September 17, 1999
Volume 1, Issue 38
Midwifery Today E-News
“Toxemia”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Protein Intake and Toxemia
5) Toxemia: Early Warning Signs
6) Question of the Week Responses
7) Switchboard
8) Classified Advertising
9) Coming E-News Themes

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1) Quote of the Week:

"A grave omission jeopardizes every pregnant woman and every unborn baby: Doctors are not required to ask each mother one simple, potentially lifesaving question: 'What have you been eating?'"

- Gail Sforza Brewer & Tom Brewer, MD

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2) The Art of Midwifery

For a Dry Mouth: Keep a couple of small sponges, such as makeup sponges, in a thermos of ice water to moisten lips between contractions. Keep mouthwash or a toothbrush and toothpaste handy to relieve a sour mouth from long hours of labor or from a bout of vomiting.

- Adrienne B. Lieberman, "Easing Labor Pain," Harvard Common Press 1992

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3) News Flashes

Children of mothers with gestational diabetes are more likely than most to have attention deficit, lower cognitive functions scores and poor motor skills, according to a study reported in Archives of Disease in Childhood: Fetal and Neontal Edition; 81: 1.

The neurological and psychological functions of 32 children born to women with well controlled gestational diabetes were compared with those of 57 controls. There were no differences between them in head circumference and height but the children born to mothers with diabetes were heavier. They were also likely to have lower IQs and did not score as well as the control group when their motor functions were measured. Authors of the study point out that these deficits are more pronounced in younger children and that their effects diminish as the children get older.

- Nursing Times, June 30, 1999

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4) Protein Intake and Toxemia

By measuring the serum osmotic pressure of 65 pregnant women, all at seven months gestation, Strauss [Am J Med Sci 190, 1935] demonstrated that the pressure was directly related to protein intake. Serum osmotic pressure, serum albumin, and dietary protein were highest among the 35 non-toxemic women in the study, second highest among the 20 women who had non-convulsive toxemia, and lowest among the 10 women who had eclampsia.

At the eighth month of gestation, 15 of the 20 non-convulsive toxemic women were placed on a diet which consisted of 260 grams of protein and were given vitamin injections; the other 5 were placed on an isocaloric diet which provided 20 grams of protein. The osmotic pressure among the women on the high protein diet increased by an average of 7%; that of the latter group declined 9%. The average daily protein intake of the 20 women was less than 50 grams.

After three weeks on the high protein diet, the symptoms of toxemia (including a reduction in the blood pressure of all 15 women) subsided. There was not one case of fetal mortality. In contrast, only two of the five toxemic women who had been placed on a low protein diet showed a reduction in blood pressure.

Ross [R Ross, S Med J, 1935], who discovered that the incidence of eclampsia was extremely high in areas where beriberi, pellagra, and other diseases of nutritional deficiencies were found, stated that "we have been struck with the number of patients in eclampsia who are in a very poor state of nutrition ...."

Hypovolemia (and usually hypoalbuminemia) precedes the onset of metabolic toxemia of late pregnancy. (T. Brewer, Metabolic Toxemia of Late Pregnancy, 1966; M. Bletka, Am J Ob Gyn 106, 1970) Hypovolemia, which is frequently iatrogenic (when low salt, low calorie diets are recommended), is caused by a deficiency of protein calories, sodium, and/or protein-metabolizing vitamins. Bletka, ibid) Also, hepatic dysfunction usually precedes the clinical symptoms of metabolic toxemia of late pregnancy. Hypoalbuminemia and hypovolemia impair the liver's ability to synthesize sufficient albumin and thereby maintain its detoxification enzymatic functions. (T. Brewer, Am J Ob Gyn 84, 1962) The fact that severe preeclampsia and eclampsia frequently result in specific hepatic ischemic or periportal lesions or infarction further indicates that maternal malnutrition leads to hepatic dysfunction. (H. Sheehan & J. Lynch, World Med J 21, 1974)

In the 1930s Dodge and Frost eradicated eclampsia by instituting a high protein diet. Toxemic women who were placed on a daily diet consisting of six to eight eggs, one to two quarts of milk, meat and legumes improved dramatically. The authors discovered that the average serum albumin level among toxemic women was 21% lower than that of those who had been on a high protein diet and who didn't have toxemia.

Tompkins and Wiehl also lowered the incidence of toxemia through dietary supplementation. (ref unavailable) They stated "the so-called 'toxemias of pregnancy' are in reality nutritional deficiency states."

- Tom Brewer MD & Jay Hodin in 21st Obstetrics Now!, NAPSAC 1977

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5) Toxemia: Early Warning Signs

The earliest clinical sign of preeclampsia is often a stable or rising hemoglobin/hematocrit (and possibly red blood cell count) which occurs as the blood volume begins to contract. Early on, this will be accompanied by a minor degree of small for dates fetal growth. At this point, usually between 22 to 29 weeks, the mother may still feel fairly well. This is one good reason to begin careful abdominal palpation from the onset of care and to become good at estimating early fetal growth with your hands. The liver is not severely compromised at this point, but it is inadequately supplied with nutrients. If you do a liver profile now, liver enzymes will likely be normal. After a few weeks, subclinical liver compromise will often be evident in a liver profile test, reflected in either rising enzymes levels or falling blood protein levels or both. Kidney function tests will not become abnormal until other lab work has been abnormal for a while, since kidney compromise usually commences after the blood volume contraction is well under way. If you have any doubt, always run a liver profile test and check the hemoglobin. If problems are identified at this stage and diligent attention is paid to increasing protein and other nutrients, the hemoglobin will start to drop rapidly and fetal growth will improve, reflecting that the blood volume is beginning to expand. If you do not catch it at this point, symptoms will worsen, but may not necessarily include high blood pressure or proteinuria. You must be alert, keeping in mind the underlying physiology of toxemia, not just the secondary symptom picture.

If you feel some degree of true toxemia exists, the most important thing is to provide the system with enough fluid and nutrients to try to make up for lost time. Focus on protein, nutrient rich calories, fluids (drink to a healthy thirst, but don't overdo it), and adequate salt. Have the mother eat a high protein item every waking hour. Initially recommend an increase to 150 to 200 grams of protein daily (250 to 350 grams or more with multiple gestations), with 3,000 to 4,000 calories and 500 mg of choline daily. Increase calcium and magnesium if indicated. What you actually recommend will depend upon lab results, whether it is a multiple gestation, and the symptom picture when you detect the problem; the worse the picture, the more protein and calories you should recommend. You want to give the liver enough raw materials to make up for a longstanding lack as rapidly as possible. An inadequate increase may allow the liver to maintain things so that symptoms do not worsen, but not offer sufficient amino acids to turn the situation around. If the woman has a history of liver disorders, recommend less protein (120-150 grams for a single fetus); her liver may be overwhelmed otherwise, and monitor her lab work closely for changes.

Recheck lab tests 4 to 7 days later. Often, women feel an immediate and profoundly increased sense of well being. If the second lab report shows some improvement, keep up the high protein intake until all values are where they should be for her gestation. Recheck again 4 to 6 days later, if the third lab result shows no change, increase the protein. Once liver enzymes and blood proteins have normalized, the hemoglobin has dropped appropriately, the fetus is an appropriate size for dates and secondary symptoms have subsided, the woman can cut back to 100 grams of protein daily (150 grams with multiples).

- Anne Frye workshop, from Pre-eclampsia Society Newsletter, No. 36, 1998

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6) Question of the Week Responses

Q: I have encouraged my clients to have birth plans for many years. I urge them to discuss using a heparin lock as an alternative compromise to routine IV. Very few moms report back that they had a lock--most all had IV. I discussed this with a CNM and she said she uses IV routinely, mostly for the "convenience" of the nurses because, she states, "heparin locks frequently get blocked."

Should I continue suggesting this alternative to "routine IV" to my clients (most of whom get IVs as a sort of "insurance policy" for the staff's comfort)?

- J.Batacan

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I too have recommended clients request a heplock instead of the whole IV. I am beginning to believe, however, that they should refuse both altogether until proven necessary .... I believe the "risk" of needing an IV is small enough in properly prepared and well supported moms that any pre-IV "just in case" is unnecessary, and the greater mobility of mom is much more important. If a nurse can't do a quick IV if it becomes necessary, then I'm not sure I'd want her treating me or any of my clients.

- Jen Taylor
Doula and aspiring CNM

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We were told in midwifery school that the only times a woman absolutely needed an IV was when getting an epidural, when having a cesarean section or when dehydrated and unable to take anything by mouth. In other situations like trial of labor after previous cesarean, antenatal history of anemia, or other medical conditions, a heplock can be used. It gives access to a vein without the burden of the drip and pole (if a woman wants to walk). A well placed heplock like a well placed IV should not block off. Is that CNM starting IV on every laboring woman? Who is she there to serve, the nurses or the laboring women? It's like the time when the RN told me her lady wanted an epidural; when I went to talk to the woman, all she wanted was an aspirin. The nurse was angry because an epidural frees her up. She doesn't have to spend time with labor support.

We must always remember who we are serving and do what's best for them and their health. This doesn't include unnecessary interventions.

- Harriet Kaufman

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A running IV tends to encourage laboring moms to change positions less, and this is more harmful to them than the small risk the lock may plug and need to be restarted. As always, the bottom line is assessing if the IV access is justified in the first place!

- Sharon Breidt RNC, BSN

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I am a paramedic and in the INTs I start, we use plain saline. Most EDs here are using INTs exclusively because IVs waste tubing, saline and other products. This saves money for the hospital. Usually money talks. I would suggest to keep offering this as an alternative. I see it as a trend that maybe has not reached the L&D floor.

- Melissa

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Why are you suggesting they need an IV line at all? Routine IV access is not something I would recommend to a woman who is having a baby. Perhaps they would be better off putting on their birth plans that they decline to have either.

- Andrea Quanchi
Australia

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7) Switchboard

I am currently writing a paper for a nursing class on nutrition in pregnancy. Specifically, I would like to compare the Brewer diet with other research that has been done on nutrition in pregnancy and prevention of toxemia. Does anyone have any suggestions of studies they have found particularly useful?

- Chava Weiman chavamom@hotmail.com

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I recently heard that a state passed a law preventing women from publicly breastfeeding unless they have a card permitting them to do so. What state is this and who can we contact to boycott this absurdity? I thought we were past this insanity!

- Amy Jones
thebirthsource@hotmail.com

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Can you help? A bill has been introduced to help midwives get reimbursed at an equitable rate. They presently receive 65% as much reimbursement as MDs. To take into account the difference in malpractice premiums, the ACNM believes 95% would be a reasonable fee. Because private industry follows Medicare, this bill has a far reaching impact. This is a first step in helping midwives be recognized and reimbursed as the primary caregivers they are.

1) Send letters, faxes or emails to your legislators *now*! Ask your consulting physician, colleagues and consumers, and everyone you know to write letters of support.
2) Contact your legislator's district office *now* to schedule an office visit or phone conference with his or her staff, or if possible, with the legislator. When you meet, ask your senator/representative (or staff) to sponsor the bill.

Visit the ACNM website: www.midwife.org
*Don't delay! We need every midwife and supporter of midwifery to take action now!*
Please send copies of what you write to Alyson Reed at AReed@acnm.org. ACNM lobbyists will follow up with the congressman's staff by saying, "We know your constituent Mary Doe wrote you about this."

- D.B.

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In response to Susan Vaughen's concerns about medical 'help' and intervention vs. natural or non-pharmaceutical assistance in birth [Issue 36]: I am a midwife, childbirth educator, and doula trainer. I have found time and time again that a woman giving birth needs loving support, not drugs and interventions, (in most case.). Her belief in her ability to give birth is important as well. Emotions and past or present psychological issues play a large role in birth outcomes. Birth is far from being just a physical event of contractions and pushing a baby out.

If caregivers, women and their support system were informed and educated about this reality, there would be far less drug and surgical intervention, and more babies would be welcomed into this world with gentleness and less fear. The result--less violence and aggression for the next 7 generations.

"Heal a woman, heal a nation."

- Rhonda Howard 7generation@abacusnet.net

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I suffered with nausea during my pregnancies and for years after pregnancies two and three. My internist finally diagnosed my gall bladder as the source. He said my having been pregnant was the biggest risk factor. Instead of having my gall bladder removed, I changed my diet. I reduced fat and protein, especially eliminating eggs. I added apples. I had to be very strict at first. Years later, I can eat more normally without nausea. I know some who have had the gall bladder out and it did not correct the nausea. Digestive enzymes and extracts were a help to me, but I don't know about their safety during pregnancy. I wish Kelli [Issue 36] improved health.

- Pam Easterday

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One request I have is that contributors to E-News thoroughly cite their sources of information, especially when they refer to studies and publications. If we are to move forward as a profession, we need to move beyond the axiom "studies have shown that..." and support our care with concrete, well reviewed information.

- Kari Michalski

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I just thought of something about marijuana [see Issue 37]: Most commonly it is smoked, as the psychoactive elements need to be heated before they can be released. Eating marijuana (leaves, stems, seeds) does nothing, unless it has been cooked first. So a baby ingesting THC may not notice any effects beyond taste if the mother has been smoking. This might explain the babies developing normally when mom has been smoking.

- Nikki Lee

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I thought this was inspiring:

Two friends met on the beach. "Good evening, friend. What are you doing?" "I'm throwing these starfish back in the ocean. If I don't, they'll die here." "There must be thousands of starfish on this beach. You can't possibly get them all. You can't possibly make a difference." She smiled, picked up yet another starfish and threw it into the sea. "It made a difference to that one!"

Isn't that what we are all trying to do, make a difference one birth at a time?

- Keri Redding

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A free international gathering of midwives will be on 2 October at the office of the KNOV (Dutch Midwives Association) from 10 am-4 pm. For the agenda, see Issue 37 of E-News. For more information: Sabine Schmitz, Midwife Foreign Office, KNOV, 31.20.6120024.

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

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8) Classified Advertising

Doula Training: Bring emotional, informational and comfort support to birthing families. Train to be a doula. October 8 and 9, New Orleans, Louisiana or October 22 and 23, West Union, Iowa. Contact Debbie, 1-800-648-3662 or theyoungs@trxinc.com.

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9) 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:

- Breastfeeding (Sept. 24)
- Omnium Gatherum (Oct. 1)
- Vitamin K (Oct. 8)
- Twin Birth (Oct. 15)

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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