October 3, 2001
Volume 3, Issue 40
Midwifery Today E-News
“Preventing Cesarean Section”
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WHOSE KNOWLEDGE COUNTS in Birth and Midwifery? This class, taught by anthropologist Robbie Davis-Floyd, is among the many fascinating courses that will be offered at Midwifery Today's international conference in Paris, France, 18-22 October 2001.

Are you a hospital midwife? Now you can learn about appropriate technology, working under restraint, closing the evidence-practice gap, humane hospitals and more. Attend the full-day pre-conference class, "Serving Women in Hospital Births" at the Midwifery Today conference in Philadelphia, Pennsylvania, U.S., March 21-25, 2002.



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Contesting Conversations in Practice, Education, Research and Policy

Adelaide Convention Centre
4-7 November 2001

Join Paul Lewis, Philip Darbyshire, Patricia Benner and others in Adelaide for Contesting Conversations, THE major international Nursing & Midwifery conference that uniquely brings together clinicians, researchers, students, educators and managers from all specialties to explore clinical practice, professional assumptions, current health issues, education policies, research approaches and more.

Contact e-mail: ccerp@sapmea.asn.au

Web: www.sapmea.asn.au/Conventions/CCERP/ccerp.htm

Quote of the Week:

"Birth is all about opening. It opens a mother's body, but it also opens her heart and her mind."

- Laurie Fremgen

The Art of Midwifery

When first learning to estimate cervical dilation, it is helpful to open the fingers of the free hand along a centimeter stick to approximate the same position of the fingers doing the exam. This provides a visual as well as a tactile assessment of the extent of dilation.

- Midwifery Today Issue 2

NEW! Birth Wisdom, Tricks of the Trade Volume III. Order before Oct. 31 and save $2 off the regular price! Use coupon code 1730 when checking out at Midwifery Today's storefront.

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News Flashes

A UK study suggests that advanced neonatal nurse practitioners are significantly more effective than trainee pediatricians at diagnosing certain problems during routine neonatal examinations. The study, undertaken at St. James's University Hospital, Leeds, looked at 527 infants referred to a specialist orthopedist, ophthalmologist, or cardiologist. All infants had first been examined at one of two hospitals by an advanced neonatal nurse practitioner or a pediatric senior house officer. Nurse practitioners were more sensitive to hip abnormalities compared with physicians (96% versus 74%). The same was true for their sensitivity to eye abnormalities, 100% compared with 33% for physicians. There was no significant difference between the nurse practitioners and physicians in terms of detecting cardiac abnormalities.

- Arch Dis Child Fetal Neonatal Ed 2001;85:F100-F104.

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Cesarean Prevention

The connection of love and trust that I developed with my midwife and knowing that she trusted the birthing process allowed me to overcome misunderstanding and fear. Caregivers, be open. Reassure each mom. Watch videos together. Be her friend. Validate her fears. Educate her about birth, nutrition and exercise. Guide her to quality childbirth education classes.

- A. Moore, The Birthkit Issue 31


Some ways practitioners can help families avoid cesarean births:

  • Do you inform parents about the cesarean rates in your local hospitals? Do you encourage them to question their doctor, midwife, or backup doctor concerning their cesarean rates?
  • Do you explain the postpartum policies at local hospitals regarding cesarean babies and make them aware of their rights and responsibilities and the possible long-range outcomes of hospital postcesarean procedures and treatments?
  • Are you aware of comfort measures for a cesarean mother's physical and emotional well being?
  • Do you have a resource list for cesarean parents? Does it include support groups, cesarean and VBAC parents, childbirth educators, midwives and doctors, counselors and reading materials--all resources that can encourage learning and growth in regard to cesarean birth?
  • Do you emphasize the importance of parents-to-be writing birth plans and requests?
  • Do you teach families about normal and natural childbirth and about cesarean prevention, including that vaginal birth after cesarean (VBAC) is both possible and advisable?

- adapted from The VBAC Workbook by Barbara Brown Hill and Lynn Baptisti Richards, excerpted from Midwifery Today Issue 2


*Have a doula with the mother during the birth process. Studies have shown that having a doula present can reduce the chance of a cesarean by 40%.

Never, ever perform an amniotomy! This reckless, irrevocable intervention exponentially multiplies the chances of increasing infection and starts the cesarean clock countdown. Remember, one of the biggest determinants in vertical infection (mother to baby) is length of time the membranes are ruptured. Plus, should you have to perform lengthy manual reduction of cervical adhesions from HPV treatments, the lack of barrier into the intrauterine environment further predisposes to infection, and the baby's bare scalp is exposed to friction from your gloves, so abrasions and infection are even more likely. Don't do it!

Some cesareans may be prevented by simply refusing to go along with the dominant paradigm characterized by surgical deliveries of multiple gestations and breeches, eroding support for VBACs, routine inductions, ubiquitous epidurals, supine positioning, restricted movement, electronic fetal monitoring and nothing-by-mouth policies. Just as protesters chain themselves to trees to prevent them from being cut down, we must attach ourselves to women to prevent them from being cut up. Think of it as maternity civil disobedience or attachment midwifery. We must all work hard to transform terror into trust, build self-confidence and courage, prevent and heal the wounds of sexual abuse, and strengthen family bonds and community health. By counteracting negative media with stories of wonderful births and viable alternatives, we must all boldly educate and inform.

- Judy Edmunds, Midwifery Today Issue 57

*It is beyond my comprehension how anyone could give a VBAC woman misoprostol (Cytotec), oxytocin, or castor oil or strip the membranes or use any other form of induction when that would triple her chance of having a uterine rupture.

- Gloria Lemay

*One of the reasons that so many of the women with whom I work have successful VBACs, even with very large babies, is that we pay strict attention to the position of their babies. Information about tuning in to the baby's position during pregnancy, in early labor, and then paying careful attention to it throughout the labor, makes a tremendous difference in birth and in VBAC outcomes.

- Nancy Wainer, Midwifery Today Issue 57


If the posterior has not been discovered until complete dilation, or if other methods have not been applied in early labor, the baby's head can still be turned to make delivery more likely. With the mother in a knee-chest position, knees slightly apart, the midwife inserts her hand into the woman's vagina. She should attempt to lift the baby's head by grasping it firmly, waiting for a contraction, then turning the baby into an anterior position. As soon as the head is correctly positioned, hold on tightly. When the uterus contracts again, urge the mother to push very hard. If the amniotic sac has not ruptured, do so now. This will assure that the position remains fixed and the baby will usually be born very rapidly. This procedure is both safe and sane, yet it must be acknowledged that it will take some physical strength to turn this recalcitrant little head against the force of a good contraction.

- Valerie El Halta, Midwifery Today Issue 36


READ ABOUT OPTIMAL POSITIONING for effective labor and delivery:

"A VBAC Primer: Technical Issues for Midwives" by Heidi Rinehart, MD, gives the basics of C-sections and VBACs, including types of incisions, types of closures, risks and contraindications for VBAC. It also includes a sample informed consent form and a list of references.

In "Choosing Cesarean Section" Marsden Wagner, MD tells us that the risk/benefit factors of C-sections depend on the reason for doing them: "Where the baby is not in trouble, the risks to the baby still exist, meaning that the woman who chooses CS puts her baby in unnecessary danger."

And that's just the beginning! Midwifery Today Issue 57 has more articles on this important topic, including "7 Steps toward Cesarean Prevention" by Judy Edmunds, CPM, "Suturing a Cesarean Wound" by Gretchen Humphries, MS, DVM, "Midwifery Care for the VBAC Woman" by Gloria Lemay, and "Cesarean Birth: What About the Baby?" by Robin Lim, CPM.

You'll also be able to read articles on subjects such as Cytotec, fetal positioning, homeopathic medicine and birth in Spain, Mexico and the Yukon.

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Check It Out!

A Web Site Update for E-News Readers

BIRTH WITHOUT BLOODSHED is one of several conference audiotapes about cesarean section that are offered at the Midwifery Today storefront.


GENTLE BIRTH CHOICES, book by Barbara Harper. This well-loved book guides readers through empowering birth choices.

Midwifery Today's Online Forum

I know that tea-tree oil is excellent to cure and prevent candida. Can someone tell me how to use it for vaginal candida?

Go to our forums to share your thoughts and experience.

Question of the Week

Has any one had experience with pertussis contracted during pregnancy? I have searched all the textbooks I have, many from local medical library, and the Internet with no significant results. My common sense tells me it could cause PROM, fetal and maternal hypoxia, and very possibly preterm labor. Any information?

- Susan Padilla

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Question of the Week Responses

Q: I am 30 weeks pregnant with my second child. Breastfeeding was tremendously difficult for me with my first child because I have extra large breasts and extremely flat nipples. My daughter was not able to latch on to the right breast (it's even bigger than the left one) and rarely latched on the left. I used pumps and syringes to bring the nipple out but the nipple never stayed extended long enough for an effective latch on. I very much want to breastfeed this baby. Does anyone have suggestions?

- Anon.


A: Can the baby's dad, who would be stronger than the baby and maybe better than a pump, help extend the nipples? I've read they will eventually stay out better on their own if you keep at it.


A: If you are not at risk for preterm labor, I would recommend wearing breast shells (with the back disk with the smaller round opening in place) for several hours a day during the remaining weeks of your pregnancy. They may help make your nipples protrude farther. Definitely find a lactation consultant in your area who'll be a resource for you after you deliver. Only with a lactation consultant's assistance would you want to consider using nipple shields to facilitate the latch initially. (These can cause serious problems when used indiscriminately.) Occasionally, the brief application of ice is helpful just prior to offering the breast to the baby. Finally, remember, this is a different baby, and, in combination with the likelihood of your milk 'coming-in' sooner for the second baby than for the first, the problem may not repeat itself!

- Kate Adams


A: I suggest you find a lactation specialist through your provider or hospital or birth center or La Leche League. They often can help you hands-on both before and after the birth with successful nursing. La Leche League would also be a good resource, both for advice and support meetings.
You might consider using breast shells (or Netsy cups) starting at 36 weeks. They fit in your bra and gently draw out your nipples. When nursing, if a pump or the baby can't bring a nipple out, and if the baby is unable to latch on, the lactation specialist might suggest temporarily using a nipple shield. There is a modern kind that is more successful that what was used 15 years ago. Also, if latch-on is again a huge problem, you might consider whether it's worth it to you to pump your colostrum and milk out and feed it to the baby with a bottle. Certainly not ideal or easy to keep up long-term, but if that's the only option in the end your baby would still benefit from your milk.

- KM

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California Association of Midwives Conference

California Association of Midwives presents 23rd Annual Conference Retreat and General Meeting
October 12-14, 2001

Hidden Valley Center for the Arts
Carmel Valley, California.
Questions about the conference? Contact Tammy 831-338-1712 or the California Association of Midwives 1-800-829-5791


Midwives, how do you approach the matter of infertility when couples come to you with a need for advice or support? What have you found that works? And how do you charge for this service if you do offer it?

- Shannon Bohjanen, apprentice


I am a second-year direct entry midwifery student in New Zealand. At the moment my sister is expecting her fourth child and is undergoing an elective caesarean section. My sister asked for my opinion on tubal ligation at the same time as the section. What is your view on having this done at the same time in respect to effectiveness and recovery. If anyone knows of a website I can access that would be much appreciated.

- Cheryl Goodall


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