September 27, 2000
Volume 2, Issue 39
Midwifery Today E-News
“Fetal Heart Tones”
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This issue of Midwifery Today E-News is sponsored by:

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Midwifery Today Conference News

OUR HOME TOWN will be the site of Midwifery Today's domestic conference next March. Come join us in friendly Eugene, Oregon ("Eugene" means "good birth"!). For more information, go to:

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Fetal Heart Tones
5) Check It Out!
6) Midwifery Today Online Forum
7) Question of the Week
8) Question of the Week Responses
9) Coming E-News Themes
10) Switchboard

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1) Quote of the Week:

"To be a midwife is inherently political: To choose midwifery instead of medicine and still practice 'medicine,' no matter how much our philosophies separate the two or reclaim the former, is to choose revolution."

- Therin River, CNM

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2) The Art of Midwifery

It is easy to lose ourselves in our schedules. The antidote is to take time with each other and tell our midwifery and birth stories. It is essential that we reflect on another's experiences, and learn, recognize, associate and validate what we see as normal.

- Jill Cohen

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TALK STORY is a regular feature at Midwifery Today conferences. Come and tell your stories, and learn from others' stories in a comfortable, supportive and enjoyable setting. Our Eugene, Oregon conference talk story will be facilitated by much-loved midwife, teacher, and Midwifery Today editor Jill Cohen. For more on this conference, go to:
www.midwiferytoday.com/conferences/Eugene2001/venue.htm

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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

Significant stress at work and at home can lead to an increased chance of preterm births, low birth weight infants, and possibly less healthy children. Pregnant women who stand for long hours or work in a stressful environment for more than forty hours a week can increase the risk of having a preterm birth or of developing preeclampsia. Women who have stressful life events during pregnancy are more likely to have preterm births. In experiments on monkeys, the infants of mothers who were stressed during pregnancy showed increased abnormal social behavior, and had poorer motor abilities and shorter attention spans.

- Childbirth Forum, Summer 1997

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4) Fetal Heart Tones

The fetal heart should be audible by 20 weeks with standard fetascope; if you cannot hear it within the following week, use a Doppler or refer for a sonogram. Normal fetal heart tone (FHT) range is 120 to 160 beats per minute (BPM), but younger babies are considered normal up to 170 BPM. The heart rate is generally higher at the beginning of pregnancy, slowing ten to fifteen points as the baby grows. In addition to the BPM, check for variability by listening for several fifteen-second increments, determining BPM for each and noting the overall range, e.g. 132 to 148 BPM. Variability may not be noted until 28 weeks. It occurs in response to manual stimulation, uterine contractions, or the baby's own movements, and is considered a sign of neurological health, as it portends an ability to handle the stress of labor. Don't forget to invite the expectant mother's partner, friends, or other children to listen to the baby. -Elizabeth Davis, Heart & Hands 3rd edition,
Celestial Arts 1997

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Auscultation of FHTs as a gestational marker: Investigators wanted to test the axiom that fetal heart tones are first auscultated at 20 weeks. They examined women for FHTs weekly between 15 and 23 weeks' gestation. At 20 weeks, 81% had FHTs detected; at 21 weeks, 95%; and by 22 weeks FHTs were heard in all cases. The mean onset was 19.4 weeks; the range, 17-22 weeks. -Bruninghaus et al, OBGYN April 1987.

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When you are first trying to find the fetal heart during early pregnancy, begin by attempting to hear it just above the pubic bone. The faint sounds seem to be amplified by the proximity of the bone and therefore are frequently more easily heard in this area. Press very firmly; the baby is well cushioned by fluid and you will cause no harm. Listen intently; it may help to close your eyes. Move your fetascope around, little by little, until you can detect the heart beat. You must listen for a regular sound behind any overlaying sounds from the mother's circulation or digestive system.... You will be less rewarded if the mother's uterus is retroverted; in early pregnancy the fundus of the retroverted uterus takes longer to rise above the pubic bone and therefore both the fetal heart tones and the true top of the fundus are more difficult to find.

As pregnancy advances, the location of the loudest fetal heart sounds will become somewhat more predictable based upon the fetal position at the time. Traditionally it has been said that the fetal heart is easiest to hear just below the anterior shoulder through the baby's back. Most of the time this will be the case, especially as the baby gets larger. Be sure to assess whether the woman is experiencing a toning contraction while you are trying to listen, which will make finding the fetal heart more difficult. Simply wait a minute or two for the uterus to relax before you continue.

Traditionally it has also been taught that the location of the fetal heart sounds are one way to double check your estimation of the baby's position. Be aware, however, that there is not a 100% correlation between the two. This is especially true if you are using a Doppler (another good reason not to!). Should you find fetal heart tones in an unexpected location relative to your estimation of the baby's position by palpation, feel again. If you still feel confident of the baby's position via palpation, give that more weight than where you hear the fetal heart. The fetal heart is often best heard below the mother's navel, even if the baby is breech. -Anne Frye, Holistic Midwifery Volume I, Care During Pregnancy, Labrys Press 1995

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TO ORDER ANNE FRYE'S COMPREHENSIVE BOOK Holistic Midwifery Vol. I, go to:
www.midwiferytoday.com/books/annefrye.htm#holistic

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5) Check It Out!

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

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NEW WATERBIRTH ARTICLES have been added to Midwifery Today's website! Go to these sites:
www.midwiferytoday.com/articles/qq54.htm
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www.midwiferytoday.com/articles/birthsea.htm

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VISIT THE BIRTH MARKET! Search the Midwifery Today directory of products and services, including Find a Midwife and Find a Doula. www.midwiferytoday.com/birthmarket

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MIDWIFERYTODAY INTERNATIONAL CONFERENCES: Join us around the world!
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6) Midwifery Today's Online Forum

I will soon be a first-time grandmother and would like my daughter to enjoy the herbal bath after her hospital birth and stay. Could someone find the ingredients or lead me to a place where I could get them?

- Tina====

To share your thoughts and experience, go to Midwifery Today's bulletin board:
www.midwiferytoday.com/forums. Click on "Midwife Chat."

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PRODUCTS SPECIALS: On the Midwifery Today Online Forum under "Product Specials," find out how to get Midwifery Today books 1/2 off the regular price.

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7) Question of the Week

In my prenatal fitness class I have a G1P0 due 12-4-00 who has intercostal neuritis. She has been adjusted by her chiropractor with no result. Gallbladder has been ruled out. I intend to work on her with massage and am wondering if anyone has any other suggestions on things she may try. Acupuncture has been suggested and declined, though she was planning to have a nerve block!

- Pam Martin, MS DONA CD, CM, apprentice midwife

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Send your responses to mtensubmit@midwiferytoday.com

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8) Question of the Week Responses

Q: I am interested in hearing about successful protocols for lactation without pregnancy. Please describe the method including duration or dose or other appropriate units.

- Morgan

A: I personally have no experience with this one, but am passing on information I have read and information from two moms I have spoken with who did it. First, like with all other nursing, frequency is a key to success. The baby must be put to breast very frequently, even every few minutes during the day for several weeks. So that baby is getting food when he/she nurses, a nursing supplementer can be used that will supply baby with food while the baby suckles. Donated breastmilk or formula can be used. It will take a while to establish a full supply. You will be able to cut back on the supplementation a little at a time. There are also drugs that will induce lactation, but no drugs are without risks. This method can work since it will even work believe it or not for a MAN. In some cultures the father nurses his child if his wife dies. Also in some cultures women relatives, some who have never birthed, may help with nursing children. One of your best bets for help, information and support in doing this, I am assuming for your adopted baby, is to contact LaLeche League.

- Anna Matsunaga

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A: What do you mean exactly by "duration or dose"? Galactogogue medications? The most-used is Domperidone. Dr Jack Newman has a handout on it. There is also a WHO publication, "Relactation, review of experience and recommendations for practices," and an information sheet is available from LLL: "Breastfeeding your adopted baby" LLLI sheet 54.

- Francoise Railhet
Manager, LLL France Medical Associates Program

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A: In the U.S. only one drug is available for this: Metaclopramide in a dose of 10 mg 3 times daily. In other countries not only is this drug available, but also Domperidone. Dr. Jack Newman uses it with good results. *Metacloprimide is used for ulcers and induction of lactation is an off-label use.* Some doctors and midwives are ready to prescribe it; others are not willing to take the potential liability for off-label use.

I use a host of different herbs depending on the woman. Generally, lactation consultants use a common blend of fenugreek and blessed thistle. Usually a woman takes three or four capsules of dried herb three times daily. It works well to increase supply and induction if the woman has a previous pregnancy in her history. I like goat's rue and homeopathic lactuca virosa. The goat's rue comes in tincture that is taken three droppersful three times daily. The lactuca is a homeopathic preparation taken several times daily for the first few days. It is then reduced to three times daily. Other herbs good for induction are fennel, dill, anise, borage, alfalfa, caraway, nettles and red raspberry. I find that tinctures seem to work faster.

In addition to herbs, I have the woman pump with a hospital rental grade breast pump. Mom initiates pumping around 4-6 weeks prior to baby if she knows he's coming. She starts at four times daily for 5-10 minutes, and builds to eight times daily for 15 -30 minutes over the weeks. This is to stimulate using her own hormones and prepares her for the frequent nursings a new baby is going to need. I have this all better explained on a website (www.Birthandbreastfeeding.com). When mom gets baby, she will need assistance with getting latch-on correct. She may also need to use a supplemental nursing system of some sort. The first rule is feed the baby. In this way baby won't lose weight; he stimulates the milk supply by suckling at the breast and mom gains confidence in feeding her baby. Also there is no substitute for watchful professional guidance with this mom. Referral to an IBCLC is helpful. Then surround her with lots of support such a La Leche League International or other support groups where she lives. Breastfeeding is not only nourishing a baby but loving and nurturing.

- Mechell Turner, M.Ed. IBCLC, Doula, CBE, Herbalist

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9) Coming E-News Themes

1. PRENATAL CARE consists of everything a woman does for herself during pregnancy, punctuated by a series of visits with you," says midwife and author Anne Frye. Any comments? 2. BIRTH RITUALS: E-News is curious about birth rituals around the world that would usually be called "old wives' tales." For example, birth attendants may be told to untie their shoes at a birth so there would be no knots in the umbilical cord, or they may avoid wearing red to prevent hemorrhage. We would love to hear other midwives' stories along these lines. (E-News thanks Fiona Thomson for this topic idea.)

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

Send your responses to mtensubmit@midwiferytoday.com

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10) Switchboard

I am a social sciences student entering my third year at Teesside Uni. I hope to study midwifery after it. I would like to do my dissertation on midwifery but I don't really have an idea for a question or research. Would any midwife out there like to suggest a research topic I could use to help midwives in the future?

- Claire Russell

(Editor's note: Readers, so far we have received only one suggestion!! This is a great opportunity to give a future midwife a "hand up" and at the same time educate the public. Send your one-sentence ideas to E-News--we could have fun with this!)

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Questions from my childbirth education class:

1. I'm taking medication for hypothyroidism, and since the beginning of my pregnancy my OB has done an ultrasound to determine if my baby is being affected and if it is growing properly. Do the risks of ultrasound outweigh the possible risks of the baby not thriving?

2. I've become aware during my pregnancy that I have gallstones. My OB has informed me that pregnancy can irritate them, and that is why I am experiencing mild pain. She also mentioned surgery after the birth. I'm wondering why I would have to have surgery and would a liver cleanse work after the baby was born while I am nursing?

My own question: I recently attended a birth where the mom's water broke and an hour later she was 9 cm dilated. This was her second birth. Twenty minutes later she was at 10 and pushing. While the CNM was doing an internal I saw chubby fingers grab hold of her hand. Needless to say she pushed for four hours and swelled up horribly. She had to have a c-section. The baby's arm had been around the side of his face with the hand presenting knuckles first. We tried many positions and the CNM tried pushing the hand back in. Any suggestions on what else could have been done?

- Jonelee

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I am a student midwife in Ontario. I am currently doing research on the growth charts that. I believe, are based on formula-fed babies and the implications they have on breastfeeding. I would love to know if there are any growth guidelines based on breastfed babies available.

- Charlotte Baici

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I have been following with interest the current discussions about midwives using drugs to induce women at home. Thankfully we manage to avoid this with UK homebirths as induction is considered strictly outside the normal and only performed in hospital. Personally I have always enjoyed attending homebirths as it gives midwives the chance to practise the 'masterly art of inactivity' in the true sense.

- Alison Andrews Wales UK

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As a midwife who has a private practice and does homebirth and birth center births, my main job is to protect and nurture the natural process of pregnancy and birth. But I also live in a community where Cytotec is used very frequently in a nearby community hospital under "controlled" conditions (with a perinatologist overseeing the outpatient administration and the women being monitored). When my clients beg for inductions (husbands going out to sea on Trident submarines for three months, or women going so overdue that they cannot use the birth center by law, etc.) I tell them this is an option in our community and after discussing risks and benefits, send them to this facility for induction if they so choose. It has become a "community standard" in our community and is available. I am not going to refuse care for a woman and her family who exercise their options. Listen to women and help advise them, but let them choose what is legitimate in our society to choose.

- Annette Manant, CNM

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I teach natural childbirth, the Bradley Method and natural family planning. A woman is trying to achieve pregnancy and her cycles are on average 48 days long with the basal temperature rise around day 32. Temps before ovulation are around 97. I have read that consistent temps below 97.6 are considered a low thyroid problem (this does run in her family). When blood work was done last year, thyroid was tested; it came back normal. Estrogen levels came back normal. Testosterone levels will be checked around day 40 this cycle. In the research I have been doing, I have found that consistent low basal temps are more accurate than blood work. Is anyone familiar with this?

- Heidi

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"There is no evidence that delivery practices that avoid perineal trauma are correlated with low Apgar scores, birth trauma, or cerebral palsy. Passing through the bony pelvis might sometimes be traumatic for fetuses, but there is certainly no evidence that soft tissues of the perineum damage fetal brains."

"In Klein's study of restricted versus routine (median) episiotomy, sexual satisfaction in women 3 months' postpartum was best with intact perineums."

(Copyright (c)2000 by The American College of Obstetricians and Gynecologists)

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I used perineal massage prenatally and during the active pushing phase with great results for all three of my births. I believe that research backs up its value, and I encourage clients to research its use. I also make sure to warn them if they do use it (prenatally) that they may (one or both persons) be sexually aroused. This is normal and should be discussed. I use it with clients (at their request) alternately with warm/hot compresses, and have not seen the swelling that others report. As a doula and monitrice, I do a lot of work in the hospitals and find that in this setting it is more helpful than not, especially since there are so many cut-happy docs. It seems that if a client chooses to have this done, the doctors are more hands-off. In my homebirth situations we may not do as much but the whole birthing atmosphere is so much different. Things tend to be slower, calmer, more hands-off anyway, unlike the hospital with the "cheerleaders" for pushing and the commands to move it along.

- Anon.

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As an acupuncturist and daughter of a dialysis nurse I decided to get both Hep A & B vaccinations. I had seen too many patients and nurses have complications (including death) from hepatitis. A couple of years later I had a positive ANA (antinuclear antibody--an indicator for lupus) test. While I don't know if one caused the other, I have to wonder. When I got pregnant with my child I was retested and my titers went up. I was considered to be higher risk than normal and ended up with five ultrasounds (which would have been much higher if I had gone to the twice-weekly visits for fetal stress monitoring).

On induction of labor: I used acupuncture to help my labor progress. It helped my contractions stay regular and less painful than menstrual cramps until I got to transition. On nausea: I threw up almost every day from week six to week eighteen of my pregnancy. I even got stomach flu. The one thing that helped was stimulating an ear acupuncture point called "point zero." My midwife suggested a B vitamin supplement with equal amounts of B1, B6, and B12 (I think those are the ones) from 50 to 100 mg. By the time I tried it, it didn't help. But I was taking B-50 when I got pregnant and didn't start having nausea and vomiting until I switched to prenatal vitamins.

- Colleen

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I was recently induced by my midwife, who delivers at a local hospital. I was induced because when I started to dilate my blood pressure was rising with every centimeter dilated. I felt she and I made the right choice for my safety. I was given Cytotec. Why is everyone so upset with this drug and what is it doing to women that is making people upset? I was just fine with it. I also had to have Pitocin and ended up with a cesarean because I failed to progress, which was just fine with me. I had such a great experience with my midwife that she changed my life. I am enrolled in school to start my path to midwifery. Any comments or suggestions would be great.

- Stephanie Ambs

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Several times in your discussion of nausea and pregnancy it was suggested to use ginger or ginger tea [Issue 2:38]. My understanding is that ginger can cause risk of miscarriage. Why do we as midwives recommend its use in pregnancy? I realize the risk may not be as strong as with other herbals, but there is still a risk, especially if combined with other lesser risk herbs. There are many other safer things to recommend and try.

- Judy Jones, CPM

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Recent studies have shown there is a strong correlation between saturated fat in the diet before becoming pregnant and a higher incidence of nausea in pregnancy. Women who eat meals high in saturated fats (the McDonalds meal) in the six to nine months before pregnancy are much more likely to suffer nausea in pregnancy than women whose diets are free of saturated fats. In traditional societies where there are no saturated fats in the diet, nausea in pregnancy is almost unheard of.

- Larry McMahan

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Do tomatoes contain vitamin K? I read that the seeds do, so that eating them improves blood circulation.

- Grace

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Regarding Theresa's question about postpartum blues [Issue 35]: Natural progesterone cream used for three weeks out of the month will help restore the mother's estrogen/progesterone balance and the blues will disappear. Do not allow doctors to put her on synthetic hormones because they will cause additional problems. Most health food stores carry natural progesterone.

- Cindy

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My baby was in the NICU in a teaching hospital which was, in my opinion, a horrible place for parents who really wanted to be involved or had plans for breastfeeding or an attachment-type style of care. I felt downright abused by the doctors and nurses. I want to better understand and resolve what we went through as well as be prepared to be effective in helping anyone I might meet who is in a similar situation. Any comments?

- Anon.

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International Conference on the Humanization of Childbirth November 2nd, 3rd and 4th, 2000
Fortaleza, Ceara, Brazil

Throughout the 20th Century, advances in science and technology have affected every aspect of our lives, including the way we are born. In many parts of the world, quick and arbitrary changes in maternity care have often resulted in the excessive use of perinatal technology, a loss of community-based models of care and an overcrowding of large hospitals.

The International Conference on the Humanization of Childbirth will take place in tropical Fortaleza, Ceara, where Project Luz, a humanization project currently being implemented, is based. The objective is to bring the international community together in order to deepen our understanding of the global situation of maternal and perinatal health, thus strengthening the humanized approach in the new millennium.

Goal: To promote humanized maternity care leading to healthy childbirth.

Participants: Those interested in maternity care and childbirth, including: midwives, nurses, obstetricians, pediatricians, consumer groups, women's groups, epidemiologists, social scientists, health administrators, policy makers, journalists and pregnant women and their families are invited.

For a complete listing of seminars, instructors, events, cost, etc.: Secretariat Eventuall Promocoes & Assessoria, Rua Dr. Gilberto Studart, 369, Papicu, CEP: 60190-750, Fortaleza, Ceara, Brazil; tel. (55) (85) 265 4022; fax (55) (85) 265 4009; e-mail: childbirth@eventuall.com.br; web site www.humanization.org.


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