May 21, 2008
Volume 10, Issue 11
Midwifery Today E-News
“Meconium”
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Quote of the Week

"When one of your dreams comes true, you begin to look at the others more carefully."

Anonymous


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The Art of Midwifery

An amnioscope is an endoscope, i.e., a tube the size of a finger (one of several calibers may be used, according to the situation) equipped with a light at one end. While doing a vaginal exam, the midwife can gently introduce the tube inside the cervix along her finger. Thanks to this rudimentary endoscope she can evaluate through the membranes the color of the amniotic fluid. More often than not she can see a beautiful clear liquid with some flecks of vernix. Then the midwife is completely reassured. Her level of adrenaline can drop. She knows that she can leave this laboring woman in peace for a long time. Since the duration of labor is to a great extent proportional to the level of adrenaline of the midwife, this practice can create the conditions for a fast and easy birth.

My aim is not to promote routine admission amnioscopy. It is just to stress that midwives, particularly homebirth midwives, might occasionally use this simple and cheap technique in a certain number of precise situations.

Michel Odent
Excerpted from "Should Midwives Re-invent the Amnioscope," Midwifery Today, Issue 80
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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.


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Research to Remember

Researchers reviewed records of 199 cesareans that were done for non-reassuring fetal condition and/or meconium stained amniotic fluid in a rural hospital to evaluate the effect on neonatal outcome. Apgars at one and five minutes were compared with those of 33 vaginal births after labour with meconium staining. Five babies out of the 232 (2.2%) had an Apgar score <7 at five minutes. Of those, one died shortly after birth. Of those born by caesarean section group for non-reassuring condition, two were stillbirths and one was an early neonatal death, giving a perinatal mortality rate of 15.1/1,000 births. Mode of delivery did not affect the five minute Apgar score in a statistically significant manner. The researchers concluded that "caesarean delivery does not improve the neonatal outcome when the amniotic fluid is meconium stained."

Journal of Obstetrics and Gynaecology 28(1): 56–59


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The Problem Is Induction

Meconium is not a problem unless it is a symptom of severe distress. Even then the problem is the distress, not the meconium. With good fetal heart tones and a normal labor, even thick meconium is rarely a problem.

Meconium is more common in labors that are induced, by any means; meconium may not even be more common in postdates labors since induction is often a confounding factor. I recently came across a study that retrospectively evaluates the likelihood of heavy meconium being a risk for meconium aspiration. The study is older, but large—it includes data on almost a thousand babies with "thick or moderate meconium." A variety of factors were found to contribute to the rate of meconium, but only 4% of the babies (39 out of 937) actually developed meconium aspiration syndrome (MAS), even though the entire group had meconium.

Induction was a strong link to both meconium waters and to MAS, but (and this surprised everyone) postdates was not found to be a factor in the babies who developed MAS. MAS was distributed equally among all gestation groups. MAS was correlated with thick meconium primarily when other risk factors were present—such as the need for resuscitation, poor heart tones or cesarean delivery.

Induction of labor was most strongly associated with MAS. We know that we see meconium more often in induced babies, and we know we see more MAS in induced babies. A logical guess may be that we see more meconium in postdates babies simply because postdates babies are far more likely to be induced than are 40-week babies.

This study confirms what most of us have seen: Meconium is "rarely a problem" even when it is thick.

Gail Hart
Excerpted from "The Problem Is Induction, Not Meconium," Midwifery Today, Issue 80
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According to a 2006 article in Pediatrics, the incidence of MAS (as a primary diagnosis) in the developed world is low and seems to be decreasing. The risk is significantly greater in the presence of fetal distress and low Apgar score, as well as Pacific Islander and indigenous Australian ethnicity.

Pediatrics 117(5): 1712–21


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Web Site Update

This article from the last issue of Birthkit is now online: Perinatal Mood Disorders: Understanding and Helping—by Vicky York
"Nothing I suggested made her feel better and I recognized from experience that she likely had more than one form of perinatal mood disorder. She was too anxious to know when things were okay and too depressed to follow up on suggestions when they weren't okay; and sleep deprivation magnified all of it."


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Question of the Week

Q: My mother had seven children in 11 years, with a few miscarriages in between. She seems to have weathered it well, with good health. She did have a hysterectomy at around 45 years old for uterine bleeding, which probably was not related at all. This got me to thinking: What is the ideal spacing between babies and why? I know that some recommend spacing births 18 months apart at a minimum, if a VBAC is planned. Are there other physical reasons to wait for a period of time between babies?

— Anonymous


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Question of the Week Responses

Q: One of our clients recently discovered that she has twins. They each have their own placenta, and she has reached 21 weeks in very good health and is extremely determined about birthing at home! This is her second birth.

We totally support her decisions and plan to attend her homebirth. However, with the increasing hospitalisation, it has been more than 20 years since there was a planned homebirth of twins here in Denmark. We only have hospital experience with twin births, and it is just so overly medicalised and regarded as high-risk with all the machinery and medicine close at hand and "the works." We are SO keen to learn more from midwives with twin-homebirth experience. Please share with me EVERYTHING that comes to mind!

— Marta
orbis@post.cybercity.dk

A: My daughter-in-law had a miscarriage and two-and-a-half months later realized that she hadn't had another period. She did a pregnancy test, which was positive, so had an ultrasound to determine a due date (they live in Cambodia and wanted to be able to give me an idea of when she was due so I could go over and help). Lo and behold it was twins, due early June. I referred to Anne Frye's Holistic Midwifery for recommendations, which she adhered to religiously.

Eat extra salt and drink 3–4 quarts of water daily (she said she was craving salt but resisted eating more, so was glad to eat to taste).

Eat half again as much protein, take extra Cal/Mag supplements and more than the usual prenatal vitamins.

I had her take Bioflavonoids to strengthen her amniotic sac.

Eat six moderate meals daily, making every calorie count for good nutrition (except for celebrating special occasions).

Her Hgb was only 9.2 when she arrived in the US at 32 weeks, so she took an herbal liquid iron which brought it up to 14 by the time she delivered—10 days late.

We did a CBC and Comprehensive Metabolic Panel to keep track of her liver function at 36 weeks and monitored her B/P regularly (she was living with me by then). She also cut back on her activity and rested a few times a day.

We prayed a lot about a peaceful birth, where the Lord knew it was best to deliver the babies and who and how many other caregivers to have available for the birth. We all continued to have peace of mind to do a homebirth. She started labor about 7 am, with contractions 20 minutes apart all day until 8:30 pm. The contractions were five minutes apart until the first baby came at around 9 pm. She had no bleeding, she nursed the baby, ate, drank and used the bathroom, while having contractions every 20 minutes again. Around 10:20 pm the contractions again changed to five minutes apart. The second baby was born at 10:54 pm. The placentas came separately about 20 minutes later, with very minimal blood loss.

We had fraternal girls, 6 lb 10 oz and 7 lb 10 oz; they are different as night and day!

— Judy Roberts

A: Thank you for your issue on twin births. I found myself pregnant with twins at nine weeks into my fourth pregnancy. We discovered it via ultrasound in the ER because of heavy bleeding. At the time I was planning my second homebirth after two cesareans. Unfortunately, my midwives had little additional information to give me regarding my twin birth. After complications arose, we decided my birth was outside the scope of the midwifery practice and I was referred to an obstetrician.

Unfortunately, again, this obstetrician had no additional information about a twin birth. I had to search on my own for good nutritional information. I wanted big, healthy babies. I found books by Dr. Barbara Luke that were very helpful. Dr. Luke's books really focus on gaining weight the right way quickly, since you probably have fewer weeks to grow your babies than with a singleton pregnancy. I recommend them to all mothers of multiples. They are somewhat medical-model based, but they are very helpful. I was able to carry my twins to 36 weeks and delivered them at 6 lb 4 oz and 7 lb 6 oz.

— Brooke Sanders Purves


Q: In a recent episode of "Baby Story," a mom in labor was offered Ambien, a hypnotic, so she could sleep until she went into hard labor. Does anyone have experience with this or other drugs in its class being used during labor? Does it pass into the baby? Isn't this just going back to the era of twilight sleep (scopolamine—a hypnotic—and morphine)?

— Anonymous

A: Regarding the question...about inducing labouring mothers to sleep with the drug Ambien (Zolpidem Tartrate), I truly fail to see the point of this practice. From the perspective of what "natural birth" is all about, whether it has been found to affect the baby or not, is a side issue and a compound problem. The immediate problem is that it forces the mother into an artificial sleep and getting disconnected, when she needs to be in full contact with her experience and with her instinct. If you interfere with that, you interfere with her whole process.

Regarding the safety of the drug, the manufacturer's own literature is hardly encouraging in terms of its administration to labouring mothers. I quote from the "Highlights of Prescribing Information" document published by the manufacturer on its Web site (http://products.sanofi-aventis.us/ambien/ambien.pdf ):

  • Severe anaphylactic and anaphylactoid reactions have been reported (5.2)
  • Abnormal thinking, behavior changes and complex behaviors such as sleep-driving have been reported (5.3)
  • Pediatric patients with attention-deficit/hyperactivity disorder (ADHD): Hallucinations (7.4%) and other psychiatric and/or nervous system adverse events were observed frequently (5.6, 8.4)
  • Depression: Worsening of depression or, suicidal thinking may occur. Prescribe the least amount feasible to avoid intentional overdose (5.3, 5.6)
  • Withdrawal symptoms may occur with rapid dose reduction or discontinuation (5.4)
  • CNS depressant effects, additive effects with CNS depressants (2.3, 5.5)
  • Potential impairment of activities requiring complete mental alertness such as operating machinery or driving a motor vehicle, after ingesting the drug and the following day (5.5)
  • Additive effects with alcohol; should not be taken with alcohol (5.5)
  • Elderly/debilitated patients: Impaired motor, cognitive performance after repeated exposure, increased sensitivity (2.2, 5.6)
  • Caution advised in patients with hepatic impairment, mild to moderate COPD, impaired drug metabolism or hemodynamic responses, mild to moderate sleep apnea (5.6)

USE IN SPECIFIC POPULATIONS

  • Labor and delivery: No established use (8.2)
  • Nursing mothers: Not recommended (8.3)
  • Pediatric use: Safety and effectiveness have not been established (8.4)

~~~~
They also take some pains to warn about the possibility of forming addiction and/or developing withdrawal symptoms upon taking the drug. In my humble, non-medical opinion, this does not sound like something to be given lightly, like a cup of lettuce infusion to help the mom rest a little bit.

At this point I believe our community should be quite clear about the ideal procedures to deal with pain and anxiety during labour:

  • Provide the mother with an intimate, warm, dark, and safe place to labor in, and don't bother her.
  • Soothing company, and a bit of loving contact and/or a judicious bit of massage will do wonders to reduce pain and anxiety.
  • Let the woman rest and sleep when she feels naturally drowsy. Powerful natural drugs (endorphins) are at work.
  • Use hot water as analgesic. A hot shower or a dip in a hot tub usually has a magical effect.
  • Acupressure and/or acupuncture are far safer pain reducing methods than any drug known.
  • When pain is truly unbearable and labor is becoming torture, then an epidural is an appropriate choice, and its effects on the baby, when properly administered by an experienced anaesthesiologist, are indeed minimal. In any event far less risky than the possible side-effects of this Ambien thing.

In my experience, there's nothing wrong with a judiciously applied epidural. It's just that there are usually better, less invasive and less risky alternatives that ought to be tried before resorting to medical drugs.

— Alejandro Araujo
alejandroaraujo@gmail.com


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

Common ingredient in infant formula was found to be linked to diarrhea, severe dehydration and seizures in babies, according to complaints submitted to the FDA.

A shocking report has been released on the adverse health effects of fatty acids found in infant formulas. The Cornucopia Institute, a US-based corporate watchdog group, presented their findings on the fatty acids DHA and ARA, which are now commonly added to formula.

The report is based on a Freedom of Information Act request that the Cornucopia Institute filed with the Food and Drug Administration (FDA), the result of which was the uncovering of 98 reports filed by parents and physicians detailing incidences when babies had reacted adversely to formula containing DHA/ARA. The reported incidences range from cases of vomiting and diarrhea that stopped when babies switched to non-DHA/ARA formula to babies being treated in intensive care units for severe dehydration and seizures.

The FDA has never been convinced of the safety of DHA/ARA additives, according to the report. In its initial analysis of the additives, the FDA stated it had reached no determination on their safety status. The administration also noted that some studies had reported unexpected deaths among infants who had been fed with DHA/ARA formula. Despite its reservations, inexplicably the FDA did not withhold approval for the additives.

INFACT Canada has long questioned the use of DHA and ARA (also marketed as omega-3 and omega-6 fatty acids) in infant formula. All major formula companies have added the fatty acids to their products in recent years, claiming that they aid in brain and eye development. However most test results have found the additives have negligible effects on infant development. But because DHA and ARA are found naturally in breastmilk, formula companies market DHA/ARA formula as "closer to breastmilk."

Martek Biosciences Corporation, the company that supplies almost all formula companies with DHA/ARA, has admitted that the purpose of the additives is not to encourage healthy development, but to be used as a marketing tool. In its promotional material to encourage investment, Martek stated:

"Infant formula is currently a commodity market, with all products being almost identical and marketers competing intensely to differentiate their product. Even if [DHA/ARA] has no benefit, we think it would be widely incorporated into formulas, as a marketing tool and to allow companies to promote their formula as 'closest to human milk.'"

While DHA and ARA are found naturally in breast milk, the idea that Martek's manufactured acids make formula closer to breast milk is ridiculous. Martek produces DHA and ARA from fermented algae and fungus, and uses hexane (a neurotoxin) in the manufacturing process. Simply adding these synthetic substances to formula cannot make artificial baby milk behave like breast milk, which is a complex, living substance that provides babies with the best possible nutrition and immunological protection.

Regular infant formula puts babies' health at risk, but now infants are being harmed for the sake of a marketing tool. This is an egregious case of formula companies putting profit margins above infant health. In light of this report, it is imperative that all parents be made aware of the potential risks of feeding their babies formula with DHA/ARA. The products should be pulled from the market until their safety can be properly assessed by independent investigations.

Babies should not have to get sick just because companies want to raise their sales figures.

For the full report, see: http://cornucopia.org/DHA/DHA_FullReport.pdf

INFACT Canada
http://www.infactcanada.ca


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