|October 27, 2004|
Volume 6, Issue 22
|Midwifery Today E-News|
“Post-Cesarean Uterine Repair”
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MIDWIFERY: BEST PRACTICE, Sara Wickham, editor
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In This Week’s Issue:
Quote of the Week
"By paying attention to the language and art of touch, it is possible to shape a positive birth experience."
— Michele Klein
The Art of Midwifery
I feel traditional herbs for clearing constipation and improving regularity are unsafe for pregnancy. These herbs can tax vital organs with extended use, and in pregnancy the organs are already working hard. The more nutritive food-type plants are still a good option for treating constipation. Bulk fibers in the form of grains and vegetables are a worthwhile choice for keeping the digestive tract clear and the bowels regular. Fiber helps absorb water and keeps constipation at bay.
Oat bran, celery fiber, wheat bran, flaxseeds, prunes, and psyllium husk powder can be found in powdered form and added by the teaspoon to a glass of juice or tea. Mom should take the mixture once in the morning and again in the evening, if needed, to encourage regularity. The powders can also be added to muffins or sprinkled onto cereals. Prunes can be eaten whole and fresh, dried, or juiced. Flaxseeds can be added to baked goods or eaten with grains and salads.
— Susan Perri, The Birthkit Issue 35
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 email@example.com.
A University of Helsinki, Finland, study of more than 1000 women found that those who consumed more than 500 mg of glycyrrhizin, the active ingredient in licorice, per week during pregnancy were twice as likely to go into labor before 38 weeks gestation than were women who consumed no licorice. Licorice affects hormone production in the adrenal glands and may cause a decrease in potassium levels as well as induce high blood pressure in some people. Licorice may stimulate the production of prostaglandin, which can induce labor.
— American Journal of Epidemiology 2002; 156: 803–805
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Stitching a Cesarean Repair
The single-layer uterine repair following cesarean section is carefully described in the literature as follows: "The uterus is closed with a one-layer continuous locking stitch. The peritoneal layers are left open." This means that the uterus is stitched together with single continuous stitching, like a hem. It can be done with locked or unlocked stitches. It also can be done with single interrupted stitches, which are knotted after each single stitch. Locked stitches provide greater control of bleeding than unlocked for the first three hours after repair. After about three hours, it makes no difference whether the stitches are locked or unlocked, because the uterus has shrunk so much that the stitches become loose. The uterus continues to contract for the next six weeks, healing itself slowly as it gets smaller and smaller. The recommended suture is Vicryl (polyglactin). The peritoneal cavity is left unstitched to close on its own.
Double-layer repair generally means that a second row of stitches, locked or unlocked, is made over the first layer of stitches. The second row sometimes includes the opposing edges of the peritoneal cavity. Other times, a third layer of stitches is used to sew the peritoneum together. Finally, the outer skin is closed up.
From 1988 to 2003, 50 scholarly articles were published in the medical literature about single-layer versus double-layer repair. All agreed that single-layer repair of the uterus is significantly faster, by 10 minutes on average. Reducing an operation by 10 minutes means less time under anesthesia and less anesthetic. Intestinal function returns faster, allowing women to eat sooner. They get out of bed significantly sooner and take fewer painkillers. Less suture material and operating room time reduce the cost. Sewing human flesh causes trauma to the tissues; the more stitches, the more broken blood vessels. Large broken vessels must be tied off to stop bleeding. Broken vessels mean more blood loss. More sutures introduce more foreign bodies to the area, and foreign bodies increase the local inflammation, which weakens the strength of the scar that forms. The single-layer technique has the theoretical advantage of less tissue damage, which may result in a stronger bond. Longer surgery is associated with an increased infection rate. Half of the studies show a similar infection rate for the methods and half show a significantly lower infection rate with the single-layer repair. No studies show single-layer repair to cause more fever or infection.
In 2002, Bujold published the third study about the uterine rupture rate of women after single- versus double-layer repairs [Bujold, E., et al. Am J Obstet Gynecol 187: 1199–1202]. Of 1527 women who had their first baby by cesarean and underwent a trial of labor for the second delivery, 21 ruptured. Fourteen of the 21 were in the single-layer repair group; the repair closed the entire thickness of the uterine wall from deciduas to visceral peritoneum with a continuous locking stitch using chromic catgut suture. There were no maternal deaths. The rupture rate for women who delivered their second babies within 24 months of the cesarean section was 2.8% compared with 0.9% in births more than 24 months beyond the cesarean. The women who had a uterine rupture in this study were significantly more likely to have been induced, used an epidural and/or had a previous cesarean for slow labor than the women who did not rupture. The study does not indicate the infection rate at the primary cesarean. High infection rates are associated with the use of catgut sutures and are associated with weak scars. The study confirms previous studies showing that it is not advisable to have another baby within two years of a prior cesarean.
More recently, Durnwald's retrospective study of 768 attempted VBACs after a first birth found no uterine ruptures in the 267 women who had had a single-layer repair [Durnwald, C., and B. Mercer (2003). Am J Obstet Gynecol 189: 925]. The double-layer repair group had a 0.8% uterine rupture rate. Vicryl sutures, which hold tissue together for seven to 10 days, with a continuous unlocked stitch had been used. Chromic catgut loses half its strength within seven to 10 days and sooner if there is an infection—which occurred 25% of the time in Durnwald's double-layer group. Durnwald suggests that using catgut, which deteriorates faster, may account for the higher uterine rupture rate in Bujold's single-layer group.
— Excerpted from "The Many Ways to Sew Up a Uterus," by Judy Slome Cohain, Midwifery Today Issue 70
[Editor's Note: It is strongly recommended to read the article in its entirety.]
Order MIDWIFERY TODAY ISSUE 70.
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Question of the Week
Q: I had beautiful skin before I had children. Late in my first pregnancy my face began to break out in horrible acne. It lasted more than a year before it started to get better. At the time I had a lot of stress in my life with work, school, a misdiagnosis that had me fearing I would lose the baby, and a cesarean. I attributed it to this and the usual hormones associated with pregnancy and breastfeeding. Since I was breastfeeding, no dermatologist would have anything to do with me. I was not willing to give up breastfeeding, but I became reclusive because I was so embarrassed. Now, five years and two more births later, I still struggle with acne, but not nearly as severe. I drink tons of water and eat nutritiously. I am still nursing. Does anyone have any suggestions or insight?
SEND YOUR RESPONSE to firstname.lastname@example.org 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: What information is available regarding breastfeeding when mom is on 20 mg Paxil [antidepressant] and has been throughout pregnancy?
— Betty Jones, York, Pennsylvania
A: Most of the studies done with SSRIs and breastfeeding were done on Zoloft, which is considered safe for breastfeeding. Since Paxil is in the same class of drugs it is also considered safe by the American Academy of Pediatrics and others. One month of taking Paxil while pregnant (which is not found in amniotic fluid) is equivalent to three years exposure of Paxil in breastmilk. So basically don't worry about it. One note is not to abruptly stop Paxil while breastfeeding because of seratonin syndrome. If the mom stops, she should do so very slowly during a wide period of time.
— Susan Wright, CNM, NP
A: According to my sister, who has a PhD in psychology, Paxil may cause low birth weight and prematurity. It is not recommended for anyone to breastfeed while on Paxil. It would be highly recommended that your client do her research and talk to her doctor who prescribed this medication. If she chooses to stop taking Paxil, please warn her that withdrawal from Paxil can be very uncomfortable (I know from personal experience.)
— Kirsten Rohl, CD (DONA), Rochester, New York
A: A better antidepressant to use during pregnancy and/or breastfeeding is Zoloft or Prozac. These medications are considered the safest if you need an SSRI. Of course St John's Wort is also a good choice but is generally better for mild to moderate cases of depression.
— Kathy Metzler, RN
A: There is a lot of disinformation spread about the use of drugs while breastfeeding. Two excellent resources are "Dr. Jack Newman's Guide to Breastfeeding" by Dr. Jack Newman, and Dr. Thomas Hale's "Medications and Mother's Milk." The commonly used pharmacology reference book for doctors is "The Compendium of Pharmaceuticals and Specialties" (CPS) in Canada and "Physician's Desk Reference" (PDR) in the United States. Both manufacturers of these books are concerned about medical legal liability, not the mother and breastfeeding baby; therefore, many drugs are listed as not suitable for pregnancy without any real data behind this recommendation. A section in the front of these books has information specific to breastfeeding women and drugs, but most doctors don't consult this section. Any drug taken by a breastfeeding mother is diluted throughout the body.
Dr. Jack's book includes this information specifically about Paxil: "Less than 1% of all the drug the mother has in her body is actually in her blood, the rest being located in other tissue such as fat or brain. Thus, very little of this particular medication can get into the milk" (Dr. Jack Newman's Guide to Breastfeeding, pg.184).
— Kimberly Rigden-Briscall, Crestwood, New York
Regarding vulvar varicosities [Issue 6:21]:
A: Routine chiropractic care works amazingly well for the treatment of vulvar varicosities. A good support belt such as the V2 support belt can be a wonderful aid in relieving pressure from the varicosities as her belly grows.
— Kimberly McCarty, CD (DONA), Chicago, Illinois
A: A client successfully used acupuncture, which helped stabilise and reduce a previously worsening case further on in the pregnancy. She previously had had an awful pregnancy, but this time it was much better. If you have good acupuncturists, use them for this condition as well as a good diet.
A: I had terrible vulvar varicosities when I was pregnant with my second and third babies (they occurred in the same spot where I had burst an artery delivering my first). Standing was very, very uncomfortable and achy, although walking around was okay. Besides lying down and applying ice (impossible with two small children to watch), I found one real godsend: a pregnancy girdle. I cut the belly part off because it felt too tight and I didn't need it, but the underwear part gave good strong all-day vulvar pressure and provided almost complete relief. I truly don't know what I would have done without it. (I bought the Leading Lady maternity girdle online and then tailored it.)
— Sarah, mother, Massachusetts
Regarding severe menstrual cramping [Issue 6:20]:
A: You are absolutely right in your thinking that you do not like your body being pumped full of hormones. We do not have all the specifics but it would be worth a shot for you to go and get evaluated by a chiropractor. Chiropractic works by helping your body heal itself. Often, imbalances in your nervous system can lead to other disturbances in your body such as hormonal shifts. A chiropractic evaluation would determine if you have subluxations (interferences to your nervous system) and if your body could benefit from those potentials being released.
A lot of women suffering from menstrual pain have been helped by chiropractic. One of my greatest chiropractic resources is the International Chiropractic Pediatric Association. It has lots of information about chiropractic in general and with regard to pregnant women and children. Go to: www.icpa4kids.org
They also have a referral page so you can locate a chiropractor near you.
— Dr. Martine Dionne, chiropractor DC, BEd, MSc, FICPA
Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to email@example.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
[Editor's Note: In Issue 6:20 we published a letter from a 16-year-old young woman named Nicole who is interested in becoming a midwife. Several responses were published in Issue 6:21, and letters have continued to arrive in the E-News mailbox.]
I am 19 years old and have been taking classes from the Midwives College of Utah for 14 months. Most of their classes are correspondence. You are required to do an apprenticeship with a proctor. You can, however, complete all the classes via mail and e-mail if your proctor is able to give you the experience required by the school. MCU is a direct-entry program offering an associate and bachelors degree in midwifery. They also have a CPM track and masters programs. Their web address: www.midwifery.edu
Thus far I have been very pleased with their program.
— Dessa Cooper, student midwife, Illinois
I very highly recommend reading "Paths to Becoming a Midwife," a book published by Midwifery Today. It's a great resource. I was once in your shoes and used this book to help me decide how to focus my energy on making this world a better place for moms and babies.
— Amy Willen, student nurse-midwife, La Crosse, Wisconsin
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To Rachel who is looking for a midwife in Riverside, California: Contact a local Bradley instructor, as many times they can put you in touch with someone. You can find a teacher in your area by going to: www.bradleybirth.com
— Amy V. Haas, BCCE
As a physician in a homebirth practice, I appreciate that you include a News Flash section in your newsletter. It is extremely important that practitioners are up to date on medical literature. My complaint, however, is that many of the studies mentioned are very old and may be outdated. In my opinion, a News Flash should be in regard to actual news—recently published studies. For example, in the last issue there was an article mentioned from 1995. This is ancient in terms of medical literature, which quickly becomes old news. I fear those using these as references may be discredited for this reason. May I suggest that articles older than two years not be included? While this may present a challenge to always find a current article, I believe this may be a case where old news is worse than no news.
— Lana A. Doxtater, MD, Rolling Meadows, Illinois
[Editor's Reply: In the vast majority of cases, studies conducted several years past still stand. We all walk the tightrope of trying to stay fully informed, up to date, yet able to determine and appreciate the validity and longevity of older studies. Because we live in an age of instant access to information, the temptation is to assume if it's new, it's best, and what's "old" (and the criteria for determining what's old these days are stunning!) no longer applies. E-News tries to strike a balance and provide solid information. Perhaps the column title News Flash is misleading! We appreciate your words of caution, and always invite readers to submit these kinds of comments to help guide us. We also invite readers to submit news items—please cite your source! And we invite readers' comments on this topic.]
I would like to offer some comments in response to the Quote of the Week, "When a woman births at home, it is a demonstration of civil and medical disobedience that defies the medicalization of her body's normal function while it honors her inherent, amazing power" [Issue 6:20] that I hope will dilute the militant and off-balance tone I perceived when reading it.
I have been receiving Midwifery Today E-News for several years in anticipation of being able to realize my dream of motherhood ushered in by a natural, glorious birth. My dream was realized six months ago when supported by my husband, doula, and CNM, I pushed my daughter into the world with great gusto and excitement.
I chose to give birth in a hospital in metro Atlanta that was supported by several practices with many CNMs to choose from and where my baby never left my side. I traveled more than an hour for my prenatal care and subjected my husband to a nail-biting drive to the hospital (I actually found lying on my side in the back seat of our old Oldsmobile relaxing as the car vibrates quite a lot when driven at high speeds!). Besides being willing to travel, I also budgeted our tight finances to employ an incredible doula. I did my homework well, reading voraciously about birth for the past several years and keeping my body in top condition through exercise and nutrition.
I chose to give birth at my selected hospital because I felt like I had the best of both worlds—a natural, hands-off birth (because of the great care I gave in selecting my birth team) and emergency equipment close by, should the need arise.
I relate my hospital birth experience because I want other expectant mothers to realize that a great hospital birth is very possible. It was not "the medicalization of her body's normal function" but a support of the birth I always dreamed of and that became a reality.
— Marigold Hibbert, Cedartown, Georgia
Editor's Note: Only letters sent to the E-News official e-mail address, firstname.lastname@example.org, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.
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Complimentary high-quality cloth diaper reference guide available to give to your clients. Provides overview of cloth diaper types, care, recommended quantities and more. Plus valuable coupon! Call 805-648-5178 or e-mail: email@example.com
Fearless Birthing Workshop, November 20, 2004 in Albuquerque, New Mexico. Instructor: Kim Wildner, author of "Mother's Intention—How Belief Shapes Birth" Contact Kim at www.fearlessbirthing.com or Jenny West at 505-294-4359 or firstname.lastname@example.org to register!
Homebirth midwife needed for beautiful rural Oregon coast community. 1–4 births a month with potential for growth. Work in a supportive homebirth climate. Call Sonya at (503) 325-0461.
Itsy Bitsy Baby/Toddler Yoga Teacher Trainings Instructor: Helen Garabedian, author of "Itsy Bitsy Yoga: Poses to Help Your Baby Sleep Longer, Digest Better and Grow Stronger." For training dates call (978) 443-8468 or visit www.ItsyBitsyYoga.com
Birth Matters! Expo, Winchester, Virginia, November 13. Come enjoy a day of food, vendors plus many classes by professionals on a variety of topics. Details are at www.virginiamom.org or call (800) 861-5761.
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