February 5, 2003
Volume 5, Issue 3
Midwifery Today E-News
“Terbutaline”
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THIS WEEK'S ISSUE

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Quote of the Week

The holistic model of birth holds that birth is a normal, woman-centered process in which mind and body are one and that, in the vast majority of cases, nature is sufficient to create healthy pregnancy and birth.

- Penfield Chester


The Art of Midwifery: Genital Herpes

For genital herpes outbreaks: There is an ingredient found in cardboard cereal packaging called butylated hydroxytoluene(BHT). Tear off a piece of the packaging, wet it, apply to herpes site, and allow it to stay on the site for a while. It has been known to cause the herpes outbreak to disappear. It is not a cure, just a reliever of outbreak. We used it 20 years ago and it worked.

- Joan M. Dolan

All Birth Practitioners: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


News Flashes: Painful Procedures

A study of 180 newborns showed that letting infants nurse while painful medical procedures such as venapuncture are being performed on them appears to help relieve their pain. The babies were placed into one of four groups: those in one group were allowed to nurse; those in a second were held by their mothers but not fed; the third group was given water as a placebo; and the fourth was given glucose and a pacifier. The researchers reviewing videotapes of the babies did not know the purpose of the study. The babies' levels of pain were gauged by indicators such as crying. It was not clear whether nursing was more effective than skin-to-skin contact, but 10 to 15 minutes of skin-to-skin contact was shown to reduce signs of pain. Nursing, on the other hand, appeared to have an effect within only about two minutes.

- NY Times, Jan. 14, 2003

Terbutaline

Most often, faulty diagnoses of premature labor are made by means of unnecessary routine vaginal exams and superfluous electronic fetal monitoring devices. Never mind that the definition of preterm labor includes contractions that get longer, stronger, and closer together while opening the cervix. Mom is so alarmed at the possibility of losing her baby that she often isn't thinking critically; she's willing to do anything to save her child. She probably doesn't know that even if the cervix is dilated a couple of centimeters, it can be completely normal.

She also doesn't know that study after study show that terbutaline doesn't do a thing to stop premature labor. She doesn't know that FDA hasn't approved this drug for use during pregnancy, labor, delivery, or lactation. Nor does she know that FDA warns that this drug should not be used to stop or slow contractions because serious adverse reactions may occur after administration of terbutaline sulfate to women in labor. The pregnancy continues, but there is no way to prove that it wouldn't have otherwise, so the assumption is that the only reason it continues is because of the interventions.

Any woman who has been put on this drug will recognize these effects: nausea, vomiting, heart palpitations, increased heart rate, shaking, chest discomfort, shortness of breath, high blood pressure, and inability to sleep. Terbutaline can also cause liver damage. Because the betaminimetic agent crosses the placenta, baby experiences the same things mom does, including heart rate accelerations. When mom is unable to eat because of nausea, combined with the effect on her already taxed liver and high blood pressure, she will quite likely develop symptoms of preeclampsia.

- Kim Wildner

Excerpted from "Terbutaline or Not Terbutaline? That is the Question," Midwifery Today Issue 63.


If a pregnancy is not yet 34 weeks along, most hospitals will attempt to stop contractions by giving the mother a tocolytic drug such as ritodrine or terbutaline, which is intended to suppress uterine activity. Terbutaline is specifically contraindicated for tocolysis by FDA and causes increased heart rate, transient hyperglycemia, hypokalemia, pulmonary edema, decreased blood flow to the heart, and irregular heartbeat in the mother and hypoglycemia and accelerated heart rate in the fetus at times, but is widely used anyway. Mothers should know that, to date, no studies have convincingly demonstrated an improvement in survival or any index of long-term neonatal outcome with the use of tocolytic therapy. On the other had, the potential damages of tocolytic therapy to the mother and newborn are well documented.

- Anne Frye,
Holistic Midwifery, Vol. I, Labrys Press 1997


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Forum Talk

I know that in order to determine station you are supposed to feel the ischial spines, but I often cannot. Any recommendations?. -Nikko

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Question of the Week (Repeated)

Q: I am a doula and have a client with pelvic floor dysfunction (PFD) and interstitial cystitis (IC). She would like to have a natural birth. She has been told to get an epidural to "quiet the bladder and pelvic nerves." Does anyone have experience with PFD or IC? Any information would be greatly appreciated.

- Rachel Porter, birth doula

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


Question of the Week Responses

More about pregnancy-induced itching [Issue 5:01]: I had PUPS when I was pregnant, starting at about 33 weeks. It was very red, raised, and maddeningly itchy and covered my arms, legs, and belly. The doctors just smiled and told me to use a hydrocortizone cream and take Benedryl, and that in most cases it would go away within three weeks of delivering. I was preparing for a homebirth and didn't want to put anything but organic food in my body, so their recommendations seemed harsh. After a week of lying naked on the couch, drugging myself on TV to try to escape my body, I knew I would go way out of my mind long before I delivered, and so I tried the drugs. They didn't even begin to affect the irritation. Blessedly, I found a very loving naturopath, and with two visits and in less than a week, it was all but gone. He recommended a combination of some herbs and homeopathic remedies, and at the second visit changed one or two things a little. I won't list the things I used because they were quite specific to my body. I believe there were many mental and emotional issues exacerbating the condition. At 37 weeks I surprisingly delivered not one, but two babies. They were beautiful, healthy 6 lb. 7 oz. and 6 lb. 7.4 oz. identical twin girls. I have since learned that because PUPS is hormone related, carrying twins increases the risk of developing this seemingly harmless but intensely irritating condition. I also think the week on the couch was similar to bed rest, and may have helped me carry the twins to 37 weeks. In a way the condition helped draw me back deeper into my body and may have helped the outcome.

Tracey


EDITOR'S NOTE: Responses to any Question of the Week may be sent to E-News at any time. Please indicate the topic of discussion in the subject line or in the message.


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Midwifery Today Magazine Question of the Quarter

Theme for Issue 66: Birth Environment

Question of the Quarter: What do you do to create a positive birth environment? In your experience, what have you seen that disturbed or facilitated the birth environment?

Please submit your response by March 1, 2003 to the editor.

All responses subject to editing for space and style.


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Here's your chance to get a free one-year subscription to Midwifery Today Magazine. Write a full-length article ( 750 words or more) about protecting the birth environment and what that means to you. Submit it by Feb. 26, 2003 for the next issue. If your article gets accepted for publication in the magazine, you get a free one-year subscription! We are especially interested in hearing from those of you who work in hospital settings. Tell us how you protect the birth environment in the hospitals, against all the inherent obstacles. Send submissions here.


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Feedback

More about pubic symphysis pain [Issue 5:02]:

First, X-rays are fallible in that they show density only, not bone or any other body part except as ghostly gradations (an exception to this would be metals). Second, your doctor is not concerned because the pain is not his; lacking concern (or dare I say aptitude), he doesn't deserve your payment for his services. Only a careful, sensitive exam could tell what the issue most likely is. When the symphisis separated for your 11+ pound baby's passage, issue (muscle, tendon, connective) is squeezed into the gap formed. The pressure of the baby's passage continues to stretch this tissue while the pubis closes, gets caught, and smashed in between. The remedy for this is simple, quick, and painless if done right after delivery and in my view should be checked for and done as a matter of routine in all full-term vaginal deliveries. Since a year has passed for you, and your squished tissue, which is perhaps showing signs of ossification due to the accumulations of metabolic waste salts in tissues with impaired circulation, there is more reaction, pain, and guarded trauma to get through, but the process is still simple and direct. The difficulty now lies in retraining your muscle response to having been in a state of dysfunction for some time. If you can find a practitioner who understands both the physiology and remediation for this problem, the process should not take more than a couple visits until you struggle to remember ever having experienced the discomfort you now feel.

- Uli K. Zangpo, osteopathic kinesiologist, Forest Knolls, CA

A woman who is 12 weeks pregnant is growing some sort of cyst/growth in her uterus (noncancerous). It is growing at the same time as the fetus. Will this cause her any problems, and what can be done about it?

- Anon.

Recently I attended a birth of a mother (G3P2) whose fundal height had just exceeded 40 cm at her last prenatal visit at 41 weeks. She was tiny and had never had a baby over 8-1/2 lb. I went into the labor somewhat concerned about shoulder dystocia. She had a longish labor (15 hours) and had been pushing very strongly for more than 35 min when we had a discussion about rupturing her membranes, which were still intact. My “little voice” cautioned against doing this, and the mother was not overly keen, so we let them remain intact until the birth of the head. When they broke I hurriedly peeled them off the baby's face. I then went in immediately for the baby's shoulders, and they came with only a moderate amount of pressure followed by the rest of the body. The baby weighed in at 9 lb. 4oz. I have since wondered if letting the membranes stay intact might have facilitated the rotation and delivery of the baby's shoulders. Any comments or experience?

- Anon.

I delivered a baby on Jan. 20. He weighed lbs 12 oz. and got stuck during the delivery. I was told that for about 2 minutes his head and his left shoulder were pulled, and now he can't move his left arm. I am very concerned and don't know what to do. I want to get your thoughts and opinions and possible methods to help my son regain use of his arm. He can grip my finger in his left hand, but otherwise it is completely limp. Please help me.

- Crystal Medina

I live in Mexico City. I'm studying medicine but I don't like it anymore. I have discovered the doula profession and I would like to study it, but I don't know of any professional schools in my country. Please share information about schools that offer this career. It doesn't matter where the schools are—I could get a scholarship. This is what I really want to do for the rest of my life. Saludos a todas ustedes!

- Perla

Regarding epidural question [Feedback, Issue 5:02]: There's a great video being used by the doula course instructor at Conestoga College in Ontario, Canada. I don't know the name of the video or the name of the instructor. The video shows newborns trying to breastfeed—both newborns whose moms had epidurals and those who didn't. It's amazing to really see the difference in rooting and suckling. I found it much more effective than what I had read previously. Health Sciences Program coordinators can be reached at 519-748-5220. Try Teresa Malott, ext. 3700.

- Sarah

I am an aspiring midwife, and I am presently taking a birth and parenthood class. We have just read a book called "A Thinking Woman's Guide to a Better Birth" by Henci Goer. I think Carol will find this book very helpful with her epidural questions.

- Suzanne Campbell

It is illegal in the United States to buy or sell human body parts, but an exception has slipped through: eggs. In ads placed in campus newspapers, so-called egg brokers dangle tens of thousands of dollars before young women with the right pedigree of looks, talent, and SAT scores. Their eggs, carrying that pedigree, are wanted by infertile women. To the donor it might sound like a deal; in fact it's an ordeal.

For about a month, the donor actually turns her body over to the process. She must inject herself daily with hormones that stimulate her ovaries to produce up to several dozen ripened eggs rather than the usual one. These mature eggs are sucked out of her swollen ovaries with needles inserted through the vaginal wall. The major risks relate to the heavy drug treatments. In about 1 in every 100 women a hyperstimulation condition balloons the ovaries to the size of grapefruit, and the belly fills with fluid, requiring hospitalization. There is a real but rare danger that an ovary will rupture or be irreversibly damaged, or even that a heart attack or stroke will occur. Brokers that solicit donors don't have to talk about this.

Safety warning: One Stanford student had a stroke while being treated for egg donation. Faced with student loans, she was one of many girls attracted by a broker's ad in the Stanford Daily offering $50,000 for the right eggs. A year ago, she told Stanford Magazine, "I wish I had been better warned." Warning patients of risks is a basic commandment in medicine. The American Society for Reproductive Medicine has developed guidelines that call for independent medical and psychological counseling about these risks. It also recommends a cap of $5,000 on donor compensation. The group is concerned that heftier payments might tempt donors to downplay risks. Jeffrey Goldberg, the head of Reproductive Endocrinology and Infertility at the Cleveland Clinic, believes the guidelines are on target, but "not all centers adhere to them." Unless the profession finds ways to enforce its standards, Goldberg believes, the government will step in. But even if standards are forced on the clinics, egg brokers and their anonymous clients are not subject to any of these professional constraints.

The use of egg donors is increasing at nearly 20% annually as more women delay childbearing to the point where their own eggs are in trouble. If human cloning, which relies on ripe eggs, becomes a reality, it will call for even more donors. Though some years off, new technology might help. Scientists are finding ways to ripen eggs in test tubes rather than in women's bodies, eliminating the risk of ovary-stimulating drugs. And frozen egg technology will enable women to store their own eggs for later use rather than look to vulnerable students in search of tuition payments.

- Bernadine Healy, MD

I feel the use of oxytoxic drugs in labour should not be given without the woman's informed consent. I welcome readers' views and personal feelings about this particular subject.

- Josephine Brown

I am a new midwife in a previously established practiced. I have a question regarding follow-up of Pap smears and first-trimester SABs. It has recently come to my attention how important these two follow-ups can be and are that they are frequently missed even in an already-established practice. I am particularly interested in how you keep track of all of your Paps and your protocol for SAB follow-up. We have recently had a couple of blighted ovums at 5-7 weeks and are not sure if we should follow these up with BHcg, US, or expectant management. If anyone has a system that works well, I would love to hear about it.

- Gennifer Robbins, CNM, South Bend, IN

How I miss reading more of your E-News. Midwifery Today offers me moments of salvation. I sit at my computer and drink a hot cup of lemon water with honey and realize just how blessed I am to be a midwife. As we all know, midwifery truly is a challenging calling. There are moments you can't wait for the beeper to go off, and then there are those days that you want to cry when it goes off. Blessings are that the computer does not beep! Thank you for continuing this great service. I do read your journal and still want for more. God bless you and once again, thanks. With deepest respect and appreciation,

- Pat Connolly-DeTura, sister midwife on the journey


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