August 6, 2003
Volume 5, Issue 16
Midwifery Today E-News
“Intact Perineum”
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Birth Information

DOZENS AND DOZENS OF ARTICLES are posted on the Midwifery Today Web site. VBAC, breastfeeding, doulas, drugs, natural remedies, homebirth, waterbirth—you name the subject, there's probably an article for you to read!

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In This Week’s Issue:

Quote of the Week

"The challenge for us midwives is to bring a greater understanding of the spiritual element of the birth process to those in our care so the sacred space of birth can be reclaimed for future generations."

Jenny Hall

The Art of Midwifery

Susun Weed, author of "Wise Woman Herbal for the Childbearing Year," says walking at least one mile a day can help alleviate morning sickness.

Midwifery Today Forums

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to

News Flashes

Between 1 and 2% of pregnant women experience hyperemesis gravidarium, or severe morning sickness. A randomized, placebo-controlled crossover study found that stimulating acupuncture point PC6 helps ease nausea and vomiting. Thirty-three women (average age 28.4 years) were divided into two groups. Group A received deep needle insertion at the PC6 point on both forearms three times per day for 30 minutes. Group B received a form of placebo acupuncture, with a needle inserted superficially approximately four inches above the wrist on each arm. On days one and two of the eight-day study, each group received their treatments; after two more days of no treatment, the procedures were switched for each group. Each day, the women rated degree of nausea and recorded instances of vomiting. Those women given active acupuncture experienced a "significantly faster reduction of nausea" compared with those who received a placebo. This reduction was seen in both groups; identical results were seen in each group when the treatment was switched. The incidence of vomiting was also reduced in both groups, with a much greater reduction seen in those receiving active acupuncture. Daily vomiting had been reported by all 22 women at the study onset; by day three less than half of the women in the active group were still vomiting compared with 75% of those in the placebo group.

Journal of Pain and Symptom Management, October 2000;20(4):273-279.

Intact Perineum

Sharing what the feeling of a baby's head stretching the perineal tissues will be like and warning the mother about the pitfalls in pushing will go a long way to her having a smooth passage for both baby and herself.

The woman will be receptive to conversations in prenatal visits about the realities of the birth process. Following is what I convey about second stage (pushing):

  1. When you begin to feel like pushing, it will be a bowel movement-like feeling in your bum. 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 in your bum 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. Because you have been educated that this is normal, you will relax and find this an interesting and weird experience.
  3. The next distinct feeling is a burning, pins-and-needles feeling at the vaginal opening. Many women describe it as a "ring of fire" all around the vaginal opening. 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.
  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. Everyone will be silent and respectful in between sensations while you regather your focus. 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 a hot face cloth (if you wish) 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 by poking, external fingers. This can lead to tearing. We will use a mirror and a flashlight to see what's happening so we can guide you. We won't touch you or the baby.

Excerpted from "Midwife's Guide to an Intact Perineum," by Gloria Lemay, Midwifery Today Issue 59.

Editor's Note: Gloria continues with several more important points for keeping the perineum intact. Read this and other excellent articles in Midwifery Today (print magazine) Issue 59.]

TO ORDER ISSUE 59: click here.

Vaginal muscle awareness and control are essential for avoiding vaginal/perineal tears. If the expectant mother can learn the difference between contracted and relaxed states of her vagina and perineum, she will be able to create either at will. Encourage her to do some exploring; have her place her fingers inside and contract her muscles around them in order to learn which motions work for her. Being able to stop the flow of urine—a common way to learn vaginal muscle awareness—does not necessarily indicate a full range of control.

My favorite exercise is the classic "elevator." In this exercise, the pelvic floor muscles are pulled up like an elevator ascending to the first floor, second, floor, third floor, fourth floor, fifth floor, then are held for 30 seconds, and let down slowly [floor by floor] and finally to the basement, the place from which we give birth.

Another exercise that imparts control of the internal muscle most likely to tear at birth (the bulbocavernosus) is a quick, snapping movement lower down in the vagina, near the introitus.

from "Heart and Hands," book by Elizabeth Davis, Celestial Arts Books, 1997

Web Site Update

Check out these articles newly posted to the Web site:

"Paris, 2001: Midwifery Today International Conference" by Jan Tritten
"The Soul of Homebirth" by Vi Sadhana
"Remembering the Small Things" by Deb Phillips

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Forum Talk

I need to find information about VBAC homebirthing. I have three girls, first vaginal, last two planned homebirth turned c-sections, nonemergencies. We just moved to Germany, and I have to convince an Army doctor to approve a homebirth for the insurance to pay for it.



Question of the Week

Q: I gave birth (completely natural) to my second child about nine months ago. Several weeks after giving birth I felt a vaginal heaviness. When I asked my midwife about it at the six-week checkup, she recommended that I kegel. I have been doing so for the past eight-plus months. I went back at six months, and she confirmed that my uterus was prolapsed. My cervix can be seen in the vaginal canal.

I know my doctors are going to recommend either surgery or a pessary (the device to "hold things up"). I prefer to treat it the natural way if possible (i.e. herbs, homeopathics, exercise). My husband and I want more children, but I am concerned about what it would do to my uterus and would it make the current situation worse.

— Danielle

SEND YOUR RESPONSE to with "Question of the Week" in the subject line.

Question of the Week Responses

Q: What can be done for endometrial hyperplasia as far as alternative methods of treatment? In my case, it falls under the category of excessive bleeding. Three cycles of progesterone haven't helped, and I don't really want to go the hysterectomy route.

— J.G.

A: Have you read about ablation? I assume you have had an ultrasound and other testing and blood work.

— Linda S.

A: Have you considered the Mirena IUD? At a recent in-service the rep said it will decrease bleeding and that many doctors are placing these instead of doing an ablation.

— B.B.

A: Read "Fertility Cycles and Nutrition" by Marilyn Shannon. You can get it from The Couple to Couple League (CCL; teaches Natural Family Planning). Her e-mail address is available from their Web site at She has also written articles specifically related to heavy bleeding in CCL's newsletter, "Family Foundations." Ask about back issues.

— Anne

A: Endometrial ablation, preferably the hot-water method, is wonderful. This is only for someone who does not wish to become pregnant again.

— Anon.

A: My mother "floods." She is on hormones to control it, and it kind of works (it keeps her out of the hospital). She had to try a couple of different doctors, and most of them said she would have to get a hysterectomy. Then she found a doctor she really liked who put her on the hormones and had her work with the pills, taking an extra pill when the flooding really kicked in. He told us if the hormones don't keep her from flooding that the next procedure he would try is cauterizing the inside of her uterus. So far, we aren't to that point, and we haven't researched that procedure. My point is that sometimes docs jump to hysterectomy when there are some baby-step procedures they can try before they remove the uterus.

— Anon.

A: Chinese Herbal Medicine is extremely effective for uterine bleeding, especially when the cause is endometrial hyperplasia. I am a Chinese Herbalist and have treated this many times in my 20 years of practice. The herbs also really go to the root of the problem, and my patients end up feeling much better in other aspects of their health. I suggest finding a qualified herbalist in your area.

— Sharon Weizenbaum

A: Have you considered endometrial ablation? Several different methods are available, including laser ablation and hyperthermia ablation. The uterus is left intact, just the endometrium is destroyed.

You can get quite a bit of information by doing a Web search on endometrial ablation. I believe the success rates range from 50 to 80% for achieving complete cessation of bleeding and much less bleeding in almost all cases. In my area it is done as an outpatient procedure and does not require recovery period of more than 1–2 days.

— Anon.

A: There are multiple interventions besides a hysterectomy for excessive bleeding. Several outpatient procedures can help: 1) D&C, which can be helpful for several cycles, and then the procedure has to be done again. This is not my favorite option for obvious reasons. 2) Hormone replacement, including estrogen and progesterone OCPs. In my experience, however, progesterone alone led to more bleeding. 3) Uterine ablation, which is done using various techniques, including freezing the inside of the uterus, nova sure, which chemically alters the endometrium, and actual burning the inside of the uterus. These methods can be very helpful and stop bleeding altogether in 90% of women. You would stop having periods, but your hormones are not altered by a hysterectomy. I know many women who are extremely happy with this alternative. 4) Pregnancy.

I am not aware of any herbal or naturopathic remedies that are really effective for treating this problem.

— Heather J., cnm/whnp

Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

Exclusively on the BirthLove site: Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out!

Question of the Quarter for Midwifery Today Print Magazine

We hope you'll take a minute to consider the Question of the Quarter for Issue 68 of Midwifery Today print magazine. Responses are subject to editing for space and style. Try to keep the word count under 400 as responses will be printed in Midwifery Today magazine, not online. E-mail responses to:

Theme for Issue No. 68: Instinctive Birth
Question of the Quarter: What does instinctive birth mean to you? How do you facilitate it?
Deadline for submission: Sept. 15, 2003


I will be reworking the site material for the Brewer Pregnancy Hotline book. I need testimonials from women who have used the Brewer diet during pregnancy and from birth professionals who recommend it. Mothers' testimonials should include something about their history and (presumably improved) outcome on the Brewer diet. Professionals should include something about their experience with clients' health when using the diet. Please include contact information for reference, but for the testimonial be sure to state exactly WHAT you want put online. First name or initials only are used to preserve privacy. Giving us your location would help (e.g., Sue R., Seattle WA). Professionals may include contact information or web address.

Please send to

Webmaster, and

I am considering my options for the birth of my fifth child. I have had two homebirths and two hospital births; all four were fine and uneventful (I could give birth on the sidewalk, they all go exactly the same). The state of Connecticut mandates HIV testing for all pregnant women, with those refusing having to submit baby to the test. I am opposed to this on many fronts, but my question is, if I exempt out for religious reasons (no way I could be positive), could they still test my newborn (I have a strict no needles on the birthday rule)? I fear Department of Social Services intervention; even if I birth out of state, can they still get to us? I would appreciate information and direction about this state's mandates. The OB/GYN I visited told me I am otherwise high risk at 37 years old, necessitating ultrasound, GBS testing, GD testing, all to be "sure" (my fifth child!). I will probably homebirth, but the HIV thing still nags at me. Suggestions, advice?


I also have experienced severe nipple pain with nursing both of my children [Issue 5:15]. When my son was born, I was diagnosed with thrush. I washed my nipples and my son's mouth with a baking soda mixture after every nursing and endured pain for 18 months. I was told numerous times to wean, since the pain often moved me to tears. When I had my daughter in 1992, again the same thing happened, and again I was told to wean. I went to doctors, naturopaths, asked my midwives, used antifungal creams on my breasts, and nothing helped. One naturopath put me on herbs that dried up my milk! It took three days of mother's milk tea and round the clock nursing to get my milk to flow again. I finally talked to a lactation consultant by phone and described the situation to her. She asked me if my nipples blanched white, if it was cold where I lived, and if I was sensitive to cold. Yes, yes, yes. She said it wasn't Raynaud's Syndrome, but something similar to it. When baby latched on, it caused vasospasms, reducing blood flow that in turn caused the blanching and pain. She gave me a few suggestions, but what worked best for me was to make sure I wasn't cold when I nursed. That meant wearing socks, drinking warm tea, sitting near the fire, and I would also rub my breasts with my hand to warm them up before baby latched on. It worked like a miracle! I nursed my little girl for 2-1/2 years.

I am a midwife and a nurse and had never seen this problem before. I had never heard of anyone else having this problem until reading of it in E-News. It was a really hard thing to go through. I was misdiagnosed with thrush, suffered terrible pain, and got little support for my commitment to breastfeed. I always wondered about how often this problem actually came up, and am happy to see some dialog about it in E-News.

Lori Land, RN

To the anonymous writer regarding older parenting [Issue 5:15]: The Web site focuses on the older mom. There is only one article per issue devoted to pregnancy, but it might be worth checking out. The editor is open to feedback and comments.

Gina Ferrara-Bates

In response to your Art of Midwifery section on yeast infections [Issue 5:15], I just picked up tea tree oil vaginal suppositories from Whole Foods. They come six to a box and seem to work great for yeast or bacterial vaginosis.


I was intrigued by the Art of Midwifery section in Issue 5:15. As more and more woman seek out complementary therapies to help protect their growing baby, this may be a valuable piece of information to store and keep until it may be of use, especially since it is a very common problem in pregnancy.

Could you tell me what consistency the tea tree oil should be? I know it is quite potent when not diluted enough especially when you won't get much primrose oil in a capsule. I want to give an as accurate as possible description to clients who may want to try it. Also, is there evidence to back up this therapy?

Dawn Higgins

Evening primrose oil was recommended as part of a treatment for vaginal yeast infection. Perhaps this ingredient should be avoided since it has also been used to soften the cervix for labor inductions and augmentations. I have read that it has prostaglandin properties.

Linda Baziuk, RN, AAHCC

Editor's Note: Only letters sent to the E-News official e-mail address,, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


Beechwood Midwifery, a homebirth practice in Rutland, VT, is offering preceptorships for students desiring a midwifery education through National College of Midwifery. See and for more info and/or call 802-786-0740.

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