March 3, 2004
Volume 6, Issue 5
Midwifery Today E-News
“Forestalling Prematurity”
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In This Week’s Issue:


Quote of the Week

"H. Deutsch, a psychologist active in the 1940s, knew that at the time of birth, it is not just a vagina that is opening, the woman's entire psyche is open and vulnerable."

Nancy Wainer and Lois J. Estner


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The Art of Midwifery

When cranberry juice, extracts, and lots of water aren't alleviating a urinary tract infection during pregnancy, try parsley tea: place one bunch parsley, washed, in a large glass bowl, pour 1 quart boiling water over it, cover and steep for 30 minutes. It can be sweetened with honey, if needed. Drink one quart in 12 hours.

Joan Dolan


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.

News Flashes

An Agency for Healthcare Research and Quality (AHRQ) retrospective study of 733 women who delivered fullterm, nonbreech infants by unplanned cesarean found that as many as 24% of c-sections for "lack of progress in labor" are performed too early. This group comprises women who undergo a c-section when their cervix has dilated 0 to 3 centimeters. The American College of Obstetrics and Gynecology (ACOG) guidelines recommend that dilation should be 4 cm or more before a failure to progress diagnosis is made. The researchers postulated that many doctors are more comfortable with the risks of c-section than they are with labors that do not progress as rapidly as expected. In addition, many doctors either do not agree with ACOG guidelines or interpret them differently.

Obstetrics and Gynecology, April 1, 2000


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Forestalling Prematurity

[Readers offer feedback to a letter published in E-News Issue 6:4]

In brief response to the powerful editorial by E. Johns [Issue 6:4], I laud her for supporting her own choices and for encouraging certain communities of providers to consider well their criticisms of conventional medical interventions.

On the other hand, a good deal of research by obstetricians and perinatologists reveals that the use of magnesium sulfate and the practice of bed rest has not affected birth outcomes significantly. In fact there is a measure of research about the use of magnesium sulfate and its potential effect of increasing cerebral bleeds in premies and subsequent cerebral palsy. This has been researched at length by a perinatology group in Chicago and is essentially ignored by perinatologists nationwide due to the lack of an alternative intervention. Many of the interventions still used, including cerclage, have their risks and are highly imperfect, facts that are not frequently passed on to pregnant, high-risk couples. Criticism and discussion is great in reference to issues surrounding obstetric intervention ... on all sides of the practice and patient spectrum.

K Michalski, RN


Good points Erica—I'm glad Isaac is a well four-year-old. You have some good advice for the real world. I also have seen bed rest, brethine, wine, cerclage, etc., work for stopping preterm labor. I believe *whatever* works is better than a baby born prematurely. Each mom, baby, labor, backup, etc., is different, so there needs to be many options. That's the beauty of getting involved in your care, as midwives usually encourage. You find what works for you. I know a lot of the literature says bed rest doesn't work, wine is never mentioned, etc. But I have clients who will swear by it, and we got all but two to term (with good homebirths) in 18 years. Maybe this feedback will save some babies. We all learn from each other.

Lisa Aman, LM, South Carolina


I agree with your reader's comments about the preterm birth article. I also found it overly negative regarding interventions. As a holistic, midwifery-supportive obstetrician who uses these interventions with a critical mind, I will say the following:

Terbutaline is way overused and many obstetricians know it. I hate the side effects such as drinking a lot of coffee, rapid heart rate, elevated blood sugar, etc. I cared for a lady during residency who had a terbutaline pump, and I literally ripped the thing out of her thigh, her heart was racing so fast. I prefer magnesium sulfate—it really does work when it's really needed. Also, magnesium deficiency is prevalent. I have a patient now who has a cerclage after two second trimester losses, done because she had cervical shortening and cramping with bleeding. After the cerclage she complained of some cramping, and oral magnesium oxide resolved it. I also like Nifedipine (Procardia) as an oral calcium channel blocker; it relaxes arterial smooth muscle to lower blood pressure and also relaxes uterine smooth muscle. No jittery side effects!

Your article struck me as overly negative and unbalanced, and I appreciated hearing from someone who had personal experience with helpful interventions. I don't like interventions, I agree that they are overused, and I plan to have my own baby at home, but your article made it sound so black or white—and it's not.

One of the reasons I went to medical school and became an OB/GYN is that I wanted to be in a position to understand and question medical interventions and avoid them in my own life. I have gone through my training and practice with a critical mind, and even midwives I work with tell me my approach toward birth is more relaxed and laid back than theirs. I feel I need to say this so my comments may not be construed as blindly supporting intervention—far from it. At the same time, I feel that to simply write off interventions—magnesium sulfate, pushing while holding the breath—is another form of putting blinders on. It is possible to question interventions and their overuse while still recognizing when they are helpful. That questioning voice must be heard. It becomes too easy to write off those who question interventions when they are not truly informed and intelligent in their critique.

Eden Gabrielle Fromberg, DO, FACOOG, DABHM
Clinical Assistant Professor of Obstetrics and Gynecology
SUNY Downstate College of Medicine
Long Island College Hospital, Brooklyn, NY


I'm sorry that Ms. Johns had such a difficult time with her fourth pregnancy and glad that in the end her baby lived.

However, despite what Ms. Johns perceives as the "success" of the interventions used in her pregnancy, the research by the very medical community she is defending does *not* support these interventions! Time and time again, studies of the various medications used to stop preterm labor show that they have no long-term impact on preventing preterm birth—all they can do is at most prolong the birth by 48 hours. Preterm *contractions* are not synonymous with preterm *birth.* I had a client who started having contractions at 28 weeks into her second pregnancy and continued throughout her pregnancy despite use of medications and bed rest. She ultimately birthed her baby at 40 weeks. On the other hand, a friend of mine birthed her first baby at 34 weeks with only a few hours of contractions, despite being pumped full of medications in an attempt to delay the birth long enough to give steroids for lung maturity. When she was pregnant with her second child she was prophylactically put on medications, and she gave birth to that child also at 34 weeks.

Bed rest is a very little-studied intervention. It has been studied in relation to multiple pregnancies, and increasing level of bed rest was found to lead to even earlier birth; however, I doubt those studies looked at placental abruption. It is very possible that bed rest is a reasonable treatment for placental abruption—I wish there were some studies to show one way or another if it was so that either more confidence could be put in it as an effective treatment, or more energy could be devoted to exploring other treatments if it is not effective.

Jenn Riedy, BCCE, CPS, CBE, doula


I'm really, really sorry you had such a hard time with that pregnancy, and certainly, if you felt that what was done to you was beneficial, then it was justified. You are 100% right in pointing out that midwives (and other researchers, I might add) point out the ineffectiveness of certain procedures without having anything better to offer. OBs also know this, though they don't necessarily volunteer that information. If you are happy with what they did, perhaps you're better off leaving it right there.

However, if you want to get into medical justification, p. 307–8 of Williams Obstetrics (1997) goes into great detail about the etiology of premature labor, speculates that it often might actually be caused by undetectable intrauterine infection, laments that it doesn't work well, but then describes what they do anyway. On p. 588 it describes the problem of incompetent cervices and observes that one of the main causes is prior trauma to the cervix, most especially cerclage. If I could find my copy of Enkins et al.'s Effective Care in Pregnancy (3rd ed., 2001) I'd point out the pages where it says that no studies have proven the efficacy of cerclage. As you don't say exactly what the medical problem(s) with that pregnancy were (do you have a copy of your hospital record, or are you just commenting on what they told you?), it's impossible to be precise about what happened in your case. I personally feel that, if one has a good outcome, it is due more to one's faith in having a good outcome than anything else. (That statement is probably going to infuriate a lot of midwives as well as a lot of OBs.)

I have yet to hear midwives deplore obstetrical intervention when such intervention is clearly justified; and very few midwives (if any) believe it's never justified, medically, anyway. Obstetrics has huge "gray areas" where whether or not to intervene is so very iffy that it's probably best left up to the mother's preference (in my opinion). Because of tort law, however, obstetricians have to carry out whatever's listed on their standard of care, whether it is scientifically shown to work or not, or even proven to be harmful, simply to keep their jobs; and so consulting the woman as to her wishes is seldom a priority. It seems to me that, if midwives tend to be riled at OBs, it is for those reasons, and also because state laws are frequently so stacked against midwifery that women aren't given the option of choosing a noninterventive style of care if they want it. To put it another way, they have to go to incredible lengths to secure a noninterventive mode of care and figure out how to pay for it, if indeed they're aware that such an approach is possible. It is truly lamentable that childbearing should have to take place in such a hostile climate, but as long as lawyers, insurance companies, and hospitals benefit and voters don't rise up in protest, I don't see how it's going to change.

Jill Herendeen


Erica Johns's letter was well stated; I too would love to hear natural alternatives to premature labor. I have seen alcohol touted as a labor stopper, and I believe it may work but I don't want my unborn child on alcohol. I've also read miscarriage remedies in Susun Weed's Wise Woman Herbal for the Childbearing Year that have seemed helpful to women in early premature labor, but the same argument could be made that their pregnancies continued because they would have anyway. Having an aunt whose first child was very premature due to incompetent cervix and then delivered normally at term with a cerclage, it's hard for me to credit an article that says they are of no value because we say they are not. Likewise, seeing many women over the years (as an obstetrics nurse) who come in dilating with contractions before 34 weeks respond with total cessation of contractions after a dose of brethine, it's hard for me to credit the assertion that they would have stopped anyway.

As a mother I'd do anything to help my baby; hoping for the best doesn't cut it. Sometimes the worst happens despite all you can do, but I'd exhaust all resources available, natural and traditional medical. Can magnesium sulfate be worse than the old method of getting drunk? It may be that there are no good choices, only ones of various risks. Each woman must decide in her circumstance what would serve her baby best. Instead of narrowing our options, I'd like to broaden my knowledge of what may help. I'd welcome anyone's experience of what helped their pregnancy (or their client's pregnancy) continue despite complications.

Catherine Fox, RN and lay midwife


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Forum Talk

I would love to hear how some of you started attending homebirths. What was your background? How did you train and for how long? Did you start as L&D nurses? How many births did you attend before you went solo and started to feel more comfortable? Do you do well-woman care as well as births? What states are homebirth friendly, and where might one find the greatest need?

Nikko


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Question of the Week

Q: I attended a birth for a friend. She had sudden spurts of running a temperature in labor with increased blood pressure for a short period of time (less than 30 minutes), with shakes. She was feeling cold and then hot. It happened twice during labor. The midwife, who did a great job, thought about transferring after the second time, but again mom leveled out at perfect vitals soon after. Baby was born at home after a good long labor, but six hours later the temp spiked with chills, and again leveled out. Mom is now taking echinacea/goldenseal, garlic, and zinc. This also occurred the day following the labor, but not as intensely. Mom's temp hit 101 and then returned to normal within 30 minutes. Any ideas? Mom had a wonderful homebirth; baby's doing great and nursing wonderfully.

— NMdoula


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.


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Question of the Week Responses

Q: What is your preferred alternative practice to ease labor (e.g., aromatherapy, acupuncture) and why?

— Anon.

A: More and more often moms are using the effectiveness of hypnosis to create calm, comfortable births. A childbirth education program called HypnoBirthing® and developed by Marie Mongan teaches couples how to use hypnosis for birth. If you are looking for classes in your area, go to www.HypnoBirthing.com for more information.

— A. Aldridge

A: One can potentially ease or facilitate labor progress in numerous ways. I don't think there is one unique or specific way that works for all. It is important for those of us who accompany families in birth to come prepared with many options for the laboring client. Aromatherapy (e.g. lavender essential oil on a tissue, for relaxation); scented or unscented massage oils for back, shoulder, foot or hand rubs; heat and cold therapy; showering (hydrotherapy); TENS (transcutaneous electrical nerve stimulation); positional changes; music; massage tools; walking; visualization or imagery exercises; sitting or leaning on a birth ball; and counterpressure are examples of alternative practices that can ease labor. In my doula practice each of these has worked differently for individual clients, and each can work at different stages of labor. The application of alternative methods is very client-specific, and it is important to come prepared to offer any of those mentioned (and more) to your laboring client. If one method isn't working, or ceases to work, reach into your bag and try something else.

— Lisa Spracklin, B.Sc. CD (DONA), CIMI (IAIM)


Regarding forced pushing [Issue 6:4]:

A: I am a British trained midwife who has worked in England, France and the Middle East and have not experienced forced pushing. We offer encouragement and support to women when the desire to push is overwhelming and compelling. We are taught from training that the mother is therefore the best judge of when and how to push. The problems with prolonged breath holding are well documented and relayed to us from training here in Europe, and I have absolutely not experienced myself nor witnessed another European midwife practise this technique of "count to ten, hold your breath."

— A.M.

A: I am not yet a qualified midwife but am in the final year of training. I have given a lot of thought to whether it is helpful to use "directed" pushing that you describe when women approach the second stage of labour. I can only tell you what I think: women (and midwives) should trust their bodies, and you will probably find that if you go with what your body is telling you, you will discover that you innately know how and when to push. Don't forget that those contractions are also moving the baby down the birth canal, and it is possible for those alone (given enough time) to do the work for you.

— Moira

A: Sometimes you just have to bear down and push! And often you don't. But big babies especially don't always come down with HypnoBirthing®-type pushing. I'm not into the cheerleader style pushing, but once in a while it's helpful.

— Eden Gabrielle Fromberg, DO, FACOOG, DABHM, Brooklyn, New York


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

I want to give you a resounding thank you for E-News Issue 6:4. I thoroughly enjoyed it. I am a pre-nursing student at Florida Atlantic University and am on track to becoming a nurse-midwife. In my Introduction to the Nursing Profession and Discipline class we had to write a paper answering the question, "What brought us to nursing?" The professor found out that midwifery brought me to nursing. Since then, she makes it a point to include midwifery in her lectures and/or examples as it relates to nursing. I love the questions I get about midwifery and I love telling people about midwifery! People are always genuinely warmed and intrigued by the profession and the snippets I give them as examples regarding the birthing process. I share some of the things I've found exciting and informing such as nipple stimulation to help in labor and with contractions and the many herbs that can be used to stop bleeding and to heal episiotomies, etc.

Just this week, two classmates were talking about shoulder dystocia. Before I knew it, I was telling them about it and what I've read about relieving it, etc. Issue 6:4 of E-News was just what I needed (thank you, Maggie Ramsey, for "The Art of Midwifery")—complete with the wonderful and very personal feedback from Erica Johns regarding premature labor. It reminded me that we are all human and that not everything works for everyone, regardless of how wonderful midwifery is, how beautiful childbirth can be, or how sincere we try to be when imparting information.

Thanks for being wonderful, thanks for being informative, and thanks for constantly reminding me about the gratifications and realities of this wonderful profession.

Carrie M. Campbell (future nurse-midwife)


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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