Commentary: A Season of Hope
December may be the darkest month, but it is also when the
sun begins to pour its generosity onto Earth again. This remarkable
time is indeed the season of hope, when we truly experience enLIGHTenment.
Beneath the mantel of snow or in the midst of cold rain, among the blackened
plant life, seeds are storing their energy and life-giving nutrients,
patiently waiting for longer days and warmer soil in which they can
work their transformation.
And so it is with the work that midwives and all conscious birth practitioners
do. Although times and conditions may be discouraging, the work daunting,
and the challenges to sane birth practices overwhelming, you can wait
your turn for renewal, harbor your energy, believe in the future. With
all the inherent wisdom of the waiting seed, practice diligence, take
one day at a time, think about what matters most and plan to implement
it when the time is right, then act in accordance with your own truth.
No need to ride into battle with swords drawn, spoiling for a fight.
To nurture the clarity of your conscience, love for your calling and
the women who seek your guidance, to practice patience, steadfastness,
and belief in your own strength and truth means that when the seasons
inevitably turn and the sun shines fully upon you, you and your truth
will prevail. Anatole France once said, To accomplish great things,
we must not only act, but also dream; not only plan, but also believe.
- Cher Mikkola, Editor, E-News
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Birth Story from Peru
I am a Canadian-Peruvian woman who is in the process of becoming
a midwife in the shantytowns on the mountains of Lima, Peru. I have no
senior midwife to supervise me or supportive medical backup. I only have
questionable hospitals that have a nasty reputation for abusing, torturing
and ultimately butchering poor women. At my tenth birth as a primary midwife,
the Goddess decided to present me with a hair-raising third stage hemorrhage.
Here I was, in an almost inaccessible hut with no running water, a kerosene
stove and one bright light bulb, with 20 year old nullipara Noemi, whom
I had just met the day before. Her LMP was unknown (but I felt she was
around 35-37 weeks) and her hemoglobin was 10. Regardless of the lack
of prenatal care, she seemed to be essentially strong and healthy with
the exception of the hemo status. Her labour went smoothly, with her blood
pressure hovering steadily around 126/86. She kept well hydrated. After
a lovely and witchy 1 1/2 hour second stage and a lovely 3,600 g. male
baby, she started to bleed like an open faucet. Blood, blood and more
blood, about 700-800 cc worth! I had never encountered this and let's
face it, as gutsy, smart, caring and committed that I might be, I was
also new at this. My brain said, Just stop this blood, whatever it takes.
I gave her 10 units of Pitocin, shepherd's purse compound tincture, Sabina
200c, and two minutes later Cinchona 200c. Noemi's bleeding stopped after
2-3 minutes. I want to be clear that after the birth, I did just as I've
read: be watchful but do not meddle with the uterus! So after births I
usually settle into checking for a happy baby, a stable mom and that perineum!
So I don't think I "mismanaged" this third stage at all. But in response
to what the hospital people said to Ms. Jones, the midwife in the Philippines
[Issue 2:49]: WHAT ELSE ARE WE TO DO BUT STOP THE BLEEDING? if we have
to use oxytocics while the placenta is still in there, so be it. Well,
Noemi's uterus didn't seem to want to give up the placenta, even with
gentle but firm and guarded uterus traction, standing up, squatting, acupuncture,
caullophylum, labour tincture, the works. I didn't feel fully comfortable
going into her uterus and removing the placenta. So after about one hour
and 40 minutes of waiting with a stable mom, I made the painful choice
to transport (from a mountain top) to an uncertain, potentially abusive
hospital, only for Noemi to report to me that the placenta all about came
out on the examining table without much fuss. After this experience, I
give Sabina and Cinchona 200c BEFORE any signs of excessive bleeding and
I am still very ready to give oxytocin when needed. Now, however, I help
the again-stable mom to squat on a basin as soon as it is OK. I know Varney
recommends massaging the uterus and helping the placenta become fully
detached in case of THIRD STAGE HEMORRHAGE only. But for some reason,
I am not comfortable doing that--there is something about it that bothers
me. I think I would only use it if after all my tricks and drugs, the
mom continued to bleed. A few days later I was presented with a mild ("teaser")
version third stage hemorrhage, after a 1 1/2 hour active labour and a
2 1/2 second stage, and it also was quickly stopped. The healthy placenta
came nicely and smoothly after 20 minutes, while Jaqueline, a 17 year
old single mom, squatted over a bucket.
- Ana Montero, CH.
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Religion, Justice and Health Care: The Many Connections
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January 19-21
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What is caring? What actions might move us toward a more just health
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Midwifery Today's Online Forum
Q: I have been appointed for a c-section;
my daughter was born with a c-section, but what makes me wonder is that
the doctor says I should have it 4 weeks before my due date. Is it a normal
practice to do that? My first child was born in Bulgaria, the second one
I'll be having in Saudi Arabia, and they seem to have a different method
in these things. Please, I need advice.
To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week
Q: I was very ill with Grave's Disease (hyperthyroidism)
after my third pregnancy, took an anti-thyroid drug for a year, and have
been in remission ever since. I had three wonderful homebirths, but wonder
if for future pregnancies I would need to be monitored by a doctor and
if I am likely to have thyroid trouble during the pregnancy.
- PHE
Send your responses to:
Coming E-News Themes
1. An E-News reader submitted the following description of her concern
for hospital-birthing women. Please share your thoughts on this issue,
and let's get some problem-solving dialogue going:
I AM A MIDWIFE WHO ATTENDS TO THE NEEDS OF WOMEN BIRTHING IN THE HOSPITAL.
I would find it useful and interesting to include "ways to inspire
confidence and a sense of the inherent power and brilliance" of women
into the Midwifery Today conference section on women who care for women
in the hospital. I work hard at this endeavor every day.... I fully support
homebirth and would love to see a movement to take normal birth out of the hospital and into the home. [But] there are women who don't have a
home suitable for homebirth.... I hope there will always be midwives willing
to attend these women in the hospital.... There is a strong need to remind
midwives why they are midwives and ways to bring those midwives back to
the fold. Comments?
- Zora
2. ASYNCLITISM: What do you do when the baby's head is not deeply engaged
in the pelvis, but is tilted up toward the pubic bone or tilted toward
the mother's sacrum?
Send your responses to:
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
QUESTION OF THE QUARTER for Midwifery Today magazine
Mamatoto: Motherbaby
How can midwives best facilitate the bonding process of motherbaby in pregnancy, birth and postpartum?
Deadline: March 31, 2001
Send your response to:
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Switchboard
I recently attended a homebirth where the baby was born with "lesions"
on the forehead, lower occiput and a small area under the scrotum. The
head lesions were large and, although not clearly fluid filled, a greenish
brown color. They were only slightly raised but circular and clustered.
They also seemed to be spreading out from a central area. Mom had no history
of herpes and RPR [rapid plasma reagin] was non-reactive. She declined
a GBS screen; membranes were ruptured for only 30 minutes. No active vaginal
infection was known. Baby seemed fine otherwise. We referred that day
to the local teaching hospital to be on the safe side. CBC [complete blood
count] did show an elevated white blood count. Antibiotics IV, lumbar
puncture, all bacterial and viral cultures came back negative. Baby was
released on day six. There was no known cause. The lesions were gone by
day four. Has anyone ever seen a baby born with lesions not caused by
herpes or syphilis? Was a cause ever found?
- Florida LM
====
Are there any goodly midwives in Ulaanbataar, Mongolia, and/or near that
area of the world?
- Angelina
Reply to: ioscofamily@juno.com
====
What are the dangers of a short second stage? I have pushed out three
of my babies in one contraction--one or two pushes. With my last birth,
the midwife "made me" stop pushing during that one titanic contraction,
and I proceeded to have about an hour of very piddly contractions, with
correspondingly piddly pushes. I was finally told to push hard during
the next few contractions, even if I didn't feel like it. Baby was finally
born, with the cord twice around her neck and then under her arm. The
midwife said it was a good thing that I had pushed more slowly this time
as there could have been problems if I had pushed her out in one contraction,
due to the cord entanglement. What could she have meant?
- Paula
====
I had toxemia with my first pregnancy which manifested in an eclamptic
seizure during labor. I was transferred to the hospital where my daughter
was born two hours later. I was given a magnesium sulfate IV before my
daughter was born which caused both of us to be very lethargic for a couple
of days. We didn't start nursing until she was two days old. I am now
23 weeks with my second baby and doing OK: blood pressure is low, no protein
in urine, steady weight gain, and baby is growing and moving right on
track.
My questions are: What experiences do you have with toxemia in consecutive
pregnancies? How have you controlled it? Are there less aggressive but
equally effective alternatives to magnesium sulfate? Are hospital midwives
allowed to deal with high risk pregnancies? I desperately want a homebirth
for many reasons.
- Leslie
Editor's note: Check out the web site mentioned in the letter below.
The Brewer method-so simple!-is highly recommended by Midwifery Today.
I recommend to the woman who wanted information on management of third
stage that she go to the WHO web site and check out their recommendations.
It includes a good deal of research.
To the woman who wanted information on preventing gestational diabetes,
I recommend that she check out the Brewer method taught in Bradley classes.
I credit not having GD a second time to a high protein, well balanced
diet, NOT weight control. Superior diet is the key! The funny part is
that I gained the same amount of weight both times, yet my second son
was 1 lb. 10 oz. larger than his brother (with whom I had gestational
diabetes)! You can find Brewer's web page at Blue Ribbon Baby, and purchase
a copy of his book.
www.kalico.net/blueribbonbaby/
====
I had a client who I recently had to transport due to an ineffective
labor. It was her second pregnancy and she would have been a VBAC. They
told her her first c-sec had been slightly turned up on one end, making
it a crooked smiley face instead of a true smiley face--so they had to
make this incision with a hook sort of like a J. They had to go beyond
the original incision and make more of a vertical, therefore she would
not be able to ever have a vaginal birth. We are not sure how to take
this. She is determined to try it again. I am researching this and would like any input. What experience have other midwives had with vertical
incisions and vaginal births thereafter?
- Dixie
====
Do any midwives out there have protocols for women who previously ruptured
their membranes preterm for no apparent reason? We have a client who ruptured
at 35 weeks, then in the next pregnancy at 34 weeks for no apparent reason.
She is an obstetrician's wife, and had very thorough prenatal care. I
remember a midwife telling me long ago that she would have her women who
smoked (who tended to have thin amniotic bags that ruptured easily) take
alfalfa because they would grow a bag that was very thick and strong.
Any truth to this? Does anyone have any documentation of this or any other
helpful tricks?
- K.G.
====
Re the woman in the Philippines with the client who has low blood pressure
{Issue 2:49]: Hormonal changes and increased blood volume during pregnancy
cause a normal increase in interstitial tissue fluids which causes swelling/edema
and distended blood vessels. With the increased cardiac output to about
33%, the side-lying position and sitting position are the best position
where cardiac output is greatest and to prevent compression of the inferior
vena cava by the uterus when in supine position (lying on the back).
Balanced workload of the heart:
The blood is less viscous during pregnancy because of the effect of prostaglandin.
Low platelet count is an ominous sign of hemorrhage. I would increase
the intake of the following: albumin, fibrin and calcium salts. The following
foods are common in the Philippines: lemon/kalamansi, greens/veggies,
cabbage, mung beans, onions, nuts, egg yolk and goat's milk. Potassium
and sodium are also important minerals. I would manage birth with less
fiddling and be very alert during the third stage of labor. The following
articles can provide more insight about the pregnant body and bleeding
after birth. Her low blood pressure might be her normal reading.
Well Expanded Blood Volume:
Estrogen also makes the blood vessels more permeable and more dilated.
The low pressure in the maternal circulation in the placenta and reduced
pressure in the peripheral vessels of the mother also compensates for
the increased workload of the heart during pregnancy.
Maternal Circulation in the Placenta:
An average of 120 spiral arteries provides an entrance of oxygenated blood
with equal number of venous openings (carries unoxygenated blood). The
blood pressure or blood flow in the placenta is slow enough to allow for
the exchange of materials between the fetal and maternal circulations
across the placental membrane.
Regulated Heart Beat:
The heart beats faster but the reduced pressure in the peripheral blood
vessels compensates for this change. The reduced uterine pressure present
in the placental vessels regulates the pressure and blood exchange.
What To Watch For:
The presence of ineffective circulation, stress, poor diet and other heart
related problems can increase the workload of the heart.
Fear not, in most well-managed births (esp. births at home with skilled
midwives) with healthy mothers, the placenta detaches wholly by itself,
the uterus contracts and retracts by itself and uterine tone reacts to
birth normally unless outside factors exist such as drugs or other interventions
in the rhythm of births. Postpartum hemorrhage or excessive bleeding--bleeding
of more than a cup of blood after birth--can be prevented. Check for early
signs such as constant flow of fresh blood, mother's alertness at first
and then fainting next.
Remove the number one cause: mismanagement or mishandling by the doctor:
Fiddling with the placenta, resulting in incomplete detachment, and just
being in a hurry and not waiting for signs of placental detachment before
starting to assist placental delivery.
Use of labor inducing drugs (Pitocin, oxytocin) which hyperstimulates
the uterus making it atonic (without normal tone/rhythm)
Blood disorders: Early prenatal blood tests would reveal high white blood
count and low platelet count.
Aspirin affects the early stages of blood clotting process.
Nutrition: Increase intake of calcium, iron and vitamin K-rich food such
as nettle and alfalfa (especially during the last trimester).
During labor and birth, the following are indicators of placental separation:
cord lengthening, change of size, shape and placement of uterus.
The placenta normally (90% of the cases) detaches by itself within 5-15
minutes after the baby is born.
Boggy uterus is not a good sign; it may indicate placenta is filling up
with blood or mom did not expel all her urine.
Ways of stopping the bleeding/contract the uterine walls (by nature uterine
muscles are living ligatures which contract and retract by themselves
as soon as baby and placenta are delivered): make sure mother urinates,
Pitocin injection, nipple stimulation, hearing the baby cry, black and
blue cohosh, and shepherd's purse tinctures.
Other preventive remedies: For all mothers, especially those who have
more than four children, exercise the abdominal and uterine muscles. Before
active labor comes, get rest. Find ways to shorten a long labor: nutrition
(fish), walking, water exercise, nipple stimulation, sex (bag of water
is not broken)
The hospital doctor or homebirth midwife final control measures:
As soon as all the placental tissues are out, manually compress the uterus.
Use manual removal to remove placental remains.
During transport, position mother to the left side, legs elevated and
assess mother's consciousness.
- Connie, Filipina/author, apprentice midwife
San Jose, CA
====
I so much enjoyed your issue on compound presentation [Issue 2:49]. My
second son was born with a nuchal hand. Exactly as described, I had no
urge to push which puzzled everyone, and pushing was the only painful
part of a near pain-free delivery. When my son emerged with his hand,
palm up, pressed to his forehead, my midwife exclaimed, "Look! He's
saying 'shalom' to all of us!" (this was in Israel).
Re: c-sec for a nuchal arm: At least one hospital in Jerusalem had a policy
of c-sec for babies diagnosed with a nuchal hand over the head. When I
asked about it, I was told there was fear of the arm causing the baby
to become impacted during delivery. Many of the midwives I spoke to at
the time felt it to be dubious, but that was the reasoning. Does anyone
else have experience with this?
- C.W.
====
I have read somewhere that to wait for a second twin to be born (hours
or even days) does not affect the baby's morbidity or mortality outcome.
Do you know where I could quickly find such information?
- Kusum
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