October 2, 2002
Volume 4, Issue 33
Midwifery Today E-News
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A 72-page quarterly print publication filled with in-depth articles, birth stories from around the world, stunning birth photography, news, reviews and more.

Quote of the Week

"The parallels between making love and giving birth are clear, not only in terms of passion and love, but also because we need essentially the same conditions for both experiences: privacy and safety."

- Sarah Buckley

The Art of Midwifery: Uva Ursi

We use uva ursi often in our practice to treat moms with urinary tract infection (UTI) during pregnancy and have always found it to work wonderfully. No one has had any problems with its use. It works so well because it is the only antiseptic herb that works directly in the kidneys. Anne Frye recommends using 1 oz per 1 qt water and steeping it for 10 hrs. Drink 1 cup every 4 hours for the first two days and 1 cup daily for three more days. This regimen works well on most UTIs.

- Midwifery Today Forum, anonymous contributor

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.

News Flashes

A study to investigate the outcome of pregnancies after maternal varicella and herpes zoster infections included 1,373 women in Germany and the UK who had varicella or herpes zoster infections in the first 36 weeks of gestation. Women who delivered within 28 days of onset of rash were excluded from this study. Radioimmunoassay tests for specific IgM were performed on cord blood and venous blood samples taken at birth, and enzyme-linked immunosorbent assay for specific IgG was carried out on samples taken at 10-12 months of age. Of the 1,373 women, 1,365 had serologically confirmed or virus isolation-proved varicella infection. Of the latter, infection was confirmed in 97 women after they received postexposure prophylaxis with antivaricella-zoster immunoglobulin. Pregnancy was aborted in 43 women, spontaneous abortions occurred in 36 during the first 16 weeks of gestation and nine fetal deaths occurred after 20 weeks.

Of the 1,285 term pregnancies, there were 1,291 live-born infants, nine of whom had abnormalities, including cutaneous lesions and limb hypoplasia. Infancy or early childhood herpes zoster occurred in 10 children who had been asymptomatic at birth. Of 631 infants who were tested for specific IgM antibody at birth, 80 had positive results. IgM was detected in 25% of infants with congenital varicella syndrome and/or zoster and in 12% of those who were asymptomatic. None of the 97 infants born after postexposure prophylaxis had congenital varicella syndrome, and the IgM detection rate was significantly lower among these infants than among those who were asymptomatic but whose mothers had not received prophylaxis. There were 366 cases of herpes zoster in pregnancy, of which 119 occurred in the first 36 weeks of gestation. A total of seven pregnancies ended in spontaneous or therapeutic abortion. There were no defects attributable to congenital varicella syndrome and no cases of zoster in the 359 live-born infants in this group. Specific IgM tests carried out in 43 infants were negative. One infant had varicella at 7 months and a positive IgG antibody test at one year. The risk of congenital varicella syndrome following maternal infection during the first 20 weeks of gestation was approximately 1%, and the highest risk (2%) was during the first 13-20 weeks.

- Lancet, 1994 343:1547-1550


Neonatal herpes is not a reportable disease in most states, so there are no hard statistics on the number of cases nationwide. However, most researchers estimate there are between 1,000 and 3,000 cases a year in the United States out of a total of 4 million births. To put this in greater perspective, an estimated 20-25% of pregnant women have genital herpes, while less than 0.1% of babies contract an infection. Neonatal herpes is a remarkably rare event, and the risk of neonatal herpes is extremely small.

Transmission rates are lowest for women who acquire herpes before pregnancy—one study (Randolph, JAMA, 1993) placing the risk at about 0.04% for such women who have no signs or symptoms of an outbreak at delivery. The chances of transmission are highest when a woman acquires genital herpes late in pregnancy.

When infants do contract neonatal herpes, the results can be tragic. About half of infants who are treated with antiviral medication escape permanent damage. But others may suffer serious neurological damage, mental retardation or death. It's fear of these terrible consequences, rather than the level of risk, that makes neonatal herpes a concern.

Fortunately, babies of mothers with long-standing herpes infections have a natural protection against the virus. Herpes antibodies in the mother's blood cross the placenta to the fetus. These antibodies help protect the baby from acquiring infection during birth, even if there is some virus in the birth canal. That's the major reason that mothers with recurrent genital herpes rarely transmit herpes to their babies during delivery. Even women who acquire genital herpes during the first two trimesters of pregnancy are usually able to supply sufficient antibody to help protect the fetus. Babies born prematurely may be at a slightly increased risk, even if the mother has a longstanding infection, because the transfer of maternal antibodies to the fetus begins at about 28 weeks of pregnancy and continues until birth.

- www.herpes.com/pregnancy.shtml

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Forum Talk: Stillbirth

A client just had a stillbirth, and I'm numb and devastated. We had a good relationship through pregnancy and she was really trying to do everything right. Any feedback—from those with first-hand experience, please—on how I should be from here on out?

- Sarah

Go to our forums to share your thoughts and experience.

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Question of the Week: Midwife Teams

Q: I'm curious to find out about midwives working in teams; that is, a few midwives who share in seeing women/couples during pregnancy, alternating being on call for births, having homebirths or hospital births, caring for families after birth. I would like to know more about the work environment, both the logistics of the routine and how pleasant it is to work under such arrangements.

- Helena, midwife

Send your responses to mtensubmit@midwiferytoday.com.

Question of the Week Responses: Herpes

Q: I have a client who has herpes. She hasn't had an outbreak for a year, but she is concerned that labor (pain and her fear around it) will trigger an outbreak and lead to a c-section. What are her options? How do I learn more as her doula? Is there anything she can do (herbs, visualizations, etc.) to lessen her chances of an outbreak while keeping the baby healthy?

- Tasha

A: Issue 2 of The Mother magazine (www.themothermagazine.co.uk) has a very helpful article on living with herpes during pregnancy and birth. The information that a woman must have a caesarian if she has an outbreak at the time of birth is misleading and outdated. It is only the first outbreak that is severe and potentially dangerous for the newborn.

The most empowering thing a woman can do is to improve her immune system. L-Lysine (available from good health stores) is very helpful for reducing outbreaks. The Holistic Guide to Living with Herpes Before, During and After Childbirth (Summer 2002) features useful flower essences, essential oils, foods, vitamin and mineral supplements and suggestions for lifestyle changes.

- Veronika Robinson,
publisher & editor, The Mother magazine

A: I suggest using olive leaf extract and staying away from sugar.

- Joy

A: I don't know if this will prevent an outbreak, but both St John's wort and lemon balm have been clinically proven to help heal herpes sores and discourage recurrences. Many women have successfully used salves and balms made of these herbs for herpes.

- Erica

A: I have had herpes for 12 years and have had three children during that time. With my first two births I had no outbreak, but with my last birth in April 2002 I had a very severe outbreak that lasted three weeks. The sore was rather large on the outside labia on the top, near the clitoris. I was not about to risk c-section and not have a homebirth as planned. After all the research I did I felt comfortable with the "risk" of exposure versus probable immunity passed to my child from me. I applied a good thick coat of super glue to the sore and had a waterbirth as planned. There were no ill effects whatsoever on me or my son.

- Debra

A: She can up her intake of zinc and vitamin C. I also recommend elderberry for the immune system. She will do fine with some positive thinking and reassurance, and she can deliver the babe without c-section if she does have an outbreak by simply covering the sore(s) with a warm cloth so that the babe doesn't come in contact with it.

- N.C.

A: I have been a midwife for 23 years. Prevention magazine printed an article close to 20 years ago about herpes. The advice it gave has been invaluable over my years of practice. This is what it said: During an outbreak of herpes take 1,000 mg lysine three times a day along with vitamin C (I have moms take 1,000 mg 3 times a day). For a maintenance dose it advised taking 500 mg lysine daily as a preventive. I never have had an outbreak during birth.

- Carol Severson, CPM, LDM

A: At 36 weeks she can take Acyclovir 400 mg BID daily until delivery. This helps prevent outbreaks at term. Many articles have been published about this subject. Check PubMed for herpes and pregnancy.

- Susan

A: L-lysine is very useful in preventing an outbreak of herpes and even useful to cut an episode short. I usually suggest 1,000 to 2,000 mg. a day as a preventive. If the mom is extra tired, have her take the higher dosage. If she thinks an outbreak is starting, she should increase it to 4,000 mg a day. L-lysine is an amino acid (a protein). I have never heard of overdosing on it. It also works well for cold sores and chicken pox as well as other types of herpes infections.

- Judy, CPM


A: I have had many clients with thrombocytopenia and have never seen platelet infusions or even steroids recommended. My policy is to recommend hospital birth if the parents were planning a homebirth if the levels got too low, especially under 80.

Platelet levels vary widely with each blood draw, so you must take into account many other factors. For example, did she have a postpartum hemorrhage with a previous birth? Is she displaying unusual signs (e.g., unexplained bruising)? I strongly recommend Vitamin K for the newborn postpartum (IM, not the oral dose). Some women also elect to ingest lots of leafy greens and nettle tea in pregnancy for the added Vit K, but I didn't see platelet levels rise. Other situations such as external cephalic version for breech presentation or maternal Rh negative may be viewed in a different light given low platelet levels.

In my experience, physicians consulted for this condition were particularly concerned with platelet levels under 50, especially if a caesarean section might be indicated. As I am not presently attending births as a midwife; I can't speak for the current climate for this condition in my community. I don't know if Toronto is unique in this regard, but our experience is that this condition is not extremely rare, and in fact, seems to happen with some frequency (if I were to guess, I'd say 1-5%).

Specialist consultations should include both an obstetrician and a hematologist. Anyone with this condition would likely benefit greatly from seeing a naturopath with experience with pregnant women. I am a clinical hypnotherapist, and the work I have done with women with this condition using hypnosis can often be enough to clear it up or at least bring the levels up high enough to allow the woman to have a homebirth. Just as women visualize bringing down a blood pressure, they can visualize the platelet levels coming up.

- Shawn Gallagher, BA, RM, C.Ht

A: There are several conditions in which low platelet levels are observed during pregnancy, some of which are serious. But "bog standard" gestational thrombocytopenia is not extremely rare; it affects 5-7% of pregnancies and is believed by haematologists simply to be an ordinary phenomenon affecting some pregnancies with no adverse implications for mother or baby.

- According to Abdul Rahim Gari-Bai, Fachartz (Hematology), a platelet count of 30-50 (when the bottom end of the "normal" range is 150) should be considered safe for the mother at delivery.

- Studies reviewed in Gari-Bai's paper, Thrombocytopenia in Pregnancy, showed no higher incidence of babies with low platelets born to mothers with low platelets than in those born to mothers with normal platelet levels.

In my experience, low platelet levels are often nothing to worry about at all but seem to be used to deem a pregnancy high risk and interfere with the normal process of pregnancy and birth. I have had low platelet counts in all three of my pregnancies (around 80 at time of birth) and had completely wonderful homebirths each time, had no syntometrine, and no excessive bleeding. As a homebirth advocate, I am very passionate that low platelets should be better understood by healthcare professionals involved in maternity services.

- Claire Davis
National Childbirth Trust

A: I will be traveling to Washington, DC and New York and am seeking advice from any of the persons who answered the Question of the Week about thrombocytopenia. Are any based in the DC or NY areas who would agree to speak to me about this subject? If you can help me I would really appreciate it—maybe even by recommending a birthing centre that may be worth a visit in DC?

- Charlotte
Trinidad, West Indies

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Re: radiation [Issue 4:32]: There's radiation and then there's radiation. Sunshine is not particularly penetrating—it primarily affects the skin, which is why you can block UV radiation with something as simple as sunscreen. You cannot block X-rays with sunscreen.

- Jennifer Rosenberg

I have noticed that surprise breech births go very much like vertex births. However, there is considerably more stress, worry and doubt about whether one should choose home or hospital with an anticipated breech birth. Staying present in the moment and not judging the experience helps combat people's natural fear of breech births, as does Rescue Remedy and homeopathic aconite given to all in the room!

- Augustine Daniels

I am a mother of two, and my first birth was very easy. We arrived at the hospital and delivered within 20 minutes with no drugs. My second child was coming head first, and I had progressed slowly. After finally dilating to 10 cm, the doctors put me on the birthing bed and checked her head for the sutures. One doctor felt the top of her ear, and refused to try and turn her. She was a little bit crooked. They simply gave me no choice but to have a c-section. She was an entire pound less than my first child. It will be one year on October 19, and I still feel ill effects from the surgery. I am from a rural community and hours from a large hospital. I would like to have a VBAC, but recently was informed that the new standard of care doesn't permit you to have a VBAC in a hospital without crash c-section capabilities available 24 hours a day. That would be about a 5-hour drive from where I live. I am only in my mid 20s and am very healthy! I only wish I would have known more about midwifery before the birth of my second child. I am positive that a c-section could have been avoided. What are my risks, and what can I do to plan for a natural birth?

- Anonymous

I am taking a self-designed course about nutrition in pregnancy. It seems that the Brewer diet is widely used and respected among midwives. I am using the book "Nutrition in Pregnancy and Lactation" by Worthington-Roberts, which states that Brewer's research into preeclampsia and high-protein diets was originally inconclusive until Brewer later analyzed the data. He then removed six cases of pregnancy-induced hypertension (PIH) from his group, giving him a lower incidence of PIH than the group with lower protein diets. She also states that other data have not supported a relationship between PIH and protein intake. "A Guide to Effective Care in Pregnancy and Childbirth" (by Enkin et al, 1991 edition) states that "there is no evidence to support the ... view that eating sufficient amounts of a good diet will reliably protect against preeclampsia."

So why do midwives use the Brewer diet? Because experience shows it works? Is there other evidence I don't know about? Does anyone have misgivings about the high dairy content of the diet? Why are vitamins A and C emphasized rather than others? Can anyone recommend other nutrition books written for midwives?

- S.

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