February 4, 2004
Volume 6, Issue 3
Midwifery Today E-News
“Premature Labor”
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In This Week’s Issue:


Quote of the Week

"No one has the right to come along after midwives have been working for thousands of years in their communities and say these women are no longer midwives."

Jan Tritten, Founder, Midwifery Today


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The Art of Midwifery

Midwifery Today Forum participants recommend the following books as guides to herbal lore for women's health:

  • Wise Woman Herbal for the Childbearing Year by Susun Weed
  • Healing Wise by Susun Weed
  • Herbal Healing for Women by Rosemary Gladstar
  • Herbal Medicine from the Heart of the Earth by Sharol Tilgner
  • The Roots of Healing by Deb Soule

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 National Institute of Child Health and Human Development study of 306 women deemed at risk for premature labor showed that portable devices such as home uterine activity monitors that are worn around the abdomen, record contractions, and send information via a telephone for evaluation do not help detect early labor and prevent premature delivery. Researchers found only a negligible difference in the number of contractions recorded in women at risk and those not at risk. Other techniques for detecting early labor such as measuring the cervix and testing for fetal fibronectin fared about as badly in the study.

Associated Press, January 2002


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Premature Labor

In study after study, terbutaline doesn't do a thing to stop premature labor. The FDA has not approved this drug for use during pregnancy, labor, delivery, or lactation. It 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" (1–6). The pregnancy continues (because it would have anyway), but there is no way to prove it wouldn't have, so the assumption is that the only reason it continues is because of intervention.

Any woman who has used this drug will recognize its effects: nausea, vomiting, heart palpitations, increased heart rate, shaking, chest discomfort, shortness of breath, high blood pressure, and the inability to sleep. Terbutaline can also cause liver damage. Because the betamimetic agent definitely crosses the placenta, baby experiences the same effects mom does, including heart rate accelerations (7). When mom is unable to eat because of nausea, combined with the effect on her already taxed liver and the high blood pressure, she will quite likely develop symptoms of preeclampsia.

Now the mom must be "saved." She will be induced. If she really had been experiencing premature labor, this course would be easy because she was on her way already, right? Except that in this case, she wasn't in premature labor. Induction doesn't work on this hard, high, closed cervix. Because many inductions start with a prostaglandin ripening agent, rupture of membranes and use of Pitocin or misoprostol (also not approved by FDA for this use and known to cause complications), the mom is on a clock. If she doesn't deliver in 24 hours, she will undergo cesarean section. Of course, because her water has been broken and fingers have been inside her constantly since she arrived at the hospital, there is a high probability she will get a hospital-acquired infection, and the cesarean may be warranted—even though this cascade of interventions was preventable and nosocomial (hospital caused).

Twenty-five percent of preterm, low birth weight cases occur without known risk factors (8). Prediction of this sector is nearly impossible. Prevention is the best medicine when it comes to decreasing the rate of prematurity. Nearly 75 percent of premature labor could be avoided if mothers took more responsibility for improving their health by not smoking or using alcohol and by eating better and preventing urinary tract infections.

Infections are another cause of premature labor. Routine vaginal exams in pregnancy serve no purpose. It has been theorized that excessive use of this pointless ritual contributes to premature labor and premature rupture of membranes by introducing germs to the cervix via the examiner's glove. Even sterile technique isn't truly sterile. In any case, a pelvic exam without medical indication tells the caregiver nothing. A woman can be dilated to 2 centimeters at 34 weeks and still be pregnant past her "due date." Likewise, a woman can be "high, firm, and closed" and have a 3-hour labor at 38 weeks.

Consider the following guide:

  1. Interventions that have been shown to be of questionable or no value include:
    • home uterine activity monitoring
    • bed rest
    • repeated vaginal exams
    • ultrasound assessment of cervical length
  2. Interventions that have been shown to be of questionable or no value and that may pose significant risk include:
    • terbutaline
    • magnesium sulfate (although it has been shown to arrest uterine contractions in women who are not actually in preterm labor but with serious side effects)
    • cervical cerclage (9)
  3. Interventions that may help but not without significant risk include:
    • prostaglandin inhibitors
    • ritodrine
  4. Interventions that seem to help without significant risk and warrant further investigation include:
    • calcium supplementation
    • progestogens
    • antimicrobial agents (antibiotics)
  5. Interventions with insufficient data to warrant regular use include:
    • diazoxide
    • oxytocin antagonists

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

References

  1. Main, D.M. (1986). "Management of Preterm Labor and Delivery," in Obstetrics: Normal and Problem Pregnancies (New York: Churchill Livingstone), p. 689.
  2. Deirse, M.J.N.C. (1984). "Beta-mimetic drugs in the prophylaxis of preterm labour: Extent and rationale of their use," Brit J of Obstet Gynecol 91(4), p. 31.
  3. Macones, G.A. and M. Berlin (2001). "Efficacy of oral beta-agonist maintenance therapy in preterm labor: A meta-analysis," Obstet Gynecol 85, p. 313.
  4. Wenstrom, K.D. et al. (1997). "A placebo-controlled randomized trial of the terbutaline pump for prevention of preterm delivery," Amer J of Perinatology 14, p. 87.
  5. Guinn, D.A. et al. (1998). "Terbutaline pump maintenance therapy for prevention of preterm delivery: A double-blind trial," Am J Obstet Gynecol 179, p. 874.
  6. American College of Obstetricians and Gynecologists (1995). "Preterm Labor," ACOG Technical Bulletin.
  7. Enkin, M. et al. (1995). A Guide to Effective Care in Pregnancy & Childbirth, 2d ed., p. 166.
  8. Obstetric Care Providers—Knowledge and Practice Behaviors Concerning Periodontal Health and Preterm Low Birth Weight.

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Web Site Update

Many details about location, accommodations and travel have been posted for the Midwifery Today Conference in Bad Wildbad, Germany, October 20-24, 2004. Take a look!

Read these articles newly posted to the Midwifery Today Web site:


Forum Talk

I know a couple who plans to have an unassisted homebirth. I'm wondering if there are any laws against unassisted homebirth. I've tried to do my own research on the Internet and haven't found anything that says whether it's legal or illegal in any state. I really am not comfortable with the idea of unassisted homebirth. I would feel a lot better if I knew that these people had a certified nurse midwife with them. This couple has never had a child before, and the father has never delivered a baby before or even attended a birth. I know they want this baby very badly and would never do anything to intentionally hurt it.

Anon.


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Question of the Week

Q: According to my midwife and information I have from Europe, forced pushing (i.e., count to ten, hold your breath) puts a lot of stress on the pelvic floor and can damage it. But such a pushing method is not necessary. Babies get born also with a much gentler approach in which the woman pushes when her body tells her to. This method usually means that she'll hold her breath for a few seconds only (if she holds it completely at all), but several times during a contraction. What do you think? Where can I find information (online) about this approach from the United States? Or is this a well-kept secret?

— P.L.


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: Are there others out there who took a long break from midwifery, then returned to practice? After 20 years (13 as a CNM), I left practice to heal from severe burnout. In spite of a new, enjoyable career and owning my own small business, I often wonder about returning to practice three years after having left. I've done lots of personal work through counseling, introspection, food changes, and exercise and wonder what others might have done practically, educationally, and otherwise to prepare to return. How did you feel about reentering practice? I'm sorting my feelings for now--grieve and let go vs. reevaluate and return.

— Anon.

A: After a few years of short staffing levels, covering other midwives' caseloads, and the general lack of respect from doctors, I have given up midwifery and am currently in the grieving process, but desperately looking for ways to remain in contact with it. I am currently working in a public health role, which is linked, but I realise that my heart lights up each time I hear of a colleague at a birth or a woman's birth story. I am very concerned that I will not achieve anywhere near the job satisfaction I had when I was a midwife. I do appreciate that I am seeing midwifery through rose-tinted glasses, but I am wondering if this feeling of loss will ever go.

— Anon., London England

A: I am currently in the process of doing this right now. I am (was) a direct-entry midwife who practiced for eight years, then took a 13-year break. I never stopped feeling like I was a midwife; I even had dreams about delivering babies. So, once all the kids were grown and gone (and my first grandchild was on the way) I decided I wanted to get back to what I really loved. Due to laws here, I have to completely redo my training. My previous apprenticeships and experience don't count. I have been apprenticing for 17 months and enjoy it so much more now that I don't have so many family obligations (including financial) to consider. I don't want to have a large, very busy practice, just enough to stay qualified, occupied, and feeling like I am doing something useful. I don't want to burn out again. I don't plan on planning my whole life around births again! I know now I need the personal time with family as well as vacations and so forth too.

— C.


Re: delivery of placenta (Issue 6:2):

A: I have learned that through experience, there is no set time for the delivery of the placenta. As a younger midwife, I read in numerous medical and nurse-midwifery text, that two hours was the outer limits to wait for the placenta. Then God and mamas taught me my lesson--that the same rule I apply to pregnancy and birth continues into this area: "If it ain't broke don't fix it!"

I had made a declaration that the placenta always comes out by two hours. HA! The next one took three, then the next five, and the next eight HOURS! The mamas had a common denominator of long tiring labors and births, they delivered, nursed, mama ate, drank, and caught her breath. Then she had one or two contractions, and out came a beautifully intact placenta. The amazing thing was the lack of postpartum blood loss. It was amazing! They passed their placentas, and then their bleeding consisted of a light pad of minimal bleeding every two hours from the very beginning.

Now, of course, you should have assessment of vital signs and fundal height for concealed bleeding. You should also urinate if necessary--a full bladder may interfere with placental delivery. But there shouldn't be a time limit on the placenta as long as mama is fine.

— Renata Hillman, traditional midwife, certified monitrice, doula, and childbirth educator


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.


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Think about It

At the 2001 ICAN conference, Marsden Wagner, MD, said that the American College of Obstetricians and Gynecologists (ACOG) is really a trade union. As such, its primary goal is protecting the interests and income of its members. If that happened to coincide with what was best for mothers and babies, well and good. If it didn't, it was women and children overboard.

In the 1990s ACOG's leaders woke up to the conflict of interest between promoting evidence-based care and ACOG's prime directive: benefiting OB/GYNs. They then deliberately changed course to wield ACOG's clout and credibility on behalf of OB/GYNs and to hell with evidence-based care.

Wagner went on to say that we shouldn't be allowing ACOG to regulate maternity care any more than we allow the auto workers union to regulate car safety. I would take his thought further.

As regards safety, a better parallel than the AFL-CIO would be if tobacco companies had their scientists conduct research about cigarettes, they published studies concluding that smoking has benefits, they buried studies showing that smoking had hazards, and then they wrote the rules that governed their liability in lawsuits. The situation is actually worse. Unlike what would be the case with tobacco companies, no one suspects ACOG or its academically credentialed obstetricians of an ulterior motive. Anything ACOG or its minions say is uncritically swallowed whole. It's a sweet arrangement, although not, of course, for women and children.

Henci Goer, in "The Assault on Normal Birth: The OB Disinformation Campaign," Midwifery Today Issue 63


THE ARTICLE excerpted above is a *must read*! Henci Goer discusses the July 2001 New England Journal of Medicine article lambasting VBAC. She also challenges the use of Cytotec for induction and induction itself and denounces the subversion of valid research and the proliferation of cesarean section.

TO ORDER MIDWIFERY TODAY ISSUE 63, CLICK HERE.


Feedback

Regarding the information from "The Second Stage Handbook" in Midwifery Today's E-News Issue 6:02—Cervical Lip: Most midwives believe this to be the most prudent move when there is a persistent posterior lip, and because of this, it is commonly used both in obstetrics and midwifery. However, I want to give you a different perspective and an alternative option that is much less stressful and painful for the mother.

During my planned HBA2C labour, I developed an anterior lip after eight hours of labour. My midwife tried to resolve it with the technique described. It was excruciatingly painful, and from that point on labour pain was focused on the anterior lip with each contraction. To reduce the pain, I would try and "lift" my baby up off that cervical lip with each contraction. Obviously this strategy was counterproductive, but neither midwife noticed my pulling my sacrum and stomach muscles in while I was doing this. Ten hours and two more attempts at resolving it later, I was transferred and had a cesarean section.

In preparation for my HBA3C with a different, more hands-off midwife, I studied the Pink Kit in depth. The Pink Kit is a video, audio and book set published by Common Knowledge Trust (www.birthingbetter.com) that provides the knowledge you need to understand your unique body structure and how it works. From this kit and from e-mail correspondence with Wintergreen, one of the Pink Kit's makers, I learned many things. I learned that an anterior lip is normal because it is the last part of the cervix to move up and out of the way, as per the physiology of baby's movement through the pelvis and the shape of baby's head as it puts pressure on the cervix. I also learned that an unresolved and eventual swollen anterior lip is caused by an immovable sacrum, usually caused by semisitting positions. Baby is moving around the pubic bone, and the anterior cervical lip is caught between the pubis symphysis and baby's head. The pivotal point for me, however, was learning how incredibly movable the sacrum is. I came to believe that my swollen anterior lip was caused by my sacrum not opening up--not because I wasn't in good positions, but rather because I wasn't moving it. I was active and in upright positions, mostly sitting in the birth pool, leaning forward. Today, most women do not move their sacrums or even know how to move their sacrums.

With that knowledge, I went into labour with my fourth child and had only one vaginal exam at 5 cm. My focus was on open positions, both for my inlet until baby dropped into my pelvis and my outlet when baby moved down, and relaxation of my inner tissues (also learned through the Pink Kit). When I again felt that familiar anterior lip (the sharp twinge of cervix caught between pubic bone and baby head), I assumed an open position (the dangle or a supported squat) and opened my sacrum to allow baby to move around the pubic arch rather than having to mold around it. I walked around the island in my kitchen between each contraction instinctually. Within a short time I had a strong urge to push, and my daughter literally fell out of me once her head was born.

In hindsight, I would strongly urge midwives to avoid resolving the anterior lip manually as described in the E-News except when all else has failed. It caused me to hold in my baby for 10 hours and led to a cesarean conclusion as I tried to avoid the pain it caused me. Teach women to move their sacrums both in and out (in opens inlet, out opens outlet). If you do, please prepare your client, allowing her to tell you when to stop, and watch closely for tension resulting from the procedure. I wholly credit the Pink Kit for my VBA3C.

Connie Banack, CCCE CLD CPD


Greetings, Maira—from Olinda, Pernambuco! [Issue 6:02]
I am an American nurse living and working in Olinda Pernambuco with a Brazilian NGO that was founded by a midwife—CAIS do Parto. I have had the privilege to be able to work together with a midwife (has a BSN in nursing, worked as a midwife in a hospital setting for many years, and now together we attend homebirths). I have lived here for four years and have slowly discovered how precarious the public health system is and how c-section-oriented the private health world is. Together through this NGO we work toward "humanizing" birth, basically meaning that we work with small numbers of women to help them discover how birth can be a marvelous, empowering, peaceful, beautiful process.

As far as I know there are no midwifery schools—either you grow up in the interior where the profession of lay midwife (parteira tradicional) is passed down through the generations but not based on western schooling, or you become a nurse who has specialized in obstetrics and is therefore trained with a western medical mindset that is completely fear-based, and work in a hospital where women come and deliver with no preparation and have no choices (most doctors are trained surgeons, don't know what a natural vaginal birth is, and definitely don't educate women during pregnancy and don't have patience to support them through labor and birth). Most women in Brazil are afraid of pain or of the effect a vaginal birth can have on their body (they also avoid breastfeeding so their breasts won't lose their form) and schedule their c-sections on a convenient day for them and their doctor.

Some organizations are working toward other means: CAIS do Parto and also amigas do parto that has representation in Rio and Sao Paulo. I can look into other resources or contacts in the Palmas region if you are interested.

Good luck and don't give up the search—Brazil can use all the midwives with your vision and desires that it can get!

Kirstin Soares

Maira, you have several good schools in Rio and Recife that are offering nurse midwife curriculums at a masters level. Sao Paulo University is about to open a course for certified midwives (obstetriz). Boa Sorte!

Regine Spindler, BSN RN SNM


Project: ONE VOICE

Why Do a Demonstration? To fight for women's rights for informed consent/informed refusal in childbearing choices.

Pressure on women to have a cesarean birth is increasing at hospitals all over the country. The American College of Obstetricians and Gynecologists (www.ACOG.org) released an opinion on October 31, 2003, that in many respects sidesteps the responsibility of physicians to initiate discussions about the risks of cesarean. This makes it more difficult for women to fully understand the true risks of cesarean surgery and make a decision based on full knowledge of benefits and risks.

We fear that if this trend continues to grow across the United States, it will change the future of normal birth forever. The World Health Organization (WHO) has taken a strong stand about lowering the cesarean surgery rate. The time to rise up is now. If we don't do something now in the early stages of this trend, the cesarean rate will gain momentum and be even harder to control in the future. It takes a great deal of courage to do what we need to do.

Please join us at one of the peaceful demonstrations—there is strength in numbers!

Project: ONE VOICE is a nonpartisan demonstration. Demonstrations will be taking place simultaneously nationwide in various other locations. We also need volunteers to help make picket signs for the day of the demonstration.

When: Saturday, February 14, 2004, 10 a.m.
Where: San Francisco (e-mail for locations)
Contact: Summer Andreason, San Francisco Coordinator, e-mail handsonsf@mindspring.com or call home: 415.753.1314
For further information about CAPPA, go to: www.cappa.net

Read a recent study cited in The Lancet titled "First Cesarean Increases Risk" at: www.thelancet.com


My daughter—my second child—was homebirthed. She has Down syndrome. When she was born I knew immediately, but I said nothing to anyone and no one said anything about it to me. I was so blown away from the birth, and that reality was too much at the moment. It was not until the next day when my midwife examined my baby that I said, "When she was born I thought she might have Down syndrome." From there my midwife expressed her concern and strongly suggested that our pediatrician listen to my baby's heart. We did this, and then blood work was done, which was very traumatic for me and my baby. As I think back to that time, it seems the most appropriate way for the midwife to have approached this outcome was if during the newborn exam or after we had bonded with our new little one she had asked if I had questions or concerns. I also would have greatly benefited from being hugged, held, and supported and had a space open for me to do this. I had so many questions: What would life be like, what health problems might she have, what caused this, what can I do to benefit her life? Having ready answers or a way to contact other parents immediately after her birth would have eased my heart and mind.

I am a midwife's apprentice, and this great journey has taught me many amazing lessons—above all, how silly it is that we let something so small in the big picture devastate us in the beginning. So celebrate and love all babies and allow families the space to grieve if necessary. Open the door to them that it is OK so that this new path can be embraced with love and support! Most of all give them time to enjoy their connection, but do not hesitate to express in a loving space your concern. It is a frightening reality at first, and all the people in my life who were totally accepting and loving are the ones who eased so much of my heartache. They were able to look past this "tragic" circumstance and embrace my daughter for all that she is, and it has healed my heart. I would not change who she is if I had the choice; she has been the true essence of unconditional love and joy in my life. Love is always the answer!

Meredith Fowler, Black Mountain, NC


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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Classified

The International School of Traditional Midwifery offers quality education to aspiring and practicing midwives through our onsite, distance learning, A&P, and short course programs. Contact us at: 541-488-8254 or www.globalmidwives.org


Birth Stories wanted. Writer seeks to interview women who gave birth between 1999-2004 for a book/play on childbirth in America. If interested, please e-mail: Brody66@attglobal.net


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