July 11, 2001
Volume 3, Issue 28
Midwifery Today E-News
“Hyperemesis Gravidarum”
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Philadelphia, Pennsylvania - March 21-25, 2002.
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Quote of the Week:

"The wounded soul must be allowed to tell its story."

- Benig Mauger

The Art of Midwifery

Most of my homebirth moms want to rent labor tubs. The one available in our area is dark in color, which is not good for seeing meconium-stained water or any other "floaties" you may want to get a look at. When getting into the tub I ask them to keep a white washcloth under their bottom in order for me to see the fluid if it breaks. It works nearly every time!

- Dawn

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News Flashes

German maternity care guidelines specify that every mother should have two ultrasound scans, although a current study showed an average of 4.7 scans per woman. In Wiesbaden Hospital in Germany, out of 2376 pregnancies, only 58 of 183 growth-retarded babies were diagnosed by ultrasound before birth. Forty-five babies were wrongly diagnosed as being growth-retarded when they were not. Only 28 of 72 severely growth-retarded babies were detected before birth.

- AIMS Journal Autumn 1998

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Hyperemesis Gravidarum

The links between psychological characteristics and hyperemesis gravidarum (HG) appear to be wildly exaggerated in medical research. The evidence to substantiate any claims of psychological "risk factors" for HG is extremely weak at best and in the case of many traits, virtually nonexistent. Nevertheless, some authors claim that "unquestionably" there is a link to psychological factors such as "infantile and immature personality," "hysteria," "strong maternal dependence," "protest reaction against pregnancy," "poor communication with husband," and "stress and doubts about pregnancy." Studies that purport such relationships admit there is a severe lack of data to support these findings. Studies on psychological components of HG "have been scarce, uncontrolled, or, when controlled, have covered series that are too small to provide valid tests."

It is thus inexplicable why so many researchers have appeared to embrace the existence of these psychological components. Such speculation may encourage doctors and others to view HG as essentially a psychosomatic condition, which is a disturbing prospect.

While the relation between most psychological factors and HG appears to be unfounded, there is some case-study evidence suggesting that dietary behavior may play a role. A risk factor for HG seems to be an "unsuitable diet, with large and infrequent meals."

References for this excerpt only:
Broussard, C. & Richter, J. (1998). Pregnancy and Gastrointestinal Disorders. Gastroenterology Clinics 27(1):1.
Fairweather, D., & Loraine, J. (1968). Nausea and vomiting in pregnancy. Am. J. Obstet. Gynecol. 102:135.
Godsey, R. & Newman, R. (1991). Hyperemesis gravidarum: A comparison of single and multiple admissions. J Reprod. Med. 36(4): 287.
Hod, M. et al. (1994). Hyperemesis gravidarum: A review. (1994). J. Reprod. Med. 39:605.

I admit to a prejudice in favor of this therapy. When I sought out a hypnotherapist in my second month, I had been unable to swallow more than a bite or two of any food for a couple of weeks. When the therapist asked me what suggestion I wanted her to introduce in the trance I said, "I would like to believe that food is good." I also said a general suggestion of happiness would be nice because I was so miserable at a time when I wanted to be celebrating.

When I left the therapist's office, I drove straight to the nearest restaurant, opened the menu, and was dazzled by how delicious everything sounded. I ate an omelet and salad, my first real meal in two weeks.

The therapist also taught me a self-hypnosis routine incorporating feelings and goals I had expressed in our interview. At least once a day I spent about 20 minutes in this exercise. It helped me feel more calm and in control of my body.
The fact that hypnosis can assuage nausea or control vomiting does not mean that nausea and vomiting in pregnancy is all in your head. People undergo dental work and even surgery under hypnosis and no one would presume to suggest that the pain of being drilled or cut open is produced by a bad attitude.

- Virginia Hege Tobiassen, "Am I Glowing Yet?", 1996, Chicago Review Press

(The preceding excerpts are from The Birthkit newsletter No. 26, Summer 2000. It includes a summary of data about HG, natural remedies, a midwife's response to the issue of HG, and an HG sufferer's commentary. Subscribe to The Birthkit, a Midwifery Today publication. Scroll to find the subscription and back issues to fit you!)

When nothing can be kept in the system, other measures must be taken to stabilize the blood sugar and turn the situation around. Keep in mind that some underlying cause such as vitamin B malabsorption, liver compromise, or active disease, kidney infection, pancreas or gall bladder problems, hydatidiform mole, or multiple gestation may be influencing the symptom picture. Dietary practices that encourage women not to gain weight, to eliminate salt, or to eat very little protein could also be at fault.
Nutritive enemas are a good first step to see if hospitalization for IV parenteral nutrition therapy can be avoided. An enema made up of wheat grass juice or a combination of liquid chlorophyll and herbal infusions and tinctures that settle the stomach may be helpful. This should be mixed with an electrolyte IV solution such as Ringers Lactate or unflavored Pedialyte. Have the woman lie on her left side and infuse the solution slowly into her colon. Have her retain as much of it as she can as long as she can. If dehydration is significant, the body will make use of the fluid and little will be expelled; the colon will absorb the fluid right into the system. Once nausea stabilizes, she must immediately begin to take nourishment orally. If this and everything else you can think of does not quickly turn the situation around, get the woman to a hospital without delay.

- Anne Frye, Holistic Midwifery Vol. I, Care During Pregnancy

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Midwifery Today's Online Forum

I have read in four herbals now about lady's mantle supposedly being great during labor. Unfortunately, none of them said what it is great for, and none of them suggested how it is used or what the dosage is.
Can anyone fill me in?

Question of the Week

I am expecting my second child soon and have genital herpes. I was lucky with my first child and didn't have any active lesions at the time of her birth and therefore had a normal vaginal birth.

I fear that I will not be so lucky this time around and really do not want to have a c-section. Is there anything that can be done to shorten an outbreak if it occurs just before my due date? How dangerous is it to my unborn baby (due 11/01) when I'm suffering from a herpes outbreak? With this pregnancy I have already had at least four outbreaks in five months and am very concerned about the baby being affected in utero.

- LW

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Question of the Week Responses

Q: What is the cause of swollen legs postdelivery? One would think, were they swollen beforehand? Could it be: preeclampsia, too much intravenous fluids, inactivity? This problem seems to be more common in the ladies who have cesareans, forceps or ventouse, but I have seen it in normal births.

A: Toward the end of pregnancy, increased venous hydrostatic pressure together with progesterone-induced vascular relaxation results in the development of peripheral oedema. In the postpartum period, circulating blood volume decreases to non-pregnant levels, resulting in a diuresis. However, if a woman is dehydrated or has difficulty passing urine, whether physiological as a result of bruising to the urethra, or reflex inhibition, or psychological (perhaps due to anxiety of painful micturition), she may experience interstitial leakage which manifests as odematous legs, hands etc. The advice is to mobilise, drink plenty of fluids, and if passing urine is painful, to wee in the shower, bath, bidet or to take a jug of warm water into the loo with her to pass over herself whilst weeing. The swelling can take a while to go but it will resolve.

- Maria, RM

I have noticed this very often in postnatal women. It is my understanding that this is a natural phenomenon and can be a normal response to adjusting to a nonpregnant state. During pregnancy the blood volume increases by 20-100% depending on the size of the woman, and all that blood needs to go somewhere after birth. Some of it will be used for the blood loss occurring at birth. I have noticed that the swelling usually is most pronounced just before the milk comes in. Perhaps some of it helps with the production of milk.

I wouldn't think that one litre of Hartmanns would have been a huge factor in causing the very swollen legs. Perhaps she was actually more dehydrated than was recognized and her body is overcompensating by holding on to fluid.

Has she had diuresis yet (peeing lots)? Often women who have retained fluid in pregnancy will have a major peeing session for a few days after birth.

Give it time; her body has undergone a big marathon and it might be taking time to recover. Watch her for signs of thrombosis and encourage her to elevate her legs and do ankle exercises. Don't restrict her fluid intake.


With both my pregnancies I had edema in my legs. My first baby was a c-section so I don't recall what happened. But my second baby was a VBAC and I remember just after she was born looking at my legs and the swelling had almost disappeared. Within a day or so the swelling came back and took a few more days to resolve. I had no IV or anything and the labor was fairly short. Perhaps there are some hormonal factors involved.

- Pam, doula


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International Connections

Thank you for the issue on caring for sexually abused women [Issue 3:27]. I am a survivor of incest from both parents. I am also an herbalist and a midwife assistant. My healing began with the birth of my sons and the "freight-train" powerful creative force that moved through my body, which made it almost impossible to ignore my need for healing these wounds. It has been nine years since I gave birth and just as many years with healing from my abuse. Now at 36, I am enjoying my body as never before and my lovely sons have watched my healing in action, which is the best way to teach anything to our children. I belly dance weekly as a way to dance the scars instead of presenting open wounds that fester all over my life. I am looking forward to another baby in the next year or so and I already feel her near me as I prepare for her now.

Two areas were particularly important to my healing. The first is the use of essential oils and our sense of smell. I worked with chamomile-infused olive oil with a bit of chamomile essential oil added. This was used often, even daily as I learned to remain present with what was happening now for me. I used it to stay present during labor, during massage, or during lovemaking, or just plain present.

Providing yourself with a place to work out the past, such as a support group or therapy, is a powerful tool for healing. It also frees you to enjoy the other parts of your life that are here and now--parts that should not be tainted with the past all the time. The sense of smell, the connection in your thinking mind with the scent and relaxation, being here and now where you are safe and loved is very powerful. Pregnant women can choose a scent safe for pregnancy that relaxes them too and work with this often while using deep abdominal breathing and affirmation. At times this was all that worked for me. Visualization is powerful but it can be challenging to keep the flashbacks out. Working with the oils brings another sense in that stimulates the brain to act on a more powerful level so visualization is easier.

One final note to women healing their childhood scars: be very mindful of when your children reach the age at which abuse began for you. Many emotions can flood up quite suddenly and if unaware can be projected on the wrong people. This is an initiation into a new level of healing and it is time to support yourself again and thank your powerful children for providing such healing opportunities for you.

- J. Costa, Herbalist
Rosendale, NY

I delivered my daughter 10 years ago at a hospital in Manhattan. I was in labor for 27 hours (active labor 4). I hemorrhaged after the labor and stayed in the hospital for four days. After going home, I delivered the remaining portion of the afterbirth that had been left inside of me. Needless to say, when I called my doctor (who was not the one to deliver her--an intern did), he instructed me to throw it away (smart man--he could have been sued!).
Could my blood have been poisoned from the afterbirth that was left inside of me for four days? I am having complications now, and the cause cannot be found. I am having a battery of tests done in my search for it. I am exploring all possibilities.
When I went to an attorney I was told that without the actual evidence there was no way of proving my case. Don't they weigh the afterbirth and wouldn't that show up in their records?

- Anon.

Regarding cleft lip and folic acid [Issue 3:27]:
The connection between folic acid deficiency contributing to NTDs is linked to homocysteine. This is a metabolite of methionine created during the breakdown of protein. Homocysteine can be quite damaging if found in large enough quantities. Certain fats in the diet, and an inability to break them down, and a deficiency in folic acid, B12 and B6 are contributors. Currently, researchers are looking into B12's link to NTDs, and I think it will open up a whole new picture. The link between homocysteine and arterial damage is conclusive, and these nutrients and factors are also suspect in gestational hypertension (and preeclampsia). It's all worth more consideration as I'm sure it is more complex than we think--thus there is no one cause.
There is little risk from taking 4 mg of folic acid. Dosages much higher than this are often prescribed for cervical cellular disorders. High doses are recommended when there is a previous history. The only concern is that it could mask a B12 deficiency (which is quite serious) if one exists, so make sure that both nutrients are provided at the same time. Folic acid can't be stored and should be taken every day. It is hard for a woman's body to recover from one pregnancy and move into the next, especially while still nursing, but not impossible. So much evidence says that conditions at the moment of conception are a bigger factor than what takes place during the first trimester (nutritionally speaking that is) that it is often hard to control unless conception is planned - which often it's not)

- Stacelynn Caughlan, Cl.N., C.H., R.N.C.
prenatal and pediatric nutritionist

I diametrically disagree with the Quote of the Week in Issue 3:26 ["We must give women the opportunity to challenge their fears, to work with them and birth through them"]. Women don't need to be "given" opportunities by concerned, empathetic caregivers--they need to ferociously claim their power: their awesome birth rite to gestate, give birth, and mother their children according to their own beautiful plan, their own innate sense of purpose. Being "given" permission is meaningless. Assuming ownership and taking control of your body and life is what birth power is.

- Leilah McCracken
British Columbia, Canada

I flew to Brazil from Australia across the South Pole (which is meant to have the highest radiation) 10 days after conception and home three weeks later. I had spotting when I got home which I never had with my other children. What are the risks of the radiation to my child? Would you suggest I have an ultrasound? I usually don't like/agree with them. I also planned to go back to Brazil at six months. What can I do to protect the baby?

- Colita

A colleague asked what I knew about the RAMP maneuver. She thought it was an English technique for relieving shoulder dystocia. Does anyone have knowledge of this maneuver?

- Susan Nickel

Re: homebirth option and government insurance [Issue 3:26]: It surprised me to see that you had plans for government intervention at all! As a doula and aspiring midwife, the last thing I want to see is third-party payment and other types of reimbursement. To me, that is oxymoronic and goes against so many of my beliefs. I do not want to be regulated by the gov't or the AMA because I will never have anything to do with them when it comes to birth.

You say, "They have their minds mostly on their agendas..." EXACTLY! Keep homebirth out of it. I just can't see where there is any place for homebirth on the agendas of gov't, insurance companies, or the AMA. Please do not encourage bringing them in, for it would be a mistake.

- Laurie

Re: wild yam [Issue 3:27]: Progesterone cream (Wild Yam Cream) is not the same as the wild yam described in the books. Wild yam contains precursors to progesterone, but the process is done in a lab, not the body--then added to creams. Wild yam as an herb is effective for nausea and to help prevent miscarriages. It does have a mild effect on reproductive hormones, but certainly not like the creams do. In Canada the creams are considered a drug; the herb is not. Therefore the creams often get pulled from the health-food store shelves because the government views them as no different from selling birth control over the counter! I have heard of women using the progesterone cream to maintain a pregnancy but have not used it on any of my own clients because I have much success with other herbs.

- Stacelynn

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