|October 18, 2000|
Volume 2, Issue 42
|Midwifery Today E-News|
“Electronic Fetal Monitoring”
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Quote of the Week:
"No other natural bodily function is painful and childbirth should not be an exception."
- Grantley Dick-Read
The Art of Midwifery
The lunge is a good way to turn a baby, or to give a right occiput posterior more room to move. Have the mom stand face forward with a chair beside her. Ask her to place one foot on the chair seat, with knee and foot pointing to the side. Remaining upright, she should slowly "lunge," or lean sideways, toward the chair so that her leg on the chair bends. She should feel a stretch on the insides of both thighs. The mom should stay in the lunge for a slow count of five then return to upright. Have her repeat during or between contractions. If you know the baby's position, she should lunge toward the side where his or her back is. If you don't know the position, have the mom try lunging in each direction to find the one that is most comfortable.
- Penny Simkin, PT, Midwifery Today Issue No. 31
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A study to analyze the effect of fetal gender on the fetal heart rate in labor and to measure its magnitude in relation to the effects of other independent clinical variables was undertaken in Oxford, England. The last hour of the intrapartum heart rates of 1,884 term singleton fetuses collected during routine clinical monitoring was analyzed. Female fetuses had significantly faster heart rates than male fetuses. Epidural analgesia, weight percentile adjusted for age and sex, parity, duration of first and second stages of labor, and a fall in umbilical arterial blood pH at birth also independently modulated the fetal heart rate. The effects of the independent variables were additive, the most important being epidural analgesia. The effect of fetal gender was less in the first stage, six to seven hours before delivery, and was not present before the onset of labor. The study concluded that the fetal heart rate response of female fetuses to normal labor differs from that of male fetuses.
- MIDIRS, June 1999
Electronic Fetal Monitoring (EFM)
If recent studies do not support the routine use of EFM, why
is it still so widely used? First, because many nurses and physicians
have not been trained in intermittent auscultation. Second, some believe
that EFM might still be a valuable assessment tool with better guidelines
for interpreting tracings and making management decisions, even though
studies comparing the ability of experts to agree on the interpretation
of an EFM tracing have shown poor interpreter reliability.
- American Academy of Family Physicians, May 1, 1999
A conversation I had a few years ago with Dr. John Ott, the author of the book Health and Light, shed some light on non-advancing labor where
the mother and/or baby is hooked up to a monitor. Dr. Ott's research in
the color spectrum wavelengths led to a curiosity about the effects of
electrical fields on the human body. His work led to the first commercially
available full-spectrum shielded fluorescent lighting. He told me that
susceptible persons are greatly weakened by artificial energy fields.
- Judy Ritchie, excerpted from her article in The Birthkit No. 23, Autumn 1999
The issue of whether EFM reduces brain damage to the offspring received its biggest surprise with the publication of a randomised clinical trial which assessed the neurological development at 18 months of age of 2 samples of children, one group born prematurely whose heart rates were monitored electronically during birth and compared with the other group of children born prematurely whose heart rates during birth were monitored by auscultation. The incidence of cerebral palsy was 20% in the EFM group and 8% in the group that was monitored by auscultation. That the use of EFM should possibly increase the incidence of cerebral palsy may be the result of birth attendants focusing on the monitor rather than the overall condition of the woman and baby. The authors admitted to being unprepared for such a negative finding and a flurry of letters in subsequent issues of the same journal indicated that many other resist data which is against their beliefs....The fact that the cerebral palsy rates have remained the same for the past 30 years in spite of widespread EFM is further evidence of the lack of efficacy of EFM to reduce neurological sequelae. These results echo those of the other randomized controlled trials: There is no scientific evidence that routine EFM during labour improves the condition of the baby at birth or reduces the possibility of brain damage.
- Marsden Wagner, MD, Pursuing the Birth Machine, Ace Graphics 1994
Doctors tell us that EFM protects against malpractice suits or hospitals have too few nurses to auscultate often enough (Ob Gyn News 1988). The malpractice argument rests on beliefs that tracings are valuable courtroom evidence and that not using EFM renders doctors liable because it is standard practice. As to the first, Sandmire (Obstet Gynecol 1990) trenchantly observes that a tracing "leaves a permanent record for hindsight interpretation by expert witnesses" who will claim that mild deviations indicate fetal distress. As for the liability issue, Gilfax (Am J Law Medicine 1984) reviewed the law pertaining to EFM and informed consent and concluded that using auscultation over EFM did not render a doctor liable because of the abundant evidence that auscultation is equally good. Indeed, Gilfix continued, informed consent demands that women be informed of risks and benefits of proposed tests and treatments, which would mean a duty to inform women that EFM has not been shown to improve outcomes but increases operative delivery rates. Finally, "too few nurses to auscultate" really means too few nurses to provide optimum care. Gilfix thinks doctors may be obliged to inform women of this too.
Meanwhile, what about "first do no harm"? Both of these defenses of EFM are predicated on benefits to doctors and hospitals at the expense of mothers and babies.
Judith Lumley (Birth 1982), quoting J.B. McKinley, paints yet a darker picture of the forces driving EFM: "The success of an innovation has little to do with its intrinsic worth...but is dependent upon the power of the interests that sponsor and maintain it....The power of such interests is also evident in their ability to impede the development of alternative practices...that could conceivably threaten an activity in which there is already considerable investment. The "need for universal EFM legitimates so many other contentious decisions on the place, style and management of labor that it will not be discarded in favor of [auscultation] but only displaced when another new, equally unevaluated procedure arrives on the obstetric scene." This would explain why only one study has looked at whether auscultation was feasible in a big, busy unit--finding, by the way, that it was (Sandmire).
- Henci Goer, Obstetric Myths Versus Research Realities, Bergin & Garvey, 1995
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Question of the Week
Q: When should the infant's cord be cut, before or after the infant is breathing well on its own? Why?
- D. Young
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Question of the Week Responses
Q: How important and under what conditions is a sterile field a primary concern in delivery?
- Karen Stokka
A: Although many circumstances come to mind, both hospital and home, home wins out for me (particularly some homes). Some people have their homes very tidy for laboring but I have been surprised a few times by dirty homes that the clutter had simply been removed from. One that comes to mind is a call for help I received from a laboring couple (almost strangers, I hadn't seen them prenatally) who had two clean diapers, a semi-clean towel, and a sleeping bag on which to birth, and that's all! Yes, I was thankful for the sterile field that night!
A: Since birth is not a sterile procedure, a sterile field doesn't make much sense. Everything is moving down and out of the vagina, and the vagina is clean, not sterile. Therefore birth is a clean process. Starting out with sterile equipment is not a bad idea. But to cover a woman in blue and paint her with Betadine is in my opinion unnecessary. Betadine is very harsh on open tissue too. Using warm washcloths and keeping your equipment clean should be sufficient.
- Molly, CNM
Q: What is the longest you have seen from full dilation to the beginning of pushing--or to the birth of a baby? What were the outcomes??
- Nancy Wainer
A: With the birth of my fifth child, I went into the birthing center at 9 pm dilated to 5 cm. By 1 a.m. I was dilated to 10 and the midwife could stretch the cervix over the baby's entire head (my water hadn't broken yet). I had absolutely no urge to push, and I chose to wait to see what would happen. By 8 the next morning I was still fully dilated and still had no trace of an urge to push although I had tried numerous things during the night (one thing I wish I had tried was evening primrose oil on the cervix). The problem was that I was becoming exhausted and I knew I would need either some sort of pain reliever/sleep inducer to get my energy back or I would need to try to have my water broken to move things along. I knew if I didn't push soon, I would be so depleted by the time it came to push I would be out of energy. After my membranes were ruptured I went through another, more intense, transition and pushed the baby out. His arm was up and over his head with the cord wrapped around his body and shoulder, so perhaps this is why he didn't begin to descend through the birth canal. Perhaps the lack of a head pushing the membranes against the cervix made a cushion so that my urge to push was not triggered. My healthy, perfect, 7 pound 6 ounce boy was born at 10:30 am.
A: Why do we think 2-3 hours is the max for first-time moms? I feel the most important questions are 1) How is the baby doing? Are there still reassuring signs that he/she is doing well and can continue to do so for a while? 2) How is the mom doing? How is her morale? Does she have the strength to continue? Does she need to rest for a while? 3) How is the father feeling about how things are going? 4) Have I honestly and completely let them know all their options?
This summer I had a first-time (homebirth) mom who pushed 6 1/2 hours. She was a very slender mom with a marginal pelvis, but in excellent physical shape. At 2 weeks postdates she went into labor and her 1st stage was less than 6 hours. The baby sounded great, and we set up quickly for delivery. One hour went to 2, then 3. Vitals were still excellent and she was making progress, although very, very slowly. We kept cheering her on, but didn't pressure her. I was very honest with her and acknowledged that, yes, this was longer than most, but she and the baby were doing great. I also gave them the option of going into the hospital (where we have a great backup), which they declined. At 5 hours we could barely see the top of the head, at which point I said, "In 30 minutes we are going to reevaluate. I know you can't do this all day and if you haven't made good progress, we will go in." I felt this would either give her the determination to finish, or if she really deep down wanted to go into the hospital she would give up pushing at that point. It worked and she made great progress and finally delivered a baby with the longest cone-shaped head I have ever seen! He also weighed 9 lbs. 2 oz. I believe it took all 6 1/2 hours to allow that baby to mold through her pelvis. I was hoping that the mom wouldn't look back on this and feel like she had been forced to endure an awful event. Instead, both parents are incredibly grateful, feeling they would have had a c-sec otherwise.
Remember, the key is not necessarily time, but how are mom and baby doing and how long can they keep this up.
- Wendy L. Lamp, CPM
A: I served a young first-time birthing couple who dilated to 10 with a little lip. We had everything set up to catch a baby, but everything stopped. I stayed around for a few hours. Mom was up and busy part of this time-she walked in the yard, took a warm shower, took blue cohosh. Nothing. Her waters remained intact. I lived 5 minutes away, so I went home. I talked with the mom often to be sure all was well. The 8th day I got my call. The mom was in the shower and I arrived just in time to catch the baby, a beautiful little boy. In the 21 years of attending births I have been with others who have done this as well. They were always farther away so I was not as comfortable leaving so I left the decision to the parents. I have never seen a problem with just waiting as long as the waters were intact.
Coming E-News Themes
1. GBS: I'm curious how other midwives counsel their clients about GBS. Do you have any new information that would make it easier to give better and clearer informed consent to clients? Do you have tricks in case the culture comes back positive?
- A.W. (Issue 2:43, Oct. 25)
2. DOULAS: If a birthing woman has good midwifery care, why might she also benefit from having a doula attend her birth? (Issue 2:44, Nov. 1)
Send your responses to:
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!
I believe Mary Bove was misquoted in Issue 2:32 concerning flavinoids for varicosities. The proper Latin name of bilberry is vaccinium, not caccinium. Women should be advised to use the proper form of this herb: Vaccinium leaf lowers blood sugar by suppressing the catabolism and release of glucose from the liver. Not a good idea for pregnancy when blood sugar is already so altered! The form with the flavinoids is the berry; however, most herbalists believe this is one of a handful of herbs that should be standardized in order to be effective. Standardized vaccinium is quite expensive. Why not use wise woman healing instead by encouraging mothers to nourish themselves with foods rich in flavinoids? These include the inner peel of citrus fruits, apricots, blueberries, broccoli, cherries, currents, grapes, kale, kasha, peppers, prunes, raspberries, and rosehips.
About vitamin K (Issue 2:39): This fat-soluble vitamin is vital for the production of prothrombin, a blood protein involved in clotting. It has no effect on circulation, but deficiencies may lead to abnormal or excessive bleeding. I have not found that tomatoes are a particularly rich source. Instead try alfalfa, nettles, kelp, and dark, leafy greens. Most of the Vitamin K we need is produced by our gut flora, yet another reason to beware antibiotics! Large doses of the synthetic form can actually be toxic to a newborn.
In response to comments about saturated fats [Issue 2:39]: Our ancestors and people in traditional societies did consume saturated fats in the form of animal meats. However their meat was all "free-range" and not fattened with grains, so the proportion of saturated fat was much lower than in most commercially available meats found at the grocery store. In addition, they ate quite a different overall ratio of fats than we eat now, with much higher Omega-3 consumption. Especially important, they did not have access to ANY trans-fats or refined/oxidized/potentially rancid fats, which are more typical of the "McDonalds meal" than just saturated fats. Animal fats do not interfere with our metabolism of Essential Fatty Acids in the way that processed vegetable oils and margarine do. Saturated fats are not the evil entities we have been led to believe. They only potentially cause problems if we are depleted of micronutients, antioxidants, and EFAs. Standard American Diet, anyone? (For more information on traditional people's diets, Weston Price is a superb author. See Udo Erasmus for information on fat biochemistry. A good general introduction to both subjects can be found in Paul Bergner's "Healing Power of Minerals.")
- Adrienne Leeds
Although recently arrested Illinois midwife Yvonne Cryns had been ordered to stop practicing midwifery, the state had no legal right to do so, according to several Illinois members of the Midwives Alliance of North America (MANA). "There is no Illinois law which either prohibits or regulates the practice of direct-entry midwifery, and there hasn't been since 1965," states Valerie Vickerman Morris of Elgin, a direct-entry midwife since 1983. "In fact, Illinois does not license midwives of any kind. Certified nurse-midwives work under the Nurse Practice Act as advanced practice nurses, and are certified by the American College of Nurse-Midwives. The State of Illinois does not issue 'midwife licenses'." Morris has received two cease and desist orders from the Illinois Department of Professional Regulation (IDPR), which she is appealing in Cook County Circuit Court. "We support the right of parents in this state to choose a direct-entry midwife for their birth, as well as their need and right to receive qualified care from a well-trained professional," said Morris. "Illinois midwives have been trying for the last twenty years to pass legislation which would provide for midwifery licensure."
In the last three years, nine cease and desist orders have been issued by IDPR to eight Illinois midwives. Cryns received an order to cease and desist the unlicensed practice of nursing and midwifery in April.
"Midwife-attended homebirth has been repeatedly shown to be a safe option for healthy, low-risk women," Morris continued, "and despite IDPR pronouncements to the contrary, it remains an option that is not prohibited by the Medical Practice Act, the Nurse Practice Act, or any other Illinois statute."
Contacts: Valerie Vickerman Morris RN, 847-931-5222; Attorney Kenneth A. Runes, 847-934-0060.
As an independent midwife in New Zealand, I have cared for a woman with severe hyperemesis. She had lost her first baby at 16 weeks as a direct result of hyperemesis as she had no medication to help her situation. With the next pregnancy the same problem occurred and she was admitted to hospital three times in the first trimester for rehydration and was put on the antiemetic prochloperazine maleate (stemetil) 10 mg 3x daily. This dose varied throughout the pregnancy according to her need but it was the only thing that worked. She also had tried all the remedies that normally would have worked. She tried at times through the pregnancy to stop the medication but had to continue right up until she delivered a healthy baby girl.
I am starting a reflexology diploma so I can apply it to my midwifery practice, my ultimate aim being to provide more choice with less risk for pain relief in labour. I wonder whether any practising midwives use reflexology in their practice? I would like to know of your experiences, the indications and contraindications, (we've been told as reflexology students we should not practice on anyone less than 24/40) and if anyone could recommend a reading/resource list.
My understanding of heartburn is that the same hormones that make your joints more flexible to make the birth easier, also relaxes the round muscle that closes your stomach. Two simple remedies can help: sleep with one or two more pillows than you are used to; it will prevent the content of the stomach from burning your esophagus. And 1/2 hour before each meal take one or two tablets of slippery-elm; this will coat and protect the area that gets burned from the acidity of the stomach content.
I hope a big grain of salt was taken with many of the interesting historical
references to birth rituals.
- Phil Watters
Editor's note: Readers may have been taken aback by some of the practices mentioned in Issue 41. But further study often reveals interesting explanations for their efficacy. Take, for example, the practice in Bihar, India, of having the woman whose labor is not progressing drink water in which her mother-in-law's big toe had been dipped. Author and researcher Janet Chawla explains: "In Ayurveda the "nadi" for "pran vayu" (which is understood to be a carrier of knowledge and experience) exits the body via the big toes--thus the custom of touching elders' feet allows for the transmission of this knowledge to those of lesser knowledge/experience. It is logical to assume, thus, that the mapping of the body implicit in the mother-in-law's big toe ritual is similar to the mapping of Ayurvedic understanding. The social hierarchy of mother-in-law/daughter-in-law is perhaps encoded in this rite, transmitting the respected female elder's permission for the birth to proceed, granting the status of maternity to the "bahu," but at the same time asserting her authority and primacy. Certainly the folk understanding of the inner terrain of the body is closer to that of Ayurveda than it is to the anatomy and physiology of allopathic medicine."
In my Italian family, no one is to point anything sharp (needles, scissors, even fingers) toward a pregnant woman's belly because the placenta may separate.
I am a self-study student from Texas, and I cannot express how Midwifery Today has made a difference in my education. I am on a limited budget and have been unable to afford a subscription, so I borrow any and every MT I can get my hands on. This has become one of the single greatest resources in my educational process. I am so grateful to all the midwives who have given their knowledge so we can learn. I have truly learned more from devouring MT than any text on the market. I just read the latest issue, and again you have done a brilliant job. I have almost finished my training and hope in the summer of 2001 to take the NARM exam. All the articles are written by real midwives who practice midwifery every day. If they write about it I know it works, and I can use it as a true frame of reference. Thank you so much!
- Dianne Bolton
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"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.
I disagree. Prenatal care is care provided by a professional, be it doctor, nurse or midwife. Proper prenatal care helps the mother select a good diet and exercise suitable for her current state of pregnancy, punctuated with a series of screenings to determine if all is continuing normally. Additionally, questions the mother may have regarding anything to do with her pregnancy contributes to the mental portion of prenatal care. Unless a mother-to-be is a professional herself doing all the regular screenings, I don't think she is justified in saying that she had prenatal care. Few mothers can order the screenings themselves and interpret them correctly without training.
Why would evening primrose be necessary in a first-time delivery or a VBAC? Why would my midwife encourage its use for my VBAC and my sister's doctor discourage its use for her first-time delivery? Are there any risks or dangers involved? What are the benefits?
I am studying for the NARM exam and am looking for the following used
midwifery textbooks: Practical
Skills Guide for Midwifery, Understanding
Diagnostic Tests in the Childbearing Year (Frye), Healing
Passage (Frye), Mayes
Midwifery (Sweet), Textbook
for Midwives (Myles), Human
Labor and Birth (Oxorne & Foote), Williams Obstetrics, A New View
of a Woman's Body (Gage), Maternal Newborn Nursing: Family Centered Approach
Greetings from Fortaleza, Brazil! As you may know, in Brazil, a country where midwifery does not exist as an established profession, the cesarian section rate in most private hospitals is as high as 90%, whilst poor women give birth in degrading conditions in the world's most crowded hospitals.
What you may not know is that in the same country, a number of initiatives have been created since the 1980s that attempt to recover human values in childbirth, a movement known as the "humanization of childbirth." On November 2, 3 and 4 midwives and others interested in maternity care from all over the world will gather at the International Conference on the Humanization of Childbirth to promote humanized childbirth.
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