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Vol. 32, No. 22                                                                                                                  Published November 15, 1997

Midwife's Level of experience Is Key


San Francisco Bureau

Vancover - The level of consultation that an ob.gyn. can expect from a collaborating midwife depends on the midwife's experience and will change with the midwife's years in practice, Elaine Mielcarski said at the annual meeting of District 11 of the American College of Obstetricians and Gynecologists. Ms. Mielcarski, a certified nurse-midwife who over her 20 year career  has performed 2,000 deliveries, is in private practice in Syracuse, N.Y., with a solo ob.gyn.

In a joint presentation with her partner, Dr. Richard Waldman, Ms. Mielcarski said that by virtue of their long association and her veteran status, "Rich and I practice together intuitively".  Dr. Waldman leaves it to her judgment as to when he should be consulted. By contrast, midwives who are relatively inexperienced would consult with an ob.gyn. more frequently

Ms. Mielcarski described a series of hypothetical and actual cases to illustrate the different roles that physicians and midwives who are working together play.

Exhausted, sleep-deprived patient with persistent Braxton Hicks contractions or prodromal latent phase labor.

In the case of a multipara who has been having contractions for 24-48 hours with no sleep and no progressive dilatation or effacement, Ms. Mielcarski will give the patient a choice: either to have a therapeutic rest induced by morphine and Seconal, or to keep going with the help of Pitocin.

If the patient elects to have Pitocin,Ms. Mielcarski will then call her partner to notify him of the patient's status so that he can better plan his day. If the patient chooses therapeutic rest and wakes up no longer in labor, Ms. Mielcarski will discharge her.

Prolonged active phase of labor

With a patient who has dilated to 6-9 cm but 1-2 hours later has not progressed, Ms. Mielcarski would check four things. She would palpate several contractions, repeat clinical pelvimetry, determine fetal heart rate and position, and get an estimated weight. If all of those factors were normal except for hypotonic contractions, she would offer the patient the option of walking and drinking fluids or of trying Pitocin.

If her evaluation increased the suspicion of macrosomia, she would consult with the ob.gyn.

A midwife just starting out, however, would respond to arrested labor or lack of progression lasting more than an hour by calling the physician would probably would want to check the patient himself or herself, Ms. Mielcarski said.

Prolonged second stage of labor

"How many times do we hear patients say, 'I just want to stop'?" Ms. Mielcarski asked rhetorically. "Sometimes I'll tell them to roll over, shut their eves, and try to sleep between contractions. Of course they can't, but often they'll start pushing more aggressively" when they are offered the "option" of taking a break.

Atypical cases

In a labor that lasted 19 hours, Ms. Mielcarski attended the patient, with several periodic phone discussions with Dr. Waldman. The patient, a 26-year-old primigravida at 41 weeks, was admitted with mild contractions, 4-5 cm dilated, 90% effaced, -4 station at 10 examined the patient and found her to be 7-8 cm dilated, occipitoposterior, -4 station, with the bag of waters intact and bulging into the vagina. Dr. Waldman concurred with the midwife's choice of breaking the membranes with a spinal needle while he was present.

At noon, with hypotonic contractions at 9 cm, -1 station, and a reassuring fetal heart rate, Ms. Mielcarski offered Pitocin augmentation and the patient agreed. She ultimately was delivered of a 9-lb 2oz baby at 5 p.m.

In another case, in which the patient had been in labor for 48 hours and had reached the point of being too tired to puch (in spite of having had a therapeutic rest induced by morphine and Secondal early in labor, Ms. Mielcarski and Dr. Waldman both concluded that he needed to perform an outlet vacuum extraction.

In answer to questions from the audience, Dr. Waldman said that in a collaboration between an experienced midwife and an inexperienced ob.gyn., the midwife's role is to teach and support the young physician.

As to fees, Dr. Waldman explained that as a corporation, he and his midwife partner bill as a unit rather than separately. He said that in Syracuse, physicians and midwives currently are paid the same fee per case, an arrangement he considers fair and reasonable.


Rules for Successful Ob.Gyn.-Midwife Collaboration

Dr.Richard Waldman outlined the key principles that make or break collaborative arrangements between an ob.gyn. and midwife.

Respect - The physician and the midwife must mutually respect each other's profession.

A prime example of the lack of such regard is the attending physician who has never worked with midwives, knows nothing of their obstetric approach, and has no interest in learning anything about it. This is the ob.gyn. who wants every midwife's patient in stirrups in the hospital delivery room, and who considers an episiotomy a standard requirement of delivery.

Team Approach - Teams must have a flat, egalitarian structure. Despite the fact that "everyone performs better when they are treated with respect, many of us are not comfortable with egalitarianism," said Dr. Waldman, who is in private practice in Syracuse. "But those who cannot learn to handle a team approach should be weeded out of a collaborative practice." 

Continuous Communication - Part of that communication involves explaining the reason behind the advice that the physician gives the new midwife, so that he or she gets the benefit of ongoing learning.

And the teaching goes both ways, he said, crediting midwives for exposing him to valuable new approaches. At St. Joseph's Hospital where Dr. Waldman is a member of the clinical faculty, the incorporation of midwifes has led to a drop in the cesarean rate to under 20%.

Another hospital that through midwives lowered a very high cesarean rate now advertises its "Midwife-style care."

Trust - The physician and the midwife must be able to trust each other.

That means that the midwife can count on the physician to come in when he or she is summoned. If the physician bites the midwife's head off for calling unnecessarily, the midwife won't make the call that the physician considers crucial. When the midwife and physician trust each other, the physician can be confident that the midwife will call when the situation requires that the care plan be changed.

Compromise - When team members can't agree, they should be able to work out an approach that both can accept. --S.S.