The Art of Midwifery
Intact in the Hospital
Here's a couple of tricks of the trade I have learned from physicians on how to conduct a birth with an intact perineum in the hospital:
l. Forget those little gauze sponges and ask the nurse to bring in ten face cloths from the linen cart. She then puts some hot water from the tap in a beaker and applies gentle, hot compresses for the woman to push toward gently. If they are contaminated by any feces, the nurse can throw them under the bed one by one as she goes through them. (They are removed later.)
2. Encourage the woman to hold and support her own tissues. Women instinctively slap any hand that is put on the crowning head. This is to be encouraged because it helps her stay in control.
3. The physician saying reassuring words such as "you are stretching beautifully," "there's lots of room for the baby to come through," and "I know this burning is intense but you're doing this nice and easy"--makes such a difference. Practice saying these phrases in the mirror so they come out easily.
-Gloria Lemay, British Columbia
It's natural for the baby to progress and regress over and over. This allows the perineum to stretch effectively. Then, massage the perineum with vernix from the baby's head. -Dr. John Stevenson, Australia
Apply warm compresses everywhere on the woman's body so there is less focus on that one spot (the perineum). The woman relaxes, the midwife relaxes.
-Naoli Vinaver, Mexico
Anal Sphincter Injury
Injuries to the anal sphincter during vaginal deliveries are surprisingly common and may cause fecal incontinence, according to national and international researchers. It has been noted that one fifth of women suffered injuries to the anal sphincter muscle during vaginal deliveries. In routine postnatal follow-up examinations patients are rarely asked specifically about incontinence problems, and they are unlikely to mention them without prompting. Scarring during the healing process can adversely affect the success of initial repairs to the sphincter, contributing to the high rate of incontinence in these cases.
Practitioners should include questions about incontinence problems in routine postnatal follow-up examinations and, when forceps are used in delivery, refer mothers to a colon and rectal surgeon for follow-up. Standard therapies, including biofeedback and surgery, are effective in about 80 percent of cases, and new surgical procedures to repair or replace severely damaged anal sphincter muscles offer hope to the remaining 20 percent. -Birth, September 1998
Preparing the Perineal Tissues
Prenatally, a well balanced diet of enough proteins, fresh fruits and vegetables and very little refined foods is critical to the integrity of the perineal muscles and tissues. Well hydrated and oxygenated tissues promote elasticity and quick healing. Women should drink a minimum of eight glasses of filtered water a day. Adequate fat intake is also important for skin suppleness and elasticity. Supplemental alfalfa tablets contain vitamins A, B-12 and D as well as calcium and phosphorus. Vitamin E (200-400 IU) taken daily with foods or drink containing fat will aid in the absorption. Also, daily intake of vitamin C (1000-2000 mg) will help circulation and tissue elasticity. Red raspberry tea is wonderful for relaxing and helping the entire pubococcygeal area to be supple, especially toward the end of pregnancy.
Greater oxygenation of tissues is not only accomplished by diet, but with exercise by increasing circulation. Athletes train their bodies and prepare the appropriate muscles for their athletic event. The pubococcygeal muscles need to be toned and exercised as well. These muscles, also known as the pelvic floor muscles, form a hammock to support all the woman's internal organs and surround the urethra, vagina and rectum. The toning of the pelvic floor enhances its integrity for life and will help prevent sagging organs later in life. Walking, squatting, duck walking, pelvic rocks, tailor sitting, kegels and swimming are all useful exercises. -Renee Stein, "Perineal Tears," Midwifery Today Issue No. 33
Protecting the Upper Tissues
Years ago I learned a technique that has proven effective in preventing both upper structure damage and perineal laceration. While using this technique the midwife encourages the baby's head to flex (tuck) as it descends to the pelvic floor and keeps it well flexed until the entire occiput is delivered.
With one hand supporting the perineum, I use the other hand to "take hold" of the baby's head toward the occiput as it presents, guiding it under the pubic bone by sort of push/pulling it down and out with the strength of the contraction (and the mother's voluntary effort if needed) behind it. Viewed from the front, added pressure appears to be placed on the perineum, but actually the pressure is directed across the head, encouraging the chin to tuck in nicely. If the baby is big, or the mother's vulva very engorged or varicose, or if she has a cystocele or urethrocele, I usually slip a finger on either side of the urethra and again guide the baby's head under the pubic bone as the contraction pushes outward. This variation squeezes the midwife's fingers between the head and the pubic bone but greatly reduces the incidence of severe bruising, laceration and structural damage of the area.
If the baby is persistent posterior, I reverse the procedure by flexing the head outward toward the pubic bone, thus seeking to reduce the diameter of head that the outlet has to accommodate. In this presentation the baby's forehead is the "hard part" most likely to jeopardize the upper structures. Again, this potential for trauma can be minimized by assisting the occiput to deliver first. If you're not absolutely certain whether a baby is anterior or posterior, it's best not to flex the head at all lest you accidentally deflex it, increasing head diameter and risking unnecessary maternal tissue damage.
To effectively employ this technique, I apply about half as much pressure through my fingers (guiding the occiput under the pubic bone and out) as the contraction and mother's effort apply outward. Additionally, it is essential to visualize, understand, and feel what's happening with the baby's skull, the woman's pelvic outlet, and her soft structures and respond accordingly.
Apart from protecting maternal tissues, this technique prevents a baby from getting caught behind the pubic bone and is most useful in effecting a rapid delivery in cases of fetal distress.
I also try to protect the urethra and clitoris by encouraging the shoulders to deliver one at a time. I usually try to ease the anterior shoulder out first. I lift the baby's head slightly as the second shoulder is more likely to "spurt out." In the case of nuchal arms, which tend to be posterior, maternal trauma can be minimized if total diameter has been reduced by delivery of the first shoulder.
Use of the flexing technique coupled with controlled shoulder delivery will result in less pain, less need for catheterization and extensive repair, and generally more comfortable postpartums, all of which result in happier mothers and families. -Cat Feral, excerpted from "Protecting the Upper Tissues," Midwifery Today Issue No. 5, Winter 1988
Reprinted from Midwifery Today E-News (Vol 1 Issue 17, Apr 23, 1999)
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