I know many of the women I work with are opposed to vaccines.  So I have decided it is necessary for me to have the best understanding possible so I know when to definitely recommend a vaccine, when to definitely recommend against, and how to help the parents understand the risks and benefits.

The first thing I often hear is that women want nothing to do with a vaccine in pregnancy, fearing it is unsafe for the baby.  This often comes up with the influenza vaccine.  CDC guidelines are clear that pregnant women should get the vaccine, but do you know why they recommend that?

1.  The recommendation is for the attenuated vaccine, not a live vaccine. This means the virus is not able to make you sick, but is still able to be recognized by your immune system to allow you to create a defense against the strains.

2. The defense you create to the influenza virus is transferred to your baby. These cells stay in your babies blood for about 6 months, meaning your baby is protected against influenza without having to get a shot.

3. When pregnant women contract influenza, they tend to be sicker than non-pregnant women. You cannot assume getting influenza in pregnancy is like getting a cold before you were pregnant.

4. Public health is about preventing disease, because the theory is if you prevent it then you do not have to deal with the problems the disease causes.

So these are the basic reasons CDC recommends pregnant women get an influenza vaccine. In terms of safety profile, the influenza vaccine has a pretty good one.  Even with H1N1, the basics of the vaccine stay the same it is the strain of virus that changes.  A group of virologists look at the strains of influenza present, then look at history to try to figure out what strain will be big next.  Some years they get it right, others (like 2009 with H1N1) they guess wrong and the major virus is not included in the vaccine.

I’m a vaccine cautious person, so what do I do?  While in school my choice is made for me, get the shot or no clinical.  But in reality I would choose to have the influenza vaccine while in school anyway.  Why?  Because in a health care office and in the hospital I am more likely than the general population to come into contact with the viruses.  If I get the virus, I will bring it home to my children and husband before I know I have it.  My children, though not asthmatic, have an unexplained asthma-like wheezy response to lower respiratory illnesses (perhaps due to my family history of allergies and asthma?).  It is my desire to reduce the number of these illnesses for my children to help prevent any asthma-like remodeling of their lungs.

Your decision may be different.  I’m sure if I didn’t have the children to think about, I might consider the value of the vaccine differently – but not being able to be in that situation I don’t know how my answer would come out.

I had the opportunity to attend a women’s health conference last week.  Not much on pregnancy, mostly preventing cervical cancer.  But one important take home point for everyone working with pregnant women.

The latest guidelines for pregnancy will be to perform a PAP test ONLY if the PAP is due.  It will not be a routine part of the prenatal visit.

And when it is due depends on many things, like the age of the woman and what type of testing she had for her last PAP and the results.  For example, if a woman has a negative PAP with HPV testing, she should not have a PAP again until 3 years – this isn’t she can stretch it out to three years, it is that she should not have it done again until 3 years.  It simply isn’t cost effective because the HPV testing has such good predictive value.

Good information to know.

I’ve had my first “traumatic” experience.  One of the clients I worked with was having difficulty managing her blood pressure and it of course spiked into dangerous territory. I knew this was a possibility, I knew it happened to some women.  But until recently, I never personally knew anyone it had happened to.

Before nursing school, I sort of understood blood pressure was a measure of overall health. I didn’t really know what it meant or why it was important.  I just knew if it wasn’t good you would be told to stop adding salt to your food.

Some would say nursing school has made me “fearful” of high blood pressure (hypertension) because I now understand this is something to be avoided. I want the families I work with to maintain healthy blood pressures, and honestly this should be manageable for most people. But it isn’t always easy to eat right and exercise (the two key factors to maintaining a healthy blood pressure). I also know if people understood the damage hypertension does to their bodies they might be more inclined to find time for that exercise and to eat right.

But I don’t understand gestational hypertension.  I don’t understand why one woman’s body responds to pregnancy this way.  I don’t know why, even with excellent nutrition and exercise, some women simply cannot maintain a healthy blood pressure during pregnancy.  And I cannot even begin to guess why some women can have gestational hypertension and return to normal after pregnancy with no ill effects while other women get progressively worse overall leading to placental problems and preeclampsia.

I guess that is why gestational hypertension seems so scary to many practitioners. It is something you cannot predict, often cannot control and can become dangerous very fast.

My questions today are about my responsibility to the families I work with.  At what point does providing information about diet and exercise become pushy and demeaning? At what point does my responsibility to educate meet their responsibility for their own health? I ask this because I know my role as a midwife is limited – decisions are not always in my hands when a woman develops gestational hypertension.  So if I am going to help her, I need to do my best to ensure she does not develop gestational hypertension. But I cannot chose what she eats, I cannot chose how she exercises, and she can do everything right and still respond with gestational hypertension.

I’ve always thought I was comfortable with the uncontrollable nature of pregnancy and labor.  But right now, I don’t feel comfortable with gestational hypertension.  I’m sure I’ll learn to understand the subtle signs mothers exhibit that will tell me if they are in danger or if they will be OK, but for right now it just feels overwhelming.

Most dietary guidelines are very generic, but the Higgins Intervention Method has specific plans for meeting the special requirements of mothers with different nutritional needs. I like the ability this method gives to really personalize the recommendations and the ability it gives me to quantify the nutritional needs rather than just saying “eat more”.

If you are working with a pregnant teen, she needs more than the standard prenatal calories and protein.  This is because her body is still growing, and she needs to eat enough to support both her growth and the growth of her baby. So you would need to add the 300 additional calories a day to the higher values of protein and calories of a teen.

Mothers who are underweight will need to eat an increased protein and calorie diet. However, the Higgins Intervention Method recommends increasing it only for the number of weeks needed to add the weight to make up for the deficit. So if she were 10 pounds underweight, adjust her diet so she gains an extra 1 pound per week for 10 weeks (or 1/2 a pound a week for 20 weeks).

Mothers who are undernourished are determined by the protein intake on the Higgins Intervention Method. To calculate the protein deficit, you would compare her protein intake to the normal pregnancy requirements.  To correct for this add as additional daily protein the amount she is deficient and increase her caloric intake 10 calories for each gram of protein she is deficient.

Vegetarian women do not need any different guidelines.  They will simply choose animal sources for their food.  The biggest struggle, which may not be a struggle at all, will be getting enough protein since vegetable sources of protein are not as protein dense as animal sources. If she has trouble consuming enough calories to get adequate protein she can consider supplementing with any number of a variety of protein supplements.

Lactating women need even more calories than pregnant women.  The 300 calorie increase becomes 500 calories.  All the principles of good nutrition still apply.

Vitamins and minerals are referred to as micronutrients.  They do not contribute calories to the diet, but do play an important role in cellular function.  Remember cells?  They make up your entire body and are responsible for your body being able to stay healthy.

I personally have never been a fan of vitamin and mineral supplementation.  I am a purist in that I believe the diet should be adjusted before a pill is taken. But I do understand there are limits to what a woman is able to eat from time to time.

Allow me to use myself as an example. Over the last two months since school began I have found myself becoming more and more tired and unable to focus.  My stress level was increasing and my schedule was really out of control some weeks.  Balancing classes, studying, clincials and family left little time for cooking and forget about shopping.  I was relying on what I could pack in the morning, selected from what my husband chose to purchase.

Two weeks ago I made two changes.  First, I decided to keep a water bottle on the counter when I am home to remind me to keep drinking water.  Secondly, I started taking a multivitamin every day.  It took a couple days, but I started feeling better. I was sold.  Because of the temporary and unique demands on my body and time right now, I will continue to use a multivitamin supplement.

Honestly, I don’t think that conflicts with my basic theory about supplementation.  Supplements are available for the unique situations that prevent a person from achieving optimum nutrition from their diet. So how does this relate to pregnant women?

Think first trimester and the most common pregnancy complaint – nausea and vomiting.  This can prevent a woman from maintaining her normally healthy diet.  Some women experience food aversions throughout their entire pregnancy.  Again, these can make it difficult to maintain a normal healthy diet.  Supplementation can help by providing a little insurance (as long as she can keep the vitamins down).

Another common pregnancy complaint is fatigue.  In many women this is linked to anemia caused by low iron stores.  Pregnancy increases your bodies need for iron, and if your iron stores where not optimum to begin with (as is common for about 40% of American women), you can experience a mild to moderate anemia.  This can be especially true if this pregnancy happened quickly after a previous pregnancy.  Iron supplementation can help to manage this problem.

Though fiber is not a nutrient, it is necessary in the diet.  Most Americans do not consume the recommended 25-30 grams of fiber a day. This can lead to problems with constipation.  Since pregnant women are more likely to experience constipation, the inability to consume adequate fiber can compound a common pregnancy problem.  Women taking iron pills may increase their risk of constipation.  Fiber supplementation can be a temporary help during this time of increased need.

Folic Acid supplementation is recommended for all women of childbearing age.  Why?  Because deficiency of this nutrient can actually cause harm to your baby in the form of neural tube defects.  Unfortunately, by the time most women discover they are pregnant the neural tube is already formed. But folic acid (or folate) is also important for preventing a different form of anemia.  So for a woman who is having difficulty consuming a healthy diet, folate supplementation can be helpful.

The key here is to understand what you are supplementing and why.  More is not always better. For example, too much Vitamin A can lead to problems for your baby. The goal of supplementation is to temporarily maintain the optimum nutrition for a woman during a time of nutritional stress.

If you have done any work with pregnant women, you have probably seen that how a person eats is a VERY personal matter.  Families who seek advice and information on nearly every other topic can seem to drift off into space if you start talking nutrition. So, how do you help a woman get optimum nutrition? That will depend on the woman.  But here are some questions to think about as you formulate a plan.

1. Is the woman ready to learn? Is she interested in what you have to say and trust the information you give her?  Is she open to making dietary changes and learning about ways to improve her nutrition? If not, you are likely wasting your time.

2. Do you know what problems she has with her diet? You can make assumptions, but unless you know what challenges she faces you cannot help her overcome those challenges.  Does she have access to food, meaning she can get to a place to buy food and money to purchase that food?  Does she have a way to store and prepare food, meaning she can actually refrigerate foods that require it and has the tools needed to cook?  Does she know how to cook food, meaning she understands how to use recipes and feels comfortable preparing her own meals? Does have time to eat, meaning she is able to purchase or prepare meals when she needs them rather than skipping meals? Is her biggest challenge not knowing how to plan a menu following recommended nutrition guideline?

3. Do you know what she normally eats? Recommended diet changes are more likely to be accepted if they follow her normal eating plan.  If you are working with a vegetarian who needs more protein, help her identify vegetable sources she likes.  If you are working with a woman who is lactose intolerant who needs more calcium, help her identify lactose free dairy alternatives and high calcium plant foods. How does she normally prepare her foods and what types of foods does she like?

4. Are you telling her what to do, or helping her learn? Giving her a list of foods to eat may be interesting, but probably doesn’t help the woman learn to solve her own nutrition problems.  Instead, have her do a 24 hour diet recall and work through her normal eating with her as she discovers where her diet may benefit from change.

5. What can she teach you? If you are truly partnering with a woman to help her improve her health, you should be willing and able to learn from her as well.  As you discuss nutrition, ask her questions and show that you are interested in how she as handled her own nutrition challenges.  She may be able to share a great recipe, introduce you to a great grocery or farmer’s market or show a food idea other families can benefit from.

Now that you have matched her needs to your teaching, here are a few other pointers you might find useful.

Reinforce what she does correctly, Celebrate what she is already doing right and build from there.

Set realistic goals, Think in small steps that she can achieve in a week. This lets her build gradually and be successful to encourage her to continue making changes.

Commitment to change, Make sure that she is on board with the plan.  This is most easily done if she had a major part in preparing the plan.

Have you seen the latest weight gain recommendations from the IOM?  They are the same except an increase for the highest BMI levels. Low BMI gain 28-40 pounds; Normal BMI gain 25-35 pounds; High BMI gain 15-25 pounds and Obese BMI gain 11-20 pounds.

I personally am a fan of increasing the weight gain for obese individuals.  I’ve always been frustrated that to ensure the recommended weight gain it meant an obese woman actually losing weight during pregnancy (when you adjust for the growth of the baby and the placenta). I prefer to focus on what a woman eats, and if her nutrition is appropriate than not worry so much about the number on the scale.

But my mind may have been changed recently. As we discussed prenatal nutrition, one of my instructors pointed out that it can be very difficult for an obese woman to gain “enough” weight during pregnancy (with enough meaning the recommended weight gain) because to maintain her body weight takes a significant amount of calories.  During early pregnancy, with nausea and food aversions many women (obese included) have difficultly consuming their customary amounts of food.  Without the high caloric intakes to maintain the weight, obese women often lose significant numbers of pounds early in pregnancy.  I hadn’t really thought about that before, but it does make sense. Maybe I can be a little less frustrated with the weight gain recommendations now.

So how do you know if a woman is eating an adequate number of calories during pregnancy?  You do the math.  The equation is to take her optimum prepregnancy weight in kg (about the middle number of the normal BMI for her height or use the old Metropolitan Life Charts), and multiply that number by 35 calories.  This is her pre-pregnancy calorie need.  Add 300 to the number and that is about the number of calories she needs everyday for a healthy pregnancy.

There is another method, called the Higgins Intervention Method, that Varney’s Midwifery introduced to me. Created by the Montreal Diet Dispensary, it uses charts of the desired weights by height (those Metropolitan Life Charts again) and charts of calorie requirement for weight and activity level (From the Canadian Dietary Standards for Female Adults).  This method seems to add 500 calories and 25 grams of protein per day after 20 weeks pregnancy without any increase prior to 20 weeks. For a multiple pregnancy you add the 500 calories and 25 grams protein for each fetus.

What is interesting about the Higgins Intervention Method, is that it also changes based on other characteristics of the mother.  If the mother was more than 5% under weight, she adds an additional 500 calories and 20 grams per day.  If she has nutritional stress such as close pregnancy spacing or pernicious vomiting, she adds 200 calories and 20 grams of protein for each stress inducing condition.

When it comes to pregnancy nutrition, there seem to be two types of people. Those who feel it is of the utmost importance, and those who feel it doesn’t matter. Want to know which side of that fence I am on?  Here is some information straight out of Varney’s Midwifery  to help you figure that out.

Low birth weight babies, whether they are small for gestational age or premature, have increased rates of perinatal mortality, mental retardation, cerebral palsy, learning disabilities, visual and hearing defects, neurological defects and poor infant growth and development. Factors that influence birth weight are: maternal disease, smoking, gestational age and maternal malnutrition. Maternal malnutrition is related to two factors, the prepregnancy weigh and the weight gain during pregnancy. That’s all.

That doesn’t quite tell the whole story.  We do know that two things seem to cause the baby’s growth to not be optimum; placental problems and poor nutrition.  But these two do not produce the same results.  When growth is restricted by the placenta, brain growth is protected even though the rest of the growth is hindered. When growth is restricted by inadequate nutrition, the brain is not spared.

Varney’s tells a chilling tale, does it not? It goes on to break down birth weights to explain what birth weights have the optimum health, and its higher than you think.  3500 – 4000 grams, which is between 7 lb 12 oz and 8 lb 14 oz. Many women might even consider these babies “big” wishing instead for a more petite version.

So we can accept nutrition is important, but that is about all I see most people will agree on. Why? Because  the food you eat is a very personal, culturally specific and emotionally charged issue. Diet is a difficult subject to bring up because families have many reasons for eating the way they do.  Finances, access to foods, experience with foods, culture and time limitations are all mixed in. So when they come to you as the midwife, and you tell them to eat well for pregnancy, what have you really told them?

It goes the opposite way too.  I have meet birth professionals who spend majority of their time focusing on the importance of  organic or whole foods or vegetarian or high protein diets. None of these things are necessarily wrong, but if you are working with a family that does not yet eat two servings of vegetables a day, you are missing an opportunity to help them make the first step.

So how do nutritional needs change during pregnancy?  They actually change very little from the standard nutritional needs.  Most nutrients needs are the same, or nearly the same for pregnant and non-pregnant women.  The big differences are that protein needs rise to 71 g per day on average and total calorie need increases by 300. In addition, pregnancy does increase your iron needs.

The recommended breakdown of food groups to meet these needs is as follows:   Fruits – 1.5 cups;  Vegetables – 2.5 cups;  Grains – 6 oz eq;   Meat and Beans – 5 oz eq;   Milk 3 cups.

And for those of you who read that list and feel frustrated that women will not get optimum benefits from eating like that unless they choose organic or whole food or whatever you personal preferences are in food, I share with you the wisdom of one of my favorite midwives: The research shows these benefits from the plain old stuff they sell in the grocery store.  If you can get her to eat it, she’s get these benefits.

If you’ve ever been in school you probably have seen a grading rubric.  It is the list of things that must be included in your paper and how many points are possible to receive for each item. I’ve become quite fond of them, because they let me know exactly what the professor expects from me.

Today I was thinking about women’s reactions to their birth experiences.  More specifically, I was pondering over women’s disappointment and frustration with their birth experiences.  I thought about the words they use to describe their goals before labor and the words they use to explain their birth after. I’ve come to the conclusion that we all have our own unique birth grading rubric, but we don’t all know what to include on it.

For example, a common comment from a first time expectant mother is that she would like to have a natural birth.  Her plan is to keep a calm environment and stay home as long as possible.  She may even have a doula.  So from this, we see her birth grading rubric looks something like this:

• Low lights
• Play Music
• Stay Home as long as possible
• Doula present
• Natural Birth

In reality, this may seem like all these things will give her a wonderful, beautiful birth experience.  But this is where it gets sketchy.  Lets say she stays home as long as possible and when she arrives at the hospital the nurse keeps insisting she needs to stay on the monitor and should order an epidural.  This will probably be frustrating to her, but she still will have met every criteria of her grading rubric.

We can go further, lets say she did stay home as long as possible but is at 5 cm when she gets to the hospital.  The on call physician breaks her bag of waters so she can progress, and since it is presented to her as a simple and non-pharmacological way to speed up labor, she still sees herself as meeting her criteria for a good birth.

But now the contractions are much more painful, and she isn’t coping well.  Her doula and labor support help her, but the experience is  nearly unbearable. And yet, she is still meeting all her criteria for a good birth. After her baby is born, when she reflects on the experience, she may be conflicted because she got everything she wanted, everything she said she needed to have a good birth; but she does not feel like the experience was good.

I hope you can see where this can go. The criteria by which you “grade” your own labor should really be reflective of the things that will make you feel good about your labor when it is over.  For some women this means the only criteria will be that they have a healthy baby and a healthy mom.  But for most women, I propose the following set of criteria:

• I am respected during the process
• I make decisions for my own health
• I am given accurate and unbiased information to make those decisions
• I am assisted in measures (natural or pharmacological) to be as comfortable as I need to cope with the work of labor
• Every effort is made to allow those I choose to be with me

These are the things I have always tried to explain to the families I work with.  These are the things that really seem to make a difference in how a woman views her birth experience.  Even families who have used cesarean to give birth, though disappointed that they did not have a vaginal birth, do not walk away feeling manipulated or as if their birth had been stolen from them. Instead, cesarean surgery was a tool they used to help meet their goals when faced with a labor challenge.

Now this is where it gets difficult, because the truth about all these items is that you, as the laboring mother, are not really in control over them.  The best you can do is to select your care team as carefully as possible. Pay attention to the way your doctor or midwife treats you during prenatal appointments, are you respected, given accurate information and expected to make your own decisions? Tour your birth place before labor starts and really listen to the words being spoken.  Is this birth place prepared to support your decision making, do the nurses treat you with respect during a visit?

As you prepare to work with families, I encourage you to find ways to help families understand that usually things like how dim or bright the lights are do not compare to things like how respected and trusted the mother is.

Moving from the idea of centering pregnancy, we explore another concept in prenatal care – home nurse visits.

In one study, home visits were associated with decreased risk of preterm delivery for African-American women. These results were similar to the results of another study.

In other studies, prenatal nurse visits demonstrate health effects beyond childbirth. These benefits include decreasing the risk of infant death.

It is possible that the best prenatal care needs to fit the specific needs of the family.  Some families may like the structure of traditional private prenatal visits.  Other families may thrive with the social support of centering pregnancy. Those with higher risk may benefit from a less formal home visit program that provides support and education.

What This Means to You

There are several ways to provide prenatal care.  Consider the prenatal services you offer to determine if they can be provided in additional formats to help meet the needs of all families in your community.