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terra-puerperio

Elements in the midwifery care for puerperium: Earth

The Earth-Involution element

During the first trimester of exterogestation, the Eart element returns, and is very important. Earth is the slow time of getting to know, of adapting, of couvage. Earth is the intimate space of home. But it is also the time of effort, of the research of a balance, of the reconstruction of new boundaries. Earth is the containers, the so-called “ecologic powers” that support the mum: the partner, the midwife, the grandmother, the doula, the friend.

On the physical level, Earth is the bites, static and prostaglandinic contractions, symptoms of an involutive process that is not as massive and fast in any other physiological circumstance. In this, the uterine regression is the most important phenomenon: the uterus can go from weighing 1kg at birth to weighing 60gr 6 weeks after it, thanks to the integration of the enzymatic-histologic myometrium cell reduction action and protein autolysis. Furthermore, there is a modification of the vessel arrangement: arteries are occluded and substituted by smaller blood vessels, as the elimination of fluids and metabolic debris through run-off vasculature and lochia increases. A big part of waste material deriving from the involutive process is reintegrated in the blood flow, to favour the evolutionary recycle process supporting the beginning of breastfeeding. The massive intervention of macrophages and leucocytes helps in the defence against invading microorganisms and allows the placental wound to regress without leaving any scar: it is, as a matter of fact, completely reconstructed through a centripetal epithelial proliferation starting from the glandular tissues underlying the insertion area (involutive- and evolutionary process).

The uterine os stays open for about 10 days, to allow the expulsion – if needed – of residue from the uterus. Then, it remains a virtual cavity to allow the lochiac flow, which is first hematic, then serous, and lastly white. Discharge is a key immune defence mechanism, both because of its own bactericidal nature, and as mechanical barrier draining colonizing pathogens and eliminating pregnancy tissue residues.

Earth is involution, regaining tone, closure. The vaginal- and abdominal walls and the ligaments go back to their pre-pregnancy characteristics gradually and with great differences depending on the woman, the type of pregnancy and birth, the grade of parity. The vagina, that at the beginning of the puerperium presents an alkaline environment with little lactobacilli and a specific flora aimed at tissue destructuration, regains its acidity and normal bacterial colonization about six weeks from birth. Conventionally, six weeks are also the envisioned time for ligament involution, while perineal muscles take a variable time and deserves a specific, physical, sensorial, intentional, and controlled care.

Lastly, the pelvis closure completes in different times: when meant as a bone cradle for the baby, its closure can be favoured by a closing ritual, to underline the end of an emotional process through the physical treatment, the reconnection of a circle’s ends, the return to origins, to what the woman once was: whole.

What to do?

Listening and nurturing

From an emotional-relational and environmental point of view, tools such as listening, containment, and activation of the ecologic powers prove to be very useful during puerperium. Support strategies that can be reached by problem solving are fundamental.

Physical- and emotional nutrition, the affirmation of new rules, and the use of repetitive rituals are typically bond to the Earth element. Rituals acquire particular importance during this first instability phase, as they offer security, give strength, and create a defence frame from external interferences through repetitivity. The respectful handling of the placenta, from lotus birth to the return to earth, from freezing to drying, from ingestion to topical use, is part of the care rituals linked to the Earth element.

Abdominal massage

In order to favour the involution of abdominal organs, muscles, the cardiocirculatory system, skin, connective- and fascial tissue, as well as uterine involution, the abdominal massage is the Earth-linked tool that can be used ever since the first day after birth.

The technique: with oiled hands, massage with centripetal motion from the groin and the lower costal margin towards the bellybutton. Follow the margins of the uterus and abdominal muscles with a first delicate, then deeper touch, avoiding the c-section scar if present. This loosens the tensions, improves blood flow, reduces uterine pain. The intention is to close, bring closer, bring back to the centre. Massage until it feels warm, on every day of the first puerperium week.

Rebozo

The closing rebozo is an external contraction- and internal expansion treatment that, depending on the intention, can help regain balance, guide the attention to the centre of self, align the organs, close the perineum and the pelvis, sedate or activate. The treatment described here, structured from low to high, can be used once or be repeated as a massage, to regain energy and as an antidepressant. Like during the first trimester of pregnancy, the activation is minimal, so the gesture should be a not-too-intense input and the whole treatment should last about 10 minutes.

The technique involves two midwives at the sides of the lying woman. They should place the rebozo under the woman’s ankles, then raise it up and swing it lightly, making small movements, then cross it under the woman’s feet, pull it horizontally, and keep it closed, stuck to the ground.

The procedure is then repeated on the knees. The rebozo is slid under the pelvis with the help of the woman, crossed over the iliac bones, and kept for a slightly longer time. Under the thorax, the rebozo is passed under the breast, keeping the arms crossed inside the rebozo.

Lastly, coming to the head, one midwife holds the rebozo with both hands, slightly pulls it back- and upwards of the nape, swings, crosses over the forehead and pulls behind the ears. Indicated also in case of c-sections, as a treatment or puerperium closing ritual.

By Silvia Garelli