Avoiding the Big E (Episiotomy)

Of all the squeamish discussions about birth experiences probably nothing makes you cringe and cross you legs quicker than when talk about labour turns to the big E…..no not the epidural but the episiotomy.

More and more women in are questioning a continuing routine procedure that involves enlarging the opening of the birth canal as your baby’s head crowns.

Many hospitals continue this outdated procedure despite significant studies that show routine episiotomies cause more harm than good.

Learn how you can avoid an unnecessary episiotomy.

Imagine the following: if you hold a piece of cloth at two corners and attempt to tear it by pulling at the two ends it’s very difficult to rip. However, if you make a small snip in the centre, and pull the corners the cloth rips easily with no resistance.

Episiotomies are ‘said’ to have the following benefits (there's no research to back these claims.

• Speed up the birth
• Prevent tearing
• Protects against incontinence
• Protects against pelvic floor relaxation
• Heals easier than tears

The following have been reported as side effects of the episiotomy:

• Infection
• Increased Pain
• Increase in 3rd and 4th degree vaginal lacerations (euphemistically called extensions)
• Longer healing times
• Increased discomfort when intercourse is resumed

Following are some of the myths surrounding episiotomies

Myth: A nice clean cut is better than a jagged tear.

Reality: "Like any surgical procedure, episiotomy carries a number of risks: excessive blood loss, haematoma formation, and infection. . . . There is no evidence . . . that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents fetal trauma or reduces the risk of urinary stress incontinence." Sleep, Roberts, and Chalmers 1989

Routine episiotomy (as opposed to episiotomy for an emergency situation such as fetal distress) is a typical example of an obstetrical procedure that still exists despite a total lack of evidence for it and a considerable body of evidence against it.

Myth: Episiotomies help prevent brain damage as the baby’s head ‘pounds’ against the tissues.

Perhaps the most absurd rationale of all is brain damage from the fetal head's "pounding on the perineum." A woman's perineum is soft, elastic tissue, not concrete. No one has ever shown that an episiotomy protects fetal neurologic well-being, not even in the tiniest, most vulnerable preterm infants, let alone a healthy, term newborn (Lobb, Duthie, and Cooke 1986 and 1990.

Myth: Episiotomies help protect the mother’s pelvic floor and reduces her chances of incontinence.

What are pelvic floor problems?

Many women experience pelvic floor dysfunction around the time of birth and/or later in life. Pelvic floor problems include leaking urine (urinary incontinence), leaking gas or — more rarely — feces (bowel incontinence), sexual dissatisfaction, and a sagging of the inner organs (uterine and other pelvic organ prolapse). It is important for every woman to understand what she can do to keep her pelvic floor strong and protect it from injury. In a study released on Dec 12 routine episiotomies increase your risk of incontinence in later life.

Separating fact from fiction: what causes pelvic floor dysfunction?

These days, there is a lot of conflicting and confusing information about the cause of pelvic floor problems. Vaginal birth has been blamed, and some suggest that enlarging the opening of the vagina by cutting it at the time of birth (episiotomy) or even having a surgical birth when there is no medical complication (elective c-section) will prevent weakened pelvic floor muscles and injury. Unfortunately, there is a lot of false, unproven, and incomplete information on this topic.

Gordon H and Logue M. Perineal muscle function after childbirth. Lancet 1985;2:123-125

Myth: Some women need episiotomies because they are not as ‘stretchy’ as others.

Another absurd example of non researched based practice. There is no medical evidence to support this.

Episiotomies are rarely necessary; you can lessen your chances of having this surgical incision. Some preventative measures that may help are:

• Chose a Doctor/midwife who doesn’t do routine episiotomies. (Ask your Doctor how often he finds it necessary to do episiotomies)
• Good nutrition (healthy skin stretches more easily)
• Do your Kegels (exercise for your pelvic floor muscles)
• Prenatal perineal massage
• Slow controlled pushing instead of directed pushing by Doctors and midwives. (Only push when you feel the urge). Let your body nudge your baby down.
• Birth in the position of your choice – not on your back.

• Labor in water
Add to your birth plan that you prefer not to have an episiotomy
Remember, as with any medical procedure, there is always a time and a place where it is a valid option for example if your baby is in distress.
Being knowledgeable about your body and any proposed procedures during labour will take you a long way to having a safer more satisfying birth.
Hartmann K, Viswanathan M, Palmieri R, Gertlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review.JAMA 2005;293:2141-8.

Eating in Labor

As pregnant moms we've probably never been more focused on food than any time in our lives. Even analogies about baby’s size and our body parts are associated with food - as if we weren’t obsessed enough!

Your baby is the size of a bean…..your uterus is now the size of a grapefruit…..your boobs are like….(well you get the picture !) You’ve probably spent endless hours online researching what you can and can’t eat during pregnancy.

Some moms have cravings and can’t get enough of a particular food...(for me it's pineapple juice)….others struggle with all day morning sickness and it takes a huge amount of willpower and determination to even get a few crackers past your lips.

There’s also Pica which is the term for unusual cravings. The reason that some women develop pica cravings during pregnancy is not known for certain. There is currently no identified cause; but according to the Journal of American Dietetic Association there may be a connection to an iron deficiency.

Some speculate that pica cravings are the body's attempt to obtain vitamins or minerals that are missing from a mom’s diet.

The most common substances craved during pregnancy are muck / clay. Other pica cravings include: burnt matches, stones, charcoal, mothballs, ice, cornstarch, toothpaste, soap, sand, plaster, coffee grounds, baking soda, and cigarette ashes…

Science recognizes that good nutrition during pregnancy is essential for both mum and baby. Newly pregnant moms often spend a significant amount of time ‘grazing’ or snacking regularly to keep their blood sugar levels normal.

If you’ve missed a meal lately you’ve probably experienced some of the following side effects

Increased crankiness…

You may even have passed out

Skipping meals during pregnancy isn’t recommended and you’d never willingly starve yourself during your pregnancy……so why would you do it in labor?

Let’s look at the history of where this began and what can happen when a mom having a normal labor is refused nourishment during labour (assuming she’s hungry - some mums have no interest in eating)

Mendelson’s Syndrome: Mendelson's syndrome is the inhalation of gastric contents and is a risk during intubation for a general anaesthetic (you’ve probably seen intubation on Grey’s Anatomy).

Most cesareans are performed with a spinal or epidural these days. It is rare to have a general anesthetic for a cesarean birth. The original article by Mendelson dates back to 1946 so it’s a little bit outdated. The great news is that in 1961 a technique called Sellick's manoeuvre (wonder if he looked like Magnum) was discovered which minimized the risk of gastric contents entering the lungs during a general anesthetic.

What a breakthrough for laboring mums….it meant that all normal low risk women (80 – 90% of mums reading this) could go back to eating in labour again !! Yay !!!………but wait a minute….that was 47 years ago…..obviously some hospitals missed that memo

Without food for a long period of time a labouring moms body enters into ketosis. When you first deprive your body of food your metabolism begins to shift to accommodate this. The first stage is known as lipolysis, and means your body is burning fat to provide you with energy (sounds like a great way of burning off those extra pregnancy pounds….AFTER you’ve had your baby !!)

Ketosis is the second part of the process that takes place when your body has no carbs to provide it with energy so it needs to use the energy from the fat being burned. In a nutshell (see …can’t stay away from those food analogies) The unused portions of the fat cells are called ketones, and are removed from the body in the urine. Ketosis is a signal that you are breaking down your fat reserves……your body is effectively eating itself to give you energy during labor. Sounds a bit like the Atkins Diet.....

So you're at the hospital....starving...cranky....exhausted.... and that's just your partner ! Plus you feel pain much more intensely ! Not exactly the recipe for a positive birth.

Of course some moms have no interest in eating in labour – if you’re very anxious and afraid during labour high adrenaline levels slow down the digestion process.

If you’re giving birth in a hospital that is stuck back in the 1940’s bring along some snacks for yourself and your partner – just in case you do get hungry. Chances are your won’t be in the mood for a Big Mac.

Even in these 1940’s hospitals there are some staff that are happy for you to snack to keep your energy levels up if you’re hungry so all is not lost ! If you ask around you might find that on one side of town you can eat & drink all you want - and on the other side you get a cup of ice chips -YUM !!

Talk to your caregiver about having the option of eating/drinking during your baby's birth. If you're having a hospital birth and meet some resistance on this topic staying home longer means you decide if you'll eat AND what's on the menu!
Bon appetite !!
Tracy Donegan

Laughter is still the best medicine - even in labor !

According to an article in the Boulder Daily Camera ("Laughter really may be among the best medicines," Nov. 4, 1996), laughter helps control pain, lower blood pressure, relieve stress, and increase muscle flexion. It also shuts off the flow of stress hormones, increases the body's ability to utilize oxygen, and triggers a flood of beta endorphins, the brain's natural morphine-like compounds that can induce a sense of euphoria. Although the article doesn't specifically mention birth, the following comments from birthing women, midwives, and doctors speak for themselves:

"Even though I was still on my hands and knees, my hearing suddenly became very acute. I could hear Gordon on the phone in the next room: Glenn? This is Gord. Could you ask Elly to come over. I think the baby's coming. You think the baby's coming? I echoed to myself. And suddenly, I laughed. I could not help it - the man's hesitation struck me as funny. I laughed at the ridiculousness of it all. Suddenly, I was looking down a tunnel the long way around, as if a telescope inside me - that was somehow outside me - was turned backwards. As I laughed, the baby's head popped out. I tightened my pelvic floor muscles and, turning my head, noticed Gordon at the doorway. Imagining how ludicrous I must have looked, reared up on my haunches with a baby's head sticking out of me, I laughed again. This time, the baby simply fell out into Gordon's out-stretched hands."
-From "They Don't Call it a Peak Experience for Nothing," by Ruth Claire (Mothering, Fall 1989)

"Then Dick said, 'The head's showing!' I laughed and said I knew. I gave one firm push while pressing on my clitoris like it shows in Birth and the Dialogue of Love (page 126) and it really helped. (It was a big head.) I wanted to lay down and then I did. Dick was still hugging me and I was laying on him and laughing inside at what a sight it must have been. He told me to let him up. I didn't want to move but I did. He got out from under me, grabbed some clean towels, and put them on the floor. I knelt and he caught the baby all in a matter of seconds."
-From The New Nativity

"She danced and danced throughout her labor. No noise, no fuss, just intense concentration and dancing. After many hours she looked up at me with a puzzled expression and said: 'I can't do this anymore.' I asked if I could check her, and when she opened her legs, the baby's head was crowning. I told her that was why she felt that way, and she began to laugh, and laughing, birthed the baby into my surprised hands. Her partner took pictures: a baby born en caul to a laughing VBAC (vaginal birth after cesarean) mother. We must witness, talk story, tell the good stories to counteract our culture's horror of birth. It is possible to birth in peace and joy."
-Anne Stohrer, M.D. in Compleat Mother magazine, Winter, 2000

"I noticed that whenever Judith would laugh at something, she'd have a very good rush [contraction] right afterward, which would dilate her cervix a bunch more. So we all sat around and had a good time talking with each other, and after a few more rushes I checked Judith again and found that she was fully dilated and ready to push the baby out."
-From Spiritual Midwifery, by Ina May Gaskin

"Sarah announced her desire to enter the world quite amusingly. As Rich looked down to see where we were, the waters broke in his face...We laughed until the next contraction which brought the crowning of her head. Then two more contraction-pushes and she was here!"
-From Two Attune

"I sat down on the floor and leaned against the pillows. The desire to push overcame me. For several pushes I pushed with caution while Bob rubbed ointment into the perineal area. He informed me that he would 'do the looking.' I had to laugh at Bob's comments. I began to pray this this would be the last push and began to act on that request with all the power within me. At this point Bob used his baseball training because our Naomi became a pop fly. Once again I found myself laughing at Bob's crazy monologue. Such sweetness!"
-From The New Nativity

"I was laughing when I was pushing, and he was just in awe. And when he came over holding this tiny baby, it was probably the most beautiful moment of my life."
-Melanie Griffith (Mrs. Antonio Banderas) in Ladies Home Journal, Sept., 1997

"Brian and I were smiling and even laughing in between contractions because even though they were very intense I felt so good in between them; it was like I wasn't even in labor. I had one really big contraction and my water broke. I felt like pushing so I got in a comfortable sitting position and with the next contraction my baby's head was out. One more push and our son was in Brian's hands."
-From The New Nativity

"With one arm around Shara and another around Cary, we attempted to walk, push, walk, push. 'Are you giggling?' Cary asked. 'No,' I smiled, I was laughing. Although my bottom was bursting, my clitoris was tickling. It felt almost orgasmic. So all of us walked around the room laughing. What a sight."
-From "Homebirth Minus a Midwife" by Alaina Chapman (Compleat Mother, Summer 1994)

"We returned to the bedroom where I positioned myself on the end of the bed to be in position for the baby to be born. (Our bed is on the floor.) I was half-sitting, half-squatting and pushing hard. The bag of waters broke then, gushing all over Bill, who was on the floor in front of me and we laughed. Oh, that felt so good."
-From The New Nativity

"Mary Louise came. She was getting stuff together and I was rushing and started noticing that when I looked in her eyes through a rush I got some strength to feel it as a force that was intelligent and courageous. I noticed that when I looked at Edward through one I felt it as a pain. When I asked her about that, she said that it was because she wasn't believing that it was painful and that I needed to keep my sense of humor and be nice to Edward. That clicked and with the next rush I laughed, and started laughing as they came. That got the energy up higher and of course the rushes came on stronger."
-From Spiritual Midwifery, by Ina May Gaskin

"I caught Max myself in a bathtub of lovely, relaxing warm water - and he was born in a 'laugh,' as I was vocalizing a HO - HO - HO sound (a very open sound which came instinctually)."
-From Waterbirth! by Cat Majors

"I didn't think the baby was moving down very fast. Loring crawled back up to tell me I was doing fine. Then he gave me a long kiss and crawled back to inspect my bottom. On his next trip back up to smooch with me he told me I had a cute behind and I really had a laugh. I guess the laugh was what I needed to do."
-From The New Nativity

"I was afraid to laugh because I thought it would make the baby come out. This was true and I realized that if I laughed and loosened up that the pain would go away and Louisa would come out really easy and everything would be psychedelic and Holy. I laughed. Mark and I started smooching a lot to keep my mouth really loose. This made the contractions come on really strong."
-From Spiritual Midwifery, by Ina May Gaskin

Tokophobia (Fear of Childbirth)

Tokophobia is a debilitating fear of childbirth which in many cases is so profound that it can lead to a complete avoidance of pregnancy or a pregnancy filled with terror and anxiety. As women are exposed to disturbing images and stories of childbirth from friends family and especially the media, Tokophobia is becoming more and more common.

Actress Helen Mirren described where her own fear of childbirth came about in a recent interview after being exposed to a childbirth video in her early teens in school. "I swear it traumatised me to this day. I haven't had children and now I can't look at anything to do with childbirth. It absolutely disgusts me." - Helen Mirren

This high level of fear is irrational and it cannot be consciously controlled by techniques such as counselling, yoga or controlled breathing…(although these will help with the feelings of panic)…...the change has to be initiated in the subconscious mind. Just like any other irrational fear such as flying or other phobias it’s easy to resolve with hypnotherapy. All the talk therapy in the world won’t even scrape the surface with an irrational fear. You can’t reason with such a strong negative belief….women often say – “logically I know birth is relatively safe and my hospital has all the tools I need if it’s necessary so why am I still so terrified?” When sufferers understand that it’s not the logical reasoning part of their mind that is creating this panic it’s the subconscious mind an area which we have no conscious control over.

If you suffer from Tokophobia you are not alone and help is available. Self hypnosis ‘upgrades’ the programming/your beliefs about birth so your mind expects childbirth to be positive and something to look forward to - not dreaded.

Having worked with many Tokophobic clients we’ve developed a self-help program that changes how you feel about pregnancy and childbirth easily and effectively in a few short weeks. You weren't born with this fear and it's easy to recondition your subconscious mind to expect pregnancy and birth to be much more positive – something to be excited about rather than feared and avoided. Using self hypnosis you begin to associate pregnancy and birth with much more positive images and feelings. You may still have the same thoughts about childbirth but the anxiety is gone.

For whatever reason (movies…..scary birth stories etc) your subconscious mind has associated childbirth with something to be feared so we are changing that association and conditioned response from childbirth = panic/hysteria and fear to childbirth = confidence and excitement.

It’s not magic but it definitely feels that way to the women who go from planning a cesarean or general anesthetic for childbirth from the moment of that first positive pregnancy test to comfortable enjoyable pregnancies and even blissful births !!