May 9, 2001
Volume 3, Issue 19
Midwifery Today E-News
“Prolonged Labor”
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Quote of the Week:

"Over the course of generous, unhurried prenatal visits, the [pregnant] woman comes to understand the midwife genuinely cares for her and will not interpose frivolously."

- Judy Edmunds

The Art of Midwifery

To rotate an occipitoposterior baby, put the mother on her side in Trendelenburg's position (supine on a table which is tilted head downward 45 degrees or less). The first time I tried it, the baby rotated and delivered quickly. It probably gets the baby's head "unstuck" from the birth canal and helps it rotate easier. Most mothers can tolerate this position better than knee-chest, and it seems to work better. We put a large wedge under the mattress of the bed. A beanbag could also work.

- Margie Riley, Midwifery Today Issue 46

E-News welcomes feedback about techniques described in "The Art of Midwifery." What experiences have you had with the same or similar technique? What side effects have you noted? What alternatives do you suggest, and why?

For hundreds more "tricks," check out Midwifery Today's "Tricks of the Trade" Volumes I & II. Get both volumes for just $40!

Watch for "Tricks of the Trade Volume III," coming this summer!

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News Flashes

A study undertaken at the University of North Carolina examined the association between frequency of eating and preterm delivery in more than 2000 women enrolled in a study from August 1995 to December 1998. All women were asked about their frequency of eating during the second trimester of pregnancy and were followed through delivery. The vast majority of women met current Institute of Medicine recommendations for eating three meals plus two snacks each day during pregnancy. Women who fell short of these guidelines had a 30% increase in risk of delivering prematurely than the others. Women who ate less often than recommended were also slightly heavier prior to conception, were older and had lower total energy intakes than the other women in the cohort. Research in animals suggests that skipping meals could result in elevated levels of stress hormones implicated in the events leading to preterm delivery. Some studies in humans also support this mechanism of action.

- Am J Epidemiol 2001;153:647-652.

Prolonged Labor

Cervical adhesions: It is not unusual to find hard spots on the cervix during examination of a woman in labor. If the woman does not have condylomas, most often what you are feeling are small cervical scars from previous births or gynecological procedures. The use of instruments for dilating the cervix or delivering the baby often causes small tears to occur, as well as women pushing their babies out prematurely (before complete dilation). These adhesions most often will break down during the active phase of labor. If you feel they are causing lack of progress (the woman remains at 5 to 6 cm for over an hour), you might consider simply pressing the adhesion against the presenting part during a contraction. You will feel the adhesion break up under your finger. This causes no pain and readily resolves the problem. There may be a spot of blood as this is done, but this is of no concern. The labor will usually progress rapidly after the adhesion is gone.

- Valerie El Halta, Midwifery Today Issue No. 46

I recommend that midwives change their notion of what is happening in the pushing phase with a primip from "descent of the head" to "shaping of the head." Each expulsive sensation shapes the head of the baby to conform to the contours of the mother's pelvis. This can take time and lots of patience especially if the baby is large. This shaping of the baby's skull must be done with the same gentleness and care as that taken by Michelangelo applying plaster and shaping a statue. This shaping work often takes place over time in the mid-pelvis and is erroneously interpreted as "lack of descent," "arrest" or "failure to progress" by those who do not appreciate art. I tell mothers at this time, "It's normal to feel like the baby is stuck. The baby's head is elongating and getting shaped a little more with each sensation. It will suddenly feel like it has come down." This is exactly what happens.

Given time to mold, the head of the baby suddenly appears. This progression is not linear and does not happen in stations of descent. All those textbook diagrams of a pelvis with little one-centimeter gradations up and down from the ischial spines could only have been put forth by someone who has never felt a baby's forehead passing over his/her rectum!

Often the mother can sleep deeply between sensations and this is most helpful to recharge her batteries and allow gentle shaping of the babe's head. Plain water with a bendable straw on the bedside table helps keep hydration up. The baby is an active participant and must not be pushed and forced out of the mother's body until he/she is prepared to make the exit.

- Gloria Lemay (To read this article in its entirety, click here)

[Ina May Gaskin] and the women of the community she serves turned away from paternalistic, fear-based medicine. They have their babies, with certain exceptions at home, and promote an acceptance of birth as natural and holy. In her book Spiritual Midwifery under "Slow Progress During the First Stage," she states, "You don't have to have any preconceived notions about what is too long for the first stage. If the mother is replenishing her energy by eating and sleeping, rushes [contractions] are light, the baby's head is not being tightly squeezed and the membranes are still intact, the first stage can stretch over three or four days and still be perfectly normal."

- Marion Toepke McLean, Midwifery Today Issue 46

Should labor commence with baby occipitoposterior (OP), time spent early on in deep knee-chest position, with legs spread wide, may effect rotation. Other tricks to consider are duck walking, stair climbing with one leg abducted, lunging, quarter-squatting or hula-style belly dancing. If these don't work, consider the uncomfortable intervention of internal manual conversion to anterior. Invasive? Very. And effective. Sure, many women push out wee ones sunny-side up with little fuss. I am convinced that multips who have ample pelvises with a history of happy births can do positively anything! However, the diminutive mom with a large baby, previously sectioned for failure to progress with a smaller, persistent posterior babe, is a poor candidate for watchful waiting. By getting close to our clients, we learn who would benefit from assertive action and who we can simply sit on our hands with. Though not often needed, internal manual conversion is an example of a strongly interventive, briefly painful technique that may avert an even worse outcome: a brutal, protracted, traumatic labor with a surgical conclusion.

- Judy Edmunds, Midwifery Today Issue 46

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I am going to do a self-study program next year and then the year after am hoping to do an apprenticeship. I live in Tennessee and would like to stay in the area. If anyone knows anyone who I can contact I would love to hear from you. I would also love to hear the stories of some who are in training or finished.

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Question of the Week

I have a student (Bradley) with a fibroid so large it is causing her great pain. She is 18 weeks and was recently hospitalized for it. It was recommended that she quit work for a while. It is located on the left side of her uterus. She desires more information on fibroids, and other than Anne Frye's book, Holistic Midwifery, I don't seem to have anything more for her. Does anyone out there have any information? She wishes to do things as naturally as possible, but understands some of her choices may be limited.

- Amy V. Haas, BCCE
Fairport, NY

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Question of the Week Responses

Q: I am a doula and have a client who had two previous c-sections with large babies and really wants to try for a vaginal birth. What information and support can you offer? She plans to have a hospital birth.

- Amy

A: I'm a newly practicing doula and the first birth I attended was for an attempted VBAC after a large babe. In the end my client had an (unneeded, in my opinion) c-section. What is the climate at the hospital? Are her doctor and the doctor on call truly supportive of VBACs? After the birth my client's doctor told her he thought she would have a cesarean but didn't want to discourage her. Sadly, his negative attitude unconsciously showed through with his interventions and meddling. Be aware how greatly you can influence your client but also be aware there will be other influences at the birth.

- Madelene Doring

A: I'm a mom of four daughters (pregnant w/fifth). I had my first two by c-section after laboring and pushing, because they were too large. When I got pregnant with my third I was determined to have a vaginal birth. I found a doctor who was supportive and a doula who could offer encouragement. I did a lot of reading on VBAC and believed I could do it. My doctor kept a close eye on the baby's weight and decided to induce me at 38 wks. After 15 hours of labor and 15 minutes of pushing my beautiful daughter was born and weighed in at 7 lbs. 15oz. My fourth was even easier. My midwife worked on my cervix, massaging with evening primrose oil, and I did a lot of squats. At 38.5 weeks I went into labor and six easy hours later my fourth beautiful daughter was born and weighed 8 lbs. 3oz. Having a vaginal birth has been the most wonderful experience. You can do it!

- Sonya

A: As a doula, I, too, have been in this situation several times. Specific questions to ask your client and her physician are:

1) Does she have such a small pelvis that the care provider is hesitant she could ever deliver vaginally?
2) What was the weight of her two previous babies and could she have an ultrasound at 36 weeks to estimate the fetal size?
3) Providing she is healthy and the fetus is of appropriate size, an induction is always a possibility. [Editor's note: Midwifery Today does not support routine induction.]
4) What were the specific reasons for her previous sections? Any other contributing factors that had nothing to do with fetal size?

Above and beyond the possibility of a repeat section, assure her that she is not a failure, that she worked very hard to carry the baby to term, and that ultimately, the outcome we all want is a healthy, happy baby and family.

- Kelly Merrow, Doula
Doulas of North America

A: I'm preparing to become a doula. I had two sons (22 & 18), the first one by c-section, the second a natural delivery. The advice I have is the following:

1. Go to the hospital; don't try a home birth.

2. If the time between the previous pregnancy and this one is less than three years, a natural delivery can be a problem.

3. Your client must prepare for this birth even more than if this was her first one. She must have a very good and healthy diet and exercise regularly. More important, she must clear her mind of fear or anything that might have interfered with the two previous births. I did rebirthing, a therapy technique based on breathing that helped me immensely, not only to release fears, doubts and other ghosts, but especially to develop new thought patterns of confidence and purpose.

4. Your client must truly understand all phases of the birthing process and what she can do to succeed in each phase.

5. Your client needs you to be especially reassuring, nourishing and supportive. There are risks involved in trying to deliver after c-sections but they are not obstacles and they can all be anticipated and prevented.

6. Don't rush to the hospital as soon as labor begins. Take time at home with warm baths and a calm atmosphere. I started my last son's labor in the early morning, and I went to the hospital only when I was already about 8 cm dilated. I arrived at the hospital at 3:00 am the following morning and my son was born at 5:30 am. At 7:30 am I was able to return home with my baby!

7. Massage therapy has a lot to offer your client if she is open to touch. It can help her mind/body connection, and it can provide a safe space in which she can relax and activate her self-healing powers.

- Elza Suely Anderson
Bethesda, MD

In Celebration of Doulas

Even if I never attend the birth, knowing I helped inform, comfort and support a pregnant woman gives me great joy! I feel this is what I was born to do. When I got started I thought I would have aspirations to become a midwife, but being "just" a doula fills me to the top with happiness. I love that I'm helping to bring birth back to basics. Being a doula is like watching the heavens open--you witness the coming of angels. The passion I feel about pregnancy and birth is only overcome by the love I have for my own sweet angels here at home. Doulas fill depleted reservoirs and uplift, comfort, acknowledge and guide with gentle hearts, strong hands and souls of light.

- Chantel
Tucson AZ

When I look into a birthing woman's eyes during labor and see my sister, mother, daughter and close friend, I know I am needed. A laboring woman deserves full attention and, in hospital births, needs protection. Her partner usually needs reassurance and a normal and stress-free birth is of paramount importance to their baby. I try to offer the element that I lacked with my first birth without a doula and provide the security, comfort and understanding that I reveled in during my second birth.

- Deb Wood, ICCE DONA

MAY IS DOULA MONTH! Doulas, please submit a one-paragraph philosophy of doula practice to E-News, or a one-paragraph description of why your work is important, or aspiring doulas, submit a one-paragraph "Why I Want to be a Doula" description to E-News. Be succinct, feel free to cite studies and experience, or be poetic, speak from the heart! We will publish as many as we can fit throughout the month of May!


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


International Connections


I wish to help a friend who lives in Geneve, Switzerland. She's 24 weeks pregnant and having a very difficult time with the system. She has been unable to locate a midwife to provide continual care (she plans a hospital delivery). Every time she goes in for prenatal care she is subjected to long ultrasound scans (every doctor wants to see for themselves.) Most recently she was told the two midwives who work for the hospital (apparently there is a shortage) will be on vacation at the time she will deliver, so most likely she will be attended by the resident on call that day, unless of course she wants to choose an OB/Gyn to be her care provider. My first thought was "Wow! Really? In Switzerland?"
What can she do?


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



Heart & Hands Midwifery Intensives will join this summer with the Midwives Cultural Exchange, Oracabessa Birth Center, to offer a month-long program combining Elizabeth's teachings and clinical experience with Jamaican birthing mothers, from mid-June to mid-July. Be a part of this exciting opportunity! VERY limited space , or

Visit our website at for information on Women's Mysteries, sexuality, current publications, and the National Midwifery Institute, Inc.


I am 15 years old and I am going to be a midwife. Do you know where to find out about midwifery schools or what I should do about school?

- Mandi


In response to Kathy's question about antibiotics affecting infants [Issue 3:18], there is a huge increase in yeast infection and thrush. With my second child I was given one dose of antibiotics about 4-6 hours before her birth. We never suffered any lasting effects. With my son we had two doses four hours apart before birth. He had a serious yeast infection around his legs and testicles about a week later and we suffered thrush for several months.
There is also a debate about using prophylactic antibiotics and creating resistant bacteria. I'm sure this would be true for the bacteria that babies are subjected to, too.

- Chantel, doula


In response to Arts of Midwifery [Issue 3:18] about foot care during pregnancy: I emailed the information to a friend who is seven months pregnant and having foot pain. She was a little alarmed to hear about using peppermint oil because she read on a web site that it was to be avoided.
The web site specifically said that peppermint oil is a uterine stimulant; avoid the oil entirely, although low doses of the dried herb can be used.
Can you please clear that up for us?
I also noticed that the web site read Raspberry leaf (Rubus idaeus): A uterine stimulant in high doses; best limited to the final six to eight weeks and during labor.
I have suggested this herb to many people and have heard many things about it helping to tone the uterus and cervix. I am really scared to think that I may have contributed to a miscarriage in early pregnancy (which did happen with another friend of mine). Please let me know if you have information proving its effectiveness otherwise.

- Anon.


In response to the 3/28 question on breech births: Unfortunately I can't help with information on breech births 100 years ago, but I do know of a midwifery trick of 700 years ago: From a graduate course on life in 14th century France, I learned that midwives were known to use a candle flame on the emerging foot of a footling breech to coerce the babe into pulling his foot back in and hopefully staying in a more manageable, complete breech position. Unfortunately I don't have a historical citation, but it does seem possible given these women really had no other recourse.

- Bethany Karn, CBE


I have a question on evening primrose oil: From what I have heard and read, EPO is a very positive aid for women after 36 weeks gestation. Can they take it before? Can you give me information on EPO so I can forward it to our local pharmacist who is not recommending it for expecting moms no matter how many weeks gestation they are.

- Linda Middleton


When I read Ms. Elsbernd's piece on midwives' connection to
their moms and to their mission [Issue 3:18], I found I could relate directly as a doula. I have experienced everything Ms. Elsbernd wrote about. She could insert the word doula in each place she used the word midwife and it would be a perfect article for any doula publication. I couldn't have said it better. I feel incredibly lucky to have found this profession (thank you, Kathy Thomas!) and the wonderful people I've met along the way--midwives, docs, nurses, other doulas--and some of the loves of my life, whether moms or dads, life partners or best friends, grandparents or significant others. My life has been blessed each time I uttered to myself all the words Ms. Elsbernd wrote.

- Maura McKnight


Please tell us what state has good laws regarding midwifery so we can request the same laws from our Oregon legislators. Time and again, it has been that "those who WRITE the laws get what they want."
Reply to:


Austin Area Birthing Center has openings for experienced , dedicated student midwives starting in June. A room is available in the center. Send your resume to (512) 345-6637 or email to
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