|February 4, 2000|
Volume 2, Issue 5
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"Hospital birth turns what should be like an ordinary car journey into a situation resembling a driving test."
- Margaret Jowitt
2) The Art of Midwifery
I had been taught that "true labor" begins at 3 cm dilation with contractions five minutes apart or closer, lasting 30 seconds or more. But it didn't seem fair to discount hours of early contractions, sometimes painful. I explain that latent labor is often the longest and most frustrating part of labor: contractions are often strong enough to prevent sleep, but not strong enough to take your whole attention, thus making them quite frustrating. After the birth, I often say something like, "Well, you began labor last night, and had 12 hours of latent labor; then active labor began at noon today, and you had a five hour active labor with 45 minutes of pushing. That's excellent!" In this way the early labor is validated, and the woman can experience a great feeling of accomplishment.
- Lani Rosenberger
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3) News Flashes
Researchers at the University of Washington in Seattle who analyzed 1,057 audiotaped encounters between primary care doctors and surgeons and their patients concluded that in nine out of 10 decisions made between doctor and patient, the doctor did not discuss the issue enough to allow the patient to make an informed choice. Something important was missing from discussions 91 percent of the time, such as talking about the pros and cons of a decision.
- AP wire service reports, 12-21-99
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4) Triumphs and Struggles, Part 2
A coup has been scored for women's rights in British Columbia, Canada! At Gloria Lemay's injunction hearing on Feb. 2 in Vancouver, Canada, it was ruled that Gloria can lawfully attend births and receive payment for her services. Now British Columbia women can freely choose their birth attendant, and know their choice is protected by precedent of law. A robust RIGHT ON for Gloria, and for the free-thinking, birth-loving women of BC!
- Leilah McCracken
For those of you who have been following my court activities with the B.C. College of Midwives, the hearing went very well. At 9:00 a.m. we had a drum circle on the front steps of the B. C. Law Courts building. Little girls were wearing signs saying "Keep Your Laws Off My Body," "My Mom Had an Illegal Home Birth," etc. We went into court at 10 a.m.
My lawyer told the judge that women have struggled in Canada to be allowed access to birth control, to be allowed to decide whether or not to keep a pregnancy and they should be allowed to decide with whom they will give birth in the privacy of their own home should they choose to have that baby. The judge agreed. He has granted an injunction to the College of Midwives preventing me from holding myself out to be a registrant of the College. This is something I have *never* done nor would ever do, so it's fine with me. He also said anyone can go to a birth and help out for a fee.
The lawyer for the College of Midwives at one point inadvertently referred
Our context for this whole exercise was "integrity." It really paid off and I'm really proud of my lawyers and myself. Thanks for all the prayers, moral support and financial contributions. I'm so grateful to not be in debt at the end of all of this. I think it will now open up the possibility of more women in the province returning to their jobs as birth attendants.
My heart fills with love and gratitude for all the support. T H A N K Y O U!
- Gloria Lemay
From Just Over the Border:
The Midwives Association of Washington State (MAWS) has a serious budget shortage
in the Department of Health (DOH) midwifery licensing program. MAWS could be deregulated.
If you live in Washington state, please contact your legislators via the legislative
hotline: 1-800-562-6000. Access their direct phone and email information on the
Donations we receive will go toward paying the costs we incur in this effort. Checks written to MAWS can be sent to MAWS c/o Janine Walker, 21721 35th Ave. SE, Bothell, WA 9802. If you need your donation to be tax deductible, you may make your check out to Citizens for Midwifery, earmarked to WA State Campaign in the memo section, and send checks to Citizens for Midwifery, PO Box 82227, Athens Georgia, 30608-2227. For more information, please call Janine at 206-300-5966. Thank you for your support.
A Reader Comments:
I am a direct-entry midwife practising in England. I cannot understand the attitude of those in the U.S. who have decreed it a felony to be one! I presume there are many OBGYN doctors who do not want to lose the financial benefit.
Here in England direct-entry midwives are beginning to outnumber those who have trained as nurses. After 3 (or sometimes 4) years of training we gain either a diploma or degree status depending on the course chosen at university.
Following qualification I have now been in practice in a large teaching hospital for 18 months. I look after women during normal labour and delivery and providing things are proceeding well, also am the sole person attending the delivery. Only if things do not go according to plan do I need to ask the assistance of the medical team. Even then I could still be the only person at the delivery if there is no need for instrumental or c-section birth. Similarly I will work with the docs when caring for women with problems. If the birth itself is predicted to proceed to a normal vaginal delivery I will be the person there.
There are other aspects to my job where I also practice autonomously, but that is the situation as far as delivery in hospital is concerned.
The powers that be in the U.S. could do well to look at the practice of midwifery in other countries; they will see that despite some problems it works well to the benefit of women. However, until the U.S. healthcare system is no longer dominated by men and money, I think it will be a long struggle for the midwives there to change things. You all have my wholehearted support and best wishes.
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6) Question of the Week
Is there any home, holistic or old fashioned remedy to prevent toxemia? Michelle is "borderline." Her doctors will induce her at 36 weeks if it gets worse. She is now at 33 weeks. Any suggestions?
I recently purchased a copy of Understanding and Teaching Optimal Foetal Positioning By Jean Sutton and Pauline Scott [available from Midwifery Today]. Having experienced two labors with babies in the posterior position I wanted to be able to provide my childbirth education students with a clear understanding of fetal presentation in labor and how to promote the best fetal position for labor. I have also read that the posterior position can cause difficult long labors for women that sometimes result in a cesarean.
The authors of this book recommend that woman do not do "deep" squatting as an exercise in pregnancy: "As an exercise, deep squatting is not advisable in late pregnancy unless the woman's baby has engaged in the pelvis in the OA position. An OP positioned baby can engage before it has had a chance to rotate to OA." I have found this statement to be quite controversial among birthing professionals. I would like to know how a midwife would approach this subject of deep squatting in late pregnancy with her moms.
- Doreen Wagner, CBE
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7) Question From Midwifery Today Magazine
(Editor's note: The next issue of Midwifery Today magazine will include a mini-theme on induction.)
Is there a technique that is used to induce labor during an internal check? My caregiver gave me two extremely painful and long internal checks during my labor and she kept saying, "Well, might as well push you along." The ordeal was so painful that I had to scream for her to stop and eventually had to push her hand away. I'm sure she did something to interfere.
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8) Question of the Week Responses
Q: I have Group B Strep. With my last 2 hospital births I was automatically given IV antibiotics. I am planning a home waterbirth for my next baby. What can be done at home for GBS? What are the risks to the baby if it contracts it in the birth canal?
- Sarah McKay
I was 37 weeks pregnant with my first child when I was told I had high concentrations of Group B Strep in both the vagina and anus. The nurse midwife from whom I was receiving prenatal care knew that I was planning a homebirth with a direct-entry midwife. She prescribed ampicillin, which I took for 2 weeks. My direct-entry midwife recommended a regimen of garlic, vitamin C, echinacea and bee propolis. I was taking twenty-something capsules a day! The payoff came two weeks later when a second culture came back negative. I went into labor two days later and had a successful homebirth.
15-40% of pregnant women test positive for GBS. Transmission from mother to baby occurs in 40-73% of culture positive women. Only 1-2% of the infants to whom the GBS is transmitted develop complications as a result. Factors that can increase the risk of GBS complications are: maternal age <20 yrs, heavy colonization, premature rupture of membranes, prolonged rupture of membranes, fever during labor, preterm labor, or a sibling who had GBS. Although only about 3 in 1,000 babies develop GBS complications, the consequences can include pneumonia, meningitis, brain or lung damage, loss of sight or hearing, or death. Scary stuff.
If you can persuade your caregiver that you understand the risks and develop an action plan in case one of the "increased risk" factors develop, perhaps you could receive oral antibiotic treatment and a second culture and still have a homebirth.
- Felicia Lumpkin
In the medical community, there are currently at least three schools of thought re: GBS+.
1) All women should be screened at 34-36 weeks with a combined vaginal rectal swab (obviously you swab the vagina first and then the rectum) and if found to be GBS+, treated with antibiotics during labour.
2) All women should be screened in pregnancy as above, and those who are GBS+ should be treated with antibiotic prophylaxis in the presence of additional risk factors in labour. These additional risk factors would include: rupture of membranes for longer than 12-18 hrs (depending on local protocol); maternal fever in labour and/or fetal heart rate elevated above the baseline.
3) Not to screen but to treat all labouring women with the above risk factors.
As a practising midwife with a combined home and hospital birth practise, my practise is to encourage flexibilty and to educate clients about GBS, the issues of screening vs. not screening and the various treatment options currently medically recommended, and allow them to make an informed choice to screen or not, and to choose the treatment option they feel is best for them, or not to treat at all. It is their baby and their choice to make. It is interesting to note that people often make very different choices than you might expect them to.
If the client plans a homebirth and wishes to treat with antibiotics, in our community she can choose to go into hospital as an outpatient to receive the initial dose of antibiotic, then to return home for the duration of the labour and birth with the midwife administering the subsequent doses at home. (The first dose is given in hospital in the event of her having an allergic reaction to the drug.)
Families have made many different choices, including women who tested GBS+ and who have had waterbirths at home, all with no adverse results; some have elected for antibiotic prohpylaxis and others have declined.
As for the issue of prolonged rupture of the membranes (GBS+ or neg.), while not yet substantiated by the research, my experience clearly shows a reduced incidence of early rupture of the membranes through avoidance of unnecessary vaginal exams in pregnancy and labour. I believe it is prudent to be extra careful about avoiding vaginal exams with GBS+ women.
For more information about making informed choices in pregnancy and birth I would recommend " Effective Care in Pregnancy & Birth" by Enkins & Chalmers as a good place to start.
IV can be done at home by a qualified practitioner. You can choose a risk-based approach to treatment, risks being membranes ruptured more than 18 hours, preterm labor (wouldn't birth at home anyway) and history of a baby with GBS disease. Was the growth heavy, moderate, or low? That can influence your choice also. I don't think I'd feel that comfortable with a waterbirth with GBS due to the increased risk of postpartum infection for the mom, but I know opinion varies on that one.
To the practitioners out there: Does anyone know about using IM antibiotics instead of IV for GBS moms who choose prophyllaxis? Are there any studies? Just 5 or so years ago the protocols around this area were for ORAL antibiotics in labor. It'd be nice not to have to do IVs for those folks with risk factors or for those who just want to treat.
Having worked in a birth center for many years, one of our biggest concerns was GBS and how to treat it. We accomplished a multitude of waterbirths, many with GBS. But be aware of the facts:
*For every 100 women with GBS at delivery, 1 infant will develop GBS
infection, and overall rate of 1 to 3 per 1,000 live births.
While the odds are that your baby won't be the 1 in 3, is it worth the risk? Treatment according to CDC Guidelines consists of intravenous administration of ampicillin every four hours during labor. This does not require a continuous IV infusion, only a heplock, which still enables moms to move around freely and have the waterbirth they dream of. If it is not possible to do this at home, then please consider a birth center that has the ability to administer this simple treatment.
- Alyn McGee, RNC
There is a very complete informed consent for GBS testing posted on www.goodnewsnet.org. You know you're already GBS positive, so it's the various risks associated with treating/not treating you'd be interested in. Thanks to Ina May Gaskin for the link to goodnewsnet.
- Kay Jackson, CNM
This goes along with the B-strep question. Can anyone direct me to studies or articles on the relationship between stripping the membranes (separating the membranes) and activating a B-strep infection? I have heard that STM can make a mother B-strep+.
- Michelle Wright
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E-News readers were interested in the Rh factor question raised within a Question of the Week response in Issue 2:4. Here are some comments:
In response to the question regarding the possibility of two Rhesus negative parents producing a Rhesus positive child. I know this is possible because my parents (Rh neg) have two neg children and my brother is positive (and looks exactly like my dad!). Genetics is a fascinating and complex area of study as is the area of blood grouping. The Rhesus system in humans is not simply a matter of being positive or negative. There are 51 different Antigen types that contribute to Rhesus status. So heredity is dependant on many different contributing antigen combinations.
Put very simply, if two parents are homozygous Rh neg, they are very unlikely to have Rh pos children as they carry the dominant gene for this grouping. But two heterozygous negative parents have a 25% chance of having an Rh pos child since they both carry the recessive gene. But in reality, the combinations are much more intricate.
So make no assumptions about need for giving Anti-D (Rhogam) when both parents are Rh neg. It is presently a blood derived product, so it is theoretically possible for blood borne diseases to be transmitted. But women need to weigh up the risks and benefits themselves and make informed decisions. The risk of complications from subsequent pregnancies without Rhogam is very high and potentially tragic.
- Karen Blake R.M. BMid., New Zealand
If you don't understand how this could happen, you also will not understand how parents with blood groups A and B can have a child with group O, or why it is impossible for a child to have group O if either one of the parents is AB. Read any basic genetics text or read up on blood groups.
I don't know what the protocols are for RhoGam use in the U.S. as I work in Norway. Here, we only give it to Rh negative mothers without anti-Rh antibodies, and whose babies are Rh positive. We test cord blood so the babies don't get pricked. Two Rh negative parents cannot have an Rh positive child, so one could make a case for testing men and deciding on that basis which women to give RhoGam. There is, however, always the possibility that the biological father of the baby is someone other than the person whom the mother feels compelled to acknowledge officially as the father, and this could lead to failure to offer RhoGam treatment to some women who need it. Testing the baby eliminates this uncertainty. In cases where a woman who is involved with an Rh negative man needs RhoGam after birth, it should be up to her whether to spell this out for her partner, and the injection should be offered in such a way as to protect her right to confidentiality.
- Rachel Myr, midwife
It is strictly impossible for two Rh negative parents to have an Rh positive baby, exactly in the same way that it is impossible for two parents with blue eyes to have a child with black eyes. Rh+ means that the gene exists; Rh- means that it does not exist. Parents can't transmit a gene they don't have.
- Francoise Railhet
She can be Rh neg if both her parents are heterozygous; i.e. have one pos and one neg gene each. She got the neg gene from both parents, a 1 in 4 chance. Two Rh neg parents cannot have an Rh pos baby (or there would be questions to be answered).
- Phil Watters, Australia
The woman who asked the question is correct: 2 Rh neg. parents will always produce an Rh neg. baby. (It is worth noting that Rh testing is not 100% accurate, so it would be best if the father had tested negative more than once in his life.) Rh negativity or lack of the Rh factor is a recessive trait. That is, it only shows up if the gene contributions from both parents are Rh neg. It is also entirely possible that someone with all 4 grandparents Rh pos. could end up Rh neg. Someone who is Rh pos. could have EITHER 2 Rh pos. genes OR 1 Rh pos. gene and 1 Rh neg. gene. Thus, 2 Rh pos. parents could produce an Rh neg. child if both parents had a recessive Rh neg. gene, and that was the gene that both parents happened to pass on to the child. Because there are four possible combinations of genes they could pass (++, + -, - +, - -), and 3 of those include an Rh pos. gene, there is a 1 in 4 chance that the child would be Rh neg.
- Sharon Fuller, LM
It's those recessive genes that are responsible. Yes, your parents could test, test, and test again, and still come up Rh+. What those blood tests don't reveal is the fact that each of your parents carried a recessive Rh- gene. Turning out Rh- requires two Rh- genes, one from each parent, because Rh negativity is a recessive trait. If you receive one Rh+ gene from one parent, and an Rh- gene from the other, Rh+ wins out, and you are what they call phenotypically (the seeable trait that shows up on the surface) Rh+. You are genotypically (the hidden traits you can't see) both Rh+ and Rh-. So the Rh+ parents who each have an Rh- gene have a 25% chance of producing an Rh- child. If you do the Mendelian box to calculate this you can figure it out.
- Kay Jackson, CNM
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Our baby's due date is today (Feb. 4). We don't know the baby's gender. We are going to have a homebirth and have been seeing a lay midwife in preparation.
My husband is Jewish. He insists upon a circumcision if we have a son, and feels he is not obeying God if he neglects this; it matters not what some rabbis and scholars say in contradiction; it is a matter of his own convictions. I have sought to dissuade him, but to no avail. I love him and am not willing to cause a divorce over this matter, although I am coming to be very much against circumcision.
In view of this, we are seeking an attempt at a compromise, and on the Midwifery Today web site came across mention of the article "Circumcision Choices" by Julia Bertschinger in Midwifery Today Issue 17. We would like to find out:
1) whether the circumcision technique of cutting off only the "floppy tip" of the foreskin is actually in use today in the U.S., 2) whether there is a way in which we can locate a mohel or a doctor who performs this form of circumcision, and 3) whether there is a way to prevent the remaining foreskin from re-fusing to the glans, which one article brought up as a complication and which suggested (but not based on any stated evidence) that this complication might be prevented by the use of petroleum jelly.
Any help would be of inestimable value. This circumcision question is causing tension of the deepest order in our marriage. My mother's heart cries out for our baby not to be abused and hurt, yet my husband's heart cries out for his heritage to be valued, cherished, and passed on (as he would define passing it on). This minimal circumcision would perhaps be just the ticket to offer us a solution we could both live with, albeit not perfectly, but more so than with any other course of action.
I have searched the Web for mohels, and emailed some of them, but none thus far does the "true brit milah," cutting off only the minimal amount of flesh. None has been able to suggest a professional organization to contact.
- Cherwyn & Hal Ambuter
Many thanks to the readers of Midwifery Today from "Pregnancy & Childbirth Tips." We are extremely pleased to announce that we have now hit "National Bestseller" status! Our heartfelt thanks to all the women who are supporting this important project. A Canadian Publisher has asked me to write a series of six childbirth books. The first book will be on pre-conception. Please send in your tips for pre-conception and fertility to firstname.lastname@example.org. Your input and expertise will be greatly appreciated and your name will be added in the book as a contributing writer.
- Gail J. Dahl
I am 40, had a miscarriage last year, and after 7 months of very careful trying, we still aren't pregnant. I went to a fertility expert last month, have done the standard tests, and will be going for artificial insemination and possibly IVF if that doesn't work.
The nurses and doctors at the fertility clinic do not exactly encourage questions and participation, and I was told basically to just relax and let the experts handle it. It is ironic that I apparently need to subject myself and my husband to these very unnatural procedures to get pg, when I have spent so much time learning about, and being committed to, natural childbirth (i.e., no medical intervention if normal). But you can't have birth without conception, so I feel I have no choice but to pursue this course of action. The statistics for us getting pg on our own at my age are not good, and we found out that my husband's sperm has low motility and a low normalcy rate. So far the tests show I am OK "structurally" and am ovulating.
Any thoughts on how I can naturalize this procedure? I have a feeling I need to do what I can to get pg, and then, if we are so blessed, I'll be sure to reclaim myself and the baby during our pregnancy. I just wish I had a midwife to help me along with this process, too. I know I am not the only one feeling like this, because I have found several pages on the net where women dialogue about their fears and frustrations with infertility.
In reference to last week's Art of Midwifery: We use the term "sweeping" the membranes. Sounds softer and is descriptively correct.
Last weekend we lost a baby (transported after long second stage, failed vacuum, no maternal effort, baby died in hospital after forceps extraction, mom almost bled to death. The mom had preexisting "herpes gestationis" or possible "papular dermatitis." She had been to a dermatologist who said it was just a rash. I didn't refer her because I wasn't involved in her prenatal care.
Any ideas on how I could find out if this condition does indeed, as Williams says, have a higher incidence of stillbirth? We transported a still-healthy, still-strong mom and baby, and an hour later, tragedy.
- Denie, Philippines
My friend has a 9 month old son with a mild hypospadius. It has been recommended to perform surgery to correct it not for medical reasons but for aesthetic purposes. She and her husband don't want to subject their son to this unnecessarily but have been told that if it is not done he may suffer as a teen and adult because he "looks different," that he may be so psychologically scarred that he will not marry or that a woman will not want him. I don't know how to advise her because my gut says leave him alone, but there is the other side. Does anyone reading this have a brother, husband, boyfriend, etc. with an uncorrected hypospadius and have they suffered long term repercussions? Please advise.
I read with interest the follow-up "Taking all fours a little further" [Issue 2:3]. I am not qualified to comment on any of the "technical" detail on rotation of either mother or baby but when reading this item I kept wondering, why does the woman have to "turn over"? Is no woman ever on all fours already? If some are and have shoulder dystocia, what do you do then? And if not, why not encourage women to be on all fours (or at least in a position which will not require them to turn over) throughout labour?
I am not calling into question the virtue of asking a woman to change position but I am deeply worried about "all fours" always being something the woman must "turn over" to achieve. They are the wrong way round to begin with.
Our local consultant OB says "as soon as we suspect SD, we ask the woman to turn on all fours." One local midwife replied, "Bit late isn't it?"
- Fiona Campbell-Smith, Scotland
In response to the letter about La Leche League [Issue 2:3]: Why reinvent the wheel? Perhaps because for some of us it needs reinventing! First of all, there are some of us who do not find LLL very supportive! I personally have had several problems with advice received from LLL leaders, advice that undermined my breastfeeding rather than supported it. I also have some real problems with some of LLL's philosophies and policies. I know many other womyn who feel the same way. While this hasn't kept me from being a member of LLLI, if I could find another group, I'd likely join it instead.
Secondly, the suggestion that an individual try to establish a LLL group in their community is an odd one coming from someone who says they are a LLL leader. Surely you know how long and arduous the process of becoming accredited as a leader is? How else would one go about starting a LLL group? This is my current situation: the nearest group is over an hour's drive away on icy roads. There is no leader in my town. I breastfed my first son for only 3 months (though I continued to pump for him for his whole first year). My second son is 6 months old. Therefore, I don't yet qualify to even begin my leadership accreditation process. There are so many womyn in my town who could benefit from breastfeeding support! I do what I can, but it's not enough! So what's wrong with me starting a non-LLL group?
- Maka Laughingwolf
I have a new client, 13 weeks gestation, who has been wearing magnets to improve general blood flow and life energy. She is not using them for pain, but does feel that they are helpful for nausea. She asks about safety in pregnancy. I have not been able to find any information about this; I wonder if anyone has.
- Rose Evans, CNM
Back in December I asked a question about providing care for a woman who contracts
cytomegalovirus (CMV) for the first time while she is pregnant. I was disheartened
to see that there has been no response from midwives out there who undoubtedly
have faced this issue. Could it be that they are afraid to "go public"
with their personal views regarding the provision of abortion by midwives? I didn't
want to offend anyone or cause a stir, but I really would like to know how others
feel about this. I understand there is a fine line separating CNMs and CPMs/DEMs
out there. But something tells me that this is a critical issue that will define
who we are and the type of care we provide. I welcome all people who would like
to privately respond via email. Amelia Terrell
[The question was: How, as midwives, do we advise a woman who contracts cytomegalovirus (CMV) for the first time during her pregnancy? What are all the options for her and the baby? Do we continue to care for her? Is it medically sound to advise abortion for this seemingly rare complication?]
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