March 17, 2000
Volume 2, Issue 11
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In This Week's Issue:

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

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1) Quote of the Week:

"There is nothing on earth more wonderful than helping women birth with respect and power."

- Jennifer Gallardo

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2) The Art of Midwifery

I use a prenatal technique taught by Penny Simkin in a full day Midwifery Today conference workshop she did with Phyllis Klaus back in 1996. I strongly recommend the audio tape of that class [see ordering information below] because the technique has so dramatically affected each and every client I work with, survivor or no.

The technique, called "The Triggers Worksheet," is designed to help survivors of sexual abuse figure out ahead of time what parts of the birth process may be problematic in terms of flashbacks and other abuse-related reactions. The doula or midwife will spend about 2-3 hours prenatally doing the worksheet with her client, but it's time very well spent. I've had clients with no abuse issues who nevertheless found the worksheet to be wonderful because it demystified the birth process in a non-scary way.

The basic technique is to go through a list of common birth practices, interventions, and birth sensations and describe them bluntly with vivid detail. The client then tells the doula or midwife if she had a strong reaction, a mild reaction, or no reaction at all. When the list is finished, they go back and look at all the "reaction" topics and clarify why they are an issue, then develop strategies for making them more tolerable/less likely to happen/less scary.

For example, I might say, "In a hospital birth, there's often a lot of traffic in the room during the pushing stage. There may be a lot of nurses or family coming in and out. Your bottom will be exposed to the room and you might not know all the people there." A mom might have a strong reaction to this and say "I really don't like the idea of being naked in front of strangers. It's very scary to me to be exposed that way." I would then use active listening to help her expand on that idea, and arrive at a couple of ways to limit traffic and exposure. Or she might discover after thinking about it that it's not so scary after all.

Clients who have not been abused react with a bit of shock to many of the worksheet topics, but upon looking closer realize they can probably handle it. We may strategize or write a birth plan for one or two "hot topics," but most of the time the best use of the technique is to remove the "fear of the unknown" issue from the equation. I've seen this worksheet session dramatically raise the confidence level of my clients, and all of them have said it was well worth the time. Kudos to Penny for this great technique. It's a godsend for me as a doula as it makes an enormous difference in how much I know about specific nitty gritty issues in the client's life as they relate to birth.

- Jennifer Rosenberg, doula

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Save $3.00 on the Midwifery Today conference tape set "Counseling Techniques for Helping Sexually and Physically Abused Birthing Women," Penny Simkin and Phyllis Klaus, teachers. Regular price $26. Email admin@midwiferytoday.com or call 800-743-0974 to order. Mention Code 940. Offer expires April 14, 2000.

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

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3) News Flashes

Researchers studied more than 2,000 at-risk pregnancies, some of which had an amniocentesis in the middle of the first trimester while the rest had one earlier. In the mid-trimester group, 0.1% of babies were born with a club foot, compared with 1.3% of the babies in the earlier amniocentesis group.

- Nursing Times, citing Journal of Medical Genetics; 36:11, 843-846

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4) Normal Birth: Do We Believe? Can We Remember?

When a woman is considering having a homebirth and we meet for an interview, she often asks, "What is the difference between a midwife and an obstetrician?" Although I can think of many differences both in philosophy and in practice between us, I have simplified my answer to explain what I believe to be a very basic difference in perspective. The obstetrician may say to the pregnant woman, through attitude, words or continual reliance on technology, "You have to prove to me that you can give birth to a baby." The midwife, on the other hand, with her attitude that birth is, in most instances, a reliable event, says to this same woman, "You have to prove to me that you cannot have a baby!"

The midwife is (or should be) an expert in normal birth, while the obstetrician must be an expert in pathology. This is exactly the way it should be. For it is that expert to whom we must turn when we do encounter the abnormal. I believe that oftentimes, the midwife is more likely to recognize situations that demand attention than the caregiver who sees all pregnancy and labor as a potentially dangerous and lethal process.

How have midwives developed such a positive attitude toward the birthing process? Is it that after watching birth and birthing women through countless generations, we know that "babies come out"? Of course, we have also seen birth tragedy, and yet after less than perfect outcomes, we are able to go on to the next labor with our belief in the process intact.

The first factor paramount to maintaining normalcy in birth and obtaining an optimum outcome for mother and her baby is our ability to provide both constancy and continuity of care. As the relationship between midwife and mother develops during the course of prenatal care, a mutual trust between the caregiver and cared for brings a sense of safety and security. Communication becomes forthright and honest, and words and ideas flow easily between them. When it comes to the time of birth, rarely must we deal with psychological issues, which may stall or impede labor, since specters of the past have been met, dealt with and put in their proper place. The midwife has said to the mother through her manner, her touch and even with her words through the preceding months: "I will never lie to you." This is great comfort to the woman with so many questions, meeting birth for the first time. So many times I have sat with a young woman who is having her first baby. When her eyes gaze into mine, when I feel her contractions crashing through her body like tumultuous waves against the rock, and I know she is doubting her strength to go forward despite her great desire to complete her task, I say to her, "OK, Suzy, now you will have to walk on water." She grasps my hand a little harder and replies, "How far do you want me to walk?" Then, we walk together.

- Valerie El Halta

To read this fine article in its entirety, go to www.midwiferytoday.com/Library/articles/normalbirth.html

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5) Check It Out!

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

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New Articles Are Up!

How does the International Code of Ethics for Midwives fit your practice?
The International Confederation of Midwives invites your feedback.
www.midwiferytoday.com/Library/articles/interncode.html

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Did you like what you read in the "Normal Birth" excerpt above? Read the remainder of the article at
www.midwiferytoday.com/Library/articles/normalbirth.html

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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

How does previous cervical surgery (such as LEEP) for dysplasia affect the ability of the cervix to dilate during uninduced labor? One CNM estimated that about 60% of her clients who have had LEEPs have cervical scarring that temporarily prevents the progress of dilatation for up to several hours. I am a 20 week primip and am trying to prepare myself psychologically for this possibility. I have seen several women experience very painful early labor as a result of this problem.

- Kari Michalski

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Send your responses to mtensubmit@midwiferytoday.com

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8) Question of the Week Responses

Q: 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

In the hospital where I gave birth at 25 weeks gestation, preemies are born vaginally unless medically contraindicated. Even though Olivia's birth required a section, they did a sonogram for me to check her position minutes before the surgery (I had an 8 cm fibroid deep in the pelvis; she was breech with cord presenting) just in case something had changed and we could chance a vaginal delivery. Since preemies are so small and the problem is not inducing labor but stopping it, many can be born vaginally with little additional trauma. But it depends on the baby & mother's condition. I never thought I would have been happy to have a c-section until it saved Olivia's life. My midwives were there, of course, through it all!

- Regina Paleau

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To my knowledge the indicators are similar to term babies, although the threshold for fetal distress tends to be lower. Also, the risk of malpresentation is higher. But it also needs to be taken into account whether or not the lower segment is fully formed, because otherwise the woman is looking at a 'classical' upper segment cesarean which to my best knowledge commits her to cesarean birth for subsequent deliveries.

- Kirsten Blacker

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Q: I would like to hear from other midwives who have dealt with pinworms in pregnancy. Did the women experience periodic spotting? Also what, if any, natural remedies are effective and safe in pregnancy?

- Deren Bader

Pinworms and spotting in pregnancy are not related. However, it would be important to rule out irritated hemorrhoids or other causes of bleeding from scratching efforts. Pinworms are fairly common and have a life cycle of about 2-6 weeks. They are transmitted by hand to mouth contact and emerge from the anus to lay their eggs. The resulting irritation causes the host to scratch; the cycle is repeated when unwashed hands touch food or the mouth. The ova can live up to three weeks.

Before medications for pinworms were developed, gentian violet was taken internally for 10 days to kill the worms. It cannot be used internally in pregnancy, but it does raise the possibility of external use at the anus to kill emerging worms. Some Naturopaths prescribe spigelia for pinworms. It is safe to use in pregnancy. Others suggest ingestion of pumpkins seeds and garlic for a period of ten days to two weeks. It is important for all family members to be treated and this includes bathing every morning to wash away ova that have been deposited outside the anus. Snug fitting underwear and regular handwashing as well as washing of bedsheets will also reduce reinfestation.

- Maryl Smith

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I recently had a client with pinworms in the first trimester. She also had vaginal yeast infection, bacterial vaginosis, and urinary tract infection. She came in with constant, dull aching throughout her abdomen, no spotting or bleeding.

I couldn't find any effective natural remedy for pinworms. So I treated the UTI first, emphasized hygiene and the need for lots of water, and discussed symptom relief through the use of warm packs. After 12 weeks gestation, the pharmacist told me we could use Vermox pinworm medication to treat the pinworm. Yogurt, garlic suppositories, and Monistat were used for the yeast infection. The bacterial infection was severe, so we decided to use a Metrogel prescription. She is now fine.

- S.K.

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Pumpkin seeds as a remedy for pinworms is very effective. It will kill them and eliminate them from the body. I don't have specific advice other than to eat them until the problem resolves, and then, I'd advise until three weeks after that to ensure no hatching visitors. A quarter cup three times a day seems like a reasonable amount.

- Beth Germano

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Understanding Diagnostic Tests in the Childbearing Year by Anne Frye discusses pinworm infestation extensively and lists numerous non-biotechnical means of ridding the body of these parasites. This comprehensive book of over 900 pages is available from Midwifery Today for $43 plus shipping & handling. E-mail admin@midwiferytoday.com or
call 800-743-0974. Mention Code 940.

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More on precipitous birth:

Yes, it is possible that you could have another precipitous birth. One risk of a precipitous birth is postpartum hemorrhage. Your midwives, if they weren't there for the birth, would probably arrive shortly after, and be able to help with any bleeding, the delivery of the placenta, and check in with you and the baby. I'm sure your midwives could do a class in emergency childbirth for you and your partner, and educate you on when to call 911 in case they weren't with you.

- Jenny

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The speed of my labors is what took me from OB care with my first two births to nurse-midwifery care with the next three, finally to a homebirth with number six. If I am going to birth, I would rather have the "equipment" and room ready for me. I remind couples as we tour the birth center (in the hospital birthing classes that I teach) that these rooms contain all the equipment the hospital prefers to have available for a birth. Then I ask what equipment is essential to have a baby. I let them ponder a moment, then submit to them that the only equipment necessary is a pregnant women! The rest of the equipment is to make things more convenient for those attending her.

I would definitely have several contingency plans worked out. Aren't most pregnant women the masters of contingency planning? The most important thing is that the expected event bring peace to your heart as you anticipate it. If the overwhelming feeling is ... well, overwhelmed, then there may still be some unfinished business to take care of, either in planning contingency, comfort level with the homebirth idea, relationships, etc. Follow your feelings and be wise in your planning.

- Patty Kartchner

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9) Switchboard

After reading about interventions that accost both mother and baby during a breech birth and then finding Maka Laughingwolf's comment on taking the baby's cue that perhaps the child just wants or even *needs* to be born that way [Issues 2:7-8-9], May I suggest that your readers refer to the breech birth article "Staying in the Humble" that appeared in the last issue of Midwifery Today. It is, by far, the best article on breech birth and acceptance of such I have ever read. It was very inspiring from both the perspective of the attending midwife and the birthing mother! Track it down and read it, folks! This baby *needed* to be born this way and had been born this way each and every time he came to earth! WOW!

- Sharon Sullivan

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To order your copy of Midwifery Today Issue 52 with the story, "Staying in the Humble," e-mail: admin@midwiferytoday.com or go the Midwifery Today website: www.midwiferytoday.com
Mention Code 940 when you place your order and receive a $1.00 discount.
Offer good through March 31, 2000.

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In reference to Diane Rugh's response to my Doppler question [Issue 2:9]: I found the information educational yet I still question the routine use of Dopplers and wonder if *most* midwives are routinely using it. So midwives, are you? Do you tell your clients that it is ultrasound? The AUIM says there is "no confirmed biological effect" yet also says, "Although the possibility exists that such biological effects may be identified in the future, current data indicate that the benefits to patients of the prudent use of diagnostic ultrasound outweigh the risks, if any, that may be present."

- A.

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Physicians for Midwifery: Dedicated to healthy, safe birth outcomes through support of midwifery services and integrative midwife-physician care.
*Do you believe almost all births are a normal and safe process without the need for expensive obstetric technology?
*Do you believe women should have a choice of birth attendants and birth settings?
Join other physicians and midwives in supporting collaborative efforts to educate students, residents, physicians and consumers regarding the midwifery model of care.
Contact: Patricia M. Burch, MD, FACOG, 112 Exchange Place, Lafayette, LA
70503; tel: 337-232-4588 or 337-232-4589; e-mail: pburch2881@aol.com

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In response to Aiyana Gregori's questions regarding her preceptor's routine practices [Issue 2:10]:

It's true that the placenta, at some point, stops functioning well and the baby can become at-risk. However, there is no reason why periodic monitoring of the placenta post-dates couldn't happen (unless access to this technology is absent). As long as there is sufficient fluid level, and the placenta doesn't appear to be too calcified, there is no reason to induce a woman only because she is past her due date. Remember, the due date is just an estimate--women grow babies at different rates! As well, women grow babies of different sizes. Unless we are consuming large amounts of growth hormones from eating animal products, I firmly believe we grow babies our body can birth! I honor your willingness to question these practices.

- Jenny Johnson

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It's odd that he says birth is a "biological process best left to occur on its own" then is highly interventive! He may have a low c/sec rate, but at what cost to the "biological" process? It sounds as though he wants to be very much in control of when women birth and that it is *his* timing of things that makes it all happen safely. As for doing a c/sec if the baby "is over 10 pounds," this is merely an estimate and is probably wrong fairly often, meaning a scheduled c/sec on smaller babies or even large babies that would have birthed well despite their size. Is this doc aware of the Gaskin maneuver: all fours for birthing large babies? Maybe he had a very traumatic dystocia with a large baby that made him say, "Never again."

I would suggest you find a homebirth midwife in your area if possible to precept with as well. A well rounded experience is extremely important. It is equally important that direct entry midwifery students have hospital experience.

- Kelley Hewitt

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To Jackie, who described a fear of public speaking [Issue 2:10]:

May I suggest that you forget "public speaking" altogether? It is to communication what "medicalisation" is to birth, which is to say an unnatural, inefficient way of doing things, with its own equivalent stress-problem-stress vicious circle, as you've discovered. What you're really trying to do is something that comes naturally to you: share the skills you have with others in order to help them become better parents. Isn't that the sort of thing that makes you want to be a midwife in the first place? Why not talk *with* (not "to," certainly not "at"!) your group as an equal member, but one who happens to have a lot of good stuff to share? In other words, don't lecture--participate. Of course, that means listening to what others have to say too, and learning from them (tough on the ego sometimes, admittedly!), but that way perhaps you'll find that you're all helping answer each other's real concerns and problems, not telling them what they're *supposed* to need to know, and you won't be worrying about how you sound, how you look, etc. Hope this helps.

- Dave

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More on timing of the baby's first bath:

I've been unable to locate any evidence that the timing of a baby's first bath has any effect on anything other than the "cleanliness" of the baby. Over the decades recommendations veer wildly from immediate to delayed bathing. At one period women were advised to postpone baths until the cord fell off, even though the cord-care sterilization of that time period meant this could be as long as three weeks!

I give my clients the following advice: bathe the baby whenever they wish. There is no need to hurry and no need to delay. Bathing before the cord detaches does no harm and does not increase the incidence of infection.

- Gail Hart

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Regarding the story about jaundice and baby's first bath: this is not a serious way to bring genuine knowledge to people; it's non significant anecdote. The reasons for jaundice are many and varied and have little if anything to do with timing of the first bath.

- Phil Watters

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I want to hear from midwives about their experiences with women who stay mobile and ambulant during their labours. I have all the research I need now, but would like some anecdotal evidence from midwives themselves, how they feel outcomes are different for women hooked up to monitors for hours, epidurals, analgesia etc. as compared to women who aren't.

- Jackie
Reply to: Infinity@cableinet.co.uk

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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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