July 12, 2000
Volume 2, Issue 28
Midwifery Today E-News
“Midwife's Birthkit”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) The Midwife's Birthkit
5) Check It Out!
6) Question of the Week
7) Question of the Week Responses
9) For Coming E-News Themes
10) Switchboard

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1) Quote of the Week:

"As we each strive to enhance and refine our personal practices, may we remember to balance technique with tenderness, deepening our sensitivity as we expand our clinical skills. Let's learn from and support each other as we lovingly serve the needs of our birthing sisters the world over."

- Judy Edmunds

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2) The Art of Midwifery

When training a new apprentice, the first thing I have her do is spend some time taking out everything in my birth bag and then repacking it--several times. This way she knows where everything is, and can instantly retrieve anything needed in an emergency or at a birth where you walk in to find the baby's head on the perineum!

- Unknown

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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

A widely reported study that concluded that echinacea, St. John's wort, ginkgo and saw palmetto could inhibit conception has been called into question. The research, conducted at Loma Linda University School of Medicine in California, exposed hamster eggs (in test tubes) to high doses of each herb, then inseminated them. After incubation, various negative effects were found. In real life, however, the active constituents of herbs must be absorbed into the bloodstream, and it is unlikely they would reach concentrations equal to the high levels in the study.

- Prevention, July 1999

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4) The Midwife's Birthkit

E-News asked readers if they include anything unusual in their birthkits. We received the following responses:

I have a sewing/craft kit for long births. The couple seems more relaxed about me being there for a long time when I have something else to do. It takes pressure off mom to perform and I get something else done. At one birth, I made an entire quilt! (I have a lot of apprentices so we make sure the mom has all the help she needs.)

- Lisa Hines L.M.
S.C.

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I used to carry a plastic soup ladle for applying pressure to the mom's back...your hands/fists can get so tired. I discovered this at a birth where my hands could take no more. I thought of an ice cream scoop and went to my client's kitchen to find one and could only find a ladle. I found that the long handle on the soup ladle worked so much better. I used this again at my grandbaby's birth in April!

- Carla Hartley

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A couple of times I have arrived at a home visit to a deeply jaundiced baby even though the mother had been instructed to call me if she noticed the yellow increasing. The problem seemed to be an inability, on a day to day basis, to observe a creeping increase. To solve the problem I printed a color sheet from my computer of jaundice-yellow on a gradient fading from light to deep and inclusive of the gradient expressed on an icterometer. When a baby is jaundiced I can hand this strip of paper to the parents and ask them to press and blanche the baby's nose then match the shade on the paper to the baby's shade of jaundice. They can mark that spot with a pencil and repeat on the following day in similar light to readily compare any change on a day to day basis.

- Maryl Smith

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Here are a few unusual things I keep in my birth bag as a doula: extra toothbrushes for client and family members, and for inductions, I keep things on hand that require some degree of ambulation and distraction: a face mask is my favorite. Both mother and I will use it.

- Connie Sultana, CD(DONA), ICCE

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Here are a few more birthkit items gleaned from Midwifery Today's Tricks of the Trade books:

- A mechanic's mirror: perfect for allowing the birthing mom to get a good look at her cervix.

- Clear eyeglasses to protect your eyes from splattered blood or amniotic fluid-they look friendlier than protective goggles.

- Walking shoes so you can take nice long walking breaks to clear your head and wake up, and give the couple some private time.

- Hydrogen peroxide--it takes blood out of anything (pour it on, let it foam up, blot it out--don't rub!).

- Tea tree oil to relieve pain and soreness when suturing perineal tears. It also helps perineal tissue recover and prevents infection.

- A good-sized plastic tablecloth with a flannel back won't slip around as Chux or other plastic sheeting will. The flannel side is more comfortable than a Chux under the mother, won't rip, has no seams that will leak, and covers a large area. It won't bunch and tear. It washes well and can be reused.

- A folding metal or paper fan. This small, simple tool can provide real comfort to a hard-working woman, plus it can give a nervous family member a useful job.

- A joke book. Even a forced smile releases endorphins, the body's natural pain medicine. It may help to tell some good jokes to a birthing mother, or even some not so good ones, especially in early labor.

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5) Check It Out!

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6) Question of the Week

What can you tell me about a tear in the placenta? A doctor diagnosed my friend with that three weeks ago, and told her to "take it easy" she is still spotting (off and on) and they don't seem to be too concerned about it.

- Stacy Watson

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Send your responses to mtensubmit@midwiferytoday.com

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7) Question of the Week Responses

Q: I would appreciate any information about caring for women with vulvar and leg varicosities--easing, reversing the effects of or treating them during pregnancy, the actual birth and for postpartum care. Do you have documentation or studies about the possibility of rupture at any point, techniques used to support these women during birth, and information on the usefulness of a waterbirth?

- Kathy Berry

A: The two homoeopathic remedies I have found most often useful for treating pregnant women with varicose veins are pulsatilla 30c and Calc fluor 6x. Either of these remedies could safely be taken three times per day. With homoeopathic medicine it is usual to take the remedy until symptoms subside and then reduce the dose, stopping when symptoms cease. If with a semi-acute remedy of this nature, there is no benefit within a period of a two weeks, then it is not the right remedy and a homoeopath should be consulted to choose a remedy that suits the individual better.

- Glenis Harris

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A: I currently have a client in my midwifery practice who
has vulvar varicosities that even extend into the lower buttocks and posterior upper thighs. She has obtained a lot of relief from acupuncture from a reputable practitioner. She also has taken care to avoid constipation, and is taking extra vitamins E and C.

- Debbie Wolfe, CNM

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Q: My wife 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. 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?

If there are any books to read on this syndrome, please let me know.

- Dan
The father of a big beautiful boy

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A: Four years ago my grandson was born having aspirated
meconium. He was airlifted to Children's Hospital where he was critically ill for about 10 days. However, he is a lively four year old today, and the only lung related problem he has is mild asthma. He gets a cough when he catches a cold, but this heals as it would with any child.

- Beryl

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A: Meconium aspiration is indeed rare but that does not really matter if your dear baby has experienced it. Babies are body/mind/spirit beings just as we all are. I believe parents are most important to determining how well baby will recover. Your baby needs your touch and to be held skin-to-skin by you and his mother. Gene Cranston Anderson, an important nurse researcher, has discovered that babies' T cells [a way to measure the strength of your son's immune system] is 50% higher when you hold him next to you skin (kangaroo care).

Prayer or meditation in accordance with your spiritual preference can have very important benefits for your son.

Also, the gestation period for humans varies from one person to another and "term" [maturity] gestation is 38 to 42 weeks. I believe your son's birth six days beyond his "due date" increased the risk for meconium aspiration only slightly. Prebirth, babies sometimes pass meconium (the sterile material in their bowel) before they are born. They do this if they are stressed and for other reasons we probably don't understand. Meconium in the amniotic fluid becomes a problem only following the first breath, and only if the baby gulps meconium into his lungs before it can be carefully removed by suctioning before the baby takes the first breath. I believe babies do not breathe until their nose and mouth are in contact with air.

The "meconium syndrome" occurs when a baby's blood oxygen level drops very low because of stress or inability to get oxygen in his lungs because of mechanical blockage due to the sticky meconium or because the baby gulped some meconium into his lungs, blocking off part of his lungs so part of the lungs could not expand.

Babies I have seen with meconium aspiration have recovered completely without chronic respiratory illness. I believe the risk of ongoing health problems for your baby will exist only if the baby had a very long time when he was not getting enough oxygen (anoxic for a long time).

Breastmilk is tremendously important for him! If he is still getting respiratory support, his mother's breastmilk can be gavaged [Given to him through a small tube placed in his stomach]. Mother's milk provides great comfort to babies who are uncomfortable because of the "love hormone" in it (oxytocin).

- Hetty

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The baby's dad reports: On June 30 my son was taken off ECMO support for his respiratory problems. He was in grave danger prior to this treatment. As of July 2 he was taken off the ventilator and is receiving oxygen through his nose. His vital signs are improving by the minute and he was fed some of mommy's milk. Our son is making a great recovery as I type this. To anyone who has concerns regarding the treatment of ECMO, keep the faith; it works miracles, and it saved my son's life.

With MAS the baby's lungs are coated with meconium and act like a sealant on the inner lining of lungs, thus disallowing the lungs to operate properly and in extreme cases not at all. In the extreme cases such as my son's, the baby is put on a high frequency ventilator. The child receives 420 breaths per minute, forcing many small puffs of air into the lungs in an attempt to penetrate the meconium. The bad thing is this attempt highly over works the child's lungs and it too can cause damage (pulmonary hypertension, inflammation).

ECMO, Extra Corporeal Membrane Oxygenation, is a heart lung bypass. The ECMO machine is an artificial lung that takes over for the infant's lungs, allowing the infant's lungs time to heal. A cannula is inserted into the vein of the carotid artery and penetrates the right atrium of the heart. The blood from the heart goes through an external bladder, through an artificial heart (the pump), through an artificial lung, through a heating apparatus, then is pumped back into the right atrium of the heart. When the blood goes through the artificial lung, it is pumped full of oxygen. So oxygenated blood is pumped back into the infant, doing what the infant's lungs would do if not coated with meconium. The lungs are run on a ventilator at low rates, keeping them going and allowing them to heal. This procedure is very invasive. A surgeon has to place the cannula in the neck of the infant and it is overwhelming to see, especially if you do not like the sight of blood.

My son is improving all the time and is expected to be home within a week to 10 days.

- Dan

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8) For Coming E-News Themes

1. 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!)

2. Who most strongly influenced the way you practice, and in what way(s)? (July 26 issue)

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

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  • Anatomy of a Birth Bag, Mari Mikel Penn. No. 991T901; reg. price $9.
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Call 1-800-743-0974 to order. Mention Code 940 to get the discount.

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http://www.waterbirthinfo.com/
Includes a Photo Gallery, over 50 firsthand waterbirth stories from moms, dads and waterbirth practitioners, a tutorial, information on great products you can order, and lots more.

Special Offer to E-News readers: Enjoy a 10% discount on your purchase of the "WATER BABY" video. Regular price is $59.95 + $7.50 p/h. Your discount price is just $53.95 + p/h. Full ordering details are at www.waterbirthinfo.com/materials.html

=THANK YOU!=

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

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9) Switchboard

In response to the question about Hepatitis C (Issue 2:27):

According to the most recent edition of "Breastfeeding: A Guide for the Medical Profession" by Ruth Lawrence, MD (5th ed, 1999), breastfeeding is NOT contraindicated, as long as the mother has no co-existing infection (i.e.: HIV).

Anti-HCV antibody & HCV-RNA have been found in breastmilk "... although the levels of HCV-RNA in milk did not correlate with the titers of HCV-RNA in serum. Nevertheless, transmission of HCV via breastfeeding (and not in utero, intrapartum, or from other postpartum sources) has not been proved in the small number of infants studied... The current position of the CDC is that no data indicate HCV virus is transmitted through breast milk. Therefore breastfeeding by an HIV-negative mother is not contraindicated." p596-597.

The above was excerpted from a much longer explanation. For more information, I suggest having your daughter call her local La Leche League leader to find out how to contact the area's professional liason leader, who should have this same reference. In addition, your daughter's healthcare provider/s (doctor, midwife, pediatrician) can call the Lactation Study Center at Univ. of Rochester Medical School (716-275-0088 during regular business hours) for more recent research on this topic.

Another possibility may be to heat-treat her milk to inactivate any possible viral components, or use donor milk from a milk bank. Contact the Human Milk Banking Association of North America (HMBANA) at 508-888-4041 for more info.

- Gabrielle

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I was disappointed to see this article appear in E-News without explanation or commentary [maternal hypertension in black women, Issue 2:27] especially after recently printing so much excellent information on Dr. Thomas Brewer's work in the area of maternal hypertension and birth outcome. This article is so brief and vague that it's difficult to interpret fairly. It seems likely that they are talking about pregnancy induced hypertension (PIH) when they say "maternal hypertension." The article tells us nothing about the way the study was conducted, or how reliable the results might be ... and if anyone has read anything by Henci Goer, we should all be acutely aware of the misinformation that can be spread as a result of poorly conducted studies. Furthermore, anyone who has read even one of Dr. Brewer's books or articles could easily come up with at least a partial analysis of this data, if results really are as they appear. Generally speaking, African American women would have higher rates of hypertension in pregnancy because they are more likely to be living in poverty (and generally receive lower quality prenatal care and poorer nutrition) than other U.S. women. It's a simple fact of demographics, not race. White women living in poverty experience it just as much, but there are fewer such women to study. But this study apparently isn't looking at poverty--it is looking at race, so the poverty issue isn't touched on.

The postpartum hemorrhage (pph) cited here may appear on the surface to be strongly correlated with "maternal hypertension," but there are many other possible causes and we have no idea whether these were accounted for in the study. Malnutrition is a major contributor to pph, as is third stage intervention by the birth attendant (e.g., "rushing" the placenta). It could even be related to drugs given during pregnancy or labor. Why the strong correlation with maternal ethnicity? Both these potential factors relate directly to demographics: malnutrition and poor (or non-existent) obstetric care.

This article, like so many others, ignores the implications of nutrition in pregnancy, and looks at other factors (like genetics in this case) which, in the end, probably have little or nothing to do with the outcome. Dr. Brewer himself spent 12 years working with the "medically indigent" in his Contra Costa clinic--black women made up a large portion of his practice. In that time, by focusing solely on good prenatal nutrition, there was no toxemia, no placental abruptions. That alone should cause us to seriously question the "facts" presented here.

- Marci O'Daffer, CCE

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Regarding pain at the pubis symphysis [Issues 2:26 & 27], many women experience pain at the pubis during pregnancy that is caused by misalignment of the pubic bones rather than excessive separation. A physical therapist can easily help align the pubic bones which greatly alleviates the pain and allows the pregnant woman to return to her normal level of activity. Midwives can also learn this simple technique. It is a great trick to know, but I don't think I can describe it on email!

- B.C.

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I am currently looking for two videos that are several years old. The first is "Is This Your First?" and features a standup comedian-type fellow by the name of Mark (?) Scherenbrock (unsure of spelling). I had purchased a copy for a hospital I worked at several years ago, and really would like another copy for my current practice. The other video, produced in conjunction with ACOG, is "Pregnancy Preparation Program" or something similar to that. It featured Art Ulene. It shows breathing techniques, relaxation and pushing techniques, but most importantly at the end gives a beautiful collage of fourteen laboring women and their very different births. Any suggestions?

- Pamela, RN, LCCE, FACCE
Respond to: ohbaby_sbl@yahoo.com

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