August 9, 2000
Volume 2, Issue 32
Midwifery Today E-News
“Nutrition”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Nutrition
5) Check It Out!
6) Question of the Week
7) Question of the Week Responses
8) For Coming E-News Themes
9) Switchboard

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1) Quote of the Week:

"When a woman accepts sympathy in place of respect, her dignity goes out the window."

- Pat Thomas, AIMS Journal Summer 1997

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2) The Art of Midwifery

For varicosity in legs and labia: Choose herbs high in bioflavinoids, which act to support connective tissue: crataegus oxyacantha, ginkgo biloba; caccinium spp.

- Mary Bove, ND, LM, The Birthkit, No.20

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3) News Flashes

A recent study shows that the combination of low birth weight and rapid weight gain in childhood may predispose males to heart disease because they develop a disproportionately high fat mass. Other possibilities are that the accelerated postnatal weight gain that often occurs in low birth weight babies is intrinsically damaging. Another study shows that low birth weight is a risk factor for early onset schizophrenia in males. (British Medical Journal 1999; 318 as reported in Alternative Medicine, July 1999)

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4) Nutrition

Building a competent brain: One critical period of neuronal growth is the first three months after conception, when each building block or nutrient must be present when the DNA/RNA blueprint calls for it. Much like a contractor working round the clock, when materials are coded for, they must be present at the instant of synthesis. If they are not there, synthesis stops and the process must start all over again. When a mother consumes a diet that undersupplies fats, proteins, carbohydrates, vitamins, minerals, and water for both her and the baby, some part of the baby's brain development will be curtailed. Some structure will go unbuilt; some function will not be performed....

If a period of malnutrition occurs anytime from week ten through week 23(prenatally), a time when the numbers of cells are increasing, it is possible that irreversible damage has occurred. Fewer or less optimum numbers of brain cells will be produced. If malnutrition occurs later, at a time when the size of the cells is increasing, the damage may not be as severe. It should be noted that it is possible that some recovery can occur, but only if the diet is made adequate.

During this period of fetal development, large amounts of fats are deposited into the brain tissue from Omega-3, Omega-6, and other fatty acids. The types and quantities of these fatty acids differ, depending on the period of development and the needs of the brain at that point in development. At various times, more arachidonic acids (AA) are required; at others, docosahexaenoic acid (DHA) is called upon, and so on.

Scientific literature seems to indicate that during periods of malnutrition, both prenatally and postnatally, the brain's needs take precedence over the rest of the body, at the expense of other organs. We can take small comfort from this in knowing that even if we are deprived of some of those essential nutrients that are so needed for brain growth, we'll get them somehow--if they are obtainable from the liver or other organs. It is, however, the biological equivalent of robbing Peter to pay Paul.

It is also clear that if the period of malnutrition or undernutrition occurs at critical junctures during brain development, the myelin does not develop properly, and when the myelin is underdeveloped, nerve transmission is hindered.

- The Crazy Makers: How the Food Industry is Destroying Our Brains and Harming Our Children, by Carol Simontacchi, Jeremy P. Tarcher/Putnam, ISBN 1-58542-035-2

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How do you counsel pregnant women about nutrition, especially in these fast-paced days of stress, little time, and junk food?

As a Bradley Natural Childbirth instuctor I do plenty of nutrition counseling. First I have the woman do a three day food and drink diary, keeping track of everything that goes into her mouth. Then I evaluate that information. I use Dr. Tom Brewer's diet for comparison. I look at what is missing, and I total up her protein. Some of them are downright scary (i.e. not even enough protein for her in a non-pregnant state, as little as 4 ounces of water daily, etc). What I do first is find *something* about her eating she is doing right. Then I look at it all and see how it could be improved with the least changes possible. In the areas where she is lacking (often green veggies for instance), I find out what kind of foods she likes in that category. Then I project a three-day balanced plan and ask her if she can see herself being able to do it. Time for food preparation is often one of the biggest obstacles, so I also give her recipes that are simple and satisfy more than one requirement. I suggest things to carry with her for snacks (i.e. sunflower seeds, peanuts, string cheese, apples, carrots, etc.). I suggest that she carry a bottle of purified water with her at all times. I encourage her to set a goal to get as much protein as she can first thing in the morning.

After the diet makeover I have her do a diet sheet each week. I put stars on the days that are balanced and have enough protein (she has a counter and totals it as the day goes along). I also praise everything she does right and give small suggestions each week on where she needs to improve.

Enlisting the help of her husband does wonders too. When he knows how important good nutrition is he often goes out of his way to be sure healthy foods she likes are in the house, and often cooks for her or takes her out to eat healthy food.

I never mince words on the importance of diet while a woman is pregnant. I let women know how serious it is, and that it could be life or death for them and their baby. I also never tell them it will be easy. I let them know that it is hard to do so they do not get discouraged when it is challenging. It enhances self esteem to do something that is hard. When they realize how important it is they will do all they can to eat well. I praise them openly in front of each other in class and I have them share ideas of how they are making the diet work for them. It is gratifying and exciting to see how completely and quickly changes happen.

- Anna Matsunaga AAHCC
Tacoma WA

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I talk to the women in my prenatal fitness class about proper nutrition in terms of quality vs quantity. Snacking healthy: pita with peanut butter or meat, chips and salsa, cheese chunks, juices, fresh fruit, and a reminder that they must take in adequate calories. I encourage them to keep a small cooler in their car stocked if they must travel a lot, or to keep a stash in the office fridge so they can graze. I also remind them about cravings, that to a degree they are normal, to pay attention to them and to satisfy them wisely. If you want chocolate, how about a few "kisses" instead of a giant bar? We also talk a lot about Brewer, protein, salting to taste, and water, water, water. Many are so surprised to hear this from me instead of their doctors. They tell me they don't hear anything really unless they gain "too much" or come back with a positive for GD. I wish I had a nickle for every time one of them said, "How come my doctor never told me that?"

- Pam Martin, MS DONA CD, CM, apprentice midwife Poland, OH

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Riboflavin is a B vitamin. Deficiencies in B vitamins tend to cause higher homocysteine levels, which increase the risk of clotting. In other disorders in which the risk of clotting is high, preeclampsia is also frequent and exacerbated by poor nutritional status. The following study is actually a good confirmation for some of Dr. Brewer's work. Doesn't he advocate eating foods rich in B vitamins during pregnancy, like eggs?

- Jennifer Rosenberg

Riboflavin deficiency can increase the risk of preeclampsia by nearly fivefold in pregnant women already at high risk of developing this complication, according to researchers at University Women's Hospital, Mannheim, Germany. The team examined the link between riboflavin deficiency and preeclampsia prospectively in 154 women already at high risk of this pregnancy complication. The incidence of riboflavin deficiency during the study was 33.8%, where 27.3% of women were riboflavin-deficient at the first antenatal visit and 53.3% were deficient by the last weeks of pregnancy. Riboflavin deficiency increased the risk of preeclampsia with an odds ratio of 4.7. Intracellular free flavin adenine dinucleotide levels were also significantly lower in women who developed preeclampsia than in those who did not. The researchers are in the process of beginning a separate study designed to better test this hypothesis using controlled supplementation. Until these data are available, the authors recommend maintaining normal riboflavin levels in pregnant women.

- Obstet Gynecol 2000;96:38-44, via Medscape

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5) Check It Out!

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A Web Site Update for E-News Readers

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6) Question of the Week

Q: At a recent birth we could not hear fetal heart tones with a fetoscope once the head was on the perineum (approx. 35 minutes). Although the scalp was always pink and mother reported fetal movement approx. 3 minutes before birth, baby was born limp and made no respiratory effort. His color was pink at birth and heart tones were always over 120 bpm. We initiated neonatal resuscitation and called EMS and baby was subsequently transported to hospital. Baby was off respirator and breastfeeding by day two and home by day six. Parents informed us that ultrasound, EEG and CT scan on day three were normal. A complaint was subsequently filed by the College of Physicians which stated that "the baby is brain damaged as evidenced by the CT scan."

1. Is there any literature/research out there to justify or confirm that a pink scalp along with fetal movement when the head is presenting is an indicator of fetal well-being? 2. Can a CT scan tell if a baby is brain damaged?

- Anon.

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Send your responses to mtensubmit@midwiferytoday.com

7) Question of the Week Responses

Q: I am a happy, healthy 39 year old mom with thalessemia minor who is considering a homebirth for my second child. My first was born when I was 37 at a birth center with CNMs. Precautions taken (planned before labor) because of my thalessemia were a heparin lock at the beginning of second stage and a shot of Pitocin in my thigh immediately following labor to help clamp down my uterus. I labored naturally and normally with the exception of third degree vaginal and perineal tears (baby came fast, kicked his way out, and my position was not optimal). My normal hematocrit is between 27 and 30. My pregnant hematocrit just before labor was 25. Three days after it was 23 and back to 30 at six weeks. I believe my platelet count was and is normal. Am I a candidate for homebirth?

- C.M.

A: I was told by my midwife during my third pregnancy that if my hematocrit dropped below 30 she would not attend me at home. The reason for this may have been that she was a lay midwife (of 17 years at the time) in a state that does not allow her to legally attend homebirths, and the doctor backing her wouldn't allow it. She just needed to be extra cautious. I also know that my iron stores were adequate (we had them tested) even though my hematocrit was low. I took a supplement of iron and yellow dock root to get my level up to 30 when it dropped to 29. It took several weeks. I also ate some meat (liver) and cheese, though I was at that time a vegan. I ate those foods medicinally. My sister, also thallessemic minor (isn't it actually called thalassemia trait?), had a low hematocrit, but she was not planning a homebirth.

Supposedly, having a low hematocrit isn't as crucial as one would think since that is measuring what is in each red blood cell and we thalessemics have extra blood cells to make up for their small size. I wish some research could be done in this area to help us all understand better whether we are as bad off as they think when our crit is low. By the way, everything went fine at the birth in my home, except for a tear which caused me to have to transport for stitches since the midwife wasn't a nurse. Donovan Chase was 9 lbs. 14 oz. at birth and weighed 10 lbs 3 oz two days later.

- Anon.

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A: I cared for one woman with the same condition. I helped her have her last three babies. Her very first was a vaginal birth of a premature stillborn son. The second was a c/s of a healthy, full-term son. The next was a VBAC of a full-term stillborn daughter. The fourth was another full-term VBAC of a healthy son and the last a homebirth of a healthy son. I researched her blood disorder heavily and basically determined it was of no threat to her in any way and to definitely not give iron. Her two stillborn babies had absolutely nothing to do with her thalassemia minor. We all knew that and had confidence in that fact. Also, when I first met her, I ran a bunch of expensive labwork which was of no use to us except to confirm the fact that she had thalassemia minor. I never did any other labs except H&H twice during each pregnancy.

- Anon.

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8) For Coming E-News Themes

1. In two to four sentences, what is the best advice to give an apprentice or aspiring midwife?
2. What have you learned both by research and experience about the effects of labor drugs on the baby? Midwifery Today has just learned of a newborn death due to morphine having been given the mother for pain.

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9) Switchboard

I am 34+ weeks pregnant and contemplating the homebirth of my twins. They are separate sac, placenta. Twin one head down. No complications during pregnancy. My birth assistant (doula) is enthusiastic about homebirth but has not assisted with twins. The local health authority will provide three midwives to me at home--one supervisor and two experienced midwives. They have delivered twins at home. I also have an acupuncturist. The dad will be present.

The obstetrician has attempted to scare me out of this plan. I am still keen but shaken by his suggestion that 30-40% of 2nd twins require intervention. He mentioned the possibility of my risking brain damage, cerebral palsy and death to the babies, and the danger of my bleeding at a level where syntometrine would be no help. I am 10 mins (max) by ambulance to the hospital.

Nevertheless, the obstetrician also made me feel even less inclined to go to the hospital, by suggesting routine syntocinon drip to get 2nd twin out as soon as possible. Also I am not keen on the continuous monitoring recommended throughout. Epidural is very common as is ceasarian for twins, and I feel this might be because of the attitude in the hospital (that twin birth is a very high risk procedure) and the inability for the mother to move around much. Birth pool is prohibited. A lot of people tend to be involved: obstetrician, pediatrician, anesthetist, as well as midwives.

I know I am fortunate in that I would be practically supported in choosing a homebirth by midwives. They are not at liberty to approve of my decision openly as it is against health authority protocol. I feel homebirth is right for me, in my individual circumstances. That said, the safety of my babies is paramount and I would not risk their well being by having a homebirth if I genuinely felt the risk was higher to them.

I have been told water pool to be used during labour only is risky for twin mums as it can exacerbate bleeding. Any thoughts on this?

Finding up-to-date relevant information to help me make an informed decision is proving difficult. Is there any way you can help with this during August (September too late)?

- Sara
Reply to: SARALTODD@compuserve.com
(Please send a copy of your message to E-News so all readers may benefit from your response.)

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I am due with my sixth baby this week, and was informed by my CNM that my GBS test was positive. If I deliver in a hospital, they will insist on IV antibiotics. What are the ramifications of such treatment, or lack thereof?

- Joanna
Reply to: dnjhagen@nls.net
(Please send a copy of your message to E-News)

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I was recently talking to a friend who was helping take care of newborn twins. Shortly after birth, one of them routinely cried hard and long. Passing it off with the old "colicky baby" label, the hospital didn't do much. The parents took the baby to a chiropractor friend when the baby was two weeks old. The chiropractor noted the baby's neck bones were out of place, almost dislocated. It probably happened during birth. The chiropractor adjusted the baby's alignment and the crying very soon stopped for good.

Taking a crying baby or "colicky baby" to a chiropractor should absolutely be on the list of things to do when trying to determine why a colicky baby cries. Find one who is knowledgeable about handling babies.

Babies cannot articulate what bothers them specifically, but they do let us know they are not comfortable. When a baby cries, don't stop until you find out why! Forget the careless phrase many like to say: "Babies just cry." This is a brush-off. They are not little people, but big people in little bodies. Being a baby is no picnic sometimes, and we should help them out any way we can.

- Anon.

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Re: the article about routine induction by Nikki Lee [Issue 2:30]. I have heard some birth stories from women who had been induced with Pitocin who report that after receiving the drug their labors "failed to progress" and went on to need more intervention, and some ended up with a c-section. I wonder if there is a link between Pitocin and slowing of cervical dilation. Often I have heard this to be the reason for the interventions and c-sections.

I am also outraged that Pitocin is used as a "routine!" This means that women are being given it without question as to whether they really may benefit from it or without being asked if they want it. I know that in theory women have the right to refuse all "routine" procedures but how do you educate people about this and how do you enforce decisions made in the hospital at the time of birth?

- Brooke Russell
San Francisco

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In response to the Bali birth story [Issue 2:31]: The blood you saw was probably either bloody show (which can be different shades of color) or it could have been placental abuption. Did the placenta slide out right after birth, or did you have to wait for separation? The baby either died from tight cord compression or placental abruption. Unless there is an unusual abnormality, the cord is inside the membranes, so with those intact it would not make sense for the cord to be the source of bleeding. I would say breaking the water would have been the best thing to do, assuming she was close to completely dilated. With mom saying the baby felt low and this being her fourth baby, the birth could have been facilitated to occur very quickly, thereby reducing the time baby's oxygen supply was cut off (checking dilation, popping water bag, coaching active pushing, and cutting episiotomy are steps to expedite birth). The baby may or may not have survived, but those are the basic steps to take. There comes a point of no return, and when baby is abnormally stressed at that point he needs to come out. You don't need to feel guilt over this birth; it was mother's choice to avoid outside help. Also, if you do feel called to continue helping at births, continue your midwifery education! There are plenty of resources out there. You will learn when to get aggressive. And don't let this shake your faith in safe homebirth.

- Danna Reed, LM, CPM

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Re: checking for full dilation before encouraging the woman to push her baby out, I too shared her exact concerns and was excited to begin testing my theories about this issue once I was practicing on my own. At times I have wanted to kick myself for NOT checking because the woman ended up with a very edematous lip. There were never any serious problems because of this; I just know from reading the books how the cervix can be seriously damaged. But that kind of injury must be pretty rare because I've never encountered it. I don't always check for full dilation. It usually depends on the woman's contraction pattern, how strong the contractions are, how quickly she's progressing, etc. Also, whether or not I helped her with her last baby and if a lip was a problem before will influence my decision to check. So, I have come to completely individualize it to the present situation and know sometimes I will be able to get by without that final check and sometimes I'll regret not checking.

- Mary Ann
Ohio

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Once again Nikki Lee has shared some valuable stuff with the kindred spirits who subscribe to MT E-News [Issue 2:30]. I am certainly one. Our regional hospital has a very high rate of inductions (they are resisting revealing it to me-what a surprise). One of the two OBs in town is now offering "elective inductions" as of 38 weeks for moms who want one. How many 38-week pregnant women might choose induction, if offered? I shudder.

I teach childbirth classes and am trying my best to teach about the potential hazards of induction, especially if mother and baby are *not ready*! A woman in my class a few sessions ago opted for an induction and ended with a caesarean section (she never progressed past 3 cm dilation). Baby came out screaming. She called me for advice four days after the birth, when breastfeeding wasn't going well. When we discussed the birth and her son's disposition since the birth, she concluded (all on her own) that the baby had not been ready to be born. Although she gave up on breastfeeding (she was exhausted, recovering from major surgery, and just wasn't able to cope), she did get treatment (chiropractic and infant massage) to help her son come to terms with his traumatic birth.

I used to be very wishy-washy in teaching my classes--I didn't want to inflame the medical community. Now I don't hold back. It is an injustice not to share current research and ancient knowledge that backs up the fact that LESS intervention is usually best for mother and infant. I am always looking for more information to back up and beef up my teachings.

- Lisa Spracklin, B.Sc. doula, CBE

Editor's note: Readers, please share your ideas, references, links, whatever information you can give each other about routine induction. Send to mtensubmit@midwiferytodya.com

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Jennifer asked for sources of anti-Rhogam information {Issue 2:31]. Peckmann's Christian Midwifery, 2nd edition has some mild anti-Rhogam information and Polly's Birth Book does as well. She might want to contact Jehovah's Witnesses via the Internet to get more.

- Debby Sapp

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In response to herbal fixes for constipated pregnant women [Issue 2:31]: yellow dock is a powerful nervine and should not be given to pregnant or lactating women under any circumstance!

- Anon.

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I am desperately trying to get hold of a copy of Silent Knife: Caesarean Prevention and Vaginal Birth After Caesarean by Nancy Wainer Cohen and Lois J Estner. It is well and truly out of print! Any offers to Andrya Grubb, Independent Midwife andrya@hecate8.freeserve.co.uk.

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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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