|November 13, 2002|
Volume 4, Issue 36
|Midwifery Today E-News|
“Obstetric Interventions, Part I”
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THIS WEEK'S ISSUE
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Quote of the Week
"One is constantly having to balance the high expectations of modern health care with the need to respect the human soul. This is especially so with birth."
- Benig Mauger, from Reclaiming the Spirituality of Birth
The Art of Midwifery: Transverse Lie
For transverse lie, some things moms can do to help the baby turn: Visualization, talking to the babe, posting pictures of head-down babies all around them and meditating on this position, drawing a head-down baby on mom's belly. Then try the inversion exercises three times a day, lying on a slant board or propped with pillows, feet and hips higher than shoulders and head for 10 to 20 minutes at a time. This will encourage babe to find the best position to enter the pelvis. Swimming can help. She can try pelvic-rock exercises. She should be trying it all because babe will not be born vaginally from a transverse lie. There may be a physiological reason her baby is transverse, and she should be working closely with her care provider, discussing the situation and the concerns for her and her babe.
- April, Midwifery Today Forums
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News Flashes: Twins
A Health Resources and Services Administration (HRSA) study found that the overall rate of twin preterm birth has risen markedly from 1981 to 1982 and 1996 to 1997. The rate of twins born before 33 weeks increased only 7% between 1981 and 1982 and 1996 and 1997, while the rate for those born between 33 and 34 weeks increased 31%. The rate for twins born between 35 and 36 weeks (moderately preterm) rose 51% during the study period, while the rate for twins born from 37 to 44 weeks (term birth) declined 2%. The "intensive" use of prenatal care, marked by an "excessively large number of prenatal visits," was much more likely to be associated with moderately preterm twin births in 1996 to 1997 than in 1981 to 1982. African-American women, teenagers, unmarried woman, women with low education and those having their first babies were more likely to deliver preterm. However, the effect of these risk factors diminished during the study period.
- HRSA news brief, March 25, 2002
Obstetric Interventions: Synthetic Oxytocin
Synthetic oxytocin administered intravenously in labor acts very differently from a laboring woman's intrinsic oxytocin. First, the uterine contractions produced by IV Syntocinon are very different from natural contractions, possibly because the drug is administered continuously rather than in a pulsatile manner and can cause detrimental effects to the baby in utero. A woman's uterine contractions can occur too closely together, leaving insufficient time for the baby to recover, and Syntocinon also causes the resting tone of the uterus to increase (1). Such effects can produce abnormal fetal heart rate patterns, fetal distress (leading to cesarean), and even uterine rupture (2). As well, oxytocin augmentation stimulates uterine contractions out of proportion to cervical dilation, compared with a natural labor (3): this creates the possibility of a "failed induction" in which a woman's cervix fails to dilate and a cesarean becomes necessary. Second, oxytocin, whether synthetic or not, cannot cross from the body back to the brain through the blood-brain barrier. This means that when it is administered in any way except directly into the brain, it cannot act as the hormone of love. It does, however, generate negative feedback -- that is, receptors in the laboring woman's body detect high levels of oxytocin and so signal her brain to reduce production. We know that women who labor with an oxytocin infusion are at increased risk of postpartum hemorrhage (4) because their own oxytocin production has been shut down. What we do not know, however, are the psychological or psychoneuroendocrine effects of giving birth without the peak brain levels of oxytocin that nature prescribes for all mammalian species. In one study, women who had synthetic oxytocin augmentation did not experience an increase in beta-endorphin levels in labor (5), indicating the complexities that may result from interference with any of the hormonal systems in labor. Other research has suggested that exogenous oxytocin may pass through the placent unchanged (6), which implies that the baby's oxytocin system may also be disrupted by administration of synthetic oxytocin in labor.
- Sarah Buckley
2. Stubbs TM. Oxytocin for labor induction. Clin Obstet Gynecol 2000 Sep; 43(3):489-94.
3. Bidgood KA, Steer PJ. A randomized control study of oxytocin augmentation of labour. 2. Uterine activity. Br J Obstet Gynaecol 1987 Jun; 94(6):518-22.
4. Gilbert L, Porter W, Brown V. Postpartum haemorrhage -- a continuing problem. Br J Obstet Gynaecol 1987; 94: 67-71.
5. Genazzani AR, Petraglia F. et al. Lack of beta-endorphin plasma level rise in oxytocin-induced labor. Gynecol Obstet Invest 1985; 19(3):130-4.
Dr. Roberto Caldeyro-Barcia has demonstrated that uterine contractions stimulated with Pitocin reach over 40 mm Hg pressure on the fetal head. The quality and quantity of uterine contractions are greatly affected when oxytocin is infused. The contractions tend to be longer, stronger, and with shorter relaxation periods between....With each uterine contraction, blood supply to the uterus is temporarily shut off. If deprived of blood supply, fetal bradycardia (decreased fetal heart-rate deceleration) follows with oxygen deprivation and cerebral ischemia, causing the grave possibility of neurological sequellae. Truly the fetus has been challenged, and the EFM dutifully records the stressed fetal heart rate. With suspicions confirmed, a diagnosis of fetal distress is noted and elective cesarean section is the treatment of choice (Ettner 1977:153).
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INTERNATIONAL ALLIANCE OF MIDWIVES
Forum Talk: Uterine Souffle
To the more experienced midwives out there: Can the uterine souffle be heard in the non-pregnant woman? I have searched all of my literature and there is very little written about it.
To share your thoughts and experience, go to Midwifery Today's Forums.
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Question of the Week: Antidepressants
Q: My best friend, who is 26, is hoping to get pregnant soon. She has been taking antidepressants since she was in high school. Will this cause damage to the baby? Is her body too medicated to reproduce? She is also wondering if she can breastfeed when the baby comes.
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Question of the Week Responses: Gestational Age Assessment, Torn Cord
Q: Has anyone developed their 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 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
A: I first look at the amount of vernix, then the sole creases. If they are consistent with what I would expect from the mother's due date, I stop there. If there is any question, I then check the ear cartilage, then the breast buds and genitalia. If all those signs are consistent, I go with that. If there are still conflicting signs, then I go for the whole Ballard-scale stuff.
Q: I just attended a birth where the doctor put so much traction on the umbilical cord that it broke off from the base of the placenta. I don't know the potential implications of an epidural and induction on the delivery of the placenta. But I would like to know if there is increased risk that the placenta won't come on its own after labor had been induced. The mother had her placenta manually extracted -- after birthing the baby beautifully -- not more than 10-20 minutes after the birth. The next morning she went to surgery to have the remaining pieces taken out since she continued to bleed. She then had a blood transfusion because her hemoglobin was so low. I am appalled by this. I really want to get some reference stats and documentation that show the detrimental effects of traction. Can you help?
- Julia Lynx, doula
A: It breaks my heart to see such an awful third stage after a great birth experience simply because of impatience on the doctor's part. I personally have seen a marked increase in "slow" placentas after induction or augmentation and the use of ergot or manual extraction to speed placental delivery in these circumstances. AIMS has an article at http://www.aims.org.uk/3rdstage.htm about third stage. The latest study is at http://www.update-software.com/ccweb/cochrane/revabstr/ab000007.htm and is exactly what the AIMS article is talking about. I would be remiss if I didn't include cord clamping in this because I also believe immediate cord clamping that holds all the blood in the placenta and impedes its release is a concern: www.cordclamping.com.
- Connie Banack, CCCE CLD CPD
A: Labor induction with Pitocin can make the uterus contract weakly after delivery, prolonging the third stage (placental expulsion). The epidural could interfere with the woman's voluntary efforts to push the placenta out. However, all that said, mismanagement of the third stage of labor was the likely cause of this situation. Mismanagement of third stage includes attempting to remove the placenta before the signs of placental separation have occurred (lengthening of the cord, gush of blood, and a "balling up" of the fundus as it contracts, pushing the placenta down into the lower uterus and out through the open cervix). My nurse-midwife instructor had a saying about "Not fiddling with the fundus" because it interferes with the natural process. In our nurse-midwifery practice, third stage was allowed to proceed naturally for 30 minutes as long as there are no signs of hemorrhage. Of course, this means that the care provider remains in the room during that period. Most physicians don't want to wait, therefore they use a variety of techniques to "assist" the placenta, including cord traction and fundal pressure (taking a chance of inverting the uterus). These are very uncomfortable for a woman who does not have an epidural.
In my opinion, the physician showed no respect for this woman's body rhythms (allowing the placenta to separate naturally), then further compounded the problem by tearing the cord and having to manually extract the placenta. Even though that happened, gentle manual extraction should result in complete expulsion of the placental cotyledons and membranes. This was not the case because the woman continued to bleed. Thus, the physician had to do a D & C the following day. All because s/he rushed a natural process.
Exclusively on the BirthLove site: Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast array of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out! www.birthlove.com/glo_doula.html.
by Gloria Lemay, compiled by Leilah McCracken
Herpes Simplex II
The general rule of thumb is that herpes I is above the waist (mouth cold sores) and herpes II (HSV II) is below the waist. Your clients will eventually include someone who is a herpes carrier because one in five women (at least) has the virus. Learn as much as you can about treatment, prevention and protocols for active outbreaks during the birth process so that you can feel confident that your client will have every chance to have a vaginal birth and a healthy baby.
The primary (first) outbreak of HSV II is usually the most painful and widespread. It is also the primary outbreak that can most damage the nervous system of the fetus/newborn. For this reason, the woman who has had HSV II for some time before her pregnancy began is in a better position to have a healthy child than the woman who contracts the virus during the pregnancy. Fifty percent of women who have a primary outbreak in the first trimester miscarry.
Only about 1 in 5,500 babies gets neonatal herpes, even though the virus is so widespread in the adult population. Neonatal herpes is not a reportable disease in most countries, so there are no hard statistics on the exact number of newborns affected. However, most researchers estimate there are between 1,000 and 3,000 cases a year in the United States out of a total of 4 million births. To put this in greater perspective, an estimated 20-25% of pregnant women have genital herpes, while less than 0.1% of babies contract an infection. Although remarkably rare in newborns, herpes outbreaks can cause severe damage to those who are infected with the virus.
Transmission rates to the baby are lowest for women who acquire herpes before pregnancy. One study (Randolph, JAMA, 1993) placed the risk at about 0.04% for such women who then have no signs or symptoms of an outbreak at delivery. The chances of transmission are highest when a woman acquires genital herpes late in pregnancy. With monogamous partners, this is a very rare occurrence.
Medical practitioners are concerned about release of the membranes for longer than four hours when a woman has a herpes outbreak. Great care must be taken NOT to release the membranes. The speculum exam should be the only pelvic exam. Internal scalp monitors must not be inserted because this can infect the child through the scalp puncture.
Dangers to the baby who develops herpes: death (60% mortality rate), herpes encephalitis or aseptic meningitis (inflammation of the brain or spinal cord), which in turn leads to neurological damage. The first symptom of disease in the newborn can be a sore on the skin which can be tested with a fluorescent stain to diagnose it as a herpes lesion. If left to develop into full-blown herpes, the baby could die, be brain damaged or blind. Early treatment is imperative if there is a suspicion that a baby might have a herpes skin eruption. Premature or otherwise compromised babies are at greater risk when a woman has a recurrent outbreak of HSV II.
During an outbreak of herpes in pregnancy take 1,000 mg lysine (an amino acid) three times a day along with vitamin C (500 mg, three times a day). For a maintenance dose take 500 mg lysine daily as a preventive. If the woman is having recurrent outbreaks in pregnancy despite all the preventive measures taken, at 36 weeks the midwife may suggest she take Acyclovir 400 mg BID daily until the birth. This helps prevent outbreaks at term but is harmful to the baby's liver.
After the birth, the mother and breastfeeding baby should be kept warm and skin to skin. Rest for the mother is extra important. Nourishing food and extra vitamin C after the birth is recommended. Visitors should be kept to a minimum, told to wash hands carefully before entering the mother's room, and asked to leave if they have an oral herpes outbreak.
Gloria Lemay is a private birth attendant in Vancouver, BC, and is a contributing expert at BirthLove.
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What Do Readers Think?
Ultrasounds marketed as keepsakes:
A: am also appalled at the practice of renting hand Dopplers out to expectant mothers, some of whom are listening to their babies several times a day. Talk about exposure! Also, if a woman isn't really trained at using one correctly, I would assume that every time she can't find the heartbeat it causes undue distress.
Russia's top health official Yuri Shevchenko reported that the gas used in the storming of a Moscow theater held by Chechen gunmen was based on fentanyl, a fast-acting opiate with medical applications. Shevchenko said the deaths were caused by the use of the chemical compound on people who had been starved of oxygen, were dehydrated, hungry, unable to move adequately and under severe psychological stress.
Injected, skin-patch and oral doses of fentanyl sold in the United States carry warnings that the anesthetic can be fatal if administered in too high a dose and that doses must be customized, taking into account the patients' size and any previous exposure to similar drugs.
Fentanyl was among drugs that Pennsylvania State University researchers suggested two years ago that the U.S. military explore as weapons to subdue angry mobs. The Pentagon has put such research on hold, however, because of worries that it would violate the international ban on chemical weapons.
Fentanyl is one of the drugs used in epidural anesthesia for childbirth ("hungry, unable to move adequately, under severe psychological stress" sounds familiar). It certainly has worked wonders on the women of this culture as a chemical weapon in the war against spontaneous, unimpeded, empowered birthing.
- Tammy Russell
In response to the inquiry about the Brewer diet [Issue 4:34], I suggest you read Dr. Brewer's books to have a better understanding of his research. I highly recommend "Metabolic Toxemia of Late Pregnancy," which you may locate by contacting www.blueribbonbaby.com.
- Amy V. Haas, BCCE
Have you read what various articles on www.virusmyth.org have said about HIV and breastfeeding? and about AIDS? Seems to me that the CDC has leapt to premature conclusions (to be charitable).
- Jill H.
I am planning a homebirth in January with a midwife. It will be my first vaginal delivery — I had a caesarean 10 years ago with my first child for CPD. I have seen an OB in the area, and he was very discouraging and reluctant to agree to be a backup doctor in case I have to go to the hospital (but he did agree). He quoted as high as a 10-15% chance of uterine rupture and said the likelihood that it would cause injury or death to the baby was very high. In all of my research on the subject, I have read that it is more like a 1 to 3% chance of rupture. He says this number is inaccurate and that the studies it is based on are probably biased.
I'm not terribly worried about statistics, but I wonder if there are any actual studies on VBAC that I could research so I could form my own opinions about whether or not they are biased. Also, I wonder if the issue of homebirth VBACs is ever discussed in the Forums. I would love to hear the opinions of some midwives on this issue. I live in Louisiana, and it seems that to do this at home with a midwife, I need to get approval from the State Board of Medical Examiners for a trial of labor at home.
[Editor's note: Log on to the Midwifery Today Forums and pose your question there. You may receive numerous replies!]
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