Essential Oil Summit

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I was offered the incredible opportunity to join Dr. Eric Zielinski in a talk about Using Essential Oils for the Ultimate Birth Experience during the 2015 Essential Oil Online Summit. This is a growing passion of mine, and an area of practice I would love to dig further into both the art and science in effort to better attain the benefits of essential oils during labor and for optimizing health throughout the life cycle.

Essential oil application is a rather new area of study and their utilization in childbirth is even less represented in the literature, so I’ve been challenged to implement them with wisdom. Unfortunately, there are a number of claims by essential oil companies that are extrapolated from single studies that are somewhat stretched or misrepresented, while other statements are entirely fabricated. Publications specific to childbirth and essential oils are largely anecdotal, and of course as the FDA has identified, passionate advocates of essential oils have also touted points that are unsupported (for example that various essential oils can combat ebola).

Using essential oils, in my opinion, is directed a bit by intuition. We know that many citrus oils awaken our attention, woodsy and flowery oils enhance our mood, wintergreen and peppermint relieve pain, and oils similar to oregano combat infection. We can follow our intuition to a degree, especially in labor, because we know what wakes us up, inspires us, or relaxes us and allows us to rest. However, making recommendations from the position of the practitioner must come with some understanding of essential oil chemistry, safe application, and support in the evidence of their efficacy. This has been tougher to discern in my experience, and has proven to be an on-going and intriguing study.

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Dr. Z was kind enough to let me talk a bit about what I do know well, homebirth and midwifery. I’ve exhausted the research on the topic here. I was able to share tips and some of what we do know from the available literature on essential oils in childbirth, and while I do hope the audience will gain some new information or be inspired to utilize essential oils in labor, I am so incredibly appreciative of the culture of intelligent people this summit introduced me to, and has inspired me to dig deeper into the growing body of evidence specific to essential oils.

Please join me in the FREE online essential oil summit!! Register today!!

 

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Cloth Diapering 101

Adding cloth diapers to our Red Raspberry Boutique was a combination of fun – we love cloth diapers – and an effort to encourage good stewardship of our earth. Cloth diapers are very earth conscience and without the sacrifice many imagine. They are also better for baby.

Modern cloth diapers are quite the luxury! They are easy to care for and very user-friendly. Even grandma and volunteers in the church nursery can navigate them easily.

There are many reason to choose cloth for your little ones. Not only will you be surprised with their ease of use, but they are so adorable they become addicting! Cloth diapers are less expensive than the investment of using disposable diapers, and you’ll be eliminating further dumping in landfills. Babies love cloth too!

The average family spends approximately $1,600 to $3,000 on disposable diapers from birth to potty training. Cloth diapers offer a wide variety of styles and price ranges. There are one-size diapers that minimize the financial investment, as they fit from newborn through to potty training. Cloth diapers require the investment of about $300 to $1,000 and if you reuse them from child to child, the cost savings is even more significant!

Babies want to wear soft cloths just as we do. Disposables contain many chemicals and toxins, including dioxin which we know to suppress the immune system, cause liver and skin issues, birth defects and even genetic damage in lab animals. It is banned in most countries, but not here in the United States of America. Tributyl-tin (TBT) is also found in disposable diapers, an endocrine toxin, and sodium polyacrylate, the gel-like substance that absorbs wetness and also causes vomiting, staph infections and fever.

The plethora of options however, can be intimidating. We have a cloth diaper expert on staff, Sabrina Hull. I don’t know of anyone who knows more or who gets more excited about cloth diapering. Sabrina offers classes in both our Lafayette and Carmel boutiques each month.

What are my options for choosing cloth diapers?

Cloth diapers have moved beyond pre-folds and pins of past generations. We now have more style choices than I could even list, more than a dozen fabrics, and endless colors, patterns, and prints. Let me discuss a few options for starters.

Pre-foldsThese are rectangular pieces of cloth folded and sewn so the more absorbent material is in the center. Most people who think of cloth diapering envision something similar to pre-folds, and many use these for burp clothes even if they haven’t chosen to use cloth for diapering. The pre-fold itself offers a number of options, from standard length to longer for better absorption or shorter to fit better in covers. There are a variety of blended fabrics, and we’ve recently added a bamboo option to the boutique! The pre-fold requires a diaper cover.

Fitted DiaperThese are essential pre-folds with either snaps or hook and loop (velcro) closures, and elastic in the legs and waist to make it fit better. This diaper also requires a diaper cover.

The pre-fold above is available in what is called, Better-Fit by OsoCozy. It doesn’t need a closure of any type. A diaper cover is sufficient. The snappi however, can be used to secure the pre-fold if extra security is desired or if bunching in the front offers the needed extra padding for little boys. We also offer the traditional OsoCozy which is longer for increased absorbency.

Pocket DiaperThe pocket diaper is similar to an All-In-One (AIO) in that it is a complete diaper with a waterproof exterior. The pocket is for stuffing absorbent material. Why? Having the ability to remove this stuffing, as opposed to the AIO, drastically decreases drying time. This is a huge advantage for the busy momma.

All-In-One (AIO): Every cloth diapering family needs at least a few AIOs in their layette. The AIO diaper is a complete waterproof system, with an absorbent center. It may also have a sewn-in or snap-in soaker. Because they are applied to the newborn as one would a disposable, they are easy to use by care-givers who aren’t familiar with cloth diapering. Grandma may appreciate these!

Diaper CoversThe pre-folds and fitted diapers are the absorbent part of the diaper, both requiring covers. These are the waterproof covers that generations ago were elastic around the waist and legs and pulled up over the cloth diaper pinned in place. Mothers in that day and age were often cleaning rather horrendous messes as they pulled down diapers over baby legs. Not today! Diaper covers are now available in front or side snaps, or hook and loop options.

Choosing Sizes

Each diaper brand will specify the weight of their specific sizes, and if you’re intimidated by the variety of size options, you aren’t alone. Quite basically, you can opt to purchase your diapers in various sizes for a better fit or in a one-size diaper to save money. A more complex explanation would be that one could opt to use pre-folds or fitted diapers, either sized or one-size, and covers that are sized or one-sized. Many companies that offer one-size diapers, also offer a newborn size for the smaller legs and bellies. Some diaper companies offer extra small, small, medium, large and extra large. Some sneak companies, such as Mother Ease offers a medium-large for a better fit in the awkward toddlering stage. Other companies offer size one and size two, while others offer all those options! Again, if you want the cliff notes, consider if you prefer a better fit or a better price.

How do I get started?

We have done a lot of research for you, and continue as the industry changes quickly. Cloth diapers are becoming more popular, so often as they hit the big box stores the quality changes. Our boutique prioritizes those companies with excellent quality, local options, ethical marketing and manufacturing, and many are made by stay-at-homes that stand behind their product guaranteeing satisfaction. Mother Ease for example has a life-time warranty! Eco-posh offers a fitted diaper that is made with plastic water bottles! We are a fan!

My point, please come in to our boutique and let us help you get started. Our class is full of information. Sabrina really is an expert and can assist you in creating the perfect cloth diaper system for your needs.

Briefly, some families prefer all AIOs (either pocket or AIOs), although most prefer a variety of options in their stash. A dozen diapers is the absolute minimum, and will require daily washing to avoid disposable. For a more relaxed laundry schedule, choose two or three dozen.

Dr. Lane’s Personal Experience

My first experience with cloth diapers was with the Mother Ease diapers. These are amazing diapers, and today are available in bamboo! They are a fitted variety that require a cover. They are also a one-size option so we could use them from the newborn stage through toddlering, and from child to child. The covers were particularly wonderful because they offer a size snap which toddlers aren’t as easily able to remove themselves. Motherease prefers the Kind Laundry detergent, and while they offer a lifetime warranty on their diapers, using detergents which are not approved voids the warranty so be cauteous!

My last two children however, I was a busy midwife so took full advantage of a local cloth diaper delivery company. This was divine in every way. We used pre-folds delivered to our door each week, and our own Mother Ease diaper covers. Not even a year later, the company closed and I was shamefully too disappointed and distraught to invest in another stash of cloth diapers. We had completed our family so finished up with the horrid disposables those last few months.

Tips I’ve Learned since Cloth Diapering My Own

My grandson is cloth diapered and so I am still learning lots of great tips. Primarily, it is essential to change diapers as soon as they are wet or soiled. Disposables allow us to delay changes until the diaper is hanging a bit low. They simply absorb so well the urine is mostly pulled away from our little one’s skin. Cloth diapers aren’t as effective in this way, which may cause skin irritation. Let me be clear, the gel in disposables that allows for this imposes its own risk to our little ones and no one should sit or play in their waste so having to change more frequently is certainly not a disadvantage.

If you find your little one requires a diaper cream, no matter which brand you use, and even if it says safe with cloth diapers – use a liner. Micro fleece diapers are particularly sensitive to creams, which most AIO’s and pocket diapers use as an inner fabric. Cotton washes out better, but Kanga Care offers the softest, thinnest diaper liners which are washable that protects your cloth from diaper creams.

Night-time Leaks

Nearly all of my boys seemed to stay quite dry at night, and then upon wakening in the morning unleashed enough urine we all required life jackets if we didn’t wake in time! This prevented the need for thick absorbent diapers, although we did have a few Mother Ease Sandy’s for this purpose. Friends have shared that they would use one-size AIOs or pocket diapers with various liner combinations for heavy night-time wetters.

What other Accessories do I need?

There are lots of fun accessories but very few are absolutely essential, although this is arguable depending on who you ask. The diaper pail is one of the more essential. When I was cloth diapering the question of the day was if one should use a wet pail or dry. I believe families have determined the dry pail to be the exclusive option today.

Wet pails are dangerous, a potential drowning risk, and are heavy! Our family purchased an inexpensive trash can from Target, with a lid, and added a pail liner (similar to a trash bag). We would fill the can and then lift the entire pail liner, turning it inside out and tossing it into the wash with the diapers.

Hanging pails are a great option today. These can hang on a hook or doorknob, and most have some variety of zipper to contain the smell. Of course, diaper pail deodorizers are available.

The wet bag is also handy. These are waterproof and quite stylish bags utilized when traveling. We have one in our family for swim days. Wet bags come in large, medium, and small sizes and have a plethora of uses beyond cloth diapering. Our recommendation is to invest in a few so you always have a clean one available. They will be used throughout child-rearing.

The wet bag is also available in a wet AND dry bag, which allows you to store your clean diapers on one side and soiled on the other. Very handy indeed.

Liners, doublers and inserts are other accessories many families find vital. Doublers lay inside the diaper and offer extra absorbency particularly at night. Inserts are absorbent pads, in multiple layers, and are used to stuff pocket diapers. Disposable liners are brilliant. These pieces of material are placed on top of the diaper interior and not only provide a stay-dry feeling on your baby’s skin, but once they begin eating solid food, they allow for much easier diaper cleaning. Simply flush the liner!

Diaper sprayers are also favorite cloth diapering accessories in many families. These attach discretely to the side of your toilet tank and are used to spray off messy diapers before they go into your diaper pail.

If you choose to cloth diaper, you might also choose to use cloth wipes and a wipe solution. Either pre-soak cloth wipes or use a spray at each diaper change with a cloth diaper, tuck the dirty wipe into the soiled diaper and wash them all together. Planetwise has these brilliant cloth wipe bags that fold over and snap.

What about Laundering my Cloth Diapers?

Once you’ve chosen your diapers and mastered their use, laundry becomes the intimidating factor. Our cloth diaper expert, Sabrina Hull, is designing a Cloth Diapering 202 class for troubleshooting cloth diaper issues, laundering and overcoming the intimidation of wool covers. Stay tuned!

We’ve already discussed how to store soiled diapers. Keep in mind, diaper covers do not need changed with every diaper. When damp, they can typically be wiped down, and changed every few diapers unless they are soiled. Wool diaper covers allow for even more use and laundering only when soiled.

We don’t really need to soak diapers anymore. Simply choose a hanging wet bag or pail, and use some sort of deodorizer such as baking soda, doe-disk, or deodorant stick. Wash one or two dozen diapers at a time with minimal laundry soap. This can build up in diapers and affect their absorbency, so more is not better. Usually about 1/4 cup is adequate. Read your cloth diaper manufacturer’s recommendations. 

Generally speaking, avoid those laundry soaps with the whitening enzymes because they seem to irritate baby skin. Diapers should be washed in hot water to disinfect, and can be pre-soaked or pre-rinsed depending on their degree of soil. Check diaper manufacturer’s instructions again with water temperature, as some recommend first washing on cold, then hot. Exclusively breastfed babies are among the easiest diapers to launder. Just toss them in and let the golden seeds wash down the drain.

Many parents have found that baking soda can help ward off odor, as can lavender oil, melaleuca oil in the wash, or white vinegar during the rinse cycle.

Do not use fabric softener as they can decrease the diaper’s absorbency. Bleach has been frowned upon, although it seems this is becoming a more common recommendation as of late. Soaps can leave a film on the diaper that cause build up, although they are more natural compared to synthetic detergents.

Most diapers can be tumble dried in a machine, and of course, line dried. The sun can also offer a bleaching effect for stains. While line drying is certainly more earth friendly, drying in the electric dryer may further disinfect diapers. Stuffing from pocket diapers should be removed prior to washing and drying.

Cloth diapering is a great deal of fun, offers loads of advantages, and is good for both the earth and your baby. We are here to help you! Attend one of our classes, or just stop in the boutique for guidance.

Redefining Detox

Through the years, many of our clients have asked for advice about detoxifying their bodies. Is it safe during pregnancy, or while breastfeeding? What are our recommended regimens? When is detox recommended and how often should it be repeated?

My recommendations have been limited, as I had not been able to craft an educated response. The literature was scarce so my thoughts were more theoretical. I did not recommend detox during pregnancy or while nursing because shedding toxins during these times may impose risk to the growing fetus or nursing baby. I also had concerns about the motivation behind the desire to detox. Were these women struggling with a unhealthy body image, or were they battling a less understood form of eating disorder? Did they feel they were unclean?

100% of the general population has tested positive for toxic residues in their blood and urine samples

Today, there is more literature to evaluate and true to most all human processes, it appears the answer is a healthy balance. Detoxing can be redefined as tuning up, rather than overhauling the body. We have thought detoxing required fasting, juicing, and other extreme forms of deprivation. The process can be done more gently however, and while bringing the body back into alignment, it can also encourage a mindfulness about wellness.

The liver requires sufficient nutrients to effectively mobilize and clear out the toxins escaping from the body during the detoxification, which would argue that minimum caloric needs must be met. Detoxing isn’t limited to one’s diet either, as a plethora of toxins come from our environment. We breathe these in through the air and invite them into our bodies through our skin.

There are 700 contaminates, most of which are not well-studied, in each person’s body.

Toxins produced internally from the foods we eat are called free radicals. These are generally eliminated through our urine, stool, perspiration and through a form of breathing called, pranayama. Eliminating these toxins to the best of one’s ability can in fact, be a very healthy practice. Every day we should strive to eat a clean diet. After the holidays, or otherwise unhealthy period in one’s life, a mindful and gentle detox regimen might prove beneficial. During weight loss programs, many find that after a early weight loss, they hit a plateau where no further weight loss is achieved. Scientists are now questioning if this results from the release of toxins stored within the adipose tissue, slowing the metabolism. A detox at this time might result in further weight loss.

water pitcher with fruitDetoxification is an invitation to optimize your body’s ability to rid itself of toxins. Not cleaning the body of stored waste can result in disease process, or commonly, inflammatory conditions such as diabetes, thyroid disease, anxiety, and chronic pain. Simple lifestyle changes can enhance the body’s ability to rid itself or stored waste, such as increasing water and eliminating refined sugar and flour. A moderate detox program can rejuvenate your body’s inherent efficiency, establish a healthier baseline and enable your to maintain better wellness choices.

Stay tuned to our website for information on an up-coming class on detoxification!

Independent Practice

As a student of midwifery many years ago, the question of whether I would pursue private practice or seek employment within a larger corporation always poked it nose into my studies. There are pros and cons to both, and certainly while many midwives have a heart for home birth, they haven’t the financial resources, family structure, or community support to invest in the path of private practice. Those of us who do take the leap, often give up retirement, health insurance, vacation, and work largely in isolation. This weekend I attended a management workshop and was reminded of all the beauties of private practice and owning a small retail boutique – we can create necessary changes instantly.

As a nurse in a large tertiary center, I remember being fired up because women were asked to sign informed consents immediately upon arrival for a plethora of procedures that were not being currently considered, may never be necessary, and most importantly did not accompany informed consent! As a nurse, I was suppose to ask every laboring mother to sign a stack of consents, including one for an epidural, another for a cesarean, anesthesia, newborn medications, and even circumcision prior to even learning the gender of the newborn. I adamantly refused to witness a signed informed consent form without a provider actually present to provide the appropriate education. I was rather sternly informed by upper management that my signature as a witness on the informed consent was absolutely required, and was the simple witness to who was signing the form, not of the informed consent process itself. I passionately disagreed, refused to follow procedure, put my job on the line, and ultimately created a league of enemies because remember, I was a nurse cross-training from another hospital. I was in foreign territory and pointing fingers at a procedure that put into question the appropriateness of other nurses who willingly participated. I made clear they were violating the rights of women.

To my favor, I had a long and respected history in this hospital system (although not the same facility) and a manager who was a strong advocate for me (thank-you, Diane). Needless to say, in spite of my own manager sticking her neck out for me and trusting my argument was backed by thorough research, she faced multiple committee appointments, work group deliniations, and agenda priorities that progressed slow enough for JACHO to arrive and determine in their own inspection that this policy was not only inappropriate, but worthy
of several thousand dollars of fines. Admittedly, this validation only served to strengthen the animosity of this nursing staff against me (the nurse from the ‘other’ hospital).

Here is where I could also share the details of my argument with a physician who asked me to administer Cytotec to a woman who had a previous cesarean (yes, I am that old). I was young, but well read. My passionate debate was not appropriate for my chain on the ladder of hierarchy. The night of my refusal this momma suffered a ruptured uterus and ended up in an emergency cesarean. My scheduled reprimand became an invitation to join the hospital’s policy and procedure committee. Sadly, I can write a book on events such as these… adoptive mothers being refused visiting rights, teenagers being refused epidurals because they did not have a parent to provide consent, women not being permitted to leave the building to smoke a cigarette (while not desired, it violated their rights to force them to stay), administering artificial milk to NICU babies rather than providing the milk their mother had pumped, and all the many other violations so many are all too familiar.

Although I appreciate the process required in hospital systems to implement new policy, and it really is quite necessary, it is not unlike asking a massive cruise ship to change course. Forty-five different committees must be consulted, another fifty-five forms need completed, research needs conducted by small groups, and these steps are when everyone is in agreement! When there is debate, these steps are multiple exponentially. Studies have shown that it takes an average of seventeen years to implement changes in practice after professional journals publish new data. Small practices such as my own are more like speed boats. We can evaluate the evidence, and change a policy in a matter of key strokes. We are in the position to do what is right, immediately. This means we are often working outside the standard, which doesn’t mean we are pushing safe boundaries, but rather, we are ahead of the popular understanding of best standards.

As a person strongly convicted about right and wrong, it was exceedingly difficult for me to participate in on-going practices that I knew to be inappropriate simply because what is right, hadn’t been approved by all the necessary committees and department heads. Private practice allows us to extend care to the very best of our knowledge-base.

The other point I have been reminded of is our ability to create a community as a small business. We develop relationships with our clients and genuinely care about their life, beyond their nine months in our practice. Many postpartum visits have made me teary eyed as I hugged couples prior to their walking out the front door. Yes, I have even had fathers say, “I love you,” inadvertently because we had developed a close relationship that was coming to a close seemingly too soon. Certainly we hope families continue to utilize our services for primary care and return for future pregnancies, but I am recognizing that the boutique is a perfect opportunity to nurture those relationships outside of the clinical role we plEvaluationsay as midwives. Our attention, as midwives, has always focused more on the practice because the demands are more vital and well, it is our primary passion, but it is our hope we can bring in some lovely women and men into the boutique to help nurture its growth and ultimately, the growth of our community of families.

We have great vision for a number of amazing classes, support groups, events, resources and jolly good fun. We’re taking ‘baby steps’ however, so we don’t build beyond our ability to do the job well, and remaining true to our commitment to add only to our practice and boutique when we can do so debt free. Currently we are working to tighten up our procedures behind the scenes and make the overall shopping experience easier for the customer, so we aren’t causing any undo frustration, but we are bursting with excitement to share all the new classes we have in development. Our desire to support families, share our passion about healthcare, clean living, and parenting is strong. We are dedicated to improving our services every single day. We can’t thank our clients enough for returning to us, and trusting us with such a precious time in your lives.

Abortifacients

Abortifacients are those herbs that have been historically used to terminate unwanted pregnancies. Women as far back as the Old Testament have utilized these herbs to invite their menses prematurely. Another class of herbs, emmenagogues, have also been utilized as abortifacients, yet not all herbs in this class work in this way.

SageWhile some abortifacients may affect the uterus directly, the bulk of them, quite frankly, work by poisoning the mother and fetus. This is dangerous and no matter one’s position on the abortion debate, herbalists generally do not assist those seeking counsel for this purpose.

Pregnant women often ask Miss Michael and I which herbs or essential oils they should avoid while pregnant, as resources can be confusing, even contradictory. Our practice offers an extensive list specific to both herbs and essential oils to our maternity clients, but briefly, culinary herbs in normal culinary amounts are not generally concerning.

When herbs and essential oils are used in medicinal amounts however, caution should be used and expert counsel sought. Oregano and rosemary should not be used in medicinal doses during pregnancy, or in their essential oil forms internally. Sage can be an abortifacient even in small doses. Essential oils taken internally in the volume required to induce abortion have been associated with increased risk of serious illness and death to the mother.

Dose is the variable in most all poor outcomes associated with herbs and essential oils. Nearly all poor outcomes associated with essential oils are associated with doses 2-3 hundred times the recommended amount. However, some abortifacients and emmenagogues may disrupt a pregnancy in even small amounts.

The following herbs should therefore be avoided in pregnancy, either due to known or theoretical risk:

  • Artemesia spp. (wormwood)
  • Berberis vulgaris (barberry)
  • Caulophyllum thalictroides (blue cohosh)
  • Chelidonium majus (celandine)
  • Chrysanthemi vulgaris (tansy)
  • Cinchona spp. (quina)
  • Crocus sativa (saffron)
  • Dryopteris felix-mas (male fern)
  • Gossypium herbaceum (levant cotton)
  • Juniperis communis (juniper)
  • Mentha pulegium (pennyroyal)
  • Origanum vulgare (oregano)
  • Phytolacca spp. (pokeweed)
  • Rosmarinus officinalis (rosemary)
  • Ruta graveolens (rue)
  • Salvia officinalis (sage)
  • Sanguisorba canadensis (rosaceae)
  • Tanacetum vulgare (common tansy)
  • Thuja accidentalis (white cedar)

Please speak openly with your chosen practitioner about your herbal choices, and seek the counsel of an herbalist for honest, accurate and up-to-date information about herbs, particularly when pregnant.

 

Midwifery Management of Breast Cancer

This is a topic for which I hope to never have personal or professional experience. Earlier this winter however, one of my closest colleagues brilliantly diagnosed breast cancer in one of her pregnant clients. Truly, to say she changed the life of this mother and child is a huge understatement; she literally saved their lives.

Two previous practitioners denied the presence of cancer, yet my colleague persisted. Her perseverance proved fruitful, as aggressive cancer was confirmed. Unfortunately, two subsequent practitioners overstepped their authority and earnestly sought to end the life of the unborn child. My colleague, committed to both the mother and child, reminded the physicians of her her role in coordinating care, as the client’s chosen primary care provider, and she proved an expert clinician.

The emotional turmoil of breast cancer overwhelms all involved, including the healthcare practitioners. Being in a position of support for this midwife reminded me of the important role we have as primary care practitioners. Breast cancer remains the most common cancer in women both in the United States and around the globe.

Assessing Risk

Family history, increasing age, exposure to ionizing radiation, and exogenous estrogen are all risk factors for breast cancer. Exposure to chemicals and viruses have also been correlated, as well as never having a full-term pregnancy or never having breastfed a child. The irony is that most women who develop breast cancer have few, if any, of these known risk factors.

Mammographic density is a newly identified risk factor that implies the role of the breast stroma, which accounts for much of the density reading. The greater the density, the greater the incidence of breast cancer. Indiana now requires patients be notified of their density screening, although to what benefit this offers is yet to be determined.

Two large tumor suppressor genes, BRCA1 and BRCA2, located on chromosomes 17 and 13, account for approximately 5% of all breast cancers. Women who carry one of these mutations have a lifetime breast cancer risk of 40-80%, depending on mutation, penetrance, and other host factors. Interestingly, women with either mutation, who have their fallopian tubes removed, reduce their risk of breast cancer by 50% (Mokbel, 2003).

Our practice does offer screening for BRCA1 and BRCA2, although universal screening for these mutations is not yet recommended. We also frequently refer for genetic screening when risk factors are identified.

Conventional strategies for prevention include a class of drugs called “selective estrogen receptor modulators” (SERM) which include Tamoxifen and Evista. Aromatase inhibitors and COX-2 inhibitors are in clinical trial. No random control trials are available for functional food or exercise programs for breast cancer prevention, as I am aware.

Surgery is a popular prevention strategy, as Angelina Jolie made popular more recently. As reconstruction surgeons improve their craft, prophylactic skin-sparing mastectomies are increasingly chosen with a success rate of greater than 90%.

Screening

Significant funds have been invested in educating the public to perform self-breast exams on a monthly basis. This investment may not have paid off, as evidence has demonstrated that the self-breast exam has not decreased mortality. In fact, a 2008 Cochrane Review suggested it may in fact lead to harm. Women who rarely perform breast exams, but do so prior to their annual exam, often find unfamiliar lumps, reporting them to their practitioner during their visit. The clinician responds by ordering diagnostic exams and biopsies which may impose greater risk, than benefit.

We are certainly an advocate for learning the norms of your own body and reporting any concerns to your clinician. However, the clinical breast exam provided by your nurse-midwife, should be performed annually. Evidence has demonstrated that trained clinicians, providing breast exams annually, find masses smaller than those discovered by women who consistently perform self-breast exams each month.

Clinicians have at their disposal a number of options for screening beyond the clinical exam. Magnetic resonance imaging (MRI), ultrasound, and breast PET scans are options, although costly. Thermography cameras and light source imaging are still investigational, so while intriguing, they should not be substituted for mammography quite yet.

Diagnostic & Treatment

Concern by either exam or mammogram leads to biopsy, where diagnosis is confirmed. Breast cancer treatment is a multidisciplinary field that includes nurse-midwifery, as my colleague above demonstrated. Too often it is assumed that nurse-midwives do not have a role in pathologic findings, but in fact, we may play the most vital role. We are the client’s best advocate. We are experts in providing informed consent. We are capable of educating and counseling the client, discerning the plan that best suits the individual, and extending a coordinated plan of care. Nurses are the most trusted profession because we are not only skilled clinicians, but also compassionate.

Surgery, radiation and oncology all play an important role in the treatment of breast cancer. Lumpectomy and mastectomy have offered fairly equivalent survival rates, and breast conservation has been preferred since the 1990 Consensus Statement. It is now standard of care to assess the most proximal lymph nodes to assure cancerous cells have not spread beyond the tumor. Systemic therapy can also be guided by molecular and genetic tests performed on the tumor itself.

Integrative Therapies

Once again, physical exercise can not be ignored. It absolutely reduces breast cancer risk, with evidence suggesting reduction by as much as 30% (Friedenreich and Cust, 2008). The more exercise the better, and the greater the intensity, the greater the benefit.

While scientists can’t detail a specific cause that links exercise with improved breast cancer outcomes, it is thought to be related to three important factors. First, exercise reduces endogenous estrogen. It also improves the body’s ability to regulate insulin. Inflammation may also be reduced with exercise. The emotional benefit can not be underestimated as well. Exercise benefits women through prevention, improves treatment outcomes, and assists with healing.

Nutrition is paramount to good health. One must strive towards a healthy weight. Obesity increases risk for breast cancer in postmenopausal women, with weight loss decreasing risk by 40% (Eliassen et al, 2006). Recommendations for specific dietary choices have yet to be revealed in the literature. The Mediterranean-style diet with high intake of whole grains, fruits and vegetables and olive oil is recommended simply because it encourages overall good health.

Alcohol intake of two or more drinks per day is known to be associated with an increased risk of breast cancer with a dose-response effect in both premenopausal and postmenopausal women. This is thought to be related to alcohol’s ability to increase estrogen and androgen levels, although folate has shown to neutralize this risk. Interestingly, grapefruit has been shown in one study to increase the incidence of breast cancer in postmenopausal women (Monroe et al, 2008). Experts believe this is due to an increase in endogenous hormone levels with the grapefruit. Neither coffee or tea have been found to increase breast cancer risk in the Nurses Health Study (Ganmaa et al, 2008).

Vitamin D deficiency should be assessed in all women, at various points in their life cycle, but particularly as they reach perimenopause. Vitamin D3 has been identified as a playing a significant role in breast cancer prevention (Gissel et al, 2008). Again, we recommend food-based supplementation to enhance absorption.

Melatonin supplementation has been suggested as a method for preventing breast cancer. Poor sleep certainly impacts health negatively, and disrupted sleep has been associated with increased risk for breast cancer. Nighttime shift workers specifically have a higher risk, potentially because increased light at night reduces levels of melatonin. Supplementation of 3 mg prior to bed may prove beneficial. Doses as high as 20-40 mg/day have been studied in women with solid, metastatic tumors (Mills et al., 2005).

Cruciferous vegetables have been shown to be a potent antiproliferative agent in human breast cancer cells. The active phytochemical is indole-3-carbinol (I3C) which can be taken as a supplement at 400 mg/day.

Botanicals

Tumeric might be one of my first recommendations, as it has apoptosis properties and is a strong aromatase inhibitor with antiinflammatory and antioxidant properties. This botanical has only minimally been studied, but because it has a long history of traditional use, its safety is trusted. Standardized extracts providing 1-2 g of curcuminoids per day are typically used for inflammatory conditions.

Five glasses of green tea daily was shown to reduce the incidence of breast cancer in one study (Sun et al, 2006). Iscador and Helixor, trade names for commerical preparations for mistletoe, and mushrooms shiitake, maitake, and reishi may all benefit those with breast cancer, although admittedly, these are outside my own expertise. Ginger of course, has a long history of offering pallative treatment for the nausea associated with chemotherapy.

Lifestyle Modification

Certainly exercise, proper nutrition and sufficient sleep is vital to overall health and improved outcomes in breast cancer women. Stress reduction is also imperative to healing. Interestingly, stress reduction is important beyond improving one’s experience and even improving one’s health outcomes, but it has recently been shown to change gene expression (Dusek et al, 2008). All women suffering with breast cancer should be offered some avenue of support, whether spiritual, talk-therapy, group therapy, dance, yoga, art, or journalism.

Nurse-Midwives & Breast Cancer

Nurse-midwives are not typically experts in breast cancer treatment, although we are in breast cancer diagnosis and advocating for our clients. Coordinating such care is not only within our scope, but is part of the expert role we take responsibility for as primary care providers. Understanding the various treatment options and being familiar with community resources is an important part of offering informed consent. Optimizing care for women who endure breast cancer includes acknowledging the need for a multidisciplinary approach, which may easily be overlooked among individual specialists. Nurse-midwives are trained to provide a holistic approach to care, and our nurse-midwives can do so with an integrative mindset.

Uterine Fibroids

Pelvic tumors are quite common in women, with more than 70% experiencing them by the age of 50 (DayBaird et al, 2003). Many go completely unnoticed, but some cause considerable havoc, disrupting the quality of life for many women. The most common complaints are abnormal uterine bleeding, pelvic pain or pressure, and infertility. Management is largely dependent on the severity of the symptoms, and the woman’s desire for future fertility.

Conventional treatment is either hysterectomy or myomectomy. More recently, innovations have allowed for less invasive options, such as laparoscopic assisted removal of the uterus or fibroid, ablation of the uterine cavity, uterine artery embolization, and magnetic resonance-guided focused ultrasound surgery. Physicians disagree on the best management, and like many areas of women’s health, there is little evidence supporting the long-term effectiveness of most conventional medical treatments. Surgical procedures, medical therapy and watchful waiting all offer advantages and disadvantages.

Fibroids are not cancerous in nature, so there is little motivation to dump millions of dollars into researching optimal fibroid management. Our clients however, seek less expensive and minimally invasive regimens for fibroid management. More specifically, most desire complementary or alternative therapies. The challenge however, is making recommendations in light of minimal research available to support such therapies. Our desire therefore, is to blend the best of both science and art in effort to create an evidence-based plan that appreciates the individual needs of each woman.

An Integrative Approach

There are a greater number of both estrogen and progesterone receptors within the uterine fibroid, making them particularly sensitive to estrogen. Metabolism of estrogen is also altered, all of which leads to vascular abnormalities, which is thought to be why some women experience excessive bleeding.

The body of evidence is growing and convincing identifying pesticides, heavy metals, pharmaceuticals, plasticizers, and even phytoestrogen, as xenoestrogens which disrupt the endocrine system, changing gene expression without DNA sequence changes. This epigenetic change can become persistent and inherited, meaning toxins in one’s environment can negatively impact gene expression in future generations.

Uterine fibroids can be diagnosed most every time by exam with a nurse-midwife. Ultrasound can augment exam, particularly in larger women or when it is necessary to rule out other pathology. Ultrasound does not however, improve long-term clinical outcomes for fibroids. Additional diagnostic testing may be indicated, such as measuring pelvic girth and obtaining a pregnancy test. The midwife may choose to obtain a complete blood count, a metabolic panel, possibly a prolactin level and/or thyroid panel, or even coagulation studies based on the amount of bleeding. Certainly, there may even be indication for MRI, CT and HSG depending on individual circumstances.

Once diagnosis is established and other pathologies are ruled out, complementary and alternative therapies can offer relief from the discomforts caused by fibroids. They may not however, shrink the overall size of the fibroid.

Nutrition, Diet and Supplements

It should be no surprise that diet and exercise is associated with whether one may suffer from uterine fibroids or not. More than one study has made clear: the greater one’s physical activity, the less likely they are to have fibroids (Baird et al, 2007 & Flake et al., 2003). Dietary choices also influence fibroids, in that food choices influence estrogen excretion. Vegetarian women for example, have a three-fold increase in fecal excretion of estrogen and 15-20% lower serum estrogen levels (Gorbach and Goldin, 1987).

Flaxseed and whole grains may be a viable dietary strategy for reducing the risk of uterine fibroids due to their phytoestrogen nature (Atkinson et al., 2006). Whole soy foods should be prioritized to concentrated or processed options, as the literature shows mixed outcomes with regards to benefits and risks of phytoestrogens.

Interestingly, cruciferous vegetables such as broccoli, brussels sprouts, cabbage and cauliflower have a phytochemical, indole-3-carbinol (13C), that alters estrogen metabolism by promoting the formation of less potent estrogen metabolities (Minich and Bland, 2007). Green vegetables have a protective effect.

Omega 3 fatty acids should also be encouraged, while reducing intake of omega 6 fatty acids, to utilize their anti-inflammatory nature for curbing fibroid growth. Vitamin D has shown to significantly inhibit the growth of leiomyomata cells (Blauer et al, 2009). Supplementation for both can be obtained through a single food-based supplementation which our practice highly recommends.

High caffeine and coffee intake may increase early follicular phase estradiol levels compared to those with lower levels of consumption (500 mg/day compared to 100 mg/day), independent of alcohol consumption or tobacco use.

Iron-rich foods would benefit the women who suffer excessive bleeding related to uterine fibroids. Taken with vitamin C, iron absorption would be improved, and the vitamin C would additionally offer the benefit of improving blood vessel walls. Depending on the class of the bioflavonoid, antiinflammatory, antioxidant, and anti-proliferative properties may also be gained.

Botanicals

It may take several months to achieve significant benefit with botanicals, and the fibroids may not shrink. However, further growth may be inhibited and symptoms are quite likely to improve. Many women choose these complementary therapies as they await the natural menopause transition.

Chaste tree berry, Ginger, Turmeric, Shepherd’s Purse, Yarrow, and Red Raspberry Leaf are among the most common herbs utilized for managing fibroid symptoms. Each offers their own advantage whether balancing a hormonal imbalance or offering symptoms relief such as excess bleeding. The nurse-midwives at Believe Midwifery can discern and recommend botanicals as appropriate to each individual. If more aggressive treatments are necessary, Believe Midwifery Services is also equipped to offer necessary diagnostics and pharmaceuticals, or refer as appropriate.

Thinking about Mary

I read today that stories infuse the ordinary with meaning and the tragic with truth. As a midwife, I long to share the beautiful details of the many births I am privileged to attend. I always say I’ll write a book someday, when so much time has lapsed that the details blur and no one will recognize themselves within my narration. There is such great beauty in what we do, watching God’s glory unfold, witnessing the vulnerability of fathers, their tenderness and tears, and the courage, as women become mothers. It is no exaggeration to say I am in awe each and every time a precious baby emerges from its mother.

As a mother myself, I appreciate the gratitude one has for their birth attendant, but let me be quite clear, that appreciation does not compare to how honored we are to be part of your journey. Every single woman who has crossed my path has made an impression on me, and has taught me about relationships, sacrifice, dedication, and grace. I am still learning, and growing as a midwife, as a woman and mother, a wife, and most importantly, a child of God. Today I wanted to share my thoughts about Mary, the mother of Jesus, and hope they touch your heart, infusing your ordinary with meaning and maybe offering your tragedy some truth.

As a child, I was always a bit of a go getter. I talked too much. I was always underfoot. I joined all the clubs and everyone was a friend. It seems a bit ironic to me now that Mary was always the woman with whom I most empathized. She was so passive and seemingly submissive, hidden even, in the background. I suppose I identified with being called. It may seem like a cliche and I am certainly not comparing my own calling to the holiness of her own, but I have no doubt that I was very specifically given a heaven-endowed mission. In fact, I remember the specific day I was told to “hang on,” that He had big plans for me and as a child, I was quite certain that meant I would have a yet unrevealed super-power, and maybe even an invisible plane.

I’ve shared this story (and its more grim details) with my staff on occasion, and with humility I will share with you. I was an unwanted child. Don’t pity. There is beauty in this story. However, in truth, my mother truly despised me. She wasn’t and isn’t today a bad woman. I think she wanted to be a good mother, but she was young, from a troubled home herself, without a husband, all alone, and we were just very different temperaments.

When I was quite young, and very alone, the Lord revealed Himself to me. He was the one and only constant I had in a home that had no love and never spoke of Our Father. He was so present in my life that today, I don’t feel the absence of parents and I truly don’t have any bitterness or sorrow. I have compassion for them and appreciation that I was a challenge for them. They tried and that was enough. My truth still remains. The Lord gave me a vision of hope, a mission to live for, and He has fulfilled His promise… short the invisible plane. This life, my being a midwife, is my evolving Wonder Woman. My children, and very good-looking husband, are my amazing side-kicks. We jet out in the night, catching babies, nurturing young families, and serving our community.

Back to Mary… Gabriel announced her mission. She well understood. She trusted the path, as have I. Men would persecute her, as I too have endured. Her child would be persecuted, mocked, hated, and even crowned with thorns. Mary chose to obey.

I have shared with staff during our tougher days that this is the Lord’s practice to build up, and it’s His to tear down. What I must do is obey. There are days that I cooperate while admittedly complaining a little. I am reminded though that Mary approached her mission with a thinking mind and a sensitive heart. It is she I remember. She accepted a path that yielded both great joy and deep pain. She willingly participated, for all of her days. This very truth is my own, and will continue to be until my very last breath.

There are many lessons in such a life, one with a clear mission. There is never question that the Lord is near. He has proven to be my counselor, my friend, my comfort, my teacher, my Father, and while not biblical, I think He has a little comedian in Him as well. Our relationship is intimate and for that, I will forever be grateful – quite literally, Amen!

Obedience draws us into God’s heart, away from the world’s influences. The midwifery career is set apart. It isn’t entirely accepted by society. Although the profession has grown tremendously in the last few decades, we’re still a joke to many. Any shame however, is replaced by righteousness. The obedience He demands however, navigates us through complexities that are difficult to comprehend outside the profession. Midwives are frequently faced with scenarios that demand a loyalty that challenges the “standard of care,” or man’s approval. We obey and respond, “Yes, Lord, I will do that. I will educate, counsel, and support by client in the face of persecution, and even possible prosecution.” There have been times that I have also had to obey and draw boundaries which caused upset to my client. These are most difficult to me, because I want to please, but I remind myself, I am not working for man.

The work of a midwife largely goes unrecognized, as it should be. We are hidden. It is our goal to empower women, couples, families – not to make them depend on us. We need not reap rewards here, but rather, as Mary did, store up each precious moment in our heart. Mary knew her mission helped shine light in an ever-darkening world. We seek to be that light too. We seek to offer choice, protection, compassion, and mercy while recognizing our duty is to do so with the greatest of wisdom.

Mary told the angel, “I am the Lord’s servant. May it be to me as you have said.”

As I seek to better understand and practice obedience, may these become my own words. May I continue to store up sweet memories in my heart and be reminded of them during the toughest days. May I continue in faith. Cindi, Kristi, and all my midwifery sisters in faith, let this be an encouragement to you. We are so very blessed.

Moxibustion

Moxibustion is a traditional Chinese medical intervention used to assist in turning the breech baby to a cephalic (head down) position. Heat is generated at the Zhiyin (BL67) point, located on the outer corner of the fifth toenail. The specific herbal preparation used is Mugwort (Artemisia vulgaris). We sell this herb in the Red Raspberry Boutique just for this purpose. Incidentally, there is evidence that suggests mugwort can assist in the treatment of stroke rehabilitation, pain, cancer care, ulcerative colitis, hypertension, osteoarthritis, constipation, and child chronic cough.

breech birthThe theory is that moxibustion stimulates the production of placental oestrogens, alterations in prostaglandin levels, and promotes uterine contractions, which leads to a stimulation of fetal movements and a higher probability of vertex presentation of the fetus.

This procedure has been familiar to me my entire nursing career, and we’ve utilized it a multitude of times in our practice. In our early years, my husband would help take our pantry door off the hinges, lay it over the couch, and assist me in laying the pregnant momma head down as we utilized rolled mugwort sticks to heat her outer toes. This was comical in itself, but even more so when the next pregnant momma presented for her appointment to find a momma on her head and our using herbal sticks near her toes that may or may not smell like cannabis.

Evidence has supported this practice in spite of the method of action being somewhat elusive. The systematic review and meta-analysis cited below included 392 potentially relevant articles specific to moxibustion. Seven random control trials were included. Interestingly, moxibustion consistently demonstrated a positive correlation for assisting the breech presenting baby in finding its way head down, but this study also found that moxibustion might decrease the need for oxytocin. Adverse events included six cases of premature deliveries, four cases of premature rupture of membranes after treatment, and one case of bleeding at week 37, but this also involved “excessive pressure on the rear of the placenta” during an external version. These outcomes did not differ from the control group.

References:

Zhang, Q., Yue, J., Liu, M., Sun, Z., Sun, Q., Han, C., & Wang, D. (2013). Moxibustion for the correction of nonvertex presentation: a systematic review and meta-analysis of randomized controlled trials. Evidence-Based Complementary and Alternative medicine. DOI 10.1155/2013/241027

Seeking Business Manager

One thing Gretchen and I always reminded each other is that this job requires someone inspired by change. Although the two of us were somewhat inspired by the practice’s ever-evolving and exceedingly quick growth, even we were challenged to stay ahead of the tide. It is difficult to make clear expectations for staff when roles are continually evolving. It is also a delicate balance with whether to move ahead, risking taking too big a leap, or standing firmly in place and missing a necessary opportunity.

Last year we recognized we were out-growing our home office and opened clinics in both Carmel and Lafayette. We also added a second nurse-midwife, both of which were dreams come true. While a challenging year, our blessings overflow. It can no longer be ignored that if we seek to nurture this work in a manner that will allow continued goodness to unfold, we must be guided by a skilled business manager.

Miss Michael and I learned today that a business manager and an office manager are not equivalent. In fact, we are not seeking an office manager or an administrative assistant. We require someone to take on the administrative duties so that we can turn our attention exclusively to practicing midwifery. Ideally, this person would be educated in business management or health administration so that their business expertise exceeds our own.

It would be our hope that this person could provide customer service and support, manage employee records, payroll, client financial accounts, tackle public relations and aggressively market, as well as offer liaison for our various business accounts such as our scheduling program, electronic health records, phone management, and faxes. This person would not oversee accounting beyond client accounts and would not hold any clinical responsibility.

While we’d love a master’s prepared business manager with Ivy League preparation and Fortune 500 success, our desire is even more great. We seek a person who has emotional-intelligence, is humble yet confident, compassionate yet draws clear boundaries, innovative, creative, and self-motivated. This person should also work well among our team, because our relationships are strong, both with each other and with our clients.

This person would work exclusively within the offices, both in Carmel and Lafayette, three days a week. If you can vision yourself within our mission, please send your resume to Dr. Penny Lane. We are eager to fill this position!

Gut Instincts

Miss Michael CNM and I have a strong draw towards functional medicine. Neither of us are yet formally trained, but we dive into any and all literature about the discipline we can locate. Our nutritionist, Megan Barnes, is currently in a graduate program that combines nutrition and functional medicine. She is brilliant and generously shares her passion with the clinical staff. It is not lost on any one of us that the health of one’s gut is vital to overall health, most especially mental health.

Not too long ago I read a study that discussed the gut as a second brain. My son and I have also had long conversations about this, as he is fascinated with the mind and the vast majority of his high school studies have surrounded the biological nature of the human brain and nutrition. What about gut instincts?

Today I have stumbled upon an article by Christopher Bergland, thanks to Cheri Goble, a Webster-certified chiropractor in Lafayette. She graciously shared a journal with me where I found the article, “Gut Instincts: Neuroscientists have Identified how the Vagus Nerve Communicates with the Brain.” There were many points that resinated with me, so I thought I’d share because we do see a fairly high number of clients with anxiety, depression, and irritable bowel.

When I was a young nurse, I worked in a high-acuity hospital with a diverse clientele. Life or death hung on the edge of every shift and although in many ways, those days inspired me, working with residents who were demanding and cruel and even worse, suffering the abuse extended by more experienced nurses was more than my vulnerable soul could bear. My irritable bowel became so intense that I would black out while at work and was extended medical leave.

It is no exaggeration to say that the face of a certain physician or nurse could cause me to pause mid-assessment, blood pressure cuff still attached to the patient, so I could sprint to the restroom in hopes of avoiding major calamity. I know you did not ask for such horrifyingly personal stories about your midwife, but I am here to tell ya, I share because I know I am not alone. Many clients have shared similar stories. In fact, while the job of a midwife is beautiful beyond description, it can also be horrifyingly stressful. Many excellent midwives have crumbled under the pressure and my best nurses have sacrificed their mental health in effort to soldier on when they are needed.

Are there people, places or situations that make you anxious? Christopher Bergland calls this a “fear-conditioned” response and apparently scientists in Switzerland have recently identified how this vagus nerve conveys threatening “gut feelings” to the brain. The vagus nerve is quite interesting in that it meanders down your body from your cerebellum and brain stem to your abdomen, touching most major organs along the way. The Jounal of Neuroscience reports on another study that identifies how “gut instincts” travel to the brain via the vagus nerve and are linked to various responses to fear.

The vagus nerve is constantly sending messages to the brain. The vast majority, between 80 and 90 percent of the nerve fibers in the vagus nerve, are dedicated simply to communicating the state of your viscera to your brain.

“Visceral feelings and gut instincts are literally emotional intuitions transferred up to your brain via the vagus nerve,” states Christopher Bergland.

A close friend of mine suffers from a plethora of food allergies. This person also suffers with anxiety. We have talked recently about how anxiety is often the reflection of inflammation in one’s body, and therefore, her anxiety may be a direct cause of her diet. How unfortunate for her! Admittedly, my husband has suffered his entire life with severe anxiety, as has all the men on his father’s side. I don’t doubt there is a genetic link, and his neurotransmitter test results were among the worst I have ever seen. There is a physiologic basis to anxiety that pharmaceuticals can not band-aid.

Healthy vagus nerve communication between your gut and your brain uses neurotransmitters such as acetylcholine and GABA like the brakes on your car. These neurotransmitters literally lower heart rate and blood pressure, and help your organs slow down so that youcan rest and digest. The question by scientists is then, can we disconnect the return messages from the gut to the brain so as to avoid anxiety and depression?

In one experiment in which the vagus nerve of rats were somehow “not fully functioning,” it was found that they were less afraid of open spaces and bright lights compared to those with intact nerves. Interestingly though, while they demonstrated a lower level of innate fear, they had a longer retention of learned fear. This seems to indicate that the vagus nerve is necessary to unlearn a conditioned response of fear. This also allows scientists to conclude that an innate response to ear appears to be influenced significantly by “gut instinct” signals sent from the stomach to the brain confirming the importance of healthy vagal tone to maintain grace under pressure and to overcome fear conditioning.

My Suggestion

Choose your foods wisely. Easier said than done, I know. I teach this daily and better than anyone, I respect the great impact each decision we make about food has on our health, but I also struggle to apply it in my life. For this reason, I have scheduled an appointment with our new health coach, Crystal Lawburgh. It is time to shed the weight I have accumulated due to the stress of independently managing a homebirth midwifery practice.

While foods are our building blocks, we genuinely can alter our health through healthy thoughts and positive self-talk. Our parasympathetic nervous system balances our sympathetic nervous system. We can calm ourselves through verbal direction or by engaging our vagus nerve through deep breathing techniques. We can also effect our neurotransmitter responses via the vagus nerve, improving recovery and decreasing post-traumatic stress disorder. The stomach plays a role in how we respond to stress.

Visit your chiropractor if you are anxious or suffer any emotional health issue. Pressure on the vagus nerve may be to cause. Improving blood flow to any and all organs is always of benefit to one’s health. Dr. Vicki Danis sees clients in our Carmel office every Wednesday. Our entire staff “pop” in her office each week.

How long is she going to let you go?

Early in my career, while writing clinical practice guidelines for my practice, I researched post-dates. How would I manage pregnancies that progressed towards 42 weeks? I can’t say I specifically remembered this being addressed in my midwifery studies, although as a nurse I had come to understand that one in 1,000 babies don’t tend to survive the 40 week pregnancy and that increases four-fold towards 42 weeks. Certainly, it is typically argued that the safest management would be early induction and at the facility where I completed my residency, 41 weeks and 3 days is that magical date.

One of the beauties of private practice, at least for me, is that I was tasked with the responsibility of writing my own guidelines. I suppose many midwives share or adopt those from other practices. Others may not have the freedom, but rather are supervised and therefore their management plan is dictated to them. I set off to gather studies on post-dates and critically evaluate professional recommendations. This seems like an unsurmountable feat for many solo midwives, but I really appreciated how it helped me thoroughly understand the science and rationales behind individual management plans and offer an extensive informed consent.

My investigation taught me that the etiology of post-date pregnancies is largely unknown, although the most frequent cause is error in dating. We know that women whose mothers had longer pregnancies, find they often do as well. Interestingly, the first time momma and those pregnant with baby boys are more inclinded to have prolonged pregnancies.

I was also reminded that the fears associated with post-date pregnancies include an aging placenta, growth restriction, meconium aspiration, asphyxia, low fluid levels, an oversized baby, and shoulder dystocia. Women are more inclinded to have dysfunctional labor, operative delivery, pelvic trauma, hemorrhage, and infection, with post-date pregnancies, yet cesarean section is twice as likely at 42 weeks compared to 40 weeks. It seemed to me that many of the maternal risks were associated with induction of labor, and many risks to baby could be monitored for as the pregnancy progressed.

That led me to investigate screening criteria; however, I only found studies that assessed outcomes if the pregnancy endured without fetal well-being assessments or studies of early induction. I did not find studies that offered close monitoring of mom and baby, and how those outcomes compared to induction of labor at a predetermined gestational date.

It seemed that the recommendations for induction in effort to avoid the risks of post-dates did not consider the risks of induction itself.

Induction is associated with increased perinatal mortality and morbity, perineal damage, operative delivery, shoulder dystocia, admission to neonatal intensive care and even autism (Duck University in the Journal of the American Medical Association). Cesarean delivery is associated with higher risks of complications, such as endometriosis, hemorrhage, and thromboembolic disease.

I also began to realize that professional recommendations on post-date pregnancies, specifically those that recommended early induction, were based on studies prior to the 1990s. At that time, fetal surveillance of pregnancies beyond 41 weeks did not occur.

What if we offered fetal surveillance after 41 weeks and determined our management on the status of mom and baby?

It is understood that a reactive fetal non-stress test offers the pregnancy a 1 in 1,000 risk of demise within the next seven days. If we offered these twice per week, doubling our screening, and have reactive strips – the lowest risk status available for pregnant women – then why intervene and face the risks of induction and potentially cesarean section?

Many of the studies I reviewed offered detailed information about the losses in each post-date pregnancy, and most outcomes would not have changed with earlier induction. One could argue that routine induction for postdates may increase perinatal mortality and morbidity, as this has yet to be discerned.

The current standards for induction are no more than a response to the fact that some babies, who are already injuried, have a tendency towards both post-dates and demise. The maturing fetal brain is part of the cascade that initiates labor. If the fetal brain does not provide the necessary hormones for labor initation due to either anomaly or trauma, then the pregnancy will prolong and the inevidible poor outcome will be contributed to post-dates.

Women aren’t going to argue this rationale because they generally don’t want to endure prolonged pregnancies. The risks of medical intervention has become acceptable, but risks of expectant management, the unforlding of nature, is no longer tolerated and ultimately ends up litigated in court. The tendency towards induction is understood, but this rationale should not be confused with sound evidence. This is a common misconception in maternal child health. Standard of care is more often driven by convenience and fear of litigation, not scientific data.

Our practice finds just over ten percent of our moms birth after 42 weeks, and another ten percent birth prior to 40 weeks. Our average is 41 weeks and 3 days. Rarely do women continue beyond their 43rd week of pregnancy, although we have had one extend to nearly 46 weeks (her mother did the same). We discuss with each client our understanding of the science concerning post-dates and we share the standard of care and the community expectation. We initiate fetal well-being testing at 41 weeks and continue this bi-weekly with a biophysical starting weekly at 42 weeks. Our practice does not support expectant management without fetal surveillance.

As a blantantly Christian practice, I have shared my thoughts from a creative perspective with a number of clients. I don’t do this until after the client has found their own conviction regarding post-dates, but I find it particularly interesting that throughout the Bible we find the number 40 to be significant. It is generally a time of testing, trial or probation. Moses for example, lived 40 years in Egypt and 40 years in the desert before God selected him to lead his people out of slavery. Moses was also on Mount Sinai for 40 days and nights, on two separate occasions (Exodus 24:18, 34:1-28), receiving God’s laws. Spies were sent to investigate the land God promised the Israelites for 40 days (Numbers 13:25, 14:34). The prophet Jonah warned ancient Ninevah for forty days, Ezekiel laid on his right side for 40 days to symbolize Judah’s sins (Ezekiel 4:6), and Elijah went 40 days without food or water at Mount Horeb. Did I mention that even Jesus was tempted by Satan 40 days and nights, and appeared to his disciples for 40 days after his resurrection from the dead.

Anyway, man has determined that the 40 week pregnancy initiates with the last menstrual period because that is an easy date for us to document. However, conception doesn’t occur for another two weeks, with the woman’s ovulation. If pregnancy is initiated at conception, then by God’s terms, the 40 week journey of pregnancy would continue 42 weeks from the last menstrual period.

The EDD is the estimated due date and it should be well understood that this is an estimate. We appreciate this, although in effort to decrease interventions later in pregnancy, whether increased fetal survelliance or induction, we do encourage a dating ultrasound when the last menstrual period or conception is unclear. We also appreciate that Dr. Franz Karl Naegele, father of the due date calculator, offered his formula based on a 28 day cycle. This is not true however, for all women. Estimating the due date, even with a known last normal menses or conception, must be done in conjunction with an understanding of each individual woman’s cycle length. Naegele’s rule also assumes that all women ovulate 14 days after the initiation of menses. This is also not true for all women. Can I say how happy it makes me that the majority of our women come into their first prenatal with a chart of their previous cycles and tell me when their estimated due date is, while also appreciating their own histories and typical gestation patterns!

No doctor can predict when a baby will crawl or walk or get his first tooth, so it is unreasonable to think that a doctor can predict the very day baby will be born. We can estimate and encourage, but we ultimately trust that in the presence of reassuring fetal monitoring, baby will come at the best time determined by mom and baby. If there is indication to intervene prior to that date, we won’t hesitate. After years in practice, we have faced this scenario three times. There is certainly no reason to push our luck, and we aren’t committed to homebirth at all costs. However, the risks of both prolonged pregnancy and induction of labor should be considered, as well as the community’s expectation. Quite frankly, and very anecdotally, babies born at 41 week sleep and breastfeed so much better than babies born at 40 weeks, and when we have the occasional birth prior to 40 weeks, we are all concerned for how well mom will cope postpartum.

Finally, I have suspicion that if more midwives had the freedom to practice without the 42 week deadline, there would be less intervention with herbs or pharmaceutical modalities and subsequently, we’d find better homebirth and birth center outcomes, particularly with VBAC mothers. I suppose however, they would have to be trained to properly assess fetal status, which has not yet occurred even within the intrapartum period… that’s a matter for another post. (See my doctoral project for more arguement on that point.)

 

 

 

Food for Thought

Food for Thought

"It is much more important to know what sort of patient has a disease than what sort of disease a patient has." Sir William Osler

Food for Thought

Happiness is underrated and critically important to health. Seriously! Unfortunately, many people just have no idea how to be happy. Aviva Romm

Food for Thought

Physicians simply do not have time to be what patients want them to be: open-minded, knowledgeable teachers and caregivers who can hear and understand their needs. Snyderman and Weil

Food for Thought #1

They say that time changes things. But you actually have to change them yourselves. Andy Warhol

Food for Thought

To think is easy. To act is hard. But the hardest thing in the world is to act in accordance with your thinking. Johann Wolfgang von Goether

Food for Thought

"Birth isn’t about avoiding one set of realities in favor of another. It’s about embracing all facets of birth--contradictory, messy, or unpleasant as some might be--as vital to the whole." Rixa Freeze PhD

Food for Thought

Why I appreciate being a certified nurse-midwife, as opposed to choosing another route for midwifery: I feel learning the science is vital so the art of midwifery is safe and effective. Dr. Penny Lane, nurse-midwife

Food for Thought

When the debate is lost, slander becomes the tool of the loser. Socrates

Food for Thought

To accomplish great things, we must not only act but also dream; not only plan, but also believe. Anatole France

Food for Thought

"Science and uncertainty are inseparable companions. Beware of those who are very certain about things. There are no absolute truths in biological sciences - only hypotheses... 'We need to train medical students and residents more in the art of uncertainty and less in the spirit that everything can be known or that it even needs to be known.'" Grimes (1986)

Food for Thought

American physicians are rewarded for doing things to patients, not for keeping them well. Grimes, 1986

Food for Thought

The false idol of technology. "Having a widget screwed into one's scalp has become an American birthright." Grimes, 1986

Food for Thought

"Between 1985 and 1987, a hospital instituted a successful program to reduce its cesarean rate. The rate fell from 18% to 12%, losing the hospital $1 million in revenues - no small sum in those days." Goer & Romano, 2012, p 37

Food for Thought

"Obstetricians are much more likely to perform a cesarean when they wrongly believe the baby weighs 4000 g or more based on sonographic estimates than when the baby actually weighs this much but the obstetrician did not suspect it." Goer & Romaro, 2012, p 35

Food for Thought

"If you play God, you will be blamed for natural disasters." Marsden Wagner (2006)

Food for Thought

An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you know and what you don't. Anatole France

Food for Thought #3

"Birth is not only about making babies. Birth also is about making mothers - strong, competent, capable mothers, who trust themselves and know their inner strength."

Barbara Katz Rothman PhD (1996)

Food for Thought #4

Believe there is always, always, always a way.

When you have exhausted all possibilities, remember this: you haven't. THOMAS EDISON

Food for Thought #5

"All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." Arthur Schopenhauer

Food for Thought #2

Yet you brought me safely from my mother’s womb and led me to trust you at my mother’s breast.

Psalm 22:9