December 17, 1999
Volume 1, Issue 51
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Risk and Benefit
5) Check It Out!
6) Question of the Week
7) Question of the Week Responses
8) Switchboard
9) Classified Advertising

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1) Quote of the Week:

"In my depths new life is teeming; all that dies shall live again."

- Luisah Teish

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2) The Art of Midwifery

I explain to the [homebirth transport] that it may take up to two hours for her to "own" the place where she is. I call it a "cool down" period, and speak of "cocooning" into a place where she can birth. Not all places acknowledge the woman's need for safety, but most will accommodate this to some degree. Decision-making should be by consensus. This is the client's birth, and she has the ultimate say over what happens to her body. The most powerful words a client or her partner may use (only in direst need) are, "I do not give my consent for that procedure." These are medico-legal power words that should not be overused: they are directly confrontational and lead to extreme power plays by authorities. However, they are the client's right.

- Anne E. Stohrer, MD
"Transporting," Midwifery Today Issue 38

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3) News Flashes

Researchers compared the bone density of 183 women ages 18-39 who had been receiving medroxyprogesterone (Depo-Provera) injections for a varying number of years with that of 274 women of a similar age who had not. They found that the average bone density among those using medroxyprogesterone was 2.5% lower at the spine and 2.2% lower at the femoral neck than non-users. The most striking differences were seen in women ages 18-21, where the average bone density was 10.5% lower at the femoral neck and 9.4% lower at the spine than that in the control group. They suggest that greater bone loss in younger women is probably the result of estrogen depletion, an effect of medroxyprogesterone, while they are still actively acquiring bone mass.

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4) Risk and Benefit
by Gail Hart

I always tell my children that life is full of risks. Some of them we can avoid and some we bring on ourselves by our own behaviors. Examples I use--driving is a risk, but driving drunk or riding with a drunk driver enormously increases the risk. Walking home is a risk, but walking at night or walking on certain streets at 3 a.m. is a bigger risk--and walking in a gang neighborhood wearing the wrong color is an even bigger risk. Marriage is a risk--but marrying too soon is a bigger risk, and marrying a partner with substance problems or who is an abuser is a much bigger risk. Every time I walk down my hallway I risk falling and breaking my neck. But my risk rises if I'm drunk and in the dark and my hallway is full of debris and garbage.

Life is full of risks. Certain risks are unavoidable if we wish to enjoy life. But we can lower our risk by making good decisions and increase our risk by making bad decisions. Or I may choose to accept some risks because the benefit is so high.

Pregnancy is a bit of a risk, but the odds are overwhelmingly good, and the chance of having a baby is a wonderful reward! You know, people play the lottery every day with odds of millions to one against. Even a mom with the highest risk pregnancy probably has a better than nine out of ten chance of a baby at the end. Many women who are "high risk" will be willing to accept the risk of sorrow and disappointment in order to "take the chance" of finally having a baby.

Everything comes down to a question of risk versus benefit, and personal responsibility.

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5) Check It Out!

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A Web Site Update for E-News Readers

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We wish you and your family blessings and fortitude for this year and into the next century.
We wish you good health and fond memories.
We wish you the gift of forgiveness.
We hope you have a happy and safe holiday!
Last, we thank you for sharing a healthy vision of birth in the next century.

****** Blessed Be to All! ******

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5) Question of the Week (repeated)

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: 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.

Choosing Your Style of Management
by Maryl Smith

  1. Conservative (expectant) Management: Fetal assessment and evaluation without intervention unless there is an indication of compromised fetal status.
  2. Active Management: Implies induced labor at a predetermined date (usually 42 weeks).
  3. Combined Management: Conservative management is followed by a shift to active management before the referral deadline (usually 43 weeks).

Several studies over the past decade seem to indicate that fetal outcomes are comparable regardless of management style. Not even one study could provide enough empirical evidence to support routine induction for healthy postdate pregnancies. Two general areas of agreement exist for management of the postdate pregnancy:

  1. Fetal assessment in the postdate period is appropriate with induction occurring if there is evidence of fetal compromise.
  2. Post-date women with additional risk factors for uteroplacental insufficiency (e.g. hypertension, diabetes, fetal growth retardation) should be induced according to her status rather than dates. This may be before 40 weeks. It is generally agreed it should be no later than 42 weeks.

Most studies seem to show that the group of primary concern is women with correct dates who do not enter labor spontaneously and eventually must be induced. Only one study showed an increase in cesarean section rates (2.7%) in the expectant management group due to fetal distress. However, in several other studies the cesarean rate was higher in the actively managed groups due to failure to progress. In a third study the outcome for patients for whom conservative management was planned but induction became necessary was no different from that of patients who underwent planned inductions at term. Whether conservative or active management is used, the two groups show no difference in the length of first or second stage labor.

There is a trend toward an increased need for intervention for fetal distress in the active group. This may be due to the increased fetal stress that can accompany use of interventions such as oxytocin. In one study Apgar scores were similar, but in another study a greater proportion of the active group required intubation and ventilation and had a greater incidence of neonatal seizures, intracranial hemorrhage, and nerve injury (an increase of about 0.5%). Umbilical cord venous pH showed a significantly lower mean in the active group. There was no difference in birth weight. In all studies the outcome for post-date mothers and babies who were allowed to go into spontaneous labor was generally good and the mortality rate was similar to the actively managed group. Multiparas were shown to have no more obstetric complications due to post-dates than if they deliver at term. Primiparas, on the other hand, seem to be at greater risk for post-dates complications as is true for primips who deliver at term. In conclusion, patient satisfaction should be the most important indicator of management style.

Emotional Factors in Prolonged Pregnancy

Begin early in pregnancy to accustom the mother to the idea that a term pregnancy lasts anywhere from 37-42 weeks. Tell primips that many first time mothers go ten days past the due date. Only 40% of mothers will deliver within 5 days on either side of the due date and about two thirds deliver within ten days. Important attention to the following will help a mother cope with prolonged pregnancy:

  1. Reassure her that her body is healthy and working perfectly. Remind her that 60% of women have their baby after the due date.
  2. Reassure her that her baby is healthy and wonderful.
  3. Help resolve any difficulties sleeping.
  4. Ask about her social contacts and family relationships.
  5. Turn on the telephone answering machine. Don't answer the phone.
  6. Give her statements that can be repeated for self reassurance.
  7. Examine worrisome statements by friends and relatives.
  8. Include family and friends in a prenatal.
  9. Check for overexertion or the inertia of depression.
  10. Has she cried? Express empathy.
  11. Leave a stethoscope, Pinard horn or Doppler with a mother if she finds it reassuring to hear her baby's heartbeat. Instruct her on proper use,inviting a phone call when she wants your input and is using a Doppler.
  12. Discuss preparation, fears and husband's feelings to clear charged issues.
  13. Discuss pressure coming from family members with impending airline departure dates. (one of my least favorite circumstances).
  14. Discuss inducement of labor.
  15. Plan moments of self indulgence and relaxation.
  16. Encourage her to talk to her baby.
  17. Provide gentle labor encouragements such as homeopathics or 5 week botanical formulas so that she feels she has some active control over her circumstances.
  18. Draw her baby on her belly with a washable felt pen.
  19. Rave about small cervix changes or any descent in station.

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7) Switchboard

Regarding the woman with a uterine prolapse after her fifth baby [Issue 48]:

Acupuncture can help pull up the prolapse. It works with hernias as well. I have seen women spared of the surgical knife with this treatment. Find yourself a very experienced acupuncturist to work with you.

- Sara Liebling, CNM

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For womb prolapses there are several good homoeopathic remedies. The most commonly prescribed are probably Sepia 30c, Calcium Fluoride and Magnesium Chloride. The potency would depend on how well the remedy matched the client. The latter two can also be taken as cell salts. I'm sure some exercises could be taught by a trained physiotherapist or yoga teacher.

- Glenis

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I'm surprised you should get such negative feedback. I do this sort of surgery quite often and am very proud of my results over 15 years, and my patients are invariable satisfied with the results. These tissues always need oestrogen support which is why I recommend oestrogen vaginal creams during breastfeeding especially if there is a tendency to or family history of prolapse. You should delay surgery until after finishing childbirth. The problem will get more pronounced after menopause so get the max long term benefit by having surgery as soon as you are ready. This is all dependent on physical examination of the pelvic floor which I obviously can't do from here.

- Phil Watters

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In many cases of mild to severe incontinence, and in several prolapse situations, I have found the rebounder to provide miraculous results. Though your doctor says you have good muscle tone, the uterus cannot prolapse if the pelvic floor is strong.

A rebounder is a small trampoline. Empty the bladder first, put on a pad (you will probably leak!), and begin gentle bounces. As you work up to more vigorous exercise, you will find the pelvic floor much strengthened and surgical repair unlikely to be necessary.

- D. Parkin, R.M.

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Grand Midwife Mrs. Margaret Charles Smith has sadly and unexpectedly lost her son Houston to an aneurysm on Thanksgiving Day. This brave woman has helped birth hundreds of babies over the years. Her commitment to midwifery and her community have directly and indirectly impacted thousands.

Houston's death has had a large social and financial impact on Mrs. Smith. He used to contribute his SS check to maintaining her house, etc., but since she was his mother, not his wife, she gets no additional benefits now that he is gone. Of course, she also misses his companionship, since she has never lived alone.

Midwife Shafia Monroe is organizing a donation drive to encourage people to contribute $10 (or more) to Mrs. Smith, sending the checks right to her: Mrs. Margaret Charles Smith, Rt. 3, Box 3-A, Eutaw, Alabama 35462. Please let's all give what we can to this lady who has given us all so much. What her wisdom and strength has given the midwifery community truly cannot be measured.

As well, we need four other midwives besides myself to commit to paying funeral home costs at $20.00 per month for the next 25 months. I pledge to be one of those midwives.

- Desiree, desireeadaway@hotmail.com

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More on Gestational Diabetes:

I am a student midwife and work with herbs. Two herbs helpful for diabetes and safe during pregnancy are buchu and uva ursi. The dosage would be: as a tea, boil a heaping teaspoon of uva ursi in a pint of boiling water for thirty minutes (low boil to prevent evaporation). Remove from heat and add an ounce of buchu leaves. Steep. Do not boil buchu leaves. Buchu is originally from Africa. If you have trouble finding the ingredients, I can help you. I also make capsules of various remedies.

Louise Hay states a probable cause for diabetes as "longing for what might have been. A great need to control. Deep sorrow. No sweetness left." The affirmation she recommends is: "This moment is filled with joy. I now choose to experience the sweetness of today." I have seen metaphysical work effect healing.

As a fitness trainer, I was taught how exercise and nutrition help diabetes. Exercise promotes the entry of glucose into the cells and so can lower a diabetic's glucose levels. Too much exercise can bring on an episode of hypoglycemia. A safe recommendation, with your care provider's approval, would be: walking (nothing you cannot talk during), plenty of hydration (water to drink) and the Bradley or Brewer diet (which can be accommodated for vegetarians). One key to stabilizing blood sugar is the required 75-100 grams of protein daily, eaten in six meals throughout the day. Pasta should be cooked al dente. White flour/sugar products should be replaced with whole grains. Carbohydrates break down into sugar, so limit portions.

- Beth, WINGDEL@aol.com

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More on Rhogam:

I didn't receive a Rhogam injection after my last birth (third baby) and am considering another pregnancy. I'm 44 years old and have no other health issues. Obviously the place to start is to have my son typed so that we'll know if there is an issue at all. But assuming that he is a positive blood type, what role would the early injection play in my prenatal care? Would the early injection safeguard my pregnancy? What should I be concerned with and considering regarding this issue as I contemplate what would be my final pregnancy?

- Eisa Morris, Tennessee

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I'm very concerned by some readers' attitudes toward Rhogam injections. My grandmother had her five children before the Rhogam shot was widely used (she is Rh neg. and my grandfather is Rh pos.). As a result of not having the shots, her 2nd, 3rd, and 4th babies had slight brain damage and lower IQs. Her 5th baby died shortly after birth due to the Rh incompatibility. The first baby (my mother) was unaffected, as most 1st Rh babies are.

Not all medical intervention is bad. Some saves lives and reduces suffering. If my grandmother would have received the Rhogam injection after my mother's birth, the other children would have been fine. Rather than listening to opinions, women need to find out the real facts. It is your responsibility to your children and your unborn children.

- Anon.

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RhoGam is the original Rh immune globulin. It was introduced in 1968. It is a specially prepared gamma globulin that contains a concentration of Rh antibodies. These antibodies suppress the Rh negative mother's immune response to the foreign Rh positive red blood cells that may enter her bloodstream during pregnancy or following an abortion or full term delivery. RhoGam is derived from Rh-sensitized moms or Rh- males that have been sensitized through blood transfusions.

In 1984, ACOG recommended that an antepartum injection of RhoGam be given to all pregnant Rh- women at 28 weeks gestation. It was reported that the incidence of immunization can be further reduced from 1.6% to less than 0.1% by administering Rh immune globulin in two doses.

I myself do not totally agree with this procedure. In my practice a routine antibody screen is done at the initial prenatal visit. I screen all my Rh- mothers, primips or multips. If they have a negative titer, I do not feel the antepartum injection is necessary. First of all, a primip would have not had any time to build up immunities. She does not need RhoGam if she has not had any transfusions, abortions etc. My biggest objection to antepartum RhoGam is the fact that the baby can be born direct Coombs positive from the RhoGam injection itself. This is one of the contraindications, although rarely mentioned by the drug company or physicians. I have seen this scenario, where the baby had to be transfused after delivery because of antepartum RhoGam.

After my deliveries, I type babies and if they are positive, then the mother is given RhoGam. Some of my mothers refuse the RhoGam and I respect their decision. They have birthed 6-7 Rh+ children and have never received one dose of RhoGam and they still test negative on their titer. On the other end of the spectrum, I worked with a woman who had a miscarriage early in her marriage and became sensitized--her healthcare provider didn't tell her about the chances of her becoming sensitized because of her Rh factor. She became highly sensitized 1:250 dilution or higher. She continued to have 7 Rh+ babies who all needed to be transfused. She has had two more children who were born negative.

RhoGam can be a sensitive subject and each person needs to research the answers. As far as contracting HIV from RhoGam, I'm sure that it has happened but within the last few years, the process of filtering the product has gone through major changes and it is micro filtered over and over again, one reason why the cost of RhoGam has risen from $25 from when I first started practicing to over $100 on today's market.

- Cathy O'Bryant CPM

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A friend wants to know what, besides raspberry leaf tea, is good for strengthening the womb and preparing for pregnancy. Another friend wants to know if having a baby after 40 (and having had a number of dental x-rays) is OK.

- J.D.

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Go to the United Nations Hunger Site: www.thehungersite.com Click a button and somewhere in the world some hungry person gets a meal to eat at no cost to you. The food is paid for by corporate sponsors. You're only allowed one click per day so in the holiday spirit, spread the word to others.

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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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