, MD MPH.
http://www.midwivesontrial.com