January 21, 2009
Volume 11, Issue 2
Midwifery Today E-News
“Diet”
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Midwifery Today Conferences

Brush up on your midwifery skills

Take one or both of the two full-day Midwifery Skills Development classes at our conference in Eugene, Oregon, March 2009. The first day starts with a segment on basic skills such as blood pressure, pulse and lab tests. You'll also learn fetal palpation techniques, how to listen to the fetal heart and how and when to resort to vaginal exams. It concludes with a session on complete physical exam skills, with attention to making the exam a valuable experience for both client and practitioner. During the second day you'll learn about preventing complications with prenatal care, VBAC skills, hemorrhage, helping the slow starting baby, the placenta and suturing.

Learn more about the Eugene conference and get a complete program.


Preserve the Spirit of Midwifery

Plan now to attend the Midwifery Today Conference in Copenhagen, Denmark, May 13–17 2009. Choose from a variety of informative classes, including Breech Workshop, Role of Oxytocin, Shoulder Dystocia, Mexican Midwifery Skills and Massage. Learn from teachers such as Ina May Gaskin, Michel Odent, Robbie Davis-Floyd, Marsden Wagner, Cornelia Enning and Suzanne Colson.

Learn more about the Denmark conference and get a complete program.

In This Week’s Issue:


Quote of the Week

"Feeling fat lasts nine months, but the joy of becoming a mom lasts forever."

Nikki Dalton


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The Art of Midwifery

Let clients know that grazing throughout the day is the best way to get the needed calories, i.e., three meals and two to three snacks a day, with protein included in each meal and snack. Many women get a picture of piling more on their plate instead of eating smaller, more frequent meals.

Darynee Blount
Excerpted from "Growing a Baby: Diet and Nutrition in Pregnancy," The Birthkit, Issue 46
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ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


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Research

A study on rats fed a diet of genetically modified (GM) (Roundup resistant) soy, done by the Russian Academy of Sciences, suggests that women who eat such foods while pregnant and breastfeeding may harm their unborn babies. In the as yet unpublished study, more than half of the babies of rats who were fed modified soy died in the first three weeks of life. This is six times as many as those with normal diets; in addition, six times as many were severely underweight.

Italian researchers previously discovered that GM soy can cause liver and pancreas damage in mice. In addition, a secret report by Monsanto showed that a diet rich in GM corn suggested possible immune system damage.

The American Academy of Environmental Medicine has asked the US National Institutes of Health to sponsor an immediate, independent follow-up study.

http://news.independent.co.uk/environment/article337253.ece


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Lecithin

Lecithin is present in many of the foods we eat, but it is most concentrated in foods that are high in cholesterol and fats. Organ meats, red meats and eggs are the most concentrated sources of dietary lecithin. With the current trend of reducing cardiovascular disease and improving overall health quality, many breastfeeding women lean toward low-calorie, low-cholesterol diets. People are limiting their consumption of organ meats and eggs, thus limiting their intake of lecithin (USDA 1979 and 1992). This reduction most likely results in an inadequate dietary intake of lecithin.

The diet of the average American today also has less lecithin than that of the previous generation because purified and refined foods comprise the bulk of their diet. With the current demand for highly processed foods, refined sugars and hydrogenated fats, consumption of lecithin is further decreased, possibly even to the point where consumption of foods containing lecithin is at suboptimal levels for health.

The average pregnant and breastfeeding woman eating the Standard American Diet (SAD), which is high in saturated fats, is not able to naturally produce enough lecithin to assist with the emulsification of fats in her blood stream and carry out milk duct cleanup.

Scientists tell us that the body, without dietary sources, is not able to synthesize an adequate supply of lecithin. Lecithin is produced in the liver, and small amounts are present in foods such as brewer's yeast, grains, legumes, fish and wheat germ. People who eat the SAD, elderly people, breastfeeding women, infants, children and those who would like to improve memory, strengthen nerve growth and decrease buildup of fatty deposits in liver, heart and brain would benefit from supplemental lecithin.

The best form of supplemental lecithin is the granular form. Avoiding liquid lecithin, usually found in gel capsules, is advisable. It is primarily designed for commercial use as an emulsifier in food, cosmetics, paints and so on. It is a bad-tasting, sticky material and consists of about 37% oil and only 60% phosphatides. This combination would add to the high dietary fat content that lecithin has to clean up in the body. Capsules are a high-calorie, low-potency supplement, but if a pregnant or breastfeeding woman cannot find granulated lecithin locally or has difficulty adapting to sprinkling granules on her food, taking lecithin in capsule form is far better than not taking it at all.

Cheryl Renfree Scott
Excerpted from "Lecithin: It Isn't Just for Plugged Milk Ducts and Mastitis Anymore," Midwifery Today, Issue 76
View table of contents / Order the back issue


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Sharing Midwifery Knowledge

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Web Site Update

Read this article excerpt from the current issue of Midwifery Today, Issue 88, Winter 2008:

"You have the best job in the world!" I hear this quite often when I tell people what I do. I agree, of course. I do have the best job in the world. I know, however, that the vision in the mind's eye of the speaker is the blissful moment when the baby slowly crowns and then slips its way into the waiting hands of a calm, not-at-all-blood-splattered midwife. The reality, of course, is that by the time the slippery-baby-entry thing happens, the calm midwife has been through many hours of back-rubbing, poop-wiping, cervix-checking, amniotic fluid-splashing labor.

Read this review from Midwifery Today, Summer 2007, newly posted on our Web site:

I think everyone who is going to have a baby should watch a variety of birth films to get an idea of what to expect. I would definitely include this video in that collection. It is an expanded version of an 11-minute video of the birth of Tamaya Okumura Vinaver. Videographed by the baby's grandfather, Georges Vinaver, and narrated by the baby's mother, midwife Naolí Vinaver Lopez, the DVD contains not only the original film, but an additional 10 chapters of footage of the birth, family bonding and placenta.

Read this review from Midwifery Today, Spring 2007, newly posted on our Web site:

This stunningly beautiful film by one of the co-founders of the "Conscious Birth" movement in Russia features 11 natural births—in the water, at home, breech and the birth of twins. Some of the most amazing scenes are of women birthing in the Black Sea.

Advertising Opportunities

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Question of the Week

Q: I am a Lamaze Certified Childbirth Educator and had learned many years ago that pain in childbirth is caused by the muscular contractions of the uterus. The theory: When the uterus contracts, a percentage of oxygen is cut off. When this is accompanied by fear, tension and holding one's breath, there is less oxygen for the uterus. I was told that a hard-working uterus needs all the oxygen it can get to help minimize pain.

However, I recently read a brief article in Fit Pregnancy (Oct/Nov 2008) that states: "Labor pain evidently comes mainly from the cervix, not the uterus, a Swedish researcher says. In non-pregnant women, the uterus contains pain-sensitive fibers, but for reasons unknown, those fibers disappear almost completely during pregnancy. Experts' best guess is that this is an evolutionary adaptation; if the nerve fibers remained, birth would be too painful—as would pregnancy. The findings could lead to more effective labor pain treatment." ~ From S.R. Karolinska Institute

I'd appreciate any input you might have on this subject and, if possible, referral to another possible source.

— Elly Rakowitz, LCCE


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.


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Question of the Week Responses

Q: I have had to have two emergency c-sections after unmedicated labors. I love my obstetrician, but he believes that the American Medical Association (AMA) recommends that physicians NEVER do a VBAC2. He is a wonderful doctor who was as disappointed with my second c-section as I was, however, I would like a second opinion regarding the fact that I "have" to have a planned c-section with my birth that is due some time after the middle of January.

Is it true that the AMA recommends that VBAC2s never be performed? I'm having a hard time finding the AMA guidelines on repeat c-sections and VBACs online.

Does anyone have a recommendation as to how I can find a doctor in my area who is friendly to VBACs where I could go to get a second opinion?

— Windy Greenway

A: I'd like to answer the question about VBAC after two prior cesareans.

I'm the author of www.plus-size-pregnancy.org. I have written extensively about VBA2C on my Web site and have presented at midwifery conferences on this topic as well. On my site, you can read my article (with full references) about the 2004 changes in ACOG's guidelines about VBA2C and a discussion of whether this change is justified in research. http://www.plus-size-pregnancy.org/CSANDVBAC/NewestVBAMCresearch.htm Here is a shortened version, edited to the specifics of this mother's concerns. You have my permission to use this in E-News.

— Pamela Vireday

In July 2004, the American College of Obstetricians and Gynecologists withdrew its previous support for a trial of labor in women with two prior cesareans. They stated:

"For women with two prior cesarean deliveries, only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor."

This change of policy has led to many women being forced into needless repeat cesareans, ignoring the very real risks that further cesarean surgeries pose to mother, baby, and future babies. It also ignores the mother's fundamental right to informed refusal and to make her own health care choices.

ACOG changed their policy based mostly on the results of one very small study (Caughey 1999) that found the risk for uterine rupture (UR) in women with two prior cesareans to be 3.7%. When controlled for confounding factors, the UR risk was nearly five times higher. This is certainly an alarming finding, and one that was heavily publicized among OBs.

However, this study was extremely small, containing only 134 trials of labor (TOLs), leading to the distinct possibility that the risk was inflated due to inadequate numbers. This is a common statistical problem.

Studies of VBAC after Two Cesareans (VBA2C) with much larger data sets have found a much lower risk of uterine rupture. For example, Lin and Raynor (2004) found a rupture rate of 1.0% among 596 TOLs. Macones (2005) found a rupture rate of 1.8% among 1,082 TOLs in 16 hospitals. These studies are far more statistically powerful than one with only 134 participants.

However, even these results include TOLs that have been induced or augmented artificially. The risk of rupture in a *spontaneous* VBA2C labor is probably even lower. In the Lin and Raynor study (2004), the risk of UR in the spontaneous labor VBA2C TOL group was 0.8%. In the Macones study (2005), it is a telling fact that 16 of the 19 ruptures in the VBA2C group occurred in labors that were induced or augmented.

The most recent VBA2C study, Landon (2006), found a rupture rate of 0.9% in a prospective study among 975 TOLs in 19 hospitals, a statistically similar risk for VBA1C and VBA2C mothers.

These studies have brought forward suggestions that ACOG change their guidelines back, but so far this has not occurred and resistance to VBA2C remains widespread. Still, Dr. Macones noted, "It seems reasonable to consider VBAC in those with two prior cesareans with no prior vaginal delivery, especially if they go into labor spontaneously."

Unfortunately, it's not about actual risk these days; it's about *perception* of risk. The political climate for VBACs has changed so strongly now that few doctors are willing to attend VBACs after one cesarean, let alone after two or more. Furthermore, some liability insurance companies refuse to cover doctors who attend VBAC after Multiple Cesareans (VBAMC), tying the hands of some caregivers who are open to VBAMCs. Thus, VBAMC has become a rare thing in many hospitals.

However, there ARE doctors and midwives out there that still support VBAMC. Some areas still have doctors that will support a VBAMC mom, and many homebirth midwives will attend them also. If you are in an area where support of either kind cannot be found, there are traveling midwives who will come to you; other midwives will attend you if you travel to them.

There are risks and benefits to either repeat c-sections or a trial of labor and these must be considered very carefully when making a decision. Neither choice is risk-free. But for those mothers who choose to consider a VBAC, there ARE still options available, and women still ARE having VBACs after Multiple Cesareans.

Join the support forums for ICAN (International Cesarean Awareness Network) at www.ican-online.org. Find out if you have a local chapter nearby and ask them for ideas about care providers in your local area. Even if there is not a local chapter nearby, chances are someone in the area can put you in touch with local resources.

You can read more about VBAMC and the changes in ACOG's guidelines at: http://www.plus-size-pregnancy.org/CSANDVBAC/NewestVBAMCresearch.htm

The site also has stories of women who have had VBACs after 2, 3, 4, and 7 cesareans. You can find them at: http://www.plus-size-pregnancy.org/CSANDVBAC/VBA2Cstories.htm

Don't give up hope. Although it can be difficult to find support for a VBA2C, it IS still possible. I'm a VBA2C mom myself, and I've done it twice now; once in the hospital and once at home. I know many other VBAMC mothers as well. It DOES still happen.

(article excerpt by Pamela Vireday)

References:

  • Caughey, A.B., et al. Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries. American Journal of Obstetrics and Gynecology October 1999;181(4): 872–76.
  • ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Vaginal birth after previous cesarean delivery. #54, July 2004.
  • Lin, C., and D. Raynor. Risk of uterine rupture in labor induction of patients with prior cesarean section: an inner city hospital experience. American Journal of Obstetrics and Gynecology 2004; 190: 1476–78.
  • Macones, G.A., et al. Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology 2005; 192: 1223–29.
  • Landon, M.B., et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstetrics and Gynecology. July 2006; 108(1): 12–20.

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


Think about It

According to http://kidshealth.org this is how the pounds a woman gains during pregnancy may add up:

~ 7.5 pounds: average baby's weight
~7 pounds: extra stored protein, fat, and other nutrients
~4 pounds: extra blood
~4 pounds: other extra body fluids
~2 pounds: breast enlargement
~2 pounds: enlargement of your uterus
~2 pounds: amniotic fluid surrounding your baby
~1.5 pounds:   the placenta


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Feedback

We are expecting a baby at the end of July/early August, but will be in Saudi Arabia at that time. Our first child was a c-section and we're not looking to repeat that experience. Does anyone know of a midwife in Saudi Arabia, or have information on how to find one?

Nicholas Pelletier
nick_pelletier@hotmail.com


Dear All,

About four Jordanian nurses have gone to help Gaza and another 10 will go. The need is immense and we need what ever resources to help the women and children who suffered a lot from this war. Please consider posting or emailing to your friends the following message:

Regardless of your political stance on the current violence raging in Southern Israel and Gaza, I think we can all agree that women and children should be safe. Women and children everywhere deserve to know that they can play, sleep, and deliver their babies in safety. However, these simple truths that we take for granted in our part of the world are currently not a reality for the women and children in Gaza and Southern Israel in the last weeks.

Humanitarian aid organizations all too often forget the needs of women and children in times of war; in spite of the fact that 80% of the world's people displaced due to war are in fact women and children. The critical measures that must be taken to safeguard their lives are simple: clean birth kits, clean water, and immunizations. By providing emergency services and support Circle of Health International (COHI) is improving the health status of women and children by insisting that their needs matter.

This local organization is doing its part to see beyond politics in serving both populations of innocents in this conflict, and they need your help. Join them in changing the conversation about the Mid-East to focus on the positive things coming out of this region, and the women and children who are depending on us to act.

Women and their health care providers in the Mid-East are asking for our help; it is our responsibility to assist them. We hope that you will join us in support of this effort.

To quote a Palestinian midwife, "We (midwives) speak the same language, regardless of our politics: women come first."

Join us TODAY in making a donation to this effort, as time is of the essence.

Thank you for your support, and may a ceasefire be reached soon to end this senseless violence.

Sera Bonds, MPH
Founder, Circle of Health International
28 Homa Umigdal
Be'ersheba, Israel
Israel mobile: 972-52-604-2561
Israel home: 001-512-535-4728
US mobile: 001-512-517-3220
sera@cohintl.org
www.cohintl.org


I recently came across Midwifery Today's Web site and after browsing through a couple of old issues of E-News, I felt it important to contact you regarding the breastfeeding information presented.

As a long-time La Leche League leader and recently accredited IBCLC, I wanted to set the record straight on a response to a question about breastfeeding challenges as the result of large breasts and flat nipples (Issue 3:40). For example, one writer recommended the use of breast shells during pregnancy to draw out flat/inverted nipples; this is not supported by current research.

A recent study found that incorrect breastfeeding advice contributes greatly to premature weaning. I urge you to ensure that the information you publish is accurate.

Ingrid Tilstra, IBCLC, LLLL


Dear Ms. Jan Tritten,

Happy New Year to all Midwifery Today staff to all contributing editors, writers, and keep the most to the mother of Midwifery Today, Jan Tritten. Word is not enough to express how grateful we are learning from different parts of the world the experiences, practices, tradition, cultural beliefs during labor, delivery and postpartum. Information on waterbirth, VBAC, effects of Caesarean section among others. We will continue to subscribe to Midwifery Today magazine and share with fellow midwives as their reference after weighing the usefulness, advantages, applicability including legal implication in their actual practice.

More power to all!

Cecille Banca Santos, PhD
National President, PLGPMI
Philippines


I was intrigued regarding Julia Vance's reply on how the fetal heart should be monitored, in regard to a finding of meconium (E-News Issue 10:24).

She recommended that the fetal heart should be listened to before, during and following a contraction. Since 2001 [the National Institute for Clinical Excellence (NICE), UK, guidelines] have clearly stated that the correct means of monitoring a fetal heart for low risk pregnancies is following a contraction for one minute, not before or during. The purpose of this is to identify late decelerations only.

What I find more concerning is that this old and outdated method of fetal heart monitoring is not only being taught to student midwives but that midwives are not updating themselves with evidence-based practice and therefore not adhering to the [Nursing and Midwifery Council (NMC) (UK)] rules.

Sandra Ebanks, Senior Midwife, SOM, RM, RN


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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