|January 17, 2007|
Volume 9, Issue 2
|Midwifery Today E-News|
“Nausea & Vomiting in Pregnancy (NVP)”
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In This Week’s Issue:
Quote of the Week
"How does one campaign for the blessedness of intimacy?"
— Lisa King
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The Art of Midwifery
Did you know that morning sickness killed Charlotte Bronte? Complications from dehydration caused the death of the pregnant author of Jane Eyre. Nearly 90 percent of pregnant women experience hyperemesis gravidarum to some extent during the first trimester. Almost every woman who has experienced pregnancy has her own stories of upset stomach, nausea and strange aversions to certain foods or aromas.
As recent clinical studies focused on ginger root have shown, the old remedy long used for upset stomach and nausea now has the backing of scientific research to validate its anti-emetic qualities. No teratogenicity or neonatal toxicity were reported in any of these clinical studies.
— Susan Perri
To learn more about how to use ginger for nausea and vomiting in pregnancy, order The Birthkit Issue 36
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NVP (Nausea and vomiting during pregnancy) affects about 70-80 percent of pregnant women. Some reports range from 50-90 percent, but most are in the 70-80 percent range. In 20 percent of NVP cases, these symptoms persist throughout pregnancy.
[Hyperemesis gravidarum (HG) is defined as] "severe vomiting in early pregnancy that causes 5% weight loss and ketonuria... usually associated with increased hCG concentration." The vomiting is typically intractable and leads to evidence of disturbed nutrition, altered electrolyte balance or dehydration. Incidence of hyperemesis gravidarum (HG) seems to be about 0.8 percent or 0.9 percent, though estimates vary from 0.3 percent to 2 percent.
HG has been linked to a variety of symptoms including dehydration, ketosis, ptyalism (excessive salivation), high thyroxine, low pyridoxine, high serum transaminase, hyperthyroidism, hyperparathyroidism, altered lipid metabolism, liver dysfunction, rising pulse rate, falling blood pressure, dry and furry tongue, loss of skin elasticity, chronic hypovolemia, and jaundice. Symptoms typically occur during the first trimester of pregnancy, usually beginning between the fourth and tenth weeks of gestation, peaking between the eighth and twelfth weeks, and resolving by the twentieth week.
While the relation between most psychological factors and HG appears to be unfounded, there is some case-study evidence suggesting that dietary behavior may play a role. A risk factor for HG seems to be an "unsuitable diet, with large and infrequent meals."
[T]reatments involving correction of fluid and electrolyte deficiencies appear to be safe and highly effective; patients receiving such treatment have an excellent prognosis with no significant increased risk of fetal loss or major complications.
— Frederic Paik Schoenberg, excerpted from "Summary of Data on Hyperemesis Gravidarum," The Birthkit Issue 26
The Birthkit Issue 26 includes a summary of data about HG, natural remedies, a midwife's response to the issue of HG and an HG sufferer's commentary. The Birthkit Issue 26
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Research to Remember
Hyperemesis gravidarum (HG), or severe vomiting during pregnancy, often requires hospitalization due to fluid volume depletion, metabolic disturbances and weight loss. A retrospective study showed that women who were hospitalized with HG had a higher risk of preeclampsia than those not hospitalized, and more often required extended hospital stays after both vaginal and cesarean births. In addition, babies born to women with HG were more likely to have low birth weights than those who did not have HG.
— Vogin, Gary D. 2005. Medscape Medical News. Report on Poster 6, presented Feb. 17, 2005, at Preventive Medicine 2005, the annual meeting of the American College of Preventive Medicine.
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Question of the Week
Q: I need some advice in dealing with/assisting a private client. She is prone to premature births, hyperemisis gravidarum (HEG) and preeclampsia, and has celiac disease (she cannot eat wheat). (I am aware that the preeclampsia is a result of the hyperemesis and malnutrition, and was attempting to help prevent it.) However, I noticed she has a history of eating disorders, and is exercising 1–1/2 to 2 hours a day.
Alarm bells have started to ring in my head as I read about how debilitating HEG can be. If she is that sick now, how can she keep going? She refuses to be hospitalized, although she spends at least one day a week there being tested. I suggested she cut her cardio down to 30 minutes a day (rather than an hour and a half!), and substitute Tai Chi or yoga. Everything the doctors have tried has seemed not to work (including Zofran). When she started forcing herself to eat regularly her vomiting increased from five times a day to 15. I've done quite a bit of research on the disease and ways to help, but apparently nothing I or anyone else has suggested works or helps in the least. Any thoughts or suggestions? I'm stumped with this one. Feel free to e-mail me privately at firstname.lastname@example.org.
— Amy Haas
SEND YOUR RESPONSE to email@example.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: 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 upcoming 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.
A: I think that it is VERY normal to be fixated on something that is not yet right for you. I, too, had a debilitating tear with my first baby. My homebirth midwife diagnosed a third degree tear as a first degree tear, insisting that if I kept my legs together all would be well. I did, and it wasn't. An attempt at an office repair (obstetrician) at eight weeks was very painful and unsuccessful; I was told that anything could be fixed if I was willing to go to the OR under anesthesia. Six years and another baby later I am just now finding peace and pleasure with the status of things.
Somewhere there is a sensitive care provider who can lovingly help you assess your perineum. Ask around; you'll be surprised how many women share your injury and worry! I was a senior apprentice midwife at the time and was shocked at how many of our past clients came forward to tell me similar stories! My second homebirth was with a midwife who did a lot of "tissue release" work around my tear and vagina, which helped things feel MUCH better. Reasonance Repatterning (previously Holographic Repatterning, www.holographic.org ) is amazing at releasing energy constrictions (trauma memory in tissue or spirit). I took care the second time to be in any position but supine or even semi-supine to give my perineum the best opportunity to stretch easily—hands and knees felt great! Or waterbirth or side-lying or standing might also work for you.
Read the birth stories in Ina May's Guide to Childbirth. The most useful thing that the second midwife said to me was that she had seen women with scar tissue have the next baby's birth stretch that scar tissue so that there was a "self-healing" quality to the birth, setting things (more) right, and that there can be a "healing stretch." That became my crowning mantra—"This is a healing stretch!"
I've changed many things about how I assess vaginal damage after a birth as a result my own experience. I think that as midwives we sometimes do a disservice to first-time mothers when we reassure them that they are "fine." What is much more important is their own perspective, and we might help more by educating women that having the "landscape" change in some way is pretty common. I find that when I explain that changes are going to occur, that they might LOOK a bit more open, they might see changes, and that they will still have great fun with that part of their body—they have a lot less dismay and fear when they take a look the first time.
I LOVE Midwifery Today's Tear Prevention and Treatment Handbook. I was tremendously empowered to know of so many views and approaches! Some of the ideas in that booklet are what have helped me feel much more healed, even though I did them many years after the birth trauma. Have a Wonderful and Healing birth!
— Beth Barbeau, Midwife
A: Take heart, there is no easy answer here. I am a new doula who did home delivery of my two babies. At the first birth, only her father and I were present. He caught her mid air—no support for my perineum. You can bet that the second time I waited for the midwife's hands. I couldn't believe the difference in my post partum healing.
Yes, my yoni is forever changed—I often say I went from a tulip to an orchid. Have you ever seen the artwork of Judy Chicago?
I hope you have the assistance you need, loving attention, discussing your fears before the birth. What about waterbirth?
I understand that the outcome for this issue varies. Excellent nutrition and faith in your body can only help.
I did go to hospital after the birth for a "touch up." This felt like cosmetic surgery but was a simple cut of a tag that had caused me pain during intercourse between babes. I was disappointed that none of my momma friends warned me about the pain of healing my perineum after the birth. Maybe this should have been obvious, but I was in shock.
You can stretch enough not to tear. You are strong enough to heal no matter what. Please keep talking about your concerns.
A: I feel like I'm reading my own story when I read your concerns about the perineal tear you experienced with delivery of your first child and your fears about the delivery of your next child.
I experienced a second degree tear with the delivery of my first child that healed "horribly"—I was unable to have intercourse for approximately a year following delivery (despite "healing nicely" according to the midwives) and continued to experience pain using internal menstrual products, having intercourse, etc., until two and a half years after the birth of my first child—until I delivered my second child.
With my second child I experienced even more extensive tearing and was transferred to hospital after his birth so an obstetrician could spend 45 minutes (under spinal anesthetic) repairing the third degree tear that was well out of the realm of my midwife's capabilities. I truly believe that there was no way for my second baby to pass through me into my arms with out "tearing" through. I knew/know that a baby's head could not move through a passage (without causing trauma) that had been stitched up too tightly to have intercourse without pain.
The recovery from a third degree tear was uncomfortable, to say the least (as you are well aware from your own experience). But I am so relieved that I experienced a tear with my second child that needed such expert repair—the obstetrician did a beautiful job and I truly "healed beautifully" this time. Yes, it took time (longer than the six weeks many suggested) to feel the absence of pain and then a little longer to feel the absence of tightness or even sensitivity, but my youngest just turned two and I now feel as normal as the days before I birthed either of my dear children.
So yes, you can "heal better" from a more expertly repaired tear following a poorly repaired tear. If indeed you must tear to permit the passage of your newest baby into your arms, then I truly hope that your are stitched by expert, careful and caring hands that may be able to restore for you the confidence that your perineum is "normal" and "healed" again. If that person is a caregiver other than the one who attends you during your birth, then so be it. You need not feel "broken" even after healing from a third degree tear.
A: I fully understand and feel your particular pain. I, too, suffered a third degree tear as well as an episiotomy that I did not agree to. I subsequently gave birth to my second child vaginally, while lying on my side so as to put minimal pressure on my perineum, and tore only a little bit. It did not require any stitching AND was toward the top of my labia, not anywhere near my perineum. Baby #2 was quite a bit bigger than #1 as well.
My point is that you can still have a beautiful, trauma-free experience this time around. I don't know how much you have done to try to nurture those tissues but it's not too late to use herbal compresses (with things like yarrow and comfrey) and do some perineal massage with oils of your own to prepare those tissues. I think for me the biggest problem I had was the fear of tearing it all over again and never being the same. Maybe the psychological part of it is the biggest part of healing for you too? With proper support, I'm sure things will be fine for you this time. My advice is to talk with your care provider about your feelings and your fears letting them know that this time around you really want extra support when it's time to push. Try to push in positions that are not stressful to your perineum as well. (For example, no squatting without lots of extra support.) Best of luck to you!
— Jodi G.R.
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Think about It
The National Center for Health Statistics (NCHS) recently released preliminary birth data for 2005. Several alarming trends were noted: an increase in the cesarean rate to 30.2%—the highest rate ever reported; and an increase in late preterm births to 9.1%. Susan Hodges, of Citizens for Midwifery, points out in her Grassroots Network E-News that [w]hile the report does not mention any connection, it is probable that planned cesareans and early inductions contribute to this kind of prematurity.
You can see more of the data here: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths05/prelimbirths05.htm
To register for the Grassroots Network E-News put out by Citizens for Midwifery, go here: http://cfmidwifery.org/Resources/item.aspx?ID=15
I am wondering if anybody knows of any free BMI calculator wheels that are available. (They would have to be able to send it to England.) I would really appreciate one for my job!
— Debra Parker, Infant Feeding Support Worker
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