February 18, 2000
Volume 2, Issue 7
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Epidurals--Real Risks for Mother and Baby
5) Check It Out!
6) Question of the Week
7) Question of the Week Responses
8) Switchboard
9) Classified Advertising

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1) Quote of the Week:

"Are you a midwife 'with woman' or a midwife 'with medicine'?"

- Jan Tritten

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2) The Art of Midwifery

Evaluate each woman's nutrition. The better the quality food she eats, the less likely she will bleed. If she is strong and healthy she will respond better to labor and birth. Try not to be judgmental culturally, and try to be creative within someone's comfort level, as food is such an emotional issue in itself. That's why I like to recommend alfalfa tablets so much; they help cover the nutritional gaps. Over-consumption of sodas will deplete her of calcium due to the high phosphorous content, and this can lead to muscles that do not respond as efficiently in labor or after birth, including the uterus.

- Lisa Goldstein, Midwifery Today Issue 48

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Midwifery Today Issue 48 is a mini-textbook on hemorrhage. Order it by calling 1-800-743-0974. Regular price $10; mention code 940 and pay only $8.50 (plus shipping & handling). Offer good until March 10, 2000.

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3) News Flashes

Recent research showing that animals exposed to certain environmental toxins developed spontaneous endometriosis has led to a new theory of what causes the condition. Because these toxins, including dioxin and PCBs, act as hormone disrupters in the body and because they have been widely prevalent in the environment only in modern times, it is thought they may be responsible for what seems to be a modern epidemic of endometriosis. There also appears to be a family link. If a mother or sister has endometriosis, the chances of another immediate female member developing it will increase seven-fold.

- Endometriosis Association news release, July 1998

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4) Epidurals--Real Risks for Mother and Baby (excerpted)
by Sarah Buckley, Brisbane, Australia

An epidural will often slow a woman's labour, and she is three times more likely to be given an oxytocin drip to speed things up (Ramin et al., Howell). The second stage of labour is particularly slowed, leading to a three times increased chance of forceps (Thorpe et al.). Women having their first baby are particularly affected; choosing an epidural can reduce their chance of a normal delivery to less than 50% (Paterson et al.).

This slowing of labour is at least partly related to the effect of the epidural on a woman's pelvic floor muscles. These muscles guide the baby's head so that it enters the birth canal in the best position. When these muscles are not working, dystocia, or poor progress, may result, leading to the need for high forceps to turn the baby, or a caesarean section. Having an epidural doubles a woman's chance of having a caesarean section for dystocia (Thorp, Meyer et al.)

When forceps are used, or if there is a concern that the second stage is too long, a woman may be given an episiotomy, where the perineum, or tissues between the vaginal entrance and anus, are cut to enlarge the outlet and hurry the birth. Stitches are needed and it may be painful to sit until the episiotomy has healed, in 2 to 4 weeks.

As well as numbing the uterus, an epidural will numb the bladder, and a woman may not be able to pass urine, in which case she will be catheterised. This involves a tube being passed up the urethra to drain the bladder, which can feel uncomfortable or embarrassing.

Other side effects of epidurals vary a little depending on the particular drugs used. Pruritis, or generalized itching of the skin, is common when opiate drugs are given. It may be more or less intense and affects at least 25% of the women who take them (Lirzin et al. & Caldwell et al.): morphine or diamorphine are most likely to cause this. Morphine also brings on oral herpes in 15% of women (John Paull).

All opiate drugs can cause nausea and vomiting, although this is less likely with an epidural (around 30% [ibid]) than when these drugs are given into the muscle or bloodstream, where larger doses are needed. Up to a third of women with an epidural will experience shivering (Buggy et al.), which is related to effects on the bodies heat-regulating system.

When an epidural has been in place for more than 5 hours, a woman's body temperature may begin to rise (Camman et al.). This will lead to an increase in both her own and her baby's heart rate, which is detectable on the CTG monitor. Fetal tachycardia (fast heart rate) can be a sign of distress, and the elevated temperature can also be a sign of infection such as chorioamnionitis, which affects the uterus and baby. This can lead to such interventions as caesarean section for possible distress or infection, or, at the least, investigations of the baby after birth such as blood and spinal fluid samples, and several days of separation, observation, and possibly antibiotics, until the results are available (Kennell et al.).

There is a noticeable lack of research and information about the effects of epidurals on babies. Drugs used in epidurals can reach levels at least as high as those in the mother (Fernando et al.), and because of the baby's immature liver, these drugs take a long time--sometimes days--to be cleared from the baby's body (Caldwell, Wakile et al.). Although findings are not consistent, possible problems, such as rapid breathing in the first few hours (Bratteby et al.) and vulnerability to low blood sugar (Swantstrom et al.) suggest that these drugs have measurable effects on the newborn baby.

As well as these effects, babies can suffer from the interventions associated with epidural use; for example babies born by caesarean section have a higher risk of breathing difficulties (Enkin et al.). When monitoring of the heart rate by CTG is difficult, babies may have a small electrode screwed into their scalp, which may not only be unpleasant, but occasionally can lead to infection.

There are also suggestions that babies born after epidurals may have difficulties with breastfeeding (Smith, Walker) which may be a drug effect or may relate to more subtle changes. Studies suggest that epidurals interfere with the release of oxytocin (Goodfellow et al.) which, as well as causing the let-down effect in breastfeeding, encourages bonding between a mother and her young (Insel et al.).

(An edited version of this paper was first published in Australia's Parents magazine, Aug/Sept 1998)

References:

  • Buggy D, Gardiner J. The space blanket and shivering during extradural analgesia in labour. Acta-Anaesthesiol-Scand 1995; 39(4): 551-553
  • Caldwell LE, Rosen MA, Shnider SM. Subarachnoid morphine and fentanyl for labor analgesia. Efficacy and adverse effects. Reg Anesth 1994;19:2-8
  • Caldwell J, Wakile LA, Notarianni LJ et al. Maternal and neonatal disposition of pethidine in child birth--a study using quantitative gas chromatography-mass spectrometry. Lif Sci 1978;22:589-96
  • Camman WR, Hortvet LA, Hughes N, et al. Maternal temperature regulation during extradural analgesia for labour. Br J Anaesth 1991;67:565-568.
  • Enkin M, Keirse M, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy and Childbirth. P 287 Oxford University Press 1995
  • Goodfellow CF, Hull MGR, Swaab DF et al. Oxytocin deficiency at delivery with epidural analgesia. Br J Obstet Gynaecol 1983; 90:214-219
  • Howell CJ. Epidural vs non-epidural analgesia in labour. [Revised 6 May 1994] In: Keirse MJNG, Renfrew MJ, Neilson JP, Crowther C. (eds) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database. (database on disc and CD-ROM ) The Cochrane Collaboration; Issue 2, Oxford: Update Software 1995 (Available from BMJ publishing group, London)
  • Insel TR, Shapiro LE. Oxytocin receptors and maternal behavior. In Oxytocin in Maternal Sexual and Social Behaviors. Annals of the New York Academy of Sciences, 1992 Vol 652. Ed CA Pedersen, JD Caldwell, GF Jirikowski and TR Insel pp 122-141 New York, New York Academy of Science
  • Kennell J, Klaus M, McGrath S, et al. Continuous emotional support during labor in a US hospital. JAMA 1991;265:2197-220
  • Lirzin JD, Jacquintot P, Dailland P, et al. Controlled trial of extradural bupivicaine with fentanyl, morphine or placebo for pain relief in labour. Br J Anaesth 1989; 62: 641-644
  • Paterson CM, Saunders NSG, Wadsworth J. The characteristics of the second stage of labour in 25069 singleton deliveries in the North West Thames Health Region. 1988. Br J Obstet Gynaecol 1992;99:377-380
  • John Paull, Faculty of Anaesthetists, Melbourne. Quoted in: "The perfect epidural for labour is proving elusive" New Zealand Doctor. 21 Oct 1991
  • Ramin SM, Gambling DR, Lucas MJ et al. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol 1995; 86(5):783-789
  • Swanstrom S, Bratteby LE. Metabolic effects of obstetric regional analgesia and of asphyxia in the newborn infant during the first two hours after birth I. Arterial blood glucose concentrations. Acta Paediatr Scand 1981; 70:791-800
  • Thorp JA, Meyer BA, Cohen GR et al. Eppidural analgesia in labor an cesarean section for dystocia. Obstet Gynecol Surv 1994; 49(5): 362-369

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Read more about epidurals and drugs in labor at the Midwifery Today web site!

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5) Check It Out!

~~~WWW.MIDWIFERYTODAY.COM~~~
A Web Site Update for E-News Readers

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Help yourself to a freebie--Midwifery Today's banners! Have a hotlink to the hippest magazine in the world of midwifery!
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~~Philadelphia Conference Update!~~

We have ICEA CEU Approval!

For Friday,March 24, 2000 through Sunday March 26, 2000 you will receive 24 contact hours. Credit is only offered for Pre-Conference on Thursday, March 23, 2000 for the following classes:
7 contact hours given if you attend:
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Do you enjoy what you're reading in E-News? Tell a friend or colleague about us! Just click: www.recommend-it.com/l.z.e?s=111968

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Theme for Midwifery Today magazine Issue No.54: Waterbirth
Question of the Quarter: What is your Favorite Waterbirth Story?
Please submit to editorial@midwiferytoday.com by March 15, 2000
See writer's guidelines on our web site! Click here--> writer's guidelines

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6) Question of the Week

I had a manual extraction of the placenta by a CNM in the hospital after my
first birth, about 5 minutes after I had delivered. I hemorrhaged quite a bit after and BP dropped to 60/30. With my second (at home), contractions stopped immediately after birth. We waited for 2 hours, had about 2 cups of blood at home, then was transported for another manual removal. The placenta was taken out in pieces. I was on the borderline for needing a blood transfusion. I smoked with the first two pregnancies but have now quit with my third.

I would like to know of any natural intervention you have as I am planning another homebirth and if necessary a manual extraction at home.

- Alida

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Send your responses to mtensubmit@midwiferytoday.com

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7) Question of the Week Responses

Q: What are the differences in hypertension that shows up at 30 weeks vs. 39 weeks? What about a BP that stays up no matter how you take it vs. a BP that is much lower when taken in a side-lying position? Can hypertension ever be considered normal for some women during their pregnancies--their body needs it for some reason--or is it always an ominous sign that means an automatic high-risk handover to a medication-happy OB? What else can you do for a hypertensive woman who is at term besides mag sulfate? Without corresponding warning signs such as headaches, vision disturbances, etc., how risky is she being with her life and the baby's by not agreeing to take mag sulfate?

- Samantha

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A client alleviated her hypertension by taking two droppersful (could have taken three) of hawthorn berry tincture, one in the morning and one at night). I had also recommended supplementing with calcium/magnesium(1000-1200mgs/500-600mgs). She took these tablets in the morning and at night to get the full amount.

- Constance Miles

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If a woman needs mag sulph she will have had all the appropriate bloods and investigations performed. This drug is never given without proven clinical reason as it is so toxic its administration alone could cause demise. Fulminating PET is life threatening; the only cure is delivery and that may mean that birth expectations may have to be reviewed. The luxury of hindsight is not available until too late. I realise that we practice very differently in the UK and have much more autonomy and act as advocates for women in the clinical situation but a fit well baby and mum is our end aim.

- Anon.

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Editor's note: Please remember the simple yet proven (by Dr. Tom Brewer) method of treating pre-eclampsia: Take in 80-100 grams of protein a day, plenty of carbohydrates, salt to taste, drink to thirst. Brewer writes, "You *can* turn toxemia around! The status quo teaches, "deliver the baby." Some midwives don't know what to do, and they panic...I threw away the things I was trained to do. I had to unlearn...and go back to basics, go back to nature, and let this body, this woman, this pregnancy, grow on its own steam."

- Midwifery Today Issue 40

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8) Switchboard

In response to a question about applying Betadine to the perineum [Issue 2:6]:

The reason you're finding it hard to find evidence to support changing the practice in your hospital from painting the perineum etc. with Betadine or similar, to washing with soapy water, is that neither method is generally used. I have never heard of this practice in this country (UK) and think it is completely unnecessary and archaic. If your unit wants research to support dropping the use of Betadine, why not ask them to try and find research to support keeping it, or in fact doing anything at all?

- C.

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The only thing that comes to mind is that Betadine will actually kill microrganisms on contact whereas ordinary (non germicidal) soap is basically just an agent to make "germs" slippery so that they may be rinsed off. At the bedside, unless you have a bed that is broken down, a bucket, and lots of water to rinse, I wouldn't have confidence that micro-organisms would be removed. Also there is the matter of having to really scrub to get germs to rinse off, which will be unpleasant for the mom.

But do we really need to protect babies from the mother's germs? In my practice I served a particular group, and I saw plenty of less than frequently showered (as in never) perineums. I also saw less than average rates of infection in both mom and baby. I used a light mixture of Betadine in water (the color of dark tea) applied with washcloths to the perineum as a combination warm pack and mild disinfectant. I never applied it straight from the bottle. This was in houses that smelled strongly of barnyard and who knows what was floating around.

My basic feeling on babies and mothers developing postpartum infections is that if left undisturbed, quiet, safe, and not exposed to harsh lights, noise, and unfamiliar surroundings, the immune system will take care of things. I am not saying what I did at a client's home will work in a hospital, but I found it to be effective within my practice.

- E.

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When I was working in Scotland, the Simpson (big, prestigious hospital in Edinburgh) conducted a large study of Chlorhexidine vs. plain tap water. They found no difference in infection rate and concluded that tap water was cheap and effective. I was used to washing down the perineum with Chlorhexidine so I would always warn women that it may sting (following birth). When we switched to warm water, I stopped seeing the usual "wince" as I rinsed the perineum. Many women in fact found it comforting. Why not write to the Simpson, Royal Infirmary, Edinburgh Scotland EH and ask for a copy of their report?

- Amy

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Regarding treatment of GBS, "Treatment according to CDC Guidelines consists of intravenous administration of ampicillin every four hours during labor" was stated in the last Midwifery Today E-News. I have always wondered what the hospital protocol is for women with short labors. My labors tend to be about 2-1/2 hrs. long.

- Paula

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Thank you for your essay discussing midwives vs. midwives [Issue 2:6]. It reminds me of the same argument between mothers who work inside the home vs. those who work outside the home. We are all doing the best job we can and need to support and work with each other.

- Kelli

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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? [Issue 2:6] Because some moms just don't want to birth that way. I much prefer the words "turn over" rather than forcing mothers into a position they find uncomfortable or unnatural and saying the words, "standard procedure."

- Anita W.

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In response to the question about turning a breech by elevating the trunk above the head [Issue 2:6]:

A tilt board with the head lower than the buttocks is commonly used for 15 to 30 minutes one or two times a day to encourage a breech to turn. Most women use an ironing board with a blanket for padding and elevate the end about 12 inches. The idea is to lift the baby's head out of the pelvic girdle so it has room to turn without being stopped by the bones. The best time for this is one to two hours after a meal when blood glucose is higher. That is the time the baby is most likely to be awake and active. If the baby is asleep then it cannot turn itself.

Some moms like to place earphones with pleasant music playing on their lower abdomen while this procedure is being done. The theory is that babies are more active when they hear music and will often move head down to get a better listen. Repetitive classical music is said to be most favored. Studies have shown that babies have a definite predisposition for Bach.

Some mothers find the slant board position uncomfortable and instead elect to choose a hands and knees position with their head and chest lowered close to the floor. Pillows are needed to be comfortable.

If neither approach is effective, seek a care provider who has experience with performing an external version, where the baby is slowly and gently manipulated through the outside of the mother's abdomen. The head is lifted out of the pelvis and the baby is gradually turned the direction it is facing until it is head down. The baby's heart rate must be monitored throughout the procedure to ensure that the position change is not creating cord entanglement that could harm the baby. Some babies turn quite easily; others take an hour or more. In some cases the baby simply cannot be turned due to lack of room or change in the heart rate that indicate a version is not a good idea. In those instances the baby is gently returned to its former position.

Most practitioners like to do an ultrasound before an external version to check for anomalies, look for cord wraps around the baby's neck and to identify where the placenta is located. If a placenta is located anteriorly, or along the front of the mother's abdomen, a version is often not attempted because the placenta may be disturbed in the process. Some mothers have bellies that contract a lot when they are being "massaged." In these cases doctors will sometimes give a medication called a tocolytic, such as terbutalin, to temporarily stop the uterus from contracting during the procedure. These medications can make a mom feel "jittery" like she has had a few shots of espresso. The jitters leave when the medication wears off. If you are RH negative, your physician or midwife may give you an injection of Rhogam after the version to protect you from becoming sensitized just in case there was small undetected placental disturbance during the procedure.

Whatever the method, after a baby turns, spend a lot of time walking and squatting during braxton hicks contractions to encourage your baby to engage in the pelvis and minimize the chance of a return to a breech position.

- Maryl Smith

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After the baby turns, continue to place music at the bottom of the abdomen to encourage the baby to stay head down. I know it sounds silly, but I have seen it work so many times that I routinely recommend "musical version" to anyone with a breech presentation.

- Kathy Herron

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Regarding the child with hypospadias [Issue 2:5]:

If the hypospadias is minor and the opening near or immediately below the glans such that urination is essentially normal, there is little reason to subject the child to surgical correction. Many urologists today recommend not intervening in such cases, especially at such a young age. To repair this condition requires taking skin tissue from the penile shaft.

Presumably, this child was NOT circumcised. Essentially the child will be circumcised in the procedure. In many cases, the extent of surgery can result in restriction and discomfort during erection.

- James E. Peron, MS, Ed.D.

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A friend's husband has mild hypospadias. He was a professional football player, so evidently was not humiliated out of locker rooms. He is a wonderful loving husband, she is now menopausal and they report a comfortable satisfactory sexual life with no need for lubricants or unusual forms of stimulation. This would not be possible if he had been circumcised or if his preputial nerves had been severed to "correct" a hypospadias.

Parents and nurses and doctors can easily open their mouths and hearts and explain differences so that children can protect themselves from any verbal insults, far more easily than infants and children can endure terrible pain of injury and destruction to the precious nerve structure that the prepuce is, and the lifelong progressive desensitization and concomitant sexual roughness which is the result of circumcision, really a sexual mutilation.

- Maurene White

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My brother was born with mild hypospadias. My parents opted not to have it corrected. He is now the father of three children and to the best of my knowledge, the hypospadias has not been an issue for him.

My son, however, had a more serious case of hypospadias. We chose to have the surgery done because we were concerned that the hypospadias would become a psychological problem as he grew older. He was ten months old when the hypospadias was corrected. We spent one night in the hospital, and my son was his happy, active old self the next day. He healed rapidly and eight years later, you'd never know there had been any hypospadias to begin with. We do not regret making the decision to undergo the surgery for my son, and my parents do not regret their decision to forego the surgery for my brother.

- Deana Lampron

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My husband has hypospadia which was allegedly repaired when he was an infant. I was not turned off by it, more fascinated, but I'm that way by nature. I did have some concerns about the mechanical function when we were having difficulty conceiving (have since had 3 pregnancies).

I know my husband sometimes found it difficult when he was growing up because at times he urinated on his hand or shoe. Even though it was allegedly repaired, he stills has an opening on the underside of his penis as well as one at the end of it.

My husband has suffered no physical problems as a result of this deformity--no urinary tract infections, etc. It has been primarily an emotional issue that he learned to deal with over the years (he's 45).

- Cindy

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My son has a mild uncorrected hypospadias. The urinary opening is slightly lower than the tip of the penis. It has not caused him any problems, nor has it affected his marital relationship or concerned his wife.

If it were more severe, we might have inquired into correction. In fact, our family physician left a small flap of skin when circumcising him (we didn't even know to consider leaving him intact that many years ago), for use in case we ever decided on corrective surgery.

I believe one reason it didn't--and doesn't--concern my son is that we never made an issue of it. And since it is mild I don't think any of his friends ever noticed it. At least not that he mentioned.

- Anon.

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When my son was born, I was working as a mother baby nurse and witnessed plenty of circumcisions done where too much foreskin was removed. I am philosophically against circumcisions, but I took the middle way and asked the surgeon to use a plastibell appliance in the circumcision so a little foreskin would be left if there were problems. The surgeon agreed but went ahead and used the typical clamp device. As it turned out, our son had a very mild hypospadius located right at the base of the glans. As a toddler he had several bladder infections which were easily treated with antibiotics. Once he was out of diapers he was fine.

I have read there are some issues around possible fertility problems in the sense that sperm may not be deposited right on the opening of the cervix, but the trauma and perhaps the physical and emotional scarring from surgical correction never seemed worth it to us.

- Anon.

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More on circumcision:

I was rabidly pro-circumcision. Not only was I adamant about it, even though my wife wasn't Jewish, I wouldn't even talk about it.

When I finally started looking online for a defense to my position, I discovered an article written by a Jewish scholar regarding Talmudic reasons why one would not circumcise. The article was very convincing in its Talmudic concepts, to the extant that I began to at least consider the alternatives, which led to a decision not to circumcise. My family has since disowned me.

Anti-circumcision people, please tone down your rhetoric because you're alienating the very people who need to hear your message. The inflammatory language and horror stories do nothing but offend Jews such as myself. We know that it is a painful, even distasteful, practice, but the rabid detractors do nothing to address every Jew's primary reason for circumcision: We perceive that G-d told us to, and to break from that SEEMS to deny G-d. Because it is a painful experience for mothers and fathers and everyone involved, many Jews try to make sure that the next generation follows exactly in their footsteps, because it hurts them to think that the pain they went through was for nothing.

This article is filled with Talmudic Law, explaining without getting dogmatic a way in which GOOD, FAITHFUL JEWS can make the choice not to circumcise without leaving the faith. Truly, a large number of us devout Jews also believe that we are not breaking from tradition by not circumcising: As the article says, it is quite within the Jewish tradition to question, and even change Jewish law as new circumstances change. Though it isn't discussed much in the Jewish tradition, many Jewish laws have been changed because of changing circumstance.

The article can be found at either students.seattleu.edu/gradb/circumcision.html, or www.circumcision.org.

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I spent last night in an emergency room having tests done. I'm 5 weeks pregnant and am told there is a blood clot by the fetus and that the heart rate is about 104 instead of the normal 180. I'm not allowed to do much and they say it probably won't make it. Has anyone ever heard of anything even close to this?

- Denise
Reply to: Denise12@netscape.net

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