April 14, 2010
Volume 12, Issue 8
Midwifery Today E-News
“Second Stage”
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Quote of the Week

“We help her all we can, but in the end, though we scream at the angels and rip their wings apart for her, it is only she who can birth her baby. This is ever and always a miracle.”

Robin Lim


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The Art of Midwifery

Salty Solution

For the woman who is already vomiting and acting transitional before 7 cm, administer some kind of salty soup or broth, such as chicken bouillon or miso, to sip between contractions. A half cup is usually enough to stop the vomiting.

— Excerpted from Midwifery Today's Wisdom of the Midwives, Tricks of the Trade, Vol. II
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Jan’s Corner
Know the Baby: Checking for Cephalic Prominences

There is a great way to check for the vertex and flexion of the baby's head before labor. I was taught this hands-on skill three decades ago. My midwife partner, Monika, and I enjoyed the prenatal process of checking for this in the palpation process. It is/was called "checking for cephalic prominences." I could not find it in any textbook except a really old, 1975 version of Textbook for Midwives, by Margaret F. Myles. She was our best reference in the 1970s, when I was a happily practicing homebirth midwife.

I was surprised when I taught it at our roundtables in Denmark last year. Out of the 75 people, mostly midwives, who attended my three roundtables, almost no one knew about it. So, I want to share it with you. According to Myles, "To determine if the vertex is presenting the two cephalic prominences, the occipital and sincipital, are located. The higher one will, if on the opposite side from the fetal back, be the sincipital and this denotes a vertex presentation, head flexed. In the face presentation the higher cephalic prominence will be on the same side as the fetal back." This is just another way of knowing what is going with the baby. One of the important reasons to know this ahead of time is because if the baby is in an unfavorable position you have time to correct with various exercises. Join us at the Philadelphia conference to learn many more hands-on skills. This also will be easier to show you in person.

Birth is a process that probably lasts about a month or more, when you think of how the baby works his/her way into position, mom's body prepares with the uterus thickening at the top and thinning at the bottom and the cervix prepares itself to dilate for the final pushes in this process. It is such an amazing, divine plan and in this day and age so easily disturbed—possibly as never before. I think induction, possibly in any form, can disrupt this plan, interrupting the baby's process of positioning and getting ready to be born. As Carla Hartley says, "Birth is safe, interference is risky."

Jan Tritten, mother of Midwifery Today magazine

Jan Tritten is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.

Jan's blog: community.midwiferytoday.com/blogs/jan/default.aspx
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Research

Training midwives and other birth attendants how to perform low-cost interventions, including neonatal resuscitation and kangaroo (skin-to-skin) care could save more than one million babies’ lives each year, according to a recent study published in the New England Journal of Medicine.

“Major global causes of perinatal mortality are asphyxia at birth, low birth weight, and prematurity. Low-cost interventions … may effectively reduce deaths from these causes,” the researchers noted. “It has been estimated that introducing these interventions as a package might decrease perinatal deaths by 50% or more.”

Noting that, annually, there are approximately 3.7 million neonatal deaths and 3.3 million stillbirths worldwide, with nearly 40% of deaths among children younger than 5 occurring during the first 28 days of life, the researchers examined results from a study that trained midwives in Zambia using the World Health Organization’s Essential Newborn Care course.

The study tested the hypothesis that improving birth attendants’ skill level and knowledge of baby resuscitation would lower death rates during the first seven days after birth, among babies who weighed at least 1,500 grams and were born in rural communities in developing nations.

“A systematic review of the literature suggests that perinatal mortality may be decreased by training birth attendants,” the researchers stated. “Thus, wide-scale implementation and evaluation of evidence-based interventions are needed to improve perinatal outcomes, particularly in rural settings, where more than 50% of neonatal deaths occur.”

— Waldemar, Carlo A., et al. Newborn-care training and perinatal mortality in developing countries, New Eng J Med 362: 614–623.

Read here: http://content.nejm.org/cgi/content/full/362/7/614


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Positions for Second Stage

Position of the mother during [birth] can significantly influence the development of baby’s facial slant. The most common position for the [birthing] mother, especially in maternity hospitals, is the recumbent position. Mother lies flat on her back on a thinly padded metal delivery table, with her legs bent in the air. This position is most efficient for the obstetrician or birthing attendant. However, it is the most compromising position for the birthing baby. The mother’s tailbone is fixed in one position and is unable to tip out of the way as baby’s head grinds by it. Gravity is also disengaged as a birthing tool. The mother’s uterine muscles must increase the intensity of their contractions in order to assist the baby’s passage through the tight tube of the birth canal, causing baby’s head to grind with greater force against the mother’s tailbone. This will usually increase the degree of facial slant.

Positions that ease the birth of the baby and present the fewest compromises to the structures of the birthing baby include:

Kneeling position

This position is often used for the natural delivery of a breech baby. This position places the majority of the mother’s bones above the baby and out of the way of most bony contact. Gravity pulls the baby downward into the soft tissues of the mother’s abdomen. The kneeling position is used to stretch the muscles of the mother’s birth canal to make it easier for the baby to pass through. This position will often relieve back pain during labor and can be used as an alternative position. Its major drawback is that gravity is again working perpendicular to the intended exit.

Squat position

This is perhaps the oldest and most widely practiced of all birthing positions. It fully utilizes gravity in the direction of exit, the uterine muscles do not have to struggle as hard, and the mother’s tailbone has the ability to tip out of the way as the baby’s head passes. Although the squat position has been practiced widely throughout the world, especially among ethnic peoples, its use is discouraged in the United States. This position is very inconvenient for the birthing attendant. In the 1980s, however, a number of avant-garde maternity hospitals provided “squatting poles” for their maternity rooms, allowing a return to this more natural style of delivery.

Justine Dobson, DC, LMT
Excerpted from "Birthing Choices," Midwifery Today, Issue 33
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Web Site Update

Read these article excerpts from the most recent issue of Midwifery Today newly posted to our Web site:

  • The Question of Homebirth—by Sister MorningStar
    “Since when do we need an expert to tell us where we are comfortable? Since when do we need an expert to tell us with whom we feel relaxed and open and able to poop or make love or birth a baby? Since when was there an animal that didn’t know how to protect itself—to flee or scratch and bite or growl when it isn’t comfortable?”
  • My Journey into Planned Homebirth in Venezuela—by Fernando Molina
    “Having my first son, Fernando Javier, at home back in 1983 was one of the most challenging times of my life, but also opened a door to the sacred pathway I would follow in the years to come. The experience assured me that homebirths were possible and safe, in spite of what they teach us in medical schools.”

Read this book review from Midwifery Today newly posted to our Web site:


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Question of the Week

Q: What was the longest second stage you’ve experienced, and how well did mother and baby pull through?

— Midwifery Today staff


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: My son, my first child, was born early at 35 weeks and no one was ever able to tell me why. My labor was very fast once my water broke (2 hours). He had to visit the NICU at the hospital for over a week due to respiratory and feeding issues. I want a homebirth this time around so badly. What natural methods can I do to increase my chances that I’ll go to at least 37 weeks this time around? Thank you.

— Jill Klink

A: Hi Jill, You might want to check out the article, “Prematurity Is Preventable!” on reducing prematurity through proper pregnancy nutrition, which was published in Midwifery Today, Issue 72. http://www.midwiferytoday.com/products/mt72.htm

— Amy Haas


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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Letters

Dear Midwifery Today,

Is there anyone interested in traveling to Bolivia to attend a birth in June? I have a client who is moving there in April and she is a candidate for a lovely homebirth, but lacking a midwife. If anyone is interested, please contact me!

Also, feel free to contact me if you know someone there or a midwife who would be willing to travel. My e-mail is mhairi.colgate@gmail.com.

Mhairi Colgate


Dear Midwifery Today,

Shanti Uganda is looking for an amazing midwife volunteer in Uganda to help our project coordinator get our newly constructed birth house up and running. With the birth house built, we will now be taking the next two months to prepare for our expected opening in June 2010. This position is open to existing midwives who are willing to help with our staff orientation, establish our prenatal education program and work with our project coordinator on our birth house guidelines and needed supplies.

For more information, please contact Kristen, our project coordinator via e-mail at kristen@shantiuganda.org

Natalie
The Shanti Uganda Society www.shantiuganda.org


Dear Midwifery Today,

Thank you so much for your articles on Ultrasound and Autism. I included a link to the articles in the monthly newsletter I send out to more than 700 of my past and present Bradley Method and prenatal yoga students. I found the response from some of my students surprising. Some were angry, some were scared, all were astonished and made to think. Some asked me why this information isn’t in the mainstream. Good question. Maybe because ultrasound is a big money maker for lots of people. I appreciate getting your newsletter and passing along the information. “Waking up” my mothers-to-be is challenging but rewarding.

Thank you,

Liza Janda, E-RYT, AAHCC www.yogajanda.com


[Editor’s Note: The following letters are in response to Jan Tritten’s editorial, “Healing after a Traumatic Birth” (Midwifery Today E-News, 12:6), which posed the question, “Is it possible to heal after a traumatic birth?”]

Dear Midwifery Today,

In response to Jan Tritten’s last editorial, I don’t believe it is entirely possible to completely heal after a traumatic birth experience, as the trauma continues long after the birth is over.

My trauma continued as I became very ill after the birth, my daughter was ill and suffering with seizures and food allergies and intolerances, crying syndrome and various immune difficulties, my relationship with my partner ended most likely due to the severe postpartum depression, caused by a reaction to the drugs during the birth. Due to the physical trauma during the birth, I also completely lost my sexual drive or any desire to continue having children. During this time I also had to change my career mid-stream as a single, or co-parent with those responsibilities—challenging to say the least. The trauma continues like a domino effect throughout my life.

Looking back over the past 14 years since the birth of my daughter, I can truly say that what does heal the wound is when I hear another mother say that because of the childbirth book I wrote and my television channel, she feels calm and confident about the upcoming birth of her baby.

I heal a little each time a mother says to me that reading my book allowed her to heal enough from her first birth to risk a second baby. I heal a little bit more when the charity I created 10 years ago raises more funds for childbirth education for the public. And I heal a little bit more when I have the opportunity to speak and show films to rooms full of bright, young university students open to looking at birth in a whole new light. When the healing is complete, I may find another path in life. I am sure this healing process has kept my passion alive through the years.

Looking back, part of me is grateful for my traumatic birth experience. Because of that, my daughter’s birth experience and her daughter’s birth experience will be very different. If I had been able to accomplish the birth that I dreamed of—the midwife-assisted waterbirth in the free-standing birth center—I am sure I would have picked up my non-traumatized baby and myself with my partner after the birth and went home without a backward glance.

Because of my traumatic birth, thousands of women have had and will have an easier birth in the past and upcoming months and years. All of this helps make me feel a little bit better and so, so very grateful for my family, my career and the opportunity to gather our women’s wisdom together to assist each other.

Without your traumatic experience, Jan, and mine, I would never have had the opportunity to meet a kindred soul, such as yourself, and to consider myself very lucky to have known your brave and generous spirit. Thank you for all you have done for our mothers and babies throughout the years. We are blessed to have you in this community. Your contribution to our collected wisdom on childbirth is truly a great gift to our world.

Gail J. Dahl, executive director of the Canadian Childbirth Association


Dear Midwifery Today,

I do believe it is possible to heal from a traumatic birth and I’ll share how I did it.

I had planned a homebirth with my fourth baby. My three older children were from a previous marriage and 17, 18 and 20 years old. (I wasn’t “allowed” a midwife with my first husband). I had a midwife with my fourth child and all seemed well.

Around 32 weeks, during my prenatal visit, I insisted that something wasn’t right; my belly seemed to have stopped growing, even smaller somehow. So I went for an ultrasound. They did the scan and were saying, “Congratulations, everything is fine,” so I repeated my unanswered questions, “How big is she? How much does she weigh?”

The technician took a few measurements and went off to get the doctor again who took his own measurements and then shattered my world, saying, “The baby weighs about two pounds; you have to go to the hospital right away so they can take her out! She’ll grow better out!” I felt as if I had been thrown off the exam table and pushed out the door. I called my midwife, who sent me to the hospital. The doctor did an NST and I was told to go home and wait, they would get back to me. A week went by before I was contacted. I was dying inside, not knowing if my baby was going to be okay. I went back on the following Friday and they did another ultrasound and NST. The doctor explained that the blood stopped flowing between pulsations but the baby wasn’t showing any signs of distress. So, I was told: come back tomorrow and Sunday or Monday we’ll send you to the children’s hospital and they’ll decide how to proceed.

My anxiety grew…by the next morning I thought I couldn’t breathe and my blood pressure had gone up. What was supposed to be a 15-minute test turned into a weekend in the hospital before being transferred to the children’s hospital.

On Monday my husband met me downtown for the test and the technician doing the scan looks up at us and said, “It’s serious, you know. The blood flow is reversed and she’s dilated all the vessels in her brain. She’s got to come out now.” I didn’t want a c-section and told them my last was born within three hours. So they agreed to let me try to deliver vaginally. They gave me a dose of steroids to help develop the baby’s lungs and I had to wait 24 hours to receive a second dose before delivering. (What happened to now?)

That evening they came to my room and said they were going to put a catheter in my cervix and blow up the balloon to dilate my cervix and “prepare” it for delivery. I refused, saying if they started the contractions now I wouldn’t have received the second dose of steroids and they would not have time to work. They came back and gave me the second dose (12 hours early) and insisted I have the procedure done. I reluctantly went with the nurse.

I was met by a student who had never performed the procedure. She had to start over three times and my contractions started quite violently. Now they were a little worried.

I was monitored for an hour and sent back to my room…but after an hour the thing fell out and I was dilated to 3 cm. They told me to lie down and not move in hopes that the contractions would stop and they would not put it back in.

I was supposed to be induced first thing in the morning—which dragged on until 2 pm—where a replacement receptionist called me on my room phone and said, “Mrs. Brown, we’re ready to induce you, please come down to the delivery room.”

Once inside the delivery room they proceeded to “hook me up” to the Pitocin drip, antibiotics “just in case” and magnesium sulphate (because my BP had gone up for two days and was normal now.) My midwife arrived while all this was going on. I refused the magnesium sulphate and the young resident said, “Then we’ll refuse to treat you.” Then he asked if I wanted an epidural…again I refused so he snickered, “Women usually end up screaming for it by the second contraction.” I wanted to kick him.

Fortunately he was stopped by the attending from breaking my water since the baby was still floating around.

The instant the magnesium sulphate hit my veins I felt terrible, and I was not allowed up from bed.

If magnesium sulphate is used to stop labour when given before 5 cm dilation, why the heck would you give it while giving Pitocin when trying to start labour? Well, that is something that never occurred to the resident, so he kept upping my Pitocin until I felt myself slip away—and it wasn’t like fainting. Then I heard them say they lost the baby’s heartbeat and this brought me back. The attending had rushed back in and stopped all meds…and told the student to wait before starting them up again and to do so slowly.

We’d been at this from 2 pm until midnight and I was only at 5 cm.

Then I felt the baby’s head touch down during a contraction. The resident insisted on breaking my water, and screwing a monitor onto the baby’s head. So I told him to hurry up because I wasn’t going to endure a contraction lying on my back. He screwed it in so tight that he pulled a cylinder of skin from the baby’s scalp. So he had to try again. Once it was done, I sat up, one leg off the side of the bed to the floor, the other knee bent and I leaned on my midwife. She felt my body stiffen during the contraction and whispered in my ear to push during the next contraction. When the next one came along, I pushed and lay back down on the bed to let Zoey out. Marie-Paule had grabbed my husband’s arm so he could see his daughter arrive and the doctors stared over my head at the monitor indicating they had once again lost the baby’s heartbeat. They never even saw her lying on the bed.

The next three weeks were a struggle and a fight to be able to breastfeed my tiny 2.5 lb baby and leave the hospital because their ideas and my instincts were not on the same wave length. We went home and my midwife continued to follow Zoey who did extremely well and is a healthy and very much alive 22 month old today without any medical or developmental problems.

I on the other hand felt angry and violated by the experience. I felt as if I had been screaming at the top of my lungs for someone to listen to me when I knew there was a problem with the baby, and then being ignored by the resident because apparently he knew more about me and my body then I did—and being threatened by him?!

The technique that really helped me move on was called “reframing the past.” It was something I had read and decided to give it a try.

Basically, you go back to the incident as a kind of observer and identify your needs at that time. For example, I needed to be heard and I needed to be respected. I needed someone to stand up for me and say no. I would have needed them to not go into “overkill” with procedures that caused more harm than good.

We can’t change what was, but in identifying the needs according to the situation and being honest it really helped me. It brings understanding and I know for sure that if ever something similar was to come again I would stand tall when needed and have more control. My husband and midwife helped, too, when I discussed how I felt about what happened and when I identified what I would have needed, my role and theirs.

Last month I lost my baby, Emma, at 30.5 weeks. My water broke at 30 weeks (on a Tuesday) and I was sent to the hospital, then transferred to another hospital. They gave me Betamethazone to mature her lungs. (The neonatologist said later that since she found herself without water she naturally secreted cortisone to develop her lungs and the injection wasn’t really necessary, not to mention that this medication is used for people with auto-immune diseases so their immunity doesn’t attack their body…a stupid thing to give a baby in an infection high-risk situation.)

By Friday my fluid started to smell and I told my nurse. Then it started coming out pink. The baby’s heart rate went up to 178 (it was around 140 before this) the nurse went to tell the doctor who was at the nursing station. Then I started having cramps, but no contractions. The baby’s heart rate went back down to 140 but was so weak we couldn’t hear it. The nurses tried changing Dopplers, changing nurses, brought in the NST machine, changing nurses again, then Dopplers. Finally, almost eight hours later, they brought me for an ultrasound. The doctor turned the monitor to me and said, “This is the heart, there’s no activity. The baby’s dead.” And after a pause, he said, “Now you have to deliver it.”

Then she told me the baby was head down. And yet, my dead child with no more amniotic fluid came out feet first.

I’ll let you know if I can get over this loss.

Debbie Brown


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