What Are Clinical Practice Guidelines In Maternity Care?
Maintaining Clinical Boundaries
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Clinical Practice Guidelines are recommendations for clinicians regarding the care of patients with specific conditions and ailments. The Institute of Medicine defines clinical practice guidelines as “statements that include recommendations intended to optimize patient care, informed by a systemic review of evidence and an assessment of the benefits and harms of alternative care options.” 1
Clinical Practice Guidelines are recommendations for clinicians regarding the care of patients with specific conditions and ailments. Well-defined practice guidelines in a health care setting are deemed essential for quality, safety and continuity of care. The American College of Nurse-Midwives, in particular, has emphasized the need for well-developed practice guidelines so that Certified Nurse-Midwives and Certified Midwives can be consistent in a particular care setting, allowing midwives to defend the quality and safety of their care, if necessary.
As examples, ACNM, ACOG, and AWHONN publish clinical practice guidelines which offer parameters of practice for the care of childbearing women. The American College of Nurse-Midwives suggests that CNMs/CMs compose practice guidelines for each area of practice such as primary care, antepartum care, intrapartum care, postpartum/newborn care, family planning, and gynecological care. Practice guidelines serve to define clinical boundaries. They should include processes for clinical collaboration, consultations, emergencies, and transfer of care. Well-written guidelines will also include an outline for relationships with other members of the team like medicine and nursing.
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Detailed Practice Guidelines
Ideally, practice guidelines should provide enough detail to support independent decisions made in specific situations. For instance, procedures for obstetrical emergencies require an outline of independent actions that a CNM may take prior to, or in conjunction with, seeking assistance and consulting with other members of the practice and health care team.
Specifically, severe hypertension, shoulder dystocia, sepsis, fetal distress, amniotic fluid embolism, and postpartum hemorrhage are a few examples of situations where the CNM, can take first steps while initiating the necessary consultation and mobilization of the care team. Guidelines must clearly define the process of clinical consultations and collaborations. The more detailed the practice guidelines, the higher the chances that they will prevail in the face of any medical-legal challenges. 2
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Practice Guidelines in Various Healthcare Industries
Practice guidelines are encouraged for all types of care providers to assist them in providing the best care possible for their patients. Other entities in health care also utilize them. Insurance companies and administrators use guidelines, developed for clinical use, only, to set policy on quality and reimbursement for care by transforming guideline recommendations into performance measures that are subsequently used to attach a grade to health care delivery. Insurance providers, like Medicare and Medicaid have created “pay for performance” programs to link payment to care providers for “quality of care”, utilizing measurement parameters that have been borrowed from clinical practice guidelines. 3
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Examination of Practice Guidelines in Litigation
Attorneys may consult care guidelines in malpractice litigation, emphasizing that care providers who have not followed their established guidelines, without a valid reason, are negligent. For health care clinicians, claims of this type have variable success due to the variety of medical specialties and a multiplicity of guidelines for the same condition that have enough variation from one another that none of them can be argued to represent one community standard of care. However, attorneys seeking to understand nurse-midwifery standards of care have only to reference the ACNM documents to determine the standards that apply to all nurse-midwives.
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Practice Guidelines and Midwifery Standards of Care/ Pactice
With certified nurse-midwifery practice, guidelines are developed from the ACNM documents; particularly the Core Competencies, Ethics, and Standards of Practice which support and represent a national practice standard for CNMs/CMs, only. Since CNM/CM Standards of Practice emanate primarily from one certifying body, the American Midwifery Certification Board, nurse-midwifery practice guidelines should not significantly differ between other CNM/CM practices across the country. Despite differences in locale, logistics, patient population, demographics, and resources, the standards of practice for every CNM/CM practice should be rock-solid reflections of the ACNM standards documents.
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CNMs/CMs Crucial To Development of Practice Guidelines
Hospitals and medical practices seeking to develop practice guidelines involving CNMs/CMs may, naturally, want to develop practice guidelines that will protect their own interests, along with those of prospective CNM/CM employees.
Despite contrary evidence, physicians and hospitals contemplating associations or employment arrangements with CNMs/CMs, usually fear the association places them at increased risk for liability. In any agreement with hospitals or individual physicians, CNMs/CMs must be allowed to provide input which protects their personal and professional interests and integrity. In employment or professional association discussions, the existing documents published by the ACNM should be used to structure and incorporate safe and effective practice guidelines. That will ensure that CNM standards of care are preserved and meet the professional and legal goals of the individual nurse-midwife. 4
1. Consensus Report, Institute of Medicine. Clinical practice guidelines that we can trust. March 23, 2011. http://www.iom.edu/Reports/2011/Clinical Practice-Guidelines-We-Can-Trust.aspx.
2. King, Takoa; Journal of Midwifery and Women’s Health, Vol. 45, No. 6, p. 448-449; November-December 2000.
3. Rosenthal, MB, et.al. Early experience with pay-for-performance:from concept to practice. JAMA 2005; 294:1788.
4. ACNM Standards For the Practice of Nurse-Midwifery. Core Competencies, Scope of Practice, and Ethics.
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