November 19, 1999
Volume 1, Issue 47
Midwifery Today E-News
“Gestational Diabetes”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Question of the Week
5) Question of the Week Responses
6) Gestational Diabetes: Brief Background
7) My Own Experience with Gestational Diabetes
8) Switchboard
9) Midwifery Today Conference Notes

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1) Quote of the Week: "You don't drown by falling in the water; you drown by staying there."

- Edwin Louis Cole

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2) The Art of Midwifery

For the woman who is already vomiting and acting transitional before 7 cm, administer some kind of salty soup or broth such as chicken bouillon or miso, to sip between contractions. A half cup is usually enough to stop the vomiting.

- Wisdom of the Midwives, Tricks of the Trade Vol. Two, a Midwifery Today Book, 1997

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Midwifery Today magazine's Tricks of the Trade column has kept practitioners informed for years. Join the forum by subscribing to the magazine! Mention code 940 and receive $5.00 off a one-year subscription. Call 1-800-743-0974 to order. Offer expires Dec. 3, 1999.

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Share your midwifery arts with E-News readers! Send your favorite tricks to mtensubmit@midwiferytoday.com

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3) News Flashes

Peak alcohol levels in breastmilk occur 30 to 60 minutes after ingestion on an empty stomach and 60 to 90 minutes when taken with food. The alcohol content of breastmilk falls as the blood alcohol level falls due to retrograde diffusion of alcohol from the milk back to the bloodstream. Emptying the breast ("pumping and dumping") does not increase the speed of elimination of alcohol either from the milk or from the body as a whole. Alcohol imparts a detectible odor to breastmilk, which apparently stimulates sucking initially. However, only one drink taken just before nursing has the net effect of decreasing milk intake by almost one-fourth during the nursing session.

- Journal of Human Lactation, Dec. 1995

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4) Question of the Week

I am concerned about the safety of the Rhogam injection, most especially when given during pregnancy. I have no information that makes me concerned, I guess it's just my natural way of questioning *any* kind of injection or intervention. Does anyone know of a reason why we as midwives/moms should be concerned?

- Elaine Friesen

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Send your responses to mtensubmit@midwiferytoday.com

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5) Question of the Week Responses

Q: If you have any new insights or information about gestational diabetes, please share it with E-News readers.

With my first pregnancy I had symptoms of gestational diabetes in my last 5 weeks of pregnancy. I was placed on a diabetic diet and monitored my blood sugar levels at home. I found the diet strange and difficult, but followed it. I gained 35 lbs on my 5' 1" frame, and did not exercise. My son was born 11 days early after a drugged labor, was 7 lbs. 4 oz., and had multiple health problems. He was recently diagnosed with learning disabilities and ADHD.

During my next full term pregnancy I followed the Brewer diet, ate a well balanced and varied diet, and exercised regularly. I gained exactly the same amount of weight, was regulary tested for gestational diabetes, but all tests were within normal limits, and I remained very healthy. My second son was born exactly on his due date after a natural labor, weighed 8 lbs. 14 oz., was extremely healthy, and continues to be so.

The only difference between the two pregnancies was diet, exercise, a midwife, and education.

- Amy V. Haas, AAHCC
Fairport, NY

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Q: I would like to know how to treat pregnancy induced carpal tunnel and what causes some pregnant women to get it.

I've found that many people, myself included, have had relief from carpal tunnel by doing the "crunchy" style sit ups that have the person keep their lower back flat on the floor the whole time the exercise is being done, with their arms folded across their chests. The exercise is done straight up toward bent knees as well as toward the sides (right elbow toward left knee, and vice versa). It should be done slowly, coming up to a slow count of five, holding it to a slow count of five, and going back down to a slow count of five, sitting up to the center. Each side is considered one set. Doing three sets twice a day is what seems to help the most. The woman should not remain on her back, but get up after she's finished each set. This seems to stretch the upper back and has brought relief to many women. Maybe it relieves pressure on the brachial plexus; I don't know.

- Debby S.

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I am a hand surgeon. My fiance is a homebirth midwife and asked me to respond. One must first confirm the diagnosis of carpal tunnel syndrome. Not all numbness or pain is indeed carpal tunnel syndrome. The diagnosis is usually confirmed by the history and physical exam. Occasionally, a nerve test may be required. Treatment may depend on whether the symptoms are only at night or occur during the day with activities. If only at night, a splint and anti-inflammatory medication may be helpful. One should avoid anti-inflammatory medication during the first trimester. If symptoms occur during the day, the best initial treatment is often an injection into the carpal tunnel with a steroid preparation (I use depomedrol combined with lidocaine). The injection is minimally painful (really !) and often can eliminate the symptoms entirely. The steroid is a very small dose and given once has effectively no side effects or risks. Most of the time, but not all the time, the symptoms will go away after the person delivers. Occasionally, the symptoms persist and further treatment, even surgery may be required. One should therefore try to delay surgical treatment until after delivery since surgery may not be necessary. This response is general information--you should consult your doctor for specifics for yourself.

- Anon.

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When pregnant moms come into my store/office and mention the problem of their wrist hurting, I ask them if they want to try a magnetic wrist band. They have all been very surprised when it doesn't hurt anymore within 10-15 minutes. But remember, magnetic therapy products are not all created equal. I only use the big name from Japan!

- PJ Jacobsen, IBCLC

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6) Gestational Diabetes: Brief Background

In 1964 O'Sullivan and Mahan reported that pregnant women with glucose values at the upper end of the spectrum were more likely to develop diabetes later in life; the added stress of pregnancy revealed a woman's "predaibetic' status. Since diabetes was known to pose serious threats to the fetus, researchers extrapolated that subdiabetic levels of glucose intolerance during pregnancy might also do harm.

During the 1960s and 1970s doctors began studying the effects of glucose intolerance in pregnant women; however, the studies were poorly designed [and] thoroughly obscured the true risk of subdiabetic glucose intolerance in pregnancy. Results convinced researchers that they had discovered a serious problem, and in 1979 they convened the first of what became a series of exponentially larger international conferences.

Opening the first conference, one of the organizers suggested that pregnancy be viewed as a "tissue culture experience." Given the preconceived notions of the researchers, the confused state of the research and a metaphor that reduced women to incubators supplying potentially faulty growth medium, it should come as no surprise that by the end of the second conference, gestational diabetes (GD) was established as a new disease. It was officially defined as: "carbohydate intolerance of variable severity with onset or first recognition during the present pregnancy--irrespective of whether or not insulin is used for treatment or the condition persists after pregnancy. [It includes] the possibility that the glucose intolerance may have antedated the pregnancy." (Second International Workshop-Conference 1985)

Thus, women with blood glucose values in roughly the upper 3% for pregnant women have come to be defined as diabetics, although the situation is different from either type of true diabetes. The only problem GD shares with Type I and Type II diabetes is that chronic hyperglycemia can overfeed the fetus, resulting in macrosomia . Even here, other factors-race, age, parity and especially maternal weight far outweigh glucose intolerance in determining the baby's weight.

The conference definition of GD confuses more than it enlightens because it jumbles together various levels of severity. This is similar to claiming that everyone with a cough and fever has pneumonia. The confusion was deliberate. The conferees considered using the term "glucose intolerance of pregnancy" but decided on "diabetes" to make sure insurance companies would pay for high-risk management and women themselves would take the condition seriously.

The 1985 conference recommended-and the 1990 conference reaffirmed-that all pregnant women be screened for GD between 24 and 28 weeks by a 50 g glucose drink and that those with values of 140 mg/dl or above be given a diagnostic 100-g oral glucose tolerance test (OGTT). Women with two values meeting or exceeding O'Sullivan and Mahan's values on the follow-up OGTT should be considered to have gestational diabetes. The American Diabetes Association endorsed the conference recommendations. The American College of Obstetricians and Gynecologists recommends the same screening and diagnostic values; however, it recommends selected screening only for women under age 30.

Keep in mind that O'Sullivan and Mahan chose their cutoffs for convenience in follow-up. No threshold has ever been demonstrated for onset or marked increase in fetal complications below levels diagnostic of diabetes. Instead of raising questions about the validity of GD testing, this lack of correlation with complications has led some researchers to lobby for a lowering of diagnostic thresholds, which would label even more women gestational diabetics.

- Henci Goer, Obstetic Myths Versus research Realities, A Guide to the Medical Literature, Bergin & Garvey 1995

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7) My Own Experience with Gestational Diabetes
by Leilah McCracken leilah@birthlove.com

Early in the third trimester of the pregnancy of my third child, I was diagnosed with gestational diabetes. But the diagnosis was a sham.

Three days before my diagnosis, I had a cooking accident--I sliced my hand open on a can lid. It was determined that I had severed some major tendons, and would need microsurgery to mend them. I was given a tetanus shot because of the can (I was assured the shot was safe), hooked up to a fasting IV, wheeled to a ward, and proceeded to wait two days for my surgery.

Those days were terrible. I was in incredible pain from the accident; I was afraid; I was lonely for my children and worried about them needing me. I was ravenous, and I couldn't sleep at all. The stress was incredible. Finally my turn came. I was wheeled to OR and given a local anesthetic. Ironically, my family doctor phoned during the almost three hour surgery. She said my one hour glucose tolerance test result was high and I would need a three hour test. I told the surgeon to tell her I'd get one right away. I packed my bags and left soon after the surgery was done.

First thing I did when I got home was eat lots of burgers and fries, then sent my husband out for a big birthday cake (and lots of Coke).

I phoned the lab for instructions on how to take the test (my doctor had called them and said I'd be coming). They told me not to eat after 6 pm. Easy enough, so the morning after my surgery, I had a three hour glucose tolerance test. And no one even asked me why I had a cast on my arm! After the first three numbers were determined to be high (they weren't *that* high), I was said to have gestational diabetes.

In learned retrospect, the diagnosis was a joke: the stress, the fasting, the junk food gorging, maybe even the tetanus shot all contributed to my elevated blood sugar levels the day of the test. There can be no other answer, because I have no contributing risk factors, and in all my pregnancies before or since (seven), gestational diabetes has never been an issue.

I learned a lot from the experience, but the burden I carried because of that diagnosis still haunts me. I had been given a barrage of ultrasounds; I had to restrict food intake to the point that I lost weight, and ended the pregnancy nine pounds lighter than I started. I wasted precious time and resources constantly transporting to a vast number of diabetes clinic appointments (and to the hand clinic and my family MD too). The testing equipment was expensive, and taking my blood sugar up to seven times a day was painful and awkward. I was also considered very high risk in subsequent pregnancies and was obstetrically managed accordingly.

Gestational diabetes does indeed exist, but one has to wonder how many women are misdiagnosed and suffer because of it. I think if women were offered optimal nutritional counseling in pregnancy, positive test results would be very, very rare. But I suppose it's just quicker and easier for physicians to test for a condition rather than work toward its prevention.

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8) Switchboard

[Long-time natural birth activist] Henny Ligtermoet is dying of cancer. She is in Albany in Western Australia and hasn't very long to live. Please send her Reiki, light, prayers or good vibes, according to your beliefs. She needs help to be calm and accept death and her Passing Over to a new life.

- Mary Murphy, midwife
Perth, Western Australia

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In response to the issue of a black midwives' forum [Issues 45 & 46]:

Midwifery Today has always attempted to give away a scholarship to a promising aspiring midwife of color because there are not enough non-Caucasian midwives coming up to serve women. At our midwifery meetings, there is a great lack of racial diversity.

Factors within our culture are keeping the stream of aspiring midwives from being diverse. Racism is real. I think as midwives we need to do all we can to nurture women from all backgrounds to come into this wonderful calling. The U.S. needs midwives from as many backgrounds as are represented in this beautiful tapestry of people we are blessed to have living here. When no Caucasian midwives were practicing, black granny midwives and Mexican American midwives were practicing all over the South. They were persecuted later than others because they were taking care of the poor that no doctors wanted.

It's to our advantage to take great pride in our diversity and nurture all midwives. I don't think it means disunity when midwives of color, Christian midwives or lesbian midwives want to meet within larger groups. Each group has issues to discuss that are unique to them. It doesn't mean they are pulling away from being midwives united in our calling.

- Jan Tritten

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1. Read and encourage your clients to read Henci Goer's new book The Thinking Woman's Guide to a Better Birth. This book may be the key to turning around the way women (in the U.S. in particular) give birth. It is easy to read, is affordable and packed with the evidence and research that would be very hard for doctors/hospital policy makers to argue with. It may be the most empowering tool women have had in the last 60 years. Her other book, Obstetric Myths Versus Research Realities, contains most of what we need to know in one volume. Let's all try to get "Better Birth" into our local library systems.

http://www.efn.org/~djz/birth/betterbirth/
http://www.efn.org/~djz/birth/obmyth/

2. My supplier of "birth balls" has stopped providing them. I was able to sell heavy gauge 55-65cm vinyl balls for $15.00 to my clients. They weren't as heavy duty as the $30 phys. therapy balls but served their purpose very well! Most of my clients cannot afford more but would like the benefits of using the ball in labor. Does anyone out there have a supplier I can buy from? I hate to send them to a physical therapy retail outlet.

- Jeanne Batacan
Reply to: rbata@msn.com

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In response to the inquiry about a healthy alternative to breastmilk [Issue 46]:

My chiropractor recommended goat milk because it most resembles breastmilk. You also add molasses for iron and brewer's yeast to help digest the milk since it isn't breastmilk. It comes in powdered form at most health food stores. One drawback: when the baby spits up it smells awful!

- Tendai Phiri

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There is a recipe for "Canned Milk Formula" in Varney's Midwifery, 3rd edition. This is what my mother fed me after weaning me at four months old. I have heard that it can be made with fresh or condensed goat milk. Some recommend adding infant vitamins to this regimen.

- Corrine

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I don't remember where I found this recipe. It is to be made fresh daily: Mix equal parts whole grains: oats, barley, wheat, millet, buckwheat, rye, flax seeds, brown rice Use 2 Tablespoons (or 3 depending on grain mixture) per quart cold water Cook slowly in covered stainless steel or glass pan for 1 1/2 hours Drain cereal through two layers cheesecloth while hot and retain liquid Use equal amounts grain liquid and cow or goat milk (I guess you could also use soy?) Add 1/4 teaspoon orange or lemon juice
Once a day add 1/8 teaspoon vitamin C and 1/4 teaspoon brewer's yeast per bottle

- Teresa

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Unless otherwise noted, share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com. If an e-mail address is included with the letter, feel free to respond directly.

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9) Midwifery Today Conference Notes

Philadelphian Birth Enthusiasts!

If you are interested in bringing Midwifery Today Conference flyers to a meeting with LLL Leaders, CBEs, nurses, doulas, doctors, parents, etc. contact:

Mothering Mommies Doula Service
Enterprise Building
4548 Market Street
Philadelphia, PA 19139
215-387-2955


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