March 10, 2000
Volume 2, Issue 10
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Caffeine and Miscarriage
5) Check It Out!
6) Questions of the Week
7) Question of the Week Responses
8) Switchboard
9) Classified Advertising

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1) Quote of the Week:

"What separates most birthing women today from women in the past is the loss of familiarity with the birth process, the loss of community with other women, and the loss of traditional feminine wisdom."

- Suzanne Arms

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2) The Art of Midwifery

About the only time you will see a healthy grand multip at risk is if she has overstretched uterine muscles ("pendulous abdomen"). This will keep the baby from engaging, resulting in danger of uterine prolapse, back pain and lack of progress because the baby isn't engaged or aimed at the exit. Use a "prenatal cradle" during pregnancy and have the mother labor lying down or with a "belly wrap" to help the baby stay vertical.

- Rahima Baldwin Dancy, CPM in Midwifery Today Issue 40

===

Share your midwifery arts with E-News readers! Send your favorite tricks to mtensubmit@midwiferytoday.com

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3) News Flashes

A Sydney, Australia study showed that breastfed babies develop an appetite for flavors from having tasted them in their mother's milk. A comparison group of artificially fed infants showed less inclination to start new foods. When they did eat them, the portion taken was about half the amount the breastfed babies took. -Journal of Human Lactation, Sept. 1996

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4) Caffeine and Miscarriage

Researchers from the National Institute of Child Health and Human Development (NICHD) and the University of Utah, Salt Lake City, analyzed stored blood samples from more than 3,000 women, of whom nearly 600 had a spontaneous abortion. Using a new method to estimate overall caffeine consumption, the researchers measured blood levels of paraxanthine, a marker for caffeine consumption. Paraxanthine is a substance produced by the liver when caffeine is metabolized. It remains in the blood longer than does caffeine.

Paraxanthine was found in 82 percent of women in both experimental groups. The mean paraxanthine concentrations were significantly higher in the miscarriage group than in the control group. However, the risk for miscarriage is not increased until blood concentrations of paraxanthine are extremely high.

Very high levels of paraxanthine were fairly rare, occurring in 11 percent of the miscarriage group and 5 percent of the live-birth group.

"Healthy women with a good pregnancy get a pregnancy signal by the fifth or sixth week," said Dr. Mark Klebanoff, director of NICHD's division of epidemiology and primary author of the study. "They are more sensitive to odors and food flavors, and they don't want to drink coffee first thing in the morning. Women who miscarry often don't get this pregnancy signal and continue to consume their normal amounts of coffee."

One factor that complicated this study was that the blood samples had been stored for more than 30 years. While the long-term stability of paraxanthine is unknown, the researchers conducted a pilot study that demonstrated "marked deterioration of paraxanthine was unlikely to have occurred."

During the 1960s, women were not cautioned against consuming caffeine during pregnancy, and according to the National Coffee Association, the national per capita coffee consumed was higher in the 1960s than it is now. Currently it is very difficult for investigators to recruit a large sample of women who consume large quantities of caffeine while pregnant.

Since there is no exact way to equate paraxanthine concentration with an amount of caffeine intake, the study cannot precisely say how much caffeine is safe during pregnancy.

- The New England Journal of Medicine 1999;22:1639-1644, 1688-1689

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5) Check It Out!

~~~WWW.MIDWIFERYTODAY.COM~~~
A Web Site Update for E-News Readers

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Midwifery Today's Product and Services Directory--The Birth Market--has opened its doors for birth practitioners to join! We are asked every day for help locating birth practitioners of all kinds--here is Midwifery Today's savvy solution!
ON SALE: For the cost of $25 and a static banner on your web page, you may join our listing. This means if you have a web page that is EXCLUSIVELY about your practice and DOES NOT SELL A PRODUCT, you may add our banner to your site and pay a $25.00 registration fee to be included in the Birth Market. This is a special price to you--a regular entry to the Birth Market costs $150.00 for businesses/websites that sell products. See
www.midwiferytoday.com/ads/bannertrade.htm. If you don't have a web page, call or e-mail Cynthia the WebGirl@midwiferytoday.com You may also read more details at
www.midwiferytoday.com/birthmarket

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On March 29, 2000 Jan Tritten, Mother of Midwifery Today, and Cynthia Yula, WebGirl@midwiferytoday.com, invite you to join them at 7 p.m. for drinks, 8 p.m. for dinner at Panchitos Mexican Restaurant, 103 MacDougal St., NYC, NY 212-473-5239. We are "going dutch" (is that politically incorrect?). But Cynthia's buying the first round of nachos! As you know, our international conference is scheduled for September 6-10, 2000 (www.midwiferytoday.com/conf/2000and.htm). We are looking for Birth Change Agents to brainstorm with. Have any addresses or phone numbers we should have? Is there someone you think we should invite? Any marketing tips to share? We're all ears! Please bring a floppy disk of addresses if you have a long list. And also, if you are interested in a web page, bring three photos for Cynthia to scan for your page.

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Birthing From Within
by Pam England, CNM and Rob Horowitz, PhD
www.midwiferytoday.com/Library/Reviews/template5.html

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Are you a birth enthusiast? You need a web page! After all, isn't a picture worth a thousand words? Have a web page created that you can hotlink from Midwifesearch.com, Midwife Link and Midwifery Today as well as your paper marketing! We even register your site into search engines! Contact Cynthia the WebGirl@midwiferytoday.com for more details.

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7) Questions of the Week

Is a cesarean indicated for premature babies? If so, how premature? The study I recall concluded that outcomes were no better having done a cesarean no matter how premature. Of course I can't find the study now, so if any of you have any information or studies on hand, please let me know of them.

- Amy Jones

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Send your responses to mtensubmit@midwiferytoday.com

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Register online at www.feminist.org or
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8) Question of the Week Responses

Q: 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. 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?

- M.W.

Just make sure your midwife is called at the first signs of labor or impending labor (backache, bloody show, etc.). Even two hours is plenty of time if the midwife is not a hundred miles away. Also, have a kit for delivery ready at home and have your midwife review how to assist in the birth, support the perineum and stimulate the baby if necessary. Your partner will feel more comfortable if these basics are reviewed in the event the midwife does not arrive in time.

- Anon.

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I had planned my fifth birth to happen at home with my family and midwives. Everyone involved knew I had a prior birth that lasted 53 minutes from start to finish. As it happened, my baby came in 34 minutes, emerging beautifully and born into the hands of his daddy and grandma (the birth happened at two in the morning.)

Our bodies are made to do this and if it happens that your midwife, husband or doula don't make it (very unlikely) it would still be better for you to be at home with all necessary supplies and education rather that YOU being the one stuck in traffic! Induction is not necessary. Just rely on planning. If your water breaks, call everyone immediately. You can even plan to have a family member stay with you for a few days before your due date.

I learned that unnecessary worry does nothing. I know I could have delivered my baby by myself if needed. On the other hand, you may have all the time in the world. Our sixth baby took over 6 hours!

- Deana Sodders

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I have five children, and my longest labor was five hours (my second). I average around two hours. My last two were born at home. With the first homebirth the midwife skidded in just in time to catch the baby. Number five was a beautiful waterbirth, 50 minutes start to finish. My husband and a friend were there and my midwife was stuck in midnight construction traffic. She got there in time to see the placenta delivered. However, by my estimates, had we opted for the hospital, the baby would have been born on the side of the road in a car.

If I had to make the decision over again, I'd still have the homebirth. I did make sure both times that I had a (doula) friend who is familiar with "emergency childbirth" with me.

- Chava Weiman

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9) Switchboard

In response to the question about the timing of baby's first bath [Issue 2:9]:

Here in the United Kingdom we bathe babies more than 24 hrs after birth and mum always performs this first ritual. Generally they almost self-clean.

- Julie

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Vitamin K synthesis is a liver function; our liver is situated in the abdomen. In some Asian cultures a belly wrap for both mother and baby is used to keep any cold air from the baby's and mom's abdomens which have been stressed from births. My first homebirth baby had a bath a day after birth yet he still had newborn jaundice. But my second homebirthed baby was not given a bath even after the second day and she had no jaundice. I would recommend the bath only after the third day.

- Connie D.

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I am a student midwife and want opinions about some of the methods my preceptor uses and believes in. First, he thinks of birth as a biological process and that the midwife's/doctor's job is to let the body birth in peace. They should only help the mother be more comfortable, etc. He also has a very low intra-hospital cesarean rate--10%--which is the lowest in the region. He definitely believes in VBAC as long as there is no danger to the mother or baby, and often sees cesareans as "unnecesareans."

He induces at 40-41 weeks if there is no sign of labor. He says he checks cervical ripeness, and if the cervix is not ready lets it go one more week so it will be a smoother and more successful induction. He reasons that the mortality rate of babies after 40 weeks rises very much, the placenta is older and within a very short time it can become insufficient.

He also does an automatic cesarean if the baby is over 10 pounds. He says shoulder dystocia is due to oversize babies who should have been cesareans, and that dystocia is more dangerous to the baby 10 lbs and up than cesarean would be.

He has a 10% cesarean rate, and thinks there is no reason for any clinic or hospital to have a rate higher than 10% without putting anyone at any risks at all.

- Aiyana Gregori

====

In response to the question about Doppler use [Issue 2:9]:

I work for Nicolet Vascular (formerly Imex Medical). Following are excerpts from a letter written to another person with the same concerns.

- Diane Rugh

First, a Doppler auscultatory device in fact uses the same technology as an ultrasound imager in that a high frequency sound wave (ultrasound) is transmitted into the body and a return signal is analyzed and processed either to display an image or transmit a sound. Doppler devices typically emit a low power continuous wave ultrasound signal and detect the change in frequency (Doppler effect) from the return signal. The frequency difference between the transmitted and received signal is typically in the audio range and can thus be heard if amplified to a speaker.

Ultrasound imaging devices emit a high powered pulsed wave ultrasound signal and detect the length of time the signal takes to return. This information is used to detect depths and can be displayed to see the image. As you know, most imagers have a Doppler mode that will show colored blood flow direction in addition to the image.

In either case, the revised AIUM statement issued in 1993, "No confirmed biological effect...", applies to both technologies in that the concern is power emitted into the body, not how you process the information you receive.

Second, you stated that the frequency of Doppler devices is higher than an imager device. This is also not true. The Hitachi unit ... has a trans-abdominal probe that transmits at 3.5 MHz. The industry standard for obstetrical Dopplers is either 2 or 3 MHz. Imex in fact sells both. Higher probe frequencies that we sell such as 5 and 8 MHz are used for vascular applications and are labeled "Not Designed For Fetal Use."

In addition, I would like to point out that the FDA limit for power intensity emitted by a continuous wave ultrasound for fetal use is 0.094 watts per square centimeter. The FDA power intensity limit for pulsed wave ultrasound for fetal use is 190 watts per square centimeter. The power emitted by a Doppler can be 2,000 times less than an imager! Imex 3 MHz probes emit 0.009 watts per square centimeter, a factor of ten times less than the FDA limit.

Lastly, I also would like to point out that the duration of an auscultatory Doppler exam typically lasts less than a minute. Though it is exciting to hear your baby's heartbeat since there is nothing to see, the exam does not take very long. At the demonstration, I understand you watched the twins for at least 20 minutes. Taken with the above power limits, this can be analogous to watching a night light for a minute as compared to watching a photographer's strobe light for 20 minutes.

Editor's note: Visit the Midwifery Today website and read Marsden Wagner's article "Technology in Birth: First Do No Harm" at
www.midwiferytoday.com/Library/articles/technology_in_birth.html
Midwifery Today also sells an excellent book by Beverley Beech called Ultrasound? Unsound, which reviews and evaluates ultrasound research; price is US$14. For more information go to
Ultrasound? Unsound
Read more about ultrasound in Midwifery Today E-News Issue 5, now archived on Midwifery Today's website. Includes excerpts from Beech's book.
www.midwiferytoday.com/E-News/enews1n5.htm

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I would like to tap into your wisdom: I am nervous about parent craft classes. We cover a multitude of issues over a period of six weeks for about eight couples per course. My problem isn't recognising what a valuable opportunity parenting classes are (I do), but getting my voice across minus the wobble which instills confidence in no one.

Does anyone have any coping strategies for getting past this block of mine? The meetings are informal and friendly, but I am still worrying. I am hoping it will become easier to do with time. As it is, I can barely deliver a coherent seminar with my student colleagues, no matter how much I practice with my mirror and family! My face goes red to my neck, my hands shake and so does my voice. I have done seminars where I have known my chosen subject inside and out, nobody has thrown questions at me I can't answer, but it doesn't help. I sit down afterward and can't remember a word I have said.

Does anyone know of any practical advice on public speaking? Books, websites? I need help! I am flapping already and don't have to do it until next term.

- Jackie
Reply to: jackie.bunp49@virginnet.co.uk

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In response to the question about the birthing mom who refused to push [Issue 2:9]:

If a c-section was actually done, was it done with or without attempts at ventouse delivery if the mother wouldn't push? I suspect the mother was asked to push too early and that waiting for descent and appearance on the perineum (so the mother could see how close she was) would have been a better way of managing this labour.

More feedback please!

- Phil Watters

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You might have suggested she sit on the toilet and push if she was fearing passing stool. Oops, I just remembered that she had an epidural. Then offering her a bed pan AND some privacy might have helped her if no one was willing to wait for her uterus to push the baby out.

- Anon.

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I had this happen to me twice. The first time the woman was 6 cm dilated, mulitparous but not progressing, with a very 'loaded' bowel. I gave her an enema (a rare thing for me), she had a BM and five minutes later ruptured membranes and delivered. A few weeks ago I was caring for a woman who was fully dilated with a full bowel. I was loath to give her an enema at that point, but did get her up onto a commode (hospital birth) to push. She had a small BM, then got back on the bed and delivered. In the second instance I think it was a combination of the bowel movement and the position change that moved the baby down.

- Kirsten Blacker

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I can speak to this issue personally (as I'm sure many other mothers who have been through labor can!). With my first child who was born in the hospital, I did not have that "urge" to push although the midwife was instructing me to do so. I did not know "how" to push correctly at first, and therefore for several pushes did not make much progress. I don't recall if someone instructed me or if I finally caught on to the "correct" way to push, but once I started pushing as if I was trying to poop, if you will, my baby made great progress and was out in just a couple more pushes. Whether more than my baby came out or not, I do not know!

With my second birth, which was at home, I knew the right way to push (the intense bearing down as if you were trying to expel whatever you could from your lower abdomen), and was more than happy to push out my baby and anything else just to end the pain of the contractions. In fact, as my husband who was one of the helping hands will probably never forget, that time more than my baby did come out!

For me, birthing without drugs is both the most wonderful and painful experience I can imagine. During transition, I will do absolutely anything to get the baby out, including pooping!

The epidural your mother received deadened her sensation to the contractions (i.e., pain for most of us) AND, I believe, heightened her sense of self-consciousness. Without that epidural, she too may have been more than happy to push correctly regardless of what embarrassment it might cause.

So my suggestions are 1) skip the drugs in order to let your body do the work it's intended to do, and 2) as the midwife, coach people in pushing as if they are trying to poop the largest poop imaginable and assure them that midwives and doctors have seen it all!

- Dianne Oliver

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In response to the inquiry about broad ligament tear as indication for c-section [Issue 2-9]:

The broad ligament is a very loose and soft layer of peritoneal membrane. Sometimes it is torn during uterine procedures such as c-sections. Being such a thin membrane it heals very well and quickly--no big deals or scars. The problem is during the procedure (c-section), mostly related to hemorrhage of arteries or varicose veins located in the intimacy of the ligament.

To my knowledge, there is nothing like broad ligament previous tear as an indication for c-section in a future pregnancy. I researched the Medline for articles on that and didn't find anything.

As for the past two c-sections, the guidelines are the same for all patients with previous c-sections, when in labor."

- Sandra Werner

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In the following experience, I listened to my body, then listened to an incompetent ER doctor and it nearly cost me my life.

One evening I stood up, took two steps and went straight to the floor. I stayed there for two hours. When I tried to sit up I found I was in intense pain from my knees to the bottom of my ribcage. I couldn't sit, lie down or get comfortable. I thought I had the flu but soon found that I was bleeding for the third time in a month.

My doctor told me to go to the emergency room. We both thought I had a tubal pregnancy. I got to ER around 11 pm. They did numerous tests, including an ultrasound. Finally at 3 am the doctor stumbled back in and said I had had a miscarriage and that he would give me something for pain. He said my uterus was empty and there was "nothing to indicate an ectopic pregnancy." They gave me half the shot that he had ordered by IV; I lay down and was out for two hours. When I came to, two nurses and my mom were slapping my face to wake me up. I don't remember the trip home and I didn't wake up again for 14 hours.

When I got up the next morning I was still in pain. Awhile later I went to the clinic. My doctor ordered the records from the hospital; they showed I had an ectopic pregnancy! It said that I had a 5.5 cm "cyst" on my left tube; the doctor who read the report said he could not rule out an ectopic pregnancy. My doctor, who was leaving town, told me to go to the hospital and get another blood test to see if the embryo was still alive. He said they would do something the next day.

The test at the hospital showed the embryo was dead. The next day I went back to the clinic and lay on the floor with my kids for a couple of hours in the waiting room. Finally the doctor came in and said he was sending me to another doctor. He packaged up my records and sent me to a neighboring city. I was glad when the doctor there said I was going straight to surgery. I was doubled over on the table after his exam.

When I came out of surgery the nurses there told me I had had a ruptured ectopic pregnancy and that I was lucky to be alive. I went home after 24 hours and other than losing my milk and having a fussy son for a couple of days, I felt fine.

- C.L.

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

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10) Classified Advertising

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