September 5, 2001
Volume 3, Issue 36
Midwifery Today E-News
“Omnium Gatherum”
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Midwifery Today Conference News

Vive La Midwife! Join us in Paris, France. October 18-22, 2001

Waterbirth: Baby Birth Movements
Cornelia reviews 20 years of waterbirth outcomes with a focus on the behavior and interaction of the baby with his environment. Breakthrough discoveries in birth psychology and newborn reflexes will be illustrated with amazing video sequences.

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Who: Michel Odent. Nancy Wainer. Robbie Davis-Floyd. Penny Simkin. Marsden Wagner. Valerie el Halta.

What: Midwifery Today's "Birth Reborn" Conference.
Where: Philadelphia, Pennsylvania, U.S.
When: March 21-25, 2002.

Why: To learn from some of the best birth teachers available, meet midwives from around the world, and revitalize yourself and your practice.

For more information and a registration form, click here.

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Looking ahead - 2002: Join us in China and The Netherlands!


THIS WEEK'S ISSUE

Contents:

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HypnoBirthing® Institute

Don't be fooled by imitation; insist on the REAL thing. If it doesn't say HypnoBirthing® Institute, and it doesn't have a capital "B", it's NOT the authentic HypnoBirthing® program founded by Marie Mongan, Director of the HypnoBirthing® Institute and author of HypnoBirthing®: A Celebration of Life.

Questions? E-mail: hypnobirthing@hypnobirthing.com

Quote of the Week:

"Would we make different choices in our lives if we acknowledged that our infants are completely aware?"

- Elly Leduc


The Art of Midwifery

When serving a client as a postpartum doula, it is helpful to find a personal chef service. That way you can show up to help with breastfeeding and do laundry with a day to a week's worth of food for the family without spending hours in the kitchen yourself. It is always well received and the services are really good at following certain diets such as no dairy or vegetarian.

- Augustine Daniels, doula and CBE

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Hundreds of tips and techniques for midwives, doulas, and childbirth educators!

Share your midwifery arts with E-News readers! Send your favorite tricks to:


News Flashes

A naturally occurring chemical found in the blood has been linked to preeclampsia, according to a report in the June 8 issue of Circulation Research, a journal of the American Heart Association. Research at the University of Pittsburgh has demonstrated that levels of S-nitrosoalbumin are significantly elevated in women with preeclampsia. The investigators compared blood samples from 21 women who were diagnosed with preeclampsia with samples from 21 healthy pregnant women and 12 nonpregnant women. The body uses nitric oxide (NO) to help keep blood vessels relaxed. Blood stores of NO are kept readily available in the form of S-nitrosoalbumin. The women with preeclampsia had levels of S-nitrosoalbumin that were two to three times higher than those of the other study participants.
Women with preeclampsia also had low levels of vitamin C in their blood. Vitamin C helps break down the S-nitrosoalbumin to release nitric oxide into the bloodstream. The authors speculate that this connection between low vitamin C and high S-nitrosoalbumin levels implies that the amounts of usable NO that are necessary for proper control of vascular relaxation are not sufficient.

- Circ Res 2001;88:1210-1215 (Thanks to E-News reader "S," who cited Nancy Sullivan's MidwifeInfo.com e-newsletter as her source..)


Midwifery Today Quiz

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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.

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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

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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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Midwifery Today's Online Forum

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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CAPPA ~ Childbirth And Postpartum Professional Association

CAPPA ~ Childbirth And Postpartum Professional Association will host a FREE Childbirth Conference on November 3 & 4, 2001 in Birmingham, Alabama at UAB. This conference is FREE to all CAPPA members.

Don't miss this great opportunity to hear dynamic speakers such as Marsden Wagner, Polly Perez and others!

To join CAPPA and attend for free, visit the CAPPA web site at www.cappa.net or call toll free 1-888-548-3672


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.

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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

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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

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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.


Switchboard

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!

~*~*~*~*

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

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INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to "International Connections." We're here to help you!

~*~*~*~*

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

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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

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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

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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.

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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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