November 8, 2006
Volume 8, Issue 23
Midwifery Today E-News
“The Perineum”
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Quote of the Week

"Just one birth that is treated as sacred can influence the life experience of one being."

Robyn Sheldon


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The Art of Midwifery

My mom, who has successfully nursed 12 babies, says that vinegar and baking soda are the best treatment for thrush. Before and after each feeding, swab the baby's mouth with a solution of baking soda in water—just enough to make a very thin paste—and dab vinegar on your nipples. This remedy takes three days of very consistent treatment.

Anon.
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Passionate Midwifery Education

My Midwifery Education: Marion McLean

I have told you something of my own Midwifery education (see blog). One our biggest blessings was to have Marion teach us a for whole year in a program modeled after Frontier Nursing Services' CNM program. She condensed the program, teaching us just the parts that were relevant to our homebirth practices. The curriculum was not very medicalized because this was 25 years ago. I am sure most curricula now are very different.

Besides teaching our didactic lessons Marion joined us in our practices. We already had very full practices of 3–5 homebirths per month. She would work one-on-one with us during prenatal and postpartum visits. She also went to births with us. This gave us a rare opportunity to learn midwifery more deeply. Marion also sweetly acknowledged that she had learned from us! I was amazed by the learning experience.

Shadowing and teaching within the practice is a good idea for all mentors, although I am sure that midwifery can be taught in many other unique and functional ways. In the UK some programs require students to do caseload midwifery.

I would really appreciate you sharing various models with me through this column. I have no special gift for midwifery education other than a burning desire to welcome new midwives into this beautiful calling.

I believe that the full year of intensive help within our practices was a time of intense learning geared to exactly what was going on there. We were still quite young midwives, having done only about a hundred births, but with total care. After this great learning experience we were able to practice with Marion for a few years. When I started Midwifery Today Marion joined us as a regular columnist and our mentoring relationship continues. She has been an incredible gift to many midwives in our community. I hope and pray every one of you finds a Marion on your journey.

love, Jan
Jan Tritten, Mother of Midwifery Today

To read all installments of our column on midwifery education, go to our Better Birth and Babies Blog.


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The Perineum

Ironically, one of the biggest contributors to perineal tearing is episiotomy, which has long been heralded as the great preventer of tearing. One recent study, which only assessed the effects of episiotomy on third- and fourth-degree tearing, found a definite correlation between episiotomy and tearing. The risk of severe lacerations was found to be nearly four times higher with episiotomy than without. Another study involving thousands of women found that the number-one risk factor for perineal tearing was episiotomy. It really should not be surprising that, like cloth, cut perineal tissue tears easier than intact tissue.

There are some other independent risk factors for tearing, such as maternal age (older women giving birth for the first time are more likely to tear), birth weight and assisted vaginal delivery (e.g., forceps). Given the choice between the lesser of two evils, a vacuum-assisted delivery is statistically less likely to make a woman tear than a forceps delivery, although it is standard practice to perform an episiotomy with assisted hospital deliveries. Take note: there have even been studies where women having forceps deliveries were not cut and did not tear.

Interestingly, the presence of stretch marks has also proven to be a fair predictor of tearing. They most likely are correlated with poor skin elasticity in general. A woman's basic physiology also affects her likelihood of tearing. Women with a short perineum, when the anus is close to the vagina, are more likely to tear during delivery.

The position a woman assumes when giving birth may be the single most important contributor to avoiding perineal damage. The top three positions for preventing tearing seem to be hands-and-knees, kneeling and squatting. The supported squat, when someone supports the woman under her armpits, letting her "hang," is also a useful position. Michel Odent, MD, author of Birth Reborn, says, "A fetus ejection reflex is usually associated with a bending-forward posture. When a woman is bending, the mechanism of the opening of the vulva is different from what it is in other positions. The risk of dangerous tears is eliminated." The kneeling and hands-and-knees positions incorporate the bending forward posture Odent recommends—the knees are shoulder-width apart and there is an optimal force of gravity at work. Again, the feet should be straight and not pointing in or out. The use of birthing stools and the squat position are beneficial during labor but may use too much gravity to totally prevent tearing.

If, for some reason, a woman cannot be upright, then lying on her side is a better alternative than on her back. Whoever holds her knees should make sure they are about shoulder-width apart during delivery—no wider. Knees should be pointing forward, as the more knees point outward, the more closed the pelvic bones are. In a side-lying position, there is no justification for having someone yank the woman's upper leg up to her ear. Such an assault is uncomfortable and can cause damage to the perineum.

Hospitals that encourage semipropped positions are all but guaranteeing every new mother will be wounded in the process. The same is true for the most infamous of positions, the lithotomy, or flat-on-the-back in stirrups. Sadly, many medical studies report that the mother's position during second stage has little influence on perineal trauma. That is because the two positions they compare—flat-on-the-back and semipropped—are equally horrible for giving birth intact. The researchers then wrongly conclude that position during delivery is unimportant. Although it is more difficult to assume an upright position with an epidural, it is possible.

Avoiding an epidural is also helpful for preventing perineal damage. In one study, women with no anesthesia had the highest rate of intact perinea (34.1%), while women with epidurals had the highest episiotomy rate (65.2%). Another study shows that women who had an epidural were more than three times as likely to suffer third- or fourth-degree tears. Why would this be? For one thing, women with epidurals often end up getting cut because they don't have enough sensation to push the baby out. The effects of epidurals are notoriously variable, and even the best anesthesiologist in the world can't predict when delivery will occur, or how different women may be affected by the same dosage of medication. Furthermore, an epidural prevents the mother from assuming optimal positions during delivery. She is also denied the natural sensations of an urge to push and must rely on external sources to tell her when it is appropriate, instead of listening to the wisdom of her body. Not surprisingly, oxytocin (or Pitocin) also increases a woman's chances of serious tearing: 47% with Pitocin versus 29% of those without Pitocin tore deeply.

One Australian hospital recently rediscovered an age-old method of delivering babies. "As the birth commences, support the perineum, keep the fetal head flexed, have the mother push gently or pant, gently push the anterior vagina over the back of the baby's head, wait until the mother pushes the anterior shoulder into view and deliver the shoulders one at a time." Using this technique, which really is the optimal way to deliver babies, the hospital was able to reduce its episiotomy rate from 78% to 7%, a rate comparable to that at many birth centers.

Michel Odent believes in a woman's innate ability to give birth. He is an expert on what he calls the "fetus ejection reflex," or pushing phase of labor. According to Odent, pushing is triggered by the release of oxytocin, which is in turn affected by the woman's state of mind. He strongly advocates for a woman's privacy and support during labor and delivery. His famous clinic in Pithiviers, France, featured dim lighting, pillows instead of a bed and warm water for the laboring woman's comfort. The importance of waiting for the mother's urge to push cannot be overemphasized. "During the powerful and irresistible contractions of an automatic ejection reflex there is no room for voluntary movements." He further warns, "It does not occur if there is a birth attendant who behaves like a 'coach,' observer, helper, guide, or 'support person.'" In other words, just having someone there "with" the laboring woman is all that is desirable. Quietly allowing the mother to discover her own pushing instinct is ideal.

Elizabeth Bruce, excerpted from "Everything You Need to Know to Prevent Perineal Tearing," Midwifery Today Issue 65


When it comes to the birth itself, it is important that women remain well-hydrated during labour to promote tissue elasticity. During second stage, women should be encouraged to push instinctively, rather than to hold their breath and actively push. Instinctive pushing allows for a gentler second stage and more time for the pelvic floor to stretch. Of course, it is then important not to implement arbitrary time limits on second stage. As for maternal position, I generally find that if women are given the space, they will instinctively find appropriate positions in which to give birth. Standing and squatting positions are useful for bringing the head down onto the perineum, but once the head is visible I like women to be "lower," on hands and knees, for example. This reduces the strain on the pelvic floor and encourages the head to be born slowly. In my experience, most women will do this anyway.

I use a hot compress on the perineum, as it seems that most women find this very soothing and it helps to give them the courage to birth their babies. I know that some midwives don't like to use hot compresses because they argue that the pain of stretching at this point is important in that it naturally helps slow the birth. I know of a few Swiss midwives who report great success with using compresses made with strong coffee. They say it helps the perineum become stretchier.

Sue Brailey, excerpted from "Making Room for Babies," Midwifery Today Issue 65


Want the whole story? Midwifery Today Issue 65 includes numerous articles about tear prevention: Issue 65
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Research to Remember

A study to determine if overweight women and obese women experience prolonged labor enrolled 612 nulliparous women with term pregnancies. The study adjusted for maternal height, labor induction, rupture of membranes, oxytocin use, epidural, maternal weight gain and fetal size. To assess labor progression, researchers determined a median duration of labor by each centimeter dilation for normal weight, overweight and obese women. The study revealed that duration of labor from 4 cm to 10 cm dilation for overweight women was 7.5 hours, with the slowest progress at 4 to 6 cm; for obese women, duration was 7.9 hours, with slowest progress before 7 cm; and for normal weight women, duration was 6.2 hours.

Obstet Gynecol 104: 943–51.


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Forum Talk

Has anyone ever tried liquid bandage as a tissue adhesive for perineal repair?

Geri Lehner
Stony Plain, Alberta, Canada


Go to our forums to share your thoughts and experience.



Learn how to keep the perineum intact.

Tear Prevention handbook

The Tear Prevention handbook gives you a variety of suggestions for both preventing tears and healing them. Topics covered include: A Natural Alternative to Suturing, The Art of the Sitz Bath, Tips on Tear Prevention and Protecting the Upper Tissues. Part of the Holistic Clinical Series, this book will be essential to your midwifery practice.



Question of the Week

Q: I injured my coccyx during vaginal delivery. The delivery was fine, but I noticed the pain continued after the rest of me was healed. I had an x-ray done one month postpartum and there was no fracture. The pain still comes and goes, and the constant pain in my tailbone even limited my breastfeeding to one month because of the pain. That was a huge letdown for me, and it still hurts emotionally to think I could never get comfortable enough to bond with my baby.

This pain is a constant reminder of how hard my recovery was. Is there anything I can take other than anti-inflammatory medications for the rest of my life? Also are there any exercises and stretches I can do?

— Pam


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.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: How do you, a birth practitioner, act during a woman's third stage—the delivery of the placenta? What is your approach to/attitude about third stage?

Midwifery Today E-News Editor

A: I think it is important for the midwife to take the lead from the mother, so my behaviour will depend on each situation. If for example, she wishes to have a physiological expulsion of the placenta, things are very easy for the midwife as you just have to sit and wait for nature to take its course. However, even if she has requested an oxytocic the midwife can still afford not to be too hasty about getting that placenta out and wait for signs of separation before using cord traction. Of course whatever option the woman chooses, she should be having skin-to-skin contact with her baby. The key thing to remember is to not be in too much of a rush—being too hasty with any aspect of birth can cause problems.

— Alison Andrews
Wales, UK

A: Long before I even thought of becoming a midwife, when I was getting my formal doula training at Seattle Midwifery School, Suzy Myers (a great midwife!) gave an amazing lecture on third stage. She said that in many traditional cultures, when the baby is born, s/he is virtually ignored at first. All the cheering and excitement happen when the placenta is delivered and hemostasis is achieved, so it is clear that the mother will probably live. I have lived through the experience of having a 23-year-old with her first baby lose her uterus to save her life five days post-cesarean. And early in my midwifery training, I had a preceptor who had spent years at The Farm who had had it with postpartum hemorrhages after lovely births; she practiced active management of third stage (routine Pitocin with delivery of the anterior shoulder). I really understand how she feels, though I don't routinely do the active management myself.

Most clients have no concept of the potential dangers of third stage, and I don't see the point of scaring them during the prenatal period. But I have never forgotten Suzy's lecture, and have a huge sense of responsibility during third stage. I don't really relax until it is over, though I hope I appear to be happy, etc., to those who are present at the birth. I try to unobtrusively do my third stage job as quickly as Mother Nature allows so that I, too, can focus completely on the beautiful baby!

— Cynthia B. Flynn
College of Nursing
Seattle University


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Think about It

Assuming their basic needs are met, givers who love to please others, without expecting anything in return, are generally happier than getters. And what's more, psychologists have found that they're also likely to live longer. When the giving is good, everyone is strengthened—the giver, the birthing woman and society. Giving all that we [midwives] can give, of our very selves, is rewarding, and more rewarding than earning tons of money. The most rewarding form of giving is when you can see that someone really needs your gift, when you see that you can make a huge difference to other people's lives, when you know that they can't do without you, when they feel fortunate that you are there for them and when you can feel their deep gratitude for your efforts. Because midwives love to give and are so good at giving, they aren't especially good at taking home good money. That's why discussing the business of midwifery is so important.

Michele Klein, excerpted from "Profits and Rewards—Why Don't Midwives Earn High Salaries?" Midwifery Today Issue 79


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Feedback

Thanks to Rayner Garner for his interesting observations about the role of fear in labor, and his technique for discharging adrenaline [Issue 8:17]. We know that high levels of adrenaline can slow labour by inhibiting oxytocin release. There are many reasons for anxiety in labor but one of the biggest, I believe, is that the labouring woman does not feel private, safe and unobserved in her labour. (Note "feel" is important; we don't all have to go and give birth in a cave).

These are the core requirements for birth in all mammals and make perfect sense if we remember that our "hard wiring" for birth comes from our hunter-gatherer foremothers giving birth in the wild. The presence of danger, or the merest suggestion of danger, would activate the laboring woman's fight-or-flight reflex, switch off her labour and divert blood away from her baby and to her major muscle groups for flight or fight. This reflex continues to be activated in modern women—e.g., moving from home to hospital. Human research has also linked high levels of adrenaline with adverse fetal heart rate (FHR) patterns, indicating a lack of blood and oxygen, and of course animal breeders know how important it is for the laboring female to feel private and safe in labor for a safe and easy birth (see my book Gentle Birth, Gentle Mothering for more about this).

So I certainly agree that discharging adrenaline would be a good idea in labor, but I would wonder if this would give an ongoing benefit if conditions for the mother were still not private, and if she felt unsafe at a primal level. It is also true that, late in a natural labor, the woman is usually less influenced by her environment, perhaps because of high levels of beta-endorphin putting her into "labor land." Perhaps this technique will get the laboring woman into that later stage. I would be very interested, as Rayner suggests, in hearing the experiences of midwives and women who have tried this in labor.

Sarah J. Buckley, MD
Anstead, Qld, Australia


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