June 25, 1999
Volume 1, Issue 26
Midwifery Today E-News
“Autonomy”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Remembering Gladys Milton, grand midwife
5) An Autonomous Midwife
6) Autonomy and Service
7) Question of the Week
8) Question of the Week Responses
9) Switchboard
10) Coming E-News Themes

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1) Quote of the Week:

"The only way there will ever be midwifery autonomy is through midwifery unity."

- Marsden Wagner, MD, Midwifery Today Issue 42

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2) The Art of Midwifery

Heart Rates
On a card, make a small table of fetal heart rates. For example, if you count fetal heart tones for five seconds and get ten beats, that corresponds to 120 beats per minute. Use the table for quick reference at births.

- Carolyn Steiger, "Becoming a Midwife," Hoogan House Publishing 1987

For Comfort's Sake
I have my moms use undergarments designed for incontinence during the first three days after birth--they are more comfortable.

- Carrie Abbott, Wisdom of the Midwives, Tricks of the Trade Volume 2, a Midwifery Today book

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3) News Flashes

Effects of Long Labor
To determine if long labor has a negative effect on fetal well being, a study evaluated the possible correlation between duration of labor (both first and second stage) on the acid base variables in the umbilical artery of the newborn. In 1,255 infants excluding those with operative delivery, multiple gestations, breech presentation, prematurity, postmaturity and small for gestational age, no correlation was found between duration of the first stage and either pH or base excess in umbilical artery blood. There was, however, a significant correlation between duration of second stage and both the pH and base excess. Yet these effects of a prolonged second stage are so small that it is hardly clincally relevant. Authors of the study found no support for the belief that a long labor in the absence of other risk factors is to the disadvantage of the fetus.

- Acta Obstetricia et Gynecologica Scandinavica 77 (8) as reported in MIIDIRS June 1999

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4) Remembering Gladys Milton, grand midwife

Gladys Milton, a dearly loved and treasured grand midwife who served communities in rural Alabama and north Florida for over forty years and who spoke, taught and wrote from her heart on behalf of midwifery, died peacefully June 17 at her home.

I met Gladys at Midwifery Today's Florida conference a few years back. I remember her as big--tall, with long graceful hands and a big voice that captured her passion in every word she spoke. Gladys had big, important things to share, deep insights, a wisdom that was reflected in her big laugh. I went everywhere she went just to try to drink up all her bigness. I learned big things from Gladys: to have hope, not fear. To hold love and not hate in your heart, no matter what happens. To give of yourself freely and without regret. To cherish family and to love life.

At the end of the conference Gladys walked up to me and put her big arm around me. It was like the arm of an angel. She handed me the book she had written, Why Not Me?, her life story. In it she wrote me a special blessing. I looked deep into her eyes and knew she would always be a part of me. Gladys Milton was an incredible midwife and an incredible person. She touched so many lives in a big way with her big smile that left us all feeling so loved.

- Jill Cohen, Midwifery Today associate editor

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We had the joy of living with Gladys at two Midwifery Today conferences. She was a woman dedicated to the Lord and to mothers, babies and midwives. I remember how honored she was to come to Hawaii--but how honored we were to have her! She said it was her life long dream to go to Hawaii. How she added to our knowledge of both midwifery and the spiritual aspects of it. She lit up the room wherever she was. After being with her for the weekend I felt I had been given an amazing blessing. The glow she gave to those she came in contact with lasts forever. I remember after an Orlando conference she said, "I am happy to be leaving midwifery in such capable hands as all of yours. I do believe midwifery will go on strong in your hands." The passing of this mantle is a charge to all of us to honor her in our work by trying to be as good as we can be. This means loving the families we are given, but it also means loving each other as Gladys loved us.

- Jan Tritten, Midwifery Today owner/editor
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5) An Autonomous Midwife

Who knew more about autonomy than Gladys Milton? Following is an excerpt from her book that tells a little about what she faced during her midwifery career.

I guess doctors in the state were starting to worry that once we had succeeded in providing for women who were delivering on their own, we would start taking away women who would have been their patients. Maybe they were also worried about getting into more malpractice trouble. If midwives did all the low risk deliveries, more of the doctors' business would be riskier deliveries, increasing the possibility that something would go wrong and the doctors would be blamed for it .... an undeclared war began on the midwives of this state. It started as a "cold" war, so to speak, but the skirmishes came more and more often and gained in intensity .... we were faced with a bombardment of new rules and regulations.

The bad feelings we were sensing from the doctors we were now getting from the health department, too. The Health and Rehabilitation Services of Florida, the same agency that invited me into my profession, geared up for what appeared to be a massive battle. Maybe it wasn't anything personal, but their attitudes toward midwives in general started becoming very obvious. My girls were coming to me with all kinds of stories about how they had been treated rudely at the health department on account of me. I just couldn't believe it, but as time went on the incidents became more frequent and they got much worse.

In a few days .... I was told that the clinic was closed .... I was not to deliver another baby in it, even if someone came to my door the next minute .... There wasn't a hospital in the county that could deliver a baby, and here they were shutting us down. There were 21 births in Walton County that year and I had delivered every one of them. We were the only safe birth option for 60 miles.

One of my patients even called the governor's office. She told the governor's aide, "Women are going to be having babies all over the woods up here if you don't get this clinic opened back up." Several of my patients collected hundred of signatures on petitions to be sent to Governor Bob Graham .... We made phone calls, and sent letters, telegrams, petitions. One of my patients explained in a letter to our representatives that babies weren't going to stop being born just because they closed down a clinic. Not one of my patients wanted to go anywhere else, so I was "on the road again."

- Gladys Milton, "Why Not Me?"

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6) Autonomy and Service

Those of us who treasure our freedoms so highly must not be led to believe that legislation which "allows" us to practice will protect the autonomy we value so much. In every instance where midwifery has been given "approval" through legislation, the only people who have truly benefited are those who despise our art ....In states where legislation seemed to bring increased autonomy to the profession, midwifery arts are gradually being restricted.

I think midwives should be governed only by midwives. The profession has the capability to support its own associations, and through them, provide a way for midwives to meet core competencies, as NARM is now doing. If midwives continue to persevere in their efforts to make midwifery the standard of care for all women, soon their exemplary care and outcomes will become apparent to even the most skeptical.

I want to be there for the woman who is told she is "too old" to have a baby, wants a home VBAC, or who wants a vaginal breech birth, or has had six previous births. I want the freedom to consider factors other than what is in black and white: things such as her nutrition, attitude, general health, habits, environment and her support system. These are factors midwives know are crucial to good care and positive outcomes. If licensing does not allow me to assist a woman in these ways, must I again be made a criminal if I choose to serve her?

When midwives allow their right of self determination to be taken away, they seriously diminish the opportunities for women everywhere to determine their own childbirth destines. If that trend were to continue, eventually no woman will retain her personal right to choose where and how she will birth her baby. She may no longer be free to choose the environment for her birth, her caregiver or even the time her baby is born.

- Valerie El Halta, Midwifery Today Issue 42

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7) Question of the Week: What have midwives used successfully to slow down/halt preterm labor symptoms, i.e. lots of early contractions in clients as early as 26 weeks. I'm interested in alternatives to tributaline. Bedrest/taking it easy is a given. Has anyone had good results using progest. creme? (external application) Homeopathy? Other? I myself have used counseling & teaching self-hypnosis techniques occasionally for
stress reduction.

- Constance Miles, LM, RN

Send your responses to mtensubmit@midwiferytoday.com

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8) Question of the Week Responses

Q: Is there any evidence that laboring in the tub after the bag of water has broken increases the rate of infection in mother or baby? I have been unable to find any research to indicate this is so, but every nurse, doctor, and even a couple of midwives are convinced that this is so. What's the real story? Fact or theory?

- Amy Jones, Henderson, NV

A: Ulla Waldenstrom og Carl-Axel Nilsson: Warm Tub Bath After Spontaneous Rupture of the Membranes. BIRTH 19:2 June, 1992, pp.57-63. Includes 25 references from literature up to that time, not all directly related to bathing in labor. Here is the complete abstract of the article and a few comments from me.

Abstract: "Increasing numbers of pregnant women take a warm bath in labor. Yet few evaluations have addressed benefits claimed and possible risks of this practice. Using retrospective data from a continuing trial at a birth center in Stockholm, we compared 89 women who took a warm bath after spontaneous rupture of the membranes at term with 89 women who had the same interval from spontaneous membrane rupture to delivery and who did not bathe. No statistical difference was observed between the groups with respect to infections, asphyxia, or respiratory problems in the newborn infant, or maternal signs of amnionitis. However, a tendency toward more complications was observed in the bathing group. Babies born more than 24 hours after rupture of membranes had significantly lower Apgar scores at 5 minutes in the bathing group than in the control group. As a result of our review of the sparse literature on this practice and the data from this study, we have modified the bathing policy at the birth center from a rather enthusiastic to a more cautious approach. Recommendations about the use of a warm bath in labor will require further investigation, such as randomized trials with large numbers of subjects."

The authors comment in their concluding discussion in the article that "The lack of published research on the effects of water immersion during labor is surprising, considering the rapid spread of the use of water in childbirth. The use of pools and bathtubs in obstetric care may well follow the same pattern as that for the development of some medical technologies, such as electronic fetal monitoring. First, the method is widely acclaimed and accepted by the profession and, second, it is scientifically evaluated." They openly acknowledge the weak scientific basis for their own more conservative approach (women with ruptured membranes were thereafter discouraged from tub baths unless birth seemed imminent) and call for further research to clarify the effects of bathing on neonatal sepsis.

This was followed the next year by a review article which also called for more evaluation of the practice.

Rona McCandlish and Mary Renfrew. Immersion in Water During Labor and Birth: The Need for Evaluation. BIRTH 20:2, June 1993, pp. 79-85. 34 references.

Abstract: "Despite widespread and increasing use of immersion in water during labor, birth or both in many different countries, no reliable information is available about its advantages, hazards, and resource implications. We describe the development of immersion in water in labor and birth, the current use of this form of care in the United Kingdom, the research that has been conducted to date, and possible strategies for future research. Three approaches to research are suggested: a survey of existing practice, a randomized controlled trial, and a confidential register of serious adverse events."

They also present the results of studies done on water in labor in a clear table which is useful for seeing what people had investigated and what they had found up to that time (various outcome measures in the 7 studies presented, no huge differences for the most part, but generally less pharmacologic pain relief in bathing groups, no differences in complications).

So, while the original question is not unequivocally answered, the issues raised are important. Should there be different critical standards for practices such as EFM and water immersion in labor? Personally, I think not. In the context of informed choice, I do feel it is acceptable and necessary to say we just don't have firm evidence on which to make sweeping recommendations when that is the case. Anything else is dishonest. (In the case of EFM, I am well aware that the results are in and that we can safely and wholeheartedly support a woman's choice to have her labor followed using other means of checking how the baby is doing!)

- Rachel Myr, Norway: rmyr@online.no

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A: I would say it's neither fact or theory but just another in the long list of excuses to control women in labour and afterward. I recently counselled (informally) a woman who had her baby, now 4 months old, taken from her at birth and put in special care for 48 hours simply because she had a bath whilst in labour. She had not had an ARM (probably an oversight!!) so the "caregivers" didn't know when her membranes had ruptured and therefore it *may* have happened in the bath.

There were signs of fetal distress during the delivery, unsurprising if you know the whole story, but although the baby was born apparently healthy, someone decided that because one, she had an SRM; two, she had a bath; three, fetal distress, added up to her having the trauma of separation from her baby and worry about his well being.

They even inserted a cannula in the baby's arm just in case he needed IV antibiotics. When the blood results came back and all was fine, they simply removed the cannula. All this for absolutely no reason at all. This woman was 85 miles from home (for no reason other than "it's local policy if it's your first baby") and had no support whatsoever.

If there was any real basis for concern about infection, there would be very few waterbirths!

- Fiona Campbell-Smith, Scotland

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Please feel free to submit a Question of the Week! Send it to mtensubmit@midwiferytoday.com

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9) Switchboard

(In response to question of pelvis size, issue 23) According to what I have read, in centuries past nutrition was not so great and girls had less access to sunlight and exercise, so they would develop rickets and thus had malformations in their bony pelves. I am quite sure this led to many of the problems of our foremothers. Sometimes there are medical emergencies that only drastic measures (such as cesarean section ) can correct. In those cases I (and many other women as well, I am sure) are grateful those options are available. But, the original comment is still valid, the majority of women *can* give birth to the babies they grow.

- Holly Sippel, student midwife & CBE, Peabody, MA

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I am 29 years old and 17 weeks pregnant with my second child. I had a horrible experience with a c-section that was desperately unwanted with my first child, and we are now looking forward to our planned homebirth VBAC. I am in search of someone who is in the same situation with whom I might correspond. I receive great support from my husband and midwife, but would like to be able to share feelings with a mother who is going through the same challenges and fears that I am experiencing right now. Can you give me any suggestions?

- Laine H., guylaine@pon.net

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Can anyone point me in the right direction to getting information on midwifery programs in France?

- Jasmine Chatelain, tongue.tied@sympatico.ca.

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10) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- is breastfeeding a feminist issue? (July 2)
- Group B Strep (July 9)
- homebirth (July 16)
- cutting the cord (July 23)

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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