FAS info
FROM: Lesley Chan, newly-qualified midwife
EMAIL:
lesleychan@hotmail.co.uk
SUBJECT: FAS info
Dear editorI would like to express my opinion about the news focus article in the last issue of
Midwives entitled
Mixing alcohol and pregnancy. I applaud and acknowledge Addenbrooke’s Hospital midwife Anne Marie Winstone’s hard work in creating a valuable tool on the sensitive subject of fetal alcohol syndrome (FAS) to enable healthcare professionals to provide information to women. Conversely though, I am rather disappointed that the terminology ‘retardation’ on the NHS pocket guide for midwives (‘infant growth retardation’) has been used.
This information may have been adopted from the National Organization on Fetal Alcohol Syndrome (NOFAS) in the US, as opposed to NOFAS-UK. Consequently, this is circulating as an NHS educational tool, thus teaching midwives and students to use this phraseology. There is a danger that to continue to acknowledge the word ‘retardation’ as acceptable terminology may risk inclusion of the word into our everyday vocabulary, and in the presence of women, this could be insensitive and even offensive.
During my own recent education at the University of Manchester, I noted every effort is being made to replace such insensitive and negative words. Student midwives are encouraged to avoid words like ‘retardation’ and replace them with ‘restriction’, ‘deficiency’ or ‘impairment’ as a more sensitive approach.
Ginger
FROM: Denise Tiran, director of Expectancy Ltd
EMAIL:
info@expectancy.com
SUBJECT: Ginger
Dear editorI write in response to the Nutrition in Pregnancy toolkit, received recently by RCM members, which appears generally to be a useful adjunct to midwifery knowledge on nutrition. However, I wish to comment on the information on morning sickness – there are several points that deserve clarification in this section, but I specifically raise here the issue of ginger.
Ginger is a remedy used in the alternative medical system of phytotherapy (herbalism). There is a plethora of scientific evidence investigating the effectiveness of its anti-emetic action, not only during pregnancy, but also for motion sickness and post-operative nausea, usually taken as teas, capsules or syrup. The number of positive studies is too many to list here, but meta-analyses of randomised controlled trials appear to confirm that the anti-emetic action of ginger is superior to that of placebo (Chaiyakunapruk et al, 2006; Jewell and Young, 2003), although one German systematic review disputed this (Betz et al, 2005).
However, like pharmaceutical drugs and other herbal remedies, ginger acts pharmacologically and therefore has specific indications, contraindications and precautions. ‘Proof’ of efficacy should not mean that ginger is viewed as universally acceptable or safe – healthcare professionals would not administer the same analgesic to everyone in pain simply because one had been extensively shown to be effective. Ginger may cause adverse reactions such as heartburn (Chittumma et al, 2007) and can interact with several medications, notably anticoagulants (Shalansky et al, 2007; Ulbricht et al, 2008). Emerging evidence suggests that ginger may also have a teratogenic action (Søndergaard, 2008; Yang et al, 2010).
Furthermore, midwives (and nutritionists) should not prescribe ginger unless they are aware of these fundamental principles in relation to their practice and in accordance with professional requirements (NMC, 2008; Tiran, 2010). Importantly, they must have adequate knowledge to advise mothers about correct dosages, methods and frequency of administration, as well as the side-effects associated with inappropriate or prolonged use.
The recommendation in the toolkit to ‘take ginger in any form: supplements, biscuits, ginger beer, tea, etc’ is inaccurate and unhelpful. Ginger biscuits, for example, contain carbohydrate, mainly in the form of sugars, which provide temporary relief of nausea, followed by hypoglycaemia, which triggers the nausea again, but there is insufficient ginger to have any real therapeutic effect other than placebo. In some women, ginger in tea, for example, can exacerbate nausea – this is partly dose dependent and partly because it is unsuited to some individuals. In traditional Chinese medicine, ginger is considered to be a ‘hot’ or ‘yang’ remedy used to rebalance internal energies in patients who are ‘cold’ or ‘yin’; administering ‘hot’ ginger to a woman who is already excessively ‘yang’ will only serve to make her symptoms worse (Tiran and Budd, 2005). The anticoagulant effects suggest that doses should be limited to 1gm per day for no longer than three weeks, although no consensus has yet been reached on optimum safe doses. Indeed, if symptoms have not resolved with this regimen, there is the possibility that either the remedy is ineffective or that the nausea and vomiting may be pathological rather than physiological.
I am gravely concerned that midwives perpetuate the myth of ginger as a universal remedy for gestational sickness, largely through ignorance, when in fact they should refrain from advising women at all, without adequate knowledge. Midwives need to stop over-stepping the boundaries of their practice, and start understanding that herbal medicine is a clinical modality outside the scope of most. However, failure to provide correct information on such a popular herbal remedy is unhelpful, since so many women believe it to be a panacea for all forms of morning sickness. It is therefore imperative that midwives acquire a contemporary, comprehensive and evidence-based knowledge of the safety of ginger in pregnancy.
References
Betz O, et al. (2005) Is ginger a clinically relevant anti-emetic? A systematic review of randomized controlled trials.
Forsch Komplementarmed Klass Naturheilkd 12(1): 14-23.
Chaiyakunapruk N, et al. (2006) The efficacy of ginger for the prevention of post-operative nausea and vomiting: a meta-analysis.
Am J Obstet Gynecol 194(1): 95-9.
Chittumma P, et al. (2007) Comparison of the effectiveness of ginger and vitamin B6 for treatment of nausea and vomiting in early pregnancy: a randomized double-blind controlled trial.
J Med Assoc Thai 90(1): 15-20.
Jewell D, Young G. (2003) Interventions for nausea and vomiting in early pregnancy.
Cochrane Database Syst Rev 4: CD000145.
NMC. (2008)
Standards for medicines management. NMC: London.
Shalansky S, et al. (2007) Risk of warfarin-related bleeding events and supratherapeutic international normalized ratios associated with complementary and alternative medicine: a longitudinal analysis.
Pharmacotherapy 27(9): 1237-47.
Søndergaard K. (2008) Ginger, pregnancy nausea and possible fetal injuries (testosterone effect).
Ugeskr Laeger 170(5): 359.
Tiran D. (2010) Complementary therapies and the NMC.
Practising Midwife 13(5): 2-3.
Tiran D, Budd S. (2005) Ginger is not a universal remedy for nausea and vomiting in pregnancy.
MIDIRS Midwifery Digest 15(3): 335-9.
Ulbricht C, et al. (2008) Clinical evidence of herb-drug interactions: a systematic review by the natural standard research collaboration.
Curr Drug Metab 9(10): 1063-120.
Yang G, et al. (2010) Genotoxic effect of 6-gingerol on human hepatoma G2 cells.
Chem Biol Interact 185(1): 12-7.
