|July 19, 2000|
Volume 2, Issue 29
|Midwifery Today E-News|
“Midwifery and Birth in Remote Areas”
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"A woman gives birth according to the way she is and how she feels about herself. Knowing herself and being supported by women who know her helps her go through her birth in a growing way and have more confidence about how she takes care of her children afterward."
- Leah Qinuajuak, Inuit midwife
2) The Art of Midwifery
One day I heard the head of obstetrics at our local hospital say, "The best pelvimeter is the baby's head." In other words, a head passing through the pelvis would tell you more about the size of it than all the calipers and x-rays in the world. He did not advocate taking pelvic measurements at all. Of course, doing pelvimetry in early pregnancy before the hormones have started relaxing the pelvis is ridiculous.
- Gloria Lemay, Midwifery Today Issue 50
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3) News Flashes
Fetal behavioral states (FBS) in normal pregnancies after 41 weeks as compared to control term fetuses were studied to determine clinical management. All subjects underwent a behavioral study using cardiotocography to record the heart rate, and two ultrasound scanners to observe body and eye movements. The median percentage of FBS known as "awake states" increased significantly from 6% in the term group to 21.5% in the fetuses after 41 weeks. FBS "quiet sleep" and "active sleep" decreased from 92% to 78%, thus indicating increasing wakefulness in utero. The fetal heart rate patterns showed large amplitude, prolonged accelerations that fused into a sustained tachycardia with only short periods of return to the baseline, resembling tachycardia with decelerations.
The study concluded that in normal pregnancies after 41 weeks, the development of the fetal central nervous system continues, resulting in an increasing percentage of "fetal wakefulness." The cardiotocography patterns that result from these behaviors can easily mimic fetal distress, and practitioners should be aware of this phenomenon.
- Early Human Development, Dec. 1994 as reported in MIDIRS, June 1995
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4) Midwifery and Birth in Remote Areas
An E-News reader asks: 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?
This is an issue that has and continues to affect many women in northern and remote areas of Canada. It is difficult to attract caregivers (physicians, nurses, midwives, etc.) to communities outside the urban centers. The long hours on call, difficulties in transporting in poor weather, poor financial incentives and isolation from professional peers and backup are all factors.
If all of one's training and experience has been in a large centre with quick access to specialized help, it is pretty scary to be the sole responsible practitioner "north of 60" with a 28 week pregnant teen who you think may be having an abruptio placenta. Oh, and by the way, there's a blizzard and no transport available for a week until the weather clears, no O.R., no ultrasound and no blood bank. So before we condemn the caregivers for wanting to ship every pregnant woman out of town, consider the whole picture.
Fortunately, there is an awareness of the stress to families of routine evacuation of pregnant women "south" for their births, and solutions are being sought. In northern Quebec the Puvirnituq midwifery training project continues to train Inuit women to care for birthing women in the north. Their outcomes are excellent and a second birthing centre is now operating in the Inukjuak Health Centre. Students from the McGill University rural medicine program spend some time with the midwives while doing their northern rotation. This helps spread the message that birth in the communities can be a safe option.
In B.C., the British Columbia Reproductive Care Program recently sponsored a Rural Obstetrics Conference with representation from medicine, nursing, midwifery and consumers. They have drafted a Consensus Statement supporting birth in rural and remote communities. This is an evidence based paper that supports birth in communities with no c-section capability for first and second time moms, among other recommendations.
If trying to establish or maintain a rural birth service, I would recommend the BCRCP consensus paper as a solid tool to convince administrators and policy makers. It was used to good effect in our rural community (where the two midwives are the only perinatal caregivers) to establish communication protocols with larger centres and to support our ongoing home and hospital birth practice. Dialogue, positive energy and respect are the keys to getting everybody on board. Birth "in the sticks" is a safe option for women and families.
We experience the same dilemma in the Highlands and Islands of Scotland. It probably exists in many other isolated communities worldwide, and there are no easy solutions. Some thoughts for this midwife are:
- Get together with other midwives practising in remote, rural, and isolated areas--by phone, email, newsletters, whatever--for mutual strength and support, sharing of professional models and strategies relevant to this type of practice (which is so very different from city/town/large hospital practice).
- Develop skills and knowledge to be able to provide midwifery care appropriate to remote practice. Only then go out and offer care confidently to the women.
- Recognise and foster the abilities of women in remote areas to evaluate their well being and that of their babies, with you as a teacher and interpreter and not always a "hands-on" practitioner, as hands-on is often not feasible where vast distances are involved. Remote & rural midwifery practice in developed countries is a unique experience. I would welcome further correspondence to enrich the ongoing Scottish dialogue.
The question you've asked does not, it would seem, have an easy answer. I live in a remote community and have chosen to birth here myself as well as support birthing women. That there is a homebirthing community in this area is a very big bone of contention to the majority of the recognised perinatal caregivers of the surrounding areas. A significant factor is that the closest hospital is two hours away (unless one is flown in by helicopter). Still, there are people who are going to birth here, and do birth here, no matter what, as long as there are no health risks (and very occasionally even when there are).
As a busy mother, particularly one who has had a previous homebirth, there was no way I was able to leave my community even if I had wanted to (which I didn't). I was, of course, very well informed regarding my choice and the logistics accompanying it, and I see this as a very important part of helping women here. I have also been around the hospital system and more medicalized practitioners a fair bit and I do understand where the concern comes from. If practitioners in this locale don't have any concern at all then they are living in a fantasy world.
I also see how, when one's training has consisted of the fear-based tactics of the medical model as we know it, one could be a whole lot more concerned than is necessary. To empower birthing women in these areas we must be straight up about the realities, focus strongly on prevention and on maintaining excellent health/nutrition, and truly believe in our hearts that birth really is a normal physiological process.
Women providing care in these areas must be courageous and strong, particularly if they are working outside legal parameters. We must bridge the existing gaps, strive to build communication, and work on making the priority the birthing community, not the political agenda. There is so much more I could say but this conveys my general feelings.
Midwifery Today Issues 40 and 42 include an excellent two-part article on the Inuit of Northern Canada from the perspective of a community midwife who has worked with them. After presenting an analytical framework that shows how some types of logic can be supervalued while others are devalued or ignored, the author tells the story of one Inuit settlement's attempt to reintegrate the authoritative knowledge of the community by supporting Inuit midwives as they choose their own criteria for decision-making in birth. Issue 40 also includes stories and articles by Inuit women.
5) Check It Out!
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It is also helpful to women, men and children who are required to be
in prolonged sitting positions. They make a unique gift for the
expectant mama, and a great addition to a labor assistant's birth
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for exercise, relief of back pain or for posture improvement. Weight
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Are you mourning? Do you know someone who is? Read about a comfort measure that
is available to soothe a broken heart. Grieving Bags by Allie Alden:
"I am a mother of 14 children. I wanted an upright birth for my last birth, so my husband went to work. He has a woodworking business making gliders for the home. With some designing and input from others he made a glider for laboring and birthing mothers. Later the midwife (Susan Stapleton,CNM, from Reading Birth and Women's Center) had a birth stool idea from a European trip. The glider wasn't transportable for homebirths; would Steve make her a birth stool? Again, with input and design from others, the birth stool came to be. Now we want to share them with others to benefit from too!"
I began Expectancy Resources to fill requests from other childbirth educators for materials developed for my own classes. After 29 years as an OB/GYN nurse and 28 as a childbirth educator, new ideas are always welcome! Wishing health and happiness to you and all those whose lives you touch, Judy O'Connor, RNC, BS, LCCE, FACCE , Expectancy Resources: www.midwiferytoday.com/loves/expectancyresources.html
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Nurturing Beginnings contain 12 modules: (These modules correspond with our 12 module on-line course available at SUNY, but will be of value with any doula training.)
[Editor's Note, April 17, 2007: Stony Brook University's School of Nursing notified us that they no longer offer this program.]
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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:
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.
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6) Question of the Week (Repeated)
Q: 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
Q: A pregnant mother is expecting her fourth child. She says she loses a lot of hair after the birth of each of her babies. She wonders if there is anything she can do or take to prevent this from happening again.
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7) For Coming E-News Themes
1. Who most strongly influenced the way you practice, and in what way(s)? (July 26 issue)
2. How do you counsel pregnant women about nutrition, especially in these fast-paced days of stress, little time, and junk food? (August 2 issue)
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More on meconium aspiration syndrome:
Babies not infrequently pass meconium in the womb. Sometimes we can never find a reason, but sometimes it's a response to the stress of labor, a pinch in the umbilical cord or some other problem that causes a drop in oxygen levels. It used to be thought that this only became a problem if the baby breathed it into her lungs with her first breaths after birth.
For several decades a great deal of energy was focused on methods to prevent meconium aspiration syndrome by developing better suction methods after the birth of the baby's head. It was a great disappointment when the incidence of MAS did not drop! Further research showed that meconium aspiration *occurs in the womb* and not with those first breaths (unless inappropriate resuscitation blows meconium into the lungs). A baby born with MAS has already suffered damage before he is born--our suction efforts have little effect.
Babies do normal breaths while in the womb. Under deep distress they take deeper breaths--a sort of "last gasp"---and take fluid (or meconium) deeply into their lungs. Our efforts to prevent MAS should focus on the prevention of fetal distress in labor and on correct suctioning/resuscitation techniques for the depressed newborn. Little can be done to prevent MAS. It is a result of a serious problem in labor--it occurs before anyone can prevent it.
The baby whose MAS started this discussion was born by emergency ceserean. The deep fetal distress that prompted the cesarean also caused the meconium aspiration. Being six days past the due date is an entirely irrelevant factor. The baby passed meconium and breathed it in *because* of fetal distress--he aspirated meconium before he was born, not after. It was no one's fault--it could not be prevented. Great medical treatment is providing the necessary support while his lungs heal. He should recover without problems.
- Gail Hart, midwife,
Regarding pain at the pubis symphysis [Issues 2:26, 27, 28]: I learned the following in a prenatal massage class: With the woman reclining at a 45 degree angle, place her feet flat on the floor (or massage table if you have one). Start with her knees slightly apart. Place your hands on the outside of her thighs and ask her to press against your hands while you resist for five seconds. Repeat this three times, each time allowing the knees to fall open a little more. Then cross your arms and place your hands on her inner thighs. Once again, ask her to press against your hands for five seconds as you resist, and repeat three times. This is a passive adjustment of the sacroiliac joint, then the pubic symphysis. There should be little movement, but she should feel better. This can be repeated if necessary.
- Teri Brickey, LMT
When my daughter was born a year and a half ago, I had what seemed to be unusual, uncontrollable pushing contractions (more than an urge) starting fairly early in labor, I think at 3 cm or so. She was in a posterior position and I had pretty severe back pain through the whole labor, so my specific memory of elapsed time is a bit fuzzy. What I most remember about the labor was how incredibly difficult it was to pant through and try to hold back these very strong pushing movements for hours, until I had dilated "enough." By the time I reached 8 cm, my muscles were so fatigued from fighting the urge to push that I had a lot of trouble getting them to cooperate to push the baby out, which took another 2 1/2 hours. I have never read anything about this pattern of labor, and the approach we took seemed to contradict the "trust your body to know what it's doing" message. Does anyone have an explanation? I'm expecting my second, and hope not to have a repeat performance.
I haven't had any experience with Trisomy 18 in my midwifery practice, but did care for a couple of women while I worked as an L&D nurse. In both cases, the mothers needed a tremendous amount of support and would have benefited emotionally by being in their own home, in a loving, supportive atmosphere. My concern is that both these women became very sick with toxemia. One wound up in intensive care with central lines and the works, and almost died. I know that women who have babies with chromosomal differences are more likely to have toxemia. If your mom wants a homebirth, watch her very carefully to keep her safe.
- Joy Wayman
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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.). Email
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