May 10, 2006
Volume 8, Issue 10
Midwifery Today E-News
“Postpartum HIV-Infected Mothers”
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Learn about First and Second Stage with Ina May Gaskin and Marina Alzugaray

Attend this full-day workshop to discover ideas and techniques to help the mother move through the first stage of labor. This discussion will include prolonged rupture of membranes, failure to progress, abnormal labor patterns and non-medical intervention. Ina May and Marina will then review second stage research from a midwifery point of view, focusing on how the standing, squatting, kneeling, hands-and-knees, supine and other maternal positions affect childbirth outcomes. They will demonstrate hands-on skills to use in a variety of situations during the moment of birth that safeguard the integrity, beauty and power of birthing mothers and newborns.

This class is part of our conference in Bad Wildbad, Germany, October 2006. Go here for info.


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In This Week’s Issue:


Quote of the Week

"In every birth it is the woman and her loved ones in the foreground, with me in the background. That is where the good midwife belongs."

Jill Earl


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The Art of Midwifery

During horrible morning sickness extending into the seventh month of my last pregnancy, my wise midwife suggested an old folk remedy: add about 1 tsp of apple cider vinegar to every 8 oz of water and sip it throughout the day and night. The effects were miraculous!

But when researching the practice of people adding vinegar to their water I realized that morning sickness may be caused by the fact that in our modern diet we drink too much water and eat sterile food!

The precursor to vinegar water was beverages containing naturally occurring enzymes and yeasts that were the result of fermentation—not alcohol, but kombucha, real honest to goodness fermented ginger ale, and much more. Every indigenous culture has consumed fermented beverages that are sometimes carbonated and always very soothing to the belly and that improve digestion. The problem with today's diet is it is sterile and full of processed foods "cooked" in a laboratory. Then we wash it all down with a lot of sterilized, often chlorinated water. No wonder so much of the population suffers from digestive issues! Even if a woman eats only whole foods, she is very likely getting little in the way of enzymes and good bacteria/probiotics unless she eats lots of yogurt and supplements with probiotics.

Anon.
excerpted from Midwifery Today Forums
full text: http://www.midwiferytoday.com/forums/topic.asp?TOPIC_ID=7971


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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Passionate Midwifery Education

Nurse-midwifery

You may be reading this because you think you want to be a midwife. The first question you will need to answer about your education is whether you want to become a CNM, a CPM or an unlicensed midwife. We will address each career path separately starting with the CNM. Jerri Hobdy, CNM, has written a great article for Midwifery Today's next issue on Midwifery Education. Here is part of that article. The whole article and many others on midwifery education will appear in Midwifery Today, Issue 78, available June 10, 2006, which you can purchase on our Web site or by calling (800) 743-0974. It will be a great help to you for planning your education along with the book "Paths to Becoming a Midwife."

— Jan Tritten, Mother of Midwifery Today

To become a Certified Nurse-Midwife (CNM), you must first complete a university-affiliated midwifery program accredited by the American College of Nurse-Midwives (ACNM) and then pass the national certification examination. This enables you to become a member of the national professional organization and demonstrates that you have met the required standards for nurse-midwifery practice.

Nurse-midwifery practice is legal in all 50 states and the District of Columbia and nurse-midwives have prescription writing authority in 48 states, the District of Columbia, American Samoa and Guam. CNMs practice in a variety of locations and types of practices: hospitals, birth centers, homebirth practices, community health centers, university practices, self-employment, in educational programs and others.

Your decision to become a CNM may be driven by access to care and to health care facilities and providers. As a licensed CNM in your state, you can provide your clients with consultation, collaboration and referral, if needed.

Over 6000 of the approximately 7000 members of the American College of Nurse-Midwives are in clinical practice. The number of CNM-attended births has continued to increase and the National Center for Health Statistics reports that over 10 percent of all vaginal births in the United States are now CNM-attended. As a CNM you are counted!

The ACNM provides two pathways to certification: as a Certified Nurse-Midwife (CNM) or as a Certified Midwife (CM). Both pathways require completion of an ACNM-accredited program affiliated with an institution of higher education and passing the same national certification examination. CNMs must previously have obtained Registered Nurse (RN) credentials prior to attending midwifery school; CMs are not RNs but still meet the certification requirements through a special program of study. Currently 43 ACNM accredited nurse-midwifery education programs are operating in the United States.

Midwifery education, like midwifery practice, is a very personal experience. Helping people realize their dream of becoming a midwife is as satisfying as the birth of a baby. For me, being a nurse-midwife was the only path that I considered—to be a part of health care system in order to change it—one woman, one service, one birth at a time.

For more information about programs visit http://www.acnm.org

Jerri Hobdy, CNM


To read the entire article, please purchase Midwifery Today, Issue 78, after June 10.

To read all installments of our column on midwifery education, go to our Better Birth and Babies Blog.


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Postpartum HIV-Infected Mothers

According to most studies, postpartum complications are more frequent in HIV-infected women than in HIV-negative women regardless of whether the birth is vaginal or cesarean. Postpartum fever and anemia are the most commonly documented complications. Most studies showed no increase in major complications such as sepsis or hemorrhage requiring transfusion. However, endometritis, wound infection and pneumonia may be increased in infected women who have c-sections. Those with emergency c-sections are more likely to have complications than are those with elective cesareans. Women with low CD4 counts (a measure of the strength of the immune system) also are more likely to have an increased risk of complications. HIV-infected women in the developing world have a higher rate of both minor and major complications.

A study from the European HIV in Obstetrics group gives an overview of the rate of complications in the developed world. In HIV-infected women minor complications (fever, anemia, wound infection, curettage, endometritis, and urinary tract infection) were found in 16.8% of women birthing vaginally and 48.7% of those with c-sections. Major complications were found in none of the women birthing vaginally and in 3.2% with elective cesareans.

In the developing world, some HIV-infected women who have been healthy but have low CD4 counts (less than 200) are seen with severe infections a week or ten days after birth. These women often have very little pain and few symptoms because their severely damaged immune systems do not mount an inflammatory reaction to the infection. Their white cells counts may be just moderately elevated.

For those women who are taking highly active antiretroviral therapy (HAART), the postpartum period can be a time when adherence is more difficult. This is best discussed and anticipated before birth. Taking into account the stresses and demands of caring for a newborn and other physical changes after birth, mechanisms for assistance in taking her medications can be in place. Families and friends are also needed to provide more support.

The postpartum HIV-infected woman will need continued well-woman care for family planning and Pap smears. Certain strains of human papillomavirus (HPV) are the known cause of cervical cancer; HPV infections are more common in HIV-infected women.

Contraceptive choice optimally should be considered and decided upon during prenatal care. Some antiretrovirals (Efavirenz) increase and others decrease (Nevirapine, Kaletra, and Ritonavir) the estrogen effect of oral contraceptives. Women on Efavirenz may have more estrogen-related side effects on pills and can use a very low dose pill without losing contraceptive effectiveness. On the other hand, women on Nevirapine, Kaletra or Ritonavir may have lower contraceptive effectiveness with low-dose pills. Ritonavir-containing regimens may reduce the effectiveness of Depo-Provera. All of this must be considered in the choice of contraceptive. All HIV-infected women should be advised to use condoms even with partners who are also infected, because of the possibility of a couple transmitting drug-resistant strains of the virus to each other.

Nancy Miller
excerpted from "HIV in Postpartum and Baby Care"
Midwifery Today Issue 75

To read the entire article excerpted above, order Midwifery Today Issue 75.


From the World Health Organization Web site http://www.who.int/reproductive-health/publications/msm_98_3/msm_98_3_9.html

In HIV-infected mothers there is an increase in puerperal sepsis, massive condylomata acuminata, and fever related to tuberculosis or of unknown origin. The postpartum period is perhaps one of the most vulnerable times for immunosuppressed women as far as TB is concerned, and signs such as persistent productive cough should be followed up. Unusual infections are encountered, e.g., peritonitis after a routine postpartum tubal ligation or pubic osteomyelitis after spontaneous labour. Retention of urine may occur caused by HIV-related damage to the nervous system. It is difficult to differentiate clinically between puerperal psychosis, cerebral malaria, and HIV-related cerebral complications such as toxoplasmosis, cytomegalovirus infection and lymphoma.

In the treatment of maternal complications it is important to realize that infectious diseases and complications in HIV-positive patients should be treated more aggressively with antibiotics than in other patients. A general rule in developing and developed countries is that transfusion of blood and blood products is a treatment with a substantial risk. It should be reserved for life-threatening complications and not be misused for the treatment of, for instance, moderate anaemia in the postpartum period. In the first weeks postpartum, when the woman is still having bloody discharge and wounds in vulva and vagina have not healed yet, sexual intercourse with an HIV-positive husband may easily infect her, if she has not been infected before. Equally, an HIV-positive woman may easily infect a man during intercourse.

Women with HIV/AIDS may experience particular psychological problems. They include fear of stigmatization by the community, victimization by relatives and neglect by health workers. Uncertainty about her baby's well-being hangs over the woman constantly and the slightest illness rekindles her sense of guilt that she may be responsible for having infected her baby. If these feelings become overwhelming they may manifest themselves as mental illness which is hard to distinguish from puerperal psychosis or infective cerebral complications.


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Research to Remember

The effects of pumping breast milk following cesarean birth to increase milk supply when babies are not nursing well were studied in a randomized clinical trial at a Baby-Friendly hospital. Sixty healthy postcesarean women were assigned either to a breast pumping group or control group. The first group used a double pump three times daily for 10–15 minutes between 24 and 72 hours postpartum. The second group used breast shields for the same duration postpartum. The groups did not differ in frequency or duration of breastfeeding. The study not only found that breast pumping did not increase milk transfer (the amount of breast milk consumed, according to pre- and postnursing weight), but that pumping may have interfered with breastfeeding and may have shortened the duration of breastfeeding. The conclusion was that pumping before the onset of lactation does not appear to improve breastfeeding outcomes and may even interfere with outcomes.

Pediatrics, 2001; 107: e94


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Forum Talk

What are people's views on male midwives? I am doing a return to practice course and hope to practice again upon completion. I'd love to know what other midwives and healthcare professionals think but I'd be particularly interested in what mothers and fathers think.

Anon.


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


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Question of the Week

Q: What is your birth community? How do you build and sustain it?

— E-News Editor


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: Does anyone have tips to help a mom who never gets the urge to push during second stage? She is completely unable to push with the contractions even though she gets in great positions: kneeling, squatting, hands and knees, birth ball, birth pool, etc. Two babies have been born fine as mom allowed her uterus to do all the work while she breathes through contractions. Is it best to let the uterus do its work alone or is there something that can help an "urgeless" mom?

— CLM, doula

A: My sister just had her second baby, a boy who weighed 8 lb 12 oz. During our conversations I told her that out of my own four births I felt the urge to push with only one. Not only do I not feel the urge to push, I don't feel second stage contractions and take to placing my hand on my belly to know when I am contracting. I also lose the ability to move, or at least move well without a lot of help. She was amazed when the same thing happened to her, but because we had talked she knew she could work through it.

My understanding is that as the fetal head comes into the vaginal canal a nerve is compressed that greatly reduces the sensation of contractions and the urge to push. Luckily this mother has had two other children, she knows her body and how to work with it and knows how to follow her instincts to birth her baby. She should do the same with this pregnancy, follow her instincts, listen to her body and birth her baby the way she feels is right. If she wanted, she could try pushing with the contraction, use the "blowing up balloon" or "sneezing" action to apply pressure to the correct muscles. However, for her, "purple pushing" is counterproductive, just as it is when the mom has an epidural. If she chooses, she can labor down before starting active pushing.

I used the bed for support, lay back on a nest of pillows—way back to help baby rotate under my pelvic bone. During pushing I came forward, sitting almost directly upright (I would hang my bottom off the edge of the bed) and curl around my baby, but I would only push once during a contraction. That worked for me.

I have a lot of hip and lower back pain both during pregnancy and in nonpregnant life; I've actually become "stuck" kneeling or lying in certain positions. For me, chiropractic adjustment is a must. This seems to be a common issue for those whose bone structure in their lower body is significantly larger than that in their upper body.

— Chantel Haynes, birth advocate

A: Saying that a mother "never" gets the urge to push is no different than diagnosing "failure to progress." If her body is not pushing out the baby on its own, there is either something in the environment that is inhibiting her body's inherent ability to do this, or her body is simply not ready. The obstetrical notion that "full dilation" means it's time to push out the baby has nothing to do with the way nature really operates.

The best way to help an "urgeless" mom is to avoid inadvertently leading her to believe that she should have the urge when she doesn't, and to be patient and give her the space and peace to allow her body to generate the type and level of hormones necessary for it to ready the tissues and spontaneously move the baby through.

— Linda Hessel

A: I teach HypnoBirthing, The Mongan Method of childbirth education. We emphasize allowing your body to do the work for which it was designed. We have seen countless women birth their babies comfortably, naturally and safely while allowing the wonderful uterus to do its job. We call this "breathing down," using the breath and visualization to move the baby along. Women in comas have given birth! In fact a year ago in Austin, Texas, a paraplegic mom gave birth at home with a midwife and did not push her baby out. Her birth was wonderful! Recent studies have shown there is no need to forcefully push a baby into the world. Trust birth!

— Jan Bennett-Collier, CHt., HBCE, doula
Austin, Texas


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.


Think about It: Elective Cesarean Surgery

An important consideration in the debate regarding elective cesarean surgery is that because biomedicine holds such a prominent position in our culture, procedures are perpetuated and performed routinely regardless of whether a causal relationship exists between the technology and improved health outcomes. Consequently, because the debate is framed as a matter of "choice," the public perceives cesarean surgery to be a normal occurrence and assumes that broader questions of efficacy and safety have already been considered. The result may very well be, as Henci Goer suggests, that by normalizing cesarean surgery and attempting to convince the public that women prefer cesareans over vaginal birth, those who have interests in the social, political and economic power structures underlying the medical system might just "succeed in making the imaginary groundswell a reality" (Goer, "The Case Against Elective Cesarean Sections").

J Perinat Neonatal Nurs 15(3): 23–38


Feedback

Regarding the question about the supposed daily average of 12 hospital newborns being given to the wrong parents (Issue 8:6):

I have been a labor and delivery RN for 11 years at two very busy hospitals. I have been involved in many, many deliveries and newborn care, both at the mother's bedside and in the nurseries. I can only say that I have never, ever been involved in, nor heard of, a newborn being returned to the wrong parent(s), even amongst friends who work in other hospitals. Not even close.

This seems to be a very common fear among parents, however. Our babies are tagged with a wristband and ankleband with numbers corresponding with the mother's wristband, and we check all three before removing the infant from the room, and when the infant is returned. But even so, every parent I have ever cared for recognizes their infant on sight. And no two newborns look alike—I don't care what anyone says!

There have been high profile "baby switch" cases in the media in the past, I know, but of children born 20 or more years ago, when most moms were routinely drugged out of their minds for delivery and were not coherent for many hours after delivery. Regardless, I believe these cases have been extremely rare, involving an "insider" who was paid plenty of money to keep quiet.

I am supportive of natural, unmedicated birth and midwifery as a whole, and find that most of my fellow nurses are as well, but we are slaves to the medical model. Regardless, I find this supposed daily average preposterous, and disagree with it totally.

D.W., Walled Lake, Michigan


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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