March 12, 1999
Volume 1, Issue 11
Midwifery Today E-News
“Smoking and Pregnancy”
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Are You Interested in Becoming a Midwife?

The Midwifery Educator's Conference and Midwifery Today is sponsoring a free and open to the public Presentations of Midwifery Schools on Friday, March 19, 1999 7-9pm at the Valley River Inn, in Eugene Oregon. The Valley River Inn is located at 1000 Valley River Way, Eugene, Oregon

The following schools will present information about their programs:

* Birthing Way Midwifery School, Portland, Oregon
* Miami Dade Community College Midwifery Program, Miami, Florida
* National College of Midwifery, Taos, New Mexico
* Oregon Health Science University Nurse Midwifery Program, Portland, OR
* Oregon School of Midwifery, Eugene, Oregon
* Sage Femme Midwifery School, Clackamas, Oregon
* Seattle Midwifery School, Seattle, Washington

Each school will present information about their program's philosophy, faculty, prerequisites and other unique qualities. There will be time afterwards for questions & answers. Facilitated by Jan Tritten, Editor of Midwifery Today Magazine.

If you are interested in attending the entire conference, call 541-338-9778 for a complete brochure or check our website at www.oregonmidwifery.org.

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If you or your organization would like to sponsor four issues of Midwifery Today E-News, contact Heather Maurer at ads@midwiferytoday.com. Don't miss our special introductory price!

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Maternal Smoking Linked to Mental Retardation
5) Why Smoking Affects Weight Gain
6) Connections
7) Switchboard
8) Join In!
9) Coming E-News Themes
10) Letters

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1) Quote of the Week:

"Culture is the land through which the river of life flows."

- Lewis Mehl-Madrona, MD

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2) The Art of Midwifery

Package research based information for yourself and to present to parents and providers. Organize the packets by topics such as VBAC, postdates, natural birth, smoking in pregnancy, and so forth. When you need quick reference or there's a turn of events, a variety of information will be right at hand--no more scrambling!

- Jill Cohen and Jan Tritten

As smoking is eliminated, stored toxins in tissues and cells will begin to pour into the body. Drinking plenty of water will help the body eliminate them quickly. Eating two large and varied servings of fresh vegetables daily will help women replace lost nutrients and add roughage so the bowels can detoxify at their peak efficiency. Whole grains and legumes will help replace depleted B vitamins. Zinc helps maintain healthy mucus membranes.

- Anne Frye, Holistic Midwifery Volume I, Care During Pregnancy, Labrys Press, 1995

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Order Holistic Midwifery from Midwifery Today. Just $69 plus shipping. email inquiries@midwiferytoday.com for information on how to order. Please mention code 940.

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3) News Flashes

Antioxidant Vitamins

Antioxidant vitamins may help reduce the damage that smoking causes to the placenta. These findings may have important implications for preventing growth retardation in the fetuses of pregnant women who continue to smoke.
A study of more than 1,500 pregnant women confirmed previous findings on the effects of smoking on placental tissue. Specifically, smoking promotes calcification of the placenta, which may cause intrauterine growth retardation and fetal distress in labor. But researchers at the University of Tennessee and other centers also found that higher intakes of the antioxidant vitamins E, C and beta-carotene could be linked to less calcification of placental tissue caused by smoking.

In the study, the amount of daily antioxidants each woman consumed was calculated using the results of interviews with nutritionists. With greater dietary intake of vitamin E, the researchers found less placental calcification. A similar trend was noted for intakes of vitamin C and beta-carotene, but this finding was restricted to African-American women.

The researchers suggest that a diet rich in antioxidants may also be important for pregnant nonsmokers whose placentas may be at increased risk of damage due to pregnancy-induced high blood pressure or exposure to environmental pollutants.

- American Journal of Epidemiology 147, 1998 as reported in Midwifery Matters, Summer 1998

Leaving a Legacy

Teenage daughters are four times more likely to smoke if their mothers smoked while pregnant, a risk that remained even when researchers controlled for social influences, according to a study conducted at Columbia University. Researchers theorized that nicotine, which can cross the placental barrier, stimulates a fetus' receptors for dopamine, the brain chemical involved with drug addiction. This "priming" may predispose girls to smoke. Animal studies have shown prenatal nicotine does affect certain brain activity once the animal is grown. Prenatally exposed boys weren't at risk, possibly because male hormones may protect them.

- AP wire service report, 1994

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4) Maternal Smoking Linked to Mental Retardation

A study looked at whether maternal smoking contributed to serious intellectual deficits such as mental retardation. Given that smoking appeared in previous studies to have even a slight effect on IQ scores, it may be that the prevalence of mental retardation--defined as an IQ score less than 70--could be increased by maternal smoking in children not known to have central nervous system damage.

In a study conducted between 1987 and 1989, 221 ten year olds with idiopathic mental retardation (not attributable to any know central nervous system damage), served as the case population and 400 children attending normal public schools served as the control group. Most of the mentally retarded children had IQs between 50 and 70. An interview was conducted with the mother of each child to inquire about reproductive history and her use of cigarettes and alcohol during pregnancy. Information about pregnancy and delivery was obtained from medical records.

Women were considered smokers if they smoked at least five cigarettes a week during pregnancy. Twenty-four percent of the control group mothers and 35 percent of the mothers of mentally retarded children smoked during pregnancy. The smokers were 75 percent more likely to have children with mental retardation than the non-smokers, an increased risk that was reduced but not eliminated when potentially confounding factors such as birthweight were taken into account.

Eleven percent of mothers in the control group and 15 percent in the case group smoked more than one pack of cigarettes per day during pregnancy, with many of these women continuing to smoke heavily into the second trimester. Heavy smokers were more likely to have children with mental retardation than non-smokers.

Smoking during pregnancy was therefore found to increase the risk of a child being mentally retarded at age ten by 50 percent, with a higher risk among heavy smokers. If this in fact represented a causal relationship between smoking and mental retardation, it would mean that one in three cases of idiopathic mental retardation among children of women who smoked during pregnancy could be attributed to smoking. However, a causal relationship has not been established. It is not yet known how fetal exposure to cigarette smoke would work to increase the risk of mental retardation. It could have a direct toxic effect or alter nutrition during pregnancy, or reduce the amount of oxygen available to the fetus. Further possibilities are that exposure to smoke after birth affects behavior or development, or that smoking mothers respond to their children differently.

- Dr. Carolyn Drews et al, "The relationship between idiopathic mental retardation and maternal smoking during pregnancy," Mediconsult.com

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5) Why Smoking Affects Weight Gain

Recent evidence indicates that the poor weight gain associated with smoking during pregnancy may not be caused by reduced food consumption as was previously thought, but by an increased need for calories. It has been suggested that inhaled carbon monoxide lowers the efficiency of energy metabolism and that nicotine increases the metabolic rate. Each of these effects could lead to a lower weight gain in pregnant smokers. Because carbon monoxide and nicotine cross the placenta and appear in the fetal blood in higher concentrations than in maternal blood, it is likely that these components of cigarette smoke contribute to poor fetal weight gain in the same way that they affect maternal weight gain.

Plasma levels of beta carotene among smokers have been reported to be substantially below those of nonsmokers despite similar dietary intkes, and smokers have been reported to need up to twice as much ascorbic acid as nonsmokers to maintain a similar body pool.

- Nutrition During Pregnancy and the Postpartum Period: A Manual for Health Care Professionals, California Department of Health Services, 1990

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Learn more about birth from Midwifery Today back issues!

Issue 15 Protocols
Issue 16 Infectious Diseases
Issue 17 Beliefs & Midwifery
Issue 18 The Challenging Birth

BEST DEAL: Order all four and pay just $22 plus shipping! Regular price: $7 each. Mention code 940

Call today: 1-800-743-0974. Save $6 when you buy all four issues. Offer expires March 26, 1999.

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6) Connections: Meet Jane Hall, a midwife in Tasmania

I live on the south east coast of Tasmania, Australia's island state to the south of the continent. The hospital I work in is a general teaching school, and has a school of medicine attached to it. I work in the sub-branch of women's and children's services, specifically in the obstetric division. We are a public hospital that caters to all of Southern Tasmania and serves the whole state for obstetric and neonatal emergencies. The women who attend the hospital while pregnant have several options for their care: doctor-based, or three kinds of midwife-based care. I work within the Know Your Midwife Scheme (KYM), which was established about nine years ago by two dedicated midwives.

I joined the team in 1993 and have never wanted to move out--I love it. We are a team of five with one holiday relief person, meaning the women we serve need to meet six of us altogether. Routine visits are four weekly until twenty-eight weeks, then two weekly until thirty-six weeks, at which time women go to the clinic for a single visit with a doctor, then weekly visits until delivery. We cater to twenty-five women per month, a hefty workload considering we do all antenatal care, attend the client all the way through her labour, run antenatal classes, and provide primary postnatal care. When a woman is in labour, she gets whichever one of us is on duty at the time, but if a special rapport has built between a caregiver and a pregnant woman, we do try to accommodate her.

We have a very good working relationship with the doctors on staff and they are always willing to see one of our clients if we are concerned that medical input may be necessary. We are permitted to care for "our" clients in labour autonomously as everyone is aware that we will not go beyond sensible boundaries and will seek help if needed. It took time to prove ourselves, but we are now trusted. I tend to continue to be involved even if there is a doctor present for an emergency.

There is still some minor opposition from about three or four of the "old school" midwives on staff who think we are all a bit "airy fairy" and cannot (or will not) see why women should get special care. My response is that all women should get special care and that there should be more midwife based teams to cater to the numbers who want to use the service.

This is such rewarding work. The many letters and cards from clients, the hugs and kisses, the shared tears, all add up to the fact that we must be doing something right.

The full version of Jane's story will appear in a coming issue of Midwifery Today. If you are not a subscriber, you may join us by sending your name, postal address and phone number to: inquiries@midwiferytoday.com. Please mention Code 940.

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7) Switchboard

In E-News Issue 11 there is the suggestion of doing a gentle speculum exam if one suspects placenta previa. This has the potential for catastrophe. I teach midwives a spoonful rule: If you are measuring prebirth bleeding in terms of spoonfuls, i.e. teaspoons or tablespoons, that is a normal amount to qualify as heavy "show." If you are measuring in terms of cupfuls, i.e. 1/2 cup, 1 cup, etc., that is too much and you must determine whether that blood is maternal or fetal. If you have an APT test kit at home (a blood test where lye changes to different colours depending on whether it is baby's or mom's) you can test. However, most midwives will transport with unusual prebirth bleeding as a precaution. No fingers or speculums are inserted in the vagina until a team is assembled and a complete stat cesarean is arranged because a finger in the vagina can poke through the placenta and cause bleeding from the baby's very limited blood supply.

I couldn't really relate to the one reference that said the baby would run into trouble because of the mother's anemia and hypotension, either. The real danger is that the placenta, cord and baby are a contained unit of fetal blood supply. If bleeding occurs of the baby's blood out of the placenta it is the same as having a gushing chest wound in an adult. Pretty soon death ensues from losing his/her own blood.

Betty Sweet's suggestion that in cases of suspected placenta previa the membranes should be ruptured did not make any sense to me either. The way it is written it sounds as if the midwife would rupture membranes at 38 weeks if there was placenta presenting--a death sentence for sure, I think. But even if there is no placenta presenting, rupturing membranes prior to term would firstly entail all the normal risks: cord prolapse, need to move to oxytocin, infection, possible error in dates resulting in prematurity, and then you would run the risk as well that you are interfering in a situation where that placenta might just get pulled up out of the way with a couple more weeks and that baby might get stronger to withstand a little more trauma. I just can't see any advantage to rupturing membranes at all in placenta previa. Am I missing something? Seems like there is so much downside I'd be terrified to do it. I'd like to hear from other midwives on how it strikes them.

The newsletters are so good and I know how hard you work to coordinate them. Please take these two comments as my commitment to have them be the best resource possible.

Gloria Lemay
British Columbia, Canada

I enjoy reading Midwifery Today e-letters. The articles on praevia are OK except... today we tend to go on ultrasound appearance plus clinical progress (bleeding/no bleeding, presenting part high/unstable or going into pelvis). Dangerous pelvic exams are thus avoided. It is not a good/safe way to make the diagnosis in this day and age.

- Phil Watters OBGYN
Hobart, Tasmania, Australia

In response to Amber's letter [Issue No. 11]: I breastfed both my boys until they stopped nursing (child-led) at ten months and eleven months. Though I think many will have a hard time believing that a child that age wanted to stop nursing, I can assure you I tried to continue with no luck. (Yes, I did all the tricks with no luck. It appears that when my boys learned to walk, they did not want to be tied down to mom). They never received formula. For that I am proud. I was like yourself. I loved my babies and I loved nursing, but there were times when I got sick of it. I thought I was abnormal. Everyone else I spoke to enjoyed nursing their babies, one and two year olds. I resented nursing my ten month old and could not understand how anyone would want to continue after a year. Though I believe in child-led weaning, I was starting to resent being tied down. Perhaps my child picked up on my emotions and that is why they weaned so young.

You asked if it could be postpartum depression. I believe it could. I suffered from that as well after the birth of both of my boys. One can develop PPD up to a year after giving birth. Talk to your midwife or someone in the healthcare industry who will really listen to what you have to say.

Whatever you do, don't listen to family or friends on when to start baby food. Listen to your baby. If she is grabbing food from the table and has a genuine interest in table food, then that is your cue. Introducing food too early can cause food allergies at a later time. Your baby will tell you when she is ready, no one else.

Amber, I think it is normal to feel tied down and not want to nurse. Hang in there, nursing does not last forever. My boys are now five and two and I dream of nursing a baby (I am not pregnant!). I miss those days (even though I felt just like you do).

- H.

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8) Join In!

Thirteen years ago, Midwifery Today was founded to provide a forum for the voices of midwives and birth practitioners everywhere. Today, your many voices are still our greatest strength. We encourage you to keep that tradition going in E-News by writing for us. Write your own story, how you got involved in birth practice, what your most burning issues are in regard to birth, techniques and arts you've learned or read, news or musings about anything related to the childbearing year.

Because brevity is an important concern, keep your words to one to three paragraphs. If you start writing and you find you must go on longer, we would be happy to consider your work for Midwifery Today magazine, The Birthkit newsletter, or an online article. Share your knowledge, stories and insights-they really matter to a lot of others out there like yourself.

- Jan Tritten, editor

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9) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- breech birth
- education
- infections
- episiotomy
- epidurals
- breastfeeding
- waterbirth
- posterior labor
- postpartum depression
- meconium aspiration
- tear prevention

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com.

Some themes will be duplicated over time, so your submission may be filed for later use.

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10) Letters

I am a long-time reader of Midwifery Today magazine and have considered myself an aspiring midwife, until recently. I am proud to say that momentarily I am a full time, direct-entry midwifery student, studying in beautiful Dunedin, New Zealand. I would love to receive your email newsletter to keep me posted on upcoming events and new information that may be forming on your side of the world. Thank you for your work and all the inspiration that it has given me. Erin R.

We opened our lovely facility on January 15, 1999. We are probably the first birth center in Washington State that is located in a rurally zoned area and that is on well water (the best!) and with a septic system. How did we do it? Hard work and learning how to read legalese (county and state codes)! We've had four births in the center so far.

- Annette M.

Hallo! I am a midwife living in Notodden, Norway. I was very happy when I found Midwifery Today E-News. I'm really interested in getting news and new contacts around the world. I'm forty-seven years old and a midwife since 1978.

- Annika S.

I really enjoyed the conference in Austin. Thank you so much!! Please put me on the email newsletter list. Have a lovely day.

- Christy T.


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This publication is presented by Midwifery Today, Inc., for the sole purpose of disseminating general health information for public benefit. The information contained in or provided through this publication is intended for general consumer understanding and education only and is not intended to be, and is not provided as, a substitute for professional medical advice, diagnosis or treatment.

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