Passionate Midwifery Education
Apprenticeship, Part I
The next three installments are by Renata Hillman from the article "Apprenticeship: Do You Really Want One?" in the Midwifery Education issue of Midwifery Today, Issue 78, Summer 2006. You can read many more articles on paths to midwifery education by buying this issue.
I would like to address the areas I believe are vital to the success of an apprenticeship.
1. Communication. I cannot say enough about the absolute necessity for open communication. Midwifery, unlike other professions or ministries, involves many long hours of constant contact between midwife and apprentice. Being able to honestly share emotions, opinions and reactions is an absolute. The apprentice needs to share, in the appropriate place and at the appropriate time, her thoughts and ideas about the case and situations in which she is involved. This is important for her growth and allows the midwife to ascertain her apprentice's needs for further instruction.
2. Respect. This is definitely a balance. The apprentice must respect:
- the midwife, for opening her practice and her personal life for the learning experience
- the clients, who will share their births and lives with her
- the time and energy given by all parties for her personal learning and instruction
The midwife must respect:
- the apprentice's right to her own opinions (realizing that the apprentice must not press her opinions on the midwife or her clients). Ideally, the midwife will have discussed important issues, and where she and the apprentice might disagree, at the entrance into the apprenticeship
- the apprentice's investment of money, time and energy to learn this calling
3. Integrity. Although not a constant in the human species, integrity is a cornerstone in midwifery services. Our sister midwives should be able to count on our encouragement and support of their efforts in the field of midwifery. When we don't agree with their actions or methods, as midwives we should at least exhibit integrity in how we react to their choices. Our circle is too small and sensitive to have differences destroy what has begun to take root once again in our country.
In addition, our clients expect us to demonstrate our integrity by performing the tasks they request of us and honestly disclosing our experience, abilities and limitations.
— Renata Hillman
To read all installments of this column on midwifery education, go to our Better Birth and Babies Blog.
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Induction of Labor
Synthetic oxytocin administered intravenously in labour acts very differently from a labouring woman's intrinsic oxytocin. First, the uterine contractions produced by IV [oxytocin] are very different from natural contractions—possibly because it is administered continuously rather than in a pulsatile manner—and can cause detrimental effects to the baby in utero.
A woman's uterine contractions can occur too close together, leaving insufficient time for the baby to recover, and [synthetic oxytocin] also causes the resting tone of the uterus to increase. Such effects can produce abnormal fetal heart rate (FHR) patterns, fetal distress (leading to cesarean section) and even uterine rupture. As well, oxytocin augmentation stimulates uterine contractions out of proportion to cervical dilatation, compared to a natural labor: this increases the possibility of a "failed induction," where a woman's cervix fails to dilate and a cesarean becomes necessary.
...oxytocin, whether synthetic or not, cannot cross from the body back to the brain through the blood-brain barrier. This means that when it is administered in any way except directly into the brain, it cannot act as the hormone of love. It does, however, generate negative feedback—that is, receptors in the labouring woman's body detect high levels of oxytocin and so signal her brain to reduce production. We know that women who labor with an oxytocin infusion are at increased risk of postpartum haemorrhage, because their own oxytocin production has been shut down.
What we do not know, however, are the psychological or psychoneuroendocrine effects of giving birth without the peak brain levels of oxytocin that nature prescribes for all mammalian species.
In one study, women who had synthetic oxytocin augmentation did not experience an increase in beta-endorphin levels in labour, indicating the complexities that may result from interference with any of the hormonal systems in labour.
Other research has suggested that exogenous oxytocin may pass through the placenta unchanged, which implies that the baby's oxytocin system may also be disrupted by administration of synthetic oxytocin in labor.
Michel Odent notes, "Many experts believe that through participating in the initiation of his own birth, the fetus may be training himself to secrete his own love hormone..." Odent speaks passionately about our society's deficits in our capacity to love self and others, and he traces these problems back to the time around birth, especially to interference with the oxytocin system.
— Sarah Buckley, excerpted from "Undisturbed Birth: Nature's Blueprint for Ease and Ecstasy," Midwifery Today Issue 63
Induction is a minefield, a setup for complications. An induced labor forces the baby out before the body is ready; before the complex hormone interaction has primed the cervix; and often before the baby has reached his full intrauterine maturity. We have drugs now that can produce contractions and soften the cervix; but this is only a small part of the complicated process of labor. We can make a woman have contractions, but we don't always succeed in forcing her body to release the baby and give birth. If we start a labor with chemicals, we may very well have to finish the labor with the surgeon's scalpel.
In some studies, induction raises the risk of cesarean by 800 percent. [Electronic fetal monitoring (EFM)] must be used in all chemical induction methods because of the risk of hypertonic contractions and fetal distress. [EFM] alone increases the risk of cesarean and of vacuum extraction or forceps [use]. Amniotomy increases the risk again. Cesarean for fetal distress is even more common—whether the distress is real or a result of EFM artifact—since non-reassuring fetal heart tones are frequently observed. Meconium staining, meconium aspiration syndrome and even shoulder dystocia are directly associated [with] inductions. The rise in induction closely mirrors the rise in cesarean delivery, as does the rising incidence of post-cesarean rupture. A woman with prior cesarean is unlikely to suffer a uterine rupture (odds are usually given under [one] percent). But if she is induced, her risk may rise to 2 percent to 4 percent.
— Gail Hart, excerpted from "Induction & Circular Logic," Midwifery Today Issue 63
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Research to Remember
A Johns Hopkins Bloomberg School of Public Health study of more than 15,000 Nepalese newborns has shown that a topical antiseptic used to clean newly cut umbilical cords reduces risk of severe infection by 75%, compared with dry-cord care. The cleansing with a topical antiseptic such as chlorhexidine must occur within 24 hours of cutting the cord. Study results indicated that the risk of death was reduced by more than one-third with use of an antiseptic. Soap and water was not shown to reduce infection or risk of mortality.
— Lancet, March 18, 2006
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Web Site Update
Read this article from Midwifery Today Issue 77, Spring 2006, newly posted to the Midwifery Today Web site:
While recent research concluded that VBACs are riskier in birth centers than the hospitals, the author points out some of the other problems that the authors of the study failed to note, such as the fact that being in a hospital increases the risk of a cesarean and on future pregnancies.
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When calculating a woman's estimated date of delivery and the woman has the kind of period where she spots for a day or two or even three before the flow really begins, do you calculate from the first day of spotting or the first day of "real" bleeding? What if she spots for a day (for example) and then it stops for another day before her period "really" begins?
Share your thoughts and experience about this topic.
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Question of the Week
Q: I am 21 weeks pregnant with my third child, which has been diagnosed with spina bifida. This is quite a shock since my other two children were homebirths and the specialists said I would require a c-section. I understand the need to deliver in a hospital where the baby can receive immediate medical treatment soon after birth, but does anyone know if there is any evidence that c-section is better than vaginal birth when delivering a child with spina bifida?
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Question of the Week Responses
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
A: I am not sure that any midwife walking into a health education class in public school would change many ideas on birth. The lot of these children have lived in institutions—born in one, raised in one from 6 weeks on, educated in one, will probably birth in one, and send elderly parents to one. They have already been brainwashed to be dependent on others to "know what is best for them." There are those independent thinkers, but they aren't the ones who need the talk about homebirth; they have already considered it or been to their own mother's.
And, given that it is mostly illegal in many states to have a midwife, most [public schools] are not going to allow it.
I think that with being the first in my family to homebirth, homeschool, and talk and walk the way of taking care of family in the home instead of a nursing care facility, we can be an example to our children as well as their peers when they come over to play or we have playgroups. It can't be just a one-hour talk. They talk about breastfeeding in health class, and have the children take care of a robot baby, with the option of "breastfeeding," and how often do the teenage girls use this option? They know they can go to WIC for free formula, and they don't really encourage breastfeeding, not really. They have to see it lived.
So, as ideal it would be to send midwives to the schools, it won't happen. And, besides, my children have been there when I birthed without one, with no problem, and they have seen me go to the hospital when we did have one. They know that homebirth is best. We live it. I think that is truly the only hope of spreading the news that there is a better way.
— Kymberli M.
A: It would be educational if natural birth were presented to the youth of our society. I have volunteered to speak for free about birth for the past eight years on a regular basis, at the nearby all-girls high school and to six other nearby schools. The answer has always been a loud resounding, "No, thank you!"
— Judy Slome Cohain
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.
A: You are in dire need of chiropractic care by someone trained in the techniques specific to pregnancy! You will be amazed at the difference, strength and health of your body. I don't know where you are located but a good resource to find a trained practitioner is www.icpa4kids.org. I have had similar stories present in my office and with proper restoration of the nerve flow to [the] reproductive organs, pelvic musculature, ligaments, and blood vessels, the women are able to have extremely healthy pregnancies with no complications. A midwife-assisted birth is a no-brainer then! Research is showing chiropractic care to be a very important piece of the puzzle for the many couples battling infertility as well! Make sure you try to find someone who has the extra training past the regular chiropractic schooling. Some chiropractic schools are not strong in teaching pregnancy-related care, so the extra education is worth looking for. The ICPA Web site will help you with that.
— Melissa Millner, DC, DACCP, FICPA
A: First of all, my heart goes out to you and your family. This has to have been extraordinarily difficult to live through. As a possibly less-interventional, less-artificial alternative to what the average reproductive endocrinologist has to offer, you might want to have a look at www.NaProTechnology.com, developed by Dr. Thomas Hilgers in Omaha.
Using the Creighton Model for the standardized observation of cervical mucus, along with the use of supportive bioidentical hormones, many couples with similar histories have been able to conceive again and carry safely to term. Dr. Hilgers is also a master of meticulous pelvic surgery, using nearly adhesion-free techniques to get rid of virtually every spot of endometrial tissue or preexisting adhesions. This does not involve either IVF or artificial insemination, but has a goal of normalizing and restoring the woman's natural reproductive capacity rather then the "band-aid" approach of focusing entirely on pregnancy rates without addressing the underlying biological dysfunction that will be with her throughout her lifetime.
After all you've been through, I can understand why your husband feels "safer" returning to a hospital for the next birth. Let's get you pregnant first, then move on to where and with whom to give birth, depending on how you're doing.
— Gabrielle Wright, CNM,
FertilityCare Practitioner Intern
A: This mother may want to ask her doctor to test her blood for the presence of H. pylori bacteria. This bacteria is the major cause of ulcers and the primary cause of stomach cancer (though many people carry it without symptoms). Some people believe H. pylori may also be the cause of hyperemesis in pregnancy. Treatment is a course of antibiotics, but is not usually recommended during pregnancy, so she may want to seek out treatment as she is looking at any endocrine issues before conception.
— Molly, doula and student nurse
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Think about It: Off-label Use of Cytotec
[One] reason to be concerned with the offhand answer of some obstetricians [about the use of Cytotec to induce labor] is that all off-label use is lumped together as though there were equal risks involved. During a case I was involved in, I asked the obstetrician about the off-label use of Cytotec for labor induction. He replied with the same answer that I have heard from so many clinicians: "We use Cytotec off-label for induction just like we use other drugs off-label all the time." Compare this to someone involved in a fatal car accident who is asked why he did not follow traffic laws and drove 100 miles per hour in a 25 mile per hour zone. The driver answers, "Traffic laws are disobeyed all the time. Why, just last week there were dozens of parking tickets given out in this city." You can't compare the risks of excessive speeding with the risks of illegal parking. And you can't compare the risks of Cytotec induction with the risk involved in giving other drugs to pregnant women off-label. A survey of 731 pregnant women revealed they had been given 10 drugs while pregnant. But of the 10 drugs given off-label, the use of nine of them on pregnant women carried very little risk while the use of the tenth drug, the prostaglandins (including Cytotec), has proven serious risks, including uterine rupture, following which one in four babies dies.
— Marsden Wagner, MD, excerpted from "Cytotec Induction and Off-Label Use," Midwifery Today Issue 67
Order Midwifery Today Issue 67
Regarding the question about number of homebirths, Issue 8:12:
In Israel, where I live, 0.2% of births are planned homebirths.
In the United Kingdom, planned homebirths = 2% of births.
In Holland, planned homebirths are the most in the world = about 30% and falling every year.
In the United States, 8% of births are midwife-assisted hospital births; I suspect that about 0.2%–0.5% give birth with midwives as home, but I don't think these data are available since the birth certificates in many states do not delineate whether the person gave birth at home or hospital and if so, was it a planned homebirth or by accident, and unattended. Please tell me if you find a published statistic for planned homebirths in America.
— Judy Slome Cohain
Regarding Prolonged labor, Issue 8:12:
I believe that there was a mistake in the description of anterior and posterior asynclitism. When the sagittal suture of the fetal head is closer to the symphysis pubis ("head tilting upwards") this is posterior asynclitism, because the posterior parietal bone is presenting itself more. The opposite is true for anterior asynclitism.
— Debby Gedal-Beer, CNM, MSc.
Coordinator of Women's Health and Midwifery Education
Sheba Academic School of Nursing
Tel Hashomer, Israel
Does anyone know of a midwife practicing in Phnom Penh, Cambodia, or the near vicinity? I have a friend there who is pregnant and due very soon!
— Kiersten Figurski, LM CPM
Northern New Mexico Midwifery Center
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August 13–15, 2006: Michigan School of Traditional Midwifery, Midwifery Skills Retreat. Skills documentation, Body Casting, Herbology and more. Make history with us! 989-736-7627 www.traditionalmidwife.org
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