Welcome to module 11

The comprehensive module on Conditions Affecting Pregnancy.

In this module, we will explore various physiological changes and common medical conditions that can arise during pregnancy. By understanding these conditions, birth attendants can provide informed support and guidance to expectant mothers, ensuring a safe and healthy pregnancy journey.

This module will be broken down into 3 sections. Firstly looking at rhesus factors and Anti-D, followed by an insight into gestational diabetes and finally exploring the various physiological changes in pregnancy and their possible side effects

Section 1: Rhesus Factor

In this section we will explore what is rhesus factor?, why it can be important in pregnancy, what is Anti-D?, why it may be recommended for some pregnant women and why some women choose not to have it.

So firstly what is rhesus factor?

Rhesus Factor in Pregnancy:

The Rhesus factor, or Rh factor, is a protein that can be present on the surface of red blood cells. The two main types of Rh factors are Rh-positive (Rh+) and Rh-negative (Rh-). The majority of people have Rh-positive blood, but around 15% of the global population is Rh-negative.

Significance of Rhesus Factor in Pregnancy:

The significance of the Rh factor becomes crucial during pregnancy when the mother and baby may have different Rh statuses. Problems can arise when an Rh-negative mother is carrying an Rh-positive baby. If the baby's Rh-positive blood comes into contact with the mother's Rh-negative blood, the mother's immune system may produce antibodies against the Rh factor. This immune response is known as Rh sensitization.

Rh Incompatibility and Haemolytic Disease of the Newborn (HDN):

Rh incompatibility poses a risk for the development of Haemolytic Disease of the Newborn (HDN). If the mother becomes sensitized to Rh-positive blood, her antibodies can cross the placenta and attack the baby's red blood cells. This can lead to a condition where the baby's red blood cells are destroyed faster than the body can replace them, causing anemia and other complications.

Anti-D Antibodies:

As a response to Rh sensitization, the mother's immune system produces antibodies called Anti-D antibodies. These antibodies can affect the baby's blood cells and contribute to HDN.

Prevention with Rhogam (Anti-D Immune Globulin):

To prevent Rh sensitization and the potential complications associated with it, a medication called Rhogam, or Anti-D immune globulin, is administered. Rhogam works by preventing the mother's immune system from producing antibodies against the Rh factor. It is typically given to Rh-negative pregnant women around the 28th week of pregnancy and again within 72 hours after the birth of an Rh-positive baby.

Ongoing Management:

For subsequent pregnancies, the Rh status of the mother is closely monitored. If the mother has been sensitized in a previous pregnancy, additional interventions and monitoring may be necessary to ensure the health of the baby.

In summary, understanding the Rhesus factor and the potential for Rh incompatibility is crucial during pregnancy. Timely screening, administration of Rhogam when necessary, and ongoing monitoring are essential components of managing Rh-negative pregnancies to prevent complications associated with Rh sensitization and HDN.

Is Anti-D a blood product?

Anti-D, also known as Rhogam or Rh immunoglobulin, is a blood product. It is derived from human plasma and contains antibodies against the Rhesus (Rh) factor. Rh immunoglobulin is specifically composed of anti-D antibodies, and it is used to prevent Rh sensitization in Rh-negative individuals, particularly during pregnancy and certain medical procedures.

The antibodies in Anti-D are obtained from the plasma of individuals who have been previously immunized to the Rh factor. The plasma undergoes a careful screening and purification process to ensure its safety and effectiveness. The Anti-D product is then administered to Rh-negative individuals to neutralize any Rh-positive red blood cells that may have entered their bloodstream, preventing the development of an immune response and subsequent sensitization.

Given its origin and purpose, Anti-D is classified as a blood-derived product and is subject to rigorous screening, testing, and processing to meet strict safety standards. Healthcare professionals administer Anti-D in specific situations to prevent Rh-related complications, such as haemolytic disease of the newborn (HDN), in pregnancies where there is Rh incompatibility between the mother and the fetus. Always consult with a healthcare professional for more information about the use of Anti-D in individual cases.

In recent times more and more women are seeking to decline blood products and derivatives during their pregnancy. As with all interventions the choice to receive Anti-D is totally up to the woman herself but it is important she has correct information to make a truly informed decision. For women who are Rh- and wish to learn more about Anti-D and her options; and for birth workers seeking to become more informed on the topic in order to assist and signpost their clients, I can strongly recommend reading Dr. Sara Wickham's book, Anti-D explained https://www.sarawickham.com/anti-d/

Sara’s book explains the science behind this area, the history of Anti-D and the research studies that have been carried out to evaluate its effectiveness. She looks at the wider consequences and side effects. Sara takes the reader on a journey through the research, explaining what we know and highlighting the gaps in our knowledge.

Preventive Measures (Holistic)

Allow the umbilical cord to pulse naturally and do not clamp cord. If cord is clamped there is only one place for the blood to go and that is back to the mother.

Section 2: Diabetes Mellitus and Gestational Diabetes

Understanding Diabetes Diabetes mellitus is a chronic metabolic disorder characterised by high blood glucose levels. There are different types of diabetes, including Type 1 (autoimmune), Type 2 (insulin resistance), and gestational diabetes. Diabetes can impact pregnancy and require careful management to ensure the health of both the mother and baby.

Gestational Diabetes Gestational diabetes occurs during pregnancy and is characterized by high blood sugar levels that develop or are first recognized during gestation. Risk factors include obesity, family history of diabetes, and certain ethnic backgrounds. Gestational diabetes can increase the risk of complications for both mother and baby, including preeclampsia and large birth weight (macrosomia).

Before we look at the ins and outs of gestational diabetes, let’s first examine what happens in a non pregnant body when diabetes occurs.

When we consume carbohydrates and sugars, enzymes play a crucial role in breaking down the food into simple sugars. Some of these sugars are digested and immediately utilised for energy, while others are stored for later use. The primary sugar, glucose, enters the tissue cells and combines with oxygen, resulting in the production of carbon dioxide and water. The energy released from this chemical reaction is essential for various bodily functions, including muscular work and maintaining body temperature. Insulin, a hormone produced by the pancreas, facilitates the transport of glucose across cell walls.

Diabetes is often simplistically associated with a lack of insulin, but according to Foster in Harrison’s Principles of Internal Medicine, the term diabetes encompasses various syndromes. One of these syndromes is diabetes mellitus, characterised by symptoms such as sugar in the urine, excessive thirst, frequent urination, increased food intake, and elevated blood sugar levels. Diabetes mellitus is typically diagnosed based on persistent high fasting plasma glucose levels.

The symptoms of diabetes mellitus are linked to three main physiological conditions: lack of insulin, elevated glucose production, or insulin resistance. Each of these conditions can have multiple underlying causes. A deficiency of insulin may result from viral infections or a diet rich in unsaturated fatty acids, low in magnesium, and vitamin B-6, which can damage the pancreas and reduce insulin secretion.

Hyperglycemia, or elevated blood sugar levels, can be triggered by infections or the presence of epinephrine (adrenaline), estrogen, or steroids in the bloodstream. Stress from infections can lead to the secretion of epinephrine and cortisol, causing the liver to break down glycogen, increasing blood sugar levels. Hormones like estrogen, progesterone, and lactogen can also counteract the action of insulin and raise blood sugar. Steroids, on the other hand, stimulate the liver to produce more glucose from proteins and fats.

Insulin resistance, the third condition, can be caused by factors like obesity, physical inactivity, or inadequate carbohydrate intake. Obesity reduces the number of insulin receptors, which are necessary for insulin transport across cell walls. Physical inactivity or insufficient carbohydrate intake can lead to decreased carbohydrate tolerance and subsequent insulin resistance. In rare cases, unusual types of insulin secretion can also cause insulin resistance.

Genetic factors can also play a role in predisposing individuals to diabetes in response to the aforementioned influences. In such cases, as well as in some of the scenarios mentioned above, individuals with normal test results may be considered potential diabetics due to lifestyle, physical history, or family history.

In “gestational diabetes,” however, a pregnant woman shows test results similar to non-pregnant individuals with diabetes, despite having no symptoms of diabetes. It is important to note that this type of “diabetes” ceases after the pregnancy ends. However, clinical diabetes that is diagnosed during pregnancy and persists beyond the gestational period should not be classified as “gestational diabetes”.

Some practitioners question the existence of “gestational diabetes” because it is often diagnosed solely based on test responses. A non-symptomatic mother might exhibit elevated blood sugar levels due to various factors. For instance, the test itself, involving fasting followed by consuming concentrated glucose, may trigger chemical changes in her body that lead to increased blood sugar. Alternatively, her body may be responding naturally to the dynamics of pregnancy.

During pregnancy, blood sugar elevations can result from various factors. Additionally, the placenta releases hormones like lactogen, estrogen, and progesterone, which counteract the function of insulin and powerful enzymes that can destroy insulin. One might wonder if the placenta, an organ designed to sustain pregnancy and support the baby’s growth for nine months, consistently makes such an “error.”

It is crucial to understand that the pregnant body handles glucose differently. During pregnancy, the body may require “hyperglycemia” or higher blood sugar levels. This ensures that glucose remains in the bloodstream for longer periods, providing an easily available energy source for the developing baby’s growth and fat storage, in addition to being converted into glycogen and stored in the liver for future use.

Research by Tom Brewer, MD, indicates that well-nourished pregnant women can maintain stable plasma glucose levels and sufficient glycogen stores in the liver. On the other hand, poorly or marginally nourished women may have minimal or nonexistent glycogen stores, resulting in a decline in plasma glucose levels shortly after eating, until the next meal.

Another normal occurrence during pregnancy is a lowered renal threshold for glucose and other sugars. The kidneys filter a significant amount of filtrate from the blood daily, but during pregnancy, the renal threshold for sugar changes, leading to glucose being excreted in the urine at lower blood plasma levels.

This lowered renal threshold for glucose serves a purpose during pregnancy. When a woman is eating well, her blood volume increases significantly, resulting in increased blood flow through the kidneys and higher rates of fluid passing through capillary walls in the kidneys. As a consequence, certain substances may not get reabsorbed as efficiently as in non-pregnancy. For example, glucose may show up in the urine during pregnancy even though blood glucose levels are normal.

Discovering sugar in the urine during a prenatal visit does not necessarily indicate unhealthy plasma glucose levels. Approximately one-sixth of all pregnant women spill glucose in their urine, and glucose in the urine is present in 50 percent of all normal pregnancies, according to William’s Obstetrics and Evelyn Burns’ report on “Diabetes Mellitus and Pregnancy.”

Testing for GDM

When assessing glycosuria (the presence of glucose in the urine) during pregnancy, birth practitioners may opt for prenatal testing to rule out clinical diabetes or other concerning symptoms. Common testing options include the fasting blood sugar test, the one-hour glucose test, the two-hour postprandial blood sugar test, the random blood sugar test, the hemoglobin A1C test, and the glucose tolerance test (GTT). Some practitioners consider the two-hour postprandial and random blood sugar tests non standardised and prefer not to use them.

The fasting blood sugar test involves an eight- to 12-hour fast, followed by a blood sample to determine fasting blood sugar levels. The normal values vary depending on the practitioner’s philosophy.

For the one-hour glucose test, an eight- to 12-hour fast is followed by a preliminary blood sample. The mother is then given a “glucola” drink containing 50 grams of glucose, and another blood sample is taken after one hour. The upper limit of normalcy increases with age and during pregnancy.

An alternative approach to the one-hour glucose test, described in the winter 1987 issue of Midwifery Today, involves conducting the test at 24 to 28 weeks gestation without fasting. A value of 140 mg/100 ml or higher suggests “gestational diabetes.”

The long fasting period required by standardised tests can be problematic. Even well-nourished pregnant women can deplete their liver glycogen stores after 12 hours of fasting, leading to nausea. Pregnant women ideally should eat something every two to three hours.

The two-hour postprandial test requires blood sampling two hours after a meal. Normal test values range from <120 mg/100 ml to <140 mg/100 ml. Eating a generous breakfast is recommended instead of using glucola.

The random blood sugar test involves evaluating blood drawn at a random time of day, without fasting. Normal values range from about 100 mg/100 ml to 110 mg/100 ml.

The hemoglobin A1C test does not require fasting and provides an analysis of glucose levels over the previous 120 days. It is not influenced by recent food intake. Normal values range from 4 to 7 percent of total hemoglobin.

The glucose tolerance test (GTT) is considered the most definitive test for assessing glucose management. It requires an eight- to 12-hour fast, and multiple blood and urine samples are taken at different intervals after drinking concentrated glucose. However, the GTT has several drawbacks, including its accuracy being influenced by factors like diet, stress, and exercise.

The accuracy of the GTT has been questioned, with positive results being accurate only 25 percent of the time. Additionally, changes in glucose level standards have led to the potential misdiagnosis of “gestational diabetes” in well-nourished women with normal plasma glucose levels.

Overall, prenatal diabetic evaluation may not be entirely reliable, and there are limitations to the accuracy of certain testing methods.

Section 3: Physiological Changes in Pregnancy

Point 1: Heartburn Pregnant women may experience heartburn due to hormonal changes that relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus. Educate expectant mothers about dietary and lifestyle modifications to manage heartburn symptoms.

Point 2: Constipation Hormonal changes and the pressure of the growing uterus on the intestines can lead to constipation during pregnancy. Encourage women to maintain a high-fiber diet, stay hydrated, and engage in regular physical activity to alleviate constipation.

Point 3: Haemorrhoids Increased pressure on blood vessels around the rectal area can lead to hemorrhoids (swollen veins). Provide advice on maintaining proper bowel habits, using topical treatments, and promoting overall comfort for pregnant individuals.

Point 4: Varicose Veins Hormonal changes and increased blood volume can lead to varicose veins, particularly in the legs. Educate women about the importance of proper circulation, wearing compression stockings, and avoiding prolonged periods of standing.

Point 5: Vaginal Discharge Vaginal discharge often increases during pregnancy due to hormonal changes. Explain to expectant mothers that an increase in discharge is normal, but any significant change in color, odor, or consistency should be reported to a healthcare provider.

Point 6: Hyperpigmentation Hormones can cause areas of the skin to darken, such as the linea nigra (dark line on the abdomen) and chloasma (dark patches on the face). Inform women that hyperpigmentation is a common physiological change and usually resolves after pregnancy.

Point 7: Backache As the baby grows, the center of gravity shifts, leading to increased strain on the back muscles. Teach women about proper posture, exercises to strengthen the core and back muscles, and using supportive pillows.

Point 8: Symphysis Pubis Dysfunction (SPD) SPD is characterised by pain and discomfort in the pelvic region due to the relaxation of ligaments. Provide guidance on gentle exercises, using support belts, and avoiding activities that exacerbate SPD.

Point 9: Leg Cramps Muscle cramps in the legs can occur due to increased pressure on blood vessels and nerves. Educate women about staying hydrated, gentle stretching exercises, and avoiding pointing toes while stretching.

Point 10: Oedema Fluid retention, or edema, is common during pregnancy, especially in the hands, feet, and ankles. Teach women about proper hydration, avoiding prolonged sitting or standing, and elevating the legs to manage edema.

Point 11: Venereal Disease Educate expectant mothers about sexually transmitted infections (STIs) that can affect pregnancy, such as syphilis, gonorrhea, and herpes. Emphasize the importance of STI screening and safe sexual practices.

Point 12: Cholestasis Cholestasis of pregnancy is a liver disorder that can cause itching and elevated bile acid levels. Explain the symptoms, risks, and management strategies to ensure timely intervention.

Understanding Obstetric Cholestasis and Recent Research Implications

A recent systematic review and meta-analysis conducted by Ovadia et al (2019) sheds new light on obstetric cholestasis, also known as intrahepatic cholestasis of pregnancy (ICP). This study, published in The Lancet, provides valuable insights into managing this condition and its implications for pregnant individuals and birth attendants.

Obstetric Cholestasis and Adverse Outcomes: ICP has been associated with adverse pregnancy outcomes, including preterm birth and stillbirth. However, the severity of the condition and its correlation with adverse outcomes had not been thoroughly established. This led to varied recommendations for interventions, such as early induction of labor, without robust evidence to guide decision-making.

Key Findings from Ovadia et al (2019): The study by Ovadia et al now offers a clearer understanding of the risks associated with ICP. The research emphasises a specific threshold related to serum bile acid concentrations, marking the point at which the risk of stillbirth becomes significantly increased. The key finding states:

“The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 μmol/L or more. Most women with intrahepatic cholestasis of pregnancy have bile acids below this concentration, and they can be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is done until delivery.”

Implications for Practice: This research brings focus to a smaller subset of women who may be at greater risk due to elevated serum bile acid levels. Birth attendants can now make more informed decisions about intervention based on this evidence. However, it is important to note that while these findings provide valuable guidance, every individual's circumstances and preferences must be taken into account. The decision to intervene should be discussed thoroughly, considering the benefits and risks.

The Balance of Knowledge: The process of managing ICP highlights the delicate balance required in maternity care. Striking a balance between vigilance and intervention is essential. While some interventions are necessary and life-saving, unwarranted interventions can lead to adverse effects on both physical and emotional levels. The concept of balance is also applicable to the knowledge that guides decision-making. In maternity care, decisions are often based on partial knowledge from various sources, including research and expert opinion.

The Importance of Humility: The study underscores the importance of humility in maternity care. Admitting uncertainty and acknowledging that there's much we don't know is essential. Experts and professionals must recognise that, despite societal expectations, "we don't know" is a valid and common response in maternity care encounters. The complexity of balancing interventions, research, and expert opinions highlights the need for clear thinking and continuous research.

In summary, the systematic review by Ovadia et al (2019) contributes significant insights into managing obstetric cholestasis. Birth attendants and pregnant individuals can use this knowledge to make well-informed decisions that prioritize both maternal and fetal well-being. The study also serves as a reminder of the balance between intervention and natural progression, and the importance of humility in the ever-evolving field of maternity care.

Point 13: Hypertension Potential risks of hypertension during pregnancy, including preeclampsia.

During pregnancy, one of the crucial roles of the body is to support the pregnancy and nourish the developing baby. The body’s effectiveness in achieving this largely depends on its ability to increase the mother’s blood volume. Typically, the blood volume is expected to increase by 50-60% throughout the pregnancy.

To facilitate this blood volume expansion, the liver produces a substance called albumin, which has properties similar to egg whites. When present in the mother’s bloodstream, albumin generates osmotic pressure, helping to draw excess fluid from her tissues back into her blood vessels. However, the liver can only produce albumin from protein that the mother consumes.

A key issue arises when pregnant women try to limit their weight gain to conform to an “ideal” number by following high protein but low-calorie diets. In such cases, much of the protein intake is used for energy, leading to a deficiency in albumin production. Dr. Brewer’s research indicates that when a woman consumes around 1/3 less than the recommended 2600 calories, approximately 1700 calories, half of the protein she ingests will be burned for energy. Consequently, only 60 out of her 120 grams of protein would be available for albumin production, along with the development of baby cells and uterine muscle cells. This deficiency in albumin can likely hinder her ability to adequately expand her blood volume during pregnancy.

Salt also plays a role in osmotic pressure, aiding in the removal of excess fluid from tissues and promoting circulation. While limiting salt intake may be beneficial for pregnant women with underlying heart or kidney conditions, it can be risky for healthy women. Generally, a healthy woman’s taste buds serve as an accurate indicator of her salt needs, and research suggests that it is unlikely for a healthy pregnant woman to consume excessive salt. Her kidneys naturally eliminate any extra salt she ingests. Moreover, studies have demonstrated that after only two weeks of practicing “salt in moderation,” a decrease in the mother’s blood volume occurs.

When the blood volume stops increasing or decreases during pregnancy, the body’s response mechanism can be mistaken. Instead of recognising that the mother is consuming less food, it interprets the decreased blood volume as a potential haemorrhage situation. As a result, the body initiates processes similar to those used during actual haemorrhages. The kidneys release an enzyme called renin, causing the blood vessels to constrict. This natural response, useful during haemorrhage to redirect blood to vital organs, leads to an increase in blood pressure during pregnancy.

Trying to address this rising blood pressure by restricting salt or weight only exacerbates the situation. It further reduces blood volume, leading to more renin production and additional blood vessel constriction, resulting in further elevation of blood pressure.

Concurrently, the kidneys strive to augment blood volume by reabsorbing as much water and salt as possible from the filtered fluid. However, due to insufficient albumin and salt in circulation to hold the reabsorbed water, much of it leaks into the tissues. This process leads to rapid swelling in the ankles and rapid weight gain as the excess water accumulates in the mother’s tissues.

The pregnant woman seeks medical attention from her birth attendant, who diagnoses her with developing pre-eclampsia. If her nutritional status is not promptly improved, her blood volume will continue to decrease, and she may progress to eclampsia (toxemia). Toxemia can have severe consequences, including convulsions, coma, and even death. Some sources claim that the cause of toxemia remains unknown, leading many practitioners to address the symptoms without success. As a result, the symptoms persist, and the mother may experience a series of complications.

Treating Pre-eclampsia and Optimising Diet during Pregnancy

To address pre-eclampsia, one effective approach is to educate the mother about the underlying cause and encourage her to follow the Brewer Diet plan. The Brewer Diet recommends regular intake of protein-rich foods throughout the day, with the goal of consuming something containing protein every waking hour. This approach helps in maintaining adequate blood volume and supporting the pregnancy.

In cases where a more immediate response is required, the birth attendant may administer albumin intravenously to boost blood volume. Antibiotics may also be prescribed to reduce the burden on the liver from aromatic toxins present in the intestines. A story is shared of a woman who, unable to receive IV albumin, managed to lower her blood pressure by consuming a substantial amount of protein-rich foods, like 52 eggs and 6 quarts of milk, over three days.

Anne Frye recommends a tailored approach to protein intake, depending on the individual’s health history and pregnancy circumstances. For instance, if the woman has a history of liver disorders, a more cautious approach to protein intake is advised to avoid overwhelming the liver. Monitoring the mother’s lab work closely for changes is essential in such cases.

It is important to note that certain mainstream obstetric and perinatology practices, including anti-hypertensive drugs, may have adverse effects on the mother’s blood volume and liver function. Liver compromise can hinder the production of sufficient albumin required to support blood volume expansion during pregnancy, and it can also affect the body’s clotting mechanisms.

To prevent or manage rising blood pressure, edema, pre-eclampsia, IUGR (Intrauterine Growth Restriction), premature labor, or HELLP syndrome, a Brewer Diet counselor can work closely with the mother to assess her lifestyle and diet for potential adjustments. For instance, if the mother experiences salt and calorie losses, she can reduce exercise, work hours, and exposure to heat while increasing salt, calorie, and protein intake.

In specific situations, it is advisable to increase diet intake by adding 200 calories and 20 grams of protein. These situations include vomiting beyond the third month of pregnancy, pregnancies spaced less than a year apart, a previous pregnancy with adverse outcomes (low birth weight, neurologically handicapped, or stillborn child), a history of recurrent miscarriages or toxemia, failure to gain ten pounds by the twentieth week of pregnancy, serious emotional problems, working full-time at a demanding job, breastfeeding an older baby during pregnancy, and multiple pregnancies (twins or more).

References – The Complete Pregnancy Diet: Meeting Your Special Needs” from the book “Eating for Two” by Isaac Cronin and Gail Sforza Brewer

http://www.drbrewerpregnancydiet.com/id36.html

Point 14: Polyhydramnios/Oligohydramnios:

During pregnancy, the amount of amniotic fluid surrounding the developing baby in the uterus plays a crucial role in maintaining a healthy environment for fetal growth and development. However, when there are deviations from the normal levels of amniotic fluid, it can lead to conditions known as polyhydramnios and oligohydramnios. Regular prenatal check-ups to monitor amniotic fluid levels are essential for ensuring the well-being of both the mother and the baby.

Polyhydramnios (Excess Amniotic Fluid): Polyhydramnios occurs when there is an excessive accumulation of amniotic fluid within the amniotic sac. This condition can be caused by various factors, including maternal diabetes, fetal anomalies affecting the baby's ability to swallow, and multiple pregnancies (twins, triplets, etc.). In some cases, the exact cause remains unknown.

Implications for Pregnancy and Birth:While mild cases of polyhydramnios may not cause significant issues, more severe cases can lead to discomfort for the mother, as well as potential complications for both the mother and the baby. Complications can include preterm labor, premature rupture of membranes, and placental abruption. The excess fluid can also increase the risk of umbilical cord prolapse during labor and delivery.

Oligohydramnios (Low Amniotic Fluid): Oligohydramnios occurs when there is an insufficient amount of amniotic fluid surrounding the baby. This condition can result from various factors, including problems with fetal kidney function, post-term pregnancy, placental insufficiency, or ruptured membranes.

Implications for Pregnancy and Birth: Oligohydramnios can have serious implications for both the baby and the mother. Reduced amniotic fluid levels can hinder the baby's lung and musculoskeletal development. It can also lead to conditions like fetal growth restriction, umbilical cord compression, and an increased risk of meconium aspiration syndrome. For the mother, it can result in issues such as placental abruption and the potential need for induction of labour.

Point 15: Fetal Growth Restriction

Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR), is a condition where a developing baby's growth is slower than expected for their gestational age.

When reading the below points, please always keep in mind the importance of blood volume expansion which is seldom discussed within mainstream maternity care. Would these conditions arise if blood volume was optimal and mother was eating enough protein?

Causes of Fetal Growth Restriction: FGR can result from a variety of factors, including:

Maternal Factors: Chronic medical conditions such as hypertension, diabetes, kidney disease, and autoimmune disorders can affect placental function and nutrient supply to the fetus.
Placental Insufficiency: Poor placental blood flow can restrict the delivery of oxygen and nutrients to the fetus, impacting its growth.
Smoking and Substance Use: Maternal smoking and substance abuse can constrict blood vessels and limit fetal growth.
Multiple Pregnancies: Twins or higher-order multiples may experience competition for nutrients and space, leading to growth restriction.
Uterine Abnormalities: Anomalies in the uterus can limit the baby's space to grow.

Monitoring for FGR:Regular prenatal care and monitoring are essential to identify FGR early. Birth attendants can consider the following approaches:

Ultrasound: Regular ultrasound assessments can measure the baby's growth, assess amniotic fluid levels, and evaluate placental health.
Fundal Height Measurement: Measuring the distance from the top of the uterus to the pubic bone can help track fetal growth.
Doppler Blood Flow Studies: Doppler ultrasound can evaluate blood flow in the umbilical cord and other fetal vessels, providing insights into placental function.

Management and Care: When FGR is detected, appropriate management is crucial to ensure the well-being of both the mother and the baby:

Close Monitoring: Increased frequency of prenatal visits allows birth attendants to closely monitor fetal well-being and maternal health.
Nutritional Support: Encourage a balanced diet rich in nutrients, as well as adequate hydration, to support optimal fetal growth.
Rest and Reduced Stress: Advising the pregnant person to reduce stress and get sufficient rest can enhance blood flow to the placenta and improve fetal growth.
Induction of Labour: In severe cases, when the risks of continuing the pregnancy outweigh the benefits, birth attendants may recommend induction of labor or cesarean delivery.
Hospital Care: If FGR is severe or if complications arise, hospitalization may be necessary for closer monitoring and management.
Consultation with Specialists: Collaborate with maternal-fetal medicine specialists and neonatologists to ensure a comprehensive approach to care.

Communication and Support: As birth attendants, clear communication with the pregnant woman and their family is essential. Explain the condition, its implications, and the recommended course of action. Offer emotional support, address concerns, and involve the pregnant person in decision-making.

Point 16: Group B Strep

Group B Streptococcus (GBS) colonisation is a common bacterial presence in the vaginal and rectal areas of some pregnant individuals. As birth attendants, it's essential to comprehend the implications of GBS colonisation on newborns, the testing procedures, preventive measures, and the significance of communicating GBS status with healthcare providers.

Impact on Newborns: GBS colonisation can pose a risk to newborns, particularly during childbirth. Babies exposed to GBS during delivery are susceptible to developing infections such as sepsis, pneumonia, and meningitis. These infections can lead to severe complications and even be life-threatening for newborns.

Testing for GBS:Routine testing for GBS colonisation is typically performed between the 35th and 37th week of pregnancy. Two common testing methods include:

Vaginal and Rectal Swabs: Samples are collected from both the vaginal and rectal areas and sent to a laboratory for analysis.
Enriched Culture Medium: A swab of the vaginal and rectal areas is placed in a special culture medium to encourage GBS growth, aiding detection.

Preventive Measures:Birth attendants and healthcare providers implement preventive measures to reduce the risk of GBS transmission to newborns:

Intrapartum Antibiotics: If GBS colonisation is identified, intravenous antibiotics are administered during labor to reduce the likelihood of transmitting the bacteria to the newborn.
Intrapartum Testing: If the GBS status is unknown, intrapartum testing can be performed to guide the decision for antibiotic administration.

Natural ways to treat: The following is anecdotal information from traditional granny midwives. We cannot fact check this information as lack of studies prevent us from observing data.

The Herbal protocol that is recommended is as follows (it works for GBS, trichamonas, or Chlamydia):

It is important to learn how to douche properly as to not harm anything inside of you.

The bathtub with a towel to lie on is a good place to do a douche. You can put some pillows under your hips to elevate them; this helps to pool the liquid inside as long as possible. Make sure the tip of the douche is NOT inserted into the cervix. Undo the douche clip, if using a douche bag, until the air is out of the line and reclip it.

Insert the tip just barely into the vaginal opening, as you slowly let the fluid out, you should hold your labia (vaginal lips) closed with the fingers of one hand around the tip of the bag or bottle. This allows the vaginal tissues to expand and the fluid to wash over all the mucosa (mucus membranes inside). As you hold this area closed, your vaginal mucosa will balloon out. Some of the fluid will run out anyway, but keeping as much in as possible for at least a few minutes is recommended.

A peri-squirt bottle can also be used to do this douching, doing it in the same manner as described above.

Making the douche and using it as described above:

Add 2 Tablespoons Hibicens to 20 oz of temped water add to peri- bottle and douche as above using once every 6 hours after labor has begun.
Add ½ teaspoon goldenseal tincture to 2 cups temped water add to your douche bag or peri-bottle use once per day for 1 week, do this a week or so before labor begins.
Add ¼ cup cider vinegar to 16 oz temped water add this to your douche bottle or peri-bottle and use once per day for 1 week, do this a week or so before labor begins.
Add 3 tablespoons hydrogen peroxide to 20 oz temped water add this to your peri-bottle and use once per day for 1 week, doing a week or so before labor begins.

Herbs to use to insert into the vaginal opening at bed time beginning at 36 weeks:

2 gelatin capsules of Lactobacillus do for 1-2 weeks, or til labor has begun.
2 gelatin capsules of Garlic do for 1-2 weeks, or til labor has begun.
1 clove peeled, un-nicked Garlic every other night, remove in morning.
Tea Tree oil cotton ball or small cotton tampon with 50-50 blend of tea tree oil and olive oil every other night removed in morning. (25-75 blend may be used if 50-50 seems to irritating).
2 drops of each Lemon, Oregano, & Mountain Savory essential oil that have been mixed and placed into a gelatin capsule, for 1-2 weeks.

Herbs to use orally during this time beginning at 36 weeks:

2 gelatin capsules of Oregon Grape Root 2 times per day for 2 weeks.
Bee Propolis 4 times daily, (if you have allergies start off very slowly) for 2-4 weeks.
2 cups Echinacea tea daily for 2 weeks.
Vitamin C 500 mg every 4 waking hours for 2-3 days.
6 capsule of EHB daily for 10 days.
½ teaspoon Echinacea & Astragalus tinctures 2 times daily.
Finally chopped raw, fresh Garlic clove add to 1 teaspoon Honey & swallow without chewing it. Use with each meal.

Herbs that can be taken the duration of your pregnancy:

3 Acidophilus capsules 4 times per day.
4 capsules Garlic 4 times per day.
1 teaspoon Colloidal Silver 3 times daily.
1-2 capsules Maga-Dophilus with each meal each day of your pregnancy.
Garlic Elixir; ½ cup Honey, ¼ cup Apple Cider Vinegar, ½ bulb (approx. 6 cloves) raw Garlic. Mix in blender til liquidy. Use ½ teaspoon 2 times daily.

Being careful how you wipe yourself after each bathroom use, always wiping from front to back to keep that bacteria away from the vagina.

Having your husband insert himself carefully into your vagina as to not wipe across your rectum area before entering vagina. Never let him enter your rectum.

Eating only well cooked meats, nothing that still has blood or very pink color to it.

Reduce the vaginal colonization by correcting the vaginal pH balance.

Any thing that you can do to boost your immune system and fight off infection will help you.

.

Point 17: Anaemia and Iron Deficiency

Anemia and iron deficiency are common concerns during pregnancy, posing potential health risks for both the pregnant individual and the developing fetus. As birth attendants, it's crucial to comprehend the significance of these conditions, the associated health issues, and the importance of preventive measures.

Significance of Anemia and Iron Deficiency:Anemia refers to a decrease in the number of red blood cells or a decrease in the amount of hemoglobin in the blood. Iron deficiency is a common cause of anemia. During pregnancy, the body's demand for iron increases significantly to support the growing fetus and placenta. If this increased demand is not met, it can lead to anemia and its associated health issues.

Impact on Health:Anemia and iron deficiency during pregnancy can lead to:

Fatigue and Weakness: Reduced oxygen-carrying capacity of the blood can result in feelings of tiredness, weakness, and overall fatigue. Women often report shortness of breathe and a racing heart.
Reduced Immune Function: Anemia can weaken the immune system, making pregnant individuals more susceptible to infections.
Complications for Fetus: Iron deficiency anemia may lead to preterm birth, low birth weight, and developmental delays in the fetus.

Preventive Measures: To prevent anemia and iron deficiency during pregnancy, birth attendants should emphasize the following measures:

Iron-Rich Diet: Encourage pregnant individuals to consume iron-rich foods such as lean meats, poultry, fish, beans, lentils, leafy greens, fortified cereals, and dried fruits.
Prenatal Supplements: Recommend prenatal vitamins containing iron as per healthcare provider's guidance to ensure adequate iron intake.
Vitamin C Intake: Suggest combining iron-rich foods with sources of vitamin C, like citrus fruits and bell peppers, to enhance iron absorption.
Limiting Iron Inhibitors: Advise avoiding consuming iron inhibitors, such as coffee, tea, and calcium-rich foods, with iron-rich meals.

Regular Blood Tests:Regular blood tests, particularly the measurement of hemoglobin and ferritin levels, are essential during prenatal care. These tests help identify early signs of anemia or iron deficiency, allowing for timely intervention.

Natural remedy: One natural method to alleviate symptoms is very simple. Take a litre jug, fill it with dark grape juice and blend in a raw (organic) egg. Drink half one day, half the next. Wait one day and start the process again.

Dark Grape Juice:Dark grape juice is recogniSed for its potential health benefits due to its high content of antioxidants and nutrients. It's suggested that dark grape juice closely mimics about 99% of blood components, providing potential benefits for addressing anemia:

Resveratrol: Dark grape juice is rich in resveratrol, an antioxidant compound that has been linked to various health benefits. Resveratrol may help improve blood circulation and contribute to overall cardiovascular health.
Iron Content: While the iron content in dark grape juice may not be as significant as that in red meat or other iron-rich foods, its consumption can contribute to maintaining adequate iron levels.
Folic Acid: Dark grape juice contains folic acid, a B-vitamin that is essential for the production of red blood cells. Adequate folic acid intake is crucial for preventing certain types of anemia.

Combining Raw Egg and Dark Grape Juice:The combination of raw egg and dark grape juice is suggested to provide a unique array of nutrients that can potentially benefit individuals with anemia:

Synergistic Nutrient Intake: Raw eggs and dark grape juice together offer a blend of nutrients, including iron, vitamin B12, protein, resveratrol, and folic acid. These nutrients collectively support the body's ability to produce healthy red blood cells and address anemia.
Diverse Nutritional Approach: Incorporating different nutrient sources from raw eggs and dark grape juice can provide a diverse and comprehensive approach to addressing nutritional deficiencies associated with anemia.

Module 11 – Conditions Affecting Pregnancy

You must be logged in to access this course