Midwives, When Do You Escalate? 5 Strategies for Collaboration, Comanagement, and Referral

Let’s say my patient is in active labor, and I know this patient’s birth with her first baby included shoulder dystocia. Let’s say this patient has a high BMI, and the baby’s head is not descended in an expected manner, although she is fully dilated. In this hypothetical scenario, the timely call would include me calling the ob/gyn (or family physician) and saying, “I think I want you here in the second stage of labor, because the risk of shoulder dystocia might be elevated.”

This proactive approach promotes much better outcomes than waiting until the turtle sign to escalate.

By laying the groundwork for care escalation in advance, all practitioners and practices can promote patient safety while mitigating their own liability risks. The following are five key strategies.

1. Know that timely escalation mitigates risk.

In responding to attorneys’ requests for me to review records, a common theme I’ve witnessed is lack of timely referral related to intrapartum management. In other words, one of the greatest sources of liability for midwives is delays in escalating care.

An escalation conversation could look like a midwife approaching a physician colleague to say, “I need to talk to you right now. Patient x is experiencing y and z. Here’s what I think the plan should be. What do you think?” Decisions from this consultation would then be noted in the patient’s medical record progress note.

Here are some barriers that can impede escalation conversations:

Reluctance to admit uncertainty: Handoffs are a given—but we may find it easier to hand off to some teammates than others. For a midwife who is newer, or lacks confidence, or is experiencing interpersonal conflict, to admit uncertainty may inspire real dread. They may think, “Well, I'll wait just a little bit longer. Maybe this will resolve itself.” But this deny-and-delay game is our worst enemy.

Remember: The decision to escalate has nothing to do with a midwife’s expertise or years of experience, and everything to do with the patient in front of you.

Reluctance to disturb someone’s day off: The comanaging physician may be playing golf or pursuing some other cherished hobby, and they may have said they don’t want to be bothered unless it’s a real emergency.

Reluctance to wake someone up: Midwives know from experience who gets angry if you wake them up for (what turns out to be) insufficient reason.

Reluctance to be blamed for lost revenue: When a midwife refers a patient out to a physician instead of comanaging them, (1) the patient who thought they were getting a midwife loses that opportunity, and (2) the midwifery service loses revenue.

As a service director for multiple midwifery practices over the years, I’ve witnessed the benefits of participating in a peer review process that asks, "What were the indicators that led to that referral?" In an era of increasingly moderate-risk to high-risk patients, and amid an ob/gyn workforce shortage, a postreferral debriefing process can be a source of ongoing professional development for practitioners and ongoing quality assurance for the practice.

2. Distinguish collaboration from comanagement and other related terms.

We may hear certain key terms used as if they are interchangeable, but risk management begins with clarifying both risks and protective steps:

Collaboration: Standards of practice for certified nurse-midwives and certified midwives underlie our education programs, which teach the scope of midwifery practice and establish the foundation for our autonomous practice (where possible). In independent practice, we may need to reach out to an obstetrician, a cardiologist, a dermatologist, or a physical therapist to collaborate with them on a patient care plan to address a particular issue.

Comanagement: If I call a physician and request an official collegial management plan for my patient, then either we’re going to comanage this patient throughout her care, or I’m going to handle her care up to point x, at which point the patient passes to the doctor.

Referral: If a patient becomes moderate or high risk, and I am no longer able to care for her—whether according to my hospital privileges, my scope of practice, or my collaborative agreement—then I refer her out for exclusive physician management.

Collaborative Practice Agreement, Required: The phrase “collaborative practice agreement” is written into many statutory requirements. This requirement, connected to licensure, typically derives from a board of nursing, board of healing arts, or board of public health. However, the definition of “collaborative practice agreement” can vary widely from state to state.

One state might settle for two sentences that document my collaborative relationship with a doctor. But another state might require a formulary of the medications I can prescribe, a list of procedures I can do, a detailed description of any degree of supervisory authority that the doctor has over me, and other details.

Collaborative Practice Agreement, Optional: Even without a statutory requirement, a care team can consult hospital bylaws to draft a document that establishes shared understanding, which mitigates practice risks. Practitioners can sit down together and say, “This is when I’ll refer to the physician” or “This is when I’ll manage patients on my own,” or “This is how we can comanage a diabetic patient.”

3. Understand that major medical professional societies promote different practice models.

As midwives in a patchwork healthcare system, we are already familiar with tensions between licensure requirements, statutory restrictions, and what our patients’ insurance will cover. But in particular, conflicting recommendations from two major medical professional societies can create confusion for healthcare systems and practitioners:

• The American College of Obstetricians and Gynecologists (ACOG) clearly articulates that midwives can and should pursue independent autonomous practice to the highest level of their education and training, and ACOG advocates for ob/gyns and midwives to work collaboratively.
• The American Academy of Family Physicians (AAFP) dictates that they supervise all midwives that work in their employment.

These two models of practice clearly contradict each other, and they also intersect in disparate ways with midwives’ employment situations, creating ripple effects with state regulations or other aspects of our practice. This is one of the reasons there is no global statement defining exactly when a midwife should collaborate with, comanage with, and/or refer to a physician.

4. Provide consistent care across your teams.

Risk assessment criteria are generally not prescriptive to the degree that they dictate when comanagement shifts into referral; many midwives comanage certain high-risk patients all the way through delivery. We don’t want a template format, because each patient is different: Care is individualized based on the patient and the discussion with your collaborators on the care team. For instance, take two patients with different presentations of hypertension: One of them might be managed by a midwife, but the other one not.

To manage our patients, who are by nature inconsistent from each other, we must be consistent across our teams in how we deliver care, and delivering consistent care demands trust, respect, and availability. If one physician goes on vacation, another physician covers those patients and practices in the same way. We commit as a team to making clear handoffs, so that we always distinguish between who is my patient, who is our patient, and who is your patient—and we clearly document these differentiations.

5. Plan ahead for patients who do not want to be referred—but need to be.

Sometimes patients are very attached to their birthing preferences. While understandable, this can impede timely escalation. Practices can communicate with patients about team-based care long before labor begins.

During 25 years of midwifery practice, I strove to ensure that my patients saw someone on the physician side at least one time, and I said to my patients something like this:

“We have eight midwives in this practice, and we collaborate with five maternal fetal medicine physicians. Our team has established protocols for how to practice together. All the midwives practice the same way—we tell different jokes, and we have different personalities, but we and the physicians all follow the same standards of care. If you are transferred out, we will listen to your wishes to the best of our ability, and we will keep you safe within the standards of care.”