February 13, 2008
Volume 10, Issue 4
Midwifery Today E-News
“C-section”
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Learn about Physiology in Pregnancy and Childbirth.

A compilation of eight articles by Verena Schmid, an independent midwife from Italy, this book will give you a unique view of pregnancy, birth and related processes. Verena applies her nearly 30 years of midwifing homebirths to providing you with a deeper understanding of the complex biological processes that make up the perinatal period. This book is must reading for informed midwives and mothers-to-be.
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Thinking about becoming a midwife?

Then you need to attend the full-day Beginning Midwifery class at our March 2008 Philadelphia conference. You will learn about both the joys and challenges of being a midwife and discover if this is the calling for you. Topics covered include Prenatal Care, With Woman, Normal Labor Physiology, Emotional Issues in Labor and Finding a Mentor or Apprenticeship.

Learn more about the Philadelphia conference and get a complete program.


Brush up on your midwifery skills.

Attend the two-day Midwifery Skills Update with Elizabeth Davis and Gail Hart and make sure you're prepared for problems and complications. In the morning of Day One you'll learn about prevention and management of hemorrhage. In the afternoon you'll learn how to handle first and second stage difficulties, including prolonged rupture of membranes, failure to progress and abnormal labor patterns. In the morning of Day Two, Gail and Elizabeth will explain causes of shoulder dystocia, symptoms and signs used to predict it and demonstrate effective treatments. That afternoon, you'll learn how to identify different types of malpresentations and discover techniques to assess and deal with them. Part of our conference in Ann Arbor, Michigan. May 2008.

Learn more about the Ann Arbor, Michigan, conference and get a complete program.

In This Week’s Issue:


Quote of the Week

"I saw hell. The hospital had divided and conquered pretty successfully."

Kate Millett


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The Art of Midwifery

[M]idwives need to know how women heal after cesarean delivery and what they can do to foster the healing process.

Early activity after a cesarean can improve lung function, overall circulation and the blood flow that brings oxygen and nutrients to the healing uterus and abdominal wall. Tissues must have ample fuel (oxygen and nutrients) to support the healing process. Blood loss during cesarean may have resulted in anemia and a decrease in the oxygen-carrying capacity of the woman's blood. Oxygenation and tissue perfusion are affected by a woman's activity level, her hemoglobin level and the function of her heart, lungs and circulatory system.

Nutrition is the backbone of healthy tissue. Eating too much, too little or foods with empty or unbalanced nutritional content inhibits overall health and the healing process. Dehydration affects kidney and circulatory function, as well as oxygenation and tissue functioning on a cellular level. Immediately following surgery, fluid balance is more important than nutrition. Once the proliferative phase of healing has begun, high quality protein and adequate vitamins and minerals are necessary to build strong tissues.

The immune response is also essential to healing the uterus. Many things affect our immune responses. Fear, depression, illness, medications and pregnancy itself may decrease immune response. Infection in the wound and the energy necessary to combat it steal resources and delay the healing process. This often results in a weaker scar. In fact, infection (either wound infection, or endometritis—an infection of the uterus) is one of the most serious causes of delayed wound healing and a compromised uterine scar after cesarean birth.

Nell Tharpe
Excerpted from "Holistic Evaluation of Healing after Cesarean Birth," Midwifery Today, Issue 72
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Research to Remember

Babies who are delivered by elective c-section have an increased risk of respiratory problems, in comparison to those who are born vaginally or by emergency c-section. This is according to a study of 2678 births at 37 to 39 weeks gestation published in the British Medical Journal. The earlier-born babies were more likely to have respiratory problems; the same was true in terms of severity, with those born at 37 weeks having five times the risk. These results held true even after excluding complications, including diabetes, pre-eclampsia, intrauterine growth restriction and breech presentation.

BMJ, doi:10.1136/bmj.39405.539282.BE, published online 11 Dec 2007


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Cesarean on Maternal Request

What is the safest plan for a pregnant woman looking forward to childbirth these days? Watch and wait, while nourishing motherbaby and monitoring their health? Induction of labor at some point, either chosen in advance or as dictated by circumstance? The choice of cesarean section has remained in the background as a sort of "Plan B," available for emergencies, until recently.

Cesarean Delivery on Maternal Request (CDMR) has emerged in recent years as a separate category of childbirth. The National Institutes of Health (NIH) states that it is a subset of elective cesarean delivery: "Cesarean delivery for a singleton pregnancy on maternal request at term in the absence of any medical or obstetric indications." During these same years, the rate of cesarean section in the United States has increased dramatically. In 2004, 29.1% of US live births were delivered surgically, the highest rate ever in this country, accounting for 1.2 million births. Is this part of the reason that our maternal mortality rate has remained unchanged in the past 30 years, despite many medical and surgical advances?

The NIH State-Of-The-Science Conference on Cesarean Delivery on Maternal Request in March 2006 brought together an extensive panel of experts to make recommendations regarding the safety and other aspects of this trend. They concluded that there is little evidence, positive or negative, for serious long-term benefit or harm from abdominal delivery.

A classic study of maternal mortality and c-section reported on a nationwide confidential enquiry into the causes of maternal death in The Netherlands from 1983–1992; nearly two million births occurred during that time, including over 100,000 cesarean sections. The researchers concluded that the risk of death in uncomplicated repeat cesareans in healthy women was 2–3 times higher than in normal vaginal deliveries. Part of the risk of cesarean section is from anesthesia, and increasing use of regional versus general anesthesia might arguably make cesarean delivery today safer than it was when this study was done.

More recent studies present similar evidence. In Great Britain, the National Childbirth Trust in a 1999 document reported that a woman is five times more likely to die as a result of a cesarean section than a vaginal birth. A population-based case-control study in France, based on data collected from 1996–2000, concluded that the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery. That figure excluded all deaths due to chronic conditions present before pregnancy and deaths due to obstetric conditions that developed during pregnancy but before delivery, and included hemorrhage due to placenta previa or accreta and abruptio placenta.

Increasing risks of complications in pregnancies subsequent to cesarean delivery also have been documented. This includes abnormal placentation, such as placenta accreta and placenta previa, which then cause an increased risk of maternal and fetal morbidity and mortality in the pregnancies in which they occur.

Perhaps the NIH expert committee believes in reserving judgment on a treatment or procedure until a double-blind study is done to prove its safety. This would be appropriate if the procedure were not already being used widely. Its safety should certainly be proven before its increasing use is recommended, even when that recommendation is made tacitly by stating that no evidence exists—which can easily be interpreted as approval.

Meanwhile, I would remind the doctors and midwives of the US who are confronted with counseling decisions as women explore their childbirth options to first do no harm! The studies I have presented might be construed by the NIH as "weak quality evidence," but they do not favor the choice of c-section on demand. Maternal mortality is a tragic result that can affect the lives of many generations. Childbearing women must be informed of the real potential risks of cesareans. Dismissing troublesome evidence from large studies trivializes maternal mortality and women's real right to choose.

Marion Toepke McLean
Excerpted from "Marion's Message: Ceasarean on Maternal Request," Midwifery Today, Issue 80
View table of contents / Order the back issue


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  Midwifery Today Issue 64


Web Site Update

Read this article excerpt from the most recent issue of Midwifery Today newly posted to our Web site:
The Bridge of Life: Options for Placentas - by Kelly Graff

¡en español!
The IAM Definition of Traditional Midwife and the IAM Goals and Beliefs are now online in Spanish on the main IAM page.


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Advertising Opportunities

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Question of the Week

Q: If you are a midwife, how do you feel when your clients refuse services like ultrasound?

— Anonymous


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.


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Question of the Week Responses

Q: I am a 28-year-old woman who has just been told that I have uterine didelphys—with two of everything (cervix, uterus and vaginal canal). According to the gynecologist I saw, I can become pregnant but she said there is a higher risk of premature birth and of a caesarean. Other than this I am perfectly healthy and have had no illnesses or anything.

While I am not planning to get pregnant in the next two years, I would really like to think about my options, to prepare myself when the time is right. I have always planned on having a homebirth with a midwife to assist. I really want the opinion of someone who is not solely from the medical side of things. I know the doctors tell me what they think is the right thing to do but I have always felt that birth is a more natural occurrence than what the majority of the medical society seem to believe.

— Deborah

A: There may be a higher risk of preterm labor, but it's not as if you can't plan a homebirth and then go into the hospital if your baby comes early. I am a NYC homebirth Midwife. If a patient of mine goes into labor before 36 weeks, she has her baby in the hospital. If you don't—Bravo! Good Luck.

— Cara Muhlhahn, CNM

A: I had the opportunity to care for a woman with a septate vagina, two cervixes, and a uterus didelphys during her pregnancy and natural birth. Although she had the baby in a hospital, she was ambulatory, unmedicated, and intermittently monitored, and the birth could very well have taken place at home. The only issue during the otherwise uncomplicated pregnancy was that the other side of the uterus bled or spotted at first, but the pregnancy itself was fine in its own side. There was no premature labor or need to consider a cesarean section for any reason. The birth was uncomplicated entirely, and as I said could have taken place at home. The only issue that was significant was that the vaginal septum tore during the birth, and due to the swelling and distortion after I repaired it, it just was not right, so I removed the stitches on the spot and revised the repair, which thankfully healed beautifully. It might be an option to have a vaginal septum removed prior to becoming pregnant to avoid this, but certainly having a skilled pair of hands available at the birth would be helpful as it was tricky to repair and reattach the swollen septum after the birth. Keep in mind that this is only one example and experience, but now you know it can be done!

— Eden G. Fromberg, DO, FACOOG, DABHM
SOHO OB/GYN, New York City

A: Read Spiritual Midwifery, an older copy if you can find it. The Farm midwives delivered a woman with your condition. The most important thing to remember is that you have less space than a single uterus but the uterus is a muscle and it can stretch! You may need to get off your feet more when you are pregnant make sure that you are well nourished and well hydrated. But that is all part of taking care of yourself when you are pregnant regardless. Good Luck. Don't listen to fear mongers and naysayers!

— Kathy Metzler, RN


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.


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Think about It

In 1965, the c-section rate was 4.5%, according to the World Health Organization. In the 1990s, the rate was reported to be 21%. It has continued to creep up, until now the rate for 2007 is expected to be one in every three babies!


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Feedback

I'm still gathering data on shoulder dystocia births in which the practitioner used the all-fours or Gaskin maneuver. I need the following information:

Month and year of birth
Mother's parity
Gestational age
Baby's weight
Apgars at 1 and 5 minutes
Baby's condition after birth (neuro, physical, etc.)
Condition of mother's perineum
Measures tried before all fours position
Measures tried after all fours position, if that is not sufficient
Maternal complications
Fetal complications
Place of birth
Attendant

This can be sent to me at: inamaygaskin@gmail.com or
Ina May Gaskin
149 Apple Orchard Lane
Summertown, Tennessee 38483 USA

Thanks from Amsterdam!
Ina May Gaskin


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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California Association of Midwives annual conference is May 16–18. Pam England, Robbie Davis-Floyd, Mary Jackson and Ray Castellino, Karen Strange and many more! www.californiamidwives.org or Fawn (707) 251-8747.


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