May 24, 2006
Volume 8, Issue 11
Midwifery Today E-News
“Postdates Pregnancies”
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In This Week’s Issue:


Quote of the Week

"I have to make myself open for a woman to be open to me."

Mabel Dzata


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The Art of Midwifery

For all kinds of pain, including postpartum pains, using the index finger, tap firmly (not hard enough to leave marks/bruises) right on, around and under the cheek bone, going back and forth on each side of your face. Tap, tap, tap tap on the right side, then tap, tap, tap tap on the left, and back again. If you do this while nursing, the pain slides away. It's a cheap and easy remedy. All you need is a finger!

Anon.
Midwifery Today Forums


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Passionate Midwifery Education

When do I call myself a midwife?

If you want to do homebirths you will probably want to be a direct entry midwife. So far in the US direct entry midwives have no opportunities for working in the hospital. Moreover, the philosophy of birth is generally different, as hospital practice is more medicalized. You can pursue training in a myriad of ways: self study, MEAC-accredited and non accredited schools, online programs and study groups. All of these need to be combined with apprenticeship. An emerging route of entry to midwifery is doula training and practice which has the advantage of yielding experience and knowledge before beginning midwifery training. Many women seem to do this to fit with family responsibilities while testing the waters for midwifery. Because there are so many excellent ways to become a midwife I'll talk about each one separately, as well as include some information on specific schools and programs in upcoming columns.

One of the advantages of a school or program is that you have help in determining when you are a midwife, ready to take responsibility for a motherbaby. The eclectic way we became midwives thirty years ago had no milestone, such as graduation. Nowadays, getting your NARM certification provides that milestone. Here is what Jill and I said about this in Midwifery Today Issue 9, Spring 1989:

The word midwife is a powerful one. I remember at the beginning of my practice calling myself a birth attendant—the word midwife was too overwhelming. Perhaps only God could call me a midwife. I was not alone in this feeling. My partners all felt the same way. Why? Was it the tremendous responsibility that goes with the title? Most of us felt we didn't quite deserve the title yet, but when would we? When do you know and understand enough? When is your experience adequate for this noble title?
I found myself working with a woman who was really relying on me. I said, "But Jenny, I don't consider myself a midwife." She said, "But Jan, I consider you my midwife." Perhaps the title midwife is bestowed when someone considers you her midwife. After the first time it became easier to accept the title of midwife. Maybe it is when we think we've learned it all that the title should be taken away.
— Jan Tritten, Midwife
It is hard to be called midwife. The word evokes so many emotional and political responses. The word midwife refers to one who stands by, protects and watches over parents and child during birth. The word is simple in form, yet complex in practice. Who could possibly live up to this noble address? How can one ever live up to the standards it takes to be midwife? Over the years I managed to skirt the title midwife until I acquired the name through others I had attended. For the rest of my life I will be trying to meet the highest standards spiritually, technically, intuitively and with the grace that being midwife bestows on me. Midwifery is a school of thought brought to empowerment by the gentle touch of nature itself. A high honor for all of those who attend.
— Jill Cohen, Midwife

love, Jan
Jan Tritten, Mother of Midwifery Today

To read all installments of Jan's column on midwifery education, go to our Better Birth and Babies Blog.


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Postdates Pregnancies

Postdates, by themselves, are not associated with poor outcomes. A pregnancy that continues long after the due date or in conjunction with poor fetal growth or developmental abnormalities has an increased risk of stillbirth. If growth restriction and birth defects are not present, no statistical increase in risk is seen until a pregnancy reaches 42 weeks and no significant risk exists until past 43 weeks. The primary "evidence" of a sharp rise in stillbirth after 40 weeks—often misquoted as "double at 42 weeks and triple at 43 weeks"—seems to come from one study based on data collected in 1958.(1)

The first question one should ask is whether neonatal mortality statistics from the 1950s should be compared to modern statistics, since labor anesthetics and forceps rates were very different. Early labor monitoring was scanty and prenatal monitoring not yet developed. The McClure-Brown report shows a rise in stillbirth from 10/1000 at 40 weeks to about 18/1000 at 42 weeks. Yes, that is nearly double. But think about those numbers. Even the beginning point is nearly ten times the modern mortality rate. Either modern delivery methods are vastly different or something is wrong with the data collection. This study should be updated by research conducted at least in this century! Modern statistics show an almost flat rate of stillbirth from 40 weeks to 42, with a slight rise at 43 weeks (all numbers being close to 1/1000).(2)

It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that in less than 10% of births at 43 weeks do babies suffer from postmaturity syndrome (more than 90% show no signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41 weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the due date but does not start on the due date. And the risks must be compared to the risks of interventions. Induction is not risk free. In addition to the risks of prematurity, induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous amniotic fluid embolism.

Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1800 postterm (past 42 weeks) pregnancies with reliable dates compared this group with a matched group delivering "on time" (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56/1000 in the postterm and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress, instrumental delivery and low Apgar were actually lower in the postdate group than in the on-time group.(3)

When a group of researchers conducted a case-matched review of nearly 300 postdate pregnancies, they concluded that the increased rate of obstetric and neonatal interventions "does not appear to be a result of underlying pathology associated with postterm pregnancy." They suggest that "a lower threshold for clinical intervention in pregnancies perceived to be 'at risk' may be a significant contributing factor." In other words, the perceived risk is greater than the actual risk and can become a self-fulfilling prophecy!(4)

— Gail Hart, excerpted from "A Timely Birth," Midwifery Today Issue 72

References:

  1. McClure-Brown, J.C. 1963. Comparison of perinatalmortality rates versus gestational age through the past three decades. Postmaturity, Am J Obstet Gynecol 85: 573–82.
  2. Eden, R.D., et al. 1987. Perinatal characteristics of uncomplicated postdates pregnancies. Obstet Gynecol 69(3, Pt. 1): 296–99.
  3. Weinstein, D., et al. Sep–Oct 1992. Expectant management of post-term patients: Observations and outcome. J Matern Fetal Med 5(5): 293–97.
  4. Luckas, M., et al. 1998. Comparison of outcomes in uncomplicated term and post-term pregnancy following spontaneous labor. J Perinat Med 26(6): 475–79.

We began teaching our clients how to challenge and count the kicks of their babies (FKC) and report any decrease in movement. …Women so often feel incapable of trusting their knowledge of whether their unborn child is doing well. There are many "old wives tales" that tell a pregnant woman that if her baby is still active, delivery is way off or that the baby will stop kicking before she goes into labor. I have used FKC to empower women and give them something they can do to truly monitor their babies' well-being. I love FKC as a teaching tool. If a baby is not moving, it needs to be assessed right away. Babies even move during contractions. Over the years, I have found that women really only use this means of monitoring if they are worried that the little one is moving less than usual. Drinking a cold glass of water usually remedies the problem and offers the reassurance these women need.

When I first began my practice in this rural community, I worked with a physician who insisted, "Mother Nature knows what she's doing." I watched one woman go four weeks past her very certain due date. I watched another go six weeks past the day we were certain she was due. I was a wreck. But my mentor was more than right. Mother Nature does know what she's doing. Women's bodies are meant to be pregnant and give birth. Babies have their own time to be born. Pushing women to deliver by 39 weeks is defensive medicine to the level of absurd. Not every baby is ready to be born in that timing.

— Kathryn Jensen excerpted from "Does Mother Nature Really Make Mistakes?" Midwifery Today Issue 72


Midwifery Today Issue 72 can be ordered.


Current medical protocol for postdatism combines fetal kick counts, non-stress testing (NST) [evaluating fluctuations in the baby's heart rate in response to its own movements], and evaluation of amniotic fluid volume with a few more obtained by ultrasound. In addition to amniotic fluid volume and fetal activity level, fetal breathing movements and muscle tone are evaluated, then combined with NST results to form the biophysical profile. With a scoring system similar to the Apgar assessment, zero, one, or two points are given for each of the five categories cited above, with ten the highest possible score. A total score of less than seven is considered an indication for induction of labor.

Can the midwife's clinical assessments of postdatism provide enough information to substitute for the biophysical profile? In my opinion, the answer is yes. Although fetal breathing movements cannot be assessed directly, these may be presumed adequate on the basis of normal muscle tone, as demonstrated by kick counts. NST is easily accomplished with a standard fetascope. And even the most subtle changes in amniotic fluid volume are readily noted with continuity of care.

For the truly postmature fetus, the most stressful time in labor is the onset. Uterine contractions are much stronger than are Braxton-Hicks, thus any degree of fetal compromise will show up almost immediately. Plan to attend the postdates labor from the very beginning, and take heart tones more frequently than usual.

— Elizabeth Davis
excerpted from Heart & Hands: A Midwife's Guide to Pregnancy and Birth,
Celestial Arts: Berkeley, CA


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Research to Remember

A multisite study of 96 lactating women found that elevated breast milk sodium concentration is associated with an increase in levels of the immunological and inflammatory factors lactoferrin, secretory leukocyte protease inhibitor, interleukin-8, and regulated on activation normal T-cell expressed and secreted, also know an RANTES. In healthy women, sodium concentrations in breast milk are low because tight junctions between mammary alveolar cells keep milk separated from other fluids. However, inflammation causes the junctions to open, which allows intercellular fluid and plasma to enter the milk. The researchers concluded that elevated breast milk sodium concentrations are sensitive indicators of mastitis.

Clin Diagn Lab Immunol, Sep 1999


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  Midwifery Today Issue 64


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Forum Talk

I wonder about the effects of adrenaline after birth. I know in my two hospital births, while they immediately placed my babies on my chest, they also whisked them away after mere moments to "warm" them. There's stress involved in that, and I've read that adrenaline will inhibit the production of oxytocin. Do you think this can account for at least some instances of postpartum hemorrhage?

Sarah


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Question of the Week

Q: What can we do to have the art of midwifery be more in the consciousness of our culture? As we know, most of the youth in our society think, as many adults do, that "having a baby" means "going to the hospital." I have been pondering lately what changes might take place in our society if midwives made a point of visiting their local middle and high schools (private and public) to speak with the health/science teachers and volunteering to come into the classroom to give a workshop (or whatever term you wish to use) as a professional expert when the class is studying human reproduction. Wouldn't it be wonderful if natural birth was presented to the youth of our society so that it is thought of as a very normal thing when, later, they are adults preparing to have children?

— Kathryn Balley


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: Does anyone have tips to help a mom who never gets the urge to push during second stage? She is completely unable to push with the contractions even though she gets in great positions: kneeling, squatting, hands and knees, birth ball, birth pool, etc. Two babies have been born fine as mom allowed her uterus to do all the work while she breathes through contractions. Is it best to let the uterus do its work alone or is there something that can help an "urgeless" mom?

— CLM, doula

A: If "two babies have been born fine" without the mom having a recognizable urge to push, I don't understand why this mother would need help or tips—what is the problem that needs solving or avoiding here? Are her second stages hard on the baby or hard on her, or is she frustrated about how she has experienced second stage? If not, just because her sensations don't follow a more common pattern doesn't mean intervention is needed. Coming up with possible "solutions" and framing them as such could set her up for feeling like a failure if they don't lead to a noticeable pushing urge.

— Ellen Harris-Braun, doula, childbirth teacher

A: Interestingly, the new HypnoBirthing manual suggests that the urge to push is a conditioned response, and that with a calm mom no more than breathing down babies is ever needed. I think the truth lies somewhere in the balance; some babies may need more of a push than others. I respect Dr. Odent's opinions, but I would never interfere with the bonding of husband and wife at this important moment by sending the father away on a fake errand. Speaking from personal experience, birth is an important time in a marriage, and there may be a "conversation" going on between husband and wife that you as birth attendant are not a party to. Without the presence of fetal distress, best to step back and let mom push or not push as compelled.

— Angelia

A: I know a mom who had no urge to push for her first three homebirths. She was put on thyrotrophin for the thyroid and adrenatrophin from Standard Process. In her fourth homebirth, she had strong pushing urges. The relationship is not proven, only anecdotal. The needs of each woman should be analyzed by a qualified naturopath.

— Anon.

A: I have always found that if there is no urge to push there is always a good reason. Usually it is a malpresentation such as posterior or a compound presentation. Do not start them pushing just because they are fully dilated. The only urge they will have will be at the very end as the baby is actually being born. Be patient and let them deliver in their own time. If it is a posterior baby, there are ways to correct that position. I prefer the diaphragmatic release—before they even go into labor.

— Judy, CPM


Q: I know that everyone says a VBAC should not be attempted if there has been a vertical cut or T-cut caesarean section done previously. Have there actually been any studies that show this to be of greater risk if there is no induction done? Or is it just by implication because of the length or location of the uterine scar?

— Judy Jones

A: All forms of induction are a major risk for VBAC women and should be avoided. All studies have shown that induction is one of the major factors that increase the risk of uterine rupture.

— Anon.

A: The vertical cut is associated with an approximate 5% rate of uterine ruptures on subsequent pregnancies without induction. The 5% risk was the justification for the "once a cesarean, always a cesarean" protocol. The low transverse uterine cut is associated with a 0.5% uterine rupture rate, which allowed VBAC protocol to be initiated.

— Judy S.
[from "The Many Ways to Sew Up a Uterus: 'Single-layer' vs. 'Double-layer' Cesarean Repair: What's Best?" Midwifery Today, 2004. 70:32–34.]

Midwifery Today Issue 70


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.


Think about It

In many cultures around the world, a new mother is cared for by a community of women who fulfill every detail of daily living for up to six weeks postpartum. She is able then to bond with her baby and allow her body to heal and balance. In India, China and Africa, for example, a mother may traditionally expect to have help for 42 days following the birth of her child. The belief that a woman is extremely vulnerable, being more open to outside forces than at any other time in her life, contributes to the practices of daily massage, child-care support and community preparation of hormone-balancing foods. The new mother thus can feel nurtured and supported, which affects how she will raise her child and give emotional support to her partner and family.

In the United States, cultural pressure for a mother to return to work as well as "get her figure back" plays a role in postpartum stress. Usually a woman must return to her job after only six weeks of unpaid maternity leave or risk losing her job. This is in contrast to other countries such as Germany where the mother is given paid leave of six weeks prior to and up to eight weeks after the birth. Either parent is then allowed up to three years unpaid leave to take care of the child.

— Adarsa Antares, excerpted from "Reducing the Risk of Postpartum Depression," Midwifery Today Issue 76

Midwifery Today Issue 76


Feedback

Yes, finally, my feelings about birth that I could not put to words, expressed by an absolutely awesome midwife [Issue 8:8]. Pamela was with our family during the birth of our last 3 of 10. She is what she says, no ego. It's not about her and that's the way it should be. I'm not trying to advertise for her. Midwives, if you aren't this, strive for it; moms, if you don't have this in a midwife, get a new one.

Laura, Mom and homebirth advocate


A high tech company called Barnev (www.barnev.co.il/) is currently manufacturing a product called a computerized labor monitoring system. This product works by placing two clips with electrodes on a laboring woman's cervix and a scalp electrode on the fetus and using ultrasound waves to measure cervical dilation and height (descent) of the fetal head. I am aware of this product because of clinical trials were held at the hospital with which I am affiliated. In spite of the midwives' opposition to using this mechanical device on women, we were not able to totally block its use (although some changes were made in the informed consent, and many women did not agree to participate due to midwives' explaining to them what was involved). The trials were moved to other hospitals where the midwives were not as vocal in their opposition, and now the company is promoting use in Europe and the US. I understand that they have received or will be receiving Food and Drug Administration (FDA) approval. The product is being promoted as a means to assess women's progress in labor without a manual vaginal examination.

I believe that this product takes advantage of and potentially harms women and their babies in labor, all for the purpose of economically profiting a biotech company. I believe that steps need to be taken at a higher level regarding the ethical considerations.

How do E-News readers suggest that I carry on from here? Can you offer any support/ideas? I feel that this issue is not only within the midwifery realm, but takes advantage of women's rights and of women's bodies for research purposes under the guise of medical treatment. You can contact me at: Debby.Gedal-Beer@sheba.health.gov.il

Debby Gedal-Beer, CNM, MSc.
Coordinator of Women's Health and Midwifery Education
Sheba Academic School of Nursing
Tel Hashomer, Israel


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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