December 20, 2000
Volume 2, Issue 51
Midwifery Today E-News
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  • Quote of the Week
  • The Art of Midwifery
  • News Flashes
  • Asynclitism
  • 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:

"I have added to my repertoire of remedies the one that helps treat everyone: the art of listening."

- Alison Parra Bastien

The Art of Midwifery

Varicose veins run in our family and the most successful natural prevention I know is to eat the white skin of the inner orange peel. Sounds strange, but this home remedy has been proven to strengthen the walls of blood vessels and veins. I have loved that part of the orange since I was a little girl and have always eaten the peeling, seeds, fruit and all! I am the first female in our family who shows no sign of varicose problems. Also, research shows that many pain relievers destroy the veins and lead to bruising, bad circulation, and other problems. Acetaminophen is the safest, but still not risk free.

- Beka

Doula tip of the week

Have moms walk through contractions taking giant steps. This is very hard but seems to help get baby in a good position within the pelvis.

- Mary, doula, CBE

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News Flashes

A study was done as a search of the literature on the use of misoprostol when there had been a previous cesarean section. It was based on case reports, a computerized search of medical records, and literature review. Eighty-nine patients with previous cesarean delivery who had labor induced with misoprostol were identified. Uterine rupture occurred in five, for a rate of 5.6 percent. Of 423 similar patients who did not receive misoprostol, there was one case of uterine rupture, a rate of 0.2 percent. Researchers concluded that misoprostol may increase the risk of uterine rupture in the patient with a scarred uterus.

- Amer J of Obstet and Gyn, June 1999, Part 1, Vol. 180, No. 6: 1535-42.

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Asynclitism is diagnosed when the suture lines of the fetal skull are not felt to be aligned exactly halfway between the symphysis pubis and the sacrum. If the baby's head is tilted up toward the pubic bone, it is called anterior asynclitism; if tilted toward the mother's sacrum, it is a posterior asynclitism.

If the baby is not deeply engaged in the pelvis, the head may be adjusted by the midwife manually lifting the baby's head upward if posterior or moving it downward if anterior. Having the mother climb up and down a flight of stairs may easily correct the asynclitism. If no stairs are available, suggest that she duck walk: while being supported, the mother bends her knees, broadens her stance, and walks, swaying from side to side, rotating her hips out and forward. Another trick as demonstrated by Penny Simkin is to have the mother place one foot on an elevated surface, with the lifted foot higher than the other knee. This position is held for several contractions and then the alternate leg is elevated. I once had an interning midwife who thought the stair thing was really silly. When she returned to her practice, the second woman she was assisting had a marked lack of progress, and when it was determined that the baby was asynclitic, the midwife thought, Well, let's try it, since the mom was on the second floor of her home. "Stuck" at six centimeters, the mom made it down the stairs and promptly delivered her baby right on the stairs, halfway back up!

These techniques will help reposition the head in cases of incomplete flexion and military presentation as well. Don't be afraid to use your hands to adjust those crooked little heads.

- Valerie El Halta, Midwifery Today Issue 46


E-News asked readers, 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?

Leave the water intact, generally my advice anyway, if there hasn't been spontaneous rupture of membranes. Mom should move around, getting in different positions that help the baby turn: squat flat-footed (increases the diameter of the pelvic outlet as much as 10-20%), assume hands and knees position, side-lie (one side and then the other), sit on the toilet, sit on a birthing ball (bouncing or moving side to side), put one foot up on a chair and lunge, slow dance (arms around partner and swaying back & forth). I call it "jiggling the baby into position."

- Donna, CBE, RN, SNM


Asynclitism is best found when the baby isn't deeply engaged, for that is an excellent time to wiggle the baby's head to a different presentation. The book Heart and Hands (Elizabeth Davis) describes how a woman can kneel with one knee up, one knee down and "walk" on her knee. This helps maneuver her little one.

- D.C.


My midwife, Susan, gets the mother into knees and chest position for a few minutes. With hands on the sacrum/lower back, she sways the mom's hips. This will unstick a malpresenting baby.

- Connie Dello Buono

Check It Out!

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Midwifery Today's Online Forum

At what point during pregnancy is a placenta truly considered to be getting old? What are the signs? What are the risks? I am familiar with the tests performed to come to this diagnosis. How accurate are they? Are they necessary? My true feeling is that a healthy mom will go into labor when her baby is ready. I am a doula who is frequently experiencing scheduled inductions because a mom is told that her placenta is old. This seems to be happening even with moms who are barely two weeks post date. Please help!
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Question of the Week

A friend suffered with obstetric cholestasis in first pregnancy from 32 weeks and baby was delivered at 36 weeks, fit and well. Now on her second pregnancy it has returned at 16 weeks. At present although she has high phosphate levels, bile salts are not being deposited in areas causing risk to the baby. Does anyone have previous knowledge of this, and any advice, comfort to offer?

- Mags

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Question of the Week Responses

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.


A: I am a family physician who strives to follow a midwifery model of maternity care. I also occasionally back up a homebirth but have not yet attended one. I recently saw a woman who is planning a homebirth with a local nurse midwife in attendance and has a similar history. After doing some research and speaking with one of the maternal-fetal medicine specialists in my medical practice group, I learned the following:

Women with a history of thyroid disease, particularly Graves' disease (it can recur and also can be followed by hypothyroidism, which is an under-functioning thyroid), have nothing to lose by obtaining thyroid testing (TSH, T3 and free T4) early in the pregnancy. Better yet, I would recommend preconception testing, as the baby is most sensitive in the first third of pregnancy. Undetected thyroid disorders where there is either over- or under-functioning can be insidious, have profound negative consequences on growth and proper brain development, and, most importantly, can be treated successfully in most cases. If the thyroid testing is within normal levels and the woman has no symptoms, then that's that....

....Except with a history of Grave's disease. Because Grave's disease is essentially an autoimmune disorder, people develop antibodies against thyroid tissue as part of the illness. Usually these levels drop dramatically with treatment, but not always. Checking for blood levels of anti-thyroid antibodies is easy to do once sometime during the pregnancy or prior to conception.

If there are detectable levels of antibodies, then, as we all know, these can cross the placenta and, theoretically, attack the fetal thyroid gland. The OB explained that this can lead to fetal goiter (an enlargement of the thyroid gland), which could cause problems with breathing and require aggressive airway management (possibly intubation) at birth. She stressed that she had never seen a case and would first obtain a third-trimester ultrasound looking for such a circumstance--only if the antibody levels in the mother were elevated.

By the way, the woman I saw had normal thyroid functioning and negative antibody levels. Hope this helps address your concerns.

- Meg Parker, MD
Madison, WI

A: My husband had/has this disease. He was ill for about six months and lost about 50 pounds before we figured out what it was. We had to fight the doctors to avoid radiation treatment to kill part of his thyroid to reduce function. A doctor finally (reluctantly) agreed to put him on medication to lower the thyroid levels, and warned us that *IF* it worked (there was only a 10-15% chance), he would have to take it for the rest of his life (and the radiation treatment was so much quicker and easier and more effective....). He took PTU for about two years (after about six months he became very lax, taking only about half the doses), then weaned himself from it completely. He has been off it for about a year and is healthy, and his blood work shows his levels are fine. We are glad we did not kill part of his thyroid when it wasn't necessary.

I do not know specific implications of pregnancy, but I do know that hyperthyroidism is easier to control, and likely completely possible to get rid of, than the doctors will admit (not to downplay its dangers). He still avoids excess iodine because it encourages thyroid function, and medications like Sudafed because it can cause excess thyroid function as well, and we'd hate to encourage a "relapse." But he has had no further problems with it.

- Anon.

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. PRECONCEPTION COUNSELING: What do you tell the aspiring parents who ask you for preconception services/advice? (Thanks to Sarah, an E-News subscriber, for this topic.)

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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

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In response to Tiffany Collins's "confusion" about the difference of "opinions of outcome" between different caregivers (midwives, OBs, etc.): I think sometimes obstetricians give an opinion based on the personal experience he/she has had and not on the professional dogma of the AMA. Obstetricians often see many of the most high-risk women birthing, those who probably would not be attended by a midwife, as well as those with very bad prenatal care (unfortunately many still exist in spite of the available resources) and many other situations, so the ideas they develop about birth are different.

On the other hand, there is the extreme among midwives as well. I think that "too much" of anything isn't a good idea. The ideal way to learn and live is to develop the intuition of being able to see the best of all situations and learn from it. This avoids boxing up hospital birth practitioners (ob/gyns, CNM, doctors etc.) as part of the dogma, and developing the humility to learn even from those you deeply and innately disagree with. This also promotes unity among birth caregivers instead of the typical groupies of midwifery, doulas, CNMs, OB/GYNs, etc. Humility (to be humble) is the best way.

Also, in reference to having a doula and a midwife at births (Issue 2:44): Be they home or hospital, there is marvelous potential to create a very powerful caregiving team with a midwife and a doula as the caregivers. They each have their own specialty, health care, and emotional care, assuring that the mother is safe, loved and protected during her birth experience. I don't know how much conflict there is between doulas and midwives, but I sincerely hope it isn't prominent. If we as midwives and doulas maintain the humble delivery of love and care that is part of our ideal, conflicts will melt like snow.

- Megan Aiyana


Could it be possible that evening primrose causes constipation? I've never experienced constipation before, but since I'm pregnant and take EPO, I have some difficulties with this.

- Anon.


I am trying to locate the international ranking for infant mortality and morbidity. Where is a website that I could find such a thing?

- Nikki Lee RN, MSN, Mother, IBCLC, CIMI
Elkins Park, PA


It is not known what causes preeclampsia/ eclampsia [Issue 2:50], but we know that poor nutrition can be a contributing factor. A primip is more likely to develop the symptoms than a multiparous woman, unless the pregnancy is with a new father. Then statistically the woman is as likely to develop symptoms as a primip. With good prenatal screening, excellent nutrition, and acute awareness on your part, there is no reason that you have to go to a high-risk physician. I have cared for many women with histories such as yours throughout pregnancy, and have been with them for delivery of their babies at the hospital. You'll have to check with your local homebirth midwives to see what they are comfortable with.

- Carolyn, CNM


In response to your question concerning the wife of an obstetrician who had unexplained premature rupture of membranes (PROM) at approx. 35 weeks gestation: I am an RN in an L&D unit. One of our patients had PROM at 29 to 32 weeks with each of her pregnancies. She would then deliver a premature baby that required months of care in an NICU. The fourth time this happened the newborn definitely had a large scratch on the top of his head. It was finally discovered that she was intentionally rupturing her own membranes in a "Munchausen by Proxy" type of response to a mental illness. I am not saying that the patient you are caring for also ruptures her own membranes, but I do find it interesting that she is married to an OB and would have the knowledge and equipment necessary to perform such a procedure. She would also be aware that her baby had a pretty good chance of a good outcome at 35 weeks and might consider this a way to skip the last month of pregnancy and deliver a smaller baby.

- L.S.


I read with interest the questions and comments of many of your readers who mention medical issues that have arisen during their pregnancies (such as thyroid disease or diabetes). Many of these women are on their third or more pregnancies and wonder how to prevent the problem from occurring the next time they conceive. Have any of them considered that the medical problems might be nature's way of telling them it is time to stop having babies? And the only way to prevent serious medical complications from occurring again is to not get pregnant anymore?

While I would never presume to tell other women (or want anyone to tell me) how many children they should have, I wonder if anyone else is considering the ramifications of having large families, not only to their bodies and their families (whom they must care for and who care for them when they are ill) but to the environment in which we live? My husband and I are very concerned for the environment and climate change and after much discussion decided that two children gave us a full parenting experience and was a responsible, lower-impact number to add to the population mix. The effects of humans on the environment and the need to reduce the population of the earth have been well established.

My midwives and doula included birth control discussions/population issues and the impact of multiple pregnancies as part of their childbirth education. Do any other midwives do the same? Shouldn't it be a moral obligation to discuss it with clients? Even if only for the safety of the woman and the children she would have?

- Anonymous student


Although most doctors are scared of the scenario of VBAC with a vertical incision [Issue 2:50], they weren't 40 years ago! I was born 44 years ago by c-section. I was breech, the OB was an expert at external version and tried it a few times but I wouldn't turn. She suspected a short and tangled cord so she was worried about a vaginal birth. She delivered me by c-section (the cord was short, and tightly wound around my neck), then assisted my mother with a vaginal birth two years later. I think when we are trying to do something which the medical profession finds too scary, we have to rely on anecdotal support because there aren't so many medical studies.

- R.C.


Comments about bags breaking early reminded me of my first pregnancy. A cold started the same day labor started. Lack of vitamin C makes tissue less strong--my water broke, which started the labor process, the only time it did out of all five pregnancies. But worst of all, a whole batch of ugly stretch marks popped out on my last day of being pregnant! I never got a single stretch mark with the other pregnancies. So keep the vitamin C up for strong bags, stretchy skin and tissue flexibility. I also tore, which never happened again either.

- Kathy Galbraith
Raymond, Alberta


Having been a student in the field of women's studies and preparing to be a first-time mom any day now, I do not feel that breastfeeding is an issue of empowerment to women or of tying us to the home. For one who has chosen motherhood, it is necessary to seek what is best for our children. The American Pediatrics Association stands by breastfeeding as being the most beneficial to our children. Even though certain health benefits have been documented for nursing mothers, it is not a matter of what is best for the mother, but what is best for her child. That the choice we make when we choose motherhood.

- Serena DeGarmo
Columbus, Ohio

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