August 30, 2006
Volume 8, Issue 18
Midwifery Today E-News
“Epidural”
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In This Week’s Issue:


Quote of the Week

"A real leader will never ask people to accept their opinion as the last word."

Debbie A. Diaz-Ortiz


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The Art of Midwifery

To treat hemorrhoids, melt shea butter in the microwave and add a few drops of tea tree oil, then place on hemorrhoid. Moms can also add some tea tree oil to their bath water.

Anon., Midwifery Today Forums


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Passionate Midwifery Education

My Midwifery Education: The Call

After I had my first homebirth I got the call, with a vengeance, to become a midwife. The call is a most amazing desire and drive, to be on the path to achieve the goal. I am not sure how others would describe it. Let me know if you have a definition for the call. My first homebirth was my second baby and it was a birth that made me high for many years. Perhaps the high was made stronger by a typical medically-bungled first birth. I did not know birth could be so ecstatic, powerful and life-changing. This drive began as soon as she was born. I kept reading my childbirth books. My husband said, "You've already had the baby, why are you still reading the books?" I said, "I think there is something more here." Wow, little did I know then that God had issued this intense calling, from the minute she was born.

Anne Frye relates her call to midwifery, which came early in life: "I was working in a cooperative store in San Francisco as a clerk. One of the employees there said she was going to the Holistic Childbirth Institute and her intention was to be a midwife. When she told me that, I remembered this dream that I had when I was about eight years old. I was down in the fog, near the water, on a dock. There were all these people standing around. There was a woman giving birth in the middle of the people and I went down to help her. There were no details in the dreams. It was a very foggy kind of a dream. But I remembered the dream very clearly and I just knew that that was what I was supposed to do."

The call is an interesting spiritual touch. In Mexico midwives have told me if you do not answer the call bad things start happening to you, like you might break your leg, until you answer the call. I tell you this so if called you will at least begin to answer it. Often you have small children so your answer to the call might have to be getting on the path in a slow walk. That is OK. Just answer it. I have said midwifery will take all the love you have to give and then some. By midwifery I mean any part of the work, whether doula, childbirth educator, activist or mother supporter. I refer to all as midwives because I believe we are all midwives. It is a natural part of women's role in all societies. It just dominates more of our lives if we are actually caring for pregnant women.

Send us the story of your call to midwifery!

love, Jan
Jan Tritten, Mother of Midwifery Today

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Epidural

Mothers-in-waiting who read all the nice things being written in the news about receiving an early epidural would be best advised to also read the full report as it appeared in the New England Journal of Medicine (17 Feb 2005), under the more cautious title, "Risks of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor."

Those who do so may come to the conclusion that if this test trial proved anything at all, it was that all epidural combinations lead to more c-sections, whenever they're given—early or late in labor. The high rates of c-sections in both the "early" and "late" epidural groups, indicated as much.

Only carefully screened and selected first-time mothers were allowed to participate in this study. No breech babies, multiples or mothers with diabetes mellitus or other conditions were studied. Nevertheless, 17.8% of the women in the early epidural group and 20.7% in the control group delivered their babies by c-section. Although the difference was deemed statistically insignificant, the c-section rate for each group was unusually high for healthy, first-time moms.

This three-year study began in November 2000, at a time when the primary c-section rate for all American mothers—with and without complications—was 16.9% Why would such "cream of the crop" nulliparae end up having so many c-sections? What common risk factor did they share, other than epidural anesthesia?

None, although a good look at the data in the full report shows that many differences existed between the two groups and even between the types of epidurals they received. Could some of the differences explain why mothers in the "early" epidural (EE) group fared better than did mothers in the "late" epidural (LE) group?

To begin with, mothers given an LE began labor in a sorrier state than moms in the EE group. More of the mothers in the late group checked in at the hospital with unforeseen complications such as prelabor ruptured membranes, which eventually led to induction—by itself a recognized risk factor for c-section. More of them received oxytocin and at higher infusion rates than mothers in the early epidural group.

If (as the authors suggest) the greater pain of a dysfunctional labor is truly why most mothers take an early epidural, this study certainly didn't prove it. On the contrary, data listed in the full report show it worked the other way around: mothers who did not take an early epidural were quicker to ask for pain relief than were those who did.

Data presented in this article show that a full 42% of the mothers in the LE group requested analgesia before reaching even 1.5 cm dilation—significantly more than the 30.9% who did likewise in the EE group. Only 27.3% of LE moms waited for pain relief before reaching 3 cm or more. This is significantly less than the 33.6% of the EE moms who managed to get that far without asking for pain relief.

Could the harder, quicker onset of pain in the LE moms have been an early warning sign of dysfunctional labor? If so, was dysfunctional labor a reason for their higher rate of c-sections? Would that also explain their surprisingly longer labors? More painful, dysfunctional labor tends to drag on and on...might the shorter, less painful labors in the EE group (prior to taking an epidural) also explain their lower rate of c-section?

Assuming that it did, this would still not explain why more mothers in the EE group needed mechanical assistance to give birth than mothers in the LE group—the ones with the longer, more painful labors. ... Nevertheless, data published in NEJM clearly show that as many as 13% of the 364 mothers in the LE group required mechanical assistance versus 16% of the 336 mothers in the EE group. Statistically, those figures are not bad for first-time moms on epidural anesthesia (who tend to need outside help during delivery four times more often than do non-medicated moms), but odd nevertheless; considering that mothers in the EE group spent an average of 90 minutes less time in labor than mothers in the control (LE) group.

Ninety minutes is a lot less time to a woman in the throes of childbirth; yet apparently for many of the mothers in the EE group, their reportedly "shorter" labors were not short enough to avoid the trauma of a mechanical delivery.

Esther Marilus, excerpted from "Just Say No to Drugs," Midwifery Today Issue 76


You'll find this extensive, important article in its entirety, in Midwifery Today Issue 76.

"Epidural Epidemic"
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News Flash

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol. 2006 Jul;108(1):12–20.

Previous to this study, the rate of uterine rupture for women attempting VBAC after more than one previous CS was shown to be between 2% and 4%. In this study the rate of uterine rupture among women after more than one CS was 1%. This was thought to be very important because the rate of uterine rupture after one CS is 0.5% to 0.9% depending on the hospital's frequency of the use of artificial induction and augmentation of labor.

The authors conclude, "A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation."

The study looked at 871 women with 2 prior CS, 84 with 3 prior CS and 20 with 4 prior CS, at 19 different study sites. Note that the author's conclusions are deceptive because 90% of the women with multiple scars were assigned to a repeat CS. The 10% of women (975) with multiple scars who underwent a trial of labor were carefully selected by doctors as most likely to have a successful VBAC: namely 51% had a previous vaginal birth and 40% had a previous VBAC. This is not true of the women attempting VBAC after one CS.

The study does show that hysterectomy, uterine rupture, endometritis, transfusion, thromboembolic disease and operative injury rate are much higher for women attempting trial of labor after multiple CS than after one CS, even in this group that was hand-selected to have as few problems as possible. Transfusion bears the risk of carrying deadly viruses like Hepatitis C, etc., and hysterectomy ends one's reproductive life.

Judy Slome Cohain
judyslome@hotmail.com
For more on VBAC, see Judy's article "Vaginal Births After C-section Are Not Necessarily Riskier in a Birth Center than in the Hospital" in Midwifery Today Issue 77.


Research to Remember

The active ingredient tetrahydrocannabinol (THC) in marijuana has been found to affect male fertility in men who smoke the drug frequently, according to a University of New York-Buffalo study. They have significantly less seminal fluid and decreased total sperm count, and the sperm behave abnormally—traveling too fast and then losing ability to complete their journey. Semen from 22 males who reported smoking marijuana approximately 14 times a week for an average of 5.1 years was compared to that of 59 fertile men who had produced a pregnancy. The study author stated that men who are regular users would have to stop smoking marijuana for four months or longer so their fertility potential would return to normal.

http://www.urotoday.com/browse_categories/male_infertility/marijuana_smoking_affects_seminal_fluid_sperm.html
accessed July 18, 2006


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Forum Talk

I am a doula but with some skills in homeopathy. I have a client who is 36 weeks pregnant with a breech presentation. Her first was born via cesarean because of the same presentation. She was going to do a VBAC this time. She tried the Webster Technique, moxi, and swimming last time with no success (I beg to differ since her first baby was born at 37 weeks due to PROM and I don't think she had time to fully take advantages of the natural techniques). So she doesn't want to go that route. Her care providers won't do a version until 39 weeks, which could be too late for her. I suggested she start taking pulsatilla 6C or 30C 3 times per day for the next 10 days. I know I can move up to 200C if the lower potency doesn't work. Is there anything else that is used for malposition of the baby, coupled with sorrow and fear? She carries a lot of grief from her first cesarean because she didn't see or touch her son for several hours. It still makes her cry when she talks about it. I also have her using ice on the fundus and inverting herself prior to doing pelvic rocks. I have also told her to talk to the baby and ask it to move into the proper position. Any other suggestions?

Michelle


Share your thoughts and experience about this topic.
**Please do not send your responses to E-NEWS!**


Question of the Week

Q: I have been told that raspberry leaf tea promotes labor. I very much want to have a natural birth, and if this will help me get through it quicker, please could you tell me how I drink it, how often, etc. I am 35 weeks already, but I am sure it's not too late to start, or maybe it's too early?

— Donna S.


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 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.

A: There is evidence to show that a c-section is less traumatic to the child than a vaginal delivery. The baby's spinal cord is outside its body, covered by only a thin membrane. If the membrane is broken during the pressure from coming down the birth canal, the baby's cord will be more susceptible to infection after delivery. In addition, the increased pressure from the vaginal "squeeze" can be transmitted directly from the sac up to the baby's brain. "If conventional delivery is chosen, the study by Shurtleff and his colleagues is important to note. Infants with neural tube defects (NTD) who were exposed to labor and vaginal delivery were more than twice as likely to have severe paralysis or motor deterioration than those delivered by cesarean section without labor. Although this remains a controversial point, most centers recommend a cesarean section prior to labor in mothers carrying a fetus with a myelomeningocele." (From e-Medicine.com "Neural Tube Defects in the Neonatal Period")

— Rebecca Cohen

A: It's my understanding, though I have not read the research, that a c-section is performed to minimize the damage that the protruding spinal cord and meninges would endure with a vaginal delivery. You might be able to find out the extent of the malformation that is occurring, whether or not anything is protruding, and proceed from there. With spina bifida occulta there is no protrusion/opening in the skin. You'll need to do your research to find out the best avenue for you and your baby.

— Wendee Whittaker Bartness

A: I did a little research on this topic for a client of mine who had a sweet little girl with spina bifida. The information I found gave mixed recommendations on this. Some of the information wasn't accessible to me as it required subscription to medical journals. I would challenge the clinic providing your care to provide you with documentation supporting their claims. The clinic my client went to defended their position by saying "It only makes sense that cesarean birth would be cleaner." The concern was infection in the baby.

Other things that can influence your decision are the availability of the best pediatric neurosurgeon you can find, to close the baby's back and insert a shunt if it is needed. My client ended up delivering by cesarean and traveling with the baby out of state (Illinois) for the baby's surgery. She had been in contact with parents of other children with spina bifida and had been told that the neurosurgeon makes a huge difference in the baby's future. The doctors in her city just assumed they would be doing the surgery, and she said "Cancel it. I'm taking the baby to Dr. 'X' in Illinois." You don't have to go along with "the plan" as it is presented to you.

I hope this is helpful, and I sincerely hope that midwives in your area are able to attend you at a home VBAC in the future if you decide on cesarean for this birth.

— Edie Wells
Beloit, Wisconsin

A: A cesarean section would be warranted for spina bifida to protect the baby's underdeveloped spinal cord if there is a meningocele or myelomeningocele. If there is an occulta (often called hidden spina bifida) spina bifida, then it may be possible to have a vaginal delivery. You need to find out more information from your provider with some testing to make a more informed decision. A hospital birth would be a must in this instance for the safety of your child (as you previously stated). Although having a cesarean section is not something I advocate for in my patient population (I am an L&D nurse), I do advocate for a safe, healthy mom and baby for delivery, so all of the information must be considered before making your decision.

— Tanya


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.


Think about It

When we consider the debate about elective cesarean surgery, it seems apparent that because biomedicine holds such a prominent position in our culture, it is possible for procedures to be perpetrated and performed routinely regardless of whether there is any causal relationship between the technology and improved health outcomes. Consequently, because the debate about elective cesarean surgery is framed as a matter of "choice," the public perceives that cesarean surgery is a normal occurrence and assumes that the broader questions of efficacy and safety have already been considered, because biomedicine tells the truth in the public interest. The result may very well be, as Henci Goer suggests, that by normalizing cesarean surgery and by attempting to convince the public that women prefer cesareans over vaginal birth, those who have interests in the social, political and economic power structures that support and underlie the medical system might just "succeed in making the imaginary groundswell a reality" (Goer 2001).

Lisa Weeks, excerpted from "Problematizing Choice in the Elective Cesarean Debate," Midwifery Today Issue 73

Reference:

  • Goer, Henci. 2001. The Case against Elective Cesarean Sections. J Perinat Neonatal Nurs 15(3): 23–38.

MIDWIFERY TODAY Back Issues are available online. Issue 73


Feedback

I totally disagree with the response that it would not be beneficial for midwives to visit high school health education classes [Issue 8:15]. First things first, midwives are not illegal in most states—particularly CNMs and CPMs.

I have participated in teen health education programs facilitated by CNMs in the Northeast, and the impact was spectacular for the young men and women participating. Most health education programs lecture to students, while the midwives I worked with interacted with students on their level.

You should have seen the way these teens lit up at the attention and knowledge that was provided by the midwives! The program meshed with state standards for health education while at the same time provided the young men and women with practical knowledge about reproductive health, normal birth, and breastfeeding. I cannot remember a single rolled eye or pair of crossed arms in any of the classes. Better yet, I do not remember anyone ever saying "Ick!"—they were the most curious young people I have ever seen. The experience was awesome, and I bet if you interviewed those students now they would light up and tell you everything they learned.

Midwives teach every day, and what they share is testimony to how the human body works and how each individual is involved in their own health. The presence of midwives would make a huge impact on health education. The trick is to stick to the state standards, know the learning style of teens, and build trust with the school system involved. Not only would the information benefit teens, it would also build the professional reputation of midwives.

Sarah

I didn't think I had anything to say about this last "Question of the Week," but after reading Kymberli's response [Issue 8:15] I think I do. I completely disagree with her—I think that "seeing it lived" is not enough. Where, unless a child is lucky enough to have a midwife for a mother, would they be sure to see that? If people find out about homebirth only through experience, the trickle-down effect is going to be slow enough to barely maintain the movement. The only way to ensure homebirth remains (or becomes) a choice is to speed up that process so that it has enough momentum to make its way into the general consciousness.

I have talked to so many people who have said, "If only I had known homebirth was an option!" Many like them are sitting in today's classrooms, oblivious to the idea of homebirth; they would be inclined to make that choice if only they knew about it. And the other children in those classrooms include future in-laws, friends, law makers, and healthcare providers to those who will choose homebirth. The worst thing we could do would be to give up on them as being "already brainwashed." For them to see a real face put to it, a professional and rational face, and to hear facts they certainly won't hear anywhere else in their education *will* help many of them to at least see homebirth as a valid choice, which those of us in the homebirth culture can only benefit by. We can plant the seed that will allow that to happen.

Toward that end, something else midwives and homebirth supporters can do is to submit articles and stories about homebirth to more mainstream publications. Yes, they'll be rejected for the most part. But a few will slip through. The story of one of my homebirths was printed in a mainstream publication, in its entirety. It can be done!

Linda Hessel

In response to Kathryn Balley's question regarding midwives sharing in public and private schools about the home birthing process, as a 17-yr-old young woman entering her senior year of high school I'd like to say YES! That would be really wonderful and I believe it would make a difference in the lives of the young people there. For the majority of girls I know—having a baby at home wouldn't even cross their minds because they are completely unfamiliar with it as an option. Would the schools allow it? Maybe, maybe not. But it is definitely worth a try.

I agree with Kymberli M.'s response to an extent—yes, it's best to see it lived. And it's great that her children know from their mom's experience. But a lot of those "independent thinkers" really haven't considered it, much less been to their mother's homebirth(s). And because the schools often don't really encourage breastfeeding is precisely why it would be so great to at least try to talk to these young women in school.

Sara Shepard
Claremore, Oklahoma

I think it's a great idea for professional midwives to offer their services as speakers in health classrooms, even though I am not surprised to read that such an offer has been turned down more than once. I don't by any means expect that such a presentation would be 100% effective in getting people out of hospitals to birth, but it would get the information out, plant the seeds if you will, in a lot more young people. If such talks aren't welcomed by your local public and private high schools and middle schools, try the colleges and community colleges (most of them offer a lower-division human sexuality course that touches on birth; these classes are taken by undergrads in all fields as well as by nurses earning CEUs—you could also try the anthropology department, which may offer cultural anthro courses that talk about birth in other cultures but neglect our own options). If there's a Unitarian Universalist church in your area, contact the Our Whole Lives (OWL) director (one of the best health, sex and life skills curricula ever devised, in my opinion) and ask if you could speak to their junior high or high school OWL class. I'm all in favor of homebirth and am planning one for myself in March, and I'm on the slow track to becoming a midwife—a track that could have been much faster and more direct if I'd heard before I was out of grad school that it was possible to be a licensed, professional homebirth midwife in the United States. If you can find a forum to share the options, by all means, do it!

Susan Way, science teacher and midwifery student
San Rafael, California


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