May 12, 2004
Volume 6, Issue 10
Midwifery Today E-News
“Preventing Perineal Tears”
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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 mtensubmit@midwiferytoday.com.

In This Week’s Issue:


Quote of the Week

"The unborn baby is truly a sentient and intelligent human being who has much to go through at birth. We owe it to future generations to change birth experiences to make birth an easier transition and a gateway to a fuller life."

Nick Owen


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The Art of Midwifery

I really like giving women chlorophyll postpartum if there's been an intense bleed. I carry a bottle in one of my birthing bags.

April

For most people, liquid chlorophyll is great for helping with anemia or just sluggishness.

K.H.

Chlorophyll and hemoglobin only differ in one group structurally, and both carry oxygen throughout the tissues. It will help anemic women during pregnancy and during a regular cycle. Nature's Sunshine makes a mint-flavored liquid form; all you do is add a few drops to a glass of water.

Anon., Midwifery Today Forums

News Flashes

Mimi de Maza of La Leche League Wins Women of Peace Award

The Women's Peacepower Foundation, Inc. has named Irma (Mimi) de Maza, Latin American representative to La Leche League International's Board of Directors, as a recipient of the Women of Peace Award. The Women of Peace Award, formerly known as the Amigas Award, honors women involved in cutting-edge society building.

Since 1989, Mimi de Maza has facilitated breastfeeding and mother-to-mother support programs in low-income communities near Guatemala City. Mimi de Maza is addressing poverty and malnutrition by promoting and supporting exclusive breastfeeding. Using mother-to-mother support is an innovative approach in Guatemala as well as in other parts of the developing world. Mimi de Maza has demonstrated that reaching out to mothers in this way has very positive results. When women are given the opportunity to learn and share information and practical help on the art of breastfeeding, they flourish and become strong agents of change in their communities.

For more information about breastfeeding or La Leche League International, visit LLLI's web site at www.lalecheleague.org.


U.S. Breastfeeding Rates

In the United States, studies are showing that welfare-to-work programs are decreasing breastfeeding rates. Statistics from 1996 to 2000 show that national breastfeeding rates six months after birth would have been 5.5% higher if the work program had not been implemented. States with the most stringent programs showed breastfeeding rates that are 9% lower. A Michigan State University, RAND Graduate School, and University of Michigan study also showed that among breastfeeding mothers enrolled in the Women, Infants, and Children (WIC) nutrition program who lived in states with the strictest welfare-work requirements, breastfeeding rates six months after birth were 22% lower than those of WIC mothers in other states. Before the welfare-to-work program was implemented in 1996, mothers with infants were exempt from work requirements. www.attachedparents.com


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Perineal Tear Prevention

Postpartum: To prepare the perineum during pregnancy, women can do two things: get good nutrition and do Kegel exercises. Vitamins C and E and the bioflavinoids all contribute to improved skin elasticity, which in turn will help the perineum stretch during delivery. Women should try to avoid using soap on their perineum during the past few weeks before delivery, because soap dries out the body's natural emollients.

In prenatal yoga, women can assume the "open position" by kneeling on both knees, buttocks resting on the heels and palms on the floor in front. She lifts her left knee so it is beside the left arm, with her left foot flat on the floor. Her left hip will be raised slightly higher than the right. The right buttock will be resting on the right foot. Then she can switch legs. This procedure opens the base of the body as wide as possible so that the muscles are prestretched before birth—ensuring they will open easily during birth.

Practicing squatting can help women stretch the Achilles tendon, which runs behind the ankle, for greater flexibility during birth. Women can practice squatting while holding onto a bar or chair for stability. When her feet turn outward, her sit bones actually move closer together. If a woman plans to use the squat for delivery, she should practice with her feet facing forward to maximize the pelvic outlet.

Excerpted from "Everything You Need to Know to Prevent Perineal Tearing," by Elizabeth Bruce, Midwifery Today, Issue 65


When women pay particular attention to their posture in the latter stages of pregnancy by adopting upright or leaning-forward postures, their babies have an optimal chance of getting into an anterior position prior to the onset of labour. When the pelvis tilts forward it allows more space for the broad biparietal diameter of the baby's head to enter the pelvic brim and more space at the front for the baby's back to rotate anteriorly.

When it comes to the birth itself, it is important that women remain well hydrated during labour in order to promote tissue elasticity.

In a textbook for midwives from 1907, I found this wonderful description of crowning:

"As the head passes through the vulva of a primipara, the pain due to the stretching of the vulval orifice will be very severe and will probably cause the patient to cry out, and so to cease from bearing down. This has been described as the 'safey-valve action' for the protection of the perineum, because the perineum is likely to be torn if the patient bears down hard while the head is passing through the vulval orifice." (Andrews, H.R.(1907). Midwifery for Nurses. London: Edward Arnold, p. 82.

Excerpted from "Making Room for Babies," by Sue Brailey, Midwifery Today, Issue 65


The best way to protect the perineum, to avoid a serious tear, and to eliminate the reasons for episiotomy is to deviate as little as possible from the physiological model of birth. In other words, the best way is to create the conditions for an authentic fetus ejection reflex.

This reflex is the effect of a sudden spectacular reduction in neocortical activity, making possible the release of a complex hormonal cocktail. The release of high levels of hormones of the adrenaline family is suggested by the sudden expression of fear that precedes the irresistible contractions, and by a sudden tendency to grasp something and to be upright. The most helpful thing to do in terms of facilitating the fetus ejection reflex is just to accept this sudden expression of fear without interfering: reassuring rational words—a stimulation of the neocortex—would inhibit the reflex. The release of a high peak of oxytocin is of course suggested by the sudden power and efficiency of the uterine contractions. As for the ecstatic state of the mother, it suggests that the hormonal cocktail includes morphine-like hormones.

I have never had to repair the perineum after a real, undisturbed fetus ejection reflex. One of the many reasons may be that in such a context of privacy, the mother is more often than not bending forward, for example, on hands and knees. In such postures, the mechanism of vulval opening is different from what it is in other postures. First, the anterior part of the vulva opens more quickly; then the deflexion of the head tends to be delayed and, when the face is coming out, the chin is in a more lateral position.

Excerpted from "Champagne and the Fetus Ejection Reflex," by Michel Odent, MD, Midwifery Today, Issue 65


We must ask ourselves whether perineal tears are always negative and harmful for women, or could they be neutral in their effects? Could there even be advantages? Having a tear does help women slow down after they give birth; they are not physically capable of moving too quickly, which might make some women take better care of their bodies and get more rest. A tear also offers the woman and her midwife an easy marker by which to gauge healing. If a woman tries to do more than her body wants her to, her tear will usually let her know.

A healing perineum helps remind women they have had a baby. Having a tear might enable some women to learn more about their bodies, their pelvic muscles, and how they can work with them. It might also be a way for midwives to introduce women to herbs or other ways of healing that they might not have previously encountered. For at least one woman I worked with, having a tear meant she had a valid reason to not engage in unwanted sexual activity after birth. More generally, helping a woman deal with a tear can open discussion about her sexuality and issues that she may never have been able to talk about before.

Birth is a rite of passage that takes women's bodies on a journey. We become marked with the symbols of our passage into motherhood and retain the cellular memories of the experience. Whether we judge these marks as good, bad, or neutral, we hold them as women whose bodies tell the stories of our lives. To what extent does the fact that we midwives often judge all tears to be bad affect the way that women perceive their bodies, their tears and scars?

Excerpted from "Is Prevention Always the Best Cure?," by Sara Wickham, Midwifery Today, Issue 65


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Web Site Update

Join the discussion online about international midwifery:
   International Midwifery Forum

Read this article newly posted to the Midwifery Today Web site:


Forum Talk

I am 30 weeks pregnant and was told I had low amniotic fluid three weeks ago. I am planning a homebirth, but the doctor says that it may not be a good idea if I continue to have low fluids at the time of delivery. I am being monitored like crazy (at least once a week), and the AFI numbers they give me seem so inconsistent, varying from day to day, hour to hour. I've been told 3.3 to 15 cm at different times. The radiology techs always get the low numbers and the OB staff always get above 9 cm. The baby is growing well, right on target, and I have no other problems. I don't know who to believe, and it is hard to trust the hospital team. I am afraid of a hospital birth with tons of unnecessary interventions. But I also want a safe birth with a healthy outcome. Any thoughts?

Anon.


Share your thoughts and experience about this topic.
**Please do NOT send your repsonses to E-News!**


Question of the Week

Q: My wife had a successful home waterbirth two years ago. However, two months later it was discovered she still had some placental tissue left behind in her uterus. An Ob/Gyn performed a D&C and ended up perforating the fundus of her uterus. Due to internal bleeding afterward he went in to stitch things up.

Afterward, he told us:

  1. Wait two years before becoming pregnant again (I can agree with that comment).
  2. You will have to have a c-section next time as there is a 25% chance of uterine rupture while delivering and a 3-5% chance of rupture while carrying. He said this was because the tear through the uterus was at the top of the uterus where it contracts the most. (I am somewhat skeptical of this recommendation).

I am looking on the Internet for information about risks of carrying a baby and giving birth vaginally after this type of scenario and have been unsuccessful thus far. I would think my wife's situation would be different than a woman wanting to give birth vaginally after a cesarean. I do understand there is more chance of a rupture if the woman has had a classical incision from a previous c-section.

My wife and I are talking about having another baby but want to be well informed before doing so. We need more opinions. I hope someone can help us find the information we need.

— Dean Collins


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


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Question of the Week Responses

Q: A client has a degenerative kidney disease called IgA nephropathy. She is showing +1-+2 protein in her urine, and her average blood pressure is 130/82. She is seeing a nephrologist and getting her labs done monthly: sodium, potassium, chloride, carbon dioxide, calcium, glucose, phosphorus, BUN and creatine, albumin all of which are in a normal range. I am looking into alternative methods for supporting and nourishing her kidneys through the pregnancy. She has seen an acupuncturist (per my suggestion) one time to receive treatment and herbal supplements. She is 20 weeks pregnant. In addition, we helped her with a homebirth 2-1/2 years ago. During that pregnancy no protein spilled in her urine, and her blood pressure was more in the range of 110/66.

Can you share recommendations and or experience?

— S.C.

A: I am currently 30 weeks along and started this pregnancy spilling +2 protein with borderline blood pressure. I currently take two Hawthorn capsules three times a day. This should help the blood pressure, but it may take as long as six weeks. Walking also helps lower blood pressure a lot. Have mom start slowly, ten minutes at a time a couple times a day.

For the protein I started taking milk thistle, four capsules a day. You want to look for a product that is standardized to 80% Silymarin. This is basically the active ingredient. Watch what other ingredients are in the capsules; some contain things that are not the best to take during pregnancy. I had a 24-hour urine test that came back +2. After a week of taking milk thistle the 24-hour test was normal. This amazed everyone because I've been spilling upward of +4 since last May. Dandelion is also great for the kidneys and can be taken in capsules, tincture, or just eaten as a salad or cooked green.

Because she already has kidney problems, eating high protein might not be the best. What she might try, though, is ingesting her protein servings in small portions throughout the day. This would keep her protein levels fairly constant.

— Laura

More about posterior-positioned babies [E-News, Issue 6:8]:

A: As a doula I coached a lady whose baby was in an occiput posterior position. Her labor was not long, but it was difficult for her to deal with. Baby was born happily face up. A year later I was back coaching her with the next baby, who was also posterior. Her midwife and I decided it would be great to help her get that baby turned to ease her labor and to deliver more easily. Turning wasn't difficult, and she was complete fairly quickly. Then came pushing. After three hours of pretty athletic pushing, baby's progress was negligible. After a short rest, we discovered that the baby had turned and was once again posterior. She delivered baby within fifteen minutes, and was absolutely exhausted.

The lesson I learned from this is, become very familiar with the history of the woman. She had a broken pelvis during her teenage years. Her first two children, born ten years earlier, were posterior. She didn't think it important to mention in her history. This woman was meant to deliver her babies in a posterior position. Had I known and trusted my instincts and hers I would not have tampered with baby's position, and I feel he would have been born much more quickly, better for baby and mommy. I was glad for an opportunity to relearn to trust the mommy and that little voice inside me.

— Barbara Packard, doula


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


Think About It

A labouring woman's production of oxytocin is drastically reduced by the use of epidural pain relief—this is the reason epidurals prolong labour. And even when an epidural has "worn off," her oxytocin peak, which causes the powerful final contractions designed to birth her baby quickly and easily, will still be significantly lessened. As a result, she is more likely to have her baby pulled out with forceps.

The drug Syntocinon, which has been called the most abused drug in obstetrics, is also implicated. It is a synthetic form of the hormone oxytocin and is used for induction and augmentation or acceleration of labour.

When a labouring woman has Syntocinon administered by drip, for induction or augmentation, her body will detect high levels of this drug in the bloodstream and her brain will respond by cutting down the release of her own oxytocin. We know that women in this situation are vulnerable to haemorrhage after birth because of this, and even more Syntocinon becomes necessary to counter that risk. However, we do not know the psychological effects of giving birth without the peak levels of oxytocin that nature prescribes for all mammals.

French surgeon and natural birth pioneer Michel Odent believes that when a baby initiates his own birth, he may be training himself to secrete his own hormone of love. Odent also notes our society's deficits in its capacity to love self and others. He traces these problems back to the time around birth, and especially to interference with the oxytocin system.

Excerpted from "Healing Birth, Healing the Earth," by Sarah J. Buckley, The Birthkit, Issue 36


To read this compelling article in its entirety, order The Birthkit Back Issue 36 here.


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Survey Question for Midwifery Today Print Magazine

We hope you'll take a minute to respond to the following question for a published forum in Midwifery Today, Issue 71:

As induction policies become more rigid in many countries, we are surveying midwives and practitioners from around the world to find out what is currently considered normal length of gestation. In France, for example, 41 weeks LMP (from last menstrual period) is the point at which induction becomes mandatory for most practitioners. While the normal term of pregnancy is considered to be between 37 and 42 weeks, women are routinely induced at 41 or 41 weeks +1 day if they haven't gone into labor by this time. Practitioners who allow women to go to 42 weeks are a very small minority. What is considered normal "term" in your region? At what point is there pressure to induce based on pregnancy length alone in an otherwise normal pregnancy?

Responses are subject to editing for space and style. Try to keep the word count at less than 150. E-mail responses by June 1 to: mgeditor@midwiferytoday.com.


Feedback

Afterbirth pains [Issue 6:9] are actually contractions that are working to get your uterus back to its normal size. This is most easily accomplished after first and second babies. With more births your uterus has to work harder to get back to its prepregnancy size, so the contractions are more intense and are doing more work to shrink the uterus back down. Be prepared for the afterbirth contractions to worsen with each consecutive birth. This is why your friend had such long-lasting pains for three days postpartum. There are tinctures you can buy that can help the pains; your midwife should know what they are.

Anon.


The afterpains are caused by your uterus working to involute, or return to normal size. They are intense for most women, but a true blessing because our wombs need to contract so that our placental sites will close off and we won't bleed to death!

I have given birth four times and have had good success with Susun Weed's After Pain brew in her book Wise Woman Herbal for the Childbearing Year. I have tried herbal tinctures that didn't do anything for me, but this one takes the edge off the afterpains for me. Every body and chemistry is different, though.

Recipe:
Infuse for 8 hours the following herbs in a sealed quart jar:
1 oz. dried cramp bark or black haw root bark
1/2 oz. dried blue cohosh root
1/4 oz. dried hops flowers
1 oz. motherwort leaves and stalk (this is my own addition; I love this plant!)

Strain out herbs, refrigerate brew. Gently reheat one cup at a time and sip as needed. Weed says a bit of salt improves the taste.

Anon.


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


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