October 8, 1999
Volume 1, Issue 41
Midwifery Today E-News
“Vitamin K”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Question of the Quarter: Midwifery Today magazine
5) Vitamin K Deficiency
6) Vitamin K in Colostrum and Breastmilk
7) Risk Factors
8) What Did Nature Intend?
9) Switchboard
10) Classified Advertising
11) Coming E-News Themes

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Quote of the Week:

"The giving of love is an education in itself."

- Eleanor Roosevelt

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1) The Art of Midwifery

The midwife's attitudes about pain and the messages she gives to women in pregnancy and during labor make a difference in the woman's experience. Consider discussing pain with your clients as opposed to pain relief. This can bee seen as one aspect of the skill of keeping birth normal.

- Nicky Leap, British Journal of Midwifery, May 1997

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3) News Flashes

A prospective survey of the prevalence of stress incontinence during pregnancy and following childbirth recruited 1,008 women from an antenatal clinic in northwest England. Fifty-nine percent of the women reported stress incontinence during pregnancy and 31% following delivery. Ten percent had daily episodes of incontinence during their pregnancy, and 2% of all women reported daily incontinence following delivery. Stress incontinence was found to be associated with parity, with women of higher parity being more likely to experience the condition. No difference in the prevalence of stress incontinence was found between women who had a normal delivery and those having an instrumental delivery. A cesarean section was found to be associated with a lower incidence compared with a normal spontaneous delivery.

- Midwifery, Vol. 15 No. 2, June 1999

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4) Question of the Quarter for Midwifery Today Winter 1999 Issue No. 52:

What alternative therapies do you find most useful in your practice?

Send your responses to mtensubmit@midwiferytoday.com You may submit up to 425 words.

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5) Vitamin K Deficiency

Symptoms of vitamin K (VK) deficiency include: melena (black tarry stools sometimes difficult to differentiate from meconium, but can be tested by placing the stool in water to see if the water turns pink. Meconium will not cause the water to turn pink.), cephalohematoma, vomiting of blood, prolonged jaundice, failure to thrive and warning bleeds such as bleeding from the umbilical site, nasal and oral bleeding, and prolonged bleeding at puncture sites.

Diagnosis of VK deficiency is made by drawing a Prothrombin time (PT), fibrinogen, and platelet count. A prolonged PT together with normal fibrinogen and platelet levels is indicative of VK deficiency. Laboratory values of plasma or urinary VK levels can be drawn in addition to PT and fibrinogen studies. Administration of 1.0 mg of VK should produce a correction of the prolonged PT, and bleeding. VK is rapidly absorbed and begins to work within 30 minutes of administration. VK can be given any time after birth, especially if prolonged or abnormal bleeding is noted in the newborn. In addition, the newborn may appear quite healthy for several days or weeks, and the only sign will be what the practitioner may consider prolonged or inconsequential bleeding around the umbilical stump. Note: Newborns do not bleed easily!

Clients must understand why vitamin K is suggested, and that one injection is not necessarily adequate to prevent a later onset of this disorder in exclusively breastfed infants. They must be told signs and symptoms of VK deficiency bleeding (VKDB) that they might notice during the course of normal caretaking. VKDB can be fatal, or produce developmental and cognitive delays in the infant. Its rarity may not allow the practitioner ample experience to recognize it. In addition, a good teaching tool would include potential concerns for infants receiving VK injections. Davis's Drug Guide for Nurses states the general side effects of phytonadione ( vitamin K1) one milligram include jaundice, hemolytic anemia, flushing, rash urticaria, or a mild local reaction at the injection site. In addition any foreign entity given by injection can cause an anaphylactic reaction. While this is extremely rare, if that were to happen in the home, it would be a devastating event. One half to one milligram of vitamin K1 is the standard intramuscular dosage for a newborn, whereas 2 mg is the standard oral dosage. Phytonadione is not absorbed from the gastro-intestinal tract unless there are some bile salts present.

In addition to a clear, informative written teaching tool, have parents sign a statement saying they want VK to be administered or that they decline VK regardless how the medication is provided (by you or by the parent). If a parent is not truly informed, or their practitioner refuses on the grounds that they are "aiding and abetting homebirth," that may place the midwife in legal limbo for not providing a standard routine medication, not to mention the heartache of having a baby die or become developmentally disabled over a disease that can be prevented nutritionally. -Sandra Stine, brief excerpt from an article slated to be published in Issue 53 of Midwifery Today, due out in March 2000.

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6) Vitamin K in Colostrum and Breastmilk

Researchers set out to assess the average total daily amount of vitamin K in colostrum and breastmilk of mothers who exclusively breastfed their infants. The study also sought to determine how much the mother's daily consumption of foods containing vitamin K (VK) affected the VK content of her colostrum or milk.

The women participating in the study were healthy nonsmoking mothers between twenty and thirty-five years of age who were not taking birth control pills, antibiotics, other medications or megadoses of vitamins. They were divided into four groups of fifteen participants each, determined by number of days postpartum. Colostrum was collected at between thirty and eighty-one hours postpartum, breastmilk was collected at one month, three months and six months postpartum. Only mothers who exclusively breastfed their infants at least five times a day were included in the study. Although the concentration of VK was found to be slightly higher in colostrum than mature milk, the authors point out that the total daily intake of VK in infants increases over time due to the fact that milk volume increases substantially over time. There did not appear to be any pattern between the number of hours postpartum that a colostrum sample was collected and the concentration of VK.

The VK content of many foods has not been adequately studied to accurately determine the maternal intake. Despite this, the authors went on to say that they could find no correlation between dietary VK intake and the VK level in breastmilk or colostrum. Dietary fat is essential to the absorption of VK, and VK concentrations in breastmilk tended to be greater in women who had a higher fat content in their diet.

A further conclusion of the study points out that VK appears to be found in the fatty portion of breastmilk. Since the fat content of breastmilk increases with the length of time spent at the breast per feeding, I would theorize that the practice of limiting the number of minutes at the breast per feeding could be decreasing the amount of vitamin K that exclusively breastfed newborns receive. -Vitamin K in colostrum and mature human milk over the lactation period--a cross-sectional study American Journal of Clinical Nutrition, 1991, 53:730-35, abstracted by Althea Seaver.

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7) Risk Factors

Risk factors for late hemorrhagic disease of the newborn (LHDN): When the infants with idiopathic LHDN are assessed they often are diagnosed with liver disorders that reduce the production of bile salts. These liver disorders are mild and asymptomatic and usually resolve without incident, except in cases where the infants have not received IM vitamin K (VK) prophylaxis. Secondary LHDN is most commonly associated with diseases that affect the concentration of bile salts in the small intestine such as cystic fibrosis, alpha-I antitrypsin deficiency, and bile duct atresia. Studies of VK absorption after oral VK prophylaxis have highlighted the large variation in absorption between infants, pointing to individual differences in VK absorption via the intestines.

- Freda Seddon, excerpted from letter to the editor, Midwifery Today Issue 42

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LDHN mainly affects breastfed babies who received no vitamin K prophylaxis or who have a gastrointestinal disorder associated with fat malabsorption or liver disease. Risk factors include prematurity, low birth weight, birth trauma (e.g. shoulder dystocia, face presentation, vacuum extraction), perinatal asphyxia, and disorders that interfere with the baby's absorption of fat.

- Jennifer Enoch, Midwifery Today Issue 40

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8) What Did Nature Intend?

Studies have shown that cord blood lacks detectable vitamin K (VK). In addition, breastmilk contains only a small amount. Administration of 1 mg IV VK to laboring women produces a very low plasma cord blood level. Is nature insulating the newborn from high levels of vitamin K for reasons yet to be discovered?

Science has yet to answer why the newborn does not produce adult levels of clotting factors, why s/he usually receives low levels of maternal VK both before and after birth, and why the normal newborn may produce a clotting inhibitor. (Some symptomatic babies may suffer from high levels of the heparin-like inhibitor. Unfortunately, no differential diagnosis is done to determine why an otherwise apparently normal baby is having clotting difficulties since all babies are treated prophylcatically.) What does extra VK do to the vast majority of newborns who do not have a deficiency? The fact that too much VK may cause hemolysis evokes questions regarding VK's stress on the liver and whether the production of certain clotting factors is low at birth to facilitate the immature liver's metabolism of bilirubin.

- Anne Frye, Understanding Diagnostic Tests in the Childbearing Year, Labrys
Press 1997

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Order Anne Frye's Understanding Diagnostic Tests in the Childbearing Year from Midwifery Today. Just $43 plus shipping. E-mail inquiries@midwiferytoday.com for information on how to order. Please mention code 940.

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Question of the Week responses

Q: What are others doing when a woman has a shallow secondary degree tear, haemostasis has occurred naturally, and the wound edges sit nicely together even with the woman's legs apart?

- Sandi

We currently (common practise for over three years) leave these wounds to heal naturally. Unfortunately we do not see these women after discharge but in the intervening time prior to discharge from hospital (5-7 days) there have been very small numbers of women who develop signs of infection. No figures on this but it could be a good research project.

- Alesa Koziol
Melbourne, Australia

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I leave it alone. Keep perineum clean. It will heal better than if I interfered.

- SW

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A second degree tear by definition involves the superficial transverse perineal muscles--it needs repair.

- Phil Watters

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Leave it! I am in strong favor of not suturing 1st and 2nd degree tears! In Scotland where I trained, many midwives were adopting the practice of not suturing 1st and 2nd degree tears that approximate nicely and aren't actively bleeding. If it is questionable, leave a pad on, legs together for awhile, then take a look. It is often remarkable how quickly a tear goes from looking pretty bad to "leavable." When you decide to leave it (and, of course, discuss the options with the mother--I bet she'll opt for no suturing), give her some advice (e.g. Arnica for swelling and bruising, frequent cleansing, lavender/tea tree baths), explain that it will probably take a full six weeks to come together completely, then don't examine *every* day as long she is comfortable, but keep an eye on it (or teach your client how to).

My baby was born at home after one of those marathon labors. I had a 2nd degree tear and it would have been a terrible thing to endure getting sutured after all that! Instead, my midwife left it, I got to enjoy my first minutes with my daughter, and I healed beautifully!

- Amy Darling

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9) Switchboard

In response to Jeanne Batacan [Issue 39]: As a new mom and a consumer of Emergen C powdered drink mix, I highly suggest this in place of Gatorade. Emergen C is a natural electrolyte booster high in Vitamin C. Unlike Gatorade, there are no chemicals in the product. I used several packets during my 24 hour labor and it helped me immensely. It helps with the shakes and weakness that kick in when you are tired and gives an extra boost. I have also used it previously with my clients for shock and to re-settle into their bodies after an intense bodywork session.

- Sheila Snow

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Annemieke, Eveline and Frederika, thanks for offering your input on midwifery, with a Dutch point of view [Issue 39]. I am a Birth Works childbirth educator; one of the things I talk about in classes is doula support. Is there an equivalent in the Netherlands? I know you have the postpartum helper (kraamhulp), but what during birth?
Karen van Loon

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Although Ina May Gaskin writes in "Spiritual Midwifery" that "The results we have had with the 1723 pregnancies under our care tend to support Dr. Tom Brewer's contention that toxemia is a disease of malnutrition," she also writes:

"While Brewer advocates that pregnant women eat plenty of meat, fish, eggs and dairy products to prevent toxemia, it would appear from the very low rate of toxemia among the women of The Farm, all of whom were complete vegetarians [vegans] during the period of their childbearing, that a diet heavily based in soy protein works just as well as one based in animal protein for the prevention of toxemia."

John Robbins ("Diet for A New America") and Sandra Steingraber ("Living
Downstream") have well documented the health hazards of meat. There's no
excuse for eating meat at the brink of the millennium.

- Jock Doubleday
President, Natural Woman, Natural Man, Inc., a California nonprofit corporation
anatole.org/nwnm.org/index.htm
jockd@usa.net

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In response to the Natural Family Planning teacher who wrote that every woman's luteal phase (the time from ovulation to onset of bleeding) is 12-14 days "always.": This is simply not true as any woman experiencing a luteal phase deficiency will attest to. A short luteal phase is a very real cause of infertility and must be considered. It is also very common to have a short luteal phase while lactating due to higher levels of prolactin. I am currently breastfeeding a 14-month old and my last cycle was 72 days long with ovulation occurring on day 67--obviously not common occurrence, but certainly within the huge range of normal for menstrual cycle variation, especially in lactating women. Perhaps it's nature's way of insuring that the baby is not displaced by another too soon. Please, please be careful when using the term "always."

- Barbara Cohen

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Re: Issue 40:

  • There is no scientific association between retroversion (what I guess "tipped" refers to) and fertility. It's a normal anatomical variant in about 20% of all women.
  • Medics should all be aware of cycle variations. For maximum fertility sex should be spontaneous, not contrived by a calendar (ie you can "try" too hard. I've always thought the idea of "trying" for a baby was humourous).
  • Clomiphene is only indicated for proven anovulation.
  • Candy Brunk gives the most succinct summary, i.e. don't "try" too hard.
  • Ovulation happens randomly from either ovary, i.e. not RLRLRLRL etc.

- Phil Watters

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I need to know any and all info on taking the supplement 5-HTP while breastfeeding! I am desperate--please e-mail me ASAP if you have any info!

- Nicole, Deetric1@gte.net

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I am an RN In Australia doing my master of midwifery through an external uni course. I have an assignment due the end of October in which I have to critique four articles relating to a research problem of my choice. I'm looking for articles relating to the safety of homebirth as opposed to hospital births. If anyone has articles they could email them to me or have the details of where I could look for articles, please e-mail me at cas60@ddis.com.au.

- Carole

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I'm a doula currently living and working in Massachusetts, but I will soon be moving to Berkeley, California. I'm looking for a birthing community there. If you are in the area, or know anything about it, I'd love to hear from you!

- Sarah Green, sadiebec@yahoo.com

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10) 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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11) 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:

- Twin Birth (Oct. 15)
- Miscarriage (Oct. 22)
- Herbs (Oct. 29)

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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