The Art of Midwifery
As care providers and teachers, we should check what a pregnant woman is eating from the very first meeting. Assess the strengths and weaknesses of each woman's diet individually. You cannot assume pregnant women are eating well, no matter how educated they are or conscientious they seem to be. Although I spend one entire class and parts of almost all others teaching about pregnancy nutrition, I still find women who are reluctant to make changes or are missing crucial elements, regardless of supreme efforts to eat well.
Having women choose a variety of food sources for the nutrients listed below will help to ensure proper nutrition:
Protein: chicken, fish, shellfish, beef, pork, turkey, tofu, nuts, legumes, beans, seeds, milk, eggs, cottage cheese, whole grains, wheat gluten, soy cheese, fortified soy milk and tahini.
Calcium: milk, yogurt, hard cheese, cottage cheese, eggs.
Non-dairy sources of calcium and protein [detailed list included in print version]
Whole grains/complex carbohydrates/minerals/fiber: brown rice, kasha (buckwheat groats), whole oats, whole wheat bread, whole grain cereals, quinoa, wild rice, wheat gluten, wheat germ, whole-wheat pastas, baked sweet and white potatoes, green peas, beans, lentils and corn or whole-wheat tortillas.
B vitamins (great variety needed!): liver, whole grains, dark green leafy vegetables, beef, wheat germ and bran, blackstrap molasses, nuts, cauliflower, mushrooms, eggs, unpolished rice, lentils, yogurt, milk, organ meats, brewer's yeast, poultry, fish, peanuts and soybeans.
Fruits/vitamin C: strawberries, kiwi fruit, apples, oranges, bananas, mangoes, cherries, cantaloupe, pears, grapefruit, plums, nectarines, peaches, blueberries, raspberries and blackberries.
Green vegetables/vitamin C/minerals: spinach, broccoli, zucchini, dark green lettuces, kale, Swiss chard, green beans, asparagus, arugula, bell peppers and lambs lettuce.
Yellow or orange vegetables/vitamin A: sweet potatoes, carrots, squash, yellow or orange peppers and corn.
Iron: red meat, organ meat, eggs, fish, poultry, blackstrap molasses, cherry juice, green leafy vegetables, dried fruits (raisins, apricots, etc.), black olives, avocados, broccoli, clams, kidney beans, pinto beans, navy beans, lentils, lima beans, oysters, pork loin, sardines, shrimp, split green peas, tuna and anything red, dark green or black in color.
Zinc: pumpkin seeds, squash seeds, sunflower seeds, seafood, organ meat, mushrooms, brewer's yeast, soybeans, eggs, wheat germ and turkey.
Folic acid: spinach, asparagus, turnip greens, Brussels sprouts, lima beans, soybeans, organ meats, brewer's yeast, root vegetables, whole grains, wheat germ, bulgur wheat, kidney beans, white beans, salmon, orange juice, avocados and milk.
Magnesium: avocadoes, wheat germ, almonds, pumpkin seeds, cashews, spinach, bran, soybeans, peanuts, lentils and hummus.
Salt: sea salt, olives, cheese, salted nuts, fish and shellfish.
— Amy Haas, BA, BCCE, excerpted from "Prematurity Is Preventable," Midwifery Today Issue 72
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A Timely Birth
The timing of birth has major consequences for a baby. Too early or too late can mean the difference between life and death. Or so we have come to believe; and it's undoubtedly true at the extreme ends of preterm and postterm birth dates. Although few babies are born at these extremes of the normal length of pregnancy, much of our prenatal care is based on bringing babies to birth "in a timely fashion"—neither too early nor too late. But our understanding of "timely" is clouded, and some of our methods are self-defeating. By intervening in the natural timing of birth, we sometimes exacerbate the problems or create entirely new ones.
Even with early pregnancy tests and ultrasounds, induction of labor remains one of the largest causes of prematurity. Ultrasonic estimation of gestational age is still an inexact science; the range of error increases as pregnancy advances. Artifact and technician inexperience can multiply the inaccuracy. Many practitioners seem unaware of this error range or, alternatively, are unwilling to second guess a due date "confirmed" by ultrasound, even when the woman's history and clinical assessment indicate a later due date. Hence, the woman may be induced, even though the baby is clearly several weeks early. Some people discount the danger of early induction as long as the baby is within the last month of gestation. But even minor degrees of prematurity can cause harm. Babies born before full maturity can suffer from breathing difficulties or transient tachypnea, requiring separation in the hospital. They may be more prone to meconium aspiration. They are at risk for hypoglycemia and may have trouble maintaining body temperature. They are at increased risk for nursing difficulties and feeding disorders. They suffer from colic and digestive disturbances. These "minor problems" can affect the early bonding experience and make family adjustments more difficult. The incidence of child abuse is higher with "difficult" babies. As midwives we should aim for our families to experience the best emotional as well as physical health possible. A timely birth is a good step in this direction!
Preterm birth is rising in the United States. Some of this rise results from misjudged due dates and the fear of postdates pregnancy. Some reason that the risk of inducing an early baby is lower than the risk of allowing a pregnancy to continue past due, even when the due date is uncertain. This might be true if the perceived risk of postdates matched the actual risk. But it doesn't!
Few medical treatments have been proven to truly prevent preterm birth. (Avoiding iatrogenic prematurity is most effective, of course!) Some of the most promising avenues are readily available to midwives, and we should share this research with our clients.
The following are factors shown to be associated with preterm birth and some strategies for lowering the risks:
Overwork, job fatigue, stress. Women in high-stress jobs or who work long hours on their feet have nearly three times the risk of preterm rupture of membranes leading to preterm birth. In a study of 3000 primips, those who worked in "high fatigue jobs" had a risk of preterm premature rupture of membranes (pPROM) of 7% compared to 2% for those who didn't work outside the home. Although many women must work until the end of pregnancy, changing to less fatiguing jobs, if possible, will lower their risk of preterm birth.
Poor nutrition in pregnancy, low weight gain. Low maternal weight gain is the single risk factor that crosses all racial and economic indicators. A woman with a low pre-pregnancy weight and/or a low rate of gain before 20 weeks is at high risk for preterm birth. A balance of protein and carbohydrates provides the best nutrition. According to the Cochrane Database, restricted carbohydrate diets may raise the risk of preterm birth without having any effect on the incidence of macrosomia.
Vitamin C supplements. Low levels of vitamin C have been implicated for several decades as contributors to prematurity and preterm rupture of membranes. In a study of 2064 pregnant women, those who had total vitamin C intakes of <10th percentile of the average intake prior to conception had twice the risk of preterm birth due to preterm rupture of membranes (relative risk, 2.2).
Low levels of vitamin C may also be implicated in the risk of preeclampsia, which leads to preterm birth, as well as, frequently, induced labor. Researchers tested women for plasma vitamin C levels. Women who consumed less than 85 mg of vitamin C doubled their risk of developing preeclampsia (odds ration 2.1). Women who consumed the lowest amounts had almost four times the risk of those who consumed the highest.
Oxidative stress is theorized to play a role in preeclampsia and we are learning that optimum levels of vitamin C protect against oxidative stress. We don't know yet the optimum level of vitamin C or the best recommendation for supplements, but 300 mg to 500 mg is probably needed. Many American women consume less than 85 mg daily!
Bacterial Vaginosis (BV) has been associated with a two to three times increased rate of preterm labor and delivery, urinary tract infections (UTIs), premature rupture of the membranes (PROM) and endometritis. Because about 50% of women show no symptoms, universal screening for BV was proposed over a decade ago. (Screening and treatment is a current WHO recommendation.) Screening is simple and several effective prescription treatments are available. BV has a tendency to recur, however, and is sometimes resistant to chemical treatment. Women may be able to discourage BV with some simple home methods. Numerous studies have shown that when natural vaginal Lactobacilli levels drop, BV invades. Lactobacilli inhibit the growth of Mobiluncus, Gardnerella vaginalis, Bacteroides and anaerobic cocci even in a petri dish. Colonizing (or recolonizing) with Lactobacilli is key to vaginal health. According to Skarin and Sylwan, "The paucity of vaginal Lactobacillus is pivotal in allowing overgrowth of many other organisms of the vagina." Lactobacilli grow best in an acidic environment. A healthy vagina is acidic and naturally resists infection by "bad" bacteria—including strep.
PH alone—the acid/alkaline level measured by nitrazine or litmus paper—is a marker for prematurity risk. Retrospective and prospective studies show that high vaginal pH (a low acid, or alkaline, state) is predictive of preterm labor and preterm rupture of membranes.
No magic pill exists to assure a timely birth—a baby born at its healthiest point in gestation, neither too soon nor too late. Born ready to breathe, eager to nurse, primed to learn and love. Good health, good nutrition, good living habits and the avoidance of stress go far to ensure the baby will thrive until his birth date. As we learn more about normal pregnancy, we gain new tools to help both mother and baby achieve optimum health. This new research may help tip the balance in favor of better health—and a timely birth.
— Gail Hart, excerpted from "A Timely Birth," Midwifery Today Issue 72
Midwifery Today Issue 72 can be purchased here.
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Research to Remember
Two research projects are currently recruiting volunteers for studies on the use of probiotics in the prevention of preterm birth. One is in Brazil and the other in Canada. Because bacterial vaginosis (BV) can be a factor in preterm birth, and it is more likely to occur when the normal vaginal microflora are low or absent, the researchers hypothesize that adding lactobacillus probiotics to the diet may normalize them and eliminate the BV, thereby preventing the premature births.
— http://www.clinicaltrials.gov/ct/gui/show/NCT00303082?order=1, accessed 3 May 2007
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The distribution of births by gestational age changed between 1990 and 2005. The percentage of preterm births (<37 completed weeks of gestation) increased 20%, from 10.6% to 12.7%; the percentage of births at 37–39 weeks of gestation also increased, from 41.4% to 53.5%, a 29% increase. In contrast, the percentage of infants born at 40 weeks and especially 41 weeks of gestation declined (15% and 43%, respectively).
SOURCE: National Vital Statistics System. Births: preliminary data for 2005. Available at http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths05/prelimbirths05.htm
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Question of the Week
Q: I am the mother of a 7-month-old girl. I live on the Big Island of Hawaii and a cold/cough has been going around for quite some time now; nothing seems to be helping my daughter/family. Strangely Dad and Grandpa have the cough as well, but I don't. A friend suggested a Chinese Herbal remedy (Plum Flower Brand—Quiet Cough Teapills/Ning Sou Wan). I can't find any information about this particular remedy so was wondering if any readers have any experience with it.
Any info would be greatly appreciated.
— Kanu Priya Bernal
SEND YOUR RESPONSE to email@example.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: My daughter's son is seven days old and she is breastfeeding him. He latches on and sucks well. Despite some soreness and bleeding of the nipples at first she is coping well and the soreness is clearing. She uses nipple shields for alternate feeds to help her breasts heal.
The baby rarely settles after a feed unless he also has some formula either from a cup or a bottle. However, once he has formula he sleeps well.
Does this indicate a shortage of milk? I recall when I was breastfeeding many years ago, my breasts were full and leaky most of the time. My daughter does not seem to feel like this and there is no leakage. Is there something we can do to make sure she has plenty of milk?
— Brenda (Sian's Mum)
A: First, I would suggest that she stop using the nipple shields. They can decrease the milk supply. I know that the pain is not easy to deal with (I used a nipple shield with my son and I realized later that it caused more harm than it helped)...but most of the time if there is pain there is probably a problem with the latch. Having a good latch and putting the baby to breast whenever he seems hungry will increase her milk supply.
Also, she could try to pump after feeding him to stimulate her breasts to make more milk, and she could feed that to him instead of formula (using a lactation aid would be best because he would still get the milk, and she would also be stimulated to make more milk. You can find info on how to do that online).
If she is still having problems I suggest that she check out her local Le Leche League group (you can find them online) or talk to a lactation consultant. The sooner she gets help the better off she will be—if the problem is with the latch it needs to be fixed or it will never go away. It is sometimes harder to fix a faulty latch when the baby has been latching that way for a long time, so definitely before the baby gets too comfortable nursing the way he is, make sure that isn't the problem.
— Crystal Devlin
A: Giving the baby formula will certainly disrupt the mom's milk supply (especially at seven days!) and may predispose her to want to go completely to feeding with formula. This practice should discontinue, and the baby's output should be the first indicator of input. Some moms do not feel "full" or leak, or even feel the letdown reflex, and efforts to measure milk by pumping or expressing can be inaccurate as a mom will let down more to her baby than to a pump.
Ina May Gaskin, in her out of print book Babies, Breastfeeding and Bonding, says that measuring the volume of breast milk is not helpful because breast milk is digested at almost 100% efficiency, whereas formula is digested at 50%. So an 8 oz serving of formula does not mean that the same serving of breast milk would be needed to equal it—quite the contrary.
As for the baby not settling, some babies are wakeful after a feed and benefit from being fed upon waking, rather than being nursed to sleep. The baby nurses, plays or is bathed, etc., then the mom watches for signs of sleepiness and helps the baby wind down to sleep. This worked best for my two babies. It could also be that the mom is not getting rest and the baby is picking up on her emotions and physical cues. She should try going to bed with the baby for a day or two.
Remember that breastfeeding takes about three months to fully establish, so keep this in mind before trying drastic measures such as supplementing.
— Vesper Stamper, CCE
A: I would suggest she contact a local Le Leche League leader www.llli.org . In order for her to make enough milk make sure she does not limit the amount of time the baby sucks at the breast (Watch the baby, not the clock). And feed the baby "on demand."
She can also use breast compression to assist with the emptying of the breast—for instructions go to Jack Newman's Web site www.drjacknewman.com.
Also drinking Mother's Milk Tea may help boost supply.
— Elizabeth Morrison, CD(DONA)
Mother Me Doula Care
A: Leaky breasts are not a reliable indicator of a full milk supply, not to mention that if the baby is not effectively removing milk from the breasts, that can hurt a milk supply that is perfectly adequate. The more formula the baby gets, the less milk he is going to want to get from the breasts.
I would drop the nipple shields. Babies can become confused by them and start to not want to latch without them, plus they can really hurt mom's milk supply because the baby is not compressing as much breast tissue. She should use a good nipple salve to help her heal, and I would recommend just grinning and bearing it to avoid the many problems nipple shields can cause. These first weeks are the hardest for sore nipples—it gets better after the first month.
I would also drop the bottles. At seven days old, there is too much potential for nipple confusion/preference. If supplementing really becomes necessary, a cup or syringe is much better.
The best indicator that baby is getting enough milk is wet/soiled diapers and adequate weight gain. Baby should be back to birth weight by 2–3 weeks, then gain an average of an ounce a day after that. By seven days he should be having at least six wet diapers in 24 hours and 2–3 poops. A poop can be as small as a quarter at that age.
I would suggest dropping all supplementation for four or five days and track his diapers. If he's having enough, they're doing just fine. If not, you could then try tracking his weight if you have access to a scale to see if a problem really exists. During this time, make sure she lets him nurse as often as he wants, and if he is excessively sleepy, wake him up at least every two hours, with maybe a longer stretch at night. Let him nurse on one side for as long as he wants, then offer the other side. At the next feeding, offer the side he ended on. At seven days, babies nurse LOTS, it can seem constant—that's good, that's the way they are designed. Don't try to schedule or limit him AT ALL.
Responses to any Question of the Week may be sent to E-News at any time. Write to firstname.lastname@example.org. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
Think about It
A news article forwarded to us by Susan Hodges (Citizens for Midwifery) reports that women in New South Wales (NSW), Australia, will no longer be able to demand cesareans for non-medical reasons. Under new policy, they must be told about benefits and risks of cesareans versus vaginal deliveries, including the adverse outcomes associated with subsequent pregnancies.
This changed policy came about in part as a result of a US study that showed that babies born by cesareans-on-demand were almost three times as likely to die as those born vaginally.
Now if only US hospitals will follow their lead.
Regarding Research to Remember: Smoking and Stillbirth (E-News 9:10)
There is another negative outcome of cigarette smoking that is rarely discussed: When a mother smokes, the baby randomly/unpredictably receives just a little bit less oxygen. The brain is in its most critical stage of development in utero; this critical period continues for about four years after birth, at which time 90% of the brain's growth is complete. This is significant because, smoking can cause a baby to be born hyper-aroused due to the trauma of having its oxygen reduced so randomly.
Trauma is very misunderstood in the general population. Stress that is overwhelming, unpredictable and prolonged, and continues on unexpressed, unprocessed and misunderstood, becomes a trauma in the body/mind system. This affects one's neurology and stress response. Because this stress occurs during a preverbal time, it cannot be integrated and, therefore, the baby is traumatized.
Cigarette smoking not only compromises the baby's physical health but also the baby's emotional and behavioral health.
I recently founded an organization, Center for Family Attachment and Healing, Inc. You can check it out at www.attachmentandhealing.com.
— Pam Moran, MSW, LSW
This is in response to the statement, "The US government does not provide any funding for the research and reduction of stillbirth." made in E-News 9:10 - Stillbirth (May 9, 2007). This statement is not necessarily true.
In 2003 the National Institute of Child Health and Human Development (NICHD) established the Stillbirth Collaborative Research Network (SCRN) to study the extent and causes of stillbirth in the United States. The information gained is hoped to be of benefit to families that have experienced a stillbirth, women who are pregnant or who are considering pregnancy, and physicians. In addition, the knowledge gained by the investigators is expected to support future research aimed at improving preventive and therapeutic interventions and at understanding the pathological mechanisms that lead to fetal death. The specific aims of the SCRN are to:
- determine the causes of stillbirth using a standardized stillbirth postmortem protocol, to include review of clinical history, protocols for autopsies and pathologic examinations of the fetus and placenta, as well as other postmortem tests to illuminate genetic, maternal, and other environmental influences;
- obtain a geographic population-based determination of the incidence of stillbirth, defined as fetal death at 20 weeks gestation or greater; and
- elucidate risk factors for stillbirth.
Five clinical sites are collaborating with a coordinating center and NICHD, as well as local hospitals, to design and carry out the study objectives. A variety of specialists, from obstetricians to grief counselors, are participating in the research initiative to support the mothers and their families and to develop guidelines for studying and reporting stillbirths.
The Network is relatively new, so the Web site is a bit sparse, but more information can be found at The Stillbirth Collaborative Research Network Web site: http://scrn.rti.org/. Hopefully this is a step in the right direction.
— Nora Kropp, CPM, MPH
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