November 12, 2003
Volume 5, Issue 23
Midwifery Today E-News
“Water and Pregnancy, Part III”
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In This Week’s Issue:


Quote of the Week

"It may be worth considering that ultimate satisfaction with the experience of giving birth may not be related to lack of pain."

Sarah Buckley


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The Art of Midwifery

Nutrition for preventing perineal tears:

  • Emphasize protein, a variety of vegetables and B vitamins along with vitamin C with rutin and bioflavinoids and vitamin E.
  • Avoid fried foods, refined flours, and sugars--they undermined tissue strength.

Joan

Also, emphasize intake of vitamins A and D.

Marlene W., Midwifery Today Forums

News Flashes

Researchers at Magee-Women's Research Institute and the University of Pittsburgh School of Medicine have found that vitamin C deficiency, even to a mild degree, apparently leads to poor vascular elasticity and function, a key symptom of preeclampsia. Arterial pressure and elasticity in pregnant and nonpregnant rats were evaluated. It was discovered that blood vessel stiffness increased in pregnant rats (but not nonpregnant rats) when vitamin C concentrations were restricted.

www.sciencedaily.com


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Water and Pregnancy, Part III

Varicosities
The extra weight of pregnancy causes a form of stress seen as varicose veins and hemorrhoids. During pregnancy, these conditions can indicate a more serious complication, especially when accompanied by edema and/or hypertension. Care providers can determine the course of action. Consistently normal blood pressure readings and urine screenings indicate the common sort of varicosity that will most likely disappear after birth. In the meantime, for the final weeks of pregnancy and following birth, women can use herbs traditionally used for such discomforts.

Astringents are herbs that have the quality of drying, shrinking, and binding tissues. They help reduce inflammation, swelling, and secretions. They can be used internally, externally at the site of stress, and in baths. The water element gives comfort and relief.

How to Use Astringents

  • Liniment: Combine extracts of selected herbs and use topically. Apply several drops to a cloth or cotton ball and saturate the appropriate area.
  • Poultice: Add extracts to powdered bentonite clay to make a paste; apply it to the affected area and allow to completely dry. Poultices can be removed when dry and freshly reapplied.
  • Compress: Made from a strong tea of the chosen herbs, a compress is a cloth soaked in cooled tea (a warm infusion tends to aggravate conditions) and directly applied where it is needed.
  • Bath: Full-body or sitz baths allow herbal essences to be taken into the body through the pores of the skin, and the external areas needing attention are sufficiently reached as well. Infusions, decoctions of the appropriate herbs, or tincture doses can be added to a bath.

The Herbs

  • Blackberry root (rubus villosus): an excellent astringent that is remarkably effective in just a few tincture doses. Varicosities also respond well to external methods of treatment.
  • Witch hazel bark (Hamamelis virginiana): A safe and effective astringent with additional benefits as an antiseptic.
  • Oak bark (Quercus): White varieties of oak followed by red are ideal choices for deep-reaching astringent action.
  • Yarrow (Achillea millefolium): The fresh tincture helps shrink swollen tissues and check fluid secretions.

Constipation
Traditional herbs for clearing constipation and improving regularity are unsafe for pregnancy. They can tax vital organs with extended use, and in progressing pregnancy the organs are already working hard. The more nutritive food-type plants are still a good option for treating constipation. Bulk fibers in the form of grains and/or vegetables are a worthwhile choice for keeping the digestive tract clear and the bowels regular. Fiber helps absorb water and keeps constipation at bay. Close attention to diet will also relieve blockages. Pregnant women should avoid heavy and difficult-to-digest foods.

Bulk fibers: Oat bran, celery fiber, wheat bran, flaxseeds, prunes, psyllium husk powder
All these can be found in powdered form and added by the teaspoon to a glass of juice or tea. Mom should take the mixture once in the morning and again in the evening. The powders can also be added to muffins or sprinkled on cereals. Prunes can be eaten whole and fresh, dried, or juiced. Flaxseeds can be added to baked goods or eaten with grains and salads.

From "The Water Element: Why It's Important to Help Mothers Keep Water in Their Diet,"
by Susan Perri, The Birthkit Issue 35

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Web Site Update

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Forum Talk

Can anyone give me their take on vitimin K and ocular antibiotics in the newborn? I would really appreciate the opinions of seasoned midwives.

Jennifer


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Question of the Week

Q: I am 21 weeks pregnant, and the doctors believe I have placenta accreta. I have asked my doctor a lot of questions, and the only answer is I need to have another c-section. Everything I have researched says the same thing. What kind of precautions should I take to prevent uterine rupture? Why does this condition normally result in premature delivery?

— Angela


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: It has been 10 years since the last time I gave birth, and now find myself for the first time having to make a decision about getting swabbed for Group B streptococcus (GBS) infection. Are the concerns that real and scary? This is my fourth pregnancy and I am 36 weeks along. I have not touched antibiotics in more than 15 years and don't care for them.

— Anon.

A: I recommend that my clients educate themselves, starting with reading the Centers for Disease Control monograph about GBS (www.cdc.gov/groupbstrep/). It is their take on why they recommend what they do. Then you can make your own informed decision.

— Cynthia B. Flynn, CNM, PhD

A: I see this from two different practices. I work in a clinic that does prenatal care by a family practice MD, and I am an RN and direct-entry midwife doing homebirths.

Is it really that scary? I am sure it is if you are among the very small number of woman who birth a baby who contracts strep B during a vaginal delivery. Babies exposed to this sometimes die in their first weeks of life from respiratory distress/failure or meningitis. However, this issue is not clear-cut.

An estimated 15-20% of women are carriers of strep B in their vaginal areas. Of these women, 3-5% will birth a baby who has been exposed to strep B. Of these babies, some may be fine, some may be somewhat lethargic and difficult to arouse to nurse. Others may develop respiratory infections that are serious and require artificial ventilation, and some may become "septic," meaning the bacteria gets into the baby's bloodstream and causes meningitis. So, scary, yes, if you are the exceptional woman who has birthed this very sick baby.

To culture women and announce that they are "safe" because they culture negative is unreliable. Women who have cultured positive for strep B in the past are carriers and may culture negative at times, positive at other times. So, is every woman who cultures negative not a carrier? Probably not. In light of this, the statistics of 15-20% and 3-5% may be invalid, indicating that the risk may be less than we might think.

I know of one woman who cultured positive and took antibiotics. She delivered a baby who was strep B positive, and baby was subsequently treated about one week after birth for lethargy--difficult to arouse and nurse--without other complications. Other things considered are length of time from rupture of membranes and delivery. It is believed that the longer the amniotic sac is open, the greater the chance of infection in the newborn. Again, this is not clear cut, and there are a lot of other influencing factors.

In my homebirth practice, I treat everyone like they may be carriers, but do cultures only at the mother's request or for women who would want antibiotics. Everyone makes their own decisions based on their informed choice. I recommend propolis tincture, goldenseal tincture, and a zinc supplement during the last three weeks of pregnancy. Zinc is thought to boost the infant's immune system. Not all mothers choose to take these supplements. Ultimately, we take responsibility for our own health and our own birth outcomes.

When thinking about exposure and infection, think about who gets sick or when do you get sick. Poor nutrition, excessive stress, and fatigue all indicate that our immune systems may not be doing their jobs well. Everyone who is exposed to an illness will not become ill. But there is that needle in the haystack, the unexpected. In the world of legalities and medical malpractice, I don't know any medical provider who is going to bet they will not get stuck with that needle, especially over time.

— Andrea Mietkiewicz, Clear Light Midwifery, Old Town, Maine

A: Just because you have the test done and you are Group B strep positive does not mean you have to have the antibiotics. I was, and I didn't! My baby is alive and well. Given the choice (which I wasn't; the midwife just said "Take off your pants, it's time for your group B swab." I had no idea what that meant at the time) I would have chosen to have the test done. It's painless and a good thing to know.

— Chrisanna


Q: It seems I read theory after theory about what causes preeclampsia and how to deal with it and get the mom back on track. What do E-News readers have to say about this problem?

— C.J.

A: Refer to the article in the last Midwifery Today [Issue 67] "Preventing Problems with Nutrition." It explains the Brewer diet for prevention of preeclampsia.

However, I understand your confusion. There are many theories, but western medicine has yet to accept or establish one as the definitive "cause." They say the cause is unknown (Dr. Brewer would disagree). That in mind, we have nothing to lose by feeding pregnant woman a superior, high-quality, varied diet. Sometimes it pays to keep things simple and work with what you know and what you have control over.

— Amy V. Haas, BCCE


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A: I have a theory that so far has played true. I suggest that hypertension and preeclampsia in pregnancy result from placental and/or cord issues. Pregnancy-induced hypertension is very often explained at birth when we find the placenta calcified early, the cord inserted differently, or a cord that is knotted or tortured in status.

We know that calcium, protein and water are essential for the body to work properly. For a mother with swelling, I always point her toward doubling her noncarbonated, noncaffeinated fluid intake and help her with her diet to ensure she is getting adequate calcium and protein. These measures, with proper rest, have so far always relieved the swelling, and if blood pressure (BP) has risen, it lowers back to normal.

When there is interference getting nutrients to/from the baby, the mother's body will automatically increase pressure to provide for proper circulation. When this occurs, the mother's body needs extra special care to prevent extended stress and complications. I have found that the mother shows signs of physical stress long before her BP rises. The high BP seems to be one of the last signs of stress.

Rest, fluids, and a proper diet are a must during pregnancy. I have found that women who follow this standard from conception have fewer complications, and those that do occur are mild. If ignored, the body will send out signs of stress, and those signs will continue to worsen until the woman takes heed and corrects her lifestyle or symptoms worsen to the point of danger.

— Chantel Haynes, Tucson, Arizona

A: I had the horrible experience of taking my nephew delivered by me to the emergency room and watching him lie in NICU for a week in critical condition due to GBS. I tell everyone now how very important it is [to monitor for it]. I have also started testing earlier as babies who are premature are more susceptible to getting GBS. My nephew delivered at 37 weeks.

— Lorrie Stanley, CPM

A: The following is an excerpt from Anne Frye's article "Unraveling Toxemia" (Midwifery Today Issue 34) and her book "Holistic Midwifery":

"Liver-related demands increase as pregnancy advances. Maintaining liver function at peak efficiency requires a well-balanced diet with enough protein, calories, vitamins, salt, other minerals, and fluids to meet the demands of increased metabolic activity. The liver can only make albumin from dietary protein. If the diet is inadequate in any essential nutrient, the pregnancy suffers.

"Adequate blood volume expansion by 28 weeks serves as a foundation for adequate transport of nutrients to the baby during the last trimester, when the mother begins to put on more weight and store nutrients for after the birth as well as for the rapidly developing brain. If the blood volume has not expanded adequately during the first 28 weeks, the mother's body is inadequately prepared to cope with the increased fetal demand and secondary symptoms of metabolic toxemia of late pregnancy become manifest. Increased fetal and placental demands place more stress on the liver to increase blood volume, which it cannot do without proper nourishment. As a result, metabolism becomes increasingly deranged. Eventually, the kidneys respond to an inadequate blood volume by reabsorbing fluid as they filter the blood.

"This reabsorbed fluid is returned to the circulation. If there isn't enough albumin or sodium in the circulation to hold this reabsorbed fluid, much of it leaks out into the tissues through the blood vessel walls. The kidneys continue to reabsorb fluid at one end, while it continues to leak out of the capillaries at the other end. Pathological weight gain, high blood pressure (in some cases) and edema are the result, with eventual reduction in urinary output, as the situation becomes more critical. These are all secondary symptoms of the primary problem, a poorly nourished liver unable to do its work. Secondary symptoms of toxemia may present before 28 weeks in a severely compromised woman. Inadequate blood volume expansion eventually affects other metabolic processes as well."

I highly recommend that you read the whole article for a complete picture, or buy the book, in addition to Dr. Brewer's books.

Amy Haas


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mgeditor@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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Question of the Quarter for Midwifery Today Print Magazine

We hope you'll take a minute to consider the Question of the Quarter for Issue 69 of Midwifery Today. Responses are subject to editing for space and style. Try to keep the word count at less than 400. E-mail your response to: mgeditor@midwiferytoday.com.

Theme for Issue No. 69: Midwifery Knowledge
Question of the Quarter: What do you consider essential midwifery knowledge? What do you consider advanced midwifery knowledge? Who owns the knowledge?
Deadline for submission: December 1, 2003.

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Cruelty in the Maternity Wards Revisited

by Henci Goer

I based the above title on the title of a highly influential Ladies Home Journal article from the 1950s. It began in the November, 1957, issue with a letter to the editor from a labor and delivery nurse who gave some examples of abusive treatment of laboring women where she worked. The editors published the letter, saying they had never heard of such mistreatment, and they invited readers to respond. The result was "Cruelty in the Maternity Wards," an outpouring that Ladies Home Journal published as an article in the May issue the following year.

Recently, the following stories appeared on a local doula list. As you can see, not much has changed.

  • Before labor, an obstetrician/gynecologist tells a woman she should schedule a cesarean section because her first baby only weighed 7 lbs., this baby will weigh at least 9 lbs., and she doesn't have a proven pelvis for a 9-lb. baby. The woman refuses. In labor, the OB/GYN tells her she can't begin pushing because she has an anterior lip. The nurse says she shouldn't have a problem because she is a multip, but proceeds to try and push back the lip anyway. The woman yells, "Don't do that! Stop, that hurts!" The doula says, "You don't have her permission to do that." Both are ignored. During pushing, the OB/GYN stretches and pulls at the woman's perineum. Again, she cries out in pain and tells him to stop, but as before, he ignores her and continues. After the birth, staff members keep vigorously massaging her uterus although there is no sign of abnormal bleeding.
  • An OB/GYN tells a 4'10" primip that if she doesn't go into labor by her due date, she should schedule a cesarean section. She is not going to be able to birth her baby anyway, she is told, and there is no point in suffering through labor and then having the cesarean section. Her sisters had cesarean sections, so she will need one too. This story is still in progress, but the mom's confidence is broken, and she is probably going to schedule the cesarean section, although she strongly wanted a natural childbirth and is a triathlete.
  • The heart tones are lost on the electronic fetal monitor (EFM) because a mother shifts to a hands-and-knees position. The OB/GYN says he wants to put in an internal EFM. The doula says it's just the mom's position--she'll change back, and then everyone will see that the baby is fine. The doula asks the mom if she agrees to the internal EFM. She says "No." The OB/GYN does it anyway. The baby is fine.
  • An OB/GYN does manual uterine exploration on a woman with no indication. The doula thinks that because so many women have epidurals, doctors think they can do anything to them. "It doesn't matter because she won't feel it," they think. But this mother was having an unmedicated birth. The OB/GYN was oblivious to the excruciating pain he caused her.
  • I just received an e-mail from a woman who is 34 weeks and has pregnancy-induced hypertension. The OB/GYN says they will probably induce any day now. The woman has been reading about Cytotec and asked how she would be induced. The OB/GYN replied, "With Cytotec." When she questioned this, she was told there was no other drug that would soften the cervix; Cytotec is perfectly safe; and if she didn't agree, her induction would surely end in a cesarean section.

If this is what's going on in my neighborhood, what does the picture look like nationally?


Henci Goer, author of "The Thinking Woman's Guide to a Better Birth" and "Obstetric Myths Versus Research Realities," is an acknowledged expert on evidence-based maternity care. She has written consumer education pamphlets and numerous articles for magazines as diverse as Reader's Digest and the Journal of Perinatal and Neonatal Nursing. She appears on www.ParentsPlace.com as the "Birth Guru." Visit Henci's own Web site at www.hencigoer.com.

Editor's Note: Readers, any comments?


Feedback

Regarding flu shot during pregnancy [Issue 5:22]:

If your friend has had the flu in the past five years or so, she will have some immunity and is unlikely to have it for at least another few years--until the next big "antigenic shift" when the flu viruses mutate, usually every five to 10 years.

She could also consider ensuring that her immune system is supported with good levels of nutrients--especially zinc, iron, and vitamins A and C (best from diet, but also check for recommended doses in pregnancy)--and perhaps herbs as well (e.g., echinacea).

The flu vaccine is said to be Category B2 in pregnancy--i.e., "There is no convincing evidence of risk to the foetus from immunisation of pregnant women using inactivated virus vaccines, bacterial vaccines or toxoids." However, this category recognises that there is limited information--i.e., that "studies in animals are inadequate or may be lacking. ..." (As far as drug safety in pregnancy is concerned, the "best" category is A, then B1, then B2, etc.). She would need to balance the potential risks and benefits for herself while making this decision. You could search "flu vaccine" (or fluvax) and pregnancy on the Internet for more information.

Sarah Buckley, GP/family MD, mother, and writer on pregnancy birth and parenting


Regarding third stage use of Pitocin [Issue 5:22]:

I highly recommend the site www.cordclamping.com, which critiques all elements of "active management" (i.e., early clamping, controlled cord traction, and use of oxytocics). My article "Leaving Well Alone--A Natural Approach to Third Stage," published in Midwifery Today Autumn 2001 (Issue 59) is posted there also.

This subject is also well researched in the following publications:

Sarah Buckley


I am 43 years old and seven weeks pregnant with baby number five. I had a miscarriage three months ago. False unicorn was recommended; do readers have a source? Other recommendations? Also I used raspberry leaf tea and reflexology with baby number four and everyone in the delivery room could not get over the awesome painless labor I had. I took arnica and hyperciun too after the birth and because the bleeding was so minimal they were going to do a DNC until I came clean and told them what I took. The Doctor shook his head and cancelled the DNC. Please e-mail me directly.

Marla, r.m.ptl@sasktel.net


Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


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