December 10, 1999
Volume 1, Issue 50
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Oxytocic Drugs
5) Question of the Week
6) Question of the Week Responses
7) Switchboard
8) Classified Advertising

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1) Quote of the Week:

"Love your neighbor, but don't pull down the hedge."

- Swiss proverb

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2) The Art of Midwifery

Listening is noting what, when and how something is being said. Listening is distinguishing what is not being said from what is silence. Listening is not acting like you're in a hurry, even if you are. Listening is eye contact, a hand placed gently upon an arm. Sometimes, listening is taking careful notes in the person's own words. Listening involves suspension of judgment. It is neither analyzing nor racking your brain for labels, diagnoses, or remedies before the person is done relating her symptoms. Listening, like labor assisting, creates a safe space where whatever needs to happen or be said can come.

- Alison Para Bastien, "The Healing Art of Listening," Midwifery Today Issue 26

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To read this beautiful article in its entirety, order Midwifery Today Back
Issue 26. Call 1-800-743-0974 or visit our website at www.midwiferytoday.com
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3) News Flashes

Women have commonly been denied trials of labor if their first cesarean section was performed for failure to progress or cephalopelvic disproportion, the most common indications for primary cesarean. In a 1987 study published in the American Journal of Public Health, the largest percentage of women attempting VBAC had cephalopelvic disproportion or failure to progress cited as the primary indication for their initial cesarean. Of these women, 65 percent--almost two thirds--went on to have normal births; many of the babies were much larger than the baby for which the original cesarean section had been performed.

- ICAN Clarion, Sept. 1997

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4) Oxytocic Drugs

Few childbearing women realize the inherent risks of oxytocic drugs. In addition to the more benign effects of uterine stimulants, the American manufacturer of Pitocin points out in its package insert that oxytocin can cause: a) maternal hypertensive episodes, b) cardiac arrhythmias, c) uterine spasm, d) titanic contraction, e) uterine rupture, f) subarachnoid hemorrhage, g) water intoxication, h) convulsions, I) coma, j) pelvic hemotoma, k) postpartum hemorrhage, l) afibrinogenemia, and m) fetal death.

Uterine stimulants that foreshorten the oxygen-replenishing intervals between contractions by making the contractions too long, too strong, or too close together increase the likelihood that fetal brain cells will die. The situation is somewhat analogous to holding an infant under the surface of the water, allowing the infant to come to the surface to gasp for air but not to breathe.

All these effects increase the possibility of neurologic insult to the fetus. No one really knows how often these adverse effects occur because no law or regulation in any country requires the doctor to report an adverse drug reaction to the country's drug regulating agency, even if the patient dies.

- Doris Haire, "Update on Obstetric Drugs and Procedures: Their Effects on Maternal and Infant Outcome," Birth Gazette 13:1, 1996.

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5) Question of the Week

Is it possible to "diagnose" a nuchal hand before birth (other than with an ultrasound in labor)? Is there anything one can do to help keep the mother from tearing when there is a nuchal hand? Any other useful information on the topic of nuchal hand/arm is welcome.

- Ulrike

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Send your responses to mtensubmit@midwiferytoday.com

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6) Question of the Week Responses

Q: Has anyone heard of a "thin uterus"? Is this a real condition, and if so do you have any suggestions on how to remedy it and strengthen the uterus? This has to do with a desired first pregnancy. -J.L.

The uterus is made of smooth muscles. Exercise strengthens and nourishes them. Calcium ions participate in the process of muscle contraction, retraction and compression. Vitamin K, calcium and iron are involved in the nourishment of the uterus and its functioning so that later on during labor, postpartum hemorrhage can be avoided with the aid of skilled midwife's hands.

Nettle and wild yam work together to nourish the developing embryo and uterus, which helps prevent threatened miscarriage. The uterus is bathed by our hormones which is a function of a healthy pituitary gland working in concert with less stress, nutritious food, enough sleep and power to relax and be open to prayers.

First time mothers in the Philippines, even before they get pregnant, get a uterine massage from skilled massage therapist/elders to position the uterus well and provide strength. The way we move our bodies, even belly dancing and pelvic rocking, squatting and our daily chores of cleaning the floor on hands and knees may influence the tone of our uterus. I believe a well toned uterus is the key to a healthy pregnancy.

- Connie Dello Buono

[Editor's note: To read more about uterine massage, order Midwifery Today Back Issue 49 for an extensive article on the Arvigo Method of Mayan Uterine Massage. 1-800-743-0974 or www.midwiferytoday.com. Please mention Code 940.]

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Q: Any ideas, advice or recommendations on how to naturally induce labour? I am a midwife with a high percentage of first time mums overdue; they get fed up, and I have run out of tips.

- Anon.

No one has mentioned using cotton root tincture for inducing labor. Anyone ever try it?

- Anon.

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According to the medical literature, human gestation ranges from 36 to 44 weeks. That is a two-month range, not the EDC plus or minus 2 weeks. The mean length of time plus or minus one standard deviation gives the 38-42 weeks range, with 40 weeks the average, or mean.

The mean has come to mean the right answer. Phooey! Here is an analogy: Few people actually have a 98.6 F temperature; that is an average. Some actually feel unwell if their temperature is 98.6 because their own body temperature is lower. Everyone has his or her own range. So it is with due dates.

Where I live, over 50% of births involve Pitocin, usually to induce, often because the practitioner wants the birth to be Monday through Friday, daylight hours. Sometimes it happens because the mother is complaining about the heaviness and pressure of late pregnancy and the provider takes that complaining seriously and tries to fix it. Sometimes it happens because the mother has dilated (even as far as 5 cm) or effaced a lot but isn't having contractions; the practitioner fears the baby will fall out (mothers wish that would happen!) and brings her in and induces. There is no respect for natural process. Even a birth center where I teach transfers 20% of women to the hospital most commonly because the women "need" Pitocin. How could the human race have survived if 20% of women couldn't give birth without drugs?

I hate the whole idea of "due date." It is only a guess that creates expectation. The woman often circles that date on her calendar so she won't schedule any other appointments for that day. Better to teach women that the misery of late pregnancy is a natural motivation to want to go into labor, which is a natural progression from the joy of showing the sweet little belly that occurs in the early months. Teach them how to pay attention to their babies to know if things are OK in there. Babies will still play and respond inside even at the very end.

Practitioners may want to see her every week, to listen to a heartbeat or check a blood pressure, to tell her how well she looks, to listen to her complain and suggest a warm bath and other comfort measures, and to communicate to her that pregnancy is a time of waiting.

As a cranio-sacral therapy practitioner, I appreciate the power of intention and belief. When the healthcare provider gets worried about the length of gestation, that worry communicates to the woman, who may delay the start of labor longer because her adrenalin level can go up. Worry and beliefs are contagious. And we all know that adrenalin is the enemy of oxytocin!

So let's organize to keep pregnant ladies happy. Watch them with love and for heaven's sake, let the baby come when it wants.

- Nikki Lee

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I think we shouldn't even consider doing anything to induce before 42 weeks unless there are definite concerns about the health of the baby. A mom is not post dates until she is past 42 weeks. Until then she is merely "due," not overdue.

I know some advocate induction near the due date because they think it will avoid problems with big babies, but the rate of fetal growth slows down near term. The average baby will gain no more than 4 to 8 ounces during that additional two week period. This quarter to half pound gain is hardly likely to significantly affect the birth outcome.

- Gail Hart

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Four of my five babies born in hospitals were induced (the fifth baby was a section). I have had one Pitocin drip, two AROMs, and one Prostin plus AROM. I have also had my membranes stripped in numerous late dates pelvic exams.

These induced births were unpleasant for many reasons; for example, the Pitocin made my contractions agonizing, the AROMs made my babies go into terrible positions for birth, and the Prostin meant twelve hours of useless, tiring, constant contractions (not to mention it's just plain disgusting to now know there was pig semen in me). These babies were induced to "get things going," and all inductions made me believe I could never "get things going" all on my own.

Not once was I told of the terrible risks that accompany labor induction. Induction was always portrayed as safe, easy, expedient. But I now know that the drip made my baby more likely to have debilitating oxygen deprivation, the AROM put my babies at higher risk of death by cord prolapse, and the long-term effects of having the sperm of another species in me are not even known. The full hazards of induction are extensive and poorly researched. (And the idea of "natural induction" is illogical--any birth made to come before its time holds risk, and the words "natural" and "induction" together create a genuine oxymoron.)

With my sixth baby, I would certainly have been induced again if I had chosen to remain within medical confines to give birth. I went a full four weeks past my "best before" date, but I had wisely chosen the care of Gloria Lemay, the least interventionist birth attendant in my province. As the weeks went by, she reassured me of my body's innate birthing wisdom and of my baby's beautiful birth. It was difficult. I genuinely believed I couldn't give birth without artificial coercion, but I trusted her. And when the time was right I simply, easily, beautifully, and magnificently gave birth.

Any woman who is impatient to get her baby out or any attendant who is impatient for her, must know that inductions hurt terribly in many ways and have effects that are not even fathomable. Inductions undermine a woman's faith in her own body, and pilfer from her the most crucial rite of passage a woman can have. The birth attendant's job is to help women trust birth and be their strong anchor when fear, distrust and impatience threaten to overwhelm completely. It is the attendant's job to keep women and babies safe and mind the pregnant and birthing woman's body as the cathedral of life that it is, never to be desecrated by tubes, hooks, needles, animal semen, beef and hog pituitary gland extracts, or overeager fingers. Birth can be trusted, and is safe.

- Leilah McCracken

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I read Phil Watters' comment about induction in the Dec. 3 issue and at first I was almost offended, but as I thought about it, I realized he is right! Midwives, we need to remember that one of the biggest reasons couples opt for homebirth is to *avoid* intervention. If we don't help protect them from that, we have done them a disservice.

Induction should never (in home or hospital) be done because mom is "antsy." One of the biggest reasons homebirth is a safe option is because nature is (or should be) allowed to do its own thing! Only in recent times has everyone started worrying about "due dates." Judging by the increasingly poor mortality rates in the U.S., all our "labor management" has not improved things much!

If I had not been a firm believer in this before I entered midwifery, I would have been after I spent time in a backwoods, doctorless maternity clinic in Bolivia. Those ladies had nothing going for them according to U.S. standards and they never worried about "due dates," yet their bodies gave birth very well to healthy babies, and I *never* saw a "deteriorating placenta!"

If mom gets impatient and uncomfortable, it is our responsibility to counsel her to be patient and help her understand the reasons why patience is still the safest option. A safer option than worrying about "due dates" would be to ensure that mom has an optimum diet so she and baby have optimum health when they go into labor.

A 280 day pregnancy is an *average* based on a 28 day cycle. To create an average, there must be those on either extreme. On the other hand, I know midwives will sometimes induce labor simply due to pressure from the medical community to conform to their standards. A case in point: A former client of mine has had seven healthy babies. The first two were medically induced, knock-em-down, drag-em-out, hospital horror stories. The next five were born in the comfort of her own home, and all were beautiful, uncomplicated, healthy births. Only one of her babies was born close to due date. She has gone 43-46 weeks every other time! All her babies weighed 10-11 lbs and she pushed them out with 2-5 pushes. No, she is not diabetic, and her mother had big babies, too. Except for birth weight, when assessing her babies according to gestational age charts, her babies always appear to be 39-week babies. If this lady were induced because her "dates" were "right" or because her baby was "big enough to be born," or when she got antsy and uncomfortable, she would always have had premature babies. For this lady, 43-46 weeks is normal, (she is one of those who helps create the averages) and induction would be harmful. She is the only mom I have ever "induced" (with herbs) and she and I both agreed to do this only because of pressure from the medical community. We knew that if we would have to transport her at that stage of "overdue" pregnancy, the flack could be pretty devastating, so we chose herbal induction as a safer option than chemical induction and hospital birth.

Phil Watters is right! Consumers often pressure their doctors to do things for convenience and comfort (if you can call medical induction comfortable!) and on the other hand, sometimes midwives do things because of pressure from the medical community. It's a two-way street, and either way we are doing couples a disservice, first for not seeing to it that they are educated well enough so that they don't want induction, and second for giving in to what we know is not wise or safe.

- Elaine

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7) Switchboard

In response to the question about hemorrhage and cayenne [Issue 49]: since the writer reports that she saw "many" postpartum hemorrhages, I think factors were at work other than the use of cayenne or any other herbs. Hemorrhage of over two cups should be relatively rare; hemorrhage of over 4 cups should be exceedingly rare. If it seemed to occur more often, I would suspect that the midwives were consistently over-estimating the amount of blood loss (this is quite common) or else there might be some unusual management of third stage. Handling the fundus, traction on the cord, and other manipulations, including clamping the cord too soon after birth, can all increase bleeding.

Even management of second stage can influence blood loss. Pushing before full dilation, coached pushing, fundal pressure, and rushing the shoulders (delivering before full restitution and the second contraction after birth) can also increase bleeding and problems with the placenta.

One midwife in a border clinic reported an incidence of hemorrhage over 4 cups of above 10%. I'm not sure what was going on, but it should be closer to one or two percent.

- Gail Hart

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I'm trying to find out about the status of midwifery in Israel. Are they used much there, how acceptable is midwifery, what is the general atmosphere, what training is necessary to practice in the country, is there physician back-up, etc.?

- Ketzia
Reply to: ketzia@sirius.com

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Where can I find information on death and emergencies in births (mother and/or child) in different countries, cultures, tribes, centuries? I'd prefer detailed info, whether from books, Internet sites, etc. I can't seem to find any info on this from the past to compare with modern statistics.

- Bruce Mitchell, blm@global.co.za

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I have an 8 1/2 month old and I am wondering about supplements for myself. Someone also said she should be taking iron drops. I bought some glucosamine sulfate and kelp for different problems. Is there a problem taking these products while nursing? I take vitamin C, E, iron, calcium and flax oil. Are there things I shouldn't take while nursing? If you can't answer my questions maybe you can direct me to who can.

- Lisa Saunders

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I am an independent midwife in the UK and am off to Mozambique and Swaziland for just over 3 weeks. I would really appreciate any contact from midwives who have worked in either of these places. I would ideally like to experience the way that traditional midwives work. Can anyone help?

- Andrya Grubb, midwife@hecate8.freeserve.co.uk

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Unless otherwise noted, 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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8) Classified Advertising

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