June 2, 2000
Volume 2, Issue 22
Midwifery Today E-News
“Choice”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Choice
5) How Middle Class Beliefs Define Normal Birth
6) Check It Out!
7) Question of the Week
8) For Coming E-News Themes
9) Midwifery Today Magazine Question of the Quarter
10) Question of the Week Responses
11) Switchboard
12) Classified Advertising

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1) Quote of the Week:

"When midwives allow their right of self-determination to be taken away, they seriously diminish the opportunities for women everywhere to determine their own childbirth destinies."

- Valerie El Halta

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2) The Art of Midwifery

A 22 year old woman carrying her first baby had headaches for a 48 hr. period. Her blood pressure was normal and the midwife asked what else she should be looking for.

Get her to come in and see you. Make a list of all the possible causes of headache and query them. Do a 24 hour diet recall (including hydration). I'd ask her:

  • Have you suffered from headaches before?
  • What triggers them?
  • Have you been really busy, experiencing stress or emotional abuse?
  • Have you had your eyes tested recently?
  • How much TV do you watch per day?
  • What is your favourite cookbook? What kind of protein do you like?
  • Have you ever had a head injury?
  • Do you ever see a chiropractor or acupuncturist?
  • Have you taken aspirin or any other meds for this headache?
  • How has your sleep been lately?
  • What's your biggest fear right now?
  • Do you use salt? How much? (Tell her to salt to taste and get "grey" salt from health food stores.)
  • Do you smoke--nicotine or loco weed?
  • Do you use caffeine? (She may have headaches because she just quit coffee/tea.)
  • Do you eat food with MSG or nitrates? (Chinese food, pizza, deli meats)

There are a million things that cause headaches. Two days of headache pain is a long time. This headache could be a symptom that leads you to something that will make a real difference at the time of birth. Your job as a healer is to facilitate the woman's self-healing. By asking lots of questions you open up her mind to more possibilities. Also, by acting with concern at this point, you let her know that it's all right to call you with physical symptoms and that you will take action to work with her on solutions. Even without other pregnancy induced hypertension symptoms, headaches can be a sign of poor protein intake and you can ward off future problems by addressing the problem now.

A friend's neighbour had severe headaches in early pregnancy. I never met her but suggested over the phone that she begin to make every bite that went into her mouth be protein. The headaches disappeared immediately and when she told her doctor he said he would pass that information on to his other patients.

- Gloria Lemay
Vancouver, B.C. Canada

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

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3) News Flashes

Researchers at the University College London have discovered that infants have a unique nervous system that makes them respond differently to pain than adults. By studying sensory nerve cells in infants, the scientists discovered that infants' reflex to pain or harm is greater and more prolonged than that of adults. The sensory nerve cells are also linked to larger areas of skin, which means they feel pain over a greater area of their body.

In a commentary on the findings, a professor of neurobiology said that because the spinal sensory nerve cells work differently in babies, even a simple skin wound at birth could lead to the area becoming hypersensitive to touch long after the wound had healed.

- London Sunday Telegraph, August 2, 1998

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4) Choice

After years of working in the arena of childbirth, a new thought has jumped into my head: Maybe we shouldn't be so tolerant of people's choices.

Before I get flamed, just think a minute. We have been saying that people need to have freedom of choice loudly and clearly for years; it is even the philosophy of a childbirth education association. Where has it gotten us? Our attitude about being tolerant of choice is not effective; we've been saying it for years and look where we are now. Birth technology is booming and being exported. The national epidural rate is over 60% and the national cesarean rate is rising again, to nearly 21%. The cesarean section rate in some private hospitals in Mexico is 90%, which shows how the technology is being exported.

Where are these kids that take guns, shoot their parents, then take the gun to school and shoot their peers coming from? Joseph Chilton Pierce made the observation that at the turn of the century, no one ever heard of a child committing suicide. Now suicide is a leading cause of death for young people, including children under age 10. Why? Evidence shows that it may be the result of our birthing, feeding and parenting practices. Just read Ghosts from the Nursery by Kerr-Morse and Wiley. [Editor's note: Also read Reclaiming the Spirituality of Birth by Begin Mauger, to be reviewed in the Sept. issue of Midwifery Today.)

It galls me to say to a mother who weans her baby at two weeks, "Good job. You did the best you could." That might be true for her, and lord knows I want to leave the door open for her to breastfeed longer next time, but how would we react if she only used an infant car seat for two weeks or resumed smoking cigarettes? Sometimes I feel like I am pussyfooting around when I avoid saying something like "You are weaning now? Too bad. What happened to lead you to that decision?" I've been taught not to hurt the mother's feelings; don't get her upset. I want her to like me, and hear what I am saying. Yet how does it make sense to support her choice to hurt her baby?

When the medical system that has the power decides something, it happens, as in "use a car seat," and "tobacco is dangerous." People are not being reminded about their choices with those campaigns. Choice is inherent in US society today. We don't need to be reminded of it all the time.

Choice has been perverted in the medical system that has the power. Witness the "informed consent" that folks have to sign before undergoing any medical procedure. Just how "informed" are they? I learned how to manipulate people in nursing school. Of course, it was for their own good, so that made it okay. Now women are scared into lying down, and having their labors started before they and their babies are ready. They are manipulated with false promises to have drugs in labor, and get their babies cut, pulled, or sucked out. "No pain, no problems, just get that epidural." This is choice??

Maybe with childbirth, we could stop reminding people that they have choice all the time. Instead, focus on evidence: "You want a healthy baby, breastfeed; there is no way around that fact." "You want an easy baby, have an unmedicated birth." People can understand that there are no guarantees, that wearing a seat belt does not guarantee survival in a car crash. However, it boosts the odds enough in their favor that it is worth it to do.

You need sperm and egg to start a baby, no choice about that. Some things, like health, are beyond choice. You need clean air, clean water, and good food to live well and be healthy. No choice about that. We can be proactive and stop reminding people about their choice all the time. Perhaps it is time to resurrect the concepts of responsibility and consequence. What do you think?

- Nikki Lee RN, MSN, Mother of 2, IBCLC, CIMI, CSTP
Elkins Park, Pennsylvania
supporter of the WHO Code and the Mother Friendly Childbirth Initiative

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Without any hesitation, having choice and control can make or break a birth experience. I have a close friend whose birth ended up as a c-section, after planning a natural birth. However her ob/gyn was so attuned to her need to have choice and control, he managed to make the experience very positive by presenting choice and allowing her to remain the one who had the final say. I had a midwife-assisted birth in hospital, here in the USA, and it was sadly very disappointing because my birth plan was largely ignored, my dignity was crushed, and I had a rude, patronizing and hostile L&D nurse. Of course, in the middle of transition you are hardly in a position to make a stand about it, either! I felt *very* sad about the whole thing. I wish I had homebirthed!

- Anon.

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Birth is such a sacred, personal part of being a living creature. Choice is how we decide our own level of responsibility. Choice is educating ourselves as much as possible not only about the process of birth, but about our beliefs about birth as a spiritual, emotional, physical, and psychological event. Pregnancy, birth and postpartum decisions should be made by the mother and her partner. The woman needs to discover her own level of responsibility and make her choices from there. Choice is the ultimate gift and ultimate responsibility of being human. We are accountable for every decision and action we make. Therefore I feel that to the fullest extent, a woman should be the one choosing her life experience. In an ideal world she is unimpeded to surround herself with wisdom, love, strength, and spiritual connection to create the birth experience she and her partner desire.

- A.T.

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I was rather taken aback when I first read the question referring to choices. What got me was the line, "To what extent should...." [Editor's note: The question was, To what extent should women and their families have choice in pregnancy, birth and postpartum? What does choice mean to you?]

How can we decide for ourselves what women should have a choice about and what they should not? Is it morally acceptable to withhold information because we do not deem it necessary they know? As well, is it morally acceptable to tell women about a procedure and then not allow them to have an option to accept or not?

Even with the staunchest homebirthers, reason most often prevails when presented with a true emergency. With people who, on the other hand, are in the hospital and are you-do-it-for-me types of birthers, education is the key, so there should be no question about "allowing" choices.

Choice to me means having complete knowledge about something, and then being able to make an educated decision regarding the impact of going with or not going with the suggested course. Choice is the right of every person on this earth. If we take away the possibility of choosing in a situation, then we are controlling that situation, and no matter what our governments or societal laws dictate, it is completely and morally unacceptable for a person to prevent another person from making a choice that pertains to their own body, be it in birth or death.

- Amber

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As an RN, I am torn in half by this question. Choice? Where is it a free choice and where is it a forced choice? Do you really have options when you birth in a hospital? It is difficult to give the woman complete freedom of choice when you have hospital policies and norms to go by. There are numerous people we have to report to, including the pregnant family. There are the doctors, administration, supervisors, etc.--anyone and everyone with a piece of paper stating how to care for that patient.

I have seen how protocol turns in favor of and against anyone interfering with it. One example: a pregnant woman with gestational diabetes was complaining about her extended stay (due to monitoring) in the labor and delivery department. She wanted the fetal monitor removed to rest during the night. The staff, having orders for continuous monitoring, oriented her against doing this. She did so anyway, and didn't want anyone to touch her. Thank God (for her RN) this was reported in her record, because when the morning shift arrived and her OB went to place the fetal monitor to auscultate a FHR, there was none. The fetus had died sometime during the night.

There's no way to tell if this unfortunate situation is going to happen unless there is continuous fetal monitoring. Preventive measures could have been implemented. So what happened as a result? Stronger policy. Everyone keeps the monitors on at all times. Where is a woman's freedom to choose? She has none. A laboring patient is not permitted to freely move around the delivery room due to fetal monitoring. Even if they're in latent phase, 95% of the patients must use the bedpan to urinate and aren't allowed to ambulate to the bathroom.

My response to this? As an RN yes, I agree with this. I am expected to run the floor without preventable complications. I am completely responsible for anything that happens on my shift. I have to follow hospital policies and department norms. Choices? FREE CHOICES? Nope. You make choices only within the options that are presented, which are fairly limited. But, then again, you arrived at a *hospital* seeking the aid of someone or some entity that has to be governed by rules in order to provide safe and efficient care for *everyone* who arrives. This includes the patient who needed no medical "interference" because everything is "normal," the patient who arrives "normal" and becomes complicated, and the complicated patient. The rules are for *everyone*.

As a patient and a mother, I have seen the other side of this. I have been "confined" to a bed and I have had the experience, not by hospital choice, but because not knowing that I was in labor (because of distractions at home) I arrived fully dilated. So I got to ambulate, shower, and urinate freely, among other things. It's pure bliss. I can't say my previous experience was "bad," because I didn't know any better. I didn't know what I could and couldn't do as a laboring patient. I didn't know that I was being stripped of some basic rights just for having stepped into the hospital.

Do we want freedom and choices? Yes. We want to feel like we're delivering as naturally as possible even though we arrived at your institution for *guidance and assistance*. Sometimes the only reason we arrive at the hospital is because it's expected of us. We need to have a prenatal record or we're considered negligent. We are required to find an institution to deliver in or we're held responsible for complications that could just as easily have occurred anywhere we chose to deliver. Where does the violation of our choices begin? Medical plans and doctors. Medical plans won't cover some deliveries if not performed under some situations. Doctors won't cover your pregnancy if you arrive after a certain number of weeks/months. So we need to have a complete change in perspective and views if we're to allow pregnant women and their families free choice as to when, where and how to deliver.

- M.B.

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Isn't it an essential component of midwifery to involve the family in choices regarding their care? I find that when my typical "Don't just do something--stand there" technique isn't enough for the reality of the situation, I like to present the options for intervention as a question to the woman or family. Occasionally this takes a lot of creativity on my part. Sometimes when met with the inevitable "what would you do?" I like to respond with, "It's not about me" or "You're the expert on you." Then I give the woman time to really involve herself in the decision making process. Many times while discussing the birth experience, women tell me how much they appreciated the space to make their own decisions.

A sense of power & control is like a drug. If I allow women to have some control, they seem to not need or want the drugs. If we don't offer the power with experience, how will we be unique? If someone wants to be dependent and allow others to overpower her, I don't think she would seek out midwifery care.

Telling moms what we think they should do is a mild form of abuse--of one's process, right of self-determination, and sense of control. The last thing someone needs when they are feeling a little out of control is abuse. They need nurturing and trust. Offering choices fosters trust. Once that sense of trust is established by allowing women to be involved and listened to, they can relax and give normal birth a chance to unfold.

- Sara Ferguson, CNM

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When it comes down to it, women and their families should have ultimate informed choice when it comes to pregnancy, birth and postpartum.

- L.L.

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Giving birth is so incredibly personal, emotional, all consuming and such a major lifetime event. It is important for as many options as possible to be available to birthing women and their families. However, women are not really free to make choices if they do so in ignorance. Educated choices are empowering. Choices made out of fear or ignorance only complicate things. Understanding the "why" behind any choice helps solidify its validity. Understanding how her body works will help her flow with her body's rhythms, not against them.

Excellent childbirth education helps women make informed choices that will truly benefit themselves and their babies.

My husband and I are anticipating the birth of our sixth child in August. We have been through one c-sec, two vaginal hospital births, two homebirths, and now we are attempting to decide just how this one should go. We have many options available, and are being prayerful about such an important decision.

- Joanna

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5) How Middle Class Beliefs Define Normal Birth
by Connie Pike-Urlacher, MS
(excerpt)

...Within a white, middle class context, safety is defined by money and the privilege and status it confers. These women must live by the rules of middle class society so they can maintain both the protection and power this status offers.

They live in a culture that says submission is best....They typically follow the advice of husbands, doctors, popular magazines and other authorities, rather than their own wisdom, in order to behave appropriately to their standing rather than make waves by inadvertently acting differently. In order to submit, they learn to sacrifice self, and they do so on the promise that they and their children will be taken care of, that they will be safe. In this safety, they can feel powerful....

A woman cannot birth outside of who she is nor the values upon which she bases her life. White middle class women have become entrapped in trying to maintain appearances, ensuring they are always taken care of and avoiding discomfort and pain. When medicine dangles the latest machines, pain medications and promises, these women fight to be first in line....

And so they line up, almost dazed by their cultural sacrifices, for a normal hospital birth full of degrading and sometimes outright barbaric torture in the name of safety. They submit to what authorities say will guarantee safety, and sit around in mothers' groups recounting their birth experiences as though they have passed some rite of passage in which mutilation is part of the practice, and never ask if another way is possible....

The system requires the dependency of these women and their political power and support to maintain the status quo. Without them, the power would shift and women could find they can do all sorts of things based upon strength and intimacy rather than fear and dependence....Women would be more able to assess all the facts more carefully and make informed choices rather than decide between the scattered and highly influenced information they receive from physicians and hospitals....

Those in power do what they must to stay in power. Those not in power often do what they have to, either to be aligned with those who are or to become one of them....

If we are to educate women on the normal processes of birth and truly offer them choice, we must be willing to both challenge why women choose medicalized birth, and even in our non-judgmental stance of honoring women's right to choose, challenge the underlying fears that may motivate them to such choices.

To read this excellent and thought-provoking article in its entirety, go to:
www.midwiferytoday.com/articles/middleclass.htm

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6) Check It Out!

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A Web Site Update for E-News Readers

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Q: What is the difference between a hospital birth and a homebirth?
A: Body integrity, privacy, respect and $10,000 of invasive technology. Learn more about homebirth at:
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7) Question of the Week

What are the detection-causes-treatment of chorioamnionitis, and simple ways to prevent it?

- Marypascal Beauregard

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Send your responses to mtensubmit@midwiferytoday.com

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8) Question of the Week Responses

Q: I recently read a small article in Fit Pregnancy magazine that says blue cohosh can cause birth defects, according to a recent study done at Lehman College of City University of New York. Have you heard anything about this? It went on to say that a woman who took the herb during labor gave birth to an infant who later developed heart failure. I have encouraged women to take the cohoshes during early labor and I myself took the herbs during labor and I would like to know if this is a new finding.

- Angel

A: I have never heard about blue cohosh causing birth defects. It seems unlikely since it's only given in the last weeks of pregnancy. I do know a lot about the supposed newborn heart failure that was attributed to blue cohosh--it was a single case study written up in Pediatrics in either 1998 or 99. That was MY client, and there is *no* proof, or even any evidence, that blue cohosh caused her baby's heart problem. It's only an association--they couldn't figure out what else might have caused this highly unusual problem, which almost killed the baby, so they blamed it on the mom's use of blue cohosh during weeks 37-38 of pregnancy. She took capsules (not a terribly potent form of the herb) for about two weeks, then quit for several days before going into labor. She had a precipitous labor and birth, baby did well initially, then crashed quickly and severely at about 30 minutes of age or so. Neither the mom nor I believe the blue cohosh had anything to do with it or we would be seeing *many* more babies with heart failure, given how commonly the herb is used to initiate labor. Thousands of women have used the cohoshes without any known ill effect, but this one published case is scaring the beejeebies out of everyone, even though it's purely speculative!

- G.B.

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About 12 years ago a friend took lots of cohosh (I'm not sure if it was black or blue) to abort an unwanted pregnancy and was unsuccessful. Her baby was born with tetralogy of Fallot, a heart condition incompatible with life, and had to have open heart surgery at less than one year of age. She always wondered if it could be attributed to the cohosh. Maybe it was the amount she took to abort that was dangerous and small doses wouldn't hurt.

- H.K.

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Medscape this week published an article that stated that "there are no known pathologic conditions for which black cohosh is contraindicated. Until recently, the herb was not recommended for use during pregnancy or lactation; according to Newall et al,[1] black cohosh binds to uterine estrogen receptors. However, more recent studies clearly demonstrate that black cohosh does not bind to estrogen receptors and therefore does not have an estrogenic effect."[16]. Even if it were shown to cause fetal anomolies or malformations, using this herb at term should not be a problem, as the fetus is already fully developed. And it has been used by midwives for years with no untoward effects. To see this entire (very interesting) article go to:
http://womenshealth.medscape.com/22047.rhtml

- Chava Weiman

Alternative Medicine--Black Cohosh
Jeremy L. Pettit
[Clinician Reviews 10(4):117-118, 121, 2000. (c) 2000 Clinicians Publishing Group and Williams & Wilkins]

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Q: Can anyone tell me the specifics of knots in cords at birth? What, if any, are the complications that might occur; can a knot in the cord often produce a stillbirth; and finally, are there any
preventions?

- Jenna Tamura

A: True knots in the cord can occur when there is a long cord and the baby has moved so that the knot occurred. I have seen several where there was no problem but did have one woman whose baby was stillborn at term and the only apparent reason was a tight knot in the cord. The baby had been breech. We sent her to the OB for a version, and when she got there the baby had turned itself already. The heartbeat seemed fine on the monitor, but the next day when she came for a visit there was no heartbeat. The mom did not want an autopsy so we don't know if something else occurred besides the knot in the cord. This was one incident out of maybe five or six with true knots, out of about 600 births altogether. I don't think there is any way to prevent a knot from forming.

- Pat Chirumbolo CNM

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9) For Coming E-News Themes:

1. What do you do to reduce an anterior lip? (June 9 issue)

2. PAIN: What causes pain in labor? Is it a birth practitioner's job to try to alleviate pain? (June 16 issue)

3. What about the "wife" in "midwife"? How do you maintain relationships with such a demanding career?

**Take part in E-News! Sound Off-Give Advice-Share Your Knowledge!**

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Send your responses to mtensubmit@midwiferytoday.com

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10) Midwifery Today Magazine Question of the Quarter:

What is your most noteworthy second stage, and what was the outcome? Please submit your response to editorial@midwiferytoday.com by June 15.

Keep the stories coming! Midwives have a lot to learn from each other, and Midwifery Today magazine is a great way to transmit knowledge!

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10) Switchboard

I was very interested in reading the nurses' replies to birth issues. I understand that some are quite frustrated at having to follow certain protocols--I know I was. That was a big factor in my quitting as an L&D nurse nine years ago. However, in our area at least, there is good reason for birthing couples to be wary. Our hospital epidural rates run over 90% and in most hospitals, over 95%. The nurses in general not only do not know how to support a laboring women, but have no desire to do so. They would scramble to take other patients first, leaving the "natural" moms for whoever was "unlucky" enough to not be at the board first. They sabotage natural childbirth at every turn ("There's no need for this suffering you know--they don't give out medals for this," and on and on). I saw moms thwarted at every turn--no help, no support, no suggestions until moms finally begged for the epidural and the nurses responded with comments like "See--now you'll know better than to try this next time." I helped where I could, but couldn't take every mom wanting a natural childbirth.

Yes, some of it is definitely women demanding "their" epidural. But in our area, great, great pressure is put on the mothers by their care providers and the nurses to have epidurals. The lack of choice (in the hospital, with most doctors) is so astounding that one doctor's office has a sign on their wall that says "Because we care about the health of you and your baby, this office does not allow Bradley classes, birth plans or doulas." Luckily, we do have a hospital-based CNM practice that not only "allows" more options but actually encourages them. Unfortunately, we have the highest birth rate per capita in the country and they just can't reach the majority of birthing women. As a homebirth midwife, I reach even fewer, but I just couldn't do it anymore.

My hat is off to those nurses (and midwives) who can stay and work within the system to make birth better for the women they serve. And, highest accolades for bravery go to the women who can "stick to their guns" in carving out the birth experience they want under difficult to hostile circumstances.

- H.R.

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Two Sign Language Interpreters Needed for Midwifery Today's International Conference

Are you proficient in American Sign Language and are you involved in midwifery? FREE ATTENDANCE at Midwifery Today's international conference in New York City, Sept. 6-10, 2000 in exchange for being available all day, Sept. 6-9 (Wed.-Sat.). E-mail conference@midwiferytoday.com or phone Karen at 1-800-743-0974.

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RE: elevated homocysteine levels and coffee drinking in pregnancy [Issue 2:21]:

Elevated homocysteine levels can be connected to abnormally excessive clotting. Pregnancy is a hypercoagulable state anyway, and excess homocysteine can magnify that state to the point where clots occur in the placenta and other systems. Most conditions associated with increased risk of clotting in pregnancy (Factor V Leiden, for example; see Issue 2: 19) are also associated with preeclampsia, repeat miscarriage, etc.

- Jennifer Rosenberg, CD(DONA)
Midwifery Today design editor

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Does anyone have helpful hints for pregnancy, labour, birth and the postnatal period for mums with symphysis pubis dysfunction/diastasis symphysis pubis? As a sufferer myself (and a member of the support group), I am trying to put together some information for other mums and also health professionals.

The support group details are: The British D.S.P. Support Group, Mont Hamel House, Chapel Place, Ramsgate, Kent, CT11 9RY. E-mail: britishdspsupport@compuserve.com; Website: http://dsp.future.easyspace.com

- Elizabeth Mayo, midwife
Gloucestershire

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It's been six months since my c-section (1st baby) and I still hurt. What exercises should I do to strengthen my tummy and uterus that won't hurt? I see lots of postpartum recommendations for regular birth, but nothing for c-section.

- C.K.

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I am about to open a new midwifery practice. Does anybody know of any available homebirth logos? Or, are there any designers around that are familiar with midwifery?

- Susan
Reply to: formidwife@crosspaths.net

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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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