December 10, 2003
Volume 5, Issue 25
Midwifery Today E-News
“Preventing Perineal Tears, Part II”
Print Page

Midwifery Today is taking a break during the holiday season, so there will be no E-News published on the scheduled date of December 24. The next issue will be sent on January 7, 2004. Have a wonderful holiday and a happy and healthy new year!

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In This Week’s Issue:

Quote of the Week

"So that we can honor all kinds of mothers, let us also honor the midwives who offer them all kinds of choices."

Robbie Davis-Floyd

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The Art of Midwifery

Marketing Your Doula Service

Silent Auction Donation: A local doula group puts together a basket with a rice sock, some red raspberry leaf tea, lavendar and massage oil, and a certificate for a doula in the group to attend a birth (several new doulas in the group are looking for experience). One woman in the group is a lactation consultant, and she is providing a certificate for a free consult. I am providing a certificate for two private two-hour classes on natural childbirth preparation. Not only is this a great way to get the idea of natural childbirth and of doula support out there, but every flyer for each event includes the name of the doula group listed as a supporter.

Radio Station Volunteers: Earlier this year the doula group also provided phone volunteers for a fund drive for the local public radio station. All morning, several times an hour for three mornings you could hear "And KANU/KPR would like to thank Heartland Doulas for providing phone support for our fund drive. Heartland Doulas is a local group of women who provide information and support for pregnancy, childbirth, and postpartum." An alternative idea if not enough volunteers are available: bake muffins and scones—the people who supply meals for the phone volunteers and the fund drive also get repeatedly mentioned and thanked on air.

Lori, Midwifery Today Forums

News Flashes

Oregon Midwife Mourned

On Thursday, midwife Peggy Sawyer of Ashland, Oregon died of an aneurysm. Those of us who knew her are deeply saddened at the loss of such a beautiful woman, this bright light that was Peggy. She was the mother of five including her youngest, 12-year-old twin boys. She is survived by her dedicated husband, Willie, who hopes to carry on her work. A memorial is planned for Saturday, December 13 at 2 pm. Information about the service and more about Peggy's life can be read here.

Formula Feeding and Infant Mortality

American babies fed infant formula have twice the relative risk of death than those who are breastfed, according to an analysis of several decades of research about infant mortality in the United States. The report, authored by Dr. Linda Palmer, is available in the December issue of Natural Family Online. Palmer's research included studies of the overall infant death rates in developing and undeveloped countries resulting from formula feeding, comparative illness occurrence rates for many illnesses and disorders in the United States and other industrialized nations, and survival rates and decreased illness rates among breastfed infants.

Palmer quotes WHO statistics showing the risk of diarrhea for formula-fed babies (FFBs) in developing countries averages more than six times that of breastfed babies. In the United States, FFBs have a doubled risk. Worldwide risk of respiratory illness for FFBs ranges from 1.5 to 8.5, and risk of neuroblastoma, a common childhood cancer, is doubled.

Palmer's report includes preterm infant illness and death rates, rates of SIDS, bacterial infection, and necrotizing enterocolitis and their correlation to formula feeding.


A Journey of the Heart

"A Journey of the Heart" is a series of Guided Imagery and Meditation recordings from Anji, Inc., designed for women on their journey to motherhood. The pregnancy recordings contain imagery exercises for each month of pregnancy, preparing physically and emotionally for labor and birth, and supporting women with preterm labor. We invite you to explore Anji, Inc., at

One Birth for the New Year

by Cher Mikkola, editor

Nearly four years ago I accepted a job offer that took me far from the familiar shores of midwife-oriented birth. Although I remained tethered to Midwifery Today as editor of E-News and a contributing editor to the print magazine, I delved full time into the world of trade magazine publishing where I could earn enough money to support my family. This turn of events took me into a culture I had only peripherally acknowledged, both in the publishing-world sense and in the lifestyle sense.

It wasn't long before I began to hear "mainstream" concepts about pregnancy and birth and conventional birth stories. I listened with as much patience as I could and smiled and nodded in all the right places. All the while my insides were knotting and the knowledge gleaned from numerous years at Midwifery Today squirmed and whined to be voiced. Caught in the quandary of wanting to inform and wanting to respect others' viewpoints and choices, I wondered what was the most respectful as well as the most caring path to take: speak up or keep smiling.

I was most challenged by watching my immediate supervisor, who had become a valued friend, go through two pregnancies. Her husband had watched the birth "reality" shows and horrified, insisted she have all the tests and a hospital birth. She first had a cesarean for "failure to progress" and then fourteen months later a triumphant VBAC after which she hemorrhaged unremittingly from an involuted uterus and nearly died. I bit my tongue to painful excess.

Meanwhile, another colleague's two friends and a cousin birthed, two in hospitals (one cesarean) and one in a birth center—a lovely, empowering experience. R, who is young and unpartnered. and I talked many times about American birth and shared our thoughts about our supervisor's second birth and about the birth center birth. She was curious and open to what I had to say. She drew her own thoughtful conclusions and maybe learned a few things from me. I learned a few things from her as well: what motivates young women, where they get their information, why they make the choices they do, and that they do care and do consider alternatives but are often overwhelmed by the media and the culture that surrounds them. In the meantime, I learned to speak with humility and caution.

As we wind up another year of E-News and anticipate a new one, I'm not sure I have anything new to say about educating the public about truly natural birth. It's an information overload out there, and the ante is constantly raised: horror stories abound, "reality" is skewed, the "perfect birth syndrome" rules, women are scared and therefore are scarred, routine prenatal care includes every bit of technology available and it is expected and accepted, and few women step outside the box to ask questions.

Nevertheless, we take the small opportunities we can to inspire a new way to look at things, a new way to birth, a new way to challenge the status quo. We look for the openings and proceed with respect and love. We speak our truth without lecturing and shaming. We share the joy of birth wherever it can be found. And with each tiny opportunity, we may spare one newborn a violent entry into our world, hopefully assuring that tiny soul that she is safe and that he has the opportunity to trust life, thrive, and bring more light to humankind.

So for each and every E-News reader may the New Year hold one single opportunity to share, support, and respect as we talk about alternatives for birth, and may we each help one single soul emerge into the peace we all deserve.


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Preventing Perineal Tears, Part II

Perineal Massage or Not?

Perineal massage, in which the perineum is massaged with our without oil in the weeks preceding childbirth gets mixed results in controlled studies. Many studies show that massage protects against perineal trauma in first-time mothers. No benefits were found in women who had already given birth once. Other studies contradict this finding and show no benefits to perineal massage in any mothers. One homebirth study actually associates perineal massage with higher rates of damage. However, these women were using massage during labor, as opposed to prenatally. It is well known that swelling during delivery increases the likelihood of tearing.

Some women may find perineal massage too threatening, especially those who are sexual abuse survivors. Obviously, for these women, massage would not be beneficial because it would have an opposing effect. Also, women who cannot trust their partners to participate would be better off abstaining, although the issue of nontrust should be addressed before the birth if possible.


Hospitals that encourage semipropped positions are all but guaranteeing every new mother will be wounded in the process. Same for the most infamous of positions—lithotomy, or flat on the back in stirrups. Sadly, many medical studies report, "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 counterproductive for giving birth intact.

In the all-fours position, there is minimal tearing, maximum opening of the pelvic outlet, and relaxation of the perineum.

In recent years, birthing chairs and stools have become popular in labor and delivery rooms. Dating back to medieval times, these stools are a definite improvement over delivering in a recumbent position. Interestingly, many midwives have abandoned the use of birth chairs because they feel the fixed position is unnatural and that perineal swelling in this position may contribute to tearing.

Avoiding epidural also helps prevent perineal damage. In one study, women with no anesthesia had the highest rate of intact perinea (34.1%), and women with epidurals had the highest episiotomy rate (65.2%). Another study shows that with an epidural women are more than three times as likely to suffer third- or fourth-degree tears. 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, 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.

[To be continued.]

Excerpted from "Everything You Need to Know to Prevent Perineal Tearing," by Elizabeth Bruce, Midwifery Today Issue 65. The remainder of the article will be excerpted in E-News Issue 6:1.

Midwifery Today Issue 65 is all about Tear Prevention. To order your copy, click here.


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Forum Talk

I had/have a client who I had to transport for a postpartum hemorrhage. She just would not stop bleeding and was going into shock with her last baby. She is now 25 weeks pregnant, and I would like to put her on some preventative herbs if possible. Any ideas would be greatly appreciated. I have her on alfalfa, red raspberry for now. I would also like some suggestions in case hemorrhage happens again.

Debbie H.



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Question of the Week

Q: A friend has just been diagnosed with Subchorionic hematoma. She is on complete bed rest, and she has three children already. I an seeking information about this condition as well as success stories, natural remedies, or other help. She will be entering her fifth month of pregnancy and has been told she is very high risk.

— Melanie Steenbeke, Allenstown, NH

SEND YOUR RESPONSE to 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: A woman who is 20 weeks pregnant is experiencing aching pain after intercourse, but not during. Several experienced midwives have suggested she may have a vaginal varicosity, but they could not offer any suggestions for relief. Any thoughts?

— Anon.

A: I developed vaginal varicosities with my last two pregnancies and found that the following helped somewhat:

  • Stay off your feet as much as possible; standing puts all the pressure of the baby on your pelvic region and perineum. Sit, or better yet, lie down for 10–15 minutes every hour or so.
  • Applying cold witch hazel compresses directly on your perineum will help relieve some of the swelling and the heavy distended feeling. I kept a bottle of witch hazel in the refrigerator and used it to soak a maxi pad once or twice a day and then sat down while wearing it. Make sure to put a towel underneath you. Sitting on a firm surface, for example a wooden chair, helped put pressure on the area and reduce the swelling.
  • Avoid hot baths, hot tubs, saunas, etc.; the heat increases blood flow to the area.
  • If you are exercising, non-weight-bearing activities are best.

Ultimately, I had to abstain from intercourse because the increased blood flow to the perineum aggravated the varicosities too much. They cleared up within a few weeks of delivery both times, and I've never had any other problems with varicosities.

— Carla Murphy

A: I have quite a bit of experience with varicosities—vulval, vaginal, and extending all the way to the tops of my feet. They were very large and protruding, from my vagina all the way down. I didn't have them with my first pregnancy, but with all my subsequent four pregnancies they have become progressively worse. They were very often so painful I was unable to stand. I have tried many different remedies, but none have proven very successful. I found that having sex, having a bowel movement, standing too long, anything that encouraged blood flow to the vaginal area increased the aching pain. The thing I found most helpful was to ONLY have sex in bed, and stay in bed for the night (or at least for several hours afterward). That way my body had time to relieve the blood flow congestion overnight. If the pain became overwhelming it helped to apply a hot rice pack to the crotch area while lying down. Elevating the hips after sex also helped relieve the pressure and aching. If the vaginal aching began because I had been standing too much, I had to get off my feet, even if it was for only a few minutes. Very warm baths also helped, even though the conventional wisdom is to avoid them.

— Cathy

A: You did not say whether or not you are experiencing orgasm with sexual intercourse. My personal experience during pregnancy, and the anecdotal experience of several women I know, suggests that engorgement of the pelvic blood vessels during sexual excitement can lead to a feeling of heaviness or "fullness" and/or pain following intercourse if there is no orgasm to relieve the engorgement. This is particularly aggravated by the normal increase of pelvic blood vessels supporting the pregnancy.

If you are healthy and all is well with your pregnancy and the baby, I would suggest you and your partner enjoy lovemaking to its best conclusion for both parties and see if that does not relieve the problem.


A: Try vitamin E, 200–400 UI twice a day, orally. This can help reduce aching resulting from varicosities. Vitamin C with citrus bioflavinoids is also helpful for strengthening veins. Dosage is 1000 mg time-release vitamin C three times a day, plus 400 mg citrus bioflavinoids (including citrin, rutin, hesperidin, favones, and flavonals, with a rutin-to-hesperidin ratio of 1:1 or 2:1) three times a day.

Natural sources of vitamin C include citrus fruits, berries, green/leafy vegetables, tomatoes, cantaloupe, potatoes, sweet bell peppers, and rosehips. Natural sources of citrus bioflavinoids include white pulp and skin of citrus fruits, apricots, blackberries, cherries, rosehips, buckwheat, plums, black currents, soybeans, and alfalfa.

Charity Bailey, student midwife

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.

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I am due now to deliver my baby and was just put on a course of amoxicillin for a bronchial infection. I am concerned about passing the antibiotic to my baby in the first few days after birth and wonder if this could cause any adverse affects to the baby.

C.E. Davies

Does anyone have information about grants and/or scholarships for aspiring midwives? I am an aspiring midwife working as a birth assistant. It pays very little, and it has become very hard to support myself. I will be going to midwifery school in one year, but until then, I am looking for grants, etc. for people in an apprenticeship situation. If you have information about this possibility, please submit it to E-News. I am sure many others would appreciate it too.


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.

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 69 of Midwifery Today. In fact, if you send us a response and we use it, we will send you a free copy of the next issue. Responses are subject to editing for space and style. Try to keep the word count at less than 400. E-mail responses, along with your mailing address, to:

Theme for Issue No. 69: Midwifery Knowledge
Question of the Quarter: What do you really need to know to be a midwife? Who owns the knowledge?
Deadline for submission: December 29, 2003.

Question of the Quarter is a feature of Midwifery Today magazine, E-News's parent publication. Responses will be printed in Midwifery Today magazine. Click here to subscribe today!

Write today! (See writer's guidelines.) We love hearing from you!

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