November 5, 1999
Volume 1, Issue 45
Midwifery Today E-News
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Broaden your education in Jamaica and Philadelphia, Pennsylvania!

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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Sponsored by:

- Mothering magazine: Mothering is in its 24th year of providing inspiration for attachment parenting. Mothering guides, nurtures, and supports while providing the latest on controversial parenting topics.

- Cascade Health Care: Cascade HealthCare Products, Inc. began business in 1979 with the primary goal to provide supplies and equipment for the emerging profession of midwifery. We have developed a complete product line that not only serves midwives, but nurse midwives, childbirth educators, lactation consultants, visiting nurses, birth centers, WIC programs, nurse practitioners, doulas, and professionals dealing with expectant parents, families and women's healthcare.

* Philadelphia, Pennsylvania, March 23-27, 2000
Mainstreaming the Midwifery Model

This conference highlights the many educational paths to midwifery.
Our only U.S. conference in 2000!
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This issue of Midwifery Today E-News is sponsored by:

- Ancient Art Midwifery Institute
- AquaDoula
- Elite Doppler
- Infantime
- Waterbirth Website

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Abstracts
5) World Waterbirth Conference
6) Question of the Week
7) Switchboard
8) Classified Advertising
9) Coming E-News Themes


1) Quote of the Week:

"Every adversity, every failure, every heartache carries with it the seed of an equal or greater benefit."

- Napoleon Hill


2) The Art of Midwifery

Waterbirth tips

  • Keep the room temperature warm.
  • Take the baby gently out of the water soon after birth.
  • Keep the baby warm using warm, wet blankets.
  • Be flexible. Don't adhere to plans if they are not working.
  • Parents should shower before entering the tub.
  • Follow the mother's instincts. If she wants to leave the water at any time, she should feel free to do so.

- Wisdom of the Midwives: Tricks of the Trade Volume Two, a Midwifery Today Book.

At Midwifery Today, we have lots of tricks up our sleeves! Purchase our two volumes of Tricks of the Trade and you'll see what we mean: Save $5 when you purchase both Tricks of The Trade. Volume I and Volume II. Only $40 plus shipping! Call today to order: 800-743-0974. Please mention Code 940.


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3) News Flashes

There are short term responses to immersion. When a parturient enters a bath at body temperature, there is immediate pain relief. This pain relief is probably associated with a reduced level of endorphins and catecholamines. Such a modified hormonal balance tends to facilitate the release of oxytocin and cervical dilation. At the same time, blood volume redistribution also tends to stimulate the release of oxytocin through a direct effect on the hypothalamic-pituitary axis.

After a certain delay, there is a phase of secondary responses when the activity of the posterior pituitary gland is more or less suppressed by the release of artrial natriuretic peptide (ANP). This delay is in the region of 1-2 hours and is influenced by the possibility to drink or not. Then the contractions get weaker and less efficient ... A possible decrease in efficiency might be anticipated when a woman has been in the bath for more than 2 hours.

- Michel Odent, MD, Journal of Nurse-Midwifery Vol. 42, No. 5, Sept./Oct. 1997



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4) Abstracts

The following abstracts have what I consider significant numbers in the analysis of retrospective data.

- Barbara Harper

Director, Waterbirth International Research, Resource and Referral Service, a project of Global Maternal/Child Health Association, a nonprofit public benefit corporation, serving women and their families for over 11 years.

Eriksson, Ladfors, Mattsson, et al. "Warm tub bath during labour: A study of 1385 women with prelabour rupture of membranes after 34 weeks of gestation." Acta Obstetricia et Gynecologica Scandinavia, August 1996, Vol. 75, No. 7, pp 642-644
Authors: and others

The goal of this study was to evaluate the influence of a bath on infectious morbidity in mothers and neonates in women with premature rupture of membranes after 34 weeks gestation.

A nonrandomized study of 1385 healthy women took place. In the first stage of labor 538 women wanted a bath while 847 did not. The women awaited spontaneous contractions up to 24 to 72 hours after the rupture of membranes before labor was induced with oxytocin. Internal examinations of the cervix were avoided until onset of active labor or until the time induction was planned.

The authors found that chorioamnionitis during labor occurred in 1.1% of the women in the bath group and in 0.2% in the reference group. Postpartum endometritis was found in three cases both in the bath group and in the reference group. The frequency of neonates receiving antibiotics was 3.7% in the bath group and 4.8% in the reference group.

The conclusions are that a tub bath did not increase the risk of maternal or neonatal infection even after premature rupture of the membranes and prolonged latency.


Brown, Lyn. "The tide has turned: Audit of water birth." British Journal of Midwifery, April 1998, Vol. 6., No. 4 pp 236-243

This study looks at a three year period (1994-1996) at one hospital, Good Hope NHS Trust, Birmingham, England, where a portable pool had been donated to the hospital by a client, then a permanent bath was installed. During that three-year period 1082 women stated prenatally that they wished to use a pool during labor. Of them, 541 actually entered the pool and 343 delivered in it, including 10 VBAC births.

Some of the guidelines for use of the pool at Good Hope include:

  • The use of tap water with nothing added
  • Maintenance of the water temperature at 37 C for the birth
  • A sample of the water prior to entry is taken
  • A high vaginal swab following the delivery of the placenta is obtained
  • Ear and umbilical swabs from the baby are taken

- The use of long gloves by the midwives and nurses who have direct contact with the patient in the water.

The three main reasons that women left the pool included:

  • Concerns by staff about fetal well being (fetal heart rates, meconium, malpresentation)
  • Requests for further analgesia (consistently primigravidas)
  • Slow progress

Twice as many primigravida left the pool prior to delivery and more multigravida delivered in the pool (57%) compared to primips (43%). It was noted that primips usually request to leave the pool during transition and that after the midwives caught on to this, encouraged these women to stay where they were and helped them cope through the confusion of transition.

87% of women who entered the pool had spontaneous onset of labor. The remaining 13% had vaginal prostin inserted for post-maturity. 68% of the induced labors delivered in the pool.

The experience gathered in this large study suggests the following guidelines on when to enter the bath.

  • Primigravida dilation should be 3-4 cm
  • Multigravida dilation should be 4-5 cm

If the woman enters the pool when the cervix is between 1-2 cm, labour may stop or slow down. That is not a reason to restrict a woman from the bath. If a labour does slow down or stop, then she may leave the pool and re-enter once labour becomes established.

Apgar scores of 7 or greater were reported in 94% of the babies at one minute and 99.7% at five minutes. There was one neonatal death reported in the bath group. Cause was attributed to intracranial hemorrhage.

There were no known infections of the cord and only one maternal infection postpartum, which responded to antibiotics.

Of the women, 46% had an intact perineum, 15% experienced 1st degree tears and 24% experienced 2nd degree tears. The numbers were further sorted into primigravida and multigravidas with primigravidas experiencing less tearing on the average.

Amniotomy is not performed routinely. There was no difference experienced in cases with or without ruptured membranes. It is sometimes difficult to assess when membranes rupture in the water. Vaginal examinations are safe and are performed routinely while women are in the pool. There is no evidence of increased risk of infection in mothers who labor in water or babies who are born in water.

The most common delivery position is a supported squat, with the mother being supported by the husband or partner.

There is never any attempt to feel for a tight nuchal cord or to clamp or cut if a tight cord is noticed. The body is delivered, then the cord is unraveled while the baby is still under the water.

Waterbabies tend to take a few seconds longer to cry than "land" babies. This is now expected and normal.

Key points:

  • Data from the audit suggests that labor and birth in water is no more dangerous for low risk women than land birth.
  • Women using the pool like it and feel in control of their labors and find it a rewarding experience.
  • Evaluation in combination with comments from women and the observations and experiences of midwives are important to identifying safe and effective waterbirth practices
  • Consideration from previous research studies is essential

(The Waterbirth Research Binder is a compilation of published articles (no media, only journals) and is available from Global Maternal/Child Health Association for $42 postage paid. Individual articles are always available for $3 each, either faxed or mailed. Many nurse managers and midwives use these articles for quick reference and for education.)


5) World Waterbirth Conference

The next World Waterbirth Conference, Waterbirth 2000, will be hosted by Global Maternal/Child Health Association (GMCHA) and held in Portland, Oregon at the downtown Marriott Hotel, Sept. 21-24, 2000. Midwifery Today is lending its expertise and support by being one of the co-sponsors. Waterbirth experts from around the world--speakers from England, Germany, Russia, Argentina, Brazil, Japan, Australia, and New Zealand and other countries-will be on hand. A follow-up to the 1995 World Waterbirth Conference held in London, this conference will help evaluate what progress has been made and what problems have been encountered in the past five years as waterbirth has mushroomed in availability and popularity. Some of the subjects covered in the conference include: establishing a waterbirth practice in a hospital setting--pitfalls and protocols; handling complications; reports from countries; incorporating prenatal aquatics into childbirth education; infection rates compared internationally; and much more.

Registration is $475 for the three days; it includes some meals. Special entertainment will include African drummers and dancers performing a special "birth dance."

GMCHA and Marina Alzugary, CNM are organizing a week long post conference AquaNatal certification course with instructors from Germany, Russia, and the US.

If you would like to be considered for a panel or speaking spot, please notify GMCHA by e-mail:
Registration materials will be available online in January on GMCHA's website: and will be mailed to all interested persons.


Midwifery Today conference audiotapes

961T435 Waterbirth: A New Tradition Created by Women, Barbara Harper
981T877 Waterbirth, Dianne Garland
921T33 Waterbirth: The Hows, Whys and What-Ifs, Barbara Harper

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An interactive educational software package focusing on pregnancy and childbirth which takes a woman through pregnancy week-by-week. Written by a doctor and a midwife. Includes a fun bonus screen saver that helps in choosing the baby's name.


6) Question of the Week: If you have any new insights or information about gestational diabetes, please share it with E-News readers.

Send your responses to


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7) Switchboard

In our birth center practice we have found that our intrapartum transfer rate for first time mothers has been cut in half in the past two years since we starting offering the birth tub for labor and birth. Our multips love it too, but I heartily recommend water for primps. It really makes a difference in their coping and relaxation and overall satisfaction with their birth experience.

- Laura Muir CNM


Join the waterbirth ONElist, a community of like-minded individuals who want to share information and learn more about waterbirth. To register:


Would you have printed the request for white sister midwives only [Issue 43]? Considerations for women of color should be integrated with all midwifery skills. We don't need to divide. There are many midwives honored who are women of color. Read the books--Onie Lee Logan, Gladys Milton, Juanita Alvarez.. I have spent time with sister midwives in Tennessee sharing conversation, hearing lectures. They happened to include women of color, not that I feel the distinction is relevant, except when we can understand each other more. I am sad and sorry to see a faction being created in midwifery. I live in New York. We have "colored" midwives here. I just don't see things that way and have honored midwives for their skills and dedication, regardless of color. Some of the most respected ones happen to be "women of color."

- Anon.


In response to Ginger [Issue 44]: A doula is a non-medical person who has had training (either in class or life experience) that helps her understand the rhythm of labor. A doula is a labor support person. She is there for the mother and family. She should not make medical or treatment decisions, but can advise the family on these matters.

A traditional midwife is someone who has become a midwife through apprenticeship and life experience. She often holds no nursing degrees but can attend births in homes and birth centers. Unfortunately traditional midwifery is illegal in many states.

A certified professional midwife (CPM) has gone to a non-nursing midwifery school. Many states forbid traditional midwifery but recognize the CPM; however, not all do. CPMs can attend births in homes, birth centers, and in some states in hospitals.

A certified nurse midwife (CNM) is a nurse who has gone to school for several years to become a midwife. Some schools in the United States allow non-nurses to get their nursing license at the same time they are learning to become a midwife. All CNMs must take a certifying exam and are recognized in all 50 states. CNMs can attend births in homes, birth centers and hospitals.

- KM


I am writing on behalf of my sister-in-law. She is 34 and has never had a living child. She has had several miscarriages and also at least 2, possibly more, premature births resulting in neonatal death. She now has a fibroid and her doctor wants to do a hysterectomy on the basis that it will solve the problem of the fibroid. She has had 5 operations in 13 years (miscarriages, ovarian cysts). The doctor says she could get it all over with, and this way would be "better off" without a living child. This last I think is cruel and not true in her case. She would desperately love to have a child of her own. She tells me the reason this happens is that the placenta "breaks up."

I have told her about myomectomy, incompetent cervix and have also suggested that she demand investigation to find out why the placenta "breaks up." Maybe she has something like lupus??

Any advice, ideas and thoughts are welcome. Annie needs the help of women everywhere to maintain her strength and to help her have a successful pregnancy.

- Jane


Could you please inform me as to ACOG's most recent protocol for intermittent fetal auscultation instead of continuous EFM.

- Ilana Shemesh


Does anyone have an educational handout for mothers on rubella non-immunity, in English and Spanish if available?

- Kathy Horgan, CNM
Reply to:


Unless otherwise noted, share your responses to Switchboard letters with E-News readers! Send them to If an e-mail address is included with the letter, feel free to respond directly.


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8) Classified Advertising

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9) 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:

- Omnium Gatherum (Nov. 12)
- Gestational Diabetes (Nov. 19)

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


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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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