September 29, 2010
Volume 12, Issue 20
Midwifery Today E-News
“Postmaturity”
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Birth Is a Human Rights Issue

The right to have the most joyous and healthy pregnancy, birth and postpartum possible should be a human right for both mother and baby. Learn how you can help. Come to our conference in Strasbourg, France, September 29 – October 3, 2010. Classes will include Mothers’ Birth Rights, Babies’ Birth Rights and Maternal Mortality Is a Pressing Human Rights Concern.

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In This Week’s Issue:


Quote of the Week

“According to traditional wisdom in rural France, a baby in the womb should be compared to fruit on the tree. Not all the fruit on the same tree is ripe at the same time…we must accept that some babies need a much longer time than others before they are ready to be born.”

Michel Odent
Excerpted from "The Tree & the Fruit: Routine Versus Selective Strategies in Postmaturity," Midwifery Today, Issue 72
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The Art of Midwifery

Lovemaking: A Natural Alternative to Induction

“The simple act of lovemaking before or during labor facilitates a quicker birth and can trigger the onset of labor. When a woman is sexually stimulated, oxytocin flows through her system, causing her uterus to contract, either in the form of orgasms or labor contractions. In addition, lovemaking provides naturally what prostaglandin gel tries to achieve artificially. Intercourse deposits semen against the cervix of the woman, which works to soften the cervix, lengthen the pelvic ligaments and allow the baby’s head to pass through with ease.”

Marnie Ko
Excerpted from Birth Wisdom, Tricks of the Trade, Vol. III
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Jan’s Corner

In the Mind

I found the following excerpt in a book I have from 1896 called Tokology, a Book for Every Woman, by Alice Stockham, MD. The book begins with a chapter on painless childbirth.

“‘I know of no country, no tribe, no class, where childbirth is attended with so much pain and trouble as in this country.’ Thus replied a traveler who had been many years in foreign lands, upon being interrogated as to the comparative sufferings of savage and civilized women. His occupation and sympathies had brought him into close relationship with all classes of people, and therefore fitted him for an intelligent and discriminating judgment in this matter.
“Neither in India, Hindustan, China, Japan, the South Sea Islands, South America, nor indeed in any country do women suffer in both pregnancy and parturition as they do in this. Possibly among the higher classes in Europe there may be equal suffering; but the peasantry everywhere is comparatively exempt.”

It has taken only a hundred years to spread this pain and suffering to nearly the whole world. Yet many of us are having amazing, awesome births. We need to spread these good birth stories to the world and reverse the notion that childbirth equals pain and suffering. It seems that what is in the mind comes out in birth. We as midwives, doulas and childbirth educators need to make sure our prenatal care is exemplary because we have the ability to help women work through their baggage and clear their minds so they can have a great birth.

At the recent Midwifery Today conference in Russia we fully realized that birth is mainly in the mind. When we take what most birthing mothers have in their minds going into their labor—everything she has learned from this society about the pain and suffering of childbirth—and combine it with the interventions she will likely suffer, we have a recipe for disaster. We have, as a society, truly stolen a miracle from our birthing mothers. Jeannie Parvati Baker used to say, “Women of Earth take back your birth.” Michel Odent tells of 50 breech births that happened in the UK where the mothers did not know their babies were breech. Those births all turned out well. It seems like a lack of knowledge helped these women. No worry was ever in their minds about having a breech birth!

At no other time in “herstory” have we had such a wealth of insight into birth. We have the ability to reverse the notion that childbirth is a horrible, painful, dangerous event. We can help our pregnant mothers work through their traumas and misinformation. We can help them go on to have miraculous births. And the news of these types of births will spread. To the midwives, doulas, childbirth educators and everyone else who has been called to this profession: Thank you for doing your prenatal work with insight, skill and love. Thank you for all the hard work you’re doing to make things great for motherbaby (and dads too).

Jan Tritten, mother of Midwifery Today

Jan Tritten is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.

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Research

Conceiving after Miscarriage? Sooner May Be Better

Scottish researchers say sooner may be better when it comes to conceiving after a miscarriage. In a study published in the August 28, 2010 edition of the British Medical Journal, researchers found that women who conceived within six months after having a miscarriage had the best outcomes in their subsequent pregnancies.

Current World Health Organization guidelines recommend that women who have miscarried wait more than six months before conceiving again. However, the BMJ study found that women who conceived sooner than the current WHO guidelines were less likely to have another miscarriage, termination or ectopic pregnancy. The researchers examined the results of nearly 31,000 Scottish women who were pregnant between 1981 and 2000 and had reported a miscarriage in their first pregnancies. Women who conceived within six months of their miscarriage and went on to have a live birth were less likely than women who waited 6–12 months before conceiving again to have a c-section, preterm delivery or a baby with low birth weight. However, women in this group were more likely to have an induced labor.

“Our research shows that is unnecessary for women to delay conception after a miscarriage,” the researchers concluded. “As such, the current WHO guidelines may need to be reconsidered.”

To read the full study visit: http://www.bmj.com/content/341/bmj.c3967.full

— Love, Eleanor, Siladitya Bhattacharya, Norman Smith and Sohinee Bhattacharya. 2010. “Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland” BMJ 341:c3967


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A Timely Birth

Postdates, by itself, is not associated with poor pregnancy outcome. Extreme postdates or postdates in conjunction with poor fetal growth or developmental abnormalities does show an increased risk of stillbirth. But if growth restriction and birth defects are removed, there is no statistical increase in risk until a pregnancy reaches 42 weeks and no significant risk 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 1/1,000).(2)

There is a creeping overreaction in dealing with postdates pregnancies. It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten percent of babies born at 43 weeks suffer from postmaturity syndrome (over 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 need to be compared to the risks of interventions. Induction, as already noted, 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 1,800 post-term (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 /1,000 in the post-term and 0.75/1,000 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) This is only one of several studies showing postdate pregnancies can be monitored safely until delivery or until indications arise for induction. Even the famous Canadian Multicenter Post-term Pregnancy Trial Group (Hannah) of 1,700 postdates women showed no difference in perinatal outcome among women who were monitored past their due date, as compared with those who were induced at term.(4)

In some studies, post-term births have shown a higher cesarean rate for suspected fetal distress. However, when a group of researchers conducted a case-matched review of nearly 300 postdates pregnancies they concluded that the increased rate of obstetric and neonatal interventions “does not appear to be a result of underlying pathology associated with post-term 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!(5) When monitoring demonstrates that fetal growth, activity and amniotic fluid levels remain within expected norms, the baby can safely wait for spontaneous labor to begin. Spontaneous labor gives the greatest chance for vaginal birth, even though the baby may be slightly larger than if the mother were induced at 40 weeks.

References:

  1. McClure-Browne, J.C. 1963. Comparison of perinatal mortality rates versus gestational age through the past three decades. 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. 1996. Expectant management of post-term patients: observations and outcome. J Matern Fetal Med 5(5): 293–97.
  4. Hannah, M.E., et al. 1992. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 326(24): 1587–92.
  5. 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.

Gail Hart
Excerpted from "A Timely Birth," Midwifery Today, Issue 72
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Read this article from the brand-new issue of Midwifery Today, Autumn 2010:

  • Who Counts Where I Come From? by Sister MorningStar
    “As a Cherokee daughter, I wondered who was counting me and counting where I come from. My people live in the hills of Missouri, not on a reservation. In the government schools, the teachers often would ask, ‘How many of you come from _____?’ There never was an answer that counted me.”

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Question of the Week

Q: Did you have a postdates pregnancy? Have you helped clients who gave birth after 42 weeks? Tell us about your experiences with postmaturity.

— Midwifery Today staff


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.


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Question of the Week Responses

Q: How does the threat of persecution affect your midwifery practice?

— Midwifery Today staff

A: The threat of persecution of my midwifery practice made me leave the profession. Persecution from the system occurred when I did not follow “routine procedures.” As an autonomous practitioner, I made decisions in partnership with mothers about which interventions, if any, were required on an individualised basis. Persecution from my colleagues came after I encouraged women to follow their instincts, to believe in their strengths, to work with pain and fear rather than suppressing it with opiate medication. In the UK there is only one route through which to practise midwifery—anything else is illegal. Therefore, for seven years now, I have worked in the lay role as a doula and doula educator, as a way of continuing to be “with women.” But in my heart I am still a midwife, and a traditional midwife at that.

— Adela Stockton, doula educator and author of Birth Space, Safe Place: Emotional Well-Being through Pregnancy and Birth (Findhorn Press, 2009) http://www.adelastockton.co.uk

A: Due to the threat of persecution, I have to have a very high level of trust with my clients. They need to know exactly what I am risking to attend their birth. Licensure is practically impossible where I practice, but women have no other birth options. I can’t sit still and say “no” to women and send them off to hospitals that have a 90% c-section rate. But I also can’t help but wonder at each birth—is this the birth that will get me deported, or worse?

— Anonymous in Asia

A: As a direct entry midwife in Nevada, where midwifery is clearly legal, I don’t fear problems in my Nevada births. My problem lies about 20 miles east of my home in the state of Arizona. For 30 years I have attended births in the small cities along the Arizona/Nevada state line—cities that are not serviced by any licensed Arizona midwives. Several years ago I received a cease and desist order from the state of Arizona. I have been categorized by the state of Arizona as a “habitual birth attendant” (we actually joke a lot about that…I’m always jonesing for a birth fix!) But it’s no joke that if I cross over to Arizona to help women I am threatened with the possibility of being arrested. Each time I get a phone call from someone in Arizona—which happens several times a year—I have to explain to them that their state has put me in a terrible bind and I have to make the decision to break the law and help them or leave them to a hospital birth or an unassisted homebirth—not an easy decision.

The last birth I attended in Bullhead City was one of the most difficult shoulder dystocias I have had in more than 30 years and 2,300 births. Both mother and baby did extremely well, but thank goodness I was there and that they didn’t do an unassisted homebirth (the baby would have died because there was no way that baby was coming unassisted) and who knows what the outcome would have been for that baby and mother if they had gone to a hospital.

At this point I am still attending some births in Arizona for special women whom I have close bonds with—people I know will protect me if a transport is needed and who will take care of getting their own birth certificates without using my name. I don’t like it and my family doesn’t like it, but what am I to do?

— Margie Dacko, CM
Las Vegas, Nevada


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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