Sleep Disorders & Pregnancy

New science seems to demonstrate that we are sleeping approximately 90 minutes less today than we were 100 years ago and the women aged 30 to 60 years of age is sleeping on average, 6.5 hours each night. One in ten adults report insufficient sleep and the incidence of disturbed sleep is even higher in pregnancy (Nodine & Matthews, 2013).

insomnia ladyDisturbed sleep is so common in pregnancy, with reports as high as 97% particularly in the third trimester, that it is considered a normal pregnancy discomfort. Growing evidence suggests experts should reevaluate their perspective, as the association between sleep disturbance and adverse maternal and neonatal outcomes is becoming more evident.

Breathing-Related Sleep Disorders

These are characterized by irregularities of respiratory pattern and/or quality of ventilation during sleep, such as snoring, upper airway resistance syndrome, or obstructive sleep apnea. Snoring is rather common among pregnant women, at a rate of approximately 11% to 35% compared to 9% of nonpregnant women. Obstructive sleep apnea is far less common among nonpregnant women at approximately 2%, yet when pregnant reports are as high as 10% to 25% (Nodine & Matthews, 2013).

Weight gain and displacement of the diaphragm by an enlarging uterus can contribute to breathing-related sleep disorders. Increased estrogen can additionally cause edema in the mucous membranes contributing to nasal congestion and reduced pharyngeal space. Growing evidence suggests these disorders are associated with increased blood pressure in pregnancy. Theories are that decreased oxygen restricts fetal growth and/or negatively impacts the endometrium, and that oxidative stress markers triger placenta changes that lead to preeclampsia (Nodine & Matthews, 2013).

Certainly we can’t ignore the fact that obese women have increased incidence of snoring and obstructive sleep apnea due to their increased body mass, and also are more inclined to suffer from disease states such as hypertension and diabetes. Chicken and egg scenario, huh? Evidence at this point does demonstrate an association between gestational diabetes and sleep disorders, as well as preterm birth and those who habitually snore or suffer sleep apnea.

The most effective treatment thus far is continuous positive airway pressure (CPAP). This works by circulating room air through the upper airway during sleep, preventing airway occlusion. One must sleep with a mask over their face so compliance can be an issue. Nasal strips have shown to be beneficial for upper airay resistance syndrome in nonpregnant women (Nodine & Matthews, 2013).

Restless Leg Syndrome

A previous blog more thoroughly discusses restless leg syndrome, but this issue alone may be the cause of insufficient sleep for many adults and particularly pregnant women. Often these symptoms are not asked about during prenatal exams and women don’t think to share their nighttime suffering with providers. Few options exist for treating RLS but a ferritin or folate deficiency may be to blame.

Insomnia

Insomnia is characterized by a difficulty initiating and maintaining sleep, as well as early-morning awakenings and nonrestful sleep, or a combination of these complaints. Those suffering with insomnia often suffer from excessive sleepiness during the day, low energy, irritability, negative mood, and more work injuries, car accidents, and sick days from work. Approximately 40% are depressed. More than 80% of pregnant women suffer from insomnia at some point in their pregnancy. Interestingly, one study found that women obtaining less than 5 hours of sleep per night were 4.5 times more likely to have cesarean births (Nodine & Matthews, 2013).

Sleep diaries can be helpful, with modifications to environment, sleep habits and positioning. Dietary modifications may be suggested and limited evidence suggests massage, acupuncture, yoga and exercise may prove helpful. Treating depression may cure both issues, and of course, there are a number of herbal and pharmaceutical remedies available for women suffering with insomnia.

Certainly it would be important to speak with your nurse-midwife about your sleep pattern and inquire about methods for enhancing your sleep for the health and well-being of both you and your baby.

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Essential Oil Safety

The dangers of essential oils is often exaggerated, usually based on insufficient evidence and inappropriate conclusions. It is true that essential oils are powerful substances, but used knowledgeably and with due diligence, pose little to no threat to one’s health. Let me first share three points made clear by Len Price:

  • There is no doubt that essential oils are powerful mixtures and have physiological, psychological and pharmacological effects, both desirable and undesirable, when applied to the body.
  • In most countries, including the UK and the United States, these oils are freely available and there is no restriction on their sale and use.
  • The majority of people who buy essential oils are members of the general public, who cannot be expected to have expert knowledge of their nature and use.

“It is remarkable then that their safety record is as good as it undoubtedly is. Despite this record, statements are sometimes made which sensationalize aromatherapy or exaggerate unwanted effects of the oils” (Price, 2007, p 43).

Essential Oil Quality

essential oil dripFor therapeutic use, the quality and wholeness of any essential oil is of paramount importance, irrespective of the cost. This is in contrast to those oils used for perfumes or flavors where the aroma or taste is of utmost importance. Generally speaking when one references a therapeutic essential oil, they are referring to ones suitable for aromatherapy use – not adulterated, not “ennobled’, not redistilled, not fractionated, no parts removed or added, but which have been distilled specifically for aromatherapy from known plant material (Price, 2007).

It is important to understand that the quality of essential oils will vary as the season. Plants are exposed to an ever-changing climate with fluctuations in light, wind, heat, cold, rain, frost, and soil compositions. These will alter the plant and subsequently the oils to some degree. This is no different than fine wine which varies from crop to crop and year to year. Perfume and flavor based oils however, must be identical and are therefore synthetic to some degree so the flavor of your preferred gum is same from package to package.

Recommendations specific to essential oils, particularly in how they should be administered, vary greatly. The cause of this is largely related to the deterpenizing of oils. Essential oils used in the fragrance industry often have their terpenes partly or wholly removed on account of their insolubility in alcohol, which would result in cloudiness – a distinct commercial and aesthetic disadvantage to perfume. To the practitioner however, this deterpenized oil is incomplete. It contains a higher percentage of the remaining constituents of the oil, and is often more hazardous. This process disturbs the natural balance of the essence, but sadly, many texts base their information on tests carried out of perfume grade oils, not those of a therapeutic-grade (Price, 2007).

Contaminants

Most essential oils are produced for the fragrance or food industry, and therefore, contamination by pesticides and fertilizers are not of concern to manufacturers. Their presence however, adulterates the efficacy and safety of the essential oil and may potentiate the toxicity of an otherwise safe essential oil (Price, 2007).

Procurement of Genuine, High-Quality, Authentic Essential Oils

Procurement is where the various essential oil distributors will argue they have cornered the market. Each claim to have superior farms and control from seed to seal. This competition among essential oil distillers is a healthy one in that it increases their accountability and desire to improve standards for harvesting and processing of the oil.

Synergism

The meaning of synergism is difficult to articulate but one might explain this as individual molecules within the oil are not nearly as effective as all the molecules working together. Essential oils are complex. Their properties work together to produce their healing effect, but when altered, their natural synergism is disrupted and therefore, ineffective. For example, isolating any part of the oil may create more toxic outcomes, as opposed to used synergistically, constitutes can work together to quench unwanted effects. Not only does the synergy of a single oil need to be well understood, but the enhancement effect of combining two or more oils should also be well appreciated.

“It is important to preserve the wholeness of an essential oil in order to guard its natural synergistic power” (Price, 2007, p 50).

Safe Administration

Care should be applied in the utilization of essential oils. They are powerful or they would not be of any use therapeutically. Over-use will cause untoward effects. Eating too many of any one food also has untoward effects, such as eating too many tomatoes, potatoes or corn. Typically oils are inhaled, applied to the skin or ingested, although only therapeutic-grade essential oils should be employed for internal use. This method is not typically recommended for pregnant women and very young children. It is not clear how the endocrine effects on the gastrointestinal tract alters metabolism during pregnancy, therefore, oral ingestion is typically discouraged at this time.

Undiluted essential oils should never be placed in the ear nor on ano-genital mucous surfaces and especially not in the eye, even diluted. Essential oils are immediately soluble in vegetable oils which gives a dissolving or flushing action, so if the eye is exposed, it may prove beneficial to flush the eye with a vegetable oil or if a genital region, to place a soaked piece of cloth on the exposed area.

Mutagenicity and Teratogenicity

“There is no available evidence that any natural essential oil has ever provoked mutagenicity or teratogenicity in an embryo or developing fetus. No tests have ever been carried out because the possibility of fragrant materials causing either genetic mutation or malformation is regarded as unlikely” (Price, 2007, p 67).

However, there are several essential oils which may have unwanted effects during the first trimester of pregnancy and it is believed that most, if not all essential oils, can pass through the placenta. Their effects on the developing fetus is unknown. Use after this first trimester, when done appropriately, can generally be done safely. It is important to work with your provider and an aromatherapist.

Allergies

We are increasingly aware that some individuals are sensitive to and can even experience anaphylactic shock from ingesting nuts. Although there does not seem to be evidence that advocates for the avoidance of nut-based carrier oils such as sweet almond or peanut during pregnancy aromatherapy or massage, it may be wise to inquire if the mother has a sensitivity and avoid use in these scenarios.

Sore Nipples? We can help.

Our practice has minimal issues with sore nipples, and I am not confident we’ve seen more than a handful of cracked or bleeding nipples. Our births are fairly uncomplicated, all are unmedicated, and all babies remain on mom’s chest through the first two hours of life unless there was a brief need to offer resuscitative measures initially. Our staff are fairly well trained in breastfeeding support, and we provide home visits to assure on-going success. On occasion though, we do have a baby with a less than optimal latch and mother suffers the consequences. Advice can three month oldrange significantly, so we thought we would offer our thoughts:

Prevention

All mothers who are new to breastfeeding or who struggled previously, should attend a good breastfeeding class and we mean one taught by a credible source. Ask yourself, what is the invested interest of the teacher? Is she passionate? Has she earned credentialing specific to lactation? Who wrote the program she is teaching? Are funds in anyway contributed by artificial human milk manufacturers to support the teaching material or equipment?

Create a support group that will build you up and encourage you during tough days. Breastfeeding can be challenging, and for some women, more of a trial than their labor and birth experience. Most all women will agree that perseverance is worth it, but it can seem impossible without good support and expert counsel.

Understand how to achieve an optimal latch and know where to get help. Poor positioning, improper latch, dysfunctional or disorganized sucking, flat or inverted nipples, ankyloglossia, strong vacuum application by the infant, C. albicans, eczema, Raynaud’s phenomenon, vasospasm, nipple bleb, incorrect pump flange size and bacterial infections are all causes of sore nipples. The first step is prevention.

Remember the days of nipple preparation? Nipple rolling, rubbing with a terry cloth towel, Hoffman’s exercises (areolar stretching), avoidance of soap on nipples, masse cream or other ointments, air exposure under clothing, breast shells, and nipple stretching… gone are those days, and for good reason. No evidence supported their effectiveness and certainly many of these interventions caused harm.

In spite of a plethora of treatments for sore nipples, some centuries old, no single treatment had been shown to be clearly superior to all others. Recommendations often lack sufficient research or evidence is conflicting about its effectiveness.

Plant Extracts and their Phytochemicals

Plants have naturally occurring chemical compounds. Some are responsible for the color, such as the deep purple of blueberries, while others are responsible for the strong smell of garlic. The term is typically reserved for those purposes which are of biological significance, but are not otherwise established as essential nutrients. Many experts throughout history, including Hippocrates, considered and prescribed phytochemicals as medications and clinical trials have proven the effectiveness of many in enhancing health states.

Phytochemicals have their place in optimizing breastfeeding as well. Green tea for example includes a class of polyphenol compounds called catechins that enhance natural would healing and at certain concentrations, have the ability to stimulate aged keratinocytes and reduce healing time. Green tea bags may in fact offer relief to the mother with abraded, sore nipples (Walker, 2013, p 110). Simply soak green tea bags in warm water and apply directly to your tender nipples.

Peppermint certainly has its place as well, having demonstrated a calming and numbing effect on skin irritations. Peppermint has also proven itself capable of increasing the flexibility and resistance to cracking in the skin tissue, and offers a strong antibacterial and anti-inflammatory property, as well as fungistatic and fungicidal activity. One study performed by researchers, Melli, Rashidi, Nokhoodchi, Tagavi, Farzadi, Sadaghat & Sheshvan (2007) comparing peppermint gel to either lanolin or placebo discovered peppermint gel to be superior in its ability to prevent cracked nipples (3.8% compared to 6.9% and 22.6%, respectfully). Also interesting, Sayyah and colleagues (2007) found that even peppermint water used prophylactically on nipples was three times more effective in preventing nipple cracks than expressed breastmilk (27% expressed breastmilk compared with 9% peppermint water) (Walker, 2013, p 110). Peppermint oil could be added to water and spritzed onto the breast.

While no studies have been conducted to evaluate the effectiveness of olive oil on damaged nipples, it is understood that suppleness and flexibility are attributes essential to the health of lactating nipples. As an emollient, olive oil is easily absorbed into the skin and can therefore, increase both flexibility and suppleness, as well as accelerate wound healing through its ability to prevent the growth of bacteria. Virgin coconut oil is similar too, and offered a great deal of anecdotal success, but is lacking sufficient clinical evaluation. One study did find coconut oil superior to olive oil however, in eliminating S. aureus from adult skin and another (2008) study demonstrated its broad spectrum activity was active against S. aureus, fungi and viruses (Walker, 2013, p 112).

Having said all that, the warm water compress, simply crafted at home, has proven more effective in studies that expressing mother’s own milk and letting it dry on her nipples, and superior to tea bag compresses, lanolin, hydrogel dressings, and peppermint gel. Simply add one-fourth to one-half teaspoon of salt per quart of warm water and apply the saline soak for 10 minutes.

Hydrogels

The use of hydrogels dressings is a concept stolen from disciplines such as geriatrics, where patients suffer bed wounds and these water-based polymer matrix dressings are applied to maintain moisture, inhibit scab or crust formation, reduce pain, and enhance epithelial migration for wound repair. Certainly, research is supportive that mothers do in fact find significant pain relief when using hydrogels for sore and cracked nipples. Another benefit of the hydrogel, is the barrier it creates between the mother’s bra and her healing nipple and the ability to store it in the refrigerator during a feeding, for cool application afterwards.

Sugar Addict? Here is help!

My children have returned from Trick-or-Treating and I’ve hidden the candy, fearful not only that they will eat too much but also that I will indulge and have regrets. As you all know, sugarsugar cravings are a vicious cycle of mouth-watering satisfaction, sluggish feelings, more cravings, body aches and sinus problems leading to more indulging and soon, a digestive system that is completely out of balance and new skin blemishes. This cycle is very difficult to break, but thankfully, Young Living Oil offers us Ocotea. Pronounced ock/ah/tay/ah, from the Andes Mountains in Ecuador, it is distilled from the leaves of Ocotea Quixos and is commonly referred to as false canilla or false cinnamon.

Ocotea essential oil is adored for its ability to balance blood glucose levels, lose weight and balance stressful emotional states. Women suffering with polycystic ovarian syndrome, diabetes or even fluctuations in their blood sugar during pregnancy enjoy its cinnamon and vanilla overtones. This oil can be added to tea, or applied directly to the tongue throughout the day to help break the sugar cravings.

Experts have reported that 1-3 drops under the tongue can drop the blood glucose level by 30 points in less than 10 minutes, while others have claimed two drops four times a day can assist in weight loss.

Authors Ballabeni, Tognolini, Bertoni, Bruni, Guerrini, Rueda & Barocelli (2007) found Ocotea essential oil to possess potent and safe antithrombotic activity attributable to its antiplatelet and vasorelaxant effects. See the article here, published in Pharmacological Research, volume 55, issue 1.

Share your results using Ocotea with us, whether you’ve noticed weight loss, blood sugar regulation, emotional stability, decreased blood clots or loved its flavor!

What if Something Goes Wrong?

Homebirth is poorly understood, and rightly so, because there are providers of all sorts extending homebirth services and their delivery model ranges quite drastically. Consumers don’t know what questions to ask or how to verify the competency of their provider.

Our practice strives to exceed the expectations of a level-one facility without wavering from the midwifery-model-of-care. However, there is no accreditation body that oversees homebirth practices and assures consumers or our medical associates that we have met minimum standard of care. There are certainly discussions about the establishment of this sort of body however, and how the creation of such an entity could not only increase the credibility of homebirth but increase the number of practices offering these services.

Our healthcare system is changing rapidly right now and a confluence of factors opens up opportunity for homebirth practices to flourish. Hospital networks throughout Indiana are laying off clinical staff in the hundreds and relocating others outside their speciality. Staff ratios are increasing and wages are being cut among those who maintain their positions. More will be let go and certainly, healthcare needs have not dwindled. Care will be compromised.

Our practice has always maintained a three-to-one ratio, meaning at every birth we have a nurse-midwife present from active labor through three hours post-birth and two nursing staff. No hospital has ever met this high level of assessment, as most don’t even have a provider in-house consistently. Having the provider in addition to nursing staff at the bedside of every laboring mother is unheard of, but rest assured, hospital staffing is going to get even worse.

The Franciscan Health Alliance mentioned in the article above laid off 400 employees recently and St. Vincent laid off approximately 17,000 of its employees. The Indiana University Health hospital system will cut 900 jobs by December 1st and is merging its two maternity units into one. Our practice has maintained its high level of care since first opening its doors. We are dedicated to improving clinical outcomes and unwilling to compromise. This was the motivation behind our transition away from accepting third party payments, so our providers are in control of how care is provided, not the industry.

My question to the community and to our medical leaders is not simply, “How will you assure optimal outcomes by supporting women in labor and counseling them through breastfeeding,” but it is, “How will you manage an emergency with insufficient staffing or appropriately trained staff? Is the plan to schedule more inductions and cesarean sections which we know increases maternal and neonatal morbidity and mortality just so it can be done when there is optimal staffing?”

Keeping women out of the hospital remains an effective strategy for achieving low cesarean rates,” (Romano, 2013, p 492).

References

Romano, A. (2013). New opportunities for birth centers in a transforming health care system. Journal of Midwifery & Women’s Health, 58(5), 492-493.

Electronic Health Records

The national health IT movement spurred by the HITECH Act is taking its toll on providers of all shapes and sizes, but practitioners in private practice have been hit especially hard. The issue is cost. Many practices simply don’t have the revenue stream to accommodate IT expenditures, and according to the latest research, these costs are rising exponentially. MGMA’s 2013 Cost Survey Report reveals that information technology costs climbed 27.8 percent between 2008 and 2012 (from a median of $15,211 to $19,439 annually). No drop in the practice for a small private practice (Congdon, 2013).

As an independent practitioner, it can also be challenging to keep up-to-date with the rapidly changing initiatives that are driving the healthcare sector. “Systems and technology are evolving faster than practices can put the processes in place to support them. Insufficient change management is having a negative effect on clinical work-flows and leaving many physicians with a bad opinion of health IT,” states Kosiorek, principal of MGMA’s Health Care Consulting Group (Congdon, 2013).

Healthcare providers that step into private practice, do so because they don’t want to spend excessive time on administrative work, cutting short patient appointments. However, new IT systems are causing practitioners to become consumed by technology deployments and so are opting to sell their practices to larger health systems to relieve themselves of the burden, hoping this will allow them to again, return their focus to patient care. Sadly, there are others that suffered poor IT deployments which lead to the ultimate demise of their practice.

Is Meaningful Use Worth the Effort?
Our practice ceased filing claims from all third party payers, including Indiana Medicaid, in early 2011. We haven’t looked back in regret for even a moment. Medicare is paying less for the same work previously provided, and all other payers have followed that lead while the cost for providing such care has increased.

Meaningful use was designed to motivate healthcare providers to adopt EHR technology and to create a structured foundation for data exchange. If you want to get full reimbursement, you must adopt these changes or soon, penalties will be applied. There is concern that this data will be monitored to determine how providers are extending care, where and when they should manage various points of care, and ultimately, providers fear that these mandates will eliminate our ability to provide an individual approach to care. Providers who had supported families, for example, who choose not to vaccinate will be penalized and therefore, may need to apply pressure to families regarding these decisions so they can increase their bottom line.

Where do we stand on the matter?
Believe Midwifery Services, LLC has implemented an EHR program and have completely eliminated paper charting. Those healthcare records which were previously in paper format are now scanned into a high level security database for retrieval and are immediately available as needed. Because we have no concern with “meaningful use” which is driven by third party payers and government funded reimbursement programs, we were free to select a program that was specific to our practice needs and we are free to deliver care in a method that best suits our clientele.

Mobile Midwife is the EHR that we felt best suit our practice needs. It offers extensive IT support with the highest level of professionalism we have had the pleasure to experience. Our practice has additionally contracted an independent IT specialist to assist with any additional support we may require, including implementation and enhancement of our practice’s health IT vision beyond our EHR program.practitioner using ipad

The move to the Indianapolis office has been a unique experience for us in that we have chosen not to purchase a printer, fax or copier. We have survived two weeks without one, as we utilize faxage for receiving faxes and have worked to utilize on-line ordering systems for diagnostics and laboratory requisitions and requests. In fact, what we have noticed, is the few times we do require something hand-written, our staff has to search for pens and paper because they aren’t already at hand. Our effort is to exponentially eliminate our waste, and I believe we’re succeeding. In fact, we hadn’t need to even take our trash bin to the curb last week!

Client hand-outs have become entirely electronic through our webpage (on our secured client access page) and our informational sessions are now presented in keynote format with all additional information obtainable on our website. Guidelines, schedules, databases and procedure manuals are also available to staff in an electronic format, further eliminating our footprint but also allowing our clinical team access to information via their secured iPads at anytime and any place they may be caring for a client.

While other healthcare practices have invested tens of thousands of dollars to implement their EHR systems, our IT system has had minimal up-front cost and because it is cloud-based, it should remain a very cost-effective option. Our staff aren’t inconvenienced by the need to update software or manage a server and haven’t any concern about hard drive capacity. Our updates are performed automatically, and our charts are synced from system to system every five minutes whether data is entered at a client’s home or in the office, without any additional effort by clinical staff. Lack of hardware support alone is an enormous economical advantage to other EHR systems.

The advantages of an EHR system for a home birth-based midwife is tremendous. Our complete medical records are available at the swipe of a finger and can be transferred to collaborating providers in a matter of seconds, including during an intrapartum transfer from home to hospital. Record presentation is professional and credibility is a matter of great importance to a practitioner who already has to work harder than others to be accepted within the healthcare system. However, what struck our practice was watching our last client of the day walk out the front door and having all our paperwork completed. Hours and hours of time were previously spent entering and reviewing data, ordering tests and uploading their results. Communication between team members previously had multiple avenues for failure and currently, our system allows us to assign tasks for immediate follow-up or set reminders for further tasks. Our clinical care has greatly improved due to our EHR system and it is one we would recommend hands down to other midwives. Paper charting has become a “thing of the past.”

Teratogens: Harmful Substances to the Unborn Baby

We live in a very contaminated world and it is impossible to avoid every harmful substance. Arming yourself with information can help to optimize your pregnancy and health of yourself and your baby, but don’t let information overwhelm you either. Take these tips one baby step at a time, continually trying to improve your environment while making certain that worry is not stealing your joy.

Toxic Materials in the Work Place: Think carefully about the potential toxic exposures you, or your partner, may be exposed to at work. These may include easily identified toxic material or may simply be children with Fifth’s Disease and/or chickenpox if one works with groups of children. Paint is a highly toxic material often forgotten about. Spouses that work with chemicals should remove their clothing before coming home and/or wash their own laundry.

Environmental Toxins within Your Home: Buy organic or locally grown produce. Don’t use ceramic dishes unless they are certified lead-free. Avoid microwaving in plastic containers or wraps; use glass. Ventilate your home well by opening the windows daily, as the air in your home can often be more toxic than that outside due to decreased circulation. Fix leaks and moisture problems to control for mold growth. Properly install and maintain combustion appliances. Install a carbon monoxide monitor and check the batteries in your smoke detectors. Test for radon gas. Stay away from gas fumes (don’t pump your own gas). Don’t sand or paint. Consider any renovation done in your home potentially harmful to your baby. Avoid toxic fumes emitted by new carpeting, vinyl floors and furniture. Discard vinyl blinds of unknown origin. Avoid gardening within three feet of your home’s foundation if built before 1978. Don’t use pesticides in your home, or on your lawn and garden. Avoid solvents found in nail polish, artificial nails, hair coloring, hair spray and perfumes. Don’t use the dry cleaners. Use mercury-free, digital thermometers. Do not get silver fillings on your visit to the dentist.

Water: Filtered water is optimal throughout your pregnancy. This is superior to both tap and bottled water. However, you should have your water tested. In the morning, allow your tap to run a few minutes to let the lead flush out before cooking with it. Cook with cold water from the tap or use filtered water.

Fish and Shellfish: Certain fish may contain high levels of mercury, which can affect the baby’s developing nervous system. Avoid swordfish, marlin, shark, farmed salmon (Atlantic salmon), fresh tuna, albacore or white tuna (fresh or canned), walleye, halibut, orange roughy, red snapper, grouper and most freshwater fish. Avoid raw (sushi) or undercooked shellfish such as oysters, mussels, prawns (shrimp) and crab. These may cause severe food poisoning if contaminated by bacteria. Limit your intake of mahi mahi, Pollock, canned light tuna (not white or albacore), ocean perch, blue mussel, and cod to no more than two servings per month. Fish that are considered safe are canned salmon, fresh/frozen wild salmon (Alaska/California), sardines, west coast oyster, flounder/sole, clams, whitefish, haddock, farmed trout, mid-Atlantic blue crab, king crab, scallops, tilapia and shrimp. For more information about environmental contaminates in foods, including breastmilk, visit www.ewg.org. Information specific to mercury can be found here.

Milk and Milk Products: Avoid unpasteurized milk and cheese. This includes soft cheeses such as feta, brie, Camembert, blue cheeses, and goat cheese. These foods may contain bacteria called listeria, which are harmful and can be deadly to unborn babies.

Raw Sprouts and Unpasteurized Juices: Use caution with store bought raw vegetable sprouts (such as alfalfa, clover, and radish) and unpasteurized fruit and vegetable juices, as these may contain bacteria such as Salmonella and E. coli. These bacteria can cause serious illness in pregnant women and the unborn baby.

Raw or Undercooked Meats, Poultry or Eggs: Undercooked meat, poultry, and eggs can contain bacteria and parasites that can harm an unborn baby. Be sure to cook ground beef and pork to at least 160°F, roasts and steaks to 145°F, whole poultry to 180°F, and eggs until the yolk and white are firm, not runny. Buy organic meat and eggs. They are worth the extra money.

Certain Meats: Avoid meat pates, and all liver products because of the risk of listeria.

Prepared Foods: Avoid ready-to-eat meats such as deli meats, pates, and hot dogs. Also avoid ready-to-eat dressed salads (potato salad or coleslaw) and packaged salads. These foods may contain listeria, a deadly bacteria. Monosodium glutamate (MSG), used to season deli foods, is known neurotoxin.

Caffeine: Caffeine crosses the placental barrier into the baby’s blood when you are pregnant. Not only is caffeine toxic to your baby’s developing nervous system but it also interferes with iron absorption and the body’s ability to effectively use insulin. It’s best to quit caffeine completely but, if you must drink it, limit your caffeine intake to less than 300 mg in one day. This is equivalent to two cups of coffee, or three cups of strong black tea, and less than a can of coke. Avoid energy drinks whether they list caffeine on the label or not.

Artificial Sweeteners: Aspartame, sucralose, and acesulfame-potassium are used in many foods such as soft drinks, desserts, yogurt, fruit spreads, salad dressings, chewing gum, and candy. These should be used sparingly.

Medications: Illicit drugs, inhalants, prescription and over-the-counter medications, and even certain herbal products affect the unborn baby. Check with your midwife before using medications and herbal products. Buy prenatal vitamins from a reputable health food store (such as the Red Raspberry Boutique) and do not take more than the recommended daily amount of Vitamins A, C and E.

Pets & Gardening: Cat liter and soil where animals may stroll at night can contain a bacteria called toxoplasmosis. This infection causes no symptoms in the mother. It is recommended that cats stay off the the counters and liter clean up be delegated to someone else in the family, or at minimum be cleaned daily before the bacteria has ability to become too bountiful. Pregnant mothers who garden are encouraged to wear gardening gloves when working in the soil.

Alcohol: Alcohol crosses the placental barrier and can cause fetal alcohol syndrome and permanent birth defects, especially if consumed in high quantities. Most organ development is completed by the twelfth week of your pregnancy. Brain development continues throughout pregnancy and after birth. Exposure to alcohol any time during pregnancy will affect the baby’s brain. The harmful effects of alcohol vary with the stage of pregnancy and the amount consumed on each occasion. However, research does show that all types of alcoholic beverages have the same negative effects during pregnancy and no amount has proven to be safe. Abstain from all alcoholic beverages if you are planning a pregnancy and while you are pregnant.

Nicotine: Smoking during pregnancy increases the risk of a baby being born prematurely and underweight. Stop smoking if you are considering getting pregnant; if you are pregnant, never smoke. Because of health risks associated with second-hand smoke, avoid any smoky environments. New evidence has shown negative effects for babies by those with nicotine on their clothing as well, even when never exposed to cigarette smoke itself.

Viral: Rubella, CMV, Parvo virus B19 (Fifth’s Disease), Varicella and Herpes simples are all viruses which can negatively impact your unborn baby’s development. Negative effect include mental retardation, deafness, congenital heart defects, severe anemia, muscle atrophy, skin lesions and death. Let your midwife know immediately if you have been exposed to any of these viruses.

References:
ACNM. (2006). Environmental hazards during pregnancy. Journal of Nurse Midwifery & Family Nursing, 51(1), 57-58.
FDA. (2008). What you need to know about mercury in fish and shellfish. www.cfsan.fda.gov/seafood1.html
Lemay, G. (2007). Teratogens. (midwifesource).
SOGC. (2007). Principles of human teratology: drug, chemical, and infectious exposure. JOGC(199), 911-917.

The Nursing Profession

As part of a Nursing Ethics study, I am reminded of my professional responsibility as a nurse and am grateful to have had the opportunity to advance my nursing practice and open an independent midwifery practice. It is this freedom that allows me to extend unwavering respect for my client’s autonomy.

“Immanuel Kant (1724-1804) is perhaps the best-known proponent of autonomy as a moral principle. He wrote that because human beings have the capacity to reason, decide, and act, they should be free from the interference of others at least as far as personal decision making is concerned. Moreover, ‘reason is the ruler of our will (Kant, 1785/1967, p. 322)’” (Grace, 2009).

Grace continues to state, “Freedom is in the interests of society-it allows people to flourish and makes for better societies.”

Nonmaleficence, beneficence, and how the two may conflict, as well as paternalism, the principle of justice, even feminist ethics and ethics of care are swirling through my head and all I can think is, how can nurses, particularly advance practice nurses, extend these freedoms to their clients if they are themselves so restricted in practice that they aren’t free to choose and think independently? Gratefully, my own practice has not had to compromise to please a supervising physician or regulating body, but as our professional organization seeks to establish homebirth standards of practice, our duty to practice ethically within an established relationship with our client, appreciating their right to self-rule is potentially in jeopardy.

Pamela Grace (2009) offers a history lesson in her text, Nursing Ethics and Professional Responsibility in Advanced Practice. It has become commonplace to describe any vocational group as a vocation, whether one is a plumber, carpenter, or dry cleaner. However, historically profession was a much more specific class of individuals.

The earliest organized occupational groups were craftsmen’s guilds, consistent with groups of technically accomplished artisans who coordinated together honing and protecting their skills and knowledge in order to make a living. These medieval groups were the beginnings of affiliations with the church for ministerial duties, but their aim was also educational and intellectual (Grace, 2009).

The original professions were ministry, medicine, and the law. These three disciplines required members to take a vow to be accountable for actions, to profess their sincerity, abilities and/or motivations. They were less included toward substantial monetary awards and more inclined towards developing virtues than many other occupational groups. Thus, a distinction evolved, that separated the artisan or tradesman from the professional. The professional groups were altruistically motivated (Grace, 2009).

In the early 1900s, professions emerged as those that have an extensive and “specialized knowledge base, take responsibility for developing and using their knowledge, have a practice or action orientation that is used for the good of the population served, and autonomously set standards for and monitor the actions of their members” (Grace, 2009, p 40). Further attempts to identify essential characteristics of a profession have noted as late as 1981, when Kepler stated, “professions are organized… (and) a high level of education is necessary to provide knowledge not readily available or capable of being understood by all” (p 40-41). Today we understand the profession to be one that is self-reflective and adapts to changing needs and has formulated codes of conduct and ethics.

Nurses and those in advanced practices such as nurse-midwives and nurse practitioners have a duty to their profession’s code of ethics that supersedes all other institutional policies and cannot be negated by other professions, by administrators, or by the demands of the workplace. Nurse and those in advance practice however, often find themselves in positions in which it is hard to resist the “pull” of the other profession’s particular aims and lose sight of the importance to individual and societal health of prioritizing nursing goals. Independent practice is a sanctuary of sorts, in that short of statutes which in some states are prohibiting, the advanced practice nurse can practice her profession and not be dictated by the aims of competing professions.

Our privileges can be no greater than our obligations. The protection of our rights can endure no longer than the performance of our responsibilities. John F Kennedy, “The Educated Citizen,” Vanderbilt Unversity 90th Convocation (May 18th, 1963).

Yeast, Thrush & Candida

Candida infections of the nipples may occur at any time during the breastfeeding relationship. Candida albicans is the culprit for both yeast infections and thrush. It likes warm, moist, dark areas and normally lives on the human body, but when the skin breaks down, yeast can become a problem. Achieving the best latch possible is the best prevention for troublesome yeast. An asymmetrical latch is the goal, with more of the underside of the areola in the baby’s mouth than areola above the nipple. The nose does not usually touch the breast. Infection can sometimes occur following antibiotic use as the good bacteria has been wiped out, allowing Candida to overgrow.sucking thumb

Typical Symptoms

Nipple pain that begins after a period of pain-free nursing is often indicative of yeast. Burning nipple pain that continues throughout the feeding, sometimes continuing until after the feeding is over, is also a classic sign of yeast. Pain in the breast, often described as “shooting” or “burning,” even “glass in my breast” radiating through to the mother’s back and shoulder are also quite common. Pain may be worse at night, may only be in the breast and not on the nipple, and may improve with use of gentian violet.

Diagnosis

There is no good test for diagnosing a yeast infection on or in the breast. A positive culture is costly and does not prove your pain is due to Candida. A negative culture does not prove your pain is not because of Candida. The experienced clinician makes a diagnosis based on history of the problem and a thorough breastfeeding assessment.

Treatment of Yeast

Gentian violet (GV) is often the first step in treating yeast on the breast. It is messy and will stain clothing. Your baby’s lips will turn purple, but the color will disappear in a few days. Gentian violet is available at most pharmacies without prescription. Call around before making the trip. Two teaspoons is more than enough for an entire treatment. Paint the inside of your baby’s mouth to cover as much as possible and then nurse, so your nipples are also treated. Apply once a day for 4 to 7 days. If pain is gone after 4 days, stop the gentian violet. If there is improvement but not resolution, then continue treatment another 7 days. Stop after the seventh day either way. If there is no improvement at all in 4 days, stop the gentian violet and call your midwife.

Your midwife may prescribe a topical all-purpose-nipple-ointment for treating topical yeast as well, which can be taken in between the applications of gentian violet. Grapefruit seed extract (not grape seed extract), 250 mg three times a day, can be taken orally by mother or it can be applied on the breast. Simply apply the diluted liquid on the nipples, then apply the all purpose nipple ointment prescribed by your midwife after each feeding. (Mix five to ten drops in one ounce of water and apply to nipples and areola with a cotton ball. Let dry a few seconds and then apply the all purpose nipple ointment. Use until pain is gone.)

If none of these steps are successful your midwife may prescribe fluconazole (Diflucan), an antifungal the mother takes by mouth. Fluconazole does pass into your milk, as it should, helping rid any yeast baby may be harboring. It may be that your midwife needs to prescribe fluconazole for your baby as well to reach appropriate levels for therapeutic treatment. The safety profile of fluconazole in infants and children is excellent. For deep breast pain, ibuprofen 400 mg every four hours may be used until definitive treatment is working (maximum daily dose is 2400 mg/day).

Natural Remedies for Thrush

Use up to three capsules of acidophilus (Lactobacillus acidophilus) three times daily. Babies may be treated with acidophilus diluted in breastmilk swabbed in their mouths, or you can dip a finger in the powder and let the baby suck. The intent of acidophilus treatment is to rebalance your body, so don’t expect instant results. Sometimes lactobacilli need a bit of help getting hold in the intestines, and some practitioners recommend FOS (fructo-oligo-saccharides) to enhance colonization.

Apply ¼ cup white distilled vinegar in 1 cup water topically to the breast. If this is too strong, you can use a dilution as weak as 1 tablespoon in 1 cup water. Allow to air dry, and do not wash off before nursing unless baby protests. This should be done at least four times a day and continued for two weeks after all symptoms are gone. Taking baths with vinegar in the water will allow the treatment of more than one source at a time. Distilled vinegar is important as the distillation process destroys any active fungus spores. Yeast cannot survive in the pH environment that is created by the vinegar, which is why making a paste of baking soda in water and swabbing the baby’s mouth at least four times a day may also be beneficial. Practice caution with baking soda as it shouldn’t be swallowed.

A strong immune system booster that may be lacking in the mother’s and baby’s intestines if they have had antibiotics is nonyeast-based vitamin B complex. Zinc is another immune system booster. Take 45 mg per day. Vitamin C can be taken to the point of having loose stools and then reducing the dosage a bit. Since vitamin C is water soluble, it must be consumed throughout the day. Echinacea capsules or tincture can be taken simultaneously to boost the immune system.

Increasing dietary garlic may be helpful, but clinically effective doses are easier to get if you take triple-strength deodorized garlic tablets (three tablets, three times daily for two weeks or more). The liquid, cold-pressed, aged garlic is thought to be the most potent. Kyolic is the brand about which the most conclusive research has been published. Note: ginger and cinnamon reportedly have antifungal properties, but there is less research in this regard.

Apply olive oil topically to breasts after each feeding. Olive oil contains linoleic acids, which are antifungal and may cut off the yeast’s oxygen supply. Caprylic acid, when taken orally, has strong antifungal properties; take to three capsules three to four times per day for two weeks (or 1 gram at meals). Citrus seed oil is a strong, but natural, antifungal, antibacterial, and antiviral substance. It can be used topically but must be diluted. Try 10 drops in ¼ cup water swallowed at once, twice daily. Tea tree oil is thought to have antifungal properties; a few drops may be added to bathwater or diluted and applied to the breast. The bath method may also be used with vinegar, and has the added benefit of helping clear the sinuses.

Take either 1 to 2 grams dried barberry bark or 1 ½ teaspoon of tincture (1:5), or 250 to 500 mg of powdered extract, three times a day. Although very bitter, golden seal is very affective at clearing yeast. Consume either 1 to 2 grams dried bark or 1 ½ teasponse of tincture (1:5), or 250 to 500 mg of powdered extract, three times a day. Caution: rapidly dying yeast can cause intestinal gas.

Pau d’arco is an antifungal tincture with a long history of use in developing countries. Take 20 to 30 drops four times a day. Warning: it tastes horrible. Maitake tea is an antifungal tea that also helps to rebalance the intestines; drink the strongly brewed tea throughout the day for two weeks (4 to 6 cups a day). Soak plantain seeds overnight in warm water and apply the resultant gel topically. Lecithin can be taken orally. Take two 250 mg gel capsules, three times per day, or the equivalent in lecithin granules sprinkled on foods. Deep massage of any plugged ducts with arnica oil as a lubricant supplements this treatment. Massage while baby nurses, taking advantage of gravity.

Household Decontamination

Boil all artificial nipples that the baby uses or simply throw them away. Change breast pads at each feeding. Go without a bra. Use soap and water, avoid antibacterial soaps. Temporarily use disposable diapers. Spray ¼ cup distilled vinegar to 1 cup water to moist body areas (pubic areas, armpits, under folds) four times a day. Get a new toothbrush for everyone in the family. Avoid cornstarch powders and deodorant. Eliminate damp laundry hampers, wet windowsills, and moist bathtubs with 10-percent bleach solution or white distilled vinegar in water. Clean floors, baseboards and walls the same. Wash laundry in the hottest water possible and then add a cup of distilled vinegar to the final rinse. Boil underwear, cloth diapers and sheets for five minutes. Boil toys baby chews on or put in the dishwasher if water is over 130 degrees, with vinegar in the rinse cycle. Use paper towels for hand drying and a fresh towel after each shower.

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