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Soothing tips for a stitched or painful perineum

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Information from NCT about physiological vs managed 3rd stage and delayed cord clamping

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Third stage of labour: delivering placenta and cord clamping | Labour & birth articles & support | NCT

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You’ve met your baby but there’s still work to be done. Here’s what happens during the third – and, good news, the final – stage of labour…

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A brief overview of the latest thinking on when the baby's cord should be cut

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Babies cords are usually clamped shortly after the baby is born. For the past 50 years doctors and midwives have mostly routinely clamped and cut the cord immediately with no evidence that timing of that clamp and cut has any significant impact.

However, evidence now shows that there are benefits in delaying cord clamping:

Cords cut before 60 seconds after delivery are classed as early cord clamping, but in a perfect world, a cord should not be cut until it has stopped pulsating - i.e. all the blood flow from the placenta to your new baby has completed it's journey.

If the cord attached to your baby is left for as long as possible, not only will your baby receive extra blood, but it can increase birth weight, can boost your baby's blood volume by up to a third and can increase your baby's iron reserves for up to 6 months. Research shows that placental transfusion is mostly complete by 3 minutes.

Iron deficiency anaemia, the most severe form of iron deficiency, affects around a quarter of pre-school children globally and 3-7% of the population in Europe. This deficiency can go on to affect a child's brain development.

The solution is to keep the baby attached for as long as possible to make sure he or she has a good amount of iron stored up for the future.

If you allow nature to take the intended course and delay the clamping and cutting of the cord, you and your baby are still attached, therefore no one can take your baby away from you. All a midwife needs to do can be done with your baby in your arms, with their skin against yours. That is a moment no one in the world can ever take away from you. And it's doing good stuff at the same time!

Is it right for you and your baby?

There may be a reason why delayed cord clamping may NOT be an option for you and your baby. The World Health Organisation tells us that early cord clamping i.e. before the magical 60 seconds, is not recommended UNLESS resuscitation is needed. Sometimes newborns don't like being forced out of their cosy environment into a bright new world and they might need a little helping hand to come round and breathe on their own. If this is the case, then it is best to get them started and cut the cord unless there is a mini resuscitaire available, which enables resuscitation with the cord intact.

Can it be done after a Caesarean Section?

There is nothing said professionally that delayed cord clamping cannot happen after a Caesarean in theatre. Increasing numbers of hospitals have guidelines in place to permit delayed cord clamping following caesarean section. Having a Caesarean does not write off your opportunities to have delayed clamping and furthermore skin to skin contact should be every woman's right to make their birthing experience the best it can be.

In a normal delivery, once your baby has been delivered, you will then embark on the third stage of labour - either physiologically i.e. waiting for the placenta to come out naturally with no help (which can usually take up to 60 minutes before intervention is required) or, an active third stage (when your midwife will give you a little helping hand and an injection to help the placenta be delivered). Whichever one you choose, or end up having, delayed cord clamping can still be offered.

Remember, Weight can Wait! Although one of the first things new parents want to know is what the baby weighs, think of the advantages of waiting just a little bit longer for that information.

YOUR Birth Preference

You have the opportunity to make your wishes heard about how you want your birth to go and it's called a birth plan/ birth preference. Here are a few ideas you might like to consider or discuss with your midwife:

I would like delayed cord clamping, if possible

I would like immediate skin to skin contact with my baby

I want [name]to cut the cord

I would like a physiological third stage if possible

Weight can wait!

I would like an UNDISTURBED 60 minutes with my baby after birth during the third stage of labour

Special Thanks

Our sincerest appreciation to Hannah Godwin and Amanda Burleigh for writing this article.

Please visit the Blood to Baby campaign for further information.

References

Bender, S (1976). Obstetrics for Student Midwives. William Heinemann Medical Books.

Campbell, D (2013). Hospitals warned to delay cutting umbilical cords after birth. The Guardian.

Fraser, D. M. & Cooper, M. A. (Eds.) (2009). Myles Textbook for Midwives: 15th Ed. London: Elsevier.

Mehigan, S. (2014). Can I ask for a delay to my baby's cord being clamped?

Roberts, M. (2011). Delay cord clamping for baby health, say experts. BBC News.

WHO (World Health Organisation) (2012). Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants.

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Babies cords are usually clamped shortly after the baby is born. For the past 50 years doctors and midwives have mostly routinely clamped and cut the cord immediately with no evidence that timing of that clamp and cut has any significant impact. However, evidence now shows that there are benefits in delaying cord clamping: Cords ...

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NCT leaflet

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More evidence based research on delayed cord clamping.

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Optimal Cord Clamping | Blood to Baby | England

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Information about the campaign to raise awareness about Optimal Cord Clamping and Delayed Cord Clamping, Blood to Baby

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The role of hormones and how you can maximise their effectiveness in helping you to achieve a straightforward birth.

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Hormones, labour and birth: an introduction

You know your hormones are going to be working hard at this time but you might not know exactly what they're doing. You'll in fact have four major hormonal systems active when you're in labour and giving birth. These hormones are:

oxytocin (the love hormone)

beta-endorphins (the hormones of pleasure and transcendence)

epinephrine and norepinephrine (the hormones of excitement)

prolactin (the mothering hormone).

(Buckley, 2002)

Here's what impact all four will have on you...

Oxytocin or the love hormone

Oxytocin is the love hormone, which is why it's released during sex, orgasm, birth and breastfeeding (Odent, 1999; Buckley, 2002).

Oxytocin will make you feel more affectionate and selfless, and its main function in labour is to bring on contractions (Dawood et al, 1978). You'll get a surge of oxytocin in the final stage, so if you're having a vaginal birth it will help you along with pushing.

Oxytocin reduces stress, calms you down and helps with pain during labour (Buckley, 2015). Impressively, your baby will also produce oxytocin before and during labour (Chard et al, 1971).

Oxytocin hangs around after birth too, helping you feel more relaxed, well-nourished and bonded with your baby (Buckley 2002, Buckley 2015). It helps with the let-down reflex during breastfeeding and protects you against postpartum haemorrhage (Buckley, 2002).

Beta-endorphins or the pleasure hormones

Endorphins are naturally occurring opiates, similar to morphine and heroin. Like oxytocin, they mostly appear during sex, pregnancy, birth and breastfeeding. Beta-endorphins reduce pain and suppress the immune system, which is important so that it doesn't act 'against' your baby (Buckley, 2002, 2015).

If you're stressed during labour, that can make you release excessive beta-endorphins, which may inhibit oxytocin and slow things down (Buckley 2015). That's why keeping things as calm as possible is a great thing in labour.

Beta-endorphin also helps with the release of prolactin during labour, preparing your breasts for feeding (Rivier et al, 1976).

And one more thing: it helps in the final phase of your baby's developing lungs too (Buckley 2015).

Epinephrine and norepinephrine or fight or flight hormones

You might have heard these two referred to as fight-or-flight hormones but their proper names are epinephrine and norepinephrine (adrenaline and noradrenaline). They are produced during stresses like fright, anxiety, hunger or cold and also when you're excited (Buckley 2015).

You're likely to get a high level of these hormones if you don't feel private, calm, safe and undisturbed and they can then inhibit oxytocin (Buckley 2015). Yet in the late-labour stage if you perceive danger or stress, they may paradoxically stimulate contractions so you give birth more quickly (Buckley 2015).

A rise in epinephrine when you're in the later stages of labour increases your levels of prostaglandin and cortisol to help with contractions. This will make you feel a sudden rush of energy and will cause several strong contractions and will help you push (Buckley, 2002, 2015).

These hormones help your baby too by protecting them against a lack of oxygen (Buckley, 2002). Your baby will have high levels of these hormones during birth but they'll drop quickly once you sooth them afterwards (Lagercrantz and Bistoletti 1977; Buckley, 2002).

Prolactin or the mothering hormone

Prolactin is the mothering hormone. And it's the major hormone for breastfeeding.

Prolactin starts to increase during pregnancy and peaks at birth (Buckley, 2002). Your baby produces prolactin in the womb too (Daniels and Martin, 1994).

Hormones and your feelings after birth

Lots of women get the baby blues during the first week after birth of her baby days (NHS Choices, 2018). You might feel down or depressed, emotional or irritated and likely to burst into tears at any second.

Don't despair though: these symptoms are totally normal. They're due to the sudden hormonal and chemical changes that happen after you give birth.

If you feel like you are suffering from something more extreme and it isn't going away though, talk to your GP or midwife. You might be suffering from postnatal depression and should get some support or help right away.

Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about birth, labour and life with a new baby.

Buckley SJ. (2015) Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, D.C.: Childbirth Connection Programs, National Partnership for Women and Families. Available from: http://www.nationalpartnership.org/research-library/maternal-health/hor... [Accessed 25th April 2018]

Buckley SJ. (2002) Ecstatic birth: The hormonal blueprint of labor. Available from: http://www.dancingstarbirth.ca/Handouts/Ecstatic_Birth.pdf [Accessed 25th April 2018]

Chard T, Hudson CN, Edwards CR, Boyd NR. (1971)Release of oxytocin and vasopressin by the human fetus during labour. Nature. 234:352-354. Available from: https://www.ncbi.nlm.nih.gov/pubmed/4944487 [Accessed 25th April 2018]

Daniels G, Martin J. (1994) Neuroendocrine regulation and diseases of the anterior pituitary and hypothalamus, In Harrison's Principles of Internal Medicine, 13th edition. New York: McGraw- Hill. [Accessed 25th April 2018]

Dawood MY, Raghavan KS, Pociask C, Fuchs F. (1978) Oxytocin in human pregnancy and partrurition. Obstetrics and Gynecology. 1978; (51):138-143. Available from: https://www.ncbi.nlm.nih.gov/pubmed/622223 [Accessed 25th April 2018]
Lagercrantz H and Bistoletti H. (1977) Catecholamine release in the newborn infant at birth. Pediatric Research. 8:889-893. Available from: https://www.ncbi.nlm.nih.gov/pubmed/887309 [Accessed 25th April 2018]

NHS Choices. (2018) Feeling depressed after childbirth. Available from: https://www.nhs.uk/conditions/pregnancy-and-baby/feeling-depressed-afte... [Accessed 25th April 2018]

Odent M. (1999) The Scientification of Love. London. Free Association Press.

Rivier C, Vale W, Ling N, Brown M, Guillemin R.(1976) Stimulation in vivo of the secretion of prolactin and growth hormone by beta-endorphin. Endocrinology. 100:238-241. Available from: https://www.ncbi.nlm.nih.gov/pubmed/187406 [Accessed 25th April 2018]

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Hormones in labour: oxytocin and the others - how they work

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You know your hormones are going to be working hard at this time but you might not know exactly what they're doing. You'll in fact have four major hormonal systems active when you're in labour and giving birth.

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Information on different birthing venues.

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Compare your local units with the national picture.

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This page shows results for all measures together per site or per trust/board. If a result is missing, this is because the site or trust/board did not pass our quality checks for this measure. Please refer to the NMPA Measures Technical Specification for exact definitions of the measures.

For 2017/18 results, Data quality and completeness limited the number of English trusts that could be included in this report. Therefore, it is not possible to report a mean that is representative of the three countries combined (the GB mean). The NMPA therefore asks audiences to refrain from interpreting that aggregate trust and board mean as being representative of a GB mean. Further information is available in the full report.

What is a spine chart?

Spine charts are useful to view results for measures in the context of other relevant measures at a selected site or trust/board, rather than in isolation.

Spine charts show the rates of all measures for the site or trust/board you have selected, and how these compare to the average of all sites or trusts/boards included in each measure. They also give an idea of the overall distributions of rates, and if the rates of the selected site or trust/board fall outside of the expected range. They are essentially slices of the funnel plot for each measure at the point of the site or trust/board you have selected.

Please use the buttons below to choose either site or trust/board level overview, and then select a maternity unit or trust/health board from the dropdown list in order to view a spine chart of its results across all measures compared to the national average.

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This page shows results for all measures together per site or per trust/board. If a result is missing, this is because the site or trust/board did not pass our quality checks for this measure. Please refer to the NMPA Measures Technical Specification for exact definitions of the measures.

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What are the consequences of knowledge?

As midwives, we do lots of things, often simultaneously. We build relationships, gather information, determine and meet needs, offer tips, reassurance, information and advice, soothe concerns and much, much more. During an antenatal check, for example, we might do all of these things while also assessing the health of women and their babies by means of carrying out those screening tests which have become a routine part of such meetings; blood pressure, urinalysis, examining the woman's abdomen and listening to the fetal heart. Often, depending on the circumstances, we may also be talking to the woman about whether she would like to avail herself of other available screening tests such as blood and antibody checks, ultrasound, glucose tolerance testing, maternal serum screening and group B strep testing. While our activities are myriad, a fair proportion of our time is spent undertaking activities which relate to the search for knowledge that may help prevent or detect problems.

On the surface, focusing on preventative health and undertaking screening tests seems like a jolly good idea. If we can detect potential problems at an early stage, we can put measures in place in an effort to prevent those problems being harmful to women or their babies. This rather lofty aim, however, is merely the tip of the iceberg that is screening, and a whole raft of issues is raised by this concept in practice. This is the first of a series of blog posts in which I share an article that focuses on the consequences of the knowledge that is gained by undertaking screening tests and raises questions about whether this knowledge carries risks as well as benefits.

Beginning with bloods...

Once upon a time, I shared a house with a couple of scientist friends who worked in a laboratory. At that time, I was (temporarily) vegan, they were both dedicated carnivores and we had a very friendly and very ongoing argument over our dinner most evenings. This argument was based around whether or not, as a non meat-eater, I could have a reasonable haemoglobin level. One day I invited them to draw a few millilitres of my blood and spin it in the lab so that they could check my haemoglobin for themselves and we could finally settle this argument one way or the other. This idea went down really well; one of them was also a phlebotomist and he gathered his kit and was literally just about to put the needle in when he suddenly stopped and swore quietly under his breath.

I asked him whether there was a problem and he said, "I've just realised ... I can't do an Hb independently of a full blood count".

"OK", I smiled. "Do a full blood count then, I don't mind."

"Well..." he replied. "Trouble is ... what about if I find out that you have acute lymphoblastic leukaemia? Would you want to know?"

I can't say that was the first occasion on which I ever thought about the potentially enormous consequences of the kinds of information that we gather daily and routinely, but when I am asked to speak to groups of midwives about screening I often begin with that story as an illustration of how very momentous the implications of even the simplest tests can be. In just a few decades, Western culture has embraced the notion that preventative health care and screening are beneficial tools and there has been a metaphorical explosion in the growth of technologies related to this area. Knowledge, however, can have serious consequences and simply because we can know something doesn't necessarily mean that we always should know it. Because of this, I believe that it is important to consider the consequences that can arise from the gathering of information about the human body.

You can read the next part of this article here.

A version of this article was originally published as Wickham S (2009) Screening and the consequences of knowledge. Birthspirit Midwifery Journal 2: 9-12.

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Screening and the consequences of knowledge (part one) - Dr Sara Wickham

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What are the consequences of knowledge? As midwives, we do lots of things, often simultaneously. We build relationships, gather information, determine and meet needs, offer tips, reassurance, information and advice, soothe concerns and much, much more.

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What are your rights in the perinatal period? Who makes decisions regarding your care?

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The NCT's guide to what to expect during labour

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Thinking about how, what happens and where to give birth? We're here to help you feel more confident. We've got information and tips on everything you need to know.

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How to encourage your baby into a good position for a straightforward birth.

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Parenthood Starts with Pregnancy

You and your baby are working together! Your job is to dilate, baby's job is to rotate. Empower yourselves with our daily activities, body balancing techniques, and smart birth positions for a more comfortable, confident birth.

Proactive Preparation for Easier Birth

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Daily Essentials can be practiced daily throughout pregnancy to help bring balance and comfort - and an easier, shorter birth.

Spinning Babies® Parent Class

Spinning Babies® Parent Class provides clear instructions on how to use Spinning Babies® for a more comfortable and confident pregnancy and labor.

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Spinning Babies - Comfort in Pregnancy and Easier Birth

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Parenthood Starts with Pregnancy You and your baby are working together! Your job is to dilate, baby's job is to rotate. Empower yourselves with our daily activities, body balancing techniques, and smart birth positions for a more comfortable, confident birth. Proactive Preparation for Easier Birth Join others who are enthusiastic for your life-giving year!

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Birthing4Blokes - Everything a 'Father to be' needs to know

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the complete resource for fathers to be - Birthing4Blokes supports you to be the very best that you can be on the day that she gives birth to your baby. The confidence to understand her needs and calls for help! My main worries were: "Could I be the person my partner needed when she needs it?"