Born Free Method: The Podcast – Details, episodes & analysis

This summary covers:- Prediction and Prevention of Spontaneous Preterm Birth - Practice Bulletin #234 - Published August 2021- Management of Preterm Labor - Practice Bulletin #171 - Published October 2016

Prediction and Prevention

Five Pearls

* PTD at <34 wga carries higher mortality and morbidity risk to newborn in delivery and long-term morbidity

* History of PTD is the greatest risk factor for PTD in a current pregnancy

* Progesterone supplementation can be considered regardless of history of PTD

* In patients w/ singleton pregnancy and history of PTD, cerclage should be offered if CL <25 mm is detected on TVUS at 16-24 wga

* Omega 3s, low-dose aspirin, lifestyle modification, and smoking cessation are also important considerations in decreasing our national PTD rate

Background

* rates of preterm delivery in the U.S. has been pretty stable

* "Although risks are greatest for neonates born before 34 weeks of gestation, infants born after 34 weeks of gestation but before 37 weeks of gestation are still more likely to experience delivery complications, long-term impairment, and early death than those born later in pregnancy"

* risk factors for PTD: prior PTD (1-2x ↑ risk), short cervical length (<20mm if no history of PTD; <25mm if prior history), vaginal infection in pregnancy, vaginal bleeding in pregnancy, UTI in pregnancy, or periodontal disease in pregnancy (treatment of any of these won't normalize risk, though), low maternal BMI, smoking, substance abuse, and short inter-pregnancy interval

* in case you were wondering, history of LEEP of CKC for cervical dysplasia has not been found to be a risk factor after all according to ACOG but there are studies that support this (and my own direct clinical experience reflects the alternative)

* White women have the lowest rate (9.3%), Hispanic women (10%), American Indian and Alaskan native (11.5%), Native Hawaiian and Pacific Islander (11.8%), with highest rates seen among black women (14%)

Who should be screened and how?

* the purpose of screening is to identify patients in whom intervention will be helpful

* really the only patients who qualify for screening are those with a history of prior PTD, PPROM, multiple gestations, but ACOG feels it’s reasonable to screen universally as 5% of all women could potentially give birth preterm

* a systematic review looked at 14 studies and found that:

“a cervical length less than 25 mm before 16-24 weeks of gestation had a sensitivity of 65.4% for preterm birth before 35 weeks of gestation, with a positive predictive value of 33.0% and a negative predictive value of 92.0%. Sub-analysis of the studies that included only women whose risk factor was prior spontaneous preterm birth found a similar sensitivity and a positive predictive value of 41.4%”

* get a baseline transvaginal ultrasound (TVUS) and repeat this evaluation every 1-2 weeks to assess for change (limited data on time interval)

* measure three times, and go with the average

* "fetal fibronectin screening, bacterial vaginosis screening, and home uterine activity monitoring have been proposed to assess a woman’s risk of preterm delivery" and none of them have panned out as useful predictors of PTD in asymptomatic women

* recent data suggests that it might actually be cost-effective to universally screen for shortened cervix in patients without history of PTD (study 1, study 2), but, for now, ACOG states it's reasonable to offer but not necessarily recommended universally

When and how to prevent PTD?

No history of PTD

* Extensively studied as a means to reduce the risk of preterm birth in asymptomatic women with a singleton pregnancy, short cervix, and no prior preterm birth.

* a meta-analysis of five randomized trials of vaginal progesterone versus placebo in patients with a singleton pregnancy, a short cervix, and no prior preterm birth was performed, including patients from the 2019 OPTIMUM (Does Progesterone Prophylaxis to Prevent Preterm Labour Improve Outcome?) trial who did not have other risk factors, and standardizing the threshold definition of shortened cervix at 25 mm or less for their analysis. Patients treated with vaginal progesterone had a significantly reduced risk of any preterm birth before 34 0/7 weeks of gestation (14.5% versus 24.6%; RR, 0.60; 95% CI, 0.44–0.82), spontaneous preterm birth before 34 0/7 weeks of gestation (RR, 0.63; 95% CI, 0.44–0.88), neonatal respiratory distress, and neonatal intensive care unit admission. The meta-analysis authors calculated that 14 patients would need to be treated to prevent one spontaneous preterm birth before 34 0/7 weeks of gestation.

* Vaginal progesterone is recommended for asymptomatic individuals without a history of preterm birth with a singleton pregnancy and a short cervix. 200 mg per vagina nightly is the best studied regimen

History of PTD:

* Before the PROLONG trial (2020), a metaanalysis was published in 1990 that showed demonstrable evidence of the benefits of 17-OH-P in preventing recurrent PTD, which led to a large multicenter RCT of 463 patients. They were randomized to receive either 250 mg 17-OHPC IM or placebo, starting between 16 0/7 and 20 6/7 weeks of gestation. Administration of 17-OHPC reduced the rate of preterm birth before 35 weeks of gestation by one third, leading ACOG and SMFM to recommend this intervention universally to women with history of PTD.

* Then came the PROLONG trial, which evaluated the efficacy of 17-OHPC 250 mg intramuscular injection weekly compared with placebo on preterm birth and neonatal morbidity among women with a singleton pregnancy and prior spontaneous preterm birth. Large, international, multicenter double-blind RCT. 1740 women randomized (of 1877 eligible). No statistical difference found in the two primary outcomes of preterm birth before 35 0/7 weeks of gestation or maternal/neonatal outcomes.

* On April 5, 2023, the FDA withdrew its approval of 17-OHP for prevention of preterm birth as a result of the PROLONG trial

* Data comparing vaginal to IM progesterone supplementation continues to roll in, so no definitive conclusions can be made yet

* In the meantime, SMFM discourages clinicians from using IM 17-OHP off-label

* Recommended to screen cervical length every week from 16-24 weeks and to offer cerclage if it measures <25 mm, though this intervention was best studied for women with history of PTD <34 weeks

* it may be more cost effective to forego cervical shortening screening altogether in those without this history

Cerclage

* Short cervix found on ultrasound: uncertain effectiveness in patients with a short cervix and no history of preterm birth. However, there is evidence of potential benefit in patients with a very short cervical length (<10 mm)

* Open cervix on physical exam: Individuals with cervical insufficiency based on a dilated cervix on a digital or speculum examination at 16 0/7–23 6/7 weeks of gestation are candidates for a physical examination-indicated cerclage (but data is mixed)

* unclear if 17-OH-P plus cerclage are additionally helpful together compared to either intervention alone

* An interesting side note: there’s no evidence, per say, that suggests that it’s a terrible idea to place an US-indicated cerclage after 23 6/7 weeks; this is merely “expert opinion”

* Because cervical insufficiency traditionally is defined as painless cervical dilation in the 2nd trimester, this restriction presented no issue when viability did not begin until the 3rd trimester and indeed may have arisen to discourage the treatment of patients with threatened preterm labor with cerclage

* But now that we have better means of keeping 23+ weekers alive in the NICU, it seems that little investment has been made to prevent babies from coming super early

* What if a specific institution doesn’t have the full capacities for keeping these very preterm babies alive? Should we not then consider an early 3rd trimester cerclage? Why not? Very little data to continue this conversation…(much of this is paraphrased from a bada$$ article that was recently published in the Green Journal)

Notes on cerclages...

There are three indications:

* Ultrasound-indicated: what we've already described

* History-indicated: cerclage placed at conclusion of first trimester and after prenatal screening has been completed in patients with cervical insufficiency

* Physical exam-indicated (e.g. rescue cerclage): option if cervical dilation >2cm is visualized on speculum exam or ultrasound <24 wga

There are three techniques (all call for Mersilene suture):

* McDonald: performed vaginally under regional anesthesia using the purse-string technique at the cervicovaginal junction; bladder emptying is recommended, but mobilization is not required

* Shirodkar: performed vaginally under regional anesthesia using purse string technique after emptying and mobilizing the bladder

* Transabdominal: performed laparoscopically or open, placing the suture in purse-string fashion at the cervicoisthmic jxn (**will require c-section); recommended if vaginal placement is determined not possible or if cervix is too short that vaginal effort is unlikely to be successful

If a patient has a cerclage in place and presents in active labor, you must remove the cerclage to avoid cervical laceration, which can lead to outrageous brisk bleeding (you can't stop active labor)

Other options

* if birth was preterm due to other comorbidities, low-dose aspirin has been demonstrated in some studies to prevent preclampsia and thus prevent indication for iatrogenic preterm birth

* tighter control over BPs in cHTN may also decrease our PTD rates

* presence of funneling hasn't been found to significantly influence the risk of PTD

* "indomethacin or antibiotics, activity restriction, or supplementation with omega-3 fatty acids have not been evaluated in the context of randomized trials for women with short cervical length, and are not recommended as clinical interventions for women with an incidentally diagnosed short cervical length."

* stop smoking

* omega 3 fatty acids show some promise (2018 Cochrane review)

* decreasing allostatic load (think: improve our racist, inegalitarian society)

* treat UTIs and vaginal infections when they arise

* avoid licorice root?

* false unicorn root

* wild yam

* uva ursi (indirectly through flushing urinary tract)

* history of PROM: check electrolytes or hair mineral analysis

Management of Preterm Labor

Five Pearls

* Preterm labor carries significant risks to the newborn: the more premature, the worse the outcomes

* Given high risk for long-term morbidity in extremely premature infants, focusing on comfort as opposed to aggressive resuscitation at time of delivery is reasonable through a shared medical decision-making process

* Corticosteroids can improve outcomes for newborns at risk of preterm birth at <34 wga (and some as late as 36w5d) if delivery anticipated within the next 7 days

* Latency antibiotics can improve outcomes for newborns in the setting of PPROM at <34 wga

* Magnesium sulfate can improve outcomes for newborns at risk of preterm birth at <32 wga

Background

* around 10% of babies are born before 37 wga

* why are we concerned? higher risk of neonatal mortality, respiratory distress, sepsis, intracranial bleeding, and long-term issues like neurodevelopmental challenges

* preterm labor definition: regular uterine contractions + cervical dilation ≥ 2 cm between 20 wga and 36w6d ga

* <10% of women who present that meet these criteria actually deliver within 7 days

So a patient presents with contractions preterm...

* you could look with a speculum exam, collect fetal fibronectin, and/or get an endovaginal ultrasound

* utility of ultrasound and FFN haven't been validated through RCTs, though observational data suggests they may be helpful in identifying patients truly at risk for preterm birth; FFN alone has poor predictive value (CONSIDER THE WHOLE CLINICAL PICTURE)

* if she looks like she's in labor, especially if >32 wga, digital exam of the cervix may be warranted - we will review prevention of preterm labor in a future episode...

When should we be worried about preterm delivery?

* consistent regular contractions and evidence of cervical dilation are good sign that preterm delivery may be happening

* in 30% of patients presenting w/ preterm prodromal labor, the process will cease spontaneously; only 50% of patients admitted for preterm labor concerns will end up delivering at term (SO BE JUDICIOUS AND THOUGHTFUL)

Pearl: ~20% of patients who present with preterm contractions without cervical dilation will deliver before 37 wga; <5% will deliver within 2 weeks of presentation

Can we stop preterm labor?

* Sometimes, but tocolytic therapy is only thought to be effective for 48 hrs (just so happens to buy you enough time to get corticosteroids on board if indicated)

* tocolysis is generally not recommended after 34 wga

* since 30% of preterm labor will resolve without any intervention, even patients with advanced cervical dilation (2 cm) at <34 can generally be observed without tocolytics, and particularly so if no cervical dilation is found

* b-adrenergics don't tocolyze well and carry significant maternal cardiovascular risks (but OK for antepartum uterine tachysystole)

What's the cut off for viability?

* <20 weeks is considered previable (no intervention indicated)

* 23 wga to ~26 wga can be considered periviable

* this NICHD calculator can be used in your counseling to guide delivery/management plan

Pearl: Just because we can resuscitate a baby doesn't mean that we should. Delivery of a peri-viable newborn must include risks and benefits of delivery methods to mom and risk and benefits of preterm delivery and resuscitation to the newborn.

What's the role of corticosteroids?

* stimulates the development of alveoli in premature fetal lungs in order to optimize transition to external environment

* can significantly improve outcomes

* recommend a single course if patient presents with preterm labor (or need for delivery due to maternal health concerns like early-onset severe preeclampsia) between 23 wga and 33w6d if you anticipate delivery within 7 days

* can repeat the course if greater than 2 weeks have passed after first course

* can recommend single course between 34 wga and 36w5d if i) no prior steroids, ii) membranes intact, iii) patient not diabetic (and don't delay delivery to complete course)

Regimens:

a. betamethasone 12-mg IM q24 hrs for 2 dosesb. dexamethasone 6-mg IM q12 hrs for 4 doses

Should I mag or should i not?

* if <32 wga, start mag for fetal neuroprotection

* mag isn't a reliable tocolytic agent

* if patient is on mag for fetal neuroprotection, adding on a tocolytic agent can still be considered, but be careful with b-agonists and Ca-channel blockers (synergistic w/ mag sulfate, so may cause hypotension); go with indomethacin

Should I recommend antibiotics?

* intrauterine infection is a well known cause of preterm labor and delivery

* antibiotics haven't been found to be helpful outside of PPROM at <34 wga ("latency" abx)

* latency antibiotics have been found to improve interval from time of PPROM to delivery, ↓ risk of chorio, neonatal infection, and need for neonatal oxygen therapy (Cochrane Review) in patients who present w/ PPROM at <34 wga

The regimen:

2x days ampicillin 2 g IV q6hr PLUS erythromycin 250 mg IV q6hr THEN 5x days amoxicillin 250 mg PO q8hr PLUS erythromycin 333 mg PO q8hr

* erythromycin and azithromycin are equally efficacious, but the latter is cheaper and better tolerated from GI standpoint

* amoxicillin-clavulanic acid (augmentin) associated with higher risk of neonatal necrotizing enterocolitis (NEC) in some studies, therefore not recommended

If PCN allergic:

Azithromycin 1 g PO x1 at time of admission PLUS 2x days cefazolin 1g IV q8hr THEN 5x days cephalexin 500 mg PO four times daily

* if severe PCN allergy, substitute cephalosporins for gentamicin/clindamycin

* at 34 wga, it's prudent to recommend IOL (risks versus benefits)

What can be done to prevent preterm delivery?

* hydration, bed rest, nor tocolytics in asymptomatic women have been found to be helpful prophylaxis against preterm delivery

* plus there's potential harm from decreased activity: ↑ risk VTE, ↑ bone demineralization, and general de-conditioning

* Atosiban is a maintenance tocolytic that isn't FDA approved for use in the US

What about preterm delivery in multiple gestations?

* no clear data to support the benefit of steroids or mag sulfate for fetal neuroprotection in multiple gestations

* many experts extrapolate that benefits outweighs risk, though

* tocolytics: risks outweigh benefits in multiple gestations

Born Free Method: The Podcast is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

Notes for this episode are found on Substack

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Medical Disclaimer: Born Free Method: The Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

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Dr. Powell is a naturopathic physician with her master’s degree in public health. She’s a doula, as well, as she has a wealth of knowledge when it comes to interpreting stool analyses and supporting the gut in pregnancy and postpartum. We met when I called Genova Diagnostics for support in interpreting a client’s GI Effects stool analysis. Now we’re friends, and I wanted to share her with the world.

Speaking of stool analyses, the reason that I prefer GI Effects is because I have run all of the major stool analyses (GI-Map, GI360, etc.), and GI Effects found several problem areas that were missed by the others. GI Effects gives you an impression of the degree of inflammation in the gut, pancreatic function, gut flora, presence of parasites, and digestion and absorption of proteins/fats/carbs. Plus, when I started running these analyses on clients, I loved that I was able to arrange for consults with Genova consultants to go deep into the results.

In this conversation, Dr. Powell teaches me about:

* What can a stool analysis tell you about your health?

* What is the optimal frequency and consistency of poop? (We say poop a lot in this episode…try to get over it)

* What might reflux or bloating tell you about your gut function?

* How do you select a probiotic?

* What role does diet play in gut health?

* What role does the gut play in hormone health?

* How can you optimize gut function in pregnancy and postpartum?

* Chiropractics and gut function

* Calcium D-Glucarate, vitamins, fermented foods, milk thistle, and more…

We go deep in this one. Enjoy.

Find Lahnor Powell, ND, MPH on Instagram. Her practice is called Okana Care.

Notes for this episode

Work with Nathan: Beloved Holistics | Born Free Method | Clear & Free | Twins-Breech Training

Medical Disclaimer: Born Free Method: The Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

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This one pairs nicely with the 2020 Bonterra Cabernet Sauvignon (Organic)

Five Pearls

1. Normal physiologic changes in pregnancy that are relevant in anemia: blood volume expands by 50% (increased iron requirement), red blood cell mass increases by 25% in a singleton pregnancy, and increased iron stores in the female body during pregnancy help to sustain the increased demand.

2. Low serum ferritin is the most sensitive and specific single lab finding in iron deficiency anemia. And yet, it’s specificity isn’t great.

3. The CDC recommends universal screening for iron deficiency anemia in pregnancy along with universal supplementation.

4. B12 deficiency and folate deficiency are common causes of macrocytic anemia; folate deficiency much more likely than B12.

5. Blood transfusions are almost never indicated in pregnancy, apart from the rare case of a large, concealed placental abruption (Hgb <6 g/dL is associated with abnormal fetal oxygenation --> non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death)

Definition of anemia in pregnancy

Hgb = hemoglobin; HCT = hematocrit

- Hgb <11g/dL or HCT <33% in the first/third trimesters

- <10.5 g/dL or <32% in the second trimester

- everybody should be screened in the 1st trimester and at 24-28 weeks

- If hematocrit level is less than 33% in the first and third trimesters or less than 32% in the second trimester, you need to investigate the cause. If iron deficiency is ruled out, other etiologies should be investigated

- Living at a high altitude and tobacco use cause a generalized increase in hematocrit and hemoglobin levels, and consideration of these factors may be appropriate when interpreting test results

Classification of anemia

Physiologic changes in pregnancy that may lead to anemia

- blood volume expands by 40-50% (increased iron requirement)

- red blood cell mass increases by 15-25% in a singleton pregnancy

- increased iron stores in the female body during pregnancy help to sustain the increased demand

**UK guidelines on iron deficiency anemia: https://www.bsg.org.uk/wp-content/uploads/2021/09/Iron-Deficiency-Anaemia-in-Adults.pdf

“An SF level of <15 µg/L is indicative of absent iron stores, while SF levels of less than 30 µg/L are generally indicative of low body iron stores. The lower limit of normal for most laboratories, therefore, lies in the range 15–30 µg/L.”

Structure of hemoglobin

- four polypeptide chains + heme

- the six chain types: alpha (α), beta (β), gamma (γ), delta (δ), epsilon (ε), and zeta (ζ)

- adult hemoglobin consists of two alpha chains + either two β-chains (hemoglobin A), two γ-drains (hemoglobin F), or two δ-chains (hemoglobin A₂)

- hemoglobin F predominates in the developing fetus from 12 -24 wga, after which hemoglobin A begins to increase

Iron deficiency anemia

- 2% prevalence in general female population (2x higher for black women compared to white)

- “An assessment of iron status in pregnant individuals in the United States using data from the National Health and Nutrition Examination Survey (known as NHANES) from 1999 to 2006 found that iron deficiency prevalence increased significantly with each trimester (mean ± standard error, 7%, 14%, and 30%, in the first, second, and third trimesters, respectively) and was higher in Mexican American pregnant women, non-Hispanic Black pregnant women, and women with parity greater than 2”

- in pregnancy, higher prevalence by far in 3rd trimester

- associated with low birth weight, preterm delivery, and perinatal mortality

- there may also be an association with postpartum depression and worse mental and psychomotor performance testing in offspring

- diagnosed by lab analysis OR if there's an increase in Hgb by 1g/dL after iron treatment OR by the absence of bone marrow iron stores on bone marrow biopsies

- iron storage may be low (iron depletion), or stored + transport iron are low (decreased erythropoiesis), or stored + transport + functional iron are all low (full blown iron deficiency anemia, yeehaw!)

- on iron studies, iron deficiency anemia presents as: microcytic, hypochromic, iron store depletion, low plasma iron, increased total iron-binding capacity (TIBC), low serum ferritin, and increased free erythrocyte protoporphyrin

- serum ferritin levels are most specific and sensitive for the diagnosis (<10-15 mcg/L is diagnostic)

- CDC recommends universal screening of pregnant women along with universal supplementation (unless the patient has hemochromatosis)

- typical American diet provide 15 mg of elemental iron per day (recommended: 27 mg daily iron intake)

- extended-release formulations are less effective

- foods rich in iron: shellfish, beef, organ meats, turkey, beans, and lentils

- foods that enhance iron absorption from the gut: citrus, strawberries, broccoli, and peppers

- foods that impair iron absorption: dairy, soy, spinach, and coffee

Macrocytic anemia

- two general categories: megaloblastic (B12 or folate deficiency, pernicious anemia) and non-megaloblastic (liver disease, myelodysplasia, increased reticulocytes, aplastic anemia, and hypothyroidism)

- mean corpuscular volume (MCV) >100 fL is characteristic of macrocytic anemia

- if >115 fL, diagnostic for folate acid or B12 deficiency (confirm by checking serum folate acid or B12 levels)

Click for source

- in the U.S., macrocytic anemia in pregnancy is due almost exclusively to folate deficiency

- recall: folic acid should universally be supplemented at 400 mcg per day in pregnancy

- however: 40-60% of the U.S. population carries of a variant of a mutation within the gene that encodes for the MTHFR enzyme, and folic acid is useless in that case

More on folic acid versus folate from Lily Nichols, RDN

- folate deficiency can be caused by diets deficient in leafy vegetables, legumes, or animal proteins (or taking antacids) - changing the diet should do the trick (you can also increased folic acid supplementation to 1 mg daily along with increasing iron supplementation)

- B12 deficiency can be seen in women who have undergone partial or total gastric resection or in Crohn disease

- treatment includes supplementing with 1000 mcg of B12 (intramuscular) monthly

What if a patient has laboratory evidence of anemia but is asymptomatic?

- mild: reasonable to investigate further through iron studies, RBC indices, etc. (otherwise you may just recommended dietary changes without investigation)

- moderate: definitely investigate the etiology (CBC, RBC indices, iron studies, blood smear), consider Hgb electrophoresis if patient is of African, Southeast Asian, or Mediterranean descent; reasonable to treat empirically with iron while awaiting further studies (you should see results in a few weeks)

When should transfusion be considered?

- almost never in pregnancy, apart from the rare case of a large, concealed placental abruption (Hgb <6 g/dL is associated with abnormal fetal oxygenation --> non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death)

- postpartum is a different story: coagulopathy (HELLP, DIC, etc.), uterine atony, placenta previa/accreta, and placental abruption may all result in the need for transfusion postpartum

- if the patient becomes symptomatic or hemodynamically unstable then it's a no-brainer

When should iron infusion be considered?

- useful for the rare patient who can't tolerate oral iron or those who have severe malabsorption issues

- 1% chance of anaphylaxis (iron dextran more likely to cause a reaction than ferrous sucrose)

- faster immediate results from IV iron compared to oral for most patients, but by day 40 after treatment, the two routes of comparable

- insufficient data to guide decisions around erythropoietin treatment in pregnancy

Click for source

My approach:

* Evaluate for all potential causes of anemia before treatment (Ready —> Aim —> Fire; Not the other way around). Often iron deficiency plays a role, but rarely is it just about iron.

* Instead of repleting iron willy-nilly, try to determine if absorption is the underlying issue. Adding acids like apple cider vinegar or HCL capsules to the diet can help with reabsorption. Calcium-rich foods can impede absorption. You can bet that absorption is at least partially responsible if ferritin is low, although ferritin itself is wildly misunderstood (including by me). For example, there is little if any iron found in a molecule of ferritin, so what’s the deal? Well, while ferritin reflects overall “iron stores”, this association is more likely indirect. Ferritin is more likely a powerful antioxidant. My clinical experience tells me that iron deficiency anemia will at least be partially corrected for (with improved outcomes) if low ferritin is managed by focusing on absorption of iron. Bear in mind, also, that the antioxidant response element, which is regulated by Nrf2, a master gene in the regulation of our response to oxidative stress, regulates the expression of the gene that is responsible for ferritin production, meaning foods and supplements meant to regulate Nrf2 can also have an impact on ferritin levels. Note: this means foods and supplements that flood the body with antioxidants may be impactful to iron storage and utilization, but, again, I haven’t figured this out entirely. But others are also asking these questions…

* I always aim for a serum ferritin level of at least 50 ng/mL

* Adequate nourishment through whole foods, namely beef liver, bivalves like oysters, bone broth, fermented cod liver oil, and farm-fresh eggs are all helpful for the increased demand on RBC production. There’s no question about this. You’ll have adequate amounts of folate (Vitamin B9), other B vitamins, fat-soluble vitamins, Omega 3s, Cu/Zn, Se, Mg, and other nutrients critical for healthy absorption, transport, and storage of iron (and general health before, during, and after pregnancy).

* I don’t generally recommend supplemental iron, as you’ll get more bang for your buck (and avoid constipation) by striving to acquire these nutrients from whole food sources.

* Address underlying inflammation, which can be tricky to identify while in pregnant state, which is, in some regards, an inflammatory state in and of itself.

* We could go much deeper…but for the every day practitioner, this is hopefully a good start.

Notes for this episode are found on Substack.

Questions? Leave a comment.

Work with Nathan:

Beloved Holistics | Born Free Method | Clear & Free | Twins-Breech

Medical Disclaimer: Born Free Method: The Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Music provided by AudioKraken / Pond5

Born Free Method: The Podcast is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

Thanks for reading Born Free Method: The Podcast! This post is public so feel free to share it.

As a dietitian, Kate Morton strongly believes in a food-first approach. That's why she created Funk It, a women's health company that makes all-natural food-based products for the menstrual cycle, including seed blends.

At its core, seed cycling is a straightforward practice that involves taking pumpkin and flax seeds daily during the follicular phase of your cycle and sunflower and sesame seeds during your luteal phase. I’ve seen so many women benefit from seed cycling, experiencing a resolution of their menstrual issues, from fertility challenges to thyroid and adrenal problems and more. Something packed into these incredibly nutrient and energy-rich seeds does wonders for women's menstrual cycles.

[00:08:37] The Birth of Funk It

[00:11:54] Kate’s Extensive Background as a Dietician

[00:19:18] How Your Lifestyle Affects Your Hormones

[00:31:04] The Power of Data

[00:37:00] The Goal Is Your Normal Consistent Cycle

[00:50:09] Disordered Eating

[00:55:13] Principles of Eating For Your Menstrual Cycle

[01:07:04] Seed Cycling

Visit the show notes for more: https://www.BelovedHolistics.com/101

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Website | FunkItWellness.com

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Period Chats Podcast

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Our cultural conditioning tells us that women aren’t capable of giving birth independently and that we should apply every possible intervention to reduce the difficulties associated with childbirth. For Michel Odent, that’s a neutralization of the laws of natural selection.

Early in his career, Michel worked as the only doctor in a maternity unit with six midwives. He took a deep interest in their experiences and asked them questions that changed his thoughts on birth work. As a general surgeon, he credits a lot to his interdisciplinary perspective. He believes that’s what allows him to make connections that other overly-specialized people do not.

Michel is a legend in the maternity care space and has been a hero of mine for many years. This interview was such an honor, and I am very grateful to host this conversation for you on the podcast. You're going to love this one.

[00:10:42] An Alternative View of Practicing Medicine

[00:12:02] Rethinking the Process of Birth

[00:22:33] Cultural Misunderstanding of Physiology

[00:26:51] The Socialization of Childbirth

[00:36:21] Shifting to a New Paradigm

[00:45:43] Interdisciplinary Perspective

[00:49:11] Avoiding Death

Visit the show notes for more: https://www.BelovedHolistics.com/100

(Transcript HERE)

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Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

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For almost nine years, Natasha Kingsbury battled with bulimia. For years before that, she fought anorexia. The whole time, nobody knew. Her story highlights the fact that no one look signals an eating disorder. It could be the ultra-thin model, the ripped athlete, the guy always showing off his abs or the sexy Playboy Club host.

Disordered eating and body dysmorphia are something I’m seeing come up more and more in my practice and among friends and family. It’s much more common than we think, and it shows up in unexpected ways.

I am so delighted that I have a person in my life who's willing to come on and talk about this issue which is often kept under wraps. Tash's story is so illuminating, and she shared so many insights not only for people who may be struggling with disordered eating but also for those who think it might be affecting someone they love.

[00:12:06] Background & Family Life

[00:14:29] Natasha’s Origin Story

[00:20:54] An Evolving Relationship with Self

[00:28:22] From Restriction to Purging

[00:35:24] Getting Off Track

[00:42:29] Blossoming Into Her Womanly Body

[00:48:50] The Healing Journey

[00:57:16] A Mind-Body-Spirit Approach

Visit the show notes for more: https://www.BelovedHolistics.com/98

Made possible by:

FullWell - code BELOVED10 for 10% off the best prenatal vitamins and men's virility vitamins on the planet!

Organifi - code BELOVED for 20% off their Pumpkin Spice Gold Latte! "It's like autumn, and a marshmallow had a baby!"

BiOptimizers - code BELOVED for 10% off the only magnesium supplement you'll ever need!

BIRTHFIT - code BELOVED to get one month FREE in their B! Community!

Connect with Natasha Kingsbury

Instagram @livingwiththekingsburys

Connect with me

Instagram @nathanrileyobgyn

TikTok @nathanrileyobgyn

Practice: BelovedHolistics.com

Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Music provided by EdvardGaresPremium / Pond5

“If you’re going to make it in this world as a couple, hard conversations are important.”

Every single person I bring to this podcast is someone who I know will be open to having the heartfelt conversations that need to happen about how we care for ourselves and one another.

What makes today different is that I’ve let go of my role as interviewer, and I’m sitting side by side with my wife, Stephanie Riley, to talk about vasectomies and healing after pregnancy loss.

In this candid and necessary dialogue, we opened up about what was a difficult time for both of us and explored how our perceptions have shifted over time as we’ve integrated the experience.

This discussion wasn’t easy, and it’s a true reflection of the flexibility that you need to have a lasting, healthy partnership. You’re not entitled to have a joyful relationship that lasts a lifetime. It takes real work. You have to be willing to be humbled and to compromise and to learn to flow together.

I hope that this conversation provides insight into how much empathy is needed on both sides when it comes to talking about contraception and whether you want to grow your family further.

[00:14:34] The “Easy” Decision

[00:22:42] A Dark Pit of Despair

[00:32:58] A Rollercoaster of Emotions

[00:42:49] The Bumpy Path to Surgery

[01:00:12] The Procedure

[01:04:32] Our Reflections on the Journey

Visit the show notes for more: https://www.BelovedHolistics.com/96

Made possible by:

Organifi - use our code BELOVED for 20% off their green and red juice for a natural boost to your energy and mood!

BIRTHFIT - use our code BELOVED to get one month FREE in the B! Community!

FullWell - use our code BELOVED10 for 10% off their high-quality prenatal vitamins!

Immune Intel AHCC - use our code BELOVED10 for 10% off their incredible immune-boosting product!

Connect with Stephanie Riley:

Instagram @ohgeezow

Connect with me:

Instagram @nathanrileyobgyn

TikTok @nathanrileyobgyn

Practice: BelovedHolistics.com

Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Music provided by EdvardGaresPremium / Pond5

The opportunity to connect with your baby’s soul energy starts long before conception.

Today’s special guest, Emily Greene, is a Psychic Medium and Spirit Baby Medium who has a beautiful ability to put clear language to something that is otherwise abstract. With her connection to spirit, Emily has helped many women conceive by opening their awareness to their innate intuitive abilities and connecting them to the souls of their children, past, present, and future.

In our conversation, we explore the transformation that spirit babies are meant to bring in our lives, how you can start communicating with your spirit baby, and why conscious conception matters.

[00:10:21] Finding Your Voice

[00:12:34] Emily’s Reawakening

[00:20:04] Spirit Baby Work

[00:31:36] Working with Plant Medicine

[00:35:30] Embodiment of the Essence

[00:41:13] Full Sensory Perception

[00:48:00] Intuitive & Psychic Development

[00:55:14] Conscious Conception

[01:08:18] Calling In Your Spirit Baby

[01:22:23] Spiritual Blocks to Conception

[01:30:49] Learn More & Connect with Emily

Visit the show notes for more: https://www.BelovedHolistics.com/95

Made possible by:

FullWell - use our code BELOVED10 for 10% off their high-quality prenatal vitamins!

Organifi - use our code BELOVED for 20% off their green and red juice for a natural boost to your energy and mood!

BiOptimizers - use our code BELOVED for 10% off supplements plus free gut health goodies!

BIRTHFIT - use our code BELOVED to get one month FREE in the B! Community!

Connect with Emily Greene:

Instagram @EmilyTheMedium

Website: EmilyTheMedium.com

Emily The Medium Podcast

Connect with me:

Instagram @nathanrileyobgyn

TikTok @nathanrileyobgyn

Practice: BelovedHolistics.com

Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Music provided by EdvardGaresPremium / Pond5

With strict and sometimes oppressive licensing and regulatory requirements, the average midwife has to prioritize maintaining their license over the experience of the birthing person.

Today I am so grateful to introduce you to Whapio Bartlett. Whapio has been an Independent Midwife for over 30 years, attending women and families in birth and educating women in the Arts of Midwifery and Healing. She also teaches Homeopathy and is affiliated with HANA (Hahnemann Academy of North America). She speaks and frequently writes about Quantum Midwifery and Returning Birth to the Family.

In our conversation, we explore what it means to be a wisdom keeper, her wise woman midwifery care model, and how you can become a birthkeeper who meets the educational standards while maintaining the integrity of what it means to be a person attending to birth. You’re going to love this episode.

[00:13:11] Conversation With The Creator

[00:19:11] Altered States

[00:32:32] Trust & Transparency

[00:47:30] Becoming a Birth Attendant

[00:52:33] What’s Behind the Title of Midwife

[01:06:27] The Light of New Birth

[01:21:50] The Wise Woman Midwifery Care Model

[01:30:22] Decriminalizing Heart-Centered Medical Care

Visit the show notes for more: https://www.BelovedHolistics.com/94

Made possible by:

FullWell - use our code BELOVED10 for 10% off their high-quality prenatal vitamins!

Organifi - use our code BELOVED for 20% off their green and red juice for a natural boost to your energy and mood!

BiOptimizers - use our code BELOVED for 10% off supplements plus free gut health goodies!

BIRTHFIT - use our code BELOVED to get one month FREE in the B! Community!

Connect with Whapio Bartlett:

Website | TheMatrona.com

Instagram @whapio_and_thematrona

Connect with me:

Instagram @nathanrileyobgyn

TikTok @nathanrileyobgyn

Practice: BelovedHolistics.com

Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Music provided by EdvardGaresPremium / Pond5

Women’s sexuality is the source of their power and their magic, yet there’s still so much shame wrapped up with it.

Throughout history, the church and the state have held on to a deep fear of women’s power. Even today, society continues to condition women to scorn their sexuality and repress it. Love, sex, and relationship coach Jade Bryce is on a mission to help people to break this conditioning, feel safe to experience pleasure, and feel worthy and deserving of pleasure.

In this interview, we talk about the deep wounds left by a fear-based, religious upbringing, Jade’s realization that we are the source of our pleasure, how she reached over 70 orgasms in one week without a partner and at least half without touch, tools to connect the divine and the physical, and how to heal from birth trauma.

[07:08] Welcome Jade Bryce

[08:23] The Birth Control Pill

[14:43] Womb Wounds

[18:22] Tools & Divine Visualization To Clear Womb Trauma

[26:52] Pleasure is Dangerous

[31:53] The Magic of Orgasm

[39:25] Archetypal Transitions

[47:52] Healing From Traumatic Birth Experiences

[57:19] Learn More & Connect with Jade

[59:49] Healing with Breathwork

Visit the show notes for resources, links mentioned, and more: https://www.BelovedHolistics.com/podcast/jadebryce

Made possible by:

Fit For Birth - use our code BELOVED for 20% off their pregnancy and postpartum-specific coaching!

Organifi - use our code BELOVED for 20% off their green and red juice for a natural boost to your energy and mood!

Connect with Jade Bryce:

Untamed & Unashamed Podcast

Instagram @TheJadeBryce

Facebook @TheJadeBryce

Twitter @TheJadeBryce

Email: jadebryce@gmail.com

Connect with me:

Instagram @nathanrileyobgyn

TikTok @nathanrileyobgyn

Practice: BelovedHolistics.com

Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Music provided by EdvardGaresPremium / Pond5