October 22, 1999
Volume 1, Issue 43
Midwifery Today E-News
“Miscarriage”
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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 Week
5) Who Miscarries?
6) Switchboard
7) Why I Became a Birth Practitioner
8) Coming E-News Themes

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1) Quote of the Week:

"We have all forgotten more than we remember."

- Proverb

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2) The Art of Midwifery

Black haw and crampbark are the two herbs most commonly used by European physicians, Native Americans and modern herbalists to calm the uterus. Red raspberry has a long history of use in pregnancy for threatened miscarriage. Standard dosage: 2 capsules three times daily.

False unicorn is prized by herbalists for its adaptogenic effect on the ovaries (normalizes function).

Wild yam (dioscorea villosa) may benefit those women who are threatening miscarriage due to stimulation to the adrenal glands as well as the antispasmodic effects of the herb.

- Shonda Parker, The Naturally Healthy Pregnancy, Naturally Healthy Publications, 1998

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3) News Flashes

A 1988 national survey showed that nearly 18 percent of pregnant women who deliver after 20 weeks of pregnancy are advised by their doctors to rest in bed for at least a week during pregnancy. Yet in nearly every case when bed rest has been studied, there is no proof of benefit. Researchers have found no evidence that bed rest reduces the rate of first trimester miscarriage, that it reduces risk of premature delivery or improves baby health in women with multiple fetuses, or that bed rest will lead to a healthier baby when the mother has high blood pressure which began before pregnancy.

- AP wire service reports, July 16, 1994

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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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4) 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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5) Who Miscarries?

Each year, between 600,000 and 800,000 U.S. women miscarry. Given that a woman is likely to have more than one pregnancy, the chances that she will have a miscarriage at some time in her life are very great. Miscarriages are a possible outcome of first as well as subsequent pregnancies, even after a woman has given birth to many full-term normal children. It is related to age--the likelihood of miscarrying is high for very young teenagers, reaches its lowest point (12 percent) for women around the age of 20, and increases to 41 percent for women pregnant at the age of 42. They are more common in early (between the seventh and fourteenth week of gestation) rather than late (between the fifteenth and twenty-eighth week) stages. Miscarriage is also a highly likely outcome of pregnancies accomplished with the assistance of reproductive technology.

Because people often believe erroneously that miscarriages do not occur after the first trimester, some women do not divulge the fact that they are pregnant during that time. People are also superstitious about miscarriages and do not like to talk about them with pregnant women. As a result, pregnant women frequently know very little about them.

Currently women receiving prenatal care who are at risk for miscarriage are prescribed bedrest, reduced activity and cessation of sexual intercourse, although none of these prohibitions has been definitely linked with increasing the chances of averting miscarriage.

The likelihood of a subsequent miscarriage increases after two experiences. Repeat miscarriages can sometimes be traced to a cause (e.g., genetic abnormality or exposure to teratogens) that may be correctable. The cause of most miscarriages is not known, although most probably reflect a defect in the developing fetus rather than a problem in the woman or her partner. Male fetuses are more likely to be miscarried than female fetuses.

- Encyclopedia of Childbearing: Clinical Perspectives, edited by Barbara Katz Rothman PhD, Oryx Press, 1992

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Fifteen percent of all clinically recognized pregnancies end in miscarriage. When pregnancy is diagnosed much earlier with very sensitive hormone tests, it is found that up to 60% of pregnancies end in miscarriage. Considering this figure of 15%, we would expect only 0.4% of women to miscarry 3 times consecutively, and it be due to nothing more than chance. In fact, 0.8-1.0% of women do so, suggesting other factors may be involved.

It is important to remember that 60-75% of women who have recurrent miscarriage (RM) will go on to have a successful pregnancy the next time, without tests or treatment. When a woman is investigated for RM, the majority of the time no cause is found.

Following are some of the things which are thought to be associated with RM:

  • Systemic Lupus Erythematosus (SLE) which is a disease affecting many systems of the body. People affected often have a butterfly-rash over the cheeks and bridge of the nose.
  • Antiphospholipid antibody syndrome. This is an immune disease where the main problems are RM, clots in the veins or arteries and often a low platelet count. If pregnancy is successful, it can be complicated by poor growth of the baby and preeclampsia.
  • Chromosome problems. Parents are fine, but when put together an unusual gene mismatch occurs (only 3% of RM).
  • Uterine (womb) abnormality. Double-womb or a septum down the middle, associated in about 4% of RM and is found in 1.8-3.6% of the normal population. Whether this type of problem actual is to blame hasn't been proven, and the risks of surgery to correct the problem must be weighed against any potential benefit.
  • Fibroids sometimes cause misshaping of the womb cavity.
  • Cervical incompetence (weakness). May cause miscarriage in 2nd trimester, but only likely if there is clear history of severe or recurrent trauma to the cervix with RM. Some women are just born with a weak cervix. This is not as common as some people report, and the diagnosis is very difficult to make.
  • Polycystic ovary syndrome. Often this disease causes infertility or trouble even getting pregnant. When it is present with a raised hormone level (LH) there is an increased risk of miscarriage. Hormonal treatment for this is being looked into, but there is minimal evidence available on who might benefit. It does appear that women with very irregular periods and a raised LH may benefit.
  • Immune problems. Couples with RM may have some similar components of the immune system. This can make it difficult for the woman to make the appropriate response to pregnancy. This is a controversial finding, and no immune therapy has been found to improve chances above and over the 60-75% seen without intervention.
  • Hormone "deficiency": In pregnancies that end in miscarriage, sometimes the levels of progesterone are found to be low. This is thought to reflect an early pregnancy failure, and is probably the *result* rather than the cause of the miscarriage. Progesterone supplements do not increase the likelihood of an ongoing pregnancy.

- D.E. Tucker, Women's Health, www.womens-health.co.uk

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6) Switchboard

In response to Valerie El Halta's recommendations for avoiding premature and low birthweight twins (Issue 42): my own experience contradicts her advice on "eating for three." My twins were discovered by ultrasound at 36 wks gestation and estimated to be over 7 lbs each at that time. By the time they were born at 40 wks + 2 days they were 8 lb 10 oz and 8 lb 9 oz. Throughout my pregnancy I ate for two, not three, gained one pound less than I did with my 7 lb 15 oz first daughter, and experienced no "twin symptoms" (such as hypertension, varicosities, etc.) other than amazing stretch marks. My diet was good, and partially organically grown, but not particularly high in protein (yet my haemoglobin was 127 at 36 wks) or calories.

I feel that the exceptionally good outcome for my twin pregnancy was due to the fact I was treated as a low-risk homebirth client for the first 8 months. I was not subjected to serial ultrasounds, blood tests and obstetric interference, which would, at the very least, have raised my blood pressure significantly. While I'm not advocating anyone ignore indications of multiple gestation, I am suggesting that early detection and obstetrical monitoring of twin pregnancies may not necessarily lead to better outcomes.

- Jennifer Landels, BA, CBE
Vancouver BC

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I am an aspiring black midwife. A forum has come together in part because of my need to meet and learn from other women of color who have chosen midwifery as their profession, and because of my quest for a mentor. I have spoken with many great women and all our talks had the same theme: how do we get women of color into quality midwifery training programs, and how do we get them to *complete* these programs and start practicing. This forum will be: A place to meet, discuss and strategize ways to encourage and support quality midwifery education amongst women of color. Midwifery in its current form is not meeting the need of minority women for one simple fact: there are not enough women of color who are midwives. I invite you to join a chat scheduled for 9:00 pm CST November 11, 1999. Please let's invite any and all women of color interested in this discussion. Send me their e-mail addresses and I will get an invitation out ASAP. Ladies, the time is now!

- Desiree
desireeadaway@hotmail.com

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In response to the Dutch midwife's letter in your last issue: I am surprised that an experienced midwife would be so quick to negate the role of the doula in birth. Was it not the World Health Organisation that found that pregnant women/women in the birth process benefit from two things: support and good nutrition? It seems very obvious to me that as the doula's role is to provide emotional support for the pregnant/birthing couple, this role is key. Every pregnancy/birth is unique, and often husbands/partners are not physically or emotionally present. In these situations wouldn't the primary caregiver benefit from having the mother's emotional needs attended to? And in the cases in which the husband/partner is able to lend full support the doula can still normalize tense situations and use her experience to guide the partner in his/her efforts. Also, I would imagine a primary caregiver is not always able to do massage or help a woman use relaxation techniques as she/he is busy attending to the clinical side of things.

- Kate Rudrum

Dutch midwife Annemieke van der Peet replies:

Thank you for your reply. It is a good thing we discuss this, for it shows our experiences are indeed worlds apart. From what I gather in Midwifery Today, etc., doulas are absolutely indispensable, but as I said, we don't have them. On the other hand we would be lost without our maternity aides in the week after the birth!

I do not think there has ever been a woman in labour who did not need emotional support; it is of utmost importance. But if all goes well, my presence does not make it any better. I also pointed out that whenever it seems useful I will stay and do whatever is needed. In that case I will sponge and massage and croon for as long as it takes. To be quite truthful, I love that part of my work, but it is *not* for me to take over; it is *their* birth, not mine.

Also, and I don't want to offend anyone, the clinical side of things is very low-key here. It is the woman I am looking after, not her belly. In fact, my clinical skills are there for the "just in case" scenario.

[Editor's note: Last week's message was incorrectly attributed to Eveline Arends, when in fact it had been written by Annemieke.]

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I am a third year midwifery student based in Worthing England. Next June we are able to travel and exchange ideas with midwives in another country. The objectives for the international perspectives of midwifery placement are: to gain an appreciation of the cultural, political, environmental and clinical issues affecting childbearing internationally. It is seen as an observational placement; however, we have some clinical skills which we would be keen to utilise should it fit into your hospital. On my return I will give a presentation of the experience.

I think it is a good opportunity to educate midwives about how women deal with an aspect of life that unifies women worldwide. I would be interested to hear from midwives in hospitals or clinics who would be able to offer such a placement, possibly where there are projects. I am willing to pay for accommodation ( within reason) as I am on a bursery.

- Dot Fogell
dotfogell@cwcom.net

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The British Columbia College of Midwives has pursued an injunction against private birth attendant Gloria Lemay. When the College was set up a year ago, it was given a mandate to "protect the public." Since Gloria is not a member of the College and is still attending women at birth, they feel she must be a danger to the public. So, imbibed with a sense of self-righteous vigor, they are going full-fuel on a publicly funded vendetta.

Many women choose to be attended by someone outside governmental control. They choose an attendant like Gloria Lemay. With Gloria, they know they'll have a less than 2% chance of cesarean section, and a fraction of a percentage's chance of induction. With Gloria, they know they'll get superlative nutritional advice, access to her vast resources and her gentle, non-intrusive assistance at birth. This woman is not a threat to public safety, she is a godsend. The families she serves cherish her, and keep her in their service for generations.

I urge everyone to contribute to the Birth Freedom Fund. Gloria's dream is to have 1,000 people send in $5, and that's not a lot of money. Please help this woman who is the catalyst of so many girls becoming women, and of babies being born gently, softly, safely into their unmedicated mothers' arms. Please help this woman who has committed her life to serving birth in the most pure form possible: in her exclusive service of women.

Send your donation to Chouinard & Co., #1201-510 West Hastings St., Vancouver, BC V6B 1L8, Canada. Write on the inside or outside of the envelope "Birth." Please make checks payable to either Chouinard & Co.(her lawyers) or Gloria Lemay. Be sure to include your name and address so Gloria can acknowledge your partnership.

More information can be found on my website:
www.birthlove.com/pages/gloria_lemay.html
Included is a link to new letters written in Gloria's support.

- Leilah McCracken

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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 waterbirth.
-HelenLholmes@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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7) Why I Became a Birth Practitioner

I have a little theory about why some of us become birth practitioners. I think one clue lies in our own birth experiences. Not of our own babies, although that seems most often to be a trigger. Rather, I am speaking of one's own birth, passing from our mother's womb into this brave new world. My mother had a difficult time with my birth, and from the clues I gleaned from her stories, I believe I was an abruption. Perhaps this has sent me on a lifelong mission to help others who need a pair of watchful eyes and a helping hand.

Interestingly, when I was on a recent interview, I was asked a similar question by the interviewing CNM. As I spoke this theory to her, a small smile spread across her face. "I was an abruption too," she told me at the end of the interview. We smiled together. Instant kinship beyond our mutual calling. How many of us who are out there had to fight to enter, and came out swinging for mothers and babies?

- Jill Earl

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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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8) 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:

- Herbs (Oct. 29)
- Waterbirth (Nov. 5)
- Gestational Diabetes (Nov. 12)

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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