March 24, 2000
Volume 2, Issue 12
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) What Midwives Want From Their Clients
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:

"No matter how much data has been accumulated on however many mothers, we can never know scientifically exactly what will happen in the next birth."

- David Stewart, Ph.D.

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2) The Art of Midwifery

I often joke with a first time mother who is preoccupied with watching the clock that no woman has ever missed her birth by sleeping through it. It is important that the mother be encouraged to rest and sleep as much as possible in very early labor. If exhaustion has occurred, labor will slow down and inertia and constriction rings may lead to operative intervention. The risk of maternal hemorrhage increases as well as the possibility of subinvolution with excessive bleeding and postpartum infection.

- Valeria El Halta, Midwifery Today Issue 46

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Read Valerie's wise comments on sixteen different causes of prolonged labor, in Midwifery Today Issue 46. Mention Code 940 when you order your copy and receive $1.50 off the regular price of US$10. Please add shipping & handling: US$2.00 in U.S.; US$3.00 Canada/Mexico; US$3.25 all other international. Ordering information is at the bottom of this newsletter.

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3) News Flashes

A recent study found that women whose diets are relatively high in saturated fat in the year before they conceive are at higher risk of experiencing severe nausea and vomiting during pregnancy (hyperemesis gravidarum). This condition can lead to dehydration, weight loss and if left untreated, liver and kidney damage. The author of the study suggests that women who have had an earlier pregnancy where they were very ill may want to consider altering their diet to alleviate the symptoms in the next pregnancy.

- American Baby, April 1999

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4) What Midwives Want From Their Clients

Be Honest: One would think that this would go without saying, but unfortunately, it does not. Not only does this quality stand as the first and foremost obligation of a woman to her midwife (and the midwife to her client, of course), but it permeates all the other qualities listed [in the remainder of the article]. Without honesty there can be no trust, and without a trusting bond between midwife and client, there can be no safe working relationship.

There are many reasons why a woman would be untruthful. Perhaps a woman has had several abortions and has not told her husband. If an oral history is taken with the husband present, she may hide the information from her midwife. A woman may be too embarrassed to let her midwife know that she has herpes. Or perhaps she has learned from interviewing other midwives that she has a certain risk factor that would preclude a homebirth. She may think that if she hides the information from the present midwife, she can get the homebirth she wants. But there are dangers inherent in these scenarios.

Each woman has the right to choose her birthplace and attendant. Conversely, midwives have the right to choose their clients according to self-imposed limits and protocols. Some midwives do not hesitate to take women who have had multiple abortions or who have herpes; others do not feel comfortable doing so. Most midwives will not assist at the delivery of twins or breeches; others do not take VBACs. And there are some conditions for which few midwives would agree to be the primary caregiver, such as preexisting medical/health problems that require the care of an OB. In these cases, the midwife might be able to co-manage your care with her backup doctor.

Unfortunately, there are some women who so desperately desire a homebirth and/or midwifery care that they are willing to do almost anything to get it. This is unfair and potentially dangerous to everyone involved. If you have any medical condition or significant past OB history, you must tell your midwife, even if other midwives have turned you down. Without thorough knowledge of your history, the midwife cannot make safe decisions regarding your care. Remember, however, that what one midwife may not feel qualified to handle, another may feel perfectly comfortable handling.

If you have special requirements or requests of a midwife, such as religion, lifestyle, philosophy, education/training or legal status, make these clear during the initial phone contact and ask if she can meet them. There is no point in signing up with a midwife only to discover later there is something about her you find unacceptable. Most midwives know other midwives in their area, and can refer you to another who might better suit your needs.

Read the remainder of this article on Midwifery Today's web site-it makes a great handout for new clients! Go to:
www.midwiferytoday.com/Library/articles/midwiveswant.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 Continue to Go Up! Check them out at

http://www.midwiferytoday.com/Library/articles.htm

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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
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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.

~~~~~~~~~

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) Question of the Week

Does anyone know of any natural remedies for blocked fallopian tubes? The woman in question has already had two children and is not aware of having had an infection that could have caused this.

- Julia Duthie

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Send your responses to mtensubmit@midwiferytoday.com

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8) Question of the Week Responses

Q: 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.

- Kari Michalski

My experience seems to be either/or: short labor, long labor.

- B.D.

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I would recommend that any pregnant woman with cervical scarring take evening primrose oil during the last month of her pregnancy, even applying it directly to her cervix. I had a cervical biopsy done between my third and fourth pregnancies and my labor for my fourth was very painful, and long. I rubbed evening primrose oil on my cervix during labor and it seemed to really help things get moving.

- Lorrie White

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I had a primip student in my Bradley class who decided to have a midwife-attended homebirth. She was in excellent health throughout her pregnancy and was not particularly concerned about the fact she had had LEEP surgery many years before. She was in labor for over two days, and at 7 centimeters (midwife could stretch her to 8 centimeters) for twelve hours. She was handling the experience well, but getting truly fatigued. The midwife finally suggested they transport to the hospital. On arrival, the doctor lost his mind that she had been that dilated for that long and wanted to do an immediate c-section. The couple refused and requested an epidural and some more time (hoping for sleep and dilation). She did not dilate any more and they did end up with a section. The midwife's response to this (according to the mom) was that her cervix was fairly well scarred. The doctor who examined her said he didn't feel any scarring. I would love any feedback you can offer on this. The couple is hoping for another baby and wants a homebirth VBAC.

- Samantha Ste.Claire

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I have been a labor and delivery nurse for years and am an aspiring midwife. I have found that often times cervical procedures such as LEEP do produce tough scarring that takes a bit longer to get going, but once the scarring has been broken up with a little digital manipulation, the cervix has the potential to open much more rapidly.

- Becky

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I always list a history of LEEP on the Problem List to remind myself during labor that there might be a problem. There never has been. Don't worry.

- J.C.

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More on cesareans for premature babies:

Here are three studies you might want to look up. They seem to indicate that after taking other complications into account, cesarean is not routinely warranted for the premature infant.

- Jill MacCorkle

Dietl J, Arnold H, Mentzel H, Hirsch HA.Effect of cesarean section on outcome in high- and low-risk very preterm infants. Arch Gynecol Obstet 1989;246(2):91-6 "Cesarean section was associated with a highly significantly improved survival rate in the high-risk group, but was not associated with differences in fetal outcome in the low-risk group. The results of this study do not support primary cesarean section as the method of delivery for all very preterm fetuses."

Malloy MH, Onstad L, Wright E. The effect of cesarean delivery on birth outcome in very low birth weight infants. National Institute of Child Health and Human Development Neonatal Research Network. Obstet Gynecol 1991 Apr;77(4):498-503
"These data suggest that after accounting for certain maternal and fetal factors, cesarean delivery is not associated with a lower risk of either mortality or IVH."

Malloy MH, Rhoads GG, Schramm W, Land G. Increasing cesarean section rates in very low-birth weight infants. Effect on outcome. JAMA 1989 Sep 15;262(11):1475-8
"We conclude that there is little evidence that the use of cesarean section for the delivery of very low-birth weight infants, independent of maternal or fetal compromise, improves overall survival. We were unable to find reasons to justify the sharp increase in the use of cesarean sections for these small infants."

More on pinworms in pregnancy:

A low sugar and white bread diet helps pinworms and all kinds of parasites thrive. Also I have heard that fennel tea helps [alleviate pinworms], although I do not know if it is contraindicated during pregnancy. It won't be hard for you to find out.

- Anon.

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9) Switchboard

A friend was just told that her blood has tested positive for "Anti-C" and that she will likely miscarry in her second trimester. She is ten weeks now. She has had five live births and last year miscarried twice, at six and eight weeks gestation. Her doctor did not (would not) take the time to explain what this is, other than some sort of sensitization from a previous pregnancy. He said it did not cause her two recent losses. I could not find any information on this condition. If you have heard of this, please help enlighten us!

- Eileen in Maryland

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

It sounds like your preceptor has the right attitude toward birth, at least in theory, but some of his routine practices seem to contradict his basic ideals about birth being a biological process and his role being only to allow women to birth in peace.

He seems to have a reasonably low c-section rate, but what about other interventions? Does he do a lot of forceps or vacuum deliveries, episiotomy, etc, due to women who are induced when neither their bodies or babies are ready for birth? Induction causes a higher incidence of instrumental delivery, which raises the risk of infection (according to Judy Barret Litoff, "American Midwives--1860 to the Present" (Greenwood Press, 1978), pp. 108-113), usually due to failure to progress. Well, that's because the baby was not yet ready to be born! There is no reason to induce a healthy woman with no medical indications other than 40 weeks. The due date is only an estimate. And if the average is 40 weeks, there will be some women who go longer. Forty-two weeks or even 44 weeks is not dangerous in and of itself; some babies take that long to prepare for birth. The placenta does not deteriorate just because the pregnancy has gone past the estimated due date. As long as both mom and baby are doing well there is no reason to induce at 40 or 41 weeks.

There is also no reason to do a c-section simply because the baby is estimated to be 10 pounds or more, besides the fact that prenatal estimations of weight are notoriously inaccurate, often by a pound or more, even with the use of ultrasound. Shoulder dystocia has more to do with positioning of babe and mom than birth weight. Many ten pound babies are born vaginally with no complications at all. The birth attendant's ability to loosen a stuck shoulder is important too, and something that must be learned. And always consider the fact that by having a c-section, the maternal death rate is up to 16 times greater than a vaginal birth (according to the British Medical Journal).

He does seem to be on the right track, but if he really believes that birth is a natural process, he needs to let it be that. And let birth happen in its own time and its own way. There are lots of studies that show the increased risk associated with these interventions; it would do you good to find them so that you have all the facts at your disposal to make a decision. Many are available on the Internet and very easy to find. The British Medical Journal is a good place to start (www.bmj.com).

- Michal Lynn Moyer, aspiring midwife

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In response to Jackie's question [Issue 2:11] regarding mobility in labor: I can't tell you how often a woman will suddenly progress after I get her up and moving. My usual excuse is, "It's time to go pee" or "How about a shower?" This most commonly occurs in multips. I find a LOT of women prefer to stay still in bed. They are afraid, of course, that the more they move, the more it will hurt. On the other hand, I have had a disappointing number of women, usually primips, who make no progress in labor despite tremendous effort on their part to remain mobile during labor or to become mobile with my encouragement. These women's births end in cesareans. So, I find it can work beautifully or not at all.

- Mary Ann Durbin, Toledo

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An Ob/Gyn conference entitled "Update 2000" will be held April 13-14, 2000 at the Marriott Downtown in Kansas City, Missouri. This conference promotes the use of medically unnecessary cesarean section as a standard of care. The following lectures are being offered:

Cesarean Section Goes Mainstream
Strategies to Optimize a Cesarean Delivery Rate
Cesarean Section: Is it Time to Change the Tune?
Vaginal Delivery and Pelvic Floor Damage
A debate "that normal gravida should be offered elective cesarean section at term"
Elective Cesarean Section at Term (38 weeks) as a Cost Control Measure
Elective Cesarean Hysterectomy at Term for the Last Delivery

A portion of the "course objective" for this conference reads "At the conclusion of this meeting, participants should comprehend: 1) that every age applies cesarean section in consideration of the obstetrical problems of the day, the safety and effectiveness of the supporting treatments, the trade-offs of cesarean and vaginal birth, and patient and societal preferences; 2) current considerations in the application of cesarean section; 3) possible future trends in cesarean section."

The Kansas City area chapter of the International Cesarean Awareness Network (ICAN of KC) will be staging a picket, phone, fax, and media protest of this conference in the hopes that every doctor who attends will be aware that women of Kansas City will not tolerate being cut for medically unnecessary reasons. Your support, locally or internationally, is essential. Please contact Anita Woods, President of ICAN of KC, at (816)822-5040, or email ICANofKC@aol.com for more information on how you can help maintain the rights of women in Kansas City.

There is now a website for the latest news and information, including a response from Truman Medical Center, on the protest of this Kansas City OB Conference. Please go to
http://hometown.aol.com/icanofkc/myhomepage/business.html

[Editor's note: Take a few minutes to read this interesting exchange!]

- Anita Woods
Chapter Coordinator, The International Cesarean Awareness Network
Leader, ICAN of Kansas City

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In response to Lisa's letter in Issue 2:9:

Do NOT let your OB talk you into an epidural, unless that's what YOU want!

My twins, born June '99, were in the same position as yours, and my OB wanted me to have an epi for the second one too. I refused and we compromised with a saline lock, which was put in place at the beginning of second stage (and I regret agreeing to that, since it was unnecessary, painful, and disruptive to what had been a very peaceful labour to that point). His concern was that the baby would turn transverse and he would need to do an internal version--reach in, grab the feet and pull--and that it would be too painful for me. I decided to use gas (Entonox) if I needed pain relief, and he was OK with that.

Eleanor was born entirely naturally, and I caught her myself with my midwife's help. I held her on my chest, cord intact, while the OB checked the position of the second baby. He broke her sac, found she was turning, and decided to pull her out feet first (I think she would have turned vertex given the chance, but he felt better safe than sorry, I guess). It was incredibly painful having his hand in my uterus, and I was offered gas, but couldn't concentrate on holding the mask and my baby, so didn't use it. However, the procedure was extremely quick. Isabel was born a mere 2 1/2 minutes after her sister.

I am SO very glad I didn't have an epidural or any other drugs. Yes it was painful, but the pain was so brief compared with the joy of being unmedicated and able to return home later that day (about 8 hours after the birth). Apparently they were still talking about us weeks later at the hospital: the huge twins (8lb 10oz and 8lb 9oz) who were born without drugs and went home the same day. (I explained to the nurses who were shaking their heads that there was no way I could nurse two babies in a narrow hospital bed!)

My only regrets are the saline lock, and the fact I had to give up my homebirth when we discovered a second baby at 36 weeks. If I'd had time, I would have found a private midwife who could deliver twins at home (the BC College does not permit it).

My advice would be:

1. Write an explicit birth plan and sign it. That makes medical staff feel more comfortable about honouring your wishes without fear of being sued. State your preferences reasonably, and have contingency plans (i.e., if a c-section is necessary, state how you would like that to proceed as well). Don't forget to include how you would like the babies to be treated (e.g.: type of suctioning, if any, when to cut cord, breastfeeding twin A to reestablish contractions for twin B, etc.).

2. If comfortable, give birth in the hands and knees position for Baby A. This makes it less likely Baby B will turn transverse (I wish I'd known this, or I would have tried). Alternatively, have your midwife or a nurse gently "hold" Baby B "upright" externally while you push the first baby out, and until the buttocks are safely engaged in your pelvis.

3. Find out from your OB how long she is comfortable waiting for the second baby. Some second babies are born hours after their twins, but not all doctors are willing to wait that long, for fear the cervix will close and may not dilate again for a breech, or one or both placentae will detach and cause haemorraging or foetal distress. Establish ahead of time both of your comfort zones in regard to watchful waiting.

Most of all, trust your body. Twins are rare but not abnormal, and if giving birth to them was really so dangerous, natural selection would have eliminated multiple gestations in our species long ago.

- Jennifer Landels, Vancouver BC

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At a midwifery conference I attended, there was a deep blending of soul feeding and practice-improving sessions that one always hopes for. But one session about grief touched a spot for me that has continued to itch and made me wonder, where is the book of shared birth stories of infant death as either late term fetal demise, stillbirth or birth of a child too ill to live long? The fantastic book "Our Stories of Miscarriages" helps and heals early losses told by mothers, fathers, and care providers. One is needed, however, for those babies born later in pregnancy not living or living but not long for life. My clients get so much from shared anecdotes that help heal or get them through troubled times.

My co-writer and I hope to compile a book of such stories. There are support groups now for such loss and grief counseling. But a collection of stories from the ones who were there, and who lived through it will really help others. In that spirit, we'd like to ask you to share the experiences you have had with infant death. We would like to hear from the caregivers, moms and dads, birth assistants, nurses, and doulas. Please write, call, or email us at:

Katy Maker, CNM, 2712 Walnut Creek Rd., Decorah, IA 52101; phone 319-382-0249; email organics@oneota.net or Debbie Young, CD-DONA, ICCE, 244 S. Walnut St., West Union, IA 52175; phone 319-422-8833; email theyoungs@trxinc.com

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Regarding the account of the ectopic pregnancy [Issue 2:10]: If things really went as written, I would strongly suggest the writer (and victim) insist on a medical review of her case! If she had been diagnosed correctly, which is not difficult with an ultrasound, her doctor may have been able to save her tube. I've never heard of a blood test to see if the "embryo is alive" in the case of ectopic pregnancy. (In the case of possible fetal demise, of course, we do serial Beta Hcg before the option of D&C.) In the case of ectopic pregnancy, that is a moot point. Immediate surgery to save the life of the mother is always the treatment.

Regarding the discussion of ultrasound [Issues 2: 9, 10, 11]: Some of the information given in the last issue was somewhat misleading. I am not a sonographer but I am married to one. The transducers used in ultrasound have various frequencies to penetrate different tissues. The transducers "not suitable for fetal studies" simply do not have the correct wavelengths to penetrate deeply enough to get an image. They would more likely be used for superficial studies such as for carotid arteries, etc. Different transducers will be used for fetal studies depending on the route (vaginal vs. abdominal) and the weight of the mother (abdominal adipose tissue).

For those who really want accurate information on the risks vs. benefits of ultrasound, what the policies are and the guidelines of the governing agencies are, I would recommend getting on the Internet and doing some reading. HealthGate ob-ultrasound.net would be a good start.

For mothers who refuse an ultrasound scan during pregnancy (because they think it is unsafe), they would also want to refuse (I would think) Doppler for FHT during prenatal visits and in labor for the same reasons. However I am unaware of any studies that have shown fetal damage--physical or mental--due to diagnostic ultrasound examinations.

- Jeanne Batacan

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I wonder if it's normal for the cord to take six to eight weeks to fall off. Both my son and daughter took a long time. I am expecting baby number three any day, and wondering if it will take this long again before I can bathe my baby in a bath instead of just sponge bathe. I was just wondering if there is a reason for this, if I am doing something wrong, or if I can do anything else to speed up the process.

- Jennifer Brotherton

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We have been advocating the Optimal Foetal Positioning exercises with our women for some time with excellent results. All the women we have worked with who have OP positions have found sitting backward on a chair every day beneficial and the babies have turned and engaged well. Don't disregard Jean Sutton's insight--it is very wise.

- Vicki

====

Get your copy of Understanding and Teaching Optimal Foetal Positioning from Midwifery Today-it's a book every practitioner should own. US$12.50 + shipping & handling (US$4.00 in U.S., US$5.00 Canada/Mexico, US$5.75 all other international). Mention Code 940. Ordering information below.

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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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