Some thoughts from the Midwifery Today Conference Eugene, Oregon April 2013 on:
“Preventing and Treating Perineal Trauma”.
Well I have been home from the Conference in Eugene Oregon for over two weeks now. My mind is buzzing with all of the things that I learnt. I highly recommend the Midwifery Today Conferences and encourage you all to attend one if you ever have an opportunity to go. The conference was very well organized and had just the right blend of topics to appeal to everyone’s needs.
One of the topics that I was particularly interested in was, How to Prevent and Treat Perennial Trauma during Birth. Ripping or tearing during birth is a common fear among many of the mothers in my care. So, I was keen to find out if there was anything that could prevent this sort of trauma happening in the first place, and if there was any alternative to having stitches.
This talk was presented by Gail Hart from USA who has been a practicing midwife since 1977. Presently, Gail is now now semi- retired whilst still managing her small midwifery practice. Her Book; Research Updates for Midwives (2012) is full of wonderful text of tit-bits to improve a mother’s experience of pregnancy, labour and birth as well as some great ideas about how to holistically incorporate evidence- based medical knowledge with traditional midwifery understandings.
Traditionally it has been thought that first time mothers are at the highest risk of tearing. This was why it was considered routine for many years to offer the mother an episiotomy (birth cut) just in case she tore. However,
“In the 1980‘s Gail did a study with 800 women to find out who is more likely to tear. Surprisingly it turns out that: The first time mum is the one that is least likely to tear!” ( Hart 2013)
It was the mothers who had already had a previous episiotomy who was at the highest risk of tearing.
Now thank goodness, this is no longer considered best practice. Gail cited other studies that reinforced her own findings in the Israeli Medical Journals and the Cochran Review.
Factors to be considered in tear prevention:
As far as the causes of tears and the contributing factors to sustaining a tear, Gail suggests that some mothers are just more “stretchable” than others. She explains that there’s a natural variation between individuals. Some mothers will just have a better skin integrity and maybe more collagen than others. So genetics definitely has a part to play here. It is a well known fact that eating well is important for a heathy baby.
But what is less well known that to reduce the chances of tearing or needing an episiotomy (birth cut),
“A well nourished mother with a diet that has a lot of vitamin C in it will fair better than the mother who only eats junk food.” (Hart 2013)
Pre-natal preparation such as perineal massage has also been mentioned in many studies. The Cochran Data base has done a review of a study done with 23,034 women and found that digital perineal massage in pregnancy has been linked to a reduction of perineal trauma requiring suturing.
However this result was significant only for women who have never given birth vaginally before. The women where instructed to do about 10 minutes of perineal massage a day from 34 weeks of pregnancy onwards. (It can be an advantage to involve partner participation, could be fun.)
Perineal massage seems to help some women as a pre-natal preparation only. As far as the second stage goes (during crowning and the birth of the baby) there does not seem to be any advantage in it.
Management of second stage.
Interestingly, the concept of “coached pushing”, where the mother is instructed to hold her breath and bear down for a count of ten. Has been shown to increase perineal trauma and vulva edema and acidosis in the mother and baby. Gail said that there is a misconception that “coached pushing” can speed up second stage and she didn’t agree with coached pushing because of these effects.
The question is then posed, “What can be helpful to reduce this type of trauma?” Gail suggests, warm compresses (i.e a warm cloth applied against the perineum) Gail outlined methodology of how she prepared the warming of the water and it’s application. She suggested the water was brought to the boil in a crock pot or large ceramic container with a whole ginger root. Allowing for the ginger root to infuse into the water that will then be used for the compresses.
Included in this ginger root mix, Gail includes Comfrey for it’s healing properties. Given that warm water is very comforting for the mother, I feel that this would be a benefit in the use of compresses. The ginger has an added benefit of keeping the blood circulating in the perineal area and preventing it from stagnating and building up in the perineal tissues. This then enhances the stretchability of the vagina and perineum.
Oils and Lubricants.
Oils and lubricants can also be very helpful in the prevention of tears, as they help the baby to slip out more easily. Gail uses olive oil but sweet almond oil and grape- seed oil are also okay to be applied in liberal amounts.
Gail stated that, “the mother’s position during birth will also have an impact on the integrity of the perineum. The absolutely worst position for the mother to be in as far as perineal trauma goes, is on her back with her legs up wide”. (Hart 2013)
Upright positions surprisingly put less tension on the pelvic floor and perineum.
Additionally, side lying while birthing has many benefits. This position should be the position of choice for women who have had an epidural. Immediate benefits of the side lying position include a decreased incidence of tearing in this position and also this is better for the baby as can be evidenced with improved cord blood studies.
”Non supine positions are associated with a decrease in perineal trauma, a decrease in vulval edema and less blood loss.’’ (Hart 2013)
Alternatives to Sutures.
When it comes to making the choice to have stitches or not, it is important to remember that stitches do not actually heal anything. All they do is bring the edges of the wound closer together so that healing can take place more easily.
Sometimes people heal faster without stitches. The inflation and irritation that can come with the sutures themselves not only delay healing but also increase the discomfort of the mother. So it is worth while to knowing about alternatives used throughout the world. Here are a few;
Stop any Bleeding.
If the wound is still bleeding the first thing you need to do is to control the bleeding. This can often be most simply done by just applying pressure to the part that is bleeding.
Some of the Amish midwives at the conference said that they soak a cloth in vinegar to stop the bleeding. They also mentioned other simple remedies such as sugar or salt. Sugar coagulates blood and will also help to stop the bleeding. Apparently salt works in the same way to clean the wound and stop the bleeding but it stings a bit so most Amish mothers prefer sugar.
The more modern midwives at the conference suggest the application of some lignocaine with adrenaline they put some of that on a swab and apply it to stop the bleeding. Easy, simple but very effective!
Honey has also been shown to enhance wound healing. However, the woman needs to limit her movement with this one so that the edges of the wound can stay close to each other. The traditional midwives spoke about binding the woman’s legs together for a day or so in these sorts of situations.
Other midwives also said that Super glue was just as effective!
In conclusion, I very much enjoyed Gail’s presentation. Gail’s way of presenting research in a matter of fact useable way was very helpful to me in my understanding of this topic. I hope you, the reader have also found something interesting or helpful that you can take away.
In the mean time, Happy Birthing!