November 26, 2003
Volume 5, Issue 24
Midwifery Today E-News
“Preventing Perineal Tears, Part I”
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In This Week’s Issue:

Quote of the Week

"I eliminated obstetrics/gynecology as a specialty because although delivering babies was a happy event, the emphasis was on the challenges of surgery."

Denise Punger, MD, IBCLC

The Art of Midwifery

Research shows that using cardiotocography (CTG) on low-risk women increases risk of operative delivery, with no benefit for the baby. CTGs provide evidence of a healthy baby only for however many minutes they are left on—they do not predict outcome. They have no place on any healthy woman with a healthy pregnancy. Using a fetascope is far less invasive and leaves the woman free to move. Mothers also can tell us if their baby is all right without the need for listening to the heartbeat.

Annie, Midwifery Today Forums

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to

News Flashes

Approximately 25 percent of American women smoke during their pregnancies. Every year, smoking during pregnancy is responsible for 61,000 low-birthweight infants and 26,000 admissions to neonatal intensive care units. The estimated annual cost of births complicated by mothers’ smoking is $2 billion.

JAMA, Vol. 278, No. 23


A Journey of the Heart

"A Journey of the Heart" is a series of Guided Imagery and Meditation recordings from Anji, Inc., designed for women on their journey to motherhood. The pregnancy recordings contain imagery exercises for each month of pregnancy, preparing physically and emotionally for labor and birth, and supporting women with pre-term labor. We invite you to explore Anji, Inc., at

Preventing Perineal Tears

Risk Factors

Posterior fetal position, where the back of the baby’s skull rests on the mother's spine, often causes tearing because the head is not optimally positioned to emerge.

Compound presentations, in which baby's hand lies alongside the head, require more space.

Episiotomy is one of the biggest contributors to perineal tearing. One study found a definite correlation between it and third- and fourth-degree tearing. Another study involving thousands of women found that the number-one risk factor for perineal tearing is episiotomy.

Independent risk factors such as maternal age, baby's weight, and assisted vaginal delivery (e.g., forceps) affect tear rates. First-time moms are more likely to tear deeply. Stretch marks have proven to be a fair predictor of tearing, indicating a correlation with poor skin elasticity. Physiologically, women with a short perineum—the anus is close to the vagina—are more likely to tear.

Decreasing Risk

  • Concentrate on good nutrition.
  • Do Kegel exercises.
  • Take vitamins C and E and bioflavinoids to improve skin elasticity.
  • Avoid using soap on the perineum during the last few weeks of pregnancy because it dries out the body’s natural emollients.
  • Practice the "open position" during pregnancy, as described in Francoise Barbira Freedman’s "Yoga for Pregnancy": The woman kneels on both knees with buttocks resting on heels and palms on the floor in front of her. She lifts her left knee so it is beside her left arm, with her left foot flat on the floor. Her left hip is raised slightly higher than the right. The right buttock rests on the right foot. Switch sides. This opens the base of the body as widely as possible so the muscles are prestretched before birth.

Perineal Massage?

Many studies show that prenatal perineal massage protects against perineal traua in first-time mothers. No benefits were found in women who had already given birth at least once.

Other studies show no benefits of perineal massage in any mothers.

The results of a homebirth study associated perinenal massage during labor with higher rates of damage. It is well-known that swollen tissue during delivery [which can be caused by perineal massage during labor] increases the likelihood of tearing.

One midwife encourages her clients to use prenatal perineal massage to help get the mother and her support person attuned to the perineum. Relaxation under pressure is one of the perceived benefits of prenatal perineal massage. It can convey a certain awareness of the perineal area that may help during delivery.

Excerpted from "Everything You Need to Know to Prevent Perineal Tearing," by Elizabeth Bruce, Midwifery Today Issue 65. The remainder of the article will be excerpted in E-News Issue 5:25.

Midwifery Today Issue 65 is all about Tear Prevention. To order your copy, click here.

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Midwifery Today Issue 64

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Forum Talk

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— Anon.


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Question of the Week

Q: A woman who is 20 weeks pregnant is experiencing aching pain after intercourse, but not during. Several experienced midwives have suggested she may have a vaginal varicosity, but they could not offer any suggestions for relief. Any thoughts?

— Anon.

SEND YOUR RESPONSE to with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.

Question of the Week Responses

Q: I am 21 weeks pregnant, and the doctors believe I have placenta accreta. I have asked my doctor a lot of questions, and the only answer is I need to have another c-section. Everything I have researched says the same thing. What kind of precautions should I take to prevent uterine rupture? Why does this condition normally result in premature delivery?

— Angela

A: Why does your doctor say accreta already? Just because of location of the placenta or because of something more specific? That's really important. The only reason accreta would be "associated" with early delivery is if it was also a previa, which is often the case. If it isn't, then there is no reason to believe it’s going to be a preterm problem.

I would recommend you get to a tertiary center and have a radiologist experienced in advanced ultrasound look at your placenta—more-accurate diagnostics could give you a better idea of whether this is just a low-lying placenta, which may yet move at 21 weeks (actually VERY likely to move), or really a problem.

In the most common form, accreta, the placenta is attached directly to the muscle of the uterine wall. This variant accounts for approximately 75-78% of all cases. In approximately 17% of cases, the placenta extends into the uterine muscle and is termed placenta increta. In the remaining 5-7%, the placenta extends through the entire wall of the uterus and is termed placenta percreta.

If you already have a scar on your uterus from prior uterine surgery, rupture is always an issue. Many years ago, the idea was put forth that a rupture might be mediated by the placenta—in other words, if the placenta was over or near the scar, rupture was more likely. We have never seen any follow-up about it, however. Accreta is typically a problem of third stage—the birth goes without a hitch but the placenta won't come, and then there are problems with hemorrhage.

As for your delivery options, you may want to wait to go to surgery until you know you really need to. Find a surgeon who knows that hysterectomy is NOT the only answer—you'll find all sorts of papers about uterine-sparing techniques to deal with accreta.

If you would like more information or support, please contact International Cesarean Awareness Network, Inc. (ICAN).

— Tonya Jamois, President, ICAN,
Gretchen Humphries, ICAN E-list moderator and Midwest regional coordinator

Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

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Regarding cruelty in the maternity wards [Issue 5:23]:

As an English trained midwife, I have worked both in Britain and New Zealand. I am now working as an RN in the United States as a traveler and I am considering whether it is worthwhile becoming a midwife/CNM here with all the retraining that might involve. My impressions thus far have been unfavorable.

As far as I can see, obstetrics is very medicalised, with little or no regard of women's rights. Women are bullied and coerced into having procedures performed on them. There is little or no discussion about what options may be available, and in many cases the practices I have seen are old fashioned and not research based.

I have yet to see a woman have a baby in a position other than lithotomy, and I have never seen so many unnecessary episiotomies—all done without consent. All tears are sutured regardless of whether it is necessary, and intravenous infusions are routine.

I am used to the women I work with and care for being empowered and knowledgeable, with rights and demands concerning how their pregnancy and labour are managed. Much of what I have seen here would be considered assault. Here, all rights seem to be surrendered to an uncaring and unsympathetic obstetric practice. The fear of being sued (and I understand that this is not uncommon in the States) ensures that the joy of pregnancy and labour is less important than it ought to be.

What I have seen of obstetric and midwifery practice in the United States is less about the woman and more about the medicalisation of obstetrics and doctors’/CNMs’ fear of malpractice.

Alison May, RN, RM, BBS, Yuma, AZ

In June I attended my friend during the birth of her child in a birthing center that was part of a larger major hospital. She had labored at home for about five hours before going to the center; the baby was born five hours later. The labor was beautiful, and the mother was managing just fine. However, the midwife kept a fetal monitor on the mother and repeatedly had her get up on the bed so she could do vaginal/pelvic checks. This was upsetting to the mother and myself, having had a homebirth with a midwife who assumed all kinds of positions to have access to my body instead of asking me to position for her convenience.

The mother became nervous, insisting to the midwife, "Please don't make me birth this baby on my back." When the fetal monitor indicated the baby's heart rate was dropping and not coming back up, the midwife went into crisis mode, called for a stretcher, got the mother on her back (or side, but it was difficult for some reason to get the mother on her side), and then cursed at me and the nurse to hold the mother's legs back. The midwife reached her hands into the mother's vagina, screamed at the mother to push, and proceeded to pull on the baby's head to get her out right away. As it turned out, the baby was born with a mild case of Down syndrome and the umbilical cord was short.

Was all this alarm necessary? The mother was completely dilated at the time the heart rate dropped. Couldn't the midwife have insisted that the mother squat and get that baby out right away? I was shocked to see a midwife adjusting a laboring mother to her convenience. And cursing! And then after all the joy and grief of the final crisis of a beautiful labor, the midwife tells the mother to feel lucky she was not cut (given an episiotomy).

The nurse was quietly preparing a shot of Pitocin to "shrink the uterus back down." When the father and I saw the needle we both asked with alarm, "What's that?!" When we were told, we answered "NO!" in unison. They weren't even going to ask the mother's permission.

What kind of birthing center and midwives are giving this kind of care? The mother inevitably felt she lost all control over her birthing experience as a result of the midwife's approach. In fact, when the baby was out she said to her husband, "I'm never doing this again." Every manner of "expert" told the mother she would not be able to nurse her Down baby. As it turns out, the baby is a great nurser.


I recently attended a birth as a doula. The mom, a primip, was laboring beautifully in the tub. It was a typical first labor, and mom and baby were taking their time. Labor had started naturally despite numerous threats of induction that began at 39 weeks. At about 4 cm dilation the obstetrician (OB) got her out to check her, and I saw the amnio hook package being opened. The OB had no intention of telling her of her plans to rupture membranes; I told the mom. She proceeded to yell, "No, I don' want this" as the OB did it anyway as mom crawled up the bed. Light meconium was present. The OB blamed mom for this and said, "I told you this would happen if you didn't get induced."

Immediately after artificial rupture of membranes, fetal heart tones (FHTs), which had been in the 140s, were showing decels into the 90s. They put in an epidural despite mom’s concerns of scoliosis and subsequent effectiveness. The OB and anesthesiologist were both informed about this condition. They kicked all family and support persons out of the room and did the epidural. It took 45 minutes. FHTs were then in the 60s. The doctor yelled, "OK, I am in control now." They rushed her in for a stat c-section. I was not permitted in the operating room, but according to mom she started to feel her legs and informed the anesthesiologist, who responded, "You ask too many questions. Just be quiet—I can't concentrate." They made the first incision and lost the scalpel. Trays were flying everywhere. When they finished the cesarean, they were about to bring in a low-level X-ray machine to search inside mom for another instrument they had misplaced. Mercifully it was found before the X-ray got there. Mom was so "agitated" that despite her wishes they pumped her full of Varsed, and she slept for the next six hours. She says she'll never have another baby.


The more I know about midwifery and homebirth, the more I realize that many doctors and nurses treat laboring women and new mothers worse than animals. My experiences are mild compared to what friends have endured. During my first birth, six years ago, the doctor ordered Nubain, and the nurse administered it by IV without my knowledge and consent (I'd wanted birth drug-free). Rather than relaxing me, I became psychotic and tried to attack my mother and husband during contractions. I was unable to cope with the contractions because of the Nubain and eventually had an epidural.

With my second, I "knew" I wasn't the type to go natural and received an epidural as soon as they'd give it. After the delivery the doctor, who happened to be the one in the group I'd specifically asked not attend my birth, pulled on the cord to extract the placenta and then, though the epidural had completely worn off, proceeded to stitch up my tear with no anesthetic. His comment after I told him how painful it was, "It's only eight stitches."

Last February I gave birth to my fourth child, a 9-lb., 2-oz. boy, in an aqua doula in our bedroom after a 45-minute labor. It was the best experience of my life. So much for not being the type to birth naturally!


With my oldest son, now seven, I had a pretty easy birth. I was 17, had spontaneous labour at two weeks "late," and no complications beyond back labour. Contractions were five minutes apart when I walked into the hospital. Because I didn't know better, I allowed IV Pitocin. When that became too much to handle, I asked for a small amount of Demerol. I was subsequently overdosed to the point of stupefaction. I still don't remember parts of his birth. I ended up with third-degree tears.

It came to light a day or so later that because I had interrupted the doctor's lunch he was unnecessarily adding stitches as he haphazardly sewed me back together. My husband lost count after 30. He also sewed me too tightly. Until the birth of my second son two years later, intercourse was extremely painful. The doctor attending his birth sewed the second-degree tear I had experienced very carefully.

The same doctor who attended my first birth has had numerous complaints lodged against him for sewing mothers without local anesthetic, being generally rude and uncaring, and even for forbidding one 16-year-old mom from breastfeeding her child until she got out of the hospital—for no discernable reason. Sadly, he's still practicing, although under close scrutiny, but my community has a shortage of doctors and we feel we can't afford to lose him.

I'm proud to say, however, that not only have I gone on to have two wonderful midwife-assisted homebirths, the seven midwives currently working in this area are finding they have more clients than they can handle. What a wonderful testimony to the care that is available!


Regarding the information about constipation from Susan Perri [Issue 5:23]:
I wonder if it is safe for pregnant women to use acidophilus/probiotics on a regular basis to bolster intestinal flora? I find it works well in combination with extra water and fiber in the diet, but I’m not sure about the safety issue.

Amy V. Haas, BCCE

Editor's Note: Only letters sent to the E-News official e-mail address,, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.

Question of the Quarter for Midwifery Today Print Magazine

We hope you'll take a minute to consider the Question of the Quarter for Issue 69 of Midwifery Today. Responses are subject to editing for space and style. Try to keep the word count at less than 400. E-mail your response to:

Theme for Issue No. 69: Midwifery Knowledge
Question of the Quarter: What do you consider essential midwifery knowledge? What do you consider advanced midwifery knowledge? Who owns the knowledge?
Deadline for submission: December 1, 2003.

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