July 6, 2005
Volume 7, Issue 14
Midwifery Today E-News
“Breech”
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In This Week’s Issue:


Quote of the Week

"The greater the risk, the more likely it is that the woman will benefit from midwifery care."

Katherine Jensen


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The Art of Midwifery

I am a birth doula and a nurse, a "turtle woman"—I help many Native American mothers. This Native recipe has been handed down in my family for generations. One of the best tricks is to have a laboring woman "duck walk" up and down stairs if labor slows. I have never seen it fail yet!

I also want to share a labor tea recipe:

  • 2 tea bags of red raspberry leaf tea
  • 2 tea bags of chamomile
  • 2 tea bags of blue cohosh tea

Steep in hot water for 5 minutes. Remove the bags and sweeten with honey or sugar. This tea will help labor be faster and less painful and will help the uterus work more effectively. Twinberry or "squaw vine" can also be added to the mix; it's best if it has been wild gathered. The other teas can easily be bought. Avoid black cohosh tea as it can make the woman nauseated.

Joy Duff


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.

Research to Remember

A Japanese research team sought to investigate the tendency of undernourished fetuses to sense food scarcity and develop a proclivity to more readily store body fat postnatally. Two groups of pregnant mice were fed low-calorie and sufficient-calorie diets. After birth, the pups of underfed mothers reached normal weight within ten days of birth. Pups from both groups who were fed sufficient calories after weaning had similar fat reserves. However, pups of the underfed mothers who were given a high-fat diet after weaning weighed about 15% more and stored 50% more fat than did the pups fed a normal diet after weaning.

The pups of underfed mothers showed a surge in leptin levels at eight to ten days following birth, while pups of normally fed mothers increased leptin production at 16 days. The team determined that the early increase in leptin levels correlated with later obesity. The early increase alters neural capacity to transport leptin to the brain in adulthood, thus causing insensitivity to "full" signals.

NewScientist.com, Accessed June 7, 2005


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Breech

If you suspect breech and you or the mother is not comfortable or confident, for whatever reasons, to birth a breech baby, seek the help of a senior midwife. Otherwise, consider any one of the many successful techniques for turning a breech and prepare your heart, mind and soul for the joys of breech birth. If the mother asks if you think she can do it, return the power to her. I often say, "Of course I do. I know you can. But me knowing it won't do us much good. You are the one who must know. You are the only one who can birth your baby, head first or head last."

Assess mother/baby well-being throughout labor and birth, just like during head-down labors. Ask yourself two simple questions: Is the mother okay? Is the baby okay? If the answer is yes, then the labor pattern is normal for this mother and baby. If the answer is no, change mother's position, offer her a drink or some fruit, ask her to breathe deeply and ask the questions again. If the answer is still no, then seek help.

Follow your own instincts; you may choose to use the following as a guide:

  • Keep your hands on baby and your eyes on mother. The baby will slip out quickly or descend slowly, just like head-down babies.
  • The feet or bottom will emerge first. Assess the color, tone, capillary refill and movement, just like with head-down babies.
  • If the descending feet or foot needs to be released or is stuck, sweep it across the body of the baby, just like you sweep an arm out in head-down babies.
  • Touch the baby very softly. Wrap a warm towel around the body.
  • The back of the baby will be facing toward you if you are facing the mother. If not, help the back rotate toward you as baby comes down and out by gently yet firmly holding the pelvis steady, not the abdomen.
  • Feel the cord for a strong pulse. Extend it gently.
  • Breathe deeply. Ask the mother to take a deep breath, just like with head-down babies.
  • Assess the baby again for color, tone, capillary refill and movement. Now assess the pulse under the left nipple as opposed to scalp pulse in a head-down baby.
  • Reassure the baby with a kiss, a gentle stroke or gentle words of love.
  • If the descending arms are stuck, rotate the baby to the opposite side and sweep an arm across the baby's body. Do the same for the other arm.
  • Reassess baby again for color, tone, capillary refill, movement, pulse and body shape at the neck, just like head-down dystocia.
  • If the neck muscles and shoulders are impacted and compacted, fold the baby's body close against the mother's perineum, wrapping the bottom and legs up the mother's back. This will help flex the head. The mother can lie flat the edge of a bed and let the baby dangle, creating the same position.
  • Don't stress a stressed baby. Prepare mentally to stimulate and, if necessary, resuscitate the baby.
  • Use gravity, encourage the mother, talk to the baby and use your hands to bring the baby's chin to the chest and free the head, respecting natural fetal position and the natural rhythm of the process.
  • Dry the baby with warm towels and stimulate with gentle yet firm strokes to the inner ears, feet and spin using your fingertips and palms.
  • The baby will respond to the mother's strokes more powerfully than to that of others.
  • Leave the cord intact.
  • Be patient and observe closely, just like head-down babies born with a shoulder dystocia. Breech babies often come into themselves slowly.
  • Resuscitate if necessary.
  • Help the mother kiss and hold her baby skin to skin while you get her a drink.
  • Cover them both with a clean, warm blanket.
  • Prepare to receive the placenta, the "first mother," whose job is now over.
  • After an hour or so of closeness and bonding, assess for birth trauma to mother or baby in body, mind, heart and spirit.
  • Repair any birth trauma to body first.
  • If fear or questions arise, settle them before you leave the new couple in the care of loving family or community.
  • Thank the mother for the privilege of serving her in a special birth.
  • Respect the fetal position that breech babies naturally assume after birth, which will resemble the position they held inside. Allow the natural flowering or unfolding of the limbs, which will take many days.
  • Seek a sister midwife or senior midwife and tell your story. Learn from your experience and share the knowledge, skill and instincts you used. There is a natural and inherent intelligence in all living beings to be whole and healthy, and being born is the first expression of that intelligence.

Sandra Morningstar, excerpted from "Instinctual Breech Birth," Midwifery Today Issue 68


MIDWIFERY TODAY Issue 68 can be ordered online.


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Products for Birth Professionals

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We have a small number of midwifery books and other items that are nearly out of stock and won't be re-ordered. These include:

  • Midwives and Changing Childbirth (Book)
  • Sexuality and Motherhood (Book)
  • Midwifery Research Database (MIRIAD) (1st edition, 1994)

When they're gone, they're gone, so order your copies before it's too late.


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Web Site Update

The scrapbook for the Germany 2004 conference is now live now online.

A more extensive list of teachers and class titles has been posted for Philadelphia 2006.

Read this excerpt of an article in the newest issue of Midwifery Today (Issue 74):


Forum Talk

[According to feedback forms] my students feel I don't teach enough relaxation. I offer an 8-class series, sometimes a 12-class series. Every class we do relaxation with visualization and massage—but I guess it is not clicking or it's not long enough. What do you do? What visualizations do you do?

Anon.


Go to our forums to share your thoughts and experience.


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Question of the Week

Q: What experiences have midwife readers had with shoulder dystocia and brachial plexus injuries? What techniques have you used successfully and unsuccessfully to relieve shoulder dystocia? Have you ever seen a brachial plexus injury where there was no shoulder dystocia, the delivery was textbook, but still an injury?

— Tanya


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: How long do you normally stay after a homebirth, and do you leave written instructions (guidelines so parents know what's normal for both mom and baby) with the couple? What things do you look for (e.g., mom urinating, baby nursing well, etc.) before you leave?

— Anon.

A: I make it a policy never to leave before two hours have passed, no matter how simple and straightforward things seem to be or how fast things got cleaned up. Usually, however, we leave about four hours postpartum. This is partly because virtually all my clients use my portable tub and I have to then drain it and put it away, which just takes more time.

Other things we do during the postpartum period:

  • Watch mom: vitals, bleeding, pulse, blood pressure, temperature, general well-being
  • Watch baby: Apgar factors, plus nursing status, temperature
  • Do newborn exam with measurements
  • Footprint baby for memento—just for fun
  • Make sure mom is fed, hydrated and has urinated. Help her shower if she's up to it.
  • Clean up all mess from the birth.
  • Wash and repack instruments.
  • Take lots of photos, if we can.
  • Go over written instructions pertaining to first 24 hours postpartum. Leave family with instructions to call me at a certain time and check in.
  • Review the birth, tell mom how awesome she was and thank her for letting us assist her.

My postpartum instructions are divided into two parts. The first page is for just the first 24 hours and covers the most vital basics: for mom, bleeding, resting and urinating; for baby, nursing, peeing, pooping, and staying warm enough. Attached to this are another four sheets that cover the rest of the first week: blood flow, perineal care, breast/nipple care, normal diuresis, bowels, the importance of eating/drinking well and not overdoing it, mood changes/hormonal shifts, signs of infection, normal newborn behavior and symptoms, jaundice, umbilical care, bathing, co-sleeping, crying, and the critical importance of nursing. We only go over the first page after the birth because I don't find moms are able to listen to much more than that. My assistant always jokes that they need to read the rest before I return at 24 hours, as there will be a pop quiz on it.

— Jan Wolfenberg, CPM, Milwaukee, Wisconsin

A: I worked with a wonderful certified nurse-midwife as her birth assistant. She was well organized and taught her clients well in advance, during the immediate postpartum period and follow-up. Most times, we were at the client's house two to four hours after the delivery. It really depended upon the family and the support available to them. We stayed with one family for six hours afterward, and returned only four hours later (one of us) and again that evening. During that time, along with assessing mom and baby, we help clean up and assess the family structure and support. The midwife I worked with left written instructions to re-enforce her teachings prior to labor and during the immediate postpartum period. Follow-up visits and phone calls would occur, once again, depending on the family/clients, to see how baby was nursing, how many wet diapers there were, if the pediatrician had been notified, how mom was feeling, how her bleeding was, etc.

Another great thing that Lynn (one of the greatest midwives I have had the pleasure of working with) did was provide a carbon copy of the labor progress notes and delivery record. That way the family had a record of how things progressed to show to the pediatrician, OB, or family doctor should the need arise, along with talking with Lynn, of course.

— Gretchen Jenkins, RN and aspiring midwife


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 really interested in becoming a midwife. I am nearly 18 years old, and I haven't any qualifications. I don't want to go to university. Is there any other way I could become a midwife?

Helen


The long-awaited study of home births attended by CPMs during the year 2000 is finally here: Outcomes of planned home births with certified professional midwives: large prospective study in North America. Kenneth C. Johnson, senior epidemiologist, Betty-Anne Daviss, project manager. 2005. BMJ; 330:1416 (18 June).

The British Medical Journal (BMJ) has published the paper on-line. Read it at: http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom

Published in the June 18 issue of the North America British Medical Journal, the study found that "planned home births for low risk women in the United States are associated with similar safety and less medical intervention as low risk hospital births," according to the BMJ press release (see below).

According to co-author Ken Johnson, this is the largest study of its kind at this time. The study is prospective (initial data submitted before the birth took place, so no births could be "left out") and includes data from more than 5000 births in the United States and Canada. It cannot be written off for being too small or not relevant to U.S. populations and circumstances.

The following is excerpted from a BMJ Press release:

Planned home births for low risk women in the United States are associated with similar safety and less medical intervention as low risk hospital births, finds a study in this week's BMJ. In the largest study of its kind internationally to date, researchers analysed more than 5000 home births involving certified professional midwives across the United States and Canada in 2000. Outcomes and medical interventions were compared with those of low risk hospital births.

Rates of medical intervention such as epidural, forceps and caesarean section, were lower for planned home births than for low risk hospital births. Planned home births also had a low mortality rate during labour and delivery, similar to that in most studies of low risk hospital births in North America. A high degree of safety and maternal satisfaction was reported, and more than 87% of mothers and babies did not require transfer to hospital.

"Our study of certified professional midwives suggests that they achieve good outcomes among low risk women without routine use of expensive hospital interventions," say the authors. "This evidence supports the American Public Health Association's recommendation to increase access to out of hospital maternity care services with direct entry midwives in the United States."

Contact:

Kenneth Johnson, Senior Epidemiologist, Surveillance and Risk Assessment Division
Center for Chronic Disease Prevention and Control
Public Health Agency of Canada
Ottawa, Canada
Tel: +1 613 957 0339
To arrange an interview: Aggie Adamczyk: +1 613 941 8189 (Public Health Agency media contact)
E-mail: ken_lcdc_johnson@phac-aspc.gc.ca

Betty-Anne Daviss, Project Manager, FIGO Safe Motherhood/Newborn Initiative
Housed at The Society of Gynaecologists and Obstetricians of Canada
780 Echo Drive, Ottowa, Canada
Tel: +1 800 561 2416 OR +1 613 730 4192 Ext. 263
E-mail: badaviss@sogc.com

Further information from Betty-Anne Daviss, Registered Midwife, co-principal investigator of the study:

The press release does not point that it was conducted by two Canadian researchers who live in Ottawa—a Canadian epidemiologist and a Canadian midwife. It was carried out on all clients having a delivery with a certified professional midwife for a given time period and reports on 5,418 births. The majority of the births were attended by American midwives, but Canadian midwives were also included in the study.

The study shows that if you aren't a high risk mom carrying twins, having a premature baby or baby coming bottom first, all of which can be judged ahead of time, your chance of having a healthy normal safe delivery are the same whether you plan a home or hospital birth. However, if you choose the home birth, intervention rates will be one-tenth to one-half of what they would be in hospital, compared with figures of the same time period from the National Health Institute of the United States.

The study is groundbreaking because former studies have been criticized for not being big enough, for not being able to distinguish between planned or unplanned births, and for being retrospective (considering only old records as opposed to requiring health professionals to register births they were going to do and then have to account for all outcomes). As well, more than 500 mothers were phoned to verify whether what the midwives said at the births actually happened.

The study suggests that legislators and policy makers should pay attention to the fact that this study supports the American Public Health Association resolution to increase out of hospital births attended by direct entry midwives.

The American College of Obstetricians and Gynecologists still opposes home birth. The The Society of Gynaecologists and Obstetricians of Canada (SOGC) has written a statement acknowledging that women have the right to choose their place of birth.

Citizens for Midwifery Press Release, sent by Susan Hodges, President; June 16, 2005, 706-549-7023. To join Citizens for Midwifery's Grassroots Network List: www.cfmidwifery.org; scroll to the bottom of the page and enter your e-mail address.


Our facility is in the process of preparing for Joint Commission Survey by means of the new continuous service readiness process. We are developing policies that align with national patient safety goals. One of the goals relates to fall prevention:

Goal 7: Reduce the Risk of Patient Harm Resulting from Falls

Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to address any identified risks.

Could readers with access to protocols or screening tools share them so our facility could review them and use them as guides in our development of policies and procedures for nursing assessment when the mother is first admitted to Labor and Delivery as well as during the postpartum period?

Elizabeth Gunn, RN, MS, Utilization Review, Lawton Indian Hospital, Lawton, Oklahoma


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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