February 26, 1999
Volume 1, Issue 9
Midwifery Today E-News
“Epidurals”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Epidural: Convenient Intervention?
5) Mom's Post-epidural Fever Affects Baby
6) Abstract
7) Commentary
8) From the Garden
9) Switchboard
10) Midwifery Today Question of the Quarter
11) Letters
12) Coming Themes

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1) Quote of the Week:

"In many cases, the "failure to progress" designation on a woman's birth records could be translated as "OB's Failure To have Patience."

- Sue LaLeike, aspiring midwife

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2) The Art of Midwifery

Dad's Remedy

Our recipe for moms who are at term or past dates, and who are anxious for their babies to arrive, is a simple one: We tell them to go on a date with their partners, have a glass of wine with dinner, then go home and make love. We remind them that semen is a remarkably effective prostaglandin enhancer and can be very effective in ripening the cervix.

- Valerie El Halta

Secret Codes

My assistant and I use our pagers in a special way to communicate with each other if one of us is at the birth and the other away from her telephone: We add 411 after the phone number if we want the other to call in for an update at her convenience, or 911 after the number if the other needs to get to the birth with great haste. Sometimes we follow with the number of centimeters dilation.

- Lani Rosenberger in "Tricks of the Trade" Volume One, a Midwifery Today publication

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3) News Flashes

Maternal Magnesium Intake

The magnesium intakes of 513 women toward the end of the first trimester of pregnancy were calculated from a record of food consumption for one week. Magnesium intake was found to be correlated with weight, length and head circumference at birth as well as length of gestation up to a threshold of around 3200 g (7 lbs) birthweight. Of the seven elements found to be significantly associated with these outcomes of pregnancy, magnesium was third in order of significance, after sodium and chloride. A subsample of mothers were given a supplement which provided 100 mg/day of magnesium during the second and third trimester; there was no effect on the outcome of pregnancy, suggesting that any influence of magnesium ws confined to the first trimester or before. A maternal magnesium intake of 300 mg/day was compatible with observed optimum birthweight, length and head circumference.

- Pre-eclampsia Society newsletter, No. 36, 1998

Maternal Analgesia and Breastfeeding Success

Maternal analgesia in labor can affect the infant's ability to breastfeed and may delay effective breastfeeding for several hours, according to a study of forty-eight mothers and infants. Infants whose mothers received either no labor analgesia or analgesia less than an hour before delivery and who initiated breastfeeding early, established effective breastfeeding significantly earlier than infants whose mothers received labor analgesia an hour or more before delivery and who experienced a delay in the initiation of breastfeeding. As primiparous women tend to experience longer labor and be exposed to more labor analgesia, they may be less likely to initiate breastfeeding during the first hour.

- Breastfeeding Reveiw, November 1995

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4) Epidural: Convenient Intervention?

It is apparent that epidural analgesia was gaining acceptance in obstetrics at the time when the contribution of anesthesia to maternal mortality was greatest. Whether the high induction rates prevalent in the early 1970s contributed to the need for general anesthesia is difficult to assess. Thus, the increasing acceptance of epidural analgesia occurred at an opportune time for anesthetists, enabling them to gain, initially, acceptance of their practice and, later, professional credibility. Although originally regarded only as a method of relieving labor pain, epidural block, through reducing or removing the need for general anesthesia in labor, contributed to the reduction in maternal deaths following anesthesia.

Favorable experiences of epidurals soon convinced obstetricians that intervention in labor could be conveniently and relatively safely managed by offering epidural analgesia. This applied equally to another increasingly likely outcome of labor, i.e. cesarean section. Mothers' acceptance of epidurals was no less willing and may have been fostered directly or indirectly by the professionals, although encouragement to take advantage of the benefits of this service was sometimes seen by mothers as coercion.

In this way, the cascade of intervention which has been identified by some observers in current obstetric practice was facilitated by the introduction of this effective method of pain control. This phenomenon may be associated with neurological changes, causing relaxation of the pelvic floor and giving rise to malposition of the fetal head, incomplete rotation and delay, especially in the second stage of labor. Oxytocic drugs may be used to overcome delay but these are associated with fetal hypoxia, identified as fetal distress, for which interventions to expedite the birth, e.g. assistance with obstetric forceps or even cesarean section, may be deemed necessary.

- Rosemary Manders, "Epidural analgesia 1: recent history," British Journal of Midwifery, Vol. 1 No. 6 Nov./Dec. 1993

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Epidural Epidemic 941T56

Penny Simkin, PT and Ina May Gaskin delve into the personal and cultural
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Epidemics: Cesareans, Epidurals, Ultrasound 981T790

Marsden Wagner, MD, Nancy Wainer Cohen, Fran Ventre, CNM. Excellent overview of these topics, with information and discussion from the personal to worldwide.

Epidural Epidemic 941T142

Michel Odent, MD and Penny Simkin, PT share their perspectives concerning the epidural epidemic.

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5) Mom's Post-epidural Fever Affects Baby

About 14 percent of women develop fevers after having epidurals. This can affect their babies: A 1997 study found that one-third of the babies whose mothers developed fevers of 100.4 degrees or higher after birth are subjected to many tests and procedures. These newborns undergo painful tests for sepsis (infection) because a fever can be an indicator of infection in the mother and, consequently, in her baby. The babies are taken to the neonatal intensive care unit to have blood drawn and, sometimes, to receive a lumbar puncture, a procedure in which fluid is removed from the spine. These babies are then kept in the hospital for up to three days, usually after their mothers have been discharged, and given antibiotics.

- Diana Korte, "The VBAC Companion, Harvard Common Press 1997

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6) Abstract

From Henci Goer's book "Obstetric Myths Versus Research Realities":

MacArthur, C., Lewis M., and Knox E.G. Investigation of long term problems after obstetric epidural anaesthesia. BMJ 1992; 304: 1279-1282.

Data on long term postpartum effects (meaning began at 3 months or less after birth, lasted 6 or more weeks, never experienced prior to birth) of epidurals were gathered from hospital case notes and postal questionnaires mailed to mothers. Data ranged from 13 months to 9 years postpartum. No information on severity was obtained. The 11,701 women represented 78 percent or more of those mailed questionnaires. Of them, 4,766 had epidurals and 6,935 did not. Discriminant analysis was used because it eliminates associations with epidurals that might arise because epidurals associate with more interventive deliveries. [But since epidurals cause operative delivery, they could be an indirect cause of problems in such cases.-HG]

Symptoms that were more likely to be reported after epidural were backache (18.2 percent versus 10.2 precent p<0.001), neckache (2.4 percent versus 1.6 percent, p<0.01), tingling in the hands (3.0 percent versus 2.2 percent, p<0.01), dizziness or fainting (2.1 percent versus 1.6 percent, p<0.05), and visual disturbances (1.7 percent versus 1.3 percent [no p value given]). Spinal headache occurred in 34 women as a result of accidental dural puncture (0.1 percent of all epidurals) or spinal anesthesia (2.5 percent of all spinal blocks). Although this headache is believed to subside within a week even without treatment, nine women reported the headache lasted more than 6 weeks and five that it lasted more than 1 year. Headache, neckache and tingling related to epidural only when reported in association with backache. Visual disturbances related only to migraine. In response to an open-ended question, 26 women reported numbness or tingling in lower back, buttocks, or leg, of whom 23 had an epidural--a "highly significant" difference. Most symptoms had lasted much longer than the six weeks of the study definition. "About two thirds were still present at the time of our inquiry. It was clear that many problems had become chronic."

- Henci Goer, "Obstetric Myths Versus Research Realties," Bergin & Garvey, Westport CT, 1995

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7) Commentary: by Jill Cohen, midwife

First off, I am absolutely a homebirth oriented midwife, although my thoughts on the subject of epidurals may cause many to believe otherwise. I am sensitive about sharing my views for fear of misrepresentation. However; my experience has led me to some basic conclusions that seem practical and useful to the art of midwifery and more importantly, the art of using technology appropriately, and I feel compelled to share them. In these times when technology is overused in childbirth and we often have to muster our reserves in order to protect women and babies from intervention, we may become blind to the fact that appropriate use of technology can lead to good outcomes.

Over the last many years I've encountered a good handful of births with long tedious labors that lasted days on end. The women were stoic and strong. We fed them, walked them, counseled them, slept them and tried and tried again to get them past a certain centimeter of dilation, to no avail. Once the mother reached a certain point her pain threshold dissolved and maternal exhaustion set in. It has always been my standard to transfer to the hospital at this crucial point. My families have also agreed, instinctually knowing it was the right thing to do.

Here is the amazing part: We get to the hospital, check in, monitor the baby, meet the doctor and so on. The least interventive thing to do at this point is to get the woman an epidural and some Pitocin. The epidural will take the pain away and let her sleep, and of course the Pitocin will strengthen the contractions. This combination works beautifully--I've seen babies born easily within two to six hours. To see epidurals used in this fashion has given me new respect for them. Seeing moms happy and relieved not to have a cesarean section, an intervention that is way over used, makes me less resistant in situations like these.

This doesn't mean I would make this decision for all long labors. We are there to make assessments based on the best care of mother and child. To the best of our ability, we must inform and encourage our mothers to birth naturally if that is their goal. But when it becomes risky and overly discouraging, alternatives must sometimes be sought.

I have strong opinions about using interventions in pregnancy and birth. I should! I am a lay midwife who attends homebirths. I don't take any transport or intervention lightly simply because of what I have learned and heard about cause and effect. But based on what I've seen, I also believe that at times an intervention can help cause less effect. Does every woman deserve an epidural, as Hillary Clinton is said to have remarked? No. Epidurals were first developed as a tool to be used in an emergency and were never intended for widespread use. So let's stick to the premise that wise use is best use, and keep birth as natural as we can as often as we can, but feel OK when we can't.

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Learn more with Midwifery Today back issues on epidurals.

Issue #14 "Keeping Midwifery Alive"
Issue #37 "The Threat of Technology"
$7.00 each
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8) From the Garden

Because red raspberry leaf provides dual qualities as mild stimulant and gentle relaxant, it has a regulating effect on the uterus. The leaves contain an alkaloid known as fragerine, which relaxes and strengthens the uterus and tones the pelvic muscles. Raspberry remains one of the safest and most effective herbs for use in the entire course of pregnancy. A recommended use of this tea is one cup three times daily in the first trimester, one to two cups three times daily in the second trimester, and two to three cups three times daily through the third trimester and postpartum. A few women have found they are especially sensitive to red raspberry's toning effect in the first trimester and tend to have too much uterine stimulation. If red raspberry is being used and uterine cramping is experienced in the first trimester, it is best to use less of it, or to stop using this herb altogether until later in the pregnancy. Raspberry can, however, have reasonable success in preventing miscarriage and hemorrhage, so careful history taking and evaluation on the part of the care provider is important.

- Linda Lieberman in The Birthkit Issue No. 6 (a Midwifery Today publication)

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9) Switchboard

I am looking for good, specific information on alternative treatments for cystocele (and/or other prolapse problems) both during pregnancy and after giving birth. Textbooks seem hardly to mention it, although it is a fairly common problem. I currently have a client with a third degree cystocele, five weeks pregnant, wondering what she can do to help alleviate the discomfort. Also, how can one best minimize further tissue damage during second stage?

- Cathy

Vi Sadhana asked about resources for nursing HIV-positive moms, the use of AZT for baby, etc. [E-News Issue No. 7]. Several recent (including current) issues of Mothering magazine have significant articles about this subject area. While I don't agree with everything that's said, they do list lots of other references at the end of the articles as well.

- K. Murray

I found the question about gestational diabetes and Passover food interesting as I am an Orthodox (observant) Jew and doula practicing with an exclusively Orthodox clientele and happen to be married to a rabbi (Orthodox) as well. While I don't have a lot of experience with gestational diabetes, I think I can be of help.

First of all, let's understand our ground rules. During the week of Passover there is the obligation to consume a specific amount of matza during the seder on the first night (and second night outside of Israel) and to drink four "cups" (also a specified amount, not an 8 oz. cup) of wine or grape juice. This much is non-negotiable. Also for the entire week five biblically prohibited grains are not consumed. In addition, Ashkenazim (Jews of Eastern European descent) don't consume other grains referred to as "kitnios"--such as corn and rice. Other than this, the whole realm of fruit, vegetable, meat, cheese, etc. is open. The high carbohydrate diet you are referring to may be the traditional diet of Ashkenazim brought over from Europe. Your client may need to be educated to rethink her food choices and think beyond the traditional meat and potatoes, potatoes, potatoes that are consumed during the holiday (with a bit of matza and potato starch sponge cake thrown in for good measure!).

In addition, general nutrition should not be a problem due to the prohibition of consuming meat and milk together. If she is having a problem getting enough protein and calcium, have her discuss the issue with her rabbi. The six hour waiting period between meat and milk (which is customary) can be reduced to one hour for pregnant and nursing mothers. Also, milk can always be consumed before meat with no waiting in between. I imagine that the real problem comes back to "traditional" diet and not the restrictions of Jewish law. Also keep in mind that many closely spaced pregnancies can have a real bearing on a woman's nutritional status, and this is often the case in the Orthodox world. Also when there are many financial burdens of raising a large family (such as private Jewish education) make sure she isn't on a low quality diet in general.

- Chava Weiman

Correction, Issue 8: The first two sentences of paragraph two of "Relactation" should have read: In this survey, more than half the mothers established a full milk supply within a month. It took another 25 percent of the mothers more than a month to fully relactate

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10) Midwifery Today Question of the Quarter: What is your favorite homebirth story?

Join us in our Golden Issue--No. 50 of Midwifery Today magazine--and tell us your story. Please adhere to a 275 word limit. We'll choose the three best stories for publication! Send your submissions to editorial@midwiferytoday.com or Midwifery Today Question of the Quarter, PO Box 2672, Eugene, OR 97402 USA by March 15.

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11) Letters

I'm looking forward to your E-News. I've been a direct-entry midwife in rural Illinois for seven years. It has been a very difficult and rewarding journey. Why can't we all honor each other's experiences and work together rather than tear one another apart? I learn something from every birth I attend. I never want to stop learning. That is just part of the gift I receive at a homebirth.

- Alison

I have read the newsletter courtesy of a friend and I think it's great, a wonderful step for midwives everywhere.

- Melissa.

I was recently accepted into the Texas Tech/UT El Paso program, to start this coming August. I am currently taking courses toward my master's in nursing. I'm just getting a little ahead for the program. I'd love to receive your newsletter.

- Helen La Rose, RN

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12) Coming Themes

- smoking and pregnancy
- placenta previa
- infections
- ultrasound
- epidurals
- educating the public
- education
- posterior labor
- cesarean section
- postpartum blues/depression
- meconium aspiration
- tear prevention


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This publication is presented by Midwifery Today, Inc., for the sole purpose of disseminating general health information for public benefit. The information contained in or provided through this publication is intended for general consumer understanding and education only and is not intended to be, and is not provided as, a substitute for professional medical advice, diagnosis or treatment.

Midwifery Today, Inc., does not assume liability for the use of this information in any jurisdiction or for the contents of any external Internet sites referenced, nor does it endorse any commercial product or service mentioned or advertised in this publication. Always seek the advice of your midwife, physician, nurse or other qualified health care provider before you undergo any treatment or for answers to any questions you may have regarding any medical condition.

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