There's Morning Sickness, and Then There's...

"Nine months of nausea is a mind-altering experience." - anonymous HG survivor

I had the honor of attending Jo last year for the birth of her little boy. And, just recently, I received that special call that every doula loves to get, "I'm pregnant again!". I am so very excited for Jo and her family! But, she has been plagued this pregnancy, like one before, with severe Hyperemesis Gravidarum (HG).

I am not sure how much you all know about HG, but Jo's story has given me a front row seat to how under-served and misunderstood HG is. With her story being the second that I had personal experience with, I was sympathetic but ignorant about how difficult it is to endure this or how to support her. So I was encouraged when she told me this:

May 15th is the first ever Hyperemesis Gravidarum International Awareness Day

What a great excuse to learn more about HG and to help the public know more about it as well! So, I did what any good blogger would, I asked her to write a guest post about this very subject.

After having a pregnancy with severe hyperemesis gravidarum, I was determined to research ways to prevent it in my next pregnancy. I maintained a healthy weight, took all the recommended vitamins and exercised daily. I was determined to have a “normal” pregnancy. I continued taking the vitamins and exercising when I got my positive test. I started to feel symptoms of morning sickness at 4 weeks and prayed it would stay just that.

I did not want to take any medications to help and had researched the Weston A Price diet for pregnancy and breastfeeding. I felt this was the best diet for babe, so my goal was to stick to it. I got to 6 weeks and full blown hyperemesis hit. I was devastated and losing weight quickly. I ended up in the ER for bags of IV fluids and a shot of Phenergan. It helped some and I was sent home with a prescription for Zofran. I filled it, but planned not to take it unless absolutely needed. Unfortunately I NEEDED it by the next day.

I was throwing up more than 15 times a day. I lay on the couch counting the hours until my next dose of Zofran and until my husband would be off to help me with my son and I could fall back asleep. I would wake up the next morning and it all started all over again. I saw my internist the next week and she gave me more Zofran. In combination with that I had to add Colace and Tylenol to counter the side effects of the Zofran. I felt so ashamed and guilty for having to take medication, so I researched and tried homeopathies.

They did very little to help, so I had no choice but to go back to the Zofran. I had a complete aversion to meat, so the diet I longed to stick to was failing. The only thing that even had a chance to stay down was the dreaded processed food. That too made me feels like the biggest failure and was quickly slipping into depression. I am sick of being sick and sick of failing. Many days I just laid there are cried wishing for it to end.

 By around the 10th week, I started to feel a little better. I was able to eat a little meat and some eggs and eliminated the processed food, but was still relying on the Zofran. Now at 16 weeks, I have good days and bad days. On the good days I am able to take care of my son, cook and even exercise. On the bad days I once again lay here and count the hours until I can have relief. I have realized that sometimes you need help and need to take medication. It is better for my precious babe to get nutrition and take medication then it would be to continue throwing up 15 plus times a day and continue to be dehydrated and depressed.

Hyperemesis is real. I hope this post helps get it out there and one day there will be a cure.

I love The Her Foundation. They are a great resource and have forums for mamas who are suffering or for family and friends who are supporting a mama.

About Hyperemesis Gravidarum:

"Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. 

It is generally described as unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids.

If severe and/or inadequately treated, it is typically associated with: loss of greater than 5% of pre-pregnancy body weight (usually over 10%) dehydration and production of ketones nutritional deficiencies metabolic imbalances difficulty with daily activities HG usually extends beyond the first trimester and may resolve by 21 weeks; however, it can last the entire pregnancy in less than half of these women. 

Complications of vomiting (e.g. gastric ulcers, esophageal bleeding, malnutrition, etc.) may also contribute to and worsen ongoing nausea. There are numerous theories regarding the etiology of hyperemesis gravidarum. 

Unfortunately, HG is not fully understood and conclusive research on its potential cause is rare. New theories and findings emerge every year, substantiating that it is a complex physiological disease likely caused by multiple factors. 

Diagnosis is usually made by measuring weight loss, checking for ketones, and assessing the overall condition of the mother. If she meets the standard criteria and is having difficulty performing her daily activities, medications and/or other treatments are typically offered. Treating HG is very challenging and early intervention is critical. HG is a multifaceted disease that should be approached with a broad view of possible etiologies and complications. 

When treating mothers with HG, preventing and correcting nutritional deficiencies is a high priority to promote a healthy outcome for mother and child. Most studies examining the risks and outcomes for a pregnant woman with nausea and vomiting in pregnancy find no detrimental effects long-term for milder cases. 

Those with more severe symptoms that lead to complications, severe weight loss, and/or prolonged nausea and vomiting are at greatest risk of adverse outcomes for both mother and child. The risk increases if medical intervention is inadequate or delayed. The list of potential complications due to repeated vomiting or severe nausea is extensive, all of which may worsen symptoms. 

Common complications from nausea and vomiting include debilitating fatigue, gastric irritation, ketosis, and malnutrition. 

Aggressive care early in pregnancy is very important to prevent these and more life-threatening complications such as central pontine myolinolysis or Wernicke's encephalopathy. After pregnancy and in preparation of future ones, it is important to address any resulting physical and psychological complications. 

Hyperemesis Gravidarum impacts societies, families and individuals. Recent, conservative estimations suggest HG costs nearly $200 million annually just for inpatient hospitalization. Considering many women are treated outside the hospital to save costs, the actual cost is likely many times greater. 

Beyond financial impact, many family relationships dissolve and future family plans are almost always limited. Women often lose their employment because of HG, and women are frequently undertreated and left feeling stigmatized by a disease erroneously presumed to be psychological." - from the Her Foundation

A woman recounts her own HG experience through a 'picture book':

"With HG, you will vomit so much the acid will erode your esophagus.  Every drop that comes back up burns all the more greatly as it comes back through your ravaged esophagus.  The doctor will look down your throat and see places where the skin has been burned away.  Your esophagus, like many parts of your body, will never be the same after HG.  Pregnancy only lasts 9 months, but HG damages you forever."   - TLT

And another local doula's client-account starts this way:

"During my first pregnancy, I really had no way of knowing how much vomiting was “normal” during pregnancy.  When I told people at the doctor's office how far along I was, they wanted me to come to a class, have a pregnancy test, get some information and then they would make me a preliminary appointment.  So I started the process.  At the class, I clutched a plastic bowl and managed to raise some red flags with the nurse.  She got me an appointment two days later.  However, before I made it to the appointment, I ended up on the floor of our bathroom.  Almost like contractions in labor, the bouts of vomiting kept getting closer and closer together.  All I could do was pull a couple of towels down next to me.  I would lift my head up just enough to heave and vomit onto the towel.  I had nothing in my stomach, not even water.  Bile and dried blood were all that came up.  My throat was raw and sore. It was when I began to beg God to let me die so that I wouldn't have to endure the pain any more that I realized the severity of my predicament.  I asked Tom* to take me to the ER.  Once there they gave me fluids and anti-nausea medication.

Many more trips to the ER followed through the rest of that pregnancy, it terminated in a miscarriage three weeks later,  and the two following pregnancies.  It was during one of these trips that the second episode occurred, although I don't remember when exactly it was.  I was once again vomiting from an empty stomach.  I begged the nurses and attendants to give me water.  Tom asked them for water. They refused because they knew I was too sick to keep the water down.  They were going to give me IV fluids and medication and told me I needed to wait for that.  The problem was that in the 15 or so minutes that I had to wait, I would throw up multiple times.  I craved the feeling of cool, clear water coming back up my throat as opposed to the harsh and bitter bile that was coming up anyway." - HG: a Personal Account

Remember, May 15th is the first ever Hyperemesis Gravidarum International Awareness Day! Ways that you can help:

• Please consider spreading the word about, and thus the understanding of, this affliction by sharing this post
• Share your story in the comments section 
• Like the HG International Awareness Day on FB
• Tell your local media about HG and the first ever HG International Awareness Day
• Be understanding and compassionate toward anyone experiencing this affliction

Together, we may be able to help find a cure!

A Quick History of Medication in Maternal Health Care - (and the Business of Being Born)

originally posted on 5/12/07

Taking the lead from another great blogger I read often - try to find her ;o) - and from a recent viewing of the Business of Being Born - I wanted to touch on the dark blemish of American Obstetrical practice - routine medication for birth. (BTW, it is funny that this was shown as a screening in the midst of a High Risk conference for Vanderbilt - on the heels of a recent development plan).

While watching the Business of Being Born - a WONDERFUL look at childbirth practices in the US - I was struck by one very apparent thing: doctor's know nothing about bodies and birth. They know everything about risk - and, as one OB nurse told me, their job was to take away pain and have a healthy mom - not to get the best outcome.

That mentality was prevalent back in the late 1800's - early 1900's when OB's infiltrated the childbirth field and it is prevalent now. FRIGHTENING! Why is it frightening you say? Let me expound...

Let's start with the advent of anesthesia in general. It all began on October 16, 1846, at the Massachusetts General Hospital in Boston, in a room now called the Etherdome, when William Morton administered the first successful public demonstration of ether anesthetic. This was a great breakthrough for SURGICAL needs, and the news spread around the world quickly. So quickly in fact, that within a month the first modern anesthetics had been given on both ends of Europe, and within six months in Australia and China.

One doctor who heard of the use of ether was James Simpson. Breaking out of his social class, he put himself through medical school and later became the chairman of obstetrics at the University of Edinburgh. He is best known for the forceps which he devised to counter his initial use of ether on maternal patients.

His first maternal patient was a woman whose pelvis was deformed by rickets (a common issue in that time from malnutrition) who delivered on January 17, 1847. These deliveries can be especially difficult because of the manipulation needed to get a baby out of a deformed pelvis.

There was a great concern, though, for this use of ether because of the knowledge that ether often stopped contractions. As well, most babies born from ether-administered mothers had ether-smelling breath, ether smelling placentas, and tires/lethargic/unresponsive babies. So, Dr. Simpson created forceps, to pull babies from their mother's wombs before they were 'too drugged' and to minimize the incidence of failed labors due to ineffective or stalled contractions. Then why was it continued?

To understand the merging of surgical breakthroughs and maternal downfalls, we need to look at the social climate of the time. Two major events were happening: childbirth was taken out of the home and into the hospital (where disease and infection ran rampant), and the feminist movement was on the rise.

"Early feminists campaigned for social reform of all types, for the abolition of slavery and the abolition of the use of alcohol. They were also concerned about improvements in health care, particularly for women and children. They had good reason to be concerned. Although death rates for men and women had been falling throughout the nineteenth century, risks of a woman dying in childbirth had not decreased. In New York City, for example, 15% of deaths of women between the ages of 20 and 40 were related to childbirth. Although deaths from other causes had decreased, deaths from childbirth had not. By 1900, 30% of the deaths of women in this age group were attributed to childbirth." - now remember that those deaths were NOT due to childbirth - but malnutrition causing complications in birth, deliveries being moved to hospitals where illnesses and disease ran rampant, and before the advent of antibiotics - IT HAD NOTHING TO DO WITH MIDWIFERY and THE SAFETY OF HOME BIRTH.

Suffragettes saw maternal health care as a significant area that needed improvements. The only problem is that they focused on the labor of childbirth (pain/discomfort) rather than the true source of the maternal and fetal demise of the time. Not to fault them as the information and scientific breakthroughs were not accomplished yet; in their early industrialized minds, pain equated illness and death.

(Maternal death rates dropped slightly in the US between 1880-90, when doctors rooted out the nature of childbirth fever in relation to cleansing practices in the hospitals. They started washing their hands between women's beds and the death rates dropped. Then, the numbers steadily rose again until 1940, when they dropped once again (steeply and greatly) with the introduction of antibiotics).

Queen Victoria used ether when she delivered Prince Leopold in 1853. From Inside Surgery:

"Queen Victoria went into labor on the morning of April 7, 1853. As her physicians readied her for the birth of Prince Leopold, John Snow positioned a handkerchief moistened with 30 drops of chloroform over her nose and mouth. The Queen had an immediate response to it. Over the next fifty three minutes he reapplied the anesthesia fifteen times, using between 15 and 20 drops each time. The birth was without complication and the child was pronounced healthy, although at the time no one knew that he was afflicted with hemophilia.When accounts of Queen Victoria's labor anesthesia reached the general public, John Snow became an instant sensation and was much in demand by the social elite of London."

The National Twilight Sleep Association was formed in order to support the use of a new maternal anethesiac development begun by a young obstetrical doctor by the name of Carl Gauss. Around 1900, Gauss combined two drugs that had been in the medical armament for a long time to treat childbirth pain. One main component was morphine, used to alleviate pain during surgery. It had, thus far, been avoided in obstetrics because of its effect on the uterus, its effect on the newborn, and its effects on bleeding and infection. The other drug was scopolamine, which causes amnesia - in the past, these had been used as poisons in high doses. Hamlet's father was killed by one of scopolamine's cousins.

Gauss mixed these two drugs and administered them in 'small doses' to his patients - the morphine provided relief from pain while the scopolamine provided the women with amnesia of their labors and what was done to them. The problems? Oh, there are many!!! Scopolamine caused women to lose their inhibitions. They would have no memory of what went on, nor did they realize what was happening, so most of them screamed during labor. They became uninhibited and psychotic. They would thrash about on the bed, causing injuries to their heads. So, their heads were wrapped with blankets or towels, turban-like. They would attempt to claw at the walls or their medical providers, so they were put in straight jackets or their wrists were strapped to the beds. Then, so that they would not fall out of bed, they were put in 'labor cribs' - and were allowed to labor, screaming, tied down, blinded and bound - often in their own urine and feces, and sometimes for days on end, until it was time to birth. The women had no memory of this, the husbands were not allowed in to see their wives, so they didn't know what was happening - and everyone was happy.

Gausses concoction was tried out first in Europe and was found to be less than satisfactory for maternal care. It would probably have died out there had it not been for an infamous article in McClure's magazine. Two female reporter's who were also staunch feminists, accompanied their friend to Germany, where she was traveling to be 'treated by Dr. Gauss'. The woman was administered Twilight Sleep and was ecstatic with it. She simply woke to a baby - with no memory of the labor or birth. The three women decided to liberate American women through Twilight Sleep.

Every woman wanted to have that type of birth. Medical research was not sought as to the safety, and feminist drive demanded quick results. So - the U.S. because predominantly a Twilight nation between the years of 1914-1945 (although my grandmother recounts her story of TS in 1956 and there are reports as late as the 1980's).

Thankfully (and sadly because of what it took) this time in American history quickly collapsed when Frances Carmody died under Twilight Sleep. Although there had been numerous women who had died under Twilight Sleep, she was the wife of a Brooklyn lawyer and happened to also be a huge rally organizer for the Twilight Sleep Campaign. Her husband and her OB assured everyone that her death had nothing to do with Twilight Sleep, but, with a key organizer gone from the game, at the very time she was using something she was promoting, the campaign began to fall apart.

Women began to have windows of remembrance, and by 1948, the baby boom got into full swing and the huge number of women having babies while under Twilight Sleep raised the issue of comfort at a cost. Women began reporting their birth trauma - both physical and emotional/mental. Moms began to speak out. And, in 1958, an article headlined "Cruelty in Maternity Wards" ran in Ladies' Home Journal. It detailed the "tortures that go on in modern delivery rooms.". The response? A flood of women sent the magazine their own horror stories. "I've seen patients with no skin on their wrists from fighting the straps," a nurse from Canada wrote.

"Just let a few husbands in the delivery rooms and let them watch what goes on there," said one reader from Detroit. "That's all it will take — they'll change it!" An Indiana mom claimed, "The whole thing is a horrible nightmare."

Women began desiring and demanding safer births - the OBs were fraught with the problem that they could not guarantee a medicated, but safe, birth. So, in the 1960's and 1970's - many women went back to natural birth. This was short lived, though, as Obstetrician's saw income diminishing... Cue the epidural.

Mothers giving birth in the late 1970s and '80s had more options than ever. They could have a medicated or unmedicated birth. They could deliver in a freestanding birthing center, a hospital, or at home (in most states). They could be attended by a midwife, an obstetrician, or both (in some states). And, through all of these options, they could have their husbands by their side.

What led up to the advent of the epidural? In 1898 German doctor August Bier injected cocaine into his assistant's spinal column. It numbed his lower body, but the next morning he awoke with horrible vomiting and headaches (cue the spinal headache). It took the next 80 years to perfect this. But, by the 1970s, lidocaine was dripped into a tube inserted by needle into a woman's spinal column. By the 1980's, it was all the rage! The hitch? The procedure numbed women to their chests, causing breathing issues and, at times, heart problems.

My question - and the question that Ricki posed in her documentary is this:

What will we find in the near future is the clinically proven downside to epidural births? We NCB advocates already know of the obvious, though seemingly unimportant to many women when compared to an easy labor, risks... But think of it...

- In the late 1880's early 1900's it was chloroform / ether - which inhibited neonatal breathing attempts, caused forceps to be necessary (which caused many horrible scarring issues with babies), maternal reproductive harm, and heart failure routinely.
- In the early to mid 1900's, it was forceps - which were necessitated from the use of 'knock 'em out medications. These scarred women's cervix's, making them incapable of dilating at all or efficiently in later pregnancies, tore ears, noses, and scalps off of babies, and created severe perineal and labial scarring in women. Forceps are still used today!
- In the mid 1920's, it was Twilight Sleep - causing maternal mental, emotional, and physical trauma, more of the same as chloroform did, AND caused a number of incidences of stillbirths.
- In the mid 1950's-60's, it was thalidomide, prescribed to pregnant women routinely - causing the widespread incidence of 'flipper babies' - children who were born with severe malformities, including phocomelia (short limbs and deformed extremities).
- In the 1970's, it was early spinal/epidurals where the needles were too large and the puncture too deep, causing a whopping 50% of women to get debilitating spinal headaches that, at the time, were not treatable.
- In the 1990's, it was Cytotec, used to induce labor (off-label and unapproved). With a HUGE risk rate, it can/did cause stillbirth, neonatal distress, uterine rupture, severe postpartum hemorrhage, and more. Cytotec is still used today!

What do all of these things have in common? NONE of these procedures are tested before they are tried out on pregnant and laboring women. We are used as guinea pigs. So, my, and Ricki's question, again, is: What will we find in the near future is the clinically proven downside to epidural births? And, at what cost?

We have a huge increase in ADHD, ADD, Autism, early and late-onset Jaundice, asthma, and allergies/intolerances... how can we know that these are not a result of our maternal health practices now? We can't. BECAUSE, we are a society driven on comfort and ease rather than health and well-being. Well-being does NOT equate to ease or comfort. And, until we demand better health care, we are doomed to repeat history on different levels - until we learn to choose better for our bodies and our babies and leave the testing to the REAL guinea pigs.

See here and here (pic) for more information on this history.

*Edited to add the great information sent to me by some readers!

The Greater Good

The other day a dear chiropractor friend of mine slipped me a film entitled “The Greater Good” and told me to watch it. I went home, fully intending to be bored into oblivion by a tyrannical or severely biased anti-vaccination documentary. I was pleasantly and completely wrong! 

“The Greater Good” is a well-balanced documentary that follows three families through situations involving 'adverse reactions' from vaccinations. It is interspersed with interviews from numerous medical professionals including vaccine developers, pharmaceutical reps, psychologists, behavioral therapists, and pediatricians.

Although the families stories definitely called to the intrinsically emotional mother in me, the information supplied called to my deeper intellect.

My daughter, Briaunna, also reviewed the movie. This is what she had to say: 

The movie was about vaccinations and how they can affect you, good and bad. My initial reaction was anger and pain for the people who were harmed by the vaccines. Helpless children who get vaccinated with, basically, poison. I liked how people are learning more about vaccines… even though many of them have to learn the hard way in order to teach others. I also like how people are learning the true risks of vaccines. 

Did you know that vaccination does not account for the impressive declines in mortality seen in the first half of the century? It was other medical advancements, including learning to just wash your hands (microbiology).

Lately, people have been giving vaccinations to newborns, which really upsets me because I am a baby freak. Also, parents are required to give 69 doses of 16 different vaccines to children. They also put aluminum and mercury in all of the vaccines. Any form of mercury in the body is toxic and can cause damage. 

Did you know that, after 2010, 85 deaths have been reported, all after taking the Gardasil shot?

The only other thought I have is that the government has gotten too much power over us. They say that if you haven’t given your children all of the required shots, you have to go to court and get your shots…. “Or else”. They think that you will endanger your child’s life if you don’t get them vaccinated, which, of course, is all in the way that you look at it. I see more risk to their lives from taking a vaccination, but that’s just me.. and my right to not get vaccines for me or my babies.

The movie covers the historicity of vaccinations, and give us a rare look into the hearts of those who developed them.

At the same time, we hear from the lawyers who defend those families who have been harmed by vaccinations. 

When asked if they believed the business of vaccinations is involved in conspiracy, one astutely replies, "A conspiracy? Yes! But a conspiracy to do good." So much so, that the risks of vaccinations are minimized through government involvement and media bias in order to promote the 'good' that vaccinations provide to the majority.

"The Greater Good" takes a critical look at the government's involvement in implementing and mandating state-wide vaccinations, as well as how individual states are trumping parental and individual rights.

"If the state can force you to put your life on the line, or your child's life on the line, for any medical intervention, then the state has too much power"

Additionally, the movie takes on the very real, very publicly acknowledged fact that many members of our government council also hold shares in the very pharmaceutical companies that create the vaccines which the state promotes. It is as true as it gets: conflict of interest is: when my politicians have a vested financial interest in vaccination pharmaceutical companies. Or, as the movie states:

"the fox watching the chicken coop"

We are given the stats on individual state's exemptions and the bias in media exposure. We are shown the process to bring a vaccine to the public and how 'fast tracking' a vaccination intended for children was foolish. We are given real risks associated with vaccinations, and given a more in-depth look at the studies used to 'prove' the safety and efficacy of vaccination. 

I was, at times, outraged, and other times saddened... I felt I learned so much, even after having done, what I thought, was thorough research on vaccinations... but there were things that still had me dumbstruck and amazed. Just one example: the placebo used in many of these 'safety and efficacy" studies is aluminum, mercury, or a combination of the two!

Some great quotes from the movie that I hope will pique your interest:

"We know that mercury (thimersal) causes neuro-toxicity, there's no controversy about that. Does it cause autism? It contributes to the damage that leads to autism." - John Green III, MD

"There are studies comparing the hair of autistic and non-autistic children. There is much more mercury in the hair of non-autistic children, showing us, at least in part, that there is some genetic precursor that makes some children more succeptible to autism."

 Would I recommend this movie? A resounding yes! Would my daughter? Well, let's just say she is already inviting her tweenage friends over for a 'movie night' at our place - her idea. I recommend this movie to every family who have children, or who will have children, of vaccination age. 

"The Greater Good" does a wonderful job of promoting this one moral: it is not about having you vaccinate or not vaccinate. It is about ensuring that families know the risks, that the studies regarding vaccinations are fair and accurate, and ensuring that vaccines are made to be and required to be as safe as possible.

To visit them on the web

To visit them on FaceBook

Would You Rather...

DISCLAIMER: there are graphic pictures in this post.

This is the post that makes women squirm, clamp their knees together, and raise their blood pressure in angst. We are going to talk about tears and episiotomies. I know, I know - it makes my stomach flip and my PC clench.

I think the most 'catch 22' question of pregnancy is the infamous, 'would you rather tear or have an episiotomy?'. Now, any woman in her right mind would say NEITHER! And wisely so.

Don't worry, we are going to talk about how to minimize the risk of tearing altogether. But, in the spirit of informed decision making, we will be talking about what both tears and episiotomies are, the risks and benefits of each, and how to minimize the risk of either occurring. 

TEARS
Let's start with tears. Tears occur for a number of reasons. Some of these include:

• The position mom is pushing in
• If baby has a nuchal hand or arm
• The speed at which crowning occurs
• How aggressive or hands-on the care provider is
• If instrumental delivery is being employed
• How relaxed and elastic mom's perineum is
• How toned and sinewy mom's pubococcygeous muscle is 
• Mom's Ethnicity 

Tearing is a natural separation of the tissue at the outlet of the vaginal opening, usually through the perineal tissue toward the anus. Some times, it occurs anteriorly, or toward the urethra/clitoris. Most tears that occur spontaneously occur at crowning and are less than 1st degree and up to 2nd degree lacerations. Although 3rd and 4th degree tears do occur naturally, it does not occur very often.

Vaginal lacerations, both naturally occurring (tears) and surgically performed (episiotomies) are measured in degrees. The degrees of lacerations are explained below:

• Skid Marks -The most common naturally occurring laceration. These are usually less deep than a split lip and do not require any stitches. They heal within a matter of days after birth.
• First Degree (1st) - The smallest laceration, extending only through the vaginal mucosa. It does not involve the underlying tissues. Many midwives do not recommend even stitching these as they heal easily when naturally occurring.
• Second Degree (2nd) - The most common type of episiotomy. It extends through the vaginal mucosa and into the submucosal tissues.
• Third Degree (3rd) - this involves the vaginal mucosa, submucosal tissues, and some or all of the anal sphincter muscle.
• Fourth Degree (4th) - The most severe laceration. This includes the vaginal mucosa, submucosal tissues, anal sphincter muscle, and the lining of the rectum. This can lead to recto-vaginal fistula and a high rate of incontinence.

EPISIOTOMIES
The episiotomy, on the other hand, is performed for a different set of reasons.

• to prevent tearing
• suspected large baby
• suspected shoulder dystocia
• longer 2nd stage
• precipitous birth
• to prevent later incontinence
• fetal distress
• routine (doctor always does it)

Reports state that the US has anywhere from a 9% to over a 40% episiotomy rate.

Stephanie Soderblom LM CPM: www.azhomebirth.com

Simply put, an episiotomy is when a care provider cuts the vaginal opening down through the nerve-filled perineal tissue toward the anus with a pair of surgical scissors. Yep, scissors. For added benefit, though, I have included the more professional definition:

Episiotomy - an incision created in the vaginal opening and tissue surrounding it in order to enlarge the opening. From the root Episio, meaning vulva and tomy, meaning incision or sectioning.

Episiotomies are an automatic 2nd degree laceration, or more. There are two main types of episiotomies: the midline and the medio-lateral. The most common in the US is midline, while the medio-lateral episiotomy is more common in other parts of the world.

Types

A midline episiotomy is when the care provider incises the vaginal opening straight down toward the anus. This type of episiotomy is reported to have less pain and less incidence of long-term tenderness or pain during intercourse than the medio-lateral episiotomy. There is often less blood loss with a midline episiotomy as well. The biggest disadvantage of this episitiomy over the mediolateral is that this type of incision is very likely to continue tearing beyond the incision, causing a larger laceration.

A medio-lateral episiotomy begins at the vaginal opening and is cut at a 45-degree angle toward either the right or left buttocks. The main advantage of the medio-lateral episiotomy is that is has less chance of tearing beyond the incision. The risks include there is a significant increase in blood loss, increased pain, more difficult repair than a midline episiotomy, and the increased risk of long-term discomfort, especially during intercourse.
How Is an Episiotomy Performed?

How It's Performed
Ideally, an episiotomy would be done when 3-4cm of the baby's head is visible at the vaginal opening, and during a contraction. Although it is rather routine to inject a local anesthetic in the perineum when an episiotomy is anticipated, this injection actually makes the perineum LESS pliant, more likely to tear in the first place, and more likely to tear if beyond the incision if the episiotomy is performed. Instead, waiting until the woman is having a contraction and until the babies head is well applied to the perineum ensures that the woman's perineum will be numb from lack of blood flow to the perineum and minimize/eradicate discomfort during the incision.

The doctor or midwife would then insert two fingers into the vaginal opening to protect the baby's head and the incision, between 2-3cm in length, is made.

RISKS (aka WEIGHING THE OPTIONS)

• Risks of episiotomies over naturally occurring tears include:
• higher risk of muscle damage
• can cause tearing beyond the episiotomy (some reports cite 30% tear beyond the incision)
• can lead to urinary incontinence
• local anesthetics can cause more tearing by swelling tissues
• take longer to heal than a naturally occurring tear
• episiotomies always requires stitching
• women report more pain from episiotomies than from tearing
• episiotomies cause more extensive scar tissue than tearing
• higher rates of infection
• swelling
• higher rates of defects in wound closure
• higher rates of sexual dysfunction
• higher rates of recto-vaginal fistula
• higher rates of fecal incontinence

Women who do tear only tear as far as their body needs to to allow baby to pass by. Episiotomies are an automatic 2nd degree laceration, whether or not her body needs that space. And, many times, a woman will tear beyond the episiotomy that is performed.

I liken it to the phone-book tear test. Try tearing a phone book down the side, it is very difficult. Now, make an incision on that side. Now, try to tear it along that incision... the book is much easier to tear. This concept extends (no pun intended) to episiotomies and tearing beyond them.

 

In addition, tears heal faster, with less pain, and less scar tissue. This is because tissue cells look like little bricks. When a woman's perineum does tear, it tears through the 'cement' holding those bricks (cells) together - there is little to no cellular damage.

On the other hand, episiotomies are an unnatural laceration that tear right through healthy cells and the 'cement' around them, resulting in not only tissue damage, but also cellular damage. This increases infection rates, healing time, discomfort in healing, scar tissue, and long term pain and sexual dysfunction.

A final risk is this: there is absolutely no way for a provider to know beyond a shadow of a doubt that a woman will tear until she does. This means that episiotomies for 'might tear's sake is moot. Most episiotomies are unnecessary.

CONSIDERATIONS (aka WTH)

Let's deconstruct both the natural reasons a woman tears and the medical reasons a provider might cut.  

First, the natural reasons a woman might tear:

The position mom is pushing in - lithotomy/supine and semi-sitting (classic) positions have the highest incidence of tearing. Other positions that require mom to bring her legs back as far as possible toward her ears also have higher incidences of tearing. It is no surprise, then that women who have homebirths and birth center births have less incidences of tearing - they are able to choose whatever position feels best (which is usually not these positions) to push in and follow their bodies cues.

Many midwives who serve the Amish and Mennonite community also report that they have a nearly non-existent tearing rate. These communities often birth on their sides or in a squat with their knees together and their buttocks pressed backward. This makes physiological sense, as it decreases the pressure/tension on the perineal tissues, allowing more stretching to occur.

A woman's best bet is to get in a better position for birthing than lithotomy or supine.

Nuchal hands or arms - nuchal hands or arms mean that there is a hand or arm up near the neck/head. This means that there is something in addition to the babies head to fill that space, increasing the chance of tearing. Obviously, one cannot anticipate or correct this, but they can minimize the chances of tearing from occurring by allowing a slow and steady crowning and resolution to occur. They can also request perineal support and counterpressure to slow the process further. 

The speed at which crowning/shoulder birth occurs - the more time the perineum has to stretch, the less chance of tearing will occur. Likewise, the more precipitous the birth, the higher the chance of tearing. This risk increases, again, with coached pushing or purple pushing.

As a baby begins to crown, the skin stretches. This stretching can sometimes feel like tingling or burning, which is natures way of having mom slow down the pushing. Instinctually, women will let up on pushing and make some noise, blow air out, or 'horse-lip' for awhile, until the burning goes away.

The slower the stretching is allowed to occur, the less chance that tearing will occur. A woman can simply 'blow' through crowning, or even do 'horse lips' to allow her body to birth the baby's head and shoulders, slowing the process down and allowing for optimal stretching.

Another tip is to request gentle counterpressure or warm compresses on the perineum, to support the perineum during crowning and minimize the chances tearing.


Ways to minimize these risks are to request no coached pushing, employing blowing/horse lips through crowning or simply letting your body do the pushing, and warm compresses or counterpressure on the perineum.

How aggressive or hands-on the care provider is - the more the provider pulls on vaginal tissue during crowning, the more swollen the tissue will become, and less elastic. Also, the more the provider pulls on and manipulates baby's head, the greater the chance of tearing.

Likewise, it is common practice in the US to pull on baby's head after it is out to hasten the birth of the shoulders. This can create unnecessary tension on the perineum, causing iatrogenic tearing.

The best odds for a woman to eradicate this as a reason for her body to tear is to make sure she has a provider that she trusts to not to act aggressively with her perineum or her baby's body.

If instrumental delivery is being employed - if a vacuum extractor or forceps are used, the incidence of tearing does increase but is not guaranteed to occur. Because instrumental delivery means a more precipitous birth will most likely occur, as well as because there is the addition of a foreign object filling the vaginal opening along with the baby's head, the chances of tearing do increase, but again, is not a guarantee.

One way to minimize this possibility is, first and foremost, reduce your chances of needing instrumental assistance by considering an unmedicated birth, an upright position for birthing in, and patience to bring baby down, especially for first time babies, which, on average, take 2 hours of pushing. Another way to minimize the chance of tearing, if, after employing the above, you still require instrumental assistance, request gentle traction, when crowning begins, 'blow' through the contractions or don't push, and allow the shoulders to be born without the assistance of a vacuum or forceps.
 
How relaxed and elastic mom's perineum is - the more relaxed mom is, the more hydrated and well nourished mom is, the stretchier her perineum is.

When a mom can breath easily, without tensing up her pelvic floor, her perineum is able to stretch gently and optimally. Coached pushing should be avoided, and a mom should listen to her body's cues on when and how to push. Studies show that a woman's vocal folds/jaw/throat is directly related to how relaxed her bottom is.

In addition, good hydration and nutrition are vital for tissue health and elasticity. Drinking water during pregnancy and throughout labor and birth will ensure that your tissues are nice and supple and well hydrated. Likewise,

"Good nutrition is vital to your body's work in preparing the perineum for stretching during birth. Hormonal changes during pregnancy cause the tissues of your cervix and perineum to become extremely thick and elastic. Crucial to this process is an adequate intake of protein, vitamin E, and short-chain fatty acids, which consist of two types of 'good' fat, Omega-3 and Omega-6. Short-chain fatty acids are found in nuts and seeds, cold-pressed oils, all types of beans, and fish such as salmon and tuna" "Avoiding an Episiotomy", Nancy Griffin, Mothering Magazine, # 75, summer 1995, (p 60).

Vitamin C is also very beneficial for cellular elasticity and regeneration. It can be found in citrus foods, most readily, but also in dark green vegetables.

Finally, squats and intercourse encourage good circulation and elasticity of the perineal tissues. Squatting is natures way of keeping our bottoms healthy and sex encourages relaxed perineal tissue with good tone.


So, a mom can help ensure that her perineum is well prepped for birth through relaxation/vocalization/breathing, prenatal nutrition, prenatal and labor hydration, and prenatal exercise.

How toned and sinewy mom's pubococcygeous muscle is - how healthy a lifestyle mom lives and how well she has treated her PC muscle (sex, squats and Kegels) has great bearing on her ability to have a more controlled pushing stage, a well flexed baby's head, and less chance of tearing.

Women who have sex throughout pregnancy have well oxygenated, more toned and conditioned PC muscles, as well as have good control of this muscle. A toned and controllable PC muscle means that babies head is more likely to be well flexed, allowing the smallest part of the baby's head to emerge from the vaginal opening first, gently stretching mom's perineum for less chances of tearing.

In addition, squats will ensure that the PC muscle remains a long, sinewy muscle, keeping it elastic and not bulky and rigid. A woman should, during pregnancy, make sure that she is taking care of her PC muscle, making sure it is not only toned, but also stretchy.

Ethnicity - women of Caucasian or Asian ancestry tend to have a higher risk of tearing. Some theorize it is because of cultural or social upbringing. Others, genetics. 


Now, for the medical reasons a provider might give to perform an episiotomy:

Routine (doctor always does it) - This argument is usually given in conjunction with any of the below reasons for performing an episiotomy.

Many practitioners who believe in routine episiotomy state that a first time mom will 'nearly always tear'. I can tell you, from my experience, I have seen only 2 first-time moms naturally tear, and only one required/asked for stitches.

Other practitioners will tell you that it is easier to repair. Truth is, an episiotomy is easier for the one stitching to line up the seams... in other words, it takes less time to sew up... what they don't mention is that, although it is faster and easier for them to stitch up an episiotomy, an episiotomy is NOT easier on your body to repair. Naturally occurring tears heal faster, with less pain, less blood loss, less rates of infection, less emotional trauma, and less incidence of long term complications, such as fecal or sexual incontinence.

Best odds, talk with your care provider before birth to find out what their policies/beliefs are.

To prevent tearing - as previously discussed, there is no way for a provider to know, beyond a doubt, that a woman is going to tear until she does. And, even so, if a woman is to tear, a tear heals faster, with less pain, statistically with less degree of damage, and with less scar tissue and long term side-effects than an episiotomy does. In addition to all of this, an episiotomy has a high risk of tearing beyond the initial incision.

Truly, the only time that a woman can really benefit from the 'to prevent a tear' argument is when there is good reason to believe mom might tear anteriorly (toward the urethra or clitoris). 

Suspected large baby - If a large baby is the only reason given, it is a sad one. Many providers who perform routine episiotomies state that large babies need more room to maneuver the birth canal. Truth be told, the perineum will not hold back the birth of a large baby, only bone or mom's relaxation might. So, an episiotomy might shorten pushing by a contraction or two, but it is not going to 'rescue a large baby' from not being able to be born.

On the other hand, any care provider who has done perineal massage can tell you, a woman who is tensing against the birthing waves meant to bring baby down can hold her baby in. This is especially true for large babies or 2nd stages that are very intense.

The best a mom can do when she is told her baby may be large is to visualize her body opening gently for babies exit, remember to breath when waves come and only push when her body tells her to. Likewise, a provider skilled in deep perineal massage can be helpful in finding and releasing tense vaginal muscles during baby's descent.

This will allow for baby to have, not only room to navigate the birth canal, releasing tense vaginal muscles, but will also give the perineum time to stretch, the baby to rotate his shoulders under the pubic bone, and tissue to be soft and supple - able to stretch around any baby.

Suspected shoulder dystocia - again, all of the above same applies.

Fetal distress - This is one of only two good reasons to perform an episiotomy (the other is when an anterior tear is likely/occurring). When a baby has been showing true distress during 2nd stage and is showing further distress at crowning, an episiotomy can reduce the length of 2nd stage by a few contractions. In an emergency situation, this can be a lifesaving tool.

When a baby is truly in distress, an episiotomy can buy the provider precious moments by getting a finger hooked on babies shoulder, or mom the ability to push baby out with the next contraction/without a contraction, and without needing to wait for the perineum to stretch.

This occurrence does not happen very often, but, when it does, those few contractions can make a world of difference in baby's health.

Longer 2nd stage - Although, as stated above, episiotomies can shorten 2nd stage by a few contractions, that is all it shortens it by. If a long second stage is the only reason given, an episiotomy is only going to shorten a birth by a few moments, but postpartum recovery will be a lot more intense/extensive.

Rather than use this time to hasten birth by a few moments, this time could be better used to let mom get ready to receive her baby into her arms, encourage mom verbally, give her a drink and provide warm compresses to her bottom, and allow her to listen to her bodies cues.

Precipitous birth - If a woman is birthing very quickly, some providers will want to perform an episiotomy. Again, it is because fast births can (not will) mean a tear might occur. The funny thing is, medical texts say that, after creating the incision, a doctor or midwife should give gentle pressure against the perineum and baby's emerging head to prevent rapid or abrupt delivery, to minimize the chances of tearing beyond the incision... this is laughable as that is one of the ways to minimize the chances of a naturally occurring tear. It makes me think, 'why didn't you do that in the first place?!?!?'.  

As stated in the natural reasons, the best bet is to provide gentle counterpressure to slow a fast birth, guide mom in an easeful crowning and gentle resolution, and help mom to breath her babies head out instead of actively pushing. 

To prevent later incontinence - Studies have shown that episiotomies do more to contribute to later incontinence issues than a naturally occurring tear or an intact perineum because of the substantial risk that the episiotomy will either automatically go through muscle as well as skin, or will tear through the same.


BEST ODDS FOR 'NEITHER'
To ensure your best bet for not tearing or having an episiotomy, consider the information above. Mom's benefit from an intact perineum by eliminating the risks associated with perineal lacerations. In addition, babies benefit from an intact perineum by having their chest pressed over the intact perineum, which breaks up the mucosa in the lungs and encourages baby to expel it from their throat, mouth, and nose, before the first breath. When this occurs, many times a baby does not require suctioning and start their first breaths with a clear airway.

I consider the above information to be best consolidated in the 4 P's:


Prenatal Health - Eating a well rounded diet full of fresh fruits and veggies, especially citrus fruits and dark green and bright colored veggies, good oils and fats/omegas, and water hydration will give your tissue elasticity and healthy suppleness. Remembering to not only be attuned to your PC muscle, but also to perform regular squats will give your bottom elasticity and control for the 2nd stage.

Perineal Massage - I am not a huge proponent of clinical perineal massage during pregnancy. By clinical perineal massage, I mean the type where a woman or her partner hooks their finger into the vaginal opening and pulls/rubs at 8 and 4 o'clock positions until the perineum burns. This is not natural and can be psychologically damaging.

http://beautyandthebump.blogspot.com/

I believe that it sends the wrong message. It tells women that their body's are not capable of stretching well enough unless the woman does something unnatural to encourage it. It also sets a woman up for fear: fear if she didn't remember/know to do it prenatally that she will tear orfear that she will feel the burning that she experienced prenatally if she did perform clinical perineal massage.

What I do encourage is for women to have a healthy and active sex life during pregnancy and for she and her partner to be comfortable and familiar with her perineum and vagina through personal/pleasureable perineal massage.

If a woman is familiar with how stretchy her perineum is, if she is comfortable and knowledgeable of her vaginal muscular bands, if she is familiar with how to touch those tense bands or tendons, feel the tension, and release it or massage it away, she is more apt to do that in labor. If a woman's partner is used to the same, the woman is more apt to respond in same to similar touch/sensations during labor and birth.

Likewise, if she is familiar with what PC contraction is, she is more apt to be able to release that common tension during pushing if she can feel it with her own fingers, or feel her partner's touch and recognize the resistance and relaxation of this muscle.

Pushing - Women who push in positions that feel 'right', and are not coerced or led into certain positions, tend to have better chances of keeping their perineum intact. Likewise, when a woman can push to her body's cues, and not to the providers count, tend to stretch more readily. Women who are encouraged to be vocal if they need to, breath through those contractions that they feel the need to, and otherwise open their vocal chords for relaxation tend also to stretch more readily.

Choosing to birth in water, or at least a darkened, quiet room, encourages mom to be relaxed, and thus, her vagina and perineum is relaxed.  The warm water of a water birth helps the perineum to stretch as well, and a darkened room allows a woman to feel uninhibited, private, and safe - all of the ingredients mom needs to be relaxed.

As baby begins to crown, when a woman can reach down and touch her babies emerging head, women will often give themselves vulvar or urethral/clitoral support, pant or blow through contractions, and otherwise ease/massage their babies out.

When a woman is not able to or willing to feel her baby's emergence, often times, reminding a mom to breath or vocalize through the crowning stage will help her to stretch more easily.

I have that, women who place their fingers inside their vagina during pushing can bring their babies down more efficiently, slow crowning more readily, avoid any perineal trauma more naturally, and spontaneously catch their babies more easily. I believe that the more 'in tune' a woman is with this intense time and her body's cues, the better the outcomes we have.

Patty Ramos: http://www.doulapattiramos.com/2008/11/birth-up-close.html

Practioner's Help - a care provider who trusts in a woman's ability to birth her baby will be more patient in the absence of distress, allowing mom more time to stretch naturally. This provider will also be more apt to listen to mom's body and her own rhythm for pushing, rather than a count of 10 or purple pushing.

This care provider will also encourage mom to be in whatever position she wants to be in, and will provide/promote a safe haven for a woman to open up to the power of birthing without coercion or demands. Likewise, a practitioner can help by encouraging a relaxed vagina and perineum by providing perineal massage, warm compresses, lubrication at crowning, and perineal/anterior support during crowning and birth, if the woman would like him/her to.

CONCLUSIONS
As you can probably tell, I am very much against routine episiotomy and highly encourage women to make an educated decision regarding this procedure before the option presents itself. I always encourage the mom's I work with to talk with their care providers before birth to find out what their provider's stance is and to talk about any inconsistencies with them ahead of time.

Treating women like mothers during their labors and births, giving their bodies the benefit of the doubt when they take a few moments longer, in the absence of fetal or maternal distress, can allow a woman to claim her birth and baby as a positively transforming act, rather than a traumatic experience.

As a woman who has had both an episiotomy (1st birth) and skid marks (last birth, and having been told that my scar tissue was so extensive that I 'would definitely' tear with any subsequent births (which I never did), I am an avid supporter and believer in all of the practices herein to minimize the possibility of a naturally occuring tear occurring. Would I rather tear or have an episiotomy? Neither. But, if push comes to shove (or, more accurately, if push comes to the risk of tearing), I would rather tear.

Remember, if you have done all that you can to ensure that you will have an intact perineum and you still tear, remember to trust that your body did only what it needed to to birth your baby. 

Take a moment to read this woman's beautiful birth story of a large baby with not even a skid mark. She talks about how she believes she was able to ease Laslo's birth and even shares a birth montage. Enjoy. 

RESOURCES/FURTHER READING

• Evidence Report/Technology Assessment No. 112, The Use of Episiotomy in Obstetrical Care: A Systematic Review (AHRQ Publication No. 05-E009-2).
• Lemay, Gloria "Midwife's Guide to an Intact Perineum," Midwifery
  Today Issue 59
• Obstetric Myths Versus Research Realities, Chapter 14: Episiotomy
  
• Murray W. Enkin MD, FRCS(C), D.J. Hunter MD, FRCOG, FRCS(C), Laura Snell RN, SCM (1984)
• EPISIOTOMY: EFFECTS OF A RESEARCH PROTOCOL ON CLINICAL PRACTICE
• Birth 11 (3), 145–146. doi:10.1111/j.1523-536X.1984.tb00768.x
• Hartmann K, Viswanathan M, Palmieri R, Gertlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review.JAMA 2005;293:2141-8.
• Saying No to Episiotomy : Getting through Labor and Delivery in One Piece By Elizabeth Bruce, Mothering Magazine, Issue 104, January/February 2001
• University of North Carolina, Center for Women's Health Research. Routine episiotomy does not provide benefits: the importance of asking questions about common things.
• The Second Stage of Labor
  
• Viswanathan M, Hartmann K, Palmieri R., Lux L, Swinson T, Lohr KN, Gartlehner G, Thorp J. The use of episiotomy in obstetrical care: a systematic review; summary. Agency for Healthcare Research and Quality (Evidence Report/Technology Assessment: Number 112.)
• Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 1997, Issue 2. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081
  
• Roberts CL, Tracy S, Peat B. Rates for obstetric intervention among private and public patients in Australia: a population based descriptive study. BMJ. 2000;321:137–141.
• Senate Community Affairs Reference Committee. Rocking the cradle: a report of childbirth procedures. Canberra: Commonwealth of Australia; 1999. www.aph.gov.au/senate_ca.
• Roberts JM. Recent advances: Obstetrics. BMJ. 2000;321:33–35.
• Albers, L. L.; Sedler, K. D.; Bedrick, E. J.; et al., D; Peralta, P (2005). "Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial". Journal of Midwifery & Women's Health 50 (5): 365–372. doi:10.1016/j.jmwh.2005.05.012. PMID 16154062
• 10% Primipara Sutured Tear rate in the absence of episiotomy. Birth 2008;35(2):167.
• Woolley RJ. Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I. Obstet Gynecol Survey 1995; 50:806-820
• Woolley RJ. Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part II. Obstet Gynecol Survey 1995; 50:821-835