Blue Cohosh, the Midwife’s “Best Friend”

Formulas Containing Blue Cohosh: As a practicing midwife and Master Herbalist I have been using my own pregnancy and birthing formulas (available at SunstoneFormulas.com) for decades, including several which contain blue cohosh, namely – Cervix Softener Tincture, Labor Prep Pills, Labor Boost Tincture, and Blue Cohosh Tincture. The first three formulas mentioned contain blue cohosh combined with other synergistic herbs. In recent months a few pregnant women who have ordered the Cervix Softener from SunstoneFormulas.com have returned it after hearing claims from their midwife or doula that blue cohosh is allegedly dangerous for the fetus. The source of this information is derived from findings of a report in a Canadian article entitled Safety and Efficacy of Blue Cohosh During Pregnancy and Lactation (2008). Unfortunately, this questionable report is blocking uninformed midwives and doulas and their clientele from taking advantage of this remarkably effective herb to assist with their labors. My intent is to provide mothers, midwives, and doulas additional information for them to consider before making decisions concerning the use of blue cohosh. This is pertinent not only for the products I have formulated, but for any other blue cohosh formula on the market.

Evidence Based Medicine:  Evidence based medicine has become a hot topic throughout all divisions of medical care. It is very evident in the direct-entry midwifery/home birth sector. Evidence based medicine is a two-fold process including the integration of 1) individual practitioner experience, and 2) relevant external clinical research. Practitioners’ expertise increases as they become more proficient in their assessment, treatment, and decision making. These practices, in turn, increase their positive outcomes. Pertinent clinical research can discredit previously accepted procedures as well as replace them with more accurate and safe procedures.

My concern is the dangerous trend to non-discriminately consider all birthing research as applicable to home birth. If the births being studied are hospital births with epidurals, along with Pitocin and other drugs, the findings in these studies may not be applicable to non-medicated births. In those two very different worlds – medicated and non-medicated — any variable being scrutinized can behave very differently in accordance with significant differences in the two environments. Furthermore, the experience and expertise of the practicing midwife is often disregarded when it is at variance with the “scientific” research.

The Canadian Study on Blue Cohosh Herb: The Canadian article, Safety and Efficacy of Blue Cohosh During Pregnancy and Lactation (2008), was a systematic review of literature for evidence on the use, safety and pharmacology of blue cohosh during pregnancy and lactation. Thus, it is important to note that this study did not contain data from their own experimental research. The study determined that 64% of the Certified Nurse Midwives (CNM) in a survey reported using blue cohosh. However, there was no information on the actual number of midwives that 64% represented. If there was a large group of Certified Nurse Midwives (CNMs) who responded, one would expect a large number of adverse cases of blue cohosh use to show up in the literature. The investigators searched years of data from many different sites to collect cases, but failed to mention which years they searched. In the discussion at the end of the article the study delineated only three case reports of blue cohosh, taken at the time of delivery, possibly being linked to heart failure in infants. To quote the article, “it is plausible that blue cohosh may have been the causative factor for these observed cardiovascular birth defects.” 

The Canadian study is inherently flawed because the case reports were lacking information in several key areas. In their defense, they were not setting up their own experiment, but just reviewing what was already in the literature. Case reports need to include 1) blue cohosh product dose, duration, and chemical analysis, 2) pregnancy history, 3) maternal health condition, 4) notes of labor including drugs given to the mother and any complications with delivery, and 5) newborn testing for blue cohosh constituents and also constituents of other drugs given the mother prior to and during the labor. There is a limited amount of literature on the pharmacology of blue cohosh. This is surprising considering the number of mothers using it to assist with their labors. Perhaps the reason is because adverse reports are rare or non-existing.

Direct-entry midwives, doulas and other health professions — especially those working in the realm of unmedicated labors — should be more discriminative when evaluating clinical studies related to birth. Since this study was done exclusively with Certified Nurse Midwives (CNMs), the three births mentioned most likely occurred in a hospital. Therefore, it is more likely that the mothers were given epidurals, Pitocin, and other drugs during labor. This information was completely overlooked in the study. The babies could easily have had an adverse reaction to other unnamed medications rather than to blue cohosh. For these reasons, the study’s conclusions are highly questionable from an evidence-based practice point of view and are inapplicable to non-medicated births.

My Experience with Blue Cohosh Herb: Experiential evidence from a trained practitioner is a strong component in keeping with the principles of evidence-based practice. Blue cohosh, Caulophyllum thalictroides, has been used as a uterine tonic for centuries by the North American Indians, who called it squaw root and papoose root. There is considerable evidence of the safe traditional use of blue cohosh. That does not mean that there were not any adverse reports. However, obviously there were not enough to cause the Native Americans to stop using it.

So, what about modern use of blue cohosh? I consider blue cohosh to be a midwife’s “best friend.” I personally have used blue cohosh by itself or in a combination of herbs with well over 1,000 births in the last 40 years. I generally use it a few weeks before the mother’s due date to help tone the uterus (Labor Prep pills and/or Cervix Softener Tincture), after the due date to help stimulate labor (Blue Cohosh Tincture), and during labor to help with the efficacy of contractions (Labor Boost Tincture). Over all these years and all these births, I have never seen blue cohosh cause tachycardia (high pulse) of the fetus nor heart failure. I have never given straight Blue Cohosh Tincture to pregnant women with extremely high blood pressure. If the mother has extremely high blood pressure, I closely monitor her if I give her an herbal combination with blue cohosh in it.

Therapeutic Actions of Blue Cohosh:  Uterine tonic, stimulant, oxytocic, nervine, antispasmodic, parturient, emmenagogue, diuretic, anti-rheumatic, demulcent.

      Because the action of blue cohosh can be strong, I do not recommend general use of blue cohosh during early pregnancy. However, because blue cohosh has antispasmodic action, I have seen it used to stop threatened miscarriage as well as false labor pains.  I recommend blue cohosh, in a combination with other herbs, at five or four weeks to the due date. I prefer to use a combination or straight Blue Cohosh Tincture after the due date. Note from the therapeutic actions above that blue cohosh is an emmenagogue, helping to bring on a delayed menstrual period and also a parturient helping to bring on labor. When some uneducated writers see that an herb is an emmenagogue they put it on the “do not take during pregnancy” list. Herbs work differently than drugs. They support what the body is trying to do.  So, if a woman is pregnant, most herbs, even if they are emmenagogues, are not abortive. But since I don’t recommend using blue cohosh earlier in pregnancy, I have no experience as to whether it is really abortive or not. Because blue cohosh is also a parturient, I have successfully used the herb to help mothers with miscarriages after fetal demise. Since the parturient action of blue cohosh is the most useful action, it is especially helpful for the mother to take at the end of the pregnancy to prepare for labor.

Constituents of Blue Cohosh:  Steroidal saponins, alkaloids, glycosides

I do not have an extensive background in chemistry and I am not an authority on the constituents. Also the constituents will be different according to the type of preparation the mother is taking – a tea, tincture, glycerite, or pills. I do know from experience that the alcohol tincture Cervix Softener is much more effective than the same herbs in a glycerin extraction. I have a great deal of experience with the practical workings of herbs. If an herb does happen to contain a potentially harmful component, often the other components of the single herb synergistically work together to lessen, or often even cancel out, the adverse effect.  Then if you put the herb in a combination, the amount of the potentially harmful constituent is miniscule and the entire group of herbs work in a synergistic way to negate any adverse effect. More research on the constituents of blue cohosh is always welcome. In the meantime, I feel very comfortable with the procedures I follow because of the excellent results I have had over so many cases and so many years. I also am very comfortable recommending them to other mothers and practitioners.

Cervix Softener Tincture: This formula is recommended to be started four weeks before the due date. Cervix softener consists of a combination of five herbs — lobelia, lady slipper, valarian, cayenne — including about 18% blue cohosh. It also is 50% rice bran syrup. The basis for the formula is Dr. Christopher’s anti puerperal convulsive syrup, which was used to prevent the mother from convulsing during and after labor. Like its name indicates, it softens the cervix. It also has herbs that specifically relax the muscle of the os of the cervix. In addition, the herbs soften the muscles of the perineum and lessen tearing and other damage. It is particularly good for first time mothers, women with a history of long labors, women with rigid cervixes, and nervous women. My experience with cervix softener has been that it has shortened many labors and has prevented many c-sections. My c-section rate is only around 3%.

Labor Prep:  This formula is in capsule form and can be started five weeks before the due date. The herbs included are blessed thistle, red raspberry leaf, spikenard, squaw vine, bayberry, eleuthro root, false unicorn root, ginger root, lobelia, motherwort and blue cohosh (about 13%). The amount of pills taken is increased each week starting with 1 pill two times a day.

Labor Boost Tincture:  This formula basically helps strengthen contractions if needed during labor. In making the contractions stronger, the labor is more efficient and shortened. The herbs include cotton root, bethroot, jasmine flower, licorice root, lobelia, and blue cohosh root (about 33%).  Use ½ dropperful every 15 minutes for an hour or two or as needed. Due to the antispasmodic property of blue cohosh, if the mother is really only having strong Braxton Hicks contractions, this formula will stop the contractions.  It generally will not force the mother’s body into labor if it is not really ready for it. This saves the mother and practitioner from experiencing a long, unproductive labor. 

Blue Cohosh Tincture: I recommend the blue cohosh tincture for use starting at the due date or a week overdue, 1 dropper, two or three times a day. It should encourage labor to start within a week. It is also good to start taking blue cohosh tincture three days prior to taking castor oil to prime the system for labor. It is also excellent to prime for labor in the case of rupture of membranes. It is better to take blue cohosh in a tincture format rather than a pill format. The pills tend to nauseate more. It can be helpful to eat a little something along with taking the blue cohosh.

In my opinion blue cohosh is a midwife’s “best friend.” It has served me very well, plus the over 1,000 mothers I have given it to in the last forty years. The inherently flawed Canadian blue cohosh study has, in essence, slandered this remarkable herb, an herb that I prize and have great thanksgiving for. So, I am just letting my voice be heard.

*Dianne Bjarnson, MSM, MH, CPM, and LDEM: Dianne, known as the Traditional Midwife, has a master’s degree in Midwifery and is a Licensed Midwife in Utah. She is the founder of the Midwives College of Utah, which is accredited with MEAC. She was president of the college for 20 years and taught Labor and Birth and Complications for 37 years. She has practiced as a Direct Entry Midwife for 40 years, with over 1,500 birth experiences. She also holds a Master Herbalist degree from the School of Natural Healing and has lectured on herbology associated with pregnancy and birth for various organizations in Wales, Mexico and the United States.