HEALTHY PREGNANCY AND PREGNANCY CARE
Compiled and presented by Averille Morgan & Sue Baxter
Health during pregnancy is a continuum of wellness and good function of body, mind and spirit. The lack of opportunity to obtain good food, rest, moderate activity, mental support, solitude etc may impact the maternal health in a negative sense. This may challenge her ability to self regulate towards a health she is used to or knows or expects for her pregnancy.
Women in the UK have come to expect intervention for their pregnancy through health care, social and political support e.g. women are encouraged by the government to take up antenatal care by 12 weeks gestation, to receive free dietary supplements e.g. folic acid and, if of low income, receive income support.
INTEGRATED SYSTEMS CHANGES DURING PREGNANCY
As the uterus enlarges during pregnancy a change in the relative position of other organs occurs. The position of each organ is inter-dependent on the position of other organs, connective tissue etc. Physiological demands of pregnancy on the cardio-vascular, lymphatic, musculo-skeletal, nervous and hormonal systems, to name a few, effect the movement and function within and between specific tissue systems.
For example: the renal system in pregnancy- the engorgement and growth of the endometrium in the first trimester stretches the anterior pubo-cervical ligaments superiorly and anteriorly. The bladder and urethra are pushed anteriorly and superiorly until the fundus moves above the pelvic brim in the second trimester. The peritoneal fascias and ileum are stretched anteriorly, the lower abdominal portions of the bowel (i.e. ileo-caecum, sigmoid colon) move superior- laterally. By the third trimester the anterior renal fascias are pulled superiorly and anteriorly with the large intestine, the posterior lamina are held taut with dilation of the renal hilus and vessels. The ureters dilate and take a more tortuous path along the psoas muscle. The venous return from the uterus, vagina, bladder and rectum meets gradually more resistance in the pelvis and dilates. The increased blood plasma levels places more demand on the glomerulus’s filtration rate increasing the extra cellular fluid potential. This leads to gradual tissue oedema.
The skill of the therapist is to subtly, gently improve the integration of the maternal body systems by contacting health in the tissues and supporting the potential to be healthy. This means that finding a tissue or fluid fulcrum, for instance, which has potential to be healthy will enable self correction of the whole body system.
NUTRITION, DIGESTION and SUPPLEMENTATION
Let’s focus on the relationship of good nutrition (in a western based diet) with digestive function in maintaining a healthy environment for the mother and unborn child.
The Food Standards Agency UK places emphasis on a diet which provides enough energy and nutrients for the maternal body to support the adequate growth of the unborn child. The suggestion include:
Plenty of fruit and vegetables- at least 5 portions of a variety of fruit and vegetables a day (fresh, frozen, tinned or dried), a glass of juice
Starchy foods such as bread, pasta, rice potatoes and pulses (e.g. beans, lentils, peas)
Protein such as lean meat, chicken, fish, eggs and pulses
Fibre by means of wholegrain bread and cereals, pasta, rice, pulses, fresh fruit and vegetables
Dairy foods such as milk, cheese, yoghurt.
Good nutrition can be described by isolating food groups such as dairy or protein or by specific nutrients, such as iron, calcium, fatty acids (such as omega 3 & 6), or menu planning (e.g. RDA for Vit E = 1 tbsp veg oil + 1 avocado) which brings foods together in a daily menu rich in folate, B6, B12 etc.
Good digestion has a less public profile in terms of digestion which is improved by time and care over food preparation, time to eat, chewing slowly, resting after a meal, breathing well whilst eating.
In what way is good nutrition accessible to each pregnant woman?
For example; does a woman want or need to know about sources of iron or folic acid;
OR does it make more sense to her to eat extra red meat, green vegetables and bread;
OR she understands meal descriptions such as a portion of red meat, lentils or vegetables served with rice or pasta or wholegrain bread for 2 meals each day.
Vitamins and minerals
Also referred to as “micronutrients” this group acts as catalysts for enzyme action for digestion ie breakdown proteins to amino acids. Vitamins and minerals are therefore important to activate enzyme activity which is required to supply energy to the mother and fetus, boost immunity, build bones and teeth, balance hormones, support neural development etc.
Vitamins and minerals are found in the food we eat, the soil in which our food is grown and in our water. Food which has been grown in rich mineral base soil (organic), prepared with little or no refinement or processing, little or no cooking of fresh fruit and vegetables will maintain a higher proportion of minerals and vitamins.
The government sets a ‘recommended daily allowance’ (RDA) as a general guide for the mass population. So packaging standards then supply some of the RDA’s in their foodstuffs to help the consumer feel like she is making an informed decision on the nutrient level available to her in that product. (See Appendix A).
However, absorption of the RDA of each vitamin or mineral requires a process of digestion in which a balance of the right enzymes, acids, alkaloids etc. will make the vitamin or mineral available for further tissue metabolism. For example, in order to utilise the ferrous iron in spinach or red meat the enzymic action needs to be coupled with Vitamin C and without high levels of calcium, caffeine or tannin.
In other cases or bodies produce the vitamin, such as vitamin B12, which is stored in body fat and made by bacteria living in the intestinal tract. The production of vitamin B12 may be improved by supporting the gut bacterial activity with a balance in gut acidity/ alkalinity or supplementation of lactobacillus (e.g. natural yoghurt, pro-biotic drinks) or sprouted beans/seeds. (See Appendix B for vitamin and mineral rich foods during pregnancy).
Are dietary supplements advisable during pregnancy?
Holford & Lawson (2004) advocate dietary supplementation as they report that most British surveys since the 1980’s show that eating a balanced diet revealed lower levels of vitamins and minerals recommended by the government‘s RDA‘s.
Holford & Lawson insist that during pregnancy a basic supplementation of folic acid, zinc, B12,B6 are essential for fetal CNS development. They assert that food production and preparation techniques, through mass farming and food packing, has contributed to a low nutrient food base. This means that even organic produce eaten within the week of harvesting will still be low in nutrients required by the pregnant and breast feeding mother. They suggest that a good diet will be deficient of optimum levels of vitamins and minerals and that supplements will counterbalance the deficiency. Holford & Lawson recommend three supplements:
1.A pregnancy multivitamin and mineral tablet/tonic
2.1,000-2,000mg of extra Vitamin C
3.Omega 3 & 6 essential fatty acids (as fish or nut/seed oil).
The main problems with supplementation is the increased risk of fetal toxicity from a too a high level of some vitamins (e.g. vitamins A & D) and minerals (Iodine & Iron). Makrides et al (2003) randomised, double-blind, placebo controlled study indicated that ferrous sulphate supplementation during pregnancy reduced the incidence of Iron Deficiency Anaemia and Iron Deficiency at delivery. They also noted no difference in gut irritability with the iron supplement. However, Roberts (2003) notes that it is the ferrous sulphate supplement which irritates intestinal linings and that ferrous succinate and ferrous fumarate supplements are more gut friendly (I.e ferrous succinate and fumarate are found in liquid tonics extracted from vegetables and fruits). Roberts also suggests that calcium supplements will decrease the iron uptake and vitamin C will increase iron uptake.
Weight gain is healthy during pregnancy
Different women gain different amounts of weight during the whole pregnancy from 10-12kg(22-28lbs). Maternal weight gain is strongly associated with birth size (Lagiou et al 2004) however, nutritional associations with weight gain are inconclusive. An association with increased weight gain from cholesterol is linked with maternal and fetal coronary heart disease. This may be seen as an unhealthy maternal weight gain during pregnancy, as is under nutrition and low weight gain during pregnancy, and may have secondary side effects on the fetus.
Maternal diet and growth of her fetus
Langley-Evans et al. (2003) report strong evidence, with animal studies, that a low protein diet adversely influences renal structure and cardiovascular function in the developing fetus. The study team noted that this programmed the fetus to later hypertension. However, they found that if protein was increased in the diet that fetal renal development corrected.
Merialdi et al (2004) conducted a double-blind trial among 242 poor Peruvian pregnant woman, giving them at 10-16 week gestation a supplement containing 60mg FE, 250mcg folic acid with or without 25mg Zinc. The study showed that fetal femur diaphysis length was greater in the Zinc supplementation group.
Over nutrition in the pregnant adolescent may be detrimental to the growing fetus. A British study (Wallace-2004) indicated that placental growth is impaired by over nutrition and maternal growth hormone is implicated in the growth restriction.
Foods to avoid: 1)infection- e.g. high levels of listeria may be found in soft mould-ripened cheeses (e.g. blue vein, brie), pate, uncooked or undercooked ready meals;
e.g. high levels of salmonella may be found in some raw eggs, raw meats, unwashed packed salads;
2)poisoning- e.g. too much Vitamin A is toxic to fetal development and can be avoided by not combining high dose multi-vitamin supplements or fish oil supplements;
e.g. mercury poisoning via tuna, marlin, swordfish, shark can be avoided if less than 4 times a medium can of fish is eaten per week.
3) dehydration-e.g.drinking less than 300mg caffeine per day
ie. 3 mugs of instant coffee, 4 cans of energy drink, 8 bars of chocolate, 6 cups of tea;
e.g. only 1-2 units of alcohol per week i.e. one glass of wine or ½ pint beer.
Drink more than 2 litres of clean water per day.
DIGESTION DURING PREGNANCY- physiological changes
The maternal physiological adaptation during pregnancy enables improved digestion and supporting maternal and fetal nutritional demands. Such digestive changes include:
Maternal saliva becomes more acidic & increased amylase = CHO digestion
Esophageal motility and sphincter control reduces = churning of food/ backwash of stomach contents
Stomach hypo tonicity and reduced motility = longer transit time
Stomach acidity reduced from increased eostrogen and placental histaminase = reduces histamine output and less immune attack on fetus in 1-2 trimester
Increased gastric lipase = increased triglyceride uptake
Increased pancreatic amylase and lipase for sugar and cholesterol uptake
Increased pancreatic enzyme secretion for protein digestion in the small intestine
Small intestine secretion of maltase and lactase for sucrose and lactose digestion
Increased height of duodenal villi = increased absorption of Ca, AA’s, vitamins
Small & large intestine increased absorption of micronutrients and water
Liver production of enzymes, proteins, serum lipids and bilirubin= liver enlargement & itchy skin
Large intestine slow transit and increased storage = increased water uptake.
CHANGING MATERNAL PHYSIOLOGY
Gastrointestinal changes during pregnancy
Progesterone relaxes the cardiac sphincter of the stomach and smooth muscles in the wall of the oesophagus. This may allow for reflux of stomach contents and acid into the oesophagus giving symptoms of indigestion or heartburn as far as the back of the throat. With an enlarging uterus applying superior pressure on the diaphragm from 32-38 weeks, the pyloric sphincter action may be constricted. The slow emptying of the stomach and small intestine is effected by hormonal and physical displacement of the small intestine and may lead to nausea or vomiting.
The small intestine, particularly the jejeno-ileum displaces superiorly and laterally to the left of the abdomen. The ileum is stretched anteriorly and inferiorly at the lower superficial portion of its pathway across the abdomen into the lower right quadrant. The enlarging uterus stretches the bowel mesenteries anteriorly and laterally. The ileo- caecum is displaced superiorly and laterally in the right lower abdominal quadrant, sometimes to be palpated superior to the right iliac crest. The increased sensitivity at the ileo-caecal junction may cause increased bowel urgency, with visceral- like spasm or diarrhoea.
The large intestine is pushed towards the more lateral portions of the abdominal cavity during pregnancy. The hepatic and splenic flexures of the colon are stretched superiorly and laterally under the liver and spleen respectively. The lower portion of the sigmoid colon, rectum and anus are compressed in the pelvic space particularly at 10-16 weeks and from 36 weeks or when fetal decent fills the space below the pelvic brim.
Again the slowing bowel motility, the enlarging uterine pressure and increased water absorption during pregnancy may lead to constipation. The practitioner may advise on increased water intake (2 litres minimum per day), small meals and often, a variety of carbohydrates and proteins and fibre, light exercise, limited amounts of heavy lifting (e.g. sit with the toddler!).
HORMONAL CHANGES IN PREGNANCY
Initially the corpus luteum increases the secretion of progesterone and oestrogen to the mother and fetus, and is then supported by the placenta. The placental hormones inhibit production of follicle stimulating, luteinising and growth hormones (from the anterior pituitary gland). Adrenocorticotrophic (ACTH) hormones increases, releasing more plasma cortisol from the adrenal gland so as to increase sugar levels in plasma and blood. The myometrium and decidua convert cortisone to cortisol, which may contribute to immunological protection for the fetus (Stables 2000).
Oxytocin is released by the posterior pituitary during pregnancy but by 30 weeks the uterine cells become more sensitive to the hormone and may be felt as low frequency high pressure Braxton Hicks contractions. Oxytocin sensitivity of the uterus and higher quantities of oxytocin released stimulates uterine contractions. Cervical ripening requires an increase in oestrogen (increases vascularity), relaxin and prostaglandin levels prior to labour.
The hormonal relationship with ligament laxity in pregnancy is well documented (Chamberlain 1991, Ostgaard et al 1993). The laxity and pliability of connective tissues including the spinal dura and central nervous system is less well understood. Oestrogens increase the level of vascular permeability and fluid congestion in pregnancy and may account for ear, nose and throat congestion and sensitivity. Moore’s (1997) study of 10 pregnant women reported that their cognitive ability alters for the worse with poor concentration and poor memory most significantly effected. This study does not clarify whether the cognitive changes are a result of hormonal influences on brain function and/ or a reduction of brain size.
Progesterone aids in secretion of insulin (insulin levels double by the third trimester) and reduces peripheral insulin usage. This means that more glucose is available for uptake by the fetus. In later pregnancy more protein is broken down into amino acids and stored adipose fats are consumed for energy uptake by the mother. The maternal CNS is the main organ which continues to absorb available glucose. Other body systems in the pregnant woman produce energy from lipids (lypolysis). Lypolysis is stimulated by growth hormones or cortisol, oestrogens increase the level of plasma cortisol.
Odent (2003a) refers to the "foetal ejection reflex" as a primitive physiologic function of the maternal body to expel the fetus. The reflex is a combination of contractions, dilation, movement, breathing and relaxation which supports the descent of the fetus and relaxation or spreading of the pelvis and pelvic floor. The sudden surges of adrenaline raise the contraction phases. Odent states that if the mother feels warm, safe, private and not observed or intervened in any way then the reflex is a gentle continuation of the birth process. She will push only when the reflex propels her to do so.
Odent also considers that it is not necessarily the maternal position which is important but rather the maternal hormonal balance. However, he does note that hormonal release will influence maternal positions e.g. if the maternal adrenaline is low then the mother will choose to lay down. He describes that it is most important that the mother finds postures or positions which enables this hormone balance. He reports that the reflex is counterbalanced by a maternal need to be supported into an upwards position and that the thigh muscles be able to relax to support the relaxation of the perineum.