|June 6, 2001|
Volume 3, Issue 23
|Midwifery Today E-News|
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Quote of the Week:
"Midwives working with women is a perfect and time-proven partnership. Bureaucracy and birth is not."
- Jan Tritten
The Art of Midwifery
One of my favorite doula tools is my Mag Boy--two ball magnets with bumps; they roll freely in a small hand-held case. Magnets help a person relax as well as give energy--what more could you ask for in labor? I can roll them for hours over mom's body whereas my hands give out much sooner when giving massages. You can even give the same energy effects by spinning them above the mom if she doesn't want to be touched.
- PJ Jacobsen, IBCLC, CD, aspiring midwife
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Perineal massage during labor does not increase the chances of an intact perineum or reduce the likelihood of pain, dyspareunia, or urinary and fecal problems, an Australian research team reports. A study from the University of South Australia randomized 1340 pregnant women to receive either perineal massage and stretching of the perineum during the second stage of labor, or supportive measures only. The researchers found that the rates of intact perineum, first- and second-degree tears, and episiotomies were similar between the groups. The massage group did have fewer third-degree tears, but the study did not have sufficient power to measure this rare outcome. Postpartum pain, dyspareunia, resumption of sexual intercourse, and urinary and fecal incontinence and urgency also did not differ between the groups. "Although perineal massage in labor did not increase the likelihood of an intact perineum, our trial does provide good evidence of lack of harm that in itself may be of value," the investigators point out. In view of the current findings, they suggest that "midwives follow their usual practice while taking into account the preferences of individual women."
- BMJ 2001; 322:1277-1280
What Do You Think?
Overland Park, KS., physician Charles Butrick used to deliver babies. Now he almost exclusively repairs the damage they can cause on their way into the world. Butrick is among a chorus of physicians and medical researchers who in recent years have been warning that certain birthing practices are creating needless damage to new mothers that could result in incontinence, sagging internal organs or pelvic pain decades down the road.
The campaign for more natural childbirth (and fewer cesarean sections) has contributed to a huge growth in pelvic floor disorders that weren't very apparent until recently, according to Butrick, a uro-gynecologist. Doctors have worked hard to decrease their c-section rates. Nationwide, the average fell from a peak of 24.7%in 1988 to a subsequent low of 20.7% in 1996. It has crept up slightly since then. Compounding that is the opposition of some pregnant women to any sort of technological intervention, Butrick said.
And yet a growing body of research indicates that although vaginal delivery is fine in many cases, in some circumstances those deliveries can stretch a woman's nerves, muscles and ligaments beyond their capacity to rebound. And that can lead to serious problems that require surgery and physical therapy 20 or 30 years later.
For decades, according to Butrick, obstetricians have suspected that certain vaginal deliveries cause damage that results decades later in problems. But only about 10 years ago did the technology develop that enabled physicians to see the actual damage to muscles, nerves and ligaments.
There is evidence that about 28 percent of vaginal deliveries cause injury to the mother, 'even though it may not result in symptoms until 20 years later,' said W. Benson Harer Jr., a gynecologist and president of the American Society of Obstetricians and Gynecologists.
[Thanks to E-News reader Kathy Jackson, who sent in the above article from the Lewiston Morning Tribune dated Wednesday, May 23, 2001. Send your comments, evidence, facts, and experience to E-News. We'll dedicate an issue or two to your discussion.]
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Question of the Week
Q: I am dealing with a bilateral inguinal hernia, which became apparent at about 24-26 weeks. I am in the eighth month of my third pregnancy. I am very active and get a significant amount of exercise. I am wearing a hernia belt, bathing with epsom salts, doing external compresses and trying to rest regularly and minimize excess lifting. My chief concern is pushing. We will be birthing at home, probably in water and I don't really expect to push until I feel a primal urge to (my 8 lb. daughter slid out pretty well on her own, a few pushes were called for). My midwife is inexperienced with hernias and as a doula I have never encountered them. Any insight would be gratefully appreciated!
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Question of the Week Responses
Q: I am going to give birth for the second time in just a few weeks. I've suffered from hemorrhoids since my first baby's birth when I used that eye-popping Valsalva pushing. I won't do that again! I want to keep the hemorrhoids from being such a distraction during my labor. Any good ideas, treatments, positions? Would laboring in water help? I love the squatting position but it doesn't work well during pregnancy when the hemorrhoids are swollen. I'd appreciate any advice.
A: Witch hazel compresses can help shrink hemorrhoids before labour starts. It also may be soothing during second stage. Honey also can be helpful--it's applied directly too. Avoid any sort of controlled/breath holding/eye-popping pushing (unless it's involuntary) and try kneeling or all-fours.
A: I have had hemorrhoids since the birth of my second child and I have eight children, all about two years apart. I have found no difference in my hemorrhoids whether I had a waterbirth (no. 4 and 7) or when I had land births (no. 1,2,3,5,6,8). I definitely don't focus on them and the only time they give me trouble is about three weeks before I give birth, at which time I apply an anti-inflammatory such as witch hazel and elder leaf salve. I try to keep them extremely clean with a squirting type of bottle after every bowel movement. They don't usually bother me after the birth or in the days that follow in the immediate postpartum.
- Jennifer Crowley, CBE, aspiring midwife
A: First, to keep from having to strain, take two capsules of flax seed
oil before bedtime, and drink sufficiently during the day to have soft stools.
If stools are usually hard, one can also take a combination of ground flax seeds,
ground fennel seeds, slippery elm and psyllium seeds in equal measure, one Tbsp
mixed with water or juice followed by a large glass of water, also before bed.
After every bowel movement, gently wash anus with a clean warm cloth, then apply
bottled or fresh lemon juice with a q-tip or cotton ball. It will sting a bit,
but the fast results are worth it. Then apply an herbal salve containing comfrey,
calendula, plantain and yarrow and maybe vitamin E oil. Homeopathic remedy hamamelis
30x can also be useful. Expect to get results in a few days of thorough treatments!
- Shanu, doula, herbal and natural health practitioner
A: Certainly water for labor should be tried since water seems to alleviate
so many discomforts. A remedy to try to decrease the hemorrhoids before labor
would include whittling suppositories of potato and inserting them into the rectum.
So I answer this question with another question: does anyone out there know if there are contraindications to such high doses of bioflavonoids in pregnancy?
- Karen Ehrlich, CPM, LM
A: Shredded raw potato placed directly on them makes them go away and feels wonderfully cool on a postpartum perineum. During labor with my second child, my midwife fully supported my anus during the last of the pushing phase (when it feels like it's inside out). I didn't have near the hemorrhoids I had after my first birth experience.
Question of the Quarter for Midwifery Today Magazine
Theme for Issue No. 59: Prenatal
Question(s) of the Quarter: What are the essential elements of good prenatal care? How does prenatal care create better birth? As a midwife/doula, what do you hope to accomplish in the prenatal period with a pregnant woman?
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To Melanie & Lisa, student midwives from England [Issue 3:22]:
I went to an "alternate birthing center" for four weeks at the end of my BN program. I suggest you browse through the ads in midwifery journals. You will need to have goals and objectives approved by the folks at both the university you attend and wherever you go for this experience.
- Sylvia L. Nicholson, RN, BN, MHSA, MS, CNM
There is a wonderful teaching clinic in Zululand, South Africa. They are willing
to take people eager to experience different cultures. The person to contact is
Colin Pfaff: firstname.lastname@example.org
[Ed. Note: Melanie/Lisa, please contact E-News at email@example.com]
I would love to hear from anyone about becoming a midwife. I have been thinking very hard about the idea, doing as much reading as I can on the topic, exploring internet sites etc, but nothing beats "spoken" word with those in the know! I'd love to hear about any aspects of midwifery from both a personal and practical perspective, especially from those of you in different parts of the globe (I'm down under in New Zealand!) Perhaps you have an opinion on the different types of training paths--nurse-midwifery vs. direct entry--which could give me some more to think about.
To the woman with the friend in Geneva, Switzerland:
I live in Basel, and don't know much about resources in the French Swiss part, but in the German part there are many birth centers committed to natural births, with excellent midwives. I gave birth in the center just outside Basel, Geburtstatte Muttenz, attended by the co-leader of the center. The midwives there also provide homebirths if you are ok'd for one. The website for muttenz is: www.geburtstatte.ch. If she wants more info, she can contact them direct at: +41 061.461.4711.
More on evening primrose oil:
Evening primrose oil (EPO), borage oil, and black currant oil, like salmon oil and flax seeds, although chemically slightly different, are all essential fatty acids. Essential fatty acids are essential nutrients in the human diet.
Essential fatty acids are found in breastmilk and appear to be building blocks for brain growth and development in the infant. Europeans have been adding essential fatty acids to their artificial infant milks for years. U.S. formula companies feel that before they can add it they must undergo rigorous testing, which may be proving to be too expensive.
The "Lawerence Review of Natural Products Facts and Comparisons,"
maybe the pharmacist's bible when it comes to alternative phytochemicals, i.e.
In addition, the standard six 500 mg capsules per day a pregnant woman is taking by the 42nd week is only 3000 mg, well below the studied 8000 mg. Upon occasion, when I have had a client go past 42 weeks, I have them increase the dosage, especially if there is very little cervical ripening apparent. I have VBACs ingest this nutrient during labor to soften the cervix. Several clients have melted a capsule in their vagina at night to "soften things up," and they have not torn. They attribute their intact perineums to the EPO. I attribute it to waterbirth or the slow pushing and panting as the fetal head emerges.
I encourage all of my mothers to continue taking EPO (or whatever their dietary choice has been) even after delivery so their milk is higher in this nutrient. Infant brain growth is the most rapid in the first year of life (and the third trimester). In this day and age with margarine and shortening contaminating most fast foods, crackers, and grain products, the EFAs a body attempts to make, or ingests in dietary form (oatmeal, spirulina) are used up fighting the "bad" saturated fatty acids and transfatty acids.
Two publications in U.S. medical libraries are dedicated to studying EFAs (their names escape me). I first saw them at the UCSD library in San Diego. I saw one of the publications in Tyler, Texas at the UT hospital library. I was thoroughly convinced of this nutrient's safety. There were numerous studies about infants, brain growth, placentas, etc. packed in the two or three issues I was blessed to stumble across. I'll bet with just a little online research or a jaunt to a medical library you can find these journals and find some articles you can share with pharmacists.
- Sandra Stine, CNM
For the woman looking to add EFAs to her diet during pregnancy: she should try pumpkin seeds! There is a seasoned prepared version known as Pumpkorn. They are very tasty and can be found in most health stores.
- Amy V. Haas, BCCE
To Andrea, who wishes to become a midwife but doesn't want children:
I am also 22, an aspiring midwife, and I plan to have children in my late 20s. I have found many warm hearts so far that have encouraged me onward, but I have also found many doubters and mothers/doulas/doctors who have made me feel like I am second rate. But midwifery is changing in so many miraculous ways and it's becoming possible to be part of a profession that was once strictly for experienced birthers. On the other hand, midwifery is about experienced women bringing their knowledge to laboring mothers. How can we empathize with these women if we have not been through it ourselves? Is there some kind of deeper spring of knowledge that we may tap into? Will we seem like fakes?
If you are dedicated and feel a spiritual calling to help women through labor, you should follow that calling and see where it leads you. Pass up the doubters and embrace those who make you feel like you are doing something worthwhile and miraculous.
- Mindy Herron,
I would encourage you not to see your childlessness as a liability. I just gave birth 15 months ago with the assistance of the "queen mother" of NE Ohio midwives, the one who trains so many of the others and is so in demand that she has to squeeze everybody into her very full schedule. Everyone is absolutely in awe of her. Initially, I wondered how she could know how to best serve a client when she didn't have children; however, so many of my friends had used her with excellent, rave reviews, that I took the plunge. She quickly won my total confidence.
Beyond a shadow of a doubt, she was the one of three midwives I've used who was the most intuitively understanding of my needs and the best in handling my painful back labor. A spirit of peace and purposefulness and gentle humility permeated the room, as well as awe of this important event. She took care of my spirit as well as my body and my baby. My other children were treated with the most love and care by her than by the earlier midwives. I shudder to think how awful the world would be had she elected not to become a midwife.
She told us the reason she never married and bore children was that she felt God had called her to be a full-time midwife and not to be hindered by a family also in need of her attention. After she said that, I felt so important and valued to be assisted by one so devoted to her art and ministry of midwifery.
You may need to initially set rather low prices to get enough clients to build a reputation. Soon you may find that people appreciate the extra availability you can accord them by not having a family to care for.
You would be an ideal midwife because you would not have your own family to have to worry about. It also would be difficult to sympathize with a woman--"I know it hurts"-when you've never experienced it. It's a two-edged sword. If you found a good midwife to practice under for a while, or maybe even join a group setting, you could gain a lot of respect. The more you age will help too. I think "book knowledge" has a lot of influence these days, even in this field. My first two OBs had never had kids, and of course there are tons of men OBs!
I first began studying birth in 1973, and I have been a midwife since 1975. I am now 54 years old and have never had a child. There is certainly a feeling among many midwives and mothers that no one who has not given birth should become a midwife. This is an issue that I and a small number of midwives have had to deal with ever since the renaissance of homebirth and midwifery.
While I understand that feeling, obviously I disagree. Even though I cannot truly "get" the profound depths of pregnancy and birth and postpartum, even though I am floating on the surface of an incredibly vast body of experience, I do have breasts and a uterus, I bled and cramped for 40 years, and I am a loving human being who cares mightily for mothers and babies and families.
Although it is perhaps harder for those who have never had a baby to understand the depth of what women go through in labor and in parenting, it doesn't mean that we can't have the requisite sensitivity, empathy, caring, skill, ethics, knowledge and ability. My clients have let me know over all these years that I am able to relate well to them, give them the information they need, support them, and be a good midwife for most of them. Certainly if any pregnant woman doubts that she can be cared for properly by a childfree midwife, then I should not be that woman's midwife, and I will happily refer her to some of the other wonderful midwives who are also mothers. I take no offense at the hesitation or reluctance to have a childfree midwife.
Cross culturally, probably the more common pattern is for older women, after having completed their families and having raised their babies past dependency, and perhaps after having raised them to adulthood, to then launch into their later-in-life callings as midwives. However, this is not universal. In some cultures, young women are trained as midwives who then devote their lives to this work; some of them do not ever go on to have children of their own. In others, indeed it is women of childbearing age who become skilled at helping their peers in birth and continue their work into older age. So the wisdom of the ages cannot help us determine what is the best age and experience for welcoming our callings as midwives.
In 1974, a childbirth educator who was helping me sit in on birth preparation classes had her first baby after having taught for about five years. She told me, almost two years after her daughter was born, that she was a much better childbirth educator before she became a mother. When she had not given birth, she told me, she had hundreds of experiences to draw on when she taught her classes. Since she had given birth, she now only had one experience.
To place a requirement on having gone through the experience oneself in order to be able to minister to another person going through that experience would ultimately mean that no one can tend to anyone--because only a midwife who has had her own baby die could be a midwife for a woman whose baby will die, except that only rarely can we know ahead of time whose baby will die. A midwife who has had a cesarean would not be able to tend to any woman who expects to give birth vaginally. No midwife who has not had a VBAC would be able to tend to a woman who wants a VBAC.
Clearly, in my opinion, there is no absolute requirement either way. I urge Andrea to go ahead and follow her heart and calling. If no children find their way through her body, she can still be a wonderful and credible midwife.
- Karen Ehrlich, CPM, LM
First, congratulations! I am 23 and due with my second baby in mid-October. My midwife has no children of her own and is not married. I take her seriously because she knows what she's talking about. Even if you don't have kids of your own, you can still be a fine midwife! The care I receive from Kara is great. She's very warm and personable, laid-back and easy-going. And it doesn't bother my husband or me that she doesn't have children. You'll do fine!
In response to the question about working with teen mothers/adoption [Issue
Now, as a doula, I have not yet been privileged to accompany a mother planning to release for adoption, but I have a few suggestions. Each mother is different: One may want all the contact she can get and pictures and such; another may not want to see the baby at all. One may want medication during the labor (as much for pain as for emotion); another may feel tremendous accomplishment in doing it naturally. You should not label and pre-decide how it will be. Be flexible and don't come to the birth trying to accomplish any of your own goals. It is hard enough for the mother without any judgment being passed.
Make sure the hospital staff knows her situation and that they will be supportive. She needs to hear over and over that she is doing the right thing, that she is strong and brave, and she can get through it. You can't praise her enough for her decision. Over time this need will subside.
Once the birth is over she will need someone to confide in and talk with. Be
available for that--it is essential to her healing. Giving up a baby feels the
same to the mother as if her child had died. She has to grieve. Be her support
and her sounding board. It is not unusual for the mother to feel as though the
world wants her to forget. It seems unacceptable to talk about the baby to her
friends or even clergy and family. You can be her friend and let her remember
her baby with you. She will never forget and this experience will change her forever.
Helping her make the appropriate contacts in the community is necessary, especially
if she is not working through an agency. Counseling is a must.
- Laura Grout, CD (DONA), aspiring midwife
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