January 21, 2004
Volume 6, Issue 2
Midwifery Today E-News
“Cervical Lip”
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ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

In This Week’s Issue:


Quote of the Week

"Even after more than 250 births, I still can't get enough of that moment."

Jerry Whiting, partero


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The Art of Midwifery

When I attend a birth, women relay verbally when they feel the almighty urge to push, and with the obvious signs—anal pouting, complete purple line (if on hands and knees)—I say, "Have a go, give it a push, and if it feels good then keep doing it at your body's rhythms." This approach works like a charm. Another way I help women is to apply pressure to the area where they can direct their pushing. I have never been intrusive; I don't quiet people down; but we do discuss this at later antenatal appointments so they are prepared, more so to help them empower themselves.

Charity, New Zealand, Midwifery Today Forums


Send submissions, inquiries, and responses to newsletter items to: mtensubmit@midwiferytoday.com.

News Flashes

A Johns Hopkins Bloomberg School of Public Health study of postpregnant teenage girls ages 13 to 18 showed that one-third "had a bone mass that meets the definitions of osteoporosis or osteopenia," according to the university's Web site. Women build 40 percent of their bone mass during adolescence, and if they are pregnant during that time, the fetus competes for calcium. The study showed that adolescent pregnancy therefore may prevent young women from attaining full bone growth. Young women who consumed more calcium during pregnancy showed less bone loss than did those with lower calcium intake.
www.jhsph.edu/Press_Room/Press_Releases/pregnant_osteoporosis.html


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A Journey of the Heart

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Cervical Lip

Internal touch is helpful when encountering a persistent anterior cervical lip. A woman may want to push, yet a flap or ridge of cervix prevents descent. To check for this externally, I ask her to carefully try a push or two. If it hurts, then the cervix is probably still in the way. After enduring many exhausting hours in transition, at many a birth, waiting for the lip to go away by itself, I resolved to actively confront this problem. Getting women out of bed and into any upright position such as in a birth chair has helped, and I see this problem much less often. Still, it occurs often enough that I mention my approach during prenatal education. This way, the procedure will be familiar should we decide to use it.

First, I make sure the mother's bladder is empty, and I ask her to try a position change. Sometimes just a little march to and from the bathroom, along with some patience, is all that is needed. If not, with the woman's permission, I place two fingers on the baby's head, move them up to contact the anterior cervical lip, and spread them about one inch apart. With my finger pads on the baby's head, tips of my fingers on the cervix, I gently push the cervix up under, or at least toward, the pubic bone. When the next contraction begins, I hold this position as the cervix becomes taut, while encouraging the woman to push gently. Usually, within a few contractions, the head moves down a little and the cervix ascends out of reach. Sometimes, especially if the presenting part is irregular or particularly large, it may take a number of contractions.

Note: This technique is not to be attempted before most of the cervix is out of reach or if a rim can be felt all the way around. Wait until only an anterior lip is impeding progress. I would not recommend using this maneuver with a breech presentation because it is too easy to manipulate the soft buttocks under an incompletely dilated cervix, which could entrap the after-coming head. You want to ensure complete dilation prior to descent. Also, never risk damaging the cervix by forcing it; instead, apply a firm, steady barrier against it slipping back down.

Sometimes the cervix gradually slips away as the head moves down; other times it snaps up suddenly and is gone. The trick is to keep your fingers in contact with the cervix prior to the contraction so it will not have a chance to tighten down around the head but will instead be guided to pull up behind it.

If your attention wanders, the cervix can change shape and slip beneath your fingers, back down to an obstructive position. Or, if you remove your fingers before it's totally gone, it may sneak back down to where it started.

It is imperative that the woman be offered breaks from the procedure, especially if it takes longer than a couple of contractions. While this technique can be truly helpful for reducing transition time, sometimes by a matter of hours, it can be uncomfortable for the women whose cervix is especially sensitive. If you offer this intervention, you must be very considerate of the woman's feelings and reactions. If she cannot tolerate cervical contact, you will have to wait it out, using forward-leaning positions and low, external, uterine support.

Excerpted from "Serving Our Birthing Sisters,"
by Judy Edmunds, in "The Second Stage Handbook," a Midwifery Today book


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THE SCIENTIFICATION OF LOVE

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Web Site Update

Read these articles newly posted to the Midwifery Today Web site:


Forum Talk

I'd like to hear some discussion from midwives doing VBACs at home: Do you risk out women who have single-layer suturing from their previous cesarean closures? I'm trying to make up my mind about this issue since hearing Ina May and others raise it in the past few years. I now have my first client who wants to deliver at home and has single-layer suturing. Any thoughts?

Anon.


TO SHARE YOUR THOUGHTS AND EXPERIENCE ABOUT THIS TOPIC, click here.
**PLEASE DO NOT SEND YOUR RESPONSES TO E-NEWS!**


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The New Zealand College of Midwives

The New Zealand College of Midwives (NZCOM) celebrates a century of midwifery in New Zealand/Aoteoroa next year and welcomes papers on relevant topics as part of the college's national conference presentations, September 2004.

The conference is to be hosted by the Wellington region of New Zealand College of Midwives. The procedure for submitting abstracts is on our Web site: www.nzcom.org.nz

Abstracts received from E-News readers within a week of the January 30 deadline will be considered.


Question of the Week

Q: Are there others out there who took a long break from midwifery, then returned to practice? After 20 years (13 as a CNM), I left practice to heal from severe burnout. In spite of a new, enjoyable career and owning my own small business, I often wonder about returning to practice three years after having left. I've done lots of personal work through counseling, introspection, food changes, and exercise and wonder what others might have done practically, educationally, and otherwise to prepare to return. How did you feel about reentering practice? I'm sorting my feelings for now—grieve and let go vs. reevaluate and return.

— Anon.


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com 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: My community has no midwives, and I must settle for a doctor and hospital for my birth. This will be my fifth baby; number four was also born in this town. I hemorrhaged quite badly after the placenta was manually removed (they didn't seem to want to give me time to push it out on my own). I fear I will hemorrhage again with this one. I tend to start labour the same way every time—my water breaks, and I start to bleed with no warning. I usually have about 10–15 minutes before my contractions start, and the baby is normally here within an hour or so. I tend to move along quite quickly when in labour. I have a different doctor this time, but she is very young and not very experienced, which may be a good or bad thing.

How long is a normal wait time for the placenta to be delivered? What (if anything) can I do now to lessen my chances of a large bleed at delivery? What would be a good delivery position? I have only done semisitting, but I tend to get as upright as the nurses will allow at the time.

— Charlotte

A: At the beginning of my practice as a midwife, we had a homebirth client who was expecting her fourth baby. She had hemorrhaged badly after each of her prior hospital births. I called [midwife/herbalist] Lisa Goldstein and asked her, expecting a negative answer, if there was anything we could suggest so this woman would not bleed at her homebirth. Lisa's one-word answer: "Alfalfa."

Alfalfa's roots go extremely deep into the soil; it contains every vitamin and mineral known to man; and it is a good source of vitamin K, a natural blood clotter. The mom began to take alfalfa religiously and had completely normal—scant even—bleeding postpartum (she had a wonderful homebirth!).

Since then I have learned quite a bit more about avoiding postpartum heavy blood loss. During the past 11 years, it has been extremely rare for a client of mine to bleed seriously. Most of my clients choose to try the following suggestions, and nearly all have had minimal, normal bleeding. I keep medications on hand but throw them out and replace them, unused.

Here is the crux of what we do:

  • Check the mom's hemoglobin at 28 weeks and again at 36 weeks; use natural means to help her avoid anemia.
  • Recommend an excellent multiple vitamin from NF formulas (available through birth supply firms), Spectrum 2C, at the full 8-per-day dose, throughout pregnancy. The number of capsules seems large, but the beneficial minerals, etc., are bulky. (many prenatals simply don't supply much in their one-a-day form).
  • Require that women take alfalfa, 8–12 tablets per day, any brand.
  • For other reasons, especially the formation of the baby's brain, I recommend taking fish oils (4 capsules per day) or vegetarian DHA capsules.

It is a lot of pills, but think of it as the nutrients your food is missing. I suggest taking half of them in the morning and half in the evening. Bagging one month's worth in small ziplocks makes it easier. Keep them where you will remember to take them (e.g., where you brush your teeth).

I have been able to compare my methods with those of other caregivers because I also worked in a birth center and assisted other midwives whose clients have not had the benefit of these protective components. I have seen some serious bleeding in women who don't use these methods. Even then, it is usually stopped with herbs. My favorite is 30 drops (three droppersful) of Lady's Mantle tincture, which stops bleeding "right now"! The Web site, www.gentlebirth.org/archives/, gives other midwives' suggestions.

I assume you will eat healthy food and take a good brisk walk (30–45 minutes) each day. It would be great if you found someone with a calmer approach to placenta birthing!

— Julie Martin, CPM, NHCM

A: You are wise to start preparing for the possibility of hemorrhage. In my experience, moms who have had manual removal with postpartum hemorrhage are more likely to experience it again. Ask your physician how she has handled hemorrhage right after birth. How many times has she done manual compression? What drugs does she use? When you tour the hospital or have an appointment with the prenatal coordinator, tell her your history and request that when you come in in labor the appropriate pp hemorrhage drugs be brought to the room immediately on admission. An extra nurse is needed should hemorrhage occur. Did you rehydrate well last time? If you breastfed, did you notice a marked decrease in your milk production? When the placenta is delivered it must be inspected carefully for completeness.

— Linda

A: It can be normal for the placenta to take up to one hour to deliver. A hands-off approach is the best method as long as you are not bleeding heavily and your blood pressure and pulse are normal. If you are bleeding before the placenta delivers it is probably partially or completely detached and should be delivered as quickly as possible to allow your uterus to clamp down. Insist that your doctor not touch the cord until it stops pulsing and then to not use cord traction to deliver the placenta but to get you into an upright (squatting) position and deliver it yourself.

Prenatal prevention of postpartum hemorrhage includes blood-building supplements, including alfalfa and yellow dock. Homeopathic Arnica (30c) 5 pellets 3–5x per day in the last two weeks of pregnancy and at the onset of labor will reduce bleeding as well. Pitocin IM immediately after the birth will also reduce the risk of hemorrhage.

— Rebekah Rico, CPM, LM

A: I spoke with a friend's mother who homebirthed 35 years ago. She said her placenta didn't emerge for four hours. Fortunately no one felt a need to intervene. There were no complications.

Doctors and OB nurses want to get on with it, clean up, and move on, so they tug the placenta. This is a dangerous practice that can cause dangerous hemorrhage. Then the doctors do some heroics to save the mother's life.

Please remember that you are not a prisoner and the doctor cannot do anything to you without your permission. Women have been trained to "be good," and so they rarely question or protest a doctor's moves.

Discuss this with your doctor *before* the labor and also have something in writing to bring with you in case you end up with an alternate doctor.

Sometimes just getting up on your knees allows the placenta to fall out. But you should wait until it separates naturally.

— R.B.


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mgeditor@midwiferytoday.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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Feedback

Regarding antibiotic administration prior to birth and its effect on the newborn [Issue 5:25]:

I opted not to be tested for Group B strep in my pregnancy and was subsequently coerced by an OB into having prophylactic antibiotics administered during labor "just in case." My son and I both developed nasty yeast infections shortly after he was born. Antibiotics kill all bacteria—good and bad. Without the presence of the good bacteria in your baby's intestines, Candida (also known as yeast or thrush) has an opportunity to grow prolifically. Start taking lactobacillus acidophilous (which is a healthy bacteria) to replace what has been killed by the antibiotic. In the meantime try not to be too concerned because most likely the worst scenario is an ugly diaper rash.

Anon.


I am 18 years old and considering going to school to be a nurse midwife. I currently live in Syracuse, New York, where I spent my childhood. Within the next six months I will be returning to Brazil where my family lives to go to college there. I know that in Syracuse midwives are very appreciated and respected. In Brazil, however, they tend to work mostly in the interior, or in public hospitals where they don't get much chance to be creative or get paid very well. Midwifery seems to be a growing profession only in large cities such as Sao Paulo and Rio de Janeiro—where I would really hate to live. My family lives in Palmas, where I will probably go to college.

I would just like some encouragement and suggestions. Maybe there are places or people I don't know about and could contact who are working toward encouraging midwives and natural homebirths.

Maira Mathews


Readers, please take time to give Maira a hand up. Direct your comments to mtensubmit@midwiferytoday.com. —Ed.

Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


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Request for Birth Photos

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Classified

Home birth practice in Chicago area: Seeking midwives and family practice doctors to join our practice. Call 847-733-8050 or e-mail bestbirth@birthlink.com. For more info go to: www.homefirst.com


The International School of Traditional Midwifery offers quality education to aspiring and practicing midwives through our onsite, distance learning, A&P, and short course programs. Contact us at: 541-488-8254 or www.globalmidwives.org


Do You Have a Wonderful Natural Birth Story? Deadline for submission February 7th. Your story is part of a book that gives new moms hope and inspiration. More information at: http://www.menelli.com/stories.html or sheri@menelli.com


CPM seeks same to start practice in beautiful Southeastern Minnesota. E-mail: Tanya Mudrick CPM at midwifetanya@yahoo.com


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