Although many midwives come to midwifery through doula work, to be an effective modern midwife and monitor the health of baby too, you must all but abandon doula-level thinking. After your first several years of practice, you may be able to provide doula like care occasionally, but the birthers comfort can never consume your focus like it does as a doula.

A skilled modern midwife must be evaluating from a ‘big-picture’, (w)holistic perspective. They’re aware of the time of day, the temperature of the tub, the stages of labor, the changing of the cervix, the status of the waters, the readiness of equipment, the location of emergency tools, the level of education of their support people, the amount of fear in the family/partner, the amount of participation the partner/siblings expect, the time to the nearest hospital, the health history of the person in labor, their relationship with their mother, countless other details PLUS the status of the fetal heart tones, over time and in relation to the contraction pattern as compared to what is normal for this baby as well as the average normal for all babies at this stage of gestation, and labor. (Did I mention, midwifery is the hardest job on the planet) 🥴. Its a lot obviously, and hopefully clear that you will loose track of important parts of the overall health status of both mom and baby and the readiness of your team to support them if you get lost in the ‘doulaing’ pain process.

Maintaining this huge amount of data and this high level of critical thinking can be difficult to maintain over long labors. Sometimes with the sleep deprivation, and the way that we all habitualize to cozy homebirth environments, wanting/willing the best for our clients, some midwives have found themselves boiling to death in a sea of complications.

Here are some ways to keep the vital perspective that will allow you to make those critical care decisions even at 3 am:

1. Use RISK ASSESSMENT CHECKLISTS in late pregnancy and early labor - this is just a list of conditions, disease processes, complications or other medical thresholds that you can cue yourself to check against each client.
2. Don’t attend birth FULL TIME - seriously, to keep perspective, you have to leave the birth room. You have to see with fresh eyes. You have to meet your own needs (like to pee, eat, hydrate, and sleep). Which means, you must take enough of a team that you can do these things.
3. SOAP CHART at least EVERY 4 HOURS - if you aren’t in the habit of soap charting your labors, then you need to consider taking my Defensive Charting Seminar. This practice allows you to not only demonstrate in the chart that you are the provider capable of making clinical care decisions, but it provides a mechanism to do just that at regular intervals.
4. Review your labor chart with your TEAM - even green students can help you keep perspective as they ask questions. Every member of a birth team is valuable, and more than that, you will be better able to keep perspective as you formulate your thoughts to ‘give report’ to your team.
5. Call a MENTOR / CONSULTANT - if you feel you have lost perspective or have reached unknown territory, call someone! Again, talking it through is one of the best ways for you to rediscover ‘where you are’ vs where you want to be. All of us senior midwives want to be used as this kind of a resource - seriously, don’t hesitate to call your old preceptor, that midwife you admire, or a colleague you respect - even at 4 am - it could make all the difference.
6. Define NORMAL - before you get too tired to remember. This is such a simple technique, but it helps so much. When you arrive at a known clients labor, you can make an educated guess about how fast they will progress. Go ahead and make that guess - make a conservative guess and a extreme guess, make a best-case scenario and a worst case scenario. Either way, use your experience at all other labors you’ve been at to define some parameters. If your client falls outside these guesses, you know it warrants closer evaluation.
7. And most importantly use written INFORMED DECISION-MAKING DOCUMENTS when ever you fall outside normal. I have created a suite of 14 informed decision-making documents for sale that are customizable, evidence-based, and lawyer-reviewed - check them out on my website. It is ok to deviate from standard of care, but only if the client is dictating the terms and leading the care decisions. Again if you want a deeper dive on this, be sure and take my Defensive Charting Seminar.

Please share a story of informed decision-making in your practice. What have you learned?