June 21, 2000
Volume 2, Issue 25
Midwifery Today E-News
“Relationships”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) The Box
5) Facing Reality
6) Check It Out!
7) Question of the Week
8) Question of the Week Responses
9) For Coming E-News Themes
10) Switchboard

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1) Quote of the Week:

"I stay quiet, do a good job, have my focus on the need that is there and try to meet it, and thus become so entrenched in the community that the community then becomes my support."

- Sr. Angela Murdaugh

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2) The Art of Midwifery

Work as a doula in unwed mothers' homes, where there are high numbers of abused women. They can learn the efficacy of touch from you. Check the woman's comfort level and respect her boundaries. Touch is an international language.

- Midwifery Today conference Tricks of the Trade circle

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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

A study of the acquisition of herpes simplex virus (HSV) in pregnancy and its effects on the newly born involved 8,538 women. All were tested for the presence of antibodies against HSV-1 And HSV-2, and serum samples obtained for routine prenatal tests at 14 to 18 weeks and at 24 to 28 weeks were saved and tested to pinpoint the time of seroconversion. Of the women, 24% were HSV negative at the onset of prenatal care; 48% were seropositive for HSV-1, 11% for HSV-2, and 17% for both. Ninety-four women, or 2.1% of all susceptible women, converted to herpes positive during pregnancy. Of these, 64% had subclinical infections. All 26 women with clinical symptoms of HSV-2 infection and 6 of 8 with symptomatic HSV-1 infection had genital lesions. About the same ratio of serum negative women and women who initially had antibodies only against HSV-1 converted to seropositive for HSV-2; however, no woman who was seropositive for HSV-2 converted to positive for HSV-1, suggesting that the former confers immunity against the latter. Younger age, not being married, and occurrence of other sexually transmitted diseases were associated with seroconversion. The only babies in the study who contracted neonatal herpes were born to women who acquired genital herpes near the onset of labor and who had not yet developed antibodies. No baby of the 94 women who seroconverted during pregnancy developed herpes; neither was an increased risk of preterm labor, intrauterine growth retardation, or spontaneous abortion found.

- New England Journal of Medicine, 1997, Vol. 337 No. 8

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4) The Box (excerpted)

From early childhood I had been excruciatingly afraid of people. I never experienced true intimacy. With the very first birth I attended I found my need for intimacy met with the birthing family. They needed me, they were totally vulnerable, they responded with gratitude to me. I could love them, give to them selflessly without fear of rejection.
My relationships with these families lasted only a short
time. This was vital. An intimacy that begins and ends
quickly is not a demanding intimacy; it is perfect for those
who are afraid of rejection. While this element of midwifery
met my needs wonderfully, my family life suffered. I became
alienated from my husband and children.

When I discovered midwifery, I had been looking for significance and purpose in my life, for a cause that transcended the mundane. It was my false belief about the nature of spirituality that caused me to make midwifery my religion. To say midwifery is a calling and to tell myself I was one of the "called ones" was a poor cure for my lack of self worth. My level of significance and security depended on numbers, my self worth depended on successful outcomes (no transports and drug free births). Needless to say, poor outcomes shook my universe terribly.

When my family, social, emotional and spiritual life finally hit bottom after spiraling downhill for years, I began to see what no one could tell me. At the same time, I met another midwife who hit bottom the same way with the same effects on her. Ironically, I met her before our simultaneous collapse and thought, "Finally, here is another midwife who is as dedicated as myself." Meeting her again at the treatment center was like looking in the mirror.

- Carolyn Eustace in Life of a Midwife, a Midwifery Today Book

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Life of a Midwife is chock full of articles and stories about what it's like to be a midwife. For more information, go to: www.midwiferytoday.com/books/lifemw.htm

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5) Facing Reality: How to Begin Your Midwifery Career (excerpted)

It is likely that your mate is a major influence in the decision-making process [to become a midwife]. If you were to choose to begin your career, what would this mean to him? More work, more money, more sacrifices from him, more, more, more? Certainly it challenges his present lifestyle that may be quite comfortable the way it is. You can determine his true feelings by using gentle encouragement, and quiet his fears as well. After all, you are not replacing your marriage with a career, only complementing it. It is sad that our society continually places women in a position in which they must validate their right to happy and fulfilling work. For those considering a change, an encouraging partner is valued beyond gold. Generally, men tend toward one of three reactions when informed of their mate's desire to begin a career in midwifery: He will wait it out patiently until she "changes her mind when things get rough"; he will use guilt to make things as tough as possible; or with love and support, he will take pride in the growth and fulfillment she is experiencing.

Every relationship has weaknesses that can become more troublesome with change. You can prepare yourself by strengthening your commitment both to your partner and to your career. Make it clear that anyone who continually argues your limitations or makes life difficult during your work hours is not using acceptable behavior. Your happiness is your right and personal responsibility. Gold stars to the loving supportive mate who thrills at your joys and can be your spine when yours can't hold you up anymore. Blessed be the mate who can listen to his partner's desire to challenge herself outside the home and supports her in word and deed. This precious man is worth all the juicing up you can provide along with constant acknowledgment of his output and personal sacrifice.

- Karen Parker, CNM in Paths to Becoming a Midwife, a Midwifery Today Book

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Paths to Becoming a Midwife shows you how to make reality out of your dream of becoming a midwife. For more information:
www.midwiferytoday.com/books/lifemw.htm

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6) Check It Out!

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

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7) Question of the Week

My friend suffered from pain caused by "pubis symphasis" during her past five pregnancies. She is currently eight weeks into her sixth pregnancy, and she's already experiencing pain. Are there any exercises that can help? Any magic cures (homeopathic remedies, etc.)? She broke her coccyx during her first labour 16 years ago, but went on to have normal, uncomplicated births with her fourth & fifth children. Her youngest child will be two when the new baby arrives. Her birth was extremely fast (40 minutes). Is homebirth an option?

- Chamutal
UK

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Send your responses to mtensubmit@midwiferytoday.com

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8) Question of the Week Responses

Q: What experience has anyone had of trisomy 18 (Edwards syndrome) in a natural birth, homebirth situation? This is what mum would prefer but has been told that possible complications may require a cesarean.

- L.T.

A: We recently helped a mom with a trisomy 18 baby deliver at home. She found out about three weeks before the birth and knew that he had multiple anomalies incompatible with life. The consulting doctor did not have a problem with her having a homebirth/homedeath. He was delivered, in a double-footling breech position, after a fairly short labor. Baby Noah lived for an hour and died in his daddy's arms. I am wondering what complications for your client would necessitate a cesarean? Babies with trisomy 18 generally do not live very long and it seems that the risks would outweigh the benefits for both mother and child.

- Holly Richardson, CPM

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A: The organisation SOFT is a wealth of knowledge on trisomy 18 and trisomy 13 (Patau's syndrome) as well as related disorders. They have an office in the United States as well as Australia and the UK. Unfortunately, I cannot get the USA web page to come up but if you go to the UK home page at http://www.soft.org.uk/ and click on the CONTACTS button, there is information on how to contact the US group. They provide booklets on all sorts of different aspects of trisomy 18, and local support groups are available.

In investigating trisomy 18 for a client a long time ago when I was living in the UK, I found that many of the "facts" surrounding trisomy 18 and the prognosis for these babies were in fact myths. I had had a client who had previously chosen to terminate a pregnancy with her first baby, who was diagnosed with Edward's syndrome because the prognosis was that he would never survive childbirth. However, I discovered that it is very difficult to determine the extent of the syndrome and that in fact many babies lived beyond one year when they had full Edward's (10%), and those with partial or mosaic Edwards had an even better prognosis. It's a terrible tragedy that so many parents are given so much inaccurate information and make choices that are not informed in any way.

- Nikki Macfarlane, CBE, doula
Singapore
www.parentlink.org

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A: Why perform major surgery on a mother when the child has a condition incompatible with life? Trisomy 18 babies rarely live long. To even suggest cesarean as a possibility is medical abuse unless it is for a complication related to the mother's well being. This baby should be born at home to protect both mother and baby from unnecessary medical intervention in a very private, sorrowful, and holy event. Monitor the baby only if mom has a need to know how baby is doing. Find a friendly ND or MD who will agree to come at the last minute and quietly note time of death and sign a death certificate. Make sure the family has sufficient time to bathe, love and take pictures and footprints of their child before relinquishing it. It helps to call the coroner ahead of time to let him know that you are attending a home labor with a baby who has been diagnosed with a condition incompatible with life. Tell him a doctor will be present to confirm time of death. This will protect you from any unnecessary inquiry. The funeral home can pick up the baby when the family is ready, or they can choose to have a trusted friend or family member transport the baby by car themselves. A car seat can be used. Call the funeral home to let them know baby is coming.

Two weeks ago I had a mother who gave birth to a trisomy 18 baby. Unfortunately, the problem was not picked up until an ultrasound at term to rule out IUGR. Because there was no time to perform chromosomal studies for a positive diagnosis, the perinatologist encouraged the parents to give birth in the hospital. However, the baby also had a major diaphragmatic hernia with the liver displaced up next to the heart as well as a ventricle septum defect of the heart. Despite the parents' expressed wishes to have the baby at home if it was not viable, the physician continued to offer them hope if they would stay in the hospital "just in case it wasn't a trisomy." I believe this pressure was based more on fear of liability than an actual belief that the baby wouldn't have a trisomy or could live through the necessary surgeries. It wasn't until mom was four hours into a cytotec induction that the parents had the opportunity to consult with a neonatologist about the seriousness of their baby's problems. At that time the parents discussed going home to have the baby. The neonatologist supported this choice, but the perinatologist was upset. The couple decided to stay for the sake of an epidural. This was mom's sixth birth and she had never had pain medication before. She said she wasn't certain that she could cope with both the pain of labor and the pain of loss at the same time. This was a valid choice. No one can measure another's grief. Sadly, the epidural was largely ineffective.

Our biggest fear was that the baby would be removed from the parents at birth and they would not be allowed to be with him when he died. The fact the parents had considered going home helped the doctor accept that they did not want any heroics. When the baby started to have severe heart rate decels into the 50s with slow recovery, the possibility of cesarean section was brought up by the doctor. Fortunately we had already discussed this ahead of time and the parents refused consent for surgery. The doctor agreed that this was a reasonable choice under the circumstances. (But why was it "irresponsible" to go home to have their baby if this was OK?) He removed the electronic fetal heart monitor and let the labor continue. When baby was born, the diagnosis of trisomy 18 was immediately confirmed and he was placed in mother's arms to die. He never took a breath. He only felt tender arms, gentle kisses, and heard whispered "I love you's." It is a midwife's sacred honor to walk with families when life is coming in and sometimes when life is going out as well. I send you my prayers as you walk this journey together.

- Maryl Smith

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A: How sad the mother has been told she can't deliver a baby with trisomy 18 at home! The abnormalities involved in this syndrome should cause no problem whatever in birth, unless perhaps it is associated with polyhydramnios. The only one I've seen born was a normal birth in the hospital. Sadly, although there is nothing that can be done for a trisomy 18 baby, before the baby was very old the hospital staff had figured out a reason why it had to be separated from the mother. The baby didn't live very long and the mother wanted it there with her, but someone just felt they had to do something, even if it was only to take the baby to the nursery "where we can watch it." Why? To me, home would be the perfect place for this baby to be born so the parents can come to terms with the situation in privacy.

- Marion Toepke McLean

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9) For Coming E-News Themes:

1. "Is the fact that midwives cut far fewer episiotomies than doctors important?" asks Marsden Wagner, M.D. in his Technology in Birth article (www.midwiferytoday.com/articles/technologyinbirth.htm). What do you think? (June 28 issue)

2. Premature rupture of membranes (PROM): what is your protocol? (July 5 issue)

3. What do you carry in your birth bag? Anything unusual, and if so, for what purpose? (July 12 issue)

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10) Switchboard

Editor's Note: If you are sometimes receiving only one part of your E-News issue and you use AOL, call their number to complain! 888-346-3704.

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How often do you currently see (following a non-traumatic vaginal delivery) a practitioner do a ring forcep cervical and vag vault check with the intent to suture any tears found? I recently endured watching this done to a person I transferred from a homebirth to hospital care. I thought this procedure went out 40 years ago. Am I wrong?

- Roberta Gehrke, CNM

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One of our patients is moving to Germany soon. Is midwifery care is the "norm" there? They are slated to move to Berlin or Frankfurt. If you know or have a way of us finding out please respond.

- Pam Jessee, L.M.
Reply to: birth_choice@email.msn.com

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I disagree with the response to the knots in the cord not being harmful. I recently attended a birth (doula); there was a knot in the baby's cord.

The mother kept going on and on to everyone about how her baby had a "perfect knot" in his cord. The nurse finally told her that a few weeks earlier they had a fetal demise due to a knot in the cord. The mother was 34 weeks. This can happen if the baby has enough room to be very active. It can pull so tight that all supply is cut off.

- Anon.

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I've enjoyed all the comments on cervical lips in the pushing stage. In each of my three homebirths I've had a cervical lip. The first time, the midwife held it back for one push till the baby's head went by. No problem. The second time, it stayed around for a few pushes, but nothing major. With baby three, the lip hung around for an hour before I could push past it.

Having the midwife's hand in there is not the most pleasant sensation! I have no scar tissue, noting peculiar about my cervix. Any comments about why this has been happening would be appreciated.

- Polly

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I am so glad to see information on pushing and when to do so in your journal. With the birth of my first child I did not know better and was told to push since I was "at a 10." My baby and I were definitely not ready. The results were a very oxygen deprived baby (the L&D nurse also coached me to hold my breath and push to a count of 10 and beyond). I also broke blood vessels all the way down past my waist, both eyes were black and swollen shut, and I also broke all the blood vessels in my eyes (I had no whites at all for over a month). It also did long term damage to my pelvic floor and gave me problems with incontinence for two years, even with faithful kegel exercises. All this could have been avoided by waiting until I had the urge to push. I never did experience the urge to push even as my son came out!

The second time around, I was a Bradley Natural Childbirth instructor and I knew better. My midwife never did do a vag exam and I pushed only after the urge hit and worked with my body--no long pushes or breath holding. There were no bruises on me or my baby this time and I had a rather easy pushing stage. This was so much better!

- Anna Matsunaga
Tacoma WA

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Have you made much use of the reference text "Mayes Midwifery"? It's been around for a long time but the latest edition (that I have seen) is the 12th (1997, reprinted 1998). It has forty-one contributing authors, entirely female, and is written by midwives for midwives. It should appeal to those who value this type of authoritative work, and answer a lot of questions outside the medical model--it's not particularly pro hospital. It could go a long way toward making the "angry powerless" feel better about the future.

- Phil Watters

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