|April 28, 2000|
Volume 2, Issue 17
|Midwifery Today E-News|
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"To respect the instinctual nature of birth, we must allow the process to unfold for each unique individual. As midwives it is our job to facilitate, not control, this process."
- Joanne Dozor
2) The Art of Midwifery
The following is a basic management plan used for a pregnant woman with fibroids: Kathy's personalized plan included restricting estrogenic foods (fats, dairy, meats); eliminating xanthines (tea, coffee, chocolate and cola) which stimulate fibroid growth; emphasizing vegetables and vegetable juices (especially carrot juice, which inhibits tumor growth), whole grains, vegetarian protein sources, fresh fruits, high-iron food and seafood. We added top quality prenatal supplements, including at least 400 I.U. vitamin E and 500 mg. bioflavinoids; homeopathic remedies including Silicea, which stimulates the organism to reabsorb fibrous tissues, and Pulsatilla for heartburn; and rest and positioning for pressure symptoms. We agreed that if a situation arose that posed a significant danger, we would revise the plan to possibly include ultrasound or hospitalization (specifically labor prior to 36 weeks, IUGR, or obstructive dystocia during labor).
- Judy Edmunds, "Facing Fibroids," Midwifery Today Issue 25
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3) News Flashes
A trial sought to determine whether injecting sterile water subcutaneously rather than intracutaneously produced less pain during injection while resulting in equal effectiveness. Ninety-nine pregnant women at term who required relief of severe low back pain during the first stage of labor were randomly allocated to receive four injections of 0.1 ml sterile water (not normal saline) intracutaneously, four injections of 0.5 ml of water subcutaneously, or placebo injections in the area of the Michaelis rhomboid in the lower lumbosacral area. The placebo treatment was subcutaneous injections of normal saline.
Both groups of women receiving intracutaneous or subcutaneous sterile water had significant reductions in pain scores after 45 minutes compared with the placebo group. No difference occurred in the women's experience of pain during the injections. When surveyed after birth, however, twice as many women receiving subcutaneous sterile water said they would not be willing to try this method in a future labor and birth, compared with those women receiving intracutaneous water.
- Birth, March 2000
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4) Keeping Childbearing Normal Through Nutrition by Marion Toepke McLean, CNM (excerpt)
Two to three pints of blood and a seven pound baby, plus a placenta, amniotic fluid, and other maternal tissues, requires sustenance. Food. The mother needs regular feedings of protein and all the other essential elements of a balanced diet including grains, fruits, vegetables and healthy liquids.
Increased growth of blood volume and other maternal tissue is notable from twelve weeks and is in full swing by twenty; the greatest nutritional need per day in pregnancy occurs from twenty to thirty weeks. After that, though baby's growth takes off, the increase in maternal tissues is essentially complete. This is fortunate because by this time, the pressure of the growing baby has reduced the capacity of the stomach. It is important that the mother choose foods that are high quality when the amount is limited by mechanical factors. Remind the mother that her baby is growing all the complex tissues of a human body.
Discuss nutrition as early as possible. For those with morning sickness, talk about what they are able to eat, what appeals to them. Be sensitive! Even discussing certain foods can make a woman feel sick.
When the time is right, take a diet history. Discuss categories of food so she can fill in nutritional gaps with foods she likes. This is difficult with some younger teens, who are still in the "there is no vegetable I like" stage. When you persist without putting them down for their diet, you can usually come up with a core of nutritional food they enjoy. The increasing appetite of the second trimester is on the midwife's side. Women tend to get hungry for the kinds of food they need. Protein is a notable example. Be sure your clients know both what good nutrition is and why it is important. Compression of the stomach by the growing uterus is felt by most women in the second trimester or before. They are hungry, yet they get full rapidly. Eating six small meals a day makes more sense than three larger ones. Talk about budgeting and using a shopping list so that appropriate foods will be on hand.
Read the full article on the Midwifery Today website. Go to:
Editor's note: More articles on nutrition will be added to the Midwifery Today web site soon. Keep checking!
5) Eating-disordered Women and Pregnancy
Having a strong support system in place is vital to eating-disordered [anorexic, bulimic] women when they are facing pregnancy and birth. According to Margo Maine, Ph.D., Director of Eating Disorders at the Institute of Living in Hartford, Connecticut, "For those people who have struggled with eating disorders and come to some level of recovery, the pregnancy can sometimes bring issues back to the surface that [the patient] felt were under control. The pregnancy can bring up a lot of issues about eating and a distrust of the urges and strong appetites that a pregnant person often has. A woman may be very fearful of her body's messages to her."
In addition, the fact that a pregnant woman's shape and size alter in such dramatic and uncontrollable ways is often a difficult psychological hurdle. Randi Wirth, Ph.D., executive director of the American Anorexia and Bulimia Association, states that "pregnancy brings up issues for every woman about her body, and anyone who has a vulnerability to body-image distortion will find that resurfacing....In particular, they fear their weight gain will be permanent. They fear losing control."
The postpartum period is a vulnerable time. The inevitable sleep loss, new demands, and dramatic life changes are enormously destabilizing, and the fact that hormones are dropping at a precipitous rate may make maintenance of psychological health even more challenging. Women and their healthcare providers need to be alert for the possibility of postpartum depression.
Those women who enter this phase of their lives with adequate preparation are apt to have a good experience. What this means is they need to have their issues under control, be of normal weight, be psychically integrated, and have an adequate support system. Likewise, it is a good idea for these women to reengage with their therapists, at least for a session or two, to deal with any concerns that may arise.
- Julianne R. Ambroz, from "Eating Disorders in Pregnancy," Midwifery Today Issue 40
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6) Check It Out!
HOLD IT !! REWIND! SCRATCH THE CLASHING CYMBALS AND DRUMS OF TRIUMPHANT JOY! That Silly Webgirl---She jumped the gun! We have a few new domain names, and FindaMidwifeToday.com will be one of them. So stay tuned...we are experiencing temporary technical difficulties!
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7) Question of the Week
Q: I am wondering about the safety of homebirth with the presence of fibroid tumors. Can someone with experience in this area help me with the risks and things to watch for?
- Bea Tarr
Q: I recently attended a birth as a doula. After labouring for 8 hrs. my client was almost fully dilated except she had an anterior lip. When the doctor did a vag exam, she was able to pull back the lip while the mom pushed with a contraction and ultimately pushed the lip out of the way. However, two hours later with strong effective pushing, the lip was still there. The doc was frustrated and couldn't figure out why the lip wasn't cooperating. An epidural was done to hopefully relax the mom and take care of the lip. After half an hour, this goal was reached. The mom continued to push when coached to do so because of course now she couldn't feel any sensations to bear down spontaneously.
My questions are:
1) What else could have been done other than an epidural to resolve the lip dilemma?
2) Once the lip had disappeared, could the epidural be turned off or at least the amount of the drug reduced so the mom could regain some feeling to be able to push more effectively?
Incidentally, this birth ended up as a c-section due to CPD. Three hours after the epidural was initiated, the baby was still quite high, too high for a vacuum so a section was suggested.
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8) For Coming E-News Themes:
1. Describe any experience you may have had with Factor V Leiden.
2. Labor & Delivery Nurses: Here is your chance to speak up! How can midwives and doulas be more responsive to your needs? How can you work more effectively together? Are there any concerns you'd like to air in E-News? Tell us about them!
3. Aromatherapists: What are some of your favorite aromatherapies for pregnancy, labor, birth and postpartum?
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9) Question of the Week Responses
Q: If the waters break during pushing and there is thick meconium, is it better to try to get the baby out quickly or allow it to stay inside mom?
- Belinda, apprentice
A: It has been my experience that if she is pushing she's usually fully effaced and dilated. If at that time the meconium is observed the baby is "more out than in." Delivery is imminent. We have let the woman deliver on her own, but avoiding a prolonged [second] stage. If the mec is observed with very little dilation and effacement, measures are taken to deliver that baby, depending on the situation... a C/S is performed.
The danger of meconium other than indicating possible fetal distress is aspiration upon delivery. How has the fetus appeared up until the point of rupture? Any indications of distress? Apparently, the fetus passes meconium in utero all the time and macrophages "clean up" the amniotic waters. As the fetus gets older, the macrophages decrease, thus leaving meconium in the waters.
Meconium in and of itself does not always mean distress (pathology). Many times when the pressure on the head becomes "severe" as in pushing and birth the baby may pass meconium. What is the whole picture telling you? Does the maternal history make you think the baby may have experienced stress? Any other stressors? If there's no indication of distress and heart tones are reactive with good variability I don't see what speeding up the birth will do.
The concern at birth is when the baby takes the first breath and aspirates meconium. Better to have a Delee trap or suction ready to clear the mouth and throat, then nose, right as the head delivers. In some facilities all babies with meconium are intubated to visualize the vocal cords. I don't think this is really necessary with thin meconium. You might want to take a NALS class to familiarize yourself with distress, apnea and meconium staining.
- Harriet Kaufman
I have had a few situations like this--meconium so thick it plops out after the bag breaks. If heart tones stay strong even with some bradycardia we just keep pushing to get baby out. Mom works hard and baby is constantly monitered with a Doppler. I will call for an ambulance in this situation in case baby does not do well. Thankfully in each situation the babies have done very well with stimulation and we have not needed to transport.
Approximately 500,000 infants are born through meconium-stained waters each year, and of those, 10% develop meconium aspiration syndrome (MAS). Many practitioners choose to intubate and suction these infants despite lack of proof that this intervention is beneficial.
A randomized, controlled, international, multicenter trial that involved 2,094 full-term, vigorous infants, compared intubation and intratracheal suctioning with expectant therapy. The infants were equivalent in all infant and maternal antenatal and intrapartum characteristics. There was little difference in outcome between the groups (including infants born through the thickest meconium) in MAS incidence (intubation group, 3.2%; expectant group, 2.7%) or in other respiratory disorders (3.8% and 4.5% respectively). Infants in the intubation group were significantly more likely to have 1-minute Apgar scores of less than 7 (17% vs. 6%), and 51 complications of intubation were noted, including bradycardia, hoarseness, or laryngospasm.
- Pediatrics, 2000 Jan; 105:1-7.
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10) Checking In
You are invited to Midwifery Today's international conference in New York City this Sept. 6-10. This is a great opportunity to meet practitioners from around the world. It is a time to work on your most compelling issues for birth change. You will participate in an important global summit meeting on such topics as taking the fear out of birth, validating and honoring traditional midwives, safe motherhood, healing birth, strengthening networks, and much more. You are welcomed to bring up for discussion your concerns as well. We really can change the world of birth if we work together using a strong vision and a sense of unity. You will meet and learn from unique and brilliant practitioners. We will study both global issues and techniques and theory well grounded in the midwifery model. The soul and spirit of motherbaby-centered care will be a strong component of this joyous event. This exciting conference will "Celebrate Diversity" to forge a new international midwifery model.
Midwifery Today was called the Switzerland of midwifery by a registrant of the Philadelphia conference. This compliment refers to our desire and efforts to bring all midwives, doulas, educators, nurses, physicians and activists together to make the childbearing year the joyful experience it was designed to be. Join us to make your needed voice heard. Everyone is welcome. Save money by registering on or before May 5. Happy International Midwives' Day!
- Jan Tritten, founder and mother of Midwifery Today
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In response to a question about gestational diabetes [Issue 2:16]:
A diagnosis of gestational diabetes would not necessarily rule you out for midwifery care or a homebirth, especially if you could avoid the insulin during the last month. However, I think the best thing would be to find a homebirth midwife who also has hospital privileges. This can be hard to find, but in the event that a hospital birth would be a better decision for either you or the baby, you would at least be with a caregiver you can trust.
- Karla Morgan
You have every chance of having a pregnancy without gestational diabetes. It is all related to your diet and level of exercise. I've taken care of a lot of moms who had this diagnosis in a previous pregnancy or in the present one. When they come under my care and guidance they have always been fine; however I'm really strict on them following the proper diet, lifestyle, and exercise. You are right, Stephanie, there is a lot of misdiagnosis of GD.
In response to information about salt restriction in pregnancy [Issue 2:16]:
There's a big difference between sea salt and the commercial chemical stuff that most people buy for salt. In Ghana [where I live] they push iodated salt which I also feel is bad. I think the chemical stuff could indeed raise blood pressure among other things and people should not be encouraged to use as much of it as they please. We also have to be careful because salt to taste could be a lot of salt depending on the diet a woman was raised with. Processed foods have so much hidden salt that our taste buds get used to the flavor. I have always suspected that we do in fact need salt, especially in Ghana where we sweat so much, but there we use only sea salt, and of course veggies have salt naturally. A lot of people there use msg and don't even know it since there's no ingredient list on most commercial food.
- Harriet Kaufman
I suffered a missed miscarriage last year. The baby died weeks before I even started to show signs of the miscarriage. I had to have a D&C to complete. Now I am 7 weeks pregnant and my practitioner suspects I am miscarrying again. Would it be more dangerous for me to have another D&C or to just wait for the miscarriage to take place? Does anyone have advice or comments on why this keeps happening to me? Prevention techniques? I have a 3 year old daughter so I know I can have a baby.
There is an excellent way to change persistent posterior babies that has worked every time I have used it. It may need to be done several times in late pregnancy, but it will turn the baby every time. It is a chiropractic technique called a diaphramatic release. It is non-manipulative and easy to learn. I learned it from Dr. Carol Phillips, who teaches chiropractic care for pregnant mothers and newborns. Every midwife should know this technique. I no longer have any posterior babies. Neither my mothers nor I miss those long hard back labors!!
- Judy Jones
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