November 1, 2000
Volume 2, Issue 44
Midwifery Today E-News
“Doulas”
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THIS WEEK'S ISSUE

Contents:

  • Quote of the Week
  • The Art of Midwifery
  • News Flashes
  • Doulas
  • Check It Out!
  • Midwifery Today Online Forums
  • Question of the Week
  • Question of the Week Responses
  • Share Your Knowledge: Coming E-News Themes
  • Question of the Quarter: Midwifery Today Magazine
  • Switchboard

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Quote of the Week

"[In my dream], under siege from the advancing army of holistic practitioners and from the unified legislative front the midwives will present, MDs will lose legislative clout as their petty 'because I said so' tactics to maintain their hegemony in each state are exposed, and midwives will increasingly be able to control their own destinies."

- Robbie Davis-Floyd


The Art of Midwifery

Ginger, an older, very experienced OB nurse, has enlightened our department with a great trick for pushing when the baby's head is having trouble descending past the pubis symphisis, or "coming around the corner." She noticed years ago that some women naturally got into this position and it worked really well.
Lay the mother supine, as flat as you can (as long as the baby tolerates it, of course) and push her knees high up toward her shoulders to the point of actually lifting her bottom off the bed slightly. This seems to help the curvature of the sacrum just enough to push the head through the pelvis, similar to the McRobert's maneuver for shoulder dystocia, or like a deep squat, only on your back with your feet in the air. This can be explained to the mother as grabbing her legs and lifting her knees as if she intends to do a backward somersault! But be prepared to instruct her in slow, steady pushes and protect the perineum from tearing, as the head tends to deliver quickly in this position. We all refer to this as "The Ginger Position"--it works every time!

- Luisa Lucero

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News Flashes

More than seventy diseases can give a false-positive HIV test. False positivity has been found to be significantly associated with any brand of influenza vaccination, or a history of recent acute illness and allergies. A cluster of false-positive blood donations in the United States in 1991 was most likely caused by the test kits used. High rates of false positivity have been found in patients with systemic lupus erythematosus and in patients with alcoholic liver disease. Even previous pregnancy can trigger a false-positive result. Antibodies to malaria can cause a false positive. A large study from Zaire reported that patients with leprosy had high rates of false positivity. Caution should be exercised when interpreting HIV-1 ELISA and WB data from regions where leprosy or other mycobacterial diseases (i.e. tuberculosis) are endemic.

- The Practising Midwife, Vol. 2 No. 7, July/August 1999

Doulas

When I first started working as a doula I took everything to births, then realized there are some items I rarely use. With some women I use almost everything; with others I never open the bag and just use my hands, heart and head! Here is a list of some of the items I carry in my birth bag and what I use them for:
- A draw sheet, large towel, or baby blanket for tug-o-war during pushing.
- Two sets of tennis balls in two white tube socks--a good old standby item I have used for years and the one thing I probably will never attend a birth without. They are great for counter-pressure for back labor. I use two clean tube socks for each mom. Roll them up and down the woman's lower back. They are also good to wedge between the mom's back and car seat for the trip to the hospital or birth center.
- Rice pack--each mom gets her own. Use either a fingertip towel or a white cotton tube sock filled with three cups of uncooked rice and tie it in a knot. Put in the microwave for three minutes.
- Cold wrap--has straps and Velcro so it straps around mom and she can get up and walk.
- Ziploc-type bags--for ice and when the ice wrap defrosts.
- Oils--for massage. Olive oil works well.
- Battery-operated hand-held fan and extra batteries.
- Two pairs of white cotton tube socks--just in case mom's feet are cold and her socks get dirty.
- Assortment of wooden massagers and rollers--must be washed with disinfectant after each birth.
- Personal care items--toothbrush, toothpaste, mouthwash, tampons, pads, clean underwear (for those long births), washcloth for freshening up, deodorant, change of clothing.
- Ponytail holders, in case mom forgets.
- Three or four audiotapes of soft music or relaxation tapes.
- Emergency kit for homebirths.
- Sterile gloves, sterile bulb syringe.
- Two books: Mother Massage by Elaine Stillerman and The Nurturing Touch at Birth by Paulina (Polly Perez).
- Labor ball and cover plus extra plugs just in case.
- Food for me!
I keep everything contained in Ziploc bags so it stays clean. I use a large canvas bag to carry it all and use luggage wheels to haul it with.
- Crystal Sada, "A Doula's Birth Bag," The Birthkit Issue 25

Editor's note: Doulas, tell E-News about a favorite item or two you keep in your supplies kit.

====

The philosophical objection to a doula providing clinical care is that when a labor support person "crosses the line" and checks heart tones, blood pressure or cervical dilation, she takes on a different role to the woman and a different level of responsibility for the birth. By not providing clinical care, we leave the medical and clinical responsibility with the client and her care provider, and are better able to focus on the emotional needs of the client. This is a two-edged sword. It is freeing not to take responsibility for the life of the baby and the mother, and allows us to stay with the woman, talking to her, explaining to her, if problems do arise. On the other hand, my clients go to the hospital a couple hours sooner than they might if I were doing vaginal checks. It is a two-edged sword professionally as well. On the one hand, caregivers are less threatened by my presence when they learn that I'm leaving the clinical duties to them. On the other hand, my opinion weighs less with them, I believe, than if I had the weight of several years of formal training behind me.
- Jennifer Rosenberg, ICCE, CD (DONA), "From Doulas to Monitrices: Differing Philosophies of Labor Support," in Paths to Becoming a Midwife, a Midwifery Today Book

====

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====

E-News asked readers, If a birthing woman has good midwifery care, why might she also benefit from having a doula attend her birth?

A doula's role can be very different in the hospital versus homebirth environment. In the hospital there is a much greater need for advocacy and education. I will usually start with the couple in their home and transition to the hospital when labor has progressed. In my area the midwives may not arrive until pushing, much like many physicians, though sometimes they may come sooner depending on their schedule, who else is in labor, etc. So the doula's role is clear in terms of support during those hours before pushing.
In a homebirth situation, I work with a midwife as her assistant. Usually my doula role is an extension of the job I am already doing. Recently, one of our homebirth clients hired me to doula for her in addition to doing my assistant role. In that situation, I was at the labor for many hours before the midwife arrived, keeping her apprised of the progress over the phone (she was at another birth). When pushing came, my role again changed to more midwifery assisting. We had all talked about this during her pregnancy to clarify everything since this was a bit different than usual.
No matter what, the midwife is responsible for her "clinical" care. If she is busy with a clinical matter, how can she also, at the same time, be dealing with an emotional issue, a physical support need, etc.? Four hands, two hearts, two brains, all working as a team to support a woman on her journey to motherhood--doulas and midwives can be a great team. It need not be a turf war.

- Pam Martin, MS, CD (DONA), CM, apprentice midwife
Poland, OH

====

It depends on what you mean by good midwifery care. A midwife can give excellent prenatal care but not always good labor support. As with the birth of my first son in 1996, my midwifery team was excellent in the care aspect yet very lacking in labor support. They were a hospital practice and they were very busy during my labor/birth and were unable to be with me at all times, and my husband was like a deer caught in headlights. This is where a doula comes in. She is there for the woman, and only that woman, for the duration of her labor and birth.
Doulas may not be needed in all situations. An example is my second birth this year. I had a birth center birth and I felt that it was a little crowded and I was overly cared for (if there is such a thing). But even with "good"(?) midwifery care a woman may need more than that during her labor. Here in NYC's big hospitals it's hard to get "true" midwifery care with midwives being pulled every which way in L&D.

- Charisse Lawson, doula/nursing student/aspiring CNM
Brooklyn, NY

====

Although midwives provide far more labour support than the average GP, I believe a woman can always benefit from the specific care a doula provides. As doulas, our primary (and only) responsibility is the emotional well-being of the mother. This care naturally spills over to the father.
I have attended several births with midwives, both home and hospital, and have never felt as though I am "in the way" or that there is "too much" labour support. I had a client who was planning a home waterbirth and had hired me to attend as her doula. When she learned there would be two midwives, she felt there would be too many people around and too much support and so chose to go without the doula. It turned out that although she was surrounded by many supporters (husband, mother, friend and midwives), she felt there wasn't the specific one-on-one support she had desired. Her family members were unsure about what they "should" be doing and her midwives, although supportive, were busy with other tasks a lot of the time. She regrets that she did not have a doula with her.
I think it depends a lot on the mother and on the doula. An experienced doula will know when her presence is desired and when it's best to back off a little. It is the guarantee of this kind of support that can make all of the difference to the mom.

- Julie Keon CD
Victoria, BC

====

Even if a woman has excellent midwifery care she can still benefit from a doula. It's important to feel very supported emotionally as well as physically during labor and birth. The doula can help support a leg, hold a hand, cheer the mother on, apply counter-pressure, wipe her face with a cool cloth, etc. During the actual delivery, the midwife will be busy at the perineum delivering the baby. The midwife is also not always free to stay with the mom from early labor all the way through, depending on her schedule. I had an excellent midwife at my homebirth, but still appreciated the support of my doula.

- A.M.


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Question of the Week

I have a client who had urinary retention between her ninth and 12th week with her first pregnancy. She is pregnant again and she recently, again during her ninth week, developed urinary retention. She has been treated by catheterization both times. She is fearful that she will develop a UTI as she did the first time. The urologists have no idea why this happens to her. Has anyone else had clients with urinary retention? Does anyone have a theory as to why it occurs in some women? Are there any prevention measures?

- Cindy Schierlinger

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Question of the Week Responses

Q: Are midwives' clients experiencing any medical problems from refusing the vitamin K shot and eye prophylaxis (assuming, of course, they tested negative for chlamydia and gonorrhea)?

- Anon.

A: We had a homebirth in New Zealand where happily, eye drops are not mandatory for newborns. My 13-month-old baby's eyes are quite healthy and normal. My baby has had no eye infections that I am aware of. If she did, I would squirt breastmilk into the eye. The opthalmologist said my baby does not have a true strabismus problem (only pseudo-strabismus due to the low nasal bridge and skin folds, which are quite normal), and she has the normal amount of farsightedness in each eye for a baby her age.
We declined to give her the Vitamin K shot, and she has had no problems.

- Anna C.

A: I have had two homebirths. With the first I accepted the vitamin K shot. During the second pregnancy, I drank alfalfa tea during the last trimester and refused the shot. I can see no effects of refusing the shot in my 20-month-old.

- L.D.


Coming E-News Themes

1.INTACT MEMBRANES: What are the fetal benefits to labor with intact membranes? Do you have any documentation to share with E-News readers?

2. PROM: A 1996 study at the University of Toronto randomly assigned 5,041 women with premature rupture of membranes (PROM) to either have their labors induced or to wait for up to four days for labor to start spontaneously. In both groups, about 3 percent of babies developed infection, and about 10 percent were delivered by cesarean section. The study concluded that physicians should present this research to patients, who should choose the option they prefer. Comments?

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Question of the Quarter: Midwifery Today Magazine

Issue No. 57 (Theme: Cesarean Prevention/VBAC)
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More on birth rituals:

Religious Jewish women swallow a pearl when they are 4-5 cm dilated as a blessing for easy and quick labor. When the baby is born its hands are washed three times with a blessing as an omen for good luck.

- Zinger Orna, midwife
Israel

====

Editor's note: Continue to send birth customs from your country and culture and we will include them as a mini-column in E-News.

====

In response to the obstetrician's concern about lengthy second stage [Issue 2:43]:

First, I would like to say that second stage is not necessarily any more dangerous than any other stage of labor, which most of us midwives consider to be a normal, healthy function. Second, women are not machines that are dangerously defective and at any moment would kill or hurt their babies or themselves. Third, we are there to provide information (risk/benefits) to the woman and her family so she can decide for herself what is the course of action or inaction that she feels is appropriate. We are not in control of women and their births. We are guardians/lifeguards. We give them the facts (without emotional manipulation) and they decide. Fourth, from the accounts of these stories of long second stage [Issue 2:41 & 42], we can get the picture that long is not necessarily bad. These births had great outcomes. Fifth, cesarean section is 10 times more dangerous than vaginal delivery. It is not the answer to everything. Women come to us so that they may avoid this most-often-than-not unnecessarily performed surgery. Sixth, if the baby sounds good and the mother is in great health and spirit, why would we not let her continue?
We do take a woman to the hospital and transfer her into your expert hands when dangerous situations arise. I believe we just have a fundamental difference on what it is that constitutes an emergency or is dangerous. Many of us have transported for placental abruption, prolapsed cord, fetal heart rate decelerations or variable decelerations, prolonged second stage, etc. We take our commitment to keep birth safe seriously, especially in a homebirth setting.
I have great faith in a woman's intuitive sense of wellness.

- Michelle Bartlett, CPM

====

Dianat may have been taught and may still believe that prolonged second stage is harmful but there is no evidence that this is so. There is ample evidence that second stage need not be rushed. The following are just four abstracts of studies that found that prolonged second stage is not harmful to the baby or the mother. Both midwives and OBs need to be professional enough to change practices which are useless or harmful. There is no justification for arbitrary limits on second stage.

- Angela Cross

References:
1: Moon JM, Smith CV, Rayburn WF. (1990). Perinatal outcome after a prolonged second stage of labor. J Reprod Med, Mar;35(3):229-31.
2. Saunders NS, Paterson CM, Wadsworth J. (1992). Perinatal outcome after a prolonged second stage of labor. Br J Obstet Gynaecol, May;99(5):381-5.
3. Paterson CM, Saunders NS, Wadsworth J. (1992). The characteristics of the second stage of labour in 25,069 singleton deliveries in the North West Thames Health Region, 1988. Br J Obstet Gynaecol, May;99(5):377-80.
4. Menticoglou SM, Manning F, Harman C, Morrison I. (1995). Perinatal outcome in relation to second-stage duration. Am J Obstet Gynecol, Sep;173(3 Pt 1):906-12.

====

I am always filled with confusion when I hear a wonderful birth story about a midwife-assisted birth at home (such as the one where the second stage continued so long, the midwife went home and returned days later to catch the baby) in one of the recent issues, and then a reply by an OB (in this last issue) that expressed the doctor's surprise at the length of the second stage and dismay that the midwife would "let it be" so long without recommending an OB referral and c-section due to the dangers of unmanaged labor. Obviously the midwife in this case did not see anything wrong with "letting it be" and saw no danger (or she surely would have referred), and the OB in a similar situation (presented with a mom with failure to progress in the second stage) would have surely gone on with a c-section, believing there to be imminent danger.
It is hard to understand the varying beliefs about medical care. Both are surely founded in training and experience--why such different conclusions? As an aspiring midwife (now a practicing doula), I worry about what training I will seek and receive, how will I know a particular obstetrical fact is a fact and not dogma? How will I know, when there are varying beliefs?

- Tiffany Collins

====

Measuring motherbaby's well-being by the clock is a very narrow and arbitrary definition. If you have never seen a second stage that took more than the short ones you described (10-30 minutes in multipara & 20-60 minutes in nullipara) I would venture that it is because you have never seen birth outside of an institution that dictated these protocols and/or attended by a caregiver who had been educated as to their limitations.
You speak about complications yet none of the anecdotes shared with E-News were reporting any problems. You mention that "nowadays there are many technical methods to understand the situation and position of a fetus in his mother's womb." What are you recommending besides FHTs, mother's vital signs and urine check? Perhaps you are not anticipating that the mother is eating and drinking and offered a quiet environment in which to rest between her labor contractions? Perhaps you are envisoning something akin to a labor induction or conduction and are not able to imagine that this woman has contractions occurring every 5-10 minutes rather than the "hurry up and birth already" type of labor that is provoked in a hospital.
I have attended more than 500 births and frankly find the ones that conform to your standards to be the exception rather than the rule. They are a welcome surprise when I am very tired and thinking of my bed (!) but they are motherbaby initiated and not tinkered with by this midwife.
As for your words, "How dare midwives let it be and why don't they refer the pregnant mother for cesarean," I would like to counter with the question, "How dare caregivers decide anything FOR their motherbabies rather than make decisions in dialog WITH them?" Any woman who has had a multi-hour second stage with me is fully informed that the cesarean exists as an alternative. Her decision to birth with my group is often based on her desire to avoid just such an occurrence (our rate is 6%).

- Joni

====

In reply to Jackie's reflexology question [Issue 2:42], there is a wonderful book called "Maternity Reflexology" by Elsa Reid and Suzanne Enzer that can be ordered from ACE graphics in Australia (they are on the Internet). As you use reflexology in your practice, your experience and intuition will make you very aware when to use it and when not to. The book is very specific about indications and contraindications, pressure points, etc. I'm sure relaxation, lymphatic drainage and gentle touch is fine to use at any stage of pregnancy but we practitioners must be alert and aware at all times. Suzanne has also just released an excellent new workbook for midwives.
Reflexolgy can be used for induction of labour, to reduce swollen feet, constipation, backache, headache and nausea, and can be used in the preconception, antenatal, intrapartum and postnatal period.

- Gloria Whyte
Australia

====

To answer your question regarding GBS urine cultures [Issue 2:43]: Our hospital protocol is to test every patient for GBS around 35-37 weeks with vaginal to rectal swab. Also, if women have their urine sent for C&S due to complaints indicating UTI or a routine screen done due to rule out UTI in the presence of preterm contractions, and GBS grows on those cultures, our providers (midwives, family practice docs or OB docs) treat with oral antibiotics at that time, and then with IV antibiotics during labor, even though it was a urine culture. If a woman has it in her urine, she may very well carry it intravaginally or externally, and they want to provide the best protection to these kiddos during labor by giving them antibiotic coverage if the patient ever has +GBS. We even treat if a woman is negative this pregnancy, but was positive during previous pregnancies.

- Lana

====

My hospital is planning to purchase new furniture for our OB unit. We are interested in having mother or family beds with a baby bed which will attach and detach to the bed, allowing mom and baby to have their own space when desired and still remain in touching distance. As this will be used in a hospital setting, it will have to be durable, easily washable, and on wheels.
I have information regarding the arm's reach bedside cosleeper. This does not meet our requirements. If anyone knows of a hospital or birthing center that has a family bed or attachable crib, please respond. Thanks so much.

- Georgia
Reply to: georgia91146@earthlink.net

====

I have to find out more about birth rituals of Jehovah's Witnesses. I know they refuse blood transfusions, but are there other particular things that are typical for their religion?

- An De Vleeschauwer
Belgium

====

A friend is looking for information about a consequence of her brutal OB attended, forceps delivered birth. One of the results of the birth is that her vagina gapes open, allowing air in--which is then passed out as flatus. The gap is large enough that my friend can no longer go swimming because her vagina fills with water and makes her very uncomfortable. The physician she saw said nothing could be done because it is due to overstretched muscles and she will just have to live with it. I had read about this somewhere and now can't find the reference. Has anybody heard of this condition and if so, do you have any suggestions to help her?

- Anon.

====

I would like to thank those who responded to my "supportive presidential candidate" question [Issue 2:43]. You were incredibly helpful!

- Amy

====

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.
Contact the Conference Secretariat at +55 85 246 4302/246 0232, by fax at: +55 85 246 2697, e-mail: childbirth@eventuall.com.br, WWW at

www.humanization.org


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