August 23, 2000
Volume 2, Issue 34
Midwifery Today E-News
“Drugs in Labor”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Drugs in Labor
5) Check It Out!
6) Question of the Week
7) Question of the Week Responses
8) For Coming E-News Themes
9) Switchboard

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1) Quote of the Week:

"The ultimate lack of trust/faith in the power of babies to be born in conformity with nature resolves itself in the cesarean section."

- Ellen C. Waff, RN

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2) The Art of Midwifery

Camomile is quite amazing for helping with afterbirth pains and menstrual cramps. The results are almost immediate. It is also useful for cranky babies. Caution: Don't use too soon after birth as it relaxes the uterus and can cause an increase in bleeding. Usually, I don't give my mothers camomile until about 8 to 12 hours after the birth, depending on need and bleeding.

- Lisa Goldstein, The Birthkit Issue 8

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3) News Flashes

A new study by researchers at the University of Minnesota Medical School indicates that the use of intrathecal [spinal] narcotics to manage labor-related pain may significantly prolong second stage of labor and double the need for oxytocin. These results contradict findings from several prior studies that support the overall safety of intrathecal narcotics compared with other analgesic options during labor.

Researchers retrospectively compared the labor and delivery outcomes of 100 women who received intrathecal narcotics and 100 who received intravenous narcotics or no analgesia during labor. Women given the narcotics had significantly longer second-stage labors than the other women, averaging 73 minutes and 40 minutes, respectively. Women who received intrathecal narcotics were also twice as likely as the others to use oxytocin, and had higher rates of urinary catheterization and pruritus. Intrathecal narcotic use was associated with a higher risk of cesarean delivery, but this association was not significant. On the other hand, the overall duration of active labor and neonatal outcomes were similar in the two groups of women.

- J Fam Pract 2000; 49:515-520.

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4) Drugs in Labor

A) When my first two children were born in the hospital, I was given a 1/4 dose Nubain each time--I requested the smallest possible. I also had Pit each time, once because my water had been broken 12 hours and I had started to run a fever in addition to having "no progress," the second when my labor stalled at 5 cms after 49 hours of posterior labor. I had epidurals with both too. (Let me also say that if I knew then what I know now... but I made choices with the information I had at the time). Kyree, my eldest, did a lot of sleeping and initially was not interested in latching on; Sam was very limp, had a double tight nuchal cord, but nursed like a bear. Both were more irritable, cried more frequently, had fussy periods that lasted months.

In comparison, my third child, Zoe, was born at home. Her personality was and continues to be more relaxed and laid back. Though she did have a period of colic/fussiness, it resolved over the course of a week or so (and a couple of chiropractic adjustments).

It is hard to say if [the difference was due to] the drugs or the atmosphere the kids were born in, but there was a definite difference.

- Pam

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B) Read Beverley Beech's informative article about drugs in labor on Midwifery Today's web site:
www.midwiferytoday.com/articles/drugsinlabour.htm

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C) No honest doctor would ever suggest that drugs given for pain are without risks. But in their pursuit of relieving a laboring mother's pain, doctors inevitably resort to prescribing drugs when, in fact, there are many non-pharmacological ways to relieve pain. For example, scientific research has proven a number of drug-free techniques to be effective in relieving the pain of normal labor, including: the continuous presence during labor of a midwife, a doula or a loved one; sitting in a tub of warm water or standing in a shower; freedom to move about and assume any position; massage; acupuncture; reflexology. None of these techniques involve any risk to the woman or her baby and are often promoted by midwives but rarely promoted by doctors. -Marsden Wagner, "Technology in Birth," Midwifery Today web site

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

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D) One study (Belsey 1981) showed that differences between babies who had received high levels of Demerol during birth continued to show effects of the drugs for six weeks afterward: they were more likely to cry during tests, to be less settled and less able to quiet themselves. The effects of Demerol were most noticeable when the babies were seven days old, particularly in those who had received higher doses. Another study (Jacobson 1990) found that children of women who had used both Demerol and morphine barbiturates in labor were more likely to become addicted to opiates as an adult than those whose mothers had not taken drugs which crossed the placenta.

- Nicky Wesson, Labor Pain: A Natural Approach to Easing Delivery, Healing Arts Press, 1999, 2000

Editor's note: Please be sure to make Jacobson's important article available to your clients: Jacobson B., Nyberg K et al, Opiate Addiction in Adult Offspring through Possible Imprinting After obstetric Treatment," British Medical Journal, Vol 3011, 10 Nov 1990, pp1067-1070.

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Help support Midwifery Today! Order Nicky Wesson's book at: http://www.amazon.com/exec/obidos/ASIN/0892818958/midwiferytoday

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E) In the rush to speed up labour, a woman's distress at the increased pain of induction or acceleration is often dealt with by giving a pethidine injection. Ironically, research by Thomson and Hillier (1994) revealed that unmedicated mothers had a first stage of labour whose mean length was 7.7 hours, compared with 11.7 hours in those who received pethidine {Demerol}. Furthermore, an incidental finding in Rajan's research (1994) revealed that when the second stage of labour was longer than an hour there was no difference between those who received pethidine and those who did not; but in the group of women who had second stages lasting less than an hour there were many more women who did not have pethidine (436 v 2770)....

Pethidine readily crosses the placenta. The baby may have greater sensitivity to the drug because of the immaturity of the blood-brain barrier and the circulatory bypass of the liver....Research shows that pethidine is most likely to have a depressant effect on the fetal respiratory system if the dose is administered two or three hours before birth. The higher the dose to the mother the greater the effect on the fetus (Yerby, 1996). As the baby's liver is immature, it takes a great deal longer to eliminate the drug from its system, 18-23 hours, although 95% of the drug is excreted in 2-3 days.

- Beverley Beech, AIMS Journal Vol 10 No. 1, 1998

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5) Check It Out!

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

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FATHERS are an important part of the birth process too. Midwifery Today has created a web page just for them. Go to:
www.midwiferytoday.com/fathers

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FIND FOUR NEW ARTICLES about fathers on Midwifery Today's web site: www.midwiferytoday.com/articles

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WATER IS A SAFE and effective alternative to drugs for labor pain. Find out how to order four different waterbirth videos through Midwifery Today:
www.midwiferytoday.com/products.htm

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6) Question of the Week

I am a 28 years old African American woman who is expecting her fourth child in March 2001. With each of my last three pregnancies I gained between 35-45 pounds. I followed a healthy diet and got plenty of low impact exercise. All three of my deliveries were uncomplicated and each of my babies had Apgars of 9 and 10 in the first few minutes after birth. However, only my first child weighed the average 7 lbs 8 oz that standard pregnancy texts say a newborn should weigh. My other two both weighed approximately 6 lbs 8 oz at birth. I understand from my mother that I weighed that much when I was born (so did my husband). All three of my girls have been extremely healthy since birth.

I am puzzled when I read texts that state that babies born in the 6 pound range and under are considered low birth weight and do not do as well as babies born weighing more than this. What groups of babies are they using to carry out these studies? Are all babies around the world expected to be the standard 7 lbs 8 oz or more? Are there no allowances made for race, the size of the parents, other hereditary factors? Are all big babies healthy babies? Any information people can provide me with would be appreciated.

- Maisha Jugant

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Send your responses to mtensubmit@midwiferytoday.com

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7) Question of the Week Responses

Q: A primigravida with spontaneous rupture of membranes at term had an uncomplicated pregnancy. The head was deep into the pelvis and one assumed that labour would progress normally. C. wanted a homebirth more than anything, and I was very happy to manage her expectantly. Twenty-four hours later, there was no sign of labour apart from a few niggles. I suggested various homeopathics, nipple stimulation, walking on the beach, etc. and monitored her temperature, pulse and foetal heart. Thirty-six hours after SRM, labour started courtesy of her husband suckling her nipples. On examination the cervix was a soft, stretchy 5 cm with the head well below spines. Good, I thought, we're on our way. All the time, she kept eating and drinking, resting when she felt like it, but still the contractions never became coordinated.

Reluctantly, I examined her six hours later to find the cervix 7 cm dilated. A further six hours down the track, she was still the same. I suggested it was time to consider going to hospital for oxytocin augmentation, and very reluctantly they agreed to transfer in. Three and a half hours later, she had a normal birth, no pain relief, moderate blood loss and they all went home. Postnatally, her fundus had almost completely involuted by the third day! I'm baffled as to why her uterus was so inefficient in labour, yet super efficient afterward. Any suggestions?

- Sharon Weir
New Zealand

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A: I guess that you were very brave, waiting almost two days, and you have insisted a lot. It is a pity that you cannot augment the labor in your country. Here in Brazil, and as an ob/gyn doctor, performing a homebirth, I use oxytocin for induction in about 18% of out of hospital births (among 150).

I had some cases very similar to yours: It seems there is something "braking" the labor. Maria Nuria intended to have a homebirth; she started contractions at 10 pm, and I passed all night long at their home. After 11 hours she went from 2 to 3 cm. She was very tired after laboring all night. She took showers, walked, etc. At 12 pm she was only 4 cm and could not keep going. We decided to go to the hospital. Another advantage we have in Brazil is that I keep in control of the labors that I take to the hospital. After we got to the hospital (1:30 pm) something changed and she had her baby in a normal, spontaneous birth at 2:15!

So, I think you have done very good work. Some laboring women need this kind of help. Congratulations.

- Adailton Salvatore Meira MD OBGYN
Brazil

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A: I believe there are forces in nature that confound us and that the birth of a child is often held back until the energies are right. Esoteric and conventional scientific approaches are useful for that reason. For example, I attended a 30 hour birth that promptly hastened as soon as the newborn's astrological moon changed signs and entered into the father's natal chart 1st house of The Self. (Sounds odd, but the ancients and many nations today, especially India and China, use these charts for many purposes.) With the child's moon in the father's first house the emotional bond would be stronger between he and his son in a family of very dominant females! Quite accurately, the father needed this support.

I have been studying charts at birth and in family "spiritual agreements" for some time now and encourage you to at least consider that there are other energies and indicators that can explain extreme situations where the usual appears "unusual," affecting deliveries for reasons that cannot immediately be understood.

- Mary B. Foote
South Florida

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8) For Coming E-News Themes

1. What do you know and/or suspect concerning the use of rhogam, that is outside the medical paradigm?
2. What is your experience with and your feelings about the
use of Cytotec in labor?

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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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9) Switchboard

Angie Jaramillo and her daughter were killed in a car accident (Angie was an advertiser with Midwifery Today through her business Precious Pouches). An auction of donated items will be held to help the family (Angie is survived by her husband and two sons, 2 and 3 years old. They have no life or health insurance and the auction will help the family and their mounting bills). All the products seem very mother-baby related--lots and lots of different baby slings, cloth diapers, etc. To view and bid on the items up for auction on Mothersnature.com, go to:
Auction for Angie
For more information, go to:
www.preciouspouch.com

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I have had a bout with Stage 1 breast cancer, no chemo, TRAM flap reconstruction. Are there are moms out there who have had successful pregnancies following a TRAM flap? Also, if there are midwives who have attended such births, and if anyone can tell me if there are any complications to watch out for.

- Anon.
Reply to: ajos@delanet.com

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Each of my newborns has seen a chiropractor within the first two weeks after birth. My chiropractor uses the B.E.S.T. method: Bio-Energetic Synchronization Technique. It is similar to using pressure points on the body which conditions the nerves/muscles to realign things on their own--there's no cracking or popping involved. This method is most effective and advantageous for newborns! You can call 1-800-874-1478 (MortarHealth Systems) to try to find a chiro in your area who has at least learned this method.

- Karen

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I have just returned from a mission's trip to El Salvador and was involved with a feeding program for the children of the 600 people living in the San Salvador dump. I understand that the infant mortality rate here is very high, as mothers birth their children in the dump. I would like to return to San Salvador to provide midwifery and childbirth education at this facility, but wanted to ask some questions first. What is the climate for lay midwifery in El Salvador, and particularly in San Salvador? I would love to hear from midwives in this area. Has anything been done in the way of midwifery or childbirth education for the women who live at the dump, and what has happened as a result of that? Do women living at the dump have the right to any medical services provided in El Salvador as a result of birth complications, if they are transported? Has anyone tried to provide a birth center on or near the dump? Population at the dump was estimated at approximately 600 people; is this correct?

- Ellie Allyn
Denver, CO
Reply to: BEE0819@aol.com ("0" after the BEE is a zero). Spanish is fine.

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Ginkgo biloba could be extremely toxic in pregnancy and lactation (cardiac and brain effects, lead to hypertension, aggression in worst cases) [Issue 2:33]. Extreme cautions is necessary when we use this herb.

- Marypascal Beauregard, herbalist

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Anonymous said that yellow dock should not be given to any pregnant or lactating women under any circumstance because it is a nervine [Issue 2:33]. None of my herbals back that statement. According to the Herbal PDR, about yellow dock, Rumex crispus, "No health hazards or side effects are known in conjunction with the proper administration of designated therapeutic dosages. Mucus membrane irritation, accompanied by vomiting, is possible following intake of the fresh rhizome, due to its anthrone content. The anthrones are oxidized to anthroquinones through dehydration and storage." Overdosage: "Oxalate poisonings are conceivable only with the consumption of the leaves as salad, one case of death following consumption of a soup made from the leaves of the curled Yellow Dock has been described."

Since yellow dock is administered almost exclusively in tincture made from the roots, not the leaves, no health hazards or side effects should be expected.

- Debby Sapp

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In response to your GBS culture being positive [Issue 2:33]: You can either refuse or accept treatment (but may have to sign some kind of release ). GBS is colonized (grows in) up to 35% of women without causing them any symptoms. If women were not treated with antibiotics when tested positive then about 1% (yes, one) would pass enough bacteria on to the baby during birth to cause it to be sick. Approximately 50% of THOSE babies could die from the infection. So, the risk of passing it on to baby are very slim and some instances increase that likelihood (listed below), but if the baby does become sick it could be very dangerous. Antibiotics bring that risk to well under 1%. But there are always possible problems with any intervention: allergic reaction in you or the baby, building resistance, over or under dose, IV risks (fluid overload, mobility restrictions, vein damage etc.). Sometimes the babies will get an IV with antibiotics even if you had one in labor (check with hospital and pediatrician policies).

Two groups have posted recommendations: ACOG, and Group B Association, (919) 932-5344. They both advise IV antibiotics for those at high risk (two of the following):

Positive GBS at 35-37 weeks
Previous baby with GBS infection
GBS cultured in urine
Membranes ruptured (water broken) for over 18 hours before delivery
Labor or water broken before 37 weeks
Fever over 100.4 in labor
Some say African American race (not sure why)
Some say under 20 years old (not sure why)

So check with your midwives' protocols, the hospital's and the pediatrician's, get more info to "back up your case" if you decide to refuse antibiotics. Sometimes you can skip antibiotics if no other risk factors exist and just watch and monitor the baby and treat if showing signs of infection.

- Melanie Jordan, CNM
kej@jps.net

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Just because a CT scan reveals brain damage doesn't mean the baby is doomed to life of dependency [Issues 2:32 & 33]. After a massive stroke at age 32 (eight weeks ago) a CT scan, MRI and goodness knows what else showed extensive O2 deprivation and brain damage in the right hemisphere. The medical team predicted that if I lived I would experience hemiplegia, probably spend a few months in the hospital before being discharged to a nursing home. Now, I am not perfect and am far from "back to normal" but I am even further from a nursing home! According to my current scans I shouldn't be able to walk, talk, etc. So keep the faith.

- Anne Boyd

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In the hospital I worked at in San Francisco, inductions were routine and a few doctors had their own computer orders for induction (rate of Pitocin per hour, when patient can have epidural, routine amniotomy, etc.) A couple of the physicians in the group having their own babies did it routinely at 35-38 weeks gestation, so they could get back to work sooner! It was not uncommon for women to come in for induction and not know why they were being induced. It could be that their doctor was going on vacation, they needed to have their baby while their mother was in town, they were due on a holiday, they were a couple days over their due date and even, because they were tired of being pregnant! It got downright sickening. It was "normal" to have 2-4 inductions every day on the schedule. Some nurses liked those patients; it was an easy routine for them. Start their IV, start their Pitocin, get them their epidural and sit at the desk and monitor them and chart thusly. They barely had to spend any time in the patient's room! I can't imagine why their cesarean section rate was higher than comparable sized ob units in the area. Needless to say, I am glad I do not work there any longer.

- Tora R. Spigner RN, MSN

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Regarding twin homebirth [Issue 2:32]:

If homebirth feels like the right choice and you have the support of your midwives, then go for it. However, I would ask your midwives how comfortable and practiced they are with delivering a second twin; i.e., have they experience with all types of breeches (frank, footling, full), and with internal version (basically reaching in to the uterus and grabbing the babe to pull her out feet first) in case twin B decides to turn transverse during or after the birth of twin A, as often happens? This latter intervention would be very painful for you (I speak from first hand experience) but can certainly be coped with without an epidural, despite what some doctors will tell you....

If you do decide on a hospital birth, make sure you have a well thought out birth plan which you discuss with your OB well in advance. Even if you go for th homebirth, make a birth plan that covers transfer to hospital. I normally suggest max. 2 pages for a birth plan, but for twins, give yourself 3 or 4.

- Jennifer Landels, BA, CBE
Vancouver BC

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It's usual for more midwives to be at a twins birth. This is for your safety and for the safety of the babies. Obviously, you and your midwives have already put safety first. If you think will be too many people, mention this to your midwife and see if someone is extraneous. You will need support people such as your doula.

Yes, the 2nd twin often needs intervention, but this intervention can be mild and expected for certain situations. If the 2nd baby doesn't move into position quickly after the 1st birth, the 2nd baby may be "nudged" into place. That is an intervention. If the 2nd baby is transverse, or in a bad position, it may be maneuvered into a good birthing position. That is an intervention. All interventions have pros and cons. Every birth and intervention carries some level of risk, but just because there is a risk doesn't mean that the "risky thing" will occur. Some birth attendants are scared of twins births; some are very experienced and judge each case on its own merits.

I hope your nutrition is as excellent as you can get, as it makes a big difference in how you do during and after labor and how long you carry your babies.

Your midwives would know if the drugs weren't helping with bleeding and you're pretty close to the hospital. Surely the hospital could be notified by phone that you were coming in and why and be prepared to receive you?

An informal survey of midwives who caught twins showed me that 2nd born twins come anywhere from 9 minutes after the first to almost 2 hours apart. This is a survey of midwives who don't routinely use drugs to speed up the 2nd birth. If your birth attendant is fearful about the births, their decisions will be made fearfully and techniques that would cause fewer problems might not even be on their list of things to try.

Personally, I would be wary of continuous electronic fetal monitoring. The continuous double ultrasound might lead to overheating of the babies. This doesn't even address the problems that arise because you would be immobilized due to it.

I can't imagine using a water pool during labor causing you to bleed more, unless they think you would be so very relaxed that your mind would turn off its "let's-not-bleed-anymore" mechanism. I find this unlikely. Maybe their perceptions of the amount of bleeding is distorted by the blood being in the water.

- Debby S.

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