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The Happiest Baby on the Block - Harvey Karp (Summary)

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What is the Golden Hour After Birth?

The Golden Hour is the time right after delivery where mom and baby have uninterrupted skin-to-skin contact for at least the first one to two hours. As long as mom and baby are well, immediate and continuous skin-to-skin contact is recommended.

Skin-to-skin contact during the Golden Hour after birth is highly recommended, when possible. It promotes bonding and milk supply. Skin-to-skin in the first one to two hours provides oxytocin production in both mom and baby. Oxytocin is "the love hormone" that helps with emotions such as trust, bond, and positivity.

When baby is placed tummy-to-tummy with mama immediately after delivery and left undisturbed for the first 2+ hours, most newborns are able to find the breast and latch with little to no, help. Read more about the benefits of skin-to-skin.

How do babies normally behave during the Golden Hour?

Babies have been found to go through 9 stages after delivery when placed in immediate skin-to-skin contact with their mother.

In a nutshell, they will cry after they are born and, when placed in skin-to-skin contact, will go through active and rest periods while moving towards the breast to find and attach to the nipple and breast. Most babies can do this with little to no help. Waiting for them to latch-on on their own may help them to get a better, deeper latch. This latch should occur within the first 60 minutes after delivery.

What can you do to help ensure skin-to-skin contact after delivery?

If all is well with you and baby, then it is recommended to do immediate skin-to-skin contact. The following are things you can do to prepare yourself and your healthcare providers for limited interruption.

Make your wishes known.
Discuss wanting uninterrupted time with your doctor, midwife, nurses, doulas, partner, and anyone else involved with the labor and delivery-that way, they can help make sure this happens.

This means that all baby assessments can be done while they are on your chest. Anything unnecessary requiring baby to be removed from your chest during this time can be delayed, such as weight check, measurements, footprints, medications, bath, etc.

Make skin access easy.
Allow access to the breasts during this time-wear clothing during labor and delivery that is easily removable for baby to have full access to your breasts. I loved the Dear Darby birth gowns I bought.

What happens if mom and baby are separated?

Ideally, skin-to-skin contact will begin immediately after birth with no separation until two hours have passed and the first breastfeeding session is complete. Unfortunately, this cannot happen in all situations.

Situations such as C-sections, difficulty breathing, meconium in your amniotic fluid, pre-term delivery, and more can cause a need for baby to be assessed further and skin-to-skin contact to be delayed. If this occurs, start your Golden Hour as soon as possible.

Skin-to-skin contact can be done after a C-section. Be sure to request this if a c-section is necessary. Also read through our C-section recovery tips.

If a long separation is necessary, use your hands to remove milk in the early hours after delivery to maximize your breastmilk supply when it transitions.

No matter your birth circumstances, advocate for your post-delivery birthright to experience the Golden Hour. It's a magical time for a reason, and you'll find a significant amount of benefits as a result.

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The Golden Hour After Birth: What is it and why is it so important? - The Lactation Collection

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Skin-to-skin contact during the Golden Hour after birth is highly recommended, when possible. It promotes bonding and milk supply. Skin-to-skin in the first

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- plenty of quiet, no questions, lowered voices

- not being observed
- dim lights, or darkness
- being warm and cosy
- your own familiar things (eg pillows, blanket, eyemask)
- care and support that helps you to feel confident and secure
- support that feels soothing and enabling
- privacy when you want it, contact when you don’t
- consider avoiding or minimising internal exams or dilation scores which can ‘wake’ you up and create unnecessary expectation/pressure
- freedom to move
- continuous supply of comforts

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Is there value in leaving the umbilical cord intact?

"Another thing very injurious to the child is the tying and cutting of the navel string too soon: which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be, a portion of blood being left in the placenta which ought to have been in the child." (Darwin 1801)

In days gone by, it would probably have been unnatural for a mother to sever the umbilical cord immediately, although common sense suggests that the timing and method of cord severing would be dependent on the circumstances and context in which a woman birthed. We can't go back in time to see how our ancestors severed their babies' cords, but we know from the animal kingdom that there are a range of behaviours. In more recent times, maternity practitioners adopted the practice of clamping and then cutting the baby's umbilical cord soon after birth, thus separating the baby from its mother. But the nature and timing of this practice has been questioned and reconsidered in turn.

There hasn't been much interest in studying what happens in women's and babies' bodies if birth is not interfered with. Because of this, much of what we know about the advantages of waiting has come out of research studies looking at the disadvantages of immediate cord clamping. This is sadly not a unique situation. There are many other situations in maternity care where normal physiology is not well understood and in which we may well be causing more harm than good by interfering on a routine basis.

Evidence of the advantages of patience

The transfer of the blood that has been circulating in the placenta in the moments after birth is the main reason that it is important to allow time before clamping and cutting the baby's cord. Many practitioners are aware that the baby needs to be able to access its full complement of blood in order to support lung expansion and additional blood volume requirements from the placenta which occur as the first breaths of air are taken. If the cord is clamped immediately at birth, blood from the placenta cannot flow through it and this blood therefore cannot be used to support the process of lung expansion and respiration. Blood then has to be 'borrowed' from the rest of the baby's circulation in order for its lungs to become fully functioning, even though the baby's other vital organs also need blood to function fully and optimally (Mercer et al 2008, Mercer & Erickson-Owens 2010).

We are only really beginning to discover the myriad reasons why babies need to be able to access their full complement of blood before we interfere with the supply by clamping and cutting the cord. Our knowledge of this area has increased fairly rapidly over the past few years, although we still have a lot to learn. In 1974, Yao and Lind found that, when a baby received its full quota of blood, it was better able to maintain its haematocrit levels (ratio of red blood cells to total volume of blood). In the past, commentators knew that this quota of blood was important (Inch 1983) but it is only more recently that we have come to understand the implications of early cord clamping more fully.

The research in this area has now become more widely known and incorporated into practice. A number of studies have shown that allowing the cord to remain intact for a period of time confers significant advantages to the baby (Mercer & Erickson-Owens 2010, Hutchon 2012, Bhatt et al 2013, McDonald et al 2013, Mercer & Erickson-Owens 2014, Hooper et al 2015). Our current understanding is that allowing the cord to remain intact helps a baby to establish their breathing and circulation, which is particularly advantageous for babies who are compromised or born prematurely (Mercer & Erickson-Owens 2010). Allowing the cord to remain intact can lead to a reduction in breathing difficulties and less need for oxygen, ventilation and blood transfusion (Mercer 2001). Other benefits include an improvement in cardiac (heart) function (Bhatt et al 2013, Hooper et al 2015), an increase in the baby's iron stores (Chaparro et al 2006, Andersson et al 2011) and neurological advantages (Hutchon & Wepster 2014).

We know that later cord clamping can lead to a baby receiving almost a billion more stem cells (which have healing qualities) than if the cord is clamped and cut early (Mercer & Erickson-Owens 2010). Later cord clamping can also reduce the likelihood of severe infection (also known as sepsis) in pre-term babies (Mercer & Erickson Owens 2006, Mercer & Erickson Owens 2010). Hutchon (2016b) suggested that the intervention of immediate cord clamping may cause some babies to need to be resuscitated. Other studies show that babies whose cords are clamped earlier experience disadvantages. Mercer et al (2008) note that babies who experience immediate cord clamping are likely to have hypovolaemia (too little blood volume) and suggest that this can lead to the release of substances called inflammatory cytokines, which are associated with cerebral palsy.

These benefits are summarised in systematic reviews and acknowledged in reviews looking at the 'management' of the birth of the placenta. In 2010, the Cochrane review comparing active management with physiological placental birth noted that about 20 per cent of a baby's blood volume is lost when the cord is clamped early (Begley et al 2010). This is also acknowledged in reviews on cord clamping, for instance where McDonald et al (2013) note Mercer's (2001) revelation that "...placental transfusion can provide the infant with an additional 30% more blood volume and up to 60% more red blood cells. " The benefits of higher iron stores are experienced for several months after birth, even if the cord remains intact for only 1-3 minutes after birth (McDonald et al 2013).

If you'd like to know more about what happens in premature babies, how long the evidence says is best to wait and so on, please see our book, which contains all of that and much, much more!

References

Andersson O, Hellstrom-Westas L, Andersson D et al (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months. BMJ 2011 343: d7157.

Begley CM, Gyte GM, Murphy DJ et al (2010). Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews Issue 7.

Bhatt S, Alison BJ, Wallace EM et al (2013). Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. The Journal of Physiology, 591(8), 2113-26.

Chaparro CM, Neufeld LM, Tena Alavez G et al (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet, 367(9527): 1997-2004.

Darwin E (1801). Zoonomia: Or the laws of organic life. London.

Hooper SB, Polglase GR, Te Pas AB (2015). A physiological approach to the timing of umbilical cord clamping at birth. Archives of Disease in Childhood - Fetal & Neonatal Edition 100(4), F355-360.

Hutchon DJ (2012). Immediate or early cord clamping vs delayed clamping. Journal of Obstetrics & Gynaecology, 32(8), 724-29.

Hutchon DJR (2016b). Ventilation, chest compression and placental circulation at neonatal resuscitation - ILCOR recommendation 2015. Journal of Paedatric Neonatal Disorders 1(1): 1-6.

Hutchon DJR & Wepster R (2014). The estimated cost of early cord clamping at birth within Europe. International Journal of Childbirth, 4(4): 250-56.

Inch S (1983). Third stage management. ARM Newsletter 19: 7-8.

McDonald SJ, Middleton P, Dowswell T et al (2013). Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub3

Mercer JS (2001). Current best evidence: a review of the literature on umbilical cord clamping. Journal of Midwifery and Women's Health 46(6): 402-14.

Mercer J & Erickson-Owens D (2006) Delayed cord clamping increases infants' iron stores. Comment. Lancet 367(9527): 1956-58.

Mercer J & Erickson-Owens D (2010). Evidence for neonatal transition and the first hour of life. In: Walsh D, Downe S (eds). Essential midwifery practice: intrapartum care. Wiley, 81-104.

Mercer J, Skovgaard R, Erickson-Owens D (2008). Fetal to neonatal transition: first do no harm. In: Downe S (eds). Normal Childbirth: evidence and debate. Churchill Livingstone, 149-74.

Yao AC & Lind J (1974). Placental transfusion. American Journal of Disease in Childhood. 127(1):128-41.

© Sara Wickham and Nadine Edwards 2019

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The value of leaving the umbilical cord intact - Dr Sara Wickham

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Is there value in leaving the umbilical cord intact? "Another thing very injurious to the child is the tying and cutting of the navel string too soon: which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases.

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The power of a birth plan is in finding out all the information. Make sure you think about induction choices and caesarean choices

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2 cups coconut water

1 cup water

2 tablespoons citrus juice

1 tbsp honey

1/2 tsp unrefined Himalayan salt

1/2 tsp bicarbonate of soda

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how to start pumping and build a milk stash while breastfeeding | Rachel O'Brien, IBCLC

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How to start pumping and building a milk stash, when to safely begin regular pumping, and tips for collecting and storing breastmilk.

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Why Express Milk?

Expressing Milk

Storing Milk

Why express milk?

There are several reasons why you might need or want to express milk for your baby. These include:

when a baby can't breastfeed

to make more milk

a return to paid work

separation

choice

When a baby can't breastfeed

Babies and parents have many instincts for breastfeeding, but it is still a learned skill that can take time and practice. When babies won't breastfeed, it is usually because they can't. This could be for many reasons, for example:

they are preterm

they are unwell

they have a tongue tie

they are sleepy as a result of birth medications

they had a difficult birth

it is taking time to learn how to breastfeed

Expressing milk when your baby cannot nurse - or nurse effectively - protects your milk supply and provides milk to feed them. Breastmilk is especially important for babies who are unwell and/or preterm as it helps protect against illness and infections, and is ideal for a baby's sensitive and immature digestive system.

Expressing milk is often a short-term solution. However, some mothers may find themselves exclusively expressing breast milk (' exclusively pumping ') long-term when their baby is ill or has medical difficulties.

A return to paid work

There are many ways to combine working and breastfeeding. It is not always necessary to express milk when returning to work. It may depend on:

the age of your baby

the length of time you are apart

your willingness - and ability - to express; pumping is not effective for everyone, although there are ways to improve this.

your baby's willingness to take your milk when you aren't there

Many mothers express initially for reassurance and comfort, and to avoid blocked ducts and mastitis. However, you may find that your body quickly adjusts to a new breastfeeding pattern and you no longer need or want to express.

You and your baby may need to be apart. This may be for illness or health reasons, an appointment or event, or a night away.

Your baby has an intense need for your presence as well as your milk, and separation can be hard for both of you. It may be possible to take your baby with you - young babies are very portable and often enjoy being out and about.

Some mothers choose to express milk some or all of the time. You might want - or feel pressured - to let a partner or other family member feed your baby. Some parents choose to exclusively pump because they don't enjoy breastfeeding, but want their baby to have the benefits of their milk.

Expressing Milk

What kind of pump do I need?

Pumps are available to hire and to buy. The pump you use depends on your reason(s) for expressing and your personal preference. We all respond differently to pumps and have different needs.

Single electric pumps and manual pumps are best suited to occasional expressing, for example, short term separation or a return to work. They can also be used to express 'to comfort' any time your breast feels very full and your baby doesn't want to feed.

Double electric pumps express milk from both breasts at once, which often saves time. It is also said that they tend to stimulate more milk production. They are available as personal use pumps and 'hospital grade' pumps.

Hospital grade pumps are very powerful and are intended to be used by more than one person multiple times a day. They are usually hired. Hospital grade pumps are recommended when you are exclusively expressing, expressing very frequently, or trying to increase your supply. Parents might start with a hospital grade and then switch to a personal use pump once their supply is established and if they need to keep expressing.

Silicone pumps tend to be best suited to occasional use. Some mothers have found them helpful to relieve blocked ducts. (Note: When attached to the breast, a silicone pump is not just a device for collecting dripping milk - it creates a vacuum stimulating a 'letdown'. If this is not your planned use, it can create supply issues.)

Hands-free pumps come as single or double electric pumps. They can be handy for mums who want to pump on the go, or pump and multitask. Hands-free pumps have small motors and are possibly best suited to occasional pumping. You can buy or make a hands-free bra for a pump to fit in to.
Types of Pump (image above)
A. Manual breast pump
B. Single electric pump
C. Double electric pump

It is also possible to express without any equipment. Hand expressing is a great skill to learn for all ages and stages! It can take a little practice, but it can quickly become second nature:

It is free and can be done any time, anywhere!

It is the perfect choice for the early days when you are producing colostrum (you can collect - or 'harvest' - colostrum before your baby is born).

You can practise antenatally and become familiar with your breasts before your baby arrives.

Getting 'hands-on' during a pumping session can increase milk output. See Expressing Tips.

What else do I need to know about pumps?

Pumps are often sold in a standard size, however pump parts come in different sizes. The funnel-shaped piece that touches your breast is usually called a flange . The tubed-shaped bit that the nipple goes into is sometimes called the nipple tunnel

If pumping is comfortable with good milk flow, you probably have a good fit. However, if pumping is painful or causing swelling and/or rubbing, you may need a bigger or smaller flange. Sometimes a different flange size is needed for each breast. A poor fit can also reduce milk flow. ¹

The nipple should have enough room to slide in and out during pumping, without rubbing. The areola (darker area around the nipples) may move slightly with it, but it shouldn't be drawn into the nipple tunnel. After pumping, the nipple will almost certainly be bigger, but shouldn't seem darker or swollen. ²
Pump Flange Sizes (image above)
A. Milk expression
B. Flange is too big
C. Flange fits
D. Flange is too small
Suction strength and cycle speed
Electric pumps often come with a range of settings. There will be settings for suction strength and settings for cycle speed.

A pump is trying to mimic a breastfeeding baby. When a baby nurses, they do a fast, light suck to trigger a letdown. Once the milk lets down, the sucking slows and they swallow more.

You might begin by using a low suction, high speed setting and once your milk starts flowing, switching to a higher suction, lower speed setting.

Exactly how high or low depends on how it feels and if it is removing milk well. Expressing should be comfortable, and a pump provides most milk when it is set at the upper end of fully comfortable. ³

Painful pumping may impact milk flow, damage your nipples, and is unlikely to make you feel like doing it!

How often and when should I express?

If your baby can't breastfeed yet, aim to express 8-10 times in a 24-hour period, including at least once at night. These do not need to be at regular time intervals, but avoid stretches longer than 5 or 6 hours. Once your supply is well established, you may find that you can get by with fewer sessions.⁴

If you are trying to make more milk, express after or between feeds. How often depends on how much more milk your baby needs and how feeding at the breast is going.

If you are returning to paid work, how often you express will depend on a number of things. Some parents look at how often they feed on average in a 24-hour period and work out how many feeds they will typically have when they are with their child, so express the same number of times when separated to maintain this daily average.

If you are stockpiling milk for short-term separation or in the run up to a return to work, express once or twice a day after or between feeds. If your baby typically feeds from one breast, you could express from the other side while they feed. The amounts may seem small, but they quickly build up!

Some mothers try 'power pumping' as a short-term strategy to increase their milk supply, or when they are struggling to fit pumping into their daytime routine. This approach involves expressing very frequently for short periods, stopping and starting as many times as possible - it is said to mimic cluster feeding.

How long should I express for?

Just like breastfeeding, expressing milk is not a 'one-size-fits-all'. Observe your milk flow, notice how your breasts feel and find what works for you.

If you are using a single pump, this usually takes about 20-30 minutes for both breasts. You might try switching sides when the milk flow slows, usually every 5-7 minutes.⁵

Double pumps save time. A double-pumping session that replaces what would have been nursing will probably last no more than 15 minutes. However, it is more important to pay attention to your breasts than the clock.⁶

How much milk will I express?

How much we can express at any one time depends on lots of different things. If you've never used a pump before, it might be helpful to think of the first pumping sessions as practice. ⁷

Expect small amounts in the early days. This will be drops for some and as much as a teaspoon for others. Many parents think of it as 'putting in their order' for more milk later.⁸

If you are breastfeeding full-time, expect to express around 15-60ml (0.5-2 fl oz) in total from both breasts per pumping session.⁹

If you are exclusively pumping, consider the overall volume in 24 hours. Full milk production is about 750-900 ml (25-30 fl oz) per baby. Milk production reaches its peak at about five weeks and stays relatively stable until around six months.¹⁰

Once milk production peaks, a typical feed is about 60-120ml (2-4 fl oz).¹¹

We all respond differently to pumps. How much you can express is not always a reliable or accurate sign of how much milk is there. It's important to remember that a baby who is nursing effectively will get more milk than a pump.

Expressing tips

Before expressing:

Wash your hands and get comfortable

Put something warm on your breasts, such as a warm flannel

Gently massage your breasts

Use any objects or techniques that help you to feel calm and relaxed. This might be a photo of your baby, an item of their clothing, a favourite warm drink or snack, music or visualisations.

While expressing:

Try 'hands-on pumping'. This is said to produce better results than relying on a pump alone¹²

Use breast compression to increase milk flow

Take a break midway and gently massage the breasts to help increase the amount of milk.¹³

Hand express from both breasts after you have finished pumping.

Try nursing your baby on one side and expressing on the other, or expressing from both sides at the same time, to encourage more letdowns

After expressing:

Hand-express for a minute or two to help increase output and supply.

Cleaning pump parts

There is not complete agreement about cleaning pumping equipment. Some public/advisory bodies (including NHS England) recommend sterilising equipment after every feed.

Others recommend washing pump parts thoroughly after every feed and sterilising once a day.

Some advisory bodies and breastfeeding organisations state that pump parts do not need to be sterilised, and that washing in hot soapy water is enough if your baby is healthy and full term.

Day-to-day milk handling

There is very little research on the day-to-day problems of milk handling, so guidelines often err on the side of caution.

Fresh human milk kills almost all bacteria, viruses and fungi that it comes in contact with.¹⁴

Mothers who are exclusively expressing, or expressing frequently, sometimes put the whole pumping kit (flanges attached) in a clean container in the fridge until the next expressing session and clean everything at the end of the day.

Breastmilk can be safely stored at room temperature for up to 4 hours (see below). Some parents apply the same timeframe to their pump and pump parts, and express multiple times within a 4 hour period before cleaning everything.

One quick method of sterilising is to use a sterilising fluid that you change every 24 hours. Submerge pump parts in the solution after washing them each time.¹⁵

Washing and drying

Ensure hands and pump area are clean.

You may like to use a separate basin and separate utensils for cleaning pump parts and equipment rather than the sink.

Clean with hot soapy water and rinse separately with clean water.

Some pump equipment is also dishwasher-safe.

Air dry or dry with paper towels.

Clean pump dials and switches with a disinfectant spray or wipe.

Store dry pump equipment in a clean container.

If you are expressing milk for a sick or premature baby, good hygiene is vital and sterilising is essential.

Storing Milk

How long can I store milk for?

There isn't complete agreement about milk storage.

Wherever you are storing milk, the fresher it is, the better.

Good hygiene is important - clean hands, clean pump parts, clean storage.

For healthy, full term babies ¹⁶:
Room temperature

Ideally, use within 4 hours.

Depending on room temperature and how clean storage conditions are, up to 6-8 hours may be safe.

Frozen milk that has thawed and kept at room temperature should be used within 4 hours.

Fridge

Ideally, use within 4 days.

When conditions are very clean, 5-8 days may be acceptable.

Store milk in the back of the fridge rather than in the door.

Frozen milk that has thawed in the fridge should be used within 24 hours.

Freezer

Ideally, use within 6 months.

Can be stored for up to 12 months.

Store at the back of the freezer, away from the door where temperatures may fluctuate.

Insulated bag
Milk left over after a feed should be used within 1-2 hours as it mixes with a baby's saliva, although it may be safe to put it in a fridge for up to 4 hours. ¹⁷

For premature or sick babies, consult with hospital staff and follow hospital guidelines.

Combining expressed milk

When combining milk expressed at different times, mix cold with cold:

Chill newly expressed milk before adding it to an existing container.

You can add refrigerated milk to frozen as long as there is less refrigerated milk than frozen.

Use within the time limit of the oldest expressed milk.

What can I store milk in?

You can store milk in any clean container, such as a hard (BPA-free) plastic or glass container with a tight-fitting lid, or a disposable milk storage bag.

Milk expands in the freezer, so leave space in the bag or bottle if you plan to freeze it.

Put the date on the container.

How much milk should I store?

Store milk in small quantities to avoid waste. Small amounts also defrost more quickly.

For babies older than one month, a feed is approximately 60-120ml. You could also store some smaller amounts in case you need to offer more.

How do I prepare stored milk?

You don't have to warm milk - some babies like it cold!

If you do warm milk, run the container under a warm tap or place it in a pan of warm water.

Never use a microwave or heat milk directly.

Swirl milk to combine rather than shaking it.

If defrosting milk, thaw it overnight in a fridge or hold it under warm running water.

Thawed milk should not be kept at room temperature. It should either be fed immediately or put in the fridge.

Smelly milk

Sometimes milk smells or tastes soapy after a short time in the fridge or freezer. This is because of an enzyme (lipase) that breaks down fats in milk. The milk is completely safe and most babies will drink it. However, if they refuse to, heat freshly-expressed milk to scalding (bubbling around the edges, but not boiling) and then quickly cool and freeze it. Scalding reduces some of the immune factors, but may be the only option for some families. You can also experiment with the length of storage time needed for the milk to acquire the smell.

Feeding your baby your milk

See Further Reading and resources below for information on ways to feed your baby your expressed milk.

Further Reading

Bottles and other tools
Comfortable Breastfeeding
How to increase your milk supply
Engorged Breasts - Avoiding & Treating
Hand Expression of Breastmilk
My Baby Needs More Milk
My Baby Won't Breastfeed
Sleepy Baby - Why and What to Do When Mum Can't Be There
Working and Breastfeeding

Online Information

Hand expressing:

Maximizing milk production when expressing:

Books

La Leche League International, The Womanly Art of Breastfeeding, Pinter and Martin, London: 2010.
Marasco, L & West, DMaking More Milk, McGraw Hill, New York: 2019.
Mohrbacher, N.,Breastfeeding Answers, Nancy Mohrbacher Solutions, Illinois: 2020.
Ruddle, L.,Relactation: A Guide to Rebuilding Your Milk Supply, Praeclarus Press, Texas: 2020.

References

1. La Leche League International, The Womanly Art of Breastfeeding, Pinter and Martin, London: 2010; 298.

2. As above, p304.

3. As above, p489.

4. La Leche League International, The Womanly Art of Breastfeeding, Pinter and Martin, London: 2010; 300.

5. As above, p500.

6. Bonyata, K. I'm not pumping enough milk. What can I do? Accessed: 28 March 2023.

7. La Leche League International, The Womanly Art of Breastfeeding, Pinter and Martin, London: 2010; 307.

8. As above, p301.

9. As above, p300.

10. As above, p309.

11. As above, p515.

Copyright LLLGB 2023

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Expressing & Storing Milk - La Leche League GB

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Why Express Milk? When a baby can't breastfeed Making more milk A return to paid work Separation Choice Expressing Milk What kind of pump do I need? What else do I need to know about pumps? How often and when should I express? How long should I express for?

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The natural flow of hormones in physiological birth

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The natural flow of hormones in physiological birth

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Popular beliefs about when babies should be 'sleeping through the night' are based on studies conducted in the 1950s and 1960s on groups of formula-fed babies. However, it is normal for babies - especially breastfed babies - to wake and feed throughout the night during, at least, the first year. Encouraging babies to 'sleep through' before they are ready to do so makes it difficult to keep breastfeeding and may encourage babies to develop mature sleep patterns out of sequence with their other circadian patterns, such as those controlling the regulation of temperature, hormone production, and the genes that control our biological rhythms.

Babies operate according to their own internal biological rhythms, and they are unaware of what their parents are reading or being told. Babies do not have a body clock when they are born. It often takes several months for a baby's day-night pattern of wake and sleep to become established, and for night-time sleep consolidation to happen. During this time many parents just need reassurance that their baby is normal, and that their baby's sleep patterns are developing as expected.

New-born babies may sleep for 18 or so hours a day, but often for only for 2-3 hours at a time. During the first-year overall sleep duration falls to around 15 hours a day, and the majority of sleep becomes concentrated during night-time as the circadian rhythms* develop.
Sleep variation
In a comprehensive systematic review (Galland et al. 2012) combined data from 34 studies relating to normal infant sleep duration. The chart below shows part of this data for babies aged up to one year. Data from each study & age range are represented by a dot which shows the average total sleep experienced. [The dotted line shows the amount of variation around that average.] It is clear that younger babies sleep longer overall, but there is also a lot of variation among individual babies, and within studies for this group.

Sleep is a developmental process, and our sleep needs change throughout our lifetimes. Babies' sleep patterns mature over the first several years of life, and the sleep architecture of newborns is very different to that of adults. Newborns sleep for 18-20 or so hours a day, but only for 2-3 hours at a time. During the first-year overall sleep duration falls to around 15 hours, and the majority of sleep becomes consolidated during night-time as circadian rhythms develop (Parmelee et al 1964).

*Circadian rhythms - biological processes which are roughly tied to the 24-hour day, and periods of daylight and dark. Processes regulated by our circadian rhythms include heart rate, temperature and our 'body clock', along with the production of hormones which make us feel sleepy or alert.*

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Options include:

music playing, no talk from OB or talked through the birth, lowered or transparent screen, ECG electrodes places on back or away from chest, slower delivery of baby, optimal cord clamping

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By Kelly Bonyata, BS, IBCLC

The First Week

How often should baby be nursing?

Frequent nursing encourages good milk supply and reduces engorgement. Aim for nursing at least 10 - 12 times per day (24 hours). You CAN'T nurse too often-you CAN nurse too little.

Nurse at the first signs of hunger (stirring, rooting, hands in mouth)-don't wait until baby is crying. Allow baby unlimited time at the breast when sucking actively, then offer the second breast. Some newborns are excessively sleepy at first-wake baby to nurse if 2 hours (during the day) or 4 hours (at night) have passed without nursing.

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Is baby getting enough milk?

Weight gain: Normal newborns may lose up to 7% of birth weight in the first few days. After mom's milk comes in, the average breastfed baby gains 6 oz/week (170 g/week). Take baby for a weight check at the end of the first week or beginning of the second week. Consult with baby's doctor and your lactation consultant if baby is not gaining as expected.

Dirty diapers: In the early days, baby typically has one dirty diaper for each day of life (1 on day one, 2 on day two...). After day 4, stools should be yellow and baby should have at least 3-4 stools daily that are the size of a US quarter (2.5 cm) or larger. Some babies stool every time they nurse, or even more often-this is normal, too. The normal stool of a breastfed baby is loose (soft to runny) and may be seedy or curdy.

Wet diapers: In the early days, baby typically has one wet diaper for each day of life (1 on day one, 2 on day two...). Once mom's milk comes in, expect 5-6+ wet diapers every 24 hours. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper. A piece of tissue in a disposable diaper will help you determine if the diaper is wet.

Breast changes

Your milk should start to " come in" (increase in quantity and change from colostrum to mature milk) between days 2 and 5. To minimize engorgement: nurse often, don't skip feedings (even at night), ensure good latch/positioning, and let baby finish the first breast before offering the other side. To decrease discomfort from engorgement, use cold and/or cabbage leaf compresses between feedings. If baby is having trouble latching due to engorgement, use reverse pressure softening or express milk until the nipple is soft, then try latching again.

Call your doctor, midwife and/or lactation consultant if:

Baby is having no wet or dirty diapers

Baby has dark colored urine after day 3(should be pale yellow to clear)

Baby has dark colored stools after day 4(should be mustard yellow, with no meconium)

Baby has fewer wet/soiled diapers or nurses less frequently than the goals listed here

Mom has symptoms of mastitis(sore breast with fever, chills, flu-like aching)

Weeks two through six

How often should baby be nursing?

Frequent nursing in the early weeks is important for establishing a good milk supply. Most newborns need to nurse 8 - 12+ times per day (24 hours). You CAN'T nurse too often-you CAN nurse too little.

Nurse at the first signs of hunger (stirring, rooting, hands in mouth)-don't wait until baby is crying. Allow baby unlimited time at the breast when sucking actively, then offer the second breast. Some newborns are excessively sleepy-wake baby to nurse if 2 hours (during the day) or 4 hours (at night) have passed without nursing. Once baby has established a good weight gain pattern, you can stop waking baby and nurse on baby's cues alone.

The following things are normal:

Frequent and/or long feedings.

Varying nursing pattern from day to day.

Cluster nursing (very frequent to constant nursing) for several hours-usually evenings-each day. This may coincide with the normal "fussy time" that most babies have in the early months.

Growth spurts, where baby nurses more often than usual for several days and may act very fussy. Common growth spurt times in the early weeks are the first few days at home, 7 - 10 days, 2 - 3 weeks and 4 - 6 weeks.

Is baby getting enough milk?

Weight gain: The average breastfed newborn gains 6 ounces/week (170 grams/week). Consult with baby's doctor and your lactation consultant if baby is not gaining as expected.

Dirty diapers: Expect 3-4+ stools daily that are the size of a US quarter (2.5 cm) or larger. Some babies stool every time they nurse, or even more often-this is normal, too. The normal stool of a breastfed baby is yellow and loose (soft to runny) and may be seedy or curdy. After 4 - 6 weeks, some babies stool less frequently, with stools as infrequent as one every 7-10 days. As long as baby is gaining well, this is normal.

Wet diapers: Expect 5-6+ wet diapers every 24 hours. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper. A piece of tissue in a disposable diaper will help you determine if the diaper is wet. After 6 weeks, wet diapers may drop to 4-5/day but amount of urine will increase to 4-6+ tablespoons (60-90+ mL) as baby's bladder capacity grows.

Milk supply?

Some moms worry about milk supply. As long as baby is gaining well on mom's milk alone, then milk supply is good. Between weight checks, a sufficient number of wet and dirty diapers will indicate that baby is getting enough milk.
This information is also found as part of the professional Breastfeeding Logs.
Additional information

@
Breastfeeding Logs Hunger Cues - When do I feed baby? Resources: Is Baby Getting Enough Milk? Normal Growth of Breastfed Babies Breastfeeding Basics
Information is Your Ally in preparing to breastfeed: 10 Tips for Success by Eva Lyford
Tips for juggling a newborn and toddler Frequent Nursing
Worried about milk supply?
How does milk production work? Is your milk supply really low? My breasts feel empty! Has my milk supply decreased? How can I find help for my breastfeeding problem?
@ other websites

The Importance of Colostrum by Paula Yount

Baby Explains- Normal Newborn Behavior by Diana Cassar-Uhl, IBCLC

It's Not Just About Breastfeeding by Danielle Rigg, JD CLC

What is Normal? by Paula Yount

Breastfeeding as Baby Grows by Becky Flora, IBCLC

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Breastfeeding your newborn - what to expect in the early weeks * KellyMom.com

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Frequent nursing encourages good milk supply and reduces engorgement. Aim for breastfeeding at least 10 - 12 times per day (24 hours). You CAN'T breastfeed too often--you CAN breastfeed too little. Nurse at the first signs of hunger (stirring, rooting, hands in mouth)--don't wait until baby is crying.

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This shows the options, benefits and risks of most options. It also mentions a TENS machine and has a link to read more about them.

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Your pain relief options

Labour can be painful - it can help to learn about all the ways you can relieve the pain.

It's also helpful for whoever is going to be with you during your labour to know about the different options, as well as how they can support you.

Ask your midwife or doctor to explain what's available so you can decide what's best for you.

Write down your wishes in your birth plan, but remember you need to keep an open mind. You may find you want more pain relief than you'd planned, or your doctor or midwife may suggest more effective pain relief to help the delivery.

Self-help in labour

You're likely to feel more relaxed in labour and better placed to cope with the pain if you:

learn about labour - this can make you feel more in control and less frightened about what's going to happen; talk to your midwife or doctor, ask them questions, and go to antenatal classes

learn how to relax, stay calm and breathe deeply

keep moving - your position can make a difference, so try kneeling, walking around, or rocking backwards and forwards

bring a partner, friend or relative to support you during labour, but do not worry if you do not have a partner - your midwife will give you all the support you need

ask your partner to massage you - although you may find you do not want to be touched

have a bath

take paracetamol, which can help relieve some of the pain in the early stages of labour

Gas and air (Entonox) for labour

This is a mixture of oxygen and nitrous oxide gas. Gas and air will not remove all the pain, but it can help reduce it and make it more bearable. It's easy to use and you control it yourself.

You breathe in the gas and air through a mask or mouthpiece, which you hold yourself. The gas takes about 15 to 20 seconds to work, so you breathe it in just as a contraction begins. It works best if you take slow, deep breaths.

Side effects

there are no harmful side effects for you or the baby

it can make you feel lightheaded, sick, sleepy or unable to concentrate, but if this happens you can stop using it

If gas and air does not give you enough pain relief, you can ask for a painkilling injection as well.

Pethidine injections in labour

This is an injection of a medicine called pethidine into your thigh or buttock to relieve pain. It can also help you to relax. Sometimes, less commonly, a medicine called diamorphine is used.

It takes about 20 minutes to work after the injection. The effects last between 2 and 4 hours, so would not be recommended if you're getting close to the pushing (second) stage of labour.

Side effects

There are some side effects of pethidine and diamorphine to be aware of:

it can make you feel woozy, sick and forgetful

if pethidine or diamorphine are given too close to the time of delivery, they may affect the baby's breathing - if this happens, another medicine to reverse the effect will be given

these medicines can interfere with the baby's first feed

Epidural

An epidural is a type of local anaesthetic. It numbs the nerves that carry the pain impulses from the birth canal to the brain. It should not make you sick or drowsy.

In most cases, an epidural gives complete pain relief. It can be helpful if you are having a long or particularly painful labour.

An anaesthetist is the only person who can give an epidural, so it will not be available at home. If you think you might want one, check whether anaesthetists are always available at your hospital.

How much you can move your legs after an epidural depends on the local anaesthetic used. Some hospitals offer "mobile" epidurals, which means you can walk around.

However, this also requires the baby's heart rate to be monitored remotely (by telemetry) and many hospitals do not have the equipment to do this. Ask your midwife if mobile epidural is available in your local hospital.

An epidural can provide very good pain relief, but it's not always completely effective in labour.

How does an epidural work?

To have an epidural:

a drip will run fluid through a needle into a vein in your arm

while you lie on your side or sit up in a curled position, an anaesthetist will clean your back with antiseptic, numb a small area with some local anaesthetic, and then introduce a needle into your back

a very thin tube will be passed through the needle into your back near the nerves that carry pain impulses from the womb (uterus). Medicines (usually a mixture of local anaesthetic and opioid) are administered through this tube. It takes about 10 minutes to set up the epidural, and another 10 to15 minutes for it to work. It does not always work perfectly at first and may need adjusting

the epidural can be topped up by your midwife, or you may be able to top it up yourself through a machine

your contractions and the baby's heart rate will need to be continuously monitored. This means having a belt around your abdomen and possibly a clip attached to the baby's head

Side effects of epidurals in labour

There are some side effects of epidurals to be aware of.

An epidural may make your legs feel heavy, depending on the local anaesthetic used.

Your blood pressure can drop (hypotension), but this is rare because the fluid given through the drip in your arm helps to maintain good blood pressure.

Epidurals can prolong the second stage of labour. If you can no longer feel your contractions, the midwife will have to tell you when to push. This means that forceps or a ventouse may be needed to help deliver the baby (instrumental delivery).

When you have an epidural, your midwife or doctor will wait longer for the baby's head to come down (before you start pushing), as long as the baby is showing no signs of distress. This reduces the chance you'll need an instrumental delivery. Sometimes less anaesthetic is given towards the end, so the effect wears off and you can feel to push the baby out naturally.

You may find it difficult to pee as a result of the epidural. If so, a small tube called a catheter may be put into your bladder to help you.

You may get a headache after an epidural. This happens in about 1 in 100 cases and can be treated.

Your back might be a bit sore for a day or two, but epidurals do not cause long-term backache.

You may feel tingles or pins and needles down one leg after having a baby. This happens in about 1 in 2,000 cases. This is more likely to be the result of childbirth itself rather than the epidural. You'll be advised by the doctor or midwife when you can get out of bed.

Remifentanil

Remifentanil goes into a vein in your arm. You control it yourself by pushing a button.

It works quickly and wears off after a few minutes. You can use it up until your baby is born.

You'll need a small clip on your finger to measure your oxygen levels, as remifentanil can make you feel breathless or need oxygen.

Side effects

Remifentanil can make you feel sleepy, sick, dizzy or itchy. These stop once you stop taking the medicine.

Like pethidine, remifentanil can affect the baby's breathing but this usually wears off quickly.

Using water in labour (water birth)

Being in water can help you relax and make the contractions seem less painful. Ask if you can have a bath or use a birth pool. The water will be kept at a comfortable temperature, but not above 37.5C, and your temperature will be monitored.
Find out more about using water during labour and birth on the National Childbirth Trust website

TENS machines

TENS stands for transcutaneous electrical nerve stimulation. Some hospitals have TENS machines. If not, you can hire your own machine.

TENS has not been shown to be effective during the active phase of labour, when contractions get longer, stronger and more frequent. It's probably most effective during the early stages, when you may have lower back pain.

TENS may also be useful while you're at home in the early stages of labour or if you plan to give birth at home. If you're interested in TENS, learn how to use it in the later months of your pregnancy. Ask your midwife to show you how it works.

How TENS machines work

Electrodes are taped on to your back and connected by wires to a small battery-powered stimulator. Holding this, you give yourself small, safe amounts of current through the electrodes. You can move around while you use TENS.

TENS is believed to work by stimulating the body to produce more of its own natural painkillers, called endorphins. It also reduces the number of pain signals sent to the brain by the spinal cord.

Side effects of TENS machines

There are no known side effects of TENS for either you or the baby.
Read more about TENS

Alternative methods of labour pain relief

You may choose alternative treatments such as acupuncture, aromatherapy, homeopathy, hypnosis, massage and reflexology. Most of these techniques are not proven to provide effective pain relief.

If you'd like to use any of these methods, it's important to discuss them with your midwife or doctor and let the hospital know beforehand. Most hospitals do not offer them for pain relief during labour.

If you want to try any of these techniques, make sure the practitioner is properly trained and experienced.
Learn more about complementary and alternative medicines and how they're regulated Find maternity services near you

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Find out about the different methods of pain relief in labour, including self-help, gas and air, birth pools, pethidine and epidurals.

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Pregnancy: Rebozo + Shaking the Apple Tree

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4 EASY ways to relieve PAIN IN LABOR with COUNTER PRESSURE

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The lengthening breath - Learn to breathe in through your nose and out through your mouth deeply and slowly. Make your out breath as long, slow and controlled a release as you can. Make sure your exhale is longer than your inhale. Imagine as you blow air out that you are blowing a long line of bubbles or you are creating a golden thread of light.

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Have a listen to the hypnobirthing tracks in my dropbox. They will help build your imagination

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How to use: gently squeeze the comb teeth into the ‘Laogong’ acupressure point on the palm of your hand.

The pressure from the comb will act as a welcome distraction from pain or discomfort elsewhere on the body, as well as distracting your mind from any anxious thoughts and feelings.

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Welcome to the Evidence Based Birth® series all about pain management in labor. My name's Rebecca Dekker, and I'm a nurse with my PhD and the founder of Evidence Based Birth®. In this first video we're going to do a quick overview of a topic about pain in labor.

Pain seems to be the number one thing that a lot of people worry about when it comes to being pregnant and going into childbirth. I work with a lot of college students, and in the beginning when I start working with them, a lot of them are terrified of the pain of childbirth. What most people don't know is that there's two main ways that you can look at the topic of pain in labor.

Two Perspectives of Pain Management during Labor

Researchers named Leap and Anderson proposed these two different viewpoints or perspectives. One perspective is the perspective of pain relief during labor, and the other is "working with pain or coping with pain."

Pain relief Perspective

Many doctors and labor and delivery nurses believe strongly in the pain relief perspective. They many believe that pain during labor is unnecessary in today's society and that we should eliminate pain, and that the benefits of pain medications always outweigh the risks. Some of them may not understand why someone would want to go without pain medication during labor, and that's because a lot of nurses and doctors were trained in medical school and nursing school that it's very important to assess people's pain and eliminate it as much as possible.

Coping with Pain Perspective

On the other hand, a lot of people believe in the coping with pain or working with pain philosophy. In this perspective, people believe that pain is a normal part of labor and that it's necessary to entice you to move around and try different positions that will help the baby come down and out. In the right environment, an environment that feels supportive and private and lets you feel not anxious, people can better cope with labor pain in an environment like that because they feel safe and supported. Also, it helps them release natural pain-relieving hormones called endorphins.

The Difference between Pain and Suffering

People who believe in the coping with pain perspective also believe that there is a difference between pain and suffering. Penny Simkin is a famous doula and author who has written a lot of about the topics of pain versus suffering. She teaches people that you can have pain without suffering. You can also have suffering without pain. They don't necessarily have to go hand in hand.

For example, people may experience pain without suffering during things like running or training for a marathon, or undergoing a planned surgery, or even for some people having labor may be painful but not suffering because they're prepared for it and they have lots of support.

Things that can help you cope with pain and prevent suffering including things like being educated so you're not as scared or fearful, companionship, reassurance, touch, feelings of safety and other positive factors.

On the other hand, it's possible for some people to be pain-free and to still suffer. People with an epidural might feel no or little pain, but could still suffer emotionally. They may feel distressed due to a long labor, to the numbness that they're feeling in the body, to feeling isolated or alone, or they may suffer if they're worrying about their baby for some reason.

Or you could have a situation where both pain and suffering are happening at the same time. Many healthcare providers that I've worked with are very attuned to their clients and noticing whether or not if they've crossed that line from pain to suffering. I prefer personally to talk about pain management. Because even with medication, sometimes it's impossible to completely relieve pain, so I believe we should talk about managing pain and helping people learn how to do that with as many methods as they need.

Approaches to Pain Management During Labor

Now pain management strategies during labor can be divided into two different kinds of approaches. There are pharmacological approaches which are using drugs and medications, and there are non-pharmacological or non-drug approaches to managing pain.

Pharmacological approaches

In this video series some of the drug approaches that we're going to talk about include epidurals and spinals, nitrous oxide, also known as laughing gas, and drugs that they can put through your IV to help with pain.

Now researchers think our bodies perceive pain in a couple different ways. The first way is by how intense the pain is, and the seconds way is how we perceive the pain to be unpleasant, how unpleasant it is to us. Now there are several different non-pharmacological approaches or non-drug ways to manage pain that help reduce either the intensity of pain or the unpleasantness of pain, or both.

Non-pharmacological approaches

Gate Control Theory

One of the ways that we can help manage pain during labor without using drugs is called the gate control theory. This is a really cool concept. Basically, the gate control theory says that if you activate your nerves in a non-painful way at the same time that you're experiencing pain, that that blocks the pain signals from reaching your brain. That's because there's a gate. There's a limited amount of information that can go up to your brain at once, and if you flood the nerves with non-painful stimuli, that prevents the painful messages from getting through.

For example, I have chronic migraines. I could have really intense pain in my head like it feels like there's an icepick coming one of my brain. But if I eat a spoonful of ice cream, the second that that ice cream gets in my mouth, it's so sugary and sweet and creamy, the pain in my head actually goes away. I can't feel it anymore because of the gate control theory. My nerves are being flooded with non-painful stimuli so the painful messages can't get through. Now that does not make the migraine go away, and as soon as I finish eating ice cream the pain comes flooding back, but that's just one example of how we can use that gate control to manage pain in labor.

What are some ways you could help block painful messages during labor? Some things include laboring in a warm tub of water, having someone massage you during labor, or put pressure on your back what their hands, positioning yourself and movement and using things like birth balls. You can even use warm packs or little TENS unit, spelled T-E-N-S. All of those things help flood your nerves so that the painful messages can't get through as well.

Central Nervous System Control Method

Another really important way that you can help manage pain during labor is through controlling your mind. That may sound kind of crazy, but scientists call this the central nervous system control method of pain management. By controlling your mind and what you're thinking, you can actually help control the unpleasantness of pain. Some examples of central nervous system control include taking childbirth education classes, hypnotherapy or using hypnobirthing or hypnobabies, continuous like from a doula, aroma therapy, music, and relaxation and deep breathing.

Some people might be skeptical and think that these non-pharmacological approaches don't work. But in 2014, researchers looked at all the research that had ever been done on non-drug approaches and found that they were actually very effective. Both using gate control methods and central nervous system methods helped decrease the chance of your needing an epidural and greatly increased your chances of being satisfied with your birth.

When people were randomly assigned, like tossing a coin, to either having a drug approach or a central nervous system approach, researchers found that people who had the central nervous system approach offered first actually experienced fewer caesarians, fewer forceps and vacuum-assisted deliveries, less use of Pitocin to stimulate labor, and they also had a shorter labor on average.

What was most effective in the study was when researchers combined multiple methods and tailored them to the individual, and also having continuous labor support from a doula was one of the most effective methods. ACOG, the American Congress of Obstetricians and gynecologists, actually recommends that people in labor be offered non-pharmacological methods because no adverse or no side effects have been found to these methods.

Some of the non-pharmacological for pain management during labor methods that we're going to talk about in future sessions include water immersion, relaxation techniques, acupuncture and massage, and support from a doula.

Bottom Line

In summary, people can feel intense pain during labor, and we can help people and you can manage labor using both pharmacological and non-pharmacological approaches. For some people, all they will need is non-pharmacological approaches. For others, they may require pharmacological or drugs as well. However, it's probably best if everybody went into childbirth while equipped with a toolkit of things that they can use to help manage pain and cope with labor. Even if you've chosen to use medication, there is going to be probably a period during labor when you don't have medication, in which case those non-pharmacological approaches might be very helpful. Also, when people are using those first before they get medication, they actually report increased satisfaction with their childbirth.

Thanks for listening. Bye.

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Pain Management during Labor - Evidence Based Birth®

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In this video and article, we talk all about pain management during labor. You will learn the difference between "pain" and "suffering", the approaches in pain management during labor and birth, and the types of pain management strategies.

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Think about what you need for a really good night sleep - or what helps you to relax and feel calm. These are your oxytocin anchors

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Push (2021) | Satire Short Film | Beautiful Birth Club

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Women sometimes get told that they cannot give birth at home with their first baby because they have an "untried pelvis".

What if we told men they couldn't have sex at home the first time because they have an "untried penis"

Just imagine a young couple going to see a health professional, to discuss their plan to have sex for the first time.

Doctor: Hello please come in, what can I help you with?

Couple: Hello, we have been together for a while now, and we feel ready to start having sex.

Doctor: That sounds about right, I will arrange for you to go to your local hospital.

Couple: Actually we were hoping to have sex at home

Doctor: At home!! For your first time?? This isn't safe.

Couple : Why? It's quite a natural thing isn't it?

Doctor: Yes it's a natural thing, but lots of things can go wrong, because you have an untried penis. When you've had sex at least once in hospital, and we know you can do it effectively and safely then we're happy for you to have sex at home. But for your first time, it's much safer to do it in the hospital

Couple: What can go wrong?

Doctor: Well we don't know how long it will last, whether you'll be able to get a strong enough erection, maintain it for long enough, that's one thing. It can also be very strenuous for the two of you, so we will need to monitor your heart rate, temperature and blood pressure. People have heart attacks whilst having sex you know? And you are both nearly 25, the risk of heart attack doubles after 25. At least if you're in the hospital there are doctors available to intervene quickly should anything bad happen.

Couple: This sounds very worrying, but we really don't like hospitals, the environment is cold and clinical, it smells of disinfectant, whereas at home we have the right atmosphere, smells, and all the comfort that we need.

Doctor: Well you won't need be there the whole time, you'll get started at home anyway, we don't really want you to come in until you're past the established arousal stage. Plus it can be quite a messy affair, you don't want to ruin your furniture, do you?

Couple: So we will have to travel to the hospital, like, in the middle of it? Won't this disrupt things?

Doctor: A bit, especially if you come to the hospital too soon, before you have reached the established arousal stage. When you come in, an intimacy midwife will assess your arousal and the strength of your erection. If your erection isn't big enough and you aren't yet in the established arousal stage, we will send you home and tell you to come back later. But once you're settled in the hospital, you should be able back into the swing of things quite quickly, especially as our staff is highly trained to support the intimacy process, and help you if you struggle. Also you need to know that nearly half of first time couples who are planning for home sex end up transferring to the Intimacy Unit anyway.

Couple: We've had a tour of the hospital and we really don't like the Intimacy Unit. The rooms are tiny, the beds are high and narrow, there are only bright lights and thin paper curtains, and no en-suite bathrooms.

Doctor: well yes for your safety is paramount that we can see what you are doing, and access the bed quickly and easily, in case something goes wrong, you see. It's also safer for you to be in the missionary position for that reason.

Couple: This really puts us off, and we're worried we won't be able to do it in there.

Doctor : Don't worry if you fail to progress, we have a lot of technology at hand to help complete the process, like Viagra and penis substitutes.

I tell you what, since you're both still kind of low risk, as long as you're still under 25 by the time you have sex, we could let you go to our Natural Climax Centre, instead of the Intimacy Unit. It's a home from home centre, with large rooms, double beds and mood lighting, and even one hot tub per room so you can get in the mood and relax. It looks more like a fancy B&B than a hospital! It's staffed by experienced intimacy midwives, who are skilled in supporting physiological sex. So it will be just yourselves, a midwife, and a couple of reproductive students. They only use intermittent monitoring every 5 min during the established arousal phase. Of course if anything goes outside of the guidelines, we would suggest you transfer to the Intimacy Unit where we can monitor your heart rate continuously, as well as intervene with a penis substitute if you cannot finish by yourself. As I said before, as you have an untried penis, we don't know which way it will go.

Couple: Regardless of the hospital location, we feel that having lots of people we don't know watching us will be inhibiting. And we don't want students!

Doctor: Oh don't worry about that, all the staff are trained and completed used to it! They see it all the time, and you once you get back into the swing of things, you won't be paying attention to what's going on around you. Plus we are a teaching hospital, so we need to train our students.

Couple: We were also hoping to do it at a spontaneous time...

Doctor: Well yes, for low risk couples it's ok to wait for sex to start spontaneously, but since you're both nearly 25 your risk of heart attack is higher, so if we haven't had sex by the time you are 25, we think it's safer for you to come in at an agreed time so we can monitor your heart rate from the beginning, and intervene if needed. We start the process in the pre-intimacy ward, by giving you some Viagra orally, and if that doesn't work we can give it to you via a drip which is more effective.

Couple: OK, doctor, we want to do what's safest and not put ourselves in danger, so we will go for what you suggest.
Why did I write this?
Comparing childbirth to sex isn't new.

The hormone that drives labour, Oxytocin, the hormone of love, is the same hormone that floods our system when we have fall in love or have sex, and because this hormone flows best in dark, private, unobserved conditions (think romantic diner atmosphere), it is generally understood that one needs a similar atmosphere to birth a baby that they needed to make the baby.

Sadly modern obstetric units rarely provide the environment for birth to unfold easily. This has been explained extremely well both in Tricia Anderson's Out of the laboratory: back to the darkened room and in Marsden Wagner's Fish can't see water articles

In the book "the function of the orgasms" Michel Odent wrote a "Dear John" wedding night preparation letter from a woman to her fiancé, where she talks about the wedding night educator she has been working with and the wedding night plan she has been writing.

There is a particularly clever satire video which depicts an Italian couple trying to conceive in an hospital, it's called " The performance". There is another one in English called "Push".

I have this wonderful role play that was written by Jill Alderton & Jill Oliver, for a home Birth Conference. It depicts a couple going to see their GP because wanting to have sex at home. I have adapted and rewritten it with the untried penis scenario.

Reading an article in the press today triggered me to write this new analogy.

There was the following quote
" Why could Meghan not have a home birth? Meghan's reported decision to abandon her home birth could have been down to an number of factors, an expert claimed. Consultant obstetrician and gynaecologist Peter Bowen-Simpkins, told the Mail: "When you have your first baby you essentially have an 'untried pelvis'. "You don't know what's going to happen when the body prepares for labour and birth. "If a woman is on her second or subsequent baby and has had a normal delivery before then it's likely there wouldn't be any problem at all. "But you don't know that's going to be the case until you have your first baby."
I got very annoyed reading this, for several reasons.

First, because it's yet another example of what is wrong with the current maternity care culture in this country. It's a fear based culture, one that treats birth like an accident waiting to happen.

Second, because it's a symbol of the patriarchal culture within the maternity system. Birth is a natural physiological function for women. For a male doctor to state "she has an untried pelvis" is implying that women cannot give birth well by default.

It's a bit like saying to a man who is getting ready for his wedding night "Here's a dildo, just in case you can't get it up-no pressure"

Reading about the untried pelvis made me wonder what would happen if we told men who hadn't yet had sex that they have an "untried penis".

So I decided to write about this, just to illustrate how supportive it would feel for men if they were told this.

Now I need to give a disclaimer. I know birth and sex are different processes. I know that bad sex doesn't have the same possible consequences as a birth that goes wrong.

I've also been a doula and birth educator for long enough (I started working in this field over 10 years ago) and seen enough births to know that nothing is ever black and white, and that things can go wrong. I'm not naive. And I'm not suggesting everybody should birth at home.

I am also a paid up member of the informed choices society so I am NEVER going to push homebirth on anybody, and I'm as likely to fiercely help a woman to have an elective cesarean if it is what's right for her that I am to support a woman to birth at home despite "high risk" factors.

Also, language is important. The words we use can either inspire confidence (your labour is progressing really well) or cause anxiety and distress (you're ONLY 3cm dilated).

This is why I dislike the expression "untried pelvis" so much. Because it implies that it won't work. That we will let you "TRY". It's not very encouraging is it?

That's why I wanted to make the analogy with the untried penis.

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Women sometimes get told that they cannot give birth at home with their first baby because they have an "untried pelvis". What if we told men they couldn't have sex at home the first time because they have an "untried penis" Just imagine a young couple going to see a health professional, to discuss their plan to have sex for the first time.

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Everything You Need to Know About Delayed Cord Clamping

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Delayed cord clamping may be beneficial to your baby’s health. This guide covers everything you need to know about what it is and why to do it. Read now.

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5 Minute Pelvic Floor Release - Relax Pelvic Tension FAST!

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This handout will talk you through why movement and position is important

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System Pressures

There are many pressures in hospitals that limit caregivers from truly supporting birthing people. Too few nurses and increased charting duties limit nurses' ability to perform intermittent auscultation or to provide hands-on support for different birthing positions-especially for patients with epidurals who require extra assistance.

If you have an epidural, you may need two assistants to help you move into certain positions, which is not possible if a hospital is short-staffed on nurses, or if the nurse is supposed to be charting on the computer every five to ten minutes for medical, legal, and insurance reasons.

If hospitals were willing to invest in more hands-on care to support birthing families, we would likely see more auscultation (instead of continuous EFM) and more staff support for position changes during labor, pushing, and birth.

Many birthing people find that one of the benefits of hiring an independent doula is that the doula can team up with other family members (such as the partner) to help you push and give birth in upright positions (whether you have an epidural or not). To read the evidence on doulas, visit https://evidencebasedbirth.com/doulas

Symbolic Importance of the Hospital Bed

Hospitals often invest tens of thousands of dollars in specialized birthing beds that can be broken down to support a range of positions (from lithotomy to hands and knees to squatting). The hospital bed takes a central location and importance in the typical hospital birthing room (almost throne-like in its placement), and each bed can cost anywhere between $4,000 and $10,000 USD.

The hospital bed itself is a potent symbol of the rite of passage of having a technologically driven birth. Anthropologist Robbie Davis-Floyd, PhD, writes that "Rituals transmit their meaning through symbols. A symbol is an object, idea, or action that is loaded with cultural meaning. Instead of being analyzed intellectually, a symbol's message will be felt through the body and the emotions... Routine obstetric procedures are highly symbolic." (Davis-Floyd, p. 49).

When a birthing person puts on a hospital gown and gets into the hospital bed, this symbol conveys that they are sick and need the technology and skills of the hospital staff. Then, when the hospital bed is combined with the lithotomy position (in which the birthing person is positioned with their legs up in the air and genitals exposed for everyone to see, with the practitioner standing over them), this can be seen as a symbol of powerlessness (for the birthing person) and status/authority (for the practitioner).

The significant financial, ritual, and symbolic meaning of hospital beds may help explain why hospital staff are so insistent that deliveries (whether upright or lying down) should always take place in bed.

In contrast, births that take place at home and in freestanding birth centers provide access to a variety of props, furniture, and tools. These environments encourage upright birthing, with the purpose of facilitating physiological birth and empowering the birthing person.

In the first randomized controlled trial of its kind (still ongoing at the time we updated this article) researchers in Germany are studying changes to hospital birthing rooms that encourage upright positions and enhance relaxation and comfort (Ayerle et al. 2018). In the "intervention group," birthing people have access to a room that includes:

Bed that is absent or hidden from sight

Mattress and foam mat on the floor

Bean bag or easy chair

Foam element shaped like a birthing stool

Snack bar with table and chairs

Posters showing upright positions

Monitor showing natural sounds/music

Sign on the door requesting privacy

In the "control" group, the delivery bed has a central place in the room and is accessible from three sides. A birthing stool, birth ball, and length of fabric suspended from the ceiling (to use for support while standing/squatting) remain available as is usual in some hospitals in Germany.

The results from this study, known as the "BE-UP" trial, have not yet been published. The researchers plan to examine the effects of the birthing rooms on Cesarean rates, episiotomy rates, perineal tears, epidural use, newborn health, and maternal feelings of self-determination.

A similar study, known as the "Room4Birth" trial, is also taking place in Sweden (Berg et al. 2019).

So, what's the actual research evidence on birthing positions?

Because most researchers study birthing positions only in people without epidurals, or only in those with epidurals, we will divide the research up based on epidural use.

Without epidurals, which birthing positions are best supported by evidence?

In a systematic review and meta-analysis published by Zang et al. (2020), researchers combined 12 randomized, controlled trials with 4,314 participants who were randomly assigned to upright vs. recumbent birth.

The researchers excluded any studies that used the lithotomy position because of its known harms and increased risks. They stated, "these horizontal positions can have serious negative effects on maternal health and are not recommended by many international organizations." As a result, this review is smaller than the Cochrane review and meta-analysis by Gupta et al. (2017), which included the lithotomy position and thus had a larger number of participants.

The Zang et al. team followed the PRISMA guidelines for reviews ( https://prisma-statement.org/ ), and they included studies that had participants with low-risk pregnancies at 37-42 weeks. Participants had to be pregnant with a single baby in spontaneous labor, and they could not have an epidural.

The researchers compared upright versus recumbent positions.

They defined "upright" as walking, standing, leaning, using a birth chair, semi-sitting, squatting, and kneeling.

However, none of the included studies used semi-sitting as an upright position.

Upright birthing positions were used only in the passive pushing phase in 4 studies, only in the active pushing phase in 3 studies, and in the entire second stage in 7 studies.

The reviewers defined recumbent as lateral (side-lying), supine (lying), or semi-recumbent (lying with the head of the bed raised up).

The studies in the Zang et al. review took place in the United Kingdom (U.K.), Finland, Brazil, China, Ireland, Turkey, and South Africa, and the publication dates ranged from 1983 to 2017. Unfortunately, the risk of bias was unclear in 8 studies, and the risk of bias was high in 4 studies. Most of the studies had problems with randomization (selection bias), blinding (detection bias), and a few studies had problems with attrition (people dropping out of the study). As such, we need to take this review's findings with caution.

Zang et al. found that upright birthing positions led to:

Lower rate of instrumental delivery (forceps/vacuum use)

Shorter length of the active pushing phase (by 8 minutes on average)

A much shorter length of the active pushing phase when squatting was used (by 16 minutes on average)

Substantial decrease in the risk of severe perineal trauma (75% relative risk reduction; only 2 of the 12 studies reported on severe perineal trauma)

Higher risk of 2nd degree tears with the positions of squatting and sitting on a birth seat

No difference in blood loss of >500 mL between groups (in contrast to earlier reviews that found a higher risk of blood loss in upright groups)

No difference in the length of the entire second stage

The effect of birthing positions on episiotomy rates was unclear because the studies had a wide range of episiotomy rates. For example, some studies had episiotomy rates closer to 0% in both groups, while some studies had episiotomy rates of close to 90%. Because all the studies were so different, it wasn't possible to combine the results on episiotomy.

Some people may be surprised to see the higher risk of 2 nd degree tears with squatting or using a birth seat. But this can be explained by the fact that in these studies, the higher rate of 2 nd degree tears with upright births was exchanged for a lower rate of episiotomies. Since other researchers have found strong evidence that natural tears heal easier and are less traumatic to tissue than episiotomies (Jiang et al., 2017), a higher risk of second-degree tear in exchange for a lower risk of episiotomy is considered a good trade-off.

Previous researchers (Gupta et al., 2017) have noticed a higher risk of blood loss with upright birth, but this was not seen in the Zang et al. (2020) meta-analysis.

Other outcomes, such as pain, satisfaction, or use of Pitocin® to augment labor, were not examined in the Zang meta-analysis. However, results from individual randomized, controlled trials, have found additional benefits to upright birth.

For example, in 2017, Moraloglu et al. published a study with 102 people giving birth without epidurals in Turkey. Participants in this study were randomly assigned to push and give birth in a standing/squatting position holding onto a bar, or the lithotomy position with the head of the bed raised 45 degrees. The study showed that those who stood, then squatted down with a bar to push during contractions, had shorter second stages of labor by about 34 minutes. They also experienced less pain, were less likely to receive Pitocin® to augment labor, and had higher satisfaction with the birth experience, compared with the group that pushed and gave birth while back-lying with the head of the bed raised.

Other individual randomized trials have found that in people without epidurals, upright birthing positions lead to:

Significantly lower rates of pain (de Jong et al. 1997; Purnama et al. 2018)

Lower rates of shoulder dystocia (Zhang et al. 2017)

Lower rates of abnormal fetal heart tones (Crowley et al. 1991; de Jong et al. 1997)

Lower rates of emergency Cesarean (Zhang et al. 2017).

For people with epidurals, which birthing positions are best supported by evidence?

Epidural analgesia is common in many countries; for example, more than 60% of those giving birth to a single baby in the U.S. use epidural or spinal analgesia (ACOG, Practice Bulletin No. 177, 2017).

In 2018, Walker et al. published a Cochrane review that examined the evidence for upright vs. non-upright birthing positions among people with epidurals. However, since this review was dominated by BUMPES randomized trial (more than three-fourths of the Cochrane review participants came from this trial), I chose to write about the BUMPES trial instead of the Walker et al. Cochrane review.

The BUMPES trial on side-lying with an epidural vs. upright with an epidural

The BUMPES trial was a very large randomized, controlled trial on birthing positions carried out by a group of researchers in the U.K. called the Epidural and Position Trial Collaborative Group (2017). The researchers compared upright vs. side-lying birthing positions in first-time birthing people, all of whom had a low-dose epidural.

Between 2010 and 2014, a total of 3,236 people were enrolled in the study from 41 centers in the U.K. To be included in the study, participants had to be over the age of 16, pregnant with a single, head-down baby at 37 weeks or greater, planning to give birth vaginally, and in the second stage of labor with a low-dose epidural.

Since participants weren't randomized to upright or side-lying positions until the second stage of labor, this research doesn't apply to positioning with epidurals in the first stage of labor. It also doesn't tell us anything about the back-lying, semi-sitting, or lithotomy positions with an epidural.

The upright group was assigned to be moving on foot, standing, sitting, kneeling, or in any other upright position.

The non-upright group was assigned to side-lying with the head of the hospital bed raised up 30 degrees. Because they were all supposed to use the side-lying position, we will call this group the side-lying group.

About 80% of participants assigned to both the upright and side-lying groups were able to move around, meaning that they had true low-dose epidurals. For the most part, people used their assigned pushing positions.

The researchers found that fewer people assigned to upright birthing positions experienced spontaneous vaginal birth compared to people in the side-lying group (35% vs. 41%). Most participants in this study gave birth either with Cesarean or with vacuum/forceps. We were surprised to see such high rates of intervention in this study-the rate of vacuum/forceps births was 51%-55% and more than half (55%-59%) of people received an episiotomy-a procedure that is known to increase harms. These numbers are very high. In the U.S., for example, the overall rate of vacuum/forceps births is only around 3% (Martin et al., 2017).

It's not clear why people assigned to upright birthing positions were less likely to have spontaneous vaginal births in this study. The researchers did not find a difference between groups in rates of failure to progress or fetal distress leading to vacuum or forceps. They also did not find differences in any other health outcomes. It could be that people with low-dose epidurals have a greater chance of giving birth spontaneously when they use a side-lying position for the second stage of labor rather than an upright position. However, the findings from this study should be taken with extreme caution-the results may not apply to settings with more support for spontaneous vaginal birth (where there is less use of vacuum or forceps).

In two other randomized trials, researchers found evidence that the lithotomy position is harmful if you have an epidural.

In the first study on the lithotomy position with epidurals:

Researchers randomly assigned 199 participants giving birth at a hospital in Spain to a "traditional model of birth" or an "alternative model of birth" (Walker et al., 2012).

People assigned to the traditional model began pushing in the lithotomy position immediately after they reached ten centimeters and gave birth in the lithotomy position.

People assigned to the alternative model delayed pushing and gave birth in a specific type of side-lying position:

The alternative model group was instructed to change position every 20-30 minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push.

Hospital staff assisted them in moving into different positions like sitting, kneeling, side-lying, or hand-and-knees.

If, after 2 hours in the passive phase, the epidural prevented people from feeling an urge to push, they were asked to start pushing with each contraction.

When people in the delayed pushing group were ready to begin pushing efforts, staff assisted them into a specific side-lying position. In this position, the lower leg remained extended on the bed and the upper leg rested flexed on the stirrup. This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. The birthing person's upper body was placed in a neutral position and supported with pillows, if necessary.

Those who delayed pushing and gave birth in a side-lying position were less likely to need forceps, vacuum, or fundal pressure (20% vs. 42%) and had a higher rate of intact perineum (40% vs. 12%) compared to people who pushed immediately and delivered in a lithotomy position.

There was no difference between groups in the rate of first-, second-, or third-degree perineal tears, so the lower rate of episiotomy (21% vs. 51%) in the side-lying group accounts for the higher rate of intact perineum in that group.

In the second study on lithotomy positions with epidurals:

Researchers randomly assigned 150 birthing people in Spain to position changes every five to 30 minutes in the passive phase of the second stage of labor or to a lying down position for the entire second stage (Simarro et al., 2017).

Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position.

The people assigned to position changes during the passive phase of the second stage of labor had better outcomes than the group that was lying down for the entire second stage, even though everyone gave birth in the same back-lying position.

The group that changed positions had fewer Cesareans (1% vs. 10%) and fewer cases of vacuum/forceps (24% vs. 39%). They also experienced shorter second stages of labor (95 minutes vs. 124 minutes) and fewer episiotomies (18% vs. 31%).

In other words, evidence continues to show today that the lithotomy position is harmful and should not be used for pushing or delivery, even in with people with epidurals.

Evidence on Birth Seats (for people with and without epidurals)

Birth seats or stools have been used for thousands of years. For example, they are mentioned in the book of Exodus 1:16:

"When you serve as midwife to the Hebrew women and see them on the birthstool..."

Recently, researchers have begun exploring the effectiveness of different types of birth stools.

The Swedish Birth Seat Trial was carried out at two hospitals in Sweden between 2006 and 2009

(Thies-Lagergren, 2013). The study included 1,020 participants giving birth vaginally for the first time between 37 weeks and 41 weeks 6 days. Nearly half (45%) used epidurals for pain relief during labor. Participants were randomly assigned to either give birth on a special birthing seat called the BirthRite seat (http://bit.ly/2FBk5a8) or in any other position.

The researcher found:

The birth seat resulted in a shorter second stage of labor by an average of 6-13 minutes, as well as less use of Pitocin® for augmentation of labor.

No difference in the rate of forceps or vacuum assistance.

People who gave birth on the birth seat were at increased risk of postpartum blood loss; however, the blood loss did not influence hemoglobin levels 2-3 months postpartum.

There was no difference between the groups as far as perineal tears, but the birth seat was linked to fewer episiotomies-2% of those who gave birth on the birth seat had an episiotomy compared to 14% of those who gave birth in other positions.

The study did not find a difference in health outcomes for mothers or infants other than the increase in postpartum blood loss. However, the participants who were assigned to give birth on the birth seat were more likely to report that they felt "powerful, protected and self-confident"-which led to greater satisfaction with childbirth.

To watch a video from Evidence Based Birth® that shows different types of birthing stools, visit here: https://www.youtube.com/watch?v=gbHujklthyo

What evidence do we have on birthing positions from observational studies?

We found three observational studies on birthing positions in the second stage of labor that have been published in the last ten years-two from Sweden and one from Italy.

Swedish Study compared "women-centered" care to standard care

The first study from Sweden looked at strategies care providers can use in the second stage of labor to improve health outcomes (Edqvist et al., 2017). Midwives treated 296 first-time birthing people with a three-part protocol called "woman-centered care," and the other 301 first-time birthing people received standard care. The use of epidurals in the study was 61%.

The group that received woman-centered care had:

Spontaneous pushing (pushing efforts were not coached or directed),

Flexible sacrum birthing positions (kneeling, standing, hands-and-knees, side-lying, birth seat)

Birth of the baby's head and shoulders in two separate contractions (for more about this evidence-based method, called the "two-step delivery method," listen to EBB Podcast Episode 168)

In contrast, the midwives who practiced standard care did not receive any special instructions.

The researchers determined that the odds of second-degree tears were less likely in those who received woman-centered care compared to those who received standard care. However, we do not know which part of the 3-part protocol contributed to the lower rate of second-degree tears.

Swedish study looks at birthing positions and severe tears

Another study also from Sweden looked at the effect of delivery position on the rate of obstetric anal sphincter injury (OASIS) (Elvander et al., 2015). These severe tears, also called third- and fourth-degree perineal tears, are related to long-term complications, such as anal incontinence, sexual dysfunction, pain, and a reduced quality of life.

The researchers included more than 100,000 people from a birth record database in the study. The database included midwives' records of which position the birthing person used during the actual birth. More than half (57%) of the first-time birthing people used epidurals and 26% of those who had given birth before used epidurals. Everyone included gave birth vaginally to a single baby, and no episiotomies were used.

The researchers found that the lowest rates of severe perineal tears occurred among people who delivered in a standing position, and the highest rates of severe tears occurred among those who delivered in the lithotomy position.

Italian study looks at birthing position and urinary incontinence

In another study, researchers in Italy explored what effect birthing positions may have on urinary incontinence (Serati et al., 2016). They conducted phone interviews 12 weeks after the birth with 296 people who used an upright position to deliver and 360 people who used a back-lying or side-lying position. To assess urinary function, participants were asked questions like: How often do you leak? How much urine do you usually leak? When does the urine leak?

The survey data showed that delivering in upright positions was related to a lower episiotomy rate (30% vs. 41%) but a slightly higher rate of third- and fourth-degree perineal tears compared to delivering in the lying down position (1.35% vs. 0%). The episiotomy rate in this study was very high, so these results may not apply to low-episiotomy settings.

Importantly, these Italian researchers found that lying down delivery positions increase the risk for postpartum urinary incontinence and of stress urinary incontinence, defined as involuntary leakage on effort or exertion or sneezing or coughing. It's possible that this increase in the risk of urinary incontinence may be related to the higher rates of episiotomies with lying down positions.

In my discussions with professionals and parents around the world, I have heard that some providers may be willing to support pushing in upright positions (passive or active second stage), but few obstetricians will attend an actual birth or "delivery" in an upright position.

For example, health care workers may support someone pushing in a squatting position, but when the baby is about to emerge, they may insist the birthing person sit back in a semi-sitting or lying back position for the delivery. They may say something like, "I need you to get onto your back right now for safety reasons" or "You don't want to tear, do you? Then get on your back right now," or "Your baby is going to get stuck under your pubic bone, unless you move right now!"

In other words, it's common to be given a vague threat combined with an urgent direction. This situation can be confusing, because parents may think it is a true emergency (which is a possibility, of course), so they almost always comply... but many times it is not an emergency, and there is nothing wrong with the birth or baby.

The coercion that some providers use to get patients to lay on their back may be due to general anxiety and fear of upright birth. Since most health care workers are not trained in true upright birth, and rarely (if ever) see one, an upright birth may make them feel nervous and uncomfortable. The easiest way to relieve these feelings of discomfort is to pressure the patient to lay on their back.

The desire for some medical staff to have the delivery happen in a "controlled" manner (non-upright position) is so strong that many birthing people have shared stories with us of either being coerced or forcibly put into non-upright positions during childbirth.

In 2016, Caroline Malatesta won a landmark court case in Alabama in which she sued her hospital for malpractice and fraud. At Ms. Malatesta's birth, the hospital nurses forcibly turned her onto her back (she was in a hands-and-knees position) during the delivery and held the baby's head in for 6 minutes until the doctor could arrive, causing a severe, lifelong, maternal nerve injury. The jury awarded a $16 million verdict in Ms. Malatesta's favor, finding that forcing a birthing person into a delivery position against their will violates the nursing standard of care, especially for un-medicated or "natural" births.

The use of forcing birthing people into the care provider's preferred position is a form of obstetric violence. In their paper describing Ms. Malatesta's case in the Journal of Perinatal and Neonatal Nursing, Pascucci and Adams (2017) state:

Obstetric violence is, in its simplest form, a form of violence against women that occurs in the childbirth setting. It is an attempt to control a woman's body and decisions and may involve coercion, bullying, threats, and withdrawal of support, as well as other violations of informed consent and physical force. Obstetric violence might manifest as forcing a woman supine because that is the doctor's preferred position for birth... Forcing someone into a particular delivery position could be viewed by the courts as negligence or battery (Pascucci and Adams, 2017).

It is best practice for hospitals, obstetric providers, and nurses to support birthing people in their right to choose positions for pushing and delivery. This does not mean that providers cannot encourage certain positions (or frequent switching of positions) if they feel that they would be helpful in specific situations-but it is unethical for a provider to use coercion or force to achieve a delivery position.

Listen to Evidence Based Birth® Podcast Episode 225 with Mandy Irby, RN, about how the lithotomy position can also be considered an unethical "restraint."

In a publication by the World Health Organization (WHO) called "Care in Normal Birth," the WHO concludes that women in labor should adopt any position they like, while preferably avoiding long periods lying down (WHO, 1996). They recommend that birth attendants get training in supporting upright births, since much of the positive effect of upright birthing positions depends on the birth attendant's experience with the position and willingness to support the patient's choice of position.

In 2017, the World Health Organization also published a document called "Managing Complications in Pregnancy and Childbirth," in which they stated the health care provider should "support the woman's choice of position during labor and birth."

In the U.S., the American College of Obstetricians and Gynecologists (ACOG) has a Committee Opinion called "Approaches to Limit Intervention During Labor and Birth." In this opinion, ACOG states that for most people, "no one position needs to be mandated nor proscribed."

ACOG also states that it is normal for people in labor to assume many different positions, and that no one position has been proven best. They cite the fact that many care providers encourage a supine position during labor even though it has known adverse effects, including low maternal blood pressure and more frequent abnormal fetal heart rates. They go on to say that continuous EFM has not improved outcomes in low risk pregnancies, and that care providers should "consider training staff to monitor using a hand-held Doppler device (intermittent auscultation)...which can facilitate freedom of movement and which some women find more comfortable."

The statement concludes with a general recommendation that care providers can support frequent position changes during labor to enhance maternal comfort and promote optimal positioning of the baby if they do not hinder monitoring and there are no complications.

In 2012, three U.S. midwifery organizations -American College of Nurse Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives-created a consensus statement on supporting healthy, physiologic childbirth (U.S. Midwives, 2012). They stated that freedom of movement in labor and the woman's choice of birth position are essential to this goal.

The Royal College of Midwives (RCM) in the U.K. recommends the use of active and upright positions to assist with labor and delivery. In their guidelines, they urge midwives to be proactive in demonstrating and encouraging different positions in labor, since birthing people often "choose" to do what is expected of them, and the most common image of the laboring person is "on the bed."

Since the environment is key to freedom of movement, RCM suggests that there should be a variety of furniture and props available in the room to encourage people to try different positions: bean bags, mattresses, chairs, and birth balls. They recommend that midwives support clients with suggestions on how to remain upright even if they're in a situation that might limit mobility-such as with traditional EFM, intravenous (IV) fluids, and different medications for pain relief.

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Evidence on: Birthing Positions - Evidence Based Birth®

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This article focuses on the evidence for birthing positions in the second stage of labor. The second stage of labor begins when the cervix is completely dilated (open) and ends with the birth of the baby.

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A peanut ball can be great for resting or if you choose an epdiural.

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Abstract

Background:

Long-term delivery is an important significant issue which is associated with mortality and fetal and maternal disorders. Based on the previous studies, consumption of dates affects uterine contractions and duration of delivery processes. This study aimed to study the effect of date consumption in late pregnancy on the duration of delivery processes in nulliparous women in 2013.

Materials and Methods:

This randomized clinical trial was conducted among 182 nulliparous women 18-35 years who presented to OmAlBanin Hospital in Mashhad in 2013. The comparison has been made between 91 pregnant women who consumed 70-76 g dates daily from the 37th week of pregnancy and 91 pregnant women who did not consume dates. Data collection tool was a questionnaire and a checklist of daily dates' intake. Data were analyzed using the Statistical Package for the Social Sciences software and statistical tests - chi-square and Mann-Whitney test, and P value <0.05 was considered significant.

Results:

The average length of active phase ( P = 0.0001), length of second phase ( P = 0.0001), and third phase ( P = 0.004) in two groups had statistically significant difference. The average length of the second phase ( P = 0.03) and the third phase ( P = 0.02) in case of spontaneous start of delivery in the intervention group was significantly lower than the control group. Use of oxytocin to accelerate delivery had a significant difference between the two groups ( P < 0.001).

Conclusion:

According to the results of this study, consuming dates in late pregnancy was effective in decreasing length of labor processes and reduced the need of oxytocin for labor acceleration. Thus, it is recommended to consume dates in women without contraindications.

Introduction

Long labor is an important and significant issue, especially in developing countries as it is associated with mortality as well as fetal and maternal disorders.[ 1] Prevalence of long labor is 2.6-2.17%, which is the cause of 8% maternal deaths in developing countries.[ 2] Sixty percent of primary cesarean in the United States is attributed to the unnatural development of laboring.[ 3] Ineffective contractions of uterine are among the most common causes for unnatural development of laboring and consequently a prolonged labor, which leads to increase in level of cesarean and induction of labor.[ 1] Lack of adequate uterine contractions are influenced by different physical and mental factors. Today, scientists focus on mother's physical and mental needs including the need for energy.[ 4] In late pregnancy, as the level of prolactin increases, pregnant women feel the need of more nutrients. This energy is stored in the body and can be used at the time of delivery.[ 5]

The amount of energy needed for labor can be compared with that of aerobic exercises; it is estimated to be between 50 and 100 kcal per hour.[ 4, 5] Because smooth muscles need energy 20-400 times more than skeletal muscles, the best materials for supplying energy are fat acids, which provide muscles with more energy than glucose; therefore, storing fats is very integral in late pregnancy.[ 5] Dates are among those energizers which have lots of carbohydrates most of them include fructose, glucose, and sucrose.[ 6] Chemical composites found in dates differ depending on weather conditions, planting area, age of tree, and process of fruit growth. The mineral content differs in various types of dates; however, 15 different types of minerals have been determined in it, including potassium, calcium, chlorine, zinc, phosphorus, iron, magnesium, and sodium, together[ 7] with saturated and unsaturated fatty acids such as oleic, linoleic, and linoleic acids.[ 8] Fatty acids play an important part in making prostaglandins apart from supplying and providing energy.[ 5]

Increase in the level of prostaglandins in pregnant women causes uterine contractions during the term.[ 9] Therefore, dates can be helpful in storing energy and strengthen uterine muscles.[ 10] Dates play a part in prevention of postpartum hemorrhage,[ 6] spontaneous labor, and speeding up the delivery progress.[ 4, 8, 9] According to studies of Kordi et al. and Yusefi et al., consuming dates in late pregnancy had a role in spontaneous labor.[ 11, 12] Results of the study performed by Alkuran et al. showed that length of the latent phase of the first stage of labor was shorter in the group consuming dates, and average cervical dilation at the time of admission was significantly higher than that in the group consuming dates.[ 10] Dates affect oxytocin receptors and make uterine muscles respond better to oxytocin, resulting in more effective uterine contractions.[ 10, 13, 14] Oxytocin receptor concentration increases 200-300 times during pregnancy, especially in late pregnancy. This increase in concentration results in increase in myometrium sensitivity to oxytocin.[ 2, 5] Stimulating oxytocin receptors in central nervous system decreases anxiety followed by the initiation, progression, and acceleration of the delivery. Because of few studies conducting regarding the effect of consuming dates on the duration of delivery,[ 15] the researcher decided to study the effect of consuming dates in late pregnancy on the duration of labor stages in nulliparous women in 2013.

Materials and Methods

This randomized clinical trial (registered in the IRCT with the code of 201304072956N4) was conducted among 182 nulliparous women aged 18-35 years who went to OmAlBanin Hospital in Mashhad in 2013. Entry criteria to the study included mothers aged 18-35 years who were in their 37-38th week of pregnancy (based on the first day of the last menstruation or sonography of the first 3 months of pregnancy), singleton pregnancy with cephalic presentation, and having no medical and midwifery problems in 26-30 weeks of pregnancy. Obstetric complications, women who had elective or emergency cesarean due to fetal distress, and those who consumed dates less than 2 weeks in the intervention group were excluded from the study. Eleven individuals in the intervention and 17 individuals in the control group were excluded from the study. First, a preliminary study was carried out among 30 individuals to determine sample size. Then, sample size was measured using the formula of comparing averages with that of thr length of the first stage of labor. Considering α = 0.01 and β = 0.1 and 95% confidence coefficient, ( ) 83 individuals in each group accounting for 10% sample attrition, 91 individuals were calculated in each group. At first, 210 individuals were entered into the study, among which 28 were excluded from the study for not meeting the inclusion criteria. Finally, the study was conducted among 182 individuals. The participants were categorized in one of the two groups of dates' consumption and lack of dates' consumption in a manner that days of the week were numbered 1-6 from Saturday to Thursday and 1, 2, 3 numbers were written on one side and 4, 5, 6 were written on the other side of the paper placed in a draw bag. Then, the first paper selected was named intervention and the second one named control group in such a manner that 3 days of the week (Saturday, Sunday, and Monday) were given to the dates' group and the other 3 days (Tuesday, Wednesday, and Thursday) were given to the control group and this order was maintained till the end of the study. The mothers were required to go to the midwifery clinic on the specified day. Therefore, 91 individuals were put in the intervention and 91 were put in the control group. Data collection tool was a questionnaire (personal information, pregnancy, follow-up form- information about labor, and its development) and a checklist of daily dates' intake. Validity of the questionnaire, follow-up form, and checklist of the daily intake of dates were determined by the content validity method. These tools were provided in the form of preliminary questionnaires studying the most updated books and articles in the field of study and delivered to 10 faculty members of Mashhad University of Medical Sciences; the final tools were developed after reviewing and applying necessary suggestions and corrections. Reliability of personal and obstetric and follow-up forms was confirmed through evaluation agreement with coefficient correlation equal to 0.90. The intervention group was given 7 packs of 70-75 g (6-7) dates in the 37th week of pregnancy. The mothers were required to carry on consuming one pack (70-75 g) every day on the three so-called days. The dates used in this study were Mazafati dates of Bam whose nutritional ingredients were specified by the experiment before the start of the study. According to the results, there was 160 kcal energy in 100 g of this type of date, consisting of approximately 70% of carbohydrates, 3.5% protein, and 0.1% fat. Moreover, the amount of dates was determined according the study performed by Alkuran and Khadem under the supervision of a nutritionist.

The control group was required not to consume dates during this period and routine care was given to the participants. After teaching the onset symptoms of delivery in both the groups, mothers were required to go to the hospital at the onset of labor pains by notifying the researcher. In case labor does not continue till the end of 40 weeks of pregnancy, more time was given to both the groups until 41 weeks of pregnancy if fetal heart rate tests were normal and the intervention group was required to carry on consuming dates. If the delivery did not start until 41 weeks of pregnancy, she would be taken to the maternity clinic and the researcher would go to this place to control development of the labor and fill the information regarding the labor in related questionnaires. Then, the information was decoded and analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics) software (version 14 th), and t-test, chi-square tests, and Mann-Whitney test were performed. Moreover, P = 0.05 was considered statistically significant.

Ethical consideration

The sampling was started after approval for the study was obtained by the disciplinary committee of Mashhad university with Code 910732. After reviewing the proposal by the Ethics Committee, the objectives of the study were described to the participants and written consent was given. Sampling was started with regard to the ethical codes and confidentiality of the participants' information.

Results

The two groups were homogeneous in terms of age ( P = 0.89), body mass index ( P = 0.49), amount of calorie consumed at the start of the research ( P = 0.89), the calorie consumed at the time of reception (0.44), and the weight of the new born at birth ( P = 0.42) in such a manner that the average age in the intervention and control group was 23.51 (3.67) and 23.58 (3.73), average BMI was 27.70 (3.26) and 27.40 (2.96), average weight at the time of the birth was 3195.38 (554.80) and 3247.52 (370.30) g, respectively. Moreover, the two groups had no statistically significant difference in terms of sports activity (0.40), sexual intercourse (0.52), taking nonsteroid pain-killer drugs during pregnancy (0.11), and taking pain-killer drugs during labor (0.80).

The cervical dilatation average at the time of reception in the maternal clinic had a statistically significant difference between two groups ( P < 0. 0001) in such a manner that it was 4.05 (1.63) in the intervention group and 2.54 (1.74) in the control group. The average length of active phase and the length of second and third phases in the two groups had statistically significant difference []. The average length of the second and the third phase in case of spontaneous start of delivery in the intervention group was significantly lower than the group control; however, there was no significant difference between average length of active phase of labor in the two groups ( P = 0.24). There was no significant difference between the average length of active phase and second and third stages of labor in cases of labor induction in the intervention and control groups [].

Table 1

Table 2

Spontaneous start of labor in the intervention group was significantly more than the control group (94.50% compared to 41.30%) ( P < 0.001). Using oxytocin to speed up labor in the intervention group was less than the control group (5.50% compared to 48.70%) ( P < 0.001).

Discussion

General result of the study showed that consuming dates in late pregnancy was effective in the duration of nulliparous labor and shortened the length of active phase, as well as the second and the third stages of the labor compared to the control group. Moreover, average cervical dilution at the time of reception, being the most important factor to estimate development of the labor in women who consumed dates, was significantly more than the women who did not. It appears that dates helps in more effective uterine contractions by better preparation of the cervix as well as saving energy, needing less time for complete dilution of the cervix, and shortening the labor.[ 10] Carbohydrates are considered to be an important source of energy in the body having the highest digestibility among food groups.[ 16] Dates are nutritional fruits made mostly of simple sugars.[ 6] Most of the energy used during delivery is supplied using oxidative pathway. Maternal glucose is the most important source of energy and the physiologic need to glucose during the labor is 10 g per hour.[ 4, 16] Adequate sources of energy are needed to maintain physical power of the person during labor activity, and consuming dates in late pregnancy and during labor can be helpful in supplying and saving energy.[ 4, 10, 11] Dates have a significant importance in saving energy andovercoming fatigue and hunger due to the high level of calories.[ 12] Moreover, tannin found in dates plays an important part in contractions of smooth muscles of the cervix.[ 13, 17] Kordi et al. (2008) showed that the length of the active stage and second stage of the labor in nulliparous women consuming date honey syrup during the labor was significantly shorter than the placebo group and usual care. In their study, amount of date consumption was equal to 132 g date honey syrup during the labor; however, consuming dates did not continue in our study by the start of labor.[ 4] Using oxytocin to speed up labor in the intervention group was less than the control group in our study. Alkuran is his study showed that date is effective in oxytocin receptors and causes more effective cervical dilutions; therefore, the need for oxytocin and prostaglandins for induction and speeding up labor in women consuming dates is less in late pregnancy.[ 10] The effect of oxytocin in developing labor, delivery, and cervix recovery to the previous state before childbirth and breastfeeding has been approved.[ 4, 10, 11, 13, 14] Oxytocin receptors' stimulation in the central nervous system decreases stress and accelerates the labor.[ 15] Oxytocin can directly stimulate oxytocin receptors or causes cervical dilutions indirectly by stimulating the production of prostaglandins in decidua and amniotic cells.[ 9] In a study reported by Alkura et al. (2011) on two groups, one consuming dates and the other not consuming dates, length of the latent phase was shorter in the dates-consuming group; however, length of active phase and the length of the second and third stages of the labor had no significance difference with the control group which differs with the results of our study.[ 10]

The reason for this was probably longer period of consuming dates and women accepting to have cervical dilutions in the maternal clinic in our study. Results of this study showed that, in case of labor induction in women consuming dates, length of labor stages become shorter but it is not statistically significant, which is because of small number of samples and the need to study with the sample size suffices. In a study done by Khadem et al. (2007) regarding the effect of consuming dates with oxytocin on the prevention of postpartum hemorrhage, the results showed that dates had semi-oxytocin effect, increased uterine sensitivity, stimulated cervical contractions, and decreased postpartum hemorrhage. Nutritional and medical properties of dates decrease postpartum hemorrhage and can be a suitable alternative for oxytocin.[ 13] Moreover, the amount of required energy during the labor was estimated to be 50-100 kcal per hour;[ 4, 5] glucose content of dates is an important source of energy supply in the body and the best nutritional material for cervical dilutions.[ 8, 10] Sherbovastav et al. (2009) showed that serum containing dextrose shortens labor duration by 20%, and this decrease is not accompanied by fetal and maternal complications.[ 18] Rahmani Beilandi et al. (1388) in their study concluded that women consumed nutritious carbohydrates such as orange juice and dates had a shorter second stage of delivery than those who did not eat anything.[ 19] Using carbohydrates during pregnancy supplied patient's energy for the delivery due to increase in energy conduits such as adenosine triphosphate; moreover, it prevents from creating harmful metabolites created during anaerobic cycle, and in case of no access to carbohydrates and negatively, affect the strength of cervical dilutions and shortens labor term.[ 16, 19]

Among the strong aspects of this study one was using a natural and accessible material for speeding and shortening of the labor. However, this study has some limitations including there was no possibility of double-blinding the study, and the accurate complete control of the pregnant mothers' regiment was beyond the researcher control. Moreover, the amount of effective dose of date was unknown, which was partly specified according to previous studies as well as comments of the dietitian. Duration of consuming dates to affect labor and the exact time of starting to consume it was not completely specified. In this article, the minimum amount of time to consume date for having optimized effect was considered to be 2 weeks with the comments of dietitian. Other limitations of this study were the lack of examination of the cervix before the intervention.

Conclusion

According to the results of this study, consuming dates in late pregnancy was effective in decreasing the length of labor processes and reduceing the need to oxytocin for labor acceleration. Moreover, it is recommended to consume dates in women without contraindications.

Financial support and sponsorship

Mashhad University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

This study is part of a research thesis proposal approved by the Mashhad University of Medical Sciences with Project No. 910732. The authors would like to thank all the mothers who participated in this study.

References

1. Gabbe SG, Neibyl JR, Simpson JL. Obstetrics normal and problem pregnancies. 5th ed. New York: Churchill Livingston; 2014. pp. 770-1. [ Google Scholar]

2. Gray Cuningham F, Leven O, Steven L, John C, Dwight J, Cathrine YW. Obstetrics. 23th ed. New York: McGraw Hill; 2010. pp. 1081-4. [ Google Scholar]

7. Vaezi S. Date Tree of life. Tehran: Azineh G0lmehr; 2004. pp. 75-83. [ Google Scholar]

9. Speroff L, Fritz MA. Clinical gynaecologic endocrinology and infertility. New York: Lippincott Williams & Wilkins; 2005. [ Google Scholar]

17. Hamood N. Mashhad: Mashhad University of Medical Science; 2008. Comparing the efficacy of dates and oxytocin in the management of postpartum hemorrhage.[Thesis in Persian] [ Google Scholar]

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Effect of Dates in Late Pregnancy on the Duration of Labor in Nulliparous Women

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Long-term delivery is an important significant issue which is associated with mortality and fetal and maternal disorders. Based on the previous studies, consumption of dates affects uterine contractions and duration of delivery processes. This study aimed to study the effect of date consumption in late pregnancy on the duration of delivery processes in nulliparous women in 2013.