CLINICAL UPDATE

MEDICALLY COMPLEX PREGNANCY: A CASE REPORTILLUSTRATING CNM/MD COLLABORATIVE MANAGEMENT

Molly Gray, RN, MS and Lisa D’Amato,CNM, BSN

ABSTRACT

In contemporary society, many women with complex medicalconditions are attempting fertility and becoming pregnant. Thepatient presents with an impressive medical complication, yetmany of her key educational and psychosocial needs are typicalof those for any pregnant woman. Striving for “normalcy,” shemay actively seek midwifery care to help her create a family-centered birth experience. Indeed, the midwife practicing withphysician colleagues may have the opportunity to collabora-tively manage increasingly complex cases. This article de-scribes the case of collaborative management during pregnancyand delivery of a patient with the cardiac syndrome Wolff-Parkinson White syndrome (WPW). First diagnosed withWPW at the age of 13, the patient’s condition was initiallycontrolled with oral medication. Eventually, the patient’ssymptomology worsened and required repeated treatment bycardiac ablation of the accessory pathway. Illustrative of thepossibilities for enhanced care of the medically complexpregnant patient via collaborative management, the discussiondetails not only the pertinent physiologic events but the benefitsand process of care. A review of the cardiophysiology of WPWis also presented. J Midwifery Womens Health 2000;45:552–7 © 2000 by the American College of Nurse-Midwives.

INTRODUCTION

In the contemporary practice environment of highlyadvanced medical technologies, many women with com-plex medical conditions, including cardiac syndromes,are attempting fertility and becoming pregnant. Thepatient presents with an impressive medical complica-tion, yet many of her fundamental educational andpsychosocial needs are typical of those for any pregnantwoman. Striving for “normalcy,” she may actively seekthe unique services of a midwife to help her create andmeet expectations for a family-centered birth experience.Indeed, the midwife practicing with physician colleaguesmay collaboratively manage increasingly complex cases,in part because women are now surviving to childbearingage those conditions that may have terminated their livesearlier in a previous era.

A 32-year-old primigravida with Wolff-Parkinson-White Syndrome (WPW) was effectively comanaged by

a certified nurse-midwife (CNM), an obstetrician, acardiologist, and an anesthesiologist during her preg-nancy and delivery. After a review of the cardiophysiol-ogy of WPW and discussion of the patient’s case history,this article highlights the benefits and process of collab-orative management for medically complex pregnantpatients.

WOLFF-PARKINSON-WHITE SYNDROME

WPW is one of the cardiac preexcitation syndromes and,as such, characteristically involves activation of a cardiacchamber by anaccessorypathway. In WPW, an impulsetraveling over the accessory pathway stimulates theventricle earlier than a nearly simultaneous impulseproceeding over the normal atrioventricular (AV) node-Purkinje pathway conduction system. Because this ac-cessory pathway lacks the decremental properties of thenormal pathway, it allows transmission of an excessivelyhigh rate of atrial impulses to the ventricles, creating thepotential for ventricular fibrillation (1). A similar atrialevent may also occur when the accessory pathway causesthe impulse to return to the atrium. The incidence ofatrial tachycardias and/or fibrillation is substantially in-creased by this atrioventricular reentry event. It should benoted that, overall, the most common arrhythmias areatrial and are generally in the form of supraventriculartachycardia.

The dual activation of the ventricles via both theaccessory pathway and the usual AV node pathwaycauses results in an archetypal electrocardiographic pat-tern. The classic WPW electrocardiograph reveals a shortPR interval of 0.11 seconds or less, a QRS complexwidth of 0.12 seconds or more, and displaysd waves.The d wave reflects the early activation of the ventricleby the impulse traveling through an accessory pathway,creating a slurring or notching of the upstroke of the QRScomplex. Recall that the P wave on a normal electrocar-diogram occurs at the beginning of each contraction ofthe atria; the QRS wave occurs at the beginning of theventricles.

The history of scientific understanding of WPW spansmany decades. Although both Cohn in 1913 and Wilsonin 1915 (1) described a phenomenon they termed “cir-

Address correspondence to Molly Gray,RN, MS, Wesson Women andInfants’ Unit, Baystate Medical Center, Springfield, MA 01199.

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© 2000 by the American College of Nurse-Midwives 1526-9523/00/$20.00• PII S1526-9523(00)00080-5Issued by Elsevier Science Inc.

culating excitation,” the specific electrocardiographicpattern of WPW was not reported until the concept of theelectrophysiologic bypass tract was proposed by Holtz-mann and Scherf in 1932 (1). In 1967, Durrer and Roosadvanced the Holtzmann and Scherf work and actuallyshowed that in WPW atrioventricular conduction indeedoccurs over an accessory pathway or bypass tract. Theiridentification of an accessory tract for conduction led theway to development of a surgical approach to ablate theaccessory pathway. The early 1980s gave rise to thedevelopment of cardiac catheter ablation using directcurrent to halt accessory pathway conduction; this wasrefined in the 1990s with the use of radiofrequencyenergy in conventional surgical cautery. Derived fromlow-power, high-frequency alternating current, radiofre-quency energy permits precise effects by varying theoutput mode, frequency, wave form, and power output.Today, the use of radiofrequency energy for catheterablation has become the safest and most effective tech-nique, resulting in a success rate of 80–90% (1).

In the clinical scenario typical of WPW, the chiefcomplaints of dizziness, syncope, and irregular heartrates bring individuals in early adulthood into the medi-cal milieu for evaluation that leads to the identification ofWPW as the diagnosis. It is estimated that 7.5 millionpeople are diagnosed with WPW, with a reported overallprevalence in the general population of 0.15% (2). Thereis a higher incidence reported in patients who havecongenital cardiac anomalies. Ebstein’s anomaly, a mal-position of the tricuspid valve that displaces the posteriorand septal leaflets downward and attaches the ventricularwall below the annulus, is the congenital anomaly mostcommonly associated with WPW. Other anomalies associ-ated with WPW include mitral valve prolapse, ventricularseptal defects, and transposition of the great vessels (3).

The inheritance pattern for WPW is autosomal domi-nant. Paradoxically, first-degree relatives of persons withWPW exhibit a low incidence (less than 1%) of actualpreexcitation disorders. First-degree relatives of patientswith multiple pathway tracts versus a single pathwaytract exhibit a slightly greater prevalence of preexcitationdisorders, with an incidence estimated to be 1.69% (3).

The overall mortality rate for patients with WPW islow, although it is possible for patients to experienceventricular fibrillation that may lead to sudden death. The

actual incidence of ventricular fibrillation with resultingdeath is rare, with an estimated frequency of less than0.1% (4).

TREATMENT MODALITIES

Treatment options for patients with WPW vary widely,depending on the individual’s clinical pattern. Somepatients do well with simple clinical observation and theoccasional use of self-employed techniques to increasethe parasympathetic influence over cardiac activity dur-ing episodes of tachycardia. Cardiac catheter ablation hasbecome the treatment of choice because of its safety andefficacy in 80–90% of cases. WPW patients experiencingan abrupt onset of symptomatic tachycardic arrhythmiaoften respond well to prompt performance of maneuversdesigned to increase parasympathetic nervous systemactivation on the heart. Examples of these maneuversinclude unilateral carotid massage and Valsalva maneu-vers. If the vagal stimulation fails to terminate thesupraventricular tachycardia, drug therapy or cardiover-sion may be used.

The objectives of drug therapy for WPW are toprolong conduction time and/or the refractory period inthe AV node, accessory pathway, or both and, thus,prevent rapid conduction rates. The primary drugs ofchoice are adenosine, which prolongs the refractoryperiod of the AV node, and procainamide, which length-ens the refractory period of the accessory pathway (5).Amiodarone, a drug that depresses cardiac impulses andincreases the relative refractory period in both the AVnode and accessory pathways, is also often effective.

There are some antiarrhythmic medications that arenot recommended for use in patients with WPW. Digi-talis use for the treatment of WPW patients experiencingatrial fibrillation has been reported to shorten instead oflengthen the refractory period in the accessory pathway,leading to an increase in the ventricular response. For thisreason, it is not advisable to use digitalis as a single agentin patients with WPW. Another medication, oral Vera-pamil, has been shown to be a useful antiarrhythmicagent in WPW. It is of interest that intravenouslyadministered Verapamil tends to speed the ventricularrate, making it a poor choice of medication for WPWpatients.

For specific clinical cases in which drug therapy hasbeen ineffective, a useful treatment choice is ablation ofthe bypass tract. After surgical or cardiac catheter abla-tion of the accessory bypass tract, the abnormal conduc-tion of impulses is effectively interrupted. Cardiac cath-eter ablation is safer, more cost-effective, and assuccessful as surgical intervention for more than 90% ofpatients today. With the development of sophisticatedtechniques for radiofrequency cardiac catheter ablation,

Molly Gray is manager of Wesson Women and Infants’ Service,Baystate Medical Center, Springfield, Massachusetts. She is a ClinicalAssistant Professor, Yale University School of Nursing, and ClinicalAssistant Professor, University of Massachusetts Amherst School ofNursing.

Lisa D’Amato is employed by Baystate Health System in Springfield,Massachusetts. She is a candidate for a Master in Public Health Degreewith a concentration in Biostatistics and Epidemiology from theUniversity of Massachusetts, Amherst.

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cardiac surgery has been virtually eliminated as a treat-ment for WPW.

WPW AND PREGNANCY

It has been suggested in the literature that pregnancy maypredispose previously asymptomatic patients with WPWtoward exhibiting supraventricular tachycardia. An im-portant prospective study was conducted by Kounis andcolleagues (6), observing six women between the ages of18 and 33 years with WPW, all of whom were asymp-tomatic or nearly asymptomatic, having experienced zeroto one episode of supraventricular tachycardia beforepregnancy. The investigators studied the cardiac status ofthese women during and after their pregnancies. Su-praventricular tachycardias, reported by the patients aspalpitations, ranged from three to seven episodes duringeach pregnancy. The episodes of supraventricular tachy-cardias occurred most frequently between 20 and 35weeks’ gestation, with a mean of 30 weeks’ gestation. Toaccount for the higher incidence of supraventriculartachycardias during pregnancy, Kounis and colleaguesproposed three theories of explanation. First, as part ofthe normal physiology of pregnancy, there is a fluidvolume peak during the 30th week of gestation, increas-ing diastolic volume and therefore increasing the averageheart rate. This accelerated heart rate may act on therefractory period and conduction velocity, triggering anatrioventricular tachycardia. Second, stress, anxiety, andfear of fetal jeopardy might activate the sympatheticnervous system through the pituitary adrenal axis, result-ing in hyperstimulation of the cardiac system. Third,estrogen is known to modulate adrenergic receptors inseveral organs and hormonal change has been postulatedto cause an increase in adrenergic sensitivity of cardiactissue. Three plausible explanations were proposed andalthough the specific causative factors are not yet clear,the symptomology of WPW did change significantlyduring pregnancy for the patients in the study (6).

CASE REPORT

The patient was first diagnosed with WPW at the age of13 years when she was admitted for hospitalizationthrough the emergency department for a complaint ofrapid heart rate and chest pain. The patient reported shehad experienced previous episodes of rapid heart ratethat, unlike this episode, resolved after she rested proneon her abdomen or held her breath. During this hospital-ization, she was observed to have an irregular heart rateaveraging 190–200 beats per minute. Supraventriculartachycardia was assumed to be the cause of the rapidventricular rate. It was during this hospitalization that thediagnosis of WPW was made.

At the age of 19 years, 6 years after the initial

diagnosis, the patient again presented to the emergencydepartment with a rapid ventricular rate. Despite carotidmassage, use of the Valsalva maneuver, and intravenousadministration of Inderal, the supraventricular tachycar-dia continued. To correct the persistent tachycardia, acardioversion was planned; however, just before theprocedure, the heart rate spontaneously converted to anormal sinus rhythm. The patient was admitted andfollowed on the cardiac telemetry unit overnight. Thenext day, she was discharged on oral medications to treatsupraventricular tachycardia.

The patient was again admitted to the hospital at age25 years, when she became more symptomatic, com-plaining of palpitations and demonstrating a heart rate of220 beats per minute. Her cardiologist treated her aggres-sively during this admission by using the technique ofradiofrequency ablation to eliminate a right posteroseptalaccessory pathway. The procedure was successful, andthe patient was discharged without antiarrhythmic drugtherapy.

Two years later, the patient’s course worsened againwhen she developed wide- and narrow-complex su-praventricular tachycardia consistent with a Mahaimfiber accessory pathway. Her cardiologist planned anattempt at treatment with cardiac catheter ablation of therecurrent accessory pathway. After 15 unsuccessful at-tempts at ablation, the decision was made to manage hercondition pharmacologically. She was discharged homein good control on Flecainide and Inderal drug therapyand observed clinically by her cardiologist.

Well maintained on oral medication for the next 2years, the patient once again presented with symptomaticsupraventricular tachycardia at age 29 years. During thisepisode, the radiofrequency cardiac catheter ablation ofthe Mahaim fiber accessory pathway was successfullyperformed. The initial discharge plan for the patientincluded continuance of the oral antiarrhythmics. Afterbeing symptom-free for 1 year, all medications werediscontinued and the patient was observed clinically.

One year after the third series of radiofrequencycardiac catheter ablations, the patient presented at themidwifery office for obstetric (OB) care, approximately 7weeks pregnant. Her initial OB history and physicalexamination were unremarkable for a nulliparous patient,revealing an 8-week size uterus, and all laboratoryanalyses revealed normal values. The diagnosis of WPWwas well understood by the patient, and she deniedexperiencing any recent symptoms of dyspnea, syncope,or rapid heart rate. Desiring a midwife-attended birth, thepatient and providers jointly developed a plan for her tobe followed during pregnancy by the CNM, obstetrician,and cardiologist working in concert. The additionalanesthesiology team member, whose input would benecessary at the time of delivery, was added later in thepregnancy.

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The formal cardiology consult, conducted at 16 weeks’gestation, found the patient to have a stable bloodpressure and to be without any arrhythmias. At this time,the recommendation made by the cardiologist was tocontinue without cardiac medications unless the patientbegan to experience symptoms including shortness ofbreath or chest pain.

A 20-week ultrasound and fetal echocardiogram revealednormal fetal anatomy. A routine, 28-week, 1-hour glucosetest was elevated at 146 mg/dL. A subsequent 3-hourglucose tolerance test was ordered, and the result was againslightly elevated. The patient was seen by the nutritionist,placed on a 2,200-calorie diet, and given instructions forglucometer monitoring. Well controlled by diet alone, thepatient’s blood glucose levels were within normal limits forthe remainder of her pregnancy, and a hemoglobin A1Crevealed good euglycemic control.

Throughout the third trimester, all nonstress tests werereactive, and fetal movement was appropriate. An ultra-sound at 37 weeks revealed a fetal weight of 3,166 g,correlating favorably with a 37-week mean of 2,890 g.

At 41-3/7 weeks’ gestation, the decision was made toadmit the patient for induction of labor under the care ofthe CNM. Overnight application of prostaglandin gel wasused for cervical ripening, followed by intravenousoxytocin. After 6 hours of continuous oxytocin infusion,the patient progressed to active labor with strong con-tractions every 2–4 minutes and 50–60 seconds induration. At this point, the patient’s pelvic examinationrevealed her to be 4 cm dilated, with 100% effacement,and with a vertex presentation at 0 station. One hourlater, the patient requested epidural anesthesia for painmanagement. Before ordering the epidural, the CNMreexamined the patient and found her to have progressedrapidly to 8 cm dilation. After discussion with hernurse-midwife, the patient opted not to have the epiduralanesthesia; she chose to ambulate and within 15 minutes,her cervix was fully dilated.

At 2 hours into the second stage, the CNM consultedwith the obstetrician partner, noting that the fetal hearttrace was reassuring, the patient’s voluntary pushingefforts were strong, and the presenting part descended to12 station. Considering these details, the midwife andobstetrician made a collaborative decision for the patientto continue pushing and not to rush to instrumenteddelivery. Forty minutes after the consultation the patientdelivered an infant girl by normal assisted vaginaldelivery attended by the CNM. The infant’s Apgar scoreswere 8 at 1 minute and 9 at 5 minutes; her birth weightwas 3,744 g.

Special preparations made for laboring the WPWpatient resulted from a brief consultation with both theperinatology– and anesthesia-attending physicians. As aresult of this consultation, adenosine was kept availablein the labor and delivery area in case it would be needed

for conversion of a supraventricular tachycardia. At therequest of the anesthesiology attending, an electrocardio-gram was completed just before the beginning of thesecond stage of labor. The study revealed normal sinusrhythm without ectopy. Throughout labor and deliveryand during the postpartum period, the patient was closelymonitored. She remained free of shortness of breath anddid not experience chest pain.

PROCESS AND CHARACTERISTICS OFCOLLABORATIVE MANAGEMENT

The comanagement of care through the collaborative modelis inherently valuable and potentially maximally effective.As described by Keleher in 1998 (7), the collaborativemodel relies on the smooth integration of team members sothat members canwork together to accomplish a taskneither could accomplish alone.The concept of collabora-tion is so significant that it has become the basis forcontinuous, systematic, and organizational improvement inquality and patient care outcomes.

Concepts of collaborative management comprise asystem that provides for consultation, collaborative man-agement, or referral as indicated by the health status ofthe patient. As the medical complexity of obstetricpatients increases along with advancing technologies andscience, midwives find themselves more often providingcare to a high-risk population that is simultaneously inneed of typical pregnancy support. The patient presentswith an impressive medical complication, yet many ofher fundamental educational and psychosocial needs arethose of any pregnant woman. She may actively seek theunique services of a midwife to help her create and meetexpectations for a family-centered birth experience. Co-management of care, through the formal process ofcollaboration, provides the very mechanism of deliveryfor comprehensive care to this medically complex pop-ulation. With consultation from the interdisciplinaryteam, the midwife retains the primary management of thepatient’s normal pregnancy, seeking the advice or opin-ion of the obstetrician or other specialist as indicated forher medical condition. The goals of excellent patientoutcomes and patient satisfaction are readily achievableby drawing on the complementary skills of the interdis-ciplinary team.

The collaborative model involves two levels of behav-ior: those reflected in the individual’s skill sets and thoseshown by the team as the whole. Least familiar is thelatter set of behaviors and thus perhaps the most chal-lenging for the team. Old issues of hierarchical relation-ships and competition between providers may arise asbarriers to collaboration. Collaborative management ofcare requires the team to exhibit several defining fea-tures. These features and behaviors include clear com-munication, true dialogue, active listening, awareness

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and appreciation for differences, and an ability to nego-tiate options, despite distinctly different educationalpreparations and backgrounds. Related individual behav-iors central to overcoming traditional barriers and toestablishing collegial relationships among providers in-clude accountability, competency, risk taking, and asser-tiveness. To be effective, collaborative partners requirethe sophistication necessary to clarify role expectationsand manage open communication and professionaltrust—all challenging and essential to ensuring patient-focused collaboration.

Team values, notably mutual trust and respect, andshared goals and vision, are key elements betweencollaborating midwives and physicians. It may be newterritory for the providers to share power or express anappreciation for each other’s perspective and ways ofapproaching problems, but these potential barriers mustbe faced and overcome. Stapleton (8) identifies relianceon the key elements of team-building as the path towardcollaborative practice. Effectiveness as a collaborativeteam is enhanced by familiarity with each other’s scopeof practice, role definitions, and practice styles. Thepatient benefits most from a team that presents a unifiedfront and that does not show conflicting values or sendmixed messages. With these skills and behaviors mas-tered, the provider partners on the team can make the bestuse of their individual skill sets as they each contribute tocomprehensive patient care.

Once the collaborative team is established, a clearprocess must be developed for the comanagement ofcare. It is essential to identify the team leader who willoversee the patient’s progress and the communicationwithin the group. Logistics and communication modelsneed to be clarified, especially plans and mechanisms forconsultation or referral. The patient care plan mustspecifically outline details such as how often consults arearranged, what clinical red flags might be anticipated,and which other consults may be pursued. Depending onthe medical complication, the team may decide to plan acase review at specific gestational intervals or othermilestones.

Less obvious benefits (beyond the clinical advantages)to the collaborative management of medically complexpatients include enhanced provider and family satisfac-tion. It is likely that the collaborative approach results inmore efficient use of time, better solutions to problems,and improved working relationships. Able to blend theclinical input from each medical specialty with theadditional set of midwifery skills, the midwife is able tonormalize the pregnancy and birth experience for thepatient. Patient satisfaction is thus enhanced by theimproved continuity of care and recognition of thechildbearing family’s basic pregnancy needs amidst theexperience of medical complexity.

The case report presented herein is an example of the

concepts of collaborative management applied to a med-ically complex case involving a cardiac syndrome.Throughout her pregnancy the patient described was seenby both the CNM and obstetrician. Although her birthplan included a desire for a midwife-attended birth, thepatient understood the gravity of her medical condition.She knew her cardiac status necessitated the collabora-tion of the attending obstetrician, cardiologist, and anes-thesiologist along with the midwife. Visits were sched-uled such that the CNM saw the patient for one visit andthe obstetrician alternately for the next. The comprehen-sive course of prenatal care included input from otherdisciplines, notably the cardiologist and nutritionist.Managed during intrapartum by the midwife with con-sultation from the obstetrician and anesthesiologist, thepatient delivered vaginally. The patient voiced satisfac-tion overall and experienced no complications during herhospitalization.

IMPLICATIONS FOR CLINICAL PRACTICE

Collaborative management of the pregnant patient with aprofound medical complication benefits both recipientand providers. The care provided is comprehensive andaddresses both the complicated and the ordinary detailsof pregnancy, delivery, and transition to parenthood. Anunexpected outcome of the collaborative management isincreased efficiency and satisfaction for the providersinvolved in the partnership. Furthermore, the expertiserequired of the midwife is both clinical (specific to themedical complication) and managerial (specific to thecollegial relationship and communication skills requiredfor success in the collaboration).

A solid knowledge base of pathophysiology, currentmedical interventions, and drug therapies (including fetaleffects) for a specific complication supports every care-giver’s ability to provide appropriate care. An ability tointerpret the medical scenarios and language, the mid-wife normalizes the otherwise complex experience forthe patient. The collaborative management team needs avery detailed plan specific to the particular patient anddiagnosis, noting such items as who reads the electrocar-diograms, who monitors medications, and how often toconduct a case conference. The midwife may be thepartner who takes the lead role in establishing thecommunication and consultation process. Objectiveswithin the plan of care arise from predicted milestones oranticipated stressors during the gestation, intrapartum,and postpartum periods. Taking on the leadership for theteam and family, the midwife should promote the normalaspects of pregnancy within the larger framework of amedical complication.

Specific to the patient with WPW, the midwife is ableto make a unique and important contribution to the careespecially through patient education and support. Key

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educational components during prenatal care of thepatient with WPW include teaching the patient how,when, and why to monitor her heart rate and rhythm. Thepatient and her family need information to enable them tounderstand the potential effects of arrhythmias and inter-ventions such as when and how to perform a therapeuticValsava maneuver. The midwife must develop with thepatient and her family an action plan for intervention ifall the usual maneuvers fail during a tachycardic episode,including a plan for quick access to a hospital.

Families need genetic counseling regarding the auto-somal dominance of WPW (and the relatively lowexpression of WPW despite this pattern of transmission)and the high association of fetal cardiac anomalies inpregnancies of women with WPW. An important area foradditional research is the advisability of a fetal echocar-diogram at 20–22 weeks’ gestation to rule out cardiacanomaly in the fetus because this is not yet supported bythe literature.

The midwife must be able to use good listening skillsand provide important feedback to the patient withWPW. When the patient reviews her past experiencewith WPW, the midwife can assist the patient in identi-fying potential triggers to her symptoms, such as physicalexertion, stress, or caffeine. Together, they may identifythe techniques that are most useful to the patient incurtailing symptoms, according to the patient’s ownpattern and experience. In light of the relationship be-tween stress and increased supraventricular tachycardia,as proposed by Kounis and colleagues (6), a desiredbenefit of this communication between patient and mid-wife may be a reduction of the level of stress for thepatient.

CONCLUSIONS

As an aftermath of today’s advanced medical technology,many women with complex medical conditions, includ-ing cardiac syndromes, are attempting fertility and in-

deed becoming pregnant. Thus, the CNM and certifiedmidwife (CM) who are increasingly practicing collabo-ratively with physician colleagues may be comanagingmedically complex cases. The outcome of a challengingclinical case, such as that demonstrated by the WPW casereport, is enhanced via the collaborative managementapproach, with each discipline making a unique contri-bution to the course of events. Imperative to the successof the process, however, are shared team values andgoals, a strong working relationship, and thorough com-munication between all involved disciplines.

Once pregnant, a patient with a complex medicaldiagnosis still looks forward to the usual and ordinaryaspects of her pregnancy and parenthood. Promotion ofthe normal aspects of pregnancy within the context of themedical condition is the task of the collaborative man-agement team. The CNM/CM is able to validate thepatient’s perception of anxiety or uncertainty about hercondition and normalize the experience while providingher with the tools necessary for the best management ofher own care.

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4. Braundwald E. Heart disease: a textbook of cardiovascular medicine.5th ed. New York: WB Saunders Co. 1997;667–75.

5. Stoelting RS. Anesthesia and co-existing disease. 3rd ed. New York:Churchill Livingstone Inc., 1993.

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