|November 8, 2000|
Volume 2, Issue 45
|Midwifery Today E-News|
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Quote of the Week:
"Whenever I am troubled by issues of great significance that will impose my choices upon someone else, I ask at least two questions: What did people do hundreds of years ago? What do people do all over the world today?"
- Lois Wilson, CPM
The Art of Midwifery
The "Ginger trick" to bring a baby down under the pubic bone [Issue 2:44] is very similar to the "towel trick" we use. Our hospital has a 75% epidural rate (30% for CNM patients). We usually let these women "labor down" their babies rather than coach them to push when they have no urge, but sometimes a baby just shouldn't wait. We set up the squatting bar (which fits into our birthing beds) and tie a draw sheet around the top bar (a towel proved to be too short). We set her feet on either side of the bar and tie a knot at the end of the sheet. During contractions, she pulls on the knot. Her feet and hips are held wide apart and she can usually get a better pushing effort with her hands gripping something in front of her than she can while holding the built-in side grips. I usually end up squatting myself, under the bar to catch the baby. As with the "Ginger trick," babies can descend quite rapidly with the "towel trick," so be prepared!
- Ohio CNM
Doula tip of the week: My all-time favorite and most-used item in my doula bag are my knee pads! I bought a pair of low-tech ones for $4.99 at a local hardware store. They strap on my knees with Velcro and are comfortable to wear even when I am standing. I can kneel with no discomfort for quite a long time.
- Judi Fitts, CD(DONA)
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In a Swedish study of eighty hypothermic newborns, 40 were placed in incubators and 40 were held skin-to-skin by their mothers. After four hours, 90 percent of the infants who had skin-to-skin contact had reached a normal body temperature while only 60 percent of the infants placed in incubators had done so. After 24 hours, temperatures of the incubated infants were slightly higher than those of the held infants, suggesting that incubated infants run a risk of becoming too warm and developing heat stress. Skin-to-skin contact also stabilizes heart and respiratory functions, according to the researchers.
- The Lancet 1998, 352:1115
The latest issue of E-News on doulas was timely because I am finishing writing an article entitled " A Doula No More." I have gone into the hospital for the last time--I will not doula any longer. I can no longer tolerate what women are willing to accept/label as a good birth, nor can I stand violence and abuse of women and babies which is perpetrated in the name of "safety." I always ask, Why would a woman go into a place to birth where she needs an advocate?! Also, in my opinion, if a midwife cannot also provide good--actually, superb--labor support, there is something wrong.
In my area, women choosing to homebirth have to wait for their midwife to drive 60-90 minutes to their homes (and that's when the roads are clear). As a doula, I can be at their home providing support to them much sooner. If problems arise during the labor or birth, I can continue to provide supportive care for the woman while the midwife attends to the concerns at hand. I can explain what is going on to the woman and provide her comfort, leaving the midwife to use her skills to correct the problem. Even in the birth center or hospital setting, I believe this premise holds true. I think midwives and doulas can create a fantastic team for birthing women.
- Maurenne Griese, RNC, BSN, CCE, CBE
I would like to suggest to the doula who wrote about whether or not doulas should be performing clinical skills that as a doula, doing vaginal checks should not usually be necessary if you are familiar with the emotional signposts of labor (notice I said usually).
- Kim Ray, LM
Re: damaging forceps birth [Issue 2:44]:
I'm sad to be a member of a profession where this sort of event still happens. Of course something can be done and there are several options but empathetic examination and assessment by a gynaecologist who is not a misogynist would be the first step.
- Phil Watters (at the other end of the world, I'm sorry)
I recommend that you seek out an OB/GYN physical therapist. I have one in the Chicago are who is very good. Never give up.
- JoAnne Lindberg, BirthLink
Re: Not giving Vitamin K
This person accepted a risk of around 1 in 3000 that her baby wouldn't get fatal haemorrhagic disease of the newborn, which is virtually untreatable and best prevented (with Vit K).
- Phil Watters
Of course there are no harmful effects to most babies not receiving a shot of vitamin K at birth. However, haemorrhagic disease still exists and its origins are mysterious. Nobody knows which babies will develop the disease. There is no evidence that supplementing the mother with vitamin K prior to the birth increases the level of vitamin K in the newborn. There have been at least four cases in Canada of babies born lovingly and gently at home into the hands of midwives and fully breastfed who have developed this terrible bleeding disorder. Usually the brain or the liver are destroyed.
Re: serving Jehovah's Witness families (excerpts)
Besides not taking blood products, another thing I have noticed is my Witness clients have been unusually able to make informed choice decisions. They often have grown up with the experience and shared stories of their fellow Witnesses taking an active role in their medical care because of the blood issue. Even the 18-year-old clients have been fully able to listen to medical recommendations and assertively ask questions and make choices that their medical caregivers would not prefer. They do not seem intimidated despite the rude and abusive comments often directed their way by medical staff.
Once, a young Jehovah's Witness client of mine accompanied her Witness friend to an external version. When the attending OB told the mother that she (the doc) had the legal right to give blood products without the mom's consent, this young observing Witness reached into her bag and brought out Supreme Court documentation and handed it to the doctor with a polite comment: "Excuse me doctor, but actually you don't have the legal right to do that--here's the documentation!"
Rhogam is a blood product so they do not use it.
- Karen Kohls, CCE, CD(DONA)
Besides not accepting blood, there are no particular rituals we Jehovah Witnesses have. We accept medical interventions as long as they do not go against what we are told in the Bible.
If a Witness mother refuses any other form of treatment or medical intervention [besides receiving blood products], it is based on her own personal decision and not based on her religious beliefs. We have literature designed to address the issue of blood transfusions and the medical field. You can receive it at no cost by contacting a Kingdom Hall.
While working with Jehovah's Witnesses, you will find they probably would not participate in rituals. A ritual is something done as a rite, religious or otherwise. Before performing a ritual they would want to know its origin and purpose, and then they still probably would not participate. They are very concerned about keeping their religious practices clean in the eyes of their Creator. They seek good care for their health and their families and many choose homebirths and alternative forms of healthcare because they value life and want good health.
What happens when they might need a blood transfusion? Often simple Ringer's solution, saline solution, and Dextran can be used as plasma volume expanders, and these are available in nearly all modern hospitals. Actually the risks that go with the use of blood transfusions are avoided by using these substances. The Canadian Anaesthetists' Society Journal, Jan 1975, pg. 12 says "The risks of blood transfusion are the advantages of plasma substitutes: avoidance of bacterial or viral infection, transfusion reactions and Rh sensitization." But, Jehovah's Witnesses have no religious objection to the use of non-blood plasma expanders.
If you ever work with them, just ask them why they do or don't do certain things. They will reasonably explain, and it won't be hard for you to understand.
- Annette Lewis, CPM, LM
While they do object to blood transfusions, Witnesses do not object to medical treatment in general and seek to find alternatives to blood transfusions. Prevention is the best approach and thus I've had many JW women seek midwifery care in order to avoid interventions that may actually increase the chances of hemorrhage. I myself encourage proper nutrition and seek to ensure a good blood count by the end of pregnancy so that they can handle a blood loss better. In our practice we would also watch carefully and be ready to take action quickly (whether that be herbs, medication or other treatment and/or transport) if blood loss seemed inappropriate.
- Karin Barasa, midwife
MANA Board Proposes to Make MANA an Exclusive Organization for CPMs and CNMs
Years ago I wrote an article for the MANA News called "The Circle of Midwives," a paradigm for midwifery to honor many types of midwives, all with the common bond of serving birthing families. By honoring the diversity of methods and philosophies, the intermingling of these would better keep midwifery vital and adaptive, just as a diversity of species keeps an ecosystem adaptable to changes of climate. The current move by the MANA board to exclude non-CPMs/CNMs from voting runs totally counter to this vision.
We midwives have created many structures to promote and protect direct-entry midwifery as practiced by homebirth midwives: MANA has grown and stabilized as an organization; MEAC was created to claim the right of direct-entry midwives to accredit direct-entry midwives; and NARM has taken on the charge of a national certification program that can be and is becoming recognized by governments as legitimate. These are fantastic accomplishments! We celebrate and honor all involved!
And now we must maintain MANA' s biodiversity as a national organization. We must not fall into the mere maintenance of what we have created by excluding (and yes, eventually deriding) those who have historically been a part of the process. Being a non-voting member of an organization is second-class status and exclusionary. It will encourage people who are now MANA members to leave and discourage others from ever joining.
It may be a developmental stage--it seemed to happen so easily in Colorado. As soon as we won the right to be legal, it became politically expedient to divide ourselves from those who still weren't legal--they aren't "up to standards." It became more difficult to talk with and learn from each other. Anyone with philosophical differences became suspect, especially if they had not embraced the legal mantel to practice under. This was in spite of the fact that WE HAD ALL BEEN PRACTICING ILLEGALLY AND ACCUSED OF THE VERY SAME BY MANY CNMS (who were legalized previous to us) JUST MONTHS BEFORE!
This defending of the territory of a title--"CPM" or "RM" or "midwife" or whatever--does not allow much room for dialogue, cross-breeding of ideas, and creative diversity in the midwife species. Those with "proper" credentials could and will be called upon to testify in courts of law and legislatures against the "other" midwives who don't have the correct credentials. This breeds distrust, lack of communication and further alienation and misunderstanding--an unhealthy climate for maintaining the strength of midwifery in the long run.
I know some wild midwives could be dangerous. Ladies (and gentlemen), do you think anyone can truly put up with practicing midwifery if they are not truly dedicated to the common ideal of serving birthing families? Excluding people discourages further education for those who need education; it discourages normative changes in behavior and protocol of those who are already out of the loop. Remember, honoring diversity is not the same as condoning malpractice, AND excluding uncertified midwives is not the same as preventing malpractice! It only reduces the chance that we can learn from each other's experience just as those who promote separation between CNMs and direct-entry midwives, and midwives from OBs, have effectively reduced the real exchange of information that would most truly serve birthing families.
Let me give you one example of how renegade midwives have contributed to midwifery in the last 20 years. In Boulder, Colorado a "renegade midwife" did waterbirths before anyone else did them. She was considered wild and bizarre ("If babies were meant to be born in water, God would have given them gills"). Yet several years later, all of the "more legitimate" midwives were open to waterbirth because other people had tried it long enough and now they felt safe with it, sure that it was statistically proven. BUT if no one had been weird and wild enough to try it with people, it wouldn't have been proven safe. Now it's acceptable even in many hospital settings.
I put forth that by excluding non-CPMs from MANA, this kind of healthy diversity and communication will be discouraged. MANA will be insulting Jeannine Parvati Baker, who has put endless hours into promoting gentle and loving birth. MANA will insult me--I won't become a CPM at this point in my career, although I encourage students to do so. MANA will lose the voices of many, many other wild and wonderful and even whacky midwives and future midwives. I believe that we can find a way to promote and honor the structures we've created without losing those voices.
None of us were CPMs when MANA began and many were illegal. We could have been certified as midwives if we went to CNM school. We could have practiced legally in all the states if we had done that. BUT we wanted to have another way open. Are we going to now negate those who don't choose CPM, in effect saying, "Now we did it right and if someone wants to be legitimate they should do it OUR way and join the club?" How is this truly different in process from what we were up against earlier?
Midwifery needs to maintain, honor and even promote diversity. CPM is a great credential, and I pray that some day the very women who have, in the past, been insulted by being called traditional birth attendants rather than midwives by the ACNM will not turn around and do the very same thing to other practicing midwives by excluding their legitimacy as MANA members.
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Question of the Week
The baby of a woman who is due in two weeks has been trembling or shivering quite hard several times a day for a week. It lasts about a minute or at most two, and is unpredictable as to when it occurs. She saw her OB several days ago and he has no idea what it might be. The baby's heartbeat was in the 140s and she was not shaking during the appointment. The OB did not seem overly concerned about it. The mother thinks the baby is having seizures. She is certain it is not hiccups because the baby also gets those daily and the mom can identify them. As a doula I have worked with many women over the last 17 years but I have never run into this. Any ideas?
- Eileen Ryan Maryland
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Question of the Week Responses
Q: 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
A: Depending on the individual woman's anatomy, the uterus may be pinching off part of the urethra in between itself and the pubic bone. I have dealt with one woman who experienced the same thing later in pregnancy twice. The first time she was catheterized and the second time we tried 200c of homeopathic Sepia and that worked extremely well.
A: Displacement of the uterus may be the problem. A retroverted pregnant uterus can completely fill the pelvis. The cervix is then drawn up toward the pelvic brim, the anterior vaginal wall is stretched and so, at the same time, is the urethra. The urethra becomes narrowed and the mother is unable to pass urine. As the fetus grows, possibly the cervix is lowered, taking the pressure off the urethra. The UTI may happen because of poor aseptic technique when catheterisation is carried out.
A: It might be an incarcerated uterus, caused by having an enlarging retroverted uterus. I understand that this tends to happen a little later in pregnancy. Maybe she has fibroids. If this is the problem an OB should know how to fix it by shifting the uterus back into place, and possibly placing a pessary to keep everything in place till the uterus becomes too large to become incarcerated again.
- Angela Cross
A: I have had two women in the last seven years who had urinary retention which was the result of a retroverted uterus that was cutting off the outlet of the urethra. Both did hands and knees about two-three times per day for about 20 minutes and voila-no problem.(We were just waiting for that uterus to lift itself up and over and stop kinking the urethra.)
- Mary Hogan-Donaldson, CNM
A: I have found that, if the uterus is retroverted, as the enlarging uterus pushes upward the cervix often ends up under the symphysis. This put lots of pressure on the bladder, and may prevent it from emptying completely. I have instructed my patients to do knee-chest pelvic rock exercises at least twice a day from about seven to 10 weeks gestation, or until the uterus has lifted up out of the pelvis. It has worked well.
- Marilyn Osborne, CNM
A: Is there any chance that her bladder may be getting trapped under the uterus? This is rare but can happen and makes mom have the feeling that she needs to urinate but is unable to. To correct it, the doctor/midwife needs to push mom's bladder out of the way and allow the uterus to come down.
- Holly U.
A: Urinary retention in pregnant women is very common, especially around the 12th week. The position of the uterus (anteverted/retroverted) can affect how well the bladder can fill/empty as it is around this time that the uterus enlarges just enough to encumber the bladder enough to affect flow. It is much less common after 12 weeks as generally the uterus has enlarged enough to be palpable just above the pelvic brim, so therefore does not encumber the bladder any more. Sometimes encouraging women to assume a forward-leaning position when trying to void may help. However catheterisation is generally the anticipated management (unfortunately).
Urinary tract infections are also common in gravid women due to hormone changes causing relaxation of the tubercules/ureters so kinking is common as is urinary stasis. Women who experience UTI when not pregnant seem to experience UTI when pregnant too. Increasing fluid intake of diuretic known fluids/herbs may help maintain good bladder maintenance as will regular exercise.
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 for Midwifery Today magazine
Midwifery Today Issue No. 57 (Theme: Cesarean Prevention/VBAC)
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More on birth rituals:
You wouldn't believe the birth rituals that have taken place in some countries of the world. Do you know they actually cut women open to get the baby out--in some countries for 25% or more of births? They even give a lot of drugs to the mothers in some places. Can you imagine? In some countries they don't wait for labor to start--they "induce." In some places they even cut the mother's birth canal which sometimes rips into her anus. In some countries they even separate the mother from the baby after birth. They put the newborn down the hall in a plastic box all by itself. Can you even imagine such a ritual? In some places mothers don't even breastfeed their babies. Can you imagine?
- Jan Tritten
How odd that they would wash the baby's hands so thoroughly at birth [Issue 2:44]. We know from recent research that newborns placed on their mother's belly, dried and covered or in a warm room, will spontaneously crawl to her breast and latch on within an hour of birth. Along the way, the infant will suck its hands, still bearing the taste and smell of the amniotic fluid. This helps the baby find the breast, which emits a similar odour/taste. A baby from whose hands the amniotic fluid has been thoroughly removed will need good luck to find its way to its mother's breast without nature's clues!
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.
Dear aspiring/practicing midwives and aspiring/practicing preceptors,
I don't even know if anyone has estimates of the current number of preceptors and apprentices, and if those numbers are growing or dwindling. How would we find such information? My sense is that there is a need to promote preceptorship. With midwifery schools forming, many assume that midwifery education is taken care of. Apprenticeship needs some kind of institution to give it equal standing and voice with the other institutions we have created: MEAC and NARM. Apprenticeship is the heart of homebirth midwifery! We must nurture apprenticeship as much as create certification and schools or we'll have lots of aspiring midwives and half-trained midwives but not so many practicing midwives. Please contact me if you wish to help get something going along these lines.
Blessings on all midwives (not just CPMs and CNMs),
I am an expectant mother who is going to September Hill Birthing Center,
an extension of Schuyler Hospital in Montour Falls, NY. The hospital's
new CEO, Don Lewis, has decided to close down the ONLY birthing center
in the region. I am asking for help to keep September Hill open.
- Wendy Sutterby
I have always thought that we do things backward by seeing women once a month until they are farther along in pregnancy, etc. It makes more sense to me to see women frequently during the first and second trimester of the pregnancy. This allows us to establish a communicative and loving relationship early on as well as guide the woman in terms of good nutrition, one of the corner posts of good care.
I am interested in your response to the recently published study in The Lancet that appears to make the vaginal breech a lost art and viable choice of the woman who delivers outside the developing countries.
- Susan M. Haas CNM
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