August 6, 1999
Volume 1, Issue 32
Midwifery Today E-News
“Premature Labor”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Premature Labor
5) Question of the Week
6) Question of the Week Responses
7) Switchboard
8) Coming E-News Themes

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1) Quote of the Week:

"It's a funny thing about life; if you refuse to accept anything but the best, you very often get it."

- Somerset Maugham

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2) The Art of Midwifery

Reframing is a good tool to help a mom through labor. When she says, "The contractions are so strong I can't stand it anymore," help her see it in a different way: "Feel how wonderfully powerful your body is!" or "You're doing just what you need to do." When mom asks plaintively, "Why is it grinding into my back?" put the sensation in a different perspective by saying, "How exciting to feel your baby working with you to move down and out!" or "Let's work to get baby's head down past that pressure point."

- Judy Edmunds, Wisdom of the Midwives: Tricks of the Trade Volume Two, a
Midwivery Today book

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At Midwifery Today, we have lots of tricks up our sleeves! Purchase our two volumes of Tricks of the Trade and you'll see what we mean: Save $5 when you purchase both Tricks of The Trade. Volume I and Volume II. Only $40 plus shipping! Call today to order: 800-743-0974. Please mention Code 940.

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3) News Flashes

A report from Italy describes a case where breastfed babies were made ill because their mothers were drinking large quantities of an herbal tea that was supposed to increase milk supply [Acta Paediatrica, 1994 vol. 83]. The tea contained licorice, fennel, anise and galega officinalis. It is known that both anise and fennel can get into breastmilk and they contain essential oils that can cause neurological symptoms. Two babies aged 15 and 20 days had been vomiting, became lethargic, had weak cries and poor sucking. One of the mothers also said she was drowsy and weak. Breastfeeding and herbal teas were stopped and babies and the mother rapidly improved. When breastmilk was restarted after two days, both babies were fine.

- AIMS Journal, 7(1), Spring 1995

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4) Premature Labor

In identifying the woman at risk for prematurity, the following factors are very important:

  1. Lower economic status. In many cases these women do not receive good prenatal care or proper nutrition.
  2. Poor nutrition. In order to have an adequate weight gain, pregnant women must consider both the quantity and quality of foods eaten. The mother should gain at least 10 pounds by the 20th week. A woman who has suffered from extreme morning sickness must be monitored carefully. I am convinced that some babies come out early because they are hungry!
  3. Previous preterm labors or births. Try to establish the reason for previous outcomes.
  4. Multiple gestations. I insist, however, that twins can come to term when the mother is "super-nourished."
  5. Smoking, alcohol or drug abuse.
  6. Urinary tract infections. It is not unusual for a woman to feel like she is in labor when she has a UTI. When a woman calls with symptoms of early labor, always get a clean catch urine specimen for laboratory diagnosis. If there is a high bacterial count, she should be treated with antibiotics as an infection can cause premature labor.
  7. Anemia or low platelet count. A low hemoglobin may contribute to placental insufficiency and preterm labor. Take in consideration the woman's general health and her country of origin. Remember that women of Mediterranean descent generally have lower hemoglobins. A woman who has always had a hemoglobin of 10 and feels well is not at risk. A more significant factor is when a normal hemoglobin of 14 drops considerably during pregnancy, and the mother feels weak and tired, and so on.
  8. Maternal trauma or extreme stress.
  9. Premature rupture of membranes. Because bacteria can be a culprit in initiating PROM, it is important that any suspicious vaginal discharge be investigated.
  10. Maternal illness, particularly with high fever.
  11. Uterine anomalies or incompetent cervix. Find out if your client had explorations of or surgeries upon the cervix or uterus. Was a previous labor "forced" through manual or oxytoxic methods? Is this woman a DES daughter?
  12. A history of "late" second trimester abortions or any abdominal surgery during pregnancy. The surgery may not be the problem as much as the anesthesia involved.

- Valerie El Halta, "Too Small, Too Soon," Midwifery Today Issue 36

====

A few other factors can come into play during pregnancy that put a woman at risk for premature delivery. The most common are:

  1. Placental abruption
  2. Placenta previa
  3. Abnormal amount of amniotic fluid. Too much amniotic fluid puts extra pressure on the uterus and may cause premature labor. This happens more frequently in multiple pregnancies and in those complicated by diabetes, or when there is an abnormality in the fetus. Too little amniotic fluid can inhibit normal fetal growth.
  4. Uterine fibroids: commonly found in women in their 30s or 40s. They can cause placental abruption, intrauterine growth retardation, and premature birth.
  5. Toxemia/preeclampsia: This can cause a reduction in the amount of blood flow through the placenta, which slows down the delivery of vital nutrients.
  6. Two or more abortions.
  7. A history of kidney disease.
  8. Pregnancy before age 16 or after age 34. Many young girls do not get proper, ongoing prenatal care. Their growing bodies may compete with the fetus for necessary nutrients. Older women may deliver prematurely because they are more prone to diseases that can negatively affect a pregnancy such as hypertension, diabetes, and heart and kidney disease.

- Frank P. Manginello, MD & Theresa f. DiGeronimo, MEd, Your Premature baby, John Wiley & Sons, 1991

====

Depending upon what the diet is lacking, and length of deficiency, labor may begin before or more frequently just after, the point where blood volume should have peaked. A lack of adequate blood volume is why hydration with oral or IV fluids is a temporary stop-gap measure which, in some cases, forestalls the onset of labor. Of course, a well nourished woman may temporarily become dehydrated and in such cases "catching up" on her hydration may calm the uterus down. However, if a contracted blood volume is the real reason the body can no longer support the pregnancy, hydration will offer no permanent solution. Neither will any drug. Bed rest, while widely recommended for preterm labor, is described as ineffective by ACOG. Unless a woman has a cervical anomaly which causes it to open under pressure, bed rest only serves to spare calories by reducing a woman's activity level. This is backward thinking. Instead, salt, calorie and protein intake must be increased to ensure the mother is taking in what she needs for her individual stress and activity levels.

- Anne Frye, "The Role of Nutrition in {Preterm Labor," Midwifery Today Issue 36

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Learn more from these Midwifery Today issues:
No. 36, Prematurity (Regular price, $7.00)
No. 24, Caring for the Unborn (Regular price: $7.00)
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Nutrition for Keeping Birth Normal: Anne Frye (Regular price $16.00)
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5) Question of the Week

In regards to treatment of genital herpes during pregnancy, are there any herbs or other preparations that you know of to prevent an active infection "flare-up?" A woman in one of my childbirth classes desperately wants to have a vaginal birth. I would appreciate any information that could help her.

- Dwindover

Send your responses or submit a Question of the Week to mtensubmit@midwiferytoday.com

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6) Question of the Week Responses

Q: What have midwives used successfully to slow down/halt preterm labor symptoms, i.e. lots of early contractions in clients as early as 26 weeks? I'm interested in alternatives to tributaline. Bed rest/taking it easy is a given. Has anyone had good results using progesterone creme (external application)? Homeopathy? Other? I myself have used counseling and teaching self-hypnosis techniques occasionally for stress reduction.

- Constance Miles, LM, RN

I have had excellent results with the following: 1500 mg. calcium + 750 mg. magnesium daily. Also include 6 tablets of alfalfa daily and nettles. If contractions come on and are more than normal Braxton Hicks, have the woman take black haw tincture--usually 10-20 drops, one dose; if she is still contracting in 20-30 minutes, repeat the dosage. Combine this with bed rest. She also needs to drink plenty of water daily (more than she wants). Of course, she should be checked by a doctor if the herb doesn't stop contractions.

- Linda Myers, CPM

====

I have had pretty good luck using vistaril, up to 100 mg orally every 4-6 hours. Opposed to terbutaline, which tends to make the heart race and makes the woman feel anxious, vistaril relaxes *everything* and most women go to sleep (as they should anyway!). I also rule out infections and hydrate with at least 3 quarts/day (unless it's hot, and then I suggest more), but I assume other midwives do these things anyway whether there are preterm contractions or not. I don't call it preterm labor unless the cervix is changing. If it is, I have terrible luck stopping it, even with mag.

- Cynthia Flynn, CNM, PhD
Kennewick, WA

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I use several different methods, depending on the woman. But I have had good luck with all of these: Benadryl, cell salt (mag phos), rescue remedy, valerian, vodka, checking for urinary infection (get it treated), and a moist heating pad on mom's lower abdomen, right above her pubic hair. Also if baby is breech or in another malposition that is stimulating the cervix, I give pulsatilla to get the baby moved. I also use bed rest with baby's head off the cervix. Calcium with magnesium also may work. Humor and prayer can work well too.

- S.H.

====

A doctor in the town where I work (I am an RN, not CNM) advises his patients to drink one or two glasses of red wine if they are having contractions. I do not know the efficacy of this, but I do know we don't get very many of his patients coming in in preterm labor.

- M. Farney, RN

====

We had women drink a small glass of red wine for prodromal labor and it worked well. We also increased the protein intake to 100 grams a day in moms threatening either preeclampsia or preterm labor. We never saw either.

- Jan Tritten

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It's very important to examine existing research as well as consider our subjective perceptions--we will find that the definition of "lots of contractions" doesn't exist. From the earliest weeks of pregnancy, the uterus contracts. Only after the gestation has obtained some indeterminate size; the placental production of hormones has reached a certain blood level; and the gravida herself notices a change in perceived uterine activity does the idea of questionable excessive number of contractions occur. Undoubtedly the norm varies widely.

The major concern is to identify and treat "preterm labor" in order to prevent "preterm delivery." Preterm labor must be understood to consist of cervical changes, i.e. dilitation and effacement in excess of what would be normal for a given gestation. Only preterm delivery is a definite diagnosis, generally considered labor (with effacement and dilitation) leading to delivery of an infant before the 37th week of pregnancy.

...Even more frustrating is that a number of pregnant women will experience "silent" preterm labor, suddenly experiencing advanced labor without any generally acknowledged warning signs such as cramping, bleeding, ROM, backache, or even increased number of contractions Moreover, it is impossible to determine which treatments actually help prevent preterm delivery vs. those that simply appear to decrease the number of contractions.

...Most providers admit that they substantially over-treat "preterm labor." Such chemical agents as terbutaline, magnesium sulfate, and nifedipine appear to suppress uterine contractions by various pathways. But do they truly prevent preterm delivery? This is debatable and very difficult to analyze with good controlled, blind-study research. Are we to risk *not* treating possible preterm labor? How then do we find good controls?

Perhaps the only truly well researched standard of treatment is provision of steroids to the pregnant woman with actual advancing cervical changes. This simple treatment speeds fetal lung surfactant production and can help prevent respiratory distress syndrome in the preterm infant.

My advice would be that a midwife "get to know" and document fully (length in cm., dilitation of os and consistency/firmness) her client's cervix so that actual changes can be readily noted by any provider in future exams. Then, when concern arises regarding the number and strength of contractions, serial cerivical exams--performed very gently--can help determine whether the patient is truly at risk for preterm labor/delivery. Patients (or a chosen friend or family member) can even be taught how to examine the cervix by themselves at home.

To conclude, in a normal singleton pregnancy for a woman with no known risk factors for preterm delivery, the client should receive education regarding all potential pregnancy warning signs, including those specific to preterm delivery, at the most appropriate time in gestation. Should she seek advice regarding any signs of preterm labor--including "lots of contractions"--she should be thoroughly assessed for cervical changes.

Let's get some good, hard prospective studies going so we will have evidence and true justification for any treatment instituted rather than just assuming that we should blindly follow protocols based on fear, not research. And please, let's consider what we are doing to women's lives, families, careers and future health when we blindly advise "bed rest with bathroom privileges." We are asking of them an overwhelming sacrifice with which few can truly comply.

- Patti Warren, CNM

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I have had very good luck with the herb vibernum opulus (cramp bark). I use a dropperful of tincture in water as needed (up to every five minutes) to stop contractions (in addition to rest and fluids, of course). I also used the tincture--3 times daily for the first trimester--to prevent miscarriage.

- Margy Porter

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7) Switchboard

I am a breastfeeding counselor. I have recently been asked about the risks of continuing to nurse through a pregnancy when the client had a history of preterm labor (requiring a pump and recommendation to stop sexual intercourse). While researching this issue, I was unable to find any concrete evidence of the risks. Most references say that nursing through a pregnancy is not an issue unless one has a history of preterm labor, but no research appears to have been done. Any opinions?

- Claire Eden

====

The Canadian Childbirth Association (CCA) is seeking to make labor induction a procedure requiring written informed consent by women in the Canadian province of Alberta. Gail J. Dahl, executive director of the CCA, has until Sept. 1 to make as strong a case as possible before presenting her research to the regional medical and health authorities. Says Gail, "I believe I am, after a three year search, close to the actual decision makers who can make an about-face on this. This will be quite a feat, but it is something that must be done to ensure safer childbirth for all women." If the CCA is successful, a critical precedent would be set: written informed consent for labor induction as well as for many other common procedures in childbirth could become a universal reality. Please contact Gail with any information regarding induction's dangers and/or traumas that would further this most worthy pursuit.
gaildahl@home.com

====

I am currently taking Prozac for severe depression. I am also 14 weeks pregnant. Everything I read assures me that Prozac is "safe enough" for pregnancy but not for breastfeeding. I am devastated at the thought of not breastfeeding. I have heard that Zoloft is a safer drug to take while breastfeeding. Does anyone have information that might help me?

- Dara

====

Share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com

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8) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- Premature labor (Aug. 6)
- Switchboard overflow (Aug. 13)
- International midwifery (Aug. 20)
- Postpartum hemorrhage (Aug. 27)
- Herpes (Sept. 3)

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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