April 1, 2009
Volume 11, Issue 7
Midwifery Today E-News
“Over-the-counter (OTC) Drugs in Pregnancy”
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In This Week’s Issue:

Quote of the Week

"If the general public continues to be indoctrinated into medicalized birth, how can we expect women to stand up and fight against the marginalization of freestanding birth centers and midwifery in this country?"

Colleen Bak

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The Art of Midwifery

When we are aware of potential risk factors or when mothers express extreme anxiety we can take steps to remedy the situation and facilitate a smooth birth. Our actions will depend on the particular situation, but often just identifying the source of worry and getting it out into the open may be all that is needed to prevent related problems from arising in labor. Ultimately we want to empower moms to use the resources and address the problems before labor begins.

Heidi Nielson Sylvester
Excerpted from "Psychological and Emotional Dystocia," Midwifery Today, Issue 81

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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A recent study showed that [female] veterinarians have more to risk than being bit by an animal, particularly if they are pregnant. They have twice the risk of miscarriage, most likely from their exposure to anesthetic gases, radiation and pesticides at work.

The risk was found to be higher in small animal practices than in large animal practices, perhaps because large animal veterinarians do more out-of-office practice. The risk can be decreased by using protective equipment—something that the researchers found is not always done. One problem noted in the report was that the veterinary profession is not as well-regulated as medical professions, which has similar risks.

HealthDay News, 23 April 2008

Some OTC Drugs to Avoid in Pregnancy

The Food and Drug Administration (FDA) [uses a] rating system to categorize the potential risk to the fetus for a given drug.

Category D [are those for which] adequate, well-controlled or observational studies in pregnant women have demonstrated a risk to the fetus. (However, the benefits of therapy may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective.)

Ibuprofen—Some common brands are Advil and Motrin. This drug is considered category B (drugs that do not appear to cause birth defects or other problems) until the third trimester, then it is category D. It has a borderline association with gastroschisis (a congenital defect characterized by an incomplete closure of the abdominal wall with protrusion of the viscera). All NSAIDs (non-steroidal anti-inflammatory drugs) used near term may cause premature closure of the ductus arteriosus and inhibit labor. Oligohydramnios after prolonged use is a common complication with NSAIDs as a class. No adequate studies have been done on ibuprofen in pregnant women. Therefore, ibuprofen is not recommended during pregnancy.

Tums (calcium carbonate) is category D in pregnancy. Extended heavy use of calcium antacids (20 grams or more daily for a prolonged time) may cause excess calcium in the blood, which can lead to kidney stones and reduced kidney function. People who already have impaired kidneys may develop milk-alkali syndrome (causing symptoms such as nausea, vomiting, loss of appetite and mental confusion) with as little as four grams a day. (The amounts listed are incredibly high intake amounts and far exceed the normal dosage recommendations.)

Know what you are taking! Ask your midwife or look up the drug yourself. Some good online resources are:

Demetria Clark
Excerpted from "Common OTC Drugs and Use in Pregnancy," The Birthkit, Issue 55
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Web Site Update

Read these articles from the current issue, Spring 2009, of Midwifery Today newly posted to our Web site:

  • The Life and Work of a Rope Midwife in Darfur—by Ramona Denk
    "My name is Fortunate and I am a traditional midwife. I live in a small village in rural Darfur, in the country of Sudan, in northeast Africa. I am a widow with seven grown children (now six, since one of my daughters died last year). I take care of her three children that she left behind. Besides my work as a midwife, I work our farmland. I grow millet and vegetables for us to eat. In good rain years, we can grow extra to sell, but in dry years, we eat one meal a day and really struggle."
  • Emotional Impact of Cesareans—by Pam Udy
    "Every 30 seconds in the US, a cesarean is performed.(1) This overuse of cesarean surgery puts moms and babies at risk—not just physically, but emotionally. My intent with this article is to show the emotional impact that cesareans can have on the family. A cesarean can reach far beneath the bogus smile on mom's face. It can scar her heart, as well as her uterus."

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Question of the Week

Q: I am writing from Indonesia, the country that got GMO soy first, to share what I am seeing, and to ask if you too are seeing the same. In 2008 Bumi Sehat Bali received 573 babies. We saw an increase in retained placentas. I also am seeing an increase in velamentous cord insertion. In 2008 and so far in 2009 we have seen [far] too many "sticky" placentas; two even had to be transported (we do manual removal on site when absolutely necessary), one for a hysterectomy and one with one liter of blood loss. In the last six weeks of 2008 I had to go after four placentas! It was not pretty, and I do not take it lightly (usually never more than one per year).

Also most shocking is the empirical experience (I have no research to prove it) of an increase of velamentous umbilical cord insertion and short cords. I also am seeing a decrease in Wharton's jelly among all our babies. Cords are also shorter. We don't cut them for a minimum of three hours at Bumi Sehat and many families choose lotus birth. Last week our midwife Ayu had to cut a cord after the birth of the head, as the body would not follow, it was that short a nuchal cord—she had never had to do this before in her life as a midwife.

What are you midwives seeing?

The study I read concerning M16 genetically modified corn showed that when fed to pregnant mice, ALL OF THE OFFSPRING, in one generation, had alterations of ALL the cells in ALL their organs! Can you see why I am worried about our precious placentas? I did not make this connection, until I began to see an increase in abnormalities and pathology due to placenta and cord troubles. The fact that so many Indonesian women depend upon genetically modified soy products (tempeh and tofu) for their day-to-day protein, and the early introduction of GMO soy here got me wondering.

— Ibu Robin Lim
Bali, Indonesia

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.

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Question of the Week Responses

Q: I am a 28-year-old woman and I've just been told that I have uterine didelphys—with two of everything (cervix, uterus and vaginal canal). According to the gynecologist I saw, I can become pregnant but she said there is a higher risk of premature birth and of a caesarean. Other than this I am perfectly healthy and have had no illnesses or anything.

While I am not planning to get pregnant in the next two years, I would really like to think about my options, to prepare myself when the time is right. I have always planned on having a homebirth with a midwife to assist. I really want the opinion of someone who is not solely from the medical side of things. I know the doctors tell me what they think is the right thing to do but I have always felt that birth is a more natural occurrence than what the majority of the medical society seems to believe.

— Deborah

A: As a doula and a CBE, I have worked with two mothers who had didelphic uteruses. The first mother did not know that she had it until she had conceived and had her first ultrasound at 12 weeks. She had conceived naturally and went into spontaneous labor at 27 weeks and called me in. The baby was born via c-section and spent a long time (two months) in NICU. He had an intestinal block that was surgically corrected. Adam is now a healthy and happy four-year-old. They only wanted one child and are happy.

The second mother knew she had it prior to conception. We met early and worked for a long time together so I know more about her and her story. We did a lot of research and found a provider who was willing to do almost anything to work with her physical and emotional needs. Mother #2 had more of a bicornuate uterus with two cervixes and two uteruses that shared a small section of septum. When the first baby was conceived, she was luckily implanted in the larger chamber and therefore was able to have more space. The mother was told to expect to give birth between 27 and 32 weeks. The mother went into spontaneous labor at 35 weeks and had a natural vaginal delivery with a totally unprepared obstetrician, as her obstetrician was out of town for the weekend. At the birth the placenta shredded and she required a D&C as the obstetrician could not remove it all manually. As the uterus emptied it collapsed into an L-shape, making manual removal impossible. Afterwards the baby spent three weeks in NICU being fed her mother's breast milk. The NICU staff was wonderful but kept scaring the mother by running more and more tests. Ultimately they did genetic testing on to baby in order to calm down an NICU doctor before he would discharge her. The baby was negative for Down syndrome, etc., but the parents learned quite a lot. In this case both parents carry the genetic code for Down syndrome. They also found out what the risks were if the next baby were to be implanted in the smaller chamber, including growth retardation. Together they have decided to be blessed with one child. This was a very hard journey for this family as they had hoped to have many children.

— Ursula Sabia Sukinik, AAHCC

A: In response to the two inquiries regarding uterine didelphys:

Anatomy lesson: Variations on the structure of the uterus, such as bicornuate uterus and uterine didelphys, are known to affect up to 1% of women—however the true incidence is likely to be much higher, as many of these variations are completely asymptomatic. Many women find out they have a uterine structural variation with their pregnancy ultrasound scans, showing that becoming pregnant IS entirely possible. Corrective surgery may be appropriate for some women to improve their obstetric outcome, although it is not generally recommended for women with true uterine didelphys.

The bad news: Women with uterine malformations are more likely to suffer menstrual discomfort, endometriosis and some (but not all) may experience infertility and first trimester miscarriage. Outcomes of pregnancy typically depend on the type of uterine malformation and the site the conceptus implants. Antenatal problems such as intrauterine growth restriction, malpresentation and premature labour may occur; during labour a vaginal septum may interfere with dilatation and descent of the fetus. Also with true uterine didelphys the non-pregnant uterus may obstruct the labour. Women with uterine didelphys have a greater risk of retained placenta and postpartum haemorrhage.

The good news: I am a UK hospital-based midwife who cared for a woman with uterine didelphys during labour two years ago. When this woman's uterine didelphys was diagnosed in her teens she was told that she would have difficulty conceiving, that she would almost certainly miscarry, that the baby would not grow properly if she remained pregnant, and that she would have to have a caesarean. This woman became pregnant after trying for only a few months, had a completely normal pregnancy, and gave birth naturally and easily to a beautiful 7+ lb boy. She had a managed third stage, with no haemorrhage, and a small tear to her vaginal septum (which did not require any repair). She had a normal postnatal period, with no gynaecological problems. When I last bumped into her she was considering trying for a second baby.

My personal recommendation to women with any sort of known uterine malformation is to have their condition thoroughly investigated before conceiving and to research their options. Due to the risk of postpartum haemorrhage, I would think very carefully about a homebirth and would opt for a managed third stage.

— Luce

Q: I am pregnant with my fourth child; the second child was a compound presentation and I had a T incision. During the c-section for my third child, the vertical extension of the T opened up after the baby was delivered, so my T has been stitched twice. I believe it is double-stitched; I know it was after the first c-section, and I'm assuming it was again with the second. Additionally, my vaginal delivery was at 41 weeks, and my second child also went 41 weeks gestation. I never went into spontaneous labor with either child, even after waters broke. I had Pitocin (no epidural) with the first, and no drug interference with the second prior to discovery of the baby's hand in the birth canal (the doctor had manipulated my uterus to expel waters and try to facilitate labor). Add to all this that I was diagnosed with gestational diabetes (GD) in December. So far my blood sugars are okay with diet. This baby will arrive almost two years to the date from my last cesarean.

Here's my problem: The recommended time for my cesarean is 39 weeks gestation, which falls on a Friday. The hospital doesn't usually do "elective" surgery on Friday, Saturday or Sunday, and my surgeon isn't available again until the following Tuesday, making me 4 days past my 39 week mark. The perinatologist is worried about rupture and suggests cesarean before 39 weeks, but then the hospital requires an amniocentesis to determine lung development. I do not like the idea of an amniocentesis, and if lung development is immature, I'd have to wait anyway.

My question is what to do? I feel an exception should be made to give me surgery at 39 weeks, rather than incurring risk to the baby from amniocentesis and respiratory problems, but I'm not sure they'll do this. What can you tell me, either about getting an exception to surgery dates and/or risk of rupture, or would you recommend doing the amnio and delivering before 39 weeks? I really do not want to deliver early, especially for the doctor/hospital scheduling policies. Any help you can give me is appreciated!

— Brigid Luzarraga

A: I would respectfully, but adamantly, insist that they make an exception to their Friday rule. This is not elective surgery in the true sense of the term. You have a valid medical reason for scheduling a repeat (not elective) cesarean. You have good evidence to back you up. You are not asking for a nose job on Christmas morning. This is what they signed up for when they became obstetricians. Hopefully, when you explain your concerns about deviating in either direction they will understand and make an exception.

— Jenny Ward McDonald, CNM

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

2008 was the first year of commercial planting of genetically modified (GM) sugar beets in the US, with that sugar expected to enter the nation's food supply this year. The Monsanto Roundup Ready sugar beet is genetically engineered to be resistant to Monsanto's herbicide glyphosate (marketed as Roundup). The Environmental Protection Agency (EPA) recently agreed to a Monsanto request to increase the allowable levels of glyphosate residue on sugar beet roots by 5000 percent.

A representative of Amalgamated Sugar estimated that 95 percent of the sugar beet crop in Idaho would be of the new GM variety in 2008. Sugar beets account for about half the sugar in processed foods.

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Thanks so much for writing about us. It might interest you to know that a grandmother who recently took our free online infant CPR course saved her seven-week-old grandson who stopped breathing. Doctors have told her that if she hadn't done CPR her little grandson would have died. She told me today that if it had not been for our course she would have not known what to do.

Keith Weaver
(The free Online Baby CPR course is available at http://www.onlinebabycpr.com)

The main article in the March 4, 2009, E-News described what, unfortunately, often happens even with a lactation consultant present…. Why were the babies being "loved, passed around and photographed?" So what that an attendant "thoroughly enjoyed preserving these one-of-a-kind memories"? Who says the postpartum mother who is having strong afterpains needs to "bring them to her breast" in the first 30 minutes? In a warm, darkened room, naked, and kept skin-to-skin, twins and other babies will figure out breastfeeding. This story made me shake my head with all the interference between the lines.

Gloria Lemay

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