The Dr. Brewer Pregnancy Diet
Premature Labor
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Falling Blood Volume is a Major Factor in Premature Labor

Special Health Alert!

For those of you who live North of the equator and are entering a season of hot and humid weather and increased outdoor activity, please be aware that extra loss of salt (through sweat) and extra burning of calories can trigger a rising BP, and other pre-eclampsia symptoms. Please see the "Special Needs" page and the bottom of the "Weekly Record" page for ideas on how to compensate for these losses and thus help yourself to prevent pre-eclampsia and other complications related to low blood volume. Please see the "FAQ" page for information about why just drinking extra water probably won't be enough to keep your blood volume adequately expanded for an optimally healthy pregnancy.

For those of you who live South of the equator and are entering the cold winter season, please be aware that many homes and work environments are over-heated (with very dry air) and may cause you to lose salt and fluids in the same way as hot weather does. And shoveling snow or working out in a gym burns extra calories. These losses might also lead to a falling blood volume, and its accompanying complications, just as the summer heat and activity can. So please be watchful and care for your personally unique needs for salt and fluids, as well as your unique needs for calories and protein.

There is a summary and list of suggestions at the end of this page

The following is reprinted from The Brewer Medical Diet for Normal and High-Risk Pregnancy, by Gail Sforza Brewer with Thomas Brewer, M.D., published in 1983. Although it was written over 20 years ago, and in response to a question from a mother who was pregnant with twins, I believe that the principles presented here apply just as well to singleton pregnancies today.

Premature Labor (p.158)

Because it's clear that a falling blood volume is a major factor in premature labor, researchers have been experimenting recently with expanding the blood volume (using a variety of agents to accomplish this, including albumin) to stop labor that starts too soon. Robert C. Goodlin, M.D., of the University of Nebraska Medical School, Department of Obstetrics and Gynecology, reported on his work along these lines with over 300 patients in an article, "The Significance, Diagnosis, and Treatment of Maternal Hypovolemia as Associated with Fetal/Maternal Illness" published in Seminars in Perinatology (vol. 5, no. 2, April 1981). Goodlin and co-workers also noted that irregularities in fetal monitor tracings can sometimes be improved by increasing blood volume through slow intravenous infusion of albumin.

This work is important because it targets the primary disturbance involved in so many premature labors, not only in twins. However, we are led to ask: Why not prevent the onset of the hypovolemia (reduced blood volume) in the first place? And that is the task facing every expectant mother and her medical consultants. If you eat well enough to keep your blood volume optimally expanded, you won't require hospitalization until you go into labor at term with strong, normal-sized babies to deliver.

For stories of twins and triplets carried to term weighing 7 to 8 pounds, see here...

For a comparison between the Brewer Diet and the ACOG Diet, see here...

It is most unfortunate that even as Goodlin and others evaluate the place in emergency obstetrical therapy for plasma expanders, the U.S. Food and Drug Administration has recently approved the use of ritodrine (the generic name for a drug marketed under the name the tradmark Yutopar) for preterm labor. If your doctor is talking drugs to stop premature contractions, this is most likely the one used. As its name would suggest, Yutopar stops labor by paralyzing the uterus, thereby preventing it from contracting and dilating the cervix. It is only effective in doing this when cervical dilation has not progressed past 4 centimeters, effacement is less than 80 percent, and when membranes are still intact.

Any drug powerful enough to subdue established uterine activity has to have equally powerful side effects. Ritodrine does not work selectively on uterine muscles. It also interferes with the normal activity of the heart, intestine, blood vessels, and lungs. For this reason women receiving ritodrine experience frightening disturbances in heart rate, blood pressure, and breathing. Some women have felt as though they were about to collapse because of shortness of breath and a racing heartbeat. These are not merely psychosomatic reactions to the stress of finding oneself unexpectedly in labor: Reports of maternal and fetal deaths attributable to ritodrine therapy are on the rise in the medical journals.

Significantly, even the leading obstetrical textbook, Willams Obstetrics, sixteenth edition (New York: Appleton-Century-Crofts, 1980), finds little to recommend the drug, despite the six-page, full-color spreads promoting the drug to the medical profession that now appear regularly in the same journals claiming that this new wonder drug is the answer to our high national rates of low-birth-weight infants and premature labors. In fact, after reviewing the research studies done to date on ritodrine, the text concludes: "Ritodrine treatment in the Danish multi-center study did not produce any recognized beneficial effects on the newborn infants when compared to those mothers who received 'standard treatment.' On the contrary, according to Kristoffersen and Hansen (1979), the condition of the infants at birth tended to be worse in the ritodrine group." This outcome is not surprising since ritodrine passes through the placenta into the baby's circulation and exerts the same effects on the baby's organs that it does on the mother's.

Ritodrine (Yutopar), according to the manufacturer's prescribing information, is not supposed to be given to anyone with hypovolemia. Since most mothers with preterm labor are hypovolemic, that would seem to limit the drug's use, but in many hospitals that caveat does not seem to be taken very seriously. Ritodrine is also not supposed to be used when the membranes are ruptured, when the mother is suffering pre-eclampsia or eclampsia (another term for metabolic toxemia of late pregnancy), or when she has an overactive thyroid, heart disease, diabetes, or hypertension. Yet almost daily we receive calls on our hotline from women with these problems who are being advised to start Yutopar therapy.

It's important for you to know that with twins you are far more likely to notice the so-called Braxton Hicks contractions, which "tune up" the uterus for labor much earlier than would occur in a mother carying only a single baby. Furthermore, you may have weeks of painful spasms of the round ligaments that hold your uterus in place (they tend to tighten when you move suddenly). Neither of these situations would be indications for any therapy other than perhaps resting for a while and applying a warm compress or heating pad over the protesting ligament. You need not live in fear that every twinge you feel will result in the premature birth of your babies. If you are eating well enough for the demands of your multiple pregnancy, your uterus will be strong and your cervix quite capable of staying contracted until you are well within the usual time for giving birth (thirty-eight to forty-two weeks of gestation is the typical range used by most obstetricians). When women really follow our twins regimen, they commonly carry 12-16 pounds of babies to term with no difficulty other than the physical strain of the bulky weight of the abdomen.

A final comment about preterm labor comes from the January 13, 1979, British Medical Journal editorial titled "Drugs in Threatened Preterm Labor," which suggests that for some mothers and babies, ending pregnancy prior to term may even be to the good: "The tacit assumption that inhibiting preterm labour is necessarily beneficial should not go unchallenged. Indeed, pre-term labour may often be nature's best option, in that the precipitating cause may be acute or chronic impairment of placental function." In other words, if the the mother and babies are being threatened by a falling blood volume to the extent that vital organs cannot function normally, preterm labor is a way out of an impending metabolic crisis, a life-saving measure for the mother. To paralyze a uterus trying to evacuate itself under these circumstances does a disservice both to the mother and to the babies, who would be forced to remain in an undernourished state for the duration of the therapy (in some cases a month or more). If they are born and cared for in a highly skilled neonatal intensive care unit with breast milk provided as part of their nutrition, they might actually fare better, though we are far from happy with this eventuality and recognize the hazards posed by neonatal intensive care.

After all is said and done, it is far better to prevent hypovolemia than to have to improvise some sort of therapy for it and its attendant complications. Keep eating, rest when you feel like it, and refuse any drugs that are not absolutely essential to your health. In this way, you will maintain your nutrition, the key to preventing hypovolemia.

See here for more information on the link between premature labor and inadequate prenatal nutrition

See here for information on the hazards of weight control

See here for more information on how to prevent having underweight babies

Please be aware that traveling and moving can break up your eating routine just enough to trigger a low blood volume problem which can start the rising BP/pre-eclampsia/HELLP/premature labor/IUGR/abruption process. Putting the brakes on that process can be more difficult than preventing it. Sometimes just being aware of this danger is enough to help you to remind yourself to continue providing for your nutritional needs, in spite of any changes and stresses which may be going on in your life.

Added later in The Brewer Medical Diet for Normal and High-Risk Pregnancy (p. 223).......

The evidence is clear, in our opinion, that the large majority of premature, or preterm, babies born each year in the United States are the direct and indirect result of maternal malnutrition and hypovolemia. Clinical research shows that all but about 1 percent of these early births can be prevented. The causes of non-nutritional premature delivery include elective induction of labor, premature rupture of the membranes, elective repeat Caesarean section, incompetent cervix, placenta previa (a placenta that covers the cervical canal), uterine anomalies, and fetal anomalies. Optimal nutrition gives the premature baby a better chance because it has obtained an optimal growth in the uterus for its gestational age and hence has an optimal development. When the baby is given breast milk, then its nutrition is maintained and it should suffer no pathology commonly encountered in malnourished-in-utero premature babies.

The Brewer Medical Diet for Normal and High-Risk Pregnancy available here

Note from Joy: Unfortunately, some areas of the "alternative medicine" community apparently have followed mainstream medicine in the belief that diuretics are important and useful for treating edema and elevated blood pressure in pregnancy. Many pregnancy teas and some supplements and juices include nettle, dandelion, alfalfa, bilberry, or celery, all of which have diuretic properties. Diuretics are no safer for pregnancy in herbal form than they are in prescription medications, so it is important for pregnant women to watch which herbs they are taking.

See here for more information on the hazards of using herbal diuretics in pregnancy

At the first sign of a rising BP, pathological edema, pre-eclampsia, IUGR, premature labor, or HELLP, a Brewer Diet counselor should sit down with the mother and help her to evaluate her lifestyle and her diet to see if any adjustments can be made to optimize the fit between her pregnancy, her diet, and her lifestyle. For example, to compensate for her salt and calorie losses, she can cut back on her exercise program and her work schedule, she can stay out of the heat (outdoors, at work, or at home), she can postpone a move until after the birth (and 6 weeks postpartum), and she can increase her salt/calorie/protein intake. One way that she can increase her diet intake is to add 200 calories and 20 grams of protein for each of the following situations:

  • Vomiting past the third month of pregnancy.
  • Pregnancies spaced less than a year apart.
  • Previous pregnancy with low birthweight, neurologically handicapped, or stillborn child as the outcome.
  • A history of two or more miscarriages.
  • A history of toxemia.
  • Failure to gain ten pounds by the twentieth week of pregnancy.
  • Serious emotional problems.
  • Working full-time at a demanding job.
  • Breastfeeding an older baby during pregnancy.
  • Multiple pregnancy (twins or more).
  • Multiple pregnancy is the only exception: each extra baby requires a nutritional supplement of thirty grams of protein and five hundred calories per day. Higgins comments that this requirement can be met most economically by adding one quart of whole milk a day to the expectant mother's diet (to be drunk, used in cream soups, custards, milkshakes, cream pies and tarts, or as exchanges in yogurt, ice milk, and natural cheeses). Of course, there are many other ways to increase the protein and calories during pregnancy by eating an additional four-ounce serving of meat, fish, shellfish, poultry, or meat substitute as detailed on the diet list.

    The above information is reprinted and adapted from the work of Agnes Higgins, and Gail Brewer's "The Complete Pregnancy Diet: Meeting Your Special Needs" from Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.

    See here for more information on adjusting the Brewer Diet to fit your lifestyle

    Eating for Two, by Gail Sforza Brewer and Isaac Cronin, available here

    Nutritional Deficiency in Pregnancy

    Control Group (750)
    Nutrition Group (750)
    (5 lb. or less)
    Infant Mortality

    --Adapted from Winslow Tompkins. Journal of International College of Surgeons 4:417, 1941.
    (*Smallest baby weighed 6 lb. 4 1/2 oz.)

    Salt in Pregnancy

    High Salt Diet
    Low-Salt Diet
    Perinatal deaths
    Abruptio placenta

    --Adapted from Margaret Robinson. "Salt in Pregnancy," Lancet 1:178, 1958.

    "Q: Scientists recently announced that certain proteins secreted by the placenta rise significantly in mothers experiencing eclampsia, suggesting that these proteins cause eclampsia. (80,82) Are these findings significant?

    Dr. Brewer: Research that's focused on "genetics" or speculative biochemical enzymatic equations never addresses the underlying cause of an illness or condition. I don't doubt that unusual proteins are produced by a starving fetus or a starving mother, but those proteins don't cause eclampsia. They're just another symptom. Inadequate nutrition causes eclampsia.

    In a New Zealand sheep experiment published in the journal Science, none of the ewes on a normal diet had premature births, but half of the ewes that were put on a moderate weight-loss diet at the time of conception gave birth prematurely. (83) The researchers decided that a mother's diet before and around the time she conceives can profoundly influence the length of pregnancy, and they called this a stunning scientific breakthrough. This is what I mean about medical researchers knowing nothing about nutrition. It's obvious, but they didn't have a clue.

    Sheep have been studied before, and they have shown all the same symptoms and problems that humans have. In one study, pregnant sheep were starved at the very end of their pregnancies, and most of them died. Other researchers have found that sheep giving birth to twins, triplets, or quadruplets are more likely to have toxemia than those giving birth to single lambs.

    This is true for humans, too. A woman pregnant with twins has to eat for three, for herself and each of her babies, and a woman pregnant with triplets has to eat for four. It isn't easy to do this, but the more good nutrition a woman can provide for her developing babies, the healthier they will be. (72)"

    See here for more of this interview with Dr. Brewer from Townsend Letter

    The following is reprinted from Nine Months, Nine Lessons, by Gail Sforza Brewer, 1983 (p. 50).


    As Figure 8 shows, it is also the action of your uterus that separates your placenta and expels it in the third stage of labor. This organ allows nutrients and oxygen to pass from your bloodstream into your baby's and also permits the removal of waste products from the baby's body. The placenta originated in cells from the fertilized egg. Enzymes on the surface of the ovum dissolved away a tiny portion of the surface of your uterine wall, opening a few arteries and veins in the process. With each beat of your heart, from that moment until your placenta comes away from the wall of your uterus, those arteries spurt jets of nutrient- and oxygen-rich blood against the surface of the placenta. This is the only blood supply to this most important organ, and only what is present in your bloodstream can nourish it and your developing baby.

    The placenta is firmly anchored to the wall of your uterus by threads of collagen throughout and by a seal around its margin. Because of this, the blood that swirls up against the placenta stays in a "lake," continuously bathing the placental tissue. This blood does return to your heart after spending some time in the "lake," via the open veins that now function like the drain in you tub or shower stall: the pooled blood is pushed into the veins by the force of new blood coming into the "lake" from the open arteries. Technically, this sort of blood supply is termed an a-v (arterio-venous) shunt, meaning that the blood passes directly from arteries to veins without first passing through capillaries (the usual way things are done in the body).

    Since the supply of blood encourages and supports placental growth, and a larger placenta requires more blood to keep it functioning optimally, ever-increasing amounts of blood are required as pregnancy advances to satisfy the needs of the placenta. If you are carrying a single baby, your blood volume will expand approximately 60 percent (if you eat well enough) to service your placenta. If you have twins (and therefore a double placenta or two separat placentas), your blood volume must expand by 100 percent or more to stay even with the demand. A falling blood volume or a blood volume that is below the needs of your pregnancy is recognized as a major cause of premature labor, underweight babies, and high blood pressure during pregnancy. When you recognize the importance of keeping your blood volume up and your placenta healthy (even though you can't see it or feel it), you will have a strong inducement to stay on your excellent pregnancy diet every day.

    See here to better understand the evolution of the mainstream medical perspective on nutrition and salt in pregnancy

    Nine Months, Nine Lessons available here

    The following is reprinted from Metabolic Toxemia of Late Pregnancy (Thomas H. Brewer, M.D.), 1966 & 1982, (p. 95).

    "Premature Labor and Delivery" (p. 103)

    Let us enter the field of speculation. Month after month, year after year in our monthly perinatal mortality conferences at Jackson Memorial Hospital, Miami, Florida, we discussed the stillbirths and neonatal deaths from the point of view of the obstetrician and pediatrician. This hospital serves both "private" patients and "staff" patients. The premature delivery rate was consistently three times higher among the "staff" patients than among the "private" patients. Even when we could account for a number of the prematures associated with severe toxemia, abruptio placentae, placenta previa, multiple pregnancies, Rh inductions, etc., we were still left with quite a large number of premature deliveries with no recognizable causes. It is among these women that I suspect that malnutrition is playing a fundamental role in causing premature labor and delivery. The premature rate of less than 2 per cent among my clinic patients at Richmond shows what good prenatal nutrition can do even in the present state of our ignorance of the exact mechanisms. Good prenatal nutrition thus can play a role in the prevention of many of the common permanent complications of the premature infant, including cerebral palsy.

    Metabolic Toxemia of Late Pregnancy available here

    Anne Frye, CPM
    Portland, Oregon
    (Pacific time--three hours earlier than EST)

    Anne provided full maternity care for women seeking homebirths for 14 years. When she studied to be a midwife, she was trained to use the Brewer diet as a primary means of optimizing each woman's chance of achieving a healthy pregnancy. In working with a poor immigrant population on the Texas/Mexican border she saw first-hand what a powerful tool diet can be to make this possible. Since that time she stopped actively practicing and focused on teaching as well as authoring professional-level textbooks with an emphasis on preventive care, including the nutritional management of pregnancy. Her textbooks include Understanding Diagnostic Tests in the Childbearing Year, Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Vol I Care during Pregnancy and Vol II Care of the Mother and Baby during Labor and Birth and Healing Passge: A Midwife's Guide to the Care and Repair of the Tissues Involved in Birth. These texts are available through her website. She also regularly offers consultations to care providers of all kinds as well as mothers who have questions about diet in pregnancy, troubleshooting preeclampsia, nutritional support for multiple gestation, interpretation of laboratory results, as well as other issues. Feel free to call her if you would like to talk to someone who has first-hand experience regarding the value of nutrition in ensuring a healthy pregnancy.

    The following is reprinted from The Pregnancy After 30 Workbook, (Gail Sforza Brewer, Editor), 1978. "The No-Risk Pregnancy Diet", by Tom Brewer (p. 25)

    Medical research during the last 40 years [as of 1978] has clearly shown that the following pregnancy complications can be directly caused by malnutrition.

    A. For Mothers:
    1. Metabolic toxemia of late pregnancy (MTLP)
    2. Preterm separation of the placenta (afterbirth)
    3. Severe infections
    4. Severe anemias
    5. Miscarriages and molar pregnancy
    6. Premature labor and delivery
    7. Prolonged and difficult labor

    B. For Babies:
    1. Stillborn babies, especially when MTLP and premature separation of the placenta occur
    2. Lowered birth weight
    3. Prematurity
    4. Severe infections
    5. Hypoglycemia
    6. Birth defects, especially defects of the brain leading to cerebral palsy, epilepsy, mental retardation, hyperactivity, and learning disabilities

    The Pregnancy After 30 Workbook available here

    See here for a time line of the development of the Brewer Diet

    See here for some of the research supporting the information in the above chart

    To summarize, here are some suggestions for treating premature contractions:

    1) Print out the weekly record on this page and post it on your refrigerator and make sure that there is a check mark in every box by the end of the day. That is the minimum intake needed. The next suggestions are for adding on top of that baseline.

    See here for a weekly record chart that you can print and post on your refrigerator

    2) Eat something with protein in it every hour of the day that you are awake, setting an egg timer or your watch or cell phone to go off every hour during the day, so that you do not skip one of these snacks. Some suggestions for these snacks include a handful of nuts, or cheese cubes, or an egg, or a cup of yogurt, or some trail mix, or a glass of milk. Keep a protein snack by your bedside for eating/drinking when you wake up during the night (suggestions: nut butter sandwich, cup of milk, cup of kifer). Try to increase the daily intake to 150-200 grams of protein (singleton pregnancy).

    Also, for three days, eat 17 eggs a day and 2 quarts of milk a day.

    3) Increase the number of nutritious calories eaten each day to 3,000-4,000 calories (singleton pregnancy). Avoid using junk food or refined carbohydrates to help with this increase.

    One way to help your needed increase of calories is to start drinking a form of milk with a higher fat content--like switching from skim to 2%, or from 2% to whole, or whatever increase you can tolerate (like a mixture of 1/2 2% milk and 1/2 whole milk).

    4) Make sure that you add salt to every serving of food that you eat. The Brewer Diet is actually a triad of salt PLUS calories PLUS protein, so an effort to expand the blood volume needs to include an increase of all three factors.

    See here for more information about the benefits of salt in pregnancy

    5) Add 500 mg. of choline to the daily supplements.

    See here for more information about the above four suggestions

    6) Evaluate your lifestyle and see if you can cut down on some kinds of physical activity, or live or work in a cooler environment, or cut out some stress-producing factors. All of these factors can add to your losses of salt, fluids, and calories. See this page for more ideas about this process (scroll to halfway down the page for the beginning of the suggestions)....

    See here for suggestions for finding an optimal fit between your pregnancy and your lifestyle and your nutritional needs

    7) Make sure that you avoid all herbs which have diuretic properties. Check the list of ingredients of all supplements and herbal teas that you use, to make sure that they do not contain any of the herbs listed on the page in the following link. My only exception to that would be Floradix, unless the use of all of the above suggestions has no effect, in which case I would suggest eliminating Floradix as well IF it includes one of the herbs listed here....

    See here for more information on the hazards of herbal diuretics in pregnancy

    8) You can also see this page for more suggestions for dealing with a rising BP (it includes some herbal suggestions)......

    See the beginning of this page for some herbs to take alongside the added protein snacks

    9) Take care to drink only fluids that have some kind of nutritious content. You can see more about that on this page....

    See here for information about which kinds of fluids are optimal for treating the pre-eclampsia syndrome

    10) If you have protein in your urine, make sure that the protein is not from a discharge from the vagina, or from a bladder or kidney infection. Sometimes at the end of pregnancy, as everything ripens, there is more discharge from the vagina, or if there's a yeast infection, some protein from the vagina can show up in the urine. To decrease the chances of protein from the vagina showing up in the urine, you can ask your midwife to help you do a "clean catch" of your urine sample. You can also ask your midwife to send your urine to a lab to be tested for other factors which may indicate a bladder or kidney infection.

    11) Ask your midwife to test your hematocrit and hemoglobin. If it is stable or rising, then there's a good possibility that you are in an early PE process. For more information about that, and what to do for that, you can see the following link....

    See here for Anne Frye's suggestions for testing and treatment of the pre-eclampsia syndrome

    Perinatal Support Services: