Saturday, June 30, 2012

Weekend Movie: Midwifery Training in Afghanistan

Women in Afghanistan are being trained to become midwives, so that women in remote areas will have a trained birth assistant with them during childbirth. Trained birth assistants are one of the worldwide efforts that have proven highly effective in reducing maternal mortality (see Millennium Development Goal 5)

This CNN video shows the women being trained. I thought it provided an interesting view of women in another country being "medically" trained - illiterate women are trained with pictograms, demonstrations are done with a pelvis and a baby doll whose face is painted and decorated just like the real newborn the video shows!

Monday, June 25, 2012

Would you Want your Mother at your Birth?

I've been to about 15 births now, and I've seen home birth, birth center birth, and numerous hospital births. Every woman has her her husband with her, though they have provided varying degrees of support. I'd say only about 4 of these women had their mother in the room with them the whole time as an additional support person. And by the whole time, I don't necessarily mean during pushing... Sometimes the mom has left for that part. I just mean for what felt like virtually the entire labor.

The first time I doula-ed with the grandma-to-be, I thought, "I definitely would not want this woman in the room if she was my mother."  It's not that she was terrible or annoying, but when she gave birth things were so different. Many grandmothers are thinking of their own birth, which was more often than not in a totally different time. They say things like, "doesn't everyone need an episiotomy?" and tell stories of how it was in her day, and sometimes make the laboring mamas very annoyed.

Some grandmothers-to-be benefit from having a doula present, for the same reasons that the dad or mom do; the doula is a less subjective person who is trained in all aspects of childbirth and can provide unique informational, emotional, and physical support. At times it is hard to be a loved one and watch objectively as your daughter or your wife seems to "suffer." Grandmas that might be simply too subjective may not be able to provide appropriate support to the laboring woman.

Sometimes grandmas are great! I had a recent birth where I just adored the grandmother-to-be. She was so chill and laid back! And of course, always a bonus, she agreed with me about how what the nurse said was weird, how a certain recommendation seemed totally unnecessary, etc. I thought she was a perfect support person - calm, quiet, provided pressure when needed, went and got cups of ice water and food for the mama, kept superfluous family members out, etc.

If my mother was like this woman, I might consider having her at my birth. As it stands at the moment, I don't think my mom would be the calming presence I'd want at my birth. Not that I don't think she'd be helpful... I think she'd think of ways to take care of me. And her birth was actually quite intervention-free and she supports my doula work, so she is knowledgeable of natural birth. I just don't think I would find her a soothing presence in assisting me to go into a relaxed inner birthing state, since I am naturally more stressed around her.

What about you? Would you want your mother in the room with you? Or anyone else?

Tuesday, June 19, 2012

HIV and Breastfeeding

In resource-poor settings where there isn't guaranteed sanitation and clean water, breastfeeding is a necessity for infant survival. Unfortunately, many of these locations also have high HIV rates. Past studies have found that HIV is present in breast milk and may be transmitted through breast milk. About 15% of children contract the virus during early childhood, and breastfeeding may be the reason.

In many African nations, the choice between keeping your child alive by breastfeeding, but weighing the risk that the uninfected child may become infected with HIV through breast milk, is a real one. Ceasing breastfeeding is associated with increased infant mortality and morbidity.

The World Health Organization says that
exclusive breastfeeding for up to six months is associated with a three to fourfold decreased risk of transmission of HIV compared to non-exclusive breastfeeding; mixed feeding, therefore, appears to be a clear risk factor for postnatal transmission.
It is also important to note that in the case where a child is already infected with HIV, breastfeeding prolongs life. For a long time the WHO's recommendation for breastfeeding while HIV positive was,
HIV-infected women breastfeed their infants exclusively for the first six months of life, unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time. When those conditions are met, WHO recommends avoidance of all breastfeeding by HIV-infected women.
Recently, the WHO had changed their recommendations to continue breastfeeding "until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs (antiretrovirals) during that period."

BUT, new research suggests the possibility that HIV may not actually be transmitted via breast milk. Partly, a very recently published research study seeks to explore why many children breastfeed from an HIV-infected mother and yet never contract the virus. The study, done with mice carrying human tissue, found that "human breast milk has potent HIV inhibitory activity that can prevent oral transmission." There is some unknown component of breast milk that kills the HIV virus, virus-infected cells, and prevents transmission.

Researchers also emphasized that HIV transmission can be further prevented from being transmitted over prolonged breastfeeding by systematically administering antiretrovirals. This may be useful if, in fact, transmission isn't occurring via breast milk but via some other oral transmission (such as blood via mother's cracked nipples).

Another interesting thing to note is that this research was done at the University of North Carolina at Chapel Hill, and extremely similar research findings was also announced by researchers at Duke University (rivalry!). The Duke study found that antibodies that help to stop the HIV virus can be found in breast milk.

I think things look very promising! What do you think?

Tuesday, June 12, 2012

Active Management of Third Stage

Third Stage

The third stage of labor lasts from when the baby is born to when the placenta is birthed. Once the baby is expelled, the uterus generally continues contracting. Stimulation of the nipples by the baby helps the uterus contract down to pre-pregnancy size. The contractions and the hormones cause the placenta to detach from the uterine wall. The mother may feel another urge to push, but pushing out a squishy placenta is much easier than pushing out another baby!

The third stage generally lasts about an hour. It can last more than that, but generally the hospital won't even wait more than 30 minutes. If the placenta is taking a long time to detach and come out, there is a fear that it is a "retained placenta," and they may manually remove it. If the placenta is retained, or if pieces of it are retained, there is a risk for postpartum hemorrhage (excessive bleeding). This is why 1. the doctor or midwife will check to make sure the placenta is intact, and 2. the doctor or midwife may administer a shot or a bolus of pitocin to get the uterus to continue to contract.

Active Management 

Postpartum hemorrhage is the biggest childbirth complication and maternal killer worldwide. The World Health Organization recommends pitocin for all women to prevent postpartum hemorrhage and maternal mortality. They refer to this as "active management."

Many women want to avoid pitocin, even postpartum, because of it's potential side effects.  Normal expulsion of the placenta is possible without pitocin. We also have the luxury, in the United States, of having immediately available emergency care. If you begin to bleed excessively after birth, either your care provider would notice and take steps to stop it, or you would be able to call 911 and have an ambulance with you in a short time.

If you don't see a problem with receiving pitocin after birth, go for it. It is preventative, and recommended. And if you don't want it but end up needing it because of a suspected retained placenta, don't worry too much about it - it is a life saver in many instances!

The midwife at Midwife's Thinking Blog wants you to know something important:
Physiological placental birth is an option and possible if you manage to avoid induction, augmentation, an epidural or complications – but be aware of how difficult it may be, and don’t beat yourself up if it doesn’t happen.
Some medical interventions can mess with a physiological placental birth because they interrupt your body's natural production of oxytocin (your labor hormone!). Just something to keep in mind, and another bonus to a natural birth. Another thing that interrupts this - stress.

Keeping baby skin to skin and on the breast immediately after birth is a great way to help that placenta out!

In a world where the majority women are having inductions, pain medication, anesthesia, augmentation, and stressful birth environments in the hospital, active management of the third stage might be the best idea for most women. 

Cord Traction

I do have to add here that I don't think cord traction is a good idea. I'm not a doctor or a midwife, but cord traction seems like a terrible idea, yet one that is done ALL THE TIME. This is when the care provider pulls on the umbilical cord to help the placenta out (sometimes in conjunction with the pitocin). This can cause additional problems - a placenta that hasn't separated from the uterus yet can cause a partial detachment (adds to hemorrhage), you can snap the umbilical cord (not a huge deal), or worst case scenario, pull the uterus out!

Even though this is "faster," which doctors like, it doesn't seem to do much good. I really wouldn't want to risk making things worse by pulling on the cord, especially if the third stage hasn't been that long, yet! 

How long did it take for your placenta to come out? What are your thoughts on the active management of the third stage?





Friday, June 8, 2012

I Am a Midwife Video Series

I am a Midwife is an innovative public education campaign designed specifically to educate women about midwifery as a high quality maternity care option. I am a Midwife is the most comprehensive and easily accessible tool available online for women seeking information about the midwifery model of care.

I am a Midwife campaign is a free series of eight short videos designed to answer a woman’s questions about how engaging the services of a midwife can achieve the kind of pregnancy and birth experience that most fits her values, culture, preferences, and needs. The video series explores the benefits of midwifery care and the full range of services a midwife provides. One video with a particular theme will be released each Friday for eight consecutive weeks beginning on May 5, 2012, International Day of the Midwife.

I am a Midwife offers a unique look at more than 40 real-life midwives and the work they do across the country providing care to women of all races and socioeconomic levels, in all childbirth settings including hospitals, birth centers and women’s homes. I am a Midwife describes why midwifery care is safe, satisfying, reduces disparities, decreases costs, and increases better outcomes for mothers and their newborns.

Here are the first few!

Midwifery Care: What's in it for Women?

Midwives Know Birth Matters

Midwives Address Health Disparities

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