June 12, 2002
Volume 4, Issue 24
Midwifery Today E-News
“Premature Rupture of Membranes (PROM)”
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Quote of the Week

"The best way to avoid a cesarean is to stay out of the hospital."

- Brooke Sanders Purves

The Art of Midwifery

Pelvic Press: Use this technique during second stage if there is a delay in descent or caput forming due to malposition or cephalopelvic disproportion. It also is helpful in occiput posterior babies, deep transverse arrest or a tight fit. It increases mid-pelvic and outlet dimensions to make room for fetal rotation and descent. The woman is in a squatting position, the partner or caregiver kneels behind her; during a contraction this person locates the iliac crests and presses them firmly toward each other. When combined with squatting, movement in rotation or descent should be visible in three to four contractions.

- From Labor Progress Handbook
by Ruth Ancheta & Penny Simkin

submitted by KarieAnn Zeinert, doula

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

News Flashes

A University of California at Davis School of Medicine study found that extending breastfeeding from four months to six months after birth greatly reduced the number of respiratory infections. The study of 2,277 children between the ages of 6 and 24 months identified five groups: formula-fed only, full breastfeeding for less than one month, full breastfeeding from one to four months, full breastfeeding from four to less than six months and full breastfeeding for six months or more. Researchers found that the chance of contracting pneumonia was reduced fivefold with two added months of full breastfeeding, and the risk of recurrent ear infections was reduced twofold. This is one of the first studies to show that breastfeeding longer adds to its benefits. The U.S. Department of Health and Human Services plans a campaign starting in 2003 to encourage breastfeeding. In the United States, 64% of women breastfeed their newborns but only 29% continue for at least six months.

- The Sacramento Bee,
May 6, 2002, page B1

Premature Rupture of Membranes (PROM)

Question the mother about the following:

  • the amount of fluid that was lost
  • degree of inability to control the leakage
  • time of rupture
  • color of fluid
  • odor of fluid
  • last sexual intercourse or use of vaginally inserted products.

Laboratory tests can confirm the presence of amniotic fluid:

  • nitrazine test
  • vaginal pH determination
  • nile blue sulfate staining
  • amniotic fluid arborization (fern test).

Midwifery Parameters of Safety
Midwives who adhere to a preventive philosophy and encourage their clients to do the same decrease the number of incidences of PROM. By educating their clients to eat a good diet and maintain good hygiene, avoid smoking and drugs, and clear up any vaginal infections, fewer cases of PROM occur.

Many midwives, after having dispensed the appropriate precautions to their client, will wait up to two weeks for labor to commence. Women who are 37 weeks or more may be encouraged to stimulate labor by various methods.

PROM and the Preterm Fetus
Thirty to fifty percent of preterm labors occur after PROM. Women with preterm (before 37 weeks) PROM should have white blood cell counts, with differentials, done every other day. They should be compared to counts taken earlier in the pregnancy.

For very early PROM, most women will be given the usual precautions: bed rest and a tocolytic drug such as ritodrine. For those closer to term (35-36 wks), precautions will be given and the preferred treatment is waiting. Fetal lung maturity accelerates after membranes rupture and most healthy babies if larger than 2,550 grams will be good candidates for a homebirth.

Risks and Complications
An unengaged fetal head can cause cord prolapse if the amniotic fluid rushes by, taking the cord with it. A small or premature baby may have a cord prolapse because there is enough room for the cord to pass.

A woman with prenatal infections such as Gardnerella or Beta strep is at increased risk of PROM. Infections may predispose a woman to PROM by weakening the bag.

A study by Dr. Lewis Mehl in California showed that infections dramatically increased after the fourth day. Another study in the Netherlands of 6,014 pregnancies found no increased risk of infection for PROM if no vaginal exams were done and delivery exceeded 24 hours from PROM.

Signs and Symptoms of Infection
Chorioamnionitis occurs when the two layers of the placental membranes, the chorion and amnion, become infected or inflamed. No one sign or symptom should be used as the only criterium for diagnosing infection. Some indications of infection are: maternal fever, seen in 85-100% of infected women; fetal tachycardia, 180 or more; chills; uterine pain and tenderness; foul vaginal discharge; low blood pressure and increased pulse; vaginal walls unusually warm to the touch; elevated white blood cell count.

Testing for Infection
Check white blood cell count with differential every other day.

Gram staining of the amniotic fluid can identify infection in up to 80% of women when the level of organisms has reached or exceeded 105. However, the presence of bacteria is suggestive and positive results should not be interpreted as confirmation of infection. Acridine orange staining may be used if gram staining yields a positive result because it can also detect mycoplasmas.

Gas-liquid chromatography is a reliable test. Others include C-reactive protein, leukocyte esterase test strip, and glucose levels in the fluid, although these tests have been reported to have questionable value.

Cesarean Section
The cesarean rate is 30-50% for women who are induced to deliver within 24 hours of PROM. Because most women will spontaneously go into labor within this time frame, the patient and wise birth attendant will wait.

Suspected causes of PROM include polyhydramnios, fetal malpresentation, multiple gestation and prenatal maternal genital infections. Repeated vaginal exams during pregnancy may predispose some women to early rupture. Some maternal genital infections that may predispose a woman to PROM are Gardnerella vaginalis, herpes, ureaplasma urealyticum, mycoplasma hominis, Bacteroides bivivus, group B strep and E. coli.

- Yvonne Lapp Cryns, "PROM by the Book,"
in Wisdom of the Midwives: Tricks of the Trade Vol. 2, a Midwifery Today book

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With Woman: Birth Language

Midwifery Tip from Gloria Lemay
compiled by Leilah McCracken

Optimal Use of Language ("Speech Magic") to Assist our Clients

The only way we can undo the mass psychosis about childbirth in North America is to invent new language and new images. We midwives must make a conscious and disciplined effort to become "speech magicians."

I train my clients to ask for what they WANT rather than what they DON'T want. For example, the client doesn't want an episiotomy = the client wants an intact perineum. Or a client says "I don't want my baby taken away from me! = the client says "I want my baby 'Velcroed' to my skin from the moment he/she is born." All my notes in my chart are what the client WANTS, not the "Don't" instructions. This way, I am constantly picturing the image of what is wanted and so are my assistants. When everyone is picturing "Baby Velcroed to skin" then it happens. This technique is particularly effective at hospital births.

Another good way to create what you want with doctors is by using "indirect" hypnosis. For example, the doctor is starting to fidget as the baby's head distends the perineum. He reaches for the scissors and you know he's getting ready to do an episiotomy. So you speak to your client, not to him by saying something like "Linda, you are stretching beautifully; there's lots of space for your baby to come through. Everything is healthy and normal -- there's lots of room to stretch even wider. Breathe some oxygen down to your muscles." Everything you are saying to your client is really intended to chill out the doctor. Speaking to him directly is less effective (it makes him more resistant to your message) than speaking obliquely to him through your words to the mother. Once the doctor starts taking deep oxygenated breaths down to his muscles, you'll see him put down the scissors.

You'll notice that Dr. Odent does word magic, too. He talks about the "fetus ejection reflex" and the "ancient reptilian brain." I don't think anyone has ever located these things in the physical universe, but they are most useful concepts and ways of languaging that lead to better births for women and help undo some of the fear-based pseudo science that passes for obstetrics.

Gloria Lemay is a private birth attendant in Vancouver, BC, and is a contributing expert at BirthLove.

Read more from Gloria's article "Pushing for First-Time Moms" on Midwifery Today's Web site.
The article is also available online in French and Spanish.

Question of the Week: Inverted Nipples

Q: I am 16 weeks pregnant for the first time at 36. I worked as a midwife for 4 years. I have deeply inverted nipples that are resistant to any attempt at rolling or suction and have been all my life. I would very much like to breastfeed my infant but have only seen failure in similar cases in hospital. Does anybody have advice/tricks that I could try in preparation?

- N Sutton, RGN, RM

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Question of the Week Responses: 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

A: Gentle choleretic/cholagogue herbs that are safe for pregnancy include burdock root, dandelion whole plant and yellow dock root. Both move bile through the gallbladder (choleretic) and stimulate the liver to produce more bile (cholagogue). The herbs can be combined and made into a tea, perhaps 2-4 cups sipped throughout the day. Alternately, tinctures are used either as simples or a mixture: one dropperful in a little warm water four times per day. In addition, use dandelion whole plant tincture as a bitter tonic by placing 5-10 drops on the tongue before meals and snacks. Bitters help set things up by stimulating the secretion of digestive juices all along the GI tract.

To help cope with unpleasant itching, scullcap tincture is my favorite. If your sister is brave she can drink the very bitter tea, which would also support her liver. I wonder if a relaxing oatmeal bath would also soothe her?

Your sister may be tempted to avoid fats right now. Even so, after a week or two on the herbs, I would recommend that she ingest some fish oil daily. The essential omega 3 fatty acids found in fish oil are major components of breast milk and the rapidly developing fetal nervous system. They also decrease the inflammation around the bile ducts that occurs in cholestasis.

- Adrienne Leeds,
herbalist and midwifery student

A: You will find an underlying problem of a stressed liver. I would address this by immediate use of dandelion tea: begin with one cup on day one, two on day two, and three on the third day and until birth, plus a few weeks beyond. I would expect my client to feel better within several days.

- Molly Germash, CPM,
Dallas/Ft. Worth, TX

A: I am a CPM and graduate RN. I recently worked with a primip who had cholestasis. Repeated attempts were made in the hospital to induce her beginning around 38 weeks -- they were unsuccessful. Her bile salts were high but not too far above the high end of normal. (Really high levels are cause for more concern.) She was managed by CNMs with Ob-Gyn consultation. The management style adopted was watchful waiting, but no one was alarmist. Finally she was given the option to go home and wait a few days before attempting induction again, with daily nonstress tests in the plan. The baby was reactive and great all along, which helped allay concerns. The parents were alarmed by dire information they had picked up on the Internet. With reassurance they were happy for respite from induction. Mom ended up going into labor spontaneously around 41 weeks and labored well but ended up with a cesarean due to persistent OP presentation. More research must be done about this condition and appropriate management. The itching is severe at first, but should subside.

- Jennifer McGeorge, CPM

A: This happened to me too, but it resolved on its own after about one week without medications.

- Anonymous

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 is 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!

Re: difficult clients [Issue 4:23]: At no point does the article suggest that the midwife should reflect on her own behaviour if the mother shows herself to be difficult. Written birth plans are seen as aggressive and fearful of birth when they could be a result of assertive behaviour and knowledge of an overly interventionist hospital. Women who are overfriendly are seen as being difficult, instead of reacting to a system of care that demands they have no previous knowledge of the important caregiver in a frightening and difficult time and is trying to make the best of the situation by getting to know her caregiver in a short space of time.

A woman's reaction to the oppressive authoritarian system in hospitals is not to blame if women become childlike in labour. No, it is due to previous ways she has had to cope with life.

I spend some time on my local Maternity Services Liaison Committee in the UK as "patient representative," trying to ensure that doctors, midwives and NHS managers do not spend their time blaming women for their own bad practice, inability to communicate and insensitivity to women's needs at this momentous time in women's lives. I frequently have to defend women against comments such as "the sort of women we get in here." This article would do much better to analyse why, if midwives' behaviour is not "adult," what happens to women. It would be better to analyse what happens to sane, assertive, intelligent women when treated inappropriately by hospital staff and how easy it is to change these women into "difficult clients."

- Susan Treacy Wolverhampton, UK

Re: fistula [Issue 4:23]: How VERY distressing for you -- so many areas of yourself affected by what should have been a beautiful, exciting experience. I don't have much knowledge about fistulas; however, one thing I would consider asking is what type of suture material was used for repair. I have seen women who have reacted to manufactured synthetic suture material such as Dexon, Vicryl, etc. and whose stitches "broke down" before complete healing took place, or whose healing was prevented by an allergic reaction to the suture material. The next wound they had was sutured with organic suture material (Chromic "catgut" and silk) with no problems.

- MJM, midwife

I too developed a fistula after the delivery of my first child. I was laboring fine at home, got to the hospital, was offered a bed, an epidural, Pitocin, etc. and ended up with a face-presentation baby who was a bit big for me. The doctor gave me a fourth degree epidural and the baby was vacuumed out. I noticed only air leaking and was told not to worry, this was normal. Two babies and one unsuccessful corrective surgery later I also do not know how to really fix the problem.

- Kim, CT

There are stories on my Web site, BirthLove.com, about fistula. You're not alone by any means.

- Leilah McCracken

Re: tight vaginal opening months after birth [Issue 4:23]: If the skin or vagina feels too tight, you may try a perineal massage. Basically you sweep with two fingers down in and on the vaginal opening. Use lubricant or natural olive oil or something similar. By doing this on and off for some time, you condition the skin to stretch. For future pregnancies you may take a bit more time and ease stretching to avoid a tear, but easing the baby out is best anyway.

- Heather Zanon

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.

A thriving midwifery birth center in Juneau, Alaska has employment opportunities for direct-entry midwives, certified nurse midwives and/or midwife-friendly MDs. Must qualify for Alaska licensure. We also have internships for student midwives. 907-586-1203 or www.juneau.com/birthcenter.

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