May 26, 2000
Volume 2, Issue 21
Midwifery Today E-News
“Labor & Delivery Nursing”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Labor & Delivery Nursing
5) Is the Hospital Safer?
6) Check It Out!
7) Question of the Week
8) For Coming E-News Themes
9) Midwifery Today Magazine Question of the Quarter
10) Question of the Week Responses
11) Switchboard
12) Classified Advertising

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1) Quote of the Week:

"Birth is an initiation.... At a fundamental psychological level, the baby's ability to survive the intensity and strain of the birth experience means a successful initiation, which teaches it about its ability to struggle and survive in the face of life's difficulties."

- Benig Mauger

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2) The Art of Midwifery

With your hands on the kitchen sink or wall, stretch away from the support. As you feel your shoulders open, let all your cares and worries fall away. Let your abdomen drop, and breathe slow, long and easy breaths. Practice Half Wall Hang for one to two minutes. To come up, inhale deeply as you take a step toward the sink or wall and stand up. Be sure to inhale as you stand up to avoid getting dizzy. I bet this pose is good for those with back pains and will probably have back labor pains.

- prepared by Connie Dello Buono
www.motherhealth.com
connie@motherhealth.com

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Share your midwifery arts with E-News readers! Send your favorite tricks to mtensubmit@midwiferytoday.com

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3) News Flashes

Breastfeeding rates have increased in 21 countries, with Iran achieving the highest average increase, followed by Brazil and Zambia. These countries have instituted initiatives to publicize the benefits to mother and baby, and to prohibit the advertising and promotion of breastmilk substitutes. Information activities, the training of health service personnel and promotion of government policies have all played a role. Conversely, breastfeeding rates have declined in Colombia, Jordan, Kenya, Kyrgystan, Morocco and Tunisia.

- Midwifery, Vol. 15 No. 4, Dec. 1999

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4) Labor & Delivery Nursing

(Editor's note: E-News invited L & D nurses to talk about their work. Following are comments sent in by a few. If you have more to add, please feel free to continue this dialogue!)

It breaks my heart to read many of the negative descriptions of labor & delivery nurses in E-News. While I am sure that some nurses are insensitive, uncaring, and uninformed, many of us are working very hard so women can have the best hospital birth experience possible. Please do not stereotype us as the "enemy" or judge us so harshly when we are trying to do our best in a difficult environment.

- Anita Jaynes, RN, BSN

====

I am a labor & delivery nurse in a small community hospital (187 beds). Our birthing center has 18 beds. I am very frustrated in my job, because most of my patients come in, and before they are 2 cm, they are howling for an epidural. As a nurse, it is my job to advocate for my patients. I have a lot of conflict because I am not a proponent of epidurals, yet I cannot promote this view to patients. Our epidural rate is 65% and climbing. I find it disturbing to work with all the technology and interventions, yet the two OB/GYN groups in this area have the obstetric population sewn up tight and believing all the interventions, scheduled c-sections, inductions etc. are necessary to giving birth. How does a nurse promote changes in this climate? How do you educate a population who is being educated long before I ever see them?

- Anon.

====

I am a midwife, I am a labor and delivery nurse, and at times I've been a women's health nurse practitioner. These are all titles, some implying higher status than others depending on the system in which you function. When you look at it, ALL of them work with women (mit-frau, midwife) and families. L&D nurses get the bad rap because they work within the system (policy/police) and they're given little power. Ghanaian midwives work within the system because the system accepts their work. The restraints are not tight like in America. Basically they are doing the medical system a favor by taking a lot of pressure off the doctors.

In a way I would say L&D nurses are the bearers of bad news: "I have to start this IV; I have to draw blood; I have to hang this Pitocin; no, you can't get up and walk, no you can't eat, drink and be merry." It goes on and on.

I have recently started working again as an L&D nurse (through an agency) at a New York City hospital. After being a "free agent" for many years it has been a major adjustment. I am shocked at how conservative it is. Every woman gets an IV and gets nothing by mouth except ice chips. Once Pitocin is started women are not allowed to walk and must use a bedpan! If they're on magnesium sulfate they MUST have a Foley catheter. Most are encouraged to have epidurals. I find it shocking--this is the year 2000! What about all the research?!

What we must realize is that women are making choices. The choice not to choose is a choice. They don't even inquire about the rules and regulations before agreeing to have their babies in this hospital. Most are not attending childbirth education classes for all kinds of reasons, from finances to time. Many speak no English and probably don't know they have choices since they might not have had any in their native lands.

So, many L&D nurses feel they are just "doing their job." Many really believe in the system's way because they've seen it for so long, it must be right. Many feel the best way to "help" a woman is to give her an epidural, i.e. take away the pain.

I was speaking with a midwife friend a few days ago and she mentioned having to go to a hospital for something. She said she'd never seen such a sad group of nurses. Everybody--L&D, nursery and postpartum nurses--looked so unhappy. It was as if they hated their work. We talked about it a little while and then she said, "Maybe they're just so frustrated about having to enforce policies that they don't agree with and feel helpless and burned out." So they shut down.

I found that as I start talking to the women I'm working with, none agree with the policies, yet they feel obligated to do as they're told/follow orders. Meanwhile they hope for changes in policy.

Personally, I try to insert lots of love in between the orders. I smile, I pamper--after all, I work with human beings. I'm still a midwife while working there. I try to give love to the families AND the other nurses I'm working with. I tell women who are having their first baby that they can choose differently next time by checking out their options and getting information. This helps me stay sane because I'm only here temporarily and know I won't be changing entire hospital policy.

Next time you encounter hostile nurses, remember they may be struggling with their own issues and feelings of impotence turned to apathy. Maybe that person wanted to be a "midwife" but was/is a single parent who couldn't sacrifice time, salary/money--becoming a recognized midwife in this country is EXPENSIVE and EXCLUSIVE!! L&D nursing may be just a job for some but it may be the only way to be with women for many others. Lets' not forget that we are all midwives working with women.

A woman came in last weekend with a blood pressure of 195/127. She was huge with edema and was spilling 4+ protein in her urine. Friday we admitted her and started magnesium. Saturday she had a c-section because her baby looked horrible on the fetal tracing. Well, magnesium and Demerol will do that to a baby, but with a blood pressure like that you can't play around. But I know this woman and her family felt well taken care of (i.e well loved) at least on our shift. All the nurses came in to greet her and help out when needed. What we talked about after the birth is next time make changes before something becomes an emergency. If she sees herself swelling up the way she did in a next pregnancy, she can make dietary/lifestyle changes before there's protein in the urine and before the blood pressure goes sky high.

I really love what I do even though I love homebirth best.

- Harriet Kaufman

====

I am an RN working on a postpartum unit and newborn nursery. I read all I can about midwifery, etc. hoping to gain information for future work in missionary nursing. This past year we have had several "Bradley couples" at our hospital, which I think is wonderful. Many of them are very sweet and we enjoy getting to know them during the few days we care for them and go out of our way to do things the way they choose.

Some are not so wonderful and seem to have been conditioned to feel hostile toward us. In deciding to come to the hospital, they need to be told that they are going to have to follow a bit of a format. It doesn't sound nice, maybe, but we have this horrid thing called "the chart" that must be filled out correctly and protocols followed because we are responsible for who comes in the door and for missing any problems.

Childbirth instructors, please be careful how you word things about the hospital staff. We became nurses because we care about people. We are here to help, not to push people around and make them miserable. Continue to encourage loving care and protection of their infant, and remind them that we, too, have those goals in mind. (Also, a box of chocolates is always appreciated!!)

- J.W. Pensacola, FL

====

As a labor nurse and doula I see many uphill battles in the labor and delivery room. The reason is that the doula is doing what the labor nurse wishes she was able to do, sometimes. Also, many labor nurses are not educated in labor support--they are not trained in that during orientation to L&D. Yes, it is sad but labor support is something you have to learn on your own (as an RN). The problem is that many nurses don't want to admit that they don't know what supporting a laboring patient can do for a woman, so they would rather give her an epidural and take care of the clinical aspect of labor. Nurses many times don't understand the empowerment a woman gains from having her desires met at her birth.

RNs have much to learn from doulas and midwives, but the teaching has to be slow and unobtrusive to HER patient. I have found that you must always make her feel in charge and let her tell you that it is OK for you to position this patient, etc. Eventually she will begin to help you and hopefully help others when there is no doula or midwife present.

- A.T.

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5) Is the Hospital Safer?

The only certain way of answering this question would be a randomized controlled trial (RCT). This could have been done in the 1950s but such a trial of home versus hospital was not suggested. Such a suggestion has now been made but it would require 500,000 women in a trial to answer the safety question. This is patently impossible so we make do with data that may suffer from the bias that women choosing home birth may be different from women choosing hospital, however well one may try to match them.

Nevertheless, one can look at the outcomes in relation to place of birth. One of the first to do so was Marjorie Tew, a statistician working at Nottingham Medical School. In her large-scale and detailed study, she analysed data from the 1970 British Births Survey and compared perinatal death rates in different places of birth (Tew, M. (1980). Place of birth and Perinatal mortality. Journal of the Royal College of General Practitioners, 35). She recognized that one would expect more "high-risk" deliveries in hospitals than at home. Tew attempted to control for this by using both antenatal and labour prediction scores to categorize expected risk ....

Tew found that babies were more likely to survive if born in a GP or at home, rather than in hospital, at all levels of risk scores. Only at the very highest level of risk were the better results at home and in GP units not statistically significant.

Tew had great difficulty finding a medical journal which would publish these results, as they went against medical "wisdom." It is possible that Tew's results may show that prediction scores do not foretell problems. They were not, however, her scores but were provided by obstetricians. Tew's results have not been refuted and the 1970 survey data do not support the then prevailing view that hospital was safer. Tew has displayed great courage over the years, initially being one voice crying in the wilderness; she can now take pride in her part in getting people to question that prevailing view.

- Geoffrey N. Marsh and Mary J. Renfrew (eds), Community-based Maternity Care, Oxford University Press, 1999

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6) Check It Out!

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A Web Site Update for E-News Readers

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7) Question of the Week

Q: I recently read a small article in Fit Pregnancy magazine that says blue cohosh can cause birth defects, according to a recent study done at Lehman College of City University of New York. Have you heard anything about this?

It went on to say that a woman who took the herb during labor gave birth to an infant who later developed heart failure. I have encouraged women to take the cohoshes during early labor and I myself took the herbs during labor and I would like to know if this is a new finding. Are there some practitioners who have heard more about this study? I understand the resistance by physicians to herbal medicine, but I don't want to take any chances on using an herb to help a mother but endanger her fetus.

- Angel

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Send your responses to mtensubmit@midwiferytoday.com

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8) Question of the Week Responses

Q: Does anyone have knowledge or experience with human papilloma virus (HPV) being transmitted from mom to baby (genital warts passed via the birth canal and appearing in the baby's throat)? Any real stories of successful healing, experience with surgical removal, or any other insight would be greatly appreciated.

- Anon.

A: I have been a CNM for 7 years and have helped about 330 babies be born in that time. I see a lot of HPV in my population and so far am not aware of any cases of HPV in the infant.

- M. Durbin
Toledo, OH

====

A: In the last few years I have learned a lot about HPV because we have had a good number of clients with this problem. We also spoke with an OB in the community who has HPV as well. What we learned is that this is a very common STD that is frequently asymptomatic with the exception of the initial flare-up. Some women may have a reoccurring breakout in pregnancy after a good amount of time without one. (Thuja cream has been very helpful for treatment.)

Transmission to babies is very rare. Unfortunately I do not have any statistics on the contraction rate. One thing the OB assured us is that transmission was NOT dependent on the type of birth, i.e. vaginal or surgical. Babies who are born to mothers with HPV should be closely watched for signs; one of the most obvious is a hoarse sounding voice. Signs may show up from 6 months to 1-1/2 years.

- student midwife
Oregon

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Q: Can anyone tell me the specifics of knots in cords at birth? What, if any, are the complications that might occur; can a knot in the cord often produce a stillbirth; and finally, are there any preventions?

- Jenna Tamura

A: Knots in the cord are perfectly harmless. They are from a baby moving around when young enough to produce a knot in the cord. The cord has a substance in it called Wharton's Jelly that prevents any kinks in the cord. My first daughter had a perfect knot in her cord. The knot does not actually kink until after birth when the placenta has stopped pulsating and its functioning is more or less finished.

- Andrea Boyette-Eliassen, CBE

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9) For Coming E-News Themes:

1. CHOICE: To what extent should women and their families have choice in pregnancy, birth and postpartum? What does choice mean to you? (June 2 issue)

2. What do you do to reduce an anterior lip? (June 9 issue)

3. What causes pain in labor? Is it a birth practitioner's job to try to
alleviate pain? (June 16 issue)

**Take part in E-News! Sound Off-Give Advice-Share Your Knowledge!**

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Send your responses to mtensubmit@midwiferytoday.com

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10) Midwifery Today Magazine Question of the Quarter:

What is your most noteworthy second stage, and what was the outcome? Please submit your response to editorial@midwiferytoday.com
by June 15.

Keep the stories coming! Midwifery Today magazine has a lot of aspiring midwife readers, and they can learn a lot from you!

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10) Switchboard

In response to a question about a midwife taking cord blood following birth [Issue 2:20]:

It depends on where you give birth. Some facilities just throw away the cord blood with the placenta but most only collect the cord blood from the placenta if the mother is O+ or Rh negative. In the facility I currently work in, we collect cord blood on all babies and send it to the lab. If a client wants to keep her cord blood she needs to let her practitioner know about it before the baby is born and she needs to make arrangements to have her cord blood stored well in advance of labor.

- Tora Spigner RN MSN

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I suspect that your midwife was collecting cord blood to test your baby's blood type and Rh factor. The pediatricians at my hospital want this information on every baby, so they can screen for incompatibilities with the mother. By drawing blood from the umbilical cord, the baby is spared having the blood drawn from its foot or arm vein. Cord blood banking is expensive and requires special collection equipment for proper storage of the blood (not just a syringe). I strongly doubt that this is what your midwife was doing. Did you ask her?

- Jeanne Preston, CNM, Ohio

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..Some parents want the baby's blood typed, so taking cord blood at birth saves the baby a heel poke! Some midwives just want to be on the cautious side. If cord blood was needed for any kind of testing after birth, they would have it. Ask your midwife why she took your baby's cord blood. If this is routine for her, she might not have thought to ask you. I agree that you should have been informed, for I imagine it could be disconcerting.

- Jenny Johnson

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..It should always be explained why cord blood samples are being taken, and usually the woman is well aware antenatally that cord blood will be taken after the birth, especially if this is not her first birth, if she is rhesus negative. I think that there was practice to take cord blood samples in the UK due to the high levels of haemaglobin that would help some blood disorders, but I am sure that this practice has ceased--I may be wrong. Your consent should have been gained if it was for banking as for any procedure as a matter of informed choice and consent....

- Helen

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How do you know your midwife took "stem cells"? It may have been that she is required by law to take a cord blood sample (which is universal) for syphilis and HIV. It is law in Texas that we send cord blood to the state lab for t hese tests, even at homebirths. When we do not, we have broken the law. Also, this is universally done in all settings. No one asks any birthing mothers' permission in the hospital to do that. No one informs the mother at any of the prenatal visits or hospital tours that it will be done. It is done, it is not questioned, it is considered a standard, and mothers have no idea it is being routinely done. Stem cell saving is expensive, and I can guarantee your midwife did not spend $600 or $1800 to save your baby's stem cells.

The next question you must ask is why did your midwife not discuss the law with you for your state? Why did she not discuss routine cord blood testing on your baby and then offer permission to refuse these routine tests if you do not believe in them?

I'm sorry that your midwife did not discuss this with you prior to your baby's birth and delivery, because communication and honesty are the hallmarks of the midwifery-client relationship. Most midwives respect your feelings about certain issues, and then allow you to refuse tests that you do not want simply by your signing a waiver after the test or procedure has been explained to you and you fully understand the benefits or consequences of refusing the test.

- Sandra Stine, CNM
midwife@lcc.net

====

In response to the questions about molar pregnancy [Issue 2:20]:

My first child was born in December 1989. My next pregnancy began in 1992 (I was 23) and was normal up until I went to my 16 week visit. We could not get a heartbeat. My OB did an ultrasound and we could see the baby was not developed that far along. He could not detect a heartbeat with ultrasound either, but wanted a second opinion to be sure. There it was confirmed that the baby was indeed dead. Up until that day I had absolutely NO idea anything was wrong. I never felt cramping or had any spotting. In fact, I was sure I had felt the baby move the day before this.

I was scheduled for a D&C about three days later. Thankfully, my OB agreed to put me under with anesthesia. I was heartbroken and couldn't bear to hear those machines doing their thing. The D&C went fine and I woke up feeling groggy and sorrowful, but physically I was OK. My OB called a few days later to tell me the tests showed that he/she had died at about 9 weeks. He said it was amazing I hadn't become violenty ill. He also said they had found I had a "partial mole" on the placenta. He had been an OB/GYN for 20 years and had never seen this in all that time. He admitted he wasn't exactly sure what to call it at first. He said it could be cancerous and that he'd continue to monitor me for several weeks.

Apparently, my human chorionic gonadotropin (HCG) levels were through the roof too. He said this is likely why my body continued to "think" it was pregnant. I had to go for weekly bloodwork for several weeks afterward to make sure my HCG levels went down on their own. After about 4 or 5 weeks they were down to normal.

I have never had any problems since. I didn't have to undergo any sort of cancer treatment or anything like that. I have had five successful (and non-problematic) pregnancies since then. I am currently pregnant with our seventh child.

- Karen (31) in Palmyra, Maine

====

I also had a molar pregnancy, 10 years ago exactly. I too was very upset and grieving. But in the 10 years since I have a wonderful 8 year old son and three beautiful daughters, 6, 4, and 2. They are all healthy and very intelligent. All my pregnancies were uncomplicated and deliveries were normal.

- Christina

====

While I have never had this experience personally, a very close friend experienced this complication over 12 years ago. She had to have two D&Cs and the doctor told her that increased her chances of further complications. She has done fine, including having two more babies.

- Debbie Williamson NY

====

Three years ago, I experienced a partial molar pregnancy. There was some fetal tissue which means it was not a complete molar. We had had no sonograms, and were not prepared for the unexpected hemorrhaging that occurred in my 16th week. It was as if the flood gates just opened. After emergency D&C and lab tests, they informed me of the molar preg. For me, it meant weekly blood draws to check my HCG levels, and then monthly for about a year. I was to avoid getting pregnant for one year. Because of the blood loss, I took beet root powder and chlorophyll. I don't know of any natural ways to bring the HCG levels down.

- Joanna

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In response to the question about episiotomy and subsequent births {Issue 2:20}:

I had a hospital birth with my second child with an obstetrician who performed an episiotomy that tore to fourth degree. Total recovery to the point where I was once again comfortable during lovemaking took approximately eight months. For my third child, I had many fears about my episiotomy scar holding up. I did tons of kegels, and we did perineal massage approximately twice weekly during the last two weeks of my pregnancy, using sweet oil, and planned a home waterbirth. I had a precipitous waterbirth, and tore 1/16 of an inch, with no perineal support. This child was a full pound bigger than my second.

- Anita W.
AAMI student, Missouri
ICAN Chapter Coordinator

====

In spite of being very fit and attending exercise classes right through my first pregnancy, I had a very extensive episiotomy with my first (9 lb 2 oz) baby; the doctor (in a country hospital) did a high rotation with forceps delivery for impacted shoulders; the episiotomy did not heal by first intention. Twenty months later I had my second baby in a mother friendly unit where midwives did most of the deliveries and was very pleased to have no episiotomy, tear or grazes (8lb 3oz baby). In spite of being most conscientious with pelvic floor exercises, two years later I had to have a vaginal repair for a prolapse and 20 years later a bladder neck suspension. I have always wondered if the two operations would not have been necessary if I had had an episiotomy the second time around.

- Laurelle (registered midwife)

====

Don't lose hope! Last month I attended a birth where the mom had a very slight skin split AFTER she had a fourth degree epis/tear at her first birth. She was repaired incorrectly the first time, (the family doc didn't realize it was a fourth degree). She then had reconstructive surgery. The couple was faithful about perineal massage five weeks prior to the second birth. It was an awesome birth--mom could not be any happier.

- Anon.

====

Kudos to Gloria Lemay for her response to the young woman's concerns about her episiotomy and what she can do to prepare for her next birth. Gloria's words were balanced, kind and fair, and full of wisdom and good advice. This is the sort of approach we should all model when trying to make sense of a troubling story. Too often we take sides or jump to conclusions, when we can't see all sides of the stories. I loved her words about being the midwife for a difficult first birth, and how easy it is to look (and feel?) like a heroine when the mother gives birth the second time. She has taught me a lot. Thank you, Gloria, and Midwifery Today for sharing her spirit with all of us. And I completely agree with her about a woman's ability to give birth over an intact perineum after a traumatic experience. I have seen this to be true over and over again. A good diet, a positive attitude, and a patient midwife can do the trick!

- Penni Harmon, CNM

====

As a labor and delivery nurse, I have personally seen women who have had previous 4th degree lacerations come in and deliver a baby over an intact perineum. And not a 5 lb baby--some have been 8 and 9 lbs. It really depend s on a patient birth attendant (whether doctor, CNM or CPM) and the birthing woman listening and working with the birth attendant. With perineal support and slow, steady pushing, it can and does happen.

- Michelle Smith, R.N.

====

I enjoyed the two articles published in the last issue re: postpartum hemorrhage. This is a particular interest of mine, both from my midwifery career (22 years so far and going strong!) and my personal experience at my own second birth where I had a 2 litre loss. I would echo the advice given in the two articles especially re: caution and prudence in the 3rd stage. It is a balance between sitting on your hands and not rushing while you wait for signs of separation and then when the placenta is ready to come, acting appropriately. I would add a few thoughts:

1) So much focus in birth is on the baby (obviously!) after the birth. Remind the woman she still has work to do and help her refocus on her body and the more subtle signs of readiness for the placenta to be birthed.

2) There are wide variations in "normal" depending on the clients that we serve. I have worked in different communities where the clients ranged from middle class educated white vegetarian homebirthers to very young teen moms, addicts, grand multips, ethnic and first nation women. While the same advice re: good nutrition and good midwifery care apply, there are varying degrees to which women will be able to follow your counsel. Poverty and lack of access to good food are powerful determinants to the short and long term health of women. The thoughtful and cautious use of oxytocin in some cases will mean the difference between a healthy postpartum and a prolonged recovery.

3) It is far scarier to the woman than the midwife to experience a PPH. She may feel that she is going to die and be very frightened. She may be afraid to go to sleep or get up to the bathroom, especially if she has already experienced a loss of consciousness. Reassurance and support are key. Someone may need to stay awake and sit with her before she is able to relax enough to sleep. Do whatever you can to make her feel safe. Even if she is stable and the PPH was well controlled, it may be worth transferring to hospital overnight.

- M.R.

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Many of you may know that Oprah Winfrey has the attention of millions of women across the nation who are waking up to the concept of being empowered in their life. She has been instrumental in getting the message out about living from within, nurturing your spirit, coming from the heart, getting values and priorities straight, and creating your own reality.

I would really like to see her do a program about birth options--get the message out to millions of women that they can be empowered in their birthing process as well. I do know that within the last two years about nine women on her staff have given birth. She has also had Cindy Crawford on her show and many may know that Ms. Crawford had a homebirth with the assistance of two doulas and a midwife and wrote the story in the March 2000 issue of Redbook.

My suggestion is that we write to the Oprah show and ask her to do a show on birth options, not to be confrontative, but to be informative. Before writing the letter, sit quietly and get in touch with what is most important to you. What aspect of the birthing process would you like to talk about i.e. the use of birth centers, birth art, home birth, baby and mom having the immediate connection from womb to breast, having a doula, episiotomies, sharing positive birth experiences, etc. Give a brief personal experience on the issue and then resources where her staff can get information about it.

I believe if we all send our requests within a one month's time, from June 1-June 30, 2000, it would have a large impact and we would have a greater chance of being heard. You can email by going to Oprah.com, click on email, then click on show suggestions and fill in the form.
You may also send a letter through snail mail. Address it to: Harpo Productions, Oprah Winfrey Show, PO Box 909715, Chicago, IL. 60607 USA.

- Kathryn Julia

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Coffee drinking has generally been viewed as one of those iffy things, probably OK but better if you don't, for the typical pregnant woman. New data on coffee drinking and a plasma homocysteine indicates that filtered coffee is likely safer than unfiltered coffee. According to Am J Clin Nutr 2000 Feb;71(2):480-4, people who drank coffee filtered through paper filters had lower levels of plasma homocysteine. The group of researchers was looking at this effect because elevated plasma homocysteine is associated with heart disease, although exactly why is unclear. Homocysteine is an amino acid that is used up when folic acid is metabolized, with any excess being dumped into the blood stream or plasma.

For the pregnant woman, having an elevated plasma homocysteine has been associated in some studies with complications of pregnancy, especially placental vascular abnormalities associated with repeat early pregnancy loss and complications of late pregnancy such as abruptio placentae or placental infarction with fetal growth restriction. See Am J Obstet Gynecol 2000, May 182(5):1258-1263 (Folic acid and B vitamins will also reduce plasma homocysteine). Pregnant women concerned about possible negative effects of coffee but who are unwilling to give up their favorite drink, may want to consider giving up the cafetiere (French press) for the filter as a precautionary measure.

- Anon.

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Unless otherwise noted, share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com. If an e-mail address is included with the letter, feel free to respond directly.

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