March 19, 2003
Volume 5, Issue 6
Midwifery Today E-News
“Labor Induction”
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THIS WEEK’S ISSUE

Send submissions, inquiries, and responses to newsletter items to mtensubmit@midwiferytoday.com

Quote of the Week

“We are accustomed to thinking that we know what we know from what we have observed, but it is just as true that how we practice sets up what is observable in the first place.”

Barbara Katz Rothman


The Art of Midwifery

White oak bark tea will kill a yeast problem on the skin and taken internally will help keep yeast down. Also, oil of oregano capsules (a natural nemesis to yeast) or grapeseed extract taken internally will help destroy yeast in the body. Avoid fermented food such as vinegars, beers, and wines.

Joan M. Dolan
Midwifery Today Forums


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

Rhesus monkey mothers can defeat a bad gene. A National Institute of Child Health and Human Development study reports that infant monkeys who have the short allele of the serotonin transporter gene, which increases the likelihood of overly anxious behavior and heightened inability to pay attention, behave normally when raised by their mothers. Conversely, when neonates with this gene variant are raised with their peers in nurseries, they show characteristic behaviors associated with this gene form. The research involved 36 mom-raised monkeys and 79 cared for in nurseries. Researchers tested the animals on four occasions during the first 30 days of the animals' lives. The study labels the impact of mom's care "maternal buffering." The researchers presently are trying to identify just exactly how the connection works. The leader of the research team surmises that it has to do with the quality of care that the young are getting from the mother.

Mol Psychiatry, 7:1058-63, December 2002

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Induction

If practitioners accept the false notion that perinatal mortality “doubles by 42 weeks,” they will be anxious to conclude pregnancies well before that date. Others will use a new study comparing induction at 42 weeks with induction at 41 weeks (showing a decreased cesarean rate) as a jump-off point to reason that inducing at 41 weeks or earlier is better than spontaneous labor at a later date. This is not what the study shows. It merely shows a slightly lower cesarean rate when comparing induced labor to induced labor. It does not compare induced labor to spontaneous labors. Large studies have been done about that question and show rather clearly that waiting for spontaneous postdate labor results in less cesarean without any rise in the stillbirth rate (1,2).

One study stands out in particular (3). This was a retrospective study of almost 1800 post-term pregnancies with reliable dates compared with a matched group that delivered "on time" (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56/1000 in the post-term and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia, and cesarean were almost identical. The rate of fetal distress and instrumental delivery and low Apgar was actually lower in the postdate group than in the on-time group. This is only one of several studies showing postdate pregnancies can be safely monitored until delivery.

Excerpted from “Induction & Circular Logic” by Gail Hart, Midwifery Today Issue 63

References

1. R. Matijevic, “Outcome of Post-term Pregnancy: A Matched-Pair Case-Control Study,” Croat Med J 39 (4), 430-434 (1998).

2. J.D. Yeast et al., “Induction of Labor and the Relationship to Cesarean Delivery: A Review of 7001 Consecutive Inductions,” Am J Obstet Gynecol 180 (3), 628-633 (1999).

3. D Weinstein et al., “Expectant Management of Post-term Patients: Observations and Outcome,” J Matern Fetal Med 5 (5), 293-297 (1996).

To read this excellent article, purchase Midwifery Today, Issue 63. To order, click here.


Occasionally the uterus becomes hypertonic [after induction]. That is, it clamps down on the baby with strong contractions lasting two minutes or longer, and this reduces the flow of blood. In normal labor, contractions squeeze the baby as if it were being hugged tightly. Blood flow is lessened at the height of contractions but is increased as each one finishes. In induced labor there is a risk that this rhythm is lost and that the uterus goes into spasm. The result is that the baby's heartbeat becomes either very fast (tachycardia) or slow (bradycardia). At birth the baby may need resuscitation and be taken to the intensive care nursery for observation.

Sheila Kitzinger, Birth Your Way, Dorling Kindersley, 2001


Nichols CW. Postdate pregnancy. Part I. A literature review. J Nurse-Midwif 1985a; 30(4): 222-239.

Most postdate babies are not postmature. “Women have been subjected to the hazards and emotional hardships of an induced labor without apparent benefit.” Except when done between six and 12 weeks menstrual age, ultrasound dating has a margin of error greater than dating by LMP. Primiparous women average longer pregnancies than multiparas, and the average gestational length is longer than 280 days. All clinical dating methods, including the LMP, have margins of error of more than two weeks. Comparing the LMP to ovulation dates from basal body-temperature records, one study found that 70% of pregnancies classified as postdates were misclassified. Another found the proportion of pregnancies classified as postdates by the LMP was 15.5% versus 4.5% by ovulation date. Only two of 110 babies were postmature, and one was not postdate. One day should be added for everyday the cycle exceeds 28 days.

We have no accurate way to identify postdate fetuses at risk. Fetal movement counts are not sensitive enough. Neither hormonal assays nor placental grading are reliable. The incidence of meconium-stained fluid increases abruptly at 38 weeks, but this relates to maturing reflexes, not distress. Oligohydramnios associates with growth retardation, thick meconium, and fetal distress and may have value [but false-positive rates are high]. The CST appears to have a lower false-negative rate than the NST, but this is based on nonrandomized studies. Several studies have shown nipple stimulation to be as safe and reliable as an oxytocin drip for the CSYT as well as cheaper, easier, and faster. The biophysical profile accurately predicts fetal distress at extreme ends of its scale. [What about midrange scores?] Two studies found no increase in abnormal FHR with postdatism.

Studies of management have not found that tests accurately identify postmature babies or that routine induction improves perinatal outcome. Epidemiologic studies have found that much of the excess perinatal mortality in the postdate population is due to outer factors: congenital anomalies, infection, or IUGR. The postmature infant is relatively rare. About 10% of pregnancies are postdates, of which 5% to 26% result in postmature babies.

From Henci Goer's book Obstetric Myths Versus Research Realities:
A Guide to the Medical Literature, Bergin & Garvey, 1995


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Forum Talk

Can anyone offer good visualizations for a doula to tell a laboring mom to help her stay focused and centered?

Anon.


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Question of the Week

Q: I am interested in information about VBACs and getting over the emotional hurdle with a subsequent baby after a traumatic hospital birth, especially those ending in c-section. I had an unnecessary c-section with my first and only baby, and will never go to an OB again. I hope to have a VBAC with a midwife if I can overcome my fears. I am interested in how midwives handle VBAC women.

— Anon.


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


Question of the Week Responses

Q: I am searching for information about the diagnosis of polyhydraminos for one of my students; i.e., the accuracy of diagnosis, implications for the condition, statistics regarding outcomes, and options for families, etc. The family in question wishes to have a homebirth even if the prognosis is bad, but they are concerned about the implications for a care provider attending such a birth.

— Amy V. Haas, BCCE

A: As a nursing student I cared for a baby girl born with a tracheoesophageal fistula (connection between the two) and esophageal atresia (blind ending of esophagus, no connection to the stomach). Mom had polyhydramnios (makes sense because amniotic fluid could not be swallowed and passed to the intestines for absorption and recycling, so it built up). As I remember it the fistula/atresia was anticipated at birth, and when it was confirmed in the first hour (no feedings because of the connection to the lungs) she was transported to the children's hospital. She recovered beautifully from the surgery and went home breastfeeding.

There are many other explanations for polyhydramnios. In my readings polyhydramnios occurs in up to 3.2% of pregnancies. It is related to malformations of the baby 20% of the time, multiples 8%, maternal diabetes 5%, other various causes 9%, and idiopathic 60% of the time.

— Christine Cox, student midwife

A: From Williams Obstetrics, 21st Ed 2001, p. 815-820, more statistics there.
Overall incidence 1 percent.
“Obvious pathological hydramnios is frequently associated with fetal malformations, especially of the central nervous system or gastrointestinal tract .... In the study of nonreferred Mayo Clinic prenatal patients, the cause of mild hydramnios was identified in only about 15% of cases. Conversely, with moderately or severely increased amniotic fluid, the cause was identified in more than 90% of cases. Specifically, in almost half of cases with moderate and severe hydramnios, a fetal anomaly was identified .... Most perinatal adverse outcomes were in nondiabetic women with hydramnios .... Using an amniotic fluid index of greater than 24 or 25 cm to identify hydramnios, most studies indicate that perinatal mortality is increased substantively.”

According to Nelson's, a pediatric reference, esophageal atresia (esophagus is blind pouch, and similar anomalies--one of the most common causes of polyhydramnios) is a "surgical emergency." There are many defects that could cause true hydramnios, usually relating to swallowing. Many of them, like esophageal atresia, are operable. This family would be endangering their baby to deliver at home without more data. A provider would be irresponsible to deliver a true hydramnios at home. It endangers homebirth as a safe option for truly low-risk women. So if the mom has a documented severe hydramnios, I would not deliver her at home. The data show abnormal outcomes for 50% of pregnancies even in the AFI 8-9.5 cm range.

— Lily Fountain, CNM, MS
U of Maryland School of Nursing


EDITOR'S NOTE: Responses to any Question of the Week may be sent to mtensubmit@midwiferytoday.com at any time. Please indicate the topic of discussion in the subject line or in the message.


With Woman

by Gloria Lemay, compiled by Leilah McCracken

Prenatal Diet: Avoiding Teratogens in Foods and Empowering the Mother

A teratogen is an agent that can cause malformations of an embryo or fetus. Alerting the pregnant woman to possible teratogens in food is an area of prenatal nutrition advice that is very important. I use the list from Susun Weed's book “Wise Woman Herbal for the Childbearing Year,” pages 12-15. Some of the particular precautions with regard to food are:

When pregnant do not ingest:

  • food that has not been properly refrigerated
  • soft cheeses (Brie, camembert, feta)
  • raw or undercooked fish or meat (no sushi or hamburgers with a pink centre)
  • ginseng products
  • most laxatives
  • deli sandwich meats
  • fruits or vegetables that are blighted, bruised or sprayed with chemicals.

Be sure to acknowledge all the smart choices that your clients make. One of my pregnant clients began crying when I said to her, “You are doing such a good job of nourishing this baby.” She shared with me that her family had always called her a “poor eater” and that she was terrified that she would not be able to feed her baby in utero properly. Her son weighed a wonderful 8 lbs and is a bright beautiful five-year-old now. I didn't realize how much she needed my encouragement and am happy I helped to give her confidence in her mothering ability.


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


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Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount 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!


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Feedback

I'm looking for someone who has a copy of “Born in the USA.” I have a 15-minute clip as part of another tape someone gave me, but I don't think it was the whole program. I want to spread this all over. I live in Israel but can get it from you in the States. Will gladly pay for your assistance.

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Re: abuse history and birth

I don't know if anyone has mentioned this yet, but I've seen many sex abuse survivors do very well pushing while sitting on the toilet. The anxiety and physical sensations many women experience in active labor seem to be particularly strong memory triggers for women who have been sexually abused. In addition to being a good physiologic position to bring the baby down, sitting on the toilet breaks the connection between active labor sensations and sex.

Kelly Fitzgerald SNM/SNP

I am a student midwife based in London doing an 18-month degree course, having trained as a nurse first. I thought I would try to give you an idea about how to train as a midwife [Issue 5:05]. You need a minimum of 3 GCSEs or the equivalent; they prefer the GCSE subjects to be a science subject and math's one. Alternatively you can take a D/C test, which is like an IQ test that is timed (I'm told it's quite tough). You only have three attempts at this route. Both we enable to do direct entry midwifery, which is a three-year diploma course. I wish you all the luck with your new plans; midwifery is a great profession, one which I'm really enjoying.

Lorraine Bryan

Where is Mother's Milk tea available? I have read about it but have never found it. I am in Canada.

Karen A.

Can anyone help me find a chart for safe bilirubin levels for newborns, both premature and term? I need to do research on when phototherapy is indicated, when babies can safely go home with monitoring, with or without a biliblanket or exposure to sunlight, etc. A local hospital has recently kept a baby born at 36-37 weeks, weighing 6.5 lbs, for a bilirubin level at 9.5. This baby was four days old and being breastfed, with an occasional supplement of formula. The baby was exposed to too much medication at birth and could not breathe well after the cord was cut. She was in the NICU because of her breathing problems, but they have kept her for the bili levels. Is this normal?

Mandy Viator

Re: Increasing milk supply while nursing [Issue 5:04-05]:

Several things can be done to increase milk production during breastfeeding. The first is to simply let the baby nurse often, every hour if necessary. The more he sucks, the more milk you'll produce (it works on the basis of supply and demand). That's why offering a bottle of formula is the worst possible thing to do at a time like this because the more other food he gets, the less he'll nurse, and then you have a downhill slide.

Also, several herbs are said to increase milk supply, including barley, red clover, red raspberry leaf, fennel, basil, marshmallow, alfalfa and borage. Lastly, be sure to get enough rest ("sleep when the baby sleeps"), eat enough, and get plenty of fluids.

R.S.

Re: WIC certification [Issue 5:05]:

WIC is a supplemental food program that provides mothers, infants, and children with nutrition information as well as food to supplement their protein, vitamin C, iron, and calcium intake. Although Medicaid recipients are WIC eligible, you do not have to be on Medicaid to get WIC (a family of four, for example, can make up to $33,485 a year and still qualify for WIC--that is the figure for 2003 and it changes every year). Other than qualifying economically, recipients need to have a nutrition risk of some sort (most moms qualify due to low hemoglobin or being overweight, but there are many other identified risks as well).

WIC certifies mothers (as well as infants and children) to receive WIC food. The people who certify these moms are sometimes called WIC certifiers. The majority of WIC done here in Mississippi is done through the Health Department where we mainly employ nutritionists to handle our WIC certifications. Some nonprofit clinics not associated with the Public Health Department also do WIC certifying. You might want to check with your local health department to see whom you should refer these mothers to for WIC certification in your area. So it is not that *you* are WIC certified (unless you yourself are a WIC recipient).

Kendall Cox, BA, IBCLC
La Leche League leader, WIC breastfeeding coordinator


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.


Classified

INSTRUCTORS NEEDED IN OREGON. The International School Of Traditional Midwifery is hiring 2 part-time instructors to start in September, 2003. Could include foreign clinical opportunities. E-mail sudy@holisticmidwifery.com before April 15th.


I am a nursing student doing a research project focusing on homebirths and legal issues. My thesis is that women should have the freedom to give birth at home, and the choice to be attended by a midwife in other settings as well. As part of my field research I was hoping that midwives could answer a few questions. All responses will be kept confidential.

  1. What state are you from?
  2. Are you a direct entry or nurse midwife?
  3. What training/education do you have?
  4. Do you attend homebirths?
  5. Do any legal issues concern you?

Shirley Tucker sjtucker@kent.edu


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