Omnium Gatherum: Readers respond to past issues
Re: A reader's comment that cerebral palsy is a result of the birth itself [Issue
3: 32]: This information is absolutely *wrong*! By publishing this answer by a
credentialed midwife, you are giving the false impression that her answer is true.
It is not. Cerebral palsy most often is believed to occur *before* labor begins.
The cause is not known, but theory has it that it may be due to asymptomatic maternal
infection.
If a cesarean section prevented CP, then we should expect to see a tremendous
decline in the number of cases of CP as the c-sec rate increases. Sadly, that
is not the case. The rate of CP has remained constant from the 1970s to the present
in spite of cesarean rates that went from 5% to 25%.
There are many sources of CP information on the Internet as well as in print
from the various organizations that assist families with members who have this
problem. Here's one source:
http://gait.aidi.udel.edu/res695/homepage/pd_ortho/clinics/c_palsy/cpweb.htm#RTFToC3
- Anon.
====
In response to Marsden Wagner's commentary on Cytotec induction [Issue 3:35]:
It disturbs me that inductions in the US occur with such frequency and for lack
of medical indication. Attention should be given to any medication given to a
pregnant or laboring woman, and adequately controlled research trials should be
done with full consent from the laboring woman and her family. Basically one of the fundamental problems with the US is use of medications without medical indication.
However, there are very few agents for induction and cervical ripening available
to physicians. Oxytocin is not the drug of choice for women who do not have a
ripe cervix, and dinoprostone has a high rate of uterine hyperstimulation, similar
to Cytotec--there are many cases of poor outcomes with its use as well. In defense
of physicians, there are times when they are taking care of a mother who is severely
preeclamptic and has a cervix that is closed thick and high. The ultimate goal
is for that woman to birth vaginally, and there are limited choices in medications
to use to make that happen. Sometimes the lesser of two evils has to be chosen--a
medication like Cytotec or a surgical birth. In the birthing world that I would like to see, these medications would only be used in the case of a medical condition
requiring birth to be imminent, and only after a woman has been truly informed
of the risks of each medication.
- Anya Wait, midwife
====
In response to the question regarding retained placenta piece [Issue 3:28]:
Your anger is understandable, but what do you hope to achieve by suing? You may
get a backlash such as we have experienced in Mexico. In Mexico the OBs have organized
a very "efficient" solution to avoiding any retained fragments of placenta.
It is called "revision de la cavidad uterina" (manual exploration and/or
cleaning of the uterus). Yes, it is just as awful as it sounds and jeopardizes
the woman by introducing bacteria into the uterus at the moment when the woman's
body is expelling its final contents. Besides being a violation of her body, it
is painful. The argument is that it is difficult to ascertain if the placenta
has been completely expelled so this procedure is initiated to forgo that uncertainty.
This continues as a routine procedure although studies such as "Efficacy
of Routine Postpartum Uterine Exploration and Manual Sponge Curettage," Journal
of Family Practice, Vol 28, No 2 p.172-176, 1989 maintain that "routine elective
postpartum manual exploration and sponge curettage of the uterus is a painful
procedure that is not clinically indicated for reducing the potential risk of
postpartum hemorrhage or endometritis and is unnecessary following routine vaginal
delivery."
The Spanish language journal Ginecologia U Obstetricia de Mexico (Vol
59, Agosto 1991)draws quite another conclusion. While maintaining that initially
the procedure was only carried out when there was reason to suspect that some
or all of the placenta had not been expelled, it goes on to assert that in large
hospitals where the birth professionals are "still learning," this selective
procedure needs to become a standard one because some cases of retained fragments
are missed. Chilling thought to contemplate this sort of backlash in the US in
response to women suing for having had faulty inspection of their placentas in
the first place!
The concluding remarks of the Mexican study are the most unnerving: "Probably
one of the most important causes of this problem is the low health education of
our patients who in general don't utilize the preventive health resources and
only frequent the caregiver when they have lost their good health." (translation
mine)
So goes the circuitous reasoning--it is the women's fault that OBs have had
to affect this barbaric routinized procedure in order to protect women from the
faulty medical care they may have incurred from caregivers not yet fully experienced
in the first place! The list of advantages to the healthcare institutions includes
five, and the list of supposed advantages to the recently birthed mother include
seven. Nowhere is it mentioned that perhaps a better training course for the caregivers
would help bypass the original problem!
Careful what you wish for, dear MT-E-News reader!
- Joni Nichols
Guadalajara, Mexico
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A client of mine has been diagnosed with HPV-genital warts. She was told by
the doctor that if there were any warts near her vagina or cervix when she went
into labor, she would have to have a c-section. The concern is that the baby will
contract laryngeal warts. However, my research so far has suggested that laryngeal
warts are very rare, not immediately life-threatening, and NOT a reason to do
a c-section. Any insights or advice in dealing with this?
- Laura Donnelly
====
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Question of the Week
Q: I am the midwife of a woman who had twins 16 months
ago in a home delivery with no problems. She had some varicose veins while carrying
the twins. She had a 12-month-old baby when the twins were born and is currently
34 weeks pregnant with another. That is four babies in less than three years.
In the last 12 months she has developed significant varicose veins that start
in her feet and go up her leg to the perineum and into the labia internally. The
veins are larger than a large thumb. What is the danger of a varicose vein bursting
while in labor? If one does burst, what are possible procedures to follow to stop
bleeding?
During this pregnancy she has been faithfully using horse chestnut, butcher's
broom, hesperidan, bioflavonoids, vitamins, a good diet, and super food supplement,
but she has done nothing topically and is not much of an exerciser. Also, are
there upper body-only aerobic programs? One will be needed after this pregnancy.
- Debi
Send your responses to:
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Question of the Week Responses
Q: What are midwives doing when women test positive
for group beta strep in pregnancy? What protocols are midwives implementing at
the birth and postpartum?
- Anon.
====
A: We are testing all our clients at 28 wks for GBS, treating with ampicillin
when positive results are returned, and also treating with ampicillin IV in labor
(2 grams every 4 hrs). We decided to treat at 28 weeks because of the association
with PROM and PTL and in labor to help prevent neonatal infection.
- Tanya Tanner, CNM
====
A: We offer screening to every woman at 37 weeks. The discussion/informed
choice information begins much earlier--usually about 34-35 weeks because there
are so many choices and so much information. We offer women three choices: test/don't
test; treat/don't treat based on test results; treat based on risk factors.
When women are given all the information we have and take responsibility for
their own choices, about 50% of our clients choose to be screened. Those who are
screened generally agree to be treated with IV antibiotics in labor if they are
GBS positive. Those who don't screen generally agree to be treated with IV antibiotics
in labor if they develop risk factors. The risk factors identified with the CDC
are: fever in labor, prolonged rupture of membranes, previously affected baby
(which thankfully has never applied to us) and GBS as the causative organism for
a UA.
We haven't yet had a woman who declines testing and refuses risk factor-based
treatment. We have had discussions about women who test positive but prefer to
be treated only if they develop risk factors. I find this option clinically acceptable
but politically concerning. If I transport a known GBS-positive mom in labor and
she hasn't had antibiotics, I will be outside my community standard of care.
I don't see what other option I have in that situation, though. Offering informed
choice means that I will honor the woman's choice. I just have to be clear in
my charting and my handouts exactly what the process of informed choice was surrounding
this issue. It's unfortunate when politics color our clinical decisions, but it's
a very real fact of midwifery.
- Melissa Jonas, licensed midwife
====
MORE RESPONSES IN NEXT WEEK'S EDITION OF E-NEWS!
Question(s) of the Quarter for Midwifery Today Issue 60
What are strengths and weaknesses of your path to becoming a midwife? How does
the current controversy over the various pathways to becoming a midwife affect
your practice, or your hopes for a practice? Do you have any specific thoughts
about midwifery education?
Please submit your response by September 30, 2001 to editorial@midwiferytoday.com
Selected responses will be published in our print magazine in the December issue.
Please include your full name, occupation and city/state/country.
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~*~*~*~*
International Connections
We are two student midwives from Bournemouth University in England and are visiting
Langkawi early in September this year. Does anyone know any community midwives
who work there who we may be able to visit whilst we are there?
- Melanie and Lisa
====
INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to
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~*~*~*~*
I would like to extend my eternal thanks to Midwifery Today and to all the women
who responded to my question regarding herpes [Issue 3:29-30]. I never imagined
that I would get such a response and am overwhelmed by the outpouring of information
and support. I have ten weeks left in my pregnancy and continue to have outbreaks.
However, my mind has been put somewhat at ease (much more than before) and I plan
to discuss all methods mentioned with my OB. Thanks to all of you, I am now hopeful
that I can have a herpes free delivery! My eternal thanks,
- LW
====
To the E-News reader who wants to educate her family about homebirth [Issue
3:32]: Kim Wildner has written an excellent article, "But What If...? Questions
Commonly Asked of Homebirth-ers." You can find the article at her website:
http://www.homepage.lakeshore.net/~kmidwife/question.htm
I love this article for its plain, simple truth, and if nothing else it is comforting
and affirming for homebirthing parents.
- Hannah Sprague
====
Regarding skin-to-skin warming [Issue 3:35]: Skin-to-skin contact has, in my
experience, resulted in faster warming of babies than electronic heating, plus
there is the added benefit of the close bonding experience that comes with a close
cuddle. Given a choice, I'd recommend skin-to-skin cuddles every time.
- Fiona Burless, C.M.
Sydney, Australia
====
In my experience as an RN and a CNM, skin-to-skin is the best way to warm a
baby after birth unless the mother's temp is unstable and she is sweating. In
my own experience with the c-section birth of my twins, my husband took his shirt
off and warmed one of our babies with a blanket covering them both. Don't allow
them to separate your family!
- Anon.
====
I am a doula wishing to focus on assisting women who may not understand the
benefits of a doula or have ever even heard of a doula. I hope readers can provide
some concrete numbers supporting birthing assistants. I know they help decrease
pain, length of labor, and interventions and increase mother and baby health,
but I find it hard to convince people of this. Can you provide me with some studies
or point me in the right direction to begin my own research?
- Kutia J.
Reply to: kj_uhuru@yahoo.com
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