|January 7, 2009|
Volume 11, Issue 1
|Midwifery Today E-News|
“Postpartum Perineal Healing”
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In This Week’s Issue:
Quote of the Week
"…a woman can give birth intact, uninjured, and unafraid."
— Ina May Gaskin
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The Art of Midwifery
Raw honey is a great remedy for first-degree [perineal] tears. Honey's thick consistency forms a barrier defending the wound from outside infections. The moistness allows skin cells to grow without creating a scar, even if a scab has already formed. Meanwhile, the sugars extract dirt and moisture from the wound, which helps prevent bacteria from growing, while the acidity of honey also slows or prevents the growth of many bacteria. An enzyme that bees add to honey reacts with the wound's fluids and breaks down into hydrogen peroxide, a disinfectant. Honey also acts as an anti-inflammatory and pain killer and prevents bandages from sticking to wounds. Laboratory studies have shown that honey has significant antibacterial qualities. Significant clinical observations have demonstrated the effectiveness of honey as a wound healing agent. Glucose converted into hyaluronic acid at the wound surface forms an extracellular matrix that encourages wound healing. Honey is also considered antimicrobial.
— Demetria Clark
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Research suggests that newborns whose mothers take selective serotonin reuptake inhibitors (SSRIs) during pregnancy are at risk for neonatal abstinence syndrome (NAS). NAS is a withdrawal disorder characterized by high-pitched crying, tremors and disturbed sleep. Sixty term babies who were exposed to SSRIs were compared to 60 who were not. The researchers found that eight of the exposed group had severe NAS and 10 had mild NAS, while none of the unexposed group showed any signs of the disorder. Symptoms in severe cases normally were seen within two days of birth, but in a few cases did not develop until four days after birth.
Interestingly, rather than recommend that pregnant women not take SSRIs, the researchers instead suggested that exposed infants be monitored for at least 48 hours.
— Arch Pediatr Adolesc Med 160:173–76, 2006
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Postpartum Perineal Healing
Physicians commonly have women return for a checkup at six weeks postpartum to assess the healing of the perineum and to make recommendations for contraception, as appropriate. But most women are told little or nothing about how to care for the perineum in the interim, or how to watch for warning signals of infection like swelling or inflammation. Pain is an important signal of problems too, but it may go unnoticed if a woman is taking painkillers during the first few days, the most critical time for healing.
I suggest that women use ice packs for 24 hours to reduce swelling, and then switch to sitz baths several times daily using hot water with selected herbs. Nothing speeds healing faster than heat, and soaking is far superior to topical application as it more deeply stimulates circulation. Fresh ginger is a good addition to the solution; it helps relieve the itching that often occurs as stitches dissolve and the skin heals.
Here is how I recommend women take a sitz bath: Grate a 3- to 4-inch piece of ginger root into a large pot of water; simmer twenty minutes; strain and divide into two portions. Save one for later in the day, and dilute the first with water in a sitz bath. After soaking for twenty minutes, thoroughly dry the perineum and expose to air or sunlight for another 10 minutes before putting on a fresh pad (or use a hair dryer to speed the process). If the perineum feels at all sticky, use aloe vera gel to dry and soothe the tissues. Avoid vitamin E or other oil-based ointments until the skin is healed over, as these tend to keep edges from closing.
The wall-like ridge characteristic of episiotomy can be softened and relaxed with thumb or finger pressure, using a little oil (just make sure to wash your hands before handling the baby or breastfeeding). When scarring is extensive, evening primrose oil (found in health food stores) may significantly help to reduce it.
If adequately repaired and cared for, the perineum should be fully healed at six weeks no matter how extensive the damage. I recently saw a woman who was experiencing pain and bleeding with intercourse seven months after perineal repair! She had been back to see her doctor, who offered little assistance. (Unfortunately, he was also a relative, so she hesitated to seek a second opinion.) As I suspected, she had been sewn up too tightly with the "husband's knot." Even gentle pressure to the area caused bleeding, as the skin tore ever so slightly apart. Both she and her partner were frustrated and miserable, and eventually, she had to have reconstructive surgery. But other women who have seen me for this problem report spontaneous resolution with application of evening primrose oil to the perineum, massaged in thoroughly twice a day.
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Question of the Week
Q: I have had to have two emergency c-sections after unmedicated labors. I love my obstetrician, but he believes that the American Medical Association (AMA) recommends that physicians NEVER do a VBAC2. He is a wonderful doctor who was as disappointed with my second c-section as I was, however, I would like a second opinion regarding the fact that I "have" to have a planned c-section with my birth that is due some time after the middle of January.
Is it true that the AMA recommends that VBAC2s never be performed? I'm having a hard time finding the AMA guidelines on repeat c-sections and VBACs online.
Does anyone have a recommendation as to how I can find a doctor in my area who is friendly to VBACs where I could go to get a second opinion?
— Windy Greenway
SEND YOUR RESPONSE to email@example.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.
Question of the Week Responses
Q: I'm looking for any information you have on safe birthing positions while suffering from symphysis pubis dysfunction (SPD). My local public hospital hasn't been able to help me at all, with two midwives I've talked to telling me that my only option is a c-section! (something I'm adamant I don't want) Can you help me in finding some more useful information?
A: Having had two babies with SPD, I can relate to the pain and challenge of finding a position that doesn't make the problem worse. As a midwife, I have found tight binding very helpful during pregnancy and labor. Use a long wrap or rebozo (and if you are a large woman, tie two or three together) and have someone help you tie the wrap tightly around your hips. In labor, you might need two people to do the work. Wrap the cloth as if you are going to make a knot, having each person pull an end after that first step. Once the cloth is very tight around your hips, have them tie a knot. After this is in place, you will feel less pain and be able to try different positions. Standing, holding onto the squatting bar, allows you to do a supported squat without spreading your legs very far.
I find that sitting on the bed, not pulling your legs apart, is a good birth position; but hands and knees is a great position for women with SPD because their legs can be fairly close together, no one is inclined to pull them apart and they have more control over the level of pain from their open legs.
I also encourage women with SPD to bind their hips during the weeks it can take for the relaxin hormones to leave the body; it helps a lot!
— Barbara E. Herrera, LM, CPM
A: I am a prenatal yoga teacher and have seen so many women with that problem over the years. A series of good chiropractic adjustments can resolve the situation in most cases. Find someone who deals with pregnant women, of course. Acupuncture may also help. It can be done, and I have seen it happen! Women can go on to have a normal vaginal delivery.
A: I can tell you that in my experience, SPD was not a problem during birth. I had SPD during my third pregnancy, and had quite a lot of pain during the last trimester. Chiropractic care helped, although the adjustments wouldn't hold longer than a few days due to the relaxin hormones of pregnancy. I had a lovely home waterbirth, with no SPD pain at all; I birthed my 9 lb 8 oz baby in an upright seated position, leaning back against my husband. After the birth, the pain came back worse than ever, but after two more chiropractic adjustments it was resolved permanently.
— Liz Matthews, student midwife
A: Though I was not formally diagnosed with dysfunction, I experienced a lot of pain in my pubic symphysis joint due to several untreated injuries from babyhood onto adulthood. At 38 weeks, my pubic symphysis joint was torqued and stuck in spite of the relaxin hormones. As a result, the baby had yet to drop down into my pelvis. Fortunately I had been doing prenatal chiropractic all throughout my pregnancy (specifically Network Spinal Analysis with the Webster technique). My chiropractors were able to do adjustments that helped the joint to loosen enough to allow the relaxin to do its work and the baby descended immediately. Also, my midwife had me take evening primrose oil to facilitate the joint loosening. I continued to receive chiropractic adjustments and entrainment (though I did not have to do the initially painful pelvic adjustment again) up until I gave birth. I gave birth vaginally at home. The baby did have a nuchal arm (hand up by the face) though.
I found this great resource on SPD: http://www.plus-size-pregnancy.org/pubicpain.htm
— Leilani Nguyen, Oakland, California
A: I suffered from progressively worse SPD with each of my three pregnancies and had successful vaginal deliveries each time. The best position to adopt is on all fours or leaning against a bed, chair or birth partner. This will ensure that a comfortable, stable distance is established between your hips, avoiding excessive movement of the pelvis. An epidural should be avoided if at all possible. If you are anesthetized you will be unable to tell whether your pelvic joints are being put under too much strain during a vaginal delivery.
A: Rather than waiting for the birth, find a chiropractor who does Webster technique and symphysis work. You can locate one at www.icpa4kids.org
— Jeanne Ohm, DC
A: I'm 5' 3" and weighed 105 lb at conception and was 151 lb at birth. When I was pregnant with my son I was told by the doctors that c-section was the only way, as well. I spoke to a chiropractor who specialized in maternity chiropractic and he manipulated my hips and lower back 2–3 times a week for the last four months of my pregnancy. The pain lessened considerably by the time I had my son. After the pregnancy I went back for about three months, until all the pain had gone away. I still go to the chiropractor three times a week for general well-being and it has been wonderful. I ended up with a home waterbirth and an 8 lb, 21 in son, with a fairly easy labor and birth. I would say, if there are not any other limiting factors, go to a chiropractor. Most insurances cover chiropractors now and they are fantastic and absolutely more knowledgeable than the doctors—and sometimes the midwives! Good luck.
A: I have had this with my last two pregnancies. I would think that learning how to map your pelvis may be beneficial, and help you figure out what position would work best for you (the Pink Kit is a good resource).
With my last birth, I HAD to give birth side-lying with my upper leg open only SO far. I was very particular about what position I could tolerate. Everything else did not feel right. I did not get chiropractic care with either of my pregnancies, but I wish I had tried it.
— Erin Behnke
Q: I am currently a labor and delivery nurse at my local hospital and am preparing to enter school to become a midwife. One of the most common questions/concerns I'm confronted with is the issue of meconium-stained amniotic fluid in a homebirth. I usually have answers for other concerns, but this one is always a little hazy. Do midwives who help moms deliver at home bring suction of some sort with them? Do they automatically transport to a hospital at the sight of meconium? Is it all dependent on the situation and the midwife?
Thanks for your help in understanding!
A: A homebirth occurred four years ago and everyone should learn from it, rather than repeat it. A first birther was home, and during second stage, pea soup-thick meconium came out. The midwives decided not to transfer because they felt the birth was imminent. But the woman did not deliver for ONE hour. The baby came out with a very low Apgar and they resuscitated it and transferred. If the mother had been transferred immediately after the pea soup was noticed, the hospital has follow-up preventive routines for babies that needed total resuscitation including drugs to prevent seizures, such as topiramate.
Because the baby went to the hospital after a homebirth and also after the resuscitation was done, the baby fell between the cracks and did not get proper follow-up care. The baby is now four and not walking, severely physically damaged probably from the multiple seizures that happened hours after birth, while in the hospital. It is very possible that those seizures could have been prevented. This is the reason that it is important to transfer for pea soup meconium, for a first birth—because most likely you have time before the delivery to make it to the hospital and the follow-up care will be better for a baby like that.
(For light meconium, I don't suction. I often do hold the baby upside down for a while.)
— Judy Slome Cohain, CNM
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Think about It
If you have a piece of cloth and try to tear it in two it requires quite a bit of effort to tear it straight down the middle.
Now take the same piece of cloth and imagine putting a small cut in it with a pair of scissors. Now, starting at that cut try to tear the cloth. It is much, much easier.
Episiotomy is much like this. Having the soft tissues of your pelvic floor cut by your doctor will weaken them and make a tear even more likely. Women who have third and fourth degrees tears have often had a first or second degree episiotomy.
— "Episiotomy Epidemic," www.naturalbirthandbabycare.com/episiotomy.html
I'd like to touch on the subject of becoming a midwife a bit. As a doula, mother of four children and a "middle-aged" college student (nontraditional student) working through nursing school, I have as many reasons to pursue my education and goals as reasons not to. There is nothing more stressful than the wants and needs of your family conflicting with the wants and needs of your instructors. Couple that with holidays, illness, cooking, cleaning, and providing and you have the instant makings for a total and complete mess. The only answer to the "do you have stress" question is "yes." It often seems that juggling does not always include prioritizing and there are times when failing is the only option. I regularly find myself competing with young students who live at home or have only themselves to care for. This venture is much harder than I could have imagined and more work than I could ever have dreamed. The stakes are high, the expectations higher and the process is at times unbearable. I am reinventing, re-evaluating and growing at exponential rates.
Yet, within this jumbled confusion occurs blissful moments of nothing, where I put down my books, ignore my assignments and focus on my family. We may go for a treat, or spend time watching a movie on the bed with popcorn and ice cream. Yes, it may mean a slightly lower GPA in the end, but it is worth it. I recognize that, while this is my opportunity for my future, this is also my only opportunity for the present and children have a propensity to grow up and move on. I often joke that I am not very appreciative of my children's housekeeping abilities, and I will just have to walk over the mess until winter or summer break. I recognize that I have the responsibility to care for my family, and yet, as a family, each of our goals is important to the other, and we support each other in an effort to love, encourage and succeed both as an individual and a family.
Honestly, it may take me years (and I do mean years) to become a midwife, and it may not be the most direct path that I take, but I believe everything will happen in due time. The goal is not just an education or degree! The goal is a happy healthy woman, mother, and family during the process of education. Some days school takes preference, and others my family gets all of my time and attention. I wouldn't have it any other way.
— Chantel Haynes,
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