November 22, 2006
Volume 8, Issue 24
Midwifery Today E-News
“Neonatal Hypoglycemia”
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In This Week’s Issue:


Quote of the Week

"We doulas and midwives must…protect the sanctity and intimacy of the birthing family, not take on the event as our own."

Heather Hilton


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The Art of Midwifery

When a laboring woman goes to a hospital to birth and you want to keep her upright and moving, have her partner pile all the labor things, suitcase, etc., on the bed immediately so that the mom isn't drawn to the bed and the nurse doesn't ask the mom to get in the bed. If that's not practical or it doesn't seem the hospital personnel will cooperate for long, try injecting comments such as, "Many women find that their labor is much quicker if they stay out of the bed" and then make up a comfy rocking chair or draw the bath. Perhaps if the practitioner continues to emphasize that being upright and moving may shorten labor—even if it's only the perception that it's shorter—may direct their attention to non-bed positions.

Anon.
Midwifery Today Forums

Try putting practical things on the bed—like a beanbag chair—So the woman labors over the beanbag on top of the bed.

Allison
Midwifery Today Forums


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.


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Passionate Midwifery Education

Elizabeth Davis

In a Midwifery Education class at Midwifery Today's conference in Bad Wildbad, Germany, on October 26, 2006, Elizabeth Davis outlined some beautiful concepts for Midwife Educators from around the world.

According to Elizabeth, the first principle of Midwifery Education is confidence-building. She tells us, "Never separate a woman from her confidence." That applies to you as a student as well as to the women you serve.

She also helped us explore the concepts of compassion, caring, being a confidante, respect, passion and patience. These threads are important in the program you choose and should be the hallmark of the midwifery teachers in your program. As I have said before, you should be treated with respect and dignity as a student because you will be entrusted to the highest calling I can think of—caring for the mother and her baby.

Elizabeth asks: "How does my program cultivate these capabilities with skill and relevant information." How does your program?

She tells us that a midwife is a midwife because she has danced with fear. She tells us that a midwife honors things for themselves. She likes being at the portal of life and death. During dramatic changes midwives are there. We are trying to recreate in others the full scope of being with the woman at all stages of life. We want more for women and for ourselves. Does this describe you?

Before embarking on this long journey, first test whether midwifery is for you. Elizabeth has a nice self-test where women take the "Heart and Hands" workshops to determine whether midwifery is what they want to do with their lives. Remember that midwifery takes all the love you have to give, and then some more. It can overtake your life, and because it requires such dedication it probably should. We can talk about balance later.

love, Jan
Jan Tritten, Mother of Midwifery Today

To read all installments of our column on midwifery education, go to our Better Birth and Babies Blog.


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Neonatal Hypoglycemia

Simply put, hypoglycemia means less than a "normal amount" of circulating blood glucose (blood sugar) below which harm will occur. Under "ordinary circumstances" the adult brain and central nervous system are obligate consumers of glucose. Like hypothermia, hemorrhage-induced hypovolemia and hypoxia, glucose deprivation, is a major stressor, a challenge to the homeostasis of any mammal. Just like any of the above stressors, prolonged acute hypoglycemia will result in brain damage or death.

What remains complex is how to define "ordinary conditions" and a "normal amount" of neonatal blood glucose concentration. The normo-glycemia range in adults is 3.9 to 6.1 mmol/l (70–110 milligrams per deciliter). These numbers have been calculated statistically using a blood glucose concentration of more than 2 standard deviations above and below the mean for populations of well adults. A similar glycemia index for neonates is problematic as regards definition, significance and clinical management.

Definition

There is no medical consensus concerning the normo- to hypoglycemia cut-off point. A review of 35 pediatric textbooks and a survey among 178 pediatricians revealed a combined range of normal from less than 1 to 4 mmols/l. More recent research has demonstrated normo-glycemia concentrations from less than 1.5 to 6.2 mmols/l for healthy term infants and from 1.4 to 5.3 mmols/l. Healthy breastfed infants have lower blood glucose concentrations than do infants who are fed artificial formula.

A large retrospective observational study examined the effects of hypoglycemia in a convenience subset of 661 preterm infants who weighed less than 1850 grams at birth and survived the first 48 hours. No baby was exclusively breastfed. The findings of this seminal study indicated that, in this group of sick, very low birth weight babies, those who had blood sugar concentrations lower than 2.6 mmols/l on five or more separate days had adverse neurological outcomes. Instead of suggesting that these sick grossly preterm infants be closely supervised, findings were extrapolated to healthy term infants during the first three days postnatal. Recommendations for practice suggested that neonatal blood glucose levels be routinely maintained at or greater than 2.6 mmols/l for all babies from birth regardless of GA and health.

Since 1988, 2.6 mmols/l has been a widely used definition of neonatal hypoglycemia. This means that extrapolated data informs policy and practice in many maternity units both in the UK and the United States. Because of these recommendations, healthy babies are often screened (drawing blood through heel or finger pricks) and supplemented with artificial feeds accordingly. It would be as if the rationale supporting postnatal maternal feeding policies were underpinned by research demonstrating that some mothers who developed gestational diabetes had neurological sequelae following successive episodes of postnatal hypoglycemia. Suppose all mothers who declined to eat after birth were screened for hypoglycemia and fed an artificial energy drink via naso-gastric tube in the early postnatal period!

Even though these views have been recently challenged by a number of experts in the field, most hospital policies continue to use 2.6 mmol/l as the cut-off point to define neonatal hypoglycemia.

The first recommendation for treatment is always to "feed the baby." Again misunderstanding of the physiological design behind the relatively small amounts of early mother's colostral milk prompts supplementation with artificial milk. However, giving bottles of artificial formula does not always raise blood glucose concentrations. Recent research has demonstrated that giving artificial formula feeds to supplement or complement breastfeeds suppresses ketogenesis, in an inverse relationship to the amount of artificial formula given. This routine practice often disturbs breastfeeding. For the metabolically compromised infant, exclusive bottle feeding may exacerbate the very condition it sets out to treat. In the eyes of the physiologist, early mother's colostral milk and artificial formula milk are not interchangeable!

A Neonatal Perspective

The adult brain is an avid consumer of glucose. Findings from studies on rats and human neonates where early diet was composed of exclusive colostrom suggest that neonatal body economy may be regulated differently from that of the adult. The HPA axis of mammals is not fully functional throughout the mammalian life cycle. During pregnancy and the first weeks of postnatal life, the relatively dormant state of the HPA axis "raises questions of whether glucoprivation is a true neonatal stressor as the term applies to the adult" (Widmaier, 1990). For Widmaier, it is clear that an understanding of the regulation of neonatal glucose homeostasis in the first days postpartum goes hand in hand with an understanding of the development of the HPA axis at the same period. Widmaier compares the stress of hypoglycemia to hypoxia. In adult mammals hypoxia results in a rapid predictable increase in the activity of the HPA axis. However, hypoxia fails to elicit much of an increase in plasma ACTH or glucocorticoids in neonatal rats. Although hypoxia is one of the most common and potentially damaging stresses for the neonatal mammal, there is a relative neonatal resistance to the effects of oxygen deprivation at least in the short term. Faced with an hypoxic episode, [the neonate experiences] a unique compensatory ability that is subsequently "lost in the adult."

Research concerning human neonates demonstrates that the newborn infant relies upon a number of mechanisms that may offer protection from the effects of the physiological systemic glucopenia that commonly occurs during the first days postnatal. These include intracerebral glycogen stores, low glucose requirements, modulating cerebral blood flow and utilisation of alternative fuels, such as lactate and ketone bodies.

Ketosis, although usually pathological for adults, may reflect appropriate and counter-regulatory neonatal physiological responses. The neonatal rat is well equipped to use ketone bodies for energy even in the fed state, and ketone bodies begin to rise dramatically in neonatal plasma within the first 24 hours after birth. Like mother's colostrum, rat colostrum has a high fat content. [According to one researcher], it is not surprising that the neonatal brain would be biochemically competent to make efficient use of this fuel source. Similar patterns of metabolic adaptation in healthy term breastfed human neonates of appropriate birthweight for gestational age have been characterised. Their findings indicate that when blood glucose concentrations are low, ketone body concentrations are high. Ketone bodies result from the beta oxidation of fatty acids utilising either body fat stores or fat from milk. Hawdon's research on human neonates shows that ketone body concentrations peak on the third day postnatal. This has been called suckling ketosis, and probably provides an alternative cerebral fuel particularly well adapted to the needs of the neonatal brain. Hawdon highlights that there is no doubt that hypoglycaemic brain damage does occur, but the severity and duration of low blood glucose levels required to cause harm varies between subjects and is related to the ability of each baby to mount a protective response.

More recent research evidence suggests that healthy but moderately preterm infants (34 to 36 completed weeks' gestation) and healthy small/large for gestational age infants generate ketone bodies like healthy term infants when they are wholly breastfed. We found that the ability of these healthy but vulnerable infants to generate ketone bodies was largely related to breastfeeding/supplementation strategy.

Suzanne Colson
excerpted from "Womb to World: A Metabolic Perspective"
Midwifery Today Issue 61

Reference:

  • Widmaier, E.P. 1990. Changes in responsiveness of the hypothalamic-pituitary-adrenocortinal axis to 2-deoxy-D-Glucose in developing rats. Endocrinology 126(6), 3116–23.

The full article is extensive and contains much more information about neonatal hypoglycemia plus a list of references. Make sure you have a copy of Midwifery Today Issue 61 so you can read the entire highly informative article:
Midwifery Today Issue 61

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News Flash

Save the Children announced earlier this year that worldwide, more than 4 million newborns die annually, and 99% of the deaths are in developing countries. The first hours after birth carry the greatest potential for infant death. The organization reports that many lives could be saved by simple means such as sterile blades for cutting the umbilical cord, antibiotics, and caps to keep the babies warm. Newborn death rates are highest in South Asia and Africa; some developing nations, however, have improved their infant survival rates, among them Indonesia, Nicaragua and the Philippines.

— wire service, May 2006


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Web Site Update

Read these articles from Midwifery Today Issue 79 newly posted to our Web site:

  • Eve's Foundation—by Florence Okra
    Common Ghanian myths about pregnancy and childbirth and the remarkable work being done by Eve's Foundation to educate women about the facts are covered in this article.
  • Do I have to leave my country and home to have my baby sanely?—by MorningStar
    A volunteer at the famous Mexican midwife hospital, C.A.S.A, recounts the birth story of a woman who came from the US to heal the wounds from her first birth while avoiding another c-section.

Advertising Opportunities

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Forum Talk

I recently did some (limited) research on the difference between the old hemoglobinometers (the ones that use glass slides and calibration) and the new Stat-Site M hemoglobin analyzer system. I purchased the Stat-Site and used it for the first time yesterday. I was pleased with the ease and simplicity of the system; however I wonder how it really compares to the old meters. I never had one myself, but used my midwife/mentor's a few years ago. Has anyone else used both and can share insights into the differences—pros and cons?

Anon.


Go to our forums to share your thoughts and experience.



holly

Midwifery Today Magazine Issue 68Give the gift of information! You'll save $5 per subscription when you order two one-year Midwifery Today subscriptions at the same time. And one of these can be your own renewal or new subscription!
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Question of the Week

Q: Thank you for the recent informative issue on the perineum. This is an incredibly tender subject for me. I had a third degree tear that still haunts me to this day, even though it has long healed and my daughter is now 16 months old. I wonder every day whether it has healed properly. I wonder every day what I did wrong to cause such trauma. Being a woman of young maternal age, and having very few stretch marks and a non-assisted delivery, I don't understand why this happened. I had a postpartum checkup six weeks after the birth and my midwife told me it was healing fine, but nothing has been said since and I constantly wonder. I feel broken. How do I know I healed normally?

I have another child due mid-February and I'm terrified. I don't know whether or not I don't want to tear, or if I do want to tear again so that maybe it can heal better. Is that even possible? Tearing again to facilitate better healing? What is "healed" and how do I know if I am? It's not like I can go to a Web site and see what "normal" perinea of women who have birthed children look like. Is it normal to be so utterly hung up on a matter like this? Thank you for your time.

— Sarah
Arizona


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.


Question of the Week Responses

Q: I injured my coccyx during vaginal delivery. The delivery was fine, but I noticed the pain continued after the rest of me was healed. I had an x-ray done one month postpartum and there was no fracture. The pain still comes and goes, and the constant pain in my tailbone even limited my breastfeeding to one month because of the pain. That was a huge letdown for me, and it still hurts emotionally to think I could never get comfortable enough to bond with my baby.

This pain is a constant reminder of how hard my recovery was. Is there anything I can take other than anti-inflammatory medications for the rest of my life? Also are there any exercises and stretches I can do?

— Pam

A: I have had very good success with chiropractics. I would also suggest checking out cranial sacral therapy also as I have had excellent success with it for postpartum treatment of many issues, though I have never personally used it for coccyx pain.

— Tamy Roloff
Long Beach, Washington

A: Please consider chiropractic care with a chiropractor who uses a low force adjusting technique like Basic Technique, Activator, or Equalizer where they use a small hand held instrument or gentle force with their hand to adjust the coccyx. I broke my coccyx when I was 11 and couldn't sit, and now I get it checked for misalignment during each adjustment. My coccyx is broken and bent inward 90 degrees and I have no pain or discomfort. There is no need for you to suffer.

— Kristine Baker, DC
House Springs, Missouri

A: I suggest seeing a doctor of chiropractic who works specifically with the coccyx. I have similar cases in our office that have responded very well. For starters, you can check this referral directory for a chiropractor in your area: http://www.icpa4kids.org/find.htm.

— Jeanne Ohm, DC

A: Did you see a chiropractor to have your tailbone adjusted? I talked to moms who hurt their coccyges during childbirth, and they said a visit to a chiropractor took care of it.

— Tina


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.


Think about It

In his book The Scientification of Love, Michel Odent speaks passionately of oxytocin, the hormone of love. He explains how a birthing woman must release a cocktail of hormones, including oxytocin, endorphins, prolactin, ACTH, catecholomines, etc. Having witnessed many, many times the miracle of pregnancy unfolding into labor and then the astounding advent of a child into the light of our world, I have developed a profound appreciation for oxytocin. The Primal Health Institute's compilation of research has given me the insight into how experiences that cause us to release oxytocin permanently enrich our ability to give and receive love.

When people sit down to a meal as a family, hold hands, kiss, go for a walk arm-in-arm, make love, pray and yes, when women give birth, oxytocin is released. Each opportunity to experience oxytocin creates receptors, molecules of proteins that on a cellular level are binding sites for this hormone of love. In other words love lays the foundation for more love. Practice makes perfect. And the love hormone is monogamous: In our bodies it looks for and binds with only its own receptors.

This explains the profound and permanent transformation from expectant woman into motherhood.

While laboring and giving birth, a woman's body is flooded with oxytocin, making such a wealth of oxytocin receptors that her capacity to love increases exponentially. Women throughout history have been astounded to find that after having a baby they can and do love everyone more profoundly. This is nothing short of a rebirth. Often new mothers tell me how much more they feel appreciation for life itself. For the postpartum woman, colors seem brighter as their eyes feel more open. Food can taste better. Soft music may sound more soothing. The postpartum woman's heart can be so open that she cries easily. A mere smile can inspire tears of gratitude. She is also so sensitive that we must protect her tender and true emotions.

Midwives, being the guardians of gentle birth, are the protectors of women's most significant oxytocin experience. Midwives are the champions of love. Let us also remember to protect the beautiful spiritual bubble that surrounds the newly postpartum woman. New mothers need meaningful, caring contact with their birth attendants. They are tender and extremely open to giving and receiving love. I so enjoy postpartum visits. I know in my heart that they benefit the new mother and her family. What is additionally wonderful is how nourished I feel after spending time with my postpartum mothers.

In the long term, midwives must be open to loving the women they have helped. Childbirth being one's most significant life passage, those close to us when we open to birth a baby will never be forgotten.

I have long said, "A woman is pregnant for nine months, she is postpartum for the rest of her life." The biochemical truth of this is good news for the healing of our planet. Postpartum women are a gentle and essential force of nature. They are full of love, and there can never be too much love.

Robin Lim
excerpted from "Postpartum: Rebirth of the Woman"
Midwifery Today Issue 61


Feedback

I am part of the Yayasan Bumi Sehat clinic in Ubud Bali whose founder is Robin Lim…. Do you any ideas of a qualified midwife who would want to come and help volunteer for the month of December? I know it's short notice, but the lady that was supposed to come cannot. It's free stay at our ashram, 10-minute walk into town. Any other questions, please e-mail me: info@bumisehatbali.org Thanks a lot, and warm regards.

Tania M.


I was so sad to read Erin's letter regarding her occipital posterior (OP) birth [Issue 8:21]. Unfortunately, some women will have OP babies no matter what they do. An anterior placenta can be a factor, a momentary lapse in the good "anti-OP" posture, having to restrict one's positioning during labour due to drugs, drips, monitoring, etc. Also, some women have a pelvis shape that accommodates OP better than occipital anterior.

Birthing practices are not one size fits all, nor are they 100% guaranteed to work. From the paltry amount of research done on optimal fetal positioning (nobody bothers because it doesn't mean lots of money for someone) the so-called statistics are neither conclusive nor reflective of the reality that millions of midwives can vouch for. (The handful of studies that have been undertaken got women to "assume the position" for a short period each day rather than teaching it as a lifestyle change to be practised at all times).

Optimal fetal positioning is valid, low-tech and works a good deal of the time. It is definitely worth the effort. I don't know of any midwives who would blame the woman if it doesn't work—perhaps there are some. But please don't write off this mother- and baby-saving technique—it truly does make a world of difference.

Alison Reid
Brisbane, Australia


I just returned from Zambia. I got to know the head of the Newborn Intensive Care Unit at University Teaching Hospital, the biggest hospital in Zambia. It is *nothing* like an NICU in the US. They have no IVs, no antibiotics and very few other supplies. With some coaxing, I received a list of sorely needed supplies that I know we could gather with little difficulty. I will hand-carry them when I return in the next month or two.

The other project I am collecting for is providing birthing kits for traditional midwives in Zambia, in at least two villages.

I will carry as much with me as I can, so any and all donations are welcome. My address is 882 West 2800 North, Pleasant Grove, UT, 84062. Cell phone number: 801-369-2836. Please forward these lists to any and all groups you might belong to who might be interested in helping.

I have set up a blog for you to see the list of needed supplies.

Holly


Early cord clamping is known to weaken the child and may lead to a deadly or fatal condition, or impairment with learning and behavior problems the rest of his/her life. Anemic conditions must be specifically tested for by a mere prick of the finger, for a drop of blood. It will reveal these conditions, medically caused by early cord clamping, a few hours after the child's birth.

The proper volume and quantity of blood that would otherwise flow into the baby's blood would be 85–100 ml./kg. at birth (Lippincott Manual of Nursing Practice, p. 1032). Thus a 9 lb baby (4 k) will have 10 oz (300 ml) of blood inside his/her body after a full infusion of the placenta blood goes into his/her expanding lungs (World Book, Vol., B [Blood], p. 324).

Fears are not a good excuse to have a cord clamped early, preventing proper blood infusion into the newborn child. This blood infusion is healthy for the baby's expanding lungs. Lungs take a considerable amount of blood to do the gas exchanges that the placenta had done. When there is any early cord clamping—30-second clamping, 1- minute clamping or any clamping before the completion of the third stage of labor—the mother and child risk birth complications and are endangered.

The mother is endangered because the engorged placenta may leak. If the blood is of a different type, or there are known Rh factor risks, the childbearing mother may have her next infant with great difficulty. They may not go full term due to their blood attacking itself, or she may miscarry. She may have to take RhoGAM, made of human tissue and containing questionable ingredients.

The infant who is clamped before the third stage of labor is completed is also at risk of anemia, with low red cells, white cells and platelets. The infant will also be missing the full quantity and quality of substances in the blood such as enzymes, hormones, minerals, vitamins and stem cells.

The Lippincott Manual of Nursing Practice states that up to 60% more blood goes into the infant if the cord is not clamped while pulsating. One must remember to instantly wrap the child, head to toe (to prevent hypothermia), and not touch the umbilical cord in an invasive manner.

Discussing such matters during an appropriate time period—not during the birth—is important.

Donna Young
Dawson Creek, British Columbia

[Editor's note: The preceding letter was excerpted due to stringent space considerations in E-News.]


Birth is an intimate event. It is both personal and universal, and it changes the lives of those who experience it. A woman who gives birth in a supportive and private environment where she feels safe and protected can relax and let go. In many cases, birth culminates in orgasmic release.

The film Orgasmic Birth shows real births in which precisely that happens. Women in Brazil, England, Mexico, New Zealand and the United States who have experienced ecstasy in birth generously permitted their deliveries to be filmed and shown. They wanted to share the powerful joy that a woman can experience when the birth setting frees her to birth as she was meant to do. Interviews with new parents reveal their high level of satisfaction in having their babies in this way. Experts explain what has gone wrong in birth and suggest ways to repair it.

To learn more about this pioneering film and how you can help it to reach as many people as possible, please visit www.orgasmicbirth.com.

Debra Pascali-Bonaro


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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