|April 26, 2006|
Volume 8, Issue 9
|Midwifery Today E-News|
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In This Week’s Issue:
Quote of the Week
"Childbirth being one's most significant life passage, those close to us when we open to birth a baby will never be forgotten."
— Robin Lim
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The Art of Midwifery
I had very bad heartburn the eighth month of pregnancy, so bad I couldn't sleep. I had to try to sleep with my chest and head elevated. Then I discovered fennel seed tea. A glass of fennel seed tea before bed would completely cure the heartburn.
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Passionate Midwifery Education
Certified Nurse-Midwife or Direct Entry Midwife
We are blessed in the United States with many routes of entry into midwifery. I think this strengthens us overall because many brilliant programs have been started by maverick midwives. On top of that, our 50 different states are like 50 different countries. That can be negative or positive depending on which state you are in. CNMs (Certified Nurse-Midwives) are legal in all 50 states; however, in all but one state, you must have a doctor agree to be a back up. This is not always easy: because of the financial, medical and political climate, doctors don't always want to provide back up. Because these different routes of entry are a complex issue, I will take three columns to explain it. Today we will just let you know that there are differences. The next columns will give the advantages and disadvantages of each route.
A CNM generally becomes a nurse first and goes to a midwifery school which is associated with a university. There are also a couple of programs whereby the midwifery and nursing can be done in the same program; Yale is an example. In the state of New York there is also the CM which is a Certified Midwife who takes a non-nurse program. This degree is just getting going and is not useful in most other states. However, these midwives are well trained could take their CPM (Certified Professional Midwife) to work in other states. The American College of Nurse-Midwives (ACNM) is working on getting the CM degree accepted. This Web site will give you a run down of the different programs and where they are located: http://www.allnursingschools.com/featured/nurse-midwife/
Thirty years ago the other midwives were called lay midwives. This term has fallen out of favor, though some of us rather like the term. Marsden Wagner calls himself a lay doctor because he learned medicine by apprenticing! Apprenticeship is a key component of direct entry midwifery. Direct entry just means that nursing is not required. The Midwives' Alliance of North America (MANA) has done an incredible job of birthing a unique credential, the Certified Professional Midwife or CPM. The extra special component of this credential is that it does not require that you go to a school; instead you must take a written and skill test and document a certain amount of required experience. It can be done totally by apprenticeship. Having said that there are many unique schools and programs that have birthed to help you learn midwifery and get your CPM or other state certification. Go here for a chart of the legal status of direct entry midwifery, state-by-state: http://www.mana.org/statechart.html Remember, we are like 50 different countries. Midwifery Education and Accreditation Council (MEAC) accredits education programs. Their list of approved programs can be viewed here: http://www.meacschools.org/programs/programs.html Twenty-some states accept the CPM credential. There are many more programs whereby you can get your education; for a complete list to date you can purchase the next issue of Midwifery Today in mid-June 2006.
Many midwives in the United States are illegal or alegal. In my home state of Oregon, one is not breaking the law by being an unlicensed midwife. In the 70s the attorney general came out with an opinion that midwifery was not the practice of medicine. In many other states, midwives just help women have their babies and do not pay attention to the law, much like the midwives in the Bible! They find credentials mean restrictions to protect the credential. We will discuss this more later. Meanwhile, welcome to midwifery!
— love, Jan
To read all installments of Jan's column on midwifery education, go to our Better Birth and Babies Blog.
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Traditionally, birth was a very private affair in which only the most intimate of a woman's relations attended her in labor. Grandmothers, aunts and wise women of the village whom the woman most trusted were the ones expected to be there. In today's society, women are taught to place their trust in the medical model of childbirth and in medical professionals rather than in people with whom they are most familiar. They are taught to accept the place of birth that medical professionals choose (because it is their "safe place"?). That is a difficult and sometimes impossible transition for many women. It so seriously affects a woman's sense of the familiar that patterns of labor are changed, birth pain is intensified, outcomes are less predictable and birth comes to be regarded as a difficult and painful ordeal, fraught with danger. To complicate matters, if the woman is in an unfamiliar and therefore "not safe place," she will protect her baby by preventing it from being born—ceasing to contract, keeping her cervix closed and in general "failing to progress," one of the major reasons for unplanned operative delivery.
Those of us who are certain that a woman's home is the most suitable environment for her birth must be particularly aware of the influence we may have on the woman's sense of safety. The most well-meaning midwife may nonetheless be a "stranger" to the mother and a threat to her need for privacy if the midwife is not fully trusted by the mother well before labor ensues.
Midwives are able to maintain normalcy in birth and help bring about an optimum outcome for mother and baby because we provide both constancy and continuity of care. As the relationship between midwife and mother develops during the course of prenatal care, an increasing mutual trust creates a sense of safety and security. Communication becomes forthright and honest, and words flow easily between them. When it comes to the time of birth, rarely must we deal with psychological issues that may impede labor, because specters of the past have been met, dealt with and put in their proper place. Over the months preceding birth, through her manner, touch and words, the midwife has said such things to the mother as "I will never leave you," "I know you can do this work of birth," "I trust you to grow a beautiful, healthy baby." What comfort this is to the woman meeting birth for the first time, with so many questions!
Thousands of times I have sat with a young woman who is having her first baby. When her eyes gaze into mine and I can feel her contractions crashing through her body like tumultuous waves against the rock, and I know she doubts her strength to go forward despite her great desire to complete her task, I say to her, "OK, now you will have to walk on water." She grasps my hand a little harder and replies, "How far do you want me to walk?" Then, we walk together.
— Valerie El Halta, excerpted from "Reconsidering Our Preconceptions about Birth," Midwifery Today Issue 59
MIDWIFERY TODAY Back Issues are available online. Issue 59
Babies Need to Bond
Babies need to bond, and if the mother is not there, an object takes her place. And if the only comfort your baby has in her first crucial hours of life is an incubator blanket, then things, not people, become her primary source of comfort for the rest of her life. Have you ever wondered why the US is such a materialistic society? Perhaps it is time to turn our wondering gaze to the routine breaking of the mother-infant bond in US hospitals over the last 50 years.
Besides being obsessively attached to things, your maternal bond-deprived child will be at increased risk of high infant stress levels, as well as compromised infant immune system function. Dr. Sarah J. Buckley writes:
It is scientifically plausible that [the] entire hypothalamic-pituitary-adrenal (HPA) axis, which mediates long-term stress responses and immune function, as well as short-term fight-or-flight reaction, is permanently mis-set by the continuing high stress hormone levels that ensue when newborn babies are routinely separated from their mothers.
The unbonded child is also at increased risk of behaviors dangerous to himself, society, or both. Studies following bond-deprived babies into adulthood have shown conclusively that the breaking of the maternal-infant bond results in higher rates of criminality, violence, schizophrenia and suicide.
Concerning the fate of unbonded infants, Joseph Chilton Pearce writes:
The unbonded female might become neurotic and be unable to bond to her child properly, but the unbonded male goes very subtly mad. Unless rooted to the mother matrix, his other matrices cannot form, and his machinery loses its balancing mechanism, its governor. He runs amok. What the unbonded male does is spend his life turning back on that matrix, trying to force from it that which is lacking. And what is lacking is his source of personal power, his possibility and his safe space. Lacking these, he turns and uses his strength to rape. He rapes either crudely or with sophistication, that is, bodily, or intellectually, raping the earth matrix with technology…. The rapist himself does not understand the real hunger that drives him.
Anthropologist Jean Liedloff writes in her culture-bending book, The Continuum Concept, that it is only sufficient in-arms time with the mother that gives children the ability to develop into mature, tribe-oriented, nonviolent adults. Without this bond, children are lost. The great majority of art produced by the hospital-born "X" generation (notably song lyrics) reflects this lostness.
In the case of the mother, the breaking of the mother-infant bond results in higher rates of postpartum depression, child rejection and child abuse.
In her infinite wisdom, nature gives new parents and newborns the desire to bond, because bonding is beneficial to our species. Bonding creates a sense of oneness between family members, between mother and infant, father and infant, mother and father, siblings and infant, and siblings and parents. The family is the bedrock of human society and the strength of the individual. The hospital institution does not promote family ties because it has no interest in strong families. The hospital's unstated goal and creed is family division. Family division begets human sickness and creates the lucrative byproduct of "belief in institutional health."
Of all the crimes against nature and human life routinely committed in the hospital institution, the breaking of the mother-child bond is the most harmful to the individual, the family and society at large.
— Excerpted from the e-book Spontaneous Creation: 101 Reasons Not to Have Your Baby in a Hospital, Vol. 1, A Book about Natural Childbirth and the Birth of Wisdom and Power in Childbearing Women, by Jock Doubleday
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Research to Remember
An Alan Guttmacher Institute study of adolescent American teen sexuality gathered data from interviews with 101 sexually active teen males ages 14 to 19. Of the young men surveyed, 43% were black, 15% were white, 15% were Hispanic and 11% were Asian. Although 75% of the young men had no plan to impregnate their sexual partners, 56% observed that there was some likelihood that pregnancy would result. The researchers commented that the needs and viewpoints of young men must be acknowledged and addressed when society works with the problem of adolescent pregnancy, and that the young men have the right to have frank discussions of reproductive issues with their caregivers and also parents and teachers and other community leaders.
— Pediatrics, September 2005
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I delivered my first at 34 weeks, five days, due to severe preeclampsia. She spent 11 days (a relatively short time) in the NICU. I spent over seven days hospitalized. I'm now pregnant, 25 months between pregnancies. I am 17 weeks. I have seen a lot of specialists. I do not have underlying hypertension. I see my cardiologist next week just to verify that everything is perfect, and after that my next appointment is with the perinatologist for my 20-week ultrasound. After those two appointments, if all is well, I'm ready to cut everyone loose and work on having a natural, healthy pregnancy and birth. I live less than five minutes away from the nearest E.R. Is it even possible a homebirth midwife would think of "taking me on"?
Share your thoughts and experience about this topic.
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Birth, The Play
Dare to be BOLD on Labor Day weekend 2006?
Question of the Week
Q: I have read all the marvelous advice regarding uterine prolapse and wondered if anyone had any advice for urethrocele, prolapse of the urethra (but not the uterus). I have tried acupuncture, Chinese herbs, am currently going for osteopathy and doing Christine Kent's exercise programme, but am unable to reverse it.
The urogynecologist says it's mild; however, when I stand up I don't even have an opening at the vagina. There's just this "adder head" mass (as it's so nicely described) that obstructs the opening (but which thankfully is not outside the body).
(I am based in Toronto, in case anyone has pointers for services here.)
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.
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Question of the Week Responses
Q: Has anyone out there had any experience with the autoimmune disorder, morphea, and pregnancy? I currently have a client who has it and it has been very difficult finding any information about its effect on pregnancy and pregnancy risk. As I understand it, and this is mostly from being educated by the client herself, morphea is a sister disease to scleroderma but does not affect the internal organs, just the skin. My client has an area of hardened scar-like tissue on her lower back but otherwise she has no problems. She is an acupuncturist and very well-educated about her condition.
At first I didn't think much of it, but I decided to run it past my backup OB just to make sure she would be low-risk. Once he heard that it was related to scleroderma he said that even he wouldn't take care of her, he would refer her to a perinatologist. Apparently he had a woman with scleroderma who ended up dying at 35 weeks or so because a blood vessel popped in her brain. I tried to explain to him that this condition was different because it doesn't affect the internal organs, so he recommended a perinatologist consult.
The first perinatologist I sent her to had no idea what morphea was but nonetheless recommended a whole slew of coag studies and genetic tests. I decided to get a second opinion and phoned a perinatologist in my area. He hadn't heard of it, but when I described my understanding of it to him and he did some quick research, he said that my client is right and it should pose no problems with the pregnancy or birth. I'm much more inclined to go with his assessment, but I'm wondering if anyone out there has ever dealt with this before and what the outcome was.
— Corina Fitch, LM, RN
A: I have a similar patch of hardened skin on one of my arms. I first noticed it during the pregnancy of my fourth child. It was then about a nickel-sized patch. I was referred to a dermatologist and even had a surface biopsy done on it. The term scleroderma was mentioned but not explained, and I had no idea of its seriousness or potential to affect internal organs. My midwife and doctors associated with her at no time expressed concern over the condition. Several different expensive creams were prescribed and were ineffective. Since it caused no discomfort I discontinued these treatments and have been simply living with it although it has enlarged but not manifested on any other parts of my body. I did at one time do a brief Internet search, but what I was able to find was frightening and no treatment or cure seemed to exist. Since it began I have given birth to five healthy babies with no problems relating to the patch on my skin that I am aware of. I recently realized there was a condition of coleostasis present, but that is another story. This query in Midwifery Today is the first I have ever heard of morphea, so of course now I am wondering if it might not be this instead of scleroderma that I am experiencing. I am not a midwife and not trained in any health related area. I would be very interested in learning any further information about morphea.
— Carla Barnes, Argentina
A: Your client should consider going to a certified homeopath. Homeopathy is a curative form of medicine and can safely be used during pregnancy. Since "morphea" is probably an inherited condition, or rather, a condition that she is susceptible to because of hereditary factors, her children will also have this tendency. Homeopathic treatment addresses the whole person, not just the physical manifestation of her symptoms, as disease, like cancer for instance, shows itself in well-documented mental and other physiological symptoms *years* before the pathology shows up.
Homeopathic treatment will also be beneficial to her pregnancy, labor and post-partum care. If she is not able to find a certified homeopath in her area, she is not without options. She can work with someone over the phone, since homeopathic treatment relies predominantly on the client's reporting of her own symptoms.
— Manfred Mueller, DHM, RSHom (NA), CCH
Q: I have used (alone and in a five-week preparation) blue cohosh in six of my ten births. Some of the babies were "in distress," but only one had meconium and all had good Apgar scores. I have read some bad press lately about blue cohosh as a "stressor" and possible heart compromiser. Has alternative medicine backed away from the use of this herb or is it still considered a good herb to use for preparation and in labor/delivery? My daughter is 21 weeks pregnant and would like to use the same five-week preparation that I used in my last birth, but she is hearing some pretty scary stories from my sister (also pregnant). [from Midwifery Today E-News Issue 7:19]
A: I am glad to see Midwifery Today addressing the safety of herbs for labor. I have several concerns.
I've wondered why anyone who promotes homebirth wants to routinely use herbs to induce or augment labor. When I refer to "natural birth," I literally mean natural—our womanly bodies birthing without intervention (including herbs taken internally). A homebirth does not equal a "natural birth" if blue and black cohosh are used to induce.
Having made that distinction, let's make sure when discussing safety we discuss route of administration, dosage and frequency. One birth provider might swear that a cohosh tea is safe, but only share, "Cohosh is a good tool in her practice." Another provider might interpret that as meaning, "A tincture or injection is just as safe." Obviously they are not equally potent options.
In my Breastfeeding Medicine-based practice I am seeing babies whose mothers report to me that they received various forms of cohosh in labor: teas, tinctures and injections (possibly even a cervical topical). I have noticed a trend with these babies: prematurity, cardiovascular distress, jaundice, meconium, failure to thrive, suck dysfunctions and hospitalizations. The mothers report to me contractions on top of each other, very intense labors and hemorrhaging. Many of these women are taking these herbs prior to 38 weeks and deliver in the 37th week. I am suspicious that many homebirth transports and neonatal admissions could be explained by the side effects of the herbals.
I think the author of this question answered her own question and observed in her own babies the same results I see. Distress and meconium are not necessarily routine problems of the neonatal period. In the author's case and in the cases I see they are iatrogenic and could have been prevented.
Incidentally, my own definition of prematurity is inclusive of all babies being induced prior to the onset of spontaneous labor even if it's an herbal induction.
How ironic it is that this question comes up in a VBAC (vaginal birth after cesarean) prevention issue of E-News. Most of your readers would educate clients not to take Pitocin or Cytotec if they attempt a VBAC to prevent uterine hyperstimulation. It is time to seriously consider the consequences of herbal induction and potential hyperstimulation and rupture in our VBAC clients.
Some midwives might rebuttal that use of these herbs is appropriate if a client is approaching 42 weeks, term rupture of membranes, or failure to progress. These herbs if used in these cases are probably safer than transport. But, I stress that if it comes to these situations then it is not just "routine" use, and the clients have a right to informed consent. The goal in using internal intervention in labor should be to use only what is needed and not more AND only if there is good reason.
As you see, I am very concerned about the use of the cohoshes. Let's not be too cavalier about their routine use.
— Denise Punger, MD, FAAFP, IBCLC
[Editor's Note: For more discussion about blue cohosh, see Midwifery Today E-News Issue 2:22.]
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.
In response to "Preparing for Breech Delivery," (Think about It, E-News Issue 8:6):
We need to know everything we can [when preparing for breech delivery]. I will probably be at a birth in a few days where no one will do a vaginal exam or even know until the very time of birth whether the baby is in the right position. Women should check for position and even have their partners check. We need to know how to get the head out safely since the head is the biggest part of the baby and [in a breech] comes out last. If the baby was breech and we knew before it was too late to get to the hospital, the mom could determine what she wanted to do. If she chose to stay home, I would want to stay with her and assist her in whatever way she needed me.
While I do not pretend to have say in it, she needs to committed to birthing [a breech] at home. If she has any doubt, then I would probe her to see if she is fearful. Or, at that point since she probably already has some fears I would want to find out what she feared more: birth at home or in the hospital where they can cut her open. That thought does not scare some people, and in fact they feel very safe with the knowledge that the doctor will be nearby to open them up and take the baby out. I too am very happy that that service is out there, but let's give a woman a fighting chance [to have a vaginal birth].
Childbirth is scary; it's hard. But that is what makes it so great!
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