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CHINESE MEDICINE IN BIRTH CARE:
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====

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~*~*~*~*~

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) HIV and Breastfeeding
5) Check It Out!
6) Midwifery Today Online Forum: Apprenticeship
7) Question of the Week Responses: VBAC
8) Switchboard
9) Classified
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1) Quote of the Week

"We cannot prepare for the future without embracing the meaning and
the relevance of the baby's perspective on life."
-Michel Odent, MD
o=o=o=o=o=o

2) The Art of Midwifery

Doula trick of the trade: In an effort to encourage the laboring mom
to make noise and keep her noises low and deep, I began modeling that
sound. We usually end up humming and moaning together. Once that
ritual is established, it almost becomes like singing or a meditative
mantra. The last mom whose birth I attended said she vividly remembers
being surrounded in a gentle bubble of vibration from our sounds. Not
only does it help relax mom, but it seems to frighten the nursing
staff to the point where they just sit back and watch in amazement!
-Kathleen Hickey
Akron, OH
====

DOULAS: We encourage you to continue to send in your favorite tricks
of your trade!
o=o=o=o=o=o

3) News Flashes

Two recent studies confirm that breastfeeding makes babies more
intelligent and healthier. One of the studies shows that babies
breastfed for up to nine months have higher IQs. It is not clear which
nutrients may play a role, but human milk contains docosahexaenoic
acid and arachidonic acid -- fatty acids that seem to be important in
brain development. The American Academy of Pediatrics recommends that
babies should get nothing but breastmilk for six months and advises
women to breastfeed to some extent for a full year. The World Health
Organization recommends that mothers should breastfeed babies for two
years.
-Reuters, May 8, 2002

4) HIV and Breastfeeding

Response to notation by Karen Ehrlich about studies on HIV-positive
women and the effects of breastfeeding on transmission [Issue 4:20]:

While the results from these studies are provocative, they must be
looked at in a larger context. We do know that breastmilk from
HIV-positive women contains the virus and that populations of
HIV-positive women who breastfeed have higher rates of transmission of
the virus to their babies through breastfeeding. The two articles by
Anna Cousoudis, et al. are actually reports of data from two different
points in the same study. The results show that at six months infants
breastfed exclusively for three months or more have no greater risk of
HIV infection than those never breastfed - 19.4% in both groups.
Infants who had mixed feeding of breastmilk and other fluids or
formula or foods had a higher risk of infection (24.7%). By 15 months
the percentages were 24.7% for those exclusively breastfed for at
least three months and 35.9% for mixed feeders (vs. 19.4 never
breastfed). It is clear that exclusive breastfeeding is better than
mixed feeding, but after six months babies in the exclusive
breastfeeding group became infected (increase from 19.4% to 24.7%).
The mothers and the infants did not receive any antiretroviral
medications.

This is a small study in which only 103 women exclusively breastfed to
at least three months and 156 women never breastfed. In addition, the
95% confidence intervals are large. Both these facts mean the data can
more easily be flawed than if the study were larger and the confidence
intervals small.

The authors made several interpretations of their results. One very
important interpretation is the authors' statement that the WHO,
UNAIDS, UNICEF recommendations for infant feeding be reinforced in
developing countries, with added emphasis on encouraging HIV-positive
women who have no access to safe alternatives to exclusively
breastfeed. Another conclusion is that other studies must be done to
confirm the results before they should influence any policy changes.
And finally, on the basis of their data (which needs confirmation) a
recommendation can be made to HIV-positive women with no access to
safe breastmilk substitutes to exclusively breastfeed for at least
three months but not longer than six months.

The WHO, UNAIDS, UNICEF current policies for infant feeding are as
follows: Exclusive breastfeeding should be promoted, protected and
supported for six months for women who are known to be HIV negative
and whose HIV status is unknown. For HIV-positive women the use of
breastmilk substitutes is recommended where "acceptable, feasible,
affordable, sustainable and safe"; otherwise exclusive breastfeeding
is recommended for the first months.

Other risk factors have been suggested to increase the risk of
transmission of HIV during breastfeeding. Cracked nipples, engorgement
and mastitis can increase the risk of exposure to maternal blood
during feedings. Oral thrush in the infant may be another factor.

All of the above has been focused on developing countries. Another
recent study in Kenya reports a higher mortality in HIV-positive women
who breastfed. The Coutsoudis et al. study showed no increase in
mortality in women who breastfed compared to those who never
breastfed. A further and refined look at all these issues must be done
before conclusions can be drawn and recommendations made.

What about the developed world? Currently the standard of care
includes a regime of antiretroviral drugs for HIV-positive women
during pregnancy and birth, antiretroviral medication for the baby to
six weeks of age and breastmilk substitutes for infant feeding. Here
the risk of maternal to child transmission of HIV is less than 2%.

Could those women with undetectable viral loads who continue to take
antiretroviral medications postpartum safely breastfeed? No
information exists about the effects of long-term exposure of the
infant to the drugs through breastmilk or if the mother taking the
drugs while breastfeeding eliminates the risk of transmission to the
baby. Does exclusive breastfeeding provide any protection against HIV
infection to the infant exposed at birth? It is just not known.

Given the above, where breastmilk substitutes are safe and readily
available, I regrettably could not recommend to an HIV-positive woman
that she breastfeed. Of course, it is her decision. It is my job to
give her all the known and unknown information, to the best of my
ability, and it is my job to support her in whatever decision she
makes.

References:
Coutsoudis, Anna, et al. Influence of infant-feeding patterns on early
mother-to-child transmission of HIV-1 in Durban, South Africa: a
prospective cohort study. The Lancet: (354), August 7, 1999. pp
471-476.
Coutsoudis, Anna et al. Method of feeding and transmission of HIV-1
from mothers to children by 15 months of age: prospective cohort study
from Durban, South Africa. AIDS, 15 (3) 2001. pp 379-387.
Coutsoudis, Anna. Promotion of exclusive breastfeeding in the face of
the HIV pandemic. The Lancet: (356), November 11 2000. pp.1620-1621.
Coutsoudis, Anna. Shaffer, Nathan. Numazaki, Kei. Correspondence, HIV
infant-feeding patterns and HIV-1transmission The Lancet: (354)
November 27 1999. pp.1901-1904.
Effect on Breastfeeding on Mortality among HIV-Infected Women. WHO
Statement, June 7 2001. Found online www.who.int/HIV_AIDS/MCTC/

-Nancy Miller, CNM
====

5) Check It Out!

~~~WWW.MIDWIFERYTODAY.COM~~~
A Web Site Update for E-News Readers
~~~~~~~~~~~~~~~~~~~~~~~~~~~~

CONFERENCE AUDIOTAPES FOR THIS WEEK'S THEME

HIV: How Can Midwives Protect Themselves and Their Clients?
http://www.midwiferytoday.com/products/951T323.htm
Complicated Birth Review
http://www.midwiferytoday.com/products/962T519.htm
Let's Talk Controversies in Midwifery!
http://www.midwiferytoday.com/products/991T941.htm
~~~~

THE SCIENTIFICATION OF LOVE
Dr. Michel Odent discusses peak experiences and their effect on human
health and well being. An informative, inspiring and deeply
thought-provoking book!
http://www.midwiferytoday.com/products/SL.htm
~~~~

BIRTHSONG MIDWIFERY WORKBOOK 3rd ed., by Daphne Singingtree
Designed to help you learn the basics about birth and midwifery.
http://www.midwiferytoday.com/products/BSMW.htm
~~~~~~~~

6) Midwifery Today's Online Forums

I am a first-year midwifery student at The National College of
Midwifery. I am looking for a 2-3 month apprenticeship opportunity in
Mexico or Central America. My preference is a medium volume clinic
(10-15 births a month). My Spanish is minimal but I am very eager to
learn. Any information is greatly appreciated.
====

TO SHARE YOUR THOUGHTS AND EXPERIENCE ON THIS TOPIC, go to
http://www.midwiferytoday.com/forums/topic.asp?TOPIC_ID=2126
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7) Question of the Week Responses

Q: I am seeking insight about having a VBAC after four c-sections.
Does anyone have experience with a situation like mine? I labored with
all but one of my babies and was labeled CPD. All my labors were
augmented. We are considering having another baby.
-NV, midwife
====

A: I've had eight homebirths after three cesareans. All went well.
-Kathy

A: I had an emergency c-section at 36 weeks, another that was planned
in advance (before I became informed) and an ectopic rupture, for
which I was opened up through the convenient previous scar. I was
induced with Pitocin with the third, vaginal birth successful, then a
spontaneous natural birth with a midwife attending with my fourth.
We'll have another, at home.
-Unsigned
====

A: My favorite VBAC story is about the woman who had had four previous
c-sections. For her fifth pregnancy four years ago (before everyone
got so hyper about VBACs) we discovered that she had gestational
diabetes. She was very careful about her diet. She started taking red
raspberry leaf, black cohosh and evening primrose in tincture form at
36 weeks. At 37 weeks she went into spontaneous labor. We were not
doing continuous monitoring of VBACs then. When she reached 5 cm, she
got into the tub for comfort. An hour later she was fully dilated with
the head on the perineum. She birthed a 6 lb. 10 oz.-girl in the tub.
The baby was about two pounds smaller than her previous smallest baby.

In January she had another successful VBAC despite pregnancy-induced
hypertension and gestational diabetes. Because of these and the
cultural changes and fears about VBAC, she was continuously monitored
and augmented with Pitocin. Active labor lasted about an hour and she
had another beautiful girl, weighing 6 lbs. 3 oz. No herbs this time
around.

The answer to your question is yes, you can VBAC after four
c-sections. Watch your diet. Even if you are not diabetic in the
pregnancy, eat well and emphasize balanced meals. Avoid sugar. Get
enough rest and help at home. Remember that the good Lord made your
body to have babies. Trust in birth.
-Tricia Shute, CNM
New Hampshire

A: While apprenticing with an experienced midwife, we had two clients
who had had multiple c-sections and both delivered vaginally at home
in very efficient, uncomplicated births. The first woman had had four
c-sections, starting with the first baby diagnosed as cephalopelvic
disproportion. With her fifth baby she had an eight-hour labor and
delivered her biggest baby yet - a baby girl just over 8 pounds. What
made her situation more significant was that this woman's
mother-in-law was at the time a state legislator who had not supported
the legalization of midwifery in our state a few years earlier,
although we are legal and VBACs are included in our scope of practice.
I don't know that she has changed her opinion on legalization, but the
birth made a favorable impression on her.

The second woman had had 13 pregnancies (2 miscarriages, 7 cesareans
for failure to progress, 2 vaginal births all in hospital) and
successfully gave birth at home in less than five hours to a healthy
8+ pound baby boy! No complications whatsoever. What a triumph!
-Dotti Kirkpatrick, registered midwife

A: I had one mother who gave birth vaginally after four c-sections and
another after three. Both had good deliveries. Remember that the labor
probably will be long and slow because the uterus is finding its own
way again. Stay hydrated and eat! Get as much rest as possible. Most
important, do not allow yourself to be induced or your labor
augmented! Let your body do its work in its own way and work with it.
Use water, massage, whatever to stick with it. Be sure to have only
those with you who believe you can and will give birth. You CAN!
-Judy, CPM

A: A lady came to me with her seventh pregnancy; the first five had
been c-sections - the first for "CPD" with an 8 lb 1 oz baby, the next
four repeats because of doctor preference. The sixth baby was an 8 lb.
3 oz. VBAC. She had VBACs at home with me for babies seven and eight,
with weights of 8-12 and 8-7. The labors were pokey, and I had to camp
out for about 24 hours each, but once she was dilated she had no
difficulty pushing the baby out and no problems with bleeding, etc.

Baby nine weighed 9 lbs. Her contractions were not good quality and
irregular but she was complete after 12 hours of active labor. After
pushing with contractions (which were not very strong and 5-12 minutes
apart) for 2 hours without real progress, we elected to transport due
to failure to descend (despite all kinds of positions) and maternal
exhaustion.

I was shocked when we reached the hospital (one I had not transported
to before) when they told her they were going to "give her some IV
fluids and let her rest a bit before letting her push her baby out! I
was glad they were going to give her a fair chance. When she was given
Pitocin I got very worried, knowing her uterus was quite worn out. But
after about 3-4 hours she had a c-sec. for "failure to progress." Her
uterus was found to be total mush. Nonetheless she had a very healthy,
big baby and had her tubes tied.

This woman was 39, obese, on a poor diet and didn't exercise. She had
had all nine babies one to two years apart. So she had a lot going
against her, yet things still went amazingly well for her. (I don't
like to have clients who don't take better care of themselves and do a
lot of teaching, but when you don't meet them until baby number seven,
sometimes they think they already know it all! I did have her using
lots of red raspberry and a good prenatal which I think helped some.)
-Esther RN, CPM

A: I have attended home VBACs after only one cesarean, as have many;
but I know of one woman who has had eight babies including traumatic
cesareans, and she now has peaceful homebirths. She is truly a birth
goddess and is out to revolutionize birth with her own stories as well
as her outspoken unashamed glorious writings which can be found at
http://www.birthlove.com I highly recommend you consult with her; she
would be happy to share her wide knowledge of this issue.
-Anon.

8) Switchboard

International Connections

I am an apprentice at a birthing center in Manila, Philippines and
would like to get a U.S. license when I return. I am interested in
locating a school to get my academic learning achieved. Ideally I
would like to do all or part of that learning by extension so I could
begin my studies while still in Manila and continue while again living
overseas. Are there any good options to doing my schooling in this
manner?
-Krista
Reply to: jerandkr@juno.com
~*~*~*~

In Australia we have some of the highest rates of obstetric
intervention in the world: 21.9% caesaraean and 25.9% induction in
1999. You can guess that our obstetric system is dominated by the
medical model and obstetricians! But you can help us change that. We
have formulated a National Maternity Action Plan (NMAP) demanding that
every woman in Australia have the option of one-on-one midwifery care,
similar to what our neighbours in New Zealand are enjoying. Our
document tells Australian politicians why and how to do it here. It's
a great summary of the benefits of midwifery care.
We are asking for support and endorsement from as many groups and
individuals as possible. All you have to do is read the Adobe document
found at http://www.communitymidwifery.iinet.com.au/nmap.html and send
your e-mail endorsement to the convenors as listed. If you are a
member of an organisation, you can ask that your organisation formally
endorse us also. We figure that a flood of endorsements from Australia
and overseas will help the state and federal governments see the
light. We would like to have them all in by late June.
Thank you from all of us in Australia!
-Sarah Buckley, for the NMAP
~*~*~*~

As a family physician who practices obstetrics, I've enjoyed receiving
your e-mail newsletters and updates and quote your sources frequently
when asked to justify my "midwife-like" techniques and tendencies. I
am therefore dismayed at the sense of hostility I got while reading a
recent issue, in regard to your allopathic medical colleagues.
Allopathic obstetricians (meaning those with medical degrees, as we
who do deliveries are all obstetricians of a sort, are we not?) have
very heartily admitted and agreed with the results of the study you
quoted from ACOG regarding VBAC.
Please remember that the "us versus them" mentality is not productive.
All of "us" want to see healthy happy mothers and babies - just like
all of "you."
-Shenary Fote MD
====

A reader asked why evening primrose oil is not recommended for VBACs
[Issue 4:21]. When there is *any* question about potential scar
integrity (i.e., if pregnancies have been very close together after a
c-section and/or if the incision was not the basic low horizontal), it
is not advisable to do *anything* to push the body toward softening
any faster than it does on its own. My point is that anything that
softens the cervix has the potential to soften the scar. Again, this
is a "use your judgment" issue. We have to remember that our herbs and
oils can have medically significant effects, that they are not safe in
every single instance. Is it possible that not using something to
"help" the uterus along may mean a VBAC mom may have to transport?
Yep. But there's also a risk that helping the uterus along will make
for a much more emergent transport later. If nothing else, the whole
Cytotec debacle highlights the need for us to respect the natural
process and respect our limitations.
-Jen
====

Correction

Re the tiny mother [Issue 4:21]: The woman I described was having her
first baby, not her second, which made it an even bigger
accomplishment.
-Cynthia B. Flynn, CNM, PhD
o=o=o=o=o=o=o

EDITOR'S NOTE: Only letters sent to the E-News official e-mail
address, mtensubmit@midwiferytoday.com, will be considered for
inclusion. Letters sent to ANY OTHER e-mail addresses will not be
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8) Classified
The International School of Traditional Midwifery in Ashland Oregon is
accepting enrollment for Fall 2002 classes. Contact us at 541-488-8254
or visit us at http://www.globalmidwives.org
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