|August 4, 2004|
Volume 6, Issue 16
|Midwifery Today E-News|
“Herpes Simplex II”
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Quote of the Week
"We cannot birth our babies through sheer force of will. We need to learn the more subtle, the equally powerful, path of surrender."
— Sarah J. Buckley
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The Art of Midwifery
Bellis: Often used with older moms and multips. The mother may complain of hip pain that stays even between contractions. I used this remedy once on a mom with twins who had trouble getting into good labor. The hip pain alerted me to the remedy and within minutes, she was in less pain and much better labor and the babies shifted and came quickly.
— Lisa Goldstein
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One in four Americans between the ages of 18 and 59 tested positive for HSV-2, the virus that causes genital herpes, in a survey of patients of 36 randomly selected primary-care physicians in six cities. Only 4% of all 5,732 people tested reported a history of the condition. The incidence rate was high across a variety of economic classes. Prevalence ranged from 13.4% in the 18 to 29 year age group, 25.2% in the 30 to 39 year old group, 31.2% in the 40 to 49 year old group, and 28% in the 50 to 59 year old group. More women than men tested positive (28.3% and 22%, respectively). The sample was 75% white, 14% African-American, 4% Hispanic; 80% were employed full- or part-time, 74% had some college or higher education, 45% had a household income of $60,000/year or better, and 68% were married or living with a partner.
— Women's Health Weekly, June 24, 2004
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Herpes Simplex II
Only about 1 in 5,500 babies gets neonatal herpes, even though the virus is widespread in the adult population. Neonatal herpes is not a reportable disease in most countries, so there are no hard statistics about the exact number of newborns affected. However, most researchers estimate there are between 1000 and 3000 cases a year in the United States, out of a total of four million births. To put this number in greater perspective, an estimated 20-25% of pregnant women have genital herpes, while less than 0.1% of babies contract an infection. Although remarkably rare in newborns, herpes outbreaks can cause severe damage to those who are infected with the virus.
Transmission rates to the baby are lowest for women who acquire herpes before pregnancy. One study (Randolph, JAMA 1993) places the risk at about 0.04% for such women, who then have no signs or symptoms of an outbreak at delivery. The chances of transmission are highest when a woman acquires genital herpes late in pregnancy. With monogamous partners, this is a very rare occurrence.
Medical practitioners are concerned about release of the membranes for longer than four hours when a woman has a herpes outbreak. Great care must be taken not to release the membranes. The speculum exam should be the only pelvic exam. Internal scalp monitors must not be inserted because insertion can infect the child through the scalp puncture.
Dangers to the baby who develops herpes include death (60% mortality rate), herpes encephalitis or aseptic meningitis (inflammation of the brain or spinal cord), which, in turn, leads to neurological damage. The first symptom of disease in the newborn may be a sore on the skin, which can be tested with a fluorescent stain to diagnose it as a herpes lesion. If left to develop into full-blown herpes, it can cause the baby's death, brain damage, or blindness. Early treatment is imperative if there is a suspicion that a baby might have a herpes skin eruption. Premature or otherwise compromised babies are at greater risk when a woman has a recurrent outbreak of HSV II.
During an outbreak of herpes in pregnancy, have the mom take 1000 mg lysine three times a day along with vitamin C (500 mg 3 times a day). If the woman is having recurrent outbreaks in pregnancy despite all the preventive measures taken, at 36 weeks the midwife may suggest she take Acyclovir 400 mg BID daily until the birth. This helps prevent outbreaks at term but is harmful to the baby's liver.
After the birth, the mother and breastfeeding baby should be kept warm and skin-to-skin. Rest for the mother is extra important. Nourishing fluids and extra vitamin C after the birth is recommended. Visitors should be kept to a minimum, told to wash hands carefully before entering the mother's room, and asked to leave if they have an oral herpes outbreak.
— Gloria Lemay, "Herpes Simplex II," compiled by Leilah McCracken for The Birthkit Issue 37
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Question of the Week
Q: I have attended nearly 100 births as a doula/midwive's assistant. Until recently I had never seen an episiotomy, even in teaching hospitals with severe OB/GYNs. My most recent birth was attended by the most natural-minded hospital-based CNM practice in our city (we have no birth center and no CNMs with OB/GYNs). I refer many of my clients to them knowing they are pretty much on the "same page" as my philosophy supporting evidence-based practice.
After almost four hours of pushing, the mom was becoming exhausted. She was too tired to push in any other position but on her back, at about 30 degrees. She refused to push on her side because she had back pain. It was quite some time before baby remained visible on her perineum. The midwife (who I greatly respect) eventually stated that she had the type of perineum that "episiotomies were meant for" (she said this mom's was long). She told the client she was going to cut a small episiotomy and then proceeded to cut a 2-centimeter midline episiotomy and promised the baby would come on the next push. She did so without consent, and before I could say the entire phrase "Could she sit up more?" (the baby was showing some distress, but I assume it was because of the mom's flat position).
When is it truly OK to do an episiotomy? As a future midwife, how will I know when to go ahead and cut? I am not sure I could do it. How about you homebirth midwives out there? Ever have to cut one? I would like to know some rules/guidelines, because everything I have researched has told me they should rarely be needed. I am still healing from mine more than 16 years ago!
— Brigitte Rhody, student RN, Bradley Method childbirth educator and labor assistant
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Question of the Week Responses
Q: I recently met a mother of four who nursed all of her children. She is adopting a 6-9 month old baby by the end of the year and really wants to breastfeed. She says she will try to nurse, but will be thrilled if she can at least give the baby bottles of breast milk. What advice might I pass along?
A: I would recommend this mother rent a hospital-grade double electric breastpump. She should pump 8-10 times per day, start at ten minutes and build up to 15. Having had four children and nursed them, relactating may be quite easy for her. She can also try taking fenugreek which will help increase her milk supply.
It is difficult to tell what her supply may be for a 6-9 month old baby. She may need to use a Supplemental Nursing System (SNS) to nurse her baby, who has probably had bottles all his life. This can be purchased from a board-certified lactation consultant, and I would definitely recommend she consult one for assistance to relactate for an adoptive baby.
— Lisa Petrino, RN IBCLC
A: I am a certified lactation counselor and mother of five. Because your acquaintance has nursed other children her chances of being able to breastfeed an adopted baby are very good. She would do well to start pumping a few weeks before her adopted baby arrives. I would recommend that she use a hospital-grade electric pump and that she pump for 15 minutes on each side every 2-3 hours during the day and every 3-4 hours during the night. She can freeze the milk - it will keep for up to three months in the freezer on top of her fridge. Once the baby arrives it may take some time for the child to learn how to latch on, but with time, patience, and sound lactation advice they ought to do well.
— Holly Sippel, CLC
A: About 2 months before she brings the baby home she should start to prepare herself physically and emotionally to breastfeed. If she is currently breastfeeding a baby or toddler, she can pump (and store) to help increase her milk supply. "Breastfeeding the Adopted Baby" by Debra Stewart Peterson and "The Womanly Art of Breastfeeding" from La Leche League International are very helpful books; she will be able to find practical tips, solutions to problems should they arise, and resources. The SNS is helpful if she is unable to relactate or induce lactation; this supplementer can be used for a couple of months or even several months while she works to relactate. A lot of adopted moms use this, and after the milk is established they stop using it.
Joining groups such as LLL and/or a group for breastfeeding adopted babies, if there is such a thing in her area, will be of benefit; being around other nursing moms may help her become more comfortable with the thought of nursing and nursing in public. If she runs into any problems, they most likely will be able to make helpful suggestions.
— Michelle Schnaars, CCCE, Lafayette, LA
A: While working as the RN in a pediatric office I had a mom come in who had adopted a baby. She had other children and had nursed them. With the aide of a bag of milk above her breast and a very small tube going down to her nipple the baby nursed and got milk in return. Eventually with much persistence, fluids, and time the mother's milk came in and the baby nursed successfully.
— Linda B. Jenkins, RN
A: Your friend should find an International Board Certified Lactation Consultant (IBCLC) experienced in relactation. One site with listings of IBCLCs is http://www.iblce.org. She has two issues here: the first is to bring in a milk supply. Having had four children who have nursed, it's possible with disciplined effort using galactogogues and/or pumping on a regular basis. It seems she has plenty of time to prepare for this baby's arrival. The second issue is getting an older baby to latch on. The older the baby, the more challenging this may be, but you don't know until you try. Your friend should remember that in an adoptive/relactation situation any breastmilk is a success, and also any skin-to-skin contact is comforting. A baby feeding from a bottle could still be held to the breast (cheek to breast) while taking a bottle or comforted by co-bathing. It is wonderful to me to hear of mothers who are researching this option.
— Denise Punger, MD FAAFP IBCLC, Fort Pierce, Florida, 34981
Re: Extended pushing [Issue 6:15]:
A: I would be interested in knowing more information about what "pushing for 18 hours" means. How far apart were her contractions, was she pushing at each of them, etc.? I have been at two births where from the first push until the birth of the child was around 18 hours, but both of them included a period of hours where the contractions slowed or stopped and the mama was able to breathe through them or even sleep for a few hours. This break gave her a rest and revitalized her so that when pushing began again, she had much more energy. In both cases we continued to monitor mom and baby, and when everything showed to be fine, we trusted the mother's body. Both moms delivered their babies with 8-10 APGARS. One needed a bit of shepherd's purse for bleeding, which resolved immediately after one dose.
If we had transferred these women, they would have had c-sections, but by monitoring and trusting in birth, they had healthy birth experiences at home and were spared an unnecessary c-section. If at any time they had preferred going to the hospital, we would have transferred them, but both felt that they were safe and healthy and wanted to trust their bodies and their babies. I think this situation ("pushing" for 18 hours, a stop of descent and contractions) seems pathological and abnormal because we don't allow ourselves to see these births—we transfer after a few hours and don't realize that they can be a variation of normal.
There was a time when we didn't realize it was normal for a woman to have a lull after reaching 10 cm, before pushing, because we didn't allow that to happen; dilation = pushing. Once we allowed women's bodies to do what they wanted, we noticed that this break is common and sometimes helpful. I think the same can be said of the second stage; if we monitor and trust healthy babies and moms, we will see that this can be a rare occurrence, but a variation of a normal, healthy birth.
— Gillian, apprentice midwife
A: Yes, instincts do have to "kick in," and some of a midwife's work is to use instincts. However, there is a baby's health and life itself that's at stake here! At some point we have to remember that we are not in control. Someone else is running the world, and if some women are meant to transfer and have a cesarean, thank G-d there is that option. We have to be a bit balanced here. I have attended more than 300 births, albeit as a doula (homebirths included) and been involved in a doula organization in Israel. When we have seen a cesarean done it saved the mom and /or the baby's life. Who is speaking up for that baby's rights when he/she is going through intense contractions and 18 hours of pushing?
Keep balanced, ladies.
— Sarah Goldstein, Jerudoula
Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to email@example.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
Operation Doula Care (ODC) is a program that provides volunteer doula services to women whose husbands are in the military and who are currently deployed in support of Operation Iraqi Freedom or Operation Enduring Freedom. This is a much-welcomed and needed program where at Ft. Bragg there are currently 60,000 troops deployed.
I am writing about the increasing use of Cytotec in our military installation hospitals. Cytotec or misoprostol (chemical name) is in increasing demand in our military hospitals because of its cost effectiveness. Cytotec is similar to prostaglandin gel used to commence inductions. However, where prostaglandin gel is PEG2, Cytotec is a PEG1 - there is a BIG difference. Searle, the manufacturer, states on its package inserts, "Cytotec is contraindicated for the use in pregnant women" in big bold print. As if that weren't enough there is even a picture of a pregnant woman with a red circle around her and a red slash over her body. This drug may be cheap, but it is a hideous medication that can cause such adverse effects as uterine hyperstimulation, fetal distress, uterine rupture, hemorrhage, hysterectomy, amniotic fluid embolism, and maternal and fetal death.
A high percentage of the mothers who are in the military healthcare system are uneducated about medications that are used in today's hospitals. Cytotec is the biggest one. A few of the physicians and midwives I have encountered at the hospitals nonchalantly mention the use of this drug as the way they are going to start induction. Our mission as a doula is to help our clients make informed decisions. Make sure you educate your clients about this potentially deadly drug…PLEASE!
Searle has a toll-free number that you can call from Canada or the United States to report complications that your clients have had from the use of this medication. They will not ask your client's information; they will ask yours, so it is not a breach of confidentiality. Searle is actively trying to get the warning label changed from, "contraindicated" to "prohibited." I only wish I had had the information that I needed about this drug to prevent my client from nearly losing her life and preventing what was to be a perfectly healthy son from becoming severely mentally retarded due to blood loss and lack of oxygen. Grave error on my part, but now I know to spread the word to help others who may not be aware.
— Jennifer K. Tallis, CD, NC State Rep. Operation Doula Care
Editor's note: Read more about Cytotec.
I have a subchorionic hematoma. I am 19 weeks pregnant with two children at home. Information about this condition is very limited. So if anyone can help with information, please do. I do have vaginal bleeding, dark brown spotting, pink mucus, small clots, cramping, and occasional bouts of diarrhea ever since I first had bleeding at 16 weeks and was diagnosed with a subchorionic hematoma. Please help! My e-mail address is: firstname.lastname@example.org
— Jada Peck
Re: Pitocin/active management [Issue 6:14]:
I just attended a homebirth apprentice workshop that covered hemorrhage. I learned that there is a rather wide range of what is considered hemorrhage. What a relaxed homebirth careprovider considers normal bleeding with birth seems to be much more than what a conservative hospital-based care considers to be a hemorrhage. It's almost like the goal of a hospital birth is to eliminate bleeding at all which makes no sense.
Editor's Note: Only letters sent to the E-News official e-mail address, email@example.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.
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Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out!
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