March 19, 1999
Volume 1, Issue 12
Midwifery Today E-News
“Meconium Aspiration”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Meconium Aspiration
5) Fetal Heart Rate May Point To Meconium Aspiration
6) Fetal Asphyxia
7) Postmaturity and Meconium Aspiration
8) Commentary
9) Switchboard
10) Letters
11) Coming E-News Themes

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1) Quote of the Week:

"Who is going to do a randomised trial to see if the most favourable outcomes are simply related to letting women do whatever comes naturally at the time--labouring and delivering in whatever positions they happen to feel most comfortable, yelling or grunting, or swinging from the chandelier, in privacy or with companions of their choice?"

- Jean Robinson, writing in AIMS Journal, Summer 1998

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2) The Art of Midwifery

Tea Tree Oil for Herpes

In my practice I have found that tea tree oil works well to numb herpes lesions and relieve the itch.

Linda Marks, LM

Meconium Stained or Not?

Use white towels when you are anticipating the bag of waters breaking or are thinking about artificial rupture of membranes. This is a good way to "see" meconium, if there is any.

- Nurse-Midwifery Birthing Services in Eugene, Oregon, from Midwifery Today Tricks of the Trade Volume One

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3) News Flashes

Give Her More Time

After excluding gestations with known obstetric complications, maternal diseases, or unreliable menstrual histories, researchers at the Harvard School of Public Health found that uncomplicated, spontaneous-labor pregnancy in private care white mothers is longer than Naegele's rule predicts. For primips, the median duration of gestation from ovulation to delivery was 274 days, significantly longer than the predicted 266. For multips, the median duration of pregnancy was 269 days. The researchers recommend a new rule: Count back three months from the LMP and add fifteen days for primips or ten days for multips.

- Obstetrics and Gynecology, June 1990

Immersion Therapy

Five women with oligohydramnios as defined by an amniotic fluid index of less than 8 cm underwent subtotal (shoulder-deep) immersion therapy. Results of the study showed that the mean pretreatment amniotic fluid index was 4.9 +/- 3 cm. After immersion therapy was instituted, the amniotic fluid index increased an average of 6 +/- 2.2 cm. In three subjects whose immersion therapy was discontinued, the amniotic fluid index fell an average of 4.7 cm. Researchers concluded that subtotal immersion may help reverse oligohydramnios stemming from utero-placental insufficiency.

- American Journal of Obstetrics and Gynecology, Dec. 1993

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4) Meconium Aspiration

Meconium in a baby's lungs blocks the thin cell walls and prevents oxygen from passing through them into the bloodstream. Meconium also irritates the lining of the lungs and can cause an inflammation known as chemical pneumonitis.

Meconium aspiration is most likely at the time of delivery as the baby takes his or her first full breath of air. The meconium may then be breathed right into the lungs. But if a baby has passed meconium earlier, aspiration can also occur earlier in labor or before labor begins.

In some cases, a baby with meconium aspiration goes on to develop pneumothorax, a dangerous condition in which a hole develops in the lung and air escapes through it into the chest. This air then exerts pressure on the lungs and prevents them from expanding.

Babies most at risk of meconium aspiration syndrome are those who are born after forty-two weeks, who are small for dates or who have been very short of oxygen during or before labor. Babies who develop an infection in the womb may also pass meconium before delivery and may take it in before or during delivery.

- When a Baby Dies, by Nancy Kohner & Alix Henley, Thorsons, 1997

5) Fetal Heart Rate May Point To Meconium Aspiration

To identify the fetus and newborn at risk for meconium aspiration syndrome the perinatal characteristics of 238 infants delivered through meconium stained amniotic fluid were prospectively examined. All infants with meconium stained amniotic fluid were routinely suctioned with a DeLee apparatus before tracheal intubation and suctioning. The type and presence of meconium in the trachea, neonatal breathing before intubation, and Apgar scores were recorded in the delivery room. Despite suctioning with a DeLee apparatus and endotracheal suctioning, meconium was present in the trachea in 87 infants (37 percent) and meconium aspiration syndrome developed in 22 infants (8.6 percent). Of the infants delivered through thick meconium, meconium aspiration syndrome developed in 19 percent, as compared with 2.9 percent and 4.6 percent in the thin and moderate meconium groups.

Thick mecomium, the presence of fetal tachycardia, and absence of intrapartum fetal cardiac accelerations identified the fetus at high risk for meconium aspiration syndrome. The presence of these monitoring findings and thick meconium should alert practitioners to the possibility of a fetus that requires intervention. Low umbilical artery pH, Apgar scores <5, and meconium in the trachea further characterized the newborn at high risk for meconium aspiration syndrome. The combination of these findings may best identify the infant delivered through meconium stained amniotic fluid who requires close observation for meconium aspiration syndrome.

The authors of the study comment:

"Our study differs from previous reports in that we analyzed fetal heart monitoring in addition to the intrapartum and newborn characteristics of infants delivered through meconium stained amniotic fluid.... The presence of fetal tachycardia may be a response by the fetus to compensate for hypoxemia and acidosis. The absence of intrapartum cardiac accelerations may represent failure of the fetus to compensate for the acidosis. The presence of these specific findings should alert the [practitioner] to a fetus at high risk of in utero aspiration of meconium. If these specific... findings and thick meconium are noted the [practitioner] or resuscitation team should be... prepared for resuscitation even if the infant undergoes suctioning with a DeLee apparatus and endotracheal suctioning.

- Elena M. Rossi MD et al, "Meconium aspiration syndrome: Intrapartum and neonatal attributes," Am J Obstet Gynecol 1989; 161: 1106-10

6) Fetal Asphyxia

Meconium stained amniotic fluid occurs in approximately 12 percent of live births.In approximately one third of these infants meconium is present below the vocal cords. However, meconium aspiration syndrome develops in only two of every 1,000 live-born infants. Ninety-five percent of infants with inhaled meconium clear the lungs spontaneously. Recent investigations have suggested that a reexamination of our assumptions about the etiology of meconium aspiration syndrome is in order. Evidence has been provided that supports the hypothesis that it is not the inhaled meconium which produces the primary pathologic condition of meconium aspiration syndrome but rather it is fetal asphyxia that is the etiologic agent. Asphyxia in utero produces pulmonary vasospasm and hyperreactivity of the pulmonary vessels. With severe asphyxia the fetal lungs undergo pulmonary vascular damage with pulmonary hypertension. The damaged lungs are then unable to clear the meconium. In the most severe cases there is right-to-left shunting and persistent fetal circulation with subsequent fetal death. The incidence of meconium aspiration may thus be essentially unaffected by current obstetric and pediatric interventions at birth. For the asphyxiated or distressed infant, suctioning at birth and tracheal intubation is recommended.

- VL Katz MD & WA Bowes Jr MD, "Meconium aspiration syndrome: Reflections on a murky subject," Am J Obstet Gynecol 1992; 166: 171-83

7) Postmaturity and Meconium Aspiration

Recent studies have concluded that true post-term babies have a higher morbidity and mortality rate, and may be at greater risk than moderately preterm babies.... There is a much higher incidence of meconium staining, premature aspiration of meconium (in utero), and meconium aspiration syndrome. Murray Enkin, et al, in "A Guide to Effective Care in Pregnancy and Childbirth," writes that "Perinatal mortality is increased in post-term pregnancy. Prolonged pregnancy is associated with an increased risk of intrapartum and neonatal death but not of antepartum death. The risk increases with the onset of labor. A higher prevalence of meconium stained amniotic fluid is an outstanding feature among the intrapartum and asphyxial neonatal deaths.... It is important, therefore, that the midwife make as accurate an estimation of gestational age as possible, in order to make appropriate care choices."

- Valerie El Halta, Midwifery Today Issue No. 38

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Issue 33 Second Stage (Regular price: $7)
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8) Commentary: Peer Review by Jill Cohen

One of the perks midwives can share is getting together with sister midwives for peer review, otherwise known as midwife teas, potlucks, sharing circles and so on. The main goal shared among the group is to enhance our love for and commitment to serving women and babies, keeping them healthy and assuring better birth and postpartum. Why do we come together? To share our birth stories, gain insights, love and support each other and acknowledge our commitments afresh. It is a priceless opportunity to review difficult cases and receive lovingly honest opinions. I've never been to a midwives' peer review that was formal. We hug, we cry and we laugh. It is intimate, and the knowledge and strength we walk away with carries us forward and nurtures us always.

Every midwifery community would benefit by creating some form of regular peer review. If you are alone in your area, do it by phone or Internet. If not everyone gets along, meet with only those who do. The time spent together creates the kind of unity and strength so needed in order to maintain our art and fortify ourselves. We all work in communities where all sorts of things are misconstrued, so it creates a means to prevent hearsay and misunderstanding. Peer review is an opportunity to come together, set things straight face to face and dispel those funky rumors so our unity is kept intact. With midwives so in the minority it is extremely important to put forward a unified front.

Peer review also provides an opportunity to talk about birth openly without the pressure of judgment. If we are like-minded, opinions can flow easily. Midwives need this kind of time together to voice their joys and their burnouts and to just be themselves. This kind of safe and honest exchange creates trust and a lasting bond. It also helps establish connections that lead to partnerships or agreements to share on-call time and backup for each other. Such bonds provide a wonderful chance to connect in an otherwise hectic life of serving.

If your peer review group is just getting started, establish dates, times and places to meet. Sharing food is always good! Privacy and confidentiality are essential. Most importantly, take the time to do it on a regular basis; you will be so glad for the support you feel and help create.

- Jill Cohen, midwife

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9) Switchboard

Readers, at what rate do you see meconium in homebirth or birth center situations? Do you think it differs from the rate it is seen in hospital births? Why or why not?

Both my girls had meconium stained water. With my first I was appalled at the deep suctioning. This baby is new in the world--what a way to welcome a child, shove a long tube down its throat. Would this not cram any aspirated meconium back into the baby's lungs? Why couldn't the baby just be suctioned as normal, and maybe just a little extra for good measure, leaving out the long tube to be crammed down into its lungs? If we could just keep a close eye on the baby after doing a regular suction, we could save these babies from a horrendous beginning. Haven't they gone through enough to get here as it is?

- Amber W.

I'm here to defend Jill Cohen in her recent article in Midwifery Today E-News Issue No. 9 in reference to using epidurals to relax an exhausted mother. I am a homebirth midwife and I of course do not use epidurals. However, I've been known to transport an emotionally exhausted woman so she could have one.

I would like to comment on Kate Simon's opinion [E-New Issue 10]. In my opinion, an IV with analgesia is not going to be strong enough to let a woman sleep. From my experience with the transports that I've done, let's first let the woman get some rest. Analgesia will only make the woman groggy and "high," and these drugs get to the baby faster than an epidural would, subjecting the baby to possible depression or fetal distress. One would not want to be on an IV with Demerol for very long. On the other hand an epidural allows the woman to remain alert after she has had her necessary rest.

I trust Jill's judgment and know that she is not going to transport at the drop of a hat, nor would she suggest an epidural to all her laboring women. Sometimes an epidural is the best option. I will always remember what midwife Valerie El Halta taught me: there is a difference between intercession and intervention.

- Cathy O'Bryant CPM
Payson, Utah

[In response to Amber's letter in Issue No. 10] I too had a child who weaned himself at ten months. He simply was not interested. He wanted to get up and go, go, go! He did not like to cuddle at all. I was so disappointed! I nursed subsequent children a lot longer (up to three years) and pretty much enjoyed it all the time, except on days when everyone wanted a piece of me!!

The child who weaned at ten months is twenty-two now and the biggest hugger and cuddler there is! He's also my healthiest kid (out of a pack of healthy kids). I can count on one hand the number of colds he's had in his life. I guess each child is different, aren't they, with different needs and wants. Understanding and meeting those needs is the big challenge.

I miss those middle of the night feedings. It was as if there were only the two of us, alone in the big world. I'll admit I was crabby about waking up in the middle of the night, but the sense of peace that descended on me was palpable. There is nothing that can compare with that. I do believe that breastfeeding is a gift you give your child, but it's also a gift for the mother. Sometimes we're in such a hurry to get through things (like labor, and difficult times with the kids) that we forget to cherish the events. Pretty soon they are just distant memories which fade with time. I've learned that even difficult events need to be cherished. Aren't they the best teachers?

- Jana McCarthy

Hello to all of you dedicated to the practice of breastfeeding! I am writing to ask for your help. I am an aspiring midwife residing in New Hampshire, where it is not legal to breastfeed in public!!! (Many other states in the USA have similar situations.) If you would be willing to write a short note stating your support of the rights of breastfeeding women and the benefits to their babies, it would be of great help. You can fax such a letter to the following and support the rights of New Hampshire women. Fax to: Honorary Members of Children and Family Law Committee, in support of House Bill 441; Fax (603)271-6689. Thanks!

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10) Letters

Thank you for a great newsletter. I am a beginning student in midwifery and I am really enjoying the information.

Kelli E.

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11) Coming E-news Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- breech birth
- education
- infections
- episiotomy
- epidurals
- breastfeeding
- waterbirth
- posterior labor
- postpartum depression
- homebirth
- tear prevention

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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