Are we supposed to SOAP chart in labor?

Are we supposed to SOAP chart in labor?

Charting in labor has been an often misunderstood part of defensive documentation by midwives. On one side, the herstory of persecution has made many wary of documenting just what went on for fear of prosecution. Secondly, there is still a lot of ambiguity about ‘what midwives actually do or are allowed to do’ nationally; also midwives are chronically short-handed at births and frequently labor/birth charting is being done after the fact. And finally, with the revitalization of (white) midwifery in the US in the 70’s and 80’s, most came to the profession through or alongside nursing - charting as a nurse is very different from charting as a midwife.

So what are we supposed to do?

I propose that midwives chart in such a way as to demonstrate that they are the primary care provider on the scene and that they know what they’re doing, they know the risk status of the client and their baby, and that they have a care plan for this birth.

Most midwives are excellent at risk assessment and do offer individualized care for each person they serve. However, most midwives are not documenting these important demonstrations of their skill. Traditionally midwifery labor charts consisted of multiple pages of columns with space to record the date, time, FHT, dilation, in/out, notes, and the initials of the provider. But when viewed over the course of a whole labor, especially a dysfunctional labor or after a poor outcome, these extensive notes amount to nothing more than a long list of the subjective and objective reports and they do NOT demonstrate that an assessment and plan were ever evaluated or followed.

The assessment and plan part of a SOAP note is the only way that outside observers, receiving physicians after a transport, or opposing attorney can see that there was a primary provider present actually taking care of a client in labor. And its also the only point in the chart where opposing opinions can be acknowledged and discussed. For example, when you think one thing and the client declines your recommendation.

Regular SOAP charting is the best way to demonstrate this. In my two online seminars, Defensive Charting (US) and Defensive Documentation (OZ), I recommend that midwives create a soap note every 4 hours in labor recording four important data points in addition to the typical ‘labor flow’.

Your assessment of the baby’s status
Your assessment of the birther’ a status
Your Plan for the labor/birth
When you will reevaluate

Almost all midwives, I know, collect these four data points, they just fail to write them down. I’m suggesting that you start writing these things down in the chart at every labor and then follow the plan you create for each client. I recommend you create a SOAP entry:

At Admission
At AROM
During a Transport
At Birth
And every 4 hours between any of these milestones

Listen, most midwives who are prosecuted in the US, are not in trouble for what they did, but for what they didn’t do. Its because a strong case can be made that they don’t ‘belong’ there, that they don’t know what they’re doing, that there wasn’t a provider present - this is because, historically, our charting doesn’t actually defend us, it incriminates us.

If you’d like to take a deeper dive into SOAP charting as well as an in-depth chart review of real midwifery charts to understand ‘do’s’ and ‘don’t’s’ please click here.