December 12, 2001
Volume 3, Issue 50
Midwifery Today E-News
“Omnium Gatherum”
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THIS WEEK'S ISSUE

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Quote of the Week:

"We must commit to keeping human beings around birthing women, to giving them touch, love, food, and prayer before trying more complex ways."

- Clarebeth Kassel


The Art of Midwifery

We must stop looking at herbs as physiologically active chemicals. There is a synergystic whole to herbal therapy, and when deciding to make use of a certain herb one must take into account the emotional, mental, and spiritual state of the person needing the herbs. Herbs function and produce effects on all of these levels, so a range of herbs is used to achieve the same results in different people.

Herbs are whole as our bodies are whole, and when working with herbal medicines we are working with whole plants to produce a state of wholeness in ourselves and our clients. Yes, herbs can be effective for pushing the body into doing something it is not ready to do, but take care with this and always think of what you can do within the physical realms (i.e., walking a woman around the block instead of using blue cohosh) first. When you work in this way, herbs can be truly powerful allies in sticky situations in which the waiting remedy truly is your best choice.

- Raven
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News Flashes

A study that included 171 mother-infant pairs was undertaken to determine the effect of polychlorinated biphenyls (PCBs) exposure on cognitive development. Prenatal and perinatal PCB exposure was estimated by measuring PCBs in cord blood and maternal milk. Postnatal exposure was determined by measuring serum PCB levels at 42 months. PCB levels in milk were inversely associated with mental and motor development, a trend that became significant from 30 months of age onward. Postnatal exposure from breastfeeding had a negative effect on development at 42 months. However, from 30 months onward, the presence of a favorable home environment appeared to attenuate the harmful effects of PCB exposure.

Doctors from Wayne State University in Detroit noted that "although much larger quantities of PCBs are transmitted postnatally than prenatally, neurotoxic effects have rarely been linked to exposure during infancy" or early childhood. " A greater sensitivity to damage during the prenatal period seems to render the fetus much more vulnerable to small quantities of these neurotoxicants," they said.

- Lancet 2001;358:1568-1569,1602-1607

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In my childbirth class a mom asked how far into pregnancy it would be OK to breastfeed. Since nipple stimulation can produce contractions, is there a point at which it isn't safe to nurse any longer, say past 36 weeks?

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Question of the Week

Q: A doula client, due in April, is a repeat client. I attended her with my mentor midwife a year ago. She had planned a homebirth, but we transported. It turned out she had a uterine infection and was sectioned for failure to progress past 4 cm. This time she's opted for a hospital birth with our favorite doc. An ultrasound shows a very low-lying anterior placenta right on her c-sec scar. The doctor told her not to worry just yet, that as her uterus enlarges it is possible the placenta will move up. If not, he said she would have a scheduled c-section and possibly a hysterectomy if bleeding can't be controlled. I told her to do some serious meditating and visualizing. She is scheduled for another ultrasound in eight weeks. Has anyone had this situation improve? Any tricks we could try?

- Belinda, doula, midwife's assistant

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Question of the Week Responses

Q: When you attend homebirths, what do you keep in your kit ahead of time for those unexpected, middle-of-the-night calls? And what is the most effective way to organize and carry your materials and supplies?

- B.H.

A: I am a Dutch midwife. In the village where I live most of the women deliver at home. In my car I have my "birthcase," a special case with an A4 bag on the outside in which there are sterile gloves, a swaddler, and sterile swabs. Inside it's divided into several compartments. In the underside I have one compartment for my special needs for the birth itself in a stainless steel box: two Kocher clamps, one pair of cord scissors, a mosquito clamp, and a pair of Waldman scissors(episiotomy). Underneath this box there is another box of stainless steel with the things I need for suturing. In that same compartment fits a smaller stainless steel box with a steel amniotomy instrument (I don't know what it is called in English).

In the other compartments I have spare cord clamps, packets of Vicryl for suturing, disinfectant cleanser for my instruments, lidocaine spray and lidocaine for injection, ampullae of Pitocin and Methergin with needles and syringes and mucus extractors.

In the space above I have compartments for after birth: a headlamp for heavy suturing, women's catheters, and a bag with my scales, vitamin K, and measuring tape. The upper and lower compartments are divided with plastic sheets and closed by a magnetic strip. So when a baby is born quick, I only have to open my bag and I have everything at hand.

I also have a hardshell beauty case in which I carry my oxygen supplies and that is also always in the car, ready to take out.

For my pre- and postnatal visits I have a small bag with a tensiometer and stethoscope, my Doppler, my cord clamp clipper, stitch cutters, sterile and nonsterile examining gloves, and the papers I need. For me, these materials work and are easy to carry.

- Mieke

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A: I consider all birth calls to be expected but exact timing is not predictable. So I like my birthkit to be ever-ready. I store my supplies in two suitcases. The suitcases attach to one another and come with wheels and a handle for easy travel. Supplies are organized according to use in labeled clear plastic containers with lids (instruments in one container, oxygen masks in another, etc.). Herbs & medications are kept in a locked tool box. When the call comes, I simply grab that handle & I'm out the door.

- Susan Karimi

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A: For hospital births (I am a doula), I keep my supplies ready to go in a large backpack attached to a wheeled luggage carrier. It has lots of pockets that I have packed as follows:

In the large center area I have my portable Aiwa CD player and a CD carrier with 12 different instrumental selections, an extra pair of scrubs and sox, a new Hot Sock for the mom, a long-sleeved white turtleneck to put under my scrubs if I get cold, a couple of handbooks for reference (Varney's Pocket Midwifery and Simkin's Labor Progress Handbook), a flashlight, and a clean towel (had to catch a baby in a van on the way to the hospital one night!), a little zipped cosmetic case containing some personal items (toothbrush and paste, comb, some Advil and Tylenol), and a little "tool" bag for the mom containing a pair of small combs for hand acupressure, a small massage roller, a new chapstick, and a box of Tic-tacs, etc. I also have a roll of thick plastic baggies bound with a rubber band that I can use as ice packs and a couple of empty water bottles with Shaklee's Performance powder (a maximum endurance sports drink) to which all I have to add is water and give it a good shake - for both mom and me.

In the long but skinny front pocket, I carry my Birth Reference Binder (my own collection of tricks and info about different positions, acupressure points, blank pages for recording information, DONA record forms, homebirth emergency procedures, and my certifications, etc.) and a large hand mirror. The mom's file goes in here as well.

Immediately in front of this pocket is a smaller one in which I keep some money. Below this pocket is a small horizontal pouch where I store food in plastic baggies: Instant soups, tea bags, granola bars, etc.

There are two small pockets on either side of my backpack. One of these holds my digital camera with an extra set of new batteries. In the other goes my box of massage oils and aromatherapy oils, which I put in at the last minute because I keep them stored in the fridge. My DONA doula name badge is kept pinned on the bag's strap and a large-faced watch with a second hand is fastened around the strap.

So if I'm called out in the middle of the night I just have to put in my box of oils and the mom's file, grab my car keys (which are in a case that contains my driver's license) and roll on out the door. Usually, the mom whose EDD is closest has my birth ball at her home and we take it with us when we go to the hospital.

- Helen Moore, CD (DONA)

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Some things we have found to be helpful are:

  • A "do list" for the family while they wait for our arrival (great for keeping grandmothers and anxious dads busy). It includes tasks such as preparing herbal infusions; cleaning bathrooms; prepping the bed, trash and laundry receptacles; warming receiving blankets and feeding mom.
  • Herbs are bagged in single- or multiple-use portions and labeled with contents and preparation instructions. We do this for prenatal tea, postpartum bath, after-pains, nursing formula, varicosities, etc.
  • Tinctures are labeled with red marker as to use and dosage. We also have laminated herbal tincture cards for quick reference. The tinctures and cards are set out at births.
  • I carry three bags. The first is what I walk into the house with. It has what I would need if baby was coming NOW: bulb syringe, DeLee, amniohook, blood pressure cuff and stethoscope, Doppler, cord clamps, gloves and gauze. The second is my main bag. It has tinctures, heating pad, scale, and other supplies, plus extras. The third holds my herbs. At around 38 weeks, we leave the family herbal packets that will be used during the birth: herbs for compresses, nutritives for mom, postpartum bath, and after-pains. This allows the family to get these brewing before we arrive.

- Debra, midwife
Washington

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THE WINNER OF THE NEW TRICKS OF THE TRADE Volume III is Helen Moore. Congratulations, Helen!

o=o=o=o=o=o

Q: Does anyone have experience with pregnancy coexisting with kidney stones?

- Anne Walters, CNM

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A: I have served several pregnant women with kidney stones. Most have done well. I had a urologist consultation in each case once the diagnosis of hydronephrosis with calculi had been made by ultrasound. One woman currently has a stent in place. I have kept all of these women on prophylaxis throughout the pregnancy (Macrodantin 50 mg hs qd) and getting adequate fluids cannot be emphasized enough. Some herbs are safe and are helpful with kidney problems including kidney stones, but most of my mothers were not receptive to taking herbs.

- Anon.


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I wholeheartedly agree with Clair [Issue 3:48]. One can do lots of research and still not come up with "evidence" of these distressing outcomes [of using labor drugs]. But that in no way should lead us to believe that these things are therefore definitely not true. I specifically remember a Midwifery Today conference audiotape with Michel Odent about these exact outcomes and the research behind them, linking epidurals and drugs in labor with later in life substance abuse.

- Anon.

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My thanks to everyone who took time to find references linking drug addiction in adults with administration of pain-relieving drugs in labor [Issue 3:49]. No doubt I missed these citations in my research because I was specifically looking for evidence of drug addiction in children of mothers who had had epidurals and not all forms of labor analgesics that have ever been used. I would like to point out some difficulties with concluding that choosing an epidural results in increased risk of drug addiction in the babies.

The Jacobsen et al 1990 study looked at the three different drugs--opiates, barbiturates, and nitrous oxide--as a group. They did not differentiate between the three types in drawing their conclusions (likely because of statistical limitations due to small study size). Further, the Nyberg study (2000) cited is based on a mere 69 drug users and 33 nonabusing siblings with a 95% confidence interval of 1.00-44.1, indicating the result is not statistically significant. There is no evidence of an effect. Further, in the 1993 Nyberg study the effect could not be seen for opiates, only for amphetamines.

So we have three studies, one of which shows children of mothers who had been administered some combination of opiates, barbiturates, and/or nitrous oxide were at increased risk for drug addiction, one study that shows nothing at all, and a third that does not find an increased risk for opiates but does find an increased risk for amphetamines. Not one of these studies is necessarily applicable to children of mothers with epidurals because the drug used is different, the dosage is different, and the route of delivery of the drug is different. However, it would seem that, of the various drugs, opiates may be the least risky as at least one study found no effect with opiates although it did with amphetemines. Since the drug administered in epidurals is similar to opiates, it may well be the safest choice when it comes to avoiding increased risk for drug addition in babies. I personally wouldn't bet my baby's future on a 95% confidence interval of 1-44, but that is what the studies say to date.

Should we be concerned about epidurals? Yes. Should we discourage widespread use of epidurals? Without question. There are a whole host of reasons to avoid epidurals and informed consent means a mother should know about all of them before she makes her decision. Should we be telling mothers not to choose an epidural because their children are risking drug addiction and suffering psychological problems such as "fuzzy thinking" and an "inability to complete a task"? No. There simply isn't evidence for such claims, and informed consent means sticking to the facts and not straying into unsubstantiated claims even if such claims support all the other very good reasons to avoid an epidural. At most, we can say there has been some equivocal evidence in two very small studies that indicates other kinds of drugs given in different ways at much higher dosages during labor have been linked with increased risk for drug addiction in the babies. There is no way to know if this applies to epidurals, but it is one more possible, albeit highly questionable reason, of many very good reasons, to consider alternatives.

- Natalie K Bjorklund

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I'm a practicing midwife in Israel in a hospital setting. We have the best facilities in Israel for natural childbirth and I enjoy assisting at these births. Most of the other women delivering babies are interested in epidurals or Demerol for the pain. I found the information given [in Issue 3:49] fascinating and terrifying. I specifically remember being told in midwifery school that epidurals do not in any way transfer to the fetus, thereby making them by far superior to the use of Demerol. I would like to hear your opinion in the use of nitrous oxide during labour. I've been told it is cleared out of the body very quickly and has no effect on the child. I used it during my last birth and found it very helpful and much better for me than the epidural. My own births have all been high risk with Pitocin and continuous fetal monitoring, and the option of the nitrous has been helpful. What do you think?

- Lauren

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My endometriosis was nearly unbearable prepregnancy, and my MD told me I'd have trouble conceiving. With some acupuncture and Reiki treatments, three weeks after stopping birth control pills I was pregnant, and the pregnancy was marvelous--especially after I switched to a midwife around month four.

I think the endo made me able to withstand severe pain; I doubted I was in labor initially. When my doula came to check on me I vomited, and that was my transition. The midwife came over to check me; I was at 9 cm and delivered an 8-lb daughter three hours later.

I'm 16 months postpartum, breastfeeding, and have yet to menstruate. I felt some twinges of endo pain; an ultrasound last week indicated a small ovarian cyst. I'm afraid the endo's returning but hope that with more sleep and exercise I can stave it off a while longer.

- Anon.

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My sister-in-law had a baby six months ago and has been told by her GP that the baby has fused labia. Now they want to scan to see if she has ovaries and a womb. Does anyone have experience of this? What treatments helped or didn't? Otherwise she is a very healthy happy baby with no apparent problems.

- Lucy

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In response to H. Henderson's questions about becoming a nurse to become a midwife [Issue 3:48]: I too wanted to be a midwife but did not want the nursing degree. After a great deal of soul-searching I decided I wanted to make a difference within the system, so I underwent the nursing degree and the master's degree in nursing so I could take the ACNM test. I didn't enjoy being a nurse very much, but I love being a midwife, doing hospital deliveries, providing a service for those women who aren't quite ready for a homebirth but also don't want a typical hospital birth. I have aspirations to someday open a birthing center. The nursing degree gave me the ability to provide primary care for women as well as credibility in the medical community and the community I live in, which is still learning about what midwives are.

- D'Anne, CNM

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In response to K. Murray's comments [Issue 3:40]: A few programs still accept diploma and associate degree RNs (usually require a year or more experience in the field of maternal child health; master's programs will take you as a freshly minted RN--no experience required--not a plus in my book) in a certificate program of midwifery. The programs are shorter--you get a certificate, not a master's degree, and take the same test as those with a master's to be CNMs. Additionally, the community-based program requires a BS, but not in nursing. The American College of Nurse-Midwives can give you a list of programs, and they are divided into masters/certificate groups.

Another thing to consider when debating the nursing verses direct entry route: as a CNM your practice may be limited by the physician backup you are able to obtain.

- Catherine , RN and direct-entry midwife

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I am presently a hospital doula and a homebirth midwife assistant for a CNM. I love the homebirth work and intend to go to school to become licensed. Herein lies the dilemma: My heart is telling me to apply to a direct-entry midwifery school, but my head is telling me it would probably be wiser to go through nurse-midwifery practice. I am very lucky as the midwife I work with says she will support me and sponsor me as an apprentice either way.

I believe strongly in homebirth and birthing naturally and feel there should be more independent homebirth midwives. At the same time, my only scope of practice as a CPM or LM is to do homebirth and well-woman care in an independent practice. I am also interested in research, in women's rights on a larger scope of practice, in working with doctors, with a low-income population in clinics. Can I do this as an LM? What if I want to take a break from the responsibility of running my own practice--as an LM I couldn't work in a doctor's office or in a clinic.

I also do not want to be a nurse. I do not want to be kow-towing to a doctor or a hospital system. I want to do birth, to help women on their paths to becoming mothers in the healthiest, happiest way possible, and I worry that going to nursing school will indoctrinate me into the medical model of care and that I will lose my trust in women and what I know are their natural abilities.

I know that there are benefits and downsides to both choices. I am just hoping there might be some resounding passionate voices out there that can help me find my answer.

- A. Williams

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As a childbirth educator, I've been noticing that a large number of my clients are experiencing premature membrane rupture (PROM)--much more than the "5% of all births" average that I often read about.

My research shows that OP presentation is often accompanied by PROM but I can't find an explanation as to why. I also hear midwives and doulas suggesting that poor diet may be a culprit (specifically, not enough intake of vitamin C for adequate collagen production or vitamin A to ward off infections that may make the membranes more likely to tear). Another theory has environmental pollutants and possibly excess use of antibiotics in animal feed as contributing factors, but have yet to come across a study proving this. Can anyone help me make sense of all this?

- Bethany Karn

===

I understand from my readings that the cord must be clamped immediately after the birth of the first identical twin due to chance of fetal blood transfusion. Why is this so? What are the chances of this occurring while still in utero, and does it, and why does it increase after one baby is already born? What about in fraternal twins whose placentas have fused? Literature says that is how it is, but not why.

- Anon.

====

For the woman with painful intercourse and hernias after long-duration pushing during childbirth [Issue 3:45]. It is possible her uterus is prolapsed as well as her colon due to the pushing. If her uterus is prolapsed then she will have poor circulation in her lower abdomen and problems from bowel movements or nonhealing hernias. If she is comfortable with needles I highly suggest acupuncture, which will support her body's energy to hold the uterus up in place and the colon as well. It will also bring circulation through the area, which will help the tissue heal. Another highly effective technique is uterine massage that can be a self-massage. It will also increase circulation in the lower abdomen and encourage the uterus to rest where it is meant to be.

Problems associated with prolapsed organs are best dealt with through holistic medicines. Western medicine with all of its great contributions has little to offer here. For instance, in Western medicine women are too often told that it is "normal" for her uterus to be out of place. A tilted uterus and PMS is not a "normal" state of affairs--common maybe, but hardly "normal." Uterine/abdominal massage is a great health maintenance regimen for all women and takes about three minutes in the mornings or evenings while lying in bed.

- Anon.

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