|March 14, 2012|
Volume 14, Issue 6
|Midwifery Today E-News|
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…when you attend the full-day class, “Developing Your Breech Skills.” Topics covered include how to turn breech babies, palpation skills, estimating fetal weight, amniotic fluid, and how to communicate with the baby with touch and words. Frank, footling and complete breech will be discussed, as well as cord prolapse, fetal heart tone, and recognizing intrauterine growth restriction. You’ll also learn the factors which may lead to breech presentation, and when external version is contraindicated. Teachers include Betty-Anne Daviss, Ina May Gaskin and Michel Odent. There will be time for hands-on practice. This class is part of our conference in Harrisburg, Pennsylvania USA, April 2012.
Attend the two-day Midwifery Skills pre-conference class at our conference in Bad Wildbad, Germany this October. Topics covered include fear, counseling, prenatal care, twins, avoiding labor complications, second stage, Mexican techniques and much more! Check the program for more information, then register for one or both days! [Photo by Caroline Brown]
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In This Week’s Issue
Quote of the Week
If a woman doesn’t look like a goddess during birth, then someone isn’t treating her right.
— Ina May Gaskin
The Art of Midwifery
The worst thing that can happen to a baby whose amniotic fluid is meconium-stained is to amputate the placenta. This organ functions for as long as 20 minutes after the birth and allows the newborn to snort, swallow, sneeze, cough, spit up and do all the myriad automatic survival functions with which the human body is blessed. Of course, if the baby has been exposed to epidural anesthetics and a Pitocin drip for 18 hours before she emerges, her body will be traumatized and this automatic nervous response may not occur. If it was my child or grandchild, I’d especially want to be at home with meconium in order to give the baby the best chance possible to clear its own lungs and airway.
Leave the umbilical cord intact; really look at the baby and see if it has good muscle tone and a strong heartbeat. Research has shown that “vigorous” newborns do not benefit from suctioning. Don’t mess with a baby that is doing fine. Sometimes the nervousness of the practitioner can cause the problem of meconium aspiration syndrome.
ALL BIRTH PRACTITIONERS: The techniques you’ve perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to firstname.lastname@example.org.
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Meconium and the Art of Midwifery
I had a case where we had old flakey meconium in early labor, but by the time the birth happened about 12 hours later, it was completely clear. Perhaps the baby swallowed and removed all of his amniotic fluid in this amount of time. Meconium is another one of those birth issues that make the homebirth midwife go on high alert. “Do I need to transport? … Is the baby stressed or compromised? … Will there be more meconium?”
PROM (premature rupture of membranes) is another high alert issue. As I think for a minute, there seem to be many of these dicey issues. This is partly what the art of midwifery is about. I am sure you can think of many more, such as long pushing stages and prolonged labor. What is prolonged labor anyway? Is “rest and be thankful” stage okay? And how long is too long? When you boil it all down, the answers seem to lie where clinical issues meet relationships. Our relationship with the mom, baby, dad and the rest of the family, taking into consideration their wants and needs balanced with the protocols of the medical community, our back up and our license (to say nothing of the new techniques that rear their ugly heads without evidence to recommend them) all have an impact. Whatever happened to amnioinfusion? Gone, I hope!
Art, love, safety, joyous birth—how to blend these takes careful practice. The midwife really does have to be an artist in so many ways. She needs to learn the dance of putting motherbaby first, while at the same time keeping them safe without sacrificing them to protocols. One of the things I tell beginning midwives is, “Midwifery will take all the love you have to give and then some more.”
— Jan Tritten, mother of Midwifery Today
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.
Midwifery Today on Facebook: facebook.com/midwiferytoday
News and Research
Brown rice syrup is a common ingredient in organic foods including organic powdered infant formula. You may want to forego buying an item, particularly one that is for your baby, if brown rice syrup is listed first among ingredients. A recent study has found high levels of potentially toxic arsenic in brown rice syrup.
A team of Dartmouth researchers, led by environmental chemist Brian P. Jackson, found “dangerous” amounts of arsenic in organic powdered infant formula whose top ingredient was brown rice syrup. The formula was reported to contain an alarming amount of arsenic—six times more than what the Environmental Protection Agency deems is safe for the water supply.
Elevated levels of arsenic were also found by Jackson and his team in some brown rice sweetened cereal bars and energy bars. This led the researchers to believe an urgent need is present for regulatory limits on arsenic in food.
Jackson was originally studying arsenic levels in major brands of baby formulas, but even those made with rice starch were low. However, two organic baby formulas (one milk-based, the other soy-based) made with brown rice syrup had 20 to 30 times more arsenic than the other formulas.
“There’s been quite a lot of press on arsenic in rice in the past six years, but less so on the rice products,” Jackson told ABCNews.com. Americans are unknowingly ingesting more arsenic with the increasing trend of switching to more organic packaged foods, gluten-free products and products made from rice instead of wheat flour.
— Allen, Jan E. “Organic Brown Rice Syrup—Hidden Arsenic Source.” ABC News. February 15, 2012. http://gma.yahoo.com/organic-brown-rice-syrup-hidden-arsenic-source-194615982--abc-news.html
Meconium Isn’t the Problem; Induction Is
Meconium is not a problem—unless it is a symptom of severe distress. Even then the problem is the distress, not the meconium. With good fetal heart tone and a normal labor, even thick meconium is rarely a problem.
Meconium is more common in induced labor. Whether meconium is even more common in postdates labor is debatable, since women with postdates pregnancies are more likely to have their labor induced. I recently came across a retrospective study that evaluated the likelihood of the presence of heavy meconium as a risk for meconium aspiration (Usta, Mercer and Sibai 1995). The study is somewhat old, but large. It looked at almost a thousand babies with “thick or moderate meconium.” While a variety of factors were found to contribute to the rate of meconium-stained amniotic fluid, only about 4% of babies actually developed meconium aspiration syndrome (MAS) (39 out of 937).
Induction was a strong link to both meconium amniotic fluid and to MAS but (and this surprised everyone) postdates was not found to be a factor in the babies who developed MAS: MAS was distributed equally among all gestation groups. MAS was correlated with thick meconium primarily when other risk factors were present. These include the need for resuscitation, poor heart tones and cesarean.
Induction of labor had the strongest association with MAS. We know that we see more meconium in induced babies, and we know we see more MAS in induced babies. A logical guess may be that we see more meconium in postdates babies simply because postdates babies are far more likely to be induced than are 40 week babies.
This study confirms what most of us have seen: The presence of meconium, in itself, is rarely a problem even when it is thick.
Web Site Update
Read this editorial by Jan Tritten from the newest issue of Midwifery Today, Spring 2012:
You may check out the table of contents of the Spring issue of Midwifery Today here. The theme is Breastfeeding.
Q: Under what circumstances do you transport from a homebirth for meconium? Do you stay home under some circumstances with meconium?
— Midwifery Today
A: Speaking of meconium, there is a lot of confusion differentiating between “old” and “new” meconium. Old is greenish or yellowish and thin, but I have seen countless doctors and midwives declare it to be “new.” New meconium is ropey or clumpy, thick and black or dark brown and is much less commonly seen during labour, and somewhat more of a concern than old meconium. Correctly identifying whether the meconium is old or fresh is an important clinical task and is so often misidentified.
— Serafine Nichols
A: I’ve not seen PROM with meconium end well at home.
— Erin Ellis
A: Three questions: 1) Mum okay? 2) Baby okay? 3) Midwife okay? If you can close the circle on all three, then stay home; otherwise, transfer!
— Maureen Collins
A: I’ve actually never had a case of a baby aspirate meconium as it’s being born. The cases I have read about are where the outdated practice of suctioning on the perineum actually caused more harm than good by doing “blind suctioning.”
— Carrie McIntosh
A: If ROM occurs with thick meconium before labor or in very early labor (not yet good contractions), I will go in even if heart tones are good. I think this is a bad news situation. If ROM occurs in labor with meconium, then I will stay home if heart tones are perfect and labor progress is normal. I will transfer if anything is not “perfect.” I may transfer if the waters started clear at ROM but meconium is passing and becoming thicker unless progress is fast. Slow progress with meconium is another bad combination. I will always transfer if meconium occurs with poor heart tones unless it is too late to go; the same applies for poor heart tones with clear fluid. If I see no signs of distress, then meconium is ‘almost’ irrelevant.
— Gail Hart
A: I never break membranes at home. Most of the time, they break spontaneously when pushing is near. With meconium, transporting or not depends on how fast labour is going and also if it is old or fresh meconium. When water breaks in the beginning of labour and shows meconium, I will suggest a transfer. Most importantly, when you have meconium, respect the time between the birth of the head and the birth of the shoulders. When the head is born, usually there will be a pause, sometimes more than one contraction before the shoulders are born. You can clearly see then that the mucus and fluids come out of the mouth and nose of the child due to the compression of the thorax. When you keep your hands off, the baby will clear his airways himself in a noninvasive, nonharmful way, and he will be able to breathe without risk of meconium aspiration. Most problems with meconium occur when the child is suctioned on the perineum. You see that those babies are shocked at birth and have low Apgar scores. Most problems with meconium are iatrogenic, caused by the way the practitioner handles it. Since I know that babies are perfectly capable of clearing their airways themselves, I never need to suction anymore.
— Lieve Huybrechts
Wisdom from the Web
Robin Williams once described it [meconium] as a “cross between Velcro and toxic waste,” and he wasn’t just being funny! Why does it look like this? Because baby’s intestines have been accumulating this gunk for a good portion of your pregnancy, and it’s a concentration of the solid parts of things floating around in the amniotic fluid.
— Angela Burwick, midwife
Meconium is a mixture of mostly water (70–80%) and a number of other interesting ingredients (amniotic fluid, intestinal epithelial cells, lanugo, etc.). Around 15–20% of babies are born with meconium stained liquor.
— Rachel Reed, independent midwife
The use of acupuncture in late pregnancy is very valuable in preparing the body for labor. Find a practitioner who has experience with induction points, and expect that it will take about three treatments around your estimated due date to have an effect.
— The midwives of East Bay Homebirth Midwifery
If you’d like to share a bit of wisdom from the Web, please send a 4–5 sentence excerpt, accompanied by a link, to firstname.lastname@example.org.
Facebook and Midwifery Today Conferences
I totally enjoy Facebook. I use it almost exclusively for midwifery and birth. It is such a great way to get feedback and opinions from all kinds of midwives, doulas and other practitioners. I ask a question on my profile page and many diverse answers come. Midwives and moms message me with questions they have from politics to hospital protocols to shoulder dystocia and everything in between. The wise words of the varied voices make for an excellent way to get an answer, learn midwifery or keep up with new and old ideas!
Donna, our Marketing Director, and I create a page for each conference; here you can meet each other and have conversations. We also put up relevant information and changes to the program. Our 2011 Germany page is up even though we have a new one now for 2012. You could go read the older threads if you would like. Facebook has made for some fun communication. I really like working with it and the wonderful people I have the chance to meet on it!
http://www.facebook.com/Harrisburg2012 — This is our Harrisburg Facebook page. You will find out what we have planned, be able to look for a roommate, etc.
http://www.facebook.com/GermanyOct2012 — This is for Germany 2012. Even if you can’t join us there you can follow us on this page. We hope you can join us, though!
http://www.facebook.com/MidwiferyToday — This is our overall page. Donna puts up great MT articles and there are good conversations here.
http://facebook.com/JanTrittensBirthPage — This is my birth page. I developed this because I have a full set of 5,000 friends and “likes” on my personal page (Facebook unfortunately doesn’t allow more than 5,000), so please join conversations here if I haven’t been able to confirm our friendship on my personal page. Know that our friendship is intact though! You are able to post on both even if we aren’t “friends,” because I keep it open for anyone to post on.
— Jan Tritten
I went to a homebirth and everything went fine. We gave the new dad the job of taking care of the placenta. Usually, people here bury it under a tree. The next day, when we came back to check on the mom and the baby, we found out that the dad had flushed the placenta down the toilet! It had clogged the toilet and was causing a problem!
— Deborah Flowers
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Global health professionals: look here for hard-to-find technologies and tools for midwifery and obstetrics. http://maternova.net/products
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