|March 3, 2000|
Volume 2, Issue 9
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"The traditional midwife maintains the social fabric of the community, gathering friends and family together for birth, and enables the birthing mother to have her experience in the context of home and loved ones. This reestablishes the global village, and puts birth back into the context of oneness and love it was originally intended to have."
- Nan Koehler Solomon
2) The Art of Midwifery
Most postpartum hemorrhages are caused by the caregiver. Any massage of the uterus before the placental delivery will almost ensure unnecessary bleeding. In rare instances a hemorrhage may begin before the placenta is delivered. This is not just an isolated gush or two of blood, but a steady stream. This is the only time it is appropriate to massage the uterus-yet even then, it may worsen matters. The best thing is to immediately administer an oxytocic and when the uterus contracts, use the Brandt-Andrew maneuver to hasten the placental delivery. Once the placenta is delivered or if bleeding continues without the placenta coming out, massage and bimanual compression are employed.
- Valerie El Halta, Midwifery Today Issue 48
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3) News Flashes
A study examined the association between method of infant feeding in the first weeks after birth and glucose tolerance, plasma lipid profile, blood pressure and body mass in adults aged 48-53. Subjects were born at term between November 1943 and February 1947 in a hospital in Amsterdam around the time of a severe period of famine. For 625 subjects, information was available about infant feeding at the time of discharge from hospital (average of 10.4 days after birth) and at least one blood sample after an overnight fast. Subjects who had been bottle fed had a higher mean 120 minute plasma glucose concentration after a standard oral glucose tolerance test than those who were exclusively breastfed. They also had a higher plasma low density lipoprotein (LDL) cholesterol concentration, a lower high density lipoprotein (HDL) cholesterol concentration, and a higher LDL/HDL ration. Systolic blood pressure and body mass index were not affected by the method of infant feeding. The study concluded that exclusive breastfeeding seems to have a protective effect against some risk factors for cardiovascular disease in later life.
- Arch Dis Child 2000; 82
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4) Induction Merits Informed Consent in Alberta
It was great news for Canadian women when on February 16 Robert A. Burns, MD, Executive Director of the Alberta Medical Association announced that the AMA's Alberta Clinical Practice Guideline for induction of labor will now include a strong recommendation that informed consent take place before the procedure is initiated.
This precedent setting move will give women across Alberta the ability to choose whether to subject their baby to the risks and side effects that may be caused by birth induction or perhaps to use a natural alternative, such as medical watching and waiting. It has been reported that until now some women have been coerced into agreeing to a birth induction without knowing risks, side effects, and alternatives to forcing the birth of their child. Some doctors have also reported that some women have asked to force their birth to get it over with or to coincide with a husband's schedule.
Gail J. Dahl, Executive Director of the Canadian Childbirth Association says the group has worked diligently over the past four years toward creating informed consent for this elective procedure in Alberta. The Association highly recommends that the new guidelines also include new research evidencing longer gestation time for first-time mothers, up to 42 weeks and longer. New research also shows that ultrasound tests used for gestational dating have an error rating regardless of the trimester, with the largest error rating to be shown in the last trimester.
Canada is not the safest country in the world in which to give birth, owing in part to its high rate of induced birth, over 30% in some areas, which often leads to unnecessary emergency cesareans.
Following is an excerpt of a letter from the Canadian Childbirth Association director to Dr. Burns:
We believe this is a positive step forward in assuring safer childbirth in the province of Alberta and we congratulate your Committee on Reproductive Care and the Alberta Clinical Practice Guidelines Program for looking into this critical area of informed consent on birth inductions.
The next step would be to create a sample informed consent for the induction of labor which would include: risks to mother and baby, side effects to mother and baby, alternatives, contraindications, (for instance cytotec, which is increasingly used to induce birth, is stated by the manufacturer to be contraindicated in pregnancy). Also appropriate warning and precautions are shown in the patient inserts and the 1999 Canadian Pharmacists Association Manual. I believe it is important to create this sample of informed consent for birth induction as our Alberta physicians do not have this information readily available for immediate use.
Your Guidelines need to state that gestation for a first-time mother is longer, up to 42 weeks and longer and that accurate dating comes from the first day of the last menstrual period. Ultrasound measurements in the first, second and third trimester of birth carry an error rating on either side of the date. Physicians using a forty-week due date for a first-time mother and errors in gestational dating by ultrasound seem to be the cause of untold numbers of premature babies being induced in Canada.
The increased cost to our healthcare and ever increasing health and birth complications arising out of inducing premature babies in Alberta will certainly decrease once your guidelines have been adjusted to include the above points.
- Gail Dahl press release
5) More on Induction
We have little evidence that modern postdates management offers benefits and considerable evidence that it does not. Randomized trials of expectant management versus routine induction show few or no significant differences in outcome. Attempts to prevent postdate pregnancy by membrane stripping or nipple stimulation initiate labor more frequently compared with controls, but studies present no data on delivery route. Vaginal application of prostaglandin containing gel may ripen the cervix but has little effect on cesarean rates. Macrosomia may be of concern because of increased c-sections and birth injuries, but ultrasound predicts macrosomia poorly (95% confidence intervals of +/- 20% with accuracy worst at extremes of weight, and we have no evidence that induction improves outcomes. We do know that performing cesareans for macrosomia does not decrease asphyxia or injury rates.
Paradoxically, treatment works best on those who need it least: induction is most likely to succeed when the fetus is healthy and the mother on the verge of starting labor on her own. The inverse also holds: treatment does least for those who most need it. Whether the process has gone awry or the mother simply is not as far along as her doctor thinks, if her body is not ready for labor, induction will likely fail. When testing reveals a compromised fetus, doctors induce whether the cervix is ready or not. Inducing an unripe cervix leads to long, hard labors, yet a baby in trouble is least able to withstand the stress. Oligohydramnios, a complication of postdates pregnancy, predisposes to abnormal fetal heart rate. When it is found, obstetricians induce. Membranes will almost surely be ruptured for one reason or another. Now the baby has no amniotic fluid.
We also have evidence that postdates management itself causes complications, and, as with surveillance tests, this ironically reinforces belief that postdatism is dangerous. Devoe and Sholl found that 30% of fetuses testing normal developed fetal distress when labor was electively induced, and the cesarean rate was 15% versus 2% for spontaneous labor. Ahlden et al. found that the most likely scenario to end in an infected baby was an overdue mother who was induced, had an amniotomy, internal electronic fetal monitoring, many vaginal exams, and whose labor ended in cesarean section. That so many healthy women carrying healthy term fetuses had cesareans for fetal distress says more about management than the dangers of 41-week gestations.
- Henci Goer, Obstetric Myths versus research Realities Bergin & Garvey 1995
Devoe LD and Sholl JS. Postdates pregnancy. Assessment of fetal risk and obstetric management. J Reprod Med 1983;28(9).
Ahlden S et al. Prediction of sepsis neonatorum following a full-term pregnancy. Gynecol Obstet Invest 1988;70(1).
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6) Check It Out!
This week we turned our website into a fully functional cornucopia of birth
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Technology in Birth: First Do No Harm
by Marsden Wagner. M.D.
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7) Questions of the Week
I would like to have my fourth baby at home with a midwife, supported by close family. My only hesitation is that my third birth was precipitous. My water broke as a first sign of labor at 11:30 a.m. After having had 2 or 3 mild-moderate contractions in the car, I arrived at the center at 1:00. The midwife noted I had arrived prior to labor because of GBS--for antibiotic shot. I had the urge to push at 1:25 and was holding a 10 lb. baby in my arms by 1:45. I disagree with induction, but am determined to have a wonderful birth experience where I am surrounded by people who will support me. There is the chance that my midwife (not to mention my husband and doula) could get stuck in traffic. What would you recommend for a mom in my position?
(Repeated): I would like to hear from other midwives who have dealt with women who have pinworms in pregnancy. Did the women experience periodic spotting? Also what, if any, natural remedies are effective and safe in pregnancy?
- Deren Bader, CPM, MPH
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8) Question of the Week Responses
Q: Could anyone provide information on herpes and vaginal birth vs. c-section? A client is considering opting for a c-section rather than risk the possibility of transmitting it to her newborn (She is currently at 27 weeks). Any suggestions or information/resources would be appreciated.
My first experience with the issue of vaginal herpes outbreak (subsequent, not primary) just prior to delivery was my own birth. I was attended by an OB/GYN and had a hospital birth. I was afraid to tell him that I thought I was starting to get an outbreak, but with all the risks I'd heard about, I knew I had to. The day before I went into labor, I showed him the blister during an exam and he told me it was small enough and far enough away from the birth canal, that he could just cover the area with a 4x4 pad during the delivery. The blister was inside the labia majora near the clitoris. I was very relieved! I had a vaginal birth the next day.
The second time I encountered the situation was with a client who had contracted herpes many years previous. She had one outbreak around 22 weeks and she too was very worried. She was aware of what foods and stressors triggered her outbreak and avoided them, but ended up having another at 39 weeks. I called a family physician (who delivered babies) at the clinic in the woman's town to ask if the woman could have an internal culture done to rule out an internal lesion. He told me that internal lesions nearly always ONLY occur with INITIAL outbreaks, and the risk of internal lesions with subsequent outbreaks (especially if she's had herpes for several years) is miniscule. He told me that if the lesion is not on the perineum, she could deliver vaginally virtually without risk. I was a little surprised, as this contradicted a lot of the information I had read about the seriousness and fear of herpes and vaginal birth.
Finally, just recently, I had a client who (as she had done with her last pregnancy with a CNM) decided to take a viral suppressant beginning at 38 weeks.
- Paula Bernini
While I can't recall the source of the information, I remember reading a while back of midwives administering superglue during labor over the herpes lesions to prevent transmission from mother to baby. It's worth looking into.
- Amy Jones
My question is how often is this woman having outbreaks? Also, did she have her first outbreak during this pregnancy or is she just having secondary outbreaks? If she is having secondary outbreaks, then perhaps a change in stress levels, diet, exercise could help her have less outbreaks. If all else fails and she is having frequent outbreaks I would offer to put her on Acyclovir, oral, for her last trimester, thus avoiding an outbreak at term.
- Annette Manant CNM
Order the Midwifery Today conference tape "Herpes" (Item No. 941T79). Andrea
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Editor's Note: the case involving breastfeeding mom Siri Wright has been dismissed as of this writing. Below is a synopsis of the case, which drew worldwide attention via email in a matter of days. This is grassroots activism at its best. Congratulations to all those who helped Siri stand up for the right to breastfeed her child for as long as she knows is appropriate. Consider letting your thoughts on this subject be known via the avenues listed below.
Siri Wright, mother of two ages 4 and 2, was assigned a trial date because she is still breastfeeding her daughter. She was summoned for jury duty, but Idaho law dismisses mothers of duty if they are nursing a child. Siri called to arrange dismissal and through a course of events that you can read in more detail at www.leftgrlls.com/supportsiri/ was given four months to end her nursing relationship. She explained that this was not possible and then was given two days notice to serve jury duty. Siri has no family in state, no childcare options, and her husband works far from home; so to comply with the notice, she appeared in court with her children. A tirade ensued by one of the court officials and Siri was notified of a coming trial date to settle the issue.
I can't thank you enough for all your supportive emails. The response has been
overwhelming. Our story was featured on two local newscasts that we hope will
spread our story even farther. My attorney has set up a web page where you can
access the latest information on my case:
The site also contains a forum where you can post your messages to me. It would
be better to contact us through this forum rather than direct email. The volume
of mail has been overwhelming, and I can't even begin to respond individually.
Also, our attorney would like a record of every response, and this forum is the
best way to do that. Even if you've already emailed me, it would be great if you
could post what you sent on the forum.
- Siri Wright
Other actions that would continue to be helpful are:
*Letters to the editor of our local paper, The Idaho Statesman. Letters
should be up to 200 words in length.
Several months ago you posted my question about how to find support for a VBAC homebirth. I was debating whether or not to attempt a homebirth given I could not find one OB or midwife in the Philadelphia area to support me. I want to thank you for posting my letter which resulted in a handful of enthusiastic supporters.
In addition, just reading your newsletter every Friday reinforced my own intuitive feelings about how I wanted to birth. You helped me find the right resources and develop the right mindset to be successful.
Charles Nicholas Henry was born at home on February 3 (9 days late!) at 8:47 in the morning. I pushed him out with the help of my excellent midwife, her nurse, two of my best friends, my husband and my 2-1/2 year old son. It was simultaneously the hardest and most wonderful moment of my life.
- Stephanie Kindt
Our birthing unit is contemplating a change to the timing of the first baby bath. Currently it is performed in the birthing suite within the first couple of hours. We have heard, however, that it is better for vitamin K synthesis to delay until the next day. Your thoughts on this or referral to any studies would be appreciated.
- Jacinta Muller
A client has had a natural birth, then two c-sections. She had a broad ligament tear during the last section which is why they are saying she has to have another cesarean. She birthed her last 8 months ago and is now 8 weeks pregnant. She is 38 and lives in an isolated community with little support. She is very keen for information and has asked me to gather as much as I can in regard to her choices (elective c-section vs VBAC attempt).
Any feedback/experience with/about this medical condition would be appreciated. I've been searching medical books and finding no specific references either to it or to the preferred action for future pregnancies and births in the presence of a torn broad ligament.
- Jackie Mawson
In response to the question about twins and ultrasound [Issue 2:8]: The only good reason I know of for extra ultrasounds for a twin gestation is to check that the growth remains concordant. Tertiary centers have procedures for correcting discordant growth which do have their risks but which can make significant differences for both children if successful. But all such procedures (and the ultrasounds) should be the decision of the parents after informed consent. It does not sound as if the woman in question has been told a thing.
- Cynthia Flynn
This article lists several studies on animal fetuses. Perhaps it will be of some help: www.drgreene.com/970106.html
- Laine Holman
In the early 1990s a large study carried out in Perth, Western Australia, called the Raine study, looked at the effect of having multiple ultrasounds in pregnancy. As I best recall, there was a link to having slightly smaller babies (but only about 30g) and an increased risk of having IUGR babies when multiple u/s where done. I don't know where you could get a hold of it, but if you went to a Medline search and looked for the Raine Study you should be able to find it.
- Kirsten Blacker
I am a mother of three children, all born at home. I had no ultrasound for my first and my third children, but had several ultrasounds performed with my second. While the two not exposed are generally mellow, agreeable, and "easy" and always have been, the second child has always been a real challenge! She is more physically active, emotionally unstable and difficult to guide, nurture, and keep safe.
Am I crazy to think this difference might be related to the ultrasound? Is there any place I can learn more about the negative side effects of ultrasound and what can be done if there was damage caused? I know that individual children are different and have different natures without cause or reason, but could there be anything to my concerns? Please let me know if you know of resourses or information for me in my quest to understand how best to parent my little girl.
- Lisa Vaughn
In response to Cindy S's comments in Issue 2:8:
First, regarding the breastfeeding remark, I have the following correspondence from Dr. Watters, dating from Jan 9, 1998: "I wholly support any efforts to make breastfeeding as easy and accepted as it should be....anywhere and anytime the infant needs it. Phil Watters (Obstetrician & Gynaecologist)" This seems pretty supportive of breastfeeding to me!
Second, I think it needs to be considered that since Dr. Watters subscribes to E-News (and also to my own birth activist newsletter, the Online Birth Center News, firstname.lastname@example.org), he's probably not a typical ob-gyn and is at least open to new ways of looking at the birth process. We women are rightfully angry about the ways the medical establishment has hurt us, historically, generally, and personally BUT you don't change peeople's minds about things by yelling at them and suggesting how wrong they are.
When we find an ob who IS supportive of midwives, breastfeeding and so on, even though he or she may be more medically minded than we'd like, it's better to cultivate the relationship and try to gently show them our view on things (with references and studies to back it up, when appropriate and possible), rather than possibly alienating them by direct attacks.
I don't mean we should bend over backward to be nice, but why antagonize an ally or possible ally?
- Donna Dolezal Zelzer
In response to turning a breech [Issue 2:8]:
I agree with Maka that breech is a variation of normal birth and sometimes a baby presents breech for good reasons. I provided a detailed outline of methods to turn a breech, both non-invasive and medical, to answer an inquiry about how breeches were turned. It was meant to inform and did not include personal opinions about preferred methods or the option to simply have a vaginal breech delivery.
It is true that midwives are guardians of normal birth and sometimes that includes breech delivery. My own third child was delivered frank breech after I refused a c-section (a big deal 19 years ago). She chose that position because of a marginal placenta and a double nuchal cord wrap. An external version, had it been attempted, probably would have failed.
I have since attended breech births. However, I have also done external versions when less aggressive methods have failed. It is wise, when making a judgment call, to take into account the level of experience the midwife has with breech delivery, the legal and medical climate in your area and any limitations a midwifery license may impose. In my area, a licensed midwife is not allowed to deliver a woman out of hospital if the baby is diagnosed as a breech before labor. When I compare the number of medical interventions that a woman would face in the hospital with the intervention of an attempted external version, it seems reasonable to try the version. If it fails, at least there are compassionate and experienced physicians in my area who will do a vaginal breech delivery. Some areas are not so fortunate to have this option and the midwife will then be faced with her natural instincts to protect the mother and baby by attending a breech birth. That is why it is important to have midwives who are well experienced in breech delivery. Routine cesarean for breech presentation is medical abuse, especially a frank breech in a multiparous mother.
Although I experienced my first surprise breech only three years ago, I haven't had to perform an external version in nearly ten years. Babies tend to turn on their own given a little room and mommy encouragement.
I hope this correspondence clears up any fears that midwives are promoting aggressive medical attitudes toward breech babies. Joyfully, I find that the opposite seems to be true.
- Maryl Smith
I cared for a primip last weekend who had an epidural and pushed for 45 minutes, then refused to go on. She said she was exhausted and just couldn't do it. The baby was at +1 station. She most definitely could have delivered vaginally. We tried to convince her to go on, but she refused to push. Part of the problem was stool in her rectum which we believe she was fearful of passing with pushing correctly (which she still had not done). I encouraged the physician to bolus her epidural (which at that point was not effective) and just let her rest, in hopes that the baby would proceed down on her own. He refused since the patient was insistent and he believed she would end up as a section anyway. As a student nurse midwife, that was extraordinarily frustrating. Can anyone offer suggestions on what else we may have tried to convince her to continue?
Do most midwives regularly make use of the Doptone? Also, shouldn't each womon
be made fully aware that the Doptone is ultrasonic? Even though the exposure periods
are usually brief, I heard that 1 min. of Doptone is much stronger--equal to 30
min of the other full-image type ultrasound. Is this true?
I am looking for stories and information about giving birth to twins. My midwife is out of state, and doesn't feel she can guarantee she will be here in time for the birth of my babies. With this in mind, I have been contending with the hospital and setting out my guidelines and preferences. The one that seems to be the largest issue is the use of an epidural. For obvious reasons, I am not eager to go that route, but at the same time, would prefer it to a c-section.
At this time, one baby is head down, and the other (the one to emerge last) is breech. While the doctor will leave me without the epidural for a vertex birth, she is eager to use an epidural for the breech birth. I'm frustrated, but I also realize her experience is not equal to that of my midwife. I am clear that the birth of my babies is not about what is easiest for my OB, yet I need information that will help inform her about the ways she can help me in my deliveries without the use of any form of sedation.
Reply to: LisaLukKen@Aol.com
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