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- Amy
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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
====
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
====
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)
====
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
====
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
====
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.
====
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
====
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
====
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.
====
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
====
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
====
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
====
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
====
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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