December 13, 2000
Volume 2, Issue 50
Midwifery Today E-News
“Omnium Gatherum”
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A PARTERA'S STORY: Listen to Mexican midwife Doña Irene Sotelo speak about her life, her culture, and her calling at Midwifery Today's Eugene, Oregon conference March 22-26, 2001.


THIS WEEK'S ISSUE

Contents:

  • Quote of the Week
  • The Art of Midwifery
  • News Flashes
  • Commentary
  • Check It Out!
  • Birth Story from Peru
  • Midwifery Today Online Forum
  • Question of the Week
  • Share Your Knowledge: Coming E-News Themes
  • Question of the Quarter: Midwifery Today magazine
  • Switchboard

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MIDIRS collects references from thousands of journals, Internet sites, databases and other sources of midwifery related topics and research information.

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Quote of the Week:

"Midwifery is based on the premise that the body is good and its messages should be trusted, that women derive great strength from integration, and that birth is a grand opportunity for personal growth."

- Elizabeth Davis


The Art of Midwifery

A great perineal "hot pack" is to take a maxi pad (the extra large ones used in hospitals are especially good), soak it in hot water from the tap, and then apply by hand. It's the perfect size and shape, holds water and heat really well, and is easy to hold in place. Of course, it should always be held in place by hand, not with panties like a regular pad.

- Kathy Montgomery, Calgary, Alberta (with thanks to Kimberley)

Doula tip of the week

Holly Disnbeer, doula, CBE, RN, always brings snacks for herself to a birth--childbirth attendants need stamina, too!

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News Flashes

Researchers at the University of Mississippi Medical Center and the Saint Barnabas Medical Center evaluated all neonatal deaths from culture-positive sepsis that occurred over a three-year period at either center. All were of 24 weeks gestation or greater and died within seven days of birth. Total number of deaths evaluated were 35: eight cases of sepsis were caused by ampicillin-resistant Escherichia coli and 27 by other organisms. The babies who died from ampicillin-resistant organisms were statistically more likely to have received ampicillin during the antepartum period than those who died of non-ampicillin resistant organisms. The researchers conclude that a relationship exists between neonatal death caused by ampicillin-resistant Escherichia coli and prolonged antepartum exposure to ampicillin.

- Journal of Obstetrics and Gynecology, June 1999, Part 1, Vol. 180, No. 6: 1345-8.

Commentary: A Season of Hope

December may be the darkest month, but it is also when the sun begins to pour its generosity onto Earth again. This remarkable time is indeed the season of hope, when we truly experience enLIGHTenment. Beneath the mantel of snow or in the midst of cold rain, among the blackened plant life, seeds are storing their energy and life-giving nutrients, patiently waiting for longer days and warmer soil in which they can work their transformation.

And so it is with the work that midwives and all conscious birth practitioners do. Although times and conditions may be discouraging, the work daunting, and the challenges to sane birth practices overwhelming, you can wait your turn for renewal, harbor your energy, believe in the future. With all the inherent wisdom of the waiting seed, practice diligence, take one day at a time, think about what matters most and plan to implement it when the time is right, then act in accordance with your own truth. No need to ride into battle with swords drawn, spoiling for a fight. To nurture the clarity of your conscience, love for your calling and the women who seek your guidance, to practice patience, steadfastness, and belief in your own strength and truth means that when the seasons inevitably turn and the sun shines fully upon you, you and your truth will prevail. Anatole France once said, To accomplish great things, we must not only act, but also dream; not only plan, but also believe.

- Cher Mikkola, Editor, E-News


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!


Birth Story from Peru

I am a Canadian-Peruvian woman who is in the process of becoming a midwife in the shantytowns on the mountains of Lima, Peru. I have no senior midwife to supervise me or supportive medical backup. I only have questionable hospitals that have a nasty reputation for abusing, torturing and ultimately butchering poor women. At my tenth birth as a primary midwife, the Goddess decided to present me with a hair-raising third stage hemorrhage. Here I was, in an almost inaccessible hut with no running water, a kerosene stove and one bright light bulb, with 20 year old nullipara Noemi, whom I had just met the day before. Her LMP was unknown (but I felt she was around 35-37 weeks) and her hemoglobin was 10. Regardless of the lack of prenatal care, she seemed to be essentially strong and healthy with the exception of the hemo status. Her labour went smoothly, with her blood pressure hovering steadily around 126/86. She kept well hydrated. After a lovely and witchy 1 1/2 hour second stage and a lovely 3,600 g. male baby, she started to bleed like an open faucet. Blood, blood and more blood, about 700-800 cc worth! I had never encountered this and let's face it, as gutsy, smart, caring and committed that I might be, I was also new at this. My brain said, Just stop this blood, whatever it takes. I gave her 10 units of Pitocin, shepherd's purse compound tincture, Sabina 200c, and two minutes later Cinchona 200c. Noemi's bleeding stopped after 2-3 minutes. I want to be clear that after the birth, I did just as I've read: be watchful but do not meddle with the uterus! So after births I usually settle into checking for a happy baby, a stable mom and that perineum! So I don't think I "mismanaged" this third stage at all. But in response to what the hospital people said to Ms. Jones, the midwife in the Philippines [Issue 2:49]: WHAT ELSE ARE WE TO DO BUT STOP THE BLEEDING? if we have to use oxytocics while the placenta is still in there, so be it. Well, Noemi's uterus didn't seem to want to give up the placenta, even with gentle but firm and guarded uterus traction, standing up, squatting, acupuncture, caullophylum, labour tincture, the works. I didn't feel fully comfortable going into her uterus and removing the placenta. So after about one hour and 40 minutes of waiting with a stable mom, I made the painful choice to transport (from a mountain top) to an uncertain, potentially abusive hospital, only for Noemi to report to me that the placenta all about came out on the examining table without much fuss. After this experience, I give Sabina and Cinchona 200c BEFORE any signs of excessive bleeding and I am still very ready to give oxytocin when needed. Now, however, I help the again-stable mom to squat on a basin as soon as it is OK. I know Varney recommends massaging the uterus and helping the placenta become fully detached in case of THIRD STAGE HEMORRHAGE only. But for some reason, I am not comfortable doing that--there is something about it that bothers me. I think I would only use it if after all my tricks and drugs, the mom continued to bleed. A few days later I was presented with a mild ("teaser") version third stage hemorrhage, after a 1 1/2 hour active labour and a 2 1/2 second stage, and it also was quickly stopped. The healthy placenta came nicely and smoothly after 20 minutes, while Jaqueline, a 17 year old single mom, squatted over a bucket.

- Ana Montero, CH.


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Midwifery Today's Online Forum

Q: I have been appointed for a c-section; my daughter was born with a c-section, but what makes me wonder is that the doctor says I should have it 4 weeks before my due date. Is it a normal practice to do that? My first child was born in Bulgaria, the second one I'll be having in Saudi Arabia, and they seem to have a different method in these things. Please, I need advice.

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 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 Midwifery Today conference section on women who care for women in the hospital. I work hard at this endeavor every day.... I fully support homebirth and would love to see a movement to take normal birth out of the hospital and into the home. [But] there are women who don't have a home suitable for homebirth.... 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 to bring those midwives back to the fold. Comments?

- 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!


QUESTION OF THE QUARTER for Midwifery Today magazine

Mamatoto: Motherbaby

How can midwives best facilitate the bonding process of motherbaby in pregnancy, birth and postpartum?

Deadline: March 31, 2001

Send your response to:


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Switchboard

I recently attended a homebirth where the baby was born with "lesions" on the forehead, lower occiput and a small area under the scrotum. The head lesions were large and, although not clearly fluid filled, a greenish brown color. They were only slightly raised but circular and clustered. They also seemed to be spreading out from a central area. Mom had no history of herpes and RPR [rapid plasma reagin] was non-reactive. She declined a GBS screen; membranes were ruptured for only 30 minutes. No active vaginal infection was known. Baby seemed fine otherwise. We referred that day to the local teaching hospital to be on the safe side. CBC [complete blood count] did show an elevated white blood count. Antibiotics IV, lumbar puncture, all bacterial and viral cultures came back negative. Baby was released on day six. There was no known cause. The lesions were gone by day four. Has anyone ever seen a baby born with lesions not caused by herpes or syphilis? Was a cause ever found?

- Florida LM

====

Are there any goodly midwives in Ulaanbataar, Mongolia, and/or near that area of the world?

- Angelina
Reply to: ioscofamily@juno.com

====

What are the dangers of a short second stage? I have pushed out three of my babies in one contraction--one or two pushes. With my last birth, the midwife "made me" stop pushing during that one titanic contraction, and I proceeded to have about an hour of very piddly contractions, with correspondingly piddly pushes. I was finally told to push hard during the next few contractions, even if I didn't feel like it. Baby was finally born, with the cord twice around her neck and then under her arm. The midwife said it was a good thing that I had pushed more slowly this time as there could have been problems if I had pushed her out in one contraction, due to the cord entanglement. What could she have meant?

- Paula

====

I had toxemia with my first pregnancy which manifested in an eclamptic seizure during labor. I was transferred to the hospital where my daughter was born two hours later. I was given a magnesium sulfate IV before my daughter was born which caused both of us to be very lethargic for a couple of days. We didn't start nursing until she was two days old. I am now 23 weeks with my second baby and doing OK: blood pressure is low, no protein in urine, steady weight gain, and baby is growing and moving right on track.

My questions are: What experiences do you have with toxemia in consecutive pregnancies? How have you controlled it? Are there less aggressive but equally effective alternatives to magnesium sulfate? Are hospital midwives allowed to deal with high risk pregnancies? I desperately want a homebirth for many reasons.

- Leslie

Editor's note: Check out the web site mentioned in the letter below. The Brewer method-so simple!-is highly recommended by Midwifery Today.

I recommend to the woman who wanted information on management of third stage that she go to the WHO web site and check out their recommendations. It includes a good deal of research.

To the woman who wanted information on preventing gestational diabetes, I recommend that she check out the Brewer method taught in Bradley classes. I credit not having GD a second time to a high protein, well balanced diet, NOT weight control. Superior diet is the key! The funny part is that 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/

====

I had a client who I recently had to transport due to an ineffective labor. It was her second pregnancy and she would have been a VBAC. They told her her first c-sec had been slightly turned up on one end, making it a crooked smiley face instead of a true smiley face--so they had to make this incision with a hook sort of like a J. They had to go beyond the original incision and make more of a vertical, therefore she would not be able to ever have a vaginal birth. We are not sure how to take this. She is determined to try it again. I am researching this and would like any input. What experience have other midwives had with vertical incisions and vaginal births thereafter?

- Dixie

====

Do any midwives out there have protocols for women who previously ruptured their membranes preterm for no apparent reason? We have a client who ruptured at 35 weeks, then in the next pregnancy at 34 weeks for no apparent reason. She is an obstetrician's wife, and had very thorough prenatal care. I remember a midwife telling me long ago that she would have her women who smoked (who tended to have thin amniotic bags that ruptured easily) take alfalfa because they would grow a bag that was very thick and strong. Any truth to this? Does anyone have any documentation of this or any other helpful tricks?

- K.G.

====

Re the woman in the Philippines with the client who has low blood pressure {Issue 2:49]: Hormonal changes and increased blood volume during pregnancy cause a normal increase in interstitial tissue fluids which causes swelling/edema and distended blood vessels. With the increased cardiac output to about 33%, the side-lying position and sitting position are the best position where cardiac output is greatest and to prevent compression of the inferior vena cava by the uterus when in supine position (lying on the back).

Balanced workload of the heart:

The blood is less viscous during pregnancy because of the effect of prostaglandin. Low platelet count is an ominous sign of hemorrhage. I would increase the intake of the following: albumin, fibrin and calcium salts. The following foods are common in the Philippines: lemon/kalamansi, greens/veggies, cabbage, mung beans, onions, nuts, egg yolk and goat's milk. Potassium and sodium are also important minerals. I would manage birth with less fiddling and be very alert during the third stage of labor. The following articles can provide more insight about the pregnant body and bleeding after birth. Her low blood pressure might be her normal reading.

Well Expanded Blood Volume:

Estrogen also makes the blood vessels more permeable and more dilated. The low pressure in the maternal circulation in the placenta and reduced pressure in the peripheral vessels of the mother also compensates for the increased workload of the heart during pregnancy.

Maternal Circulation in the Placenta:

An average of 120 spiral arteries provides an entrance of oxygenated blood with equal number of venous openings (carries unoxygenated blood). The blood pressure or blood flow in the placenta is slow enough to allow for the exchange of materials between the fetal and maternal circulations across the placental membrane.

Regulated Heart Beat:

The heart beats faster but the reduced pressure in the peripheral blood vessels compensates for this change. The reduced uterine pressure present in the placental vessels regulates the pressure and blood exchange.

What To Watch For:

The presence of ineffective circulation, stress, poor diet and other heart related problems can increase the workload of the heart.

Fear not, in most well-managed births (esp. births at home with skilled midwives) with healthy mothers, the placenta detaches wholly by itself, the uterus contracts and retracts by itself and uterine tone reacts to birth normally unless outside factors exist such as drugs or other interventions in the rhythm of births. Postpartum hemorrhage or excessive bleeding--bleeding of more than a cup of blood after birth--can be prevented. Check for early signs such as constant flow of fresh blood, mother's alertness at first and then fainting next.

Remove the number one cause: mismanagement or mishandling by the doctor:
Fiddling with the placenta, resulting in incomplete detachment, and just being in a hurry and not waiting for signs of placental detachment before starting to assist placental delivery.

Use of labor inducing drugs (Pitocin, oxytocin) which hyperstimulates the uterus making it atonic (without normal tone/rhythm)

Blood disorders: Early prenatal blood tests would reveal high white blood count and low platelet count.

Aspirin affects the early stages of blood clotting process.

Nutrition: Increase intake of calcium, iron and vitamin K-rich food such as nettle and alfalfa (especially during the last trimester).

During labor and birth, the following are indicators of placental separation: cord lengthening, change of size, shape and placement of uterus.

The placenta normally (90% of the cases) detaches by itself within 5-15 minutes after the baby is born.

Boggy uterus is not a good sign; it may indicate placenta is filling up with blood or mom did not expel all her urine.

Ways of stopping the bleeding/contract the uterine walls (by nature uterine muscles are living ligatures which contract and retract by themselves as soon as baby and placenta are delivered): make sure mother urinates, Pitocin injection, nipple stimulation, hearing the baby cry, black and blue cohosh, and shepherd's purse tinctures.

Other preventive remedies: For all mothers, especially those who have more than four children, exercise the abdominal and uterine muscles. Before active labor comes, get rest. Find ways to shorten a long labor: nutrition (fish), walking, water exercise, nipple stimulation, sex (bag of water is not broken)

The hospital doctor or homebirth midwife final control measures:

As soon as all the placental tissues are out, manually compress the uterus. Use manual removal to remove placental remains.

During transport, position mother to the left side, legs elevated and assess mother's consciousness.

- Connie, Filipina/author, apprentice midwife
San Jose, CA

====

I so much enjoyed your issue on compound presentation [Issue 2:49]. My second son was born with a nuchal hand. Exactly as described, I had no urge to push which puzzled everyone, and pushing was the only painful part of a near pain-free delivery. When my son emerged with his hand, palm up, pressed to his forehead, my midwife exclaimed, "Look! He's saying 'shalom' to all of us!" (this was in Israel).

Re: c-sec for a nuchal arm: At least one hospital in Jerusalem had a policy of c-sec for babies diagnosed with a nuchal hand over the head. When I asked about it, I was told there was fear of the arm causing the baby to become impacted during delivery. Many of the midwives I spoke to at the time felt it to be dubious, but that was the reasoning. Does anyone else have experience with this?

- C.W.

====

I have read somewhere that to wait for a second twin to be born (hours or even days) does not affect the baby's morbidity or mortality outcome. Do you know where I could quickly find such information?

- Kusum


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