October 31, 2001
Volume 3, Issue 44
Midwifery Today E-News
“Vitamin K”
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Quote of the Week:

"Birth is not logical."

- Gloria Lemay

The Art of Midwifery

When a supported squat gets too tiring for everyone but the help of gravity is needed to get a baby born, I bring in two kitchen chairs and set them apart a bit. I then have mom straddle them, putting one leg on each chair with her bottom in the middle, kind of suspended.

- Chris Roberts, The Birthkit Issue 30

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News Flashes

The tumor suppressor protein p53, brought on by youthful pregnancy, appears to reduce the risk of breast cancer, according to a Baylor College of Medicine study. One of the researchers commented that women who have a pregnancy at age 19 or younger have a 40% to 50% decreased risk of breast cancer. In the study, estrogen and progesterone were given to young female rats and mice. They found a significant increase in both the levels and nuclear accumulation of p53 compared with untreated age-matched virgin animals. When the researchers induced cancer with carcinogenic chemicals later in the animals' lives, they observed that hormone administration blocked mammary gland epithelial cell proliferation. Whether this effect is the same in humans is not known.

- Proc Natl Acad Sci 2001;98:12379-12384.

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Vitamin K

[Editor's note: The following are excerpts from a lengthy article published in Midwifery Today magazine. For fuller understanding of this complex topic, we recommend you read the article, which lists 40 references, in its entirety. This issue also contains two other excellent, referenced articles about vitamin K.]

The recommended daily intake (RDI) of vitamin K is 10 mcg for infants. Human milk does not provide this much vitamin K to the breastfed baby at any stage of lactation, despite the fact that mothers on average consumed 670% of the adult RDI. In fact, nursing babies received on average only 7-13% of the RDI. Giving the mothers a modest daily supplement of 88 mcg/day did not increase breastmilk concentration of the vitamin. A large daily supplement, 5000 mcg, taken by breastfeeding mothers increased the amount of vitamin K in their milk to the same level with which formulas are fortified.

Whether or not the RDI represents the amount of vitamin K that babies truly need is a matter that can be debated. The small quantities of vitamin K in human milk are adequate for most babies, as evidenced by the fact that the vast majority of breastfed babies do not develop vitamin K deficiency bleeding (VKDB).

A single IM dose results in extremely high levels of vitamin K in the newborns' blood soon after injection: the peak median plasma concentration at 12 hours is 9000 times the normal adult level, and from one to four days after the injection the levels are about 100 times higher than in a normal adult. It is unknown what risk there is in exposing the newborn to these high concentrations of vitamin K. Cancer was suggested as a potential risk as early as 1983, but the evidence to date is inconclusive.

Golding et al. found that intramuscular vitamin K supplementation given to newborns was associated with an increased risk of certain childhood cancers (B J Cancer 62: 304-308). This unexpected result occurred in a national cohort study done in Britain. The authors found similar results in a second study. Several subsequent studies showed no evidence of risk. However, the most recent studies have been unable to exclude the possibility that intramuscular vitamin K given to newborns may raise their risk for developing acute lymphoblastic leukemia in childhood. The evidence does not prove that intramuscular vitamin K is carcinogenic, and the risk, if any, is likely to be low. The evidence does not suggest that oral vitamin K poses a risk.

Some opponents of vitamin K supplementation argue that evolution designed human milk to contain the optimal amount of vitamin K for the nursing baby. This may well be true, but it is possible that a design that worked well for lactating women during the majority of human evolution would not work as well in the contemporary world. The majority of human evolution occurred during the long period before agriculture, when humans were hunter-gatherers. The diets of humans during those times were likely very different than diets today, and this could have affected the level of vitamin K present in mothers' milk.

Intramuscular vitamin K prevents late VKDB in almost all babies. Although late VKDB does sometimes occur after a single oral dose, and to a lesser extent after a series of three doses, these oral dosing regimens do confer some degree of protection.

A recent study, using data from Britain, estimates that among breastfed babies not given vitamin K, the risk of late VKDB is 19.1 per 100,000, or almost one in 5000. This risk can be considered low because the vast majority of babies will not develop the disease. A midwife could practice many years and never see a single case.


  • Provide parents with information during pregnancy so they can make an informed decision about whether or not they want vitamin K prophylaxis and if so, which type (IM or oral).
  • The baby's healthcare provider should be made aware of whether or not the baby received vitamin K, and, if so, in what form. Knowing the baby did not receive prophylaxis can improve the chances of early diagnosis and treatment in the rare event of VKDB.
  • For parents who decide not to give vitamin K, give a handout explaining the symptoms of VKDB and advise them to obtain immediate care for a baby who develops symptoms.
  • If jaundice is present after two weeks, bilirubin should be evaluated to see which type of jaundice is present. Conjugated hyperbilirubinemia may indicate cholestasis, which puts a baby at higher risk of developing VKDB.

- Jennifer Enock, "Babies and Vitamin K," Midwifery Today Issue 56, Winter 2000


I suggest it is extremely unlikely that the relationship between vitamin K levels and hemorrhagic disease of the newborn (HDN) is a simple one. I can think of several birth-related factors that might affect this issue. For instance, we should ask a woman what happened during the third stage of her labor. Was the cord cut quickly, or was the baby allowed as much time as she needed to regulate the amount of clotting factors and other relevant components in the baby's blood? What impact does the woman's diet during pregnancy have on the situation? And what are the possible reasons that nature intended babies to have low levels of vitamin K?

I worked in a community midwifery practice at a time when the decision was made to increase from one to three doses of the (oral) vitamin K given to breastfed babies. The first dose was given at birth and the second on the seventh day postpartum. While we would generally stop seeing women on the tenth day postpartum, the other midwives and I noticed that almost as soon as this new policy became practice, we suddenly had moderate numbers of women who were not discharged from midwifery care until the twelfth or thirteenth day. Analysis of the records showed that the majority of these women had babies who were becoming jaundiced on the eighth or ninth day following their second dose of vitamin K. Another midwife has suggested that perhaps babies cannot handle the increased prothrombin that comes about as a result of receiving vitamin K. Perhaps this would explain why babies are born with their relatively low levels.

Von Kries (BMJ 316:161-62) summarizes some of the recent history of vitamin K, which in some areas was not given until the early 1980s because late-onset HDN had not been a problem until then. This in itself should raise concerns. If all babies were pathologically deficient in vitamin K, surely someone would have noticed in these areas sometime before the 1980s. How does the increase (in some areas) of late-onset HDN relate to the changes in the practices women experience during childbirth? Did the "need" for routine vitamin K increase alongside increasing medicalization of birth?

- Sara Wickham, "Vitamin K: A Flaw in the Blueprint?", Midwifery Today Issue 56

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Question of the Week

Q: Has anyone developed her own system for newborn gestational age assessment? The New Ballard Scale seems more elaborate to me than is necessary for term babies who are born at home. I know that experienced midwives can quickly look over a baby and estimate the gestational age, but for now I would like to find a concise format to document characteristics for EGA.

- Amy Kieffer, student midwife

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Question of the Week Responses

Q: As a care provider for women during their childbearing years, it is also essential to be able to have competent information I can give to the women who I continue to care for beyond the birthing times of their lives. What are the signs and symptoms of breast cancer and what is the percentage of women who breastfeed to those who don't correlate with cancerous tumors in women's breasts? Can you recommend any books that are informative, honest and coming from a natural healing perspective?

- Amanda Moore, midwifery student


A: Your question is timely as I am preparing a curriculum about breast health. I would strongly recommend Susun Weed's Breast Health: The Wise Woman Way. She describes many different approaches to maintaining healthy breasts, as well as prevention and treatment of cancer. Dr. Susan Love's Breast Book and Christiane Northrup's Women's Bodies, Women's Wisdom are also essential resources. Susan Love's text is a wonderful reference text on the female breast, breast care and screening, diagnosis, treatment and research. Chapter 10 of WBWW is excellent, and finally Natalie Angier's Woman: An Intimate Geography explores the cultural context of breasts, their care and function in chapters 7 (Circular Reasoning, the Story of the Breast) and 8 (Holy Water: Breast Milk). There are also extensive resources on the web including access to medical, midwifery and nursing journals through a number of sites.

- Anne Maranta, RM


A: Read Breast Cancer? Breast Health! By Susun Weed. It is the best book I have read about breast cancer risks and prevention. It is wonderful.

- Aiyana


A:Breast Cancer, Breast Health by Susan Weed is an excellent book not only for breast health concerns but for anyone about to undergo any type of surgery. Highly recommended by everyone I have offered it to.

- Anon


Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!


In regard to Samantha McCormick's statement about BTL (Bilateral Tubal Ligation) and early menopause [Issue 3:42]: I will take you up on finding or creating the research on BTL. For a few years I have questioned why some people so adamantly accept that women do go through some changes after having BTL. I know that it's going to take a fairly long time to acquire the information because even though it is out there, it's not published.

In addition, anyone interested in supplying information either from clients, friends, family or self in regard to changes or effects after a BTL, your input will be more than welcome. I'm going to get started on a questionnaire/survey so I would also appreciate questions to help make it a complete one.

I have always thought that women went through an array of changes after BTL and have always asked "professionals" about it--only to end up with the same type of response that Ms. McCormick stated. Yet, when I go to the source, the women, many of them have something to say to contradict the "professionals". But they keep quiet and move on because they have no one to back them up. Let's change that and provide them with peace of mind knowing that what they are feeling and experiencing is not unique to them and may be a "medical response" to BTL.

- Margie Bou
Puerto Rico

Re: psychological or physiological reasons for a fast labor [Issue 3:43]: I am only speaking from my personal belief and experience. My sister-in-law's due date was 10 days before mine. I am a very relaxed person; she's uptight. Right away, she was told she had high blood pressure. Throughout our pregnancies, I exercised, meditated, ate right, and journaled about my pregnancy and what I thought motherhood would be like. She did not. I took hypnobirthing as my only childbirth education class--I couldn't be worried with the "what ifs" of labor and delivery; I was more concerned with facing any hidden fears I may have had about birth (which really only turned out to be other people's fears that landed on me). She was too concerned with the "what ifs" and attended all her hospital CBE classes faithfully. When it came time for each of us to bring our babies into the world, she was induced due to preeclampsia. She entered the hospital fearful of "pain" and made her fears come true. She did deliver vaginally, but it was after 27 hours of labor, cervidix, Pitocin, Nubaine, a sliced membrane sack, epidural, two episiotomies, a pretty good natural tear, fetal distress, a vacuum extraction, three doctors, seven nurses, much screaming and four days of hospital recovery (which is pretty unusual for our local hospitals unless a woman has had a cesarean birth).

I, on the other hand, experienced an easy and beautiful waterbirth with a four-hour labor. In fact, I didn't know I was in labor until my midwife told me. I felt no fear, but joy to an extent I had never felt before. My baby descended on her own until she was just about to be born. And when I decided to push, I did so through three surges, and on the last one, she crowned and continued to slide right out of me into the warm water so fast I didn't even realize it was over. I did tear a little because she had a 14-inch head, but that was the extent of my "birthing trauma." I knew as soon as it was over I would do it again. I am a firm believer in the power of the mind, and I have very little rebutting this belief from the experience I've faced. You cannot control birth, but you can make a great impact on how it will be from your thoughts and feelings.

- Abbie


I recently suffered from obstetric cholestasis and just wish to let you know about my experience. At 35 weeks I had intense, unbearable itching all night long (everywhere, including soles of feet) and to a lesser degree during the day. At 36 weeks a blood test showed a bile acid level of 16. By the time of the blood test I'd started a rapid cleanse diet--just water for a day, then fresh vegetable juices for two days, then fresh fruit and vegetables. Within five days, all itching vanished. The hospital told me there was no point in having another bile-acid test (to see if it had returned to normal) because once cholestasis is diagnosed, the diagnosis does not change. I do not know if the measures I used were any use in combating cholestasis but in my case it certainly relieved (and totally got rid of) any itching.

- Anni Taylor


I am a qualified midwife in England about to embark on my degree dissertation. I want to look at the appropriateness of pethidine (pamergan, demerol, meperidine) as a pain relief in labour. In addition to looking at "official" studies and RCTs, I want to know the experiences of women and birth attendants with this drug. If anyone has any experiences, feelings or stories good or bad, I would love to hear them. In particular I am interested in how well it did or did not relieve pain, the emotional impact, and any impact on breastfeeding.

- Sarah Carter


I recently read an article on the Internet stating that women may have more problems with pinworms than men because the pinworms can go into the vulva, uterus and the fallopian tubes. Is this possible in a pregnant woman? My OB knows nothing; neither do the midwives in my area.

- Shannon


Has anyone heard of the link between zinc deficiency and long gestation, two to three weeks overdue?

- Francie Smith


Regarding the doula whose client has a bicornate uterus: I had a student with this condition who went on to birth vaginally, full term, after a 67-hour labor. The biggest risk as I understood it was that of third trimester stillbirth/miscarriage, followed by breech. Prolonged or prodromal labor apparently is common. I found the most helpful information in Anne Frye's books Holistic Midwifery and Understanding Diagnostic Tests in the Childbearing Year. You might want to make sure her nutrition and emotional support are excellent. It stands to reason that a strong, healthy, well-nourished woman can grow a strong healthy baby, better built to withstand any problems occurring from structural abnormalities. Check out Dr. Brewer's website at www.blueribbonbaby.com

- Amy V. Haas, BCCE
Fairport, NY


EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.

Midwifery Today Issue 61: Postpartum

The Spring issue of Midwifery Today magazine will focus on postpartum issues and situations. If you have a clinical article, personal experience piece or something educational regarding this period after childbirth, please submit it to editorial@midwiferytoday.com.

Deadline is December 1, 2001. We look forward to seeing your stories!

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