June 18, 1999
Volume 1, Issue 25
Midwifery Today E-News
“Episiotomy”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Third and Fourth Degree Tears
5) Length of Second Stage
6) Episiotomy: Its Ritual Function
7) Question of the Week Responses
8) Coming E-News Themes
9) Coming E-News Themes

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1) Quote of the Week:

"Apparently God, who could make a tree, knew not how to make a perineum."

- Dr. Herbert Ratner

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2) The Art of Midwifery

Do Nothing

Many birthing women experience a respite at the beginning of second stage. I believe their bodies are resting for the big push. My favorite trick is to do nothing and let Mother Nature give her the gift of rest. This in turn can prevent exhaustion, hemorrhage, and other problems women may have when they are told to push right at 10 centimeters. If hospital personnel would routinely recognize this resting phase, many moms would not be hastened toward delivery, nor would birth be increasingly engineered by the use of drugs.

- Jill Cohen

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3) News Flashes

Closed Glottis Pushing There is no clear evidence that closed glottis pushing (Valsalva's maneuver) shortens second stage, decreases fatigue or minimizes pain. It has otherwise been suggested that bearing down for a prolonged period with a closed glottis alters the contractile pattern of uterine smooth muscle, leading to inefficient contractions and failure to progress. Studies suggest that consideration be given to encouraging women to believe in their ability to push the baby out of their own volition. A variety of studies published between 1992 and 1996 show that physiological effects of Valsalva's maneuver can include: impeded venous return; decreased cardiac filling and output; increased intrathoracic pressure; affected flow velocity in middle cerebral artery; raised intraoccular pressure; changed heart action potential/repolarization; increased artierial pressure up to 480/350 mmHg; increased peripheral venous pressure; altered body fluid pH, which contributes to inefficient uterine contractions; decreased fetal cerebral oxygenation.

- Nursing Times 95:15, April 15, 1999

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4) Third and Fourth Degree Tears

In 1989, James M. Thorp and Watson Bowes, Jr. reported their review of the literature on episiotomy. They summarized twenty-five studies of how often third- and fourth-degree tears happened. In nearly 50,000 women who had episiotomies, 6.5 percent had third- or fourth-degree tears. In nearly 39,000 women who did not have episiotomies, 1.4 percent had similar tears. Women with episiotomies had almost five times as many severe tears as women without episiotomies. Thorp and Bowes concluded that routine episiotomy is not supported by the evidence, and "may well increase the incidence of third- and fourth-degree lacerations." [from "Episiotomy: can its routine use be defended?", Amer J of Ob & Gyn, 160(5), May 1989]

- Diana Korte & Roberta Scaer, A Good Birth, a Safe Birth, Harvard Common Press 1992

Midwifery Today is looking for a dedicated staff member to work full time on advertising, marketing and Internet activities. Must live in area of or move to Eugene, Oregon. Must be organized, outgoing and comfortable on the phone. Dedicated to helping Midwifery Today grow and flourish. Computer skills (PC) necessary. No benefits except job flexibility, knowing you are changing the world for mothers and babies, and working with wonderful women. Starting pay $8.00 per hour. Eugene has great alternative and birth communities with a midwifery school here and in Portland, study groups and all kinds of midwives, doulas and childbirth educators.

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5) Length of Second Stage

[A] presumed benefit of episiotomy is to protect the baby from the adverse consequences of an extended second stage of labour, including lack of oxygen and trauma to the head, which has been said to lead to cerebral palsy and mental retardation.... The importance of the length of the various stages of labour and birth is still debated, raising doubts about the advisability of a policy favouring fast labour. Research that has tried to show that a longer second stage of labour is bad for the baby has failed to find this result or has been poorly designed, with questionable interpretation of results. Conversely, some studies suggest that speeding up the second stage may be bad for the baby but... data are insufficient. In summary, "There is no evidence to suggest that, when the second stage of labour is progressing and the condition of both mother and fetus is satisfactory, the imposition of any arbitrary upper limit on its duration is justified. Such limits should be discarded." (Sleep, J. et al, 'Care during the second stage of labor,' in "Effective Care in Pregnancy and Childbirth.") Studies of [cerebral palsy and mental retardation] suggest that they originate for the most part before labour and birth. Neither of the two clinical trials which looked at this issue found any evidence that episiotomy reduces trauma to the fetal head. No surgical procedure, even one that seems rather trivial to the people who perform it, should be widely used without convincing evidence of benefit. As yet, no published study adequately proves the claimed benefits of episiotomy.

- Marsden Wagner MD, Pursuing the Birth Machine, Ace Graphics 1994

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6) Episiotomy: Its Ritual Function

[Medical anthropologist] Robbie Davis-Floyd observes that surgery holds the highest value in the hierarchy of Western medicine, and obstetrics is a surgical specialty. Episiotomy transforms normal childbirth--even natural childbirth in a birthing suite--into a surgical procedure. Davis-Floyd also points out that episiotomy, the destruction and reconstruction of a woman's genitals, allows men to control the "powerfully sexual, creative, and male-threatening aspects of women." It... partially explains why most trails of episiotomy have been done in European countries where normal birth is conducted by female midwives, not in the U.S. or Canada where birth is conducted (until recently) by male doctors: women are not subconsciously threatened by birth. In short, routine episiotomy has a ritual function but serves no medical purpose. If any reader believes otherwise, I challenge him or her to find a credible study done in the past 15 years that supports that belief.

- Henci Goer, Obstetric Myths Versus Research Realities, Bergin & Garvey 1995

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7) Question of the Week Responses

Question:

Is there any evidence that laboring in the tub after the bag of water has broken increases the rate of infection in mother or baby? I have been unable to find any research to indicate this is so, but every nurse, doctor, and even a couple of midwives are convinced that this is so. What's the real story? Fact or theory?

- Amy Jones, Henderson, NV

I have a paper, "Water Birth: One Birthing Center's Observations," Linda K. Church, CNM, RNP, published in 1989 by Elsevier Science Pub. Co., Inc., which states on Page 169, "As of June 1, 1989, there have been 1,335 births at the Center.... Infection rate:

1. This multipara had been in the water for eight minutes when she experienced spontaneous rupture of membranes with the birth of the head. The body was born with the next contraction. She became febrile (102 degrees F) with moderate uterine tenderness 48 hours after birth and was managed with Amoxcillin orally as an outpatient."

- Kathy Corzine, KACorzine@aol.com

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Many viruses and bacteria seem to like a waterborne environment, especially one that is heated to body temperature or above. Broken waters mean there is no protective membrane surrounding the baby and potentially the water could travel up into the vaginal tract to the baby. Many feel, however, that the anatomy of the body does not allow water to enter the vaginal canal except during vaginal exams. Many midwives are comfortable with a woman staying in the water once the membranes break as long as labor is rolling along. Many will recommend vitamin C and echinacea to help boost the immune system and fight off infection. Do you feel secure that your tub was clean before use and that the water has not become a potential breeding ground? Use your own judgment!

- Tania

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I am a new CNM presently working in the hospital where I worked as an L&D nurse for several years before going to midwifery school. We have Jacuzzi tubs in all five labor rooms. We have always put women in labor with ROM in the tub! We have no increased infection rate. We started back in the early '90s with one tub put in at a midwife's request. It was intended for labor only, but over the years births in the tub have not only become acceptable but they are common. We have not published any statistics, but I can assure you we do not have increased infection rates. The process of labor and the downward flow of fluids with regular contractions may have something to do with it. We don't put women in the tub if they have ROM and no labor, but that is because they have no need for the tub if they aren't in labor yet. The name of the hospital is Hudson Valley Hospital Center, in Peekskill, New York.

- C. G., CGallag108@AOL.com

Following are a couple of citations that showed no increase in infection with baths after rupture of membranes.

- Jane Helwig, MD Acta Obstet Gynecol Scand 1996 Aug;75(7):642-4: Warm tub bath during labor. A study of 1,385 women with prelabor rupture of the membranes after 34 weeks of gestation. Eriksson M, Ladfors L, Mattsson LA, Fall O: Department of Obstetrics and Gynecology, East Hospital, University of Goteborg, Sweden.

BACKGROUND:

To evaluate the influence of a bath on infectious morbidity in mothers and neonates in women with prelabor rupture of the membranes after 34 weeks of gestation.

METHODS:

A nonrandomized study of 1385 healthy women. During the first stage of labor 538 women wanted a bath while 847 did not. The women awaited spontaneous contractions up to 24 or 72 hours after the membranes had ruptured before labor was induced with oxytocin. Digital examinations of the cervix were avoided until onset of active labor or until the time induction was planned. For statistical analysis Fisher's exact test was used.

RESULTS:

Chorioamnionitis during labor occurred in 1.1% of the women in the bath group and in 0.2% in the reference group (p = 0.06). Postpartum endometritis was found in three cases both in the bath group (0.6%) and in the reference group (0.4%) (p = 0.68). The frequency of neonates receiving antibiotics was 3.7% and 4.8% respectively (p = 0.43).

CONCLUSION:

A tub bath did not increase the risk of maternal or neonatal infection after premature rupture of the membranes and prolonged latency. Birth 1996 Sep;23(3):136-43: The effects of whirlpools baths in labor: a randomized, controlled trial. Rush J, Burlock S, Lambert K, Loosley-Millman M, Hutchison B, Enkin M

BACKGROUND:

Showers and tubs in labor were not generally used in our center. When three whirlpool baths (Jacuzzis) were ordered as part of our renovations, a randomized, controlled trial was initiated to explore their effects on narcotic and epidural requirements.

METHODS:

This study employed an intent-to-treat design, and the sample size was estimated to account for the fact that some women would be unable to use the tub. The experimental group of 393 women was offered the tub during labor and the control group of 392 women received conventional care.

RESULTS:

No births occurred in the tub. The tub group required fewer pharmacologic agents than controls (66% vs 59%, p = 0.06), experienced fewer deliveries by forceps and vacuum (p = 0.019), and were more likely to have an intact perineum than the standard-care group (p = 0.019). Labor was longer for the tub group (p = 0.003), who coincidentally were more primiparous and in earlier labor on admission. No differences were noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes. A subset of mothers expressed satisfaction with the tub experience and labor support. The cesarean rate among both groups was lower (8.9%) than our overall rate (16.6%) during the study period.

CONCLUSIONS:

Whirlpool baths in labor have positive effects on analgesia requirements, instrumentation rates, condition of the perineum, and personal satisfaction. Further study is being planned. (Abstracts from PubMed, the on-line free National Library of Medicine literature search Web site:

http://www.nlm.nih.gov/nlmhome.html)

Please feel free to submit a Question of the Week! Send it to mtensubmit@midwiferytoday.com

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8) Switchboard

I'm going to be a boring midwife and say the usual but still not widely practised *there is no place for episiotomy in normal birth.* I am happy to say that I have not cut an episiotomy since my hospital training. Women do tear but only as much as they need, if they need to. I have had no 3rd degree tears. I know that the critics will cry that I have a select client group and that explains away any good outcomes from any homebirth experience, but I don't believe that serious tears or the "need" for an episiotomy has anything to do with place of birth or socio-economic groups. Additionally I have not had any cases of infection after I have repaired a tear and no reports of discomfort once the tear is healed when sexual intercourse is resumed. Conversely I have worked with more than 20 women who have had episiotomies with their previous birth and have needed healing work to get over the pain they experience still as a result of their episiotomy. This is my experience, after eight years as a homebirth midwife, from a group of more than 100 women.

- Sally Westbury, homebirth midwife, salute@geelong.hotkey.net.au

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Educating the Public:

Citizens for Midwifery (CfM) is a tax-exempt grassroots organization of volunteers whose goal is to see the Midwifery Model of Care universally recognized as the optimal kind of care for pregnancy and birth, and available to all childbearing women and their families. CfM has an extensive web site with many resources and links, consults with people regarding grassroots organizing, legislative efforts and other projects, and publishes a quarterly newsletter that supports advocates of the Midwifery Model of Care (referring to the definition by MANA, MEAC, NARM and CfM) and other literature.

Our "Public Education Packet" is available for the asking (free, though a donation is always appreciated; $4 covers costs).

This packet includes tips on how to think about and plan public education projects, as well as suggestions and examples of many kinds of projects. Some are very simple and easily done; others are more complex and might require an organized group and a substantial investment of time and money. There are also fact sheets, fliers and other items available through the web site. CfM board members are also available for consultation, suggestions and trouble-shooting, and may have additional resources that are not yet on the web site. The July issue of the CfM News will include an article about techniques of persuasion that anyone can easily learn; these can help you be more effective in changing someone's mind about birth and midwifery. The latest CfM project is a brochure about the Midwifery Model of Care. It is aimed at people who perhaps have heard about midwives but don't know much, and it provides information in an inviting way that would help a person understand what is meant by the "Midwifery Model of Care" and be able to identify healthcare providers who give this kind of care. This brochure should be available by the end of the summer. CfM literature is available to everyone, whether you are a member or not. CfM is a membership organization especially for consumers, but everyone is welcome.

Please see the web site for the text of the CfM brochure and the membership form, and contact us with any questions.

- Susan Hodges, president,
Citizens for Midwifery, PO Box 82227, Athens, GA 30608-2227, 1-888-CfM-4880;
cfmidwifery@yahoo.com
http://www.cfmidwifery.org

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I'm looking for information on the relationship between fibroids and diet, specifically soy products. Is there a link between soy intake and estrogen production? Which foods affect fibroid growth and what would be a great diet for a vegetarian mom in terms of protein?

- Merwife, San Rafael

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Does anyone know of a deaf midwife? I have a deaf applicant for midwifery school and she would like to know if there are any others she can connect with. Contact midwife3@aol.com

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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:

- autonomy (June 25)
- is breastfeeding a feminist issue? (July 2)
- Group B Strep (July 9)
- homebirth (July 16)
- epidurals
- breastfeeding
- waterbirth
- breech birth
- nutrition

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.

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