July 23 2003
Volume 5, Issue 15
Midwifery Today E-News
“Shoulder Dystocia”
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Send submissions, inquiries, and responses to newsletter items to: mtensubmit@midwiferytoday.com.

In This Week’s Issue:

Quote of the Week

"The current medical backlash in birth is actually the death throes of an outmoded way of thinking and behaving. Men and women, mothers and babies, midwives and doctors—we are all awakening together."

Sarah Buckley

The Art of Midwifery

For vaginal yeast infection during pregnancy, dilute tea tree oil with either a little olive oil or evening primrose oil (break open a capsule), use a tampon soaked in the mixture, a rolled up gauze pad, or (my favorite) a clean sea sponge. Insert it overnight. Garlic clove peeled and inserted overnight (usually takes three or four nights in row) is also a good remedy. Acidophilous caps inserted vaginally as well as taken orally also are effective. All the usual dietary concerns for yeast are the most important precaution/treatment.

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

A study to determine if tightening of nuchal cord entanglement is more likely to occur where normal cord coiling is absent and when there is deficient Wharton's jelly included singleton pregnancies with cephalic presentation and spontaneous labor. Placental insertion, nuchal entanglement (tight or loose), length, presence of knots, umbilical coiling index (UCI), and the amount of Wharton's jelly were recorded. Longer cords were more frequent amongst male infants and were predisposed toward entanglement. The study found no significant differences in the amount of Wharton's jelly or in the UCI between tight and loose nuchal cord groups. The only measurement that differed significantly was the total cord length, with shorter cords predisposed toward tightening.

Acta Obstet Gynecol Scand 2002; 82: 32–37.


"Water Born"

Three beautiful home waterbirths attended by families and friends as mothers catch their own babies underwater.
30-minute video, $25 includes shipping and handling. Send check or money order to Melanie Moore, CPM, 1917 Taylor Av, Wilton, IA 52778 or call 563-732-3094. www.dragonsthree.com/waterborn/

Shoulder Dystocia: Traditional Midwifery Solutions

The basic premise: To move the baby, move the mother.

When squatting, standing, and the Gaskin Maneuver don't work:

A Running Start
With mother on her hands and knees, she quickly lifts a knee and sets the foot down flat. [Her assistant may choose to do this for her because it is difficult for a birthing mom to process verbal instructions.] The mother now has one knee down and one knee up, like a runner waiting for the signal to begin. This move rotates the symphysis pubis joint and rolls the shoulder off and into the open pelvis. The symphysis shrugs off the shoulder, like the lumberjack rolling of the log. The pelvis widens on the side that the knee is raised, so the midwife may want to raise the knee on the side where she suspects the baby's back is on. But in a flurry, just grab a leg and lift it. The posterior shoulder should immediately slide out and with it, the baby.

Praying Hands Rotation
If the baby is still stuck, the next step is for the midwife to slip the fingers of both hands inside. With flat palms, one hand braces the baby's back and the other hand braces the chest, like a prayer around the baby. Thumbs are not required and can stay out of the mother. The baby is rotated so that the posterior shoulder moves toward the chest. The baby is essentially spiraled out.

Lift the Sacrum
If the posterior arm can't move, it may be that the baby is too large to rotate easily in the praying-hands rotation. The midwife uses her dominant hand to attend the posterior shoulder. She uses the back of that hand like a wedge between baby and sacrum and lifts the sacrum up with her knuckles while her fingers sweep the posterior arm to baby's chest (and into the oblique diameter). Opening the sacrum enlarges the pelvic outlet diameter.

Bring the Posterior Arm Out from the Hands and Knees Position.
Whenever success in bringing the baby's shoulder into the oblique fails to bring the baby, the midwife should go after the posterior arm and bring it out. For the mother already on her hands and knees, it is easy for the midwife to slip the four fingers of her hand inside along the mother's thigh. She will want her hand along the baby's back, not the chest. She should then sweep the fingers upward toward the tailbone. This act alone may move the posterior arm into the oblique.

Any difficulty getting the posterior arm out now is likely due to the arm's position. The midwife can reach in to find the posterior shoulder and follow down the arm with her fingers. It may be that one or both arms are behind the baby's back! An arm behind the back has to be worked to the chest of the baby before the shoulder can be rotated into the oblique.

Excerpted from "Shoulder Dystocia: The Basics," by Gail Tully, CPM, Midwifery Today Issue 66

Editor's Note: This article continues to discuss in detail how to extract the posterior arm, lifting the sacrum if needed, working with the baby's joints. It's an excellent read! TO ORDER ISSUE 66, click here.

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Web Site Update


  • "Home—Our Birth Right" by Judy Edmunds, CPM Click here to read this article.
  • "Pelvises I Have Known and Loved" by Gloria Lemay Click here to read this article, previously available online only in Spanish.
  • "The Personality of Birth" by Jan Tritten Click here to read this editorial from Midwifery Today Issue 50.


  • "Complications of UTIs in Pregnancy" Click here to read this news item.
  • "Airport Security Hard to Swallow" Click here to read this news item.

Forum Talk

I have a client who is being treated for severe mastitis. Her OB put her on Vancamycin. Does anyone know of side effects of this medication? Or could you tell me of a reliable and thorough source (book, website or other) for information on medications and breastfeeding?

Samantha Searcy, LMT



The Frontier School of Midwifery and Family Nursing

The Frontier School of Midwifery and Family Nursing is a private, non-profit, distance-education graduate school offering directed web-based learning certification for nurse-midwifery, family nurse practitioner and OB/GYN nurse practitioner with a 9-credit Master's Degree completion at Frances Payne Bolton School of Nursing Case Western Reserve University. Visit us at www.midwives.org or phone us (606) 672-2312.

Question of the Week (Repeated)

Q: What can be done for endometrial hyperplasia as far as alternative methods of treatment? In my case, it falls under the category of excessive bleeding. Three cycles of progesterone haven't helped, and I don't really want to go the hysterectomy route.

— J.G.

SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line.

Question of the Week Responses

Re: Broken coccyx [Issue 5:14]

A: Have you considered chiropractic care? Sometimes the coccyx can get displaced during childbirth and can be very easily brought back into alignment with gentle spinal adjustments (yes, even to the coccyx). If x-rays were not taken there is no way to confirm that your coccyx is in fact broken, but many medical doctors often assume that is all it could be. With all the ligament laxity during both pregnancy and childbirth, the pelvic bones can easily become misplaced. Your coccyx (or other pelvic bones) may simply be malpositioned and would likely respond very well to chiropractic.

To find a chiropractor in your area who specializes in pre- and postnatal care, contact the International Chiropractic Pediatric Association at 1-800-670-KIDS, or check out the website www.icpa4kids.com.

— Dr. Melissa Vecchio, DC, FICPA
Collingwood, ON, Canada

Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mgeditor@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

Exclusively on the BirthLove site: 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! www.birthlove.com/glo_doula.html


A study of 11,721 British women has concluded that eating seafood rich in omega 3 fatty acids—key building blocks of the brain—may help pregnant women avoid depression before and after childbirth. Read about this study and other comments about the efficacy of omega 3 during pregnancy in Midwifery Today's coming issue, Issue number 67.

I have just finished research for my Masters Thesis in East Timor. Women there sit by the fire for 40 days, a common practice in southeast Asia and some Latin American countries. Do you know if there have been any medical or clinical studies showing whether this practice is harmful or helpful? I have found a number of articles outlining what women do, but I am most interested in knowing whether medical science has a basis for disapproving.

Vanessa van Schoor

What is the risk of having low amniotic fluid volume, and why must a mom be induced? Is there a natural way to increase fluid so mom can carry full term? Mom is now at 41 weeks gestation; fluid volume is 4.2 liters.

Angela Stocksdale

I too have experienced blanche nipple pain in exactly the way you describe [Issue 5:14]. My third baby, after a happy homebirth, had not developed a good rhythmic suck at four days, and my milk was slow. I was 42 and had a 15-year gap between baby two and three. I had a very successful breastfeeding history and I have been a practising midwife since 1980. A lactation consultant helped me establish that he had a "bubble palate." Feeding began in earnest; he would *not* receive formula. I used a combination of manual compression during feeds, hand expressing to increase stimulation and to give after a breastfeed, and tried to correct his latch using a cut nipple shield (my husband, using a craft knife, cut out the bottom third of a nipple shield so that baby's tongue had direct contact with my breast but the bubble palate was bridged by the top half of the shield). This prevented my nipple from flipping up into his palate, causing trauma. At about 10 days thrush became evident. I treated it with homeopathic borax, and at two weeks blanche nipple began. I cannot describe the pain as my nipples filled with blood after each feed, they turned white then purple then red and the pain would last up to one hour. Weight gain was adequate, but only just.

If I had been a first-time breastfeeder I am sure I would not have tolerated it, but I knew I could do it. Finally the perseverance paid off and at seven weeks we began feeding without a shield and at 12 weeks he was totally independent again. He continued to feed beautifully right through my next pregnancy. Boy 1 finished his breastfeeding career at three years and boy 2 is still going strong at 26 months. I am now 46 years old and work full-time as a core midwife in a secondary care facility.

Sue Pace, New Zealand

I was interested to read your main feature article about preventing postpartum hemorrhage [Issue 5:14]. I recently came across a Cochrane review of four trials that were done on active versus expectant management of labour. Their conclusions were the opposite of Margaret Scott's opinion, and while instinctively what she says sounds right, it's difficult to go up against a body of evidence as substantial as a Cochrane review. Since this issue has major implications for practice, I would be interested in getting some feedback.

The abstract follows.

Robyn Sheldon, student midwife

Date of most recent substantive amendment: 9 March 2000

This review should be cited as: Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour (Cochrane Review). In: The Cochrane Library, Issue 4, 2002. Oxford: Update Software.


Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord.

The objective of this review was to assess the effects of active versus expectant management on blood loss, postpartum haemorrhage and other maternal and perinatal complications of the third stage of labour.

Search Strategy
We searched the Cochrane Pregnancy and Childbirth Group trials register.

Selection Criteria
Randomised trials comparing active and expectant management of the third stage of labour in women who were expecting a vaginal delivery.

Data Collection and Analysis
Trial quality was assessed and data were extracted independently by the reviewers.

Main Results
Five studies were included. Four of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64.37); postpartum haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence interval 0.32 to 0.46); prolonged third stage of labour (weighted mean difference -9.77 minutes, 95% confidence interval -10.00 to -9.53). Active management was associated with an increased risk of maternal nausea (relative risk 1.83, 95% confidence interval 1.51 to 2.23), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby.

Reviewers' Conclusions
Routine "active management" is superior to "expectant management" in terms of blood loss, postpartum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (e.g. nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).

I just turned 40, and my husband and I are exploring the possiblity of another child. A nurse practitioner has requisitioned a blood test to determine function of my ovaries. I have had previous homebirth.

There seems to be little information out there for older moms. Do readers have helpful suggestions, health-wise, especially about keeping nutrition and energy going if we went ahead with a pregnancy, and about pursuing a pregnancy?


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.

Question of the Quarter

We hope you'll take a minute to consider the Question of the Quarter for Issue 68. Responses are subject to editing for space and style. Try to keep the word count under 400. E-mail responses to: mgeditor@midwiferytoday.com.

Theme for Issue No. 68: Instinctive Birth
Question of the Quarter: What does instinctive birth mean to you? How do you facilitate it?

Please submit your response by Sept. 15, 2003 to mgeditor@midwiferytoday.com. (All responses are subject to editing for space and style.)


Birthing From Within Level 1 Mentor Training: Learn to teach parents the power of birthing-in-awareness. A multi-sensory process that helps reclaim the spirituality and power of birth. Taught by Pam England. San Francisco August 15–17 www.birthingfromwithin.com Info: kleinimp@pacbell.net


Midwives: Free herbs for participation in a study on Shepherd's Purse and Yarrow as a p.p. hemorrhage remedy! More info: jesicadolin@yahoo.com or (503) 702-5392.

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