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 ìnothingî they could do but show up for their chemotherapy treatments. They were told to relax and let the chemotherapy fight their cancer, but they didnít feel comfortable with that. Both wanted to be more proactive in their care. So, after each asked me questions that I couldnít 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 Iíd learned practicing prenatal care. As a young obstetrician just out of residency, I quickly realized that my approach was too dogmatic. Iíd often say to a pregnant woman, ìThis is the way it isójust do what I say.î In that situation, the woman might do what I asked, but she didnít 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, ìThis never would have happened if I hadnít had the C-section.î 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 didnít trust my decision to perform the Cesarean because she hadnít felt sheíd 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 couldnít 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 hadnít developed a real partnership.

That single, under-the-breath comment was the ìahaî 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 partneró because you just canít anticipate every little thing thatís 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, Iíve been able to create an integrative medical practice, one that combines the best of conventional and complementary medicine.

Iím now a senior faculty member of the Center for Mind-Body Medicine in Washington, D.C., through which Iíve 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 rewardingó 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 womanís 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 bodyís 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 womanís 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 donít try to dictate what you should do. For example, I donít believe thereís a ìrightî way or a ìwrongî 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 itís 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 youíre thinking about getting pregnant, actively trying to conceive, currently pregnant, or have just given birth, thereís 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, youíll find the voices of women describing their own experiences, as well as interviews with expertsócomplementary practitioners, midwives, doulas, and othersówho have important insights to contribute to understanding pregnancy.

1

Holistic Medicine

Holistic medicine; alternative, complementary, and integrative medicineóthese terms are sometimes used interchangeably, but theyíre 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 youíll find:
ï Defining Holistic Medicine
ï Finding a Complementary or Alternative Medicine Practitioner
ñ Quality matters
ñ Figure out your needs
ñ Collect names
ñ Set up a consultation

Defining Holistic Medicine
ï 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 elementsóbody, mind, and spiritóneeds to be accounted for in any medical treatment. In other words, no one symptomófor example, chronic headaches or gastrointestinal problemsóis understood or treated as an isolated event. Holistic medicine embraces prevention and self-care, using noninvasive treatments that support a personís natural abilities to heal.

ï Alternative medicine generally refers to diagnostic and treatment methods (also known as ìmodalitiesî) 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 ìalternativeî 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 medicineóand 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.

ï 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.

ï CAM is an abbreviation for ìcomplementary and alternative medicine.î CAM is most often confused with complementary medicine, but CAM is the umbrella term for both complementary and alternative medicine.

ï 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, physicianís assistant, or certified nurse-midwife.

ï Integrative medicine shares holistic medicineís 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.

ï 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 bodyís 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 youíre using them. Homeopathic remedies sold in health food stores have such small amounts of the active ingredients that they shouldnít pose a problem. (Avoid any preparationóhomeopathic or otherwiseó 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 donít use it regularly in my own obstetric practice, and, for the most part, it wonít 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 donít. 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 preferencesódoes she like to be touched, is she afraid of needlesóand 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, Iíll 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, weíve 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 youíre looking for a new doctor or nurse-practitioner, when you set outto find an alternative practitioner you want to find someone whoís not only well qualified, but whoís 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 itís 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 ìbuyer bewareî; 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:

ï 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.
ï Accreditation and certification are generally administered by voluntary, nonprofit organizations or trade associations.

Once you have some names, feel free to ask questions: If thereís a state licensing board where you live, you can check with it to make sure that a practitioner is registered. If there isnít a state board, you can check with the specialtyís major professional organizations to learn more about accreditation and find out if the practitioner is in good standing. Finally, donít be shy about asking a practitioner if heís accredited or licensed, and what that means in terms of his training.

Finding a qualified practitioner isnít always easy, but itís 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 youíre looking forómassage therapist, chiropractor, herbalist, acupuncturistówhen you set out to find a complementary or alternative practitioner, first take some time to figure out whatís important to you.

ï 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 youíll be comfortable.
ï Travel time: If youíre lucky, youíll 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.
ï 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 sheís 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.
ï Expertise: Most important, since youíre either pregnant or trying to be, look for someone who specializes in womenís health and pregnancy care. If youíre 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 youíre looking for, begin to assemble a list of names.

REAL VOICES
Iíd moved to a new city, and I wanted to find a craniosacral therapist because Iíd 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 canít 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 stateófor example, licensed massage therapists.
7. Get a list of practitioners in your area who are accredited by the national organization for that disciplineófor 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 isnít willing to have a consultation or let you tour his workspace, look for someone else. Ask about special consultation feesóthe visit may be free or a practitioner may have a lower consultation-only fee. Let the practitioner know whether youíre pregnant or trying to conceive and what youíre 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 youíre there for? Do her explanations make sense to you? If youíre 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, weíre bombarded with information every day about the latest study on this or that new drug or supplement. Weíre taught to think that the medicine weíre given by doctors has been stringently studied before we take it. But thatís not always the case. In fact, not every conventional medical treatment has substantial data behind it, especially when weíre 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 patientís individual needs and wishes combined with their clinical experience, meaning their experience practicing medicine day-to-day and the knowledge theyíve 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 therapiesóas opposed to the knowledge about CAM thatís been disseminated by practitioners over time, sometimes centuriesóis 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, itís difficult to run an ethical clinical trial of any medicationóconventional or herbalóto assess safety in pregnancy. Finally, even with conventional allopathic medicine, scientific studies arenít always available to give us answers for every clinical situation.

Is it best to avoid even ìsafeî medications and herbs during pregnancy? Yes. Is that always realistic? No. The odds are that at some point during a pregnancy, youíll get a cold or have indigestion or back pain, which a conventional or alternative treatment can help. Will the treatment work? Probably (thereís no 100 percent guarantee for any treatment). Is the treatment or medication safe? If an experienced, well-trained doctor or midwife recommends you take somethingóbe it medicine or herbóif you trust her as a prenatal care provider, you can trust that she wouldnít suggest a treatment if she didnít 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 youíre working with a Chinese or Western herbalist or homeopath whoís 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 youíre 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, itís 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 youíre wondering about. For example:
ï What kind of training do you have?
ï How long have you been practicing?
ï Whatís your experience with womenís health issues in general and pregnancy in particular?
ï How can you help me?
ï Is there scientific literature supporting your approach? (Itís okay if there arenít many conventional, controlled studies of the modality, but you should know whatís out thereó 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 Womenís Health. Specializing in womenís 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 everythingóan internal issue like a fibroid can take months. But for pain, you should start feeling better after a couple of treatments. If youíve had more than, say, four treatments and youíre 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 itís your bodyís intelligence receiving the treatment, making sense of it, and then integrating it. The practitioner isnít some big ìHealerî; 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
ï 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.
ï 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.
ï 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 doesnít ask thorough questions, you need to find someone else.


Contents

Foreword vii
Introduction ix
Contributors xv

Part One
1: Holistic Medicine 3
2: First Steps: Preconception Health 13
3: Moving Toward Optimal Preconception Health 22
4: Getting Pregnant 37
5: When Pregnancy Is Delayed: Fertility Tests, Treatments, and Technologies 47
6: Mind-Body Medicine and Fertility 61

Part Two
7: The First Trimester 75
8: First Things: Early Prenatal Care 91
9: The Emotional and Physical World of Early Pregnancy 104
10: A Pregnancy Timeline 126
11: Pregnancyís Effects 149
12: How to Treat Everyday Illnesses 200
13: Prenatal Nutrition 215
14: Exercise and Pregnancy 249
15: Prenatal Tests 280
16: Living and Working 308
17: Medical Complications of Pregnancy 333
18: Pregnancy Loss 367
19: Preparing for Labor and Birth 388
20: The Last Weeks of Pregnancy 424
21: The Stages of Labor 444
22: Assisted Vaginal Births and Cesareans 472
23: Postpartum 487
Afterword: Personal Reflections 515

Appendices: 1. Resources 521
2. Glossary of CAM Terms 525
3. Prenatal YogaññAdditional Sequences 530
4. BMI Table and Pregnancy Food Journal 535
Acknowledgments 543
Index 545
About the authors 553