February 28, 2001
Volume 3, Issue 9
Midwifery Today E-News
“Charting”
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THIS WEEK'S ISSUE

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Doula Trainer Workshop

Presented by PinnacleHealth System
Three-part workshop September 13-15, 2001, Harrisburg PA
Desired Background:
* Experienced doula who would like to train new doulas
* Min. ten births or two years as a doula
* Certified childbirth educator
Faculty: Penny Simkin, PT
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Quote of the Week:

"When midwives trust birth, mothers trust birth."

- Diane Barnes


The Art of Midwifery

Many of pregnancy's discomforts are alleviated by the use of alfalfa tablets, including morning sickness, heartburn, constipation, and anemia with its many complications. Alfalfa tablets raise the vitamin K level of pregnant women, reducing postpartum bleeding in both quantity and duration, and they increase the vitamin K stores in newborns, reducing bleeding problems for them as well. Additionally, they support success in lactation because they help increase and sustain milk supply.... They also seem to help reduce swelling and improve erratic blood sugar levels.

To avoid loose bowel movements, my clients start slowly, with one alfalfa tablet the first day, then two the second day, and so on until they are taking two after each meal and two before bed.

- Lisa Goldstein, The Birthkit Issue 21

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News Flashes

A study found that women whose diets are relatively high in saturated fat in the year before they conceive are at a higher risk of experiencing severe nausea and vomiting during pregnancy (hyperemesis gravidarum). This condition can lead to dehydration, weight loss, and if left untreated, liver and kidney damage. Each year more than 50,000 pregnant women are hospitalized in the United States for this condition. The author of the study suggests that women who have had an earlier pregnancy where they were very ill may want to consider altering their diet to alleviate the symptoms in the next pregnancy.

- American Baby, April 1999

Charting

There are two types of records: source oriented and problem oriented. Source oriented record keeping uses traditional narrative charting. Problem oriented records use SOAP or SOAPIER charting. SOAP(IER) is an acronym for Subjective information (reported by the client), Objective information (observed by the practitioner), Assessment (drawn from the data), Plans (for action related to the problem), Implementation (of plan), Evaluation (of plan), and Reassessment (of client's needs). In this kind of charting, each entry is on a separate line, labeled with the midwife's initials.

The legal requirements are very specific. All entries must be legible and done in black ink so the chart can be easily photocopied. Errors must be corrected by drawing a single line through the notation so it remains legible. Mistakes may not be obliterated by scratching, blacking, or whiting out. The word "error" is written above the mistake and initialed by the person making the correction. The correct information is then written beside or below the error.

Each page must be marked with the client's name, the date, and the legal signature of each person charting on that page. All entries must be initialed by the person entering the data. Each entry on the labor record must also contain the correct time. In narrative charting, you must never leave a space or partially blank line. Draw a line through the blank area and then initial at the end of the line.

Never chart a procedure until it is done, but chart it immediately. If your client refuses care, notate that along with an explanation. Charting requires that a midwife use her skills of observation. We talk about "looking" for symptoms, but we should also be listening, smelling, and touching. As long as a midwife is with a client, she should be continuously observing her, actively watching and listening at every opportunity. We can often learn as much by what is not said as by what is said.

Charted information may be overt (obvious), covert (hidden), and either objective (measurable by an observer) or subjective (known only to the client). Overt information includes such observations as the client's fundal height or degree of pitting edema. Covert information could include an asymptomatic vaginal infection or the client's hemoglobin count. Objective information includes a client's blood pressure or the fetal heart tones. Subjective information could be the client's report of vaginal itching, burning upon urination, or nausea.

The ABCs of charting consist of Accuracy, Brevity, and Completeness. You cannot be judgmental ("can't handle pain"). Rather, write "client moaning with each contraction." Avoid vague terms such as "large" ("passed large clot of blood"). Be specific: "passed blood clot approx. 5 cm in diameter." Be sure that abbreviations are proper and commonly used. Be brief: complete sentences are not necessary. Be complete: Review, assess, and explain results of care given.

- Lani Rosenberger, Midwifery Today Issue 33


Check It Out!

WWW.MIDWIFERYTODAY.COM
A Web Site Update for E-News Readers

HAVING A BABY TODAY: Midwifery Today's new publication! From preconception to the first birthday, this newsletter will help parents and parents-to-be learn how to have a healthy and happy baby and mother. To learn more, go to www.HavingaBabyToday.com

"No enema. No antiseptic wash. No shaving of pubic hair. If I wanted to shave something, I'd shave my head. Like Jean-Luc Picard. I've always wanted to be captain of a star ship. When I give birth, I explore uncharted territory, I move and writhe into new worlds. I want to go where no man has gone before." Excerpted from BIRTH PLAN, an article by Janine DeBaise.


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Midwifery Today's Online Forum

Any recommendations as to how to get a laboring mom up and out of the bed? I recently attended a first-time mom who reported that her contractions were so much stronger when she moved around that she just wanted to stay put, semi-sitting/reclining on her tailbone. She hated just going to the bathroom, so walking around a lot to get the baby to engage was certainly impossible. She was afraid of her pain and wanted to avoid it. She ended up with an episiotomy - no surprise there! I'd like to know what to do should this situation occur again. How do you get the mom to realize that it's really better for her to move around, in spite of the fact that it hurts?

Go to our forums to share your thoughts and experience.


Question of the Week

I've met a lady who is wishing to have a VBAC. Her previous c/sec was due to complications arising from cholestasis. She is currently around 19 weeks gestation and so far she has no sign of itching. There seems little available natural treatment or preventative ideas that we've come across. However, the threat of its return is looming within the literature (high risk of recurrence). Being a VBAC mum myself, and able to acknowledge the obstacles that can exist, I'd dearly love to hear of any experiences that carers have used to combat cholestasis.

- Anon.

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E-News Readers Speak Up on Charting

My charting is short and sweet. I make out an index card for each new mom. Top left is EDD (estimated date of delivery); top right, blood type; and name of other midwife involved. Then name (and partners), address, phone number, then directions to their house. Across the bottom, names and ages of other kids. On the other side, turned lengthwise, I keep notes on each visit. Always, date of visit; gest age/fundal ht; fht; V.S. & urine dip results, then any other pertinent data like, "started hawthorn," "quickening," "cx posterior & to the right," "encouraged more protein, grn leafies & squatting ex." Usually each visit fills up one or two lines, so the whole pregnancy fits on one card. During the pregnancy I keep these cards in my purse, filed by due date. After the last postpartum visit, I file them alphabetically by last name. I have another file of my copies of MANA stat forms, filed by date.

- T.W.

I work as a hospital based midwife and take the subject of charting very much to heart. I have already had the misfortune to be caught up in a court case, and it was the precise charting that was the lynchpin for my eventual acquittal of the (ridiculous) charges.

However, when I am caught in the middle of an emergency, accuracy of charting is one of my first priorities. As we train midwifery students in our hospital, they, or even the new graduates, need to learn about obstetric disasters, but it can often be a Catch 22 as they might not always be able to be productive, and therefore "in the way" in a delivery room where the emergency is happening.

What I like to do in a resuscitation emergency for example is to put the student with the notes and a pen in the room. She is then involved, but not out of her depth. She can chart every action, at every correct time and she can observe and learn from the proceedings without being overwhelmed or flustered. Her input is then a valuable contribution to a retrospective view of the events. Recently we had such a situation: the student charted at the time of the resuscitation but the resident doctor did a retrospective charting on the same piece of paper. Gross errors were seen in the Rmo's notes in both time, Apgars and actual events. It's easy to see which will be viewed as the more correct were it to be investigated.

- Robin Moon
Sydney, Australia

The most important thing to remember in charting is the belief that "if it wasn't charted, it wasn't done." I have recently gone through an investigation with my professional governing body--nursing--and it really opened my eyes to the realization that six months down the line, when they are asking you hundreds of questions, the reality is that you just don't remember and you really do rely on your chart to refresh your memory. Questions are asked such as How was the lighting? What kind of flashlight did you use? One that you hold? One that straps on your head? Believe it or not, I just could not recall until after the questioning was over and I had checked it out with my partner.

It is important to document who did what. The second midwife usually does all the charting when the primary midwife is at the perineum but this charting should be checked and perhaps initialed by the primary midwife after the birth, e.g. perineal compresses applied by so-and-so, apprentice; head delivered by so-and so, apprentice; tight nuchal cord clamped and cut on perineum by so-and-so, primary midwife; PPV initiated by so-and-so, primary; EMS called by so-and-so. It all sounds so minor but in reality, six months down the way, it is very difficult to recall who did what. We were so used to just flowing together, doing what needed to be done by whomever, but in reality, when they (the employers, governing bodies, lawyers, etc.) are investigating, they ask these questions and you need to be able to answer them. Quite frankly, I may have gone to the extreme now after this extremely difficult experience but I keep the client's chart open and document everything I see, hear, feel, assess, hear the mom saying, the ambience in the room, the lighting, everything.

It's also important to clearly document all discussions with the parents; informed choice is extremely critical in today's midwifery practice and must be documented: all the options you've given her, the benefits, the potential side effects, her response or decision. I had been a nurse for 30 years prior to this incident, doing homebirths outside the law for the last seven years. I had a lot of unlearning to do in the area of informed choice. I was used to seeing doctors doing things to women and then telling them what they'd just done. At the time of birth, we were unable to hear the fetal heart tones for the last 40 minutes and relied on scalp colour and fetal movement. We didn't tell the parents of this because we did not want to worry them. That is a huge no-no in this process of informed choice. In hindsight, they may have chosen to go to the hospital for further monitoring if they had known. This was a very important lesson to learn. I am just very happy that the baby is doing fine one year later. But it has been hell (mentally and physically) throughout this process. I hope this will help prevent other midwives from going through what I've just gone through.

- Gisele Fontaine, CPM


QUESTION OF THE QUARTER for Midwifery Today magazine

Mamatoto: Motherbaby

How can midwives best facilitate the bonding process of motherbaby in pregnancy, birth and postpartum?

Deadline: March 31, 2001

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Switchboard

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

Suzanne Arms to research in Holland for upcoming video and new edition of book: Suzanne and homebirth midwife (CPM) Sally Kane from Colorado will be travelling to Holland, Paris and Germany March 20th of this year to research midwifery and the details of maternal-child health policy and care. We're focusing on Holland and would appreciate any contacts in Amsterdam in public health and also help financing the on-land travel costs. Tax deductible. For more info: contact Sally at Sallyk@paonia.com.

====

I'm a midwifery student at CWRU in Cleveland. I 'm looking for resources re: herbal preparation for cervical ripening and labor induction. So far Lisa Summer's article and Barbara McFarlin's are the best I have found. I want to find midwives who have practice guidelines, or protocols for their use of cohosh, red raspberry, evening primrose and castor oil. This all started with a look at Cytotec, which is used a lot here. I'm not close to birth centers, and most midwives in this area practice in a hospital/medical model. If anyone is willing to just talk (even if you want to remain anonymous) I would love to hear about what you are doing and how, and any resources for knowledge about herbals that you think are good.

- Laurie
Reply to: Matthews_laurie@hotmail.com or lhm2@po.cwru.edu

====

I am O+ and my husband is A- blood group. My first child is A- and within six hours of his birth, he became severely jaundiced and needed a blood transfusion due to ABO incompatibility. I was informed by the physicians that subsequent children I have will experience this problem unless they are the same blood group as myself. The problem may be mild or severe as in the case of my first child. Is there an alternative to blood transfusion in the more severe case and the mechanism of ABO incompatibility? I am due to have my second child in approximately five weeks.

- Anna

====

In conjuncture with the article in O this month, there is a message/post board at Oprah's website asking for our opinions about homebirth. My highest hope is that it will be inundated with requests to do a show (series?) on homebirth. There isn't another avenue that would reach so many people at once. If you share my hope, please post a message. This is an especially opportune time since she is actually asking us for our opinions. Maybe if she gets a bazillion replies she'll do a show!!! Click here to read more or visit their message boards to post!

- Charisse Lawson, doula

====

I am interested in fetal malpresentation during labor, especially relating to maternal position changes, the how, when, and where of them, and if they positively affect the c-section rate. I have been able to find very little on this topic in the major medical and nursing databases. Can anyone give me some direction on finding relevant research on this topic?

- Colleen Kelly, RN, L&D
Reply to: ckelly3@wpo.it.luc.edu

====

Is it true that prostagladin gel is derived from pig semen?

- Amy Jones
Henderson, NV


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