August 2, 2006
Volume 8, Issue 16
Midwifery Today E-News
“Prematurity”
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In This Week’s Issue:


Quote of the Week

"As we acknowledge the need to give ourselves spiritual attention and acknowledge the unborn child's sensitivity as a spiritual being making a significant transition, we can better help the mother to bond with her child in the most enduring way, spirit to spirit."

Kathleen Johnson


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The Art of Midwifery

When you begin a nipple stimulation series for a client, check the prenatal record to see what her normal lie of blood pressure is. One of the ways you can tell whether or not she is truly kicking over into labor is that her blood pressure will rise. If it doesn't you're going to be doing nipple stimulation for a long, long time. Even though a rise in blood pressure is not quantitative, it is a good indicator because oxytocin works only on the body's smooth muscles: the uterus, the secreting cells in the breast (alveoli), and the arteries. If the woman has good oxytocin stimulation, her arteries are being stimulated and contracting harder and her blood pressure should go up.

Sr. Angela Murdaugh


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.


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Passionate Midwifery Education

Apprenticeship, Part II

This is the second of three installments from the article "Apprenticeship: Do You Really Want One?" by Renata Hillman in the Midwifery Education issue of Midwifery Today, Issue 78, Summer 2006. You can read many more articles on paths to midwifery education by buying this issue.


4. Humility. This characteristic is a necessary trait of all midwives. We spend countless hours at mothers' feet, massaging, cleaning, assessing, praying, encouraging. We are servants, by the very definition of our role. We must not put our desires before our mothers' needs or wants.

The apprentice should direct her humility and appreciation to the midwife who shares her experience—most of which was probably acquired through many hours of study and laboring, as well as much expense and travel. Many times, apprentices may not come up to the grade or may need to be corrected. They should be humble enough to receive constructive criticism, as well as willing to improve and to grow to complement their mentor during the apprenticeship. A time will come when they will have to make their own choices independent of a mentor.

The midwife, on the other hand, should hesitate, especially when the apprentice has erred, and take time to remember her own beginnings, when her knowledge and experience were small, but her heart was big. While she may need to critique the actions of the apprentice, gentleness, promptness and accuracy are important factors in how well the critique is received.

Renata Hillman


To read all installments of this column on midwifery education, go to our Better Birth and Babies Blog.


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Premature Rupture of Membranes

Following are some factors associated with preterm birth and some strategies for decreasing the risks:

Overwork, job fatigue, stress: Women in high-stress jobs or who work long hours on their feet have nearly three times the risks of preterm rupture of membranes leading to preterm birth. In a study of 3000 primiparas, those who worked in "high-fatigue jobs" had a risk of preterm premature rupture of membranes of 7% compared with 2% for those who didn't work outside the home.(1)

Poor nutrition, low weight gain: Low maternal weight gain is the single risk factor that crosses all racial and economic indicators. A woman with a low prepregnancy weight and/or a low rate of gain before 20 weeks is at high risk for preterm birth. A balance of protein and carbohydrates provides the best nutrition.

Low levels of Vitamin C: Low levels of vitamin C have been implicated for several decades as contributors to prematurity and preterm rupture of membranes. In a study of 2064 pregnant women, those who had total vitamin C intakes of <10th percentile of average intake prior to conception had twice the risk of preterm birth due to preterm rupture of membranes (relative risk: 2.2).(2) Low levels of vitamin C may also be implicated in the risk of preeclampsia, which leads to preterm birth.(3) It is theorized that oxidative stress plays a role in preeclampsia, and optimum levels of vitamin C protect against it. It has been proposed that 300 to 500 mg is probably needed.

Bacterial vaginosis: BV has been associated with a two to three times increased rate of preterm labor and delivery, urinary tract infections, premature rupture of membranes, and endometritis. Because about 50% of women show no symptoms, universal screening for BV was proposed more than a decade ago.

High vaginal pH: This condition is a marker for prematurity risk. One prospective study of 21,554 women screened for vaginal pH and outcome showed that women with a vaginal pH of 5.0 or greater had a significantly increased risk of preterm birth and/or low birth weight.(4) Alkaline organisms other than Gardnerella (BV) are implicated. Women with high levels had more than a 300% increase in rate of premature rupture of membranes.(5)

Gail Hart, excerpted from "A Timely Birth," Midwifery Today Issue 72

References

  1. Newman, B., et al. 2001. Occupational fatigue and preterm rupture of membranes. Am J Obstet Gynecol 184(3): 438–46.
  2. Siega-Riz, A.M., et al. 2003. Vitamin C intake and the risk of preterm delivery. Am J Obstet Gynecol 189(2): 519–25.
  3. Zhang, C., et al. 2002. Vitamin C and the risk of preeclampsia. Epidemiology 13(4): 409–16.
  4. Hauth, J.C., et al. 2003. Early pregnancy threshold vaginal pH and Gram stain scores predictive of subsequent preterm birth in asymptomatic women. Am J Obstet Gynecol 188(3): 831–35.
  5. Ernest, J.M., et al. 1989. Vaginal pH: A marker of preterm premature rupture of membranes. Obstet Gynecol 74(5): 734–38.

MIDWIFERY TODAY Issue 72 can be purchased.


A team of nurse-midwives from Cooperstown, New York, reported on the success of an essentially hands-off approach to premature rupture of the membranes (PROM). Where appropriate, women with ruptured membranes were permitted to wait at home for labor to start. In the year that the program has been in effect, it has led to a decreased cesarean section rate without increase in neonatal or maternal morbidity.

Crucial to the program's success was refraining from performing digital vaginal exams on women who are not yet in labor. The program, called expectant management, asks that after an initial assessment determines that the mother can be managed at home, she return to the hospital every 12 to 24 hours for another assessment.

Barriers to implementation of expectant management include the backup physicians who are unwilling for labor to begin spontaneously, pediatricians concerned about the baby's health, nurses who insist on performing digital vaginal exams, and pregnant women who refuse to return home to wait for labor to start after their membranes have ruptured.

— excerpted from "Hands Off PROM," Wisdom of the Midwives: Tricks of the Trade Vol. II, A Midwifery Today Book


I have strict protocols [for PROM], and I have not had any clients develop uterine infections nor have I had any sick babies.

My protocols include the following:

  • Never put anything, sterile or not, into the vagina. This means no baths, no sex, no vaginal exams. When using the toilet, I instruct the woman to wipe front to back and use white toilet paper. After a bowel movement, she should cleanse with hexol mixed 1:20 with warm water.
  • Teach the parents how to listen to fetal heart tones at least once a day.
  • Have the mom drink at least four to eight ounces of fluids per hour, preferably water.
  • Mom should check her temperature every morning before rising; the reading will be more accurate than after she has been up and moving around.
  • Have the mom take up to 1000 grams of vitamin C daily.
  • Check for amniotic fluid thrill daily. This will tell you if there is still plenty of amniotic fluid for the baby so the cord does not become compressed. Parents can be taught how to test for thrill: Have the woman relax in a semi-sitting or almost flat position. Put your hand on one side of her abdomen, flat against it. With your other hand, very gently flick your finger against her tummy. You should be able to feel the ripple of the water against the hand that is flat on her tummy. Do this all around, feeling for pockets of water, until you have a general sense of how much water is around the baby. If her bag is leaking, and if you feel like there is less and less water as the days elapse, seek medical advice and/or ultrasound.

Patty Sherman, excerpted from "The Apple Will Drop When It Is Ripe," Wisdom of the Midwives: Tricks of the Trade Vol. II


Wisdom of the Midwives can be purchased.


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News Flash

New Zealand SIDS Death Rate Decreases

New statistics released by the New Zealand Ministry of Health show that the national rate of Sudden Infant Death Syndrome (SIDS) fell by 70% after an educational campaign in wrapping mattresses with special polyethelene covers was begun. The program began after research by a NZ scientist showed a link between SIDS and the toxic fumes emitted by mattresses.

According to the statistics, NZ Maori babies are 10 times more likely than NZ European (Pakeha) babies to die of SIDS.(2) Following the implementation of mattress-wrapping by the Pakeha community over the last eleven years (with an 85% reduction in their SIDS rate), New Zealand has the highest inter-ethnic SIDS disparity of any country in the world.

In contrast to the US and UK, where back sleeping has been adopted as a method to prevent crib death, New Zealand began to publicize mattress-wrapping in 1994, with the practice widely adopted. Since then, the rate of deaths on unwrapped mattresses has continued to increase, while no deaths have been reported for babies sleeping on wrapped mattresses. Another advantage to this solution is that babies can sleep in a variety of positions and not suffer from plagiocephaly, or flattened heads.

The results of the New Zealand mattress-wrapping program have been published in two peer-reviewed journals of environmental medicine(3) and far exceed the results of any other SIDS prevention program in the world.

Notes

  1. Source of statistics: New Zealand Ministry of Health (final statistics to 2001; provisional statistics for 2002 and 2003; progress counts for 2004 and 2005).
  2. NZ Maori SIDS rate: 2.0 deaths per 1000 live births; NZ European/Pakeha SIDS rate: 0.2 deaths per 1000 live births.
  3. Journal of Nutritional & Environmental Medicine 2004;14(3): 221–232. Zeitschrift fuer Umweltmedizin 2002; 44: 18–22.

For further information, see: www.cotlife2000.co.nz


Research to Remember

Of all unplanned pregnancies in the United States in 1994, women age 20 or more accounted for 76%. A study intended to identify a dose-response association between childhood sexual abuse or other family dysfunction and unintended first pregnancy queried 1193 women age 20 to 50 whose first pregnancy occurred at or after age 20. Unintended first pregnancy and correlated psychological abuse, physical abuse, sexual abuse, physical abuse by the partner, and substance abuse and mental illness in household members were measured. Of the more than 45% of participants whose first pregnancy was unintended, nearly 66% reported childhood exposure to two or more types of abuse or household dysfunction. The strongest associations were with psychological abuse, frequent abuse by the partner, and frequent physical abuse. Women who reported four or more types of abuse were 1.5 times more likely to have an unintended first pregnancy. The study concluded that 1 in 5 unintended pregnancies are related to childhood abuse or household dysfunction.

JAMA, 1999, No. 282, 1359–64


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Web Site Update

Read these articles from the most recent issue of Midwifery Today, Issue 78, Summer 2006, newly posted to our Web site:


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Forum Talk

A few pregnancies ago I began spotting at 11 weeks. An ultrasound showed the baby to be seven weeks and no heartbeat. I knew in my heart I had lost my baby and knew my dates were correct. The doctor sent me home saying my dates were probably off and to wait and see. I have never spotted before. I called the doctor on call later that night to ask about progesterone since my sister and a friend both told me they had similar stories and it was because of low progesterone. The doctor called in a prescription for me. I ended up miscarrying a few days later and the doctor told me to take the progesterone the next time I even think I'm pregnant. No one tested my levels and I had had five healthy pregnancies before this. I had another very early miscarriage, just after getting a positive, a couple months later and conceived two weeks after that. I was told to take the progesterone and did until 14 weeks. Next pregnancy I was told by my midwife to use the cream instead and that progesterone won't hurt me, even if I don't need it, so I did. Now, I am pregnant for the 10th time. Should I use the cream or can I wait and see if I need it? Can spotting be an indicator that I need more progesterone, or has harm or death already occurred?

Anon.


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Question of the Week

Q: I am 21 weeks pregnant with my third child, which has been diagnosed with spina bifida. This is quite a shock since my other two children were homebirths and the specialists said I would require a c-section. I understand the need to deliver in a hospital where the baby can receive immediate medical treatment soon after birth, but does anyone know if there is any evidence that c-section is better than vaginal birth when delivering a child with spina bifida?

— H.


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. Responses to any Question of the Week may be sent to E-News at any time.


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Think about It

To the baby, birth is about being received. We unfold to the world and know our value when received with love and acceptance, in our own perfect timing. If someone yanks us out of a place intrusively, we naturally recoil and go within in order to maintain balance against this outside force. The results of being "received" or being "forced" is either opening to this world or shielding ourselves from it. Out of this experience comes baby's first decision, either, "The world is a friendly place" or "The world is a hostile place." This decision is the initial filter that determines if baby opens to or shields herself from the world, from then on. All other decisions about life spring from this original one inlaid within the blueprint. The personality of baby exhibits the blueprint.

Sunni Karll, excerpted from "Making a Difference: A Blueprint for Harmony," Midwifery Today Issue 58

MIDWIFERY TODAY Back Issues are available online. Issue 58


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Feedback

If we need to tag our babies and moms like cattle there is something wrong, seriously wrong, and more reason to birth at home [Re: E-News Issue 8:6]. As for moms not recognizing their own babies, stop the drugs and they would know, and let mom have the baby instead of the baby going to the incubator. I'm sure the incubator won't mind—oh wait, the corporation that makes the incubator might. In my opinion the only baby that should leave mom is the baby of the mom who had an emergency situation and mom can't take care of the baby.

Laura Carlson


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