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Midwifery Today Conferences
COMPLICATED BIRTH REVIEW: Individual small-group roundtables with each teacher. Learn perspectives and clinical skills from the combined experience of Nancy Wainer, Marina Alzugaray, Cornelia Enning. Bring your toughest questions/experiences for discussion. Class presented at Midwifery Today's conference in Philadelphia, Pennsylvania, March 21-25, 2002.
Look for the conference program here:
Guangzhou, Guangdong, CHINA, "Healthy Birth": June 7-9, 2002
The Hague, THE NETHERLANDS, "Revitalizing Midwifery": November 2002
The Vagina Monologues
Salem Oregon, February 15, 8:00 pm
with silent auction and wine-tasting at 6:00 pm.
Benefit performance for the Oregon Midwifery Council and two other organizations. The production of the V-monologues is usually only staged as a benefit for organizations that work to end violence against women. The OMC was so convincing in its argument that midwifery helps prevent violence against women that it was given permission to stage this benefit performance. For further information: 503-409-2888
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In This Week's Issue:
1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Turning Posterior Babies
5) Check It Out!
6) Midwifery Today Online Forum: Suturing after c-section
7) Question of the Week: Cravings
8) Question of the Week Responses: Placental tear
9) Midwifery Today Question of the Quarter: Postpartum care
Quote of the Week
1) "The traditional midwife believes that birth proceeds in a spiral fashion: labor starts, stops and starts, while the baby goes down, up and down, and the cervix opens, closes and opens. Nature has no design for failure; she holds her own meaning for success."
- Sher Willis
2) The Art of Midwifery
I believe in the old adage about prevention being worth more than the cure. To this end, I encourage mothers to keep their bellies nice and warm by buttoning up their jackets or wrapping a wrap or shawl around them. I think some occiput posterior babies are just trying to keep their bums warm when they assume this position!
3) News Flashes
A study of 22 mothers ranging in age from 22 to 43 years who gave birth to a second child within two years of the birth of their first child measured the mothers' milk output over a 24-hour period during the first and fourth weeks after birth. The women produced about 31% more breastmilk in the first week after birth with their second child and slightly more milk by the fourth week, the report indicates. Furthermore, those whose milk output was the lowest with their first child had the greatest increases in milk production with the second baby. "Health professionals should encourage women to breastfeed all their children, whatever [the women's] experience with their first child," the researchers stated.
- Lancet 2001;358:986-987
4) Turning Posterior Babies
Occiput Posterior/Occiput Transverse (OP/OT): notes from Obstetrical Training Day, October 31, 1997, Rochester General Hospital (New York)
Speaker: Henci Goer
[Ed. Note: These are excerpts; in no way do they represent Henci's entire presentation. Notes courtesy of E-News reader Amy Haas. Thank you, Amy!]
- Half of the cesarean rate results from OP/OT babies. With an epidural this rate increases to three-quarters. 15 -30% of all labors start with an OP/OT baby.
How to Diagnose:
1. Self-diagnosis: Belly shape; feels lots of hands and feet; frequent urination; irregular labor pattern; ruptured membranes, back pain; hard to pick up fetal heart tones, long painful labor
2. Caregiver's diagnosis: external palpation (harder to do in labor); vaginal exam (look for suture lines when mom is dilated enough)
1. Pelvic shape: convergent sidewalls, narrow pubic arch, sacrum
intrudes, prominent ischial spines
2. Size of baby: either very large or very small (not guided by pelvic floor, can't get into position)
3. Right occiput anterior in pregnancy as opposed to left
4. Exaggerated spinal curvature (lordosis) and a relatively inflexible spine
Correcting OP/OT in pregnancy:
1. Pelvic rocks: 10+ pelvic rocks on hands and knees per day
2. Dancing: rotate hips
3. Yoga: One midwife noted that her clients who do yoga have a smaller incidence of OP/OT.
4. Crawling on hands & knees in a kiddie swimming pool
Strategies to Promote Rotation:
1. General tips:
- DON'T RUPTURE MEMBRANES
- Usually what the mother finds most comfortable is also most effective. Let her move instinctively. Epidurals prevent instinctive movement.
- Help the baby rotate by using positioning that opens the pelvis, activities or manipulations that shift the baby, and gravity to bring the baby down.
2. Birth ball: lean on it, or sit on it and lean on bed. Rotate hips.
- Hands and knees during pregnancy. One study showed a 3/4 rotation in 10 min.
- Side-lying, SIMS position. Lie on the same side as the baby is facing, then switch.
- Lunge: opens one side of pelvis, feels good; let mom choose side
- Squat-Kneel: opens pelvis
- Dangle: almost a hanging sit, mom's back to sofa, don't go into a full squat
- Standing leaning forward
- Kneeling, facing back of hospital bed
- Knee-chest position (rear end in the air), 30-35 min. in early labor will almost always turn baby.
- Semireclining, heels together (don't use with epidural)
- Pelvic rocks
- Change position
4. Activity or Manipulation
- Lots of position changes
- Pelvic rocks
- Stroke the mother's belly in between contractions in the direction you want the baby's back to go.
- Double hip squeeze: Sit facing mother, place both hands on back of each hip and squeeze.
- Write the baby's name with pelvis
- Stair climb
- Crawl back and forth
- Acupressure: fingernail pressure on outer edge of little toenail (could also turn breech)
- Delay epidural until at least 5 cm dilation. Doing one earlier may lock the baby in the OP/OT position. Stay off back, even semireclining. Hands and knees may be possible. Supported squat (w/ epidural): Set up bed like a birth chair, use stirrups as hand holds and to support forearms.
- Manual internal rotation by care provider (Valerie El Halta - see Midwifery Today Issue 36). Do early. May invoke negative memories for women with a history of sexual abuse.
- Don't rupture membranes - could wedge baby permanently into the OP/OT position, preventing rotation.
- Cup mothers kneecaps and push back to relieve pain.
Coping with a Long Difficult Labor:
1. Extra support: Secondary labor support person (doula); use talking for relaxation and positive reinforcing attitude (e.g., "My body knows
just what to do" chant).
2. Food and drink: calories, especially at home
3. Stay home in early labor, which is often prolonged.
4. Reframing the problem:
- It's normal for an OP/OT labor to be longer and hard.
- Going from 50% effaced to 70% effaced is a major change.
- Stuff is happening.
- Cervix going from anterior to posterior is progress.
- Use short-term goals, bargain for milestones.
- Stay in the present; focus on the now.
5. Develop a ritual: women will often do this automatically if allowed to.
6. Groan "open" on the exhale.
7. Use shower or bath. (One hospital reduced its epidural rate by 80% by requiring women to take a bath before getting their epidural.)
8. Show the mom on pelvis model what she is feeling looks like
9. Hot pack with rice and herbs heated in microwave
10. Avoid vaginal exams
11. Don't push too soon; delay until head on perineum - reduces use of forceps.
12. Per American College of Obstetricians and Gynecologists: The duration of second stage is not related to fetal outcome as long as fetal heart tones are good.
Coping with Back Pain:
1. Temperature: A laboring woman's skin is sensitive to temperature. Hot items should be cool enough to hold, frozen items should have intervening layer(s).
- Heat: Local blood flow and temp. increase, muscle spasms decrease - contributes to relaxation
- Cold: Local blood flow and temp. decrease - works best for decreasing pain because it slows transmission of painful sensations (Ice chips in an exam glove, frozen peas)
- Acupressure - low on sacrum (inch out on either side), sciatic point (dimples in rear end), palm (center, high five and hang on)
3. Sterile water injection: intradermally, 20 sec; sharp local pain: 1-2 hr. relief. Do not use saline. (See Midwifery Today Issue 44)
4. TENS (transcutaneous electronic nerve stimulation): effectiveness questionable
5. Pain medication: Delay epidural until 5 cm. dilation, delay pushing until head is on perineum (reduces the use of forceps).
Factors that Hinder Rotation in Labor:
1. Reclining: Gravity works against you; reclining fixes sacrum so it can't open.
2. Early epidural: Relaxes pelvic musculature too much; Pitocin use and C-section rates increase.
3. Early amniotomy: Head surges down and there is a deep transverse arrest. May actually slow labor down.
For a copy of the bibliography, please contact Amy V. Haas, email
Henci Goer is the author of "Obstetric Myths versus Research
Realities" and "The Thinking Woman's Guide to a Better Birth," New
York: Perigee Books, 1999. More information about the latter and an
order form can be found at the book's Website
http://www.efn.org/~djz/birth/betterbirth or at Amazon.com. The book
is also available in bookstores. Thinking Woman is required reading
for Lamaze, Bradley, ICEA, and BirthWorks childbirth education
certification programs as well as a number of midwifery certification
programs. Henci is an internationally known speaker on evidence-based
care in pregnancy and childbirth.
5) Check It Out!
A Web Site Update for E-News Readers
AUDIOTAPES FOR THIS ISSUE'S THEME
Complicated Birth Review with Experienced Midwives:
Second Stage Difficulties Roundtables:
MIDWIFERY TODAY ISSUE 36 for Valerie El Halta's article about turning a posterior baby: http://www.midwiferytoday.com/products/MT36.htm
OPTIMAL FOETAL POSITIONING, book by Jean Sutton & Pauline Scott:
6) Midwifery Today's Online Forums
I've heard that OBs are now doing only a single suture of the uterus
when suturing after c-sections, instead of an inner and outer suture.
Has anyone heard of this?
TO SHARE YOUR THOUGHTS AND EXPERIENCE ON THIS TOPIC, go to
**PLEASE DO NOT SEND YOUR RESPONSES TO E-NEWS!**
To order the MIDWIFERY TODAY back issue on Cesarean Prevention and
VBAC, go here:
7) Question of the Week
Q: A woman who is about 25 weeks along is experiencing almost overwhelming cravings for soap. She says the cravings have increased with each pregnancy. Her labs are all fine - no evidence of anemia. Suggestions?
- Anne Walters CNM
SEND YOUR RESPONSE to <firstname.lastname@example.org> with "Question of the Week" in the subject line.
8) Question of the Week Responses
Q: What can be done to repair a small placental tear in the third
A client lost her baby in the seventh month of pregnancy as a result of a tear in her placenta. She is pregnant again and due in May. Her OB told her he could see a small tear on her placenta. Apparently there was only a 10% chance of this happening again. Is there anything she can take or do to help correct this problem?
A: I'd consider bioflavinoids (1000 mg three times/day) and vitamin C (1000 mg twice daily - no more than 2000 mg of vitamin C per day; be sure to calculate in what she's getting in her prenatal if she's using one). Vitamin C and bioflavinoids help stabilize capillary vessel walls that may prevent further tearing.
- Keyena McKenzie, N.D.
A: Sometimes "tears in the placenta" (usually actually a separation of the placenta from the decidua of the uterus) can be caused by high blood pressure. That's probably why they are more common in tobacco smokers (nicotine causes vasoconstriction). Also seen in women who use methamphetamine or any kind of speed-like substance, or cocaine - they raise blood pressure. This condition is also more common in women who have elevated blood pressure for any reason. Keep the mother "cool and calm." Be sure she's not doing anything to raise her blood pressure. If the blood pressure is high, do what you can to lower it. However, if it has been high throughout the pregnancy, lowering it suddenly, for example with blood pressure medication, can result in decreased blood flow to the baby, which might cause trouble in itself. If nothing else seems to work, modified bed rest might help. Anecdotal evidence suggests that vitamin E, vitamin C complex, and vitamin A from natural sources might help keep blood vessels and the placental connection intact.
- Marion Toepke
9) Question of the Quarter for Midwifery Today Issue 61
Q: What are the essential elements of good postpartum care? What is your most noteworthy postpartum experience with a mother/baby/family and what was the outcome?
Responses are subject to editing for space and style. Maximum word count 400. If we print your response, you'll receive a free issue.
E-mail responses to: email@example.com. Include your postal address.
We must receive all responses by February 6, 2002.
In New Zealand you have a choice of free service from a GP who delivers babies or a midwife who attends births, or to see an obstetrician for a fee. If you go for the midwife option, she will see women fairly frequently - usually monthly until 28 weeks, fortnightly until 36 weeks, then weekly until the baby is born. Whether the visits are in the woman's home or a more central clinic depends on the midwife and the women's circumstances. Postnatal visits vary; the legal minimum is 5 at home. Generally 2-4 times in the first week, then as required after that, to weekly at 4 to 6 weeks. Baby and mum are referred to Plunket, a specialised infant and toddler nurse team, at 6 weeks and back to their GP for any followup at the same age. GPs mostly use hospital midwives for labour and postnatal care. Obstetricians work with either hospital or independent (self-employed) midwives for labour and postnatal care. I am a self-employed midwife working in a fairly busy central Auckland Practice and providing care for 4 to 6 women a month, with one weekend a month off call. The service is completely funded by the government for NZ citizens and residents.
I congratulate midwives who are not polarized from your colleagues. Although it is difficult not to become frustrated watching how things are commonly done in hospitals, I believe in being friendly, respectful, and making efforts at learning from everyone - CNMs, RNs, and obstetricians who are very medically oriented. I would prefer to do everything possible the holistic midwifery way if I had my choice. I have learned, though, that with softness and love, and most of all respect, it is easier to get to a point where you can openly share very different birth ideas with people who do things differently. In the end, there is communication and a positive change toward the goal: make birth a safe, loving and spiritual experience, and help women give birth how they choose.
An integral part of holistic midwifery is the gradual use and promotion of natural and organic foods as an important way to prevent complications. Unfortunately, a lurking enemy of organic foods are genetically modified foods (GM crops), which create far more problems than any of us may imagine. Please visit the following website and read the latest bulletin. There will be an action in national supermarkets against Kraft (see why in the bulletin) on February 6. <http://www.organicconsumers.org/> for the web site and bulletin <http://www.gefoodalert.org/takeaction/> to email Kraft <mailto:firstname.lastname@example.org> to email and offer to distribute leaflets in your community
- Aiyana Megan Gregori, midwifery student
Does anyone have advice about what to do for severe vaginal varicose veins? During her last pregnancy, a former client had a severe case. They were protruding from about two inches below her pubic hairline all the way back to her anus and were bulging interiorly as well. In the last trimester her labia were swollen to about two inches thick and couldn't touch each other even when she tried to close her legs. She would like to have more children. She is afraid of having the veins removed with the laser procedure because her OB told her the procedure causes the veins to shut and blood finds other ways to get where it's going. Would those other veins just bulge out and become varicosities with all the extra flow?
Can women who have vaginismus have vaginal birth?
- Azar Golmakany
Reply to: email@example.com
I am a registered midwife in the province of British Columbia. I would like to assure readers that the statements Ms. Lemay makes [Issue 4:4] about being "terrified of our governing body" and being "cautioned in writing...not to go near that office without a lawyer" do not apply to me or to any of the 40 or 50 registered midwives I know and am in contact with on a frequent basis. All the colleges for healthcare professionals are regulatory bodies that set guidelines to ensure public safety and that professional standards are met by their members. So far I have found the BC College of Midwives to be most helpful and supportive in situations where I felt unclear about my role or was having difficulty with another healthcare professional, an organization, or a client. Midwives in this province as well as the College of Midwives fervently hope that the women we are serving are happy with our services. Unfortunately we cannot ever guarantee that. Neither, of course, can Ms. Lemay. I know clients who were not happy with her services just as some were not happy with mine.
Our clients are free to choose whether or not their babies receive eye medications and vitamin K injections. The fact that none of Ms. Lemay's clients receive either of these things makes me wonder if the parents are receiving good unbiased information and are free to make their own decisions about these medications. I feel deeply insulted by her comment that she has not "had to hurt or 'strip membranes' on anyone in order to retain a license." I have no idea where this notion of what midwives in BC do or are required to do comes from. I have only swept membranes at clients' request, and even then very infrequently. Performing the sweep has nothing to do with my license but rather with the client's desire to promote an earlier labour or "get things going." If it hurts them, we don't continue. I resent the portrayal of licensed BC midwives as interventionist, uncaring and hurtful in our practice.
I can assure you that I do not spend my time "pleasing physicians or hospital administrators." Yes there are times when hospital protocols must be acknowledged, and yes there are times when my preferred management approach differs from that of an involved physician, but on the whole I find that I have benefited from hearing the opinions of others, and once in a while they have been right, or they have seen something I haven't seen or know something I didn't know. One of the most dangerous things any of us can do is assume we are always right or that we know more than anyone else. Pregnancy, labour, birth, and the early days of life are miraculous, wonderful, and awe-inspiring experiences. I hope everyone involved with birthing families has a deep respect for these miracles and the humility to acknowledge that neither they nor anyone else can claim to know it all when it comes to the creation of life.
- Julia Atkins, RM
If Gloria Lemay has never administered vitamin K to a baby, then she is not offering informed decision-making to her clients. Such decisions belong to the parents - armed with the best available information - not to the caregivers.
Registered midwives in BC have thousands of satisfied parents in their care each year. They are offered choice of birthplace in a funded program. They realize that they are treated with decency and respect, given good care and information, and encouraged to question all procedures and treatments.
- Catherine Ruskin, RM
EDITOR'S NOTE: Only letters sent to the E-News official email address,
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I am interested in an apprenticeship with a home birth midwife. I have a BSN and I am working toward a CNM. I do not care if the midwife is a CPM or a CNM. I am willing to relocate. I have no family obligations as I am a single 50 year old. Please help me to achieve my dream. Thank you. email address is email@example.com
12) CLASSIFIED ADVERTISING
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