The Whole Pregnancy Handbook: An Obstetrician's Guide to Integrating Conventional and Alternative Medicine Before, During, and After Pregnancy

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Introduction

Pregnancy is a magical and mysterious time of life. As it progresses and you move toward parenthood, youfre aware of all the profound ways life is about to change=it will be filled with joy and responsibility, challenges and love. It can all be exhilarating and overwhelming. The purpose of this book is to help you make the best choices for yourself and your child from before you conceive all the way to the first weeks after birth. It's my hope that The Whole Pregnancy Handbook will help you experience your pregnancy as a fulfilling and transforming first phase in your life as a parent.

Embracing a Holistic Philosophy Over the years, it's been my privilege to participate in the physical and emotional journey of pregnancy both as a doctor and a father. In that time, my approach to my entire medical practice has changed. I started out as a classically trained, conventional ob-gyn, but through a series of lessons taught to me by patients, I gradually began to practice integrative medicine, embracing a holistic philosophy that focuses on self-care and the principle that true wellness reflects the coming together of emotional, spiritual, and physical well-being.

My orientation shifted to a holistic approach about five years into my medical practice. Over the course of a couple of months, two colleagues, nurses whom I had worked closely with, came to me after being diagnosed with cancer. Both were told by their oncologists that there was 8nothinge they could do but show up for their chemotherapy treatments. They were told to relax and let the chemotherapy fight their cancer, but they didn't feel comfortable with that. Both wanted to be more proactive in their care. So, after each asked me questions that I couldn't answer about what she could do to help heal her cancer, we began a journey together, discovering how mind-body medicine combined with alternative modalities like acupuncture and herbal medicine could improve not only their responses to treatment, but also the quality of their day-to- day lives.

The lessons I learned with these women about the importance of self-motivation and participation resonated with what I'd learned practicing prenatal care. As a young obstetrician just out of residency, I quickly realized that my approach was too dogmatic. I'd often say to a pregnant woman, 8This is the way it is=just do what I say.e In that situation, the woman might do what I asked, but she didn't believe in my recommendation. This problem hit home after a birth where a woman had experienced complications in labor and required a C-section. Afterward, she developed a wound infection, a not-unusual postoperative event that meant she had to come into the office two or three times a week. As she was leaving one of these visits, she said under her breath, 8This never would have happened if I hadn't had the C-section.e I was surprised that she felt that way because she was basically okay and her baby was healthy. So I asked her to stay to talk about the Cesarean. I learned that she didn't trust my decision to perform the Cesarean because she hadn't felt she'd been a part of it. I realized that this lack of trust and her sense that she was an observer instead of a participant in her birth experience couldn't have begun in the labor room. Instead, I believe it reflected the fact that over the course of the nine months of her pregnancy, we hadn't developed a real partnership.

That single, under-the-breath comment was the 8ahae that helped me to see that I needed to change, to become a source of support, information, and comfort to pregnant women, someone they could turn to for guidance, but not someone who would impose proscriptive or dogmatic opinions. I changed my entire approach to prenatal care. I learned how to be open and listen to my patients in a new way, to follow their lead as we work together with the shared goals of a healthful, vital pregnancy, a childbirth anticipated with excitement instead of fear and anxiety, and a newborn brought into the world in a room filled with love, all the while realizing the mystery and sacredness that surrounds the experience.

REAL VOICES For me in childbirth it was important to have a provider that I trusted, who would include me in the decision-making along the way and treat me as a partner= because you just can't anticipate every little thing thatfs going to happen.
Martha*, mom of two

Over the last ten years, as I explored a holistic approach with all of my patients, I began to practice mindful meditation on my own. I studied nutritional, herbal, and mind-body medicine and collaborated with experts in traditional Chinese medicine/acupuncture, craniosacral therapy, reflexology, and Reiki. Through this work, Ifve been able to create an integrative medical practice, one that combines the best of conventional and complementary medicine.

I'm now a senior faculty member of the Center for Mind-Body Medicine in Washington, D.C., through which Ifve participated in and/or planned mind-body workshops in the Middle East, Macedonia, and in New York, working with firefighters after 9/11. I became the first and only (as of this writing) physician in Connecticut to be board certified in both obstetrics/gynecology and holistic medicine. As an assistant clinical professor at both the Albert Einstein College of Medicine and the College of Physicians and Surgeons of Columbia University, I teach medical students and doctors- in-training about holistic care.

My own journey has been both intellectually fascinating and personally rewarding= and I truly believe that my patients are better served as a result of my embrace of a holistic philosophy of care.

Holistic Obstetrics What does it mean for an obstetrician to practice holistic medicine? It means that I look to the women I work with, my patients, to be active participants in their care. It means that instead of focusing on individual symptoms, I try also to understand a womanfs emotions and how the situations she faces in her daily life may be affecting her health. It means I always try to use gentle, noninvasive treatments that promote overall wellness and build on the bodyfs ability to heal.

This approach is especially important when a woman is pregnant or trying to conceive. I firmly believe that conception, pregnancy, and childbirth are extraordinary biological events that the body has the wisdom to guide. I see my role as that of a helper who stays in touch with a womanfs physical and emotional experiences, someone who tries to uncover and allay any fears that being pregnant may generate. I never expect complications or difficulties, and I never think of pregnancy as a series of medical disasters waiting to happen. But if something starts to go wrong during a pregnancy, I can apply my medical training to the situation.

At the same time, over the course of most pregnancies, I can offer the tools of complementary and alternative medical treatments to relieve typical pregnancy aches and pains, help prepare a woman for a positive childbirth, and support her overall physical and emotional health.

The Whole Pregnancy Philosophy This book is designed to help you make choices that are right for you, your child, and your family. As in my practice, I don't try to dictate what you should do. For example, I don't believe therefs a 8righte way or a 8wronge way to approach pain management in labor. For some women, an epidural is a good choice; for others, a medication-free approach to childbirth is best. And while I do recommend using mind-body exercises to start to prepare for labor as early as the start of the second trimester, these are only suggestions. You can, and should, pick and choose what feels right for you on every front.

The goal of this book is simply to give you the information you need to make your own decisions. To show how an integrative approach to preconception, prenatal, and postpartum care can bring together the very best of conventional medicine with the best of complementary and alternative medicine. I try to answer questions you may have and help you experience the joy, confront the fears, and meet the challenges that pregnancy can bring. I hope that by presenting you with a range of approaches not only to your prenatal care but also to your own unique experience as a pregnant woman, this special time can become one of empowerment and self-discovery.

How to Use This Book You can read this book straight through, but it's designed to be a resource you can turn to at any point, from before conception through postpartum. You can plunge in wherever you like and find the material you need. Whether youfre thinking about getting pregnant, actively trying to conceive, currently pregnant, or have just given birth, therefs something here for you.

The Whole Pregnancy Handbook is loosely chronological. The first chapters cover preconception, fertility, and the first trimester. Then comes a chapter that provides an overview of all nine months. It includes a discussion of the physical and emotional milestones of pregnancy; a description of fetal development and prenatal care; and mind- body techniques you can use to connect with your child emotionally, energetically, and physically, and to prepare for childbirth. Later chapters are on common physical symptoms of pregnancy; nutrition; exercise; prenatal tests; complications; and miscarriage, so you can easily find what you need when and if you need it. The final chapters of the book go through preparing for childbirth; the contours of labor and childbirth; and life postpartum.

Throughout, youfll find the voices of women describing their own experiences, as well as interviews with experts=complementary practitioners, midwives, doulas, and others=who have important insights to contribute to understanding pregnancy.

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Holistic Medicine

Holistic medicine; alternative, complementary, and integrative medicine=these terms are sometimes used interchangeably, but theyfre not exactly interchangeable. To clarify what I mean when I use them, here are basic definitions of terms I use throughout this book, along with a discussion of how to find practitioners who are right for you.

In this chapter youfll find:
n Defining Holistic Medicine n Finding a Complementary or Alternative Medicine Practitioner
± Quality matters
± Figure out your needs
± Collect names
± Set up a consultation

Defining Holistic Medicine n Holistic medicine is based on the fundamental principle that good health comes from physical, emotional, and spiritual well-being. Holistic practitioners believe that each of these elements=body, mind, and spirit=needs to be accounted for in any medical treatment. In other words, no one symptom=for example, chronic headaches or gastrointestinal problems=is understood or treated as an isolated event. Holistic medicine embraces prevention and self-care, using noninvasive treatments that support a personfs natural abilities to heal.

n Alternative medicine generally refers to diagnostic and treatment methods (also known as 8modalitiese) that are independent of those taught and practiced in most American medical schools and hospitals. Because they often encompass entire systems of medical theory that developed separately from what we in the West know as conventional medicine, they are typically considered 8alternativee only in the U.S. Ayurveda, Tibetan medicine, traditional Chinese medicine, and herbal medicine are all examples of alternative medicine. In theory, alternative medicine is used independently of conventional medicine=and some alternative treatments must be used alone. In practice, alternative treatments are often used alongside conventional care. Medical schools in the U.S. are now beginning to teach some modalities of alternative medicine (primarily herbal medicine and nutritional therapies). However, knowledge of alternative medicine is not required for a medical license in any state.

n Complementary medicine combines alternative and conventional medical treatment. For example, using regular massage therapy sessions to reduce stress and lower high blood pressure or having acupuncture to supplement fertility treatment.

n CAM is an abbreviation for 8complementary and alternative medicine.e CAM is most often confused with complementary medicine, but CAM is the umbrella term for both complementary and alternative medicine.

n Conventional or allopathic medicine is the mainstream medicine taught in U.S. medical schools and delivered in U.S. hospitals by licensed professionals, such as a medical doctor, physicianfs assistant, or certified nurse-midwife.

n Integrative medicine shares holistic medicinefs philosophy; it emphasizes prevention and self-care, and uses conventional medicines and surgery only when necessary. An integrative medical doctor understands how alternative and complementary treatments can be used alongside or instead of conventional medical care.

n Functional medicine also shares the principles of disease prevention, self-healing, and noninvasive treatment with holistic medicine. It fine-tunes that approach by focusing on improving the function of the bodyfs digestive, immune, and hormonal systems, primarily through nutrition, dietary supplements, and lifestyle changes.

There are hundreds of types of complementary and alternative medicine modalities. In this book I focus on those that are widely available and generally recognized as effective and safe during pregnancy. These are: mind-body medicine; acupuncture and Chinese herbs; nutrition and dietary supplements; herbal medicine; and manual therapies like chiropractic, massage, craniosacral therapy, and reflexology. I also discuss the therapeutic role exercise and yoga can play during pregnancy. (For a description of these complementary and alternative modalities, see the Glossary of CAM Terms, page 525.)

Note: Homeopathy is a well-known form of alternative medicine that uses individualized remedies to treat specific physical complaints and illnesses. Generally speaking, during pregnancy, homeopathic remedies may be used to treat various nonthreatening but uncomfortable side effects, as well as everyday viruses and bugs, as long as your primary medical practitioner knows youfre using them. Homeopathic remedies sold in health food stores have such small amounts of the active ingredients that they shouldnft pose a problem. (Avoid any preparation=homeopathic or otherwise= containing blue cohosh, which is used to stimulate uterine contractions.)

Classic homeopathic remedies are tailored to the individual, and require a long, in- depth patient-practitioner interview before they can be prepared. In the United States, homeopathy lacks standard accreditation or licensing in any state. Therefore, its safety and effectiveness depend heavily on the skills of the practitioner. For these reasons I don't use it regularly in my own obstetric practice, and, for the most part, it wonft be included in this book.

Q: Do you always recommend the same complementary or alternative treatments for particular problems?

Dr. Evans: No. In some cases I may recommend a particular therapeutic approach, but for the most part, I don't. For example, for pregnancy-related back pain in the second and third trimesters, acupuncture, massage, and chiropractic are all treatments that can help. If a patient wants to work with an alternative practitioner for typical, pregnancy-related back-pain relief, I will ask about her preferences=does she like to be touched, is she afraid of needles=and explain what each treatment is like. Then, I leave it up to the patient to decide which approach is right for her. Sometimes, since I work with a group of alternative practitioners regularly, Ifll recommend massage therapy over acupuncture simply because I sense the patient will get along especially well with the massage therapist. And if a patient asks for a specific recommendation, I always give one that takes into account the personality of patient and practitioner, and the nature of the treatment.

That said, there are times when I recommend one treatment over others because my clinical experience has shown it to be especially effective. For example, I always recommend acupuncture combined with herbal treatment for women with elevated levels of follicle-stimulating hormone (FSH) or other symptoms of early menopause (known as perimenopause) because in my practice, we've had consistently good results with that approach. (For more on elevated FSH, see page 38.)

Finding a Complementary or Alternative Medicine Practitioner Just as when youfre looking for a new doctor or nurse-practitioner, when you set outto find an alternative practitioner you want to find someone whofs not only well qualified, but whofs also a good match for your personality and needs. Finding an experienced practitioner whose approach you agree with and personality you click with may not be easy, but it's worth the effort. It can make a world of difference in your treatment, its result, and your emotional experience along the way.

Quality matters Complementary and alternative health care providers most often go through extensive training in their individual fields. But because alternative medicine is relatively new in this country, national and state standards for licensing and accreditation have yet to be uniformly established. Unfortunately, that means 8buyer bewaree; it may be worth your while to do a little research to find out not only what qualifications a practitioner has, but also what qualifications she should have to be considered in good standing professionally. The Web can be a great resource; a quick online search of sites devoted to specific treatments should tell you what the accreditation/licensing standards are. When checking credentials, bear in mind:

n Licensing is administered by state governments, and requirements change from state to state. Keep in mind that standards can vary according to prior professional training. For example, with acupuncture, medical doctors may have fewer requirements for licensure than nonmedical professionals.
n Accreditation and certification are generally administered by voluntary, nonprofit organizations or trade associations.

Once you have some names, feel free to ask questions: If therefs a state licensing board where you live, you can check with it to make sure that a practitioner is registered. If there isnft a state board, you can check with the specialtyfs major professional organizations to learn more about accreditation and find out if the practitioner is in good standing. Finally, don't be shy about asking a practitioner if hefs accredited or licensed, and what that means in terms of his training.

Finding a qualified practitioner isnft always easy, but it's important to learn how caregivers are licensed so you can choose from a well-qualified group of practitioners.

Figure out your needs No matter what kind of practitioner youfre looking for=massage therapist, chiropractor, herbalist, acupuncturist=when you set out to find a complementary or alternative practitioner, first take some time to figure out whatfs important to you.

n Office setting: Some people work out of their homes; some will come to your house; still others work out of professional spaces. If you have a strong preference for one environment over another, pay attention to it and look for someone who works in a space where youfll be comfortable.
n Travel time: If youfre lucky, youfll only get the names of people who work near your home or office. But your friend may know a great acupuncturist or massage therapist who lives forty-five minutes away. Decide in advance how important a convenient location is to you. Keep in mind that complementary and alternative therapies often involve regular sessions, so you may be making this trip as often as once a week.
n Cost: How often you see a practitioner may depend not only on travel time, but also on price. Since a new baby means new costs, set a reasonable budget for what you need. When you talk with a practitioner, ask if her fee structure changes based on the frequency of your visits. If she's out of your price range, see if she can recommend someone whose fees are more affordable. Also, check with your insurance company to see if the treatment is covered. Many insurance companies now cover a range of complementary and alternative treatment options, but they often require a referral from your primary care physician.
n Expertise: Most important, since youfre either pregnant or trying to be, look for someone who specializes in women's health and pregnancy care. If youfre already pregnant, check with your doctor or midwife before you try a new treatment.

Collect names Once you have a general sense of what kind of practitioner youfre looking for, begin to assemble a list of names.

REAL VOICES I'd moved to a new city, and I wanted to find a craniosacral therapist because I'd recently miscarried and I thought it would help me feel more centered and energetic. I called one woman whose name I found online. She seemed to have a lot of experience, but when we talked, I felt like I had to keep repeating myself for her to get what I was saying. I thought, this can't be right. I never went to her, but after asking around I did find a great massage therapist who really helped me.
Rebecca, pregnant

1. Ask your doctor, midwife, or nurse-practitioner. As complementary and alternative treatments become more popular, more medical professionals are developing a network of practitioners they work with regularly.
2. Ask friends, coworkers, and family members for recommendations.
3. Check with your health insurance company, which may have a list of recommended or in-network practitioners.
4. Look for ads for practitioners in alternative newspapers, magazines, and health food stores.
5. Search online: Even though these listings may be incomplete or out-of-date, an online search can be a good way to get started.
6. Get a list of licensed practitioners in your state=for example, licensed massage therapists.
7. Get a list of practitioners in your area who are accredited by the national organization for that discipline=for example, herbalists who are members of the American Herbalists Guild.

Set up a consultation Once you have a couple of names, start calling. See if you can set up a pre-treatment interview and, if you have time, a tour of the workspace. If a practitioner isnft willing to have a consultation or let you tour his workspace, look for someone else. Ask about special consultation fees=the visit may be free or a practitioner may have a lower consultation-only fee. Let the practitioner know whether youfre pregnant or trying to conceive and what youfre specifically interested in working on. You may find the perfect match right away, or it may take talking to several practitioners. Odds are, when you find someone you can work with, you will know.

Before the interview, take a few breaths to help focus. Throughout your talk, pay attention to how you are feeling. Does the practitioner inspire confidence? Do you like her voice? Does he understand what youfre there for? Do her explanations make sense to you? If youfre touring the workspace, take a few minutes in the parking lot before you go in to check in with how you feel. When you walk in, notice your sensations. Does the space feel comfortable to you? Do you like the smell? All these signals contribute to your gut feeling about the practitioner, and if something feels off, look for someone else.

Complementary and Alternative Medicine:
Do You Need a Study to Know It Is Safe?
As consumers, we're bombarded with information every day about the latest study on this or that new drug or supplement. Wefre taught to think that the medicine we're given by doctors has been stringently studied before we take it. But thatfs not always the case. In fact, not every conventional medical treatment has substantial data behind it, especially when we're talking about medication in pregnancy. Even over-the-counter medicines have not always been subject to in-depth clinical studies on humans. (The ethical issues are enormously complicated.) Doctors often decide on or guide a patient toward a course of action based primarily on their patientfs individual needs and wishes combined with their clinical experience, meaning their experience practicing medicine day-to-day and the knowledge theyfve gained from teachers and peers.

Studies of alternative and complementary therapies that are constructed according to the standards of Western science are in an early stage in the U.S. and Europe. The information we have from these clinical trials about CAM therapies=as opposed to the knowledge about CAM thatfs been disseminated by practitioners over time, sometimes centuries=is scanty. Clinical studies are hard to design because many CAM therapies, and the philosophies behind them, require that treatment be tailored to the individual. To complicate things even more, it's difficult to run an ethical clinical trial of any medication=conventional or herbal=to assess safety in pregnancy. Finally, even with conventional allopathic medicine, scientific studies arenft always available to give us answers for every clinical situation.

Is it best to avoid even 8safee medications and herbs during pregnancy? Yes. Is that always realistic? No. The odds are that at some point during a pregnancy, youfll get a cold or have indigestion or back pain, which a conventional or alternative treatment can help. Will the treatment work? Probably (therefs no 100 percent guarantee for any treatment). Is the treatment or medication safe? If an experienced, well-trained doctor or midwife recommends you take something=be it medicine or herb=if you trust her as a prenatal care provider, you can trust that she wouldnft suggest a treatment if she didn't believe it to be safe for you and your baby. That said, you can choose whether or not to take something, and you can do your own research on drug safety and ask your provider any questions you may have.

Likewise if youfre working with a Chinese or Western herbalist or homeopath whofs experienced working with pregnant women, ask what his philosophy is. Is he cautious in giving herbs to pregnant women? Where does he get his information about herb safety? (For example, Commission E, the German FDA, is a recognized authority on botanical medicine.) How long has he been using this herb with pregnant women and where does he get his herbs? If youfre not familiar with any of his answers, feel free to take notes and do follow-up research. In general, you probably can trust that established, experienced practitioners would err on the side of caution when working with herbs during the preconception, pregnancy, and postpartum periods. But just as with your medical provider, it's important to ask the questions. And you should check with your doctor or midwife before taking anything.

Ultimately, when it comes to safety in all health-related matters, but especially in pregnancy, there are no absolutes, only our best knowledge at any given moment in time.

FIRST QUESTIONS Before the consultation, prepare a list of questions. You can ask about anything that youfre wondering about. For example:
n What kind of training do you have?
n How long have you been practicing?
n What's your experience with women's health issues in general and pregnancy in particular?
n How can you help me?
n Is there scientific literature supporting your approach? (It's okay if there arenft many conventional, controlled studies of the modality, but you should know whatfs out there= and the practitioner should be able to tell you.)

Is This Practitioner Good for Me?
Jacques Depardieu, MSOM, L/Ac, treats patients with acupuncture, Chinese herbs, diet, and qi gong. He works with me at the Center for Women's Health. Specializing in women's health, Jacques speaks widely on acupuncture, Chinese medicine, and herbal medicine.

Q: How do you know if a practitioner is good?
Jacques Depardieu: First, the match of experience to condition has to be right. Some acupuncturists are phenomenal at back pain, and some practitioners are incredible for gastrointestinal problems, but not everyone is great for everything. And you should get results relatively quickly. Not for everything=an internal issue like a fibroid can take months. But for pain, you should start feeling better after a couple of treatments. If youfve had more than, say, four treatments and youfre not feeling better, I would strongly suggest that the practitioner may not be good for your specific problem.

Another key thing is to find a connection with a practitioner and to cultivate that connection. In the U.S., you get so many different types of practitioners and styles of acupuncture, as well as other modalities of complementary medicine. You as the patient need to feel a practitioner is there for you and listening to you. Really, feeling connected to a practitioner can be more important than the modality itself.

Finally, I believe that a practitioner should empower a patient. As a patient, you should understand that it's your bodyfs intelligence receiving the treatment, making sense of it, and then integrating it. The practitioner isnft some big 8Healere; your body is doing the work. So when you see someone, be open to being critical and engaged. Question them. Why? Why are you giving me those herbs? What can I do for myself? Can I change my diet? Do you suggest I do yoga or qi gong? Do you think I should take naps? The point is that the practitioner should be able to help you engage in your own healing process.

WHAT TO WATCH FOR n Locking you into multiple sessions: A practitioner might recommend that you come in regularly, and he may even offer a discount if you purchase a number of visits in advance, but you should not have to pay for multiple sessions up front.
n Dirty space or disheveled appearance: A workspace may have unusual decor, but it needs to be clean. Likewise, a practitioner needs to look professional and put together.
n No questions asked: A practitioner should have a lot of questions about your current health, your health history, and your treatment goals. If a practitioner doesn't ask thorough questions, you need to find someone else.
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