1. Columbia St. Mary’s-Milwaukee Women’s Hospital
Sixteenth Street Community Health Center- Karen Lupa, CNM
CSM- Family Medicine Residency Program- Camille Garrison, MD and Paul Koch, MD, MS

2. Disclosures
Nothing to Disclose

3. Stats
Abuts the poorest and most affluent zip codes in Milwaukee County
2700+ deliveries a year
700+ by Sixteenth Street Community Health Center(SSCHC)
150 by CSM Family Health Center (FHC)
200 by family physicians in private practice
1700 by obstetricians
Joan Hintz is pulling stats for all of these to confirm- will have numbers by early February- just spoke with her again 2/3/2016

4. Columbia St. Mary’s Family Medicine Residency Program
Medical College of Wisconsin – Milwaukee
Columbia St. Mary’s Family Health Center
Speaker notes:
Medical College of Wisconsin – Milwaukee Campus (additional campuses in Central Wisconsin and Green Bay)
Pilot Site: Columbia St. Mary’s Family Health Center in Milwaukee, WI​ - meets the clinical needs of the underserved, Family Medicine Residency Program
History of accepting medical ECLs​
Clinical Team consists of  Physicians, Pas, NPs, RNs, and MA’s
Challenge: Recent decrease in faculty preceptors and increase in the number of ECLs​

5. Opportunities for FM residents to learn normal risk obstetrics
Two month required intern rotations focus on uncomplicated laboring patients: > 37 weeks, no TOLAC, cHTN, preeclampsia, GDM, IUGR
Pool of deliveries drawn from private OB’s, FM’s and SSCHC- CNM’s weekdays, FM’s weekends
Option of nurse midwifery elective rotation in 3rd year of residency- curriculum developed
CSM FM Residency Program

6. Opportunities for FM residents to learn high risk obstetrics
3 MCH tracks at residency: no OB, standard OB, advanced OB tracks
No OB track- 2 months inpatient OB, 10
continuity patients at FHC
Standard OB track- 4 months inpatient OB, 15 continuity patients at FHC
Advanced OB track- 6 months in patient OB, 20+ continuity patients at FHC
CSM FM Residency Program

7. Opportunities for FM Maternity Track residents to learn high risk obstetrics
All required to:
function as OB intern on L&D and triage/manage high risk patients
get training in limited OB US
attend FHC MCH clinics(CG, PK)
participate in multidisciplinary monthly OB PCMH rounds on our pts.
teach in OB prenatal group visits
present an OB patient case review for FM peers
present a HROB patient in MFM teaching rounds
Suspended OB group prenatal visits due to lack of attendance- restarting for e) brief EBM-based review on an interesting aspect of one or more of their own prenatal patients- interactive and practical; f) on average once a residency- IDEALLY…
CSM FM Residency Program

8. CSM-FM CNM Rotation CSM FM Residency Program EDUCATIONAL OBJECTIVES:
At the end of this rotation, the resident will be able to:
Contrast the advantages and disadvantages of a non-interventionist approach to pregnancy, labor and delivery, and postpartum.
Define continuous labor support and list its primary components.
Explain the use of complementary labor support techniques, i.e. birthing ball, non-traditional delivery positions, sterile water papules, 3rd trimester home perinatal massage, etc.
Discuss the nurse midwife’s scope of practice, how it differs from a family physician’s; and how nurse midwives practice in a collaborative relationship with the physician obstetrics provider and consultant.
List 4 examples of how he/she will change his/her perinatal education approach and content after working with the certified nurse midwives.
CSM FM Residency Program

9. Sixteenth Street Community Health Center
Three clinics in Southside Milwaukee.
Waukesha clinic opened 2012.

10. Brief history of OB practice
Year
1990
1993
2003
2012
2015
Births
337
328
695
761
702
OB-GYN 2
CNM 1 6 9 FM 4 8
Shows how we manage without OB
Sixteenth Street Community Health Center

11. Outcomes Karen will emphasize excellent outcomes
Year
1991
2001
2007
2012
2015
births
286
609
846
761
702
C/S rate
 10%
13%
15%
LBW
 3%
 4% 5%
PTD
 5% 7% 6%
Karen will emphasize excellent outcomes
Sixteenth Street Community Health Center

12. TOLACs and VBACs
The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates Melissa G. Rosenstein, MD, MAS, Malini Nijagal, MD, Sanae Nakagawa, MS, Steven E. Gregorich, PhD, and Miriam Kuppermann, PhD, MPH VOL. 126, NO. 4, OCTOBER 2015 OBSTETRICS & GYNECOLOGY
Sixteenth Street Community Health Center

13. TOLACs and VBACs, continued
Year
2011
2012
2013
2014
2015
VBAC rate
37%
42%
49%
33%
Success
TOLAC
82%
80%
85%
86%
76%
Karen- from what I understood at recent meeting- of those who try TOLAC at SSCHC- 80% success rate- very high!
Sixteenth Street Community Health Center

14. Scheduling
Sunday 1730-Friday 1730: CNM in house H and Ps, triage Medical student or FM/OB resident attend some births Friday 1730-Sunday 1730: Family Medicine on call House staff does H and Ps, triage, most births
Sixteenth Street Community Health Center

15. Uncomplicated pregnancy, labor and delivery
CNM or FP manages No OB participation except “watching the board”
Sixteenth Street Community Health Centers

16. Patients with complications
Consultation by phone, chart review or clinic evaluation during pregnancy Labor and delivery: consultation or co-management CNM or FP follow all patients postpartum Transfer of care for high risk pregnancies (e.g. twins, incompetent cervix, pre-existing diabetes)
Sixteenth Street Community Health Center

17. Main points
CNMs and FPs are the guardians of normal childbirth: freedom of movement in labor, avoidance of unnecessary interventions, breastfeeding Collaborative practice uses the best skills of all!
Sixteenth Street Community Health Center

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