You are on page 1of 7

DEMYSTIFYING THE NURSE-MIDWIFERY MANAGEMENT PROCESS

Diane Kane Erwin, CNM, MSN, and Betty Hosford, CNM, MA

ABSTRACT

A major challenge faced by nurse-midwifery students is that of learning to utilize the


nurse-midwifery management process as a foundation for clinical practice. The authors
have attempted to unravel some of the difficult areas students have found while
learning to master this process. This article seeks to remove the mystique from essential
steps of the nurse-midwifery management process as well as give insight into common
pitfalls of beginning practice. Its intent is to help students (and indirectly the nurse-mid-
wifery clinicians who guide them) in their quest for the development of mature judg-
ment and ability to manage care skillfully and safely.

This article is presented as a resource of the normal physiologic and psy- tion of judgements, and decision-
for those who are using the nurse- chological aspects of the maternity making. Steps of the process may be
midwifery management process for cycle, the neonatal period, and the outlined in various ways but include
the first time. Inspired by both the inter- and postconceptual phases of the following actions:
importance of this process and em- the female life cycle.
pathy with students who are at- The nurse-midwife assumes direct 1. Investigating and obtaining all
tempting to learn it, the authors ex- primary responsibility for managing data needed for a comprehensive
amine the essential steps of the care of normal childbearing women evaluation of the clients status,
nurse-midwifery management pro- and their babies; and of nonpreg- including past and current his-
cess, and attempt to shed light on its nant women who need well-woman tory, physical examination, and
various facets. interconceptional or gynecologic laboratory findings.
care. At times, she comanages with 2. Making an assessment, or identi-
the physician the care of women fication of problems and needs
THE NATURE OF THE PROCESS
and/or babies with more serious based on an interpretation of the
The nurse-midwifery management health problems. The nurse-midwife data. Differentiating normal from
process is the way nurse-midwives must be able to recognize and diag- abnormal and identifying possible
care for clients. It uses a problem- nose what is normal (for which she causes of symptoms outside the
solving format refined by basic tenets can assume management responsi- normal range.
of nurse-midwifery philosophy and bility) as well as deviations from 3. Developing a comprehensive
practice. Nurse-midwifery is holistic, normal that require referral, consul- plan of care with the client/family
health oriented, and focused on a tation, or comanagement with the that is based on the needs identi-
philosophy of self-care. It is dedi- physician. fied, needs that may call for im-
cated to indepth study and support All of this is reflected in the nurse- mediate nurse-midwifery inter-
midwifes approach to care known ventions, consultations, collabo-
as the nurse-midwifery management rative management, and/or
Address correspondence to: Betty Hosford, process. Individuals who have referral.
CNM, University of Medicine and Dentistty of learned the management process 4. Implementing the plan of care
New Jersey, School of Health-Related Profes-
sions, Nurse-Midwifery Educational Program, have developed skills that include with the client and/or family with
100 Bergen Street, Newark, NJ 07103. critical thinking, evaluation, forma- medical or other input as appro-

26 Journal of Nurse-Midwifery ?? Vol. 32, No. 1, January/February 1987


Copyright 0 1987 by the AmericanCollege of Nurse-Midwives 0091~2182/87/$03.50
priate within the protocols of the women before, during, or after child- possible, in the event of the devia-
service setting. bearing, as well as needs of the tions from normal, is an essential
5. Evaluating the effectiveness and normal neonate. task that will be addressed below.
completeness of the care given An important addition to the phys-
with the client and/or family and ically oriented impression of the
APPLYING THE PROCESS
instituting an alternative plan of clients well-being is the nurse-mid-
care when necessary. Adequate data are the key to ade- wifes assessment of her needs for
quate assessment and planning. information, emotional support,
These steps form the framework
General protocols and record forms, health promotion, guidance in self-
for the nurse-midwifes activities re-
developed to guide and ensure uni- care, and social or other special ser-
lated to helping clients with health
formity of basic physical assessment vices. Of equal significance is an as-
problems in a manner that demon-
of women and babies, provide sessment of individual and family
strates a holistic health approach.
helpful parameters as the nurse-mid- strengths upon which to build. For
From the earliest encounter clients
wife sets out to gather initial data. example, is the woman highly moti-
are encouraged to become active
For example, the initial prenatal visit vated to achieve optimal health? Are
participants in their own care.
in most settings includes a history, family members cohesive and
This holistic approach implies in-
general physical screening examina- anxious to lend support? Have
formation gathering and the making
tion, and detailed examination of the family members hung in there de-
of assessments that address physical,
pelvic organs and bony architecture spite unusual stresses? What are the
emotional, social, nutritional, general
of the pelvis. Length of gestation is pluses and minuses in this clients sit-
health, and informational needs of
carefully assessed from history and uation?
physical findings. Specific laboratory Collection of data regarding some
tests are important for assessing ma- or all of these factors may be initiated
ternal and fetal health and screening by specific questions written into the
Diane Kane Erwin receiued her BSN for potential problems. printed histoy forms of some ser-
from the University of Pennsylvania and Similarly, data considered basic to vices, If not, the nurse-midwife can
is a 1980 graduate of Columbia the initial assessment of the new- still put out feelers or questions and
Universitys Nurse-Midwifery Program,
born, and outlined on initial assess- be generally alert to cures from the
New York, NY. Since then she has been
ment forms, generally include: ma- client and/or family. Getting to know
a fatuity member and nurse-midwife in
the Uniuersity of Pennsylvania Nutse-
ternal and family health history, ones client as a person is basic to in-
Midwifey Program and is currently an events of pregnancy, labor, and viting that client to become a partner
assistant clinical professor in the Nurse- birth, measurements, vital signs, in her own care!
Midwijey Education Program at the head-to-toe physical examination, After gathering all appropriate
Uniuersity of Medicine and Dentistry of and gestational assessment. Certain data, the nurse-midwifes next task is
New Jersey, Newark, New Jersey. laboratory tests such as determina- to make an assessment based on the
tion of blood type, Rh factor, data. She identifies problems or
Betty Hosford received her BSN from Coombs test, serology, hematocrit, needs requiring immediate or con-
Keuka College, Keuka Park, New York and screening for a variety of pos- tinuing intervention in concert with
and MA in Nursing Education from
sible genetically transmitted diseases, the woman and/or family. This in-
Teachers College, Columbia University,
are almost standard. The nurse-mid- cludes problems within the sphere of
New York, New York. After graduating
from Maternity Center Associations wife soon becomes familiar with nurse-midwifery and those requiring
School of Nurse-Midwifery, New York, these and the content of initial data medical consultation and/or referral
NY, she helped to set up and undertake collection guides or forms for the in- to the physician or other health spe-
an internship in Nurse-Midwifery at the trapartal and postpartal periods, as cialist. She includes not only those
Johns Hopkins Hospital, Bakimore, MD. well as for well-woman health problems and needs that are imme-
A nursing educator for many years, her screening and family planning care. diate, but also those that might occur
nurse-midwifery experience has included All data gathered in an initial or for which anticipatory guidance may
directing Internship Program at State
an follow-up encounter may support a be important. She consults and
University of New York Downstate sound impression of normalcy. On refers problems as indicated and im-
Medical Center and contributing toward
the other hand, elements of the his- plements those aspects of the plan
the deue/opment of Maternity Center
tory, physical findings, or laboratory that she is prepared to carry out. This
Associations Childbearing Center. She
is a Clinical Associate Professor in the
results may suggest one or more may include helping the woman to
Nurse-Midwifery Education Program at problems and the need for additional assume a more active role in various
the Unioersity of Medicine and Dentistry data to pinpoint just what those aspects of her own health care as
of New Jersey, Newark, NJ. problems are. Compiling the most well as treating specific health
complete and appropriate data base problems. It might also include the

Journal of Nurse-Midwifery ??Vol. 32. No. 1, January/February 1987 27


provision of information regarding are an inherent part of assessment in spontaneously offer data that help to
specific signs and symptoms for the management process. They are single out a likely explanation for her
which she should be on the alert. as follows. symptom(s).
All of these interventions are later
evaluated jointly by the client and Recognition of Symptoms That Listing All the Plausible Compli-
the nurse-midwife. If need be, a new May Mean Deviation(s) From cations That the Symptom(s)
approach to the identified needs Normal. Noting the existence of the Might Signify. This is the formula-
and/or problems is formulated jointly symptom is only a start. The practi- tion of a differential diagnosis. It is
toward the goal of improved client tioner must learn the exact nature of similar to that which the physician
health and satisfaction. that symptom by gathering all pos- may make, but the nurse-midwife
Nurse-midwifery management is sible microdata or details about it. usually confines such a list of rule
an ongoing process. Needs change, For example, in the course of con- outs to the more common condi-
new problems arise, and client satis- ducting a return prenatal visit, the tions. She does not have the exten-
faction may vary with circumstances. nurse-midwife may find all historical sive background in medicine and pa-
All these changes generate the need and physical examination findings thology that the physician has, but
for new observations, reassessment, within the realm of normal with one her work contributes to the arrival at
and new plans with their implemen- exception- a complaint of abdom- a diagnosis either by herself or the
tation and evaluation. inal pain. This symptom must be ex- physician. Her rule outs cover
amined. To learn the actual nature of much basic ground.
the pain the nurse-midwive must
Assessing the Deviations find out what it feels like, when it
from Normal Going Through Each of the
occurs, whether it is steady or inter- Listed Conditions Methodically,
The nurse-midwife is in every sense mittent, how and when it started, Gathering Additional Data by Way
the expert in normal maternity and what, if anything, it appears to be re- of Pertinent History, Laboratory
well-woman care. By virtue of in- lated to, what has been done about Test, and Physical Examination.
terest, preparation, and continuing it, what helps, what makes it worse, This will either rule in or rule out
experience, she is aware of what is etc. A hands on examination may each possible complication on the
normal and commonplace and what help to determine its exact location list. It is the end result of this pains-
is normal but less frequently encoun- and character, whether it is asso- taking and completely documented
tered. ciated with tenderness, rebound ten- investigation (carried out within the
It is this intense appreciation of derness, muscular rigidity, a mass, limits of the protocols and standing
what is normal that enables her to distention, or discoloration. The orders of the specific service setting),
recognize deviations that may signal more complete the gathering of this which is presented to the physician,
problems-often those of a most symptom-specific data, the more re- if indicated. On the other hand, the
subtle nature. Implied in the recogni- fined and narrowed down will be the problem may be one that can be
tion of these deviations is a thorough list of possible explanations for the documented and addressed by the
knowledge of the more common pain. This is a case of more meaning nurse-midwife if it falls within the
conditions that may complicate preg- less! The most reasonable possible realm of her delegated responsibility.
nancy, labor and birth, the puer- explanations of the symptoms are In that instance, she moves along to
perium, and the neonatal and inter- identified only after this paring the planning and implementing
conceptional periods. down. phases.
When deviations from normal are Sharing with the client the reasons
found, the nurse-midwife consults for all of the questioning and why it
with or informs the physician of is important to get specific informa- Working on the
those findings in accordance with tion can help her to become an as- Differential Diagnosis
protocols set forth by the specific tute observer and active partner in
The investigative steps are high-
practice setting. She is expected in her care. If she becomes aware of
lighted below.
most instances, however, to do more different symptoms and what these
than just report symptoms. Her re- differences can mean, she will be- 1. Obtain as much detailed infor-
sponsibility includes beginning the come more knowledgeable about mation as possible about the
process of differential diagnosis of her own body and how to interpret symptom(s).
the more common obstetric, gyneco- its messages. 2. Identify the most likely causes of
logic, and neonatal complications. What do you think about this? the symptom(s) as it presents in
This differential diagnosis involves is not a bad way to begin, for the this situation.
specific steps to assure correct identi- client has usually done some ruling 3. Check out each possible cause
fication of the problem. These steps in or ruling out already. She may to either rule it in or rule it out.

28 Journal of Nurse-Midwifery ?? Vol. 32, No. 1, January/February 1987


4. Examine the data obtained and charge in the absence of any other analysis, and who takes an active
attempt to arrive at the most symptoms. This may be ruled in or part at each step along the way, is
plausible explanation for the out rather quickly and easily by in- very likely to be an interested and
symptom(s). structing the woman carefully and active participant in making and im-
5. If the data do not support any of collecting a second clean catch spec- plementing a plan of care. She alone
the common conditions usually imen. may be able to verify the nutse-mid-
responsible for the symptom(s), To investigate the possibility of wifes analysis of needs, such as
documentation of what has been UTI, the nurse-midwife inquires those generated by lack of informa-
considered and a precise descrip- about symptoms such as frequency, tion, fears, concerns, preferences,
tion of the original symptom(s) burning on urination, hematuria, su- and limited resources. She is also
are presented to the physician, prapubic or low abdominal pain, and better prepared to help evaluate the
who then assumes responsibility other signs of infection. She asks effectiveness of the care plan and
for further diagnostic workup and about any previous occurrence of suggest need for modifications that
treatment. bladder or kidney infection and might be helpful. In every sense,
scans the chart for medical and nurse-midwifery management is
The above process may seem family history suggestive of urinary problem-solving for and with clients
cumbersome at best, but it will dis- tract problems. She notes laboratory and families, with client and family
courage jumping to conclusions. findings on urinalysis. On physical participation adding a significant and
On-the-spot hunches regarding examination she looks for costover- vital part of the care.
symptoms may prove correct. How- tebral angle and suprapubic tender-
ever, it is the tireless, detailed investi- ness. A stat microscopic examination
AVOIDING THE PITFALLS OF THE
gation and specific documentation of a clean catch urine specimen may
MANAGEMENT PROCESS
that lead to safe practice. For ex- rule in or rule out cystitis. However,
ample, a complaint of headache in if everything else appears to negate Learning to apply the process takes
the third trimester could mean pre- the possibility of UTI, the results of a time and practice, and along the way
eclampsia, eye strain, migraine, urine culture and sensitivity test will there are tempting pitfalls. The fol-
hunger, sinusitis, tension, injury, al- perhaps be the most convincing doc- lowing suggestions are offered to fur-
lergy, or something else. Details umentation for or against its exis- ther prepare the new practitioner for
about the symptom are needed to tence. a smoother course.
narrow down the list of possible In similar fashion the possibilities
causes. Identification of cause is im- of preeclampsia, vaginitis, and the
The Clinician Must Remember
portant if it is to be dealt with effec- other explanations are likewise ex-
That the Management Process Is
tively and, especially, if it signals a amined in turn and ruled in or out.
Dynamic, Not Static
potentially serious condition.
In another instance, a symptom Therefore, the nurse-midwife cannot
Client Participation-a Hallmark
such as one-plus proteinuria could: always use the process in sequence.
and a Help
1) signal the presence of silent uri- S/he sometimes proceeds out of
nary tract infection (UTI); 2) reflect The above scenario may sound ex- order in certain clinical situations,
vaginitis or contamination of the hausting, however, the nurse-mid- only to reenter at another level.
specimen by vaginal secretions; 3) wife need not conduct all this inquiry When the process is completed,
nify the progression of pre- and testing in the seclusion of her however, all areas will have been
lmpsia; 4) comprise a normal own expertise! The client herself can covered to the best of his/her ability.
pnysiologic response to a vigorous be recruited as an expert partner.
exercise program or high protein di- Given a picture of the most plausible Example. Ms. Brown, a 22-year-
etary regime; or 5) suggest a more explanations of her symptoms, the old gravida 1, para 0, comes to the
obscure medical condition. Discov- client may draw upon her first hand clinic for her first prenatal visit at the
ering the cause will require reexami- knowledge to help eliminate or iden- beginning of her fifth month of preg-
nation or acquiring of new historical tify causes. Both the nurse-midwife nancy. Data collected by the nurse-
data, selective physical examination and her client do well to look at the midwife conducting the visit leads
focused on ruling in or ruling out the most simple explanations first, be- her to suspect anemia. She empha-
above entities, and specific labora- cause they are always the most sizes to Ms. Brown the importance of
toy tests to back up or rule out the *likely, with exotic conditions happily taking iron and vitamin supplements,
various possibilities. being rare. along with good diet, as part of her
The most simple explanation may The client who is abreast of all management for the visit.
be contamination with vaginal dis- aspects of data collection and its final On Ms. Browns second visit 3

Journal of Nurse-Midwifery ?? Vol. 32, No. 1, January/February 1987 29


weeks later, reports of her laboratory have been missed and another others. Each plan must reflect the in-
results are back and attached to the problem perpetuated by providing a dividual and the particular circum-
chart. Her hemoglobin electropho- less than optimal medication. The stances. It is very difficult to check
resis results indicate that she has clinician must avoid being intimi- the pelvic findings at 30 weeks of
beta-thalassemia minor. dated into providing a service that is pregnancy, when there is little likeli-
not appropriate for a client. hood of PID occurrence. There is no
Comments. These additional data set management for all situations
require a revamping of the original Example: Exception to the Rule. that the nurse-midwife may en-
assessment and management of the Ms. Jones arrives on the labor and counter.
anemia by the nurse-midwife. Re- delivery unit at term bleeding
entry into the process becomes im- heavily. Fetal heart tones are 80
The Clinician Must Resist the
portant to addressing the clients beats per minute.
Temptation to Throw in the
needs most appropriately.
Kitchen Sink With Her/His Data
Comment. Although the nurse-
Collection, Differential Diagnosis,
midwife does not have a total pic-
The Clinician Must Avoid Making and Plan
ture, s/he knows that the data are in-
Decisions on an Incomplete
dicative of emergency attention and In an attempt to cover all territory it
Data Base
consultation. After s/he has attended may be inviting to the nurse-midwife
It is important that the nurse-midwife to the immediate need, s/he re- to include everything s/he knows
take the time to get data together. Al- enters the process to complete her/ about a topic to ensure being thor-
though the nurse-midwife begins for- his data collection and management ough. This can be time-consuming
mulating ideas about a differential until the womans needs are met. and expensive, and can sometimes
diagnosis, s/he needs to keep an This is done in a collaborative lead to invasive treatment that may
open mind until her/his data collec- fashion, of course! cause iatrogenic problems.
tion is complete. Hunches should
never cloud objectivity. The excep- Example. An evaluation of the
The Clinician Should
tion, of course, is the emergency sit- newborn on the second postpartum
Avoid Cookbooking
uation that is obvious and in need of day demonstrates an elevated tem-
immediate action, consultation, or There is no recipe that can be perature of 100.6F. The nurse-mid-
referral. used repeatedly for problem-solving. wifes first suspicion is infection, and
The process of data collection is the s/he immediately refers the baby for
Example. Ms. Amat appears for a same, but the content is not. There- a septic work-up.
gynecologic visit with the comment: fore, the nurse-midwife must avoid
I have another urinary tract infec- trying to use the same information Comment. While infection is a
tion. I get them all the time, and my for different problems. No two possibility, it is wise for the nurse-
doctor always gives me Macrodantin. people or situations are alike. midwife to investigate the obvious. Is
I dont know why I have to see you. the baby overheated, overdressed,
Why cant you just give me my Example. Ms. Green comes into or dehydrated? Often the more
Macrodantin? the clinic at 30 weeks of pregnancy simple explanation is the correct
The nurse-midwifes data collec- with a chief complaint of exposure to one. It is not wise to expose the baby
tion reveals that Ms. Amat is anemic gonorrhea. The nurse-midwife to unnecessary testing (spinal tap) if
and jaundiced, and that her glucose- knows that this is an infection that the elevated temperature is sec-
6-phosphate dehydrogenase can cause pelvic inflammatory dis- ondary to the above problems. On
(G6PD) levels are abnormally high. ease (PID). Should she, as a consci- the other hand, sepsis is still a con-
On further analysis it appears that entious clinician, prepare Ms. Green sideration that must be kept in mind
Ms. Amat has a problem with her for a bimanual examination to check and acted upon if other clinical
G6PD pathway that is being aggra- pelvic findings? Indeed, she should symptoms are present or develop.
vated by the Macrodantin therapy. not. The need here is rather for a
The nurse-midwife proceeds to con- speculum examination and cervical
When Considering Differential
sult for treatment with Ampicillin and culture to detect infection, which is
Diagnosis It Is Important for the
follow-up of Ms. Amats medical especially hazardous for the baby at
Nurse-Midwife to Proceed From
problems. the time of birth.
the Benign to the Complex

Comment. Without a complete Comment. What may be relevant S/he should try to avoid making pa-
data base the GGPD problem would for some clients may not be for thology her/his first consideration

30 Journal of Nurse-Midwifery ?? Vol. 32, No. 1, January/February 1987


while being thorough in her/his eval- In the Evaluation of the Clients Example. The laboratory results
uation. Situation, It Is Not a Sign of of Ms. Cox show a total Ts, T4, T, to
Inadequacy if the Nurse-Midwife be elevated. The nurse-midwife
Example. Ms. A. appears on the Formulates and Lists More Than quickly refers this woman to internal
labor floor at term with a chief com- One Impression medicine for an evaluation of her
plaint of pain in her abdomen. She is thyroid status. The response to her/
examined and her cervix is found to For each significant concern identi- his consultation: In view of Mrs.
be closed and uneffaced. Given no fied, corresponding rule outs should Coxs pregnancy status, these tests
uterine or fetal abnormalities the pa- be listed until the problem(s) can be are within normal limits.
tient is discharged. The next day she documented with appropriate infor-
appears in the clinic for a routine visit mation and safely resolved. Comment. All data must be
and the nurse-midwife examines her. viewed in terms of the individual
At this time a urinalysis is done to client and all that is known about
Example. Ms. James has had a
rule out a UTI. The results show in- her/him. It is this carefully applied
protracted labor. The second shift
numerable bacteria and white blood limitation that adds the dimension of
nurse-midwife is taking over. Her
cells, and no epithelial cells. The safety to data analysis.
differentials, related to Ms. James
woman is treated with Ampicillin 500 and the four Ps of labor, are: 1)
mg four times a day for 10 days. Powers-Contraction pattern and One Diagnostic Parameter Does
effect on dilatation and effacement? Not Equal Adequate Data
Comment. Although labor is 2) Passenger-Size, position, atti- The nurse-midwifes management
always a first suspicion for a woman tude, presentation, fetal heart tones? must be based on her assessment, or
who is at term and complaining of 3) Passageway- Clinical pel- professional judgment, after histoy-
pain, a thorough evaluation is essen- vimety? Potential cephalopelvic dis- taking, physical examination, and
tial to rule out other possibilities so proportion? and 4) Personality-MS. the procuring of laboratory informa-
that important care is not omitted. James level of anxiety, ability to
tion as indicated.
cope, orientation to childbirth, etc? Ms. Rios VDRL, taken upon her
An additional diagnosis may focus admission for delivery, is reported
The Nurse-Midwife Must Not on management concerns such as subsequently as weakly positive.
Overlook the Obvious support, hydration, nutrition, elimi- Someone tells Ms. Rizzo that she
Dont look for zebras when you nation, and rest. may have to be treated for syphilis
hear the sound of horses hoofs is before she goes home, and that her
constantly applicable. Comment. It may indeed be nec- husband will need treatment as well.
essay to deal simultaneously with The woman becomes frantic, visibly
Example. Ms. Olsons concen- more than one differential at a time. hurt, and suspicious. Her husband
trated urine sits on the table while Only after a period of awaiting the threatens to confront the laboratory
the student nurse-midwife conscien- effect of a management plan or a re- technician with his fists! Joy about
tiously performs her antepartal visit. port of laboratory values can the their baby is clouded by anxiety and
Since Ms. Olsons weight gain has nurse-midwife rule out certain suspi- mutual distrust.
been limited, the student is busily in- cions. This may take more than one The nurse-midwife points out to
volved with questioning her about prenatal visit or a few hours of labor the Rizzos that the VDRL is only a
nausea, vomiting, and gastrointes- management. Listing several differ- screening test that could reflect any
tinal upset. As the student is in the entials usually reflects thoroughness one of a number of different infec-
process of collecting a nicely detailed and safety, not inadequacies. Listing tions or conditions. Upon careful his-
inventory of all the things Ms. Olson excessive numbers of differentials toy-taking, she learns that Ms. Rizo
enjoys eating, her instructor enters may indicate the clinicians need to had the flu 5 weeks before delivery.
the room, sees the urine, and states, refine and develop greater speci- She points out the likelihood of that
No breakfast, I see. ficity, a need to hone in on a few, being the cause of the positive test.
while eliminating superfluous rule Sure enough, Ms. Rizzos FTA-ABS
outs. test comes back negative!
Comment. In an attempt to gather
data, sometimes red flags are Comment. Interpretation of one
missed. Particularly important in this It Is Important to Interpret Data in parameter can be misleading. The
category are the nonverbal messages Light of the Clients Individual nurse-midwife must always view a
a client may give. Condition and Circumstances single parameter in terms of the full

Journal of Nurse-Midwifery ?? Vol. 32, No. 1, January/February 1987 31


picture. Laboratory and x-ray data aware that because of the limitations 2. Judge RD, Zuidema GD: Physical
are compliments to what the gath- of her practice as a nurse-midwife, diagnosis, 3rd ed. Boston, Little, Brown,
ering of historical data and laying on there will always be circumstances in 1974.
of hands can reveal to the astute cli- which consultation will be necessary. 3. Prior JA, Silberstein JS: Physical
nician. This awareness protects her and as- diagnosis: The history and examination
of the patient, 5th Edition. St. Louis, The
In closing, the nurse-midwifery sures the safety of her clients.
CV. Mosby Company, 1977.
student can be reassured that, as she
REFERENCES 4. University of Medicine and Den-
gains knowledge and experience, the
tistry Modular Curriculum: The Manage-
data base will become increasingly 1. Elstein, Shulman, Spranfna: Na- ment Process, 1985.
more comprehensive. As it expands, tional problem solving: An analysis of 5. Varney H: Nurse-midwifery.
so will her ability to manage various clinical reason. Cambridge, Howard Uni- Boston, Blackwell Scientific Publications,
situations. However, she must be versity Press, 1978, p 2. Inc., 1980.

32 Journal of Nurse-Midwifery ?? Vol. 32, No. 1, January/February 1987

You might also like