August 8, 2001
Volume 3, Issue 32
Midwifery Today E-News
“Transporting to the Hospital”
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THIS WEEK'S ISSUE

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Contesting Conversations in Practice, Education, Research and Policy

Adelaide Convention Centre
4-7 November 2001
Join Paul Lewis, Philip Darbyshire, Patricia Benner and others in Adelaide for Contesting Conversations, THE major international Nursing & Midwifery conference that uniquely brings together clinicians, researchers, students, educators and managers from all specialties to explore clinical practice, professional assumptions, current health issues, education policies, research approaches and more.

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Quote of the Week:

"The reverent pleasure of attending births is an equal trade-off for personal forfeitures."

- Karen Parker


The Art of Midwifery

As a doula, I found having the partner pack the hospital bag works great. After the mother has selected the things she would like to bring, the partner then packs and organizes them. This makes it very easy for the partner to quickly find what she needs. Simple but very effective!

- Sue Brown

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News Flashes

A great effort has been made to reduce cesarean section rates at Princess Basma Teaching Hospital in North Jordan. With an annual delivery rate of about 8250, the hospital has worked to decrease its cesarean section rate from 13.5% to 6.5%. The rate has been almost constant since then. In 1987, cephalopelvic disproportion and fetal distress were responsible for nearly 65% of cesarean section rates; this rate dropped to about 30% in 1990. This decrease is due to the change in the approach to management of the two conditions. The reduction in cesarean section rates in the four-year period was associated with a drop in the perinatal mortality rate, showing that cesarean section rates can be reduced without increasing the perinatal mortality rate.

- Ann Saudi Med 1995; 15(1):29-31
www.kfshrc.edu.sa/annals/151/93303.html for the entire study.


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Transporting to the Hospital

Out-of-hospital birth has been shown scientifically to be safe when attended by midwives who, when necessary, can be in close contact with a hospital capable of emergency cesarean section. This is why homebirth and freestanding birth centers have been proven safe in those places in the United States with good communication and respect between home and hospital. The midwife can telephone the hospital and describe the emergency, and while the woman is in transport, the hospital staff is preparing, scrubbing in, etc.

How long does it take to do a cesarean section if the labor is in a tertiary care hospital in the United States? While the American College of Obstetricians and Gynecologists (ACOG) has recommended in the past that the "decision to incision" time be no more than 30 minutes, in one study at a university hospital in the United States (1), 52% of the emergency cesarean sections for fetal distress had a decision to incision time which exceeded 30 minutes.

One reason for this delay is that in the United States it is not the laboring woman who is in transport, it is the absent doctor who is in transport, the doctor who has been trying to monitor the labor in the hospital by telephone. The ACOG recommendation "to have a physician immediately available" is in reality a criticism of the U.S. system in which the laboring woman's doctor is usually not available and must be called to come in.

The elegant solution is not to take away valid choices for childbirth from the woman and her family but to change the system. Rather than insisting that the woman having a vaginal birth after cesarean (VBAC) be transported at the beginning of labor to a big hospital that is away from her primary caregiver, her family, her friends and familiar community, instead do what is done in the other highly industrialized countries with maternal and perinatal mortality rates lower than ours: Develop a system in the United States in which there is close communication during childbirth between primary care in the community--home, birth center, small hospital--and the big hospital, so that when the woman in labor needs to be transported, the decision to incision time is no greater than if the same woman were laboring in the big hospital and needed to be transported from the delivery suite to the surgical suite for a cesarean section.

- Marsden Wagner, MD, excerpted from "What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin #5, July 1999, 'Vaginal Birth After Previous Cesarean Section'."
Click here to read this informative article in its entirety

====

In Mexico and other countries, the United Nations has just discontinued funding for traditional birth attendant (TBA) training courses. Because maternal mortality rates have not dropped after 20 years of TBA training, the conclusion is that the courses do not work. This conclusion is based on the assumption that mothers die because midwives give them inadequate care or fail to transport them in cases of need. But as we have just seen, sometimes it is the hospital that gives inadequate care. And often women in need are simply unable to reach the hospital. I remember well when Dona Nieves, a very short and very experienced traditional midwife from rural Oaxaca, Mexico, bravely stood up in the big auditorium in Mexico City in the middle of the Safe Motherhood Conference and said to all assembled:

"Do not blame us for failing to transport women. We know when we should transport. But none of us own cars, nor do our clients, the buses run very irregularly, there is no ambulance service and if there were our clients couldn't pay for it, and the only taxi driver in our town charges far more than our women can pay. How then do you expect us to get our clients to the hospital in the city an hour away? No, we can't, we just have to do the best we can with no help from anyone. If you want me to transport women who need to go to the hospital, give me a car!"

- Robbie Davis-Floyd, excerpted from "Anthropological Perspectives on Global Issues in Midwifery."
Click here to read this fascinating article

====

If a transport during labor, birth or postpartum should become necessary, how will you remove the mother from her home? Note the location of stairways, doors, 90-degree angles, narrow halls and passageways, etc. Make a mental note of your best route of exit. Some midwives insist that the mother give birth on a first floor to avoid difficult or impossible transports in the event that the mother cannot walk to the transport vehicle herself. Be sure that the partner or some other person who is sure to be present knows the route to the nearest hospital and to the hospital of choice (if these are not the same). Have them drive the routes to make sure they are aware of how to get there from her home. Don't assume you know the best routes from a multitude of different locations unless your community is quite small. In addition, maps and directions should be posted by the phone in case the person who knows the route cannot be there to help. Another alternative is to have copies of the hospital directions in the chart as well.

- Anne Frye, Holistic Midwifery Vol. 1, Care During Pregnancy, Portland, OR, Labrys Press.

HOLISTIC MIDWIFERY, VOL. 1 is available from Midwifery Today's online storefront.

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Question of the Week

I'm 20 weeks pregnant (first time) and am seeing a CNM. At our first ultrasound the baby measured great but they told us we are on the low end of normal for amniotic fluid (an 8). Is there anything I can do to increase my amniotic fluid? Is this number particularly low? What are the possible chromosomal effects of having low amniotic fluid?

- Melinda Collins

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Question of the Week Responses

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

A: I was blessed to be able to attend my cousin's wife when she had her sixth baby at home. She had been diagnosed with MS five years previous and was advised to stop having children. During her pregnancy, all her symptoms of MS diminished and have been slow to return since. It has been five years. I didn't see any reason prenatally for her to not have a homebirth. Her birth was beautiful with no complications. I would be interested in hearing if others have run into problems with a client with this diagnosis.
I should also add that she was very aware of good nutrition and had eliminated most sugars and other unnatural foods from her diet. I do think this was an influence on her outcome and her reduced symptoms.

- Mary Holbrook, traditional midwife
WI

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A: I have had a client for several pregnancies who had quite severe MS. I attended her homebirths. She was able to be symptom-free during her pregnancies, during which I worked with her by having her drink fresh goat's milk every day. At one time she was nearly blind and immobile but after drinking goat's milk for a period of time, she improved so dramatically that her pregnancies and births went very smoothly.

- Merilynne Rush

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A: Pregnancy usually will cause an autoimmune disease to go into remission. She should be fine through delivery. But beware that after delivery she will probably go through a severe exacerbation of the MS in the next few weeks.

- Judy

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A: I have served several women with MS, and it never gave any problems during labor or birth. The first time--mainly because of MY worries--we opted for a midwife-conducted hospital birth. Ever since, if the condition is as you describe it, we've gone for a homebirth. The MS in itself has never caused problems, but I do tend to be more patient if the pushing is a bit slow. So long as mother and baby are doing well, there is all the time in the world. This goes for every birth of course, but with a MS-lady the muscles tend to be more lax. Then again, this may also relax the pelvic floor muscles, thus allowing for a quicker second stage and fewer tears.

- Annemieke van der Peet
the Netherlands

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A: I'm an experienced CNM and have had several clients with MS over the years. Both were mild and in remission or I would have felt that medically the patient should have been with an OB. I made sure they saw their neurologist once in the pregnancy for a follow-up. MS can definitely worsen during pregnancy, perhaps because of the major changes in the immune system function then. Both of my patients were fine and had no flare-ups. It's important to know that, should this patient need transfer for a cesarean, she should not have spinal anesthesia (epidural is OK). Hopefully she won't need to transfer, and if so, hopefully a cesarean wouldn't be needed. Also, the first six months postpartum is a time for increased flare-ups of the disease, so your patient shouldn't ignore or dismiss any neurological symptoms that occur, and chalk them up to being postpartum.

- Anon.

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A: I have MS and have birthed two children--the first by c-section because I had an active herpes lesion when I went into labor and the second a home VBAC at 40 years old, having had MS for 7 years. YES your friend can birth at home. If I could get through a c/sec and a home VBAC, she can homebirth.

Be aware of her keeping her energy up. That is the biggest thing with people with MS. Keep her rested in early labor, deep breathing to her comfort level only in all labor and birth (oxygen is very important in MS); see if she can nap during labor or at least relax with a massage or other therapeutic touch. Get her started on phosphatidyl choline, evening primrose oil, and fish oil (NOT cod liver oil) as soon as possible for the omega 3s she needs. Laughter and happiness and enjoyment are true MS medicines. Keep her spirits up during labor and birth--even read jokes to her! Other than all that, her body will function like anyone else's. Empower her with that belief. And don't worry--it's contagious. If she is in remission and is relatively symptom-free, as I have been, she will be just fine.

In response to foregoing comments: It is in fact quite commonly known that pregnancy brings much-improved health to the woman with MS. Symptoms are very often much reduced. Breastfeeding caused that state of well-being to continue for me, so you might advise your friend to keep it up for a nice long time! Postpartum may be difficult because women with MS commonly experience exhaustion anyway, and after a baby is born she can be very dangerously exhausted. Arrange for her to get lots and lots of support from friends and family, professional postpartum doulas, etc. for several weeks after the birth. That will also help her avoid breast infections. But there is no reason to expect a serious exacerbation postpartum, especially if she gets plenty of rest and help.

The goat's milk connection is mystifying but I have read that people with MS seem to respond well to placebos!

In Midwifery Today Issue No. 52 I reviewed a fine little book called Multiple Sclerosis and Having a Baby, by Judy Graham, Healing Arts Press, 1999. I rated it an A-plus for having been written by a woman with MS and for being honest, informative, sympathetic, empathetic, supportive, and down-to-earth.

- Cher Mikkola, E-News editor

Click here to learn more or to order Issue 52

====

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: Most women have an umbilical hernia near the belly button. You didn't mention your type. The hernia is a hole in the fascia, which is a layer of tissue lying over the abdominal muscle. This layer can't be repaired by any method except surgery. The pain is caused by the bulging of abdominal contents against the hole, or even through it, producing a lump. Once your uterus grows another month or so it will lie against that area and cover it up, so you will probably have much less trouble until after delivery. If your hernia is inguinal (groin) it will not change much during the rest of your pregnancy.

The real risk with a hernia is if a loop of intestinal tissue gets caught in the hernia, even for a period of hours. It can lose blood supply, causing "strangulation" of that part of the bowel, which is life-threatening. If you ever have severe or persistent pain in the hernia, or the lump won't recede when you lie down, or you have pain with nausea and vomiting, etc., go to the emergency room! If you need surgical repair of your hernia, it's a pretty short, simple outpatient procedure. I've even had several patients need repair during pregnancy and all went well with mom and baby.

- A CNM


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~*~*~*~*

International Connections

A traditional midwife in Queensland, Australia is undergoing investigation for practicing in homebirth. Her record over a 20-year period is impeccable. The Queensland Nursing Council states that she is possibly breaching the Nursing Act (1992) by having
1. taken action that is capable of being understood to indicate, or is calculated to lead persons to believe, that Ms Brassard is a midwife
2. practiced as a nurse
3. performed nursing services and/or
4. practised as a midwife.
There has been no complaint from any of her clients.
Her home was left in disarray and over 30 files were taken even though the warrant was for one particular file (the family are currently filing suit against other care providers).
Ms Brassard's contribution to the birthing community is valued & wanted. She is also a naturopath & craniosacral therapist.
If anyone feels to, could they assist in writing to the QNC, Mr Jim O'Dempsey, Executive Officer, GPO Box 2928, Brisbane Q 4001 Australia.
Ms Brassard has a large practice which the QNC do not want to see continue operating.
Thank you for any support given.

- R.

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I'm a student midwife and from reflection during my placement I am beginning to question if the protocols implemented in practice take into consideration the women's choice and are they restricting the midwife's autonomy?

- Rachel J Howells

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For the couple with the breech baby [Issue 3:31], if you are very concerned about genetic defects, an ultrasound might give some reassurance or clearer information about your baby, although many birth defects are not visible on ultrasound and it shouldn't be seen as a definitive answer. The cerebral palsy (CP) rate might be related to labor or birth in the breech position, and although most cases of CP don't occur from the birth process, the vaginal birth of a breech baby is risky enough that you would be wise to consider not delivering vaginally. The main thing is, your baby is not rare, being breech. Five of 100 babies are breech at term and most of them are perfectly healthy and just happen to be breech with no associated abnormalities.

- Anon.

====

Henci Goer wrote a great article about the study about vaginal birth after cesarean (VBAC) reported in the New England Journal of Medicine. You can find it at: Is vaginal birth after cesarean risky?
http://www.parentsplace.com/pregnancy/labor/gen/0,,264115,00.html

- Chrys Holland, D, CBE, MT
Saratoga, CA

====

More on herpes:

In addition to increased vitamin C and lysine, I have found a stress B complex (Twin Labs has a great one with 1000 mg vit C added) very effective for stopping an outbreak altogether when administered immediately upon recognition. The body is stressed--treat the stress, not the symptom. It has worked so effectively, I have used it for four years.

- Kelli J, CPM

====

I'm a stay-at-home mom who gave birth with midwives in a free-standing birthing center (much to my family's chagrin).
My stepmother recently made a comment that made my eyes bulge. My sister-in-law just gave birth after a difficult labor that almost resulted in a c-section (baby's heart rate lowered with each contraction). The cord was entirely wrapped around the baby. My stepmother said, "The baby would have died if it was a homebirth." This comment was most likely directed at me and my beliefs, which I can't discuss with my family, who all favor modern medicine and are anti-home birth.

I explained that it makes sense that midwives are more cautious than doctors because they have more at risk. There's a big difference between the repercussions that a doctor experiences after losing a baby's life in the hospital than those experienced by a midwife losing a baby's life at home or in a center. I told her that midwives will transfer laboring mothers to the hospital at the first sign of trouble. She disagreed saying that a midwife would never be responsible enough to move a patient to the hospital.

This all makes my blood boil but I don't have the technical knowledge to argue it. Are there any midwifery "rules" that might help me to explain midwifery to my family?

- Lauren McGinley

====

Per my husband, a United Airlines pilot, and the ALPA Air Safety Dangerous Goods Coordinator: Radiation exposure is measured in Sieverts. There are 1,000 millisieverts (mSv) in one Sievert. The typical exposure to persons on the ground from terrestrial radiation falls in the range of 1-3 mSv per year. For reference, a typical chest x-ray represents an effective dose of about 0.1 mSv. Therefore, a person who does not fly is exposed to anywhere between 10-30 chest x-rays per year.

According to an article in Aviation, Space and Environmental Medicine, the total recommended maximum dose for an entire pregnancy is 2 mSv. A few long flights during pregnancy does not significantly increase the amount of radiation exposure one experiences in a year. For example, the calculated cosmic radiation level in June 2000 for a flight between Los Angeles, CA and Melbourne, Australia was 0.0385 mSv.

Cosmic radiation exposure during flight is mostly a concern of flight crews who log 60 hours a month on polar routes and who reach an average of 3.04 mSv per year for 700 block hours of polar flight time. These individuals often overstep the radiation limits set for pregnancy and so many airlines, like British Airways, ground their pregnant flight crew members. United Airlines suggests avoidance of polar routes and a reduction of flight time for pregnant women.

If you would like to estimate your amount of exposure on flights, there is a software program available for public use through the Federal Aviation Administration called CARI-5E at http://www.cami.jccbi.gov/research/610/600radio.html
It is for flight crews, so it may require the input of some information that is not readily available. I would expect that you would need an estimate of flight
time and a rough idea of the route your flight took.

- Charity M. Pitcher-Cooper

References:
"Frequently Asked Questions about Cosmic Radiation" (Oct. 2000) a joint publication of United Airlines Flight Operations, Onboard Service and Medical Department.
Geeze, D.S. "Pregnancy and In-flight Cosmic Radiation" (1998) Aviation Space and Environmental Medicine.

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