|May 5, 2000|
Volume 2, Issue 18
|Midwifery Today E-News|
“International Midwives' Day”
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"Through partnership, within a respectful relationship and within a two-way exchange of ideas and knowledge, we can weave together both traditional midwifery and the appropriate use of evidence-based practice within a midwifery model: midwives, working together to strengthen each other and make birth safe and sacred for women worldwide."
- Jenna Houston
2) The Art of Midwifery
Midwives, remember these things about babies: guard and protect them in the birth process; talk to those babies as you care for them, as you help them to the breast, while you do their baby exams. I am constantly noting the level of their response, even during little things like when I look a baby in the eye and say, "What a fine looking baby." I invariably see a proud and happy look appear on the baby's face. Advocates of gentle birth have criticized painful birth practices, including injections and heel lancing in the neonatal period. We cannot always avoid these things. However, when I approach the baby, I always look at him or her first and say, "I'm sorry honey, I have to stick your heel"-a gesture, at least, to the intelligent newborn. It is truly said that midwives hold the future.
- Marion Toepke McLean, Midwifery Today Issue 32
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3) News Flashes
When Finland's number of small maternity units dropped from 132 in 1964 to 45 in 1995, the accidental birth rate rose. Rates were more common when women already had three or more children. Babies were likely to be smaller and preterm. The crude perinatal mortality rate was 37.9 per 1,000 compared with 6.4 for hospital births; adjusted for risk factors (prematurity and small babies), the rate was 20 per 1,000 when adjusted by birthweight and 18 per 1,000 adjusted by length of gestation. Researchers concluded that when a birth care system in a sparsely populated area is centralized, causing greatly increased traveling time, the higher risk of accidental out of hospital births needs to be considered.
- AIMS Journal, Spring 2000
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4) A Sampling of International Articles and Letters
Anthropological Perspectives on Global Issues in Midwifery (excerpt)
A distressing cross-cultural trend is showing up in the growing body of anthropological literature about midwifery and birth in the developing world. From Tanzania to Papua New Guinea, anthropologists who observe professional midwives giving prenatal care and attending births increasingly note that, far from the midwifery ideal, professional midwives often treat women very badly during birth, ignoring their needs and requests, talking to them disrespectfully, ordering them around, and sometimes even yelling at them and slapping them. At the same time, and in direct correlation, the professional midwives are themselves often treated badly by the healthcare systems in which they work. They are almost always underpaid, are frequently mistreated by physicians who rank above them in the medical hierarchy, and generally work long hours under stressful conditions that often include inadequate facilities and equipment and too many women with too few midwives to care for them well. In short, professional midwives are often trapped in the biomedical healthcare system, a system that is failing to meet the needs of birthing women in developing countries....
Not surprisingly, even though the governments of these countries have embarked on massive programs to bring birth into the clinics and hospitals, many rural women resist, choosing instead to birth at home with a community midwife. Officially labeled "traditional birth attendants" (TBAs) by WHO and UNICEF because they do not meet the international definition of a midwife, these community midwives are usually older women who have given birth several times and who have become midwives by being asked to attend the births of friends and relatives, slowly gaining first-hand experience of birth. Some of them undertake long apprenticeships with experienced community midwives, while others learn simply by attending births. From the point of view of villagers and townsfolk all over the developing world, the biggest difference between community and professional midwives is that community midwives are recognized by their community as midwives, while the professionals are often seen as young and inexperienced women who have to prove their worth to the villagers before they can be trusted.
To read in its entirety this compelling article, written by an anthropologist whose specialty is midwifery and birth practices, go to:
The Benefits of a Different Perspective
Traveling to other communities, especially those in other countries, is a great way to break routine and get a new perspective on life and midwifery. Observing different forms of midwifery care can inspire one's own practice. I will never forget the first time I saw a cesarean section in a hospital in China. A single acupuncture needle supplied the only anesthesia to the wide awake woman, who chatted with the doctors while they opened her up. The point was not for me to run home and do surgery this way but to realize that the way we do surgery is only one way to do it. When I was in England and learned about their Good Birth Guide in which hospitals and their birthing options--including choices for visitors, birthing positions, anesthesia, and so on--are listed by name and rated from no star to four stars, I learned a new idea about effective political strategy to improve birthing practices.
- Marsden Wagner, Midwifery Today Issue 41
From The Bahamas
We are all excited here about celebrating International Midwives' Day. We have involved the director of nursing and administrators at both our major hospitals in supporting midwives and mothers at this time.
We plan to participate in a health walk on May 6, we held a press conference on May 3 and are wearing buttons to work on Midwives' Day. We will also man a booth at a shopping mall to show that midwives are not old women but young, vibrant, intelligent women!
We are already planning next year's celebration, which will include a luncheon or banquet to honour pioneering midwives in the country and outstanding practising midwives.
- Maxine Brown
From a Hospital Somewhere in Europe: A Sad Lesson
I have a colleague who is a brutal midwife. She does not hesitate to use a drip of syntocinon full speed so the woman gives birth very fast (2 or 3 hours). Sometimes(far too often)the baby shows signs of suffering. She then dilates the cervix forcefully with fingers, and calls the obstetrician for a forceps. (If a woman wishes an epidural-free birth she acts the same way, a bit less brutal maybe but hardly. Maybe the baby has less cause for suffering, but the mother, more).
This time she welcomes a woman for her third birth. It is around 8 p.m., so I believe she speeds up the labour as she does usually. The baby starts to show slight discomfort. The dilatation is 8 cm. She calls the registrar for help. The registrar tries forceps to no avail (too much difficulty with the cervix and a preceding case of injured baby). So she stops, and they decide on a cesarean. They have no special worry and do not listen anymore to the trace. When the baby is born, it is not alive anymore.
It is a very sad story for mother and baby but it is a strong sign that such brutal behaviour with women and babies is wrong. I hope she can hear this warning (is it the proper word? As she had already warnings before with babies escaping dips and bradycardia. But did she care? She thought she proved right most of the time.)
In my normal, day to day life, with family, friends, co-workers and neighbors, I am a pleasant, easy to get along with person with a balanced personality, not subject to mood swings, with a rather optimistic view of life. As a midwife taking care of women, I am understanding, enthusiastic, and supportive.
As a midwife trying to bring about changes in so many ways, I myself change--into a schizophrenic, mania/depressive personality!
There I am one day, setting the date for our first meeting with the doctors of the ward, to talk about the change of concept needed if we are to enable our women to deliver their babies without drugs and intervention. I type up pages full of midwifery philosophy and birth plans, read paragraphs over the telephone to another midwife, ask which doctors should be invited and who I should send all these papers to. The next day, with my adrenaline high, I give the papers to our head doctor, who had originally approved of the idea. Two hours later he comes back to me, angry: Who was I to take it upon myself to write these papers, and to suggest who they should be sent to?! Oh, and did we decide on a date for this meeting? He didn't remember such a thing.
BANG! All the air is out of my balloon. Was I crazy to think that change was really possible? That's it--it is only a huge illusion that any real change will be made in our ward. Oh yes, perhaps the doctors will OK the idea to spend some money on a decorative lamp or bed cover, and a little sign near an enlarged room saying "Room for Natural Childbirth," or maybe even a bath!--but will any real effort be made to change anything in our policies toward making childbirth a more normal physiological happening rather than a potential for an any-time-now catastrophe?
For two days I contemplate leaving--maybe forever!--my loving family, my community, my friends and going off to any part of the world so I can *just be a midwife!* For two days I just do my work, expecting nothing but complicated births, and surprisingly the women I am with have beautiful, uncomplicated births and are so appreciative of my way of helping them! So in spite of myself, my spirits rise. And when another midwife asks me to quickly put in an IV line and add some Pitocin to a birthing mother who is rather stuck in her second stage, I quietly suggest that we try the "towel method" (the mother pulling the towel while pushing the baby out) that I learned from the Alaska List. Two pushes later, the baby is out. This usually ungracious midwife compliments me on the "new method" and I am happy again! When I think about all the changes that have taken place at our ward in the past three years, I *know* that change *is* possible! But then a thought goes through my mind again: this is only a drop in the sea!
So am I schizophrenic, or what?
From New York
Doulas honor and celebrate the work of the midwife.
On International Midwives Day, the Metropolitan Doula Group, in cooperation with the Elizabeth Seton Childbearing Center, is hosting its second annual celebration of midwives in New York City. Five hundred midwives and birth professionals have been invited to share an afternoon of massage, refreshment and entertainment. The members of the doula group will massage any midwife (or reporter) who attends, in an effort to demonstrate a tangible part of the work that they do during labor.
The Metropolitan Doula Group is a support group for aspiring and experienced doulas. This year the members of the group have provided labor support to over 150 women. In a growing effort to reach out to the communities, they have provided volunteer doulas to pregnant women who would otherwise give their babies up for adoption. Volunteers also work with women in need at Brookdale Hospital and at the Elizabeth Seton Childbearing Center. The group is an active participant with Maternity Center Association in the Mother/Baby Health Project for homeless women in two shelters in Brooklyn.
The greatest challenge for both doulas and midwives is working with families, care providers and institutions that fear birth. Since midwives do not have privileges at many hospitals, doulas, who are accepted into every hospital in the NY area, can offer their continuous calming presence during labor to families who want something more than routine obstetrical care. Doulas hope to give these families, and the institutions they give birth in, a small taste of the value of the midwifery model of care.
From Montreal, Quebec, Canada
Since September 1999, midwifery is legal in Quebec Province, Canada. Before, we had "no legal status" for midwives, and families in Quebec worried about the risk of legal prosecution. We wanted midwives to be able to practice where women give birth [in the home, if desired].
Today we have birth centers. At first there were the "projets-pilotes" to evaluate how midwives practice (eight years). Law 28 (my worst nightmare) has delayed approval of homebirth until the government passes homebirth practices rules. Our government (social-democratic) didn't want to have to also pay midwives in case of transfers, so midwives stopped going with women in case of complications. We have a public health system here; it means society now pays for midwifery care, and this means regulations, norms, protocols, etc.
The situation is hard here because women give birth alone, or in the hospital, and I'm afraid we have lost our midwifery soul. If a midwife goes to the home she can be fined between CAN$600-$6,000, and if a friend and/or husband performs midwives' protected acts (like catching the baby) they can be fined too, for each act-illegal midwives' act and illegal birth place. What is for our future, for our children's future?
International Credentialing of Midwives
The world has become a global village. With this freedom to share information comes the ability to travel and relocate. When midwives move from one country to another, they should, with equivalent education and credentials, be able to practice their profession wherever they live. However, cultures, languages, customs, values and attitudes can cause midwifery practices to vary from one country to another. Prerequisites and the curricula of midwifery education, as well as the credentialing process, may differ from place to place.
Read further about international credentialing of midwives at:
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5) Check It Out!
The Midwifery Today International Exchange Network Directory is helping build a worldwide community of birth practitioners who can learn from each other, visit each other's homes and practices, and form lasting friendships. To learn more about it and how to be included, go to: www.midwiferytoday.com/mt/international/ntdirectory95.html
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6) Question of the Week
Q (repeated): I am wondering about the safety of homebirth with the presence of fibroid tumors. Can someone with experience in this area help me with the risks and things to watch for?
- Bea Tarr
Q: I have a client who is expecting her third baby. She planned a homebirth with her first baby, but transferred to a hospital after her cervix became very edematous. During her second labor (planned hospital birth), she again developed a very edematous cervix in active labor. She had a CNM as a birth attendant, and many things were tried, including water therapy, hands & knees, ice to the cervix, other position changes. She eventually requested and received an epidural at 9 cm, due to exhaustion, and delivered with vacuum assistance. Does anyone have any ideas, such as herbal treatments during pregnancy, other options during labor, hopefully to prevent the edema, or at least to more effectively reduce it? Has anyone used arnica during labor, either sublingually or directly to the cervix? Is that safe? This very lovely lady is only about 20 weeks, so has some time to prepare.
- Rose Evans
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8) Question of the Week Responses
Editor's note: Responses to last week's question about anterior lip will be held over to a coming issue. Stay tuned!
9) WHAT ARE YOU DOING FOR INTERNATIONAL MIDWIVES DAY?
*Send your local midwife a card of thanks!
*Lobby on her behalf! Contact your local association of midwives for
information about key issues.
Our midwives are our protectors. If we want them to continue providing care, we need to demonstrate our love and care of them, and promote their role in women's health. Do all you can!
- Midwifery Consumer Advisory Board (MCAB)
Midwifery Today Issue 53 (current issue) is all about INTERNATIONAL MIDWIFERY, and is a fascinating read! Special price to E-News readers: $11.50 plus shipping & handling when you mention Code 940 (Regular price is $12.50). To order back issues, call 1-800-743-0974 (orders only, please).
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Many readers responded to a letter in last week's issue regarding diaphragmatic release as a way to resolve persistent posterior. Following is midwife Judy Jones's explanation of how to do it:
It is easy to recognize a persistent posterior baby. You cannot feel the back on palpation, rather only little lumps and bumps of limbs. To do a diaphragmatic release, it is best to have the mother lie on her back. If she is in advanced pregnancy and this makes her very uncomfortable, you can have her lie in a recliner or semi-sitting position. If you use that position, place a small pillow or adequate support behind her lower back.
One hand will go horizontally across her lower back where the uterine ligaments attach. This is where you would put lower back pressure during labor. You do not need to press, as just the pressure of the mother lying on your hand will be sufficient. (Be sure you take off any rings you may be wearing, for your hand's sake!)
The top hand will go on top of the abdomen, horizontally just above the pubic bone with the thumb upward. Just rest it lightly on the abdomen, no pressure. Then all you have to do is wait. Things may start right away or it may take several minutes before you feel anything. What you will feel is a motion beneath your hands. For the hand in back it will feel much like it does when there is a contraction taking place during labor as you feel the muscles tighten and contract beneath your hand and release. For the top hand it will be either a waving motion or a circular motion under your hand. At first you will think you are just imagining it, but you are not. The best description I can give is that it feels as if the mother has a tennis ball in her abdomen that is being bounced back and forth between your hands. As it hits one hand it will roll across it or around underneath it and then bounce back to the other hand. Sometimes the motion is so great that it will actually make your hand wave on the abdomen. Sometimes the mother will feel things inside, sometimes not. What she feels may not be located where your hand is located. The movement under your top hand may stay all in one place or move around. If it moves, try to gently follow it with your top hand to keep it centrally located under your hand. Do not move the back hand. Sometimes it will move around in a circle, sometimes off to one side, or even clear down to a hip. It all depends on the muscles that are involved and the type of injury that precipitated all the spasm of abdominal muscles. Our muscles really only know how to contract and shorten, not how to relax and lengthen. They depend on another counter muscle to contract and pull the first one out of contraction. Abdominal muscles do not have as many counter muscles, so this technique allows the muscles to relax.
If you go back into the mother's history, you will almost always find a history of a car accident (especially with a seat belt on, where there has been a twisting of the abdominal muscles because we use only one-shoulder restraints) or severe fall. However, I have had a mother cause it simply by doing too much hoeing in the garden.
You continue the diaphragmatic release as long as you feel motion under your hand. Usually it will just fade away and you will no longer feel it. Sometimes, if you end up over a bony prominence, it will end with a vibration. The process takes some time, often at least 20-45 minutes. But if you consider the time you save in labor, it is well worth it. You may need to repeat the process over several visits. I usually start at about the 6th month unless I have a mother with a history of car accident or several prior posterior babies. This procedure has also been used this technique to turn breech babies. I use it for transverse but find it less effective for breech. I usually use a tilt board for breech and then do a diaphragmatic release after the baby turns. It works marvelously well for posteriors. I have never done one where the baby did not turn to anterior. However, on some occasions, after a few days the baby will turn back to posterior and you will need to repeat the process more than once. The more severe the history, the more likely you will need to do it several times before the baby will stay anterior.
Posterior babies use to be the worst problem I had in births. The long hard back labors wore us all out and occasionally ended in transfers for maternal exhaustion. I am thrilled not to have these any more. Now my biggest problem is cervical lips! But I am working on a solution for that also, using evening primrose oil!
I do believe every midwife should have this valuable tool, the diaphragmatic release, in her bag of tricks. It is so easy and non-interventive. It is much better than other suggestions I have seen of putting your fingers in the baby's suture lines and trying to turn the head!
- -Judy Jones
Some weeks ago Nikki Lee wrote in that "according to the medical literature human gestation ranges from 36-44 weeks." Here in Colorado we are required by law to send any woman who goes longer than 42 weeks to a doctor. We are no longer able to be her midwife. Legislation may be changed on May 15 and I would like to be able to support the SAFETY of going longer. Can someone help me with documentation of this so what I say might be more effective?
Midwives know that the 280 day pregnancy is merely an average, but "what we know"
doesn't seem to hold water with law makers! I'd appreciate any documentation I
can get from medical literature. I do not have access to the Internet except at
the public library, where time is very limited.
We need your help!!
I am expecting my first baby and although I won't be giving birth for 7 more months, I'm already nervous about the experience. I have a low tolerance for pain so I would like to give birth in a hospital because I am considering an epidural. I would rather not have to lie on my back with my feet in stirrups while giving birth. Do hospitals allow the mother to use different positions such as squatting and sitting? Any information you can give me would be greatly appreciated.
I am an RN on maternity leave. While I love just being a homemaker, I figured I could also use the time to enhance my career. I want to become a certified childbirth educator and a doula. I figure I'll get certified in lactation consulting in a few years since it takes so long. I can't decide which of the first two would be best to do now. Any suggestions?
This is a follow up to my question about miscarriage posted in last week's issue:
The other sonogram and subsequent blood work ruled out another miscarriage but we are all a little baffled. The first sono revealed a 4 wk sac and fetal pole (but my calendar showed 7 wks), the second sono exactly one week later revealed a healthy 8 wk fetus and a yolk sac, and my HcG level was consistent with an 8 wk. pregnancy. Can anyone explain this? Have you seen it before? Is this "normal"? Even my practitioner is a little stumped. I'm just happy that it wasn't a miscarriage!
I am 14 weeks pregnant. I had breast reduction surgery 15 years ago and also have inverted nipples (not as a result of the surgery). Is there anything I can do to increase the chances that I'll be able to breastfeed? Does anyone know the stats on the percentage of mothers who can breastfeed following breast reduction?
I am breastfeeding my one year old. I go to classes two nights a week and her father gives her bottles of my expressed milk. Later this month I am attending a doula conference and will be away from her all day for three days. My freezer is inadequate and frozen milk usually ends up tasting bad, therefore I express it fresh for her. I am considering using goat milk on the days I will not be available for her. I will also try to express as much milk as possible. Has anyone had any experience with feeding babies goat milk? I gave her a small amount to try and she seems to tolerate it well.
Editor's note: Midwifery Today does not advocate the use of breastmilk substitutes of any kind except under the most serious circumstances.
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