May 12, 2010
Volume 12, Issue 10
Midwifery Today E-News
“Choice in Childbirth”
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In This Week’s Issue:


Quote of the Week

“It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.”

United Nations Secretary-General Kofi Annan


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The Art of Midwifery

Be Personal

Call women by their names—it shows warmth and most people respond to it very positively. It seems so simple, but we often forget to do so.

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Excerpted from Sharing Midwifery Knowledge, Tricks of the Trade, Vol. IV
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Jan’s Corner

Mary Cooper is a fabulous midwife and conference speaker. She has done a couple thousand births and is "birth-sharp," with insights and outside-the-box thinking. She did a birth last week of a baby who weighed more than 10 pounds and the momma tore on an old episiotomy scar. Mary called me to ask about using Super Glue on the tear. I told her to not get her glove caught in it accidentally! She took a different approach though, so I've asked her to write about it for you. I also wanted to ask all of you if you have had experience with using either Super Glue or seaweed in place of suturing a tear, or if you have other techniques to share with us. ~ Jan Tritten

A Different Approach to Tear Repair

I had the wonderful privilege of helping Lynn and Danielle have their second baby at home. To give a little history, Lynn and Danielle had their first baby in the hospital, 2-1/2 years ago, a little girl who was 7 lb. Danielle was induced—she was a week late and her doctor was going out of town.

From the start, the Pitocin drip caused the contractions to be very painful. Seven hours later, Danielle was pushing. She liked pushing a lot and said she felt she could "finally do something" during her labor. She pushed hard and had a long, big tear. She tore to her rectum, and has, even now, had problems with re-occurring rectal pain, bleeding and swelling.

Danielle initially went to another midwife (who has years of experience), while I prayed about attending and helping at the birth. I started doing the prenatal check-ups at 26 weeks. She had an unremarkable prenatal course. Two times, the fundal height was 1/2 to 1 cm higher, which can be normal.

Danielle also wanted to have a waterbirth and had her birth tub set up and filled in the warm kitchen. Danielle had lots of contractions and started her labor already at 4 cm, 100% effaced. The labor was totally opposite of her daughter's birth, in that the contractions were 5–7 minutes apart and were effective but not as intense. Danielle was in the birth tub several times, but each time the contractions would stop, so she decided to get out and take a shower. Along with the upright position, she felt the shower helped the labor.

Danielle was 9-1/2 cm with a cervical lip. The lip did not go back, as her baby's head was +1, and fitting in her pelvis. I had her squat and walk, but the lip was still there. She then wanted me to push the lip, during a contraction. It took two contractions for the lip to pass back over the baby's head.

Danielle then started pushing and did not feel the progress she had with her daughter. I then said, "Come here, I want to 'hang you.'"

And, with that, I got behind her and put my arms around her and held onto her wrists. When the contraction started I held her against my body and she squatted and even sometimes lifted her feet off the ground—literally "hanging," thus the name I gave the position.

After several contractions, the baby moved and then started to emerge and to start to crown. We did warm arnica compresses and gentle massage to stretch the perineum. Danielle was on her knees, her arms on a chair. She gently breathed the baby out and her perineum was intact until she got to the baby's ears. The baby "sat" on the perineum for a while until the contraction came, and then the shoulders were born and then the rest of this alert and aware baby boy came into his father's hands. Lynn and I had seen the perineum blanch and start to tear, as the baby's ears birthed, and I felt the tear had gotten deeper and longer with his shoulders.

In assessing the tear, most of the perineum tore down the old episiotomy line. Danielle also had a labial tear, like a stretch mark or a skin split. With Danielle lying down, and the bottom of the perineum being at a six o'clock position, she had a partial "letter c" tear at 7 o'clock, then the tear came over to 6 o'clock and then went down the old scar line, ending before the pucker of the rectum.

It was a mutual decision to not stitch this tear and to use old methods that had worked for me in my busy practice, when the choice was made to not stitch a tear. I froze gauze pads with arnica oil on them for the swelling, and used sterile strips on the perineum, on either side of the tear. The blood flow would help the strips to not stick to the tender area, but the perineum would still be held in place. I then used a 2-1/2 foot strip of 1/2-inch adhesive tape on the side of Danielle's buttocks, bringing the tape through the middle of her healing perineum, then placing the tape on the side of her other buttock. Because her buttocks "stood out" more than her perineum, the healing perineum was never taped or sore from tape, but her taped buttocks held the perineum tightly together. I also used a piece of thin rope to tie Danielle knees together, as a reminder for her to keep her buttocks together. Danielle had help, so she could lie down for two weeks, nurse her baby boy and just bond and heal. The first day the sterile strips fell off with the pad changes, and the 1/2-inch adhesive tape had to be replaced, but by day three the blood flow was down a lot and the changes could be done without the tape coming off. The stinging from the urine was almost gone and the bruising was going away. The perineum was staying together and the swelling was almost gone and her odor had a good, clean smell. The labial tear also was almost gone. These types of tears are painful in the beginning, with urination, but heal well and that "droopy, hang-dog" look goes away with healing. The labium pulls back up into its rightful position as it heals. There usually is not even a mark or scar.

Now, in the state of Ohio, if a parent wants a birth certificate, they must take the baby in to see a doctor so the baby is "verified" and the mom must be there, so the doctor can also be a witness to the mother. So Danielle had to make a trip in to see the doctor to be seen in this process of getting a birth certificate. I suggested to her to keep the little rope around her knees and to take little steps and to put her bottom into the car first and let her husband swing her legs into the car and she lifted the top portion of her body, while he put her legs into the car, then reverse the maneuver to get out of the car.

On the seventh evening after the birth, Danielle took a bath, as she had a deep tub to soak her breast that had clogged milk ducts. She had figured out a way to step into the tub and to step out and still keep her bottom together. I was visiting in the beginning every day and bringing good meals, then I came every other day and then, on the 11th day postpartum, the final day, I checked her bottom and we used a hand mirror to look together at the healing taking place and at the index fingernail-sized place that was still healing where the skin had torn. We had to spread her bottom a little bit to even see it. From the external view of Danielle's vagina and perineum, that tear could not be seen. It was internal. The tear resembled a thin piece of tissue, as if it had been shaved with a cheese shaver. This thin piece of skin had rolled together and resembled a hymeneal tag on the bottom side of the perineum. Danielle had said she wanted to look at her bottom and was delighted with the healing and felt the time was well spent in staying on her couch for those 11 days. She has decided to stay for the remainder of the two weeks and give her bottom three more days of downtime to heal, before her life gets busy again.

Danielle's other midwife was going to be in the area, four days postpartum, so she stopped by with an herbal remedy to help the healing process and also checked her bottom and said it was healing so nicely that Danielle did not need the herbal healing powder, which would have been sprinkled on her pad, to promote healing—yet! Thanks Frieda, for your help and encouragement. Danielle never had problems with having a bowel movement, or rectal pain, as she had in her first birth. She had been expecting some of the same problems and pain, but they never happened.

I have written this to encourage you and to teach you there are other ways to healing, for different people. I learned this method, when another of my mother's chose to not have a third degree tear sutured. Her doctor had stitched her so tight that relations with her husband had been painful and too tight. When she had the next baby, she had wanted to heal naturally to "get back" some of her normal tone and elastically. This was the mother who taught me another way—a way off the beaten path, but still a path, for her, to heal and as she had said to "right herself back into herself."

Mary Cooper

Editor's Note: To read more about alternatives to suturing, read Midwifery Today E-News 12:7.

Jan Tritten, mother of Midwifery Today, is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.

Jan's blog: community.midwiferytoday.com/blogs/jan/default.aspx
Jan on Twitter: twitter.com/jantritten
Midwifery Today on Facebook: facebook.com/midwiferytoday


Research

Dramatic Decrease in Global Maternal Mortality Rate

The British journal Lancet has published a study of maternal mortality rates (MMR) in 181 countries from 1980–2008 that shows the rate of women dying during pregnancy and childbirth have dropped dramatically over the past two decades.

The analysis shows countries around the globe are making progress toward the Millennium Development Goal 5, which calls for a 75% reduction in the world's MMR from 1990–2015.

The study found the global MMR has dropped from 422 deaths per 100,000 live births in 1980 to 320 in 1990 and 251 in 2008. More than half of all maternal deaths occurred in six nations—Afghanistan, the Democratic Republic of the Congo, Ethiopia, India, Nigeria and Pakistan.

Although the research shows only 23 countries are "on track to achieve a 75% decrease in MMR by 2015," some countries are progressing faster than others, including Bolivia, China, Ecuador and Egypt.

— Hogan, Margaret C., et al. 2010. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 12 April, early online publication doi:10.1016/SO140-6736(10)60518-1. Accessed 22 Apr 2010.


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Preserving Women’s Choices in Birth

Every woman deserves to have a choice about where she wants to birth. Kitty Ernst, the Mary Breckenridge Chair of Frontier School of Midwifery and Family Nursing, said that "it is really sad in this country that you can die anywhere, but only birth in a few places."

That is what midwives are about, and that is what we must work to preserve, that women can birth where and how they want to. Sadly, there are women who do not know that they have a choice. Many women buy into the medical community's script of fear.

I lead the charge in our hospital in the '70s to have my husband in the delivery room when my youngest child was born. I had already worked as a nurse in that labor room for years. We had to convince dear Dr. Carver that there would not be more time spent attending the father than her. I was lucky, I knew what I wanted, more than what I didn't want. Fetal monitors had been invented, but we did not have any on the unit for three more years. I had no interventions other than a horrible enema, which I could not convince my friend not to give me. Mothers were not allowed to hold their babies until they were bathed. So, Dr. Carver was shocked when I grabbed my beautiful baby girl from her hands to my chest.

What happened to our "natural childbirth" world? Where did this fear of birth come from? Where did what is best for the baby disappear? It all disappeared about the time anesthesiologist decided that no one should have any pain, and they could make lots of money preventing any feeling. We know it is not possible to have no pain in life, and that pain is part of growth.

Elaine Wakeland
Excerpted from "Choices," Midwifery Today, Issue 86
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Question of the Week Responses

Q: What was the longest second stage you've experienced, and how well did mother and baby pull through?

Midwifery Today staff

A: Marcie, 40 years old, had finally carried her first of eight pregnancies to term and I was her doula. Her caregiver was probably the best perinatologist in Northwest Florida. She had had a previous surgery for cervical cancer with significant scarring, and desperately wanted a normal vaginal birth. First stage passed relatively quickly—about six hours. The doctor came in on his day off to sit in the rocking chair in her room and just observe. She pushed for two hours and begged to be allowed to continue. His calm response was, "As long as you're okay and the baby's okay, it's your call—you can continue as long as you want to." Her husband and I worked as a team. I kept warm compresses on her perineum and he kept the warm compresses coming. Marcie pushed for another four hours, for a total of six hours, and achieved the vaginal birth she so wanted! Her baby boy weighed 7 lb 9 oz, was 19.5 inches long, with APGARS of 8 and 9. This was one gloriously happy mother! My thank you note to the perinatologist expressed my feeling that I had spent the day with a midwife.

— Helen Moore, CD (DONA), CIMI
Florida


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.


Midwifery Today Short Video Contest Announcement

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Entry Deadline is August 10, 2010, so get your creative gears spinning! Go here for more information and instructions.


Think about It

FDA Reviews Triclosan, a Common Ingredient in Body Care Products

The U.S. Food and Drug Administration (FDA) has updated its Web site, www.fda.gov, with information about triclosan, an antibacterial chemical that has become ubiquitous in antibacterial soaps, detergents and personal body products.

In January, Rep. Edward J. Markey, chairman of the House Energy and Commerce Subcommittee on Energy and the Environment, sent a letter to the FDA requesting information about the status of FDA's ongoing review of triclosan in consumer product.

The FDA is reviewing triclosan in light of animal studies that have raised questions about the drug's safety. The chemical has been linked to liver and inhalation toxicity and even low levels may disrupt thyroid function. For a list of products containing triclosan, go here.


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