February 28, 2002
Volume 4, Issue 9
Midwifery Today E-News
“Intact Perineum”
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MEET THE PRACTITIONERS WHO HAVE LONG INSPIRED YOU. Midwifery Today conference teachers always make time to get to know registrants! Meet Michel Odent, Nancy Wainer, Marsden Wagner, Jan Tritten, Penny Simkin and many others at the Philadelphia conference, March 21-25, 2002. Look for the conference program and all the general information, including status of CEUs, on the Midwifery Today Web site:


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Guangzhou, Guangdong, CHINA:

"Healthy Birth" June 7-9, 2002

Get the full program online:


The three-day conference will have components of Midwifery Today conferences as well as the presentation of several papers. Chinese doctors have been asked to arrange for midwives to be present as well as doctors, and it has been noted that we are interested in Chinese medicine. A hospital focused on the practice of Chinese medicine is located across the street from Shamin Island, where our venue is located.


"Revitalizing Midwifery" November 13-17, 2002

A two-day midwifery education conference precedes three days of international conferencing.


Send submissions, inquiries and responses to newsletter items to mtensubmit@midwiferytoday.com


In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Intact Perineum
5) Check It Out!
6) Midwifery Today Online Forum: Doula Books
7) Question of the Week: Group B Strep
8) Question of the Week Responses: Bipolar
9) Switchboard
10) Connections


1) "Women today not only possess genetic memory of birth from a
thousand generations of women, but they are also assailed from every
direction by information and misinformation about birth."

- Valerie El Halta


2) The Art of Midwifery

For pregnant women who need calcium: The best calcium herbs are oat straw, borage and bancha twigs. Bancha twigs are LOADED with calcium. Another thing very high in calcium is hijiki seaweed. A half-cup has about 1,400 mg. of calcium! Pregnant women should also make sure they're ingesting a fat/oil of some sort within an hour or so since calcium binds with fat/oil in the stomach and assimilates this way.

- Raven


3) News Flashes

Young women who exercise regularly and use oral contraceptives may not get the boost in bone strength seen in women who exercise and do not use oral contraceptives. A recent study showed that while regular resistance training and aerobic exercise over a two-year period strengthened bones in women aged 18 to 31, oral contraceptives appeared to prevent the buildup of bone density. The findings suggest that women who take oral contraceptives may be compromising their chances of attaining peak bone mass, according to Dr. Connie M. Weaver of Purdue University. Women who did not use oral contraceptives had higher bone mineral content at skeletal sites throughout their body at two years compared with women who used oral contraceptives.

- Medicine & Science in Sports & Exercise 2001 33:873-880


New Zealand College of Midwives
7th Biennial National Conference

Celebrating Diversity within Unity
4-6 July 2002
Dunedin Centre, Dunedin, New Zealand

Pre-conference workshop, 3 July 2002, featuring internationally renowned speakers:

- Beatrijs Smulders, Midwife from The Netherlands
- Wendy Savage, Obstetrician from the United Kingdom

For further information contact:

Mary Whitham, Convener Phone - 03 466 7945
E-mail: marywhitham@hotmail.com


4) Intact Perineum

An intact perineum is the goal of every birthing woman. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant. The intact perineum begins long before the day of the birth. Sharing what the feeling of a baby's head stretching the tissues will be like and warning the mother about the pitfalls in pushing will go a long way to having a smooth passage for both baby and mother. The woman will be receptive to conversations in prenatal visits about the realities of the birth process. Here is the information I convey for the second stage:

1. When you begin to feel like pushing it will be a bowel movement-like feeling. We will not rush this part. You will tune into your body and do the least bearing down possible. This will allow your body to suffuse hormones to your perineum and make it very stretchy by the time the baby's head is there.

2. The feeling will increase until it feels like you are splitting in two and it's more than you can stand. This is normal, and no one has ever split in two, so you won't be the first. Because you have been educated that this is normal, you will relax and find this an interesting and weird experience. You may have the thought, "(My
midwife) told me it would be like this, and she was so right. I guess this has been going on since the beginning of humankind."

3. The next distinct feeling is a burning, pins-and-needles feeling at the opening of the vagina. Many women describe this as a "ring of fire." It is instinctive to slap your hand down on the now-bulging vulva and try to control where the baby's head is starting to emerge. This instinct should be followed. It seems to really help to have your own hands there. Sometimes women like to have very hot cloths applied to their perineum at this point. If you like or dislike the feeling, say so.

4. Most women like pushing more than dilating. When you're pushing, you feel like you're getting somewhere and that there really is a goal for your efforts.

5. This is a time of great concentration and focus. Extraneous conversation will not be allowed in the room. Once you begin feeling the ring of fire, there is no need for hurry. You will be guided to push as you feel like until the baby is crowning. All that will be touching your tissues is the hot cloth and your own hands. It is important for the practitioner to keep her hands off because the blood-filled tissues can be easily bruised and weakened, which can lead to tearing.

6. The point of full crowning is very intense and requires extreme focus on the burning. It is a safe, healthy feeling but unlike anything you have felt before.... Panting and rising above the pushing urge will help you focus, and you will have less discomfort in the long run.

7. You will be offered plain water throughout this phase because hydration seems to be important when pushing. You can take the wateror leave it.

8. Once the head is fully born, you will feel a great sense of relief. You will keep focused for the next sensation, which will bring the baby's shoulders out and the baby's whole body will quickly emerge after that with very little effort on your part. The baby will go up onto your bare skin immediately, and it is the most ecstatic feeling in the world. Your perineum may feel somewhat hot and tender in the first hour after birth. The remedy that helps the most is to apply very hot, wet cloths. This is in keeping with the Chinese medicine theory that cold should never be applied to new mothers or babies. Women report they feel instantly more comfortable when heat is applied, and any swelling diminishes rapidly.

I also like to twist a diagonally folded bath towel into a very tight roll and coil that into a ring for the woman to sit on when breastfeeding.

- Gloria Lemay, "Midwife's Guide to an Intact Perineum," Midwifery Today Issue 59


ORDER MIDWIFERY TODAY ISSUE 59 AT http://www.midwiferytoday.com/products/MT59.htm


5) Check It Out!

A Web Site Update for E-News Readers



Tear Prevention and Alternatives to Suturing

Tear Prevention Techniques from Around the World

Traditional Approaches to Second Stage


Want healthier babies and easier births?

Order BIRTH WISDOM, TRICKS OF THE TRADE, VOL. 3, and you'll learn tricks and tips from practicing midwives, childbirth educators, naturopaths, doulas and parents. Topics include philosophy of care, remedies, prenatal, labor and postpartum.

To order BIRTH WISDOM, click here: http://www.midwiferytoday.com/products/01TT3.htm



We have chosen numerous informative, supportive, fascinating articles for Midwifery Today Web site visitors to read.



5) Midwifery Today's Online Forums

What are everyone's favorite books about supporting women during their births? I have read The Birth Partner by Penny Simkin and enjoyed it, but feel it's really geared toward dads.

- Anon.


Go to our forums to share your thoughts and experience.


6) Question of the Week

Q: A friend was just diagnosed, by urinalysis, with Group B strep. She is planning to have her baby at home (this will be her third successful homebirth). She has been told she will need IV antibiotic intrapartum. Is it safe to have a homebirth and if so what precautionary measures should be taken? She is due March 20.

- Colleen


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line.



The Farm Midwifery Workshops, taught by Ina May Gaskin and The Farm midwives, strive to teach the skills and knowledge you will need to make the birthing environment safe, pleasant, and responsive to the needs of women and their babies. For more information with dates, curriculum, and fees, write to us:


The Farm Midwifery Workshops
P.O. Box 217
Summertown, TN 38483


7) Question of the Week Responses

Q: My daughter is 18 and just discovered she is about 9 or 10 weeks pregnant. She has bipolar disorder and was on Depakote ER 1,500 mg, which we know can cause birth defects, specifically neural tube defects. She stopped taking her med's as soon as she suspected she might be pregnant (at about 8 weeks). She is taking prenatal vitamins with folic acid to try to help the situation, if such a thing is possible. Is there anything else she should be taking to help with this? Can she deliver with a midwife out of hospital or should she go to a hospital for birthing? If there are any birth defects, what can she expect to happen at delivery?

- Anon.


A: I served a bipolar mom who gave birth at home. She went off med's before she hired me. She went through many mood swings, repeated herself often and had to be counseled often, but nothing outrageous happened as is often portrayed. She needed praise, trust and as much info as she could get. This super-intelligent woman had a great pregnancy and ate well, although she had a few bouts of high anxiety, mainly from a boyfriend who wasn't at home much and drank often. She birthed a 9 lb., 8 oz. baby after many days of prodromal labor. She lost herself a few times in labor screaming and letting energy out, but nothing abnormal about that - she just needed to let go. It took some time for her to birth the head; baby was a mild dystocia but was perfect in 2 minutes.

I think if she had had a hospital birth, she would have been violated many times. She would have been pressured to have an epidural to "shut her up," and I think she would have had an "episode" from the trauma. She planned to take something in the upcoming months after the birth, but wanted to give baby breastmilk for some time, so held off. She did much research on the 'net to find out what would work best. She did confess that she smoked marijuana 2 to 3 times during her bad times in pregnancy. I assume she had planned to use it after birth only if absolutely necessary, until she could go back on med's.

- Midwife


I am bipolar and take Depakote. I was taking it before each pregnancy (I have five children), and they were all just fine. The doctors will look for things throughout the pregnancy using ultrasound and other tests to know if something could be wrong. But as long as she has stopped taking it, she should be fine!

- Carmen Rae


A: It is important to remember that just because a drug "CAN" cause birth defects doesn't mean that it will. It just means there is a higher risk of this rare problem. Fortunately neural tube defects are easily detected in pregnancy. There are several screening procedures your daughter can use to find out if all is well. Only "IF" you see a problem would it be worth worrying about where the baby should be born. At this point in pregnancy, there is no reason why your daughter should not be able to begin prenatal care with a midwife in the anticipation of a homebirth -- unless problems become apparent later in the pregnancy.

- Gail Hart, midwife


A: Unfortunately, neural tube closure happens during the days in the first week after that first missed menstrual period. Taking folic acid at eight weeks will not make any difference in preventing neural tube defects, although less well-documented potential benefits such as a possible reduction in lip and palate abnormalities makes continuing with the supplementation a good idea anyway.

At this point I would recommend she inform herself on options for prenatal diagnosis of neural tube defects. The easiest of these is a blood test for maternal serum alpha feto-protein which is drawn at 16 weeks and, when elevated, picks up 80 percent of spinal defects and 95 percent of brain defects of the neural tube defect category. (Just remember most women with an elevated result have perfectly normal babies. It is a screen for the defect, not a diagnostic tool. So an elevated result does not mean there is something wrong with the baby most of the time. Nor does a normal result guarantee the baby is fine.) MSAFP screening in combination with fetal assessment by ultrasound is the best option for prenatal diagnosis of neural tube defects. If the baby is fine she can then deliver wherever she chooses.

If a defect is present, she will then have the option of deciding to terminate the pregnancy, trying to arrange one of those new experimental in utero repair surgeries, which seem to have good outcomes, or planning the birth that will best care for and protect the baby. If she were to carry a baby with a neural tube defect to term, there are advantages to knowing in advance of the birth. These include: arranging for a c-section delivery if that is determined to be best for the baby; an earlier delivery if the baby develops hydrocephalus (a common problem in babies with spina bifida); birthing in a center that specializes in the surgical procedures that close the open defect of the spine after birth. This way she can remain with the baby throughout the recovery period. She can also arrange for support and prepare herself mentally for the stress she will experience.

Let's hope that her baby is fine and that the neural tube has closed perfectly and no other part of the baby's system has been affected. In the meantime she has to take care of herself and continue on med's for her bipolar disorder that will not affect the baby. She will need careful monitoring by someone familiar with both pregnancy and bipolar disorder or two people who can work closely together for her and her baby's benefit.

- Natalie Bjorklund


A: It is wonderful that your daughter is taking a naturopathic approach to her unborn baby's health! And your support is an added positive element. Yes, other preventatives may help with good development of her baby. One of them is zinc. When we take it in a water-soluble form and with a little vitamin C, the amount the body needs is easily absorbed. Zinc helps brain development and is considered helpful to prevent brain defects and other developmental anomalies. Also the usual supplements: B vitamin complex (brown rice based) along with the folic acid and a good calcium/magnesium (citrate or a water soluble form), etc., not only help with baby's development but also the well being of the mother during (and after) pregnancy. There is no need to overdo any one supplement, which can be harmful. A balance of good foods and a little extra supplementation on a regular daily basis is of great benefit. Even if she may not have a homebirth for some reason, I would certainly employ a very nutrition-knowledgeable midwife during the prenatal period. This kind of prenatal care has shown to be one of the reasons for better outcomes. She might wish to consider a naturopathic physician for the bipolar condition as well, to help achieve healthful, confidence-building results. Whatever your choices, positive thoughts will also be very helpful.

- Julia


A: Several issues in your letter need to be addressed: The increased risk of neural tube defect with Depakote use is 1 to 2 percent, about the same as in someone with a family history of neural tube defect. The risk is when women take the medication between days 17 and 30, during formation of the neural tube; thus taking folic acid now, as well as discontinuing her Depakote use will not decrease the risk of a neural anomaly. Your daughter needs to do several things: First, she should discuss the risks and benefits of drawing an AFP and other antenatal testing with her care provider. Next, she should consider a level II ultrasound for fetal anatomy. Finally, she should discuss with her psychiatric provider and her OB provider (preferably a perinatologist who has experience taking care of women with bipolar disorder in pregnancy) the risks of discontinuing her bipolar medication during pregnancy and other medication options for her depending on the severity of her illness. I think delivering at home is the least of her worries. But then again, if through antenatal testing birth defects are ruled out and her psychiatric condition is under control, why else would it be a problem?

- Linda Simon-Price CNM


8) Switchboard

Editor's note: Last week's insertion about how women handle stress can be found in its entirety at http://www.psu.edu/ur/2000/womenstress.html The study, led by UCLA principal investigator Dr. Shelley E. Taylor, will be published in an upcoming issue of Psychological Review, a journal of the American Psychological Association.


The article about women's responses to stress in Issue 4:8 reminded me of the motto two of my friends made up for themselves at a time a few years ago when they were both pregnant moms with young children at home: "When the going gets tough, the tough make dinner."

- Marion


Repeat miscarriage [Issue 3:7,8]: Raven Lang suggested in one of her lectures that women should at least wait the duration of the pregnancy before trying to get pregnant again - unless age is an issue. I would highly recommend she seek out a practitioner of traditional Chinese medicine. We have many herbs that are for repeated miscarriage.

- Colleen


Getting enough protein [Issue 4:8]: When I was following the Brewer
diet, I started my day with two slices of wheat toast, two eggs, two
pieces of cheese (2 ounces total) and two ounces of ham or sausage.
While this is a hearty sandwich, I never had trouble finishing it and
it gives 25 grams of protein right off the top.

- Erika O.


I have found very little medical study or information about pregnancy massage beyond "good for relaxation." Can someone point me in the right direction?

- Kathryn


10) Connections

I saw Midwifery Today in a health market in my area. A front-cover line caught my eye: "A Natural Alternative to Suturing." I had a median episiotomy and suturing from a physician somehow dragging the scissors down toward my midline region - about one extra inch on each side of my fourchette. I was never told I was getting an episiotomy. Ever since, I have had a constant dull ache in this area, an ache that was at first a burning ache. My physician assured me everything looked normal and treated me like this was all in my head. I have been frustrated to the point of tears.

Please, can someone direct me to a midwife (preferably one in my area but I am willing to drive or fly anywhere to finally have this corrected) who would be willing to re-do this scar using the seaweed instead of sutures technique? My physician referred me to a vulvar specialist, whom she sarcastically referred to as "The World's Leading Expert." I am not averse to seeing physicians, but emotionally I would really like to be treated by a compassionate individual committed to women's health - physical, emotional and spiritual - and not by a paternalistic healthcare provider.

I live in Fairfield County, Connecticut. I have no idea how to go about finding a midwife or physician in the field of natural medicine who might be able and willing to help me.

Please reply to: Rickkoen@optonline.net


Student nurse midwife seeks CNM preceptor for Intrapartum experience. Contact Joan McCarthy, CRNP, FNM, student nurse-midwife at: MJOAN186@aol.com or by phone at (412) 371-7238.


EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.


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