November 22, 2000
Volume 2, Issue 47
Midwifery Today E-News
“Down Syndrome”
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THIS WEEK'S ISSUE

Contents:

  • Quote of the Week
  • The Art of Midwifery
  • News Flashes
  • Down Syndrome
  • Check It Out!
  • Midwifery Today Online Forum
  • 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:

"Everything that happens after delivery is the outcome of preceding events."

- Sheila Kitzinger


The Art of Midwifery

Always test beforehand any preparations you might choose to use on a woman's perineum during birth. You don't want her to get hives on her perineum from an allergic reaction--it would be worse than tears!

- Midwifery Today conference Tricks of the Trade circle

Doula tip of the week

Bring a digital camera to births so you can send pictures immediately online to family members.

- Holly Disnbeer, doula, childbirth educator, RN

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News Flashes

Suggestions that the risk of having a child with Down syndrome is linked to the number of pregnancies a woman has are false, according to a study from Australia. Researchers studying the data of all births between 1985-86 and 1986-87 found no link between the number of live births, pregnancies, and previous miscarriages. Maternal age remained the most important risk factor.

- British Medical Journal, 317:7163


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Down Syndrome

Editor's note: Because there were such interesting and varied responses to last week's Question of the Week, we are dedicating this issue of Midwifery Today E-News to Down Syndrome.

Down syndrome (DS) is a chromosomal disorder occurring in about 1 out of every 800 births. People with DS may have mild to severe learning disabilities and physical symptoms that include a small skull, extra folds of skin under the eyes, a flattened nose bridge, and a large, protruding tongue. Muscle tone throughout the body is usually low. The condition was formerly known as "mongolism" because the features of people with Down syndrome were thought to resemble those of Mongolian Asians. This term is now considered offensive and inappropriate and is no longer used.

DS results when a person inherits all or part of an extra copy of chromosome 21. This can occur in a variety of ways, the causes of which are unknown. The most common chromosomal abnormality that produces DS (accounting for about 95 percent of all cases) is Trisomy 21, a defect in which an extra, third copy of chromosome 21 is present in every cell in the body.

Two other chromosomal abnormalities cause Down syndrome and occur in about 2 to 3 percent of all cases. The first, translocation, takes place when a child inherits a small, extra piece of the 21st chromosome that is attached to another chromosome. If, in addition to the translocation, two normal 21st chromosomes are also present, the person will have some of the features of DS. If there is only one normal 21st chromosome, the person will not display symptoms but the children may inherit Down syndrome. Mosaic DS results from a second type of chromosomal abnormality in which only some cells in the body have an extra chromosome.

People with DS are subject to a variety of medical conditions. Heart abnormalities that may require surgery are present in about half of all DS cases. Thyroid problems (underproduction or overproduction of thyroid hormones) affect 10 to 20 percent of people with DS, but these problems respond well to treatment. The risk of acute leukemia is somewhat increased, although treatment is successful in the majority of cases.

- excerpted from "Down Syndrome," Microsoft(r) Encarta(r) Online Encyclopedia 2000
http://encarta.msn.com (c) 1997-2000 Microsoft Corporation. All rights reserved.

====

Abnormal levels of maternal serum alpha-fetoprotein (MsAFP) alone may identify 10% to 20% of Down syndrome babies. MsAFP may also be used in a triple screen combination with estriol and beta-human chorionic gonadotropin values to detect Down syndrome more accurately, but still missing about 30% to 40% of cases.

According to one source, in 1,000 maternal serum alpha-fetoprotein (MsAFP) tests, approximately 950 women will have normal results. Of the remaining 50, 48 to 49 will have false positive tests and normal babies. This leaves 1 out of every 1,000 with a defect. (Blatt, 1988) Another source predicts that out of an 8% positive test rate, 6% will have lower results and only 2% of those babies will have Down syndrome. (Meagher, 1993) The principal conditions associated with false positive values are multiple pregnancy (60% of twins and nearly all triplets have elevated results if judged as for a singelton pregnancy), threatened miscarriage, underestimation of gestation age (MsAFP normally increases as gestation advances), small-for-dates fetal growth, or a sample contaminated with fetal blood (which might occur after a fetal death). However, women who are carrying perfectly normal singleton pregnancies may show a false positive result as well. Maternal liver disease or alcoholism may raise levels.

- Anne Frye, Understanding Diagnostic Tests in the Childbearing Year 6th ed., Labrys Press 1997.
References:
Blatt, R. (1988). Prenatal Tests: What They Are, Their Benefits and Risks and How to Decide Whether to Have Them or Not. New York: Vintage Books.
Meagher, K, genetics counsel, Kaiser Sunnyside Medical Center, Portland, OR. Editing comments, 8/6/93.

====

Newborns with Down syndrome have an increased risk of having a condition called transient leukemia (also called transient abnormal myelopoiesis, transient blastemia or myeloproliferative syndrome). This condition resembles leukemia, but disappears on its own without treatment in just a few weeks or months. One researcher found that up to 10% of newborns with DS had evidence of transient leukemia on blood tests. On the blood test, the number of white blood cells is greatly above normal and there are immature white blood cells ("blasts") present in the blood as well. While this condition resolves without treatment, the concern is that there is an increased risk of these infants to develop leukemia later in childhood. In one study of 85 infants with transient leukemia, 30% went on to develop a type of leukemia called "nonlymphoid" (also called "myelocytic," or AML) within the next 3 years. The reason for the development of transient leukemia isn't understood but is definitely linked to the extra 21st chromosome.

Leukemia is more common in children with DS, being seen anywhere from 10 to 30 times more often than in the general population of children. The vast majority of cases occur in the first 5 years of life. In the first 3 years of life, nonlymphoid leukemia is the most common form of leukemia in children with DS; after age 3, approximately 80% have acute lymphocytic leukemia and 20% have nonlymphocytic leukemia.

There are also functional defects of white blood cells in Down syndrome. White blood cells in people with DS have a decreased response to infection and a decreased killing ability of microorganisms. This may be one reason for the decreased immunity to infection seen in children with diseases of the blood and Down syndrome.

- Dr. Len Leshin, MD, www.ds-health.com/hemat.htm


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Question of the Week

I have a client who has been diagnosed with varicose veins in her vulva. Can anyone give me suggestions on how to help her with this?

- Chrys Holland, doula/massage therapist

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Question of the Week Responses

Q: I recently attended a birth where both the primary midwife and myself suspected that the baby had Down syndrome because of low ears and other facial features. How do other midwives handle situations like this? All parents want their child to be perfect, so how do you approach this topic in a supportive, caring and helpful manner? And what do you look for when trying to rule out something like this? Down babies have such a distinctive look, but what if we were wrong and caused undue stress for the parents?

- Shannon, student midwife

A: Tell them the facts without diagnosing. Start with something positive. For instance you could say, "Your baby looks very healthy, good color, good heart rate and rhythm, lungs are fine and clear. The ear cartilage looks like 40 weeks, but I notice the ears are set a little lower than usual. That may be a coincidence but is sometimes related to a chromosomal defect, especially when (here name any other signs) are also present. If it is trisomy disorder, often these visible abnormalities are accompanied by other internal abnormalities including heart problems. But before we jump to conclusions, it may be a good idea to have (name baby) checked out by a pediatrician, then we would know for sure.

I have never had a trisomy 21 (Downs) baby, but I have had a trisomy 13 baby who lived 3 months; those defects were quite obvious at birth. Unfortunately there was no way to gently ease the parents into the reality. I have also had a baby with severe hypospadias. This baby also had only 2 umbilical vessels. At the birth I simply pointed out that the two things might be related and may signal other internal problems. This couple does not have insurance. They know there is a possibility that the baby has only one kidney, but they have chosen not to do an ultrasound to find out at present. They are praying for guidance as to the right course of action (or inaction) to take. I am giving them time to adjust to the situation, even though I would really like to know exactly what's in there. This is just one more example of the patience it takes to be a midwife!

A: I had a birth once where the baby also looked like it had DS (low-set ears, etc.). I made sure it was checked by a doctor in the next few days. It turned out to be fine and I was glad I didn't say anything to the parents about it.

- Lisa Hines, LM
South Carolina

A: Several years ago I had been called to a DOMINO* delivery for a lady I had cared for throughout her pregnancy. Because of religious beliefs, both she and her husband had opted not to have any foetal screening tests. The labour progressed quite quickly and uneventfully. As baby's head delivered all still seemed perfectly normal. It was only when the babe's body was delivered that I suspected Down's may be a possibility; there being a short cord, small genitalia, and crooked little fingers. Both parents were overjoyed that they had a son (they already had a little girl). How would I tell them? When I gave the babe his full post-delivery examination I realised his facial features were also indicative of Down's. He also had single palm creases.

I found that being perfectly honest with the couple about my suspicions was the best way of dealing with the situation. I also had faith that the paediatrician on call that night would be able to handle the situation with sensitivity and tact, as nothing would be confirmed until a chromosome analysis had been carried out. The doctor handled the whole situation brilliantly. The couple were happy and said that they would love their little boy even if tests confirmed our suspicions. I left the couple alone with their son to make them tea and toast.

Unfortunately a slightly senior paed. happened to visit the labour ward at this time and had decided to take a look at the baby. When I returned to the room I found this doctor proudly telling the parents that the baby almost definitely had Down's syndrome. I was horrified; all the good work had been undone. The mum's face just crumbled but she had enough presence of mind to ask this doctor to leave at once. I took the baby from the paed. handed him to his mum, followed the doctor to the office and gave him a piece of my mind. The doctor stormed off the labour ward. I stayed with the couple until mum was transferred to the postnatal ward. The next day I went to visit mother and baby on the ward, and mum informed that the doctor had been back to apologise!

Yes, the baby had Down's and he grew into a lovely little boy. Within two years his mum had another baby, this time a little girl whom she delivered at home.

- Alison Andrews
UK

*Note for U.S. readers: A DOMINO is a birth in which the mother delivers at the hospital but returns home shortly after the birth. She is then provided ample support in the home by a trained professional.

A: In the past year my mentor and I have had three Down babies born in our practice. Each time we knew right away and agonized over telling the parents. It is true that you must be up front with them--it is their baby, after all. But at the same time you don't want to cause undue stress if you misdiagnose. Prayer was the first step--asking God to help convey the message with grace. Usually our next step is to tell the father our suspicion and work with him on when to tell the mother. One of our moms was having her third and probably last baby, first homebirth and homebirth had been her dream. She had all her friends around her to support her and was on top of the world. The dad decided to wait for a while (at least until everything calmed down) to share his information. This way she got to relish those first few hours without worry. As it turned out some of the typical signs of Down like low ears and the crease on the hands were traits actually shared by the father, so this family was still in doubt until they got all their lab results back. It's true everybody wants their baby to be perfect, but it's also true that a family will fall in love with the baby they are given. After all, Down babies are as much of a gift as any other.

- DEM
North Carolina

A: The diagnosis of DS needs to be made by a pediatrician or neonatologist based on many things. It is not unheard of for a baby to look like he may have DS and to have the family members all say that he looks exactly like a sibling or like one of the parents did as a newborn. I would not say anything until I had a chance to consult with an MD or NNP about my suspicions.

I delivered a baby girl last year who was born and placed immediately on her mom's chest. Mom, dad and baby all had a little while together to become acquainted. It wasn't until later when the baby was in the warmer that we even noticed there was a problem. I was grateful that mom and baby had a little while together before they began a life of many obstacles and challenges.

- Maggie, CNM

A: Five years ago a couple I was caring for gave birth to a beautiful little girl, breech presentation, at home. She was well at birth but a little floppy and with strong DS characteristics. It was my intuitive response to say nothing at the birth or for the first four hours until I left to return for an afternoon postnatal visit. The baby had suckled well and all her vital signs were good. It was their fifth child and second homebirth.

The next day the mum commented that the baby was very quiet and undemanding but suckled well when offered the breast. I examined the baby in front of her mother and again it felt to me it was better to wait until this mother came to her own conclusions.

Another day later when I asked her how the baby was, she said, "You seem a bit concerned about baby." This gave me the "permission" to be honest with her. I showed her the baby's characteristic features of DS and said I wondered if T. had Downs. She nodded and said yes, she thought so, too. We talked about finding out. She was adamant about not going to hospital or doing anything at that point. The baby was well so there was no need to do anything clinical. It had been Easter weekend and Tuesday would be the first working day. She thought she might go to her GP then. She rang her homebirth midwife sister-in-law in another state whose response was "Emma would not have suggested this to you if she wasn't reasonably sure" and affirmed what I had told her about needing tests to diagnose.

When she told her husband on Monday he was angry and didn't want me to visit again. We arranged that I would go when he was out. On Tuesday she decided not to go; she wasn't ready. I felt a little anxious, but talking with a colleague affirmed what I felt--that nothing would change anything; the baby was well and it was the mother's right to find out in her time. I felt it was emotionally much healthier for her to assimilate this enormous experience herself.

She and her husband finally went to their GP on Friday when T. was one week old. He was furious and read them the riot act about homebirth, etc. She was amazingly composed and confronted him, asking what difference would hospital birth and earlier diagnosis have made? He arranged for a paediatric consultation that afternoon. (In Australia a GP has to refer patients to a specialist). The paediatrician handled it all fairly badly, was angry about the "late diagnosis," and furious about the homebirth and me. He said he was going to report me to authorities, etc. Again she asked how it could have made any difference and tried to get him to hear her story. Perhaps he did because nothing happened to me about this case except that the paediatrician can still barely bring himself to say hello whenever I see him.

Two weeks ago this mother was a doula at a friend's homebirth with me. Her daughter is doing well, is integrated in the regular school system, and is a present and a happy beautiful little girl. The mother has often told me how important it was for her to have control and make her own choices.

Often I think we practitioners can act out of fear of reprisals from colleagues. However, all women and infants deserve unconditional love and respect and I believe honouring them is my first priority. Continually "holding the space" for them to step into is how I define being a midwife and therapist.

- Emma Baldock, independently practising midwife, RN, RM
Canberra, Australia

A: The first thing to do is show the parents all the perfect things about the baby--ten fingers and toes, beautiful eyes, etc. This is extremely important in children with very visible abnormalities such as a cleft lip. I then say that I am a little concerned about (blank) and show the parents what I mean. If the defect is clearly visible, I identify it by name and reassure them (if I'm sure) that there are good treatments for this. I then emphasize that their baby is no different from others in that (s)he needs a lot of love, caring and unconditional love. I then assure them that together we will find the answers and walk down this unexpected path. My experience has been that when I am suspicious of something, so are the parents, so stating my concerns rarely meets with astonishment. We also must acknowledge that there will be a grieving process for the dream they had for their family which now must change as well as for the "perfect child" which isn't. Supporting parents through this (instead of subtly reinforcing society's silence about this loss) will be perhaps your most important work in this family's life. Also, I have never had a family mad at me when my suspicions proved wrong and their child is fine.

- Lynette, family doc

A: I have looked after two women who've had DS babies. With the first woman it was her fourth baby; within the first 24 hours she realised herself that the baby had DS. She was distressed when the results were confirmed by telephone (by the specialist) rather than in person. Even though one "knows" something it is still a shock when it is made "official."

The second one was much harder as the mother was a teenager with a history of depression. The birth was at home, and the baby was born in good condition. I suspected immediately. I spoke to midwife colleagues and a GP for their advice and I went to the Internet for DS info. I decided to wait for her to bring up the possibility. In retrospect I think it would have been better that it was brought up earlier, not least due to the probability of lethargic baby and feeding difficulties, but because these babies frequently have heart conditions. This particular baby was very healthy and gaining weight by 12 days. The mother is pleased that she had the first weeks without her baby being labeled. One of the reasons I chose to wait was the stories of women who had been told at birth and who went into shock. I didn't want the bonding process interfered with. I think it is a balance of honesty, good timing and individual circumstances.

- Anon.

A: When a couple receives their newborn they are first and foremost engaged in bonding and making the baby part of the family, enjoying the miracle of birth and taking in all the new sensations. Mothers' instincts are usually quite sensitive when it comes to the welfare of their baby, unborn and just born and beyond. By focusing on the baby's "problem" and presenting it as such you are affecting that initial impression time that is so crucial in the relationship between parents and baby. If a baby was born with a physical deformity such as digit malformations or obvious birth marks, the "need" to discuss this with the parents would probably wait until the parents discovered it. Why make it any different for the DS baby? Unless there is an obvious life-threatening situation with the baby that would require discussing the probable diagnosis in order to begin treatment, then let the parents guide your timing and depth of discussion. When that time comes I feel honesty is the best policy; and unless you are 100% sure of the diagnosis, wait until you are sure before labeling the baby. After all, there is no urgency and the condition will not change. The baby deserves to first be recognized as it is: a miracle.

- M. Jordan CNM
California

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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. COMPOUND PRESENTATION: What do you do?

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QUESTION OF THE QUARTER for Midwifery Today magazine

Issue No. 57 (Theme: Cesarean Prevention/VBAC)
How do you prevent cesareans?

Deadline: Dec. 15, 2000

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Know a strong woman? Helping empower one? If you haven't so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

More on Vitamin K:

I sent in the original question regarding vitamin K shots. It seems to be something most people accept as necessary and assume it has no bad side effects. I find it hard to believe that God goofed by not having babies born with vitamin K stores. Could there be a reason that our blood is not supposed to clot so easily in the first week of our lives? There's also a lot of research that's shown that breastfed babies are at higher risk since breastmilk doesn't have the same amount of vit K that formula has. I wonder what, if any, the underlying causes of hemorrhagic disease may be, and if it's not being studied that much because the vit K shot seems to prevent any problems. The assumption that all babies need a vitamin K shot seems to go against the belief in the birth process and the superiority of breastmilk over formula. By "birth process" I mean the belief that women had been having babies for many years without their babies getting this shot. I would be more likely to accept vit K if there was a test that showed which babies were at risk rather than the blanket assumption that we're not born with what we need to survive and that breastmilk is inadequate.

- Anon.

I was especially intrigued by Phil Watters's stat of 1 in 3,000 babies deveolping HDN. I am not currently informed of the stats and having accurate info on appropriate treatment would be great. Also, is there still a link to rare childhood cancers from IM Vit K?

- Amy Jones

None of my four children have received the vitamin K shot but my midwife is getting some flak from some of the pediatricians about her patients not accepting it. I was wondering if anyone knows what else is in the shot. What are some of the preservatives? Is there any known documentation about babies receiving it and still having problems?

- V.S.

I was interested in your ongoing discussion on HDN. It seems that if you are a care provider who hasn't experienced HDN in your own practice or in your midwifery community, you may believe that it is so "rare" that the babies you care for will never succumb to such a disease. At least this was my position (or attitude) before we had two HDN cases reported in the midwifery/homebirth community in 1999. (see California Association of Midwives News, Summer 1999) One baby is now severely brain-damaged because of the cerebral hemorrhage and the other is blind. The other unfortunate situation was that the midwife in the case of the brain-damaged baby had a suit brought against her because the parents didn't feel that they had received adequate information to make an informed choice in declining the vit. K.

After this incident, I began making oral vit. K available which has addressed the understandable concerns of most parents of not wanting their baby to get the injection.

- Kimberly

Editor's Note: The coming issue of Midwifery Today (#56, Winter) focuses on vitamin K and features research and comment by Sarah Wickham, MA, BA (Hons), RM.

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More on Premature Rupture of Membranes (PROM):

If a woman's membranes rupture, she is healthy and the baby is well, I do not intervene. In 13 years of homebirth practise I have never seen a woman or baby with an infection. I rarely perform vaginal examinations in labour and certainly not in pregnancy. There seems to be no accounting for the invasive and violating effects of VE no matter how sensitively it is performed. I want women to stay in touch with their birth canal during labour and birth, so avoiding any procedure which may encourage them to "split off" is very important.

Ten years ago I cared for a woman whose membranes leaked from 36 weeks. Her elderly experienced GP obstetrician advised her to report if she was unwell, had a fever or any changes she felt with the baby. She also told her husband to have a sniff "down there" and if she smelt good everything was OK! She went on to birth a 10 lb 12 oz baby one week past term! There was plenty of liquor in spite of her leaking all day and night. Liquor is continually made and has a cleansing effect, so keeping examining fingers out of women's vaginas is the best course to prevent infection.

A younger obstetric doctor I respect recently questioned whether leaks might be an osmotic process when the membranes are stretched. Many multiparous women could be walking around quite dilated for weeks before the onset of labour.

- Australian independent midwife (CNM)

My first baby's waters broke at 6 a.m. Wednesday morning, my due date, but no labor began. I was in touch with my midwife all day, and followed all her hygienic rules. Labor did not begin until 2 a.m. Thursday morning and our daughter was born at 12:20 p.m., over 30 hours since my waters broke. Thank G-d by being home I avoided a cesarean because she was also born face first.

Six weeks before the due date of our second child, I fell off a stool (yes, it was silly that I was up there!), and my waters broke. I refused to go to the hospital, so my midwife came and monitored me for three days. Though contractions initially started after I fell, with total bed rest and drinking lots of water (plus taking echinacea and vitamin C), the contractions stopped and the amniotic bag sealed up. Our son was born six weeks later.

During my fourth pregnancy, after over-exerting myself with some housecleaning, my waters broke one month early. I went right to bed for three days, drinking a lot, not lifting, etc. and the pregnancy continued uneventfully. The body heals back up if given a chance, and babies are born fine if you stay away from the germ-laden hospital and all its invasive procedures that introduce bacteria.

- Anon.

Recently we have experienced several episodes of very, very clear fluid released from mom, who thinks her water has ruptured. This fluid in many circumstances has 500 cc quantity or more and leaks and trickles just like SROM only it is crystal clear--no cloudiness, no particulate vernix, no tinge. And in all cases we have found further in labor a bulging bag of water that ruptures and presents itself as "normal" amniotic fluid. We have ruled out hydrorrhea gravidarum as it directly precedes labor, sometimes by several days. In these three circumstances the chorion was stretched greater than the amnion. We experienced these three circumstances within three weeks of each other. I'm curious if anyone else is experiencing this super clear SROM only to find a truly big BB of water--or is something strange in our water?

- KJ

I am very interested in the use of continuous epidural infusions versus top-up epidurals. I am a UK-trained RGN and midwife with varying experience on the delivery suite and in the community conducting homebirths. I have recently returned to the UK from working in Singapore. After working on a very busy delivery suite of 16,000 deliveries a year I was interested in their epidural rates and also their use of continuous epidurals. I was amazed how effective they were in controlling pain relief in labour, the reduced assisted delivery rates, reduced fetal/ maternal distress and also the reduced amount of work load for the primary midwife. Once the woman was fully dilated the hospital's policy was to switch off the infusion and await events. In nearly all the cases I was involved in the epidural still managed to give effective pain relief throughout the 2nd and 3rd stages.

I would be grateful if anyone could send any thoughts or experience with managing continuous epidurals as I want to approach this subject with my manager and colleagues at my hospital in Staffordshire, UK. Any research would be very helpful.

- Claire Ashworth

====
In response to the suggestion that urinary retention may be a hormonal problem [Issue 2:46]: Progesterone relaxes smooth muscle. The bladder is not the same as uterine muscle anatomically nor in its hormonal response or innervation.

- Phil Watters

====

More on Group B Strep (GBS):

During my fourth pregnancy I tested highly positive for GBS. We tried several natural remedies to eradicate it, including silver taken orally and various douches. IV antibiotics during labor was not an option at home, and we doubted we would have time to get them at the hospital if we delivered there--I have a history of short labors and was told you need two doses 4 hrs. apart during labor. We did not want to go to the hospital to receive IV antibiotics and then be induced. So we prayed like crazy that God would allow the baby to be born "in the veil" so that no bacteria could enter his eyes, nose, etc. as he passed through the birth canal. The labor turned out to last 1-1/2 hrs. total, and the water broke as the head was birthed! We monitored him closely for symptoms of GBS disease, but he had none. We credit God and the intact membranes!

- Paula

Re: Anon's concern in her community that antibiotics start at 18 hours for PROM [Issue 2:46]: I have not read the CDC's guidelines, but in my community there are doctors who are comfortable with starting antibiotics with the start of active labour if the membranes have been ruptured more than 18 hours. Certainly as midwives, we provide women a choice of starting antibiotics right away or waiting. Most women prefer to wait. There is a big difference between providing antibiotics at 18 hours from when the membranes ruptured as compared to providing them once active labour starts. In the latter instance, a woman could go four days with term PROM and get the antibiotics at the four-day mark.

I understand not wanting babies to die from GBS. It is a frightening and confusing issue to deal with in pregnancy and birth. But are the practitioners in your community so frightened that they misunderstood the intent of the timing of antibiotics?

- Shawn Gallagher, R.M., C.Ht
Toronto

====

Way to go Luisa Lucero! [Issue 2:46] I'm a hospital-based midwife and I'm sick of being treated like a second-class citizen by my e-colleagues. As Luisa says, not all women have a choice in birth place and some actively choose hospital birth. It's their birth, not mine. I give them all the information and support in the choices they make. By the way, my practise includes optimal fetal positioning and baths. Give us a fair go!

- Anon.
Australia

I've gone through a lot of misery trying to be the most perfect wife/patient/client/mother that I can be, and it's so refreshing to hear other people take a more moderate position--not left or right, but respectful of everyone. I agree with the most natural approach possible for myself. Personally, I'd have to be given a darned good reason to go anywhere near a hospital if I become pregnant again. I've experienced hospital birth (c-section), homebirth with transfer, homebirth (normal?), and a breech homebirth with no complications. Although it saddens me to hear of so many women experiencing the potential horrors of hospital birth, isn't the most important thing to allow a woman to choose the place of birth and the practitioner, or none, who she feels the safest with? As much as I wish I could tell every pregnant woman of my experiences so that she can avoid my mistakes and experience birth as joyous, beautiful, and fulfilling, most women will never even realize there is an option. Even if they do, if they just don't feel safe at home, for whatever reason, is that really the best place for that individual to birth?

The pressure upon moms and expectant parents is enormous! Every single person in the world, it seems, has an opinion and is only too happy to express it. Please, let's come together in an atmosphere of support for each other's personal choices, and stop fighting with one another. Let's save our collective energy for the policy makers and work to change public opinion in open forums, not berating innocent women for the differing, but loving, and committed choices they make! All of us have made decisions that someone disagreed with. Does that mean we or they were wrong? Sometimes, but that is how we learn, and that is the best thing any of us can do for ourselves!

- Erin Hildebrandt

A non-technical response in reference to the pregnant woman in her ninth month, with appearance of prolapsing uterus and passing of mucus plug: No, it is not simply the fact that it is her "third pregnancy" (which the obstetrician claimed) that is causing the lowering of the cervix. I know several women over 40 years of age who have recently given birth to their eighth or ninth child who have no such "third pregnancy" symptom. There are several other possibilities, usually not dangerous (such as, if the baby is already hanging around in a descended position, that pressure can be bringing the lower segment of her uterus down. Or some women could have more softening of the ligaments).

To tone the muscles of the vagina and position of the uterus, it is never too late to begin Kegel exercises! There are midwives who would have recommended nutritional support such as supplements of extra folic acid (part of the B vitamin complex) and also vitamin E. Calcium with magnesium also helps strengthen the uterus, and these days it is available in highly absorbable water-soluble supplements. Raspberry leaf tea has been particularly helpful. I blend other strengthening herbs such as alfalfa and blessed thistle.

In my experience it is normal for a woman to lose her mucus plug and not go right into labor. Toward the end of pregnancy, the hormones that cause the cervix to ripen and soften in preparation for birth can also inspire some dilation, usually more so in multiparas (and this is the part that could have something to do with it being her third pregnancy) as a normal effect of childbearing. Yet I have also known women whose cervixes remained firm and tight until they began labor contractions in a notable rhythm. Out of my own five births, with the second through the fifth baby, I was dilated between one and a half to three centimeters for two weeks before going into "actual" labor (membranes did not rupture until after regular contractions began). The hormone release during those weeks gave me a calm, aware, spiritual feeling in preparation for birthing and affected anyone who was around me. Of course, I did not want to allow those who would try to direct fear or negativity toward my natural "flow" to be near me and my unborn baby.

Each pregnancy and birth is going to be different. Although many aspects can be the same, each of us is affected by the changes in unique ways. Educating ourselves is very important. Healthy nutrition and exercise are always major factors, along with attitude. For a good boost toward confidence in one's own abilities, a pleasant book to read might be "Birthing From Within" by Pam England & Rob Horowitz.

- Julia

====

I am researching different forms of management of third stage of labour. It seems that every doctor and midwife has a different view on how third stage should be conducted. I am talking about following a normal birth with no drugs, baby breathing at birth, no signs of haemorrhage.

I am particularly interested in the use of oxytocics (Pitocin, ecbolic, Syntocinon, Syntometrine, etc). It is common practice in Australian hospitals to administer Syntometrine as soon as the baby is born and then deliver the placenta by controlled cord traction. This is the usual obstetric dogma. In birth centres, physiological third stage is offered to women, and the Australian belief is that no interference at all should occur unless there is excessive bleeding. I have heard that in the U.S. the placenta is delivered by controlled cord traction soon after birth, and Pitocin is only used after delivery of the placenta: this is the exact opposite to what is taught in Australia. I would be very interested to know the average length of third stage when it is managed this way. Also, I would love to hear from hospital midwives about the protocols they are expected to follow and how long it is reasonable to wait for delivery of the placenta. Protocols that are based on research would be greatly appreciated (e.g. have there been any studies on comparing the incidence of postpartum haemorrhage as a result of Pitocin after birth of placenta versus before?). If you have a hospital protocol for third stage, is this evidence-based, or just the chief midwife's or OB's beliefs?

I would also love to hear from homebirth midwives and their practices regarding third stage.

- Marianne

====

My due date is Feb 5, 01. This is my second child. I have developed an inguinal hernia on the right side of my pubic bone and also have a few large patches of varicosities on my right lower thigh which are sometimes painful. I have started to wear a maternity support brace to help with the pain of the hernia. Ultrasound has shown that the baby is measuring average.

My questions are:

Have you encountered others with a hernia during pregnancy? Is there anything I should or shouldn't do? How could this affect my delivery, particularly the pushing stage, which I am assuming will create a lot more pressure?

I have a 50/50 chance of developing gestational diabetes again for this pregnancy. I have a strong family history of diabetes. Fortunately I was able to control it by diet only for the first pregnancy and my son weighed 7 lbs 4 oz at birth.

I am looking for any advice/thoughts for proper monitoring of the diabetes and baby's health/growth.

- TLK
Canada


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