CNMs/CMs as primary care providers: scope of practice issues.

Since the proliferation of managed care organizations and the expansion of the central role of the primary care provider in the early 1990s, certified nurse-midwives and certified midwives have debated the merits and drawbacks of their inclusion in this category of provider. The present article explores the history of primary care and reviews the most commonly accepted definition of primary care. The boundaries of scope of practice in primary care and the legal and economic ramifications of certified nurse-midwives/certified midwives practice in this area are discussed.

Care of the at-risk neonate born at home. A model for nurse-midwife/physician collaboration.

Because certified nurse-midwives (CNMs) who practice in the home lack the structure and boundaries provided in an institution, they must provide the elements of a safe environment for their practice, both physical and intangible. The relationship between the CNM who practices in the home and the physician(s) with whom s/he collaborates when women or neonates experience complications beyond the scope of nurse-midwifery practice is a critical element of this structure. This paper describes models for collaborative care for home birth, outlines the process of developing a collaborative practice agreement, and discusses specific factors to consider when forming a relationship. The care of the compromised home-birth neonate is developed as a model for collaborative practice. The paper discusses identification of the home-birth neonate requiring collaborative care, the preparation for potential newborn complications, and the initiation of emergency measures to be taken by the CNM when such a complication occurs.

Estimates of net photosynthetic parameters for twelve tree species in mature forests of the southern Appalachians.

Leaf gas exchange, temperature, and incident radiation were measured in situ for 20 mature trees of 12 deciduous species spanning a range of heights from 7.9 to 30.1 m and growing in the southern Appalachian Mountains. Air temperature, water vapor pressure, total radiation, photosynthetically active radiation, and carbon dioxide concentration were also measured. Estimated mean, light-saturated net assimilation rates ( micro mol m(-2) s(-1)) were: Quercus coccinea Muenchh. (10.3), Q. prinus L. (9.9), Q. rubra L. (8.9), Betula lenta L. (8.1), Liriodendron tulipifera L. (7.9), Q. alba L. (7.6), Carya glabra Mill. (7.2), Acer rubrum L. (5.6), Nyssa sylvatica Marsh. (3.9), Cornus florida L. (3.5), and Acer pensylvanicum L. (1.7). There were significant differences in both net assimilation rates and quantum yield efficiencies between species, with the understory species C. florida and A. pensylvanicum exhibiting lower net assimilation rates at saturation and higher estimated quantum yield efficiencies than the other species. Average temperature and light decreased from the canopy top to bottom, whereas ambient CO(2) concentration increased, and vapor pressure and vapor pressure deficits were inconsistent. We observed curvilinear effects of temperature and vapor pressure deficit on net assimilation response to light, and these effects varied by species. Errors in predicted net assimilation ranged from 1 to 3 micro mol m(-2) s(-1) under the environmental conditions prevailing during the study.