November 7, 2001
Volume 3, Issue 45
Midwifery Today E-News
“Prenatal Care”
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Quote of the Week:

"You don't have to do the service, the sacrificial part, or do a certain number of births each year to be a good midwife."

- Sister Angel Murdaugh


The Art of Midwifery

Prenatal care consists of documenting the weeks, weight, fundal height, fetal heart tones, blood pressure and pulse. I also do palpation for size and position, and a urine test. This takes about 20 minutes. The rest of the one- to two-hour prenatal consists of talking. We discuss anything and everything--supplies, techniques, birth visions and plans, complications and concerns, relationships, feelings, what's for dinner. It's different every time. It's not so much the content as the contact.

- Jill Cohen, Midwifery Today Issue 24

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News Flashes

In women with gestational diabetes mellitus (GDM), discrepancies between 1-hour and 2-hour postprandial measurements vary depending on the time of day at which they are taken, according to a study undertaken in Israel. Sixty-eight women newly diagnosed with GDM were instructed to measure capillary blood glucose at fasting and 1 and 2 hours postprandial after meals for 1 week. The rate of abnormal glucose levels per person was 27.1% during fasting and 17.8% and 17.2% 1 and 2 hours after meals, respectively. Following breakfast, glucose was elevated in 22.4% of patients after 1 hour, but only in 8.5% of patients after 2 hours (p = 0.002). After lunch, the two values did not differ significantly. Following dinner, more 2-hour measurements were elevated compared with 1-hour measurements, at 30.1% and 16.3%, respectively (p = 0.0035). The researchers suggest these differences may be attributed to varying meal composition or to increased insulin resistance in the morning hours.
- Am J Obstet Gynecol 2001;185:604-607.

Prenatal Care

I had prenatal groups gather in my home. Pregnant women and those with babies and young children would come, sit around, drink tea, and share their collective wisdom and stories. Even though American society currently supports birth education, I have found there's no better way to learn than from other women and men who have a wealth of experience and information to share. I have seen women and their families grow in confidence, awareness, and understanding of the pregnancy process by listening to others, considering carefully and sifting through information. This learning process is very transforming and empowering. Friendships develop and deepen.

Groups typically consist of six pregnant women, one father, three children ages two to four and two midwives. Visiting relatives are always welcome. We ask that everyone arrive promptly to the meetings, which last one to two hours. We exchange names and begin with a simple question: Any stories, questions or information for the group? The only rule we have is that we must stick with one topic at a time.

If a member is reluctant to share difficult past experiences, we must provide a nonjudgmental atmosphere and directly ask for the story. The facilitator may lead a bit but mostly follows the direction the speaker takes. It takes time to build the trust to share pain, and the facilitator must be sensitive to this process. We also encourage participants to keep a journal.

Having babies and children in the group is essential. When tears begin to flow, very young children invariably give hugs and kisses. As for the unborn babies, we check them at the end of the discussion. We check blood pressure and encourage the parents to include the baby in their talks.

My real work as a midwife has been to get out of the way, and let women do their work. In such an intimate group setting, boundaries must be maintained and the process turned back to the participants. The midwife's role in this is to be a guardian. We bring the circle together and facilitate the linking. Then we slowly back away from the circle and extend our arms to protect and watch over them.
- excerpted from "Group Prenatal Care" by June Whitson, Midwifery Today Issue 24

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When a woman comes under your care, assume she's undernourished. The majority of women have no idea that diet is important, even today. And if a woman comes to you late into her pregnancy and you haven't seen her before, it is never too late to get her started on the nutrition program to prevent toxemia. Never. Tell your women to learn to graze. Small, frequent feedings is a fine way to increase dietary volume and value. Tell them not to pass the fridge or the fruit bowl without having a glass of milk, just one more egg, a small sandwich, an apple. The only guideline I ever gave was "Eat according to your appetite (good foods), salt to taste, drink to thirst (I caution against drinking too much water), be active and exercise, and rest when you're tired."

Every aspect of labor is easier of the woman's diet was good during her pregnancy. Women who eat conscientiously and train to become "birth athletes" do not exhibit a lot of pain during delivery, and they find breastfeeding far easier as well. Tell women that if they eat enough calories, the protein goes to the baby and to the breast, where it belongs.
- excerpted from "What Can Midwives Do?" by Tom Brewer, Midwifery Today Issue 40

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Health professions can have a spectacularly positive effect on the emotional state of pregnant women through their vocabulary, their attitude and even their body language. They can also encourage, or even organize, events that are outside the framework of medical consultations. In the maternity unit at the Pithiviers hospital in France, we used to meet around the piano and sing together on Tuesday nights: pregnant women, young mothers and newborn babies, midwives, cleaning ladies, secretaries, and so forth, could join the group. After singing, and often dancing, there was an atmosphere of happiness and even euphoria. Such sessions were probably more beneficial for the growth and the development of the fetuses than would be a series of sophisticated ultrasound scans or a Doppler screening of placental perfusion.

The brain is mostly made of fat. This means that its basic needs must be first expressed in terms of lipids. Without being too technical, we must recall that the brain of the fetus has a real thirst for highly unsaturated fatty acids, particularly those of the omega-3 family. The mother-to-be can use two ways to satisfy the huge demand for such fatty acids.

The first is direct: have a diet rich in preformed, highly unsaturated omega-3 fatty acids. This means eating sea fish from the beginning of the sea food chain such as sardines, pilchards, herring, or common Atlantic mackerel.

The second is indirect. It is to make sure that the maternal body will be able to transform the parent molecule of this family, which is abundant in the land food chain, into longer and more desaturated molecules. Yet certain hormones, such as cortisol, are blocking agents of the metabolic pathway of unsaturated fatty acids. People who are not happy release cortisol at a higher level, typically when they feel dominated by somebody (e.g., an authoritarian spouse) or by a situatoin. We con conclude, from modern scientific data, that it is better for a pregnant woman to be happy.
- excerpted from "Eat Sardines, Be Happy, and Sing!" by Michel Odent, MD, Midwifery Today issue 59


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Midwifery Today's Online Forum

As a new doula, I'm curious to know how other doulas feel about suggesting/offering herbs (to calm nausea, strengthen uterus, for overall health) to their pregnant clients. I consider a huge part of my role to be nurturing and empowering a woman to learn about and take care of her body. But I also realize this may become sticky if my client is working with a doctor (or midwife) who opposes the use of herbs or with someone who doesn't communicate well with me. This could also be a problem if the mother has some kind of condition that she didn't share with me. I am also wondering about the legalities of using herbs.

- Kiva

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Question of the Week (repeated)

Q: Has anyone developed her own system for newborn gestational age assessment? The New Ballard Scale seems more elaborate to me than is necessary for term babies who are born at home. I know that experienced midwives can quickly look over a baby and estimate the gestational age, but for now I would like to find a concise format to document characteristics for EGA.

- Amy Kieffer, student midwife

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Switchboard

One of my students described attending a hospital birth in which the physician applied pressure to the big toe of a woman who had just delivered. She said it helped the placenta to separate. Does anyone know about this practice and the details of where to press, etc.?

- Anne Katz, RN PhD
Winnipeg, MB, Canada

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I had a tubal reversal that seems to have been unsuccessful because of scar tissue. I would like to know more about Bromaline--how it works, where to buy it, how to use it, etc.

- Tammy Kimble
Cabins, WV

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Re: Zinc deficiency and overdue babies [Issue 3:44]: I was zinc deficient with my second baby, and she was 17 days overdue. Labour was slow and sluggish, a side effect of low zinc. My daughter, now nearly four, still gets white flecks occasionally on her fingernails (zinc deficiency). I encourage women (before conception) to watch their zinc because it is involved in over 300 different processes. Women whom I have spoken to with late/slow labour babies who then had sufficient zinc before the next baby had much quicker and easier births.

- Veronika Robinson

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Does anyone know of any research that says massaging the uterus before the placenta is out either prevents or causes hemorrhage? An OB and I have different styles. I am encouraging her to not massage the uterus because it avoids causing a PP hemorrhage. She is not convinced by information printed in books stating not to massage unless there is scientific research to back it up. She thinks there is no harm in doing the massage because nothing in the research literature says not to. I cringe at her aggressiveness and would love to find something to convince her to stop this practice.

- Lis Worcester
San Francisco

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I had a student who had a long birth and was fully dilated for a long time before pushing her baby out. Now she is experiencing pain and bleeding with intercourse. She describes part of it as her "cervix hurting." Her midwife said she would heal. She also says she has acquired two hernias from either pregnancy or labor. They aren't huge but they are enough to affect her flute playing, which is her livelihood. The doctor who discovered them says they won't get better. Her midwife said they will close up. Any comments or suggestions for these problems?

- Amy V. Haas, BCCE

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Re: Story of two births [Issue 3:44]:

I have no doubt that much of the relative ease with which you gave birth is owing to your positive attitude and preparations. But birth is one of life's great mysteries and every birth is full of gifts and perfection, even if we do not see it. Many women have prepared wonderfully and still had difficult deliveries and vice versa.

As women, it behooves us to support one another. Your sister-in-law prepared for birth in the way that felt appropriate to her. And she, like you, on some level, was given an experience of labor and birth that simply was what it was- not only a reflection of preparedness or psychic state in the end so much as the perfect experience needed at the time, full of its own hidden gifts. When we judge each other for the way we prepare for or give birth or we allow our egos too much self-congratulation for how much "better" we did it, the Universe/Spirit/God may in turn bring us a difficult experience of our own to bring us back to a state of compassion and humility. In Sufism, there is the jalal and the jamal, the difficulty and the beauty, given by God at different times in life according to what is needed for growth. But the wise seeker welcomes both without judgment and accepts the gifts inherent in both. This surrender is one of the great
lessons of birth.

- Julie Cooper, CD, PLCSW, healer, mom-to-be

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The sentence at the end of the birth story jumped out at me: "You can't control birth, but you can make an impact on how it will be from your thoughts and feelings." I plan to use this as my opening statement for future childbirth education classes. It is such a powerful message. So many women want to control the labour and birth processes and this statement is a great introduction to the fact that it can't be controlled any more than we can control the sun and the moon. But we can have an impact--either negative or positive. It really is up to each of us as individuals.

- Alesa

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It is obviously her position that being relaxed and at ease with her body contributed to an easy birth and her sister's uptight attitude about birthing resulted in her difficult delivery.

I tend to agree with Abbie, but I think I should point out another possible explanation. Perhaps Abbie could be so relaxed about her body because she was feeling well and her body sent her signals that her pregnancy was proceeding normally and her delivery would go easily and quickly. With those kinds of signals it would be easy to relax and really get into the pregnancy with journaling, meditation, information-gathering and all the other things she did.

Contrast that withher sister-in-law whose, body was perhaps not handling pregnancy well. Her body was signaling to her that she was going to be in for difficulties later on and so she was very uptight and worried. She had no desire to learn everything she could or do meditation or journal because she was facing up to the horrible delivery her body was signaling. Water delivery, homebirth, and everything else would have been impossible or even dangerous for her. Meditation and journaling would have focused her fears in bad ways. Concentrating on horror stories of survivors was her way of mentally preparing herself.

I'm afraid I was once quite insufferable with some of friends who ended up with c-sections. Now that I am studying variants of folate metabolism in great detail. I am see that some women with perfectly normal-appearing early and midpregnancies may well carry a genetic complement that puts them in the path for complications like preeclampsia, no matter what they do "right" during pregnancy. I'm sure we've all seen women who did everything "wrong" and then dropped their babies with ease.

I try to no longer look upon women who insist on hospital deliveries in level four health care facilities with NICUs and specialists in attendance "just in case" as psychological cowards, out of touch with their bodies. I no longer think they go on to have complications because they are essentially neurotic about childbirth and unable to "open" or "give themselves" to the experience. Learning what I have about the genetics involved, I try to see them as women who are, in fact, very much in tune with their bodies and who sense they are going to get into trouble because of their personal genetics. They want to have everything there they may need right at hand for when they do get into difficulties. Maybe these are the women who 100 years ago would have died in childbirth instead and their choice is wise, saveing their lives and the lives of their babies.

Childbirth is about choices and education and one of those choices is the choice made by Abbie's sister-in-law. Instead of judging her we should give her the benefit of the doubt. She may well have known exactly what she was doing and may well have made the best and safest choice for her and her baby. We need to support whatever choice the mother makes and trust her to know best what she needs.

- Natalie K Bjorklund

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