The other day I was reading through some blogs and came across a story about the correlation between Vitamin D deficiency and an increased risk of C-sections. The article, Vitamin D deficiency ups risk of C-section deliveries, study says, is featured in Scientific America. Funnily enough, that same day, one of my students came up to me before class informing me that her general care practitioner notified her that she is deficient in vitamin D and asked if I knew the correct amount a pregnant mom should take? Well, I didn’t know that information off the top of my head, but told her I would look into it especially since I had just read about the relationship between vitamin D and cesareans.
So, I spent some time today searching around the internet for this information and even called my own doctor. He didn’t know the correct amount, either. I did find a recent article that explains how much a pregnant mom should consume daily. According to the Vitamin D Counsel, “Of particular concern is a deficiency of the vitamin among pregnant women, as low levels can have a negative impact on both the mother and the child. Unlike the United States, the United Kingdom has specific dose recommendations on Vitamin D for pregnant women: 10 micrograms daily. Pregnant women in the United States, however, generally follow the guidelines for adequate intake for all adults at 5 micrograms per day (200 IU).
Pregnant women who are Vitamin D deficient are at increased risk of preeclampsia, gestational diabetes, and bacterial vaginitis. Some studies show that infants born to Vitamin D deficient mothers may be at greater risk of low birth weight, lower respiratory tract infections, asthma, and weak bones.” Another concern is Vitamin D is definitely involved in muscle strength…. contractions of the uterus [which is made of smooth muscle] may not be performing as well as they could be,” making it difficult for the woman to help push the baby out herself.
Sunlight exposure is a good way to get Vitamin D, since exposure causes our bodies to produce it. However, with winter coming on, I would suggest exploring other options to get vitamin D. I typically try to get my nutrients from whole foods (meaning not processed foods, not from the supermarket). With that in mind, here is a list of foods rich in Vitamin D
Cod liver oil 1 tablespoon 1,360 IU (International Units)
Salmon, chinook, baked/broiled, 4 ounces 411.00 IU
Sardines, canned in oil, drained 1ľ ounces 250 IU
Shrimp, steamed/boiled 4 ounces 162.39 IU
Orange juice, fortified with vitamin D 8 ounces 100 IU
Cow’s milk, 2% 1 cup 97.60 IU
Cod, baked/broiled 4 ounces 63.50 IU
Egg, whole, boiled 1 each 22.88 IU
Along with Vitamin D, there are some other nutrients that will help prepare your body for labor and postnatal healing. Here are some suggestions:
FOR LAST MONTH OF PREGNANCY
BY: Sandra Fields, CNM, NYC Home Birth Midwife
Food suggestions contributed by Luisa Gui
TEA COMBINATION DRINKS:
Raspberry Leaf Alfalfa Leaf Comfrey Leaf
(all of these teas help to tone and strengthen the uterus) 2-3 cups a day
YOGURT AND ACIDOLPHILUS : daily, 8 oz . prevents yeast infections
COOKED GREEN LEAFY VEGATABLES DAILY : Good for Vitamin K source to stop hemorrhaging
INCREASED POTASSIUM FOODS: fish, soybeans, fruits and veggies to help in the muscle strengthening
DECREASE SALT INTAKE: only in the last month
VITAMIN C 3-5 grms./day, calcium ascorbate powder in juice prevents perennial tears. ½ tsp. 4x/day in juice. Food options: Citrus fruits, bell peppers, green beans, strawberries, papaya, potatoes, broccoli and tomatoes
VITAMIN E: 600 IU’s daily, prevents jaundice in baby and promotes tissue elasticity and muscle strength. Food options: Vegetable oil, wheat germ, nuts, spinach, fortified cereals
ZINC: 10-15 mgs./daily, 1-2 weeks before due date. (This could already be in prenatal vitamin, please check) promotes more rapid and efficient labor and tissue elasticity. Food options: Red meats, poultry, beans, nuts, whole grains, fortified cereals, dairy products
VITAMIN B COMPLEX : 50 mgs of this 2x/day and only 1x if in prenatal vitamin. This protects you from stress during labor and birth. Food options: Whole grains, fortified cereals, wheat germ, organ meats, eggs, rice, berries, legumes, meat, poultry, fish, liver, chicken, spinach, bananas, kale, broccoli, brown rice and oats
PROTEIN: maintain 80-100 grams a day. Food options: Red meats, poultry, beans, nuts, whole grains, fortified cereals, oysters, dairy products
PERENNIAL MASSAGE NIGHTLY
Here is a recipe from Luisa Gui called “Green Extravaganza Pesto Farfalle”:
Start with a bunch of dark leafy green vegetables to boil or steam. For example, broccoli, kale and spinach. (A very powerful team of Vitamin A, E, C B6, Carotene, Folic Acid, Iron and Calcium)
After boiling the three ingredients, strain and put in a blender.
Add a small handful of walnuts (rich is B1, B3, B6, Folic Acid, protein and zinc)
Enhance the mixture with a bit Parmesan cheese (high in Calcium, B2, B3 and protein)
Add a few drops of lemon juice (good source of Vitamin C)
Add a few drops of olive oil (good source of Vitamin E) and a few drops of low sodium soy sauce or tamari.
Blend all together until the texture is creamy
After preparing your al dente pasta of choice, it could be whole wheat pasta, kamut, spelt, get creative! Save a little of the pasta water to add to the combination of the pesto mixture and pasta to maintain a smooth consistency.
Top your pesto pasta with raw butternut squash flakes by grating the squash with a cheese grater. (Adding a pinch more Vitamin A, B,C and Carotene)
Before putting the fork in your mouth, take a moment to feel the warmth of the food and smell the ingredients. While you eat, look at the food, as recommended in Ayurveda. You and your baby will be happy and feel all the love of nature.
November 30th, 2009
“Cervical dilation” and “effacement” are terms that you will hear your care provider talk about toward the end of your pregnancy and throughout your labor. These terms refer to the opening and thinning of the cervix. Dilation is measured in centimeters, from 0-10cm, and being at 10 cm means that you are fully dilated and can start push when you feel the urge to do so. Effacement is the thinning and shorting of the cervix measured in percentages, from 0-100%, and being at 100% means your cervix is paper-thin.
It is not uncommon for me to hear students come in and proclaim that they are 1cm dilated and expect labor to start any moment. Realistically, that is probably not going to happen. You can walk around dilated for several weeks before the onset of labor. As a labor support doula, I am more interested in how effaced a client is than how dilated. If the cervix is not shortening and thinning it doesn’t really matter much that it is has opened a bit. The cervix will not open significantly if it is not effaced very much. Once the cervix is on its way to fully becoming effaced, change in dilation will often happen.
What can you do to help effacement? The cervix becomes soft or effaced by the secretion or application of prostaglandins. “Prostaglandins are produced by the mother’s body as well as by the fetus and placenta.” (Holistic Midwifery pg 190) However, there are some other nonpharmaceutical ways to help ripen the cervix. Since semen contains prostaglandins, sexual intercouse is one of the best, natural ways to apply prostaglandins directly to the cervix. I know that toward the end of pregnancy, that may not seem all that appealing, so you can also insert evening primrose oil directly into the vagina. Please note: THIS IS NOT TO BE DONE IF YOUR MEMBRANES HAVE BROKEN! The recommended dosage is 2,500mg capsules a day. This can also be done by taking the oil capsules orally if you are not comfortable with inserting it vaginally.
Another natural method is called “stripping the membranes,” but again, note: THIS PROCEDURE NEEDS TO BE PERFORMED BY A MIDWIFE OR DOCTOR! It is done by the doctor or midwife inserting two fingers inside the cervix and separating the amniotic sac from the cervix. This may stimulate the body’s natural production of prostaglandin. “In two studies, sweeping the membranes successfully induced labor in half the cases attempted.” (Ina May’s Guide to Childbirth. Pg 216.)
If your cervix is not ripening on its own and, for a medically sound reason, your care provider is advising you to be induced, you will receive a vaginal suppository of either cervidil or cytotec. These both contain prostaglandins to help soften the cervix and make it favorable for dilation.
Take a look at the picture below to get an idea of how the cervix shortens and thins out.
Before moving on to discussing dilation, I also want to take a moment to mention the mucus plug. This is just an accumulation of secretions that forms a seal in the cervical canal. Its main function is to create a barrier for infection. As the cervix starts to change, the mother will notice the passing of the mucus plug. Some women describe it as clumpy mucus others experience the release as more of a stringy mucus discharge. The color can be anywhere from pinkish to slightly brownish. The passing of the mucus plug does not guarantee the rapid onset of labor, just an indication that some change is starting to happen.
Cervical dilation can best be described as the baby’s head pushing through a turtleneck sweater. It is the downward pressure applied directly to the cervix that causes the cervix to open. A well-applied head is regarded as being more efficient at dilating the cervix during labor. This pressure is made possible by the uterus contracting around the baby and pushing it downward. Gravity also helps apply pressure to the cervix, which is why squatting can be so beneficial and productive. If you are either stalled in labor or hit a plateau in dilation, it could be a result of poor fetal positioning. Read “Explanation of Fetal Of Position” for more details.
Although this is not to scale, you can get an idea of how the cervix widens and thins until there is no cervix left, at which point full dilation (10 cm) has been reached.
Also keep in mind that second or third time, mothers tend to dilate more, up to 3 or 4 cm before labor even starts. Some mothers may experience this kind of dilation for several weeks before the onset of labor.
The whole reason I was prompted to write this blog was the many questions and concerns that have come up in class. One mother was particularly concerned about doing yoga at 37 weeks pregnant, being 1cm dilated. I always refer to the care provider should there be a medical reason I am unaware of, but for most women, it is fine to continue your yoga practice right up until labor, dilated or not. I wish I could say yoga will help further efface or dilate the mother’s cervix and start labor. The best I can offer is that the yoga practitioner walks (or waddles) out of class more relaxed which is good for the hormonal cocktail that supports labor. But as far as I know, it can not jump start your labor.
November 19th, 2009
In the past week I have heard two rather disturbing stories from my students. One student came back and told me the unlikely unfolding of her birth story: the mother hit her due date, and the doctor predicted she was going to have a baby weighing nearly 10 pounds. Because of this “guestimation” on the baby’s size, the doctor strongly urged the mother to have a cesarean birth due to concerns about shoulder dystocia. The mother reluctantly agreed to have the surgery and gave birth to a beautiful baby girl weighing in at 8 pounds, two ounces. The second story involves a second-time mother, approaching her due date. She had a very quick delivery with her first child, giving birth to a 7-pound baby two weeks early. Her doctor, like in the first case, is concerned that this baby will be too big for the mother to birth, so she wants to induce on her due date.
What’s the moral of the story? There can be a significant margin of error in estimating fetal birth weight and these doctors may be practicing out of fear, or what I call “defensive medicine.” They are assuming there is a problem before a problem presents itself. I do have empathy for the position the doctors are in since obstetrics can a tricky field. The care provider is responsible for the well being of the mother and the child, but there needs to be some trust that the human race would not have survived if our bodies were inherently broken.
Back to the topic -Estimation of fetal weight. The average error in birth weight predicted by sonogram is estimated to be between 6 and 15 percent. That seems to be a pretty big margin of error to take into consideration where the options of induction or undergoing major abdominal surgery are concerned. It is also important to keep in mind when in the gestation period these estimations are being made. Sonograms obtained before 37 weeks resulted in fewer errors in predicting true birth weight than sonograms obtained after 37 weeks gestation. If the pregnant mother is continuing to have sonograms to estimate the fetal weight up to the end of her pregnancy, there is going to be an even higher chance of miscalculation. An article published by ACOG American College of Obstetric and Gynocology states, ” These estimations can also be significantly less accurate in infants less than 2500 g [5 pounds 8 ounces] or greater than 4000 g. [8 pounds 13 ounces]” So if your care provider is telling you at 41 weeks that your baby is estimated to be over 9 pounds, you may want to take into consideration the higher chance of inaccuracy when making a decision of what to do with this information.
This brings us to the question: what are the risks of delivering a “big baby?” I would like to interject that I have seen perfectly healthy large babies - over 9 pounds - born vaginally. My own doctor agreed that most of the time big babies can be born vaginally if the baby is in a good fetal position. The main risks are: undetected gestational diabetes (which means the baby could be at risk of having a low blood glucose level), third- or fourth-degree vaginal lacerations, and an increased risk of cesarean. The most disconcerting risk, which is very rare, is shoulder dystocia. Shoulder dystocia occurs when the baby’s head is delivered but the anterior shoulder is caught on the mother’s pubic bone or, even more rarely, when the posterior shoulder is caught on the mother’s sacrum.
The overall incidence of shoulder dystocia varies based on fetal weight, occurring in 0.6-1.4 percent of all infants between a birth weight of 2,500 g (5 lb, 8 oz) and 4,000 g (8 lb, 13 oz), increasing to a rate of 5-9 percent among fetuses weighing between 4,000 and 4,500 g (9 lb, 14 oz). Although rare, there are risks for both baby and mother. The RCOG, Royal College of Obstetricians and Gynecologist state 10% of babies may experience brachial plexus injury, temporary nerve damage of the baby’s neck, with only 1% suffering permanent nerve damage. The baby may also experience a fracture of the clavicle (collar bone) or humerus (arm) bone. In the vast majority of the case, these injuries heal without a problem. In extremely rare and severe cases, hypoxic injury or death may occur. The mother may also suffer injury from shoulder dystocia, and the possibilities include: 3rd degree vaginal tears, postpartum hemorrhaging and the emotional impact of a traumatic experience.
It may seem overwhelming and even scary to read about possible negative outcomes from shoulder dystocia, however it is important to see the numbers in context. The chance of occurrence is very low and the chance of permanent damage extremely low. Many people may think that the best thing to do with suspected big babies is to jump straight to induction or schedule a cesarean. Although research from the American Academy of Family Physicians states differently: Evidence is lacking to support labor induction or elective cesarean delivery in women without diabetes who are at term when a fetus is suspected of having macrosomia. In two studies of 313 women without diabetes, induction for suspected fetal macrosomia did not lower the rates of shoulder dystocia or cesarean delivery, nor did it improve the rates of maternal or neonatal morbidity. ACOG holds strongly to its position of NOT inducing suspected large babies.
There are several maneuvers that the care provider can use to help dislodge the baby should it get stuck. For example, the Gaskin Maneuver, named after midwife Ina May Gaskin, has undergone numerous studies with very positive outcomes. The Department of Obstetrics and Gynecology at Vanderbilt University Medical Center is one example of such a study: . The Gaskin maneuver is really quite straight forward. Get the mother into a hands-and-knees position. This will change the diameter of the pelvis up to 20mm and may dislodge the shoulder from the pubic bones. The results and conclusion of the study mentioned above are very positive, with no maternal or perinatal mortality occurring. Morbidity was noted in only four deliveries: a single case of postpartum hemorrhage that did not require transfusion (maternal morbidity, 1.2%), one infant with a fractured humerus and three with low Apgar scores (neonatal morbidity, 4.9%). All morbidity occurred in cases with a birth weight > 4,500 g (P = .0009). CONCLUSION: The all-fours maneuver appears to be a rapid, safe and effective technique for reducing shoulder dystocia in laboring women.
This information is so important take into account when you may be considering an induction or cesarean birth due to estimated fetal weight. It is upsetting how many times expectant mothers come to me and tell me their doctor wants to induce them for suspected big babies. Some of these mothers are even encouraged to be induced before their due dates! The birth of your child is something that you will carry with you for the rest of your life. It is the first introduction for your baby into the world and the first of many experiences you will share with your child. If it is not a medical necessity to be induced, allow yourself and your baby the opportunity to see how your story together starts on its own.
November 11th, 2009
