Care during the Prenatal Period
Helping a woman stay healthy during pregnancy

Midwifery Today Conference March 2005

Gail Hart ©


PRENATAL CARE: is the art and science of helping a woman and baby through pregnancy.


The goal is to culminate with a healthy mother and healthy baby. Science and fact can help us achieve this goal. The problem is that not everyone sees the same facts -- or understands them in the same way. An agreement on facts can help us reach agreement and understanding, even if our philosophies differ widely. Midwives NEED to know the same facts which obs know. I think every midwife should be able to hold her own with any obstetrician on the subject of normal childbirth! Stand proud. We should learn the medical language -- facts, the definitions, and the buzzwords -- even if we would never use term with our clients or even if we disagree with them!


-- reaction to facts: seeing what’s there. Sometimes midwives and doctors overreact to certain facts - and under-react to subtle ones. We have to walk a careful balance . Is a problem really a problem -- is it only a “potential” problem. “Risk” does not equal "fact" - it only means potential. What is the real risk? Is it detectable preventable, beneficial to avoid -- does the treatment outweigh the risk, or the potential risk?


POINTS OF PRENATAL CARE


1. Is the woman healthy and is she likely to remain healthy? Does she have underlying problems; infections, malnutrition, anemia – or some uncommon but serious conditions like heart disease, diabetes, renal disease thyroid etc

how to know this?

  • (there is great value in a recent physical exam. In a perfect world, all pregnant women would have a complete physical about three months before they concieved)

  • complete family history

  • complete medical history

  • complete current history - symptoms.


(SIMPLE DETECTIVE WORK can discover most problems, or most potential problems. Sometimes things just come out of the blue, but they USUALLY are the end point on a long pathway. If we can discover the problem BEFORE it is serious, we might be able to still achieve a happy ending.


CHARTS

Charts can help us a lot especially in our early years.  Some people work off of a list - or you can ask the questions by 'category". Or more conversationally , as in “Tell me about yourself....Have you ever been in the hospital, ever had an operation, have you seen the doctor for any reason in the last five years?” etc.

Do what works best for you -- just make certain the questions are asked! (You are Sherlock Holmes on a detective mission! Ask those probing questions. Search out the facts!)

Ask about: personal history, gynecological  history, birth history, social history.

CHARTING – is a visual record of the FACTS of the course of the pregnancy. We gather each fact to help us Use your charts to help you “see” the pregnancy! (charts may also be a legal document or tool, but that’s a separate issue).


2. FIND OUT what’s wrong, but also find out what’s RIGHT! Reassurance and reduction of anxiety are also parts of prenatal care. Everything is a piece of the picture.   Wellness is a wide concept -- it includes social, emotional economic, generational, and even “national” health .


At every prenatal ask yourself:

  • what is “right” about this pregnancy (and TELL the woman - she needs to hear this)

  • is anything “wrong” here. (SHE MIGHT - OR might not, need to hear THIS).

  • is something different or unusual. (this might be good or it might be bad -- "unusual" is not necessarily "abnormal" -- and even "abnormal" might not be a bad thing. There is a huge range within the definition of normal.


CHARTING – is a visual record of the FACTS of the course of the pregnancy. Use your charts to help you “see” the pregnancy! We gather each fact to help us see the picture -- the clues - the pieces of the puzzle.


A STANDARD CHART begins with, at minimum:

  • history - personal and family

  • baselines – initial labwork (blood type, antibody screen, vdrls, hematocrit, hemoglobin)

  • pregnancy test date?

  • LMP. ASK QUESTIONS about the Last Menstrual Period -- was it normal? short, long. Are her periods regular? How SURE is she about that date? Is it just a guess?

  • EDD (estimated date of delivery). Taking extra time to confirm a due date now, will save you a lot of worry later on. (A large portion of babies thought to be postdate are simply babies who were conceived later than first thought). Can the woman remember ovulation symptoms and dates? ADJUST THE DUE DATE according to the woman’s OWN cycle history!

  • Weight – pre-pregnancy, and then on occasion during pregnancy to make sure she is gaining appropriately. 

  • blood pressure

  • pulse (for a baseline)

PRENATAL VISITS

Time according to what is usual in your community; usually monthly till 32 weeks then biweekly or weekly after 34.

Chart:

  • Date: (including year)

  • Weeks: wks (gestation according to lmp)

  • Fundal Height: FH, the height of the uterine fundus measured in centimeters above the woman’s pubic bone should equal roughly the weeks of gestation –within about 3 cms range. This measurement is useful ONLY AFTER 20 weeks. It is not accurate before that point, and is only a very rough guage afterwards. Consider it as a tool to measure consistent growth – IE 4 weeks equals 4 cms growth. (Traditional landmarks work better – but may be harder to quantify).

  • Blood pressure: BP. Many things can affect BP, especially the systolic measurement – anxiety, last meal, caffeine, smoking, position, talking etc. The BP normally ranges throughout the day. A rising BP may be a sign of pre-eclampsia.

  • Edema: ED. Almost all women have edema to some degree. It is normal in pregnancy, but note if it increases or if it is “above the waist”.

  • Urinalysis: UA. Many caregivers are doing “dipsticks” less routinely; testing for glucose or protein occasionally, or according to symptoms.

  • Fetal Heat Tones: FHT. (Or Fetal Heat Rate, or Baby’s Heart). Range, location, reactive?

  • Fetal Position

  • Your remarks: how is the woman feeling, how is the baby moving (ask!). Any questions, changes, worries?


ISSUES IN PRENATAL CARE


Fact: Most women do well in pregnancy. They carry their babies to term and their babies are born without problems.

 Most women do very well with “midwifery style” prenatal care. Every variety of childbirth practitioner collects the same data as we do. Our charts are very similar. We look for the same things, the same conditions. The philosophies are a bit different, but the greatest difference is in “style”. Midwifery style care is different – or should be different – from the hurried and impersonal care we’ve come to expect as “standard”.

Two of the common serious problems of prenatal care are PreTerm Birth and Pre-eclampsia. These conditions are sometimes linked – and they have similar causes – and they “can” be influenced to some extent by care in pregnancy.


Preterm Birth:

PTB is strongly  associated with – a low social/economic group, oppressed racial minority, tobacco use, drug abuse, long work hours, poor diet, stress, and low maternal weight gain. These factors compound each other – and they have similar solutions. Is has been said that prematurity is – at least to some extent – a societal disorder.


The solutions start with getting the mother as healthy as possible by providing nutrition counseling, stop/decrease smoking programs, and creating a greater feeling of client responsibility (empowerment = Putting the mother back in charge of her pregnancy!) I believe that one reason why midwifery statistics are generally superior is because of our prolonged prenatal visits. Most midwives spend an hour or more with their clients. The midwife is seen as a good listener, one who is interested in the woman herself and her situation, not just in the hard facts of her pregnancy. Midwives exhibit the best qualities of "the bed-side manner - now a long neglected medical skill.


From conception to motherhood is a nearly year long process. It is a physical, social, emotional and perhaps even spiritual event. And most women will need support and aid on all of these levels. EFFECTIVE prenatal care cannot be done in 5 or 10 minute visits! Our most effective tool to improve prenatal outcome is the time we give our clients during prenatal visits. Don’t skip on “caring”.


LONG and frequent prenatal visits are a primary effective "care" for preterm birth prevention; both to detect early labor when it truly begins and to reasure the woman about false alarms. .

Other solutions to prevent preterm birth are beyond midwife capabilities. A reduction of stress – higher wages so women don’t have to spend long hours at work, a realistic maternity leave program, adequate shelter, and food etc – would go a long ways towards preventing the rate of premature births. Perhaps midwives might advocate for society to address these issues? It was Women’s Social agitation which brought clean water, sewer systems, good schools, and community hospitals to this country. “The March of Dimes” – which conquered polio -- was a WOMAN’S march! The heath of pregnant women, their unborn babies, and their children IS A WOMAN’S ISSUE and I think it should be a primary political concern of all midwives.


Back to midwifery: Fight PreTermBirth!

Strive to help the woman reach optimal health:

  • Physically -- through healthy living, avoiding drugs and dangers

  • Nutritionally --- good diet, moderate protein, calories, HIGH in vitamin C, E, Bs, and adequate weight gain!

  • Emotionally – reduce stress, worry, and fear

  • Socially – MURDER AND ASSAULT are major causes of maternal mortality!

  • Vaginally – optimal vaginal health fights BV, yeast, and GBS


Diet:

The Cochrane database meta-analysis reports no evidence that protein supplementation (alone) in pregnancy improves outcome . Women who “increase protein levels”. WITHOUT ALSO INCREASING CALORIES AND FAT – show no benefit; and show some detrimental effects (an INCREASE in PIH and Preterm labor). iii But women who improve their diets by increasing a balance of protein and calories showe “a modest rise in maternal weight and a small rise in fetal weight”. They reduce their risk of small-for-dates babies by nearly half -- and three studies show a reduction in stillbirth and neonatal death as well.iii There is currently NO study showing effectiveness or any benefit of reduced-calorie or reduced-carbohydrate diets for “gestational diabetes or “impending macrosomia”. iv The limited research shows NO DIFFERENCE in the rate of babies over 4000 gms and no affect on cesarean rates. Women who gain less than 35 pounds in pregnancy are at increased risk of preterm birth and pre-eclampsia. Inadequate weight gain is the single most important risk factor for preterm birth!


Calcium Supplements: Supplementation with 2000 mg of calcium carbonate results in a modest reduction in pregnancy induced hypertension and in pre-eclampsia (a drop of about 25%). Those at highest risk of both conditions showed a major reduction in risk (from 60% to 80% decrease).There’s also a lower risk of babies with low birthweights. v (Other forms of calcium may be more effective, but haven’t been studied).



FATTY ACIDS, Linoleic acids, Butter, “Fish oils”

Supplementation with N3, N6 fatty acids may decrease prematurityvi . An accumulation of data is beginning to show that intake of “natural fats” – butter, dairy, and fish oils has a positive effect on fetal weight, and reduces both prematurity and posttmaturity rates. More importantly, these fats may have beneficial effects on the development of the fetal nervous system – but a high intake of synthetic poly-unsaturated fats may have subtle detrimental effects on the developing brain.vii Pregnant woman should be advised to avoid “synthetic fats” – shorting, margarine, salad oils – and use foods which contain“natural fats” like butter, olive oil, and ocean fish.



VITAMIN C

Supplementation with Vitamin C - or a substantial increase in vitamin C containing foods -- may help prevent many pregnancy complications! Research shows that in “women who develop pre-eclampsia, anti-oxidant activity is DECREASED, and this results in endothelial cell damage, which may trigger vasoconstriction” (pg 103 Essential Obstetrics and Gynecology. Symonds and symonds). viiiAlso, NO (nitric oxid) or Endotherlium-derived relaxing factor (EDRF) is a vasodilater and NO synthesis is reduced in Pre-eclampsia. Vitamin C increases NO productionix

W women who consume less than 85 mg (the current RDA is 60 for non-pregnant) have double the risk of pre-eclampsia. Women with less than half the RDA have a four fold risk!x Women at high risk of pre-eclampsia who took 1000 gms daily reduced their risk to one-fourth compared to high-risk women who took normal supplementsxi or placebo. Low vitamin C levels may be a marker for those at risk for PIH xii and several studies show high dose vitamin C may effectively TREAT severe pre-eclampsia xiii Women with low levels of vitamin C and beta-carateen have a higher risk of premature labor and of Premature rupture of membranes xiv

xv Some researchers suggest that women should consume three times the RDA of vit C, and ten times the RDA of vitamin Exvi to prevent PTB and PROM.

IRON

Iron supplements may increase the risk of pre-eclampsia and prematurity xvii. The normal hematocrit in pregnancy is a good deal lower than the non-pregnant hematocrit (A hemoglobin of 9.5 at term is “normal”). Iron supplements should be reserved for women who are truly anemic due to lack of iron. If treatment is advised, B complex, A, and C are generally effective.



i COCHRANE ONLINE REVIEW PROTEIN: .. trials provide no evidence of benefit on fetal growth; indeed, the adjusted mean difference in birth weight is -58.4 g. One trial also reported a non significantly increased risk of neonatal death with high-protein supplementation.

ii Isocaloric balanced protein supplementation in pregnancy (Cochrane Review)

Kramer MS

. The results suggest a decrease in maternal weight gain and mean birth weight and an increased risk of small-for-gestational-age (SGA) births with isocaloric protein supplementation, but no effect on mean gestational age or preterm birth. .

Citation: Kramer MS. Isocaloric balanced protein supplementation in pregnancy (Cochrane Review). In: The Cochrane Library, Issue 4 2002. Oxford: Update Software.

iii FROM COCHRANE REVIEW DIET AND PROTEIN

Citation: Kramer MS. Balanced protein/energy supplementation in pregnancy (Cochrane Review). In: The Cochrane Library, Issue 3 2002. Oxford: Update Software.

iv Dietary regulation for 'gestational diabetes'.
Walkinshaw SA.
Fetal Centre, Liverpool Women's Hospital NHS Trust, Crown Street, Liverpool, UK, L8 7SS. swalki@yahoo.com
. No differences were detected between primary dietary therapy and no primary dietary therapy for birthweight greater than 4000 grams (odds ratio 0.78, 95% confidence interval 0.45 to 1.35) or caesarean deliveries (odds ratio 0.97, 95% confidence interval 0.65 to 1.44).

v Citation: : Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems (Cochrane Review). In: The Cochrane Library, 1, 2002. Oxford: Update Software.

vi

Exp Biol Med (Maywood) 2001 Jun;226(6):498-506

The role of n-3 fatty acids in gestation and parturition.
Allen KG, Harris MA.

PMID: 11395920

vii Exp Biol Med (Maywood) 2001 Jun;226(6):498-506

The role of n-3 fatty acids in gestation and parturition.
Allen KG, Harris MA

viii Int J Gynaecol Obstet 1999 Feb;64(2):121-7

Impaired antioxidant activity in women with pre-eclampsia.
Sagol S, Ozkinay E, Ozsener S.

ix Redox Rep 2002;7(4):223-7

Lipoic acid and vitamin C potentiate nitric oxide synthesis in human aortic endothelial cells independently of cellular glutathione status. PMID: 12396668

x Epidemiology 2002 Jul;13(4):409-16 Vitamin C and the risk of preeclampsia--results from dietary questionnaire and plasma assay.
Zhang C, Williams MA, King IB, Dashow EE, Sorensen TK, Frederick IO, Thompson ML, Luthy DA.
After adjusting for maternal age, parity, prepregnancy body mass index, and energy intake, women who consumed <85 mg of vitamin C daily (below the recommended dietary allowance), as compared with others, experienced a doubling in preeclampsia risk (OR = 2.1; 95% CI = 1.1-3.9). The OR for extreme quartiles of plasma ascorbic acid (<42.5 vs > or = 63.3 micromol/liter) was 2.3 (95% CI = 1.1-4.6). Compared with women in the highest quartile, those with plasma ascorbic acid <34.6 micromol/liter (lowest decile) experienced a 3.8-fold increased risk of preeclampsia (95% CI = 1.7-8.8). CONCLUSIONS: Our results, if confirmed, would suggest that current public health efforts to increase intake of fruits and vegetables rich in vitamin C and other antioxidants m
ay reduce the risk of preeclampsia.
PMID: 12094095

xi Effect of antioxidants on the occurrence of pre-eclampsia in women at increased risk: a randomised trial.
Chappell LC, Seed PT, Briley AL, Kelly FJ, Lee R, Hunt BJ, Parmar K, Bewley SJ, Shennan AH, Steer PJ, Poston L

PMID: 10485722

xii Am J Obstet Gynecol 2002 Jul;187(1):127-36 longitudinal study of biochemical variables in women at risk of preeclampsia.
Chappell LC, Seed PT, Briley A, Kelly FJ, Hunt BJ, Charnock-Jones DS, Mallet AI, Poston L.
… Ascorbic acid was reduced early in preeclampsia and small-for-gestational-age pregnancies. Leptin, placenta growth factor, the plasminogen activator inhibitor (PAI-1)/PAI-2 ratio, and uric acid were predictive of the development of preeclampsia. CONCLUSION: Gestational profiles of several markers were abnormal in the group with preeclampsia, and some of the markers that may prove useful in the selective prediction of preeclampsia were identified.
PMID: 12114900

xiii Br J Obstet Gynaecol 1997 Jun;104(6):689-96 Antioxidants in the treatment of severe pre-eclampsia: an explanatory randomised controlled trial.
Gulmezoglu AM, Hofmeyr GJ, Oosthuisen MM.PMID: 9197872

xiv Int J Vitam Nutr Res 1994;64(3):192-7

Eotential role of ascorbic acid and beta-carotene in the prevention of preterm rupture of fetal membranes.
Barrett BM, Sowell A, Gunter E, Wang M.
PMID: 7814234

xv Biol Reprod 1998 Aug;59(2):326-9

Modulation of 72-kilodalton type IV collagenase (Matrix metalloproteinase-2) by ascorbic acid in cultured human amnion-derived cells. Pfeffer F, Casanueva E, Kamar J, Guerra A, Perichart O, Vadillo-Ortega F.
….. A low intake of vitamin C during pregnancy has been linked to a higher risk of premature rupture of the membranes (PROM) because of its well-known role in collagen biosynthesis. …PMID: 9687303

xvi Am J Obstet Gynecol 2001 Jul;185(1):5-10

  • Vitamins C and E: missing links in preventing preterm premature rupture of membranes?
    Woods JR Jr, Plessinger MA, Miller RK.PMID: 11483896

xvii Am J Obstet Gynecol 2002;187:412-418.

xix . Am J Obstet Gynecol 2002 Jul;187(1):137-44

Antimicrobial factors in the cervical mucus plug.
Hein M, Valore EV, Helmig RB, Uldbjerg N, Ganz T.
: Cervical mucus plugs were collected from healthy women at delivery…: Both intact cervical mucus plugs and their aqueous extracts exhibited antimicrobial activity against aerobic microbes, in the order of potency: group B Streptococcus > E coli > C albicans. CONCLUSION: The cervical mucus plug is not only a mechanical but also a chemical barrier to infection that ascends from the vagina. PMID: 12114901

xx OBSTETRICS; compendium, Gabbe, Neibyl, Simpson pg 603, 577

xxi Nutritional and antimicrobial interventions to prevent preterm birth: an overview of randomized controlled trials. AUTHORS: Villar J; Gulmezoglu AM; de Onis M AUTHOR AFFILIATION: UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland. SOURCE: Obstet Gynecol Surv 1998 Sep;53(9):575-85.

xxii Nutritional and antimicrobial interventions to prevent preterm birth: an overview of randomized controlled trials. AUTHORS: Villar J; Gulmezoglu AM; de Onis M AUTHOR AFFILIATION: UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland. SOURCE: Obstet Gynecol Surv 1998 Sep;53(9):575-85.


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