Deborah Howell (Host): Doctors and Midwives are invaluable complements for any care team, especially during pregnancy. From childbirth to emergency surgery to everything in between, many women work with both to get the best care possible. Today, we'll learn how Certified Nurse Midwives, or CNMs, and OBGYN Physicians collaborate in labor and delivery to provide the best hospital patient care.

Joining us from the OB Hospitalist Group are Dr. Nicole Fanning, Market Medical Director, Site Director, and OBGYN Hospitalist, and Barbara Dudley, CNM Director. Dr. Fanning and Barbara provide care at Henrico Doctors Forest Campus in Virginia. This is the Obstetrics Podcast from OB Hospitalist Group. I'm your host, Deborah Howell.

Welcome to both of you. I'd like to start by asking you, Dr. Fanning, can you tell us about the history of the OB Hospitalist program at your hospital and whether both OB Hospitalists and CNMs have been part of the program from the start?

Nicole Fanning, MD: Yeah, sure. Of course. Thanks for having me on this morning. So I would say, you know, in terms of obstetrics and gynecology, we're a new field. We're a growing field. Our company is only about 15 years old and the idea of OB hospitalist was not a welcome one at the inception of our company a few years ago.

And so, the OB hospitalist program was really just a one off idea by a few smart physicians, 10 to 15 years ago, and now I think you'll see a decent global or nationwide uptake of this hospitalist use across the nation. And I think, you know, honestly in 10 years from now, we'll probably see it as the only model for practicing obstetrics in the United States.

Our program here at Henrico, in and of itself, with, with our company is about three and a half, four years old. As a hospitalist program, in its existence, we've been here about 14 years at Henrico Doctors Hospital with a prior company. And so, we were just a physician based group 14 years ago, and now we're obstetric and midwife group, as of the last three and a half, four years.

We've had a large uptake in the utilization of midwives over the last three years, I'd say. And now I find them as an integral part of what we do. And I don't think we can exist as a hospitalist team or hospitalist program without them.

Host: I love it. Now, Barbara, can you tell us about your role, how many midwives there are, and how you work with Dr. Fanning and the rest of the L& D team?

Barbara Dudley, CNM: Absolutely. Thanks for having me. This is my third year as the midwifery site director. We 11 midwives in total; 4 full time and 5 part time, with 2 additional PRN midwives. Part of what I do is I try to keep them satisfied. The first part of that is with the schedule.

I act as a resource for them when needed. And then we are always working to encourage healthy relationships between nursing and our team. Our program is a little bit different than others, in that any patient in the community can request midwifery care. It's encouraged prenatally, our physicians are recommending it, and then if their patient speaks up and says they'd like to have a low intervention birth, they then recommend it even further.

For those patients, the midwife will admit, and labor and deliver them, round on them postpartum, and then discharge the patient, so there is continuity of care. In addition to our hospitalist service, we offer one to one birth support when a unit allows. We host a Meet the Midwives meeting monthly, which gives them an opportunity to meet us before ever coming into the hospital. We're also working to start a birth circle and our low intervention support class for the nursing staff. Anything you have to add, Dr. Fanning?

Nicole Fanning, MD: I find them an integral part of what we do from day to day, right? As a community and a culture at large, we are having to undo and recreate births in and of itself from what it used to be. Many women would come in, they'd get their morphine and they'd kind of not remember their births.

And now there's a huge push for autonomy in the birth world for patients and what they want to experience during the birthing process. And so midwives are integral in supporting the mother during their birth process. And then here at Henrico, we do 400 to 450 births a month.

And as physicians, we can't be everywhere, right? If I have an emergency, that I'm going to surgery for, I'm going to need that midwife not only to be there as the one to one birth support for the midwife patient, but to stay and help me manage the floor for even the physician based laboring patient. So, we cannot function without midwives on our floor for women and, women's health, but also just for the flow of the floor.

So, yeah, we need them badly for a multitude of reasons here.

Host: Yeah, that makes perfect sense. Now, as a team of CNMs and OB hospitalists, what are your average days like and how do you decide who does what? Let's start with you, Dr. Fanning.

Nicole Fanning, MD: Yeah, so our average day, I'm here today in the hospital and I've got 16 full labor rooms, right? So I can't be everywhere and neither can my midwife and so what we usually do is try to split them up by acuity and by gestational age. We'll pair off and give the midwives their comparable patients, right?

So they're not going to see the extreme preterm birth at 26 weeks or the one with shortness of breath having a new oxygen requirement. So we'll give the midwives their midwife appropriate patients, term, near term, whether they're first time moms or, you know, multiple births in the past, and we'll divvy out those patients to the midwife team.

And then usually that means they're managing a few more labors than we are, right? And having to juggle that stress of managing more labors. But in the end, that gives me time and mental bandwidth to focus on those really sick patients that are there and need the physician level care. And our normal day is, we do our team sign out at 7am and, you know, the team for the day will divvy up the patients and then we'll go meet all the patients, answer the phones as they ring, going down to the ER or helping a postpartum patient and then managing the labors together. And that even means sometimes having the midwives manage a high risk patient, they'll do the labor and I'll do the hard medical stuff.

Host: Sounds like you go through a lot of coffee, probably.

Nicole Fanning, MD: We do.

Host: Barbara, do you have anything to add?

Barbara Dudley, CNM: We divide and conquer. Our midwives love catching babies, so any chance they have, they will take the opportunity.

Nicole Fanning, MD: That's correct.

Barbara Dudley, CNM: Because we do a team based approach, we know about everybody, and so if our docs are busy, we step in as needed, even for the little ones that we aren't prepared to catch.

Nicole Fanning, MD: Right. And we thank you for it.

Host: All right, Barbara, how do private physicians in the community work with your team?

Barbara Dudley, CNM: The majority of our private docs value our contribution and welcome patients requesting midewifery care. There's always a few of the very old school ones who want to deliver their own patients, and we totally understand it. Even for those, if the patient wants midwifery care, we encourage the doctor to come in the room with us, and it's perfecthappy world.

They get to see their patient deliver, they feel like they were a part of it, and we do it together. Even for those that they are planning to deliver, they may often request help with labor support, or if the baby's not coming down and they've been pushing for a while, they'll help us assess position and figure out how to get the vaginal delivery.

Occasionally if the private is super busy and we know about it, then we'll tee the patient up for delivery. We'll go in and push with them for a couple hours and then call them for delivery. They're always very appreciative.

Host: I bet. Yeah. Anything you'd like to add, Dr. Fanning?

Nicole Fanning, MD: Yeah. I mean, I just feel fortunate that we have such an ambitious group of midwives and on the other side of the coin, we have a very open set ofprivate physicians. I think there's a hundred percent acceptance of midwives here at this hospital and in this community, which can't be said for other institutions, other states.

And so, I think, like I said before, midwives are key to successful vaginal birth and there's a big push for vaginal birth nationwide. And so they 100 percent help us achieve those national goals of keeping first time moms having vaginal birth and avoiding C-section. So, like I said, I can't live without them.

Host: Yeah. And doctor, how do you think this collaboration impacts the community in Virginia?

Nicole Fanning, MD: As the busiest hospital in Richmond and Central Virginia, people hear about us, people know about us, and people set their compass towards us. And so, I do think we have a large impact on the way people are practicing in Central Virginia, if not in Virginia at large, and fortunately or unfortunately, the community talks, right?

There's social media, and people hear about us and word travels. So, I think we do have a large outreach just with what we do here at Henrico Doctors and touching, you know, even the corners of Virginia and the community. So.

Host: Barbara, you concur?

Barbara Dudley, CNM: I do. The midwives caught about 1,500 babies last year and so the exposure is high even for those patients not planning to have a midwife. It's worked out really well. Because we can work collaboratively together on the high risk patients, we don't have to transfer their care, which also allows for a seamless delivery, eventually reducing that C-section rate a little further.

Host: All right, I have a final question for both of you. Is there anything that you'd like people to know about your hospital team collaboration? Let's start with you, Dr. Fanning.

Nicole Fanning, MD: I think for collaboration to work, you have to understand each other's why's and each other's goals at the end of the day. And you have to understand what one another does. And that's on a larger level, larger perspective, doctors and midwives, but it's also on an individual level, right?

So I live and I thrive on obstetric emergencies. That is what wakes me up in the morning and that is what gets me through my day, is to be able to respond and save a mom's life. For me, that leaves vaginal birth a little lower tier for things I really enjoy doing, but still, is a part of my job and love doing, but then that helps the midwives thrive, and instead of having two vaginal births that day, they might get three or four, which they love, and I think the collaboration is a global mentality about the individual and then larger to, the skill set of midwives and docs so that we can fill in each other's gaps.

And I think part of the difficulty and uptake and utilization in midwives in the community is just not understanding that by physician providers. It's just being kind of afraid of what, you know, the midwife means versus really understanding what they do and how they can augment care.

Host: Right, how they can bring so much to the table. Barbara, do you want to answer that?

Barbara Dudley, CNM: Absolutely, we definitely do not thrive on obstetric emergencies, so this works out really well. Historically, physicians are hesitant about midwives and vice versa because they don't trust each other. We, at our institution don't practice witchcraft and wizardry. When they see and understand what we do, they trust us and they see it because they're welcome in the room. Our team collaborates well because the midwives include the physicians and the physicians do the same. We receive reports together, communicate about all patients all the time, and are welcoming of the help when indicated. The handoff is always seamless.

Host: Well, it just seems like just such a great collaboration. And Barbara and Dr. Fanning, I want to thank you both so much for being here today on the podcast. We really appreciate everything you do.

That's Dr. Nicole Fanning and Barbara Dudley, CNM. And for more information about the benefits of OB Hospitalist programs with OB GYNs and CNMs, go to OBHG.com. If you found this podcast to be helpful, please share it on your social channels and make sure to check out the entire podcast library for additional topics of interest. I'm Deborah Howell. Thanks for checking out this episode of the Obstetrics Podcast from OB Hospitalist Group. Take care.