July 10, 2002
Volume 4, Issue 27
Midwifery Today E-News
“Immediate Postpartum”
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THIS WEEK'S ISSUE

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Quote of the Week

"All over the world there exists in every society a small group of women who feel themselves strongly attracted to giving care to other women during pregnancy and childbirth. Failure to make use of this group of highly motivated people is regrettable and a sin against the principle of subsidiarity."

- Dr. Kloosterman,
Holland


The Art of Midwifery

It is not uncommon to see postpartum women with 3+ pitting edema. I see it very often in women who have experienced birth intervention, especially induction; epidurals with their concomitant, anesthesia-driven over-hydration; and in very hot weather. The best treatment is prevention. We can best do this by empowering pregnant women to be informed consumers and to understand the risks associated with birth interventions. The choice of midwives as care providers is an important preventative step!

Pregnancy massage is a wonderful help for pregnancy edema. Lymph-clearing massage from a person trained in this technique is enormously helpful. Also, self stimulation of the lymph system by gently compressing the sternum [as in pediatric CPR] to the depth of 1/2 inch seems to help. Natural nutritional diuretics such as those in the melon family seem to help and are very available this time of year.

- Hetty, Seattle

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News Flashes

Thirty-seven women on public assistance with at least one risk factor for postpartum depression were randomly assigned either to a four-session group intervention based on interpersonal therapy or a treatment-as-usual course. The first intervention session consisted of psychoeducation about baby blues and PPD, the second focused on role transitions, the third on setting goals and getting support, and the fourth on skills for resolving interpersonal conflicts as well as on reviewing interventions. Structured diagnostic interviews were used to assess major postpartum depression. Within three months postpartum, 33% of the women in the treatment-as-usual group had developed major postpartum depression compared with none in the intervention group. Read the study report.

Immediate Postpartum

During the latter half of pregnancy, a fluid is continually produced in our unborn lungs that diminishes in volume 48 hours before our birth. This fluid is thought to be produced by the pulmonary epithelium, and helps shape the space that will one day be filled with air; it also nourishes the lung's cells. Before birth the epithelium must secrete fluid, yet at birth it must reverse its function to one of absorption. Catecholamines normally released during labor facilitate this switch in function.

During the second stage of labor we move into readiness for taking our first breath. The temporary decrease in oxygenation experienced during pushing and the squeeze of the birth canal begins to set off our chemoreceptors. Within moments of birth, our oxygen rises from the intrauterine level of 25 mm/Hg to 50 mm/Hg, and then to 70 mm/Hg in the first few hours after birth.

As we lie in the birth canal our lungs are compressed so much that some of the fluid in them is forced upward into our mouth and nose. This fluid escapes, leaving behind a potential air space in the lungs. As our chest emerges, it recoils to the prebirth state, and in the absence of the missing fluid it pulls in air with the recoil. This is called "passive inspiration." The breath of life follows and involves the diaphragm muscle pulling in the air with such force as to inflate the alveoli sacs in the lung. The remaining fluid is then removed by an increase in activity in the lymph glands serving the lungs and the increased circulation to and from the lungs. This increased blood flow to the lungs happens because putting the lungs to use has opened the arteries that serve them—also bringing about the important drop in pulmonary vascular resistance (PVR).

Another factor influencing the breath of life is the shift in temperature from the womb to the outside world. The stimulation to the nerve endings from this temperature shift, as well as the tactile contact of hands, blankets, air, skin and so on, contribute to starting the rhythmic breathing of life. After the first breath, a small amount of residual air is retained, and this serves to keep the lungs inflated while the next several breaths complete the task of complete activation of our air-breathing system.

This somewhat sudden use of the lungs also serves to reduce PVR. At birth, the flow through the umbilical arteries back to the placenta ceases. The umbilical vein, however, continues to bring placental blood into the body for another three minutes. When the baby is held at the level of the birth canal or slightly below it, it increases the baby's blood volume by as much as 50-60% if the cord is not clamped for three minutes. This potential for an increase in blood volume, when combined with the cessation of flow back to placenta, dramatically increases systemic vascular resistance (SVR), which was low before birth.

- excerpted from "The Physiology of Fetal Transformation at Birth"
by Mayri Sagady, RN, SNM,
Midwifery Today Issue 34


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. For more information please visit Mothering magazine's Web site.


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Other Products of Interest

What was it like to be a midwife in the 18th century?
Read Mother and Child Were Saved, The Memoirs (1693-1740) of Frisian Midwife Catharina Schrader, and find out.

Hurry! Only a limited number of copies are available.


Read Anne Frye's extensive information about Lyme disease in her 971-page book Understanding Diagnostic Tests in the Childbearing Year. Order Anne's book from Midwifery Today's Storefront.


INTERNATIONAL ALLIANCE OF MIDWIVES
Midwifery Today's Web-based organization that networks international midwives.


Forum Talk: Oxytocin

I am looking for evidence or research that oyxtocin, regardless of its brand name, may be preserved with harmful toxins.

- Donna

To share your thoughts and experience, go to Midwifery Today's Forums.


Question of the Week: Loose Stools

Q: Do readers have insight or remedies for a pregnant mother who has had loose stools all of first and second trimester? Why does this happen, and is it normal for some pregnancies?

- Anonymous

Send your responses to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line.


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, 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!


Question of the Quarter, Midwifery Today magazine

Q: Is unity possible in this diverse midwifery community? Can we stand up for and support one another when there is such a range of philosophical approaches to training and practice?

Please submit your response by Sept. 30, 2002, to editorial@midwiferytoday.com. All responses subject to editing for content and style. Sorry, but we cannot reply to each individual submission.


With Woman

by Gloria Lemay, compiled by Leilah McCracken

Thoughts on Breech Birth

In breech birth, the first stage should be progressing smoothly. If you have a start and stop first stage, that may be a signal that the second (pushing) stage will be the same way. You do not want this scenario with a breech -- it could be a valid indication for a cesarean. Most OBs, in hospital, want Pitocin running during breech births to make sure there is no stalling at the end. This use of an artificial hormone, of course, can cause a lessening of the oxygen supply to the baby and has no place in homebirth or midwifery practice. It's reassuring if it is a second (or later) baby that is presenting breech and not the first because the pushing stage tends to be more rapid and smooth.

Breech is the ultimate time in birth where we must practice the 3 Ps: "patience, patience, patience." The birthing woman should avoid bearing down for 45 minutes after full dilation is achieved to avoid the possibility of the head becoming trapped if the cervix still has another cm of dilating to do. I usually have the birthing woman get into knee/chest to get as much control over her pushing urge as possible. Even with this "no push" effort, the baby's bum will be at the introitus after 45 minutes, but you'll be assured that full dilation has been accomplished by waiting the 45 minutes. The baby's body should be birthed in 4-7 minutes after the body is out to the umbilicus.

The mother should be instructed to slowly pant the top of the head out. Great care must be taken with the birth of the top of the baby's head because a sudden great push that completely expels the head can result in a tear of the cerebral tentorum (a drumskin-like membrane that protects the brain) when the overlapping bones of the skull are suddenly freed. Bringing the nose and mouth out is all that's necessary to establish breathing for the baby, and then the mother should be instructed to halt all pushing effort and let the top of the head ease out slowly.

The breech baby has weaker neck muscles, keeps his little feet up near his face for a few days, has a greater likelihood of having dislocated hips, and has a flatter top of the head than the vertex baby. They march to the tune of a different drummer but are sweet as can be.

Gloria Lemay is a private birth attendant in Vancouver, BC, and is a contributing expert at BirthLove
Read more from Gloria on Midwifery Today's Web site: "Pushing for First-Time Moms"
Note: This article is also published online in French and Spanish.


Feedback

Thank you for including Gloria Lemay's comments about castor oil [Issue 4:26]. We all want to see women empowered to make truly informed choices about their care. Unfortunately, most birthing women tend to simply trust that their birth attendant will know what is best for them. The danger of this occurring in a homebirth environment is no less than in a hospital setting and may in fact be more insidious, because while so many of us distrust the obstetrician's medicalized approach, the homebirth midwife is regarded as especially wise in the ways of birth, as well as unintrusive and noninterventive. The definitions of these last two terms are of course relative, and midwifery, just like obstetrics, is based in traditions that are not always safe or beneficial.

I came to understand this first from experience. My labor was not difficult, but it was longer than average. My midwife encouraged me to drink castor oil to speed up the process. Eager to escape the tedium of labor and to see my baby, I agreed. It was a huge mistake. The stomach cramping was severe and compounded the pain from my contractions, which were now coming fast and furious. Back labor was very painful [in subsequent births], yes, but do-able; my castor oil labor was a tortured hell. Now I know that I was putting my baby at risk as well. I would have much preferred the tedium of a long labor.

- Linda Hessel
Peoria, OR


Physicians, hospitals, birth centers, insurance companies and health regulatory agencies are no longer allowing a woman the right to choose a VBAC where and with whom she desires. A truthful examination of the research indicates that VBAC is still safe when spontaneous labor is allowed to proceed without induction or augmentation. The Web site of the International Cesarean Awareness Network (ICAN) contains information regarding the safety of VBAC.

A petition sponsored by ICAN to support VBAC as a safe method of childbirth and to require childbirth professionals, hospitals and birth centers to allow VBAC is online. To sign the petition, which will be sent to the American College of Obstetricians & Gynecologists, American Hospital Association, Aetna, Blue Cross & Blue Shield, Cigna and Kaiser Permanente, visit the petition site or go to the ICAN Web site and click on the petition link.

- A.W.


Re: Fifth's disease [Issue 4:26]: All the symptoms listed are the same symptoms for Lyme disease. Get a second opinion fast!

- Joan Dolan, CNM for 37 years

EDITOR'S NOTE: Read Anne Frye's extensive information about Lyme disease in her 971-page book, Understanding Diagnostic Tests in the Childbearing Year. Order Anne's book from Midwifery Today's Storefront.


Re: painful intercourse postpartum [Issue 4:25]: It was not until 10 months after delivering that I was able to have pain-free sex. My husband, who is an acupuncturist and has done bodywork in the past, did very deep massage to help release the adhesions from the scar tissue. It was intense and painful [but effective]. There are some homeopathic remedies for scars.

- Colleen


A friend told me that after 4 months of breastfeeding she developed an allergy to her own milk, giving her eczema all over her nipples, breasts and down her arms. After two and a half years she still has severe eczema, and she sees a Chinese doctor for treatment. Is it likely she developed an allergy to her own milk? Surely it would go once she stopped breastfeeding? Other than not breastfeeding the next baby, any suggestions on how to prevent it?

- Debra, doula
UK


I am 26 years old and am 9 weeks pregnant with my sixth baby. My first was 8 lbs 9 oz, Keilland's rotation with epidural after being induced, as he was posterior -- after two hours of pushing he got stuck. My second was 5 lbs 12 ozs and was a normal spontaneous delivery. Third was 4 lbs 15 oz born at 36 weeks and hypoglycaemic at birth; fourth was 7 lbs 4 oz, labor accelerated by membranes being ruptured after 3 cm dilated for over five hours; fifth was 8 lb 2 oz born 11 months ago and induced on her due date as I had had false labor since the 29th week. This birth was extremely hard as my waters were broken; I started contracting, was not assessed (for dilation) and put on the syntocinon drip because the hospital staff didn't think my contractions were strong and regular enough. She needed oxygen after birth. I stopped pushing for about a half hour while my cervix dilated from 8-10 cm. After birth my body went into shock and I couldn't stand without feeling faint, and my husband and midwife sounded far away. This time round I am hoping that I will not have another big baby. My waters have never broken spontaneously. Is it a good thing to have ARM or is it best to let them break on their own? My labors are manageable when waters are intact but quite harsh after being broken.

- Angela
Australia


I have a client whose OB says she has cholecystectomy syndrome from having her gallbladder removed, and that 5-8% of pregnant women can get it after removal. It very painful at times, and the pain is located under her ribs on the left side. Do readers have information about this condition?

- Linda Middleton, CD, CBE


I am trying to find research supporting the use of diamorphine in labour. Current practice at my maternity unit is to use it only in primips who have prostin pain or in cases where labour is not established but mum is not coping in the latent phase. Can anyone help?

- L.T.


More about inverted nipples [Issue 4:25]:

Fashion has something to do with why we see so many women with flat and inverted nipples today. Just look through pictures in any history book and you can see how changing beauty standards have molded our soft breast tissue into every conceivable shape. There is no one natural shape for our breasts -- we are all unique -- but the current fad is a globe shape (in the 1950s it was quite a different story!). Wearing bras that hold our breasts in a globe/round shape means that a lot of us are having our nipples pushed or held inward starting from puberty. One need only think about the tactics to correct inverted nipples (forcing the nipples out) to grasp that the opposite action (forcing the nipples in) actually encourages adhesions to remain permanent. Where women do not wear bras at all, inverted nipples are much rarer, but I am not suggesting this as the only solution. I do, however, think we should discuss the drawbacks of certain types of brassieres with our moms/clients.

I've heard that in Korea there is a tradition for the prevention of inverted nipples: In many families, at the start of puberty the mother pinches her daughter's nipples very firmly (it hurts), but just once, so that they will "have a good shape." This would seemingly break any adhesions at the very start of breast development, which is probably the ideal moment to do so. I would love to hear your responses.

- Natalya Lukin, midwife, CPM
Mill Valley, CA


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!


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.


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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 http://www.juneau.com/birthcenter


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