|February 18, 2004|
Volume 6, Issue 4
|Midwifery Today E-News|
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Quote of the Week
"Becoming a midwife is a political statement. It says that women's health has been too long managed by people who care more for the bottom line than for health. It says we must take back our bodies and revisit our roots. It is about choice, safety, and the power of women."
— Elise Murphy
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The Art of Midwifery
Good positions for promoting pelvic roominess are side lying, kneeling, all fours, squatting, and waterbirths with mom's butt floating. That being said, one of the most tried and true and effective moves to deliver a stuck baby is the McRoberts maneuver in which mom is flat on her back with knees spread and hoisted up to the shoulders. This opens up the sacrum in the rear of the pelvis and in the front of the pelvis and rotates the symphysis pubis upward and over baby's stuck shoulder (very uncomfortable and can promote pelvic ligament and joint injury, so don't use it unless absolutely sure you have a true shoulder dystocia situation; in other words, not for slowed second stages because of big babies).
In moderate or mild degrees of stuck shoulders, when you're not sure that the baby is really stuck, simply rolling mom to her side can free the shoulders (fast, easy, and nontraumatic). If this action is not effective, then it is easy to roll from the side to the all fours (Gaskin maneuver) position or back onto the back for the McRoberts. Even if the shoulders are not stuck and the baby is way bigger than you thought, rolling mom to her side for the delivery of the shoulders helps prevent tears.
The idea is to have a routine that moves logically and quickly from gentle maneuvers that are unlikely to cause harm to the more aggressive maneuvers that may cause injury to mom or babe. Obviously you need to get baby out, and sometimes injury is unavoidable, but often caregivers get overly anxious and overly aggressive.
— Maggie Ramsey, Midwifery Today Forums
A study conducted by the Department of Obstetrics and Gynecology at Cambridge University looked at 120,633 second births of singletons. Among 17,754 of these women who had delivered their first babies by cesarean section, 68 had stillbirths, or the equivalent of 239 per 10,000 per week. Among 102,870 who had birthed vaginally the first time, there were 244 stillbirths before labor, the equivalent of 144 per 10,000 women per week. The risk of unexplained stillbirth associated with previous cesarean was most significant at 34 weeks gestation. "The absolute risk of unexplained stillbirth at or after 39 weeks was 1.1 per 1000 women with previous cesarean and 0.5 per 1000 women with no previous cesarean," according to the researchers. Denver Post, Nov. 28, 2003
— Submitted by Patricia Kay, CNM, Olympia, WA
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Question of the Week
Q: What is your preferred alternative practice to ease labor (e.g., aromatherapy, acupuncture) and why?
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Question of the Week Responses
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?
A: My experience as a doula in hospitals here in the United States is that most healthcare providers encourage forced pushing—get that baby out as fast as you can. Many of them count for the mother as she holds her breath. Homebirth midwives here tend to let women push as their bodies direct. This works well for women whose bodies tell them to push. In my last birth (a HBA2C), I was complete for several hours and *never* felt the urge to push. We finally all agreed that I should just push that baby out, and I did without contractions, holding my breath only when my body felt like it. Forty minutes and he was out!
A: I have delivered five children and have never had a strong urge to push. My first delivery involved forced pushing because I was in the hospital, and I didn't know to argue with the doctor yet. My second son was c-section, so there was no pushing. My daughter was stillborn, and although she was very small, the doctor had me push even more than the first time in his effort to get it over with. I think he was trying to help himself more than me. Anyway, my last two sons were entirely different experiences. I had them both at home with lay midwives. I did not have an urge to push either time. This also applied to my other deliveries. The midwives were not concerned about this. Guess what? My sons were born anyway! I can tell you that not having to go through the strain of forced pushing made my deliveries much easier. I wish, as many of us do, that I was more informed before my last two sons. I have not found much information about this topic, either. However, if you are considering using a midwife, she may have some answers for you about where you can find it.
A: The kind of pushing you describe is advocated by The Bradley Method. I don't know about online resources, but all Bradley material, including Natural Childbirth The Bradley Way by Susan McCutcheon, discusses normalized and natural breathing patterns throughout labor. In my personal experience with hospitals, however, I'd say that this is still a well-kept secret.
— Stacy McCarthy, AAHCC
A: HypnoBirthing®—The Mongan Method emphasizes a gentle "breathing down" of the baby rather than the forceful pushing of the baby through the birth path. This technique has been espoused by Grantly Dick-Read, Bradley, and many other childbirth professionals. However, when the time comes for the baby to move down, a great many obstetricians, midwives, and doulas forget it and fall back on the "hold your breath and push." This tires the mom and decreases the chance of the baby's head and mom's body reshaping and adjusting as they need to. This in turn leads to the baby moving back up into the birth path more and also an episiotomy. To find out more about HypnoBirthing®, go to www.hypnobirthing.com.
— Joleen Streit, MA, CHt, HBCE, CD(DONA), New Mexico
A: This source isn't online, but the best information I have read has been in the UK AIMS booklet entitled Birthing your Baby—the Second Stage (see aims.org.uk). Authors Nadine Edwards and Beverley Beech provide excellent information and references about the problems with forced pushing, which can also slow down second stage, contribute to fetal distress, and make spontaneous birth less likely, they say.
Constance Beynon—a UK obstetrician (you can search her on medline)—is quoted as saying that when pushing is spontaneous women do not push very much until their baby's head is down on their perineum. They also do not push early in the contraction but only in the second half. She argues that the early part of a contraction draws up the woman's internal structures, allows her vaginal muscles to be held taut, and stops her bladder ligaments and supports from being pushed down.
She uses an analogy of a lined coat sleeve—she says that the function of the first part of a second-stage contraction is to draw up and tighten the lining. Then, when the mother pushes in the second part, her baby can come down the mother's vagina without forcing the lining to prolapse.
This makes a lot of sense to me because it also explains why incontinence can happen after a "spontaneous" vaginal birth. It also trusts the mother's spontaneous second stage behaviour.
— Sarah J Buckley, 245 Sugars Rd, Anstead, Qld 4070, Australia
A: Regarding persistent anterior cervical lips [Issue 6:02]: I believe that most are related to the baby being occiput posterior. Get the baby to turn and the lip will vanish. Side lying, hands and knees, or knee-chest positions often help the baby turn.
Regarding leaving midwifery and returning [Issue 6:03]: I have recently had to go on medical disability after 20 years of practice as a CNM. I doubt that I will ever be able to return to clinical practice, even in the office. I have experienced intense grief and loss; much of my identity was tied into being a midwife. As I've worked through my feelings, I've realized that I will always be a midwife. In the future, I hope to work with families to develop healthy relationships, break destructive cycles of abuse and violence, and learn healthy parenting. I have assisted many births of beautiful babies, only to feel sadness at the homes they would be going to—not families bad enough for removal, but adults without the knowledge or tools to meet a child's emotional needs. So, instead of birthing babies, I hope to help birth healthy families.
— Rose Evans, CNM, Indiana
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I am extremely disappointed in your article about premature labor [Issue 6:03]. I am a mother of six children, one of whom was born at 29 weeks after a very difficult and dangerous pregnancy. Before you suppose that I don't know anything but the obey-your-doctor mode of thinking, let me tell you that my preemie was my fourth child, born after an OB-attended birth, a midwife-attended homebirth, and a midwife-attended birthing center birth. I am widely read on natural childbirth and healthy pregnancy. I went into my fourth pregnancy expecting a normal and excellent pregnancy and birth. In fact, my husband and I were planning to have either a midwife-attended homebirth or an unassisted birth. However, problems started early on, and we got on the high-risk pregnancy track before we knew it.
I had a large placental abruption, but we did not know it at that time. I was bleeding every day for months. I spent seven weeks on bed rest. I can tell you without a doubt that when you are on bed rest you are much less likely to aggravate an abrupted placenta, and you bleed less. I can tell you that magnesium sulfate stopped labor when I was hemmorhaging three different times. I can tell you that I am thankful for every single extra day we were able to keep my baby within my womb! The interventions we went through were definitely highly valuable!
I am deeply saddened to read your ignorant article which would lead readers to believe that nothing a doctor has to offer is going to help in a premature labor situation. Guess what? You are dead wrong. Thankfully I did not listen to articles like this when I was in need of information about this subject. If I had, I doubt that my days would be graced with the presence of my healthy, happy, nearly 4-year-old son Isaac!
Certainly these interventions can and do have undesirable side effects. At times it was truly hellish to go through what I did. However, there were no alternatives, and interestingly, this little portion of your article offers no substitutions. So, I suppose the author would prefer that all women in premature labor just carry on as usual and hope for the best. No thanks!
The idea that cerclage has little or no proven benefit is also outrageous. Tell that to a woman who has suddenly lost her early-second-trimester baby because her cervix suddenly opened up! I will tell you, those women are very thankful to have a cerclage and bed rest the next time around so they get to end up with a baby in arms at the end of their pregnancy instead of a heart full of grief. What would your author suggest for a woman with an "incompetent cervix"?
I truly wonder what the point is of articles like this. It seems to me that this is a huge plank in the eye of natural childbirth advocates: They love to point out all the supposedly bad and worthless interventions available in an allopathic model of care, but they have no real solutions or alternatives to offer. Guess what? Sometimes things go wrong, and we need and benefit from interventions! Certainly we do not want these interventions to be handed out without good reason. My experience was that I had very attentive high-risk specialists who wanted to maximize the benefit and minimize the negative aspects of the treatments I got. Is it possible that some things were done that were not completely helpful? Yes. Unfortunately, that is the paradox that goes along with a situation like the one I was in. I had to do the best I could with the information I had to help my baby. Which, interestingly, there was *nothing* from the all-natural crew! Guess what—All Natural Mommas sometimes run into high-risk pregnancies and premature labor, even when they did everything "right"!
If you have information to offer women in premature labor situations that would help them have healthy babies and avoid the rigors of bed rest, monitoring, and medications, please offer them! But no more worthless articles pointing ignorant fingers at the things we do have available to help! Your article does a great disservice to all women struggling with premature labor.
— Erica Johns, Kentucky, USA
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