May 11, 2016
Volume 18, Issue 10
Midwifery Today E-News
“Uncommon Complications”
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In This Week’s Issue

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Download Hemorrhage and you’ll receive a collection of 11 articles by the brightest minds in natural childbirth. Articles in this e-book include “Preventing Postpartum Haemorrhage” by Michel Odent, “Postpartum Hemorrhage in Bali: A Day at Bumi Sehat” by Robin Lim, “Hemorrhage: Stay Close and Pay Attention to Your Mothers” by Judy Edmunds and “Preventing Postpartum Hemorrhage by Respecting the Natural Process of Third Stage” by Beth Anne Moonstone. All articles were previously published in Midwifery Today magazine.

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Quote of the Week

If birth matters, midwives matter. In Europe, there are hospitals where the cesarean rate is less than 10%, and you’ll find midwives in these hospitals, you’ll see a lot less re-admissions with infections and complications, and you’ll see a lot less injury to mothers.

Ina May Gaskin

The Art of Midwifery

It is so important during the prenatal period to find out what makes a mother “sick to death.” Never underestimate the effect of a situation where the mother feels she “would rather die” than deal with it. Eating fresh food can only go so far if something is eating away at a mother’s soul. Care about what she cares about. She is deep in a river that is carrying her to an unknown shore and she needs companionship. Step into the river and journey with her until you can see clearly what it is like to live her life.

Sister MorningStar
Excerpted from “Sick Pregnancies,” Midwifery Today, Issue 112
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Midwifery Today Conferences

Fernando MolinaAre you ready for uncommon complications?

Listen and learn as Fernando Molina shares his experiences to illustrate assessment techniques, problem solving and ways in which you can build your self-confidence in dealing with emergency and unusual situations. He will present ways to be more prepared for uncommon complications such as unusual bleeding, thrombocytopenia, meconium, neonatal jaundice, hematoma formation, signs of embolism and more.

Learn more about the Suva, Fiji, conference, 20–24 June 2016..

Improve your midwifery skills

Attend the full-day Midwifery Skills class with Cornelia Enning, Carol Gautschi, Mindy Levy, Fernando Molina and Eneyda Spradlin-Ramos. Topics covered include Handling Birth Complications in Waterbirth, Helping Mothers through Trauma, and Miraculous Beginnings.

Learn more about the Strasbourg, France, conference.

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Editor’s Corner


There are many common and uncommon complications. Many, if not most, can be ascertained ahead of the labor and birth process. The complications that cannot be sorted out are the ones that make having a knowledgeable, loving midwife a really good idea. Midwives are trained to deal with the many things that come up in labor and birth. One of the more common complications is hemorrhage after birth. It can be minimized by not disturbing the oxytocin flow, which means, as Michel Odent says, “Do not disturb the mother.”

The one thing that I think the whole world should know about is using the cord or membranes to stem bleeding if the placenta is still inside the mother and using some of the placenta if it is delivered. When we did our Tricks of the Trade circle in Harrisburg, this subject came up. One mom, once she ate a bit of the placenta, wanted more and more of it. One thing that was said is that maybe a small piece placed buccally wouldn’t work to stem a bad hemorrhage but maybe a larger piece would. The midwife said the woman probably consumed a cup of placenta! Please keep this important cure for hemorrhage in mind when doing births and remember that we have a few examples where a piece of cord was placed buccally to bring out the placenta. Do wait until the cord stops pulsing before using this method. Membranes are available once the baby is out though!

I really believe this knowledge, if applied to the whole world of birth, would save many lives. I am hoping the ICM (International Confederation of Midwives) picks up on this knowledge and spreads it! The thing is, unlike other medications, the placenta and membranes are always available!

— 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.

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Conference Chatter

“Uncommon Complications” is a very important class that we routinely cover in conferences. Dr. Fernando Molina will be teaching on this topic in Fiji and in Strasbourg, France. It is a great class. In Strasbourg, Gail Hart and Tine Greve will do a shoulder dystocia class and Diane Goslin and Gail Hart will be covering “Second Stage Issues.” Midwifery Today concentrates a lot on getting important and lifesaving issues covered in conferences as well as in our magazine.

Our conference in Harrisburg, Pennsylvania, was a fantastic event. (See conference scrapbook here.) It is so important to do face-to-face conferences, and so we plan to keep doing them! There is something about being together to learn, hug and share that is truly special.

Many people cannot attend a conference because of being on call or because of cost or other issues. We therefore plan to do online classes as well as face-to-face events to bring you the best of what Midwifery Today offers. “Uncommon Complication” might be available online soon!

— Jan Tritten

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Featured Article

When Pregnancy Goes South: Keeping Birth Gentle

Suffering in childbirth need not be the norm, for without drugs and without medical interventions imposing iatrogenic risks, healthy, well-supported women, carrying healthy babies, may make the passage of childbirth with dignity, surrounded by people of their choice, with joy, grace and even pleasure. The gentle birth movement advocates for the basic human right of women to labor and deliver their own babies with respect from their health care providers, with support for their choices and privacy. Furthermore, families and wise health care providers are advocating for the rights of babies to be handled in a way that does not impair their future health, well-being, intelligence and longevity, i.e., delayed umbilical cord severance and skin-to-skin uninterrupted contact with mother following birth. Clearly, much of the trauma experienced by mothers in childbirth and babies at birth is preventable.

As a midwife, I find myself walking the delicate line between completely advocating and supporting every mother’s human right of choice in planning her baby’s birth and needing to sometimes become the “bad gal” when risks determine that a particular motherbaby must be referred for obstetrical care.

As a midwife, I do not often refer mothers to obstetrical care, unless it really is important to do so. Bumi Sehat Bali* has about a 2% rate of referral for cesarean among mothers who begin labor with us. Sometimes transport is really needed; other times it is caused because of the national protocols we must adhere to in order to keep our licenses. Other times, transport happens because of pressure from the extended family, especially when labor is long. This is cultural and cannot be avoided. We try to support families to make wise decisions by keeping them informed of the mother and baby’s health status throughout labor.

Last night, our team of Bumi Sehat midwives supported four birthing motherbabies. One was a VBAC, who was told by doctors on two islands not to attempt a natural birth. Our back-up Ob/Gyn advised her to try a natural birth at Bumi Sehat. Her birth was lovely, and her baby girl was a good size—3.8 kg (about 8.4 lb). Next we helped a first-time mother with no apparent risk factors; she also did very well and birthed her baby boy in a side-lying position. Another was a first-time mother, who was told she must have an elective cesarean birth because her eyesight is -7 (which is not really that bad, by the way) and a natural spontaneous vaginal childbirth would pose a risk of retinal detachment. Fortunately, this young mother did her research and found no reason for her to elect cesarean to preserve her eyes**. This young mother’s birth was glorious as she squatted in the water tub, singing. The next mother to birth was a second-time mom, who was quite malnourished, but showed good lab results. She did have a mild shoulder dystocia, which was resolved by the Gaskin (hands-and-knees) maneuver. She lost 450 cc of blood, which is not unusual given the normal Indonesian diet of white rice and GMO soy tempeh.

One would think that all mothers are willing to give up their plans for childbirth without interventions should medical procedures become necessary for the baby and/or mother’s safety and well-being. This does not mean the birth cannot be gentle and respectful. I have witnessed many necessary, gentle, miraculous cesarean births.

*To donate to the Bumi Sehat Foundation, please visit the Bumi Sehat Foundation website. The organization is always in need of funding, and with the incredible need they face in their country, it is vital that readers of Midwifery Today and others around the globe give financially to keep the organization afloat.

**We concluded that prenatal treatment of asymptomatic retinal pathology is not indicated and that spontaneous vaginal delivery may be allowed to take place in women with high-risk retinal pathology. (View reference)

Robin Lim
Excerpted from “When Pregnancy Goes South: Keeping Birth Gentle,” Midwifery Today, Issue 113
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Website Update

Read this article excerpt from Midwifery Today magazine, now on our website:

  • Outside the Evidence: Births Missing from the Research—by Sarit Shatken-Stern

    Excerpt: We worshipped the evidence. From the evidence, our managers made protocols for every scenario. I never read the protocols, but it wasn’t necessary. I was acculturated to the rules at every signout when I’d be asked my plan, and the correct answer was always eventually, “If she hasn’t changed in two hours, start Pitocin.”

Birth Q&A

Q: What uncommon complication have you experienced in your practice? How did you handle it?

— Midwifery Today

A: Shoulder dystocia with anterior nuchal hand. It was very stuck. Hands and knees, pushed hand back in, delivered posterior arm, then posterior shoulder, anterior shoulder still stuck, rolled to left side and delivered anterior shoulder, then baby came. Nuchal cord x 2, unwrapped and delayed cord clamping. Mom had a small laceration that did not require stitches. Baby’s Apgars were 7 and 9.

— Vicki Gilbert Ziemer

A: Biliary atresia twice in 550 births when incidence is 1/18,000 live births. This is a rare liver disorder babies are born with. An early symptom would be prolonged or late on-set jaundice developing at 2–3 weeks of age. With the first incidence, I phoned the mother after seeing a Facebook photo of her baby at 3–4 weeks because he looked yellow. He had been fine at our 2-week appointment, so it didn’t make any sense. After a few weeks of testing, he was diagnosed. He didn’t make it, and he died at 11 months waiting for a liver transplant his uncle was lined up to donate to him.

The second incidence was a few years later. This little boy presented with unusual bruising and jaundice at about 2 weeks. We couldn’t make sense of it and wondered if it was caused by the toddler or the dog or someone else. We just couldn’t explain the numerous quickly-developing bruises. This mother hadn’t wanted vitamin K at birth so we advised having it then since more bruises would appear overnight. Baby was admitted and we all thought he had a vitamin K deficiency. He was diagnosed fairly quickly with biliary atresia. He had a procedure done to reset his bile flow from the liver to the intestine (in atresia, flow is blocked and backs up into the liver). He will be 2 this summer and is doing well. He will always need treatment but can live his life.

It’s remarkable to me that for most homebirth midwives, they won’t attend 18,000 births in a lifetime, and so they probably will never see this complication, but I’ve seen two in 550 births.

— Kate Aseron

A: Of course this had to happen during a snowstorm, way out in the country. All had been going smoothly with a good heart rate; the mom was relaxing well with contractions, etc. Water broke like pea soup. Then the fetal heart tones were 40, where they had been 140 just 10 minutes earlier, with good variability. Mother was dilated to 7 cm. I panicked! I roughly manually dilated her, then told her to push. She said she wasn’t having a contraction. I said, “I don’t care. Push!”

In seven minutes, the head was out and in two more minutes the body was out. After two minutes of resuscitation, all was well. She’s a grown woman now, quite healthy and competent.

— Marlene Waechter

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