October 11, 2006
Volume 8, Issue 21
Midwifery Today E-News
“Postpartum Hemorrhage”
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Can you work in a hospital without compromising your values?

A hospital is nothing more than a building with people: people are the problem. How do we bring out the compassionate part of our colleagues to make a sacred space for women to work their miracle? Learn what you can do at the full-day "Humane Hospital Birth" class with Barbara Harper, Marsden Wagner, Lisa Goldstein and Debra Pascali-Bonaro. This is a must-attend class for any midwife or birth professional who attends hospital births and is part of our conference in Bad Wildbad, Germany, October 2006.

Go here for info. Preregistration deadline is noon PST October 13 in office. After that, only walk-in registrations will be accepted.

Plan to attend our Eugene conference in March 2007. You'll be able to choose from classes such as:

  • Beginning Midwifery
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  • Herb Walk

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Quote of the Week

"One of the most natural remedies I know of is grown and cultivated in the human spirit. It is the healing art of listening."

Alison Parra Bastien

The Art of Midwifery

It's important that a baby's cord be left alone until the placenta is birthed. Once the placenta is in a bowl, … then place one clamp about an inch away from the baby's belly and press it together until you hear a "click"—then you know it's locked. Cut on the side away from the baby's belly (you can leave another inch on the cut side of the clamp.) Then, leave the umbilical cord alone—use no peroxide or alcohol to clean it. It will dry up and fall off in about six days. It's important that no blood seeps out of the cord once it's clamped or tied off. The plastic clamps have teeth that prevent seepage.

Gloria Lemay,
Midwifery Today Forums

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Passionate Midwifery Education

Development of an Education Program

Having passed the 25 year mark with Ancient Art Midwifery Institute, I am in a phase of reflection. There was a time when my promotional efforts were geared toward financial survival. However, the promotional efforts for the past few years are motivated by my extreme enthusiasm for what we offer. We continually add or refine more benefits and options, enhance our support and revise the curriculum. The program is so much better than it was even a year ago. I get so excited just making a list of all the new ways we have devised to help our students research, discern, file and even retain all things "birth."

But what really feeds my soul is the feedback from students about how the total program is life-changing, stretching them in ways they did not expect. We don't teach a student a checklist of what one needs to know to be a midwife; rather we walk with her as she BECOMES a midwife. We address so many issues other than pregnancy, birth and babies that are relevant to midwifery: character, integrity, logic and reasoning, communication skills, decision making, organization and time management, study skills, navigating the apprenticeship and preparation for practice. And at the same time we approach everything academic from a non-academia mindset.

Not that we don't delve deeply into the academics…Advanced Midwifery Studies is unapologetically the most challenging course on the planet. That is our trademark, so to speak. I did not design this course to be the "most" anything as there was nothing for comparison. I just knew that midwives needed to know "our stuff and theirs too," that knowing WHY we do things would give us the power and voice to articulate the validity of the profession. But more importantly, the work is comprehensive in order to ensure that my students will be prepared to practice the profession in the "trust birth" way. My theory is that knowing more leads to doing less, interfering less. And now in my grandmothering stage as a midwifery educator I see proof of my theory. Yes, my students are usually walking encyclopedias, but they are also confident, birth-trusting, other-centered, wisdom-seeking, family-oriented, hands-off, with-woman midwives.

Carla Hartley
Ancient Art Midwifery Institute

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

Postpartum Hemorrhage

Hemorrhage before the complete birth of the placenta can be very severe and happen without much warning. In this case the uterus is still supplying the placental bed as if it were supporting the life of a term fetus, with the normal 500 cc per minute of blood flow. The uterus, however, has released the baby, but due to the lack of placental detachment, it is failing to contract as it should. The uterine wound of the detached area will be pouring out blood. You must act quickly in this event. Resist the temptation to pull too hard on the cord as a way to extract the placenta. Some cords are quite fragile and can tear off, leaving you in a then much more difficult position. I have even witnessed a uterus pulled entirely out by this desperate technique.

If the mother is slim enough and there is not an abnormally attached placental area, you may be able to get this placenta to detach by an action that resembles squeezing a cherry to pop out the pit. Both hands are placed on either side of the uterus (not on the fundus) and begin compressing toward each other. Stand to the mother's side and work with strong steady pressure, slightly lifting the uterus up (toward her chest) while compressing, which will often in itself help the uterus to contract and expel the placenta. The pressures of the hands work toward one another, with greater proximity at the top of the uterus than at the bottom; in other words, press the mass of the placenta toward the cervix, slightly. Before you begin, explain to the mother what is happening, what you are about to do, and why. Depending on the rate of blood flow, the mother may have time to push the tardy placenta out on her own first, or you may have to act more quickly. This cherry-pit technique seems to work in greater than 60% of these cases. If it doesn't and bleeding is brisk, you cannot dally. You must go in after the placenta because this 500 ml/minute (or more) loss can deplete the mother within moments. If her condition is weakened (poor health, long labor, or the emotional factors that will be discussed), and there is time, try to get something nourishing down her to boost her strength. I like Vegex vegetable bouillon; I have seen women with no color in their faces pink up while they take the first few sips. Miso broth is also excellent, better still if it has seaweed in it. Giving oxygen to the mother by mask can help increase the oxygenation of her plasma; this appears to give strength to her muscle tone as well as improving her status in general.

All else has failed, so now you have to fetch the placenta. Depending on her condition and how much blood she is losing, you must gauge how quickly you will act. However, you must never act so brusquely that you risk damaging her tissues or cause her to fall more rapidly into shock from an abrupt increase in pain. Make eye contact and tell her that her placenta is still not out, she is bleeding, and you have to go after it. Tell her that you will explain it all to her later, but right now you have to work quickly. With one hand create some light traction on the cord, and with the other hand follow it up into the uterus like a path through the woods. When you get to the cervix, form your fingers as closely together as you can to make a wedge to get through the opening. Most often it is still very open; remember, your hand is much smaller than the baby's head that just came through that same opening. You may not feel the edge of the cervix, perhaps realizing only after noticing the surface of the placenta at the end of the cord that you have passed through the cervical opening. Needless to say this will be uncomfortable to her, but if it is very painful you may be trying to push through in the wrong area. Stop for a moment and try to evaluate where you are. You may be in the vaginal vault (which you can perforate, as you can the uterus), rather than through the cervix (which is where you want to go).

The other possibility is that part of the placenta may be hanging out of the cervix, covering one edge of it, confusing what you think you are feeling. Travel with the surface of your hand which now should be flattened, to an edge of the placenta. Your outside hand should have been re-positioned just before this action to now be on the abdomen, acting as a barrier by helping stabilize the uterus and keep it from raising away from your reach. This hand should remain very still, flattened, and cupping the fundus gently. Too much movement and fiddling around by this outside hand is not beneficial at this time. The inside hand will now hunt the margin of the placenta for a loosened edge. If there were a border of the placenta outside the cervix, this area would be the perfect place to start. The idea is to lift the placenta off the wall of the uterus—imagining a cold fried egg stuck to a paper plate—with your hand under it, gently acting like a spatula moving back and forth, gently lifting but trying not to either pop the yolk or tear the plate.

Sometimes you will feel a textural change in part of the area of the placenta that is still attached. Often a small area of placental tissue may have adhered to the wall and was either not ever a part of the body of the placenta (a satellite lobe), or is a lobe that may have been left behind when the neighboring placenta separated. Continue over the entire surface of the uterus, quickly but gently hunting for wayward parts. When you have investigated the surface and all is loosened, try to wad what you have into one mass. Occasionally this is not possible and you may have to go back in for the rest. Most often, you can grasp the mass of parts twisted up in the membrane bag and pull them gently out. Membranes that remain attached to the inside of the uterus tend to peel off more completely when twisted out slowly. Toward the very end of this process use an easy seesaw motion as the membrane parts exit the introitus. Trailing membrane strands that come out last can often be expelled most simply by asking the mom to cough a few times. The slight intra-abdominal pressure created by this action will usually plop them right out. If not, gentle traction with a sponge forceps may be needed. However, immediate action toward getting the uterus to contract must not be delayed unless it is obvious that everything has not been retrieved. Things usually tighten right up as soon as the culprit is out. Briefly delay efforts to get uterine contractions only if you have to go back in for missed parts. Wrap your gloved hand first in an opened, sterile-gauze square. This will give traction to this surface, and you can more easily scrub up little pieces to get them out. While you are doing this seek-and-find-journey, someone else should be inspecting the placenta to see how much may be missing. This, however, is a notoriously nonexact science. Do the best you can. If there are any questions about the mother's physical condition at this point or completeness of what you have removed, transport, and take what you have already retrieved with you.

Lisa Goldstein, excerpted from "Some Thoughts on Postpartum Hemorrhage," Midwifery Today Issue 48

MIDWIFERY TODAY Issue 48 includes numerous articles about maternal hemorrhage.

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Research to Remember

In one study of pregnancy and drug use, 70% of the study participants reported they had been in one or more relationships in which their male partner had physically battered them. Of the 84 women who had been assaulted by their partners, nearly half (45%) reported being battered during their current or most recent pregnancy. Twenty-five of the 84 women (30%) who had been victims of partner violence were in abusive relationships at the time of the interview. In addition to the violence they endured within their homes, the neighborhoods these women grew up in were, in many instances, veritable "combat zones." Between gang warfare, police raids, random shooting, and drug dealing, fear became a way of life for the overwhelming majority of women who participated in this study.

http://advocatesforpregnantwomen.org/issues/domestic_violence_and_drug_use/drugs_pregnancy_and_battering.php. Accessed 9 Sep 2006.

Children of women who experience domestic violence during pregnancy have a significantly increased risk of death during the earliest stages of childhood, according to a study of families in India. This risk of death was more than doubled during the perinatal and neonatal period, when compared with rates for children of mothers who did not experience domestic violence. The 18% rate of domestic violence in the state studied is substantially higher than the estimated 2–4% in the US.The study is published in the August 2006 edition of the American Journal of Public Health.

http://www.jhsph.edu/publichealthnews/press_releases/2006/koenig_violence_mortality.html. Accessed 18 Sep 2006.

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Web Site Update

Confirmed speakers and classes are now posted on our Costa Rica conference page.

Read this article excerpt from the most recent issue of Midwifery Today newly posted to our Web site:

"Midwives trust the process of birth and strive to allow it to unfold naturally, with little unnecessary management or manipulation. It would follow then that midwives also trust the process of newborn adaptation to respiratory life and strive to allow it to unfold just as the birth has, naturally and harmlessly."

Midwifery Model of Care—Phase II: Newborn Care—by Alyssa Martin

Forum Talk

I currently have a client who just found out her baby has only two vessels in her cord. She's been planning a homebirth, and we are trying to gather information from midwives who've had experience with two-vessel cords. My client has had two quite detailed ultrasounds, the last one from a very experienced OB who reassured her about her baby's normality (baby gaining well, normal kidneys and heart). I did a review of studies on PubMed and they were not so reassuring: one mentioned a real increase in the PMR [perinatal mortality rate] for these babies. When I surveyed the local midwives here the only negative experience was a baby with a heart murmur that was diagnosed at 48 hours. I am hoping to get a bit of feedback from anyone who's worked with mothers experiencing this variation from the norm; I am especially interested in hearing about any intrapartum safety issues for these babies.


Go to our forums to share your thoughts and experience.

Question of the Week

Q: This year I gave birth to my first baby. After forceps failed, an hour-and-a-half emergency cesarean was performed. The first incision made was a low transverse. Upon discovering I had [what is known as] Bandl's ring [a ridge that forms around the upper and lower segment's of the uterus, a sign of threatened uterine rupture], a classical incision was made. My baby's head was through this ring and after about an hour-plus of tugging, the decision was made to pull her out breech. I am sure a single layer of sutures was used on my uterine incisions because the time spent sewing me up seemed extremely brief. Subsequently my baby spent three weeks in the NICU and I returned to the hospital for ten days of IV antibiotics for a persistent postpartum infection. Despite the extreme amount of stress and worry this has all caused, I want to have one more baby. I appreciate any knowledge midwives have to share because I want to make a fully informed decision about my next pregnancy.

— Katie

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 have been told that raspberry leaf tea promotes labor. I very much want to have a natural birth, and if this will help me get through it quicker, please could you tell me how do I drink it, how often, etc. I am 35 weeks already, but I am sure it's not too late to start, or maybe it's too early?

— Donna S.

A: Red raspberry leaf has an ancient tradition of use in pregnancy to sustain and tone the tissue of the womb, support contractions and check hemorrhage during labor. The herb in itself does not promote labor; it does help tone and work with the needs of the uterus during your pregnancy. Raspberry leaf extract apparently contains a component that stimulates contractions of the smooth muscle in the uterine wall; these are toning contractions. Toning contractions will not make the contractions stronger but can help the uterus work more effectively. One double blind randomized trial found the use of raspberry leaf tablets by women in their last month of pregnancy was associated with a significant shortening of stage two labor, but not of stage one. Red raspberry leaf is rich in calcium, magnesium and iron, so using it can promote toning contractions and give you a rich source of vitamins and nutrients. It is a great herb to use, but more important, our bodies know how to give birth and they know how to make babies; the herbs are just a bonus.

— Demetria

A: First, red raspberry leaf (RRL) does not promote labor. RRL is a uterine toner, hormonal balancer, whole-body tonic—lots of trace minerals, preventer of miscarriage and the most easily assimilated form of calcium we have. You can start taking RRL now in preparation for a lovely birth. After all, your body does know exactly how to birth a baby with or without herbs and books and online chat rooms.

If you would like to assist the timing of your birthing, you may take hot RRL tea throughout labor. It's been said that it helps to make the tea very strong and drink it very hot during labor. However, I have not seen either one of those approaches make a big difference.

I have seen that drinking RRL tea during labor facilitates the birth by keeping mom more comfortable, more relaxed and allowing the birthing muscles to do the very job they are designed to do. So, drink up and have a wonderful birth!

— Jennifer West

A: There are several very effective formulas for naturally inducing labor, as well as several others that promote labor. I think they involve more than just raspberry leaf. But drink as much raspberry as you can and nettle too, because they are nutritive herbs and it is very difficult to do harm. They are very helpful toning herbs.

— Eternal Blossom

Q: I am 21 weeks pregnant with my third child, which has been diagnosed with spina bifida. This is quite a shock since my other two children were homebirths and the specialists said I would require a c-section. I understand the need to deliver in a hospital where the baby can receive immediate medical treatment soon after birth, but does anyone know if there is any evidence that c-section is better than vaginal birth when delivering a child with spina bifida?

— H.

A: I saw a remarkable surgery that is done while the baby is in utero. Surgeons sew up the tissues and spine with the baby still in mom, who is opened up during the process. However, the baby avoids almost all possible problems since the spine is sealed from then on. Please let her know, if she is a candidate for this or if insurance will cover it.

— Winter Phillips

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

We who live in the United States are fully aware how different our country is from most others when it comes to midwifery and the way the state looks at childbirth. If we try to list every variety of midwife that has come into existence during the last half-century, we have to write a very long sentence with lots of adjectives and commas. We lead the world in the number of criminal trials for the practice of medicine by midwives, or even manslaughter or second-degree murder charges brought against unlicensed midwives. In this dubious sweepstakes, we have the company of our neighbor to the north, Canada, which got itself into a similar societal mess a century ago by neglecting to create a way for midwives to continue to exist by following the example of the rest of the industrialized world. In both countries, obstetrician-surgeons became the overlords of childbirth, and two generations of women came to consider it "normal" to have their babies in hospitals where there was no such person as a midwife.

Childbearing women in the United States live with another unusual feature when it comes to women's rights in childbirth. Our country has the sad distinction of having come up with the court-ordered cesarean. This legal assault upon the integrity of a woman's body allows public officials to pose as better caretakers of our babies than we are, by stereotyping women who oppose such surgery as "selfish" or bad mothers whose babies need state protection. It is galling—to say the least—that we continue to live with such a lack of legal protection in a country that prides itself on inventing feminism and on valuing motherhood as highly as apple pie.

Because our society includes such extremes, the arrival at some measure of unity among self-respecting midwives and those who advocate for them is much more challenging than in many other countries. Even so, I continue to believe that a goal of unity (focused vision) is well worth striving for. In fact, I believe that it is critical to the development of a responsible, autonomous, sustainable midwifery profession in the United States.

The question remains: what is the best way to proceed from our various standpoints, considering the often bewildering complexity of strategies that various midwives choose? Some unlicensed practitioners decide to remain unlicensed and uncertified, feeling that if they stand their ground, they will represent the best chance for midwifery to resist co-optation by the for-profit, dominant wing of the medical profession. Others (myself included, although I stayed with the previous strategy for more than twenty years) have opted for the path of certification and licensed practice, believing that this path holds the best chance for creating an independent midwifery profession that works in partnership with childbearing women. Still others lack the organization or agreement to carry out the legal struggle required for acceptable legal recognition or are currently engaged in such a struggle.

Ina May Gaskin, excerpted from "Unity," Midwifery Today Issue 64

Read all of Ina May's article in MIDWIFERY TODAY Issue 64.


A comment to Linda Hessel [Issue 8:18] about publishing educational articles in mainstream magazines: I'm sure Utne Reader would be interested in doing an article about homebirths. Also, Prevention magazine might want to do one.

Also, I am so much in favor of midwives sharing their powerful knowledge with high school teens! As a childbirth educator I am always pleased to see women's reactions when they hear the story of how babies can be birthed gently and naturally.

Melody Masi

In response to Issue 6:8 (re: occipital posterior):

I followed the principles of Optimal Foetal Positioning to the letter. I sat on a fitness ball instead of an office chair, the floor instead of the couch, and slept on my side throughout the pregnancy. My ankles were swollen to twice their usual size from never elevating them, which made my last trimester extremely uncomfortable. I am tall and maintained an excellent healthy weight throughout pregnancy. My baby was not particularly large. Nonetheless, my birth proceeded with persistent occiput posterior and after 38 hours, my baby was finally delivered by forceps after failed vacuum extraction.

There is neither research nor statistics to support Jean Sutton's view that babies are born occiput posterior because their mothers are lazy and put their feet up. Her attitude adds one more burden to those who are already suffering through a difficult recovery. Stop perpetuating the myth!

Erin Buttermore

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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