Protocols: Standards Meeting Needs
by Jill Cohen

[Editor's note: This article first appeared in Midwifery Today Issue 15, 1990.]

"What are your protocols?" Parents often ask, and it always takes me a moment to gather up the answer to this question. There are so many different situations that can arise during pregnancy and birth that there is no pat way to respond to the issue of protocol. As a rule, however, I always consider that no set protocol takes the place of good judgment and experienced intuition.

As I define them, protocols are a set of guidelines drawn up by an individual or group which outlines a standard of practice. In my practice as a lay midwife, my protocols are flexible enough to accommodate each situation I meet. For instance, with premature rupture of membrane, I once transported a woman by the twenty-four hour mark because she had not gone into labor. Another woman may not go into labor for three days after her water has broken, and in that particular case I might discourage transport.

Why would I change my protocols? In the first case, the woman was living in an unclean and infested environment. Her temperature had risen and the baby was showing stress. The second woman lives in a very clean and arid environment. Both baby and mom are doing well and continue to do so until labor evolves. These examples demonstrate how protocols can be flexible to accommodate the unique circumstances and needs of those we serve.

An important factor in determining my guidelines of practice is my own intuitive sense of what is appropriate at any given time. Using my intuition—how I sense or perceive a situation—is very important to my practice, for there are times when what a woman tells me and what I sense are quite different. Also, I have learned to trust my own intuition because it helps me to set protocols which are specifically tailored to an individual.

I attended a woman who was so sure of herself and how her labor would go that I questioned if perhaps she was trying to convince herself, and overcome some inner fears. I explained to her my different protocols and what I felt comfortable and uncomfortable with. She told me that we would not even need to think about anything—the baby would just come.

Her baby did come, but not "just." After an 80-hour labor and a lot of strong lessons her baby arrived safe and sound. I was humbled by the way this woman slowly but surely let down her assuredness and worked through each fear until she was finally able to let go and have her baby. My intuition had told me that this possibility was present and I was able to both encourage her and help her with her fears before birth, as well as to adjust my protocols to meet her personal needs. I find this essential in my practice.

When I first started practicing midwifery, protocols helped me to structure what I was doing and find the people who were comfortable with my ways. The parents I attend always ask a lot of questions; oftentimes, we set protocols together according to what their particular desires are. It's important that the parents know what you do in a given situation, and if there are different options, then those must be discussed. The parents tell me what they are comfortable with, and I help to educate them regarding different methods and choices.

We come up with a secure plan, but in the long run, I always do with consent and understanding what I need to do to have a healthy mom and baby. Protocols are a means to guide me to this satisfying end, but stretching some protocols doesn't necessarily jeopardize that end. I bring both my logic and my intuition to bear against the basic nature of the process—a process which often needs no intervention whatsoever to bring it to completion.

Still, the progress of birth moves across the many facets of a woman's being. The most comprehensive overview of any development in the birth must consider physical, emotional, even spiritual factors. As every birth and every birthing mom is unique, we find that there are innumerable ways in which the course is taken. Protocols help to keep this spectrum in line by creating an arena in which these various factors can be defined and assessed. If the arena of consequence is not big enough to work in comfort, I increase its scope. If it becomes too big to allow for safe response, I bring it back to a manageable place. I find I must create and adjust protocols to fit my practice and the individual style and knowledge of the woman I am attending.

In many states, the legal status of midwifery creates a need for more structured protocols in practice. With established guidelines, the parents have a better understanding of what the midwife can offer within the parameters of the usual standards of practice in her community. What one midwife does can directly affect all the midwives in her state—especially in states considering outlawing midwifery. In these states it seems essential to set a standard of practice to protect the availability of homebirth. This does not need to be a staunch standard, but one that sets the stage for an effective homebirth option in the face of adversity. (In states like my own where there are no laws, it is easier to be more flexible.)

A few years ago, I was asked to attend a couple of births in Hawaii. I was more than happy to attend birth in the tropics! But I became concerned when I learned that midwives were persecuted there. I reviewed my practice and decided that I needed a few more technical skills to help prepare myself, and to feel more secure entering such a midwifery-hostile environment.

I took the necessary steps to acquire the skills I wanted, and went off to bake in the sun. The births went beautifully, with little intervention needed. But I could not help feeling the need to review and re-review my standards of practice. Knowing the repercussions on other midwives practicing in Hawaii made me feel just that much more careful. From this experience, I gained a real appreciation for the definition protocols can lend to both my method and my mental outlook. The potential for serious circumstances formed my protocols in advance; knowing them unequivocally gave me a sense of security to proceed with confidence, in spite of my environment.

In other cases, my protocols are clearly drawn by the distance I must travel. There is a big difference in being one mile away from the nearest hospital and being fifty miles away. For people who live in rural or remote areas, I make a point of knowing firsthand what access I do have to emergency assistance. I call the nearest fire station and introduce myself. I try to find out who I likely will be meeting in case of emergency, and what their experience is. Travel time constraints order my preparation, and obviously they also affect my response to any emergency or unusual development; my assessments will always weigh the distance I must travel if I need to transport.

But there are always the what-ifs, the factor unaccounted for which suddenly looms into crisis proportion. When I go to a birth, I try to be as prepared as possible. (I've even been accused of being too prepared at times!) However, no matter what the standard of practice is, I know of no midwife who has not had a situation arise that was sudden and surprising—be it a complication or baby. In those situations, I find protocols are sometimes useful to see me through the event. In other cases, everything gets thrown out the window—common sense must occasionally usurp procedure. Babies don't always wait for protocols to define the course; they come when they're ready! Remaining flexible seems to be the key: I deal with things accordingly. My protocols—if they are effective—should lead me to the point of being able to exercise good judgment. This being the case, I rarely find that a spontaneous decision based on common sense is outside the scope of my protocols.

Flexibility is also the order of the moment when working with a sister midwife. It is important to discuss each other's set of protocols. Two people collaborating can often create a broader scope of practice; I might be very comfortable in one situation that you are uncomfortable with, and so on. In pooling strengths and weaknesses, we find good common ground and plan for the variety of possible outcomes. Also, any time I am able to work with a more experienced person, my knowledge is enhanced and my spectrum of protocol is widened. I then am more willing to take on diversified situations and thereby reach more people.

This kind of growth is fundamental to midwifery—we all strive to learn from each other, from our shared experiences. It is only natural then that I see the set of protocols I started my practice with as very different from the ones I use today, ten years later. I assume that certain standards will continue to grow and change. I've seen myself become more strict with some protocols, and I have relaxed with others. Always, what I experience directly with the birthing woman affects the way I use my set of protocols. (After any shift or change in my protocols, when all is said and done, my rebellious side teases me with the thought that some rules are just meant to be broken!)

Protocols are useful tools and good guidelines. Even so, they do not shield me from poor judgment. In the final analysis, I myself am responsible for the decisions I make. I am best equipped when my protocols are informed by my experience, my intuition, and my common sense.

Jill Cohen has been a community midwife in Eugene, Oregon for more than 20 years. She has been with Midwifery Today for 14 years, where she is associate editor of Midwifery Today magazine and senior editor of The Birthkit. Click here for more biographical information.
