Safe Motherhood

The chal­lenges to safe moth­er­hood vary depend­ing where in the world you live. In some areas the chal­lenge may be to get ade­quate nutri­tion or clean water; in other areas, it may be to pre­vent infec­tion; and in still other loca­tions it may be try­ing to avoid preg­nancy before your body is ready or get­ting access to pre­na­tal care. In the U.S., it may mean avoid­ing being seden­tary and mak­ing poor food choices, or hav­ing to deal with the high tech­nol­ogy envi­ron­ment of med­ical birth that can sab­o­tage the innate phys­i­o­log­i­cal process of labor and birth.

Birth begins the bond­ing or unique love between mother and child.

The biol­ogy of birth is a com­plex series of cause-effect processes…baby’s brain releases chem­i­cal sig­nals to the mother and the pla­centa begins to man­i­fest the mater­nal immune system’s rejec­tion of the fetus.

To help the ball get rolling, relax­ation (the trophotropic response) helps pro­mote the release of oxy­tocin. With the help of grav­ity, the head presses on the cervix, ampli­fy­ing the uter­ine con­trac­tions. After an ultra-distance aer­o­bic endurance test, the cervix opens enough to let the baby move into the vagina and the mother’s dis­com­fort moves from sharp cramp­ing into the bony struc­ture as she tran­si­tions to the strength test of push­ing. She tran­si­tions. Relax­ation mod­u­lates into an ergotropic — adrenal — response to gather her power.

Push­ing is an inter­est­ing term…more mas­cu­line, I think, than the one I pre­fer:  Releas­ing. Releas­ing or let­ting go of the baby. It’s a cathar­sis. In this por­tion of the labor another set of impor­tant processes help the baby clear its lungs of amni­otic fluid, stim­u­late its adrenal sys­tem and chal­lenge its immune sys­tem, as the con­trac­tions drive the baby down­ward. The mother’s deep trans­verse abdom­i­nal mus­cles — if strong enough — squeeze the uterus like a tube of tooth paste, to aid this expul­sion. In the mean­time, the labor is help­ing set up the mother to fall in love and pro­duce milk. When the baby emerges and moves onto the mother’s chest, s/he smells and tastes the mother, rec­og­niz­ing her mother’s fla­vor and set­ting up the poten­tial for bonding.

Any way you slice it, there are two parts to safe moth­er­hood. One is a safe preg­nancy…healthy nutri­tion, phys­i­cal fit­ness, safe water, infec­tion pre­ven­tion, sup­port and a safe envi­ron­ment. The other is a safe labor. In a safe labor, there is both an envi­ron­ment that pro­motes the nat­ural process of labor and the means nec­es­sary for med­ical assis­tance when needed. Women die at an alarm­ing rate from preg­nancy or birth-related prob­lems. Despite some progress made in recent years, women con­tinue to die every minute as a result of being preg­nant or giv­ing birth.

What keeps us from hav­ing a bet­ter record on moth­er­hood is often lack of care in the devel­op­ing world and too much inter­ven­tion in the U.S.. They are two sides of a coin. Moth­ers’ expe­ri­ence and health needs are not on equal foot­ing with other cul­tural val­ues. In places where basic pre­na­tal care or fam­ily plan­ning are low pri­or­i­ties, at-risk women are vul­ner­a­ble to the phys­i­cal stresses of preg­nancy and birth. In the U.S., machine-measured data is para­mount, even if it pro­duces high rates of false pos­i­tives, unnec­es­sary inter­ven­tions or coun­ter­pro­duc­tive pro­ce­dures. We are learn­ing that obe­sity and seden­tary lifestyles have detri­men­tal effects, but fewer preg­nant women than their non-pregnant coun­ter­parts exercise.

Despite the money spent to sup­port the tech­no­log­i­cal model of preg­nancy and birth in the U.S., there are parts of the world with lower rates of mater­nal deaths — espe­cially Scan­di­navia, North­ern Europe and parts of the Mediter­ranean and Mid­dle East (Greece, the United Arab Emi­rates, Israel, Italy and Croa­tia). In fact, in the U.S., mater­nal deaths are on the rise.

It’s a tricky busi­ness. Clearly West­ern med­i­cine has a lot to offer the devel­op­ing world when there are med­ical con­cerns. On the other hand, import­ing the U.S. model could cre­ate more prob­lems than it solves. Instead, the micro-solutions now being devel­oped in many loca­tions will be observed and evi­dence col­lected by orga­ni­za­tions such as the White Rib­bon Alliance and UNICEF.

There is an effec­tive inter­na­tional mid­wives model adopted by JHPIEGO, the Johns Hop­kins NGO work­ing toward improved birthing out­comes. It assesses the local power struc­ture, social con­nec­tions, poten­tial for trained birth assis­tants, and loca­tion of avail­able trans­porta­tion to cre­ate a net­work so that locals will know when a labor is in trou­ble and who can get the woman to the near­est hospital.

In the U.S., there are in-hospital birth cen­ters that allow low-risk moth­ers the oppor­tu­nity to labor and birth in a set­ting designed to encour­age the innate processes. Women are begin­ning to vote with their feet…staying home for birth. Women are going abroad to give birth. At the same time, women are com­ing to this coun­try to give birth, believ­ing it is safer than where they are. There are sev­eral ways these scenes could play out.

But, I’ll wager, improv­ing out­comes will involve com­pro­mise:  Watch­ful­ness and sup­port in most births, plus bet­ter ways to assess dan­ger and pro­vide tech­nol­ogy. No mat­ter where you live in the world, the solu­tion may be essen­tially the same.

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Fitness Starts Early!

Preg­nancy fit­ness is not only impor­tant for moms, but for the fetus as well. Evi­dence is clear that aer­o­bic fit­ness improves brain, heart, immune and meta­bolic function…at all ages, includ­ing in utero. If con­tin­ued early in life, healthy phys­i­cal adap­ta­tions that occur in the uterus become rein­forced behav­ior, prepar­ing a good foun­da­tion for a healthy lifestyle. Babies are acute observers of move­ment and activ­ity, and learn from each other. A key com­po­nent of a good mom-baby pro­gram is the inter­ac­tion of the babies them­selves. A good teacher will facil­i­tate healthy activ­ity among our small­est class members!

There is grow­ing evi­dence that at all ages, aer­o­bic fit­ness pro­duces the great­est num­ber of ben­e­fits. Recently, researchers deter­mined that aer­o­bic fit­ness in 9 and 10 year olds pro­duced ben­e­fits in the devel­op­ment of two impor­tant brain regions — the basal gan­glia and the hip­pocam­pus — that are sig­nif­i­cant fac­tors in problem-solving intel­li­gence. This is just one of the lat­est reports that tells us the capac­ity to absorb and use oxy­gen (which improves with aer­o­bic fit­ness) is a key to health, qual­ity and length of life…beginning in the womb!

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Pregnancy Pathway — Exercise

How lucky is this? Just a few days ago, yet another study was released and has been cir­cu­lat­ing on Med­scape and other med­ical sites that indi­cates exer­cise is ben­e­fi­cial in preg­nancy, whether the mother is a pre­vi­ous exer­ciser or not. Just in time for this entry!

Behavior Affects Pregnancy Outcome

Behav­ior Affects Preg­nancy Outcome

Phys­i­cal exer­tion (we call it “exer­cise” nowa­days) is a nor­mal state for healthy humans. Only in the last cen­tury has the desire to rest or the need to store extra calo­ries as fat become more pos­si­ble to achieve than our need to move about to survive.

Preg­nancy is a state in which both of these fac­tors (rest­ing and stor­ing calo­ries) are enhanced through organic changes in body chem­istry, adap­ta­tions that favor fetal sur­vival. The cur­rent seden­tary lifestyle exag­ger­ates these meta­bolic changes and results in syn­dromes that increase the risk for a num­ber of meta­bolic, car­dio­vas­cu­lar and immuno­log­i­cal dis­or­ders of pregnancy.

When con­fronted by the idea that it is coun­ter­in­tu­itive to think exer­cise in preg­nancy might be safe (let alone ben­e­fi­cial) I am dumb­founded. To me, it is coun­ter­in­tu­itive to think that a seden­tary lifestyle in preg­nancy might be safe!

Burning Calories in Pregnancy Improves Outcomes!

Burn­ing Calo­ries in Preg­nancy Improves Outcomes!

What is the evi­dence that exer­cise in preg­nancy is ben­e­fi­cial? Keep in mind that some stud­ies have been exe­cuted more expertly than oth­ers. But, what is com­pelling is that numer­ous well-respected researchers have sought to test the hypoth­e­sis that exer­cise is not safe, but come away with results that indi­cate the opposite!

Here are some of the major findings:

• The pla­centa is larger and has more trans­port sur­face in exer­cis­ers than seden­tary women

• The fetuses of (aer­o­bic) exer­cis­ing moth­ers make ben­e­fi­cial car­dio­vas­cu­lar adaptations

• Women who do aer­o­bic exer­cise are less likely to develop severe preeclamp­sia or ges­ta­tional dia­betes, and the long term health prob­lems that accom­pany these disorders

• Women who are aer­o­bi­cally fit recover from birth 10 times faster than seden­tary women (as mea­sured by time needed to metab­o­lize free rad­i­cals pro­duced in labor)

• Women who exer­cise in preg­nancy are more likely to be phys­i­cally fit in midlife

• Babies of aer­o­bi­cally fit women are at reduced risk for pre­ma­tu­rity and low birth weight
DTP_mover2
So, we have arrived at the take-home mes­sage: MOVE!! Preg­nancy works best when you move and burn calo­ries in a mod­er­ate to vig­or­ous fash­ion. But, alter­nate this activ­ity with rest and good nutri­tion, and be sure to stay well hydrated.
If you want more specifics and resources on this topic, try these:
“Women and Exer­cise” in Varney’s Mid­wifery.
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Pregnancy Pathway, Pregnancy — Maternal Immunological Response

Today: Mater­nal Immuno­log­i­cal Response…or…the Mother/Fetus Dance!

Maternal Immune Response During Pregnancy

Mater­nal Immune Response Dur­ing Pregnancy

Back to work! Thank you for your fore­bear­ance while we wrote a chap­ter for a nurs­ing textbook!

Dur­ing the course of preg­nancy, the mother/fetus dance is ongo­ing. The mater­nal immune sys­tem and the tro­phoblast cells con­tinue to influ­ence each other even beyond the implantation.

Because the mother’s immune response mod­u­lates near the start of each trimester, the fetus is affected to some degree and mounts a response, as well. For a long time it was thought that mater­nal and fetal DNA mate­r­ial was not exchanged across the pla­cen­tal mem­brane, how­ever recent find­ings indi­cate that there is some exchange of mate­r­ial. Thus, we all carry some por­tion of our mother’s DNA and our mother car­ries some of ours.

What is the impact of this chimeric effect? It depends on how well our DNA gets along!

How does this affect the fetus in utero? The fetus may be affected by clot­ting issues. Depend­ing on mater­nal health sta­tus s/he may be sub­ject to a stronger or weaker immune system.

How does this affect the mother? Women are more likely than men to develop autoim­mune dis­or­ders (preg­nancy play­ing a role here), and those who bear male off­spring are more likely than those who only have girls to have these disorders.

The maternal/fetal dance goes on.…

Be Prepared for Birth!

Be Pre­pared for Birth!

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Pregnancy Pathway, Pregnancy

Time for an entre: Preg­nancy!!

Up for discussion…

Health Influences in Pregnancy

Health Influ­ences in Pregnancy

Let’s start at the begin­ning…in the first trimester you feel sick and tired, right? Three things:

1) your immune sys­tem is pro-inflammatory (caus­ing nau­sea and fatigue), 2) your body is pro­tect­ing your fetus from some tox­ins (if you eat some­thing not so great for the fetus, you throw up), and 3) you have extreme swings in blood sugar lev­els so that after you eat, the level soars and you feel sick.

Num­ber 3 can be fixed with behav­ior, but you may have to wait out 1 & 2. To fix num­ber 3 eat very small meals fre­quently (6 or 8 times a day) and be sure to eat pro­tein, that is, eggs, meat, fish, fowl, cheese, nuts, rice & beans, soy, etc. with each small meal. This sta­bi­lizes blood sugar and pre­vents dra­matic ele­va­tions that can cause nausea.

In most healthy preg­nan­cies, the immune sys­tem will rebound in the sec­ond trimester so that you feel good; it is pro­tect­ing you again!  But, those wicked tox­ins and infec­tions are still out there in the envi­ron­ment, so the mes­sage is beware bad air (smog, smok­ing, indus­trial air pol­lu­tion), highly processed foods (lunch­meats, things with names you can’t pro­nounce), any drugs or meds not pre­scribed or okayed by your ob or mid­wife, alco­hol, and dan­ger­ous bac­te­ria, viruses and other microbes!

Exer­cise wisely…no sky-diving or scuba div­ing! Eat healthy food and get enough sleep. De-stress through relax­ation and med­i­ta­tive tech­niques. Don’t take risks with your health, but do stay active and start to pre­pare for birth and bring­ing home a baby (or two?).

Third trimester & the immune sys­tem goes on the fritz again — can’t keep this baby in here for­ever; must expel! You may feel sick and tired again. BUT, keep your pre­na­tal care appoint­ments, keep mov­ing, get good nutri­tion, rest and stay focused. Before you know it the real work begins, not to men­tion the 18 years of sleep deprivation.

Get­ting from here…

Being Fully Present in Your Pregnancy...

Being Fully Present in Your Pregnancy…

…to here..

Being Fully Present as Mom

Being Fully Present as Mom.

…is a jour­ney like no other. The adap­ta­tions of your body to the demands of preg­nancy are amaz­ing. If you pay atten­tion, you will learn more about the mean­ing of exis­tence from this than from any­thing else.

BE HERE NOW!!

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Pregnancy Pathway…Important Notes from Wonderrobyn

The fol­low­ing are notes from co-author Robyn Bran­cato, CNM (cer­ti­fied nurse mid­wife) who prac­tices in New York City, or, as she is know here: Won­der­robyn! You can read about both authors in the About tab above. Here they are on the beach in San Diego, when they gave a talk at con­fer­ence there a cou­ple years ago. Robyn on the left, Ann on the right.

Robyn and Ann, Pathway authors

Robyn and Ann, Path­way authors

1. Addi­tion to Small Rant: “Resist the temp­ta­tion to watch A Baby Story on TLC! It does not por­tray birth accu­rately, as they con­dense 15 hours of labor into 30 min­utes and play up the drama so that you will be on the edge of your seat! In the major­ity of women, birth is not that dangerous.”

2. Regard­ing: When does con­cep­tion occur? “This is a really inter­est­ing post… I love the dis­cus­sion about at what point con­cep­tion occurs! Per­son­ally, I like the Bib­li­cal notion of quick­en­ing. Even though this varies from woman to woman and can range any­where from 16 to 22 weeks ges­ta­tion, it seems like the most nat­ural theory.”

Dear Reader:  What do YOU think? Did you read the con­cep­tion post on March 23, ’09?

3. About sperm & preeclamp­sia. “Is the con­nec­tion between bar­rier meth­ods and preeclamp­sia actu­ally estab­lished? I have read stud­ies stat­ing the con­trary — that bar­rier meth­ods have no effect on preeclamp­sia rates.”

HURRAY! THIS REQUIRES FURTHER CONSIDERATION.

More infor­ma­tion: The immune mal­adap­ta­tion the­ory sug­gests that tol­er­ance to pater­nal anti­gens, result­ing from pro­longed expo­sure to sperm, pro­tects against the devel­op­ment of preeclamp­sia. Thus, bar­rier meth­ods and being young may pre­dis­pose women to this major dis­or­der of pregnancy.

Evi­dence exists on both sides of this the­ory. Here are two recent stud­ies (one of each) that read­ers may find help­ful in under­stand­ing this idea. Keep in mind that other fac­tors than just sperm expo­sure may be affect­ing research find­ings. But, it does seem that under some con­di­tions, bar­rier meth­ods and amount of expo­sure to sperm can affect the preg­nancy itself.

Ness RB,  Markovic N, Harger G, Day R. Bar­rier meth­ods, length of pre­con­cep­tion inter­course and preeclamp­sia, Jour­nal: Hyper­ten­sion in Preg­nancy 23(3):227–235. 2005.  Results did not sup­port the immune mal­adap­tion theory.

Yousefi Z, Jafarnezhad F, Nas­rol­lai S, Esmaeeli H. Assess­ment of cor­re­la­tion between unpro­tected coitus and preeclamp­sia, Jour­nal of Research in Med­ical Sci­ences 11(6):370–374. 2006. In a matched con­trols study, women with <4 months cohab­i­ta­tion or who used bar­rier meth­ods had higher risks of devel­op­ing preeclamp­sia than those with >4 months cohab­i­ta­tion. Oral con­tra­cep­tion users had a lower preeclamp­sia rate than those who used no oral contraception.

In a com­men­tary arti­cle in OB/GYN News ‚  July 1, 2002, the fol­low­ing note was made by Dr. Jon Einars­son: With insuf­fi­cient expo­sure, preg­nancy may induce an immune response and preeclamp­sia in some women with pre­dis­pos­ing fac­tors such as an endothe­lium that already is sen­si­tive to injury due to age, insulin resis­tance, or pre­ex­ist­ing hypertension.

Is there a plain and sim­ple truth about sperm expo­sure and preg­nancy risks? Alas, no. But, know your cir­cum­stances. If you are young, pro­tect your­self. Wear a con­dom. When you are ready to be a mom, you will be ready to fig­ure out your risks. So, this, too fol­lows the axiom:

Events in life are rarely plain and never simple.

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Pregnancy Pathway, Preconditions — Genetics

Please refer to Feb­ru­ary 5 entry for com­plete graphic. The Pre­con­di­tion we will dis­cuss today is Genetics.

bubblus_preconditions_-_genetics

There are genetic fac­tors totally out­side your con­trol that deter­mine things as sim­ple as your offspring’s hair or eye color, how the ear­lobe attaches to the side of the head and whether or not s/he can roll the tongue. More com­plex things, such as a pre­dis­po­si­tion to types of can­cers, bleed­ing dis­or­ders or var­i­ous other dis­eases, also have a genetic basis.

Because the male con­tributes the sex of the off­spring, once con­cep­tion hap­pens, the sex off the fetus is deter­mined — at least genet­i­cally. But, it turns out not every­thing genetic is set in stone. In utero, hor­mone expo­sures may affect how male and female char­ac­ter­is­tics develop, so that some girls will be very girlie, some will be tomboys, and some may be gay. A sim­i­lar effect will influ­ence how boys develop.

Genetic, envi­ron­men­tal and behav­ioral pre­con­di­tions can be  inter­twined. Envi­ron­men­tal fac­tors can alter genes, caus­ing them to express pro­teins that would oth­er­wise be dor­mant. Like­wise, our behav­ior affects some of our genes. If we have a fam­ily propen­sity for heart dis­ease, but we eat a healthy diet, exer­cise and avoid risky behav­iors, we alter the impact of our genetic code.

Keep in mind that some things will be com­pletely deter­mined by genes. It is not rea­son­able to hope, for exam­ple, that our off­spring will be 6’5″ if both par­ents are short (or vice versa). If the mother has “thrifty genes” — that is, genes that make it easy for her to gain weight — she may well do so dur­ing preg­nancy, even if she fol­lows a rea­son­ably healthy lifestyle. If the immune sys­tems of both par­ents have some sim­i­lar­i­ties, it may affect the mater­nal immune response to the implant­ing tro­phoblast cells, thus affect­ing the pla­centa and, indeed, the entire pregnancy.

So, how do we advise peo­ple who are think­ing of preg­nancy to pre­pare them­selves for a healthy preg­nancy genet­i­cally? Surely, to deter­mine all the poten­tial genetic pos­si­bil­i­ties is not fea­si­ble or afford­able at this point. Maybe in another cen­tury! But, we can know some fac­tors:  Is there sickle cell ane­mia in both fam­i­lies? Is there a Mediter­ranean type of sickle cell dis­or­der? What about clot­ting fac­tors or dif­fer­ences in Rh? What about dis­eases or dis­or­ders that are not com­mon, like ALS? These are things that poten­tial par­ents may want to discuss.

Like so much of life, we can’t know every­thing. There are no guar­an­tees. There is a lot to be learned still about human genes and how they work.

This blog has at its heart the notion that phys­i­cal activ­ity has tremen­dous ben­e­fits for mother and offspring…and for part­ners, too. How does the genetic com­po­nent affect this? First, pre­con­cep­tion fit­ness low­ers some risk fac­tors for moth­ers and babies. Sec­ond, each mother’s genes will make it eas­ier or more dif­fi­cult for her to enjoy or ben­e­fit from the activ­ity of exer­cise. We appre­ci­ate this and encour­age young moms-to-be to find some­thing enjoy­able that you like doing and find peo­ple or sit­u­a­tions that sup­port you in being active now before you become pregnant.

If you need assis­tance or advice, please go to www.dancingthrupregnancy.com (use the BlogRoll)

Find Ask the Expert under the Con­sumer menu. Let us know how we can help!

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