July 25, 2001
Volume 3, Issue 30
Midwifery Today E-News
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Quote of the Week:

"Medicine and midwifery are not sciences, they are clinical practices. It is the nature of scientific work to expose inconsistencies, to show the flaws in the old paradigm. Clinical practice is not about generating data--it's about treating people."

- Barbara Katz Rothman

The Art of Midwifery

When a woman is having an especially difficult time dealing with contractions, I often ask the husband what her favorite radio station is and "tune her in" to something other than how each contraction is feeling. My most memorable example is when I was working with a mom who was having her third large baby. The baby was posterior and she was really hurting. Her husband was asking her if she wanted some Nubain! We turned on the oldies station and the woman went from fighting her contractions to trying to sing through them! What a beautiful birth!

- Amy K.

Psycho-Physiological Influences on Labor: Audiotape package of four tapes of Midwifery Today conference classes.

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News Flashes

Neonatal herpes is not a reportable disease in most states, so there are no hard statistics on the number of cases nationwide. However, most researchers estimate between 1,000 and 3,000 cases a year in the United States out of a total of 4 million births. To put this in greater perspective, an estimated 20-25% of pregnant women have genital herpes, while less than 0.1% of babies contract an infection. "Neonatal herpes is a remarkably rare event," says Zane Brown, MD, an expert on neonatal herpes and a member of the Department of Obstetrics and Gynecology at the University of Washington. "Compared to all the other possible risks in a pregnancy, the risk of neonatal herpes is extremely small." Transmission rates are lowest for women who acquire herpes before pregnancy--one study (Randolph, JAMA, 1993) placed the risk at about 0.04% for such women who have no signs or symptoms of an outbreak at delivery. The chances of transmission are highest when a woman acquires genital herpes late in pregnancy.

- www.herpes.com/pregnancy.shtml


Q: 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

A: High doses of L-lysine (3000 to 5000 mg daily) will help, as well as using tea tree oil.

- Annette Lewis, CPM, LM
Salmon, Idaho

A: Look into taking a glyconutrient supplement called Ambrotose. It is the best nutrient supplement available for support of the immune system. It is entirely safe to take during pregnancy--basically it is just good food that we don't get in our diets these days. I have taken it for 2 1/2 years and through both of my pregnancies. Herpes is a virus that will cause outbreaks when the body and immune system are under stress. Obviously this occurs during pregnancy. Glyconutrients are the best way to support your immune system. There is a lot of research on this subject--go to www.glycoscience.com to learn more. Please contact me if you would like to get on this supplement.

- Dr. Lisa Staudt

A: The very first two things: 1. What are you eating? 2. What is your stress level?

My guess is that your life is very stressful at this time with either a move, a job loss, a change in partners, living with family members, etc. It is important to address the stress. Herpes outbreaks are usually stress related. Perhaps some counseling is in order. Please take stock of what is going on inside. Perhaps persistent worry about a c-section due to a herpes outbreak is the stressor? Work to change that perception of yourself by hypnosis and/or affirmations such as "I am healthy and whole." It really is important to change the thinking patterns that are evident in your letter.

A diet that is out of kilter is the next common cause of herpes outbreaks. Ask yourself what you are doing to strengthen your immune system. Is your diet nutritious? Organic? Made of whole foods? Fresh fruits and vegetables? What supplements are you taking? Red raspberry leaf tea has mild antiviral properties. Transferfactor (www.4-life.com) is the most immune-building substance available. It far exceeds echinacea. It is very important to support your immune system with something safe for your baby. Transferfactor is safe for baby. Zovirax is not necessarily safe, and it is "suppressive therapy." But a prescription may be best for you. The majority of women who are pregnant and seeing a physician have been given a prescription to suppress herpes so they can have a vaginal birth. It does seem to work. It is an alternative available for you that has not shown to be harmful to baby.

The next agenda is to look at foods high in L-lysine (an amino acid). L-lysine seems to decrease herpes outbreaks because it competes with arginine, a substance the virus feeds on. Foods high in L-lysine are potatoes, meat, milk, brewer's yeast, fish, liver and eggs. Foods high in arginine (foods to be avoided) include chocolate, nuts, cola, rice, cottonseed oil and meal. L-lysine has been shown to have an inhibitory effect on virus replication in vitro. A person may need to take more than 500 mg twice a day to get that effect in vivo.

A herpes outbreak during birth can cause congenital herpes and a newborn can die from this very serious consequence. However, research indicates congenital herpes is generally a sequelae of an initial herpes outbreak (primary). Most healthcare practitioners are not willing to take the chance with your baby and will offer cesarean if you have a herpes lesion on the genitals at the time of labor or when your water breaks. It is thought that when the bag of waters breaks, the infant should emerge within three hours before the virus moves upward.

- Sandra Stine, CNM

A: I read somewhere that external lesions of genital herpes can be covered with rubber cement right before birth and the baby can be born over them.

Try to process your fears with someone, preferably trained in "Birthing from Within" holistic birth preparation. They could help you focus on birthing-in-awareness, not just looking to the outcome. They can be reached at www.birthpower.com

- Augustine Daniels, CBE, CD
Bordentown, NJ

A: I commonly prescribe acyclovir (taken daily) starting at 36 weeks to suppress herpes outbreaks. In our practice we have been doing this for about 3-4 years and have seen no adverse effects. We've also had no active outbreaks during the last month of pregnancy since using this protocol. Perhaps this is an option you could discuss with your care provider. The company that makes the drug is maintaining an exposure database and could probably provide useful info to any provider who is interested.

Regarding your question of in-utero exposure: I can't claim to be an expert, but my understanding is that outbreaks during pregnancy are not harmful to the baby. I don't know if this is because the virus does not cross the placenta or because your antibodies also cross the placenta and provide protection to your baby. I believe that the most dangerous thing for a baby is to be born during or shortly after the mother's initial outbreak (before any maternal antibodies are developed) because the baby's immune system cannot fight the virus.

About 5 years ago we used to do weekly herpes cultures during the last month of pregnancy to avoid vaginal exposure of the virus in mothers with a history of herpes. I once assisted a woman in birth who had 3 previous cultures return negative. She gave birth (vaginally) before the result of the 4th test was back. We were both very worried when the most recent culture returned positive. Her baby had no problems, which was a real relief. I have also assisted at a birth when the mom had a lesion on her labia, but she denied any history of herpes. At the time of vaginal delivery, we noted the lesion and sent a culture, which was positive for herpes. Again, the baby had no problems.

I know your concerns are very real and I don't mean to treat them lightly by sharing these stories. However, I do want to give you some reassurance and some hope for an effective management. Here are some web sites that you may find helpful:

- I.R.

A: Acyclovir is the oldest and least expensive medication. An active lesion on the perineum at the time of labor does expose the baby to disseminating herpes that can have grave consequences, including death. In the last 20 years I have been in practice, I have not seen a woman having to have a cesarean for active herpes. The biggest concern is a primary outbreak at the time of labor, but having acyclovir around for the possible outbreak at term would be worth doing.

- Peg, CNM

A: I know a few people who have treated their herpes sores with hemp oil. After the oil is applied directly to the sores, they go away very quickly. It is good to apply the oil at least once a day until the sore is gone. The brand we have had the most success with is Hempola--any natural foods store should be able to special order it for you.

- Bren

A: A book called The Natural Pregnancy Book by Aviva Jill Romm describes the treatment of herpes. It is excellent. She talks about all sorts of herbal treatments that strengthen immunity and purify the blood to prevent outbreaks and help treat any current outbreaks.

- Anon.

A: Try Lysine 500 mg twice a day for prevention. If you feel an outbreak coming on, take Lysine 1000 mg three times a day for five days--it will shorten and sometimes avert the outbreak. Herpes outbreaks are mediated by the balance of amino acids in food. Choosing foods that are high in lysine and low in arginine is very helpful. Avoid chocolate, peanuts, other nuts, processed foods including lunchmeat. Choose fish, fruits and veggies. Limit dairy. Some grains are high in arginine. This has been very useful in our practice; even the perinatologist who backs us recommends this to his patients.

- Liza McKinney, CNM

A: I had genital herpes, though not while I was pregnant. I used an herbal product called Vagistatin (inserted vaginally), along with another product taken orally to clear heat from the body, from a company called Health Concerns. At my follow-up visit, the lesion had completely disappeared. I was followed every six months for two years following and had a negative Pap every time. I'm sure you could call and ask about the product's safety during pregnancy. Their phone number is 800-233-9355.

- C.M.

A: My first birth was a c-section because I had an active lesion. My doctor at that time would not prescribe Zovirax because she felt the risks of the drug outweighed the benefits (yeah, right). My second and third births were VBACs and my (new) doctor prescribed Zovirax starting at 34 weeks (I think I took 200 mg a day) to keep outbreaks away. This time around she has prescribed Valtrex, 1000 mg day if having an outbreak and then starting at 34 weeks 500 mg day. Valtrex is a Class C drug and Zovirax is a Class B (I think).

- Jenn D

A: Listen to your body choosing what it needs: Herpes = "her peace." Get as much rest and sleep as you can, give yourself the gift of lots of positive self-talk, visualizations of health and successful birth, touch therapy, deep breathing, meditation. Love yourself and give yourself peace.

- Anon.

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Question of the Week

Q: I am 22 weeks pregnant with my third child and was just diagnosed with a pregnancy hernia. My baby is growing normally. I have few complaints except for the hernia pain and backache. I am looking for information about birthing naturally with a hernia. I gave birth naturally both previous times and intend to do the same this time.

- Christine Staricka

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MANA Conference

Spend an afternoon with ALICE WALKER, explore a pueblo, soak in a natural spa...oh yeah, and earn your CEUs at the 2001 MANA conference.
September 21 to 23 in Albuquerque, NM. Watch this site for further info.


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International Connections

Although I do not know what the RAMP maneuver is [Issue 3:28], it is not the English technique for relieving shoulder dystocia! The maneuver we use for this obstetric emergency is based on the HELPERR mnemonic. Here is a definition of the maneuver which is used as an emergency drill for shoulder dystocia by midwives in our region of Britain:

H - Call for help
E - Evaluate for episiotomy
L - Legs into Mc Roberts' position
P - Pressure: apply suprapubic pressure
E - Enter (Perform Woodscrew maneuver)
R - Remove the posterior arm
R - Roll over (roll woman onto all fours) and start again

- Julie

I am 35 years old, fit, healthy and 30 weeks pregnant with my fifth child. I have birthed 3 of the children at home with a midwife, as I will the fifth. I am experiencing a lot of pain in the uterine ligament that attaches (I think) to my hip bone and then through my abdomen and into my back. These ligaments regularly spasm and I experience excruciating pain.

During the last pregnancy the same thing occurred. I managed it using comfrey gel directly on the area, oral mag. phos., and massage as needed. It helped me cope but didn't stop the spasms. During the last labour the spasms were with me almost 100% of the time and worsened as labour progressed. During postpartum the pain remained off an on for about 4 days and then subsided. I vomited because of the pain for the 4 days.

I am afraid of things getting worse and am looking for help.

- SB

To tell a woman to push before she is ready is like telling her to poop before she is ready, while people stand around chanting Poop! Poop! Poop! It just doesn't work very well!

- Amy Reay, doula

Re: the question about radiation and the South Pole [Issue 3:29]: A: While pregnant with my daughter, I was on airplanes every few days for the entire first 4 months. With my son we were in the process of moving to Guam from the mainland U.S. so I crossed the Pacific Ocean via the North Pole, then via Japan, several times during that pregnancy. Both children are generally healthy, bright-eyed, developing normally and very smart. If the radiation exposure had any effect on them I cannot see it.

During the first few weeks of pregnancy the embryo has the amazing ability to repair itself (to a certain extent), so if there is any damage from exposure to harmful substances that damage can sometimes be undone. If the pregnancy is not viable, perhaps a chromosomal abnormality, there is not much that your body can do to repair and save it and the problem would have probably been present at conception. No amount of air travel would likely be responsible for that kind of chromosomal damage.

Flying at high altitudes for extended lengths of time--as in transcontinental flights--does expose you to more radiation--not a higher dose, just a longer period of exposure. My pilot husband says it is about the equivalent of several dental x-rays a day.

I did make it a point to drink some herbal teas and infusions (mostly dandelion root) that helped my liver function remain strong. My thinking was if my body had strong cleansing capabilities it would be best for the babies and might help cleanse them of any inadvertent exposure to harmful substances.

Short of wearing a lead apron over your belly for the entire flight to Brazil, there is not much you can do to limit your exposure. You could fly another route that doesn't pass over the South Pole. You could take a flight that travels at lower altitudes that will further lessen your exposure. Traveling at night also lessens the exposure to gamma radiation. You could explore the possibility of taking potassium iodine which is supposed to protect the body from radiation exposure but I am not sure it is safe to use during pregnancy.

There was a long-term study of the effects of radiation exposure on pilots and the only significant increase was in skin cancers and neurological disorders (such as Parkinson's disease), both appearing at late stages in life and most significantly in men. Your body is working overtime to protect your unborn baby so you were probably at a greater risk from the exposure than the baby was.

- L.S

Thank you for your article on folate levels [Issue 3:29]. Our fourth-born child had a fatal neural tube defect, anencephaly, and died during preterm labor, just 18 hours after diagnosis. Immediately after his birth, I started taking 4 mg of folic acid in addition to the 800 mcg in my prenatal vitamin. In August 2000, we were blessed with a healthy daughter.

My concern with the current recommendation for folic acid supplementation is that it is too low. Most prenatals have 800 mcg, which is not a high enough level to prevent NTDs, not as effectively as 3 mg or more.

- Ann Marie Henninger

Re: Folate deficiency as a cause of cleft palate, I would like to add that environmental factors may be involved as well. For more information about research on the effects of pesticides on fetal development in laboratory animals, go to www.chem-tox.com/pesticides/.

- Rachel Westfall

Re: Inquiry about safety of VBAC article in The Lancet:

"Here's a link to the study:

Basically, it says the risk of uterine rupture in a VBAC woman who goes into spontaneous labor is 3 times greater than in a woman who never goes into labor and has a repeat c-sec. The kicker here is that women who are induced with something other than prostaglandin gel (like Pitocin) are 5 times more likely to have a rupture, and women who are induced with prostaglandin are 15 times more likely to rupture. Looks to me like induction is the real culprit of rupture, and that any woman attempting a VBAC is obviously at risk for uterine rupture, just as any women having a repeat c-sec is in danger of complications that can be just as deadly. Women need to weigh the risks of a c-sec against a *natural* VBAC (not induced, which is too risky, according to this study).

- Angela McLauchlin, aspiring doula

The following link has a wonderful referenced analysis of the study:

- Anita Woods
Vice president, International Cesarean Awareness Network

The American College of Nurse Midwives has posted on their website an informative news release in response to NEJM. It suggests the study left several questions unanswered, and should not be used to frighten women considering a VBAC, among other things. Worthwhile read, as the other side of the coin usually is! You can read it at: www.midwife.org/press/pr01-vbaccall.htm

- Erin Buchanan

In general, the study really showed nothing new, but the press is reporting it as "increased incidence of rupture." Plus, the ICD9 codes used make the study confusing because they included dehiscence as an actual rupture. With all the politics currently going on surrounding VBAC, and as a VBAC mom myself due in 4 weeks, I was very disappointed in how the press presented this story. One doctor states his opinion about how VBAC is not safe for babies and that is what the press picked up on.

- Teresa Jorgenson, BCCE and doula

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