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Practice Guidelines

aka Protocols

I have resisted making protocols for my practice for a long time for several reasons. Mainly because I didn't want to be hemmed into adhering to them. I admit I was influenced a great deal by the midwives around the state and the major midwifery organization that cried foul every time the California Medical Board tried to institute anything remotely looking like protocols. It was seen as the worst possible thing, to have someone hand down how and when we were to do tests, procedures, screens and deal with variations on the absolute norm.

Over time and reading as many books and informational websites about charting, I am seeing the positive aspects of protocols and am beginning to finally write guidelines I can live with. We had to write them for our licensing exam and they are in the office, but they are more blanket than itemized; I am now writing an itemized book of protocols.

(It helps me a LOT to call them "practice guidelines." The word "protocols" sits blechy in my stomach. I'm using the word to try and de-sensitize myself regarding its usage.)

Below is the beginning of the list of items I will be writing guidelines for. I am asking myself:

- What symptoms does a woman present with
- What is our course of action as far as recommendations
- What tests might be done to confirm
- What will we do with the test information
- When will we notify woman of diagnosis or suspicion
- When do we refer to an OB
- What do we do if the woman refuses treatment/referral
- What will we watch for during the remainder of the pregnancy, during labor and postpartum (extra observation? more testing? more counseling? etc.)

This is a non-inclusive list of items to be written about:

Initial Bloodwork
AFP/Triple/Quad Screen
Newborn Screen
Erythromycin eye ointment
Vitamin K
Prenatal Visit
Labor evaluation
Vaginal Exams
Course of Labor
Course of Delivery
Low FHTs
Increased maternal Temp
IV antibiotics
Water for comfort in labor
Placental expulsion
Retained membranes
Delayed Placenta
Non-reassuring NST
Non-reassuring FHTs
Increased BP
Fundal Height greater than dates
Breech in pregnancy
Breech in labor
Breech at birth
Twins in pregnancy
Twins in labor
Twins at birth
Hands-off pregnancy
Hands-off labor
Hands-off birth
Fetal Heart Tones in labor
Vitals during labor
Vitals postpartum
History of GDM
Diagnosis of GDM
Thyroid Disorders
History HSV
History HPV
History asthma
History Domestic Violence/ Rape/ Sexual Abuse
History of cesarean - one, two or more
History of uterine surgery
History of cervical surgery
History of cancer
UTI in pregnancy
Pyelonephritis in pregnancy
Bacterial Vaginosis
History of psychiatric issues
Low platelets
Cardiac issues - mitral valve prolapse, etc.
Supplementation - prenatal vitamins, iron, herbs, etc.
RH Negative mothers
Testing Baby postpartum for RH factor
Rhogam for mother in pregnancy and postpartum
Large weight gain in pregnancy
Obese woman
Very thin woman
History of eating disorders
Extreme diets (vegan, raw foods, fruitarian, etc.)
Drinking alcohol
Recreational Drugs
Prescription Meds
Advanced Maternal Age
Grand multipara
Out-of-State clients
Illegal Immigrants
Birth Certificates
Family Medical Leave paperwork
Flying in pregnancy
Exercise in pregnancy
Ectopic pregnancy
Non-stress tests
Biophysical profiles
Post-dates pregnancy
Pre-term labor
Term pregnancy definition
Rupture of membranes
Premature Rupture of membranes
Rupture of membranes without contractions
Natural induction methods - castor oil, enema, blue & black cohosh, cimicifuga and caulophylum, stripping membranes, rupture of membranes
Malposition in pregnancy
Malposition in labor
Prolonged labor
Prolonged second stage
Prolonged third stage
When to give pitocin
When to give Methergine
When to give antibiotics
Antibiotics (type and schedule)
Transient Tachypnea of the Newborn
Respiratory Distress
Neonatal Resuscitation training schedule
CPR training schedule
IV practice schedule
Peer Review
Neonatal Hypoglycemia
Large for Gestation Age
Small for Gestational Age
Shoulder Dystocia
Hyperemesis in Pregnancy
Hyperemesis in Labor
Fainting postpartum
Newborn resuscitation
Oxygen usage

Am I missing anything?

How did I change my views? I believe going to New Orleans and being willing to go out of state to do births helped my realization that I can step out of the guidelines - as long as the mother and family are hyper-aware of my limitations (legally and education-wise). Legally, I don't know how protected I would be, but I am wanting to do what I can to protect myself while also honoring women in their desires and needs. I do not believe I am practicing defensively at all - I don't think I allow The Law to dictate my work with women, but if I am to continue my work, I best think about some protection, right?

I look forward to others' thoughts on this topic.

References (1)

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Reader Comments (5)

careful careful with your wording- there is some danger if the wording locks you in to a particular action- for example

7. Post-Dates
a. Review history of dates, gestational length of previous pregnancies
b. Auscultated NST at 40 weeks with manual assessment of fetal tone and fluid volume.
c. Fetal movement/activity record by mother daily after 41 weeks
d. Assess cervical condition; consider natural methods to ripen cervix and encourage labor
e. Assess client’s mental/emotional readiness for birthing; reassure as needed.
f. If not delivered by 41 weeks
- consult with MD
- consider BPP/NST
- consider AROM if Bishop score 7 or greater
- consider transfer to hospital for induction

8. Preterm labor
a. If preterm labor suspected prior to 36-37 weeks, and no risk factors present for preterm labor, consider immediate home visit for evaluation
b. If contractions noted and no cervical change consider:
- U/A and/or C&S
- warm tub bath
- oral or IV fluids
- vaginal culture, wet-mount, Fetal Fibronectin
c. If contractions continue or cervical change noted, consult with/refer to MD.

a. Evaluate with:
- Client history
- Nitrazine testing
- Sterile speculum exam; no vaginal exams until active labor
- Crystallization test
b. Educate client regarding risks of GBS infection and recommended CDC guidelines (see appendix)
c. Assess fetal well-being, (FHTs) and clients need for rest, relaxation, hydration, reassurance
d. Consider natural measures to stimulate contractions (i.e. nipple stimulation, walking, imagery, and castor oil) e. Instruct client in ROM precautions, including:

August 8, 2006 | Unregistered CommenterAnonymous

I sent one thing and it was just to show wording-and to explain more you have to be careful how you say what you "might" do in a situation now what you will do- this allows for some changing up without breaking with your protocols. Since there are patient right's protections that allow for any choice to be refused by a care provider that could be added to the top of your protocol list and I would probably add that any of these protocols may be superseded by parental choices but that I have the decision as to if I feel safe to continue care and call an ambulance to transfer care to them. but this would probably have to be discussed in your community of midwives so that you will not be blasted if you did such a thing- there are alot of things I will break rules for but I usually only to break 1 rule- what I have noticed is some situational logic that ends up being many protocols broken and a bad outcome we are at peer review about. and I don't know how to write a protocol about that nor do I want to but it is an unwritten policy I try to adhere to.

for instance how about a recent case we had with a complication a disorder in pregnancy that can either be mild or become bad- so we did labs and a referral and we are still walking a balance beam of sorts- nothing really helps but it seems to not be getting worse- then add to it PROM- how long will you want to wait for labor to start with PROM? how about in someone with GBS status unknown and parents had consented to test but had not been done yet? Add to that some variable hypertension and with the original disorder there are some cross over problems in the liver labs that could look like Pre-eclampsia -- but other parts are fine-
see what I mean by stacking risks- once I have one problem - then the woman is no longer simple low risk - add to that PROM with no labor for 40 hrs used every trick I know of to start labor- nothing worked BP that is questionable on it's own... WWYD?

August 8, 2006 | Unregistered CommenterAnonymous

Practice guidleines are NOT a bad thing!
Do them. They are guidelines and as the previous poster pointed out your wording in them makes that clear.
I am glad you are doing them!

August 8, 2006 | Unregistered CommenterLesley

hey guess what I found today- I think you will like this site it is on physician reform if you click on the blog page it has several posts that go through the process of grief and eventually how to change or how to approach problems--- he sites communication errors as being the biggest problem in making a medical mistake>>>>>>>


August 9, 2006 | Unregistered CommenterAnonymous

Anon: I really appreciate your input... it is extremely helpful. Your comments are absolutely coherent... no worries there, okay?

Part of why I want to do them is so I *can* step around them. But, I understand the having to do steps A, B and then C... I don't want to do that, you are right.

I wish "consult with an MD" was an option; it isn't at this time, sadly. Sending them to an OB is, however, what I would need to do.

I look forward to incorporating your thoughts into my guidelines.

August 9, 2006 | Unregistered CommenterNavelgazing Midwife

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