|March 20, 2002|
Volume 4, Issue 12
|Midwifery Today E-News|
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THIS WEEK'S ISSUE
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Quote of the Week
"Mothers need to know that their care and their choices won't be compromised by birth politics."
- Jennifer Rosenberg
The Art of Midwifery
It is as important to know when not to speak as it is to know what to say. Sometimes silence is best.
- Jennifer Hall,
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Researchers have long noted that firstborn children or those who have few siblings are more likely to have asthma and allergies than those with many siblings. The "hygiene hypothesis" suggests that children with many siblings are exposed to a large variety of germs early on and may develop stronger immune systems. Now a study of 1,000 children born on the Isle of Wight in Great Britain finds that the sibling effect may have its origin in utero. They tested IgE antibodies in the children's cord blood; twice the number of firstborn children had high levels of IgE compared with children born later. When tested at age 4, the children with higher levels of IgE in their cord blood were more likely to have allergic reactions affecting their skin. This occurred regardless of whether they were firstborns or children born later.
- American Journal of Epidemiology,
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Midwifery Today's Online Forums: Cytotec
I recently had a very traumatic birth as a result of a prolapsed cord. I was also given Cytotec for induction. From what I've read, Cytotec can cause a very hard and fast birth, and a prolapsed cord could come from a gushing or sudden break of the bag of water. I had both of these. Do you think the Cytotec is related to the cord prolapse?
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Question of the Week: Hepatitis B
Q: How many of today's midwives, doulas and others in the birthing field feel the need to get the hepatitis B vaccine? I believe the actual incidence of contracting this disease is low, but I wonder what other professionals think.
- Christy, doula, Illinois
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Question of the Week Responses: Waterbirth
Q: We have more and more mothers who want to give birth in water. I've made a literature review and find it's very difficult to draw an objective conclusion about waterbirth. For many years I have practiced waterbirth but it's difficult to give confidence to my colleagues. It's always the same -- people remember only the bad things. I would like to hear reflections on the subject as well as some experiences.
- Dominique Porret, Quebec, Canada
[Editor's note: Because of space limitations this week, answers to last week's Question of the Week will be divided between this issue and the next.]
A: In the midwifery community in Lancaster County, Pennsylvania, many of the midwives have decided not to do waterbirth because two waterbirths ended with respiratory problems for baby. I think the problems may have happened because waterbirths in this community often happen by accident -- in the bathroom tub -- and are not planned. I helped with one planned waterbirth, nice big tub, easy to get to mom. The baby was just lifted up out of the water as soon as it was born and spent less than a few seconds actually in the water. No problems occurred.
-Mary McLane, CNM
A: I also was nervous before my first waterbirth, about five years ago. I asked a local midwife who did them routinely if I could watch. It was a marvelous birth. I attended my first waterbirth as primary; the baby had sticky shoulders and the mom a postpartum hemorrhage. It was slightly scary, yet I feel midwives should facilitate the birth women want.
The next waterbirth was easy. Mother laboured, baby birthed, as can be expected. Now I attend about 50+ births a year, and usually five or six women want waterbirths. They seem to be no different than any other birth except for cleanup. The one thing we insist on is a bed very near the water tub, and a tub that we have easy access into. A shoulder dystocia, and no way to get the woman out quickly to a safe surface is not realistic.
Waterbirth must be discussed with reluctant midwives as just another medium for birth that requires some thinking ahead of time as to what they will do in case of emergencies, and also discussion with the parents about the same emergencies. Showing the video "Born In Water - A Sacred Journey" may also help. It is a very realistic waterbirth video.
-Jennesse Oakhurst, Maple Ridge, BC, Canada
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I was disturbed by some of the responses to the question about group B strep [Issue 4:10]. Herbs, acidifying the body, and clearing emotional issues will not remove this pathogenic bacteria from the body. Before recommending nonstandard medical care, we should first educate women about the risks they are taking, exactly what B strep is, and why it is usually not dangerous.
B-strep is a normal bacterium that lives in the gut of many people. At normal levels, it is not harmful. However, when a newborn contracts this bacteria, it can develop into a life-threatening illness that proceeds very rapidly from happy, healthy baby to near-death. It is the speed with which newborns develop the disease that is so problematic, necessitating all kinds of acrobatics on the part of care providers. Treating the baby after it is born and shows signs of the disease is almost always too late. Therefore we have to identify and treat the mothers to temporarily reduce the bacteria count in her body and to pre-treat the baby (who gets the antibiotics given to the mother).
This issue has been extensively researched and debated. All the details are available at www.cdc.gov.
There are a couple of big problems with B-strep. One is the speed of disease onset, meaning we cannot wait for symptoms and treat only the babies who get sick. The second is the mystery of how many women carry the bacteria and pass it to their infants yet how few infants develop the disease. The details are covered on the CDC Web site. Basically, even if you test with the highest level of colonization, the chances of an individual baby dying from the disease is only 1 out of roughly 60,000. Of every 200 women who test positive, only one of their babies will get sick without antibiotics. This is why herbs and emotional healing and even antibiotics appear to work -- because most babies wouldn't get sick anyway! The problem is that a few of them will get sick, and they will get very, very sick -- and if they live, they will be brain damaged and suffer other lifelong disabilities.
So we in the midwifery/medical world end up giving antibiotics to hundreds of thousands of women (and their babies) every year to prevent a handful of cases of B-strep disease. It stinks! We are not only wasting money, we are needlessly alarming women and medicalizing birth. However, I believe it is the woman’s decision, not her caregiver's. We are not the ones who have to live with the consequences (unless we get sued, of course). We need a better way to identify those babies who are truly at risk, but we don't have one right now.
There are two ways to approach B-strep:
1) Risk factors: Anyone with risk factors is recommended to receive IV antibiotics (abx) during labor (at least 2 doses 2 hours apart). This can be done in any setting: home, birth center or hospital. These include a prior baby infected with B-strep (not a positive B-strep test in a prior pregnancy, a common mistake made by OBs and midwives), having a fever during labor or having ruptured membranes for more than 18 hours or delivering earlier than 37 weeks.
2) Testing: All women are tested at 35-37 weeks of pregnancy with a swab of the outer vagina and rectum, and those who are positive are recommended to receive IV abx during labor. Included in this category are women whose urine is so full of B-strep that it grows out on a routine urine culture. Tests have shown that these particular women are heavily colonized by bacteria (meaning they have a lot of B-strep in their bodies) and are at greatest risk of having an affected newborn. Again, the odds are still small, but these women are in the highest risk category. These women need oral abx when the urine infection is discovered and IV abx during labor.
Every pregnant woman should educate herself about B-strep testing and treatment. I personally think we are chasing a disease we cannot do much about and abhor the needless overtreatment with abx that results, but bear in mind how devastating B-strep disease of the newborn can be. We cannot afford to be cavalier about treatments.
Herbs and other alternative treatments might be helpful. Unfortunately, we have no good information to go on. More than likely, if we did nothing at all, most of the babies we help birth would be fine, but it only takes one case of newborn B-strep to make you sit up and take notice that this is a very serious issue.
- Samantha McCormick, CNM,
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Loop Electrosurgical Excision Procedure (LEEP)
Elizabeth Davis briefly mentions LEEP in Heart & Hands (3rd ed.). My first concern would be the possibility of incompetent cervix leading to premature labor. The mom should know the signs of premature labor/cervical dilation (lots of egg-white consistency mucus, menstrual-like cramping/cervical-lower segment contractions, etc.). If there is scar tissue that would retard dilation, Ms. Davis suggests that evening primrose oil, massaged on gently toward the end of the pregnancy, might help soften it.
- Charity Bailey, midwifery student, New York
I had cryotherapy, a similar procedure, a couple of years before the delivery of my first child. Dilation took its time, but an observant nurse realized there was scar tissue from the procedure that was holding me back and gently removed it. Dilation and labor then proceeded more rapidly.
- Shauna E.
Unlike the more traditional cold knife cone biopsy used to remove dysplasia from the cervix, LEEP has not been shown to contribute significantly to incompetent cervix. I have seen several clients over the years who have had a CKC, LEEP, multiple D&Cs, abortions, etc., who had a stenotic cervix in labor. They will have powerful labor, be 90-100% effaced, have a bulging lower uterine segment, but be only a fingertip dilated and not make progress. We have found that if we rather vigorously dilate them with our fingers to 3-4 centimeters (uncomfortable but freeing) they will make good progress in labor because the scar tissue has been loosened or broken up. I don't know if there are any herbal remedies that could safely soften dense scar tissue.
- Heidi Rinehart, MD, FACOG
A number of clients I have attended have had the procedure as a result of having had an abnormal Pap smear. It is my perception that the first 3 cm of dilation is the most difficult. You must be very patient with the cervix, and she has to have strong contractions to break through the scar tissue. The scar tissue from the laser/freezing procedure is very tough to break down. Anything that can be done to help the cervix soften close to her due date will be helpful -- herbs, semen, etc. Once the cervix gets to 3 cm she will start dilating at a more normal rate, and then as soon as the last of the scar tissue lets go she will dilate very quickly. It can be done; all my clients delivered vaginally but it took a lot of patience on everyone's part and a lot of hard work on the client's part for the first 3-5 cm. She will need a lot of ongoing support and encouragement to hang in there since the first part of her labor can be very slow going and very tiring.
- E. Reilly, RN, Austin, Texas
The LEEP procedure is commonly done to remove areas of the cervix that exhibit some form of cancerous or precancerous cells (usually moderate to severe dysplasia). An electrical current passed through a wire loop effectively cauterizes the tissue (minimizing blood loss and trauma) as it excises it. The depth of the incision depends upon the depth of the invasion of the abnormal cells, so this is typically performed after the colposcopy defines the affected area. Obviously, if the affected area is deep in the cervix, the area removed can be extensive. The procedure is usually performed in the office under local anesthetic, causes minimal cramping, and usually very little bleeding. It is, however, cervical surgery.
Any time you remove tissue from the cervix, there can be residual effects. As part of the informed consent before the procedure, clients should be advised of alternative treatments (including doing nothing) and the possibility of cervical incompetence during pregnancy, or cervical rigidity during labor, premature labor or early miscarriage due to cervical incompetence. This procedure cuts away cervical tissue, and if extensive, can compromise the integrity of the cervix by shortening its length and damaging the muscle.
I recently attended a homebirth for a young lady, G1/P0 who had a LEEP performed about 18 months before her pregnancy for repeated atypical Pap smears. She was not advised of any potential complications of the procedure or how it might affect her planned pregnancy. At intake, her cervix measured 3 cm long. I gave her precautions for threatened premature labor, etc. following the LEEP procedure. At 26 weeks she noticed increased uterine contractions; her cervix measured 2 cm. She was placed on bed rest and a calcium channel blocker to decrease the contractions. At 32 weeks her cervix was softer and 1.5 cm in length and 1 cm dilated. Her fetal fibronectin test was + positive, so her medication was increased. She remained on the medication and bed rest until 37 weeks, when she discontinued all efforts to stop labor. At 38 weeks she began contractions, and I attended her planned homebirth. When I arrived, her contractions were Q 3-4 min. X 50-60 seconds and moderate. Her cervix was completely effaced, the lower uterine segment was abnormally taut, the head at 0 station, and the internal os felt like a metal band was threaded through it. It took about 20 minutes of massage with evening primrose oil to break up the scar tissue at the internal os before she rapidly dilated to 6 cm over the next 20 minutes and birthed an 8 pound 12 ounce boy.
I have had other clients with history of LEEP and/or cryosurgery with similar cervices during labor. It is usually easy to break up the scar tissue with massage during the contraction. In the large majority of cases, there are no complications either of pregnancy or labor following these procedures.
- Vicki Taylor, LM, CPM, Pensacola, Florida
I had a LEEP procedure done before my fourth delivery and found that I did not dilate as I felt I should. As a doula, and being supported by a doula, I knew that the scar tissue could hold my cervix closed. I was at 2 cm and felt like I was approaching transition! I asked the doc to do a cervical check and during my next contraction manually break the scar tissue with her fingers. It was very uncomfortable, and she was very apologetic, but I kept reassuring her to continue as I breathed. This and additional position changes seemed to help, and I was fully dilated and baby was crowning within 40 minutes! I know that if I had not had the knowledge I did, the simple solution would not have been used, and I could have faced the "failure to progress" diagnosis and possible c-section. Knowledge and having your own powerful voice are amazing tools!
- Staci Herrick, certified doula, Evans, Colorado
I am an L&D nurse who has taken care of several women who have had this procedure. I have found that the cervix will dilate to 2-3 and then just sit there for a while, sometimes hours, sometimes minutes, usually depending on the parity of the woman. The cervix will feel tough and firm, no stretch to it. Your friend must stay relaxed, work with her body, and not give in to the pressure for "progress" that can sometimes lead to a unneeded c-section. Encourage her to be mobile -- walk, squat, straddle a chair, or get in a tub of water/jacuzzi. Usually the cervix will "pop" and she will go from 2 cm to 8 cm in just a few moments. Our docs believe LEEP causes scar tissue that takes significant pressure from the infant's head to dilate. This will be one of those times when patience is a virtue.
- Karen M., RN
The International School of Traditional Midwifery in Ashland Oregon is accepting enrollment for 2002 classes that start in May. For information call 541-488-8273, or go to www.globalmidwives.org
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