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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
9) Classified Advertising
1) Quote of the Week:
"Are you a midwife 'with woman' or a midwife 'with medicine'?"
- Jan Tritten
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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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)
- 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
Read more about epidurals and drugs in labor
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5) Check It Out!
A Web Site Update for E-News Readers
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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:
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A2 > Education Day
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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 firstname.lastname@example.org by March 15, 2000
See writer's guidelines on our web site! Click here--> writer's guidelines
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.
Send your responses to email@example.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?
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
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.
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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presentations include: Millennium Babies-Restoring Soul to Childbirth.
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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?
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.
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?
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.
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.
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.
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
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
- Maryl Smith
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
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.
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
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
- Deana Lampron
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).
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.
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.
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.
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?
Reply to: Denise12@netscape.net
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