June 9, 2000
Volume 2, Issue 23
Midwifery Today E-News
“Anterior Lip”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) What Do You Do To Reduce an Anterior Lip?
5) When to Push: Listening to the Body's Cues
6) Midwifery Today Magazine Question of the Quarter
7) Check It Out!
8) Question of the Week
9) Question of the Week Responses
10) For Coming E-News Themes
11) Switchboard
12) Classified Advertising

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1) Quote of the Week: "One hundred years ago, hospital birth was considered to be the radical and dangerous alternative to a midwife-assisted homebirth."

- Leilah McCracken

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2) The Art of Midwifery

Do whatever you can as well as you can do it, no matter how small. I first heard this lovely truth from the wise and humble midwife Mabel Dzata. A new midwife will be tempted to think about all the things she doesn't know, and those thoughts can paralyze you! Instead, focus on doing what you can do, then do it with all your heart. Your knowledge and experience will surely grow. There is no task so small as to be insignificant when done in loving service for another.

- Lois Wilson

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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

Each year approximately 20,000 infants are born to women with chronic hepatitis B (HbsAg positive) in the United States. Without appropriate intervention, up to 85% of these babies will become infected, not specifically during labor and delivery but during the neonatal period. These infants have a 90% risk of chronic hepatitis B infection and up to 25% will die prematurely of chronic liver disease, including cirrhosis and hepatocellular carcinoma. Proper screening and treatment can almost completely prevent this problem.

- The Perinatal Advisor, Vol. 1 No 3, 1998

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4) What Do You Do To Reduce an Anterior Lip?

I learned as a student nurse-midwife 18 years ago how to, in most cases, reduce an anterior lip. First of all, though, it may not be a problem at all and simply needs more time. But if the mom is tired or has been stuck for a while then I may try to intervene. I tell her that it is going to hurt but I ask her to work with me during one contraction. I will ask her to push as hard as she can and get three good pushes in, holding her breath and really bearing down. I ask her to lie in a semi-reclining position. I push up on the lip with 2 fingers while she bears down—usually, I can push the lip back. I then keep my fingers in—a lip tends to slip back down. In between contractions I may then try to ease the lip back. I try this for only 2 contractions. If it doesn't go, we need "tincture of time." Sometimes using a squat position can be a successful alternative to the semi-recline. If it doesn't stay back, I then may try several position changes—hands and knees, side-lying—to get the pressure off the lip from the baby's head. I may then re-try the above after 30 minutes or so have passed. Eventually, through time or descent of the head, success is achieved. It certainly is very rare to end up with a c-section for a persistent anterior lip that cannot be reduced.

- Patty,CNM
Indianapolis

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Assuming that time hasn't taken care of an anterior lip, I usually use arnica oil rubbed straight on the cervix. Sit back and wait a few contractions and if it isn't gone, you can usually reduce it much more easily. Primrose oil sometimes works and I used that before I got sick of stubborn anterior lips, especially in primips, and got some arnica oil, which is also lovely on a swollen perineum.

- Samantha McCormick, CNM
Brooklyn, NY

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The best way I have found to reduce an anterior lip is to lie the women in a left lateral position for a few contractions. When it's gone she can get into the position she wants to to deliver.

- G.R., community midwife
England

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I have found anterior lips appear mostly with ROA or posterior babies. My best remedy that has worked 99% of the time for a lip or edematous cervix:

Using a 10cc syringe w/18 0r 20 gauge needle, puncture five evening primrose capsules, then draw oil into syringe. After all five have been drawn up, add an equal amount of gelsimium, arnica and blue and black cohosh into the syringe (if the primrose caps equal 1cc, add 1cc of each tincture). Dispose of needle. Shake the syringe to mix remedy. It is best if mother is in knee chest position. Do a digital exam and locate the lip or swollen area. Slide the syringe along your fingers to the spot and slowly insert the remedy. There will be some stinging sensation, which directs the mind to attend to that swollen spot. Tell the mother to think about that spot and melt the cervix away. Massage the remedy on the lip or swollen area. After administering all the concoction, keep the mother in knee chest for at least 20 minutes.

- Shine Herfindahl, CDM, CPM
Let me know how your lip melting goes: shine@girdwood.net

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I have found a few thing that help in this situation.

  1. Have the mom WALK during contractions—she will need to take very large steps and will need to have someone on each side of her. This really hurts!!!!
  2. If walking down the hall is not possible (care provider wants continuous fetal monitoring), have the mom lift each leg in an exaggerated stomp, then squat and repeat several times.
  3. If mom is confined to a bed, roll her from side to side over and over.

I realize the above solutions are NOT fun for mom at all but they work!

- Mary, doula

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  • If the mom is not having a really strong urge to push, just wait it out with her, doing relaxing breathing as much as she can.
  • Try hands and knees, or side-lying to reduce pressure on the cervix.
  • Put some ice chips into the finger of a glove, then put this glove over your gloved hand and hold the ice against the lip. Mom can be in any position that allows you to reach her cervix.
  • If she is having a strong urge to push and the cervix isn't moving out of the way, you can have her flex her hips more by having her hold her knees back (she is semi-sitting/reclining on her back) and put 2 fingers against the lip and hold it up during contractions and then put pressure against it in between contractions. I always keep talking to the mom if I'm doing this because it hurts her. I try to reserve this for the times I've seen that big purple cervix pushing out with the baby's head, or the lip is increasing, or the mom's pain is increasing as she pushes (they especially say it is hurting more right above the pubic bone when pushing against a lip that isn't shrinking). Sometimes "blowing" breathing can help her avoid pushing against the lip.

Keep an eye on the baby's position in labor - often persistent anterior lips are seen with posteriors.

- Pat C.

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5) When to Push: Listening to the Body's Cues by Lois Wilson

Excerpted from a coming issue of Midwifery Today, due in your mailbox in September!

At Victoria Jubilee Hospital in Jamaica... no one pushed actively for more than half an hour... women come across the hall to the birthing room when they feel a strong and absolutely irresistible urge to push. Prior to that, they are not "checked" for effacement or dilation, but rather are simply allowed to labor undisturbed. Their only cues to their progress in labor are their own physiologic sensations and their intuition. Once she is in the birthing room, the woman climbs onto the cot and a midwife checks her dilation. Very rarely does a mother come into the birthing room too soon-women are almost always completely dilated and ready to go, often with the baby's head on or near the perineum.... [They] subsequently finish the job in thirty minutes or less! Thus the question begs to be asked: How many gloved hands have reached up inside of women followed by the declaration "You're complete! You can push now!" followed by hours of exhausting effort, frustration, and intervention? ... even when a woman is feeling a little "pushy," she may be fully dilated but not really ready to actively push. I honestly believe that in our well-meaning attempt to tell a woman when we think she is at the pushing stage of her labor, we encourage her to push way too soon. The consequence is that when a woman begins pushing before a strong and irresistible urge is present (because her midwife tells her "it's time!"), she uses her energy to accomplish a task that her body would do more effectively on its own if she was listening to her body's cues rather than her birth attendant. Maternal exhaustion, a swollen cervix, fetal distress, and sometimes a transport for vacuum extraction or a cesarean section often follow. This is too high a price to pay!

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6) 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! Midwives have a lot to learn from each other, and Midwifery Today magazine is a great way to transmit knowledge!

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7) Check It Out!

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A Web Site Update for E-News Readers

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8) Question of the Week

Q: I'm currently 30 weeks pregnant with my third child. My first pregnancy was breech. I ended up with a c-section. My second pregnancy was vertex. I ended up with an unnecessary c-section after attempting a VBAC. This time, I am trying for VBAC with my third baby. I need your help about herbs [or other methods] to enable the baby to turn to head down. I have been using a lot of pelvic tilt, visualizations, etc. but my breech baby hasn't turned. Any suggestions or advice?

- Beth McGinnis

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Send your responses to mtensubmit@midwiferytoday.com

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9) Question of the Week Responses

Q: I recently attended a birth as a doula. After labouring for 8 hrs. my client was almost fully dilated except she had an anterior lip. When the doctor did a vag exam, she was able to pull back the lip while the mom pushed with a contraction and ultimately pushed the lip out of the way. However, two hours later with strong effective pushing, the lip was still there. The doc was frustrated and couldn't figure out why the lip wasn't cooperating. An epidural was done to hopefully relax the mom and take care of the lip. After half an hour, this goal was reached. The mom continued to push when coached to do so because of course now she couldn't feel any sensations to bear down spontaneously.

My questions are:

1) What else could have been done other than an epidural to resolve the lip dilemma?

2) Once the lip had disappeared, could the epidural be turned off or at least the amount of the drug reduced so the mom could regain some feeling to be able to push more effectively?

A: An anterior cervical lip occurs when the presenting part is not positioned correctly upon the cervix, causing unequal pressure that results in unequal dilation. Think of a square peg trying to come through a round hole. If there is unequal pressure, and the fetal head is not given enough time to accommodate (mold), then the narrowest diameter of the fetal head cannot come through the widest diameter of the inlet. In my experience, if a cervical lip is developing, you are dealing with an abnormal presentation—either an asynclitism (where the head is tilted out of the midline) or an extension of the head which must be corrected in order to facilitate the descent.

The temptation is to treat the symptom—the lip—by pushing it back out of the way, without considering why it is there in the first place (the malpresentation) and correcting that. If you allow the fetal head to back off the cervix, even just a bit, it will often allow the baby to tuck its chin and approach the pelvis at a better angle.

As a doula, coach, or midwife, you have two choices. You can change the head directly by applying pressure to it, which is not comfortable for either the mom or the baby, OR you can encourage the baby to back off the cervix by changing the mother's position. I have had great success with encouraging the mom to try two contractions on her left side, two contractions on her right side, two contractions on her hands and knees, and two in a knee-chest position. Have her epty her bladder first (she can use all the room she can get!), have her blow through the contractions, and refrain from pushing. These positions will usually make it easier to do that anyway. I rarely have to go through more than two cycles of the eight contractions before the lip disappears and descent takes place. If you detect an asynclitic presentation, have the mom pull up on her top leg as she is side lying, which will open that side of the pelvis a tad more (sort of a half McRoberts position).

Remember, you are trying to allow the baby a little room to back off the cervix so it can reposition its head correctly. Even if the mom has an epidural, she can be rolled from side to side, the upper leg adducted to facilitate the flexion. In this particular situation, an upright sitting position is not as helpful, and in fact the 45 degree angle pushing position which is de rigeur in the hospital actually compounds the situation because the pushing urge becomes so strong, and the angle so acute, that the baby has no room to back up and cannot reposition itself. Remember that the uterus is extremely competent at working the head down into the pelvis at the appropriate speed and angle if given the opportunity to do so.

- Vicki L. Taylor, L.M., C.P.M.
Pensacola, FL

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A: The most probable reason for the persistent anterior lip under the scenario you describe is a large head that needs to mold.

If hands and knees or side-lying with the top leg all the way over onto the bed things doesn't work, eventually I try an epidural as a last resort just in case the woman is unconsciously holding back. Of course the epidural could have been turned off for pushing and then re-dosed for a cesarean birth if it became necessary. But if it's any consolation, it may have turned out the same if it truly was CPD. I hope the client knows what a good job she did!

- Cynthia Flynn, CNM, PhD

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A: As I read the account of the labor with the lip that would not be reduced, I wondered if the birth would end up being a c-section. I'm sure that many will recommend an all-fours position or knee chest or upright postures, birth balls etc. as postural ways to help reduce the lip. These sometimes work. I've heard of putting ice on thick swollen lips, but have not tried it myself. I imagine there are herbal preparations that are used too. However, my own experience is that those persistent lips are an ominous sign—they just hang on and slip back over the head, despite efforts that seem to result in their disappearance. Often, a persistent OP is involved (all the more reason to read Optimal Foetal Positioning by Sutton and Scott), sometimes CPD, as in this case, where baby just didn't descend. I imagine that the epidural gave the mother a chance to rest and regain some strength for the push ahead.

I don't know of any physiologic reason why having an epidural would cause the lip to go away. Does mother's lack of relaxation cause a lip? Letting epidurals wear off after pain relief is achieved is a problematic situation, I think, particularly if the mother does not want to reexperience the pain. It almost seems unethical to provide relief and then to say, "Now we're going to withdraw it." Most mothers who receive epidural here seem to push quite effectively if allowed to await the urge to push as the baby descends.

- Karen Pettigrew CNM
South Dakota

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A: Perhaps my question is part of the answer; What POSITION was the mother assuming during most of the second stage—squatting (upright), Fowler's or side lying?

- J.B.

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A: ... rushing 2nd stage by attempting to "resolve" the lip may in turn cause the baby to be pushed down too soon in an unfavorable position for vaginal delivery. I don't practice the "you're complete, now push" management of 2nd stage. I think this sets up the problem described above. From what I've seen so far, if the mom is going to push the baby out, no lip of cervix is going to keep her from doing that. I feel a stubborn anterior lip is more a symptom of other problems than THE problem. Positional changes (hands and knees) and putting her in water may allow enough relaxation to enable the baby to BACK UP and get in a flexed position.

- Kelley Hewitt, LM

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Q: What are the detection-causes-treatment of chorioamnionitis, and simple ways to prevent it?

- Marypascal Beauregard

A: The primary way to prevent chorioamnionitis is to limit vaginal exams. So many inductions end up with maternal fever and more abx, probably soley because of the many vaginal exams to "monitor progress."

- Samantha McCormick, CNM
Brooklyn, New York

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10) For Coming E-News Themes:

  1. PAIN: What causes pain in labor? Is it a birth practitioner's job to try to alleviate pain? (June 14 issue)
  2. What about the "wife" in "midwife"? How do you maintain relationships with such a demanding career?
  3. "Is the fact that midwives cut far fewer episiotomies than doctors important?" asks Marsden Wagner, M.D. in his Technology in Birth article. What do you think?

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

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11) Switchboard

E-NEWS WILL SWITCH TO WEDNESDAY PUBLICATION STARTING NEXT WEEK, June 14.

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See you again on Wednesday, June 14!

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More on the subject of choice, the theme of last week's issue:

A big "right on!" to Nikki Lee. She stated that maybe we shouldn't be so tolerant of other people's choices. I couldn't agree with her more. By hiding behind the cloak of "choice" people are able to make very poor decisions. I particularly liked Ms. Lee's comment about how it galls her to say to a mother who weans her baby at two weeks, "Good job! You did the best you could!" As a La Leche Leader, I have agreed to espouse La Leche League philosophy which respects a mother's choice and experience wherever she may be in regard to breastfeeding. And as a LLL leader, I do just that. However, it is sometimes a major feat. From a personal standpoint, I am not able to rally support behind a decision to wean at two weeks. If the world were run by me, breastfeeding would not be a choice. It would be the way babies were fed, period. Unusual, rare, and unfortunate circumstances would require a prescription of formula. There's way too much political correctness and tiptoeing around so as not to offend people, and mothers, children and families are suffering for it. People don't want to make others feel "guilty" for their choices. What people often don't realize is that you cannot make someone else feel guilty. Guilt is a feeling within a person—a feeling of responsibility for some real or imagined offense. Guilt is the perfect teacher. Maybe when guilt arises in a person regarding a particular choice they have made, the next time they make a better choice. That can't be all bad, can it?

- Dianne Oliver

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I completely agree with Nikki Lee and her comments about choice. Nikki, thank you for being so bold and speaking the truth. Thank you to Midwifery Today for publishing her comments.

- Lisa

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I was enthralled reading your readers' response to the question of choice in birth. I especially liked Nikki Lee's, and I share her viewpoint completely.

I am president and co-founder of a not-for-profit childbirth awareness group called CHOICES, covering all of Northwest Indiana. Informing parents about smart consumerism and getting them educated about all the issues is the main goal of CHOICES (Choices in Homebirth Offering Information, Communication, Education, and Support). But when it comes down to it, we realize people are going to absorb only as much as they like. Birth is a very touch and go phenomenon. People bring a lot of baggage to the event, and as a Bradley Method instructor I've found that sometimes people make poor decisions regardless of all the proof, pressure, or praise I can give. They come back to me with regrets, even though I warned them to switch physicians, find a different hospital, get more protein, keep hydrated, etc.

Sometimes experience is the best teacher, and we can't take it all upon ourselves to teach lessons that others must learn by trying and failing. I have come to comfort myself with my faith in the Laws of Nature, or God's Way, or whatever you want to call it. I believe that each child comes to this world and experiences the kind of birth he/she needs to experience, in order to evolve, learn life lessons, whatever. It has taken many years of learning to let go, but my letting go has brought more people to me, and opened more minds than any amount of preaching and dire warnings.

- Sharon Thornton, AAHCC

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"Breastfeeding Nemesis" by Susanne Colson, [excerpted in Issue 2:15] is an article about a very important, highly polarized issue, namely breastfeeding vs. bottle-feeding as it plays itself out in many familiar contemporary cultures today and in years prior. Many points she makes are so right on; those addressing capitalism and the inevitable overarching greed of 99.9% of those who practice it to the detriment of mothers and babies world wide; those of the ethical and moral poverty of the greedy ones, even to the point of pushing products that literally don't support human infant health and growth when perfect infant food is readily available to all babies within their mothers' breasts; and especially those of the woeful ignorance and apparent irresponsibility of the medical establishment (male and female members all) who have for years and years advocated bottle feeding over breastfeeding (in ways subtle and overt), and when they have taught breastfeeding have, more often than not, done so out of a paucity of accurate information regarding the normal physiology of human breast milk production and the near perfection of simple maternal-infant breastfeeding practice.

I would like to mention here, as well, a further ramification of the breast vs. bottle controversy; that of those mothers who prefer not to breastfeed, regardless the amount of accurate, well understood information they may have in favor of breastfeeding. I submit here that not all women want to give of their bodies in terms of physically nourishing their children. Furthermore, there are many mothers who do not espouse the "attachment parenting" kind of nurture when raising their children. Core issues of physical touch and personal, physical and emotional boundaries are highly operant, deep seeded aspects of each human psyche. Besides, our culture, and other cultures as well, hold up prominently such rights as a woman's right to choose what is or is not done with and to her body by other parties, which includes her children. These mothers also deeply need support from mothering advocates as they give birth and bond with their babies. We professionals may need to ask ourselves what are our motives in our work in support of mothers and children in birthing, breastfeeding, and parenting? Are we lost in our beliefs about how it "should" be done to the exclusion of the needs of so many women who may not mirror our beliefs but are seeking the shelter of our circle within which to enter into their motherhood? I believe we have the best, most beautiful, effectual mindset about birth and nurture of mothers and their young. Our fruits are laid out lavishly for all women and their children, wherever and however they walk, to eat or not to eat at will. If they eat nothing at our table may we count it an honor that they have entered in to share their life and wisdom with us that we "all walk in [ever greater] beauty" with grace and service.

Which brings me to my last point: some of us, perhaps including Ms Colson, seem to expend too much or our time and energy using the knowledge we hold and the beliefs we espouse as forums for derisive rhetoric and divisive agendas. Accusatory, judgmental rhetoric re: (for instance) the arrogance of male scientists and fantasy scenarios of their plans for women's detriment serve no constructive purpose to our class. Are we, here, not behaving arrogantly ourselves? I submit that such attitude serves no one but the one who holds it. Is not our work for the wholeness of women and babies? I am a feminist but I am not an "anti-masculinist," and even if I were, it would not serve my mothers to hold their male partners in such apparent disdain. I support free speech, don't get me wrong, but I don't believe Midwifery Today is the proper forum for anti-male sounding, anti scientific sounding rhetoric and religious sounding analysis of issues of women and their children. Our most doctrinaire rhetoric should be saved for non-professional times when we can just let it all hang out. Professionally we must not speak of such things except in the most gentle, professional, respectful, and objective ways. Our clients and potential clients read our journals and many do not espouse our feminist and possibly religious beliefs at all. Our mothers need to be able to trust that we deeply respect their beliefs. Birth professionals come in close contact with their clients. I strongly believe the deep wisdom of one of our long practicing midwives when she spoke of our treading in close with our mothers as they birth and nurture their children: "Stay in the humble," she said. Therein lie our powers, strength, and confidence for the benefit of each other and those we serve. Submitted With respect and love,

-Raverna Wynn Stahl, RN, Doula
Seattle, WA

Editor's Note: to read "Breastfeeding Nemesis" in its entirety, go to:
www.midwiferytoday.com/articles/breastfeednem.htm

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More on L&D Nursing:

I am a former L&D nurse with seven years of experience in a 500 birth a month high risk hospital setting. Recently, I began working in a small birth center that just opened in my community. I was amazed at the beautiful outcomes moms have experienced there. Being present at these births was truly an honor. Even though the birth center is located in a portion of the hospital, the difference in the energy when you walk through the doors to the birth center is unreal. I find that when I need to go in to the hospital unit for supplies I am met with much resistance by an unhappy nursing staff. If all women could experience a birth in this setting it would change the way we view birth in this country. It has for me.

- P.H., RN (CPM midwifery student)

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I am an aspiring midwife currently undergoing doula training and I have a visual disability. I am legally blind in one eye, with minimal vision, and am rather nearsighted, about 20/80 visual acuity, in the other. I am able to read regular print, but am not able to drive, and I realize that would limit my practice to birth centers or semi-urban areas. However, I wonder if my visual difficulties would prove it difficult or impossible for me to perform such delicate tasks as suturing, etc. (realizing that midwifery by definition emphasizes low-tech, very hands-on care)?

- Jenn in Baltimore
Reply to: JLCrowell@worldnet.att.net

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I want to thank the person who recommended writing to Oprah [Issue 2:21] I sent in my letter today. I think it's an excellent suggestion and want to encourage all the women who wrote in about choice to send similar thoughts to Oprah. I was told she had a show with midwives when she was talking about the book The Midwives, but this is much more because it's about choices, power and educating women about what's possible.

- Harriet Kaufman
New York City

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Two Sign Language Interpreters Needed for Midwifery Today's International Conference

Are you proficient in American Sign Language and are you involved in midwifery? FREE ATTENDANCE at Midwifery Today's international conference in New York City, Sept. 6-10, 2000 in exchange for being available all day, Sept. 6-9 (Wed.-Sat.). E-mail conference@midwiferytoday.com or phone Karen at 1-800-743-0974.

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