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Blue Cohosh Controversy

I would rather use blue cohosh to get labor going if it is relatively safe and effective, than go transport for post dates, which I do at 42 weeks. We went through a whole thing on stripping membranes (which I consider very invasive) a few weeks ago, and that is a great way to get things going, and I think the potential is there for the labor enhancing herbs to be a nice complement to that. There are many things we can do to get things going, and I wonder should the old B&B tradition be scrapped for good now cause of these two case reports?

I am just interested in why and how some are venomously opposed to the use of blue cohosh. I just like to explore and get info. So far I hear that it's ecological impact, as well as it's lack of efficacy are issues. I guess it's good from the ecological standpoint if those that don't find it effective stop using it! But what if the cardiac issues are not real, and the lack of efficacy comes from our poor communication of dosages? Before "Blue Cohosh is dangerous and should never be used" or even "Blue Cohosh doesn't work" becomes gospel, I think it's worth a lively debate.

I liked that Tiera Low-Dog article on Blue Cohosh someone posted, that was really helpful. I checked in with Aviva Romm, too, and she said she is preparing a statement for midwives based on the same info given in that article that recommends it no longer be used in pregnancy. I feel better now about retiring my use of this herb. Still wonder if it's ok for missed AB's. I am interested in learning about hearing other herbal induction protocols that are considered safe...

About the cocaine metabolites, I checked around, and this is what I got from the owners of Herb Pharm:

Here is some background on the Blue Cohosh controversy from the current newsletter of the American Herbal Products Association (AHPA).

NOTABLE NEWS
Blue Cohosh, Neonatal Stroke and . Cocaine?

I was interviewed regarding a very curious letter that appeared in the New England Journal of Medicine on July 15, 2004 (Finkel RS, Zarlengo KM. Blue cohosh and perinatal stroke). This case report concerned a baby who had a stroke shortly after birth and tested positive for a metabolite of cocaine, benzoylecgonine. The mother denied cocaine use and provided a sample of a blue cohosh tea she had been taking to induce labor. This product and a different blue cohosh commercial preparation both tested positive for this compound!
The authors went on to state, "These toxicologic studies suggest that either benzoylecgonine is a metabolite of both cocaine and blue cohosh or the blue cohosh was contaminated with cocaine." While researching this case, including a conversation with one of the authors, it turns out that the case was originally reported ten years ago. In fact, Joseph Betz, formerly with AHPA, now with the NIH Office of Dietary Supplements, gave a lecture on this case during his tenure with FDA.

It had originally been assumed that blue cohosh could produce a false positive assay for cocaine because of its constituent alkaloid methylcystisine. This newly resurfaced report now seems to argue against a false positive, but that is inconsistent with the known chemistry of blue cohosh. (See Betz JM et al. Gas chromatographic determination of toxic quinolizidine alkaloids in blue cohosh Caulophyllum thalictroides (L.) Michx. Phytochem Anal. 1998;9:232-236.) The authors were unable to find all of the original analytical documentation, as the original Denver lab has since changed hands. Aside from possible effects on a fetus, it is important to determine if blue cohosh, or blue cohosh use, produces a positive drug test result that could be mistaken for cocaine use. I have interested a forensic scientist in this question, and we hope to have an answer soon.

NEW YORK — Many herbal preparations taken during pregnancy are innocuous, but some are ineffective, and others are downright dangerous, Dr.Tieraona Low Dog said at a meeting on botanical medicine sponsored by Columbia University and the University of Arizona.

Blue cohosh used to stimulate labor, should be wholly avoided in pregnancy. Blue cohosh is often combined with black cohosh and taken as a uterine tonic or partus preparator during the last 6 weeks of pregnancy, according to Dr. Low Dog of the University of New Mexico, Albuquerque.

Blue cohosh was listed in the U.S.Pharmacopeia for labor induction at the end of the 19th century. It is still widely prescribed by lay midwives, and, in one survey, 90 of 174 (52%) certified nurse-midwives said they recommended labor-stimulating preparations; of these, 64% used blue cohosh, and 45% used black cohosh.

Complications, which were reported by 21% of respondents who used either black or blue cohosh, included transient fetal tachycardia, meconium-stained fluid, and nausea.

Blue cohosh contains compounds that exhibit cardiotoxic, vasoconstricting, and uterine-stimulating activity, Dr. Low Dog said.

Cases involving stroke, cardiomegaly, and pulmonary edema have been reported in infants of mothers who took blue cohosh during pregnancy. “Leave this herb alone,” she said.

Probably the herb most commonly taken by pregnant women in the United States and Europe is raspberry leaf, which is often prepared as a “pregnancy tea.” It is believed to alleviate morning sickness, prevent miscarriage, and aid in childbirth.

A randomized, controlled trial of 192 women found that those who used raspberry tea from week 32 through delivery had no adverse effects. However, the herb had no perceptible effect on the timing or length of labor or on the need for analgesia, Dr. Low Dog noted during the meeting.

Raspberry leaf contains several vitamins and minerals and might have provided nutritional benefits many years ago for women who had no other way of getting those benefits.

“There's no reason not to take it,” she said.

Ginger is often taken to alleviate morning sickness, and three clinical trials have confirmed some benefit in this regard, without finding evidence of harmful effects to the mother or infant.

The German Commission E, which regulates the use of herbal remedies in that country, has stated that ginger is contraindicated during pregnancy but provided no data to support this contention.

In excessive doses, ginger may affect bleeding tendencies; one study associated a significant reduction in agonist-induced platelet aggregation with the ingestion of 10 g.

“To be on the safe side, women should limit ginger consumption to 1 g/day, Dr. Low Dog said.

Chamomile, which is often ingested in a tea made from its flowers, is considered safe for consumption during pregnancy by the German Commission E and by the British Herbal Medicine Association, and there have been no reports of adverse effects.

Questions of teratogenicity have arisen, however, in connection with animal studies using high doses of alpha-bisabolol, a volatile oil that is found in chamomile. The concentrations used in the study, however, are far in excess of what would be seen in human plasma under conditions of normal use, Dr. Low Dog said. 

Blue cohosh linked to newborn's stroke

WEDNESDAY, July 14 (HealthDayNews) — Just as expectant mothers needed to be careful about what medications they take, they should also exercise caution when taking herbal supplements.

That's the conclusion of a case study, which appears in a letter in the July 15 issue of the New England Journal of Medicine. The letter details the story of a baby who had a stroke, possibly because its mother drank blue cohosh tea to induce labor.

"Blue cohosh has been known to stimulate uterine contractions, and was a folk remedy used to initiate labor if a mother was past her due date," said Dr. Richard Finkel, one of the doctors who reported the case and an associate clinical professor in pediatrics and neurology at Children's Hospital of Philadelphia. When this happened, Finkel was a consulting pediatric neurologist at Littleton Adventists Hospital in Littleton, Colorado.

Blue cohosh is from the plant Caulophyllum thallictroides, according to Mark Blumenthal, executive director of the American Botanical Council.

"Blue cohosh is not a widely sold herbal dietary supplement in the U.S.," he said. "Blue cohosh contains teratogenic compounds and the herb has been viewed as relatively toxic, thereby reducing its use in the general market over the past five-plus years."

It should not be confused with the more commonly used herb known as black cohosh, which is used to help control the symptoms of menopause.

According to the research letter, the woman was a healthy 24-year-old in her 40th week of pregnancy. Her obstetrician recommended that she drink a tea made with blue cohosh to hopefully stimulate contractions that would begin her labor. She did so, and did go into labor, Finkel said.

He said the baby initially looked healthy, but then started having seizures. Since a common cause of seizures in infants is stroke, a CT scan was ordered, which confirmed that the infant had, in fact, had a stroke.

When an infant has a stroke, Finkel said there are routine tests doctors run to try to figure out the cause of the stroke, and one of them is a toxicology screen. The results of the toxicology screen on this baby showed a metabolite of cocaine. The test, said Finkel, can't test for cocaine, but instead checks for the compounds that cocaine breaks down into as the body metabolizes it.

When he asked the mother how she thought the baby may have been exposed to cocaine, he said she adamantly denied any drug use and said the only substance she had taken was the blue cohosh tea.

They then tested her bottle of blue cohosh, and it tested positive for cocaine metabolites. Then, Finkel said, the neonatalogist involved in the case purchased a different brand of blue cohosh, and again they found cocaine metabolites in the product.

Finkel said he contacted the U.S. Food and Drug Administration, but because it was an herbal dietary supplement, not a medication, the federal agency "didn't have the authority to follow up." He said if it had been a medication, procedures are in place to report and follow-up on adverse events.

In a search of the medical literature, Finkel said he found another case where blue cohosh was implicated in a bad outcome for an infant. In this case, the infant had a heart attack.

The doctors weren't able to find out if blue cohosh does break down into cocaine metabolites, or if the product had been contaminated somehow with cocaine.

"It remains important to determine if blue cohosh produces a positive assay for cocaine use. Finding cocaine metabolites in the baby and in two different blue cohosh products tends to rule out product adulteration and strongly suggests that the assay results were falsely positive, as they are inconsistent with the known chemistry of blue cohosh," said Steven Dentali, vice president of scientific and technical affairs for the American Herbal Products Association.

However, Dentali also noted that while most herbal dietary supplements are safe, "there are known concerns regarding [blue cohosh's] use in pregnancy. Not all herbs will be devoid of side effects. Pregnant women should be taking safe, non-toxic herbal supplements."

While they weren't able to positively link blue cohosh to the baby's stroke, Finkel said he suspects it played a role.

"Blue cohosh shouldn't be taken in pregnancy," he stressed. "If it's being recommended to initiate labor, women should know that it may not be entirely safe."

More information

To learn more about herbs and pregnancy, go to the American Pregnancy Association.

-- Serena Gordon, HealthDayNews

What you can do
Source: Richard Finkel, M.D., associate clinical professor, pediatrics and neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia; Mark Blumenthal, executive director, American Botanical Council, Austin, Texas; Steven Dentali, Ph.D., vice president, Scientific and Technical Affairs, American Herbal Products Association, Silver Spring, Md.; July 15, 2004, New England Journal of Medicine
Copyright © 1997-2004 ScoutNews, LLC. All rights reserved.

I heard that the baby that had some kind of catastrophic episode about 30 minutes after a precipitous birth was born to a mom who had take some cohosh a few days earlier. The doctors couldn't find any other explanation, so wrote it up as a fancy article, acting as if their theory was fact.

The "traditional" dosage would be to chew the root or sip the yucky tasting tea given to you by your Algonquin midwife.

 Anyone who has chewed a blue cohosh root can understand part of why this use was effective.

 I can just imagine primip women deciding to stop complaining and surrender to get their babies out in order to avoid chewing that root again.

Blue cohosh is a critically endangered species which is difficult to farm. Beyond that, it really doesn't work very well to get women into labor or augment slow labors.

 I've never seen a woman successfully induce labor with blue and black cohosh and I personally know many who have tried.

 Most of the midwives I've asked about this report similar lack of results.

 The few who insist that blue cohosh works well for inducing use it in combination with castor oil or high, hot enemas and would most likely get the same results without the herbs.

I must be out of the norm then, because the first midwife I ever apprenticed with used it with great results, and I have used it successfully as well as long as the woman's body is ripe enough.

 I don't use it in combination with castor oil or enemas.

  I have used blue and black together, and blue on it's own, and as I said both with great results.

I'm not into inducing since I think nature knows what it's doing most of the time, but if there is a situation where I think it's truly warranted, I'll continue using blue cohosh.

 It's safe, it's effective, and I've never had trouble finding it.

I've watched far too many herbs be help up by the FDA as unsafe that truly are not unsafe if you know how to use them.

 And no one should be using herbs they don't know how to use.

I Aviva Jill Romm's  protocol for inducing with Blue and Black, and only after 41 1/2 weeks. I sometimes combine with nipple stim. I tell the family to get ready to spend maybe three days working on it, and not to get too tense and performance oriented. Then they do this:

Mix in a tincture bottle
2 parts Cottonroot
1 Part Blue Cohosh
1/2 part Black Cohosh
(so, in a 1 oz tincture bottle, 1/2 oz Cottonroot, 1/4 oz Blue Cohosh, 1/8 oz Black Cohosh)

Take 1 tsp of combo tincure every hour for four hours in am, then in afternoon do every 1/2 hour for four hours. Stop at 8 hours. Do second day, on third rest or do castor depending on local cliimate!

I used to feel sketchy about using B&B, as I had read a very official case study in a journal about the cardiac concerns (This was in 1998 or 1999, was this Gretchen's Client?). The way I remember it, the woman had been on PN-6 for several weeks before birth, and decided to double or triple the dose with out telling her caregiver. They pulled on the PN-6 off the shelves for a while to reformulate it without Blue Cohosh after that. I don't know if the story as I recall it is correct, but that's how I remember it, and I didn't keep the article. Still, I felt cautious about it, like if there was a problem then I couldn't defend my use of it. I still think about that aspect when I elect to us it.

So sometimes now, and what I used to do all the time was use homeopathic B&B, caulophylum and cimicifugia instead. Homeos work good with some types with real clean systems that can use energy medicine, but I think they totally fail with more grounded types who resonate better with herbs and don't respond to airy- fairy energy medicine sorts of things. So I really wanted to have another option besides the homeos and just castor oil.

So I hosted a workshop with midwife, herbalist, and mom of four Aviva Jill Romm a year or two ago, and felt much more confident about using herbs after that. I invited her to speak cause she is THE BEST resource as far as I am concerned, for herbs and midwifery. Her book the "Natural Pregnancy Book" is aimed at consumers of midwifery care, and is full of very good recipes and herbal knowledge for midwives. It includes an herb tincture recipe for first trimester Threatened AB that I think actually works. After reading this book and wanting to use her suggestions in my practice, but wanting to understand more before I did, I invited her here to teach.

She is very evidenced based, and is very active in and president of the American Herbalist Guild. She has developed a credentialing system for herbalists based on the CPM. She is always on top of what the buzz is about any herb, and has great resources for determining fact from fiction. She really knows her pharmacology, and what has been used over time in what culture and what context. While she honors many herbal traditions and incorporates them, she does so carefully, and opposes using something just based on "traditional use".   She next book  is due soon, and is an herb book for midwives and obstetricians.  She is working on going to medical school at the moment. She is a great scientific wise-woman.

She is working on a course for midwives that will be available soon- I will post two things in files, a nice long herb lesson from her, and an intro to the study course she is offering to midwives that will be available in Fall or Spring.

  I bet this plan would work just as well with just the cotton root, a great oxytocin synergist.  In fact, I bet it might work just as well without any of the herbs, because most women will go into labor on their own in this timeframe.

I agree that Aviva is a wonderful herbalist and most of the AHG are very evidence based when they can be.  Unfortunately, the realm of birth carries with it such enormous liability issues that we don't have any evidence from the scientific model supporting the prenatal and intrapartum use of blue cohosh.  What we do have are two prominent journal reports and another incident mentioned on this list citing suspicion of harm.  Granted the cases cited are isolated, anecdotal events, but shouldn't we as midwives follow the precautionary principle that we pride ourselves on?

I went to herb school for two years, have practiced herbalism for 10 years, and have taught at the National College of Botanical Medicine.  I love herbs and have devoted much of my life to plants.  I also think herbs in the birth place are over-rated.

I used to insist that all of my clients take a partis preparator tincture to get the uterus ready for labor.  I used to give squirts of blue and black cohosh to all of my moms with slow progress or dilational plateaus.  I recommended the same herbs for labor induction.  When I switched to growing most of my own plants and using primarily herbs from my bioregion, I quit using the cohoshes and other endangered species.  What happened?  My transport rate dropped as I became a more seasoned midwife, my rate of post-datism went down as well, and I noticed fewer "dysfunctional" labors.

I don't want to take anyone's herbs away from them.  I want to  challenge all of the smart midwives on this list to question our routines and assumptions.  Just because we've always done something one way, doesn't mean it's the best way.  We are asking doctors to question and, when appropriate, change their rituals and procedures around birth.  There may be places where it would benefit moms and babies for us to do the same.

The problem with herbals, for me, is that there is such a wide variation in dosage, and I imagine that there is also a wide variation in potency.  With pharmaceuticals, you know that you are getting 25mg or 50mg or whatever of the active ingredient, and you know that you should take it once per day or every four hours or whatever; and when these things are discussed it is all very clearly spelled out.

I was taught that blue cohosh should be taken 10 drops, every 4 hours, in juice, from breakfast time to dinner time.  No potency given, I guess it is assumed that all bottles are made the same, or that herbals work the same as homeopathics, where the more dilute the active ingredient, the better it works (am I the only one that doesn't "get" that?)

If I understand correctly, the below dosage is for 17 drops blue cohosh, 12 doses per day, for two days.  That is 411 drops, about 1 1/6 ounces, or about 7 teaspoons of blue cohosh over the course of two days.  (Not to mention twice that in cottonroot and half as much in black cohosh.)  And no potency is implied.  Am I getting this right?  (60 drops per teaspoon, six teaspoons per ounce.)

I can imagine that there would be a difference in outcome from one midwife, using 205 drops per day, to another, using 40-50 drops per day, plus all the other things that would go into an induction coctail or induction routine.

Is this "safe"?
Is this "midwifery model of care"?

Herbals and homeopathics are incredibly different not only in preparation but how they work in the body.  Most people educated to the western medical model of pharmaceuticals don't understand (not pointing fingers here so no one flame me unnecessarily please) how a homeopathic can work.  Yes the more dilute it is, the better it works.  Because it is the vibrational imprint of the original material that is doing the work.  It works on the physical levels at the lower potencies, on the mental level, emotional level, etheric level etc at higher potencies.

The basic premise is that illness or disorder of any kind doesn't manifest first in the physical body, but trickles down through the etheric or vibrational levels first, ending up in the body where symptoms are then seen.  So clear it out at the source, on the vibrational levels, and you get a real cure not a suppression of symptoms like you get with most conventional pharmaceuticals.

In response to another's post about pharmaceutical herbs... yes you get a standardized amount and that's certainly helpful for knowing exactly how much that person is getting.  But you're using a chemically extracted component of the herb, not generally the whole plant or the whole parts of the plant that nature intends to be used.  Using the plant whole, whether leaves, roots, flowers or all at once depending on the herb, means you get all the components together.  That's why ephedra used properly is so much safer than ephedrine.  Ephedrine, even the natural and not synthesized forms, cuts out components that your body needs in order to assimilate and properly use that herb.  You get rid of nature's built in safety measures.  And there are always going to be people that can't take ephedra.  I'm one of them.  It's phenomenal when it comes to bronchial congestion and asthma, but it races my heart so much it feels like it's going to explode.  So I use other herbs for congestion in myself.  You have to use common sense not only when taking herbs but ESPECIALLY in recommending them to others.

Yes dosing is harder, yes potency is varied, which is why you find a source with a potency you see working well and you stick with that source.  Getting your herbs in caps at walmart is ludicrous.  You have no idea of the source or the potency.  I've personally seen a substandard, old shipment of cut and sifted roots sent back to the supplier because they had a greatly reduced potency.. these herbs were so old they had little hope of doing anyone any good.  When asked what the supplier was going to do with the 50lb bag of herb we were sending back... they replied they'd be sold to a health food store.  I don't buy my herbs in bulk at health food stores unless I know what company supplies them, and how often their stock is rotated out.  (standard rule is one drop per every ten lbs of body weight for tinctures in case anyone is wondering, dosages on the bottles are based on a 150lb person normally so you have to adjust accordingly and you have to watch how that particular person responds to that herb and that dose)

Every woman is different in their chemical makeup.  Women respond differently to different herbs.  I had a woman bleeding that did not respond to any of the herbs I normally carry for that.... I finally used one my assistant happened to have on hand, that I had never used before... and she quit instantly after taking it.  Yeah maybe all the other herbs finally kicked in at once and got her to quit, but my intuition and instinct and years of herbal experience and study  tell me that her body was just sensitive to that last herb and that's the one that worked for her.  There are herbs I don't take because they don't seem to do anything for me.  Yet they work wonders with others.  That is just how it is and you flat out can't standardize that.  Herbal medicine is not an exact science any more than midwifery is.  And anyone that can't work with that and understand that, shouldn't be using herbals to start with.

As for me, I'll take herbs any day over pharmaceuticals.  I always will.  I'm radical in that way :)  Give me the natural form or don't give me anything.  No one will ever convince me that chemicals are better for the body than herbs and whole food.  But, that's why I became an herbalist, naturopathic doctor, and even a midwife, instead of a medical doctor. :)

I ask every woman who decides to use this herb to let me know before they begin using it.  I have not been convinced of its safety in pregnancy, though it is listed on our Vitamins and Herbs for Pregnant and Nursing Mothers sheet.  During initial exam I circle it on the sheet and inform the ladies to tell me if they wish to use it.