December 6, 2000
Volume 2, Issue 49
Midwifery Today E-News
“Compound Presentation”
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THIS WEEK'S ISSUE

Contents:

  • Quote of the Week
  • The Art of Midwifery
  • News Flashes
  • Compound Presentation
  • Check It Out!
  • Midwifery Today Online Forum
  • Question of the Week
  • Question of the Week Responses
  • Share Your Knowledge: Coming E-News Themes
  • Question of the Quarter: Midwifery Today magazine
  • Switchboard

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Quote of the Week:

"Ownership is within us. Our bodies, and our babies, are begging us to claim it."

- Leilah McCracken


The Art of Midwifery

Share your midwifery arts with E-News readers!
One trick that I've used for varicose veins is a sitz bath with five drops of essential oils of cypress and five drops of lavender. It helps a lot.

- Chinmayo, CDM
Anchorage, AK

Doula tip of the week

I attend mostly hospital births. For an emergency "hotpack" for the perineum, if I don't have a crock pot on hand, I get a bottle of warm water and microwave it, pour the water into a latex glove, and tie the glove off, then wrap it with a wash cloth. It works great and lasts a long while.

- Terry Gyde, in Toledo, Ohio

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News Flashes

Researchers at Queen Charlotte's and Chelsea Hospital in London learned that women who are anxious during pregnancy have lower birthweight babies because blood flow to the uterus is impaired. In the study, 100 pregnant women completed questionnaires on anxiety levels during their third trimester. Researchers then compared the anxiety scores with results from color Doppler ultrasound to measure uterine blood flow. In women who were most anxious, 27% had an abnormally high uterine artery resistance score. A high resistance to blood flow has previously been shown to be associated with poor obstetric outcomes, especially impaired fetal growth and preeclampsia. In women who were least anxious, only 4% had an increased resistance.

- Nursing Times, Jan. 27-Feb. 4, 1999


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Compound Presentation

Compound or nuchal arm occurs so frequently that it is considered fairly normal. Yet, when all other causes for hang-ups of labor have been eliminated, compound or nuchal arm is likely the cause. When suspected, the baby's elbow or hand may often be palpated just above the symphysis. The attendant may actually be able to cause the baby's hand or arm to retract by gently and firmly putting pressure against it externally and moving it away. This is much easier to accomplish if the mother is submerged in water.

Upon vaginal examination, I have found the hand at the side of the head or even over the head, and have been able to cause it to withdraw by simply poking at the fingers. The problem may not be discovered until the mother is approaching second stage, and is one reason for her not feeling a pushing urge. She may say that she has supra-pubic pain while pushing. While you are certain that she is not completely dilated, or has a cervical lip, it will be the baby's elbow making pushing painful. Have the mother put counter-pressure against the area while she bears down. She will know just how much pressure to use as it is difficult for the attendant to gauge. When the baby delivers, check for a hand. If it is there, grasp it firmly, pulling it straight out while pressing firmly against the mother's perineum. This will facilitate delivery, while avoiding severe labial and vaginal tears.

====

E-News asked readers what they do about compound presentation.
Here is one reader's response:

I've seen a number of babies born vaginally with compound presentations. On a personal note, both of my boys presented hand first. With my older son, a cesarean birth was discussed with me by my attending physician when he found the hand presenting. I talked him into patiently waiting to see what transpired. I gave birth to my son vaginally four hours later. With my youngest son, my physician found it very early and patiently watched as I progressed quite normally and gave birth to him vaginally as well. Both sons, now six years old and 3 1/2 months old, prefer to sleep with one of their hands alongside their head!

Recently, a friend was having her third baby. Her baby had been footling breech and was turned externally. She was delighted to be having a chance at a vaginal birth and was induced after the version. She ended up having a cesarean birth following two vaginal births because of a compound presentation. She was progressing quite normally and the fetus was healthy. Now she is having to cope with that loss. Why did this happen? Perhaps I am being harsh and do not know all of the circumstances but her baby was born around 4 pm. Is this a clear case of 9-5 obstetrics?

What do you do with a compound presentation? Watch patiently. As long as the fetus and mother are healthy, why do anything else?

- Maurenne Griese, RNC, BSN, CCE, CBE


Check It Out!

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

ONLINE HOLIDAY PAK: Print and use coupons for a variety of birth-related items, plus use clickable links to product web sites. Go to: www.midwiferytoday.com/specials

HOLIDAY GIFT GIVING is as easy as a click of your mouse! Go to Midwifery Today's website to order birth jewelry, books, subscriptions to Midwifery Today magazine and The Birthkit newsletter, educational packs, and much more!


Midwifery Today's Online Forum

I am an intern midwife in the slum area of the Philippines. I am dealing with my first low blood pressure woman, rather malnourished as our patients normally are. Her hematocrit is 32, she is due in a few days. Does anyone have a suggestion on how to improve a low blood pressure in such a short time? I am worried that if she hemorrhages, she would not have high enough blood pressure. What is your experience on this?

To share your thoughts and experience, go to Midwifery Today's Forums.


Question of the Week

Q: I was very ill with Grave's Disease (hyperthyroidism ) after my third pregnancy, took an anti-thyroid drug for a year, and have been in remission ever since. I had three wonderful homebirths, but wonder if for future pregnancies I would need to be monitored by a doctor and if I am likely to have thyroid trouble during the pregnancy.

- PHE

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Coming E-News Themes

1. An E-News reader submitted the following description of her concern for hospital-birthing women. Please share your thoughts on this issue, and let's get some problem-solving dialogue going:

I AM A MIDWIFE WHO ATTENDS TO THE NEEDS OF WOMEN BIRTHING IN THE HOSPITAL. I find that many "modern" (i.e. dot.com) American women and a large percentage of my Chinese immigrant women have difficulty recognizing and validating their strength and power in the process. I think the midwives who attend the [Midwifery Today Eugene] conference probably identify the same problem, especially those whose clients have the good fortune of being cared for by midwives by virtue of showing up at a clinic that midwives attend and having no knowledge of the issues of philosophy, etc.

I would find it useful and interesting to include "ways to inspire confidence and a sense of the inherent power and brilliance" of women into the section on women who care for women in the hospital. I work hard at this endeavor every day, but because our presence is diluted by all the non-midwives who work in the "institutions," I find it draining.

Your conferences are restorative and invigorating. However, I also feel a sense of disappointment or frustration because I don't attend homebirths and the most glorious stories usually are from homebirths. I fully support homebirth and would love to see a movement to take normal birth out of the hospital and into the home. There are women who don't have a home suitable for homebirth--they live in what the Chinese call "pigeon houses" where many families share a common bathroom and kitchen, are often alone and unsupported. I hope there will always be midwives willing to attend these women in the hospital.

There is a strong need to remind midwives why they are midwives and ways of bringing those midwives back to the fold.

- Zora

2. ASYNCLITISM: What do you do when the baby's head is not deeply engaged in the pelvis, but is tilted up toward the pubic bone or tilted toward the mother's sacrum?

Send your responses to:

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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Question of the Quarter for Midwifery Today Magazine

Issue No. 57 (Theme: Cesarean Prevention/VBAC)

How do you prevent cesareans?

Deadline: Dec. 15, 2000
Send your response to editorial@midwiferytoday.com


Switchboard

It was interesting to see the questions from Australia concerning third stage [Issue 2:47]. We've just had an interesting third stage where the woman was hemorrhaging, Pitocin was given to facilitate delivery of the placenta, and a manual removal was attempted in the end. The cervix had closed already and only one or two fingers could be admitted. The patient was transported (to a local government hospital here in the Philippines) and a complete hysterectomy was performed. She had a history of retained placenta with previous pregnancies. The doctors berated us for giving Pit before the placenta was out. So the question ensued as to whether or not it was OK to give oxytocic drugs while the placenta is still inside, in the event that it does cause the cervix to close sooner than normal. I realize this was an unusual happening with the retained half of a placenta in this case, but I'm curious also to hear about others' experiences with this.

I've personally been on a quest to stop meddling with things during third stage, knowing it increases the risk of hemorrhage and we have enough of that to deal with since we are working with high-risk and sometimes malnourished mothers. I'm enjoying facilitating placental delivery instead of taking the easy road and just pulling it out. It works wonders to have the mom in an upright position. Being flat on your back makes it all the harder to allow the placenta to deliver spontaneously. My last two patients just got a funny look on their face minutes after delivery and plopped out their placentas without a word from me as to what to do. They were both on the birth stool, holding their babies and bonding. Most of the time we just wait, monitoring the mother's vitals, watching for signs of separation, and when we see that, encouraging the mother to push it out on her own. We like to initiate breastfeeding during this time to cause the uterus to contract, especially if it's taking a while. I feel we get too impatient at times, wanting to finish things up, poking at the uterus to see if it's firm, checking to see if it's rising, fiddling with the cord, or tugging on it to see if the placenta is there. Most of these things are fine and even necessary to monitor what's happening, but gentleness is the key.

- S.Jones
Philippines

====

Re the cultural hand-washing ritual [Issue 2:45]: We need to remember that bonding and attachment are not just physical phenomena, they are also emotional and cultural. I don't believe we can or should try to create "one way" to have a baby or to bond or to raise children, all of which are somewhat culturally, ethically, or religiously guided. We can strive for the safety of women and children in all aspects of their lives but if, for instance, there is a cultural dictate to wash the baby's hands, the dictate may be more important than the amniotic fluid that remains there. In my experience the entire birthing environment takes on the smell of mother and baby--does this mean the baby is confused? I'd rather think that the baby feels safe surrounded by so much familiarity. Let's give ourselves a little slack in how we live. Let's celebrate diversity.

- P.R.

====

I am currently taking fertility drugs (Clomid) after everything natural failed. Is it still possible to have a homebirth or would it be considered a high-risk birth?

- Tendai Phiri
Reply to: atphiri@ruggedwest.com

====

I recommend that the woman concerned about gestational diabetes [Issue 2:48] check out the Brewer diet taught in Bradley Childbirth classes. I credit not having GD a second time to a high protein, well balanced diet, NOT weight control. Superior diet is the key! I gained the same amount of weight both times, yet my second son was 1 lb. 10 oz. larger than his brother (with whom I had gestational diabetes)! You can find Brewer's web page at Blue Ribbon Baby, and purchase a copy of his book: www.kalico.net/blueribbonbaby/

- Amy V Haas, BCCE
Fairport, NY

====

Thank you, Terra, for your excellent commentary related to MANA [Issue 2:45]. I saw the trend they were following over a year ago and elected not to renew my membership. If it were not for the awesome efforts of those midwives who never did become "certified," we would not be where we are today! I know that as an illegal midwife and nurse-practitioner, a university education is not what makes an excellent nurse or midwife. There is so much more to it than title, certification, etc. I worked alongside lousy nurses who had BSN/MSN after their names--they knew the paperwork inside and out, but had no love/bedside manner for their poor patients. So, as always, we all fight one another and get nowhere. Look at the medical doctors, who regardless of differences still hold together and have one of the biggest, most effective voices in the world. I am so sad to even admit that I know some of you who fight so hard against anyone who doesn't adopt your beliefs.

- Anon.

====

Re a letter describing dystocia [Issue 2:43] in which after 13 minutes the baby's head was pushed back and a c-section was performed: never in my life have I heard that somebody waited for 13 minutes before doing a c-section! And secondly, regarding the statement that the baby survived because the cord was not cut, the cord is cut after the baby is born, so there was nothing special about the fact that the cord wasn't cut, because the baby wasn't born yet.

- O.S. midwife

====

I just had my third child. My first was nine days early, 6 lbs. 8 oz via c-section due to being stuck; second was on his due date, 7 lbs. 12.8 oz, VBAC; third was one week overdue, 8 lbs. 6.2 oz, VBAC but stuck. We managed to get him out vaginally. My midwife and the attending physician suggested I should never attempt to give birth to another large baby. My question is, HOW does one grow a smaller baby? Does it have to do with being overweight? The foods one eats? The week overdue? I do not believe in using epidurals so I labor drug-free. I would prefer my next birth goes natural and not be forced into induction or scheduled c-section.

- Priscilla

====

As I was carefully taught (by some of the best midwives on the planet) occasionally it makes sense to break the water [Issue 2:48]. I was taught, as well, that it is important to know the head position of the baby before taking this step and to combine what you have learned with your intuition, skill, and heart whenever making decisions with the mom-to-be.

I have had three situations in the recent past in which breaking the bag seemed to be--and was--the "right" thing to do. The first was a woman who was at 7-8 cm for several hours. She was tired and the bag of water was bulging in front of the baby's head. We tried a few things but decided to release the bag. (I should state here that my mothers eat extraordinarily well and grow "bags of steel" that often do not break until pushing!) As soon as I did, the baby came down and she dilated steadily to ten and had the baby. She was very grateful for this intercession (as opposed to intervention, a la Valerie El Halta, one of my mentor midwives).

In another situation, a wonderful, intuitive and feisty mom ordered me at 9 cm to break the bag. She had had her first bag released at this point in her labor and the baby had come soon after. I was reluctant to break it, and discouraged her, at which point she said " I want you to break it now! If you don't I'll reach in myself and snag the thing on my own!" I released the bag and within a few minutes, she began pushing and had a large and beautiful baby.

The third situation was a woman with polyhydramnios. I was encouraged by several midwives with far more experience than myself to release the water gradually while exerting gentle but steady pressure downward externally on the baby's body and head, rather than to wait for it to release on its own. The woman was at 7 cm and had been there for a while. With the head now well applied, she circled (my hypnobirthing term for dilated) to 10 cm within the next hour and had her baby.

So even at my age, I am learning!

- Nancy Wainer


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