Transporting to the Hospital
Out-of-hospital birth has been shown scientifically to be safe when attended
by midwives who, when necessary, can be in close contact with a hospital capable
of emergency cesarean section. This is why homebirth and freestanding birth centers
have been proven safe in those places in the United States with good communication
and respect between home and hospital. The midwife can telephone the hospital
and describe the emergency, and while the woman is in transport, the hospital
staff is preparing, scrubbing in, etc.
How long does it take to do a cesarean section if the labor is in a tertiary
care hospital in the United States? While the American College of Obstetricians
and Gynecologists (ACOG) has recommended in the past that the "decision to
incision" time be no more than 30 minutes, in one study at a university hospital
in the United States (1), 52% of the emergency cesarean sections for fetal distress
had a decision to incision time which exceeded 30 minutes.
One reason for this delay is that in the United States it is not the laboring
woman who is in transport, it is the absent doctor who is in transport, the doctor
who has been trying to monitor the labor in the hospital by telephone. The ACOG
recommendation "to have a physician immediately available" is in reality
a criticism of the U.S. system in which the laboring woman's doctor is usually
not available and must be called to come in.
The elegant solution is not to take away valid choices for childbirth from the
woman and her family but to change the system. Rather than insisting that the
woman having a vaginal birth after cesarean (VBAC) be transported at the beginning
of labor to a big hospital that is away from her primary caregiver, her family,
her friends and familiar community, instead do what is done in the other highly
industrialized countries with maternal and perinatal mortality rates lower than
ours: Develop a system in the United States in which there is close communication
during childbirth between primary care in the community--home, birth center, small
hospital--and the big hospital, so that when the woman in labor needs to be transported,
the decision to incision time is no greater than if the same woman were laboring
in the big hospital and needed to be transported from the delivery suite to the
surgical suite for a cesarean section.
- Marsden Wagner, MD, excerpted from "What Every Midwife Should Know
About ACOG and VBAC: Critique of ACOG Practice Bulletin #5, July 1999, 'Vaginal
Birth After Previous Cesarean Section'."
Click here to
read this informative article in its entirety
In Mexico and other countries, the United Nations has just discontinued funding
for traditional birth attendant (TBA) training courses. Because maternal mortality
rates have not dropped after 20 years of TBA training, the conclusion is that
the courses do not work. This conclusion is based on the assumption that mothers
die because midwives give them inadequate care or fail to transport them in cases
of need. But as we have just seen, sometimes it is the hospital that gives inadequate
care. And often women in need are simply unable to reach the hospital. I remember
well when Dona Nieves, a very short and very experienced traditional midwife from
rural Oaxaca, Mexico, bravely stood up in the big auditorium in Mexico City in
the middle of the Safe Motherhood Conference and said to all assembled:
"Do not blame us for failing to transport women. We know when we should
transport. But none of us own cars, nor do our clients, the buses run very irregularly,
there is no ambulance service and if there were our clients couldn't pay for it,
and the only taxi driver in our town charges far more than our women can pay.
How then do you expect us to get our clients to the hospital in the city an hour
away? No, we can't, we just have to do the best we can with no help from anyone.
If you want me to transport women who need to go to the hospital, give me a car!"
- Robbie Davis-Floyd, excerpted from "Anthropological Perspectives
on Global Issues in Midwifery."
Click here to read this fascinating article
If a transport during labor, birth or postpartum should become necessary, how
will you remove the mother from her home? Note the location of stairways, doors,
90-degree angles, narrow halls and passageways, etc. Make a mental note of your
best route of exit. Some midwives insist that the mother give birth on a first
floor to avoid difficult or impossible transports in the event that the mother
cannot walk to the transport vehicle herself. Be sure that the partner or some
other person who is sure to be present knows the route to the nearest hospital
and to the hospital of choice (if these are not the same). Have them drive the
routes to make sure they are aware of how to get there from her home. Don't assume
you know the best routes from a multitude of different locations unless your community
is quite small. In addition, maps and directions should be posted by the phone
in case the person who knows the route cannot be there to help. Another alternative
is to have copies of the hospital directions in the chart as well.
- Anne Frye, Holistic Midwifery Vol. 1, Care During Pregnancy, Portland,
OR, Labrys Press.
VOL. 1 is available from Midwifery Today's online storefront.
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Question of the Week
I'm 20 weeks pregnant (first time) and am seeing a CNM. At our first ultrasound
the baby measured great but they told us we are on the low end of normal for amniotic
fluid (an 8). Is there anything I can do to increase my amniotic fluid? Is this
number particularly low? What are the possible chromosomal effects of having low
- Melinda Collins
Send your responses to:
Question of the Week Responses
Q: I have a lady who really wants a homebirth. It
is her first birth and she has multiple sclerosis but is in remission, not taking
any drugs, and is symptom-free. Do you know any reason why she should not have
a homebirth? Have any of you had any experience with MS and birth? From my textbooks,
it seems to me to be OK. She is due in three weeks and the pregnancy is fine.
- Ilana Shemesh
A: I was blessed to be able to attend my cousin's wife when she had her
sixth baby at home. She had been diagnosed with MS five years previous and was
advised to stop having children. During her pregnancy, all her symptoms of MS
diminished and have been slow to return since. It has been five years. I didn't
see any reason prenatally for her to not have a homebirth. Her birth was beautiful
with no complications. I would be interested in hearing if others have run into
problems with a client with this diagnosis.
I should also add that she was very aware of good nutrition and had eliminated
most sugars and other unnatural foods from her diet. I do think this was an influence
on her outcome and her reduced symptoms.
- Mary Holbrook, traditional midwife
A: I have had a client for several pregnancies who had quite severe MS.
I attended her homebirths. She was able to be symptom-free during her pregnancies,
during which I worked with her by having her drink fresh goat's milk every day.
At one time she was nearly blind and immobile but after drinking goat's milk for
a period of time, she improved so dramatically that her pregnancies and births
went very smoothly.
- Merilynne Rush
A: Pregnancy usually will cause an autoimmune disease to go into remission.
She should be fine through delivery. But beware that after delivery she will probably
go through a severe exacerbation of the MS in the next few weeks.
A: I have served several women with MS, and it never gave any problems
during labor or birth. The first time--mainly because of MY worries--we opted
for a midwife-conducted hospital birth. Ever since, if the condition is as you
describe it, we've gone for a homebirth. The MS in itself has never caused problems,
but I do tend to be more patient if the pushing is a bit slow. So long as mother
and baby are doing well, there is all the time in the world. This goes for every
birth of course, but with a MS-lady the muscles tend to be more lax. Then again,
this may also relax the pelvic floor muscles, thus allowing for a quicker second
stage and fewer tears.
- Annemieke van der Peet
A: I'm an experienced CNM and have had several clients with MS over the
years. Both were mild and in remission or I would have felt that medically the
patient should have been with an OB. I made sure they saw their neurologist once
in the pregnancy for a follow-up. MS can definitely worsen during pregnancy, perhaps
because of the major changes in the immune system function then. Both of my patients
were fine and had no flare-ups. It's important to know that, should this patient
need transfer for a cesarean, she should not have spinal anesthesia (epidural
is OK). Hopefully she won't need to transfer, and if so, hopefully a cesarean
wouldn't be needed. Also, the first six months postpartum is a time for increased
flare-ups of the disease, so your patient shouldn't ignore or dismiss any neurological
symptoms that occur, and chalk them up to being postpartum.
A: I have MS and have birthed two children--the first by c-section because
I had an active herpes lesion when I went into labor and the second a home VBAC
at 40 years old, having had MS for 7 years. YES your friend can birth at home.
If I could get through a c/sec and a home VBAC, she can homebirth.
Be aware of her keeping her energy up. That is the biggest thing with people
with MS. Keep her rested in early labor, deep breathing to her comfort level only
in all labor and birth (oxygen is very important in MS); see if she can nap during
labor or at least relax with a massage or other therapeutic touch. Get her started
on phosphatidyl choline, evening primrose oil, and fish oil (NOT cod liver oil)
as soon as possible for the omega 3s she needs. Laughter and happiness and enjoyment
are true MS medicines. Keep her spirits up during labor and birth--even read jokes
to her! Other than all that, her body will function like anyone else's. Empower
her with that belief. And don't worry--it's contagious. If she is in remission
and is relatively symptom-free, as I have been, she will be just fine.
In response to foregoing comments: It is in fact quite commonly known that pregnancy
brings much-improved health to the woman with MS. Symptoms are very often much
reduced. Breastfeeding caused that state of well-being to continue for me, so
you might advise your friend to keep it up for a nice long time! Postpartum may
be difficult because women with MS commonly experience exhaustion anyway, and
after a baby is born she can be very dangerously exhausted. Arrange for her to
get lots and lots of support from friends and family, professional postpartum
doulas, etc. for several weeks after the birth. That will also help her avoid
breast infections. But there is no reason to expect a serious exacerbation postpartum,
especially if she gets plenty of rest and help.
The goat's milk connection is mystifying but I have read that people with MS
seem to respond well to placebos!
In Midwifery Today Issue No. 52 I reviewed a fine little book called Multiple
Sclerosis and Having a Baby, by Judy Graham, Healing Arts Press, 1999. I rated
it an A-plus for having been written by a woman with MS and for being honest,
informative, sympathetic, empathetic, supportive, and down-to-earth.
- Cher Mikkola, E-News editor
Click here to learn
more or to order Issue 52
Q: I am 22 weeks pregnant with my third child and
was just diagnosed with a pregnancy hernia. My baby is growing normally. I have
few complaints except for the hernia pain and backache. I am looking for information
about birthing naturally with a hernia. I gave birth naturally both previous times
and intend to do the same this time.
- Christine Staricka
A: Most women have an umbilical hernia near the belly button. You didn't
mention your type. The hernia is a hole in the fascia, which is a layer of tissue
lying over the abdominal muscle. This layer can't be repaired by any method except
surgery. The pain is caused by the bulging of abdominal contents against the hole,
or even through it, producing a lump. Once your uterus grows another month or
so it will lie against that area and cover it up, so you will probably have much
less trouble until after delivery. If your hernia is inguinal (groin) it will
not change much during the rest of your pregnancy.
The real risk with a hernia is if a loop of intestinal tissue gets caught in
the hernia, even for a period of hours. It can lose blood supply, causing "strangulation"
of that part of the bowel, which is life-threatening. If you ever have severe
or persistent pain in the hernia, or the lump won't recede when you lie down,
or you have pain with nausea and vomiting, etc., go to the emergency room! If
you need surgical repair of your hernia, it's a pretty short, simple outpatient
procedure. I've even had several patients need repair during pregnancy and all
went well with mom and baby.
- A CNM
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Critical issues in pregnancy and neonatal care with current interventions for
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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!
A traditional midwife in Queensland, Australia is undergoing investigation for
practicing in homebirth. Her record over a 20-year period is impeccable. The Queensland
Nursing Council states that she is possibly breaching the Nursing Act (1992) by
1. taken action that is capable of being understood to indicate, or is calculated
to lead persons to believe, that Ms Brassard is a midwife
2. practiced as a nurse
3. performed nursing services and/or
4. practised as a midwife.
There has been no complaint from any of her clients.
Her home was left in disarray and over 30 files were taken even though the warrant
was for one particular file (the family are currently filing suit against other
Ms Brassard's contribution to the birthing community is valued & wanted. She
is also a naturopath & craniosacral therapist.
If anyone feels to, could they assist in writing to the QNC, Mr Jim O'Dempsey,
Executive Officer, GPO Box 2928, Brisbane Q 4001 Australia.
Ms Brassard has a large practice which the QNC do not want to see continue operating.
Thank you for any support given.
I'm a student midwife and from reflection during my placement I am beginning
to question if the protocols implemented in practice take into consideration the
women's choice and are they restricting the midwife's autonomy?
- Rachel J Howells
For the couple with the breech baby [Issue
3:31], if you are very concerned about genetic defects, an ultrasound might
give some reassurance or clearer information about your baby, although many birth
defects are not visible on ultrasound and it shouldn't be seen as a definitive
answer. The cerebral palsy (CP) rate might be related to labor or birth in the
breech position, and although most cases of CP don't occur from the birth process,
the vaginal birth of a breech baby is risky enough that you would be wise to consider
not delivering vaginally. The main thing is, your baby is not rare, being breech.
Five of 100 babies are breech at term and most of them are perfectly healthy and
just happen to be breech with no associated abnormalities.
Henci Goer wrote a great article about the study about vaginal birth after cesarean
(VBAC) reported in the New England Journal of Medicine. You can find it at: Is
vaginal birth after cesarean risky?
- Chrys Holland, D, CBE, MT
More on herpes:
In addition to increased vitamin C and lysine, I have found a stress B complex
(Twin Labs has a great one with 1000 mg vit C added) very effective for stopping
an outbreak altogether when administered immediately upon recognition. The body
is stressed--treat the stress, not the symptom. It has worked so effectively,
I have used it for four years.
- Kelli J, CPM
I'm a stay-at-home mom who gave birth with midwives in a free-standing birthing
center (much to my family's chagrin).
My stepmother recently made a comment that made my eyes bulge. My sister-in-law
just gave birth after a difficult labor that almost resulted in a c-section (baby's
heart rate lowered with each contraction). The cord was entirely wrapped around
the baby. My stepmother said, "The baby would have died if it was a homebirth."
This comment was most likely directed at me and my beliefs, which I can't discuss
with my family, who all favor modern medicine and are anti-home birth.
I explained that it makes sense that midwives are more cautious than doctors
because they have more at risk. There's a big difference between the repercussions
that a doctor experiences after losing a baby's life in the hospital than those
experienced by a midwife losing a baby's life at home or in a center. I told her
that midwives will transfer laboring mothers to the hospital at the first sign
of trouble. She disagreed saying that a midwife would never be responsible enough
to move a patient to the hospital.
This all makes my blood boil but I don't have the technical knowledge to argue
it. Are there any midwifery "rules" that might help me to explain midwifery
to my family?
- Lauren McGinley
Per my husband, a United Airlines pilot, and the ALPA Air Safety Dangerous Goods
Coordinator: Radiation exposure is measured in Sieverts. There are 1,000 millisieverts
(mSv) in one Sievert. The typical exposure to persons on the ground from terrestrial
radiation falls in the range of 1-3 mSv per year. For reference, a typical chest
x-ray represents an effective dose of about 0.1 mSv. Therefore, a person who does
not fly is exposed to anywhere between 10-30 chest x-rays per year.
According to an article in Aviation, Space and Environmental Medicine, the total
recommended maximum dose for an entire pregnancy is 2 mSv. A few long flights
during pregnancy does not significantly increase the amount of radiation exposure
one experiences in a year. For example, the calculated cosmic radiation level
in June 2000 for a flight between Los Angeles, CA and Melbourne, Australia was
Cosmic radiation exposure during flight is mostly a concern of flight crews
who log 60 hours a month on polar routes and who reach an average of 3.04 mSv
per year for 700 block hours of polar flight time. These individuals often overstep
the radiation limits set for pregnancy and so many airlines, like British Airways,
ground their pregnant flight crew members. United Airlines suggests avoidance
of polar routes and a reduction of flight time for pregnant women.
If you would like to estimate your amount of exposure on flights, there is a
software program available for public use through the Federal Aviation Administration
called CARI-5E at http://www.cami.jccbi.gov/research/610/600radio.html
It is for flight crews, so it may require the input of some information that is
not readily available. I would expect that you would need an estimate of flight
time and a rough idea of the route your flight took.
- Charity M. Pitcher-Cooper
"Frequently Asked Questions about Cosmic Radiation" (Oct. 2000) a joint
publication of United Airlines Flight Operations, Onboard Service and Medical
Geeze, D.S. "Pregnancy and In-flight Cosmic Radiation" (1998) Aviation
Space and Environmental Medicine.
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