September 29, 2004
Volume 6, Issue 20
Midwifery Today E-News
“Biophysical Profiling and Suspect Diagnoses”
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In This Week’s Issue:


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Quote of the Week

"When a woman births at home, it is a demonstration of civil and medical disobedience that defies the medicalization of her body's normal function while it honors her inherent, amazing power."

Chantal Molnar


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The Art of Midwifery

I rarely touch mother and baby to "help" them breastfeed because it disturbs the confidence of the mother and gives the baby the feeling that he must have help to take the breast. Being there and supporting them with the confidence you have in them is more important.

Lieve, Midwifery Today Forums


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News Flashes

Studies have shown a correlation between breastfeeding and significantly lower rates of child abuse and abandonment. When Leningrad Maternity Hospital instituted the Baby-Friendly Hospital Initiative, which supports breastfeeding, abandonment of babies was reduced by one half. A Costa Rica study followed the progress of 78,000 babies for seven years. For those who had had early mother-infant contact, rooming in, and breastfeeding support, the rate of weaning before six months was reduced by half. The rate of child abandonment was also significantly reduced. A 1995 study found that children of women who did not breastfeed their babies were 38 times more likely to have suffered abuse than were those who had been breastfed.

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Biophysical Profiling and Suspect Diagnoses

Many North American women are being told at the very end of their pregnancies to go to an ultrasound clinic and have a biophysical profile. Most are impressed by the thoroughness of their practitioner and have no idea what this test involves or what sort of harm could follow from consenting to this diagnostic procedure. They will probably not be told that there is no scientific basis for having faith in the test results and that no improvement in health has been proved from large numbers of fetuses being "profiled." Certainly no one will mention that the only benefits of the procedure are one, the ultrasound clinic will earn $275, and two, medical practitioners will be able to cover themselves legally in the very rare instance that a baby might die in utero.

Until recently, physicians and midwives would tell women who were carrying their babies beyond 41 weeks gestational age to do kick counts. If the baby makes 10 distinct movements between the hours of 9 am and 3 pm, it is widely accepted that the baby is thriving.

In a culture that loves technology and with the push to expand the commercial use of ultrasound, it was inevitable that someone would come up with a more complex strategy to provide reassurance of the baby's well-being in late pregnancy. Thus, the biophysical profile (BPP) was born.

Following are the contents of the testing [source: Family Practice Notebook Web site (www.fpnotebook.com/ob/fetus/BphysclPrfl.htm)]:

  1. Cost: $275
  2. Criteria (2 points for each)
    1. Fetal Breathing
      • Thirty seconds sustained breathing in 30 minutes
    2. Fetal Tone
      • Episode extremity extension and flexion
    3. Body Movement
      • Three episodes body movement over 30 minutes
    4. Amniotic Fluid Volume
      • More than 1 pocket amniotic fluid 2 cm in depth
    5. Non-Stress Test
      • Reactive
  3. Scoring
    • Give 2 points for each positive above
  4. Interpretation
    1. Biophysical Profile: 8–10
      1. Low risk or Normal result
      2. Repeat Biophysical Profile weekly
      3. Indications to repeat Biophysical Profile biweekly
        1. Gestational Diabetes
        2. Gestational age 42 weeks
    2. Biophysical Profile: 8
      1. Delivery Indications
        1. Oligohydramnios
    3. Biophysical Profile: 6
      1. Suspect asphyxia
      2. Repeat Biophysical Profile in 24 hours
      3. Delivery Indications
        1. Repeat Biophysical Profile less than or equal to 6
    4. Biophysical Profile: 4
      1. Suspect asphyxia
      2. Delivery Indications
        1. Gestational age 36 weeks
        2. Lung Maturity Tests positive (L/S Ratio 2)
    5. Biophysical Profile: 0–2
      1. Likely asphyxia
      2. Continue monitoring for 2 hours
      3. Delivery Indications
        1. Biophysical Profile < 4

An unusual number of diagnoses seem to be made that "there is not enough amniotic fluid." This seems to be the factor in this outline that is most often used as an excuse for induction. It is important for parents to know that this is likely an inaccurate assessment.

What the ultrasound technician is doing could be compared with viewing an adult in a see-through plexiglass bathtub from below the tub. In such a scenario, it would be difficult to assess how much water is in the tub above the body that is resting on the bottom of the tub. You might be able to get an idea of the water volume by measuring how much water was showing below the elbows and around the knees, but if the elbows were down at the bottom of the tub too, you might think there was very little water.

This is what the technician is trying to do in late pregnancy—find pockets of amniotic fluid in little spaces around the relatively large body of an eight-pound baby who is stuffed tightly into an organ that is about the size of a watermelon (the uterus). If most of the amniotic fluid is near the side of the uterus closest to the woman's spine, it cannot be seen or measured. This diagnosis of low amniotic fluid frightens the parents into acquiescing to an induction of labor. Even though the official BPP guidelines do not require immediate induction for a finding of low amniotic fluid, in practice the parents are pressured to induce. Stories abound of mothers who are induced for this indication and then report having abundant fluid when the membranes released in the birth process. The risks of induction, which can be catastrophic, and the resulting increase in the need for pain relief medication and cesarean section are usually not discussed with the parents before embarking on induction.

Gloria Lemay, "Suspect Diagnoses Come with Biophysical Profiling," Midwifery Today Issue 69


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Forum Talk

I am an aspiring midwife—unsure of CNM or traditional track. I am an RN who currently works in a neonatal ICU, but I used to work in labor and delivery as well as postpartum/newborn nursery. I would be so intimidated to have a baby in a hospital because of privacy issues, germs, and the fear of the unknown of who would be my care providers. On the other hand, I still am not totally comfortable with homebirth but really want to be. For all of you experienced homebirth midwives, please share what you have learned from mother or baby losses to ease my concerns.

How many babies have you delivered safely? How many baby losses or mom losses have you had? After each experience, was there anything you could "put your finger on" that helped you to learn from your experience? Was it totally unpredictable? Did you have any gut feeling that you later looked back on and wished you'd listened to? Did the mom have any particular risks such as pre-existing medical condition, past OB history, advanced maternal age, or anything out-of-the-ordinary during the pregnancy? How long before/after delivery were the baby losses? Was there anything unusual surrounding the birth or pregnancy that later made you suspicious of a connection? How did these outcomes affect how you screened moms in the future?

What is the longest distance you feel comfortable being from a transport hospital (time-wise)? The other concern I have is just being able to find a good back-up physician.

Laura


Share your thoughts and experience about this topic.
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Question of the Week

Q: A friend had a vulval varicosity from week 16 in her first pregnancy and was extremely uncomfortable with it. She is now 17 weeks pregnant with her second baby, and this time it has come up again—from week 9. The local consultant can only offer induction at 37 weeks as a solution (she had her first baby at home and intends to do so again). Does anyone know of remedies, treatments, or solutions to her uncomfortable problem?

— Nickie Sutton, United Kingdom


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 am 19 years old, and I've been menstruating for seven years. Usually my periods come between 21 and 33 days. I have severe cramps, especially on the first and second days of my menstrual cycle, but less severe cramps last on and off through the sixth day. I also feel hot and very weak, almost ready to faint, and I have headaches and lower back pain. I don't have diarrhea but I go to the bathroom quite frequently. OB/GYNs have prescribed birth control pills and pain killers. A CNM prescribed the same things. I usually feel a little better when I can stay home and take a shower or use a hot-water compress. The pain killers also help, but the more I use them the stronger the pain killer it seems I have to use. I'm wondering if there is anything else I can do to help me with these symptoms. I hate the idea of taking hormones. I have never been pregnant.

— Mai

A: Have you looked into Mayan abdominal massage? Go to http://www.arvigomassage.com for a list of practitioners near you. This therapy is usually quite helpful for those symptoms.

— Anne Walters, CNM

A: I am 17, and for the past year I had the same problems as you with my menstrual cycle. I had severe cramping, especially on the first day. It got to the point of emergency room visits and lots of painkillers. I also feel really weak and faint. I get headaches once in a while and also lower back pain. I get diarrhea, which makes the pain worse. I also would get really bad PMS. All the OB/GYNs I had gone to had also prescribed birth control. But through lots of study and talking with other people I told them flat out I wasn't going to take it because the pill has not been legally tested for menstrual cycles. It has only been tested as a contraceptive and to clear up acne. It does not take care of the problem that causes all your pain and other symptoms; it only covers up the symptoms, and the actual problem grows worse. Doctors today are lazy and take the easy way out—prescribing the pill—instead of find the real problem.

The doctor I have been seeing for the past seven months thinks all my problems are symptoms of endometriosis. The only way to be sure you have it is to have a laparoscopy, which I will have soon. Endo and all our symptoms are caused by hormonal imbalances. If you don't get those hormones balanced the problem grows worse. So for the time being I have been doing lots of hormone testing and treating my symptoms with natural hormone replacements and vitamins. The hormone I have been taking is progesterone. I love it—I immediately felt results! I have also been taking calcium replacement along with a daily multivitamin that has really been helping. With endo your body does not process calcium properly. Calcium is so important; if I don't take my vitamins my cycle is much harder that month. For the headaches I take an herbal supplement called feverfew that works great! It is well-known to help headaches/migraines.

The doctor I have been seeing is an NFP—natural family planning doctor, which means he does not prescribe any type of contraceptive. He works with the Pope Pius VI institute. This organization works to help women with any type of womanly problems such as hormonal testing and certain types of surgeries.

As for the hormone testing, sadly there are only three or four labs that do it. You can find these doctors all over the United States; you just might have to search a little.

— Kjersti

A: Most women know that our menstrual cycles are governed by our hormones, but what many women don't realize is that we are constantly ingesting and coming in contact with chemicals that affect our hormones. With this in mind, you might look at what you're eating and also the products you're using on your skin. Caffeine may be a problem—I've talked with women whose menstrual symptoms were improved after they simply quit drinking soft drinks or coffee. Many commercially-available meats are pumped full of large amounts of antibiotics and growth hormones, which are a huge problem if you consume too much of them. You could try to cut back on meat or simply eat organic meats. Just thinking about what you're putting in your body could give you a great turn-around in how your body responds to your cyclic hormones.

Also, everything you put on your body also enters your body. Your skin is porous, and most (if not all) leading skin products (e.g., shampoos, lotion, makeup, sunscreen, etc.) are full of various chemicals such as phthalates and parabens that have been shown to affect your hormones, among other things. A harsh look at the products you use may be helpful. Two invaluable resources for learning about what's in the products you use are the National Library of Medicine's Household Products Database (http://householdproducts.nlm.nih.gov) and the Environmental Working Group's comprehensive database of cosmetic products and ingredients (http://www.ewg.org/reports/skindeep).

— Jennifer Chendea, labor doula, Virginia Beach, VA

A: What you are describing could be due to endometriosis or it could simply be that your body still has not found its monthly rhythm yet. Usually around age 19 to 21 you start getting more regular with your cycles if you weren't to begin with. Try a vitamin B complex and 600-800 mg of Advil (ibuprophen) when cramps are really bad. It can really relieve the pain without as much side effects as prescription painkillers. Just make sure you have something in your stomach when you take it.

A cycle that is less than 24 days long can indicate that on that particular cycle you were not ovulating. An anovulatory cycle will not have the same premenstrual symptoms as an ovulatory one mainly because there is no corpus luteum generating progesterone. As you have more ovulatory cycles you will have more irritability, cramps, bleeding, breast tenderness, and headaches with or just before your period starts. Birth control pills just mask the problem by preventing ovulation. Don't let anyone tell you not to worry until you want to get pregnant, either. Some irregularities are easier to fix sooner than later, especially if you should have endometriosis. But that usually includes symptoms like pain during sex and absolutely unbearable pain during menstruation. I would recommend you read a book called "Taking Charge of Your Fertility" by Toni Wheschler. It can help you learn to attune to your body's signals so you can determine for yourself if and when you are ovulating, when you have symptoms etc.

— Kathy Metzler, R.N.

A: I practice traditional Chinese medicine with a specialty in gynecology. I lived and studied in China with a wonderful 80-year-old gynecologist and have been treating women for more than 20 years. I highly recommend seeking out an herbalist who is skilled in Chinese herbalism. The fact that hot water bottles help your pain some indicates that, from a traditional Chinese perspective, you have cold congealing the blood in your uterus. From my experience, this type of dysmenorrhea is easy to resolve completely. I do not recommend taking the birth control pill before trying to heal your dysmenorrhea. The pill will never heal the congealed blood. I don't know where you live but you can find a practitioner through http://www.acufinder.com/. Make sure you see someone who is well trained in Chinese herbology.

— Sharon Weizenbaum, Amherst, MA

A: I use a progesterone cream that I get from a health food store. You apply it twice a day for three weeks and then not at all for the seven days during menstruation. It helps alleviate the symptoms, shorten your bleeding days, and even helps even out your mood swings that result from hormones.

I suggested this to a friend and she is very excited about the positive changes in her cycle as well.

— Amy Bechtel, Springfield, MO

A: We have had numerous patients helped with regular chiropractic adjustments. I myself had painful cramps and a very irregular cycle until I started care 30 years ago. Since becoming a chiropractor myself, I have seen many women go through great changes with menstruation, infertility, and maintaining their pregnancy when they are under regular care. You can find a doctor in your area at: http://www.icpa4kids.com/find_pediatric_chiropractor.htm

— Jeanne Ohm, DC, Executive Coordinator, ICPA http://www.icpa4kids.com


Regarding child spacing [Issue 6:19]:

A: Although I am not a certified midwife, I definitely aspire to this calling. I have had personal experience in this area. My second and third children are 366 days apart; the oldest was born by emergency c-section after the midwife determined her heart rate was 280 beats per minute. Becoming pregnant when this little one was only three months old was kind of scary, but other than elevated postpartum bleeding because things weren't back into shape yet, everything was fine. The second child was a VBAC with a 3-1/2 hour labor!

You mentioned the backaches; I remember those, too. But I found mine were because of posture affected by packing around an infant with pregnancy hormones softening my ligaments and pelvic joints. A heating pad helped.

— Janean


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.


Feedback

I am a doula practicing in Singapore. We often hear caregivers here mention that Asian women's perineums are particularly "tight" or "short," and therefore that Asian women tend to "require" an episiotomy more often than their Causacian counterparts. One recent Question of the Week response [Issue 6:18] mentioned that the writer's colleague had suggested the same sort of thing. And yet in our practice here in Asia, our Asian clients have about the same rates of episiotomy (3-5%) and serious tears as Caucasians.

I would suggest some caution in accepting this expectation of Asian women's perineums. I have read a couple of studies that seem to support the idea that Asian women's perineums don't seem to cope well with the strains of childbirth, but does it make sense that a vast portion of the world's women have bodies that "don't work"? I wonder how much of the increased incidence of tearing and episiotomy among Asian women shown in some studies is due to the expectations of the caregiver, the expectations of the women, the positions taken for birth, how the woman is encouraged to breathe. How do cultural stereotypes of Asian women as "modest" or even "submissive" contribute to the ways options are presented about things like positions for birth? How much does the apparently common medical expectation that Asian women's perineums are vulnerable contribute to the perceived need to intervene to "prevent" a serious tear?

This is such a difficult hypothesis to test if one is to consider all the variables. In our practice, where most of our clients choose expectant care, Asian women's perineums fare quite well. I would love to see good research done on women having expectant care (no arbitrary time limits on second stage, upright and active positioning, spontaneous breathing) so as to remove some of the possible confounders. Until such research proves otherwise, I will be wary of claims that Asian bodies don't work as well as those of Caucasians!

Sandy Meadow, doula, Singapore


I'm 18 years old. Earlier today I visited a friend at the hospital who was having a baby. I was appalled by the way bringing life onto this earth was handled like a medical emergency. I never knew that midwifery was a career option! In my life I have struggled to find a career but was only exposed to the typical doctor, lawyer, school teacher cliches. I have always wanted something different but could never find what it was. But I know that this is it! The only problem is I don't know how to get started. What can I do now to start preparing to become a midwife?

— Nicole, Wisconsin

Editor's Note: Midwife/doula/mother readers, please give Nicole support in her search for information about becoming a midwife or doula by writing to Midwifery Today E-News. The world needs her!]


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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