November 21, 2001
Volume 3, Issue 47
Midwifery Today E-News
“Due Date”
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Quote of the Week:

"Obstetrics should be both art and science. The science lies in what we know to be true, the art lies in how that information is used for greatest benefit to mothers and babies."

- Don Creevy, OB

The Art of Midwifery

For heartburn during pregnancy: Chew a few pieces of diced papaya before meals. Papaya tablets are also safe--just follow the directions.

The best way to handle heartburn, however, is to prevent it. No super-spicy meals, eat small meals more frequently, bananas soothe the stomach, do not lie down after a meal but try walking or moving your body a bit. The sphincter muscle at the top of your stomach relaxes right along with all the rest of your body to soften up for birthing, and food/stomach acid can get pushed up. This is where the burning part comes in.

Another handy little remedy is slippery elm throat lozenges available from health food stores. Slippery elm bark is safe for pregnancy and it soothes the stomach, but take it only if/when the above suggestions do not work.

- Raven

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News Flashes

Reduced growth in utero is associated with noninsulin dependent diabetes and impaired glucose tolerance in adult life. Researchers studied people born before, during, and after a famine that occurred in the Netherlands from November 1944 to May 1945 and found that people exposed to famine in utero during the second and third trimesters of pregnancy show impaired glucose tolerance and insulin resistance, which predispose to both diabetes and heart disease. The most significantly affected were exposed during the third trimester. Affected people were also more likely to be obese as adults. Official rations during the famine varied from 400 to 800 calories per day. The study findings of glucose intolerance in adults exposed to maternal malnutrition in fetal life adds credence to the hypotheses of fetal origins of adult disease. Permanent changes in pancreatic function and other body systems occurred in these subjects.
- The Lancet, Vol. 351, no 9097, January 17, 1998.

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Due Date

The concept of [a due date] is based on a gestational length established by fiat in the early 1800s. Franz Carl Naegele officially declared that pregnancy lasted 10 lunar months (10 x 28 days), counting from the first day of the last menstrual period). However, when Mittendorf et al. measured the median duration of pregnancy, they found that healthy, white, private-care, primiparous women with well-established due dates averaged 288 days and multiparas averaged 283 days, values significantly different from both Naegele's rule and each other. Others have found similar results. Mittendorf et al. also cited other studies showing racial differences in gestational length. For example, one showed that black women averaged 8.5 days fewer than white women of similar socioeconomic status.

Moreover, ultrasound-determined due dates are not accurate. One study used the date established by ultrasound at 16 to 18 weeks to test the validity of dating by the last normal menstrual period (LNMP). It found that as gestational age went past term, positive predictive values for the LNMP declined from 95% to 12%. The authors took this to mean the LNMP was inaccurate, but, of course, the ultrasound date is the problem. Even first trimester measurements have an error bar of +/- 5 days in the second trimester and +/- 22 days in the third.

Few practitioners appreciate the limitations of ultrasound or clinical data. Otto and Platt say the due date should not be changed unless the discrepancy is more than two weeks, yet they see doctors changing a due date by a few days, no trivial alteration if a woman will be induced when she exceeds a certain date.

Some risk does accrue in healthy postdate pregnancies (notably meconium passage and big babies) but it does not follow that we should induce all women. Studies have found that as gestational age goes from 37 to 44 weeks, perinatal mortality and morbidity distribute in a U-shaped pattern. If we try to eliminate postdate pregnancies on grounds of increased complications, should we not equally logically try to delay labor onset in the early-term group?

- Henci Goer, Obstetric Myths vs. Research Realities, Bergin & Garvey 1994


A prospective study was conducted at a West German US Army Hospital to compare the accuracy of fetal weight estimation by a physician's clinical estimate as compared to ultrasound. One hundred women had Leopold's and vaginal examinations, an estimate was made. Then the same examiner performed an ultrasonic estimation of weight. The exam was done within 48 hours of delivery. The mean error for the clinical estimate was 7.9%. The error by ultrasound was 8.2%. There was no significant statistical difference between the two types of estimates, including for the extremes of birth weight.
- Journal of Reproductive Medicine, Vol. 33 No. 4, April 1988


Wood's method: Carol Wood, Yale nurse-midwifery professor, came up with a method to calculate the due date that takes into account individual variations in the menstrual cycle as well as the effect of a woman's having had previous pregnancies.

1. Add 1 year to the first day of the last menstrual period, then
For first-time mothers, subtract 2 months and 2 weeks
For multiparas, subtract 2 months and 2.5 weeks (18 days)
2. Add or subtract the number of days her cycle varies from 28 days

*1st-time mothers with 28-day cycles: LMP + 12 months - 2 months, 14 days = EDD
*Multiparas with 28-day cycles: LMP + 12 months - 2 months, 18 days = EDD
*For cycles longer than 28 days: EDD + (actual length of cycle - 28 days) = EDD
*For cycles shorter than 28 days: EDD - (28 days - actual length of cycle) = EDD

EDD: Estimated day of delivery
LMP: Last menstrual period

- Anne Frye, Holistic Midwifery Vol. 1, Labrys Press 1995

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Question of the Week Responses

Q: Would readers please share their experience with and information about endometriosis and pregnancy/labour? Our pregnant client has quite severe endometriosis with nonpregnant symptoms of frequent nausea, very painful cramping premenstrually and during menstruation, heavy bleeding, and bleeding from the rectum.

- Anon.


A: My first experience with a client with such severe endometriosis before and during pregnancy was more than 20 years ago. Beloved homebirth physician (wholistic MD and naturopath), Dr. Paul DuGre responded with nutritional advice: immediate daily supplementation of 1200 mcg. folic acid along with the rest of the B-complex vitamins in the more digestible and assimilable brown rice based form. He also suggested "Floradix Liquid Iron and Herbs" at one ounce per day for the first week, then 1/2 ounce daily. He recommended replacing starchy, sugary, processed foods with whole grains and natural foods high in vitamins and minerals, and vegetable proteins because they digest more easily and do not overstress the colon and rectum, and would help regenerate strong cells in the woman's body. The advice included eating lots of gentle fruits such as avocadoes and those rich in enzymes, as are papayas, bananas. Paul encouraged kegel exercises and general low-stress exercise such as swimming.

Paul also warned about what to avoid such as table salt (cheap sodium chloride), which should be replaced with mineral-rich salt such as sea salt and a sufficient amount of potassium-rich foods. He described the toxic side effects of additives like aspartame (Nutrasweet) and of sodium fluoride that has been infiltrated into city water and toothpaste and which proved to be harmful to women's systems and unborn babies (mentioning that the original idea of calcium fluoride might have been beneficial in some ways, but that the less-expensive sodium fluoride proved to be extremely harmful, especially to women's systems and unborn babies.)

- Julia Swart


A: Endometriosis is a condition in which the cells that create the lining of your uterus also grow inside your pelvis. Each month these cells thicken as if they were in the uterus, but they cover the outside of the ovaries, fallopian tubes, uterus, and the ligaments in the pelvis. Then like the lining of the uterus, they bleed each month--except there is nowhere for the blood to go and it sits in the pelvis, clots, and causes adhesions and pain. Some of these adhesions are called chocolate cysts and they grow on the ovaries.

There are many signs of symptoms and endometriosis and not everyone gets all of them, which makes it hard to diagnose. Signs & symptoms: heavy painful periods, pain during ovulation, pain during intercourse, constipation or diarrhea around period time, pain around the rectum, PMS, spotting of brown discharge two to three days before a period actually starts, and many more. Doctors used to think it was a condition that only older women got but now they know that one can have it from teen-age. When one becomes pregnant all these symptoms cease or decrease considerably until the baby is born. Usually the symptoms remain at bay as long as a woman breastfeeds but often return to some degree once menses commence again.

The Australian book "Explaining Endometriosis" by Ann Henderson can probably be found at your library or bookseller.

- Diana Stubbs, RM, IBCLE, BA Nurs
Geelong, Australia


A: Seek a naturopathic physician in your area to get the best treatment advice.

- Leslie Peterson, ND


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Re: Midwife Melissa Jonas's statements about respecting all woman's choices [Issue 3:46]: I agree to a point, but the question is whether women who choose high-tech birth are doing so because they are truly informed and educated about their health and birth choices or because that is what they are told they need to do? Are they choosing high tech out of fear and ignorance? Most women today have no idea that they have choices, or that there are risks to high-tech/high-intervention births. We live in a society that assumes that more technology is better and that the medical care provider is the best person to make decisions regarding one's health. This is an extremely complicated issue. Korte and Scaer said in A Good Birth, A Safe Birth, "If you don't know your options, you don't have any."

On the other hand I remember a story that Penny Simkin told of an abused woman who chose a drugged birth because she wanted one day in her life without pain. Who could blame her?

We need to talk with the women we work with and find out why they are choosing the things they are and make sure they are truly informed before making those decisions. You never know which category she may fall into.

- Amy V. Haas, BCCE
Fairport, NY


I felt compelled to respond, in way of thanks, to a sensitive and insightful letter written by M. Jonas, LM. You have written as a homebirth midwife who has extended herself to the nonhomebirth women (for whatever their reasons), and by association I feel to those of us who care for women giving birth in hospitals. Many in the homebirth community do quickly write off, so to speak, those women and those midwives caring for them as somehow doing it the wrong way, which may simply be doing it a different way. You mentioned "the lack of compassion for women making choices other than those we recommend," which is caused by judgments and affects interactions with them as well as conveys a lack of respect.

As a CNM practicing in an urban hospital, with private patients, I too must keep constant vigil against not wanting women to make choices I would not make, when I have offered a noninterventionist approach. We have jacuzzis, showers, birth balls, etc., and yet I too have to remember that I must support women in an informed decision, this is their birth, these are their choices, and I have chosen to be "with woman" whether or not she is choosing to do what I think best or useful. For all midwives, in all locations, I appeal for unity and respect that we might best serve all the women in their diverse natures that live among us.

- Trish McPeak-LaRocca, CNM


Giving birth is about having a baby. Particularly in America the choices women often feel they have the right to make do not include the needs of her baby. I'm not talking about, e.g. someone who has unresolved sexual abuse issues and is terrified of labor and delivery and so opts for a cesarean, but about the average woman with average prenatal care and the "average" caregiver. The choices she is generally informed about typically leave out or minimize vital information about possible effects of her choices on her baby and possibly also on the relationship between mother and baby as a result. When a mother contemplating an epidural is asked "Why be a martyr?" she is not told that babies exposed to more than an hour's worth of obstetrical medications are, at worst, more predisposed to become substance abusers than those who are not, and at best, may experience feeling disconnected from their bodies, fuzzy thinking when under stress, feeling inadequate and incapable of completing things they start, and a whole list of other possible consequences, she is not truly making an informed choice. Nor is she being informed that motherhood begins before conception with the intention, or not, to conceive a child, nurture it in the womb for nine months, and encounter the profound spiritual, physical, family, rite of passage that birth was designed to be, so that when she has accomplished it she will, as the research has shown us, feel more confident in herself as a mother, more delighted in her baby, more likely to breastfeed and for longer, etc. than a woman who experienced less pain with her epidural, but missed the endorphins, the sense of accomplishment and wonder, and the ability to bond with an alert baby rather than a sleepy one with a poor suck who gets cranky about a week later when the drugs finally clear his/her system.

The very reason for giving birth, the baby, all too often in this culture gets left out of the equation except as a cute "product" of all this planning and devising and orchestrating and intervening. I'm reminded of Leboyer's photograph in his book "Birth without Violence" (published in the 70s!) showing everyone smiling at the success of the birth while the baby is held upside down by his feet, his hands on his ears and an expression of unadulterated anguish on his face. Have we really come very far since then as far as the baby is concerned?

Meanwhile, studies of prenatal communication between babies and parents point the way to a very different form of birth plan: one in which mother and baby are in communication with each other, in which mother trusts her intuitions about her baby and her body, in which baby trusts mother to move as she needs to in order to assist its passage through the birth canal, in which the motherbaby dyad work fluidly together to accomplish the birth as a profound celebration, and father stands guard as a protector of the birthing process in his family as well as loving support for his partner and child. This is a birth in which baby is informed of any procedure to be initiated that will impact him/her before it is begun: a birth in which the personhood of the baby is acknowledged, respected, and included in planning and decision-making. This type of birth has always been possible, but the machines that go "ping" are so enticing.

- Claire Winstone, M.A.,educator: pre- & perinatal psychology, doula


Regarding labor and cramping, make sure enough calcium/magnesium is in the diet. I've "cured" many of my menstrual cramps with cal/mag. I was also given a recipe for a "labor ade" from my midwife to drink during labor, which included--wouldn't you know it--crushed cal/mag tablets.

- Anon.


I had a baby three months ago. I was unable to see my very busy midwife again until nine weeks postpartum. Apparently one of my stitches popped open during initial healing and some underlying tissue snuck out. I was told to wait two more weeks to see if it would heal, and if it didn't, to come back. At my next visit an OB/GYN checked me out. I have to go to the hospital for a fistulagram to see if I have any fissures. Has anyone ever dealt with this situation? How would a homebirth midwife assess internal tearing? Is there any way to put that tissue back in place without being sliced open? (I opted to tear because of the research I had done on episiotomy. Is there anything I can do herbally or homeopathically to heal quickly, keep from getting infection, and avoid that whole "pain during sex" thing for the rest of my life?

- Abbie


Re: separation of abdominal muscles postbirth [Issue 3:46]:

It's called a divided rectus sheath; many women experience this. Simple exercises should close the gap. You may wish to discuss this with a physiotherapist. Exercises should not be painful and are usually started in the first week postpartum, gently at first, then increasing. My own gap closed after a month or two. It's better to have strong muscles than weak divided ones!

- Margaret Watson, UK midwife


When you do the sit-ups, focus on pulling the muscles together by hugging your arms across your body in an "X" pattern. Only lift slightly and pull at the same time. Also make sure you are using your abs and not your neck, shoulders, or back to pull up. Make sure your pelvis is tilted toward your sternum. (From Denise Austin's Pregnancy Plus Workout.)

- Jennifer Crowley


I had this same muscle separation following my third pregnancy. My midwife taught me to cross my arms over my belly, and with my hands grasping the outsides of the muscles and pulling them INWARD across the abdomen, doing my crunches. Just doing plain sit-ups won't help bring the muscles together again. You need to "train" them together by pulling them together with your hands (during the sit-up). Shape's "Fit Pregnancy" magazine publishes photos of this procedure every so often. They may have it at their online Web site.

- Cherwyn


In my previous practice I referred women with this problem to a physiotherapist. The condition is labeled "diastasis of the rectus abdominii." In other words, the muscles have separated! The immediate care for these women was to give them a very supportive tubular "corset" of "tubigrip" that supported the abdomen from just under the breasts to just below the pubic bone. The exercises recommended were very shallow curl-ups with knees bent and arms sliding up the legs to the knees only. She would have them start with two pillows under their heads for several days, then gradually remove the pillows. Great emphasis was placed on being very careful of getting out of bed--i.e., turn on side, then get up, and also not lifting anything heavier than the baby. The rectus muscles act as a corset and support your spine, so you have to be very careful to lift and bend properly. I am guessing, but you may find in future pregnancies that you "pop" out sooner and may need some support for your growing uterus.

- Mary Jo


I've read countless times about how you shouldn't rush the delivery of the placenta. I had my first baby 19 months ago, and my midwife had me pushing to deliver my placenta right after birth. She also tugged very gently to help it along. I believe it was because I had a tear from the birth that she wanted to stitch up before I lost too much blood. I had no ill effects from a "rushed" placental delivery that I know of. Is this an exception to the rule? If there is a tear to be closed, how does this affect delivery of the placenta?

- Jennifer


I am 37 and pregnant with my third child. I had a placenta abruption and emergency c-section at 34 weeks with my first child, and the same with my second child at 38 weeks. Am I risking too much to want to try to have a vaginal birth if I can make it that far without the placenta abrupting? Have any midwives ever had clients in this situation? I'm 45 minutes away from a competent hospital. I don't smoke, didn't have gestational diabetes, high blood pressure or any problems before it happened.

- LaDonna in N.C.


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