October 26, 2005
Volume 7, Issue 22
Midwifery Today E-News
“Nutrition and Preterm Labor”
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Quote of the Week

"Whenever a woman reclaims her right to experience birth exactly as she desires, she opens the door to unprecedented joy and fulfillment, while firmly reestablishing the primacy of motherhood in our culture."

Elizabeth Davis

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The Art of Midwifery

I had the honour and privilege to be present at the labour of my friend and catch her baby last night. I had one of those cheap plastic spray bottles filled with water and sitting in a jug of ice on standby. During second stage and that "ring of fire" moment, I sprayed the icy water on her perineum. J. and I had discussed it previously, and she had been willing to give it a try. When the moment came I asked her if she wanted me to do it—I said I would spray once and asked her to just nod or shake her head if she found it helpful. I sprayed once and she yelled "YES!" She said she found it extremely helpful.

I learnt this tip from the Midwife of the Year last week—an LW midwife from Liverpool Woman's, although I adapted it from her idea of trickling the water down the perineum from a container.

Carrie, Edinburgh

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Research to Remember

A Finnish study of 484 babies aged 7 to 18 months revealed a correlation between pacifier use and increased risk of ear infection (acute otitis media). The children were assigned to one of two groups: one group's pacifier use was restricted by 21 percent for several months; the other group's pacifier use was not restricted. The incidence of ear infection among the restricted group was reduced by 29 percent. Researchers recommend that pacifiers should only be used just before sleep and then discontinued completely after 10 months of age.

Pediatrics, 5 Sep 2000

Nutrition and Preterm Labor

A variety of contributing factors are associated with preterm labor and birth. The most common physical reason for preterm labor is inadequate maternal nutrition. Poor nutrition, or a lack of sufficient quantities of good quality foods, can lead to an array of maternal/fetal complications. Perhaps the most well-recognized complication is metabolic toxemia of later pregnancy. However, the contracted blood volume resulting from a poor quality or otherwise inadequate diet can have myriad other repercussions. One of the most common of these is preterm labor.

Depending upon what the diet is lacking, and length of deficiency, labor may begin before, or more frequently just after, the point at which blood volume should have peaked. Lack of adequate blood volume is why hydration with oral or IV fluids is a temporary stop-gap measure which, in some cases, forestalls the onset of labor. Of course, a well-nourished woman may temporarily become dehydrated, and in such cases "catching up" on her hydration may calm the uterus down. However, if a contracted blood volume is the real reason the body can no longer support the pregnancy, hydration will offer no permanent solution. Neither will any drug. Bed rest, while widely recommended for preterm labor, is ineffective [according to American College of Obstetricians and Gynecologists].

If nutritional concerns are addressed and continuously monitored from the onset of care, even women who have a history of preterm birth can go on to have healthy, good-sized, full-term infants in subsequent pregnancies. Ask what emotional and psychological circumstances were associated with previous pregnancies. Often you will discover a preterm labor was preceded by an unduly stressful pregnancy without adequate nutrition to compensate for the increase stress. Discuss with your client whether eating disorders have been a problem, and if so, how have they been dealt with. Encourage all your clients to think of weight gained during pregnancy as beneficial and even protective of their health and their baby's. Watch how each woman is faring as the weeks progress. You must ask specifically if salt, fat, eggs and other foods have been eliminated from the diet. If they have, explain why salt and calories are just as important as protein to maintain an optimally healthy pregnancy.

A jump in weight gain of 5 to 10 pounds often precedes the blood volume peak, which approaches around 30 weeks. The weight gain indicates the body is retaining adequate fluids. While not every woman's blood volume expansion will be signaled in this way, it is a reassuring sign in a well-nourished woman. Be sure not to mistake it for the onset of secondary toxemia symptoms. Restricting the diet during and after blood volume peak can have serious consequences and may precipitate preterm labor even if nutrition has been good until then.

— Anne Frye, excerpted from "The Role of Nutrition in Preterm Labor," Midwifery Today Issue 36

Midwifery Today ISSUE 36 can be ordered.

Be sure a woman's calories and protein intake are adequate for her stress and activity levels. A diet inadequate in both protein and calories leaves mother and baby severely compromised. When a woman eats a third less calories than she needs for her energy output, she burns half of the protein she eats for calories. This may leave a woman at risk for an inadequately expanded blood volume even though she makes high-quality dietary choices.

If you feel your client has some degree of true toxemia, the most important thing is to provide her system with enough fluid and nutrients to try to make up for lost time. Focus especially on protein, nutrient-rich calories and adequate salt. Advise her to eat a high protein item every waking hour. Actual recommendations will depend upon laboratory results and the symptom picture. Initially, daily protein levels should be increased to between 150 grams and 250 grams (200 grams or more with multiple gestations). Your client should also take 500 mg of choline daily. Often, women feel an immediate and profoundly increased sense of well-being.

Monitor your client's progress by repeating the lab test five days later. If the report shows improvement, your client should maintain a high protein intake until all values are appropriate for her gestation. Do a third test four to six days later. If there is no change, she should increase her protein intake. Women with a normal liver will suffer no adverse effects from keeping protein levels this high for several weeks. If the woman has a history of liver disorders, recommend less protein—120 to 150 grams for a single fetus—or her liver may be overwhelmed. Monitor her lab work closely for changes. Once liver enzymes and blood proteins have normalized, the hemoglobin has dropped appropriately, and the fetus is an appropriate size for dates, the woman can cut back to 90–100 grams of protein daily (150 grams or more with multiples). At this point she has caught up with her deficiencies and simply needs to maintain liver support for the duration of her pregnancy so she doesn't get sick again. Because the placenta continues to grow throughout pregnancy, any improvement makes a big difference in the mother and baby's health.

— Anne Frye, excerpted from "Turning Toxemia Around," Midwifery Today Issue 35

Midwifery Today ISSUE 35 can be ordered.

Editor's note: Anne Frye's two previously cited articles and another in Midwifery Today Issue 34, "Unraveling Toxemia," are highly recommended reading.

Midwifery Today ISSUE 34 can be ordered.

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Forum Talk

I had a very traumatic miscarriage last September, as did a friend a month before. She went on to get pregnant again and just miscarried again. Another friend just miscarried over the weekend. The hospitals here insist on a D&C. Is it necessary? Better? Some say if they want to get pregnant again it might be better if they start with a clean canvas. We are all very healthy young women, two of us were RH negative, but did have rhogam after our first. And is there anything in the way of a special ceremony (e.g., blessingway suggestions we could use) to put some closure on these tragedies?


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Question of the Week

Q: I am looking for information for a client regarding septate uterus. She is now 21 weeks pregnant and can find resources only for prevention rather than stats about outcomes or what can be done to attempt to ensure a safe outcome and carry the baby to full term.

— Shari Gorman

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Question of the Week Responses

Q: I am a mom of six and would like to find out how most midwives deal with Group B Strep (GBS)-positive mothers. Are there herbal remedies or are they destined to a hospital birth and IV antibiotics?

— Anon.

A: I am a midwife attending homebirths in Melbourne Australia. I don't usually screen for GBS, so I don't know who is GBS-positive and who is not. I recommend clinical risk assessment as the basis for decision-making. I also do not perform internal exams without a good reason, thereby reducing the risk of infecting the baby. When a woman is labouring, I am observing for signs of infection such as fetal tachycardia, maternal thermal instability, and raised maternal temperature. I would seek to transfer to hospital care if there are actual signs of infection. I don't have access to antibiotics or pathology services in the home.

— Joy Johnston

A: I do homebirths in a rural community, and if one of our mothers tests positive for GBS she needs to have a hospital birth in order to have IV antibiotics during labor. We discuss this protocol with them before moms have the test done at 34 weeks. Right now there are two approved "choices" regarding testing for GBS: One is based on risk factors such as previous pregnancy with GBS, previous preterm delivery. The other is to just "screen everyone." Both are approved by ACOG. Women do need to be educated about the pros vs. cons of screening and what it could potentially mean for the baby (as GBS does not bother the mother) should she be GBS-positive. At this point no research says herbs or oral antibiotics will decrease the risk of transmission of GBS to the baby. Right now it is IV antibiotics in labor. It is a tough choice for a mother who wants a homebirth!

— Anon.

A: I have recently researched this topic as part of my training as an Active Birth Teacher in the UK, and I would like to make the following points:

  • 25% of all women are colonised with GBS at any time, with no symptoms or signs of infection.
  • If the mother is colonised by GBS she will also carry the antibodies, which are passed to her baby in the last eight weeks of pregnancy.
  • Unless the baby is born before 32 weeks, or colonisation is extremely high, or the mother/baby has poor health, the dangers of the baby becoming infected are very low.
  • Less than 1% of full-term babies colonised with GBS develops symptoms.
  • In the UK, where only 1 in 2,000 babies are born infected with GBS, the 2003 guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG) state that antenatal screening and treatment have not yet demonstrated an effect on neonatal mortality and may carry disadvantages for the mother and baby. These include potentially fatal anaphylaxis, the medicalisation of labour and the neonatal period, and infection with resistant organisms. Newborn rates of infection in the United States are 1 in 100 births. Why are they so high?
  • Interventions such as membrane sweeping and artificial rupture of membranes should be avoided as they increase the risk of infection via vertical transmission.
  • Vaginal washing with chlorhexidine may be a useful alternative to antibiotics, although the negative impact of removing the vaginal flora needs to be considered.
  • The following nutritional/herbal remedies may be useful:
    • Echinacea can boost the immune system and help fight bacteria and viruses.
    • Vitamin C helps heal damaged tissue, including amniotic sacs, which helps provide a strong barrier between the baby and the GBS bacteria. It can also strengthen the immune system.
    • Garlic is well-known for its antibacterial properties.
    • Astragalus is an immune system tonic well-known in Chinese medicine.
    • Probiotics contain lactobacilli, which cling to vaginal cell walls, so they may displace the GBS bacteria already present. However, it does not have specific anti-microbial action against GBS as it does with Gardnerella and Candidiasis.

— Paula L. Sims

A: I always screen my pregnant moms for beta strep, and then I treat them according to their general health. I have found very often that supplementation with echinacea 4–6 times per day will strengthen the immune system of most moms, enough to counteract the beta strep. It is best to do this before the test if you suspect the woman may be susceptible. Who is susceptible? The more tired and worn out moms, those who do not eat a good balanced diet, those who eat sugary foods and high carbohydrates and thus lower their immune system's response to conditions such as beta strep overgrowth. Sometimes I give oral antibiotics if I feel it is a serious infection and we don't have much time before delivery. I have also used herbal suppositories vaginally, but they must be safe in pregnancy, so be careful. The medical "gold standard" for beta strep positive moms is to administer IV antibiotics during labor. Many midwives and naturopathic physicians who deliver out of hospital are trained to do this and can administer the IV at home. You may want to research what is possible in your area. Where I practice, my colleagues and I do not transport a woman to the hospital because she is beta strep positive. We treat it during the pregnancy as a marker of her overall immune status and health, and treat during labor. We also carefully monitor mom and baby after delivery for signs and symptoms of infection.

— Katherine Zieman, ND, LM

A: There are several alternative treatments you can try. One of the most effective is to soak a tampon in tea tree oil* and insert it vaginally. Continue this treatment for 5–7 days, changing the tampon periodically. You can also try inserting cloves of fresh garlic, but they will burn if there are any vaginal scratches, etc. A yogurt douche is helpful as well.

— Melinda Kelly, Bay Springs, Missouri
*[Note: the recommendation is 98% olive oil, 2% tea tree oil.]

A: When antibiotics are given to all GBS-positive women in labor, 60% of newborn GBS infection will be prevented. Women who culture positive for vaginal GBS currently have the following alternatives to IV antibiotics in labor:

  1. Chlorhexidine gel inserted into the vagina every four hours in labor.
  2. Garlic cloves inserted into vagina nightly for a few weeks before labor.
  3. Refusing all treatment.

Although chlorhexidine has the potential to kill GBS, there is inadequate research as yet to know whether it can prevent newborn strep disease. In theory, it should work as well as antibiotics (60%).

A protocol on the web http://www.gentlebirth.org/archives/gbsCohain.html is collecting data on women who culture GBS-positive and then use garlic in their vaginas and then reculture. The data so far show that 50% of the women who previously cultured positive, culture negative for GBS after 3–8 days of garlic use. The research is just starting and it is unknown how effective garlic is at actually preventing newborn strep disease.

Some women refuse all treatment. Since GBS-positive women who receive antibiotics still run a 1 in 2000 risk of their baby getting GBS, some women do not want to risk the side effects of antibiotics, when they must be vigilant in any case, about the health of their newborn.

— Judy Slome Cohain

A: I was GBS-positive in my second pregnancy. I had a traditional hospital protocol—IV ampicillin treatment. For my third birth, a homebirth, my midwife used a treatment program that included culturing for GBS at 35–36 weeks and treating with Zithromax if the culture was positive and oral amoxicillin in labour (2 grams at onset of labour and 1 gram every 4 hours, with a goal of 3–4 doses before delivery). I cultured GBS-negative but still had the amoxicillin in labour because her thought is that it is a somewhat cyclical infection, and four weeks is sufficient time to recolonize (the Zithromax to treat and prevent reinfection within that 4-week window). She is a CNM and her attending physician is an MD/MPH who did a fair amount of research into GBS well before the CDC did. They had lost several babies to GBS meningitis early in their practice, before there were any established treatment recommendations. Since they began treating this way, they have had no other cases of GBS meningitis in any births.

The postpartum thrush that *always* seems to follow high dose antibiotics was much less difficult to manage after the oral antibiotics as compared with the IV ones.

— Maureen Huizinga, BA, RN
Glen Allen, Virginia

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.


In response to Issue 7:18, Cesarean Prevention:

As a hospital-based CNM I am also concerned about the increasing epidural/c-section rate in our hospitals, especially now that VBACs will soon be available only to those who choose large hospitals with 24-hour coverage. A lot of this is due to patients receiving their only prenatal education from the television where untoward complications due to meddling are edited out. Our society is one for the quick fix; women do not want to experience pain; they have no labor support except voyeurs who show up at the birthing room to be entertained. The only way anyone could labor in this Grand Central Station atmosphere is to have an epidural. If the staff discourages the traffic in order to help provide a more conducive environment, the families get mad at us.

I do want to clear up the continued misinformation about reimbursement and c-sections. Contrary to what many lay midwives and childbirth educators seem to believe, hospitals actually lose money on c-sections. Insurance companies reimburse providers a flat fee for normal births, perhaps a couple hundred more for c-sections—certainly not enough to make them financially attractive. The hospital is reimbursed a flat fee for patient care. You get the same amount of money for the woman who goes home in 24 hours and the woman who has complications requiring more care. The truth is, the more normal and uncomplicated the birth, the more money the hospital makes because it saves them money. There are plenty of reasons we are seeing the statistics of increased intervention in hospitals. Client demands, physician burnout and fear of litigation are but a few, but getting more money is absolutely not one of them.

— Peg Browning, CNM

My main comment about elective cesarean is, what about the baby? Does s/he have a choice as to whether to be exposed to this kind of birth, including the high rate of injuries, lack of bonding, etc., that this involves? We are so women-centered we forget the baby has no choice.

— Jan Tritten, Founder, Midwifery Today

I can understand women choosing cesarean section given today's birthing climate in the United States. The normal anxiety about birth has been exacerbated by moving birth from home to the hospital, by the assumption that technologically-driven birth is equivalent to spontaneous, undisturbed birth, and by a birthing environment that does not believe in nor support natural birth.

Women are admitted to hospital too early in labor, are routinely given Pitocin, are starved, confined and assaulted continually by strangers. Labor is run on a factory schedule. Scary birth stories are featured regularly on television. Media feature scary stories about the dangers of labor. Injured women and damaged babies are commonplace after hospital birth. Where is the incentive to go through labor?

So it makes sense to me, given that US culture does not value birth, and that women have been frightened about it, that a person would "cut to the chase" and choose to skip labor and go for surgery.

We have some task ahead of us to re-direct national birth energy in view of the fact that denial is a national coping strategy and that there is a generation of healthcare professionals that has never seen a natural birth, don't believe that it is possible, and who are more comfortable with machines than with humans.

— Nikki Lee, RN, MS, mother of 2, IBCLC, CCE

I'm a nursing student, and today I did postpartum care for a Kenyan mother and baby girl. I've heard—and now experienced—that it's a cultural tradition to keep the environment very warm during and after birth. Does anyone know why?

— Kelly

While I agree with 90% of Ms. Lemay's comments about "only mom" holding baby after birth [Issue 7:19], I disagree that it should continue for four hours after birth. Recent research has shown that father/infant bonding is improved if dad holds baby for just 15 minutes during the first hour or so.

— Anon.

Do any readers know where to get netsy cups? I had some 30 years ago with both of my children but loaned them out and never got them back! I have a pregnant daughter now and would love to get some for her as she is planning to breastfeed.

— Angie

It's encouraging that the birth center where I work now has its own reality show on Discovery Health Channel (national TV). The show is called "House of Babies" and will air 26 episodes that feature waterbirths and land births at the Miami Maternity Center, with five licensed midwifes and one CNM (me). They are already planning for a second season. To get a full schedule of episodes go to: discoveryhealth.com

— Angela Bolivar, CNM

I don't have to tell you what implications this has on a local and national level and how much this can do for midwifery. We all know many pregnant women are obsessed with TV shows about labor and birth. As a student I loved watching them too (until I knew better). Of course it's Discovery Health and it's a birth related show, so of course some things if not many things are going to be made dramatic, but how many women all over the country will see this show and think, Where can I have a birth like that? The show airs in the perfect spot, right after Birth Day early in the morning, at midday, and then early afternoon (yes, six times in the same day, two different episodes). Topics already covered or scheduled to be covered: VBACs, waterbirth, the moon and birthing. I've got to say whatever one's feelings are...this is an amazing thing. Check Discovery Health's Web site for more details.


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.

Classified Advertising

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International School of Traditional Midwifery has a part-time job opening for an Onsite Coordinator/Instructor. Ashland is a great place to live and Oregon is a great place to be a midwife. sudy@globalmidwives.org or 541-488-8254

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