Second Stage: Cephalic Birth
Part 3
The other method for applying gentle downward pressure on the baby's head is to apply one palm to the top of the baby's head, fingers pointing toward the baby's face and the other hand on the underside of the head, fingers pointing toward the baby's face. If the baby restituted facing the mother's right thigh, the right hand would be the top hand; if it restituted to the mother's left, the left hand would be on top. With this method, the fingers never come into contact with the fetal/newborn neck. This is the technique I recommend for beginners, although it is awkward unless you are standing to one side or the other of the mother's legs. When you are sitting between the mother's legs, it is necessary to shift your body in the opposite direction to which the baby restitutes so you can apply your hands properly.
Once the top shoulder impinges under the symphysis pubis, the next action is to draw the head and body upward toward the sky to birth the baby following the Curve of Carus. To securely hold the baby, your hands must support the head with the fingers spread open, applying support to both the head and the shoulders. The hands and wrists sandwich the baby's emerging body. All that is needed now is to place the baby on the mother's abdomen, cover and dry. The baby has safely been received into this world.
When receiving the head of a direct occiput posterior baby, the technique for flexing the head requires lifting and gently pushing upward on the emerging occiput (forehead). To place downward pressure at this time would deflex the head prematurely, causing the larger occiput frontal diameter to birth, possibly stretching or tearing the vaginal tissues. All other maneuvers would be similar to the occiput anterior delivery.
The best way to learn these techniques is to practice many, many times with a doll and pelvis or a similar model. This enables motor memory of the moves needed to catch a baby so when the time arrives for your first catch, your hands will have already learned the movements. The explanations given in this series appear lengthy, but in actuality the experience will go by much more quickly.
- Kimberly Hulsey, LM in The Birthkit Issue 29
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Forum Talk: Breech Birth
Have any doulas been with a woman during a breech birth? What was your experience and how did it differ from other births?
- Sarah
To share your thoughts and experience, go to Midwifery Today's Forums.
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Question of the Week: Herpes
Q: I have a client who has herpes. She hasn't had an outbreak for a year, but she is concerned that labor (pain and her fear around it) will trigger an outbreak and lead to a c-section. What are her options? How do I learn more as her doula? Is there anything she can do (herbs, visualizations, etc.) to lessen her chances of an outbreak while keeping the baby healthy?
- Tasha
Send your responses to mtensubmit@midwiferytoday.com.
Question of the Week Responses: Thrombocytopenia
Q: 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
A: Thrombocytopenia was treated with regular platelet infusions to avoid any maternal and foetal difficulties. Outcome: healthy baby, happy mother.
-Anonymous
A: I cared for a woman in conjunction with an obstetrician and haematologist with idiopathic thrombocytopaenia which developed in pregnancy. Her platelet count got as low as 60,000. She had no treatment because the haematologist's policy was that as long as she was symptom free—i.e., no bleeding or bruising—not to treat unless her platelet count fell below 50,000. Both the obstetrician and the haematologist were supportive of her having a homebirth and a physiological third stage, which she indeed went on to have.
-Sue
A: Idiopathic thrombocytopenia purpura is just that—unknown cause for low platelets. I have followed many women with this condition. Most times it is not a problem. If the platelets stay above 100,000 I deliver out of hospital. If the platelet count goes below 100,000, the docs give steroids, and the count goes up and stays up. While theoretically the woman could develop bleeding, I have never seen it and most do really well without treatment.
-Lonnie, CNM, ND
A: One would have to know what the platelet count was. If it is below 50,000 then it would be very worrisome indeed. Some ladies develop an immune throbocytopaenia during pregnancy and it is usually benign. The patient should have her platelet count followed probably every two to three weeks. The size of the platelets is important as well as the shape of the red cells. I don't think that steroids would be necessary in all cases. It probably wouldn't hurt to involve a haematologist.
-Henry Mueller
Greenville, PA
A: Follow with platelet counts. Steroids probably aren't needed unless the count is 60,000 or less. Because there is a greater tendency to bleed, hospital birth probably is more prudent.
-Peg Browning, CNM
A: I am a nurse in labor and delivery and an aspiring midwife. Recently, a client was admitted for what was thought to be a normal and uncomplicated delivery. After her lab work was returned, it was discovered her platelet count was 5,000 and her white blood count was elevated. The mother delivered with no complications, no hemorrhage. In her previous vaginal deliveries, she had experienced retained placenta and hemorrhage. Unfortunately, she was diagnosed with acute cystoblastic leukemia. The baby had no difficulties with the birth transition and breastfed beautifully.
-Aimee
Editor's note: Responses to any Question of the Week may be sent to E-News at any time.
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 print 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 editorial@midwiferytoday.com.
All responses subject to editing for content and style. Sorry, but we cannot reply to each individual submission.
With Woman: Meconium
by Gloria Lemay, compiled by Leilah McCracken
Should Women be Induced to Prevent Meconium Staining?
The philosophy that women should be induced to prevent having a baby with meconium in the amniotic fluid ignores the possibility that the induction causes the passing of meconium. I have seen a lot of late babies in my career. We seem to grow them big and late up here in the Pacific Northwest, just like the trees. I very seldom see meconium in the amniotic fluid of 42-week plus babies.
I associate meconium in the amniotic fluid with smokers (dope or nicotine) in the few cases I do see. Every time a woman smokes a cigarette it has the same effect of putting a pillow over a baby's face. When the baby is getting mature it can evacuate the bowel as a response to oxygen deprivation. When we're scared, smothered or choked, we poop or have diarrhea as a defense. When they used to hang criminals by the neck, they knew that they would poop once the oxygen was cut off.
If there is meconium in the waters, the last thing to do is cut off the oxygen supply, which is exactly what happens in hospital in order to "help" the floppy, meconium-stained baby: The cord is cut immediately after birth. This forces the lungs to draw in the meconium that is really unsuctionable in the lungs (they can only go into the nose, mouth, and trachea). But if the cord is intact and the heart is pumping well, oxygen will keep circulating to the baby, and the baby will have a chance to cough, sputter, gag, phlegm up some gunk -- all the things we do automatically if we go face down in a mud puddle to clear our airways and lungs.
Meconium is not really a problem. It's a wake-up sign for the practitioner to watch for distress, but it's estimated that only 10% of the time it is distress. The other 90% of the time it means nothing. So, to induce thinking you're going to prevent is ridiculous.
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 www.birthlove.com/gloria.html.
I talked to Gloria on the phone recently. Here is what she has to say about how she is doing:
"I am well and happy and with good people. I am using the opportunity to have a rest from being on my pager and being responsible for people's births. It warms my heart to know that my sister birth attendants in Vancouver are stepping into my role and doing a brilliant job. I am really focusing on areas of my life that I need to work on in order to be fit and healthy. When I get out of here, I'll be a better birth attendant than before."
While it is admirable that she is using her time behind bars in positive ways, the fact that she is there at all is a grave insult to caring, gentle people everywhere. We must appeal this sentence. If left without appealing, this case will color how women in BC and beyond are forced to give birth, severely limiting choice and freedom. Homebirth attendants will be brought before the courts for as little as keeping a box of gloves in their birth bags, and women will be forced to choose attendants and birth places they instinctively resist, leading to unnecessary interventions and pain. The implications of this case are chilling.
-Leilah McCracken
Feedback
Re: checking for a nuchal cord [Issue 4:30]. I do not routinely check for a nuchal cord after birth of the head. If the baby does not restitute, or if the delivery of the head was much slower than expected, I will check for a cord. I will also check if the shoulders do not deliver with the next contraction after birth of the head. On the other hand, I have never seen any damage (tearing) caused to the mom by checking for a cord. The moms, for the most part, definitely don't like it, though.
- Edie Wells, CPM
Beloit, WI
I too was surprised to read this outdated and unnecessary step in E-News. It is neither useful nor appreciated by women, and as the midwife said, what if you cut the cord because you checked and found it around the neck and then had a shoulder dystocia to manage? That baby would be better off by far with the cord still intact.
We all learned a variety of outdated/unnecessary procedures in our training such as suctioning on the perineum (only appropriate with thick/gloppy or fresh meconium) or suctioning as an automatic step during neonatal resuscitation. To keep our practice up to date and evidence based, it's important to read from a wide variety of sources. I highly recommend the Association of Radical Midwives' Web site to all midwives, as well as the Association for Improvement in Maternity Services' Web site.
- SJ
I had a fantastic experience with waterbirth. I had a hospital birth with my first son, and it was nothing short of disastrous. I did manage a vaginal delivery but not without an episiotomy with an extended tear. My second delivery was amazing (home waterbirth). I had no problems whatsoever with postpartum hemorrhage, and I didn't even tear! I recommend this method of birthing.
- -Tina Henry, doula
There is so much conflicting information concerning radiation. When you're not pregnant, at the dentist's office they will tell you their X-rays have such low levels of radiation that you get more radiation while you're out on a sunny day or by flying cross-country. But they advise against X-rays when you're pregnant, to (understandably) avoid unnecessary radiation. If by flying or being out on a sunny day one gets the same amount (or more) radiation than from dental X-rays, then shouldn't we be warning pregnant women not to fly and to stay out of the sun when they can? What about nonpregnant women getting suntans/sunburns on their bellies? Does that radiation get through to ovaries and do any damage?
- Anonymous
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