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It is vital for the mother's liver to be functioning at full capacity to meet the demand for increased blood volume to supply an extra placenta (or two). When women do not get the nutritional support they need, clinical symptoms begin to become apparent around the 24th to 26th week of pregnancy, just before blood volume should peak. Problems crop up sooner than in a singleton pregnancy because the demand for more blood volume is so much greater.
Be sure to check for a history of liver disease or disorder (which includes drug use). Four droppersful daily of spring dandelion root or yellow dock root tincture will give the liver a boost. It is normal to see more swelling, a lot more weight gain, a somewhat higher blood pressure, an increased desire for salt, and a somewhat lower hemoglobin than in a singleton pregnancy. These physiological compensations are no cause for alarm. Because multiple fetuses are all storing iron, supplementation is a good idea.
The fact that typical biotechnical medical management results in a toxemia rate of 50% in twin pregnancies and 75% in triplet pregnancies is ample proof of the nutritional neglect = hypovolemia = toxemia etiology. Modern practice includes several ultrasound exams to monitor fetal growth. Cervical cerclage and labor suppressing drugs may be recommended along with bed rest, weight restriction, and cesarean section. Predictably, this results in low birth weight, premature babies as well as a higher incidence of abruption and hemorrhage in mothers.
— Anne Frye, Understanding Diagnostic Tests in the Childbearing Year, 6th ed. Labrys Press, 1997
When the first twin is delivered, check inside the mother to find out what part of the second baby is presenting and how far it has descended. If the baby is in a transverse position, try to turn it into a breech or vertex externally. If the head or butt is down far enough so that the cord won't prolapse, you can break the water bag.
It will normally take less time to push out this baby, as the cervix is well dilated and the mother's bones are already stretched apart as far as they need to be. Check the fetal heart tones often. Keep track of how much time has passed, but go by how the energy feels. If the time lapsed is feeling like too much, you may need to pull the second twin out by "internal podalic version," which means taking hold of the baby's feet and turning the baby's body so that the feet come out first, pulling the baby slowly out and delivering as for a breech. Wear a long sterile glove. This maneuver should not be done routinely; it should be used only if the spontaneous delivery of the second twin does not happen within an hour or so after the first twin, or if there is fetal distress.
— Ina May Gaskin, Spiritual Midwifery, 4th ed., Book Publishing Company, PO Box 99, Summertown, TN 38483
Mom is now eating for three, and must increase her intake. Common complaints of pregnancy multiply due to low blood sugars and lack of adequate caloric intake. She has to be committed to nutrition, and I ask her to give me a complete diet history weekly. I ask for her family's support in making sure she is adequately nourished.
Parents have to be fully informed of the risks and benefits of a midwife-attended delivery. They must accept their role in the decision-making process. I encourage them to read books, join "twin clubs," and talk with other families with twins. If problems arise during the prenatal course or during birth, the parents will know what to expect.
- Are backup systems for early notification of the midwife or for transport in place? Often, early signs of labor go unnoticed, and delivery can be imminent.
- Twice as many birth supplies (towels, blankets, etc.) and an extra set of birth instruments are needed. Can extra oxygen be borrowed? A way to identify each twin should be established beforehand.
- Extra support persons may be needed. I usually have two midwives, two assistants, someone to take notes and record times, and someone to be on hand to run errands. Everyone should be trained in neonatal resuscitation.
- Have mom choose support carefully. With twins, there is often pressure from family and friends to be there to "just watch." Support persons should be willing to provide snacks, back rubs, and encouragement to both mom and dad. They should be discouraged from bringing babies and small children.
Provide educational materials for breastfeeding. Locate La Leche League support groups, lactation consultants, and other mothers of twins for support. Postpartum care often includes extra home visits and more-frequent phone calls. Exhaustion, overwhelming sense of responsibility, and loss of a sense of self need to be addressed.
— Diane Barnes, "When Twins Are on the Way," Midwifery Today Issue 39
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Products for Birth Professionals
CONFERENCE AUDIOTAPES FOR THIS WEEK'S THEME:
Other Products and Services of Interest
Gentle Birth Choices, a book by Barbara Harper, outlines the many choices pregnant women and their caregivers face today. It belongs on the shelf of every practitioner and is a great gift for an expectant mom.
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What's black and white, read by birth professionals around the world, filled with informative articles and inspiring birth stories, and shows up in your postal mailbox four times a year?
Web Site Update
Read these articles newly posted to the Midwifery Today Web site:
Birth of a Midwife - by Amanda Moore
How to Make a Portable Waterbirth Tub - by Melanie Moore
Question of the Quarter: What is your favorite homebirth story?
A Declaration of the Rights of Childbearing Women - by Leilah McCracken
A woman in my care recently took Zythromax antibiotic for a sinus infection. She is now spilling moderate ketones in her urine. She says she is feeling fine, she eats well. She is 30 weeks pregnant and has been the picture of health. I was wondering if anyone knows if Zythromax could cause false positives? I am a bit baffled. After a high-calorie diet it has been a week and she is still spilling ketones.
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Question of the Week
Q: I am 26 years old. About two years ago I was 42 weeks pregnant and desperate. I had been having contractions for weeks but had not dilated at all, so my midwife scheduled me for an induction. I arrived at the hospital early in the morning and was given Cytotec (not knowing anything about its experimental use), and within hours I was in extremely hard labor. My contractions were seconds apart for 5–6 hours, and I felt like I couldn't move or breathe. The intensity of the contractions was beyond anything I had ever imagined. Luckily I delivered a healthy baby boy, and aside from a heart murmur, which is gone now, he is very healthy. I on the other hand have had numerous health challenges. When my fertility returned after ceasing breastfeeding I became very nauseated and sick. I took several home pregnancy tests; all were negative. A couple of days passed and I started having extremely sharp pains in my lower abdomen. A nurse practitioner did another pregnancy test, which was negative, and sent me home. Later that day I started bleeding and didn't stop for about 10 days. Ever since then I have had terrible cramping throughout my cycle with and without my period. I have hot flashes, extreme mood swings, and episodes of nausea and dizziness, all of which I had never experienced before giving birth. Has anyone else had a similar experience to mine?
I feel the use of Cytotec is a very grave injustice to women who have been, without their knowledge or consent, subjected to the experimental use of a very powerful and potentially very dangerous drug. I would be most interested to hear from readers who have anything to say about the effects of Cytotec, long or short term.
SEND YOUR RESPONSE to firstname.lastname@example.org with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.
Question of the Week Responses
Q: We have a client who in her first birth had a retained placenta. Retrieving was complicated by a vagal response. She ended up needing to be transported, and the placenta was removed while she was under anesthesia. We are trying to collect data about incidence of repeat retained placentas and any suggestions for reducing its incidence. We are aware of the possible role of vitamin E, and she is minimizing her intake in this pregnancy.
A: I had a retained placenta with my fifth birth. I strongly believe it was from a combination of Pitocin being given to me during labor and premature traction of the placenta. My sixth birth was a homebirth with a skillful midwife. She told me to drink lots of red raspberry tea, and I did. I took a good multivitamin and I made sure my protein intake was strong. When it came time to deliver the placenta, she was very gentle and let me push it out. I did not retain any placenta. Definitely diet, herbal teas, and a skillful midwife who does not use traction are important.
Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to email@example.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
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A group of us on the midwivestrial yahoogroups list are creating a legal manual for midwives to be titled "From Calling to Courtroom: A Midwifery Survival Guide." We are now working together on a separate yahoogroups list, and work is progressing at an amazing rate! Because we believe this information is so important for every midwife, this book will be available for FREE online upon its completion, and at cost for those who wish to have a hard copy. The outline of the book looks like this:
- Why You Aren't Safe!
- Preparing Ahead of Time: What You Need to Know and Do
- Understanding the Legal System
- Finding and Working with a Lawyer
- After the Dust Settles
This is an extraordinary project. Once completed, it will find its home on the MANA Web site as well as the Birthwithlove site. Please consider contributing to its success in the following ways:
- We still need input from persecuted/prosecuted midwives. What do you wish you had known? What do you wish you had done? What would you do differently? Your experience can be of tremendous help to midwives who have been prosecuted or may be prosecuted in the future.
- We are in great need of people who can help compile a resource list. This need not take a lot of your time, but please put your Internet skills to work to help track down and verify the resources needed by persecuted/prosecuted midwives.
If you are able to contribute in any way, please let us know.
— Valerie, firstname.lastname@example.org
I would like more information about why the midwife from Canada mentioned she would recommend an Epsom salt bath in early labor "provided the amniotic sac is intact" [Issue 5:18]. Please explain the provision.
— Lynda, SNM, Indiana
Can you give information about the possibility of uterine rupture due to grand multiparity with no previous history of cesarean? I have found no studies that do not include previous c-section history. Does the risk go up when you have had more than five births? I would like to deliver our seventh child at home but am 45 minutes from a hospital should anything go wrong. With my last birth, I had no labor—we delivered surprised and unassisted at home.
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