May 23, 2001
Volume 3, Issue 21
Midwifery Today E-News
“Tear Prevention”
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THIS WEEK'S ISSUE

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Quote of the Week:

"The role in which mothers, fathers, free-spirited doctors, midwives, nurses, childbirth educators, and doulas have been chosen to take part, in some spiritual realm, shows that we are each anointed, all part of this world-changing, life-continuing experience named 'birth.'"

- Chellisa Brown


The Art of Midwifery

When faced with a deflexed head jammed on the spines at or nearly full dilation, upend the lady, find the shoulders and give a quick firm pull to pull the baby up a bit. This allows the baby to become unstuck a bit so the head can flex and rotate when you get the mother into an upright position. Because this action is an uncomfortable one you probably will be able to do this only once.

- Terry Stockdale, independent midwife
Hobart, Australia

Midwifery Today Magazine

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In a study of 500 women at high risk for breast cancer--all of whom had normal mammograms--a procedure called ductal lavage found malignant cells in 5% of the women and atypical cells in 15%. The procedure flushes cells out of the lining of the milk ducts, where 95% of all breast cancers begin. Ductal lavage is best for high-risk women. The test may find breast cancer cells 8 to 10 years before a tumor is large enough to be detected by mammography. Go to www.producthealth.com for more information.

- Prevention, February 2001

Tear Prevention

Tear prevention begins with a healthy body. When mothers are encouraged to maintain a good diet, they are not only growing healthy babies but they are also preparing their bodies to function well during birth. Exercise and kegeling go hand in hand with good diet. We must remind our clients several times about the importance of kegeling for tear prevention....

At full crowning or at any point where slow stretching is necessary to prevent a tear, slow things down. Your connection with the woman really pays off at this point, because she needs to be in contact with your voice and your touch. Then she can pant a little or push a little when needed. Avoid conflicting suggestions.

The partner midwife can create slack in the perineum as another tear prevention measure. Cupping the perineum between outstretched thumb and fingers as the baby's head begins to emerge, she applies inward and upward pressure. She should not push inward into the mother but rather use inward pressure of the thumb and fingers toward each other, as if in a large pinch. She creates slack in the perineum until after the shoulders are born.

- Jan Tritten, Tricks of the Trade Vol. 1, a Midwifery Today book

Years ago I learned a technique that has proven effective in preventing both "upper structure" damage and perineal laceration. While using this technique the midwife encourages the baby's head to flex (tuck) as it descends to the pelvic floor and keeps it well flexed until the entire occiput is delivered.

With one hand supporting the perineum, I use the other hand to "take hold" of the baby's head toward the occiput as it presents, guiding it under the pubic bone by sort of push/pulling it down and out with the strength of the contraction, and the mother's voluntary effort, if needed, behind it. Added pressure may seem to be placed on the perineum, but actually the pressure is directed across the head, encouraging the chin to tuck in nicely. If the baby is big or the mother's vulva very engorged or varicose, or if she has a cystocele or urethrocele, I usually slip a finger on either side of the urethra and again guide the baby's head under the pubic bones as the contraction pushes outward. This variation squeezes the midwife's fingers between the head and the pubic bone but greatly reduces the incidence of severe bruising, laceration, and structural damage of the area.

If the baby is persistent posterior, I reverse the procedure by flexing the head outward toward the pubic bone, thus seeking to reduce the diameter of head that the outlet has to accommodate. In this presentation, the baby's forehead is the "hard part" most likely to jeopardize the upper structures. Again, this potential for trauma can be minimized by assisting the occiput to deliver first. If you're not absolutely certain whether a baby is anterior or posterior, it's best not to flex the head at all lest you accidentally de-flex it, increasing head diameter dramatically and risking unnecessary maternal tissue damage.

To effectively employ this technique, I apply about half as much pressure through my fingers (guiding the occiput under the pubic bone and out) as the contraction and mother's effort apply outward. Additionally, it is essential to visualize, understand, and feel what's happening with the baby's skull, the woman's pelvic outlet, and her soft structures and respond accordingly.

Apart from protecting maternal tissues, this technique prevents a baby from getting caught behind the pubic bone and is most useful in effecting a rapid delivery in case of fetal distress.

- Cathryn Feral, Tricks of the Trade Vol. 1, a Midwifery Today book

To order both of Midwifery Today's Tricks of the Trade books, visit our secure storefront!

Comfrey (Symphytum officinale)
Apply a warm cloth soaked in a strong comfrey infusion that has been strained of all plant parts. Reheat the cloth as necessary. Make a fresh comfrey infusion daily. Sitz baths and herbal baths of comfrey leaf/root are wonderful for healing traumatized tissue. Steep leaves 20 minutes for quick first aid or one to two hours for maximum concentration of infused materials; do not boil leaves but simmer roots 40 minutes. Use glass or ceramic containers for preparation.

For perineal tears, hold a cloth in place overnight by having mom wear a sanitary belt and napkin up against the cloth. Remove the wet poultice when it becomes cold or uncomfortable. Some sources advise placing the powdered root directly on a wound but be aware that tissue regeneration may happen so quickly that foreign particles can be encased within the wound, requiring debridement.

- Linda Lieberman, CNS in Wisdom of the Midwives: Tricks of the Trade Vol. 2, a Midwifery Today book

I used to apply warm herbal compresses to the perineum [during second stage], and women said it felt great. However, I've cut back on this practice because I found it can bring too much blood into the area, resulting in unnecessary vulval swelling, engorging the perineum to the point where it could no longer easily stretch. Now if I use compresses, I am careful to wait until just prior to crowning.

- Judy Edmunds, Wisdom of the Midwives: Tricks of the Trade Vol. 2, a Midwifery Today book


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Midwifery Today's Online Forum

The hospital where I am apprenticing uses Cytotec (and Pit) to regulate irregular contractions into a nice pattern and therefore bring the labour on. I have recently read some very scary articles about Cytotec--that it is not supposed to be used in labour and is for peptic ulcers. But because it has been approved by the FDA for peptic ulcers it can slip thru a legal loophole and be used for laboring mums.
There have been many incidents of the uterus rupturing, infants suffocating, brain death and death of the mother. What are people's opinions on this supposedly wonder labour drug? I am of the opinion that I never want to offer this drug to anyone, especially a laboring mother.

To share your thoughts and experience, go to Midwifery Today's Forums. Click on "Legal Battles and Birth Politics" and "Cytotec." PLEASE DO NOT SEND YOUR RESPONSES TO E-NEWS!


Question of the Week

Q: One of my women is suffering from acute glomerulonephritis. She is dumping large amounts of protein; as yet, hypertension hasn't developed. I wanted to help her prevent it and suggested taking calcium, magnesium, and potassium supplements, but then thinking it over, I decided that it was bad advice because of the kidney damage. Does anyone have advice?

- Jordana

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Question of the Week Responses

Q: There is some question in my community about whether not suturing a tear compromises the integrity of the pelvic floor. Can anyone with experience give me some feedback, including your experience(s), on this? I have always felt allowing the tear to heal naturally without suturing was best but this has been debated recently.

- Tara King

A: I tore and had a small episiotomy with my first son, and was stitched. It was very painful for weeks and it took four months before I could have intercourse without tears. My second son was a huge beauty with a nice round head and I had a big tear. It too was stitched, but too tightly, and I promptly re-tore in a few days. My midwife did not want to restitch so I was left to heal alone, and it did beautifully! I kept it very clean and did sitz baths twice a day. Intercourse was not painful at the six-week mark. My sister recently had her first, and her small tear was left to heal alone. Just ten days later she feels great--no perineal pain or discomfort. Next time, no stitches for me!

- Sarah Pendergraft

A: I think it will depend on your patient whether she allows you to have her torn perinium repaired. I encountered some women here in Brunei (I am from the Philippines). Even if they have a big tear they don't want to be stitched because they couldn't bear the pain. It will depend also on the culture of the people. Some men find their wives not tight anymore down below. That is why quite a lot of women go for vaginal repair. If the tear is just small and not affecting the inner muscle of the perinium, maybe it is wise not to stitch it.

- Sonia

More on fibroids [Issue 3:20]:

One of the problems with fibroids is that they can put mom into premature labor quite easily, especially if she is already in pain at only 18 weeks. My suggestion is to find a homeopathic doctor in your area. Homeopathy has proven very successful with conditions like these in pregnancy. Dr. Moskowitz in the Boston, MA area is the best out there specializing in pregnancy, labor and delivery. He could help over the phone or can refer you to someone in your area.

- Sherry Morris, doula

I experienced the same thing with my first child. I had severe pain and was given tocolytics at 14 weeks and then had to be hospitalized at 18 weeks. I was on bedrest with tocolytics for the rest of the pregnancy. At 38 weeks my doctors scheduled a cesarean because the position of the fibroid prevented my son's head from engaging and he was a footling breech. We were just grateful he went full-term after 5 months of contractions. After his birth, I was advised to have surgery to prevent "future problems." I declined and focused on decreasing the fibroid through diet (very few animal products, no caffeine or alcohol, lots of soy). The fibroid was smaller when I got pregnant a year and a half after the birth of my son, shrunk during the pregnancy, and despite a couple of scares, I had a successful VBAC at 39 weeks. So, I hope for your client an easier time with this pregnancy, but if it doesn't happen, please remind her that every pregnancy is different and it won't necessarily happen the same way another time.

- D.H.
Queens, NY


In Celebration of Doulas

I was called to become a doula in the late summer of 2000. It was a regular day; I was planted in front of the television watching a childbirth program on The Learning Channel. The family portrayed in this particular episode hired a doula to support mom during labor. I felt like I was being struck by lightning! It made so much sense to me: I am a nurturing person, and I had a very difficult pregnancy and birth (29-week emergency c-section for severe preeclampsia) in which a doula would have been a Godsend. So I answered the call. I wanted to give something back to the childbirth world for all the support I had received, and I wanted to help women, including military families like mine, who are usually far away from friends and family when they need them most.

I have attended four births so far, including a waterbirth. The waterbirth transformed me even more than I thought possible. I realize I am the luckiest woman alive. I have a now perfectly healthy 3-year-old daughter, a loving husband and family, and a career I love. At last, I have found a career in which my soul sings.

- Eileen Chevalier, CD (DONA)
Midwest City, OK

If I can help a mother have the birth she wanted and she has a birth memory that is joyous and fulfilling, then I feel I have done my job as a labor support provider. Each birth is unique; it is the caring touch and attitude, along with creativity, knowledge and faith in a woman's inner resources, that really are making a difference in women's births, one baby at a time. Doulas help facilitate this. Each one of us is capable of helping make birth the best it can be when women need extra guidance and support.

- Maurenne Griese, RNC, BSN, CCE, CBE


Switchboard

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

International Connections

I am planning to move to northern Scotland in a few years and need some information. Do you have links or email addresses I could use to contact someone there about learning to become a midwife? I would need to know costs of the course and any prerequisites, etc.

- Cydnee J. M. Highfield
Reply to: moondancing2@hotmail.com

More help for the pregnant woman in Switzerland [Issue 3:19 & 20]:

I am working in Switzerland and I understand the problems. There are different hospitals in Geneve and nearby so maybe she could try to choose another hospital. There are not many midwives who do home delivery in Switzerland. I am sure there are some in Geneve, she needs to ask.

- anon.

INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to "International Connections." We're here to help you!

~*~*~*~*

It's time to pay again on Dr. Tom Brewer's email account. Some of you probably know that about a year ago a number of people chipped in and bought him a Mailbug plus a year's worth of service so he could communicate via email with pregnant women. He really enjoys it and frequently sends me copies of the emails he receives both from women who need his help and women thanking him for saving them and their babies.

I need to pay for another year of service now ($99) and would greatly appreciate any contributions you might be willing to make. Last time we received contributions ranging from about $5 to $50. Whatever you can do is helpful regardless of how small it may seem. Last year some people wanted to send cash, and that's fine too. This is a gift, not a tax deductible donation. Anything received over and above the current account cost will be put toward next year's fee.

And whether you can help financially or not, please take a minute to drop Dr. Brewer a note and tell him how much you appreciate his work to save pregnant moms and their babies! You can reach him at mailto:tombrewer@mailbug.com

If you can help out with this gift to him, please mail checks to me at:

Marci O'Daffer, CCE
6523 Fairview Rd. SW
Olympia WA 98512

Why do so many midwives and OBs think it is somehow "gentle" or OK to do cord traction in third stage after only about 10-20 minutes following birth? I have now witnessed numerous incidents of "gentle cord tractioning" by two midwives (CNMs). Of about eight births I've seen with them in the past six months, two of the mothers have had postpartum hemorrhage (PPH). One was a natural multip birth--the mom was Latina; the other mom was given morphine/Pit/Nubaine/epidural; she has some Asian in her lineage. Studies show that PPH is more common in Latinas and Asian women. That may be, but I truly feel that "gentle cord traction" is really unnecessary, lazy, and harmful more often than not to mothers. Please educate me on the pros and cons. It seems to me the cons far outweigh the pros.

- Anon.

For all the talk we do about the language of birth, why do I so often hear the word client used to describe the women we serve? It feels so impersonal. These women and babies are our friends, our love, our future.
I've enjoyed reading E-News since its inception, but over and over I see and think about the written word, the power it has, and the impact language has on women and birth attendants. Let us be careful about the terms we use--we have such influence and reach more and more people in the birthing world. We want to empower the process of birth by using words that are dear and personal, bringing about the natural reinforcement and positive intentions all women need through our kind words.

- Jill Cohen
Eugene, OR

Re Excessive bleeding:
I also have a woman in my care with this problem. I began working with her on her fourth pregnancy. After much study and contemplation I took equal parts of cinnamon and cayenne and added them to a pint of 100 proof vodka to make a tincture. Within minutes the herb formed a large clot-type substance that imitated placenta-like material. I have continued to use this with great success for the past three years. The mother delivered her seventh child and has not had the problem since using this formula. She drinks several sips during transition. I keep a bottle in my bag at all times and use it in most cases of hemorrhage. Another remedy I recently was told about by a midwife in Mexico is to have the woman drink 4 oz of freshly ground nutmeg "tea" during transition. Care must be used as nutmeg in large doses has hallucinogenic properties; therefore in 4 oz of hot water grate only about 1/8 teaspoon.

- Anon.

I would very much like to know the source of the info about peppermint being linked to miscarriage! [Issue 3:19] I don't trust web sites about herbs. Any idiot can make up whatever they want about herbs without doing any research or having to show any actual knowledge of herbs. It's very important to cross-reference and *check your sources*! I have visited several sites about herbal medicine and some of the content was entirely untrue. The Internet can be used for good and bad--anyone who is anti-herb could post false information to throw off the undedicated. Peppermint is an herb that has been trusted and used without complications for centuries! I can't imagine peppermint causing a miscarriage in anyone--this information seems very suspicious.

- Bren

Peppermint oil is considered emmenagogic and is very stimulating. It is a middle note. It is not considered safe for topical application but can be used by inhalation to treat migraines, headaches, anxiety and morning sickness. To use it for that purpose, a single drop is placed on a cotton ball, either in combination with other oils or alone, and inhaled. The cotton ball can also be placed inside the pillow case over night. Care should be taken that the face will not come into contact with that area of the pillow.

- Pam Martin, MS, DONA CD, CM, CPMT, CBE

I suggest and used myself raspberry leaf tea as soon as I knew I was pregnant. High dosage requires more than a few cups of tea a day! In tincture I would be more careful.

Same for peppermint. I used it to relieve migraines, using it directly on the head and under the tongue (few drops of real therapeutic essential oil).
I had a beautiful pregnancy and birth.

- Marie-Helene Lessard, naturopath

In response to the question on raspberry leaves in pregnancy: Rodale's Encyclopedia of Natural Home Remedies by Mark Bricklan includes a section called the Raspberry Leaf Tea Story. This interesting account presented is told by a woman who originally got her information from her Scottish mother and then did research on her own, also quoting from Dr. W.H. Box's book, Dragged to Light. Raspberry leaf tea is said in her testimonial to prevent miscarriage when taken in a dose of one cup per day. Please see book for ratio of leaves to water--the dose for early pregnancy is quite different from the dose for late pregnancy or labor. Also noted is the decrease of after pains when taken quite strongly in late pregnancy. I have personally used the tea at the recommended strong dose in late pregnancy, and while it did not induce labor, it seemed to make labor much quicker and more comfortable. I also had less after pains than with my previous children. I encourage anyone interested to check out the book.

- Shawna, certified doula

I would like to know how midwives globally manage pelvic relaxation in pregnancy and delivery techniques to prevent further trauma to the symphysis pubis and any other information, research, statistics, etc. that could help women who contact us for support regarding symphysis pubis dysfunction.

- Angie Lambert, charity founder & director
The British S.P.D. Support Group

A woman who has contacted me for some counsel is planning to give her baby up for adoption (teen mom). She knows she does not want the baby. This will not be a homebirth because of legality issues with the adoption agency, but she still came to me wanting counsel. What kind should I give her? Books and articles to read? Has anyone had experience helping a birthing mom through an adoption process? I will probably be with her in the hospital as her friend and doula.

- Wantina Engle

Is it a new practise to not give a bath to a full-term healthy newborn baby? The baby will be given a bath after 24 hours, is this so? Is there any significance to this?

Please give me details if there are new methods of episiotomy and repairing it. Since I have been practising my profession for more than 20 years here in Brunei (working in an Army hospital, very seldom do we deliver our pregnant patients) my knowledge is probably obsolete.

- Sonia

Thank you for your issue on prolonged labor [Issue 3:19]. It encouraged me to go back and read Midwifery Today Issue 46 on prolonged labor. What amazing stories!

I recently assisted at a homebirth that ended in a healthy baby but lasted 47 hrs. I was able to be present for the first 18 hrs. and then had to go home to my family. Luckily the mom had lots of family labor support as well as her midwife. I went back to the hospital on the third day just in time for the birth. If my brief participation left me floored, imagine what the mom and her family felt like!

The labor was started with castor oil induction at 42.4 days. The mom immediately experienced long, hard, close contractions (1-3 min. long and 1-3 min. apart) that stayed that way for the entire labor. She was complete after 13 hrs. but had no urge to push. She tried pushing on and off for about six hrs. Later that afternoon they transported due to mom's high blood pressure. Up until that point both mom and baby had been rock-steady in their vitals. The baby's vitals never varied throughout the whole labor!

After the transport the mom lost 5-6 cm. of dilation. It then took another day for her to dilate fully again, and then she pushed for another seven hrs. Both mom and dad were committed to doing this naturally as long as mom and baby were OK. She ended up augmented with Pitocin, had an IV and a catheter, but no pain medications or other interventions. A healthy, 10 lb. 14 oz. baby boy was born on the third day, screaming and peeing, with Apgars of 8 and 10. I think the hospital staff were really impressed. I am still processing this, and I'm sure the mom will for years to come.

- Amy V. Haas, BCCE
Fairport, NY


Connections

Looking for a Labor Doula who is trying to get certified and would consider helping me for a minimal fee. This is my first child - DD: July 7, 2001.
Please contact Phyllis @ 770-457-9455 OR email pmaslia@intermedia.com


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