March 31, 2004
Volume 6, Issue 7
Midwifery Today E-News
“Miscarriage”
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SIT UP AND TAKE NOTICE"SIT UP AND TAKE NOTICE: Positioning Yourself for A Better Birth," a book by Pauline Scott, explains the pivotal importance of fetal position to the outcome of labor and birth.
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In This Week’s Issue:


Quote of the Week

"Midwifery calls upon you to be the best you can be: the best advocate, guide, healer, counselor, mother, comrade, and confidant of the women seeking your care."

Anne Frye


The Art of Midwifery

I give out a sign for postpartum moms to hang on their door (wording from AyurDoula Martha Oakes):

WELCOME, FRIENDS

_____________________ was born at _____ o'clock ____ on ________, _______ 200_, weighing in at ____ lbs ____oz.

In order for baby, parents, and siblings to get rested and get to know each other in a quiet, peaceful atmosphere, it is requested that EVERYONE limit their visits to 15 minutes.

This is a very special time, and the desire to share with you must be weighed against the need for rest and quiet.

Before you leave, it would be so helpful if you lent a hand: quietly wash up any dirty dishes, take the laundry home, water the plants, sweep the floor, tend to any pet needs, check the food supply and shopping list, or any other nice thing you feel inclined to do!

We Mother the Mother after a Birth

Adrienne, Midwifery Today Forums


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.

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News Flashes

Sexual activity in late pregnancy does not increase the risk of preterm delivery, according to a University of North Carolina/Chapel Hill School of Public Health study. In the past, some practitioners have advised against intercourse because of the release of oxytocin during orgasm, which presumably could induce contractions. The study's survey of more than 600 women showed that frequency of orgasm or intercourse in weeks 29 to 36 was not related to early deliveries.

Obstetrics and Gynecology, February 2004


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Is It Miscarriage?

Differential diagnosis of symptoms suggesting miscarriage:

Reasons for benign bleeding include

  • implantation bleeding caused by erosion of maternal blood vessels at the uterine implantation site. This painless spotting/bleeding may occur any time during or throughout the week when implantation takes place.
  • cervical bleeding due to softening, stimulation during sexual activity, increased vascularity, lesions, infection of the cervix, or presence of polyps
  • stretching of decidual capillaries as the uterus grows
  • menstrual breakthrough bleeding during the first few months of pregnancy at the time a woman would normally have had her menstrual period
  • false pregnancy
  • delayed menstruation followed by excessive bleeding from accumulated layers of endometrial tissue in a woman who is not pregnant.

Reasons for benign cramping/pain by itself include

  • indigestion/gas
  • stretching of the round ligaments
  • orgasm
  • vulval engorgement.

Other causes of bleeding and cramping may include

  • poor nutrition
  • urinary tract infection
  • scar tissue adhesions in the lower abdomen
  • adhesions within the uterus: 15% to 30% of women with intrauterine scar tissue adhesions miscarry. Adhesions may form after invasive procedures such as curettage postpartum, intrauterine surgery, or endometritis.
  • ovarian cysts
  • hydatidiform or vesicular mole (an abnormality of the placenta that can mimic a more typical threatened miscarriage)
  • fibroids: submucosal and intramural fibroids are the two types most commonly associated with miscarriage.
  • uterine scars
  • cervical or uterine cancer
  • preexisting maternal disease such as severe kidney or heart disease will make carriage of a pregnancy unlikely, impossible, or dangerous
  • torn hymenal vessel
  • inevitable miscarriage of an intrauterine pregnancy. 50% to 60% of first trimester miscarriages are due to verifiable abnormalities of the baby or placenta. In these cases the baby usually dies before bleeding begins. The average time between death of the fetus and expulsion is 6 weeks, and the average time for the actual miscarriage to occur is 10 weeks from the last menstrual period.
  • ectopic pregnancy
  • loss of an intrauterine multiple gestation
  • emotional issues.

Excerpted from Anne Frye's "Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice" Vol. 1: Care During Pregnancy (Labrys Press, 1995)


TO ORDER "Holistic Midwifery," go here.


Repeated Miscarriage

Numerous causes may contribute to repeated miscarriage, also called habitual abortion. Chromosomal problems; hormonal problems; maternal disease including immune disorders; abnormalities of the uterus; or environmental and lifestyle considerations may all play a role. Different miscarriages may have different etiologies for the same woman.

Half of all pregnancies that end in the first trimester are caused by fetal chromosomal abnormalities. Most of them occur by random chance. In repeated miscarriage, a genetic workup may be indicated.

Lack of sufficient progesterone may cause the fertilized egg to be sloughed off with the uterine lining early in pregnancy. Hormonal supplements may treat this problem successfully.

Illnesses in the mother such as heart or kidney disease, diabetes, lupus or thyroid disease may cause habitual abortion. Appropriate treatment may allow pregnancy to continue. Immune system problems can be caused by differences between mother and fetus or mother and father. Antibody blood tests may pick up these problems. Genital-tract infection may be screened for by vaginal or cervical culture.

Maternal congenital abnormalities may be discovered by hysterosalpinography, hysteroscopy, laproscopy, or ultrasound. They may include abnormalities of the uterus such as double uterus, fibroids, or problems with the cervix.

Maternal or paternal smoking and alcohol or other drug use may contribute to repeated miscarriage. Inadequate diet or exposure to environmental toxins or radiation is also linked to habitual abortion.

And sometimes no reason will be discovered, despite numerous tests and treatment courses. These women may benefit from referral to organizations that offer infertility counseling, referrals, and support groups.

Excerpted from "Recurrent Spontaneous Abortion," by Sharon Glass Jonquil, CNM, Midwifery Today Issue 41.


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Forum Talk

I am presently under the care of a midwife and concerned that we may not be communicating effectively. She is thoughtful and kind, but I get the sense that she is concerned about this birth for some reason. I have researched VBAC very carefully and have found no evidence, statistical or otherwise, that might indicate a problem, and I have tried to indicate to her that I am well educated on the benefits and risks of the path we have chosen. Does anyone have pointers on effective communication with your midwife?

Tracey


Share your thoughts and experience about this topic.
**Please do not send your repsonses to E-NEWS!**


Question of the Week

I am currently 32.5 weeks pregnant with my third child. My first baby was anterior. My second baby was persistently posterior. He turned *just* before delivery. Both births were unmedicated. My baby is currently posterior—at around the same time my son became posterior. I tried acupuncture, water exercise, yoga, pelvic rocking and tilting, hands and knees, etc. with my son. I have been doing the same things this time with the addition of chiropractic (and I have not done acupuncture yet). I am planning a homebirth this time and am very anxious about repeating my 2.5 day excruciating posterior labor. I am also very familiar with Pauline Scott's new book [Sit Up and Take Notice: Positioning Yourself for a Better Birth]. Are there any suggestions that would be helpful for me? Or is there anything else I have not tried yet?

Robin


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: 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 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

A: I once had a client like that. After consulting a gynaecologist, we found she happened to have an infection of syphilis. In fact it could be any kind of not-so-innocent infection.

— Gre Keijzer, midwife

A: When I have seen this happen it has involved a potential problem somewhere in the thyroid/adrenal/pituitary system. In one recent case the mom had low normal T4 levels and almost nonexistent thyroid-stimulating hormone (TSH) output. This was discovered prenatally due to severe depression and feeling "wrong." She was supported with adrenatrophin prescribed by a naturopathic physician, and her overall health improved. Of note was that she had had difficulty with milk production in her previous pregnancy. After this recent birth she had exactly the symptoms you describe (fever/chills), including a pulse that rose to 140, but no other symptoms of infection. We saw a doctor for evaluation. They expected to find hyperthyroid, but instead they found low T4, improved TSH. At that time the endocrinologist decided she needed a cortisol evaluation. He recommended that it be done after the postpartum period. She had a second episode of fever/chills a day later (both times in the evening, which is interesting as cortisol levels shift depending on the time of day). She has not yet had a cortisol eval. so I cannot tell you what the final conclusion was.

— Maryl

A: I chalk such patterns up to hormone surges that are stronger than average, but still a normal finding.

— Cynthia B. Flynn, CNM, PhD

A: The most obvious cause of fever is infection. But hormones in birth control pills can cause low-grade fevers. The drug MDM, which mimics the release of endorphins at orgasm, causes the temperature to go up to about 100, depending on the dose. Dehydration is also a cause of fever.

— J.S.


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

My wife is 28 years old. She smokes but not when pregnant and rarely drinks alcohol, maybe once every two months. We have one daughter. Our second attempt at pregnancy ended in a miscarriage. It was very difficult emotionally for my wife. It has been about eight months now and she is pregnant again, but she has been spotting a few times. This is exactly how the miscarriage began last time, and she is extremely worried about having a repeat event. We are sick and tired of hearing the same response from my doctor: "Basically there is nothing we can do." Are there any medical or natural options available to help avoid a miscarriage? I can't just sit by and do nothing.

RSC


I am neither a midwife nor a medical student. My son was born with a severe brain injury. I would like to know what is the acceptable time frame between crowning and full spontaneous delivery.

My baby was born in May 2003. Since birth he has not been able to cry, suck, or swallow. We now tube feed him; he tends to vomit each time we try to feed him. In his first two weeks of life, his eyes remained shut and his body movements were hypotonic. Though he is now able to move a bit more, at times the movements are spastic, and he tends to arch his neck when agitated. His pupils are not equal, and he does not appear to be able to focus. We now discover that he is also unable to see and hear.

Bryant is my first child. The latent phase took two hours, and the active phase was approximately six hours. After the latent phase there was a change of nurses at the hospital, and we were at times left unattended. It was two hours from the time I was fully dilated (according to a nurse that came in to check) before the doctor came to deliver the baby.

During the second stage I was told by yet another nurse to push the baby until the crown showed while we awaited the doctor's arrival. The baby was born with an Apgar of 5 and was not breathing. He had to be resuscitated and was subsequently sent to the NICU. Resuscitation was also delayed. Fetal monitoring showed merely 2 (Type 2 dips) during the whole process. I was tested for some metabolic diseases, and all results were negative. Both my husband and I have no family history of illnesses and we lead healthy lifestyles (no smoking or drinking). Bryant's ECG test (done about three weeks of life) showed little bursts of activity. Although not confirmed, the diagnosis we feel is pointing toward infant asphyxia (HIE). Bryant sees a neuro specialist right now and visits the physiotheraphist once a month.

Valerie Gan, Malaysia


Regarding breastfeeding support, Issue 6:06:

I learned that the two most important predictors of successful breastfeeding are partner support and friends and family support. Therefore I think the problem is much more insidious than the "Milk Angel" idea would solve. We need to change the culture and the rest will follow. I have seen this many times in my own experience. If a woman's group of friends nursed for six months, she is likely to nurse for six months too. I joined La Leche League (LLL) and watched my friends nurse for years, tandem nurse, and wean when their child led them to, so this is what I did as well. When I was nursing, I felt the best thing I could do was nurse in public to help "normalize" the occurrence in other people's minds and give other moms the example that it can be done.

What can we do if we are non-nursing professionals? Encourage mom/baby nursing support groups where mom can meet nursing peers and where child-led nursing is gently encouraged (LLL already does this, but I think the more groups the merrier as not all people will feel comfortable attending LLL groups) and educating fathers about the importance of breastfeeding and their part in making it a success.

Robyn Chambers, BEd., Doula CD (Dona), CBE


I read the responses [Re: premature labor, Issues 6:3, 6:4, 6:5, 6:6] but didn't see my favorite remedy—vistaril. Unlike terbutaline, it calms women down, helps them and their uterus relax, and puts many women to sleep. In the hospital, I will often give the terbutaline and hydrate just to stop the initial uterine irritation (after checking for infections), but for home use, I prefer oral vistaril.

Cynthia B. Flynn, CNM, PhD


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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Question of the Quarter for Midwifery Today Print Magazine

We hope you'll take a minute to consider the Question of the Quarter for Issue 70 of Midwifery Today. In fact, if you send us a response and we use it, we will send you a free copy of the next issue. Responses are subject to editing for space and style. Try to keep the word count at less than 400. E-mail responses, along with your mailing address, to: mgeditor@midwiferytoday.com.

Theme for Issue No. 70: Hands-on Care
Question of the Quarter: : What does hands-on care mean to you? What do you think it should involve? What are its advantages?
Deadline for submission: April 15, 2004.

Question of the Quarter is a feature of Midwifery Today magazine, E-News's parent publication. Responses will be printed in Midwifery Today magazine. Click here to subscribe today!

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Classified

What is the ecology of childbirth? Find out at the International Congress of the Ecology of Childbirth - A Celebration of Life, Rio de Janeiro, Brazil, May 27–30, 2004. For more information or to register: http://www.partoecologico.com.br


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