Naturopathic Doula Training Course

DR. JESSICA SANGIULIANO-DUPONT, ND

© Jessica Sangiuliano HELLO

¡ Doula since 2012; Naturopath since 2013 ¡ Course administrator since 2014 ¡ Practice focus is Women’s Health, Endocrinology, Fertility, Perinatal Care and Birth Services ¡ Attended over 200 births across the Dr. Jessica Dupont, ND & Birth Doula GTA (hospital, homebirth, birth center, midwives, OB/GYNs, water births, cesareans, etc.) ¡ Owner York Region Naturopathic Doulas ¡ www.yorkregiondoulas.com Course Goals

— You will: ¡ Learn to manage perinatal cases effectively utilizing proper assessment techniques, standard diagnostics, and treatment. ¡ Realize the importance of the spoken word as well as body language in affecting the outcome of a birth ¡ Have a good understanding of proper nutrition and supplementation during the childbearing year and beyond ¡ Learn useful, natural remedies for common perinatal concerns and issues that arise during labour/childbirth ¡ Be able to demonstrate various exercises, maneuvers, massage techniques, and acupressure points used in labour ¡ Be able to support a woman and her partner through pregnancy, a live birth and post-partum. ¡ And so much more… INTRODUCTION

MODULE 1: DOULA BASICS MODULE 2: PREGNANCY MODULE 3: LABOUR/BIRTH MODULE 4: POSTPARTUM MODULE 5: BUSINESS & CASES

MODULE 1

DOULA BASICS

DOULA: DOULA-ing: dou-la \ doo-la

“The act of , loving, “…a woman educatng experienced in respecting, listening, embracing, childbirth who advocating for, & assisting provides continuous a woman prenatally, during labour, physical, emotional childbirth & after, so that she may and informational support to the remember this experience in a mother before, positive way for the rest of her life” during and just after childbirth.”

Mothering the Mother by Klaus, Kennell & Klaus

Benefits of Doula-assisting labours

Benefits to Mother Benefits to Baby

— A more positive — Shorter hospital stays experience — Fewer admissions to — Fewer requests for interventions special care — Fewer C-sections — Easier breastfeeding — Reduced post-partum — More affectionate depression mothers post-partum — Quicker healing time — Fewer interventions — Shorter labour with less complications therefore less side effects How is a Naturopathic Doula different?

Combine the supportive efforts of a Doula with our ability to properly assess, diagnose, and treat utilizing our Naturopathic modalities.

Have the opportunity to see the client before the birth and assist with a healthy pregnancy via proper nutrition, supplementation, and preparation acupuncture. You also have the ability to use your Naturopathic treatments during the labour, as well as treat baby and mom post-partum. At this point, they are not only your Doula Client, but life- long Patients.

DONA certified Doulas: require many hours of experience before certification. DONA training alone does not train the attendees to use Naturopathic modalities; in fact, it is illegal for them to use these modalities unless they are also Naturopaths or Acupuncturists or Homeopathic Doctors and able to prescribe remedies within their scope. Choice, choices, choices…

OB/GYN - an OB/GYN is a medical doctor with a specialization in Women’s Health. They take over when a birthing situation becomes high risk, and can perform surgical procedures such as Cesarean, Vacuum and Forceps.

GENERAL PRACTITIONER – an MD is a medical doctor who also delivers babies. They can deliver babies when the labour is low-risk, but cannot perform high-risk procedures such as vacuum extraction or C-section.

MIDWIFE - Registered midwives are health professionals who provide primary care to women and their babies during pregnancy, labour, birth and the postpartum period. As primary care providers, midwives may be the first point of entry to maternity services, and are fully responsible for clinical decisions and the management of care within their scope of practice. Midwives provide the complete course of low-risk prenatal, intrapartum and postnatal care, including physical examinations, screening and diagnostic tests, the assessment of risk and abnormal conditions, and the conduct of normal vaginal deliveries. Midwives can deliver in hospital, home or birth center.

Midwife references: http://www.canadianmidwives.org/what-is-a-midwife.html, http://mana.org/ Hospital or Homebirth? Water birth? Positions? 100% Natural? Mostly natural with some interventions? Cesarean? Induction? ….

Midwives vs Family Physicians Where do you fit in?

Pregnancy – You can prescribe natural remedies for common pregnancy concerns; you can provide emotional support but shouldn’t counsel unless you have additional counsel training; you can do regular checkups and physical examinations (including fundal height and Leopold's Maneuver) but you are never to check cervical dilation or do cervical “stretch-and-sweeps”.

Birth – You are NOT the primary healthcare provider; this means that you are NOT to do temperature, heart rate, blood pressure, etc. during the labour at any time. You are also NOT to make any decisions for this client. You are there for physical and emotional support ONLY but you can still use acupuncture, homeopathy and other tools safely at this time as long as it is within your scope.

Postpartum – You can treat postpartum ailments with natural remedies within your scope. You can also assist with breastfeeding if you are comfortable. The client is still within the OBs or Midwives care for 6 weeks pp. After this time, they can choose to have you as their infants primary care provider.

HOME vs HOSPITAL

HOME BIRTH HOSPITAL BIRTH

— Any position, any room — A lot of waiting time — Choice of number of supporters — Limit of 2 support persons in the — Quiet and less interruptions room — Midwife — Emergency care readily available — STATS: moved to hospital for C-section — Higher risk of intervention or being 5.2% of the time sent home — More likely to breastfeed for longer period of time — Midwife/OB/MD — Familiar environment — STATS: Cesarean sections 8.1%

YOUR JOB IS TO: • Encourage your client to interview multiple healthcare providers • Inform them of their options and aid them in making an informed choice • Encourage good communication with their healthcare team and supporters to ensure that everyone is familiar with the Birth Plan.

Fearless Birth

• There is a direct correlation between a mother’s mindset and how her birth moves forward • Fear and anxieties will increase adrenaline and cortisol, leading to stalled labours (cases of labour stopping, or even reversing) • Tension in any muscles will cause tension in the uterus and cervix, causing more intense contractions and a longer labour due to a tense cervix.

Sphincter Law

• According to Sphincter Law, labours may not progress or stall because of fear, lack of privacy, humiliation, being self-conscious, emotional upset and stimulation of the wrong part of the brain. The Sphincters will close. • Just as the rectum and bladder need complete relaxation to function properly, as does the cervix and vagina. • They function best in an environment of intimacy and privacy • They do not respond well to demands such as “Push!” “Relax” “Harder” • The relaxation of the mouth and jaw is directly related to the opening of the cervix • Sing “Ooooh and Ahhhhs”

Reference: Ina May Gaskin Fear vs. Confidence

Fear during childbirth can cause: Confidence during labour brings:

Increased need (or give in) for medical Peace of mind interventions Smooth and easy labours Lack of trust in the process Understanding and making the right Indecision choices for you and baby

Increased “pain” Less unnecessary interventions

Slowed labour Relaxed muscles and therefore less intense contractions and faster Stalled Labour or Reversal “Failure to progression of labour Progress” Builds a strong bond right away Hormones in Labour

• Prostaglandins: soften and thin the cervix to prepare it for labour.

• Oxytocin: causes uterine contractions; when baby moves through the birth canal a sudden rise in oxytocin stimulates the “falling in love” connect between mom and baby

• Adrenaline: does the opposite of oxytocin. Secreted under fear and stress and stalls or slows labour progression.

• Endorphins: nature’s opiates; releases when we are warm, feeling loved and supported; block receptors of painà “orgasmic birth”

Uterine Physiology During Labour

During pregnancy, the cervix is thick and closed. As you approach the time of birth, your contractions draw the cervix up into the body of the uterus, and it becomes thinner (called effacement) and opens (called dilation). When the cervix is fully dilated (10cm), contractions help the baby begin to move from the uterus into the vagina.

Myometrium (2 layers) – forms a protective web Inner layer is circular and perpendicular to the long axis, spirals up around uterus (close the outlet) – sympathetic state (“fear”) Outer layer run parallel to the longitudinal axis (expulsive) – parasympathetic state (“relaxation”)

Releasing Fear

• Understand the natural process of labour: what to expect physically, emotionally and in the labour room • Trust your body • Identify fears and anxiety ahead of time and release • Identify areas of your life that could possibly serve as obstacles • What was your birth like? (ask your mother) • How are other people’s birth stories affecting you? • Previous labour experience? • Support? Relationship? • Experience of abuse? END OF MODULE 1 SUMMARY

• A doula is a woman experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during and just after childbirth. • Doula presence = shorter hospital stays, better breastfeeding outcomes, lower rates of cesarean and other interventions, lower risk of PPD, and short labours. • High risk pregnancies and high risk procedures are delivered/performed by OBs only. • There are 4 hormones crucial for childbirth: adrenaline, oxytocin, endorphins and prostaglandins • For the cervix to thin (efface) and open (dilate), a parasympathetic state is necessary. MODULE 2

PREGNANCY

PREGNANCY SUPPORT

• INITIAL CONSULTATION • DOULA SERVICES AGREEMENT • NUTRITION AND SUPPLEMENTATION • PRENATAL TESTING • INTERVENTIONS • BENEFITS OF NAT. MODALITIES • BIRTH PLAN • STAGES OF LABOUR AND EMOTIONAL CHALLENGES • ACUPUNCTURE (PREPARATION, HOLDING PREGNANCY, INDUCTION, CONTRAINDICATIONS) • HOMEOPATHIC INTAKE • BOTANICALS FOR COMMON AILMENTS • STRESS MANAGEMENT TECHNIQUES AND LABOUR PREPARATION Before meeting with client…

• Gather essential information: Patient Summary • 15 min. Meet & Greet • What are the mother’s requirements? • Send Doula Services Agreement (DSA) • Booking appointments: initial / birth / post-partum follow-up

Initial Consultation

DOULA SERVICES AGREEMENT (DSA)

At your first meeting, you should discuss your Doula Services agreement, and have it signed by both yourself and the client before end of visit. In addition a Consent form should be signed by both mother and partner.

A DSA should contain:

• Clearly outline your services (what you do, and what you don’t do) • What would happen in the event that the Doula fails to provide service? • Scheduled Cesarean Clause* • Fee schedule • Back up doula information

Initial Consultation

• Discuss medical history, previous pregnancy history, current pregnancy history, allergies, supplements/medications, etc..

• Perform a physical assessment including weight, cardiovascular exam, uterine measurements, skin/hair/nails, lung exam, Leopold's maneuver (if late in pregnancy) à VIDEO

• Order appropriate laboratory testing (or request)

• Discuss nutrition and supplementation, stages of labour, emotional challenges, interventions, how to prepare a birth plan

• Discuss support

• Homeopathic intake (brief)

• Treat any concerns presented using Naturopathic Modalities Labs and Findings

Weight • Optimal weight gain 25-35lbs (7lbs baby, 2.5 lbs gain uterus, 1lb placenta, 3lbs gain breasts, 4lbs gain mothers blood, 5lbs gain mothers fat). This may vary depending on patients weight before pregnancy.

Labs • Prenatal screening: Rhesus (+/-), Hb and Ferritin, CBC w/ WBC diff., Rubella (German measles), toxoplasmosis, Syphilis, Hep B, HIV/AIDS (optional), urinalysis, Gonorrhea and Chlamydia • 11-14 weeks: genetic screening tests (Integrated Prenatal Screening (IPS), First Trimester Screening (FTS) now upgraded to Enhanced FTS, nuchal translucency ultrasound) • Diagnostic testing: amniocentesis, Maternal Serum Alpha-Fetoprotein Testing(MSAFP) (15-18wks), chorionic villus sampling (9-11weeks) (risk: miscarriage) • Glucose challenge test (GCT): 24-28 weeks (screen), the OGTT if comes back positive • 2nd ultrasound at 18-20 weeks • ABO Bloodtype testing • GBS screen at approx. 36 weeks • Additional testing: Thyroid panel, Vitamin D status, B12

Fundal Height • Begin at 20 weeks. Extend from top of belly/fundus to top of pubic bone. 1 cm=1 week gestation.

If you are going to be their primary caregiver during pregnancy…Appointments with caregiver every 4-6 weeks during beginning of pregnancy, every 2-3 weeks after 30 weeks, and after 36 weeks, 1-2 weeks until she goes into labour.

FTS versus IPS

First Trimester Screening (FTS) and Integrated Prenatal Screening (IPS) are the most commonly offered prenatal screening tests. eFTS does not screen for open neural tube defects, as the 18 week ultrasound is more accurate for this.

Enhanced First Integrated Prenatal Trimester Screening Screening (IPS) (eFTS) Screen for Down Syndrome, Screen for Down Syndrome, Trisomy 18 Trisomy 13 or 18, neural tube defects Results available earlier in Results available after pregnancy (approx. 13 second bloodwork (approx. weeks) 15-21 weeks) Reference: trilliumhealthpartners.ca What is NT?

Nuchal Translucency (NT) - fluid filled space at the back of every baby’s neck • A larger NT measurement (>3.5mm) is associated with an increased chance for chromosome disorders like Down syndrome and some other genetic and non-genetic issues like congenital heart defect. Diagnostic Testing

Currently, pregnant women are eligible for amniocentesis or CVS if they have: • a positive prenatal screening test • abnormal ultrasound findings • a family history of genetic disease or are known chromosome rearrangement carriers • conceived by IVF with intracytoplasmic sperm injection

Prenatal diagnostic testing consists of chorionic villus sampling (CVS) and amniocentesis.

Amniocentesis – inserts long sterile needles through abdomen and into uterus. Amniotic fluid is tested for birth defects and chromosomal abnormalities (e.g. downs syndrome, hemolytic anemia, metabolism disorders, and cystic fibrosis. Risks: puncturing umbilical cord, placenta or uterus; infection, miscarriage)

CVS – before 12 weeks; invasive tests for chromosomal abnormalities. Advantage: can be done earlier than amniocentesis and so catches genetic abnormalities sooner. Risks: damage to the embryo, cervix or uterus; infection, hemorrhage, miscarriage.

Reference: prenatalscreeningontario.ca Gestational Diabetes

You're more likely to develop gestational diabetes if:

• Your body mass index (BMI) is 30 or above. • You have previously given birth to a large baby (4.5kg/9.9lb or more) • You have had gestational diabetes before. • You have a parent, sibling or child with diabetes. • You have a family origin with a higher prevalence of diabetes, for example, if you're of South Asian, Middle Eastern or African-Caribbean descent.

If you fall into one or more of these groups, it's recommended that you have a glucose tolerance test. The glucose tolerance test does, however, have a large false positive rate.

Frequent Ultrasound Dilemma

• Routine ultrasounds are at 8 weeks (dating), 12 weeks (genetic screening) and 18-20 weeks (anatomy). Patients will also usually have multiple third trimester ultrasound to assess for fluid levels, breech presentation, health of placenta (post-dates) etc.). • Additional ultrasound toward end of pregnancy (to assess fluid levels, size of baby, placenta location, etc.).

Risks of routine ultrasounds:

• Heat • Cavitation • Acoustic Streaming

**It is clients choice! (i.e. one ultrasound? All ultrasounds? No ultrasounds) Conflicting results… What are we to do?

• Methodology of many of the trials is poor • Very few trials comparing outcomes between women who have received NO ultrasounds at all and women who have • Scanning intensities used today are up to 6-8 times higher than they were in the 1990s. • Subjecting a large group of low-risk patients to a screening test with a relatively high false positive rate is likely to cause anxiety and lead to inappropriate intervention and subsequent risk of iatrogenic morbidity and mortality. • Routine ultrasound also increases the likelihood that more tests will be performed, which could also increase the risk of complications. Recommendations

Minimize exposure to ultrasound during pregnancy in the following three ways:

1. Using ultrasound only when medically indicated, i.e. only when a problem is suspected, rather than as a routine screening to determine the sex of the baby or check on its development. 2. Minimize total exposure time (by choosing a skilled and knowledgeable operator). 3. Minimize exposure intensity (i.e. avoiding Doppler during the first trimester especially).

Group B Strep Screening

Vagina and Rectum is swabbed for this bacteria at 36 weeks gestation. In newborns, GBS is a major cause of meningitis (infection of the lining of the brain and spinal cord), pneumonia (infection of the lungs), and sepsis (infection of the blood).

• About 1 in 5 women will test positive at 36 weeks (colonized NOT sick) • Most women will test positive “on and off” throughout their pregnancy. Women with preterm births more likely to be colonized. • Asymptomatic, but some women may experience frequent UTIs or placental infection • Out of the 15-20% of women colonized at labour, 50% of babies will be colonized. 98% or more DO NOT become ill, however 1-2% will develop infection. Of those 1-2% infected, death rate is 2-3%. • If they do, side effects are severe à fatal in 10% of cases

Two types of infection: Early and Late Early infection: occurs within first 7 days; symptomatic within 12-48 hours; caused by a direct transfer of GBS from mother to baby, usually after water breaks (do not want waters to be broken for more than 18 hours before delivery); bacteria travel from vagina into amniotic fluid and swallowed by baby into their lungs. GBS can also present on babies skin and mucous membranes as they move through birth canale, but most of these “colonized” babies stay healthy. Reference: Evidence Based Birth Risk Factors

People with these risk factors may be more likely to be colonized with GBS: • African-American populations • Multiple sex partners • Male to female oral sex • Frequent or recent intercourse • Tampon use • Infrequent hand-washing • <20 years of age

Babies are more at risk of infection if: 1. Low birth weight or premature (<37 weeks) 2. Membranes ruptured more than 18 hours or Premature ROM 3. Long labours with multiple vaginal examinations 4. Interventions such as induction, internal fetal monitors, vacuum, forceps 5. Fast fetal heart rates in labour 6. Mothers who develop fever in labour 7. Vaginal cultures show HEAVY colonization or GBS in urine 8. Babies who need resuscitation at birth 9. Infection of the uterus (chorioamnionitis)

Antibiotics or Not?

Antibiotics (penicillin) – drops risk of baby developing infection by 80% (e.g. from 1% to 0.2%). For women who screen positive at 36 weeks, 84% remain positive by delivery. 16% however become negative, and may be given antibiotics unnecessarily. Similarly, women testing negative at 36 weeks can also become positive.

QUALITY OF EVIDENCE IS LIMITED with regards to antibiotic use.

CDC recommends antibiotics given every 4 hours, starting more than 4 hours before the birth. *Ask for saline lock!

Risks: harmful to microbiome, allergy, increase in maternal and infant candida (15% rate), the potential medicalization of labour and birth

Affect on the Microbiome

Studies have shown an alteration in babies microbiome, up to 1 year after birth.

Vaginal deliveries - At 3 months, infants exposed to antibiotics during labour or birth had a decreased level of Bacteroidetes (a beneficial bacteria), as well as a decrease in the “richness” of their microbiome, regardless of whether they were exclusively breastfed or not.

Cesarean: Infants born by Cesarean also had higher levels of Clostridium, Enterococcus, and Streptococcus. At one year of age, most of these differences were gone, showing that the effect on the microbiome was short-term. Infants not breastfed showed deficiencies for longer periods of time.

Other options?

Risk-based approach – treat based on risk factors only (e.g. long labours where waters have been broken, fever during labour, etc.)

Chlorhexadine (aka Hibiclens) – topical disinfectant that kills bacteria on contact. Anti-GBS affect lasts for 3-6 hours. Midwives in US use this often; safe to use and easy to administer. However research shows this option to be INEFFECTIVE.

Natural remedies: Oral Probiotics, Oregon Grape, Echinacea. Can safely use HMF Candigen suppositories (garlic and probiotic) despite warning on label. Begin approx. 10 days before testing. If positive, continue Echinacea, probiotics and vaginal suppositories up to labour. No sugar, dairy or wheat 2 weeks before test and if positive, continue this diet until after delivery. Nutrition / Supplementation

Poor nutrition can be an indirect cause of gestational diabetes, birth defects, pre-eclampsia and C-section! Good nutrition can help with nausea, headaches, fatigue, constipation, legs cramps and more during pregnancy.

Symptoms of nutrient deficiencies include: leg cramps (Magnesium/Calcium), constipation (magnesium, fiber), fatigue (iron), breathlessness (iron), craving for ice cream (Calcium, protein)), pickles (calcium), chips/pretzels (sodium, fats)

Diet requires approximately ______more calories per day. Approx. 2300cal/day and ____more grams of protein (compared to pre-pregnancy)

Basic Diet: • 5-12 servings of fruit and vegetables • 75g protein (64g when nursing) • Variety of foods from their natural state – unprocessed, unpackaged, fresh, organic • Whole grains, nuts and seeds, beans, f&v, hormone-free dairy and meat • Avoid caffeine, alcohol, recreational drugs, tobacco, sugar, and dairy, shellfish, raw eggs and sushi • 2-3 L of water a day

Weight gain: around 4.0 kg in the first 20 weeks, second 20 weeks 8.5kg. At 40 weeks of pregnancy the average fetus weighs 3.4 kg, the placenta .65kg, amniotic fluid 8kg, and the increase in blood volume 1.25 kg.

LISTEN TO YOUR BODY!

Nutrition

Calorie intake = 300-500 calories MORE than pre-pregnancy Protein intake = 60g/day (25g MORE than pre-pregnancy)

Introduce BLOOD BUILDING foods à bone broth, blackstrap molasses, leafy greens, nutritional yeast, lentils, beets and pumpkin seeds

Introduce WARMING foods à soups, stews, squashes, Fall foods

What are good fats? Pumpkin, flax, walnut, algae, cold water fish, olive oil – BALANCE Omegas 3s and 6s. Increased TRANS fats and decreased essential fats are linked to pre-eclampsia.

What is good protein? Tofu, tempeh, beans with rice, free range/organic chicken or turkey, nuts and seeds, vegan protein powders, wild fish-smaller, cold water

What are good carbohydrates? Kitchari, Brown rice, quinoa, ancient grains! FIBRE is important (oats, flax, bran) àwill help reduce constipation.

As a general rule, always eat fresh, organic fruits and vegetables, and always cook meat. Avoid buying processed meats and other foods as they may have been contaminated with food-borne illnesses. FRESH FRESH FRESH!

AVOID

What should mothers avoid?

-Damp foods (bananas, milk, wheat, soy, ice cream). Dairy not best source of calcium, hard to digest, high in fat, makes larger babies, and is linked to atopic conditions, IBS and food sensitivities. -Seafood: seafood is high in mercury and can damage the baby’s neurological development. Try eating cold water fish, and the smaller the fish, the better! -Raw eggs/sushi – raw eggs are major carriers of ______. I think it goes without saying, that sushi and raw chicken are out as well. -Sugar: this can increase risk of gestational diabetes, cause the baby’s blood sugar to spike, and also can make women very lethargic during pregnancy.

Vegetarianism and Veganism

• Women can absolutely have a healthy pregnancy as a Vegan or Vegetarian • As with any diet, ensure proper balance of carbohydrates, fats and proteins • Healthy vegetarian proteins: • Quinoa • Chickpeas • Lentils • Beans and legumes • Nuts and seeds • Vegan protein powders • Sprouted Tofu or tempeh. miso • If vegetarian, can still have eggs

• Supplementation with B12 is critical. I would suggest additional B12 than what is in the prenatal. Symptoms of Nutrient Deficiencies

• Leg cramps à Calcium/Magnesium • Constipation à Magnesium • Cravings for sweets or chocolate à Magnesium or low blood sugar • Fatigue à Iron, B12, lack of protein • Breathlessness à Iron • Cravings for ice cream à Calcium, Vitamin D Supplementation

• Prenatal vitamin (Favourite is______) • Fish Oil 2000mg (high in DHA for neural tube development and post-partum depression) • Vitamin D3 – 4000IU/d. Important for preventing C-section http://www.ncbi.nlm.nih.gov/pubmed/19106272 • Iron (30-60mg/d) – liquid and non-constipating! • Methyl-B12 - 1000mcg sublingual • Probiotics – consider one with L.reuteri and L. rhamnosus • MTHF – 1200mcg/d (Thorne has a great product) • CoQ10 – 200mg/d from 20 weeks on. Reduces risk of pre-eclampsia http://www.ncbi.nlm.nih.gov/pubmed/19154996 • Cal/Mag (1200mg Calcium, 450mg Magnesium) – increase this in third trimester • Choline: important for development of memory and brain function. Can effect spatial awareness post-birth. Pregnancy and lactation are two periods when maternal choline is depleted. _____ are an excellent dietary source of choline. http://www.ncbi.nlm.nih.gov/pubmed/11023003

The Folic Acid Dilemma

Researchers analyzed data from 1,391 mother-child pairs in the Boston Birth Cohort, a predominantly low-income minority population.

The mothers were recruited at the time of their child’s birth and followed for several years, with the mother’s blood folate levels checked once within the first 3 days postpartum– of this group, 100 children were later diagnosed with autism spectrum disorder. It was found that of those diagnosed, there was an association with higher levels of folic acid in 17 of 100 of these mothers at the time that they gave birth.

Why?

-consumption of folic acid-fortified foods? -too much folic acid supplementation? -are some women genetically predisposed to absorbing larger amounts of folate or metabolizing it slower?

Analyzing the research…

1. Consider the group - The families in this study were from lower income groups. We know that synthetic folic acid is added to many processed foods – meaning that those who eat processed foods are exposed to much more on a daily basis.

2. A large percentage of people have a MTHFR mutation and can’t effectively process folic acid (causing it to stick around in the bloodstream, unmetabolized). Autism is linked to the MTHFR C677T mutation. This study measured total folate in the bloodstream, which includes unmetabolized folate. Unmetabolized folate in the bloodstream increases when synthetic folic acid is taken by those with MTHFR mutations, as they are unable to use it effectively. As such, the autism risk in this study may be increased by having MTHFR itself, and serum folate may be raised due to having the mutation.

The Human Microbiome

• The initial exposure of the fetus to microbes depends on mode of delivery (vaginal vs Cesarean) • These initial exposures lead to changes in colonization and alter the immune system. • Babies born via Cesarean are at high risk of atopic conditions, obesity, immune deficiencies, Type I diabetes, and gastrointestinal disorders.

• Solution à VAGINAL SEEDING • Place saline-soaked gauze in mother’s vaginal canal for 1 hour before Cesarean delivery • Rub into babies mouth, eyes, nose, ears, and onto skin, genitals and rectum. • Re-populates Lacto and Bifido strains orally and topically

Common Illnesses in Pregnancy

• UTIs – eliminate sugar, Echinacea root tincture, Uva ursi tea (caution in first trimester, and use only for 5 days), cranberry extract 10-20g/d, homeopathic Cantharis or Staphysagria • Kidney stones – cranberry extract, Undas • Yeast infections – Herbal prep: chickweed, burdock, dandelion, Echinacea Topically: yogurt Internal: garlic, probiotics • Anemia – Nettles, Astragalus, Iron supplementation, B12. Acu: BL17, ST36 (moxa). Qi or Blood deficiency? Tang Kuei and Peony herbal formulation • Hypothyroidism – Selenium, Iodine, Zinc, Vit C, Adrenal support (Ashwagandha) • Colds/Flus – Vitamin C, Echinacea, Vit D, Garlic, Ginger tea, warming socks • Heartburn – Nausea (Qi stag)àHeartburn (counterflow qi)àvomiting (rebellious qi). ST36 (consider: St44, CV12 (caution after 32 weeks),15,17, PC6, GV20. Ear points:______. Eat smaller meals. Herb:______• Nausea / Vomiting: PC6, KD27, KD6, KD21, ST30 (if severe). Vitamin B6, and Ginger. Eating small portions every 1 to 2 hours and eating and drinking separately can be helpful. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231543/ • Varicose veins/hemorrhoids: witch hazel topically, fiber, magnesium • Constipation • Mummy gruel (for constipation): dates, prunes, apricots (and/or figs)all chopped with 1 cup oatmeal, 3tbsp flaxseeds to 2-3 cups water! • Hot water with lemon! NO CASTOR OIL!!! • Needle: SJ6 (DDX: Blood Xu St36, KD Yin Xu, BL23, LV qi Stag LV3, ST fire ST44) • Increase water intake and fruits

Pregnancy Complications Pre-eclampsia

• Pre-eclampsia – Signs/Sx: swelling, proteinuria and hypertension (usually >20 weeks); headache, abdominal pain, dizziness, nausea, sudden weight gain (over 2 days). If untreated, can lead to eclampsia (risk to mom and baby – lack of blood flow to fetus, low birth weight, placenta abruption, learning disabilities, epilepsy, cerebral palsy and vision problems, HELLP Syndrome, stillbirth) *Immediate referral to ER.

• Affects 5-8% of pregnancies

• Linked with increased trans fats, and deficiencies in essential fats, calcium, magnesium, folic acid, B6, B12 (homocysteine), and Vitamin C. Insufficient bloodflow to uterus can also lead to underfunctioning placenta and pre-eclampsia. At risk groups à hx of diabetes, kidney dz, lupus and RA

• Conventional tx: depending on severity, bed rest, fetal monitoring, anti- hypertensives, anti-convulsants, steroid injections

• Natural recommendations: Assess salt intake. Diet: use sea salt (lightly), drink lots of water, eat fresh, + protein. Rest on left side for 20min. De-stress. Acu: LI11, LV3 If edema: SP9, ST36. Nettles for Proteinuria. • Severe cases: Magnesium sulfate injections (IV) to prevent seizures

Pre-eclampsia

Edema: St36, SP6, SP9, UB23, KI3, KI6

Hypertension: LV3, PC6, HT 7, LU9, SP6, GV20

Ear points: Shen Men, heart, hypertension, blood-pressure reducing groove

Gestational Diabetes

• Gestational Diabetes– elevated blood glucose levels during pregnancy and in which resolves postpartum. > 20 weeks gestation usually. Signs/sx similar to DM Type II however in most cases no signs or symptoms.

• Affects 1-3% of pregnancies

• Risk factors: >25 yoa, hx of prediabetes, family hx, BMI > 30

• Risks to baby: +birth weight, preterm, respiratory distress syndrome, hypoglycemia (low blood glucose), diabetes later in life

• Risks to mom: hypertension and pre-eclampsia, future diabetes

• Conventional tx: insulin, Induction at 37 weeks, Cesarean (routine care versus evidence based care)

• Natural Recommendations à rest, eat well (high fiber, low sugar and fat diet, GF), regular exercise (30min/day), chromium, cinnamon in smoothies, Vitamin C (reduces diabetes later in life), Astragalus, antioxidants

Group B Strep

Vaginal/Rectal swab at 36 weeks. Conventional protocol for a positive test – IV antibiotics in labour Remember – client can choose to forgo antibiotics, or choose a risk-based approach!

GBS – Prevention Protocol 2 weeks before testing (34 weeks) - Probiotics, Oregon Grape, Echinacea. Can safely use HMF Candigen despite warning on label. GBS positive only relevant at 35-36 weeks mark. Consider no sugar, dairy or wheat 2 weeks before test.

GBS Treatment Protocol – Vaginal and oral garlic and probiotics, Echinacea. No sugar, wheat or dairy. In early labour, insert vaginal probiotics (membranes in tact). Delay rupture of membranes for as long as possible (i.e. forgo cervical stretch-and-sweeps, no AROM)

If antibiotics are provided in labour, mother and baby should be given probiotics for first 6 weeks post-partum.

In cases of Cesarean, NO VAGINAL SEEDING!

Hyperemesis

• Rest, avoid stress and aggravation • Drink warm tea (ginger or chamomile) before getting up in the morning – avoid dehydration • Small frequent meals to keep blood sugar levels stable • Rub fresh ginger roots on tongue before eating or taking medications • Supps: B complex, Ginger • Avoid cold foods and beverages, coffee, sour foods, spicy and fatty foods • Lemon and peppermint essential oils

Nausea tea: ginger, coriander, fennel, green

Injections: Inject ____ at ear point Shen Men TCM: Stomach qi def, stomach def cold, spleen qi def, liver qi stag, stomach heat, phlegm accumulation Acupuncture: ______Ear points: ______

*initial aggravation possible Diclectin

An anti-nauseant combination of Pyroxidine HCl (Vitamin B6) 10mg and doxylamine succinate (antihistamine) 10mg to treat severe nausea and vomiting in pregnancy.

Nonmedicinal ingredients: ammonium hydroxide, n-butyl-alcohol, carnauba wax powder, colloidal silicon dioxide, croscarmellose sodium, FD&C Red No. 27, denatured alcohol, FD&C Blue No. 2, hypromellose, isopropyl alcohol, magnesium stearate, magnesium trisilicate, methacrylic copolymer acid, microcrystalline cellulose 102, PEG 400, PEG 8000, polysorbate 80, propylene glycol, shellac glaze, simethicone, sodium bicarbonate, sodium lauryl sulfate, talc, titanium dioxide and triethyl acetate. Gluten-, lactose-, sulfite-, and tartrazine-free.

Common side effects: diarrhea, sleeping difficulties, dizziness, headache, irritability, nervousness, fatigue CAUTION: antidepressants, antihistamines, gravol and other meds that cause drowsiness Hypothyroidism

Levothyroxine (Synthroid) is drug of choice for pregnant women with an underfunctioning thyroid. à decreased risk of lower APGAR scores and babies with lower birth weight. In subclinical hypothyroidism (TSH>2.5 in first trimester, >3.0 in 2nd and 3rd trimester) à no difference in pregnancy loss or maternal/neonatal outcomes.

Natural support: Treat if TSH>2.5. Iodine, zinc, selenium, ashwagandha, tyrosine Headaches/Migraines/Pain and Fever

Very common in pregnancy. Acetaminophen (Tylenol) is drug of choice prescribed by midwives and obstetricians.

Recent study (2017) links chronic acetaminophen use to a a two-fold increase risk of ADHD. Study may be flawed (it was a cohort study) and we know that ADHD diagnosis is not standardized. However, it makes us think twice about its recommendation.

Alternatively – consider peppermint essential oil on the scalp, feet in hot water and ice on back of neck, Magnesium, removing food sensitivities Other potential issues…

• Placenta previa • Low lying placenta covering partial or complete cervix. Will likely move up later in pregnancy. • Oligohydramnios • Low amniotic fluid levels. Monitor levels with a NST. Drink a lot of fluids! • Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPS) or Polymorphic Eruption of Pregnancy (PEP) • Skin rash showing in 3rd trimester

Pregnancy Symptoms that require immediate referral:

• Persistent vomiting (with signs of dehydration such as cracked lips, scanty urination, and positive urine ketone test). • Severe abdominal pain (can indicate ectopic pregnancy or placenta abruption) • Vaginal bleeding (miscarriage – can be accompanied by low back pain or cramping; placenta previa) • Frontal headaches, intolerance to bright lights and sudden edema (hands and face) (could indicate pre- eclampsia or hypertension) Pre-natal Acupuncture

Acupuncture can:

• Treat morning sickness: Add PC6, CV12 (needled down) • Promote emotional health and relaxation. The March 2010 issue of Obstetrics and Gynecology reported that “women who used acupuncture for depression during pregnancy experienced a greater reduction in symptom severity and expressed a more positive response than those in control groups”. • Enhance uterine circulation and help develop the placenta • Reduce bleeding in threatened miscarriages. Some causes of vaginal bleeding include implantation bleeding and cervical erosion. By strengthening weaknesses in the mother’s health, acupuncture can calm the uterus to help prevent uterine contractions and certain types of threatened miscarriages. • Manage pain during labour

Lumbar pain Acupressure at ST36, BL32,60,67, CV4,6, KI3

Important notes about TCM in pregnancy

Pregnancy involves natural changes in quality and quantity of Qi and Blood. These should not be confused with pathological developments.

In a normal pregnancy, you USUALLY have:

• An increase in Blood • Increased Heat • Increased dampness • Increased liver energy • Decreased kidney energy

Tongue and pulse may differ throughout pregnancy. At ______: normal to have ______pulse, ______, ____in Liver position

Preparation Acupuncture

In normal pregnancy, using points which, according to TCM, facilitate labour, should begin in the ______week and continue until time of delivery (1 session per week).

ST36, GB34, SP6, BL67 (if babies position is not optimal), BL62, BL60 (descending action) *BL60 is a sensitive point, can cause mother stress (moxa can be a good alternative)

Mental/Emotional: GV20, PC6, HT7, LI4

**Labours are reduced by 2-3 hours, increased cervical ripening, reduced C section rates, improvement in contraction coordination, reduced need for pain medication Threatened Miscarriage

If your patient has a history of miscarriage, consider the following TCM diagnoses and treatments. START WITH____, _____ and _____, then add:

1. Deficiency of Kidney and Spleen - A kidney and spleen deficiency will lead to an inadequate quantity of essence and blood. As a consequence, the fetus cannot be nourished and miscarriage occurs. Points: DU20, UB17, UB20, UB23, ST36, KI3, Sp1) 2. Deficiency of Kidney Qi with Blood Stagnation in Uterus – common in OCP use or MANY miscarriages/IVF attempts. The fetus is devoid of blood supply and stops growing. more likely to occur in women who have autoimmune disorders or anti-phospholipid syndrome (blood clotting disorders)Points: Du20, UB17, UB18, UB23, SP1-, KI4) 3. Deficiency of qi and blood - could cause inadequate blood production and the sinking of qi, consequently failing to nourish and hold the fetus. Common in early pregnancy in women with Hypothyroidism. Points: DU20, Ying Tang, Pc6, St36, and moxa on UB17, UB18, UB20 and SP1. 4. Yin Deficiency with blood heat – women with long-term emotional stress/fear/anger; leads to Liver Fire and blood heat which will lead to infections in pregnancy. It is likely to occur in women producing anti-sperm antibodies, natural killer cells or hyperthyroidism. Points: Ying Tang, SP10, LI11, PC6, HT7, KI3, LV3, UB17, UB18 5. Damp Heat Stagnating the Uterus – women with endometriosis, fibroids, or UTIs. Likely to occur in 2nd or 3rd trimester. Points: Ying Tang, PC6, LI11, SP10, ST36, SP9, UB17, UB18, UB20, LV3 UB67

Regulates pregnancy and childbirth. Specific for turning the fetus, or for malposition of the fetus.

Apply moxabustion to this point for 2 weeks starting at 35 weeks. For 20min EVERY 2 DAYS. • Increases fetal movement • More cephalic presentation • Decreases ECV’s and • Decreases need for oxytocin during labour

Research: JAMA. 1998 Nov 11, 280(18):1580-4 Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003928 J Matern Fetal Neonatal Med. 2004 Apr;15(4):247-52 Points to AVOID

• Lumbo-Sacral points (can cause contractions) UB31-34 • SP6, LI4, GB21, UB60, UB67 (except to turn breech) • Extra point Du Yin DuYin • Avoid the use of lower abdominal points unless specific indications; such as ST 30 for morning sickness or CV 4 (needling towards CV 8) for threatened miscarriage. • Avoid Yuan source points yin meridians – to avoid the possibility of drawing on a woman’s Qi at a time when it should be directed towards the uterus. This includes LU9, SP3, HT7, KD3, PC7, and LV3 (exception LV 3 if needing to disperse qi)

POINT COMBINATIONS TO AVOID LI4 and SP6 LV3 and SP6 BL60 and SP6

PRECAUTIONS • Points on lower abdomen CV2-CV7, AND CV9-CV15 (do NOT needle perpendicular or too deep) Early labour and Impending Premature Delivery

Causes: stress, exhaustion, infection, placental insufficiency, multiple pregnancy, polyhydramnios, cervical tears.

Acu: GV20, HT3, HT7, PC6, ST36, GB34, LV3, SP6 Ear points: ______

Before Acu, determine cause of early labour.

Acu should take place every day.

Breech Presentation

MOXA :____

Start of therapy: Not before 33rd week End of therapy: end of ___week LATEST!, no moxa after that time Time between treatments: ______10min application each side

Position: knee-elbow position, Or pelvic tilt (breech tilt)

Homeopathic:______Pre-natal Homeopathy

Constitutional at this point: do appropriate intake, and consider which remedies the client will likely need during labour.

1. Constitutional drainage / UNDAS 2. Appearance 3. Reactions to procedures and upcoming labour 4. Reactions to new role as mom 5. Body language and verbal language 6. Physical state and complaints 7. Personality 8. Fears 9. Work and home issues 10. Support team 11. Dreams, sleep 12. cravings 13. Temperature 14. Position of baby Pre-natal Flower Essences

Bach flower remedies: extreme dilutions

Bach thought of illness as “the result of a conflict between the purposes of the soul and the personality’s actions and outlookànegative moods and energy blockingàphysical disease”.

• Mimulus (for fear of health & delivery), Rock Rose (feeling of loss of control or frozen from fear), Walnut (state of oversensitivity, helps with adjustment to change), Aspen (fear of the unknown), White Chestnut (sleeplessness), Olive (exhaustion) • RESCUE REMEDY!!!

Resource: Flower Essence Repertory by Patricia Kaminski and Richard Katz

Pre-natal Botanicals

Raspberry leaf tea (at 37 weeks) – helps labour to progress at nice, easy, steady pace; tones the uterus. One small study found that women who drank the tea regularly towards the end of pregnancy had a shorter second, pushing stage of labour. Also less likely to have a birth assisted with forceps (can start earlier, but should be drinking 3 cups per day by 37 weeks)

Lactation tea: Fennel seed, Fenugreek seed, red raspberry leaf, Urtica dioica (stinging nettle) leaf, Milk thistle seed, Citrus sinensis (orange) peel, Anise seed, Caraway seed, Medicago sativa (alfalfa) leaf, Goats rue, Lemon Verbena, Oatstraw, Blessed Thistle (start at 39 weeks – 2 cups per day)

Stress tea: Lemon balm, Withania, Schisandra, Lavender

AVOID these herbs during pregnancy:

• Bitters (metabolic stimulation, smooth mm. stim) • Alkaloid containing plants (toxic!) • Essential oils (internal) (toxic!) • Anthroquinone laxatives (stimulates bowel) • NS stimulants (e.g. ephedra) • Detoxifying herbs

Pre-natal Stress Reduction

• Meditation, Yoga (decreases risk of pre-term delivery, reduces pain, increases satisfaction with pain relief, reduces rate of assisted vaginal delivery, reduces risk of pregnancy-induced hypertension, and reduces risk of intrauterine growth restriction) • Massage, Deep Breathing • Music Therapy (Effects of music therapy on psychological health of women during pregnancy by Mei-Tueh Change. Journal of Clinical Nursing.Volume 17(19): 2580-7. Oct. 2008.) • Hypnobirthing, Lamaze, Bradley method • Acupuncture • Asking for help & utilizing support team • ADDRESS FEARS!

Efficacy of yoga: http://www.ncbi.nlm.nih.gov/pubmed/ 16008324

Pre-natal Counseling

Listening is important!! Maintain eye contact, be open and listen from your heart. Remind patient that their feelings are more powerful during pregnancy due to hormone involvement, but the feelings are very real and warranted.

1st trimester: Counsel on Acceptance (what to expect, body changes, emotional change) 2nd trimester: Counsel on Adjustment (fetal movement, relationship change, home change) 3rd trimester: Counsel on Anticipation (labour/birth, ability to mother, attention to signs of labour, preparing for baby, Kick Counting)

Counsel on stages of labour, emotional challenges during labour, and how to recognize signs when to go to hospital. ADDRESS FEAR!

Perineal Massage

• 4-6 times per week 4-6 weeks before due date

Lubricate index finger to second knuckle, insert into vaginal canal, put downward pressure on the perineum by pulling down and out until one feels slight stinging; once one adjusts to stinging sensation, perform a sweep (U-shape curve to left/center/right) back and forth 3x. Continue.

Oils to use: Hypericum Oil or Olive Oil

C/I: infections, Herpes, inflamed vaginal canal

Risk: Can introduce infection, so best to use gloved hand. (You will automatically do this as a practitioner, but be sure to educate partner if they are the ones performing the procedure).

Alternative: Epi-No

Where’s my baby?

NATUROPATHIC INDUCTION: Post-dates considered 40-42 weeks, but you can begin the week of due date.

• GB21 (helps to move baby down, and great for breastfeeding), SP-6 (ripens cervix and dilation) ,KI-1,LI-4,St-36 (establishing regular contractions), SP10 (blood mover), UB-60 (helps if baby is posterior), Backshu, all sacral points. Acupressure at UB67, source points • My personal regimen: Have client lie on left side. Needle right sided only à GV20, GB21, LI4x3, sacral points, SP10x3, SP6x3, UB60 • Begin treatment week of delivery, every 1-2 days, and continue manipulating the needles for at least 1 hour. *Best results after a “stretch and sweep”.

Homeopathics: Hypophysinum 200K, Alternating Caulophyllum 12CH and Cimicifuga 12CH every 2 hours.

Castor Oil Belly Rub, Nipple Stimulation (pumping), Intercourse. Internal Castor oil as last resort (1/4 c. every 2 hours in orange juice to a maximum of 3 doses – risk: Loose stools, nausea). There is no evidence linking castor oil to meconium.

Foods: Eat Curry/Spicy Food (stimulates the uterus), Pineapple (softens cervix), Raspberry Leaf Tea 3x/day

Botanicals: Blue Cohosh (CAUTION!), Black Cohosh, Mitchella repens, Red Raspberry, Chamaelirium

Evening Primrose oil – begin at 37 weeks. 1000mg orally and vaginally (to soften cervix)

Physical activity: walking, bouncing on a birthing ball, blowing up balloons, stimulating hormones by watching sad movies

Ask about: issues with partner, fatigue, nesting

Refer for: massage, craniosacral therapy, chiropractic care, non-stress test or stress test Where’s my baby?

MEDICAL INDUCTION: The use of any un-natural method to induce labour

Membrane “Stretch-and-sweep” – cervical dilation checks including a stretching of the membranes. Releases oxytocin to stimulate contractions. Obstetricians will begin them as early as 38 weeks. PROS – can prevent an induction with medication, reduces chances of needing induction beyond 41 weeks (from 41% to 23%); decreases pregnancy by 1-4 days CONS – cannot perform if cervix is closed; spotting and bleeding (common); can be painful; can cause irritable uterus and uterus to contract irregularly; risk of infection; risk of premature rupture of membranes (10% risk); sometimes done without informed consent

Artificial Rupture of Membranes / Amniotomy – breaking the waters before contractions begin or to augment labour PROS – can induce or “speed up” labour without having to resort to medications (ie. prostaglandin or Pitocin); can visualize meconium if present CONS – can increase risk of Pitocin use; increases risk of infection (baby exposed longer); compression of umbilical cord; there is no evidence that supports a shorter labour being more beneficial for mom and baby; increases Cesarean rate; Head may be misaligned àLonger labour since babies head is not supported by amniotic fluid

Cervical Prostaglandin Gel - Synthetic Prostaglandins applied to the cervix via tablet, gel, or suppository to soften the cervix. PROS – increases likelihood of vaginal delivery in 24 hours CONS – overstimulates uterus causing fetal distress; usually client ends up needing Pitocin anyways

Balloon Catheter – mechanical method to stretch and open the cervix PROS – can dilate the cervix and “hopefully” bring someone into labour; lower risk of hyperstimulation compared to prostaglandins; reduce risk of Cesarean compared to Pitocin (Oxytocin) CONS – most patients have waters broken or pitocin started after Balloon use

Pitocin (Oxytocin) – IV oxytocin administered to induce or augment (speed up) labour/strengthen contractions PROS – induce labour as needed; shortens labour CONS – increases pain of contractions; no time to adapt to contractions; uterus has increased tonicity at rest leading to fetal distress; increase likelihood of epidural use; increases Cesarean rate; increases risk of post-partum hemorrhage; requires continuous fetal monitoring Summary of Labour Preparation

Before 36 weeks – prenatal yoga, book appointment with pelvic floor physiotherapist, Hypnobirthing classes, increase Red Raspberry Leaf tea to 3 cups daily

At 36 weeks – pack for hospital/prepare homebirth materials; begin perineal stretching or use of an Epi-No

At 37 weeks – Evening Primrose Oil (EPO) 1000mg orally and vaginally, begin bouncing on ball, eating dates and pineapple, lots of walking

At 38-40 weeks – Begin Partus Preparatus tincture or homeopathic remedies (Caulophyllum 12K and Cimicifuga 12K alternating)

At 40-41 weeks – Induction acupuncture, constitutional homeopathic remedies, intercourse, nipple stimulation or use of breast pump 20 min 2x/day, castor oil belly massage. Refer for NST.

BIRTH KIT FOR MOTHER

• PERINEAL BOTTLE with PERIWASH HERBS • Pads • EmergenC for Electrolytes • Snacks: protein bars, fruit • Socks, slippers, hair brush, toothbrush, change of clothes, housecoat, etc. • Nursing bra, nipple cream • Hair clips or elastic • Music – MP3, computer, iPhone, earphones • Rescue remedy • Homeopathics: incl. Arnica 1M,. Staph 200C. • Lactation tea/tincture • Unopened bottle of olive oil (for massage) • Books!!! BIRTH KIT FOR SUPPORT

• Copy of Birth Plan • Mother’s Health Card and important health history • Important contact information and phone numbers (e.g. cord blood, placenta encap) • Cash • TIMER (watch or phone) • Change of clothes • Snacks • Swimsuit (if water birth) • Camera • Phone • Bring you’re A game! BIRTH KIT FOR BABY

• Diapers • Clothing with hat and booties • Blanket • Car seat (installed) • Bum cream • Non-chorine, natural baby wipes • Vitamin D 400IU • Probiotics (if needed) HOME BIRTH SUPPLIES

(supplied by couple)… • Birth tub (optional) • Thermometer for birth tub • Several pillows • Overnight sanitary pads • Paper towels • Fan in the Summer • Electric heating pad • Ice packs • Periwash bottle • Relaxing music • Plastic fitted sheet or shower curtain for bed • Basin for placenta • Towels and facecloths • Receiving blankets • Clean bed sheets • Garbage bags • Large pots to heat water MODULE 3

LABOUR/BIRTH

LABOUR SUPPORT

• WHEN TO GO TO HOSPITAL • REVISITING THE BIRTH PLAN • STAGES OF LABOUR • EMOTIONAL CHALLENGES • PAIN MANAGEMENT • HOSPITAL INTERVENTIONS • BIRTH CHALLENGES • ACUPUNCTURE • HOMEOPATHICS IT’S TIME!

1. Spontaneous Rupture of Membranes (SROM) • First sign (only in 15-20% of labours) • “popping” sensation; clear fluid with pink tinge (can be a trickle or large gush) • Can last days, no control over flow, continuous, ‘semen’ smell (not urine) 2. Contractions • Abdominal or Lumbar, can radiate antàpost or postàant • 3-5 min apart and roughly 1 min long = good sign in labour • Should get stronger and last longer with shorter time in between • Climbing the “mountain peak” or riding the “wave” 3. Mucus Plug / ‘Bloody’ Show • Watery, sticky, or jelly-like; brown, pink or red tinge; loonie size • Can last several days and occur up to 2 weeks before labour 4. Involuntary Shivering • Your body’s way of losing “tension” • Relax, take a warm shower, massage, deep breathing, counting backwards or holding breath for 5 seconds 5. Lightening • Baby drops; breathing a little easier; more pressure on Bladder 6. Diarrhea/Loose stools • Increased prostaglandin production stimulates bowel; making room for baby 7. Increased Braxton Hicks Contractions • Can become more frequent and intense; very irregular and no pattern; can occur throughout pregnancy (this is not a sign of imminent labour) WHEN SHOULD CLIENT GO TO HOSPITAL?

Counsel client to proceed to hospital if: • They are bleeding • Their waters have broken and the fluid is green, brown, yellow or anything other than clear or pink (meconium) OR they are GBS+ and wanting IV antibiotics OR waters have been broken for >12 hours and no contractions have started • Baby isn’t moving (kick count) • They feel something is wrong (Intuition) • They can’t stop vomiting • They have unbearable pain • They want to push

Counsel client to NOT proceed to hospital until/unless: • They have spoken with their midwife/triage nurse first • Their waters break • It’s their first baby and they are feeling slight bowel pressure • They would like an epidural • They are having good 4-5 minutely contractions (4-1-1 rule Primips; 5-1-1 rule multips) • They’ll hit peak hour traffic on the highway if they wait

Birth Plan / Wishes / Preferences

• Environment

• Labour

• Birth

• Post-partum Delayed Cord Clamping

Delayed clamping of the umbilical cord from 1 min to the point where the cord stops pulsing.

Nearly one-third of a baby’s total blood volume resides in the placenta at birth. This is equal to the volume of blood that will be needed to fully perfuse the fetal lungs, liver, and kidneys at birth. Half of that blood is transfused into the baby by 1 minute of age. By 3 minutes, more than 90% of the transfusion is complete.

Higher iron stores and smoother cardiopulmonary transition at birth. This increase in red blood cells also could mean more of a breakdown of red blood cells, increasing risk of jaundice. Skin-to-Skin

Recommended skin-to-skin with mother for the first 1-2 hours postpartum. If mother cannot do skin to skin, father should.

• Establishes better breastfeeding outcomes • Easier transition from the womb • Stabilizes babies heart rate, breathing and temperature • Regulates blood sugar • Swallows good bacteria off of moms skin reducing risk of pneumonia, ear infections and digestive issues • Less crying • Pain relief (if getting a heel prick or Vitamin K) • Enhancement of mom-baby communication (feeding cues, signs of discomfort, etc.) and bonding

Encourage skin-to-skin as much as possible in the first few weeks of life. Discourage relatives and friends handling the baby. Erythromycin Eye Ointment

Topical antibiotic - Was first introduced to protect infants eyes against Gonorrhea infection (Ophthalmia neonatorum – aka “pink eye”). Gonorrhea eye infections can lead to blindness in 3% of babies affected if untreated. Babies CAN be treated.

If mother does not have Gonorrhea and never has, the risk is ZERO – PLUS woman are screened during pregnancy.

Gonorrhea has evolved to become resistant to this antibiotic.

Pediatricians across Canada have removed it from routine care, except ONTARIO! Not done in European countries. American Academy of Pediatrics still stands by their recommendation to do mandatory eye ointment.

There is NO EVIDENCE showing that it protects against “other harmful bacteria” in the vaginal canal

Side effects: eye irritation and redness

Vitamin K

Babies born with very low amounts of Vitamin K (low amounts in breast milk and very small amounts cross placenta) Those at highest risk of bleeds after birth (those who do not have injection, and those exclusively being breastfed (formula high in Vitamin K) Babies are at risk until 6 months of age, when solids are introduced.

Late bleeds happen to: • 4 to 11 babies out of every 100,000 who do not receive any Vitamin K at birth • 1 to 7 babies out of every 100,000 who receive 3 doses of oral Vitamin K after birth • 0 to 0.64 babies out of every 100,000 who receive injectable Vitamin K after birth

There is only 1 oral regimen that is as effective as the shot: 2 mg orally at birth plus 1 mg weekly while breast milk makes up > 50% of feedings. There is no FDA-approved oral version in the U.S.

Research has shown that it does NOT cause Leukemia.

Routine IM Pitocin Injection

Forces uterus to contract and expel the placenta àreduces risk of post-partum hemorrhage. Given IM to mother (or IV bolus) during third stage of labour.

Rapid onset and short half life à IM injection onset of action 2-4 min and lasts 30-60 min; IV onset of action <1min and lasts <30 minutes.

***More studies are needed to support this routine procedure, especially around dosing. Revisiting the Birth Plan

- Is everyone on board with who is to be present, and under what circumstances? - Discuss again how open or against they are to interventions and which ones - Discuss options for movements during the labour, and positions during Birth - Discuss time of cord clamping/cutting. Who will do it? - How attached are they to the birth plan? - What is most important to you? What is least important? - When do you want me to advocate for you? - Revisit natural pain relief options

At end of discussion: • Mom should feel empowered • Mom should feel that she can make an informed choice • Mom should feel like she has control, but know that it is ok if things move away from her “plan” STAGES OF LABOUR – STAGE 1

Dilation of the cervix 0-10cm. Cervix dilates, thins and moves forward. 3 PHASES:

Early labour: • Dilates the cervix 0-5cm (longest part of labour) • Can begin with water breaking spontaneously, or small contractions (with no water breaking) • Contractions longer apart • Mom able to talk, sleep, walk during contractions. • This is the longest period, so mom may get frustrated and ask for pain medications at this time. REMIND HER the longest part is over. • Best tools: Mom can sit on toilet in dark, or use a shower head all over body to help cope, listening to hypnobirthing CDs, sleeping, meditation and relaxation, massage, TENS machine, homeopathics

Active labour: • Begins at about 3-4cm dilation • 1 min long contractions and 2-5min apart, more intense. • Mom cannot speak or move during contractions. • REMIND HER This part goes much quicker • Best tools: acupressure, squeezing hips, pressure on sacrum, massage, visualization, submersion in water, homeopathics

Transition: • last few cm of dilation (8-10cm) • Contractions are strongest in intensity, with a short interval (20sec) in between • shortest time period lasting approx. 10 contractions • Cervix is 10cm at end of transition. • Best tools: hands on approach, shower or bath, Nitrous

STAGES OF LABOUR – STAGE 2

THE PUSHING / BIRTH STAGE

• Fully dilated; Woman needs to push! • Contractions CHANGE. Not as frequent, uterus may contract and expel baby spontaneously • Woman becomes empowered • Baby is pushed from the muscles of the pelvic floor, cervix and birth canal • Crowning – baby’s head moves out of the vagina, stretching the tissues of the vulva (mom will feel stretching/burning sensation) àshe will be counseled to stop pushing • Baby’s head is born, then shoulders, rest of baby follows

STAGES OF LABOUR – STAGE 3

BIRTH OF PLACENTA

• Within 10 minutes the uterus will contract again and expel placenta • Limit this stage to 30 minutes • Women may need to give a small push but placenta will slide out easily compared to baby • “TOURING” the placenta https://www.youtube.com/watch?v=uiZEmjfBeog • Encapsulating and consuming Placenta • Step 1 – Freeze • Step 2 – Thaw and wash thoroughly • Step 3 – Steamer • Step 4 – Cut into pieces • Step 5 – Heat in oven until dried • Step 6 – pulverize in blender until powdered • Step 7 – Encapsulate

• ***Could it inhibit milk supply???

INTERVENTIONS

Augmentation of Labour:

Prostaglandin gel Can be used if waters have broken and cervix is closed (no contractions started)

Pitocin Can be used to intensify/strengthen or lengthen contractions (with end goal of getting baby out faster). Can be used to dilate cervix if labour is slow or stalled.

Artificial rupture of membranes Can progress labour if stalled, can visualize meconium (if present)

INTERVENTIONS

Pain Relief

Nitric Oxide (NO) (aka Laughing Gas) No known effect on mother or child which is great! Mom and hold the mask so she is in control of when it is administered. Best for Transition phase or even for perineal repair; eases anxiety and slows breathing; takes the “edge off” pain Risks: nausea and vomiting; dizziness; drowsiness. Temporary relief only.

Epidural Pain relief administered via needle in spine, mother remains awake and alert (sometimes!), narcotic in epidural can lead mom to sleep, fewer side effects compared to narcotics Risks: not always complete relief, lack of mobility, prolongs labour, can spike fever leading to antibiotic use, uneven pain relief, depresses respiration, convulsions, headache, spinal infection, neurological complications, backache, fecal/urinary incontinence, pins and needles sensations, emotional detachment from experience, catheterization, increased Pitocin, increase risk of episiotomy, forceps and C section, dural puncture, prolonged labour, lowers BP, nausea and vomiting Baby àdistress, lower muscle tone and strength in first few hours, sepsis if maternal fever spikes, jaundice, lower oxytocin and prolactin levels in mom leading to difficult breastfeeding

Narcotics/Injectable Opioids (IV/IM) Good for women unable to have epidural, can be given early in labour; can still move during labour 5 commonly used drugs: Fentanyl, morphine, pethadine (Demerol)àcan take 1 week after birth to leave newborns body. No opioids are 100% safe – all cross placenta. Typically not given toward end of labour because may slow labour and affect breathing, and affect breastfeeding after birth Risks: may delay labour, respiratory depression, BP lowered, nausea and vomiting, itching, can decrease uterine activity, slow cervix dilation, decreased heart rate variability, can cause resp. distress for baby, poor suck reflex; low APGAR scores; poor breastfeeding

INTERVENTIONS

Baby Removal

Episiotomy Shortens pushing phase, prevents shoulder dystocia, prevents 4th degree perineal laceration, makes room for forceps or vacuum Risks: skin cells heal slower so part-partum healing takes longer Alternative: reverse-kegels, EPI-NO, birthing on hands and knees or side lying (no birth stool), warm compresses, perineal stretching, push with urges and not with counting, oil and lubricant

Vacuum/forceps Used when mother is exhausted or if baby is having trouble coming down through the birth canal; can turn the baby into anterior position; last resort before C-section Risks: injury to baby and/or mom, episiotomy needed, post-partum pain, medication required to reduce infection; fetal skull fracture; bruising and hemorrhaging Alternatives: squatting or hands and knees position can widen hips

INTERVENTIONS

C-section • Used in emergency situations when mom or baby is under stress; more common decision is not clear-cut and it is up to mom and doctor to decide • More commonly performed as a routine procedure; decide when your baby is going to be born • Rates increase with maternal age, primips, glucose tolerance issues

Risks: Major abdominal/pelvic surgery, pain, longer recovery time, medications (antibiotics, pain relievers, anesthetic), infection, blood clot, adhesions, injury to bladder or other neighboring organs, higher risk of more surgery in future, hysterectomy. Baby: immune system alteration (microbiome), breathing problems; injury from scalpel Effect on future births: low lying placenta, , increase likelihood of another C- section, uterine rupture

Risks after Cesarean are higher if: • Overweight • Previous C-section (risk increased with the more Cesareans client has had) • Medical conditions such as heart disease • Gestational age >40 weeks • Augmentation of labour (Oxytocin or Prostaglandin use)

A note on VBAC or TOLAC

VBAC = Vaginal Birth After Cesarean (this means successful) TOL = Trial of Labour After Cesarean (this means trying for) ERCP = Elective Repeat Cesarean Delivery

Success rate has increased due to new stitching method (60-80% success rate). Risk of uterine rupture is 2.7/1000 (or approx. 1/500) Risk of death from uterine rupture (1.5/10,000) Risk of hysterectomy from uterine rupture (4.8/10,000)

10% decrease in success when Oxytocin or Prostaglandins is used to augment labour.

Chances of successful TOL are higher if: Maternal age <40 yoa Prior vaginal delivery (particularly after a cesarean previously) Favorable cervix INTERVENTIONS

Other interventions:

Vaginal exams Benefits: assessing progress (limit exams as much as possible; most hospital repeat exams every 3-4 hours) Risks: carrying bacteria up vagina and cervix leading to infection, especially if amniotic sac has already ruptured, may rupture membranes

Continuous fetal monitoring Benefits: used if induction or augmentation of labour is used, signs of fetal distress, high BP in mother, when pain meds are administered risks: increases C section and forceps/vacuum delivery rates, mothers movement is restricted, more likely to use pain medication, (alternative: Doppler)

Intervention Cascade Alternatives for Pain Management

• Breathing (Count 4 breaths in, 4 breaths out) • Visualization • Freedom of movement • Squeezing hips to open the hips, relieve back pain and cervical pressure • Pressure on sacrum (provides counter pressure in back labour) • Immersion in water/shower: oxytocin is release in higher amounts when catecholamines are lower. Endorphin levels are also increased, changing mothers perception of pain. Takes gravity off of the cervix. • Massage • Acupressure (LI4, KI1, SP6, BL60) • Hypnotherapy • Music or white noise • Position changes / use of birth ball – provides comfort; alters relationship between baby and uterus; increases effectiveness of uterine contractions • Walking in early labour – brings baby down • Homeopathics and Acupuncture • TENS – research shows most beneficial in early labour • Saline injections (for back labour!)

Labour Positions

VIDEO…

Homeopathics - ACONITE

USE M POTENCY – less likely to aggravate

• (

Homeopathics - ARSENICUM

• (

Homeopathics - Caulophyllum

• Nervous, excited • Joint pain • Uterus feels congested, contractions slow, labour slowing • Tension and fullness • Thirsty • False labour • Bearing down sensation • Great for tonifying the uterus • Great dystocia remedy

Homeopathics - Cimicifuga

• Labour stops – was dilating now suddenly closed by spasm • Uncoordinated contractions • Pains felt everywhere other than the uterus • Lots of sighing • Suspicious • Great dystocia remedy Homeopathics - Chamomilla

• Frequent urination • Irritable • Argumentative • Pacing during labour • Alternate to pulsatilla and kali-c in back labour • Hemorrhage after delivery with dark blood and clots • Labour slow (ddx Caulophyllum) Homeopathics - Gelsemium

• > motion and bending forward • Anticipatory anxiety • Best remedy for 1st labour/delivery • Mom could ‘change her mind’ once contractions begin… “what’s happening?” panic=tight os • Heaviness, sleepy, droopy, eyes heavy • No thirst • Trembling • Flu sx, nausea Homeopathics - Ignatia

• Sighing (Ddx gels) • Grief remedy • May have hx of fertility issues or miscarriage • Fear that miscarriage will occur • Oversensitive to pain, in early labour or with Braxton • Recent loss (baby, relationship) Homeopathics - Phosphorous

• < lying on left • Sensitive to anesthetic • Outgoing • Highly sympathetic – wants to please everyone else…will not say anything to hurt anyone • > firm massage • Cold remedy (chills) • Fears thunderstorms (or loves them) • Craves cold drinks • Hemorrhage remedy • Frequent colds and flu that always move to chest Homeopathics - Pulsatilla

•

Homeopathics - Sepia

• craving vinegar, nausea

Homeopathics - Staphysagria

• Itching or sensitive vulva, (repeated UTIs) • Mild sweet women who follow advice without argument or questioning • Sensitive to rudeness, mortification • ailments from humiliation • Suppressed anger, dissociation • VBAC, history of sexual abuse or promiscuity

Hands tell all!

Nux-v

Hamamelis (risk of hemorrhage)

Kali-carb Belladonna (flushes only when anemic) General Acupressure/Puncture in Labour

GB21 descending action (brings baby down) BL32 promotes dilation and prevents appearance of radiating back pain KD1 calms the mind LI4 increases intensity and frequency of contractions SP6 for use in delayed, prolonged or difficult labour BL60 pain relief BL67 repositioning a posterior baby PC6 alleviating nausea and vomiting

General Analgesia

Hands on: -Acupressure/puncture: GV 20 should be needled from start of first contraction. Add LI4, and LI10 (analgesic points) – can add electrostim 20Hz to these spots (gentle) *Continuously stimulate points for 30-60min! Take 30-60min break. Analgesia kicks in after 15-20min! Also can add: St36, SP6, extra points nei ma, wai ma. For FEARFUL patients, add UB67. -Abdominal and Neck Massage, hip squeeze, knee push, sacral pressure

Hydrotherapy: Heating pack on Abdomen

Other: Visualization, Meditation, Music Therapy, Immersion in water (only after ____ dilation), Breathing, Hypnosis, Freedom of movement, Homeopathics, Essential Oils Lumbar Pain

Early in labour: Acupuncture at ST36, BL32,60,67, CV4,6, KI3

Opening up the Hips: • Squeeze mothers hips • Place hand over sacrum and apply pressure • Wrap towel around waist and pull (like tightening a scarf)

Homeopathic: Kali-c, Puls, Cham (if pain extends down leg), Gels (if pain extends upward)

Injection Therapy: (Meso/Biopuncture) – sterile water is injected Sub-Q at 4 specific points around the sacrum

Hydrotherapy: Warm compress on lumbar Dysfunctional Labour and Insufficiently Coordinated Uterine Contractions

Causes: 1. Functional imbalances: cervical dystocia and insufficiently coordinated uterine contractions (hypotonic, hypertonic) 2. Anxiety, tension, pain 3. Mechanical problems: Cephalopelvic disproportion, malposition, abnormal fetal presentation, cephalic position

Acupuncture: LV3, GB34 (Hyperfrequent: sedating; Dysfunctional and hypofrequent: tonifying)

Acupuncture CONTRAINDICATED in: undeliverable situations, uncorrectable problems, endangerment to mother, impending uterine rupture – endangerment to fetus Dystocia

Obstruction or constriction of birth canal (usually by arm or shoulder), or an abnormal size, shape, position or condition of fetus. Can also be due to size and shape of pelvis. Labours will be slow and difficult

Solution? Open the birth canal

Alternative positions: pelvic tilts (while on all fours or on birthing ball), walking, squatting

Hydrotherapy: warm bath or shower; ensure hydration

Homeopathics: Caulophyllum (stitching pains in the cervix), Cimicifuga (cervix opens and closes), viscum album (brings baby down), chamomilla, coffea (tearful and weepy)

Other: nipple stimulation, lying on left

Dystocia

HANDS ON:

Acupuncture/pressure: LI4, SP6, ST36 (tonifying technique), UB32, GB21, GV3, GV4, GV20

Labour stalls at 5-6cm dilation – UB67, UB60 Labour not starting well – LV3, CV4, LV2, GB34, UB32, UB18 Late dystocia (8cm) – CV24

Ear points – Shen Men, Autonomic ND, Endocrine

Contractions Stop

Homeopathics: Cimicifuga

If contractions stop when crowning:

• Mag–mur- if dilating stopped • Causticum – if feels numbness, worn out, too hard to push • Platinum – hypersensitivity; unpleasant Baby Position

Look at the babies occiput, where is it located?

Baby Positioned Posterior

Can result in a difficult labour, as baby’s head is not lying in optimal position. Woman will experience increased back pain.

Solution? TURN BABY

Alternative positions: pelvic tilts, hip swivels, climb stairs, all fours, open lunge in direction of baby’s occiput, fire hydrant pose

Homeopathics: Pulsatilla. Consider back pain remedies like kali-c.

Hydrotherapy: Hot Compress to lumbar, shower

HANDS ON: Acupuncture/pressure – UB60, UB 67 (moxa), SP6, GB21 Massage and add pressure to sacrum, Hip squeeze (while mom on all fours), Knee Press (while mom seated), roll over lumbar Failure to Progress

Labour stalls, and cervix no longer dilates even with medical augmentation of labour (i.e. does not respond to Pitocin)

*Assess for cervical scarring (can stop cervix from dilating) **Discuss fears and anxieties around birth ***Relax pelvic floor as much as possible (orgasm?) ****Cervical massage *****Mag-mur homeopathic remedy Mom wants to give up!

Encourage the mother and get her to refocus Reassure her that her body is doing what it needs to do, and everything is normal. Keep hydrated, and give her energy (i.e. FOOD!)

Botanicals: Anxiolytics such as Skullcap, passionflower, Lemonbalm (helps reduce tension and anxiety, restore nerves, analgesic, promotes rest). Rescue remedy!

Homeopathics: Sepia (exhausted/irritable), Gels (exhausted/can’t keep eyes open), Aconite (panic), Caust (numbness, too tired to push) EMOTIONAL CHALLENGES OF LABOUR

1. 5CM dilation Difficulty: How can I possible carry on? Solution: Birth partner assures her that the longest part is over. Mom must think: “Do NOT let it take control of you. You are in control.” Decrease fear, have confidence in your body, remain in control and relax

2. TRANSITION – last cm of dilation Difficulty: physical discomfort and intense backache. Contractions are very close and strongest. Solution: Birth partner ensure her that baby is almost here. The worst is almost over Mom-to-be: maintain relaxed breathing (higher and deeper), keep focus. Keep control. EMOTIONAL CHALLENGES cont’d…

3. BABY’S HEAD REACHES PELVIC FLOOR Difficulty: Fearful and Exasperated! Birth partner: Reassurance that her body is naturally made for this! Remind her not to resist. On next contraction, tell her to push as hard as she can. The baby will move past the painful spot and pressure will reduce.

4. CROWNING Difficulty: Woman feels like she will burst! Tearing and burning sensation. “ring of fire” Birth Partner: relax the pelvic floor (do not squeeze as this can enhance burning). Do not push, because it could cause tearing of perineum. Breathing changes to quick panting.

Types of Pushing

Spontaneous Directed

— Relax pelvic floor — Holding breath (may gasp for air) — Practitioner or partner may — Avoid straining count — 3-4 pushes per contraction — Push as body tells you Breathing to avoid bearing — Avoid prolonged breath down — Very light and fast to avoid holds bearing down and allow gentle birth of head and shoulders — Exhale during pushing — Lift chin off chest, mouth open, and vocalize as needed jaw relaxed Cesarean Birth

Before the procedure: Dose Arnica 1M, Rescue Remedy, Vaginal Seeding Protocol, meditation

In the room: keep mother calm (talk to her about what you can see, OR distract her – whichever she needs); assist her with Skin-to-skin OR encourage dad to do skin-to-skin and talk to baby.

Post-Cesarean – protocol discussed in next section; establish breastfeeding as soon as possible. MODULE 4

POST-PARTUM

POST-PARTUM SUPPORT

POSTPARTUM FOR BABY CHALLENGES BREASTFEEDING BREAST HEALTH BABY BLUES VS PPD POST-CESAREAN PERINEAL HEALING NOURISHMENT

Postpartum for Baby

APGAR assessment, weight and measurements, suction (if needed)

Erythromycin eye ointment, Vitamin K injection

PKU and Blood sugar testing

24 hour newborn screening (heel prick) and jaundice testing, hearing test

Delaying Newborn Bath à minimum 48 hours • Vernix provides moisture to the skin and provides protection against infection. • Bathing causes crying, stress and the release of stress hormones. Stress hormones can cause a baby’s blood sugar to drop, which can make a baby too sleepy to wake up and breastfeed, causing the blood sugar to drop even more. • Bathing too soon can cause hypothermia • First 48 hours critical for skin to skin and breastfeeding RETAINED PLACENTA

DETACHING THE PLACENTA NATURALLY:

Wait until after childbirth. If 20-30min goes by, and placenta is not expelled:

Acu: ______(0.5cun lateral to umbilicus), also needle top of fundus. 80% effective! Additional points: LI4, Sp6, GB21, BL60, CV3. Ear point Uterus

Botanicals: Angelica Sinensis 1tsp q15 min for 1 hour; Gossypium (placenta won’t deliver after oxytocin), Jasmine essential oils Other post-partum challenges…

Hemorrhage • Acu: Sp6, Sp10, LI4 • Homeopathy: Arnica, Phosphorous, Secale (homeopathic Ergot) • Botanicals: ______and ______30gtt q15min

Difficult Urination • Acu: Sp6, SP9, CV2, CV3, CV4, ST29, KI3, UB62, GV20 • Homeopathy: Cantharis • Botanicals: Peppermint essential oil

Difficult Bowel Movements (Constipation): LI4, LI10, LI11, ST25, ST29, ST36, UB25

After pains: Uterus contracts to move into pre-pregnancy position. Can last days to weeks. Enhanced when baby is nursing. Worse with every subsequent pregnancy. • Acupressure: Partner presses SP6 while mom is nursing • Acupuncture: CV4, CV2, KD14, ST29, ST30, UB21, UB32 • Homeopathy: Arnica • Botanicals: -Angelica sinensis (for pain, prevents blood stasis, milk laxative) -Motherwort (blood mover, tonic for fear, hysteria, melancholy) *Add heating pad on abdomen while nursing Botanical Tincture for After Pains

3 parts Motherwort, 2 parts Crampbark, 1 part Dang Gui, 1 part Black haw.

Can add Astragalus if mother lost a lot of blood and is pale. Supplements for BABY

Homeopathics: Day 1: Arnica (liquid placed on breast) Day 2: Sulphur

Supplementation: -Probiotics (containing B.infantis) -Vitamin D3 400IU (mother can take 6500IU Vitamin D3 instead if breastfeeding) Breastfeeding 101

It takes approximately 3-4 days for a mother’s milk to “come in”. Baby needs no more than the colostrum she is producing.

Day 2 – prepare mom for cluster feeding and a “fussy” baby. This is NORMAL. Her baby is not starving and does not need formula. This is natures way of bringing milk in faster.

Early Start – Put baby to breast as soon as possible after the birth. Better outcomes with skin to skin.

Mother should feed “on cue” and wake baby every 2-3 hours for feeding (8-12 times in a 24 hour period). Alternating breasts is important in the first 2 weeks. Timing on each breast doesn’t really matter!

Cues of hunger: • turning towards the breast • rolling tongue, licking lips or smacking lips • opening and closing mouth • sucking on lips or tongue • putting hands in their mouth • fidgeting and moving around a lot • fussing or crying Colostrum

Colostrum is provided in the first few days before breast milk comes in. This is what we call LIQUID GOLD!

Produced in small quantities (tsp not ounces) but is satisfying for baby’s small tummy.

Protects against infection, clears meconium, and helps reduce jaundice.

If latch is a concern, mother can hand express the colostrum into a tsp or collect with a dropper and give to baby. Latching

Jack Newman (Latch) - https://www.youtube.com/watch?v=NO5ZDKynaD0

LATCHING: • Sit comfortably • Tuck baby under the opposite arm just under the breast (cross chest hold) • Baby’s face and body turned toward mom • Baby’s chin is leading and nose it tilted back in sniffing position • Move the breast into position with your hand if needed • Baby’s bottom lip and chin are against the breast • Top lip brushes the nipple and mouth opens wide • Quickly pull baby in close to latch on. • Baby’s mouth with cover a large part of the areola • Lips should be flanged out and nipple touches the roof of babies mouth

Hand Expression

Compression Technique www.newborns.standford.edu/Breastfeeding/HandExpression.html

Has a lot of preventative value: • If she is too full (engorged) • If she is separated or could not latch the baby • If she becomes sore • If early on she needs more stimulation to produce milk • Softens the nipple so easier for baby to latch • Helps get the flow going for baby if expressed before feeding

1. Massage the breast 2. Place fingers on opposite sides of areola at 3 and 9 o’clock position 3. Press back towards your chest 4. Compress fingers toward each other, drawing slightly toward nipple but not sliding skin 5. Release pressure, relax hand

Is Baby Getting Enough?

Babies will lose 7-10% of birth weight over the first few days. >10% weight loss is considered a concern by most physicians.

How do you know if baby is getting enough? • 6 wet diapers a day, 3 dirty (after day 5) • Poo’s are mustard yellow (after day 5) • Baby is gaining weight (regains birth weight by Day 10-14). Weight gain should not be less than 6 ounces per week after this. • Breasts feel softer and less full after feeds • Breastfeeding becomes painless after about a minute (when letdown occurs) • Baby is actively swallowing (not suckling) • Baby is not feeding for hours • Baby has firm skin that bounces back (sign of Hydration)

BREAST HEALTH

For normal day to day breast health…

• Apply ice packs/cabbage leaves on breasts after feeding to reduce engorgement. Do not do this for too long and too often…it can reduce milk supply.

• Apply nipple cream or breast milk on nipple to prevent chafing.

Points for all Functional Breast Issues: ST15, ST16, ST18, CV17

Weaning: Acu: GB37, 41 Botanicals: Drink 2-3 cups sage tea Hypogalactia

Enhancing Milk Supply (Hypogalactia): • Botanicals: Blessed thistle, fenugreek, goat’s rue, fennel • Acu: CV17 (2 needles toward point until tips almost touching), SI1 (toward SI2), SI2, ST18, ST36, GB21, LI4, LV3, SP9, GV20, SI3 (toward SI1) – treatment begins____days post-partum • Ear points: mammae, endocrine, ANS, shen men, thorax, liver

Nursing tea recipe: NUTRITIVE

• Goats rue, Lemon Verbena, Fennel, Fenugreek, Oatstraw, Nettles, Blessed Thistle, red raspberry, hops, dandelion leaf, red clover

Acupressure: Support partner GB21 multiple times per day (let down reflex) Other: frequent nursing, on demand (q2hours), nourishment, hydration, rest, pumping until breasts are EMPTY (after feeds) to increase demand

Engorgement

Breasts moderately swollen, exhausted

TCM: qi and blood Xu

Acu: St30, 36, UB17, 20, 43

Topical: Cabbage leaves or cold compress between feedings

Other: • Warm showers or compresses before feedings to help with let down. For too much milk… • Hand express before feeding to soften Acu: CV17 (aim toward breast), breasts. SI1, SI2 (toward SI1) • Nurse frequently! Offer only one breast at feeding. Feed against gravity.

Galactocoele (blocked duct)

A galactocoele is a retention cyst containing milk or a milky substance that is usually located in the mammary glands. Painful swollen breasts without milk secretions

TCM: Obstruction of LV qi Acu: UB18, UB51, ST34, 45, 16, 18, CV3, LV1, 13, 14, CV18

Galactostasis: ST15, ST16, ST18, CV17, LI4, PC6, ST44, LV3, GV20, Ear point ______

Other: Raw potato poultice and or cabbage leaves, Sage topically

Hydrotherapy: warm compresses (use tea infusions of ______, ______, ______, ______)

Massage in warm water Feeding and/or pumping on that side frequently

For stubborn or repetitive blockages, 3600-4800mg Lecithin per day for 2 weeks. Mastitis (inflamed tissue)

• Acupuncture: clear heat, reduce pain. LI11, LV2, LV3, ST44, GB41 (pain and distension) Local: ST18 Ear points:_____, ______, _____

• Botanicals: o Echinacea tincture o Mastos Breast Oil (St Francis) o Grated potato poultice/ raw cabbage leaves

• Supplements: o ACES and Zinc (boost immune system and heal tissue)

• Homeopathy: PHYTOLACCA

For sore nipples in general... • Correct positioning and latch (#1!!!) • Break suction before taking baby off • Offer least sore breast first • Hand expression • Apply nipple creams (containing Calendula) after every feed. Breastmilk can also be very healing. Thrush

How to recognize it: Mom has extremely sore nipples which will burn and itch. Can have shooting pain and blisters. Baby may have white raised patches on inside of mouth or diaper rash with red pustules.

Homecare: wash bras after daily use, dry bras at high temp or in sun, avoid use of breast pads and shields, expose nipples to direct sunlight for 20 min/d, allow air to circulate nipples, keep nipples clean and dry.

AVOID: foods high in sugar, dairy, gluten

Topicals: plain unsweetened yogurt or apple cider vinegar (diluted) to nipples after nursing, Gentian Violet! Gentian violet, in a 1% aqueous (water-based) solution: Use a cotton-tipped Q-tip to apply the solution in the baby's mouth (swab inside baby`s cheeks, gums, tongue, roof of the mouth and under the tongue) so that all areas are covered violet. Once that is done, let the baby feed on both breasts.

Topical botanicals: Tea tree oil (diluted in carrier oil), Grapefruit seed extract (Citricidal) 2gtt/ ¼ Cup of oil. Rinse nipples before nursing. Try Black Walnut tincture. For SEVERE cases, apply paste of _____ and______powder to nipples after nursing. Rinse off before nursing again.

To heal cuts and sores: Vitamin E or calendula

Thrush in Baby

Swab baby’s mouth qid with a cotton swab dipped in black walnut tincture. Do not replace the cotton swab into the bottle of tincture after it has been in baby’s mouth.

Alternative: swab baby’s mouth with Powdered Probiotics (diluted in water) Mental/Emotional Disorders

BABY BLUES POST PARTUM DEPRESSION

— Normal; mild; 50-80% of — >2 weeks (mild or not); moms; subsides 2 weeks <50% of moms — Stressed, weepy, forgetful, — Can get in way of normal vulnerability functioning (even if they — Subsides in 2 weeks occur in first 2 weeks PP) — Caused by hormonal shifts — MAO-A increases as affecting neurotransmitters Estrogen declines — Monitor mother daily — Loss of appetite, poor — Support adrenals conc., anxiety, anger, deep — Exercise and time to self sadness, low self esteem, — Assess support system hopelessness, overwhelm Post Partum Depression Protocol

TCM: Blood Xu, liver qi Xu, Yin Xu

Acupuncture: MAIN POINTS GV20, PC6, HT7, SI1 Additional points include HT3, SP6, ST36, LV3, KI3, KI6, UB23, UB62, CV6, CV15, shi shen cong Ear seeds: shen men Treat daily for 20 min. Tonifying technique.

Botanicals: Rhodiola, Hypericum, Licorice, Skullcap, Rosemary

Homeopathy: Ignatia, Nat mur, Sepia, CONSTITUTIONAL

Supplementation: 5HTP, Fish Oil (DHA), Vitamin B6, Adaptogens, Neurapas (Pascoe), Vitamin D, Sam-e

Diet: remove wheat and dairy; increase intake of foods high in tyrosine and tryptophan (become epi or nor-epi and dopamine)

POST-CESAREAN

Acu: surround the dragon UB40, LI1, LI11, LU7, GB39, ST26, ST36, KD3, KD26, SP4, CV15, CV23

Homeopathy: Arnica, Hypericum IM

Abdominal massage after incision heals with Castor or Hypericum oil

Supplementation: ACES and Zinc Review: The Microbiome

• The immune system undergoes major development during infancy and is highly related to the microbes that colonize the intestinal tract at birth • Researchers have found that the microbial colonization of a baby from a vaginal delivery is substantially different than those babies born via Cesarean and can lead to changes in long term colonization and subsequent altering of immune development • Babies are bathed in vaginal fluid containing various healthy gut flora which sets up their immune system in the first year of life • Babies born via Cesarean are at high risk of atopic conditions such as asthma, allergies and eczema, food sensitivities, Gastroenteritis, Diabetes Mellitus Type 1, and Celiac Restoring Microbiota after Cesarean

Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer.

Dominguez-Bello, M et al. Partial restoration of the microbiota of cesarean- born infants via vaginal microbial transfer. 2016 Nature Medicine 22, 250-253.

• Followed 18 babies from birth to 1 month of age (7 vaginal; 11 Cesarean) • Of the 11 born via Cesarean, 4 were rubbed down with vaginal fluid • For first month, researchers swabbed babies mouths, bums and skin and analyzed microbial growth • Babies born via Cesarean had a very different colonization compared to vaginally delivered • The babies swabbed with vaginal fluid after Cesarean had a similar colonization to the vaginal delivered (particularly early enrichments of Lactobacillus and Bacteroides) which were not seen in unswabbed Cesarean deliveries. Skin and oral colonizations were similar. Rectal growth was still very different however. PERINEAL HEALING

Periwash: Calendula, Comfrey, Gotu kola, Witch Hazel

Sitz baths: AVIVA - 2oz comfrey leaves, 1oz calendula flowers, 1oz lavender flowers, 1oz sage leaf, ½ oz myrrh powder. Steep 1 large handful of herbs in 4 cups boiling water for 30min. Strain liquid and discard herbs. Add 2 cups of liquid to tub. Keep remaining liquid for another bath, compress, or peribottle. Can also add Yarrow Blossoms, rosemary leaf, sage and fresh garlic to the mix.= (do not use garlic in peribottle or compress) If infection, add garlic cloves (blend garlic in water and strain). Add to sitz bath or periwash.

Topical Oils: Vitamin E oil topically St. Johns Wort Oil topically NOURISHMENT

A refreshing green and minty tea, this is rich in trace minerals and excellent for enriching the quality and quantity of breast milk.

Nourishing Tea: • 1 oz nettle leaf • 1 oz red raspberry leaf • ½ oz alfalfa leaf • ½ oz red clover blossoms • ½ oz rose hips • ¼-1/2 oz spearmint leaf Steep 4 tbsp per quart of boiling water for 30 min.

Healthy diet, hydration and lots of rest!

Discuss healthy quick snacks, prepared meals, and discourage unhelpful visitors. When afraid to ask for help, put sign on fridge of what tasks ppl can help with.

Supplementation: DHA, Prenatal, Probiotics, Placenta (or Nourish Essence)

MODULE 5

SELF CARE

THE BUSINESS OF BEING A DOULA Doula Self Care

• Make sure bag is packed 2 weeks before due date • Have a back-up Doula (x2) on hand. Create a support network of doulas you love and trust. • Bring enough snacks and water for yourself • Know your boundaries/limitations • Careful with positions of support (pain-free) • Get lots of sleep while on call! Many women go into labour in the middle of the night • Ensure adrenals are supported • Treat yourself to some bodywork (spa, massage, chiro)

BIRTH KIT FOR DOULA

• Extra pads for mom (just in case) • Healthy snacks for self and mom-to-be • Essential oils: lavender, peppermint • Acupuncture needles and ear seeds • Homeopathics • EmergenC • Herbal teas (red raspberry, chamomile) • Comfortable clothes / change of clothes • Bathing suit (if water birth) • Water • Castor oil and other massage oil (Olive, Jojoba, Coconut) • Birth Ball (supplied by hospital or mom usually) • Rescue remedy • Heating packs/cold packs • Towels and facecloths • Relaxing music (either on phone or computer) – just in case! Business of a Doula

Doula Services Agreement, and Consent forms signed by BOTH partners

Arranging appointments Meet and greet – What is a Doula and how are Naturopathic doulas different? Your services and fee schedule, ask them what they are looking for in a doula, tell them about your experience First visit – nutrition and supplementation, stages of labour and emotional menaces, fears and anxieties, creating a birth plan, signing of DSA and Consent forms Second visit – finalizing a birth plan, preparing mind/body for labour Postpartum visit – assess baby, mood, latch, sleep and nutrition

Setting up a file for your doula clients In your file • all case notes • Doula summary • Signed DSA and Consent forms Client handouts: • Left hand side à What is a Doula? Doula interventions, hospital interventions, stages of labour, emotional challenges in labour, preparing a birth plan, your information and when to contact you • Right hand side à Nutrition in pregnancy, breastfeeding handouts, preparing for labour, perineal stretching, perineal healing, postpartum care, references for parents

Billing and Invoicing

Marketing

Advertising (Facebook, Instagram, Doctors / Midwives offices)

Gain experience! à Hearts and Hands Doulas Facebook group

Make professional connections: LaLeche, Midwives, Naturopaths, Acupuncturists and Homeopaths, Counselors, perinatal exercise classes, Mommy and Baby groups, Postpartum services, other Doulas, etc..

Website -workshops, blogging, newsletters. Creates VISIBILITY, CREDIBILITY, OUTREACH

Bring business cards to your births!

What’s your pitch?

Challenges you may face…

Challenges to your beliefs Be honest with your client and do not do anything you aren’t comfortable with

Challenges between you and hospital staff… -Learn when to step in and when to step back -Always be pleasant -Discuss everything in front of the patient -Re-establish connection with your client

Challenges which may arise between mom to be and her partner… -Can happen during the pregnancy, labour or postpartum -If you feel comfortable and are licensed, you can provide counseling services. OR recommend a counselor. -Keep mother focused on the relationship between her and her baby -Remind mom to be, that you are a support for her at any time

Challenges with the birth/birth plan… -Remind the client that baby always has its own plan and to be willing to SURRENDER -You must also surrender and know when it is best to step away from the birth plan

Case 1: Early Labour

You receive a call in the middle of the night and your client is experiencing some back pain that comes and goes. She is feeling mild abdominal cramps, but mostly lower back pain. She is noticing that it is waking her up at night. Client is 38 weeks pregnant.

What would you ask her?

What would you instruct her to do? Case 2: Premature ROM

Your client calls you and her waters have broken. Contraction have not yet started. She is a premip 41 weeks.

What would you ask her?

What would you instruct her to do?

She calls back 6 hours later, and her contractions are 5 minutes apart, lasting 1 minute in length. Her pain level is 6/10.

What would you instruct her to do? What if this client was a multip? Case 3: Mom wants to give up

Your client gets to the hospital after 24 hours of early labour. She is exhausted. The hospital staff examines her cervix and she is 5cm dilated. She says “I can’t believe I am only half way, I can’t do this for another day, I want the epidural”

What do you say to her?

What other pain relief tools can you use to help her cope? Case 4: Failure to Progress

Your client has been labouring well. She has decided to get an epidural when she is 6 cm dilated. Her contractions space out and she stops dilating. 2 hours later the hospital staff begins Pitocin but the baby is not tolerating it well. Her cervix stalls at 6cm and the staff is considering Cesarean.

What can you do to keep labour moving? Case 5: Birth plan negligence

Your clients birth plan is not being adhered to by hospital staff. They may: • fail to read it when presented to them • laugh and say “I don’t know why women make these plans, it never works out the way they want it to” • repetitively try to convince the client to get an epidural even when she has denied it several times • Automatically assume the client wants a saline lock in place, and continuous monitoring • Cut the cord immediately after birth • Bring in a pediatrician to discuss eye ointment and vitamin K with the client after she has refused it • Etc…

What do you do?

Case 6: Unplanned Cesarean

Mom has been labouring well. She is now fully dilated and has been pushing for over 2 hours. However, the baby is showing signs of distress and fatigue (hear rate is dropping). The OB suggests an emergency Cesarean. Your client is completely unprepared and begins to cry.

What can you do to comfort her? How can you avoid her disappointment?

What can you do postpartum to assist her? Case 7: Back pain in labour

Your client has been in early labour for 2 days, with contractions 5-7 minutes apart. She is having back labour.

What homeopathic remedy would you prescribe?

What positions can you tell her to get into?

What acupuncture point would you consider? Case 8: Fear and Panic

Mom-to-be reaches transition and changes her mind about having a baby. A sudden onset of fear consumes her and she clenches her entire body saying “I can’t do this, I don’t want to do this”.

What homeopathic remedy would you prescribe?

What would you say to her? References

Natural Health After Birth: The Complete Guide to Postpartum Wellness – Aviva Jill Romm, MD Medical Acupuncture in Pregnancy – Ansgar Thomas Roemer Birth and Breastfeeding – Michel Odent In Labour: Women and Power in the Birth Place – Barbara Katz Rothman Meditations in Pregnancy – book/CD – Michelle Leclaire O’Neill, PhD, RN The Business of Being Born – VIDEO Husband Coached Childbirth – the Bradley Meth Acupuncture in Pregnancy and Childbirth – Debra Betts Childbirthjoy Prenatal Hypnosis – Shawn Gallagher Homeopathy and Obstetrics: Dysparunia and Hemorrhage – John Millar, ND The Natural Pregnancy Book: Herbs, Nutrition and Other Holistic Choices – Aviva Romm, MD Dr. Jack Newman’s Guide to Breastfeeding – Jack Newman, MD The Natural Pregnancy Book I am a Doula because I want to Empower women To believe in themselves and their Innate strength As women and as mothers,

Not so I can advocate for natural childbirth.

But believe me, If that’s what she wants, I will be there for her.

I am a Doula. Contact Information

Dr. Jessica Dupont (Sangiuliano), ND

Clinic locations: It’s All About You York Region Naturopathic Doulas 14550 Dufferin St. www.yorkregiondoulas.com King City, ON [email protected] 905-833-6444 647-983-5171

Personal Website: www.DrJessicaND.com | Email: [email protected]

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