How to tell the difference between midwifery care & the idea of ‘performing a delivery’ ~ background & context: part 2

by faithgibson on March 2, 2013

in Info ~ Medical Board Members, Mfry Student Issues, Physician Supervision Issues

link back to part 1 ~ Written Testimony-Sunset Review: Do midwives ‘perform deliveries’ plus controversy over mfry assistants

Legal distinctions between:

* the lawful assistance by California-licensed midwives during a normal childbirth
* the obstetrically-based surgical procedure of ‘performing a delivery’ while being assisted by non-credentialed ‘lay’ person during a ‘delivery’ as seen from the perspective of the medical model

The first and foremost issue is that midwives don’t ‘perform deliveries’, which is medical terminology describing the surgical procedure used by obstetricians and other physicians during the last 5 to 15 minutes of the mother’s labor just prior to and during the birth.

For certified nurse-midwives and licensed midwives, the midwifery practice acts of both professions specifically state that the license to practice midwifery does NOT authorize the holder to practice medicine or surgery. During normal childbirth midwives are never engaged in ‘performing’ (i.e., a medical terminology) the surgical procedure known by its billing code as a “vaginal delivery”. As a result, anyone helping  the midwife would not be involved in assisting during the surgical procedure of ‘delivery’.

Terminology such as “performing deliveries” commonly refers to hospital-based obstetrical care, which customarily divides the intrapartum services for childbearing women between the two professions of nursing and medicine.

In this regard, the medical model is dramatically different from the midwifery model, which traditionally treats pregnancy and childbirth as ‘whole cloth’ experience. The goal of midwifery care is to provide continuity-of-care, so the professional midwife who cares for the pregnant women during the prenatal period is the same person who provides care during her labor, also attends her while the baby is being born and seamlessly continues to care for both mother and new baby immediately after the birth and during the 6 weeks-long postpartum and neonatal period.

Hospital protocols are quite the opposite, as physicians are not directly involved during the mother’s labor or after the birth and they never provide any services to the newborn.

In the medical model the nursing staff of the Labor and Delivery unit manage all of the first stage and most of the 2nd stage of labor. This includes phoning the obstetrician to get a doctor’s order for medical treatments and drugs, or to notify the physician of a possible complication. Typically the doctor is only present on the L&D unit after being contacted by the nurse when she anticipates the birth of the baby within the next 5 to 15 minutes.

The surgical billing code for vaginal delivery reflects the technical definition a ‘surgical procedure’ in many ways. Unlike labor that goes on for hours and hours, the procedure of vaginal delivery is a desecrate activity with a specific start-and-stop time. This describes a situation in which surgeons do not customarily provide on-going medical services to the patient during the ‘pre-op’ period before the scheduled operation or procedure, or afterwards during the ‘post-op’ phase of recovery. Relative to normal childbirth, nurses provide all the pre-op care (i.e., the labor), as well as the post-op care (postpartum recover period and all care of the newborn). The physicians/obstetrician is called in only to perform the ‘op’, that is, the delivery, which typically takes from 12 to 45 minutes.

True to that definition of normal birth as the surgical procedure, the physician is only present in the laboring woman’s room during the last few minutes of the perineal stage. This is when the baby’s head is so low in the mother’s pelvis that there are visible indicators that the birth is imminent, such as a few centimeters of the baby’s head being visible at the outlet of the birth canal.

The doctor’s responsibility for the procedure of delivery includes managing the final 5 to 15 minutes of expulsive stage, as the mother spontaneously pushes her baby out. Sometimes the doctor has reason to believe that obstetrical interventions are necessary, and performs an episiotomy and/or using forceps or a vacuum extractor to deliver the baby.

In either case, the surgical billing code of this delivery-as-procedrue will determine the level of reimbursement based on the number and magnitude of medical interventions and surgical procedures performed by the physician.

High Contrast, Non-Medical Model: the un-surgical, non-procedure in a non-medical setting of a midwife assisting at a normal labor, spontaneous birth and postpartum-neonatal care

While midwives do attend births, which includes ‘catching babies’, midwives don’t “perform deliveries” as a legally defined surgical procedure that appropriately falls under a surgical billing code. As defined by a century of midwifery textbooks, there is no separate activity for midwives described as ‘performing the delivery’.

As taught in textbooks and clinical practice, there are 3 stages of labor:

  • 1st stage, when uterine activity (contractions or ‘labor pains’) progressively dialates the mother’s cervix
  • 2nd stage when stronger uterine contractions and both voluntary and involuntary muscular efforts of mother helps her to spontaneously push the baby out (give birth)
  • 3rd stage when the placenta separates from the uterine wall, is spontaneously expelled by uterine contrastions, and the uterus continues to contract regularly for the next several days to prevent excessive maternal bleeding

Within the midwifery model, the last couple of minutes before and the moment of the birth (when the baby is born) is experienced as the normal and expected culmination of second stage of labor.  The English Code of Conduct — a handbook of rules for midwives — include rules for managing second stage that never uses the word “birth” to create any distinct period of time or responsibility by the midwife. The culmination of second stage is part of the seamless progression of biological events occurring under the watchful eye and care of the same professional midwife as birth attendant.

The midwifery model doesn’t have a “hand-off” of responsibility between two professions which requires a professional nurse to hand her responsibility over to a member of another profession (medicine). As a result, midwives don’t think about or define the few moments during which the mother pushes her baby out and the midwife ‘catches’ the baby and hands it immediately up to its mother, as a surgical procedure. It not experienced as different or unique that would be described as having “performed the delivery”. As a midwife birth attendant, there is no separate bill for a professional service that is separate from the care provide by the midwife to the mother both before or after the baby made its appearance.

Continue to part 3 ~The Midwifery Perspective of Normal Childbirth (link below on web page)

 

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