May 12, 2000
Volume 2, Issue 19
Midwifery Today E-News
“Factor V Leiden”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Pregnancy, Clotting, and Factor V Leiden: An Overview
5) Check It Out!
6) Question of the Week
7) For Coming E-News Themes
8) Midwifery Today Magazine Question of the Quarter
9) Question of the Week Responses
10) Switchboard
11) DONA Celebrates Mothers Day
12) Classified Advertising

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1) Quote of the Week:

"The first relationship is crucial for establishing man's humanity; it gives him a model for all other relationships in life and if we interfere with it, wittingly or unwittingly, we are condemning the child to a distorted perception of what it is to be human and be part of society."

- Margaret Jowitt

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2) The Art of Midwifery

Ask your homebirth clients to line up an advocate in case of a hospital transfer. If you depend on a physician for backup, you may not be able to be as assertive with him/her as an otherwise uninvolved person could be.

- Laura Osborn, in Wisdom of the Midwives: Tricks of the Trade Vol. Two, a Midwifery Today book

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3) News Flashes

A study from Oxford Radcliffe National Health Service Trust in Oxford, England says a surprising number of parents are given false-positive ultrasound diagnoses, where an ultrasound image finds an abnormality that just isn't there. After following 33,000 pregnancies between 1991 and 1996, researchers found 174 babies born healthy and normal after ultrasound suggested abnormalities. And over the course of the study, 43 percent of the fetuses identified as having an abnormality through ultrasounds or other tests were aborted. Advances in ultrasound technology make them sensitive enough to pick up unusual features that can be temporary but may be interpreted as abnormalities.

- The Lancet, Nov. 14, 1998

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All the following information on Factor V Leiden has been prepared by Jennifer Rosenberg, CD (DONA).

4) Pregnancy, Clotting, and Factor V Leiden: An Overview

The past 10 years have brought new understanding of and explanations why some women clot on birth control pills and during pregnancy. Research into genetic origins of disease has uncovered many coagulopathies, some of them surprisingly common. The most common is Factor V Leiden, also known as Activated Protein C Resistance, which carries a 3-10 times greater risk of clot when someone has one copy of the gene and 30-140 times greater risk of clotting for someone with two copies.

Between 3% and 10% of Caucasian people are heterozygous for Factor V Leiden, and a much smaller percentage are homozygous. In Sweden the rate of heterozygous mutation may be as high as 15% in some areas, while in other parts of the world and among other races only a fraction of a percent of the population may have it. It is thought that the original mutation occurred as much as 20,000-30,000 years ago in a single individual.(1)

Women with Factor V Leiden (FVL) have a substantially increased risk of clotting in pregnancy (and on estrogen containing birth control pills or hormone replacement) in the form of DVT (deep vein thrombosis, sometimes known as "milk leg") and pulmonary embolism. They also have an increased risk of preeclampsia, as well as miscarriage and stillbirth due to clotting in the placenta, umbilical cord, or the fetus (fetal clotting may depend on whether the baby has inherited the gene). Note that many, many of these women go through one or more pregnancies with no difficulties, while others may miscarry over and over again, and still others may develop clots within weeks of becoming pregnant.

There may be nutritional and lifestyle reasons why some women clot and some women don't. There is some evidence that low magnesium levels can increase the tendency to clot (2). Likewise, high homocysteine levels may magnify the effects of FVL or vice versa. The treatment for high homocysteine levels is supplementation of vitamins B-6, B-12, and folic acid (3). Both birth control pills and pregnancy demand higher intake of these nutrients, so nutritional deficiencies in women with FVL can have extreme consequences. Likewise, women who exercise regularly and are not immobile for long periods of time will have better circulation and less opportunity for clots to form. Given that the vast majority of people with FVL are unaware of the condition, and the fact that in the U.S. it is a safe bet that every midwife has had at least one and probably many clients with FVL, it pays to be aware both of the nutritional issues and the symptoms of abnormal clotting.

Women who are diagnosed with FVL are generally considered high risk in pregnancy, particularly if they have had clotting in the past. Standard medical practice in most cases is prophylactic treatment with low-dose Low Molecular Weight Heparin (LMWH, usually Lovenox) for women who are not actively clotting and therapeutic anticoagulation with LMWH for women with active clotting. There is considerable debate about appropriate treatment for women who are diagnosed (due to having relatives with problems) who have not had any clotting episodes. It may be that these women do not need to be anticoagulated with heparin, and may instead simply follow a regimen of careful nutrition and a baby aspirin per day, if that.

Some herbs may be useful if women with FVL choose not to use heparin. Garlic, ginger, ginkgo and purple grape juice are just a few of the many foods and herbs with anticoagulant activity.

Remember that approximately one in twenty of the women you serve will have FVL. Approximately one in a hundred of women with FVL (estimates vary radically from a 1% thrombosis rate (4) to a 25% thrombosis rate (my hemotologist) will have a serious DVT during pregnancy. Please be aware of warning signs of deep vein thrombosis (tenderness, swelling, pain that does not subside) and pulmonary embolism (shortness of breath with pain, localized pain that does not subside, a 'bruised' feeling on deep inhale). Both are easily confused with other problems but can be life threatening. Most people are initially misdiagnosed. Listen to your mothers!

References

  1. Zivelin, A, Rosenberg, N, et al. (1998). A single genetic origin for the common prothrombotic G20210A polymorphism in the prothrombin gene. Blood, 92:1119.

  2. www.execpc.com/~magnesum/estrogen.html.

  3. www.nejm.org/content/1998/0338/0015/1009.asp.

  4. www.nejm.org/content/1998/0338/0015/1009.asp. A discussion of the merits of screening for Factor V Leiden in oral contraceptives users. Gives detailed descriptions of testing methods and reasons why screening may or may not be useful.

    "Estimates suggest that there are 5 cases of venous thrombosis per 100,000 women not using oral contraceptives per annum, 15 per 100,000 women users of second generation oral contraceptives and 30 per 100,000 users of third generation oral contraceptives, and 60 per 100,000 pregnancies." This superb article describes very realistically the shortcomings of testing.

Additional Resources

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FVL, Vitamin K, the Fetus, the Newborn, and Children

FVL is inherited. This means that for every pregnant woman who has FVL, the child she carries has at least a 50% chance of inheriting the disease (more if the father also has it). We know the fetus is influenced by hormone levels in the mother's system, as witnessed by the occasional breakthrough bleeding in girl babies and "witch's milk" found in babies of either sex in the immediate postpartum when hormone levels plummet.

Vitamin K encourages clotting, and thus there is some concern among parents with FVL about giving their newborns the prophylactic vitamin K bolus. At the very least such treatment should NOT occur immediately after birth, when hormone levels are still up, in my opinion as a parent. And it may be advisable (though research has not been done!) to do the quick screening test for FVL (not the genetic test; this test simply checks to see how resistant clots are to activated protein C) prior to giving the infant vitamin K later. Perhaps testing cord blood for APC resistance immediately after birth and only giving negative babies vitamin K would be reasonable. Another approach would be to delay the vitamin K shot for 6-12 hours if not longer, to allow hormone levels to drop. I am aware of one family that feels their baby's death was caused by the vitamin K shot. Although the story is completely anecdotal, it echoes fears I had with my own daughter.

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FVL: Drink to Thirst!

Hydration is a critical issue for anyone with clotting problems. When fluid levels decrease, the blood tends to be "stickier" simply because it is harder for the body to move blood that is not carrying enough fluid.

This jibes very well with Anne Frye's description of contracted blood volume being an indicator of preeclampsia, and the fact that women who have FVL tend to get preeclampsia more often. Adequate fluids are a must for any pregnant woman, but it is life-and-death for a woman with FVL to stay hydrated. This means that women with FVL may need to be treated a bit more aggressively during morning sickness if they are becoming even a little dehydrated.

A personal note: In the first part of my pregnancy (I am FVL heterozygous) I was very dehydrated and tended to clot very easily. Once I figured out how to control my nausea with a rehydration drink and frequent small meals, the clotting I'd been experienced subsided. This coincided with my improving my nutrition and adding purple grape juice, garlic, and ginger to my diet. After about the third month of my pregnancy I had no further problems with clotting. It is impossible to say whether it was the hydration, the herbs, prenatal vitamins or the foods that inhibited my clotting, but any and all of them could have helped.

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FVL: A Health Alert on Heparin and Epidurals

http://www.4um.com/tutorial/currents/lmwh.htm

Summary:

LMWH (low molecular weight heparin, usually Lovenox) is the standard treatment drug for pregnant women with Factor V Leiden.

A number of independant safety issue reports suggest that people on heparin risk paralysis if epidural or spinal anesthesia is used while they are on heparin. This is of significance to pregnant women, though it should be kept in mind that under most circumstances women on heparin during pregnancy are taken off heparin before delivery.

When heparin cannot be discontinued a sufficient time before delivery, epidural and spinal anesthesia should be avoided. This means emergency c-sections should probably include general anesthesia. Time from discontinuation of heparin is a vital concern when deciding if epidural use is an acceptable risk.

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FVL: Activated Protein C Resistance

A brief primer for those who are new to the subject of FVL:

"Factor V Leiden" (FVL) is a description of a specific mutation. What that mutation causes is "Activated protein C resistance." All people with FVL have activated protein C resistance to one degree or another. However, it *is* possible to have activated protein C resistance without having FVL. There are probably certain other populations where APCR (Activated Protein C Resistance) is "acquired" through disease or environmental problems. The most common cause of APCR is FVL.

Activated Protein C resistance means that when your body forms clots, those clots are more durable than they should be, which means they don't break down as easily as they ought to and they grow faster than they should. One hematologist said he thinks of it as "clot formation not slowing down the way it is supposed to." Activated Protein C is a natural anticoagulant in the blood.

There are many, many other causes of thrombophilia (tendency to clot excessively), many of which are genetic. Some people have more than one form of thrombophilia and there are many degrees of it even in people with "identical" seeming genetic mutations. Some people are fine during most of their life (including things like pregnancy) and then suddenly have problem after problem for a period of time and then are fine again for a long time. Some people never have a problem. Some people constantly have problems.

Lifestyle factors like smoking, poor diet, lack of exercise, dehydration, pregnancy, and birth control pills can dramatically increase the risk of clotting. However, some people "do everything right" and still have problems. This is why each individual with FVL or other thrombophilia must be evaluated on a case-by-case basis. It is also a reason why people with FVL should learn as much as possible about risk factors and lifestyle issues before they decide between the risks of clotting with minimal anticoagulation or the risks of bleeding with therapeutic anticoagulation. The risk/benefit ratio will be somewhat different for every person.

While the risks associated with FVL can be severe (pulmonary embolism can kill someone extremely quickly and make resuscitation difficult or impossible by blocking the oxygenation capacity of the lungs), FVL is NOT a death sentence. Many, even most people with FVL live long lives and die of something else. It simply makes certain behaviors and choices more risky than they might be otherwise, and requires a bit more caution and thought in daily living.

When I compare living with the knowledge that I have FVL to diabetes or other chronic illnesses, I see that my life is much less affected by FVL than it might be by other conditions. On a daily basis, food allergies are more annoying than the need to get up and move around every hour or two. If I were on medication, it would be very different. I've been on coumadin, seen my mother on heparin, and I've seen my dad on insulin and they're pretty similar in level of life impact on a day-to-day basis. The risks are different but the nuisance level is about the same.

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5) Check It Out!

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6) Question of the Week

Q: Can anyone tell me the specifics of knots in cords at birth? As a childbirth educator and doula I know that babies can be born with knots in the cord and still thrive. However, I've received several inquiries from students as to how common this is; what, if any, are the complications that might occur; if a knot in the cord could often produce a stillbirth; and finally, are there any preventions?

- Jenna Tamura
Wholebirth--Dallas, TX

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Send your responses to mtensubmit@midwiferytoday.com

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7) For Coming E-News Themes:

1. CHOICE: To what extent should women and their families have choice in pregnancy, birth and postpartum? What does choice mean to you?

2. Labor & Delivery Nurses: Here is your chance to speak up! How can midwives and doulas be more responsive to your needs? How can you work more effectively together? Are there any concerns you'd like to air in E-News? Tell us about them!

3. Aromatherapists: What are some of your favorite aromatherapies for pregnancy, labor, birth and postpartum? What is truly informed choice?

**Take part in E-News! Sound Off-Give Advice-Share Your Knowledge!**

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Send your responses to mtensubmit@midwiferytoday.com

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Program and registration information at:
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8) Midwifery Today Magazine Question of the Quarter:

What is your most noteworthy second stage, and what was the outcome? Please submit your response to editorial@midwiferytoday.com by June 15.

9) Question of the Week Responses

Q: I have a client who is expecting her third baby. She planned a homebirth with her first baby, but transferred to a hospital after her cervix became very edematous. During her second labor (planned hospital birth), she again developed a very edematous cervix in active labor. She had a CNM as a birth attendant, and many things were tried, including water therapy, hands & knees, ice to the cervix, other position changes. She eventually requested and received an epidural at 9 cm, due to exhaustion, and delivered with vacuum assistance. Does anyone have any ideas, such as herbal treatments during pregnancy, other options during labor, hopefully to prevent the edema, or at least to more effectively reduce it? Has anyone used arnica during labor, either sublingually or directly to the cervix? Is that safe?

- Rose Evans

A: I would be very cautious against using arnica internally; it can be toxic and cause death.

- Calista

A: Possibly one answer would be for the woman to attend a hypnobirthing class so that she can learn to truly relax during the labor. Usually a cervix becomes edematous because of resistance to pressure, and if she can totally relax and give in to the pressure of labor, her cervix may not even become edematous in the first place. I have seen hypnobirthing work like a miracle on everyone who has trained in it.

- Linda Seeley

A: I have successfully used arnica (homeopathic tincture sublingually) for cervical and labial swelling. Now I hate to attend a birth without it. Lisa Goldstein, who spoke at the last Midwifery Today conference, makes my favorite arnica preparation. She also makes a wonderful arnica oil.

- Kathryn Berkowitz, apprentice midwife

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10) Switchboard

Regarding an inquiry about breast reduction surgery and inverted nipples, and ability to breastfeed [Issue 2:18]:

A friend had a reduction and also runs a website and an email list for women who want information about breastfeeding after a reduction. You can sign up for the list at the website
http://www.magsi.com/liquidgold/index.html
If midwives and other professionals would like information, she has a list for them to learn more too; you can sign up at the same website for the information list.

- Belinda Bohnert

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1. Inverted nipples: Some actually claim that employing Hoffman's technique and/or wearing breast shells (NOT nipple shields) during pregnancy is helpful in drawing out inverted nipples. The theory is that there are adhesions at the base of the nipple that need to be released. First of all, who diagnosed this? Are your nipples truly inverted? Do they ever come out (like when you're cold). Even if this is the case, the most important thing is to get the baby latched on well to the breast (they don't suck on the nipple, unlike with artificial-feeding), and to avoid the introduction of artificial nipples/teats until baby is nursing & gaining WELL. Which brings us to the next issue:

2. Breast reduction: This is the more difficult one. While you will *produce* milk in the remaining glandular tissue (and most women are not reduced to an "A" size!) there is always a question of how much is actually getting to the baby, due to the interrupted pathways. There is some evidence that some recanallization of the ductwork *may* occur, but it is impossible to predict or evaluate how much. Find out from your surgeon exactly what was done: How much was taken out? Was the nipple completely detached and "pasted on" or was a pedicule used?

In either case, I strongly suggest that you discuss your situation with several La Leche League leaders and/or lactation specialists (knowledge base and experience varies, so keep asking) as soon as possible. You will need to have a supportive, knowledgeable pediatrician who is willing to consider alternative feeding methods in the likelihood that your baby does not gain well, and you will need someone experienced in using those methods (cup, syringe, supplementing at the breast, etc.) Some babies will do OK just breastfeeding, but most will need some supplementation. The main questions will be "how much," "what fluid" and "how delivered?"

Do your homework...you have plenty of time. Your baby will be grateful for whatever effort you put into this venture.

- Gabrielle
LLL Leader in NY

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I was very adamant about breastfeeding although I had breast reduction surgery prior to getting pregnant. After a failed attempt at breastfeeding my first child, I got lots of support and managed to breastfeed my second with the help of an SNS (supplemental nutrition system). Take advantage of your local La Leche Leauge and/or lactation consultant. Your lactation consultant will have a special scale that can weigh your baby before and after breastfeeding if you are concerned about your output. Fenugreek also helps increase milk supply. However, with breast reduction surgery it is usually nerve damage that causes breastfeeding difficulty by inhibiting the let down reflex. Even if your let down reflex is damaged you can still have a great breastfeeding experience by using an SNS.

- Amy

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Find out how the surgery was done. If the incisions were made from the nipple back, fewer milk ducts are cut than if you were cut around the areola. But a very experienced lactation consultant in my area reminds her moms that milk ducts form during pregnancy and in the early days of breastfeeding and you never can tell just how resilient the tissue will be. Give it a shot and keep in contact with a La Leche League Leader or lactation consultant.

As for the inverted nipples, that also can be overcome. Try drawing out the nipple with a breast pump or try nipple rolling as described in the Breastfeeding Answer Book (also LLL). If you can't get them to evert, don't worry too much. The baby is good at everting them and as that lactation consultant says, "babies don't nipple-feed, they breastfeed."

Set up your network of support before the baby is born, in expectation of some hard work the first few days. It's worth it!!

- Anon.

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Did you just have fatty tissue removed? If your incision was low, you have a great chance of breastfeeding successfully. If your nipples were removed and reattached, you may not be able to breastfeed. Inverted nipples: begin now to evert them. Gently roll them between your fingers and/or wear breast shields. Check with your midwife concerning wearing them in late pregnancy, as the stimulation can sometimes hasten labor (not so great if you're only 35 weeks!) You can accomplish the same thing using a breast pump, but it's much less comfortable. I would urge you to visit a lactation consultant. In many cases, these visits are covered by insurance. Or, check with your local WIC office--a lot of them have LCs on staff.

- Amanda B.

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1. Lactation consulting, if done *properly*, is generally no picnic. Nor is it particularly lucrative except for hospital-based, salaried, staff positions. Then you have to deal with all the usual hospital issues that undermine breastfeeding to begin with.

When I'm approached by RNs (often they express the desire to "get out of staff nursing"), they tend to have an idealistic vision of making gobs of money in their spare time by "helping mothers with breastfeeding." Private practice is rarely that simple. It often involves difficult situations, with babies at some degree of risk (you should carry individual malpractice insurance, which most RN carriers won't cover under your RN policy). Most private practice LCs make many F/U calls and/or visits, and may or may not be able to bill for them. And you need to be available when the mom & babe need you, not in a few days, especially if there's *any* question of weight gain or the baby's intake.

Then there is the problem with insurance, like no coverage for LC visits most of the time, so families are understandably reluctant to pay out of pocket.

Before you invest the considerable time & money necessary to sit for the IBLCE exam, talk with as many LLL Leaders and IBCLCs in your area as you can find. Maybe thing are better from where you sit.

2. Doula (Labor support & postpartum) & childbirth education: Great for the stay-at-home or part-time employed mom, especially for when your baby is a tad older. Getting the word out & getting people to see the benefit in spending money for doula services can be frustrating, but midwives' clients are a great target market. I wish more use was being made of both. Several women in my area provide a combination of these services, and are fairly busy. Check with ALACE, DONA, ICEA, Birthworks, Bradley, & "real" Lamaze (Lamaze International) for information, workshops, certification, etc. You can begin slowly, while your baby is young, so that much of the educational stuff is out of the way. Then you can apprentice with someone (doula or CBE) when he is able to be without you for extended periods of time.

- Gabrielle in NY

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I found being a doula was too demanding with young children who needed their mommy. Many childbirth educators work from home. Consider La Leche League or Nursing Mothers' Groups for experience with postnatal moms.

- Michelle Wright

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To the mother inquiring about epidural [Issue 2:18]:

Although some hospitals allow you to use different birth positions, if you have an epidural you will not be ABLE to stand or squat. You will not have the use of your legs in that capacity; you will be giving more control to your "caregivers."

- Anon.

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To the mom who asked about goat milk as a three-day temporary substitute for breastmilk {Issue 2:18]:

1. Freshly expressed breastmilk CAN be stored in the refrigerator for 5-7 days. La Leche League has a great information sheet on this. If it's not on their website, call any leader.

2. Frozen breastmilk does sometimes smell/taste "soapy." This may be due to subtle changes in some of the lipids (fats), but the milk has not usually gone bad. If your freezer keeps ice cream frozen solid & frozen vegetables seem OK, then your milk is probably OK too.

3. While goat's milk has been used by many people for many years for a variety of reasons (some more valid than others), it is *not* nutritionally equivalent to human milk. I am not aware of any evidence that supports its use for infants, especially when human milk is available. Just because it is "natural" and not from a cow does not mean it is inherently "safer than" or "superior to" artifical products.

4. Can you bring along someone who can mind the baby while you're at sessions, then nurse during the breaks? Your baby will miss more than just your milk while you're gone.

5. You may need to express/pump while you're away. Breastmilk can be safely stored at normal room temp for several hours, or (better) in an insulated lunch bags with frozen blue-ice packs.

- Gabrielle

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Research states breastmilk can be stored for 5-8 days in the refrigerator for a healthy full term baby. (Pardou, 94) A one year old may not be taking huge amounts of milk anyway and you could get by with 6-8 oz. per day. But why does she need a substitute at all? She is the perfect age to drink from a cup. Also, there are plenty of ways to get calcium into your child without milk. If you are concerned about cow's milk proteins, how about cheeses or yogurt? Even if made from cow's milk, the enzyme structure is different due to the fermentation process. Or you could use goat's milk cheese, etc.

- Mary Kay Smith, IBCLC
Chicago IL

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In response to "Sad Lesson" [Issue 2:18]:

This article sounds like the horrors in Romania under Ceaucescu. I hope it's over. This is pure barbarism. I can't believe this still happens in "developed" countries.

- Phil Watters

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Responding to Leslie from Israel [Issue 2:18]:

It is encouraging to hear there are other midwives in "rather solitary" situations like myself in Chile. I am a student midwife, and where I am it is not badly looked upon, but there are really no midwives or homebirth, and a bit of "fear" around the idea of homebirth.

I have found that time and gentle patience is very helpful in our kind of situations. Your optimism, and going to work as normal, with examples of how good natural birth can be right there on the job really do a silent work and help clear the road for you. I think there is a lot in not getting fired up (as we are tempted to do, knowing the terrible things that happen in the hospitals and should not have to happen) and letting pure good energy of your working attitude, and good obvious examples do the hard work for you. Also, a lot of times doctors are so busy they do not even notice what was written in the letter, and we should be understanding that being trained in the gauntlet of medical school is pretty hard to deal with. It creates a whole different reality, headspace, and ideals than what our circle of midwifery around the globe so wonderfully and gently teaches us. All strength to you Leslie, and may midwives be united in sacred birth!!

- Aiyana Gregori

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For years I have dreamed of being a midwife. I have let one thing get in my way. I am hoping to find someone to tell me they have successfully overcome this obstacle. For years I have been battling the ups and downs of bipolar disorder. I am doing all I can to stay healthy, but the cycling continues. My dream of helping moms birth their babies also keeps surfacing and I really want to do something with it. I'd love to hear from someone who has had victory in their life over manic-depression.

- Anon.
Reply to:lorilee@carolina.rr.com

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We need your help!!
Please email webgirl@midwiferytoday.com with names of celebrities or major, minor or local "names" who have had a homebirth or used a midwife or doula. We need info--news clippings or information regarding this matter--ASAP!
Reply to: WebGirl@midwiferytoday.com

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11) In Celebration of Mothers Day
DONA Sponsors International Doula Month, May 2000

In May, Doulas of North America (DONA), an international non-profit organization, will sponsor the third International Doula Month with celebrations and activities for parents and maternity care providers in communities all over North America.

The non-medical care doulas provide has been recognized by professional organizations and healthcare policy makers as an important factor in the improvement of birth outcomes for mothers and babies. Doulas provide the benefit of high-touch care in an increasingly high-tech birth environment.

A doula understands the emotions and physiology of normal birth and is trained to assist with relaxation, pain coping techniques, effective positions and movements to help labor progress. She can facilitate communication between the laboring woman, her partner and her medical caregivers. Doulas support women through medicated and unmedicated labors, and through vaginal and cesarean births.

A doula does not replace the father or partner, but helps him participate at his own comfort level. Family members often feel more relaxed knowing they can rely on a doula's familiarity with unpredictable labor events and the medical environment. A doula never leaves a woman alone, no matter how long the journey to birth may take. Many women choose to have an independent doula; some women give birth at a hospital or birth center that provides doula care as part of their maternity services.

Numerous scientific studies have found that women who receive continuous doula care in childbirth have shorter labors, fewer complications, and healthier babies. Doula-assisted women are less likely to need oxytocin to speed up labor, pain medications, forceps or vacuum-assisted deliveries and cesarean births.

The benefits of doula care may go far beyond the birthing room. There is some evidence that having a doula facilitates mother-infant attachment, encourages breastfeeding and reduces the likelihood of postpartum depression. Doula care also seems to be a particularly beneficial form of prenatal intervention for at-risk expectant mothers, such as teenagers, economically disadvantaged families, and incarcerated women.

DONA will be celebrating in May with mothers and their families. DONA members have planned free workshops, family picnics, film showings, book donations to libraries, exhibits at baby fairs and gift baskets for maternity caregivers. To find out about local doula activities, locate doula services, or learn more about becoming a DONA-trained doula visit the DONA web site, www.dona.org. You may also call DONA at (801) 756-7331, email doula@dona.org, or write to DONA at 13513 N. Grove Dr., Alpine, Utah 84004.

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12) Classified Advertising

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Comparable to 3 yr. Includes books, skills training, midwifery tools.
Combines Distance Learning with 3 one-week training sessions.
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