June 5, 2002
Volume 4, Issue 23
Midwifery Today E-News
“Difficult Clients”
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Quote of the Week

"It is amazing to witness a water being become a land creature, an air creature, passing through [the ring of] fire. All the elements participate."

- Lois Hubb

The Art of Midwifery

Doula trick of the trade: One of my favorite positions for a laboring mom is back-to-back sitting on the bed. Mom sits up straight on the side of the bed with legs crossed in a tailor-sitting position or resting on a chair or lap. The partner or doula sits behind her; their backs are pressed firmly together. This position works very well with a tired mom who wants to remain upright, with mom on the monitor, or while mom gets a foot massage. When I am behind the mom, I love that she can really be focused on her partner in front of her but still feel fully supported by her doula. I can talk her through a contraction if need be, but I often use the time to chart or even catnap sitting up. Moms love the way it feels on a tired back, and so do I!

- Rachel Hansen

Share your midwifery arts with E-News readers! Send your favorite tricks to:

ALL BIRTH PRACTITIONERS: We encourage you to continue to send in your favorite tricks of your trade!

News Flashes

Homebirths are no riskier than hospital births, according to the first major Canadian study to compare the two types of deliveries. The study compared 862 planned homebirths in British Columbia with 571 midwife-attended hospital births and 743 doctor-attended hospital births between January 1998 and the end of 1999. It found no increased maternal or neonatal risk associated with planned homebirth under the care of a regulated midwife. The research did find homebirths slightly more associated with complications such as maternal bleeding, need for infant respiratory care and even infant death, although the numbers were so small they were deemed to be statistically insignificant. Of the women in the homebirth group, 31 (3.6%) required emergency hospital care for complications ranging from breech delivery and reduced fetal heart rate to respiratory distress.

Researchers found that women who deliver their babies at home are less likely to undergo any of the range of medical interventions that generally accompany hospital deliveries: epidurals, episiotomies and medically induced labour. Only 6.4% of women giving birth at home had cesarean sections, compared with 18% of those births overseen by a physician. There were three infant deaths in the homebirth group compared with one in the hospital setting. The infant mortality rate with homebirths is below the provincial average.

- Canadian Medical Association Journal,
February 5, 2002
(Submitted by Maggie Ramsey)

Difficult Clients

EGO STATES: In transactional analysis, Eric Berne, MD, describes three different ego states: parent, adult and child. In your role as midwife or other birth practitioner, you will improve your communication with difficult clients by being conscious of your ego state. The goal is to be in the adult ego state as much as possible.

  1. Parent: "Critical parent" or "nurturing parent." Shadow side is codependency -- possibly enabling or patronizing.
  2. Adult: The "reality reader" who sees the situation as it is -- the ideal adult who is able to listen and who can develop communication skills. Regardless of your client's state, you stay in the mode of reality reader, able to respond rather than to react.
  3. Child:
    • Natural child: untrained, spontaneous, impulsive, expressive
    • Attached child: whines, complies, rebels
    • Sleepy child: goes away, disassociates, sleeps a lot
    • Spunky child: mischievous, rebellious
    • Spooky child: fearful, takes things personally. Three major fears: suffocation, fear of abandonment or being invisible, fear of annihilation. The more fiercely defensive someone is, the greater his or her fear.
  • When you are having frequent difficulties with a client, her childhood issues may be being triggered. Keep the issues current and stay in the adult ego, responding, not reacting.
  • If a woman does not respond well to healthy boundaries you set for yourself as a midwife, then you are in trouble. Each of us must decide what limits are healthy for us. Burnout is often caused by lack of boundaries. Better to have disagreements in the prenatal period than in labor. Communication about boundaries can make or break the midwife-client relationship.
  • If a situation feels unworkable, it is important to let the client go. Chalk it up to experience. Make sure you are schooled in the correct legal and political method, however, to avoid being charged with abandonment.
  • A woman who has very particular opinions about standards of care may prove to be a difficult client. If the client signs a waiver, you nonetheless must be sure you are truly comfortable working with her. You are the one who will be held responsible -- if not legally, at least in your medical community -- even if a client signs a waiver.
  • Although midwifery is not about control, it is not about being controlled either. It is a cooperative venture.
  • A woman who intellectually tries to control labor with a long list of demands often does not feel safe in the world and does not trust. Help her get in touch with her need to control -- but she may have a hard time hearing what you are saying.
  • The codependent woman focuses on everyone but herself and in this way does not deal with her own need and pain. These women have learned to deal with their pain by focusing outside themselves, and they have a difficult time focusing within -- making birth difficult.
  • Women who get too friendly too quickly may have issues of severe abandonment. She may make you into a goddess one moment and an enemy the next. Watch out for your own needs; set appropriate boundaries.
  • The client who sees herself as a victim is not a good risk for a homebirth. Be blatantly honest with her, saying things like "I am really concerned that no matter what I do and no matter how well I care for you, somehow you will find a reason to blame me." A woman who can then talk about her issues no matter how complicated is a much better risk than a woman who is totally in denial.
  • If a client displays inappropriate behavior, she may be coming from the ego state of a child. She may therefore feel easily shamed and criticized and may take things you say personally. Being honest is always best; however, your client may become alienated easily.

Remember, you must look at a woman's pattern of behavior, not just what she is saying in the moment. The behavior you're having trouble with is how your difficult client has learned to cope in the world. It is how she has survived. Don't blame. However, remember that her behavior can affect her birth and be dangerous to you as her midwife.

- excerpted from "Working with Difficult Clients," by Joanne Dozor, RN, CPM,
The Birthkit No. 29, Spring 2001

Mothering magazine

Mothering magazine

Mothering celebrates the experience of parenthood as worthy of one's best efforts and fosters awareness of the immense importance and value of parenthood and family life in the development of the full human potential. As a readers' magazine, we recognize parents as the experts and wish to provide truly helpful information upon which parents can base informed choices.

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Midwifery Today's Online Forums: Herbs for Scarred Uterus

What herbs would be best for strengthening the uterus, particularly the area scarred from previous c-sections? I know about red raspberry leaf, but what else? And would it be better to start taking them before pregnancy?

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Question of the Week: Cholestasis

Q: At 30 weeks gestation, G2P0, my sister is experiencing cholestasis of pregnancy. She has high bile acid levels and an unrelenting itch. They have tried solu-medrol pack, Questran rx, all to no avail. Any ideas for treating this condition? What about the baby?

- Ellen Haynes, RN ICCE

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Question of the Week Responses: Nursing while Pregnant

Q: Are there any studies, observations or research that indicate a correlation between nursing throughout pregnancy and postdate babies? A friend/LLL leader and I have compared notes and see a correlation: moms who nurse throughout pregnancy and especially moms who tandem nurse throughout pregnancy seem to grow their babies for a bit longer.

- Carrie Foster Evans, future CBE

A: I went past my due date and I was nursing my 3 year old throughout my pregnancy. I was due on Jan. 23 and I delivered on Feb 3 at home. I went past my due date by 9 days with my first baby as well. Was this a connection with the nursing or am I just a late birther -- who knows?

- Jennifer Pridmore,
LLL Leader & student CBE

A: I too have seen a correlation between nursing through the pregnancy and longer pregnancies. I am a childbirth educator and see many couples who use liberal midwives or choose to birth unassisted (so they carry until they labor, not getting induced) and regularly I see 2-, 3-, and 4-week-overdue mamas with older nurslings. It is interesting to note, though, that I haven't seen or heard of any truly postmature babies; all babies have been healthy although a little bigger than average!

- Augustine Daniels,
Bordentown, NJ

A: I breastfed throughout my second pregnancy; my daughter was born 17 days past her due date. That was more than four years ago. She and her six-year-old sister are still nursing.

- Veronika Robinson

A: The Breastfeeding Answer Book refers to two studies related to breastfeeding in pregnancy:

  • Moscone, S. and Moore, J. "Breastfeeding during pregnancy." J. Hum Lact 1993; 9(2):83-88. Assures mothers that nursing does not cause premature births.
  • Merchant, K. et al. "Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals." Am J Clin Nutr 1990; 52:280-88. Shows that newborn weight is unaffected by sibling nursing.

Perhaps these studies could give you the data you were looking for.

- Pam Easterday,

A: My then-3 1/2 year old nursed several times a day throughout my last pregnancy. His sister was born only 2 hours after her due date.

- K.P.

The BirthLove Web site has helped many women grow trust in birth and in their bodies. It has helped women resist Cytotec, find good midwives and stop believing everything their doctors say. There are hundreds of homebirth stories: unassisted VBAC, fathers' stories, twin (and triplet home VBAC!) stories, breech stories -- for things that people get sectioned for daily, there are homebirth stories on the site. Marsden Wagner, MD is a contributing expert, as are Sarah Buckley MD, Gloria Lemay and Gretchen Humphries. BirthLove has changed and saved lives through education, communication and love. Become a member of BirthLove today and be inspired!


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!

I gave birth last year and had fourth-degree tears and also had an episiotomy. I had complications and ended up developing a rectal-vaginal fistula. I had surgery seven days after I delivered to try to fix the problem, but it was unsuccessful. I broke down in two weeks and developed fistulas again, this time rectal-vaginal and rectal-perineal. Six months later I was referred to a specialist and had surgery again. I thought everything was healing until a few months ago when I began to drain stool again. I have developed another fistula. This was my first child, and I am very upset. I don't know what to do or who to trust anymore. Do you have any advice for me?

- Unsigned

Re: breastfeeding and HIV [Issue 4:22]: Certainly a lot is still unknown about the subject, and it is difficult to have a valuable opinion about such a difficult concern. There is a Web site dedicated to HIV and breastfeeding, with interesting articles, presentations, press releases and position papers: http://www.anotherlook.org/

- Francoise Railhet,

After reading some of the other reports on HIV and breastfeeding I was led to believe that while HIV transmission rates might be higher in babies that were breastfed longer, the actual mortality rates were lower than for the infants being fed artificial milk, especially in developing countries. This is important to take into consideration if one were making the decision to breastfeed when HIV+.

- Fiona

I birthed naturally seven months ago, and I think the midwife put one too many stitches on my minor perineal tear. Intercourse is still uncomfortable and it is not because of insufficient lubrication. Does anyone know what can be done? Will it affect future childbirth?

- Loredana

Re: VBAC after several previous cesareans [Issue 4:22]: There is a page about VBAC after two or more caesareans on my site, www.homebirth.org.uk

You can also access the full text of a recent BJOG article on a vaginal birth after three caesareans: Sharma S, Thorpe-Beeston JG. Trial of vaginal delivery following three previous caesarean sections. BJOG. 2002 Mar;109(3):350-1

- A.H.

EDITOR'S NOTE: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


The International School of Traditional Midwifery in Ashland, Oregon is accepting enrollment for Fall 2002 classes. Contact us at 541-488-8254 or visit us at www.globalmidwives.org

Better Birthing With Hypnosis. The complete Leclaire Method, classes since 1989. Books, trainings, audio and video tapes, CEU's. http://www.leclairemethod.com. Call (310)454-0920 for free information. birthing@gte.net

"Returning Birth to the Family" Midwifery Conference in Asheville, NC -- August 23-25th. Grand Midwife Margaret Charles Smith, Wise Woman Herbalist Susun Weed, Waterbirth Pioneer Marina Alzugaray. Southeast MANA meeting. Contact Cheryl -- 828-628-6345 or ancientheart9@aol.com or www.thematrona.com

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