April 13, 2005
Volume 7, Issue 8
Midwifery Today E-News
“Nutrition to Prevent Prematurity”
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In This Week’s Issue:


Quote of the Week

"I am amazed to have been a midwife from the era in which women marched in the streets, demanding normal births without medication, to a time when they expect an epidural as soon as it is allowed in labor, even planning elective cesareans and giving up the gift of birthing their children altogether."

Katherine Jensen


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The Art of Midwifery

Colic can happen when the breastfeeding mother has a rapid letdown. A local doctor who is a real gem for breastfeeding problems saw a friend of mine who had a colicky baby and pointed out to her that, early in the feeding, the baby started making little noises (sort of like a little hum). The mother was advised to take the baby off the nipple right then—even though the feed had just begun—and burp the baby by putting the baby up to the shoulder. Sure enough, the baby burped up a big bubble from too-rapid gulping right at first to prevent drowning in the rapidly letting-down milk! That did the trick.

Gloria Lemay


ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


Send submissions, inquiries, and responses to newsletter items to: mtensubmit@midwiferytoday.com.

Research to Remember

A study of nearly 9000 pregnant women who had been in car crashes and hadn't buckled their seatbelts showed that they were about three times more likely to lose their babies than those who had worn seatbelts. The unbuckled mothers who did not lose their baby were nearly twice as likely to bleed excessively when they delivered.

Obstetrics and Gynecology, Vol. 102 No. 2


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Nutrition to Prevent Prematurity

Adequate nutrition during pregnancy prevents prematurity in many ways: by boosting the immune system to prevent infections that can cause chorioamniotitis and premature rupture of membranes; by supplying adequate hydration to prevent dehydration and oligohydramnios, common causes of premature labor; by supplying the liver with adequate protein for the production of albumin and supporting the expanding blood volume, thus preventing preeclampsia; by supplying the body with enough nutrients for optimal functioning to prevent intrauterine growth retardation and support a full-term pregnancy.

Recent studies have examined the impact of nutritional quality on pregnancy outcomes. A University of North Carolina study showed that women who failed to eat with recommended frequency and regularity had a higher incidence of premature delivery than did those who met certain guidelines. Animal and human research suggests that skipping meals elevates stress hormones that can contribute to premature delivery (1).

Similarly, a study in India in 2000 found that preterm birth rates among women whose diets were improved by nutritional supplementation were half those of women whose diets weren't supplemented (2).

A study published in the American Journal of Obstetrics and Gynecology looked at the effect of nutritional counseling for twin pregnancies and found that it improved all pregnancy outcomes significantly, up to the age of three years. This included increased birth weights and gestation periods and a reduced number of births prior to 36 weeks, as well as reduced incidence of premature rupture of membranes and preeclampsia (3).

Other research found that women deficient in vitamin C had higher rates of premature rupture of membranes and that this could be counteracted by vitamin C supplementation (4). I suggest that eating adequate amounts of fruits and vegetables high in vitamin C might have the same effect.

Extensive research has been done in Europe on ingesting fish and increasing omega 3 fatty acids. A Swedish study found that women who had low consumption of seafood tended to have higher rates of premature labor and women who ate higher amounts had longer gestation periods and bigger babies.

Sadly, most research focuses on a single element of diet. This evidence is useful to the extent that it is incorporated into a broader nutritional plan. In our current medical, magic substance/pill mindset, we must help interpret these studies to the public so women don't mistakenly create an apparent malnutrition by focusing solely on one food source.

A side effect of the Brewer diet is not only the eradication of preeclampsia in a high-risk population, but the reduction of prematurity rates in that population to 2%. This number is only impressive when you realize that the present prematurity rate is 12.1% in the general population and higher in high-risk populations. According to the March of Dimes, since 1981 the rate of premature birth has increased by almost 30%.

As care providers and teachers, we should check what a pregnant woman is eating from the very first meeting. Assess the strengths and weaknesses of each woman's diet individually. You cannot assume pregnant women are eating well, no matter how educated they are or conscientious they seem to be. Although I spend one entire class and parts of almost al others teaching about pregnancy nutrition, I still find women who are reluctant to make changes or are missing crucial elements, regardless of supreme efforts to eat well.

Amy V. Haas; excerpted from "Prematurity Is Preventable!," Midwifery Today Issue 72

  1. Siega-Riz, A.M., et al. 2001. Frequency of eating during pregnancy and its effect on preterm delivery. Am J Epidemiol 153: 647–52.
  2. Agarwal, K.N., et al. 2000. Impact of the Intergrated Child Development Services (ISDS) on maternal nutrition and birth weight in rural Varanasi. Indian Pediatrics 37(12): 1321–27.
  3. Luke, B., et al. 2003. Specialized Prenatal Care and Maternal and Infant Outcomes in Twin Pregnancy. Am J Obstet Gynecol 189(4); 934–38.
  4. Siega-Riz, A.M., et al. 2003. Vitamin C intake and the risk of preterm delivery. Am J Obstet Gynecol 189(2): 519–25.

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The body has mechanisms for ensuring that its protein needs are met. As the caloric value of food goes up, so does the efficiency with which protein is utilized. If you are getting enough calories, the effective quality (biological value) of the protein you eat actually rises.

In pregnancy, calorie and protein requirements become greater, and the lack of sufficient quantities of either one has more serious immediate consequences. It therefore becomes more important to pay some attention to combining protein sources during pregnancy to be sure one is getting adequate proteins and calories. Increased calorie intake makes protein more available because protein is not being burned for energy needs.

If calories are insufficient, the body will burn available protein for energy instead. When protein is burned due to a lack of sufficient calories, less amino acids will be available for fetal growth and development, for albumin production to expand the blood volume, and to help with uterine muscle growth. This relationship cannot be reversed—that is, if extra calories are ingested but protein needs are not met, the body cannot convert calories to protein in the same way. The pregnancy will suffer in this situation. If a women is not obese and her ingested calories are just one-third less than she requires, half of her protein intake will be burned for energy.

Doctors and midwives will often suggest a diet that provides plenty of protein (90 to 100 grams) but only 1500 to 2000 calories. Reasoning that the woman is eating a high-protein diet, midwives may dismiss a woman's diet as a causative factor when she develops toxemia or premature labor. Quite often midwives will state that a woman was eating well but she became toxemic anyway. A woman can be making good food choices and still not be getting what she needs; women must eat enough calories and protein from nutrient-rich sources to meet their particular requirements.

Anne Frye, in Holistic Midwifery, Vol. I: Care During Pregnancy (Labrys Press, 1995)


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Forum Talk

I strongly feel a need to find an experienced midwife who is willing to pull me under her wing for the next several years. I know I will do best to learn wisdom, rather than textbooks. I'd like to find someone who is willing to teach me all she knows until we both feel I'm ready to go solo. Yet, I wonder how realistic this is? She would need to have a similar stance to birth as I do, that it's natural and requires little to no intervention and that the midwife's role is primarily one of educating, not necessarily baby catching, and hopefully she's within a hundred miles of me! I'm in southwest Oklahoma; is there anyone in this area think they could/would do this or know a midwife who might? I'm also interested in hearing anyone's thoughts and experiences.

Camie


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Question of the Week

Q: My daughter-in-law has had a chronic perineal fistula that flares up every month with drainage, since she was pregnant. Her son is now 15 months old. The tunneling is so deep that surgery would be a great risk for her (possible colostomy due to nerve damage). She also got a staph infection while in hospital and has been on antibiotics a few times. She has been applying lavender and oregano oils to the site. She is still breastfeeding her baby. Any suggestions for healing would be most welcome!

— Bea


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


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Question of the Week Responses

Q: I was blessed with a wonderful homebirth under the watchful eyes and in the warm hands of a two local midwives in the state of Illinois. This was my fourth homebirth and sixth pregnancy. The birth of my eight-pound, four-ounce baby went beautifully. It was not until I got out of the birthing pool and on to the birthing stool to release our placenta that my uterus prolapsed. My midwives did their best and gave me all the information they knew about uterine prolapse. I am reaching out to the bigger midwife community for additional advice about how to treat a prolapsed uterus and maintain uterine health through the rest of my life. I am only 24, and who knows what is in the future. If we choose to have another baby, what will likely happen? Your support, knowledge, and resources would be greatly appreciated.

— Jahmanna

A: Good nutrition, belly support in the form of binding, and "girdles" can be of great help. I also suggest Mayan abdominal massage. Visit a practitioner and also learn the self-massage techniques. They are amazing; I use them just to keep my heart on my uterine health. (www.arvigomassage.com/courses.html#self) Doing kegels is also helpful. Some good herbs for uterine health are dong quai (Angelica sinensis), true unicorn root (Aletris farinosa), red raspberry leaf (Rubus idaeus), lady's mantle (Alchemilla vulgaris), false unicorn root (Chamaelirium luteum). Make sure you are getting enough manganese and vitamins A and C in your diet.

— Demetria

A: It is important to remember that all the muscular and physiological issues involving the uterus are controlled by sacral nerves and that these nerves and their function can have a profound effect on the function and healing of your uterus. It is not a cure for your problem, but if you improve sacral and pelvic biomechanics it can have a profound impact on your future fertility and pregnancies. You should consult a doctor of chiropractic in your area who is Webster-technique certified; you can find a complete list of these physicians at www.icpa4kids.org.

— Paul R. Mahler, D.C.

A: Look into the Arvigo techniques of Maya abdominal massage. Prolapse of the uterus is one of the many symptoms helped by this technique. You can find information on the following: www.earthdancermassage.com and www.arvigomassage.com

You will be able to locate a practitioner near you on Rosita Arvigo's Web site.

— Samantha Ford, CMT, RMT, CHCT, certified ATMAM practitioner

Q: Are there any sources of information regarding the relationship between the throat and perineum during birth—when the throat is tight, the vaginal floor will also be tight?

— Giselle E. Whitwell, doula, board-certified music therapist, Birth Works childbirth educator, certified prenatal parenting educator

A: I haven't seen "written" proof as to the connection between the throat and perineum, but as a L&D nurse, I have witnessed the connection many times and tell my patients about it while in labor. Try encouraging your patients to "blow through a straw," literally or figuratively, the next time they are holding back their baby or they cannot void for whatever reason. You can see a difference in perineal relaxation when blowing through a straw because your jaw is relaxed then. I use this technique quite often when a patient can't void because of an ITN, swollen bottom from stitches, or cesarean section and low and behold, most of them easily void with a little patience and a straw.

— Anon.

A: In Switzerland where I trained as a physical therapist, we were taught that a Danish professor (Van Vanderheiden, I believe) once tested the connection between the female tongue and mouth with the cervix and vagina—a fact which deep (tongue) kissing reaffirms. For the past thirty years I have been teaching a form of Swiss Deep Relaxation to childbirth educators, doulas and mothers, based on this principle. Although invisible to all those around her, a mother who lets her tongue go slack is bound to have a soft cervix very soon. For extra measure, try visualizing blood flowing around in the tip of the cervix—warming it. This too is believed to soften the cervix by improving blood flow to the uterus. During the past three decades, many mothers who read about this in my book (Natural Childbirth the Swiss Way [Prentice Hall, Inc.]) have written to tell me how well these little tricks worked. Try it and let me know.

— Esther Marilus, director of Swiss Antenatal Fitness & Education


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Question of the Quarter for Midwifery Today Print Magazine

We hope you'll take a minute to consider the Question of the Quarter for Issue 74 of Midwifery Today. In fact, if you send us a response and we use it, we will send you a free copy of the next issue if you are not already a subscriber. Responses are subject to editing for space and style. Try to keep the word count at less than 400. E-mail responses, along with your mailing address, to: mgeditor@midwiferytoday.com.

Theme for Issue No. 74: Complications
Question of the Quarter: What is the worst complication you have dealt with? How did you handle it?
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Feedback

After experiencing a horrible full-blown case of toxemia with my firstborn child that led to an emergency c-section nine weeks early and 10 days in the hospital for me and three weeks for my three-pounder, I vowed to find a cure.

My next pregnancy was clouded with doctors suggesting "low doses of baby aspirin," three gallons of water a day, and no salt. I took matters into my own hands and followed the Brewer diet to the letter (much to my doctor's disapproval). To prove it was working, I told my doctor I would go off it for four days. I swelled up like a balloon, and my blood pressure went to 165/130. After a week back on the diet, all my symptoms vanished. I was blessed to have two more VBACs and healthy pregnancies because of Dr. Brewer. I owe my health and the health of my babies to him. My OB was so impressed he now uses the diet for his clients. I believe *every* pregnant woman should follow the Brewer diet. You have only 40 weeks to make a perfect baby.

L.W.

I would like to respond to Judy Slome Cohain and her claim that some women have a pathological fear of the hospital [Issue 7:6]. I used to think this idea was crazy. I read about it in "Silent Knife" when it first came out in the early 80s. I had recently had a cesarean. I now believe it with all my heart, although most people think I am nuts. I had my first son in the hospital. I was not overly concerned when I went there, and according to medical community standards, everything went well. However, I was left terrified of going back. I wanted another baby but was very afraid of returning to the hospital. With my second son, I would start labor and head for the hospital. Labor would stop before I would reach the hospital. This happened several times. Finally, three weeks after my due date, my water broke. Two hours later, my son was born by c-section. Now I was even more afraid.

During my third pregnancy I was seeing a doctor (to please my husband) and a midwife while I worked on convincing him of the safety of homebirth. I read everything I could find. I ended up with a hospital birth again because my daughter died at six months, and I had to have labor induced since I didn't ever start on my own. My third and fourth sons were born at home. There is no comparison. Both deliveries were wonderful, and I wish all my sons had been born at home (my cesarean I now know was not necessary). Women are afraid, and fear can stop labor. I strongly believe it is time for doctors to acknowledge that their methods can be a stronger cause for fear than labor or delivery itself. Maybe then they can try to humanize the experience for the women who choose (or must) use their services.

Karen Current

I too had to comment on the position (soles together) offered by Mary Jo Terrill [Issue 7:4]. A little more than one year ago I provided labor support for my sister-in-law, who instinctively chose this position. It was her first baby, and the birth took place in the hospital where she had worked very hard to avoid having an I.V. and to be allowed freedom of movement. She had progressed wonderfully through labor but encountered some initial difficulty when it was time to push. After a little experimentation with different positions, she instinctively chose to push in a position almost exactly as Mary Jo describes. The only exception was, she held her feet herself (soles almost touching) and could nearly pull them to her nose! In my inexperience I kept encouraging her to try more upright positions, and her OB voiced concern about the stress she was placing on her knees. Despite our suggestions, she kept on in this position and went on to deliver an OP baby, with a 14-inch head, over an intact perineum—one and a half hours from the first push. How she managed to do that has always baffled me until now!

Jennifer Dean, BS, CCCE

I am a senior in high school, and I am considering training to become a midwife. My sister-in-law had a midwife for her third birth and said it was wonderful compared to going to the hospital. I live in Idaho, and I was told you don't have to have gone to school to be a midwife here. Obviously it would be safer to have gone to midwife school, but is it true, or do you have to have schooling to become a midwife in Idaho? Also, I would like to know if anyone knows of a midwife college in Idaho.

Marie

I just wanted to share the update on the case of stroke during pregnancy that was listed in the Question of the Week Responses [Issue 7:5]—for what's it worth! [See letter below.]

Amy V. Haas, BCCE

From the Mom:

The neurologist thinks I can allow labor to happen naturally, so I guess it's not only the OB's decision, but his and the hematologists' as well. The neurologist had the blood results from when I was in the hospital, which showed my blood protein level is 58 versus the normal range of 65–120. This means my blood has a propensity to clot. Now, we don't know if this is "normal" for me in general or if the protein level dropped because of the pregnancy. He still wants to do a heart test after I give birth.

He says that people who inject themselves with blood thinners need to stop before they have dental work, surgery, etc., and people have that small window of time where they *can* get a clot/stroke, but it's such a slight chance of actually having a stroke/clot again versus *never* injecting yourself with the medicine. So, technically I can be OK if I deliver without this medication or with an IV of heparin for a few days. If tests show there's nothing wrong with the heart, then the most likely treatment would just be blood monitoring for a while afterward. But if having low protein levels is "normal" for me *after* I give birth, then I just need to take aspirin for the rest of my life. Simple, huh?

It is most probably/definitely a stroke because of the protein count/clotting theory, and the damage in the brain corresponds to the area where the numbness/tingling is.

The hematologist I saw today thinks the blood clot/stroke thing was a freak thing—my blood protein level is a bit lower than normal, but it's perfectly OK because it's due to the pregnancy—nothing to be alarmed about. There is no sign of cancer, disease, etc. He believes I can deliver naturally and will discuss with the OB about not inducing. The only concern is being on the shots of Fragmin and I absolutely cannot have an epidural—period! And I wouldn't need an IV or anything like that to replace the blood thinners (heparin) while in labor. It's a huge weight off my shoulders—I'm excited. Just want me to continue to be on the Fragmin to ensure that things continue to go well.

[Later] The OB said it's fine to deliver naturally! She said that when labor begins, to stop doing the injections of Fragmin—ideally it would be nice to have it out of my system in 48 hours, but I doubt the labor would be that long. But both OB/hematologist feel there should be little risk to delivering naturally with Fragmin in the system. She just asked that if contractions are about 15 minutes apart or feels like it's getting progressively stronger, to give her a call so they're aware of it and see how labor progresses.


Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


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