July 4, 2007
Volume 9, Issue 14
Midwifery Today E-News
“Protocols”
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Volunteer Spanish translator needed for our upcoming conference in Oslo, Norway, September 12–16, 2007. You will get to attend the conference in trade for translating for a dynamic and experienced traditional midwife, Angelina Martinez Miranda. You will need to translate her class sessions into English and help her by translating some of the conference classes back to her. This is a great opportunity to get to know an amazing and humble midwife. E-mail: Jan@midwiferytoday.com

In This Week’s Issue:


Quote of the Week

"Anyone who considers protocol unimportant has never dealt with a cat."

Robert Heinlein


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The Art of Midwifery

Our understanding of birth physiology is based on the simple fact that adrenaline (the emergency hormone mammals release when they are scared, when they are cold or when they feel observed) and oxytocin are antagonistic. In other words, when human beings release adrenaline, they cannot release oxytocin.

This indicates the main role of the midwife: to protect the laboring woman against any situation associated with a rising level of adrenaline. This is an art because it involves the personality, the way of being, the background, the experience and the intuition of the birth attendant. Since adrenaline release is highly contagious, one of the main preoccupations of the birth attendant is maintaining her own level of adrenaline as low as possible. Midwives often use tricks to keep their stress levels low. One of these is to engage in a repetitive task, such as knitting.

Avoiding useless stimulation of the maternal neocortex, which is the source of powerful inhibitions, is a real art. Remaining silent when verbal language is not absolutely necessary is an art. Escaping notice while, at the same time, being able to detect whether something is wrong is an art. Adapting to every particular case and to every particular situation is also an art.

— Michel Odent, excerpted from "Can the Art of Midwifery Survive Protocols?" Midwifery Today Issue 73


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.

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Protocols vs. Guidelines

The term protocols is confusing sometimes because it is used differently from location to location, state to state. In general, protocols have to be very carefully written, or midwives damage themselves legally. The midwife should be certain that the way she practices and interacts with clients fits within her protocols. For example, a protocol in Florida is usually between a CNM and a physician and serves as a contract to limit the midwife's practice. Should she deviate from working within the protocol (in this case as determined by the agreement she has with the physician), she may be liable for damages in a malpractice claim and may be unable to get insurance coverage for her defense. The same is true for a midwife whose practice uses written protocols. Most of the time protocols are decided by a group of practitioners and serve to insulate the group from legal action should one of the members deviate from them.

Midwives need to understand the terms standards, clinical guidelines and protocols so that they can use them in the same way that others in the medical and legal fields do. This is a mechanism by which to protect the midwife, her practice and the midwifery profession.

The terms Guidelines and Standards should NOT be interchanged. Standards provide the midwife with process. Clinical guidelines provide research-based information. Standards are rigid. Clinical guidelines may be flexible to meet client needs and the particular circumstances. Clinical guidelines do not take the place of standards, but rather provide research-based options for decisions.

Clinical Guidelines are:

  • Operational tools to assist in clinical decision-making
  • Detailed and client-focused
  • Based on procedures or clinical conditions
  • Recommended courses of action and/or practices for meeting standards of care
  • Sources of continuity, quality of care and a range of acceptable practices and options that can be adapted to specific needs

For guidelines used by other professionals, see: www.guideline.gov

— Suzanne Hope Suarez, excerpted from "Protocols vs. Guidelines," Midwifery Today Issue 73


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Research to Remember

A retrospective study in Hong Kong compared outcomes of "post-term" pregnancies that were routinely induced at 42 weeks per hospital protocol with outcomes after the protocol was changed to require routine induction at 41 weeks. Prior to the protocol change, a routine cardiotocogram (non-stress test) was performed at 41 weeks and if normal, induction was scheduled at 42 weeks.

Routine induction of labor at 41 weeks reduced the mean gestational age at delivery by only three days, while it more than doubled the rate of labor induction in women at or beyond 41 weeks of gestation. The average length of labor was significantly longer, and use of epidural analgesia was significantly more common among "post-term" women after the protocol changed. No differences were found in maternal characteristics, mode of birth or newborn.

Eur J Obstet Gynecol 125: 206–10, 2006


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Women with asthma now make up 10% of pregnant women. When compared to women without asthma, perinatal risks to women with asthma were only slightly higher than to those without. Women with asthma were shown to have a modest increased risk of miscarriage.

American Journal of Respiratory and Critical Care Medicine, May 15, 2007


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Web Site Update

Read these articles recently posted to our Web site:

  • Vegan Pregnancy Diet—by Mindy Goorchenko
    "Aside from the details of my homebirth of twins, Psalm and Zoya—a vertex son and a footling breech daughter—the questions I get most frequently concern my vegan diet. Many, many women are interested in, even long for, a vegan diet, yet find the idea seemingly impossible to implement."
  • Herbs for Postpartum Perineum Care: Part Two—by Demetria Clark
    "The author discusses uses of herbs for postpartum perineum care, such as gotu kola, comfrey, horsechestnut, marshmallow and St. John's Wort."

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Question of the Week

Q: A doula recently told me that a large percentage of clients for whom she had worked in hospital births had decided to have a homebirth upon becoming pregnant with their next child. They were motivated by the belief that what went wrong in the first birth was related to being in the hospital. Have other doulas had similar experiences?

— Anonymous


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 am the mother of a seven-month-old girl. I live on the Big Island of Hawaii and a cold/cough has been going around for quite some time now; nothing seems to be helping my daughter/family. Strangely, Dad and Grandpa have the cough as well, but I don't. A friend suggested a Chinese Herbal remedy (Plum Flower Brand - Quiet Cough Teapills/ Ning Sou Wan). I can't find any information about this particular remedy so was wondering if any readers have any experience with it.

Any information would be greatly appreciated.

— Kanu Priya Bernal

A: The folks with the coughs should be evaluated for pertussis, or whooping cough. In December 2006, the Centers for Disease Control (CDC) came out with a new recommendation that all adults who will have contact with an infant less than one year be re-vaccinated with the new DTaP vaccine.

Last summer, a newborn from our practice in NYC was hospitalized with pertussis, and the previous winter there were mini-epidemics in the counties outside of NYC. Apparently the old vaccine, which many in the alternative health movement questioned as being unsafe, also did not confer lifelong immunity and, in fact, even having had pertussis itself does not confer lifelong immunity. The new vaccine has includes an acellular rendering of pertussis and thus is felt to be much safer.

— Nancy Kraus, CNM

A: Aloha Kanu. As a neighbor of yours on Maui, we are keenly aware of the "vog" (volcanic fog) that travels over when the Kona winds blow, as it brings on new challenges for most of us. Many experience the cough, along with other ailments such as sore throat, crusty noses, fever, headache and body aches. I also have a friend who grew up there and has commented on the difficulties presented by the vog, and that moving back there isn't an option for her because of it.

Where we live on the island we also have to deal with smoke from burning the sugar cane fields, so when they are not burning those we seem to have the vog to contend with! My son and I are particularly bothered by it and we try to close up the house and use a great air purifier as our number one defense. After that, we use Maui Sun Tea, four cups a day, and Umcka (herbal cold care remedy) religiously until symptoms are relieved. I do use one of the Chinese teapills, but not the particular one you mentioned, and I am using it for prenatal balance. I really like it and would recommend you call one of your local health food stores (Alive and Well here is great) that have certified herbalists or Naturopaths, as they are usually well-versed in those remedies. God bless you and your family.

— Lisa

A: A persistent cough should be assessed medically. Your case rings a bell with me as we had the same thing happen to us years ago. My four-year-old daughter got whooping cough at a birthday party and it lasted for over six months. Because not many doctors see it these days, it was misdiagnosed a number of times and it eventually ran its course. Her father and grandfather also had a cough after exposure to her, but they had a lesser version of it. Her grandfather had one serious episode of coughing while driving where he couldn't get his breath. He was quite distressed after this experience. Her brother did not get it. Both she and her brother had not received vaccinations for pertussis. I didn't get it. I don't know the herbs you mention, but we found that cough syrups (over-the-counter and herbal) didn't work. Homeopathy, however, was very helpful.

— Shawn Gallagher, BA, BCH
info@midwiferyconsulting.com
Toronto, Canada


Q: My daughter's son is seven days old and she is breastfeeding him. He latches on and sucks well. Despite some soreness and bleeding of the nipples at first she is coping well and the soreness is clearing. She uses nipple shields for alternate feeds to help her breasts heal.

The baby rarely settles after a feed unless he also has some formula either from a cup or a bottle. However, once he has formula he sleeps well.

Does this indicate a shortage of milk? I recall when I was breastfeeding many years ago, my breasts were full and leaky most of the time. My daughter does not seem to feel like this and there is no leakage. Is there something we can do to make sure she has plenty of milk?

— Brenda (Sian's Mum)

A: I had the same problem with my daughter. As much as I hate to say it, your daughter needs to discontinue supplementing with formula and I also would encourage her to stop using the nipple shields. What worked for me was feeding frequently and on demand as well as pumping with a good quality hospital grade pump for 10–15 min. after each feed.

If she feels she needs to supplement, she can give the baby her pumped milk, preferably with a lactation aid so the baby doesn't receive a bottle and mom will still get the additional stimulation. One thing I would say is a "must-have" is gel nursing pads called "soothies." You can put them in the refrigerator and they work really well to soothe sore nipples when used with a good lanolin cream. Definitely get in touch with a lactation consultant - they are worth their weight in gold!

— Melissa


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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Think about It

The UNICEF UK Baby Friendly Initiative and the Department of Health have published a new 18-page color brochure to assist health professionals to implement best practice and to inform parents about breastfeeding.

Called "Off to the best start," the brochure is intended to be used as a teaching aid when health professionals are discussing the benefits and management of breastfeeding with pregnant women and when they are teaching new mothers how to breastfeed.

With beautiful illustrations and clear text, the brochure includes information on the benefits of breastfeeding, as well as on skin-to-skin contact, positioning and attachment, and hand-expressing.

The brochure can be downloaded from either the Department of Health Web site, at www.breastfeeding.nhs.uk or the UNICEF UK Baby Friendly Initiative Web site at www.babyfriendly.org.uk/pdfs/otbs_leaflet.pdf.


Feedback

The nonprofit Bumi Sehat in Indonesia, a provider of culturally sensitive prenatal, postpartum, birth services and breastfeeding support, reports that they have only enough money in the bank to support the Aceh and the Bali clinics for three more months. As you are probably aware, Aceh is the area that was most heavily affected by the Tsunami. Since the Tsunami is no longer in the news, grant funding has dried up.

Donations to Bumi Sehat are tax-deductible through the Sakthi Foundation (www.sakthifoundation.org/).For every dollar sent to Sakthi that is EARMARKED for Bumi Sehat, the Zimmerman Foundation makes a 25% match, so any donation will automatically increase.

Please help by making a donation!
Send checks EARMARKED FOR BUMI SEHAT to:
Sakthi Foundation
1507 Lone Oak Circle
Fairfield, Iowa 52556

Alternatively you can transfer a donation directly to their US$ account in Indonesia:

PT. BANK NEGARA INDONESIA (PERSERO) Tbk
Branch Denpasar, KLN Ubud.
Address: Jl. Cok Oka Sudarsana, No: 45 Ubud, Bali, Indonesia
Account Name: Yayasan Bumi Sehat
Ds. PKR Nyuh Kuning
Account #: 117-766-133
Swift Code: BNINI DJADPS

Robin Lim


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