On a more personal note....

So, the year is about to come to a close and we are all thinking about what it is that we want to change, let go of, forget. My mother always added something--I think she found it easier to add a positive to life than to take away a negative. For me, the new year seems to begin with the Winter Solstice, so I have been working on the "new year's resolution" for a bit. Mostly, I want to experience more joy. I have decided that if I am experiencing joy in my actions and choices, I will know I am in the right place. It isn't as easy as I thought, but in the last few weeks it has become smoother. Christmas was hard. My family was together in Switzerland and I was "stuck" in Porltand, on call for births that didn't come. However, there were some blessings that came: I saw my grandmother, and my cousins, and this premature baby had a healthy entry into this world, and I am getting ready to teach a childbirth class. Here are some pics of beautiful Arianna, my cousin Heather and I, and my cousins dog Scout, recently recovered from some sort of leg surgery... Happy New Year to you all!!


"Contrast helps you to identify desire. Desire is summoning. It's always flowing through you. You have the opportunity of opening to the harmony of the vibration of your desire or not. As the desires are being summoned through you, and you go with the flow, you thrive, but if you use things to be your excuse for not going with the flow, you are arguing for your limitations. We want to show you how to go with the flow. Which means nothing more than finding vibrational harmony with your own desire, and letting the Universal Energy that your desire is summoning to it flow to it through you. It is optimum creative experience." Abraham Hicks

C-Sections Cont.

Before I started midwifery school I was working in the kindergarten at the Princeton Waldorf School. While I was there the school went through an accredidation review process. One of the people sent to "review" the school was a woman in her early thirties. She was probably about 6 months pregnant. She and I, of course, got into a conversation about her pregnancy and she told me that she was having a scheduled c-section. I asked her what was wrong, and she said that everything was fine. What she then confessed was that she and her husband had not gotten pregnant as early as they wanted and the baby her original plan had been to have the baby right before spring break so that her maternity leave would be longer, this didn't happen, but she had decided to keep the same scheduled c-section date. This means that not only was she giving birth to a premature (about 34 weeks old) baby, but that the doctor was completely ok with it. I have to say I was shocked. I couldn't believe that this mother to be and her doctor would put the baby (not to mention the mom's body) at risk because for scheduling purposes. Yikes!


More information about cesarean sections from Childbirth.org

These facts are presented by the ICEA Cesarean Options committee with the hope that parents, childbirth educators, nurses, midwives and doctors together can effectively reduce the rate of unnecessary cesarean sections and consequently, their effects.

* A cesarean section is major abdominal surgery. When a cesarean is necessary, it can be a life saving technique for both mother and infant.
* The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.
* In the past twenty years, the cesarean section rates have nearly quintupled in the US to 23.8% in 1989 and nearly quadrupled in Canada to 18.3% in 1987-8.
* A cesarean section poses documented medical risks to the mother's health, including infections, hemorrhage, transfusion, injury to other organs, anesthesia complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth.
* An elective cesarean section increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial costs. Even mature babies, the absences of labor increases the risk of breathing problems and other complications.
* Cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding and the establishment of family bonds.
* In the US and Canada, over one-third of all cesareans are repeat cesareans. The American College of Obstetricians and Gynecologists (ACOG) recommends that the concept of routine repeat cesarean be replaced by a specific indication for surgery, and that most women can be counseled and encouraged to labor and have a vaginal birth after a cesarean (VBAC).
* In 1989, 81.5% of all US women with a previous cesarean had a repeat cesarean. The VBAC rate was 18.5%. The VBAC rate is greater in every eastern and western European country.
* The "once a cesarean, always a cesarean rule is outdated now that most of uterine incisions are low and horizontal and the risk of rupture of the old scar is almost nonexistent. A review of all VBAC literature from 1985-1990 found a rupture rate of 0.22% for low transverse scars in 22,000 planned labors after cesarean. (In developed nations the rupture rate was 0.18%.) By comparison, the incidence of other childbirth emergencies, such as prolapsed cord, placental separation, or sudden fetal distress is 1-3%.
* ACOG states that the hospital requirements for VBAC are the same standards for all obstetrics. These include the capacity to respond to acute obstetric emergencies by performing a cesarean within 30 minutes. However, many hospitals in North America that offer maternity care do not allow or encourage women to labor and have a VBAC.
* In a review of all the medical reports published on VBAC from 1926-1990, 75% of all women who planned labor after a cesarean gave birth vaginally. Several medical studies record VBAC rates of over 90%.
* The latest statistics indicate that 967,000 cesareans were performed in the US in 1989. The Public Health Citizen's Research Group estimates that over one-half the cesareans performed in 1987 were unnecessary and resulted in 25,00 serious infections, 1.1 million extra hospital days and a cost of over $1 billion. About 500 women a year die from bleeding, infections and other complications of cesarean sections, although these may be related to the reasons the operation was performed and not just to the procedure itself.
* A cesarean costs nearly twice as much as a vaginal birth ($7,186 average vs. $4,334 average in 1989 in the US). It has been estimated that in Quebec, Canada, if the current rate of cesareans (18.8%) were reduced to that of Finland (11.9%), costs incurred by the provincial health care system could be reduced approximately $19 million per year.
* The four most common medical causes contributing to the increase in cesarean section rates in North America are: routine repeat cesareans; dystocia (non- progressive labor); breech presentation; and fetal distress. Some reports suggest that more careful diagnosis and management of dystocia could halve the primary section rate. Combined with fewer cesareans for breech presentation (along with more cephalic versions), careful diagnosis of fetal distress and active encouragement of VBAC, these efforts have resulted in lowering cesarean rates to less than 12% in various parts of the world.
* Up to 77% of women for whom the indication for cesarean delivery was a non- progressive labor (sometimes diagnosed as cephalopelvic disproportion or CPD) and who tried labor again, had a VBAC for a subsequent birth. Approximately one-third of these women gave birth to babies that were larger than their previous "CPD" baby.
* ACOG states that a woman with two or more previous cesareans deliveries with low transverse incisions who wishes to plan a VBAC should not be discouraged from doing so in the absence of contraindications.
* Cesarean rates are influenced by non-medical factors. Rates are higher for women who have private medical insurance, are private rather than public clinic patients, are older, are married, have higher levels of education and are in a higher socio-economic bracket.
* In 1989, a medical study done in Houston, Texas, concluded that epidural analgesia is associated with significant increases in the incidence of cesarean section for dystocia in women having their first labor.
* Cesarean sections are sometimes performed for other than maternal or fetal well-being, such as avoidance of patient pain, patient or provider convenience, provider legal concerns or provider financial incentives.
* Although rare, there have been reports of court-ordered cesareans performed on women against their will. One such case was appealed, supported by 118 US organizations, claiming that the decision was unconstitutional and raises complex legal, moral and religious issues. The appeal judge issued a forceful decision asserting that "in virtually all cases the question of what is to be done is to be decided by the patient -the pregnant woman- on behalf of herself and her fetus."
* In March 1990, an ACOG survey of 2,213 obstetricians documented the changing attitude about VBAC in the US. The survey reported that women under the care of younger physicians and physicians in practice for fewer years were more likely to accept the option of VBAC than women under the care of older physicians and those in practice the longest.
* Of 11,814 women admitted for labor and delivery and attended by midwives to 84 free standing birth centers in the US, 15.8% were transferred to the hospital and 4.4% had a cesarean section. Although the women were lower than average risk of a poor pregnancy outcome, their cesarean rate is one-fifth of the national average.

Calendar of the Soul: December 18, 2005 - December 24, 2005

Thirty-ninth Week

Surrendering to spirit revelation
I gain the light of cosmic being;
The power of thinking, growing clearer,
Gains strength to give myself to me,
And quickening there frees itself
From thinker's energy my sense of self.
___________________________________
Rudolf Steiner
English translation by Ruth and Hans Pusch

Surgical Births: Cesarean Sections

A recent article was published by the International Cesarean Awareness Network or ICAN. ICAN is a nonprofit organization. The organization promotes the improvement of maternal-child health by preventing unnecessary cesareans. They provide education , support for cesarean recovery, as well as and promoting vaginal birth after cesarean or VBAC.

The article discusses the rising Cesarean rate, the falling VBAC rate, and the increase in elected Cesareans. Cesareans were originally reserved for emergencies. "Experts state that any laboring woman faces unpredictable complications--such as umbilical cord prolapse, acute fetal distress, or hemorrhage from a placental abruptiont--that might require an emergency cesarean. The odds of these complications are 2.7 percent, " states Nicette Jukelevics of Mothering Magazine. What I find interesting is that a US study found that mothers are four times more likely to die from a cesarean unrelated to health problems, compared with women who have vaginal births. Other complications associated with Cesarean sections include blood transfusions, prolonged healing and recovery, difficulty breastfeeding, failure to thrive, as well as future complications in subsequent pregnancies. Also, a traumatic birth of any kind can leave a woman feeling disempowered, violated, or betrayed. Healthy babies born by Cesarean are more likely to have difficultires, including respiratory problems that require intensive care.

The Cesarean birth rate is the highest it has ever been, 29.1%, in the US. The cesarean delivery rate rose 6 percent in 2004 and the rate has increased by over 40 percent since 1996. Much of this is due to the drop in VBAC, which dropped by 13% in 2004. In some hospitals VBACs are being banned. There are currently about 300 hospitals where VBACs are not permitted, including about 50 in California. This means that once a woman has a C-section she will not be permitted to birth vaginally. The saying goes "once a Cesarean always a Cesarean." I want to know what happened to a woman's right to choose.

"The recommendation by Consumer Reports is for pregnant women to be informed about the cesarean rate of their physicians and hospitals, and to look for rates below 15 percent in women who haven't had the procedure and about 60 percent in those who have. Another recommendation is to ask about the doctor's willingness to try non-surgical steps first. Alternatively, Consumer Reports also recommends women consider giving birth in a hospital with a certified nurse-midwife, if available, since their births have lower cesarean rates than births with obstetrician." The article also explores out of hospital options and includes several links and resources. "Giving birth in a free-standing birth center or at home with a midwife is another option that women should study. Midwifery care has been proven over and over to be a safe alternative for most pregnant women", says Jamois. "Countries where the majority of babies are born into the hands of midwives, such as The Netherlands, have cesarean rates below 10 percent, and they boast the best maternal and infant health outcomes in the world."

ICAN article
VBAC article

The Path to Becoming a Midwife

I had a conversation with a friend recently about midwifery and the sacrifices we make as midwives. At Birthingway, where I attend classes, we hold a forum every August called "So, you want to be a midwife?" At the forum dads and sometimes children of midwives come and talk about what it is like having a mother that misses Christmas and birthdays and has to leave in the middle of arguments or love-making. I have been thinking a lot about why we decide to become midwives and why it is that we must lose precious moments with our families. It is hard to imagine what it will feel like to miss out on those moments and yet, I know that I am fulfilling my purpose. Maybe that is part of what helps us cope. So many midwives I have listened to talk about the magical way they fell into the practice of homebirth. It is more than just a job. On many levels it isn't a job at all. I feel like I was called into this work. My mother had her children out of the hospital, as did many of her friends, so homebirth was never a foreign concept for me. But once I thought about becoming a midwife nothing else really seemed to fit or satisfy as deeply. In so many ways I feel I had no choice...this was the work I was born to do. In December, 2002, I had been accepted to Birthingway, but had decided that becoming a midwife was going to be too much work; that being a midwife was too much work. I had a dream that changed my perception and committed my completely to this work. I don't know how many of you out there actually believe dreams are a different state of consciousness, but in this dream I received a clear message. The shortened version of the dream is that I was apprenticing with a spiritual leader in a small village. When it came to be my turn to give the spiritual teachings I couldn't remember them. I was very upset with myself and convinced that I was not supposed to be a the next village spiritual guide. When the woman asked me how my first day had been I told her that she had been mistaken, I was not the next teacher. She looked me square in the face and said "we do not get to pick the path we walk, and the more important the path, the harder it is to walk it." Needless to say, I woke up and sent my letter of acceptance to Birthingway. I believe I am walking the midwifery path for many, many reasons, but on some level, it is because an old woman in a dream told me this is my purpose or destiny or fate. So, when I think about the sacrifices I have made and will make I come back to that dream. Yes, I believe we have a hand in our own destiny and that it can constantly morph and transform, but someone or something bigger than me is also directing me down this path, and the purpose for that I have yet to discover.

Legal Status of Midwifery

I believe that midwifery is illegal in 16 states and in states where it is legal regulations are varied. In some of the illegal states, it is legal to be a Nurse-Midwife and practice homebirth under specific regulations. You can check out the midwifery regulations at the link below. Anyway, I recently came across the article below and am excited that things have changed in Virginia.

Virginia Lifts Midwifery Laws
Legal Status of States

Ultrasounds

There are three types of ultrasound: scanning or sonograms (may be external or vaginal), doptones, and electronic fetal monitoring. Ultrasound is most often used in women who are considered high-risk, women above the a is a high frequency sound wave that vibrates at 10 to 20 million cycles per second, or 2-4 megahertz. Actual sound, that you hear, travels at 10-20 thousand cycles per second, or around 20 kilohertz. The return of the sound wave creates an image or echo of the tissue and bone composing the baby. Because bone is denser it appears whiter on the sonogram screen. Ultrasound is considered radiation, although not as intense as X-rays. Ultrasound is not limited to sonogram imaging. It is also used in hand-held Doppler’s and electronic fetal monitors, both of which detect fetal heart rate. Exposure time to the doppler may be significantly less than to ultrasound, however the frequency rate is much higher. In addition, the doppler is used, generally beginning around 10 weeks pregnancy, at each prenatal visit. Some women may also experience the use of internal vaginal ultrasound, especially during early pregnancy. Although the exposure to frequency levels may be the same, the scan is closer to the tissues, and the fetus is at a more vulnerable stage. Exposure time is often longest with the EFM. Women are generally hooked up to the monitor for 20 minute phases, although some women may be monitored continually.
Ultrasound may be used for a variety of reasons including pregnancy and gestational age confirmation, position of baby, position of placenta, and amniotic fluid amount. Ultrasounds may also be used to rule out multiples, abnormalities, small for dates babies, postdates (stress tests), and may be used in conjunction with other interventions.
The FDA recommends using ultrasound as diagnosis of pregnancy at 18 weeks, but warns against the routine use of ultrasound in pregnancy, stating the ultrasound should be used for diagnostic purposes only.
Although studies have been done on the risks of ultrasound use, they do not prove that ultrasound is harmful. Studies on animals, exposed to high levels of ultrasound, have displayed cellular changes. Additionally, ultrasound has been used in surgery and on a therapeutic basis because it can create cell lysis. Ultrasound is also known to cause cavitation—small pockets of gas, found in tissues, vibrate at a high rate, until the pockets collapse. These studies confirm that ultrasound, at least at increased exposure to very high frequency; can cause changes within the body. Randomized studies were done in Sweden and Norway showing and increased rate of left-handedness among children who had been exposed to frequent ultrasounds. Although the results are non-harmful, the increase in left-handedness suggests changes in the CNS and raises the question about long-term ultrasound effects which may not yet be visible. Other possible effects include delayed speech, miscarriage, and intrauterine growth restriction. These studies conclude that ultrasound use may be proven unsafe overtime if good randomized, controlled studies are conducted.
Ultrasound radiation may be avoided if women commit to having fewer ultrasounds and limit the exposure time to dopplers. Women who are not birthing with midwives can ask the ultrasonographer to perform the procedure as quickly and effectively as possible. Because we still have not had enough studies on the iatrogenic effects of ultrasound, it may be difficult to counsel women to avoid them altogether. However, it is apparent that the fetus is more vulnerable in early pregnancy and with long exposure time. Women might want to make note of the intensity of the exposure, duration, the manufacturer of the ultrasound equipment and the type of ultrasound used. It should also be suggested that they see and ultrasonographer who is highly experienced and comfortable with limiting the exposure time.

Birth Article

This is a wonderful article about birth by Sarah Buckley. She discusses the effects our hormones have on the birth process and the possible effects of using synthetic drugs as pain killers and labor enhancers. I have included the introduction and some of the conclusion, followed by a link to the complete article....
Giving birth in ecstasy: this is our birthright and our body's intent. Mother Nature, in her wisdom, prescribes birthing hormones that take us outside (ec) our usual state (stasis) so that we can be transformed on every level as we enter motherhood. This exquisite hormonal orchestration unfolds optimally when birth is undisturbed, enhancing safety for both mother and baby. Science is also increasingly discovering what we realize as mothers- that our way of birth affects us life-long, mother and child, and that an ecstatic birth, a birth that takes us beyond our Self, is the gift of a lifetime.
Giving birth is an act of love, and each birth is unique to the mother and her baby. Yet we also share the same womanly physiology and the same exquisite orchestration of our birthing hormones. Our capacity for ecstasy in birth is also both unique and universal, a necessary blessing that is hard-wired into our bodies but that requires, especially in these times, that we each trust, honor, and protect the act of giving birth according to our own instincts and needs.
Dutch professor of obstetrics G. Kloosterman offers a succinct summary, which would be well placed on the door of every hospital birth room:
Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine--nil nocere [do no harm].

Mother Magazine Article: Ecstatic Birth

EPIDURALS

Epidurals are considered the “gold standard” in pain relief. They have been shown to provide better pain relief and more continual support than other forms of anesthetic or pain medication. The use of epidurals has been widely studied in terms of effectiveness, especially in comparison to the other available medications. However, there are no randomized studies comparing the effectiveness of epidurals in birth to births where no pain medications are used. Additionally, most studies regarding epidural use have not looked at overall maternal satisfaction of the birth.
Epidurals are a type of anesthetic administered into the lower region of the spine. The anesthetic may be a combination of anesthetic drugs such as xylocaine and bupivicaine, and opioids such as fentanyl. Once the epidural has been administered into the spinal region, the anesthesiologist must remain available in case the epidural needs to be turned off, turned down, or dosage increased.
Epidurals are useful when a woman can no longer labor without pain relief and when a woman is being referred for a cesarean birth. However, this gold standard of American birth culture does not come free of side effects and risks. First of all, the use of any intervention, including epidurals increases the use and need of other interventions. Studies show that the use of epidurals increases the likelihood of a cesarean birth from 10-50%, depending upon the stage of labor. Women are 50% increase in cesarean rate if the epidural is administered at 2cm, a 33% increase at 3cm, and 26% increase at 4cm (Dozar and Baruth, 1999). Other interventions include an increase in forceps and vacuum extractor deliveries. Often these procedures become necessary because the woman has trouble pushing. Epidurals inhibit leg and muscle sensation and control and often prevent a woman from birthing in upright or more effective positions. Additionally, if women receive an epidural in the earlier phases of labor, less than 5cm, the likelihood of the uterus relaxing increase. This may cause the baby to remain or move into a less than optimal position, which in turn may increase the difficulty of pushing.
Potential risk factors or complications caused by epidural use include, but are not limited to maternal hypertension (which can lead to fetal bradycardia and distress), urinary retention, mild to severe headaches lasting up to a few days, backache, septic meningitis, maternal and fetal toxicity (epidural anesthesia crosses the placenta and into the fetal blood stream), discoordinate uterine contractions, fecal and urinary incontinence, slowed uterine contractions and thus the need for oxytocin, allergic reactions, seizures, and ineffective pushing. Additionally, women may experience uneven numbing and dissatisfaction in the birth process if they were hoping for a natural birth. The WHO explains that despite the fact that women who receive an epidural may be considered low-risk, they are no longer having a “normal birth” because an epidural changes a natural experience into a medically managed procedure. Medical management is not part of the normal, physiological process of birth.
Both women considering and wanting an epidural should be supported in their birthing process and the choices they are facing. Women who are able to surrender to the birth experience and who are able taught to cope with their fear may experience less tension in their body and therefore less pain. Having a supportive, loving and nurturing birthing staff and partner can help women release into the birth process. Additionally, studies have shown the women undergoing good CBE classes and women who choose to have a doula present at birth are more likely to be satisfied with their experience, and often do it without becoming a part of the epidural epidemic.

Nutrition and Pregnancy

Women who eat healthily, nutritionally, during pregnancy birth healthier babies. And not only are you giving your baby and yourself a good beginning, but babies who are nurtured with a wholesome diet during pregnancy are also healthier throughout life! It is amazing that you can positively impact the life of your child by eating food that is good for you!

What to eat: protein, fat, carbohydrates and calories
It is important to remember that having good nutrition does not mean how much you eat, but what you are eating. Often we eat too much of things that are limited in their nutritional value. For example, if you are craving a bagel, it might be a good idea to grab the whole wheat one because it is higher in protein. Or if you are feeling like you need a snack, why not snack on carrots or apples, rather than a bag of chips?
Protein is required for the increase of blood volume in your body. The health of your body, your uterus, and your growing baby depend on this wonderful substance. You will need about 60 to 80 grams of protein during the first half of pregnancy and about 80 to 100 grams during the second half. Most women get about 60 grams of protein a day. Vegetarians should try and eat on the higher end of the scale (70-80 grams during the first half and 90-100 during the second half of pregnancy).
Some protein sources: Cheese, eggs, fish, meat, organ meats, poultry, milk, yogurt, black beans, quinoa, rice, bulgur, chickpeas, lentils, tofu, almonds, and split peas.
Fat is where you build up and store your energy. These reserves will help you support the growth of your baby and provide you the resources you need to breastfeed during the first weeks following the birth. Fat is very important to the pregnancy diet. It helps regulate and produce hormones and helps you use important vitamins. You will need about 60 grams of fat per day, or about 30% of your calorie intake. It is generally easy to get fat in your diet and therefore it is encouraged that you eat low-fat foods. Additionally, eating foods that are high in omega-3 and omega-6 oils is important and highly recommended. Omega-3 and omega-6s are found in fish (anchovy, bluefish, salmon, and swordfish), cod liver oils, flaxseed oil, and some in walnut oil, wheat germ oil, and soy products. The easiest place to get omegas is from fatty fish or cod liver oil.
Some fat sources: Avocados, cheese, milk, egg yolks, meat, nuts, olives, vegetable oil, and poultry skin.
Some fat sources to try and avoid: It is important to avoid trans-fatty acids or trans fats. These fats have been hydrogenated, that is they have been chemically changed from a liquid to a solid. An example is margarine and vegetable shortening. These fats lead to coronary disease and increase the risk of heart disease.
Other sources of hydrogenated, trans fats are: coconut oil, some peanut butters (that do not have to be stirred), palm oil, and shortening.
Sources of saturated fat and cholesterol are: butter, cheese, meat, whole milk, beef, and liver.
Some better sources of fat: Unsaturated fats include canola oil, flaxseed oil, corn oil, safflower oil, sunflower oil, and olive oil (olive oil is actually monounsaturated and may have cholesterol reducing properties).
Carbohydrates should make up the largest portion of your caloric needs. They are found in two forms, simple and complex. Simple carbs are found in fruits, sugar, and sweets like candy. Complex carbs are found in vegetables, beans, whole grains, and potatoes. Both are the fuel your body needs for energy and is also the primary source of energy and fuel for your baby. Carbohydrates breakdown into glucose and glucose is what the developing baby needs. Not getting enough carbs can negatively impact the nervous system of the baby. You should try and eat more complex carbs than simple carbs. These generally have more nutritional value and may be high in important vitamins, minerals, and fiber, all essential for your pregnancy. Simple carbs like candy and cookies do not have other nutritional value and should be eaten in limited quantities. Fruit, although a simple carb is also high in nutrients and fiber.
Calories: You will need about 2,000-2,400 calories per day during your pregnancy. Essentially you need an additional 300 calories a day while you are pregnant and 500 additional calories per day while breastfeeding. However, the amount of calories needed depends upon your age, height, and weight. If you are concerned about the number of calories you should be getting, it might be a good idea to discuss at a prenatal so your calorie intake can be determined.

What should you avoid?
The most important things to avoid during pregnancy and while breastfeeding are alcohol, drugs and cigarette smoke (including second hand smoke). Both of these have negative effects on your own personal health and the health of your growing baby. Additionally, consuming caffeine from soda, coffee, and tea inhibits your absorption of important nutrients and may increase dehydration.

Where does the weight go?
Fluid retention: 2-3 pounds
Increased blood volume: 3-4 pounds
Breast growth: 1-2 pounds
Uterus growth: 2-3 pounds
Amniotic fluid: 2-3 pounds
Baby: 6-9 pounds
Placenta: 1-2 pounds
Fat stores: 4-6 pounds

During the first trimester weight gained is generally not very much (but remember that every individual is different and every pregnancy is different, so you may have your own special version of what is considered “general”). You may gain between 3 and 6 pounds. During the second trimester weight gain is about 6 to 12 pounds, about ½ to 1 pound per week. You may notice increased growth during one week and less during another, this is very common. Each woman has her own weight-gain and baby growth pattern. During the third trimester weight gain is again between 6 and 12 pounds.
The recommended weight gain for “normal” weight women is between 25 and 35 pounds. If you are eating healthily and getting plenty of fluids, calories, and protein, you should do just fine!
Women under the age of 19 should gain more weight, about 30-45 pounds
If you are carrying twins you will probably gain more weight. You are going to be making two babies, two placentas, and carrying more amniotic fluid. It is good to try and gain 35-45 pounds.
If you have concerns about how much weight you are or want to be gaining bring those questions to your next prenatal.

Snacking
Snacking is a great way to obtain calories, protein, and nutrients. If you are always on the go, prepare some lunch bags of snacks you will enjoy ahead of time. Always have some snacks on hand. Keeping a box of crackers in your car or a bag of nuts, for example, is a great way to ensure that you have food on hand for that unexpected moment of hunger.
Food that is great to snack on includes:
Fruit: Apples, oranges, bananas, grapefruit, melon, mango, peaches, blueberries, raspberries, pears, peaches, plums and pineapple.
Dried fruit: Prunes, dates, figs, pineapple, apples, unsulferated apricots, and raisins.
Seeds and nuts: almonds, peanuts, hazelnuts, pecans, pumpkinseeds, sunflower seeds, cashews, and walnuts.
Breads and grains: bagels, trail mix, granola, whole grain breads, and granola or protein bars.
Dairy products: (it is preferable to eat organic dairy when possible) cottage cheese, yogurt, goat cheese and goat milk, low-fat ice cream, frozen yogurt, low-fat cheeses.

Supplements/Prenatals
Supplements or prenatals provide vitamins and minerals you might not be getting from your food sources. Calcium, iron, vitamin C and D, folic acid and B vitamins are all extremely important. Many of these come from your diet, especially if you are eating a lot of dark, leafy vegetables. However, even if you are eating a diet high in nutrients, absorption of these nutrients can be difficult for some individuals. Therefore, it is recommended that everyone take some form of a supplement or prenatal vitamin.
Prenatals are generally expensive, but getting a prenatal that was made, by people who are truly invested in doing good research is important. I recommend a few types of prenatal vitamins and can help you find one that suits your nutrient needs and budget. I am also happy to review with you any prenatal you are currently taking or considering using.

Nausea and Vomiting
Nausea and vomiting can present a challenge during pregnancy. Some women find that eating small, frequent amounts of bland carbs, like bread and potatoes is helpful, while other women can only consume liquids. In all cases it is important to stay well hydrated. Drinking tea that has fresh ginger, lemon balm, raspberry leaf, and nettle leaf may be helpful as well as making sure you are getting enough of the B vitamins.

Herbs and pregnancy: What herbs are safe, and which ones to avoid
If you are taking any herbal supplements or drinking any herbal teas make sure you discuss them at a prenatal. Certain herbs may stimulate early labor or even cause miscarriage. However, there are some herbs, like raspberry leaf, nettles, alfalfa, lavender, chamomile, lemon balm, and mint are considered safe.

Organic foods
Organic foods are grown without the use of harmful pesticides and chemicals. They are also grown on land that has not been exposed in at least three years prior to the harvest to synthetic chemicals or other prohibited substances which are considered harmful. Buying organic is important, not only because you are protecting your body from synthetic chemicals and pesticides, but also your baby. The baby gets exposed through your blood stream and the placenta. Important foods to buy organic are apples, bananas, celery, carrots, squash grown in the U.S., fresh peaches, grapes, U.S. grown beans, U.S. dairy products especially milk, and meats. If you buy food at the local farmers market ask if they are an organic farm. Some farms may be “transitional” meaning that they follow all or most of the organic standards, but have not yet been approved as an organic farm, sometimes for financial reasons.

Fluids
It is very important to stay well hydrated during pregnancy. Women should be drinking 8 glasses of water or juice a day. I recommend drinking at least half the amount in water. Herbal teas and carbonated beverages are considered ok, but liquids with caffeine are not. If you are drinking coffee, soda, or teas with caffeine, I recommend that you drink a glass of water before or after that caffeinated beverage. This way you will stay hydrated. Dehydration can lead to numerous problems in pregnancy, including constipation, fatigue, headaches, rapid pulse, and fetal heart tone variations.
You can tell if you are dehydrated by examining the color of your urine. If your urine is light yellow or clear, with no or little odor you are well hydrated. If your urine is a darker yellow or amber with or without odor you are dehydrated and should drink more water.

Some helpful ideas
Always carry snacks and water with you. Keep crackers or fruit in your purse and car.
Buy a 32 ounce water bottle and fill it up through out the day. Drink a larger amount before you leave the house in the morning, that way you start the day off well hydrated.
Buy produce that is in season and buy organic. Examples might be apples, oranges, bananas, carrots, cabbage and onions. If it is July and berries are in season
Buy frozen fruits and vegetables or freeze produce as you buy it.
Buy products that are on sale
Buy things you know you can make, don’t be overly ambitious
Buy in bulk. Buying sugar, flour, nuts, rice, oatmeal, cereals, and dried fruit in bulk will save you money. Remember that you pay for packaging and if you buy in bulk you can purchase the exact amount you need.
Shop at food warehouses for basic needs such as pasta. Household items are often cheaper here too, and the money you save could be spent on food items at other stores
Buy local. Shop at your farmer’s market. This is a great way to support your local community, buy food that is in season, and save some money
Grow your own
Think leftovers. Always make more and freeze it small containers or bags.
Raid the cupboards and the refrigerator before you go buy groceries. You may be surprised at how much is already in your kitchen
Make soups. Soups are a great way of using up the vegetables in your house and can easily be frozen for a later date.
If you have time to chop vegetables or fruit today, spend a few extra minutes chopping or preparing food for tomorrow.
Buy fortified foods, such as cereal, for an extra, nutrient boost.

From the Calendar of the Soul, Rudolf Steiner

The calender of the soul is a collection of weekly verses. I belong to a anthroposophical list where the weekly verse is sent to my email....although I do not generally read the verse daily, like Steiner suggested, I do enjoy reading them each Sunday when the verse arrives in my inbox...sometimes I find the verse moving, compelling, and sometimes it is takes me a while to find the meaning. Maybe this has more to do with the translation for German to English? I would love to know what you think of the verse and next week I will try and include another...
[December 04, 2005 - December 10, 2005]

Thirty-seventh Week
(December 15-21)

WINTER

To carry spirit light into world-winter-night
My heart is ardently impelled,
That shining seeds of soul
Take root in grounds of worlds
And Word Divine through senses' darkness
Resounds, transfiguring all life.

Birth Story 2

One of the first things I have learned since attending birth is that they never, ever go the way you expect them to go (although now that I have said that the next one probably will). The most recent of birth I attended was happened completely unexpectedly. I was at work (I nanny three 18 monthers) and a bit worried that the parents had decided to drive to the Ape Caves on Mt. St. Helens for the day. I had the fleeting thought of "what if (mom) goes into labor? I doubt there is cell service in the Ape Caves." Needles to say, I was relieved to find Hope home when the triplets (Connor, Riley, and Sean) and I returned from the park. I found most of this odd, because the mom I was on call for wasn't due for another couple of weeks. But, within five minutes of me having these thoughts, the midwife called and let me know the mom was in labor.
I want to add here that as I attend more and more births I feel like my instincts and intuition grow stronger. It may sound odd, but I have found other ways of knowing what is happening than phone calls, conversations etc. For example, a few months ago I dreamt that I had a dream that a client was trying to tell me she was in labor. I woke up and within a minute received a phone call from that client. Sure enough, she was in labor.
So, you see, these random thoughts often have deeper meaning. Anyway, we spent most of the day setting up the birth tub and getting everything set for this birth. Mom labored beautifully. She was surprisingly quiet. Kept going back and forth between the tub and the bathroom. Moms as a rule love to labor on the toilet. This was one of the first births where I was told to "step forward." Meaning, I was doing more work than usual--or rather more coaching and support. This also meant that I was going to catch the baby...
When a mom begins pushing, the energy of the birth becomes much more intense and deep. This mom pushed for a long time, common with first births. But she did so beautifully. I had my gloved hands on her perineum, could feel the bulging as she pushed and opened and brought the wee one closer and closer to this world. It feels really strange when a head is being born right into your hands. It is amazing how slowly the head is born and how quickly the body of the baby follows. Babies truly swim into their new life...This one came out with a big gush of water and a lot of sweetness. He seemed very tiny and precious. I just sat there on the bed, stunned. I was yet again, so amazed to have been witness to this experience and to have held this wee one as he entered the world. It is such a gift, to be the first to touch such innocence and beauty. There is really no way of describing the connection you feel with the universe, god, goddess, new delicate life. This time I felt almost helpless. I couldn't move from the cocoon we had just created. The midwives talked above me--checked the baby's breathing, made sure mom was not bleeding. They worked quickly and quietly to ensure everyone was safe and healthy. I continued to sit in awe for what seemed like forever wondering, how exactly is it that we are able to give birth?

Recent Study on Homebirth

This is an interesting article about homebirth safety. As many of you probably know there has been an ongoing debate between the obstetric and midwifery community on this subject. Most of the studies done on homebirths have been retrospective, which contributes to concerns about accurate reporting and bias. This study is a prospective cohort study carried out with assitance from the North American Registry of Midwives NARM. In this study the outcomes of low risk women giving birth at home with a CPM (certified professional midwife) were compared to outcomes of low risk women giving birth in the hospital. 409 practicing CPMs agreed to take place in this study, enrolling all of their patients with an expectant date of delivery in the year of 2000. The study group was eventually narrowed down to 5418 women who intended to give birth at home. This population was then compared to all the low risk women who gave birth to singleton, vertex babies of at least 37 weeks gestation in a hospital in 2000. Low risk was determined through a screening tool consisting of 13 personal and behavioral variables associated with perinatal risk. The data for this control group was provided by the National Center for Health Statistics. In conclusion, it was found that the rate for medical inverventions was much lower for the homebirth group as compared to the hospital birth group and the mortality rates for mothers and infants were the same for both groups. It could thus be concluded (from a statistical standpoint) that for low risk women, homebirth is just as safe as hospital birth and vice versa.

Link to the full study


Outcomes of planned home births with certified professional midwives: large prospective study in North America
Kenneth C Johnson, senior epidemiologist1, Betty-Anne Daviss, project manager2

1 Surveillance and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, PL 6702A, Ottawa, ON, Canada K1A OK9, 2 Safe Motherhood/Newborn Initiative, International Federation of Gynecology and Obstetrics, Ottawa, Canada
Correspondence to: K C Johnson ken_lcdc_johnson@phac-aspc.gc.ca

Introduction

Despite a wealth of evidence supporting planned home birth as a safe option for women with low risk pregnancies, the setting remains controversial in most high resource countries. Although several Canadian medical societies and the American Public Health Association4 acknowledge the viability of home births, the American College of Obstetricians and Gynecologists continues to oppose it. Studies on home birth have been criticised if they have been too small to accurately assess perinatal mortality, unable to distinguish planned from unplanned home births accurately, or retrospective with the potential of bias from selective reporting. Studying direct entry midwifery practices across North America, we carried out the largest prospective study of planned home births to date, with direct entry midwives involved with home births across North America. We compared perinatal outcomes with those of studies of low risk hospital births in the United States.

Methods

The competency based process of the North American Registry of Midwives provides a certified professional midwife credential, primarily for direct entry midwives who attend home births. Our target population was all women who engaged the services of a certified professional midwife in Canada or the United States as their primary caregiver for a birth with an expected date of delivery in 2000. In autumn 1999, the North American Registry of Midwives made participation in the study mandatory for recertification and provided an electronic database of the 534 certified midwives whose credentials were current.

We contacted 502 of the midwives (94.0%). We sent data forms and information on the study to the 409 midwives actively practising. For each new client, the midwife listed identifying information on the registration log form at the start of care and updated this every three months, obtained consent, and completed a form on course of care. She had to account for all registered clients.

We reviewed the clinical details and circumstances of stillbirths and neonatal deaths, and we telephoned the midwives for confirmation and clarification. Information was verified through reports from coroners, autopsies, or hospitals on all but four deaths, for which we obtained peer reviews.

We contacted a stratified, random 10% sample, of over 500 mothers, including at least one client for every midwife in the study. The mothers were asked about the date and place of birth, any required hospital care, any problems with care, the health status of themselves and their baby, and 11 questions on level of satisfaction with care.

We focused on the mother's personal details, reasons for leaving care prenatally, the rates and reasons for transfer during labour and post partum, medical interventions, health and admission to hospital of the newborn or mother from birth up to six weeks post partum, intrapartum and neonatal mortality, and breast feeding. We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000,6 as a proxy for a comparable low risk group. We also compared medical intervention rates with the listening to mothers survey.7 Intrapartum and neonatal death rates were compared with those in other North American studies of at least 500 births that were either planned out of hospital births or comparable studies of low risk hospital births.

Results

A total of 409 certified professional midwives from across the United States and two Canadian provinces registered 7623 women whose expected date of delivery was in 2000. Eighteen midwives (4.4%) and their clients were excluded from the study because they failed to actively participate and had decided not to recertify. Sixty mothers (0.8%) declined to participate. (See bmj.com for the screening choices of women through the study.)

We focused on the 5418 women who intended to deliver at home at the start of labour. These women were on average older, of a lower socioeconomic status and higher educational achievement, and less likely to be African-American or Hispanic than full gestation, vertex, singleton hospital births in the US in 2000 (see bmj.com). Of the 5418 women, 655(12.1%) were transferred to hospital intrapartum or post partum (table 1). Five out of every six women transferred (83.4%) were transferred before delivery, half (51.2%) for failure to progress, pain relief, and/or exhaustion. After delivery, 1.3% of mothers and 0.7% of newborns were transferred to hospital, most commonly for maternal haemorrhage (0.6% of total births), retained placenta (0.5%), or respiratory problems in the newborn (0.6%). The midwife considered the transfer urgent in 3.4% of cases. Transfers were four times as common among primiparous women (25.1%) as among multiparous women (6.3%).

Individual rates of medical intervention for home births were consistently less than half those in hospital, whether compared with a relatively low risk group (singleton, vertex, 37 weeks or more gestation) that will have a small percentage of higher risk births or the general population having hospital births (table 2). Compared with the relatively low risk hospital group, intended home births were associated with lower rates of medical interventions. The caesarean rate for intended home births was 8.3% among primiparous women and 1.6% among multiparous women.

No maternal deaths occurred. Excluding three babies with fatal birth defects, five deaths were intrapartum and six occurred during the neonatal period (2.0 deaths per 1000 intended home births; see bmj.com). Excluding planned breeches and twins (not considered low risk), intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births.

Breech and multiple births at home are controversial among home birth practitioners. Among the 80 planned breeches at home there were two deaths and none among the 13 sets of twins. In the 694 births (12.8%) in which the baby was born under water, there was one intrapartum death (birth at 41 weeks, five days) and one fatal birth defect death.

Apgar scores were reported for 94.5% of babies; 1.3% had Apgar scores below 7 at five minutes. Immediate neonatal complications were reported for 226 newborns (4.2% of intended home births).

Health problems in the six weeks post partum were reported for 7% of newborns. Among the 5200 (96.0%) mothers who returned for the six week postnatal visit, 98.3% of babies and 98.4% of mothers had good health, and no residual health problems were reported. Among the stratified, random 10% sample of women contacted directly by study staff to validate birth outcomes, no new transfers to hospital during or after the birth were reported and no new stillbirths or neonatal deaths were uncovered. Mothers' satisfaction with care was high for all 11 measures, with over 97% reporting that they were extremely or very satisfied.

Discussion

Women who intend at the start of labour to have a home birth with a certified professional midwife had a low rate of intrapartum and neonatal mortality, similar to that in most studies of low risk hospital births in North America. A high degree of safety and maternal satisfaction were reported, and over 87% of mothers and neonates did not require transfer to hospital.

A randomised controlled trial would be the best way to tackle selection bias of mothers who plan a home birth, but a randomised controlled trial in North America would be unfeasible. Prospective cohort studies remain the most comprehensive instruments available.

Our results for intrapartum and neonatal mortality are consistent with most other North American studies of intended births out of hospital and studies of low risk hospital birth (see bmj.com). A metaanalysis8 and research in several countries,1 9 10-12 have reinforced support of home birth. Researchers reported high overall perinatal mortality in a study of home birth in Australia, 13 qualifying that low risk home births in Australia had good outcomes but that high risk births gave rise to a high rate of avoidable death at home. Two prospective studies in North America found positive outcomes for home birth,14 15 but the studies were not of sufficient size to provide stable perinatal death rates. None of this evidence, including ours, is consistent with a study in Washington State based on birth certificates.16 That study reported an increased risk with home birth but lacked an explicit indication of planned place of birth, creating the potential inclusion of high risk unplanned, unattended home births.17 18

Our study has several strengths. Internationally, it is the largest of the few prospective studies of home birth done to date. We accurately identified births planned at home at the start of labour and included independent verification of birth outcomes for a sample of 534 planned home births. We obtained data from almost 400 midwives from across the continent.

Regardless of methodology, residual confounding of comparisons between home and hospital births will always be a possibility. Women choosing home birth may differ for unmeasured variables from women choosing hospital birth. On the other hand, women who choose hospital birth may have a psychological advantage in North America associated with not having to deal with social pressures on their choice of birth place.

Our results may be generalisable to a larger community of direct entry midwives. The North American Registry of Midwives was created in 1987 to develop the certified professional midwife credential—a route for formal certification for midwives involved in home birth who were not nurse midwives and who came from diverse educational backgrounds. Thus the women who chose to become certified professional midwives were a subset of the larger community of direct entry midwives in North America whose diverse educational backgrounds and midwifery practice were similar to certified professional midwives. From 1993 to 1999, using an earlier iteration of the data form, we collected largely retrospective data on a voluntary basis mainly from direct entry midwives involved with home births approached through the Midwives Alliance of North America Statistics and Research Committee and the Canadian Midwives Statistics' Collaboration. This unpublished data of over 11 000 planned home births showed similar rates of intervention, transfers to hospital, and adverse outcomes.

Our main limitation was the inability to develop a workable design from which to collect a national prospective low risk group of hospital births to compare morbidity and mortality directly. Forms for vital statistics do not reliably collect the information on medical risk factors required to create a retrospective hospital birth group of precisely comparable low risk,19-21 and hospital discharge summary records for all births are not nationally accessible for sampling.

One exception, and an important adjunct to our study, was Schlenzka's study in California. The author was able to establish a large defined retrospective cohort of planned home and hospital births with similar low risk profiles because birth and death certificates in California include intended place of birth and these had been linked to hospital discharge abstracts for 1989-90 for a caesarean section study. When the author compared 3385 planned home births with 806 402 low risk hospital births, he consistently found a non-significantly lower perinatal mortality in the home birth group.

What is already known on this topic

Planned home births for low risk women in high resource countries where midwifery is well integrated into the healthcare system are associated with similar safety as low risk hospital births

Midwives involved with home births are not well integrated into the healthcare system in the United States

Evidence on safety of such home births is limited

What this study adds

Planned home births with certified professional midwives in the United States had similar rates of intrapartum and neonatal mortality to those of low risk hospital births

Medical intervention rates for planned home births were lower than for planned low risk hospital births

An economic analysis found that an uncomplicated vaginal birth in hospital in the United States cost on average three times as much as a similar birth at home with a midwife.22 Our study of certified professional midwives suggests that they achieve good outcomes among low risk women without routine use of expensive hospital interventions. This evidence supports the American Public Health Association's recommendation3 to increase access to out of hospital maternity care services with direct entry midwives in the United States.