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MIDWIVERY-PRACTICE DOCUMENTS

I. Introduction
II. Practice-Directive Documents
III. Informed-Choice Documents
IV. Midwifery-Care Documents
V. Examples

I. Introduction

The mission of Midwives College of Utah (MCU) is to develop "Midwives of Excellence," that is, midwives who possess technical expertise, professional excellence, and personal greatness. As an MCU student midwife progresses in her academic and clinical training, she develops a personal philosophy of midwifery practice. This philosophy is reflected in the individual care she gives the mother and family. The midwife must develop wisdom in implementing her philosophy, so that she remains flexible and adept at varying her clinical strategies and techniques according to the setting of care, cultural considerations, and the needs and desires of the mother. The midwife's philosophy should direct rather than drive her practice.

Not only is this philosophy of practice expressed through the care of the client, it is also expressed in the many written documents used in the midwife's practice. There are three major types of midwifery documents: 1) practice-directive documents, 2) informed-choice documents, and 3) midwifery care documents.

Practice-directive documents include practice guidelines and protocols. Midwives are required to make many decisions, some of which are critical to the health of the mother and family. Written practice guidelines and protocols can be helpful to the midwife in making these decisions. They are a guide to the management of general care as well as to the management of specific problems or clinical findings. They also define the parameters of care and/or the midwife's scope of practice. The midwife's scope of practice is influenced by the quality of her education, amount of experience, and skill level. The practice setting also greatly affects the scope of practice. This is due to guidelines, standards, regulations, rules, and laws of states, provinces, professional organizations, collaborative working relationships, birth centers, hospitals, etc. Informed-choice documents include client handouts, informed care services, informed disclosure, informed consent, and waivers. Informed-choice documents are used to assist the client in making decisions about her own care, as well as to give the midwife written documentation of those decisions.

Since the midwifery model emphasizes woman-centered care, informed-choice documents often practically apply more than practice-directive documents. For example, take the topic anemia in pregnancy. The most significant action of the midwife in this situation is to give the client a handout that explains what anemia is, some of the symptoms and possible consequences of anemia, and a list of recommended supplements and food to help correct the problem. In this case, the education of the mother is extremely crucial, because she is the one who must actively correct the problem.

However pertinent and effective informed-choice documents are by themselves, when such documents combine with practice-directive documents, the benefits are even greater. For example, relative to the case above, a practice guideline for anemia in pregnancy that diagnoses the problem and delineates a plan for its management could stipulate that the client receive the aforementioned handout. The guideline could refer to the handout and thus obviate the need to repeat the information. Furthermore, the plan could include follow-up directives, including additional lab tests and remedies, and consultation, if the client is unresponsive to the treatment.

Midwifery-care documents are the paper forms or electronic programs used to record data. They include client forms, requests for records, MANA statistics project study consent and birth certificates.

II. Practice-Directive Documents

Elizabeth Gilmore, President of National College of Midwifery stated, “Midwifery schools have a responsibility to shed light on how guidelines and protocols are utilized in practice, the evidence on which they are based and changed, the context of their implementation in local, state, national and international arenas, and their ultimate impact on maternal/child health, midwifery practice and obstetrics, in general.”

There are several different professions, including DEMs, CNMs, MDs, OBs, NPs and RNs, which work within the areas of maternal and child care and well-woman care. Each profession has its own philosophical base, standards of care, and practice-directive documents. Elizabeth Gilmore has recommended that students come to understand these multiple points of view and their philosophical underpinnings. While students do their studies and research, they will come across procedures within each profession that are followed out of convenience or tradition and that scientifically may have been proven ineffective or even harmful. Medical practice has a long history of cultural warping. Both external and internal pressures within the health care community are great. Elizabeth Gilmore commented on these pressures, “...some are so severe that despite authoritative studies showing that a protocol is harmful, components of the health provider community feel compelled to continue a discredited practice.”

Elizabeth goes on to say, “Because new research can change the way a condition is managed, it is very important that guidelines and protocols be in a form that are flexible enough to allow instant changes in response to new requirements/information. Details of management must not be mandated by law – otherwise you’d end up going to Public Hearing or Legislative Sessions to respond to a new protocol suggested by the CDC for Group B Strep, for example. In the worst case, a life might be lost because of the slow nature of these change mechanisms.” Students should be searching for the most viable practice guidelines and protocols that have been proven by scientific study and empirical data. The bottom line is that these practice-directive documents should be aimed at reducing maternal/child risk.

Practice Guidelines vs. Protocols

There is a great deal of confusion in the midwifery field about the difference, makeup, and use of the two types of practice-directive documents: practice guidelines and protocols. Typical questions are: Which one do I use? Are there any differences between them? How do I write them? These questions will elicit a variety of answers depending on whom or what organization you ask. Definitions of practice guidelines and protocols as well as requirements for their use vary significantly according to state, province, location, organization, facility, etc. This variation is not necessarily a bad thing, because it offers more latitude and flexibility. Standards of practice differ so widely between direct-entry midwives and doctors that this difference must be reflected in the protocols of the two groups.

In an attempt to clear up for students as well as faculty the confusion of whether to use protocols or practice guidelines, Kristi Ridd-Young, President of MCU appointed a task force to research this topic. Angella Jones, Protocol and Practice Guideline Task Force Chair and MCU graduate student, conducted a survey of midwifery associations and schools. The survey asked questions concerning any distinction between the terms "protocol" and "practice guidelines" as they relate to midwifery.

Heidi Fillmore-Patrick, CPM, NHCM, and Executive Director of Birthwise Midwifery School, offered a clear differentiation between the two terms. She described practice guidelines as "evidence-based practice suggestions that include a variety of possible good management options. They tend to include more theoretical information to inform a midwife's decision-making process, and they work better for practices that deliver individualized care." She described protocols as "step by step management instructions that are agreed upon 'best practice' for a particular organization, practice or institution. Protocols are to be followed closely." Heidi reported that at Birthwise Midwifery School they use practice guidelines as a learning tool. She added that protocols can be used in a few applications, but they are difficult to apply to complications.

The program chair of Bastyr University, Morgan Martin, defined practice guidelines as a general guide devised by practitioners to manage both common and emergency situations, allowing for individualized alterations and clinical judgment." She said that protocols are "...a rigid definition of care that must be applied in every situation despite individual client desire or clinical situation." She observed that protocols were generally defined by hospital managers to reduce the need for individualized judgment calls and thus ease the staff's clinical load.

The Bastyr representative further pointed out that the main difference in the terms has to do with flexibility: "Protocol implies that there is only one way to manage a situation, while guideline allows for the application of clinical judgment. The vague language makes it more challenging for anyone to determine whether or not a deviation from the appropriate course of action has occurred. Lawyers have to work harder to prove that the midwife failed in some way." She further stated that: "...guidelines put the midwife and the family in the position of having to decide what they are comfortable with in each situation that deviates from the middle ground vaguely defined in a guideline. Guidelines make OBs and nurse midwives feel less comfortable talking with [direct-entry] midwives, because they can not point to a hard and fast line, at which point the client is no longer eligible for midwifery management." Her advice to student midwives is that they "need to define where their clinical limitations are (i.e., under what circumstances they must refer to an MD) and where they are comfortable allowing for deviation from the 'middle ground' defined by a guideline."

Suzanne Hope Suarez, an attorney and RN, wrote the following paragraph in an article "Protocols vs. Guidelines" in Midwifery Today (Issue 73, Spring 2005): "The term protocol is sometimes confusing because it is used differently from location to location, state to state. In general, protocols have to be very carefully written, or midwives damage themselves legally. The midwife should be certain that the way she practices and interacts with clients fits within her protocols. For example, a protocol in Florida is usually between a CNM and a physician and serves as a contract to limit the midwife's practice. Should she deviate from working within the protocol (in this case as determined by the agreement she has with the physician), she could be liable for damages in a malpractice claim and may be unable to get insurance coverage for her defense. The same is true for any midwife whose practice uses written protocols. Most of the time protocols are a group decision by a group of practitioners and serve to insulate the group from legal action should one of the members deviate from them."

Some midwifery educational institutions such as the Seattle Midwifery School make no distinction between practice guidelines and protocols. Also North American Registry of Midwives (NARM) does not distinguish between the two terms. NARM only requires that Certified Professional Midwives (CPMs) have a written guide to direct their care.

MCU requires graduating students to hand in an electronic copy of their practice guidelines and/or protocols, including an Emergency Care Plan, to the Clinical Dean. Although MCU encourages students to use practice guidelines whenever possible, it is up to the students to use what is appropriate for their individual practice settings. If students are required in their locality or clinical situation to use a protocol for a particular situation, then the student should submit a protocol for their assignment.

Tips For Writing Practice-Directive Documents

1. Begin by creating a three-ring binder titled “Midwifery-Practice Documents.” The 3- ringed binder format allow you to easily add new documents and review older ones, as you see fit, such as after a midwifery conference or whenever your skill level increases and/or your scope of practice expands.
2. The first section of this binder should include the following:
a) The Midwives Model of Care, available on the Citizens for Midwifery website (www.cfmidwifery.org).
b) The Midwives of North America (MANA) Guiding Principles of Practice, which is the first section of MANA Core Competencies for Basic Midwifery Practice on their web site (www.mana.org).
c) Any laws or regulations that you are subject to in your jurisdiction.
d) Any personal or organizational mission statements.
e) Any other documents you consider applicable.
3. Use the term "practice guidelines" rather than "protocols," unless you are required by law, the place of practice, or working relationships to use the term "protocols."
4. If you must use the term "protocols" for general care and specific problems or clinical findings, write them in the form of a practice guideline. Although the medical profession uses the term protocols in a more rigid way, midwifery practice has a different philosophical base, and so the protocols of a midwife must reflect that.
5. Use a separate piece of paper for each individual topic. This will make it easier when you want to revise your guideline.
6. You may want to put a date at the top of the page, noting the last time that you reviewed the topic. In this way you will know if the guideline is current.
7. Check different sources for examples of guidelines. One excellent source is A Midwife's Guide to Protocols by the Association of Texas Midwives (www.texasmidwives.com). Another source by Nell Tharpe, CNM, is Clinical Practice Guidelines for Midwifery & Women's Health, published by Jones and Barlett Publications, Inc. If you are beginning to write guidelines, it is well worth it to purchase these books.
8. Although you want your guidelines to represent your own philosophy of practice, you don't have to entirely "reinvent the wheel." Feel free to copy parts of other guidelines. Just be sure to cite the source of your information.
9. Start writing practice guidelines by outlining the general care of the client. The general care should include 1) antepartum care schedule, 2) intrapartum care schedule, 3) postpartum care schedule, 4) the newborn, and 5) well-woman care schedule.
10. After writing the general care schedules, write guidelines for specific problems or clinical findings.
11. Write your practice guidelines in outline form.
12. The SOAP format is used in A Midwife's Guide to Protocols for specific topics: a) definition, b) subjective: signs and symptoms, c) objective: findings, d) assessment, and e) plan. Appropriate items are listed under each of these divisions.
13. Another style is the four-component format: a) diagnosis, b) risk factor, c) management, and d) follow-up care.
14. The style used in Clinical Practice Guidelines for Midwives by Nell Tharpe, CNM includes: a) key clinical information, b) client history to consider, c) physical examination to consider, d) clinical impressions to consider, e) diagnostic tests to consider, f) therapeutic measure to consider (Tharpe differentiates between standard and alternative therapies, but direct-entry midwives will not make any distinction), g) educational and support measures to consider, and h) follow-up care to consider. Use of these categories is flexible.
15. In your plan section, be sure to note any applicable rules and regulations that apply to you and your practice setting. Safe practice is essential. Even if you are not governed by laws, it is important to include guidelines for consultation or referral.
16. Do not confuse the writing of a skill guideline with the writing of a practice guideline. The direct-entry midwifery profession already has accepted-skill descriptions. If it is a skill (e.g., how to wash your hands, how to give an injection, how to measure fundal height, how to do a newborn exam, how to suture, etc.), you should not be writing a practice guideline for it.
17. Keep it simple! Do not overwrite.
18. Keep it flexible! Use phrases like "...include but not limited to..."
19. Avoid getting too prescriptive. Practice guidelines should be specific enough to ensure safe care. But they also must be broad enough to encompass the needs of the client within the midwife's parameters of practice.
20. Thoroughly research the topic.
21. Record references.
22. Remember that midwifery is both a science and an art. When midwives write evidencebased guidelines for making decisions, they will include experienced intuition as well as research findings.
23. Keep your guidelines client-focused!

III. Informed-Choice Documents

What is Informed Choice?

Informed choice is a central principle of the midwifery model of care. In fact, it influences to a great extent the type of care the midwife provides and the relationship she develops with the client.

The MANA Statement of Values and Ethics makes it clear that the client has an ongoing right and responsibility to make decisions concerning her care. “We value the concept of personal responsibility and the right of individuals to make choices regarding what they deem best for themselves. We value the right to true informed choice, not merely informed consent to what we think is best” (MANA 1997).

The client makes a variety of choices during pregnancy, labor and birth, and postpartum for herself and her baby, e.g., type of care, individual caregiver or clinic, how to proceed with conditions that are variations of normal, and acceptance or refusal of various procedures. The client also makes personal choices about how to care for herself, e.g., how she eats, supplements, and exercises to optimize her health and the health of her baby.

The midwife is responsible for informing and advising the client, drawing upon her (the midwife’s) education, research, clinical experience, and guidelines of practice. This service should inform the client so she can make more educated choices about caring for herself and her baby. The mutual effort of midwife and client to listen to each other and be educated by each other is a fundamental requisite of the informed-choice process. Thus, the concept of informed choice goes beyond a mere written statement by the midwife. It is, rather, an ongoing, synergistic process whereby the midwife and client discuss diverse aspects of client care, explore differences in models of care, prepare for the approaching birth, and champion the rights and responsibilities of the client and her family support unit.

The midwifery model encourages the use of diverse types of information in the creation of informed choice statements. It recognizes that there is no “value-neutral” information. The information may be evidence-based, personal experience and/or judgment, etc. This model equally values the knowledge of the client – her prior experiences, health education, input from family and friends, intuitions, emotions and spiritual beliefs. All these things will inevitably influence decisions the client makes.

How does the Informed-Choice process enhance the Midwife/Client relationship?

Informed choice, as delineated above, allows for the development of mutual respect and trust between client and midwife. The midwife encourages the client to gain more knowledge by studying handouts, reading books, taking classes, doing research, etc. and to always ask questions and communicate her concerns. This interaction empowers the client to become a true partner with the midwife in the birthing process.

What are legal implications of Informed Choice for the Midwife?

Informed choice is an agreement to do something or to allow something to happen or not to happen only after the relevant facts are disclosed. For a wide range of decisions, written consent is neither required nor needed. However, if a written statement is preferred or required, a midwife can use one of the following types of forms:

1. Client Handout – Basic information to help the client 2. Informed Care – Describing midwifery services 3. Informed Disclosure – Describing conditions that are variations of normal 4. Informed Consent – Describing procedures 5. Waiver -- Informed refusal of procedures

By having the client sign and date such a form, the midwife can legally prove the parameters of the client’s informed choice. This may limit the midwife’s liability if the client were to later sue her based on the outcome of the procedure, birth, or lack of treatment. Informed-choice documents may not offer complete protection to the midwife. Problems can arise when the information on the form is not adequate. Considerations in creating such forms should include: 1. What would the average client need to know and understand in order to make an informed decision? 2. Is there any additional information that this individual client would need to know and understand in order to make an informed decision? 3. What would be a reasonable midwife standard in determining what information is appropriate to disclose? Before the client signs the statement, the midwife must ensure that the client thoroughly understands all the information in it by discussing it and answering all her questions. This discussion should be documented on the client’s chart. The time spent in communicating and educating during the course of the prenatal period is added protection to any signed statement. Good documentation at each visit is an important protection for the midwife. Begin each entry with the date and time. Then write detailed notes about the content of the communication exchanged. The notes could include titles of information handouts given to the client, topics taught, agreements made, non-performance of recommendations made by midwife, referrals, nutritional/supplementation suggestions, concerns of the client, questions asked, informed choice forms signed, etc. The client’s initial refusal to abide by any procedure required by law needs to be noted along with a plan for follow-up education. In such situations, the midwife can write on the chart a quote Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 7 from the client and have her sign it. Midwives can also write out a disclosure on a chart and have the client sign after it. NARM recommends that the midwife initial every entry, fill in blank spaces with a single line, and sign a full signature at the end of each page. The midwife has the right to: refuse specific procedures or care requested by the client; discontinue the client’s care; and continue care in emergency situations even when it is outside the midwife’s practice guidelines. These situations should be documented on the client’s chart. 1. Client Handouts Information that can help the client take better care of herself and her baby can be presented in the form of an information handout or a client handout. The handout can be on a separate sheet of paper, included in a handbook, and/or set up to be e-mailed to the client. Information handouts support the principle that the client herself is a direct care provider for herself and her baby. These handouts do not need to be signed by the client or the midwife. However, the midwife should note on the chart that the client received it. Midwives may want to make a list of topics they want to discuss and information handouts they want to give to the client during her course of care. As the education proceeds, the topics and handouts can be checked off the list with a date notation. Examples of topics suitable for information handouts are: Prenatal * Anemia * Bleeding * How to Turn a Breech Baby * Constipation * Diet Recommendations * Exercise Recommendations * Hypertension * Morning Sickness * Posterior Position of Baby * Rh- Blood Type * Sciatic Pain * Supplementation Recommendations * Urinary Tract Infection * Varicose Veins * Vaginal Infection Labor and Birth * Labor and Birth Positions * Easing the Stress of Labor * Relaxation Exercises * Signs of Labor * Supply List * Water Birth * When to Call the Midwife Postpartum * After-birth Pains * Breast Care * Depression Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 8 * Hematoma * Hemorrhoids * Infant Jaundice * Infant Metabolic Screening * Perineal Care * Postpartum Hemorrhage (Late) 2. Informed Care -- Services An Informed Care statement gives the midwife an opportunity to educate the client about her practice, thus enabling the informed client to accept or reject her services. Both MANA and NARM give guidelines of what a midwife needs to include in an Informed Care statement. MANA does not specify that everything needs to be in written form. However, NARM is very clear that there needs to be a formal document written in language that the client can understand. MCU requires graduating students to send a copy of this document to the Clinical Dean. It is suggested that the midwife include the following items in the statement: 1. Midwifery training, including education, continuing education, and Peer Review process 2. Experience level in the field of midwifery 3. Current legal status 4. Basic philosophy of practice 5. Services provided and, optionally, services not provided 6. Some coverage of practice guidelines, e.g., giving the client a separate copy of practice guidelines or noting that such guidelines will be given if requested by the client, outlining antepartum, intrapartum, and postpartum conditions requiring consultation, transfer of care, and/or transport to a hospital 7. Medical back-up or transfer plan 8. Financial charges for service (may be handled separately) 9. Expectations of the pregnant woman and her family system 10. Availability of a grievance process 11. A statement that the client understands the content 12. Client signature and date 13. Midwife signature and date Additional items may be included. Midwives should check their local laws for legal requirements. Although there is a lot of information to cover in the statement, it still can be very concise. A signed copy of the Midwife Informed Care statement should be placed in each client’s permanent file. This must be completed before the midwife documents a medical history, conducts any examination or provides any care. 3. Informed Disclosure – Conditions When a client has a preexisting condition that is a variation of normal or develops a condition during pregnancy that is a variation of normal, the midwife may want to have the client sign an Informed Disclosure form which addresses her particular condition. In essence, the midwife wants the client to acknowledge that because of her condition there may be some additional risk to the labor and birth, but the client still wants to continue with the midwife’s care. The form should be clear and concise and preferably include documentation of sources. Disclosure statements can be quite varied depending on the needs of the midwife and client. The following are some suggested items which could be included in a disclosure: 1. An explanation of the condition 2. A discussion of risks and uncertainties associated with the condition Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 9 3. A statement that the condition may involve risks to the client and/or baby/babies which are currently unforeseeable 4. An explanation of availability of alternate care 5. An explanation of specific developments at which time the midwife will advise or require consultation, collaborations, transfer of care, or transport to a hospital 6. A space for the midwife to insert any additional information 7. A plan for how the midwife and client will deal with the condition 8. A statement that the client can change her mind concerning her care at any time 9. A statement that the client understands the written statement 10. A statement that the client accepts any additional risks, is any 11. A space for the client to make a comment about her choice/s 12. Signature of client and date 13. Signature of the midwife and date Examples of topics for Informed Disclosures are: * General fill-in-the-blank disclosure * Breech * B Strep * Herpes * Twins * VBAC 4. Informed Consent – Procedures An Informed Consent form is used when a client is giving consent for a certain procedure. The information should be provided in a way that the woman and her family can understand it. It should be clear, concise, and preferably include documentation. It is helpful to give sources for the client to check if she wants additional information about the procedure. The form should include a discussion of the following elements: 1. An explanation of purpose of the proposed procedure 2. A description of the proposed procedure 3. An explanation of the relevant risks, benefits, and uncertainties of the procedure 4. A discussion of reasonable alternative procedures including risks and benefits 5. A discussion of the consequences of not accepting the proposed procedure 6. A space for the midwife to write in any additional information 7. A statement that the procedure may involve risks to the client and/or baby which are currently unforeseeable 8. A statement that the client has a right to withhold her consent to the proposed procedure 9. A statement that the client may withdraw consent to the procedure at any time 10. A statement that the client understands the written statement 11. A statement that the client accepts the procedure 12. Signature of client and date 13. Signature of midwife and date Ideally the client should be given time to think about the information, discuss it with others, and do her own research. However, it is important to note that in an emergency situation informed consent is not needed. For example, in a situation like postpartum hemorrhage, a midwife should not take the time to get an informed consent. It is of utmost importance that she works on the pressing problem. In most emergency situations, where quick, focused action of the midwife is required, it is still possible to keep the client informed of what is going on and illicit the cooperation of the client, maintaining the collaboration of the midwife/client relationship. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 10 Examples of topics for Informed Consent are: * General fill-in-the-blank Procedure * B Strep * Induction of Labor * Infant Eye Prophylactics * Infant Immunization * Infant Vitamin K * Water Birth 5. Waiver -- Informed Refusal of Procedures An Informed Refusal form, commonly called a waiver, is used when a client does not want a certain procedure or test done. For some procedures, it is practical to put an Informed Refusal at the bottom of the Informed Consent form so that the form can be used for both situations. Items that should be included on the Informed Refusal form are: 1. An explanation of purpose of the proposed procedure 2. A description of the procedure 3. A discussion of possible consequences of not accepting the proposed procedure 4. Space for the client to write in why she is refusing the procedure or test 5. A statement that the client understands the written statement 6. A statement that the client refuses the procedure 7. Signature of client and date 8. Signature of midwife and date Examples of topics for Informed Refusals are: * General fill-in-the-blank Waiver * Infant Eye Prophylactics Waiver * Infant Immunization Waiver * Infant Vitamin K Waiver * Infant Metabolic Screening Waiver * RhoGam Waiver * Rubella Immunization Waiver+ * Stress Test Waiver III. Midwifery-Care Documents Students will need to collect, compile and/or make up forms for their practice. A practice name, logo and tag line, if available, should be included on the forms. Having these documents available before starting midwifery practice makes the initial transition go smoother. a. Client Forms Client forms include forms for medical history, physical examinations, prenatal care, labor and birth, newborn examination, postpartum visits, well-women care, payments, transport, etc. b. Request for Records A midwife should have available a form for the client to sign which requests medical records from previous caregivers. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 11 c. MANA Statistics Project Study Consent The MANA Statistics Project Study Consent form can be downloaded from www.manastats.org. The form is available in English and Spanish. If a midwife is participating in the MANA statistics project, the consent form should be read and signed by the client on her first visit. The midwife should then send the form to MANA. d. Birth Certificate Midwives should have all the forms and/or electronic means to submit birth certificate information to their state or province. In addition, they should give information about voluntary declaration of paternity to parents who are not married. This can be documented in the client file. IV. Examples The following examples are found after the bibliography. Additional examples will be available later and some of these taken out or redone. Example 1 – PG: Dehydration in Labor. This is an example of a simple PG. It is mainly taken from A Midwife’s Guide to Protocols. It follows the SOAP model. Example 2 – PG: Variations in Fetal Well-Being. This is an example of a more open style PG. Example 3 – PG: Extended Cephalic Presentation: Anterior Face, Posterior Face, Anterior Brow, Posterior Brow This is an example of a very detailed, overdone PG. It is something that you would like to have access to if you happen to have a face or brow presentation because they are such rare occurrences. To facilitate access to a PG if you want to review something at a birth, it would be good to have a copy of your Practice Guidelines in the trunk of your car. Example 4 – PG: Face Presentation This is an example of a simplified PG version for Face Presentation. This is more practical than Example 3. Example 5 – Client Handout: Fetal Movement Record This Client Handout is very helpful in determining possible problems with the fetus. Example 6 – Client Handout: Tension Release Breathing Exercises This handout is a good general breathing exercise program for pregnancy. References: AMA, Legal Issues, “Informed consent”: HYPERLINK "http://www.ama-assn.org/ama/pub/category/4508.html" http://www.amaassn. org/ama/pub/category/4508.html Association of Texas Midwives (2003). A Midwife's Guide to Protocols. www.texasmidwives.com Childbirth Connection, “Informed Decision Making, Informed Consent or Refusal”: HYPERLINK "http://www.childbirthconnection.org/article.asp?ck=10081" http://www.childbirthconnection.org/article.asp?ck=10081 Carter, Sarah (2007). A Midwifery Student's Guide to Midwifery Protocols and Practice Guidelines, 4 pages. Midwives College of Utah. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 12 Cohen, Jill. Protocols: "Standards Meeting Needs," Midwifery Today Issue 15, 1990. Jones, Angella (2008). Midwives College of Utah Protocols & Practice Guidelines Survey. MedicalMalpractice.com, “Informed Consent and Patients”: HYPERLINK "http://www.medicalmalpractice.com/Informed-Consent.cfm" http://www.medicalmalpractice.com/Informed-Consent.cfm Merz, Jon F., “An Empirical Analysis of the Medical Informed Consent Doctorine; Search for a ‘Standard” of Disclosure”: HYPERLINK "http://www.fplc.edu/risk/vol2/winter/merz.htm" http://www.fplc.edu/risk/vol2/winter/merz.htm Midwives Alliance North America, “Core Competencies for Basic Midwifery Practice”: HYPERLINK "http://www.mana.org/manacore.html" http://www.mana.org/manacore.html Midwives Alliance North America (Revised October 2, 2005), “Standards and Qualifications for the Art and Practice of Midwifery” HYPERLINK "http://www.mana.org/pdfs/MANAStandardsQualifications:pdf" http://www.mana.org/pdfs/MANAStandardsQualifications:pdf Midwives Alliance North America (Revised and Approved October 1997) “Statement of Values and Ethics”: HYPERLINK "http://www/mana.org/valuesethics.html" http://www/mana.org/valuesethics.html New Zealand College of Midwives Consensus Statement (11 May 1996), “Informed Consent and Decision Making”: HYPERLINK "http://www.midwife.org.nz/index.cfm/3,108,271/informed-consentpdf" http://www.midwife.org.nz/index.cfm/3,108,271/informed-consentpdf North American Registry of Midwives, “Informed Consent Form,” NARM Candidate Information Bulletin, page 55: HYPERLINK "http://www.narm.org/pdffiles/cib.pdf" http://www.narm.org/pdffiles/cib.pdf Rasansky Law Firm, “Informed Consent”: HYPERLINK "http://www.texasinjurgyattorney.com/medical/informed-consent" http://www.texasinjurgyattorney.com/medical/informed-consent Spoel, Philippa (Laurentian University, Canada, June 2004), “The Meaning and Ethics of Informed Choice in Canadian Midwifery” : HYPERLINK "http://www.inter-disciplinary.net/mso/hid/hid3/spoel%20paper.pdf" http://www.inter-disciplinary.net/mso/hid/hid3/spoel%20paper.pdf Suarez, Suzanne, RM, BSN, JD, “Guidelines for Informed Consent,” NARM Candidate Information Bulletin, page 54: HYPERLINK "http://www.narm.org/pdffiles/cib.pdf" http://www.narm.org/pdffiles/cib.pdf Suarez, Suzanne Hope. Protocols vs. Guidelines. Midwifery Today Issue 73, Spring 2005 Tharpe, Nell (2006). Clinical Practice Guidlines for Midwifery & Women's Health. Sudbry, Massachusetts: Jones and Bartlett Publishers Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 13 Rural Maternity Care Dianne Bjarnson, MSM, CPM, DEM PRACTICE GUIDELINE Dehydration in Labor A. Subjective Signs and Symptoms: 1. Maternal fatigue 2. Emotional discouragement 3. Thirst 4. History of vomiting/diarrhea 5. History of decreased fluid intake 6. History of prolonged latent phase B. Objective Findings: 1. Decreased urinary output 2. Increased urinary concentration 3. Excessive vomiting/diarrhea 4. Inadequate fluid intake 5. Fetal tachycardia 6. Pulse higher than 100 bpm 7. Ketonuria/fruity odor on breath 8. Increased Hct 9. Abnormally elevated temperature/fever 10. Dry lips, mouth, and skin 11. Not coping well with pain C. Assessment: 1. Maternal dehydration D. Plan may include, but is not limited to: 1. Re-hydrate: 2 – 4 ounces every 20 – 30 minutes or more if she can take it 2. Fluids: any type of juice the mother likes; water; warm red raspberry tea with honey in it; warm pregnancy tea with honey in it; labor-aide -- 3 T honey, 3 T lemon juice, ½ cup water, pinch of cayenne; broth; catnip tea with honey; frozen juice bars; ice chips 3. Enema – ½ to 1 cup and hold as long as possible: water plus liquid minerals; red raspberry tea with a dropper full of lobelia tincture 4. Relax in bath tub. Epsom salt bath 5. If want to stop vomiting: homeopathic Ipecac 1 dose every 15 minutes until vomiting stops 6. Tummy Soother 7. Reflexology points for stomach, digestive system, urinary tract etc. Rub feet to relax. 8. Start an IV of Lactated Ringers or equivalent 9. Keep re-evaluating vital signs References Association of Texas Midwives (2003). A Midwife’s Guide to Protocols. Frye, Anne (2004). Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Volume II Care of the Mother and Baby from the Onset of Labor Through the First Hours After Birth, Portland, Oregon: Labrys Press, Publilsher Simkin, Penny and Ruth Anchera (2005). The Labor Progress Handbook, Second Edition, Blackwell Publishing. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 14 Rural Maternity Care Dianne Bjarnson, MSM, CPM, DEM 3/4/09 PRACTICE GUIDELINE Variations in Fetal Well-Being Findings: 1. FHR abnormalities 2. Signs of marked pulse, variability and patterns 3. Excessive or decreased fetal movement 4. Meconium staining Assessment: 1. Abnormal FHR Attempt to determine possible causes: 1. Cord: compression, prolapse, tight knot, short cord, multiple nuchal cords 2. Uteroplacental deficiency: pre-date, post-date, abruption, dysfunction 3. Uterus: hypertonic contx, infection, rupture, VBAC 4. Maternal conditions: position, PIH, hypertension, anemia, dehydration, exhaustion, hypoglycemia, infection, CPD, shock, hemorrhage 5. Fetal condition: head compression and/or molding, infection, CPD, malposition or presentation, congenital problems, pre-date, post-date, anemia, arrhythmia (heart block), interuterine growth retardation 6. Amniotic fluid: decreased, heavy meconium. infection 7. Environmental influence: hot tub, cold Treat causes appropriately including, but not limited to: 1. change of maternal position, especially left lateral or knee-chest. 2. slow controlled breathing, with O2 supplementation, 6-8 liters per minute to oxygenate fetus 3. hydrate/nourish the mother. 4. use brisk message of the mother’s abdomen to stimulate the baby. 5. stimulate the fetal scalp 6. change maternal environment. 7. use herbs, homeopathics, supplements, massage and other nonallopathic treatments. 8. continue to assess FHT rates and patterns. Evaluate the effect of the treatment relative to: 1. stage of labor 2. progression of labor 3. maternal and fetal well-being 4. expected time of delivery/travel time to hospital If abnormal FHT do not resolve: 1. continue to administer oxygen to the mother 2. consult with another midwife, a physician, or hospital personnel 3. prepare for resuscitation/call EMS 4. transport for diagnosis and treatment Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 15 If mother is pushing or birth is imminent, be prepared to: 1. administer oxygen to the mother 2. deliver as quickly as possible 2. manually dilate the mother to facilitate a quick delivery 3. cut an episiotomy to facilitate delivery 4. suction the newborn 5. stimulate the newborn and/or 6. resuscitate the newborn 7. make sure the newborn is warm and dry 8. consider/call EMS and/or transport the newborn to the hospital Regarding the mother (in relation to above): 1. always keep her informed 2. be sure she understands the severity of the problem (and have her cooperation) 3. give emotional support. This is a very scary situation for the family 4. be prepared for a possible postpartum hemorrhage 5. be prepared to treat her for shock 6. administer oxygen 7. start an IV 8. consider/call EMS and/or prepare for transport Document results References Association of Texas Midwives (2003). A Midwife’s Guide to Protocols. Fraxer, Diane, and Margaret Cooper (2203). Myles Textbook for Midwives, 14th Edition, Edinburgh: Churchill Livingstone. Frye, Anne (1995). ). Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Volume I Care During Pregnancy, Portland, Oregon: Labrys Press, Publilsher Frye, Anne (2004). Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Volume II Care of the Mother and Baby from the Onset of Labor Through the First Hours After Birth, Portland, Oregon: Labrys Press, Publilsher Olds, Sally, Marcia London, and Patricia Ladwig (1996). Maternal-Newborn Nursing, A Family- Centered Approach, Menlo Park, California: Addison-Wesley. Tharpe, Nell (2006). 2006 – 2009 Clinical Practice Guidelines for Midwifery & Women’s Health, Sudbury, Mass: Jones and Bartlett Publilshers. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 16 Rural Maternity Care Dianne Bjarnson, MSM, CPM, DEM 2/20/09 PRACTICE GUIDELINE Extended Cephalic Presentations: Anterior Face, Posterior Face, Anterior Brow, Posterior Brow Definition Face and brow presentations are variations of normal labor & birth. The head is in some degree of extension rather than flexion. Face Presentation Brow Presentation: Lie: longitudinal longitudinal Presentation: cephalic cephalic Presenting Part: face between orbital ridges & bregma Attitude: complete extension halfway extension Denominator: mentum: M (chin) frontum: Fr (forehead) Presenting Diameter: submentobregmatic 9.5 cm verticomental 13.5 cm The incidence of face presentation is an average of 1 in every 545 births (Frye 2004). Although the labor may take longer and be more difficult for the mother when the face is presenting, 90% actually deliver vaginally without problems (Oxorn 1986). The incidence of brow presentation averages 1 in every 1,444 births (Frye 2004). This position is usually transitory and either extends to a face presentation or flexes to a vertex presentation. If the brow position persists, obstructed labor usually results. The causes of face and brow presentations include anything that interferes with engagement in flexion. Face and brow presentations are often diagnosed late or may not be diagnosed at all. It may be helpful, whenever there is failure of progress during labor, to examine the mother again specifically to detect if there is a face or brow presentation. The midwife should proceed in these situations according to her discretion. The following guidelines contain quite a bit of detail to clarify uncommon situations. The midwife will find the following guidelines helpful, but she is not limited to them, nor is she required to use all of them. Physical Examination 1. Abdominal Examination a. Assess FHR and location b. Back and cephalic prominence on the same side (for both face and brow) Back is hyperextened, “hollowed” or arched back. Occiput becomes cephalic prominence. c. Anterior, transverse or posterior position? d. Head engaged? (often not engaged at onset of labor) e. Head size -- small, normal or large? Head may feel larger than you would anticipate compared to a well flexed head. (Hx: previous babies head sizes) f. Fetal weight -- small, normal or large? (Hx: previous babies weights/gestations) g. Fetal irregularities (multiple nuchal cords, anencephaly)? Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 17 2. Vaginal/Pelvic Examination a. Face 1) Soft, irregular presenting part (may be mistaken for breech) 2) Identification of parts of the face – eyes, nose, mouth & chin 3) What direction is the chin pointing? b. Brow 1) Anterior fontanelle, frontal sutures felt. 2) Sagittal suture usually out of reach. 3) Identification of the supraorbital ridges is key. 4) What direction is the forehead pointing? c. Anterior, transverse or posterior position? d. Pelvis – small, normal or large? (Hx: length of 2nd stage) e. Pelvis type? In android pelvis, flat pelvis more face presentations e. Uterus/Pelvic/Vaginal irregularities? (Hx: high parity) f. Suspected CPD? g. Status of membranes? After Diagnosis 1. If diagnosis is made at the onset of labor or during 1st stage a. Discuss risks, procedures with mother/parents. b. Have mother/parents sign birth record that you had the discussion. c. Always keep mother/parents informed as to progress d. Warn the parent/s that the baby may look “battered” but that the swelling should disappear within a couple of days and the bruising within a week.. 2. Transport if a. Maternal/parent preference b. Birth Attendant preference c. Nonreassuring FHR pattern and birth is not imminent d. Large baby/small pelvis – CPD e. Arrest of descent f. Brow that does not flex or extend 3. Proceed with birth if a. Maternal/parent preference b. Birth imminent c. Best prognosis if 1) Small to normal size baby 2) Normal to large pelvis 3) Good contractions 4) Mother has given birth before 4. Before transporting a. Options to attempt to reposition a larger fetus out of any of the following positions: anterior brow, posterior brow and posterior face. 1) Make sure the mother’s bladder is empty 2) Put mother in knee-chest position to pull fetus back 3) Administer homeopathic pulsatilla to mother 4) Give potassium to mother 5) Use Reboso 6) Bind mother’s belly. A pendulous abdomen changes uterine axis. The buttocks leans forward and the force of the contractions is directed towards the chin rather than the occiput. 7) Try to have the mother throw up 8) The uterus tilting to one side can encourage extension. 9) Can try flexion when cervix is dilated and soon after ROM. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 18 b. Spontaneous Conversion for Brow 1) Spontaneous conversion 50% of time – 30% to face, 20% to vertex 2) Conversion rate as high as 67 – 75% if brow detected early. 3) Greatest chance of turning vertex is conversion at the pelvic brim. 4) Greatest chance for conversion to face is deep in the pelvis. 5. Safety Procedures a. General Safety Procedures 1) Prepare for neonatal resuscitation 2) Do not apply internal electrode 3) Make sure mother’s bladder is kept empty (catheter if necessary) 4) During vaginal exams care must be taken not to damage the eyes. 5) Vaginal exam should be done after ROM to check for cord prolapse. b. 2nd Stage Safety Procedures – Progress is the key to safety of mother and baby 1) Oxygenate fetus by giving mother O2 2) Vaginal checks to assure that internal rotation is anterior 3) Have mother upright (on birthing stool) during descent 4) As face is “crowning” apply pressure on fetal brow to maintain extension until chin in born. 5) Control head allowing gradual flexion and birth of the remainder of the head. c. Postpartum Safety Procedures 1) Because of larynx may be swollen, watch the baby for difficulty in breathing in the first 24 hours. 2) Recommend a chiropractic adjustment and/or baby head shaping for the newborn if applicable. 3) Recommend a pediatric visit if applicable. 4) Use arnica on the baby’s face to help with bruising. Anterior Face (70% anterior or transverse) LMA, RMA, LMT, RMT 1. Leave anterior face presentation alone a. LMA flexes to ROP. RMA flexes to LOP. It can make the situation worse. b. If partially flexes it becomes Brow which cannot deliver unless very small. 2. During internal rotation the chin must rotatate anteriorly. This may take time! 3. May be delay at the inlet and in rotation. 4. Movements of Labor: LMA Extension and descent: LMA Internal rotation: LMA to MA 45 degrees Flexion: MA Restitution: MA to LMA 45 degrees External Rotation: LMA to LMT 45 degrees Posterior Face (30% posterior) RMP 1. 50 -63% of posterior faces rotate anteriorly and deliver spontaneously.(Frye 2004) 2. Check vaginally that the mentum is lower than the sinciput because rotation and descent depend on this. 3. Rotation may not occur until the face is distending the pelvic floor. 4. Patience. 5. A persistent posterior face position puts the fetus at risk for brain and spinal trauma 6. Resistant posterior may not progress – Cesarean section. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 19 7. Thorn maneuver can be used when posterior face has descended with no rotation and the cervix is fully dilated. There are three motions to be done at the same time: a. Facing mother, insert hand that is on the same side as the cephalic prominent through the cervix and pull from the back of the head to try and flex it forward. b. On the outside of the abdomen with the other hand push against the fetal chest area pushing it back. c. On the outside of the abdomen a second person cups the breech and pulls it forward 8. RMP flexes to LOA. 9. Movements of Labor: LMP, LONG ARC Extension and descent: LMP Internal rotation: LMP to LMT to LMA to MA 135 degrees Flexion: MA Restitution: MA to LMA 45 degrees External rotation: LMA to LMT 45 degrees Anterior Brow LFrA, LFrT, RFrT 1. This position is often transitory and head either flexes to an occiput presentation or extends completely to a face presentation. 2. Descent is slow and late. Usually the head does not settle into the pelvis until the membranes have ruptured and the cervix has reached full dilation. 3. Persistent Brow -- Cesarean section 4. Unless the fetus is small, the best chance to deliver vaginally is to diagnose the position early and try to get the fetus to flex. LFrA flexes to ROP. LFrT flexes to LOT. RFrT flexes to ROT. Then work to turn the ROP to a transverse or anterior position. Posterior Brow LFrP, RFrP 1. Persistant Brow – Cesarean section. 2. Nonprogressive brow – fetal mouth is open and the lower jaw becomes lodged against the pelvis. 3. Unless the fetus is small, the best chance to deliver vaginally is to diagnose position early and try to get the fetus to flex. LFrP flexes to ROA. RFrP flexes to LOA. References Fraxer, Diane, and Margaret Cooper (2203). Myles Textbook for Midwives, 14th Edition, Edinburgh: Churchill Livingstone. Frye, Anne (2004). Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Volume II Care of the Mother and Baby from the Onset of Labor Through the First Hours After Birth, Portland, Oregon: Labrys Press, Publilsher Oxorn, Harry (1986). Oxorn-Foote Human Labor & Birth, 5th Edition, Norwalk, Connecticut: Appleton & Lange. Varney, Helen, Jan Kriebs, and Carolyn Gegor (2004). Varney’s Midwifery, Fourth Edition, Sudbury, Massachusetts: Jones and Bartlett Publilshers. Weaver, Pam and Sharon Evans (2007). Practical Skills Guide for Midwifery, Fourth Edition, Wasilla, Alaska: MorningStar Publishing Company. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 20 Rural Maternity Care Dianne Bjarnson, MSM, CPM, DEM 4/30/09 PRACTICE GUIDELINE Face Presentation Definition: Face presentation is a variation of normal labor & birth. The head is extended rather than flexed. The incidence of face presentation is an average of 1 in every 545 births (Frye 2004). The midwife should proceed according to her discretion. The midwife will find the following guidelines helpful, but she is not limited to them, nor is she required to use all of them. Presentation Determination: 1. Abdominal Examination: Back and cephalic prominence are on the same side 2. Vaginal Examination: Softer irregular presenting part. Mouth gums are hard. 3. Late Diagnosis: May not make diagnosis until progress slows down when face reaches pelvic floor. 4. Determine anterior/transverse/posterior position 5. RULE OUT big head/small pelvis, CPD Assessment: 1. Face Presentation Prognosis: 1. Labor may take longer 2. Possible delays at inlet and internal rotation 3. Rotation may not occur until the face is distending the pelvic floor. 4. 90% deliver vaginally without problems (Oxorn) 5. 2/3 of posterior face presentations rotate anteriorly and deliver spontaneously. 6. More work for mother 7. Fetal face becomes swollen 8. Edema of larynx may result from prolonged pressure of hyoid region of the neck against the pubic bone. 9. Best prognosis if a) small to normal size baby b) normal to large pelvis c) good contractions d) mother has given birth before Informed-Choice: 1. If diagnosis is made before the baby is crowning, discuss risks, procedures with the mother/parents. Have mother/parents sign birth record that you had the discussion. 2. Keep mother/parents informed as to progress 3. Warn the parent/s that the baby may look “battered” but that the swelling should disappear within a couple of days and the bruising within a week. Transport if: 1. Large head/small pelvis – CPD 2. Nonreassuring FHR pattern and birth is not imminent 3. Maternal/parent preference 4. Midwife preference 5. Arrest of descent Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 21 Proceed with birth if: 1. Maternal/parent preference 2. Prognosis good 3. Birth imminent General Safety Procedures: 1. Prepare for neonatal resuscitation 2. Do not apply internal electrode 3. Make sure mother’s bladder is kept empty (catheter if necessary) 4. During vaginal exams care must be taken not to damage the eyes. 5. Vaginal exam should be done after ROM to check for cord prolapse. 2nd Stage Safety Procedures: 1. Progress is the key to safety of mother and baby 2. If there are significant fluctuations in FHTs, oxygenate fetus by giving mother O2 3. Vaginal checks to assure that internal rotation is anterior 4. LMA – chin must rotate anteriorly. It may take time. 5. If LMT arrests, rotate to LMA manually. 6. If pelvis is normal, leave anterior face presentation alone. If it flexes LMA goes to ROP and RMA to LOP which may make the situation worse. If it flexes partially it becomes a brow which may not be delivered. 7. Have mother upright (on birthing stool) during descent 8. As face is “crowning” apply pressure on fetal brow to maintain extension until chin in born. 9. Control head allowing gradual flexion and birth of the remainder of the head. Postpartum Safety Procedures: 1. Because the larynx may be swollen, watch the baby for difficulty in breathing in the first 24 hours. 2. Recommend a chiropractic adjustment and/or baby head shaping for the newborn if applicable. 3. Recommend a pediatric visit if applicable. 4. Use arnica on the baby’s face to help with bruising. References Fraxer, Diane, and Margaret Cooper (2203). Myles Textbook for Midwives, 14th Edition, Edinburgh: Churchill Livingstone. Frye, Anne (2004). Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Volume II Care of the Mother and Baby from the Onset of Labor Through the First Hours After Birth, Portland, Oregon: Labrys Press, Publilsher Oxorn, Harry (1986). Oxorn-Foote Human Labor & Birth, 5th Edition, Norwalk, Connecticut: Appleton & Lange. Varney, Helen, Jan Kriebs, and Carolyn Gegor (2004). Varney’s Midwifery, Fourth Edition, Sudbury, Massachusetts: Jones and Bartlett Publilshers. Weaver, Pam and Sharon Evans (2007). Practical Skills Guide for Midwifery, Fourth Edition, Wasilla, Alaska: MorningStar Publishing Company. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 22 Tension Release Breathing Practice 15 minutes every day. Do this exercise in a sitting position with your hands on your knees. 5 Minutes – Cleansing Breathing Breathe In – Cleansing Breath 1. Place the tip of your tongue on the outer edge of your upper lip. 2. Breathe in through the nose. Bring in the breath slowly filling your lower abdomen. 3. As you place the tip of your tongue up and begin to breathe, open your eyes, spread your fingers, and smile. Open your body out a little. Breathe Out – Cleansing Breath 1. Place the tip of your tongue on the outer edge of your lower lip. 2. Breathe out through your mouth. Slowly exhale in little bursts. 3. As you place the tip of your tongue down and begin to exhale, close your eyes, close your fingers, and purse your lips. Pull body slightly forward relaxing more with each burst. 5 Minutes – Building Breathing Breathe In – Building Breath 1. Place the top of your tongue in the top of the crevice that lied between your top teeth and your top lip. 2. Breathe in through the nose. Bring in the breath slowly filling your lower abdomen. 3. As you place the tip of your tongue up and begin to breathe, open your eyes, spread your fingers, and smile. Open your body out a little. Breathe Out – Building Breath 1. Place the tip of your tongue in the bottom of the crevice that lie between your bottom teeth and your bottom lip. 2. Breathe out through your mouth. Slowly exhale in little bursts shouting “Hah” with each burst. 3. As you place the tip of your tongue down and begin to exhale, close your eyes, close your fingers. Pull body slightly forward and crunch in a little in the abdomen area keeping the rest of the body relaxed. 5 Minutes – Balancing Breathing Breathe In – Balance Breath 1. Place the tip of your tongue high on the soft palate at the top of your mouth. 2. Breathe in through the nose. Bring in the breath slowly filling your lower abdomen. 3. As you place the tip of your tongue up and begin to breathe, open your eyes, spread your fingers, and smile. Open your body out a little. Midwifery Practice Documents by Dianne Bjarnson, MSM, BSE, CPM, DEM 6/2/2009 23 Breathe Out – Balance Breath 1. Place the tip of your tongue down and back so it touches the soft floor of your mouth. 2. Breathe out through your mouth. Slowly exhale in bursts sighing with each burst. 3. As you place the tip of your tongue down and begin to exhale, close your eyes and close your fingers. Pull body slightly forward relaxing more with each sigh. 1. Set a regular time during the day to do your breathing exercise. It might be good to include it in a morning routine or couple it with some other daily routine so that you will actually get around to doing it. 2. If you have some body pain or tension from something, it would be a good time to do some of the exercising. Note how you feel before and after. 3. If some emotional trauma happens during the day. Use the breathing to release the tension. 4. Make a habit of doing tension release breathing when any tension comes up. 5. The Cleansing Breathing is particularly good for lower back pain and abdominal tensions. 6. The Building Breathing is particularly good for middle back pain and cramps. 7. The Balancing Breathing is particularly good for upper back pain and stiff neck and shoulders. 8. Pain is a muscle’s cry for oxygen. 9. The slow breath in, works with the natural movement of the uterus which naturally rises with a contraction. 10. As you practice your breathing, work at getting the inhales and exhales longer and longer. 11. As you become proficient in this breathing, it will be a good time to do emotional releasing during the exercising. 12. A baby in the uterus can handle a lot more stress if he/she has a good oxygen supply from the breathing of the mother. We appreciate your help with this little project. Please report back about your experiences at each prenatal.