April 18, 2001
Volume 3, Issue 16
Midwifery Today E-News
“Active Management of Labor”
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International Cesarean Awareness Network (ICAN)

International Cesarean Awareness Network (ICAN) presents its 2001 conference: Celebrating the Gift of Birth: Empowering, Embracing, Acknowledging
April 20-22, 2001
Radisson Hotel Cleveland Southwest
Cleveland, Ohio
A phenomenal lineup of speakers includes Ruth Ancheta, Nicette Jukelevics, Marsden Wagner, MD, Nancy Wainer, and others. For more information, see www.ican-online.org or contact Anita Woods at conference@ican-online.org or call (816) 505-0116. See you in Cleveland!

Quote of the Week:

"For me, midwifery has always been an accelerated course in spiritual growth."

- Lynn Baptisti Richards


The Art of Midwifery

Rosehips are very high in vitamin C, which helps your body absorb iron. They also taste very good in tea. I have used them for nausea when other herbs didn't work.

- Bren Chance

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News Flashes

The Department of Obstetrics and Gynecology of the University of Texas Southwestern Medical Center, Dallas, Texas studied deliveries and newborns of 56,317 women who delivered between 1988 and 1998, to compare outcomes of those who delivered at 40, 41, and 42 weeks. Women with hypertension, prior cesarean, diabetes, malformations, breech presentation, placenta previa, or multiple gestation were excluded. During the study period, labor was induced for women who were undelivered at 42 weeks. Neonatal outcomes were similar in the three groups, including the incidences of 5-minute Apgars of less than 4, umbilical artery pH less than 7, seizures, and perinatal mortality. Sepsis was more frequent in the 42-week group than the other groups, as was admission to the neonatal intensive care unit. Labor complications increased from 40 to 42 weeks, including oxytocin induction (2% vs. 35%), length of labor, forceps use, and cesarean delivery. The researchers concluded that there is no advantage to induction of labor for postdates at 41 weeks.

- Obstetrics & Gynecology, August 2000

Active Management of Labor

The principles of active management of labor were developed in the 1970s at the National maternity Hospital in Dublin, Ireland. The basic [abbreviated] principles are: diagnosis of labor based either on painful contractions and complete cervical effacement or rupture of membranes; one hour after admission, progress is assessed and amniotomy performed; cervical dilation must advance by at least 1 cm per hour or oxytocin is started and increased until mother has 5-7 contractions every 15 mins; maximum labor length is 12 hours; a midwife stays with each woman throughout labor; the midwives manage labor, senior staff consults; induction is rare; pain medication is available but discouraged.

Any woman who did not progress at the statistical mean of 1 cm per hour dilation should be given oxytocin to correct her problem. At one stroke, her deviation from average became pathological, and a philosophical basis was created for devising a protocol to force all primiparous labors to conform to the average. Achieving this goal meant giving 40% of women oxytocin. If 40% of women need oxytocin to progress normally, then something is wrong with the definition of normal, but this point escaped the Dublin doctors.

A study of women's opinions of oxytocin augmentation [Crowther et al] found 80% of mothers said labor hurt more and over half would not want it again. Penny Simkin (1986) surveyed 159 new mothers and found that 765 of them said oxytocin drips were stressful and 46% said the same of amniotomy. Vaginal exams were rated "stressful" by 56%. Rectal exams, the norm in Dublin, would presumably be worse. For 55% and 61% respectively, external and internal electronic fetal monitoring was stressful. Restriction to bed stressed 64% of women, and restricting movement in bed, stressed 77%.

Even diehard cesarean apologists do not try to defend a 24% cesarean rate [American rate by 1986], so when active management appeared, American doctors jumped at it.... Unfortunately, the only pieces of the program that survived the Atlantic crossing were routine amniotomy, the liberal use of oxytocin, and the time limit on labor. Other parts--the continuous support of an experienced woman, that residents did not make decisions, the minimal use of epidurals (5%), the minimal use of induction (<10%), not using painful contractions as the sole diagnosis of labor--did not make it.... Moreover, the Dublin doctors expected women to give birth vaginally....

Active management may be better than what it replaces, but that proves nothing but how injurious typical obstetric management is.... Even among proponents of active management, waiting one more hour before starting an oxytocin drip led to an equally low cesarean rate and half the number of augmentations. Based on their study of amniotomy and oxytocin, Seitchik, Holden, and Castillo argue that 1 cm pr hour progress is too rigid a standard and that oxytocin should not be used until two hours with no progress. But the real point is active management is not needed at all. Midwives also maintain 4% cesarean rates simply by leaving most women alone.

Sheila Kitzinger, commenting on active management, offered insight into its hidden agenda. The medicalization of birth, she said, denies and suppresses female sexuality, which obstetricians perceive to be dangerous, threatening, and disruptive. By viewing women as defective machines to be managed on the fetus's behalf, by draining the warmth and sensuality out of the experience, by converting it to a timetable-driven mechanical process, by becoming the central figure in the drama and controlling every aspect of the mother's behaviour and activities down to the sounds she my make, birth comes to feel safe to the doctor.

- Henci Goer, Obstetric Myths Versus Research Realities, Bergin & Garvey 1995

- Crowther C, et al. Prolonged labor. In A guide to effective care in pregnancy and childbirth. Enkin M, Keirse MJNC, & Chalmers I, eds. Oxford: Oxford University Press, 1989.

- Kitzinger, S. The desexing of birth; some effects of professionalization of care; the god-sibs; what matters to women--their words. Paper presented at Innovations in Perinatal care: assessing Benefits and Risks, 9th conference presented by Brith, San Francisco, Nov 1990.

- Seitchik J, Holden AE, & Castillo M. Amniotomy and the use of oxytocin in labor in nulliparous women. Am J Obstet Gynecol 1985; 153(8): 848-854.

- Simkin, Penny, Stress, pain and catecholamines in labor: part 1. A review. Birth 1986; 13(4)227-233.

In an article on delivery after previous caesarean section, Dublin obstetrician Michael Turner comments that in 10 years the Coombe hospital had 15 cases of uterine rupture in 65,488 deliveries. Thirteen of the 15 were in women with a previous caesrean and 13 had had oxytocic drugs to induce or speed up labour. He also gives the caesarean rates for the three Dublin maternity hospitals for 1994: 12.6% at the Coombe, 16.4% at the Rotunda, and 8.8% at the National.

Association for Improvements in Maternity Services (AIMS) comment:

Without the use of oxytocin and protaglandins the risk of rupture of the uterus even after a caesarean operation seems very small-about one in 33,000 deliveries in this series, and it confirms the findings in other areas. Dublin still has women who have had large families, and therefore have a uterus more vulnerable to rupture. This study confirms our experience, that using prostaglandins and oxytocin is a major risk factor for rupture in women who had a previous caesarean.

- AIMS Journal, Vol. 9 No. 2 Summer 1997

Active management illustrates the confusion in the medical approach to what is normal and what is pathological in birth. Active management is an extreme form of medicalization in which the clock has been speeded up. If a woman's labor is not progressing at a rate doctors arbitrarily define as satisfactory, the woman is said to be suffering from "dystocia" and in need of intervention to augment labor.

A critical element of active management is the need for doctors to control the birth. Since labor is involuntary, unpredictable and out of control, the only things doctors have had any success with controlling is pain and length of labor. Active management is primarily for the benefit of doctors and hospitals, not for the birthing woman. The inventors of active management extol its "military efficiency" and ability to relieve staff from the frustration of waitng out "tedious hours." Promoters also state it allows much better planning for staffing needs.

Proponents also claim active management reduces the need for cesareans. But active management is an aggressive, invasive protocol that carries all kinds of associated risks. Other much less dangerous ways of lowering cesarean rates are readily available: use of labor companions; using midwives rather than doctors as the birth attendant; out-of-hospital birth. In fact, an entire country, The Netherlands, has a cesarean section rate as low as the hospital in Dublin, Ireland--where active management started--without resorting to active management.

Active management lacks a scientific base. It has been used for 25 years, yet not a single randomized controlled trial has been undertaken to compare active management with other methods of reducing cesarean section rates.

Ironically, the only component of active management that has been shown scientifically to reduce excessive cesareans is the continuous presence of the midwife. Yet this essential component is often ignored and many people in the United States and elsewhere attempting to replicate active management in their own hospitals fail to include this component.

And in the Dublin hospital, 40% of all women having their first baby are found to have a "dysfunctional myometrium" incapable of expelling baby without the help of doctors and drugs. But the inventors of active management have never attempted to measure myometrial activity.

- Marsden Wagner, Midwifery today Issue No. 37, Spring 1996


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Midwifery Today's Online Forum

I am in my last semester of a BSN program in the San Francisco Bay Area. Although I am doing well in the program and remain very committed to following my calling of being a midwife, I am in need of some rejuvenation.
My final clinic is L&D in an affluent, urban hospital. All the unnecessary intervention, 98% epidural rate, and "birth out of the hospital setting is unethical" lectures are beginning to sap my emotional and spiritual reserves. I feel persecuted every day for trusting birth.
I am feeling a little like an "ugly duckling"- not accepted by the other BSN/CNM students for trusting birth and not accepted by direct entry students because of the medical background. Are there other CNM and direct entry aspiring midwives who are experiencing the same tension? How have you refreshed your midwifery energy? Any suggestions or anecdotes would be a big help.
Thanks,
Charity

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Question of the Week

Q: I am a lay midwife and doula. I recently took on a doula client with a rectal prolapse subsequent to her last delivery which was a Pitocin induction, epidural, forceps to turn an asynclitic head followed by vacuum extraction and shoulder dystocia. The McRoberts maneuver was used to deliver the baby's shoulders. She was given an episiotomy. I'm not sure how deep it went, but she doesn't believe it extended. I have searched for information on rectal prolapse in my textbooks, but can find none. Does anyone know of remedies (besides surgery), possible complications (she plans to labor at home,) or any other information?

- Anon.

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Question of the Week Responses

Q: I would like to hear how midwives deal with long, long prodromal labors. In a recent birth the woman began prodroming on a Saturday evening and didn't sleep for four nights. She finally went active on Tuesday evening and got to complete on Wednesday morning. But by the time she got to complete she had no energy left to push and no urge to push. Fetal position was favorable.
Now that research is saying that morphine use in labor leads to increased incidence of drug addiction for the child later in life, I don't even feel comfortable recommending hospitalization for sleeping the mother. Alcohol was out because she began having trouble with nausea/vomiting on Monday evening, and homeopathy didn't resolve that.

- Karen, CPM, LM

A: After 24 years of practice, I have seen my share of prodromal labor. Yes, morphine works well and even a little bit goes a long way (5-10 mg.) but of course you need a doctor for this. If it is available it works wonders but the pros need to weighed against the cons, as always.

Alternative treatments:

Beer or wine (one beer usually does it, but you can increase this to two if one doesn't work)

- Hot bath, massage, dark room, no stimulation

- Effective herbs: passion flower (can cause nausea, however) valerian, hops; simple raspberry leaf tea can help "quiet" the uterus.

Prodromal labor is tiring, and can lead to mothers feeling traumatized by a long labor and unable to be "present" for their birth and their baby. As always, weigh treatment options pros and cons. But in my experience, if the simple remedies don't work and the mother is NOT able to sleep, she should be offered an effective treatment, and that certainly can be morphine.

- Jenna Houston, CNM

A: I am a hypnobirthing childbirth educator and I had a long prodromal labor at home and gave birth with a certified nurse midwife. I had been in early labor for probably close to two days when I was still only 1 cm and fully effaced. My midwife did not want me to get in the birthing tub until I was 4 cm. But when she left my home after checking me I told my husband and girlfriend I was getting in the tub. I went from 1 cm to 9 1/2 cm in less than 3 hours. (Several months later I realized that I had visualized and expected all my labor to occur in the tub-probably why I never progressed until I got into the tub). I did "lose" my pushing urge in second stage and couldn't get it back. I couldn't urinate and even got into the shower to try to stimulate it. Contractions still did not restart. My midwife suggested that she catheterize me and give me a sugar water IV because I had been complete for quite a long time (I can't honestly remember at this point--but I had the most wonderful, marvelous midwife who I completely trust and she said the baby has to come out soon or we have to go to the hospital.) When she catheterized me I was holding a lot of urine and she said I was dehydrated. When she gave me the sugar water IV my contractions (surges) were very strong and I pushed the baby out in about 20-30 minutes.

I have had first-time moms as clients who had hospital births where doctors told them after they'd labored for 24 hours that their uterus wasn't working, or they had no urge to push. I ask them how much they have been eating or drinking in the past 24 hours--it usually isn't a lot. How can we expect this very strong and powerful uterine muscle to work without any fuel? I now suggest to all my clients if this happens to them in labor, ask for a sugar water IV first, rather than Pitocin.

- Carol Wiener Marks
Pacific Palisdes, CA


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~*~*~*~*

International Connections

~*~*~*~*

PARIS (April 12, 2001 3:24 p.m. EDT http://www.nandotimes.com) Some 1,000 French midwives marched to Prime Minister Lionel Jospin's residence Thursday demanding higher wages and greater recognition of their qualifications. The midwives had declared Thursday a "day without midwives" in maternity, mostly symbolic because the strike affected mainly consultations, not births. The protesters, clad in pink and white medical smocks and some carrying plastic babies, chanted: "Push! Push (up) our salaries!" The midwives began nationwide protests March 20 after the government announced a monthly pay increase of $40 for novice midwives and $250 for their more experienced colleagues. Midwives currently earn a monthly salary ranging from $1,280 to $2,000 based on a 39-hour work week. They say they deserve higher pay that takes into account their responsibilities and education--four years of study after high school.

~*~*~*~*

Does anyone know of an instructional tape for learning to coach a woman through birthing in French? I have occasional French clients and would love to communicate with them better. In the past I have listened to tapes on Spanish for midwives and they have helped me tremendously with my Spanish-speaking moms and dads.

- Carol Gaudey, Birthing RN
Reply to: caroleyan@aol.com

~*~*~*~*

INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to "International Connections." We're here to help you!

~*~*~*~*

Re: Limitation on mother's age and homebirth {Issue 3:15]:

You treat her just like any other pregnant mom: assess her diet, her weight gain, maybe consider random fasting blood sugar checks to see where her blood glucose fluctuates, assess her ability to exercise and practice relaxation with other children in the home. Did she have any trouble birthing a large baby? Has she had a postpartum hemorrhage in the past? Age is not necessarily a precipitating factor in either of those things, but parity can be. Is she exposed to cigarette smoke (placental problems), drink alcohol?

Help her learn to take good care of herself in preparation for parenting a newborn again. There are some statistical risk factors related to genetic anomalies, especially the incidence of Down syndrome as women grow older. Educate yourself and your client on the screening tests available to detect such events, the invasiveness of them and the risk of erroneous results. Most prenatal tests used to detect such concerns are very invasive and not done until after the first trimester. Only options are late abortions or preparing for a differently-abled or medically fragile infant. That information can be good for helping parents prepare, and may risk them out for a homebirth.

Generally, I believe that women under 40 are not such a concern as women over 40. Older primips may have a more challenging labor as their bones are more calcified and may be less flexible, but the hormones of late pregnancy work wonders to loosen them up. Kegel exercises become more important with both increased parity and age. Teach her well and encourage her to do them daily to prevent stress incontinence. Ditto hydration--the temptation is to curtail liquids when one begins to experience stress incontinence, and dehydration can exacerbate the problem. When working with "older" mothers, please bear in mind the sexism and ageism of our medical language. First-time moms over 35 years are considered "elderly primiparas."

- K. Davis

====

I am 41 year old gravida 11 and have experienced unassisted childbirth with the past six births and have delivered 9 of 10 at home. I've never had a problem with postpartum bleeding. I usually deliver the placenta at about one hour after birth. We plan to have a licensed midwife (LM) present at our next birth in October but, hopefully, just as an observer. Husband and I enjoy our roles in birth.

- Bernadette Clark, Doula
Florida

====

I gave birth at home for the 7th time when I was 40 years old. I was told that as long as you are having periods, you are able to get pregnant and give birth. I felt the effects of my age throughout all my later pregnancies in my lower energy level, etc., but it was most definitely do-able. In fact my back went out in my 6th month and spasmed quite badly, which left me needing to rest a lot for the remainder of my pregnancy. The lack of exercise, I think, made that labor harder than any of my others, but it was still a beautiful birth, and I have a beautiful daughter from it.

I was glad my faithful midwife saw me as normal. When did we begin thinking there was some age at which women should no longer be capable of giving birth well? If she is still female, and has no specific health concerns that have come up, and is pregnant, then she is probably capable of birth-giving. It may be harder in some ways, better in others, but age by itself shouldn't make that big a difference.

- Kathy

====

I had a home VBAC birth at age 40, and I have multiple sclerosis. I think the key component is having midwifery care from midwives who are unruffled by medical-world hand-wringing, who trust birth, trust you, and you trust yourself, birth, and them. Taking it from there, a lot is possible.

- C.M.

====

Keep Midwifery Alive in Oregon: Support Senate Bill 730

- This bill is about to reach the floor. The Oregon Medical Assoc. is lobbying hard against us.

- It is extremely important that you write to your senators and representatives immediately! Ask them to support this bill.

- Then, plan to join us at the State Capitol in Salem Monday, April 23. Call your senator to make an appointment on this date. We will be available to meet you before you go in to see them.

I cannot overstate the importance of taking action! It will ensure that your right to have a homebirth remains an option.

Zip code, senator or representative's name:

97404: Susan Castillo, Robert Ackerman; 97430: Gary George, Alan Brown; 97401, 97402: Lee Boyer, Vicki Walker; 97405: Susan Castillo, Phil Barnhart; 97487: Tony Corcoran, Cedric Hayden; 97477, 97478: Lee Boyer, William Morrisette.

Write to them at: State Capitol, Salem, OR 97301

====

I am pregnant (15 weeks) and was wondering is it safe for me and my babe if I take flax, borage, or hemp oils for the essential fatty acids (gamma linolic acids etc.)? I have searched everywhere and cannot find a clear answer. What about dosage? These are not herbs but the oils derived from a food product so I assume they are safe, but I really want to make sure.

- Anon.

====

Do you have information or leads to information about the complications and long-term effects of having a tubal ligation done? I need information such as change in hormone imbalances, sexual dysfunction and recurrent problems from having this procedure performed. I have a client wishing to have this done as a means of birth control after this next pregnancy.

- R.S.
Reply to: robin@color-country.net


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