July 21, 2004
Volume 6, Issue 15
Midwifery Today E-News
“Second Stage of Labor”
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In This Week’s Issue:

Quote of the Week

"What a beautiful gift we offer families when we return their power to them."

Judy Edmunds

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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.

The Art of Midwifery

For turning a posterior baby even when an epidural has been administered: This will require some extra helping hands either from other staff or family, especially in the presence of epidural anesthesia. If the anesthesia is administered by pump and you can turn down the rate of infusion, it is helpful to do so so the mom can at least move her legs at her command. Have the epiduralized mom scoot to the side of bed and turn completely over, lifting the head of the bed up to help her to a kneeling position. Position an exercise ball (labor ball) under the patient's upper body. When contracting, have mom "frog back" (knees are bent, on bed, roll back like a frog sitting down), lift mom's abdomen/uterus as she pushes. It takes effort both from the supporting family holding mom in the position, the mom, and yourself as you hold up the uterus, but well worth it to avoid a c-section. Of course moms without epidurals can stand, holding onto partner, and nurse can stand behind and lift the uterus inward during contraction. "Frogging" also is a great alternative with the unepiduralized mom.

Gretchen Jenkins, RN

News Flashes

Government studies show that administering a 20-minute HIV test during labor can identify possible maternal infection with the virus and allow caregivers an opportunity to start early preventive treatment in newborns. An estimated 300 infants in the United States are born each year infected with the virus that causes AIDS, and an estimated 700,000 children worldwide developed HIV infection last year.

Journal of the American Medical Association, July 2004

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Second Stage of Labor: Herbs and Natural Remedies

Sometimes it becomes clear that a particular labor or a particular mom needs more than just path-breaking: she may need active guidance. This kind of behavior on the part of the midwife or other attendants should be viewed with the same reservations and concern as any other intervention.

This translates into both a philosophy and a set of behaviors for me. Some of my behaviors are constrained by the location in which I attend births. Still more are influenced by the expectations and needs of the women who have chosen me to attend their births. Keeping in mind that every intervention came about because of a real or perceived need in at least some circumstances, I tend to work in particular ways with moms toward the end of labor.

I prefer to do a minimum of vaginal exams. I work to provide a peaceful and optimistic environment. When a woman indicates a need or desire to push, I ask her to let the baby do the pushing for a while and to add in her own efforts only if she can't help it. I remind her that her body probably knows what she needs to do to birth this baby. Sometimes a mom will appear to be floundering with her contractions; sometimes a suggestion that she try a push with the next contractions will be what she needs to hear. I tell moms that if it feels better to push through the contraction than to breathe through it, then it is probably time to push. Somewhere along the way I will probably do an exam to see where the baby's head is, and then I can tell the mom approximately how much farther down she will need to push the baby. I often have to ask family members to be quiet and not coach the mom. I have trained most of the nurses where I work to avoid loud exhortations and "count to ten" pushing advice. If I am not seeing progress or if I notice that the mom is sending the pushing energy elsewhere, I ask her to focus the energy downward.

Sometimes I put my hand on the perineum to show what "downward" means. I work a lot with the midwife's mantra: "If you want to move the baby, you gotta move the mother." I use the toilet a lot as a pushing place. Sometimes a situation calls for intervention such as putting the mom in exaggerated lithotomy (McRoberts) position or having her push athletically, or having her pant or blow through a strong pushing urge. I have a philosophy and a way I prefer for things to happen, but sometimes the mom and baby have different ideas and I must adapt to them.

Excerpted from "Second Stage: An Artificial Division," by Alicia Huntley, CNM, in The Second Stage Handbook (a Midwifery Today book)

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Forum Talk

I am 30 weeks pregnant and was told three weeks ago that I had low amniotic fluid volume. I am planning a homebirth but the doctor says it may not be a good idea if I continue to have low fluids at the time of delivery. I am being monitored at least once a week; the AFI numbers they give me seem so inconsistent, varying from day to day, hour to hour. The baby is growing well, right on target and I have no other problems. I don't know who to believe, and it is hard to trust the hospital team. I am afraid of a hospital birth with tons of unnecessary interventions. But I also want a safe birth with a healthy outcome. Any thoughts?


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Question of the Week

Q: I recently met a mother of four who nursed all of her children. She is adopting a 6–9 month old baby by the end of the year and really wants to breastfeed. She says she will try to nurse, but will be thrilled if she can at least give the baby bottles of breast milk. What advice might I pass along?

— Anon.

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: I recently had a friend who dilated to 10 centimeters in eight hours. She then pushed for 18 hours at the encouragement of her midwife. The parents then insisted on going to the hospital, where a c-section was preformed. I have two questions. How long is too long to push, and are there criteria we follow as homebirth midwives?

— Anon.

A: An arbitrary time limit on pushing is not necessary. The key factors are the condition of the mother, condition of the baby, and progressive descent. There should be noticeable progress in descent after an hour or two of pushing. Make sure you are evaluating true descent of the head and not just increasing caput. As long as the head is advancing and the mother and baby are stable, you can keep pushing. On the other hand, if the head isn't descending after one to two hours of pushing in a variety of positions, it probably isn't going to descend.

— Anita Jaynes, CNM

A: Eighteen hours is too long. Two hours should have made the midwife think of a referral to a hospital.

I am Dr. Akshai Daniel Kolagani, MBBS, DA, (male, 34 years), a private hospital anaesthesiologist in Karimnagar, Andhra Pradesh State, South India. My father is an MBBS and has a clinic in a small village 150 kilometres from the place where I live. He has been practising midwifery for more than 30 years. His clinic has no operation theatre—the nearest hospital is at least 30 kilometres. I have observed several times the need for referring a patient for delay in the second stage—and never a trial was given for more than two hours—and of course an extra hour for the transportation.

A: I would suggest that in future you might try encouraging the laboring mother to mimic fighting off a predator by beating cushions and growling! Such delays are usually due (in my experience) to the fight or flight syndrome being activated. It is essential for the adrenaline to be excreted in order for labour to progress. As flight is inappropriate, strenuous activity is to be recommended. I find that depending on the severity of the reaction that 15 to 30 minutes of exercise will be required for labour to recommence. If you want to read some articles by me that go into greater detail, I suggest you go to the Google search engine and type in: rayner garner labor.

Rayner Garner

A: Pushing for too long? I think any responsible midwife would have called it quits after four hours, tops! To think that the mother in question did not have some reservations about the duration of her pushing is astounding. I am guessing that the midwife in question was extremely negligent with her decision to put mother and child at risk for many different complications. Fetal distress is the biggest one that comes to mind, secondly the factor of uterine rupture, maternal exhaustion, or a complete placental abruption are also questions. I took this question to work with me; most of the midwives I work with said, "impossible," "unbelievable," "If that were me and I had a midwife telling me to push for that long, I would have told her to get lost, and definitely would not recommend her to anyone."

The parents of this mother in question apparently had more sense than the midwife. Hospitalization seemingly was the necessity here.

—Jen, CD, LMT, NC State Director, Operation Doula Care

A: I can't believe any midwife would have a woman push for 18 hours. There are criteria for home deliveries where I practice and I am sure there must have been some guidelines and criteria for this midwife. Eighteen hours—come on!

— Anon.

A: We have recently had a rash of similar births in our practice. In one instance, the mother dilated very nicely to 10 centimeters, then pushed for about 18 hours or so. She eventually pushed out the baby, then severely hemorrhaged from complications with a placenta accreta. Another woman dilated very quickly to 10 and had a nice urge to push and pushed for 24 hours. Baby sounded perfect all this time, and mom was keeping up her strength nicely. She eventually pushed out a baby with his fist on top of his head. This baby did not breathe for 10 minutes and needed to be resuscitated and transferred.

In both of these circumstances the women and their partners really believed in their ability to give birth at home and were almost refusing transfer. And we found ourselves with a mother with strength to continue and a baby that sounded good all the way through. Should we have transferred when the pushing went on for so long? Were there clues that something beyond the curve of normal was going on? I would say yes, but the mothers would say that their birth experience was just what they wanted. They would say that if something were to go wrong that they were happier to be at home than in the hospital where they may have been "punished" for trying to have a homebirth and so disrespected. Here's where the instincts kick in, and I don't think there is a clear answer either way.

— Andi, apprentice midwife

Re: Birth after perforated uterus [Issue 6:11]

A: Ask yourself why it is so important to you that your wife has this baby vaginally. Now weigh those reasons against having a c-section, which will protect the lives of your wife and baby. Why risk a life and death situation with a ruptured uterus when there is an alternative delivery method that is much safer in the case of your wife.

You stated you were not able to find information about the specific odds as it relates to your case. However, I know that there are stories posted online of women who have experienced uterine rupture themselves, nearly lost their lives, and had to have their uterus' removed, never to have another child again. Ask yourself if this is a chance you want to take.

— Anon.

Re: Hip Pain [Issue 6:14]

A: I have found that cranial sacral therapy works wonders for a broken coccyx. This is a very painful condition and will likely take longer than six weeks to get better. The problem is that if the tailbone heals out of place, pain can continue for life or until it is broken again and reset.

An osteopath would be the first person I would recommend. Some women have good success with a chiropractor. Homeopathy can be very helpful as well (i.e. homeopathic comfrey, but it is best to have a classical homeopath assess first).

Emotionally, issues around the tailbone (birth trauma) can be explored with the use of hypnotherapy that will assist healing. Self suggestions for healing well, having all the support you need, giving the tailbone permission to drain out the pain, etc., might also be helpful.

— Shawn Gallagher, RM, C.CHt

Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@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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Re: Pitocin/active management [Issue 6:14]

To help educate women about the risks and uses of drugs during labor, we have put together a birth information day free and open to the public. A couple hours on Saturday once a month, we have discussion about birth, homebirth, medical interventions, and more. The expectant parents watch natural birth videos and take home a packet of information we provide with more-detailed articles about epidurals and narcotics in labor, safety of homebirth, circumcision, etc. I also teach natural childbirth classes in the midwifery office that are open to hospital birthing couples as well as the homebirthers in the practice. Matching these couples together teaches us all a lot about choices and acceptance.

Andi Hamus, apprentice midwife

Recently the International Confederation of Midwives (ICM) and the International Federation of Gyn. and Obst. (FIGO) released a joint statement about management of the third stage of labor to prevent postpartum hemorrhage (www.internationalmidwives.org/) wherein it was stated that "active management of the third stage of labor should be offered to women since it reduces the incidence of postpartum haemorrhage due to uterine atony." In the details of the statement, it is recommended to give oxytocin 10 IU to the mother within one minute of the delivery of the baby (not at the delivery of the anterior shoulder) in conjuction with controlled cord traction and uterine massage. The statement is of course evidence-based and is supported by the review of literature given in the Cochrane Data Base. It is important to remember that these two organizations deal with midwifery on a worldwide basis, because death due to postpartum hemmorhage is still a major concern.

There are several relevant points for the specific question posed here:

  • Notice that the wording of the statement says "should be offered to," meaning that it is a decision the woman can make for herself after receiving objective information.
  • The timing of the oxytocin administration: it sounds very traumatic for the mother to receive a shot just as the baby is coming out. It certainly means that there must be several practitioners present since the midwife certainly cannot do both at once.
  • It sounds reasonable that the decision could be made if and when the first sign of excessive bleeding presents.
  • While the evidence supports the administration of oxytocin as a way to reduce the incidence of postpartum hemorrhage, there has never been a trial that compares immediate breastfeeding with oxytocin administration (probably because it would be unethical to randomize women to a nonbreastfeeding group).

Debby Gedal-Beer, CNM, MSc.

Please notice that the routine intervention that's the new protocol is always to DO something, and never to NOT DO something. What is the reason for this? The hospital can always bill for doing something; it cannot bill for not doing something, i.e., waiting. If the doctor doesn't follow the hospital's protocol, he will either lose his job soon or he will be liable for malpractice should anything ugly happen. A patient who is asking the doctor to stick his neck out like that is being rather hard on the doctor, don't you think? Do I think the patient should then put up with whatever undesired protocol the doctor is insisting upon? Only if pleasing the doctor is her top priority in her baby's birth.

Maybe women who want natural childbirth should have the gumption to birth at home with a midwife or with a copy of Dr. Gregory White's Emergency Childbirth or with friends who happen to have done some reading up, whatever. The hospitals will do anything they like as long as women line up for their "services." As long as the intervention(s) are part of their "standard of care," they're malpractice-proof, even if this standard of care is killing people (and it is! If this isn't obvious enough in obstetrics, then look at the HIV=AIDS "standard of care!).

This is why mere publicity is probably not going to help midwifery. Insurance companies and hospitals and politicians all have their hands in each others' pockets and benefit from keeping midwives from horning in, and they will continue to do so until either an enraged public votes those politicians out of office or succeeds in getting real campaign-financing reform or universal health care (when the cost and effectiveness of healthcare will, for the first time, be truly important), or large percentages of women stop birthing at hospitals, or something similarly drastic that I can't foresee. The medical industry is about making money, not making anyone healthier. (If people are healthy, they don't make nearly so much money.) This is why tort law only insists that the doctors follow the standard of care and has nothing to do with whether that standard of care is beneficent or not. The law assumes that doctors are right, even though stacks of epimediologic evidence prove that they are not. This is what the New York Federal Appeals Court judge said in his summary defending the 1993 PMPA, which makes independent midwifery in New York state a felony. The judge's assumption was duly backed up with a lot of legal precedent, including the Bowland Decision. This may be bad for midwives and birthing mothers, but it's perfectly legal. The judge also said, in his summary, that women are free to give birth anywhere they like. Maybe if enough of them did, the powers that be would sit up and take notice. I'm sorry if this sounds cynical; but it's true. Please try and disprove it - I want to see if I've missed something.

Jill Herendeen

My intuition tells me that universal administration of Pitocin, as with any drug, is not a wise practice. The oxytocin in a woman's body is naturally being produced at the correct levels to get the job done, contracting the uterus both during the birth and afterward to prevent excessive bleeding and to aid with breastfeeding. Introduction of the synthetic Pitocin at this point would send the signal to the woman's body to stop making its own. Once the synthetic hormone wore off, there would be a period of risk when the body would have to catch up again to get back to the proper amount of oxytocin. This would be especially true for mothers who have not had it during labor. I imagine there may be a justified need for the administration of Pitocin after birth to a woman who has already received it during labor, because, up until that time, her body was relying on the synthetic hormone and not producing the proper amount on it own.

Christine Cuppoletti, Livermore, CA

I am an aspiring midwife in an Ontario high school. I am looking for ways to train to become a midwife. So far I've been considering the McMaster Midwifery Programme and Ancient Art Midwifery correspondence. I am wondering what people have heard of either of these. Also, I have been trying to look into straight apprenticeship but haven't been able to find much about it, like whether or not it is a recognized way of training, or how to find a midwife to train with, etc. If anyone has any information regarding this, I would greatly appreciate a response. My e-mail address is heatherholdcroft@yahoo.com.

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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