May 9, 2007
Volume 9, Issue 10
Midwifery Today E-News
“Stillbirth”
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Learn about traditional midwifery at our Costa Rica conference in May 2007.

Attend two full-day sessions on Traditional Midwifery and discover what our sisters from Central America have to teach us. You'll learn traditional techniques for dealing with shoulder dystocia, hemorrhage, posterior, postpartum care and more. You'll also participate in a discussion about ways to preserve and strengthen midwifery, and ways to institute birth change when needed.

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In This Week’s Issue:


Quote of the Week

Don't 'push the panic button.' Panic is of no benefit in midwifery.

Marion Toepke McLean


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The Art of Midwifery

The pregnant woman thinks, "Nine more months of this? I can't!" And gradually she learns to enjoy her changes, her growth, one month, one week at a time.

The laboring woman thinks, "Eight more centimeters of this? I can't!" And gradually she adjusts to the feelings, one centimeter at a time.

The contractions get harder, closer together and she thinks, "One more minute of this? I can't!" And she learns to take it one contraction, one second at a time.

She learns to unfold into timelessness, to expand in ways she didn't know that she could.

The young midwife thinks, "If only I get my first catch, then I'll be a midwife…my first client as supervising midwife…my first 100 births under my belt…my first breech…my first apprentice." She eventually realizes that there is no "there" there; only the never-ending process of Becoming. Not just a midwife, but a fully human being.

— Alison Bastien, excerpted from "Life Lessons," Midwifery Today Issue 60


Midwifery Today Issue 60 may be purchased here.

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The Tragedy of Stillbirth

Unexplained stillbirth in late pregnancy is the single largest cause of perinatal death in the Western world. In the United States alone, approximately 39,000 babies of 20 weeks gestation or more died last year. Globally, 4.5 million babies never took their first breath. Sudden Antenatal Death Syndrome (SADS) has risen 20% in the last 10 years, despite "advancements" like 3-D ultrasound, increasing rates of labor induction and a rising cesarean section rate. These death tolls are estimates because stillborn babies aren't counted in any data on child death. Infant mortality rates in the US do not include stillbirth rates. Statistically, stillborn babies are not considered infants or children.

Some causes of stillbirth are known: genetic defects, Rh incompatibility, placental abruptions, maternal diabetes, infection, high blood pressure, clots and malformations of the placenta and maternal hypertension. Some contributors can be corrected before pregnancy occurs, like maternal smoking, poor nutrition and obesity. However, the majority of stillbirth cases are simply labeled Sudden Antenatal Death Syndrome.

Very few efforts are being made to research stillbirth. The US government does not provide any funding for the research and reduction of stillbirth. No uniform stillbirth autopsy protocol is in use today anywhere in the world. Every autopsy is done according to local practice. Because of that, no uniform data are available for analysis. If the family of a stillborn child chooses to have an autopsy, the mother is rarely interviewed, in spite of the fact that she may have vital clues to her baby's cause of death. Nearly 70% of all autopsies performed on stillborn babies will yield no conclusion as to the cause of death. These unexplained deaths are usually labeled SADS.

This is an absolute tragedy for thousands of bereaved families; they will experience no closure. With no funding for a department that would record the deaths and autopsies of stillborn babies, no research can be done to discover additional causes of stillbirth and SADS. Amazingly, SADS outnumbers SIDS ten to one, yet it does not benefit from any public movement like the famous "back to sleep" campaign that has reduced the rate of SIDS.

Babies suffering from umbilical cord accidents (UCAs) may not die suddenly. The baby may adjust to changes in blood supply due to cord compression for several hours or days, until further compensation for the diminished supply is impossible. This suggests that there may be time to evaluate and deliver the baby.

The most important factor for insuring a safe neonatal and maternal outcome is quality prenatal care. This starts with educating the mother on providing a safe environment for her baby and monitoring his health. Doing kick counts every day, after fetal movements are apparent, is the easiest and least invasive way to know how the baby is doing (NSS 2004). A mother should be aware of her baby's sleep/wake cycle, general activity level and hiccups. The National Stillbirth Society recommends kick counts every evening after eating. The mother should record at least five movements in one hour. If she does not, the test should be repeated, registering at least 10 movements in two hours. If the test fails again, the NSS recommends that the mother alert her midwife or doctor or go to the hospital for electronic fetal monitoring (EFM). Other warning signs a mother should look for are: more than 10–15 hiccups per minute occurring more than four times in 24 hours, extreme hyperactivity (especially during maternal sleep), constant Braxton Hicks contractions, fetal quivering, very strong kicking or localized uterine pain.

— Jeska Vannoy, excerpted from "The Tragedy of Stillbirth," Midwifery Today Issue 74


Get the whole story. Read more articles about complications in Midwifery Today Issue 74.

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Research to Remember

Unborn babies who are exposed to cigarette smoking by their mothers may have damage to developing organs or adverse effects on the immune system. Whatever the effect, babies, both born and unborn, may be predisposed to a variety of diseases. In a 2001 retrospective study of 25,102 singleton children of pregnant women in Denmark - of whom 30% smoked - scheduled to deliver between September 1989 to August 1996, exposure to cigarette smoke was associated with a higher risk of death both in utero and within the first year of birth. After adjusting for other factors, including alcohol and caffeine intake, they found these results the same: an increased risk of stillbirth and rate of infant mortality twice that of nonsmokers.

Of note was the fact that women who stopped smoking during the first trimester had stillbirth and infant mortality rates comparable to those of women who did not smoke during pregnancy. The authors reported that approximately 25% of all stillbirths and 20% of all infant deaths in a population with 30% pregnant smokers could be avoided if all pregnant smokers stopped smoking by the sixteenth week of gestation.

Am Journal Epidemiol 154(4): 322-27, 2001


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ALACE Executive Director Search

ALACE, a national, nonprofit organization dedicated to supporting women's choices in childbirth, is seeking a full-time Executive Director in our Cambridge, MA, office. The Director is responsible for administration and management of ALACE, including programs, strategic planning and business operations. Send resume and cover letter to:

Susan Cassel / ALACE
PO Box 390436, Cambridge, MA 02139
scassel@alace.org


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What was it like to be a midwife in the 18th century?

Read MOTHER AND CHILD WERE SAVED, The Memoirs (1693–1740) of Frisian Midwife Catharina Schrader, and find out. You'll read about the births of 64 sets of twins and three sets of triplets, successful births with placenta previa, many types of breech deliveries and more. Only a limited number of copies are available, so get your copy now.

MOTHER AND CHILD WERE SAVED


A new consumer Web site on breast pumps was posted on March 27th by the FDA's Center for Devices and Radiological Health (CDRH): www.fda.gov/cdrh/breastpumps/

The site provides general information on breast pumps, and features an animation outlining how breast pumps work. Also included are links to a list of FDA-approved breast pumps at Devices@FDA, the MedWatch adverse events reporting system, FDA's medical device recalls Web site, the US Department of Health and Human Services Breastfeeding Helpline, and contacts for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This Web site is the product of an effort that was initiated with the US Breastfeeding Committee.


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Web Site Update

Read these articles newly posted to our Web site:

  • Herbs for Mother's Care Postpartum—by Demetria Clark
    Handling postpartum issues naturally gives the mother more control and is generally less invasive then going to a doctor. Make sure the mother knows when to seek additional medical care.
  • HypnoBirthing: Instinctive Birthing through Relaxation—by Tracy Donegan
    Birthkeepers of the world are divided on whether pain does or does not have to exist in birth; each of us is firm in our stance that our belief is right. For many the notion of comfortable or even joyful birthing still remains just outside of our grasp.

Advertising Opportunities

Costa Rica Conference 2007

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Question of the Week

Q: My daughter's son is seven days old and she is breastfeeding him. He latches on and sucks well. Despite some soreness and bleeding of the nipples at first she is coping well and the soreness is clearing. She uses nipple shields for alternate feeds to help her breasts heal.

The baby rarely settles after a feed unless he also has some formula either from a cup or a bottle. However, once he has formula he sleeps well.

Does this indicate a shortage of milk? I recall when I was breastfeeding many years ago, my breasts were full and leaky most of the time. My daughter does seem to feel like this and there is no leakage. Is there something we can do to make sure she has plenty of milk?

— Brenda (Sian's Mum)


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: I am a senior midwife working in an obstetrical hospital in Malta and I am very interested to know how you manage the mothers in the stages of labour. Moreover, since we are migrating to a new hospital with a completely different system, I would appreciate knowing whether the mothers stay in the same ward in the prenatal, labour and postnatal care. Is there a continuity of care by the same midwife with every mother?

— Josette

A: In the hospital-based collaborative practice where I work as an RN in (Cooperstown, New York), we have LDRPs (labor, delivery, recovery, postpartum rooms). We have 24-hour rooming-in for the babies as well, unless a baby requires extra support of some type. Basically, the RNs are in labor with the patients when they arrive and the CNM will evaluate them on an ongoing basis as the CNM will also be "rounding" on postpartum and outpatients, too. Once the CNM's presence is needed more (whether by the patient, RN or CNM's request) she stays with the patient and RN more, delivers the baby and will "round" on that patient again as needed until the CNM's shift is over (they work 24-hour shifts and sleep right on our unit). There is continuity then throughout the labor and into the postpartum period for the patient.

The goal is to not have to move a patient from room to room, but rather have her arrive and settle in a LDRP right away after initially assessing that she is in labor. Then she will stay in that same room until she goes home with they baby in 24-48 hours, depending on the course of care. While being seen prenatally, the patient may be seeing one midwife at only one outreach clinic, or she may choose to see a multitude of midwives because she realizes that she does not know who will end up delivering her baby in the long run (it will just happen to be whomever the CNM is on the inpatient ward for that 24-hour period when she comes into labor).

All patients at all outreach clinics are considered part of the same collaborative practice, so all patients are everybody's patients and the patients are well aware of this. All patients see CNMs unless they request to be MD-only patients, which are far and few between. Eleven midwives and five obestetricians in this practice share all patients. It works quite smoothly with the CNMs shift starting at 8 am and ending the next morning at 8 am.

— Tanya Jennison, RN

A: I am a third year student midwife in Nottingham and I have just read your question of the week and thought I would write and tell you what we do at Nottingham City.

The women who come into hospital in established labour stay on "Labour Suite" in the same room the whole time, unless they are mobilising, or transfer to the pool room for any time. We have 17 labour rooms along two corridors.

Continuity of care to me mostly indicates continuity of carer so will discuss that briefly here. When a woman comes into labour suite a midwife is allocated to her. This midwife will attend the woman for the whole of her shift; should the woman continue on in labour after the midwife's shift, that midwife will introduce the next midwife to the woman before leaving.

Should a woman come into hospital in early labour/or have labour that slows she is invited to go home until labor is established, or she can go upstairs to the ante/postnatal ward. She will be cared for by the midwives up there until she has a need for strong analgesia or has clinical evidence of established labour. On the ward the woman will be allocated another midwife for the duration of her shift, so continuity of carer in that environment is maintained to offer individualised care and trusting relationship for the woman.

Once they have given birth women are discharged home or taken upstairs either to an ante/postnatal ward or to the patient hotel (low risk normal birth). There are two ante/postnatal wards, each with 27 beds: four 4-bed bays; a 2-bed bay and the rest single rooms. The wards allocate certain bays and some side rooms for antenatal women depending on the number in hospital at any given time. One ward has a bay for transitional/special care babies as well. The patient hotel here is a place where women who have had a normal birth and are self-caring can go to establish as a family before going home. One midwife is on duty to assist if they need advice or help overnight; the usual is a one-night stay.

I hope that this information helps. I am aware that different hospitals are set up differently. At Kingsmill, for example, I think [there is] an early labour room and an established labour room so I get the impression women have to transfer when progressing in labour. I'm not sure I like the sound of this system, but I haven't seen the set-up to see how if "feels."

If you have any questions feel free to write.

— Alison Bradley
Nottingham
alisonj.bradley@ntlworld.com


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

Primal Health Bill in Hawaii Legislature

The Safe Baby Resolution asks legislators in Hawaii to order a study of the early primal period of conception through infancy as the foundational time for health, wellness and harmony as well as foundational time of the myriad of social and physical concerns of society. The goal is to make gestation and birth gentle, drug-free and safe for mothers and babies as well as for medical caregivers and society.

This resolution can be viewed in PDF format at: http://www.capitol.hawaii.gov/sessioncurrent/Bills/SCR8_.pdf To send a letter of support for this bill, e-mail David Y. Ige, testimony@capitol.hawaii.gov, with the subject line: Ing - SCR 8 Testimony and cc to planetpuna@yahoo.com.


Feedback

I just met with a group of french students and future midwives (to practice English with them). I gave a file to them, asking what they knew about the pregnancy of their mother and of circumstances of their own birth? I was interested and surprised to find two very different groups: one with extremely positive pregnancies and birth and one with complicated difficult pregnancies and birth. I just wondered if this is the norm? If so, no wonder we can't communicate: If our opinion on birth is linked closely with the way we were born, these two very different groups can never be on the same wavelength. Easy birth would lead to midwives ready to attend homebirth or natural birth; difficult birth would lead to midwives more likely to use interventions and technology.

If this is so, we have less and less hope for natural birth, as interventions are catching up very fast! It would be interesting to do a larger scale research project on the topic of where you work/how was your birth?

Françoise Bard
France


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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Calling in the Voices of Midwifery: The California Association of Midwives will be holding our 2007 conference June 1–3 in Occidental, California. See our list of classes and register at www.californiamidwives.org


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