September 10, 1999
Volume 1, Issue 37
Midwifery Today E-News
“Circumcision”
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Make plans now to attend one or both these conferences:

* Ocho Rios, Jamaica, December 2-6, 1999
Birth Without Borders--Weaving a Global Future
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* Philadelphia, Pennsylvania, March 23-27, 2000
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Program is now available. For your copy of the printed programs send your full name and postal address to inquiries@midwiferytoday.com. Please mention code 940.

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Circumcision Myths and Facts
5) The Solution: Colonize
6) Question of the Week
7) Question of the Week Responses
8) Switchboard
9) Coming E-News Themes

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1) Quote of the Week:

"Doctors should not be doing circumcisions. Removing normal tissue for no medical reason is not covered by their licenses. In addition, a doctor violates all seven Principles of the AMA Code of Ethics every time he performs a circumcision."

- Dr. George Denniston, president of Doctors Against Circumcision

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2) The Art of Midwifery

After a birth, rather than ask the mother specific questions about her birth, I do a birth review in which I guide the mother into telling me the whole story of the birth, as if I hadn't been there. I am often amazed at the feelings that surface when she has control of the story and where it goes.

- Kate Patterson Neelt, Midwifery Today Issue 39

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3) News Flashes

Researchers tested the level of breastfeeding after home visits from community trained lay breastfeeding counselors on 130 women in Mexico City. In one group 44 mothers were visited six times, and in another group 52 women were visited three times. A control group of 34 had no visits. At three months after delivery, 67% of mothers who had been visited six times were breastfeeding exclusively, compared to 50% of mothers visited three times and 12% of control mothers. There was a twofold decrease in diarrhea among the breastfed babies.

- The Practising Midwife, June 1999

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HYGIEIA COLLEGE is accepting enrollment in the INTERNATIONAL MYSTERY SCHOOL up to December 31, 1999.

- Founded by Jeannine Parvati Baker (author of Prenatal Yoga, Conscious Conception, and Hygieia: A Woman's Herbal).

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4) Circumcision Myths and Facts

About four thousand years ago, the original Jewish circumcision consisted of cutting off only the tip of the foreskin--the floppy part that extends past the glans in the normal male infant. Called "milah," the procedure left most of the foreskin alone.

Two thousand years ago, Jewish hellenists, wanting to assimilate characteristics of the Greek way of life, obliterated the sign of their "tip" circumcisions. Most of their foreskins were still intact, so they found ways to lengthen them, to make it look as if they had not been circumcised at all. This practice was unacceptable to ancient rabbis, who decided to begin cutting all of the foreskin off in infancy. Babies circumcised in this manner could not possibly later hide the fact that they had been circumcised. Significantly, most rabbis today erroneously refer to total foreskin amputation as milah.

Myths and Facts:

Myth: Unmyelinated nerves do not transmit pain.
Fact: Not only do unmyelinated nerves transmit pain, they transmit the most excruciating kind of pain.
M: Babies don't feel pain because some of their nerves have not become myelinated.
F: Babies do feel pain, especially since they have more unmyelinated nerves than adults.
M: Local anesthetic makes the circumcision painless.
F: Injecting the anesthetic into the genital area is painful for the baby. Because the anesthetic wears off soon, the postoperative pain that lasts for days is just as bad for a baby who had anesthetic than for one who had none.
M: The baby's intact penis is harder to keep clean and take care of than a circumcised penis.
F: Because of the extra care that one must take in caring for and bathing a circumcision wound that is in the process of healing, and because of the frequent complications such as meatal ulcers that occur in circumcised penises, the intact infant penis is actually much easier to care for. It basically needs no care, no retraction, no nothing.
M: There are sound studies proving that circumcisions prevent urinary tract infections (UTI).
F: The highly publicized studies "proving" that circumcisions prevent UTIs have many flaws. No major scientific body has accepted these studies as proof that circumcisions prevent UTIs. In addition, contradictory studies also exist, showing no correlation between UTIs and circumcisions.
M: By age five the foreskin should retract on its own.
F: Normal, spontaneous, and sometimes gradual full retraction may take up to 17 years to complete. Under no circumstances should the infant foreskin be retracted, even in a gentle manner. It is simply not necessary.
M: It is difficult to teach a boy to keep his intact penis clean.
F: A girl's genitals are more difficult to keep clean than a boy's intact penis. Boys, like girls, can easily figure out for themselves the details on how to clean their own genitals.
M: Male family members will have psychological problems if some have circumcised penises and others have intact penises.
F: When the English abruptly stopped circumcising most of its population, there were no psychological problems reported about the circumcised fathers and intact sons.

- Julia Bertschinger, CCE, in Midwifery Today Issue 17

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5) The Solution: Colonize

The best protection from UTIs comes not from cutting off a small piece of the baby's skin, but from the mother herself. Jan Winberg et al (the Lancet, March 1989) concludes that the number of UTIs in newborn males could be reduced by strict rooming in of mother and baby or by active colonization of the baby with his mother's anaerobic gut flora. In this research, UTIs in newborn males were caused by Escherichia coli, bacteria not of maternal origin; therefore, infants had no passive resistance to these pathogens.

During delivery in a natural setting, the infant acquires aerobic and anaerobic intestinal flora from the mother, together with the necessary immunoglobins to resist infections from these agents through the placenta and breastmilk. When an infant is born in a sterile hospital setting, he is carefully protected from the possible contamination caused by his mother's body fluids, and then isolated in a nursery. His first contact with the E. coli strain is from the hospital environment itself, against which the infant has no resistance.

During the first few days of the infant's life, he should be handled by the mother and other members of his immediate family as exclusively as possible, whether circumcised or intact. The mother's resistance to the pathogenic effects of her own gut flora and that of the other family members should protect the infant from early UTIs. Once the infant has established his own gut bacteria colony, this will help protect him from colonization by stray pathogens.

The baby born in a typical hospital labor setting who is then removed to the nursery is at much greater risk for UTIs from stray bacteria than the infant born at home. Circumcision is no guarantee of health; contact with the mother and her breastmilk are an infant's first and foremost protection from infections.

- Diana Haught, Midwifery Today Issue 14

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8) Question of the Week

I have encouraged my clients to have birth "plans" for many years. I urge them to discuss using a heparin lock as an alternative compromise to routine IV. Very few moms report back that they had a lock--most all had IV. I discussed this with a CNM and she said she uses IV routinely, mostly for the "convenience" of the nurses because, she states, "heparin locks frequently get blocked."

Should I continue suggesting this alternative to "routine IV" to my clients (most of whom get IVs as a sort of "insurance policy" for the staff's comfort)?

- J.Batacan

Send your responses or submit a Question of the Week to mtensubmit@midwiferytoday.com

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9) Question of the Week Responses

Q: Here in Mexico it is big business to be able to turn a breech baby anywhere between 3-6 months. I wonder about the risks involved and if anyone out there finds this a successful procedure?

- Evette, aspiring midwife

Three to six months is early to worry about breech. Babies turn, often as late as 34 weeks and some at birth. External version is not considered before this. Ina May Gaskin says the best time for external version is 7 1/2 to 8 months, or any time up to mom's due date. (Spiritual Midwifery, 3rd ed.) Gayle Peterson recommends that the mom resolve tensions that may be causing involuntary tightening of the lower uterine segment. Her explanation on using psychophysiological integration with an 80% success rate is found in her book, Birthing Normally.

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10) Switchboard

I had my son circumcised when he was 9 days old, believing that if God told the Israelites to wait 8 days, he had a reason. I am not Jewish and neither is my husband. I had worked in a nursing home and saw some men who did not have their foreskins cleaned properly and was fairly traumatized by it. We saw a mohel and he did a very good job. Not being Jewish, we did not observe the ritual aspects of the circumcision, only had the surgical procedure done. Afterward my son was so traumatized by it he did not cry, he screamed. He was unable to nurse and cried himself to sleep. He literally would try to nurse, latch on, then decide he needed to scream instead.

We used an antibacterial ointment applied to a topper sponge or gauze square and put it on the end of his penis until it healed. In about 4 or 5 days he was much better. He had some adhesions that have pretty much cleared up (he turned 4 this July) and he seems OK now. But I fought with my husband during the last trimester of our third child's pregnancy to avoid another circumcision. I got my wish, the baby was a girl.

- Holly Sippel

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I would like to bring your attention to the web site sicsociety.com. I found it very interesting that some men are actually restoring their foreskins. My husband is circumcised, but I was adamant about my 12 year old son *not* being circumsized. A public health nurse and I got into quite the heated argument about circumcision. She was all for it due to the major infections she saw in her practice. I finally realized she was part of the problem. I explained that as healthcare workers we need to know how to care for the uncircumcised. Did she change? Probably not. I gave her some information, though. I think we need to be sure our women know all about the whys and why nots and what to do when you decide to leave your babe alone.

- Kelley Thomas-Hill, CD

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On the question of marijuana use and breastfeeding [Issue 36]: I hope the following references are helpful.
Francoise Railhet
Manager, LLL France Medical Associates Program
frailhet@magic.fr

Drugs in pregnancy and lactation. Briggs, Freeman and Yaffe. Ed Williams and Wilkins, 1990.

Delta-9-tetrahydrocannabinol (TCH), the main active ingredient of marijuana, is excreted into breastmilk. Analysis of THC and two metabolites, 11-hydroxy-THC and 9-carboxy-THC, were conducted on the milk of two women who had been nursing for 7 and 8 months, respectively, and who smoked marijuana frequently (69). A THC concentration of 105 ng/ml, but no metabolises, was found in the milk of the woman smoking one pipe of marijuana daily. In the second woman, who smoked seven pipes/day, concentrations of THC, 11-hydroxy-THC, and 9-carboxy-THC were 340 ng/ml, 4 ng/ml, and none, respectively. The analysis was repeated in the second mother, approximately 1 hour after the last use of marijuana, using simultaneously obtained samples of milk and plasma. Concentrations (in ng/ml) of the active ingredient and metabolites in milk and plasma (ratios shown in parenthesis) were 60.3 and 7.2 (8.4), 1.1 and 2.5 (0.4), and 1.6 and 19 (0.08), respectively. The marked differences in THC found between the milk samples was thought to be due to the amount of marijuana smoked and the interval between smoking and sample collection. A total fecal sample from the infant yielded levels of 347 ng of THC, 67 ng of 11-hydroxy-THC, and 611 ng of 9-carboxy-THC. Due to the large concentration of metabolites, the authors interpreted this as evidence that the nursing infant was absorbing and metabolizing the THC from the milk. In spite of the evidence that the fat soluble THC was concentrated in breastmilk, both nursing infants were developing normally.

In animals, THC decreases the amount of milk produced by suppressing the production of prolactin and, possibly, by a direct action on the mammary glands (42) While data on this effect are not available in humans, maternal marijuana use does not seem grossly to affect the nursing infant. In 27 infants evaluated at 1 year of age, who were exposed to marijuana via the milk, compared to 35 nonexposed infants, no significant differences were found in terms of age at weaning, growth, and mental or motor development.

Although no adverse effects of marijuana exposure from breastmilk have been reported, follow-up of these infants is inadequate At the present time, the long term effects of this exposure are unknown and additional research to determine these effects, if any, is warranted. The American Academy of Pediatrics considers the use of marijuana during breastfeeding to be contraindicated.

Breastfeeding and drug exposure. CR Howard and RA Lawrence. Obstetric Gynecol Clin of North America 1998; 25(1): 195-217.

Animal studies indicate that THC reduces prolactin levels. Data on this effect, however, are not available in humans. Marihuana appears in human milk as THC, which is poorly absorbed in this form; however; with prolonged exposure, the compound may cause an infant to be lethargic and to feed less frequently and for shorter periods of time. In infants evaluated at 1 year of age, no differences were found in growth or mental or motor development when infants exposed to marihuana in breast milk were compared with non-exposed infants. Follow-up of these infants, however, has been limited, and long-term effects of marihuana exposure through breastmilk are unknown.

Maternal judgment may be impaired, and secondary behavioral changes may interfere with a mother's ability to care for her infant or to breastfeed adequately. As is true for cigarette smoking, passive exposure to marihuana poses additional risks to the infant. The American Academy of Pediatrics considers the use of marihuana during breastfeeding to be contraindicated.

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Dr. Thomas Hale (pediatrician and pharmacist) has been quoted as saying the marijuana tends to be sequestered in peripheral compartments, that THC does enter milk easily, but due to low concentration in the maternal plasma, the absolute dose to the infant is low. If the mom smokes occasionally, she should expect that only small levels will be transferred to the infant, probably subclinical amounts, which is why the studies show no developmental abnormalities. The infant will show a positive drug screen, but it is not known for how long; probably correlates with the maternal dose ingested.

There is difficulty with many studies as the mothers are using other drugs along with marijuana. So one can not ascribe any negative effects to any one particular drug.

A study described in Pediatrics 1994; 93:254-260, (Dreher MC, Nugent K and Hudgins R) compared the babies of Rastafarian mothers (smoking up to 5 joints a day) and non-smoking controls. Both groups of mothers were breastfeeding. After one month, the babies of the heavily smoking mothers scored better on the developmental testing done. The speculation was that the Rastafarian mothers had better social networking and support for being new mothers.

All this evidence goes against the mainstream belief that marijuana is bad.

- Nikki Lee RN, MSN

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I have recently been told about olive leaf extract for treatment of herpes in pregnancy. Has anyone experience in its use, i.e., dosages and frequencies?

- Brenda

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I heard a delightful story recently of a mom who had active herpes at the time she was birthing. Mother Nature helped out and baby was born with membranes still intact, totally protected from touching any of the lesions on the way out Another good reason to not break membranes if they are still intact in second stage!

- Anne

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Active herpes in pregnancy should exclude midwifery care, *period*. A few errors in this article [see E. Davis excerpt Issue 36]. I'm sure they mean inspection of the vulva. No one I know can diagnose active herpes by looking at a cervix (or exclude it, more importantly). How long does it take your labs to get a HSV result back? Screening after SRM is too late. The actual risk of cerebral herpes is around 1:5000 but it's devastating to the baby so ignoring it is indefensible.

- Phil W.

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I am confused by Phil's comments. Does he imply that, since visual inspection of the cervix (which is standard of care in my area) and HSV screen (results here are prompt) cannot be relied upon, *every* woman with a history of herpes and SROM must have cesarean birth? This is certainly not usual practice in the States. (In screening the cervix, we look for inflammation, discoloration or the obvious ulcers).

- Elizabeth Davis

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A free international gathering of midwives will be on 2 October at the office of the KNOV (Dutch Midwives Association) from 10 am-4 pm. Agenda:

- Introductions, Epic Women slide show with music, by Harriette Hartigan

- Jan Tritten from Midwifery Today and Mary Scheffler Zwart will discuss international midwifery, plans for an international school, visioning, sharing our common problems and challenges

- Merilynne Rush and Mickey Sperlich, overview of the US apprenticeship model

- Lunch

- Aimee Centivany- Birth in the Ivory Coast, W. Africa

- Open Discussion and Tricks of the Trade

- Closing: Discuss future plans, networking ideas, ways to help each other

For more information: Sabine Schmitz, Midwife Foreign Office, KNOV, 31.20.6120024.

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Share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com

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11) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- Preeclampsia (Sept. 17)
- Breastfeeding (Sept. 24)
- Vitamin K (Oct. 1)
- Twin Births (Oct. 8)

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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