Research to Remember
Epidural Anesthesia Leads to More C-Sections
Despite recent headlines to the contrary, the results of a flawed three-year study published in the New England Journal of Medicine did not show that early epidurals are safer than late epidurals. The real news was that so many of the first time mothers even had cesarean sections—17.8% of those who had early epidurals versus 20.7% of those given epidurals late in labor. To read Esther Marilus' thought-provoking response to reporting on this study, go to:
Tea Tree Oil and MRSA
An alternative to the use of mupirocin to treat methicillin-resistant Staphylococcus aureus (MRSA) was sought in a study at University of East London Department of Life Sciences. Mupirocin has been found to exhibit unpredictable levels of resistance to MRSA. Isolates treated with tea tree oil conforming to International Standard (ISO 4730) were found to be susceptible to the oil; 64 of them were MRSA and 33 were mupirocin-resistant MRSA. The study revealed very uniform susceptibilities of MRSA to tea tree oil. The researchers concluded that tea tree oil may be an effective and more predictable alternative to mupirocin in the treatment of MRSA.
— Antimicrobial Chemotherapy 35(3): 421–424, Mar 1995
Mexico Midwifery Immersion Program
National College of Midwifery announces the Mexico Midwifery Immersion Program. Spend 2 months in Tepoztlan Mexico, learning intensive midwifery academics, Spanish and clinical care with professional and traditional Mexican midwives. Beautiful colonial mountain town. $5,000 includes airfare from Albuquerque, ground transport, room and board, great home-cooked meals, tuition, excursions and field trips. Contact NCM at 505-758-8914 or www.midwiferycollege.org
Abstracted by Henci Goer in her book, Obstetric Myths versus Research Realities (Bergin & Garvey 1994):
Myers, S., and N. Gleicher. A successful program to lower cesarean-section rates. N Engl J Med 1988;319(23): 1511–1516.
This Level III Chicago teaching hospital serving mostly inner-city poor women reduced its cesarean rate by instituting new policies on the clinic service. The cooperation of private doctors was voluntary. Policies were:
- Second opinion for all non-emergency cesareans.
- Trial of labor for all women with previous cesarean(s) (which led to 86% trial of labor rate).
- Diagnosis of dystocia only after two hours of no progress with adequate contractions (41% had oxytocin).
- Vaginal delivery of breech fetuses except for true neck hyperextension [the baby's head is tipped back instead of curled forward, which may cause neurological injury during the birth] or estimated weight greater than 4300 g.
- Peer review process.
Sanchez-Ramos, L., et al. Reducing cesarean sections at a teaching hospital. Am J Obstet Gynecol 1990;163(3): 1081–1088.
A Florida teaching hospital serving indigent women reduced total cesarean rates from 27.5% in 1986 to 10.5% in 1989 and primary cesarean rates from 19.5% to 7.2% (p < 0.0001) by the following means:
- All women were candidates for trial of labor except for previous classic incision, more than two cesareans, prior uterine surgery or unknown scar.
- Elective cesarean was not an option.
- When contractions were adequate (spontaneous or augmented), a diagnosis of dystocia required arrest of dilation for 2 hours or arrest of descent for 1 hour in primiparas or 30 minutes in multiparas.
- When contractions were weak, the diagnosis required arrest of dilation for four hours on oxytocin.
- Cervical ripening with prostaglandin gel would precede induction of labor with unripe cervix.
- Fetal distress must be confirmed with fetal scalp blood sampling or acoustic stimulation.
- Breeches would undergo external cephalic version, and vaginal birth was possible in selected cases.
Henci notes, When Myers and Gleicher reduced the cesarean rate from 17.5% to 11.5% over two years, the hospital lost $1 million in revenue.
It is important for a woman to understand that nothing happens by accident. This does not mean that she is "to blame" [for having had a cesarean], and this should not be inferred in your discussion with her. You should, however, invite her to notice the connection between events. Unconsciously she (as we all do) set herself up for the outcome of the birth and needs to look at how such events supported her in her life at that time.
Often, too, the woman who winds up with a cesarean has been sexually abused. Remembered or not, the abuse may make the stretching of the pelvic tissues and the passage of the baby a very unsafe and frightening experience. Giving over control in labor may recapitulate the feeling of lack of control over the abuser. Some women responded to sexual abuse by "freezing"; in labor this can lead to failure to progress.
Regardless of the circumstances, the drama and intensity of birth highlights a woman's psychological and emotional patterns. She cannot birth apart from how she lives the rest of her life. Therefore birth is an opportunity to see these patterns in high relief and, hopefully, become more conscious of them as a result. Support women to view their birth as a growing experience.
Most of the time a woman who has experienced a surgical birth has felt completely disempowered. Not infrequently, she has undergone numerous ultrasound exams, internal exams, fetal monitor tracings, blood tests and a multitude of other interventions, all of which serves to externalize her sense of control and safety. Subtle and not so subtle remarks may have left her feeling completely powerless. Often, she arrives at the threshold of surgical birth feeling like her baby is being rescued from her body or that she is being saved form an endless, ineffective labor.
How different it is for such a woman to be told, quite categorically, that she and she alone can make a difference in her birth; that the most important things that need to be done are what she alone can do: that she, in fact, has central and almost complete control over how her pregnancy and birth go, and that taking care of herself by eating well and avoiding drugs, cigarettes and alcohol eliminate the need for all those tests and interventions.
Emotionally, women have had a dramatic event that magnifies some pattern in their life which they now wish to change. An array of issues come to mind: passivity in the face of (male) authority, being a "good girl" and following instructions, control issues, fear of success, attention getting, poor body image…the list goes on. Just making the effort to seek a care provider who will encourage them to believe in themselves is for many women a major breakthrough. Affirmations and visualizations of yoni [vaginal] birth done on a daily basis, with specific emphasis on seeing themselves moving past the point where they had surgery before, will help contradict their negative belief patterns. Counteract negative messages with affirming statements such as:
- my body knows how to labor and give birth
- my uterus has strong, powerful contractions in labor that bring my baby down and out
- my placenta separates and births easily and my uterus clamps down after birth
- it is safe to let the baby come out
- I am strong and capable of birthing my baby
- I deal with whatever labor brings me
- birth heals and cleanses my pelvis
- contractions caress and massage the baby and prepare it for birth
- my baby is head down, facing my back and has its chin on its chest my uterus is healed and whole
— Anne Frye, excerpted from Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice, Vol. I, pp. 916–917.
HOLISTIC MIDWIFERY VOL. I may be ordered from Midwifery Today.
Midwifery Today asked readers how they prevent cesarean sections. Following are some excerpted responses:
- Choose a care provider with a low c-section rate.
- Wait until active labor to go to the hospital.
- Avoid Pitocin administration.
— Holly Dinsbeer
Have a doula with the mother during the birth.
— Arlene Tuttle
Start with nutrition and exercise, and emphasize that it is the client's responsibility to help herself stay healthy and low risk. This includes avoiding harmful substances and procedures when unnecessary, and educating herself if a question comes up. We discuss how to handle labor naturally, without drugs.
— Amy Haas
Active labour mums stay upright, mobile, not on a bed in a prone position. Stop continuous monitoring of the fetal heart and uterine action.
— Lorna Jones
- Homebirth: absence of medical gadgets and tools.
- Family-friendly hospital: Belief in the woman's power to birth, the support of family and bonding with the baby.
— Connie Dello Buono
You have to believe these things:
- Pregnancy and birth are natural bodily functions, not diseases.
- Doctors are trained to fix problems—they are pathology oriented, like to be in control and are therefore not ideally suited to attend a normal, natural childbirth.
- The baby will be the right size, in the right position, will come when it's ready; that your cervix will open, your perineum will stretch, your baby will come out; breathe, and be healthy, and you can do this labor yourself without artificial aids. Believing you can do it is necessary to be able to relax and enjoy labor. One intervention opens the lid of Pandora's Box.
— Marlene Waechter
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Products for Birth Professionals
Looking for a book that supports a grass-roots, traditional midwifery model? "Joan Donley's Compendium for a Healthy Pregnancy and a Normal Birth" is packed with information on alternative treatments such as herbs and acupuncture. Starting with sections on prenatal care and nutrition, this 402-page book goes on to cover problems in pregnancy and labor, infections and postnatal concerns.
If you're a mom-to-be who wants to make informed decisions, you need this book. If you're a birth professional the "Compendium" will confirm your belief in the normal birth process, and help you help your clients have the best births possible.
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Read this review:
I'm pregnant with my fourth. I've been contracting since 22 weeks and was put on procardia and progesterone, which didn't help so my midwife took me off at 23 weeks. Friday contractions were coming every four minutes, very strong for hours. Went to L and D—cervix is still 1 cm and long and thick. Yesterday contractions got really painful, coming two minutes apart—can't walk or talk through them anymore. I can't cope like I have been. I was so irritable with my kids. When I try to sleep, contractions just wake me up. Any advice or feedback would be very appreciated by midwives, doulas or moms who have dealt with this.
Share your thoughts and experience about this topic.
**Please do not send your responses to E-NEWS!**
Certified Nurse Midwife, FT—Capital Health System
Busy OB/GYN practice in Lawrenceville, NJ and Yardley, PA. Provide antepartum, postpartum, gynecological, family planning services in clinic setting. Provides intrapartum, immediate postpartum care on LDRP unit. Graduate of accredited midwifery school; NJ & PA RN licenses required. Apply online: www.capitalhealth.org, click on Employment, search Job ID: 5110. Mail: Recruiter, Capital Health System, 446 Bellevue Ave., Trenton, NJ 08618; fax: 609-394-4444. EOE.
Question of the Week
Q: I recently assisted a mom with a beautiful normal labor until she reached eight centimeters. Then her cervix began thickening and swelling all around. The baby was left occiput transverse (LOT), and mom adopted leaning-forward positions naturally throughout her labor. At the peak of contractions when at eight centimeters, she began some uncontrollable grunting/pushing, which I am sure contributed to the swelling more. We tried open knee chest and Trendellenburg while panting to get the baby off of the cervix, but nothing seemed to work. What other things have worked for others to reduce cervical swelling and the urge to push too early?
— Mary Callender, birth and postpartum doula, Richmond, Virginia
SEND YOUR RESPONSE to firstname.lastname@example.org with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.
Question of the Week Responses
Q: What experiences have midwife readers had with shoulder dystocia and brachial plexus injuries? What techniques have you used successfully and unsuccessfully to relieve shoulder dystocia? Have you ever seen a brachial plexus injury where there was no shoulder dystocia, the delivery was textbook, but still an injury?
A: Within our unit we all practice together and have routine drills with regard to shoulder dystocia. We all use the mnemonic HELPERR, as advocated by the Advanced Life Support in Obstetrics (ALSO) course that most of our midwives/medical staff have attended.
H = call for help
E = assess for episiotomy
L = legs in McRoberts position
P = Pressure (supra pubic against fetal back)
E = Enter (wood screw manouevre)
R = Reverse (wood screw manouevre)
R = Repeat procedure.
Each manouevre should take approximately 30-45 seconds.
Everyone within the unit is trained in using the HELPERR mneumonic and finds that it works. The staff work as a team because each person knows which manouvre is next. Shoulder dystocia remains one of the scariest obstetric emergencies I have ever encountered.
— Anne Brewitt
A: While evaluating [the Pink Kit] I began to try out positions on my own to see which position I felt more "open" in. I discovered several positions that I feel sure would have opened my own vagina and changed my own shape enough to let my son pass uninjured through. Each mother and baby has unique sizing and fits and will require a positional change unique to that very moment. Hands and knees and standing are two of the positions I have seen used in dystocia resolution without injury.
Confidence and flexibility are essential.
Of course a more experienced midwife should share about the next step in resolution if positional changes do not work.
It is my understanding that breaking the clavicle allows for passage of the shoulder and leaves only a broken bone which will heal as opposed to a lifelong injury.
Dystocia resolution is near and dear to me—thank you for asking this question. I can offer mother to mother support to anyone with a child who has experienced a brachial plexus injury (erbs palsy).
— Mary Rainer, home birth assistant, Fort Pierce, Florida email@example.com
Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to firstname.lastname@example.org. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
Think about It: Choosing Cesarean Birth
Does a woman have an inalienable "right" to choose a cesarean section? It has been clearly established in law that an individual has the right to refuse medical treatment, but it does not follow that the converse is also true that an individual has the right to demand treatment that is not medically indicated. If a woman asks for a CS but is refused because there are no medical indications, is it correct to say she will have a "forced" vaginal delivery? Pregnancy is not an illness. Most women need no medical or surgical treatment during pregnancy, delivery and the puerperium. Vaginal birth is the consequence of being pregnant, a state for which the woman and her sexual partner must take responsibility, not the medical profession.
— Marsden Wagner, MD
What do you think? Send your opinions to Midwifery E-News.
I am a 29-year-old mother of two (almost 4 and almost 2 years). I am 35 weeks pregnant and have been on bed rest and a terbutaline-type drug for preterm labor. (My family and I live in Asia so the medicine is not exactly terbutaline, but is the equivalent available here.) At four and a half months gestation I started thinking I was feeling contractions, maybe three or four a day. At my five-month checkup I mentioned this to my OB, and she did a cervical check. She said it was closed, but soft and short—half the size of a normal cervix. She then recommended the bed rest and medicine (my second child was born at 35 weeks with early labor for a month, causing a dilation of three centimeters. A rupture of membranes was followed by birth an hour later). The medicine stopped all contractions until the seventh month. From there I started having three or four a day, then more and more. At eight months she changed the medicine to an Albuterol-type drug, which helped with the respiratory symptoms I had begun to have, but didn't affect the contractions. Right now I have about seven to ten a day. When I didn't have the medicine one day recently, the contractions began to come more frequently and harder.
I am wondering if this is truly "preterm labor" or something that would cause the baby to be born early. A cervical check at seven months revealed no change from the fifth month. When a contraction comes, I also often feel a tightening in my chest and then neck and head muscles. Occasionally I have had the tightening in the chest and head without having a contraction. Has anyone ever heard of this happening with any of the women they have cared for?
— Joy Hearn
What is the purpose of LABOR DAY TAKE BIRTH BACK events? To put information into the hands of every person we can about the truth of birth, as well as contacts for further information. Why on Labor Day? This three-day holiday weekend makes it easier for everyone to do something toward this effort, and the play on words makes a good point.
It is my hope that the Labor Day weekend will be a weekend of purpose and that all birth-related organization, and every one of you as individuals, will do something every Labor Day to inform women about the truth of birth for at least a few minutes during that weekend, whether it is part of an official take back birth event or not.
— Carla Hartley
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email@example.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.
The University of Kentucky Department of OB/GYN is recruiting a Certified Nurse Midwife to provide comprehensive prenatal/postpartum care to low risk women. Apply online for Job #SG508928 www.uky.edu/ukjobs by 9/30/05.
Seeking apprenticeship. Birth, postpartum doula; aspiring midwife. Ginny Elliott (503) 236-7564/235-5054 or firstname.lastname@example.org. Willing to temporarily relocate.
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