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THE INSTANT SUNDAY TIMES BESTSELLER

'Few books are as urgent as Shon Faye's debut ... Faye has hope for the future - and maybe so should we'Independent
'Unsparing, important and weighty ... a vitally needed antidote' Observer
'A moving and impressively comprehensive overview of trans life' Vogue
Trans people in Britain today have become a culture war 'issue'. Despite making up less than one per cent of the country's population, they are the subjects of a toxic and increasingly polarized 'debate' which generates reliable controversy for newspapers and talk shows. This media frenzy conceals a simple fact: that we are having the wrong conversation, a conversation in which trans people themselves are reduced to a talking point and denied a meaningful voice.

In this powerful new book, Shon Faye reclaims the idea of the 'transgender issue' to uncover the reality of what it means to be trans in a transphobic society. In doing so, she provides a compelling, wide-ranging analysis of trans lives from youth to old age, exploring work, family, housing, healthcare, the prison system and trans participation in the LGBTQ+ and feminist communities, in contemporary Britain and beyond.

The Transgender Issue is a landmark work that signals the beginning of a new, healthier conversation about trans life. It is a manifesto for change, and a call for justice and solidarity between all marginalized people and minorities. Trans liberation, as Faye sees it, goes to the root of what our society is and what it could be; it offers the possibility of a more just, free and joyful world for all of us.

'Fundamentally not a culture-war book. It operates outside the narrow coverage of trans people in the mainstream, and lays bare the inarguable facts' New Statesman
'Monumental and utterly convincing - crystal clear in its understanding of how the world should be' Judith Butler

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THE INSTANT SUNDAY TIMES BESTSELLER 'Few books are as urgent as Shon Faye's debut ... Faye has hope for the future - and maybe so should we' Independent 'Unsparing, important and weighty ... a vitally needed antidote' Observer 'A moving and impressively comprehensive overview of trans life' Vogue Trans people in Britain today have become a culture war 'issue'.

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Pride in Birth brings together for the first time the academic and medical research about LGBTQ+ people's experiences of conception, pregnancy, birth, and the postnatal period. In each episode, Mari will talk to a different researcher, finding out what question about LGBTQ+ pregnancy they were asking, how they went about finding answers, and what they discovered. Guests include professors, obstetricians, midwives, psychiatrists and academic researchers. The podcast will explain some of the issues LGBTQ+ people face when they start a family, helping to reduce isolation amongst LGBT+ new and expectant parents, and aiming to help those caring for them to improve the services they provide.

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Pride in Birth brings together for the first time the academic and medical research about LGBTQ+ people's experiences of conception, pregnancy, birth, and the postnatal period. In each episode, Mari will talk to a different researcher, finding out what question about LGBTQ+ pregnancy they were asking, how they went about finding answers, and what they discovered.

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Welcome to my Anti-D information hub, which offers links to all of the Anti-D resources on my website.

This topic is one that I have been researching for many years and I have written a book on this topic, Anti-D Explained.

Anti-D is a medicine made from blood. It is offered to rhesus negative women who may have been exposed to rhesus positive blood. The most likely time for this to happen is during birth. Anti-D is offered at several points during pregnancy and after birth. It is given to prevent the woman becoming sensitised to the rhesus factor, which may cause a problem for any future rhesus positive babies.

Anti-D Explained explains the science behind this area, the history of Anti-D and the research studies that have been carried out to evaluate its effectiveness. She looks at the wider consequences and side effects. Sara takes the reader on a journey through the research, explaining what we know and highlighting the gaps in our knowledge.

My articles and informational blog posts on this site (which are all freely available) include:

Anti-D information: getting started

9 things you might not know about Anti-D...

How to save 40,000 women a year from having unnecessary Anti-D...

Anti-D in pregnancy: how we haven't moved on...

Yet more evidence to help women avoid unnecessary anti-D

More evidence on targeting anti-D

Here's more on my book:

You can hear me chatting about Anti-D and my book on a podcast which is linked here:

Sara Wickham is in The Midwives' Cauldron!

An article I wrote on this quite a few years ago now:

Anti-D: exploring midwifery knowledge

And there's loads more in my book on this topic, which was written to help parents and professionals to understand the science, the issues and the evidence relating to Anti-D.

# data[].attributes.attachment_link.description
Welcome to my Anti-D information hub, which offers links to all of the Anti-D resources on my website. This topic is one that I have been researching for many years and I have written a book on this topic, Anti-D Explained. Anti-D is a medicine made from blood.

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How an epidural is given during childbirth

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Harrogate and District NHS Foundation Trust

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Sterile water injections for relief of labour pain (the SATURN trial): study protocol for a randomised controlled trial - Trials

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Trial design

This will be a pragmatic randomised placebo-controlled superiority trial specifically designed to provide evidence of the efficacy of water injections to relieve abdominal labour pain. Following provision of informed consent participants will be randomised to receive either water injections (intervention) or normal saline injections (control). For both groups pre-injection preparation with a vapocoolant spray will occur. The participant flow is demonstrated in Fig. 1.

Study setting

The trial will be conducted at a tertiary maternity unit in Brisbane Australia providing labour and birth care for approximately 5000 women annually. The research site provides both birth-centre and standard labour and birth care.

Study population and recruitment

We plan to recruit and consent provisionally eligible women in the late antenatal period (36-37 weeks). Whilst this may include women who are either ineligible at the onset of labour, or remain eligible but decline participation, this strategy will reduce the need to rely on clinical staff, in the birth suite and birth centre, to identify, screen, provide participant information and complete consent documentation whilst also providing care. This also minimises the ethical issue of recruiting and consenting in labour when pain and/or effect of medications may impact on the woman's capacity to consent to participation in research. Women may also be recruited upon presentation to the Birth Centre or Birth Suite in early labour.

The study site offers a number of models providing care to women likely to meet the inclusion criteria. These are broadly defined as Midwifery and General Practitioner (GP) Shared Care. Midwifery care models are provided by the Birth Centre, Midwifery Group Practices (MGP). Women attending GP shared care all return at 36 weeks gestation, providing an opportunity to discuss the trial and participation. Women attending Birth Centre and MGP antenatal clinics will be approached during their 36-37 week visit. Consent processes will be undertaken by the Research Midwives or in their absence, a midwife who is not providing direct care to the woman.

In the event that COVID-19 restrictions prevent a face to face consent process Potential participants will be provisionally approached during the routine antenatal video conference and asked if they are interested in discussing participation in the trial with a research midwife. Interested participants will be asked for contact details (email address, mobile phone number) to arrange a suitable time for a discussion regarding the trial and potential participation using their preferred video conferencing format (e.g. FaceTime, Zoom, Teams). A link to the SATURN Trial Participant Information and e-Consent form will be sent to the potential participant so they can review the trial information and consider any questions prior to the discussion.

The e-Consent form requires a three step verification process consisting of i) indicating 'yes' to verify statements that appear on the consent form; ii) drawing a signature on the screen either with a mouse or device touch screen; iii) final declaration that the participant is aware that submitting the form with the signature is equivalent to providing a signed consent form. The participants are then able to download a copy of the completed and signed SATURN trial Participant Information and e-Consent form and a pdf copy is sent to a designated email address.

This trial does not involve the collection of biological specimens.

Eligibility criteria

Eligibility criteria consists of ≥16 years of age, singleton cephalic (head down) pregnancy, ≥ 37 weeks gestation, spontaneous or induced labour, no serious concurrent medical conditions (pre-eclampsia, coagulopathy, diabetes other than diet controlled), cognitively capable of providing consent, able to read and understand instructions written in English. Upon admission to the birth suite randomisation will occur when the participant's self-assessment of labour pain ≥60 mm (Visual Analogue Scale [VAS] 0-100 mm, 0 = no pain 100 = worst conceivable pain), and requesting pain relief.

Randomisation and blinding

Randomisation schedules will be prepared by a statistician independent of the study using computer-generated pseudo-random numbers, using varying block sizes. Identical ampoules of either normal saline or sterile water will be pre-prepared by the study site pharmacy and packed in opaque black plastic packets and arranged based on the allocation schedule. Following confirmation of consent two midwives will remove the next ampoule in sequence and administer the injections. Normal saline for injection 0.9% will be used as the placebo solution. Normal saline is an active placebo resulting in some minor injection discomfort and some degree of analgesia, it has been used successfully in previous placebo controlled trials [ 15, 25]. Outcome assessment will be undertaking by the midwife administering the injections. The use of the vapocoolant in both the intervention and control arms will reduce the chance of participant and outcome assessor unbinding as all women will experience cooling effect of the vapocoolant. The data analysis will be blinded to the allocated group.

Interventions

Participants in the intervention groups will receive intradermal injections of 0.1-0.3 ml of sterile water into six anatomical points on the abdomen (Fig. 2). The volume required to be injected is based on the visual estimation of the resulting blister or 'bleb'. If the needle is inserted beyond the intradermal layer the bleb does not occur and the needle may require repositioning to achieve the correct anatomical depth. The location of the injections is based on a previous RCT of water injections versus acupuncture and early studies that used intradermal injections of local anaesthetic into the abdomen to relieve pain in labour [ 22, 26, 27]. These studies suggested that injections given in a line extending medially from the fundus to the suprapubic area and extending laterally from the suprapubic region will produce an effective analgesic response. As the experience and location of contraction pain varies considerably the precise location and number of injections may vary based on the areas of greatest discomfort indicated by the woman. Otherwise there will be no special criteria for modifying the allocated interventions. The injection procedure will be ceased at the request of the participant. Up to three repeat courses of injections will be provided for women who request them.

Data items such as location of injections, VAS and duration of effect will be collected for the initial and repeat injections. To improve adherence to study protocols all midwives administering water injections will be credentialed in this technique using a competency based assessment that was used successfully in our previous trials [ 22, 28]. Midwives will indicate the number and location of the injections given on the data collection form which will be monitored by the research officers for adherence to the protocol.

Participants in the control group will receive intradermal injections of 0.1-0.3 ml of normal saline 0.9% for injection into the abdomen as previously described. All other components of the administration will be the same as the intervention group.

Both groups will also receive skin preparation immediately prior to the injections using the vapocoolant spray PainEase® manufactured by Gebauer. PainEase® spray contains 1,1,1,3,3-Pentafluoropropane and 1,1,1,2-Tetrafluoroethane which are non-flammable and unlike ethyl chloride are not absorbed through the skin and therefore safe to use in pregnancy. The cooling effect occurs through the rapid evaporation. PainEase is registered with the Australian Therapeutic Goods Administration as a vapocoolant topical anaesthetic available to the general public. The injection points will be sprayed with PainEase® spray at a distance of 12 cms from skin for a period of 5 to 8 s immediately prior to administering the injections.

Implementing the injections of sterile water of saline will not require alteration to usual care pathways. Participants in both arms will have access to any form of standard care including combinations of currently available pharmacological and non-pharmacological options.

Provisions for post-trial care There is no anticipated harm and compensation for trial participation. In the event that participants experience harm as a result of participation they will be able to apply for compensation through trial insurance provided by the sponsor.

Outcomes

The primary outcome for the trial is the mean difference in VAS scores of labour pain between intervention and control groups at 30 min following the administration of the injections. Secondary outcomes include the number of women experiencing an at least 30% or 50% reduction in pain following the injections. This is the measure of analgesic effectiveness recommended in the Cochrane Review of water injections for back pain in labour [ 29]. Other secondary outcomes are detailed in Table 1.

Table 1 Schedule of enrolment, interventions and assessments

Postnatal survey

Following birth all participating women will be asked to complete an electronic survey of their experiences of the injections and spray they received in the context of their labour and birth.

The survey is based on versions used in our previous studies and measures levels of satisfaction with pain relief, relaxation, likelihood to use in a subsequent labour and recommend to other women, most positive and negative aspects of the trial experience [ 15]. Survey data will be identifiable only through the allocated study participant code to enable matching with the allocated group in the clinical trial.

Participant retention and completion of follow-up

As the primary and clinical outcomes data is collected prior to or at birth loss to follow-up is expected to be minimal. Therefore, there are no specific plans to promote participant retention beyond this timeframe. Reasons for discontinuing the injections or declining further rounds of injections (i.e. birth, progress to use of epidural, other maternal reason, other fetal reason (e.g. abnormal CTG)) will be collected by the midwife on the data collection form. For women who remain in hospital following their birth the survey will be completed on a tablet device. For those women opting for early discharge or discharged on weekends, a link to the survey will be emailed with one follow up contact from a research assistant within 2 weeks.

Sample size

We have calculated the sample size based on the recommended minimal clinically significant reduction in VAS scores: 10 mm difference on a 100 mm VAS score between intervention and placebo [ 30]. To demonstrate a 10 mm reduction (SD 20 mm) in VAS scores with 80% power and 0.05 significance (two-sided) would require 64 participants per group. Based on previous studies [ 15] we estimate an attrition of 20% due primarily to women giving birth or requesting epidural analgesia prior to the measurement of the primary outcome. The total sample size required would be 154 participants, 77 per trial group.

COVID-19 safe data collection

We have designed a method of data collection that is both COVID-19 safe and compatible with the realities of providing care during labour and birth. Data will be entered directly into a REDCap database using an iPad specifically configured with the REDCap mobile application for the trial. Participants will carry a card that contains a unique study number that once entered will link to an existing database entry. Following randomisation the attending midwife will enter minimal required data (e.g. allocation code, results of most recent vaginal examination). The iPad will then be placed in a waterproof protective sleeve that will allow the woman to use touch screen 'sliders' to indicate their level of pre-treatment, injection and post-treatment on a 100 mm VAS scale. The use of digital VAS has been validated against paper versions [ 31]. The protective sleeve will prevent device contamination from body fluids, shower and bath water and can be disposed of following data entry. Direct data entry will reduce data transcription errors contributing to trial fidelity. Each midwife will have a unique code to identify them as responsible for data entry in keeping with Good Clinical Practice (GCP) principles. A horizontal VAS is used to measure the primary outcome, the experience of self-reported pain scores. The VAS is sensitive to pain intensity, validated for use in research and most individuals have no difficulties using it [ 32]. Demographic and clinical data will be extracted from the research sites perinatal database.

Data management

Data entry, both paper and electronic, will be stored and maintained at the University of Queensland as specified by the relevant UQ Policies and Procedures, specifically: 4.20.06 Research Data Management, 6.40.01 Information Management Policy. Paper files will be stored within a locked cabinet with a locked office with only relevant research team members provided with access. Electronic files will be stored on a secure password protected network with access restricted to relevant research team members. Data sharing arrangements will specify transfer of required data using secure password protected files and file transfer platforms or restricted access to cloud based datasets (REDcap). The final dataset will only be accessible to investigators participating in the data analysis as specified within the trial agreements.

Data analysis

All women who underwent randomisation and for whom primary outcome data is available will be analysed in their allocated treatment groups regardless of the intervention received (i.e. intention to treat). Randomisation should ensure that any baseline differences between groups occur by chance. To control for cluster effect repeated measurement, a linear mixed-model analysis will be conducted to investigate the difference in mean VAS score pre and post intervention. Missing VAS data will be addressed through imputation (last observation carried forward) A sensitivity analysis will be conducted following imputation to assess any effect on findings. Clinical data will be analysed on an available case basis with numbers of participants with missing data presented in the results tables. Categorical data will be analysed with chi-squared tests and non-repeated continuous variables will be analysed with t-tests if normally distributed or Mann-Whitney U test if non-normally distributed. Additional multivariable analysis will be employed if baseline differences are noted between the two groups. Treatment effects will be presented as mean difference or relative risks with 95% confidence intervals. All study outcomes will be analysed using a two-sided P value of < 0.05 to indicate statistical significance. We do not plan to undertake any subgroup analysis or interim analysis.

For the postnatal survey data descriptive statistics will be calculated for all variables, including mean, median, standard deviation, range, and percentages as appropriate. Free text responses will be analysed thematically.

Economic analysis

A cost-effectiveness analysis will be undertaken to compare costs and outcomes of between intervention and placebo groups from the perspective of the health system. The approach to identification, measurement and valuing resource use will follow a similar approach to that which we have used in previous studies [ 15]. Information about resource use and costs will be collected at the research site. In the case of the intervention, resources to be identified and measured will include those associated with the establishment of the intervention (staff training, development of educational resources and credentialing) and staff time required for administration. Costs will be allocated to the relevant resource items using appropriate values. For example, staff time will be costed using hourly award rates plus on-costs; and the costs of length of stay and complications from admission to discharge of hospital will be estimated using appropriate Diagnostic Related Groups. The outcome for the economic evaluation is VAS pain score difference between two groups. The incremental cost-effectiveness ratio will be calculated and the cost-effectiveness acceptability curve will be graphed to summarise the uncertainty of cost-effectiveness according to different willingness to pay.

Monitoring and reporting of risks

Standard Operational Procedures (SOPs) will be developed for risk management and reporting based on those used in previous clinical trials [ 15]. The SOPs will detail role responsibilities and processes for risk reporting and be reviewed and approved by a Data Safety Monitoring Board (DSMB) and trial Steering Committee. The DSMB members consist of an Obstetrician, midwife, statistician, and a consumer representative and provide independent oversight of the trial. The Steering Committee will consist of the Chief Investigators and Trial Manager and convene every 2 weeks. Each SOP will define and stratify any potential risk according to the University of Queensland Risk Level Calculator, which assesses the 'likelihood' versus the 'consequences' of risk and thereby assigns ratings from 1 = low to 5 = very high. The SOPs will also outline the standardised response and reporting procedure per risk level. Emergency code breaks for trial allocation will be available 24/7 if required. All adverse events will be reported and actioned immediately. The DSMB will manage the Risk Register, and recommend necessary modifications or termination of the trial. The DSMB will meet quarterly, or in response to serious adverse events and may undertake audits of trial conduct. Code breaking (unblinding) is possible in the event of a serious unexpected adverse event that requires identification of the allocated intervention to progress treatment. A sealed envelope containing the allocation will be held onsite in a secure location and accessible 24 h a day. Annual reports on trial progress will be provided to the Human Research Ethics Committee (HREC). The HREC will also be notified of any serious adverse events.

Dissemination of findings

The results will be reported in conferences or peer-reviewed journals. The results will also be shared with participants, healthcare professionals and the public through lectures or science handbooks.

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Sterile water injections for relief of labour pain (the SATURN trial): study protocol for a randomised controlled trial - Trials

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Background Up to 80% of women use some form of pharmacological analgesia during labour and birth. The side effects of pharmacological agents are often incompatible with the concurrent use of non-pharmacological pain relieving strategies, such as water immersion, ambulation and upright positioning, or may have negative effects on both the mother and fetus.

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The effect of evening primrose oil on cervical ripening and birth outcomes: A systematic review and meta-analysis

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Heliyon. 2023 Feb; 9(2): e13414.

Abstract

Background and purpose

The results of various studies on the effect of evening primrose oil (EPO) on cervical ripening are controversial. The purpose of this systematic review and meta-analysis was to assess the effect of EPO on cervical ripening and birth outcomes.

Materials and methods

The Cochrane Library, Embase, PubMed, Scopus, Web of Science and Persian databases were searched for studies published from the inception of the databases up to February 2021 (search updated in May 2022). Full-text articles published in English or other languages, randomized controlled trials, and quasi experimental studies with control group were included. Studies published in form of conference proceedings, and those whose full texts were not available, as well as studies with control groups receiving other treatments for cervical ripening, and those in which the intervention group received drugs besides EPO were all excluded. The Cochrane handbook was used to determine the risk of bias of the included studies. All data were analyzed using Review Manager 5.4 and reported in forest plots.

Results

Seven trials involving 920 women were included in the meta-analysis. In five studies, including 652 participants, cervical ripening was evaluated using Bishop score. The use of EPO was found to significantly improved Bishop score (MD = 3.23; 95% CI: 3.17, 3.29). The meta-analysis showed no significant differences between two comparison groups in terms of 1-min Apgar score and length of the second stage of labor. However, the two groups were significantly different in terms of their 5-min Apgar score and the time interval between administration of EPO and birth. Based on subgroup analysis by route of administration, both vaginal and oral use of EPO increased Bishop score significantly in the intervention group compared to the placebo group.

Conclusion

This study showed that using EPO in term and post-term pregnant women was clinically effective in improving their Bishop score.

Keywords: Bishop score, Cervical ripening, Evening primrose oil, Systematic review

1. Introduction

The progressive process of cervical ripening commences in the first trimester of pregnancy and continues until term [ 1]. An unripe cervix increases the risk of caesarean section and prolonged labor [ 2]. Prolonged duration of second stage has been associated with some maternal and neonatal morbidities such as third and fourth-degree tears, post-partum hemorrhage, low Apgar scores and sepsis [ 3]. In high-risk pregnancies, when the continuation of pregnancy is dangerous for the mother and baby, induction of labor (IOL) is one of the measures taken to reduce maternal and infant mortality [ 4, 5]. Cervical ripening is the most important factor in the success of IOL and increases the likelihood of vaginal birth [ 6, 7]. The pre-induction 'favorability' of the cervix is assessed by the Bishop score, which is a standard method for the prediction of the duration and outcome of induced labor [ 8]. The Bishop Scoring system was first described by Bishop in 1964 and is based on assessing multiple items (the position, consistency, effacement, and dilatation of the cervix, and the fetal station) [ 9]. A score below six is indicative of a reduced success [ 3] of vaginal birth [ 10]. Numerous approaches have so far been suggested for cervical ripening and labor induction, which are divided in two groups of mechanical and medical. Mechanical methods include a trans-cervical catheter, hygroscopic dilators and stripping, whereas medical methods consist of some agents such as prostaglandins E1 and E2. Using mechanical methods may lead to increased caesarean sections, uterine infections and unnecessary vaginal examinations [ 11]. Misoprostol (prostaglandin E1), which is widely used for induction of labor, is associated with maternal and fetal complications such as diarrhea, abdominal pain, hyperthermia and fetal tachysystole [[12], [13], [14]]. Hence, given the maternal and neonatal adverse effects associated with pharmaceutical induction methods, there has always been a concern for midwives and obstetricians in achieving effective low-risk interventions [ 9].

In addition to the methods described above, there are some traditional methods such as different forms of herbal medicines, which are used for preparing the cervix and accelerating childbirth [ 11]. Using such medicines for cervical ripening is accompanied with many benefits, such as decreased number of post-term pregnancies, and less need for elective induction, and increased rate of successful induction [ 15]. An example of such herbs is evening primrose oil (EPO), which is used by some health providers for cervical ripening and labor initiation [ 16]. EPO is recommended in some midwifery literatures as a cure for post-dates pregnancy, and more than 60% of US nurse-midwives prescribe it in late pregnancy [ 17, 18]. It is also the most common herbal remedy for cervical ripening used by certified midwives in Iran [ 19].

Evening primrose, scientifically known as Oenothera Biennis belongs to the Onagraceae family [ 20]. In addition to its use as a treatment for some inflammatory diseases such as rheumatoid arthritis, evening primrose is used for managing women's health issues, including mastalgia, premenstrual and menopausal symptoms, and labor induction or augmentation [ 21]. The therapeutic effect of primrose is attributed to the oil extracted from its seeds, which comprises mainly of linoleic acid (60%-65%), gamma-linolenic acid (7%-14%), oleic, palmitic, and stearic acids [ 22, 23]. Although EPO is a product most frequently used by health providers, its effectiveness in cervical preparation and shortening the duration of labor has been a controversial topic in literature. According to a quasi-experimental study by Dove et al., oral administration of EPO from 37 weeks of gestation till birth, had no effect on reducing the duration of pregnancy or length of labor [ 17]. Investigating the effectiveness of EPO vaginal suppositories on cervical readiness of term pregnancy, Nonette et al., found a positive effect of EPO on Bishop score [ 24]. Also, a randomized controlled trial on 71 pregnant women with full-term pregnancies showed that daily consumption of three oral capsules of EPO for one week could increase the Bishop score and cervical effacement [ 25]. The greater number of reviewed articles and outcomes are the distinguishing feature of this review from the recent systematic reviews. Furthermore with different results of two prior systematic reviews, we cannot draw a definite conclusion about the effect of EPO on cervical ripening. Therefore, this systematic review and meta-analysis was designed with the aim of assessing the effect of EPO on cervical ripening and birth outcomes.

2. Materials and Methods

2.1. Study registration

This systematic review and meta-analysis followed the methodology consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA2020) (Supplementary material). The protocol of this systematic review and meta-analysis was registered in PROSPERO with the reference number of CRD42021230488.

2.2. Search strategies

We searched for published studies in the following databases: The Cochrane Central Register of Controlled Trials (CENTRAL), Embase, PubMed, Medline, Scopus, Web of Science and Persian databases (Magiran, SID, IRCT.ir) from database inception up to March 2021 (search was updated in May 2022). Some of the search keywords used were: "evening primrose oil" AND "Bishop score" OR "cervical ripening" OR "cervix preparation" OR "labor induction" AND "prolonged pregnancy".

2.3. Inclusion and exclusion criteria

2.3.1. Types of included studies

We included the following studies: a) full-text articles published in English or other languages, b) randomized controlled trials, c) quasi experimental studies with control groups. Studies published in form of conference proceedings and those whose full texts were not available, as well as studies with control groups receiving other treatments for cervical ripening, and those in which the intervention group received drugs besides EPO were all excluded. We also excluded studies on the effect of EPO on other diseases.

2.3.2. Types of participants

Women who were nullipara with term or post term pregnancy were included.

2.3.3. Types of intervention

2.3.3.1. Experimental intervention

Studies using EPO alone were included.

2.3.3.2. Control intervention

Studies in which the control groups received placebo were included.

2.4. Types of outcome measures

2.4.1. Primary outcomes

Improvement of Bishop Score

Length of the second stage of labor

The time interval between primrose administration and childbirth

2.4.2. Secondary outcomes

One and 5-min Apgar scores

Adverse effects of EPO administration

2.5. Data collection and quality assessment

2.5.1. Literature selection and data extraction

The search was carried out by SS and MC. Two review authors (SS and MK) independently screened titles and abstracts of all searched studies as well as their full texts using the Covidence software. Possible conflicts between authors, were resolved by discussion. When two reviewers were unable to reach a consensus, the conflict was resolved by a third party (PA or SJ). For data extraction, we designed a form according to the data extraction form recommended by the Pregnancy and Childbirth Cochrane Group. Two review authors (SS and MK) independently extracted information from the included studies. The following pieces of information were extracted: study design (method), participants, intervention, risk of bias, inclusion and exclusion criteria, Bishop score, length of labor, and outcomes of the pregnancy.

2.5.2. Assessment of risk of bias and quality of the included studies

Two review authors (SS and MK) used the Cochrane Collaboration's Tool for assessing risk of bias in randomized trials. They assessed the risk of bias for each study independently and in cases of disagreement, they consulted a third person (PA). The following domains of risk of bias (ROB) were assessed for each trial: random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other biases. Each potential risk of bias was graded as high, low, or unclear.

Studies were qualified using GRADE (The Grades of Recommendation, Assessment, Development and Evaluation Working Group). Table 2 .

Table 2

Outcomes

Anticipated absolute effects* (95% CI)

№ of participants (studies)

Certainty of the evidence (GRADE)

Comments

Risk with Placebo

Risk with Evening primrose

Bishop score

The mean bishop score ranged from 3- 7

MD 1.8 higher (0.32 higher to 3.28 higher)

652 (5 RCTs)

⨁⨁⨁◯ Moderate a

One-minute Apgar score

The mean 1-min Apgar score ranged from 8- 9

MD 0.08 lower (0.22 lower to 0.05 higher)

449 (4 RCTs)

⨁⨁◯◯ Low b

Five-minute Apgar score

The mean 5-min Apgar score ranged from 9- 10

MD 0.32 higher (0.24 lower to 0.89 higher)

449 (4 RCTs)

⨁⨁◯◯ Low b

2.6. Statistical analysis

2.6.1. Strategy for data synthesis

Mean differences (MD) with 95% confidence intervals (95% CI) were calculated to assess the differences between intervention and control groups in terms of Bishop scores, length of the second stage of labor, the time interval between primrose administration and birth, and Apgar score one and 5 min after birth. Forest plots were used to demonstrate effect sizes and 95% CI. Heterogeneity among the included studies was assessed by I ² statistics. By default, we used a fixed-effect model for all pooled studies.

According to the primary results of heterogeneity, if I ²>40%, a random-effect model was used to be compared with the fixed-effect model. We also conducted a sensitivity analysis to explore the potential sources of heterogeneity if and when the heterogeneity across studies was statistically significant. Sensitivity analyses were carried out by sequentially omitting one single study each time to test the robustness of uncertainty in the meta-analysis. All data were analyzed using Review Manager (Rev- Man 5.4). The significance level was set ≤0.05.

We carried out sub-group analysis by route of administration (vaginal versus oral rout of administration).

2.6.2. Dealing with missing data

After gathering missing data, incomplete information, or data errors, we asked the corresponding author via email or telephone for the correct information.

3. Results

3.1. Literature search

A flow diagram of the included and excluded studies is shown in Fig. 1 . The database searches identified 1028 records. After removing the duplicates (n = 440), two reviewers (SS and MK) independently screened the titles and abstracts for potentially relevant studies (n = 588), and 561 studies were not relevant to the review. 26 full-text articles were considered eligible. 20 studies were excluded, so six studies were finally included in the meta-analysis. Among 20 excluded study, in three studies a medication (misoprostol, castor oil, oxytocin) were administered in control groups, in two studies other medications besides EPO were used, the full text of four studies were not accessible and after contacting the authors, we did not get any response, a quasi-experimental study without control group, In nine study EPO was used before gynecologic procedure in non-pregnant women, one study was without enough information. We updated the search in May 2022 and two articles were added, but one of them was excluded, because it involved a different treatment for cervical ripening (misoprostole) in the control group [ 26]. Therefore, seven studies were considered for meta-analysis.

3.2. Characteristics of the included studies

The seven included studies were published from 1999 to 2022. Six studies were randomized controlled trials (RCTs) and one was quasi-experimental study with a control group. Four studies were conducted in Iran [ 10, 19, 27, 28], and three were carried out in Egypt, the United States, and the Philippines [ 15, 17, 25]. The studies included a total of 920 participants. The characteristics of the studies included in meta-analysis are shown in Table 1 . The sample size of the mentioned studies ranged from 71 to 240. As far as cervical preparation was concerned, five studies have investigated the Bishop score and birth outcomes [ 15, 19, 27, 28], and one measured only the time span between the administration of EPO and onset of childbirth [ 10].

Table 1

Reference

Methods

Participants

Interventions (Dosage)

Interventions (Duration of treatment)

Outcomes

-double blind

CG: 87

CG: Placebo vaginal

-Duration of the latent phase

-two arms

6 h before oxytocin induction of labor

- The parturition time

- length of the active phase

-The second stage of labor

-Apgar scores

-triple blind

CG:80

CG: 2 placebo vaginal capsule

-The time span between intervention and birth onset

-two arms

- Cesarean rate

-double blind

CG:43

CG: Vaginal capsule

-Duration of the latent, active and second stage of labor

-two arms

Placebo daily

-Induction and augmentation of labor

- First and fifth minute Apgar scores

-Mode of delivery

-Postpartum hemorrhage

-triple blind

CG:40

CG: oral capsule placebo two times daily

-Duration of pregnancy and labor phases

-two arms

-double blind

CG:120

CG: oral capsule placebo two times daily

-Bishop score

-two arms

- Cesarean rate

-The time from first dose to active labor

-Induction-to-delivery interval

-Duration of labor

-Neonatal outcomes

Ty-torredes et al., 2006

-RCT a

EG:38

EG: oral capsule EPO 1500 mg three times daily

Full-term pregnancy (1 week)

-Bishop score

-Double blind

CG:33

CG: oral capsule placebo three times daily

-two arm

Dove et al., 1999

-RCT a

EG b:54

EG: Oral EPO capsule three times daily

1 week

-length of labor

-Double blind

CG c:54

CG: Oral EPO d capsule placebo three times daily

-Incidence of postdate induction, -Prolonged ROM

-two arms

-Cesarean, vacuum, NVD in 14 days

-Apgar scores

-Neonatal body weight

EPO was used in form of vaginal suppository in three trials [ 10, 19, 28]. In one study, a daily dose of 1000 mg vaginal suppository of EPO from the 38th week of pregnancy until birth was used [ 28]. In Hashemnejad et al.'s (2019) study, a single dose of 1000 mg vaginal suppository of EPO was used at 37 weeks of pregnancy [ 10]. In another study, two soft capsules containing 500 mg of EPO, was applied 6 h before induction of labor with oxytocin [ 19]. Oral capsules of EPO were used in four trials [ 17, 25, 27, 29]. In one of the included studies, 1000 mg oral capsule was administered, twice daily, for 7 days from the 40th week of pregnancy until childbirth [ 27]. In Zahran et al.'s (2009) study, participants attending the antenatal care clinic, received 1000 μg of oral EPO capsules every 12 h for 10 days [ 29]. In one study, 1500 mg oral EPO capsules were used three times daily for one week, and in another study, the prescribed dosage of EPO was 500 mg orally three times daily for seven days, beginning at the 37th weeks of gestation, and then was reduced to 500 mg orally once per day until labor [ 17, 25]. In all studies, Bishop score was used for assessment of cervical ripening.

3.3. Risk of bias in the included studies

Two reviewing authors (SS and MK) independently assessed the risk of bias for each study using seven criteria that are required by Cochrane guidelines for quality assessment of randomized controlled trials ( Fig. 2 ). Three studies reported the method of random sequence generation and were rated as having a low risk for selection bias [ 19, 25, 27]. Five studies had a low risk of bias for allocation concealment [ 10, 19, 27, 28]. Blinding of participants bias was low in six studies and high in one trial [ 17].Five studies used independent outcome assessors who were blinded to intervention assignment [ 10, 19,[27], [28], [29]]. Only one study was rated as having a high risk for attrition bias [ 17]. Selective reporting bias was unclear in three trials [ 17, 25, 29].

3.4. Effects of interventions

3.4.1. Bishop score

The use of EPO for improving Bishop score was evaluated in five studies involving 652 participants [ 19, 25,[27], [28], [29]]. The results showed that EPO could significantly improve Bishop score (MD = 3.23; 95% CI: 3.17, 3.29) ( Fig. 3 ). The level of heterogeneity was high (P < 0.00001; I ² = 97%) and did not change using the random effect model, but after utilizing sensitivity analysis and by eliminating three studies [ 25, 27, 29], it was reduced to 0% (MD = 3.29; 95% CI: 3.23, 3.35). ( Fig. 3 ).

3.4.2. Length of the second stage of labor

EPO was used for assessing the length of the second stage of labor in three studies involving a total of 341 participants [ 19, 27, 28]. Results of meta-analysis showed that the difference between two groups regarding length of the second stage of labor was not significant (MD = −2.81; 95% CI: [−6.09, 0.46]) ( Fig. 4 ).

3.4.3. The time interval between EPO administration and birth

EPO was used for decreasing the interval between its administration and birth in three studies involving 482 participants [ 10, 27, 29].There was significant difference between the two studied groups in terms of the time interval between EPO use and childbirth (MD = −0.62; 95% CI: [−0.89, −0.34]) ( Fig. 5 ).

3.4.4. One- and 5-min Apgar scores

Three studies (involving 363 women) reported 1-min Apgar score [ 17, 19, 27]. Results of meta-analysis showed no significant effect of EPO on 1-min Apgar score (MD = −0.08; 95% CI: [−0.22, 0.05]) ( Fig. 6 ). Five-minute Apgar score was significantly higher in the EPO group compared to the control groups (MD = 0.48; 95% CI: [0.40, 0.56]) ( Fig. 6 ). After utilizing sensitivity analysis and eliminating one study [ 17], the level of heterogeneity was reduced to 43%, so the difference between the groups remained significant (MD = 0.65; 95% CI: [0.53, 0.77]). It is worth mentioning that for analyzing Apgar scores at one and 5 min, a study was omitted, because standard deviation was zero in control group, therefore the mean difference was not estimable [ 28].

With respect to the route of administration, subgroup analysis was performed for five studies containing 652 participants [ 19, 25,[27], [28], [29]]. Three studies, including 391 women, were in the oral administration route subgroup, while two studies including 261 women were in the vaginal administration route subgroup. While vaginal administration of EPO improved bishop score (MD = 3.29; 95% CI: [3.23, 3.35]), a significant difference was observed between the two compared groups in terms of oral administration of EPO (MD = 0.89; 95% CI: [0.49, 1.30]). After utilizing sensitivity analysis and by eliminating one study [ 27], the level of heterogeneity was reduced to 76%, and the difference between the groups regarding oral administration of EPO remained significant (MD = 1.46; 95% CI: [0.46, 2.45]).

3.4.5. Adverse event reported

Of the seven included studies, two studies reported no adverse events [ 19, 27]. In one study nausea, vomiting, diarrhea and hyperthermia reported in both intervention and control groups [ 29]. In another study, there were five cases of meconium stained amniotic fluid in the intervention group, and there was one case of asphyxia neonatorum in the control group [ 25]. One study reported protracted active phase, prolonged rupture of membranes and arrest of descent in intervention group [ 17]Two studies did not report on adverse events [ 10, 28].

4. Discussion

The purpose of this study was to investigate the effect of EPO on cervical ripening and birth outcomes. The results of this systematic review showed that EPO could significantly improve Bishop score. It is believed that gama-linoleic acid in EPO facilitates E2 prostaglandin synthesis and that prostaglandins play the most important role in the process of cervical ripening, as determined by Bishop score [ 30].

Several studies have indicated the effectiveness of EPO in the improvement of Bishop score during pregnancy, and even before gynecologic procedures [ 19, 26, 31, 32], but some have not shown any positive effect of this herbal oil on cervical priming of pregnant women [ 17, 27, 29].The contradictory results of these studies could be attributed to differences in route or frequency of EPO administration, EPO dosage, initiation time and length of using EPO during pregnancy, complete or incomplete use of EPO capsules by the intervention group and combination of EPO with other medications like misoprostol or oxytocin, which provides greater effect than EPO or these medications alone [ 11, 13, 26, 30]. Hence, this lack of homogeneity among studies caused that despite performing subgroup analysis, the I square did not decrease significantly. But regarding the discrepancies among studies, most of them reporting a significant difference between the two comparison groups in terms of Bishop score and vaginal route of administration of EPO [ 10, 19, 26, 28]. However, due to high variation between studies, further clinical trials of high methodological quality are needed to obtain certain results.

In the current study, the latent and active phases of the first stage of labor were not analyzed, because one related article was excluded from the study and the reporting of the two included articles on latent and active phases of labor were different in terms of time. In the present meta-analysis, EPO administration did not decrease the length of the second stage of labor, which is in line with the results of three other trials [ 19, 27, 28]. In this regard, Najafi et al. (2019) argued in their study that vaginal use of EPO significantly reduced length of the latent phase in the intervention group, which can be attributed to cervix ripening. They pointed out that since the effect of EPO was related to its half-life and taking EPO by intervention group was stopped at the onset of labor, it showed no effect on the other stages of labor except for the latent phase [ 28]. In our study, a significant difference was observed between the two groups, in terms of the time interval between taking EPO and childbirth. It is believed that following cervical assessment, the length of time until the onset of labor is directly related to the cervical ripening [ 17].

There was not any difference between the two groups regarding to 1-min Apgar score, eventhough 5-min Apgar scores were higher among the EPO group. Hemmatzadeh et al. in their systematic review and meta-analysis reported no significant difference between the two comparison groups in terms of one- and 5-min Apgar scores and discussed that they assessed mentioned outcomes in two studies with small sample sizes without enough power [ 33]. However, we included four studies in our meta-analysis in terms of Apgar scores, but according to GRADE the quality of studies for secondary outcome of Apgar score were low and may lead to unreliable results.

There have been reports indicating that using EPO during pregnancy does not increase complications [ 13, 25]. However, Dove and Johnson concluded that the oral use of EPO in pregnancy, may be associated with increased incidence of premature rupture of membranes, use of oxytocin for augmentation, arrest of descent and higher usage of vacuum [ 17]. Wedig and Whitsett reported widespread ecchymosis and petechiae in an infant following the mother's use of raspberry leaf tea and EPO during her pregnancy for ripening of the cervix [ 34]. Hence, for acquiring strong evidence in this regard, more well-designed randomized clinical trials are needed.

4.1. Limitations of the study

Because of the high level of heterogeneity among the included studies, results of the present systematic review should be interpreted with caution. Also, all included studies except for two were conducted in developing countries such as Iran and Egypt, which is a challenge in generalizing results. In addition, the limited number of included studies led to decreasing the number of outcomes and detailed analysis.

5. Conclusion

This systematic review and meta-analysis showed that the use of EPO during pregnancy significantly improved Bishop score and reduced the length of the time interval between EPO administration and birth. In addition, it was significantly effective in increasing 5-min Apgar score of neonates. Therefore, EPO might offer a natural way for enhancing cervical ripening.

Author contribution statement

Sholeh Shahinfar, Parvin Abedi, Shayesteh Jahanfar: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Mahin Khajehpoor: Conceived and designed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data.

Mohammadreza Chashmyazdan: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

No data was used for the research described in the article.

Declaration of interest's statement

The authors declare no competing interests.

Abbreviations

IOL

induction of labor

EPO

evening primrose oil

PROSPERO

Prospective Register of Systematic Reviews

Appendix B. Supplementary data

The following is the supplementary data related to this article:

References

3. Niemczyk N.A., Ren D., Stapleton S.R. Associations between prolonged second stage of labor and maternal and neonatal outcomes in freestanding birth centers: a retrospective analysis. BMC Pregnancy Childbirth. 2022;22:1-10. [[ PMC free article] [ PubMed] Google Scholar]

4. Cunningham G., Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. 2014. Williams Obstetrics. [ Google Scholar]

5. Roudsari F.V., Ayati S., Ghasemi M., Mofrad M.H., Shakeri M.T., Farshidi F., Shahabian M. Comparison of vaginal misoprostol with foley catheter for cervical ripening and induction of labor. Iran. J. Pharm. Res. (IJPR): IJPR. 2011;10:149. [[ PMC free article] [ PubMed] Google Scholar]

6. Ricci S.S., Kyle T. Lippincott Williams & Wilkins; 2009. Maternity and Pediatric Nursing. [ Google Scholar]

8. Alanwar A., Hussein S.H., Allam H.A., Hussein A.M., Abdelazim I.A., Abbas A.M., Elsayed M. Transvaginal sonographic measurement of cervical length versus Bishop score in labor induction at term for prediction of caesarean delivery. J. Matern. Fetal Neonatal Med. 2019:1-8. [[ PubMed] Google Scholar]

13. Bahmani S., Hesamy K., Shahgheibi S., Roshani D., Shahoei R. Comparison of the effect of vaginal capsule of evening primrose oil and misoprostol on cervical ripening of nulliparous women with post-term pregnancy. J. Pharm. Res. Int. 2019:1-9. [ Google Scholar]

22. Fecker R., Buda V., Alexa E., Avram S., Pavel I.Z., Muntean D., Cocan I., Watz C., Minda D., Dehelean C.A. Phytochemical and biological screening of Oenothera biennis L. hydroalcoholic extract. Biomolecules. 2020;10:818. [[ PMC free article] [ PubMed] Google Scholar]

33. Hemmatzadeh S., Charandabi S.M.A., Veisy A., Mirghafourvand M. Evening primrose oil for cervical ripening in term pregnancies: a systematic review and meta-analysis. J. Compl. Integr. Med. 2021 [[ PubMed] Google Scholar]

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The effect of evening primrose oil on cervical ripening and birth outcomes: A systematic review and meta-analysis

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The results of various studies on the effect of evening primrose oil (EPO) on cervical ripening are controversial. The purpose of this systematic review and meta-analysis was to assess the effect of EPO on cervical ripening and birth outcomes.The Cochrane ...

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🤍VERNIX🤍

Wondering what that white greasy cheese like substance that’s covering your baby at birth? 🧀

That’s VERNIX! - a multifunctional skin cream made by the foetus’ sweat glands and skin cells. It is composed of mostly water, as well as protein, lipids and cholesterol.

Vernix is amazing and have loads of benefits:

💦Waterproofing the baby in the aquatic environment of amniotic fluid. It allows the thick outer layer of skin to develop - hence no pickled skin when born🥒

👶🏽When swallowed by the foetus it helps in gut development and protection

🤰🏾It is a natural lubricant during labour to help reduce friction as the baby comes through the birth canal

🧖🏾‍♀️Properties help with perineal wound healing for Mama

We know, it looks kinda gross and you might be wanting to get it off your baby ASAP

But DON’T.. It’s actually extremely beneficial for them and you after birth too! 👍🏻

After delivery it keeps the baby’s skin moisturised and it’s anti-infective properties help stave off bacterial infections 🦠

It also is suggested to help babies latch on too. The scent of vernix is part of triggering neural connections in babies' brain needed for breastfeeding 🍉🍉

You may even love the smell of it and that’s because the smell is designed to jack into the parental brain to create a pleasurable response and get all that oxytocin flowing 🥰

Hence delay in baby’s first bath for as long as possible is advised (WHO)(Exception being babies born with meconium stained fluid, or to mothers with HIV, Hepatitis or Chorioamnionnits)🛁

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Rʜᴏᴍʙᴜs Mɪᴄʜᴀᴇʟɪs🤯🤭

“The rhombus of Michaelis (sometimes called the quadrilateral of Michaelis) is a kite-shaped area that includes the three lower lumber vertebrae, the sacrum and that long ligament which reaches down from the base of the scull to the sacrum. This wedge-shaped area of bone moves backwards during the second stage of labour and as it moves back it pushes the wings of the ilea out, increasing the diameters of the pelvis. We know it’s happening when the woman’s hands reach upwards (to find something to hold onto, her head goes back and her back arches. It’s what Sheila Kitzinger (1993) was talking about when she recorded Jamaican midwives saying the baby will not be born ‘till the woman opens her back’. I’m sure that is what they mean by the ‘opening of the back’."

https://www.sarawickham.com/articles-2/the-rhombus-of-michaelis/

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The Ultimate Dad Website & Community - Dadnatal®

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The Ultimate Dad Website & Community - Dadnatal®

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The place of in between - Zwischen | Nest & Nurture

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Are you in the last few weeks or days of pregnancy? There is something unique about this time of in-between and the Germans have a word for this "Zwischen." I would love to be able to write about this "in-between space" as eloquently as Jana Studelska did in her article, " The Last Days of Pregnancy: A Place of In-Between," so I will share Jana words which carry remarkable meaning and hope that they have some relevance to your last days of pregnancy.

"The last days of pregnancy are a distinct time of in-between. It's a tricky time for mothers, as these last few days are biological and psychological events.
She's curled up on the couch, waiting, a ball of baby and emotions. A scrambled pile of books on pregnancy, labor, baby names, breastfeeding ... not one more word can be absorbed. The birth supplies are loaded in a laundry basket, ready for action. The freezer is filled with meals, the car seat installed, the camera charged. It's time to hurry up and wait. Not a comfortable place to be, but wholly necessary.

The last days of pregnancy - sometimes stretching to agonizing weeks - are a distinct place, time, event, stage. It is a time of in between. Neither here nor there. Your old self and your new self, balanced on the edge of a pregnancy. One foot in your old world, one foot in a new world.

Shouldn't there be a word for this state of being, describing the time and place where mothers linger, waiting to be called forward?

Germans have a word, zwischen, which means between. I've co-opted that word for my own obstetrical uses. When I sense the discomfort and tension of late pregnancy in my clients, I suggest that they are now in The Time of Zwischen. The time of in between, where the opening begins. Giving it a name gives it dimension, an experience closer to wonder than endurance.

I tell these beautiful, round, swollen, weepy women to go with it and be okay there. Feel it, think it, don't push it away. Write it down, sing really loudly when no one else is home, go commune with nature, or crawl into your own mama's lap so she can rub your head until you feel better. I tell their men to let go of their worry; this is an early sign of labor. I encourage them to sequester themselves if they need space, to go out if they need distraction, to enjoy the last hours of this life-as-they-now-know-it. I try to give them permission to follow the instinctual gravitational pulls that are at work within them, just as real and necessary as labor.

The discomforts of late pregnancy are easy to Google: painful pelvis, squished bladder, swollen ankles, leaky nipples, weight unevenly distributed in a girth that makes scratching an itch at ankle level a feat of flexibility. "You might find yourself teary and exhausted," says one website, "but your baby is coming soon!" Cheer up, sweetie, you're having a baby. More messaging that what is going on is incidental and insignificant.

What we don't have is reverence or relevance - or even a working understanding of the vulnerability and openness a woman experiences at this time. Our language and culture fails us. This surely explains why many women find this time so complicated and tricky. But whether we recognize it or not, these last days of pregnancy are a distinct biologic and psychological event, essential to the birth of a mother.

We don't scientifically understand the complex hormones at play that loosen both her hips and her awareness. In fact, this uncomfortable time of aching is an early form of labor in which a woman begins opening her cervix and her soul. Someday, maybe we will be able to quantify this hormonal advance - the prolactin, oxytocin, cortisol, relaxin. But for now, it is still shrouded in mystery, and we know only how to measure thinning and dilation.

"You know that place between sleep and awake, the place where you can still remember dreaming? That's where I'll always love you, Peter Pan. That's where I'll be waiting." -Tinkerbell

I believe that this is more than biological. It is spiritual. To give birth, whether at home in a birth tub with candles and family or in a surgical suite with machines and a neonatal team, a woman must go to the place between this world and the next, to that thin membrane between here and there. To the place where life comes from, to the mystery, in order to reach over to bring forth the child that is hers. The heroic tales of Odysseus are with us, each ordinary day. This round woman is not going into battle, but she is going to the edge of her being where every resource she has will be called on to assist in this journey.

We need time and space to prepare for that journey. And somewhere, deep inside us, at a primal level, our cells and hormones and mind and soul know this, and begin the work with or without our awareness.

I call out Zwischen in prenatals as a way of offering comfort and, also, as a way of offering protection. I see how simple it is to exploit and abuse this time. A scheduled induction is seductive, promising a sense of control. Fearful and confused family can trigger a crisis of confidence. We are not a culture that waits for anything, nor are we believers in normal birth; waiting for a baby can feel like insanity. Giving this a name points her toward listening and developing her own intuition. That, in turn, is a powerful training ground for motherhood."

Credit to Jana Studelska and words from her article " The Last Days of Pregnancy: A Place of In-Between,"

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The place of in between - Zwischen | Nest & Nurture

# data[].attributes.attachment_link.description
Are you in the last few weeks or days of pregnancy? There is something unique about this time of in-between and the Germans have a word for this "Zwischen." I would love to be able to write about this "in-between space" as eloquently as Jana Studelska did in her article, "The Last Days of Pregnancy: [...]

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Study looking at comparative outcomes in women having epidural anaesthesia (science direct)

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Abstract

Objective

To compare labour and birth outcomes between nulliparous women who used versus did not use intrapartum epidural analgesia.

Design

Prospective cohort study.

Setting

Two maternity hospitals in Ireland.

Population

A total of 1221 nulliparous women who gave birth vaginally or by emergency caesarean section.

Methods

Multinomial logistic regression was used to analyse categorical outcomes, with results presented as ratios of relative risks (RRR). For dichotomous outcomes we used logistic regression, with results presented as odds ratios (OR).

Main outcome measures

Mode of birth, IV syntocinon use, pyrexia (≥38 °C), antibiotic treatment, first stage labour ≥10 h, second stage labour ≥2 h, blood loss (≥500 mls, ≥1000 mls), perineal trauma. Neonatal outcomes included Apgar score ≥7 at 1 min and 5 min, admission to neonatal intensive care unit, and infant feeding method.

Results

Women using EA were more likely to require a vacuum-assisted birth (RRR 3.35, p < 0.01) or forceps-assisted birth (RRR 11.69, p < 0.01). Exposure to EA was associated with significantly greater risk of ≥10 h first (OR 6.72, p = 0.01) and ≥2 h second (OR 2.25, p < 0.01) stage labour, increased likelihood of receiving IV syntocinon (OR 9.38, p < 0.01), antibiotics (OR 2.97, p < 0.01) and a greater probability of pyrexia (OR 10.26, p < 0.01). Women who used EA were half as likely to be breastfeeding at three months postpartum (OR 0.53, p < 0.01). No differences were observed between groups in neonatal outcomes.

Conclusions

Our data shows significant associations between EA use and several intrapartum outcomes.

View full text

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Comparison of labour and birth outcomes between nulliparous women who used epidural analgesia in labour and those who did not: A prospective cohort study

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To compare labour and birth outcomes between nulliparous women who used versus did not use intrapartum epidural analgesia. Prospective cohort study. Two maternity hospitals in Ireland. A total of 1221 nulliparous women who gave birth vaginally or by emergency caesarean section. Multinomial logistic regression was used to analyse categorical outcomes, with results presented as ratios of relative risks (RRR).

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Stories by parents who have experienced mental health issues before or after birth

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"Make sure you ask for support if you need it" is a phrase I often catch myself saying as a secondary school teacher and pastoral leader. Taking my own advice is one of the best decisions I ever made.

I became pregnant in November 2019. Having tried and failed to have children with another partner a number of years ago, I was naturally incredibly apprehensive. I wasn't sure my mental health could cope with another miscarriage or another year of getting my hopes up every month, only to be caught crying in the bathroom after another failed opportunity.

This time, pregnancy came easily but with it came extreme paranoia about the outcome. I had a private scan at 6 weeks and I was told it was too early to tell, and I should return at 8 weeks. It was like time stood still; I didn't know how I was going to fill 2 weeks' worth of time before knowing for definite if there was life inside me.

Then at 7 weeks pregnant, my mother unexpectedly died. She was ill, but not "that ill", my father and I would say. I was very close to her, even though she lived abroad, and I had fortunately told her about the pregnancy as soon as I had found out myself. I was suddenly on a plane to Cyprus and spent almost a week there sorting through my Mum's belongings, attending the funeral and trying to keep myself as steady as I could for the sake of this "maybe baby". Having a history of miscarriages, being so far from home (and the trusty NHS) was almost too much to bear, but I literally took it hour by hour.

I returned to the private scan place at 8 weeks, having already talked myself out of the baby. And yet, this little blob of a miracle was there, on the screen, its heart beating strongly. I burst into tears. I had never gotten this far before.

The next couple of months passed fairly uneventfully. My Dad came over from Cyprus for a private cancer operation, and that seems to go well. The 12 week scan was great; the first hint that this was going to be a rocky road was at around 16 weeks when potential low Papp A hormone was discovered. I had my 20 week scan a fortnight early and was told that yes, I had low Papp A, and large fibroids, and this could mean a whole host of things. The words "pre-term labour" were mentioned a few times, and when I pressed the doctor for what that actually meant, she said, word for word, "You could give birth at any time".

I was absolutely devastated and started to mentally spiral. Any spare time I had was taken up with googling my issues including the viability of babies born at XX weeks. I was an absolute nervous wreck, and became obsessed with what I could/couldn't do while pregnant and whether I was harming the baby. I also started to blame myself for my health issues, saying that I felt I deserved them. It was then that my partner very sensitively said that I needed some professional support.

I self-referred to Healthy Minds (in Birmingham, where I lived) and explained everything: the pregnancy, my mother dying, my father having cancer for 3rd time, my history trying to conceive and how my personal life was crumbling. At school, the students still had no idea about the pregnancy and I was becoming increasingly exhausted with having to maintain a cool, calm exterior at school but coming home and falling apart. Healthy Minds were brilliant and organised some general CBT support within a couple of weeks.

These sessions were really useful. A trained professional allowed me to offload every fortnight and explain my worries. He also gave me some practical tips for my concerns about the birth and how to seek support. The sessions started just as Covid and lockdown hit the UK, so I was lucky to have this support in place as the world as we knew it turned upside down.

However, nothing could truly alleviate me from my concerns about bringing the baby to full term. As lockdown began, we panic bought thousands of pounds worth of baby things (pram, nursery furniture, preemie baby clothes, toys...) because I was so scared that I might "give birth at any time". I would hear those words ringing in my head countless times a day. I would chant them at 4am when I was awake and the baby was kicking. Now that I was working from home, I had even more capacity to launch myself into an online rabbit hole of pre-term labour, birth defects, still-born babies and child-birth fatalities. I had my hospital bag packed at 20 weeks. Although the CBT was very useful, there was a very big void to fill.

I somehow got through the second and third trimester but was in hospital quite a lot due to bleeding. At around 32 weeks, I had a three day stay there and was given steroid injections to mature the baby's lungs just in case I had to give birth early. Every time I bled, which became weekly, I would end up taking everything to the hospital just in case it was time. I was a nervous wreck at this point and with Covid, was having to do it all alone. But somehow, I managed to get to 40 weeks and they induced me at this point.

This is a blog about mental health rather than birth stories, but suffice to say that I was one of those women whose birth plan might as well have been written in the sand. I ended up having a category 1 c-section (which I later found out meant "risk of death to mother and/or child") and welcomed a healthy baby into the world at the beginning of August. I had done it, and had kept myself steady enough throughout the process to survive.

And survive is an apt word for what happened next. At three days old, the baby was having a particularly sicky day and vomited green bile. I remember a midwife saying "green is seen", so not knowing what to else do, we called an ambulance. The operator very calmly asked me if the baby was breathing. I said I didn't know. She asked me quite urgently to check. I said I'm really sorry, but I didn't know, but I think perhaps he wasn't breathing because I couldn't see his chest moving. Panic started to set in. I was talked through how to perform CPR on him, which I did, and suddenly saw his little chest rising and falling. At this point, the paramedics arrived and took over. His breathing seemed better but they wanted to take us into the Children's Hospital just in case. I furiously packed the baby's essentials while my partner sat with the baby. And off to hospital I went (no partner because of Covid) via ambulance. The baby kept stopping breathing on the way, and that 20 minute journey was the longest of my life. The baby ended up spending almost a week in hospital being treated for sepsis, though they never really got to the bottom of the issue. He had a brain scan, chest x-rays, blood tests, and all sorts of other tests but it just seemed to be one of those things.

I had naively assumed that my mental health would be fine after the birth because all my concerns about something going wrong during the pregnancy/birth would be gone. Of course, my mental health was much, much worse. Even though my instincts had saved the baby's life (twice if you count the birth as well - I had had to be very pushy about things not being normal and I was totally right), I started to blame myself. Was I a bad mother? Was I being punished? Did my own mother leave me alone in the world because I needed to atone for everything I'd ever done wrong? These thoughts now seem ludicrous but at 3am when you're simultaneously watching the baby's chest, fixating on the Groegg and googling SIDS statistics, they seem fairly rational.

I would lie there all night and watch the baby sleeping as I was terrified he was going to stop breathing. I became obsessed with temperature (with its link to SIDS) and was constantly changing the baby's clothes, opening windows, repositioning the Moses basket, etc. If it got too hot (bearing in mind he was born in August), I would move him and me downstairs, where it was a bit cooler, and watch him and the Groegg all night. I was clearly also suffering from some sort of PTSD from the birth and the hospital stay and would replay those moments over and over again. In addition, we had been to A&E a number of times with him for blood in his nappy, which finally got diagnosed as CMPA (a cows milk protein allergy). As I changed the 12th bloody nappy in a 24 hour period, I would sob and wonder when it was all going to get easier.

We were under the midwives' care for longer than normal because of the baby's health issues. The team were fantastic and really pressed me to get some post-natal support. I got back in touch with Healthy Minds and also a local charity called Acacia. I was more hesitant this time about asking for support because I felt I'd already had my allotted amount during pregnancy and felt that some of this was just the baby blues. Surely worrying about your baby is normal? Looking back, it absolutely wasn't the baby blues and my anxiety levels weren't normal at all. Hindsight is a very powerful tool for seeing things for how they truly were.

In my second Healthy Minds session, we got to the root of the problem. My Mum had died unexpectedly. My Dad realistically was on borrowed time after his 3rd bout of cancer and his general poor health. I had had a terrible birth experience and a traumatic first few weeks with the baby, plus he had the ongoing CMPA. The counsellor made me say it out loud: "I think the baby's going to die". Once I'd said it, it was like a burden had been lifted. I'd known it at the back of my mind but saying it made me see it for what it was: just a thought. A very real thought, but a thought nonetheless. With illness and death associated with my pregnancy and birth, it was absolutely no wonder I felt that way, I was told. I wasn't "mental" for thinking this. I didn't secretly want him to die. But I had resigned myself to the fact that I would never see him beyond being a tiny baby.

At that realisation, we booked his first birthday party venue. I know that sounds ridiculous, particularly with the uncertainty of Covid, but I needed a goal to work towards. If I can keep him alive until his first birthday, I thought to myself, then we'll both be okay. That's quite a burden to put on yourself but I could visualise what I ultimately wanted to happen.

The counselling continued to go well and I was discharged when the baby was around 6 months. We did a lot of work around unhelpful thoughts, rationalising my thinking and dealing with uncertainty. I pushed myself to do a "brave thing" at least every week, which might be not checking the temperature more than 6 times a night, leaving him with my mother-in-law for a period of time alone or doing a car journey without stopping to check whether he was still breathing. I really had to take baby steps and learnt that it's okay to have anxious days and days where I can't be brave. I missed out on seeing a friend because I couldn't cope with the car journey that day and it wasn't the end of the world. Some days I felt it was too cold to take him out so we stayed in; that doesn't mean I'm a failure or a bad mum because he's been inside all day.

With Acacia, I had some group sessions and had the chance to (virtually) meet other mums. It was so comforting to know that they were just like me: scared, anxious and just trying to survive one day at a time. Some mums had similar backgrounds to me (poorly babies, difficult births, recent bereavement) and some didn't; we were not all in the same boat but we were weathering similar storms. I was also put onto a well-being WhatsApp group for Mums receiving support, and that has been a fantastic resource. You can really saying anything to these Mums and they're non-judgemental and full of helpful advice. I was discharged from Acacia a couple of months ago but am now part of a well-being WhatsApp group for recovering mums, which continues to be very useful.

The baby turned 9 months last week, and that felt like a big milestone for me. He's 3/4 the way to that 1st birthday party. I'm continuing to recover. I accept that some days are anxious days and often there's no rational explanation for it. Despite having a breathing monitor mat, some nights I need to check up on him more than others. I still worry about temperature but have managed to fix it so that our bedroom light comes on if it gets too hot/cold in his room at night. I accept that most mums don't need that, but I do. I had to pull over whilst driving yesterday to check he was still breathing. But these things don't mean I'm a failure. They mean that I'm still learning how to rationalise my fears. The journey isn't yet over.

For anyone looking to get some support, I have three pieces of advice:

1. Absolutely definitely take the plunge. It is not easy admitting you need help, but it is the first step on a much larger mental health journey.

2. You don't have to have had a traumatic pregnancy/birth to "need" support. Plenty of mums I connected with didn't. Post-natal depression and anxiety is not just linked to trauma. Your feelings aren't any less valid because other mums have had it tougher (in your eyes!). Everyone deserves the support.

3. Being introspective isn't the easiest things to do, but it is so, so important. When you're tired and run down and don't feel like spending time discussing your thoughts and feelings, it becomes more important that you do. It's an investment - the more time and energy you can put into your mental health, the more you'll get out. Having that time and space to talk about yourself is an act of self-care. The laundry can wait!

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"Make sure you ask for support if you need it" is a phrase I often catch myself saying as a secondary school teacher and pastoral leader. Taking my own advice is one of the best decisions I ever made. I became pregnant in November 2019.

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Pelvic floor excercise app (NHS)

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The multi-award winning app supporting people with their pelvic floor muscle exercise programmes. Recommended by pelvic health specialists around the world because it works.

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Induction increasing caesarean birth outcomes

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Induction increasing caesarean birth outcomes

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Study review in science direct

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Abstract

Background

The cesarean delivery rate has been rising in recent years, having associated maternal morbidities. Elective induction of labor has also been seen to rise during this same time period.

Objective

This current study investigated the difference in the cesarean delivery rate between induction of labor and spontaneous labor among nulliparous, term, singleton, and vertex-presenting women.

Study Design

A retrospective cohort in a single institution over a seven-year period was used for this analysis, observing the difference in cesarean delivery rate at different term gestational ages and neonatal morbidity using the 5-minute Apgar score < 5.

Results

A statistically significant difference was found in cesarean delivery rate between those women whose labor was induced and those whose labor began spontaneously, at each term gestational age of labor initiation (P < 0.001). The proportion of indications for induction was described (i.e. elective vs. medically-indicated), and no difference was found for neonatal morbidity between the groups analyzed, using the 5-minute Apgar score as the perinatal outcome measure.

Conclusion

A comparison was made between spontaneous and induced labor regarding the resultant cesarean delivery rate, and a significant difference was found favoring spontaneous labor. This should be considered when electing to deliver using an induction methodology for nulliparous women, especially when there are no medical indications for it.

View full text

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The cesarean delivery rate has been rising in recent years, having associated maternal morbidities. Elective induction of labor has also been seen to rise during this same time period. This current study investigated the difference in the cesarean delivery rate between induction of labor and spontaneous labor among nulliparous, term, singleton, and vertex-presenting women.

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NHS trust leaflet

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NHS trust

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ICAN

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Perineal massage demo (video)

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RCOG information leaflet

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You know having a baby will be life-changing, so you might be preparing yourself by attending classes and Googling just about everything to do with childbirth. You might also be thinking about alternative pain relief methods and labour techniques, like hypnobirthing.

Hypnobirthing is gaining popularity as some say it's a way of birthing gently and calmly. Some people describe it as allowing them to give birth without medication (The Guardian, 2015). So if you're wondering what hypnobirthing is all about, here we introduce you to this mysterious-sounding technique...

What is hypnobirthing?

"Hypnobirthing teaches relaxation, visualisation and self-hypnosis skills (Varner, 2015)."

This preparation tries to give pregnant women a positive view of birth and the belief that childbirth does not have to be painful. The aim is a shorter, more comfortable, easier labour, with less need for intervention or pain relief (Madden et al, 2016).

How does hypnobirthing work?

Hypnosis focuses on preparing a woman for birth by reframing the representation of labour from a painful and difficult experience to a positive one (Catsaros, 2020).

Women's experience of labour pain can vary in intensity; but fear, tension and anxiety can worsen it (Catsaros, 2020; RCM 2014) and the mental and physical activities practised through hypnobirthing can lessen this.

So can it really work - what's the evidence?

A systematic review of hypnosis-based interventions during pregnancy found that it improved childbirth experience by reducing fear and pain and enhancing a sense of control (Catsaros, 2020).

It improved women's emotional experience and outlook towards birth with less anxiety, increased satisfaction, fewer birth interventions, more postnatal wellbeing and a better childbirth experience overall (Catsaros, 2020). Other research has found that self-hypnosis promoted 'feelings of calmness, confidence and empowerment (Finlayson et al, 2015).'

How can I practice hypnobirthing?

Practitioners say hypnobirthing can create an altered state of conscious awareness (Madden et al, 2016). Hypnobirthing involves learning techniques that you can use in preparation for and during labour like:

visualisation

pregnancy and birth affirmations

relaxation

deep breathing

self-hypnosis

mindfulness.

(Semple et al, 2011; Madden et al, 2016)

How do I learn hypnobirthing techniques?

You can learn about hypnobirthing by reading about it, or through listening to hypnosis tracks or podcasts. Some of the online resources that you'll find are free (Madden et al, 2016).

If you'd prefer to attend a class, some NCT courses include elements of teaching about hypnobirthing as well as breathing techniques and ways to stay relaxed during labour. But you can find specialist hypnobirthing courses that add more specific techniques (Madden et al, 2016). Hypnobirthing classes teach the techniques mentioned above, such as self-hypnosis, deep relaxation and deep breathing, in addition to birth positions and the basic physiology of birth.

Once you've learnt the techniques, you'd use them to help you focus and concentrate completely on your body and your baby. Hypnobirthing can be used in all birth settings, during vaginal or caesarean birth, with or without all types of pain relief and can be added to your birth plan.

If I try hypnobirthing will I be aware of what is happening?

A common misconception about hypnobirthing is that women lose control of their thoughts and actions in a hypnotic state. In fact, women who learn hypnobirthing use it to be less aware of external stimuli. They also learn to have a more focused attention and responsiveness to verbal or non-verbal suggestions. The idea is that these suggestions might make her feel safer, more relaxed and comfortable, and give her some relief from her pain (Madden et al, 2016).

So women who use self-hypnosis during labour are fully in control and aware of what is happening to them and to those around them. What hypnobirthing actually aims to do is help a woman focus and enhance her birthing experience.

What are the advantages of hypnobirthing?

It can help women feel more confident with themselves and their capacity to go through labour feeling in control, leading to a more positive birth experience (Catsaros, 2020).

Hypnobirthing reduces anxiety and reduces fears related to pregnancy and childbirth (Which?, 2018; Downe, 2015). This can lead to lower perceptions of pain during labour and a shorter labour (Catsaros, 2020).

It can promote positive mental health and self-confidence after birth (Catsaros, 2020).

NICE states that women who choose to use hypnosis during childbirth should be supported in doing so (NICE, 2014).

A review of the evidence suggested hypnosis might help to reduce the pain of labour and does not seem to have any adverse effects on outcomes (Smith et al, 2006).

What are the disadvantages?

There can be a difference between what you expect to or hope will happen during labour and the reality of your birth experience.

Styles and language may vary between different hypnobirthing schools or practitioners, so you may wish to look into what suits you best (Varner, 2015).

It takes time to learn about hypnobirthing, practice it and master the breathing, visualisation and self-hypnosis techniques. It is more effective when it has been practised regularly during pregnancy so will take time and commitment (Varner, 2015; Catsaros, 2020).

Hypnobirthing courses are an additional cost. Although in some parts of the UK, NHS hospitals have introduced free hypnobirthing classes (Which?, 2018).

Women who use self-hypnosis techniques may seem so relaxed that health care professionals could underestimate their progression of labour (Catsaros, 2020).

There is very little research on the feelings and experiences of birth partners when hypnobirthing is used (Catsaros, 2020).

How do I find out more about hypnobirthing?

Ask your midwife whether there are any local antenatal courses that might include hypnobirthing.

Ask friends and family members about their birth experiences and talk to those who have tried hypnobirthing.

Read hypnobirthing birth stories online and listen to podcasts on the topic.

This page was last reviewed in March 2021.
Further information

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

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

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

Learn how to use breathing exercises in this labour video from Tommy's.

Catsaros S, Wendland J. (2020) Hypnosis-based interventions during pregnancy and childbirth and their impact on women's childbirth experience: A systematic review. Midwifery. Available at: https://doi.org/10.1016/j.midw.2020.102666 [Accessed 23rd March 2021].

Downe S, Finlayson K, Melvin C, Spiby H, Ali S, Diggle P, et al. (2015) Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness. BJOG. 122(9):1226-1234. Available at: https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.13433 [Accessed 23rd March 2021].

Finlayson, K., Downe, S., Hinder, S. et al. Unexpected consequences: women's experiences of a self-hypnosis intervention to help with pain relief during labour. BMC Pregnancy Childbirth 15, 229 (2015). https://doi.org/10.1186/s12884-015-0659-0&nbsp;

Madden K, Middleton P, Cyna AM, Matthewson M, Jones L. (2016) Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev. (5):CD009356. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009356.pub3/full [Accessed 23rd March 2021].

NICE. (2014) Intrapartum care for healthy women and babies. Available at: https://www.nice.org.uk/guidance/cg190 [Accessed 23rd March 2021].

RCM. (2014) How to support hypnobirthing. Midwives. 5:34-35. Available at: https://www.rcm.org.uk/sites/default/files/34-35_0.pdf [Accessed 19th April 2021].

Semple A, Newburn M; NCT. (2011) Research overview: self-hypnosis for labour and birth. Perspective. December: 16-20. https://www.nct.org.uk/sites/default/files/related_documents/Research%20overview-%20Self%20hypnosis%20for%20labour%20and%20birth%20%282011%29_2.pdf

Tommy's (2018) What is hypnobirthing? Available at: https://www.tommys.org/pregnancy-information/labour-birth/pain-relief-labour/hypnobirthing [Accessed 21st March 2021].

Varner CA. (2015) Comparison of the Bradley method and HypnoBirthing childbirth education classes. J Perinata Educ. 24(2): 128-136. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744344/ [Accessed 23rd March 2021].

Which? (2018) What is hypnobirthing? Available at: https://www.which.co.uk/birth-choice/coping-with-pain-in-labour/what-is-hypnobirthing [Accessed 23rd March 2021].

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Hypnobirthing: where to start | Labour & birth articles & support | NCT

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We discuss what you need to know about hypnobirthing and the potential advantages and disadvantages of using this technique in labour and birth.

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Antenatal breathing and relaxation for labour 

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Antenatal breathing and relaxation for labour 

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(Video)

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Antenatal Breathing and Relaxation for Labour

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What affects my breathing in labour?

All of these responses may be experienced during labour. These feelings may change your normal breathing pattern in either of these ways:

Breath holding

Panic breathing (hyperventilation).

These may make you more tense, frightened and anxious.

Breathing for the first stage of labour

Contractions are felt as the uterine muscles tighten and the muscles of the cervix relax and open. Some may be experienced as backache, aching in legs or similar to deep cramp of period pain. It is important to maintain a regular breathing pattern to assist the uterus by:

Relaxing

Listening to your breathing

Use a phrase with your breathing.

'Sigh Out Slowly' (SOS)
'Breathe in through my nose and sigh out through my mouth' (in 2,3 out 2,3).
Breathe in through your nose and imagine, as you sigh out, that you are causing a candle flame to gently flicker.

You may find it useful to greet the contraction with a sigh and end with a sigh.
You and your birth partner
Practice breathing together, before the birth.
You

Imagine a contraction is arriving

Greet the first discomfort with a sigh

Relax and breathe through the pain

End with a sigh.

Your birthing partner

Can time your breathing for you, to practice the length of contraction

Can learn to breathe at the same rate as you

Can help to remind you of a phrase if you are using one for labour

Can help you to concentrate on your breathing and relaxation throughout labour.

Breathing and relaxation through a contraction will help release endorphins (the body's own natural pain reliever) and ease your discomfort.
Breathing for second stage of labour
During the second stage of labour, you need to use your breath control to help push your baby out. Work with your body, listen to what your body is telling you. Your midwife may feel she can help you with this. Try to relax your pelvic floor muscles and not hold your breath while pushing.

As the baby begins to emerge, stretching the perineum, the midwife may ask you to stop pushing. Panting can sometimes help you with this.

Either slow panting or gentle blowing (just hard enough to make a candle flame flicker) will allow the baby to emerge slower and the midwife will be able to control its arrival whilst trying to avoid tearing.

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All of these responses may be experienced during labour. These feelings may change your normal breathing pattern in either of these ways: Breath holding Panic breathing (hyperventilation). These may make you more tense, frightened and anxious. Contractions are felt as the uterine muscles tighten and the muscles of the cervix relax and open.

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I wonder how uncomfortable a diaper must be after 9 months suspended naked in fluid.
I wonder how cold a crib must be after 3 trimesters of warmth.
I wonder how unpleasant hunger must be when your belly was always full in the womb.
I wonder this, and I stop wondering why newborns want to be held and fed so much. You are their security and safe place. Their warmth. Their whole world.

So when you see me holding my sleeping newborn, no, I’m not “spoiling” her. I’m being her comfort, her warmth, her security.

𝙄’𝙢 𝙗𝙚𝙞𝙣𝙜 𝙝𝙚𝙧 𝙨𝙖𝙛𝙚 𝙝𝙖𝙫𝙚𝙣. ❤️

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We recommend bringing a small bag with you onto labour suite, leaving a larger bag or case in the car for after you have given birth. Space on labour suite is limited so make sure you bring what you need.

For Mum in labour and for after birth

Something loose and comfortable to wear during labour (top/nightie/shirt)

Face cloth to help keep you cool during labour

Lip balm (your lips will become dry particularly if you use Gas and Air support)

Tennis ball (to relieve stress and to use as a massage tool)

Isotonic drinks and high energy snacks

Washbag with toiletries

Supportive bra or nursing bra

Books, magazines to keep you busy while you wait

A loose comfortable outfit to wear after you have given birth, and to come home in.

Front opening nightie if you are going to breastfeed

Dressing gown and slippers

Bring your own music. Our new birthing pools even have Blutooth technology.

For Baby immediately after birth

For partner during labour

What to pack in your hospital bag poster

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We recommend bringing a small bag with you onto labour suite, leaving a larger bag or case in the car for after you have given birth. Space on labour suite is limited so make sure you bring what you need.

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We use cookies to improve your experience. By continuing to use this site you are agreeing to our use of cookies.

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Dangerous sleeping bags?
Only 3 put of 15 passed safety checks

"New Which? research reveals the dangers posed by baby sleeping bags bought from online marketplaces and uncovers safety problems with big-name brands, too. We tested 15 baby sleeping bags bought from online marketplaces, high street stores and online from leading brands, and 12 of the bags failed some of our safety tests. Only three bags – from Asda, John Lewis and Mamas & Papas – passed all of the safety requirements. All nine of the baby sleeping bags we bought from sellers listing through online marketplaces AliExpress, Amazon Marketplace, eBay, Etsy and Wish failed to pass our safety tests. And three bags from Aldi, Grobag and Jojo Maman Bebe also failed at least one of our tests. The safety problems uncovered included neck openings that are too wide, which could lead to a baby slipping down into the bag and suffocating. We also found inaccurate tog ratings that could lead to a baby seriously overheating. And many bags simply didn’t provide key safety information in the instructions."

Read more: https://www.which.co.uk/news/2020/09/which-safety-tests-uncover-dangerous-baby-sleeping-bags/ - Which?

https://www.which.co.uk/news/2020/09/which-safety-tests-uncover-dangerous-baby-sleeping-bags

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Which? safety tests uncover dangerous baby sleeping bags - Which? News

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Our tests found safety issues with 12 out of 15 baby sleeping bags from well-known brands and online marketplaces.

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A reminder that, earlier this year, expert researchers at Oxford Brookes University brought together research on childbirth, birth setting and the use of water immersion in labour and shared key points which highlighted the safety and benefits of the use of water for labour and birth, during and beyond the coronavirus pandemic.
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Their points included that:
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Water immersion for healthy women is associated with a number of beneficial maternal outcomes with no known adverse risks to the neonate.
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COVID-19 is not a waterborne virus, therefore, the water environment dilutes respiratory droplet and faecal contamination potential.
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In the Coronavirus context, water immersion presents a lower risk of contamination risk for midwives compared with bed birth because it promotes the use of social distancing without interrupting normal midwifery care. Burns et al (2020)
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The authors also noted that:
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"The birthing pool environment presents a natural barrier between the woman and her midwife.
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Supporting women in the water reduces droplet, aerosol and faecal contamination, presenting a low-risk transmission activity for the Coronavirus.
💧
Water immersion for healthy women is associated with a number of beneficial maternal outcomes with no known adverse risks to the neonate.
💧
For primiparous women, birthing in midwifery-led settings (AMU/FMU or home) water immersion reduces transfer rate with the greatest benefit seen at FMU.
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Water immersion for labour and/or birth should be supported and encouraged as an effective method of analgesia."
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Burns E, Feeley C, Venderlaan J et al (2020). Coronavirus COVID-19: Supporting healthy pregnant women to safely give birth. Oxford: Oxford Brookes University.
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Loads more birth information at www.sarawickham.com

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TENS Machine!

We are currently having a culture shift. Birthing people are no longer assuming they will birth in hospital, which is awesome. One of the fears that comes up though, is the amount of comfort measures (pain relief) available outside of traditional obstetric units.

That is where our snazzy TENS machine comes in! TENS stands for 'Transcutaneous Electrical Nerve Stimulation'. They are known for their use to ease chronic pain, usually back discomfort but can be used (near enough) anywhere on the body.

The way they work is two-fold:

1. Our brains can only process one sensation at a time, so act as a distraction from labour discomfort

2. Working on the production of endorphins, which are the body's natural painkiller and are 10 times stronger than morphine

You put the sticky pads on your lower back, start on the lowest setting and work your way up if needed. Each time you have a surge (contraction) press the 'boost' button - this is a special function on maternity TENS so make sure you get one specifically for labour to get the best results.

If you have tried a TENS machine before, you will know the sensation it gives isn't the most pleasant and certainly won't be for everyone, but many women find it super helpful in the early stages of labour and others go on to use it throughout. Others bloody hate it and want to rip it off!

Our final words of advice:
⚠️ don't use it in the pool!
⚠️ keep it on - if you take it off thinking it isn't working, you will lose the effect of the endorphins and may not deal so well after taking it off
⚠️ get a maternity one - you can buy one or hire one fairly inexpensively
⚠️ build up the settings slowly if you need to

Do you have any questions? Have any of you used a TENS in labour or considering it? 🥰💖🤰

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Pride and Joy: A Guide for Lesbian, Gay, Bisexual and Trans Parents https://www.amazon.co.uk/dp/1780664206/ref=cm_sw_r_oth_api_i_Lf.qFbSSJCC4C

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𝑮𝒓𝒂𝒗𝒊𝒕𝒚 𝑮𝒖𝒊𝒅𝒆𝒔 𝒀𝒐𝒖𝒓 𝑩𝒂𝒃𝒚 𝑬𝒂𝒓𝒕𝒉𝒔𝒊𝒅𝒆.🌎

💁🏽‍♀️What does research tell us about upright labor and birth?

According to the Cochrane Pregnancy and Childbirth Group, a respected international organization that defines best practices based on research, the use of any upright or side-lying position, compared with supine or lithotomy positions (lying on back, legs supported by stirrups), is associated with the following results:

✅shorter second stage of labor;
✅a small reduction in vacuum or forceps-assisted birth;
✅fewer episiotomies;
✅less chance that the woman will report severe pain;
✅fewer abnormal fetal heart rate patterns;
✅a small increase in second-degree lacerations (in the upright group only); and
✅an increase in estimated blood loss, although there was no evidence of serious or long-term problems from the extra blood loss (Gupta, Hofmeyr, & Smyth, 2004).

⬆️Upright and gravity-neutral positions are safe during pushing and are often more comfortable than lying on your back.

➡️Following your own urge to push is less stressful for your baby than directed pushing.

⬇️Pushing when and how your natural urge tells you to gives you the best chance of preventing tears and muscle weakness in your pelvis after the birth.

Photo Cred: @doulaviewllc

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Life with a newborn: why it’s so hard to take a shower

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Life with a newborn: why it’s so hard to take a shower

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Life with a Newborn: Why It’s so Hard to Take a Shower Video

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Tips and benefits (NCT)

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Before babies are able to understand language, we often communicate and comfort them through touch. If a baby cries, for example, parents will hold, cuddle or stroke them. Baby massage is part of this natural impulse.

Find out about the benefits of baby massage for you and your baby in this video.

What is baby massage?

Baby massage is the gentle, rhythmic stroking of your baby's body using your hands. As part of a massage routine, you might gently manipulate your baby's ankles, wrists and fingers.

"You might also talk softly, hum or sing to them while massaging to create a sense of calm and reassurance for your baby".

What are the benefits of baby massage?

Baby massage was introduced about 30 years ago in neonatal wards to support the development of premature babies in intensive care units. A study in 2004 found that babies in intensive care units who were massaged spent less time in hospital, had slightly better scores on developmental tests and slightly fewer postnatal complications.

Today, there is widespread belief that baby massage can increase a mum's awareness of her baby's needs and support their early bond, as well as improve her sense of well-being if she is suffering with postnatal depression or other mental health issues. The evidence is inconclusive on these points but parents do say they find baby massage a lovely way of bonding with their baby.

Many talk about the following benefits:

Becoming more confident in handling their child and better at recognising their needs.

Improved positive interaction with their baby.

A great way for partners, family members and carers to bond with baby.

Improved sleep for their baby.

When can I start baby massage?

There are no set guidelines regarding the minimum age for when to start baby massage. Although nurturing touch can be given from birth, some babies may find formal, structured massage too stimulating in the very early weeks.

When it comes to baby massage classes, some babies may find a formal class overwhelming in the early weeks. It can also be hard for parents to make it to a class on time or consistently with a newborn. As a result, many parents prefer to wait until their baby is about six weeks old when their routine is more settled and their behaviour is sometimes more predictable.

"It can also be helpful to start baby massage after your baby's six week check so any issues with development, such as hip dysplasia, might be identified".

Getting ready to massage your baby

Here are some tips to help you try baby massage at home:

Choose a time when your baby is content and alert, not tired or hungry, and interested in what's going on around them. This makes it more likely that they'll be ready to interact with you.

Try sitting on the floor, bed or sofa, with your baby safely on a towel in front of you.

Find a position that's comfortable, gives you good eye contact with no overhead lights and where your baby is warm.

It's up to you whether your child is nappy-free, but it can help to at least loosen their nappy when massaging the tummy.

It can be a nice idea to introduce a massage after bath and before bed as part of a bedtime wind-down.

How to give your baby a massage

Before beginning 'ask permission' by rubbing a little oil between your hands near your baby's ears, and ask 'can I give you a massage?' This may sound a little strange but your child will become familiar with this cue and know that massage is about to start. It also gives your baby a chance to let you know if they don't feel like a massage.

It's great to massage the whole of your child's body using a range of techniques. To get you started, we describe some strokes below for the legs and feet.

Once you have 'asked permission', gently hold one of your baby's legs between your palms.

Then, with one hand, hold your baby's ankle securely. Mould your other hand around the top of your child's thigh, then slide it down the leg towards the ankle.

Swap hands and repeat. Always keep your child's ankle supported and use slow, flowing strokes.

Next, cradle your child's foot in your hands and use your thumbs to stroke over the sole of the foot from heel to toes, one thumb after another. Hold your fingers in a tripod grip and gently tug each toe between thumb and finger.

Holding your child's foot in your hands, walk the thumbs across the middle third of the foot from one side to the other like a little caterpillar crawling on a leaf.

You could also do circles on the palms of their hands singing 'Round and round the garden like a teddy bear'. Continue with finger and thumb tugs.

Finish by repeating the stroking action in the opposite direction, i.e. from ankle to thigh.

You can repeat each stroke a few times, always responding to what your child seems to enjoy.

What oils/products should I use for baby massage?

While using oil can make massage easier for parents and more relaxing for their baby, there is limited evidence on what oil is best to use for baby massage.

Most research into the use of oils on a baby's skin has not focussed on their use for baby massage but for skincare issues, such as dry skin or eczema. This is important to note because there may be a difference in the effect of using oils in baby massage once a week compared to every day for skincare reasons or for more frequent massage.

The NHS also recommends parents do not use any oils or lotions until their baby is one month old. This is because at birth, the top layer of a baby's skin is very thin and easily damaged. Over the first month (or longer in premature babies), a baby's skin matures and develops its own natural protective barrier.

Here is a list of oils and what is know about them:

Cold-pressed oil - while there is a lack of evidence on its benefits, some parents prefer to use a cold pressed oil, which is manufactured differently to cooking oils and has fewer impurities.

Mineral oils or petroleum-based ointments are an option if your baby has dry or broken skin, as they have been found to be effective and safe for treating skin problems, such as dermatitis and eczema.

Mustard oil can have a toxic effect on the skin barrier, causing irritation and potential damage to delicate baby skin.

Olive oil is not recommended for baby massage because of its high oleic acid content. This can make some layers of a baby's skin dryer.

Other oils, such as grapeseed oil or coconut oil - these have not been effectively tested in research trials so there isn't much information about their effectiveness or risks.

Peanut oil contains proteins that may sensitise a baby to an allergic reaction to peanuts or cause a reaction on a baby's skin.

Sunflower oil is often recommended for baby massage but recent research has suggested it might have adverse effects on a baby's later skin barrier function. This was only a small trial though and more research is needed to establish the exact risk.

Vegetable oils high in polyunsaturated fats may be gentler on your baby's skin.

Safety tips for baby massage

Here are some tips to help you massage your baby safely:

* Make sure you use oil that is safe for your baby's skin and if it was to get into their mouth (see list above).
* When massaging your child's arms or legs, always support the ankle or wrist with one hand.
* When massaging your child's tummy with a circular motion, go clockwise rather than anti-clockwise.
* If your child becomes upset or falls asleep, stop massaging.

Enjoy baby massage

If your baby doesn't seem to enjoy massage right away, don't worry. It's a new experience for you both and it can take a bit of getting used to. Try a few minutes the first time and build up as your child gets more used to it.

Further information

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

Why not try one of our NCT Mother and Baby Yoga courses or baby massage classes?

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Before babies are able to understand language, we often communicate and comfort them through touch. If a baby cries, for example, parents will hold, cuddle or stroke them. Baby massage is part of this natural impulse. Find out about the benefits of baby massage for you and your baby in this video.

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Immunisations and vaccinations for your baby 

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Many women find having a bath or shower very comfortable in pregnancy, and this feeling of relaxation in water can continue in labour. What's not to love about it - it's warm and you're buoyant so you can move more easily into any position that suits you. Being in the water also increases the chance of respectful midwifery care, and women say it improves their experience (Lewis et al, 2018).

But what about the potential for mess? When might you need to get out? And what will the midwife be doing? Here we answer your questions...

When should I get in the pool?

The great thing is that there's no should about it - you can feel free to get in and out as you wish. There's no evidence that the timing of when you get into the pool makes much difference. You might be a little wobbly on your feet so a birth partner should help you as you get into and out of the pool.

How can my birth partner help?

Here's your chance to get waited on. While in the pool, it's a good idea to have your partner offer you drinks frequently, to make sure you stay hydrated. Your partner can even join you in the pool if you like.

What will my midwife do?

The midwife's role in a water birth is the same as with a land birth. That is, they will monitor you and your baby during labour and birth.

You can decide if you are willing to get out of the pool at any point for internal checks. Try not to worry though, the midwife will have equipment to check all is well while you're in the water too. They'll have waterproof equipment to monitor the baby's heartbeat and a mirror to check the baby as they emerge. They'll also check both your temperature and the pool's hourly, to make sure you're comfortable (NICE, 2014).

Midwives are trained in how to use water for labour and birth, and each NHS trust will have its own guidance for use of their pools (RCM, 2012). This guidance will include measures to check the quality of the water reaching the pool, protocols for cleaning the pool and infection control procedures (RCM, 2012; NICE, 2014).

What temperature will the birthing pool be?

The midwife will keep an eye on the temperature, and will let you know if it's getting too hot (NICE, 2014). The water temperature should not be above 37.5°C (NICE, 2014).

What if I want to get out?

Sometimes women feel their labour has slowed and want to get out of the pool to walk around until it starts again. You can do that and return to the pool if you want. Whatever the case, you'll want warm dry clothes to make sure you don't get too cold.

You might want to get out to use the toilet, or get extra pain relief, or because you simply don't find it comfortable. Some women prefer to get out of the pool and birth the baby on dry land.

What's the longest time I can spend in the water?

Your time in the pool during labour should not be restricted. There is no evidence to say it's an advantage to limit how long you stay in the pool when you're labouring (RCM, 2012).

Will my midwife suggest I get out of the water?

Your midwife might ask you to get out of the water for a vaginal examination to assess progress. You can accept or decline.

If the midwife becomes concerned about you or your baby's wellbeing, she might suggest getting out of the water. This might include if you develop a high temperature, pulse, or blood pressure or are bleeding from the vagina. Concerns about the baby would include changes in the baby's heart rate or meconium (baby's poo) in the water.

What happens if my baby is born in water?

Don't worry, your baby won't drown. If your baby is born in the water, they are brought gently to the surface by the mother or midwife. The baby will not breathe until they meet the air, and they continue to get oxygen through the umbilical cord.

Initially, the baby's body is kept in the water, and against the mother's body, to stay warm. The baby might be very calm, and not cry loudly. You can offer your breast at this point if you like. For more on how your baby will start breastfeeding, see here.

Do I need to get out of the pool to birth my placenta?

You don't have to get out of the pool to birth the placenta (RCM, 2018). Sometimes women decide to get out, and sometimes they stay in. You can tell your midwife what you'd prefer in advance, and you can always change your mind.

Try to remember, this is a common way to birth (CQC, 2018). Midwives are well trained to help you give birth in water. So you're in good hands, and you can relax and let the water help you along.
This page was last reviewed in March 2019.
Further information

Our helpline offers practical and emotional support in all areas of pregnancy, birth and early parenthood: 0300 330 0700.

For further support and information, see the AIMs, MVP and Which? Birth-choice websites.

Make friends with other parents-to-be and new parents in your local area and see what NCT activities are happening nearby.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, McCourt C, Marlow N, Miller A, Newburn M, Petrou S, Puddicombe D, Redshaw M, Rowe R, Sandall J, Silverton L, Stewart M. (2011) 'Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study'. BMJ.343:d7400. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22117057 [Accessed: 13th November 2018]

Cluett ER, Burns E, Cuthbert A. (2018) Immersion in water in labour and birth. (5):CD000111. Available from: https://www.cochrane.org/CD000111/PREG_immersion-water-labour-and-birth [Accessed: 13th November 2018]

CQC. (2018) 2017 Maternity survey: national tables for England. Available from: https://www.cqc.org.uk/publications/surveys/maternity-services-survey-2017 [Accessed: 13th November 2018]

Cumberledge J, Expert Maternity Group; Department of Health. (1993) Changing childbirth. Part 1, report of the expert maternity group, London, HMSO. [Accessed: 13th November 2018]

Dekker R. (2018) The evidence on: waterbirth. Available from: http://evidencebasedbirth.com/waterbirth/ [Accessed: 4th March 2019]

Garland D. (2000) Waterbirth: an Attitude to Care. 2nd edition. Oxford: Books for Midwives Press

Lewis L, Hauck YL, Crichton C, Barnes C, Poletti C, Overing H, Keyes L, Thomson B. (2018) 'The perceptions and experiences of women who achieved and did not achieve a waterbirth', BMC Pregnancy and Childbirth. 18(1):23. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5763519/ [Accessed: 13th November 2018]

NICE. (2014) CG190 Intrapartum care. Available from: https://www.nice.org.uk/guidance/cg190/chapter/recommendations#timing-of-regional-analgesia [Accessed: 13th November 2018]

Public Health England. (2014) Patient Safety Alert: Legionella and heated birthing pools filled in advance of labour in home settings. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/06/psa-legionella-birth-pool.pdf [Accessed: 4th March 2019]

Redshaw M, Henderson J. (2015) Safely delivered: a national survey of women's experience of maternity care 2014, Oxford, NPEU. Available from: https://www.npeu.ox.ac.uk/downloads/files/reports/Safely%20delivered%20NMS%202014.pdf [Accessed: 13th November 2018]

RCM. (2012) Evidence based guidelines : Immersion in water for labour and birth. Available from: https://www.rcm.org.uk/sites/default/files/Immersion%20in%20Water%20%20for%20Labour%20and%20Birth_0.pdf [Accessed: 13th November 2018]

RCM. (2018) RCM Midwifery Blue top guidance No. 1, London, Royal College of Midwives.

Ulfsdottir H, Saltvedt S, Georgsson S (2018) 'Waterbirth in Sweden - a comparative study', Acta Obstet Gynecol Scand. 97(3):341-348. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29288489 [Accessed: 13th November 2018]

Winterton N. (1992) Maternity Services: Second report of the House of Commons Health Committee (The Winterton Report), London, HMSO.

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How to labour in water or have a water birth | Labour & birth, Different types of birth articles & support | NCT

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Knowing what to expect when you're in labour and using a birthing pool could help you feel prepared. Here's what happens during a water birth...

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Debra Betts

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Debra Betts - Acupuncture and Acupressure for Pregnancy and Childbirth

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Wecome to this webpage about the use of acupuncutre and acupressure in pregnancy and for postnatal recovery Acupressure is a safe evidenced based therapy you can use to prepare for Labour. Acupressure Resources The Acupressure resources on this webpage have been updated. You will now find videos to assist you locate each point and illustrated handouts.

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NHS

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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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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.

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Pain Management Series: TENS for Pain Relief during Labor

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Pain Management Series: Massage for pain relief during labor

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NCT info page

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You know having a baby will be life-changing, so you might be preparing yourself by attending classes and Googling just about everything to do with childbirth. You might also be thinking about alternative pain relief methods and labour techniques, like hypnobirthing.

Hypnobirthing is gaining popularity as some say it's a way of birthing gently and calmly. Some people describe it as allowing them to give birth without medication (The Guardian, 2015). So if you're wondering what hypnobirthing is all about, here we introduce you to this mysterious-sounding technique...

What is hypnobirthing?

"Hypnobirthing teaches relaxation, visualisation and self-hypnosis skills (Varner, 2015)."

This preparation tries to give pregnant women a positive view of birth and the belief that childbirth does not have to be painful. The aim is a shorter, more comfortable, easier labour, with less need for intervention or pain relief (Madden et al, 2016).

How does hypnobirthing work?

Hypnosis focuses on preparing a woman for birth by reframing the representation of labour from a painful and difficult experience to a positive one (Catsaros, 2020).

Women's experience of labour pain can vary in intensity; but fear, tension and anxiety can worsen it (Catsaros, 2020; RCM 2014) and the mental and physical activities practised through hypnobirthing can lessen this.

So can it really work - what's the evidence?

A systematic review of hypnosis-based interventions during pregnancy found that it improved childbirth experience by reducing fear and pain and enhancing a sense of control (Catsaros, 2020).

It improved women's emotional experience and outlook towards birth with less anxiety, increased satisfaction, fewer birth interventions, more postnatal wellbeing and a better childbirth experience overall (Catsaros, 2020). Other research has found that self-hypnosis promoted 'feelings of calmness, confidence and empowerment (Finlayson et al, 2015).'

How can I practice hypnobirthing?

Practitioners say hypnobirthing can create an altered state of conscious awareness (Madden et al, 2016). Hypnobirthing involves learning techniques that you can use in preparation for and during labour like:

visualisation

pregnancy and birth affirmations

relaxation

deep breathing

self-hypnosis

mindfulness.

(Semple et al, 2011; Madden et al, 2016)

How do I learn hypnobirthing techniques?

You can learn about hypnobirthing by reading about it, or through listening to hypnosis tracks or podcasts. Some of the online resources that you'll find are free (Madden et al, 2016).

If you'd prefer to attend a class, some NCT courses include elements of teaching about hypnobirthing as well as breathing techniques and ways to stay relaxed during labour. But you can find specialist hypnobirthing courses that add more specific techniques (Madden et al, 2016). Hypnobirthing classes teach the techniques mentioned above, such as self-hypnosis, deep relaxation and deep breathing, in addition to birth positions and the basic physiology of birth.

Once you've learnt the techniques, you'd use them to help you focus and concentrate completely on your body and your baby. Hypnobirthing can be used in all birth settings, during vaginal or caesarean birth, with or without all types of pain relief and can be added to your birth plan.

If I try hypnobirthing will I be aware of what is happening?

A common misconception about hypnobirthing is that women lose control of their thoughts and actions in a hypnotic state. In fact, women who learn hypnobirthing use it to be less aware of external stimuli. They also learn to have a more focused attention and responsiveness to verbal or non-verbal suggestions. The idea is that these suggestions might make her feel safer, more relaxed and comfortable, and give her some relief from her pain (Madden et al, 2016).

So women who use self-hypnosis during labour are fully in control and aware of what is happening to them and to those around them. What hypnobirthing actually aims to do is help a woman focus and enhance her birthing experience.

What are the advantages of hypnobirthing?

It can help women feel more confident with themselves and their capacity to go through labour feeling in control, leading to a more positive birth experience (Catsaros, 2020).

Hypnobirthing reduces anxiety and reduces fears related to pregnancy and childbirth (Which?, 2018; Downe, 2015). This can lead to lower perceptions of pain during labour and a shorter labour (Catsaros, 2020).

It can promote positive mental health and self-confidence after birth (Catsaros, 2020).

NICE states that women who choose to use hypnosis during childbirth should be supported in doing so (NICE, 2014).

A review of the evidence suggested hypnosis might help to reduce the pain of labour and does not seem to have any adverse effects on outcomes (Smith et al, 2006).

What are the disadvantages?

There can be a difference between what you expect to or hope will happen during labour and the reality of your birth experience.

Styles and language may vary between different hypnobirthing schools or practitioners, so you may wish to look into what suits you best (Varner, 2015).

It takes time to learn about hypnobirthing, practice it and master the breathing, visualisation and self-hypnosis techniques. It is more effective when it has been practised regularly during pregnancy so will take time and commitment (Varner, 2015; Catsaros, 2020).

Hypnobirthing courses are an additional cost. Although in some parts of the UK, NHS hospitals have introduced free hypnobirthing classes (Which?, 2018).

Women who use self-hypnosis techniques may seem so relaxed that health care professionals could underestimate their progression of labour (Catsaros, 2020).

There is very little research on the feelings and experiences of birth partners when hypnobirthing is used (Catsaros, 2020).

How do I find out more about hypnobirthing?

Ask your midwife whether there are any local antenatal courses that might include hypnobirthing.

Ask friends and family members about their birth experiences and talk to those who have tried hypnobirthing.

Read hypnobirthing birth stories online and listen to podcasts on the topic.

This page was last reviewed in March 2021.
Further information

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

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

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

Learn how to use breathing exercises in this labour video from Tommy's.

Catsaros S, Wendland J. (2020) Hypnosis-based interventions during pregnancy and childbirth and their impact on women's childbirth experience: A systematic review. Midwifery. Available at: https://doi.org/10.1016/j.midw.2020.102666 [Accessed 23rd March 2021].

Downe S, Finlayson K, Melvin C, Spiby H, Ali S, Diggle P, et al. (2015) Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness. BJOG. 122(9):1226-1234. Available at: https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.13433 [Accessed 23rd March 2021].

Finlayson, K., Downe, S., Hinder, S. et al. Unexpected consequences: women's experiences of a self-hypnosis intervention to help with pain relief during labour. BMC Pregnancy Childbirth 15, 229 (2015). https://doi.org/10.1186/s12884-015-0659-0&nbsp;

Madden K, Middleton P, Cyna AM, Matthewson M, Jones L. (2016) Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev. (5):CD009356. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009356.pub3/full [Accessed 23rd March 2021].

NICE. (2014) Intrapartum care for healthy women and babies. Available at: https://www.nice.org.uk/guidance/cg190 [Accessed 23rd March 2021].

RCM. (2014) How to support hypnobirthing. Midwives. 5:34-35. Available at: https://www.rcm.org.uk/sites/default/files/34-35_0.pdf [Accessed 19th April 2021].

Semple A, Newburn M; NCT. (2011) Research overview: self-hypnosis for labour and birth. Perspective. December: 16-20. https://www.nct.org.uk/sites/default/files/related_documents/Research%20overview-%20Self%20hypnosis%20for%20labour%20and%20birth%20%282011%29_2.pdf

Tommy's (2018) What is hypnobirthing? Available at: https://www.tommys.org/pregnancy-information/labour-birth/pain-relief-labour/hypnobirthing [Accessed 21st March 2021].

Varner CA. (2015) Comparison of the Bradley method and HypnoBirthing childbirth education classes. J Perinata Educ. 24(2): 128-136. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744344/ [Accessed 23rd March 2021].

Which? (2018) What is hypnobirthing? Available at: https://www.which.co.uk/birth-choice/coping-with-pain-in-labour/what-is-hypnobirthing [Accessed 23rd March 2021].

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Hypnobirthing: where to start | Labour & birth articles & support | NCT

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We discuss what you need to know about hypnobirthing and the potential advantages and disadvantages of using this technique in labour and birth.

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SHORT VIDEO (nhs)

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nice infographic of the needs of babies

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questions to consider...

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video of activity in group

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Bridget Supple demonstrating how a Baby's Brain wires - 'The Wool brain' exercise

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CESAREAN SECTION 3D ANIMATION (YouTube video)

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how to minimise perineal tearing (PDF Royal Berkshire NHS)

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Virtual tour of Maternity departments at UHCW (video)

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Virtual Tour of the Maternity Departments at UHCW NHS Trust

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Induction with synthetic oxytocin (AIMS article)

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AIMS Journal, 2019, Vol 31, No 4 By Linn Shepherd
Administration of synthetic oxytocin - induction of contractions
Synthetic oxytocin has been used since the 1950s for induction and augmentation of contractions. Induction and augmentation only differ in that induction is to try to start labour, whilst augmentation happens after contractions have started, to improve their strength or organisation, and make them more efficient.

In the UK, 'Syntocinon' is the name that most people associate with synthetic oxytocin, but other companies now produce synthetic oxytocin under the simpler name 'Oxytocin'.

According to the approved instructions licensed for synthetic oxytocin for induction and augmentation of labour, the concentrate should always be a well-diluted solution for administration intravenously, and never administered undiluted, by intramuscular injection before the baby has been born.

When a woman has consented to intravenous synthetic oxytocin, the infusion (controlled by an electric pump) will be started:

at least 6 hours after induction of labour with prostaglandins;

after rupture of membranes (spontaneous or artificial) with a favourable cervix;

before rupture of membranes with a favourable cervix;

to augment contractions (as described earlier).

Limitations set by the licensed instructions for synthetic oxytocin
The maximum dose of synthetic oxytocin to start an infusion when no contractions are present is 4 milliunits per minute (4 mU/min).

Increases of infusion rate can be made from 20 minutes after the previous increase, at no more than 2 mU/min more than the previous infusion rate. The licensed terms of use and guidance for managing synthetic oxytocin infusion should be applied in all cases aiming to reduce the rate slightly - if possible - once labour is established, to minimise the input of synthetic oxytocin in the presence of maternal oxytocin.
See Figure 1 below for an illustration of the dosages.
Good practice when using synthetic oxytocin
During augmentation of labour, it may be possible to start with less than 4 mU/min because maternal oxytocin is already at work. If the initial rate-per-minute of the intravenous infusion has not achieved the desired effect (about 3 contractions in 10 minutes), the dosage rate is speeded up slightly.

Fine-tuning with smaller increases of 0.5 mU/min or 1 mU/min can be tried first, to blend with maternal oxytocin.

Standard prescribing practices
If a doctor prescribes you medicine, the prescription relays instructions to the pharmacist, who checks the prescription, and provides the requested drugs clearly labelled with the name of the drug, your name, information about the dose and timings of the doses, and any warnings, such as 'Do not exceed stated dose'. If a pharmacist is concerned that a mistake has been made with a prescription, they have processes to follow to address this.

Doctors can prescribe drugs that are not licensed for pregnancy for the condition you have and at greater doses than are recommended, if the licensed dose has been ineffective. When prescribing a higher dose, they should explain their reasons during the discussion with you, and formally obtain your consent.

Current prescribing of synthetic oxytocin
Hospital doctors should also follow this standard of prescribing procedure for every use of synthetic oxytocin that does not adhere to the licensed instructions. But somehow synthetic oxytocin, as it is currently being prescribed for during and after labour, is slipping through the 'consent' net. The RCOG's recommended regime dilutions, dosage steps and a final maximum that all rise well above the recommended and (therefore) licensed limitations and this is not being explained to women, and their consent is not being obtained.

If unlicensed dilutions are declined by women who wish to receive the licensed dilution with full dosage range and fine-tuning options (via volumetric pump), in hospitals where only syringe drivers are available, a drip infusion can be requested, as a midwife will (or should) be in attendance continuously.
See Figure 2 below, which is from the Royal College of Obstetricians and Gynaecologists, called 'active mangement', first issued in 2001.
These RCOG guidelines suggest that after rupture of membranes (whether spontaneously or artificially), the infusion should be started at 1 mU/min, being raised to the licensed maximum (20 mU/min) by three hours later. In practice, contractions should start and settle in the range from 4-12 mU/min.

The recognition of early disorganised contractions and their attempt to organise themselves is an important skill which midwives should develop to protect patients from receiving an unnecessarily high infusion rate, which risks desensitising oxytocin receptors, thus causing contractions to ease off. The midwife may mistakenly assume that a higher infusion rate is needed, but it would be better to reduce the infusion to the rate when contractions were last palpable, and wait a bit longer.

Always, infusion rates should be increased only according to the clinical need, to improve the contraction rate without losing complete relaxation for at least a minute between them. (The clock times on a table of infusion rates are a loose guide only.)

Consent and additional risk factors
This article highlights the need for doctors and prescribing midwives working in NHS hospitals to restore standard consent procedures to hospital practice for the RCOG's unlicensed synthetic oxytocin regimes, and to inform women of other choices open to them, such as the licensed dosage range.

The RCOG's unlicensed synthetic oxytocin regime comes with the National Institute for Health and Care Excellence's (NICE) recommendation for an epidural in advance, accepted by many women, and the loss of fine-tuning options, which increase the risk of overly-strong contractions, fetal distress, complicated births and postpartum haemorrhage.

Providing this information, and seeking informed consent for unlicensed regimes, is not only the legal standard that women should expect from doctors registered to practise in the UK, but it protects non-prescribing practising midwives from seeking consent for unlicensed synthetic oxytocin regimes, for which they are not qualified or covered to take responsibility. It also protects prescribing midwives and doctors from potential allegations of assault for treatment carried out without informed consent, therefore finding themselves in conflict with the Montgomery ruling.

Obtaining valid informed consent cannot be skipped over as too challenging or too time-consuming. The prescriber must have clinical reasons for going 'off licence' (as required by the RCOG's regime); must explain these to the woman; must warn her of the risks being added to her labour in so doing, also describing any benefits offsetting those risks; and must accept the woman's decision if she declines.

Regardless of what a woman has agreed to earlier in the labour or before labour, a doctor must request consent again following a full assessment of the patient, if they find what they consider to be an obstetric reason to prescribe over 20 mU/min (the licensed maximum). If the woman declines, 20 mU/min must not be exceeded. It is illegal for the doctor to proceed - as implied in many synthetic oxytocin policies - without formal consent.

In all cases, people can change their minds after consenting to any drug or procedure and it must be discontinued. It is illegal to start or continue a procedure or treatment for which consent has not been given, or after consent has been withdrawn.

Practical implications of the RCOG's regime
The RCOG regime increases the dosage range to 32 mU/min, as shown in Figure 2 below, 12 mU/min over the maximum licensed dose! The inflexibility of this regime, now used all across the UK, means that the optimum infusion rate for as natural a labour as possible may be missed for some women.
See Figure 3 below for the rates omitted by RCOG, and the unlicensed increments
This regime is administered from a variety of unlicensed dilutions using volumetric pumps (or syringe drivers that offer 50 ml of intravenous solution at a time). For volumetric pumps, synthetic oxytocin is added to 500 ml suitable diluent, but the ability of volumetric pumps to provide an accurate dose is reduced when they are run at the slowest rates, as is required by the unlicensed dilutions recommended by the RCOG, of 10 IU or 30 IU in 500 ml.

The licensed 5 IU in 500 ml facilitates the full dosage range in a greater volume of fluid which can be administered more accurately via volumetric infusion pump.

The unlicensed increments of the RCOG's regime (after 4 mU/min) reduce the likelihood of successfully fine-tuning the infusion with maternal oxytocin, as only when changes of 0.5 mU/min are available (an option in the licensed instructions) can fine-tuning be achieved. While this situation persists with the RCOG's regime, so does the likelihood of partially desensitising oxytocin receptors.

When using syringe drivers to administer the infusion, it has been common for trusts to permit 10 IU in 50 ml (twenty times stronger than the licensed dilution) so that 50 ml lasts longer. The syringe driver is more efficient than a volumetric pump, and fine-tuning is possible (although not being practised) but the bolus option should be disabled before a synthetic oxytocin infusion is started, because 0.5 ml of 200 mU/ml would risk fetal or maternal distress if accidentally infused.

Some trusts use weaker dilutions in their syringes but none uses the licensed dilution.

In other words, the full range of licensed options has not been transferred into the RCOG's regime. Currently, no in-between rates are supplied for midwives to even try fine-tuning (see Figure 2 below). The clinical effects of not being able to control a synthetic oxytocin infusion optimally, within the recommended dosage range as licensed, include contractions coming too often and/or lasting too long and/or allowing too little relaxation between, such that the biochemistry of normal contractions gets progressively out of sync risking an increase in fetal distress, that may lead to caesarean section in first stage or instrumental delivery at the end of second stage, and also postpartum haemorrhage after third stage. All of which may impact the baby and will certainly impact the mother, both during this birth and in subsequent pregnancies and births.

Importantly, the dilutions being used to facilitate the RCOG's regime should be deemed pharmacological because they function as a drug, instead of blending with maternal oxytocin physiologically, as the licensed dilution can achieve. Theobald (1965) stated, 'it has never been shown that the pharmacological drip is more effective than the physiological one, and it is certainly less safe'.

(A half-strength physiological dilution can also be therapeutically effective.)

Synthetic oxytocin and other effects on blood pressure
Physiological dilutions of synthetic oxytocin normally reduce blood pressure slightly, but pharmacological dilutions more-so.

When the latter also require epidural for relief of otherwise shock-inducing pain, blood pressure also falls due to the epidural. The natural response to shock is also lowered blood pressure to facilitate oxygenation of distressed tissues.

The overworking of the uterine muscle stimulated to contract by synthetic oxytocin over a period of hours, and sometimes without sufficient time to recover between contractions, produces acidosis which naturally leads to vasodilation - yet another blood-pressure-lowering effect. Acidosis also affects the unborn baby.

If oxytocin receptors are desensitised as well, their part in achieving vascular and muscular tone when it is needed at the end of labour is diminished or removed. Brindsden and Clark (1978) discuss this in their research report on postpartum haemorrhage following their trial with experimentally large increments of synthetic oxytocin.

These five factors make a major contribution to excessive bleeding after birth, which could be prevented by using so little synthetic oxytocin that maternal oxytocin controls postpartum bleeding in the same way as after a spontaneous labour.

Is a shorter labour actually a benefit?
It is common for the term 'shorter labour' to be touted as a benefit of the use of synthetic oxytocin. But, even if the length of labour is actually being reduced on average, are individual women actually benefitting from this? Length of labour for an individual cannot be known beforehand, so determining whether an individual's labour has or has not been shortened by the 'active management' of their labour is not possible. So justifying high doses of synthetic oxytocin for this reason does not make sense.

Do epidurals mean the increased pain of induced labour is not an issue?
Giving an epidural that successfully obliterates the pain generated by higher-than-necessary doses of synthetic oxytocin might address the issue of the pain, but it does not overcome the other potential risks from the use of unlicensed synthetic oxytocin, and an epidural itself introduces new risks.

Care of women during induction of labour
When a woman agrees to prostaglandins treatment, or a synthetic oxytocin infusion, it is important that midwives recognise her status as a patient undergoing treatment, with new care needs which are more complex than the natural biochemical interactions of spontaneous labour.

This is because the synthetic oxytocin infusion requires continuous supervision by a qualified professional, and as many fine adjustments as necessary, according to its effect on the woman, the baby's tolerance of it, and to ensure every relaxation between contractions lasts for one whole minute or more. Therefore, the woman can never be left on her own with the infusion still running. This is clearly stated in the instructions, and underlined by advice from the World Health Organisation.

If the midwife has to leave the woman, then the synthetic oxytocin infusion should be paused, and this should be recorded in the notes and on the cardiotocography (CTG) trace. After the midwife returns, she should count the fetal heart with a Pinard's stethoscope to check that it is still in the normal range and reassess the contractions for 10 minutes. If all other observations are normal (and recorded), the infusion can be restarted at a slightly lower rate than when it was paused. These details must also be recorded in the notes.

Finishing labour after physiological dilutions of synthetic oxytocin
Once labour is established, the infusion can often be slightly reduced. An additional benefit of fine-tuning synthetic oxytocin is that, as far as possible, the rest of labour proceeds under the influence of maternal oxytocin with no further infusion rate increases.

During second stage, as expulsive contractions begin, maternal oxytocin rises significantly, allowing for synthetic oxytocin to be stepped down and discontinued within the hour before the baby is born.

When this handover between synthetic oxytocin and physiological labour is conducted with skill during second stage, after third stage (birth of the placenta) natural oxytocin normally achieves a sustained, spontaneous contraction that prevents excessive postpartum bleeding. Traditionally, a midwife stays another whole hour to check regularly that the womb is well-contracted, or bleeding is well-managed.

Restoring choice to clinicians and women
Nearly-natural labours are well within reach when the synthetic oxytocin infusion is managed according to the licensed instructions. Reinstating them formally is an essential consideration for Trusts, both from a safety and a legal perspective, as the standard licensed dilution is strong enough for its role to enhance sluggish contractions, without desensitising oxytocin receptors.

Remembering the baby
The baby should not be accepted as 'the canary in the mine' to indicate when something is wrong, rather than eliminating predictable causes of fetal distress beforehand. The ability to fine-tune synthetic oxytocin during labour is the most accessible way to prevent fetal distress during induced and augmented labour, or to address it immediately by slowing or discontinuing the infusion. It should be noted that fetal distress can occur for other reasons when synthetic oxytocin is not in use, which is why fetal distress when sythetic oxytocin in use, must immediately be taken seriously.
Summary
Consent from the woman for synthetic oxytocin infusion must always be sought, but currently no-one is informing women that when synthetic oxytocin is recommended, it is likely to be prescribed and administered in unlicensed dilutions and increments, with regular disregard for the benefits and safety measures built into the licensed instructions.

Restoring fully informed consent procedures, and the licensed dosage range as a valid option to be selected by women, doctors and midwives for a myriad of clinical reasons - and a natural maternal desire for as normal an outcome of labour as possible - promotes far better outcomes for women and babies, and higher professional satisfaction.
Illustrative tables
The following tables may be useful to give to your midwife or doctor to illustrate the figures and calculations in this article. In the Key and charts, 1 International Unit (IU) = 1000 milliunits (mU).
Linn Shepherd is a retired nurse-midwife from Scotland, who practised midwifery in Scotland and England until leaving to raise her children. She has investigated the early research that underpins the instructions licensed for intravenous infusions of synthetic oxytocin, for outcomes of enhanced obstetric labour comparable to those of spontaneous labour.
1. Mylan Ltd has taken Syntocinon ® over from Novartis, who had the licence from 1977 to 2018. Other UK manufacturers call their product 'Oxytocin'. https://www.medicines.org.uk/emc/product/9457/smpc

2. STEER PJ, LITTLE DJ, LEWIS NL et al. (1975). 'Uterine Activity in Induced Labour'. BJOG: An International Journal for Obstetrics and Gynaecology 82(6): 433-441. http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1975.tb00666.x/full

3. ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS: Setting Standards to Improve Women's Health (2001). 'Induction of Labour: Evidence-based Clinical Guideline Number 9'. Page 13 (24 of 90). http://www.perinatal.sld.cu/docs/guiasclinicas/inductionoflabour.pdf

4. NATIONAL COLLABORATING CENTRE FOR WOMEN'S AND CHILDREN'S HEALTH (UK): Funded to Produce Guidelines for the NHS by NICE (2008). 'Induction of Labour, 2nd Edition'. Clinical Guideline 2008, No. 70. Section 2:88 (106 of 124), Appendix D, Table D.2, footnote b. Published by RCOG Press. https://www.nice.org.uk/guidance/cg70/evidence/full-guideline-pdf-241871149

5. BEAZLEY JM, BANOVIC I and FELD MS (1975). 'Maintenance of Labour'. British Medical Journal 2(5965): 248-250. https://www.bmj.com/content/bmj/2/5965/248.full.pdf
https://doi.org/10.1136/bmj.2.5965.248

6. BUDDEN A, CHEN LJY and HENRY A (2014). 'High-dose versus Low-dose Oxytocin Infusion Regimens for Induction of Labour at Term'. Cochrane Database of Systematic Reviews. http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009701.pub2/full

7. BRAMLEY S (2019). 'Consent to Treatment Post Montgomery - plus ça change?'. AIMS Journal 31(3). https://www.aims.org.uk/journal/item/montgomery

8. VRACHNIS N, MALAMAS FM, SIFAKIS S et al. (2011). 'The Oxytocin-Oxytocin Receptor System and Its Antagonists as Tocolytic Agents'. International Journal of Endocrinology 2011:350546. Open Access online at https://www.hindawi.com/journals/ije/2011/350546/ http://dx.doi.org/10.1155/2011/350546

9. THEOBALD GW (1965). Letter, 'Buccal Oxytocin'. British Medical Journal 1(5428): 190-191. https://www.bmj.com/content/1/5428/190.5

10. MANSY A (2017). 'Does Labor Augmentation with Oxytocin Increase the Risk of Postpartum Hemorrhage? A Randomized Controlled Trial'. Clinics in Mother and Child Health 14:3 https://www.longdom.org/open-access/does-labor-augmentation-with-oxytocin-increase-the-risk-of-postpartumhemorrhage-a-randomized-controlled-trial-2090-7214-1000268.pdf

11. BRINSDEN PRS and CLARK AD (1978). 'Postpartum Haemorrhage after Induced and Spontaneous Labour'. British Medical Journal 2(6141): 855-856. https://www.bmj.com/content/bmj/2/6141/855.full.pdf

12. WORLD HEALTH ORGANIZATION (2017). Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors, 2nd edition. P-23: 355 of 492 . Free PDF download (4.26 MB) at http://www.who.int/maternal_child_adolescent/documents/managing-complications-pregnancy-childbirth/en/ ISBN: 978-92-4-156549-3

13. BERDE, B. (1965) 'Some Observations on the Circulatory Effects of Oxytocin, Vasopressin and Similar Polypeptides'. P 11 and 'Release of Oxytocin during Parturition'. P 51. Advances in Oxytocin Research: Proceedings of a Symposium held by the Blair-Bell Research Society at the RCOG on the 1 st May. (ed) J, H, M, Pinkerton. London. Pergammon Press Ltd. eBook ISBN: 9781483156507

14. WEEKS A and NEILSON J (2015). 'Rethinking Our Approach to Postpartum Haemorrhage and Uterotonics'. British Medical Journal 2015;351:h3251. https://doi.org/10.1136/bmj.h3251
https://livrepository.liverpool.ac.uk/2047825/1/Weeks%20Neilson%20BMJ%202015%20351%20h3251.pdf

[Dosage tables courtesy of www.oxytocinmeasures.com. Other info is at: GMC website, NMC website, Birthrights.org.uk]

Published on 1st December 2019

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Induction with synthetic oxytocin: less is more

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AIMS Journal, 2019, Vol 31, No 4 By Linn Shepherd Administration of synthetic oxytocin - induction of contractions Synthetic oxytocin has been used since the 1950s for induction and augmentation of contractions. Induction and augmentation only differ in that induction is to try to start labour, whilst augmentation happens after contractions have started, to improve their strength or organisation, and make them more efficient.

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(Image: Facebook)

A lesbian couple have become the first parents to carry a baby in both of their wombs through a revolutionary IVF procedure.

Jasmine Francis-Smith, aged 28, gave birth to her son Otis using an egg that was implanted by the London Women's Clinic after it was first incubated by her wife, Donna, 30.

More than 100 babies have been born to lesbian couples using artificial incubation, but this is a world first procedure called "shared motherhood" in which both parents contribute.

Donna, 30, who is a British Army officer, told The Telegraph: "We're overwhelmed to be honest, it's blown up massively.

"You get a lot of same-sex couples where one person is doing the whole thing, and the one person is getting pregnant and giving birth, whereas with this we're both involved in a massive way.

"It's definitely brought us closer together emotionally. We're a close couple anyway but we both have a special bond with Otis as well which was helped by the way we've done it.

"It's my egg, and then they did the egg collection from me and then put it back into my body for 18 hours before being put into Jasmine's body, and she became pregnant."

During the treatment one partner contributes and incubates the egg, and the other carries the foetus

Jasmine, 28, gave birth on Sept 30 in Colchester, Essex, where the family live and the couple said that the procedure made them feel "equal in the whole process"

Jasmine said: "The Anecova procedure has really made me and Donna feel equal in the whole process and has emotionally brought us closer together, we are a true family. If we had to go through the process again there is nothing we would change."

Doctors claim it is the first time a baby had been grown in two wombs.

Nick Macklon, medical director at the London hospital where Otis was born said: "This is the first time this has been done. It's very exciting because it means that for lesbian couples wanting to have babies together both of them can be involved in actively creating the embryo and then creating the baby."

Advocates of the procedure, say the procedure gives both partners a practical and emotional stake in the pregnancy.

They also claim it provides the embryo with additional nutrients.

Anecova is a Swiss medical device company based at the EPFL Innovation Park in Lausanne.

The couple tied the knot in April last year after meeting in 2014 through online dating.

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British lesbian couple become the first in world to carry a baby in both wombs

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A lesbian couple have become the first parents to carry a baby in both of their wombs through a revolutionary IVF procedure. Jasmine Francis-Smith, aged 28, gave birth to her son Otis using an egg that was implanted by the London Women's Clinic after it was first incubated by her wife, Donna, 30.

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You can’t spoil a baby by comforting it when it’s crying

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Many new parents are given conflicting advice. The baby should sleep on their stomach... wait no, the back or... the side? The baby should sleep with the mother, no, in their own crib, no, in their own room. Sometimes the advice comes from a trusted place, like a doctor or a family member. Most of the time it's unsolicited from well-meaning people, who often chirp things like, "Enjoy this age while it lasts!" "Catch up on sleep when the baby sleeps," and the cherry on top, "Stop holding the baby so much - you're going to spoil them."

Parents struggle when it comes to comforting a crying baby. Their instinct is to rush over and hold their child, but with advice like, "don't spoil him," they might hesitate the next time they hear the cry.

The good news is there is no reason to hesitate when cuddling with your crying baby. Here's the truth: it's impossible to spoil them.

The Purpose of a Baby's Cry

Notre Dame psychologist Darcia Narvaez led a research team that found children become healthier and happier adults when they have parents who treated them with affection, sensitivity, and playfulness since birth.

"Sometimes, we have parents that say, you are going to spoil the baby if you pick them up when they are feeling distressed. No, you can't spoil a baby," said Professor Narvaez.

There are many possible reasons to explain why a baby is crying and Professor Narvaez reassures parents that it's never wrong for wanting to give the child comfort.

"Part of it is following your instincts because we as parents want to hold our children," she says. "We want to keep that child close, follow that instinct. We want to keep the child quiet and happy because the cry is so distressing." [1]

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The Research

Professor Narvaez worked with two colleagues, Lijuan Wang and Ying Cheng, to conduct this research and their findings will be published in an upcoming article in the journal Applied Developmental Science.

The three professors surveyed over 600 adults about their childhoods. They examined things like how much affectionate touch was given in their household, how much free play they were allowed as a child, and how much positive family time they experienced. The researchers found that adults with less anxiety and overall better mental wellbeing had positive childhoods.

"These things independently, but also added up together, predicted the adults' mental health, so they were less depressed, less anxious, and their social capacities - they were more able to take other people's perspective," said Professor Narvaez. "They were better at getting along with others and being open-hearted."

J. Kevin Nugent, director of the Brazelton Institute at Children's Hospital in Boston and a child psychologist, said that a newborn baby learns from his interactions with his parents that the world is reliable, and can trust that his needs will be met.

Responding to baby's cries "isn't a matter of spoiling," he said. "It's a matter of meeting the child's needs." [2]

Open Letter to Parents

Professor Narvaez encourages parents to respond to their baby's cries, whether it means holding them, touching them, or rocking them; it's all good. [3]

"What parents do in those early months and years are really affecting the way the brain is going to grow the rest of their lives," explains Narvaez, "so lots of holding, touching and rocking, that is what babies expect. They grow better that way. And keep them calm, because all sorts of systems are establishing the way they are going to work.

"If you let them cry a lot, those systems are going to be easily triggered into stress. We can see that in adulthood - that people that are not cared for well, tend to be more stress reactive and they have a hard time self-calming."

The researchers found that free play in and out of doors is vital for child development, as well as growing up in a positive, warm home environment.

Narvaez believed that humans need these important things from the time they are born. Therefore, she recommends parents follow their instincts.

"Sometimes, we have parents that say, you are going to spoil the baby if you pick them up when they are feeling distressed. No, you can't spoil a baby. You are actually ruining the baby if you don't pick them up. You are ruining their development," says Narvaez. "...So follow the instinct to hold, play, interact, that is what you want to do."

After all, a baby's cry is heart-breaking for a reason.

It Takes a Village

While a parent might feel relieved that they can pick up their baby every time he cries, this quickly becomes exhausting, especially if there's only one parent at home while the other works most of the day. The at-home parent might struggle to eat, sleep, and do basic chores when they attend to the baby's every cry.

"We need to, as a community support families so they can give children what they need," Professor Narvaez says, who recommends involving grandparents, aunts, uncles, cousins, and friends in the baby's life.

"We really didn't evolve to parent alone. Our history is to have a community of caregivers to help - the village, so that when mom or dad needs a break, there is someone there who is ready to step in." [4]

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"You can't spoil a baby!" New research says to comfort crying babies

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Many new parents are given conflicting advice. The baby should sleep on their stomach... wait no, the back or... the side? The baby should sleep with the mother, no, in their own crib, no, in their own room. Sometimes the advice comes from a trusted place, like a doctor or a family member.

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Pelvic floor is a super trendy expression with new exercises to do or machine to train them. We use it more and more as we realised how it is important for women to protect and to exercise it correctly. But do you actually know what is it exactly? Do you have an idea how it looks like? No?

So today let's have a look at Pelvis & Pelvic floor Anatomy in order to understand how it works and to then be able to protect and exercise it correctly!

Pelvis bones

It is a complex of bone enclosing visceral organ of the perineum

#1: Pubis symphysis is a junction (joint) between two bones. In pregnancy a lot of pressure is applied on this junction and may lead to inflammation and pain in this area or spread lower through the adductor muscles which insert directly on the Pubis symphysis

#2: Ischions are the bony prominence on which we sat. In pregnancy, this area is often painful due to muscles spasm of the piriform (here a video to stretch it)

#1 : Iliac crest are the bony prominences you can feel on the side of your lower abdomen

#2 : vertebrae

#3: Pubis symphysis

#1 Vertebrae

#2 Sacrum is a big bone at the end of your spine. It ends with a small bone coccyx!

#3 Coccyx

Genital organ

#1 Ovary

#2 Uterus is held by ligaments attached to the sacrum

#3 Bladder rest on the pubis symphysis

#4 Vagina is a big gap in the middle of the pelvis

#5 Urethra is a canal to empty the bladder

#6 Sacrum

#7 Rectum is terminated by an angle and the anus to retain faeces allowing anal continence

#8 Pelvic floor muscles

#9 Vaginal opening

Pelvic Floor muscles

These muscles form a hammock holding the pelvis organs (bladder, uterus, vagina, rectum...) in place.

Here you see what is visible from the outside:

Now let's see the muscles hiding behind, the pelvic floor muscles!
There are 3 different layers: superficial, intermediate and deep muscles.

1# Ischiocavernosus muscle

2# Superficial transverse perineal muscle helps to close the urethra and allow urine continence

3# External anal sphincter as suggest by it is name, it close the anus 😉

4# Bulbospongiosus muscle inserts around the clitoris. It helps to erect it and to close the vaginal opening

5# External urethral sphincter as its name say, it close the urethra and allow urine continence

6# Bulbo coccygeal muscle is an involuntary muscle and also helps to close the vaginal opening. It is always tear during natural birth

7# Fibrous Perineal body

#1 & #2 Levator ani muscles allow anus contraction and anal continence but also trigger its relaxation allowing defecation.

I hope this rapid review of Pelvis and Pelvic floor muscles anatomy will help you to understand what is going on down there.
As usual, don't hesitate to ask your questions in the comment below!

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Pelvis & Pelvic floor Anatomy - My French Physio

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Pelvis & Pelvic floor Anatomy Pelvic floor is a super trendy expression with new exercises to do or machine to train them. We use it more and more as we realised how it is important for women to protect and to exercise it correctly. But do you actually know what is it exactly?

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How pregnancy can be more difficult.. (article in The Conversation from Mari Greenfield)

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Rawpixel.com/Shutterstock

Maternity records in the UK have spaces only for the expectant mother and the baby's father. This inflexibility can cause difficulties for the pregnant person, their partner, and their unborn baby if they do not fit into these boxes.

Over the last decade there has been a significant increase in the number of people conceiving outside of the traditional model of a heterosexual couple, so this affects an increasing number of parents. It's not known exactly how many lesbian women give birth, but fertility treatment in UK clinics for lesbian couples has increased 15-20% year-on-year for the past decade. In 2016 there were 1,404 live births registered to same-sex female couples.

No data is available for the numbers of trans men (that is, female-to-male transgender people) who give birth in the UK. But some trans men choose to do so, and the number of referrals to gender identity clinics is rising each year.

Research shows that problems occur when heteronormativity - the perception that heterosexuality is the normal, default, or preferred sexual orientation - is communicated either overtly or subtly in the way healthcare staff treat patients, the way leaflets are worded, or the assumptions made in the way administration systems are designed.

This means that co-mothers (the non-birth mothers in lesbian families) may not be recognised as parents, and so miss out on support such as breastfeeding advice for example, and it can leave both pregnant trans men and lesbian co-mothers feeling excluded.

Poor experiences in the run-up to, during and after birth can negatively affect expecting couples emotionally and psychologically in ways that lead to problems for the whole family, including the baby. For example, postnatal depression is common and associated with adverse outcomes for both mother and child. A number of studies, while small scale and qualitative in nature, point to higher incidence of symptoms of postnatal depression among lesbian birth mothers. There are also similarly small scale and qualitative studies that suggest similarly heightened feelings of anxiety and depression among lesbian co-mothers.

For co-mothers in particular, this seems linked to their sense of connection with the baby, and from the extent to which they feel recognised as a parent or not by maternity services, family and friends and wider society. The combined stress of identifying oneself as lesbian or bisexual to healthcare staff, and the attitudes of wider society, alongside the stress of pregnancy generally are greater than that experienced by heterosexual pregnant women, and represent a plausible reason for higher symptoms of postnatal depression among lesbians.

This wider issue of difficulties experienced due to heteronormativity in maternity services is something research suggests exists worldwide.

Discrimination and danger

For a decade I have worked as a doula, offering non-clinical care and support to women during their pregnancy, through labour and birth and in the days and weeks afterwards. In my experience issues have often arisen among those who do not fit the configuration of a heterosexual couple.

Earlier this year, I cared for a pregnant trans man whose unborn baby had a 50:50 chance of having a life-threatening medical condition, and might have needed blood transfusions while still in the womb. The condition can be tested for through a maternal blood sample, which his midwives requested. But the laboratory repeatedly failed to do the right test on the blood sample, assuming that the forms had been mixed up because a maternal test was requested for a patient whose records stated was male. This caused weeks of delay, at a time when, for the baby's health, every day counted.

In a case from the US, a pregnant trans man who attended hospital with severe stomach pain was not treated urgently, after it was initially assumed he was obese rather than pregnant. As a result, doctors missed that his baby's umbilical cord had slipped through the cervix before the baby - a rare but serious birth complication that requires an immediate birth by caesarean - and the baby subsequently died.

Africa Studio/Shutterstock

It is sometimes not patient records or administration systems but individual staff whose heterosexist assumptions mean birth partners are treated differently. For example, it is common for partners to be allowed longer visiting hours on postnatal wards, and encouraged to fetch food from the canteen for their partners. But lesbian partners may be denied access to wards or not allowed to assist their partners because staff assume all partners are male, and that women trying to come into a postnatal ward are merely other visitors.

They may also encounter blatant homophobia or transphobia from those caring for them, such as the midwife who told a new mum that it was " disgusting" that her baby had two mums. Discrimination may be illegal, but there is evidence that covert, harder-to-prove prejudicial treatment continues, including the doctor who found inventive ways not to offer fertility treatment to a lesbian by trying to frighten her, and then by not responding to her queries or passing on her test results. Or the midwife who showed her disapproval of lesbian mums by performing rough vaginal examinations on a woman in labour.

It is more common however that healthcare staff are well-intentioned but lack the skills, confidence and training to provide good care to pregnant lesbians and trans men. The Royal College of Nursing and birth support charity NCT have highlighted the issue, but midwives say that while treating lesbian birth mothers is part of their job, they don't always know how to treat the co-mother. Some say colleagues struggle to care for pregnant lesbians due to their religious beliefs.

Better data will reveal the reality

In the UK, NHS Trusts do not yet collect data on the gender or sexual orientation of pregnant people and their partners. Because we don't have this data, we don't have much information about the statistics for lesbian and trans men's pregnancy outcomes or birth experiences. Most pregnancy and birth research and most laws and regulations assume babies are created in a heterosexual relationship.

There is no simple solution - substituting "pregnant people" for "pregnant women", or "partners" for "fathers" on documents may lead to invisibility (especially of women), confusion about whether genetic or social information is required, and is a sticking plaster that doesn't solve the difficulties they face. We need to understand the problem better: the physical and mental health needs of pregnant lesbians and trans men are hugely under-studied, and so poorly understood.

A good start would be for NHS maternity records to properly record the gender and sexual orientation of pregnant people and their partners in order that we can more accurately know the number of lesbians and trans men giving birth in Britain, and begin to understand how their experiences may be similar or different to heterosexual women's birth experiences.

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How pregnancy can be made more difficult by maternity care's notions of 'normal'

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Maternity records in the UK have spaces only for the expectant mother and the baby's father. This inflexibility can cause difficulties for the pregnant person, their partner, and their unborn baby if they do not fit into these boxes.

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Vitamin K (NHS document)

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Patient leaflet not found - Oxford University Hospitals

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What to do if the patient leaflet you are looking for is no longer available.

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Vitamin K (AIMS)

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What is Vitamin K?

What we refer to as Vitamin K is an important group of chemicals which help our blood to clot. There are several different types of Vitamin K and these different types all have different effects on the body. The only effect that is being considered when Vitamin K is offered to your baby is its role in reducing the chance of complications from excessive bleeding known as Vitamin K Deficiency Bleeding (VKDB). VKDB was previously known as Haemorrhagic Disease of the Newborn (HDN) and the two names refer to the same condition. VKDB is very rare but it can be very serious, which is why the parents of all babies in the UK are offered an injection of Vitamin K for their baby, just after birth, even though almost all of those babies will not benefit from it. If parents decline the injection they should be offered an oral dose given several times over a few weeks.

Types of Vitamin K Deficiency Bleeding (VKDB)

There are three recognised types of VKDB:

Early Onset, which occurs within 24 hours of birth

Classic Onset, which occurs 2-7 days after birth (some researchers define classic onset as 2-14 days after birth)

Late Onset, which occurs between 8 days and 3-4 months after birth (or 2 weeks onwards for those who define classic onset as being 2- 14 days after birth).

Early Onset VKDB is almost always caused by medications taken by the baby's mother such as some epilepsy drugs, and anticoagulants which have passed to the baby before they were born and stopped the baby's body from being able to clot their blood properly. It is the Classic Onset form of VKDB for which artificial Vitamin K supplementation is most effective - almost all babies who are given the supplement do not experience VKDB. Late Onset VKDB is often caused by an underlying problem in the baby such as a liver condition, but, for most babies, Vitamin K supplementation at birth stops Late Onset VKDB.

Consequences to babies of Vitamin K Deficiency Bleeding

VKDB is extremely rare, but it can be very serious. While most babies, if treated quickly, will recover, some babies will have permanent damage, and very rarely, a baby will die. The type of damage that a baby has after such a bleed will depend on where the bleeding happens and a bleed in the brain may cause significant brain damage. Some babies may experience excessive bleeding due to Vitamin K deficiency following an operation such as circumcision and, in this case, babies can lose a dangerous amount of blood.

How Common is Vitamin K Deficiency Bleeding?

Because artificial Vitamin K is given to so many babies, and because VKDB is extremely rare even if babies are not given Vitamin K, it is very difficult indeed to get a clear picture of how common VKDB actually is.

Some numbers of babies who experience VKDB when not given Vitamin K supplementation, which come from various studies which refer to developed countries like the UK are:

1/10,000 (McNinch and Tripp 1991, Von Kries and Hanawa 1993, Passmore et al 1988)

5.8 to 17.8/100,000, which is between 1/17000 and 1/5500, so consistent with the 1/10000 (Sanker 2016)

1/14,000 - 1/25,000, which is also consistent with the above numbers. This is looking at LATE onset only, not early onset or classic onset (Shearer 2009)

It is clear from these numbers that the risk to any individual healthy baby experiencing VKDB is very low. It may be higher in at-risk babies (see below).

babies have low levels of Vitamin K?

Babies are born with lower levels of Vitamin K compared to older children and adults. It is not understood why this is, and it may be important for a process that we don't yet understand. It might be that giving additional Vitamin K to babies through any method - injection, oral drops or high levels in artificial baby milk (formula) - may cause harm that we don't yet know about. We don't have any evidence of this - but then there are no long term studies on the potential health impacts (risks or benefits) of giving Vitamin K either. So, while you might be told that there is no evidence of long term harm, it is also the case that equally we have no evidence of its long term safety. We have just not looked at either safety or harm.

We are sometimes told that breastmilk has 'low levels' of Vitamin K when compared to formula, but this actually makes no sense. Formula has high levels of Vitamin K only because this is what is added into the product. It's rather like adding food colouring to formula, then saying that breastmilk has low levels of food colouring compared to formula! However, the additional Vitamin K that is added to formula does mean that those babies whose bodies do need extra Vitamin K will normally get it from the formula, whereas breastfed babies will receive the biologically normal amount, which in the rare case of a baby needing extra, may not be enough to stop them from experiencing VKDB.

Although most of our Vitamin K needs come from food (so, for babies, their milk), Vitamin K is also manufactured in the human gut. It may be that babies have lower levels of Vitamin K because their gut needs to start working efficiently in a way that it didn't need to do in the womb. This might take longer for some babies than others. We do know that breastfed babies who experience VKDB, and who were not given Vitamin K, very often have not fed well from birth, so it's possible that the cause of the VKDB was that they were not receiving enough milk. This is one reason why early and effective breastfeeding after birth is important; if a woman decides to give formula, feeding should also start as soon as the baby shows an interest.

Methods of giving Vitamin K to babies

Intramuscular (IM) injection

This is an injection given to the baby, usually shortly after birth although it can wait for a few hours so that the mother can first spend time getting to know her baby, have plenty of skin to skin and hopefully initiate breastfeeding - all of which are likely to reduce the chance of VKDB.

The injection is very effective against Classic Onset VKDB. It is extremely hard to obtain accurate figures as to the effectiveness of the injection. This is because different studies look have very different methodologies. However, evidence from the UK shows that with this injection the rates of VKDB drop to below 1/100,000.

This is where the Vitamin K liquid is put into the baby's mouth. Vitamin K is a fat soluble vitamin and so it is considered important to give the doses of oral Vitamin K immediately after a feed of breastmilk or formula because the fat in the milk helps the Vitamin K to be absorbed.

There is no good evidence to show how much Vitamin K to give, and how often to give it, however in the UK it is normal for 3 doses to be given although this might differ from product to product so always check for the correct information for the Vitamin K product that you are using. For some products, babies who are formula fed may not be offered the third dose. Babies may spit up the oral dose, often making it impossible to know whether or not they've swallowed any, and if so, how much.

There is no evidence that we have been able to find which looks at whether the oral version of Vitamin K affects the baby's gut bacteria.

Deciding to not give Vitamin K

Some parents choose to not give their baby Vitamin K, and it is their legal right to decide this provided that they have parental responsibility for their child, and that there is no court order stating that someone else has responsibility for medical decisions. Health Care Providers are not allowed to try to coerce or force parents into giving any intervention, treatment or prophylaxis. Instead they should offer balanced information to support the parents' informed decision making, which they should then support. If this doesn't happen, you can remind them of their obligations to provide information and then support your decision.

One option that some parents choose is to make the decision to have Vitamin K only if their baby shows signs of having a liver condition, or if they are not feeding well and they become concerned, bearing in mind that injury from VKDB can occur before symptoms show. Another situation may be that the baby needs a tongue tie revision (snip) and some practitioners who treat tongue ties will not do so if the baby hasn't had Vitamin K. In this case, it is usually possible to obtain the Vitamin K through the GP, although a few areas of the UK have reported that the local NHS Trust is not allowing this. While this could be challenged, it might be worthwhile finding out in advance how open your local Trust is to this option as fighting it when feeding is going badly is likely to be incredibly stressful. Another option is to attempt to find a practitioner who will do a tongue tie revision without Vitamin K, but this may need to be a private practitioner.

What are the risks of Vitamin K supplementation?

Injections are painful for babies. Considering that most babies have never before felt pain, being given the vitamin K by injection is likely to be a deeply unpleasant experience for them. It is often given very soon after birth, during the time where the baby and mother are just starting to get to know one another, and the pain of the injection can impact on this important bonding period. There is no reason to give the injection until mother and baby are ready - you don't need to be rushed into it just for the convenience of the medical staff. If you make the decision to allow your baby to have the VK injection, you can decide when it's given. We do know that babies can feel less pain when they are breastfeeding, so you might decide to wait until your baby is feeding well, which may be a few hours after birth, before allowing them to have the injection - or longer if you wish.

It is not uncommon for babies to get a bruise at the site of the injection.

Like all medications, it is possible, although very unlikely, that the wrong medication or the wrong dose may be given. The UK has robust protocols to avoid this but you are entitled to see the bottle of medication before it's used to ensure that you are happy that it is the correct product.

There is one known case of an allergic reaction to Vitamin K supplementation. There are three known cases of pneumonia caused by aspiration of the oral Vitamin K.

The Vitamin K dose is much higher than babies would ever have naturally in their body and we do not know if this may have a negative effect on them when they are given the dose, or later in life. One research paper showed that preterm babies given 0.5-1mg of VK (1mg, if injected, is the norm for term babies) still had levels which were 1900-2600 times higher than babies who were not given the Vitamin K two days after the injection, and 550-600 times 10 days after. Although babies who are premature (less than 36 weeks' gestation) should be given a dose which relates to their birthweight, we have had reports of babies being given the full dose for a term baby. There is also some concern that formula fed premature babies may have excessively high levels of Vitamin K in their bodies as the formula's added Vitamin K is an extra supplement.

There was a study in 1992 which appeared to show an increase in childhood cancer for babies who are given Vitamin K by injection, but not orally. Further research studies did not find an increase in cancer rates and concerns about the way the 1992 study was carried out have been raised. No randomised controlled trials have ever been done to look at this possible risk. It is very unlikely that this will ever happen and we will probably never know for certain whether this link exists or not.

I've heard that as many as 1/60 babies may experience Vitamin K Deficiency Bleeding. Is this true?

Much of the research that we have on Vitamin K is of poor quality and cannot be relied upon to give us accurate information.

For instance, one study, Sutherland et al (1967) looked at whether there was a difference between the amount of bleeding seen in breastfed babies compared to babies fed on formula, and how Vitamin K affected this. This is an important study to mention because it is frequently referred to, even now, and references which state that VKDB can be as high as 1 in 60 babies refer back to this study. Even The Guardian newspaper published an article in 2019 which gave this statistic. https://www.theguardian.com/news/2019/feb/21/anti-vaxxers-delivery-ward-doctor-mother-newborn

In this study there were four groups:

1. Babies who were breastfed and given Vitamin K

2. Babies who were breastfed and not given Vitamin K

3. Babies who were formula fed and given Vitamin K

4. Babies who were formula fed and not given Vitamin K

Babies were not put to the breast until 8-12 hours after birth, and formula fed babies were given sterile water for 1 -3 feeds FROM 12 hours old (it appears they were starved before this) and thereafter an artificial milk made from evaporated milk mixed with carbohydrate. The results actually showed that the breastfed babies who were given Vitamin K had fewer incidents of bleeding than any other group - possibly because the formula did not have added Vitamin K (this is not stated in the paper) or maybe because the breastfed babies were able to take in nutrients sooner than their formula fed counterparts. By contrast, babies who were breastfed but did not have Vitamin K were most likely to show signs of bleeding. There is very little of value to be taken from this study given that the babies were not fed appropriately, and in addition many were circumcised, with the amount of bleeding from the penis being one marker for problematic bleeding. It is possible that the removal of the attached foreskin from the glans of the baby's penis (which is similar to removing a fingernail), done without pain relief on an awake and immobilised infant, could change other physiological processes which may affect blood clotting.

The Tennessee Cluster

In addition to this research, in June 2014 Schulte et al released a paper looking at five babies in Tennessee, USA, who experienced VKDB, plus a further two who had blood tests and were found to have what was considered to be dangerously low levels of blood clotting factors but had no symptoms. We are not able to evaluate how many babies this is, compared to babies who did not experience VKDB in this region, as this information is not included in this paper, so we do not know if it was an unusual number of babies. Every baby was older than 2 weeks (the youngest was 6 weeks) and therefore all of the babies who had bleeds were experiencing Late Onset VKDB which may mean that there was an underlying illness in these babies. This is not a research paper or a trial, and there is not enough information in it to draw the conclusion that VKDB is more common than the above studies have reported.

Does artificial Vitamin K contain any animal products?

Some versions of the Vitamin K supplement do contain animal products. A vegan version is available and you can ask your midwife to source this for you if you wish.

References:

1. Shearer, Vitamin K Deficiency Bleeding in Early Pregnancy: www.ncbi.nlm.nih.gov/pubmed/18804903

2. Association of Tongue Tie Practitioners (ATTP): www.tongue-tie.org.uk/ ; Lactation Consultants of Great Britain: www.lcgb.org/

3. Koklu et al, Anaphylactic shock due to vitamin K in a newborn and review of literature: www.ncbi.nlm.nih.gov/pubmed/24059412

4. Bhandari et al, Aspiration pneumonia in association with oral vitamin K: www.ncbi.nlm.nih.gov/pmc/articles/PMC1721474/

5. Costakos et al, Vitamin K prophylaxis for premature infants: 1mg versus 0.5mg: www.ncbi.nlm.nih.gov/pubmed/14703597

6. Pediatrics Journal: Did "Controversies Concerning Vitamin K and the Newborn" Cover All the Controversies? https://pediatrics.aappublications.org/content/113/5/1466.2.long

7. Golding et al, Childhood cancer, intramuscular vitamin k, and pethadine given during labour: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1883000/

8. Zipersky, Vitamin K at birth: www.ncbi.nlm.nih.gov/pmc/articles/PMC2351614/?page=1

9. Sunderland et al, Hemorrhagic disease of the newborn. Breast feeding as a necessary factor in the pathogenesis: www.ncbi.nlm.nih.gov/pubmed/6071586

10. Schulte et al, Rise in late onset vitamin K deficiency bleeding in young infants because of omission or refusal of prophylaxis at birth: www.ncbi.nlm.nih.gov/pubmed/24842255

Further reading:
Cochrane, Pre-term babies and vitamin k: www.cochrane.org/CD008342/NEONATAL_prophylactic-vitamin-k-prevention-vitamin-k-deficiency-bleeding-preterm-neonates

Evidence Based Birth on vitamin k: https://evidencebasedbirth.com/evidence-for-the-vitamin-k-shot-in-newborns

Circumcision and vitamin k : www.yourwholebaby.org/vitamink

Written by: Emma Ashworth
Reviewed by: Debbie Chippington Derrick
Review on: 19/10/2019
Next review needed: 19/10/2021

AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email helpline@aims.org.uk or ring 0300 365 0663.

Published on 19th October 2019

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What we refer to as Vitamin K is an important group of chemicals which help our blood to clot. There are several different types of Vitamin K and these different types all have different effects on the body.

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Birth beyond the binary (AIMS article)

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To read or download this Journal in a magazine format on ISSUU, please click AIMS Journal, 2019, Vol 31, No 2 By AJ Silver here What is non binary?
Before we start, we must be clear that this is not trauma top trumps. It isn't who is the most at risk, or who is the most deserving of our time, effort and inclusion. Inclusion isn't pie, there is always enough to go around if we make the choice to be inclusive.

Non binary is not always the lack of gender. It doesn't necessarily look like assigned female at birth (AFAB) people who are wearing a suit from the men's section. It's more complicated than that. Non binary in general, although not always, is the absence of associating fully with the world's assumptions of your personality, likes and dislikes, abilities, strengths and weaknesses based on your assigned at birth gender. Assigned at birth gender refers to whether your genitals look like they are male or female, or perhaps not one or the other. It is also expected that our genital appearance will match our chromosomes, but this is not the case for many people.

Some non binary people will go by gender queer, demi gender, agender, bigender and more. Some will identify as trans. The most basic explanation of trans is that your assigned at birth gender doesn't fit who you are, who you present as. Other non binary people will identify as femme (feminine), others masc (masculine). The standing theme is that we do not fit into the world's cis-heteronormative expectations.
What is Dysphoria?
Non binary can be an AFAB person in dresses with long hair, it can be AMAB (assigned male at birth) people with a beard, suits and eyeliner. There is no one "look" or dress code. They may change their clothing style from day to day, or like me, they have found clothes that feel comfortable and they wear the same clothes day in day out to avoid dysphoria. Non binary people don't always present as androgynous people, although they might.

Dysphoria is when a person experiences distress or discomfort with the skin they are in, as this does not reflect their gender identity. This may be a non binary person wishing their chest or breasts were bigger or smaller, or a trans woman wanting to have a more "feminine" frame, walk or voice. These experiences vary dramatically from person to person. Not all trans and non binary people feel dysphoria at all, and many have no desire to change the body they were born in with surgery, hormones or anything else. Others feel that it is imperative to their life that they change their body's appearance. There is no wrong or right way to be trans or non binary. For many people, being referred to by the wrong pronouns can also be very upsetting and trigger dysphoria.

Something that triggers one person's dysphoria may not trigger another's. It's important to remember that gender euphoria also exists! "Follow the euphoria" can be a valid and safe way to explore gender expression in order to find an expression that fits, or more closely resembles your identity.

Some argue that gender roles in society have a lot of sway in a person's dysphoria and identification. In other words, boys can wear dresses, and like makeup and unicorns, and girls can be scientists, roll around in the mud and be physically stronger than boys. But by removing or dismantling the world's perceptions of femininity and masculinity will we remove dysphoria and remove the need for people to "change" or "transition" from one gender to another? Unfortunately not. Being a "tom boy" or a "butch woman" doesn't mean you want to transition to being a boy or a man, want to have any surgeries or want to use male pronouns. Similarly, being a feminine boy, loving dollies and dressing up as princesses doesn't mean that all of these "girly girl boys" want to, or will grow up to be trans.
Being non binary in the "maternity" system
It is interesting to consider what the situation would be if in society we HAD equality. If every opportunity and availability that is afforded to AMAB persons were available and given to AFAB people (and vice versa) would we still have "tomboys" and "girly girls"? Would people still transition? Would non binary still be a "thing"? Maybe - but for the time being, like it or not, we live in a hugely gendered society that constantly insists we are pigeon holed into abilities, likes, dress, jobs, interests and personality traits based purely on our genitals.

There are very few studies of any queer people birthing, and there is no research into gender queer or trans peoples' birthing experiences that pre-dates 2013. The research that there is focuses more on lesbians experiencing pregnancy and the evidence does show that queer people may be at greater risk of perinatal mental health difficulties.

However, there has been no follow up to these findings in the UK. Given that the percentage of lesbian couples registering birth has been rising by around 15-20% (these stats also do not include single parents) year on year over the last decade, we can make an educated assumption that other queer people are also registering more babies year on year.

The birthing and parenting world is difficult for non binary people in a number of ways. The obvious and most prevalent are the ways the world constantly pushes us into boxes: Male or Female. Mum or Dad. Non binary people may choose to go by a different name, just as some grandparents are Nanny or Grandma, Pops or Granddad. Bubba seems to be fairly popular choice in the non binary world, as it's gender neutral, and super cute! The needs and wants of the non binary community aren't far removed from the wants and needs of the trans community who birth and feed their babies. AIMS has already covered a lot of this in their "He's not the mother" article, but I will discuss some additional issues below.
How can we be more inclusive in the Maternity system?
Feedback from parents is encouraging health care providers and birth workers to move away from calling new parents "mum and dad." The fear is that it's dehumanising to anyone - straight, cis, trans, non binary people - to lose their identity as soon as they've brought a baby into the world, to stop being who they are and to simply be referred to by their relationship to their child. This is a fantastic example of how inclusive language doesn't just serve trans or non binary people - it can be viewed positively for everyone who births in society. It ensures recognition for the overwhelming majority, so let's take another half step to include even more people.

So, the first and arguably the easiest step is language. Can we be inclusive without language?

Misgendering someone is using the wrong pronouns (using the person's assigned at birth gender's pronouns: calling a trans woman he / him for example), or using their "dead name" (the name they were given at birth, if they have decided to no longer use it, rather than their chosen name, if they have one). The easiest way to explain how this feels, or what it does for the relationships that health care providers and service users are trying to forge, is that it destroys all confidence that the non binary person has in the person providing the care for them. If your health care provider kept getting your name or date of birth wrong, or calling you "Mr So and So" if you identify as a woman, would you feel confident that they understood you, your medical history or that they had prepared for the meeting?
Removing the word "Woman" is not an option.
The journal of adolescent health in 2018 published its findings that using a person's chosen name and pronouns may cut the risk of suicide by a massive 65%. Given that the Stonewall research has uncovered that a staggering 89% of trans people have considered suicide, and that 27% have attempted suicide, using their chosen names and pronouns isn't just polite, it could be a matter of life and death.

Pleas for inclusion are often met with the objection that it is erasing the overwhelming majority of those who birth, the mothers, the women. This thought process needs some examining here.

The example I always fall back on is that ramps on public buildings take nothing away from the able bodied people that want to access them, but it makes it possible for disabled persons to access them. Cis-heteronormativity will not disappear overnight because we include language, tick boxes and space in our hearts and minds to accept that not all who birth are women or mothers.
Issues that trans and non binary people experience around maternity care
The wider LGBT+ community accepts and acknowledges that removing any and all references to women is in no one's interest. If we remove language that protects any person that births their baby we risk the principle of bodily autonomy being diluted. If we give equal rights to the non-birthing parent, we could risk giving the right to make decisions about our own bodies to other people such as fathers, known and unknown sperm donors and partners of the women and birthing people, rather than, as it should be, entirely the choice and decision of the pregnant woman or person. This needs further collective work, thought and time to ensure that no one is left out, no one's rights are diluted, and that we are all included in being able to access these basic human rights surrounding birth and pregnancy.

One of the issues faced by Trans and non binary parents is their legal right to be known as the father (for trans men) and the mother (for trans women). The current law of the Human Fertilisation and Embryology Act 2008 states that whoever gives birth to the baby is legally the mother. However, if the birthing parent is a trans man he may want to be known as the baby's father. If the child is adopted by a lesbian couple, they can amend the birth certificate, and both be listed as parents (parent 1 and parent 2), and gay men can apply for a court order to then adopt their child. This leaves a hole for trans and non binary people who, in a legal document, are unable to be referred to as, or to be recognised for, their true relationship to the child. Even if the person birthing is legally male (have obtained a Gender Recognition Certificate, or GRC), they are currently recorded as being the mother.

There is currently an ongoing legal battle in the UK for a trans man who birthed his baby to be listed as the father rather than the mother. The case could be a landmark victory for the LGBT+ community and open the doors for gender queer people to be recorded on official documents in accordance to their identities. If it is rejected by the court, the rights of LGBT+ persons, especially when it comes to gender and identity, will be rejected by officials once more. This is yet another blow to our freedom and rights to be who we are born to be.

The baby of a trans man has no legal protection to be breastfed in public. The Equality Act 2010 says that it is discrimination to treat a woman unfavourably because she is breastfeeding. Limiting the protection to just women, means trans men - who are legally men - are excluded from the protection that the Act offers. This therefore risks the baby's right to being given breastmilk, and, of course, risks the person breast or chest feeding that baby to be discriminated against.

Similarly, a trans man is not clearly protected by the Equality Act 2010 for aspects of the Act which only refer to women. A trans man therefore may have no protection, for example, against dismissal or unfair treatment based on pregnancy, nor rights regarding maternity pay, nor maternity leave. This situation has not yet been tested in court.

This goes some way to explain why many gender queer people will default to their assigned at birth gender, or remain closeted (or not "out") when birthing and parenting as there is often no other option for them. They are better protected as a woman, in a legal sense, despite the psychological distress that this may cause

There is no universal legal proof in the UK, or any document that a non-binary person can acquire to "prove" their gender, or lack thereof. Some countries (such as Canada, Portugal, and certain states in America) are emerging with a "third option" on driving licence, passports and birth certificates and so on, but the UK is lagging behind.

Documents have been issued in these countries as early as 2003 with an "X" or a "U" to indicate the bearer is neither "F" (female) or "M" (male).

There are small leaps being made across the world for the right for people to be legally neither male nor female, however, we are often forgotten or erased in the battle for these small victories.
AJ Silver
www.birthkeeperdoula.co.uk AJ Silver is a birth and postnatal doula, babywearing consultant and trainee breast / chest feeding counsellor with ABM. They are currently writing the UK's first LGBT+ competency course for birth workers to educate and encourage the dialogue of birthing outside of the binary and heteronormative. They live in Essex with their 2 children and spouse.
Having health care providers and birth workers that acknowledge our gender is an essential link in the chain to improving the outcomes for parents who do not fit into the world's cis-heteronormative expectations.

References:

1. https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199778072.001.0001/oxfordhb-9780199778072-e-003
2. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/families/bulletins/familiesandhouseholds/2017
3. "He's not the mother", AIMS Journal 2017, Vol 29, No 2 https://www.aims.org.uk/journal/item/hes-not-the-mother
4. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/85008/business-quickstart.pdf
5. Human Fertilisation and Embryology Act 2008 https://www.legislation.gov.uk/ukpga/2008/22/section/33
6. Legal case of a trans man who gave birth applying to be listed as the baby's father: https://www.pinknews.co.uk/2018/06/09/transgender-man-starts-legal-battle-to-be-recognised-as-the-father-of-baby-he-gave-birth-to
7. Equality Act on breastfeeding: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/85008/business-quickstart.pdf
8. Non binary gender registration models in Europe: https://www.ilga-europe.org/sites/default/files/non-binary_gender_registration_models_in_europe_0.pdf

Published on 20th July 2019

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To read or download this Journal in a magazine format on ISSUU, please click AIMS Journal, 2019, Vol 31, No 2 By AJ Silver here What is non binary? Before we start, we must be clear that this is not trauma top trumps.

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He’s not my mother! (AIMS article)

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AIMS Journal, 2017, Vol 29 No 2 Mari Greenfield looks at language, LGBT and inclusion
When lesbian, gay, bisexual and transgender (LGBT) people have children, the language commonly used by those providing maternity care can be either inclusive or exclusive, as can the assumptions that lie behind that language. In this article I am going to talk about both my experiences as a lesbian mother who has given birth and about the experiences of other LGBT parents, including parents I have worked with as a doula, and as reported in academic texts and the press. There are examples of good practice and poor practice.

How do LGBT people conceive?

In order to understand the barriers that LGBT parents might face, it is important to understand that LGBT people may create families in different ways. For the purposes of this article, which is about birth, I am going to leave aside options that include adoption, and having children from a previous relationship. Lesbians and bisexual women may have babies as a single parent, or as part of a couple. Single lesbian and bisexual women are likely to face the same assumptions and language barriers as single heterosexual women. Therefore, in this article, I will concentrate on LGBT people having babies within a same-sex relationship, or as an 'out' transperson (or both).

Lesbian/bisexual women couples may have conceived using sperm from a fertility clinic, or they may have conceived using sperm from a 'known donor'. Their intentions may be to raise the baby with the two women as the only parents, or if using a known donor, there may be additional parents involved in a variety of roles in the baby's life.

Gay and bisexual men may become parents through a co-parenting relationship with a single woman, or a lesbian/bisexual woman couple. They may also become parents through surrogacy. Their role in their baby's life may include the baby living full-time or part-time with them, or not living with them at all. It may be that only the genetic father is intended to have a role as a father, or it may be that he and his partner are intending to have an equal parenting role. Transmen and transwomen may also become parents. This may be as the partner of a genetic parent, or through being the genetic parent themselves. They may be in same-sex or opposite-sex relationships when they become parents, or they may be single.

What are LGBT people's experiences of giving birth?

The academic literature shows that there are specific issues faced by LGBT parents during birth. Similarly, press accounts show that the experience of being the non- biological mother can include being dismissed and not treated as the mother, as Montbaston (2017) says to the point where:
'I ended up in tears saying that I felt I constantly had to justify that I was the baby's mother'.
Montbaston's experience also included people assuming she, as the more feminine presenting partner 'should have' been the pregnant one. Post birth, her experience was that when she did introduce herself as the mother, and talked about her partner, it was assumed that she had given birth, and her partner was a man, even when she said

'My partner is a woman. She had a baby on Sunday' (Montbaston, 2017)

This impacted whether she was allowed to go and get food from the trolley for her partner, who was assumed to be a man, and therefore not allowed to have the hospital food. For Montbaston this lack of recognition as a partner and parent was distressing. For Montbaston's partner, it meant a newly postpartum woman who was not able to get out of bed was likely to be denied food.

Research by Maccio and Pangburn in 2012 links these experiences of non-inclusion to a slightly elevated level of post-partum depression in lesbian birth and 'co-mothers'. This finding is reinforced by the work of Abelsohn, Epstein and Ross in 2013, which found that 'non-birth lesbian, bisexual and queer' parents' mental health in the perinatal period was affected by four groups of factors;

biology, connectedness, and relatedness

social recognition, including recognition from Maternity Services

social support

changes during pregnancy, which should be discussed by the maternity care provider

This means that maternity care providers getting the support right for LGBT parents has an impact on physical and mental health of the genetic and birth parents, non- birth parents, and the baby in very real ways.

What problematic assumptions might those involved in perinatal care make?

Most people conceive within a heterosexual relationship, with the woman giving birth. Recognising that this is a majority experience is fine, but assuming that this means that all people conceive this way leads to the difficulties like those above.

It is problematic for lesbian/bisexual women couples when maternity care providers assume the woman's partner will be a man, and the genetic parent of the child. It is problematic for gay/bisexual men when it is assumed that they will not be involved as a father, or that only the genetic father will be involved, or when it is assumed that his partner will definitely be involved (as this may not be the case).

In the circumstances of a gay/bisexual man/couple becoming parents through surrogacy, healthcare providers need to recognise that the birth choices are still the birthing woman's to make. However, all involved may have decided that the postnatal decisions are for the father/fathers to make (or they may have not decided this). Clarity is needed, for the parents, and the healthcare providers.

For transmen and transwomen having children, the problems may become even more complex. Transitioning can include taking hormones, and sometimes having surgery, which can affect the person's ability to be a genetic parent in the future. In the UK, the NHS has the discretion to offer to freeze eggs or sperm prior to transition, but can also refuse to do so. The number of applications which are accepted/refused are not known. This year, Cross, a 20 year old pregnant transman, chose to be public about the fact that the NHS's refusal to freeze his eggs led him to have few choices;

1. Never be a genetic parent, or

2. Wait many years to medically transition, or

3. Have a baby as a single father at a younger age than he would have ideally chosen.

Cross chose the last option, but in an article by Dale (2017), expressed unhappiness that he had been put into this situation, when he would have preferred to have had the choice to become a parent later on, and possibly as part of a couple.

Choices about birth may also affect the transitioning process for some transpeople. Research by MacDonald et al (2016) into transmen's experiences of birth and infant feeding suggested that more than one man had: ' actively withheld his desire to have children from his surgeon, worried that any questions about breastfeeding would hamper his chances of obtaining the surgery.'

Further difficulties can be experienced simply getting access to services. MacDonald himself reports that during his second pregnancy, after 'worrying symptoms' led him to need to go straight to the hospital, he was denied access to the obstetric unit by a security guard, and had to: 'come out to them as transgender and explain a lot of my backstory in the middle of a hallway alongside other people who were also trying to get past the security desk... that didn't feel particularly safe.'

Most of the difficulites discussed above stem from the same group of assumptions. These are that:

It will be a woman giving birth

If she has a partner, he will be a man

These two will be the only parents of the baby

Genetic parents, legal parents, and those raising the baby are the same, and the terms are interchangeable.

How does the language used reflect these assumptions?

Many forms, computer records, and written policies relating to pregnancy and birth will have a space for 'mother' and one for 'father'. Sometimes, they genuinely do want the details of the two genetic parents - for example NHS forms which calculate the probable height the child will be as an adult, or which record likely allergies. Other times, the details actually sought will be about who will have care of the child, or who will be present at the birth, or who will have legal responsibility for the child.

In recognition of the latter situation, some NHS Trusts have replaced 'father' with 'partner' on some policies and forms. Where such substitutions have not been made on forms, some individual practitioners will substitute 'partner' for 'father' when talking to women, if they are aware that the parents are a same-sex couple. This is well-intentioned, but not always helpful. For example, in my own first pregnancy my midwife, in an attempt to be inclusive, asked my partner about her family health history, which was entirely irrelevant to the risk factors for our baby, but did lead to a referral to a consultant for a genetic condition that exists in my partner's family!

Other problems exist for gay men becoming parents. The substitution of the word 'partner' for 'father' may exclude gay men who are not the partner of the birthing woman. Also, when surrogacy involves egg donation to a gestational surrogate, simply having one space for 'mother' in forms may not be accurate. Health details of both the egg donor and the surrogate may influence the pregnancy and birth.

It is problematic for transmen when it assumed that only women can become pregnant, and that pregnant people will all use terms such as 'mother' and female pronouns such as 'she' and 'her'. It is problematic for transwomen who are genetic parents when it is assumed that the person who supplies the sperm that creates the baby will use male pronouns, and the terms 'man' and 'father'. In some cases, this can lead to real difficulties, such as for Yuval Topper-Erez, a transman, and his husband, who struggled to register the birth of their baby in Israel. The problems arose because legally, male parents could only be recorded as 'father', and two biological fathers could not be listed on a birth certificate.

For some transpeople, the language used for body parts can reinforce any underlying dysphoria. For example, MacDonald et al's (2016) research showed that many transmen preferred to term their nursing relationship as 'chestfeeding', rather than 'breastfeeding', as 'breast' denotes gender. However, different people will prefer different terms, and (as with partner for father), simply substituting one term for another will not necessarily improve the experiences of all LGBT parents.

How could we improve our language?

Inclusion is something which many maternity care providers are striving to achieve, which is very welcome. Moves towards greater inclusion in language can be seen in the common adoption of the term 'partner', rather than terms such as 'husband' and 'father'. However, as shown above, it cannot simply be a case of replacing these terms, because the realities of LGBT parenting do not conform to a two parent, two genders, model. Improving our language needs to start from the recognition that there may be more than two parents, and different parents may have different roles (genetic parents, legal parents, parents who are raising children). Equally, in LGBT families, a parent's gender does not necessarily denote their role.

This makes it difficult for those supporting LGBT families, as there are not always simple substitutions that can be made to improve the language used.

The answer to this difficulty may be a process of rethinking how we approach our own understandings of the perinatal family:

Be aware of what assumptions you have. We all have assumptions, but being aware of what they are is a necessary first step to being open to alternative possibilities.

Don't be afraid to ask questions, but think about whether they are necessary.

If you don't know whether the baby's genetic health history is known, it is fine to ask if it is. Equally, if you are not sure what pronouns a person prefers, ask. However, questions about why parents decided how to conceive/who was to carry the child/for non-medically relevant details of transition are not actually necessary, and can be upsetting.

Think about gendered terms.

For convenience, we can slip into using terms such as 'the mother' and 'the father', but these can be problematic for LGBT families. 'The mother' implies there is only one mother, and assumes that the person who is pregnant is going to identify as a woman and a mother. There may be one mother, two mothers, or no mothers when LGBT people have children, and the same is true for 'the father'. Using names instead of roles can avoid this.

Think about what you actually need to know.

As mentioned above, simply substituting one term for another does not lead to inclusion, and can lead to inappropriate questions and/or referrals. Before asking a question, think about what you actually want to find out, and then phrase the question accordingly.

'Who are the baby's parents?' and 'who gave birth?' are much better questions than 'who is the real mother?' or 'where is the mother?'

When you have been told something, record it.

Asking about someone's gender, pronouns, or who their partner is once is perfectly fine, and often welcome. However, once that information has been obtained, the same question should not be asked repeatedly, or by multiple people.

This process can be applied by individual professionals to their interactions with clients. It can also be applied by organisations, in particular as an aid to work through and improve their forms, recording systems, policies and practices.

MacDonald (2015), urges those involved in maternity care not to choose between celebrating women, and ensuring we include all pregnant people. He advocates being 'generous with our ink' and ensuring we include everyone. In the context of LGBT inclusive language, we could add the suggestion to those involved in maternity care to be 'generous with our questions' - star ting with a generous approach to questioning our own assumptions.
Mari Greenfield

References

1. Abelsohn K, Epstein R & Ross L (2013) 'Celebrating the "Other" Parent: Mental Health and Wellness of Expecting Lesbian, Bisexual, and Queer Non-Birth Parents' Journal of Gay and Lesbian Mental Health, 17:4
2. Dale R (2017) 'I'm four months pregnant' The Sun, 7th January 2017
3. Maccio E. & Pangburn J (2012) 'Self-Reported Depressive Symptoms in Lesbian Birth Mothers and Comothers' Journal of Family Social Work, 15:2
4. MacDonaldT(2015)'Transphobia in the midwifery community' Huffington Post, 15th September 2015.

5. MacDonald, Noel-Weis, West, Walks, Biener, Kibbe & Myler (2016) 'Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: a qualitative study' BMC Pregnancy and Birth, 16:106

6. Montbaston J (2017) 'My daughter's birth' online blog, retrieved from readingmedievalbooks.wordpress.com/2017/03/30/my-daughters-birth/. Published 30th March 2017, accessed 25 April 2017.

Published on 1st June 2017

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AIMS Journal, 2017, Vol 29 No 2 Mari Greenfield looks at language, LGBT and inclusion When lesbian, gay, bisexual and transgender (LGBT) people have children, the language commonly used by those providing maternity care can be either inclusive or exclusive, as can the assumptions that lie behind that language.

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Swaddling for sleep

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Woman’s bones in back move during labour

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An image shared on social media has shown a bulge in a woman's back where he bones have moved to make way for her baby during child birth.

The photo, which was originally shared on North Dallas Doulas Instagram, shows a woman leaning over on her front with her back to the camera. In it, you can see the bulge protruding from the bottom of her back against her skin.

Tangi Birth Services, a pregnancy care centre, then shared the image on Facebook where it racked up likes, with many commenting to say they didn't realise why their back hurt so much during childbirth.

The rhombus of Michaelis. Credit: Instagram/northdallasdoulas

They shared it with the caption: "Can you see that bulge on her lower back? That is the rhombus of Michaelis. During the second stage of labour, a combination of bones including your sacrum actually move backwards and in doing so, increases the diameter of your pelvis. This is what is known as opening of the back.

"This is completely normal and is in fact an integral part of a physiological birth as it allows your baby the maximum amount of space to turn as they navigate their way out into the world.In order to facilitate the opening of your back, you should use active birth positions where you are upright and leaning forwards. So cool right!

"And while your pelvis is expanding, your baby's head is moulding - changing shape to fit through those pelvic bones! Your body was made to do this! And your body and your baby work together! is not something to be feared... it is something to be understood!"

One woman wrote: "My husband told me about this! I give birth on my knees and he said the base of my back pushed out. Fascinating to see a photo of it thank you.

"And ouch! No wonder I found labour worse on my back! I soon flipped over."

Another wrote: "When my bones shifted for birth I felt a pop like when you crack your knuckles and it felt SOOOOO GOOD!!! I had been having terrible back labour and then POP and just this extremely wonderful release and the pain was gone. So amazing."

Featured Image Credit: PA

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Woman's Bones In Back Move During Childbirth In Astonishing Photo

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An image shared on social media has shown a bulge in a woman's back where he bones have moved to make way for her baby during child birth. The photo, which was originally shared on North Dallas Doulas Instagram, shows a woman leaning over on her front with her back to the camera.

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Immersion in water in labour and birth (Cochran database)

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Cochrane Database Syst Rev. Author manuscript; available in PMC 2014 Apr 10.

Published in final edited form as:

Background

Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Critics cite the risk of neonatal water inhalation and maternal/neonatal infection.

Objectives

To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2011) and reference lists of retrieved studies.

Selection criteria

Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers.

Data collection and analysis

We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy.

Main results

This review includes 12 trials (3243 women): eight related to just the first stage of labour: one to early versus late immersion in the first stage of labour; two to the first and second stages; and another to the second stage only. We identified no trials evaluating different baths/pools, or the management of third stage of labour.

Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials). There was also a reduction in duration of the first stage of labour (mean difference −32.4 minutes; 95% CI −58.7 to −6.13). There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28,five trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (RR 1.58; 95% CI 0.63 to 3.93, five trials), neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials), or neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials).

Of the three trials that compared water immersion during the second stage with no immersion, one trial showed a significantly higher level of satisfaction with the birth experience (RR 0.24; 95% CI 0.07 to 0.80).

A lack of data for some comparisons prevented robust conclusions. Further research is needed.

Authors' conclusions

Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. However, the studies are very variable and considerable heterogeneity was detected for some outcomes. Further research is needed.

History

The use of water immersion as a therapeutic medium is not new. Its exact origins are unknown, but there is evidence of immersion in water being used as a treatment for physical and psychological ill health by the Chinese, Egyptians, Japanese and Assyrians, as well as Greeks and Romans ( Reid Campion 1990; Reid-Campion 1997). Warm water immersion during labour, including birth, used for relaxation and pain relief, has a long history in lay and clinical care ( Garland 2000). Igor Tjarkovsky, a Russian boat builder, stimulated the foundation of a movement to promote waterbirth in Soviet Russia in the 1970s. He became convinced of the benefits of water immersion as a means of maximising physiological potential. Michel Odent subsequently popularised water immersion in other European countries ( Odent 1983). Although considered a fad by some, the use of water during labour and birth appeals to both women and their carers, particularly those striving for a woman-centred, intervention free, 'normal' experience. In 1995, the first international waterbirth conference was held in London, followed by many subsequent study events and international conferences.

Official acceptance of the use of water immersion as a care option during labour came in the UK in 1993, with the publication of the Changing Childbirth report ( Department of Health 1993), which recommended that a pool facility should be an option available to women in all UK maternity units. Professional recognition of the use of water during labour and birth came in 1994 when both the Royal College of Midwives ( RCM 1994) and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting ( UKCC 1994) published position statements, which incorporated water immersion during labour into the role of the midwife. The use of water during labour/birth is now integrated in the UK Midwifery Rules and standards ( Nursing and Midwifery Council 2010), and UK policy for maternity services with section 8.4 of the National Service Framework for Children, Young People and Maternity Service ( Department of Health 2004).

Most of the evidence on the use of water immersion is based on observational studies ( Garland 1997; Garland 2002; Geissbuehler 2004; Ohlsson 2001; Thoeni 2005). A tension has arisen with regard to the perceived acceptability of randomised controlled trial (RCT) design, as some midwives and women perceive this as obviating maternal choice to what is now a widely available option, while women with strong preferences may decline to participate ( Garland 1994). Factors such as depth of water, size of the pool and whether the water is still or aerated/whirlpool water have not been compared, as pool design and practice have tended to be based on local availability and customs.

Water immersion during first stage of labour - what it offers women

The positive physiological effects of hydrotherapy such as buoyancy, hydrostatic pressure, and associated thermal changes, are relevant to women labouring in water, where labour is defined as including the first, second (birth) and third stages. The buoyancy of water enables a woman to move more easily than on land ( Edlich 1987). This can facilitate the neuro-hormonal interactions of labour, alleviating pain, and potentially optimising the progress of labour ( Ginesi 1998a; Ginesi 1998b). Water immersion may be associated with improved uterine perfusion, less painful contractions, a shorter labour with fewer interventions ( Aird 1997; Garland 2000; Moneta 2001; Otigbah 2000; Geissbuehler 2004; Thoeni 2005; Zanetti-Daellenbach 2007). In addition, the ease of mobility that water immersion offers women may optimise fetal position by encouraging flexion ( Ohlsson 2001).

Hydrotherapy has marked physiological effects on the cardiovascular system ( Cefalo 1978). Shoulder-deep warm water immersion reduces blood pressure due to vasodilatation of the peripheral vessels and redistribution of blood flow. It is suggested that water immersion during labour increases maternal satisfaction and sense of control ( Hall 1998; Richmond 2003). A woman who feels in control during childbirth experiences greater emotional wellbeing postnatally ( Green 1998).

The UK is promoting water immersion during labour and waterbirth as a means of empowering women and is consistent with the current agenda of normalising birth ( Royal College of Midwives 2011), the consensus statement from the maternity Care Working Party ( Maternity Care Working Party 2007); both of whom use a waterbirth image to illustrate normal birth, as does the Vision for Midwifery expressed by the Midwifery 2020 programme ( Midwifery 2020 Program 2010).

Although the use of additives such as essential oils to the water appears to be gaining popularity ( Calvert 2000), to date no trial has generated reliable evidence to support or refute the use of any additive.

Waterbirth (second stage of labour) - what it offers women

It has been suggested that waterbirth may reduce the uptake of pharmacological pain relief and likelihood of perineal trauma ( Burke 1995; Burns 2001; Garland 2000; Geissbuehler 2000; Otigbah 2000). There may also be increased maternal satisfaction with the birth experience.

Water immersion and the fetus/neonate (first and/or second stage)

It could be argued that the fetus benefits from a relaxed mother, as this maximises placental oxygen perfusion. 'Nature's opiates', endogenous endorphins, predominate. When the mother is not fearful, oxytocin is released to stimulate effective contractions. Labouring in water, compared to land, has been found to reduce stress hormones, catecholamines, which inhibit oxytocin and labour progress. The fetus may be more likely to adopt a flexed position, because the mother can easily explore different positions to maximise her pelvic diameters if the pool is sufficiently large ( Ohlsson 2001).

Concerns raised in a survey and case reports about birth in water for the baby include 1) thermoregulation during labour, 2) infection, 3) respiratory difficulties and 4) snapped cord ( Gilbert 1999; Kassim 2005; Mammas 2009; Nguyen 2002; Pinette 2004).

1. Thermo regulation

As with any labouring woman, it is important to avoid her becoming pyrexial. Therefore, the water temperature of a pool should not exceed the maternal body temperature, as immersing a woman in water above her natural core temperature will result in fetal hyperthermia and associated cardiovascular and metabolic disturbances ( Johnson 1996). High temperatures have been identified as a safety issue by several authors as being associated with fetal mortality and morbidity, based on individual case studies and/or theory ( Deans 1995; Johnson 1996; Rosevear 1993). The theory underpinning this was originally based on a study on pregnant ewes ( Cefalo 1978). The fetus responded to an increase in maternal temperature by becoming tachycardiac, reducing resistance in the placenta bed and thus heat dissipation. As the temperature increased, there was a tendency to exceed the heat that could be dissipated by the placenta, leading to an increased risk of fetal mortality ( Cefalo 1978). A review of the literature on temperature control in mammalian fetuses, mainly sheep, primates and a limited number of human participants, identified that the fetal metabolic processes produce heat ( Power 1989). This heat is transferred to the mother primarily via the circulatory system, the umbilical cord and placenta where the large surface area and constant blood flow facilitate heat transfer. A second pathway for heat transfer is via fetal skin, to amniotic fluid, the uterus and maternal system. To enable this heat transfer, the fetus is 0.5°C warmer than the mother. This difference is apparently constant across species, although the basal temperatures differ ( Power 1989). When maternal temperature increases, heat transfer is inhibited and the fetal temperature rises, until transfer is again possible. However, there is a concomitant rise in metabolic activity and oxygen demands as temperature increase, the effect of which may be seen in fetal heart rate changes, and which may contribute to fetal compromise during labour. Temperature regulation, and its assessment, are therefore important during labour/birth irrespective of the use of water immersion.

2. Respiration

The diving reflex prevents a healthy baby born in water from drowning. This is an apnoea on expiration (the opposite of an adult who dives having taken a breath), with a closed larynx. The fetal larynx has a myriad of airway chemoreceptors which prevent fluid aspiration. The diving reflex is stimulated via facial skin receptors conveying stimuli along the trigeminal nerve, triggered as these receptors make contact with the water ( Johnson 1996).

Fetal breathing is inhibited at the hypo-pharynx. This mechanism is associated with hormonal factors such as prostaglandin and adenosine; sensors in the oral pharynx, including free nerve endings/taste buds, prevent aspiration, and indeed the normal mechanism is that any lung fluid rising into the oro-pharynx is swallowed. Mild hypoxia further inhibits breathing until chronic sub lethal override point, leading to the belief that an uncompromised human neonate will not breathe under water ( Johnson 1996). A compromised neonate born underwater has the potential to gasp before the nose and mouth are above the surface, thus inhaling bath water into the lungs. Inhalation of even a small quantity of fresh water can be absorbed quickly into the circulation causing appreciable haemodilution and fluid overload - as seen in fresh water drowning.

There have been two reports of neonatal death following waterbirth attended by a midwife ( Burns 2001; Rosser 1994). These adverse outcomes are very rare, and causality cannot be inferred on the evidence to directly link the reported case studies of rare adverse outcomes with waterbirth.

3. Infection

It has been suggested that fetal/neonatal infection may occur due to cross-contamination from the water and pool, and from the woman ( Hawkins 1995; Rawal 1994). However, several comparative studies, cohort studies, and audits report no increase risk of infection for the fetus/neonate ( Alderdice 1995; Anderson 1996; Eriksson 1997; Otigbah 2000; Rush 1996; Robertson 1998; Zanetti-Daellenbach 2007). As with all maternity provision, it is incumbent upon practitioners to ensure they have appropriate cleaning protocols for labour and birthing pools, and employ universal precautions.

To date, there is no evidence of increased maternal, fetal or neonatal risk associated with water immersion, compared with labouring and giving birth on land. Two UK national surveys were undertaken during the 1990s: Alderdice 1995 included 2885 women and their neonates, while Gilbert 1999 evaluated the neonatal outcomes for 4032 infants. Both surveys indicated that there was no reliable evidence to justify denying the choice of water immersion for labour and/or birth to women at low risk of complications. In addition, multiple cohort studies/audits have suggested the safety of water immersion during labour and birth for women at low risk of complication ( Garland 2006; Geissbuehler 2004; Otigbah 2000; Thoeni 2005). RCTs have been conducted which are the focus of this review.

Maternal adverse effects of water immersion during labour have been theorised. These include the possibility that it may promote unrealistic expectations about labour, restrict choice of analgesia, restrict mobility, reduce contraction effectiveness, and increase perineal trauma ( McCandlish 1993). Increased risk to the mother of infection caused by water entering the uterus has been proposed ( Rosevear 1993). If warmth has a relaxing effect on the uterine muscles, the uterus may contract less efficiently postpartum ( Church 1989; Deans 1995). A theoretical risk of water embolism has been hypothesised ( Odent 1983). The logic of this hypothesis has been challenged ( Wickham 2005). To date no studies have reported an association between water immersion during labour/birth with this adverse event.

4. Snapped umbilical cord

Concerns have been raised about the dangers of umbilical cords at water births ( Gilbert 1999). Cords also snap in land births; there are however, no data for this. Cord snaps associated with waterbirth may be related to undue traction exerted on the cord as the baby is lifted out of the water.

Third stage of labour

We are not aware of any studies which have compared third stage of labour management or whether the placenta was delivered in or out of the water.

Water immersion during labour and birth: what it offers caregivers

Labour and birth is a complex, multifaceted and major life event encompassing physiological, emotional, psychological and social elements. It is therefore highly individualised and its features and outcome cannot be predicted with certainty. Although much of health care is based on understanding pathology and ill health, and while that may be appropriate for some, in maternity care, women are experiencing a normal physiological process. Midwives Downe and McCourt ( Downe 2004) advocate that midwifery care should be set in the context of salutogenesis.

The salutogenic theory originated from interviews conducted with Israeli women who had survived the Holocaust about their time in concentration camps during the Second World War. It was noted that some stayed healthy despite horrendous experiences. This epidemiological study stimulated sociologist Antonovsky to develop the salutogenic paradigm as a way of focusing on health rather than disease ( Antonovsky 1979; Antonovsky 1987). Central to salutogenesis is a person's sense of coherence, which Antonovsky defined as a global orientation that denotes the degree of self-esteem and confidence an individual possesses to enable them to deal with life's vicissitudes. In essence salutogenesis involves fostering a positive outlook and sense of self-worth to empower the individual to realize their potential. Empowerment is a key element of woman-centred care and the drive to normalise birth - an international initiative, led in the UK by the Royal College of Midwives ( RCM 2008). The development of normal birth care pathways is consistent with these aims ( NHS Wales 2004). Another stimulus to normalise birth is the international concern over the rise in caesarean sections in particular, but the medicalisation of labour and birth in general ( RCOG 2001). The medicalisation of childbirth has many women believing that childbirth is inherently dangerous ( Green 2007). It can be argued that water as an environment changes the context in which care is provided; it facilitates the paradigm shift, from professional-centred to woman-centred, from pathology dominated to normality expected. The woman is in her own 'world' and access to her is mediated by the water.

Water implies relaxation and warmth, and many would suggest it also conveys femininity and sexuality ( Odent 1999). Clarke 2007 report an increase in the use of water immersion during labour and birth as one result of increasing the focus of one maternity unit to normality through the use of a care pathway. A birthing pool therefore offers midwives an opportunity to develop the skills required to provide woman-centred care, form a therapeutic rapport with women, facilitate their freedom and participation in decision making, and support them in having choice and control over their care ( Nursing and Midwifery Council 2010).

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs) only. (We will not include results from quasi-RCTs in the analyses but we may be discuss them in the text if little other evidence is available.)

We have reported trials that included randomised and non-randomised subjects if the randomised data are presented separately. We have included published, unpublished and ongoing studies with reported data.

Types of participants

Nulliparous or multiparous women in labour with a singleton pregnancy, irrespective of gestation or labour characteristics.

Types of interventions

This review is one in a series of Cochrane reviews examining pain management in labour. These reviews contribute to an overview of systematic reviews of interventions for pain management in labour, and share a generic protocol. To avoid duplication the different methods of pain management have been listed in a specific order, from one to 15. Individual reviews focusing on particular interventions include comparisons with only the intervention above it on the list. Methods of pain management identified in the future will be added to the end of the list. The current list is as follows.

1. Placebo/no treatment

2. Biofeedback ( Barragán 2011)

3. Intracutaneous or subcutaneous sterile water injection ( Derry 2011)

4. Immersion in water (this review)

5. Aromatherapy ( Smith 2011a)

6. Relaxation techniques (yoga, music, audio)*

7. Acupuncture or acupressure ( Smith 2011b)

8. Manual methods (massage, reflexology)*

9. Transcutaneous electrical nerve stimulation (TENS) ( Dowswell 2009)

10. Inhaled analgesia

11. Non-opioid drugs ( Othman 2011)

12. Local anaesthetic nerve blocks ( Novikova 2011)

13. Epidural (including combined spinal epidural) ( Anim-Somuah 2005; Simmons 2007)

Accordingly, this review includes comparisons of any kind of bath/tub/pool that enabled immersion during any stage of labour, regardless of care setting, compared with: 1. no treatment (no immersion); 2. hypnosis; 3. biofeedback; 4. intracutaneous or subcutaneous sterile water injection; and 5. immersion during a different stage of labour.

Types of outcome measures

We chose primary outcomes that we thought would be the most clinically valuable in assessing safety and effectiveness for the woman, fetus/neonate and caregivers. We identified all outcomes that were considered to be of interest from the perspective of the woman and her baby, primary caregivers and related service providers. These (list below) are analysed within the comparison groups:

immersion in water versus no immersion during the first stage of labour;

immersion in water versus no immersion during the second stage of labour;

comparison of different types of bath/pool;

additives versus no additives to water used for immersion during labour and/or birth;

early (cervical dilation less than 5 cm) with late (cervical dilation more than 5 cm) immersion.

Primary outcomes

Maternal outcomes

Morbidity - side effects

○ Blood loss during labour (first, second, third stage, and immediate postnatal period)

○ Infection during labour/postnatal period

○ Perineal trauma

○ Postpartum depression

○ Post-traumatic stress disorder

○ Pain intensity (first and second stage, as defined by trialists)

○ Mode of delivery (spontaneous birth, assisted vaginal births and caesarean sections)

Wellbeing

○ Satisfaction with childbirth experience (as defined by trialists)

○ Satisfaction with pain relief (as defined by trialists)

○ Sense of control in labour (as defined by trialists)

○ Effect (negative) on mother/baby interaction

Neonatal outcomes

Morbidity - side effects

○ Apgar score less than seven at five minutes

○ Cord pH immediately after birth (arterial and or venous cord blood)

○ Admission to special care baby unit/neonatal intensive care unit

○ Respiratory support (oxygen/ventilation required)

○ Lung hypoplasia

○ Infection, including markers of infection such as pyrexia and raised white cell count

○ Neurological pathology, e.g. seizures, cerebral palsy

○ Snapped cord

○ Birth injury

○ Poor infant outcomes at long term follow-up (as defined by trialists)

Wellbeing markers

Secondary outcomes

Maternal outcomes

Labour

○ Augmentation of labour (artificial rupture of membranes and/or oxytoxic administration)

○ Use of non-pharmacological analgesia

○ Use of pharmacological analgesia (including regional and general anaesthesia) during any stage of labour

○ Duration of labour (first, second and third stage)

Wellbeing

○ Temperature (first and second stage)

○ Pulse and blood pressure (first, second and third stage)

○ Maternal self-esteem

○ Preference for care in subsequent labour

Fetal outcomes

Search methods for identification of studies

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register by contacting the Trials Search Co-ordinator (30 June 2011).

The Cochrane Pregnancy and Childbirth Group's Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from:

1. quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);

2. weekly searches of MEDLINE;

3. weekly searches of EMBASE;

4. handsearches of 30 journals and the proceedings of major conferences;

5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the 'Specialized Register' section within the editorial information about the Cochrane Pregnancy and Childbirth Group.

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords.

Searching other resources

We used personal contacts to identify other potential trials (published and unpublished) and we retrieved and assessed relevant references referred to in the reviewed papers for appropriateness for inclusion in this review.

We did not apply any language restrictions.

Data collection and analysis

Selection of studies

We re-evaluated trials included and excluded within the previous review and confirmed their inclusion or exclusion. As previously, two review authors independently examined abstracts of all potential studies identified by the search to ascertain which met the inclusion criteria. We resolved any disagreement through discussion among all review authors. We have added one new paper since the last update.

Data extraction and management

We used a data extract template provided by the Cochrane Pregnancy and Childbirth Group and modified for the topic for the evaluation and data identification/extraction process. Elizabeth Cluett (EC) entered data into Review Manager software ( RevMan 2011), and Ethel Burns (EB) checked for accuracy.

Assessment of risk of bias in included studies

For this current review two review authors, EC and EB, independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011). We resolved any disagreement through discussion.

(1) Random sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

(2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal allocation to interventions prior to assignment and assessed whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment. We assessed the methods as:

(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. Where sufficient information is reported, or can be supplied by the trial authors, we will re-include missing data in the analyses which we undertake.

We assessed methods as:

(5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found. We assessed the methods as:

(6) Other bias (checking for bias due to problems not covered by (1) to (5) above)

We described for each included study any important concerns we had about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

(7) Overall risk of bias

We will make explicit judgements about whether studies are at high risk of bias, according to the criteria given in the Handbook ( Higgins 2011). With reference to (1) to (6) above, we will assess the likely magnitude and direction of the bias and whether we consider it is likely to impact on the findings. We will explore the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity analysis.

Measures of treatment effect

Dealing with missing data

We have analysed data on all participants with available data in the group to which they were allocated, regardless of whether or not they received the allocated intervention, and irrespective of whether they used additional interventions. If, in the original reports, participants were not analysed in the group to which they were randomised, and there was sufficient information in the trial report, we have attempted to restore them to the correct group. For included studies we have noted levels of attrition.

Where data were not reported for some outcomes or groups we attempted to contact the study authors.

Assessment of heterogeneity

As part of the meta-analyses we examined heterogeneity between trials using the I ² statistic.

Assessment of reporting biases

If there were 10 or more studies in the meta-analysis we planned to investigate reporting biases (such as publication bias) using funnel plots. We would assess funnel plot asymmetry visually, and would use formal tests for funnel plot asymmetry. For continuous outcomes we would use the test proposed by Egger 1997, and for dichotomous outcomes we would use the test proposed by Harbord 2006. If asymmetry was detected in any of these tests or was suggested by a visual assessment, we proposed to perform exploratory analyses to investigate it.

Data synthesis

We carried out statistical analysis using the Review Manager software ( RevMan 2011).

Subgroup analysis and investigation of heterogeneity

For the primary outcomes, where data were available, we planned the following subgroup analyses.

1. Spontaneous labour versus induced labour.

2. Primiparous versus multiparous.

3. Term versus preterm birth.

4. Continuous support in labour versus no continuous support.

Sensitivity analysis

We planned to carry out sensitivity analyses to explore the effect of trial quality assessed by concealment of allocation, high attrition rates, or both, with poor quality studies being excluded from the analyses in order to assess whether this made any difference to the overall result.

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification.

One-to-one care in labour is known to affect labour outcomes ( Hodnett 2007), and this was clearly documented in four trials ( Cammu 1994; Da Silva 2006; Nikodem 1999; Taha 2000). Where it was stated that normal/routine/standard care was provided, this was understood to mean that the practitioners who normally provided intrapartum care to women in labour in the study centre provided care for the study participants ( Da Silva 2006; Eckert 2001; Eriksson 1997; Nikodem 1999; Rush 1996; Schorn 1993; Woodward 2004). Cammu 1994 indicated that care was supervised by obstetric staff.

Water temperature is known to be important in the care of women using water immersion during labour. This varied across trials, with some using a temperature up to 37°C ( Cammu 1994; Eckert 2001; Kuusela 1998); others up to 38°C ( Da Silva 2006; Eriksson 1997; Taha 2000); and still others not stated ( Chaichian 2009; Ohlsson 2001; Schorn 1993; Woodward 2004). Rush 1996 refers to a temperature of 38 to 39°C. The higher temperatures may affect outcomes, but there are no studies comparing outcomes for the use of different water temperatures.

The studies collected a wide range of data, but the specific outcome measures collected were very variable, and collected in different formats. For example, some studies did not consider neonatal wellbeing. Use of Apgar scores was also variable; some used them as continuous data, others as dichotomous, making comparison across studies challenging, and resulting in the reporting of many variables based on the results from one study.

Results of the search

We identified a total of 20 studies (some described in more than one report/paper) for consideration for inclusion in the review. Of these, we have now included 12 and excluded six; two await further assessment while we seek additional information from the authors. For more information see Characteristics of excluded studies.

Included studies

Of the 12 trials included in this review, eight related to the first stage of labour only; one related to early versus late immersion in the first stage of labour; two involved immersion during the first and second stages of labour; and one involved women in the second stage of labour only. There were no studies evaluating the use of different types of baths/pools at any stage of labour or the effects of water immersion on the third stage of labour. We identified no trials that evaluated immersion versus no immersion during pregnancy (i.e. not in labour).

For further details, see Characteristics of included studies.

Excluded studies

We excluded the two studies by Cluett ( Cluett 2001; Cluett 2004), primarily because all the women were nulliparous who had been diagnosed as having dystocia in the first stage of labour, and the comparison (control) group all received augmentation of labour. Hence comparison and inclusion in any meta-analysis with women at low risk of complications is inappropriate. In addition, Cluett 2001 was a feasibility study and only involved four women in each arm. Cluett 2004 suggested that in nulliparous women who have been classified as having slow progress in the first stage of labour, labouring in water reduced the incidents of epidural analgesia, although this did not reach statistical significance (P = 0.056). The pain scores were significantly lower, but as the comparison group received augmentation of labour, it could be argued that this was to be expected. This further supports the rationale for not including these women in this review, as doing so would not represent the situation when water immersion would be used, namely in a low-risk labour and birth.

One pilot study ( Calvert 2000) compared the use of essential oil of ginger with the use of essential oil of lemon grass. The data from this pilot are not in an appropriate form for analysis and so we excluded the study from the review. Use of other additives, such as salt, has not yet been evaluated in an RCT.

We excluded Benfield 2001 because of inadequate allocation concealment and the nature of the intervention.

Risk of bias in included studies

See details under Characteristics of included studies, ; .

Blinding

None of the trials cite any blinding of outcome assessment, and this is likely to be difficult to achieve, as use of water during labour is usually clearly documented in case records.

As an intervention, it is not possible to blind participants or carers to water immersion. Not all participants and/or carers will be in a state of equipoise between immersion or non-immersion, that is being equally comfortable and confident about water immersion. This may positively or negatively influence outcomes such as pain perception and hence subsequent analgesia use, maternal satisfaction, self-esteem and postpartum depression. An example of this is Woodward 2004, which reports that some midwives were apparently not supportive of women using water, suggesting a positive bias within the women, and in this case a negative bias within the midwives. Conversely Rush 1996 reports practitioners as maintaining a interest in low-intervention labour practice, suggesting a positive bias towards water immersion. Water immersion, however, is as much a psychological choice as a physical pain management strategy, and as such pragmatic clinical trials are assessing the effect of the whole package.

Incomplete outcome data

Compliance with trial allocation was variable across the trials. Of the trials that involved water immersion in the first stage of labour, Rush 1996 reported that 46% of women allocated to water immersion did not actually enter the water, while Woodward 2004 planned a 2:1 ratio allocation to water anticipating that about 50% of women would not use water, but of the 40 allocated to use water, only 24 used the pool. Four (of 58) women in Da Silva 2006 did not receive the water intervention due to medical/obstetric reasons. Another five trials ( Cammu 1994; Eckert 2001; Eriksson 1997; Ohlsson 2001; Woodward 2004) reported some crossover between groups. Kuusela 1998 and Chaichian 2009 did not provide information on this.

Rush 1996 and Da Silva 2006 referred to post-randomisation exclusion. For Rush 1996 this was 41 (of 785) women who were ineligible for the trial but recruited and allocated to a trial arm. They indicate that these 41 women were included in the analysis as it was on an intention-to-treat basis, but they also supply subgroup analysis with these women excluded.

Other potential sources of bias

The trials adopted a variety of definitions for water immersion, with different size baths/pools containing different volumes of water. To date, there is no evidence as to whether different degrees of immersion, or the amount of mobility possible within the bath/pool, affect outcomes. Schorn 1993 refers to a tub with a moulded seat, which may restrict mobility and the freedom to adopt different positions while immersed. Likewise, Rush 1996 used a pool where the woman could not change position. Schorn 1993 and Rush 1996 used a whirlpool (hot tub with jets) and the effect of moving water during immersion may be different to the effect of still water. Kuusela 1998 refers to a tub that is 70 cm deep and holds 730 litres; Da Silva 2006 indicates tub volume as 194 litres; Eckert 2001 and Eriksson 1997 cite tub depths of 54 cm and 40 cm, respectively. Differences as to what constitutes water immersion makes comparisons of outcomes across trials difficult.

Most of the included trials have small sample sizes and therefore a high risk of bias. These factors limit comparison across trials and the reliability and validity of the trial findings.

Fetal outcomes

Abnormal heart rate pattern

Three trials ( Eckert 2001; Schorn 1993; Taha 2000) provided data on abnormal fetal heart rate patterns and there was no significant difference amongst women allocated to immersion in water during the first stage of labour compared to controls (RR 0.75; 95% CI 0.34 to 1.67), Analysis 1.30, and substantial heterogeneity was detected (heterogeneity: I ² = 57%, T ² = 0.22, Chi ² test for heterogeneity P = 0.13) and so we used a random-effects meta-analysis.

Meconium liquor

Five trials ( Da Silva 2006; Eckert 2001; Kuusela 1998; Rush 1996; Woodward 2004) provided data on the presence of meconium-stained liquor and there was no significant difference amongst women allocated to immersion in water during the first stage of labour compared to controls (RR 0.95; 95% CI 0.76 to 1.19), Analysis 1.21.

Implications for practice

Despite limitations in the validity and reliability of the randomised controlled trial evidence to date due to trial design, the statistically significant reduction in rate of epidural/spinal/paracervical analgesia indicates that water immersion during the first stage of labour reduces the need for this invasive, pharmacological pain mode of analgesia, which disturbs the physiology of labour and is associated with iatrogenic interventions. We found no evidence that this was associated with poorer outcomes for neonates, longer labours or more complex births. The other significant findings come from data from one study only and therefore have to be read with caution. Women can be advised that the use of water immersion in the first stage of labour may reduce the incidence of epidural/spinal/paracervical analgesia, and midwives and other birth attendants can suggest water immersion as part of labour pain management strategy.

There is insufficient evidence about the use of water immersion during second stage of labour and therefore clear implications cannot be stated.

Overall, the evidence indicates that immersion in water during the first stage decreases maternal uptake of epidural/spinal analgesia, and that water immersion during the first stage of labour can be supported for women at low risk of complications.

Immersion during the second stage of labour needs further investigation, but at present there is no clear evidence to support or not to support a woman's decision to give birth in water.

Implications for research

There is some evidence that immersion in water during the first stage of labour reduces the need for analgesia, but the limited reliability and validity of the studies means that this would benefit from further research, in particular from a study of an appropriate size to assess equivalence. There is a lack of clarity as to what constitutes water immersion, and further evaluation of the relative merits of different shaped/sized pools is required, and of still versus moving water, and the relative merits of water immersion during early labour (latent phase). There is insufficient information to support or not to support the use of immersion during the second stage of labour (birth), or the third stage. The safety regarding infection and neonatal outcomes are not addressed, and large collaborative trials are needed to answer these critical issues. It has been suggested that maternal satisfaction increases with water immersion, although there is a need for a large trial to evaluate this.

There are no data on caregiver outcomes and this warrants investigation.

PLAIN LANGUAGE SUMMARY

Immersion in water in labour and birth

This review includes 12 trials (3243 women). Water immersion during the first stage of labour significantly reduced epidural/spinal analgesia requirements, without adversely affecting labour duration, operative delivery rates, or neonatal wellbeing. One trial showed that immersion in water during the second stage of labour increased women's reported satisfaction with their birth experience. Further research is needed to assess the effect of immersion in water on neonatal and maternal morbidity. No trials could be located that assessed the immersion of women in water during the third stage of labour, or evaluating different types of pool/bath.

Thanks are extended to Cheryl Nikodem for establishing the review group and to both Cheryl and Rona McCandlish for their extensive work on previous editions, which underpins the current review.

Thanks to Leanne Jones, Research Associate, Cochrane Pregnancy and Childbirth Group, for restructuring the review and checking data.

SOURCES OF SUPPORT

Internal sources

OCHRAD Oxford Brookes University, UK.

School of Health Sciences, UK.

University Of Southampton

External sources

UK NIHR Programme of centrally-managed pregnancy and childbirth systematic reviews of priority to the NHS and users of the NHS: 10/4001/02

CHARACTERISTICS OF STUDIES

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Bastide 1990
Unpublished data from 1990 available only. Inadequate data for assessment at this time. We contacted the author for further information, but nothing was provided

Benfield 2001
Only 18 women, 9 in each group. Randomsied by drawing slips of paper from a total of 52 paper slips in a bag which is inadequate allocation concealment. Women were in a limited depth of water; were asked to adopt a semi recumbent positions on a partially inflated air raft with attached head pillow (authors description) for 1 hour, and had cannulation to facilitate repeat blood samples. All of which limits mobility and is not consistent with water immersion in normal labour

Calvert 2000
Results of this pilot study (22 women) are not given in a format that can be used in the review. The aim was to compare the effect of the essential oil of ginger compared to essential oil of lemon grass on the progress of labour. The pilot study showed no differences on frequency of contractions, cervical dilatation or duration of first stage of labour between the 2 groups

Cluett 2001
Feasibility study: only 4 women in each of the 3 trial arms.
Women had all been diagnosed as having dystocia in the first stage of labour (less than 1 cm/hr progress after established labour)

Cluett 2004
Women had all been diagnosed as having dystocia in the first stage of labour (less than 1 cm/hr progress after established labour) and the comparison group was women receiving augmentation of labour

Labrecque 1999
The method does not meet the inclusion criteria for this review. It is impossible to disentangle the effects of immersion in water. The aim of the trial was to compare 3 non-pharmacological approaches to relieve back pain. A total of 34 women were randomly allocated to receive 1 of 3 treatments: (1) intracutaneous sterile water injections, (2) transcutaneous electrical nerve stimulation and (3) standard care that included back massage, whirlpool bath and liberal mobilisation. The sample size is small and results should be interpreted within the setting only. Women in the ISW group experienced a decrease in the intensity and unpleasantness of their backache, but they would not like to use this method in a future labour

DATA AND ANALYSES

Comparison 1

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

Comparison 2

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

Comparison 5

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

FEEDBACK

Wein, December 2006

Summary

How can the review authors conclude "Overall, the evidence indicates that immersion in water decreases maternal reported pain levels and the uptake of pharmacological analgesia" when their analysis reports the odds ratio for pharmacological analgesia as 1.08 (95% CI 0.71 to 1.65)?

(Summary of comment from Peter Wein, December 2006)

Reply

In the authors' conclusions section of the previous update of this review ( Cluett 2002), the statement "immersion in water decreases maternal reported pain levels" was based on the one trial ( Taha 2000) that reported this outcome (OR 0.23, 95% CI 0.08 to 0.63). The limitation of only one study is indicated in the maternal outcome section of the review. The reference to a decrease in maternal 'uptake of pharmacological analgesia' was based on the outcome 'use of epidural/spinal/paracervical block' (OR 0.84, 95% CI 0.71 to 0.99), which included data from four trials, not the outcome 'any pharmacological analgesia' which include data from two trials and is the one cited by Wein above. We accept the wording was ambiguous, and have clarified it in the current update.

Interestingly, in this update data for these outcomes have altered minimally: use of epidural/spinal/paracervical block is now OR 0.82, 95% CI 0.70 to 0.98, with data from six trials; 'any pharmacological analgesia', remains unchanged, as do the data for maternal pain experience.

(Response from Elizabeth Cluett, October 2008)

WHAT'S NEW

Last assessed as up-to-date: 23 August 2011.

HISTORY

Protocol first published: Issue 3, 1996

Review first published: Issue 3, 1997

30 June 2011

New search has been performed

Papers from June 2011 search reviewed and data incorporated as appropriate. 1 new study included ( Chaichian 2009) and 2 added to Characteristics of studies awaiting classification pending more information from the authors. Risk of bias tables generated. Text updated, although no change in overall conclusions

5 January 2009

New citation required but conclusions have not changed

Change in authorship.

20 November 2008

New search has been performed

Search updated. New trials identified, appraised and data are included
Title changed to reflect focus on water immersion in labour and birth, so pregnancy removed from title, and outcomes updated accordingly
Background information updated.
Results and discussion sections updated but no change to overall conclusions

20 November 2008

Feedback has been incorporated

Response from authors to feedback from Wein incorporated.

29 October 2008

Amended

Converted to new review format.

25 April 2004

New search has been performed

Search updated. Five new trials are included ( Eckert 2001; Eriksson 1997; Nikodem 1999; Ohlsson 2001; Taha 2000).

25 April 2004

New citation required and conclusions have changed

The inclusion of the new trials has resulted in a change in the implications for practice, which now indicates that immersion in water during the first stage of labour reduces reported maternal pain and the use of analgesia.
The outcome measures have been modified to ensure clarity. Neonatal outcomes have been added to reflect current methods of wellbeing assessment Change in authorship for this update.

DECLARATIONS OF INTEREST The first review author (E Cluett) is chief investigator of two trials related to the subject of this review ( Cluett 2001; Cluett 2004); we have excluded both.

INDEX TERMS

Medical Subject Headings (MeSH)

*Immersion; *Labor Stage, First; *Labor Stage, Second; *Water; Analgesia, Obstetrical [utilization]; Natural Childbirth; Randomized Controlled Trials as Topic

MeSH check words

Female; Humans; Pregnancy

References to studies included in this review

* Indicates the major publication for the study

Cammu 1994. [*. Cammu H, Clasen K, Van Wetteren L, Derde M. 'To bathe or not to bathe' during the first stage of labor. Acta Obstetricia et Gynecologica Scandinavica. 1994;73:468-72. [ PubMed] Google Scholar]

Eckert 2001 * Eckert KA, MacLennan AH, Turnbull DA. Immersion in water in the first stage of labour: a randomised controlled trial. 4th Annual Congress of the Perinatal Society of Australia & New Zealand; 1998 March 30-April 4; Australia: Alice Springs; 1998. [ Google Scholar]

Nikodem 1999. Nikodem C, Hofmeyr GJ, Nolte AGW, De Jager M. The effects of water on birth: a randomized controlled trial. Proceedings of the 14th Conference on Priorities in Perinatal Care in South Africa; South Africa. 1995 March 7-10.1995. pp. 163-6. [[Nikodem VC. Guidelines for underwater deliveries: evidence from randomized controlled trial. Fifteenth Conference on Priorities in Perinatal Care in South Africa; March 5-8; South Africa: Goudini Spa; 1996. [ Google Scholar] *. Nikodem VC. Immersion in water during birth: a randomized controlled trial [thesis] University of Witwatersrand; South Africa: 1999. Google Scholar] Google Scholar]

Ohlsson 2001 * Rydhstrom H. Trial to test the effect of bathing vs no bathing in labour on transfer to neonatal intensive care. Personal communication. 1994.

Taha 2000. De Jager M, Nolte AGW, Hofmeyr GJ, Nikodem VC. Immersion in water during first stage of labour. A randomised controlled trial. Personal communication. 2001. [Taha M, Nolte AGW, Hofmeyr GJ, Dorfling CS. Water as a method of pain relief: a randomised controlled trial. 20th Conference on Priorities in Perinatal Care in Southern Africa; 2001 March 6-9; South Africa: KwaZulu-Natal; 2001. [*. Taha M. The effects of water on labour: a randomised controlled trial [thesis] Rand Afrikaans University; Johannesburg: 2000. Google Scholar] Google Scholar]

References to studies excluded from this review

Calvert 2000. Calvert I. The evaluation of the use of herbal substances in the bath water of labouring women. Personal communication. 2000.

References to studies awaiting assessment

Additional references

Dowswell 2009. Dowswell T, Bedwell C, Lavender T, Neilson James P. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database of Systematic Reviews. 2009;(Issue 2) [DOI: 10.1002/14651858.CD007214.pub2] [[ PMC free article] [ PubMed] Google Scholar]

Jones 2011a. Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews. 2011;(Issue 7) [DOI: 10.1002/14651858.CD009234] [ Google Scholar]

Jones 2011b. Jones L, Dou L, Dowswell T, Alfirevic Z, Neilson James P. Pain management for women in labour: generic protocol. Cochrane Database of Systematic Reviews. 2011;(Issue 6) [DOI: 10.1002/14651858.CD009167] [ Google Scholar]

Ullman 2010. Ullman R, Smith Lesley A, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain relief in labour. Cochrane Database of Systematic Reviews. 2010;(Issue 9) [DOI: 10.1002/14651858.CD007396.pub2] [[ PMC free article] [ PubMed] Google Scholar]

References to other published versions of this review

Cluett 2009. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews. 2009;(Issue 2) [DOI: 10.1002/14651858.CD000111.pub3] [[ PMC free article] [ PubMed] Google Scholar]

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Cochrane Database Syst Rev. Author manuscript; available in PMC 2014 Apr 10. Published in final edited form as: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Critics cite the risk of neonatal water inhalation and maternal/neonatal infection.

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Children and the law - a guide to lesbian parenting

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Click here to download the PDF guide to Children and the law: a guide to lesbian parenting

What does it mean to be a legal parent?
Who are the legal parents?
What is parental responsibility (PR)?
Birth mother
If you are the civil partner or wife of the birth mother
How to obtain PR for your wife or civil partner's child
If you are not married/ in a civil partnership with the birth mother
How to obtain PR if you are not married to or in a civil partnership with the birth mother
Child arrangements order
Adoption
Fostering a child
Fathers from previous relationships
Known donors
Assisted conception and anonymous donors
Co-parenting agreements
What if we separate?
Useful contacts

Deciding to co-parent a child or children with your lesbian partner or wife can be exciting but complicated. You may decide to foster or adopt a child, conceive by artificial or donor insemination, co-parent with a third party, or you and your partner may already have children from previous relationships. This legal guide gives information about your legal status as a child's birth mother, non-birth mother or step parent. It also looks at the legal status of your child's biological father. Rights of Women publishes a number of other legal guides that may be useful including Children and the law: the Family Court process and Children and the law: parental responsibility. You can access our full range of legal guides at www.rightsofwomen.org.uk
What does it mean to be a legal parent?
A child can only have two legal parents. Being a child's legal parent means:

You have financial responsibility for the child which includes paying child maintenance if the child does not live with you

You will be considered parent and child for the purposes of British nationality, inheritance and pension rights

Who are the legal parents?
The birth mother will automatically be one of the child's legal parents. We refer to the birth mother rather than the biological mother because in England and Wales, the law says that whoever gives birth to the child is the legal mother (even if she used donated eggs).

The identity of the other parent depends on how the child was conceived and in what circumstances.

If the child was conceived through sperm donation at a UK registered clinic, the second legal parent will be chosen on the paperwork at the clinic at the time of the sperm donation.

If the child was conceived through sexual intercourse or through artificial insemination (but not at a UK registered clinic) the other legal parent will be the biological father. However, if the birth mother is married or in a civil partnership at the time of conception, and the child was conceived through artificial insemination, the husband, wife or civil partner will be the child's other legal parent, even if they are not the biological parent.

The only way that you can change a child's legal parents is by adopting the child, or if there has been a surrogacy arrangement, through a parental order. If a child is adopted then the adoptive parents will become the legal parents and the birth/biological parents will no longer be legal parents or have parental responsibility. For more information about surrogacy, seek specialist advice.
What is parental responsibility (PR)?
The law says that PR is:
all the rights, duties, powers, responsibilities and authorities which by law a parent of a child has in relation to the child and the child's property
People with PR can make or be involved in the important decisions necessary in a child's life including issues relating to where a child should live, their education and health, their name, religion and whether they can travel or live abroad.

Any number of people can have PR for a child. This means that it is possible for more than two people to share parental responsibility for a child.
Birth mother
As your child's birth mother you are automatically your child's legal parent and you have PR. The only way you can lose PR and legal parentage is if your child is adopted (unless your child is adopted by you and your partner).
If you are the civil partner or wife of the birth mother
Child conceived after 6 April 2009

If your civil partner or wife conceived a child after 6 April 2009 through artificial insemination (at a clinic or at home), you and your civil partner/ wife will be the child's legal parents and will both have parental responsibility. This is true whether the sperm donor is known or unknown. You should ensure both of your names are registered on the child's birth certificate, for the sake of clarity.

If your wife or civil partner conceived a child after 6 April 2009 through sexual intercourse with a man, you will not automatically have any rights to the child.

Child conceived before 6 April 2009

If your wife or civil partner conceived a child before 6 April 2009 you will not automatically have any rights to the child.
How to obtain PR for your wife or civil partner's child
If you are married or in a civil partnership with the birth mother, you can obtain PR by either entering into a parental responsibility agreement (PR Agreement) or applying to the court of a parental responsibility order (PR Order). For more information about PR see Children and the law: parental responsibility.

PR Agreements:

Entering into a PR Agreement is straightforward. If the father of the child or anyone else has PR, he will need to be involved in signing the PR Agreement or be notified of your application for a PR Order. You, your partner and the child's father (if he has PR) will need to complete a form C(PRA2) which you can download from the HMCTS website. The form will need to be signed in the presence of a court official at your local county court or family court and you will need to bring along the child's birth certificate and your photo ID. You then send two copies of the form to the Central Family Court, First Avenue House, 42-49 High Holborn, London, WC1V 6NP.

PR Orders:

If the father or someone else who has PR does not consent to the PR Agreement, you can apply to the Family Court for a PR order. You make this application on a Form C1, which you can download from the HMCTS website. If the child's father has PR, he will need to be notified and involved in the court proceedings.
If you are not married/ in a civil partnership with the birth mother
Child conceived outside of a licenced fertility clinic:

If your partner conceived a child at home (not at a licenced fertility clinic), and you are not married or in a civil partnership, you will not automatically have any rights to the child.

Child conceived at a licenced fertility clinic:

If your partner conceives a child at a licenced fertility clinic, you can both give your written consent to the clinic for you to be the child's second legal parent. The child will have no legal father and you and the birth mother will have equal parental rights and responsibilities and you can be named on the birth certificate. Either you or your partner can withdraw consent any time before the sperm, egg or embryo transfer.

If your partner conceives at a licenced fertility clinic and you do not want to be the child's second parent, you should sign a form indicating that you do not want to be the second parent of the child.
How to obtain PR if you are not married to or in a civil partnership with the birth mother
If you have not married or entered a civil partnership with the birth mother, and you do not already have PR for the child then you can obtain it by applying to the family court for a child arrangements order stating that the child lives with you or with you and your partner. If the order says the child 'lives with' you then you automatically have PR for the child. Another option would be to adopt the child which would make you one of the child's legal parents. See Adoption for further information.
Child arrangements order
A child arrangements order is an order which states who the child lives with and when, and who the child spends time with and when. Child arrangements orders have replaced what were previously known as residence orders and contact orders. Applying for a child arrangements order involves an application to your local Family Court. A child arrangements order stating that the child lives with you or with you and your partner will give you PR for your partner's child.

If you have been living with your partner's child for a period of 3 years in the last 5 years you will automatically be able to make an application for a child arrangement s order. If not, you will need the permission of everyone who already has PR for the child - her mother and perhaps her father. If you do not have permission from everyone who has PR you will have to get the permission of the court in an application for leave. To obtain the court's permission you will have to satisfy the court that you have a connection with the child and that the proposed application would not disrupt the child's life. For further information see our guide Children and the law: when parents separate.
Adoption
Civil partners and married couples can adopt a child together as a couple. This means that you will be able to adopt a child who has no biological connection with either of you. Adoption involves a fairly lengthy and complex procedure involving an assessment by Social Services and court proceedings.

If the child you are adopting has a known biological father who has PR he will need to be part of any court proceedings and if he does not agree to the adoption the court will have to decide whether adoption is in the child's best interests. When the court looks at whether adoption is in the child's best interests one of the factors that it has to take into account is the fact that if adopted by you the father would lose PR and all legal status in the child's life. The court may not agree to an adoption where, for example, the father has played an active role in the child's life and the court believes it is in the child's best interests for this to continue.

Once you have adopted a child you will gain PR and become the child's legal parent. Adoption is therefore a more permanent option than a child arrangements order. Seek legal advice if you are considering adopting a child.
Fostering a child
Another way in which you and your partner can become involved in parenting a child is to become foster parents. For more information about fostering contact your Local Authority.
Fathers from previous relationships
A father to whom you or your partner are or were married will automatically have PR for any child of that marriage. If you were not married then whether or not he will have PR will depend on your child's date of birth, whether he is on the birth certificate or whether he obtained PR through other ways (see Children and the law: parental responsibility). If the father does have PR he has the right to be involved in all the important decisions you make during your child's upbringing. He has the right to apply to the court for orders in relation to your child including child arrangements orders. He will need to be involved in any court proceedings about your child.

He will also have a legal financial responsibility to his child. See our guide Children and the law: child maintenance.
Known donors
If you are married or are in a civil partnership and you or your partner/wife conceive a child outside of a licensed fertility clinic using a known donor, the donor will not have any legal rights to the child and both you and your civil partner/wife will have PR.

If you are not in a civil partnership/married and you conceive a child outside of a fertility clinic in the UK with a known donor, for example at home, the donor will be the legal father of your child and will automatically have certain legal rights and your partner will have no legal rights to the child. You will need to discuss what involvement he will have in your child's life. If you cannot reach an agreement or if the agreement breaks down you or the donor can apply to the court for a child arrangements order.

One important decision you will have to make is whether his name should be registered on the birth certificate. If your child was born on or after 1st December 2003 or registration took place after this date and the father's name was registered on the birth certificate, he will automatically have PR for your child and the right to an involvement in all the important decisions you make in your child's upbringing. If he is not registered on the birth certificate, he will not automatically have PR but he could obtain it by entering into a PR Agreement with you or applying to the court for a PR Order. Whether or not he has PR or is named on the birth certificate, he will also have a legal financial responsibility for his child. As you will not be living together you can apply to the Child Maintenance Service for child maintenance, for more information see Children and the law: child maintenance.
Assisted conception and anonymous donors
If you use an anonymous donor at a fertility clinic, the anonymous donor will not have any legal status in relation to your child and will have no involvement in their life. However, children born by anonymous after April 2005, will have the right to receive information about their donor when they are 18 years old.
Co-parenting agreements
If you decide to co-parent with friends, it can be helpful to enter a co-parenting agreement which deals with important questions as to how you will raise your child. The agreement may deal with questions such as how much time your child will spend with each of you, what religious education your child will receive, what will happen if you or the other parents separate or form new relationships and who will contribute financially to your child's upbringing. Whilst a co-parenting agreement can be a useful roadmap to navigate future parenting disagreements, it is important to be aware that these agreements are not legally binding documents and you cannot rely on them in court.
What if we separate?
The courts have recognised that non-birth lesbian co-parents have an important ongoing role in their child's life following relationship breakdown. Your rights will depend on your legal relationship to your partner and child. If you and your partner share PR for your child you can both apply for child arrangements orders to determine who the child lives with and how much contact the child should have with the other parent or if there should be shared care.

If you already have a child arrangements order (or residence order), the part of the order which states who the child lives with will last until the child is 18 years old. If you and your partner separate either one of you can apply to change or discharge the order. To discharge an order means to cancel it. Discharging the order would mean the non-birth mother would lose her PR unless there is a PR Agreement or PR Order in place.

If you adopted a child together you will both remain that child's legal parents despite your separation and either of you will be able to apply to the court for orders concerning her or him without first having to obtain the court's permission. Neither of you will lose PR for the child. For further information on all of these issues see our legal guides Children and the law: parental responsibility and Children and the law: when parents separate.
The law is complex and may have changed since this guide was produced. This guide is designed to provide general information only for the law in England and Wales. You should seek up-to-date, independent legal advice. Rights of Women does not accept responsibility for any reliance placed on the legal information contained in this guide. © Rights of Women February 2017
For free, confidential, legal advice contact our advice lines
Useful contacts
Finding a solicitor
The Law Society - 0207 320 5650 - www.lawsociety.org.uk/find-a-solicitor/
Ministry of Justice - 020 3334 3555 - www.find-legal-advice.justice.gov.uk/
Resolution - 01689 820272 - www.resolution.org.uk/

Emergency contacts
Police (emergency) - 999
24 hour domestic violence helpline - 0808 200 0247 - www.nationaldomesticviolencehelpline.org.uk
National LGBT Domestic Abuse Helpline - 0800 999 5428 - www.galop.org.uk

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Children and the law: a guide to lesbian parenting - Rights of Women

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Click here to download the PDF guide to Children and the law: a guide to lesbian parenting What does it mean to be a legal parent? Who are the legal parents? What is parental responsibility (PR)? Birth mother If you are the civil partner or wife of the birth mother How to obtain ...

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Abstract

Objective

To evaluate the effect of LI4 acupressure on labor pain and duration during the first stage of labor.

Methods

Parturient women (n=149) with singleton pregnancies in the active phase of spontaneous labor, without any medical or obstetric problems, were enrolled in this single-blinded, randomized, clinical trial. Participants were placed into one of three groups: an LI4 acupressure group, a touching group, and a control group in which no pharmacological or non-pharmacological methods of pain relief were used. Pain intensity was measured by visual analog scale before and after the intervention in the first stage of labor. Pressure or touch was applied for 30 minutes during uterine contractions.

Results

The difference in the pain scores between the acupressure and control group was statistically significant ( p<0.001) but there was no statistically significant ( p=0.942) difference in the duration of the first stage of labor between the three groups.

Conclusion

Acupressure is an effective, non-invasive, and easily applicable technique to reduce labor pain.

Keywords: Acupressure, Labor pain, Length of labor

Introduction

Labor is a phenomenon that exists in many creatures and unlike other acute and chronic pain, the pain of labor does not correlate with any disease or pathology. Labor pain has been reported as the severest pain in humans. Known complications of pain are tension and anxiety, prolonged labor, and abnormal fetal heart rate, the incidence of cesarean delivery, neonate's low Apgar score, and even long-term mental disorders. One of the most pressing concerns and fears for pregnant women is the pain of labor, which leads to an increase in the number of cesarean sections. Pain relief in labor is an important issue in obstetric care, however, as yet, there is no standard and accepted technique for the relief of that pain without side effects. Generally, there are two options for pain relief during labor, these use either pharmacological or non-pharmacological methods. Pharmacological methods have adverse side effects for the mother and fetus, whereas non-pharmacological methods are free from side effects.

An example of a non-pharmacological method is acupressure, which is a traditional Chinese medicine where acupuncture points are stimulated by hands, fingers, thumbs, or small beads. This method acts according to the gate control theory where burning, massaging, and scratching can stimulate the large fibers responsible for transmitting nerve impulses to the spinal cord. A sustained stimulation can keep the gates of pain transmission closed, which may result in decreased pain. On the other hand, the stimulation of acupressure points using heat, needles, or pressure causes the release of endorphins.

Acupressure is a non-invasive method which is used to augment labor, provide pain relief, and shorten delivery time. It increases the intensity of uterine contractions (based on Montevideo unit) without affecting the duration and intervals of uterine contractions and, eventually, reduces the duration of delivery. A variety of acupoints are useful in childbirth to induce and manage labor, and shorten delivery time, including LI4. Hugo point (LI4), or Large Intestine 4, is one of the 14 main meridians on the body and studies have shown that the stimulation of this point plays a key role in reduction of labor pain. Some studies have examined the effects of ice massage on LI4 and found that labor pain decreases. There are limited studies of this method, since non-pharmacological methods are not commonly used in Iran. We sought to evaluate the effectiveness of LI4 acupressure on labor pain and duration.

Methods

A single-blinded, randomized, control trial was carried out over a seven-month period, between October 2011 and April 2012, at Dr. Shariati University Hospital in Bandar Abbas, Iran. The trial was approved by the Ethics Committee of Hormozgan University of Medical Sciences (HUMS), Iran.

Singleton pregnant women at a gestational age of 37-42 weeks, cephalic presentation, 4-5 cm cervical dilatation with spontaneous onset of labor, and with no history of previous high-risk pregnancy, cesarean section, cephalopelvic disproportion, or narcotic use within the past eight hours were included in the study. Patients were excluded from the trial if they needed an emergency cesarean section, labor augmentation using oxytocin or pharmacological pain relief, or if they chose to withdraw.

Following selection, participants were given information about the study, and asked to give written consent. The subjects were randomly assigned to one of three groups: an acupressure group (acupressure on point L14), a touching group (touching point LI4 in order to eliminate any psychological effects caused by the presence of a researcher), or the control group (using no form of pain relief). Participants were kept in quiet rooms with similar conditions, and treated with routine care (including the use of a simple saline infusion, made immobile and lying in a lateral position). Selection of the sample size was according to similar studies where at least 35 participants were needed in each group. shows the method of participant allocation.

Pain intensity was measured using the visual analog scale (VAS). Researchers have previously approved the validity and reliability of the VAS as a standard tool for the assessment of pain intensity. Pain intensity was measured before and several times after the intervention at 30 minutes, one hour and every hour after intervention until the end of first stage of labor. In the acupressure group, a trained and registered midwife, certificated in the acupressure method, performed the treatment. Pressure was applied bilaterally within the contraction on Hugo point (LI4), which is located on the medial midpoint of the first metacarpal within the skin of the thumb and the index finger []. Prior to applying pressure the patient was asked to take a deep breath then a rotational and vibration pressure was applied for 60 seconds, she then received a 60 second rest, and pressure was repeated. This cycle continued for 30 minutes. Accurate location of the acupoint was confirmed when the subjects felt heaviness, pressure, tingling, or numbness in the area or a pleasant feeling. If the participant reported feeling severe pain at the site of pressure, the pressure was stopped temporarily and commenced after a few minutes. The sign of the intensity of the pressure was partial discoloration of the nail bed to white. In the touching group, the same point was touched but with no pressure applied. The 30-minute intervention time used is based on acupressure theory, which says the time needed to turn the energy in the body's energy circuits is about 24 minutes.

VAS was used to estimate the pain intensity. Based on an 11-point scale where 0 indicated no pain and 10 indicated extreme and intolerable pain. At every stage of the trial, the participant ticked her pain level on a VAS. For each group the average pain intensity was calculated before and after the intervention, and then comparisons made between the groups.

The duration of the first stage of labor calculated the period from cervical dilatation 4-5 cm up to 10 cm cervical dilatation.

Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 16.0. The chi-squared test was used for qualitative variables and for calculating the pain intensity changes in groups, and sphericity assumed test of analysis variance with repeated measurement and ANOVA to compare the duration of the first stage of labor.

Results

A total of 149 participants were enrolled across three groups, 50 in the acupressure group and touching groups, and 49 in the control group. There were no significant differences in demographic characteristics [] between the three groups ( p= 0.933). All three groups were similar in terms of gestational age, gravidity, parity, and cervical dilatation before intervention [].

Table 1

Table 2

Change in pain intensity was assessed for each group separately before intervention, at 30 minutes, and at one hour after intervention using analysis variance test with repeated measurement. The difference between the changes was calculated using Mauchly's sphericity test. The result showed no significant changes in pain intensity in the acupressure group, but there were significant changes in the touch and control groups. In the acupressure group, pain intensity decreased and then remained constant after the application of pressure, but pain intensity was increased in the other groups, this means that acupressure had been more effective in controlling and reducing pain intensity than the other two groups []. In all three groups cervical dilatation showed a significant increase after intervention. However, those differences were not significant among all three groups. No statistically significant difference was observed in duration of first stage of labor ( p=0.942), type of delivery ( p=0.840) and Apgar scores at one and five minutes ( p= 0.621) between three groups.

Table 3

Discussion

In this study, we sought to determine the effect of acupressure on labor pain and the duration of labor. Use of the acupressure technique on Hugo (L14) point was significantly effective in reducing pain intensity, while in the touching and control groups the intensity of pain significantly increased after the intervention. Acupressure through the gate control theory of pain and the secretion of endorphins reduces the severity of labor pain.

The results of this study were consistent with other studies done in this field. Chung and colleagues studied the effect of L14 and BL67 acupressure on labor pain and uterine contractions and found a significant difference in pain intensity after the intervention . However, in the transitional labor phase no pain reduction was observed.

Studies by Enjezab et al, and Waters et al. showed that using ice massage on the Hugo point decreased pain intensity 30 minutes after intervention., In addition, Fan Qu studied the effect of electro-acupuncture on points L14 and SP6 on the intensity of labor and concluded that the technique could cause reduction in pain during the active phase. Another study showed that applying acupuncture on specific points such as LI4 compared to ineffective points could reduce labor pain in 30 minutes, one to two hours after the intervention.

The common ground of all these studies was that using acupressure or acupuncture on specific points during the active phase of labor reduced labor pain, but during the transitional phase when pain intensity reaches its highest, those techniques had no significant effect. Chung et al. concluded that acupressure was not effective in reducing labor pain intensity at the latent phase of labor as well as the transition phase.

What distinguishes this study from other studies is the inclusion of two control groups where both placebo effects, indoctrination and physical presence, are completely removed. We used the pressure technique alone while other studies also used ice massage on the same point or in combination with other points to relieve pain.

Duration of labor did not differ between the three groups, suggesting that applying pressure on the L14 point reduces labor pain but does not disrupt the delivery process. This finding was consistent with the Enjezab's study but Chung et al found that the duration of the first stage of delivery in the acupressure group was shorter than their other groups. Other variables examined in their study, were the delivery type and Apgar scores after the first and fifth minutes of birth, to determine how well the baby tolerated the birthing process and how well the baby is doing outside the mother's womb, respectively. No differences were found between the groups.

A limitation of our study is that we did not assess maternal anxiety and fear, which are additional factors that can affect the severity of labor pain during labor.

Conclusion

Our study suggests that L14 acupressure is a suitable non-pharmacological technique that is easy to perform and effective in elevating pain, without causing adverse side effects for the mother or baby. It can be used to reduce pain during the active phase of labor rather than using pharmacological methods. According to the World Health Organization's policies to reduce the rate of cesarean deliveries and promotion of safe childbirth, it is necessary to make childbearing pleasant and reduce maternal fear of natural childbirth using safe methods to reduce labor pain and increase the rate of vaginal delivery. In order to make this possible, midwives need training in using non-pharmacological techniques and the attitudes and policies of the hospitals need to be altered. Due to the simplicity and safety of the acupressure technique, additional research using a larger sample size and in combination with other techniques to apply pressure on different points of body is suggested.

Disclosure

The authors declared no conflict of interest. This research project was supported financially by Hormozgan Fertility and Infertility Research Center of Hormozgan University of Medical Sciences (HUMS).

Acknowledgments

We thank the midwives and participating women in the delivery ward at the Dr. Shriati University Hospital, for their cooperation.

References

1. Lowe NK. The nature of labor pain. Am J Obstet Gynecol 2002 May;186(5)(Suppl Nature):S16-S24. [ PubMed]

2. Caton D, Corry MP, Frigoletto FD, Hopkins DP, Lieberman E, Mayberry L, et al. The nature and management of labor pain: executive summary. Am J Obstet Gynecol 2002 May;186(5)(Suppl Nature):S1-S15. [ PubMed]

3. Tournaire M, Theau-Yonneau A. Complementary and alternative approaches to pain relief during labor. eCAM 2007; 4 (4)409-417. [ PMC free article] [ PubMed]

4. Abbasi Z, Abedian Z, Fadaei A. The Effect of Back Massage on Pain Intensity during First stage of labor in primiparous women. Iranian Journal of Obstetrics, Gynecology and Infertility .2009 ;(4):39-47. (Persian)

5. Shoorab NJ, Zagami SE, Mirzakhani K, Mazlom SR. The effect of intravenous fentanyl on pain and duration of the active phase of first stage labor. Oman Med J 2013. Sep;28(5):306-310. 10.5001/omj.2013.92 [[ PubMed] [ CrossRef] PMC free article] [ Google Scholar]

7. Enjezab B, khoushbin A, Bokaei M, Naghshin N. Effect of ice massage on Hugo point for reduction of labor pain. Journal of Shahid Sadoughi University of Medical Science and Health services 2008; 15(4):69-74. (Persian)

9. Mc Coffoery M, Beebe A. Pain Clinical manual for nursing practice. 1994; 1st edition. Mosby. London. [ Google Scholar]

10. Heydari P, Mozhdeh F, Mazloum SR, Tanbakouei K, Joudaki K. Effect of acupressure on labor pain intensity. Hakim 2008;11(2):39-46. Persian. [ Google Scholar]

12. Heydari P, Mozhdeh F, Masloum SR, Tanbakouei K, Joudaki K. Effect of SP6 acupressure on length of labor. Iranian Journal of Obstetrics and Gynecology 2008;11(2):15-22. Persian. [ Google Scholar]

15. Qu F, Zhou J. Electro-Acupuncture in Relieving labor pain. eCAM 2007;4(1)125-130. [ PMC free article] [ PubMed]

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The Effect of LI4 Acupressure on Labor Pain Intensity and Duration of Labor: A Randomized Controlled Trial

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To evaluate the effect of LI4 acupressure on labor pain and duration during the first stage of labor. Parturient women (n=149) with singleton pregnancies in the active phase of spontaneous labor, without any medical or obstetric problems, were enrolled in this single-blinded, randomized, clinical trial.

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Donor conception network

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Are you a sperm bank or egg bank? Why not give your donors one of these books as a thank you for their wonderful gift. The new Our Story books for donors help them explain to their own children that they have donated to other families New children's books for donors.
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Are you a sperm bank or egg bank? Why not give your donors one of these books as a thank you for their wonderful gift. The new Our Story books for donors help them explain to their own children that they have donated to other families New children's books for donors.

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Seahorse; The Dad who gave birth (BBC documentary)

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One trans man's quest to start his own family. As a gay transgender man, deciding to carry his own baby took Freddy years of soul searching, but nothing could prepare him for the reality of pregnancy.

Freddy is 30 and yearns to start a family but for him this ordinary desire comes with unique challenges - he is a gay transgender man.

Deciding to carry his own baby took years of soul searching, but nothing could prepare him for the reality of pregnancy, as both a physical experience and one that challenges society's fundamental understanding of gender, parenthood and family. He quickly realises that what to him feels pragmatic, to others feels deeply confusing and confronting - this was not part of his plan.

Against a backdrop of increasing hostility towards trans people the world over, Freddy is forced to confront his own naivety, mine unknown depths of courage and lean on every friend and family member who will stand by him.

Made with unprecedented access and collaboration over three years, the film follows Freddy from preparing to conceive right through to birth. It is an intimate, audacious and lyrical story for the cinema about conception, pregnancy, birth and what makes us who we are.

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BBC Two - Seahorse: The Dad Who Gave Birth

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One trans man's quest to start his own family. As a gay transgender man, deciding to carry his own baby took Freddy years of soul searching, but nothing could prepare him for the reality of pregnancy. Freddy is 30 and yearns to start a family but for him this ordinary desire comes with unique challenges - he is a gay transgender man.

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Same-sex parents fact sheet (TAMBA)

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Parenting and same-sex relationships (Family Lives)

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When it comes to parenting, the challenges will be much the same, whether you are same-sex parents or not. That said, there might be additional concerns for same-sex parents as they can face problems regarding being accepted into society, and feeling supported. Family Lives does recognise that this is improving as same-sex families become more recognised as part of today's society, but there is always room for improvement.

If you are in a same-sex relationship but have children from a previous heterosexual relationship, you might have concerns about losing custody, or fear that the courts will look favourably towards heterosexual parents. If you had children through donor insemination you might have the additional worry later in life when your children might start to wonder who their donor father is.

Children growing up in same-sex parented families might have concerns about how others might view their family and whether they will be looked at differently to their peers who might live with a mum and dad. These are all real concerns for children and it is important that they reassured on a continual basis. Same-sex parents might also be concerned about whether their children will be affected by growing up in a household of same-sex parents and what impact this might have on later life, if any.

So what challenges are same-sex parents likely to face?

Same-sex families encounter challenges similar to other families but also have some very different concerns such as worrying about whether their child will be bullied for having a different family life setting. There are ways that you can help your children with this such as pointing out the things you think are special about your family life. You can also talk to them about discrimination and help them think about why people tease or bully others, whilst reinforcing that this is not acceptable behaviour and they have done nothing wrong to deserve to be treated in this way.

Prejudice is another challenge that same-sex parents face either on a personal level or an institutional level where there is a lack of support, understanding, services and legislation. Children might suffer at school because they are not accepted by their peers or because their teachers are insensitive to their family set up and find it easy to blame their family life for any trouble.

So what can you do to help your child?

Get some books that deal with these issues that are age appropriate. They can then read these in their own time at their own pace.

Getting the school involved might also be helpful and you might like to speak to the teacher to see if they would be willing to talk about family structures to help educate other children.

Joining a local support group so your children can meet others in a similar situation which might help if they feel as though they are struggling to "fit in" society. If no such groups exist, how about doing some research into setting your own group up in your local area?

Further Support

You can get in touch with Stonewall as they can offer advice, support and information. Please click here for more. information.

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Same sex parenting, gap parents - Family Lives

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When it comes to parenting, the challenges will be much the same, whether you are same-sex parents or not. That said, there might be additional concerns for same-sex parents as they can face problems regarding being accepted into society, and feeling supported.

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Rainbow and same-sex parents; a family story (Raising Children Network )

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Life in a same-sex family: a personal story

Helen and Bernadette have two children - Madeleine, aged six, and Dominic, aged four. They live in a regional town in New South Wales. The children's donor father, Craig, lives in Sydney.*

Helen
'We were in a relationship for several years and we both decided we wanted to have children.

'We weren't that fussed about who had the children. It just so happened that I was considerably older and we felt that Bernadette's family had to be eased into the situation. We've had two children, one each, to the same sperm donor. But we don't make biological distinctions - they're both our kids and we're both their mummies. They know whose tummy they came out of, and that Craig is their donor dad and they have an older sister, but other than that, in their family they have two mummies.

'Once the babies came along, it changed things with our families considerably. Grandparents want interaction with their grandchildren and our relationships were then greatly improved with Bernadette's family. Her background is non-Anglo and they're strict Catholics. It took a long time for them to warm to our relationship, but the kids really helped. My family still experiences a level of fear. They still have a fair way to go, but they're doing their best. After all, there are so many diverse family structures nowadays - ours is just one.

'The children have contact with their dad - he's in Sydney with his other daughter. In the future we might move back to Sydney or they might want to spend more time with their extended family. The situation is open and we're just going to leave it up to them when they're older.

'The other thing is the way people view same-sex families. We live in a small country town - homophobia is the same everywhere, and people find difference a challenge. But we do an enormous amount for the schools and we're very involved in the community. I think this is helpful for the community. They know we're a two-mummy family and the children are very open about that.

'People soon realise we're just a pretty average family - what makes us special isn't our family structure, but just us!'

*Not their real names

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Rainbow and same-sex parents: a family story

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Helen and Bernadette have two children - Madeleine, aged six, and Dominic, aged four. They live in a regional town in New South Wales. The children's donor father, Craig, lives in Sydney.* Helen 'We were in a relationship for several years and we both decided we wanted to have children.

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Parenting rights; parental responsibility, adopting, fostering, co-parenting and surrogacy

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Information on parenting rights, parental responsibility, adopting, fostering, co-parenting, fertility treatment and surrogacy for lesbian, gay, bisexual and trans (LGBT) people.

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Othermotherhood  (we are family magazine)

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Different families; exploring what it’s like to grow up with lesbian or gay parents (Stonewall )

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Exploring what it's like to grow up with lesbian or gay parents.

What makes a family? Are families with lesbian and gay parents different to families with straight parents? And what's life like for children growing up in LGB families? In their own words, children of lesbian and gay parents talk about family life, growing up, and going to school.

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Exploring what it's like to grow up with lesbian or gay parents. What makes a family? Are families with lesbian and gay parents different to families with straight parents? And what's life like for children growing up in LGB families? In their own words, children of lesbian and gay...

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LGBT parents: a network for LGBT parents and those thinking about becoming parents

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Shared breastfeeding and induced lactation (we are family magazine)

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One lesbian couple explains why having both mothers breast-feed was a positive way to start their parenting journey.
Jane*, 30 and Sarah*, 34, have just finished weaning their daughter Lily*, now 8 months old. As a lesbian couple who wanted to be equal parents from the start they both breast-fed Lily from birth.

When Sarah was pregnant they heard about the concept and popularity of induced lactation with lesbian couples in Sweden. With both mothers breast-feeding, they share the task of meeting the demands of a newborn and can both start bonding with the baby from early on. The couple decided to give it a try. Sarah planned two months off work after the birth, combining paternity leave with annual leave - making it logistically possible.

A woman who has not carried a child can create a milk supply as long as she has working mammary glands. Induced lactation is more common in the USA but is known about in the UK in the context of adoption (breast-feeding can help adopted babies and young children who have attachment issues), re-lactation (when a woman is forced to stop breast-feeding due to illness or other unforeseen interruptions), surrogacy (when a mother who has used a surrogate to carry her child wants to breast-feed) and wet nursing. However now lesbian communities are hearing about it, and some are attempting it.

Jane found The Newman-Goldfarb Protocol online - an American method used to induce lactation. It is possible to induce a milk supply simply using a breast pump but it's not easy to achieve a decent supply without the assistance of drugs. Jane's best chance of success was to go on the combination pill, providing the oestrogen and progesterone needed to build breast tissue. A month later she would come off the pill and go onto domperidone, an anti-emetic (anti-sickness) drug which has a side effect of increasing lactation, then start breast-pumping regularly with an electric breast pump. Timing this to just before Sarah was due to give birth, Jane planned to put their baby Lily onto her breast at three days old (allowing Sarah's primary milk supply to come in first), stimulating milk flow and building her supply. Jane ran the Protocol past her GP who prescribed the pill and verified that it was safe to take domperidone whilst breast-feeding, and she started the process six weeks before their due date. "I was pumping for about 20 minutes, four or five times a day. It seemed like nothing was happening. It was quite dispiriting but then, after a week, a drop of milk appeared!" Slowly her supply increased, and after about a month Jane was producing about 25mls from each breast each time she pumped.

Lily was born in hospital and was put on Sarah's breast at 20 minutes old. Then Sarah needed stitches, which took some time. While this happened Lily was crying so Jane put her to her breast and the baby fed without a problem. On their first night at home Sarah's milk had not come in yet and despite her feeding and feeding Lily was screaming with hunger. Jane fed her and she went to sleep. "We were really happy that Lily got what she needed and that was that," Jane recalls.

"This is a great success story," says Emma Pickett, a lactation consultant in London and breast-feeding counsellor with The Association of Breast-feeding Mothers. "It's hard work to get a full milk supply built up with induced lactation. It takes a lot of physical and emotional commitment." Emma has many lesbian clients and has advised a few couples on induced lactation, but none have managed to follow it through. "One of the fears is that the birth mother's milk supply is threatened in the first six weeks. But there's no reason why you can't protect her milk supply by expressing using a breast pump."

Luckily, once it came in, Sarah's milk supply was strong. Because breast milk production is based on demand the couple carefully maintained both their milk supplies by balancing the feeds. "I'd feed Lily first," says Jane, "then if she was still hungry I'd pass her to the big guns!" As Lily got older Jane's milk supply would not sustain a full feed but was enough to comfort her. This meant Sarah could get good stretches of sleep at night and breaks in the day, so neither parent suffered the extreme sleep deprivation common with having a newborn. "We feel that our start to parenthood was easier than it might have been," says Sarah.

The couple found responses from other people were varied. Their midwives had never come across the concept of induced lactation before and avoided engaging with it. But midwives knowledge and expectations vary considerably and many others would have been open to it. "I would be doing a lot of signposting, says Judy*, a midwife in the southwest who has practised for 30 years, and has come across induced lactation before. "To me it seems like a really obvious thing to do - share the parenting. So many men say, 'I wish I could breast-feed the baby. All this burden is on her, I want to take some of it away.'"

At first Jane found it tricky explaining to her boss that she needed to pop away from her desk to pump in the lead up to the birth. "Once he understood he was supportive," she recalls, "some friends and family admitted they felt uncomfortable about us both breast-feeding at first but didn't say so until they were over it."

"We've had loads of supportive and positive reactions from other parents," says Jane. "The main attitude has been 'I wish my husband could breast-feed too, I'm so jealous!'"

The couple plan to have another child, and Jane will carry this time. "I'd really like Sarah to breast-feed too. I did half the nights - that one is going to come back! I'd much rather share that role and have the help."

Jane and Sarah are now both equally bonded to Lily. "She doesn't express a preference about who she goes to for comfort," says Sarah. "This was one of several strategies that we put in place in order to try and make sure Lily has two primary parents and it worked well. It's been great for me and lovely seeing Jane and Lily also bond from the start."

All breast-feeding support services will be able to advise on induced lactation.

National Childbirth Trust NCT: www.nct.org.uk

Association of Breastfeeding Mothers: www.abm.me.uk

This article was printed in issue 6 of We Are Family magazine, Summer 2014. Details may have changed - please do not rely on this information solely when making decisions - do your own research, make your own checks and get legal or health advice as appropriate.
* names have been changed to protect identities

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One lesbian couple explains why having both mothers breast-feed was a positive way to start their parenting journey. Jane*, 30 and Sarah*, 34, have just finished weaning their daughter Lily*, now 8 months old. As a lesbian couple who wanted to be equal parents from the start they both breast-fed Lily from birth.

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Relactation and induced lactation (NCT)

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What issues can lesbian co-mothers face in the transition to parenthood? (NCT)

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Same sex parents with twins, triplets or more (TAMBA)

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We have lots of resources available to help support other members of the family when you are expecting twins, triplets or more.

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Stonewall - pregnant pause - A guide for lesbians on getting pregnant ( lots of information on pregnancy, birth and the postnatal period

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Stonewall - A Guide for Gay Dads

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A guide for gay men taking them through the choices available to them to starting a family including legal advice on parenting rights in various situations.

Learn how you can help LGBTQ+ people Sign up for news

What's in my area?

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A guide for gay men taking them through the choices available to them to starting a family including legal advice on parenting rights in various situations. Learn how you can help LGBTQ+ people Sign up for news

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14 stages of labour (Milli Hill - positive birth book)