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In This Week's Issue:
1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Fetal Heart Tones
5) Check It Out!
6) Midwifery Today Online Forum
7) Question of the Week
8) Question of the Week Responses
9) Coming E-News Themes
1) Quote of the Week:
"To be a midwife is inherently political: To choose midwifery instead of medicine and still practice 'medicine,' no matter how much our philosophies separate the two or reclaim the former, is to choose revolution."
- Therin River, CNM
2) The Art of Midwifery
It is easy to lose ourselves in our schedules. The antidote is to take time with each other and tell our midwifery and birth stories. It is essential that we reflect on another's experiences, and learn, recognize, associate and validate what we see as normal.
- Jill Cohen
TALK STORY is a regular feature at Midwifery Today conferences. Come and tell your stories, and learn from others' stories in a comfortable, supportive and enjoyable setting. Our Eugene, Oregon conference talk story will be facilitated by much-loved midwife, teacher, and Midwifery Today editor Jill Cohen. For more on this conference, go to:
Share your midwifery arts with E-News readers! Send your favorite tricks to firstname.lastname@example.org
3) News Flashes
Significant stress at work and at home can lead to an
increased chance of preterm births, low birth weight
infants, and possibly less healthy children. Pregnant women
who stand for long hours or work in a stressful environment
for more than forty hours a week can increase the risk of
having a preterm birth or of developing preeclampsia. Women
who have stressful life events during pregnancy are more
likely to have preterm births. In experiments on monkeys,
the infants of mothers who were stressed during pregnancy
showed increased abnormal social behavior, and had poorer
motor abilities and shorter attention spans.
- Childbirth Forum, Summer 1997
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4) Fetal Heart Tones
The fetal heart should be audible by 20 weeks with standard
fetascope; if you cannot hear it within the following week,
use a Doppler or refer for a sonogram. Normal fetal heart
tone (FHT) range is 120 to 160 beats per minute (BPM), but
younger babies are considered normal up to 170 BPM. The
heart rate is generally higher at the beginning of
pregnancy, slowing ten to fifteen points as the baby grows.
In addition to the BPM, check for variability by listening
for several fifteen-second increments, determining BPM for
each and noting the overall range, e.g. 132 to 148 BPM.
Variability may not be noted until 28 weeks. It occurs in
response to manual stimulation, uterine contractions, or the
baby's own movements, and is considered a sign of
neurological health, as it portends an ability to handle the
stress of labor. Don't forget to invite the expectant
mother's partner, friends, or other children to listen to
the baby. -Elizabeth Davis, Heart & Hands 3rd edition,
Celestial Arts 1997
Auscultation of FHTs as a gestational marker: Investigators
wanted to test the axiom that fetal heart tones are first
auscultated at 20 weeks. They examined women for FHTs weekly
between 15 and 23 weeks' gestation. At 20 weeks, 81% had
FHTs detected; at 21 weeks, 95%; and by 22 weeks FHTs were
heard in all cases. The mean onset was 19.4 weeks; the
range, 17-22 weeks. -Bruninghaus et al, OBGYN April 1987.
When you are first trying to find the fetal heart during
early pregnancy, begin by attempting to hear it just above
the pubic bone. The faint sounds seem to be amplified by the
proximity of the bone and therefore are frequently more
easily heard in this area. Press very firmly; the baby is
well cushioned by fluid and you will cause no harm. Listen
intently; it may help to close your eyes. Move your
fetascope around, little by little, until you can detect the
heart beat. You must listen for a regular sound behind any
overlaying sounds from the mother's circulation or digestive
system.... You will be less rewarded if the mother's uterus
is retroverted; in early pregnancy the fundus of the
retroverted uterus takes longer to rise above the pubic bone
and therefore both the fetal heart tones and the true top of the fundus are more difficult to find.
As pregnancy advances, the location of the loudest fetal
heart sounds will become somewhat more predictable based
upon the fetal position at the time. Traditionally it has
been said that the fetal heart is easiest to hear just below
the anterior shoulder through the baby's back. Most of the
time this will be the case, especially as the baby gets
larger. Be sure to assess whether the woman is experiencing
a toning contraction while you are trying to listen, which
will make finding the fetal heart more difficult. Simply
wait a minute or two for the uterus to relax before you
Traditionally it has also been taught that the location of the fetal heart sounds are one way to double check your
estimation of the baby's position. Be aware, however, that
there is not a 100% correlation between the two. This is
especially true if you are using a Doppler (another good
reason not to!). Should you find fetal heart tones in an
unexpected location relative to your estimation of the
baby's position by palpation, feel again. If you still feel
confident of the baby's position via palpation, give that
more weight than where you hear the fetal heart. The fetal
heart is often best heard below the mother's navel, even if
the baby is breech. -Anne Frye, Holistic Midwifery Volume I,
Care During Pregnancy, Labrys Press 1995
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Vol. I, go to:
5) Check It Out!
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6) Midwifery Today's Online Forum
I will soon be a first-time grandmother and would like my
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and stay. Could someone find the ingredients or lead me to a
place where I could get them?
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7) Question of the Week
In my prenatal fitness class I have a G1P0 due 12-4-00 who
has intercostal neuritis. She has been adjusted by her
chiropractor with no result. Gallbladder has been ruled out.
I intend to work on her with massage and am wondering if
anyone has any other suggestions on things she may try.
Acupuncture has been suggested and declined, though she was
planning to have a nerve block!
- Pam Martin, MS DONA CD, CM, apprentice midwife
Send your responses to email@example.com
8) Question of the Week Responses
Q: I am interested in hearing about successful protocols for
lactation without pregnancy. Please describe the method
including duration or dose or other appropriate units.
A: I personally have no experience with this one, but am
passing on information I have read and information from two
moms I have spoken with who did it. First, like with all other nursing, frequency is a key to success. The baby must
be put to breast very frequently, even every few minutes
during the day for several weeks. So that baby is getting
food when he/she nurses, a nursing supplementer can be used
that will supply baby with food while the baby suckles.
Donated breastmilk or formula can be used. It will take a
while to establish a full supply. You will be able to cut
back on the supplementation a little at a time. There are
also drugs that will induce lactation, but no drugs are
without risks. This method can work since it will even work
believe it or not for a MAN. In some cultures the father
nurses his child if his wife dies. Also in some cultures
women relatives, some who have never birthed, may help with
nursing children. One of your best bets for help,
information and support in doing this, I am assuming for
your adopted baby, is to contact LaLeche League.
- Anna Matsunaga
A: What do you mean exactly by "duration or dose"?
Galactogogue medications? The most-used is Domperidone. Dr
Jack Newman has a handout on it. There is also a WHO
publication, "Relactation, review of experience and
recommendations for practices," and an information sheet is
available from LLL: "Breastfeeding your adopted baby" LLLI
- Francoise Railhet
Manager, LLL France Medical Associates Program
A: In the U.S. only one drug is available for this:
Metaclopramide in a dose of 10 mg 3 times daily. In other
countries not only is this drug available, but also
Domperidone. Dr. Jack Newman uses it with good results.
*Metacloprimide is used for ulcers and induction of
lactation is an off-label use.* Some doctors and midwives
are ready to prescribe it; others are not willing to take
the potential liability for off-label use.
I use a host of different herbs depending on the woman.
Generally, lactation consultants use a common blend of
fenugreek and blessed thistle. Usually a woman takes three
or four capsules of dried herb three times daily. It works
well to increase supply and induction if the woman has a
previous pregnancy in her history. I like goat's rue and
homeopathic lactuca virosa. The goat's rue comes in tincture
that is taken three droppersful three times daily. The
lactuca is a homeopathic preparation taken several times
daily for the first few days. It is then reduced to three
times daily. Other herbs good for induction are fennel,
dill, anise, borage, alfalfa, caraway, nettles and red
raspberry. I find that tinctures seem to work faster.
In addition to herbs, I have the woman pump with a hospital
rental grade breast pump. Mom initiates pumping around 4-6
weeks prior to baby if she knows he's coming. She starts at
four times daily for 5-10 minutes, and builds to eight times
daily for 15 -30 minutes over the weeks. This is to
stimulate using her own hormones and prepares her for the
frequent nursings a new baby is going to need. I have this
all better explained on a website (www.Birthandbreastfeeding.com).
When mom gets baby, she will need assistance with getting
latch-on correct. She may also need to use a supplemental
nursing system of some sort. The first rule is feed the
baby. In this way baby won't lose weight; he stimulates the
milk supply by suckling at the breast and mom gains
confidence in feeding her baby. Also there is no substitute
for watchful professional guidance with this mom. Referral
to an IBCLC is helpful. Then surround her with lots of
support such a La Leche League International or other
support groups where she lives. Breastfeeding is not only
nourishing a baby but loving and nurturing.
- Mechell Turner, M.Ed. IBCLC, Doula, CBE, Herbalist
9) Coming E-News Themes
1. PRENATAL CARE consists of everything a woman does for
herself during pregnancy, punctuated by a series of visits
with you," says midwife and author Anne Frye. Any comments?
2. BIRTH RITUALS: E-News is curious about birth rituals
around the world that would usually be called "old wives'
tales." For example, birth attendants may be told to untie
their shoes at a birth so there would be no knots in the
umbilical cord, or they may avoid wearing red to prevent
hemorrhage. We would love to hear other midwives' stories
along these lines. (E-News thanks Fiona Thomson for this
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I am a social sciences student entering my third year at
Teesside Uni. I hope to study midwifery after it. I would like to do my dissertation on midwifery but I don't really
have an idea for a question or research. Would any midwife
out there like to suggest a research topic I could use to
help midwives in the future?
- Claire Russell
(Editor's note: Readers, so far we have received only one
suggestion!! This is a great opportunity to give a future
midwife a "hand up" and at the same time educate the public.
Send your one-sentence ideas to E-News--we could have fun
Questions from my childbirth education class:
1. I'm taking medication for hypothyroidism, and since the
beginning of my pregnancy my OB has done an ultrasound to
determine if my baby is being affected and if it is growing
properly. Do the risks of ultrasound outweigh the possible
risks of the baby not thriving?
2. I've become aware during my pregnancy that I have
gallstones. My OB has informed me that pregnancy can
irritate them, and that is why I am experiencing mild pain.
She also mentioned surgery after the birth. I'm wondering
why I would have to have surgery and would a liver cleanse
work after the baby was born while I am nursing?
My own question: I recently attended a birth where the mom's
water broke and an hour later she was 9 cm dilated. This was
her second birth. Twenty minutes later she was at 10 and
pushing. While the CNM was doing an internal I saw chubby
fingers grab hold of her hand. Needless to say she pushed
for four hours and swelled up horribly. She had to have a
c-section. The baby's arm had been around the side of his
face with the hand presenting knuckles first. We tried many
positions and the CNM tried pushing the hand back in. Any
suggestions on what else could have been done?
I am a student midwife in Ontario. I am currently doing
research on the growth charts that. I believe, are based on
formula-fed babies and the implications they have on
breastfeeding. I would love to know if there are any growth
guidelines based on breastfed babies available.
- Charlotte Baici
I have been following with interest the current discussions
about midwives using drugs to induce women at home.
Thankfully we manage to avoid this with UK homebirths as
induction is considered strictly outside the normal and only
performed in hospital. Personally I have always enjoyed
attending homebirths as it gives midwives the chance to
practise the 'masterly art of inactivity' in the true sense.
- Alison Andrews Wales UK
As a midwife who has a private practice and does homebirth
and birth center births, my main job is to protect and
nurture the natural process of pregnancy and birth. But I
also live in a community where Cytotec is used very
frequently in a nearby community hospital under "controlled"
conditions (with a perinatologist overseeing the outpatient
administration and the women being monitored). When my
clients beg for inductions (husbands going out to sea on
Trident submarines for three months, or women going so
overdue that they cannot use the birth center by law, etc.)
I tell them this is an option in our community and after
discussing risks and benefits, send them to this facility
for induction if they so choose. It has become a "community
standard" in our community and is available. I am not going
to refuse care for a woman and her family who exercise their
options. Listen to women and help advise them, but let them
choose what is legitimate in our society to choose.
- Annette Manant, CNM
I teach natural childbirth, the Bradley Method and natural
family planning. A woman is trying to achieve pregnancy and
her cycles are on average 48 days long with the basal
temperature rise around day 32. Temps before ovulation are
around 97. I have read that consistent temps below 97.6 are
considered a low thyroid problem (this does run in her
family). When blood work was done last year, thyroid was
tested; it came back normal. Estrogen levels came back
normal. Testosterone levels will be checked around day 40
this cycle. In the research I have been doing, I have found
that consistent low basal temps are more accurate than blood
work. Is anyone familiar with this?
"There is no evidence that delivery practices that avoid
perineal trauma are correlated with low Apgar scores, birth
trauma, or cerebral palsy. Passing through the bony pelvis
might sometimes be traumatic for fetuses, but there is
certainly no evidence that soft tissues of the perineum
damage fetal brains."
"In Klein's study of restricted versus routine (median)
episiotomy, sexual satisfaction in women 3 months'
postpartum was best with intact perineums."
(Copyright (c)2000 by The American College of Obstetricians
I used perineal massage prenatally and during the active
pushing phase with great results for all three of my births.
I believe that research backs up its value, and I encourage
clients to research its use. I also make sure to warn them
if they do use it (prenatally) that they may (one or both
persons) be sexually aroused. This is normal and should be
discussed. I use it with clients (at their request)
alternately with warm/hot compresses, and have not seen the
swelling that others report. As a doula and monitrice, I do
a lot of work in the hospitals and find that in this setting
it is more helpful than not, especially since there are so
many cut-happy docs. It seems that if a client chooses to
have this done, the doctors are more hands-off. In my
homebirth situations we may not do as much but the whole
birthing atmosphere is so much different. Things tend to be
slower, calmer, more hands-off anyway, unlike the hospital
with the "cheerleaders" for pushing and the commands to move
As an acupuncturist and daughter of a dialysis nurse I
decided to get both Hep A & B vaccinations. I had seen too
many patients and nurses have complications (including
death) from hepatitis. A couple of years later I had a
positive ANA (antinuclear antibody--an indicator for lupus)
test. While I don't know if one caused the other, I have to
wonder. When I got pregnant with my child I was retested and
my titers went up. I was considered to be higher risk than
normal and ended up with five ultrasounds (which would have
been much higher if I had gone to the twice-weekly visits
for fetal stress monitoring).
On induction of labor: I used acupuncture to help my labor
progress. It helped my contractions stay regular and less
painful than menstrual cramps until I got to transition.
On nausea: I threw up almost every day from week six to week
eighteen of my pregnancy. I even got stomach flu. The one
thing that helped was stimulating an ear acupuncture point
called "point zero." My midwife suggested a B vitamin
supplement with equal amounts of B1, B6, and B12 (I think
those are the ones) from 50 to 100 mg. By the time I tried
it, it didn't help. But I was taking B-50 when I got
pregnant and didn't start having nausea and vomiting until I
switched to prenatal vitamins.
I was recently induced by my midwife, who delivers at a
local hospital. I was induced because when I started to
dilate my blood pressure was rising with every centimeter
dilated. I felt she and I made the right choice for my
safety. I was given Cytotec. Why is everyone so upset with
this drug and what is it doing to women that is making
people upset? I was just fine with it. I also had to have
Pitocin and ended up with a cesarean because I failed to
progress, which was just fine with me. I had such a great
experience with my midwife that she changed my life. I am
enrolled in school to start my path to midwifery. Any
comments or suggestions would be great.
- Stephanie Ambs
Several times in your discussion of nausea and pregnancy it
was suggested to use ginger or ginger tea [Issue 2:38]. My
understanding is that ginger can cause risk of miscarriage.
Why do we as midwives recommend its use in pregnancy? I
realize the risk may not be as strong as with other herbals,
but there is still a risk, especially if combined with other
lesser risk herbs. There are many other safer things to
recommend and try.
- Judy Jones, CPM
Recent studies have shown there is a strong correlation
between saturated fat in the diet before becoming pregnant
and a higher incidence of nausea in pregnancy. Women who eat
meals high in saturated fats (the McDonalds meal) in the six
to nine months before pregnancy are much more likely to
suffer nausea in pregnancy than women whose diets are free
of saturated fats. In traditional societies where there are
no saturated fats in the diet, nausea in pregnancy is almost
- Larry McMahan
Do tomatoes contain vitamin K? I read that the seeds do, so
that eating them improves blood circulation.
Regarding Theresa's question about postpartum blues [Issue
35]: Natural progesterone cream used for three weeks out of the month will help restore the mother's
estrogen/progesterone balance and the blues will disappear.
Do not allow doctors to put her on synthetic hormones
because they will cause additional problems. Most health
food stores carry natural progesterone.
My baby was in the NICU in a teaching hospital which was, in
my opinion, a horrible place for parents who really wanted
to be involved or had plans for breastfeeding or an
attachment-type style of care. I felt downright abused by
the doctors and nurses. I want to better understand and
resolve what we went through as well as be prepared to be
effective in helping anyone I might meet who is in a similar
situation. Any comments?
International Conference on the Humanization of Childbirth
November 2nd, 3rd and 4th, 2000
Fortaleza, Ceara, Brazil
Throughout the 20th Century, advances in science and
technology have affected every aspect of our lives,
including the way we are born. In many parts of the world,
quick and arbitrary changes in maternity care have often
resulted in the excessive use of perinatal technology, a
loss of community-based models of care and an overcrowding
of large hospitals.
The International Conference on the Humanization of
Childbirth will take place in tropical Fortaleza, Ceara,
where Project Luz, a humanization project currently being
implemented, is based. The objective is to bring the
international community together in order to deepen our
understanding of the global situation of maternal and
perinatal health, thus strengthening the humanized approach
in the new millennium.
Goal: To promote humanized maternity care leading to healthy childbirth.
Participants: Those interested in maternity care and
childbirth, including: midwives, nurses, obstetricians,
pediatricians, consumer groups, women's groups,
epidemiologists, social scientists, health administrators,
policy makers, journalists and pregnant women and their
families are invited.
For a complete listing of seminars, instructors, events,
cost, etc.: Secretariat Eventuall Promocoes & Assessoria,
Rua Dr. Gilberto Studart, 369, Papicu, CEP: 60190-750,
Fortaleza, Ceara, Brazil; tel. (55) (85) 265 4022; fax (55)
(85) 265 4009; e-mail: email@example.com; web site
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