A model for the future. Certified nurse-midwives replace residents and house staff in hospitals.

In one model of the future, certified nurse-midwives (CNMs) replace most obstetric residents and house staff in hospitals. This model offers numerous benefits, such as cost containment and quality outcomes. Furthermore, its application could open opportunities for educating CNMs and residents in a truly collaborative model in an educational setting and begin to balance the ratio of physicians to CNMs in the care of low-risk populations. This model was used with some success in the late 1980s to early 1990s at an inner-city Midwestern medical center. By definition, CNMs are educated in the two disciplines of nursing and midwifery and possess evidence of certification according to the requirements of the American College of Nurse Midwives (ACNM, 1978). Nurse-midwifery practice is the independent management of care of normal newborns and women, antepartally, intrapartally, postpartally, and/or gynecologically. Certified Nurse Midwifery practice occurs within a health care system that provides for medical consultation, collaborative management, and referral (ACNM, 1978). Physician and CNM roles differ. Certified nurse-midwives focus on supporting the process of normal birth, whereas physicians focus more on the management of complications. There are data that suggest that CNM outcomes are equivalent to those of physicians (American Nurses Association, 1992; Thompson, 1986; Wilson, 1989); that CNM costs are less than those of physicians (Bell & Mills, 1989; Cherry & Foster, 1982; Gravely & Littlefield, 1992; Rooks, 1986); and that the cost of educating CNMs is much less than the cost of educating physicians (Safriet, 1992). Within an environment of health care reform and cost containment, CNMs can replace residents and house staff in hospitals in the care of low-risk clients and work in consultation with physicians for the care of high-risk clients. This article compares medical education and nurse-midwifery education, reviews nurse-midwifery outcome data, and discusses the pros and cons of a practice model for the future.

Sexually transmitted diseases in pregnancy: diagnosis, impact, and intervention.

Sexually transmitted diseases are a major health problem for the 1990s. The etiology of gonorrhea, chlamydia, syphilis, trichomonas, and bacterial vaginitis are presented, along with their treatment, pregnancy-related factors, intrapartum and neonatal factors, and follow-up. The incidence of sexually transmitted diseases has increased, and health care professionals must teach not only about disease impact but also about lifestyle and behavioral changes.

Strategies for dissemination of policy research.

Although there is evidence of high-quality care and cost-effective practice by certified nurse-midwives, CNMs still face many barriers to practice. Outcomes must be documented and disseminated more widely so that policy makers will be convinced that restrictions to CNM practice must be removed. The author identifies three obstacles to policy-related research dissemination: lack of cumulative data, lack of relevance to specific issues, and lack of power. To overcome these obstacles, five strategies are proposed to promote a wider dissemination of policy-related research results. CNMs must use these strategies to promote nurse-midwifery to the general public, government officials, interest groups, and policy makers.

Anticardiolipin antibodies. A review of the literature.

Repeated fetal loss may be a result of a variety of causes. Immunological factors have been implicated in fetal loss, intrauterine growth retardation, preeclampsia, and thrombocytopenia. Anticardiolipin antibodies (ACAs) belong to a family of autoantibodies known as antiphospholipid antibodies. Platelet aggregation and increased coagulation results from the presence of these antibodies, and is believed to contribute to the fetal complications. This article is a review of the physiological implications of ACAs, screening criteria for the presence of ACAs, prevalence rates, diagnostic measures, treatment options, and possible postpartum effects of ACAs. When women with recurrent pregnancy losses present for care, the nurse-midwife needs to be able to discuss possible causes, aspects of diagnosis, and treatment options available. With a better understanding of what these are, the nurse-midwife will be better able to plan care that will promote a positive pregnancy outcome.

The integration of a QA/RM program in a rural healthcare obstetrical service.

Obstetrical services in a rural healthcare setting have special problems because the number of deliveries per month is below 100, with some facilities averaging fewer than 10 to 15 births per month. Medical resources may include obstetricians, pediatricians, or family practitioners, but not necessarily all three. Because it is not cost-effective to staff an obstetrical unit 24 hours a day when a low census is the norm, staffing patterns may be atypical and creative. The development of an effective credentialing system for both nursing and medical staffs is the first component of a QA/RM plan. Nursing staff play a vital role in modifying potential risk. When nurses do not routinely provide care on a unit, an efficient quality assurance plan is vital. Components of the plan must include staffing patterns and ratios, policies and procedures, and documentation. QA indicators should address both volume and outcome-oriented clinical indicators. Medical follow-up when indicated should also be part of the plan. Ongoing communication among team members and utilization of outside resources can assist in promoting an effective program. Although obstetrics is an area where the potential for risk exposure remains great, it is possible to create an efficient, practical risk management system.

Maternal tasks of the puerperium reidentified.

A descriptive study of women receiving hospital postpartum care was undertaken to determine whether or not these women exhibited the behaviors of taking-in and taking-hold defined by Reva Rubin and whether or not these behaviors and attitudes changed over time during hospitalization. A modified version of a questionnaire by Martell and Mitchell was administered at five separate intervals to 50 postpartum women with uncomplicated vaginal deliveries. The women's behaviors and attitudes did change over time, but at a rate faster than that found by Rubin.