September 4, 2002
Volume 4, Issue 31
Midwifery Today E-News
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Quote of the Week

"Waterbirth is one of many lovely ways to enter the world."

- Judy Edmunds, CPM

The Art of Midwifery

I keep a newborn-size baby cap in my birth bag. When a mom begins to get discouraged and lose her focus during labor, I pull out the hat so she can hold it and play with it. I point to her belly and tell her that this little hat will go on that little head. The mom usually smiles and giggles, regains her focus and feels encouraged to go on. Later the little hat can serve as a great focal point during pushing.

- Tracee Jackson, birth doula
Indianapolis, IN

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News Flashes

The Centers for Disease Control estimates that each year, more than 130,000 pregnant women in the United States consume alcohol levels that increase the risk of having a baby with fetal alcohol syndrome (FAS) or fetal alcohol effects (FAE). Health officials suggest complete abstinence from alcohol during pregnancy. A study that analyzed data from four states found that the rate of binge and frequent drinking among pregnant women hasn't declined since 1995 despite public health warnings. The results also showed that some racial/ethnic populations have consistently higher rates of FAS.

- Morbidity and Mortality Weekly Report, CDC
51(20):433-5, May 24, 2002

Dolphin Circle Waterbirth Tub Kits

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Perhaps the words of Frederick Leboyer in his 1975 classic "Birth Without Violence" have been taken to the extreme by people who advocate keeping a baby underwater for a minute or more after birth: "Once the infant has been born and delivered from the mother, it remains bound to her by this umbilicus, which continues to beat for several long minutes: four ... five ... sometimes more" (p. 50). Continues to beat, yes, but what is the amount of blood flow during those minutes? Keep an eye on the cord during the next birth you attend. At first it is stiff, turgid, deep blue. Look again after one minute. It is becoming flaccid, gray. True, if you feel carefully near the baby's body you can feel a pulse for several hours. But the flow of heavy blood to the placenta and back is at an end. The little capillaries in the villi are disrupted, deprived of access to maternal blood. The blood in the baby's body needs another oxygen source, and a perfect one is available: the baby's lungs. The only safe way to practice waterbirth is to bring the baby out to where it can breathe directly after birth.

- Marion Toepke McLean, Midwifery Today Issue 54

The first hospital birthing pool happened in the 1970s in a French state hospital... At that time women were not influenced by the media or by what they read in books about childbirth. Their behavior was unpremeditated. This phase of the history of childbirth was ideal for learning about the genuine effects of a watery environment. One of the most typical scenarios (with many possible variations) was the case of a woman entering the pool in hard labor at around 5 cm, spending an hour or two in water, and then feeling the need to get out of the pool at a stage when the contractions were less and less effective. Going back to the dry land was often a way to induce a short series of irresistible and powerful contractions so that the baby was born within some minutes. From the time when such a scenario became common, the pharmacy bill of the maternity unit started to drop dramatically. In other words, we learned that the birthing pool can replace drugs.

- Michel Odent, Midwifery Today Issue 54

[Editor's note: Part III of Second Stage (Cephalic Birth) will be published in E-News Issue 4:32, Sept. 18.]

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Other Products and Services of Interest


Midwifery Today's Web-based organization that networks international midwives.

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Southern Oregon Midwifery Conference

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Packed with in-depth, fun and intensive workshops taught by Midwives, OBs, including Anne Frye LM, Holly Scholles LDM, Jan Stafl MD, Abby Hoffar LDM, Judy Edmunds LDM. Learn alternative treatment for Hemorrhage and Gestational Diabetes, Prevention of C-Section, Nurturing the Mom, Charting, Apprenticeship, etc. Preregistration required for advanced classes in Cervical Cap Fitting, Venipuncture, etc. Some meals included. CEU's for MWs & NDs Register before Sept. 15 $150, $170 after that.

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Forum Talk: Relationships

Not too many months ago I had a terrific homebirth with a great midwife. During the course of my pregnancy I came to feel she was much more than just a medical care provider; she was a good friend. I was very happy with the whole experience. Do midwives ever maintain relationships with their clients? I find that I miss the relationship I had w/ my MW. It seems a little bittersweet that I don't have any contact with someone who was such a big part of one of the most intimate, meaningful and intense experiences of my life. I know it would be nearly impossible to maintain relationships with every mom. It just seems strange, you get to know someone really well, they get to know you, they deliver your baby then... you may never see them again. Input?

- Anonymous

Go to our forums to share your thoughts and experience.

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Question of the Week: Thrombocytopenia

Q: A mum is 18 weeks pregnant and has just been diagnosed with thrombocytopenia. This is extremely rare in pregnancy. The doctors wish to treat with steroids, which she does not want. If you have dealt with this condition in pregnancy, what was the outcome? What are her chances of avoiding more complications due to her low platelet count?

- Anonymous

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Question of the Week Responses: Waterbirth and PPH

Q: I am a student midwife in my final year. I have developed a fear of waterbirth because of the connection with postpartum hemorrhage (PPH) that I have seen at each one. My mentor is fantastic and is a great believer in natural birth—especially in water—natural pain relief and no medical intervention. However, even she is beginning to doubt the use of water because of PPH. I have tried to restore my faith in waterbirth by attending conferences and reading books that inspired me, but it doesn't seem to happen in reality. Has anyone else had such an experience?

- M Thornton

A: It is extremely difficult to accurately estimate blood loss in waterbirths. The blood mixes with the water and the amount appears to be far greater than it is. It sometimes helps to put a white towel under the mother so you can watch the blood flow as it first appears and before it has a chance to mix with the water. I think hemorrhage is more rare in waterbirth than in land birth (when accurately measured) because the third stage is more likely to be physiologically managed.

- Gail Hart, midwife

A: I have been waterbirthing for 15 years and have never had a PPH because of it. I ask the woman to exit the water after about 10 minutes and then await the separation and expulsion of the placenta (physiological third stage). I have occasionally had to give IMI Syntocinon because of a heavier than desirable loss after the expulsion of the placenta but have never consciously attributed it to birth in water. Because Syntocinon is readily available to me as a nurse-midwife, my use has been to prevent the heavy loss continuing. The only scary PPHs I have witnessed have been from placenta percreta and acreta.

- Mary Murphy

A: I have attended a dozen waterbirths and have had several myself. Never once have I witnessed PPH at a waterbirth. Michel Odent's research into the subject is extensive, and he has found only positive influence of water on birth. I have witnessed several severe PPHs, all of them at births where delivery of the placenta was rushed.

- Shawna Stewart, midwife

A: I had a home waterbirth that went absolutely perfectly. My midwife had me get out of the tub as soon as I delivered the placenta to better assess my blood loss but never expressed any concern. I will certainly be planning a waterbirth for my next baby. Look into it more until you are comfortable enough.

- HM

A: I have found no such connection in my practice. Maybe it's just a coincidence, or maybe some other factor is entering in. Do you screen for nutritional and other causes of PPH?

- TW

A: I have not seen a connection between PPH and waterbirths. About 75% of the births I've attended have been waterbirths and I've never had a PPH with one—only with out-of-water births. Don't play into that fear. A midwife has to trust birth. My very first licensed birth was a 5-minute true shoulder dystocia. After that I was fearful of birth for a while. Then I realized if you do midwifery long enough you are going to experience every type of complication. You are probably very experienced with PPH now. That is a good thing. Keep the faith.


A: I cannot assure you that with enough experience you will overcome your fear of waterbirth. I have done hundreds in the past 20 years and the more I do, the more I have encountered some real problems that would have been dealt with in a safer manner outside the tub. I am not totally convinced that the warm water creates heavy blood flow postpartum, but I think the water makes it difficult to properly assess the amount of blood being lost and very difficult to instigate steps to deliver the placenta and contract the uterus. A large tub simply takes time to drain, and for me, there have been times when it would have been an advantage to the mom or baby not to have lost that time.

Last week a fourth-time mother experienced a partial abruption while pushing in the birthing tub. It was very much a struggle to resuscitate the baby (Apgars 2 and 7) on her chest in the tub and facilitate placental delivery. The outcome was excellent but took quite an emotional toll on the midwives involved.

Some mothers make better candidates than others for a waterbirth. A multip with a great birthing history would be a better candidate than a first-time mother with a large baby and borderline blood pressures, for example. Another note: Most midwives have noticed the tub artificially lowers the blood pressure. A client with mild PIH will suddenly "seem normal" in warm water (she's not). Anyone with risk factors for shoulder dystocia, hemorrhage (tired uterus, overdistended), any client with blood pressure concerns, a client with a very tight introitus (who might need good visibility to prevent tearing and the absence of warm water on a deep laceration to prevent excessive bleeding) should be encouraged to find a nonaquatic position for the birth.

I think your fear can be a good thing if you channel it into good preparation for the problems that can occur during a waterbirth (i.e., oxygen tanks ready and easy to reach, board close by to provide firm surface for CPR or resuscitation of baby, stethoscope at hand, medications near the tub to control hemorrhage, etc.), but I still feel little flutters of fear in my stomach after all this time.

- JS

A: I have also noticed an increase in postpartum bleeding following waterbirths, but I still think the benefits outweigh the risks. Now I have the mom get out right after the baby is born, without lingering and bonding in the water. If she gets help and there is a padded surface (futon or mattress) ready next to the tub, it works. I think the warm water relaxes the uterus and makes the contractions lighter, which is desirable when in active labor but when the baby is out, the uterus needs all the support it can get to push out the placenta and clamp down. Sometimes I prefer the mom to deliver out of the water if she has had a particularly long birth and potentially tired uterus at a higher risk of bleeding after birth. Some moms have chosen not to deliver in the water because of the need to get out quickly and deliver the placenta out of the water, but they are still very happy with the experience because of the soothing qualities of the water during active labor and transition.

- M. Jordan, CNM
Morgan Hill, CA

A: In my experience, the *only* instance where I have never seen a PPH happen is when the baby is born underwater.

- Michelle Carrucan, midwife

A: Before giving a clear response to this question, I would have to ask a few questions such as: What is the interval between the birth of the baby and the cutting of the cord? What, if anything, is done to prepare the mother for delivery of the placenta, such as homeopathic remedies or postpartum herbal teas? Is breastfeeding initiated before delivery of the placenta? Is there any touching or pulling or traction on the cord? Is the cord cut before delivery of the placenta? After these questions are answered, then we can discuss the incidence of PPH in association with waterbirth.

It is interesting to note, however, that both the Natural Childbirth Clinic on the Island of Malta, run by midwives and Dr. Jose Muscat, and the midwifery department at John Radcliffe Hospital in Oxford, England, as reported by Ethel Burns, registered midwife, saw a great reduction in the percentage of PPH when the birth of the baby took place in the water AND the birth of the placenta was done physiologically. The definition of physiologic third stage is no intervention of any kind between the birth of the baby and the birth of the placenta—no cutting, clamping, cord traction, or administration of oxytocic preparations or artificial drugs. Dr. Muscat based his evaluation on over 500 cases of waterbirth during several years and did a controlled trial of cases both in and out of water to verify his experiences. He found that when third stage was undisturbed there was much less PPH. Your question can only be answered when the other questions about the way a birth is conducted and the immediate postpartum period are handled. At Waterbirth International, where we have surveyed hundreds of practitioners during the past 10 years, there is not a statistically significant difficulty with PPH.

- Barbara Harper, RN
Director, Waterbirth International

[Editor's note: Responses to any Question of the Week may be sent to E-News at any time.]

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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 are 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!

Question of the Quarter, Midwifery Today magazine

Issue 64, Unity

Is unity possible in this diverse midwifery community? Can we stand up for and support one another when there is such a range of philosophical approaches to training and practice?

Please submit your response by Sept. 30, 2002, to

All responses subject to editing for content and style. Sorry, but we cannot reply to each individual submission.

With Woman

by Gloria Lemay, compiled by Leilah McCracken

About Cord Blood Collection

Never underestimate how much money can be bilked out of North American parents in the name of wanting the best for their children. I bet, in a few years, we will have a big scandal because:

  1. People paid money for cord blood storage and now the storage place has gone out of business and didn't notify anyone.
  2. Someone got the vials mixed up and now no one knows whose blood goes with whom.
  3. Some child gets HIV or hepatitis from what was supposed to cure her of cancer—oops, the vials got mixed up.
  4. There is a power failure and no one realizes all the blood thawed and now they don't know what to do.

Didn't we go through all this with sperm banks that anyone could open up with no control whatsoever? I think that as teachers and wise women, we must share this experience with the public. I have never been asked about this by clients, but I would tell them to invest their $1,500 (that's what it costs in Canada) in a midwife and/or doula, a new home freezer where they can freeze their whole placenta if they want, or their child's education fund.

I would then tell them the things I know "might" help reduce their child's chances of getting cancer:

  1. Compost, recycle and clean up the environment.
  2. Eat organic.
  3. Breastfeed.
  4. Don't take drugs in birth or Vit K after.
  5. Don't have ultrasounds (including dopplers) or X-rays.
  6. Don't sit watching TV all day.
  7. Don't vaccinate.

The cord blood-banking phenomenon is another drive-through/fast food solution to the cancer scare by a continent full of people who don't want to do the hard work of really keeping our earth and children healthy. Midwives could cause an interruption in this escapism mentality by speaking up about these types of scams.

Gloria is currently incarcerated for being a "midwife" in a Canadian province where "midwife" is a term owned and monopolized by the provincial government and their midwifery agents. To write to her, send letters (no stickers or other objects included, just paper and ink) to: Gloria Lemay, c/o 7900 Fraser Place Drive, Burnaby, BC V5J 5H1 Canada

To make a donation to her legal defense fund, please go to


There has been a lot of discussion recently between members of the UK Association of Radical Midwives about checking for the cord after delivery of the head (Issue 4:30). The feeling is that this is unnecessary, intrusive and liable to damage a woman's labia unnecessarily. Several midwives reported clamping and cutting a tight cord only to have difficulty delivering the shoulders and ending up with a hypoxic baby. I was surprised to see Midwifery Today advocating this practice.

- Anonymous

Re: long labours and baby's position [Issue 4:30]: I can confirm your statement. My daughter spent most of her last month on the right side; her back & bottom could always be easily distinguished there. She was posterior and an extremely long labour (96+ hours). My son was breech until 30 weeks, then turned himself and spent the rest of the pregnancy on my left side, also easily seen and felt. He was born in 3 hours from first contraction to delivery of the placenta. Granted, the first time vs. second pregnancy could also be the reason for the major differences in my two labours, but I will definitely pay attention to the position of my next one as an indicator of what to expect! I work with a doula and she has also noticed this in her practice.

- LS

I was so inspired by Robin Lim's beautiful quote [Issue 4:30]. I feel birth is a timeless connection—a way for all womankind to connect with the true essence of being female, the power of creation. In birth we have the chance to reach alternative levels of consciousness, the same levels our sisters from millennia ago reached, and we become part of the collective Great Female. Birth is a challenge, but a challenge spiritually. If we open to the occasion, we can be sure that our "spiritual DNA" will change. Because we have birthed and have opened to a power greater than any force a human can know, we as women have an incredible, wonderful opportunity to elevate our consciousness. The fact that birth is a unique experience to the female animal cannot be ignored. If only our culture accepted the gravity of this fact, perhaps womankind across the world would be more honored, treasured and revered. For in the process of birth, we women truly possess the ability to touch the hand of God.

- Beth Leianne Curtis, MSW, CCE

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!

EDITOR'S NOTE: Only letters sent to the E-News official e-mail address,, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


The International School of Traditional Midwifery in Ashland Oregon is accepting enrollment for February 2003 classes. Contact us at 541-488-8254 or visit us at

QUEEN JIN'S HANDBOOK OF PREGNANCY is now available for you. Secrets of raising a wise & healthy child in the womb have spread from ancient China through the Far East & now to mothers & fathers in America. or 106 pages $14.95

Better Birthing With Hypnosis. The complete Leclaire Method, classes since 1989. Books, trainings, audio and video tapes, CEU's. Call (310) 454-0920 for information.

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