1. Martha Carlough MD MPH Narges Farahi, MD Siobahn Wulff, RN, C-EFM
UNC/Chapel Hill
Martha Carlough MD MPH
Narges Farahi, MD
Siobahn Wulff, RN, C-EFM
Intro – Martha, Narges, Siobahn

2. Disclosures
The presenters have nothing to disclose

3. Family Centered Maternity Care at UNC
STRONG clinical faculty (including a midwife and lactation support) with a depth of experience and an integrated MCH service
Gradually increasing # of deliveries from approximately 100 (1994)  450 (2015)
Partnerships with community practices, a CHC network, a local health department and a free standing AABC accredited birth center
Martha

4. A little history… STFM 2005 The Courage to Bleed: Changing the Culture on a Labor and Delivery Unit
Martha
Andrew Hannapel, MD
Valerie King, MD, MPH
Kathryn Trotter, CNM,FNP
Warren Newton, MD, MPH
The University of North Carolina at Chapel Hill
Department of Family Medicine

5. A contentious, albeit true article published in Family Medicine
The “Perfect” Storm
Years of growing tension at UNC/CH around FM, OB and midwives practicing maternity care in a shared space
A contentious, albeit true article published in Family Medicine
A vacuum delivery complication setting off fire works between OB, nursing and FM
Martha
Helton and Nusbaum. A Birth Crisis. Fam Med 2002: 34(6);

6. Mandated movements towards a better environment
Called meeting – Dean, CEO, Chief of Staff and Chairs of OB and FM meet – mandated mediation ($$$)
Interim “rules of play” and directive to establish joint CQI and peer review processes
Commitment to address triangulation between FM, OB and nursing by expectations of direct communication and professional
Principles of negotiation – separate PEOPLE from the problem, insist on objective criteria and evidence that applies to all disciplines, focus on joint interest – healthy moms and babies
Martha
Needed external mediation because of complex and long-standing nature of conflict, power differentials between FM and OB and need for neutral party
What FM learned through this: validation of contribution of nursing to the toxic environment, showed OUR contribution to the problem and the different cultures in FM dept vs. OB department

7. FM/OB Guidelines Began with the Michigan Guidelines *
Started with areas of agreement and progressed to areas of disagreement
Confirmed that each department privileges their own faculty and that the “attending of record” is ultimately responsible
Definitions of consult, co-management and transfer (Level I – III) established
Reviewed and updated annually with key players involved
Also include principles of working on L&D and guidelines for communication - MARTHA
Berman, et.al. Model of Family Medicine and OB GYN Collaboration in Obstetric Care at the U of Michigan. Obs and Gyn (2)

8. Other Outcomes of Mediation
Rapid Review
Multidisciplinary CQI – QWIPIC
“FYI” notice
from FM resident/attending to OB chief/attending on admission of FM patient
FM/nursing:
Post birth “huddle” to debrief routinely
Involvement in collaborative initiatives (low risk birth, introduction of skin to skin, nitrous oxide, continuing education for nurses – ALSO/NRP, nursing conferences)
Commitment to communicate with nurses about new faculty, fellows, midwives from all departments
Narges

9. Evolving…
Increased collaboration with OB and Peds on quality and safety efforts in maternal and newborn care at UNC
NBN Triad and Protocols
Mombaby.org
Development of an (informal) maternal and child health fellowship in collaboration with UNC OB and a new community hospital partner
Narges

10. Interdisciplinary developments…
Integration of perinatal psychiatric services at the Family Medicine Center
Revival of lactation services and home visiting program
Increased involvement, leadership and visibility of the MCH perinatal nurse coordinator within the institution
Siobahn

11. Women’s Birth and Wellness Center
Non-profit birth center with community board, accredited by AABC and backed up by UNC FM
The 2nd largest birth center in the USA
In 2015, 497 births, 72% at the WBWC
6 CNM FTE, 2 FNP’s and 4 LCs
Intrapartum transfer rate DECREASED in last two years, but total births at UNC increased – reflects increasing inductions (AMA, HTN in pregnancy, etc) that are a part of local standard of care
Complex Breastfeeding Clinic
Collaboration with new Birth Center opening with in Asheville/MAHEC in Jan 2016
Need end of year 2015 stats - ??? Too much to say?

12. Commitment to underserved
Piedmont Health Services (CHC) deliveries – and negotiating this….commitment to underserved in NC and importance of FP’s
Integration of newborns from local CHC network into our service as our underserved track continues to develop
Continue to care for prenatal patients from local health department
Narges

13. Obstetric Ultrasound
Implementation of resident and faculty education for limited third trimester ultrasound
Development of expanded procedure credentialing for family physicians at UNC to include ultrasound
Development of inpatient and outpatient clinical services at academic and CHC sites – COMPLEX!
Narges

14. How do we teach and evaluation residents in collaboration?
We are a team – residents, faculty (MDs and CNMs), nurses from all depts – we equally share in Rapid Reviews, QWIPIC involvement
Residents have driven progress in OB US and certification, and are part of our interdisciplinary teams in lactation, perinatal mental health
Milestones - ! Continual feedback/evaluation of our residents (and F3 – they evaluate US!)

15. Lessons Learned and that we are still learning…
Most of the time the system is the problem; people are great to work with
Things sometimes have to get worse before then get better
There are costs for action and inaction – demands constant attention and communication
Backsliding is a danger
Trust is hard to earn, and difficult to give
Narges

16. Resources
Berman DR, Johnson TR, Apgar BS, Schwenk TL. Model of FM and OB/GYN collaboration in Obstetric care at the University of Michigan. Obstetrics & Gynecology, 2000; 96(2):
Helton and Nusbaum. A Birth Crisis. Fam Med 2002: 34(6);
Negotiating at an Uneven Table: Developing the Moral Courage in Resolving Our Conflicts, 2nd edition, Kritek.
Getting to Yes: Negotiating Agreement without Giving In, 2nd edition, Fisher, Ury and Patton.
The Prince, 2nd edition, Machiavelli. Translated by Mansfield.
- Conflict resolution in clinical care

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