November 10, 2004
Volume 6, Issue 23
Midwifery Today E-News
“Breech”
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Quote of the Week

"I have been empowered by my 'culturally unacceptable birth' [breech]."

Denise Punger


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The Art of Midwifery

A word to the wise about nutrition: Urge the women you serve to treat every day during the last couple of weeks of their pregnancy like it is the day they will go into labor. Many women and their uteruses get exhausted and give up after long hours of labor. Hospital staff often will not let women eat to replace lost energy and nutrition. So they should do it before they get there to avoid the complications that come with a tired body and uterus.

Mercedes, Midwifery Today Forums, www.midwiferytoday.com/forums/


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 mtensubmit@midwiferytoday.com.

News Flashes

University Hospital of Geneva conducted a study of 705 singleton term breech presentations, 385 of which were planned vaginal deliveries and 320 elective cesareans. There were significantly fewer maternal complications in the planned vaginal deliver group than in the elective cesarean group. Five neonates with major malformations died. There was no difference in corrected neonatal morbidity between the planned vaginal delivery group and the elective cesarean group. Risks independently associated with intrapartum cesarean were nulliparity, maternal age greater than 30 years and higher body mass index. The researchers concluded that "there is no firm evidence to recommend systematic elective cesarean section for breech presentation at term."

Br J Obstet Gynaecol. 1998 Jul. 105(7): 710-17.


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Breech Pregnancy and Birth

Meta-Analyses

In Langer et al.'s 1998 meta-analysis, all the data collected came from obstetric departments with strict selection protocols and specialized medical care available at birth. In a sample of 7,239 breech births, there was no increased risk of mortality with vaginal breech birth. They did find an increase in risk for morbidity but argue that the wide variety of definitions of morbidity makes this difficult to interpret, and draw attention to long-term follow-up studies suggesting that there appears to be no significant difference in long-term handicap between vaginally and abdominally born breech babies. They conclude that "the process of resorting to caesarean section for every breech presentation at term does not seem defensible."(1)

Weiner concluded that "when good clinical sense was applied, the selected near-term breech and term breech fetus was delivered as safely through the vagina as through the abdomen." He also pointed out that "cesarean section did not eliminate the risk of a traumatic delivery."(2)

Stein reviewed four studies comprising 2,610 breech babies. He found no significant differences in mortality or morbidity between vaginal and caesarean births.(3)

However, there are meta-analyses which suggest benefits of elective caesarean section. Spelliscy-Gifford et al. pooled studies to form a group of 3,056 women, 1,231 of whom had a trial of labour. They found small improvements in babies' outcome for the caesarean group over the vaginal group in both morbidity and mortality, though they point out that "the risk of fetal injury in either case is small." Risk for mortality was not significant when analysed alone. They concluded "the potential increased risk of neonatal morbidity after a trial of labour should be considered along with the increased maternal risk from caesarean delivery." Their study has been critisized for choosing its criteria for injury arbitrarily.(4)

Cheng and Hannah reviewed studies which included 12,278 women. Their conclusion, though apparently supportive of caesarean section is a cautious one: "The results suggest that planned vaginal delivery may be associated with higher perinatal mortality and morbidity rates than planned caesarean delivery. Because of selection bias in the majority of studies, differences in outcomes may be due to factors other than the planned method of delivery. An appropriately sized randomised controlled trial is needed to answer this question definitively."(5)

This study was criticised for including studies as old as 1972. Difficulties with data this old include nonavailability of fetal heart rate monitoring in labour and ultrasound to detect major fetal malformations antenatally, and the dramatic improvement in neonatal care which has occurred since then.

Bingham and Lilford reviewed studies published between 1974 and 1987 and found that vaginal delivery was associated with an increased risk of four deaths and four babies handicapped per 1,000 compared to caesarean section. This risk appeared to decrease in the more recent studies to an excess risk of 2 per 1,000 for vaginal over caesarean delivery. They argue that the apparent disadvantage of maternal morbidity in elective caesarean section may not be as significant as the maternal morbidity produced by failed trials of labour that end in emergency caesarean.(6)

References:

  1. Langer, B., et al. 1998. Breech presentation after 34 weeks—a meta-analysis of corrected perinatal mortality/morbidity according to the method of delivery. Journal of Obstetrics and Gynaecology 18: 127–32.
  2. Weiner, C.P. 1992. Vaginal breech delivery in the 1990s. Clinical Obstetrics and Gyaecology 35(3): 559–69.
  3. Stein, A. 1986. A cooperative nurse-midwifery medical management approach. Journal of Nurse Midwifery 31(2): 93–7.
  4. Spelliscy-Gifford, D., et al. 1995. A meta-analysis of infant outcomes after breech delivery. Obstetrics and Gynaecology 85(6): 1047–54.
  5. Cheng, M. and M. Hannah. 1993. Breech delivery at term: a critical review of the literature. Obstetrics and Gynaecology 82(4): 605–18.
  6. Bingham P. and R.J. Lilford. 1987. Management of the selected term breech presentation: assessment of the risks of selected vaginal breech delivery versus caesarean section for all cases. Obstetrics and Gynaecology 69: 965–78.

Excerpted from Breech Birth, by Benna Waites (Free Association Books: London, 2003).


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How do you turn breech babies and what do you do if you can't turn them? Find out from Mabel Dzata and Doña Irene Sotelo. Attend the Breech Birth class, part of our Eugene conference, March 17–23, 2005.
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Web Site Update

Don't miss the early registration deadline for our Eugene, Oregon conference. Save on conference fees when you register by the November 15, 2004 deadline. More info and to register.

Read this International editorial newly posted to our Web site:


Forum Talk

I need input and suggestions for a woman who has had moderate to severe labial pain, from the middle of the inner labia to up above the urethra since her birth seven months ago. She has been to her obstetrician several times and to a urologist as well. No one can "find" any reason for her pain. She said when she birthed she felt stretching pain in this region, more than she felt with baby number 1. She also had to "hold her baby in and wait for the doctor." She said by the time he came she did not want to push because the pain was so severe. Obviously, she has some physical birth trauma that is not apparent but nonetheless is real. What would you suggest to her to aid in her healing? She ranks her pain between a 3 and an 8 depending on the day and described the pain as stabbing, burning and achy.

Mary


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Question of the Week

Q: What do you do when you don't have a last menstrual period to track the conception date? I had a tubal pregnancy. After a D&C it was determined that I would need either tubal surgery or Methotrexate. I chose Methotrexate because I didn't want to have part of my tube removed. Subsequent to the Methotrexate, I was getting blood samples taken to confirm that the HCG levels were going down, and they were.

While waiting for my period so that I could start oral contraceptives, the condom broke, and I've been waiting for my period. It's late - I think. I was just getting my cycle back from 10 months breastfeeding so it wasn't regular. If I'm pregnant, what do I do? How can I determine my due date?

— Catherine Sutton


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


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Question of the Week Responses

Q: I had beautiful skin before I had children. Late in my first pregnancy my face began to break out in horrible acne. It lasted more than a year before it started to get better. At the time I had a lot of stress in my life with work, school, a misdiagnosis that had me fearing I would lose the baby, and a cesarean. I attributed it to this and the usual hormones associated with pregnancy and breastfeeding. Since I was breastfeeding, no dermatologist would have anything to do with me. I was not willing to give up breastfeeding, but I became reclusive because I was so embarrassed. Now, five years and two more births later, I still struggle with acne, but not nearly as severe. I drink tons of water and eat nutritiously. I am still nursing. Does anyone have any suggestions or insight?

— Eva

A: I would give a homeopath in your area a try. You can find out about homeopathy on the NCH Web site: www.homeopathic.org. Homeopathy will not interfere with nursing. It will help you "heal" naturally. You can also search for a homeopathic practitioner close to you on that Web site.

— Kim Costa, RN BSN IBCLC RLC

A: Check out rosacea and PCOS (polycystic ovarian syndrome). Both conditions have an onset in the childbearing years due to hormonal changes. A dermatologist may know exactly what it is just by looking at your skin and asking a few questions.

— Elaine

A: I too struggle with acne, although I had a little respite from it during my pregnancy and for a year and a half once my son was born. Your diet does not seem to be the issue; in my case it is not, either. I tried a variety of natural healing techniques to no avail until recently when I came across a book called Dr. Chi's Method of Tongue and Fingernail Diagnosis and started taking some of his herbal formulas (especially Chi-F, which balances hormones). After three weeks of taking the herbs I notice a definite improvement.

— Jenn

A: I, too, went through this with my first child, and I started using Proactiv. It has almost completely cleared my skin of all acne. Now I use it just as a preventive against breakouts. I was very skeptical at first as I had seen it in an infomercial, but I was so desperate that I would try anything. More information can be found at www.proactiv.com.

— Anon.

A: We have had excellent results with a product called "Nature's Cure," a homeopathic remedy sold at Walmart in the cosmetic department. A tablet in the morning and the evening and a face cream once a day is all that is needed. It's safe and it works!

—Anon.

A: You might want to have your thyroid levels checked. Pregnancy can cause a previously normal thyroid function to become altered. Some people with hypothyroidism experience increased acne. For some, treating the hypothyroidism greatly decreases the severity and frequency of their acne. Find a doctor who will take your concerns seriously. Get your TSH and Free T3/Free T4 levels checked. Keep in mind that some "borderline normal" levels accompanied by symptoms may actually benefit from a trial of meds, too. Although it's still controversial, some docs are coming to believe that a much narrower range of "normal" is actually most desirable. Do some research on thyroid issues (see www.thyroid-info.com/articles.htm) and discuss what you find with your doctor.

— Anon.


Q: Has anyone had a mom who bleeds excessively? This mom has done many herbal/vitamin supplements to build her blood and still has a history of excessive bleeding prior to delivery of the placenta. As her uterus clamps down to deliver the placenta, there is a significant gush of blood. Pitocin has been the only thing her previous midwife used that was effective, but I am looking for an herbal remedy.

— Robe

A: I'm a mom of two who hemorrhages like this after birth. With both births I was given Pitocin immediately following (it was administered via IV in the hospital w/ my son and a shot in the perineum after the birth of my daughter at home). After my son's birth the attending doctor told me I'd lost three pints of blood, "about twice the normal amount." That was a sobering thought, considering I refuse blood transfusions.

During my pregnancy with my daughter my midwife had me taking red raspberry leaf capsules (6/day), drinking one-quarter cup of chlorophyll daily (to boost iron), and I drank red raspberry leaf and mother's milk teas. I also discovered that the homeopathic remedy erigeron canadensis helps stop hemorrhaging after birth. I still lost a considerable amount of blood but I think it may have been because I hesitated to take it until some time had gone by. I still think it worked, though, because the bleeding wasn't as much as what I lost with my son's birth. I've also heard of some moms who eat a piece of placenta or put a small piece under their tongue and the bleeding stops.

— Carrie Cooling, Fredericksburg, Texas


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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Feedback

Regarding post-cesarean uterine repair [Issue 6:22]:

I observed two uterine repairs this year. One physician did the repair by enclosing from the exterior edge through to the inner edge of each side of the wound of incised uterus and bringing the sides together. She did repeat the process. Even though there were two rows of stitches, this is a one-layer repair. The other physician placed the stitches from the interior of the uterus through half of the body of the uterus on each side of the wound, bringing the inner layer together. Then the second layer was brought together by going from the exterior to the middle to close the wound completely. There was a huge difference in the look of the integrity of the uterus. The first looked rough and ragged; the second looked smooth and closed. I have found that physicians' surgical reports do not make it absolutely clear as to how the sutures were placed to differentiate between rows or layers. I'm also not sure physicians always know the difference.

Elaine Taylor, CPM, LDM


I am a nurse who has been working in the homebirth field for about 27 years. In this current atmosphere of fear and anxiety regarding the flu and the shortage of flu vaccine, I have to question the protocol that has been set up wherein pregnant women and children are given priority for receiving the flu vaccine. How can it be safe for pregnant women and children to receive the vaccine when it is preserved with thimerserol (mercury)?

Joy Jones


In response to homebirth quote critique by Marigold Hibbert of Cedartown, Georgia [Issue 6:22]: I am very happy to hear what an amazing birth you had. After all the research and effort you put in, you deserve it! I think it is great to let others know how amazing a hospital birth can be when the right set of people and ideas come together. I had just such a birth as well, that included two midwives, a doula, my husband and mother-in-law. Through a lot of effort and research, I was able to have a birth that was not a "medicalization of her [my] body's normal function."

However, I truly understand what the quote was saying. I also had a homebirth with my first child. "When a woman births at home, it is a demonstration of civil and medical disobedience that defies the medicalization of her body's normal function while it honors her inherent, amazing power" [Issue 6:20]. No one asks you if you are going to birth at a hospital or at home - they always assume a hospital. When people found out I was going to birth at home, with my first baby - Horrors! You'll die! The baby will die! Little did they know that a homebirth was as safe as or safer than a hospital birth. I made sure they did by the end of our conversation.

Both experiences were great, and I give all the credit to the midwives. They had already fought a lot of battles with the hospital on my and other moms' behalf. However, there are so many things that I couldn't do at the hospital that I could at home, such as eating, relaxing in a tub, getting away from laughing nurses, etc. I had a lot more leeway at home than I did at the hospital.

The real question I always ask is, Where are you and your chosen birth team going to feel the most comfortable? If it is at the hospital, then that is absolutely where you should be. If it is at home and you are a normal healthy mom, then you should be at home.

Thank you, Marigold. The more people who bring safe natural birth to the hospital, the more they see how amazing and wonderful (and cheap) it can be for them. And thanks to all the ladies who birth at home. The more business the hospital loses to homebirth, the more people will see homebirth as a viable choice, and the more the hospital will see that their methods are based on shoddy assumptions.

Karen Crow, AAHCC


Sunset is the time the State of Texas decides whether to keep the Texas Midwifery Board or not. It could also be decided to move the Midwifery Board under the Nursing Board in an effort to consolidate the number of boards needing management and review. If the Midwifery Board ceases to exist, midwifery and homebirth will also cease to exist. If the Midwifery Board is moved under the Nursing Board, the Texas Medical Association (TMA) will be able to control and dissolve Texas midwifery by summarily rewriting the Midwifery Rules of Practice. For example, changing the rules to require midwives to have physician back-up in order to practice, which opens the door to doctors refusing to give the midwives back-up, can make it impossible for them to practice legally. This situation has the ability to change the family freedom to select midwifery and homebirth in Texas.

In the past, TMA has taken subtle action against Certified Nurse Midwives - some hospitals in Texas abruptly ended their CNM programs while citing expense as the excuse. Another obvious attack on midwifery was TMA's blatant stalling and opposition during the rules revision process of the Texas Midwifery Board - TMA held it up for over a year. TMA has taken extreme measures to shut down midwifery in Texas. Their efforts have included lobbying for an insidious midnight amendment which would give them the right to rewrite the midwifery rules and eventually make it impossible to legally practice midwifery. Their representatives at the last legislative session made it clear that they intend to try again at the Midwifery Board Sunset Review. They intend to remove midwifery from Texas family care. This is the time when supporters and consumers can communicate the need for access to midwifery and homebirth.

For more information and background about Sunset Review, the significance for midwifery in Texas, and why consumer action is essential, see: www.tfmidwifery.org/Sunset.htm and www.tfmidwifery.org/The%20Sunset%20Risk.htm

Zoie Hawley


Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


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