August 18, 2004
Volume 6, Issue 17
Midwifery Today E-News
“Physiological Birth”
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In This Week’s Issue:


Quote of the Week

"It's kinda fun doing the impossible."

Walt Disney,
contributed by Robin Lim (midwife in Bali, Indonesia)

Think about it! How often do you birth practitioners accomplish what mainstream medicine has declared "impossible"?


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The Art of Midwifery

A few drops of peppermint oil (the real aromatherapy oil, not fragrance oil) works well inhaled from a tissue to alleviate feelings of nausea during transition.

Leigh Hudson, birth doula, Houston


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

Researchers from the Colorado Centre for Reproductive Medicine examined embryos from mice that had been fed a high-protein diet, which can affect the levels of ammonium in the female reproductive tract. Ammonium reportedly affects the H19 gene on chromosome 7, important to growth. They found that this kind of diet affected the ability of embryos to implant. Only one-third of the mice on a high-protein diet developed with a normal H19 gene, as opposed to 70% in the control group. Of those embryos that did implant among the high-protein diet group, 84% developed further; in the control group, the rate of successful growth was 99%. The researchers concluded that a high-protein diet is not advisable while trying to conceive.

The Guardian, June 29, 2004


Physiological Second-Stage Labor

The rhombus of Michaelis - a kite-shaped area at the lower spine that includes the sacrum and three lower lumbar vertebrae - moves back as much as 2 centimeters as second stage labor begins. This diamond-shaped "bump" appears to rise on the lower back and moves, visible especially if the laboring woman is kneeling or on all fours. Not visible are the wings of the ilia fanning outward, increasing internal dimension of the pelvic cavity. The backward movement of the rhombus of Michaelis and fanning of the ilia are thought to occur because the back of the baby's head contacts a nerve plexus where the bladder and urethra join.

The following spontaneous actions then occur: the mother reaches upward for something stable to grasp; her body sags forward and knees roll out; her back arches and she begins to wriggle her lower body; the uterus contracts and forces the baby downward (a series of actions very similar to those during orgasm).

The woman must be in the following position for the movement of the rhombus to occur: her weight is "in front of her ischial tuberosities, with the angle between her spine and her thighs at least 120 degrees (i.e., the distance between her hips and her head is less than the distance between her knees and her head)."

A reclining position for birth places the baby too deep into the back of the pelvic floor, causing the need to push - a concept unheard of in old midwifery textbooks. The rounded back caused by bringing the knees up brings the spine and symphisis pubis so close that baby's shoulders are far more likely to be stuck at the brim.

"If a baby is lined up properly and his mother keeps her knees down, half an hour is normally plenty for a first baby and ten minutes for a subsequent one."

Paraphrased and quoted from "Birth without active pushing," by Jean Sutton, in Midwifery: Best Practice, Sara Wickham, editor

Similarly, if a baby is in the occipito-posterior position (OP) with head rotated to transverse and right shoulder on the pelvic brim and left shoulder on the opposite side of his mother's spine, the baby has difficulty moving his shoulder past mother's sacrum because his spine rather than his soft arms is toward his mother's back. This is the source of very painful "back labor." His position causes the stimulation of the nerves at the back of the pelvis rather than those at the front. The "fetal ejection reflex" is not triggered, and the extra space normally provided by the movement of the rhombus is not afforded. Mother must get on her feet or knees with her weight in front of them in order to flex her pelvis and move the baby. A combination of maternal mobility and an anthropoid pelvis facilitates dramatic resolution. However, a gynecoid pelvis may reduce the chances of rotation, and an android pelvis (narrows toward the outlet) affords no space in which the baby can rotate.

Paraphrased from "Occipito-posterior positioning and some ideas about how to change it!," by Jean Sutton, in Midwifery: Best Practice, Sara Wickham, editor

ORDER "Midwifery: Best Practice"—An outstanding book that every midwife/birth practitioner should own!

During the powerful and irresistible contractions of an authentic ejection reflex there is no room for voluntary movements.... A typical fetus ejection reflex is easy to recognize. It can be preceded by a sudden and transitory fear expressed in an irrational way ("kill me," "let me die," etc.). In such a situation the worst attitude would be to reassure with words. This short and transitory expression of fear can be interpreted as a good sign of a spectacular increase of hormonal release, including adrenaline. It should be immediately followed by a series of irresistible contractions. During the powerful last contractions the mother-to-be seems to be suddenly full of energy, with the need to grasp something. The maternal body has a sudden tendency to be upright. For example, if the woman was previously on hands and knees, her chest tends to be vertical. Other women stand up to give birth, more often than not leaning on the edge of a piece of furniture. A fetus ejection reflex is usually associated with a bending-forward posture. When a woman is bending, the mechanism of the opening of the vulva is different from what it is in other positions. The risk of dangerous tears is eliminated. After a typical ejection reflex, the placenta is often separated within some minutes.

These considerations about ejection reflex versus "second stage" are opportunities to suggest that the true role of the midwife is to protect an environment that makes the ejection reflex possible. The point is to reconcile the need for privacy and the need to feel secure. This means the importance of the midwife as a mother figure. A mother is first a protective person. Furthermore, one does not feel observed and judged by one's mother.

Excerpted from "Insights into Pushing: The Second Stage as a Disruption of the Fetus Ejection Reflex," by Michel Odent, Midwifery Today Issue 55

The more births I attend, the more I realize how much I disturb the birthing woman. Disturbing often comes disguised in the form of "helping." Asking the mother questions, constant verbal coaching, side conversations in the room, clicking cameras - there are so many ways to draw the mother from her ancient brain trance (necessary for a smooth expulsion of the baby) into the present-time world (using the neocortex, which interferes with smooth birth). This interaction must be avoided.

Excerpted from "Pushing for First-Time Moms," by Gloria Lemay, Midwifery Today Issue 55

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Forum Talk

What is your policy with a mom who has no idea of when her last menstrual period was? I know as midwives you would not be overly focused on dates, but it's always in the back of your mind as you're watching things, right?

Leanne


Go to our forums to share your thoughts and experience.


Question of the Week

Q: I am 36 years old and the mother of an 11-month-old boy. I was induced twice for his birth because I was late by two weeks, and he was born by c-section. I think I have conceived again. Will the baby and I be okay? Is it too soon after a cesarean to be pregnant again? Might I have any complications (problems)? At times I have backaches.

— Jane


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: I have attended nearly 100 births as a doula/midwife's assistant. Until recently I had never seen an episiotomy, even in teaching hospitals with severe OB/GYNs. My most recent birth was attended by the most natural-minded hospital-based CNM practice in our city (we have no birth center and no CNMs with OB/GYNs). I refer many of my clients to them knowing they are pretty much on the "same page" as my philosophy supporting evidence-based practice. After almost four hours of pushing, the mom was becoming exhausted. She was too tired to push in any other position but on her back, at about 30 degrees. She refused to push on her side because she had back pain. It was quite some time before baby remained visible on her perineum. The midwife (who I greatly respect) eventually stated that she had the type of perineum that "episiotomies were meant for" (she said this mom's was long). She told the client she was going to cut a small episiotomy and then proceeded to cut a 2-centimeter midline episiotomy and promised the baby would come on the next push. She did so without consent, and before I could say the entire phrase "Could she sit up more?" (the baby was showing some distress, but I assume it was because of the mom's flat position). When is it truly OK to do an episiotomy? As a future midwife, how will I know when to go ahead and cut? I am not sure I could do it. How about you homebirth midwives out there? Ever have to cut one? I would like to know some rules/guidelines, because everything I have researched has told me they should rarely be needed. I am still healing from mine more than 16 years ago!

— Brigitte Rhody, student RN, Bradley Method childbirth educator and labor assistant

A: I am a student midwife who recently gave birth at home with a midwife and had an episiotomy. I had been pushing very hard for 2-1/2 hours. The baby's heart rate began to drop during contractions and was getting slower to recover. On the final 2 contractions before the episiotomy and subsequent birth, we lost heart tones altogether during the contraction. My midwife cut a small episiotomy and pulled the baby out. The baby was healthy, pink and breathing well at birth. At first I was very upset to have this unexpected thing happen to me. I did not expect to get an episiotomy at my homebirth. However, after much reflection I realized that I could have delivered the baby on my own in maybe two more contractions but by then, we may have had a floppy baby who needed resuscitation. I would much rather endure the pain of episiotomy over endangering the life of my baby.

Remember that intervention does not always equal a negative. When it is necessary, that is what it was created for. Incidentally, the problem was found at birth that the baby's head was in an OT position or turned looking over her right shoulder. I do think, however, that conditions such as these are very rare and that most homebirth midwives will probably never encounter a situation in which an episiotomy is necessary. During my training, I was ordered to cut two different episiotomies that I do not believe were necessary. In any case, when to cut is not an easy question to answer but I would suggest that you will know when it is needed.

— Anon.

A: I think I have cut six episiotomies in my life (650+ births). Two were while I was in school because they made me learn how to do them on real women. One was because there was unusual bleeding and I was concerned that the woman was abrupting. One was a direct OP presentation on a primip, and the baby was showing signs of severe distress. Two were on the same woman (babies number 4 and 5, her only two with me) who had an unbelievably stretchy perineum. The baby was literally out to its ears and the opening was only 50-cent sized. She *begged* me to cut, and I made 1-cm cuts each time, which allowed the baby to come. I've never done an episiotomy without asking permission.

— Cynthia B. Flynn, CNM, PhD


Regarding breastfeeding an adoptive baby [Issue 6:16]:

A: There is a "new optimism" regarding "induced lactation." A woman who has previously breastfed biological children has a better chance of being able to nurse an adopted child. Some breast preparation may be helpful; see the protocols available online at www.asklenore.info.

Kate Adams, RNC, IBCLC, MSN

If the woman has breastfed four children she will be able to breastfeed an adopted baby! Put the baby to the breast, and she/he will do the rest. If mom doesn't have enough milk right away, she can use a lactaid. Her local La Leche League (LLL) branch will be able to give her information and support.

The younger the baby is, the easier it will be.

Christina Hurst-Prager, London and Zurich

A: The best thing you can do for her is let her know that this, indeed, can be done. Even women who have never given birth are capable of inducing lactation, although the degree of success varies.

The next thing to do is to refer her to an experienced LLL leader and/or a qualified lactation consultant. You might want to speak with the Area Professional Liaison for referrals to experienced LLL leaders in her vicinity. Many excellent resources and books are available, and there are several options as to how to proceed. This mom needs individualized, ongoing support. For example, she may or may not need to pump, initial and subsequent feeding options will depend on how the baby responds to direct breastfeeding, and so on.

None of us knows everything, nor does any one of us have to. Educate yourself, but know when to hand off to those with more experience.

Gabrielle Wright, CNM, IBCLC, APL for LLL of NY-East

A: I loved breastfeeding my first three and thought I knew it all. HA! My fourth was born at home, then hospitalized for severe weight loss and dehydration at ten days old. Turns out he had a UTI and was too weak to nurse. After treatment he refused to nurse because he associated my breasts with starvation. However, I was successfully able to pump and supply him with milk for 2-1/2 months until a La Leche League leader helped me get him back to the breast. I've advised other mothers since then because I was able to establish a milk supply of 100+ ounces per day (my midwife laughed hysterically when she heard that!) by the time my son went back to the breast at three months old. My goal was to freeze enough to stop pumping at six months and have breastmilk for him until he was a year, hence the outrageous supply. Following are some things I found helpful for establishing a milk supply:

  1. Take fenugreek. A lactation consultant or LLL leader can advise you about the proper dose.
  2. Pump frequently at first - every two to four hours and at least once in the middle of the night. If you find yourself exhausted, lengthen time between pumpings.
  3. Use a hospital-grade pump for the initial establishing period - check with WIC (Women, Infants, and Children) if you qualify, otherwise you can rent.
  4. Pump one side at a time. Use the other hand to massage from the armpit down toward the nipple. As you move around the breast you'll find ducts that you can put pressure on to force milk out. The more you empty, the more you'll produce the next time. Pumping both at once doesn't empty them as well.
  5. Don't be discouraged. Expect to start out getting little, if any, results. Your supply will build up. (Pumping does a number on your nipples - they do get used to it.)
  6. Invest in a good pump to keep that is nearly hospital grade (not your typical store-bought pump). Medela makes a nice one in its own carrying case.
  7. Buy an adapter so you can plug in your pump in your car. Check Radio Shack. Once you have your milk supply established you'll still need to pump every 3-4 hours, and sometimes it's not convenient to go home.

Tips for getting the older baby to the breast:

  1. Co-sleep topless so the baby grows accustomed to your smell.
  2. Try latching on while the baby sleeps. Even if the baby doesn't suck, accepting the nipple is a step in the right direction. If that works, keep doing it and try to express while she's latched on to encourage sucking.
  3. Express a bit first so baby gets instant gratification.
  4. Try a nipple shield. If baby accepts feedings with the shield, begin cutting the tip off bit by bit.
  5. Try a supplementer - it was quite a disaster with us but I hear some moms do okay with it.
  6. If all else fails, as it did for us, try the "cold-turkey" method:
    • Banish all distractions from your life for 2-4 days. I made my husband sleep downstairs because I knew my baby was going to get really cranky.
    • Give baby nothing to suck on for the first 24-36 hours - no bottles, sippy cups, pacifiers, fingers, etc. (at least as completely as possible).
    • Feed baby only from a spoon or cup (remember, no sucking!). Mix a bit of rice cereal with the breastmilk to thicken it a bit to make it easier to give to the baby. You may spend a lot of time feeding the baby this way to make sure she gets enough calories.
    • After 24-36 hours, offer baby breast for comfort. Continue offering baby breast for comfort and add in offered feedings.
    • Stay calm.
    • If baby doesn't begin taking feedings from the breast by day three, take a break from the method to make sure baby's getting enough to eat.

Because my son would literally freak out when I attempted to put him to breast, I didn't think he'd ever nurse. The cold turkey method was my last-ditch effort. By the time we were 22 hours in he was so desperate to suck he took my breast, sucked twice, stiffened to scream, got milk and settled in for a feeding. He was three months old. Fourteen months later he's still nursing. Also, breastmilk will keep in a deep freeze for months. Freeze it flat in zip lock freezer bags to store them easier. Also, let it thaw in the fridge, warm it in water (no microwave) and *don't shake the milk*. Shaking breaks up the strands of fatty acid chains. It still has positive properties, just not quite the same.

If your baby never takes to the breast and you can give her breastmilk from a bottle, know that you are doing the very best you possibly can. Every bit of breastmilk helps her development.

K.H.


Regarding extended pushing [Issues 6:15 and 6:16]:

A: I was recently at a birth like this. I wonder, did that mom have such a hard time letting go and pushing that she eventually chose to go to the hospital to get away from her midwives who were "watching her and judging her" (mom's words)? Different from the previous story, however, our mom didn't dilate to 10 cm as she wasn't checked until two hours into pushing and was 9 cm and undilated during the 12 hour pushing time to 7 and then 6 and finally to 4 cm upon admission to the hospital, but pushing the whole time. This was a VBAC mom. I have several questions: Why do homebirth midwives sometimes think homebirth is the end-all, be-all, the outcome worth striving for? Why can't it just be about the mom's (and baby's) journey? She was an amazing laborer. Why can't we just leave it at that and not make her feel guilty or ourselves feel guilty if she doesn't have a homebirth? Did these midwives resist transport because of perceived repercussions from the medical world, and if so, what is that doing to this mom and baby? And with these long push stages, isn't there something else going on besides the physical? Have other midwives seen something else shift in moms too?

Anon.

A: I recently had a first-time mom deliver at home. She had an approx. 30-hour labor. We (the other midwife and I) felt her perineum just "give way" even before the head was completely crowned. The baby did have her posterior hand up by her head. After the placenta was delivered, which was close to one hour later, she began to hemorrhage. Herbs were administered as well as a lot of massaging. The baby nursed on both sides, but mom continued to have a slow trickle of blood that would not stop. As soon as we stopped massaging she would start bleeding again, and even while massaging it would never completely stop. We ended up transporting, and they gave her Pitocin and two units of blood. Even then her uterus still did not stay clamped down.

Has anyone ever had experience with a mother tearing at the point this woman did, and could it be diet and exercise related? Any ideas why this would have happened and what can be done to prevent it next time? Her tear ended up being a fourth-degree tear.

Amy


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.


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 72 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. 72: Prematurity and Postmaturity
Question of the Quarter: Do you do anything to prevent preterm and/or post-term pregnancies? If so, what? If not, why not?
Deadline for submission: September 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. Subscribe.

Write to us! (See writer's guidelines.) We love hearing from you!


Feedback

Regarding Pitocin/active management [Issue 6:14]:

I am an RN. I had the experience of observing the birth of my daughter's baby May 2003. I encourage all who have anything to do with birthing to do your Internet research. Birthing today is a very serious matter. Natural birth can be done and should be. But this is controlled by the protocol set up. So do your search in every avenue of birth. You will find position at birth is very important. I have read that one-third of the birth canal is compromised when flat on your back or in a sitting position that is customary in today's controlled birthing. After the experience of my daughter's birth I was amazed at how birthing in hospitals takes control. My daughter wanted to go natural with no drugs. She wanted no cutting of the cord because of its necessary benefits. Yes, please do your homework. You will find the truth.

Marie


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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