Research to Remember
A study that included 3373 women exposed to diethylstilbestrol (DES), a synthetic form of estrogen, and 1036 unexposed controls revealed that mothers who took DES during pregnancy are more likely to experience delays in conceiving (32% of the women in the study) and are less likely to ever conceive. Those who do conceive have a 30% risk of first-trimester miscarriage and face three to four times the odds of having a preterm birth, second-trimester miscarriage or ectopic pregnancy.
— Obstetrics & Gynecology, 2000, 96(4): 483-489.
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Our hospital performs on average 500 deliveries every year, and they are mostly low-risk. Seventy percent are usually physiological events requiring no medical assistance. After the renovation of the delivery rooms and installation of a water pool for delivery, the number of deliveries increased over the years. Women decide on their own if they wish to delivery in the water. In every phase of delivery they choose the position and the preferred delivery procedure. From May 1997 until December 2003, 1355 babies were born in the water bath. The proportion of water deliveries rose from an initial 20% to 51.7%.
In the 1355 water deliveries there was a significant reduction in episiotomies. The indication of its use for episiotomy is handled very restrictively. Only six episiotomies, which corresponds to 0.44%, were noted at the beginning of our experience. However, the significant reduction of episiotomies is not paralleled by an increase in lacerations.
In 57% of primiparae who delivered in the water (356 of 624), the perineum remained intact, compared with 36% and 48% in the other two groups. In primiparous women, episiotomy rates decreased from 30% in 1997 to 15.8% in 2003. The indication of episiotomies in primiparas was administration of oxytocin due to a prolonged time of expulsion in 66% and abnormal CTG in 34%. In the literature the percentage of Grade III lacerations was between 0.4 and 6%, whereas our rates were 0.53% in water and 1.7% on the birthing stool. No woman with lacerations in water had functional deficits postpartum.
There was no need for analgesics among the women delivering in the water due to the effect of water immersion and attenuation of labor. Moreover, we never used oxytocic drugs to augment labor in the pool.
In the primiparas who delivered in water, we noticed a reduction in the dilatation period compared to the control group, whereas the second stage of labour showed only a slight difference. This acceleration of the dilatation period could be attributed to optimal relaxation of the woman and greater muscular elasticity of the pelvic floor in water. Further factors that influence the shorter dilatation period are the semi-erect position adopted by the women and greater freedom of movement in the pool.
In our and others' experiences, women who enter the pool at a dilatation of three to five cm should not stay in the water for longer than 120 minutes, because it causes a reduction in uterine activity, particularly in primiparous women. However, we have found that if the woman leaves the pool for about 30 minutes, the uterine activity increases and the woman can re-enter the pool at a greater dilatation. During the time the woman is out of the pool the pool water can be renewed.
All 1355 babies born in water were in good clinical condition. Experienced paediatricians in our hospital have confirmed that water delivery is not detrimental to babies, provided the mother is considered to have a normal pregnancy and labour. In the study, no infections were noted. As long as the known exclusion criteria are followed, due to a protective reflex (diving reflex) that is maximally efficient during the last few weeks of intra-uterine life, ingestion pneumonia should not occur.
Naturally the heated water (body temperature) used must be of an excellent drinking water standard and the water pipes must be free of microorganisms such as Legionellae and Pseudomonas aeruginosa. In our hospital the water system is cleaned and checked on a monthly basis for Legionella pneumoniae. By adherence to high hygienic standards and compliance to exclusion criterion we noted no difference between babies born in water or in bed.
There were no requirement for analgesics in the 1355 women having underwater births, the relaxant and analgesic effect of the water proving sufficient. Only 4.3% of women who started labour in water later requested peridural anaesthesia (epidural).
Criticism of waterbirth can no longer be justified based on concepts unsupported by current evidence. An example of this is the belief that the newborn can aspirate water. In low-risk babies this finding is completely unsubstantiated with regard to neonatal physiology and respiratory adaptation to extra-uterine life. In fact, intrauterine acidosis is the only factor that alters or diminishes the protective mechanisms of the fetus, particularly the diving reflex, which is controlled by primitive cerebral structures that prevent the newborn from inhaling water. The diving reflex reaches its maximum efficiency in newborns at term and disappears after four months following birth. The diving reflex stops any pathogenic organisms found in the water from reaching the lungs, thereby preventing infection. The diving reflex is inhibited only when the facial receptors of the newborn encounter air for the first time.
Waterbirth represents more than just a soft delivery. It represents a realistic alternative for low-risk women. Women having waterbirths have been shown to have high maternal satisfaction rates due to being able to actively participate in their labours and benefit from less perineal trauma.
The midwife, as a central figure of delivery assistance in physiological childbirth, accompanies the mother in this experience, while the obstetrician stays as much as possible behind the scenes. Our aim is to re-create the atmosphere of a home delivery inside the clinic.
— Dr. Albin Thöni, excerpted from "Giving Birth and Being Born in Water,"
Midwifery Today Issue 70
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A prospective Swiss study of 2014 waterbirths from among 5953 births (including 1108 Maia birthing stool births and 2362 bed births) in which the parity and newborn birth weight were compared showed that episiotomy was performed in 12.8% of the waterbirths, 27.7% of the stool births, and 35.4% of the bed births. The bed births had the highest third- and fourth-degree laceration rate. Maternal blood loss was lowest and fewer painkillers were used in the waterbirth group; average arterial blood pH of the umbilical cord and 5-minute and 10-minute Apgar scores were significantly higher. No neonatal water aspiration or other water-related perinatal complication of mother or child resulted.
— Clinic for Obstetrics and Gynecology, October 2000, 15(5): 291-300.
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Can a woman be tested for "gestational diabetes" at 24 hours postpartum? Here is the scenario: G2P2 now, homebirth with first baby and sought care from the same midwife during this pregnancy. At approx. 20 weeks, mom was reporting "feeling very pregnant." When the midwife went to see her, she was dismayed to see a fundal height of around 32 cm. She immediately referred to the OB, who referred for a Level 2 ultrasound. Only one normally formed babe, with polyhydramnios. The mom agreed to co-care with the OB and midwife, and determine the safest site for the birth as the pregnancy progressed. Yesterday, at 34 weeks, her blood pressure was 160/100 with 4+ proteinuria. Fundal height was 42 cm. All agreed that induction was prudent. Mom had a fairly good birth, with an 8 lb 4 oz boy who apparently did have 34-week features, copious amniotic fluid, a 70 cm cord, and an ultrasound revealed "swollen kidneys."
[The medical community] are now trying to say that she was inappropriately cared for by being an undiagnosed gestational diabetic. (Mom was given truly informed consent regarding the GTT and declined.) The staff are saying they are "going to test her for gestational diabetes" to help determine how to best care for the baby. I thought prenatal GTT determines how the placenta is affecting the maternal use of glucose and insulin release. She no longer has a placenta! And if the baby is hypoglycemic (possibly because they "are not letting her breastfeed until tomorrow"?), why not treat that? Why would knowing if mom had GDM matter in the baby's care? Any thoughts about the GDM would be greatly appreciated.
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Question of the Week
Q: My daughter-in-law has had a chronic perineal fistula that flares up every month with drainage, since she was pregnant. Her son is now 15 months old. The tunneling is so deep that surgery would be a great risk for her (possible colostomy due to nerve damage). She also got a staph infection while in hospital and has been on antibiotics a few times. She has been applying lavender and oregano oils to the site. She is still breastfeeding her baby. Any suggestions for healing would be most welcome!
Q: Recently, as an L&D nurse, I ended up delivering a double-footling breech baby. I received some criticism from another nurse that I should have let the baby's head remain in the vaginal vault. She states that it is OK to leave such a presentation for up to an hour. The OB who came in later said, You have 4 minutes to get the baby delivered. Who is correct? I entered into this delivery at change of shift, and patient was in triage area awaiting a surgeon for c-section. I was presented with two feet and buttocks out of the perineum.
— Gretchen Jenkins, RN
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Question of the Week Responses
Regarding uterine prolapse [Issue 7:8]:
A: The day after my fourth baby was born, we discovered that my uterus was prolapsed. We could see and touch my bruised cervix at the opening of my vagina. My midwife had arrived five minutes after he was born because I did not believe I was in labor until things were really moving.
My first labor lasted 3 days, ending in a cesarean for CPD with a 7 lb 7 oz 10-day "early" baby. My next was born after 13 hours with a 9 lb 4oz homebirth after cesarean (HBAC), 23 days "past due." The third HBAC was 7 hrs for 7 lb 12 oz, 17 days "late," and my last HBAC was 3.5 hours, 9 lb and 2 days after my dates!) I feel I pushed with a swollen lip, and the anxiety of having no one really listen to heart tones well (I had been a midwife for several years) made me just want it done, and the baby in my arms! I pushed so intently. He was in excellent condition.
I was anxious to do what I could to not have my cervix/uterus hanging between my legs, since surgery was not an option (we planned more children). I read and followed Anne Frye's recommendations in her suturing manual, with a twist. I did shoulder stands (most uncomfortable due to expanded blood volume of recent pregnancy), opened my vaginal lips to let in air so the uterus could drop easily into position. I lowered myself (with help sometimes) carefully slowly back to the bed for the next few hours and did kegels galore, until one day my uterus did not drop as much when I was upright for short periods. It gradually got better. (I also had a rectocele bad enough that I had to insert a finger into my vagina to direct pressure downward to show my bowel movements the correct way out!)
I noticed improvement in pelvic floor tone and uterine elevation to more acceptable heights as I continued the kegels and coincidentally began walking and doing lunges, other leg exercises, and abdominal work. It has now been years since I have had problems. Pilates has tightened everything further, making sex at 43 much better than I would have ever hoped. I would not have believed that exercises would have been so effective if I had not experienced it myself. If only that jelly belly skin were as cooperative!
Regarding the relationship between the throat and perineum during birth [Issue 7:8]
A: I have found that it really helps to encourage a deep grunting, moaning sound deep from within the gut. This then of its own accord, goes into a higher register from the throat, with a corresponding relaxation of the pelvic floor. I find this really useful as a prelude to expressing deep feelings often of suppressed rage. This really helps the mother engage in strenuous exercise, beating pillows, etc., which will help discharge the adrenaline that is often flooding the system after going into a fight or flight reaction. This, in my experience over the past 25 years, is the main culprit in failure to progress. All mammals require a quiet, safe and dark environment in which to give birth. Any intrusion into the birthing environment is often felt as a threat, and fight or flight reaction will be stimulated. Logic or rational reassurance does little to ward this off.
— Rayner Garner
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The governor of Utah just signed a bill last week making Utah the 21st state to have laws on licensing midwives to legally use drugs in homebirth. A small group of us fought hard against this for months and sat up at the capitol and watched it pass. We are so disheartened by the medically-minded thinking behind this bill. It turns midwives into medwives, and it imposes drugs upon natural birth. We feel very strongly that it will slowly do away with traditional midwives who refuse to license, and it undermines our very integrity and philosophy of natural, drug-free midwifery care.
I hope readers may have some insight into this situation, and maybe some have a broader perspective that would help us organize our own group and put back into the laws a clause for midwives who remain traditional and choose not to license.
— Lori Wrankle, Toquerville, UT
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MIDWIFE-TO-BE training program. Pay as you go. Done by mail or e-mail. SC DHEC approved. Low cost. Much offered. www.newlifehomebirth.com email@example.com Lisa Aman, LM
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