Re: [ozmidwifery] Re Episiotomy

[Nikki Macfarlane]

Oh Denise, so beautifully asked - without a trace 
of rancour or cynicism! Physiological third stage is one of my more obvious 
irritations - the one I probably become most passionate about. Listening to 
caregivers talk about the Cochrane trials and how they recommend managed third 
stage drives me nuts. Having scoured through all the original papers used for 
the Cochrane trial it is so clear that there were many flaws in the studies they 
reviewed. Bath was only one of many! Third stage is even more of an issue here 
now with an amazingly high number of parents opting for cord stem cell storage 
through private companies - there is no public bank. They are always surprised 
when we communicate to them that their obstetrician will receive $500 from the 
storage company for each stem cell collection he/she makes.We currently have a 
big drive from EPI-No as well of the same ilk - each doctor stocking these 
ridiculous contraptions receives a payout. No surprise then that many doctors 
are encouraging the women they care for to use them. Never mind that Epi-No were 
unable to satisfactorily reply to any of my questions to them. Bit the same as 
the storage of stem cell companies here - asked them some pretty direct 
questions 6 months ago - they were going to find out the answers but clearly 
were unable to - or unable to share their findings! Not that I am a believer in 
"money driving the health care system" of course.
 
Nikki MacfarlaneChildbirth Internationalwww.childbirthinternational.com 
[EMAIL PROTECTED] 
Distance training for the world's childbirth educators and doulas

  - Original Message - 
  From: 
  Denise Hynd 
  To: [EMAIL PROTECTED] 
  
  Sent: Sunday, June 15, 2003 2:39 AM
  Subject: Re: [ozmidwifery] Re 
  Episiotomy
  
  Dear Nikki
   
  Are you sensing that possibily the results of the 
  HOOP study maybe reminiscent of the Bath study on physiological third and more 
  recently the Breech Trial in that the results may be influenced or 
  contaminated by the expereince of the operators?Denise
  
- Original Message - 
From: 
Nikki 
Macfarlane 
To: [EMAIL PROTECTED] 

Sent: Friday, June 13, 2003 4:02 
AM
Subject: Re: [ozmidwifery] Re 
Episiotomy

Thanks for the clarification Lesley and 
Marilyn. The HOOP trial conclusions was what I had read in MIDIRs some time 
ago and had assumed that this was what was being recommended by midwifery 
organisations. I am pleased to see that the trial results have been 
interpreted differently by some.
 
After reading the HOOP trial I was frustrated 
that they did not seem to provide enough information to determine why it was 
that the hands poised group had a significantly higher rate of manual 
removal of placenta. I can't think of any reason why this would be so - 
unless the midwives caring for these women were applying a different type of 
care for the third stage, either consciously or subconsciously, to the hands 
poised group. If they were providing different care, why was this? Perhaps a 
different subconscious attitude towards this type of care? Or something they 
were uncomfortable with? And if so, how did that affect other aspects of the 
trial? 
 
Can anyone else think of any reason the hands 
poised group would have significantly higher levels of manual 
removal?
 
Nikki MacfarlaneChildbirth Internationalwww.childbirthinternational.com 
[EMAIL PROTECTED] 
Distance training for the world's childbirth educators and 
  doulas

Re: [ozmidwifery] Re Episiotomy

[Denise Hynd]

Dear Nikki
 
Are you sensing that possibily the results of the 
HOOP study maybe reminiscent of the Bath study on physiological third and more 
recently the Breech Trial in that the results may be influenced or contaminated 
by the expereince of the operators?Denise

  - Original Message - 
  From: 
  Nikki 
  Macfarlane 
  To: [EMAIL PROTECTED] 
  
  Sent: Friday, June 13, 2003 4:02 AM
  Subject: Re: [ozmidwifery] Re 
  Episiotomy
  
  Thanks for the clarification Lesley and Marilyn. 
  The HOOP trial conclusions was what I had read in MIDIRs some time ago and had 
  assumed that this was what was being recommended by midwifery organisations. I 
  am pleased to see that the trial results have been interpreted differently by 
  some.
   
  After reading the HOOP trial I was frustrated 
  that they did not seem to provide enough information to determine why it was 
  that the hands poised group had a significantly higher rate of manual removal 
  of placenta. I can't think of any reason why this would be so - unless the 
  midwives caring for these women were applying a different type of care for the 
  third stage, either consciously or subconsciously, to the hands poised group. 
  If they were providing different care, why was this? Perhaps a different 
  subconscious attitude towards this type of care? Or something they were 
  uncomfortable with? And if so, how did that affect other aspects of the trial? 
  
   
  Can anyone else think of any reason the hands 
  poised group would have significantly higher levels of manual 
  removal?
   
  Nikki MacfarlaneChildbirth Internationalwww.childbirthinternational.com 
  [EMAIL PROTECTED] 
  Distance training for the world's childbirth educators and 
doulas

Re: [ozmidwifery] Re Episiotomy

[Jayne]

Speaking from my own birth experiences (3), I 
support 'hands on' - my OWN hands!  This came so naturally - I just did 
it.  I remember with the last birth and I felt a ripple thru the water 
and I presumed the midwife was going to put a hand 'there', I yelled at her 
"DON'T TOUCH"!
 
Jayne
 

  
  Actually Mary, if you want to get your hands on, 
  the only position you can't is water birth (unless you are in the tub too 
  (joke)) and possibly a deep squat.  We used the deBuy birth stool a lot 
  there and trust me, you can definetly get your hands on. By hands on i am not 
  meaning anything beyond perineal support (which as the article discusses is 
  favoured by US midwives), and a gentle hand on the baby's head (not really 
  doing much). Mum's (mom's) I attended in the USA truly expected this, perineal 
  support especially is promoted in birth literature there. This means the 
  midwife is also in many and varied positions.  I know it isn't usually 
  done here, I don't know for how long it hasn't been done: before or after the 
  Hoop trial?  It will be interesting to see what the outcomes of this 
  study are, especially to see if it leads to practice change. By this  I 
  mean if the study supports "hands off", then will US midwives change their 
  practice? And if it supports "hands on" will Australian and Uk midwives change 
  theirs?  Or will we have to do a repeat study here? Possibly the result 
  will be ambiguous and claim there is no significant difference betweeen 
  practices and so no change will happen anywhere. Interesting that's 
  all.
   
  marilyn
   

Re: [ozmidwifery] Re: Isolated birth

[Ross W Timbs]

Jan,
Could I have a copy of your birth plan too please.
Jacky
[EMAIL PROTECTED]

- Original Message -
From: "Jan Robinson" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Saturday, June 14, 2003 8:57 AM
Subject: Re: [ozmidwifery] Re: Isolated birth



Hi Lyle
You can count me in too if you can get me there! The closest I have ever
been to Pitcairn is Norfolk and that's a long way from you.

However, the reality is that you will probably be unassisted except for the
woman's immediate family and the priority now would be to prepare them all
for a natural birth (if natural birth is unfamiliar to them and you). It is
important to work out the role of each family member in supporting the woman
through her labour and possibly assisting you if unexpected circumstances
occur.

Have you got lots of resources, videos, pictures, books depicting natural
birth so you can all get together and discuss options and prepare this
woman's birth plan with her? Also discuss what will be focused on as pain
management. The woman will do much better without drugs and needs to have a
plan on how she will achieve this.  Verbal analgesia from her family will
help.

I can send you a copy of a really good birth plan electronically that will
guide you in your discussion with this woman if you would like it.
Discussing aspects of the birth plan at each prenatal visit will remind you
to leave no part of the pregnancy, labour/birth and aftercare untouched and
will in fact become your documentation of obtaining informed consent for
your management.

Regards
Jan Robinson

__
 Jan Robinson Phone/fax: 011+ 61+ 2+ 9546 4350
 Independent Midwife Practitioner e-mail: <[EMAIL PROTECTED]>
 8 Robin Crescent www:   midwiferyeducation.com.au
 South Hurstville  NSW  2221  National Coordinator, ASIM
__



On 13/6/03 10:00 AM, "Andrea Quanchi" <[EMAIL PROTECTED]> wrote:

> I'd say go for it. You obviously both understand the limitations of
> isolation and so long as that is the case then it is ultimately her
> decision.  The woman is better with you than without you.  I am assuming
> that you must have someone else on the island who is proficient in CPR
> and I would include them in your birth preperations.  Once the baby is
> born there are two people to be considered and it is reassuring to know
> that there is someone who can care for each in the unlikely event that
> they are needed.  Non birthing people seem to panic at the idea so
> springing it on someone at the last minute is not a good idea but if
> they get to work through the remainder of the pregnancy with you both
> and see that you are making the decision on healthy ideals then they
> will be more comfortable when the time comes.
> What about offering an island holiday to a midwife +/- family around the
> time of birth, Anyway have a great time and keep us informed about the
> plans
> Andrea Quanchi
> On Wednesday, June 11, 2003, at 12:14 PM, Medical Officer wrote:
>
>> Hi everyone,
>> I am at present the sole medical person and midwife on an isolated
>> island where the nearest medical help is seven days away by ship. All
>> mothers over the past 10 years have gone to Auckland to have their
>> babies. I am at present looking after a mother with her second
>> pregnancy (to a new partner) who would like to have this baby on the
>> island where she resides. She had a fairly easy first delivery and
>> this pregnancy has progressed well (she is 24 weeks) with no
>> complications. I am reasonably happy to continue looking after her and
>> delivering on island but I am wondering what other midwives etc. would
>> recommend.
>> Any feedback on this would be great.
>> Thanks,
>> Lyle
>

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Re: [ozmidwifery] Re: Isolated birth

[Mary Murphy]

Jan wrote to Lyle: " I can send you a copy of a really good birth 
plan electronically that willguide you in your discussion with this woman if 
you would like it."
 
Jan, How about sharing this birth plan with all of us?  Cheers, 
MM
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RE: [ozmidwifery] Re Episiotomy

[Ward, Birthing Centre Midwives]

Just a thought about the increase in mild pain experienced by women who had
"hands poised" care at birth: was the increased rate of manual removal of
placenta a confounding factor? It would be interesting to compare those who
had "hands poised" care at birth and did not have a manual removal with
those who did have a manual removal because 
having the trauma from a manual removal could add to pain. I agree with
others about the position of birth,  when women are upright and gently
breathe the baby's head out according to their instincts without directed
pushing they do it all themselves. I think midwives can cause harm by
directing pushing and making women lay on their backs and then give
themselves credit when women have intact perineums. The midwife is the one
'in control' with hands on and instructing the woman when women can give
birth under their own steam and our job is to support this natural process
not to control it. Unfortunately some women do tear & I think there is more
to perineal integrity than the midwife's hands. Just being in hospital in an
alien environment has a huge influence on the birth process. 

>From jan Prider
--
From:  Marilyn Kleidon[SMTP:[EMAIL PROTECTED]
Sent:  Sunday, 15 June 2003 00:28
To:  [EMAIL PROTECTED]
Subject:  Re: [ozmidwifery] Re Episiotomy

Dear Andrea: I think this issue (mother's birth position) as well as
a lot
of other information is intended to be included by the study being
undertaken by the nurse midwives in this study Mary posted:
Reducing Genital Tract Trauma at Birth: Launching a Clinical Trial
in
Midwifery
A midwifery practice offers an ideal setting to study hand
techniques to
prevent genital trauma.
J Midwifery Womens Health 48(2) 2003

It is really worth having a read. While I do acknowledge the hands
on
techniques probably arose from women being in the "stranded beetle"
position, at least in the USA they (the hands)are also applied to
just about
every other position too. There, as I said before it has come to be
expected: especially among homebirth women (who were my clientelle
(sp)), as
in at the first interview: "You will support my perineum at the
birth?" This
is also acknowledged in the introduction to the study as women will
have to
agree to be randomised to one group or the other. I had never caught
a baby
with the mother flat on her back ...until I came here. Many were
hands and
knees, others supported squats, birthstool, water, and if lying
down, side
lying on the floor with mum's leg on my shoulder... and my hands on.
We had
so few tears that required suturing (5/60 at home) I almost didn't
get
enough suturing experience to be signed off for graduation. But, I
am sure
anecdotally, we could all justify our practice, none of us want to
hurt
women, quite the contrary.  These results will be interesting, at
least in
the USA where, the practice is mostly (again, it is such  a bug
country, at
least in some parts of Washington and California) "hands on".

marilyn
- Original Message -
From: "Andrea Robertson" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Friday, June 13, 2003 5:49 AM
Subject: Re: [ozmidwifery] Re Episiotomy


> Hi Marilyn, Mary et al,
>
> The interesting thing about this trial was that all the women are
in the
> reclining position - the training video used to show midwives
taking part
> how they were to participate clearly showed this.  When a woman is
lying
> back in the semi sitting or lithotomy position, there is a lot of
pressure
> on her perineal tissues as the baby's head sweeps up under the
pubic arch,
> and the tissues become extended, thin and much more fragile as a
result.
> When the woman is upright, this "ironing out of the perineum"
doesn't
> happen and the tissues can slip behind the baby's chin much more
readily.
> Of course, when the woman is upright and using gravity, the speed
of the
> birth is also much faster and it is important that she is not
encouraged
to
> push at all.
>
> Perhaps what the HOOP trial shows is that when women are forced
into poor
> physiological positions, then an intervention is required: the
perineum
> will need to be supported if it is to withstand the unnatural
pressures
> caused by gravitational forces on the baby's head. I have been
sayingf for
> years that the old techniques used by midwives of "supporting the
perineum
> and easing the head out with manual pressure against it" probably
derived
> from a midwife's instinct to try and keep the perineum intact when
it is
> clearly under huge stress. It may have been

Re: [ozmidwifery] Re: Isolated birth

[Jan Robinson]

Hi Lyle
You can count me in too if you can get me there! The closest I have ever
been to Pitcairn is Norfolk and that's a long way from you.

However, the reality is that you will probably be unassisted except for the
woman's immediate family and the priority now would be to prepare them all
for a natural birth (if natural birth is unfamiliar to them and you). It is
important to work out the role of each family member in supporting the woman
through her labour and possibly assisting you if unexpected circumstances
occur.

Have you got lots of resources, videos, pictures, books depicting natural
birth so you can all get together and discuss options and prepare this
woman's birth plan with her? Also discuss what will be focused on as pain
management. The woman will do much better without drugs and needs to have a
plan on how she will achieve this.  Verbal analgesia from her family will
help.

I can send you a copy of a really good birth plan electronically that will
guide you in your discussion with this woman if you would like it.
Discussing aspects of the birth plan at each prenatal visit will remind you
to leave no part of the pregnancy, labour/birth and aftercare untouched and
will in fact become your documentation of obtaining informed consent for
your management.

Regards
Jan Robinson

__
 Jan Robinson Phone/fax: 011+ 61+ 2+ 9546 4350
 Independent Midwife Practitioner e-mail: <[EMAIL PROTECTED]>
 8 Robin Crescent www:   midwiferyeducation.com.au
 South Hurstville  NSW  2221  National Coordinator, ASIM
__



On 13/6/03 10:00 AM, "Andrea Quanchi" <[EMAIL PROTECTED]> wrote:

> I'd say go for it. You obviously both understand the limitations of
> isolation and so long as that is the case then it is ultimately her
> decision.  The woman is better with you than without you.  I am assuming
> that you must have someone else on the island who is proficient in CPR
> and I would include them in your birth preperations.  Once the baby is
> born there are two people to be considered and it is reassuring to know
> that there is someone who can care for each in the unlikely event that
> they are needed.  Non birthing people seem to panic at the idea so
> springing it on someone at the last minute is not a good idea but if
> they get to work through the remainder of the pregnancy with you both
> and see that you are making the decision on healthy ideals then they
> will be more comfortable when the time comes.
> What about offering an island holiday to a midwife +/- family around the
> time of birth, Anyway have a great time and keep us informed about the
> plans
> Andrea Quanchi
> On Wednesday, June 11, 2003, at 12:14 PM, Medical Officer wrote:
> 
>> Hi everyone,
>> I am at present the sole medical person and midwife on an isolated
>> island where the nearest medical help is seven days away by ship. All
>> mothers over the past 10 years have gone to Auckland to have their
>> babies. I am at present looking after a mother with her second
>> pregnancy (to a new partner) who would like to have this baby on the
>> island where she resides. She had a fairly easy first delivery and
>> this pregnancy has progressed well (she is 24 weeks) with no
>> complications. I am reasonably happy to continue looking after her and
>> delivering on island but I am wondering what other midwives etc. would
>> recommend.
>> Any feedback on this would be great.
>> Thanks,
>> Lyle
> 

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Re: [ozmidwifery] Re Episiotomy

[Marilyn Kleidon]

Dear Andrea: I think this issue (mother's birth position) as well as a lot
of other information is intended to be included by the study being
undertaken by the nurse midwives in this study Mary posted:
Reducing Genital Tract Trauma at Birth: Launching a Clinical Trial in
Midwifery
A midwifery practice offers an ideal setting to study hand techniques to
prevent genital trauma.
J Midwifery Womens Health 48(2) 2003

It is really worth having a read. While I do acknowledge the hands on
techniques probably arose from women being in the "stranded beetle"
position, at least in the USA they (the hands)are also applied to just about
every other position too. There, as I said before it has come to be
expected: especially among homebirth women (who were my clientelle (sp)), as
in at the first interview: "You will support my perineum at the birth?" This
is also acknowledged in the introduction to the study as women will have to
agree to be randomised to one group or the other. I had never caught a baby
with the mother flat on her back ...until I came here. Many were hands and
knees, others supported squats, birthstool, water, and if lying down, side
lying on the floor with mum's leg on my shoulder... and my hands on.  We had
so few tears that required suturing (5/60 at home) I almost didn't  get
enough suturing experience to be signed off for graduation. But, I am sure
anecdotally, we could all justify our practice, none of us want to hurt
women, quite the contrary.  These results will be interesting, at least in
the USA where, the practice is mostly (again, it is such  a bug country, at
least in some parts of Washington and California) "hands on".

marilyn
- Original Message -
From: "Andrea Robertson" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Friday, June 13, 2003 5:49 AM
Subject: Re: [ozmidwifery] Re Episiotomy


> Hi Marilyn, Mary et al,
>
> The interesting thing about this trial was that all the women are in the
> reclining position - the training video used to show midwives taking part
> how they were to participate clearly showed this.  When a woman is lying
> back in the semi sitting or lithotomy position, there is a lot of pressure
> on her perineal tissues as the baby's head sweeps up under the pubic arch,
> and the tissues become extended, thin and much more fragile as a result.
> When the woman is upright, this "ironing out of the perineum" doesn't
> happen and the tissues can slip behind the baby's chin much more readily.
> Of course, when the woman is upright and using gravity, the speed of the
> birth is also much faster and it is important that she is not encouraged
to
> push at all.
>
> Perhaps what the HOOP trial shows is that when women are forced into poor
> physiological positions, then an intervention is required: the perineum
> will need to be supported if it is to withstand the unnatural pressures
> caused by gravitational forces on the baby's head. I have been sayingf for
> years that the old techniques used by midwives of "supporting the perineum
> and easing the head out with manual pressure against it" probably derived
> from a midwife's instinct to try and keep the perineum intact when it is
> clearly under huge stress. It may have been a "handy midwifery hint" that
> developed into a standard habit that is still used today. Note that in the
> summary below, the significance fo the birth positon of the woman is not
> mentioned at all - probably because very few women deliver (not "give
> birth") off the bed and in upright positions in the UK at the present
time.
> The fact that the relationship of the woman's position to perineal
pressure
> was not even canvassed as a variable says a lot in itself.
>
> Personally, I would like us to acknowledge that women choosing their own
> birthing positions (something upright) will not need perineal support and
> that this is an intervention only needed when we limit women's choices. As
> long as she is encouraged to take her time and is not rushed she will be
> better able to judge her own efforts to get the baby born gently and for
> her tissues to stretch. Some will tear (e.g. when there is a compound
> presentation) but this is a quirk of nature and must be accepted too.
>
> I think these issues of protecting the perineum are much better understood
> and practised in Australia than they are in the UK and probably in the US
> as well. We've been talking about "hands off the perineum" for almost 20
> years (since I started doing "Active Birth" workshops and others also
began
> promoting these ideas) and I would hope that something has sunk in here
and
> there by now!
>
> Regards
>
> Andrea   (in the UK  at present and still trying to change UK midwives'
> practices!!)
>
>
> >  A randomised controlled trial of care of the perineum during second
> > stage of normal labour - British Journal of Obstetrics and Gynaecology ,
> > vol 105, no 12, December 1998, pp 1262-1272 McCandlish R; Bowler U; van
> > Asten H; et al - (December 1998)
> >  

Re: [ozmidwifery] genital herpes

[LesiaKyriakou]

Hi,

Don't know if anyone else has mentioned this?

Bergamot is recommended as it is anti viral and especially suited to Herpes 
also it is a lovely uplifting oil to use anyway, my next birth is a Herpes 
sufferer and has been given some amazingly bad advice :(

Good Luck

Lesia

PS if you want any info on dilution etc please contact me.
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Re: [ozmidwifery] Re Episiotomy

[Nikki Macfarlane]

Thanks for the comments Andrea. Your comments are certainly borne up by our
experiences here in Singapore as well. Whilst we only have a small sample to
use as an example (about 90 births so far) they are for the most part
natural, vaginal births with hands poised, in positions chosen by the women
themselves with absolutely no direction from anyone else, a calm, dimmed
environment, no controlled pushing techniques, and completely natural third
stages. I have seen 2 PPH's - one with a managed third stage and one with a
physiological, both with the same caregiver. Those women who have birthed
vaginally almost always choose to birth their babies in an all fours
position or standing, and usually their partner catches the baby with
caregiver guidance if needed. I have seen one third degree tear in a woman
who had serious pre-eclampsia and severe oedema to her tissues. Our
episiotomy rate is only 3%. No fourth degree tears. Some second degree but
predominately intact or first degree, and rarely any stitching for these. No
retained placentas diagnosed at all. Although several have taken more than
an hour to be born.

So our conclusions based on small sample size? Hands poised works best in an
environment where the woman is well supported, provided with good
information, has a suportive caregiver and a normal labour. It has no impact
on perineal postnatal pain, no impact on infant outcomes, and no impact on
placental problems.

Oh yeah. The caregiver we work with? He is a Singaporean obstetrician. No
midwifery care here - just doesn't happen. The midwives are limited in what
they are able to do and effectively restricted to working as obstetric
nurses.

Nikki Macfarlane
Childbirth International
www.childbirthinternational.com
[EMAIL PROTECTED]
Distance training for the world's childbirth educators and doulas


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Re: [ozmidwifery] Re Episiotomy

[Andrea Robertson]

Nikki wrote:
After reading the HOOP trial I was frustrated that they did not seem to 
provide enough information to determine why it was that the hands poised 
group had a significantly higher rate of manual removal of placenta. I 
can't think of any reason why this would be so - unless the midwives 
caring for these women were applying a different type of care for the 
third stage, either consciously or subconsciously, to the hands poised 
group. If they were providing different care, why was this? Perhaps a 
different subconscious attitude towards this type of care? Or something 
they were uncomfortable with? And if so, how did that affect other aspects 
of the trial?
I feel sure that this outcome (higher rate of manual removal) is due to the 
time limits placed on the management of the third stage. If the hands are 
poised then maybe it follows that routine syntometrine is also slower or 
that contolled cord traction is delayed. It is another very unsatisfactory 
aspect of this trial. not enough information is given. In the UK a 
delay in the third stage beyond 15 - 30 minutes will most likely lead to an 
automatic manual removal patience is at a premium here. The idea of 
waiting for the placenta (at all) was greeted with amazement in the 
workshops Lynne Staff and I have just concluded

Regards,

Andrea

-
Andrea Robertson
Birth International * ACE Graphics * Associates in Childbirth Education
e-mail: [EMAIL PROTECTED]
web: www.birthinternational.com
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Re: [ozmidwifery] Re Episiotomy

[Andrea Robertson]

Hi Marilyn, Mary et al,

The interesting thing about this trial was that all the women are in the 
reclining position - the training video used to show midwives taking part 
how they were to participate clearly showed this.  When a woman is lying 
back in the semi sitting or lithotomy position, there is a lot of pressure 
on her perineal tissues as the baby's head sweeps up under the pubic arch, 
and the tissues become extended, thin and much more fragile as a result. 
When the woman is upright, this "ironing out of the perineum" doesn't 
happen and the tissues can slip behind the baby's chin much more readily. 
Of course, when the woman is upright and using gravity, the speed of the 
birth is also much faster and it is important that she is not encouraged to 
push at all.

Perhaps what the HOOP trial shows is that when women are forced into poor 
physiological positions, then an intervention is required: the perineum 
will need to be supported if it is to withstand the unnatural pressures 
caused by gravitational forces on the baby's head. I have been sayingf for 
years that the old techniques used by midwives of "supporting the perineum 
and easing the head out with manual pressure against it" probably derived 
from a midwife's instinct to try and keep the perineum intact when it is 
clearly under huge stress. It may have been a "handy midwifery hint" that 
developed into a standard habit that is still used today. Note that in the 
summary below, the significance fo the birth positon of the woman is not 
mentioned at all - probably because very few women deliver (not "give 
birth") off the bed and in upright positions in the UK at the present time. 
The fact that the relationship of the woman's position to perineal pressure 
was not even canvassed as a variable says a lot in itself.

Personally, I would like us to acknowledge that women choosing their own 
birthing positions (something upright) will not need perineal support and 
that this is an intervention only needed when we limit women's choices. As 
long as she is encouraged to take her time and is not rushed she will be 
better able to judge her own efforts to get the baby born gently and for 
her tissues to stretch. Some will tear (e.g. when there is a compound 
presentation) but this is a quirk of nature and must be accepted too.

I think these issues of protecting the perineum are much better understood 
and practised in Australia than they are in the UK and probably in the US 
as well. We've been talking about "hands off the perineum" for almost 20 
years (since I started doing "Active Birth" workshops and others also began 
promoting these ideas) and I would hope that something has sunk in here and 
there by now!

Regards

Andrea   (in the UK  at present and still trying to change UK midwives' 
practices!!)


 A randomised controlled trial of care of the perineum during second 
stage of normal labour - British Journal of Obstetrics and Gynaecology , 
vol 105, no 12, December 1998, pp 1262-1272 McCandlish R; Bowler U; van 
Asten H; et al - (December 1998)
  Objective: To compare the effect of two methods of perineal management 
used by midwives at the end of second stage on the prevalence of perineal 
pain reported by women at 10 days after birth. The methods compared were: 
1. 'hands on', in which the midwife's hands are used to put pressure on 
the baby's head in the belief that flexion will be increased, and to 
support ('guard') the perineum, and to exert lateral flexion to 
facilitate the delivery of the shoulders. 2. 'hands poised', in which the 
midwife keeps her hands poised, prepared to put light pressure on the 
baby's head in case of rapid expulsion, but not otherwise to touch the 
head or perineum; the shoulders are allowed to deliver spontaneously. 
Design: Randomised controlled trial. Setting: Recruitment and data 
collection: Southmead Health Services NHS Trust, Frenchay Healthcare NHS 
Trust, Royal Berkshire and Battle Hospital NHS Trust, West Berkshire 
Priority Care Service NHS Trust, Severn NHS Trust, United Bristol 
Healthcare NHS Trust, Weston Area Health NHS Trust and Glan Hafren NHS 
Trust. Randomisation: Southmead Health Services NHS Trust, Bristol; and 
The Royal Berkshire and Battle Hospital NHS Trust, Reading; Sample: 5741 
women who gave birth between December 1994 and December 1996 Eligibility 
and recruitment. During routine antenatal care midwives gave written 
information about the trial to pregnant women and discussed 
participation. A woman was eligible to participate if she had a singleton 
pregnancy with cephalic presentation, was expecting a normal birth and 
was not planning delivery in water, had not been prescribed an elective 
episiotomy, and did not plan to give her baby up for adoption. If all 
these criteria were fulfilled she was asked to give oral consent to join 
the trial. Women were assured of their right to withdraw from the trial 
at any time. Once a midwife had discussed the trial with a woman

[ozmidwifery] Breastmilk - great stuff

[Graham & Helen]

Another good reason to 
breastfeed..
 
http://www.abc.net.au/science/news/stories/s877755.htm
 
Helen Cahill

Re: [ozmidwifery] Re Episiotomy

[Nikki Macfarlane]

Thanks for the clarification Lesley and Marilyn. 
The HOOP trial conclusions was what I had read in MIDIRs some time ago and had 
assumed that this was what was being recommended by midwifery organisations. I 
am pleased to see that the trial results have been interpreted differently by 
some.
 
After reading the HOOP trial I was frustrated that 
they did not seem to provide enough information to determine why it was that the 
hands poised group had a significantly higher rate of manual removal of 
placenta. I can't think of any reason why this would be so - unless the midwives 
caring for these women were applying a different type of care for the third 
stage, either consciously or subconsciously, to the hands poised group. If they 
were providing different care, why was this? Perhaps a different subconscious 
attitude towards this type of care? Or something they were uncomfortable with? 
And if so, how did that affect other aspects of the trial? 
 
Can anyone else think of any reason the hands 
poised group would have significantly higher levels of manual 
removal?
 
Nikki MacfarlaneChildbirth Internationalwww.childbirthinternational.com 
[EMAIL PROTECTED] 
Distance training for the world's childbirth educators and 
doulas

[ozmidwifery] melbourne

[Sally]

Hi Folks,

I'm going to be in melbourne for the next 3 weeks. If anyone would like to
have a yarn about midwifery stuff with me while i'm over ease let me know.

Any study/conference/networking opportunities over east please also alert me
to.

Love Sally Westbury
Homebirth Midwife
Community Midwifery Program
Western Australia

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Re: [ozmidwifery] Re Episiotomy

[Marilyn Kleidon]

My understanding of the Hoop Trial was that there 
was no significant (statistical) difference in physical trauma between "hands 
on" and "hands off", but, that there was less pain (postpartum) experinced 
by women in the "hands on" group. While in the USA this was taken to support 
"hands on". However, since being here, I have been under the impression that the 
trial was interpreted the other way: to support "hands off".  Maybe not by 
all.
 
marilyn

  - Original Message - 
  From: 
  Nikki 
  Macfarlane 
  To: [EMAIL PROTECTED] 
  
  Sent: Thursday, June 12, 2003 5:28 
  PM
  Subject: Re: [ozmidwifery] Re 
  Episiotomy
  
  I am confused by this discussion so hoping for 
  some clarification! My understanding of the results of the HOOP trial was that 
  it favoured the use of Hands On - a finding that the midwives in the UK were 
  surprised by. I had read summaries that clearer pointed out an improvement in 
  perineal outcomes with a hands on approach. Was there re-analysis carried out 
  that found the opposite to be true? It sounds from this discussion that the 
  HOOP trial is now being said to have favoured hands off. Can someone 
  help?
   
  Nikki MacfarlaneChildbirth Internationalwww.childbirthinternational.com 
  [EMAIL PROTECTED] 
  Distance training for the world's childbirth educators and doulas
  
- Original Message - 
From: 
Marilyn 
Kleidon 
To: [EMAIL PROTECTED] 

Sent: Saturday, June 14, 2003 12:43 
AM
Subject: Re: [ozmidwifery] Re 
Episiotomy

Actually Mary, if you want to get your hands 
on, the only position you can't is water birth (unless you are in the tub 
too (joke)) and possibly a deep squat.  We used the deBuy birth stool a 
lot there and trust me, you can definetly get your hands on. By hands on i 
am not meaning anything beyond perineal support (which as the article 
discusses is favoured by US midwives), and a gentle hand on the baby's head 
(not really doing much). Mum's (mom's) I attended in the USA truly expected 
this, perineal support especially is promoted in birth literature there. 
This means the midwife is also in many and varied positions.  I know it 
isn't usually done here, I don't know for how long it hasn't been done: 
before or after the Hoop trial?  It will be interesting to see what the 
outcomes of this study are, especially to see if it leads to practice 
change. By this  I mean if the study supports "hands off", then will US 
midwives change their practice? And if it supports "hands on" will 
Australian and Uk midwives change theirs?  Or will we have to do a 
repeat study here? Possibly the result will be ambiguous and claim there is 
no significant difference betweeen practices and so no change will happen 
anywhere. Interesting that's all.
 
marilyn

  - Original Message - 
  From: 
  Mary 
  Murphy 
  To: [EMAIL PROTECTED] 
  
  Sent: Thursday, June 12, 2003 5:30 
  AM
  Subject: Re: [ozmidwifery] Re 
  Episiotomy
  
  Marilyn Wrote.  I must admit after my 
  training in the USA it has been hard to do and I am definetly more "hands 
  on" than "hands off". 
   
  I find discussions about hands on and off interesting, given that if 
  a woman is birthing in a pysiological position, (upright squat, hands and 
  knees or kneeling leaning forward), there is nowhere for a midwife's hands 
  to be except in the "catch" position, especially if a woman is birthing in 
  water.  I wonder if all this discussion and trials  would be 
  going on if birth was truly in the hands of women?  MM
   
  
 

Re: [ozmidwifery] Re Episiotomy

[Lesley Kuliukas]

Hi
Here's the MIDIRS abstract which concludes by 
recommending hands on.
Lesley


  
  
 A randomised controlled trial of care of 
  the perineum during second stage of normal 
  labour - British 
  Journal of Obstetrics and Gynaecology , vol 105, no 12, December 
  1998, pp 1262-1272 McCandlish R; Bowler U; van Asten H; et 
  al - (December 1998)
  
 
Objective: To compare the effect of two methods of 
  perineal management used by midwives at the end of second stage on the 
  prevalence of perineal pain reported by women at 10 days after birth. The 
  methods compared were: 1. 'hands on', in which the midwife's hands are 
  used to put pressure on the baby's head in the belief that flexion will be 
  increased, and to support ('guard') the perineum, and to exert lateral 
  flexion to facilitate the delivery of the shoulders. 2. 'hands poised', in 
  which the midwife keeps her hands poised, prepared to put light pressure 
  on the baby's head in case of rapid expulsion, but not otherwise to touch 
  the head or perineum; the shoulders are allowed to deliver spontaneously. 
  Design: Randomised controlled trial. Setting: Recruitment and data 
  collection: Southmead Health Services NHS Trust, Frenchay Healthcare NHS 
  Trust, Royal Berkshire and Battle Hospital NHS Trust, West Berkshire 
  Priority Care Service NHS Trust, Severn NHS Trust, United Bristol 
  Healthcare NHS Trust, Weston Area Health NHS Trust and Glan Hafren NHS 
  Trust. Randomisation: Southmead Health Services NHS Trust, Bristol; and 
  The Royal Berkshire and Battle Hospital NHS Trust, Reading; Sample: 5741 
  women who gave birth between December 1994 and December 1996 Eligibility 
  and recruitment. During routine antenatal care midwives gave written 
  information about the trial to pregnant women and discussed participation. 
  A woman was eligible to participate if she had a singleton pregnancy with 
  cephalic presentation, was expecting a normal birth and was not planning 
  delivery in water, had not been prescribed an elective episiotomy, and did 
  not plan to give her baby up for adoption. If all these criteria were 
  fulfilled she was asked to give oral consent to join the trial. Women were 
  assured of their right to withdraw from the trial at any time. Once a 
  midwife had discussed the trial with a woman she attached a specially 
  designed HOOP sticker to the woman's notes and if she was ineligible for 
  any reason crossed it through. When a woman who was >/=37 weeks 
  gestation and in established labour the midwife attending her re-checked 
  eligibility and consent to take part. Randomisation: At the end of second 
  stage, when the attending midwife was confident that a normal vagina] 
  birth was likely, she opened the next in a series of sequentially 
  numbered, sealed, opaque envelopes. This contained a card with details of 
  the woman's randomisation group. Data collection: Attending midwives 
  completed data collection forms for every woman who was randomised 
  immediately after birth, at 2 days and at 9-11 days postnatally; each 
  participating woman also self-completed a trial questionnaire at 2 days, 
  10 days and at 3 months after birth. Results: Questionnaires were 
  completed by 97% of women at 10 days after birth. 910 (34.1 %) women in 
  the 'hands poised' group reported pain in the previous 24 hours compared 
  with 823 (31.1%) in the 'hands on' group RR= 1.10 95% Cl 1.01 to 1.18: 
  absolute difference 3%, 0.5% to 5%, p=0.02). The rate of episiotomy was 
  significantly lower in the 'hands poised' group (RR 0.79, 99% Cl 0.65 to 
  0.96, p=0.008) and the rate of manual removal of placenta was 
  significantly higher in that group (RR 1.69, 99% Cl 1.02 to 2.78; p = 
  0.008). There were no other statistically significant differences detected 
  in any outcomes measured. Conclusion: Women in the 'hands on' group 
  reported significantly less perinea] pain than those in the 'hands poised' 
  group. Although this finding related mainly to mild pain at 10 days 
  afterbirth, it has the potential to affect large numbers of women. In the 
  light of this evidence, a policy of 'hands poised' care is not 
  recommended. If 'hands poised' care is used then audit of important 
  outcomes, for example relating to third stage, should be maintained; a 
  policy of 'hands on' care merits audit of episiotomy rates. The majority 
  of women who give birth in the UK experience a range of direct midwifery 
  interventions during normal labour. Such routine care affects huge numbers 
  of women and must be based on reliable assessment of risks and benefits. 
  In this trial thousands of women and hundreds of midwives committed 
  themselves to he