October 15, 1999
Volume 1, Issue 42
Midwifery Today E-News
“Twin Birth”
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Birth Without Borders--Weaving a Global Future

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* Philadelphia, Pennsylvania, March 23-27, 2000
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Send responses to newsletter items to mtensubmit@midwiferytoday.com

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Question of the Quarter: Midwifery Today magazine
5) Question of the Week
6) Twins: Some Things to Consider
7) Briefs
8) Switchboard
9) Why I Want to be a Doula
10) Classified Advertising
11) Coming E-News Themes

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1) Quote of the Week:

"Love and self are one, and the discovery of either is the realization of both."

- Unknown

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2) The Art of Midwifery

For acute back pain, use an ice pack at the site of pain, anywhere between the site of pain and the brain, or on the side opposite the pain. Because of the gating mechanism in the central nervous system, intense cold at any of these locations may beat a pain message to the brain. An ice pack may even be applied to the back of the woman's neck for the duration of a contraction.

- Adrienne B. Lieberman, Easing Labor Pain, Harvard Common Press, 1992

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Share your midwifery arts with E-News readers! Send your favorite tricks to mtensubmit@midwiferytoday.com

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At Midwifery Today, we have lots of tricks up our sleeves! Purchase our two volumes of Tricks of the Trade and you'll see what we mean: Save $5 when you purchase both Tricks of The Trade. Volume I and Volume II. Only $40 plus shipping! Call today to order: 800-743-0974. Please mention Code 940.

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3) News Flashes

A study of 199 pairs of twins evaluated the effect of delivery interval on the outcome of the second twin. All twins in the study weighed greater than 1,500 grams and were at or beyond 34 weeks gestation, and the first twin was delivered vaginally. Neonatal data evaluated included the five-minute Apgar score and evidence of birth trauma.

Time intervals between the births of each twin were divided into four categories: 15 or less minutes, 16 to 30 minutes, 31 to 60 minutes, and greater than 60 minutes. An interval of greater than 60 minutes between twin deliveries did not have an adverse effect on outcome, as judged by Apgar score, length of stay in the hospital, or birth trauma.

Researchers concluded that a prolonged delivery interval between twins did not have an adverse effect on the outcome of the second twin.

- MIDIRS, June 1996

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4) Question of the Quarter for Midwifery Today Winter 1999 Issue No. 52:

What alternative therapies do you find most useful in your practice?

Send your responses to mtensubmit@midwiferytoday.com You may submit up to 425 words.

=PLEASE SUPPORT OUR SPONSORS!=

Mayo Clinic Midwife Opportunity

Mayo Clinic is seeking applicants for a full-time Nurse Midwife Program Director (job posting #99-4110.MWT) to plan midwifery activities and supervise other certified nurse midwives. School of Nursing graduate with MS and ACNM certification required.

Mayo Clinic offers an excellent salary, relocation assistance and great benefits package.

Please submit resume to: Mayo Clinic, Julian Currie, Human Resources OE-1, 200 1st Street SW, Rochester, MN 55905. Fax: 507-284-1445, e-mail: currie.julian@mayo.edu
www.mayo.edu

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5) Question of the Week: What is one of your favorite herbal remedies or preventatives? Be specific about amount, frequency and application. Think outside the usual!

Send your responses to mtensubmit@midwiferytoday.com

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6) Twins: Some Things to Consider

Many of the factors that place multiple pregnancies at risk may be virtually eliminated when the mother is adequately nourished, and this means "eating for three." The mother of twins is more at risk of developing preeclampsia due to the added stress upon her body. Yet, based on many years of experience with women of all risk categories, I am convinced this condition need never develop when adequate amounts of protein are consumed. Other conditions such as anemia, varicosities, placental insufficiency, prematurity, hemorrhage, uterine dysfunction and uterine atony are all hallmarks of a multiple gestation which are to be expected, according to obstetric literature. I believe, however, that these conditions may be completely preventable as well.

Why do so many multiple births happen prematurely? The medical theory is that multiple pregnancy not only causes added stress on the maternal system but that over-distention of the uterus causes premature contractions and labor. If that is so, why do so many very large babies (over 9 pounds) often go to term, or are even overdue? I sincerely believe most twins are born prematurely because they are suffering from starvation in utero, and come out early so that they can be fed!

Several important considerations should be noted when anticipating a twin delivery. These include: the mother's commitment to her nutrition and general health; the type of twins (fraternal, monozygotic, etc.); the placental attachment site; the position of the babies and their growth and development. It must be noted that monozygotic twins have a greater likelihood of having fetal anomalies and are at risk for developing twin-to-twin transfusion. For this reason, I strongly advise clients to have at least three ultrasound exams during the course of the pregnancy.

The first should be done at the time the multiple gestation is suspected or diagnosed. In my experience, this is usually between 16 and 20 weeks. At this time, the gestational age and the type of twins expected are most easily diagnosed. Hopefully, even if only one placenta is seen (it is possible that two placentas have fused early in pregnancy), individual amniotic sacs will be identified. If both babies are within one amniotic sac, the delivery risk is very high, as the babies, and most important their umbilical cords, may become entangled.

The second ultrasound should be done at about 30 weeks, so results can be compared with the first scans. At this time, problems such as intrauterine growth retardation (IUGR) may be diagnosed in one or both babies due to placental insufficiency. Or, any life-threatening anomalies in one or both babies can be identified so that preparations and plans can be made as to mode and place of delivery. An ultrasound at this time may also detect a discrepancy in size and estimated gestational age, which is possible when there is a separate conception date (rare) for the babies.

Also at the 30-week mark, if twin-to-twin transfusion is taking place, the babies will be remarkably dissimilar in size and weight, and the mother should be referred for high risk care. In this case, the babies will be monitored closely and delivered as soon as they have reached sufficient maturity.

Interestingly, the baby most at risk is the larger one who has received a surplus of blood. This baby must be handled very delicately as its internal organs have been stressed. Often, the suffused baby will require one or more exchange transfusions to first reduce and then to supplant red blood cells. The smaller, anemic baby can simply be given extra blood.

It is wise to have at least one more ultrasound done as close to term as possible in order to verify the babies' presentation and position. Even with the most experienced hands, this information is often difficult to assess as there are so many parts to feel!

- Valerie El Halta, Twins: A Very Special Occurrence, Midwifery Today Issue 39

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7) Briefs

Occasionally the placenta and membranes of the first twin are delivered before the second baby is born. Excessive bleeding may occur from the placental site and the placenta of the second twin may also begin to separate. The second sac of membranes should be ruptured immediately and the baby and placenta delivered as quickly as possible. The uterus should then contract and bleeding be controlled.

- Mayes' Midwifery, Betty Sweet Ed., Balliere Tindall, 1997

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Research has shown that women who are expecting twins can have a VBAC as easily as women expecting one child without added risks, including uterine rupture.

- Diana Korte, The VBAC Companion, Harvard Common Press, 1997

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The obstetrical tendency toward weight and salt restriction has made many multiple pregnancies a nightmare of complications, and most doctors view them as high risk. The fact that typical bio-technical medical management results in a toxemia rate of 50% in twin pregnancies and 75% in triplet pregnancies is ample proof of the nutritional neglect=hypovolemia=toxemia etiology.... Cervical cerclage and labor suppressing drugs may be recommended along with bed rest, weight restriction, and cesarean section. Predictably, this results in low birth weight, premature babies as well as a higher incidence of abruption and hemorrhage in mothers.

- Anne Frye, Understanding Diagnostic Tests in the Childbearing Year, Labrys Press, 1997

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Immediate postpartum: Watch for signs of shock! Treat prophylactically: keep mother supine and elevate lower extremities. Keep mother and babies warm. Offer sweetened fruit juice or other high fructose beverages, as tolerated.

Be prepared to stay with mother and baby for at least 12 hours postpartum. It may take babies somewhat longer than normal to stabilize. Mother needs to be watched for any signs of postpartum eclampsia, which is more common after twins due to rapid changes in circulation, excessive fluid retention, etc. There is more necessity for immediate diuresis, yet kidney function is slower.

- Valerie El Halta, Study Outline for Twins, Midwifery Today Issue 39

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8) Switchboard

I am a 32 year old African American woman pregnant with my first baby. I am 5 months and have been diagnosed with gestational diabetes. I have been put on a special diet. If my glucose levels do not stabilize, I will not be able to continue my pregnancy with the midwifery practice. I'll have to be transferred to the doctors who will administer insulin. I do not want this to happen. I have been very strict about the diet, but would like to know if there are any herbal recommendations that would assist my diet and lifestyle changes. I read up on bitter melon and fenugreek herbal supplements, but found warnings against taking them during pregnancy. Please help. I only have two weeks to make this change.

- Monica Z. Utsey, mutsey@ahma.com

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To Karen van Loon [Issue 41]: No, in the Netherlands we don't have doulas; usually women in labour cope very well with just the husband there. When I visit, I assess the woman and her progress. Then, after discussing when I will be back and explaining how I can be contacted if I am needed before the agreed time, I leave them. Generally, this works as a boost for the morale: the mere fact that I expect them to cope on their own increases their self-confidence. But if a woman is apprehensive or needs a lot of support, I stay and simply wait it out.

- Eveline Arends

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In response to Sheila Snow [Issue 41]: While Emergen-C is, indeed, a great electrolyte booster, the high content of vitamin C can cause excessive bleeding after birth, surgery, dental work, or other "bleeding potential" event. High doses of vitamin C can promote anti-coagulence. Caution should be exercised when employing this powder during labor. Dr. Andrew Weil (Spontaneous Healing) cautions against high doses of vitamin C before surgery. While childbirth isn't surgery, one bleeds naturally. Since we are all concerned that mothers do not bleed more than necessary, the use of regular strength "Emergen-C" during childbirth is *not* a good idea. Diluting it in twice or three times the water called for in the package directions may be a more appropriate solution than using it full strength. This dilution would then reduce the total Vitamin C intake accordingly.

For a better option, try this:

"Labor Aid" Mix
1 qt water
1/3 c honey
1/3 c juice from a real lemon
1/2 t salt
1/4 t baking soda
2 crushed calcium tablets
Serve cold or freeze into small ice.

- Kim Mosny, CPM

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In reference to B. Cohen's statement, "please be careful when using the term 'always,'" [Issue 41]: Two words I try to avoid in my professional life are "always" and "never."

- Phil Watters

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I have been informed by a consultant paediatrican that it is commonplace to give complementary nasal gastric or oral gastric feed to infants of breastfeeding mothers in the first days of life until milk is established. Is this true? I would have thought this untrue unless there was a medical reason to do so. Surely complementary feeds will delay the breastmilk coming through.

- Gabrielle Flynn

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I want to find more information on suturing tears versus not suturing 2nd degree straight tears that meet up. Are there any studies on long term effects on vaginal tone, rectocele, sexual comfort, length of time of healing? I was taught to suture everything 2nd degree but have recently been questioning this practice when a woman has a straight 2nd degree tear and she could follow through on the instructions to religiously keep her legs together in addition with a sprinkle of comfrey root powder to increase healing.

- Beckie Wood, CPM

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We are just leaving Zimbabwe, having spent a month traveling 4000 km around the country. In between safaris, national parks and Victoria Falls I've visited a few rural clinics and met midwives and mothers--one in labour who had a Hb of 4.6 g/dl--nothing unusual in many of the poorer areas apparently. Women work hard here; they carry water from the bore hole, and firewood from the forest, grind the corn, cook, feed the animals, wash and look after the kids, all with a baby strapped on their back and none of the household appliances we take for granted.

I'm sure the men do something but it seems to me they spend a lot of time sitting around watching the women! Despite this, women also make sure they have fun.

On a visit to meet traditional midwives with Dr. Sibanda from Common Knowledge, we were greeted by them singing and dancing a welcome, and our conversation was punctuated by much laughter and clapping. We might do some things differently--I haven't ever tried dried donkey placenta during a difficult labour, for example, but what was exhilarating for me was the many similarities. One midwife picked up her empty cola bottle to demonstrate how she gets a woman to blow into it to help deliver the placenta--exactly what my independent midwife in London suggested during my second child's birth at home.

So thank you and goodbye to all the midwives and women I've met here. My admiration and respect go out to you all. We're off to Nepal and our next adventure. Watch this space!

- Annie Francis, midwife

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I am a first year Dip HE midwifery student at DeMontfort University, UK and would appreciate any tips, advice, comments, pros and cons on a physiological third stage of labour to help with a presentation. I have completed a literacy search with a little success but need further info. especially with regard to a water birth.

- HelenL.holmes@rothley66.freeserve.co.uk

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Share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com If an e-mail address is included with the letter, feel free to respond directly.

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9) Why I Want to be a Doula

I have been interested in midwifery for some time. My father had three daughters and dreamed that one of us would become a midwife. After having a homebirth, my interest deepened. Following my second homebirth I began studying with my midwife.

My third baby was due December 24th but I fully anticipated that he would be early as my other two had been. I went into labor a week early. On the way to my home my midwife had a wreck in the snow. After a couple of hours, labor stopped. I felt responsible for her accident. A week later I called her again and she stayed with me for over 24 hours while I went in and out of labor. The next day labor quit again and everyone packed up, including my family. I have never felt so alone in my entire life and I have lived alone in a foreign country for three years.

An hour later my father called to see how I was doing and I started to cry. My parents then came to pick me up and I went to see another midwife at a clinic. She looked at me and asked "Are you sure you are not in labor?" Not wanting to be immediately sent to the nearest hospital, I declined to answer. When I left her office I called my homebirth midwife and asked her to come back and break the water as the baby had moved down to +/- one station. Within two hours I went from 4 cm. to holding my son, who weighed 9 1/4 pounds!

Because of that experience I am interested in finding out more on how to become a certified doula. I want to be there for other moms so they don't have to go through what I experienced. If anyone has information on how to become one I would be glad to hear from you.

- Cindy Lou Bailey
bailey@pioneer-net.com

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Why did you become a birth practitioner--or why do you aspire to become one? Send your responses to to mtensubmit@midwiferytoday.com

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10) Classified Advertising

Doula Training: Bring emotional, informational and comfort support to birthing families. Train to be a doula. October 8 and 9, New Orleans, Louisiana or October 22 and 23, West Union, Iowa. Contact Debbie, 1-800-648-3662 or theyoungs@trxinc.com.

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11) 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:

- Miscarriage (Oct. 22)
- Herbs (Oct. 29)

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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