May 26, 2004
Volume 6, Issue 11
Midwifery Today E-News
“Protocols for Midwifery Practice”
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In This Week’s Issue:

Quote of the Week

"The deadening of the sensory awareness of the body that occurs with the administration of regional anesthesia for birth not only threatens the memory of how to birth, but the part of the heart's energy that tells us we have the capacity to give birth."

Judy Luce

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The Art of Midwifery

I saw an interesting suturing technique done by an OB for a pocket tear. She took a long 3-0 vicryl, rapide and entered from the outside top of the tear on one side, made a half circle bite going down, on the same side coming out into the center of the tear about half the depth, then made another half circle bite entering on the same side and exiting on the opposite side on the bottom of the tear then reversed on that side up to the top. It was like two inverted S's on both walls of tear then she pulled it all together and it held really well with no puckering. She said she made this up on her own. I haven't had a chance to use it, though.

April, Midwifery Today Forums

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to

News Flashes

One hundred and twenty women scheduled for gynecological surgery participated in a randomized, double-blind clinical trial. The women received one gram of dried ginger root powder as a postoperative prophylactic. The study found the ginger treatment to be as effective as a standard dose of metoclopramide, a medication administered for postoperative nausea. The ginger root powder did not result in any apparent side effects.

Mills, Simon and Kerry Bone (2000). Principles and Practices of Phytotherapy. London: Churchill Livingstone.

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Protocols for Midwifery Practice

It is your responsibility to keep your midwifery knowledge current and to revisit your protocols annually to ensure they are up-to-date.

Three ways to format protocols

  1. SOAP charting (subjective, objective, assessment, plan), which begins with a definition of a condition. Here are the steps:
    1. Define the condition
    2. Subjective: List signs and symptoms.
    3. Objective: List findings to back up your suspicions (e.g., lab values, pallor, tachycardia)
    4. Assessment: What the findings lead you to believe is the problem.
    5. Plan: What are you going to do about the client's condition? You may want to consider actions for mild, moderate, or severe forms of the condition. Consider also factors such as number of gestational weeks. State everything you are comfortable suggesting or doing.
  2. Four-component formatting
    1. Diagnosis: How did you come to the conclusion that the client has the condition? Lay out subjective and objective data in a format that is simple enough that an apprentice could use it as a checklist before presenting her suspicions to a senior midwife.
    2. Risk factor: List all risk factors that would apply to the condition (e.g., postpartum hemorrhage, elevated blood pressure).
    3. Management: What actions will you take in regard to the woman's condition?
    4. Follow-up care: Are you going to reevaluate the client? When and how are you going to reassess? Does she remain high risk, and if so, what will be your plan of care?
  3. Format a simple plan of action: Review history, list actions and follow-up.
Referencing your protocols

Referencing protocols helps apprentices learn about courses of action. It also provides information should you need to defend yourself in court or in peer review.

  1. Search for information
  2. Record the name of the publication, author, edition number, page numbers.
  3. References can be kept in a bibliography in the back of your protocol manual.

Excerpted from "Ideas on Writing Protocols for Your Practice," by Paulette Griffin, CPM, RN, Midwifery Today, Issue 69, Spring 2004

Ideally, midwives should have very loosely written protocols. This requires each midwife to be very clear with herself regarding her limits and capabilities. It also requires readily available consultation and good communication to help form a plan of action for dealing with situations outside the midwife's realm of expertise. In my situation, where I practice in the same office with my employer and backup physician, I can consult the physician informally on a moment's notice and keep him informed of any developments or signs of impending problems. I do not feel this collaborative arrangement interferes with my ability to practice good midwifery (as differentiated from medical) care and, in fact, even enhances it by building the physician's trust in my judgment and abilities. This leads to overall optimal care for my clients.

Barbara Kaye, CNM, 1990

Expanding our thinking refreshes, redefines, and refines protocols. Anthropologist Robbie Davis-Floyd suggests the following ways to remain open to new information:

  1. Attend midwifery conferences. When a midwife goes away to a conference, she is free from the daily pressures of her practice to take in new information. She is exposed to ways of thinking, knowing, and practicing that may not match her own. Every midwifery conference I have ever attended has offered its participants many ways to think beyond established paradigms and practices.
  2. Learn from women. Midwives who practice the same way for many years are usually midwives who have stopped listening to mothers. Every woman a midwife attends can bring something new to her knowledge and practice. I have often been struck by the changes in practice that can result from listening carefully to and learning from just one woman, who perhaps is unusual but can teach the midwife something new about how best to provide woman-centered care.
  3. Learn from midwives. When midwives get together, they share important aspects of what they learn and how they learn it and of what they know and how they use that knowledge, whether it is didactically obtained or intuited in the moment. Midwives tend to tell stories of normal birth or of how they helped a birth that could have become pathological stay normal.
  4. Pay attention to the scientific evidence. The body of scientific evidence supporting many traditional and professional midwifery practices is ever-growing. Real science differs fundamentally from biomedical tradition. Every midwife should have science at her command - all references ready to counteract every biomedical objection to the kind of care she wishes to give.
  5. Pay attention to other healing philosophies and modalities. It is not possible for every midwife to know all systems, but it is possible to be open to what they can offer by learning about them, incorporating one or some of them, and finding practitioners to whom clients can be referred.

Excerpted from "Ways of Knowing: Open and Closed Systems," by Robbie Davis-Floyd, Midwifery Today, Issue 69, Spring 2004

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Forum Talk

I am interested in finding out how midwives balance their knowledge and use of the "natural" childbirth movement with "medically-managed" births. How does a midwife's personal perspective on childbirth play out in their practices? Essentially I want to find out what pregnancy and birth means to them. I would like to see how medical expansion has impacted the role of the midwives (if they have practiced for a while and have noticed this) over time and how they have accepted, rejected, or have compromised with the medical management of birthing processes.


Go to our forums to share your thoughts and experience.

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Question of the Week

Q: I am undergoing in-vitro fertilization (IVF) and wonder if midwives have noticed any special characteristics with the IVF mother/baby population, and also if they have insights about how to care for moms in this population.

— Leslie K.

SEND YOUR RESPONSE to with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.

Question of the Week Responses

Q: My wife had a successful home waterbirth two years ago. However, two months later it was discovered she still had some placental tissue left behind in her uterus. An Ob/Gyn performed a D&C and ended up perforating the fundus of her uterus. Due to internal bleeding afterward he went in to stitch things up.

Afterward, he told us:

  1. Wait two years before becoming pregnant again (I can agree with that comment).
  2. You will have to have a c-section next time as there is a 25% chance of uterine rupture while delivering and a 3-5% chance of rupture while carrying. He said this was because the tear through the uterus was at the top of the uterus where it contracts the most. (I am somewhat skeptical of this recommendation.)

I am looking on the Internet for information about risks of carrying a baby and giving birth vaginally after this type of scenario and have been unsuccessful thus far. I would think my wife's situation would be different than a woman wanting to give birth vaginally after a cesarean. I do understand there is more chance of a rupture if the woman has had a classical incision from a previous c-section.

My wife and I are talking about having another baby but want to be well informed before doing so. We need more opinions. I hope someone can help us find the information we need.

— Dean Collins

A: Get a copy of the operative report so you know exactly what the physician did. Take the report to another Ob/Gyn physician (or two) for a second opinion. Unless it was a bad tear, there is probably no increased risk of rupture with labor. Generally, uterine perforations heal without any problems.

— Susan Wright, CNM

A: Contact Aaron Aldridge at He is a therapist, but more important, he can address your questions and give you objective information about your situation. As a midwife, I'm not sure there is anything to worry about. I know I'd take you as a client, possibly ask for a sonogram in the third trimester to confirm the placenta's locale and have a baby!

— Jenny West, LM, CPM, HBCP

More about posterior-positioned babies [Issue 6:8]:

Have you read Janie McCoy King's Back Labor No More, which is about getting rid of back labor (and expediting birth) by pulling upward on the mom's belly (or getting her to do it) to redirect the vectors involved?


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

Think about It

As a child, I asked my grandmother how to make her special spaghetti. She couldn't tell me much. She said she puts in a little of this and a little of that, using her intuition for that batch on that day.

I followed behind her like the apprentice, watching and trying to evaluate a pinch of salt. Was it a half teaspoon or a quarter teaspoon? How big was the batch today? How much oregano did she use?

I finally learned the flavors and knew that though the numbers changed with the group I would feed, I could approximate the flavor.

We have lots of cookbooks we can study about birth. We can validate knowledge with them. But how do we evaluate intuition? How do we evaluate passion, touch, and caring? How do we pass these things along? Just as my children and grandchildren look to me for an example, the future midwives will look for examples. Are they there? What are they teaching?

Diane Barnes, CNM


More about afterpains [Issue 6:10]:

If mother is breastfeeding, have her empty her bladder prior to nursing. If mother's bladder is full the uterus has to work harder. If she is not breastfeeding, have her empty her bladder frequently. Many mothers following birth cannot tell if their bladders are full.

Helen Vermilya, RNC, IBCLC, CHP

Editor's Note: Only letters sent to the E-News official e-mail address,, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.

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