February 16, 2005
Volume 7, Issue 4
Midwifery Today E-News
“Protecting the Perineum”
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In This Week’s Issue:

Quote of the Week

"Birth must be honored and given every opportunity for the growth that is inherent in its potential."

Raven Lang

The Art of Midwifery

After 30 years of assisting mothers in labor at home and in the hospital, I have found some techniques that help empower mothers when they are pushing. In the beginning and at the time of birthing it is very relaxing and easy for some mothers to be on their side. If side-lying pushing does not seem to bring progress, then an upright position, preferably a standing squat or kneeling squat, can work well. Birth in a squatting position seems to encourage rapid expulsion and tearing, so I ask mothers to lean back in a semi-recline for the actual birth. I do use gentle perineal support, usually with a warm cloth and oil as needed.

But when different positions have been tried and the fetal head is unable to come under the pubic arch, I encourage the mother to lie flat on her back with just a pillow under her head. I help her bring her legs up with the soles of her feet together. I wrap a towel around her feet and have her grasp the ends of the towel and pull as she pushes. This motion brings her legs back and the position causes a widening of the outlet, even more than squatting. The mother's elbows should be out and one should resist the urge to raise her upper body because this action seems to make the push less effective. Coaching the mother to "push the baby down and then up to the ceiling" seems to help as well.

This position has saved many of my mothers from a c-section. I try to suggest it after the mother has tried any positions she prefers and before she becomes exhausted. I explain that, while it may seem to be a strange position, it may shorten the time needed to push the baby out. At the time of serious crowning, the towel can be abandoned and the mother may assume any position desired.

It makes me sad when I see current writings that caution women to refrain from lying on their backs at any time during labor. We all know why women are told this, but we also know there are exceptions to everything. By the way, this position works with or without regional anesthesia, for those practicing in hospital settings where anesthesia is common.

Mary Jo Terrill, RN, BSN, MSW
Santa Barbara, California

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 mtensubmit@midwiferytoday.com.

Research to Remember

Babies may experience withdrawal symptoms in the first few days of life if their mothers had taken antidepressants such as Paxil or Prozac while pregnant, according to a Spanish study. Infants' postbirth symptoms include convulsions, irritability, abnormal crying and tremors. Although infants seem to recover within a short period of time, the study raised concern about developmental impact following exposure to antidepressants in utero. The University of La Laguna School of Medicine researchers recommend the lowest effective dose of antidepressant, psychotherapy, and/or other approaches whenever possible.

The Lancet, Feb. 5, 2005

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Protecting the Perineum

With the vast majority of births, the perineum is intact. Otherwise, there may be a few minor abrasions ("skid marks"), none of which require stitches. These are most likely to occur on the labia and look rather like torn chicken skin with smooth and intact flesh underneath. Suturing these is contraindicated, because stitches will not hold unless imbedded in the flesh.

Sometimes a minor internal split of the bulbocavernosus muscle occurs, even thought the perineum remains intact. If bleeding can be controlled with a bit of pressure (using sterile gauze), I usually do no suturing at all. Internal tear edges will usually meet and join together as long as the split is no more than halfway through the muscle. First-degree perineal tears also heal nicely by themselves if the mother takes good care of them.

But be sure to make a thorough and honest assessment of each and every laceration. Unfortunately, there is a strange status quest among midwives regarding the ability to do tear-free births; do not let this prevent you from suturing when it is clearly necessary. Sometimes the mother will be more comfortable if sutured, especially if tear edges do not approximate (fit together by themselves).

Elizabeth Davis
Excerpted from her book, Heart and Hands: A Midwife's Guide to Pregnancy and Birth, 4th ed. (Celestial Arts, 2004)

In a branch of medicine rife with paradoxes, contradictions, inconsistencies, and illogic, episiotomy crowns them all. The major argument for episiotomy is that it protects the perineum from injury, a protection accomplished by slicing through perineal skin, connective tissue, and muscle. Obstetricians presume spontaneous tears do worse damage, but now that researchers have finally done some studies, every one has found that deep tears are almost exclusively extensions of episiotomies. This makes sense, because as anyone who has tried to tear cloth knows, intact material is extremely resistant until you snip it. Then it rips easily.

By preventing overstretching of the pelvic floor muscles, episiotomies are also supposed to prevent pelvic floor relaxation. Pelvic floor relaxation causes sexual dissatisfaction after childbirth, urinary incontinence and uterine prolapse. But older women currently having repair surgery for incontinence and prolapse all had generous episiotomies. In any case, episiotomy is not done until the head is almost ready to be born. By then, the pelvic floor muscles are already fully distended. Nor has anyone every explained how cutting a muscle and stitching it back together preserves its strength.

Henci Goer,
Excerpted from Obstetric Myths Versus Research Realities: A Guide to the Medical Literature (Bergin & Garvey, 1995)

They kissed lovingly as their baby's head began to emerge from her perineum. It was almost too intimate a moment to witness: mother and father expressing their love as the mother opened her lips, soft and moist, and the baby boy came into the world, slowly emerging. His parents barely separated from their kiss and turned to look at the baby revealing himself to the world. His mom reached down and, in one slow caress, placed him upon her breast where he was welcomed into their love. She was Intact and a first-time mom.

Seconds after the birth, her perineum looked as if no birth had happened at all. Her vaginal lips and perineum were as normal as they had been before she was pregnant.

Body workers and holistic practitioners know that the body is interconnected with itself. They explain that the lips of the mouth are related to the lips of the vulva, the mouth to the vagina (they even have similar mucosal tissue), the uvula to the cervix and the jawbone structure to the pelvis. The relationship works in synchrony. An open jaw opens the pelvic girdle, a relaxed mouth relaxes the vagina, and soft lips ready to kiss work wonders for the perineum.

Marina Alzugaray,
Excerpted from "Tear Prevention the Orgasmic Way," Midwifery Today Issue 65

MIDWIFERY TODAY ISSUE 65 can be ordered.

If a mom is in the birth tub, I encourage her to position herself instinctively and put her hands on her perineum as the head emerges. This eliminates entirely the "push a little, now pant, now push a little" routine. The mother knows exactly how much to push. I have seen virtually no tearing, even in primips, and I love how empowering it is for the mother.

If the mom is out of water, I pour a lot of olive or grapeseed oil in the introitus and let her move into whatever position she chooses without giving her suggestions, unless she wants them. Most women end up on hands and knees or squatting. Sometimes they stand, but they almost never lie down. I don't use hot compresses anymore since a study came out that showed hot compresses and perineal massage may increase tears.

Anon., Midwifery Today Forums

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Web Site Update

Membership in the International Alliance of Midwives (IAM) is now free! Join this web-based organization to learn about birth around the world and meet other people interested in safe, gentle birth. When you become a member, you'll receive access to a searchable directory of IAM members and a subscription to the IAM newsletter, sent to you three-four times a year by e-mail.

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We have made the most recent issue of the IAM newsletter available password-free so that you may view it before joining. This captivating and informative issue of IAM includes contributions from readers around the world. The varied postings include:

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IAM is not just a generator of information, but a purposeful and interactive publication!

Forum Talk

What do you wiser women tell your clients about when to resume sexual relations? One OB said, "the playground is closed till she comes back to see me." I generally tell them when they are no longer bleeding and feel comfortable. Sometimes I think moms need some "protection" to be able to refuse—a start date. Does that come up in your cases? I don't know health-wise what I should be saying. Also, what do you say about sex during pregnancy? I tell them they can as long as they want to, unless the water is broken. I also think sometimes women are looking to me to give them a stop date too.


Go to our forums to share your thoughts and experience.

Question of the Week

Q: I have a student who has had a numb and tingling arm for two days. She is 30 weeks pregnant. Any suggestions as to cause or where I could find more information for her? They have started her on the rounds of doctors, but I am concerned they won't have accurate information for her.

— Amy V. Haas, BCCE

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.

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Question of the Week Responses

Q: I recently had a c-section for twins because twin A was a footling breech. Unfortunately, I had to be put under general anesthesia because my platelet levels were too low to safely have an epidural. Is there any sort of homeopathic or herbal remedy that I might try to build up my platelets? My platelets generally are around 70 and have been that way for years, with 50 being the point where treatment is needed, but 100 is the cutoff to get an epidural. When I have another child, I would like to have a VBAC, but if it doesn't work, I don't want to have to be knocked out again.

— J.B.

A: A low platelet count is a clue that there may be another underlying health problem such as an autoimmune disorder. The first recommendation is to have further blood tests done to find out if you do have an autoimmune disorder. If you do test positive, then you would need to develop a plan to keep yourself as healthy as possible in spite of the disorder. By taking care of your whole body, including stress management, you should be able to improve your platelet count. Platelets facilitate blood clotting so that you don't bleed too easily. Diet is the best way to build healthy blood and normal clotting factors. Deep green veggies and sprouts are the best dietary sources.

— Marcia McCulley, NP, LM
Simi Valley, California

A: I wonder if your doctor has diagnosed you with idiopathic thrombocytopenia (IP). This just means that there is no underlying medical condition that is causing your low platelet count. You stated that your platelet count is always around 70, which leads me to that question. Some people still clot just fine with a platelet count of 70, if they have IP. I would see your care provider and discuss your concerns with her. There are then some blood tests (clotting studies) they can do to see if you are clotting OK even with a low platelet count. A count of 100 is a general cutoff for an epidural, but if your clotting studies are fine, most anesthesia providers will do an epidural. When you first are in labor, make sure you alert your care provider immediately so she can have anesthesia work you up and do those clotting studies again. This could help you avoid general anesthesia.

— Karen Roeske, RN, IBCLC

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

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When I first practiced midwifery in the early 1970s, obstetrical standards of care encouraged universal episiotomy. It was supposed to protect the perineum from over-stretching and "shattering," preserving the birthing woman's sexuality. Later, studies showed that experiencing episiotomy during childbirth leads to a higher incidence of sexual dysfunction. The use of the procedure has decreased dramatically in most countries.

In exchange, we have a movement toward near-universal cesarean section to prevent pelvic floor damage! Thus a technological system embraces a technological solution.

As a practitioner who does hundreds of gynecological exams every year, it's hard for me to understand the reasons for this trend. I see woman after woman who has had children and presents for her pelvic exam with the vaginal orifice so neat and tight, the pelvic musculature so strong, that I have to glance back at the chart to assure myself that she has indeed given birth. For the majority of well-nourished women, the healing power of the human body is remarkable. Healing that seems inadequate at the six-week exam may be perfect by the time the baby is six months old.

Marion Toepke McLean
Excerpted from "Childbirth and Healing" (Marion's Message), Midwifery Today Issue 65

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April 21–23, 2005 Indianapolis, Indiana

Speakers include: Jan Tritten, Doran Richards, Shonda Parker, Roxanne Trent, Eneyda Spradlin-Ramos and Laurie Zoyiopoulos.

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Aceh Midwifery Relief Update from Robin Lim

February 2, 2005

Dear family, loved ones,

In two days our "Mother/child survival" team will leave for Aceh. It has been a wild ride getting ready.

The direct family members going along will be Wil, Deja, Thor and myself. Other team members include Ida Tanjung, Kelly, and Oded. We will join a group of 16 sanitation (well and out-house diggers) workers from Bali.

We will travel from Medan to the West coast of Sumatra, to an area near Meulaboh, to a small area not on most maps called "Sama Tiga." There we will be setting up human resource services. My focus will be women and children (no surprise). The reports we had from this area yesterday said, "It's a lot worse than we imagined. The women are hiding, no matter how sick, hungry, pregnant or injured, they won't come out to seek medical aid, or food, or any help, as they culturally cannot have contact with male relief workers. Get over here, fast." These were the words of Christine, whose husband, Ngurah heads up the sanitation guys. Thor, by the way, will be digging those out-house holes.

"Birth buckets" are the most important things will be bringing for the expectant women. The birth buckets contain high protein foods, rehydration fluids, a sarong (remember, they lost everything in the tsunami, including 80% or more of the population), veils (Muslim women will not come out unless their heads are covered), candles, a lighter, underwear, receiving blankets, baby clothing, cloth diapers, vitamins, herbs to prevent hemorrhage and Betadine for cleaning hands where there is no water. Looking at the first buckets we made up, I cried, knowing that if I had been given one of these buckets when I was a young mother-to-be, it would have been useful, and I would have been full of gratitude.

Please read the rest of Robin's update.


Kelly Dunn is a lay midwife working with two nongovernment organizations (NGOs). Yaysan Bumi Sehat (Healthy Mother Earth Foundation) had run a successful community cooperative clinic in the village of Nyuh Kuning. However, after the tsunami everything has been destroyed. Yayasan Bumi Sehat is a nonprofit organization (NPO) of community members, midwives, and doctors who help advocate for reproductive rights for low-income, marginalized, and displaced women and their children. They are now offering their services to the thousands of women who are birthing without any assistance or help. They offer free prenatal, postpartum and birth services. They also promote and educate natural family planning. Right now they are creating birth buckets to give birthing women in this area the basics for a birthing mom. They are getting some funding through IDEP (www.idepfoundation.org/), an NGO in Indonesia working directly with the people. Both these groups are well-known, and all their money is documented. Midwives and readers who want to give directly to these organizations can find more information at www.idepfoundation.org/Idep_partners.html.

Kelly and all the people on her team are volunteers. It would be really wonderful to be able to help these people. I am doing everything I can from this side to help them raise funds. They are doing terrific work, and Kelly is now volunteering her time overseas.

Heather Mauer, Executive Director
The Institute for Professional and Executive Development, Inc.
Washington, DC 20004

In response to Sandy Caldwell [Issue 7:3]:

I also think you should consider where we young women get our "dramatic" ideas. Remember, many of us grow up hearing from our mothers and grandmothers how scary, painful and dangerous labor and delivery are. Is it any wonder many of us are jumpy or flat-out looking for ways to avoid the whole ordeal? Many mothers and grandmothers are encouraging our "dramatic" behavior. If we want to change the c-section rate, we will need a little compassion for the emotional climate the women of our country are coming from.


I agree with Gloria's statement and discernment. I attended a birth center in a culture where the older women mentor the younger and was amazed at the length of their second stages! These women pushed their babies out in minutes compared with our culture's hours. No observable fear, no drama, and many times a calm, present mother as support.

I see in myself the need to "be still and listen," to absorb. In essence, I've only come to this realization after listening to the communication of an older, more seasoned midwife. I never got this from my relationships with other women and now wonder why.

Thanks for pointing out the unfortunate reality that we are not mentoring our younger women. This is yet another area we can only individually adjust, if we choose. Still learning, growing and changing at forty-something; now slowing down long enough to hear, from you and others. Also, as I read it, the truth can only set you free IF you know it. Maybe madness is yet another form of internal unrest? Good expression nonetheless.

Lisa Byrd, licensed midwife, certified doula

The evidence of a 28% c-section rate has nothing at all to do with the dramatic nature of young girls. To blame women for a problem created by a patriarch commanding control of the female birth process is short sighted, indeed. The lack of education about options is to blame for the c-section rate. Media and advertising pumping fear into the minds and bodies of men and women regarding birth is to blame for the c-section rate. Older women teaching and mentoring young girls only goes so far when they are up against hundreds of visual television images that teach the young girl to fear birth, distrust her body, and run from the unmanageable pain.

I am appalled at your continued short-sightedness—to publish a rebuttal that is continuing to miss the point makes me question this newsletter. Shall we go ahead and blame "female immaturity" for the sexual assault crisis in our world?

Deanna, Denver

Gloria is correct. As a labor and delivery nurse from an impoverished area, I see so many women come in with expectations of a quick and painless labor. As we all know, childbirth is rarely quick or painless. At 2 cm I have women writhing, screaming and kicking. They beg for an epidural before they are even in active labor. Many women plead with the doctors to induce them at 37-40 weeks because they are "tired of being pregnant." To keep the patients happy, many doctors will concede.

Perhaps we are missing the extended family wisdom. We no longer have a community of women who come to the laboring woman's home to give comfort. We have lost the wisdom of letting nature take its course.

I'm sure many doulas and midwives will disagree, but social, economic and educational levels must be taken into consideration. Clients who can afford a doula or to pay for an independent midwife will have educated themselves and be more prepared for the reality of birth. In my experience, the more affluent and the very poor are more likely to demand intervention. The exception to this has been our Hispanic and young African American clients. Those women with stronger cultural bonds seem to accept the discomfort and hard work required to birth a baby into this world. These cultures in our area seem to be wary of medications and procedures that will negatively affect the baby. They are less likely to smoke, drink or use street drugs, and amazingly, their babies do much better regardless of their gestational age! A young woman who comes in expecting a natural, low-intervention birth is a joy to work with.

Lori Brubaker, RN
Downingtown, Pennsylvania

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

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