Re: diet

[Kleimar]

I think it is this obsession with cost that rules dietetic services in hospitals of all kinds. I actually had a fairly good course in nutrition during my midwifery education, however I would be surprised if even the very best education on nutrition in mid education programs would have any impact on the meals served in hospitals. I think it must be incredibly frustrating to be a dietician in these establishments. Nevertheless, surprise me! Of course nutrition should be a very important part of any midwifery education program however, I think the use of this education will be preconceptual, antenatal and postpartum unless the mums birth at home, that is where the mothers have control of the food bought, prepared, and eaten.
marilyn

changing email provider.

[Kleimar]

I have forgotten how I get in touch with the webmaster. I am changing providers but want to stay on the list.  marilyn

Re:

[Kleimar]

well said Liz. marilyn

Re: melbournes child

[Kleimar]

I think this is an excellent response as it hits many of the issues involved when women wean early. I haven't read the article but  got from your response that the main issue was "insufficient" infant weight gain in the first week or so. I am also guessing ( because I have heard this from mothers) that the advice given by staff may have been diverse and thus confusing. I think this goes with the territory of lactation, since it is just a little (or a lot) different for everywoman. There are some essential basics, such as supply = demand but after that different positions work better for different women, nipples themselves have an enormous variation, skin types etc. etc. not to mention maternal and infant personality and preference. I think the very best advice is to somehow convince the woman in her antenatal period to attend a local ABA meeting (formally Nursing Mothers Association). This was by far the gem my GP insisted up!
!
on almost 26 years ago in Brisbane, and even though I didn't become a member then, I was impressed with the variety of breastfeeding relationships between mother and baby. I also knew I had a 24hr hotline available. I don't know if Corinda Maternity is still open, but I do know they had a staff dedicated to establishing breastfeeding before you went home which was about a week then. I do think it is important for the mothers to be aware that the most important indicators  of the baby's well being are # of pees and poops and allertness vs irritability and/or lethargy in the baby. Slow weight gain is fine if all else is normal, if it isn't then why the mother's milk is not in by day 3 or 4 should be investigated. I hate to sound too medical but no weight gain/ continued weight loss do/does need to be investigated, nipple pain at every feeding can have other causes (Candida for one) besides poor latch, and previous breast surgeries may pose some difficulty.

Last year I worked with a mom (it was in the USA, I am here though now) who had had breast reduction surgery 7 years ago. Her milk was slow to come in and as her care givers the other midwife and myself had different ideas on whether she should supplement. Denise Fischer at BreastEd.com gave me and subsequently the mother excellent advice. The mother also accessed some excellent midwife/lactation consultants in Santa Cruz, California, who gave wonderful support. The baby had lost 10% of her birthweight and was irritable and lethargic, mom could pump some milk, so the process was working but the supply lines needed some time to reconnect (I think). Anyway, she did supplement always feeding first but comping before the baby got too tired. The baby was fully breastfed by 4 weeks and is still nursing and thriving over 12 months later. 

For me the key ideas are flexibility on the part of the care giver. The other midwife had read the research on breastfeeding and AIDS mothers and taken from that that babies must be only ever given breast milk because otherwise the linings of their stomachs will be damaged (perhaps forever). She really and truly in her heart felt that supplementing that baby was wrong. So, she couldn't advise her to feed the baby anything but breastmilk.  I however could, after advice from Denise. Now, I am mentioning this just to emphasise how women can get different advice from care givers in this case in the same practice. The woman concerned was very well informed, a doula and CBE herself, so she had the resources to deal with the conflicting info, however I am sure that women without such connections must be overwhelmed.

Hence my plug for ABA. At a meeting you see the variety of styles for yourself and somehow it impresses upon you the uniqueness of the breastfeeding relationship: it is just you and your child.

marilyn

Re: FHM

[Kleimar]

Deb
I think Ann was asking about non electronic monitoring ie doppler/ fetascope/pinard during labor. Do you have any research on that? One of my classmates at Seattle Midwifery School did her Senior paper on this topic, however I don't have her paper with me and it is unpublished. I generally have listened to FHt's every 30 minutes (before, during and after a ctx) in active labor, and then every 5 minutes during second stage/ after every contraction.  Obviously we are listening for decels and it is contentious as to if we can differentiate late, early, or variable decels with a doppler (probably not with a pinard/fetascope). I think there is great  practitioner variability with the use of intermitent auscultation. I am interested to here what others do at home and at birth centers/ hospital.
marilyn

Re: Closure of Liverpool Team Midwifery Project

[Kleimar]

Why can't they come up with a salary payment method for midwives who work in groups/teams?  marilyn

Re: practical questions

[Kleimar]

So well said, Lynn.
regards, marilyn

Re: NCAD 'C-Scape' 2002

[Kleimar]

Wow, Jo I think this is wonderful. I think this is the kind of exposure that women need. I hope you all didn't think in my comment about informative videos on c/s that I think women should be scared out of having them. I really don't think the surgery should be minimised, however I think it is a truly difficult though significant task to educate women thoroughly on the matter. Looks like "C-Scape 2002" is a step in the right direction. marilyn

Re: Launch of www.birthjourney

[Kleimar]

Dear Lois: A truly lovely site. What an inspiration.  Marilyn

Re: 'educated' women

[Kleimar]

yes, those too. marilyn

Re: 'educated' women

[Kleimar]

I really think all women considering elective cesareans should be shown graphic videos of the operation and exactly what will be done to their body. As a midwifery student I was quite interested to witness my first c/s and it was nothing at all like the pre-op videos I had seen in CBE classes or at school and certainly not at all like the birthday TV shows. Also, since there is quite a lot of variety in the length of time to perform the surgery etc., I think several such videos should be shown to those requesting elective c/s for non obstetric/medical reasons. I think this would be true informed consent. Having been with a few friends lately who have had necessary surgeries for a variety of conditions, I was shocked at how the body trauma of the surgery was minimised to these women. I was also shocked at the response I received when I tried to inform one family of the help their mum would need after such a major operation (she nee!
!
ded a complete hysterectomy after torsion of her fallopian tube and her ovary becoming a 5 pound mass). The surgeons had really minimised the post-op recovery etc.. presumably to get my friend to have the surgery, which incidently I totally agreed she needed. Anyway, I think people need reality checks every now and again.  marilyn

Re: Yahoo! News Story - Home Births Linked to More Infant Deaths

[Kleimar]

I sent that news story to the Executive Director of Seattle Midwifery School and here is her response (apparently the paper was presented as a poster at the ACOG conference and has not as yet been published):
 From Jo Anne Myers-Cieko:
"It hasn't been published yet.  It was presented at the ACOG conference -- I 
believe as a poster.  I have a copy of it because Benedetti distributed a 
draft at a Medicaid advisory committee meeting.  Sarah Huntington and I 
drafted a critique of the study - it's got a lot of flaws - which was sent 
to the primary author and Benedetti last week.  Marijke's taking it to the 
state perinatal advisory committee meeting this morning with a request that 
the authors respond.  We're still trying to figure out if we can/should 
distribute what we've got even though it clearly says on it that it's 
embargoed until publication.  Given the media report, it seems like we 
should so that everyone can see it and respond appropriately"

This is clearly some sort of political issue with ACOG and homebirth in Washington. Something is quite up. The women mentioned in the quote, Sarah Huntigton and Mariike are actively practising homebirth midwives in Washington and very active politically.

marilyn

Re: nitrous oxide

[Kleimar]

Hi all:
It was quite interesting to me when I was visiting in Sydney in January, to 
witness the use of N2O2, since we don't use it in the US. Some midwives here 
(homebirth) have heard of midwives in Great Britain and Canada using it 
(nitrous) at home and are quite intrigued by that. I have read some (not all) 
the articles in the research list and was not aware that the associations 
made with narcotics given in labour were also made with nitrous. I think the 
non use of nitrous in labour in the USA is tradition based rather than 
evidence based. But I don't know that the use in Aus/GB/CA is evidence based 
either. I have read at least one article in the Practising Midwife that found 
some adverse effects of nitrous in care providers (midwives and maybe 
dentists) who monitor the use of nitrous in their clients/patients. Dont have 
the reference at my finger tips though.

Re Tens machines: we have our homebirth clients rent the machines if they are 
interested and usually the support person (partner or doula) operates them. 
Have never had a really good protocol/guideline for their use though, which I 
think has reduced their efficacy.

I think regarding medications for pain relief, that we have to bear/bare (I 
can't spell to save myself anymore) in mind that for a normal labour most 
women can and do cope with minimal intervention with the right support. But 
if needed, they (the drugs) can be a godsend. Yes there are associations with 
drug use in the babies later on but it is my understanding that though there 
was more use in the babies whose mothers had labour meds it was only slightly 
more than in the babies whose mothers didn't use drugs in labour. I am not 
sure if the greater incidence was in fact statistically significant. I seem 
to remember, the studies called for more research in the area. I think I need 
to reread the articles.
 
I have to get off line and pack my bags.
marilyn
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Re: Fw: prem care

[Kleimar]

Dear Rhonda and all:

I don't think the gestational age for the development of sucking has changed 
other than we are more aware of the age range at which it may occur. Some 
perfectly normal preemies will not suck well until 35-36 weeks to term, yet 
others will suck well from 32-33 weeks. I think preemie care is fascinating, 
however I don't have much personal experience with it. My most recent 
experience was with a mum who had preterm twins at 31 weeks. They did well 
only ever receiving EBM, first from a gavage tube, then from bottles, and 
then the breast. We did have many discussions regarding offering the bottles 
and nipple confusion was a big issue. The mum was pumping amazing amounts of 
milk. However, the hospital would not let them home (unless they went AMA) 
until either the mum learnt to gavage feed/babies were either successfully 
breast/bottle feeding EBM. They decided to go with offering bottles and trust 
there would not be nipple confusion (they read every drop of research and the 
latest seems to indicate that nipple confusion is a myth??). Once they 
started feeding from the bottles, they realised just how long it took their 
little ones to feed and how quickly the babies got tired. However they all 
perservered, babies came home around 35-36 weeks taking both breast and 
bottle, and are still totally breastfed until this day (16 months later). 
They did try to institute kangaroo care, but the nursery staff were 
unfamiliar with the evidence, however both parents held their babies skin to 
skin for feedings and whenever they could. Of course when they took them home 
they could do this more often. I think we all have to remember that those who 
work in the SCN see a lot of cases of failure to thrive and very sick babies. 
That's all, marilyn
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Re: Abruptio Placenta

[Kleimar]

Dear List: I haven't read any research beyond Dr. Brewers that replicates his 
claims. I wish it were as simple as a good high protein diet as preventive 
treatment for pre-eclampsia. I don't think that works for everyone, but that 
doesn't mean it isn't worth trying. I think the web sites Tina gave us give a 
good synopsis of abruptio placenta (too bad the site didn't have references) 
and the Path Site gave some excellent slides.  I think beyond PIH, 
pre-eclampsia and gestational hypertension being causes of abruptio placenta 
we have smoking, substance abuse and trauma (either accidental or 
intentional) as being causes as well as unknown causes. I think the tricky 
part with AP is when you have intermittent antepartal bleeding that is not 
associated with pain. The midwife I was precepting with last year and myself 
had a mum present with intermittent antepartal bleeding in the 3rd trimester, 
we consulted with an OB and sent our mum for ultrasound, BPP, etc.. No 
abruption was detectable, no previa etc., and baby was fine, so we waited for 
labour. The mum wanted a home birth, which the OB did not condone (and quite 
honestly I was not thrilled about), however the mum wanted to try at home so 
she started her labour there with close surveillance, she did start to bleed, 
not horribly and the baby was fine, but, she wasn't dilating, so we 
transferred and when we got to the hospital the EFM picked up decels, mum had 
a c/s, baby had apgars of 8/9 but had to be lavaged for blood, the placenta 
was in the process of completely abrupting, mum's uterus also had a dehiscent 
window but no rupture, all worked out well, but I thought it was a bit close, 
for me. My preceptor was fine with it though and the parents were too. 
Anyway, I do think antepartal bleeding in the third trimester is a good 
indication for a hospital birth (even with previa ruled out).  Marilyn

PS Sue I looked up PUB MED for the CRP (i was completely ignorant about it).

I entered "C-reactive protein" AND "newborn respiratory distress" and got a 
lot of articles with informative abstracts. I seems that measurement of CRP 
is used to differentiate between uncomplicated RDS and those with pneumonia, 
aspiration, and extra pulmonary sepsis. The levels of CRP go up with the 
onset of sepsis in Late Onset Sepsis. According to these articles the CRP is 
elevated when above 10mg/L. CRP apparently is an anti-inflammatory agent 
(acute phase reactant) and measurements are done in conjunction with 
leucocyte counts and measurement is valuable in the diagnosis of neonatal 
bacterial infection. I think Lois also said this, so I am being redundant 
here. I hope the baby continues to do well.
regards marilyn
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Re: sorry -ignore previous email here

[Kleimar]

 I support all of you who are defending this program against the "attack" by 
was it Dr. Mudge. However, I would like to offer a note of caution. Australia 
is not the Netherlands in many ways though many of its health care programs 
are excellent. Howeverthere seems to be simultaneously an attempt by US based 
healthcare corporations to get get involved in healthcare in Australia. These 
corporations are entirely profit based (not that I think profit in itself is 
a big evil, but I do think social responsibility is critical in health care) 
and will erode  great programs by cost cutting and diminishing services. This 
happened to early discharge programs in the US and continues to this day. 
Women can be discharged from 6 hours after a spontaneous vaginal birth or as 
soon as they are stable. The federal government had to pass a law making it 
illegal for hospitals to discharge women and babies before 48 hours after the 
birth. The women get another 24 hours if they had a c/s. Of course they get 
no follow up care other than phone numbers to call if they are concerned. 
They can initiate care, but it is not offerred to them. I guess my note of 
caution to early discharge programs is that support services are GLUED to 
them as I believe (without any RCT's at my finger tips) that they are 
critical to mother and baby's well being. Oh! all of the above is not true 
about midwifery led programs in the USA. I am talking about normal mainstream 
OB led care.  marilyn
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Re: consumer representation

[Kleimar]

I think this list is a good place to start in looking at what has been 
improved in any country in the last 20 years or so, what has stayed the same 
and what has gotten worse. 

marilyn
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Re: consumer representation

[Kleimar]

That was exactly my reaction Louise but my experience in Australia is limited 
so I refrained. Even in many places in America the list is old. Eye meds 
(usually antibiotic cream) are still the law  even though  text books state 
that antibiotic eye ointment of the type routinely used would NOT be the 
treatment for gonorrhea or chlamydia infection in a newborn. So, my question 
here is what research/evidence stopped the routine use of eye meds in 
Australia? I know I changed the topic.

I'm not sure what your terminology for a heplock is but I think I heard 
someone refer to it as an IV cannula with a bung in it...

marilyn
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midwifery positions

[Kleimar]

Dear List: 

As many of you may know I have been hanging out at the list for a while. I 
have now finished my midwifery education in the USA (direct entry at Seattle 
Midwifery School), have received my license to practice midwifery in 
Washington, and am in the process of applying for registration in Australia. 

I have downloaded application packages from the Nurses Boards in NSW, Qld., 
and SA. and I am in the process of collecting the portfolio of certificates 
etc. that are required .   I have a couple of questions regarding the NSW 
application: they want to know if I have had traffic infringements (the 
wording is convictions specifically including traffic infringements), do they 
mean speeding tickets? (yes, I have had 4 in various jurisdictions over the 
last 33 years of driving). The other question is more crucial: I had 
collected a package (when I was in Australia in January) from the nurses 
board for applying to be registered as a midwife only (which is what I am, I 
am not trained/educated as a nurse), I then downloaded stuff from the web 
site and on the midwife application it had a sentence which was not there 
before: to be completed by midwives who are RN's. Has something changed in 
NSW? Should I wait  to send in my application in NSW until the new ammendment 
has passed through the parliament? 
 
I have nothing against Victoria or Western Australia, I have been advised 
though that the states I have listed above might be more amenable to my 
qualification than either Victoria or WA. I am open to input. 

I am still an Australian citizen so I don't need a work visa  to come to 
Australia. I am planning on leaving the USA on May 22nd. However I am 
wondering if any of you know of any midwifery or midwifery related positions 
that are available, anywhere in Australia. 

Thanking you in advance for any responses.
marilyn
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Re: Fenugreek

[Kleimar]

I have been advised previously that it increases milk production: it was 
recommended for a client of mine who had had previous breast reduction 
surgery and subsequent delayed onset of lactation, it was definetly 
beneficial for my client (as well as determination etc.).  marilyn
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Re: moxibustion

[Kleimar]

I don't think we know how it works: whether it is the heat alone or a combo 
of the heat and the herb. Traditionally moxa is made from Artemisia vulgaris 
common name mugwort, the Japanese name is moxa. Traditionally these are the 
herbs used and in the study cited the researchers could not do a placebo 
comparison with another herb or with no herb at all and only heat because the 
population of women are so familiar with moxibustion treatment. Perhaps the 
trial should be repeated in another place/culture where women are less (or 
un-) familiar with traditional moxibustion and so a placebo treatment could 
be used. So right now the treatment is to burn/smoulder the moxa stick on the 
acupuncture pont indicated. It is stinky (to most westerners) and we don't 
know if simply placing heat over the point would work as well or at all.
love marilyn
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Re: 'turning' breech presentations.

[Kleimar]

Joy you raised some very interesting questions. Firstly the numbers of women 
included in the trial were actually quite small (130 in each arm), so the 
percentages translate to even smaller numbers (the 75% of moxa treated women 
with cepalic fetuses at term reprsents 98 women and the 62.3% of women in the 
control group with option of ECV represented 81 women with fetuses in 
cephalic presentation. The stats given for these numbers were P=.02;RR 1.21; 
95% CI, 1.02-1.43. 

Second was the timing of the moxa. My comment here is I think we are all 
reluctant to change our traditions. According to this paper, the standard of 
care for breech babies in China (or at least the hospitals were the trial 
took place) is moxa early in the 3rd trimester followed by ECV around 36-37 
weeks. In the introduction the authors present research on the probability of 
breech fetuses of primips, multips with prior breech, and multips with no 
prior breech turning spontaneously before 33 weeks, 35 weeks, etc..  They 
then decide to do the moxa treatment trial in the 33-35 week window ( which 
is not surprising to me because this is when it is done anyway). They appear 
to believe that spontaneous turning of a primip breech after 35 weeks in 
unlikely and so they want to use the moxa to enhance the likelihood of 
spontaneous turning (they give a figure of 15.5% for spontaneous correction 
of breech in primiparous women based on and article by Gottlicher and 
Madjaric, which is in a German publication (if anyone wants the name of it I 
will copy it later).  

Since moxa is traditionally done relatively early in the 3rd trimester, there 
is actually nothing in the literature to suggest that it is better than doing 
nothing at all later in the third trimester. Even though it is a procedure 
that the woman can do at home, it takes a lot of time and preparation to do 
right (or at least in the way it is done in the trial: 2 half hour 
stimulation per day for one to two weeks or until the baby is confirmed 
cephalic presentation). I realise that women who are making there own herbal 
preparations etc. may have no trouble with this but, I have worked with women 
who found it difficult to tolerate the smoke etc., not to mention the 
considerable irritation on their toes, and one client whose husband did not 
realise he had to extinguish the moxa stick and created a small fire in the 
kitchen. I don't know (because I have never offered it before 36 weeks) but I 
tend to think the discomforts would be more tolerable at 33 weeks than 37 
weeks. Then ECV is your back up. 


I have only worked with 4 clients who had breech presentations. 2 turned with 
ECV and were born vaginally and 2 were born vaginally in breech presentation. 
Of the 2 breeches at birth, one was undetected until labor and was born at 
home, the other refused to turn with 2 attempted ECV's [plus moxa daily from 
37 weeks and was born in the hospital with a necessary forceps lift out. The 
home birth was a multip, the hospital birth was a primip. My second daughter 
was breech (24 yrs ago and the dx was not made until 37 weeks, after which I 
had to change care providers (since my GP was recommending a c/s), get u/s, 
educate myself, and run around in a flap without appearing to be in a flap). 
I would have preferred to know earlier I think with full disclosure of all 
options, I don't know. I think it should be the woman's choice ultimately. 
But how can she choose if she doesn't have all of the information. 

Oh! The awareness of increased fetal movement: the paper admits it doesn't 
know how it (moxa) works, but they assume since increased awareness of fetal 
movement occured in the moxa subjects then that is related to how it works. 
They call for further investigation.  The paper states: "since moxabustion 
and ECV must be performed at different gestational ages, we may regard them 
as completmentary therapies to be used in succession".

Interestingly enough both of the groups in the trial had a high c/s rate even 
amongst babies cephalic at term. In the treatment group the c/s rate was 
35.4% (26 for breech at term) and in the control group 36.2% were c/s, again 
26 for breech at term. And this was apparently at hospitals wher the routine 
for breech birth was vaginal delivery.

Sorry this is so long. Marilyn
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Re: 'turning' breech presentations.

[Kleimar]

It is actually an interesting article to read. The researchers had apparently 
wanted to use an alternate herb / treatment as a placebo, but Chinese women 
are so familiar with moxibustion to turn a breech baby, they decided the 
placebo effect would be null and void. The paper describes the treatment 
protocol in detail. As I wrote earlier, it seems to me to be critical to use 
the moxa between 33 and 35 weeks to get the optimum effect. Unfortunately, 
many of us (midwives) are unwilling to make a diagnosis of breech at 33 
weeks, so as to not alarm the mum, and since 50% will turn on their own by 
35/36 weeks this reluctance is understandable. However, that leaves ~25% of 
mum's with breech babies at 33 weeks with breech babies at 36 weeks/at term. 
I think we should talk about the treatment with a handout and options for 
getting the treatment as close to 33 weeks as possible. Good on you Lois for 
getting the moxa.  Marilyn
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Re: 'turning' breech presentations.

[Kleimar]

The paper called "Moxibustion for Correction of Breech Presentation - a 
Randomized Controlled Trial" by Cardini, F. and Weixin, H. was published in 
JAMA 1998 Nov 11;280(18):1580-4. It was done in the outpatient dept. of the 
Women's Hospital of Jiangi province, Nanchang, and Jiujiang Women's and 
Children's Hospital in the People's Republic of China. The women were primips 
in their 33rd week with a u/s diagnosis of breech presentation. The 130 
subjects randomized to the treatment group received stimulation of acupoint 
BL67 by moxa (Artemisia vulgaris or mug wort) for 7 days with another 7 days 
of treatment if fetus persisted in breech. The control subjects received 
routine care but no interventions. Subjects with persistent breech after 2 
weeks were offered ECV any time between 35 weeks and EDD. Main outcomes 
increased fetal movement counts in treatment group vs controls; in 35 th week 
75.4% of fetuses in treatment group were cephalic vs 47.7% of fetuses in 
control group. 24 subjects in the control group and 1 in the treatment group 
underwent ECV. At birth 75.4 % of fetuses in the treatment group and 62.3% of 
fetuses in the control group were cephalic. Conclusion: Among primigravidas 
with breech presentation during the 33rd week of gestation, moxibustion for 1 
to 2 weeks increased fetal activity during the treatment period and cephalic 
presentation after the treatment period and at delivery.

I think timing is critical with this treatment. I have seen clients who 
waited for the baby to turn by itself until 37 weeks and then the baby was to 
snug (it appeared to me) to turn, though ECV was often succesful at this 
later gestation. marilyn
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Re: RE: Information on twin births

[Kleimar]

Congratulations Sally  on  making the space  for  that  woman to birth her 
babies. 

I recently had the opportunity to observe 2 sets of twin births about a week 
apart. The first woman (a multip)came into labour spontaneously at home so 
that by the time she was admitted etc.. she was fully. So, the birth proceded 
naturally, she did allow an IV for the hospitals protocol for the 2nd twin 
but it wasn't needed as everything just proceded beautifully, midwives 
delivered both babies with OB and peds standing by, but not needed. Hospital 
/OB protocols re the epidural were not followed.  The second woman was not so 
lucky, the twins were her first pregnancy, the second twin was diagnosed as 
IUGR so she was induced at 39 weeks. OB insisted on an epidural, there were 
language barriers so the woman was not able to effectively refuse, although 
she was 9+ cm when the epidural was finally in place. Second stage was rushed 
to say the least with the OB using a vacuum on both babies (I think 2.6 kg 
and 1.9 kg respectively). Babies were fine but cared for by the peds as mom 
proceded to have a postpartum hemorrhage despite a barrage of oxytocics on 
hand and had to be sent to theatre. She had  a torn cervix not uterine atony 
or placental fragments. Anyway, after seeing that birth of twins, I cannot 
imagine recommending IOL for a  healthy twin pregnancy at term, it just 
seemed to make it all so much worse. To be honest, I can't imagine 
recommending IOL for a complicated twin pregnancy either, I mean if you have 
IUGR going on then you have problems with placentation and sufficient blood 
to the compromised baby, couldn't/wouldn't you be making a bad situation 
worse by causing uterine hyper stim.. I guess I am wondering, if you are 
concerned about the babies' inutero environment and want them born, in that 
scenario wouldn't either a cesarean if they have to be born NOW be better or 
if it really isn't that urgent, waiting for a natural more gentle (perhaps) 
labor? I don't know? Has anyone seen a twin birth with IOL and epidural on 
board go smoothly? marilyn
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Re: VBAC question

[Kleimar]

I have actually read about it in either an article on VBAC or an ACOG 
protocol on VBAC, however I have never heard of anyone actually doing it 
before. The midwife I was precepting with was (and is) having her VBAC 
clients birth in the hospital and so after a successful birth when the OB was 
hovering (as they were doing with midwife VBACs in Seattle), she asked the OB 
if she ever did this procedure (checking the scar) and the OB gave a firm NO 
with a horrified look on her face. And that was the end of the discussion. 
So, I don't know where the idea came from, but it seems that, fortunately, 
those who do it are rare and far between. I also think they think they are 
following some safe practice guideline and maybe this needs to be raised in 
some such forum. marilyn
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Re: [BMidStudentCollective] Re: Flinders Uni PI Insurance !!!!!!!!

[Kleimar]

Dear list:
Firstly PI for midwives:
I recently heard from a Canadian midwife what is happenning there re PI: they 
were faced not with withdrawal of insurance but with savagely escalating 
costs of premiums (from $2,000 per yr to $40,000 per yr). Apparently in 
British Columbia the College of Midwives in conjunction with the government 
developed a self insurance scheme where by the midwives pooled their premiums 
and were underwritten by the government. So far there haven't been any big 
law suits, and if there is one then they may be belly up, so  to speak, but 
for the moment they are insured for a  reasonable premium. I am presuming the 
students are also covered.

Now student insurance: when I came over as a student midwife to ST. George, 
there was concern that my insurance wasn't sufficient. In the US we didn't 
have to be insured as a student unless we worked in a hospital, then because 
we weren't a hospital employee, we needed insurance. It is provided by Dean 
Insurance Agency, Inc. (for those of you who have access to copies of 
Midwifery Today they advertise there). The contact person is Ann Geisler, her 
email is:
[EMAIL PROTECTED]  she would be able to advise you re what is currently 
available.
It appears that a lot has changed since September 11 (the date and reason 
publically given for either withdrawing insurance or raising the premiums 
astronomically). If Dean is still offering insurance to midwives and student 
midwives, one possible drawback is that any court cases would have to be in 
the USA.? That is how my policy is worded. 

The other concern raised in Sydney was my lack of workers compensation, which 
wasn't really covered by my policy, and since I wasn't a hospital employee I 
didn't have. My school drew up an official looking agreement stating that St. 
George would not be held liable by the school or myself if I was injured or 
became ill due to working there. 

But, it seems the hospitals and clinics that students will work in while at 
Flinders Uni could solve this by making you employees. I think that is how 
the med students will get by: they will probably restrict the actual medical 
students to observation roles, but the residents  will have a salary (albiet 
a pittance) but it will cover them insurance and workers comp. wise. So, 
maybe you all have to become resident midwives/midwifery residents/student 
midwife residents or whatever and be temporary employees of the hospitals and 
clinics. How are the Victorian Uni's handling it?? I thought that was how it 
was done anyway?

PI in general: even though it appears sometimes that midwives are being 
targeted specifically it appears to be (to me) that it is any small business 
person, midwife, doctor, house painter, landscape architect. Here is Seattle 
many GP's are going out of business as their PI insurance goes through the 
roof (around $40,000/year without obstetrics). Something has to be done 
unless we are happy to all go to the one place for everything. (that is a 
very  flaky sentence, but oh well).
lots of love to you all. I am still waiting for my exam results. marilyn
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Re: Any support for a frightened mum

[Kleimar]

In a message dated 3/21/2 4:32:30 AM, [EMAIL PROTECTED] writes:

<< http://www.pinky-mychild.com/cgi/discuss/ >>

Pinky: I tried to get to the message, but I didn't know where to go once I 
arrived at the page the address took me to. Marilyn
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Re: RE: Finally - cord cutting and clamping

[Kleimar]

Dear Joy...

Thanks for your information. How you describe your management of third stage 
is very similar to what we do in Seattle;  basically we are hands off until 
after the placenta has delivered, and the cord is never cut routinely before 
it has stopped pulsing. So, that is why when faced with active management of 
third stage is was pretty much do it as it is described in the protocol. And 
there seemed to be such an urgency about getting that cord cut as soon as the 
oxytocic was given. I have a passion for physiology so I want to know what 
this urgency is all about. At this point I am thinking it is habit.

I have read Michel Odent's "The Scientification of Love" and found it a quick 
and informative read. I think it is a very interesting question that has been 
raised regarding the incidence of PPD and administration of oxytocics at any 
stage during labour. One thing I came across when doing some research on 
postpartum haemorrhage (and I can't remember the citation, unfortunately) was 
a small study done (I think in UK) with only about 100 women, where the 
researchers measured the levels of naturally occurring oxytocin in women 
postpartum following a spontaneous birth. There was quite a range. They were 
looking for at least an association with oxytocin concentration and incidence 
of PPH. They did find one: low levels greater chance of PPH but, if I 
remember correctly, it wasn't significant. I will try to find it again on 
Pubmed. I was then reading an article in Scientific American by Roger Smith, 
where he was looking at the hormonal orchestration of labour. I was struck by 
the work done on oxytocin receptors in uterine muscle, not only the number of 
receptors but when they become receptive to oxytocin and what turns them off. 
 As usual it seems the more we find out the more questions arise. Just 
thinking about it, I am wondering if there could also be a link/association 
between either lower natural oxytocin production, lower number of oxytocin 
receptors, induction and/or augmentation of labour, and post partum 
depression. Of course finding oxytocin receptors on a woman's cells would be 
an invasive procedure: much of the research for Smith's article had been done 
on sheep. I am just prattling on. I just find it all incredibly interesting.
love, marilyn
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Re: RE: Finally

[Kleimar]

Thank you all for your responses to my question. I too like to leave the 
maternal end of the cord unclamped, although as a student I had some midwives 
ask me to reclamp it as they wanted to know where the blood being lost was 
coming from.  On thinking about the responses I would like to venture that 
the concern about the baby getting extra blood has been also raised in 
discussions of physiologic third stage and I think Lois's response is right 
on the money: it depends on the position of the baby in relation to the mum 
how much extra blood the baby is getting. Regarding the stronger contractions 
causing more blood being pumped to the baby, I don't think it works this way 
for these reasons: 1. The baby's heart is pumping the blood, not the uterus. 
2. When you augment or induce a woman in labour and if her uterus experiences 
hyperstimulation, then the baby may receive less blood not more resulting in 
fetal distress. 3. The intent of the oxytocic in third stage is to schear the 
placenta off the uterine wall with the increased contractions constricting 
the uterine capillaries, if anything perhaps the stronger uterine 
contractions would restrict the amount of residual placental blood available 
to the baby.  4. My original concern about the oxytocic crossing the placenta 
to the baby also seems to be mute if what I just wrote is in someway correct. 
 Bottom line is I still feel like I am guessing about this. 

The question came up when as a student the mum I was caring for had agreed to 
having third stage actively managed (she had had a "long labour": tired 
uterus), but she didn't realise that this meant the cord would be cut 
immediately after the oxytocic was given (this was our fault as we hadn't 
covered this with her in the discussion, which brings to mind the flaws of 
giving informed consent in labour). So, when I was about to clamp the cord 
she said "Oh, but it hasn't finished pulsing", I said "your right then, we'll 
just wait for a minute or 2" and the midwife who was supervising me said "Oh! 
but we've given the pitocin, so we have to cut the cord now". And we did, the 
mum seemed to be ok with it, she had had a lovely and triumphant birth (I 
think and hope) apart from that. It was just after reading AndreaQ's lovely 
story, I felt a pang of guilt and also a lack of knowledge re the 
consequences of delayed cord clamping after an oxytocic has been administered.
Again, thank you to all who responded, I am still pondering.  marilyn
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Re: RE: Finally

[Kleimar]

Thank you all for your responses to my question. I too like to leave the 
maternal end of the cord unclamped, although as a student I had some midwives 
ask me to reclamp it as they wanted to know where the blood being lost was 
coming from.  On thinking about the responses I would like to venture that 
the concern about the baby getting extra blood has been also raised in 
discussions of physiologic third stage and I think Lois's response is right 
on the money: it depends on the position of the baby in relation to the mum 
how much extra blood the baby is getting. Regarding the stronger contractions 
causing more blood being pumped to the baby, I don't think it works this way 
for these reasons: 1. The baby's heart is pumping the blood, not the uterus. 
2. When you augment or induce a woman in labour and if her uterus experiences 
hyperstimulation, then the baby may receive less blood not more resulting in 
fetal distress. 3. The intent of the oxytocic in third stage is to schear the 
placenta off the uterine wall with the increased contractions constricting 
the uterine capillaries, if anything perhaps the stronger uterine 
contractions would restrict the amount of residual placental blood available 
to the baby.  4. My original concern about the oxytocic crossing the placenta 
to the baby also seems to be mute if what I just wrote is in someway correct. 
 Bottom line is I still feel like I am guessing about this. 

The question came up when as a student the mum I was caring for had agreed to 
having third stage actively managed (she had had a "long labour": tired 
uterus), but she didn't realise that this meant the cord would be cut 
immediately after the oxytocic was given (this was our fault as we hadn't 
covered this with her in the discussion, which brings to mind the flaws of 
giving informed consent in labour). So, when I was about to clamp the cord 
she said "Oh, but it hasn't finished pulsing", I said "your right then, we'll 
just wait for a minute or 2" and the midwife who was supervising me said "Oh! 
but we've given the pitocin, so we have to cut the cord now". And we did, the 
mum seemed to be ok with it, she had had a lovely and triumphant birth (I 
think and hope) apart from that. It was just after reading AndreaQ's lovely 
story, I felt a pang of guilt and also a lack of knowledge re the 
consequences of delayed cord clamping after an oxytocic has been administered.
Again, thank you to all who responded, I am still pondering.  marilyn
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Re: Finally

[Kleimar]

Thank you Andrea that was a lovely story, a beautiful birth. I have a 
question about active management of 3rd stage. Having gone to school in the 
US, my experience with  3rd stage at a spontaneous birth is mainly 
expectant/physiologic management. If we do give an oxytocic it is usually 
after the cord has stopped pulsing and has been cut and clamped. I have a 
question regarding clamping and cutting the cord immediately (or ASAP)after 
giving the oxytocic (when it has been administered either when the anterior 
shoulder is born or after the birth of the baby. The question is: is it 
dangerous to wait for the cord to stop pulsing after giving an oxytocic? Is 
this because of fear that the oxytocic will cross the placenta and harm the 
baby? Is there any evidence to support this? I have looked up text books and 
online but all I find are protocols, no rationale.  Thanks, marilyn
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Re: Hep B and health care workers

[Kleimar]

Hi Sue and all: yes at Seattle Midwifery School Hep B vac was recommended too 
but not required, it was more or less informed consent for us as health care 
providers. In most clinical sites it wasn't an issue but if it is then the 
clinic/midwife is informed  that this student is not vaccinated (on a form 
provided by the student). I do not know of anyone being refused a placement 
on vaccination status. However, I feel confident to say that some hospitals 
may feel otherwise. I was vaccinated some 6years ago for the work I was doing 
with developmentally challengd adults, so when I applied for a volunteer 
position a few years later at Stanford University Hospital, California they 
checked my titer levels and I was surprised to find them low, so I was 
revaccinated: given a booster. I had them checked again 2 years after that at 
midwifery school, and was given another booster, they were recently checked 
and were fine. I have never had problems with vaccinations so this was  just 
an interesting side note for me as I feel if I am going to be vaccinated it 
may as well be active. Having a titer done is just a blood draw, no biggy. 

In the event of someone challenging you on not being vaccinated it might be 
worth having a titer done to show you're not a carrier, I mean you can't 
spread the disease if you haven't been exposed and contracted it and if 
you're willing to take the risk of getting exposed over the risk of  being 
vaccinated then surely that is your choice. There must be something your can 
sign.

Regards marilyn
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Re: Jaundice and meconium; Minimum service levels

[Kleimar]

Yes I agree Leigh, it is the jaundice in the first 24 hrs that is concerning 
with this baby and hopefully the concern with meconium passage was not a red 
herring. It does seems that the obvious potential causes of hemolysis in the 
baby (and hence, jaundice): Rh factor and ABO incompatibility were ruled out 
by the mother's blood group and type: B+. There could be several other 
syndromes involved all of which are quite rare (Gilbert's syndrome comes to 
mind, never seen it just read about it, in relation to early jaundice). 
However, it seems that starting simple and as gentle as possible can be a 
good thing (removing the mec), while keeping a careful eye on the baby. Was 
there  any reason for the baby to have experience bruising or hemmorhage? 
Kirsten, was this the end of the story? Was the delayed passage of mec in the 
first day responsibel for the jaundice? And while I know any jaundice in the 
first 24 hrs is a concern, how extensive was it? The only baby I personally 
have seen who had some jaundice on the first day which increased over the 
next week was with a mom who developed fulminating HELLP syndrome in labor 
(we had transfered to the hospital for failure to progress at 3-4 cm but no 
concerning BP's). On arrival at the hospital her BP was more elevated than it 
had been but still less than 140/90. When it didn't dip after she had an 
epidural the OB ordered PIH labs (actually apologizing for being conservative 
and CYA). She was as surprised as all of us when they can back elevated. Here 
we use mag sulfate for preventing seizures, so our poor mom had to put up 
with the side effects during pushing (she went to complete in 2 hours after 
getting the epidural). She birthed her lovely 8 lb baby in about 45 minutes. 
There was heavy mec at birth and baby did need some resusc. but was really 
quite fine (Apgars 7/9). The hospital staff were fastidious about checking 
the baby for jaundice and when he did yellow up on the first day checked his 
bilirubin levels, they were not at a level requiring therapy but they were 
high and went higher. The parents actually refused phototherapy, and the baby 
did recover after losing weight down to 7lb in the first week, and causing us 
all some concern (they discharged on day 2, we visited on day 3 and called in 
the pediatrician to assess the baby, bili levels were high and borderline 
(sorry I can't remember the numbers or the units)) but the parents were 
convinced all would be ok, and it was, once the milk really came in, but he 
was always pooping (right from birth) and peeing and nursing around the 
clock. Long story. 

I  searched the net for associations of newborn jaundice and HELLP syndrome, 
and all I found was an association, but no explanation. I am assuming that 
one of the enzymes that causes hemolysis in the mum can cross the placenta 
and cause hemolysis in the baby, but I am making that up. Does anyone know or 
does no one know? Associating jaundice with the baby of a mom with 
fulmimating HELLP  seemed to be tacit knowledge on the postnatal ward at the 
hospital, but maybe they check bili levels on all their babies (I am sure 
they check on all those jaundiced in the first 24 hrs). This mom too had no 
blood incaompatibility problem she is A+.

marilyn
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Re: Jaundice and meconium

[Kleimar]

Dear Kirsten: I am with you in that the jaundice by 24hrs seems a little 
early to be blaming it on unpassed mec. I have seen p(a)eds here (USA, 
Seattle and one in California) give suppositories to babies who are a little 
lethargic and  yellow on  days 4 or 5, however the first 24 hrs is a 
different story. But it couldn't be ABO or Rh incompatibility: you ruled that 
out.  marilyn
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Re: RE: re BMid

[Kleimar]

Dear Macha:

Firstly I want to say I totally agree with everything Pete said, and if the 
course had been available just a little earlier I would be there too. But 
there may be some grains of truth in what is being said to you. Please 
correct me others as I may well be wrong. I have completed my direct entry 
midwifery education in the USA and soon will be applying for registration. It 
appears that if I am successful (and this is a big IF) I would be registered 
as a class B nurse restricted to the practice of midwifery. On the 
application form it reads like a class B nurse is an enrolled nurse. I think, 
depending on the hospital/clinic and my desperation for $$ I could be placed 
anywhere on the pay scale. This may be where the statements are coming from.

 I don't think current nursing awards cover DEM midwives. I think we will 
have to organise: to 1. work to our educational level not below it. and 2. to 
be payed accordingly. This may or may not have something to do with if the 
midwifery education was at the baccalaureate or masters degree level: people 
who have master's seems to get paid a little more everywhere and it seems to 
be the ticket to moving on up (if this is your aspiration). This of course 
would benefit nurses as their midwifery training (at least for recent grads) 
is at the master's level. Currently there is no midwifery masters available 
in Australia for those of us with  non-nursing bachelor degrees, so our 
masters degrees will have to be in something else. My personal aspiration is 
independent practice with sufficient work to tide me over until I get 
established. I don't think I will need a master's for that. Just insurance 
and registration, but that is another matter. I hope this isn't too rambly 
and is somewhat intelligible.

I have had a problem (which is now corrected) with my acrobat reader software 
so I was unable to read the recent proposed changes to the NSW nurses and 
midwives act, if someone could send me the web address again I will peruse it 
directly.

love, marilyn
 
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Re: re Apgars

[Kleimar]

I have only seen a 10 minute apgar done on babies <5 at 1 min or < 7 at 5 
min. Marilyn
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Re: umbil cord bld merchandising.

[Kleimar]

These companies who want the parents to pay to store their baby's cord blood 
are just marketeers. I am sure there has not been any research done on the 
benefits to  the baby of keeping the blood vs storing it: the storage hasn't 
been around long enough for them to know. It is a big marketing campaign here 
in the US, some companies charfging $1,000 to $2,000 US per year to store it. 
Then there is the donated cord blood for stem cell research which is another 
whole can of worms (this one I actually don't have that much of a problem 
with). And the blood can be collected after the cord has stopped pulsing, 
depending on the birth, for most babies it would be blood they wouldn't be 
getting anyway (which is another interesting topic).  Take care, marilyn
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Re: Is there moulding in a breech presentation?

[Kleimar]

Interesting quote Jenni. It is also interesting that the baby seems to me to 
have been in an extended position. The "ideal" position for a breech baby is 
fully flexed , which would (it seems to me) prevent the head from receiving 
moulding from the contracting fundus. As I said previously I have only been 
at 3 vaginal breech births and none of the babies had moulded heads, a very 
small number to draw any conclusions from (I have also been at vertex 
presentations with no apparent moulding). Marilyn
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Re: PUPPS

[Kleimar]

Yes, I agree with the previous definitions (but can never remember them all) 
I think the essential thing to remember is that the pruritis/severe itching 
can also be a symptom of choleostasis and so liver involvement should be 
ruled out. Once liver involvement is ruled out it appears that PUPPS is 
essentially a benign condition with extremely irritating symptoms. If 
antihistamines work, then the woman is lucky and she should get what relief 
she can, I personally haven't seen mum's get much releif until the the 
condition itself passes.  marilyn
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Re: Rural births

[Kleimar]

PJ: wonderful to know there is a plan for emergencies. Regards marilyn
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Re: Is there moulding in a breech presentation?

[Kleimar]

Dear Melinda: I think (someone please correct me if I am wrong) that that is 
one of the primary concerns with breech birth: there is no moulding. To come 
out the diameter of the baby's skull that presents to move onder the pubic 
arch and out of the pelvic outlet has to match the diameter of the presenting 
part which in a breech would be the bisacromial diameter (hip to hip). If the 
baby is at term and has grown symmetrically, and is well flexed so that the 
smallest diameter of the baby's head presents to be born then all should go 
well.  This lack of moulding is evident on observation of the baby: the 
occiput area may even seem a little flat. Conversely the legs remain in a 
rather flexed position for a while after birth.  I have been present at only 
3 breech births: my second daughter's 24 years ago, and 2 in the last 2 
years. At my daughter's birth the OB used "forceps to ach" (written on her 
identity card) which he explained as necessary to prevent too sudden 
expansion of her cranial bones as she moved so quickly through my pelvis (she 
was only 6lb 8oz, HC 34.5 cm), in any case he used then to guide her out, she 
came out screaming. The first breech I observed was here in Washington in the 
OR and was an attempted standing breech with a primip. The baby's head did 
get stuck and would not deliver, the mom got back onto the "delivery" table 
and the OB delivered the head with forceps (no epis and no tear!), all within 
5 minutes although they were SUCH a long 5 minutes, baby's apgars were 3 then 
8 then 9. Quite scarry, obviously the baby needed resucc at birth but 
recovered well.  That baby was 6 lb 12 oz with a 14.5 inch head (37cm) and 
U/S had detected a large head, the labor had been a pretty typical primip 
labour long and slow with a 2-3 hour second stage. The third baby was an 
undiagnosed breech at home: mum's second baby, rapidly progressing labour (2 
hours active), arrived to mum on all fours making pushing noises and thick 
mec coming from her vagina. Actually relieved to find the presentation was 
breech. By the time  all was set up (10 minutes) she was pushing on de by 
birth stool and baby popped out in 3 to 4 pushes, Apgars  10/10 (no blue even 
on the toes), screaming and 9lb 2oz, don't have a record of the head 
circumference. This is probably more than you wanted, hope it helps. marilyn
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Re: rural births

[Kleimar]

Yes Meaghan: I should have qualified the "30 minute rule" as I agree it is 
entirely arbitary, but is what is used to "disqualify" a service or hospital 
around here (Washington). In reality people are often a couple of hours from 
a hospital. As you said having an emergency plan is what is important, so 
that if the unlikely event occurs you can swing into action.

I have a question of a previous response that said the air ambulance was 
reluctant to take multips for fear they would deliver in flight. My question 
would be, if we are requesting an emergency transport of a multiparous women 
in active labour, then we probably have diagnosed an obstructed labour with 
or without fetal distress(amongst other things), the problem is precisely 
that either the baby wont come out or it wont come  out soon enough. We would 
give terbutaline/brethine to stop contractions and stabilize both the mother 
and baby, I can't see the baby being delivered in flight as being a problem, 
if it happened (I know things just happen sometimes) then the midwife would 
still be in attendance with full birth kit etc., and mother and baby would be 
on their way to the hospital in the event of a continuing emergent situation. 
 

I can see the reluctance to transport a normally progressing multiparous 
women in normal active labour as she probably would give birth on the plane 
and should have just been at home.
regards, marilyn
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Re: what can I advise?

[Kleimar]

Dear Macha: I liked Wendy's response. It seems that we should be writing 
grant/funding proposals for midwifery led care for rural communities 
throughout Australia. I was recently up in North Queensland and discovered 
that maternity care at the local hospital where I grew up (Tully) was 
basically discontinued and that women travelled to Cairns to have their 
babies at the base hospital. It is hard to understand why or how women are 
accepting this, but maybe they just feel they have no other options. 

 One concern might be the plan for transfer to hospital in case of an 
emergency. Where I am now (Seattle) if we need an aid car we can usually have 
one in 5-10 minutes and then another 5-10 minutes to the hospital which is 
within the 30 minutes required to set up for an emergency c/s, however for 
women in remote areas it is harder, though we do have emergency ambulance 
helicopters. Is such a service available in rural Australia? I would have 
thought so, but I don't know. Also while just recently in Australia I saw the 
NET helicopter transfer a sick neonate from Bali to Westmead in Sydney, so I 
think this is doable. I think it is critical to have a realistic emergency 
transfer of care plan and OB's who are oncall who you would be transferring 
to in such a situation. 

It is one of my pet peeves that the increasingly high tech nature of 
hospitals has made the practice of rural medicine (unfortunately, including 
childbirth) almost obsolete. I think it we have ti be creative about this 
before it disappears altogether.

regards marilyn
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Re: hippies...

[Kleimar]

Me too... all applies except that I don't live on a commune at the moment. A 
pity it seems to be considered a negative. Oh well. Such is life. I am not 
vegan but all three of my daughters are (they are 26, 24, and 21 years). love 
and peace, marilyn
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Re: VBAC

[Kleimar]

Dear Listers: I am trying to find the author and title of the book about 
fistulas and the hospital in Ethiopia. I have just done a search on 
BarnesandNoble.com and only came up with what looked like a medical text book 
called : Obstetric Fistulas by Zaccharin, something tells me this is not the 
book people have been discussing on this list. Can anyoone help me? Thanks, 
marilyn
PS to Jan Robinson: I have been trying to send you an email and it keeps 
coming back to me saying your quota is full, hope this one gets through, love 
marilyn 
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Re: VBAC

[Kleimar]

Wonderful story Mary. Here is the reference of the previously mentioned 
article:
Lydon-Rochelle, M., Holt, V. L., Easterling, T. R., and Martin, D. P. 
"Risk of Uterine rupture during labor among women with a prior cesarean 
delivery". N Engl J Med 2001;345:3-8. 

Even though the authors' conclusion is specifically directed towards women 
with one prior c/s who have been induced, it seems to me that this paper has 
changed the way institutions and insurance companies have/ or are looking at 
VBAC. Here in Seattle ( where midwives can still buy insurance however, the 
insurers have just recently chosen to exclude homebirth VBAC as a procedure 
that would be covered). As was discussed previously on this list, this paper 
has many limitations but while we are discussing it academically, policies 
are being re written. The authors' conclusion: "For women with one prior 
cesarean delivery, the risk of uterine rupture is higher among those whose 
labor is induced than among those with repeated cesarean delivery without 
labor." seems reasonable enough, but it was their results that were 
provocative though I personally think it was because they were reported in 
incidence per thousand instead of as a %. I wont regurgitate the results 
unless someone wants me to.  Take care, marilyn
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Re: VBAC soap box

[Kleimar]

It was in the New England journal of Medicine, around june 2001:It was a 10 
year retrospective study that compared incidence of uterine rupture amongst 
women who had had one previous LUCS in Washington State done at University of 
Washington. The groups compared were elective c/s, IOL with and without 
prostoglandins, spontaneous labor at term. Not sure if othernmgroups were 
included. Can't remember the authors. I will look  up the citation and email 
to you. Am a little brain dead at the moment, took my Washington state 
licensing exam today so ,was seated at a table filling in circles for 8 hrs. 
Not hard but tedious.
I will get back to you
marilyn
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Re: narcotics clearance by neonates

[Kleimar]

It is my understanding that pethidine is demerol just a different brand name.
marilyn
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Re: VBAC soap box

[Kleimar]

It's that VBAC study published in the New England Jnl of Med. It has 
hospitals running scared. As we all know what it really raised our concerns 
about was VBAC inductions especially with prostaglandins, but I personally 
think ( no research to back this up) that VBAC's are not being offered as 
much as they were before that article.
What do you all think.
marilyn
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Re: sanctimonious pretensiousness

[Kleimar]

Believe it or not there was something I forgot to say.
I have only seen it on this list that the training of Australian Midwives is 
not recognized internationally. It occurs to me that  regardless of how true  
this is, it may have something to do with our tendency to put ourselves down 
rather than blow ourselves up (figuratively). And I don't mean as midwives, I 
mean as Australians. Having lived in the US for 20 odd years, one of the 
hardest things for me to do has been to blow my own trumpet so to speak, 
which to put it mildly, seems to be a national pastime here. Just a thought.  
Marilyn
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Re: sanctimonious pretensiousness (long)

[Kleimar]

Bravo I agree too. There is a place where we meet in the middle. In my 
opinion, in the best of all possible worlds, we homebirth midwives ( and that 
is my training, DEM, Seattle Midwifery School) can safely assist moms to 
birth at home, which is most of the time, and make appropriate transfers of 
care to the hospital when necessary,  hopefully to be greeted by hospitable 
nursing staff. At the moment, in Seattle that is mostly the case, although 
some hospitals and obstetricians remain hostile to out of hospital birth. But 
I do bristle at those who seem to imply that if a mom is committed enough, 
and trusts her body enough, then if she also has attendants who do the same, 
she will birth normally and gently. I have to say, not necessarily so. 
Perhaps we come from different spiritual paths and that is the source of 
differences of opinion on this. I just know that neither my body nor my mind 
are perfect, and sometimes as Kirsten (I think, or was it "thrupps") said, 
our bodies go off the rails. As midwives, whether at home or in the hospital, 
we need the skills to assess these situations. From what I have read on the 
list, I don't think anyone disagrees with that. And there are many ways to 
get these skills. 

Ina May and her fellow midwives at the Farm where fortunate enough to run 
into amiable docs along the way who provided training and education. The 
commune was also large and included women already trained as nurses. Aspiring 
midwives were also required to train as emergency medical techicians, the 
Farm at one time had their own ambulance service. Through all this, Ina May 
became President of MANA (midwives association of north america) and a strong 
advocate of lay/dem midwives credentialing themselves with through the NARM 
process to become CPM's. This has met with some dissention from within the 
MANA community as some people are philosophically opposed to any form of 
credentialing or regulation or professionalisation of any profession or 
calling including midwifery. 

Apparently there is no means for lay midwives in Australia to become 
certified or registered as their training (for whatever reason) is not being 
recognized by the ACMI, Nurses boards, or Universities. Maybe it is time for 
them to start their own organization similar to MANA and develop their own 
certifying process. Maybe you do this already. Even if you do this, their 
will be people who place themselves outside the system. This is their choice. 
The B. Mid programs will not necessarily solve these problems, especially if 
they do not recognize prior, documented experience in some appropriate way.

In my training as a direct entry midwifery student (in the US) I have come 
across a wide range of tolerance of deviations from the "normal" amongst my 
various preceptors. They have been from conservative to radical and you 
wouldn't have been able to pick their style of midwifery from either their 
credentials (lay, dem, cnm), their deamenour, or their appearance. Usually 
their philosophy was disclosed to potential clients in their initial 
interview. Amazingly, in looking at my stats, their transfer rates have been 
about the same, the more conservative midwives transfering clients earlier, 
being the main difference. 

Interestingly, none of my preceptors have been willing to work with free 
birthers. All were occassionally fooled by people who came for prenatal care 
and then either called too late in labor for the midwife to arrive in time, 
or didn't call at all. None were happy when they weren't called. Of course we 
 get called to births where you arrive as the baby is coming out. Obviously, 
some of us could birth successfully in the back of a truck or up in a tree, 
and some of us could not. Some of us and our babies would have died on the 
prairie, in the wagon train, on the convict transport ship, and some of us 
survived and thrived. At this point in time our society has a low tolerance 
for maternal and infant mortality and morbidity. How we react to this  is 
critical and I believe, requires radical, open, and honest debate.

Sorry if I have raised  too many issues in one email. I could go on and on 
but need to continue packing my bags.

regards
marilyn

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Re: Support homebirth on Thursday

[Kleimar]

Just a note. Ina May is a recognized midwife: she is a CPM: certified 
professional midwife and runs her own training workshops for midwifery 
assistants at The Farm. There are many divergent paths to midwifery 
competency and Ina May is now a strong advocate for determining this. 
Personally, I agree women's choice needs to be respected, I have no problem 
with lay midwives presenting themselves as such or as traditional midwives, 
so long as they don't present themselves as professional or registered or 
certified  or licensed midwives if in fact they are not. Of course the law 
may be interpreted otherwise and anyone who practices as a midwife needs to 
be informed of the rules and regulations for practice in the jurisdiction 
she/he serves.

marilyn
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Re: for interest- Medscape - due dates

[Kleimar]

Interesting stuff Rhonda. Preeclampsia is one of those issues in pregnancy 
and birth where care givers preexisting notions as to its origins definetly 
affects their care. If you look it up  in medline data bases etc. (as I am 
sure you have) some researchers chase diet, others genetics and so on. They 
all seem to agree that it is possibly some underlying problem with placental 
implantation probably at the trophoblast stage. These problems have been 
linked to immune responses and also to familial/genetic tendencies. But like 
everything in this disorder, not always. Which allows some caregivers 
(midwives as well as OB's) to chase their own theory around. 

Anyway, I think handing down familial tendencies in prenancy and birth is an 
invaluable source of knowledge for our daughters. My own grandmother birthed 
her 5 children at home in the bush some miles out from Mareeba in the far 
north. Her doctor and midwife rode out for the births, only the first in a 
normal position, the others were 2 breeches, one sunnyside up, and the last 
my mother, was a transverse lie who was pulled out footling. And they all did 
just fine. Nanna must have had a roomy pelvis. Anyway my mother  just had me, 
normal position, but of my three girls the first was OP/sunnyside up, the 
second breech, and my third was OA normal position. So, I think there is a 
bit of a familial tendency there. Amazingly enough I didn't have unusual 
labours with any of my babies, they were efficient and progressed quite 
nicely, it was just a little tricky at the end and I am sure it was the same 
with my grandmother. 
Regards, marilyn
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Re: formula without consent?

[Kleimar]

yes, I think we all need to be aware that the birth plans on the internet all 
seem to be about 20 yrs out of date. We don't use eye drops anymore in 
America at least not in Washington or California. And does anyone give 
perineal shaves anymore? But those items are still on the internet birth 
plans. I guess they just need to be updated. We seem to need a template for 
everything.
marilyn
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Re: formula without consent?

[Kleimar]

This confirms my own experience albiet from a different anle. My mother being 
a 1930's trained midwife was a strong breast feeding advocate, having breast 
fed me her only child in 1951, despite considerable social pressure to be 
more modern. When she returned to work in 1958 I do remember her being at the 
very least appalled at not only the drugs being used in labour but the 
decline in breast feeding. She always encouraged mums to breast feed when she 
could and I knew in my heart from an early age that was the only way to feed 
a baby in her eyes. At the small rural hospital wher she worked (Tully, 
Qld.,) the midwives routinely collected breast milk from term mothers for any 
preemies that were in the nursery and needed extra milk (they were all quite 
fastidious, I remember, so I am sure the milk was treated appropriately). 

So, when I had my own babies there was no conflict only support from my mum. 
I had my first 2 daughters at Corinda Maternity Center in Brisbane, Qld., in 
1976 and 1978 and I felt the staff were very supportive of breast feeding. 
They did encourage pumping so that if we needed to sleep through at night 
they had milk for feeds. I remember checking the fridge to see that my milk 
was appropriately labelled. To my knowledge no formula was given and even 
though we didn't have rooming in for my first daughter, they did 2 yrs later. 
I wonder if Corinda Maternity still exits??

So, i agree grandmothers have a strong influence on how infants are fed and 
if at all possible should be included in childbirth/infant care classes.
Regards, marilyn
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Re: Candida in pregnancy

[Kleimar]

Dear Allison: I have known women with a similar problem, who received no 
relief from prescription yeast meds ( micanazoles, difucan etc) but did 
receive relief from homeopathy. I can't give specifics as I am not a 
qualified homeopath, but would suggest you could refer her to one in your 
area. If this too does not help, then culture for the Candida species 
involved as if it is not albicans it may not be sensitive to the above 
mentioned drugs. Terazole has neen found to successfully treat Candida 
glabratta and others. Let the list know what is successful.
Regards, marilyn
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Re: moving to Oz

[Kleimar]

Dear Meaghan: I am going on a student placement to St. George Hospital, 
Kegorah, Sydney. It will be Jan2 through Feb 7 or there abouts. I am 
returning to Seattle for most of 2002, to take the state licensing exam here 
and to work while I wait for my daughter to finish nursing school. I am not 
an RN so, as I explained in a reply to Denise, I am not sure what that means 
for me in NSW.  I plan to return to Australia, most likely NSW towards the 
end of 2002 or early 2003. It is my dream to practice caseload midwifery 
there, I can't imagine doing it any other way, but I will do whatever it 
takes to become registered and practice midwifery. 

To those of you in independent practice, do you rent office space in 
professional buildings and if so, what do you pay for the space?

Regards, marilyn
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Re: Birthing Stool Policy

[Kleimar]

Exactly Tina: I have received several babies with the mom on the birth stool 
( a de By). I only recently noticed my knee acting up after a water birth and 
a 40 minute second stage ( which actually was short as the mom was a primip). 
I know changing positions and yoga and stretches etc would help. However, in 
second stage I seem to get stuck in positions that require my knees to be 
bent for at least 30 minutes at a time. I have to get over this. I think at 
the moment I need a knee brace as it even gets sore when I bend my knee 
during sleep. Oh well, I am sure it will mend with a little rest and 
relaxation, it has been a busy year. I hope to get to another 4 births and 
then I am on the plane to Sydney on December 16. Regards, marilyn
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Re: Birthing Stool Policy

[Kleimar]

Dear Jackie: I totally agree it is all about control; BUT after being at some 
60 home births in the past year as a midwifery student, I have a very painful 
knee after all the squatting, kneeling, etc..I have been doing. Not that I 
want to change and have the mums assume the "beetle postion" at optimum 
height for myself, but I would like some tips on preserving my own joints. It 
is weird because I don't even notice my discomfort at the birth, it is in the 
days afterwards that I do, until the next time when I get into any position I 
have to, to be with the mum. Any advice is welcome. Marilyn
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Re: for interest re : Misoprostol /Cytotec

[Kleimar]

Dear Danielle:
My heart goes out to you in your loss. I also don't want you to think that I 
support the use of cytotec for induction of labor, I totally agree with you 
regarding the cavalier way it is used and I cringe every time I read of its 
use in this way. I witnessed this first hand when I was assisting a midwife 
with a woman (primip) who was planning a homebirth and at 43 weeks gestation. 
Both she and her midwife agreed to try ripening her cervix  with 
prostaglandin gel for induction at 43 weeks: her cervix was still " long, 
thick and closed" and not at all appropriate for castor oil induction at 
home. We were admitted to the hospital for monitoring and insertion of the 
gel and we requested that our client not be given cytotec and that 
cervadil/prostin be used instead. The obstetrician completely contradicted 
the information we had given our client regarding uterine hyperstim and 
uterine rupture associated with cytotec and persuaded our client that cytotec 
was the most efficient and cost effective cervical ripening agent available, 
that she had not seen any adverse effects with its use, and that this 
hospital only recommended using the other prostaglandins with VBAC moms. I 
have no doubt that had we not raised the issue regarding the safety of 
cytotec it would not have been raised and certainly no informed consent form 
was used/signed in this case. Despite our client being persuaded to use 
cytotec she did not rupture, but neither did she dilate, so she did go on to 
have a cesarean birth. 

All this being said, while in my opinion, use of cytotec for labor induction 
is not a safe option, the drug does appear to have other obstetric uses which 
appear to be safe. I do believe that studies are being done around the world 
on these uses. There needs to be a moratorium on its use to induce labor, at 
least until the appropriate trials have taken place. 

Once again, I am truly sorry for your loss Danielle and also sorry for any 
pain my email may have caused you.

Kind regards, marilyn
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Re: Waterbirth, Strep B, Thrush, Herpes2 and mec

[Kleimar]

Hi all again: where I am in Washington State, USA  I have had the opportunity 
to participate  in a number of water births at home and in free standing 
birth centers. We (the midwives I have precepted with) do offer our mom's to 
culture or not to culture with Strep B (GBS) and risk based or culture based 
protocols per the CDC guidelines, GBS status does not preclude water birth. 
The reasons we advise against birthing in the tub (if this is the mom's 
choice)are around fetal distress and meconium liquor. If we are expecting a 
depressed baby we prefer to birth "on land" just because of the time saved if 
resuccitation is needed. If there is moderate to significant mec again we 
prefer to birth on land so that we can suction on the perineum. I don't think 
any of these protocols are based on research but rather experience and 
opinion. I do know of other midwives who don't follow either of these 
guidelines. Again a hx of herpes does not preclude water birth. Obviously 
vaginal/cervial lesions at time of birth would (as they would probably 
indicate a c/s), however I have attended a number of births with mom's who 
have a hx of herpes and none have had lesions at time of birth, however we 
are always vigilant. Both the Cochrane data base and Midirs have research on 
these questions, try also PubMed and BMJ for full text articles.
take care, marilyn
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Re: short cord

[Kleimar]

Hi all: Mareeba is in far north Queensland, the Atherton tableland, north 
west of Cairns. My grandmother lived in Mt. Molloy which is a very small town 
north of Mareeba on the road to Cooktown.
love, marilyn
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Re: Fw: BMJ Table of contents for 27 October 2001; Vol. 323, No. 7319

[Kleimar]

 I find this trend concerning and I have a question. What was the total 
operative delivery rate in England 30 yrs ago? I mean the rate of high 
forceps, mid forceps and low forceps delivery? Or can we assume that the 96% 
of deliveries that did not have a c/s had a NSVD? Also, what were the 
mortality and morbidity stats especially on the high and mid forceps births? 
I am asking these questions because I was at a lecture/presentation in the 
last year (in the USA) where an OB defended part (and only part!!) of the 
higher c/s rate as being because high and mid forceps deliveries where no 
longer done as frequently (if at all) as they were 20-30 years ago mainly 
because of the poor outcomes associated with and attributed to these methods. 
 I was also at a birth recently where the mom had progressed rapidly to 
complete and then stalled. We waited 3 hours at home trying various position 
changes and methods to stimulate labor, when there was no change in descent 
(-3 with caput forming) we transferred to hospital. With another 2 hrs of 
pitocin augmentation and no change the OB gave the mom a choice of c/s or a 
mid forceps with possible damage to the baby (she (OB) said skull fracture) 
and to the mom's coccyx (OB said it was rigid): mom chose a c/s. Baby was 
6#4oz persistent OP. I only mention this because I think (but don't know) 
that 30 years ago this would have been a forceps delivery. So, I guess my 
question is: is there a corresponding decline in # of operative vaginal 
deliveries with rising # of cesarean deliveries or are these apples and 
oranges? Comments please.

marilyn
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Re: The Algebra Of Infinite Justice(LONG)

[Kleimar]

Thanks Denise for this information. Living in the USA it is hard to get 
information that isn't slanted. Public radio has provided BBC news at night. 
The saber rattling is deafening even though many segments of society are 
clammering for more information. Again thank you for this.  Marilyn
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Re: Mid-term abortion

[Kleimar]

My experience with misoprostol for abortions has been during my gyne 
rotations at abortion clinics. It is commonly used with either methtrexate or 
mifestoprene (s) (RU486) for medical or chemical abortions only well within 
the first 9 weeks at the women's clinics I was at. At these clinics all later 
abortions were done surgically. I have heard of it being used at other 
clinics in other parts of the country where it has been associated with 
uterine hyperstim. It is my understanding that the same precautions regarding 
prostaglandin use and uterine rupture with VBAC's should be observed with 
women with a prior c/s wanting an abortion: ie it shouldn't happen because of 
the risk of uterine rupture. Again I have read of this happening with 
misoprostol and abortions but do not have a citation. If it is in the 
literature it should show up on Pubmed/Cochrane/Midirs. 
Hope this is helpful
marilyn
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Re: Hep B

[Kleimar]

I have not had to deal directly with  this situation, but theoretically this 
is what midwices at the homebith practices (in the USA) I have precepted in 
would do: on diagnoses of the positive hep B on the prenatal screen and 
confirmation of this, we would make sure we had both  Hep B vaccine and Hep B 
immunoglobulin at birth. This is the one case where we would give the Hep B 
vaccine. Hep B Immune Globulin (HBIG) is given within the first 12 hours of 
birth and then the first complete primary Hep B vaccine is also given at 
birth. The second dose of the Hep B vaccine is given at 1 month and the 3rd 
dose at 6 months. Breast feeding is not contraindicated. This dose not 
guarantee 100% prophylaxis  a combined success rate of 90% or more published. 
If mother doesn't want to vaccinate, then baby needs to be watched for  liver 
disease which mother should also be watched for. Neither contraindicate 
breastfeeding as transmission is usually vertical via placenta. Again this is 
all theoretical, never had to practice this.
Marilyn
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Re: Recommended reference book

[Kleimar]

I 'll be really interested to read others responses on this. I had to convert 
the mmol/L to mg/dL and came up with 165mg/dL which is a little high if this 
was a normal blood glucose: not a 1hour after a 75g screening load (in which 
case it is reasonable). If not a loading and not a fasting just a random draw 
then when had she last eaten and what was it? Hopefully Henci's book can 
bring some  restraint to the rule out of homebirth and  talk of c/s. I don't 
(personally) think it is unreasonable to screen some women in pregnancy for 
diabetes, not for the  usual reason of trying to avoid a large baby but 
because if the mum is more than normally glucose intolerant then overloading 
the baby's system with glucose can stress the baby in other ways and lead to 
to other problems such as SGA even. Of course we want to avoid micromanaging 
the pregnancy and a lot of unnecessary interventions, and the GTT and 
screening tests are notoriously unreliable and controversial, so I will just 
be interrested to read it all.
marilyn
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Re: Fw: Physiological 3rd Stage

[Kleimar]

you can also try the Cochrane data base, MIDIRS, Pubmed (which is the 
National Library of Medecine. On Cochrane you will need a password etc to get 
more than abstracts. On Midirs you will need to sign up to get more than very 
basic also. Pubmed will give you abstracts and citations. The British Medical 
Journal is free on-line and you can get the complete article there. I forget 
the exact www. addresses but most search engines will get you there with a 
keyword. You uni's library should have a password etc.. for the Cochrane data 
base. Have fun.
marilyn
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Re: UPDATE on PI INSURANCE FOR ALL

[Kleimar]

I would think that there is the benefit of having IPMs with affordable 
insurance available for consumers to use. The reasonable rate obtained can 
probably only be obtained by spreading the cost of premiums over as large a 
membership base as possible. I can't believe what I have been reading though: 
is the cost of PI through ACMI, $250 ? as opposed to the $4000 being 
discussed previously? Am I missing something?
marilyn
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Re: "natural" induction

[Kleimar]

In a message dated 9/27/01 5:31:33 AM Pacific Daylight Time, 
[EMAIL PROTECTED] writes:

<< [EMAIL PROTECTED]  >>
Being currently in the USA I am not sure what PET stands for.
However, I am quite familiar with OOH (out of hospital) induction techniques: 
unless otherwise contraindicated I think sexual intercourse should be as 
frequent as possible to at least ripen the cervix. I am not sure how 
successful nipple stim would be with an "unfavourable" cervix, however if the 
cervix is favorable the nipple stim should be done until you have 
contractions, then stopped while the contraction occurs, resumed again when 
the contraction is over. It should continue until a regular ctx pattern is 
under way. Nipple stim can be done by self, partner, electric breast pump, 
nursing toddler/baby. I think it works best in a situation where love 
hormones are involved (ie not the breast pump) but this is not always 
possible. I have also seen castor oil work wonders but again only on a 
favorable cervix and there is even a study (I don't have the exact reference) 
but it is in a recent naturopathic journal, they stated that the therapeutic 
dose that worked most consistently was 4 ounces (usually diluted in about 8 
oz of orange juice). It creates quite a messy environment for the birth 
though ( nothing that can't be handled, but messy from time to time 
neverthless).

Marilyn
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Fwd: Research Critique??

[Kleimar]

 



Thanks for the reply, as I said I had only read the abstract. The midwife I 
referred to (Audrey) had not participated in the study but as I tried to 
write, in the public radio talk session, and she was not defending the dstudy 
but critiquing it! Sorry to be confusing. IN facxt she wrote her Senior 
thesis on the VBAC-lash. From the abstract, it appears that there was one MD 
and 2 Ph.D.'s and I would be guessing as to there area's of study.  Marilyn

Re: Research Critique??

[Kleimar]

Dear Denise and List:
This study is generating considerable debate here in Seattle both within and 
without the midwifery community especially since it was done right here at 
the University of Washington (it was all over the local TV news). We were all 
expecting the results re augmented and induced VBAC labors (especially with 
prostoglandins) but the incidence of rupture in non-induced/augmented labors 
being 3.3 times higher than rupture in planned cesarean births is disturbing. 
We had all been quoting the incidence of rupture with planned c/s and TOL as 
being similar (1.0 - 1.5 %). I haven't read anything but the abstract yet 
(from the NEJM) but my school (Seattle Midwifery School) now has a copy of 
the entire article. Also there was a discussion here last Monday on Public 
Radio with one of the local midwives and an MD on the paper. The midwife who 
participated is Audrey Levine, LM and she has previously published in this 
area also. There is reportedly an audiotape of the discussion. If anyone is 
interested and if I can lay my hands on it I will send a copy on. Take care, 
Marilyn
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