December 19, 2001
Volume 3, Issue 51
Midwifery Today E-News
“Paths to Becoming a Midwife”
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====

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Quote of the Week:

"Midwifery must face the challenge of becoming more 'scientific' without becoming more technological."

- Lorna Davies


The Art of Midwifery

We must stop looking at herbs as physiologically active chemicals. There is a synergistic whole to herbal therapy, and when deciding to make use of a certain herb one must take into account the emotional, mental, and spiritual state of the person needing the herbs. Herbs function and produce effects on all of these levels, so a range of herbs is used to achieve the same results in different people.

Herbs are whole as our bodies are whole, and when working with herbal medicines we are working with whole plants to produce a state of wholeness in ourselves and our clients. Yes, herbs can be effective for pushing the body into doing something it is not ready to do, but take care with this and always think of what you can do within the physical realms (i.e., walking a woman around the block instead of using blue cohosh) first. When you work in this way, herbs can be truly powerful allies in sticky situations in which the waiting remedy truly is your best choice.

- Raven
Midwifery Today Forums

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News Flashes

Researchers at the Ulleval University Hospital in Oslo examined nearly two million births in Norway between 1967 and 1998. They found that mothers of children born in August had the lowest risk of preeclampsia and that the risk was highest in December and other winter months. This pattern held after adjustment for maternal age, parity, year and place of residence. The researchers hypothesized that factors present in springtime during the first and second trimesters may be important in the genesis of preeclampsia and account for its peak prevalence in December. They speculated that perhaps cold weather can lead to the kind of vasospasm that is part of the pathogenesis of preeclampsia.

- Br J Obstet Gynaecol 2001;108:1116-1119.

The Midwifery Path

Should I pursue the direct-entry/homebirth path or the CNM/hospital birth path?

There are ways to become a nurse-midwife without having to work as a nurse and kowtow to doctors. Some BSN/MSN programs accept students for their nursing degree at the bachelor's and the master's level from the beginning, so you start as a nursing student and move directly into the master's program and graduate being able to sit for your boards. The University of Pennsylvania is one such program and I know there are others. In addition, it is possible to get your nursing degree and get accepted into a master's of nursing program without ever having to work as nurse. The caveat is that these programs often want you to spend some time working with a labor and delivery nurse because it is perceived that the culture of birth in the hospital is an important part of the learning experience.

Going to nursing school to become a midwife did *not* indoctrinate me into the medical model. It gave me a healthy understanding of the system and a big reminder that the work I want to do as a midwife is very important. I actually work labor and delivery while I am in school for midwifery, and I love it, because I am supporting my families in ways they wouldn't receive in most hospitals with many nurses. You would be surprised, however, at some hospitals and the approaches they take toward childbirth--some are very progressive. Try checking out "Planetree" hospitals; it's a philosophy I'm sold on if I ever have to be in a hospital.

- Melissa R.

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I am not a midwife yet; I'm a doula and aspiring/struggling midwife. I entered one of the three-year CNM programs for nonnurses and left before completing it mostly for financial reasons, but also because I felt those three years would be better spent studying midwifery rather than nursing. I strongly believe that midwifery has an authentic body of knowledge and does not need to "justify" itself to anyone. On the other hand, I also feel called to spread the word about midwifery through research and teaching. My solution/goal is to become a licensed midwife and also pursue an advanced degree in public health or a related area. If those with an academic bent only follow the CNM route, then I believe the scientific establishment will continue to disregard and disrespect us, mostly out of ignorance. I think that direct-entry midwives must challenge the system from within as well as from without.

- Anon.

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I also had no desire to become an RN, but I did want to be a midwife. I chose to go the route of a CNM and I'm glad I did. The program I chose, the Institute of Midwifery, Women & Health (Pennsylvania) I could complete from home and a bachelor's degree of any discipline is accepted. A BSN is not required.

Being an RN on an OB floor gave me a lot of experience. Lest you think it makes me a "medwife," you are wrong. Perhaps it helped that I had been a childbirth educator with an independent group for 10 years before I went to nursing school that gave me my base/belief: birth is normal and natural. On the OB floor I worked as an RN weekend nights in a community hospital where I had a lot of autonomy (docs don't want to be bothered then - which to me was a good thing!). I worked many extra shifts with the RNs who had the innate abilities and insight I wanted to learn about - again, not necessarily medical things. Because of my reputation as a CBE (and some RNs thought I was a pain in the neck and "out there" in my beliefs) I usually had the patients others thought were a bother, the ones who wanted active labor & births, which is exactly what I wanted anyway. Along the way, some of the RNs & MDs also learned and changed their practices, or at least tolerated and "allowed" me to work actively with patients.

I had wanted to go right from nursing school to midwifery school, but once I was on the OB floor, I realized there were things I needed to learn and do. I put off midwifery school until I had three years of OB experience. While I was very anxious to get on with it and become a midwife, the time as an RN on the OB floor was invaluable. I am now a CNM with a master's of science in midwifery and I am at a freestanding birth center (midwife owned/operated). A few of our moms choose to use the hospital and I am comfortable in the hospital setting and know what we face there. As a CNM I also have privileges at the hospital, which the licensed midwives in the state I am in do not.

- Donna Harvel Balo, CNM, MS

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I share my experience as someone who has the heart of a midwife yet has chosen to work within the medical system. When I birth, I will choose to birth at home. I love and respect my sister midwives who are working on the home front keeping the true art alive. But knowing how horrible most hospital birthing experiences are for women, I had to go into the system and try to change it.

The hospital birthing unit I work at operates with a midwifery philosophy largely due to the nursing staff. This unit does waterbirths, has an episiotomy rate of less than 1%, an epidural rate of 18%, 65% of our women delivered without any medication, and the cesarean rate is less than 20%. Women birth their babies in the shower, on the toilet, standing, squatting--whatever works for them. Our hospital has the highest breastfeeding rate in the state (89%). We offer yoga, hypnotherapy, Reiki, and we have an herbalist who works with the unit. The unit buys her products and the nurses give them to the moms (healing sitz baths, teas, and salves).

Nurses become handmaidens only if they allow it to happen. The only way hospital birth will improve is if women who truly care about birth remain in the field, or go into the field and settle for nothing less. At the same time, the only way the true art of midwifery will survive, and the only way to ensure that homebirth is a legal option for women in every state, is for women to choose direct-entry and fight the fight on the "home front."

We are fighting for the same cause but on different fronts. Hospital birth is not ideal birth, but it is the route most women in this country choose. One way to enlighten and reach more women is for some of us to work within the system and offer women another way.

Listen to your heart and you'll find your path. My hope as a student midwife is that no matter what path midwives have chosen, we band together and support each other. We will be more powerful as a united group than a divided group.

- Annie C.

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I graduated from nursing school in June 2001 and I am currently working as an RN in labor and delivery. I went to nursing school so I could go on and become a CNM. I believe wholly in the midwifery model of care, and I often debate which path--CNM or licensed midwife (LM)--is best for me. In my community there is very little respect for LMs (unfortunately), but CNMs are slowly gaining ground and making changes. I have chosen to pursue the CNM route hoping I will be able to have a little more power to help women have better births in all settings. Ideally, I would like to have a homebirth practice, but I want to be able to help women who choose to birth in hospitals have a good experience.

I do not feel that going through nursing school indoctrinated me with the medical model. I still believe very much in the same ideals about birth care that I did before I went into nursing school. If anything, my nursing training enabled me to fully explore all of the evidence (that much of the medical community ignores) that supports homebirth and low-intervention births. Nursing embraces a much more wholistic model of care than the medical model and is closely related to the midwifery model.

I do have frustrations working in a hospital environment and working with nurses and physicians who think homebirths are foolish and that all women need Pitocin and epidurals. However, there are some who do not feel this way, and I cherish the opportunities I have to serve women who choose to birth naturally. If I want to make a difference in women's health and childbearing, I may have to work within a system I do not agree with. Only by gaining the respect of the community will I be able to influence it to change.

One of the nurses I work with said to me, "Midwives are dangerous." Her statement was based on one experience with a midwife many years ago who made a poor decision. Unfortunately that happens, but the other truth is that we are all human, and we all make mistakes. I see doctors making poor decisions all the time. In order to change the point of view that she expressed, we need midwives demonstrating safe practice and good outcomes in places where they can be seen.

- H. Horn, RN
Olympia, WA

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I work in an L&D suite in a hospital. Let it be known that I *never* kowtow to the physicians or hospital system. As a Birthworks-certified childbirth educator, I am committed to a woman's instinctual ability to birth. I can help women get the birth they hope for. I am blessed to work in a hospital that supports natural alternatives (volunteer doulas, and 49% of our ladies delivered in the water in 2000-2001). If a doc suggests an intervention that is not in sync with a mom's birth plan, I think nothing of asking him to step out into the hall to discuss the rationale. Not all nurses are forced to bend to the system. Some of us work very hard to keep the system supportive of our moms and their choices. There are plenty of hospital horror stories out there, but all hospitals and all nurses should not be labeled.

- Sharon Breidt, RNC,CCE

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I chose to give birth in a hospital with a midwife mostly because I knew I needed to be taken care of postpartum, something that would not have happened so well at home. I also knew that the hospital environment had changed since both my grandmother and mother homebirthed--a choice they made because of the barbaric OB interventions. My midwife trusted me and my body in its ability to give birth. I was in too much pain to lie still for the hospital nurse to put an IV in (I was in transition when I got there) so we didn't. The result was a completely unmedicated birth from start to finish. My husband did acupuncture to stimulate my oxytocin to help deliver the placenta. My baby was born with a hand presenting, meconium when the waters broke, and the cord wrapped around her neck. My midwife was great in this situation. I can only imagine how many other women she has touched and given a safer hospital birth than if they had been attended by an OB.

As for education brainwashing you, that is a choice you alone would make. If you are truly firm in your trust of women, nothing will shake that. I went to acupuncture school after deciding to not go to medical school. My undergraduate degree was in biochemistry and molecular biology. I was told by some of my teachers that my western background would make my acupuncture studies more difficult. I did not believe them. In fact, it helped my understanding.

Follow your heart and touch as many women as possible by giving them the gift of midwifery care. May spirit be with you and guide you to the right path.

- Colleen

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PATHS TO BECOMING A MIDWIFE: GETTING AN EDUCATION, a Midwifery Today book. The quintessential guide to preparing yourself to become a midwife or other birth practitioner. Read about realities, politics and philosophies, direct-entry and certified nurse-midwifery, childbirth education, labor support and postpartum caregiving, the future of midwifery. Extensive resources listings.


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Midwifery Today is in the process of updating Paths to Becoming a Midwife and we need your help!

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Question of the Week

Q: A mom just delivered after a 43-week pregnancy. The labor was terribly long but OK for her. The baby looked 40 weeks; the gestational age came in at 38 weeks. There is no way we were off on dates. She had a circumvallate placenta. The cotyledons were really mushy where they tore really easily. I've read that a circumvallate placenta has a higher risk for postpartum hemorrhage, which she had--a long, trickle bleed. Why or what causes this type of placenta? Did it cause her baby to stay in so long yet look and test out to be a normal, term baby?

- Heather Zanon

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Question of the Week Responses

Q: A doula client, due in April, is a repeat client. I attended her with my mentor midwife a year ago. She had planned a homebirth, but we transported. It turned out she had a uterine infection and was sectioned for failure to progress past 4 cm. This time she's opted for a hospital birth with our favorite doc. An ultrasound shows a very low-lying anterior placenta right on her c-sec scar. The doctor told her not to worry just yet, that as her uterus enlarges it is possible the placenta will move up. If not, he said she would have a scheduled c-section and possibly a hysterectomy if bleeding can't be controlled. I told her to do some serious meditating and visualizing. She is scheduled for another ultrasound in eight weeks. Has anyone had this situation improve? Any tricks we could try?

- Belinda, doula, midwife's assistant

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A: A low-lying placenta doesn't actually move, but because of the size of the uterus right now and more importantly with the enlarging of the uterus her placenta will look like it moves. I agree that it is too early to be overly concerned with the location of the placenta. The best thing is for her to know that it is not uncommon for it to look low and for it to appear to move. She should relax--stress, which affects her and her baby, is something she has a better chance of doing something about.

- Heather Morrison, student midwife, hypnotherapist

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A: Contact your local HypnoBirthing instructor. Our practice has accomplished amazing things with hypnosis, the ultimate in visualizations.

- Jenny West, LM, CPM

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A: This woman is still second trimester, too soon to give up hope. About 20% of placentas appear low-lying during the first trimester because the placenta is large compared to the size of the uterus. By 32 weeks, most have moved away from the cervix. I've seen a few move as late as 36 weeks but no later than that. Yes, the placenta grows upward with the uterus for two reasons: the rising, stretching uterine wall literally takes the placenta upward with it, and the placenta tends to "migrate" toward a better blood supply, which is found at the top of the uterus. Most placentas move. It must be just a few centimeters away from the cervix to allow space for initial dilation, then later in labor as the baby descends the head will compress the placenta edge against the uterine wall and provide some help there. Identification of the edge of a placenta is tricky and should be done by someone experienced in ultrasound of pregnancy. There is the possibility of hemorrhage leading to hysterectomy in the worst-case scenario if she needs a c-section and the placenta is implanted there. But she shouldn't feel that that is *likely*. Also, she has every reason to hope for vaginal birth and should do what she can to make that possible, i.e., use positions in labor to facilitate progress, avoid epidural, etc. Visualizations are a fine thing to do.

- K.Mm, CNM

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More about kidney stones [Question of the Week, Issue 3:50]:

I have regular bouts with kidney stones due to MEN I (multiple endocrine neoplasia type I) and experienced multiple calculi during pregnancy with my daughter. The situation worsened when I reached about 6-7 months because of the increased renal activity that is most vigorous in the last trimester. The stones then were able to move quickly from kidney to ureter so I found that rather than passing single large stones I was passing many, many smaller stones

and therefore experiencing pain of longer duration. During labour I experienced excruciating back pain despite having an anterior baby. My midwives were baffled and insisted that I actually was experiencing no back pain. In fact, shortly after my daughter was born, I passed a rather large stone. The stone was moving down my ureter at the same time as I was labouring. After birth I continued to pass smaller stones for a while, including a few through my milk ducts.

- Mary-Tim Hare
Rockwood, Ontario

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In my CNM practice we see kidney stones about twice a year. They often crop up in the second trimester. They are usually painful and diagnosed because of workup for the pain. They are sometimes silent and seen incidentally on an ultrasound, in which case they often never cause symptoms. When a patient has pain with them, it is often acute, and within a few hours becomes localized and severe, usually causing vomiting because of the pain level. The woman generally has no or minor fever, and often a normal urinalysis (UA) except for RBCs seen.

Often the first few hours it seems like pyelonephritis but then veers into classic stone pain. Generally it hurts so much we have the patient in labor and delivery so we can give adequate pain control. Once UA and ultrasound are done, we support the patient thru the pain for however many hours it takes, usually a few. Watch for preterm labor. When the stone passes the pain decreases remarkably, and although we always have them screen urine thru a filter we rarely identify the passed stone. If so it goes to lab for composition breakdown.

People who make stones tend to make more sometimes, so they're often put on prophylactics (we use daily Macrodantin). If they have a mildly troublesome renal stone that isn't in the pathway to be passed down the ureter and will likely remain in the kidney, it sometimes causes mild chronic renal pain and intermittent RBCs in the urine, and occasional bladder pain from the "gravel" that breaks off the stone and irritates the bladder. So we prophylax these women also because they're also at high risk of getting a urinary tract infection. The nice thing is once they've birthed and the pressure is off the ureter from the uterus, the problem seems to go away.

- Kathleen Murray

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I have a friend who also gets kidney stones during her pregnancies. In her case, I believe it's from her eating so much extra protein. Excess protein "kicks" calcium out of the body, sometimes resulting in kidney stones. She is normally vegetarian but will crave and therefore eat meat during her pregnancies.

- Jen Lehman, CD, CBE


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Switchboard has been held over for the January 2, 2002 issue of Midwifery Today E-News. Next week will bring an abbreviated version of the newsletter so the editor can take a break. It has been truly a wonderful blessing to serve readers this year, and we look forward with joy to sharing the coming year with you!

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.


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