CNM/CM Emergency Action
The chain of command (COC) is a familiar concept to many, particularly individuals with backgrounds in the military, law enforcement, firefighting, and healthcare. A chain of command is a power hierarchy of individuals contacted when emergencies or difficult situations arise. For nurses working in a hospital, the COC might begin with a staff RN, progress to a charge nurse, then to various nursing managers, directors of nursing, and finally to a chief nursing officer. Hospital chains of command vary across departments and specialties. Any member of the medical or nursing staff of a hospital corporation must be clear about COC reporting in the context of their specialty.
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 is an entirely inappropriate course in an obstetrical/midwifery emergency, which demands that the appropriate assistance be summoned in a timely manner.
For nurse-midwives delivering their patients in hospitals, a clear and expedient path to appropriate individuals must be established within the policies of hospital units where they practice. Depending on the nurse-midwife's role and the need to engage the 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 may 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 very little value to the CNM in an emergency. In rare circumstances when the OB chief and attending physician are unavailable, the chain of command can expand laterally to any attending obstetricians (deck docs) present in the hospital. For administrative or other non-emergent matters, individuals at higher levels of decision-making might include the director of OB or, further up, the hospital's chief medical officer.
Chain of Command For CNMs/CMs Not Employed By the Hospital
CNMs on the hospital staff, but not hospital employees, may need to use any OB attending who is 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 employ in-house hospitalists and laborist groups who are available 24/7 to address acute emergencies on the labor and delivery unit.
Emergency Planning for Out-of-Hospital
Midwives 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 delays in emergencies, it is essential that a cooperative, written plan is in place and that it can be readily located by the midwife delivering at home, as well as by CNMs at birth centers and hospitals. Plans should include call schedules and contact information for assisting physicians who have agreed to take transfers, as well as 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 relatively infrequent. From a medical-legal standpoint, a coherent and organized written plan will provide evidence that CNMs, in all settings, have prepared for obstetrical emergencies, consistent with ACNM Standards of Practice. In addition to 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 practice. It may be important evidence in the event of legal inquiries.
© 2025 Martha Merrill-Hall