August 13, 1999
Volume 1, Issue 33
Midwifery Today E-News
“Omnium Gatherum”
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Broaden your education in the United Kingdom and Jamaica!

Make plans now to attend one or both these conferences:

London, England, September 9-13, 1999
Evidence Based Midwifery

Ocho Rios, Jamaica, December 2-6, 1999
Birth Without Borders--Weaving a Global Future
Sponsored by:

- Mothering magazine: Mothering is in its 24th year of providing inspiration for attachment parenting. Mothering guides, nurtures, and supports while providing the latest on controversial parenting topics.

- Cascade Health Care: Cascade HealthCare Products, Inc. began business in 1979 with the primary goal to provide supplies and equipment for the emerging profession of midwifery. We have developed a complete product line that not only serves midwives, but nurse midwives, childbirth educators, lactation consultants, visiting nurses, birth centers, WIC programs, nurse practitioners, doulas, and professionals dealing with expectant parents, families and women's healthcare.

Important Conference Notes:

- Students receive price reductions of 25% for Jamaica, 30% for London.
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- Subscribe to Midwifery Today magazine and receive a reduced conference price.
- CEUs for Jamaica are in progress.

For your copy of the printed programs send your full name and postal address to inquiries@midwiferytoday.com. Please mention code 940.

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This issue of Midwifery Today E-News is sponsored by:

- Austin Birth Center
- Waterbirth Website

Look for their ads below!

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Switchboard
5) Coming E-News Themes
6) Classifieds

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1) Quote of the Week:

"Women complain about premenstrual syndrome, but I think of it as the only time of the month I can be myself."

- Roseanne

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2) The Art of Midwifery

Whatever herbs you choose to recommend to others for breastfeeding, strive toward creating a tasty blend. Nutty flavors blend well with spices, leafy tastes call for mint or citrus, and savory flavors go well in soups or broths. Bitter flavors are tough to mask, and sweeteners don't really help. For these, it's best to make small, concentrated quantities and down it quickly.

I follow a self imposed rule that calls for first trying anything I ask someone else to take. That way I know what they're really up against, and I'm more motivated to create something that tastes good.

- Judy Edmunds, Bresastfeeding Herbs, The Birthkit, a Midwifery Today newsletter

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3) News Flashes

The nursing patterns of 82 exclusively breastfeeding mother-infant pairs were observed four to five days postpartum on the maternity ward at University Hospital in Malmo, Sweden. The breastfeeding outcomes and pacifier use was assessed by regular telephone contacts during a four month follow-up. The breastfeeding rate at four months was 91 percent in the non-pacifier group and 44 percent in the pacifier group. An incorrect superficial nipple-sucking technique at the breast from the start combined with pacifier use resulted in early weaning in most cases.

- Birth, June 1997

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4) Switchboard

Premature labor can be a real problem, although excellent nutrition can prevent much of it. Another real problem is the current perspective on "normal" length of pregnancy. I have observed over many years that the length of pregnancy varies as much as the women. I have observed many healthy full term babies born several weeks outside the "official" due dates.

I read somewhere that one could predict a woman's normal gestation by looking at her normal menstrual cycle length. Long cycles often imply longer pregnancies, short cycles imply shorter pregnancies. Overall this theory has shown promise in my practice.. Both my children were born "prematurely." My first at 34.5 weeks by calendar had a gestational age by assessment of 36 weeks. My second was born at 35 and 4 weeks by calendar and assessed at 38.5 weeks. (A 7 lb 8 oz homebirth transport for prematurity--ha!) I have always had a personal history of very short cycles (21-26 days).

When discussing premature labor, we need to be cautious that we are not really dealing with normal shorter gestations, just as the "post-term" mom may also be normal for her longer gestation.

- Pamela Golliet LPN, IBCLC, ICCE, CD

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In the article on homebirths, I was very intrigued by the statistics [Issue 29]. My philosophy on birth is that every woman should choose the setting she feels most comfortable with, as is the case with her care provider. Our hospital strives to provide a home like environment for all our births through home-like rooms, one on one care, intermittent monitoring, whirlpools, ambulation during labor, frequent position changes, and encouraging the woman to do whatever is necessary to make it through labor. I have never asked a patient to remain on her back in order for me to get a continous monitor strip, and a patient does not have to curl up in a ball for an hour for an epidural, which takes on average 5 to 10 minutes to insert. Our doctors are for the most part laid back and relaxed and encourage women to do what they want as long as the baby is not compromised.

I don' t know if my hospital setting reflects others like it or if other units are more strict in their protocols. I do know that I would not hesitate to deliver a baby there with the knowledge that I would be able to do what I wanted in order to speed the labor and help me make it through.

- M. Farney, RN

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I did a small randomised controlled study on the effect of hot packs on the perineum in second stage in terms of pain and trauma. The results follow in the abstract below. This study was printed and presented at the Australian College of Midwives Conference in Melbourne in 1997.

Our unit now routinely uses hot packs and continues to have an unsutured perineum rate of around 70% across the board for vaginal births. We also have an episiotomy rate of less than 5%. Much of this is attributed to hot packs. If you would like further details please contact me.

- Heather Musgrove, registered midwife Mildura, Australia
hmusgrove@hotmail.com

Abstract:

Perineal Preservation and Heat Application During Second Stage of Labour - Randomised Controlled Trial

This study sought to examine the effectiveness of hot packs via a randomised controlled trial in the second stage of labour.

The experimental group received hot packs (n=36) and the control group did not (n=35). There were a total of 71 women in the study. The results show high levels of patient comfort and pain relief from hot packs. This is demonstrated by results such as: 70% of the recipients of hot packs felt the packs relieved pain and 80% said they provided comfort. The midwifery staff involved also supported the women's view that hot packs were beneficial in reducing pain and perineal damage. In the experimental group 70% of the women required no suturing, being either intact (61%) or having a superficial first degree tear (8%). A further 8% had a first degree tear sutured, 22% of this group sustained a second degree tear (17%) or an episiotomy (3%). As compared to the control group with only 54% of women not requiring suturing and a second degree tear rate of 23% and episiotomy rate of 6%, sutured first degree tears were 17%.(i.e. 16% less suturing in the experimental group).

This study, although small, has begun to validate a midwifery practice that until now had only anecdotal support. With this kind of research expanding midwifery's knowledge, such simple non-invasive techniques like hot packs can be practised and further researched by midwives for the benefit of the women they care for.

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I found the same thing in my homebirth practice. We also had the women do perineal massage 6 weeks ahead--we were free to practice homebirth but not to stitch. You do all you can to reduce tearing when you otherwise have to call in another practitioner to do it or transfer to the hospital just for stitches.

We also put fresh ginger root cut into quarter size pieces into the boiling water. It was said to oxygenate the tissues which helped reduce tearing. The women *loved* it--the ginger felt good. When I first started doing births we put lavender into the water so births always smelled like lavender for my first 50 and like ginger for the next 250. Obviously both those smells remind me of birth.

- Jan Tritten

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I am very interested in hearing from readers regarding PKU screening in the newborn. For several decades here in New Mexico, licensed midwives have typically done one PKU screen on the newborn at approximately Day 5 of life. Recently, however, after speaking with a local perinatal endocrinologist who believes that a PKU screen at 24 to 36 hours and again at 2 weeks are crucial, I have begun to rethink the wisdom of doing only one screen on Day 5.

What is your experience with the PKU screen? Has any research been conducted regarding these two choices?

- Janis Zloto, LM, CPM

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I gave birth to a very healthy boy in February; it was my third birth. Two weeks prior to labor, I was sitting and upon standing, there was a gush of clear fluid. I thought my water had broken and went in for a checkup. I was told it wasn't fluid and the gush wasn't explained. I was sent home with some nitrazine paper to check the fluid if it happened again.

One week later, the same thing happened-I sat up and gush! The fluid turned the nitrazine paper bright purple/blue. I thought for sure the water had broken. Went I went in and was checked, I was again told it wasn't water, and that I either must be mistaken about the paper color or something else caused it to turn color. The next morning I woke up in labor. I labored for 20 hours at home, then went to the hospital. When I was checked I was at 6 cm. After seven more hours of labor my baby was finally born. Throughout labor there was no leaking of water. Even when I was pushing, no water came out-it was very dry and difficult. The baby crowned for 18 minutes. At one point the doctor asked, "So, when did your water break?" I told him I never noticed that it did.

My question: Could my water have broken the two weeks prior and by the time labor started it was depleted?

- Jennifer Layton, California

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Have you heard of the Safestart? It's a new sterile, disposable (single-use) tool that cuts the cord while completely shielding the surrounding area from spray to protect the participants against blood-borne infections. I saw one once at a conference. The number I have to order one is 1-888-950-2246. I called to see if they would send me a sample, but I didn't have a provider number (since I'm not a medical provider). They wouldn't send it without one. Is there a CNM out there who has experience with this gadget, or can order one?

- Margaret Henderson, aspiring midwife

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I have been considering starting a pregnancy, birth and breastfeeding newsletter in my community. I would like to include such things as area resources (midwifes, childbirth classes, birth assistants, support groups, La Leche contacts etc.) as well as informative articles about birth options. I am wondering if anyone knows of something similar in their community that is successful. I am wondering how something like this would do given that the target audience (pregnant women) is frequently changing and that I want to keep it "free" and a non-profit entity. Any insight would be greatly appreciated!

- Carol Kightlinger

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Gloria Lemay really struck a chord with me about the title "midwife" [Issue 27]. I understand completely why she uses private birth attendant instead. The term is much less intimidating and seems more intimate with the birthing woman. It has a very non-threatening appeal. You don't need a fancy title to be a wonderful, caring, nurturing, supportive childbirth attendant (aka midwife). After all, whose birth is it anyway? Thanks, Gloria!

P.S. If you ever want any other members in the International Confederation of Private Birth Attendants, I'd like to be the second to join!

- Alison

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I was interested in the article by Valerie El Halta titled, "Not Among Strangers" [Issue 29] and her comment that if "the woman is confronted with an unfamiliar and therefore 'not safe place,' a survival mechanism will kick in. She will protect her baby by preventing it from being born by ceasing to contract, keeping her cervix closed and in general 'failing to progress.'"

I have been posting my observations concerning failure to progress and suggestions for mitigating or eliminating pain and distress during labor. So far, I have received only confirming and favourable comments from midwives, doulas and physicians confirming my observations. However, I am also looking for comments, criticisms, objections, to further clarify my observations and to make sure that what I have said is correct. I am also interested in whether anyone is going to replicate the solution I have suggested in reducing pain and distress in labor.

The main question I would like to see debated is: Where there is pain, there is pathology. So where is the pathology in a normal birth, with a prepared and healthy mother?

I have been suggesting to mothers, midwifes, doulas and physicians that greater awareness of this survival mechanism is called for and remedies for mitigating or avoiding it are needed. I believe a great deal of intervention and trauma could be avoided if this problem is given the attention it deserves.

I think the frequency and the power of that survival mechanism, the fight or flight syndrome, has been severely underestimated. It has been my experience that birthing mothers are very sensitive to the presence of others in the birthing environment. Even close family members can precipitate this unconscious response if there are unresolved issues between a family member or birthing attendant and the mother. As it is an unconscious mechanism designed to protect the mother and emerging infant from predators, it is not always easily detected. Neither is it usually responsive to conscious attempts to mitigate its severity and power to inhibit birth and cause extreme pain and distress.

Solutions: Either help the mother discharge the adrenaline when aroused or evade the fight or flight syndrome with absolute privacy coupled with safety. Private birthing rooms or home birthing environments could be provided with video monitoring by midwifes, thereby ensuring a benign birth coupled with the security of qualified help if needed.

- Rayner Garner

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I have heard a lot of conflicting information about the safety of SSRI drugs such as Prozac and Zoloft in pregnancy and lactation [see Issue 32]. Most MDs say they haven't been around long enough, that pregnant women are advised not to take them so we lack anectodal data, and that it is unethical to conduct studies. Drugs used during pregnancy are usually considered OK during lactation, but check with a *good* experienced lactation consultant.

We've had a lot of success in our practice using breastfeeding itself as an antidepressant, with supporting herbs and very good nutrition to help manage overwhelm/fatigue/blues. We have used sedating teas: catnip, skullcap, licorice. We have used mood and hormone stabilizers in tincture form as needed: motherwort, dong kwai, lemon balm. We have used Bach Flower Remedies as needed: olive and rescue remedy. Many mothers who previously used psych meds are skilled at determining when the herbs are not enough for them.

I think the jury is still out on Prozac and breastfeeding, but your blood levels in pregnancy are likely to be higher than your milk levels postpartum. Get a postpartum doula and get help from helpful people only. Join a support group or La Leche League. You are most certainly not alone.

- S. Condon, CNM in NY

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I am undertaking an educational visit to San Diego from 10-25-99 to 10-30-99. I would like to make contact with any midwives who work within the hospital environment there who could arrange for me to visit their unit during this time. Besides the midwifery aspect I am also interested in Shared Leadership/Governance programs that may be in place. I attended the ICM Conference in Manila this year and heard some interesting discussions about midwifery in the USA.

- Jan Morris England Jan.Morris@panp-tr.northy.nhs.uk

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I want to do some writing and education on the study that was done in Dublin on active management of labor. So many hospitals jumped on the band wagon, but with their own "twist" (quite unscientific, I'd say). The twist in my area is no continuous labor support and women are admitted to the unit anytime after 2-3 cm. I wouldn't be surprised if there are many other deviations as well. My question: Does anyone know what the Dublin protocol is and, despite having an exceptionally low C/S rate, was this rate higher than before they tested active management? Any help would be appreciated.
rbata@email.msn.com

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We are looking for ways to prevent polyhydramnios. A friend developed it in her last pregnancy for no known reason. As a result, she gave birth prematurely at 28 weeks. Now at 20 weeks in her current pregnancy she is concerned that she may be starting to exhibit similar signs of polyhydramnios, the same time she began experiencing signs in her last pregnancy. She very much wishes to avoid another premature birth, and is very interested to learn of *any* theories as to how to prevent polyhydramnios.

Please reply as soon as possible or forward this request to any other appropriate place. Thank-you.
dismith@island.net

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I am an English midwife going to Vancouver Island to visit relatives at Qualicum Beach in March 2000.If you know of any midwives I could meet or any workshops that are on, please e-mail: Staverton@ aol.com

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Share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com

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Learn more from these Midwifery Today issues:
No. 36, Prematurity (Regular price, $7.00)
No. 24, Caring for the Unborn (Regular price: $7.00)
Save $1.00 on each of these back issues! Call 800-743-0974 to order.
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5) 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:

- International midwifery (Aug. 20)
- Postpartum hemorrhage (Aug. 27)
- Herpes (Sept. 3)

- Circumcision (Sept 10)

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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