June 7, 2006
Volume 8, Issue 12
Midwifery Today E-News
“Prolonged Labor”
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In This Week’s Issue:


Quote of the Week

"Unfortunately we live in a society that is addicted to drama, and the mainstream media continue to help satisfy the addiction with their sensational stories about birth."

Linda McHale and Barbara Nobel Schelling


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The Art of Midwifery

When a pregnant woman's extremities swell, it's a sign that nature is taking toxins as far away from the baby as possible. Tell women to pay attention to how their body is detoxifying, i.e., peeing, pooping, sweating. Pregnant women need extra salt, water and roughage to make the elimination systems work, and they need brisk exercise that raises the heart rate every day and makes the woman sweat.

Gloria Lemay, Midwifery Today Forums


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Passionate Midwifery Education

Direct Entry Path

Once you have decided that you want to take the direct entry route you still have many excellent choices for getting your education. Let's first talk about schools and programs. Either can lead you to get your NARM certification http://narm.org/index.htm if you want or need it. Next issue we'll concentrate on self-study which will also give you the choice of becoming NARM-certified. No matter which process you choose you will need to find someone with whom to apprentice. If no midwives are in your area and you cannot move, consider becoming a doula so you can get some experience by going into the hospital and helping there. Many midwives have gone to Maternidad de la Luz or another high volume school for several months to get experience. Some have volunteered in other countries. For your NARM certification http://narm.org/htb.htm you will need to document 20 births as an active participant and 20 births under supervision as a primary midwife.

A question to ask yourself is whether you want to attend class for most of your didactic or take an online course. You must work well on your own to succeed in an online program. You might consider starting a study group even if you are enrolled in an online program. Another question is: what schools are available in your area? Are you free to move? Logistics are important to resolve. This site has a fairly extensive list of schools and programs http://www.midwiferyeducation.org/schools.htm and also lists them by state. Try to get a list of graduates you can talk with to make sure the program, teachers and style are for you. You can find much more information about choosing a program in Midwifery Today's book Path to Becoming a Midwife. If you are serious about midwifery it is a great investment. http://www.midwiferytoday.com/reviews/pathssue.asp

Remember you should be treated with a welcome to the calling of midwifery and with great respect, just as you will be expected to be respectful to those who dedicate their lives to teaching you. Midwifery is a beautiful way to spend your life. I can think of nothing better. A healthy start sets the tone like a healthy pregnancy does for the baby. Feed yourself well in both cases.

love, Jan
Jan Tritten, Mother of Midwifery Today

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Prolonged Labor

Following are the most common factors that occur before a diagnosis of failure to progress is made.

Possible cephalopelvic disproportion (CPD): Although this is a possible condition, I believe it is relatively rare. I have seen only three true cases of CPD in my career.

Malpresentations of the fetal head most often result from the woman having an adequate to ample pelvis and a smaller baby who can move around freely.

Ascynclitism: Diagnosed with the suture lines of the fetal skull are not felt to be aligned exactly halfway between the symphysis pubis and the sacrum. If the baby's head is tilted up toward the pubic bone, it is called anterior ascynclitism; if it is tilted toward the mother's sacrum, it is a posterior ascynclitism.

Posterior labor: It is my experience that with appropriate diagnosis and minimal intervention this condition can be corrected by assisting the baby to rotate as soon as it is diagnosed. Many times the position is not diagnosed until labor is advanced and progress arrested. At the onset of labor, it is important for the midwife to assess the position. It is relatively simple to assist the rotation of the baby when the mother is in early labor and very difficult once labor becomes advanced.

Brow presentation: These are extremely rare, occurring less than 1% of the time. Passage of a brow through the pelvis is slower, harder, and more traumatic to the mother than any other presentation. Perineal laceration is inevitable and may extend high into the vaginal fornices or into the rectum because of the large diameter offered to the outlet. The brow may be adjusted with little effort if found in early or at the beginning of active labor. At this point the adjustment is made manually and is not painful for the mother.

Face presentation: While traumatic, the face presentation may be delivered safely as long as the position is anterior. The posterior face presentation—baby's body toward mother's back—is very difficult if not impossible because the baby's head is forced back upon its shoulders, and the head cannot come into the pelvic outlet. Early diagnosis is imperative to ensure the best outcome. I encountered four face presentations in twenty years of practice.

Uterine atony: If a malpresentation is not discovered or other factors contribute to a long, nonprogressing labor, the uterus resumes with a good outcome if the mother is allowed to rest and labor is not forced to proceed. There have been cases of stalled labors that have been oxytocin augmented without remedying the cause, and they have resulted in uterine rupture. If there is neither malpresentation nor any other contributing factor (or they have been resolved) and the fetus is in no distress, the mother should be allowed to rest as long as necessary. She should be encouraged to eat and drink high carbohydrate, nourishing foods. If she is dehydrated and an IV is not available (or permissible), try giving potassium and electrolyte fluids both orally and by rectum, per enema bag. To stimulate contractions before mother is well rested will only lead to further complications such as the development of constriction rings, fetal distress and third stage difficulties.

Incoordinate uterine action: This phenomenon is rare and difficult to diagnose and is often mistaken for failure to progress or assumed to be false labor. Incoordinate uterine action presents as painful, frequent though irregular contractions that do not cause either effacement or dilation. When this condition is suspected, it is very important for malpresentation or posterior presentation to be ruled out. The diagnosis may be confirmed by the attendant touching the cervix during a contraction and noting no tension of the cervix. The only effective treatment is to stop the contractions and rest the mother for a period of time. When contractions resume spontaneously the condition will be resolved and labor will progress normally.

Maternal exhaustion: It is important that the mother be encouraged to rest and sleep as much as possible in very early labor. If exhaustion has occurred, labor will slow down and inertia and constriction rings may lead to operative intervention.

Maternal hypoglycemia: Hypoglycemia is probably the most frequent cause for slow progress in labor and increasing maternal irritability and difficulty in dealing with contractions. Because of the increased stress of labor, the mother's stores of blood sugar diminish rapidly. It is important for the mother to be fed during labor. Giving fruit juices during labor is not recommended because they may cause hyperacidity, leading to heartburn and vomiting, which will heighten the problem.

Cervical dystocia: Simple failure of the cervix to efface and dilate or abnormal rigidity of the cervix and cervical conglutination are the pathological reasons for cervical dystocia. It may also be caused by scarring from a previous birth or from artificial cervical opening, or from injury to the cervix from operative intervention. It has been shown that nulliparas who have been on the pill for some time may have a rigid cervix.

Cervical adhesions: It is not unusual to find hard spots on the cervix. If the woman does not have condylomas, most often what you are feeling are small cervical scars from previous births or gynecological procedures. The use of instruments for dilating the cervix or delivering the baby often cause small tears to occur, as does pushing babies out prematurely. These adhesions most often will break down during the active phase of labor.

Psychological factors: If there are significant psychological problems that may negatively impact labor and birth, it is important that they are discovered and acted upon before the time of birth. If the mother needs counseling or psychiatric help, the time to get it is before labor begins.

Tight nuchal or short cord: A nuchal cord is present in about one third of all deliveries and usually presents no problems. The issue, therefore, is whether it is able to function in its delivery of blood and oxygen to the fetus during labor and delivery. When there is a deceleration of the fetal heartbeat at about 6 or 7 centimeters, I immediately suspect a tight or short nuchal cord. First, change the mother's position to either hands and knees or to the left-side lie. Nothing should be done to accelerate labor at this point. The cord will stretch if given enough time.

If the cord is not nuchal or shortened, it may be compressed. A good rule with bradycardia is that three separate episodes of decelerations of the fetal heartbeat are definitive of persistent, recurring bradycardia, and if this is the case, the woman should be transported to the hospital.

Compound or nuchal arm: this occurs so frequently that it is considered fairly normal. When all other causes for hang-ups of labor have been eliminated, compound or nuchal arm is likely the cause. The problem may not be discovered until the mother is approaching second stage, and is one reason for her not feeling a pushing urge. She may say she has supra-pubic pain while pushing.

Thoroughly familiarizing yourself with a variety of circumstances that could lead to prolonged labor not only helps you diagnose a condition when it presents, but may make it possible to avoid transport to the hospital. Once we get beyond the standard pronouncement that there is failure to progress, we can take deliberate steps to facilitate a safe, successful delivery without medical intervention.

Valerie El Halta, excerpted from "Preventing Prolonged Labor," Midwifery Today Issue 46

Editor's note: This information has been severely excerpted from the original article. You are encouraged to purchase the issue and read the entire article, which includes extensive information about how to remedy each of these impediments to normal progress of labor.

MIDWIFERY TODAY Back Issues are available online. Issue 46


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Research to Remember

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Web Site Update

A scrapbook of the Midwifery Today Bahamas 2005 conference is now online.

"Aspiring and Student Midwives Are Our Hope for the Future" by Jan Tritten
Read this editorial from the brand-new issue of Midwifery Today (Number 78): "Just as we each have a responsibility to birthing women to ensure the future of midwifery, as "mother midwives" we also have a responsibility to educate the next generation of midwives. Midwifery is fairly fragile in the US and we must acknowledge our responsibility to protect it. Educating aspiring and student midwives in how to carry on the motherbaby-centered birth culture that we are creating is critical to protecting motherbaby.""

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I know I had a miscarriage last week but my doctor thinks I am an "imaginative idiot" (my words, not hers) because the blood test was negative. No other test was done even though I had passed (while urinating) a properly formed 4-week-old baby/fetus. … I never experienced severe pain or bleeding. What pain I had was from my naval downward and in the area of my lower left abdomen. I believe I have expelled all that should be expelled. … I am now recuperating, but would very much like to hear from someone who had a "case" similar to mine.

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Question of the Week

Q: My husband and I are both 35 and have two children, 9 and 11 years old. We are trying to conceive for the sixth time, as we've experienced three early pregnancy losses with no known cause. (I have two minor heart conditions which are unrelated to the losses.)

In my first pregnancy, I went into preterm labor at 32 weeks and after strict bed rest and the use of Brethine, I carried to 36 weeks and gave birth (hospital with an obstetrician) to a healthy 7 lb 10 oz boy. In my second pregnancy, I went into preterm labor at 25 weeks. It was a much more difficult pregnancy and I was on strict bed rest for 11 weeks and took Brethine again. I managed to carry to 36 weeks and gave birth (hospital again, although with a midwife) to a healthy 5 lb 12 oz boy.

In each pregnancy, I was diagnosed with extreme hyperemesis and even had home-nursing care and IV hydration at home and during occasional hospital stays. I had sickness, vomiting and extreme dehydration for almost seven months of my pregnancies.

I didn't make it past 11 weeks in my last three pregnancies. We are now seeking fertility treatments with a reproductive endocrinologist because we haven't conceived in over eighteen months. After we do become pregnant, I would like to pursue homebirth, but my husband feels we would be safer with an obstetrician in a hospital because of the complications of my past pregnancies and the difficulties we've had conceiving. I would like a midwife's opinion about whether or not I might be a candidate for homebirth and whether it is possible that a midwife would consider assisting us.

— Melissa

Question of the Week (Repeated)

Q: What can we do to have the art of midwifery be more in the consciousness of our culture? As we know, most of the youth in our society think, as many adults do, that "having a baby" means "going to the hospital." I have been pondering lately what changes might take place in our society if midwives made a point of visiting their local middle and high schools (private and public) to speak with the health/science teachers and volunteering to come into the classroom to give a workshop (or whatever term you wish to use) as a professional expert when the class is studying human reproduction. Wouldn't it be wonderful if natural birth was presented to the youth of our society so that it is thought of as a very normal thing when, later, they are adults preparing to have children?

— Kathryn Balley


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Think about It

To quote Rumi, "Let the beauty you love be what you do." This sums up pretty well the wisdom tradition of granny midwives as I experience it. As midwife, I draw out beauty from a mother, her family. When in the presence of midwives, I am struck by the beauty of my sisters—how I wish they could see themselves as I do.

This is one aspect of the multifaceted services that midwives give, to walk in beauty as we do our work, providing the nurturing role model a new mother needs. In the Southwest where I live, the reigning deity is Grandmother Spider, Mother of Changing Woman. Her myths tell us to "walk the beauty way." She is the one who spins the web of life, hence, my favorite metaphor of the "web of service" that links midwives. By serving one another, we sustain the web—that is, our interconnectedness. She teaches us that what is done to one is done to all.

My salutation of choice for years has been "Blessed Be and Blessed Do." Midwifery is a beautiful way to spin a web of sustenance and caring in our communities, one midwife, one mother and one family at a time.

— Jeannine Parvati Baker


Feedback

I am preparing to teach a group of paramedic students the obstetrical portion of their training and I am curious about how many home deliveries occur every year with a midwife or some other support.

Anita Lang, RN


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