Posterior Labor: A Pain in the Back, by Valerie El Halta

Posterior Labor: A Pain in the Back
by Valerie El Halta
© 2005 Midwifery Today, Inc. All rights reserved.[Editor’s note: This article appeared in Midwifery Today Issue 76, Winter 2005. Reprinted from Midwifery Today, Number 36, Winter 1995, p. 19-21.]

I have become increasingly frustrated and angry that posterior position and its ensuing complications in labor and delivery account for an inordinate number of caesareans. Many of the women who come to us desiring VBACs have suffered a previous cesarean for “failure to progress” and “cephalopelvic disproportion” (CPD). Yet when we preview the women’s records, the post-operative diagnosis usually confirms a posterior position (back of the baby’s head toward the mother’s back).

My experience is that with appropriate diagnosis, this condition can be corrected with minimal intervention by assisting the baby to rotate. But many times, the position is not diagnosed until labor is advanced and progress has stopped. Labor and delivery nurses are often untrained in diagnosing posterior positions, and the woman may not see her physician until she nears the end of labor. Even if the physician were present to make an early diagnosis, generally he/she would do nothing to correct the position. Instead, comfort measures would be offered until the situation eventually resolved itself, or was corrected in second stage after labor had arrested.

When labor progresses slowly, the first action often taken is breaking the amniotic sac, followed by Pitocin augmentation. This is the worst thing that can be done in a posterior labor since contractions are intensified. The baby’s head descends quickly, which worsens the situation. In order to become anterior, the head must go through a long rotation of up to 180 degrees. (Normal rotation requires a 90 degree turn or less.) If the head descends too deeply before rotation is accomplished, the risk of a deep transverse arrest increases, and chances for successful vaginal delivery are greatly diminished. If the position is not adequately diagnosed until late in labor, the only recourse may be to offer a paracervical block or an epidural anesthesia as it is almost impossible for the mother to calm down enough to allow the deep muscles of the pelvic floor to relax sufficiently to allow the baby to turn.

Nothing can prepare a mother for the severe, unrelenting pain that accompanies a posterior labor. Often labor begins with short, painful yet irregular contractions, which are often shrugged off by caregivers as “false labor.” Even though the labor may not be “productive,” since the ill-fitting posterior head is not properly applied to the cervix, the mother is experiencing discomfort. She may be sent home to wait for “real labor” to begin. Meanwhile, she is unable to sleep and may be unable to eat, sometimes for several days. So, adding to the stress of a painful back labor, we have a mother who is already tired out. I have heard women describe the pain as: “It felt as though someone were sawing my back in half,” or, “I couldn’t even tell when I was having contractions because my back hurt so much.” All attempts to ease the pain have little effect and the labor is a long, hard exercise in determination.

Many midwives attending out-of-hospital births have not been taught to help correct a posterior position. So despite their best efforts, they may be forced to transport the woman when she begs for pain relief or when several hours of pushing have resulted in little progress or formation of a large caput.

Another scenario is the mother who finally delivers her baby after a 36-hour labor, but is so exhausted by the ordeal she has difficulty bonding with the baby. Postpartum involution is delayed and she may suffer from a urinary tract infection due to pressure upon, and swelling of, the anterior vaginal wall.

As a midwife, my goal is to do everything I can to help the mother achieve an optimum birth outcome. To this end, I use my skills to alleviate unnecessary pain and suffering so a new family can begin in safety, peace and joy.

Early Diagnosis Is the Key
The incidence of a posterior position occurring at the onset of labor is 15-30 percent; many of these babies rotate spontaneously to an anterior position. When the pelvis is adequate, a posterior baby may be born face up with little or no difficulty, as if saying, “Surprise! It’s my little face!” This happened once as a woman delivered precipitously in our center.

“Mom, the baby’s ear is upside down!” said my daughter, who was assisting, just before the rest of the head came out, with the baby looking straight up at her mother.

Because we are unable to guess at the onset of labor what the outcome will be, every effort must be made to avoid both a long and difficult labor, and possible necessary operative intervention, by early diagnosis and correction of the position.

We see our clients weekly during the last month of pregnancy. We are careful to assess the baby’s presentation and position. An ROA position (right occiput anterior) is watched expectantly, as this position is statistically more likely to become posterior than LOA (left occiput anterior). If the baby is posterior, we give the mother exercises to try to help the baby turn.

At the onset of labor, we re-evaluate the baby’s position. If the exercises have not helped to change the presentation, we encourage the woman to come into the birth center in early labor. Assisting the baby’s rotation early on is relatively simple, but once labor becomes advanced it is very difficult.

Some women seem to be more at risk for a baby that settles into a posterior, or other abnormal, presentation. Those with an android or anthropoid pelvis, or a narrow inlet, are more prone to these positions. Certainly, the woman who has had a previous posterior labor is much more likely to suffer a repeat.

Prenatal Diagnosis of Position
During the prenatal exam, the mother often exclaims that the baby has too many hands and feet and the moving limbs may be easily felt and seen.
The mother often complains of frequency of urination due to the baby’s brow pressing against her bladder. Sometimes she will also be incontinent as the baby’s head presses out urine.

The mother may exhibit signs of a urinary tract infection (UTI) with the above frequency of micturition, a feeling of constant pressure at the symphysis (above the pubic bone) and an attendant lower backache. (In this case, testing the urine for bacteria is always appropriate, as UTIs are more likely when the bladder is not completely emptied.

Auscultating fetal heart tones may be difficult, or the tones may be indistinct. If you suspect the baby is in a posterior position, have the mother roll to the side and the heart tones will be more easily heard.

While the baby in breech position is easily palpated at the fundus, feeling the outline of the posterior baby’s back may be difficult or impossible and the head will appear to be engaged.

Assisting with Anterior Rotation Prenatally
Have the mother do the “pelvic rock” exercise at least three times daily in sets of 20.
Suggest that she assume a knee-chest position for 20 minutes, three times a day.
Have the mother lie on a slant board (as with breech position) several times a day for 30 minutes at a time.
Have the mother take warm baths and gently massage and encourage her baby to “roll over.” We have found that having mother visualize her baby in the correct position and talk to her baby, telling it to move is often effective.

Once, we had a particularly stubborn baby who liked the way he was lying just fine. The mother had suffered with a previous posterior labor and was very anxious about repeating it. She had tried in vain to get the baby to cooperate, so I called the dad in and said “Show this baby who’s the boss!” Dad said, “Turn over, baby!” and he did!

Diagnosis of Posterior in Labor
Early labor may be marked by a long period of irregular uterine contractions with little or no dilation. Contractions may be more frequent yet of shorter duration than desired or expected in early labor. For example, they may occur every three minutes but last only 30 seconds. This is due to inadequate application of the presenting part.

Abdominal palpation of the baby’s position is not sufficient as the deeply engaged head may possibly remain posterior even though the baby’s body appears to be aligned in a right occiput anterior (ROA) or left occiput anterior (LOA) position.

Auscultation of the fetal heart tones is not a reliable method of assessing fetal position, as they may be heard through the baby’s chest as well as through his back.

The mother usually complains of a persistent backache, which even in early labor may be severe enough to cause the pain of contractions to become secondary. Since a backache may be present even in a normal anterior position, a vaginal examination must be done to correctly assess the baby’s position by the fontanels.

In the ROP position (right occiput posterior), the sagittal suture line will be felt obliquely, (from one o’clock to seven o’clock), and feeling the bregma (larger front fontanel) at the top and to the side of the pubic bone (by one o’clock) will be impossible. You may be able to feel the top of the baby’s ear as well.

Assuming that the mother’s cervix is soft and a little dilated, insert a finger through the cervical opening in order to accurately determine the direction of the suture lines and to find the anterior fontanel. If the head is in a posterior position, you will readily find it between 12 o’clock and three o’clock on the fetal skull. Have courage! This exam may not be pleasant for either you or the mother. Your task will be easier if you keep in mind that you may be saving her endless hours of an extremely painful labor, with no guaranteed outcome. If you are not able to find the anterior fontanel, the baby is probably in the correct position; when the head is LOA or ROA, the posterior fontanel usually cannot be felt unless the head is assuming a military position. (That, of course, is another story….)

Assisting Anterior Rotation during Labor
When the baby has been determined to be in a posterior position, the first thing I do is have the mother assume and maintain a knee-chest position for approximately 45 minutes. Although this position is not the most comfortable one for the mother, it is very effective as the baby has more room in which to rotate. I find the mother tolerates this position well if she is not in advanced labor. We make sure that she is well supported by lots of pillows and give her lots of encouragement and emotional support. Often, contractions become more regular and more effective while in the knee-chest position, which also assists the baby’s rotation.

If the mother cannot tolerate the knee-chest position for as long as necessary to turn the baby, we alternate by placing her in an exaggerated Simm’s position (lying on left side, two pillows under right knee, which is jack-knifed, left leg straight out and toward the back).

Make every effort to avoid rupturing the membranes, as the “pillow” offered by the forewaters gives a cushion on which the baby’s head may spin more easily. Furthermore, if the waters break before the baby has rotated to the anterior, sudden descent of the fetal skull may possibly result in a deep transverse arrest.

If labor is more advanced when the posterior is identified, say 4 to 5 centimeters, the attendant may help by placing her hand in the mother’s vagina, gently lifting and somewhat disengaging the head thus allowing it to turn to anterior, while the mother is in the knee-chest position.

If the posterior has not been discovered until complete dilation, or if the other methods have not been applied in early labor, the baby’s head can still be turned to make delivery more likely. With the mother in a knee-chest position, knees slightly apart, the midwife inserts her hand into the woman’s vagina. She should attempt to lift the head by grasping it firmly, waiting for a contraction, then turning the baby into an anterior position. As soon as the head is correctly positioned, hold on tightly. When the uterus contracts again, urge the mother to push very hard. If the amniotic sac has not yet ruptured, rupture it now. This will assure that the position remains fixed and the baby usually will be born very rapidly. While this procedure is both safe and sane, it will take some physical strength to turn this recalcitrant little head against the force of a good contraction.

Liberating Women
I hope that through early diagnosis and appropriate intervention, many women can be liberated not only from long and difficult labors, but also from the complications of such labors that can lead to caesareans. I have used these techniques for many years, and have had very favorable results. To date, I have transferred only one woman for a transverse arrest (and that was in 1977), due to my inexperience with diagnosing her posterior baby.

A word of caution: Women who have had caesareans due to posterior labors, or who have had vaginal delivery after long posterior labors, often are in advanced labor before they realize they are in labor with a subsequent baby that is not in a posterior position. This has led to many interesting and amusing situations!

Occiput Posterior Babies

Turning Posterior Babies

Occiput Posterior/Occiput Transverse (OP/OT): notes from Obstetrical
Training Day, October 31, 1997, Rochester General Hospital (New York)
Speaker: Henci Goer
[Ed. Note: These are excerpts; in no way do they represent Henci’s
entire presentation. Notes courtesy of E-News reader Amy Haas. Thank
you, Amy!]

-Half of the cesarean rate results from OP/OT babies. With an epidural
this rate increases to three-quarters. 15 -30% of all labors start
with an OP/OT baby.

How to Diagnose:
1. Self-diagnosis: Belly shape; feels lots of hands and feet; frequent
urination; irregular labor pattern; ruptured membranes, back pain;
hard to pick up fetal heart tones, long painful labor
2. Caregiver’s diagnosis: external palpation (harder to do in labor);
vaginal exam (look for suture lines when mom is dilated enough)
Predisposition:
1. Pelvic shape: convergent sidewalls, narrow pubic arch, sacrum
intrudes, prominent ischial spines
2. Size of baby: either very large or very small (not guided by pelvic
floor, can’t get into position)
3. Right occiput anterior in pregnancy as opposed to left
4. Exaggerated spinal curvature (lordosis) and a relatively inflexible
spine
Correcting OP/OT in pregnancy:
1. Pelvic rocks: 10+ pelvic rocks on hands and knees per day
2. Dancing: rotate hips
3. Yoga: One midwife noted that her clients who do yoga have a smaller
incidence of OP/OT.
4. Crawling on hands & knees in a kiddie swimming pool

Strategies to Promote Rotation:
1. General tips:
-DON’T RUPTURE MEMBRANES
-Usually what the mother finds most comfortable is also most
effective. Let her move instinctively. Epidurals prevent instinctive
movement.
-Help the baby rotate by using positioning that opens the pelvis,
activities or manipulations that shift the baby, and gravity to bring
the baby down.
2. Birth ball: lean on it, or sit on it and lean on bed. Rotate hips.
3. Positions:
-Hands and knees during pregnancy. One study showed a 3/4 rotation in
10 min.
-Side-lying, SIMS position. Lie on the same side as the baby is
facing, then switch.
-Lunge: opens one side of pelvis, feels good; let mom choose side
-Squat-Kneel: opens pelvis
-Squat
-Dangle: almost a hanging sit, mom’s back to sofa, don’t go into a
full squat
-Standing leaning forward
-Kneeling, facing back of hospital bed
-Knee-chest position (rear end in the air), 30-35 min. in early labor
will almost always turn baby.
-Semireclining, heels together (don’t use with epidural)
-Pelvic rocks
-Change position
4. Activity or Manipulation
-Lots of position changes
-Pelvic rocks
-Stroke the mother’s belly in between contractions in the direction
you want the baby’s back to go.
-Double hip squeeze: Sit facing mother, place both hands on back of
each hip and squeeze.
-Write the baby’s name with pelvis
-Stair climb
-Crawl back and forth
-Acupressure: fingernail pressure on outer edge of little toenail
(could also turn breech)
-Delay epidural until at least 5 cm dilation. Doing one earlier may
lock the baby in the OP/OT position. Stay off back, even
semireclining. Hands and knees may be possible. Supported squat (w/
epidural): Set up bed like a birth chair, use stirrups as hand holds
and to support forearms.
-Manual internal rotation by care provider (Valerie El Halta – see
Midwifery Today Issue 36). Do early. May invoke negative memories for
women with a history of sexual abuse.
-Don’t rupture membranes – could wedge baby permanently into the OP/OT
position, preventing rotation.
-Cup mothers kneecaps and push back to relieve pain.

Coping with a Long Difficult Labor:
1. Extra support: Secondary labor support person (doula); use talking
for relaxation and positive reinforcing attitude (e.g., “My body knows
just what to do” chant).
2. Food and drink: calories, especially at home
3. Stay home in early labor, which is often prolonged.
4. Reframing the problem:
-It’s normal for an OP/OT labor to be longer and hard.
-Going from 50% effaced to 70% effaced is a major change.
-Stuff is happening.
-Cervix going from anterior to posterior is progress.
-Use short-term goals, bargain for milestones.
-Stay in the present; focus on the now.
5. Develop a ritual: women will often do this automatically if allowed
to.
6. Groan “open” on the exhale.
7. Use shower or bath. (One hospital reduced its epidural rate by 80%
by requiring women to take a bath before getting their epidural.)
8. Show the mom on pelvis model what she is feeling looks like
9. Hot pack with rice and herbs heated in microwave
10. Avoid vaginal exams
11. Don’t push too soon; delay until head on perineum – reduces use of
forceps.
12. Per American College of Obstetricians and Gynecologists: The
duration of second stage is not related to fetal outcome as long as
fetal heart tones are good.

Coping with Back Pain:
1. Temperature: A laboring woman’s skin is sensitive to temperature.
Hot items should be cool enough to hold, frozen items should have
intervening layer(s).
-Heat: Local blood flow and temp. increase, muscle spasms decrease –
contributes to relaxation
-Cold: Local blood flow and temp. decrease – works best for decreasing
pain because it slows transmission of painful sensations (Ice chips in
an exam glove, frozen peas)
2. Touch
-Counterpressure
-Acupressure – low on sacrum (inch out on either side), sciatic point
(dimples in rear end), palm (center, high five and hang on)
3. Sterile water injection: intradermally, 20 sec; sharp local pain: 1
-2 hr. relief. Do not use saline. (see Midwifery Today Issue 44)
4. TENS (transcutaneous electronic nerve stimulation): effectiveness
questionable
5. Pain medication: Delay epidural until 5 cm. dilation, delay pushing
until head is on perineum (reduces the use of forceps).

Factors that Hinder Rotation in Labor:
1. Reclining: Gravity works against you; reclining fixes sacrum so it
can’t open.
2. Early epidural: Relaxes pelvic musculature too much; Pitocin use
and C-section rates increase.
3. Early amniotomy: Head surges down and there is a deep transverse
arrest. May actually slow labor down.

Why Posterior?

One of the most important lifestyle changes has been the advent of television. This has meant a change from straight-backed armchairs and sofas to furniture which is designed to relax in while watching TV. When a pregnant woman sits down in a modern design armchair or sofa, her pelvis tips backward and so does her “passenger.” To balance her body in this position, the woman has to cross her legs–which further decreases the amount of space in the front, or anterior part of her pelvis. Her “passenger” has no alternative but to lie toward the back or posterior part of her pelvis. If the woman spends a lot of her time resting in modern furniture during the latter part of her pregnancy, it is probable that her baby will remain occipito-posterior and enter the pelvic brim in this position. The same sequence of events can happen if the woman travels in a car seat, especially if it is a “bucket” type seat, for long periods at a time.

Another important factor in relation to lifestyle changes is the way women work now and how they did in the past. In times gone by pregnant women worked physically hard in the home scrubbing floors on their hands and knees and doing other menial tasks around the house or farm, which usually meant leaning forward. In that era also, the importance of correct posture and good deportment was encouraged. Young women learned to sit upright with their knees together and to walk with their shoulders straight. All these postures are ideal for correct alignment of the fetus into the maternal pelvis.

If a woman (primigravida) regularly uses upright and forward leaning postures, particularly during the last six weeks of her pregnancy (the last 2-3 weeks for a multigravida), her baby is given an excellent chance of positioning itself into the occipito anterior position. This is because when the pelvis tilts forward, it allows more space for the broad biparietal diameter of the fetal head to enter the pelvic brim. Most of these postures, especially those that are forward leaning, are positions where a woman’s knees are lower than her hips. Many postures can be incorporated into the woman’s daily life; for instance, TV watching can be accomplished by sitting on a dining room chair or kneeling on the floor, leaning over a bean bag or a couple of floor cushions. Another way is to sit on the sofa or armchair but to make sure a firm cushion is placed under the woman’s bottom and lower back so that she is sitting more upright. When resting or sleeping the woman should make sure she is lying on her side with pillows behind her back and her top leg resting forward so that the knee touches the mattress. This ensures that her abdomen is forward, creating a “hammock” for her baby. An extra cushion may be needed between the woman’s thighs.

Vaccination Tip

Here is a handy tip for avoiding the ill effects of a vaccine without reaping the whirlwind of medical pressure and emotional blackmail.

This tip is cheap and easy. Simply purchase a tube of green clay paste from a health shop or pharmacy, plus a guaze bandage and a roll of plaster. As soon as the arm has been vaccinated, spread the clay liberally over the puncture wound. Plaster bandage over the top and leave on for two hours, so that the clay absorbs all the vaccine.

French homeopaths who recommend this procedure to their patients on a regular basis claim it to be 100% effective for avoiding any side effects or repercussions.

Herbs for Mother’s Care Postpartum, by Demetria Clark

Herbs for Mother’s Care Postpartum
by Demetria Clark
© 2004 Midwifery Today, Inc. All rights reserved.[Editor’s note: This article first appeared in The Birthkit Issue 44, Winter 2004.]

The following herbs for common postpartum problems support mother in a holistic fashion. If she has been given any type of drug, please properly research the drug and herb combination.

Moms will need extra nutrition, and this tea is a staple in my herbal and doula practice. Clients love it, as do the midwives and family members.

YOU ROCK! Mamma Tea and Infusion

2 parts chamomile flower (Matricaria recutita)
2 parts hibiscus flower (Hibiscus sabdariffa)
1 part rose petal (Rosa spp.)
1/8 part lavender flower (Lavendula officinalis)
1/4 part rose hips (Rosa canina) 3 parts lemon balm leaf (Melissa officinalis)

Make this by the gallon. It is rich in nervines, vitamins and minerals. Mom, family and care providers can drink this throughout the day, hot or cold.

Delayed Placenta

For a delayed placenta you can use angelica root extract (Angelica sinensis). Place a drop under the tongue and drink with a swig of water. This will swiftly bring the placenta.

Hot basil leaf (Ocimum basilicum) infusion smells and tastes great, as well as producing results. Drink this by the cupful.

Make a feverfew flower (Tanacetum parthenium) infusion when labor starts by adding four teaspoons of the herb to a quart jar, fill with boiling water and cap. Allow to sit at room temperature for thirty minutes, then refrigerate. This keeps the infusion fresh, in the case of a longer birth.

Hemorrhage

All hemorrhage mixtures should be made ahead of time.

Prepare a hemorrhage extract from:

1 part yarrow flower extract (Achillea millefolium)
1 part shepherd’s purse seed, leaf or flower extract (Capsella bursa-pastoris)
Drink a half-teaspoon in warm water every half hour.

Make an infusion using equal parts raspberry leaf and nettle: This can be drunk as a beverage.

Make an extract blend using this recipe:

1 part shepherd’s purse seed, flower or leaf (Capsella bursa-pastoris)
1/4 part blue cohosh root (Caulophyllum thalictroides)
1 part motherwort leaf (Leonurus cardiaca)
1 part witch hazel leaf or bark (Hamamelis virginiana)

Give mother two dropperfuls orally. You can follow with juice. Repeat in one minute, if needed, then again in ten minutes.

Or use:

1 part motherwort flower and leaf extract (Leonurus cardiaca)
1 part witch hazel leaf or bark extract (Hamamelis virginiana)
2 parts shepherd’s purse flower, seed and leaf extract (Capsella bursa-pastoris)
1 part bayberry bark or root extract (Myrica cerifera)

Use two dropperfuls as above and repeat if needed in ten minutes.

If a woman is hemorrhaging, please follow proper protocols and seek appropriate medical attention. Transport if the herbs are having no effect.

Afterpains

Afterpains are caused by the contraction of the uterus. They are generally worse after the second child.

Alleviate pain by having the mother relax and nurse regularly (this will really hurt, but it will contract the uterus faster), and try the following herbal extracts or combine them in an extract blend: cottonwood bark, black haw and cramp bark. This can be prepared as a tincture and given in doses of 20 drops two to three times a day.

Apply the following after birth pain relief extract:

2 parts motherwort (Leonurus cardiaca)
1 part lavender flowers (Lavendula officinalis)
1 part chamomile (Matricaria recutita)
1 part cramp bark (Viburnum opulus)
1 part lemon balm (Melissa officinalis)

Use 20-30 drops two to three times a day.

Night Sweats

Make a tea from strawberry leaf. Drink a cup before bed.

Varicosities

Witch hazel (Hamamelis virginiana) serves as a base for many remedies for varicose veins, vaginal area varicosities and hemorrhoids.

1 cup 80 proof alcohol
1 cup water
1 cup witch hazel leaves (Hamamelis virginiana)

Cover the leaves with the alcohol and water. You can add more leaves if you want. After four weeks strain and bottle. Add five to ten drops cypress oil, if desired. Apply to affected area with a cool cloth.

Hemorrhoids

Apply the following herbal teas, once cooled, to the area:

St. John’s wort, witch hazel (Hamamelis virginiana), plantain leaf (Plantago major), sage (Salvia off.), parsley (Petroselinum crispum), shepherd’s purse (Capsella bursa-pastoris).

Extracts or tinctures of these plants can also be used as a compress.

Create afterwipes by applying witch hazel extract (Hamamelis virginiana) to soft tissue or cloth and using it to wipe the affected area if traditional wiping is uncomfortable. These can also be used for tears and swelling. Cotton pads from the drug store placed in a small plastic food container and covered with witch hazel extract (Hamamelis virginiana) also make wonderful healing wipes for mom. I suggest using cotton flannel cloths.

Difficulty Urinating

Add a few drops of peppermint essential oil to the toilet before mom goes to the bathroom. Relaxation and deep breathing also helps.

Encourage the mother to use a vaginal steam. Find an old chamber pot chair or cut a hole in the seat of a thrift store chair and chop the legs down to a foot and a half. Then when the mother feels she needs to go but is unable, place a bowl full of hot water with steeping lavender flower (Lavandula officinalis), peppermint leaf (Menthe piperita) and comfrey leaf (Symphytum officinale) under the chair. Wrap the mother in blankets and have her sit over the steam. (Don’t fill the bowl completely, in case the mother accidentally urinates in the bowl. This may happen when she feels soothed and her body relaxes.) Make sure the steam is not too hot or too close, so she will not get burned. Women can also use the steam for yeast infections, vaginal infections and so on.

For Tears and Episiotomies

I suggest allowing a small tear versus a large cut. The body can repair itself much more easily.

A perineum wash can be made with a diluted infusion of lavender flower. To a cup of warm water add 1/4 cup of lavender infusion. Add a drop of tea tree or patchouli oil to a liter of water or the lavender infusion. Rinse the vulva after urinating. This is used to sooth swollen and sore vaginal tissues after birth.

Apply ice immediately after the repair to decrease swelling.

Apply aloe vera gel (best if extracted directly from the plant, as commercial types can contain irritating preservatives). You can break off a leaf and squeeze out the fresh gel and apply to the affected area.
Encourage the mother to get plenty of fresh air. Exposure to sunlight speeds healing. This is at times an unrealistic recommendation. I just encourage mom to get fresh air, as exposing the bottom to the air is not always easy or appropriate for your neighborhood!

Have mother decrease activity; severe tears heal faster with bed rest.

Increase mother’s internal dosage of vitamin E to 600 mg/day.

Use comfrey leaf (Symphytum officinale) for compresses and sitz bath. The mother can also drink it to promote healing.

Calendula flower (Calendula officinalis), comfrey leaf (Symphytum officinale), St. John’s wort flower (Hypericum perforatum) and plantain leaf (Plantago major) are all used as ointments or in sitz baths.

Recommend sitz baths with infusion of vulnerary herbs (see below).

Sitz Baths

Sitz blend:

To 3 cups simmering water add:

2 tablespoons comfrey leaf (Symphytum officinale)
2 tablespoons St. John’s wort flower (Hypericum perforatum)
4 tablespoons calendula flower (Calendula officinalis)

Turn off the heat. Allow it to steep for 20 minutes. Pour into shallow bath. Add four drops lavender essential oil(Lavendula off.) and two drops cypress essential oil. Mix well to disperse essential oil.

Postpartum Sitz Bath:

2 parts plantain flower (Plantago major)
part calendula flower (Calendula officinalis)
1 part comfrey leaf (Symphytum officinale)
1 part burdock (Arctium lappa)
1/2 part violet flower and leaf (Viola odorata)
1 part yarrow flower (Achillea millefolium)
1/2 part lady’s mantle flower and leaf (Alchemilla vulgaris)
1/2 part lemon balm leaf (Melissa officinalis)

Mix well. You can add sea salt to the mixture if you wish. Add approximately one cup of herb and salt blend to six quarts boiling water, strain and add to shallow bath. You can also use as a compress.

Or try the following blend:

1 part uva ursi leaf (Arctostaphylos uva ursi)
1 part shepherd’s purse leaf, seed (Capsella bursa-pastoris)
1/2 part myrrh gum powder (Commiphora momol)
1/2 part garlic (Dried or fresh. If fresh, use 1-2 cloves. Use whole; do not cut or smash as fresh oil can be very strong and irritating.)
1/2 part comfrey root (Symphytum officinale)
1/2 part sea salt (optional)

Prepare in same manner as Postpartum Sitz Bath (see above).

Another popular sitz bath blend contains:

1 cup sea salt
1/2 cup plantain leaf (Plantago major)
1/2 cup calendula flower (Calendula officinalis)
Use six cups of water.

Oak bark (Quercus robur), rosemary leaf (Rosmarinus officinalis), witch hazel leaf or bark (Hamamelis virginiana) and yarrow flower (Achillea millefolium) are great for healing sitz baths. If the mother is stitched, limit the bath to once a day.

Other great herbs and herbal sitz baths for the perineum are calendula flower (Calendula officinalis), St. John’s wort (Hypericum perforatum) and essential oil of cypress or lavender

Handling postpartum issues naturally gives the mother more control and is generally less invasive then going to a doctor. Make sure the mother knows when to seek additional medical care.

Instructions for Herbal Preparations:
These basic herbal formulation instructions will assist you with the formulas in this article.

Infusion: Pour boiling water over the plant matter and allow it to steep between 20 minutes and overnight for a medicinal infusion. I let my infusions steep for a generous amount of time, as it is important that they are medicinally potent, since I suggest infusions for so many tonic and medicinal uses.

Infusions are made from the more fragile parts of the plant. There are a few exceptions to this. Valerian, for example, is a root prepared as an infusion because of its high volatile oil content.

Decoctions: This method is used to get the healing constituents from more tenacious plant material, such as bark, roots or nuts. Allow the plant matter to simmer gently in water for 20 minutes. A decoction is also the preferred method of preparation for pre-blended roots and leaves. Allow the decoction to steep for 30 minutes to an hour after it has been removed from heat.

Amount of herb used for decoction or infusion: 1 tablespoon dried herb or 2 tablespoons fresh herb per cup of water. Teas can be made by the quart and refrigerated for convenient consumption.

Extracts: Extracts are easy to make and a convenient way to take herbs. Place as much of the herb as you want into a glass jar. Then add beverage alcohol, such vodka or brandy, to a depth of three fingers higher than herbal matter if dried herbs are used or two fingers higher if fresh herbs are used. Close the jar and allow it to sit in the sunlight for a few days to soak in the healing power of the sun and then put it away until done. If it is macerating during a full moon, put it outside to gather the moon’s energy also. Many people allow extracts to sit for only a few weeks to a month. I allow mine to sit for over four months in order for them to become as potent as possible. Always store your extracts in glass in a dark, dry spot.

When finished, pour the extract through a cloth, such as layers of cheesecloth. Squeeze the remaining herbs thoroughly to remove as much fluid from them as possible. Extracts can be made of single herbs or herbal amalgamations, depending on your needs. Some run the extracted herbs through a juicer and strain them. Extracts can be taken straight or in juice.

Appropriate strength of alcohol for extracts:

35-40% (70-80 proof) alcohol for leaves and flowers
40-60% for barks, roots and seeds
90% for Kava Root. (Kava is best fat-extracted because it is fat soluble. Fat extraction uses an oil, like coconut.)
Eighty-proof alcohol has an alcohol content of 40%. These alcohol percentages are just baselines. You may find some herbs work better for you with different percentages.

This is the traditional method of making extracts, called the “simplers” method. Some herbs are best made into teas, rather than extracts.

Tinctures: A tincture is a diluted extract, traditionally. The tincture is diluted with water and is one-fifth as strong as the original extract. Unfortunately, the terms “extract” and “tincture” are often confused. An extract is the mother of a tincture and five times stronger.

Demetria Clark is the director of Heart of Herbs Herbal School in Vermont (www.heartofherbs.com) and a labor support doula.

A Mother’s Guide to an Intact Perineum, by Gloria Lemay

An intact perineum is the goal of every birthing woman. We love to have whole, healthy female genitalia. Many people consider the health of the vagina/perineum to be a matter of chance, luck or being at the mercy of the circumstances of the forces that prevail at the time of the birth.Folklore abounds about doing perineal massage prenatally. No other species of mammal does this. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant.

The intact perineum begins long before the day of the birth. Sharing what the feeling of a baby’s head stretching the tissues will be like and warning the mother about the pitfalls in pushing will go a long way to having a smooth passage for both baby and mother.

The woman will be open and receptive to conversations in prenatal visits about the realities of the birth process. Here, in point form, is the information I convey for the second stage (pushing):

1. When you begin to feel like pushing it will be a bowel-movement-like feeling in your bum. We will not rush this part. You will tune in to your body and do the least bearing down possible. This will allow your body to suffuse hormones to your perineum and make it very stretchy by the time the baby’s head is stretching it.

2. The feeling in your bum will increase until it feels like you are splitting in two and it’s more than you can stand. This is normal and no one has ever split in two, so you won’t be the first. Because you have been educated that this is normal, you will relax and find this an interesting and weird experience. You may have the thought, “Gloria told me it would be like this and she was so right. I guess this has been going on since the beginning of humankind.”

3. The next distinct feeling is a burning, pins-and-needles feeling at the opening of the vagina. Many women describe this as a “ring of fire” all around the vaginal opening. It is instinctive to slap your hand down on the now-bulging vulva and try to control where the baby’s head is starting to emerge. This instinct should be followed. It seems to really help to have your own hands there. Sometimes women like to have very hot face cloths applied to their perineum at this point. If you like the feeling of this, say so, and if you don’t, say so. We will do whatever you feel like.

4. Most women like pushing more than dilating. When you’re pushing, you feel like you’re getting somewhere and that there really is a goal for your efforts.

5. This is a time of great concentration and focus for you. Extraneous conversation will not be allowed in the room. Everyone will be silent and respectful in between sensations while you regather your focus. Once you begin feeling the ring of fire, there is no need for hurry. You will be guided to push as you feel like until the baby is crowning (the biggest part of the back top of the head is visible). All that will be touching your tissues is the hot face cloth and your own hands. It is important for the practitioner to keep their hands off because the blood-filled tissues can be easily bruised and weakened by poking, external fingers. This can lead to tearing. We will use a plastic mirror and a flashlight to see what’s happening so we can guide you. We won’t touch you or the baby.

6. This point of full crowning is very intense and requires extreme focus on the burning-it is a safe, healthy feeling but unlike anything you have felt before. You may hear a devil woman inside your head who will say to you, “All you have to do is give one almighty push here and it will all be over-who cares if you tear . . . just give it hell and get that forehead off your butt!” This devil woman is not your friend. Thank her for sharing and then have your higher self say, “Just hang in there. It’s OK. Panting and rising above the pushing urge will help me stay together, and I will have less discomfort in the long run.” Your practitioner will be giving only positive commands at this point, and she will be keeping them as simple as possible to maintain your focus.
Typically the birth attendant’s instructions are “Okay, Linda, easy . . . easy . . . easy . . . pant . . . pant with me . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah. Good, that one’s over. You’re stretching beautifully; there’s lots of space for your baby. This baby’s the perfect size to come through.”

7. You will be offered plain water with a bendable straw throughout this phase because hydration seems to be important when pushing, and you can take the water or leave it, as you wish.

8. Once the head is fully born, you will feel a great sense of relief. You will keep focused for the next sensation, which will bring the baby’s shoulders out, and the baby’s whole body will quickly emerge after that with very little effort on your part. The baby will go up onto your bare skin immediately, and it is the most ecstatic feeling in the world to have that slippery, crawling, amazing little baby with you on the outside of your body. Your perineum may feel somewhat hot and tender in the first hour after birth, and believe it or not, the remedy that helps the most is to apply very hot, wet face cloths. This is in keeping with the Chinese medicine theory that cold should never be applied to new mothers or babies. Women report that they feel instantly more comfortable when heat is applied, and any swelling diminishes rapidly.

9. When you push your placenta out, the feeling will be like that of a large, soft tampon just plopping out. It is a good feeling to complete the entire process of birth with the emergence of the placenta.

When a new mother has an intact perineum, she recuperates faster and easier from birth. I like to twist a diagonally folded bath towel into a very tight roll and coil that into a ring for the woman to sit on when breastfeeding. Lovemaking can resume whenever the couple is ready; it feels good to use a little olive or almond oil as a lubricant the first few times.

A Tip for Birthing Women, by Gloria Lemay

A Tip for all Birthing Women…

Many births begin in the night…. the woman will get up to pee, feel her membranes release and then an hour later begin having sensations fifteen minutes apart. Because we think of birth as a family/couple experience, most women will wake up their husbands to tell them something’s starting and then, probably because we all hope we’ll be the 1 in 10,000 women who don’t experience any pain, we start getting the birth supplies organized, fill up the water tub, etc. I have seen so many births that take days and days of prodromal (under 3 cms. dilation) sensations and they usually begin this way. The couple distracts themselves in that early critical time when the pituitary gland is beginning to put out oxytocin to dilate the cervix. Turning on the light, causes inhibition of the oxytocin release. Many couples don’t call their midwives until they’ve got sensations coming 5 minutes apart at 7:00 a.m. but they’ve been up since midnight timing every one of the early sensations. If they had called their midwife at midnight she would have said “Turn off the light and let your husband sleep as much as possible through the night. You, stay dark and quiet. Take a bath with a candle if it helps and call me back when you think I should come over.” That first night can make all the difference and yet so many couples act like it’s a party and don’t realize they are sabotaging their births right at the beginning. Staying up all night in the early part does two things-it throws off the body clock that controls sleep and waking and confuses the brain AND it inhibits the release of the very hormone you need to dilate effectively. When you begin to have sensations, I urge you to ignore it as long as you possibly can. Don’t tell anyone. Have a “secret sensation time” with your unborn baby and get in as dark a space as you can. Minimize what is happening with your husband, family and the birth attendants. What would you rather have-a big, long dramatic birth story to tell everyone or a really smooth birth? You do have a say over your hormone activity. Help your pituitary gland secrete oxytocin to open your cervix by being in a dark, quiet room with your eyes closed.

Birth Plan, by Janine Debaise

Birth Plan
by Janine DeBaise
© 1996 Midwifery Today, Inc. All Rights Reserved.[Editor’s note: This article first appeared in Midwifery Today Issue 37, Spring 1996.]

Here is the plan for the birth of my child. I’ve taken words from the dreams of 200 women. I’m translating them for the hospital staff.

1. No blue hospital gown. No sterile drapes. When I give birth, I want to be naked. I want my body to choose the colour of its growing.

2. No enema. No antiseptic wash. No shaving of pubic hair. If I wanted to shave something, I’d shave my head. Like Jean-Luc Picard. I’ve always wanted to be captain of a star ship. When I give birth, I explore uncharted territory, I move and writhe into new worlds. I want to go where no man has gone before.

In 1872, an English doctor named John Braxton Hicks discovered pre-labor contractions. This was sort of like Columbus discovering America. Some people already knew it was there.

3. No drugs. No epidural.

I want to feel the baby moving, his hard head pushing through layers of me. My bones shifting, my uterus contracting. I want to feel birth. I want to know fire.

4. No episiotomy. No amniotomy. I don’t want anything that rhymes with lobotomy. I prefer to stretch slowly, burning in a rim of panting breaths, around my baby’s head.

Pierre Vellay, MD, wrote that pregnant women must be “trained in the proper way.” His vision: Laboring women “like expert engineers with perfect machines and carefully presented information (who) control, direct and regulate their bodies.”

5. No Pitocin drip. No synthetic hormone to stimulate labor. Let my baby choose his own birthday. My body does not recognize the ticking of the clock on the wall.

I don’t want to control my body. I want to surrender. Let the darkness soak through me, drip down my legs. Let the pulse of that unborn voice throb through me.

I don’t want a needle stuck in my hand. If my labor slows, I’ll lie in the sun on a fur quilt and let my husband caress MY nipples. I prefer to get my hormones the primitive way.

6. No electric fetal monitor.

I don’t need a machine to tell me how my baby is doing. He kicks, he twists, he somersaults inside of me.

Robert Bradley, MD, advocated the idea of the husband as the labor coach. He liked the idea of natural birth, but still he thought that somehow a man had to be in charge.

7. No bright lights. No noise. No softball cheers. Don’t give me instructions. My body knows what to do. Birth is not a team sport. I don’t want a coach. I want my husband’s presence. His hands to grip. His arms a sling to lean the baby bulk against. His face a mirror in which I can watch my baby emerging.

8. No stupid jokes. No cheerful chatter. No television, please. I want to listen to the moans rising in my throat. I want to hear the child singing in my womb.

In the 1950s a French obstetrician named Ferdinand Lamaze began teaching something he called childbirth without pain. French Catholics were horrified, the Bible said it was supposed to be painful.

9. No delivery table. I am not a plate of spaghetti. Let me give birth on the bed. A table works fine for conception, but it’s way too hard and far too awkward for birth.

“Male science disregards female experiences because it can never share them.” Grantly Dick-Read said this in 1933. No one listened to him.

I know what I want for my baby.

No nursery. No pacifier. No bottles. No crib. No cheerful, white-coated, well-scrubbed, briskly walking, thermometer-wielding nurses, please.

Let the baby sleep against my skin, nurse from my breast, wrap his wrinkled blue limbs in the heat of my body.

10. Nothing intrauterine, nothing intravenous.

I prefer to give birth in simple words. Breathe. Push. Touch. Pain. Wet. Stretch. Bum. Birth. Yes.

For 50 years, doctors have used these terms. Braxton-Hicks contractions. Bradley birth. Lamaze breathing. But a woman knows. The mystery is too overwhelming. We can never name it.

When the baby’s head crowns, I want to touch the wrinkled scalp. I want to cradle the head in my palms while he is still inside of me, his neck stuck in the warm swollen parts of me. My moans will be the guide I need to pull him out of myself.

Hot compresses. Yes.
Dim lights, a bathtub of warm water. Yes.
Hands massaging me. Yes.
My husband lying next to me, solid to lean against. Yes.
The smell and feel of a slippery newborn baby wriggling against my naked skin.
Yes.
Yes.
Yes.
Janine DeBaise teaches writing and literature at the State University New York College of Environmental Science and Forest (SUNY-CESF), but she says her most important job is rearing her four children (ages 1, 4, 7 and 9). Her poem “Birth Moment” was in Midwifery Today Issue No. 36.

A Butcher’s Dozen, by Nancy Wainer

A Butcher’s Dozen
by Nancy Wainer
© 2001 Midwifery Today, Inc. All Rights Reserved.[Editor’s note: This article first appeared in Midwifery Today Issue 57, Spring 2001.]

I’m so tired! Exhausted. It’s the wee hours of the night and it’s dark and freezing cold. I am driving home slowly-darn, the roads are icy-from back-to-back births. I realize that both of the women whom I have just attended would have had cesareans had they been with typical American obstetrical care providers. Two more women who weren’t cut, who birthed their babies powerfully and naturally. Two more babies who were born into calm and joy. I’m not quite so tired anymore. In fact, I begin to feel exhilarated. The roads aren’t icy, they’re sparkling, and I’m going to build a (pregnant, of course) snowwoman before I go inside!
I have been asked to write on VBAC-vaginal birth after cesarean. Good. I’ll use this invitation to share some stories, pass along some information, give a quick retrospective history on the subject, and, OK, yes, to vent a little steam.

VBAC. A victory and a relief for most of the women who have one. A deep and generous healing for many of them. And still, very much a sham, because most of the women never really needed to be cut in the first place, so they didn’t really need to be VBACs after all. In that respect the whole concept of VBAC is actually, unfortunately, pathetic. In this country the subject of whether or not VBAC is “safe” is also subject to the obstetrical fashion of the hour.

I receive thousands of inquiries about VBAC every year. This week I have gotten several calls from midwives throughout the United States who tell me that the hospitals they work for no longer want to do VBACs, or that doctors who have been backing VBAC are getting a lot of heat. Today I received a letter from the coordinator of a cesarean education and support group in Australia.

She writes that South Australia has a section rate of 25 percent-so I guess we in the United States aren’t the only ones who are ignorant and knife-happy. She writes that “the vast [majority] of doctors are scared of VBAC. Current hospital policies do not support VBAC women’s needs. …[T]he general statement [from the heads of all hospital birth units] is that they do not need to address the issues of VBAC because there is no issue! . . . I would like to ask you for your advice on how to make ‘them’ listen to us ‘mere women'”

Mere women. Without us, my dear new Australian sister, they wouldn’t be here, cutting women. We must remember that cesareans are just one more reminder that we live in a misogynistic world-they are a form of violence and abuse and they are symptoms of fear, hatred, greed, misuse of power, and sexual dysfunction.

For the moment, let’s just arbitrarily begin with the last 12 women who have used me as their midwife. They all had homebirths, and let’s get one thing straight: I did not deliver their babies-they delivered their babies. I did not do their births-they did their births. But I did assist, and I did work hard, and I did influence, and I did suggest, and I did listen, and I did trust, and I did support, and oh-dear-God/dess yes, I did love.

Dawn had had two previous sections. She was two weeks past dates. She had prodromal labor for several days, during which time we made many suggestions to keep her relaxed and trusting and to help line up the baby (see addendum); then, when she went into labor, she birthed her baby in two-and-a-half hours with a big smile on her face. She said people thought she was crazy having a homebirth at all; after learning she’d had two sections, they thought she was stupid. But they were really convinced that her wiring was crossed, she says, when she told them she loved being in labor and wants to do it again! She’d have been sectioned.

Deb, sweet and tiny, five feet tall, had had a section for cephalopelvic disproportion (CPD). This time she had a five-and-a-half hour labor. She went into labor two weeks prior to her due date, on the day her three-year-old was having his birthday party. There were 20 guests, and an entertainer who brought animals to her child’s party. Deb had her baby with a ferret, a boa constrictor, a tarantula, and some bunnies very (very!) close by. She had the exact same difficulty during pushing that she’d had last time. But we do things differently and she had a nine-pound baby. She would have been sectioned, sans ferrets.

Laura, small in stature as well, had been sectioned for CPD the last time. That baby was nine pounds, 14 ounces; so, of course, with such a big baby-sarcasm dripping here-that section must certainly have been “necessary.” This time, she had a four-hour labor, an 11-pound baby with a huge head circumference, and no stitches.

Jean had a nine-pound, seven-ounce VBAC baby last month; in fact, many of our mothers have babies that are nine pounds or more and have them in less than five hours-love that HypnoBirthingTM! I am so glad that I learned early on from one of my wonderful mentors (thanks, Val) that larger babies come through very easily when their heads are lined up-and how to help them line up!

By the way, Laura was past dates with this very big baby-like most other VBAC hopefuls in this situation, she most likely would have been induced, Pitocin’d, and well, you know the rest of the story. But most of the people who are involved in birthing in this culture don’t know. They don’t understand that when you induce a woman, her body isn’t ready to give birth-if it was, it would be in labor!-and so you are, in effect, trying/hoping to blast a square peg through a round hole. And at what cost? At cost to the woman’s insurance company (ah, but that is a major subject for a different day . . .) as well as to her physical and-if she is a conscious individual-emotional health. And at cost to the baby as well.

Pam birthed last night. Another tiny woman, she and her husband and 20-month-old son moved all the way across the country so she could birth with me. I wanted desperately for her, as I want for all of my couples, a wonderful and healing birth. I knew they must have had a very traumatic birth last time for them to sell everything so they could move here.

Last time, she had a posterior baby and had pushed for hours and hours with absolutely no progress and was cut. This time she also had a posterior baby; however, we continually tweaked this baby’s head position. She pushed 45 minutes and had an eight-and-a-half pound baby. The only song that Pam’s toddler, Oliver, knew was “The Wheels on the Bus,” so to that tune, we were all-including Pam-singing “The mommy in the bed goes push push push” as she was birthing. Pam was laughing as Mack’s head, and then his body, was born. When we came back the next day for the first postpartum visit, Oliver started laughing and singing again. What joy. A healing for him, as well. An hour after the birth she commented that her baby hadn’t cried, and I repeated what I had learned: “Why would he cry? He hasn’t left your side, his cord has not been cut, he feels the love and joy in this room, and no one’s been mean to him!”

Amy had a section for fetal distress the last time. This baby was as happy as a pig in mud all throughout the labor. This baby was fed during the entire labor-at six centimeters his mom was eating a sandwich and scrambled eggs. This baby had no drugs to contend with and had no one disturbing/distressing his mother. We see almost no fetal distress at any of our births. But Amy would most likely have been sectioned because she had high blood pressure for much of the pregnancy. She would have been induced for sure. She said to me, “If you think my blood pressure is high now, take me into a hospital and you’ll really see it soar.” We (my apprentice midwife and my assistant) spent gobs of time with her and worked diligently with nutrition (Much love to you, Dr. Tom Brewer!), herbs, relaxation, homeopathics, chiropractic and other natural means to keep her blood pressure at a manageable level. She birthed at home.

The other women would also have been sectioned for a variety of reasons. One had her water leaking for several days. We waited until she went into labor on the third day and had a homebirth. We have never had an infection, even last summer when one woman’s water released at 32 weeks and she waited and had her baby at home at 36. One woman had very poor muscle tone-the doctor told her that her uterus did not have the tone to birth and scheduled her for a section-she birthed at home and had a four-hour labor. One woman’s waters contained meconium. We do not necessarily transport for this-it depends on a variety of factors. Our suggestions often work, and within a short time the meconium is cleared. She had a lovely homebirth.

One woman was 42 years old. She didn’t think she was a good candidate for a homebirth. I told her that some people aren’t good candidates for the presidency, but that doesn’t stop them! (OK, so I’m not a political humorist, so shoot me.) She had her VBAC baby (last child was born 17 years ago!) in under five hours. She lives in one of the oldest houses in Massachusetts-it is 275 years old, and very beautiful. There was a borning room!!! as well as the original beam floors in much of the house. We thought about all the babies that had been born in that house-and there were plenty of them-and all the midwives who came to attend the mothers there over the centuries. What a travesty it would have been for her to have been in a chrome and plastic hospital bed with the “potluck (or un-luck) OB of the day” who had to look at a chart to see what her name was.

Here’s one: Mary came to see me two days before Christmas. Because her baby was breech, her doctor insisted on a cesarean and had scheduled her for one. She wanted suggestions from me as to how to turn the baby and asked if I recommended she go in for an external version. My first suggestion, of course, was to not have the version done at a hospital! They do it all wrong and it hurts like the dickens and it’s rarely successful, and they give drugs that are actually counterproductive to the turning, but who cares, the docs get hundreds of dollars whether or not the baby turns anyway. She came to see me for a consult, and I palpated her and told her that her baby was not breech. She was surprised. To make a long story short, every time she went to see her doctor the baby was breech or transverse; she would come to me and the baby was head down. This happened three times. I made several suggestions, including chiropractic, homeopathy and so on and sent her on her way with good wishes. She called five days ago, and asked to come and see me again. She said she was considering a homebirth (she was “overdue” at this point). I told her to go home and think about it. The next morning she called and said they had just made the decision to stay at home. I told her that I had already fallen in love with them and they would be fine. I apologized and said that we would not get to know them as well as we know most of our clients. She said, “Are you kidding? In the first hour [we had spent four altogether] you spent with us, you had already spent more time with us than our OB has spent with us in the nine months of this pregnancy!” She went into labor two hours after she called, and had a two-and- a-half hour labor!

And last summer, VBAC-hopeful Bettina would have been re-sectioned because her baby was breech. We invited our expert breech midwife to come to Boston and teach us as she assisted Bettina. Bettina’s eight-and-a-half pound breech daughter slid out of her body. She was “lucky,” the doctors say? Lucky to have birthed safely outside the hospital? No, Bettina was lucky not to have been in the hospital getting cut. The same experienced midwife assisted Emma, who would have been sectioned as well-for twins; instead, she had them at home, gently and easily.

Ah, and Anna. She’d had two cesareans. At 39 weeks pregnant she decided to drive eight hours to have her baby here. The doctors in her area seemed itchy to cut her again. They had no faith in her ability to birth. Instead, this beautiful, large woman (over 300 pounds) had an eight-pound, 11-ounce VBAC baby four full days after her water released. She is so happy. Sooooooooo happy.

A while back, I had a true shoulder dystocia with one of our small (under five feet) VBAC moms. Her baby was large, 10 pounds, four ounces (although our three, over-11-pound babies have slid out). This is of course every midwife’s nightmare-I’m talkin’ real dystocia and not just sticky shoulders here. We did the Gaskin Maneuver-flipped her onto her hands and knees-and we were able to help the baby out; he is now an active, healthy three-year-old. During my training I was an observer at a hospital when there was a shoulder dystocia and the baby died. In hospitals, laboring women are usually medicated and epidural’d-they have monitor belts around them and are entwined in IV lines. IVs create a continually filling bladder (big deal, right, we’ll just catheterize) which compromises the amount of space for the baby. Women are often weak from lack of food. It is almost impossible to get them turned quickly and efficiently over onto their hands and knees-the position that often helps dislodge the shoulders.

Don’t we get it? Women have babies! Even when there are situations that arise! There are billions of people on the planet-they get here without being cut into the world! All our ancestresses had babies or we wouldn’t be here, and they all birthed outside of the hospital. I will say it again and again and again until I no longer have the breath: Hospitals are for sick people, and birth is not an illness. Every study that has ever been done has shown that planned homebirth is as safe (safer, I think safer) as hospital birth. Best kept secret in the country, wouldn’t you say?

Oops. I’m sorry. Please pardon the sarcasm-it just slipped out. Get me talkin’ about birth and VBAC and a whole lot of emotion comes up.
I have counseled thousands of VBAC mothers. They understand that they were robbed, and that birth is joy. They are exuberant-for years after their VBACs. Their bodies work, there is nothing wrong with them, they are normal. The “voices of VBAC” are profound and passionate. VBAC mom Megan proclaimed, ” I want to do this again!”-much to her husband’s shock, since only the head of this baby was out at this point. Brenda wrote, “When I met you, I had little faith in my ability to birth a baby. You gave me confidence and courage to let go and trust my body. Ryleigh’s birth was more powerful than I ever could have imagined. During Ryleigh’s birth, I found a strength within me that I did not know existed. I now find that strength extending into all areas of my life . . . Being surrounded by so much love and support was the key to my success. I wish I had the words to describe the impact your touch and encouraging words had on me during my labor. From that point I never doubted my ability to birth my baby . . . I am so grateful and I look forward to the day when all women can expect to receive the loving care I did throughout my pregnancy and birth.” Marcia said, “You have healed me of the trauma I experienced two years ago and given me back my birth rite. You granted my heart’s desire to push my baby out and feel it.” Rachel wrote: “I feel that you are the gardener who tended me while I blossomed. I’m sitting here with this bundle of flesh and bones, hands and feet, blood and smiles, eyes and ears, love and spirit on my lap. I stroke his head, and know that he is nothing less than a complete miracle. I know that it was the grace and power of my body and the creative force within it that carried him into the light. But I also know that you do whisper magic that makes miracles happen. And that your love and mothering nature tends to make things bloom. My experience of giving birth made me whole in a way I wasn’t aware of being broken.”

A Timely Birth, by Gail Hart

A Timely Birth
by Gail Hart
© 2004 Midwifery Today, Inc. All rights reserved.[Editor’s note: This article first appeared in Midwifery Today Issue 72, Winter 2004.]
Photo by Caroline Brown

The timing of birth has major consequences for a baby. Too early or too late can mean the difference between life and death. Or so we have come to believe; and it’s undoubtedly true at the extreme ends of preterm and postterm birth dates. Although few babies are born at these extremes of the normal length of pregnancy, much of our prenatal care is based on bringing babies to birth “in a timely fashion”-neither too early nor too late. But our understanding of “timely” is clouded, and some of our methods are self-defeating. By intervening in the natural timing of birth, we sometimes exacerbate the problems or create entirely new ones.

Normal human pregnancy is approximately 280 days, with a variation of about three weeks. There may be reason for concern if labor has not begun weeks after the due date, since placental function begins to slow after some point in gestation. Placental insufficiency can lead to poor fetal growth and, eventually, damage to the baby’s organ systems or even stillbirth. This is rare, but it is not necessarily connected to the calendar. The placenta can begin to fail at any point in pregnancy, and part of good prenatal care is monitoring growth and fluid levels so we can act before the baby’s reserves are drained. We induce labor-even advise a cesarean without labor-if the baby is in trouble, regardless of due dates. It is obvious that a baby is “better off out than in” if the placenta can no longer nourish him/her or if the uterus has become a dangerous place.

Induction Risks

But induction of labor causes so many problems that it should be a rarity, performed only when the benefits can be proven to outweigh the risks. Induction multiplies the risk of cesarean section, forceps-assisted delivery, shoulder dystocia, hemorrhage, fetal distress and meconium aspiration. It is a major contributor to birth-related expenses and complications in the US Yet it is so common that we almost think of it as normal. More than a third of American women were induced in 1999, and another third had labors augmented with Pitocin. (The FDA says that this is the lowest estimate and that the true incidence of induction is “widely under-reported.”)

Even with early pregnancy tests and ultrasounds, induction of labor remains one of the largest causes of prematurity. Ultrasonic estimation of gestational age is still an inexact science; the range of error increases as pregnancy advances. Artifact and technician inexperience can multiply the inaccuracy. Many practitioners seem unaware of this error range or, alternatively, are unwilling to second guess a due date “confirmed” by ultrasound, even when the woman’s history and clinical assessment indicate a later due date. Hence, the woman may be induced, even though the baby is clearly several weeks early. Some people discount the danger of early induction as long as the baby is within the last month of gestation. But even minor degrees of prematurity can cause harm. Babies born before full maturity can suffer from breathing difficulties or transient tachypnea, requiring separation in the hospital. They may be more prone to meconium aspiration. They are at risk for hypoglycemia and may have trouble maintaining body temperature. They are at increased risk for nursing difficulties and feeding disorders. They suffer from colic and digestive disturbances. These “minor problems” can affect the early bonding experience and make family adjustments more difficult. The incidence of child abuse is higher with “difficult” babies. As midwives we should aim for our families to experience the best emotional as well as physical health possible. A timely birth is a good step in this direction!

Preterm birth is rising in the United States. Some of this rise results from misjudged due dates and the fear of postdates pregnancy. Some reason that the risk of inducing an early baby is lower than the risk of allowing a pregnancy to continue past due, even when the due date is uncertain. This might be true if the perceived risk of postdates matched the actual risk. But it doesn’t!

Postdates

Postdates, by itself, is not associated with poor pregnancy outcome. Extreme postdates or postdates in conjunction with poor fetal growth or developmental abnormalities does show an increased risk of stillbirth. But if growth restriction and birth defects are removed, there is no statistical increase in risk until a pregnancy reaches 42 weeks and no significant risk until past 43 weeks. The primary “evidence” of a sharp rise in stillbirth after 40 weeks-often misquoted as “double at 42 weeks and triple at 43 weeks”-seems to come from one study based on data collected in 1958.(1)

The first question one should ask is whether neonatal mortality statistics from the 1950s should be compared to modern statistics, since labor anesthetics and forceps rates were very different. Early labor monitoring was scanty and prenatal monitoring not yet developed. The McClure-Brown report shows a rise in stillbirth from 10/1000 at 40 weeks to about 18/1000 at 42 weeks. Yes, that is nearly double. But think about those numbers. Even the beginning point is nearly ten times the modern mortality rate. Either modern delivery methods are vastly different or something is wrong with the data collection. This study should be updated by research conducted at least in this century! Modern statistics show an almost flat rate of stillbirth from 40 weeks to 42, with a slight rise at 43 weeks (all numbers being close to 1/1000).(2)

There is a creeping overreaction in dealing with postdates pregnancies. It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten percent of babies born at 43 weeks suffer from postmaturity syndrome (over 90% show no signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41 weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the due date but does not start on the due date. And the risks need to be compared to the risks of interventions. Induction, as already noted, is not risk free. In addition to the risks of prematurity, induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous amniotic fluid embolism.

Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1800 postterm (past 42 weeks) pregnancies with reliable dates compared this group with a matched group delivering “on time” (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56 /1000 in the postterm and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress, instrumental delivery and low Apgar were actually lower in the postdate group than in the on-time group.(3) This is only one of several studies showing postdate pregnancies can be monitored safely until delivery or until indications arise for induction. Even the famous Canadian Multicenter Post-term Pregnancy Trial Group (Hannah) of 1700 postdates women showed no difference in perinatal outcome among women who were monitored past their due date, as compared with those who were induced at term.(4)

In some studies, postterm births have shown a higher cesarean rate for suspected fetal distress. However, when a group of researchers conducted a case-matched review of nearly 300 postdates pregnancies, they concluded that the increased rate of obstetric and neonatal interventions “does not appear to be a result of underlying pathology associated with post-term pregnancy.” They suggest that “a lower threshold for clinical intervention in pregnancies perceived to be ‘at-risk’ may be a significant contributing factor.” In other words, the perceived risk is greater than the actual risk and can become a self-fulfilling prophecy!(5) When monitoring demonstrates that fetal growth, activity and amniotic fluid levels remain within expected norms, the baby can safely wait for spontaneous labor to begin. Spontaneous labor gives the greatest chance for vaginal birth, even though the baby may be slightly larger than if the mother were induced at 40 weeks.

Preventing Prematurity

Few medical treatments have been proven to truly prevent preterm birth. (Avoiding iatrogenic prematurity is most effective, of course!) Some of the most promising avenues are readily available to midwives, and we should share this research with our clients.

The following are some factors shown to be associated with preterm birth and some strategies for lowering the risks:

Overwork, job fatigue, stress-Women in high-stress jobs or who work long hours on their feet have nearly three times the risk of preterm rupture of membranes leading to preterm birth. In a study of 3000 primips, those who worked in “high fatigue jobs” had a risk of preterm premature rupture of membranes (pPROM) of 7% compared to 2% for those who didn’t work outside the home.(6) Although many women must work until the end of pregnancy, changing to less fatiguing jobs, if possible, will lower their risk of preterm birth.

Poor nutrition in pregnancy, low weight gain-Low maternal weight gain is the single risk factor that crosses all racial and economic indicators. A woman with a low prepregnancy weight and/or a low rate of gain before 20 weeks is at high risk for preterm birth. A balance of protein and carbohydrates provides the best nutrition. According to the Cochrane Database, restricted carbohydrate diets may raise the risk of preterm birth without having any effect on the incidence of macrosomia.

Vitamin C supplements-Low levels of vitamin C have been implicated for several decades as contributors to prematurity and preterm rupture of membranes.(7) In a study of 2064 pregnant women, those who had total vitamin C intakes of <10th percentile of the average intake prior to conception had twice the risk of preterm birth due to preterm rupture of membranes (relative risk, 2.2).(8)

Low levels of vitamin C may also be implicated in the risk of preeclampsia, which leads to preterm birth, as well as, frequently, induced labor. Researchers tested women for plasma vitamin C levels. Women who consumed less than 85 mg of vitamin C doubled their risk of developing preeclampsia (odds ration 2.1). Women who consumed the lowest amounts had almost four times the risk of those who consumed the highest.(9)

It is theorized that oxidative stress plays a role in preeclampsia, and we are learning that optimum levels of vitamin C protect against oxidative stress. We don’t know yet the optimum level of vitamin C or the best recommendation for supplements, but it has been proposed that 300 mg to 500 mg is probably needed. Many American women consume less than 85 mg daily!

Bacterial Vaginosis

Bacterial Vaginosis (BV) has been associated with a two to three times increased rate of preterm labor and delivery, urinary tract infections (UTIs), premature rupture of the membranes (PROM) and endometritis.(10) Because about 50% of women show no symptoms, universal screening for BV was proposed over a decade ago. (Screening and treatment is a current World Health Organization recommendation.) Screening is simple and there are several effective prescription treatments. But BV has a tendency to recur and is sometimes resistant to chemical treatment.

However, women may be able to discourage BV with some simple home methods. Numerous studies have shown that when natural vaginal Lactobacilli levels drop, BV invades. Lactobacilli inhibit the growth of Mobiluncus, Gardnerella vaginalis, Bacteroides and anaerobic cocci even in a petri dish.(11) Colonizing (or recolonizing) with Lactobacilli is key to vaginal health. According to Skarin and Sylwan, “The paucity of vaginal Lactobacillus is pivotal in allowing overgrowth of many other organisms of the vagina.”(12) Lactobacilli grow best in an acidic environment. A healthy vagina is acidic and naturally resists infection by “bad” bacteria-including strep.

In fact, pH alone-the acid/alkaline level measured by nitrazine or litmus paper-is a marker for prematurity risk. Retrospective and prospective studies show that high vaginal pH (a low acid, or alkaline, state) is predictive of preterm labor and preterm rupture of membranes. Viehweg, et al. state: “Measurements of the vaginal pH value are able to verify an alkalinization of the vagina caused by atypical vaginal flora….In contrast to normal pregnancies there is a relation between a pathological pH value > 4.5 and consequent preterm birth in pregnancies with preterm labor.”(13) In the Multicenter Bacterial Vaginosis (BV) Trial-a prospective study-21,554 women were screened for vaginal pH and outcome. Women with a vaginal pH of 5.0 or greater had a significantly increased risk of preterm birth and/or low birth weight.(14)

Several alkaline organisms other than Gardnerella (BV) are implicated in PROM. Women with high levels of these alkaline-producing bacteria had over 300% increase in rate of PROM. In an article on pPROM, Ernest, et al. note: “Numerous infectious organisms that change the normal vaginal milieu have been associated with preterm PROM. Because these organisms alter vaginal pH, the use of pH was evaluated as a potential marker for women at increased risk for preterm PROM….Those with a mean vaginal pH above 4.5 had a threefold increased risk of preterm PROM as compared with those with a mean pH of 4.5 or lower.”(15)

Testing pH level is simple, fast, inexpensive and non-intrusive. Women can do it themselves by touching a strip of nitrazine paper to their vaginal walls. Nitrazine or litmus paper is available in most drug stores. The urine test strips used by most midwives also assess pH.

Cultivating Good Bacteria

How can a woman GET an acidic vagina? The old time vinegar douche is an acidic wash and effective treatment for BV and yeast. Vinegar’s mild cleansing action is stronger against undesirable bacteria than against Lactobacilli, and it has a short residual effect, which helps encourage rapid regrowth of Lactobacilli. (In pregnancy, a woman should seek her caregiver’s advice and use only a low-pressure, low-level douche.)

An infusion of two tablespoons of hydrogen peroxide kills BV and helps Lactobacilli colonize. But recent research shows that Lactobacilli themselves are the source of most of the acid produced in a healthy vagina! They create their own optimum growth pH. “Lactobacilli bacteria, not epithelial cells, are the primary source of lactic acid in the vagina,” according to an article in Human Reproduction (16)

So… a woman can get an acidic vagina by GROWING the Lactobacilli. How? By planting them-just like any good gardener!

Researchers are working on a two-pronged approach to using Lactobacilli as a natural antibiotic. Some are trying to analyze, isolate and replicate the effective ingredient, while others are working on methods to establish optimum vaginal growth. Pharmaceutical companies want to create a Lactobacilli super pill, but I think we women should do our own home gardening!

Yogurt-Vaginal Application

Many methods have been advised for colonizing the vagina directly. Wearing a tampon soaked in yogurt is an old folk remedy used for yeast infections (it works!). The yogurt can be used like a cream or gently squeezed in with a bulb syringe.

Many strains of Lactobacilli exist. You can purchase acidophilus compounds and special “probiotics” at some pharmacies and most health food stores. But good yogurt contains live cultures, is readily available, inexpensive and proven to be effective. In the Tasdemir study, pregnant women with bacterial vaginosis were treated with commercial yogurt. The yogurt was administered daily with a 10-ml syringe for seven days and then was repeated after a one-week interval. All the women showed clinical improvement on the third day of treatment. A month after the second treatment, 90% of the women had no signs or symptoms of bacterial vaginosis. The researchers concluded: “Commercially available yogurt may restore the microenvironment and pH of the vagina,” cure BV and “prevent prematurity.”(17)

In another study, from Japan, women with BV were treated with intravaginal application of 5 ml of commercial yogurt. In the initial cultures, 29 strains of bacteria were detected. The women were evaluated and recultured three days later. There was significant decrease in discharge and vaginal redness, and the vaginal pH was lowered significantly (acidified). All 14 strains of Gram-negative bacteria disappeared! The researchers concluded that “the Lactobacillus therapy was effective in both clinical and bacteriological responses.”(18) In other words, improvement occurred in both the SYMPTOMS and the cultures.

Yogurt-Oral Introduction

But yogurt doesn’t need to be planted directly into the vagina, in order to grow there. Several studies have shown that simply EATING it will result in increased vaginal Lactobacilli! The Lactobacilli colonize the intestinal tract and migrate to the vagina and urinary tract system. (Urinary tract infections are also risk factors for preterm labor and newborn infections.) Researchers say: “The instillation of Lactobacillus GR-1 and B-54 or RC-14 strains into the vagina has been shown to reduce the risk of urinary tract infections and improve the maintenance of a normal flora. Ingestion of these strains into the gut has also been shown to modify the vaginal flora to a more healthy state. In addition, these strains inhibit the growth of intestinal, as well as urogenital, pathogens, colonize the gut and protect against infections.”(19)

In one study, ten women with a history of BV, yeast and urinary infections, drank a Lactobacilli solution in milk twice daily. The Lactobacilli were molecularly typed for identity. One week later, the researchers were able to culture the tagged Lactobacilli from the vaginas of every participant. (And six of the cases of BV were resolved within the week). This is one of several studies that have proved that the oral route can seed the vagina.(20)

Of course, the quality of the yogurt is crucial. If it doesn’t contain live cultures, it’s useless! Make sure it’s really yogurt and not simply a form of milk pudding!

These once-alternative ideas have become mainstream. The American Journal of Obstetrics and Gynecology published an article in March 2003 stating, “Certain Lactobacilli strains can safely colonize the vagina after oral and vaginal administration, displace and kill pathogens including Gardnerella vaginalis and Escherichia coli and modulate the immune response to interfere with the inflammatory cascade that leads to Pre-term Birth.”(21)

In sum, cultivating a healthy vaginal “floriculture” can reduce the incidence of preterm birth and lower the rate of bladder infection and UTIs.(22) A healthy colony of Lactobacilli guards the mother and baby against yeast and E. coli infections.(23) It also may offer protection against Group B Strep. Adding live-culture yogurt to the diet-or treating with “probiotics”-is an effective natural method to treat subclinical vaginal infections. It can also treat intestinal infections, which may trigger preterm birth. I agree with the conclusion of these researchers: “The lack of systemic side effects makes it a drug of choice in the treatment of pregnant women.”

No magic pill exists to assure a timely birth-a baby born at its healthiest point in gestation, neither too soon nor too late. Born ready to breathe, eager to nurse, primed to learn and love. Good health, good nutrition, good living habits and the avoidance of stress go far to ensure the baby will thrive until his birth date. As we learn more about normal pregnancy, we gain new tools to help both mother and baby achieve optimum health. This new research may help tip the balance in favor of better health-and a timely birth.

Gail Hart graduated from a midwifery training program as a Certified Professional Midwife in 1977. She was certified by the Oregon Midwives Council and licensed in 1995. She is now “semi-retired” and no longer maintains her license, but still has a small practice. Gail is strongly interested in ways to holistically incorporate evidence-based medical knowledge with traditional midwifery understanding.

References:

McClure-Browne, J.C. 1963. Comparison of perinatal mortality rates versus gestational age through the past three decades. Postmaturity, Am J Obstet Gynecol 85: 573-82.
Eden, R.D., et al. 1987. Perinatal characteristics of uncomplicated postdates pregnancies. Obstet Gynecol 69(3 Pt.1): 296-99.
Weinstein, D., et al. 1996 Sep-Oct. Expectant management of post-term patients: observations and outcome. J Matern Fetal Med 5(5): 293-97.
Hannah, M.E., et al. 1992 Jun 11. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 326(24): 1587-92. PMID: 1584259
Luckas, M., et al. 1998. Comparison of outcomes in uncomplicated term and post-term pregnancy following spontaneous labor. J Perinat Med 26(6): 475-79. PMID: 10224605.
Newman, B., et al. 2001 Feb. Occupational fatigue and preterm rupture of membranes. Am J Obstet Gynecol 184(3): 438-46. PMID: 11228500
Woods, J.R., Jr., et al. 2001 Jul. Vitamins C and E: Missing links in preventing preterm premature rupture of membranes? Am J Obstet Gynecol 185(1): 5-10. PMID: 11483896.
Siega-Riz, A.M., et al. 2003 Aug. Vitamin C intake and the risk of preterm delivery. Am J Obstet Gynecol 189(2): 519-25. PMID: 14520228
Zhang, C., et al. 2002 Jul. Vitamin C and the risk of preeclampsia. Epidemiology 13(4):409-16. PMID: 12094095.
McCoy, M.C., et al. 1995 Jun. Bacterial vaginosis in pregnancy: an approach for the 1990s. Obstet Gynecol Surv 50(6): 482-88.
McGregor, J.A., and J.I. French. 2000 May. Bacterial vaginosis in pregnancy. Obstet Gynecol Surv 5(5 Suppl 1): S1-19.
Skarin, A., and J. Sylwan. 1986 Dec. Vaginal Lactobacilli inhibiting growth of Gardnerella vaginalis, Mobiluncus and other bacterial species cultured from vaginal content of women with bacterial vaginosis. Acta Pathol Microbiol Immunol Scand [B]. 94(6): 399-403.
Ibid.
Viehweg, B., et al. 1997. [Usefulness of vaginal pH measurements in the identification of potential preterm births]. Zentralbl Gynakol 119 Suppl 1: 33-37. PMID: 9245123. German.
Hauth, J.C., et al. 2003 Mar. Early pregnancy threshold vaginal pH and Gram stain scores predictive of subsequent preterm birth in asymptomatic women. Am J Obstet Gynecol 188(3): 831-35. PMID: 12634666.
Ernest, J.M., et al. 1989 Nov. Vaginal pH: a marker of preterm premature rupture of the membranes. Obstet Gynecol 74(5): 734-38. PMID: 2812649.
Boskey, E.R., et al. 2001 Sep. Origins of vaginal acidity: high D/L lactate ratio is consistent with bacteria being the primary source. Hum Reprod, 16(9): 1809-13.
Tasdemir, M., et al. 1996. Alternative treatment for bacterial vaginosis in pregnant patients; restoration of vaginal acidity and flora. Arch AIDS Res 10(4): 239-41. PMID: 12347751.
Chimura, T., et al. 1995 Mar. [Ecological treatment of bacterial vaginosis]. Jpn J Antibiot 48(3): 432-36. PMID: 7752457. Japanese.
Reid, G., and J. Burton. 2002 Mar. Use of Lactobacillus to prevent infection by pathogenic bacteria. Microbes Infect 4(3): 319-24. PMID: 11909742.
Reid, G., et al. 2001 Feb. Oral probiotics can resolve urogenital infections. FEMS Immunol Med Microbiol 30(1): 49-52. PMID: 11172991.
Reid, G., and A. Bocking. 2003 Oct. The potential for probiotics to prevent bacterial vaginosis and preterm labor. Am J Obstet Gynecol 189(4): 1202-28.
See also Elmer, G.W., et al. 1996 Mar 20. Biotherapeutic agents. A neglected modality for the treatment and prevention of selected intestinal and vaginal infections. JAMA 275(11): 870-76.
Reid, G., and J. Burton. op cite.
Andreeva, P., and A. Dimitrov. 2002. [The probiotic Lactobacillus acidophilus-an alternative treatment of bacterial vaginosis]. Akush Ginekol (Sofia) 41(6): 29-31. Bulgarian.