Another chance for me to be informed about birthy stuff whilst pregnant - Gestational Diabetes

I realise I launched into my thoughts on my experience with gestational diabetes quite late on in the journey without actually talking about the whole GD thing from the beginning.

The main reason for that, is that once again I found myself in the midst of having to deal with yet another pregnancy and birth related 'problem' whilst being pregnant.  I don't deal brilliantly with stress at the best of times but whilst pregnant well thats a whole nother level.  I felt optimistic that having an independent midwife this time round would make things less stressy than having to deal with a multitude of NHS staff.  I was visualising my homebirth more and more frequently now we had settled into our new home and not once did it have NHS intervention or any issues attached to it.


"Gestational diabetes mellitus (GDM) is a (usually) temporary form of diabetes that occurs during pregnancy. It happens when the hormones made by the placenta during pregnancy make it harder for insulin to work. Insulin is a hormone that helps process your food and keeps your blood glucose level stable. If you can’t make enough insulin your blood glucose levels will rise. High blood glucose levels can cause the baby to put on too much weight. This can impact on the baby’s well being and your delivery and can affect the baby’s health later in its life"Understanding Diabetes - Natasha Leader

During my 18week midwife appointment, my sugar levels from peeing on a stick were very high.  We put it down to the fact that it had been Halloween the night before and we had all eaten a tremendous amount of sweeties!!  I had been given a blood test a few weeks before, which luckily (since we hadn't asked for it), showed my sugar levels as being within the normal limits.  I was advised to cut out refined sugar.  It had been on my mind to at least cut down.

Then at my 27week midwife appointment, my sugar levels were once again raised.  This time and for some unknown reason, except that I am possibly an idiot, I had a bowl of coco pops and raw milk just before she arrived.  I had a major craving for this childhood cereal because I was loving enjoying milk again after stopping whilst breastfeeding.  I have not had sugary cereal like this for at least 4 years.  We cut down gradually by calling it weekend cereal and only having at weekend for a while, until I stopped it altogether.  There was clearly some subconscious voodoo wake up call type thing going on.  I also think it was a last blow out as me and the girls were stopping ALL refined sugar that week after a particularly crazy December of sweets and chocolate.

Then at 30weeks more sugar showed in my urine so this time it was decided I should get a glucose Tolerance Test.  I also fell into a lot of risk categories for possibly having gestational diabetes: older mama, overweight, previous big baby and two family members with late onset type 2 diabetes.

The main concern with gestational diabetes is the size of the baby, a large baby at full term can in some cases cause shoulder dystocia, something my IM has had no experience with either.  Other issues are hypoglycaemia in the newborn who is used to having large amounts in utero.  This can also be due to stress after birth, so skin to skin straight away and establishing breastfeeding are of the utmost importance.  To this end, I am sorting out expressing colostrum and organising donor milk just in case there are problems and my baby needs milk before my own milk comes in.  (video for expressing)

So a week later after researching as much as I could about 'consuming a phenomenal amount of sugar after eating nothing and testing my sugar levels' that's where I found myself.  I was not keen on doing the test since a lot of articles I read seem to question the validity of it.  Michel Odent talks about the discrepancies in diagnosis and whether this is a disease or a diagnosis.

We made the decision based on my other risk factors and the fact that our IM midwife had never had a client with GD before, so she was unclear yet of protocols and risks.  It is also good to have a more clear answer than the peeing on a stick test.

I had also begun my diet change.  After discussing it with my CC mothers group, most of whom are incredibly knowledgeable with regards to healthy dietary habits, I formulated a nominal can and can't have list based on low and high GI.  Basically, the foods with a lot of carbohydrates.  The can have is much larger so I have not included it, but it contains many many vegetables, black eyed beans, quinoa and brown rice instead of white forms of pasta.  I will right more about my diet at a later stage as in midst of it at moment!

CAN'T

white potato – sweet potato instead

white pasta – wholemeal instead

white bread

white cous cous

white rice -wholemeal instead

fruit juice

honey (have small amounts occasionally)

milk

yoghurt

bananas (can have half) -  

all sugar (had already stopped this a month or so before)

the fruit one is a hard one since I ate tons before, now half an apple or two tangerines or half a banana are my allowance probably not all at once!

I also bought a blood glucose monitor and started checking my levels first thing in the morning.  I would recommend starting to monitor 2hrs after eating and keeping a food diary as soon as possible, but for me, it was a lot to take in, a lot of changes being made and a lot of information being researched that I was just not ready to incorporate that regime if I didn't HAVE to. I managed the food diary.

[A very important issue to note regarding blood glucose monitors are that they have a discrepancy rate of 10% which means that if I get a reading of 6.5mmol it could mean 7.15 or 5.85 which, when one is trying to keep levels below a certain criteria, can make a massive difference.  The other issue with the monitor is that the way the blood is taken can also affect the reading.  Fingers should be clean since there is glucose on so many things from paper to the counter or food that may have been touched hours before.  Also, the way the blood comes out makes a difference.  The finger pricker is meant to cause enough blood to appear to be sucked onto the strip but often it doesn't and squeezing can cause plasma to come out which affects the reading.  All of these together often leaves me feeling very frustrated and upset and quite often makes me think that the whole thing is a waste of time, completely impossible to monitor and means nothing]

I can tell you I was crying whilst I ingested the 75g of lucozade plus into my body, because not only did it have caffeine (which I don't normally have) but it had various other colourings and additives that I don't want my children going near, especially my unborn ones.  I let the midwife know in no uncertain terms how appalling it was that this was their drink of choice.  Being there also felt to me as the start of a whole NHS invasion into my life which we had chosen to avoid this time around and this was even more upsetting.

Blood Sugar Levels for pregnant - non pregnant

Unfortunately, the result were not up to standards.  6mmol at fasting and 9.3mmol at 2hours.  This is where I have my issues.   Different levels from different sources, different doctors using different numbers.  The interpretations all depend on which protocol whichever particular hospital is using.  For ours, it was the SIGN guidelines, Scotland specific. <5.1mmol at fasting and <8.5mmol at 2hours.

Whatever way we looked at, I had gestational diabetes and a complete overhaul of my diet was required.  I was given an appointment at the clinic for 3days time and sent on my not so merry way, flying as high as a kite and wired to the moon on sugar.  The effect lasted most of the day and was not pleasant.

The day before my first clinic appointment, my midwife came for another check up and we found ketones in my urine.  I still do not understand fully what this meant, neither did she but made it clear I was to let them know at my appointment the next day.  There are studies regarding the long term effects of GD and of ketones on my child but I decided it is not the best place (35weeks, emotional, stressed and generally peeved) to be reading about that kind of thing.  I will at some point, when I am feeling stronger.  Informed is the key but overwhelmed is inadvisable, i know my limits!

The diabetic clinic appointment was actually not as invasive or threatening as I had worried it might be.  We were seen by a very informed and friendly diabetic nurse who answered all my questions and allowed me to follow her into the testing room and stand talking with her whilst she checked my urine and ketones.  I was given the all clear on both counts, no infection, no ketones.  My blood glucose level that day was 6.4mmol and I was informed that they were very happy with the results and I was to keep my levels between 5mmol and 8mmol.  We spoke with a dietician who looked at the diet I had been keeping since 23rd January and told me the reason I may have ketones, is that there was just not enough carbohydrates in my diet and so I had begun using fat as an energy source instead of carbohydrate or sugar.  Ordinarily this would have pleased me greatly..burning fat YAY! (akin to atkins diet)  Unfortunately, she was unable to tell me, as were most of the doctors I spoke to, the risk for my baby of having ketones in my body.  I was simply told it was not a great state to be in for the baby.  This dietician basically told me to eat more carbohydrates in my diet.  I decided not to discuss with her my views on wheat and dairy, as it seemed her basis for discussion was for people with a completely different diet than mine.  I was thoroughly confused with her advice to eat more carbohydrates (bread, potato, pasta) as I knew that would increase my blood glucose levels.  I already did not eat the white forms of these anyway and rarely if ever ate bread any more.

As it turns out,  my downfall and major error was really my portion sizes.  I followed her advice for a few days and soon realised that even though brown rice or basmati rice or even quinoa are low in carbohydrates compared to their white counterparts, eating a huge portion is still going to push my glucose level through the roof!!

During this appointment I also made sure I had a very important test called the HBA1C.  During my initial phone call with the Dr regarding my appointment, he seemed very non-committal over the importance of this test, so I was relieved I would not have to fight to have it done.  Basically, this test shows the average blood glucose levels over the past 8-12weeks since our amazing bodies store this information for us!!  It lets you know, how long the sugar issue has been going on.  Mine was within normal limits which shows that this was a relatively new problem and had not simply been missed.

I left that appointment feeling pleased with all my results and optimistic about my abilities to control my blood glucose levels with my diet.

13days later I met with the big guns at the obstetric diabetic clinic.  It was quite a full waiting room.  I had been pre-warned that there could be at least 6 people in the room and not to freak out at this, it was not a reflection on my progress but merely a way of seeing all relevant people at the one time and place.  Still, it was overwhelming to walk into a roomful of unrecognisable faces.  Faces of NHS staff who could potentially scupper my homebirth plans.

Did you know that within the NHS, there is ONE woman who has gestational diabetes and this is how they deal with it?  Same measures for everyone, all treated as that one clinical patient.  These are my husbands words on one problem with NHS being involved in pregnancy

"The real problem with the nhs being involved in a pregnancy is everything is reduced to risk and risk management.  Of course the NHS provides an important and valuable service when needed.  But the NHS views risk factors as the start of the road to maximum intervention.  Everything becomes an exercise in monitoring and assessing risk based on current studies and statistics.  
Mothers are removed from deciding what they want, from knowing what they need, or choosing how they want the birth to be… unless they are prepared to battle.  The mother’s focus shifts from preparing for the birth to dealing with the NHS.  The power of a woman to take control of her birth experience is undermined at the very moment that she needs to be connecting with her capabilities and strength"


They basically wanted to start me on insulin straight away and outlined their protocols for this outcome, which is full time monitoring and attached to machines.  Not the community midwife unit, not at home but in their medicalised labour ward.  It was handed to me as the only option but unusually he did say it was still my decision at the moment. For some reason, they also changed their own bracket for my blood levels to 5mmol-7mmol, a total difference to two weeks previous which  upset me greatly as it makes controlling with diet even harder.

I also declined the scan and my midwife was quite surprised to note that there was no palpation of the baby or any hands on checking whatsoever.  They made another appointment for two weeks later.  I doubt it even occurred to them that I was not accepting outright and would make a decision later regarding the scan.


I came away from the meeting with the following thoughts:

"Processing the info and crapness of info, But as of right now I am screaming NOOOoooo
No placetal function cord doppler sizing
No hospital labour hooked up to iv machines
No monitoring
No progressing police
No
No
No
No
NOOOOOOOOOOOOOOOOOOOOOOoooooooooooooooooooo"


They asked me to keep them informed of my blood levels by calling in with my numbers, which brings me to my other post which were my first thoughts on the whole GD experience.

This has been my journey so far....I have decided to have the scan on Wednesday, my midwife would feel more comfortable knowing a rough size estimate although by her calculations I have been consistently 2cm more than my week with no major increases.  Also, it helps to appease the NHS, not that it should be a major factor, I just do not want to have another battle and fight with them.  I fully expect the placental and cord function to be normal and the baby's growth to be slightly high (growth scans are still notoriously inaccurate)but I think it will be manageable.  After all I have done this twice before!!



Meltdowns - minimal
Losing the Plot - intermittent
Breastfeeding - got the colostrum bottles, now waiting to pump at 36weeks!

CLICK HERE FOR RESOURCES AND ARTICLES USED FOR OUR RESEARCH

Resources for Gestatonal diabetes

This is some of the many resources we used for GD

Understanding Gestational Diabetes - Natasha Leader 

How can I tell whether I'm at high risk for gestational diabetes?

Shoulder Dystocia The real story  - Midwife Thinking

The Importance of colostrum - La Leche League 

Donor Milk - Human milk for human babies

Hand expression of Breastmilk - Stanford School of Medicine

Gestational diabetes - Revisited - Bellies and Bumps

Gestational diabetes: A diagnosis still looking for a disease? - Michel Odent

SIGN - Scottish Intercollegiate Guidelines Network - Management of Diabetes

Ketones in Urine During Pregnancy

What is HBA1C?

Diet Preparation for 3hr glucose tolerance Test - Ronnie Falcao

Normal Blood sugars in Pregnancy - Diabetes Update Blood Sugar 101

Glucose Tolerance in Adults After Prenatal Exposure To Famine - the Lancet

Gestational Diabetes - Homebirth Reference site

Gestational Diabetes in Pregnancy - BellyBelly

Gestational Diabetes - the Emporer Has No Clothes - Henci Goer

Gestational Diabetes - KMom

Gestational Diabetes Troubleshooting High Readings - KMom

Gestational Diabetes The Numbers Game - KMom

Systematic Review of Herbs and Dietary Supplements for Glycemic Control in Diabetes

Michel Odent on GD "Gestational Diabetes: A Diagnosis Still Looking For a Disease?"

"Gestational Diabetes: A Diagnosis Still Looking For a Disease?"

Primal Health Research: A New Era in Health Research
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road
London NW3 2JR
Summer 2004 Vol. 12 No.1 

An article of the same title appeared in The Journal of Prenatal & Perinatal Psychology and Health (JOPPPAH) Volume 19, Number 2, Winter 2004

Nowhere in obstetrics is there such a discrepancy between evidence and practice as in the matter of gestational diabetes. This diagnosis has been mentioned briefly in several issues of our newsletter, in order to illustrate the frequent “nocebo effect” of prenatal care. (1,2,3,4) I have recently received so many phone calls of sorely distressed women that I find it necessary to provide updated answers to frequently asked questions. 

How to explain? How to explain with simple words the real meaning of this scary diagnosis? How to explain that it is not a disease like with symptoms leading to complementary inquiries, but the mere interpretation of a laboratory test? 

It is essential to emphasize that such a diagnosis is made after the “glucose tolerance test” is included in the battery of tests routinely offered to pregnant women. It is easy to illustrate this fact by referring to the results of a huge Canadian study.(5) In some parts of Ontario routine screening was interrupted in 1989, while it remained usual elsewhere in that state. It became clear that the only effect of routine glucose tolerance test screening was to tell 2.7% of pregnant women that they have gestational diabetes. It did not change the statistics of prenatal mortality and morbidity. 

Simple physiological explanations can also help reassure a certain number of women. One role of the placenta is to manipulate maternal physiology for fetal benefit. The placenta may be presented as the advocate of the baby, so that the transfer of nutrients to the fetus is optimized. It is via hormonal messages that the placenta can influence maternal physiology. The fetal demand for glucose increase gradually throughout pregnancy. The mother is supposed to react to this demand by reducing her sensitivity to insulin.(6) This leads to a tendency towards hyperglycaemia that is easily detectable after a meal or after ingesting glucose. Some women can compensate their peaks of hyperglycaemia more effectively than others by increasing insulin secretion. When hyperglycaemia peaks above a pre-determined conventional threshold, the term “gestational diabetes” is used. In general glucose tolerance will recover its usual levels after the birth of the baby. 


Practical recommendations

The practical advice one can give to women carrying the label of “gestational diabetes” should be given to all pregnant women & another reason to question the practical benefits of such a diagnosis. This advice concerns lifestyle, particularly nutrition and physical activity. 

Nutritional counseling should focus on the quality of carbohydrates. The most useful way to rank foods is according to their “glycaemic index” (GI). Pregnant women must be encouraged to prefer, as far as possible, low GI foods. A food has a high index when its absorption is followed by a fast and significant increase of glycaemia. In practice this means, for example, that pregnant women must avoid the countless soft drinks that are widely available today, and that they must also avoid adding too much sugar or honey in their tea or coffee. Incidentally, one can wonder if the tolerance test, which implies glucose consumption (the highest substance on the GI), is perfectly neutral and harmless. GI tables of hundreds of foods have been published in authoritative medical journals.(7) These tables must be looked at carefully, because the data they provide are often surprising for those who are still influenced by old classifications contrasting simple sugars and complex carbohydrates. Such classifications were based on the mere chemical formula. 

From such tables we can learn in particular that breakfast cereals based on oats and barley have a low index. Wholemeal bread and pasta also are low-index foods. Potatoes and pizzas,(8) on the other hand, have a high index and should therefore be consumed with moderation. Comparing glucose and fructose (the sugar of fruit) is a way to realize the lack of correlation between chemical formula and GI. Both are hexoses (small molecules with six atoms of carbon) and have pretty similar chemical formulas. Yet the index of glucose is 100&versus 23 for fructose. This means that pregnant women must be encourage to eat fruit and vegetables, an important point since pre-eclampsia is associated with an oxidative stress. 

The quantity of carbohydrates should also be taken into consideration. French nutritionists showed that, among pregnant women with reduced glucose tolerance, there is no risk of having high birth weight babies if the daily consumption of carbohydrates is above 210g a day.(9) This implies a moderate lipid intake. About lipids, the focus should also be on their quality, the ratio between different fatty acids. For example we must take into account the fact that monounsaturated fatty acids (such as the oleic acid of olive oil) tend to increase the sensitivity to insulin. We must also stress that the developing brain has enormous need of very long chain polyunsaturates, particularly those abundant and preformed in the sea food chain.(10) 

Advice regarding physical activity is based on theoretical considerations and on the results of observational studies. Skeletal muscle cells initially use glycogen stores for energy but are soon forced to use blood glucose, thus lowering glycaemia in the short term.(11) In addition, exercise has been shown to increase the insulin sensitivity of muscles and glucose uptake into muscular cells, regardless of insulin levels,(12) resulting in lower glycaemia. The effect of exercise on glucose tolerance has been demonstrated among extremely overweight women (body mass index above 33). 10.3% of obese women who took no exercise had a significant reduction of glucose tolerance, compared with 5.7% of those who did any exercise one or more times a week.(13) “A walk in the shopping mall for half an hour to an hour a couple of times a week is all that is needed”, says author Raul Artal. According to what we currently know, the benefits of a regular physical activity in pregnancy should be a routine discussion during prenatal visits, whatever the results of sophisticated tests. 

Looking for a disease 

Almost everywhere in the world, “gestational diabetes” is a frequent diagnosis. We should therefore not be surprised by the tendency to assign it the status of a disease. This might appear as a feat, since this diagnosis is not based on any specific symptom, but just on the effects of an intervention (giving glucose) on blood biochemistry. 

One of the ways to transform a diagnosis into a disease is to list its complications. The well-documented fact that women carrying this label are more at risk than others to develop later on in life a non-insulin dependent diabetes has often been presented as a complication.(14) But this “type 2 diabetes” is not a consequence of reduced glucose tolerance in pregnancy. It is simply the expression, in another context, of a particular metabolic type. One might even claim that the only interest of glucose tolerance test in pregnancy is to identify a population at risk of developing a type 2 diabetes. But when a woman is looking forward to having a baby, is it the right time to bother her with glucose intake and blood samples, and to tell her that she is more at risk than others to have a future chronic disease? It is probably more important to talk routinely about nutrition and exercise. 

Gestational hypertension has also been presented as a complication of gestational diabetes. In fact an isolated increased blood pressure in pregnancy is a transitory physiological reaction associated with good perinatal outcomes.(15, 16, 17, 18) Once more the concomitant expression of a particular metabolic type should not be confused with the evolution of a disease towards complications. 

Professor Jarrett, a London epidemiologist, made a synthesis of the questions inspired by such associations. He stressed that women who carry this label are, on average, older and heavier than the overall population of pregnant women, and their average blood pressure is higher. This is enough to explain differences in perinatal outcomes. The results of glucose tolerance tests are superfluous. According to Professor Jarrett, gestational diabetes is a “non-entity”.(19) 

The concept of fetal complications is also widespread. Fetal death has long been thought to be associated with gestational diabetes. However all well-designed studies looking at comparable groups of women dismissed this belief, in populations as divers as Western European (20) or Chinese (21), and also in Singapore (22) and Mauritius.(23) High birth weight has also been presented as a complication. In fact it should be considered an association whose expression is influenced by maternal age, parity and the degree of nutritional unbalance. If there is a cause and effect relation, it might be the other way round: a big baby requires more glucose than a small one. It is significant that in the case of twins “when the demand is double” the glucose tolerance test is more often positive than for singleton pregnancies. Only hypoglycemia of the newborn baby might be considered a complication, although there are multiple risk factors. 

Another way to transform a diagnosis into a disease is to establish therapeutic guidelines. Until now, no study has ever demonstrated any positive effect of a pharmacological treatment on the maternal and neonatal morbidity rates, in a population with impaired glucose tolerance. On the contrary no pharmacological particular treatment is able to reduce the risks of neonatal hypoglycaemia.(24,25) However gestational diabetes is often treated with drugs. The frequency of pharmacological treatment has even been evaluated among the fellows of the American College of Obstetricians and Gynecologists (ACOG).(26) It appears that 96% of these practitioners routinely screen for gestational diabetes. When glycaemic control is not considered acceptable, 82% prescribe insulin right away, while 13% try first glyburide, an hypoglycaemic oral drug of the sulfonylureas family. 

While practitioners are keen on drugs, there are more and more studies comparing the advantages of human insulin and synthetic insulins lispro and aspart,(27, 28) or comparing the effects of twice-daily regimen with four-times-daily regimen of short-acting and intermediate-actinginsulins.(29) Meanwhile the comparative advantages of several oral hypoglycaemic drugs are also evaluated. The criteria are always short- term and “glycaemic control” is the main objective.(30) The fact, for example, that sulfonylureas cross the placenta should lead to caution and to raise questions about the long-term future of children exposed to such drugs during crucial phases of their development. 

The nocebo effect of prenatal care 

After reaching the conclusion that the term “gestational diabetes” is useless, one can wonder if it is really harmless. Today we understand that our health is to a great extent shaped in the womb.(31) Furthermore we can interpret more easily the effects of maternal emotional states on the growth and development of the fetus. In the current scientific context we can therefore claim that the main preoccupation of health professionals who meet pregnant women should be to protect their emotional state. In other words the first duty of midwives, doctors and other practitioners involved in prenatal care should be to avoid any sort of “nocebo effect”. 

There is a nocebo effect whenever a health professional does more harm than good by interfering with the belief system, the imagination or the emotional state of a patient or of a pregnant woman. The nocebo effect is inherent in conventional prenatal care, which is constantly focusing on potential problems. Every visit is an opportunity to be reminded of all the risks associated with pregnancy and delivery. The vocabulary can dramatically influence the emotional state of pregnant women. The term “gestational diabetes” is a perfect example. 

When analyzing the most common reasons for phone calls by anxious pregnant women, I have found that, more often than not, health professionals are ignorant of or misinterpret the medical literature, and that they lack of understanding and respect for one of the main roles of the placenta, which is to manipulate maternal physiology for fetal benefit.

Prenatal care will also be much cheaper on the day when the medical and scientific literature will be better interpreted! 

Michel Odent 

Références : 

1 - Odent M. The Nocebo effect in prenatal care. Primal Heath Research Newsletter 1994; 2: 2-6.

2 - Odent M. Back to the Nocebo effect. Primal Heath Research Newsletter 1995; 5 (4).

3 - Odent M. Antenatal scare. Primal Heath Research Newsletter 2000; 7 (4).

4 - Odent M. The rise of preconceptional counselling vs the decline of medicalized care in pregnancy. Primal Health Research Newsletter 2002;10(3)

5 - Wen SW, Liu S, Kramer MS, et al. Impact of prenatal glucose screening on the diagnosis of gestational diabetes and on pregnancy outcomes. Am J Epidemiol 2000; 152(11): 1009-14.

6 - Vambergue A, Valat AS, Dufour P, et al. Pathophysiologie du diabète gestationnel. J Gynecol Obstet Biol Reprod (Paris) 2002 ; 31(6 Suppl) : 4S3-4S10.

7 - Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values. Am J Clin Nutr 2002; 76(1): 5-56.

8 - Ahern JA. Exaggerated hyperglycemia after a pizza meal in well-controlled diabetics. Diabetes Care 1993; 16: 578-80.

9 - Romon M, Nuttens MC, Vambergue A, et al. Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women with gestational diabetes. J Am Diet Assoc 2001; 101(8): 897-902.

10 - Odent MR, McMillan L, Kimmel T. Prenatal care and sea fish. Eur J Obstet Gynecol Biol Reprod 1996; 68: 49-51.

11 - Chipkin S, Klugh S, Chasan-Taber L. Exercise and diabetes. Cardiol Clin 2001; 19: 489-505.

12 - Wojtaszewski JP, Nielsen JN, Richter EA. Invited review: effect of acute exercise on insulin signaling and action in humans. J Appl Physiol 2002; 93(1): 384-92.

13 - Dye TD, Knox KL, Artal R, et al. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997; 146(11): 961-5.

14 - Kim C, Newton R, Knopp R. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25: 1862-8 

15 - Symonds EM. Aetiology of pre-eclampsia: a review. J R Soc Med 1980; 73: 871-75.

16 - Naeye EM. Maternal blood pressure and fetal growth. Am J Obstet Gynecol 1981; 141: 780-87.

17 - Kilpatrick S. Unlike pre-eclampsia, gestational hypertension is not associated with increased neonatal and maternal morbidity except abruptio. SPO abstracts. Am J Obstet Gynecol 1995; 419: 376.

18 - Curtis S, et al. Pregnancy effects of non-proteinuric gestational hypertension. SPO Abstracts. Am J Obst Gynecol 1995; 418: 376.

19 - Jarrett RJ. Gestational diabetes : a non-entity ? BMJ1993 ; 306 : 37-38.

20 - Roberts RN, Moohan JM, Foo RL, et al. Fetal outcomes in mothers with impaired glucose tolerance in pregnancy. Diabet Med 1993; 10(5): 438- 43.

21 - Lao TT, Ho LF. Impaired glucose tolerance and pregnancy outcome in Chinese women with high body mass index. Hum Reprod 2000; 15(8): 1826- 9.

22 - Tan Y, Yeo GS. Impaired glucose tolerance in pregnancy_is it of consequence ? Aust NZ J Obstet Gynaecol 1996; 36(3): 248-55.

23 - Ramtoola S, Home P, Damry H, et al. Gestational impaired glucose tolerance does not increase perinatal mortality in a developing country: cohort study. BMJ 2001;322: 1025-6.

24 - Jensen DM, Sorensen B, Feilberg-Jorgensen N, et al. Maternal and perinatal outcomes in 143 Danish women with gestational diabetes mellitus and 143 controls with a similar risk profile. Diabet Med 2000; 17(4): 281-6.

25 - Hellmuth E, Damm P, Moldted-Pederson L. Oral hypoglycaemic agents in 118 diabetic pregnancies. Diabetes Med 2000; 17(7): 507-11.

26- Gabbe SG, Gregory RP, Power ML, et al. Management of diabetes mellitus by obstetrician-gynecologists. Obstet Gynecol 2004; 103(6): 1229-34.

27 - Jovanovic L, Ilic S, Pettitt D, et al. Metabolic and immunologic effects of insulin lispro in gestational diabetes. Diabetes Care 1999; 22: 1422-7.

28 - Pettitt D, Ospina P, Kolaczynski J, et al. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Diabetes Care 2003; 26(1): 183-6.

29 - Nachum Z, Ben-Shlomo I, Weiner E, et al. Twice daily versus four times daily insulin regimens for diabetes in pregnancy: randomized controlled trial. BMJ 1999; 319: 1223-7.

30 - Langer O, Conway D, Berkus M, et al. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med 2000; 343: 1134-8.

31 -La banque de données du Primal Health Research Centre est spécialisée dans les études explorant les conséquences à long terme de ce qui se passe au début de la vie.

Girls thoughts on baby

WEAR HAVA BABY I WONR HOW WE R GOWING TOO GET THE BABY OUT - Ellie(typed herself)


But why didn't you let me see the baby being made - Ellie

How exactly does the seed get to the egg? - Ellie


The big giant penis baby will get me if I go to the toilet - Maia


I'm going to call the baby booboo and I will hold the baby and stroke the baby and not hit or kick or bite the baby - Maia


I'm listening to your baby and its saying 'junk junk junk junk junk' - Maia


Mummy I don't think you are having a baby
What's that then?
That's just your big belly
Gee thanks Maia


I love holding babies. When you are in the kitchen making porridge I will hold the baby - Maia


We will keep this baby.  I will hold him on my knee and cuddle him - Maia


We should have a party when the baby comes, with one candle.  We should have a party every day. - Ellie


Does mummy take you in to nursery?
When I was a little girl she did
Are you not still a little girl?
No cos I'm a big one now
So what happens now?
You look after the baby (when you are a big girl) - Maia

Wean Me Gently: A response from a place of guilt

I did not wean you gently my darling

It has been my chagrin

It is one of the things that causes me pain

It's one of those things I have had to learn to move on from

because move on we must

It is one of those things I have learned a lot from

Its one of those things that kept us bonded

Its one of those things that tested our bond

I did not wean you gently my munchkin

and for that I'm truly sorry

NHS gives bad advice *shocker*

I am so utterly appalled, but hardly surprised, at the advice being given by our National Health Service: controlled crying, unreasonably high expectations for a 6month old, no clear cut age limits for techniques, techniques which I find highly questionable as it is. Just unbelievable.

There has been enough research out there to prove that controlled crying is harmful but to not even give a balanced view point is symptomatic of the main problem with most of the NHS parenting advice.

Suggesting a 6month old is capable of sleeping through the night is not only biologically wrong, it completely undermines and harms the breastfeeding relationship. Babies need to eat frequently, they have small tummy's that do not hold much for long. "to nurse *very* frequently, based on the composition of the milk of the species," Sleeping through the Night by Kathy Dettwyler

This advice page MUST be rewritten taking into account the clear links between controlled crying and the damage it does to developing intact brains and the conflicting advice it purports which definitely has implications for the breastfeeding dyad.

Here is a link to my co-sleeping articles.

Here is a fraction of the papers out there on the dangers of cry it out and controlled crying: -

http://www.askdrsears.com/topics/fussy-baby/science-says-excessive-crying-could-be-harmful

http://www.naturalchild.org/james_mckenna/cosleeping.pdf

http://www.naturalchild.org/guest/pinky_mckay.html

http://www.smh.com.au/news/national/despairing-mums-told-to-ditch-controlled-crying/2007/03/10/1173478729137.html

http://www.guardian.co.uk/society/2010/apr/21/leaving-baby-to-cry-brain-development-damage

http://www.independent.co.uk/life-style/health-and-families/health-news/babies-left-to-cry-can-suffer-brain-damage-warns-parenting-guru-1950702.html

http://www.dailymail.co.uk/health/article-2149060/Babies-left-unhappy-hours-stress-hormone-remains-high.html

http://www.bellybelly.com.au/baby-sleep/the-con-of-controlled-crying

http://www.phdinparenting.com/2008/07/05/no-cry-it-out/

Please add your comments on the NHS article page and lets keep the NHS informed

Sleep, What's the deal??

Does self regulation truly exist?  How do you decide what comes under the need to 'self regulate'?

A newborn is 100% self control, they pee, poop, eat, sleep and do everything else when they need to and when they want to.  We don't interfere with that process, we don't stop them from doing what they need to do, we trust that they know what they need, when they need it and we listen.  We respond.  We clean the poop, we wipe the pee, we feed them and we let them sleep whenever and wherever they fall asleep (usually on top of one of us!).  We attempt to respond to their needs lovingly,  effectively,  instantly and efficiently.  The fact that we use EC, breastfeeding, co-sleeping and baby wearing (among other things) as tools to help us achieve this is not only in part due it being a biologically imperative [Cosleeping and Biological Imperatives:Why Human Babies Do Not and Should Not Sleep Alone] but also because it just makes sense and is far easier on the heart body and mind than the alternatives.

With the kind of parenting that we do, sleep training/cry it out [The con of controlled Crying] from an early age was never going to be a choice.  When our babies were babies, they slept when they needed and wanted and we kept them with us until we felt they were ready to be in bed either alone or with someone.  This usually occurred around the age of one. Until then, they would be on the beanbag or the sofa or the mummy or the daddy downstairs asleep until they woke for whatever their reason was.

At some point though this sleeping arrangement was changed by us.  We did not continue to leave the control 100% within the remit of our offspring. I know many of us have tried this approach and have felt it not work (myself included), but yet there are some who have managed it[Sleeping for Unschoolers] , so it *is* possible.   I so wanted to be a family who made it possible. What happened?

As far as I can work out, several things happened as our children got older:-

1. They began to need to wake for milk less frequently so did not need to be near me
2. They began to need to wake for eliminating less frequently so did not need to be near us
   
   These two alone would not be reason enough to change (break) their self regulatory streak

1. They began to stay awake longer and need to sleep less frequently and did need to be near us
2. We  began to need a more consistent block of sleep
3. We began to need some space where our every move and thought was not consumed by their wants and needs

I am trying to work out if this is too simplified or if there are other factors involved. Why the change?  We let them self-regulate as newborns and for longer, so why not continue it....there are so many issues involved around, could it just because our needs overtook theirs?  Perhaps our way of living interfere with our ability to live a self regulated life, the need to be up at an early time in the day, the need for a consistent block of sleep? Maybe their personality affects their own ability to self regulate? Most of the time lack of tribe is a massive factor?

In actuality (and sadness),  I believe one of the main reasons that we stopped leaving them to self manage their sleep, which they had been doing quite happily and effectively up until then, was because our needs overtook theirs and our personality and temperament blocked their autonomy to self regulate?

Does self regulating sleep work for you?

Meltdowns - one major one after looong day in drizzly wet park
Losing the Plot - too tired
Breastfeeding - must buy pipette bottles

Thoughts on Gestational Diabetes Experience

Its so fucking much to process at the moment its crazy....having meeting with IM tomorrow to suss out each others comfort zones for making a home birth happen... although occasionally I think FUCK IT induce and caesarean...thats how crazy it can get!!!

Numbers are down, nhs appeased off insulin for another week or so, making decision on scan in 2weeks re worth the risk of notoriously off sizing chart and more stress...pinning waay too much hope on going early like last two but know thats not a definite....

I'm having to work out the whole food thing in a short space of time to get my numbers under control so i can help my birth happen with the least interventions and complications and fuck me its not easy!! Been off refined sugar for nearly two months now and still get major craving every so often, like tonight.

I've been sending Maia's birth video to my sister for her advice and holy crap, I kind of wish I hadn't watched it just now. It took me 2yrs to write her birth story, thats how hard it was to process!!

"I've seen the future, and this all works out reasonably well." Almost Famous



Meltdowns - sporadic and usually between sisters
Losing the Plot - minimal
Breastfeeding - buying pipette bottles for colostrum

OP Tricks by Alison Ewing

OP TRICKS

by Alison Ewing

OPEN KNEE-CHEST. From hands and knees position mother lowers head and chest to the floor. Knees should be apart and further back than hips. A bean bag can help the mother to retain this position for 30-45 minutes.

GORILLA STOMP. Have mom stomp up and down stairs to center an oblique baby. This is the same stomp we use to bring down a high baby or stimulate ctx. One of our dads named it the "Gorilla Stomp"- make sure there is a spotter below her on the stairs, flat footed, have her set her feet wide apart and stick her tail out a little. Then she stomps down the stairs one at a time, placing her feet wide and swinging her hips from side to side as though she were trying to hit the sidewall of the staircase. Really heavy footfalls. Do a drop squat at the bottom of the stairs. Stomp up the stairs, again placing her feet wide apart, taking the steps two at a time if she can. Some short moms can't manage that.Do a drop squat at the top. I've seen one or two trips up and down the stairs center a baby perfectly.

DUCK WALKING.OR STOMP STOMP SQUAT. Mum walks flat footed, picking her knees up high with each step. Shakes her tail, like a duck. Squats at end of ctx. Good for getting the humour quotient up.

OLD TIME MIDWIVES PUSH TECHNIQUE. Have a multip try pushing with a contraction or two even if they're only 6 or 7 cm. I had a G5 P3 recently stuck WAY up there in an OP position, and couldn't get the head to descend far enough to spin on the soft tissue even after a long painful time of standing and squatting. One of our older docs suggested I have her push a time or two even though she was 6 cm....you can guess what happened on the next ctx. It sure worked! Ann Shields in Germany

ANN SHIELD'S EPIDURAL TECHNIQUE.( can be used without the epidural) This works well with too heavily epiduralized patients. Sit them absolutely straight up with their legs Indian- style, and tie a sheet or towel onto the birthing bar. Have them rock back and forth from on hip to the other, holding onto the sheet for stabilization (since the bar is usually too far forward to grab onto in this position). I suspect the alternating weight on one acetabulum at a time moves the spines out of direct opposition and gives the head a little more room. Also seems to work well for asynclitism but not as well in either malposition as all fours. Anne shields in Germany.

HANDS AND KNEES. Mum leans forward over a birth ball a chair or the back of the birth bed, if it can be adjusted that way. Put something soft under the mother's knees and help her to get as comfortable as possible so that she can stay this way while swaying and rocking her hips or tilting her pelvis through as many ctx as possible.

SHAKIN' THE APPLES. 1) Mom is in hands and knees and she rocks back and forth keeping her back parallel with the floor at all times. 2) You (or her partner or anyone really) sit behind her with your arms extended in front of you with fists made. 3) When mom rocks back she bumps into your fists (which you are holding steady). Your fists hit her at the bottom of her pelvis. She can bump into you as hard as she wants, yet you never go and bump into her. This little 'jolt' also helps to dislodge the OP baby. ilana (who learned this from the wonderful ladies in Alaska)

SLOW DANCING. Mother slow dances with a partner, usually with hands over the partner's shoulders. This enables her to be supported while she sways and circles her hips. Partner can also move mothers hips for her while she hangs from his/her neck.

OLLIE'S TECHNIQUE. Put mum flat on floor with a rolled blanket/pillow in the small of her back to arch her belly out and hyperflex her back. Baby doesn't like and will turn sometimes. Ollie Anne Hamilton, LDEM, CPM

ANOTHER FOR EPIDURAL OPS. On a flat bed, Mom on side (preferably left, but doesn't matter) with lower leg straight and upper leg pulled way up and on a pillow or two (give ample room to tummy). Lower arm behind and upper arm up and over the pillow her head is on. Now lower the head of the bed into shock position (head lower than feet). This give baby lots of room to move, turn and the head-lower-than-feet helps baby disengage from pelvis to make turning easier. Connie Banack

PENNY SIMKIN'S TECHNIQUE. There's a difference between the mechanics of the side lying position and the semi-prone position. If you're recommending which side the mom should lie on to turn her baby from posterior, it matters which of those two positions the mom is using. If the mom is side lying (really on her side, with her legs one on top of the other, and her body perpendicular to the bed) suggest she lie on the side that puts the baby's back "toward the bed". Try this with your doll and model pelvis to see what I mean. Gravity tends to pull the back of the baby's head down toward the bed, so he'll (hopefully) rotate from OP to OT. If the mom is semi-prone (rolled forward so her top leg is in front of her bottom leg, and her belly's more toward the bed) suggest she lie so that the baby's back is "toward the ceiling". Gravity will tend to pull the back of the baby' toward OT, and from there toward OA.

SIMILAR IDEA FROM OB NURSE. When I have a mom who's not bringing the baby down well or who is "stuck" at a certain level of dilation, I routinely turn her to her right side. When I say right side, I mean FAR right--I tell her to try to lay on her stomach! This almost always works to rotate that baby right into an OA position, she progresses and baby descends and delivers. If the baby doesn't tolerate the far right side, I have mom try the far left. It seems the most important part is that she is almost on her stomach. This is especially useful if you have determined that baby is OP

VICKI TAYLOR'S PANCAKE FLIP. Two contractions on left side, two on right side, two on hands and knees, and two in knee-chest. Rarely have I had to do more than two cycles of that to turn a posterior. Turning a posterior with the mom on in an upright position is difficult because you lose the flexibility of the sacrum.

FIGURE EIGHTS/ BELLY DANCING. Mother swinging hips in a figure 8 like a belly dancer.This can also be done to mother on hands and knees with helper moving mother's hips in a figure eight during a contraction. Works well on a birth ball too.

CAT STROKING. Mom should do a couple dozen slow, deep pelvic rocks while on her hands and knees. Really let her tummy hang and exaggerate the movements. Then she gently puts her hand on the baby's back and strokes and clothes" him toward the center of her tummy and even to the other side if the baby turns easily. (Almost always this means mom moves the baby from the right side to the center).

The tummy hanging and the slow deep rocks help the baby move upward so he has more room to turn. And if you move the baby's back then the head will follow. I think mom should do this rather than us, because she knows how much strength to use. I've helped mom stroke sometimes though just to give her the idea of how to do it. Gail Hart Should be done between ctx.

HOT COMPRESSES. Also I have used hot compresses to the lower abdominal muscles to relax them and aid in the repositioning, as the lower uterine segment gets tight.

JUDY JONES' DIAPHRAGMATIC RELEASE. It is easy to recognize a persistent posterior baby. You cannot feel the back on palpation, rather only little lumps and bumps of limbs. To do a diaphragmatic release, it is best to have the mother lie on her back. If she is in advanced pregnancy and this makes her very uncomfortable, you can have her lie in a recliner or semi-sitting position. If you use that position, place a small pillow or adequate support behind her lower back.

One hand will go horizontally across her lower back where the uterine ligaments attach. This is where you would put lower back pressure during labor. You do not need to press, as just the pressure of the mother lying on your hand will be sufficient. (Be sure you take off any rings you may be wearing, for your hand's sake!)

The top hand will go on top of the abdomen, horizontally just above the pubic bone with the thumb upward. Just rest it lightly on the abdomen, no pressure. Then all you have to do is wait. Things may start right away or it may take several minutes before you feel anything. What you will feel is a motion beneath your hands. For the hand in back it will feel much like it does when there is a contraction taking place during labor as you feel the muscles tighten and contract beneath your hand and release. For the top hand it will be either a waving motion or a circular motion under your hand. At first you will think you are just imagining it, but you are not. The best description I can give is that it feels as if the mother has a tennis ball in her abdomen that is being bounced back and forth between your hands. As it hits one hand it will roll across it or around underneath it and then bounce back to the other hand. Sometimes the motion is so great that it will actually make your hand wave on the abdomen. Sometimes the mother will feel things inside, sometimes not. What she feels may not be located where your hand is located. The movement under your top hand may stay all in one place or move around. If it moves, try to gently follow it with your top hand to keep it centrally located under your hand. Do not move the back hand. Sometimes it will move around in a circle, sometimes off to one side, or even clear down to a hip. It all depends on the muscles that are involved and the type of injury that precipitated all the spasm of abdominal muscles. Our muscles really only know how to contract and shorten, not how to relax and lengthen. They depend on another counter muscle to contract and pull the first one out of contraction. Abdominal muscles do not have as many counter muscles, so this technique allows the muscles to relax.

You continue the diaphragmatic release as long as you feel motion under your hand. Usually it will just fade away and you will no longer feel it. Sometimes, if you end up over a bony prominence, it will end with a vibration. The process takes some time, often at least 20-45 minutes. But if you consider the time you save in labor, it is well worth it. You may need to repeat the process over several visits. I usually start at about the 6th month unless I have a mother with a history of car accident or several prior posterior babies. This procedure has also been used this technique to turn breech babies. I use it for transverse but find it less effective for breech. I usually use a tilt board for breech and then do a diaphragmatic release after the baby turns. It works marvelously well for posteriors. I have never done one where the baby did not turn to anterior. However, on some occasions, after a few days the baby will turn back to posterior and you will need to repeat the process more than once. The more severe the history, the more likely you will need to do it several times before the baby will stay anterior.

Posterior babies use to be the worst problem I had in births. The long hard back labors wore us all out and occasionally ended in transfers for maternal exhaustion. I am thrilled not to have these any more. Now my biggest problem is cervical lips! But I am working on a solution for that also, using evening primrose oil!

I do believe every midwife should have this valuable tool, the diaphragmatic release, in her bag of tricks. It is so easy and non-interventive. It is much better than other suggestions I have seen of putting your fingers in the baby's suture lines and trying to turn the head! --Judy Jones

STANDING LUNGE Mother stands with one foot flat on the floor and the other foot at right angles on a foot stool or low chair. She turns her body to face the chair, rests her hands on her leg and leans forward onto that knee during or between ctxs. She may need someone to support her while doing this. The lunge will feel more comfortable in one direction than the other, that is the better way to lean. Do it over several ctxs.

STANDING LUNGE 2 Mother stands with one foot flat on the floor and the other foot at right angles on a foot stool or low chair. She remains facing forward, away from the chair. remaining upright she leans sideways toward the chair lunging so that the knee on the chair bends. Slowly count to 5 then return to upright . The mother should feel the stretching on the inside of both thighs. The lunge will feel more comfortable in one direction than the other, that is the better way to lean. Do it over several ctxs.

KNEELING LUNGE Kneel with one foot flat on the floor lean forward onto the raised knee during ctxs.

SIDE LYING LUNGE. If a woman can't get out of bed because of hypertension or because she has had an epidural, I have had great results with a side-lying lunge. Mom lies on one side with three or four pillows stacked in front of her tummy. Her top knee is bent and placed on top of the pillows at as strong an angle as she can stand. Her lower leg is kept straight and angled back on the bed as far as she can stand. She'll look like a hurdler lying down. Turning from side to side about every half hour, repeating the position, is very effective. The nurses in our area hospitals are starting to use this position because they've seen how well it works. -Marla Lukes, certified doula, Minneapolis, MN

TOILET SITTING. Sitting on the toilet for a few ctx can turn a baby as the mother has been acculturated to let go of the pelvic muscles since toddler hood. Make her comfortable with a chair stacked with pillows or with a pillow over the back to encourage forward leaning position. Alternatively she can sit facing backwards with pillows to keep her comfy.

ANOTHER FOR SUPINE MUMS. To rotate an occipitoposterior baby, put the mother on her side in Trendelenburg's position (supine on a table which is tilted head downward 45 degrees or less). The first time I tried it, the baby rotated and delivered quickly. It probably gets the baby's head "unstuck" from the birth canal and helps it rotate easier. Most mothers can tolerate this position better than knee-chest, and it seems to work better. We put a large wedge under the mattress of the bed. A beanbag could also work. Margie Riley, Midwifery Today Issue 46

WALCHER'S POSITION. Some moms with a posterior baby seem to instinctively arch their backs once they begin pushing. This probably pulls the sacrum away from the occiput and opens up the pelvis a bit more. The following trick for helping a mom arch her back: Take a towel or blanket and roll it up. Have the mom lie flat on her back with the small of her back directly over the rolled-up towel. Her back will be arched pretty steeply. She needs to stay there through at least three contractions, maybe more. Some women find this very uncomfortable, but some women find it feels better or that the pressure on the sacrum feels great.

TUMMY TUCK or BELLY LIFTING. The mother stands with her feet apart and her hands tucked under her belly. When the contraction starts she bends her knees, thrusts forward her hips (pelvic tilt) and lifts up her belly by pressing inward and upward with her hands. The belly lifting can be done by someone else, but I prefer to support the mother from behind while she does it. When a mum has an OP baby it feels great to do this trick. When this was what she needed labour can progress very quickly . What I like about it is that it is something the mothers can do for themselves.

ROBOZO TECHNIQUE. The shawl ( long rectangular) is laid open horizontally (east/west) on the floor and mom lies vertically (north south) in the middle of the shawl; the rest of the shawl spreads out equally on both sides of the mother. The width of the shawl should reach ~ from the middle of mom's back to just below her butt. The midwife and her assistant, or another midwife, stand on opposites sides of the mom and lift up their end of the robozo. Mom's hips at this point, are cradled about a foot off the ground. Her feet are still on the floor. The midwives then get a rhythm of gently pulling the robozo upwards and back and forth between them--it reminds me of a see saw . They count off maybe two or three "rocks," and then one of the midwifes will give a sharper and higher pull which makes mom's stomach kind of "lurch" to the opposite side. This is done 2-3 times and heart tones taken. If baby is say, ROP, the midwife on the mom's right hand side will do the "lurch tug" until baby is approaching an anterior position. Some midwives will stop at this point and have mom labor for about an hour on her side to get the baby to complete its rotation OR they will continue to use the robozo until baby is anterior.

ROBOZO PICTURES. http://www.mother-care.ca/rebozo.htm

STERILE WATER PAPULES. NON PHARMACOLOGICAL PAIN RELIEF. http://www2.coastalnet.com/~coyotemidwife/SWP_PAPE.htm

___INVASIVE TECHNIQUES_____

OLD TIME DOC'S TECHNIQUE Here is the technique, as described, only slightly abbreviated. He uses the rectal rather than the vaginal approach for 2 reasons: 1) it is (he states) easier to appreciate the posterior fontanel rectally 2) it does not require the membranes to be ruptured nor will it accidentally rupture an intact bag.

1. The patient lie on her back in an ordinary bed. 2. The doctor stands on the patient's right and a nurse on her left. 3. Inhalation analgesia (Trilene in this case) is administered. 4. Using his right index finger, the doctor, by means of a rectal examination, located the posterior fontanel. 5. The patient was then rolled over to her left side by the nurse, the operator meanwhile keeping his finger constantly in contact with the posterior fontanelle. 6. The docotr performed two (bimanual) movements simultaneously while the mother was being turned over to her left side by the nurse. a) he exerted pressure upon the baby's anterior (left) shoulder with his left thumb to cause the shoulder to roll forwards from right to left clockwise (if one was looking up at the maternal pelvis from below). b) the right index finger of the accoucheur.....exerted light tangential pressure at the posterior fontanelle to guide the foetal occiput round from the 7 o'clock position to the 12 o'clock position, the manipulation being very similar in force and direction as that used in a telephone; it is quite as quickly and smoothly completed as that. The movement of the patient's body, combined with the two simultaneous light movements of the accoucher's hands on its body and head, easily and gently rotated the foetus.....the description takes far longer to read than to perform." he also notes that this does not require full dilation of the cervix to perform.

VALERIE EL HALTA (very short version). Put her in knee-chest at 2 cm with her head to the side on a pillow and keep her there for 20 minutes to a half hour, making sure her belly is away from her knees enough to allow the baby to float out of the pelvis. Get your fingers in there and apply pressure to the baby's head until it turns. Once in position, break her BOW so the head will stay. If it doesn't work the first time, keep trying after a rest.

V E H"S TECHNIQUE V. LONG (slightly edited).

Posterior Presentation - a pain in the back

By VALERIE EL HALTA The Birth Center Valerie El Halta is a Certified Professional Midwife with NARM (North American Registry of midwives). She has been practicing midwifery for 20 years and has helped birth over 2,500 babies. She is co-director of the Birth Center in Dearborn, Michigan.

Assisting in Anterior Rotation Prenatally: 1) Have the mother do the "pelvic rock" exercise at least three times a day. 2) She may assume a knee-chest position for twenty minutes, three times a day. 3) Have the mother lie on a slant board (as with a breech position) several times a day for thirty minutes at a time. 4) Have the mother take warm baths and gently encourage her baby to "roll over". We have found it very effective for the mother to visualize her baby in the correct position and to talk to her baby, telling it to move as well. One time we had a particularly stubborn baby, who liked the way he was lying just fine. The mother had suffered with previous posterior labour and was very anxious that this not be a repeat performance. She had tried in vain to get this kid to cooperate, so I called the dad in and said, "Show this baby who's the boss!" Dad said, "Turn over, baby!" and he did.

Assisting Anterior Rotation During Labour: 1) When it is verified that the baby is in a posterior position, the first thing that I do is have the mother assume and maintain a knee-chest position for approximately 45 minutes. Although this position is not the most comfortable one for the mother, it is very effective as it allows the baby more room in which to rotate. I find that the mother tolerates this position well if she is not in advanced labour. We make sure that she is well-supported by lots of pillows and giver her lots of encouragement and emotional support. Often, while in the knee-chest position the contractions become more regular and more effective, which also assists the baby's rotation. 2) If the mother cannot tolerate the knee-chest position for as long as necessary to turn the baby, we alternate by placing her in an exaggerated Simm's position (lying on left side, two pillows under the right knee, which is jack-knifed, left leg straight out and toward the back). 3) Every effort should be made to avoid rupturing the membranes, as the "pillow" offered by the forewaters gives a cushion on which the baby's head may spin more easily. Furthermore, if the waters break before the baby has rotated to the anterior, it is possible that sudden descent of the fetal skull will result in a deep transverse arrest!

If labour is more advanced when the posterior is identified, say 4-5 cm, if may be helpful while the mother is in the knee-chest position for the attendant to place her hand in the mother's vagina and gently lift the head, somewhat disengaging the head and allowing it to turn to anterior. If the posterior has not been discovered until complete dilation, or if the above methods have not been applied in early labour, the baby's head may still be turned to make delivery more likely. Again, placing the mother in the knee-chest position, with knees slightly apart, the midwife may place her hand into the woman's vagina (remember, your hand is smaller than the baby's head!). Attempt to lift the head up by grasping the head firmly, waiting for a contraction and turning the baby into an anterior position. As soon as the head is corrected, hold on tight and when the uterus contracts again, urge the mother to push very hard! If the amniotic sac has not previously ruptured, rupture it now. This will assure that the position remains fixed and the baby will usually be born very rapidly. This procedure is both safe and sane, yet it must be acknowledged that it will take some physical strength to turn this recalcitrant little head against the force of a good contraction.