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Have you heard of a link between use of Pitocin during labor and subsequent
problems with milk supply? I am investigating several mitigating factors
that resulted in my inability to nurse my first child. Someone has mentioned
to me a possible link between Pitocin use and diminished milk supply.
My labor was not augmented with Pitocin, but I did receive a shot of the
drug after delivering the placenta, in order to bring bleeding under control.
Could either the shot itself have contributed to my problem with supply,
or could my need for the shot indicate an oxytocin deficiency?
- Theda
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Question of the Week Responses
Q: I have recently been supervising a German
midwife in Manitoba who uses xylocaine 2% jelly to numb the perineum prior
to repairing perineal tears. Is there anything in the literature to back
this practice up? I certainly was impressed at the benefit that it provides
of not distorting the tissue as does injectable xylocaine and the mom
feels no pain. However when I checked it out in our Pharmaceutical Reference
book, it instructs us to not apply over broken skin, etc. Do any of you
use this jelly? Have there been any negative outcomes? allergic reactions?
How much should be applied to the perineum?
- Gisele Fontaine, CPM
A: After the birth of my daughter I had tearing that for various
reasons could not be repaired until months after the birth and did not
heal in that time. In the interim, the surgeon prescribed xylocaine 2%
to help with the pain. I wore reusable gloves and applied only the smallest
of smears to each of the open tears. If I used too much xylocaine I would
immediately become slightly dizzy. Once I learned how very little was
required I was able to use it successfully to eliminate some of the pain
as I awaited surgery.
- Mary-Tim Hare
Rockwood, Ontario
A: I am an Israeli midwife who had to go to Finland for a month
to learn to suture because midwives in Israel are not allowed or taught
to suture. Since I do homebirths, it was necessary for me to learn this
skill. The midwives there at the hospital used a xylocaine spray on all
labial tears and before injecting the xylocaine in the perineum for suturing.
It seemed to work well enough for the superficial labial tears that needed
suturing, and perhaps eased the pain of the needle injection. I don't
remember what percent was used.
- Ilana Shemesh
A: I don't know about doing it postpartum, but the nurse midwife
who delivered my children (and her physician partner) uses this gel periodically
while doing perineal massage when there is time. With my first child I
could push but did not feel the burning sensations as strongly as I did
the second time when my child came out in 10 pushes or so. She still needed
to inject xylocaine to repair tears for my first birth. The gel was not
sufficient for me.
- Sarah, RN, monitrice
KY
A: I had my second child at home and due to a bad episiotomy during
my first birth, I had a very serious 4th-degree tear that required some
major surgery after the second birth. The doctors used xylocaine jelly
to numb my very torn perineum while they rubbed off some of the dead tissue.
I had no negative outcome or allergic reaction. They used about the same
amount of jelly as you would use toothpaste on a toothbrush for lack of
a better measurement! I healed better and sooner from the major surgery
than I did from the episiotomy. Keep in mind that these were doctors who
had no interest in anything natural and were not impressed at my homebirth.
When I asked if the same thing would happen with my next birth, their
answer was "oh, just have a c-section! That will solve your problem!"
I did go on to have another beautiful homebirth with just a small 1st-degree
tear.
- Anon.
A: I have not had success using it for repairs, but I have used
it to help to decrease the sense of burning of the perineum. It was especially
useful for a patient with hemorrhoid pain that did not want to push. Putting
the gel on her rectum greatly enhanced her ability to push.
- Susan
A: We have been using a spray lidocaine (similar to that used
in dental offices) for repairs and have found that it works exceedingly
well for most women. It has clear advantages: it causes no additional
swelling of the perineum, it is easily applied (usually without having
to touch the tissues excessively) and it works very quickly. For most
tears, it provides excellent numbing action. I have not seen any negative
reactions to it, but we always double check to be sure that the woman
isn't allergic to any anesthetic (often they have had experience with
the spray at their dentists.) Because it is applied topically it can cause
a sensation of coldness or stinging, but that quickly subsides. We do
carry additional injectible anesthetic, but we haven't needed to use it.
I would think that topical jellies could be used in a similar fashion:
I would be more concerned about allergies to the base of the product rather
than the actual xylocaine. Obviously checking with the client about past
history of anesthetic usage is crucial in any case. A clear disadvantage
would be having to physically touch all of the damaged tissues to apply
it thoroughly.
- Christina Oertel, DEM, CLC
Q:Does anyone know the story on short umbilical
cords? And how short is too short to deliver vaginally? Is it genetic,
does it run in families, is it likely to occur more than once, is it nutrition-related,
is it avoidable? I've known two ladies to have very short cords and they
are afraid to attempt a vaginal delivery again.
- Amy Jones
Henderson, NV
A: I would also like to know the answer to this question. I recently
had a cord snap at birth in a pool. It measured 31 cm (about 12 inches)
from navel to placenta. The literature suggests 50 cm as an average length.
This still seems very short. I have now started measuring those that are
especially long or short. The longest so far is 100cm (about 3 foot 5
inches).
The one that snapped appeared to go into "spasm" and blood
loss was minimal. Apparently, 30 ml loss to a baby is the equivalent of
a 600 ml postpartum hemorrhage in an adult. This particular baby was clinically
well, feeding and we were some miles from the nearest "baby unit"
with paediatricians available. We observed the baby closely, and the following
day sent capillary blood samples in for various tests. All were within
the realms of normality. Mother and baby continued to do well.
This particular woman was a mature multip who did not appear to be "unhealthy"
or nutritionally deficient in any way. She was a well-educated woman,
and neither of her previous two babies had had short cords.
- Lynn G Walcott, RM
A: My midwifery partner has had two children: the first with a
very short cord (complicated by several wraps around his neck) who ultimately
was born by c-section. Her second child had an extremely long cord which
was wrapped around the baby's shoulder, neck, abdomen and leg and who
was a VBAC at home without problems. She had severe morning sickness with
both pregnancies and ate whatever would stay down, often in very odd combinations
or quantities. She focused on protein with the second pregnancy, having
read somewhere that it would help make a longer cord.
As far as too short for a vaginal delivery, it depends on all of the
variables involved with each mom and baby. I don't know that there is
a way to predict whether or not it's "too short" until they
are in labor. Over time I think you'd expect to see a huge variety in
both the length of cords and what works in birth.
What was the situation with the two ladies you know? Was the problem with
descent or with birth? Did they deliver vaginally? Were the babies okay
or did they need help getting started? Each woman needs to be evaluated
for where she's at. I don't think that there is an easy answer, but the
possibility of having a short cord shouldn't be the only criteria for
avoiding a vaginal birth.
- Christina Oertel, DEM, CLC
A: I recently cared for a primip woman in labour who had a really
straightforward quick first stage of labour. In the second stage of labour
she pushed involuntarily for over two hours, with the head almost crowning
for at least an hour and a half. Eventually the baby was born with the
cord so short that the baby could not be placed farther up then the symphysis-pubis.
(She wanted a physiological third stage). The placenta did not want to
appear either, and after an hour we opted for active management and it
delivered with no problem. I can only think that the pressure applied
on the placenta by the short cord during the birth of the baby disturbed
the normal physiological process of placental separation. There were no
signs of distress from the baby during the second stage by intermittent
auscultation, and she scored well at birth. However, I also think if there
had been restrictions on the length of second stage and she had ended
up with an instrumental delivery, then the short cord would have been
cited as an abnormality. As it was she had a normal birth, albeit a bit
longer than usual. Are we making a fuss about something that is not abnormal?
- Pauline McGill
A: I just doula-ed for a couple with twins and one died at 39+
weeks. Doctor's initial comment was that baby had a very short cord--approx.
5 inches. Don't know the details or have the pathology or ME findings
yet, but he indicated that the short cord was a symptom of underlying
difficulties. If I remember my education correctly, cords are supposed
to be between 10 and 22 inches. I'll be glad to hear what others know.
- Debbie
Iowa
A: I am interested in hearing how a definitive diagnosis of "short
cord" can be made prior to the actual delivery. Though I am aware
that short cords do indeed cause legitimate problems, I have never attended
a delivery where a short cord prevented vaginal delivery. Most interesting
to me is the statement at the end of the question--that two mothers are
afraid to attempt vaginal deliveries for fear of repeat short cords? The
only alternative to vaginal delivery that I am aware of is cesarean section.
I sincerely hope that no one would advocate a c-section for this purpose.
- Kim Ray, L.M.
QUESTION OF THE QUARTER for Midwifery Today magazine
Issue No. 58
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 editorial@midwiferytoday.com
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====
In response to the question about blood types [Issue 3:9]:
I am O+ and my husband A+. Both our children are B+ and experienced jaundice
before or around 24 hours after birth. My first child was born in the
hospital and had a level of 13 around 12 hours. She was immediately put
under phototherapy lights in the nursery. After two days I was allowed
to take her home and continue phototherapy with a biliblanket. My son
was born at home and was taken to the pediatrician after 48 hours. The
doctor also recommended phototherapy and wanted to hospitalize him. Fortunately,
we were able to keep him home with the home unit.
For both births the cord was not cut until it had stopped pulsing. With
the second birth, my midwife recommended alfalfa a few weeks before birth.
After birth she gave me a liver cleanser. Could any of these procedures/herbs
have helped or hindered cleansing of the bilirubin from the blood? I would like another child in the future, but the ABO incompatibility jaundice
and a possible blood transfusion is a scary thought. What are the accepted
levels at different times? Are there any more alternative therapies? (Both
children were born in November when there is not an abundance of sunlight
to put them in.)
- Claudine (jscl@mindspring.com)
====
I also have O+ blood with my husband being A-. Of my 7 children only
one has experienced problems with severe jaundice related to and diagnosed
as direct ABO incompatibility. As it was explained to me by our pediatrician
the key to reducing the severity of the jaundice is to produce milk as
quickly as you can. We know that breastmilk helps break down the bilirubin.
I also used phototherapy. This child did have to have regular blood tests
for the first six weeks of her life. Although there is a possibility of
other children having this condition it is not likely as the condition
is very rare. Subsequent children tested for this incompatibility have
not had this problem. I am expecting my eighth and I am not worried. My
advice to you is to do the appropriate tests when your babe is born. Then
embark on an aggressive milk production program which may require extra
stimulation as these babes tend to be sleepy. Take alfalfa capsules now
and continue this for at least six weeks postpartum. Chances are everything
will be fine!!
- Anon.
====
The pharmacy department at the hospital where I work contacted the manufacturers
of prostaglandin gel who stated that prostaglandin gel is not derived
from pig semen. [This was in response to the query in E-News in Issue
3:9.]
- Christine Holliday, midwife
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