January 1, 1999
Volume 1, Issue 1
Midwifery Today E-News
“Transportation”
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In This Week's Issue:

1) Quote of the Week
2) Welcome!
3) News Flashes
4) Transport: Planning Ahead
5) Transporting in the Hospital?
6) Who Am I to Judge? A Transport Story
7) The Art of Midwifery

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1) Quote of the Week: Encouragement is the true heart of midwifery.

- Roxanne Potter, midwife

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2) Welcome!

Welcome to Midwifery Today E-News! Quick, direct communication is a dream come true for us. There have been many times during the past twelve years of publishing a quarterly magazine that we wished we could inform you about something that was time sensitive. This format gives us a concrete and quick way to reach you in case anything of interest in the realm of midwifery takes place. As always, we continue to be dedicated to bringing you information you can use in every issue. Please forward issues of this newsletter to every midwife, doula, childbirth educator and interested parent you know. Our goal is to weave an extensive network of people interested in the midwifery model of care. With it we can "safety net" more and more mothers and babies all around the globe. Modern technology is providing the means--let's take advantage of it! As well, if you have a web page, please post information about this newsletter on it and help us get the word out. You do not have to be a subscriber to Midwifery Today magazine in order to receive this newsletter, but of course you are always welcome to subscribe. Our quarterly print publication has an impressive history of educating and supporting practitioners and parents of all walks.

Thank you for being part of this important network and for getting the word out. Please email us at mtensubmit@midwiferytoday.com if you have ideas, articles, techniques or news for the newsletter.

- Jan Tritten

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3) News Flashes

Nuchal Cord Entanglement

A study that looked at the outcomes of pregnancies complicated by a multiple nuchal cord entanglement included 8,565 deliveries. A single loop of cord around the fetal neck at delivery was found in 2,191 deliveries, and more than one loop was found in 326 deliveries. Pregnancies with a multiple cord entanglement were more likely to have an abnormal cardiotocograph consisting of persistent variable decelerations in advanced labor. These infants were also more likely to have meconium, a low Apgar score at one minute, and a low umbilical artery pH of <7.10. There was no difference in the rate of cesarean sections, placental abruption and Apgar scores at five minutes between the two groups, and no stillbirths occurred in the cord entanglement group. The study concluded that with multiple nuchal cord entanglement there was no risk of adverse neonatal outcome, and that a multiple cord entanglement is not a contributing factor in intrapartum stillbirth, placental abruption or cesarean delivery. (MIDIRS, December 1996)

Breastmilk Reduces Infection Rate in NICU

Breastmilk provided to very low birth weight, preterm infants in the neonatal intensive care unit (NICU) may decrease the chances of these infants acquiring infections in the NICU by 53 to 57 percent. Researchers from Georgetown University Miedical Center and Johns Hopkins School of Hygiene and Public Health studied the medical records of 212 very low birth weight, preterm infants who were hospitalized between January 1992 and September 1993. They compared the incidence of infections in infants who received human milk with those who received formula exclusively. The researchers discovered that 29.3 percent of the preterm infants who were fed human milk acquired infections vs. 47.2 percent of the formula-fed infants. in addition, sepsis and/or meningitis occurred in 19.5 percent of the infants fed human milk and 32.6 percent of the formula-fed infants. All infections occurred after the very low birth weight infants started receiving feedings. (Women's Health Weekly, September 14, 1998)

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4) Transport: Planning Ahead

During a home visit, I make sure the parents have posted emergency phone numbers by every phone in the house. The list should include: their hospital, the nearest hospital, the midwife's and assistant's numbers, the ambulance, a babysitter, their pastor, and relatives they would want notified in an emergency. I ask them to decide at this time if they would call an ambulance or drive to the hospital themselves.

I make sure I am familiar with all hospitals in the area. I have a general idea what their birthing policies are. Some hospitals still will not let support people in the labor room unless they are related. Depending upon the legal status of midwifery, some midwives cannot or are not willing to go along on a transport and parents should know this ahead of time.

Role playing is an important tool in conducting a smooth transport. I get together with my assistants and act out both simple and bizarre situations. We switch places so everyone gets to try out the primary role. This is good practice in case an assistant gets to the birth first and has to handle an emergency by herself. Things we think of: How to get mom down a flight of narrow circular stairs if she can't walk or if she is in a knee-chest position; how to transport an apneic infant to a hospital one half hour away in January; how to keep an infant warm; how to do CPR along the way, and so forth.

When a transport does occur, it is important to stay calm. I know the parents will look to me for strength. My assistants also look to me for guidance at this time. If anyone gets hysterical the transport will be a catastrophe. I use Rescue Remedy if I have time to swallow a dropperful. If not, I do some deep breathing which helps me calm myself and focus on the task at hand.

I write a summary of the labor to present to the hospital staff. Sometimes I bring the placenta for examination. If I opt for transporting before the birth, I bring along the Doppler and oxygen. Once we are in the hospital, I help the parents wade through "technojargon." I let them know they are still involved in the decision-making process. I'm a strong advocate. I try to be cordial and polite, not hostile, presenting midwifery as the gracious art it is.

I always go over the hospital bill with the family. Many of them have no insurance and I have found countless errors in billing. After my last transport, I found about five hundred dollars worth of errors that the hospital had to deduct.

I make myself available during the postpartum period. Families who go through a transport must heal from the experience. Often I have to address feelings of failure, disappointment and anger toward me. Keeping the lines of communication open gives all of us a chance to resolve the experience and come to peace with it.

- Marissa Neal, Midwifery Today Issue No. 24

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5) Transporting in the Hospital?

Don't think the concept of transporting applies just to home or birth center births. A midwife friend in Paris described a birth during which she simply needed a consult from the obstetrician. Instead, the obstetrician came into the birth room and took over quickly. The woman ended up with a cesarean! The midwife in fact believed the woman would have had a normal vaginal birth.

So be sure to consider who it is you bring into any birth. In second stage you may simply want a standby resuscitation team for some minor reason, then end up with a perfectly healthy baby being whisked away from its mother just because the team is there and needs something to do. They don't understand the value of sitting on their hands. Can you think of situations in which you regretted having called for help in the hospital?

- Jan Tritten

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6) Who Am I to Judge? A Transport Story
It's been a long time since I've seen a long labor that just would not progress, but recently I encountered one. After one of my moms had three days of prodromal labor, I had to transport her to the hospital.

It was not for lack of effort, however. This mom walked up hills and down hills. She took herbs and she took homeopathics. We massaged her and rested her. She did nipple stimulation, she cried, processed, gave in and gave over, but still she never opened up.

Was it physical? Emotional? We midwives ask ourselves these kinds of questions over and over. We go back over the labor with our fine-toothed combs. Sometimes we may never find the answer, for the birth process is magic, often dictated by forces greater than what we can ever perceive.

In this case it took an epidural and a lot of Pitocin to get this woman's uterus to respond consistently to contractions greater than eight minutes apart. When she finally opened after three days of trying, she pushed for three hours and finally birthed her nine pound child with grace. It was an amazing process to watch.

Although this was a homebirth transport, this family loved their birth experience! In case this was delusion on my part, I checked in with them repeatedly, only to find them ecstatic about the entire event. I wondered why. Wouldn't they be feeling the sting of failure for not having accomplished a homebirth? Wouldn't the interventions be considered barbaric and full of trauma? Didn't they have a horrid experience in the hospital?

Of course not! They knew what the possibilities were long before the woman went into labor. We talked about the what-ifs at prenatals. We set standards together and when the time came to change over from home to hospital, we cried and mourned together. We went to the hospital before there was time for a crisis to develop, which established good feelings and rapport with the doctor, who in turn bent over backward to help this woman have a good birth, one with the least interventions possible. This was based on good cooperation, true heartful intent, and a determination to keep our sense of humor and have fun. The hospital staff had a great time with us, and we had a great time with them.

Midwives are like the middle child. We have the ability to see both sides, bridge gaps, create pathways, take responsibility, and walk boldly forward on behalf of the families we attend. It's not always about where you are, but rather the love you provide in order to nurture a birth to a satisfying finale.

Without a doubt, each time I transport to the hospital, it's hard. After all, it's not what we wanted. But the family has been prepared and educated for the possibility. When I see a family who has worked hard and been so happy in spite of how things turned out, then who am I to judge? I am only here to bear witness and preserve life on an individual basis. If transport serves the greater good, then I must honor that path and recognize it as success, not failure.

- Jill Cohen

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7) The Art of Midwifery

Before you transport, know your patient's bill of rights. Policy and authority are two different things. Hospitals are institutions run on policy that sometimes gets perverted by authority. The patient's bill of rights helps protect the parents from the needless ego of authority as it is played out by individual hospital staff.

Stay with the mom at all times. All may seem well until you step out; when you return, you may find that intervention has elbowed its way through the door.

Be nice. You have transported because you need help. Honor that and collaborate in the woman's care as much as possible. You might be surprised at what a good response you can get when you stick to a noncombative attitude.

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