May 12, 2000
Volume 2, Issue 20
Midwifery Today E-News
“Postpartum Hemorrhage”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Postpartum Hemorrhage
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) Classified Advertising

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1) Quote of the Week:

"No matter how good a midwife I am, no matter how experienced and skilled, whether I have all the right equipment, feel active spiritual contact, phenomenal partnership, know just what to do, how to do it and have done it successfully before, it is not ultimately up to me whether the baby comes out or if it then begins to breathe."

- Stephanie Brill

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2) The Art of Midwifery

Shortly after delivery--usually while waiting for the placenta to deliver--I give women a glass of very warm sweetened water with 30 drops of blue cohosh/shepherd's purse ginger tincture added to it. I'm convinced this reduces the incidence of hemorrhage and also helps improve the mother's condition following the birth because: the hot water replaces some body heat and fluids; sweetening the drink makes it palatable and gives her a little energy boost; the blue cohosh encourages the uterus to clamp down firmly; shepherd's purse seems to slow internal bleeding because it's a hemostatic and coagulent; ginger promotes circulation and warmth in the pelvic region (improved circulation helps the uterus do its work better).

- Cathryn Feral, Wisdom of the Midwives: Tricks of the Trade Vol. 2, a Midwifery Today Book

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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

Mastalgia (breast pain) is common in women during the reproductive years, and may be related to the menstrual cycle or can be non-cyclical. A study of 175 women with severe mastalgia confirmed that it tends to a chronic, relapsing course with most of the women experiencing breast pain for at least five years. The median age for mastalgia to start was 36 years. Over half the women who were initially cyclical later developed non-cyclical pain. All women with cyclical pain, and many with non-cyclical pain, lose it at menopause.

- Professional Care of Mother & Child, Vol. 10 No. 2, 2000 citing Journal of the Royal Society of Medicine 1998; 91

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4) Postpartum Hemorrhage

All midwives worry about postpartum hemorrhage. The three main keys to avoiding its occurrence are 1) good nutrition and supplements as needed; 2) knowing the mother; and 3) not rushing the delivery of the placenta. I have found that by applying these three keys as fully as I can both prenatally and in the third stage, my practice has a very low incidence of postpartum hemorrhage.

The first key to preventing postpartum hemorrhage is good prenatal nutrition and supplements. I always require that my mothers keep a five-day diet diary to give me early information about their diet. As soon as possible I recommend changes in their dietary habits if they are needed. I encourage them to use such supplements as liquid chlorophyll, red raspberry and nettles. I also make a tincture of nettles, yellowdock, alfalfa and red raspberry, which I have on hand if it is needed. I have found the Spectrum 2C multivitamins by NF Formulas to be unsurpassed in their effectiveness for pregnant and lactating women. My families and I firmly believe in these vitamins, and many of them order from me long after the "big day." I also use them to maintain my own energy level, as I am a busy midwife and the mother of two teen girls and a baby!

The second key, knowing the mom, entails making sure that you have recent blood work for this pregnancy. Check hemoglobin and hematocrit, of course, but also platelet count. You want to make sure the mother's blood will clot properly after the placenta detaches. This key also includes knowing the mother's nutritional status as discussed above.

The third key to preventing postpartum hemorrhage is to not rush the delivery of the placenta. Almost all postpartum hemorrhages, in my opinion, are caused by being in a hurry to deliver the placenta. In these cases, I believe hemorrhage is caused by the intervillous spaces not having a chance to contract and help control the flow of blood. Also, the overmanipulation of the uterus to facilitate placental delivery can cause lobes to be left on the uterine wall which result in uneven contraction of the uterus. These lobes need to be manually removed to prevent postpartum hemorrhage and infection. This is not any fun for the mother or the midwife! I have seen many physicians and a few midwives who will not give the placenta time to deliver on its own. I, too, have fallen victim to feeling a little harried as I waited for the placenta to come. But a policy of hands off, unless there is due cause, is the most important key to preventing postpartum hemorrhage. I have seen some bad postpartum bleeds, which may have been avoided if the practitioner had not intervened and over-managed the placenta delivery.

- Margarett Scott, CPM

To read this article in its entirety, go to:
www.midwiferytoday.com/articles/hemorrhage.htm

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If Arnica is used at the beginning of labor and repeated as needed during and after labor (provided no other remedy is indicated at these times), it will prevent much trouble and afterpains. Give Arnica 200 as soon as labor starts, if no other remedy is indicated and the mother is progressing normally. Repeat as needed; every half hour if the labor is progressing rapidly and/or very difficult pushing occurs. It will lessen the need for other painkillers and prevent hemorrhage. Repeat immediately after birth to prevent postpartum hemorrhage. Consider Bellis perennis or Hamamelis if Arnic is not effective.

- Sandra J. Perko, Ph.D., Homeopathy for the Modern Pregnant Woman and Her
Infant, 1997, Benchmark

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Ordinarily the myometrial fibers of the uterus contract and retract causing kinking of the blood vessels at the placental site. The kinked vessels cease providing blood to the placental site and bleeding is controlled. Uterine atony is responsible for 80 percent to 90 percent of postpartum hemorrhage cases. This failure may be due to uterine dysfunction, anesthesia, ineffective first and second stage contractions, overdistention of the uterus, exhaustion due to a long labor, multiparity, myomas and operative deliveries which traumatize the uterus, and mismanagement of the placental stage of labor. Most of these causes can be anticipated and the appropriate management taken to lessen the risks of a hemorrhage. Third stage hemorrhage can be caused by overzealousness on the part of the attendant to get the placenta out. Massaging a uterus with an as-yet unseparated placenta attached may cause a partial separation with the resultant bleeding by vessels that still have maternal blood coursing through them. Pulling on the cord to remove a still-adhered placenta may accomplish the same effect. -Yvonne Lapp Cryns, Midwifery Today Issue 34, excerpted

To read the remainder of this article that explores many other causes of postpartum hemorrhage and offers prevention and treatment methods, order Midwifery Today Issue 34 by calling 1-800-743-0974 (orders only). Mention Code 940 and receive a $1.00 discount (add shipping/handling). Regular price $7.00.

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Midwifery Today Issue 48 is a mini-textbook on hemorrhage. Order your copy by calling 1-800-743-0974. Mention Code 940 and receive $2.00 off the regular price of $10.00 (add shipping/handling).

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5) Check It Out!

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A Web Site Update for E-News Readers

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6) Question of the Week

Q: Does anyone have knowledge or experience with human papilloma virus (HPV) being transmitted from mom to baby (genital warts passed via the birth canal and appearing in the baby's throat)? Any real stories of successful healing, experience with surgical removal, or any other insight would be greatly appreciated.

- Anon.

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Send your responses to mtensubmit@midwiferytoday.com

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7) Question of the Week Responses

Q: Can anyone tell me the specifics of knots in cords at birth? 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

A: I am a UK trained midwife with 14 years experience. I have seen many variations of knots. We were taught that there were two types: "false" knots occur when the vessels in the cord clump and bulge together inside the cord itself. They sort of make 's' shapes and create areas on the cord that look "knotty" but don't interfere with the circulation of blood. The second is "true" knots where the baby has somehow swum through a loop of cord and actually created a knot. At least I surmise this is how they are
created.

It depends on where the knot occurs, how long the cord is and how tight the knot becomes either during the baby's wiggling inside or during the journey into the outside world, as to whether it becomes a serious issue. If the knot pulls tight so as to cut off circulation, the baby will experience hypoxia and possibly anoxia. I have seen babies who have died because of a true knot in the cord. They are extremely rare, though. Please reassure your students that it is a rare happening. I have not heard of anything that can be done to prevent this knotty problem, but I'm continually surprised in life, so who knows?

- MJM

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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 find there are several situations where I am more likely to see an edematous cervix or cervical lip. If the mother's cervix is tilted way toward the back, if she has a very large baby carried high, if she begins pushing too soon or if she has no stretch marks, you are more likely to have a problem. I know that the "no stretch marks" may sound unusual but I really see a connection. The mother's skin is so stretchy and so is her cervix. It stretches right down with the baby's head as it moves down instead of pulling up over it.

The best thing I have found is to put evening primrose oil directly on the edematous area. The hard part is getting it in there in a sufficient quantity. I am working on some kind of delivery system. After it has been applied, give the mother a break for at least 15-20 minutes. Be sure she does not do any pushing with her contractions. The evening primrose oil will shrink the swollen tissue very well. Occasionally you may still need to push the lip up over the baby's head once the swelling has decreased.

By the way, evening primrose oil works very well on swollen perineal tissues and varicosities both before and after birth as well. It also will reduce any hematoma on the baby or any swelling and bruising of soft tissues as in a breech delivery. I have not heard of any dangers connected with its use.

- Judy Jones, CPM

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8) 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? (June 2 issue)

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! (May 26 issue)

3. What do you do to reduce an anterior lip? (June 9 issue)

**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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9) 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.

Keep the stories coming! Midwifery Today magazine has a lot of aspiring midwife readers, and they can learn a lot from you!

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Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

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10) Switchboard

I had not discussed cord blood banking with my midwife, but after my daughter had been delivered, I looked down to see my midwife taking some in a syringe. Was it ethical for her to take the stem-cell blood from my cord without my consent, (and also it would have been without my knowledge had I not looked) or is this normal practice?

- Anon.

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Is anyone aware of a recent study that shows incoordinate contractions with labor inducing drugs?

- Gail Dahl

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I was just 8 weeks pregnant when an ultrasound discovered that I had a molar pregnancy. I had a D & C, and now, besides grieving the loss of a child, I have to think about the consequences of this kind of complication. Instead of having a baby, I might be getting cancer! Of course, I had never heard of this possibility previous to the day before yesterday. Now I am reeling with info gleaned from the Net, all about the possible outcomes following a molar pregnancy. Does anyone out there have any experiences with this first hand? Success stories would be very much appreciated at this point. A list-serve or other form of communication with other women who have been through this would be very helpful for me, but I can't seem to find any out there on the Net. Also, are there any particular alternative therapies to help me get my HCG levels down, and to prevent recurrence?

- Annika
Ashland, OR

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Santa Barbara Graduate Institute is now accepting applications for Fall 2000. New innovative degree programs are offered-the first MA and Ph.D. degrees in prenatal and perinatal psychology in the world. Students from all over the country will gather one weekend each month with leading edge clinicians, researchers and educators as faculty. Each degree program offers in-depth theory and application, experiential learning, as well as important therapeutic skills within a humanistic/transpersonal framework. There is an increasing need for professionals equipped with knowledge, skills and vision to help sculpt this new territory. Midwives, parent educators, therapists and healthcare professionals who work with infants and families are finding this new discipline an exciting and rewarding venture.
Contact Santa Barbara Graduate Institute at 805-681-0077, email info@sbgi.edu and visit the web site at www.sbgi.edu where you can browse and download the entire catalog and application.

- Marti Glenn, president

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I would like to know if there are any Baby-Friendly hospitals in or near Quetta, Pakistan. Any information about hospitals in the area, or any contacts, would be welcome. I'm a midwife currently working in Darwin, NT, Australia.

- R.A.
Reply to: aulmann@bigpond.com

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I gave birth to my daughter in February at home with a certified nurse midwife. The midwife made me believe an episiotomy was necessary due to a long labor and fatigue. It was devastating to have to go through this after many months of preparing for a normal birth for both my baby and my body. Unfortunately, the CNM didn't assess or repair my perineum or my rectal muscles correctly. I had to have another surgical procedure to have my body put back together.

I want to heal as completely as possible with minimal scar tissue in hopes of having future homebirths without being cut. Is the herbal supplement gotu kola safe to take while breastfeeding? My research has shown that this herb is great for skin regeneration. However, half the information I have found states that it is safe for anyone to take, and the other half states not to take if you are breastfeeding.

The OB/GYN who performed my repair surgery said I will always have to have an episiotomy with all future births. I don't want to believe this is true. How many midwives out there can tell me if they have had clients who have had a similar situation, or have had clients who have had a fourth degree episiotomy and have gone on to have births without having major tears?

- N.E.

(Editor's Note: E-News asked British Columbia private birth attendant Gloria Lemay to respond to this letter. Other readers are urged to respond as well.)

Your letter brings up several issues that I would like to reply to. First, the use of herbs. I am not familiar with the herb you are inquiring about but my own policy with herbs, medications, and vitamin products is "If in doubt (especially for pregnancy/lactation), don't take it."

Second, it sounds like you have doubts that your episiotomy was really necessary and really repaired correctly. I urge you to write to the CNM and express your feelings to her. Is it possible to meet with her and talk?

Episiotomies are rare in midwifery cases but there are a small number that are done and the situation you had is a tough one for the practitioner (long labour, pushing contractions fading out, baby on an unyielding perineum for too long, etc.) Obviously, it was horrible for you but, having been in that situation myself, I would not be judgmental of the midwife based on what you have said. Doing an episiotomy in a homebirth situation is a last resort because the suturing after is difficult and exhausting to an already exhausted midwife.

I encourage clients to speak directly to the practitioner involved because they might open up some improvement in that person's practise that could make a difference in the care given to another woman. Complaining is usually best done directly to someone who can take action about the problem.

Third, remember that obstetricians love to knock midwives at every
opportunity and that is probably our karmic comeupness because (guess what!) midwives like to knock obstetricians just as much. So, the clients end up in an endless morass of professional turf battles. It sounds to me like the obstetrician is very negative about your chances of having a birth with an intact perineum perhaps because he/she wants to make a point with you about midwifery care being inferior. Most midwives can tell you about lots of cases like yours where episiotomies were cut, repaired, the repair fell apart, re-repaired and the woman gave birth just fine after all that. One of the reasons that so much surgery has been performed on the female genitalia in N. America is that healthy young women recover and heal from this abuse amazingly well. If you have healed to the extent that you do not have fecal incontinence and you are able to have comfortable sex, I would be very optimistic about your second birth having a great outcome.

One word of caution to your future midwife: it's always nice to be the midwife in the second birth because everything goes quicker and stretches easier than the first time. There is a great sense of accomplishment to see a woman who has had a tough birth the first time just breeze through the second one. Don't be disparaging of the first midwife because the woman may have had a cesarean the first time without her. There is a very good karmic reward for those midwives who give proper credit to the woman who was there for the long, hard first birth. This is something learned through maturity and experience. The roles will be reversed in your future and you will appreciate those midwives who do the same for you.

Fourth, the actions you can take to have healthy, stretchy tissues right now are:

- Eat a healthy diet and doing lots of kegels to take blood supply to your vagina.

- Keep up good communication with your partner on what he can do to help you have pleasurable sex.

- When you give birth next time, do lots of talking with your midwife about your fears and needs for reassurance during the pushing stage. Your midwife will guide you by letting you know that it's normal to feel like the baby's head is too big, it's normal to feel like it's coming out through your bum, it's normal to feel a lot of burning sensation, etc. She will encourage you to reach down and support your own tissues and will help you pant the baby's head out rather than give a hard push at the end. She will also use warm oils or immersion in a water tub to help everything be slippery and stretchy.

- Taking prenatal yoga and toning classes would be helpful for you, too.

My personal experience is that I had an episiotomy (lots of stitches) with my first baby, a one inch tear (not stitched) with my second and no tear with the third. Of course, the no tear birth was my favourite way to go. You are wise to be taking actions to achieve this goal.

- Gloria Lemay
Wise Woman Way of Birth Courses
www.birthlove.com/pages/wise_woman.html

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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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11) Classified Advertising

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