The Nurse-Midwifery Service a t Harlem Hospital Center

By Patricia Boone, R.N., C.N.M., M.S.

Miss Boone is Nurse-Midwife Coordinator, Harlem Hospital Center, New York. This paper was presented at the Annzial Meeting of the ACNM, Milwaukee, May, 1967.

Harlem Hospital is one of the city’s twenty municipal hospitals, located in the Central Harlem area of Manhattan. The hospital has approximately 900 beds and Serves a population of almost a quarter of a million persons as estimated in 1960. The hospital has an intern-residency training program. At present there are twenty-four obstetrical-gynecological residents on the service. The intern program is a rotating one. Since obstetrics is an elec- tive experience there have been few interns on the service sinc? I began work at Harlem Hospital Center.

The hospital is affiliated with Columbia University and its Fac- ulty of Medicine. However, at present Harlem Hospital is not

Nurse-Midwife cares for patient in evening antepartal clinic. Picture credit: Elizabeth Wilcox.

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Young mother discusses her concerns about her baby with the nurse- midwife. Picture credit: Elizabeth Wilcox.

utilized as a training site for medical students. In addition, there are two nursing programs using the clinical facilities for their students: the Hospital’s two and one half year diploma school preparing professional nurses and a school for practical nurses under the auspices of the city of New York.

About three and one half years ago, Dr. Donald P. Swartz, Director of Obstetrics and Gynecology, began discussions with the then Commissioner of the Department of Hospitals, Dr. Ray- mond Trussel, regarding the possibility of utilizing nurse-midwives in service to help improve the quality of maternity care. Dr. Swartz was familiar with the care that can be given by nurse- midwives, having worked with them in his residency training at Johns Hopkins Hospital. He also thought Harlem Hospital Center would provide excellent clinical experiences for the Columbia University graduate students in maternity nursing-nurse-mid- wifery. He was also aware that the concept of nurse-midwifery was not new to New York City as four municipal hospitals were already using nurse-midwives for various aspects of obstetrical care.

In March of 1965 the Commissioner of Hospitals wrote to the Director of the Medical Board of Harlem Hospital, “The need for a great improvement in the quality of care rendered to obstretric patients is an urgent one, and the participation by Harlem Hos- pital in the opportunity to develop more staff in this field is one which I endorse strongly. It is significant to realize that beyond the needs of New York City, this is an opportunity to participate in the forefront of a development which is destined to extend

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across the nation in coming years.” With the pledged support of the Medical Board the hospital ad-

ministrator, and the Director of Nurses, one nurse-midwife was hired to begin a nurse-midwifery service in 1965. At the present time there are seven nurse-widwives on the staff. Four devote full time to clinical practice and the remaining three combine clinical practice with administrative duties.

The objective of the nurse-midwifery service during the last two years was to ascertain the priority of needs among the women in the Harlem community and to identify what we as nurses and as nurse-midwives could contribute in meeting these needs. Now our entire staff participates in all traditional aspects of maternity care; antepartum, labor and delivery, postpartum and family planning. We also help with many projects that relate to improve- ment of patient care.

Family Planning When the nurse midwifery service began at Harlem Hospital,

it was felt that the greatest gap in maternity care was in the area of family planning. Prior to 1964 there was little family planning service available. At the time of my arrival, the director’s hard- fought efforts in behalf of patients were paying off; policies were being changed, and funds were becoming available for personnel and supplies.

I spent much of my time during the first six months at Harlem talking with all newly-delivered mothers about their desires for family-planning and developing an educational program to reach all interested patients. I discovered that ninety-five percent of patients were interested in receiving family planning assistance. We were able to help with the administrative aspects of setting up the clinics to care for these women. One important aspect was to train the nurses, nursing assistants and clerks who helped in providing this service. In two years the staff has grown from six to twenty-two. Most of the earlier work in administration and teaching has been turned over to fully-trained nurses and clerical personnel, allowing nurse-midwives to function in other aspects of family planning care.

Antepartum Care. Nine months later a second nurse-midwife joined the staff

and an evening antepartal clinic was initiated. This enabled ex- pectant mothers who worked during the day and mothers with

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children who had difficulty finding daytime baby sitters to come to clinic. It was felt that this would reduce the number of skipped visits. Patients were seen initially in a day clinic by a physician and as many routine procedures as possible carried out. Women presenting no major complications were scheduled for their re- visits in the evening clinic if they so desired.

The evening clinic is now staffed with three attending physicians and three nurse-midwives. The Assistant Director attends as con- sultant to all staff. Each patient is seen for revisits by the same person. The case load is divided as equally as possible. The aver- age load is eight to twelve patients in a three-hour clinic session.

Although the time spent with each patient averages fifteen minutes, we are fortunate to see the patient as often as twelve to fifteen times during her pregnancy. By keeping brief notes on a conference record included in the antepartal record, we keep track of many brief counseling sessions and pinpoint major educa- tional, counseling and referral objectives.

The medical management of patients in the clinic is facilitated by management policies given all staff in writing by the Director and some specifically for use by the nurse-midwives in the man- agement of minor problems of pregnancy, such as heart burn, vaginitis and constipation. We liberally use the services of the medical consultant in checking our findings and to discuss the management of deviations from normal. We have found that one visit in four usually requires medical consultation.

At least two nurse-midwives now attend every antepartal clinic session and are responsible for seeing a “fair share” of patients. Nurse-midwives have learned to work with and utilize the services of all other clinic personnel. We have in our clinic a patient educa- tor, a conference nurse, a dietician, two social workers, a labora- tory technician, plus several nurses and nurses’ aides. As you know nurse-midwives and patients often find it very satisfying for the nurse-midwife to do all counseling, but this takes time and it is not always possible in a busy clinic. At the end of each clinic ses- sion we discuss individual patients who attended with other mem- bers of the team who have seen them that day and help plan future care.

We have worked closely with three social workers in caring for our young mothers. All patients sixteen years old or under attend a special clinic and we make every attempt to provide as much counseling and guidance for them as possible. An average

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of twelve teenagers attend these clinic sessions. They meet as a group with the patient educator for discussions at the beginning of clinic visits and then are seen individually by the nurse-mid- wives and the physician if further consultation is necessary. We give special attention to preparing the teenager for labor.

We have been conducting one small volume antenatal clinic. The purpose of this clinic is to serve patients who need extensive counseling and also to serve as a “slower pace clinic” in which nurse-midwifery students can learn antepartal care.

Labor and Delivery. As staff expanded we extended our services into the labor and

delivery area. One nurse-midwife is assigned there daily for at least two out of three eight hour shifts. We work with the resi- dents, caring for patients that are in the unit at the time.

The nurse-midwife and senior resident make joint decisions about which patients “are the most likely candidates’’ for nurse- midwifery management. If there are few patients in labor, the nurse-midwife generally stays with one patient, supports her in labor and conducts the delivery. If there are many patients in labor, the nurse-midwife helps the nursing and resident staffs with the care of all the patients until conditions are such that she can devote her entire attention to one patient. Because of the great number of patients seen by the nurse-midwives in the antepartal clinic, they often see “familiar patients’’ in labor.

Although we work within the framework of standing orders and policies for labor management we work closely with the resident in individualizing care for each patient. At times our most im- portant function is to assist the resident in the care of patients with major complications by providing constant nursing care.

Postpartum Services. At least one of the nurse-midwifery staff is assigned to the post-

partum wards each day and visits all of the patients. We work with the ward resident and nursing st& in the observation and management of minor postpartum problems that often arise. We initiate referrals to the social worker and visiting nurse service.

We have regularly scheduled postpartum classes for the patients and conduct impromptu sessions as often as needed. We are on hand at many newborn feeding times to assist with breast feeding.

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Every patient who returns to the postpartum clinic, four weeks post delivery or abortion, sees a nurse-midwife fist, who talks with her about her family planning desires and intentions. Most of the patients have already attended classes focused on family planning in the antepartal clinic or on the postpartum ward.

One of the nurse-midwifery staff usually helps with the entire postpartum visit for those patients who do not want family planning advice.

The nurse-midwifery staff assists in the counseling and teaching aspects of the family planning service and provides follow-up care in the oral contraceptive clinic. One nurse-midwife who has a major interest in family planning is the overall coordinator for both in-patient and out-patient family planning care. She is an assistant to the Director in administering family planning services. She plans patient and personnel educational programs and co- ordinates the work of several organizations conducting research programs in population control and family planning.

Community Work. One of our many efforts to improve quality and continuity of

patient care has been directed toward preparing young women from the community as labor and delivery technicians. They are now contributing a valuable service to the women in labor. They provide constant observation and support, assist at delivery and provide constant observation during the fourth stage of labor.

We are working with the social service department and the patient educator to expand the antepartal health program into a special educational program that the community provides for pregnant school girls. These girls are not permitted to attend regular schools when pregnancy is discovered and the New York City Board of Education provides them with only minimal oppor- tunity for continued education. We are trying to supplement this minimal program with classes in growth and development, sexual adjustment, care in pregnancy, preparation for labor and delivery plus family life, infant care and family planning information. We also expect our antepartal services will soon be expanding into a new satellite clinic.

Finally the nurse-midwives work closely with the obstetrical nursing supervisor to improve procedures and policies that make for better patient care. As clinical specialists we offer our services to help in every way possible with on-going staff education.

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