|March 19, 2003|
Volume 5, Issue 6
|Midwifery Today E-News|
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THIS WEEK’S ISSUE
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Quote of the Week
“We are accustomed to thinking that we know what we know from what we have observed, but it is just as true that how we practice sets up what is observable in the first place.”
— Barbara Katz Rothman
The Art of Midwifery
White oak bark tea will kill a yeast problem on the skin and taken internally will help keep yeast down. Also, oil of oregano capsules (a natural nemesis to yeast) or grapeseed extract taken internally will help destroy yeast in the body. Avoid fermented food such as vinegars, beers, and wines.
— Joan M. Dolan
ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to firstname.lastname@example.org.
Rhesus monkey mothers can defeat a bad gene. A National Institute of Child Health and Human Development study reports that infant monkeys who have the short allele of the serotonin transporter gene, which increases the likelihood of overly anxious behavior and heightened inability to pay attention, behave normally when raised by their mothers. Conversely, when neonates with this gene variant are raised with their peers in nurseries, they show characteristic behaviors associated with this gene form. The research involved 36 mom-raised monkeys and 79 cared for in nurseries. Researchers tested the animals on four occasions during the first 30 days of the animals' lives. The study labels the impact of mom's care "maternal buffering." The researchers presently are trying to identify just exactly how the connection works. The leader of the research team surmises that it has to do with the quality of care that the young are getting from the mother.
— Mol Psychiatry, 7:1058-63, December 2002
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If practitioners accept the false notion that perinatal mortality “doubles by 42 weeks,” they will be anxious to conclude pregnancies well before that date. Others will use a new study comparing induction at 42 weeks with induction at 41 weeks (showing a decreased cesarean rate) as a jump-off point to reason that inducing at 41 weeks or earlier is better than spontaneous labor at a later date. This is not what the study shows. It merely shows a slightly lower cesarean rate when comparing induced labor to induced labor. It does not compare induced labor to spontaneous labors. Large studies have been done about that question and show rather clearly that waiting for spontaneous postdate labor results in less cesarean without any rise in the stillbirth rate (1,2).
One study stands out in particular (3). This was a retrospective study of almost 1800 post-term pregnancies with reliable dates compared with a matched group that delivered "on time" (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56/1000 in the post-term and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia, and cesarean were almost identical. The rate of fetal distress and instrumental delivery and low Apgar was actually lower in the postdate group than in the on-time group. This is only one of several studies showing postdate pregnancies can be safely monitored until delivery.
— Excerpted from “Induction & Circular Logic” by Gail Hart, Midwifery Today Issue 63
1. R. Matijevic, “Outcome of Post-term Pregnancy: A Matched-Pair Case-Control Study,” Croat Med J 39 (4), 430-434 (1998).
2. J.D. Yeast et al., “Induction of Labor and the Relationship to Cesarean Delivery: A Review of 7001 Consecutive Inductions,” Am J Obstet Gynecol 180 (3), 628-633 (1999).
3. D Weinstein et al., “Expectant Management of Post-term Patients: Observations and Outcome,” J Matern Fetal Med 5 (5), 293-297 (1996).
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Occasionally the uterus becomes hypertonic [after induction]. That is, it clamps down on the baby with strong contractions lasting two minutes or longer, and this reduces the flow of blood. In normal labor, contractions squeeze the baby as if it were being hugged tightly. Blood flow is lessened at the height of contractions but is increased as each one finishes. In induced labor there is a risk that this rhythm is lost and that the uterus goes into spasm. The result is that the baby's heartbeat becomes either very fast (tachycardia) or slow (bradycardia). At birth the baby may need resuscitation and be taken to the intensive care nursery for observation.
— Sheila Kitzinger, Birth Your Way, Dorling Kindersley, 2001
Nichols CW. Postdate pregnancy. Part I. A literature review. J Nurse-Midwif 1985a; 30(4): 222-239.
Most postdate babies are not postmature. “Women have been subjected to the hazards and emotional hardships of an induced labor without apparent benefit.” Except when done between six and 12 weeks menstrual age, ultrasound dating has a margin of error greater than dating by LMP. Primiparous women average longer pregnancies than multiparas, and the average gestational length is longer than 280 days. All clinical dating methods, including the LMP, have margins of error of more than two weeks. Comparing the LMP to ovulation dates from basal body-temperature records, one study found that 70% of pregnancies classified as postdates were misclassified. Another found the proportion of pregnancies classified as postdates by the LMP was 15.5% versus 4.5% by ovulation date. Only two of 110 babies were postmature, and one was not postdate. One day should be added for everyday the cycle exceeds 28 days.
We have no accurate way to identify postdate fetuses at risk. Fetal movement counts are not sensitive enough. Neither hormonal assays nor placental grading are reliable. The incidence of meconium-stained fluid increases abruptly at 38 weeks, but this relates to maturing reflexes, not distress. Oligohydramnios associates with growth retardation, thick meconium, and fetal distress and may have value [but false-positive rates are high]. The CST appears to have a lower false-negative rate than the NST, but this is based on nonrandomized studies. Several studies have shown nipple stimulation to be as safe and reliable as an oxytocin drip for the CSYT as well as cheaper, easier, and faster. The biophysical profile accurately predicts fetal distress at extreme ends of its scale. [What about midrange scores?] Two studies found no increase in abnormal FHR with postdatism.
Studies of management have not found that tests accurately identify postmature babies or that routine induction improves perinatal outcome. Epidemiologic studies have found that much of the excess perinatal mortality in the postdate population is due to outer factors: congenital anomalies, infection, or IUGR. The postmature infant is relatively rare. About 10% of pregnancies are postdates, of which 5% to 26% result in postmature babies.
— From Henci Goer's book Obstetric Myths Versus Research Realities:
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