|April 23, 1999|
Volume 1, Issue 17
|Midwifery Today E-News|
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"No force of mind or body can drive a woman in labor; by patience only can the smooth course of nature be followed."
- Grantly Dick-Read, natural childbirth pioneer
2) The Art of Midwifery Intact in the Hospital
Here's a couple of tricks of the trade I have learned from physicians on how to conduct a birth with an intact perineum in the hospital:
l. Forget those little gauze sponges and ask the nurse to bring in ten facecloths from the linen cart. She then puts some hot water from the tap in abeaker and applies gentle, hot compresses for the woman to push towardgently. If they are contaminated by any feces, the nurse can throw themunder the bed one by one as she goes through them. (They are removed later.)
2. Encourage the woman to hold and support her own tissues. Women instinctively slap any hand that is put on the crowning head. This is to be encouraged because it helps her stay in control.
3. The physician saying reassuring words such as "you are stretching beautifully," "there's lots of room for the baby to come through," and "I know this burning is intense but you're doing this nice and easy"--makes such a difference. Practice saying these phrases in the mirror so they come out easily.
- Gloria Lemay, British Columbia
It's natural for the baby to progress and regress over and over. This allows the perineum to stretch effectively. Then, massage the perineum with vernix from the baby's head.
- Dr. John Stevenson, Australia
Apply warm compresses everywhere on the woman's body so there is less focus on that one spot (the perineum). The woman relaxes, the midwife relaxes.
- Naoli Vinaver, Mexico
At Midwifery Today, we have lots of tricks up our sleeves! Purchase our two volumes of Tricks of the Trade and you'll see what we mean: Save $5 when you purchase both Tricks of The Trade Volume
3) News Flashes
Anal Sphincter Injury
Injuries to the anal sphincter during vaginal deliveries are surprisingly common and may cause fecal incontinence, according to national and international researchers. It has been noted that one fifth of women suffered injuries to the anal sphincter muscle during vaginal deliveries.
In routine postnatal follow-up examinations patients are rarely asked specifically about incontinence problems, and they are unlikely to mention them without prompting. Scarring during the healing process can adversely affect the success of initial repairs to the sphincter, contributing to the high rate of incontinence in these cases.
Practitioners should include questions about incontinence problems in routine postnatal follow-up examinations and, when forceps are used in delivery, refer mothers to a colon and rectal surgeon for follow-up.
Standard therapies, including biofeedback and surgery, are effective in about 80 percent of cases, and new surgical procedures to repair or replace severely damaged anal sphincter muscles offer hope to the remaining 20 percent.
- Birth, September 1998
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4) Preparing the Perineal Tissues
Prenatally, a well balanced diet of enough proteins, fresh fruits and vegetables and very little refined foods is critical to the integrity of the perineal muscles and tissues. Well hydrated and oxygenated tissues promote elasticity and quick healing. Women should drink a minimum of eight glasses of filtered water a day. Adequate fat intake is also important for skin suppleness and elasticity. Supplemental alfalfa tablets contain vitamins A, B-12 and D as well as calcium and phosphorus. Vitamin E (200-400 IU) taken daily with foods or drink containing fat will aid in the absorption. Also, daily intake of vitamin C (1000-2000 mg) will help circulation and tissue elasticity. Red raspberry tea is wonderful for relaxing and helping the entire pubococcygeal area to be supple, especially toward the end of pregnancy.
Greater oxygenation of tissues is not only accomplished by diet, but with exercise by increasing circulation. Athletes train their bodies and prepare the appropriate muscles for their athletic event. The pubococcygeal muscles need to be toned and exercised as well. These muscles, also known as the pelvic floor muscles, form a hammock to support all the woman's internal organs and surround the urethra, vagina and rectum. The toning of the pelvic floor enhances its integrity for life and will help prevent sagging organs later in life. Walking, squatting, duck walking, pelvic rocks, tailor sitting, kegels and swimming are all useful exercises.
- Renee Stein, "Perineal Tears," Midwifery Today Issue No. 33
5) Protecting the Upper Tissues
Years ago I learned a technique that has proven effective in preventing both upper structure damage and perineal laceration. While using this technique the midwife encourages the baby's head to flex (tuck) as it descends to the pelvic floor and keeps it well flexed until the entire occiput is delivered.
With one hand supporting the perineum, I use the other hand to "take hold" of the baby's head toward the occiput as it presents, guiding it under the pubic bone by sort of push/pulling it down and out with the strength of the contraction (and the mother's voluntary effort if needed) behind it. Viewed from the front, added pressure appears to be placed on the perineum, but actually the pressure is directed across the head, encouraging the chin to tuck in nicely. If the baby is big, or the mother's vulva very engorged or varicose, or if she has a cystocele or urethrocele, I usually slip a finger on either side of the urethra and again guide the baby's head under the pubic bone as the contraction pushes outward. This variation squeezes the midwife's fingers between the head and the pubic bone but greatly reduces the incidence of severe bruising, laceration and structural damage of the area.
If the baby is persistent posterior, I reverse the procedure by flexing the
head outward toward the pubic bone, thus seeking to reduce the diameter of head
that the outlet has to accommodate. In this presentation the baby's forehead is
the "hard part" most likely to jeopardize the upper structures.
To effectively employ this technique, I apply about half as much pressure through my fingers (guiding the occiput under the pubic bone and out) as the contraction and mother's effort apply outward. Additionally, it is essential to visualize, understand, and feel what's happening with the baby's skull, the woman's pelvic outlet, and her soft structures and respond accordingly.
Apart from protecting maternal tissues, this technique prevents a baby from getting caught behind the pubic bone and is most useful in effecting a rapid delivery in cases of fetal distress.
I also try to protect the urethra and clitoris by encouraging the shoulders to deliver one at a time. I usually try to ease the anterior shoulder out first. I lift the baby's head slightly as the second shoulder is more likely to "spurt out." In the case of nuchal arms, which tend to be posterior, maternal trauma can be minimized if total diameter has been reduced by delivery of the first shoulder.
Use of the flexing technique coupled with controlled shoulder delivery will result in less pain, less need for catheterization and extensive repair, and generally more comfortable postpartums, all of which result in happier mothers and families.
- Cat Feral, excerpted from "Protecting the Upper Tissues," Midwifery Today Issue No. 5, Winter 1988
Learn more from these Midwifery Today issues:
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6) Question of the Week: What is your protocol for premature rupture of membranes?
Why? Send your response to:
7) Question of the Week Responses
Q: At what rate in your practice do babies pass meconium before birth, not counting breeches? Are your statistics from a homebirth practice or hospital practice?
I recently finished my 1998 statistics and was surprised to find only 2% of my clients had meconium stained fluid. I am a CNM who does home, hospital and birth center births. I had no transfers for meconium but I carry the necessary equipment for meconium and only transport for thick meconium with fetal heart rate abnormalities.
Ten out of 62 hospital births, 8 of these light staining, suctioned with bulb syringe on perineum before birth of shoulders.
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Some suggestions I believe worked for me to prevent perineal tears: perineal massage (done by either your midwife or partner twice a week for 5-10 minutes each time during the last two weeks of pregnancy), having a waterbirth (water moistens the perineum), and focusing on keeping your vocal energy at more bass tones instead of high tones (low tones tend to help the cervix oooopen, as high or piercing tones tend to make the cervix shut).
- Grace S.
I have tried for over a year to obtain hospital privileges in northern
Do E-News readers have suggestions for up to date statistics, information, etc.
for convincing an administrator of a hospital that they need midwives?
- Shauna Zerhusen
[ Last week's Quote of the Week] makes sense to me but in a law court a lawyer will expect me to back my opinion with scientifically valid data or I'll be crucified--so these sentiments are only OK until something goes wrong. Also, people with these sorts of results [regarding outcomes of tubal ligations as described in News Flashes, Issue 16] should quit and do something else. My figures are 1 in 3,000--safer than any other, reversible method.
- Phil W.
This past month we had two clients transfer into our care from local obstetricians. Both were told by their doctor that they had strep B and would have to have IV antibiotics in labor. The doctors made this assumption based on urine screens. We did vaginal cultures on both and came up negative. I can't figure out why doctors would think that urine screens are a valid way to test for strep B. I am wondering if anyone has more information or an explanation for why they would have screened this way.
To answer Mischa [Issue 17], I am an assisted study student with Utah College of Midwifery. I'm about half way through their program and I like it very much! The course work is very clear, easy to understand and relevant. Marilyn Skosen, the assisted studies director to whom students send all course work, is very helpful, prompt and knowledgeable. The college is accredited by MEAC and will prepare you for NARM. They have a skills conference each year that's great. I recommend them highly!
>From Discover magazine, December 1995: A group of researchers at the National
Institutes of Health has found evidence for a more specific cause of postpartum
blues. New mothers, the researchers say, have lower than normal levels of a stress
fighting hormone that earlier studies have found help combat depression. When
we are under stress, the hypothalamus secretes
During the last trimester of pregnancy, the placenta secretes a lot of CRH. The rise of CRH levels in the maternal bloodstream increases threefold. "We can only speculate," says the endocrinologist who led the NIH study, "but we think it helps women go through the stress of pregnancy, labor, and delivery."
But what happens after birth after the placenta is gone? The researchers monitored CRH levels in 17 women from the last trimester to a year after they gave birth. All the women had low levels of CRH--as low as seen in some forms of depression--in the six weeks following birth. The seven women with the lowest levels felt depressed.
It was thought that CRH levels are temporarily low in new mothers because CRH from the placenta disrupts the feedback system that regulates normal production of the hormone. During pregnancy when CRH levels are high in the bloodstream, the hypothalamus releases less CRH. After birth, however, when this supplementary source of CRH is gone, it takes a while for the hypothalamus to get the signal that it needs to make more CRH.
My Personal Findings: When I was pregnant with my first, I found out my family had a mild history of PPD, so I took interest. It was my conclusion that since cortisol levels were low after birth, I should supplement with cortisol. I discovered there was no such thing on the market--and then it hit me. Other cultures traditionally ingest the mother's placenta or fertilize their garden with it. In this way the mother can ingest her own cortisol and CRH, possibly avoiding PPD (along with better health and social support). Since Americans as a rule view ingesting placentas as repulsive, I came up with a "friendly" way of getting the placenta into the mothers body:
Slice the placenta thin, dry it out, grind it to a powder, encapsulate the placenta powder and have the mother swallow the capsules.
- Amy Jones
Amy, I also wonder how your birth went. It seems that homebirth midwives have significantly less postpartum depression in their caseloads. Because hospital birth is generally so much more stressful, it must affect the hormones. Breastfeeding also must have much to do with decreasing or alleviating depression.
There is so much overall depression in American life. How much of it is left from birth trauma? It has also been noted that many women suffer post traumatic shock syndrome after giving birth. Because of the need to get on with their lives they just bury their emotions. But the emotions don't go away; they just lie festering.
There are so many reasons to change the way the world is birthing. My homebirths were the absolute highs of my life. Since then I have worked hard to help as many moms experience this feeling as possible. Motherhood is a most creative and wonderful path and birth is the door that opens onto it. I am sad that so many are missing this incredible joy.
- Jan Tritten, Midwifery Today founder & editor
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9) Coming E-News Themes
Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:
- International Midwives' Day (April 30)
We look forward to hearing from you very soon! Send your submissions to firstname.lastname@example.org. Some themes will be duplicated over time, so your submission may be filed for later use.
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