|June 19, 2002|
Volume 4, Issue 25
|Midwifery Today E-News|
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Questions of the Quarter
Midwifery Today Issue 63, Autumn 2002. Theme: Interventions
What is the worst case of interventions-gone-awry that you know of? Please submit your response by June 30, 2002 to firstname.lastname@example.org.
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Quote of the Week
"To help mothers achieve pain-free childbirth, we must free ourselves from the mechanistic view of life and embrace a new holistic philosophy that does not presume to put arbitrary limits upon women, the experience of giving birth or life itself."
- Laura Kaplan Shanley
The Art of Midwifery
Sometimes, especially in transition, a mom can start giving up and making negative statements about her ability to continue. Helping her rephrase those statements can make a huge difference. I assisted one mother who had hit about 9 cm and was feeling very overwhelmed, calling for help over and over. In between contractions I asked her to say something different with me during the next contraction. Together we chanted "out baby, out baby." Pretty soon she was chanting it all on her own and her words had changed from a desperate cry for help to a strong, deep, primal call for her precious baby to come out. She no longer felt she needed help but was back within herself.
- Pam Sorochan (doula),
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Researchers in Sweden instructed 60 healthy pregnant women who suffered from morning sickness (nausea and vomiting) to wear an acupressure band either at acupressure point P6 (the Neiguan point, an area of the wrist on the inside of the forearm) or at another point -- or to use no treatment. Stimulation of the Neiguan point is traditionally recommended to relieve nausea and vomiting. Both groups of women who wore the bands improved immediately; however, within a few days the women wearing the bands on an area other than point P6 became sick again. The women who wore the bands on the Neiguan point had consistently less nausea and vomiting than the other groups, and the favorable response persisted as long as the bands were needed.
- J of Reproductive Med, 2001(46)
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What works to help relieve standard edema with no other symptoms? Warm weather is approaching, and the problem of edema will increase.
- Jennesse, Maple Ridge, BC
For relief of standard edema with no other symptoms, potassium supplementation, either in capsule form or food form (bananas and apricots are excellent sources) will substantially alleviate excess fluid. Lemon tea (10 oz of water with 2 Tbsp. fresh lemon and 2 Tbsp. pure maple syrup) can be consumed, hot or cold, every morning to flush the kidneys. Of course it is always important to maintain appropriate water intake as well.
Use acupressure for swelling of extremities during pregnancy, specifically Spleen 9 (on the inside of the leg below the knee and under the large bulge of the bone).
Recommended reference for acupressure: Acupressure's Potent Points by Michael Gach. Pay attention to whether points are forbidden during pregnancy.
- Judy Ballinger, RN, CMT, CD
Physicians at Chapel Hill, North Carolina compared sidelying bedrest, sitting with legs horizontal in a bathtub of waist-deep water at 32 degrees C, to sitting immersed in shoulder-deep water at the same temperature with legs extended downward. They found that urine output increased after all interventions, was greater for the bathtub sitters than for the bedresters, and greater still for the hot tubbers. Shoulder-deep immersion also resulted in the greatest reduction in mean arterial blood pressure.
- Obstetrics and Gynecology, 75 (2)
When edema is coupled with elevated blood pressure, I first thoroughly inform the woman about the course of preeclampsia. I first suggest deep relaxation, mild exercise, increasing protein to 125 grams per day, calcium to 2000 grams per day and water to three quarts per day. I then suggest one cup of uva ursi tea per day. In severe cases, drink one cup every 12 hours. Recheck blood pressure and edema in three days.
Tea: Place one handful of uva ursi leaves in a jar, add 2 cups of boiling water, cover and steep for 8 hours.
- Alison Osborn,
Nettle is a simple diuretic. This means it acts quickly and safely to remove excess water without disturbing the body's potassium/sodium balance. In addition to promoting the flow of urine, it acts as an antibacterial in the bladder and urinary tract. Use the fresh leaves and root and combine with dandelion whole plant for elimination.
- Althea Seaver,
Pathological swelling of pregnancy: Pathological swelling progressively increases, does not tend to fluctuate throughout the day and tends to be generalized (from head to toe) rather than primarily in the lower body. Pathological swelling results when circulatory fluids seep into the spaces between the cells surrounding the blood vessels. Blood vessels are not distended and may even be less noticeable due to swelling. In the otherwise normal woman with normal kidneys, pathological swelling occurs because the protein/sodium ratio in the bloodstream is out of balance and therefore incapable of retaining the fluid in the circulating blood volume where it needs to be. As fluid becomes trapped in the interstitial spaces, the hemoglobin rises, reflecting a contracted blood volume. The point at which a marginally contracted blood volume will begin to cause pathological swelling varies among individuals. Therefore lack of excessive swelling cannot be taken as "proof" that the blood volume is adequate.
Since pathological swelling's ultimate cause is dietary inadequacy, it is reasonable to assume that a woman is already suffering from an inadequately expanded blood volume before swelling becomes apparent. This protein/sodium imbalance represents insufficient dietary intake, which can be corrected by reviewing the diet and adding more salt, protein and nutrient rich calories as necessary. If this imbalance is not corrected, pathological swelling can persist and increase, draining more and more fluid from the circulation into the surrounding tissues. The end result can be a hypovolemic crisis that precipitates premature labor, placental abruption or stillbirth depending upon how acute the problem and how inadequate the diet was to begin with. Even if the dietary intake has been good, just two weeks of inadequate salt intake can begin to cause a reduction in the circulating blood volume due to fluid being shifted into the intercellular spaces outside the blood vessels.
- Anne Frye,
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Midwifery Today's Online Forums: CBE
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Question of the Week: LGA Babies
Q: I have two boys who were large for gestational age (LGA) babies. First baby was born 2 days before his EDD, 10 lb 13 oz, 21 1/2" long, hospital birth with episiotomy, 4th degree tear, vacuum. Second baby was born on his EDD, 11 lb 4 oz, 23" long, waterbirth at home, no episotomy, tiny tear with no stitches. I tested negative on the GTT both pregnancies. Besides shoulder dystocia and possible blood sugar problems (which didn't happen with either of my kids) what, if any, are the medical risks for LGA babies/moms? Most of the clients I teach or provide labor support for choose hospital births with OBs, and I'd like to be able to give them some evidence that they don't necessarily need to be induced or sectioned if their babies look "too big" on ultrasound, etc.
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Question of the Week Responses: Inverted Nipples
Q: I am 16 weeks pregnant for the first time at 36. I worked as a midwife for 4 years. I have deeply inverted nipples that are resistant to any attempt at rolling or suction and have been all my life. I would very much like to breastfeed my infant but have only seen failure in similar cases in hospital. Does anybody have advice/tricks that I could try in preparation?
- N. Sutton, RGN RM,
A: Try the Hoffman technique: Place a thumb on each side of the nipple, directly at the base. Press thumbs firmly into chest well, simultaneously drawing thumbs away from each other. This stretches the nipple & breaks the strong connective tissue that pulls them inward. Stretch only to the point of minor discomfort. Repeat 5 times daily. Start breast shells around 28 weeks. Re-attempt pumping after the birth. Pump 5 minutes before latch-on. If you have successfully broken the connective tissue, the nipple will probably respond.
- Susan Karimi,
A: I've seen many inverted nipples pop out by placing a bottle nipple on the breast over the inverted one and letting the baby suck. It pulls the nipple out as well as allows the milk to be expressed. Some argue that the baby will be confused by the plastic nipple versus his mother's, but the pros outweigh the cons whenever I've tried this. The baby latches on with minimal encouragement after the nipple has been pulled out enough.
- S. Jones, midwife,
A: One of the most important things to remember about breastfeeding a baby when you have flat or inverted nipples is that the baby should be breastfeeding, not nipple feeding. Focus on learning the basics of a good latch. The baby's mouth should take in a good part of the aereola so that the baby can compress the milk sinuses with each suck. When that happens, the shape of the nipple is immaterial. There is some research that shows that babies can be affected both by narcotics and epidural medications given to women in labour, resulting in sleepiness and poor sucking coordination for days to weeks. It may be helpful to avoid such medication as much as possible. If you have access to the Breastfeeding Answer Book published by La Leche League, there is a good section on flat and inverted nipples beginning on page 396. You may find encouragement, support and a great source of breastfeeding information at La Leche League meetings.
- E. Finch
A: I also have inverted nipples. I didn't breastfeed my first child because it was too painful. For my second, I was determined. I consulted a lactation professional, who gave me breast shields to wear during the last three months of pregnancy. It got my nipples used to protruding. And it worked! I always have to pull my nipples back before I latch my baby on, but after the fifth child it comes naturally now. For the first couple of weeks I really paid attention to position and pulling them back and making sure I was hearing swallowing and watching his/her cheeks for dimples. But you know right away when they are not attached properly.
A: I suggest using a comfortable but snug bra with the nipples cut out for the balance of your pregnancy. (OK, you have to be careful about sheer or light material in your maternity clothing.) I was told I couldn't nurse my babies because of severely inverted nipples. I did this with all my pregnancies and had no problem with nursing my babies, including no sore nipples. As your pregnancy progresses you will likely find your nipples want to come out by themselves anyway and the combination of pressure around them and release over them encourages that quite effectively. Mine returned to their previous inverted state very soon after I stopped nursing with each pregnancy.
- Natalie Bjorklund
A: I highly recommend Jack Newman's Web site. He briefly addresses the inverted nipple issue here. However, there is much more information throughout the site. If you still need specific help, contact him. He is wonderfully committed to helping women and takes time to respond.
A: At 34-35 weeks, start wearing breast shells (NOT breast shields) inside your bra regularly as much as you can. It will help realign the connective tissue holding the nipples in -- like wearing a ring changes the shape of your finger.
The BirthLove Web site has helped many women grow trust in birth and in their bodies. It has helped women resist Cytotec, find good midwives, and stop believing everything their doctors say. There are hundreds of homebirth stories: unassisted VBAC, fathers' stories, twin (and triplet home VBAC!) stories, breech stories -- for things that people get sectioned for daily, there are homebirth stories on the site. Marsden Wagner, MD is a contributing expert, as is Sarah Buckley, MD, Gloria Lemay, and Gretchen Humphries. BirthLove has changed and saved lives through education, communication and love. Become a member of BirthLove today and be inspired!
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!
I am a student midwife in Botswana, Africa, who needs to find information about different attitudes toward and beliefs about the disposal of the placenta amongst different cultures worldwide. I am having some difficulty sourcing information.
- Robyn Sheldon
Re: Cholestasis [Issue 4:24]: During my training we had a lecture from a researcher/midwife re: cholestasis and the relationship with unexplained stillbirth. They were running a clinic for women who had had cholestasis and previous stillbirth. There appears to be a direct link and I would suggest careful monitoring of both your sister and her baby.
I did have one client at 37 weeks with obstetric cholestasis diagnosed mainly because of itchy hands. I sent her for liver functions and they were definitely off. She was hospitalised and induced three days later -- normal birth and healthy baby.
Re: Difficult clients [Issue 4:23]: From the outset the article is based on an assumption that the client, not the midwife/birth professional, is the source of the friction. Simply telling the midwife that she is to be the "reality reader" in the relationship without adequately explaining all that this process entails based on the theory of transactional analysis could be unhelpful in the least, and possibly harmful. This seems to be contrary to the heart of midwifery.
The title itself is negative and encourages harmful labels based on a very brief synopsis of a complex theory, and gives broad generalities of pathological terms and situations. (e.g. terms such as "triggered," "boundaries" or "codependent," or saying that a difficult client's behavior is dangerous without explaining why). This promotes haphazard psychological assessment that should be left with a mental health professional trained in the use of Berne's theory in the context of a formal therapeutic relationship.
Nowhere is a referral to a professional for counseling mentioned as part of the birth professional's duty to her/his client if "childhood issues" are suspected as sources of conflict. Even more important than "being charged with abandonment" is the question of actually abandoning the client by not referring out to the proper resources when a situation is beyond one's scope of practice.
Finally, the author herself does not appear to be a mental health professional. Therefore she is speaking out of her realm of expertise. She does an injustice to all those who come through our doors who may seem "difficult" but who also have many strengths to bring to the birth and to the relationship if given the chance and the right tools.
Perhaps it would be more constructive to print an article that centers on communication skills in general, or defining concepts such as boundaries in the context of working with clients in general. The birth professional who will have success either working with so-called "difficult clients" or effectively referring out will be one who is first self-aware so that she/he is not adding counter-transference, or her own unresolved issues, which will then enable her to be a "reality-reader" in the true sense of the word. Giving birth professionals a few psycho-lingo terms to throw around does everyone an injustice.
- Jamie S. Rodriguez, MA
I am a 23-year-old mother of one and am diabetic. My first child was born at 38 weeks by c-section after what I believe to be a botched induction. I was and am in excellent health with blood glucose levels close to perfect (with an insulin pump). We are trying to get pregnant again and would like to avoid a repeat of my first child's birth. Could I get some advice about how to go about this? I have a new doctor who says he'll try to deliver me naturally but I can't go past 40 weeks and a doula/midwife who unfortunately is nearly as ignorant about my options as I am.
In the hospital where I work, the deliveries usually take place in lithothomy position or a variation. I have noticed that when a woman is lying on her side during second stage and pushing the baby out, there seems to be less lacerations! Does anyone know about good material to read on this subject and/or has anyone experienced the same thing?
- Nellie Kahania-Herman, CNM
Re: Muscular dystrophy [Issue 4:15]: Has she checked with a genetics counselor regarding the type of MD she has? It's possible that it could be inheritable, and sometimes these conditions become more profound (worse outcome) in each successive generation.
I am following a woman through her pregnancy, and lately she has been unwell with flu-like symptoms, aching joints and a rash. After repeated blood tests, her GP has told her that she has parvo virus! (measles and rubella negative). In Australia, this is something we immunise our dogs against, not ourselves. Her obstetrician was quite evasive as to how she may have contracted the virus and also what the effects on the foetus may be. He mumbled something about congestive cardiac failure. Does anyone know anything about this virus?
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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 www.globalmidwives.org
"Returning Birth to the Family" Midwifery Conference in Asheville, NC -- August 23-25th. Grand Midwife Margaret Charles Smith, Wise Woman Herbalist Susun Weed, Waterbirth Pioneer Marina Alzugaray. Southeast MANA meeting. Contact Cheryl -- 828-628-6345 or firstname.lastname@example.org or www.thematrona.com
A thriving midwifery birth center in Juneau, Alaska has employment opportunities for direct-entry midwives, certified nurse midwives and/or midwife-friendly MDs. Must qualify for Alaska licensure. We also have internships for student midwives. 907-586-1203 or www.juneau.com/birthcenter
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