August 1, 2001
Volume 3, Issue 31
Midwifery Today E-News
“Second Stage of Labor”
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THIS WEEK'S ISSUE

Contents:

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Birth… Both Sides Now!!

Durango, CO August 20 and 21, 2001

Critical issues in pregnancy and neonatal care with current interventions for the Midwives. Lecture topics include: Intrauterine Substance Abuse, Multiple Gestation Pregnancies, The First Ten Minutes of Life, Controversies in Neonatal Resuscitation and Diagnosis and Management of Respiratory Distress.

Check our web site at: www.throwstars.com call Erika Larson @ 970 884 1696.

Quote of the Week:

"It is no small coincidence that midwives who cultivate faith in the process of birth often have practices that are markedly joyful."

- Caroline Eustice


The Art of Midwifery

Meditate just prior to being with your birthing mother--nothing fancy, just a few quiet moments to sit, breathe deeply and link with the universe. With a little concentration, it is possible to produce amazing heat from your hands so that when you return to support your birthing mum, you can lay your hands on her lower back or lower tummy area to provide soothing relief. A little essential oil (your mum's favourite perfume, maybe) mixed with olive oil and rubbed into your hands adds that extra little comfort.

I have found that this is most effective, and requested, during the latter stages of first stage labour, prior to pushing. After that time, it has been my experience that the birthing mum becomes too hot and does not get relief by this method. This procedure at the optimum time feels like a hot water bottle that never goes cold (so I am told)!

It is possible to keep the heat flowing for as long as required just by concentrating on your hands. Take a short break from time to time to relax and meditate again.

- Beryl Trimble

HANDS, OUR TREASURED TOOLS: Midwifery Today conference audiotape. Gladys Milton and Mabel Dzata, teachers.

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News Flashes

A study at the University of Montreal examined 4.5 million births in the United States and Canada in the 1990s. The researchers found that compared with U.S. babies born at full term, those born at 32-34 weeks were about six times more likely to die within their first year. Babies born closer to term but still early--34-36 weeks--were nearly three times more likely to die than full-term infants. The causes of death included infection, respiratory distress, various birth defects, and sudden infant death syndrome. A Chicago neonatologist says the advent of medical treatment for inadequately functioning lungs--a common complication in premature infants--has created the misperception that labor can be induced early with few risks. Treating the lungs "doesn't do anything for the kidneys, hearts or skin, all of which have problems involved in preterm births," he said.

- NewsEdge Corp. citing Aug. 16, 2000 JAMA


The International Alliance of Midwives (IAM)

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Second Stage of Labor

The passage toward the fetus ejection reflex is inhibited by any interference with the state of privacy. It does not occur if there is a birth attendant who behaves like a "coach," observer, helper, guide or "support person." It can be inhibited by vaginal exams, by eye-to-eye contact, or by the imposition of a change of environment. It does not occur if the intellect of the laboring woman is stimulated by the use of rational language ("Now you are at complete dilation--you must push"). It does not occur if the room is not warm enough or if there are bright lights.

A typical fetus ejection reflex is easy to recognize. It can be preceded by a sudden and transitory fear expressed in an irrational way ("kill me," "let me die"). In such a situation the worst attitude would be to reassure with words. This short and transitory expression of fear can be interpreted as a good sign of a spectacular increase of hormonal release, including adrenaline. It should be immediately followed by a series of irresistible contractions. During the powerful last contractions the mother seems to be suddenly full of energy, with the need to grasp something. The maternal body has a sudden tendency to be upright. The fetus ejection reflex is usually associated with a bending-forward posture. When a woman is bending, the mechanism of the opening of the vulva is different from what it is in other positions. The risk of dangerous tears is eliminated. After a typical ejection reflex, the placenta is often separated within some minutes.

- Michel Odent, MD, excerpted from "Insights into Pushing: The Second Stage as a Disruption of the Fetus Ejection Reflex," Midwifery Today Issue 55, Autumn 2000

The question begs to be asked: How many gloved hands have reached up inside women, followed by the declaration "You're complete! You can push now!" followed by hours of exhausting effort, frustration, and intervention?

As midwives, we're making a huge assumption that "completly dilated" equals "time to push." In the instant that this realization became clear to me, I made a vow to myself and the women in my practice that I would never do a vaginal exam to determine complete dilation or tell a woman it was time to push.

I honestly believe that in our well-meaning attempt to tell a woman when we think she is at the pushing stage of her labor, we encourage her to push way too soon. The consequence is that when a woman begins pushing before a strong and irresistible urge is present, she uses her energy to accomplish a task that her body would do more effectively on its own if she was listening to her body's cues rather than her birth attendant. Maternal exhaustion, a swollen cervix, fetal distress, and sometimes a transport for vacuum extraction or a cesarean section often follow. This is too high a price to pay!

When the women in my practice get "grunty" or "pushy," very few ask me what they should do because they already know the answer lies within. If they ask, I simply remind them to "keep listening to your body--you know what to do." So far, without exception, the women I've served have never actively pushed for more than about 30 minutes before holding their baby in their arms. This includes primagravidas, "big babies," and VBACs, moms of all ages giving birth in every imaginable position, on land and in water.

- Lois Wilson, excerpted from "When to Push: Listening to the Body's Cues," Midwifery Today Issue 55 Autumn 2000

After hours of full dilation with dwindling sensations, what if the mother is languishing? The sense of anxiety and fatigue in the room builds, and nothing is served by allowing this to go on too long. In this kind of situation the midwife can help by changing the direction of the flow. Normally we think of the baby coming "down and out." In this scenario, nothing is moving. It's a bit like having your finger stuck in one of those woven finger traps. The more the mother attempts to bring the baby down the more tired and tight the process becomes. At this point, it can be helpful to get the mother into knee/chest position and tell her to try to take the baby's bum up to her neck for a few pushes. This will sound like strange instruction but, if she has learned to trust you, she will give it a whirl. Reversing the energy and moving it the opposite direction can perform miracles. After five or six sensations in this position with minimal exertion of the mother, the fetal head often appears suddenly at the perineum. For those of you who know Eastern martial arts, you will understand this concept of reversing directions in order to gain momentum. This is midwife tai chi!

- Gloria Lemay, excerpted from "Pushing for First-time Moms," Midwifery Today Issue 55 Autumm 2000

SECOND STAGE is the theme of Midwifery Today Issue 55, a mini-textbook on the subject.


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Midwifery Today's Online Forum

Does anyone have tips about great doula films or birth films in general? I'm looking for a good film to show to people who don't know anything about doulas, as well as birth films to show clients. As for the birth films, I'm looking for one that shows unmedicated labour as well as the actual birth.

To share your thoughts and experience, go to Midwifery Today's Forums. Click on "Doula/CBE Chat" and "Doula Films." PLEASE DO NOT SEND YOUR RESPONSES TO E-NEWS!


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Question of the Week

Q: I have a lady who really wants a homebirth. It is her first birth and she has multiple sclerosis but is in remission, not taking any drugs, and is symptom-free. Do you know any reason why she should not have a homebirth? Have any of you had any experience with MS and birth? From my textbooks, it seems to me to be OK. She is due in three weeks and the pregnancy is fine.

- Ilana Shemesh

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Question of the Week Responses

Q: I am 22 weeks pregnant with my third child and was just diagnosed with a pregnancy hernia. My baby is growing normally. I have few complaints except for the hernia pain and backache. I am looking for information about birthing naturally with a hernia. I gave birth naturally both previous times and intend to do the same this time.

- Christine Staricka

A: Explore the option of hypnotherapy. I suggest that you find a hypnotherapist who has advanced training in pain management. The training a certified clinical hypnotherapist receives goes far beyond an individual that is only trained to do programs like HypnoBirthing. You will need to go beyond deep relaxation and be show advanced pain management techniques. Contacting the American Council of Hypnotist Examiners - Hypnosis Certification would be a great resource for finding someone who is properly trained.

- Aaron Aldridge, C.Ht.

A: I don't know exactly what type of hernia you are referring to, but I had inguinal hernias during four pregnancies without mishap. The first appeared when I was having my first baby. It was repaired surgically and three years later it reappeared in my second pregnancy. By the time I was pregnant for the third and fourth times I had bilateral inguinal hernias. They caused some pain and discomfort in pregnancy but no problems for labour.

- Mary Murphy, RN, RM, homebirth midwife


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~*~*~*~*

International Connections

I am a midwifery student interested in doing research about why nipple sores are still prevalent in breastfeeding mothers, even with guidance in breastfeeding e.g., proper latching techniques and any other ways to prevent it. I would be glad if there are some journals or research papers pertaining to this topic that can be forwarded to me for reading.

- Leta
Singapore
Reply to: babelicious20@hotmail.com

Make more International Connections--Join IAM! The International Alliance of Midwives is an online directory of birth enthusiasts with an exclusive newsletter. You can share your thoughts, ideas, make connections and possibly visit midwives from countries around the world!

~*~*~*~*

What criteria do midwives use to decide which moms with cardiac problems are safe for home delivery, which ones are safe to have a midwife-attended hospital birth, and which ones should only receive direct care from obstetricians? Many cardiac patients in hospitals are encouraged to have early epidurals because a high level of pain is known to cause stress on the heart. However, I often wonder how actually the fluid boluses required to receive epidurals affect these women whose hearts may not particularly handle excess fluid volumes in the body very well. Also, with epidurals, moms may not be able to assume positions that would work best for them, which in the long run may be greater work on the heart. Bearing down with pushing is very stressful on the heart--an epidural can prevent this urge, but is it possible at all for a woman to ignore the urge and allow the baby to descend on his own? What is the better option--performing an episiotomy so the baby has more room to come with less stress on mom's heart or going without one to prevent infection at all costs to someone who is at risk for developing endocarditis? I have read the pros and cons in the past between c-sections and vaginal births for cardiac patients, and c-sections often seemed the better alternative, but I feel this could be a result of the mode of transportation and not the route that was so stressful to mom's heart. Any good articles/books or personal experiences to share?

- Laura L., (RN)
North Carolina

More on herpes:

Has anyone heard of red marine algae as a treatment for herpes, and specifically, is it safe to use in pregnancy? I used it to treat periungal (along the edges of my fingernails) warts that were refractory to conventional treatments (cryo, lazer, and bleomycin) and they were gone in one month. A friend was taking it for herpes, and I figured that herpes is a virus, warts are caused by a virus, and this stuff is antiviral, so maybe there would be a cross-sensitivity, and it seemed to work. I would love to do an RCT on this stuff--especially looking at its effect on bad Paps (LGSIL/HGSIL) and rates of cervical cancer.

- Anne Schnedl, CNM, MN/MPH
aschnedl@earthlink.net

There are a couple of things essential in managing a pregnancy with a history of genital herpes. The first is to eat the most complete and nutritionally packed diet possible (i.e., the Brewer diet). In addition to this, take 2000 mg vitamin C, 500-600 mg L-lysine, and 50 mg zinc daily. This will help prevent eruptions. If active lesions do occur, the amounts of the above supplements should be doubled to ease and shorten the outbreak.

The other essential thing is to learn effective stress control. Deep relaxation and visualization techniques are invaluable in any health problem as well as wellness, and are effective in controlling mental, emotional and spiritual stressors. Physical stressors must also be considered, including things such as sun exposure, which stresses some cells into viral replication.

- Jill
jille99@yahoo.com

"The Ramp Maneuver" [Issue 3:29] is described very well with a picture in the Journal of Nurse-Midwifery Vol. 39, No. 6, Nov./Dec 1994 p. 387. It needs three people to make it work effectively and is used in anticipation of shoulder dystocia or when the "turtle sign" appears or the baby does not restitute or externally rotate. The author of this letter to the editor, Cydney L. Afriat, CNM, MSN (Brown University School of Medicine), claimed to have been using the "Ramp Maneuver" in her practice for three years. I would be happy to describe it in a future issue but feel the picture is very valuable to the article and that it can probably be easily looked up at most university/college libraries. Perhaps the author might even be available to describe what has happened with the procedure since 1994.

- Ellie Allyn
Aurora, CO

As a homeopath with 20 years experience, the remedy I have found that most often helps women with ligament pain [Issue 3:30] is Ruta. I would suggest you take it in 30c potency starting with 3 doses daily and try reducing the frequency as the symptoms improve.

- Glenis

My wife is nearly 36 weeks pregnant and the baby is in breech position. I have read that breech babies tend to have more genetic defects and other abnormalities such as cerebral palsy. Obviously this scares us. The baby seems to be doing OK in terms of size and heart rate, and he moves around a lot. Because my wife is nearly at full term, the baby will not be premature. Given these circumstances, what is the likelihood that there will be a problem with our baby? I read that breech babies tend to have more problems, but I haven't seen the statistics.

- Anon.

I am going to be the doula at a birth in November. The mom is a 27-year-old primip who had no fertility treatments. She had hoped for a homebirth but because of the two babies has opted for a midwife-attended hospital birth. She is taking great care of herself and has a great diet. What can we expect at a hospital birth for twins? And what can we do to make the experience as intervention-free as possible?

- Shonti, doula, breastfeeding counselor

I recently caught twins. One weighed 9 lb. 2 oz and the other 7 lb. 1 oz. The mom labored for only four hours and had them within 10 minutes of each other. It was the perfect labor and birth. Only a few pushes--about two each and they were out. There were no complications, no bleeding, her blood pressure stayed perfect, and she was cheerful and pleasant the whole time.

When I assessed the situation in relative terms, I realized she lost almost a third of her body weight within 10 minutes. WOW!

How long should it take a mom to get back on her feet after birthing twins? We tried to rehydrate her with every kind of fluid, but she was still dehydrated. Although her blood pressure stayed fine, she would get very light-headed and passed out once or twice trying to get up to urinate. Can anyone offer suggestions? We ended up transporting her for IV fluids. The boys stayed home, and she was back within four hours looking much better. The hospital was amazed at how perfect her body and story were. They said they found it hard to believe she had had a homebirth, and they could not find one thing wrong. They even said they hated to admit that it actually sounded really good about how well it went.

- Chantel

For the woman who had retention of lochia: I would suggest finding a seasoned practitioner of Oriental Medicine in your area. Chinese herbology has many herbs that can help treat toxicities in the blood.

Thank you to J. Costa [Issue 3:28] for her tip about being cautious of how you treat your children when they reach the age you were when the abuse started/ occurred. I have done much healing and am generally quite aware of my issues, but this is a huge issue that had not occurred to me. It rings so true. I hope this advice travels far and wide.

- Colleen Morris, L.Ac.

EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.


Classifieds

Experienced licensed midwife needed beginning late September 2001 at Northern New Mexico Women's Health and Birth Center, Taos, NM. A combined direct entry midwifery and OB/GYN practice. Visit our website www.womenshealthandbirth.org or call 505-758-1216


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