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This issue of Midwifery Today E-News is sponsored by:

- Nanny's Notes
- Waterbirth Website

Look for their ads below!

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Why learn about global midwifery? Find out at Midwifery Today's international conference in New York City in September!

For all the information you'll need:
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Thank you to the following businesses for sponsoring the New York conference:

- Mothering magazine: Mothering is in its 24th year of providing inspiration for attachment parenting. Mothering guides, nurtures, and supports while providing the latest on controversial parenting topics.

- Cascade Health Care: Cascade HealthCare Products, Inc. began business in 1979 with the primary goal to provide supplies and equipment for the emerging profession of midwifery. We have developed a complete product line that not only serves midwives, but nurse midwives, childbirth educators, lactation consultants, visiting nurses, birth centers, WIC programs, nurse practitioners, doulas, and professionals dealing with expectant parents, families and women's healthcare.

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Send responses to newsletter items to mtensubmit@midwiferytoday.com

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Episiotomy
5) Making the new Way
6) E-News Readers Speak Up
7) Check It Out!
8) Question of the Week
9) Question of the Week Responses
10) For Coming E-News Themes
11) Switchboard

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1) Quote of the Week:

"In a branch of medicine rife with paradoxes, contradictions, inconsistencies, and illogic, episiotomy crowns them all. The major argument for episiotomy is that it protects the perineum from injury, a protection accomplished by slicing through perineal skin, connective, tissue, and muscle."

- Henci Goer

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2) The Art of Midwifery

I learned at a Midwifery Today conference tricks of the trade circle to increase the room temperature as moms crown. The moms I attend don't chill anymore and I haven't had a baby temperature below 98 degrees since I started using this technique. Once mom is warm enough, the thermostat is lowered gradually. The room is toasty warm for weighing and bathing after the baby has nursed. I tell the family in advance that I'll be turning up the heat, and so far I've never had a family member complain (or faint!).

- Roxanna Augustine, RN

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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

Pregnant African American women with maternal hypertension have a three-fold greater risk for postpartum hemorrhage than those without hypertension, according to a Morehouse School of Medicine study. The study found no significant association between maternal hypertension and postpartum hemorrhage among other ethnicities. According to the study, the higher incidence of maternal hypertension among African American women may contribute to the gap in low birth weight, preterm deliveries, and Perinatal and infant illness and mortality between African Americans and other U.S. women.

- Women's Health Weekly, April 1996

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4) Episiotomy

Is the fact that midwives cut far fewer episiotomies than doctors important? Scientific evidence shows that having an episiotomy means more bleeding, more pain, more permanent deformity of the vagina, more painful sexual intercourse for months or even years. As well, unnecessary episiotomy is a form of sexual abuse. Some women's groups in America are rightly concerned about the practice of female genital mutilation in parts of Africa. They need to be equally concerned about the millions of American women who have suffered female genital mutilation--unnecessary cutting of the genitals at birth at the hands of doctors.

While midwives trust women's bodies, use low tech assistance such as the skilled use of their hands, and understand the importance of preserving normalcy, doctors in general do not trust women but trust drugs and machines, use high tech assistance and focus on the pursuit of abnormality. So having a highly trained surgeon obstetrician assist at your birth is about as sensible as hiring a pediatric surgeon as a baby sitter for your healthy two year old when you go out in the evening. Like the obstetric surgeon who gives the normal woman a shot to hurry her labor, the pediatric surgeon babysitting your normal child will focus on medical management: When your robust two year old gets tired and fussy, the pediatric surgeon will give him or her a shot to hurry the child to sleep. The result? In the one case the medicalization of birth (remember, birth is not an illness) with a lot of unnecessary risky interventions and very expensive medical care, and in the other case the medicalization of childhood (being two years old is also not an illness) with unnecessary risky interventions and very expensive babysitting. When deciding on your primary maternity care provider, it is important to ask midwives or doctors about their practices: find out if they prefer to put you on your back during birth, how often they do episiotomy, forceps or vacuum extraction, and cesarean section. If they don't know their rates of surgical interventions or refuse to tell you what their rates are, look out! Beware of any tendency to patronize you, to suggest that you cannot possibly understand all this technical stuff, or that you should just "trust me, I'm the doctor." -Marsden Wagner, MD, Technology in Birth

To read this article in its entirety, go to:
www.midwiferytoday.com/articles/technologyinbirth.htm

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5) Making the New Way

Where fears remain to obstruct the natural course of birth, there will remain a ubiquitous use of technology. Choices--no matter how educated or informed the consent--are not real choices when they are made within the context of fear. When a mother embraces a procedure along with its dangers, we are bound by our relationship to her to make sure the freedom of her choice is not compromised by anxiety. In protecting the integrity of her choice in birth, we find we exponentially affect the quality of birthing in general: Mothers who have fears also hand down fearful attitudes about birth to daughters, and to every other woman who will listen. But each woman who gains the confidence to birth as unhindered or as freely as her biological circumstances will allow, will go on to encourage her sisters and daughters with birth words and images that resound with all the potential strength and beauty of birth. And so, with-women, we must make the new way our way--better, one birth at a time. -Jan Tritten, Making the New Way

To read this editorial in its entirety, go to:
www.midwiferytoday.com/articles/newway.htm

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Women who have previously had clitorotomies [episiotomies] should be warned that they will feel considerably more stretching and burning when no clitorotomy is performed. During pushing, unprepared women are often alarmed by these sensations, insisting that something is wrong. Explain the benefits of an intact birth and what to expect. Prenatal stretching will help them immensely. -Anne Frye, Holistic Midwifery Vol. 1, Labrys Press, 1995

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6) E-News Readers Speak Up

Is the fact that midwives cut far fewer episiotomies than doctors important?

It is up to the mother who is cut.

- D.B.

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The reason midwives "cut far fewer episiotomies" is because most of us are patient and appreciate the physiology of normal delivery. Doctors are so often only involved in the abnormal; they do not wait for the perineum to stretch and ease. Indeed many doctors have seldom been involved in a normal, physiological labour.

- Karen Little, RM

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7) Check It Out!

~~~WWW.MIDWIFERYTODAY.COM~~~
A Web Site Update for E-News Readers

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WHAT IS MIDWIFERY TODAY? Find out by going to:
www.midwiferytoday.com/company/aboutmt.htm

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8) Question of the Week

My wife just gave birth to a 10 lb. 1 oz. baby boy on June 15. According to her doctor, the baby was six days late. Currently our baby is suffering from meconium aspiration syndrome. My wife had an emergency c-section; however, our boy had already taken the meconium into his lungs. He is being given oxygen through a ventilator and appears to be having a difficult time at the moment breathing on his own. The hospital where he is being taken care of seems to be doing all they can do. It appears the levels he has are relatively rare from the few articles I have found.

My questions are:

* What are the percentages of babies that get this type of syndrome?
* What are my baby's chances of surviving without any lung damage?
* What are the survival rates?

I know the last question sounds awful but we would like to know. Please help. If there are any books to read on this please, let me know their names.

- Dan
The father of a big beautiful boy

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Send your responses to mtensubmit@midwiferytoday.com

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9) Question of the Week Responses

Q: My friend suffered from pain caused by "pubis symphasis" during her past five pregnancies. She is currently eight weeks into her sixth pregnancy, and she's already experiencing pain. Are there any exercises that can help? Any magic cures (homeopathic remedies, etc.)? She broke her coccyx during her first labour 16 years ago, but went on to have normal, uncomplicated births with her fourth & fifth children. Her youngest child will be two when the new baby arrives. Her birth was extremely fast (40 minutes). Is homebirth an option?

- Chamutal
UK

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A: In osteopathic medicine, some very simple manipulations can be used to "reset" the cartilage of the pubis symphysis. A D.O. in your area who is skilled in osteopathic manipulative medicine (OMM) may be able to offer some relief (and, perhaps, teach her some muscle energy techniques to do at home).

- Tami Michele, med. student

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A: SPD is the new discovery in the U.K. Where I work there is one of the highest instances. Things that can help:

- Rest!
- Sleep on a slippery sleeping bag so you can turn over easily in bed
- Try not to abduct hips
- Sit on a plastic bag in the car so you can slide when getting out
- A pelvic support like a girdle reduces pain

Homebirth is no problem; just be careful about abducting the hips. Use a piece of string to measure how far you can comfortably open your legs. Use the string in labour so as not to allow anyone to open your legs more than this distance! --If the condition gets quite bad you may need crutches. Hydrotherapy is really useful.

- Julie

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10) For Coming E-News Themes

1. Premature rupture of membranes (PROM): what is your protocol? (July 5 issue)

2. What do you carry in your birth bag? Anything unusual, and if so, for what purpose? (July 12 issue)

3. How do we help women in isolated communities birth with dignity and freedom, trust themselves, and not be separated from their families? Who in their communities will provide midwifery services and how will they go about doing so? And what can we do to help? Where do we start? (July 19 issue) (Editor's note: These questions were asked by a midwife who lives and works in the Yukon Territories. Let's help her help her communities!)

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**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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11) Switchboard

Editor's Note: If you are sometimes receiving only one part of your E-News issue and you use AOL, call their number to complain! 888-346-3704.

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With all the discussion of cervical lips and when to push, I have some questions concerning both. I apprentice in a midwifery practice where it is standard of care to do a vaginal exam to check for complete dilation when a woman starts to make those pushing noises or vocalizes an urge to push. The theory is that we are making sure that there is no lip and that a woman is truly "complete." Frequently we do find a lip, and usually the woman is asked to pant and breathe through a few contractions before another vaginal exam is done, to make sure the lip is gone before she gets the OK to push. If the lip is swollen, then it is treated with time, ice, different positions, homeopathy.

I am concerned that we end up directing the birth process too much, and the woman doesn't feel trusted to know when she should or shouldn't push. We tell women to "listen to their bodies" and that they'll "know what to do," and then we second-guess them, and have to make sure we know for ourselves. How do other midwives feel about this issue? I would love to think that if a woman's body begins pushing naturally, then even if there was a lip, that it would just melt away. I would also like to think that I will be more trusting when I get to primary care, but I want to be informed, not naive.

- Jenny
Oregon

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I agree that in most situations it would be fine to deliver a trisomy 18 baby at home. But there are occasions, just as with other births, when it would not be appropriate. One of my moms who had a trisomy 18 baby also had a placental abruption. I sent her in for an ultrasound because of symptoms of partial abruption. The abruption, SGA, trisomy 18 pattern of defects were all missed on the ultrasound and they sent her home until she went into more serious abruption. Then they sent her to a larger hospital for a c-section. The problems for mother were more because of the placental abruption than the trisomy 18 birth. The baby lived about 35 hours.

- Judy Jones, CPM

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I looked up trisomy 18 in Taber's: "causes severe deformity and mental retardation. These children usually do not survive beyond the first year of life. Characterized by prominent occiput, overlapping of index finger over third finger, frequent facial abnormalities, straight nose coming off sharply from the forehead, low-set ears, and cleft palate and lip."

As a midwife I don't see anything here contraindicating a natural vaginal delivery. With cleft palates there are often special feeding needs, but that can be worked out with a lactation counselor who has training in that area. Anecdotal evidence suggests that babies with severe anomalies often present other than vertex, so discussion about a breech birth might be in order.

The provider handbook for the AFP/Triple Screen says that these babies often spend what little time they have in a neonatal intensive care unit--all the more reason to have a homebirth. Our practice has had a baby with (undiagnosed prenatally) severe anomalies inconsistent with life. We ended up in hospital because of maternal infection in labour (broken waters), where a sono told us what was coming. The mom went on to have a completely natural, uncomplicated 10 hour labour and birth, catching her baby in the bath with only her partner and one of us with her. It was all she had left of her original dream and she cherishes that memory. If your family wants a homebirth, they should have the same opportunity as any other family, because they will have only a short amount of time with their child; because that time will be spent walking a path far and away from the one they envisioned when creating this child; because this child will be taken from the family soon enough, it should not be "taken" from its mother's body. You and your family are in our prayers.

- Anon.

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My friend is an independent midwife, and the study she mentions (below) is on the web at
www.utoronto.ca/breech. If you can help in any way, I would appreciate it, and so would she and her daughter.

- Jackie Mawson

Mary writes:
Today I accompanied my foster daughter to an antenatal at KEMH. She is 33 weeks pregnant with twins, 3rd pregnancy. First birth was difficult--forceps, 8 lb 8 oz.; second birth was normal, 8 lb 8 oz. We have been querying the recommendation for a c-section because the baby is breech and because it's twins. The doctor said research previously found the two modes of birth are equal in outcome but new information says *definitely* c-section for all breeches whether single or multiple, primip or multip.

Supposedly there is a multicentre research program taking place, possibly out of Oxford, that has just been stopped because the outcome for breeches was so bad. He was unable to give me any other information and said the results wouldn't be published until next year, so he couldn't help me with my questions, such as those about maternal morbidity.

This has upset my daughter of course--she feels devastated. I know that she will have a c-section if it means her babies are at risk, but she feels a little trapped. Any help with information about this research? I don't want to give her my intuitive response as I may be misleading her in my desire for her to have a normal birth.

- Mary Murphy

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I read on in disbelief when it was stated that cord knots are not dangerous. How can they not be dangerous? The umbilical cord is the lifeline to the baby. If that cord tightens the baby will not receive all vital oxygenation, nourishment, etc. I completely disagree with the person who believes knots to be "OK." As an RN in an L&D dept. I have seen my share of knots--some loose, OK, no problem, others so tight that the baby in some instances was delivered without life.

- Margie Bou, RN

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I am a family nurse practitioner who will be working in an OB/GYN office. Can anyone direct me to a reference with protocols for the pregnant patient?

- Joanne Pecoraro

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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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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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